Interventional Treatment of a Symptomatic Neonatal Hepatic Cavernous Hemangioma Using the Amplatzer Vascular Plug

Percutaneous intervention is one treatment option for symptomatic hepatic hemangioma in infants. We report the case of a newborn (birth weight 4060 g) with a large hepatic cavernous hemangioma, which presented early with high cardiac output failure due to arteriovenous shunting and signs of incipient Kasabach-Merritt syndrome. We performed a successful superselective transcatheter coil embolization of three feeding arteries on the seventh day of life. Because of remaining diffuse very small arteries causing a relevant residual shunt, additional occlusion of the three main draining veins was necessary with three Amplatzer vascular plugs. Cardiac failure resolved immediately. Without any additional therapy the large venous cavities disappeared within the following months. The tumor continues to regress in size 8 months after the interventio

The role of critical incident monitoring in detection and prevention of human breast milk confusions

Feeding a mother's expressed breast milk to the wrong infant is a well-known misidentification error in neonatal intermediate care units (NICU) with potential harmful consequences for the neonate. In this study, we aimed to analyze the role of critical incident monitoring on detection and prevention of human breast milk confusions. The critical incident monitoring made us aware of this misidentification error on our NICU. Despite the implementation of system changes to make breast milk application clearer and safer, we failed to reduce the incidence of breast milk confusion

Intermittent flushing improves cannula patency compared to continuous infusion for peripherally inserted venous catheters in newborns: results from a prospective observational study

Aims: Peripheral cannulas in newborns are commonly used for intravenous treatment. However sustained maintenance of cannula patency is often difficult to achieve in this age group. This study compares the duration for which cannula patency can be maintained in newborns under continuous infusion, or an intermittent flushing regimen, with normal saline. Methods: A prospective observational study was conducted during a 12-month period. All newborns admitted to the 16-bed intermediate care unit, who required intravenous treatment, received either continuous peripheral infusion with 0.9% saline at an infusion rate of 2 mL/h or an intravenous cannula, which was flushed with 1 mL of 0.9% saline at least once every 24 h. Results: A total of 53 patients with 86 cannulas were included. Twenty-five (47%) patients received 41 continuous infusions. The intermittent flushing group consisted of 28 (53%) patients with 45 cannulas administered. The cannula patency was significantly longer in the intermittent flushing group (mean 62.1 vs. 92.8 h, P=0.01). The patient's underlying disease and the cannula insertion site were not related with the duration of the cannula patency. Conclusions: Our study shows that intermittent cannula flushing is associated with improved cannula patency for peripherally inserted venous catheters in newborn

Accuracy of a Novel Transcutaneous PCO2 and PO2 Sensor with Optical PO2 Measurement in Neonatal Intensive Care: A Single-Centre Prospective Clinical Trial

BACKGROUND AND OBJECTIVES Transcutaneous PCO2 and PO2 measurement systems offer non-invasive blood gas trend monitoring. The aim of this prospective study was to assess bias and precision of a transcutaneous PCO2 and PO2 measurement system incorporating a novel pO2 sensor (Sentec OxiVenT™) in neonates ≥34 weeks of gestational age (GA) admitted to intensive care. METHODS Transcutaneous PCO2 and PO2 were compared to arterial and capillary blood gas measurements. Bias and precision were calculated by fitting linear mixed models to account for repeated measurements, and influence of clinical covariates on bias and precision was assessed. RESULTS We obtained 611 paired transcutaneous and blood gas measurements in 110 patients (median GA 38.3 [interquartile range 36.1-39.7] weeks; age 9 [4-15] days; weight 3,000 [2,500-3,500] g). Transcutaneous PCO2 showed significant bias to arterial PCO2 (+0.61; 95% confidence interval 0.46, 0.76 kPa), but not to capillary PCO2 (-0.23; -0.46, 0.002 kPa). Bias of transcutaneous PO2 was significant to arterial PO2 (-2.50; -2.94, -2.06 kPa), while no significant bias compared to capillary PO2 was observed (+0.17; -0.30, 0.64 kPa). Precision intervals were ±1.8/2.0 kPa for arterial versus capillary PCO2 and ±4.9/3.3 kPa for arterial versus capillary PO2 comparisons, respectively. Further, sensor operating temperature (43°C vs. 42°C), soft tissue oedema, vasoactive drugs, weight, and GA significantly altered bias (p < 0.05). CONCLUSIONS The tested transcutaneous blood gas measurement system showed no significant bias compared to capillary PCO2 and PO2, acceptable bias to arterial PCO2, and limited agreement with arterial PO2. Precision intervals were wide for all comparisons

Antithrombin activity in children with chylothorax

Objective: To determine whether increased antithrombin loss is present in children with chylothorax after cardiac surgery. Methods: Plasma and pleural effusion samples of children with chylous and non-chylous pleural effusion were assayed for antithrombin activity. Results: Ten children with chylothorax and five children with non-chylous pleural effusion were investigated. There was statistically significant increase in mean antithrombin activity in chylous samples (32.2 ± 11.4%) compared to non-chylous samples (14.4 ± 13.9%), and significant decrease in plasma of children with chylothorax (44.6 ± 15.4%) compared to children with non-chylous pleural effusion (69.9 ± 22.4%). Seven of 10 children with chylous and none of the children without chylous developed thrombosis (p < 0.007). Conclusions: Increased loss of antithrombin is present in children with chylothorax, potentially predisposing these children to an increased risk of thrombosis. Repeated antithrombin substitution should be considered in critically ill children with chylothora

Long-term subcutaneous morphine administration after surgery in newborns

Aim: To analyze the management of newborns after major surgery receiving morphine subcutaneously and to identify possible side effects. Methods: Morphine was administered via a subcutaneous catheter (Insuflon®) in 20 newborns after major surgery. Side effects like hypotension, pain during morphine administration and local infection were noted. Morphine dose was adjusted according to the hospital guidelines with the Neonatal Infant Pain Score (NIPS) and the Finnegan withdrawal score. Results: Surgery was performed at the median age of 38 5/7weeks (range: 32 1/7-49 5/7weeks). Before starting subcutaneous morphine administration, patients received intravenous morphine for a median of two weeks (range sixdays to sevenweeks). All patients showed good pain relief with no severe side effects. Three patients reacted with crying to the first dose of subcutaneous morphine. No other side effects occurred. Conclusion: Subcutaneous application of morphine with the Insuflon® catheter is an alternative to intravenous treatment of postoperative pain in neonates. In this small group pain relief was good and side effects were harmles

Neonatal visual assessment in congenital heart disease: A pilot study

This study assessed neonatal visual maturity in infants with congenital heart disease (CHD) and its predictive value for neurodevelopmental outcomes. Neonates with CHD underwent a standardized visual assessment before and after cardiopulmonary bypass surgery. Visual maturity was rated as normal versus abnormal by means of normative reference data. Twelve-month neurodevelopment was assessed with the Bayley-III. Twenty-five healthy controls served as the reference group. Neonatal visual assessment was performed in five neonates with CHD preoperatively and in 24 postoperatively. Only postoperative assessments were considered for further analysis. Median [IQR] age at assessment was 27.0 [21.5, 42.0] days of life in postoperative neonates with CHD and 24.0 [15.0, 32.0] in controls. Visual performance was within reference values in 87.5% in postoperative CHD versus 90.5% in healthy controls (p = 1.0). Visual maturity was not predictive of neurodevelopment at 12 months. These results demonstrate the limited feasibility and predictive value of neonatal visual assessments in CHD

Incidence and treatment of diaphragmatic paralysis after cardiac surgery in children

Objective: Diaphragmatic paralysis (DP) caused by phrenic nerve injury is potentially life-threatening in infants. Phrenic nerve injury due to thoracic surgery is the most common cause of DP in children. We retrospectively analyzed incidence, surgical details, management and follow-up of our patients with DP after cardiac surgery to develop an algorithm for the management and follow-up. Methods: Retrospective analysis of 43 patients with DP after cardiac surgery performed between 1996 and 2000. Results: Median age at cardiac surgery was 1 month (range 3 days to 9 years). Incidence of DP was 5.4%. A trend towards higher incidences of DP were observed after arterial switch operation (10.8%, P=0.18), Fontan procedure (17.6%, P=0.056) and Blalock-Taussig Shunt (12.8%, P=0.10). Median time from cardiac surgery to surgical plication was 21 days (range 7-210 days). Transthoracic diaphragmatic plication was performed in 29/43 patients, no plication was done in 14/43 patients. Patients in whom diaphragmatic plication was required were younger (median age 2 months, range 21 days to 53 months versus 17.5 months, range 4 days to 110 months; P≪0.001). Indications for plication were failure to wean from ventilator (n=22), respiratory distress (n=4), cavopulmonary anastomosis (n=2), and failure to thrive (n=1). All these symptoms resolved after diaphragmatic plication, however, 8/29 patients with plication and 2/14 without plication died. Cause of death was not related to diaphragmatic plication in any patient. Position of plicated diaphragm was normal in 18/21 surviving patients 1 month after plication. In 2/12 surviving patients without plication hemidiaphragm showed a normal position 1 year after surgery. The rate of pulmonary infections was not significantly different during 12-60 months follow-up. Conclusions: DP is an occasional complication of cardiac surgery. High incidences of DP were seen after arterial switch operation, Fontan procedure and Blalock-Taussig shunt (BT). Respiratory insufficiency requires diaphragmatic plication in most infants with DP whereas older children may tolerate DP. Transthoracic diaphragmatic plication is an effective treatment of DP and achieves relief of respiratory insufficiency in most patients. Spontaneous recovery from postsurgical DP is rar

Too much of too little: xylitol, an unusual trigger of a chronic metabolic hyperchloremic acidosis

Homeopathic globules are frequently used in children as a first-line treatment. Most of these globules are coated with sugar substitutes like xylitol; these substitutes are known for their laxative effect. Our patient shows that consumption of globules coated with xylitol does not have only laxative effects. It may cause indeed considerable weight loss and life-threatening enteral bicarbonate loss by diarrhea when overdosed in an infan