Vein Thrombosis Associated with Umbilical Vascular Catheters with Color Doppler
Manijeh Mostafa Gharehbaghi,
Reza Taei Nobari,
The aim of this study was to evaluate the incidence and risk factors of umbilical catheter associated thrombosis in newborn infants using color Doppler. In this analytic-descriptive study, 256 newborn infants with umbilical catheters were evaluated during a 15 month. Color Doppler ultrasonography was employed for detection of vascular thrombosis associated with the umbilical catheter placement in the first 24-48 h after admission, weekly until discharge and 72 h after discharge. Among 256 newborns, 12 cases (4.7%) had vascular thrombosis. The rate of thrombosis was 6.9 and 5.7% in the umbilical artery and vein catheters, respectively. Umbilical catheters is accompanied with the risk of thrombosis. Color Doppler ultrasonography is a good way for diagnosis of this thrombosis.
Received: March 14, 2013;
Accepted: April 13, 2013;
Published: January 09, 2014
Umbilical artery catheterization is a common procedure in the neonatal intensive
care unit and has become the standard of care for arterial access in neonates
(Azimi et al., 2013; Goldust
and Rezaee, 2013; Lotti et al., 2013; Verheij
et al., 2010). Catheter can be used as umbilical arterial (UAC) or
umbilical vascular (UVC) (Nejad et al., 2013;
Gharehbaghi et al., 2011; Goldust
et al., 2013a; Mohebbipour et al., 2012).
The placement of umbilical catheters is an essential technique for the treatment
of many newborns in unstable condition (Golforoushan et
al., 2013; Razi et al., 2013; Salehi
et al., 2013a; Yousefi et al., 2013).
Thrombosis formation on tip of the umbilical arterial catheter is always problematic
(Goldust et al., 2013b, c;
Qadim et al., 2013; Sakha
et al., 2007). According to several reports, real incidence rate
of thrombosis varies from 4.7 to 95% (Goldust et al.,
2013d; Nemati et al., 2013; Roy
et al., 2002; Vafaee et al., 2012).
Clinically, those thrombosis associated with umbilical catheters are detected
difficultly since more than one third of the cases are asymptomatic (Daghigh
et al., 2013; Goldust et al., 2012;
Kim et al., 2001; Sadighi
et al., 2011). Therefore, evaluation using color Doppler may be useful
in detecting these cases. Following thrombosis detection, risk factors developing
thrombosis such as combination of infusion fluid through catheter, size and
material of catheter, location of catheter tip, duration of catheter leftover
and etc., can be commented. However, the available data is heterogeneous (Golfurushan
et al., 2011; Milan et al., 2011;
Salehi et al., 2013d; Vali
et al., 2010). Developing NICU and increase of umbilical arterial
and vascular catheter to monitor very ill infants revealed that evaluating incidence
rate of the resulted thromboses as well as determining the risk factors related
to thrombosis incidence seems applied and necessary (Goldust
et al., 2011; Sadeghpour et al., 2011;
Soleimanpour et al., 2013). The present study
aimed at evaluating these possible risk factors.
MATERIALS AND METHODS
In this cumulative retrospective study, 256 infants with umbilical vascular
catheters were evaluated considering thrombosis and using color Doppler sonography
in NICU of Tabriz Pediatrics hospital for 15 months. Accordingly, the patients
were divided into two with and without thrombosis and possible risk factors
related to thrombosis were studied. Doppler study was conducted in all understudy
patients and during first hours and days (i.e., at least 6 h and utmost to 7
days after catheterization). If catheterization was lasted, re-lasted and continued
after catheterization, Doppler study was repeated one, two, three and four weeks
later. The patients were evaluated during initial 48-72 h after catheter placement
with sonography, every week until removing the catheter and 72 h after its removing.
All patients were evaluated using Ultrasonix-XP sonography set with multi-frequency
canox probe of 3-7 MHZ. Suffering from major definite anomaly, congenital cardiac
disease and any other systemic disease (e.g., renal dysplasia, etc.) during
every period of hospitalization, dehydratation, sepsis, polycythemia, congenital
heart disease. were regarded as the exclusion criteria. Considering study method,
there was not any special administrative or moral problem. The studied cases
included thrombosis location, detection time of thrombosis, gender, at-birth
weight, delivery age, type, size and location of catheter, duration of umbilical
catheterization, background diseases, calcium and vancomycin prescription using
Statistical analysis: The obtained data has been stated as Mean±standard
deviation, frequency and percentage and SPSS TM-15 was used as the statistical
software. Mann-Whitney U-test (Student T-test (Independent Samples) were used
to compare the quantitative variables. Contingency tables, Chi-square test and
Fisher's exact test were used to compare the qualitative variables considering
the governing conditions. In all understudy cases, the results were regarded
statistically meaningful if p = 0.05.
In this study, 256 infants with umbilical vascular catheter were evaluated.
Vascular thrombosis was confirmed in 12 cases using color Doppler sonography.
Out of 144 arterial, 35 vascular and 77 arterial-vascular catheters, there was
thrombosis in 10 and 2 cases, respectively. Thrombosis was located in port vein
of 8 patients (66.7%), umbilical vein in 3 cases (25%) and port-umbilical vein
in one patient (8.3%). The thrombosis was diagnosed during first week in 1 patient
(8.3%), second week in 2 cases (16.7%) and 72 h after removing the catheter
in 9 patients (75%). The understudy variables in both with and without thrombosis
groups have been summarized and compared in Table 1. Accordingly,
only mean of catheterization duration in the group suffering from thrombosis
was meaningfully more than the group without thrombosis. There was not any statistically
meaningful difference in other cases.
The present study evaluated incidence rate of vascular thrombosis resulting
from umbilical vascular catheters using color Doppler. Accordingly, 4.7% of
infants with umbilical vascular catheter suffered from thrombosis. It was respectively
6.9 and 5.7% in cases with umbilical arterial and umbilical vascular catheter.
In their study, Boo et al. (1999) studied 137
infants with umbilical vascular catheter using Doppler sonography 48 h after
removing the catheter. Finally, thrombosis was registered in 32.3 and 4.1% of
cases with umbilical arterial and umbilical vascular catheter, respectively.
Incidence rate of thrombosis was totally 28.2% in these infants (Boo
et al., 1999). Comparing with results of other studies, outcomes
of the current study are at low level although located in this range.
|| Variables studied in both groups of with and without thrombosis
|* Non-parametric test, HMD: Hyaline membrane disease, MAS:
Meconium aspiration syndrome
In our study, 75% of thromboses were detected 72 h after removing umbilical
vascular catheter. Thrombosis was occurred in port vein (66.7%), umbilical vein
(25%) and simultaneously port and umbilical vein (8.3%) in our study. The study
conducted by Oppenheimer and Carroll (1982) indicated
that out of 10 cases of thrombosis associated with umbilical arterial catheter,
5 cases occur in aorta, 3 cases in aorta and common iliac artery and 2 cases
in common iliac artery (Oppenheimer and Carroll, 1982).
As referred, the above-mentioned study only evaluated those infants with umbilical
arterial catheters. One of the effective factors in this regard is objective
of umbilical vascular catheterization determining placement of catheter tip
(Turebylu et al., 2007). The major differences
among the many investigations include the prospective or retrospective nature
of the study; the diagnostic method used to study the thrombus; the time schedule
of examinations and catheter variables such as size, location and duration (Fardiazar
et al., 2013; Ganjpour Sales et al.,
2013; Salehi et al., 2013b, c).
In general, prospective US examinations, starting shortly after catheterization,
revealed a 17-44% incidence of thrombosis associated with use of umbilical venous
catheters, umbilical arterial catheters, or femoral venous catheters (Farhoudi
et al., 2012; Kujur et al., 2012;
Nourizadeh et al., 2013; Yilmaz
et al., 2010). Different risk factors can be introduced as one of
the factors related to variability of incidence rate of thrombosis associated
with umbilical vascular catheters in different studies (Karzar
et al., 2012; Seyyednejad et al., 2012;
Shakeri et al., 2013; Vahedi
et al., 2012). Our study demonstrated that there was not any meaningful
relationship between thrombosis incidence and factors such as infant's gender,
at-birth weight, delivery age, type of umbilical catheter (arterial/vascular),
size of catheter, catheter placement, background disease and hind of medicine
prescribed using catheter. Duration of umbilical catheterization was the only
variable related to this condition. Hermansen and Hermansen
(2005) stated that 55% hematocrit during first week of life, infant premature
and history of mother's pre-eclampsia were as risk factors related to thrombosis
incidence (Hermansen and Hermansen, 2005). As mentioned
previously, results of different studies are really varied in this regard (Ganjpour
Sales et al., 2012; Sadeghpour et al.,
2012; Smith and Dills, 2003). The reason can be
attributed to complexity of development process of thrombosis and its relationship
with umbilical vascular catheters. Evidently, placement of umbilical vascular
catheters significantly increases risk of thrombosis incidence. It has been
estimated about 3.5 times (Grupo de Hospitales Castrillo,
2000; Fardiazar et al., 2012; Nikanfar
et al., 2012).
In this study, 4.7% of infants with umbilical vascular catheter suffered from
thrombosis, 6.9% of the infants with umbilical arterial and 5.7% of infants
with umbilical vascular catheter suffered from thrombosis. Catheterization duration
was the only risk factor related to incidence of secondary thrombosis in umbilical
vascular catheters (averagely 5.3 days in patients with thrombosis vs. 3.3 days
in cases without thrombosis).
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