1. In the name of God Dr. M.Habibi Neonatologist Assistant professor of pediatrics

2. Vasospasms and thromboembolism in neonate:
*Cause : usually occur with indwelling arterial or sometime venous catheters.
More commonly umbilical & less common with peripheral line.
Neonates are at a high risk because of their :
A: immature hemostatic system
B: smaller vessel size
Vasospasm commonly occur in arterial catheterization but thromboembolism common with venous catheterization.
* most medications if given too rapidly can cause vasospasms

3. *risk factors : A) Maternal: 1) Autoimmune disorder 2) PROM 3) Diabetes 4) Preeclampsia 5) Oligohydramnios 6) Prothrombotic disorder 7) Chorioamnionitis 8) familial history of thrombosis 9) anti-phospholipid or anti-cardiolipin Ab

4. B)Delivery : 1) Instrumentation 2) Fetal heart rate abnormality
3) C/S Emergency
4) Traumatic delivery

5. C) Neonate :
1) C.A.C (central arterial catheter)is the most common risk factor
2) Central venous catheters
3) Congenital heart disease
4) Asphyxia
5) Sepsis
6) SGA & IUGR
7) RDS
8) NEC

6. 9) Polycytemia 10) PPHN 11) Dehydration 12) Congenital Nephrotic syndrome 13)DIC 14) Impaired liver function 15) low cardiac output & hypotention 16) Prothrombotic disorder ( protein C & S deficiency, factor V leiden mutation, anti-thrombin deficiency , elevation of lipoprotein A level & other things like impaired liver function.)

7. ɪ) Vasospasm: a. Less severe vasospasm:
Due to muscular contraction it is commonly arterial
1. catheter
2. injection of medication
3. Sampling
a. Less severe vasospasm:
Involves a small area of one or both legs
(usually some of the toes and parts of the foot or hand)
* in this type : skin has a mottled appearance & pulses are present but diminished.

10. b. severe vasospasm: Involves large area of one or both extremity and sometime progresses to buttocks and abdomen. * in this type: skin maybe completely white -Perfusion decreased -Pulses of affected extremity are week but detectable

15. Arterial thrombosis: Venous thrombosis :
Is a medical emergency in which pulse usually are completely absent & persistent bacteremia & thrombocytopenia may be associated with thrombosis
Venous thrombosis :
More common and it’s first sign is catheter dysfunction
Extremities are swollen – cyanotic –hyperemic and discolored with distended superficial veins
but renal vein thrombosis is most common type of spontaneous venous thrombosis

20. Laboratory studies:
Not usually needed for vasospasm but in suspected thromboembolism following studies should be done:
1.Coagulation profile : PT, PTT , TT ,Plasma fibrinogen concentration.
2.Hb & HCT
3.Platelate count & function (BT)
4.CMV workup
5.workup for thrombotic disorder
(Protein C & S & anti-thrombin ɪɪɪ - factor V leiden & antiphospholipid & cardiolipin Ab

21. Imaging: 1. Plain radiograph of the abdomen (for catheter placement)
2.ultrasound (Doppler flow) for thrombosis(also evaluate Brain & kidney sonography)
arterial
3.Contrast angiography ( gold standard)
Venous
4.magnetic resonance (MR)angiograph
Is done in some centers especially for suspected stroke.

22. Some general recommendations for Prophylaxy:
1. Small catheters should be used
2. heparin is used for patency of peripheral and central Arterial catheter u/kg/d(0.5unit/ml)concentration
3.heparin is not used in peripheral venous line
4.in central venous and PICC sometimes Heparin is recommended
5.Umblical line Should be removed as soon as possible ; arterial line should not be in place longer than 5 days and venous line not longer than 14 days.
6.PICC line has lower incidence of thrombosis.
7.Use peripheral line over umblical line.

23. Management: A)Vasospasm: Guide lines vary extensively
1. If possible remove the catheter
2.Warming the contra lateral extremity wrapping of unaffected extremity should cause reflex vasodilation of the affected vessels . continue it for min.
3.Gentle massage at the Site of occlusion)
4.Topical nitroglycerin therapy (2%ointment)4 mm/kg every 8 hours for (2-27day) improvement usually seen within min.

24. 5. If it is not possible to remove the catheter (it is the only line) consider papaverin 60 mg/500cc/N/s with 0/1unit/ml heparin continuous for 48 hr if vasospasm persist removed catheter. 6.lidocaine(controversial) 2mg/kg/hr 7.Morphine 8.surgery (sympathectomy)

25. B) Thromboemboli : ** Supportive care **
1.prompt removal of the catheter
2.treatment of volume depletion- Electrolyte abnormality – Sepsis – Thrombocytopenia – anemia
3.Emergency consultant with surgeon & hematologist
4.Evaluate for IVH
5.Rule out contraindication of anticoagulant & thrombolytic therapy (surgery & asphyxia in the last 10 days) – severe coagulation deficiency – platelate under – fibrinogen under 100 mg/dl – INR>2