Lower extremity ischemia following umbilical artery catheterization: A case study and clinical update

Digital Ischemia in an Extreme Preterm Infant Treated with Nitroglycerin Patch

Ischemic limb lesions occasionally occur in neonates admitted to neonatal intensive care units. Known risk factors include the placement of arterial catheters, arterial punctures to obtain blood samples, and the use of vasoactive/vasopressor medications for hypotension. Prolonged peripheral tissue ischemia may result in serious complications, and successful management depends on early detection, proper assessment, and the institution of appropriate intervention. Currently, there is no standard approach for the management of peripheral tissue ischemia in extreme preterm infants. Topical nitroglycerine use is one of the promising options used to manage ischemic limb injuries in neonates, as demonstrated in several case reports. We report a case of digital ischemia in an extreme preterm infant with no clear risk factors except extreme prematurity, which recovered after topical nitroglycerine therapy.

Indications, Measurements, and Complications of Ten Essential Neonatal Procedures

About 10% of newborns require some degree of assistance to begin their breathing, and 1% necessitates extensive resuscitation. Sick neonates are exposed to a number of invasive life-saving procedures as part of their management, either for investigation or for treatment. In order to support the neonates with the maximum possible benefits and reduce iatrogenic morbidity, health-care providers performing these procedures must be familiar with their indications, measurements, and potential complications. Hence, the aim of this review is to summarise ten of the main neonatal intensive care procedures with highlighting of their indications, measurements, and complications. They include the umbilical venous and arterial catheterizations and the intraosseous line which represent the principal postnatal emergency vascular accesses; the peripherally inserted central catheter for long-term venous access; the endotracheal tube and laryngeal mask airway for airway control and ventilation; chest tube for drainage of air and fluid from the thorax; and the nasogastric/orogastric tube for enteral feeding. Furthermore, lumber puncture and heel stick were included in this review as very important and frequently performed diagnostic procedures in the neonatal intensive care unit.

Amino acid infusions in umbilical artery catheters enhance protein administration in infants born at extremely low gestational age

AIM

It is challenging to provide extremely low gestational age neonates (ELGANs) with adequate protein supply. This study aimed to investigate whether amino acid (AA) infusion in the umbilical artery catheter (UAC) in ELGANs is safe and enhances protein supply and growth.

METHOD

A before and after study including infants born <27 weeks, treated in Uppsala, Sweden, during 2004-2007, compared those receiving normal saline/10% dextrose in water with those receiving AA infusion in the UAC. Data were retrieved from the Extremely Preterm Infants in Sweden Study, hospital records and the Swedish Neonatal Quality Register. Group comparisons, univariate and multivariate analyses were conducted.

RESULTS

AA group (n = 41, females 39%) received on average approximately 0.3 g/kg/day more protein during the first postnatal week, compared to control group (n = 30, females 40%) (unstandardised coefficient (B) 0.26, p .001) but no difference was noted during 8-28 postnatal days. The type of infusion was not associated with growth variables. The incidence of neonatal morbidities and UAC-related thrombosis did not differ between the groups.

CONCLUSION

AA infusions in the UACs in ELGANs is safe and enhances protein supply during the first postnatal week. However, this practice is not associated with growth during the first 28 postnatal days.

Pentoxifylline in the treatment of neonatal vasospasm and thromboembolism: An observational case series study

WHAT IS KNOWN AND OBJECTIVE

Newborns, particularly preterm babies, are prone to vascular vasospasm and thromboembolism. Differences in the haemostatic system, small vessel diameter and presence of any serious diseases are predisposing causes of thromboembolic disease in newborns. The lack of randomized controlled studies on the management of vasospasm and thromboembolism exacerbates the problem. We present a case series of the successful and safe use of PTX for the treatment of vasospasm and thrombosis in neonates.

METHODS

The study was conducted in the Bezmialem Vakif University Hospital Neonatal Intensive Care Unit (NICU). A retrospective chart review was performed on consecutive patients treated for vascular spasm and thrombosis. Nine patients diagnosed with vasospasm or thrombosis were enrolled in the study.

RESULTS

Five patients had arterial injuries. Six patients were premature, and five patients were diagnosed with thrombosis by using Doppler ultrasonography (US). The drug was diluted with 5% dextrose and administered intravenously at a dose of 5 mg/kg/h over six hours, ranging from 1 to 5 days. No drug-related side effects were observed. All babies recovered, and no amputation was performed.

WHAT IS NEW AND CONCLUSION

PTX may be an alternative treatment for vascular vasospasm and thromboembolism with fewer side effects than anticoagulant and thrombolytic agents in neonates. Starting PTX in the early stages of vascular insult may prevent the development of vasospasm and thromboembolism and thus limb ischaemia.

Are there changes to regional tissue oxygenation and circulation following umbilical artery catheter placement? A prospective cohort study in newborn infants

AIM

The use of umbilical arterial catheters (UACs) is a standard of care in monitoring critically unwell infants. Serious vascular complications are rare but when they do occur, they can be associated with significant morbidity, risking limb loss or even death. Near infra-red spectroscopy has the potential to monitor limb perfusion. Our study investigates changes in tissue oxygenation and perfusion in the abdominal and leg circulation following UAC insertion.

METHODS

A prospective observational study performing ultrasound pulsed Doppler measurements in the coeliac, superior mesenteric artery, renal arteries and the femoral arteries as well as near infrared spectroscopy measurements of both thighs at three time points (immediately before = Time 1, 1 h after = Time 2 and 24 h after UAC insertion = Time 3).

RESULTS

We monitored 30 infants, the mean gestational age was 30 weeks (24-41) and the mean birthweight was 1720 g (600-4070 g). We observed statistically significant changes (P < 0.05) in pulse Doppler measurements in coeliac (mean peak systolic velocity (PSV): Time 1 = 70.51, Time 2 = 61.75; resistive index (RI): Time 1 = 0.75, Time 2 = 0.67), superior mesenteric (PSV: Time 1 = 41.72, Time 2 = 36.10; RI: Time 1 = 0.92, Time 2 = 0.87), renal (same side end-diastolic velocity: Time 1 = 1.98, Time 2 = 3.80; RI: Time 1 = 0.93, Time 2 = 0.87; opposite side end-diastolic velocity: Time 1 = 2.62, Time 2 = 3.84; RI: Time 1 = 0.92, Time 2 = 0.85) and femoral arteries (same side PSV: Time 1 = 72.75, Time 2 = 62.18; opposite side PSV: Time 1 = 81.89, Time 2 = 62.74). Tissue oxygenation in lower limbs remained unaffected (same side (mean): Time 1 = 68.59, Time 2 = 68.99, Time 3 = 66.40, opposite side: Time 1 = 67.72, Time 2 = 66.92, Time 3 = 65.40). All infants on clinical examination had normal lower limb perfusion, lower limb arterial pulses and normal perfusion to the gluteal region before and after insertion of UAC.

CONCLUSIONS

While sub-clinical changes in perfusion occur in abdominal and leg circulation, these changes are not consistent across vessels and regional tissue oxygenation remains unaffected.

Thromboembolism and anticoagulation management in the preterm infant

The incidence of preterm thromboembolism has been increasing due to advances in diagnostic imaging which allow better detection of thrombi in sick preterm infants. At the same time, improvement in neonatal intensive care unit supportive care has increased the number of surviving and living preterm infants with thromboembolic risk factors. Disruption in the fine balance of hemostasis with potential risk factors, specifically septicemia and indwelling catheters, increase the occurrence of thromboembolic events. Treatment strategies in preterm infants are challenging due to limited data.

Umbilical vascular catheter associated portal vein thrombosis detected by ultrasound

OBJECTIVE

To determine catheter-associated thrombosis by color Doppler ultrasound and to detect duration of catheter placement as a risk factor for thrombosis.

METHODS

All newborn infants with umbilical vascular catheterization for more than 6 h duration were included in this study. Color Doppler ultrasound examination was performed within 24-48 h of catheter insertion, 48-72 h after its withdrawal and weekly until hospital discharge or clot resolution.

RESULTS

Portal vein thrombosis (PVT) was determined in five cases (3.04%) of 164 infants received umbilical vascular catheterization. The mean duration of catheter placement in patients with PVT was 3.4 ± 1.94 days, which was not significantly different from infants without thrombosis (3.5 ± 2.03). Thrombosis was completely recanalized and resolved after 3-6 weeks in three survived neonates. There was history of exchange transfusion for hyperbilirubinemia via umbilical vein in two neonates with PVT.

CONCLUSIONS

Catheter-associated portal venous thrombosis was uncommon in our study. The duration of catheter placement was not longer in patients with portal vein thrombosis than those without thrombosis.

Vascular access in the neonate

Up to recently, inserting venous or arterial 'lines' in the neonate was essentially based on clinical skill and experience. The recent advent of portable ultrasound (US) machines with paediatric probes has resulted in the development of new approaches that, if correctly learned and used, should allow quicker and safer vascular access in this population. Both classic and new techniques are reviewed on the basis of literature and authors' experience.

Functional limb salvage following muscle rigor in a pediatric patient

Acute limb-threatening ischemia is a vascular surgical emergency. Traditionally, 4 to 6 hours are usually available from the onset of acute ischemia to successfully revascularize before irreversible damage occurs. The presence of ischemic rigor traditionally represents irreparable local damage to muscle in the adult population and is an indication for limb amputation. Although the literature is scarce on this topic, few authors have reported superior limb salvage rates in pediatric patients despite the presence of severely impaired arterial perfusion. We present a case of a 10-year-old girl with rigor of the left lower extremity, who underwent surgical reperfusion for acute ischemia approximately 14 hours after the initiation of symptoms. The patient presented with an insensate and paralyzed limb. Pulsatile flow was restored to her lower extremity. She regained protective sensation and suffered no significant sequelae of systemic reperfusion syndrome.