Arterial catheterisation in neonates can result in severe ischaemic complications but does not impair long-term extremity function

Acute Limb Ischemia in Pediatric Intensive Care Units

BACKGROUND

To determine the outcome of children treated for acute limb ischemia (ALI) in pediatric intensive care units (ICUs).

METHODS

A single-center, retrospective cohort study including all patients diagnosed with ALI between 2005 and 2022 in 2 different pediatric ICUs: respiratory and cardiac ICU. Data collected included patients demographics and comorbidities, location and cause of arterial occlusion, and type and duration of therapy. Primary end point was freedom from amputation. Secondary end point was all-cause mortality.

RESULTS

A total of 78 patients (58% male) with ALI were included in the study. Median age was 3.8 months (range 0.03-201). The lower extremity was involved in 55 (70%) patients. The limb ischemia was caused by arterial instrumentation in 94% of the patients. Anticoagulation was administered as the first-line therapy in all patients. Unfractionated heparin was administered for a median duration of 5 days (range 1-48). Low molecular weight heparin was continued for a median period of 28 days (range 4-420). Thrombolytic therapy was administered in 5 patients and 2 required surgical revascularization, all for failure of anticoagulation therapy. Mean follow-up was 21 months (range 1-188 months). None of the patients required major upper or lower extremity amputations during or after the index admission. Overall survival at 30 months was 68%. The causes of mortalities were unrelated to the limb ischemia.

CONCLUSIONS

This large, single-center study demonstrates that ALI in the pediatric ICU population can be treated conservatively and is associated with a low amputation rate following nonoperative management. The favorable outcome exists regardless of the etiology of the ALI and underlying diseases.

Complications of Peripheral Arterial Access in Preterm and Term Neonates: A Systematic Review

The aim of the study is to provide a comprehensive review of vascular complications secondary to peripheral arterial catheterization in preterm and term neonates. The systematic review consisted of searching PubMed, Scopus, Google Scholar, Cochrane Database of Systematic Reviews, and references of journals using pre-trialed MeSH terms and articles. Eight studies were included for full text analysis from 2,369 initial articles: six retrospective reviews and two prospective studies. Rate of complication was 8.6% and all complications were ischemic in nature. Complications most often occurred in neonates with pulmonary/cardiac comorbidities and lower gestational ages. No association was found for weight and sex of neonates. The radial artery site presented with lower rates of complication of 6% and the femoral presented with the highest (16%). Complications predominately occurred in catheter sizes larger than 22 gauge and most often within 1 day of insertion. A low rate of complications (7.4%) was observed in studies that used heparinized saline at the time of catheterization. This study demonstrates an increasing overall rate of complications with ischemia presenting as the most common complication. There seems to be an association between gestational age, comorbidities, site of catheter, size of catheter, and duration of catheter with such complications. This study also demonstrates the association between the use of heparinized saline and a reduction in rate of complications. The authors advocate for a national data collection tool of all pediatric arterial catheters and its complications to be able to analyze and work on best practice to minimize life changing iatrogenic complications.

Local nitroglycerin to facilitate peripheral arterial cannulation in children: systematic review and meta-analysis

BACKGROUND

Neonates and children admitted to intensive care units require peripheral arterial cannulation to monitor their blood pressures and for blood sampling, but many times it is unsuccessful.

OBJECTIVE

To conduct a systematic review and meta-analysis to evaluate the efficacy and safety of local nitroglycerin (NTG) to facilitate peripheral artery cannulation in neonates and children.

REVIEW METHODS

PubMed, EMBASE, CINAHL, Emcare and Cochrane library were searched till August 2021. Grey literature was searched through Mednar. Data were extracted by two reviewers independently using a prespecified form and the risk of bias was assessed. Meta-analysis was conducted using a random-effects model. The I2 statistic was used to quantify statistical heterogeneity. Certainty of evidence was assessed using the criteria of inconsistency, imprecision, indirectness, publication bias and size of effect as per the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines.

RESULTS

Two randomised controlled trials (RCTs) were included in this meta-analysis (n=153). One was conducted in children 2-8 years of age and the other was in children <2 years. Both trials found increased success rates with the use of local NTG. Pooling of the two studies found that the first-attempt success rate was significantly higher in the NTG group (risk difference: 0.44, 95% CI 0.05 to 0.83; I2=89%). Overall procedure time was significantly lower in the NTG group (mean difference: -100.28 s, 95% CI -136.74 to -63.82; I2=0%). No major complications secondary to the use of NTG were noted. The GRADE of evidence was very low.

CONCLUSION

Local NTG may be useful in facilitating peripheral arterial cannulation in children. Adequately powered RCTs are needed to confirm these findings.

Phenotyping respiratory decompensation following definitive closure of the patent ductus arteriosus in preterm infants

OBJECTIVE

To identify risk factors associated with high-frequency ventilation (HFV) following definitive closure of the patent ductus arteriosus (PDA).

METHODS

We performed a retrospective study of premature infants (<37 weeks) who were mechanically ventilated before and after surgical or transcatheter PDA closure. Primary outcome was HFV requirement within 24 h of procedure. Logistic regression was used to estimate clinical associations with post procedure HFV requirement.

RESULTS

We identified 110 infants who were mechanically ventilated before PDA closure, of which 48 (44%) escalated to HFV within 24 h after closure. In the multivariable model, surgical ligation (OR 21.5, 95% CI 1.6-284), elevated Respiratory Severity Score (RSS) 1 h post-procedure (OR 1.78, 95% CI 1.07-2.99) and 12 h post-procedure (OR 2.12, 95% CI 1.37-3.26) were independent predictors of HFV.

CONCLUSION

Surgical ligation and elevated RSS values over the first 12 h after PDA closure are risk factors for HFV.

[Transient Ischemia of One Leg in a Very Low Birthweight Infant]

Ischemias in the extremities are rather rare in the neonatal period. Both intrauterine and postnatal factors can cause ischemias. We present the diagnostic procedure and the course in a female very low birthweight (VLBW) infant with transient ischemia in the lower extremity.

Value of peripheral perfusion index to predict acute limb ischaemia in newborns after peripheral artery cannulation

AIMS AND OBJECTIVES

To investigate the feasibility of using peripheral perfusion index (PPI) to monitor acute limb ischaemia (ALI) in newborns after catheterisations.

BACKGROUND

ALI is common complication of neonatal peripheral artery cannulation. It is important to address as soon as the early signs of ALI. PPI could aid in noninvasive evaluation of distal extremity perfusion in an effort to notify risk of potential ischaemic injury from catheterisations.

DESIGN

A nested case-control study.

METHODS

Clinical information of newborns who had been admitted to the Neonatal Intensive Care Unit of Jiangxi Provincial Children's Hospital and had received peripheral artery cannulation from January 2018 to January 2020 was prospectively collected. Transcutaneous blood oxygen saturation (TcSO₂ ), PPI and delta-PPI (ΔPPI1; the difference in PPI values of the two arms. ΔPPI2; difference in the PPI values before and after cannulation) were recorded. We used STROBE checklist as an EQUATOR in this study.

RESULTS

A total of 25 newborns with ALI were included in the study. These were then paired with 100 newborns without ALI. The PPI and TcSO₂ of the cannulated limb were significantly lower in the ALI group than in the non-ALI (NALI) group (p < .05). The area under the receiver-operating characteristic curve was significant for ΔPPI1. The ΔPPI1 had a sensitivity and specificity of 92% and 87%, respectively, for diagnosing ALI. ΔPPI1 greater than 0.315 suggested that the infant was at risk of ALI.

CONCLUSIONS

Monitoring the change in the PPI in newborns after catheterisations helped in the early assessment of ALI.

RELEVANCE TO CLINICAL PRACTICE

Drops in the PPI and TcSO₂ of the cannulated limbs might, to some extent, reflect the possibility of ALI in newborns. ΔPPI1 (the difference in PPI values of the two arms) proved to be a simple, objective parameter to predict the presence of ALI.

Adverse events associated with umbilical catheters: a systematic review and meta-analysis

OBJECTIVE

To determine the incidence of adverse events (AEs) associated with umbilical catheters in the neonatal population.

STUDY DESIGN

Systematic review and meta-analysis of observational studies and randomized controlled trials published between 2010 and 2020.

RESULTS

In total 14,226 umbilical venous catheters (UVCs) and 4228 umbilical arterial catheters (UACs) were included. Overall, 13.4% of UVCs were associated with an AE (95% CI: 10.1-17.0) or 2.4 per 1000 catheter days (95% CI: 1.8-3.0). UACs had an AE rate of 9% (95% CI: 5.9-12.8) or 0.87 per 1000 catheter days (95% CI: 0.4-1.3). UVC malposition was the most common (41.7% [95% CI: 27.6-56.5]). Local injury from UAC taping was the most common AE in one study.

CONCLUSIONS

Umbilical catheters have a high incidence of AEs. Research into accurate methods of tip verification, tip surveillance, and securement is required.

Risk factors for umbilical vascular catheter-related adverse events: A scoping review

INTRODUCTION

Adverse events associated with umbilical catheters include malposition, bloodstream infections, thrombosis, tip migration, and extravasation, resulting in loss of vascular access and increased risk of morbidity and mortality. There is a need for greater understanding of risk factors associated with adverse events to inform safe practice.

OBJECTIVES

The aim of the study was to summarise the existing evidence regarding risk factors for umbilical catheter-related adverse events to inform the undertaking of future research.

REVIEW METHOD USED

A scoping review of peer-reviewed original research and theses was performed.

DATA SOURCES

The US National Library of Medicine National Institutes of Health, Embase, EMcare, and ProQuest Dissertations and Theses were the data sources.

REVIEW METHODS

Informed by the Joanna Briggs Institute Reviewer's Manual, all types of original research studies reporting adverse events published in English from 2009 to 2020 were eligible for inclusion. Studies where umbilical artery catheter and umbilical venous catheter data could not be extracted separately were excluded.

RESULTS

Searching identified 1954 publications and theses, 1533 were excluded at screening, and 418 were assessed for eligibility at full text. A total of 89 studies met the inclusion criteria. A range of potential risk factors for umbilical arterial and venous catheters were identified. Longer dwell time and prematurity were associated with increased risk of bloodstream infection and thrombosis in cohort studies. Case studies detailed analogous factors such as insertion techniques and lack of catheter surveillance during dwell warrant further investigation.

CONCLUSIONS

We identified a vast range of patient, device, and provider risk factors that warrant further investigation. There was a lack of large cohort studies and randomised controlled trials to demonstrate the significance of these risk factors. Improvement in methods to ensure correct catheter tip location and to detect adverse events early is essential. In addition, policy needs to be developed to guide clinicians in catheter surveillance measures to reduce the risk of adverse events.

Discrepancy between invasive and non-invasive blood pressure readings in extremely preterm infants in the first four weeks of life

Background

The agreement between invasive and non-invasive blood pressure (BP) readings in the first days of life of preterm infants is contentiously debated.

Objective

To compare mean, systolic and diastolic invasive (IBP) and non-invasive BP (NBP) readings obtained during routine care in the first four weeks of life of extremely preterm infants.

Methods

We extracted pairs of IBP and NBP readings obtained from preterm infants born below 28 weeks of gestation from the local database. After exclusion of erroneous measurements, we investigated the repeated measures correlation and analyzed the agreement (bias) and precision adjusted for multiple measurements per individual.

Results

Among 335 pairs of IBP and NBP readings obtained from 128 patients, we found correlation coefficients >0.65 for mean, systolic and diastolic BP values. The bias for mean BP readings was -0.4 mmHg (SD 6.1), for systolic BP readings 6.2 mmHg (SD 8.1), and for diastolic BP readings -4.3 mmHg (SD 6.5). Overestimation of systolic IBP and underestimation of diastolic IBP by the non-invasive measurement were found both in the group with gestational age from 23 to 25.9 weeks and in the group with gestational age from 26 to 27.9 weeks. Systolic NBP readings tended to exceed invasive readings in the range <50 mmHg (bias 9.9 mmHg) whereas diastolic NBP readings were lower than invasive values particularly in the range >30 mmHg (bias -5.5 mmHg).

Conclusion

The disagreement between invasive and non-invasive BP readings in infants extends to the first four weeks of life. Biases differ for mean, systolic and diastolic BP values. Our observation implies that they may depend on the range of the blood pressure. Awareness of these biases and preemptive concomitant use of IBP and NPB readings may contribute to reducing over- or under-treatment.