Risk of morbidity following catheter removal among neonates with catheter associated bloodstream infection.

OBJECTIVE: We hypothesized that infectious morbidities following percutaneously inserted central venous catheter (PICC) removal would be greater among neonates with central-line associated bloodstream infection (CLBASI). STUDY DESIGN: This retrospective cohort study, included all neonates who required a PICC over a ten-year period. Outcomes assessed following PICC removal included: late bloodstream infection, rule-out sepsis workups, need for a subsequent PICC and antibiotic days and PICC days after PICC removal. Odds ratios (OR) and 95% confidence intervals (CI) were determined for outcomes. Regression analyses were used to control for confounders. RESULTS: Two-thousand nine hundred and thirteen neonates required at least one PICC during the study period. After adjusting for confounders neonates with CLABSI were 3.4 (95% confidence interval (CI) 2.5, 4.6) and 2.2 (95% CI 1.2, 4.0) times more likely respectively to require a subsequent PICC or develop a late bloodstream infection after PICC removal. Neonates with CLABSI required 1.33 (95% CI 0.77, 1.89) more days of antibiotic treatment and 6.85 (95% CI 5.34, 8.37) more PICC days following PICC removal than neonates without a CLABSI. CONCLUSIONS: Neonates with CLABSI are at risk for additional infectious morbidities after PICC removal. Future intervention studies aimed at reducing CLABSI should evaluate whether morbidities following catheterization are also reduced.

Serious head injuries from lawn darts.

Serious injuries secondary to lawn darts have not been reported. In this article two cases of penetrating skull injuries are reported. One patient developed a polymicrobial brain abscess necessitating surgical drainage and a prolonged hospitalization. Psychologic function was diminished at discharge. The second child required surgical repair of a depressed skull fracture. Thirteen lawn dart head injuries have been reported to the Consumer Product Safety Commission between 1983 and 1985. These injuries are summarized along with the reported cases to point out the seriousness (neurologic impairment in 5/10 head injuries) of such injuries and warn parents and physicians of the potential dangers of this game.

Increased risk of gastrointestinal perforations in neonates mechanically ventilated with either face mask or nasal prongs.

Twenty cases of gastrointestinal perforations not associated with necrotizing enterocolitis or a bowel obstruction (GPNN) were reviewed. Fifteen infants suffered perforations during cycle ventilation. Perforations were localized in the stomach, duodenum, ileum, and jejunum. To determine if the type of mechanical ventilation used (ie, face mask, nasal prongs, or endotracheal tube) was associated with GPNN, a matched case-control analysis was performed. Case and control infants were matched by means of Apgar scores, gestational age, and length of time on ventilatory support. The Mantel-Haenszel estimate for estimating odds-ratios was used to determine that infants ventilated with nasal prongs or face mask were more likely to develop a gastrointestinal perforation than control infants ventilated with endotracheal tubes (odds-ratio greater than or equal to 29.6). This risk was associated with both upper gastrointestinal perforations (odds-ratio greater than or equal to 21.0) and lower gastrointestinal perforations (odds-ratio greater than or equal to 15.3). Routine use of mechanical ventilation with either nasal prongs or face mask appears to be associated with an unacceptable risk of gastrointestinal perforations in sick neonates.

Fatal rhabdomyolysis following influenza infection in a girl with familial carnitine palmityl transferase deficiency.

Severe rhabdomyolysis following an influenza B infection developed in a previously well 13-year-old girl. There was no history of trauma. Her course was complicated by episodes of severe hyperkalemia, hypocalcemia, hyperphosphatemia, and myoglobinuria. Renal failure, hypertension, and life-threatening arrhythmias developed; she died. Muscle biopsy revealed that this girl had carnitine palmityl transferase deficiency. An asymptomatic sister was demonstrated to have the same disorder. Although carnitine palmityl transferase deficiency is usually associated with mild bouts of rhabdomyolysis that become apparent only in adulthood, severe forms of this disorder may be seen in children. Life-threatening rhabdomyolysis and myoglobinuria may follow any infection associated with decreased intake. If carnitine palmityl transferase deficiency is diagnosed in a proband, other siblings should be evaluated so that proper preventative measures can be undertaken to help prevent the development of symptoms in susceptible individuals who have not been recognized to have the disease.

Peripheral intravenous catheter complications in critically ill children: a prospective study.

Six hundred fifty-four peripheral Teflon catheters in 303 pediatric intensive care unit patients were examined to determine complication rates and associated risk factors. Phlebitis, extravasation, and bacterial colonization occurred at rates of 13%, 28%, and 11%, respectively. Logistic regression of factors that increased phlebitis risk revealed infusion of hyperalimentation (odds ratio 2.9) or lorazepam (odds ratio 2.2) and catheter location (odds ratio 2.9) as the most important determinants of phlebitis risk. Age (less than or equal to 1 year, odds ratio 2.0), catheter time in situ (less than or equal to 72 hours, odds ratio 2.1), and infusion of antiepileptics (odds ratio 2.1) were the most important determinants of extravasation. Catheters were colonized most frequently with coagulase-negative Staphylococcus (51/54). Sepsis attributable to catheter colonization occurred in 1 patient. Duration of catheter placement (greater than or equal to 144 hours, odds ratio 5.8) was an important determinant of catheter colonization. Colonization risk increased from 11% in catheters that were in situ for 48 to 144 hours to 34% for catheters that were in for longer than 144 hours. Infusion of diazepam (odds ratio 11.0) or lipid emulsions (odds ratio 2.5) and age (less than or equal to 1 year, odds ratio 2.2) were also important determinants of colonization risk. Replacing catheters in critically ill children every 72 hours would not decrease phlebitis, bacterial colonization, or catheter-induced sepsis and could increase extravasation risk. Catheters can be safely maintained with adequate monitoring for up to 144 hours in critically ill children.

A three-day course of dexamethasone therapy to prevent chronic lung disease in ventilated neonates: a randomized trial.

BACKGROUND: Although several trials of early dexamethasone therapy have been completed to determine if such therapy would reduce mortality and chronic lung disease (CLD) in infants with respiratory distress, optimal duration and side effects of such therapy remain unknown. PURPOSE: The purpose of this study was: 1) to determine if a 3-day course of early dexamethasone therapy would reduce CLD and increase survival without CLD in neonates who received surfactant therapy for respiratory distress syndrome and 2) to determine adverse effects associated with such therapy. DESIGN: This was a prospective multicenter randomized trial comparing a 3-day course of dexamethasone therapy beginning at 24 to 48 hours of life to placebo therapy. Two hundred forty-one neonates (dexamethasone n = 118, placebo n = 123), who weighed between 500 g and 1500 g, received surfactant therapy, and were at significant risk for CLD or death using a model to predict CLD or death at 24 hours of life, were enrolled in the trial. Infants randomized to receive early dexamethasone were given 6 doses of dexamethasone at 12-hour intervals beginning at 24 to 48 hours of life. The primary outcomes compared were survival without CLD and CLD. CLD was defined by the need for supplemental oxygen at the gestational age of 36 weeks. Complication rates and adverse effects of study drug therapy were also compared. RESULTS: Neonates randomized to early dexamethasone treatment were more likely to survive without CLD (RR: 1.3; 95% CI: 1.03, 1.7) and were less likely to develop CLD (RR: 0.6; CI: 0.3, 0. 98). Mortality rates were not significantly different. Subsequent dexamethasone therapy use was less in early dexamethasone-treated neonates (RR: 0.8; CI: 0.7, 0.96). Very early (

Airway burns in an infant following aspiration of microwave-heated tea.

Airway obstruction developed in an infant who sustained thermal burns to the oropharynx and trachea after he aspirated microwave-heated tea. Bronchoscopic examination revealed upper and lower airway hyperemia, edema and blister formation. Physicians should be aware of this potential hazard of microwave-heated fluid. Early assessment and stabilization of the airway is important following scald injuries to the face and oropharynx.

Outcome of infants with cystic fibrosis requiring mechanical ventilation for respiratory failure.

Previous studies have documented a 75 to 80 percent mortality rate in infants (less than 12 months) with cystic fibrosis who present with RF/MV. We investigated the current outcome of these patients by comparing the outcome of five infants with cystic fibrosis and RF/MV between the years 1980 and 1986 with that of age-matched control subjects with cystic fibrosis and no respiratory failure. Recent Shwachman scores and the number of hospitalizations during the study period were used to assess outcome. All study cases were alive one to six years after the episode of RF/MV. Their mean Shwachman score (83 [range: 70 to 95]) did not differ from the recent mean Shwachman score (78 [range: 50 to 95]) of the control group. Number of hospitalizations did not differ between groups. We conclude that the outcome of infants with cystic fibrosis whose initial presentation is RF/MV is not as grave as once thought. If indicated, infants with cystic fibrosis and respiratory failure should be ventilated.

Infectious complications during peripheral intravenous therapy with Teflon catheters: a prospective study.

Infectious complication rates and associated risk factors occurring during peripheral intravenous therapy with Teflon catheters were determined during a prospective study of 286 cannula insertions. Suppurative phlebitis, cannula-related sepsis or suspected sepsis did not occur. Semiquantitative cannula cultures revealed a colonization rate of 10.4% (12 of 115). Coagulase-negative nonadherent Staphylococcus was the most common colonizing organism occurring in 10 of 12 positive catheters. Alpha Streptococcus and adherent coagulase-negative Staphylococcus colonized the remaining catheters. Colonization was not related to the rate of phlebitis, extravasation or cannulation time. No patient- or catheter-related factors increased the risk of colonization. In children in a general pediatric ward the risk of catheter colonization and subsequent sepsis should not be used as reasons for routinely removing complication-free peripheral Teflon catheters at 72 hours.

Trends in mortality in children hospitalized with meningococcal infections, 1957 to 1987.

We reviewed charts of 261 children seen at Children's Hospital of Wisconsin from 1957 to 1987 with culture-proven meningococcemia or meningococcal meningitis, and we analyzed trends in mortality and disease severity for that interval. Overall case fatality was 10%, ranging from 9% in the period 1957 to 1963, to 16% in the period 1980 to 1987 (P = 0.15). The percent of patients admitted with severe disease increased from 14% to 38% (P = 0.001). When stratified by disease severity, case-fatality rates did not change with time. We conclude that technologic advances of the past 30 years had no measurable impact on mortality from meningococcal infection in our hospital and that crude case-fatality rates can be misleading if disease severity is not considered.

Comparison of 10% povidone-iodine and 0.5% chlorhexidine gluconate for the prevention of peripheral intravenous catheter colonization in neonates: a prospective trial.

The purpose of the study was to compare the efficacy of 10% povidone-iodine with that of 0.5% chlorhexidine gluconate in 70% isopropyl alcohol for the prevention of peripheral intravenous catheter colonization in neonates. This was a multicenter, nonrandomized prospective study in a tertiary neonatal intensive care setting in which povidone-iodine and chlorhexidine gluconate were each used as antiseptic skin preparations over sequential 6-month periods. During the first 6 months of the study when povidone-iodine was in use 9.3% (38 of 408) of catheters were colonized. During the second 6 months of the study when chlorhexidine gluconate was in use, catheter colonization occurred in 4.7% (20 of 418, P = 0.01). Catheter-related bacteremia occurred during only 0.2% (2 of 826) of all catheterizations. Heavy skin colonization before catheter insertion (relative risk, 3.6; 95% confidence interval, 1.9, 7.0), catheterization > or = 72 hours (relative risk. 2.0; 95% confidence interval, 1.01, 3.8) and gestational age < or = 32 weeks (relative risk, 1.8; 95% confidence interval, 1.02, 3.3) increased colonization risk. Ampicillin infusion (relative risk, 0.4; 95% confidence interval, 0.2, 0.7) and 0.5% chlorhexidine gluconate cutaneous antisepsis (relative risk, 0.4; 95% confidence interval, 0.2, 0.8) were factors associated with decreased colonization risk. We conclude that 0.5% chlorhexidine gluconate in 70% isopropyl alcohol appears to be more efficacious than 10% povidone-iodine for the prevention of peripheral intravenous catheter colonization in neonates.

Outbreak of Serratia marcescens infection in a neonatal intensive care unit.

We report an outbreak of Serratia marcescens infection in the neonatal intensive care unit of a community hospital. The outbreak involved eight neonates, (five infected and three colonized), one of whom died. Pulsed-field gel electrophoresis confirmed that all isolates were identical strains. Cohorting and isolation of the infected neonates helped to control the outbreak. No environmental source of infection was found.

Treatment of infants with indirect hyperbilirubinemia. Readmission to birth hospital vs nonbirth hospital.

BACKGROUND/OBJECTIVE: Indirect hyperbilirubinemia is a common cause for readmission to a hospital during the first week of life. Many newborn nurseries are ill equipped to readmit such newborns. The purpose of this study was to compare the care and treatment of infants with indirect hyperbilirubinemia who were readmitted to their birth hospital with those who were admitted to a hospital that differed from their birth hospital. DESIGN: Retrospective cohort study. SETTING: Children's and community hospitals. PATIENTS: We reviewed the records of 100 newborns who were readmitted during the first week of life (36 were readmitted to their birth hospital) with a primary admission diagnosis of indirect hyperbilirubinemia. RESULTS: Infants who were admitted to their birth hospital were less likely to have blood cultures (none of 36 vs 17 of 64, P = .0005), urine cultures (none of 36 vs eight of 64, P = .02), or more than one complete blood cell count (two of 36 vs 18 of 64, P = .001) performed compared with infants who were admitted to a nonbirth hospital. Antibiotic, intravenous therapy (P = .0005), and emergency department (P = .0001) use was more common among infants who were admitted to a nonbirth hospital. Infants who were admitted through the emergency department at a nonbirth hospital had phototherapy started later (mean +/- SD, 5.3 +/- 1.6 vs 2.2 +/- 1.7 hours; P = .0001) than did infants who were directly readmitted to the same nonbirth hospital. CONCLUSIONS: Readmitting infants with indirect hyperbilirubinemia to birth hospitals or ensuring that accurate, timely, and complete information is obtained from the birth centers by admitting hospital personnel before laboratory studies and treatment are performed will reduce diagnostic workups and should reduce hospital charges for these infants. Phototherapy should be initiated in the emergency department if stabilization is required before admission.

Hypocarbia before surfactant therapy appears to increase bronchopulmonary dysplasia risk in infants with respiratory distress syndrome.

OBJECTIVE: To determine to what extent the risk of bronchopulmonary dysplasia is affected by ventilatory management before the first dose of rescue artificial surfactant. STUDY DESIGN: Retrospective cohort study. SUBJECTS: One hundred eighty-eight low-birth-weight infants (< or = 1700 g) who received artificial surfactant therapy for respiratory distress syndrome and who were alive at 36 weeks of gestational age. OUTCOME: Bronchopulmonary dysplasia was defined by a need for supplemental oxygen to maintain an arterial saturation of 92% or more at 36 weeks of gestational age. RESULTS: Thirty-seven percent (70/188) of the cohort met study criteria for bronchopulmonary dysplasia. Early determinants significantly associated with bronchopulmonary dysplasia (given as odds ratio, 95% confidence interval) in the most parsimonious backward stepwise logistic regression model included the following: birth weight of 1000 g or less (5.1, 2.4 to 10.7), cesarean birth because of fetal distress (4.4, 1.7 to 11.4), ventilatory efficiency index of 0.15 or less before surfactant therapy (3.1, 1.4 to 6.8), arterial-alveolar oxygen ratio of 0.15 or less before surfactant therapy (2.2, 1.01 to 4.6), and a low arterial PCO2 (< or = 29 vs > or = 40 mm Hg, 5.6, 2.0 to 15.6; 30 to 39 vs > or = 40 mm Hg, 3.3, 1.3 to 8.3). The inverse relationship between hypocarbia and bronchopulmonary dysplasia persisted even in stratified analyses limited to infants with measures of cardiovascular or respiratory illness that suggested less severe manifestations of disease. CONCLUSIONS: Ventilatory management before rescue treatment with artificial surfactant therapy that result in hypocarbia may increase the risk of bronchopulmonary dysplasia. These findings suggest that early ventilatory management should not only provide adequate oxygenation but also limit hyperventilation.

Vasoactive intestinal peptide (VIP): an amnestic neuropeptide.

Vasoactive intestinal peptide (VIP) is a neuropeptide present in high concentrations in the hippocampus. The studies reported here demonstrate that VIP administered into the third ventricle of the brain caused amnesia in mice trained on a left-right footshock avoidance task in a T-maze. VIP resulted in amnesia when administered directly into the rostral portion of the hippocampus at a 10-fold lower dose than was needed to produce amnesia when VIP was administered intracerebroventricularly. When VIP was administered 24 hr after training, it failed to impair retention measured a week later. VIP receptor antagonist ([4-Cl-D-Phe6,Leu17]VIP) enhanced retention when administered into the rostral portion of the hippocampus, suggesting that VIP plays a physiological role in memory modulation. VIP receptor antagonist administered 24 hr after training did not facilitate retention. To gain some insight as to how VIP may be affecting memory processing, we determined if some memory-improving compounds showed a selective ability to block amnesia induced by VIP. The amnestic effect of VIP was blocked by peripheral administration of the memory-enhancing agents, arecoline, naloxone and ST 587 (a noradrenergic receptor agonist) but not by cholecystokinin octapeptide. Central administration of arecoline, but not neuropeptide Y, blocked the amnestic effect of VIP. It is concluded that VIP is a potent amnestic peptide.

Evidence that cholecystokinin-enhanced retention is mediated by changes in opioid activity in the amygdala.

Mice, partially trained to avoid footshock in a T-maze, showed enhanced retention relative to vehicle-injected mice when treated peripherally with arecoline, D-amphetamine, cholecystokinin octapeptide (CCK-8), epinephrine or naloxone. Both intra-amygdaloid and intraventricular injections of beta-endorphin resulted in amnesia. D-amphetamine and arecoline blocked the amnestic effect of beta-endorphin administered into the amygdala but it required higher doses for CCK-8, epinephrine and naloxone to block the amnestic effect of beta-endorphin. The effects of CCK-8, epinephrine and naloxone showed a differential ability to block amnesia induced by beta-endorphin intraventricularly with epinephrine and naloxone preventing amnesia but CCK-8 not improving retention. This data suggests that the memory enhancement produced by peripherally administered CCK-8 involves the amygdala and that both CCK-8 and epinephrine interact with opioid amnestic mechanisms within the amygdala to alter memory processing.

Accuracy of primary bedside neonatal nurse-generated score for neonatal acute physiology (SNAP) scores.

OBJECTIVE: To determine whether 24-hour SNAP scores generated from data gathered by primary bedside nurses agreed with the SNAP scores of one trained research nurse. STUDY DESIGN: Primary bedside nurses (n = 50) in a level III private nursery collected data necessary for generating 24-hour SNAP scores on 60 consecutively admitted inborn neonates who lived at least 24 hours. The amount of time required for data collection and scoring was also determined. SNAP scores and the time required to generate them were compared with the unit research nurse's SNAP scores and time required to generate them on the same 60 patients. The Wilcoxon rank test and Spearman's rank correlation were used for statistical analyses. RESULTS: SNAP scores generated from primary bedside nursing data did not differ from those of the research nurse's SNAP scores (11.7 +/- 0.8 vs 11.4 +/- 0.9 [mean +/- SEM], p = 0.7), and they correlated well over a wide range of SNAP scores (r = 0.93, p = 0.0001). Primary bedside nurses required more time (15 +/- 0.7 vs 3.0 +/- 0.08 minutes, p = 0.0001) to generate SNAP scores than the research nurse. CONCLUSION: Primary bedside level III nurses can accurately obtain data for SNAP scores during 8- to 12-hour shifts.

Clinical utility of a bedside blood analyzer for measuring blood chemistry values in neonates.

OBJECTIVE: The purpose of this study was to determine whether blood chemistry measurements obtained by a bedside blood analyzer through an umbilical artery catheter agreed with those obtained with use of conventional laboratory analyzers. STUDY DESIGN: Forty-two neonates (1910 +/- 1000 gm) being treated in a level III neonatal intensive care unit had 88 blood samples drawn through an umbilical artery catheter. Serum sodium, potassium, glucose, and hematocrit concentrations were measured (n = 352) with use of a laboratory analyzer (0.7 ml of blood) and a bedside blood analyzer (0.06 ml of blood). RESULTS: Only 5.7% of all measurement differences (20/352) were outside the predetermined clinically acceptable difference range, and just 1.4% (5/352) might have affected clinical decision making. Correlations between laboratory analyzer measurements and bedside blood analyzer measurements were excellent: serum potassium, r = 0.97, p = 0.0001; serum glucose, r = 0.93, p = 0.0001; and blood hematocrit, r = 0.93, p = 0.0001. Serum sodium measurement correlation was significant (p = 0.0001) but weaker (r = 0.86). CONCLUSION: The bedside blood analyzer evaluated in this report is clinically useful for neonatal patients and could limit phlebotomy loss if used routinely.

Cord blood and postnatal serum leptin and its relationship to steroid use and growth in sick preterm infants.

OBJECTIVE: To study the effect of prenatal and postnatal glucocorticoids use on serum leptin and weight gain in sick preterm infants and its correlation with caloric intake. METHODS: Serum leptin was measured in 24 neonates at day 1 (cord), 14 and 28 by radioimmunoassay. Total caloric intake (enteral and parenteral) and weight were measured on days 14 and 28 of life. RESULTS: Mean birth weight and gestational age of study infants were 864 +/- 273 g (mean +/- SD) (range 520-1755 g), and 26.6 +/- 2.4 weeks (23-32 weeks) respectively. Cord blood leptin was greater in infants whose mothers received antenatal steroids (1.98 +/- 1.05 ng/ml vs 0.94 +/- 0.39 ng/ml, p=0.004). Serum leptin increased postnatally from 1.52 +/- 1.0 ng/ml at birth to 2.2 +/- 1.3 ng/ml on day 28 of life (p=0.03). Mean serum leptin had an inverse exponential relationship with postnatal weight gain by day 28 of life (R2=0.56). Total caloric intake on days 14 and 28 of life did not correlate with postnatal weight gain. CONCLUSIONS: Increased serum concentration of leptin following glucocorticoids may be associated with poor weight gain in sick preterm infants.

Association between tracheal pepsin, a reliable marker of gastric aspiration, and head of bed elevation among ventilated neonates.

OBJECTIVES: To determine the frequency of tracheal pepsin in ventilated neonates and whether the angle of head elevation was associated with tracheal pepsin. STUDY DESIGN: Serial trachael samples (at 3, 7, 14, 21 and 28 days of ventilation) were obtained from intubated, ventilated very low birth weight infants. Presence of tracheal pepsin was determined by Western blot analysis using a specific anti-human pepsin antibody. RESULTS: Tracheal pepsin was detected in 35/66 (53%) of the ventilated neonates (birthweight: 798 ± 268 grams [mean ± standard deviation]). Neonates whose head elevation was in the upper quartile (≥14 degrees) during the first sampling time (day 3) were less likely (4/16 vs 9/10, P = 0.0013) to have tracheal pepsin when compared to neonates whose head elevation was in the lowest quartile (≤8 degrees). CONCLUSIONS: Pepsin, a marker for gastric secretion aspiration, was detected in 53% of ventilated low birth weight neonates; early elevation of the head of the bed was associated with a lower rate of tracheal pepsin.