Topical nitroglycerin ointment as salvage therapy for peripheral tissue ischemia in newborns: a systematic review

Sushko, Katelyn; Litalien, Catherine; Ferruccio, Lauren F; Gilpin, Andréa; Mazer‐Amirshahi, Maryann; Chan, Anthony; J, van den Anker; Lacaze‐Masmonteil, Thierry; Samiee-Zafarghandy, Samira

doi:10.9778/cmajo.20200129

Cited by 7 publications

(18 citation statements)

References 31 publications

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“…A recent systematic review by Sushko et al, 26 9 Concerning the duration of treatment, it varies from 3 h to 27 days, depending on the clinical response: usually the discontinuation is considered when signs of perfusions, (e.g., skin discoloration resolution) clearly appear. 3 Based on our experience and on the scientific literature so far reported, we strongly recommend the application of 2% NTG ointment as soon as possible when the ischemic lesions appear, referring to the upon reported dosage of 4 mm/kg.…”

Section: Discussionmentioning

confidence: 99%

“…A recent systematic review by Sushko et al, 26 including 23 articles (case reports, case series, and retrospective audit) about newborns treated with NTG ointment, patch or spray concluded that NTG ointment represents a safe therapeutic modality for neonatal tissue ischemia, although its production in Canada was discontinued in July 2018. Luckily, to date, in Italy NTG ointment, or at least its galenic preparation, is easily disposable.…”

Section: Discussionmentioning

confidence: 99%

“…The application of ointment can be repeated after 6/8 h if lesions reappear or fail to resolve. We do not advise on NTG patch or spray since the scientific evidence at this point is extremely limited 26 and we have no direct experience of using this alternative options. However, we believe that their use does not allow adequate adaptability of doses and respect of boundaries of the lesions.…”

Section: Discussionmentioning

confidence: 99%

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Neonatal ischemic limb lesions: From etiology to topical nitroglycerine. A case series analysis

Falsaperla

Bianco

Giugno

et al. 2022

Dermatologic Therapy

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Although rare, ischemic lesions in neonates may occur in Neonatal Intensive Care Units (NICUs) secondary to routine procedures and/or medicaments. We present double‐center case series, reporting three preterm neonates with ischemic lesions following cardiac arrest and radial blood sampling. The overall outcome after treatment with 2% nitroglycerine (NTG) ointment showed optimal results with no adverse events. The most frequent causes responsible for the onset of such lesions are peripheral arterial catheterization procedures and dopamine extravasation. Our series describe the cardiac arrest as an underestimated cause of onset. Despite the optimal results emerging from the treatment of such lesions with NTG ointment, both in our experience and in the scientific literature, a defined protocol for its use in NICUs is not currently available, hence the need for further studies.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Neonatal ischemic limb lesions: From etiology to topical nitroglycerine. A case series analysis

Falsaperla

Bianco

Giugno

et al. 2022

Dermatologic Therapy

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“…The best strategy for managing extravasation is prevention as well as checking intravenous line access repeatedly [ 9 ]. The current approach to neonatal peripheral extravasation appears to be conservative management, which includes removing an intravenous catheter, limb elevation, applying warmth on an opposite limb( reflex vasodilation), elastic bandaging, manual lymphatic drainage immobilization, and local dressing [ 14 , 15 ]. Many treatments and methods are discussed, such as antidote injection for neutralizing vesicant solution of chemotherapy extravasation [ 16 ].…”

Section: Introductionmentioning

confidence: 99%

“…Many treatments and methods are discussed, such as antidote injection for neutralizing vesicant solution of chemotherapy extravasation [ 16 ]. Furthermore, applying topical nitroglycerin (TNG) ointment on the tissue ischemic injuries of neonates with 76.0% complete recovery may be effective [ 15 ]. TNG is useful in the extravasation of vassopressors due to its local vasodilatory effect [ 17 ].…”

Section: Introductionmentioning

confidence: 99%

A new approach to skin extravasation injury management during the neonatal period

2022

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Background To identify a standard protocol for managing extravasation injuries in neonates. Methods We recruited all the neonates with extravasation wounds from the neonatal intensive care unit of Shariati hospital, Tehran, Iran, between October 2018 and October 2020. Sixteen patients with grade 3–4 extravasation were evaluated in this retrospective study. All grade 3 and 4 extravasation wounds were injected with hyaluronidase at 5 points of the wound circle; the procedure was repeated every 5 min at different points in a smaller circle to the core. The wound was then covered with a warm compress for 24 h. Twenty-four hours after injection, the cover was changed twice a day with normal saline irrigation. Fibrinolysin ointment was applied on top of the wound. The ulcer was then dressed with phenytoin ointment until healing. Results Out of 16 neonates who were followed up, 10 of them were male, with the average birth weight being 1.37 (range 1.05–3.75) kg. The mean (± SD) wound healing duration was 13.12 (± 6) (range: 7–29) days. Factors including the cannulation duration before the appearance of the lesion (R:0.2, P = 0.2), birth weight (R = -.37, P = 015), and extravasated substances (p = 0.2) were not associated with the duration of hospital stay. The only exception to this trend is the wound size factor of 7.31(± 7.45) (R = .83, P < 0.001). Continuous and categorical variables were summarized as mean (SD) and proportions, respectively, and the Kruskal–Wallis test and Spearman correlation coefficients were used. Conclusions Limited evidence exists on the effects of different protocols on extravasation management in neonates in the NICU. We recommend our method as a standard protocol in NICU for high-stage extravasated lesions because of the shorter duration of healing, non-invasive nature of this procedure, and lack of side effects or surgical involvement.

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Topical nitroglycerin in newborns with ischemic injuries: A systematic review

Mosalli

Khayyat

Qarni

et al. 2021

Saudi Pharmaceutical Journal

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Background Arterial catheterization is frequently performed in neonatal intensive care units with an inherent risk of peripheral ischemic injury, especially in preterm infants. The treatment options following vascular damage involve invasive and non-invasive modalities. The primary objective of this systematic review was to evaluate the evidence of the use of topical nitroglycerine (TNG) either alone or as adjunctive therapy. The secondary aim was to develop an approach to the treatment of catheter induced ischemia in infants based on the available evidence. Methods A comprehensive search was conducted of available databases for relevant articles that involved the treatment of peripheral tissue ischemia in neonates with the use of TNG. Citations were restricted to human subjects. Results Six hundred and eighty-nine articles were identified, and twenty-seven case reports and case series were compatible with the inclusion and exclusion criteria. Sixty-eight infants out of the 76 published cases (89%) experienced a favorable outcome and 79% (n = 60) demonstrated complete recovery with the topical application of TNG to the ischemic site. Conclusion The available evidence demonstrates that TNG is effective for the treatment of peripheral ischemia in neonates after standard conservative measures have failed. However, due to the absence of robust evidence for this therapeutic modality, there are no uniform guidelines regarding the frequency, duration, and safety of TNG use. Planning the management of peripheral ischemia in neonates with TNG should be a multidisciplinary decision that includes close surveillance of blood pressure, methemoglobin levels, and follow up cranial ultrasound.

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Topical nitroglycerin ointment as salvage therapy for peripheral tissue ischemia in newborns: a systematic review

Cited by 7 publications

References 31 publications

Neonatal ischemic limb lesions: From etiology to topical nitroglycerine. A case series analysis

Neonatal ischemic limb lesions: From etiology to topical nitroglycerine. A case series analysis

A new approach to skin extravasation injury management during the neonatal period

Topical nitroglycerin in newborns with ischemic injuries: A systematic review

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