Does mechanical circulatory support help neonates with HMPV?

Question

Hello doctor,

I am managing an HMPV outbreak at our neonatal cardiac surgery recovery unit. Six post-operative infants were affected, with three showing signs of acute heart failure. My twins (two months, post-arterial switch operation) suddenly developed severe respiratory distress. Their chest tubes showed increased bleeding, and oxygen requirements tripled overnight. The echocardiogram shows worsening ventricular function. Two other babies required emergency re-sternotomy due to cardiac tamponade. Surgical sites show delayed healing with possible mediastinitis. Should we consider mechanical circulatory support? What about the risk of graft thrombosis? I also noticed increasing vasoactive medication requirements.

Please help.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

This is a very unfortunate situation. The HMPV (human metapneumovirus) outbreak in neonatal cardiac surgery recovery units with infants showing signs of acute heart failure is a critical situation. It will require multidisciplinary intervention to manage this situation.

You can consider mechanical circulatory support. Mechanical circulatory support, such as ECMO (extracorporeal membrane oxygenation), may be necessary if infants are showing signs of worsening ventricular function, inability to maintain oxygenation or signs of shock.

But there are some unfortunate challenges that come with ECMO, for example:

ECMO in post-operative infants increases the risk of graft thrombosis, bleeding, and infections like mediastinitis, pericarditis, etc.
ECMO requires antivirus medicines which can worsen the bleeding from chest tubes.

Inform the ECMO team, ask them to be on call, and in the meantime assess whether the infant's condition can stabilize with current medical management.

For graft thrombosis, you can take some preventive measures, such as:

Monitor closely for signs of graft thrombosis with serial echocardiograms and coagulation profiles.
Manage anticoagulation carefully, particularly in infants with ongoing bleeding.

Here are a few points to know:

The increased requirements for inotropes and vasopressors means the cardiac output or systemic perfusion is worsening.
Adjust fluid status carefully to avoid volume overload. Manage inotropic and afterload-reducing medications carefully.
Chest tube bleeding can be due to coagulopathy, thrombocytopenia, or surgical complications. Do a coagulation study and platelet count and manage on the basis of the reports (with fresh frozen plasma (FFP), cryoprecipitate, or platelets).
Any infection after surgery can cause delayed healing, increased mortality, and morbidity. To prevent mediastinitis, do a blood culture and start broad-spectrum antibiotics such as a combination of Vancomycin plus Meropenem.
There are no anti-viral drugs available for HMPV but you can give supportive treatments. You can manage respiratory problems with nebulization or pulmonary support. Use corticosteroids cautiously.
For cardiac tamponade, immediate re-sternotomy to relieve pressure is lifesaving. Ensure perioperative management includes tight hemodynamic and infection control.

Follow strict isolation protocols to prevent further spread. Move the healthy babies to another room and do not overlap the staff.

This is a very critical moment and you need as much help as you can get. Inform the hospital management about the situation and ask for more help.

I hope this has helped you.

Please feel free to reach me again, in case of further queries.

Thank you.