Lymphocutaneous fistula as a long-term complication of multiple central venous catheter placement.

We report a case of a lymphocutaneous fistula in a 19-month-old boy who had been a premature neonate, born in the 23rd week of gestation. The fistula, an apparent complication of central venous line placement during the patient's first 5 months of life, was composed of a distinct lymphatic vessel bundle in the right supraclavicular region, with its exit point at the posterior aspect of the right shoulder. The drainage ceased immediately after resection and repair of a 1-cm obstruction in the superior vena cava.

Pregnancy in renal transplant recipients: case report.

Pregnancy in a renal homograft recipient resulted in an emergency cesarean section at 32 weeks' gestation secondary to maternal small bowel obstruction with necrotic bowel and subsequent intestinal perforation. The 1814 gm female product of this pregnancy had a moderate degree of in utero asphyxia, which subsequently, based on radiologic studies, had to be differentiated from the possibility of a congenital viral infection. Several concerns arose regarding the effects on the fetus by maternal immunosuppressive therapy, the risk factors faced by both the fetus and the mother secondary to the mother's renal disease, and the general outcome of the increasing number of pregnancies in this population.

Follow-up of patients who underwent arterial switch repair for transposition of the great arteries.

Thirty infants underwent arterial switch for transposition of the great arteries within the first week of life (mean age, 2.8 days). An additional three patients underwent repair at 5 1/2, 8, and 9 1/2 months of age. Six (18.2%) of 33 patients died. All the survivors were not receiving cardiac medications or diuretics at the time of the last follow-up visit. Examination of 24 of 27 survivors at 1 to 5 years of age revealed normal growth in 75% of the patients. Two patients had height, weight, and head circumference below the fifth percentile for age. Four patients had height and weight appropriate for age but head circumference below the fifth percentile. Neurodevelopmental testing yielded normal findings in 18 patients. Three patients were considered suspect and an additional three were abnormal neurodevelopmentally. Head circumference less than the fifth percentile, abnormalities on computed tomographic scans of the brain, and emergency balloon atrial septostomy or emergency switch operation were more likely to occur in patients who had low neurodevelopmental scores. We conclude that the majority of patients who undergo arterial switch repair demonstrate normal growth and development and no impairment of cardiovascular function. However, significant morbidity in the form of neurodevelopmental problems may occur.

Extracorporeal membrane oxygenation selection criteria: partial pressure of arterial oxygen versus alveolar-arterial oxygen gradient.

Extracorporeal membrane oxygenation (ECMO) has dramatically increased the survival rate of hypoxemic neonates who are unresponsive to maximum conventional medical therapy. Because ECMO involves multiple risks, including ligation of the right common carotid artery and right internal jugular vein, ECMO candidates should be neurologically intact neonates with a high probability of death despite maximum conventional ventilatory support. Currently, criteria based on the calculated alveolar-arterial oxygen gradient (A-aDO2) have replaced the neonatal pulmonary insufficiency index for predicting mortality and, thus, ECMO eligibility. A retrospective review of death prediction for the 26 months prior to the initiation of an ECMO program revealed a sensitivity of 67% and a specificity of 96% using the criterion of a PaO2 of less than 50 mm Hg for four hours. An equivalent A-aDO2 criterion of greater than or equal to 630 for four hours produced a sensitivity of 61% and a specificity of 96%. Prediction of mortality in neonates with sepsis was poor regardless of the criteria used. Excluding the deaths due to sepsis increased the sensitivity to 86% and 79% using criteria based on PaO2 and A-aDO2, respectively. It is concluded that the use of criteria based on PaO2 is equivalent to criteria based on A-aDO2 for predicting mortality. Criteria based on PaO2 may, however, decrease both the false-negative rate (patients with an elevated PCO2) and the false-positive rate (patients with intentionally induced hypocarbia secondary to hyperventilation alkalosis).

Right atrial thrombus formation screening using two-dimensional echocardiograms in neonates with central venous catheters.

Two-dimensional echocardiograms were used to prospectively screen 49 patients with 56 central venous catheters for right atrial thromboses from October 1985 to May 1986. All but four patients received a two-dimensional echocardiogram prior to insertion of the catheter. Once the catheters were in place, two-dimensional echocardiograms were performed no later than 3 weeks after insertion and then every 14 days until the catheter was removed. A single thrombus was detected 79 days after catheter placement (an incidence of 1.8%). Previous recommendations for weekly screening with two-dimensional echocardiogram were based on case reports alone. The 95% confidence limits for a negative two-dimensional echocardiogram result suggest that the initial two-dimensional echocardiogram screen for thrombus be obtained no sooner than 3 weeks after catheter insertion. In addition, significant gastrointestinal disease requiring operative intervention was present in 10 of 11 previous case reports as well as in our patient. Further studies with larger sample sizes are needed to determine whether subgroups of infants exist who are at a relatively higher risk for right atrial thrombus formation.

Developmental sequelae in premature infants undergoing ligation of patent ductus arteriosus.

One hundred sixteen infants who underwent on-unit ligation of patent ductus arteriosus (PDA) were examined for developmental sequelae. Mean gestational age of the study group was 29.1 weeks; mean birth weight, 1,232 gm; and mean duration of follow-up, 20.7 months (chronological age). Seven infants died of severe bronchopulmonary dysplasia (4) and severe central nervous system dysfunction (3) before they were 3 years old. Sixty-five percent of the remaining infants exhibited normal motor and mental development, although 58% showed some degree of postnatal growth retardation. There was no evidence of left arm dysfunction caused by the thoracic incision; 3 infants had minor problems with nonabsorbed sutures at 3 to 6 months of age. No infant demonstrated recurrence of ductal patency. Mild sensorineural handicaps not expected to be of long-term importance were noted in 20 infants. Eighteen other infants (15.5%) were classified as having moderate to severe impairments, which may have substantial impact on development and ability to function. Surgical ligation of PDA in premature infants has been shown to be safe and effective in the short run. Long-term follow-up suggests that infants who undergo PDA ligation do not appear to be at increased risk for sensorineural handicaps.