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A study of venous pressure in the newborn infant
A STUDY OF VENOUS PRESSURE RICHARD
P.
NEW
IN THE NEWBORN INFANT
PARKINSON, ORLEANS~
~W.D. ~
LA.
m e a s u r e m e n t of venous pressure. A r u b b e r tube leading to a glass adapter, which holds the h y p o d e r m i c needle, also c o m m u n i c a t e s with a small pressure c h a m b e r in which the p r e s s u r e can be v a r i e d b y t u r n i n g a screw. W h e n the pressure in the c h a m b e r is reduced, a small a m o u n t of aqueous solution-of sodium citrate is d r a w n up into the needle to f o r m a meniscus in a glass adapter. W i t h insertion of the needle into the vein, the p r e s s u r e causes blood to enter the needle and move the meniscus f a r t h e r along the glass a d a p t e r . The pressure in the c h a m b e r is increased until the meniscus assumes the original position; the venous p r e s s u r e is then r e g i s t e r e d on the column of water. 2
A
S T U D Y of the l i t e r a t u r e fails to reveal a n y r e p o r t of venous pressure m e a s u r e m e n t s in the n o r m a l n e w b o r n i n f a n t within the first few minutes of life. Because such d a t a would p r o v e interesting and useful, the p r e s e n t s t u d y was u n d e r t a k e n . Numerous technical difficulties were e n c o u n t e r e d e a r l y in the study. A n a t t e m p t was m a d e initially to measure the pressure in the veins of the hand, i n t e r n a l j u g u l a r vein, a n d a n t e c u b i t a l space, but difficulty in i n t r o d u c i n g t h e needle into these sites m a d e t h e m unsatisfactory. The umbilical vein was t h e n considered because of its accessibility, but the v a l i d i t y of the readings was questioned because of f u n c t i o n a l closure of this channel. I t is b e l i e v e d , however, t h a t this channel remains p a t e n t for t h r e e d a y s p o s t n a t a l l y and t h a t as long as a p o s i t i v e pressure can be r e c o r d e d in the veins, it is a t r u e reflection of the pressure in the r i g h t side of the heart. 1
Procedure.--Measurements with the p h l e b o m a n o m e t e r were made in the delivery rooms of the C h a r i t y Hospitals at N e w Orleans and I n d e p e n d ence, Louisiana, d u r i n g t h e m o n t h s of J a n u a r y and F e b r u a r y , 1955. A f t e r the i n f a n t was delivered, the c o r d was c l a m p e d a n d cut, the i n f a n t was placed on his b a c k on the table to eliminate g r a v i t a t i o n a l effects, and the needle was inserted into the umbilical vein at a distance of 10 era. f r o m the umbilicus. Correction for position was made b y a d j u s t i n g the site v e r t i c a l l y to the level of the r i g h t auricle, a n d the venous pressure was t h e n recorded.
YCIETHOD
Instruments.--Both the Burch-Winsor p h l e b o m a n o m e t e r 2 and the MortizT a b o r a m a n o m e t e r were used in this study. The p h l e b o m a n o m e t e r is an e x t r e m e l y sensitive i n s t r u m e n t for T h i s w o r k w a s d o n e in f u l f i l l m e n t o f t h e requirement for a Senior Thesis by the Department of M e d i c i n e , Tulane University S c h o o l of M e d i c i n e , N e w O r l e a n s , L a . * A t p r e s e n t , r e s i d e n t p h y s i c i a n in G e n e r a l P r a c t i c e , S u t t e r C o u n t y I~Iospital, Y u b a C i t y , Calif.
174
PARKINSON:
STUDY
OF V E N O U S P R E S S U R E
A n a t t e m p t was made to measure Lhe venous pressure within the first few seconds of life, when the i n f a n t was not cold, crying, or kicking, since these factors obviously increase venous pressure significantly. Sixteen of the seventeen measurements in this series were recorded within the first sixty to two h u n d r e d f o r t y seconds after delivery; the last was made b y passing a polyethylene tube into the umbilieaI vein of an i n f a n t in the fifth hour of life. TABLE
I.
VENOUS
PI%ESSUI%E IN UMBILICAL
VENOUSPRESSURE ( 1Vs1V[.It20)
CASENO. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 M e a n o f 14 m e a s u r e ments taken under standard conditions
80 80 80 85 85 85 88 94 80 80 90 140 180 80 120 98 80 85
RESULTS
Results are summarized in Table I. I n this series of seventeen determinations, venous pressure varied from 80 to 180 ram. H20. The measurements obtained on warm, still infants, with no disturbances, v a r i e d f r o m 80 to 98 ram. H20 (mean 85 mm. H20).* I n the last measurement, obtained at 5 hours of life, the polyethylene tube * U s i n g tiffs t e c h n i q u e , D r . A. R. S i n g l e ton, of the Independent Obstetrics Service, Charity Hospital, New Orleans, obtained one m e a s u r e m e n t o f 86 rnrn. I t 2 0 u n d e r s t a n d a r d c o n d i t i o n s in a n i n f a n t n o t i n c l u d e d in t h i s series.
IN NEWBORN
175
was passed with ease at a distance of 6.5 cm. f r o m the umbilicus, the r i g h t side of the heart being used as a base, and the height of the column of blood was measured at 80 ram. It20. I t was noted d u r i n g the s t u d y that when the obstetrician stripped the vein, the pressure was increased over the average for the series. No undesicable effects were observed in any of the infants studied in these experiments. W h e n the i n f a n t was still and no other disturbances existed, the phleVEIN
OF I~OICMAL
~ERVAL F R O ~ CLANIPING OFCORD ( SEC.) 60 60 60 60 60 60 60 60 60-90 60-120 60-120 90-120 90-120 120-180 120-180 180-240 18,000
IN~EWBOI%N INFANT
DISTVRRANCES DURING I'r ENT
Infant crying Cord stripped
b o m a n o m e t e r was b y f a r the more suitable i n s t r u m e n t for this purpose. I n the presence of such disturbing factors and consequent fluctuation in the readings, however, the MortizTabora m a n o m e t e r p r o v e d more sarisfactory. The p h l e b o m a n o m e t e r offered the a d v a n t a g e of convenience and facility of manipulation, whereas the Mortiz-Tabora m a n o m e t e r necessitated sterilization of the instrument for each determination. ]factors that m a y have influeneed these measurements include the use
176
THE JOURNAL OF PEDIATRICS
of drugs, such as vasopressor agents. These were not studied in the present series but should be investigated. SUMMARY AND CONCLI~SIONS
A s t u d y of the venous pressure in the n e w b o r n i n f a n t was carried out within the first few minutes of life. D e t e r m i n a t i o n s were m a d e in the umbilical vein at a distance of a b o u t 10 cm. f r o m the umbilicus w i t h the inf a n t in the reclining position, the site being a d j u s t e d to the level of the r i g h t side of the heart. The m e a n venous p r e s s u r e for f o u r t e e n determinations obtained u n d e r s t a n d a r d conditions w a s 85 ram, H20. It seems i m p o r t a n t that d e t e r m i n a tions be m a d e (1) within the first few
minutes of life, before functional closure of the channel occurs and (2) w h e n conditions are s t a n d a r d , i.e., w h e n the i n f a n t is not cold, crying, or contracting. On two occasions it was noted t h a t s t r i p p i n g the cord increased the readings significantly. No u n t o w a r d effects f r o m this p r o c e d u r e were noted in this study. I wish to acknowledge the valuable guidance and assistance of Dr. G. E. Burch in the conduct of these experiments. REFERENCES ]. Dent, J o h n It.: Personal communication. 2. Butch, G. E., and Winsor, T.: The Phlebomanometer: a New Apparatus for Direct Measurement of Venous Pressure in L a r g e and Small Veins, J. A. M. A. 123: 91, 1943.
A b o u t the year 1785, the Scarlet-Feverj w i t h s.ore-throat: appeared among the children at Detrolt~ and swept off, in this littIe place, upwards of sixty children, and even ~ f e w grown persons, in t h e term of a f e w weeks. Our Indian. congregation, then living in the neighbourhood, though they frequently visited this place, never took the disorder. A persou .at Detroit then remarked to me) t h a t this disease did not affect the children of French-Canadians as much as it did 'those of Europeans. However, a disorder called the tIooping-Cough, attended, at length, w i t h a sore-throat, I have l~nown to prove destructive to the I n d i a n children, in t h e i r settlements. --PHILADELPI-IIA ~/[EDICAL • PHYSICAL JOURNAL, 1804.
P.
NEW
IN THE NEWBORN INFANT
PARKINSON, ORLEANS~
~W.D. ~
LA.
m e a s u r e m e n t of venous pressure. A r u b b e r tube leading to a glass adapter, which holds the h y p o d e r m i c needle, also c o m m u n i c a t e s with a small pressure c h a m b e r in which the p r e s s u r e can be v a r i e d b y t u r n i n g a screw. W h e n the pressure in the c h a m b e r is reduced, a small a m o u n t of aqueous solution-of sodium citrate is d r a w n up into the needle to f o r m a meniscus in a glass adapter. W i t h insertion of the needle into the vein, the p r e s s u r e causes blood to enter the needle and move the meniscus f a r t h e r along the glass a d a p t e r . The pressure in the c h a m b e r is increased until the meniscus assumes the original position; the venous p r e s s u r e is then r e g i s t e r e d on the column of water. 2
A
S T U D Y of the l i t e r a t u r e fails to reveal a n y r e p o r t of venous pressure m e a s u r e m e n t s in the n o r m a l n e w b o r n i n f a n t within the first few minutes of life. Because such d a t a would p r o v e interesting and useful, the p r e s e n t s t u d y was u n d e r t a k e n . Numerous technical difficulties were e n c o u n t e r e d e a r l y in the study. A n a t t e m p t was m a d e initially to measure the pressure in the veins of the hand, i n t e r n a l j u g u l a r vein, a n d a n t e c u b i t a l space, but difficulty in i n t r o d u c i n g t h e needle into these sites m a d e t h e m unsatisfactory. The umbilical vein was t h e n considered because of its accessibility, but the v a l i d i t y of the readings was questioned because of f u n c t i o n a l closure of this channel. I t is b e l i e v e d , however, t h a t this channel remains p a t e n t for t h r e e d a y s p o s t n a t a l l y and t h a t as long as a p o s i t i v e pressure can be r e c o r d e d in the veins, it is a t r u e reflection of the pressure in the r i g h t side of the heart. 1
Procedure.--Measurements with the p h l e b o m a n o m e t e r were made in the delivery rooms of the C h a r i t y Hospitals at N e w Orleans and I n d e p e n d ence, Louisiana, d u r i n g t h e m o n t h s of J a n u a r y and F e b r u a r y , 1955. A f t e r the i n f a n t was delivered, the c o r d was c l a m p e d a n d cut, the i n f a n t was placed on his b a c k on the table to eliminate g r a v i t a t i o n a l effects, and the needle was inserted into the umbilical vein at a distance of 10 era. f r o m the umbilicus. Correction for position was made b y a d j u s t i n g the site v e r t i c a l l y to the level of the r i g h t auricle, a n d the venous pressure was t h e n recorded.
YCIETHOD
Instruments.--Both the Burch-Winsor p h l e b o m a n o m e t e r 2 and the MortizT a b o r a m a n o m e t e r were used in this study. The p h l e b o m a n o m e t e r is an e x t r e m e l y sensitive i n s t r u m e n t for T h i s w o r k w a s d o n e in f u l f i l l m e n t o f t h e requirement for a Senior Thesis by the Department of M e d i c i n e , Tulane University S c h o o l of M e d i c i n e , N e w O r l e a n s , L a . * A t p r e s e n t , r e s i d e n t p h y s i c i a n in G e n e r a l P r a c t i c e , S u t t e r C o u n t y I~Iospital, Y u b a C i t y , Calif.
174
PARKINSON:
STUDY
OF V E N O U S P R E S S U R E
A n a t t e m p t was made to measure Lhe venous pressure within the first few seconds of life, when the i n f a n t was not cold, crying, or kicking, since these factors obviously increase venous pressure significantly. Sixteen of the seventeen measurements in this series were recorded within the first sixty to two h u n d r e d f o r t y seconds after delivery; the last was made b y passing a polyethylene tube into the umbilieaI vein of an i n f a n t in the fifth hour of life. TABLE
I.
VENOUS
PI%ESSUI%E IN UMBILICAL
VENOUSPRESSURE ( 1Vs1V[.It20)
CASENO. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 M e a n o f 14 m e a s u r e ments taken under standard conditions
80 80 80 85 85 85 88 94 80 80 90 140 180 80 120 98 80 85
RESULTS
Results are summarized in Table I. I n this series of seventeen determinations, venous pressure varied from 80 to 180 ram. H20. The measurements obtained on warm, still infants, with no disturbances, v a r i e d f r o m 80 to 98 ram. H20 (mean 85 mm. H20).* I n the last measurement, obtained at 5 hours of life, the polyethylene tube * U s i n g tiffs t e c h n i q u e , D r . A. R. S i n g l e ton, of the Independent Obstetrics Service, Charity Hospital, New Orleans, obtained one m e a s u r e m e n t o f 86 rnrn. I t 2 0 u n d e r s t a n d a r d c o n d i t i o n s in a n i n f a n t n o t i n c l u d e d in t h i s series.
IN NEWBORN
175
was passed with ease at a distance of 6.5 cm. f r o m the umbilicus, the r i g h t side of the heart being used as a base, and the height of the column of blood was measured at 80 ram. It20. I t was noted d u r i n g the s t u d y that when the obstetrician stripped the vein, the pressure was increased over the average for the series. No undesicable effects were observed in any of the infants studied in these experiments. W h e n the i n f a n t was still and no other disturbances existed, the phleVEIN
OF I~OICMAL
~ERVAL F R O ~ CLANIPING OFCORD ( SEC.) 60 60 60 60 60 60 60 60 60-90 60-120 60-120 90-120 90-120 120-180 120-180 180-240 18,000
IN~EWBOI%N INFANT
DISTVRRANCES DURING I'r ENT
Infant crying Cord stripped
b o m a n o m e t e r was b y f a r the more suitable i n s t r u m e n t for this purpose. I n the presence of such disturbing factors and consequent fluctuation in the readings, however, the MortizTabora m a n o m e t e r p r o v e d more sarisfactory. The p h l e b o m a n o m e t e r offered the a d v a n t a g e of convenience and facility of manipulation, whereas the Mortiz-Tabora m a n o m e t e r necessitated sterilization of the instrument for each determination. ]factors that m a y have influeneed these measurements include the use
176
THE JOURNAL OF PEDIATRICS
of drugs, such as vasopressor agents. These were not studied in the present series but should be investigated. SUMMARY AND CONCLI~SIONS
A s t u d y of the venous pressure in the n e w b o r n i n f a n t was carried out within the first few minutes of life. D e t e r m i n a t i o n s were m a d e in the umbilical vein at a distance of a b o u t 10 cm. f r o m the umbilicus w i t h the inf a n t in the reclining position, the site being a d j u s t e d to the level of the r i g h t side of the heart. The m e a n venous p r e s s u r e for f o u r t e e n determinations obtained u n d e r s t a n d a r d conditions w a s 85 ram, H20. It seems i m p o r t a n t that d e t e r m i n a tions be m a d e (1) within the first few
minutes of life, before functional closure of the channel occurs and (2) w h e n conditions are s t a n d a r d , i.e., w h e n the i n f a n t is not cold, crying, or contracting. On two occasions it was noted t h a t s t r i p p i n g the cord increased the readings significantly. No u n t o w a r d effects f r o m this p r o c e d u r e were noted in this study. I wish to acknowledge the valuable guidance and assistance of Dr. G. E. Burch in the conduct of these experiments. REFERENCES ]. Dent, J o h n It.: Personal communication. 2. Butch, G. E., and Winsor, T.: The Phlebomanometer: a New Apparatus for Direct Measurement of Venous Pressure in L a r g e and Small Veins, J. A. M. A. 123: 91, 1943.
A b o u t the year 1785, the Scarlet-Feverj w i t h s.ore-throat: appeared among the children at Detrolt~ and swept off, in this littIe place, upwards of sixty children, and even ~ f e w grown persons, in t h e term of a f e w weeks. Our Indian. congregation, then living in the neighbourhood, though they frequently visited this place, never took the disorder. A persou .at Detroit then remarked to me) t h a t this disease did not affect the children of French-Canadians as much as it did 'those of Europeans. However, a disorder called the tIooping-Cough, attended, at length, w i t h a sore-throat, I have l~nown to prove destructive to the I n d i a n children, in t h e i r settlements. --PHILADELPI-IIA ~/[EDICAL • PHYSICAL JOURNAL, 1804.