Thrombosis and infection complicating central venous catheterization in neonates.

To determine the risk of complication associated with Broviac central venous catheterization in neonates, we reviewed the records of 107 infants who were catheterized an average of 5 weeks after birth and cared for in our neonatal intensive care unit. Forty-five of the 107 neonates (42%) had one or more catheter-related complications. Infants with complications had significantly lower birth weights and gestational age, longer duration of catheterization, and more repeat catheterizations than infants without complications. The mortality rate in infants with complications was not different than that of infants without complications. The most common complications were thrombosis (23 neonates) and infection (20 neonates). The birth weight and the number of catheterizations were the best predictors of the risk of complications as determined by multiple regression analysis. We conclude that the risk of complication associated with central venous catheterization is high in our population of predominantly premature neonates; that the risk of complication is increased in neonates weighing less than 1,000 g or requiring more than one catheter; and that despite the high complication rate central venous catheterization was not associated with increased mortality in this population.

The spectrum of cholelithiasis in the first year of life.

Cholelithiasis is being diagnosed with increased frequency in the very young. We encountered 12 patients over a 5-year period in whom cholelithiasis was diagnosed prior to age 1 year. The earliest diagnosis was made in utero during the seventh gestational month. While most of the children suffered from complex medical disorders, 4 of the 12 had no recognizable predisposing factors. Eight of the 12 were treated at some point prior to diagnosis with central parenteral nutrition. Three presented with infectious complications requiring prompt operative intervention. Two children underwent elective cholecystectomy nearly 2 years after the diagnosis for symptoms of biliary colic. Of the remaining seven, spontaneous stone resolution was documented in three, while four remain asymptomatic after a minimum of years follow-up. The spectrum of presentations in this series highlights the uncertainties regarding the etiology, natural history, and treatment of this increasingly more common disorder.

Vasoactive intestinal polypeptide potentiates the hypoxemia-induced decrease in splanchnic circulation in the rat.

The effects of acute infusion of vasoactive intestinal polypeptide (VIP) and hypoxemia on splanchnic circulation were examined in 35 awake Sprague-Dawley rats. Indwelling catheters were placed in the superior vena cava and the proximal aorta via the internal jugular vein and internal carotid artery, respectively, while the rats were under ether anesthesia. Four hours later, when the rats were awake and active, VIP (molecular lot 3226) was infused intraarterially for 30 minutes. The distribution of cardiac output was measured at the end of VIP infusion using 125I-labeled microspheres. VIP was administered at a low (1.5 ng/min) and a high infusion rate (44.1 ng/min) for 30 minutes. The effect of hypoxemia on circulatory response to VIP was examined only in the high VIP infusion group, by placing the rat in a 10% oxygen environment. Appropriate control experiments were performed with each group. The high-dose VIP resulted in a marked reduction in distribution of cardiac output to the splanchnic circulation. This effect was potentiated by hypoxemia, particularly in the distal ileum and colon. The metabolic clearance rate of VIP increased with the rate of VIP infusion and was decreased by hypoxemia. It was concluded that only in high concentration does VIP have any effect on splanchnic circulation. However, in the presence of hypoxemia, VIP may have an important role in cardiovascular compensatory response and may contribute to the development of ischemic bowel injury.

Nonoperative management of liver injuries following blunt abdominal trauma in children.

In a 4-year span, 12 patients with hepatic trauma were treated at our institution. After initial resuscitation, three underwent emergency celiotomy because of the severity of their injuries. This communication analyses the other nine. All of these had significant liver injuries and were managed nonoperatively. Hepatic injury was diagnosed and the severity defined by ultrasonography, radionuclide scintigraphy, or computed tomography (CT). These stable patients were initially admitted to the intensive care unit (ICU) and upon transfer to the ward, maintained on restricted activities. Seven of the nine children received blood transfusions. Although liver enzymes were initially elevated in each case, they returned to normal in 1 week. In-hospital and post-discharge imaging documented healing of the hepatic injuries in each case. Eight children are well at 3 months to 4 years follow-up. Only one of the nine nonoperatively managed patients died and this was secondary to severe head injuries. To date, there are no complications. Our nine children are added to the 23 nonoperatively treated pediatric hepatic injuries found in the literature.

Pediatric blunt liver injury: establishment of criteria for appropriate management.

There is no consensus regarding the most appropriate management of pediatric blunt liver injury. This study addresses this issue by reviewing our experience with blunt liver trauma in relationship to the grade of injury. Forty-one pediatric patients with blunt abdominal trauma and documented liver injury were managed from 1979 to 1989. Fifteen (37%) underwent celiotomy. Three children had extensive parenchymal injuries (grade IV or V) requiring resection and three others died intraoperatively, secondary to exsanguinating hemorrhage of associated injuries (grade V) to the hepatic veins and inferior vena cava. The need for celiotomy was obvious in these patients. In 9 of the 15 children who underwent exploration (60%), bleeding from the liver injury (grade II or III) had ceased by the time of celiotomy. These children did not appear to benefit from the operation. Twenty-six of the 41 patients (63%) were selected for nonoperative management because they were hemodynamically stable after initial resuscitation and did not show signs of associated intraabdominal injuries requiring surgical intervention. These children underwent evaluation by abdominal computed axial tomography scan (grade I, II, III, and IV injuries). Blood transfusions were given to keep the hematocrit above 30%. Seventeen of the 26 children managed nonoperatively (65%) did not require blood replacement. The mean (+/- SEM) transfusion volume for the remaining nine children was 14.8 +/- 2.5 mL/kg. Blunt liver injury represents a spectrum from a minimal parenchymal hematoma to massive liver disruption. We conclude that celiotomy is necessary for hepatic injury hemodynamically stable injured children with transfusion requirements less than 40 mL/kg can be managed nonoperatively in an appropriate setting.

Pediatric perineal impalement injuries.

Pediatric perineal impalement injuries are relatively uncommon. There may be difficulty in recognizing or properly treating such injuries, because their severity may not be reflected accurately by the external appearance of the perineum. The authors describe 3 case reports of patients with perineal impalement injuries and their management. The authors emphasize how a thorough workup can prevent missed injuries, leading to timely surgical repair and good outcomes.

Pediatric hepatic trauma: does clinical course support intensive care unit stay?

PURPOSE: The objective of this study is to determine if grade of liver injury predicts outcome after blunt hepatic trauma in children and to initiate analysis of current management practices to optimize resource utilization without compromising patient care. METHODS: A retrospective review of 36 children who had blunt hepatic trauma treated at a pediatric trauma center from 1989 to present was performed. Hepatic injuries graded (AAST Organ Injury Scaling) ranged from grade I to IV. Injury Severity Score (ISS), Glasgow Coma Score (GCS), transfusion requirements, liver transaminase levels, associated injuries, intensive care unit (ICU) length of stay, and survival were analyzed. RESULTS: Mean (+/-SEM) age was 6.6+/-0.8 years, mean grade of hepatic injury was 2.4+/-0.2, mean ISS was 17+/-2.6, mean GCS was 13+/-1, and mean transfusion was 15.4 mL/kg of packed red blood cells (PRBC). There were three deaths with a mean ISS of 59+/-9 and a mean GCS of 3+/-0. Death was not associated with a high-grade liver injury, survivors versus nonsurvivors, 2.3+/-0.2 versus 2.7+/-0.3, but was associated with ISS, 13+/-1.4 versus 59+/-9 (P = .005) and GCS, 14+/-1 versus 3+/-0 (P = .005). Only one patient (grade III, ISS = 43) underwent surgery. There were no differences in mean ISS or GCS between grades I to IV patients. The hepatic injury grades of patients requiring transfusion versus no transfusion were significantly different, 3.4+/-0.2 versus 2.2+/-0.2 (P = 0.04). Abused patients had high-grade hepatic injuries and significant laboratory and clinical findings. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were significantly higher in grade III and IV injuries than in grades I and II, 1,157+/-320 versus 333+/-61 (P= .02) and 1,176+/-299 versus 516+/-86 (P= .04), respectively. No children with grade I or II injury had a transfusion requirement or surgical intervention. There were no liver-related complications. CONCLUSIONS: Mortality and morbidity rates in pediatric liver injuries, grades I to IV, correlate with associated injuries not the degree of hepatic damage. ALT, AST, and transfusion requirements are significantly related to degree of liver injury. Low-grade and isolated high-grade liver injuries seldom require transfusion. Blunt liver trauma rarely requires surgical intervention. In retrospect, the need for expensive ICU observation for low-grade and isolated high-grade hepatic injuries is questionably warranted.

Antenatal ultrasonography: the experience in a high risk perinatal center.

During a 52-month span, 14,324 ultrasonographic examinations were performed on 9,453 pregnant patients. One-hundred and fifty-one anatomical malformations were found in 122 fetuses (1.29%). Our analysis of patients referred to the perinatal center for ultrasonography indicates that the number of high risk patients has increased, and a parallel increase of neonatal surgical anomalies has resulted. An analysis of fetuses concluded that anomalies of the: gastrointestinal tract had improved care, deaths occurred due to associated anomalies or severe prematurity; genitourinary system received earlier diagnosis and treatment; central nervous system/musculoskeletal system/hydrops--no difference in management, treatment or outcome was noted; teratoma/cystic hygroma--did not effect treatment; cardiovascular system--inutero medical treatment by digitalization of the mother was possible. Paradoxically, an increase in the mortality of diaphragmatic hernia patients was noted and concluded to be secondary to the extremely early detection of this anomaly.

Transverse testicular ectopia.

In transverse or crossed testicular ectopia, the affected gonad lies in the same canal as the normally descended testis. During a 5-yr span, three children with this form of ectopia were seen. All presented with a symptomatic right inguinal hernia and an empty scrotum on the left side. The ages at operation were 1, 3, and 5 mo. Only the first patient was reoperated. In this child, the diagnosis of transverse testicular ectopia was made during the herniorrhaphy and the ectopic, but otherwise normal, gonad returned to the abdominal cavity. A subsequent left orchidopexy through a celiotomy was done. In the last two patients, the correct diagnosis was made preoperatively. Both gonads were of equal size and normal, occupying the same hemiscrotum. A herniorrhaphy with fixation of the ectopic gonad to the opposite hemiscrotum was done in both. All three children are otherwise normal. Cases collected from the literature are discussed. The condition should be suspected if a unilateral hernia is associated with a contralateral, nonpalpable testis and may not be as rare as formerly thought.

Selective management of pediatric pancreatic injuries.

BACKGROUND: Despite trauma being the most common cause of pediatric pancreatitis, the diagnosis and management is often difficult. METHODS: The hospital course, diagnostic and surgical procedures, and complications for all children with traumatic pancreatitis evaluated at a Regional Level I Trauma Center were reviewed retrospectively. RESULTS: Twelve of 3,500 children (0.35%, mean age, 8.7 +/- 1.2 years) were reviewed. Intraoperative diagnosis was made in three after penetrating trauma. Nine children sustained blunt pancreatic trauma (BPT) with serial radiographic imaging confirming the diagnosis in seven. Serial serum amylase levels, when performed, were normal in two and elevated in six, but did not predict injury severity or need for further intervention. Endoscopic retrograde cholangiopancreatography was performed in three children and indicated the need for surgical intervention in two and prevented planned laparotomy in one. Two children underwent computed tomography-guided fluid drainage. Pseudocysts developed in five children. Mortality rate from penetrating injuries was 66% with no deaths from BPT. CONCLUSIONS: A combination of serial radiographic, laboratory, and ERCP findings will improve the diagnosis and management of BPT. Penetrating or main ductal injuries require surgical intervention, and fluid collections may require drainage, but, otherwise, most BPT can be managed nonoperatively with minimal morbidity and mortality.

Pediatric airbag injuries: the Ohio experience.

BACKGROUND/PURPOSE: We sought to determine if properly restrained children, less than 13 years of age, placed in the front passenger seat are at greater risk for trauma from airbag deployment than unrestrained children. METHODS: The charts of children treated at any of 3 regional pediatric trauma centers in Ohio were reviewed for airbag injuries sustained in motor vehicle crashes between January 1995 and September 1998. Injury Severity Scores (ISS) were compared with Mann-Whitney Rank Sum Test and outcome data with Fisher's Exact Tests. Statistical significance was set at P< or =.05. RESULTS: Twenty-seven children aged 1 month to 12 years sustained airbag-related injuries. Sixty-one percent were girls. ISS ranged from 1 to 75 with a mean score (+/- SD) of 10 (14.5). All crashes were at reported speeds of less than 45 mph, and 64% were head-on collisions. No significant differences in the mean ISS (P = .074) occurred between groups. Both groups had similar closed head, ocular and facial injuries, extremity fractures, and number of deaths (P = 1.0). Abdominal organ injury was exclusive to the restrained group. Decapitation only occurred among unrestrained children. CONCLUSION: Our data showed that airbags, with or without proper safety restraints, can lead to mortality or serious morbidity in children.

Thoracic injuries in children.

The successful management of pediatric thoracic injuries includes immediate and careful evaluation of the injury type and severity. Early treatment can be conservative in nature or require surgical management. Prompt intervention can reduce morbidity and mortality rates, associated complications, and ensure optimal outcomes.

Effects of pediatric head trauma for children, parents, and families.

Severe pediatric head injury has negative consequences for children of all ages. Even mild and moderate head injury results in residual impairment for school-age children and adolescents. Data are needed on the effects of these less severe insults, especially for preschoolers. Although research on the impact of the child's head injury on the parent-child relationship and family functioning is limited, the experience is likely to be very stressful for the parent and the family. Indeed, family integrity may be at risk. Research is needed that examines the effects of a child's head injury for the parent and the family over time and identifies factors related to these outcomes.

Plasma vasoactive intestinal polypeptide in the newborn infant.

Vasoactive intestinal polypeptide (VIP) has been suggested as a possible contributor to the development of gastrointestinal problems. VIP is produced by nerve endings in the intestinal tract and appears to have marked effects on gut motility and its blood flow. Since necrotizing enterocolitis and feeding intolerance are common problems in the newborn, we examined the plasma VIP responses to feeding in healthy preterm and term newborn infants. Plasma VIP levels were measured in 20 full-term newborn infants (gestation of 39.4 +/- 0.9 weeks, mean +/- SD, and weight of 3,351 +/- 477 g) and 38 preterm infants (gestation of 27-35 weeks, weight of 920-2,440 g). In term infants, cord blood samples were obtained from the umbilical artery and vein and then before and after the feed. For preterm infants, blood samples were obtained prior to the introduction of oral feeds during the first week, and then before and after feeding once a week over the next 4 weeks. Feeding ranged from diluted premature formula to special care (24 calories per ounce) for the preterm, and breast milk or regular commercial formula for the term infants. Twenty-one healthy adults, age 25-42 years, were studied for comparison. In the term newborn infants, the plasma VIP levels in the umbilical venous blood were lower, although not statistically significant (p = 0.06), than the umbilical arterial blood (10.78 +/- 5.89 vs. 13.54 +/- 6.71 pmol/L), suggesting placental metabolism of VIP. After birth, there was a significant increase in plasma VIP levels (18.89 +/- 10.07 pmol/L, p = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

An unusual late complication of necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) now is managed frequently successfully without surgical intervention. NEC may result in strictures, which present after the acute inflammatory process has resolved. Strictures usually present as obstruction in the first year or two of life. A case report is presented of an 11-year-old child who had symptoms from a previously undiagnosed NEC stricture as a result of pica when coins obstructed the stricture. As treatment of NEC continues to improve, more and later complications of this disease can be expected. J Pediatr Surg 36:1853-1854.

The accuracy of antenatal ultrasonography in identifying renal abnormalities.

OBJECTIVE: To determine the accuracy of measuring antenatal renal pelvic diameter for prediction of renal abnormalities. RESEARCH DESIGN: Prospective evaluation of all pregnant women undergoing ultrasonography. SETTING: A teaching hospital providing primary and referral maternity care. PARTICIPANTS: Fifty-six pregnant women with suspected fetal hydronephrosis or cystic lesions identified from 7500 ultrasonograms over 3 years. METHODS: Antenatal renal pelvic diameter was measured in the anteroposterior dimension. Neonates underwent postnatal ultrasonography after day 3 of life; if the results were abnormal, a cystogram and renal diuretic scan were obtained. RESULTS: None of 50 kidneys 15 mm or smaller in anteroposterior pelvic diameter had obstruction; 11 (79%) of 14 kidneys larger than 15 mm were obstructed or demonstrated vesicoureteral reflux. Of 12 kidneys believed to be multicystic before birth, five (42%) proved to have hydronephrosis. CONCLUSIONS: Since the majority of fetuses with suspected hydronephrosis proved to be normal, parents should not be unduly alarmed by the physician. Renal pelvic diameter of more than 15 mm is strongly predictive of hydronephrosis. Since severe hydronephrosis is treatable and can be mistaken for a multicystic kidney antenatally, full radiologic evaluation is needed soon after birth.

Acute hemoperitoneum in children: prevalence of low-attenuation fluid.

BACKGROUND: Recent evidence indicates that acute hemoperitoneum may have lower than expected attenuation values at CT. OBJECTIVE: To characterize the attenuation of acute hemoperitoneum at CT in children following blunt abdominal trauma and to assess the prevalence of low-attenuation fluid. MATERIALS AND METHODS: The CT scans of 19 consecutive children with isolated hepatic or splenic injury and associated peritoneal fluid were retrospectively analyzed. The attenuation value of peritoneal fluid was assessed in all peritoneal spaces. RESULTS: Fluid was noted in 53 peritoneal spaces (27 abdominal, 26 pelvic). Fluid attenuation ranged from 20 to 64 HU. The mean fluid attenuation in pelvic spaces (37.5 +/- 9.4 HU) was significantly lower than in abdominal spaces (444.9 +/- 10.2 HU) (P = 0.008). Fluid in 8/26 (31 %) pelvic spaces and 2/27 (7 %) abdominal spaces had attenuation values < or = 30 HU. Fluid surrounding the site of injury (perihepatic or perisplenic space) was significantly higher in attenuation than fluid at other sites (P < 0.001). There was no correlation between the mean attenuation value of peritoneal fluid in each patient and the admission hematocrit (r = -0.14, P = 0.55). CONCLUSIONS: There is great variability in the attenuation of acute hemoperitoneum. Blood in pelvic spaces has significantly lower attenuation than blood in abdominal spaces. Hemoperitoneum in the pelvis has values of < or = 30 HU in approximately one-third of spaces. The attenuation of acute hemoperitoneum does not correlate with hematocrit.

Effect of cross-sectional imaging on negative appendectomy and perforation rates in children.

PURPOSE: To compare negative appendectomy and perforation rates in children who underwent ultrasonography (US), computed tomography (CT), or no imaging before urgent appendectomy. MATERIALS AND METHODS: All children who underwent urgent appendectomy during a 4(1/2)-year period were identified in a surgical billing database. Pathology reports were coded as negative or as showing acute inflammation or perforation. Imaging up to 14 days before appendectomy or abscess drainage was noted, and imaging-based diagnoses were compared with pathologic findings. Patient age and sex were recorded. RESULTS: Two hundred ninety-nine children, 176 (59%) male and 123 (41%) female (mean age, 10.4 years; age range, 1--21 years), underwent urgent appendectomy. One hundred twenty-six (42%) underwent no imaging, 121 (41%) underwent US with or without CT, and 52 (17%) underwent CT only; 44 (15%) underwent both US and CT. There were significantly higher rates of appendectomy with normal pathologic findings ("negative appendectomy") in patients who underwent no imaging (14% [18 of 126]) or US (17% [20 of 121]) versus the rates in those who underwent CT only (2% [one of 52]) (P =.02 and P =.007, respectively). The negative appendectomy rate was 7% in 96 patients who underwent CT with or without prior US. The perforation rates were not significantly different. CONCLUSION: As compared with children who underwent no preoperative imaging and those who underwent US, children who underwent CT had a significantly lower negative appendectomy rate, without a significantly higher perforation rate.

Evaluation of suspected appendicitis in children and young adults: helical CT.

PURPOSE: To evaluate the accuracy of helical computed tomography (CT) for the diagnosis of appendicitis in children and to assess the utility of CT in establishing alternative diagnoses. MATERIALS AND METHODS: The medical records of 154 children (median age, 12 years; age range, 1-20 years) who were suspected to have appendicitis and who underwent CT were reviewed. The gastrointestinal tract was opacified in 151 of 154 patients: Only orally administered contrast material was used in 126 patients; only rectally administered contrast material, in 21 patients; and both oral and rectal contrast material, in four patients. CT findings were correlated with surgical and histopathologic findings or with clinical follow-up findings. RESULTS: Sixty-four CT scans were interpreted as positive for appendicitis and included 58 true-positive and six false-positive scans. Ninety scans were interpreted as negative and included 87 true-negative and three false-negative scans. CT had a sensitivity of 95% and a specificity of 94% for the diagnosis of appendicitis. In addition, in 32 (34%) of 93 patients without appendicitis, an alternative diagnosis was established on the basis of CT findings. CONCLUSION: Helical CT is useful in a pediatric population to diagnose or exclude appendicitis and to establish an alternative diagnosis.

Imaging evaluation of suspected appendicitis in a pediatric population: effectiveness of sonography versus CT.

OBJECTIVE: The purpose of this study was to compare the diagnostic accuracy of graded compression sonography with that of helical CT for the diagnosis of appendicitis in a pediatric and young adult population. SUBJECTS AND METHODS: Between June 1996 and April 1999, 386 pediatric and young adult patients with suspected appendicitis were examined using sonography, CT, or both: 233 underwent sonography only, 71 underwent CT only, and 82 underwent sonography and CT. All sonograms and CT scans were prospectively interpreted as showing positive or negative findings for appendicitis by one of six pediatric radiologists. CT and sonographic findings were correlated with surgical and histopathologic findings or findings at clinical follow-up. RESULTS: Helical CT had a significantly higher sensitivity (95% versus 78%, p = 0.009) and accuracy (94% versus 89%, p = 0.05) than graded compression sonography for the diagnosis of appendicitis in children, adolescents, and young adults. The specificity of both techniques was 93%. Twenty of 82 patients who underwent both sonography and CT had discordance between the findings of the two examinations. The CT results were correct in a significantly greater number of patients with discordant examinations (17/20 patients [85%]). CONCLUSION: Helical CT has a significantly higher sensitivity and accuracy than graded compression sonography for the diagnosis of appendicitis in a pediatric and young adult population, particularly in children more than 10 years old.