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  378 Kathleen A. Marinelli Majid Rasoulpour 53 Peritoneal Dialysis Acute Peritoneal Dialysis (1–5) In neonates, acute peritoneal dialysis (PD) is frequently preferred over hemodialysis (HD), continuous arteriovenous hemofiltration with or without dialysis (CAVH/D), and continuous venovenous hemofiltration with or without dialysis (CVVH/D), because it is technically easier to perform. Peritoneal surface area per kilogram of body weight is relatively larger in newborns and children than in adults. Therefore, PD usually allows adequate clearance and removal of excess fluid (6). In addition, PD avoids the need for anticoagulation and maintenance of adequate vascular access, which are required for the other methods (7). A. Indications 1. Renal failure, when conservative management has failed to adequately control any of the following conditions (8,9). a. Hypervolemia b. Hyperkalemia c. Hyponatremia d. Refractory metabolic acidosis e. Hyperphosphatemia f. Azotemia g. Additional fluid space

  7. 22-gauge angiocatheter or a femoral catheter with guidewire 8. A temporary catheter such as a 14-gauge angiocatheter or one of the commercially available temporary dialysis catheters, (e.g., a Trocath [Trocath Peritoneal Dialysis Center, Kendall McGaw Laboratories, Sabana Grande, Puerto Rico]) 9. Dialysis solution (1.5%, 2.5%, or 4.25%) a. Other concentrations can be made by manual mixing of standard solutions 10. Heparin 11. Inline burette set 12. Ultra Set CAPD Disposable Disconnect Y-Set 13. MiniCap Extended Life PD Transfer Set with Twist Cap 14. Medicap with povidone–iodine solution 15. FlexiCap Disconnect Cap with povidone–iodine solution Nonsterile 1. Waterproof tape 2. Baby weigh scale with low resolution (e.g., Medela, which has a resolution of 2 g from 0 to 6,000 g) (Fig. 53.2) An alternative approach is to utilize a pediatric cycler set. Experience in using this equipment is necessary. We recommend a commercially available cycler that provides a minimum fill volume of 5

  Pediatric Ophthalmology and Strabismus. Screening examinations of premature infants for retinopathy of prematurity. Pediatrics. 2006;117:572. Erratum Pediatrics 2006;118:1324. 2. Wilkinson AR, Haines L, Head K, et al. UK retinopathy of prematurity guidelines. Early Hum Dev. 2008;84:71. 3. Jefferies AL, Canadian Pediatric Society; Fetus and Newborn Committee. Retinopathy of prematurity: recommendations for screening. Paediatr Child Health. 2010;15:667. 4. An International Committee for the Classification of Retinopathy of Prematurity. The international classification of retinopathy of prematurity revisited. Arch Ophthalmol. 2005;123:991. 5. Silva RA, Murakami Y, Lad EM, et al. Stanford University network for diagnosis of retinopathy of prematurity (SUNDROP): 36 month experience with telemedicine screening. Ophthalmic Surg Lasers Imaging. 2011;42:12. 6. Kivlin JD, Biglan AW, Gordon RA, et al. For Cryotherapy for Retinopathy of Prematurity Group. Early retinal vessel development and iri

  d. Sterile cotton-tipped applicators (CTA) e. Sterile gloves f. Topical Betadine g. Topical antibiotic drops (ciprofloxacin 0.3%) and ointment h. Sterile syringe of bevacizumab (0.625 mg in 0.025 mL) with 30-gauge needle (one per eye) 7. Complications (Table 52.3) a. The most worrisome risk is postinjection infection (endophthalmitis). Babies with active or recent ocular surface or lid infections (e.g., conjunctivitis) should not have intravitreal injection b. The risk of adverse systemic side effects (bradycardia, oxygen desaturation) is mitigated by the absence of systemic sedation/anesthesia, and the rapid nature of the procedure. However, it is reasonable to follow those precautions listed for laser treatment in Section F4. 8. Technique a. The baby’s eyes are dilated according to the standard dilation protocol. b. Sterile towels are placed around the baby’s head. c. Topical anesthetics are instilled. d. The lids are prepped with Betadine. e. Wire lid speculum is placed. f. The ca

  374 Section IX ■ Miscellaneous Procedures j. Portable argon or diode laser (9) with indirect (headlamp) delivery system k. Appropriate laser safety goggles 5. Precautions and Complications (Table 52.2) a. Ensure that laser is fully functional. b. If the infant is at high risk for an adverse event that would terminate treatment prematurely, treat the more advanced eye first (assuming both have threshold ROP). c. Discontinue feedings at least 4 hours before the procedure, or empty the stomach with an orogastric tube. d. Establish IV access for infusions of medications and IV fluids. e. Observe oxygen saturation monitor carefully, and adjust administered oxygen appropriately. Table 52.2 Complications of Laser for Retinopathy Complication Treatment/Action Systemic: Intra- and immediately postop Bradycardia Interrupt treatment. Assess airway, oxygen delivery. Atropine 0.1 mg IV Hypoxia/cyanosis Evaluate airway. Administer supplemental oxygen. Apnea Evaluate airway. Gentle stimulation. Adm

  Chapter 52 ■ Treatment of Retinopathy of Prematurity 375 f. Stabilize the infant: Correct electrolyte imbalances, platelet deficiency, etc. g. Use only 1% phenylephrine if there is a history of hypertension. h. Wipe off any excess drops spilling onto the skin to avoid transcutaneous absorption (skin vessel blanching occurs with phenylephrine). 6. Technique a. General preparation (1) Instill eyedrops (per orders from ophthalmologist) into both eyes in the hour prior to procedure. Maximal dilation is critical for optimum laser; therefore, several (three or four) instillations of drops may be required, especially in eyes with neovascularization/vascular engorgement of the iris. (2) Transport the patient to surgical suite or designated procedure room in the nursery. (3) Ensure monitors are attached and functioning. b. Immobilize infant: Swaddle in a clean towel or blanket to immobilize arms and legs. c. Ensure that the IV tubing is accessible. d. Administer IV sedation. If local anesthes

  Chapter 52 ■ Treatment of Retinopathy of Prematurity 373 (2) Administers topical anesthetic (3) Ensures that all personnel present at the treatment are wearing laser safety goggles (4) Performs the laser (5) Watches for and treats ocular complications that may arise during and after the procedure (6) Follows the baby postoperatively until ROP is resolved b. Neonatology fellow, attending neonatologist, or pediatric anesthesiologist (1) Administers systemic sedative agents (midazolam, fentanyl, ketamine, or a combination) (2) Monitors patient for and treats any systemic complications that develop during or after treatment (3) Provides information to the ophthalmologist regarding the patient’s overall condition throughout the procedure c. Assistant to the ophthalmologist (1) Helps with laser and instruments (2) Records the treatment parameters used during treatment d. Neonatal nurse (1) Instills dilating drops several times in the hour preceding treatment (2) Immobilizes the patient dur

  (1) Determines the need for treatment Table 52.1 Follow-up Examination Schedule Findings Follow-up Stage 1–2 in Zone 1 1 wk or less Stage 3 in Zone II Immature retina (no ROP) in Zone I 1–2 wk Stage 2 in Zone II Regressing ROP in Zone I Stage 1 in Zone II 2 wk Regressing ROP in Zone I Immature retina (no ROP) in Zone II 2–3 wk Regressing or Stage 1–2 in Zone III From Section on Ophthalmology, American Academy of Pediatrics, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus. Screening examinations of premature infants for retinopathy of prematurity. Pediatrics. 2006;117:572. Erratum Pediatrics 2006;118:1324. Fig. 52.1. Scheme of retina of right eye (RE) and left eye (LE), showing zone borders and clock hours employed to describe location and extent of retinopathy of prematurity. (From Committee for Classification of Retinopathy of Prematurity. An international classification of retinopathy of prematurity. Arch Ophthalmol. 1984;102:1130,

  370 Section IX ■ Miscellaneous Procedures References 1. McComb JG, Ramos AD, Platzker AC, et al. Management of hydrocephalus secondary to intraventricular hemorrhage in the preterm infant with a subcutaneous ventricular catheter reservoir. Neurosurgery. 1983;13:295. 2. Limbrick DD Jr, Mathur A, Johnston JM. Neurosurgical treatment of progressive posthemorrhagic ventricular dilation in preterm infants: a 10 year single institution study. J Neurosurg Pediatr. 2010;6:224. 3. Willis B, Javalkar V, Vannemreddy P, et al. Ventricular reservoir and ventriculoperitoneal shunts for premature infants with posthemorrhagic hydrocephalus: an institutional experience. J Neurosurg Pediatr. 2009;3:94. 4. Peretta P, Ragazzi P, Carlino CF, et al. The role of the Ommaya reservoir and endoscopic third ventriculostomy in the management of post-hemorrhagic hydrocephalus of prematurity. Childs Nerv Syst. 2007;23:765. 5. Brouwer AJ, Groenendaal F, Koopman C, et al. Intracranial hemorrhage in full term newbor

  371 William F. Deegan Jayashree Ramasethu Treatment of Retinopathy of Prematurity 52 Retinopathy of prematurity (ROP), a disorder of developing retinal blood vessels in the preterm infant, may lead to poor visual acuity or blindness. Screening and timely treatment improves visual outcomes. A. Screening for ROP (1–3) Guidelines for screening preterm infants for ROP are published and updated regularly (1–3). Recommendations for screening in the United States are (1) 1. Infants with a birth weight of <1,500 g or a gestational age of 30 weeks or less (as defined by the attending neonatologist). 2. Selected infants with a birth weight between 1,500 and 2,000 g or gestational age of more than 30 weeks with an unstable clinical course, including those requiring cardiopulmonary support and who are believed by their attending pediatrician or neonatologist to be a high risk. 3. The timing of the first exam varies with gestational age. The initial examination for infants born between 22 and