Peripheral nerve blockade and neonatal limb ischemia: our experience and literature review

[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.

Management of Neonatal Limb Ischemia Secondary to Peripheral Arterial Lines: A Systematic Review

Limb ischemia is a rare complication of peripheral arterial lines, but there is inconsistency with management. We aimed to describe the variation in the management of limb ischemia secondary to a peripheral arterial line and to determine a consensus for management. The systematic review consisted of searching PubMed, Scopus, Ovid MEDLINE, Google Scholar, Cochrane Database of Systematic Reviews, and references of journals using pre-trialed medical subject headings terms and articles. The sources were scrutinized against inclusion and exclusion criteria. Twenty-six articles were included for full-text analysis: seven retrospective reviews and 19 case reports. The most common site of insertion was femoral (30%), followed by radial (25%). Seventy-one percent of the patients were treated medically, 18% surgically, 9% both medically and surgically, and one patient was treated conservatively with debridement and accurate approximation. The majority of interventions were successful in treating limb ischemia, with 91% achieving a good outcome. All patients who received glyceryl trinitrate (GTN) and all surgical interventions, including conservative management, achieved good outcomes. Medical management was successful in 92%, whereas a combined approach of surgical and medical management was successful in 75% of patients. There is wide variation in the management of limb ischemia secondary to peripheral arterial lines. There is apparent success observed with topical 2% GTN and surgical interventions, with thrombolysis and, in case of no improvement, with thrombectomy, across various studies. We recommend that an updated international consensus be reached on the management of neonates with limb ischemia secondary to a peripheral arterial line.

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.

Neonatal limb ischemia: caudal blockade and NIRS monitoring

The treatment of neonatal limb ischemia (LI) is challenging for neonatologists. Peripheral nerve blockade (PNB), alone or in association with other therapies, represents a valid therapy in case of vascular spasm or thromboembolic events responsible for LI. In the present case report, we describe the clinical history of a preterm neonate with catheter-related thrombosis of the left leg. PNB was not performed according to the traditional technique but rather by a peridural catheter left in situ for 9 days with a continuous infusion of ropivacaine. In conclusion, the effectiveness of this approach was confirmed by the contemporary near-infrared spectroscopy monitoring, documenting gradual improvement of leg perfusion.

Topical Nitroglycerine for Neonatal Arterial Associated Peripheral Ischemia following Cannulation: A Case Report and Comprehensive Literature Review

Arterial cannulation in neonates is usually performed for frequent blood pressure monitoring and blood sampling. The procedure, while easily executed by skilled neonatal staff, can be associated with serious complications such as vasospasm, thrombosis, embolism, hematoma, infection, peripheral nerve damage, ischemia, and tissue necrosis. Several treatment options are available to reverse vascular induced ischemia and tissue damage. Applied interventions depend on the extent of tissue involvement and whether the condition is progressive and deemed life threatening. Standard, noninvasive measures include immediate catheter removal, limb elevation, and warming the contralateral extremity. Topical vasodilators, anticoagulation, thrombolysis, and surgery are considered secondary therapeutic strategies. A comprehensive literature search indicates that topical nitroglycerin has been utilized for the treatment of tissue ischemia in three preterms with umbilical arterial catheters and four with peripheral arterial lines. We report the first successful use of nitroglycerine ointment in a critically ill preterm infant with ischemic hand changes after brachial artery cannulation.