The impact of patent ductus arteriosus in neonates with late onset sepsis: a retrospective matched-case control study.

BACKGROUND: Late-onset sepsis (LOS) in neonates with patent ductus arteriosus (PDA) may predispose them to more complicated hospital courses. The objective of this study was to determine the incidence, the distribution of pathogens, and the clinical features of LOS in neonates with PDA and analyze their outcomes. METHODS: The medical records were reviewed retrospectively of infants with PDA and LOS who were hospitalized in NICUs of Chang Gung Children's Hospital between January 2003 and December 2009. The clinical features of these infants were compared with a group of gestational age and birth body weight-matched neonates with LOS during the same period. RESULTS: During this period, 224 neonates were found to have at least one event of blood-culture proven LOS and 79 (35.3%) were documented to have PDA. Although most LOS episodes (85/104, 81.7%) in neonates with PDA occurred after closure of PDA, neonates with PDA had a significantly higher rate of bronchopulmonary dysplasia (81.0% vs. 61.0%, p = 0.002) and a relatively higher rate of recurrent sepsis (25.3% vs. 15.2%, p = 0.079) than those without PDA. Longer durations of ventilator support and hospital stay were also noted in neonates with PDA as compared to those without (p = 0.001 and 0.005, respectively). CONCLUSION: In neonates with LOS, the presence of PDA, even though it is aggressively treated with indomethacin or surgical intervention, may still contribute to the complexity of hospitalization. Close monitoring and aggressive treatments are warranted in these neonates with PDA.

Catheter management in neonates with bloodstream infection and a percutaneously inserted central venous catheter in situ: removal or not?

BACKGROUND: This study investigated whether removal of a percutaneously inserted central venous catheter (PICC) is compulsory in neonates with bloodstream infection (BSI), and also examined the risk factors for infectious complications when a PICC is retained in these patients. METHODS: This was a cohort study of neonates with a PICC who developed a BSI between 2001 and 2007. BSI was defined according to Centers for Disease Control and Prevention criteria. RESULTS: Of the 234 neonates in the cohort, 99 had early removal of PICC (ER-PICC, defined as removal within 3 days after the onset of clinical sepsis), and 135 had late removal of PICC (LR-PICC, defined as retention for more than 3 days after the onset of clinical sepsis). Resolution of clinical sepsis within 2 days was more frequent in the ER-PICC group compared with the LR-PICC group (80.8% vs 57.8%; P < .001). There was no significant difference between the 2 groups in terms of infectious complications and case fatalities, but the LR-PICC group had a significantly higher incidence of recurrence within 1 month after BSI (P = .002). Inappropriate initial antibiotic treatment was the only variable independently associated with infectious complications (odds ratio, 11.4; 95% confidence interval, 3.34∼39.2; P < .001). CONCLUSIONS: PICCs should be removed in neonates with BSI, because retention of PICCs for more than 3 days is associated with delayed resolution of clinical sepsis and a higher incidence of recurrence within 1 month.

Complications associated with 2 different types of percutaneously inserted central venous catheters in very low birth weight infants.

OBJECTIVE: To identify the prevalence and risk factors for complications associated with percutaneously inserted central venous catheters (PICCs) and evaluate the effect of different catheter types and their indwelling time on catheter-related complications. DESIGN: Retrospective cohort study. SETTING: A 49-bed neonatal intensive-care teaching hospital in Taiwan. PATIENTS: Between 2004 and 2007, 518 single-lumen PICCs (defined as "old type") and 290 PICCs with a stiffening stylet and a thicker introducer ("new type") were inserted in a total of 534 neonates with a birth body weight of 1,500 g or less. RESULTS: Independent risk factors of catheter-related sepsis (CRS) were longer duration for PICC placement and PICC inserted at femoral site (compared with nonfemoral sites) (odds ratio [OR], 1.53 [95% confidence interval {CI}, 1.07-2.25]; P = .044). An independent predictor of catheter-related noninfectious complications was time spent for PICC insertion of more than 60 minutes (compared with less than 30 minutes) (OR, 1.96 [95% CI, 1.08-3.53]; P = .026). New-type PICCs were significantly associated with a higher rate of femoral site insertion, catheter-related noninfectious complications, and longer time for successful insertion than old-type PICCs. The hazard rates of CRS according to indwelling time, determined over 5-day periods by survival analysis, showed 0.05% for catheters in place for 4 days or less; 0.27% for 5-9 days; 0.40% for 10-14 days; 0.68% for 15-19 days; 1.18% for 20-24 days; 3.96% for 25-29 days; and 10.45% for 30 or more days. CONCLUSIONS: Different catheters do influence the complication rates. Spending more than 60 minutes for successful PICC insertion and PICCs indwelling for more than 30 days are associated with higher rates of catheter-related complications.

Complication rates with central venous catheters inserted at femoral and non-femoral sites in very low birth weight infants.

OBJECTIVE: To compare the complication rates of femoral versus nonfemoral sites of percutaneously inserted central venous catheters (PICCs) in very low birth weight infants. METHODS: Between 2004 and 2006, 518 PICCs inserted in 334 neonates with a birth body weight>or=1500 g were studied. 278 catheters were inserted at nonfemoral sites, and 240 catheters at a femoral site. All catheter-related complications were recorded and analyzed. RESULTS: The infants with femoral PICCs had a significantly higher rate of catheter-related sepsis (CRS) than those with nonfemoral PICCs (22.5% vs. 12.2%, P=0.002) and the incidence rate was also significantly higher (10.9 vs. 6.8 episodes per 1000 catheter days, P=0.012). The infants with nonfemoral PICCs had significantly higher rates of phlebitis, catheter site inflammation, and need for early removal than those with femoral PICCs. Multiple logistic regression analysis showed that the significant contributors to CRS were duration of the PICC placement (P<0.001) and insertion of the PICC at a femoral site (P=0.010). CONCLUSIONS: Because of a higher rate of CRS, the femoral site should not be considered for the placement of PICCs in VLBW infants, when possible.

Lower erythrocyte glutathione peroxidase activity in bronchopulmonary dysplasia in the first week of neonatal life.

BACKGROUND: Bronchopulmonary dysplasia (BPD) is a major pulmonary complication in premature infants and is considered a free radical disorder. Erythrocyte catalase (CAT) and cellular glutathione peroxidase (c-GPx) are antioxidant enzymes that detoxify peroxides generated from dismutation of superoxide anion. The study goal was to measure enzyme activity for preterm infants during the first week of life. METHODS: Blood samples were collected from umbilical arterial lines or the radial artery of 44 preterm infants (gestational age range: 25-30 weeks) on days 0, 2, and 5 after delivery. Erythrocyte CAT and c-GPx activities were evaluated, while clinical data were obtained and the correlations of enzyme activity and BPD status were examined. RESULTS: There was no correlation between enzyme activity and gestational age or birth weight. Packed red cell transfusion did not affect enzyme activity and there was no difference in CAT activity between the patient groups. C-GPx activity from preterm infants with BPD was significantly lower than those of preterm infants without BPD on day 5. CONCLUSIONS: Erythrocyte c-GPx may play an important role in the development of BPD. Lower c-GPx activity in early post-natal life might be a risk factor of BPD.

[Mothers' experiences and perspectives of neonatal death: a qualitative retrospective inquiry].

The purpose of this qualitative study is to understand mothers' experiences and perspectives concerning neonatal death.?In-depth interviews with eight mothers were conducted. Data were collected using a retrospective method based on semi-structured interview guidance, and analyzed according to Colaizzi's (1978) phenomenology approach. Four themes evolved: (1) Puzzlement on the brink of neonatal death: neonatal death, as an unpredicted event, constitutes a puzzle for mothers; they tend to seek the cause of the mishap, and in turn, fall into a dilemma about whether to try to save the newborn. (2) Chaos in the wake of the loss of babies: mothers' experience of physical, mental, and behavioral changes which might stymie their original positive attitude toward the role of being a mother, and further cause a divergence of expectations between the husband and wife. (3) Adjustments in the wake of the loss: when mothers try to adjust themselves, common approaches, such as good-will pep-talk and emotional utterance/sharing, are not really helpful. Certain factors also play a part, ether positively or negatively, in the mental adjustment process; they include responsibility for the household, intentional mood-diversion, prohibiting the mother from participating in funerals for the babies. (4) Professional guidance: mothers expect to receive professional guidance to help them to face the fact of death, especially in the moment of separation; providing memorabilia and personalized follow-ups for mothers are beneficial. In conclusion, it is suggested that mothers experiencing neonatal death should be encouraged to express their grief through appropriate emotional channels, and receive professional follow-up to rebuild physiologically, psychologically, and spiritually, rather than suppressing their mourning.

Erythrocyte anti-oxyenzyme activity in preterm infants with retinopathy of prematurity.

BACKGROUND: Retinopathy of prematurity (ROP) is the main cause of visual impairment in premature infants and is considered to be a multifactorial disease. Because of the similarity between the human retina and the erythrocyte concerning their antioxidant mechanism, the aim of this study was to measure the erythrocyte anti-oxyenzyme activity of preterm infants. METHODS: This prospective study was performed on a tertiary referral hospital. Blood samples were collected from umbilical arterial lines or the radial artery of 33 preterm infants within 24 h after delivery to evaluate erythrocyte anti-oxyenzyme activity. Clinical data and oxygen administration were obtained and the correlations of enzyme activity and ROP status were examined. RESULTS: Gestational age, birth weight, 1-min Apgar score, and cellular glutathione peroxidase activity were significantly lower in preterm infants with ROP. There was no correlation between enzyme activity and gestational age, birth weight, or severity of ROP. There were no differences in cumulative oxygen and ventilator administration. CONCLUSIONS: Gestational age and birth weight, 1-min Apgar score, and glutathione peroxidase activity are risk factors for ROP. Defective glutathione peroxidase activity may contribute to the initial phase of ROP.

Successful removal of a ruptured silastic percutaneous central venous catheter in a tiny premature infant.

The spontaneous rupture of a Silastic catheter is a rare occurrence. We describe our experience of managing a tiny premature infant with embolization of a Silastic percutaneous central venous catheter (PCVC) and discuss the possible mechanisms of the embolization. A 28-week, 980 g, preterm male infant received a Silastic PCVC (Epicutaneo Cava Catheter, Vygon, Germany) for parenteral nutritional support at 4 days of age. The catheter was introduced percutaneously and advanced without difficulty through the right antecubital vein, and was subsequently withdrawn 2 cm following confirmation of tip position using radiography. A following chest radiograph, taken 15 hours later, showed rupture of the catheter, and an echocardiogram revealed a piece of the catheter had lodged between the right atrium and the right ventricle. The dislodged fragment of the catheter was retrieved successfully using a snare catheter (Microvena, White Bear Lake, Minn) by a pediatric cardiologist without complications. We want to stress that clinicians should be aware that rupture of the catheter is rare and can also occur asymptomatically and that an embolized fragment can be safely removed without extensive surgical manipulation, even in a tiny premature infant.

Erythrocyte Cu/Zn superoxide dismutase activity in preterm infants with and without bronchopulmonary dysplasia.

BACKGROUND: Erythrocyte Cu/Zn superoxide dismutase is believed to play a major role as a first-line antioxidant defense. Studies have reported varying results from measures of superoxide dismutase activity in cord blood samples from neonates. OBJECTIVE: The study goal was to assess enzyme activity for preterm infants representing a range of gestational ages during the 1st week of life. Clinical data were obtained and correlations with superoxide dismutase activity were examined. METHODS: We collected blood samples from umbilical arterial lines or the radial artery of 44 preterm infants (gestational age range 25-30 weeks) on days 1, 3, and 6 after delivery and evaluated erythrocyte Cu/Zn superoxide dismutase activity. RESULTS: There was no correlation between enzyme activity and gestational age or birth weight. Superoxide dismutase activity gradually increased in preterm infants with bronchopulmonary dysplasia on days 3 and 6, with levels significantly higher than those of preterm infants without bronchopulmonary dysplasia on day 6. We found that packed red cell transfusion did not affect erythrocyte superoxide dismutase activity in either group. However, higher cumulative oxygen administration was noted in preterm infants with bronchopulmonary dysplasia. CONCLUSION: Higher cumulative oxygen administration may be one factor that upregulates the activity of erythrocyte superoxide dismutase.