Umbilical Catheter Research Articles

P-125 REX SHUNT IN A DEVELOPING COUNTRY – IS IT POSSIBLE?

Extrahepatic portal vein obstruction (EHPVO) is a frequent cause of noncirrhotic portal hypertension in children. Describe the experience in the surgical treatment of EHPVO in children, in a developing country. Retrospective case series study, with medical records review of patients with EHPVO, who underwent surgical treatment, by an experienced surgeon, between July 2016 and May 2019. Patient profile, laboratory test, images, liver histology, surgery performed, postoperative complications and shunt patency were analysed. 12 patients, median age of 4 years, umbilical catheterization was present in 8 patients (66,6%). Ten patients performed portography, and 60% had type A by Baveno VI criteria. Despite normal liver tests, liver biopsy revealed ductular proliferation in 83,3% of patients and mild portal fibrosis in 66,7%. Splenomegaly was present in 91,7% and thrombocytopenia in 83,3%. All patients had oesophageal varices and gastrointestinal bleeding occurred in 83,3%. Among the coagulation tests, the deficiency of C and S proteins is noteworthy in most patients, with 72,3% and 63,6% respectively. It was possible to perform meso-Rex bypass in 10 patients (83,3%); in the other 2 distal splenorenal shunt was performed. Early post-operative complications occurred in 58,3% of patients, the most common was ascites in 4 (33,3%), which resolved in less than 1 month. One patient developed shunt thrombosis in the first 7 days after surgery, not resolved with thrombectomy. In outpatient follow-up one patient developed thrombosis in the Rex shunt and another 4 had stenosis. All of them underwent to interventional radiology. Currently 8 of 10 meso-Rex patients (80%) have patent shunt. Rex shunt is possible in developing countries with an experienced surgeon and multidisciplinary team.

The incidence of pericardial effusion requiring intervention in infants with a history of umbilical catheter placement: the US national database.

To assess the association of umbilical catheters (UC) placement with pericardial effusion (PCE) in newborn infants. We analyzed the National Inpatient Sample dataset. We compared prevalence of PCE in infants with UC versus those without in three subpopulations: infants with birth weight (BW) > 2500 g or GA > 34 weeks, preterm infants with BW < 1500 g, and term infants with congenital heart disease (CHD) using regression analysis methods while controlling for clinical and demographic variables. First analysis included a weighted sample of 22,751,313 infants with no hydrops fetalis. Of them, 1869 neonates (0.01%) had PCE. Pericardial effusion was found in 0.17% of infants with only UAC, 0.21% of infants with only UVC and 0.29% of infants with both catheters with an adjusted odds ratios (aOR) (1.5, CI:1.2-1.9), (2.3, CI:1.7-2.9), and (2.9, CI:2.4-3.6), p < 0.001, respectively. Similar findings were found in infants <1500 g and in those with CHD. Umbilical Catheter placement is associated with increased risk for pericardial effusion.

A Quality Improvement Initiative to Provide Timely Central Vascular Access in a Neonatal Intensive Care Unit.

Timely central venous access is essential in the care of critically ill neonates. Peripherally inserted central catheters (PICCs) are the preferred form of central venous access when umbilical venous catheters cannot be placed or are discontinued. However, time delays increase risk for injury from peripheral intravenous lines and may contribute to inconsistent delivery of necessary fluids and medications. The aim of this quality improvement project was to decrease wait times for PICC placement in the neonatal intensive care unit (NICU). A unit-based PICC team was developed consisting of NICU nurses and attending neonatologists and implemented in 2 phases. Data were collected from chart reviews before, during, and after implementation of the team. We tracked time between PICC order and placement and number of attempts. Hospital metrics on peripheral intravenous line infiltrations and central line-associated blood stream infection were also monitored. At the end of the project, we continued tracking outcomes to determine whether gains would be sustained past the project period. Implementation of a unit-based interdisciplinary specialty team led to a 50% reduction in mean PICC wait times from 1.2 days to 0.58 days. Benefits of the initiative were sustained past the initial project period. The development of a dedicated, local team played a key role in improving vascular access in the NICU. Proximity of specialized teams provides a solution to address gaps in care in the NICU.

Ultrasound guided percutaneous catheterization of the brachiocephalic vein by small caliber catheter: An alternative to epicutaneo-caval catheter in newborn and premature infants.

Umbilical Venous Catheter (UVC) and Epicutaneo-Caval Catheters (ECC) are reference catheters in the neonatal period. However, many factors such as the corpulence of neonates, poor venous capital, and anatomical variants can complicate ECC insertion or make it impossible. In newborns with failed ECC insertion, we developed an hybrid technique that combines the insertion of a long-lasting silicone or polyurethane small caliber catheter, usually used as a ECC in newborns, with the ease and speed of ultrasound guided puncture of the brachiocephalic vein (BCV). Three years retrospective single center experience of ultrasound guided BCV insertion of silicon or polyurethane small caliber central catheter in a tertiary neonatal intensive care in case of insertion fail of ECC. Twenty-one echo guided BCV-ECC insertions were performed in 20 newborns. Median age was 16 days (range: 0-110 days), median weight was 1700 g (range: 605-4960 g) at insertion. In most cases, insertion was on the left side (17/21). No failures were noted. Only one attempt was necessary in all cases. Insertion time, when noted, was always of <45 min. The median duration of use of these catheters was 11 days (range 3-35 days). No complication was noted during insertion or catheter use, including catheter-related infections and thrombosis. Echo guided percutaneous catheterization of the brachiocephalic vein with a long lasting silicone or polyurethane small caliber catheter is a safe alternative to the ECC if insertion has failed. However, it requires a mastery of ultrasound-guided insertion technique in term and premature neonates.

Radiological imaging on umbilical venous catheter’s placement in preterm infants in the neonatal intensive care unit

Umbilical vessel catheterization is a technique used for neonatal reanimation, in neonatal intensive care units.Imaging techniques provide a strong support for the performance of this practice. In this case, radiography is themost widely used instrumental investigation for the evaluation of umbilical venous catheter placement. By protocol,the image is acquired with an antero-posterior projection of the thoraco-abdominal district, with perpendicularradius to the median sagittal plane. The following descriptive study has been carried out on 20 newborn patientsof the Neonatal Intensive Care Unit of the University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, bornbetween December 4th 2020 and March 31th 2021. This study describes the effectiveness of the “thoraco-abdominal”radiological technique for the assessment of neonatal umbilical catheter placement. The basic premise for patients’recruitment was the request for evaluation of umbilical venous catheter placement in preterm infants.

Radiological imaging on umbilical venous catheter’s placement in preterm infants in the neonatal intensive care unit

Umbilical vessel catheterization is a technique used for neonatal reanimation, in neonatal intensive care units. Imaging techniques provide a strong support for the performance of this practice. In this case, radiography is the most widely used instrumental investigation for the evaluation of umbilical venous catheter placement. By protocol, the image is acquired with an antero-posterior projection of the thoraco-abdominal district, with perpendicular radius to the median sagittal plane. The following descriptive study has been carried out on 20 newborn patients of the Neonatal Intensive Care Unit of the University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, born between December 4th 2020 and March 31th 2021. This study describes the effectiveness of the “thoraco-abdominal” radiological technique for the assessment of neonatal umbilical catheter placement. The basic premise for patients’ recruitment was the request for evaluation of umbilical venous catheter placement in preterm infants.

Peripheral Arterial Lines in Extremely Preterm Neonates: A Potential Alternative to Umbilical Arterial Catheters.

Arterial catheterization is a routine procedure in extremely preterm neonates. Umbilical arterial catheters (UACs) are typically used for this purpose, but life-threatening complications have been described. Peripheral arterial lines (PALs) might offer a valuable alternative, but their feasibility in extremely preterm newborns is unclear. To investigate efficacy and complications of PALs in extremely preterm neonates. Retrospective analysis of patients born below 26 weeks of gestation in 2011-2014 (cohort 1, UAC as primary arterial access) and 2015-2019 (cohort 2, PAL as primary arterial access). Arterial line placement during their first 14 days of life, duration of arterial access, reasons for discontinuation, and long-term complications were recorded from health records. In total, 161 of 202 newborns had an arterial line during their first 14 days of life. In cohort 2, the life span of a PAL was significantly longer than that in cohort 1. Signs of dysfunction were the primary reason to discontinue a PAL. Signs of peripheral ischemia were present in 36 of 105 cases (34%) when the PAL was removed but persisted in only 2 patients. UAC-associated persistent ischemic damage occurred in 2 of 97 patients. PALs are a valuable alternative to UACs even in preterm newborns below 26 weeks of gestational age. A special focus on ischemic complications is warranted. Prospective, multicenter studies to verify safety and efficacy of arterial line management and complications in extremely preterm infants are warranted.

Value of preoperative computed tomography for meso-Rex bypass in children with extrahepatic portal vein obstruction

BackgroundExtrahepatic portal vein obstruction (EHPVO) is the most important cause of hematemesis in children. Intrahepatic left portal vein and superior mesenteric vein anastomosis, also known as meso-Rex bypass (MRB), is becoming the gold standard treatment for EHPVO. We analyzed the value of preoperative computed tomography (CT) in determining whether MRB is feasible in children with EHPVO.ResultsWe retrieved data on 76 children with EHPVO (50 male, 26 female; median age, 5.9 years) who underwent MRB (n = 68) or the Warren procedure (n = 8) from 2013 to 2019 and retrospectively analyzed their clinical and CT characteristics. The Rex recess was categorized into four subtypes (types 1–4) depending on its diameter in CT images. Of all 76 children, 7.9% had a history of umbilical catheterization and 1.3% had leukemia. Sixteen patients (20 lesions) had associated malformations. A total of 72.4% of Rex recesses could be measured by CT, and their mean diameter was 3.5 ± 1.8 mm (range 0.6–10.5 mm). A type 1, 2, 3, and 4 Rex recess was present in 9.2%, 53.9%, 11.8%, and 25.0% of patients, respectively. MRB could be performed in patients with types 1, 2, and 3, but those with type 4 required further evaluation. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of CT were 100%, 83.8%, 42.1%, 100%, and 85.5%, respectively.ConclusionsAmong the four types of Rex recesses on CT angiography, types 1–3 allow for the performance of MRB.

Adverse events associated with umbilical catheters: a systematic review and meta-analysis.

To determine the incidence of adverse events (AEs) associated with umbilical catheters in the neonatal population. Systematic review and meta-analysis of observational studies and randomized controlled trials published between 2010 and 2020. In total 14,226 umbilical venous catheters (UVCs) and 4228 umbilical arterial catheters (UACs) were included. Overall, 13.4% of UVCs were associated with an AE (95% CI: 10.1-17.0) or 2.4 per 1000 catheter days (95% CI: 1.8-3.0). UACs had an AE rate of 9% (95% CI: 5.9-12.8) or 0.87 per 1000 catheter days (95% CI: 0.4-1.3). UVC malposition was the most common (41.7% [95% CI: 27.6-56.5]). Local injury from UAC taping was the most common AE in one study. Umbilical catheters have a high incidence of AEs. Research into accurate methods of tip verification, tip surveillance, and securement is required.

Risk Factors Associated With 30-Day Mortality Among Neonates With A. baumannii Sepsis.

Acinetobacter baumannii sepsis constitutes an extreme threat with a poor prognosis and is a difficult infection to control, especially in Asia. Moreover, a knowledge gap in the risk of mortality in neonatal A. baumannii sepsis still exists. This study aimed to identify the risk factors of mortality in neonates with A. baumannii sepsis in Thailand from 1996 to 2019. A multivariable logistic regression model was analyzed for nonsurvivors and survivors of neonatal A. baumannii sepsis. In a 24-year period, 91 neonates with A. baumannii sepsis were reviewed. The median (interquartile range) gestational age and birth weight were 33 (28.5, 37.5) weeks and 1740 (987.5, 2730.0) g, respectively. The 30-day case fatality rate was 36.3% (33/91). In univariable analysis, nonsurvivors of neonatal A. baumannii sepsis was associated with smaller neonates, lower Apgar scores, septic shock, mechanical ventilation, umbilical catheterization, neutropenia, severe thrombocytopenia, carbapenem-resistant A. baumannii sepsis, inadequate empiric antimicrobial therapy, and acute kidney injury. In multivariable analysis, nonsurvivors of neonatal A. baumannii sepsis were associated with septic shock (adjusted odds ratio [OR] = 41.38; 95% confidence intervals [CI]: 3.42-501.13; P = 0.003), severe thrombocytopenia (adjusted OR = 33.70; 95% CI: 3.44-330.55; P = 0.002), and inadequate empiric antimicrobial therapy (adjusted OR = 10.05; 95% CI: 1.40-71.98; P = 0.02). In high multidrug-resistant areas, empiric treatment with broader spectrum antimicrobials should be considered in neonates with sepsis shock or severe thrombocytopenia.

Increased Prevalence of Left Lobe Atrophy in Long-standing Extrahepatic Portal Vein Obstruction.

The aim of this study was to describe long-term changes in standard blood tests and ultrasound (US) findings in pediatric patients with Extrahepatic Portal Vein Obstruction (EHPVO) who have not undergone Meso-Rex Bypass (MRB) surgery. US, laboratory, and endoscopic data of 77 patients were analyzed and compared at 2 different points in time: at initial workup and at most recent follow-up. Differences were assessed using McNemar and Wilcoxon tests, while correlations were evaluated using generalized estimating equations. Upper gastrointestinal bleeding was the most frequent initial manifestation of EHPVO, in 45.4% of subjects. The mean age at diagnosis was 4.3 years. Seventy-four percentage had a previous history of umbilical catheterization and/or neonatal sepsis. Over time, there was a significant increase in the prevalence of leukopenia, thrombocytopenia, and, interestingly, of left lobe atrophy (LLA), even though the number of esophageal varices and the need for endoscopic interventions reduced. A significant correlation was found between history of umbilical catheterization and LLA, splenomegaly and LLA, and gallbladder wall thickening and LLA. Overall, the number of patients with cholelithiasis at initial workup was low (and therefore, not analyzed with inferential statistics); however, we observed a relative increase over time. In this cohort of patients with EHPVO followed over more than 8 years without treatment with MRB, we report the novel finding of a significant increase in the prevalence of LLA over time. LLA correlated with past medical history of umbilical catheterization, and findings of splenomegaly and gallbladder wall thickening. We propose that that LLA should be further explored as a marker of portal hypertension, particularly in the context of a history of umbilical catheterization.

Assessment of the patency of the left portal vein during mesoportal shunting in children with extrahepatic portal hypertension

BACKGROUND: One of the most common causes of extrahepatic portal hypertension in children is portal vein thrombosis. The causes of this disease are different and, in most cases, remain unrecognized. Along with this, the mesoportal shunt (Rex shunt) proved itself and today is considered the gold standard to treat extrahepatic portal hypertension in children. The restoration of hepatopetal blood flow eliminates gastroesophageal bleeding, splenomegaly, hypersplenism, and many other complications. For the results of mesoportal shunt to be successful, several conditions must be met, one of which is the patency of the umbilical portion of the left portal vein. Despite the importance of preoperative diagnostics of the patency of this area, the most optimal instrumental research method has not yet been found.&#x0D; AIM: This literature review aims to highlight the main issues of extrahepatic portal hypertension etiopathogenesis, surgical treatment methods, and the most effective preoperative diagnostic methods to assess the patency of the left portal vein.&#x0D; RESULTS: The authors analyzed the sources of domestic and foreign literature on the etiology, pathogenesis of HSV in children, and laboratory and instrumental diagnostic methods to assess the patency of the PVI to plan the mesoportal shunting operation.&#x0D; CONCLUSIONS: Extrahepatic portal hypertension is a polyetiological disease with a possible hereditary predisposition to a thrombotic process under the influence of various triggers. The most common causes of portal vein thrombosis are omphalitis and umbilical vein catheterization in the neonatal period. Unfortunately, to date, none of the existing instrumental diagnostic methods can reliably answer the question about left portal vein patency. Due to the small number of works, the lack of a unified view on the problem of preoperative diagnosis of patients with extrahepatic portal hypertension, we could not reliably determine the specificity, sensitivity, and accuracy of each instrumental method. Therefore, we could not identify the gold standard method. Nevertheless, with further improvement of the methods for preoperative assessment of the left portal vein patency, surgeons will be more likely to predict the successful outcome of mesoportal shunting, which will generally affect the surgical treatment quality of extrahepatic portal hypertension in children.

A Quality Improvement Project to Increase Frequency of Skin-to-Skin Contact for Extreme Low-Birth-Weight Infants in the Neonatal Intensive Care Unit.

Benefits of skin-to-skin contact (SSC) are documented but often delayed in the extremely preterm population due to medical complexity and staff misconceptions about safety. This quality improvement initiative was designed to increase SSC utilization among infants born before 29 weeks' gestation regardless of respiratory support by addressing nursing barriers inhibiting SSC. A pre-/postsurvey evaluated comfort level performing and perceived barriers to SSC utilization. Implementation consisted of an updated unit-specific SSC protocol and tailored education specific to identified barriers. Evaluation included SSC rates and maternal human milk usage in the first 30 days of life. In total, 81 patients (22-28 weeks, 370-1410 g) were included. SSC rates ranged from 3.3% to 17.7% at baseline and increased to 33.2% to 39.1% postintervention. Maternal human milk utilization increased above target (≥75%) postintervention for days 7 and 14, but declined towards baseline on days 21 and 30. A statistically significant increase was observed in nursing comfort level when performing SSC for intubated infants as well as infants with a peripherally inserted central catheter or umbilical venous catheter. SSC rates increased with infants younger than 29 weeks requiring intubation and central line management, possibly as a result of greater nursing comfort surrounding with SSC.

#21: Risk Factors and Clinical Characteristics of Stenotrophomonas Maltophilia Infections in Neonates &amp; Children from Day 1 to 21-Year Old Between the Years 2008 to 2020

Abstract Background Stenotrophomonas maltophilia is a ubiquitous organism associated with opportunistic infections. In the immunocompromised host, increasing prevalence and severity of illness is observed, particularly opportunistic bloodstream infections and pneumonia syndromes. S. maltophilia is intrinsically resistant to most currently available broad-spectrum antibiotics, including carbapenems and beta-lactams. This intrinsic resistance is due to the presence of chromosomally expressed beta-lactamases, L1 (a metallo-carbapenemase), and L2 (an extended-spectrum beta-lactamases), which together can hydrolyze nearly all betalactam antibiotics including carbapenems. In vitro activity is observed with tetracyclines and fluoroquinolones, but resistance can be rapidly induced mainly due to efflux pumps. Trimethoprim/sulfamethoxazole (TMP-SMX) generally is considered the treatment of choice for S. maltophilia infection, although consideration of S. maltophilia in treatment guidelines is sparse. Additionally, a recent study suggests that S. maltophilia susceptibility to TMP-SMX may be decreasing globally, due in part to acquired antibiotic resistance. Though historically identified as a cause of nosocomial infections, communityonset infections increasingly are being reported. From 1996 to 2016, S. maltophilia was commonly isolated from patients hospitalized with pneumonia and bloodstream infection (BSI), and the incidence of S. maltophilia infection is increasing Methods A retrospective analysis of characteristics and outcomes in patients with S. maltophilia–positive cultures were conducted using the Healthbridge EHR. Study Population This retrospective matched case control study was carried out in neonates with S. maltophilia infections at UHB DOWNSTATE MEDICAL CENTER NICU and Pediatric Department between 2008 and 2020. To identify the case patients, we reviewed the admission and medical records of patients and records from the Microbiology Department in the study period. Control patients were selected from the patients who admitted for at least 72 hours and had pneumonia and/or nosocomial sepsis caused by pathogens other than S. maltophilia. To determine the risk factors for S. maltophilia infections among 35 case patients were compared with 35 control patients. Medical charts of all infants with positive cultures for S. maltophilia and control cases were reviewed for birth weight; gestational age; delivery type; postnatal age at hospitalization; prolonged rupture of membranes; invasive procedures (mechanical ventilation, intubation, urinary catheter, umbilical catheter); duration of mechanical ventilation (day); exposure to antimicrobial agents (aminoglycosides, carbapenems, cephalosporins, penicillins); administration of total parenteral nutrition (TPN); duration of TPN; histamine 2 (H2) blockers; exposure to steroids; cholestasis; elevated liver enzymes; death; sepsis-related death; and duration of hospitalization. All the risk factors for infection were calculated before the onset of infection in both groups. Results in progress Conclusions:

A Fetal Risk Stratification Pathway for Neonatal Aortic Coarctation Reduces Medical Exposure

To test the hypothesis that a fetal stratification pathway will effectively discriminate between infants at different levels of risk for surgical coarctation and reduce unnecessary medicalization. We performed a pre-post nonrandomized study in which we prospectively assigned fetuses with prenatal concern for coarctation to 1 of 3 risk categories and implemented a clinical pathway for postnatal management. Postnatal clinical outcomes were compared with those in a historical control group that were not triaged based on the pathway. The study cohort comprised 109 fetuses, including 57 treated along the fetal coarctation pathway and 52 historical controls. Among mild-risk fetuses, 3% underwent surgical coarctation repair (0% of those without additional heart defects), compared with 27% of moderate-risk and 63% of high-risk fetuses. The combined fetal aortic, mitral, and isthmus z-score best discriminated which infants underwent surgery (area under the curve=0.78; 95% CI, 0.66-0.91). Compared with historical controls, infants triaged according to the fetal coarctation pathway had fewer delivery location changes (76% vs 55%; P=.025) and less umbilical venous catheter placement (74% vs 51%; P=.046). Trends toward shorter intensive care unit stay, hospital stay, and time to enteral feeding did not reach statistical significance. A stratified risk-assignment pathway effectively identifies a group of fetuses with a low rate of surgical coarctation and reduces unnecessary medicalization in infants who do not undergo aortic surgery. Incorporation of novel measurements or imaging techniques may improve the specificity of high-risk criteria.

Automatic Detection and Classification of Multiple Catheters in Neonatal Radiographs with Deep Learning.

We develop and evaluate a deep learning algorithm to classify multiple catheters on neonatal chest and abdominal radiographs. A convolutional neural network (CNN) was trained using a dataset of 777 neonatal chest and abdominal radiographs, with a split of 81%-9%-10% for training-validation-testing, respectively. We employed ResNet-50 (a CNN), pre-trained on ImageNet. Ground truth labelling was limited to tagging each image to indicate the presence or absence of endotracheal tubes (ETTs), nasogastric tubes (NGTs), and umbilical arterial and venous catheters (UACs, UVCs). The dataset included 561 images containing two or more catheters, 167 images with only one, and 49 with none. Performance was measured with average precision (AP), calculated from the area under the precision-recall curve. On our test data, the algorithm achieved an overall AP (95% confidence interval) of 0.977 (0.679-0.999) for NGTs, 0.989 (0.751-1.000) for ETTs, 0.979 (0.873-0.997) for UACs, and 0.937 (0.785-0.984) for UVCs. Performance was similar for the set of 58 test images consisting of two or more catheters, with an AP of 0.975 (0.255-1.000) for NGTs, 0.997 (0.009-1.000) for ETTs, 0.981 (0.797-0.998) for UACs, and 0.937 (0.689-0.990) for UVCs. Our network thus achieves strong performance in the simultaneous detection of these four catheter types. Radiologists may use such an algorithm as a time-saving mechanism to automate reporting of catheters on radiographs.

Extrahepatic Portal Vein Thrombosis, an Important Cause of Portal Hypertension in Children.

One of the most important causes of portal hypertension among children is extrahepatic portal vein thrombosis (EHPVT). The most common risk factors for EHPVT are neonatal umbilical vein catheterization, transfusions, bacterial infections, dehydration, and thrombophilia. Our study aimed to describe the clinical manifestations, treatment, evolution, and risk factors of children with EHPVT. Methods: We analyzed retrospectively all children admitted and followed in our hospital with EHPVT between January 2011–December 2020. The diagnosis was made by ultrasound or contrast magnetic resonance imaging. We evaluated the onset symptoms, complications, therapeutic methods, and risk factors. Results: A total of 63 children, mean age 5.14 ± 4.90 (33 boys, 52.38%), were evaluated for EHPVT during the study period. The first symptoms were upper gastrointestinal bleeding (31 children, 49.21%) and splenomegaly (22 children, 34.92%). Thrombocytopenia was present in 44 children (69.84%). The most frequent risk factors were umbilical vein catheterization (46 children, 73.02%) and bacterial infections during the neonatal period (30 children, 47.62%). Protein C, protein S, antithrombin III levels were decreased in 44 of the 48 patients tested. In 42 of these cases, mutations for thrombophilia were tested, and 37 were positive. Upper digestive endoscopy was performed in all cases, revealing esophageal varices in 56 children (88.89%). All children with gastrointestinal bleeding received an octreotide infusion. In 26 children (41.27%), variceal ligation was performed, and in 5 children (7.94%), sclerotherapy. Porto-systemic shunt was performed in 11 children (17.46%), and Meso-Rex shunt was done in 4 children (6.35%). The evolution was favorable in 62 cases (98.41%). Only one child died secondary to severe sepsis. Conclusions: EHPVT is frequently diagnosed in the last period in our region due to the increased use of umbilical vein catheterization. Furthermore, genetic predisposition, neonatal bacterial infections, and prematurity certainly play an important role in this condition. A proactive ultrasound assessment of children with risk factors for EHPVT should be encouraged for early diagnosis and treatment.

Risk factors for the development of neonatal sepsis in a neonatal intensive care unit of a tertiary care hospital of Nepal

BackgroundSepsis is an overwhelming and life-threatening response to bacteria in bloodstream and a major cause of neonatal morbidity and mortality. Understanding the etiology and potential risk factors for neonatal sepsis is urgently required, particularly in low-income countries where burden of infection is high and its epidemiology is poorly understood.MethodsA prospective observational cohort study was conducted between April 2016 and October 2017 in a level three NICU at a tertiary care hospital in Nepal to determine the bacterial etiology and potential risk factors for neonatal sepsis.ResultsAmong 142 NICU admitted neonates, 15% (21/142) and 32% (46/142) developed blood culture-positive and -negative neonatal sepsis respectively. Klebsiella pneumoniae (34%, 15/44) and Enterobacter spp. (25%, 11/44) were the most common isolates. The antimicrobial resistance of isolates to ampicillin (100%, 43/43), cefotaxime (74%, 31/42) and ampicillin-sulbactam (55%, 21/38) were the highest. BlaTEM (53%, 18/34) and blaKPC (46%, 13/28) were the commonest ESBL and carbapenemase genes respectively. In univariate logistic regression, the odds of sepsis increased with each additional day of use of invasive procedures such as mechanical ventilation (OR 1.086, 95% CI 1.008–1.170), umbilical artery catheter (OR 1.375, 95% CI 1.049–1.803), intravenous cannula (OR 1.140, 95% CI 1.062–1.225); blood transfusion events (OR 3.084, 95% CI 1.407–6.760); NICU stay (OR 1.109, 95% CI 1.040–1.182) and failure to breast feed (OR 1.130, 95% CI 1.060–1.205). Sepsis odds also increased with leukopenia (OR 1.790, 95% CI 1.04–3.082), increase in C-reactive protein (OR 1.028, 95% CI 1.016–1.040) and decrease in platelets count (OR 0.992, 95% CI 0.989–0.994). In multivariate analysis, increase in IV cannula insertion days (OR 1.147, 95% CI 1.039–1.267) and CRP level (OR 1.028, 95% CI 1.008–1.049) increased the odds of sepsis.ConclusionsOur study indicated various nosocomial risk factors and underscored the need to improve local infection control measures so as to reduce the existing burden of sepsis. We have highlighted certain sepsis associated laboratory parameters along with identification of antimicrobial resistance genes, which can guide for early and better therapeutic management of sepsis. These findings could be extrapolated to other low-income settings within the region.

A novel and accurate method for estimating umbilical arterial and venous catheter insertion length.

To develop a novel, rapid, and more accurate model for estimating umbilical arterial (UAC) and venous catheter (UVC) insertion length. We evaluated UACs and UVCs from a retrospective cohort to determine the rate of correct initial positioning based on conventional birth weight-based equations utilized in our neonatal intensive care unit. We then derived new equations, developed the mobile application, UmbiCalc, to simplify implementation of the new equations, and validated their accuracy with prospective utilization. The conventional equations successfully predicted insertion length in 69% (364 of 524) of UACs and only 36% (194 of 544) of UVCs. Our new model was prospectively applied to 68 UAC and 80 UVC placements with successful initial positioning achieved in 90% [95% CI, 80.2-94.9] and 76% [95% CI, 65.9-84.2], respectively. Our novel approach more accurately estimates UAC and UVC insertion length.

Effect of a Larger Flush Volume on Bioavailability and Efficacy of Umbilical Venous Epinephrine during Neonatal Resuscitation in Ovine Asphyxial Arrest.

The 7th edition of the Textbook of Neonatal Resuscitation recommends administration of epinephrine via an umbilical venous catheter (UVC) inserted 2–4 cm below the skin, followed by a 0.5-mL to 1-mL flush for severe bradycardia despite effective ventilation and chest compressions (CC). This volume of flush may not be adequate to push epinephrine to the right atrium in the absence of intrinsic cardiac activity during CC. The objective of our study was to evaluate the effect of 1-mL and 2.5-mL flush volumes after UVC epinephrine administration on the incidence and time to achieve return of spontaneous circulation (ROSC) in a near-term ovine model of perinatal asphyxia induced cardiac arrest. After 5 min of asystole, lambs were resuscitated per Neonatal Resuscitation Program (NRP) guidelines. During resuscitation, lambs received epinephrine through a UVC followed by 1-mL or 2.5-mL normal saline flush. Hemodynamics and plasma epinephrine concentrations were monitored. Three out of seven (43%) and 12/15 (80%) lambs achieved ROSC after the first dose of epinephrine with 1-mL and 2.5-mL flush respectively (p = 0.08). Median time to ROSC and cumulative epinephrine dose required were not different. Plasma epinephrine concentrations at 1 min after epinephrine administration were not different. From our pilot study, higher flush volume after first dose of epinephrine may be of benefit during neonatal resuscitation. More translational and clinical trials are needed.