Topical Nitroglycerine Treatment for Sustaining Umbilical Arterial Catheter While Resolving Peripheral Ischemia: A Case Report

Sarah Gil; Kamela Loo; Indira Chandrasekar

doi:doi:10.11648/j.ajp.20220804.25

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Topical Nitroglycerine Treatment for Sustaining Umbilical Arterial Catheter While Resolving Peripheral Ischemia: A Case Report

Sarah Gil, Kamela Loo, Indira Chandrasekar

Published in American Journal of Pediatrics (Volume 8, Issue 4)

Received: 17 November 2022 Accepted: 8 December 2022 Published: 27 December 2022

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Abstract

Presence of umbilical arterial catheters in extremely low birth weight infants is critical for their management including minimal handling in first few days of life. However, one of the associated risks of indwelling umbilical arterial line is occasional development of peripheral ischemia. In most cases, it invariably leads to discontinuation of the catheter to salvage the ischemic tissue. Discontinuation of the arterial line places the preterm neonate at risk for multiple venipunctures and capillary blood draws and suboptimal hemodynamic monitoring. We report the first case of peripheral ischemia, specifically ischemia of the toes, due to umbilical arterial catheterization in an extremely low birth weight infant [380 grams and 25 weeks gestation secondary to maternal chronic hypertension, preeclampsia, and severe intrauterine growth retardation], where both the umbilical arterial catheter and toes were salvaged by use of topical nitroglycerine ointment. We conclude that topical application of nitroglycerine ointment did not lead to significant hypotension, methemoglobinemia, or intraventricular hemorrhage in this neonate. Currently there are no uniform guidelines regarding the frequency, duration, and safety of nitroglycerin topical administration in the treatment of ischemia in extremely low birth weight infants. A proposal for development of a guideline which should incorporate close blood pressure monitoring, methemoglobin levels, and serial cerebral ultrasounds. This method may help to reduce unnecessary early removal of catheters in the first few days of life, as many neonatal units are moving towards resuscitating peri-viable infants worldwide.

Published in	American Journal of Pediatrics (Volume 8, Issue 4)
DOI	10.11648/j.ajp.20220804.25
Page(s)	276-279
Creative Commons	This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Copyright	Copyright © The Author(s), 2024. Published by Science Publishing Group

Keywords

Extremely Low Birth Weight Infants, Umbilical Arterial Catheters, Peripheral Ischemia, Methemoglobinemia, Peri-Viable Infants, Intraventricular Hemorrhage

References

[1]	James L. S. Biochemical aspects of asphyxia at birth. In: Adaptation of extrauterine life. Report of the 31st Ross Conference of Pediatric Research, Vancouver, B. C. 1959.
[2]	Baserga MC, Puri A, Sola A. The use of topical nitroglycerin ointment to treat peripheral tissue ischemia secondary to arterial line complications in neonates. J Perinatol. 2002; 22 (5): 416-419.
[3]	Smeeta R. Sardesai, Maria K. Kornacka, Wojciech Walas & Rangasamy Ramanathan (2011) Iatrogenic skin injury in the neonatal intensive care unit, The Journal of Maternal-Fetal & Neonatal Medicine, 24: 2, 197-203.
[4]	Kim J, Lee JW, Kim DY. Analysis of characteristics of peripheral arterial ischemia in premature babies and effects of nitroglycerin patch application. Child Health Nurs Res. 2020; 26 (4): 434-444.
[5]	Mosalli, R., 2021. Successful use of nitroglycerine spray to treat a neonate with ischemic injury. Pediatr. Int. Mar 25. PMID: 33764568.
[6]	Weerasekera M., Lakmini C., Imbulana N. S., Hettiarachchi K. R., Sampath G. U. Topical nitroglycerine in management of peripheral ischaemia in a neonate following arterial cannulation. Sri Lanka J. Child Health. 2019; 48: 263–265.
[7]	Wong A. F., McCulloch L. M., Sola A. Treatment of peripheral tissue ischemia with topical nitroglycerin ointment in neonates. J. Pediatr. 1992; 121: 980–983.
[8]	Varughese, M., 2001. Successful use of topical nitroglycerine in ischaemia associated with umbilical arterial line in a neonate. J. Perinatol. 556–558.
[9]	Vasquez P., Burd A., Mehta R., Hiatt M., Hegyi T. Resolution of peripheral artery catheter-induced ischemic injury following prolonged treatment with topical nitroglycerin ointment in a newborn: A case report. J. Perinatol. 2003; 23: 348–350.
[10]	Ballabh P. Intraventricular Hemorrhage in Premature Infants: Mechanism of Disease. Pediatric Res. 2010; 67: 1–8.
[11]	Kamar R., van Vonderen J. J., Lopriore E., Te Pas A. B. Nitroglycerin for severe ischaemic injury after peripheral arterial line in a preterm infant. Acta Paediatr. 2013; 102: e144–e145.
[12]	Vivar del Hoyo, P., Sánchez Ruiz, P., Ludeña del Río, M., López-Menchero Oliva, J. C., García Cabezas, M. Á., 2016. Use of topical nitroglycerin in newborns with ischemic injuries after vascular cannulation. An. Pediatría (Barc). 85, 155–156.
[13]	Sardesai S. R., Kornacka M. K., Walas W., Ramanathan R. Iatrogenic skin injury in the neonatal intensive care unit. J. Matern Fetal Neonatal Med. 2011; 24: 197–203.
[14]	Teo, M. C., Shah, V. A., 2015. Digital ischaemia following inadvertent arterial cannulation of a peripherally inserted central catheter in a very low birth weight infant. Singapore Med. J. 56, 482–483.
[15]	Han Y. S., Song S., Sung T. J., Chun J. Successful management of severe peripheral tissue ischemia after arterial catheterization in micro preemies using humidification & topical nitroglycerin. Neonatal Med. 2017; 24: 197–201.
[16]	Rizzi M, Kroiss S, Kretschmar O, Foster I, Brotschi B, Albisetti M. Long term outcome of catheter-related arterial thrombosis in infants with congenital heart diseaseJ Pediatr. 2016; 170 (181–187. e1).
[17]	Dilli D., Özyazici E., Fettah N., Kaya O., Pala Akdoan M., Zenciroğlu A., Okumuş N., Güzoğlu N. Rupture and displacement of umbilical catheter: bilateral arterial occlusion in a very low birth weight preterm. Arch. Argent. Pediatr. 2015; 113: e283–e285.
[18]	Mosalli R., Elbaz M., Paes B. Topical nitroglycerine for neonatal arterial associated peripheral ischemia following cannulation: A case report and comprehensive literature review. Case Rep. Pediatr. 2013; 1–7.
[19]	Akingbola O., Singh D., Steiner R., Frieberg E., Petrescu M. High-dose tissue plasminogen activator, topical nitroglycerin, and heparin for severe ischemic injury in a neonate. Clin. Pediatr. (Phila) 2012; 51: 1095–1098.
[20]	Bogaert M. G. Clinical pharmacokinetics of glyceryl trinitrate following the use of systemic and topical preparations. Clin. Pharmacokinet. 1987; 12: 1–11.
[21]	Chu L. C., Gale R. M., Schmitt L. G., Shaw J. E. Nitroglycerin concentration in plasma: Comparison between transdermal therapeutic system and ointment. Angiology. 1984; 35: 545–552.
[22]	Mousavi S. A., Sahebpour A. A., Shahmohammadi S. Neonatal gangrene of the extremity: a complication of umbilical catheterization. Pak. J Med Sci. 2010; 26: 488–489.
[23]	Maffei G., Rinaldi M., Rinaldi G. Resolution of peripheral tissue ischemia secondary to arterial vasospasm following treatment with a topical nitroglycerin device in two newborns: case reports. J. Perinat. Med. 2006; 34: 252.
[24]	Samiee-Zafarghandy S., Van Den Anker J. N., Ben Fadel N. Topical nitroglycerin in neonates with tissue injury: A case report and review of the literature. Paediatr. Child Health. 2014; 19: 9–12.
[25]	Mintoft A., Williams E., Harris C., Kennea N., Greenough A. Methemoglobinemia during the use of glyceryl trinitrate patches in neonates: Two case reports. AJP Rep. 2018; 8: e227–e229.
[26]	Lavie-Nevo, K., Molad, M., Eidelman, M., 2020. Ischaemic limb injury and autoamputation complicating peripheral cannula insertion. Arch Dis Child Fetal Neonatal Ed. fetalneonatal-2020-318899.

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APA Style

Sarah Gil, Kamela Loo, Indira Chandrasekar. (2022). Topical Nitroglycerine Treatment for Sustaining Umbilical Arterial Catheter While Resolving Peripheral Ischemia: A Case Report. American Journal of Pediatrics, 8(4), 276-279. https://doi.org/10.11648/j.ajp.20220804.25

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ACS Style

Sarah Gil; Kamela Loo; Indira Chandrasekar. Topical Nitroglycerine Treatment for Sustaining Umbilical Arterial Catheter While Resolving Peripheral Ischemia: A Case Report. Am. J. Pediatr. 2022, 8(4), 276-279. doi: 10.11648/j.ajp.20220804.25

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AMA Style

Sarah Gil, Kamela Loo, Indira Chandrasekar. Topical Nitroglycerine Treatment for Sustaining Umbilical Arterial Catheter While Resolving Peripheral Ischemia: A Case Report. Am J Pediatr. 2022;8(4):276-279. doi: 10.11648/j.ajp.20220804.25

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@article{10.11648/j.ajp.20220804.25,
  author = {Sarah Gil and Kamela Loo and Indira Chandrasekar},
  title = {Topical Nitroglycerine Treatment for Sustaining Umbilical Arterial Catheter While Resolving Peripheral Ischemia: A Case Report},
  journal = {American Journal of Pediatrics},
  volume = {8},
  number = {4},
  pages = {276-279},
  doi = {10.11648/j.ajp.20220804.25},
  url = {https://doi.org/10.11648/j.ajp.20220804.25},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajp.20220804.25},
  abstract = {Presence of umbilical arterial catheters in extremely low birth weight infants is critical for their management including minimal handling in first few days of life. However, one of the associated risks of indwelling umbilical arterial line is occasional development of peripheral ischemia. In most cases, it invariably leads to discontinuation of the catheter to salvage the ischemic tissue. Discontinuation of the arterial line places the preterm neonate at risk for multiple venipunctures and capillary blood draws and suboptimal hemodynamic monitoring. We report the first case of peripheral ischemia, specifically ischemia of the toes, due to umbilical arterial catheterization in an extremely low birth weight infant [380 grams and 25 weeks gestation secondary to maternal chronic hypertension, preeclampsia, and severe intrauterine growth retardation], where both the umbilical arterial catheter and toes were salvaged by use of topical nitroglycerine ointment. We conclude that topical application of nitroglycerine ointment did not lead to significant hypotension, methemoglobinemia, or intraventricular hemorrhage in this neonate. Currently there are no uniform guidelines regarding the frequency, duration, and safety of nitroglycerin topical administration in the treatment of ischemia in extremely low birth weight infants. A proposal for development of a guideline which should incorporate close blood pressure monitoring, methemoglobin levels, and serial cerebral ultrasounds. This method may help to reduce unnecessary early removal of catheters in the first few days of life, as many neonatal units are moving towards resuscitating peri-viable infants worldwide.},
 year = {2022}
}

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TY  - JOUR
T1  - Topical Nitroglycerine Treatment for Sustaining Umbilical Arterial Catheter While Resolving Peripheral Ischemia: A Case Report
AU  - Sarah Gil
AU  - Kamela Loo
AU  - Indira Chandrasekar
Y1  - 2022/12/27
PY  - 2022
N1  - https://doi.org/10.11648/j.ajp.20220804.25
DO  - 10.11648/j.ajp.20220804.25
T2  - American Journal of Pediatrics
JF  - American Journal of Pediatrics
JO  - American Journal of Pediatrics
SP  - 276
EP  - 279
PB  - Science Publishing Group
SN  - 2472-0909
UR  - https://doi.org/10.11648/j.ajp.20220804.25
AB  - Presence of umbilical arterial catheters in extremely low birth weight infants is critical for their management including minimal handling in first few days of life. However, one of the associated risks of indwelling umbilical arterial line is occasional development of peripheral ischemia. In most cases, it invariably leads to discontinuation of the catheter to salvage the ischemic tissue. Discontinuation of the arterial line places the preterm neonate at risk for multiple venipunctures and capillary blood draws and suboptimal hemodynamic monitoring. We report the first case of peripheral ischemia, specifically ischemia of the toes, due to umbilical arterial catheterization in an extremely low birth weight infant [380 grams and 25 weeks gestation secondary to maternal chronic hypertension, preeclampsia, and severe intrauterine growth retardation], where both the umbilical arterial catheter and toes were salvaged by use of topical nitroglycerine ointment. We conclude that topical application of nitroglycerine ointment did not lead to significant hypotension, methemoglobinemia, or intraventricular hemorrhage in this neonate. Currently there are no uniform guidelines regarding the frequency, duration, and safety of nitroglycerin topical administration in the treatment of ischemia in extremely low birth weight infants. A proposal for development of a guideline which should incorporate close blood pressure monitoring, methemoglobin levels, and serial cerebral ultrasounds. This method may help to reduce unnecessary early removal of catheters in the first few days of life, as many neonatal units are moving towards resuscitating peri-viable infants worldwide.
VL  - 8
IS  - 4
ER  -

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Author Information

Sarah Gil

Department of Neonatology, Valley Children’s Health Care, Madera, United States
Kamela Loo

Department of Neonatology, Valley Children’s Health Care, Madera, United States
Indira Chandrasekar

Department of Neonatology, Valley Children’s Health Care, Madera, United States

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APA Style

Sarah Gil, Kamela Loo, Indira Chandrasekar. (2022). Topical Nitroglycerine Treatment for Sustaining Umbilical Arterial Catheter While Resolving Peripheral Ischemia: A Case Report. American Journal of Pediatrics, 8(4), 276-279. https://doi.org/10.11648/j.ajp.20220804.25

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ACS Style

Sarah Gil; Kamela Loo; Indira Chandrasekar. Topical Nitroglycerine Treatment for Sustaining Umbilical Arterial Catheter While Resolving Peripheral Ischemia: A Case Report. Am. J. Pediatr. 2022, 8(4), 276-279. doi: 10.11648/j.ajp.20220804.25

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AMA Style

Sarah Gil, Kamela Loo, Indira Chandrasekar. Topical Nitroglycerine Treatment for Sustaining Umbilical Arterial Catheter While Resolving Peripheral Ischemia: A Case Report. Am J Pediatr. 2022;8(4):276-279. doi: 10.11648/j.ajp.20220804.25

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@article{10.11648/j.ajp.20220804.25,
  author = {Sarah Gil and Kamela Loo and Indira Chandrasekar},
  title = {Topical Nitroglycerine Treatment for Sustaining Umbilical Arterial Catheter While Resolving Peripheral Ischemia: A Case Report},
  journal = {American Journal of Pediatrics},
  volume = {8},
  number = {4},
  pages = {276-279},
  doi = {10.11648/j.ajp.20220804.25},
  url = {https://doi.org/10.11648/j.ajp.20220804.25},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajp.20220804.25},
  abstract = {Presence of umbilical arterial catheters in extremely low birth weight infants is critical for their management including minimal handling in first few days of life. However, one of the associated risks of indwelling umbilical arterial line is occasional development of peripheral ischemia. In most cases, it invariably leads to discontinuation of the catheter to salvage the ischemic tissue. Discontinuation of the arterial line places the preterm neonate at risk for multiple venipunctures and capillary blood draws and suboptimal hemodynamic monitoring. We report the first case of peripheral ischemia, specifically ischemia of the toes, due to umbilical arterial catheterization in an extremely low birth weight infant [380 grams and 25 weeks gestation secondary to maternal chronic hypertension, preeclampsia, and severe intrauterine growth retardation], where both the umbilical arterial catheter and toes were salvaged by use of topical nitroglycerine ointment. We conclude that topical application of nitroglycerine ointment did not lead to significant hypotension, methemoglobinemia, or intraventricular hemorrhage in this neonate. Currently there are no uniform guidelines regarding the frequency, duration, and safety of nitroglycerin topical administration in the treatment of ischemia in extremely low birth weight infants. A proposal for development of a guideline which should incorporate close blood pressure monitoring, methemoglobin levels, and serial cerebral ultrasounds. This method may help to reduce unnecessary early removal of catheters in the first few days of life, as many neonatal units are moving towards resuscitating peri-viable infants worldwide.},
 year = {2022}
}

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TY  - JOUR
T1  - Topical Nitroglycerine Treatment for Sustaining Umbilical Arterial Catheter While Resolving Peripheral Ischemia: A Case Report
AU  - Sarah Gil
AU  - Kamela Loo
AU  - Indira Chandrasekar
Y1  - 2022/12/27
PY  - 2022
N1  - https://doi.org/10.11648/j.ajp.20220804.25
DO  - 10.11648/j.ajp.20220804.25
T2  - American Journal of Pediatrics
JF  - American Journal of Pediatrics
JO  - American Journal of Pediatrics
SP  - 276
EP  - 279
PB  - Science Publishing Group
SN  - 2472-0909
UR  - https://doi.org/10.11648/j.ajp.20220804.25
AB  - Presence of umbilical arterial catheters in extremely low birth weight infants is critical for their management including minimal handling in first few days of life. However, one of the associated risks of indwelling umbilical arterial line is occasional development of peripheral ischemia. In most cases, it invariably leads to discontinuation of the catheter to salvage the ischemic tissue. Discontinuation of the arterial line places the preterm neonate at risk for multiple venipunctures and capillary blood draws and suboptimal hemodynamic monitoring. We report the first case of peripheral ischemia, specifically ischemia of the toes, due to umbilical arterial catheterization in an extremely low birth weight infant [380 grams and 25 weeks gestation secondary to maternal chronic hypertension, preeclampsia, and severe intrauterine growth retardation], where both the umbilical arterial catheter and toes were salvaged by use of topical nitroglycerine ointment. We conclude that topical application of nitroglycerine ointment did not lead to significant hypotension, methemoglobinemia, or intraventricular hemorrhage in this neonate. Currently there are no uniform guidelines regarding the frequency, duration, and safety of nitroglycerin topical administration in the treatment of ischemia in extremely low birth weight infants. A proposal for development of a guideline which should incorporate close blood pressure monitoring, methemoglobin levels, and serial cerebral ultrasounds. This method may help to reduce unnecessary early removal of catheters in the first few days of life, as many neonatal units are moving towards resuscitating peri-viable infants worldwide.
VL  - 8
IS  - 4
ER  -

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