- Email: [email protected]
Warning: New umbilical catheter
848
E d i t o r i a l correspondence
The lateral decubitus position has been applied successfully by us at two other institutions. In 4 years 18 premature patients were treated via this maneuver at the University of Washington Hospital in Seattle. After treatment with decubitus positioning for periods ranging from 7 to 25 days, there was complete resolution of PIE in 16 and one responded initially but had a late recurrence. Lobectomy was required in one infant with treatment failure. One patient initially responded to 3 days of positioning for right-sided PIE, but 1 week later developed left-sided PIE that was successfully treated with 3 days of positioning. Several other patients have been successfully treated via the lateral decubitus position at Mt. Zion Hospital and Medical Center in San Francisco. We also observed one patient there in whom PIE was initially treated with extubation. Thereafter, without further exposure to positive airway pressure, the PIE progressed, resulting in mediastinal shift, contralateral atelectasis, and respiratory failure, demonstrating the susceptibility of certain predisposed neonatal lungs to this pathologic process. We continue to believe that the lateral decubitus position appears to be a relatively benign, noninvasive therapeutic maneuver that should be attempted before more invasive methods are used to treat serious focal pulmonary interstitial emphysema. However, caution should be exercised and the patient closely monitored when it is used.
Ronatd S. Cohen, M.D. Department o f Pediatrics Mt. Zion Hospital & Medical Center San Francisco, CA 94115 David K. Stevenson, M.D. Department o f Pediatrics Stanford University Stanford. CA 94305 Allan N. Schwartz, M.D. C. Benjamin Graham, M.D. Departments o f Pediatrics and Radiology Children's Orthopedics Hospital and Medical Center Seattle, WA 98105
WARNING." New umbilical catheter To the Editor." Recently, the length markings on the standard polyvinyl catheter (Argyle, Sherwood Medical Industries, St. Louis) were c h a n g e d Previously labeled with black marks at 5.10. and 15 cm. the catheters are identical except for additional markings at 20 and 25 cm. The new packaging is virtually identical to the older style, and although the label does state the new marking locations, this change is not emphasized. Moreover, this packaging is removed prior to vcsscl cannalation, thus decreasing the likelihood of prompt recognition of the altered catheter markings. Both catheters are frequently stocked side by side during the transition. We have encountered five cases in three intensive care nurseries in 1 month in which residents and fellows, unaware of this change, have inserted the catheters, following the guidelines of Dunn, ~ 10 cm beyond the intended location. This mistake is easily understood if one assumes the final marking outside the infant's body is at 15
The Journal o f Pediatrics November 1984
cm when it is actually at 25 cm. Although the errors were immediately detected in all cases, the potential for d a m a g e is substantial. We have notified the manufacturer of our concerns and hope this letter can serve as a timely warning to pediatricians.
Douglas Richardson, M.D. Mervin Yoder, M.D. Endla Anday, M.D. Division o f Neonatology Hospital o f the University o f Pennsylvania and Children's Hospital o f Philadelphia Philadelphia, PA 19104 REFERENCE
1.
Dunn P: Localization of the umbilical catheter by postmortem measurement. Arch Dis Child 42:69, 1966.
Carnitine and neonatal lipid metabolism To the Editor. The conclusion of Orzali et al? that low carnitine plasma concentrations do not necessarily indicate a depletion of body carnitine and therefore are not associated with impaired lipid utilization is probably correct in the patients (primarily term infants) studied. However, it may not be true in premature infants. We recently found a 50% decrease in liver carnitine content in premature infants who had received carnitine-free total parenteral nutrition for longer than 10 days. Premature infants also had much lower carnitine tissue reserves on the first day of life compared with full-term infants. This suggests that the possible metabolic consequences of carnitine-free nutrition are gestational age related. Accordingly, we could demonstrate impaired fatty acid oxidation and ketogenesis resulting from carnitine deficiency only in infants of <34 weeks gestation? The design of Orzali's study m a y not give a final answer to the question whether carnitine is a rate-limiting factor in fatty acid utilization: Glucose simultaneously infused with Intralipid will depress fatty acid oxidation, as the authors pointed out. Moreover, the time span of carnitine administration (4 hours) m a y not be long enough to restore carnitine-depleted tissues even if unphysiologically high doses (200 m g / k g L-carnitine) are given. In our opinion, the most important question yet to be answered is not whether the utilization of Intralipid can be pharmacologicall3 influcnccd by k-carnitine but whether carnitine mu~t be considered an essential nutrient in a defined group of infants at risk for carnitine deficiency.
Eberhard Schmidt-Sommerfeld, M.D. Duna Penn, M,D. Zemrum ff~r KitMerheilkuade Justus-Liebig-Universitgzt 6300 Giessen, West Germany REFERENCES
1.
Orzali A, Maetzke G , Donzelli F, Rubaltelli FF: Effect of carnitine on lipid metabolism in the neonate. II. Carnitine addition to lil~id infusion during prolonged total parenteral nutrition. J PEDIATn 104:436, 1984.
E d i t o r i a l correspondence
The lateral decubitus position has been applied successfully by us at two other institutions. In 4 years 18 premature patients were treated via this maneuver at the University of Washington Hospital in Seattle. After treatment with decubitus positioning for periods ranging from 7 to 25 days, there was complete resolution of PIE in 16 and one responded initially but had a late recurrence. Lobectomy was required in one infant with treatment failure. One patient initially responded to 3 days of positioning for right-sided PIE, but 1 week later developed left-sided PIE that was successfully treated with 3 days of positioning. Several other patients have been successfully treated via the lateral decubitus position at Mt. Zion Hospital and Medical Center in San Francisco. We also observed one patient there in whom PIE was initially treated with extubation. Thereafter, without further exposure to positive airway pressure, the PIE progressed, resulting in mediastinal shift, contralateral atelectasis, and respiratory failure, demonstrating the susceptibility of certain predisposed neonatal lungs to this pathologic process. We continue to believe that the lateral decubitus position appears to be a relatively benign, noninvasive therapeutic maneuver that should be attempted before more invasive methods are used to treat serious focal pulmonary interstitial emphysema. However, caution should be exercised and the patient closely monitored when it is used.
Ronatd S. Cohen, M.D. Department o f Pediatrics Mt. Zion Hospital & Medical Center San Francisco, CA 94115 David K. Stevenson, M.D. Department o f Pediatrics Stanford University Stanford. CA 94305 Allan N. Schwartz, M.D. C. Benjamin Graham, M.D. Departments o f Pediatrics and Radiology Children's Orthopedics Hospital and Medical Center Seattle, WA 98105
WARNING." New umbilical catheter To the Editor." Recently, the length markings on the standard polyvinyl catheter (Argyle, Sherwood Medical Industries, St. Louis) were c h a n g e d Previously labeled with black marks at 5.10. and 15 cm. the catheters are identical except for additional markings at 20 and 25 cm. The new packaging is virtually identical to the older style, and although the label does state the new marking locations, this change is not emphasized. Moreover, this packaging is removed prior to vcsscl cannalation, thus decreasing the likelihood of prompt recognition of the altered catheter markings. Both catheters are frequently stocked side by side during the transition. We have encountered five cases in three intensive care nurseries in 1 month in which residents and fellows, unaware of this change, have inserted the catheters, following the guidelines of Dunn, ~ 10 cm beyond the intended location. This mistake is easily understood if one assumes the final marking outside the infant's body is at 15
The Journal o f Pediatrics November 1984
cm when it is actually at 25 cm. Although the errors were immediately detected in all cases, the potential for d a m a g e is substantial. We have notified the manufacturer of our concerns and hope this letter can serve as a timely warning to pediatricians.
Douglas Richardson, M.D. Mervin Yoder, M.D. Endla Anday, M.D. Division o f Neonatology Hospital o f the University o f Pennsylvania and Children's Hospital o f Philadelphia Philadelphia, PA 19104 REFERENCE
1.
Dunn P: Localization of the umbilical catheter by postmortem measurement. Arch Dis Child 42:69, 1966.
Carnitine and neonatal lipid metabolism To the Editor. The conclusion of Orzali et al? that low carnitine plasma concentrations do not necessarily indicate a depletion of body carnitine and therefore are not associated with impaired lipid utilization is probably correct in the patients (primarily term infants) studied. However, it may not be true in premature infants. We recently found a 50% decrease in liver carnitine content in premature infants who had received carnitine-free total parenteral nutrition for longer than 10 days. Premature infants also had much lower carnitine tissue reserves on the first day of life compared with full-term infants. This suggests that the possible metabolic consequences of carnitine-free nutrition are gestational age related. Accordingly, we could demonstrate impaired fatty acid oxidation and ketogenesis resulting from carnitine deficiency only in infants of <34 weeks gestation? The design of Orzali's study m a y not give a final answer to the question whether carnitine is a rate-limiting factor in fatty acid utilization: Glucose simultaneously infused with Intralipid will depress fatty acid oxidation, as the authors pointed out. Moreover, the time span of carnitine administration (4 hours) m a y not be long enough to restore carnitine-depleted tissues even if unphysiologically high doses (200 m g / k g L-carnitine) are given. In our opinion, the most important question yet to be answered is not whether the utilization of Intralipid can be pharmacologicall3 influcnccd by k-carnitine but whether carnitine mu~t be considered an essential nutrient in a defined group of infants at risk for carnitine deficiency.
Eberhard Schmidt-Sommerfeld, M.D. Duna Penn, M,D. Zemrum ff~r KitMerheilkuade Justus-Liebig-Universitgzt 6300 Giessen, West Germany REFERENCES
1.
Orzali A, Maetzke G , Donzelli F, Rubaltelli FF: Effect of carnitine on lipid metabolism in the neonate. II. Carnitine addition to lil~id infusion during prolonged total parenteral nutrition. J PEDIATn 104:436, 1984.