Digital ischaemia following inadvertent arterial cannulation of a peripherally inserted central catheter in a very low birth weight infant

Inadvertent Arterial Placement of a Peripherally Inserted Central Catheter in an Infant With Dilated Cardiomyopathy: A Case Report

Peripherally inserted central catheter (PICC) placement under real-time ultrasound guidance has emerged as a favorable procedure in children as a method to efficiently obtain central access. Nevertheless, small infants with hemodynamic instability are at high risk of complications and extra precautions are necessary. We present a case of an inadvertent arterial placement of a PICC in a two-month-old infant with dilated cardiomyopathy and decompensated heart failure. Differentiation of arteries and veins under ultrasonographic evaluation may sometimes be difficult when the applied tourniquet pressure exceeds the patient's arterial blood pressure. In particular, arterial flow can be easily compromised by applying tourniquet pressure in small children with low blood pressure. A thorough understanding of the upper extremity vascular anatomy, basic scanning techniques, and meticulous preparation especially in small infants with hemodynamic instability are essential for maintaining the safety and efficacy of this procedure.

Digital Ischemia in an Extreme Preterm Infant Treated with Nitroglycerin Patch

Ischemic limb lesions occasionally occur in neonates admitted to neonatal intensive care units. Known risk factors include the placement of arterial catheters, arterial punctures to obtain blood samples, and the use of vasoactive/vasopressor medications for hypotension. Prolonged peripheral tissue ischemia may result in serious complications, and successful management depends on early detection, proper assessment, and the institution of appropriate intervention. Currently, there is no standard approach for the management of peripheral tissue ischemia in extreme preterm infants. Topical nitroglycerine use is one of the promising options used to manage ischemic limb injuries in neonates, as demonstrated in several case reports. We report a case of digital ischemia in an extreme preterm infant with no clear risk factors except extreme prematurity, which recovered after topical nitroglycerine therapy.

Management of Neonatal Limb Ischemia Secondary to Peripheral Arterial Lines: A Systematic Review

Limb ischemia is a rare complication of peripheral arterial lines, but there is inconsistency with management. We aimed to describe the variation in the management of limb ischemia secondary to a peripheral arterial line and to determine a consensus for management. The systematic review consisted of searching PubMed, Scopus, Ovid MEDLINE, Google Scholar, Cochrane Database of Systematic Reviews, and references of journals using pre-trialed medical subject headings terms and articles. The sources were scrutinized against inclusion and exclusion criteria. Twenty-six articles were included for full-text analysis: seven retrospective reviews and 19 case reports. The most common site of insertion was femoral (30%), followed by radial (25%). Seventy-one percent of the patients were treated medically, 18% surgically, 9% both medically and surgically, and one patient was treated conservatively with debridement and accurate approximation. The majority of interventions were successful in treating limb ischemia, with 91% achieving a good outcome. All patients who received glyceryl trinitrate (GTN) and all surgical interventions, including conservative management, achieved good outcomes. Medical management was successful in 92%, whereas a combined approach of surgical and medical management was successful in 75% of patients. There is wide variation in the management of limb ischemia secondary to peripheral arterial lines. There is apparent success observed with topical 2% GTN and surgical interventions, with thrombolysis and, in case of no improvement, with thrombectomy, across various studies. We recommend that an updated international consensus be reached on the management of neonates with limb ischemia secondary to a peripheral arterial line.

Topical nitroglycerin in newborns with ischemic injuries: A systematic review

BACKGROUND

Arterial catheterization is frequently performed in neonatal intensive care units with an inherent risk of peripheral ischemic injury, especially in preterm infants. The treatment options following vascular damage involve invasive and non-invasive modalities. The primary objective of this systematic review was to evaluate the evidence of the use of topical nitroglycerine (TNG) either alone or as adjunctive therapy. The secondary aim was to develop an approach to the treatment of catheter induced ischemia in infants based on the available evidence.

METHODS

A comprehensive search was conducted of available databases for relevant articles that involved the treatment of peripheral tissue ischemia in neonates with the use of TNG. Citations were restricted to human subjects.

RESULTS

Six hundred and eighty-nine articles were identified, and twenty-seven case reports and case series were compatible with the inclusion and exclusion criteria. Sixty-eight infants out of the 76 published cases (89%) experienced a favorable outcome and 79% (n = 60) demonstrated complete recovery with the topical application of TNG to the ischemic site.

CONCLUSION

The available evidence demonstrates that TNG is effective for the treatment of peripheral ischemia in neonates after standard conservative measures have failed. However, due to the absence of robust evidence for this therapeutic modality, there are no uniform guidelines regarding the frequency, duration, and safety of TNG use. Planning the management of peripheral ischemia in neonates with TNG should be a multidisciplinary decision that includes close surveillance of blood pressure, methemoglobin levels, and follow up cranial ultrasound.

The Perfect Storm: Exam of a Medical Error and Factors Contributing to Its Possible Escalation

OBJECTIVE

After an initial medical misadventure, failure of recognition and continuing factors that could perpetuate the error are examined.

METHODS

A critical evaluation of the continuum of care after the initial error was conducted through chart review and comparison to published standards.

RESULTS

Analysis of the continuum of care after the original error demonstrated numerous system failures that should have alerted the providers to the initial error.

DISCUSSION

Technology, electronic medical records, lack of critical communications, and short cuts have the potential to not recognize patient care safety issues and potential harm.

CONCLUSIONS

Medical errors are multifactorial. Blame casting and accusations are not productive. Critical analysis of systems/processes, current technology, eliminating shortcuts, and critical communications may increase patient safety.

When the course deviates from expected: Misplacement of an epicutaneo-caval catheter in a neonate

Central venous access, a common and essential component of the care of the critically ill neonate, is associated with complications such as infection, thrombosis, and bleeding. Unintentional arterial cannulation of a venous catheter is a rare but potentially dangerous complication. In the report, we describe the accidental cannulation of an artery with an epicutaneo-caval catheter in an extremely low birth weight infant. We discuss the physical and radiological findings that raise the suspicion of an arterial placement of a catheter, the diagnostic tools to confirm the misplacement, the potential complications, and strategies to prevent it.

Topical nitroglycerin ointment as salvage therapy for peripheral tissue ischemia in newborns: a systematic review

BACKGROUND

Topical nitroglycerin (TNG) ointment has been used for almost 3 decades to treat neonatal peripheral tissue ischemia, but this product is now no longer being produced by its Canadian manufacturer. Our aim was to investigate the efficacy and safety of TNG products in newborns in neonatal intensive care units.

METHODS

In this systematic review we searched Embase, CINAHL, MEDLINE, PubMed and Web of Science from inception to April 2020 for studies on the use of TNG products (TNG ointment, TNG spray, glyceryl trinitrate [GTN] patch) for the treatment of neonatal tissue ischemia. We did not apply language or study design limitations. Animal studies and duplicate records were excluded. Two reviewers screened and extracted data. The Tool for Evaluating the Methodological Quality of Case Reports and Case Series was used to assess the risk of bias of individual studies.

RESULTS

We included 23 articles (20 case reports, 2 case series and 1 retrospective audit) describing the use of TNG ointment, TNG spray or GTN patch in the treatment of 39 tissue ischemia events in 37 newborns. Twenty-three (62.2%), 12 (32.4%), 1 (2.7%) and 1 (2.7%) infants received TNG ointment, GTN patch, both TNG ointment and GTN patch, and TNG spray, respectively. Nineteen (76.0%) and 7 (53.8%) injuries treated with TNG ointment and GTN patch showed complete recovery, respectively. Two (16.7%) infants treated with GTN patch experienced adverse events (i.e., methemoglobinemia) requiring treatment discontinuation.

INTERPRETATION

TNG ointment presents a safe therapeutic modality for salvage therapy of neonatal tissue ischemia. Engagement of stakeholders is essential to address its recent commercial inaccessibility in Canada.

Analysis of Characteristics of Peripheral Arterial Ischemia in Premature Babies and Effects of Nitroglycerin Patch Application

Purpose: The aim of this retrospective study was to analyze the characteristics of peripheral arterial ischemia and tissue necrosis in premature babies, as well as the effects of nitroglycerin.Methods: In total, 513 newborns were enrolled who were admitted to the neonatal intensive care unit with a gestational age of 34 weeks or younger. Data were collected on general personal and clinical information, peripheral arterial ischemia, and nitroglycerin patch application in the premature infants. The collected data were analyzed using the x² test, t-test, Mann-Whitney U test, logistic regression.Results: Thirty-six (7.0%) infants had peripheral arterial ischemia, while 477 (93.0%) infants did not. Lower gestational age (x²=35.97, p<.001), lower birth weight (x²=29.40, p<.001), lower blood pressure (x²=23.10, p<.001), and insertion of an umbilical artery catheter (p<.001) were significantly associated with the occurrence of peripheral arterial ischemia. Among the preterm infants in whom nitroglycerin patches were applied, 30 (83.3%) premature infants without necrosis improved without complications, 4 (11.1%) showed hypotension, and 2 (5.6%) showed skin damage.Conclusion: Based on a review of our experiences with nitroglycerin patches, we recommend closely observing skin color and using nitroglycerin patches on the skin to help improve flow in premature infants with peripheral arterial ischemia.

Late neurological deficit after attempted PICC insertion in the arm

INTRODUCTION:

Insertion of central catheters in peripheral vessels is a common procedure performed for a variety of indications, including parenteral nutrition. Hyperemesis gravidarum may require parenteral nutrition in exceptional situations. Although globally safe, insertion of peripherally inserted central catheters (PICCs) can lead to complications.

CASE REPORT:

We describe a case of a pregnant woman who required parenteral nutrition and underwent an unsuccessful PICC insertion attempt resulting in arterial puncture, and who 34 days later presented with right upper limb paresthesia. A pseudoaneurysm with nerve compression was diagnosed and treated by open surgery, without maternal or fetal complications.

CONCLUSION:

We recommend active surveillance ultrasound (e.g. in the first 24-48 h) of unsuccessful PICC insertion attempts, because late complications may occur and require invasive procedures for treatment.

Identification and confirmation of suspected unintended peripheral arterial cannulation during anaesthesia

Unintended arterial cannulation and injection of drugs may result in ischaemia and tissue necrosis. Various methods used to differentiate accidental arterial from intravenous cannulation have their own shortcomings. Here we present the case of a 13-year-old girl having an elective procedure under general anaesthesia and the challenges faced in distinguishing suspected intra-arterial cannulation from what was indeed an intravenous cannulation. We recommend the use of an open-ended saline-filled ‘T’ connector–syringe system and pressure transduction as the methods of choice to identify and confirm, respectively, a suspected arterial cannulation during anaesthesia.