Complications of intravenous hyperalimentation in newborns and infants

Urokinase therapy for a central venous catheter thrombus

A 670 g premature infant is described in whom an intracardiac thrombus was documented. This thrombus formation probably resulted as a complication of an indwelling right atrial catheter. Thrombolytic therapy with urokinase was instituted, resulting in total and rapid dissolution. No hemorrhagic complications resulted. We believe that this particular thrombolytic therapy is safe and effective and should be considered when facing this particular complication.

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.

Saphenofemoral venous cutdowns in the premature infant

Thirty-five preterm neonates that had 42 central venous lines placed via saphenofemoral cutdown in the groin are reviewed. The mean gestational age was 29 weeks; mean birth weight 1,320 g. There were no catheter-associated deaths. Minor complications occurred in 50% of patients. Leg swelling (43%), catheter occlusion (12%), and catheter fluid leakage (10%) were the most common. Infections were minor and occurred in 8% of the cases. We believe this study shows the effectiveness and safety of the saphenofemoral cutdown for central venous access in the premature neonate.

Subdural collection of intravenous fat emulsion in a neonate. Complication of central venous catheterization for total parenteral nutrition

An infected subdural collection of intravenous fat emulsion (Intralipid) was diagnosed in a 5-week-old premature infant who was receiving total parental nutrition (TPN) through a facial vein cutdown. This fluid was successfully drained and the infection, due to Staphylococcus epidermidis, was treated with vancomycin. We postulate that the subdural collection occurred as a result of septic thrombosis of the internal jugular vein with subsequent retrograde flow and infiltration of Intralipid from the bridging veins into the subdural space. This complication of central TPN has not been reported previously.

Superior vena cava syndrome in childhood and adolescence: a review of the literature and report of three cases

Obstruction of the superior vena cava is rare in childhood and adolescence. Its etiology is now mainly iatrogenic. Mediastinal tumors are the main primary causes of the superior vena cava syndrome (SVCS) in childhood and adolescence. The most common mediastinal tumors presenting with the SVCS are the lymph node tumors and especially the lymphosarcomas. About 50% of the mediastinal tumors are primary in the mediastinum. Early treatment is designed to cause a rapid shrinking of the tumor and should not be delayed by an overly diligent pursuit of the diagnosis. Treatment should consist of a combination of radiation therapy, chemotherapy, and steroids. Surgery should be limited to obtaining tissue for diagnosis, except when the tumor is localized to the mediastinum and is completely resectable. One hundred and seventy two children and adolescents with the SVCS are reviewed and three patients are added.

Primary epiduritis

An infant, born with multiple anomalies of the gastrointestinal tract, required intravenous hyperalimentation for virtually his entire life. His course was characterized by multiple episodes of sepsis or phlebitis, culminating in death five and one-half months after birth. The brain and spinal cord at necropsy were normal on gross inspection. However, microscopic study showed inflammation of the dura surrounding the spinal cord with sparing of the spinal and cerebral subarachnoid spaces.

Route of pediatric parenteral nutrition: proposed criteria revision

This study reviews the experience of the Nutrition Support Service at the Children's Hospital of Philadelphia over a 13-mo period from 1977 to 1979. Parenteral nutrition was administered to 585 children, 385 by peripheral vein infusion and 200 by central vein infusion. Weight gain was seen in 63% of those patients receiving peripheral vein infusions and 82.5% of those receiving central vein nutrients, and this apparent difference is likely due to the longer duration of therapy in the central vein recipients (33.7 versus 11.4 mean days) and the greater caloric intake delivered to these same patients (128 Kcal/kg/day versus 63.2 Kcal/kg/day). The complication rates were calculated for the more than 11,000 patient days of therapy surveyed; 35 of the 385 peripheral vein patients developed complications, the primary type being solution administration soft tissue sloughs. This amounted to an incidence of 9.08%. Central vein patients in 40 circumstances likewise had complications, 21 being infectious and 12 being metabolic. This accounted for 20% of all central vein recipients, a difference from the peripheral vein group significant to a p value of less than .01. However, when total days of therapy are considered in this complication incidence, a per diem complication rate between these two groups is not different, and in fact, is somewhat worse for the peripheral vein nutrient recipients. Vascular access in this group of patients was via peripheral vein cannulation or via central venous catheter placement, the latter more recenty done exclusively by percutaneous subclavian vein catheter insertions. This technique was safe and allowed repeated access to the central venous system. These data suggest that the only legitimate determining factor for selecting proper nutritional support of the pediatric patient is the caloric need of the individual.

Tubes wires and the neonate

The structure and function of the various tubes and wires that may be seen on radiography of neonates undergoing intensive care are described. The desired position for these and some examples of the consequences of malposition are considered and illustrated; practical conclusions are made.

Rickets as a complication of intravenous hyperalimentation in infants

Fifteen newborn infants developed roentgenographic evidence of rickets while on long-term intravenous hyperalimentation. In each instance, the initial diagnosis of rickets was suggested on the chest roentgenogram, where characteristic cupped and frayed upper humeral metaphyses were noted; subsequent knee and wrist roentgenograms substantiated these findings. Factors which may have predisposed to the development of rickets include inadequate doses of vitamin D, prematurity and a rapid change in body weight during hyperalimentation therapy.

Total management of short gut secondary to midgut volvulus without prolonged total parenteral alimentation

Absorption studies in rats have shown that intestinal adaptation after catastrophic injury can be stimulated by early enteral feeding. Using this concept, we have devised a technique of early initiation and advancement of oral feedings that begins with Cho-Free and Polycose and gradually adds sucrose and MCT in increasing proportions. The increasing complexity and caloric density of this diet provide sufficient nutrition to allow weaning from total parenteral alimentation within 2--3 wk. Our preliminary experience in babies with midgut volvulus, necrotizing enterocolitis, and gastroschisis has been successful and uncomplicated. These patients have demonstrated consistent weight gain and have been spared the complications associated with prolonged parenteral alimentation.

Home total parenteral nutrition: an alternative approach to the management of children with severe chronic small bowel disease

A home program of total parenteral nutrition (HTPN) has been developed for managing patients with severe chronic small bowel disease who would otherwise be unable to leave the hospital. Six such children were treated by this program using a Broviac catheter to shorten hospitalization, to decrease the cost of care, and to normalize their lives as much as possible. They ranged in age from 2 1/4-17 yr and received HTPN for periods of from 1-11 mo. Criteria for instituting this therapy were the inability to maintain fluid and nutritional balance on therapeutic diet or oral formula, or a need for 30 or more days of conventional TPN. The 6 patients had a total of 1139 days on HTPN with 1 episode of catheter sepsis and 1 localized infection at the catheter site. None of the catheters clotted but 1 was accidentally dislodged. Small bowel adaptation occurred in 4 of the 6 patients. This allowed gradual discontinuous of HTPN and reinstitution of total oral alimentation.

A technique for evaluating sepsis in TPN patients

Sepsis continues to be one of the most feared complications of total parenteral nutrition. Many techniques have been advocated for dressing changes, solution preparation, and evaluation of patients with fever spikes. Our technique in evaluating such a patient with suspected sepsis is to remove the tubing and solution from the pumping mechanism and place the bottle below the patient, permitting approximately 10 cc of blood to flow into the tubing. The entire set-up of solution and tubing is then quickly replaced and the infusion resumed. The removed blood is transferred to a series of three standard blood culture bottles. The first bottle will be culturing blood; the second, a mixture of blood and infusate; the third, solution alone. When performed carefully, negative culture results appear to exclude TPN as a source of spesis. Positive results are obviously helpful, but must be interpreted with caution in that the blood, catheter, tubing, filter, or solution may be suspect.

Neonatal septic arthritis

Neonatal septic arthritis of the knee was encountered in nine infants during a two-year period, representing an incidence of 16.5 per 1,000 admissions to a neonatal intensive care unit. The etiologic agents included Staphylococcus aureus (3), Klebsiella (1), Streptococcus, group B (2), and Candida albicans (3). Two infants with systemic fungal infection died. Arthritis was the presenting feature of neonatal septicemia in three of six infants with bacterial infection and was accompanied by osteomyelitis in two. In eight of the infants, the same organism was cultured from the skin of the umbilicus as was cultured from the joint. Umbilical catheters had been placed in all of these infants. Full recovery of joint function has been noted in the seven surviving infants.

Intravenous feeding of young infants with persistent diarrhoea

42 infants with persistent diarrhoea were fed intravenously using a simplified regime based on Intralipid and an aminoacid, Fructose and ethanol solution. Peripheral veins were used for up to 56 days, and with scalp veins complications were few and minor. The use of arm and leg veins caused more frequent local problems and is not advised. Central venous lines became necessary in 5 infants, and 3 developed septicaemia. The regime was well tolerated with adequate weight gain when intake was adjusted to the infants' needs. Rates of infusion of 1 g Intralipid/kg hourly over 2 hours and up to 1 g fructose/kg hourly over 14 hours did not cause persistent lipaemia (except transiently in 2 infants) nor metabolic acidosis. Infants must be fully rehydrated with correction of acidosis and electrolyte imbalance before starting intravenous feeding, or acidosis and dehydration from osmotic diuresis may occur. Intravenous feeding should be started gradually and cautiously in severely malnourished infants, and should not be used where liver function is abnormal.

Isosmolar coma during parenteral alimentation with protein hydrolysate in excess of 4 gm/kg/day

Isosmolar coma occurred during the first week of parenteral nutrition in four infants when the amount of protein hydrolysate infused was rapidly increased to or above 4 gm/kg/day. Coma developed within a 6- to 12-hour period and was characterized by (1) a normal serum osmolality, (2) an elevated urine specific gravity, and (3) the rapid reversal of the clinical signs when the protein containing solution was discontinued. A very gradual increase in protein content to a total of no more than 4 gm/kg/day is advised to provide an adequate yet safe protein load for intravenous nutrition.

Total parenteral feeding in infants using peripheral veins

Fifteen infants with life-threatening gastrointestinal anomalies received total parenteral feeding for periods ranging from 10 to 54 days; their ages ranged from one day to 5 months. The solutions were administered through peripheral veins. All patients gained weight during the period of observation and no cases of septicaemia were encountered.

Use of 5-fluorocytosine in systemic candidiasis in infancy

Three cases of systemic candidiasis were successfully treated with 5-fluorocytosine (5-FC), an antifungal agent. The fungaemia developed during continuous intravenous alimentation for intestinal malabsorption. The diagnosis was confirmed by repeated positive cultures from blood, urine, and faeces. The fungus was also grown from cultures of intravenous solutions and catheters. The clinical features varied and included unexplained fever, oedema, stupor, tachypnoea, convulsions, hepatosplenomegaly, and congestive heart failure. The clinical symptoms receded rapidly and the cultures became negative after oral or intravenous treatment with 5-FC.