Successful Management of Severe Peripheral Tissue Ischemia after Arterial Catheterization in Micro Preemies using Humidification & Topical Nitroglycerin

Abstract

Micro preemies usually undergo arterial catheterization for frequent blood pressure monitoring and blood sampling. Peripheral tissue injury associated arterial cathe terization is a well described morbidity observed in neonates. Despite the potential permanent disability associated with this complication, the currently available thera peutic options remain limited. We report a unique case of a preterm infant who de veloped severe tissue ischemia after arterial catheterization of the radial artery and was successfully treated using extensive humidification and topical nitroglycerin oint ment application over an extended period (36 days) until complete clinical recovery.

Analysis of Characteristics of Peripheral Arterial Ischemia in Premature Babies and Effects of Nitroglycerin Patch Application

“…The logistic analysis showed that the factors affecting peripheral arterial ischemia were lower gestational age, lower birth weight, lower 1-minute Apgar scores, lower 5-minute Apgar scores, occurrence of PDA, the duration of inotropic agent use, the duration of ventilator treatment, and the duration of in-dwelling umbilical arterial lines. The factors affecting peripheral arterial ischemia were the duration of umbilical artery catheterization, which was also identified as a cause of peripheral arterial ischemia by Teo and Shah [20], Rizzi et al [21], and Han et al [9]. In the study of Samiee-Zafarghandy et al [8], a low Apgar score, lower gestational age (26+4 weeks), and ven-tilator treatment were also identified as significant factors, as in this study.…”

“…In this study, it was also found that the application of nitroglycerin patches in premature newborns with peripheral arterial ischemia resulted in improvements in 83.3% of patients. Specifically, premature newborns without necrosis showed improvement within an average of 4.32 days and those with necrosis showed improvement within an average of 7.50 days, indicating that patches led to faster improvements than the 2 weeks needed for improvements in response to ointments in earlier studies [9].…”

“…Surmising that the risk of amputation is higher when the tissue ischemia is more extensive and the degree of necrosis is more severe, additional treatment besides local application of nitroglycerin ointment may be needed in patients with serious symptoms. All the studies described above reported that the application of nitroglycerin medication was followed by improvements in peripheral arterial ischemia and circulation of areas with necrosis, restoration of skin color, and recovery of the skin, except in areas of partial loss [2,5,[8][9][10][11]13,14].…”

“…Immediate and non-invasive methods of treating peripheral tissue ischemia and areas of necrosis include evaluating the need for catheters in blood vessels and removing them, elevating the limbs of the relevant areas, applying heating on the limb where thrombosis has not occurred, and performing soft massages [2,5,7]. However, some researchers, such as Samiee-Zafarghandy, van den Anker, and Ben Fadel [8] and Han, Song, Sung, and Chun [9], reported that tissue ischemia and necrosis did not improve after implementing non-invasive treatment methods, meaning that these techniques have limitations in the treatment of peripheral tissue ischemia and necrosis. In contrast, nitroglycerin patches, anticoagulants, thrombolytic agents, and mechanical thrombectomy, which are also treatments for ischemia in newborns, are regarded as secondary treatment methods due to their high hemorrhage risks [5].…”

Topical nitroglycerin in newborns with ischemic injuries: A systematic review

“…An ointment is also more applicable in non-contiguous areas such as joints ( Generali and Cada, 2001 ). The most common dose of ointment employed in 16 subjects was 4 mm/kg ( Elboraee et al, 2018 , Han et al, 2017 , Samiee-Zafarghandy et al, 2014 , Akingbola et al, 2012 , Sardesai et al, 2011 , Mousavi et al, 2010 , Vasquez et al, 2003 , Baserga et al, 2002 , O’Reilly et al, 1988 ). The physiological effect commenced within one hour and lasted for approximately six hours ( Dilli et al, 2015 , Baserga et al, 2002 ).…”