Search

Real-time echocardiography was used to position a pulmonary artery catheter in a septic child in whom the usual placement methods were not successful. This technique to facilitate pulmonary artery catheter placement avoids radiation, is portable and allows direct visualization of intracardiac catheter orientation. When smaller children and infants undergo pulmonary artery catheterization at the bedside, real-time echocardiography may allow catheter insertion when the usual techniques have failed.

Endogenous opiate peptides have been implicated in the cardiovascular depression of hemorrhagic shock. Beta-endorphin immunoreactivity was measured during hemorrhagic shock and the effects of beta-endorphin suppression during shock on cardiac hemodynamics and myocardial blood flow were studied. Fourteen dogs (group 1) were pretreated with 30 milligrams per kilogram of methylprednisolone (MP) prior to shock. Ten dogs (group 2) received saline solution and were the control group. All dogs were bled to a mean arterial blood pressure of 35 millimeters of mercury for two hours, then resuscitated with blood and lactated Ringer's solution. Beta-endorphin concentrations increased 600 per cent during shock in the control group. Dogs pretreated with MP had lower beta-endorphin concentrations (p less than 0.05) during shock than did dogs in the control group. The rate of left ventricular pressure rise (dp/dt) was significantly improved during shock (p less than 0.04) and after resuscitation (p less than 0.006) in dogs with suppressed beta-endorphin immunoreactivity. Blood flow from the coronary artery was higher during shock and after resuscitation (p less than 0.001) in the dogs in group 1. Our data indicate significant correlation between improved ventricular performance and decreased beta-endorphin levels in shock and after resuscitation.

Endogenous opiate peptides are released in early hemorrhagic shock and may mediate hypotension during hypovolemia. We compared the effects of naloxone alone versus incomplete volume resuscitation on survival and splanchnic blood flow. Dogs were bled to a MAP of 35 mm Hg for 2 hours. In eight dogs, shed blood was returned; eight dogs received naloxone (2 mg/kg bolus and 2 mg/kg/hr in 0.5 ml/kg/hr normal saline) with no shed blood returned. Seven dogs received normal saline alone without shed blood or naloxone and served as untreated controls. Untreated dogs survived a mean of 18.6 minutes. All other dogs survived for 180 minutes. Naloxone and shed blood were equally effective in improving hepatic and renal blood flow; gastric, intestinal, pancreatic, and splenic blood flow remained unchanged from shock values in both groups. These data indicate that in the face of hypovolemia naloxone improves survival and blood flow (ml/min/gm) to splanchnic organs despite no return of shed blood.

Golytely, a polyethylene glycol electrolyte solution (Braintree Laboratories, Braintree, MA), was evaluated in the preoperative bowel preparation of 21 infants and children. Weight, temperature, pulse, respiratory rate, and electrolyte concentrations were documented before and after mechanical bowel preparation. All children were given 25 mL/kg/h of Golytely until rectal effluent was clear and free of particulate matter. All preparations were started and completed the afternoon prior to surgery. Weight, vital signs, and electrolyte concentrations did not change significantly. All preparations were felt to be fair or excellent. Follow-up for 1 month postoperatively revealed no infectious complications. Golytely is safe and effective in preparing the bowel prior to surgery in children. Using Golytely can eliminate the need for multiple-day hospitalizations for bowel preparation and thus decrease the cost of medical care.

Numerous risk factors for necrotizing enterocolitis (NEC) including prematurity, bowel ischemia, pathogenic bacteria, and hyperosmolar feedings have been proposed. Recent studies have demonstrated feeding intolerance and bowel dysfunction in children with hypoalbuminemia. No association between hypoalbuminemia and NEC has been suggested. The records of 45 patients with NEC and complete documentation of prenatal and birth histories were reviewed. A control (CONT) group of 90 children matched for maternal age (+/- 1 year), parity, gestational age (+/- 1 week), birth weight (+/- 20 g), type of delivery, sex, race, type of initial feeding, and perinatal stress was compiled. While all other measured parameters were similar in the two groups, premorbid albumin was significantly lower in the patients who subsequently developed NEC (P less than .001). These data suggest that newborns with hypoalbuminemia may have an increased risk of developing NEC.

An 8-year-old American Indian girl presented with acute pancreatitis. Ultrasonography and computerized tomography (CT) showed two large cystic masses near the head of the pancreas. During 4 weeks of complete bowel rest and total parenteral nutrition, she had multiple exacerbations of pancreatitis without resolution of the cysts. There were no symptoms of biliary ductal obstruction. Endoscopic cholangiopancreatography (ERCP) showed an 8-cm pancreatic pseudocyst, pancreas divisum, and a 10-cm choledochal cyst. The junction of the common bile duct and the pancreatic duct of Wirsung had a normal relationship. She underwent a Roux-en-Y pseudocyst-jejunostomy and an accessory sphincteroplasty. Three months later, a choledochal cyst excision was performed with biliary reconstruction. The patient is well and asymptomatic 1 year later. This case suggests that pancreatic juice reflux into the common bile duct may not be the only etiology of choledochal cyst formation.

The effects of temperature on naloxone treatment in canine hemorrhagic shock were examined in 24 dogs hemorrhaged to a mean arterial blood pressure of 35 mm Hg (ambient temperature, 21 degrees C). After two hours of hypotension, the blood reservoir was clamped with no return of shed blood. Dogs were divided into three groups: Control (n = 8) received normal saline (0.5 cc/kg/hr); naloxone-cold (n = 8) and -warm (n = 8) received naloxone (2 mg/kg bolus and 2 mg/kg/hr constant infusion). Body temperature was maintained in four dogs with a warming blanket, and four dogs received no external warming. Rectal temperature fell to 34.2 +/- 0.9 degrees C in naloxone-cold animals; naloxone-warm animals were maintained at 38.6 +/- 0.1 degrees C by external warming. Control dogs rapidly deteriorated after reservoir clamping (survival, 18.6 +/- 5 min). Naloxone infusion significantly increased survival regardless of body temperature (cold, 125 +/- 21 min; warm, 199 +/- 13 min). Naloxone transiently increased mean arterial pressure and dP/dt in the colder dogs, while coronary perfusion, myocardial oxygen metabolism, and plasma beta-endorphin levels were unchanged. In the warmer dogs, naloxone significantly improved hemodynamic function and myocardial perfusion as indicated by the increased mean arterial pressure, cardiac output, stroke volume, dP/dt, and coronary blood flow. Furthermore, naloxone reduced plasma beta-endorphin levels and corrected the metabolic derangements of shock in this group. Our data indicate hypothermia significantly diminished the beneficial effects of naloxone treatment in canine hemorrhagic shock.

The chest tube is presented as a device for the tunneling of central venous catheters. It offers several advantages over currently recommended tunneling devices. It is readily available in multiple sizes to accommodate different diameter catheters, produces lengthy atraumatic tunnels, and can be bent into various shapes to facilitate passage through the subcutaneous tissues.

Intravenous (IV) vasopressin has been used to control human upper gastrointestinal (GI) hemorrhage for over 30 years. Although the use of vasopressin has been studied extensively in adults, no study has evaluated its use in children. Vasopressin was used therapeutically in 15 episodes of esophageal variceal hemorrhage and two episodes of bleeding peptic ulcer. Nine of 17 episodes were controlled with vasopressin alone (53%). Balloon tamponade and variceal sclerosis were required for control in the remainder. Blood requirements averaged 53 mL/kg prior to control of hemorrhage. Metabolic complications occurred in 65% of the episodes. There were two groups of patients identified: those receiving greater or those receiving less than .01 units/kg/min of IV vasopressin. All of the complications identified occurred when greater than .01 U/kg/min of vasopressin were used (P less than .05). Control of bleeding was not improved with higher doses of vasopressin. These data suggest that the use of IV vasopressin at doses greater than .01 U/kg/min to control GI bleeding will increase the incidence of complications without improving control of hemorrhage.

One hundred sixteen patients underwent a modified Thal fundoplication to correct gastroesophageal reflux (GER) between July 1, 1983, and January 30, 1987. Ninety-one percent of patients were relieved of GER. When patients were evaluated with respect to the presence or absence of CNS impairment there was a marked difference in the success rate of this procedure. Eight of 48 patients with CNS disorders had recurrent reflux with gastrostomy feedings after a modified Thal fundoplication (16%) while only two of 68 neurologically normal children had a failure of operation (3%; P less than .05). These data indicate that the modified Thal fundoplication is very effective in correcting GER in neurologically normal children but is less effective in children with CNS impairment.

Aspiration of foreign bodies in children can lead to illness and even death if not recognized and treated promptly. Seventy-six patients were referred to our hospital for suspected foreign body aspiration. The following is a retrospective review of their diagnosis and treatment. There was no foreign body found at bronchoscopy in seven patients (9 percent), and there were nine patients (12 percent) with bronchial foreign bodies who had a delay in diagnosis of foreign body aspiration. The delay averaged 35 days. These children, as a result of a prolonged period before diagnosis, were treated unnecessarily for pneumonia and asthma. Once correctly diagnosed, they had a significantly longer hospital stay. We propose that some negative bronchoscopies are necessary in order to prevent the morbidity that occurs from a missed foreign body aspiration.