Differentiation of systemic infection and congenital obstructive left heart disease in the very young infant

Management of the neonate with symptomatic congenital heart disease

“…The clinical distinction between an obstructed systemic circulation—for example, coarctation of the aorta, critical aortic stenosis, hypoplastic left heart syndrome—and severe sepsis remains extremely difficult, as the incidence of the two is about the same. A study that assessed the use of clinical findings to distinguish these two entities suggested that most of the available clinical variables, either alone or in combination, had insufficient sensitivity to provide an accurate differentiation 7. In this study, although a murmur or weak pulses occurred commonly in infants with an obstructed systemic circulation, 22 of the 47 patients with this type of cardiac lesion did not have a cardiac murmur at presentation 7.…”

“…A study that assessed the use of clinical findings to distinguish these two entities suggested that most of the available clinical variables, either alone or in combination, had insufficient sensitivity to provide an accurate differentiation 7. In this study, although a murmur or weak pulses occurred commonly in infants with an obstructed systemic circulation, 22 of the 47 patients with this type of cardiac lesion did not have a cardiac murmur at presentation 7. Furthermore, it would be fair to say that a sick neonate with systemic sepsis may have reduced peripheral pulses secondary to a low cardiac output.…”

Clinical presentations of critical cardiac defects in the newborn: Decision making and initial management

“…In addition to careful history-taking and physical examination, chest radiography and electrocardiography are very useful to differentiate CHDs from other causes in emergent situations. One study in the neonates presenting with either bacterial sepsis or meningitis, or left-sided obstructive lesions showed that the presence of cardiomegaly predicted heart defects with 85% sensitivity and 95% specificity with a positive predictive value of 95% for CHDs6). If a neonate presenting with shock is suspected to have a CHD, the initial management should involve the basics of advanced life support along with immediate prostaglandin infusion to maintain the PDA even before an accurate diagnosis is made by a cardiologist5).…”

The Critically Ill Neonate

“…Importantly, 85% manifest cardiomegaly, 70% have diminished lower extremity pulses (and lower arterial saturation in the feet compared to the hands), and over half have a murmur noted on examination. 26 Clinicians must be aware that prostaglandin E 1 may be life saving in patients with ductus-dependent systemic fl ow (hypoplastic left heart, interrupted aortic arch, critical coarctation of the aorta, transposition of the great arteries with tricuspid atresia) and pulmonary fl ow (tetrology of Fallot, Ebstein's anomaly, critical pulmonic stenosis, tricuspid atresia, and pulmonary valve atresia).…”