Marcelo Eller Miranda

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.

Use of a plastic hemoderivative bag in the treatment of gastroschisis

Abstract The authors report their experience with the use of a polyvinyl chloride (PVC) bag for blood-derivative transfer as a prosthesis for the creation of a silo for surgical treatment of gastroschisis (GS) in seven newborn infants. The bag is sterile, impermeable to micro-organisms, transparent, flexible, resistant, internally smooth, does not adhere to the bowel loops, readily available, and inexpensive, properties that make it an excellent alternative as a prosthesis for staged surgical treatment of congenital anomalies of the abdominal wall such as GS and omphalocele. The importance of a multidisciplinary team for the care of newborns with GS is also emphasized for a good postoperative outcome.

Omphalocele: how big does it have to be a giant one?

We read with great interest the recent article by Kumar et al [1] showing the significant differences in the frequency of associated anomalies between small and large omphaloceles. Children were divided in 2 groups, depending on the size of the abdominal wall opening: small (≤4 cm) or large omphaloceles (N4 cm). As the authors emphasized, determination of the omphaloceles size was based on a nonstandardized method of measurement made by initial physical examination and/or at operation. Defining minor and major omphaloceles based on a single measurement is controversial for several reasons. Varying defect size has been randomly employed to characterize minor and major omphaloceles. Minor omphaloceles have been defined as those smaller than 3 cm [2], 4 cm [3], or 5 cm [4-6]. Major omphaloceles have been characterized as those larger than 5 cm [4-11], 6 cm [2,12-17], or 8 cm [18]. Although most authors measured the diameter of the abdominal wall opening [1,2,5-8,11,12,16], others referred to the diameter of the omphalocele sac [4], and some did not specify what was being measured [9,10]. Measuring only the diameter of the abdominal wall defect is inadequate because we know that a large volume of viscera may leave the peritoneal cavity through a narrow opening [19] (Fig. 1). Measuring only the diameter of the omphalocele sac is also inaccurate because this size can changes in different states (if the infant is awake or sleeping, crying, or under general anesthesia). To determine if an omphalocele is amenable or not to primary closure, the degree of peritoneal cavity hypoplasia (ie, size of the peritoneal cavity) is as important as the diameters of the abdominal wall opening and of the omphalocele sac. Computed tomography was used in 1 infant [17] and 1 older child [16] to show relative volumes of the omphalocele sac and the peritoneal cavity in an attempt to estimate the degree of visceroabdominal disproportion. However, the benefit of exposing every newborn with an omphalocele to an abdominal computed tomographic scan is uncertain. Some authors also have used the presence of liver inside the omphalocele sac as a parameter to characterize the anomaly as a large one [6,7,9-11,14,16]. This concept lacks specificity because the volume of eviscerated organs (not only the liver) is actually a consequence of peritoneal cavity hypoplasia. In a study by Stringel and Filler [2], the presence of liver inside the omphalocele sac did not impact mortality. For all the reasons listed above, we suggest that the presence of a single organ or the use of a single measurement to differentiate small from large omphaloceles should be avoided. Clinical judgment of the pediatric surgeon is sufficient to estimate the degree of visceroabdominal disproportion and to classify an omphalocele as a minor defect (amenable to primary closure) or major defect (not amenable to primary closure), thus simplifying concepts and management. www.elsevier.com/locate/jpedsurg

Percutaneous central venous catheterization through the external jugular vein in children: is inserting the guide wire into the superior vena cava essential for successful catheterization?

BACKGROUND/PURPOSE The external jugular vein (EJV) is an attractive alternative for percutaneous central venous catheterization (PCVC), with fewer complications. The inability to pass the guide wire into the superior vena cava (SVC) is, however, a major reason for the failure of this approach. The authors report a modification of the Seldinger technique to increase the effectiveness of this procedure in children. METHODS Between May 2008 and June 2009, we performed 100 PCVCs consecutively in children using the Seldinger technique through the EJV (Step 1). In cases in which the guide wire could not be passed into the SVC, the guide wire was kept in the EJV; and only the catheter was introduced into the central venous position (Step 2). Differences between the standard and modified Seldinger techniques were analyzed. RESULTS The procedure with the standard Seldinger technique (Step 1) was successful in 13 (13%) out of 100 patients. In 84 (96.5%) of the 87 remaining patients, PCVC was achieved with the modified Seldinger technique, without the insertion of the guide wire until the SVC (Step 2). Altogether, 97 catheters (97%) were successfully inserted, with 85 (87.6%) correctly positioned in the SVC. In addition, there were 7 (7%) clinically irrelevant hematomas during catheterization. CONCLUSIONS The EJV is an excellent alternative anatomical location for the completion of PCVC in children. Placing the guide wire in a central position is not essential to the success rate of this approach. The proposed modified Seldinger technique allowed PCVC to be performed through the EJV safely and with a high success rate in children and adolescents.

Association of posterior urethral valve with congenital lobar emphysema: A case report

Posterior Urethral Valve (PUV) is the most common cause of bladder outlet obstruction in boys, with an incidence of 1 in 5,000 to 8,000 male births. Congenital lobar emphysema (CLE) is an uncommon cause of congenital pulmonary airway malformation, with an incidence 1 per 20,000 to 30,000 deliveries. These congenital malformations have never been described together before. A boy newborn with prenatal suspicion of PUV, confirmed in first days of live presented respiratory distress that lead CLE diagnosis. Our multidisciplinary team submitted him to a twostep surgery correction successfully.

Metástases pulmonares em crianças: estamos operando desnecessariamente?

OBJECTIVE to determine, in pediatric patients with malignant neoplasms, the characteristics of pulmonary nodules identified on computed tomography, as well as the possibility of differentiating benign lesions from metastases. METHODS we conducted a retrospective study of patients submitted to pulmonary resections of nodules diagnosed as metastases in a period of seven years. We compared computed tomography and surgery findings, as well as results of anatomopathological examinations. RESULTS we studied nine patients submitted to 11 surgical interventions. Among the studied variables, only nodule size greater than 12.5mm proved to be statistically significant to predict malignancy. CONCLUSION among the tomographic characteristics of pulmonary nodules in children with malignant neoplasms, only the size of the lesion was a predictor of malignancy.

Bladder perforation by ventriculoperitoneal shunt

BackgroundBladder perforation by ventriculoperitoneal shunt is a rare complication that has been describe in 19 cases in prior literature.Case descriptionThis work describes the case of a 4-month-old baby who presented with extrusion of the distal catheter through the urethra. The patient underwent a laparotomy; the catheter was cut close to the bladder wall and repositioned into the peritoneal cavity. The bladder wall was sutured, and the remaining distal portion of the catheter was removed through the urethra.Discussion and conclusionBased on this single experience and a literature review, the authors classified the clinical signs and symptoms of bladder perforation by the ventriculoperitoneal shunt catheter. Finally, the authors propose a more conservative approach for this rare complication.