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.

Central venous catheter bloodstream infections in the neonatal intensive care unit.

PURPOSE: The goal of this study was to identify symptoms and signs related to central venous catheter (CVC) bloodstream infections (BSI) in neonatal intensive care unit (NICU) patients that would predict infection and to identify factors that might influence CVC longevity. METHODS: This was a retrospective cohort study evaluating 268 lines representing a total of 5,212 CVC days placed in 157 NICU patients over 29 months by the pediatric surgery and neonatology services at one children's hospital. Centers for Disease Control (CDC) criteria were used to determine laboratory-confirmed BSI. Data were analyzed by univariate methods and logistic regression and determined significant at the P less than .05 level. RESULTS: Sixty-five lines (24%) from 54 patients had confirmed CVC BSI. Fever (49%) and pulmonary dysfunction (30%) were the most common symptoms of CVC BSI. Erythema or purulent discharge at the insertion site was found in only 20% of cases. Staphylococcus epidermidis was the most common organism isolated. Factors that significantly decreased the incidence of CVC BSI were increasing estimated gestational age (EGA; P < .0013) attime of insertion, associated vancomycin use at the time of catheter placement (P < .0057), and fewer days of catheter use (P < .0291). There were no significant differences noted caused by line location or catheter type. CONCLUSION: Fever and pulmonary dysfunction were the most common signs of CVC BSI in neonates. Lower EGA and increased catheter duration were significantly correlated with infection. The use of vancomycin concurrent with catheter insertion was associated with a decreased incidence of CVC BSI, howeverconcerns regarding the emergence of vancomycin-resistant organisms preclude support of its use as a prophylactic agent.

Exogenous surfactant decreases oxygenation in Escherichia coli endotoxin-treated neonatal piglets.

Abnormalities of pulmonary surfactant function have been described in association with the acute respiratory distress syndrome (ARDS). Because gram-negative sepsis is a common cause of ARDS, we treated neonatal piglets with Escherichia coli endotoxin to create a neonatal ARDS model. We hypothesized that under these conditions administration of exogenous surfactant would improve pulmonary function. Study groups included: control (n-8), Exosurf (5 mL/kg, 13.5 mg phospholipid/mL, n-7), Survanta (4 mL/kg, 25 mg phospholipid/mL, n-6), and saline (5 mL/kg, n = 6). E. coli endotoxin 12 micrograms/kg was infused over 30 min and resulted in significant pulmonary and hemodynamic abnormalities, histopathologic evidence of nonhomogeneous lung injury, and elevated protein levels in bronchoalveolar lavage washings. Neither Exosurf nor Survanta ameliorated the pulmonary effects of endotoxin. Instead, there was a prolonged decrease in arterial oxygen tension (PaO2) and dynamic lung compliance after administration of surfactant and saline. Distribution of a bolus of Exosurf was uneven throughout the lung. We conclude that in this neonatal piglet model of ARDS, bolus surfactant administration had a detrimental effect on oxygenation and pulmonary function.

Preservation of pulmonary function in the ventilated neonatal piglet with normal lungs.

Little attention has been focused on the progressive pulmonary deterioration which occurs in mechanically ventilated infants with normal or mildly abnormal lungs. We hypothesized that lung function would deteriorate over a 24-hr period in anesthetized neonatal piglets with normal lungs mechanically ventilated at 2 cm H2O PEEP (2PEEP group). We further hypothesized that an intermittent lung inflation procedure consisting of 15 out of 60 min of increasing lung distention (4, 8, 12 cm H2O PEEP), with the remaining 45 min at 2 cm H2O PEEP (Inflation group) would prevent this deterioration in lung function, similar to piglets mechanically ventilated continuously at 6 cm H2O PEEP (6PEEP). Results indicate that 2PEEP piglets experienced progressive deterioration in lung function, including dynamic lung compliance (-42%) and lung resistance (+55%). In contrast, inflation piglets and 6PEEP piglets had no deterioration in lung function. Hemodynamics were similar between groups, although they were the most stable in the 6PEEP group. Histopathological changes were not significantly different. We conclude that (1) prolonged mechanical ventilation at 2 cm H2O PEEP in neonatal piglets resulted in progressive deterioration in pulmonary function, (2) intermittent lung inflation or continuous 6 cm H2O PEEP prevented deterioration, and (3) functional changes occurred without changes in histopathology. Lung inflation strategies other than PEEP can be used to prevent deterioration in lung function which accompanies prolonged mechanical ventilation in anesthetized nonspontaneously breathing piglets with normal lungs.

Contraceptive practices before conception and after the birth of a child with a chronic health problem.

Sexual and marital relations as well as family functioning may be altered by the birth of a child with a chronic health problem. After the birth of a child with a health problem, mothers have varied responses from an urgent desire to have another baby to a firm desire to avoid pregnancy. Mothers of healthy infants and mothers of infants who had been placed on apnea monitors for at least 5 months were surveyed on their contraceptive practices, family functioning, their marital satisfaction and sexual satisfaction, as well as their desire to have or not have another child. Surveys were conducted at 6 months and 12 months after delivery. The type of contraception used varied significantly between the two groups of mothers. There was an increase in the use of oral contraception after birth for the women whose infants were on apnea monitors. Frequency in the use of contraception varied between the two groups, with the mothers of healthy infants reporting more consistent use prior to the pregnancy, which was also more frequently planned than in the apnea group. Correlation matrices demonstrated a significant relationship between type of contraception and marital satisfaction, employment, and spousal support. The findings reinforce the need for health professionals to assist families in identifying how the birth of a child with chronic health problems has affected the family. Contraception counseling as well as marital counseling may be needed for some families.

PIP: In a US Midwest urban area, nurse researchers compared data on 50 mother-father dyads of healthy infants with data on 20 mothers and 17 fathers of infants at risk for apnea (ARFA) to learn their contraceptive practices, family functioning, marital satisfaction, sexual satisfaction, and future fertility preferences. By 12 months, none of the ARFA infants needed the apnea monitor. Mothers of healthy infants were significantly more likely to be satisfied with their marriage than ARFA mothers at 6 and 12 months (p = .031 and .004, respectively). In fact, between 6 and 12 months, marital satisfaction decreased considerably for ARFA mothers (p = .027). Parents of healthy infants had just slightly more sexual satisfaction than ARFA parents at 6 and 12 months. Contraceptives varied significantly between the 2 groups (p + .027). At 6 months, ARFA mothers accepted oral contraceptives (OCs) (42%) significantly more often than any other contraceptive method. In fact, between preconception and the postpartum period, OC use for this group increased 24%. Just 2 mothers of healthy infants at 6 months and none at 12 months used OCs. Parents of healthy infants were more likely to use condoms than ARFA parents (28% vs. 10%). Little difference existed between the 2 groups in use of diaphragms (20% for healthy and 27% for ARFA). Mothers of healthy infants were more likely to use contraception prior to conception of index infant the ARFA mothers (72% vs. 40%). At 12 months, ARFA parents who received emotional support from their spouses and who were more satisfied with their marriage were significantly more likely to not use contraceptives than those who did not receive support and were unsatisfied with their marriages. This relationship did not exist for parents of healthy infants. These findings support the need for health providers to help families learn how an infant affects the family as well as the parental relationship, so they can arrange for appropriate counseling, including contraception counseling.

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.

New technique for stabilizing umbilical artery catheters in very low birthweight infants.

The securing of umbilical artery catheters (UACs) with tape bridges has been associated with significant dermal complications in the very low birthweight neonate. We describe a new technique for UAC stabilization using an anchoring adhesive tape applied directly to the catheter, which is in turn sutured to the cord. This technique provides a very satisfactory method of UAC stabilization and avoids skin complications associated with the standard methods.

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.

Functioning parathyroid lipoadenoma. Report of a case diagnosed by intraoperative touch preparations.

Lipoadenoma of the parathyroid gland is an unusual cause of primary hyperparathyroidism. Inasmuch as they may grossly resemble lipoma more than parathyroid adenoma, these tumors may be missed by surgeons and surgical pathologists alike. In this case, the diagnosis was made during surgery utilizing touch preparations because frozen sections were technically difficult to perform due to the fat content of the tumor. Examination of multiple sections disclosed a neoplastic proliferation of parathyroid cells, thus supporting the premise that this entity represented an adenoma rather than a hamartoma.

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.

Tetraploidy: a report of three live-born infants.

We present three live-born infants with tetraploidy and compare them with two previously reported live-born infants with the same genetic defect. Common anomalies noted included microcephaly; a prominent, narrow forehead; microphthalmia/anophthalmia; cleft palate; orthopedic anomalies; genital ambiguity; and abnormalities of the central nervous system, including pituitary hypoplasia. Together these constitute a rather characteristic phenotype. An error in cytoplasmic cleavage is theorized to be a mechanism for the chromosome anomaly and is supported by the presence of parental polymorphisms in one of our cases; however, the presence of a small percentage of tetraploid cells in the leukocytes and skin fibroblasts of this patient's mother does not exclude maternal mosaicism as the basis for polyploidy in certain instances.

Factors related to parathyroid weight in normal persons.

In a study of the parathyroid glands from 100 subjects who consecutively underwent autopsy, we found that median individual gland weight was 25.7 mg (95% weighed between 8.2 and 75.0 mg) and median individual gland parenchymal weight was 17.2 mg (95% weighed between 5.3 and 49.3 mg). Values were significantly skewed toward higher weights. Glandular weights were lower in patients with chronic illnesses, lower in women than in men, and lower in whites than in blacks. We found an inverse correlation between parenchymal weight and serum calcium concentration. Our results suggested that both total and parenchymal weights have a wider range of normal than is generally appreciated, and that a variety of factors probably affect parathyroid gland weight. A reevaluation of the weight of the parathyroid gland in normal persons is needed.