Catheterization of umbilical vessels in newborn infants.
About: This article is published in Pediatric Clinics of North America.The article was published on 1970-11-01. It has received 162 citations till now.
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TL;DR: In this paper, a continuous positive airway pressure was applied to 20 infants severely ill with idiopathic respiratory-distress syndrome (IRS) to lower the inspired oxygen within 12 hours.
Abstract: We applied a continuous positive airway pressure to 20 infants (birth weight 930 to 3800 g) severely ill with the idiopathic respiratory-distress syndrome. They breathed spontaneously. Pressure, up to 12 mm of mercury, was delivered through an endotracheal tube to 18 infants and via a pressure chamber around the infant's head to two. Arterial oxygen tension rose in all, permitting us to lower the inspired oxygen an average of 37.5 per cent within 12 hours. Minute ventilation decreased with increased continuous positive airway pressure, but this had little effect on arterial carbon dioxide tension, pH, arterial blood pressure and lung compliance. Sixteen infants survived, including seven of 10 weighing less than 1500 g at birth.
1,093 citations
TL;DR: It is concluded that the fluctuating pattern of cerebral blood-flow velocity in infants with the respiratory-distress syndrome indicates an extreme risk of the development of intraventricular hemorrhage and may represent a major and potentially preventable etiologic factor.
Abstract: We studied whether changes in cerebral blood-flow velocity occur during the respiratory-distress syndrome and whether, if present, they are related to the subsequent occurrence of intraventricular hemorrhage. Fifty infants weighing less than 1500 g at birth who required mechanical ventilation for the respiratory-distress syndrome were studied from the first hours of life. Blood-flow velocity in the anterior cerebral artery was measured at the anterior fontanel by means of the Doppler technique. At 12 hours of age, the infants had blood-flow velocity patterns that were either stable or fluctuating and that reflected the patterns of simultaneously recorded blood pressure. Intraventricular hemorrhage subsequently developed in 21 of 23 infants with the fluctuating pattern (in most of them, within the next 24 hours), but in only 7 of 27 infants with the stable pattern. Preliminary data suggest that the cerebral hemodynamic fluctuations are related to the respiratory disease and particularly to the mec...
479 citations
TL;DR: Infection and complication rates were similar between infants managed with an umbilical vein catheter in place for up to 28 days compared with infants managed for 7 to 10 days, and durations beyond the current Centers for Disease Control and Prevention–recommended limit of 14 days may be reasonable.
Abstract: BACKGROUND. Umbilical vein and percutaneous central venous catheters are often used in preterm infants, but they can lead to complications, including infection. OBJECTIVE. We hypothesized that long-term umbilical vein catheter use would result in fewer infections than short-term umbilical vein catheter use followed by percutaneous central venous catheter placement. DESIGN/METHODS. Infants ≤1250 g with umbilical vein catheters placed at admission were randomly assigned to a long-term (umbilical vein catheter up to 28 days) or short-term (umbilical vein catheter for 7–10 days followed by percutaneous central venous catheter) group. Catheter infection was defined as symptoms and ≥1 positive blood culture for definite pathogens or >1 positive culture for other organisms, with a catheter in place. Clinically significant echocardiogram findings were defined as thrombi threatening vascular occlusion, crossing/blocking heart valves, or otherwise felt to be significant by the cardiologist. The primary outcome was time from birth to catheter infection, analyzed by the log-rank test. RESULTS. There were 106 subjects in the short-term group and 104 in the long-term group with birth weights of 915 ± 198 and 931 ± 193 g and gestational ages of 27.8 ± 2.0 and 27.7 ± 2.2 weeks, respectively. The distribution of time to catheter infection did not differ between the groups. The overall incidence of catheter infection was 13% in the short-term group and 20% in the long-term group. Median age at catheter infection was 11.5 days in the short-term group and 14 days in the long-term group. There were 7.4 infections per 1000 catheter-days in the short-term group and 11.5 per 1000 in the long-term group. Seven infections in the short-term group were in umbilical vein catheters, and 18 infections in the long-term group were in umbilical vein catheter. Echocardiograms detected 4 infants in the short-term group and 7 infants in the long-term group with significant thrombosis. All significant thrombi were at the site of the umbilical vein catheter tip. No thrombus caused hemodynamic compromise, no child had clinical symptoms of thrombosis, and none required therapy. Of the 45 small-for-gestational-age infants in the study, 9 developed thrombi (short-term group, 4; long-term group, 5). The incidence of thrombi was higher in the small-for-gestational-age group (20%) versus other study subjects (9%). There were no differences in time to full feedings or to regain birth weight or in the incidence of necrotizing enterocolitis or death. CONCLUSIONS. Infection and complication rates were similar between infants managed with an umbilical vein catheter in place for up to 28 days compared with infants managed with an umbilical vein catheter replaced by a percutaneous central venous catheter after 7 to 10 days. Umbilical vein catheter durations beyond the current Centers for Disease Control and Prevention–recommended limit of 14 days may be reasonable.
134 citations
TL;DR: Current methods to determine insertion length and confirm location of UVCs are not adequate and echocardiography should be considered to confirm correct placement of U VCs.
Abstract: OBJECTIVE: To compare techniques for guiding and confirming placement of umbilical venous catheters (UVCs) using two-dimensional echocardiography. STUDY DESIGN: Fifty-three newborns admitted to our neonatal intensive care unit who required an UVC or who were transferred within 24 hours of UVC placement at a referring hospital were studied. UVC position was assessed by antero-posterior (AP) chest radiography (CXR), lateral CXR, and oxygenation data. The accuracy of the above techniques was compared to echocardiography with saline contrast injection. RESULTS: Echocardiography revealed that UVCs were located ideally at the right atrial/inferior vena cava junction in only 12 (23%) of 53 patients. Twenty-four (45%) were incorrectly positioned in the left atrium. The sensitivity and specificity of AP CXR in evaluating inappropriate UVC position were 32% and 89%, respectively. Lateral CXR and thoracic level on AP CXR did not predict accurately catheter position. UVC pO2 data were not useful in excluding left atrial placement. CONCLUSION: Current methods to determine insertion length and confirm location of UVCs are not adequate. Echocardiography should be considered to confirm correct placement of UVCs.
117 citations
TL;DR: The objective was to determine the risk factors associated with umbilical vascular catheter‐associated thrombosis and to establish a registry of patients diagnosed with this condition.
Abstract: Objective: To determine the risk factors associated with umbilical vascular catheter-associated thrombosis. Methods: All consecutive inborn infants with umbilical arterial (UAC) and/or umbilical venous catheters (UVC) inserted for more than 6 h duration were included in the study. Each infant was screened for thrombosis in the abdominal aorta and inferior vena cava by 2-D abdominal ultrasonography within 48-72 h of insertion of umbilical vascular catheters. Subsequent serial scanning was performed at intervals of every 5-7 days, and within 48 h after removal of catheters. Results: Upon removal of umbilical catheters, abdominal aortic thrombi were detected in 32/99 (32.3%) infants with UAC. Small thrombi were detected in the inferior vena cava of 2/49 (4.1%) infants with UVC (one of whom had both UAC and UVC). When compared with those who received only UVC (n = 18), infants who received either UAC alone (n = 68) or both UAC and UVC (n = 31) had significantly higher risk of developing thrombosis (odds ratio (OR): 7.6, 95% confidence interval (Cl): 1.1, 325.5)). Logistic regression analysis of various potential risk factors showed that the only significant risk factor associated with the development of abdominal aortic thrombosis following insertion of UAC was longer duration of UAC in situ (for every additional day of UAC in situ, adjusted OR of developing thrombosis was: 1.2, 95% Cl : 1.1, 1.3; P = 0.002). Conclusion: Umbilical arterial catheter-associated thrombosis was common. Umbilical arterial catheter should be removed as soon as possible when not needed. Upon removal of UAC, all infants should be screened for abdominal aortic thrombus by 2-D ultrasonography.
115 citations
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Journal Article•
665 citations
TL;DR: In this study ACh was used to demonstrate a mechanism, and a firm recommendation for use of ACh (or other pulmonary vasodilator) in this syndrome must await a convincing test carried out with proper experimental design in a sufficiently large number of subjects.
Abstract: We made detailed observations of the cardiopulmonary manifestations of the respiratory distress syndrome in 27 infants. In most respects these confirmed observations reported by other investigators. Expiratory complaint was a major feature of the disease, and its effects on cardiac input and on the work of breathing have been discussed. It may have been the result of reflexes initiated in the pulmonary vessels when they were strongly stimulated to constrict. Infants with severe respiratory distress showed systemic hypotension, cutaneous vasoconstriction, oliguria, and ileus. They usually had slightly increased minute volume. Lung compliance and volume and the ratio of compliance to lung volume were decreased, but respiratory resistance was normal. Apparent physiological deadspace was greatly elevated, and apparent alveolar ventilation was therefore greatly decreased. Arterial oxygen tension was below the predicted values, and there was moderate to very large fractional right-to-left shunt which appeared to occur principally through the foramen ovale and to a lesser extent through the ductus arteriosus. There was both respiratory and metabolic acidosis. Effective pulmonary blood flow was often strikingly reduced, as was cardiac input, roughly estimated from effective pulmonary blood flow and fractional right-to-left shunt. Administration of dipalmitoyl lecithin as an aerosol was followed by increase in lung compliance, which occurred even in those infants who died. Infusion of acetylcholine caused a rapid, large increase in effective pulmonary blood flow accompanied by a marked rise in estimated cardiac input, a decrease in fractional right-to-left shunt, an increase in carbon dioxide elimination, alleviation of expiratory complaint, an increase in cutaneous blood flow and an increase in responsiveness and motor activity. We conclude that these infants had marked pulmonary vasoconstriction and ischemia because they had low effective pulmonary blood flow when the right ventricular pressure was normal and because acetylcholine rapidly increased effective pulmonary blood flow with a drop in right ventricular pressure. Pulmonary ischemia was present early in the disease. We also conclude that these infants had low systemic blood flow, especially in the renal, mesenteric, and cutaneous vascular beds, and that administration of acetylcholine and increase in pulmonary blood flow brought about a rise in the estimated cardiac input and a more normal distribution of systemic flow. Because administration of dipalmitoyl lecithin was followed by an increase in lung compliance, even in infants whose gas transfer was not improved and who died, and infusion of acetylcholine caused prompt improvement in gas transfer, blood flow, and clinical status without simultaneous increase in lung compliance, volume or ventilation, we conclude that ischemia in pulmonary and certain systemic vascular beds may have presented greater functional difficulty to these infants than did pulmonary atelectasis and hyaline membranes. In this study ACh was used to demonstrate a mechanism, and, in our opinion, a firm recommendation for use of ACh (or other pulmonary vasodilator) in this syndrome must await a convincing test carried out with proper experimental design in a sufficiently large number of subjects.
287 citations
Journal Article•
TL;DR: Hemodynamic measurements by means of cardiac catheterization were obtained in 38 infants in the first 30 hours after birth and the infants with severe respiratory distress had widely patent ducti, with large left- to-right shunts and, in some instances, right-to-left shunts.
Abstract: Hemodynamic measurements by means of cardiac catheterization were obtained in 38 infants in the first 30 hours after birth. Nineteen of these infants were considered to have normal circulatory and respiratory systems. Nine had mild respiratory distress, and 10 had severe respiratory distress. The circulatory systems of infants with mild respiratory distress did not appreciably differ from the normal. Some infants in both these groups showed evidences of patency of the ductus arteriosus with a small left-to-right shunt for the first 10 to 15 hours after birth. The infants with severe respiratory distress had widely patent ducti, with large left-to-right shunts and, in some instances, right-to-left shunts. The pulmonary arterial and systemic arterial pressures were lower in these infants as compared to the normal and those with mild respiratory symptoms. These characteristics of the severely distressed infants could be related to the disease process, but may be due to prematurity alone. The possible role of left ventricular failure associated with a large left-to-right ductal shunt is discussed. A generalized lack of vasoconstrictor tone could possibly be responsible for systemic and pulmonary arterial hypotension as well as for the widely patent ductus arteriosus.
199 citations
TL;DR: A recent 3.5-fold increase in thrombosis of large vessels in autopsies is believed to be related to direct mechanical injury and alteration of flow in catheterized vessels.
181 citations
TL;DR: Risk of local and systemic infection associated with polyethylene intravenous catheters was determined in a prospective study of 213 catheterizations in 176 general medical and surgical patients and such bacteremia was a major contributing cause of death in 1 per cent.
Abstract: Risk of local and systemic infection associated with polyethylene intravenous catheters was determined in a prospective study of 213 catheterizations in 176 general medical and surgical patients. Catheters were used in approximately 80 per cent of all patients receiving fluids. Phlebitis occurred in 39 per cent of catheterizations but was not a reliable sign of local infection; cultures of less than half the catheters removed from phlebitic patients were positive at the time of removal. One third of all catheters were positive by culture at removal. Risk of local infection with pathogenic organisms increased with duration of use. Risk of catheter-induced bacteremia was 2 per cent in the study group, and such bacteremia was a major contributing cause of death in 1 per cent. Further studies to curtail or modify the use of intravenous catheters are indicated.
169 citations