Neonatal hypoglycemia associated with umbilical artery catheter positioned at the eighth to ninth thoracic vertebrae

Previous reports of neonatal hypoglycemia have been associated with malpositioned umbilical cord artery catheters. Neonatal hypoglycemia in association with normally positioned umbilical artery catheter and responsive to catheter repositioning is reported for the first time.     

早期新生儿低血糖产科相关因素的分析

目的了解产科高危因素与新生儿低血糖之间的相关性。方法选择我院1996年1月至1998年6月之间出生并诊断为低血糖的新生儿73例,与同期非低血糖新生儿73例进行分析比较。结果新生地低血糖组孕母妊高征、妊娠合并糖尿病、慢性高血压、胎儿宫内发育迟缓（IUGR）、早产、双胎的发生率明显高于对照组。新生儿低血糖组合并新生儿高明红素血症、窒息、肺炎、脱水等并发症明显高于对照组。结论应注意监测妊高征、妊娠合并糖尿病、慢性高血压、IUGR、早产、双胎孕妇分娩的新生儿血糖,及早发现低血糖;对新生儿合并高胆红素血症、窒息、肺炎、脱水时在疾病治疗过程中亦应密切监测血糖变化,及时发现并纠正新生儿低血糖。     

Hypoglycemia in Beckwith-Wiedemann syndrome

Beckwith-Wiedemann syndrome (BWS) is an overgrowth syndrome associated with macrosomia, macroglossia, abdominal wall defects, hypoglycemia in the neonatal period and embryonal cancers of infancy and early childhood. The frequency of hypoglycemia in this population is between 30% and 50%. The majority of infants with hypoglycemia will be asymptomatic and have resolution of the hypoglycemia within the first 3 days of life. Less than 5% will have hypoglycemia beyond the neonatal period requiring either continuous feeding or a partial pancreatectomy. The cause of hypoglycemia is unclear, but direct and indirect evidence supports a hyperinsulinemia as the major factor. Recent identification of the majority of genes associated with BWS in the 11p15 region and the genotype of persistent hyperinsulinemia hypoglycemia of childhood also in the 11p15 region may provide a molecular basis for hypoglycemia in BWS, particularly for the occasional patients with hypoglycemia requiring a partial pancreatectomy. Detailed genotype phenotype evaluations are needed and should provide an insight as to why patients with BWS have hypoglycemia.     

Hypoglycemic injury to the immature brain

Despite the fact that hypoglycemia is an extremely common disorder of the newborn, consensus has been difficult to reach regarding definition, diagnosis, outcome, and treatment. With improved neuroradiologic techniques, such as MRI and PET scanning becoming increasingly available, studies to determine the correlation between hypoglycemia and outcome will help to clarify issues surrounding the effects of hypoglycemia on brain pathology. Long-term epidemiologic studies correlating the severity and duration of hypoglycemia with neurologic consequences are required, and can be complemented by appropriate parallel investigations in animal models of neonatal hypoglycemia.     

Hypoglycemia.

Except in diabetic patients receiving insulin or sulfonylureas, hypoglycemia is a rare disorder. It is identified by modified Whipple's criteria consisting of neuroglycopenic symptoms, a blood glucose level equal to or less than 40 mg/dL, and relief of symptoms by glucose use. The sources of the body glucose are dietary intake, glycogenolysis, and [figure: see text] gluconeogenesis. The metabolism of glucose involves oxidation and storage as glycogen or fat. Causes of hypoglycemia include medications or toxins capable of decreasing blood glucose, disorders associated with fasting hypoglycemia, and postprandial hypoglycemic disorders. The most common type of hypoglycemia is insulin-induced hypoglycemia in diabetics. Insulinoma is rare; however, it is the most common hormone-secreting islet cell tumor. The diagnosis is made by the occurrence of hypoglycemia in the presence of symptoms of neuroglycopenia and inappropriately high levels of insulin and C-peptide. In hospitalized patients, the diagnosis is best made by prolonged fast. Most insulinomas are small and require invasive methods for precise localization. In surreptitious insulin use, hypoglycemia is associated with low plasma C-peptide. Postprandial hypoglycemia occurs in response to feeding and is generally caused by excessive insulin effect. It is seen in patients with postgastric surgery and rarely in early diabetes mellitus. Idiopathic postprandial hypoglycemia is rare and seems to be caused by subtle abnormalities of insulin response to food. Treatment of postprandial hypoglycemia consists of frequent small meals, with deletion of refined carbohydrate and increased protein intake. Primary treatment of insulinoma is surgical resection of the tumor.     

Prevalence of nocturnal hypoglycemia in first trimester of pregnancy in patients with insulin treated diabetes mellitus

BACKGROUND: Excellent metabolic control before conception and during diabetic pregnancies is the aim in order to avoid malformations and perinatal morbidity. Since an inverse correlation between median blood glucose concentration (BG) and hypoglycemia as well as a high prevalence of nocturnal hypoglycemia have been described, we investigated the frequency of nocturnal hypoglycemia and the predictive value of bedtime blood glucose concentration for development of this condition in insulin treated diabetic patients. METHODS: During hospitalization, with no other changes in the patients' normal schedules, hourly blood samples were drawn from an iv-cannula from 22.00 h to 07.00 h for one night. BG (venous whole blood) and hemoglobin A1c were determined the following day. RESULTS: Fifty-three patients participated; subsequently ten were excluded due to discontinuation of blood sampling during the night, caused by either discomfort or cannula problems. Of the remaining 43 patients, 16 (37%) had at least one blood glucose <3.0 mmol/l. The duration of hypoglycemia was 2.4 (1-7) h with the highest prevalence at 05 h. Only one patient felt hypoglycemic during the night. Hemoglobin A1c was similar in patients with (7.1+/-1.2%, mean+/-s.d.) and without (6.8+/-0.8%) nocturnal hypoglycemia. Women with nocturnal hypoglycemia had significantly lower BG before bedtime compared to patients without hypoglycemia, 6.4+/-3.6 mmol/l vs. 7.9+/-2.4 mmol/l, p<0.05. The best predictive value for nocturnal hypoglycemia was a BG below 6.0 mmol/l at 23.00, which resulted in a risk of nocturnal hypoglycemia of 71%. Conversely, if the BG was > or =6.0 mmol/l, the chance of avoiding nocturnal hypoglycemia was 83%. CONCLUSION: Nocturnal hypoglycemia was seen with a prevalence of 37% during a night in the first trimester of pregnancy in insulin treated patients. Only one patient registered the hypoglycemia. Nocturnal hypoglycemia could be predicted in the majority of patients by measurements of BG before bedtime.     

Intravascular catheter complications in the neonatal intensive care unit

Central and peripheral intravascular catheters serve many important functions for sick neonates; however, the use of these catheters also carries significant risk of permanent disability or even death. This article examines the risks of catheter-related thromboembolic events, vasospasm, and infection. The article also looks at risks that are specific to umbilical artery catheters, umbilical vein catheters, peripherally-inserted central catheters, peripheral artery catheters, and peripheral intravenous catheters. Specific recommendations are made to reduce the possibility of an intravascular catheter-related complication.     

Transient hyperinsulinism in an asphyxiated newborn infant with hypoglycemia.

We describe a case of transient hyperinsulinism in an asphyxiated newborn infant with hypoglycemia. Although hypoglycemia in birth asphyxiated infants is generally attributed to depletion of glycogen stores, we observed severe hyperinsulinism associated with the hypoglycemia. The hypoglycemia was refractory to high glucose delivery rates (25 mg/kg/min), but responded to a combination of octreotide and diazoxide. At 3 weeks of age, the medications were discontinued and infant was normoglycemic on glucose infusion rates of 5-8 mg/kg/min. Subsequent insulin studies were within normal limits. Transient hyperinsulinism should be considered in asphyxiated infants with protracted hypoglycemia and medications designed to suppress insulin secretion may be useful in refractory cases.     

新生儿低血糖(附58例临床分析)

目的 研究新生儿低血糖的高危因素、诊断标准及治疗中出现的反复低血糖和高血糖的病因。方法 采用血糖检测试纸对６３８例患儿进行血糖筛查。结果 发现低血糖５８例,经治疗血糖恢复正常时间平均为１０．９ｈ;低血糖持续时间：≤２４ｈ５２例,～４８ｈ１例;反复低血糖１６例,高血糖８例。结论 对有低血糖高危因素的新生儿要连续监测血糖,及早发现,合理治疗,尽快纠正,减少反复低血糖和高血糖的发生,避免血糖大幅度波动加     

Significantly improved peripheral intravenous catheter performance in neonates: insertion ease, dwell time, complication rate, and costs.

A prospective, randomized, controlled study was performed in neonates in an intensive care nursery to compare the performance of a peripheral intravenous catheter made of Aquavene material (test catheter) with that of a conventional peripheral catheter made of Teflon material (control catheter). Aquavene is a newly developed biomaterial that softens and expands on contact with body fluids. A total of 105 catheters (50 test and 55 control) were inserted in 63 neonates. The median time to a catheter-related complication was 3.60 days for the test catheters and 1.75 days for the control catheters (p = 0.0007). Infiltration rate for the test catheters was 56% as compared with 78% for the control catheters (p = 0.03). The test catheters provided fewer catheter-related complications (p = 0.006), with 34% of the test catheters reaching end of therapy as compared with 9% of the control catheters (p = 0.004). On average, 1.8 test catheters were used per insertion versus 2.3 control catheters (p = 0.08). The test catheters were rated easier to insert (p = 0.05), with a shorter time required for insertion. Because of improved performance, cost savings were realized with the test catheters after the first day of therapy, even though the per unit cost of the test catheter was greater. These data indicate that the test catheter, made of Aquavene material, is superior to the Teflon catheter for peripheral intravenous therapy in neonates.     

Complications of indwelling central venous catheters in bone marrow transplant recipients

Complications associated with indwelling central venous catheters in patients undergoing bone marrow transplantation are presented. The study group was comprised of 123 patients who underwent transplantation from 1982 to 1988 in whom 139 catheters were placed. One hundred and fifteen of 139 catheters placed had a triple lumen, while 24 had a dual lumen. Percutaneous placement through the subclavian vein was used in 127 of 139 catheters with a low complication rate. Catheters remained in place for 65.0 +/- 55.5 days (mean +/- standard deviation). One hundred and eight catheters remained functional during the course of treatment for these patients and lasted until elective removal or until the patient died. Thirty-one catheters were removed because of a complication. Infection was the most common complication, occurring in 22 catheters. Seven infected catheters were salvaged with antibiotic therapy. Coagulase negative staphylococcus was the most frequent organism identified. Mechanical problems causing catheter malfunction, migration, thrombosis and cuff erosion occurred in 19 catheters; 15 were removed. We concluded that double and triple lumen Silastic (silicone rubber) catheters provide relatively safe and effective access for bone marrow transplant recipients. The triple lumen catheter provides an additional venous access port that facilitates intensive care. The duration of catheter function is sufficient in most patients for therapy during and after bone marrow transplantation. Infection is the most common complication; our results indicate that catheters can be maintained and salvaged in some patients with septicemia. Noninfectious complications are less frequent, although catheters with persistent mechanical problems are less likely to be salvaged.     

孕期口服葡萄糖耐量试验结果中血糖水平较低者的围产儿结局

目的 探讨孕期口服葡萄糖耐量试验(oral glucose tolerance test,OGTT)结果中血糖水平偏低孕妇的围产儿结局特点.方法 统计OGTT结果了解空腹、服糖后1 h、2 h、3 h的血糖百分位数分布.血糖水平小于第5百分位者为血糖水平较低组,小于第1百分位者为血糖水平极低组,比较血糖水平较低组、血糖水平极低组和血糖水平不低组孕妇的围产儿结局. 结果 空腹血糖水平与新生儿体重和身长分别呈正相关(r=0.16,P＜0.01;r=0.081,P＜0.05).空腹血糖极低组孕妇分娩的新生儿平均出生体重明显低于其余孕妇[(2817±764)g和(3439±487)g,t=3.344,P＜0.01];其小于胎龄儿分娩率亦高于血糖水平不低组(3/7和3.4%,y2=22.78,P＜0.01);其出生体重＜3000 g的新生儿分娩率明显高于其余孕妇(5/7和14.73%,P＜0.01).服糖后2h血糖水平较低组孕妇分娩的新生儿平均出生身长(49.03±1.68)cm,显著低于血糖值不低组(49.48±1.65cm,P＜0.05). 结论 OGTT结果 中血糖水平偏低的孕妇分娩的新生儿体重低、身长短、小于胎龄儿分娩率高.     

Catheter complications associated with intraperitoneal chemotherapy

Intraperitoneal administration of chemotherapy in ovarian carcinoma is currently under investigation. Numerous recent publications have described clinical studies employing a variety of chemotherapeutic drugs. Little information exists regarding the delivery systems employed or the complications encountered. This study reviews our experience with "single-use" and "long-term" catheters. Thirty-three catheters were placed in 28 patients. Of these catheters, 12 were long-term Tenckhoff catheters and 21 were temporary single-use catheters. Both types of catheters had complications associated with their usage. However, there was a dramatic difference in the number and severity of complications when the two groups were compared. Sixty-seven percent of the Tenckhoff catheters were associated with complications. Nineteen percent of the patients with single-use catheters experienced complications. This 19%, however, represented only 3.8% of the total number of single-use catheter insertions. In our hands, the temporary percutaneous approach has been a safe one, which is technically easy to perform with minimal complications.     

Rate and risk factors of hypoglycemia in large-for-gestational-age newborn infants of nondiabetic mothers

OBJECTIVE: The purpose of this study was to investigate the rate of hypoglycemia in large-for-gestational-age infants of nondiabetic mothers in relation to maternal or neonatal risk factors. STUDY DESIGN: Hospital charts of all term large-for-gestational-age infants born between 1994 and 1998 (n = 1136) were analyzed for the rate of neonatal hypoglycemia (capillary glucose level, < or =30 mg/dL) during the first 24 hours of life. Infants of women with preexisting or gestational diabetes mellitus were excluded (n = 180). Neonatal glucose testing was performed at 1 or 2 hours of life, with subsequent measurements every 4 to 6 hours. Maternal and neonatal parameters were compared between neonates with and without hypoglycemia, including recent oral glucose tolerance test values in those women who were tested (n = 358). RESULTS: Of 956 infants, 69 infants (7.2%) were not tested for hypoglycemia. In the remaining 887 infants, hypoglycemia occurred in 142 infants (16%) within the first 24 hours of life. The incidence of hypoglycemia decreased sharply during the first few hours of life, from 9.2% within the first hour of life, to 3.5% between 2 to 5 hours (cumulative) of life, and 2.4% between 6 and 24 hours of life. Gestational age at delivery was the only neonatal parameter that differed significantly between infants with and without hypoglycemia (39.5 vs 39.3 weeks, P =.01). The antenatal 1-hour oral glucose tolerance test value was the only predictive maternal parameter (141.5 vs 163.0 mg/dL, P <.006). There was an incremental risk of hypoglycemia with increasing 1-hour oral glucose tolerance test values, with hypoglycemia rates of 2.5%, 9.3%, 22.0%, and 50.0% that were associated with maternal 1-hour glucose values of <120, 120-179, 180-239, and > or =240 mg/dL, respectively (P <.05, for all comparisons). CONCLUSION: Routine glucose testing is indicated in large-for-gestational-age newborn infants of nondiabetic mothers. The 1-hour glucose value of the maternal oral glucose tolerance test is a fairly good predictor of subsequent neonatal hypoglycemia. A single elevated 1-hour value of > or =180 mg/dL markedly increases the risk of neonatal hypoglycemia.     

Thrombolytic therapy for adhesion of percutaneous central venous catheters to vein intima associated with Malassezia furfur Infection.

OBJECTIVE: To report our experience with thrombolytic agents in the management of two infants with silicone central venous catheters that had adhered to the vein wall as a result of infection with Malassezia furfur. STUDY DESIGN: Case review of two very low birth weight infants with adherent central venous catheters. RESULTS: Treatment with urokinase and tissue plasminogen activator facilitated the removal of these catheters without breakage or surgical intervention. CONCLUSIONS: Thrombolytic agents should be considered as a treatment of adhered catheters, as well as of occluded catheters.     

Insulinoma causing hypoglycemia in a patient with type 2 diabetes.

Insulinoma in a patient with pre-existing diabetes is extremely rare. A 74-year-old woman with type 2 diabetes mellitus who had been treated with a sulfonylurea for 6 years began experiencing frequent episodes of hypoglycemia. Endogenous hyperinsulinism was found 9 months after the sulfonylurea was discontinued, and transabdominal ultrasonography and magnetic resonance imaging identified a pancreatic tumor. Pathology examination of the resected tumor demonstrated an insulinoma. Postoperatively, the patient had no further episodes of hypoglycemia. Thereafter, she required insulin to control her hyperglycemia. Although hypoglycemic agents are the commonest cause of hypoglycemia in type 2 diabetes, insulinomas may occur in these patients. This possibility should be considered if the hypoglycemia persists despite dose adjustment or cessation of the drugs.     

Blood glucose determinations in large for gestational age infants

Our purpose was to identify factors that may contribute to hypoglycemia in large for gestational age (LGA) infants and subsets of infants for whom blood glucose screening would be clinically helpful. LGA infants of 36 to 42 weeks of gestational age using the Denver criteria were identified from the 1999 through 2001 birth log at Marquette General Hospital, Marquette, Michigan, a rural referral hospital, for a retrospective chart review. Infants of mothers with diabetes were excluded. The impact of maternal factors, intrauterine factors, and birthweight on blood glucose levels was assessed using marginal mixed models, Poisson regression, and receiver operating characteristic curves. We found 457 infant records documented blood glucose levels among the 727 infant records analyzed. The lowest blood glucose levels occurred in the first 90 minutes of life. Blood glucose levels were positively associated with weeks of gestation and breastfeeding. Birthweight did not predict hypoglycemia in any of the multivariable models constructed. Symptoms consistent with hypoglycemia occurred only in boys and were negatively associated with gestational age. Models using prenatal and perinatal factors to predict hypoglycemia or symptomatic hypoglycemia had little clinical value. In this large community-based sample of LGA infants, we found no evidence that higher birthweight increases the risk for hypoglycemia. The clinical usefulness of routine blood glucose monitoring in healthy LGA infants is not supported by this retrospective analysis and needs to be established by prospective studies.     

Groshong versus Hickman catheters.

There has been an increasing need for safe and efficient means of establishing vascular access in the patient with cancer. Recently, the use of percutaneous cannulation of the central veins, using guidewires, venous dilators and tearaway introducer sheaths, has become a popular method of establishing such access. The greatest concerns with the use of such catheters include sepsis, thrombus formation within the vein and catheter malfunction. The current study compared the incidence of these complications with Groshong (Cath Tech CV catheters with Groshong valve) and Hickman (Bard Access Systems vascular access catheters) catheters. Although there was no significant difference in septic complications and thrombus formation between the two groups, there was a significant (p less than 0.05) difference in catheter malfunction. Patients with Hickman catheters experienced significantly less problems with one way intermittent and one way catheters than did patients with Groshong catheters. We conclude that, based on catheter function, the Hickman catheter appears to be a more favorable alternative when compared with the Groshong catheter in the patient with cancer.     

Fractured ureteral catheters in gynecologic oncology

Two cases of fractured polyethylene double-pigtail ureteral catheters in pelvic cancer patients are reported. Current literature leaves a large void in guiding the management of these catheters. Surveillance techniques to help avoid complications in patients requiring these catheters are suggested.