0:00

So this was a newborn term infant

0:03

with concern from meconium aspiration syndrome.

0:06

And, um, we'll go over the life support devices together.

0:09

So our endotracheal tube projects over the upper one third

0:12

thoracic trachea, so it's in an okay position,

0:15

the enteric tube course below the diaphragm.

0:17

The tip projects over the stomach.

0:19

So that looks like it's in an okay position.

0:22

This one is our umbilical arterial catheter.

0:24

You can tell because it, uh,

0:25

courses into the iliac vasculature

0:28

and then it, uh, uh, courses into the midline

0:31

or left side of the abdomen.

0:33

Um, the tip is at the T 11 vertebral body, so

0:36

that's just within normal limits for, uh,

0:38

the level they will accept.

0:40

And then this is, uh, a temperature probe

0:42

that has been placed into the rectum of this, of this krill,

0:45

critically ill infant to be able

0:47

to more accurately monitor the temperature of this patient.

0:50

The important finding in this image

0:52

besides all of these opacities in the lungs,

0:54

is this umbilical Venus catheter.

0:56

So the umbilical vein should enter the, uh,

0:59

the abdomen at the, uh, level of the umbilicus.

1:04

The catheter should course through the umbilical vein,

1:07

and then it should join, uh,

1:09

and go into the ductus benum somewhere near

1:12

the umbilical segment.

1:13

Left portal vein, which should be right around here.

1:16

This is, this infant isn't super rotated.

1:19

These clavicles are pretty, um, symmetric

1:21

and the ribs have a pretty symmetric appearance.

1:23

So in this nont rotate patient, I'm not sure

1:26

where this catheter is going.

1:28

It looks like it's extending beyond the umbilical vein

1:31

beyond the left portal vein,

1:32

and it's projecting over the left upper part

1:35

of the left lobe of the liver.

1:37

So I'm concerned this is an int hepatic location

1:41

of this umbilical venous catheter tip.

1:43

So the next thing we're gonna do is we're gonna recommend an

1:46

ultrasound to see where the heck this tip is

1:48

and to see if there's been any complications related

1:50

to this abnormally position catheter.

1:53

So this patient went on to abdominal ultrasound to assess

1:56

for complications of the malpositioned umbilical vein,

1:59

and they actually did a complete abdominal

2:01

ultrasound protocol in this infant.

2:03

So we started the level of the pancreas.

2:05

We're looking at pancreatic head

2:06

and part of pancreatic body.

2:08

Um, more views of the pancreas with sup mesenteric vein

2:12

to esent enteric artery.

2:13

And then this is gallbladder with, uh,

2:15

look at the pancreas here.

2:17

As we are continuing on with our protocol, we see part

2:20

of stomach here, um,

2:22

and the leftward aspect of the liver in the sagittal plane.

2:25

There is something echogenic in the superior aspect

2:28

of this left hepatic lobe.

2:30

So we'll keep an eye at what that, on, what that looks like.

2:33

On, on subsequent images,

2:35

this looks mostly just like collapsed stomach over here.

2:38

The sonographer noted there's something funky happening in

2:40

this left lobe of the liver tube

2:41

because she put color doppler on to see

2:44

what is happening in this left hepatic lobe.

2:46

So some abnormal academic foci, um,

2:49

diffusely throughout the left, um, lobe of the liver

2:52

with some more focal, um, epigenic, uh, uh, kind of, uh,

2:57

focused hyper

2:58

Genicity of the superior left hepatic lobe.

3:01

Kind of where that tip looks like it might be on the x-ray.

3:05

Um, o umbilical venous catheters I think are super hard

3:08

to see sonographic.

3:09

So we see part of this, um, sort

3:12

of tram track echogenic structure in the umbilical vein,

3:14

but it's hard for me to see the tip of of this catheter.

3:18

Um, sometimes the shadowing is all

3:20

that you can see of the catheter.

3:22

So we're moving on. We see a normal right adrenal gland,

3:24

normal looking right kidney.

3:26

We, this is a sagittal plane of our, uh, right hepatic lobe.

3:30

We do have a little bit of ascites at the inferior

3:32

aspect of this liver.

3:34

Um, so we'll kind of pay attention

3:36

to what that looks like later.

3:38

Um, and here's where we're gonna pay attention to it.

3:41

So now we're in the transverse plane.

3:42

Looking at the superior aspect of the liver.

3:44

Not only do we have some ascites, um, around the, uh,

3:47

superior aspect of the liver, but we have some anasarca.

3:50

So this lace, like, uh,

3:52

hypo coic fluid is tracking in the subcutaneous fat

3:55

of the abdominal wall of this infant.

3:58

And here come those echogenic foci again.

4:00

So there's um, sort of scattered punctate, echogenic foci

4:03

and then a region of kind of heterogeneous, uh,

4:07

but more focal hyper echogenicity.

4:10

Um, so it does look like that umbilical venous catheter

4:13

was indeed malpositioned.

4:15

Probably the tip was in the superior aspect

4:17

of the left hepatic lobe

4:19

and I bet you they injected something in, in through it

4:23

before realizing it was probably not

4:24

in the appropriate position.

4:26

Just to orient you about landmarks, this is dist esophagus,

4:29

left, middle, and right hepatic vein.

4:32

And um, you see color fill in of that, uh,

4:34

left hepatic vein.

4:36

But we have just sort of heterogeneous color fill in

4:39

of this, um, little, uh, heterogeneous collection where

4:42

that catheter had been.

4:45

Um, anytime I have a malpositioned on vocal vein,

4:47

I wanna make sure that my portal venous structures are

4:50

patent, especially the left portal vein

4:52

and um, so we'll pay close attention to

4:54

that on our cinematic images.

4:57

Um, this is uh, uh, um,

5:00

we have an umbilical arterial catheter in

5:03

our abdominal aorta.

5:04

This is IVC and this is renal vein crossing over here.

5:07

We do have some sludge it looks like in this gallbladder

5:10

with a little bit of wall thickening

5:12

that's probably secondary in nature in this infant.

5:15

And here we have doppler,

5:16

so the tech added doppler on for us.

5:18

So we have, uh, pretty normal ity with antegrade flow

5:22

of our main portal vein on the spectral Doppler image.

5:25

Nice normal preserved color doppler flow on

5:27

this color Doppler image.

5:29

Our right portal vein has some pulsitile flow

5:31

but is antegrade, um, in direction.

5:34

And then the good news is we do see some flow in our left,

5:37

um, our left portal vein here.

5:39

So even though the, uh,

5:41

umbilical venous catheter was malpositioned potentially

5:44

extending through that left portal vein into the parenchyma,

5:47

the left portal vein does look patent.

5:49

We have some nice normal hepatic arterial waveforms.

5:52

Our IVC is patent a reminder that umbilical veins do not

5:56

Go into the IVC at the abdominal portion.

5:59

They, uh, will join with the IVC at the level

6:02

of the ductus fum, um,

6:04

near the lower cable atrial junction level.

6:06

Um, so, uh, IVC is nice and patent.

6:09

We have normal ity of our hepatic veins.

6:13

Um, we have gallbladder sludge that we already saw on some

6:16

of the earlier image plus gallbladder wall thickening.

6:20

This, the sonographer has measured that for us.

6:23

Um, this is bile duct.

6:26

Um, so within normal limits we have our spleen

6:29

as well looked at on this complete abdominal ultrasound.

6:32

This is normal in a term infant, what we see

6:35

of left kidney looks normal as well.

6:37

Splenic artery and vein are patent

6:39

at the level of the hilum.

6:40

And then this is gonna be gastric, uh, a decompressed, uh,

6:44

uh, stomach here, um, adjacent

6:47

to the spleen in this left upper abdominal

6:48

quadrant on this transverse spleen.

6:50

So the big finding here is

6:52

that not only is there probably a little bit of, um,

6:56

portal venous gas in this left hepatic lobe,

6:58

there is a collection related to

7:00

that malpositioned umbilical vein.

7:02

So depending what it was that they injected through

7:05

that umbilical vein, that's, that's gonna be what,

7:07

what is located in this liver.

7:09

Prima, I don't actually see the umbilical venous catheter,

7:13

um, remaining in this patient at this point.

7:15

So I'm, I'm, I think I'm thinking they have removed

7:18

that malpositioned catheter at this point.

7:21

Um, so we will just make sure that they follow up

7:23

and that that resolves

7:25

and doesn't become superimposed infected in this infant.