Broviac catheter insertion: operating room or neonatal intensive care unit

Bedside surgery in the newborn infants: survey of the Italian society of pediatric surgery

Introduction

This is the report of the first official survey from the Italian Society of Pediatric Surgery (ISPS) to appraise the distribution and organization of bedside surgery in the neonatal intensive care units (NICU) in Italy.

Methods

A questionnaire requesting general data, staff data and workload data of the centers was developed and sent by means of an online cloud-based software instrument to all Italian pediatric surgery Units.

Results

The survey was answered by 34 (65%) out of 52 centers. NICU bedside surgery is reported in 81.8% of the pediatric surgery centers. A lower prevalence of bedside surgical practice in the NICU was reported for Southern Italy and the islands than for Northern Italy and Central Italy (Southern <Northern<Central, p < 0.03). The most frequent clinical characteristics of neonates was preterm neonates with birthweight < 1200 g, with cardiorespiratory instability and/or ventilatory dependence. The most frequently selected indications to surgery were pneumothorax, pleural effusion, pericardial effusion, central venous catheter (CVC) positioning, intestinal perforation, patent ductus arteriosus ligation and congenital diaphragmatic hernia. More than 60% of respondents report no institutional recommendations and dedicated informed consent on bedside surgical procedures. The lack of dedicated areas and infrastructures is considered a relative contraindication to the performance of bedside surgery.

Conclusion

Bedside surgery is performed in the majority of the Italian pediatric surgery centers included in this census. The introduction of a national set of surgery guidelines would be widely welcomed.

A comparison of postoperative outcomes with PDA ligation in the OR versus the NICU: a retrospective cohort study on the risks of transport

Background

Although patent ductus arteriosus (PDA) ligations in the Neonatal Intensive Care Unit (NICU) have been an accepted practice, many are still performed in the Operating Room (OR). Whether avoiding transport leads to improved perioperative outcomes is unclear. Here we aimed to determine whether PDA ligations in the NICU corresponded to higher risk of surgical site infection or mortality and if transport was associated with worsened perioperative outcomes.

Methods

We performed a retrospective cohort study of NICU patients, ≤37 weeks post-menstrual age, undergoing surgical PDA ligation in the NICU or OR. We excluded any infants undergoing device PDA closure. We measured the incidence of perioperative hypothermia, cardiac arrest, decreases in SpO2, hemodynamic instability and postoperative surgical site infection, sepsis and mortality.

Results

Data was collected on 189 infants (100 OR, 89 NICU). After controlling for number of preoperative comorbidities, weight at time of procedure, procedure location and hospital in the mixed-effect model, no significant difference in mortality or sepsis was found (odds ratio 0.31, 95%CI 0.07, 1.30; p = 0.107, and odds ratio 0.40; 95%CI 0.14, 1.09; p = 0.072, respectively). There was an increased incidence of hemodynamic instability on transport postoperatively in the OR group (12.4% vs 2%, odds ratio 6.93; 95% CI 1.48, 35.52; p = 0.014).

Conclusion

PDA ligations in the NICU were not associated with higher incidences of surgical site infection or mortality. There was an increased incidence of hemodynamic instability in the OR group on transport back to the NICU. Larger multicenter studies following long-term outcomes are needed to evaluate the safety of performing all PDA ligations in the NICU.

Keywords

Patent ductus arteriosus, Newborn infant, Neonatal intensive care unit, Surgical wound infection, Postoperative period, Hemodynamics

Safety of peritoneal and pleural drain placement in pediatric stem cell transplant recipients with severe veno-occlusive disease

Hepatic VOD (veno-occlusive disease) is a serious complication of HSCT (hematopoietic stem cell transplantation) and has historically been associated with high mortality. This obstruction to hepatic flow often results in fluid collections in the peritoneal and pleural cavities. Catheter placement to drain ascites or pleural fluid may reduce intra-abdominal hypertension and/or improve respiratory parameters. The safety of these interventions among critically ill, immunocompromised children is unknown. Among 32 HSCT recipients (2000-2012) with severe VOD, we assessed the primary outcome of procedural complication from peritoneal drain placement. Twenty-four (75%) patients underwent peritoneal drain placement. No patient sustained visceral perforation or hemorrhage with drain placement. Overall mortality was 47% (n = 15). The procedure was not associated with increased overall mortality (p > 0.99). Eight (25%) peritoneal drains required replacement for malfunction. Of 24 patients with peritoneal drains, one (4%) patient had a positive culture from ascitic fluid. Eight (25%) patients underwent pleural drain placement. No pleural drain-related procedural complication or infection occurred. Four (50%) of the eight patients with pleural drains had de-escalation in oxygen requirement at drain removal, compared to time of placement. In this study, peritoneal and pleural drains were safe interventions for children with severe VOD.

The outcome of critically ill neonates undergoing laparotomy for necrotising enterocolitis in the neonatal intensive care unit: a 10-year review

PURPOSE

To evaluate outcomes in critically ill neonates with necrotising enterocolitis (NEC) undergoing a laparotomy in the neonatal intensive care unit (NICU).

METHODS

This is a retrospective review of neonates diagnosed with NEC who underwent a laparotomy on NICU between 2001 and 2011. Demographic, diagnostic, operative and outcome data were analysed. Nonparametric comparison was used. Data are reported as median (range).

RESULTS

221 infants with NEC were referred for surgical evaluation; 182 (82%) underwent surgery; 15 (8%) required a laparotomy on NICU. Five had NEC totalis, 4 multifocal disease and 6 focal disease. Five had an open and close laparotomy, 8 stoma with/without bowel resection and 2 bowel resection and primary anastomosis. Ten (67%) died at a median of 6.5-hours (2-72) postoperatively; 2 died at 72 and 264-days. The 30-day mortality rate was higher (p=0.01) among infants undergoing a laparotomy on NICU (10/15; 67%) than in theatre (54/167; 32%). There was no significant difference in mean Paediatric Index of Mortality 2 Scores between survivors and nonsurvivors (p=0.55). Three (20%) infants remain alive with no or minimal disability at 1.4 (0.5-7.5) years.

CONCLUSION

Laparotomy for NEC on NICU is a treatment option for neonates who are too unstable to transfer to theatre. However, with 67% dying within 6.5-hours and a further 13% after months in hospital, we must consider whether surgery is always in their best interests. Development of a prediction model to help distinguish those at highest risk of long-term morbidity and mortality could help with decision making in this difficult situation.

Cost and safety of pediatric intensive care physician-placed broviac catheters

OBJECTIVE

To compare the cost and safety of placement of Broviac catheters in children by pediatric intensivists in a sedation suite versus placement by pediatric surgeons in the operating room.

DESIGN

Single-center retrospective analysis.

SETTING

Pediatric sedation suite and operating rooms in a tertiary care children's hospital.

PATIENTS

All pediatric patients with Broviac catheters placed (n = 253) at this institution over a 3-year period from 2007 to 2009.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We reviewed the charts of all pediatric patients with Broviac catheters placed, either by intensivists or surgeons, and compared cost and outcomes. Procedure safety was assessed and categorized into immediate, short-term (within 2 wk of procedure), and long-term outcomes. Anesthetic safety and billing data for the procedure were also collected. Among similar patient populations, immediate complications, such as pneumothorax, procedure failure (p > 0.999), and anesthetic complications (p = 0.60), were not significantly different. Short-term outcomes, including infection (p = 0.27) and catheter malfunction (p > 0.999), were not different. Long-term outcomes, including mean indwelling catheter days (p = 0.60) and removal due to catheter infection (p = 0.09), were not different between the groups. Overall cost of the procedure was significantly different: $7,031 (± $784) when performed by surgeons and $3,565 (± $311) when performed by intensivists (p < 0.001).

CONCLUSIONS

Pediatric critical care physicians can place Broviac catheters as safely as pediatric surgeons and at a lower cost in a defined patient population.

Scope and feasibility of operating on the neonatal intensive care unit: 312 cases in 10 years

PURPOSE

To report the scope, feasibility and learning experience of operating on neonates on the neonatal intensive care unit (NICU).

METHODS

(1) Review of all NICU operations performed by general neonatal surgeons over 10 years; (2) 6-month prospective comparison of procedures performed in NICU or operating room; (3) structured interviews with five surgeons with 1-13 years experience of operating on NICU.

RESULTS

312 operations were performed in 249 infants. Median birth weight was 1,494 g (range 415-4,365), gestational age 29 weeks (22-42), and age at operation 25 days (0-163). Nearly half (147) were laparotomy for acute abdominal pathology in preterm, very low birth-weight infants There were no surgical adverse events related to location of surgery. Surgeon satisfaction with operating on NICU for this population was high (5/5). Several factors contribute to making this process a success.

CONCLUSIONS

This is the largest reported series of general neonatal surgical procedures performed on NICU. Operating on NICU is feasible and safe, and a full range of neonatal operations can be performed. It removes risks associated with neonatal transfer and is likely to reduce physiological instability. We recommend this approach for all ventilated neonates and urge neonatal surgeons to operate at the cotside of unstable infants.

In-situ emergency pediatric surgery in the intensive care unit

BACKGROUND

The role of surgery in the intensive care unit (ICU) remains unclear. Although previous studies have not shown any increase in morbidity when operating on patients in the ICU for surgical procedures; there remains a reluctance to operate on sick patients in the ICU.

AIM

We did a retrospective study of critically ill children and neonates who underwent in-situ surgery (ISS) to further evaluate its safety and potential. Surgery was aided with the use of operative loupes and high-intensity headlight.

METHODS

The medical records of all patients who had undergone surgical procedures in the pediatric ICU over an 11-year period from January 1998 till December 2008 were retrospectively reviewed. We reviewed our experience looking specifically at wound infection rates along with other morbidities in 543 patients.

RESULTS

Our morbidities were comparable with that of operations performed in the operating theater, with low wound infection rates (1%) for all surgeries undertaken in the pediatric ICU.

CONCLUSION

ISS avoids the risks of transfer to the operative theater and the potential delays in theater access. Our results suggest that ISS in a tertiary-level pediatric surgical hospital is safe and does not impact adversely on clinical outcome.

Surgical procedures performed in the neonatal intensive care unit on critically ill neonates: feasibility and safety

BACKGROUND AND OBJECTIVE

Transferring unstable, ill neonates to and from the operating room carries significant risks and can lead to morbidity. We report on our experience in performing certain procedures in critically ill neonates in the neonatal intensive care unit (NICU). We examined the feasibility and safety of such an approach.

METHODS

All surgical procedures performed in the the NICU between January 1999 and December 2005 were analyzed in terms of demographic data, diagnosis, preoperative stability of the patient, procedures performed, complications and outcome. Operations were performed at bedside in the NICU in critically ill, unstable neonates who needed emergency surgery, in neonates of very low birth weight (<1000 g) and in neonates on special equipment like high frequency ventilators and nitrous oxide.

RESULTS

Thirty-seven surgical procedures were performed including 12 laparotomies, bowel resections and stomies, 7 repairs of congenital diaphragmatic hernias, 4 ligations of patent ductus arteriosus, and various others. Birthweights ranged between 850 g and 3500 g (mean, 2000 g). Gestational age ranged between 25 to 42 weeks (mean, 33 weeks). Age at surgery was between 1 to 30 days (mean, 10 days). Preoperatively, 19 patients (51.3%) were on inotropic support and all were intubated and mechanically ventilated. There was no mortality related to surgical procedures. Postoperatively, one patient developed wound infection and disruption.

CONCLUSION

Performing major surgical procedures in the the NICU is both feasible and safe. It is useful in very low birth weight, critically ill neonates who have a definite risk attached to transfer to the operating room. No special area is needed in the the NICU to perform complication-free surgery, but designing an operating room within the the NICU would be ideal.

Ventriculosubgaleal shunts at Columbus Children's Hospital: Neurosurgical implant placement in the neonatal intensive care unit

OBJECT

The authors review all cases in which ventriculosubgaleal (VSG) shunts were placed at Columbus Children's Hospital for the treatment of posthemorrhagic hydrocephalus in order to assess the surgical procedure, effectiveness of surgery, and complications of cerebrospinal fluid diversion to the subgaleal space. The purpose of the review is to make a comparison between cases in which shunts were placed in the operating room (OR) and those in which they were placed in the neonatal intensive care unit (NICU). Considerations and complications specific to patient transport to the OR or surgical implantation in the NICU are discussed.

METHODS

Seventeen infants with posthemorrhagic hydrocephalus were treated with VSG shunt placement over a period of 4 years. A retrospective analysis of these cases was performed to evaluate multiple aspects of the procedure. Specifically, the surgical procedure, duration of shunt function prior to shunt conversion, neuroimaging changes, operative complications, and risk of infection are discussed. The authors also performed a comparative analysis of shunt placement in the NICU and the OR.

RESULTS

The length of the procedure was similar in the two locations. No differences in perioperative or intraoperative risks and no increased risk of infection were seen in either location in this pilot study. Interestingly, the mean lifespan of primary implants placed in the NICU (73 days) was longer than that of those placed in the OR (43 days).

CONCLUSIONS

Ventriculosubgaleal shunt placement offers a safe and effective temporary means of treating post-hemorrhagic hydrocephalus and can be reliably and safely performed at the bedside.

Differences in the outcome of surgically placed long-term central venous catheters in neonates: neck vs groin placement

BACKGROUND/PURPOSE

Long-term tunneled central venous catheters (CVC) are frequently used in the neonatal intensive care unit (NICU) babies. They are placed either in the neck or groin based primarily upon the surgeon's preference. There is meager published information available about the relative risks of these lines.

METHODS

This is a retrospective analysis of all the tunneled central venous catheters placed in NICU babies at a children's hospital over a nearly 5-year period. Single lumen Broviac catheters were used in all cases.

RESULTS

A total of 137 catheters were placed in 126 patients. There were 88 neck lines and 49 groin lines. Age, gestational maturity, and body weight were significantly lower for babies who underwent groin line placement. There was no significant difference in the number of days the catheters were live between the 2 groups. Total complication rates and catheter infection rates were significantly higher with neck lines. The accidental removal rate was higher with neck lines but did not reach statistical significance.

CONCLUSIONS

Broviac catheters placed in the groin of NICU babies are associated with significantly fewer complications compared with those placed in the neck.

The use of alteplase to restore patency of central venous lines in pediatric patients: a cohort study

We evaluated the efficacy and safety of alteplase to restore central venous line (CVL) patency in a consecutive cohort study. A uniform, weight-dependent protocol for alteplase administration was established prospectively. For children < or =10 kg, a dose of 0.5 mg was used; for children >10 kg, doses of 1 to 2 mg were used. The alteplase remained instilled for 1 to 4 hours or overnight. Retrospective data accrual found that 25 children received alteplase for a total of 34 courses; 29 (85%) of the 34 courses of alteplase completely restored CVL patency. Alteplase appears to be a safe and effective thrombolytic agent for CVL patency restoration in children.

Nosocomial sepsis in neonates with single lumen vascular catheters

Catheter-related sepsis is commonly encountered in the neonatal intensive care unit. We retrospectively studied infants with vascular catheters at 2 NICUs. Data were obtained from the computerised admission records available at both the hospitals. Our aims were to describe the clinical and microbial profile of nosocomial sepsis in infants with vascular catheters [umbilical artery (UA), umbilical venous (UV), central venous Broviac (CV), percutaneously placed central venous (PC), peripheral artery (PA)], and to determine the association between catheter type, duration and sepsis in a subset of the population. Nosocomial sepsis (positive blood culture after the 3rd postnatal day) occurred in 217 of 2091 (10.4%) infants. Infected infants, in contrast to non-infected, had a significantly (P < 0.001) greater number of multiple catheters (2.3 vs 1.4) had lower birth weights (1.2 vs 2.1 kg), were younger (28 vs 33 weeks) and had lower 1 and 5 minute Apgar scores (4.3 and 6.7 vs 5.5 and 7.4). The most common organism was coagulase negative Staphylococcus. In a subset population as analyses revealed, longer duration of UA use was associated with higher infection rates [13.6% with UA use for > or = 8 days vs 1.3% for < or = 7 days (P < 0.0001)]. PC use had a lower rate of sepsis than CV use (5.1% vs 15.2%; P < 0.05). Use of intravascular catheters should be balanced between the need for vascular access and the risk of sepsis.

Neonatal surgery: intensive care unit versus operating room

The critically ill neonate with a surgical condition requires transfer to an operating room (OR), a process which may be associated with significant morbidity. In an effort to reduce such morbidity, we performed surgery on critically ill neonates in a designated area of our neonatal intensive care unit (NICU) over the past 4 years and have compared the outcome for infants operated on within the NICU with infants operated on in the OR over the same period. There were 81 procedures performed in the NICU compared with 112 in the OR. Infants operated on in the NICU had lower birthweights (1,758 g v 2,457 g), lower gestational ages (31.3 weeks v 35.8 weeks), and lower presurgical weights (2,118 g v 2,922 g) (all P < .0001). In addition, infants operated on in the NICU had a greater severity of illness with 78% requiring mechanical ventilation versus 26% for the OR group (P < .0001) with a higher presurgical FiO2 (.43 v .31, P = .005), and a higher presurgical mean airway pressure (8.0 cm H2O v 6.2 cm H2O) for infants requiring mechanical ventilation. The overall mortality was higher in the NICU group (14% v 2%), reflecting their underlying prematurity, illness, and anomalies. There was only one surgically related death, which occurred in the NICU group. There was no significant difference in culture-proven sepsis, length of surgery, change in weight, temperature, blood pressure, heart rate, FiO2, mean airway pressure, or oxygen index associated with surgery, but there was a significantly higher incidence of hyperthermia with a temperature of greater than 37.5 degrees C in the OR group (17.8% v 3.7%, P = .002). Our experience suggests that surgical procedures can be performed in the NICU for the unstable critically ill neonate with a morbidity comparable to that seen in the OR. Further experience is needed to compare the risks and benefits of this approach.

Broviac central venous catheters inserted via the saphenous or femoral vein in the NICU under local anesthesia

We present our experience with 92 Broviac central venous catheters inserted into 84 infants over a 31-month period. Our technique specifies placement in the neonatal intensive care unit under local anesthesia, with insertion to the inferior vena caval-atrial junction via the saphenous or femoral vein, with a subcutaneous tunnel to an exist site on the anterior thigh. We conclude this technique to be safe, efficient, convenient, cost-effective, and minimally uncomfortable to the infant, with no increase in morbidity or mortality in comparison to previously described methods.

Central venous catheters in surgical neonates

Central venous catheters (CVCs) are widely used in neonates, but have significant complication rates. Over a 4-year period, 65 lines were inserted in 55 surgical neonates with a total of 877 catheter days. The mean length of insertion was 13.5 days, with a range of 1 to 35 days. Eighty percent of the surgical diagnoses were of necrotising enterocolitis, diaphragmatic hernia, or gastroschisis. Insertion was almost exclusively via the internal jugular vein. Only two Broviac catheters were used, the other catheters were noncuffed. Fourteen (22%) were inserted in the neonatal unit, with a similar complication rate to those inserted in the surgical theater. Overall, complications occurred with 22 lines (34%), seven of which (11%) were primary catheter sepsis (infection incidence, 1:125 days). One patient died as a result of catheter sepsis. Although the complication rate was similar, the complication incidence per day of catheter usage was higher than comparable reports. It is not clear if this was due to the pathological conditions of the surgical neonate, surgical or nursing technique, or the type of catheter used.