Unusual complications of central venous catheters in two infants with congenital venous anomalies associated with congenital heart disease

We report two infants with congenital heart disease who had unusual complications of indwelling central venous catheters related to anomalies of systemic and pulmonary venous drainage. Correspondence to: B. J. Pettitt     

PICU儿童先天性心脏病心导管术后并发症及处理(附69例分析)

目的总结我院7年来先天性心脏病(先心病)心导管术患儿,需入重症监护病房(PICU)治疗的严重并发症的类型及处理方法。方法回顾性分析入PICU治疗的69例患儿并发症类型、发生率、死亡原因及防治等。结果需入PICU的先心病患儿心导管术并发症包括麻醉后呼吸抑制及呼吸道分泌物增加、肺瘀血、术中心率下降、严重心功能不全和/或低血压或肺水肿、严重心律失常、介入治疗后心包积液、缺氧发作、麻醉后低血压、造影剂过敏等。并发症发生率为1.5%。入住PICU时间为30.5 h,呼吸机使用时间为26.9 h。死亡4例。结论对于不同类型并发症采取不同的处理方法,减少心导管术后严重并发症的病死率。     

中心静脉置管导致早产儿心包积液的临床分析

目的 探讨早产儿中心静脉置管导致心包积液的临床特征.方法 回顾性选择发生中心静脉置管相关心包积液的11例早产儿为研究对象,分析其置管特征、表现、治疗及预后.结果 中心静脉置管相关心包积液发生率为0.42％(11/2599).11例心包积液患儿的平均胎龄(30.1±2.6)周,平均出生体重(1240±234)g.心包积液...     

Central venous catheter placement in children: a prospective study of complications in a Brazilian public hospital

Central venous access is frequently used in infants and children with a wide variety of conditions. This report evaluates our experience and the complications from central venous catheters (CVC) placed percutaneously in children at a public hospital of a developing country—Brazil. To identify associated complications, data were collected prospectively and 155 consecutive catheterizations in children at a public hospital over a nearly 8-month period were analyzed. Data collected included sex, age, weight, primary diagnosis, indication for placement, presence of blood coagulation disturbance, hospital department for procedure, type of anesthesia, type of catheter (diameter, lumen number, material), site of catheterization, number of attempts, number of puncture sites, complications during puncture, the time catheter remained in place, later complications (mechanical, infectious) and reason for catheter removal. A total of 155 catheters were placed in 127 patients. There were 130 neck lines and 25 groin lines. The success rate was 81.9% at the initially chosen puncture site and rose to 100% with the inclusion of the second site. Perioperative complications occurred in nine (5.8%) cases, including six (3.9%) hematomas and three (1.9%) arterial puncture. There was no pneumothorax, hemothorax or hydrothorax. During the time the catheter remained in place, there were 51 (32.9%) complications, of which 33 (21.3%) were mechanical and 18 (11.6%) suspected catheter-related infection. These complications were responsible for the removal of the catheter. Despite the relatively high complication rate there were no catheter-related deaths. Body weight was significantly lower for children who underwent more than one puncture site (P=0.01). Age, sex, type of catheter and primary diagnosis were not associated with complications. Knowledge of anatomy and familiarity with the Seldinger technique highly increase the catheterization success rate, with few surgical complications. A better nursing care of CVC is emphasized. The available modern venous catheters at a public hospital in Brazil have contributed to improve the quality of pediatric medical care. Nowadays, the percutaneous CVC is the preferred method in pediatric patients.     

Partial anomalous pulmonary venous connection to the azygos vein with intact atrial septum

Summary The case of a 13-year-old girl with an unusual form of partial anomalous pulmonary venous connection is reported. Cardiac catheterization revealed anomalous connection of the right pulmonary veins to the azygos vein and an intact atrial septum. Rationale for nonsurgical management and four-year follow-up results are discussed.     

In vivo MRI measurement of blood oxygen saturation in children with congenital heart disease

Objective: The purpose of this prospective study was to measure in vivo blood oxygen saturation (%O₂) by MRI in children with congenital heart disease (CHD) using population-based values for T₂O (T₂ signal decay of fully oxygenated blood) and K (a parameter representing the deoxyhemoglobin effect) and compare the %O₂ with direct cardiac catheterization measurements. Background: MRI can determine %O₂ using in vivo measurement of signal decay (T₂) and an in vitro calibration curve relating T₂ and %O₂, based on the equation: 1/T₂=1/T₂O+K(1–%O₂/100)². Recent studies have correlated the T₂/%O₂ in children with CHD with the adult calibration statistics. Methods: A total of ten children (five male, five female) with single ventricle CHD (median age 4.8 months, range 2 months to 4.4 years) undergoing cardiac catheterization were included in the study. The blood T₂ measurements for each patient were performed in a 1.5 T GE CV scanner. The %O₂ was then calculated based on the equation using values of T₂O determined from individual hematocrits, and a population average value of K derived for children. The %O₂ values were compared with direct %O₂ measurements from cardiac catheterization. Results: The %O₂ values by MRI were strongly correlated with direct cardiac catheterization measurements (R=0.825; P<0.001). Conclusion: The study indicates that the noninvasive measurement of %O₂ by MRI can accurately measure oxygen saturation in children with complex CHD.This work was supported by a grant from the Physicians Services Incorporated Foundation.     

复杂紫绀型先天性心脏病体-肺动脉分流术后早期并发症及处理措施

目的：分析复杂紫绀型先天性心脏病体-肺动脉分流术后早期并发症发生原因及处理方法。方法回顾性分析212例复杂紫绀型先天性心脏病患儿施行升主动脉到肺动脉干的中心分流手术的临床资料,探讨术后早期并发症及相关处理措施。结果术后早期出现并发症61例(28.77%),其中严重低心排出量综合征27例,急性肺水肿14例,24 h 内分流管道堵塞12例,室上性心动过速8例。术后平均随访时间(2.49±1.21)年,术后所有患儿肺血管发育均明显生长,其中8例(3.77%)肺血管发育较差者经介入体肺侧支封堵后改善。至随访结束,77例患儿达到根治标准,根治率为36.32%。结论术前积极改善心脏功能,严格掌握手术适应证;合理的手术方法;及时纠治并发症;加强术后监护及综合治疗均为提高该手术成功率的因素。     

10公斤以下低体重婴幼儿先天性心脏病的外科治疗

目的：探讨10 kg以下低体重婴幼儿先天性心脏病的外科治疗问题。方法：自2000年1月至2007年12月,外科治疗10 kg以下低体重婴幼儿先天性心脏病105例,体重3.5~10 kg,年龄2个月至3岁,其中合并中度以上肺动脉高压和/或反复肺部感染史56例,复杂先天性心脏病35例。中度低温体外循环下手术88例,常温非体外循环心脏跳动下手术14例,深低温停循环选择性脑保护下手术3例;根治手术101例,姑息性手术4例。结果：住院死亡5例（4.8%）,存活100例,随访2月至3年,根治手术的97例中,室间隔缺损少量残余分流2例,无其他并发症和死亡,均生长发育良好,心功能I级;姑息手术的3例症状明显减轻。结论：随着围术期管理、麻醉、体外循环和外科技术的提高,10 kg以下低体重婴幼儿先天性心脏病外科治疗是安全的,临床效果良好。     

小分子RNA在先天性心脏病中的研究进展

小分子RNA（miRNAs）是一类在转录后水平调控基因表达的小分子非编码RNA。它们具有进化保守性、组织细胞特异性和核酸杂交高度特异性。miRNAs 在心肌细胞的增殖、分化和凋亡、心脏神经嵴细胞的迁移、心脏形态发生和心脏图式发育等诸多过程中扮演着重要角色,可为先天性心脏病发生机制的阐明提供一种全新的视角。miRNAs 在先天性心脏病发生机制中的研究可分为临床研究和动物研究两类,该文就这两类研究的研究进展及其研究结论对先天性心脏病机制的阐释以及目前国内研究的现状和局限等方面进行综述。     

Heparinization during percutaneous cardiac catheterization in children

Summary The effect of heparin on blood clotting was studied by measuring the activated clotting time (ACT) in 120 infants and children with congenital heart disease after a single intravenous bolus of 100 IU heparin/kg body weight. Before heparinization, infants and children with cyanotic heart disease showed signs of hypocoagulation. Heparin bolus led to a threefold increase of ACT after 15 min. After 1 h, the ACT was still two times the normal value. Any further administration of heparin may be based on ACT monitoring.Dedicated to Prof. H. W. Rautenburg.     

Cardiomegaly in a premature neonate after venous umbilical catheterization

Umbilical venous catheters allow rapid central access in neonates, but may be associated with various complications. We present a case of a newborn with pericardial effusion following umbilical venous catheterization. An extremely low birth weight infant was intubated for respiratory distress syndrome and had umbilical venous and arterial lines in place. Massive cardiomegaly was noted on the subsequent chest X-ray. Echocardiography revealed a large pericardial effusion without signs of tamponade. After removing the catheter, the effusion gradually resolved. While pericardial effusion is a well-known complication of percutaneous long central lines, only a few case reports have documented sudden cardiovascular compromise associated with umbilical venous catheters. Pericardial effusion may be asymptomatic and should be suspected in infants with central catheters and progressive cardiomegaly. The prompt removal of catheters and, if signs of cardiac tamponade are present, emergency pericardiocentesis may prove to be life-saving.     

Oxygen consumption in infants and children during heart catheterization

Oxygen consumption was measured in infants, children, and adolescents during diagnostic heart catheterizations. A total of 825 measurements of oxygen consumption (VO₂) was performed in 504 subjects using a semiopen hood system and a paramagnetic oxygen analyzer. In 256 subjects under 3 years of age, body dimensions and heart rate were found to be significant factors for oxygen consumption. The regression equation for both sexes was: VO₂/BSA (ml/min · m²) = 3.42 · height (cm) − 7.83 · weight (kg) + 0.38 · HR − 54.1 (r ²= 0.39, SD = 38.7), where BSA is body surface area and HR is heart rate. VO₂/BSA was significantly lower in infants less than 3 months of age (133 ± 33 ml/min · m²) compared with infants of 3–12 months (171 ± 37 ml/min · m²; p < 0.01). In 272 children aged 3 years and older and adolescents, gender was a significant factor in oxygen consumption together with BSA and HR. The regression line equation for males was VO₂/BSA (ml/min · m²) = 0.79 · HR − 7.4 · BSA(m²) + 108.1 (r ²= 0.45, SD = 34.2). The regression line equation for females is VO₂/BSA (ml/min · m²) = 0.77 · HR − 5.2 · BSA(m²) + 106.8 (r ²= 0.43, SD = 34.4). Hematocrit, systemic oxygen saturation, and blood pressure were not significant factors. The predictive value of nomograms for oxygen consumption is limited because of the large interindividual variations not explained by differences in gender, body size, or simple hemodynamic variables. Preferably, oxygen consumption is measured; but if nomograms for oxygen consumption are used for hemodynamic assessment, the wide confidence intervals should be considered.     

Immediate complications and late sequelae of arterial catheterization in children with congenital heart disease

Summary Early vascular complications and late sequelae are reported in relation to 195 left heart catheterizations, 125 performed by brachial arteriotomy (BA), and 70 by percutaneous femoral artery puncture (FAP) with the Seldinger technique. Vascular complications occurred in 25 patients, 11 requiring surgical intervention, which was successful in restoring normal circulation in all. The rate of complications was higher after FAP in children 6 years old or less, while after BA the rate was significantly higher in patients of 2 years or older. In patients under 2 years, brachial artery suture repair resulted in more complications than ligation, but the cases were not randomized.Late follow-up of 101 catheterizations (35 FAP, and 66 BA, of which 38 were ligated and 28 sutured) included clinical evaluation, Doppler pressure measurements, and a comparison of the length and bone development of the catheterized and non-catheterized limbs. All these have indicated an absence of any serious late sequelae in this group 6 months to 9 years (average 4 years) after catheterization.Part of MD Thesis submitted to the Hebrew University, Hadassah Medical School, Jerusalem.     

Developmental delay in infants with congenital heart disease

Summary The mental and motor development of 173 infants with congenital heart disease was assessed by means of the Bayley Scales of Infant Development and clinical neurological examinations. The relationship between age, sex, congestive heart failure, hypoxemia, hospitalization, and test results was evaluated. The presence of congestive heart failure was found to be significantly associated with both mental and motor developmental delay. Hypoxemia and hospitalization were associated with delayed motor development. Developmental delay could be recognized as early as 2 months of age. Supported in part by training grant HL 05855 and program project grant HL 10436 from the National Institutes of Health, Bethesda, Maryland     

中央分流术在治疗复杂先天性心脏病中的应用

目的 总结68例中央分流术的应用及随访,探讨中央分流术在复杂先天性心脏病治疗中的应用及效果.方法 68例患儿,男36例,女32例,年龄1 d～17岁,体重(9.75±5.83)kg.患儿在不同时期进行了中央分流手术,比较手术前后血氧饱和度的变化.术后进行随访,了解肺动脉发育和后续治疗的情况.结果 死亡8例,病死率11.76%.存活患儿症状改善,术后血氧饱和度比术前显著提高(P＜0.05).随访病例肺动脉比术前显著增粗(P＜0.05).26例患儿进行了二次手术,21例为根治手术,5例为再次姑息性手术,2例死亡,再次手术病死率7.7%.结论 作为姑息性手术的一种,中央分流术损伤小、操作简单,能改善症状,提高生活质量,为根治手术创造条件.     

Percutaneous catheterization in newborn infants and older children

Summary Between 1966 and 1977 we performed percutaneous venous or arterial catheter insertions in 174 newborn infants and other children. Insertion was successfully completed in all but three. Catheterization, using the same vessels, was repeated in 13 patients between four days and three months later. Peripheral arterial pulses remained palpable in all patients, but in one instance a broken catheter tip embolized into the posterior tibial artery. Vascular complications and unsuccessful insertion of the catheter were avoided in a high percentage of cases by careful attention to detail.     

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目的探讨多层螺旋CT(MSCT)及联合经胸二维超声心动图(TTE)检查在先天性心脏病诊断中的意义。方法收集广东省心血管病研究所自2002年9月至2003年12月间86例儿童先天性心脏病病例,全部患儿接受了MSCT和TTE检查,12例接受心导管检查,其中69例进行了外科手术,将术前MSCT、TTE和心导管检查结果分别与手术诊断进行比较。结果69例患儿共计有129处畸形,TTE正确诊断116处(89.9%),MSCT正确诊断112处畸形(86.8%),两者联合正确诊断127处畸形(98.4%),12例心导管检查未能提供更有价值的资料。结论MSCT对先天性心脏病诊断具有较高的价值,尤其是联合TTE可取代部分心导管检查为外科手术提供正确和充分的术前诊断。对于年龄小或重症不耐受心导管检查的患儿具有更大的意义。     

Delayed sternal ossification in infants with congenital heart disease

A review of the lateral chest radiographs of 118 children less than two years old and suspected of having congenital heart disease yielded 11 who had delayed ossification of the mesosternum. In all 11 congenital heart disease was confirmed by cardiac catheterization, with the most frequent lesions being patent ductus arteriosus, ventricular septal defect, and atrial septal defect. A review of the lateral chest radiographs of 110 normal infants failed to demonstrate any case of delayed ossification of the sternum. If sternal segments do not appear ossified on chest radiographs of infants having no other clinical abnormalities, congenital heart disease should be suspected.     

婴儿先天性心脏病133例心导管检查术分析

目的　探讨婴儿先天性心血管畸形的心导管检查特点及并发症的防治经验。方法　分析婴儿期先天性心脏病患儿 133例 ,年龄为 5d至 12个月 ,体重 2 4～ 9 6kg。导管进路经股静脉穿刺 12 7例 ,大隐静脉剖开 6例 ,同时做动脉穿刺进路 7例。行右心导管检查 82例次 ,右室造影 96例次 ,左心系统造影 2 2例次。结果　诊断紫绀型复杂心血管畸形 74例 (其中法洛四联症 4 9例 ) ,无紫绀型心血管畸形 5 9例 ,4 7例伴严重肺动脉高压。心导管检查术非致死性有意义并发症 5 .3% ,无死亡。结论　心导管术是确诊婴儿复杂心血管畸形最准确的方法 ;心导管检查中要严密观察婴儿病情变化 ,由有经验医师细心操作 ,先天性心脏病婴儿心导管检查术比较安全。     

Fatal cardiac tamponade in a neonate with a polyurethane central venous catheter

Fatal cardiac tamponade in a neonate receiving total parenteral nutrition via a polyurethane central venous catheter is presented. The literature is reviewed and the implications for management discussed. Correspondence to: G. Nicholls