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  1. Problem. An infant with an indwelling umbilical artery catheter develops a vasospasm in one leg. The nurse notifies you that another infant with an umbilical line has no pulses in the lower legs and has severely decreased perfusion.

  2. Immediate questions

      1. Can the catheter be removed? Evaluate the need for the catheter. If the catheter can be removed, this is the treatment of choice. Vasospasm is most commonly related to the use of umbilical artery catheters (UAC), but it can also occur in other catheters such as radial artery catheters. Over 80% of venous thromboembolism in newborns is secondary to central venous lines. Arterial thrombosis is less common than venous thrombosis. The incidence of UAC-related thrombosis is 14–35% by ultrasound, and up to 64% by angiography. In some cases of thrombosis, the catheter should not be removed so thrombolytic medication can be given through it.

      1. Was a medication given recently through the catheter? Most medications, if given too rapidly, can cause vasospasm.

      1. How severe is the vasospasm? Deciding on the severity of the vasospasm may dictate treatment choices (see physical examination).

      1. Is there a pulse in the affected extremity? A loss of pulse with a thrombus is a medical emergency.

      1. What are the risk factors for vasospasm? Besides the umbilical catheter, the most common risk factor, infection, polycythemia, hypoxia, maternal diabetes, hypotension, dehydration, intrauterine growth restriction, and an increase in blood viscosity can all increase the risk.

  3. Differential diagnosis

      1. Vasospasm is a muscular contraction (spasm) of an arterial vessel, manifested by acute color change (white or blue) in the perfused extremity (upper or lower extremity, sometimes only on the toes or fingers). Occasionally, the color change extends to the buttocks and the abdomen. The change in color may be transient or persistent. It may be caused by prior injection of medication or a manifestation of thromboembolism/thromboembolic phenomenon. Arterial blood sampling can also be a predisposing factor.

      1. Thromboembolism. A thrombus is a blood clot formation in an artery or vein and can cause partial or complete obstruction. An embolus is a clot that is mobile and lodges in a blood vessel and may cause obstruction or vasospasm. Neonates are the most common affected age group with an incidence of ~41 cases in 100,000 per year. The initial sign is usually that the catheter does not work. One can not infuse fluid or withdraw from the line. Less commonly, thromboembolic phenomenon are due to inherited or acquired thrombophilias (heterozygous factor V Leiden; protein C or S deficiency). Congenital CMV is a rare cause of neonatal aortic thrombosis.

  4. Database

      1. History. Obtain a detailed family history of any inherited clotting or other hematologic disorder. Did any one in the family have a thromboembolism?

      1. Physical examination. The severity of the vasospasm and thrombosis must be assessed because it dictates treatment. The areas of involvement, appearance of the skin over the involved areas, and pulses of the affected extremity are measures of severity. Compare the affected extremity with the other extremity. A handheld Doppler ...

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