Management of hydrocephalus secondary to intraventricular hemorrhage in the preterm infant with a subcutaneous ventricular catheter reservoir

To control hydrocephalus resulting from massive intraventricular hemorrhage in premature neonates with respiratory distress syndrome, we inserted a specially designed low profile subcutaneous ventricular catheter reservoir (reservoir) by the 12th day of life (average; range, 3 to 30 days) in 20 neonates whose mean birth weight was 1110 +/- 270 g (28.7 +/- 1.6 weeks of gestation). The reservoir was repeatedly aspirated over 10 to 48 days. No cerebrospinal fluid infection, reservoir obstruction, or breakdown of the skin overlying the reservoir occurred. Serial computed tomographic scans documented control of the hydrocephalus and an increase in the thickness of the cortical mantle of the survivors. No mortality was associated with placement of the reservoir or its subsequent conversion, if necessary, to a ventriculoperitoneal shunt. However, only 7 of the 20 infants survived. On follow-up 3 to 5 years later, 2 of the 7 have normal intellectual and motor development. Two infants are normal intellectually, but have a motor deficit. The remaining 3 patients have both significant intellectual and motor developmental delay. The use of the reservoir is offered as a safe and effective alternative to repeated ventricular punctures, external ventricular drainage, or initial shunting. Aggressive management of hydrocephalus secondary to intraventricular hemorrhage may improve neurological function in some surviving neonates.     

External ventricular drainage for treatment of rapidly progressive posthemorrhagic hydrocephalus.

Twenty-seven newborn infants (birth weight, 1503 +/- 776 g; gestational age, 31 +/- 3 wk) (mean +/- standard deviation) with rapidly progressive posthemorrhagic hydrocephalus and increased intracranial pressure were treated by external ventricular drainage. The progression of hydrocephalus was arrested during the drainage period in each patient. The drainage was kept in place for 23 +/- 9 days, the longest drainage period being 48 days. In 16 of 23 surviving patients, progressive ventricular dilation recurred after removal of the drainage, requiring a definitive shunt implantation (nine ventriculoatrial, seven ventriculoperitoneal). For the remaining seven infants, no further therapy was necessary. Implantation of the permanent shunt was done days 28 to 88 (body weight, 2400 +/- 950 g). Bacterial cultures from cerebrospinal fluid and/or the tip of the ventriculostomy catheter were negative in 175 instances and positive in 11 instances (7 patients). No clinical or biochemical evidence of ventriculitis was noted. Four of the 27 patients died of causes unrelated to external ventricular drainage. Twenty-three infants survived. Seventeen of 23 survivors suffered from intraventricular hemorrhage Grade 3; in 7, neurological and developmental outcomes were classified as normal; 9 patients experienced mild to moderate paresis and/or mild to moderate developmental delay; and only 1 patient was severely retarded. Six patients with parenchymal lesions had severe motor and/or developmental handicaps. We consider external ventricular drainage an effective and safe therapy in newborn infants with rapidly progressive posthemorrhagic hydrocephalus and increased intracranial pressure. The ultimate outcome, however, depends mainly on the mode and the extent of the primary brain lesion.     

Feeding the preterm infant

The sick preterm infant has special nutritional needs, and the provision of appropriate nutrition is now recognised as an important part of the increasingly intensive management of this population. Optimal nutrition is difficult to define for an individual infant, but prospective randomised studies have shown that the early diet given to preterm infants can have a major impact on their neurological development and growth, with the best outcomes for those receiving either a preterm formula or maternal milk fortified with a range of nutrients. In contrast, diets suitable for term infants do not meet the needs of small preterm infants, either in the short or longer term, and should not be used. This article reviews the nutritional needs of the preterm infant and outlines the strategies commonly used in this area of neonatal intensive care.     

Priapism in preterm infant

This report of transient priapism in a preterm newborn with respiratory distress syndrome discusses clinical course, therapy, possible etiologic factors, and previously reported cases in newborns. Possible causes include use of arterial catheter, red cell transfusion, hemodynamic changes from a patent ductus arteriosus, and hypoxia.     

The treatment of hydrocephalus in preterm infants with intraventricular haemorrhage

Summary The hospital charts and clinical course of forty-one patients requiring one or more ventricular drainage procedures for hydrocephalic complications of neonatal intraventricular haemorrhage were evaluated retrospectively. All drainage procedures were performed on patients with intraventricular haemorrhage with ventricular dilatation (Grade III [25 patients]) and intraventricular and intraparenchymal haemorrhage (Grade IV [16 patients]) who were medical management failures. Twenty-six ventricular reservoirs (Rickham or McComb reservoirs) were placed in neonates weighing less than 1500 grams, allowing for a safe but intermittent ventricular access. Eighteen of these reservoirs were subsequently converted to ventriculoperitoneal shunts.Thirty-two percent of the patients incurred a shunt and/or reservoir infection and 59% required a shunt revision during the first year of life. There was no mortality related to the neurosurgical interventions. These results compare favorably with the published literature.No grade IV patients achieved a normal functional level, while 10 grade III patients did. The incidence of severe developmental delay (44% versus 28%) and death (38% versus 12%) was greater in the grade IV than the grade III patients.The placement of ventricular reservoirs is acceptable as an alternative to the early placement of ventriculo-peritoneal shunts. This approach may reduce the incidence of shunt infection as well as noninfectious shunt complications.     

Perioperatively acquired methaemoglobinaemia in a preterm infant

Methaemoglobinaemia is an uncommon cause of neonatal cyanosis. A case that illustrates the aetiology, diagnosis, and treatment of this condition is presented.     

Blood viscosity during fluid infusion in the preterm infant.

Whole blood viscosity, haematocrit and plasma osmolality were measured in a group of preterm infants receiving a standard infusion (60 ml/kg/d) of 10,7% dextrose water with 4% sodium bicarbonate. There were no significant changes in the three parameters during the infusion period. It was concluded that although the infused solution was hypertonic, it did not result in a hyperviscous or hyperosmolar state.     

Post-operative apnoea in the former preterm infant: a review

Former preterm infants are known to be at increased risk for apnoea, periodic breathing, and bradycardia. When surgery cannot be postponed until respiratory function is more mature, speical peri-operative considerations and measures are essential. In this article, the literature concerning this subject is reviewed, summarizing prospective and retrospective studies of risks associated with surgery in former preterm infants during the first year of life. This work is placed within the context of our ongoing studies of peri-operative risk in former preterm infants undergoing surgery at the Children's National Medical Center (CNMC), which have focused on three particular areas: (1) the effects of spinal versus general anaesthesia on the incidence of post-operative apnoea and bradycardia; (2) the possible contribution of anaemia of prematurity to surgical risk; and (3) the effect of peri-operative caffeine in preventing post-operative apnoea. Recommendations are made concerning surgical and anaesthetic management of infants who undergo surgery at < 44 weeks' post-conceptual age.     

Oral-ibuprofen-induced acute renal failure in a preterm infant

The side effects of indomethacin for ductal closure in preterm neonates (e.g. increased incidence of necrotizing enterocolitis, decreased cerebral blood volume and transient renal failure) have led clinicians to seek a safer alternative. Intravenous indomethacin and ibuprofen appear to be equally effective for patent ductus arteriosus closure, but oral ibuprofen remains an experimental option with theoretical advantages yet with potential side effects. We herein report a case of transient but severe acute renal failure developing in a preterm infant in whom oral ibuprofen was used and discuss the safety of this drug in relation to its pharmacokinetics.     

Extremely low birth-weight infant with hydrocephalus; management of hydrocephalus using a miniature Ommaya's reservoir

Use of the miniature Ommaya's reservoir in the treatment of extremely low birth-infant (under 1,000 mg) with hydrocephalus was studied in a series of five patients. The reservoir has a small-caliber with a 3 cm ventricular catheter. For these infants, this miniature Ommaya's reservoir is extremely useful for protection of the cortical mantle until a definitive procedure can be carried out after increase of body weight. The clinical course in five cases are summarized.     

Colocolic intussusception in a preterm infant with intestinal malrotation

The association of intussusception and intestinal malrotation is referred to as Waugh syndrome. A prospective study among 49 children with intussusception found a 40% incidence of malrotation. We describe the rare occurrence of colocolic intussusception in a neonate with malrotated intestine. We believe this is the first reported case in the neonatal period where the pathogenic lead point was an intestinal lymphangioma.