Limits...
Urosepsis and postrenal acute renal failure in a neonate following circumcision with Plastibell device.

Kalyanaraman M, McQueen D, Sykes J, Phatak T, Malik F, Raghava PS - Korean J Pediatr (2015)

Bottom Line: Occasionally, instead of falling off, the device may get buried under the skin along the shaft of the penis, thereby obstructing the normal flow of urine.Necrosis of penile skin, followed by urethral obstruction and renal failure, is a serious surgical mishap requiring immediate corrective surgery and medical attention.Immediate medical management was initiated with fluid resuscitation and mechanical ventilation; thereby correcting life threatening complications.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatric Critical Care Medicine, Children's Hospital of New Jersey at Newark Beth Israel Medical Center, Newark, NJ, USA.

ABSTRACT
Plastibell is one of the three most common devices used for neonatal circumcision in the United States, with a complication rate as low as 1.8%. The Plastibell circumcision device is commonly used under local anesthesia for religious circumcision in male neonates, because of cosmetic reasons and ease of use. Occasionally, instead of falling off, the device may get buried under the skin along the shaft of the penis, thereby obstructing the normal flow of urine. Furthermore, the foreskin of neonates is highly vascularized, and hence, hemorrhage and infection are possible when the skin is cut. Necrosis of penile skin, followed by urethral obstruction and renal failure, is a serious surgical mishap requiring immediate corrective surgery and medical attention. We report a case of fulminant urosepsis, acute renal failure, and pyelonephritis in a 4-day-old male neonate secondary to impaction of a Plastibell circumcision device. Immediate medical management was initiated with fluid resuscitation and mechanical ventilation; thereby correcting life threatening complications. Pediatricians and Emergency Department physicians should be cognizant of the complications from Plastibell circumcision device in order to institute appropriate and timely management in neonates.

No MeSH data available.


Related in: MedlinePlus

Ultrasound image of the urinary bladder. The urinary bladder (between crosshairs) was distended to 60 mL, which was the estimated maximal capacity for a neonate, and which contained multiple foci of increased echogenicity (white arrows) representing retained debris, findings consistent with obstruction.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4414631&req=5

Figure 2: Ultrasound image of the urinary bladder. The urinary bladder (between crosshairs) was distended to 60 mL, which was the estimated maximal capacity for a neonate, and which contained multiple foci of increased echogenicity (white arrows) representing retained debris, findings consistent with obstruction.

Mentions: Ultrasound of the abdomen showed bilateral hydronephrosis with the right kidney measuring 5.6 cm×3.1 cm×2.9 cm, and the left kidney measuring 5.8 cm×3.5 cm×3.2 cm and urinary bladder was distended to 60 mL with multiple foci of increased echogenicity consistent with bladder obstruction (Figs. 2, 3). Penile block was performed using 1% lidocaine and the Plastibell device was removed. Urinary catheterization was done and urine was purulent. After immediate output of 80 mL, patient remained polyuric with urine output as high as 19.5 mL/kg/hr. Patient received a fluid bolus of 20 mL/kg of normal saline, 2 mEq/kg of sodium bicarbonate, and urine output replacements with fluid containing 77 mEq of sodium as sodium bicarbonate initially and then sodium chloride after correction of acidosis. Patient was started on ampicillin and cefotaxime. Patient had significant respiratory distress and became bradypneic and hence was intubated and placed on mechanical ventilation. Blood and urine cultures grew Escherichia coli within 24 hours of sampling. Patient remained thrombocytopenic and was transfused with platelets when the count decreased to 15,000/µL. His hemoglobin decreased to 7.4 g/dL after hydration and blood loss following central venous line and arterial line catheterization. He received packed red blood cell transfusion. Patient was extubated on the third day of hospitalization and at this time urine output decreased to 3 mL/kg/hr and creatinine was 0.38 mg/dL. On the seventh day of hospitalization, patient was febrile and grew E. coli from the blood again after a previous negative blood culture. The glans penis by this time appeared well healed. Renal ultrasound at this time showed a slight decrease in the size of the kidneys, with the right kidney measuring 4.5 cm×2.7 cm×2.3 cm, and the left kidney measuring 5.0 cm×2.1 cm×1.9 cm. Increased echogenicity was noted in the upper pole of the right kidney, and there was echogenic nonshadowing debris in the collecting system of the left kidney with increased collecting system dilatation since the previous examination. These findings possibly represented pyelonephritis, and papillary necrosis. Based on sensitivities of the E. coli, cefotaxime was continued and gentamicin was added. Ampicillin was discontinued and patient remained afebrile for the remainder of hospitalization. Voiding cystourethrogram did not show vesicouretral reflux or obstruction. He was discharged 11 days after hospitalization and was on cephalexin for one week following discharge. Patient was noted to be thriving well without any complications on follow-up examinations.


Urosepsis and postrenal acute renal failure in a neonate following circumcision with Plastibell device.

Kalyanaraman M, McQueen D, Sykes J, Phatak T, Malik F, Raghava PS - Korean J Pediatr (2015)

Ultrasound image of the urinary bladder. The urinary bladder (between crosshairs) was distended to 60 mL, which was the estimated maximal capacity for a neonate, and which contained multiple foci of increased echogenicity (white arrows) representing retained debris, findings consistent with obstruction.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4414631&req=5

Figure 2: Ultrasound image of the urinary bladder. The urinary bladder (between crosshairs) was distended to 60 mL, which was the estimated maximal capacity for a neonate, and which contained multiple foci of increased echogenicity (white arrows) representing retained debris, findings consistent with obstruction.
Mentions: Ultrasound of the abdomen showed bilateral hydronephrosis with the right kidney measuring 5.6 cm×3.1 cm×2.9 cm, and the left kidney measuring 5.8 cm×3.5 cm×3.2 cm and urinary bladder was distended to 60 mL with multiple foci of increased echogenicity consistent with bladder obstruction (Figs. 2, 3). Penile block was performed using 1% lidocaine and the Plastibell device was removed. Urinary catheterization was done and urine was purulent. After immediate output of 80 mL, patient remained polyuric with urine output as high as 19.5 mL/kg/hr. Patient received a fluid bolus of 20 mL/kg of normal saline, 2 mEq/kg of sodium bicarbonate, and urine output replacements with fluid containing 77 mEq of sodium as sodium bicarbonate initially and then sodium chloride after correction of acidosis. Patient was started on ampicillin and cefotaxime. Patient had significant respiratory distress and became bradypneic and hence was intubated and placed on mechanical ventilation. Blood and urine cultures grew Escherichia coli within 24 hours of sampling. Patient remained thrombocytopenic and was transfused with platelets when the count decreased to 15,000/µL. His hemoglobin decreased to 7.4 g/dL after hydration and blood loss following central venous line and arterial line catheterization. He received packed red blood cell transfusion. Patient was extubated on the third day of hospitalization and at this time urine output decreased to 3 mL/kg/hr and creatinine was 0.38 mg/dL. On the seventh day of hospitalization, patient was febrile and grew E. coli from the blood again after a previous negative blood culture. The glans penis by this time appeared well healed. Renal ultrasound at this time showed a slight decrease in the size of the kidneys, with the right kidney measuring 4.5 cm×2.7 cm×2.3 cm, and the left kidney measuring 5.0 cm×2.1 cm×1.9 cm. Increased echogenicity was noted in the upper pole of the right kidney, and there was echogenic nonshadowing debris in the collecting system of the left kidney with increased collecting system dilatation since the previous examination. These findings possibly represented pyelonephritis, and papillary necrosis. Based on sensitivities of the E. coli, cefotaxime was continued and gentamicin was added. Ampicillin was discontinued and patient remained afebrile for the remainder of hospitalization. Voiding cystourethrogram did not show vesicouretral reflux or obstruction. He was discharged 11 days after hospitalization and was on cephalexin for one week following discharge. Patient was noted to be thriving well without any complications on follow-up examinations.

Bottom Line: Occasionally, instead of falling off, the device may get buried under the skin along the shaft of the penis, thereby obstructing the normal flow of urine.Necrosis of penile skin, followed by urethral obstruction and renal failure, is a serious surgical mishap requiring immediate corrective surgery and medical attention.Immediate medical management was initiated with fluid resuscitation and mechanical ventilation; thereby correcting life threatening complications.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatric Critical Care Medicine, Children's Hospital of New Jersey at Newark Beth Israel Medical Center, Newark, NJ, USA.

ABSTRACT
Plastibell is one of the three most common devices used for neonatal circumcision in the United States, with a complication rate as low as 1.8%. The Plastibell circumcision device is commonly used under local anesthesia for religious circumcision in male neonates, because of cosmetic reasons and ease of use. Occasionally, instead of falling off, the device may get buried under the skin along the shaft of the penis, thereby obstructing the normal flow of urine. Furthermore, the foreskin of neonates is highly vascularized, and hence, hemorrhage and infection are possible when the skin is cut. Necrosis of penile skin, followed by urethral obstruction and renal failure, is a serious surgical mishap requiring immediate corrective surgery and medical attention. We report a case of fulminant urosepsis, acute renal failure, and pyelonephritis in a 4-day-old male neonate secondary to impaction of a Plastibell circumcision device. Immediate medical management was initiated with fluid resuscitation and mechanical ventilation; thereby correcting life threatening complications. Pediatricians and Emergency Department physicians should be cognizant of the complications from Plastibell circumcision device in order to institute appropriate and timely management in neonates.

No MeSH data available.


Related in: MedlinePlus