788
Clinical and laboratory observations
liver, spleen, gastrointestinal tract, and adrenal glands) is reduced during patency of the ductus arteriosus, 11 mainly because of a reduced perfusion pressure. In our study a patent ductus arteriosus was ruled out by Doppler echocardiography before the blood flow studies. Vasoactive factors may also affect blood flow velocity. The administration of vasoactive drugs was excluded in our study. Endogenously produced vasoactive substances (e.g., catecholamines, atrial natriuretic peptide, renin), however, also play a role in the regulation of renal blood flowJ 2 We did not measure plasma concentrations of these substances in our infants. A lower urinary output in infants with severe respiratory distress, as described by others, was confirmed in our study. Serum urea nitrogen and creatinine levels 24 hours after birth are poor indicators of prerenal failure. We had insufficient data to allow us to analyze the relationship between R B F V and urinary output. We conclude that severe R D S is associated with a reduced RBFV, suggesting a decrease in actual renal blood flow. A higher intrathoracic pressure in the infants with severe R D S may have impaired the venous return and therefore the C O and stroke volume.
REFERENCES l. Engle WD, Arant BS, Wiriyathian S, et al. Diuresis and respiratory distress syndrome: physiologic mechanisms and therapeutic implications. J PEDIATR 1983;102:912-7. 2. Greene ER, Venters MD, Avasthi PS, et al. Noninvasive characterization of renal artery blood flow. Kidney Int 1981;20:523-9.
The Journal of Pediatrics November 1990
3. Sampson D, Abramczyk J, Murphy GP. Ultrasonic measurement of blood ftow velocity changes in canine renal allografts. J Surg Res 1972;12:388-93. 4. BaUard JL, Kazmaier-Novak K, Driver M. A simplified score for assessment of fetal maturation of newly born infants. J PEmATR 1979;95:769-74. 5. Hey E, Scopes JW. Thermoregulation in the newborn. In: Avery GB, ed. Neonatology: pathophysiology and management of the newborn. Philadelphia: JB Lippincott, 1987:20111. 6. Boemelburg T, Jorch G. Investigations of renal artery blood flow velocity in preterm and term neonates by pulsed Doppler ultrasonography. Eur J Pediatr 1988;147:283-7. 7. Walther F J, Siassi B, Ramadan NA, et al. Pulsed Doppler determinations of cardiac output in neonates: normal standards for clinical use. Pediatrics 1985;76:829-33. 8. Reller MD, Donovan EF, Kotagal UR. Influence of airway pressure waveform on cardiac output during positive pressure ventilation of healthy newborn dogs. Pediatr Res 1985;19:33741. 9. Fisher DJ. Comparative effects of metabolic acidemia and hypoxia on cardiac output and regional blood flows in unanesthetized newborn lambs. Pediatr Res 1986;20:756-60. 10. Buckley NM, Diamant S, Frasier ID, et al. Vasoactive compound effects on autoregulating versus nonautoregulating intestinal and renal circulations in young swine. Biol Neonate 1988;54:49-59. 11. Clyman RI, Mauray F, Heymann MA, et al. Cardiovascular effects of patent ductus arteriosus in preterm lambs with respiratory distress. J PEDIATR 1987;111:579-87. 12. Varille VA, Nakamura KT, McWeeny O J, et al. Renal hemodynamic response to atrial natriuretic factor in fetal and newborn sheep. Pediatr Res 1989;25:291-4.
Percutaneous femoral venous catheterization in preterm neonates F a r o o q A b d u l l a , MD, K e n n e t h A. Dietrich, MD, a n d Arun K. Pramanik, MD From the Department of Pediatrics, Louisiana State University Medical Center, Shreveport
Maintenance of total parenteral nutrition requires longterm venous access, which is difficult to achieve in small preterm newborn infants because of the size and fragility of peripheral veins. Repeated venipunctures for intravenous
access or blood withdrawal are required, but they reduce the number of available peripheral venous sites and may result in transient hypoxemia, hypothermia, hypoglycemia, or nosocomial infections. ]
Submitted for publication July 20, 1989; accepted June 4, 1990. Reprint requests: Arun K. Pramanik, MD, Section of Neonatology, Department of Pediatrics, Louisiana State University Medical Center, 1501 Kings Highway, Shreveport, LA 71130-3932. 9/24/22880
TPN
Total parenteral nutrition
]
Placement of percutaneous central venous catheters has recently been introduced in the management of neonates. Several routes have been used, the choice depending on the infant's size and the accessibility of the veins, including the
Volume 117 Number 5
external jugular, median basilic, axillary, saphenous, popliteal, and scalp veins.~, 2 Reluctance to use the femoral vein in premature infants arises from concerns about a potential increase in catheter-associated sepsis related to groin hygiene, as well as the rare occurrence of complications such as septic arthritis of the hip after femoral vein puncture. These complications generally involve multiple punctures to obtain blood for laboratory studies and a venipuncture technique whereby the hip joint is entered. 3 In contrast, the present use of percutaneous femoral venous catheterization is a safe, effective method of achieving central venous access in infants and children admitted to pediatric intensive care units.4, 5 The use of percutaneous femoral venous catheterization in preterm neonates has not been reported. We designed this study to evaluate prospectively its feasibility in a busy tertiary care neonatal unit, to assess duration of catheterization and its complications, including infection rate, and to compare percutaneous catheterization with the use of similar catheters in nonfemoral peripheral venous sites. METHODS Critically ill premature infants admitted to the neonatal intensive care unit were considered as possible candidates for percutaneous femoral or nonfemoral venous catheterization. Criteria for inclusion in the study were an anticipated period of 1 week or more of TPN administration, no other central venous lines in place, and complete enteric feedings not anticipated for 1 to 2 weeks at the time of entry into the study. We excluded any patient who had a coagulation or bleeding disorder, documented sepsis, or cutaneous infection. Data were collected on age, weight, diagnosis, catheter location, and duration of catheter use. Any complications associated with central venous catheters inserted via femoral and nonfemoral (external jugular, axillary, saphenous, cephalic, brachiat, popliteal, and scalp) venous routes were recorded. The catheter insertion site was chosen by the patient's attending physician on the basis of variables such as available access, previous or current sites, and preference. A 1.gF percutaneous silicone rubber catheter (Gresco International, San Antonio, Tex.) was used for all patients. 6 Each patient was placed in a supine frogleg position, and the femoral region was washed with Hibiclens cleanser (Stuart) for 2 minutes, allowed to dry, and washed again. The procedure was done under sterile conditions with the technique described by Dolcourt and Bose. 1The introducer needle was inserted at a 30-degree angle approximately 1.0 cm below the inguinal ligament and 5 mm medial to the femoral pulse, and advanced 0.5 to 1.0 cm toward the umbilicus (Figure). On blood return, the silicone rubber catheter was advanced through the needle to the desired length. Catheter length was estimated by measuring the distance from insertion to
Clinical and laboratory observations
789
the ipsilateral nipple. After the catheter was advanced, the introducer needle was pulled out, broken, and separated from the catheter. The catheter and insertion site were dressed with a triple-antibiotic ointment (Neosporin ointment, Burroughs Wellcome Co., Research Triangle Park, N.C.) and a semipermeable transparent dressing (Tegaderm, 3M, St. Paul, Minn.). A chest roentgenogram was obtained to confirm catheter position. The dressing was changed every 72 hours and the catheter inspected daily for functional status or signs of local infection. All catheters were left in place as long as their use was required and they remained functional, unless catheter-related sepsis was proved. Parenteral nutrition fluids containing dextrose, crystalline amino acids, electrolytes, minerals, and vitamins were administered through the catheter. One unit of heparin was added for each milliliter Of TPN solution. The solution (Intralipid, KabiVitrum, Inc., Alameda, Calif.) was administered through the catheter in doses ranging from 0.5 to 3.0 gm/kg/day. Antibiotics and other drugs were infused through the catheter as needed. Catheters were not used for withdrawing blood, although they were used for erythrocyte transfusion when no other intravenous access was available. We placed nonfemoral central venous catheters, using the technique and equipment described above and guided by the anatomic landmarks particular to the site. Data obtained from the analysis of femoral catheterizations were compared with results from nonfemoral percutaneous central venous catheters by means of analysis of variance, the Mantel-Haenszel test, and chi-square analysis with the Fisher Exact Test. RESULTS From November 1988 to January 1990, 120 percutaneous silicone rubber central venous catheters were placed in 95 premature neonates in the neonatal intensive care unit. Sixty-three catheters were placed through the femoral vein and 57 through nonfemoral veins: external jugular (30), axillary (12), saphenous (2), cephalic (5), brachial (5), popliteal (2), and scalp (1). Postnatal age at the time of catheter insertion was similar for both the femoral and nonfemoral groups. Femoral catheters were placed successfully in 63 of 70 attempts (90%). In 6 of these 63 patients no other peripheral venous site was available. The procedure required from 20 to 75 minutes to complete. Accidental femoral artery puncture occurred in 18% (13/70) of attempts; bleeding was controlled by gentle compression for 1 to 3 minutes and was not associated with adverse sequelae. No other complications occurred during the procedure. In six patients, after unsuccessful attempts at nonfemoral sites, percutaneous femoral venous catheterization was achieved with ease. In the nonfemoral group, 57 (84%) catheters were successfully
790
Clinical and laboratory observations
The Journal of Pediatrics November 1990
,I
INGUINAL LIGAMENT
FEM AR'
VEiN [
Figure. Femoral vein lies inferior to inguinal ligament and medial to femoral artery. Needle is directed into femoral vein approximately 1.0 cm below inguinal ligament and 0.5 cm medial to the maximal pulse of femoral artery. Introducer needle is advanced at 30 degrees toward umbilicus. IVC, Inferior vena cava.
Table. Patients' weight at time of catheter insertion, duration of use, and reason for removal
Site Femoral 1 Kg TOTAL Nonfemoral
Clinical and laboratory observations
liver, spleen, gastrointestinal tract, and adrenal glands) is reduced during patency of the ductus arteriosus, 11 mainly because of a reduced perfusion pressure. In our study a patent ductus arteriosus was ruled out by Doppler echocardiography before the blood flow studies. Vasoactive factors may also affect blood flow velocity. The administration of vasoactive drugs was excluded in our study. Endogenously produced vasoactive substances (e.g., catecholamines, atrial natriuretic peptide, renin), however, also play a role in the regulation of renal blood flowJ 2 We did not measure plasma concentrations of these substances in our infants. A lower urinary output in infants with severe respiratory distress, as described by others, was confirmed in our study. Serum urea nitrogen and creatinine levels 24 hours after birth are poor indicators of prerenal failure. We had insufficient data to allow us to analyze the relationship between R B F V and urinary output. We conclude that severe R D S is associated with a reduced RBFV, suggesting a decrease in actual renal blood flow. A higher intrathoracic pressure in the infants with severe R D S may have impaired the venous return and therefore the C O and stroke volume.
REFERENCES l. Engle WD, Arant BS, Wiriyathian S, et al. Diuresis and respiratory distress syndrome: physiologic mechanisms and therapeutic implications. J PEDIATR 1983;102:912-7. 2. Greene ER, Venters MD, Avasthi PS, et al. Noninvasive characterization of renal artery blood flow. Kidney Int 1981;20:523-9.
The Journal of Pediatrics November 1990
3. Sampson D, Abramczyk J, Murphy GP. Ultrasonic measurement of blood ftow velocity changes in canine renal allografts. J Surg Res 1972;12:388-93. 4. BaUard JL, Kazmaier-Novak K, Driver M. A simplified score for assessment of fetal maturation of newly born infants. J PEmATR 1979;95:769-74. 5. Hey E, Scopes JW. Thermoregulation in the newborn. In: Avery GB, ed. Neonatology: pathophysiology and management of the newborn. Philadelphia: JB Lippincott, 1987:20111. 6. Boemelburg T, Jorch G. Investigations of renal artery blood flow velocity in preterm and term neonates by pulsed Doppler ultrasonography. Eur J Pediatr 1988;147:283-7. 7. Walther F J, Siassi B, Ramadan NA, et al. Pulsed Doppler determinations of cardiac output in neonates: normal standards for clinical use. Pediatrics 1985;76:829-33. 8. Reller MD, Donovan EF, Kotagal UR. Influence of airway pressure waveform on cardiac output during positive pressure ventilation of healthy newborn dogs. Pediatr Res 1985;19:33741. 9. Fisher DJ. Comparative effects of metabolic acidemia and hypoxia on cardiac output and regional blood flows in unanesthetized newborn lambs. Pediatr Res 1986;20:756-60. 10. Buckley NM, Diamant S, Frasier ID, et al. Vasoactive compound effects on autoregulating versus nonautoregulating intestinal and renal circulations in young swine. Biol Neonate 1988;54:49-59. 11. Clyman RI, Mauray F, Heymann MA, et al. Cardiovascular effects of patent ductus arteriosus in preterm lambs with respiratory distress. J PEDIATR 1987;111:579-87. 12. Varille VA, Nakamura KT, McWeeny O J, et al. Renal hemodynamic response to atrial natriuretic factor in fetal and newborn sheep. Pediatr Res 1989;25:291-4.
Percutaneous femoral venous catheterization in preterm neonates F a r o o q A b d u l l a , MD, K e n n e t h A. Dietrich, MD, a n d Arun K. Pramanik, MD From the Department of Pediatrics, Louisiana State University Medical Center, Shreveport
Maintenance of total parenteral nutrition requires longterm venous access, which is difficult to achieve in small preterm newborn infants because of the size and fragility of peripheral veins. Repeated venipunctures for intravenous
access or blood withdrawal are required, but they reduce the number of available peripheral venous sites and may result in transient hypoxemia, hypothermia, hypoglycemia, or nosocomial infections. ]
Submitted for publication July 20, 1989; accepted June 4, 1990. Reprint requests: Arun K. Pramanik, MD, Section of Neonatology, Department of Pediatrics, Louisiana State University Medical Center, 1501 Kings Highway, Shreveport, LA 71130-3932. 9/24/22880
TPN
Total parenteral nutrition
]
Placement of percutaneous central venous catheters has recently been introduced in the management of neonates. Several routes have been used, the choice depending on the infant's size and the accessibility of the veins, including the
Volume 117 Number 5
external jugular, median basilic, axillary, saphenous, popliteal, and scalp veins.~, 2 Reluctance to use the femoral vein in premature infants arises from concerns about a potential increase in catheter-associated sepsis related to groin hygiene, as well as the rare occurrence of complications such as septic arthritis of the hip after femoral vein puncture. These complications generally involve multiple punctures to obtain blood for laboratory studies and a venipuncture technique whereby the hip joint is entered. 3 In contrast, the present use of percutaneous femoral venous catheterization is a safe, effective method of achieving central venous access in infants and children admitted to pediatric intensive care units.4, 5 The use of percutaneous femoral venous catheterization in preterm neonates has not been reported. We designed this study to evaluate prospectively its feasibility in a busy tertiary care neonatal unit, to assess duration of catheterization and its complications, including infection rate, and to compare percutaneous catheterization with the use of similar catheters in nonfemoral peripheral venous sites. METHODS Critically ill premature infants admitted to the neonatal intensive care unit were considered as possible candidates for percutaneous femoral or nonfemoral venous catheterization. Criteria for inclusion in the study were an anticipated period of 1 week or more of TPN administration, no other central venous lines in place, and complete enteric feedings not anticipated for 1 to 2 weeks at the time of entry into the study. We excluded any patient who had a coagulation or bleeding disorder, documented sepsis, or cutaneous infection. Data were collected on age, weight, diagnosis, catheter location, and duration of catheter use. Any complications associated with central venous catheters inserted via femoral and nonfemoral (external jugular, axillary, saphenous, cephalic, brachiat, popliteal, and scalp) venous routes were recorded. The catheter insertion site was chosen by the patient's attending physician on the basis of variables such as available access, previous or current sites, and preference. A 1.gF percutaneous silicone rubber catheter (Gresco International, San Antonio, Tex.) was used for all patients. 6 Each patient was placed in a supine frogleg position, and the femoral region was washed with Hibiclens cleanser (Stuart) for 2 minutes, allowed to dry, and washed again. The procedure was done under sterile conditions with the technique described by Dolcourt and Bose. 1The introducer needle was inserted at a 30-degree angle approximately 1.0 cm below the inguinal ligament and 5 mm medial to the femoral pulse, and advanced 0.5 to 1.0 cm toward the umbilicus (Figure). On blood return, the silicone rubber catheter was advanced through the needle to the desired length. Catheter length was estimated by measuring the distance from insertion to
Clinical and laboratory observations
789
the ipsilateral nipple. After the catheter was advanced, the introducer needle was pulled out, broken, and separated from the catheter. The catheter and insertion site were dressed with a triple-antibiotic ointment (Neosporin ointment, Burroughs Wellcome Co., Research Triangle Park, N.C.) and a semipermeable transparent dressing (Tegaderm, 3M, St. Paul, Minn.). A chest roentgenogram was obtained to confirm catheter position. The dressing was changed every 72 hours and the catheter inspected daily for functional status or signs of local infection. All catheters were left in place as long as their use was required and they remained functional, unless catheter-related sepsis was proved. Parenteral nutrition fluids containing dextrose, crystalline amino acids, electrolytes, minerals, and vitamins were administered through the catheter. One unit of heparin was added for each milliliter Of TPN solution. The solution (Intralipid, KabiVitrum, Inc., Alameda, Calif.) was administered through the catheter in doses ranging from 0.5 to 3.0 gm/kg/day. Antibiotics and other drugs were infused through the catheter as needed. Catheters were not used for withdrawing blood, although they were used for erythrocyte transfusion when no other intravenous access was available. We placed nonfemoral central venous catheters, using the technique and equipment described above and guided by the anatomic landmarks particular to the site. Data obtained from the analysis of femoral catheterizations were compared with results from nonfemoral percutaneous central venous catheters by means of analysis of variance, the Mantel-Haenszel test, and chi-square analysis with the Fisher Exact Test. RESULTS From November 1988 to January 1990, 120 percutaneous silicone rubber central venous catheters were placed in 95 premature neonates in the neonatal intensive care unit. Sixty-three catheters were placed through the femoral vein and 57 through nonfemoral veins: external jugular (30), axillary (12), saphenous (2), cephalic (5), brachial (5), popliteal (2), and scalp (1). Postnatal age at the time of catheter insertion was similar for both the femoral and nonfemoral groups. Femoral catheters were placed successfully in 63 of 70 attempts (90%). In 6 of these 63 patients no other peripheral venous site was available. The procedure required from 20 to 75 minutes to complete. Accidental femoral artery puncture occurred in 18% (13/70) of attempts; bleeding was controlled by gentle compression for 1 to 3 minutes and was not associated with adverse sequelae. No other complications occurred during the procedure. In six patients, after unsuccessful attempts at nonfemoral sites, percutaneous femoral venous catheterization was achieved with ease. In the nonfemoral group, 57 (84%) catheters were successfully
790
Clinical and laboratory observations
The Journal of Pediatrics November 1990
,I
INGUINAL LIGAMENT
FEM AR'
VEiN [
Figure. Femoral vein lies inferior to inguinal ligament and medial to femoral artery. Needle is directed into femoral vein approximately 1.0 cm below inguinal ligament and 0.5 cm medial to the maximal pulse of femoral artery. Introducer needle is advanced at 30 degrees toward umbilicus. IVC, Inferior vena cava.
Table. Patients' weight at time of catheter insertion, duration of use, and reason for removal
Site Femoral 1 Kg TOTAL Nonfemoral
![[Femoral venous catheterization: a case of late femoral hematoma].](/assets/img/hold.png)
