Midwest Society for Pediatric Research (MWSPR): Annual Meeting

MADISON, WIS. – The one-size-fits-all approach to traumatic brain injury may be facing the same demise observed in the management and treatment of cancer and its protean forms.

"One of the arguments for why traumatic brain injury has been so difficult to get anything to work in a clinical trial is that we’ve been really naive in terms of trying to consider it one disease," said Dr. Patrick Kochanek, director of the Safar Center for Resuscitation Research at the University of Pittsburgh. "People have argued that we are treating traumatic brain injury as if we were treating cancer as a single disease. Maybe we need to do classifications."

To punctuate the point, Dr. Kochanek highlighted the now-classic computed tomography slide by the renowned neurosurgeon Dr. Geoffrey Manley, vice chair of neurological surgery at University of California, San Francisco, that illustrates six unique paths to a Glasgow Coma Scale score of four in traumatic brain injury (TBI) – epidural hematoma, contusion/hematoma, diffuse axonal injury, subdural hematoma, subarachnoid/intraventricular hemorrhages, and diffuse swelling.

The need to target distinct TBI subgroups was further illustrated by results from the recent NABISH II (National Acute Brain Injury Study: Hypothermia II), which failed to confirm the overall benefit of early hypothermia as a neuroprotectant among 232 patients with severe TBI. Subgroup analyses, however, revealed a significantly improved outcome in patients with hematomas treated with hypothermia, while those with diffuse brain injuries appeared to do worse (Lancet Neurol. 2011;10:131-9).

Pediatric considerations only further magnify the challenge of translating neuroprotective therapies for TBI to clinical practice, Dr. Kochanek said at the annual meeting of the Midwest Society for Pediatric Research. Diffuse cerebral swelling, the most common cause of brain death following severe TBI in both adults and children, is 3.5 times more common in children than in adults and typically more common in younger age groups than in older children.

Hypothermia has been shown to reduce intracranial pressure after pediatric TBI and to be beneficial in pediatric cardiac arrest and hypoxic-ischemic encephalopathy (HIE). Still, a lack of quality data demonstrating a consistent benefit has contributed to the lack of a recommendation of prophylactic hypothermia in pediatric severe head trauma management. Hopes for additional, high-quality data were dashed after the $11.5 million-dollar, multicenter Cool Kids trial evaluating 48 hours of hypothermia within 6 hours of injury recently was stopped for futility.

It’s possible that 6 hours is too late for a therapeutic window or that patients are rewarmed too early during peak edema or too fast, thereby exacerbating hypotension, or that the brain responds differently to hypothermia following TBI versus HIE or cardiac arrest, Dr. Kochanek suggested.

A biomarker trial led by colleague Dr. Rachel Berger used serial serum neuron-specific enolase measurements to demonstrate that neuronal death is frequently delayed in HIE, but predominantly acute in children with TBI (Dev. Neurosci. 2006;28:327-35). This may explain why hypothermia and other therapies have not been effective other than to reduce intracranial pressure after TBI, he said.

"The take-home message is that if you are targeting neuroprotection in TBI, you better get the therapy on board fast," he added.

Better monitoring and management of fever after brain injury also is needed. Notably, the odds of death or disability increased 3.6- to fourfold for every single degree Celsius increase in a study involving 99 infants with HIE (Pediatrics 2008;122:491-9).

"We do a poor job of dealing with this issue," Dr. Kochanek said. "Just go through the ICU, particularly a pediatric ICU, and take a look at the temperature recordings of patients with head injury or cardiac arrest, and you’ll be pretty much disappointed."

The lack of surface cooling devices specifically designed for children or endovascular cooling catheters for pediatric patients prompted colleagues, led by Dr. Ericka Fink, to use iced intravenous saline 20 mL/kg infused over 15 minutes to treat fever among 18 children, aged 1 week to 17 years, with TBI, intracranial hemorrhage, or cardiac arrest. The treatment resulted in a significant reduction in core temperature after infusion for fever and a trend toward lower temperatures for induction of hypothermia (Pediatr. Crit. Care Med. 2010 [doi: 10.1097/PCC.0b013e3181fe27c7]).

"People have argued that we are treating traumatic brain injury as if we were treating cancer as a single disease."

What is uncertain is how long the brain remains vulnerable to fever after an injury, Dr. Kochanek said. "It’s one thing to be comatose and aggressively cool to control fever, and it’s quite another to do this 5 days out when you’re awake and your stress response to cooling and need for sedation become a real problem," he observed.

Much of the emphasis in treating pediatric TBI patients has been on reducing secondary insult through the use of intracranial pressure (ICP) monitoring and osmolar therapy, but this may not be enough. A retrospective analysis from the University of Pittsburgh team reported a 50% incidence of unfavorable outcome among 22 infants with severe TBI, despite nearly 900 hourly ICP readings in a PICU with rigorous ICP control and an excellent 8.6% severe TBI mortality rate (Dev. Neurosci. 2010;32:413-9).

"In many cases, we may need to identify other therapeutic targets," he said, adding that axonal injury may offer a temporally friendly therapeutic target in both TBI and abusive head trauma.

Finally, Dr. Kochanek suggested that abusive head trauma should be established as a separate entity from accidental TBI. He pointed out that the biomarker study, cited above, also found that patients with abusive head trauma demonstrate considerable delayed neuronal death, mirroring HIE more than TBI.

"Abusive head trauma is a separate entity and deserves its own therapeutic targets," he said.

Dr. Kochanek reported funding from the U.S. Army, the National Institute of Child Health and Human Development, the National Institute of Neurological Disorders and Stroke, the Defense Advanced Research Projects Agency, the Laerdal Foundation for Acute Medicine, and the American Heart Association.

MADISON, WIS. – The one-size-fits-all approach to traumatic brain injury may be facing the same demise observed in the management and treatment of cancer and its protean forms.

"One of the arguments for why traumatic brain injury has been so difficult to get anything to work in a clinical trial is that we’ve been really naive in terms of trying to consider it one disease," said Dr. Patrick Kochanek, director of the Safar Center for Resuscitation Research at the University of Pittsburgh. "People have argued that we are treating traumatic brain injury as if we were treating cancer as a single disease. Maybe we need to do classifications."

To punctuate the point, Dr. Kochanek highlighted the now-classic computed tomography slide by the renowned neurosurgeon Dr. Geoffrey Manley, vice chair of neurological surgery at University of California, San Francisco, that illustrates six unique paths to a Glasgow Coma Scale score of four in traumatic brain injury (TBI) – epidural hematoma, contusion/hematoma, diffuse axonal injury, subdural hematoma, subarachnoid/intraventricular hemorrhages, and diffuse swelling.

The need to target distinct TBI subgroups was further illustrated by results from the recent NABISH II (National Acute Brain Injury Study: Hypothermia II), which failed to confirm the overall benefit of early hypothermia as a neuroprotectant among 232 patients with severe TBI. Subgroup analyses, however, revealed a significantly improved outcome in patients with hematomas treated with hypothermia, while those with diffuse brain injuries appeared to do worse (Lancet Neurol. 2011;10:131-9).

Pediatric considerations only further magnify the challenge of translating neuroprotective therapies for TBI to clinical practice, Dr. Kochanek said at the annual meeting of the Midwest Society for Pediatric Research. Diffuse cerebral swelling, the most common cause of brain death following severe TBI in both adults and children, is 3.5 times more common in children than in adults and typically more common in younger age groups than in older children.

Hypothermia has been shown to reduce intracranial pressure after pediatric TBI and to be beneficial in pediatric cardiac arrest and hypoxic-ischemic encephalopathy (HIE). Still, a lack of quality data demonstrating a consistent benefit has contributed to the lack of a recommendation of prophylactic hypothermia in pediatric severe head trauma management. Hopes for additional, high-quality data were dashed after the $11.5 million-dollar, multicenter Cool Kids trial evaluating 48 hours of hypothermia within 6 hours of injury recently was stopped for futility.

It’s possible that 6 hours is too late for a therapeutic window or that patients are rewarmed too early during peak edema or too fast, thereby exacerbating hypotension, or that the brain responds differently to hypothermia following TBI versus HIE or cardiac arrest, Dr. Kochanek suggested.

A biomarker trial led by colleague Dr. Rachel Berger used serial serum neuron-specific enolase measurements to demonstrate that neuronal death is frequently delayed in HIE, but predominantly acute in children with TBI (Dev. Neurosci. 2006;28:327-35). This may explain why hypothermia and other therapies have not been effective other than to reduce intracranial pressure after TBI, he said.

"The take-home message is that if you are targeting neuroprotection in TBI, you better get the therapy on board fast," he added.

Better monitoring and management of fever after brain injury also is needed. Notably, the odds of death or disability increased 3.6- to fourfold for every single degree Celsius increase in a study involving 99 infants with HIE (Pediatrics 2008;122:491-9).

"We do a poor job of dealing with this issue," Dr. Kochanek said. "Just go through the ICU, particularly a pediatric ICU, and take a look at the temperature recordings of patients with head injury or cardiac arrest, and you’ll be pretty much disappointed."

The lack of surface cooling devices specifically designed for children or endovascular cooling catheters for pediatric patients prompted colleagues, led by Dr. Ericka Fink, to use iced intravenous saline 20 mL/kg infused over 15 minutes to treat fever among 18 children, aged 1 week to 17 years, with TBI, intracranial hemorrhage, or cardiac arrest. The treatment resulted in a significant reduction in core temperature after infusion for fever and a trend toward lower temperatures for induction of hypothermia (Pediatr. Crit. Care Med. 2010 [doi: 10.1097/PCC.0b013e3181fe27c7]).

"People have argued that we are treating traumatic brain injury as if we were treating cancer as a single disease."

What is uncertain is how long the brain remains vulnerable to fever after an injury, Dr. Kochanek said. "It’s one thing to be comatose and aggressively cool to control fever, and it’s quite another to do this 5 days out when you’re awake and your stress response to cooling and need for sedation become a real problem," he observed.

Much of the emphasis in treating pediatric TBI patients has been on reducing secondary insult through the use of intracranial pressure (ICP) monitoring and osmolar therapy, but this may not be enough. A retrospective analysis from the University of Pittsburgh team reported a 50% incidence of unfavorable outcome among 22 infants with severe TBI, despite nearly 900 hourly ICP readings in a PICU with rigorous ICP control and an excellent 8.6% severe TBI mortality rate (Dev. Neurosci. 2010;32:413-9).

"In many cases, we may need to identify other therapeutic targets," he said, adding that axonal injury may offer a temporally friendly therapeutic target in both TBI and abusive head trauma.

Finally, Dr. Kochanek suggested that abusive head trauma should be established as a separate entity from accidental TBI. He pointed out that the biomarker study, cited above, also found that patients with abusive head trauma demonstrate considerable delayed neuronal death, mirroring HIE more than TBI.

"Abusive head trauma is a separate entity and deserves its own therapeutic targets," he said.

Dr. Kochanek reported funding from the U.S. Army, the National Institute of Child Health and Human Development, the National Institute of Neurological Disorders and Stroke, the Defense Advanced Research Projects Agency, the Laerdal Foundation for Acute Medicine, and the American Heart Association.

MADISON, WIS. – The one-size-fits-all approach to traumatic brain injury may be facing the same demise observed in the management and treatment of cancer and its protean forms.

"One of the arguments for why traumatic brain injury has been so difficult to get anything to work in a clinical trial is that we’ve been really naive in terms of trying to consider it one disease," said Dr. Patrick Kochanek, director of the Safar Center for Resuscitation Research at the University of Pittsburgh. "People have argued that we are treating traumatic brain injury as if we were treating cancer as a single disease. Maybe we need to do classifications."

To punctuate the point, Dr. Kochanek highlighted the now-classic computed tomography slide by the renowned neurosurgeon Dr. Geoffrey Manley, vice chair of neurological surgery at University of California, San Francisco, that illustrates six unique paths to a Glasgow Coma Scale score of four in traumatic brain injury (TBI) – epidural hematoma, contusion/hematoma, diffuse axonal injury, subdural hematoma, subarachnoid/intraventricular hemorrhages, and diffuse swelling.

The need to target distinct TBI subgroups was further illustrated by results from the recent NABISH II (National Acute Brain Injury Study: Hypothermia II), which failed to confirm the overall benefit of early hypothermia as a neuroprotectant among 232 patients with severe TBI. Subgroup analyses, however, revealed a significantly improved outcome in patients with hematomas treated with hypothermia, while those with diffuse brain injuries appeared to do worse (Lancet Neurol. 2011;10:131-9).

Pediatric considerations only further magnify the challenge of translating neuroprotective therapies for TBI to clinical practice, Dr. Kochanek said at the annual meeting of the Midwest Society for Pediatric Research. Diffuse cerebral swelling, the most common cause of brain death following severe TBI in both adults and children, is 3.5 times more common in children than in adults and typically more common in younger age groups than in older children.

Hypothermia has been shown to reduce intracranial pressure after pediatric TBI and to be beneficial in pediatric cardiac arrest and hypoxic-ischemic encephalopathy (HIE). Still, a lack of quality data demonstrating a consistent benefit has contributed to the lack of a recommendation of prophylactic hypothermia in pediatric severe head trauma management. Hopes for additional, high-quality data were dashed after the $11.5 million-dollar, multicenter Cool Kids trial evaluating 48 hours of hypothermia within 6 hours of injury recently was stopped for futility.

It’s possible that 6 hours is too late for a therapeutic window or that patients are rewarmed too early during peak edema or too fast, thereby exacerbating hypotension, or that the brain responds differently to hypothermia following TBI versus HIE or cardiac arrest, Dr. Kochanek suggested.

A biomarker trial led by colleague Dr. Rachel Berger used serial serum neuron-specific enolase measurements to demonstrate that neuronal death is frequently delayed in HIE, but predominantly acute in children with TBI (Dev. Neurosci. 2006;28:327-35). This may explain why hypothermia and other therapies have not been effective other than to reduce intracranial pressure after TBI, he said.

"The take-home message is that if you are targeting neuroprotection in TBI, you better get the therapy on board fast," he added.

Better monitoring and management of fever after brain injury also is needed. Notably, the odds of death or disability increased 3.6- to fourfold for every single degree Celsius increase in a study involving 99 infants with HIE (Pediatrics 2008;122:491-9).

"We do a poor job of dealing with this issue," Dr. Kochanek said. "Just go through the ICU, particularly a pediatric ICU, and take a look at the temperature recordings of patients with head injury or cardiac arrest, and you’ll be pretty much disappointed."

The lack of surface cooling devices specifically designed for children or endovascular cooling catheters for pediatric patients prompted colleagues, led by Dr. Ericka Fink, to use iced intravenous saline 20 mL/kg infused over 15 minutes to treat fever among 18 children, aged 1 week to 17 years, with TBI, intracranial hemorrhage, or cardiac arrest. The treatment resulted in a significant reduction in core temperature after infusion for fever and a trend toward lower temperatures for induction of hypothermia (Pediatr. Crit. Care Med. 2010 [doi: 10.1097/PCC.0b013e3181fe27c7]).

"People have argued that we are treating traumatic brain injury as if we were treating cancer as a single disease."

What is uncertain is how long the brain remains vulnerable to fever after an injury, Dr. Kochanek said. "It’s one thing to be comatose and aggressively cool to control fever, and it’s quite another to do this 5 days out when you’re awake and your stress response to cooling and need for sedation become a real problem," he observed.

Much of the emphasis in treating pediatric TBI patients has been on reducing secondary insult through the use of intracranial pressure (ICP) monitoring and osmolar therapy, but this may not be enough. A retrospective analysis from the University of Pittsburgh team reported a 50% incidence of unfavorable outcome among 22 infants with severe TBI, despite nearly 900 hourly ICP readings in a PICU with rigorous ICP control and an excellent 8.6% severe TBI mortality rate (Dev. Neurosci. 2010;32:413-9).

"In many cases, we may need to identify other therapeutic targets," he said, adding that axonal injury may offer a temporally friendly therapeutic target in both TBI and abusive head trauma.

Finally, Dr. Kochanek suggested that abusive head trauma should be established as a separate entity from accidental TBI. He pointed out that the biomarker study, cited above, also found that patients with abusive head trauma demonstrate considerable delayed neuronal death, mirroring HIE more than TBI.

"Abusive head trauma is a separate entity and deserves its own therapeutic targets," he said.

Dr. Kochanek reported funding from the U.S. Army, the National Institute of Child Health and Human Development, the National Institute of Neurological Disorders and Stroke, the Defense Advanced Research Projects Agency, the Laerdal Foundation for Acute Medicine, and the American Heart Association.

CHICAGO – A full 45% of all peripherally inserted central catheter lines placed in the basilic or cephalic veins migrated 24 hours after insertion in a retrospective analysis of 100 consecutive lines placed in a neonatal intensive care unit.

Of the 76 peripherally inserted central catheter (PICC) lines placed in the basilic vein, 35.5% migrated inferiorly and medially (mean 1.48 cm), 14.5% migrated laterally (mean 1.74 cm), and 50% did not change position.

Of the 19 PICC lines placed in the cephalic vein, 21% migrated inferiorly and medially (mean 1.36 cm), 15.7% migrated laterally (mean 1.75 cm), and 63.3% did not change position.

None of the five PICC lines placed in the saphenous veins migrated, lead author Dr. Ansel Tjin-A-Tam reported at the annual meeting of the Midwest Society for Pediatric Research.

"We’re not sure why they migrated," he said.

In light of the findings and the potential for catheter migration to result in neonatal death due to cardiac tamponade, he recommended that all neonates have x-rays repeated at 24 hours post-insertion and PICC lines adjusted accordingly.

The chart review involved 100 consecutively placed PICC lines in the NICU at Mount Sinai Hospital in Chicago from January 2010 to March 31. All PICC lines were placed by two certified NICU nurses. X-rays were obtained immediately after insertion and 24 hours post-insertion, and reviewed by a single board-certified pediatric radiologist. The position of the arm was adducted and internally rotated at the shoulder and extended at the elbow on all the x-rays, explained Dr. Tjin-A-Tam, a third-year resident at the hospital.

A recent literature review of studies evaluating the best method to confirm PICC placement in neonates, identified a paucity of information on the subject and the importance of arm position when performing radiographs because movement of the arm can cause migration of the catheter (Neonatal Netw. 2010;29:23-35). The authors suggest supplementing supine chest radiographs with contrast or ultrasound when the line tip position is unclear, and that supine and lateral abdominal radiographs are useful to ensure placement in the inferior vena cava when placing a PICC in the saphenous vein of a neonate.

Dr. Tjin-A-Tam said all of the patients in the study were supine at the time of the radiograph, and agreed that ultrasound could be useful during placement, particularly given concerns for radiation exposure in neonates.

In the current analysis, the neonates’ average birth weight was 1,266 grams (range 420-3,795 g), and the mean dwell time of the PICC lines was 30 days (range 1-45 days).

A recently published review found that 164 (14%) of 1,148 PICC insertions in a NICU had to be replaced due to blockage or migration, and that those exchanged by using the old PICC as a guide wire were associated with a significantly higher risk of central line-associated blood stream infections, compared with those inserted into a new site (9.8% vs. 1%). This association remained significant even after adjusting for confounders (Am. J. Perinatol. 2011;28:419-24).

Dr. Tjin-A-Tam said he was unaware of any infections during the study period.

"If the radiologist shows that it has migrated, they don’t replace the whole PICC line, they just adjust it," he said. "If there is an infection, obviously you have to take the line out."

Dr. Tjin-A-Tam and his coauthors reported no relevant financial disclosures.

CHICAGO – A full 45% of all peripherally inserted central catheter lines placed in the basilic or cephalic veins migrated 24 hours after insertion in a retrospective analysis of 100 consecutive lines placed in a neonatal intensive care unit.

Of the 76 peripherally inserted central catheter (PICC) lines placed in the basilic vein, 35.5% migrated inferiorly and medially (mean 1.48 cm), 14.5% migrated laterally (mean 1.74 cm), and 50% did not change position.

Of the 19 PICC lines placed in the cephalic vein, 21% migrated inferiorly and medially (mean 1.36 cm), 15.7% migrated laterally (mean 1.75 cm), and 63.3% did not change position.

None of the five PICC lines placed in the saphenous veins migrated, lead author Dr. Ansel Tjin-A-Tam reported at the annual meeting of the Midwest Society for Pediatric Research.

"We’re not sure why they migrated," he said.

In light of the findings and the potential for catheter migration to result in neonatal death due to cardiac tamponade, he recommended that all neonates have x-rays repeated at 24 hours post-insertion and PICC lines adjusted accordingly.

The chart review involved 100 consecutively placed PICC lines in the NICU at Mount Sinai Hospital in Chicago from January 2010 to March 31. All PICC lines were placed by two certified NICU nurses. X-rays were obtained immediately after insertion and 24 hours post-insertion, and reviewed by a single board-certified pediatric radiologist. The position of the arm was adducted and internally rotated at the shoulder and extended at the elbow on all the x-rays, explained Dr. Tjin-A-Tam, a third-year resident at the hospital.

A recent literature review of studies evaluating the best method to confirm PICC placement in neonates, identified a paucity of information on the subject and the importance of arm position when performing radiographs because movement of the arm can cause migration of the catheter (Neonatal Netw. 2010;29:23-35). The authors suggest supplementing supine chest radiographs with contrast or ultrasound when the line tip position is unclear, and that supine and lateral abdominal radiographs are useful to ensure placement in the inferior vena cava when placing a PICC in the saphenous vein of a neonate.

Dr. Tjin-A-Tam said all of the patients in the study were supine at the time of the radiograph, and agreed that ultrasound could be useful during placement, particularly given concerns for radiation exposure in neonates.

In the current analysis, the neonates’ average birth weight was 1,266 grams (range 420-3,795 g), and the mean dwell time of the PICC lines was 30 days (range 1-45 days).

A recently published review found that 164 (14%) of 1,148 PICC insertions in a NICU had to be replaced due to blockage or migration, and that those exchanged by using the old PICC as a guide wire were associated with a significantly higher risk of central line-associated blood stream infections, compared with those inserted into a new site (9.8% vs. 1%). This association remained significant even after adjusting for confounders (Am. J. Perinatol. 2011;28:419-24).

Dr. Tjin-A-Tam said he was unaware of any infections during the study period.

"If the radiologist shows that it has migrated, they don’t replace the whole PICC line, they just adjust it," he said. "If there is an infection, obviously you have to take the line out."

Dr. Tjin-A-Tam and his coauthors reported no relevant financial disclosures.

CHICAGO – A full 45% of all peripherally inserted central catheter lines placed in the basilic or cephalic veins migrated 24 hours after insertion in a retrospective analysis of 100 consecutive lines placed in a neonatal intensive care unit.

Of the 76 peripherally inserted central catheter (PICC) lines placed in the basilic vein, 35.5% migrated inferiorly and medially (mean 1.48 cm), 14.5% migrated laterally (mean 1.74 cm), and 50% did not change position.

Of the 19 PICC lines placed in the cephalic vein, 21% migrated inferiorly and medially (mean 1.36 cm), 15.7% migrated laterally (mean 1.75 cm), and 63.3% did not change position.

None of the five PICC lines placed in the saphenous veins migrated, lead author Dr. Ansel Tjin-A-Tam reported at the annual meeting of the Midwest Society for Pediatric Research.

"We’re not sure why they migrated," he said.

In light of the findings and the potential for catheter migration to result in neonatal death due to cardiac tamponade, he recommended that all neonates have x-rays repeated at 24 hours post-insertion and PICC lines adjusted accordingly.

The chart review involved 100 consecutively placed PICC lines in the NICU at Mount Sinai Hospital in Chicago from January 2010 to March 31. All PICC lines were placed by two certified NICU nurses. X-rays were obtained immediately after insertion and 24 hours post-insertion, and reviewed by a single board-certified pediatric radiologist. The position of the arm was adducted and internally rotated at the shoulder and extended at the elbow on all the x-rays, explained Dr. Tjin-A-Tam, a third-year resident at the hospital.

A recent literature review of studies evaluating the best method to confirm PICC placement in neonates, identified a paucity of information on the subject and the importance of arm position when performing radiographs because movement of the arm can cause migration of the catheter (Neonatal Netw. 2010;29:23-35). The authors suggest supplementing supine chest radiographs with contrast or ultrasound when the line tip position is unclear, and that supine and lateral abdominal radiographs are useful to ensure placement in the inferior vena cava when placing a PICC in the saphenous vein of a neonate.

Dr. Tjin-A-Tam said all of the patients in the study were supine at the time of the radiograph, and agreed that ultrasound could be useful during placement, particularly given concerns for radiation exposure in neonates.

In the current analysis, the neonates’ average birth weight was 1,266 grams (range 420-3,795 g), and the mean dwell time of the PICC lines was 30 days (range 1-45 days).

A recently published review found that 164 (14%) of 1,148 PICC insertions in a NICU had to be replaced due to blockage or migration, and that those exchanged by using the old PICC as a guide wire were associated with a significantly higher risk of central line-associated blood stream infections, compared with those inserted into a new site (9.8% vs. 1%). This association remained significant even after adjusting for confounders (Am. J. Perinatol. 2011;28:419-24).

Dr. Tjin-A-Tam said he was unaware of any infections during the study period.

"If the radiologist shows that it has migrated, they don’t replace the whole PICC line, they just adjust it," he said. "If there is an infection, obviously you have to take the line out."

Dr. Tjin-A-Tam and his coauthors reported no relevant financial disclosures.

MADISON, WIS. – Adding blood pressure readings to pulse oximetry screening prompted additional testing and failed to identify any newborns with critical congenital heart disease in a retrospective analysis of 10,012 infants.

In all, 84% of infants who failed the initial heart disease screening, failed based on blood pressure (BP) measurements alone.

Twelve of the 13 infants with positive screens had positive BP measurements, which resulted in 6 echocardiograms being performed that likely would not otherwise have been done, Dr. Kristi Boelke reported at the annual meeting of the Midwest Society for Pediatric Research.

Pulse oximetry screening can identify infants with asymptomatic critical congenital heart disease (CCHD) before they are discharged home, but it is not currently included in most state newborn screening panels. Congenital heart defects account for 24% of birth defect–related infant deaths in the United States, according to the Department of Health and Human Services.

To date, no studies have evaluated BP measurements as a screening tool for CCHD, according to Dr. Boelke, a neonatology fellow at the University of Wisconsin, Madison.

Dr. Boelke and her colleagues reviewed the charts for pulse oximetry and BP screening results for all infants born at more than 34 6/7 weeks’ gestation at Meriter Hospital in Madison, Wis., between Feb. 12, 2008, and Dec. 31, 2010. Charts at three hospitals providing pediatric care in the area also were reviewed for infants seen in the emergency department or readmitted with a diagnosis of any congenital heart disease at less than 30 days of age, and compared with the newborn Meriter data.

Screening was completed at 24 hours of age or prior to discharge, if discharge occurred before 24 hours. Pulse oximetry was done on a lower extremity, with oxygen saturation of less than 95% considered positive. BP was measured on the right upper extremity and one of the lower extremities, and considered positive if the systolic pressure in the right arm was 15 mm Hg more than the systolic pressure in either lower extremity.

In all, 127 infants failed the BP screening, 23 failed the pulse oximetry screening, and 1 failed both screens, Dr. Boelke reported in a poster presentation.

After repeat screening within 2 hours, 12 infants failed the BP screening and 1 failed both screens. Seven of the 13 infants had an echocardiogram performed, and none of these infants had CCHD. This resulted in a false-positive rate for the BP screen of 0.13%, with almost all of the false positives due to the BP portion of the screening, she noted. Specificity of the screening was 99.9%, and negative predictive value was 100%.

The echocardiogram results were one small ventricular septal defect, one small patent ductus arteriosus (PDA), one small atrial septal defect and PDA, and four structurally normal hearts.

A chart review of the three local hospitals revealed no infants who had been discharged with unrecognized CCHD.

"Blood pressure measurements created more additional testing, including repeat blood pressure measurements, additional physician and nurse evaluation of the infant, and echocardiograms than pulse oximetry testing," the authors wrote. "This additional testing was of no clinical benefit to the infants as it did not identify any infants with unrecognized CCHD."

The authors noted that BP measurements were sometimes repeated several times on one infant because of the difficulty of obtaining accurate measurements in infants, and that the additional testing sparked by the BP screen also likely created unnecessary anxiety for families.

The Meriter Hospital health information department compiled the data for the analysis. The authors reported no relevant financial conflicts.

MADISON, WIS. – Adding blood pressure readings to pulse oximetry screening prompted additional testing and failed to identify any newborns with critical congenital heart disease in a retrospective analysis of 10,012 infants.

In all, 84% of infants who failed the initial heart disease screening, failed based on blood pressure (BP) measurements alone.

Twelve of the 13 infants with positive screens had positive BP measurements, which resulted in 6 echocardiograms being performed that likely would not otherwise have been done, Dr. Kristi Boelke reported at the annual meeting of the Midwest Society for Pediatric Research.

Pulse oximetry screening can identify infants with asymptomatic critical congenital heart disease (CCHD) before they are discharged home, but it is not currently included in most state newborn screening panels. Congenital heart defects account for 24% of birth defect–related infant deaths in the United States, according to the Department of Health and Human Services.

To date, no studies have evaluated BP measurements as a screening tool for CCHD, according to Dr. Boelke, a neonatology fellow at the University of Wisconsin, Madison.

Dr. Boelke and her colleagues reviewed the charts for pulse oximetry and BP screening results for all infants born at more than 34 6/7 weeks’ gestation at Meriter Hospital in Madison, Wis., between Feb. 12, 2008, and Dec. 31, 2010. Charts at three hospitals providing pediatric care in the area also were reviewed for infants seen in the emergency department or readmitted with a diagnosis of any congenital heart disease at less than 30 days of age, and compared with the newborn Meriter data.

Screening was completed at 24 hours of age or prior to discharge, if discharge occurred before 24 hours. Pulse oximetry was done on a lower extremity, with oxygen saturation of less than 95% considered positive. BP was measured on the right upper extremity and one of the lower extremities, and considered positive if the systolic pressure in the right arm was 15 mm Hg more than the systolic pressure in either lower extremity.

In all, 127 infants failed the BP screening, 23 failed the pulse oximetry screening, and 1 failed both screens, Dr. Boelke reported in a poster presentation.

After repeat screening within 2 hours, 12 infants failed the BP screening and 1 failed both screens. Seven of the 13 infants had an echocardiogram performed, and none of these infants had CCHD. This resulted in a false-positive rate for the BP screen of 0.13%, with almost all of the false positives due to the BP portion of the screening, she noted. Specificity of the screening was 99.9%, and negative predictive value was 100%.

The echocardiogram results were one small ventricular septal defect, one small patent ductus arteriosus (PDA), one small atrial septal defect and PDA, and four structurally normal hearts.

A chart review of the three local hospitals revealed no infants who had been discharged with unrecognized CCHD.

"Blood pressure measurements created more additional testing, including repeat blood pressure measurements, additional physician and nurse evaluation of the infant, and echocardiograms than pulse oximetry testing," the authors wrote. "This additional testing was of no clinical benefit to the infants as it did not identify any infants with unrecognized CCHD."

The authors noted that BP measurements were sometimes repeated several times on one infant because of the difficulty of obtaining accurate measurements in infants, and that the additional testing sparked by the BP screen also likely created unnecessary anxiety for families.

The Meriter Hospital health information department compiled the data for the analysis. The authors reported no relevant financial conflicts.

MADISON, WIS. – Adding blood pressure readings to pulse oximetry screening prompted additional testing and failed to identify any newborns with critical congenital heart disease in a retrospective analysis of 10,012 infants.

In all, 84% of infants who failed the initial heart disease screening, failed based on blood pressure (BP) measurements alone.

Twelve of the 13 infants with positive screens had positive BP measurements, which resulted in 6 echocardiograms being performed that likely would not otherwise have been done, Dr. Kristi Boelke reported at the annual meeting of the Midwest Society for Pediatric Research.

Pulse oximetry screening can identify infants with asymptomatic critical congenital heart disease (CCHD) before they are discharged home, but it is not currently included in most state newborn screening panels. Congenital heart defects account for 24% of birth defect–related infant deaths in the United States, according to the Department of Health and Human Services.

To date, no studies have evaluated BP measurements as a screening tool for CCHD, according to Dr. Boelke, a neonatology fellow at the University of Wisconsin, Madison.

Dr. Boelke and her colleagues reviewed the charts for pulse oximetry and BP screening results for all infants born at more than 34 6/7 weeks’ gestation at Meriter Hospital in Madison, Wis., between Feb. 12, 2008, and Dec. 31, 2010. Charts at three hospitals providing pediatric care in the area also were reviewed for infants seen in the emergency department or readmitted with a diagnosis of any congenital heart disease at less than 30 days of age, and compared with the newborn Meriter data.

Screening was completed at 24 hours of age or prior to discharge, if discharge occurred before 24 hours. Pulse oximetry was done on a lower extremity, with oxygen saturation of less than 95% considered positive. BP was measured on the right upper extremity and one of the lower extremities, and considered positive if the systolic pressure in the right arm was 15 mm Hg more than the systolic pressure in either lower extremity.

In all, 127 infants failed the BP screening, 23 failed the pulse oximetry screening, and 1 failed both screens, Dr. Boelke reported in a poster presentation.

After repeat screening within 2 hours, 12 infants failed the BP screening and 1 failed both screens. Seven of the 13 infants had an echocardiogram performed, and none of these infants had CCHD. This resulted in a false-positive rate for the BP screen of 0.13%, with almost all of the false positives due to the BP portion of the screening, she noted. Specificity of the screening was 99.9%, and negative predictive value was 100%.

The echocardiogram results were one small ventricular septal defect, one small patent ductus arteriosus (PDA), one small atrial septal defect and PDA, and four structurally normal hearts.

A chart review of the three local hospitals revealed no infants who had been discharged with unrecognized CCHD.

"Blood pressure measurements created more additional testing, including repeat blood pressure measurements, additional physician and nurse evaluation of the infant, and echocardiograms than pulse oximetry testing," the authors wrote. "This additional testing was of no clinical benefit to the infants as it did not identify any infants with unrecognized CCHD."

The authors noted that BP measurements were sometimes repeated several times on one infant because of the difficulty of obtaining accurate measurements in infants, and that the additional testing sparked by the BP screen also likely created unnecessary anxiety for families.

The Meriter Hospital health information department compiled the data for the analysis. The authors reported no relevant financial conflicts.

MADISON, WIS.  – Cyclic parenteral nutrition may be a viable option in very low birth weight infants requiring parenteral nutrition for several weeks, results of a prospective, randomized trial suggest.

Among 114 neonates weighing no more than 1,500 g, the incidence of cholestasis was nearly double at 24% with continuous parenteral nutrition versus 12.5% with cyclic parenteral nutrition.

Although this did not reach statistical significance at a P value of 0.109, there was a downward trend in direct bilirubin beginning in week 7 favoring cyclic parenteral nutrition that was statistically significant by week 8 (1.4 mg/dL vs. 3.2 mg/dL, P = .042), Dr. Maliha Shareef and her colleagues reported at the annual meeting of the Midwest Society for Pediatric Research.

"While feeding advancement regimens may vary in NICUs, this study indicates cyclic parenteral nutrition as an important option when parenteral nutrition is required for extended periods of time," the authors concluded.

Parenteral nutrition-associated cholestasis can develop in up to 35% of premature infants by 1 month of age and be as high as 67% by 3 months of age. The mortality rate is 3%-14% overall, and even higher in infants with short bowel syndrome.

Cyclic parenteral nutrition (PN) has been shown to be effective in reducing cholestasis in children and adults, but minimal data exist on its use and effects in very low birth weight (VLBW) infants, due primarily to concerns for the risk of hypoglycemia.

Theoretically, cyclic PN is thought to prevent PN-induced fatty infiltration of the liver, decrease hyperinsulinemia seen with continuous infusion of dextrose, prevent lipogenesis, and possibly reduce the respiratory quotient, noted Dr. Shareef, an associate professor of pediatrics and neonatology at Loyola University Chicago, Maywood, Ill.

The researchers enrolled 114 infants weighing no more than 1,500 g at birth, who were hemodynamically and metabolically stable and needed PN for more than 1 week. Their median gestational age was 28 weeks. Median birth weight was 1,000 g in the continuous group and 1,050 g in the cyclic group.

All infants were started on continuous total PN and then were evenly randomized beginning on day 7 to continuous PN or 20 hours of total PN and 4 hours of D10 intravenous solution with sodium, potassium, and calcium to provide the glucose infusion rate (GIR) that is within 30% of GIR in total PN. Serum glucose was checked the first 3 days at 30 and 60 minutes off total PN and 30 minutes before restarting total PN. Weekly liver and basic metabolic panels were also obtained.

Hypoglycemia, defined as a serum glucose level less than 40 mg/dL, did not occur in the cyclic group, Dr. Shareef reported in a poster.

Gastrointestinal complications were observed in eight infants in the continuous PN group and seven in the cyclic group, and gram-negative rod infections in six and eight infants, respectively.

The average number of days on total PN was 31.5 in the continuous group and 29 in the cyclic group.

"Cyclic total PN is tolerated in lower birth weight neonates when glucose infusion rate is supported during off hours," the authors wrote. "Further study is needed to determine when cyclic PN should be initiated."

Dr. Shareef and her associates reported no relevant financial disclosures.

MADISON, WIS.  – Cyclic parenteral nutrition may be a viable option in very low birth weight infants requiring parenteral nutrition for several weeks, results of a prospective, randomized trial suggest.

Among 114 neonates weighing no more than 1,500 g, the incidence of cholestasis was nearly double at 24% with continuous parenteral nutrition versus 12.5% with cyclic parenteral nutrition.

Although this did not reach statistical significance at a P value of 0.109, there was a downward trend in direct bilirubin beginning in week 7 favoring cyclic parenteral nutrition that was statistically significant by week 8 (1.4 mg/dL vs. 3.2 mg/dL, P = .042), Dr. Maliha Shareef and her colleagues reported at the annual meeting of the Midwest Society for Pediatric Research.

"While feeding advancement regimens may vary in NICUs, this study indicates cyclic parenteral nutrition as an important option when parenteral nutrition is required for extended periods of time," the authors concluded.

Parenteral nutrition-associated cholestasis can develop in up to 35% of premature infants by 1 month of age and be as high as 67% by 3 months of age. The mortality rate is 3%-14% overall, and even higher in infants with short bowel syndrome.

Cyclic parenteral nutrition (PN) has been shown to be effective in reducing cholestasis in children and adults, but minimal data exist on its use and effects in very low birth weight (VLBW) infants, due primarily to concerns for the risk of hypoglycemia.

Theoretically, cyclic PN is thought to prevent PN-induced fatty infiltration of the liver, decrease hyperinsulinemia seen with continuous infusion of dextrose, prevent lipogenesis, and possibly reduce the respiratory quotient, noted Dr. Shareef, an associate professor of pediatrics and neonatology at Loyola University Chicago, Maywood, Ill.

The researchers enrolled 114 infants weighing no more than 1,500 g at birth, who were hemodynamically and metabolically stable and needed PN for more than 1 week. Their median gestational age was 28 weeks. Median birth weight was 1,000 g in the continuous group and 1,050 g in the cyclic group.

All infants were started on continuous total PN and then were evenly randomized beginning on day 7 to continuous PN or 20 hours of total PN and 4 hours of D10 intravenous solution with sodium, potassium, and calcium to provide the glucose infusion rate (GIR) that is within 30% of GIR in total PN. Serum glucose was checked the first 3 days at 30 and 60 minutes off total PN and 30 minutes before restarting total PN. Weekly liver and basic metabolic panels were also obtained.

Hypoglycemia, defined as a serum glucose level less than 40 mg/dL, did not occur in the cyclic group, Dr. Shareef reported in a poster.

Gastrointestinal complications were observed in eight infants in the continuous PN group and seven in the cyclic group, and gram-negative rod infections in six and eight infants, respectively.

The average number of days on total PN was 31.5 in the continuous group and 29 in the cyclic group.

"Cyclic total PN is tolerated in lower birth weight neonates when glucose infusion rate is supported during off hours," the authors wrote. "Further study is needed to determine when cyclic PN should be initiated."

Dr. Shareef and her associates reported no relevant financial disclosures.

MADISON, WIS.  – Cyclic parenteral nutrition may be a viable option in very low birth weight infants requiring parenteral nutrition for several weeks, results of a prospective, randomized trial suggest.

Among 114 neonates weighing no more than 1,500 g, the incidence of cholestasis was nearly double at 24% with continuous parenteral nutrition versus 12.5% with cyclic parenteral nutrition.

Although this did not reach statistical significance at a P value of 0.109, there was a downward trend in direct bilirubin beginning in week 7 favoring cyclic parenteral nutrition that was statistically significant by week 8 (1.4 mg/dL vs. 3.2 mg/dL, P = .042), Dr. Maliha Shareef and her colleagues reported at the annual meeting of the Midwest Society for Pediatric Research.

"While feeding advancement regimens may vary in NICUs, this study indicates cyclic parenteral nutrition as an important option when parenteral nutrition is required for extended periods of time," the authors concluded.

Parenteral nutrition-associated cholestasis can develop in up to 35% of premature infants by 1 month of age and be as high as 67% by 3 months of age. The mortality rate is 3%-14% overall, and even higher in infants with short bowel syndrome.

Cyclic parenteral nutrition (PN) has been shown to be effective in reducing cholestasis in children and adults, but minimal data exist on its use and effects in very low birth weight (VLBW) infants, due primarily to concerns for the risk of hypoglycemia.

Theoretically, cyclic PN is thought to prevent PN-induced fatty infiltration of the liver, decrease hyperinsulinemia seen with continuous infusion of dextrose, prevent lipogenesis, and possibly reduce the respiratory quotient, noted Dr. Shareef, an associate professor of pediatrics and neonatology at Loyola University Chicago, Maywood, Ill.

The researchers enrolled 114 infants weighing no more than 1,500 g at birth, who were hemodynamically and metabolically stable and needed PN for more than 1 week. Their median gestational age was 28 weeks. Median birth weight was 1,000 g in the continuous group and 1,050 g in the cyclic group.

All infants were started on continuous total PN and then were evenly randomized beginning on day 7 to continuous PN or 20 hours of total PN and 4 hours of D10 intravenous solution with sodium, potassium, and calcium to provide the glucose infusion rate (GIR) that is within 30% of GIR in total PN. Serum glucose was checked the first 3 days at 30 and 60 minutes off total PN and 30 minutes before restarting total PN. Weekly liver and basic metabolic panels were also obtained.

Hypoglycemia, defined as a serum glucose level less than 40 mg/dL, did not occur in the cyclic group, Dr. Shareef reported in a poster.

Gastrointestinal complications were observed in eight infants in the continuous PN group and seven in the cyclic group, and gram-negative rod infections in six and eight infants, respectively.

The average number of days on total PN was 31.5 in the continuous group and 29 in the cyclic group.

"Cyclic total PN is tolerated in lower birth weight neonates when glucose infusion rate is supported during off hours," the authors wrote. "Further study is needed to determine when cyclic PN should be initiated."

Dr. Shareef and her associates reported no relevant financial disclosures.