Michael Zayek

Acquired Left-Sided Pulmonary Vein Stenosis in an Extremely Premature Infant: A New Entity?

t c F p p p a ( large patent ductus arteriosus (PDA) was surgically ligated in a 22-week preterm infant after failed attempts at pharmacological closure with ibuprofen. The results of multile echocardiograms performed early were negative for other cardiac bnormalities. By 3 months of age, the child was off all respiratory upport. At 6 months, he had a respiratory deterioration requiring e-intubation and mechanical ventilation. With echocardiography, evere pulmonary hypertension and left lower pulmonary vein steosis were demonstrated. Inhaled nitric oxide (iNO) and sildenafil herapy was initiated. Although the child was extubated in 3 days, e had continued pulmonary hypertension for the next 16 months, equiring near continuous nasal cannula iNO therapy. During his ospital stay, a pulmonary perfusion scan was performed, which emonstrated decreased perfusion of the left lung (Figure 1). At 23 onths, the child had an acute respiratory decompensation and ied. At autopsy, stenosis of the left lower pulmonary vein was onfirmed (Figure 2A). Histological sectioning at the stenotic site howed narrowing of the pulmonary vein lumen and medial thickning (Figure 2B). Acquired pulmonary vein stenosis resulted in late onset pulonary hypertension in this child. Although pulmonary vein steosis after cardiovascular surgery in children is described, less is now about acquired pulmonary vein stenosis in extremely premaure infants. The long-term prognosis for children with acquired ulmonary vein stenosis is poor, with most having relentless proression of pulmonary hypertension. The unilateral left-sided steosis in our patient is intriguing. In preterm infants with a hemoynamically significant PDA such as this patient, left-to-right shunt ow may preferentially stream into the left pulmonary artery, thus ncreasing blood flow through the left pulmonary veins. This uniigure 1. Quantitative radionucleotide lung perfusion scan shows ecreased perfusion of the left lung.

Pleural effusion as a complication of a remotely placed catheter in a preterm infant

CASE PRESENTATION A newborn female infant, born at 29 weeks of gestation, was delivered via caesarian section for fetal heart rate decelerations and suspected chorioamnionitis. She weighed 1460 g. Her mother was a 39-year-old African American who recently had 17% total body burn. She was being treated with vancomycin and ceftriaxone. The mother’s prenatal labs were within normal limits. Infant’s Apgar scores were 7 and 9 at 1 and 5 min after birth, respectively. She subsequently developed an increase in work of breathing that required the use of nasal continuous positive airway pressure (NCPAP). Antibiotics (ampicillin and ceftazidime) were started on admission. The infant was intubated at 10 h of life and was given surfactant for respiratory distress syndrome. An umbilical arterial catheter (UAC) was placed for blood sampling, blood pressure monitoring, and infusion of total parenteral nutrition (TPN). Placement of an umbilical venous catheter was not attempted. At 22 h of age, the infant was extubated and placed back on NCPAP with an oxygen concentration of 21%. On day of life (DOL) 3, the UAC was removed and a peripherally inserted central catheter (PICC) was placed (Figure 1a) in order to continue TPN while progressively increasing her enteral nutrition. On DOL 6, she developed a sudden increase in work of breathing and a rise in oxygen requirement, up to 71%. The infant was reintubated. A plain X-ray image of the chest and abdomen revealed a large right pleural effusion with midline shift (Figure 1b). In addition, when compared to the last X-ray film obtained at the time of the placement of the PICC (DOL3), it was found that the catheter’s tip had migrated from the right external iliac vein to a location at the level of the 12th thoracic vertebrae (T12). A thoracocentesis was performed. Cytopathological analysis of the pleural fluid revealed 22 nucleated cells per ml (22 10 cells per l; mesothelial cells 32% (0.32), neutrophils 29% (0.29), lymphocytes 22% (0.22) and macrophages 17% (0.17)) and 2690 red blood cells per ml (2.7 10 cells per l). Chemical analysis revealed pleural fluid levels of glucose at 704 mg dl 1 (39.1 mmol l ), lactate dehydrogenase (LDH) at 21U l 1 (0.35 mkat l ), protein at o2 g dl 1 (o20 g l ) and triglycerides at 27 mg dl 1 (0.3 mmol l ). Blood glucose levels remained in the

Reducing antibiotic utilization rate in preterm infants: a quality improvement initiative

BackgroundJudicious use of antibiotic therapy in preterm infants is necessary as prolonged and unwarranted use of antibiotics have been associated with adverse short-term and long-term outcomes.Local problemOur baseline data review revealed overuse and unnecessary prolonged antibiotic exposure among preterm infants despite a low suspicion for sepsis.Methods and interventionsThe baseline overall AUR was calculated retrospectively from our pharmacy database for a period of 4 months prior to the quality improvement (QI) initiative (pre-QI phase). The principal QI intervention included the development and implementation of guidance algorithms for evaluation and management of suspected sepsis incorporating key QI measures, such as an emphasis on early discontinuation of antibiotics by 36 h if blood culture remained negative and the introduction of multiplex polymerase chain reaction assay for early identification of causative organisms. This QI initiative was implemented through multiple Plan-Do-Study-Act cycles, starting in February 2016 (QI phase), with an objective to achieve a 10% reduction in the baseline overall AUR by December 2016, in preterm infants with gestational ages between 250/7 and 336/7 weeks. Data for the QI phase of the study were collected prospectively.ResultThe overall AUR (outcome measure) decreased from 154.8 to 138.4 days of treatment per 1000 hospital days (10.6% decrease, p < 0.05) over the 11-month period. However, the overall rate of adherence to guidance algorithm (process measure) remained below the target goal of 90%.ConclusionThis multiphase QI initiative was able to reduce the overall AUR at our NICU. The beneficial impact of this decrease in AUR in preterm infants remains to be determined.

Infantile Hepatic Hemangioendothelioma: An Uncommon Cause of Persistent Pulmonary Hypertension in a Newborn Infant

Multifocal and diffuse infantile hepatic hemangioendotheliomas commonly present with signs of high-output congestive heart failure. In addition, prolonged persistent pulmonary overcirculation eventually leads to the development of pulmonary hypertension at a later age. We report a 2-day old, full-term infant with multifocal, large infantile hepatic hemangioendothelioma, who presented with an early onset of pulmonary hypertension, managed successfully with supportive care and systemic therapy directed toward the involution of infantile hepatic hemangioendothelioma.

EFFECT OF INHALED NITRIC OXIDE (NO) AND pH ON PULMONARY VASCULAR RESISTANCE(PVR) IN THROMBOXANE INDUCED PULMONARY HYPERTENSION. 1974

EFFECT OF INHALED NITRIC OXIDE (NO) AND pH ON PULMONARY VASCULAR RESISTANCE(PVR) IN THROMBOXANE INDUCED PULMONARY HYPERTENSION. 1974