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Umbilical Artery Catheters Do Not Affect Intestinal Blood Flow Responses To Journal of Perinatology (2007) 27, 375–379 r 2007 Nature Publishing Group All rights reserved. 0743-8346/07 $30 www.nature.com/jp ORIGINAL ARTICLE Umbilical artery catheters do not affect intestinal blood flow responses to minimal enteral feedings T Havranek1, P Johanboeke1,2, C Madramootoo1 and JD Carver1 1Department of Pediatrics, Division of Neonatology, University of South Florida College of Medicine, Tampa, FL, USA and 2Siemens Medical Solutions, Tampa, FL, USA Introduction Objective: To investigate the effects of umbilical artery catheters (UACs) The superior mesenteric artery (SMA) is the blood vessel that on superior mesenteric artery (SMA) blood flow velocity (BFV) following supplies the greatest volume of blood to the small intestine. The enteral feedings in very low birth weight preterm infants. use of Doppler ultrasound to measure SMA blood flow velocity Study design: Very low birth weight preterm infants who had UACs (BFV) is increasingly used to investigate intestinal hemodynamics inserted as part of standard clinical care were enrolled in this prospective in neonates. We1 and others2–6 have demonstrated that SMA BFV study. On the day the UAC was scheduled to be removed, pre- and progressively increases during the first week of life in preterm postprandial SMA BFV (mean, peak systolic and end diastolic velocities) infants, which likely reflects increasing maturation of the intestinal were measured in conjunction with a minimal enteral feeding given tract. Several clinical factors may impact SMA BFV in preterm while the UAC was in place. The same measurements were made with the neonates, including the initiation of enteral feedings,6–9 the next feeding given after the UAC was removed. Preprandial measurements administration of vasoactive medications,10–13 the administration were made at least 3 h after the last enteral feeding, and postprandial of continuous positive airway pressure,1 phototherapy14,15 and measurements were made 30, 45 and 60 min after the feeding began. The umbilical artery catherization.16,17 same volume and type of feeding were used for both studies. Umbilical artery catheterization is a procedure commonly Results: The birth weight and gestational age of the 19 infants who performed in very low birth weight (VLBW) infants. Umbilical completed the study were 1014±221 g and 27.4±1.9 weeks, respectively. artery catheters (UACs) are used for routine monitoring of blood Infants were 4.6±1.7-days-old when the first SMA BFV measurement was gases and chemistries, and for the administration of fluid and made, the volume of enteral feedings was 1.3±0.6 ml, and the time hyperalimentation if alternative access is not available. Intestinal between the two enteral feedings was 4.7±3.2 h. Preprandial SMA BFV did disturbances such as abdominal distension, ischemia and not differ with the UAC in place compared with the UAC removed. Peak necrotizing enterocolitis have been attributed to UACs. Postulated postprandial velocities were at 45 min after feedings began. The percent mechanisms include the release of thrombi by the UAC, and increase from baseline was not significantly different with the UAC in decreased blood flow to the SMA secondary to a reduction in 18–20 place compared with the UAC removed. the diameter of the lumen of the aorta. However, the effect of UACs on SMA blood flow remains controversial; several Conclusions: Preprandial SMA BFV and postprandial SMA BFV responses investigators report that UACs have no effect on SMA blood to minimal enteral feedings were not affected by the presence of a UAC. flow,21,22 whereas others report that UACs are associated with Journal of Perinatology (2007) 27, 375–379; doi:10.1038/sj.jp.7211691; reduced SMA blood flow.16,17 published online 29 March 2007 Neonatology practice guidelines reflect the controversy regarding Keywords: very low birth weight; premature infant; blood flow velocity; UAC effects on intestinal hemodynamics. The guidelines for enteral superior mesenteric artery; nutrition; regional blood flow feeding range from non-permissive,23 to undecided24 or supportive.25 As alterations in intestinal perfusion may predispose an enterally fed infant to the development of necrotizing enterocolitis26,27 neonatologists are often hesitant to feed infants with UACs. A survey Correspondence: Dr T Havranek, Department of Pediatrics, Division of Neonatology, of neonatal intensive care directors in the US revealed that newborns University of South Florida College of Medicine, USF Pediatrics, 17 Davis Blvd, Suite 200, with UACs in place receive enteral feedings most of the time (30%), Tampa, FL 33706, USA. some of the time (49%) or none of the time (22%).28 E-mail: [email protected] Received 3 November 2006; revised 26 January 2007; accepted 7 February 2007; published Although the effect of UACs on SMA BFV has been investigated, online 29 March 2007 albeit with conflicting results, we are not aware of studies that have UACs and intestinal blood flow velocity T Havranek et al 376 investigated the effects of UACs on SMA BFV responses to enteral Doppler ultrasound studies feedings. We investigated the effect of UACs on intestinal blood flow SMA BFV was measured using pulsed Doppler ultrasound (Acuson responses to feedings by measuring pre- and postprandial SMA BFV Sequoia C512, Mountainview, CA, USA) and a 10.0 MHz transducer. in VLBW neonates before and after UAC removal. The sampling volume of the pulsed Doppler was placed 3 mm distal to the origin of the SMA using a real-time two-dimensional image from a longitudinal abdominal approach. When five stable Patients and methods consecutive waveforms were obtained, the curve was traced and the Study design mean velocity, mean peak systolic flow velocity and mean end In this prospective study, SMA BFV responses to feeding were diastolic flow velocity were recorded. All measurements were measured while a UAC was in place, and in the same infants after performed by one of two ultrasound technicians. the UAC was removed. On the day the UAC was scheduled to be Statistical analyses removed, pre- and postprandial SMA BFV measurements were made A t-test for paired samples would require 20 completed subjects to in conjunction with a minimal enteral feeding given while the UAC detect a 40% difference in peak postprandial SMA BFV with the UAC was in place (Study 1). The same measurements were made with in place compared with the UAC removed (two-tailed, a ¼ 0.05, the next feeding that was given after the UAC was removed b ¼ 0.80). Regression analysis was used to measure the (Study 2). Preprandial measurements were made at least 3 h after relationship between SMA BFV (baseline and postprandial change the last feeding, and postprandial measurements were made 30, 45 from 0 to 45 min) and the presence of a patent ductus arteriosus and 60 min after the feeding began. The same type and volume of (PDA), the administration of caffeine, phototherapy or ventilation feeding were used for Studies 1 and 2. support. A two-way paired-samples t-test was used to analyze Subjects differences in preprandial SMA BFV and physiologic measurements Infants admitted to the NICU at Tampa General Hospital and who between Studies 1 and 2. A repeated-measures analysis of variance had UACs inserted according to standard clinical care guidelines (ANOVA) was used to measure the significance of changes in SMA were eligible for enrollment. Additional inclusion criteria were birth BFV from 0 to 45 min. Wilcoxon signed ranks test for two related weight <1 500 g, birth weight appropriate for gestational age, samples was used to compare differences in the percent increase cardiovascular and hemodynamic stability, and postnatal age from baseline to maximum SMA BFV with the UAC in place p2 days. Exclusion criteria were clinical evidence of major compared with the UAC removed. SPSS (SPSS Inc., Version 14.0, congenital anomalies or congenital heart disease, and a diagnosis Chicago, IL, USA) was used for all analyses. Data represent the of anemia (venous hemoglobin (Hgb) <10 g/dl) or polycythemia mean±s.d. unless otherwise indicated. (venous Hgb>22 g/dl). Infants who, in the opinion of the attending neonatologist, would not tolerate enteral feeds were also excluded. Results This study was approved by the University of South Florida Twenty-one infants were enrolled. Two infants had increased Institutional Review Board for the Protection of Human Subjects. gastric residuals and moderate bowel distension after SMA BFV Informed consent was obtained from the parent(s) of all enrolled measurements were made with the UAC in place. Feedings were infants. withheld from these infants for more than 12 h, and the infants were withdrawn from the study. The mean birth weight and Standard clinical care gestational age of the remaining 19 infants were 1014±221 g and All enrolled infants received standard clinical care for our 27.4±1.9 weeks, respectively (Table 1). During hospitalization, two NICU, which includes enteral feedings for most infants with (11%) infants developed necrotizing enterocolitis (XBell Stage 2), UACs. UACs were inserted in the ‘high’ position (tip at the T6 to T9 five (26%) developed intraventricular hemorrhage (three infants level) within 2 to 3 h after birth. UACs remained in place for 3 to 7 with XGrade III) and three (16%) developed bronchopulmonary days. Small amounts of preterm infant formula or unfortified dysplasia. Infants reached full enteral feedings (150 ml/kg/day) at human milk were given by nasogastric tube within the first a median age of 22 days (range 14 to 93), and the median length 48 h of life. The rate of increase of the feedings (typically 15 to of hospitalization was 60 days (range 24 to 210). 20 ml/kg/day) was based on signs of feeding intolerance. Infants were 4.6±1.7-days-old when SMA BFV measurements UACs were removed at the discretion of the attending were made with the UAC in place.
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