Transseptal decompression of the left heart during ECMO for severe myocarditis.

A 16-month-old boy suffered a cardiac arrest as a result of acute myocarditis, and venoarterial extracorporeal membrane oxygenation was instituted. Twelve hours later, acute left heart distention developed with cessation of left ventricular ejection. Under transesophageal echocardiographic guidance, a long introducer was placed into the left atrium through a transseptal puncture and connected in-line to the venous circuit. Within hours, left ventricular function improved and ejection returned. Left heart decompression was continued for 5 days, and the patient was weaned from extracorporeal membrane oxygenation after 6 days with normal cardiac and neurologic function.

An appropriate negative bronchoscopy rate in suspected foreign body aspiration.

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.

Adenocarcinoma of the colon in adolescents.

A retrospective study was carried out in nine children between the ages of 10 and 20 years with adenocarcinoma of the colon. No family history, significant medical history, or predisposing factors were identified, except for Turcot's syndrome in one child. Common presenting signs and symptoms were vague abdominal pain, nausea and vomiting, weight loss, change in bowel habits, and guaiac-positive stools. Five of the patients' diagnoses were delayed for an average of 11.6 months, the majority of whom had Dukes' D disease. Their median survival was 4 months compared with 24 months in the four patients diagnosed early. As with adults, the mainstay of therapy is operation. Our data indicate that an increased awareness and consideration of colon cancer in children will result in earlier diagnosis, a more favorable disease stage, and prolonged survival.

Morbidity and mortality of an endemic pathogen: methicillin-resistant Staphylococcus aureus.

Over an 8-year period, two epidemics of methicillin-resistant Staphylococcus aureus (MRSA) occurred in a burn unit. Sources of sepsis were the burn wound and lung. Fourteen percent of the patients colonized with MRSA became bacteremic. The mean postburn day of bacteremia was 19 and the mortality rate was 5 percent. MRSA was introduced to the burn unit when a patient was transferred from another unit, on readmission of a previously infected patient, or heavy burn census when MRSA was epidemic in the hospital. Although the morbidity rate associated with MRSA infections was high, the mortality rate was low. Gram-negative sepsis has continued to be more lethal.

Advances in pediatric surgical critical care.

The advances in pediatric intensive care outlined here point out the differences between children and adults that need to be considered when taking care of children with surgical diseases. In the past, advances in pediatric critical care have not kept pace with advances in adult care, but these and other new techniques have rapidly closed this gap in knowledge.

The chest tube: a simple device for the tunneling of central venous catheters.

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.

Pancreas divisum, pancreatic pseudocyst, and choledochal cyst in an 8-year-old child.

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.

Real-time echocardiography: a new technique to facilitate Swan-Ganz catheter insertion.

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.

Intravenous vasopressin and gastrointestinal hemorrhage in children.

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.

Hypoalbuminemia may predispose infants to necrotizing enterocolitis.

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.

Outpatient bowel preparation in children.

A polyethylene glycol electrolyte solution was evaluated as a mechanical bowel preparation prior to surgery in an outpatient setting. Twelve children underwent outpatient bowel preparation (OPBP) prior to a variety of surgical procedures. The technique was well tolerated and consistently produced a well-prepared intestinal tract. This technique will decrease the overall cost of hospitalization, and it enhances patient and parental acceptance of mechanical bowel preparation.

Dog bites in children.

Dog bites, a common cause of traumatic injury, tend to be a greater source of morbidity and mortality in children than in adults. We evaluated 13 children, who, during a 10-year period, required surgical intervention for dog bites. The greatest cause of morbidity in these children was the penetrating component of the dog bite. Most initial evaluations focused on the crushing component of the bite, but in children with serious dog bites, wounds must be evaluated with respect to both the crushing and penetrating injury components.

Rapid isotonic fluid resuscitation in pediatric thermal injury.

Intravenous fluid resuscitation within the first 24 hours after a burn is critical to prevent shock and maintain organ function. The Parkland burn resuscitation formula suggests that one half of the first 24-hour fluid requirement be given in the first 8 hours. Results of recent studies in animals suggest that compression of the first half of the initial resuscitation from 8 to 4 hours may have a physiological benefit. We reviewed the medical records of 44 children under 12 years of age who had burns of greater than 29% of total body surface. Twenty-two children received a standard resuscitation of one-half volume given over the first 8 hours, followed by one-half volume over the next 16 hours. Twenty-two children received a rapid isotonic fluid resuscitation of one-half volume over 4 hours or less, followed by the remainder given over 20 hours. Vital signs, urine output, urine specific gravity, blood gases (acidosis), ventilator need, morbidity, and mortality were compared between the two groups. The rapid group had increased normalization of vital signs (P < .001), increased urine output and normalization of urine specific gravity (P < .01), and decreased requirement for ventilator support (P < .05). The authors conclude that rapid isotonic fluid resuscitation is well tolerated by pediatric patients and may be better than the standard burn resuscitation technique.

Operative treatment of anterior ectopic anus: the efficacy and influence of age on results.

In our experience, anterior ectopic anus (AEA) is a common cause of constipation in children. We have performed 54 anoplasties for AEA in the past 8 years. Seventy-eight percent of the patients were girls. The average age at surgery was 23.8 months and the average stool frequency prior to surgery was once every 3.2 days. Eighty percent of the children had undergone attempts at medical therapy. We compared the functional results of anoplasty in children by age. The children who had surgery prior to the age of 6 months had a significantly better outcome than did older children. These data suggest that patients with AEA have a better response to operative therapy when anoplasty is performed prior to 6 months of age. Early recognition, referral, and surgery is appropriate therapy in this patient group.

The efficacy of Thal fundoplication in the treatment of gastroesophageal reflux: the influence of central nervous system impairment.

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.

The safety and cost-effectiveness of polyethylene glycol electrolyte solution bowel preparation in infants and children.

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.

Improvement in catheter sepsis rate in burned children.

Routine frequent central venous catheter (CVC) changes in burned patients (either change in insertion site or change over guidewires) has been advocated to decrease catheter-related sepsis. The need for this management has not been verified for children with burns. We reviewed our pediatric burn population with regard to CVC sepsis rate and individual CVC longevity to confirm this traditional policy. From 1978 to 1988, 70 children admitted to the Children's Hospital of Oklahoma Burn Unit required central venous access. Patients in whom CVCs were changed frequently (FC), (n = 10; no. of CVC, 46) were compared with those in whom CVCs were changed only for mechanical complications or sepsis (NFC), (n = 60; no. of CVC, 74). There were 10 septic CVCs in each group. The difference in mean length of individual CVC use between FC and NFC was significant (4.6 v 17.7 days; P less than .01). The difference in the number of septic CVCs per total number of catheter days in each group was highly significant (FC: 10 CVC/212 d. = 0.05; NFC: 10 CVC/1,112 d = 0.009; P less than .001). This study demonstrates a significant decrease in catheter-related sepsis when CVCs are not changed on a routine frequent basis.

Extracorporeal life support for nonimmune hydrops fetalis.

BACKGROUND/PURPOSE: Most babies born with idiopathic nonimmune hydrops fetalis (NIHF) suffer generalized cardiopulmonary collapse and die despite maximal medical therapy. With reported survival rates of less than 10%, many centers consider NIHF an unsalvageable situation and the babies who have this condition, untreatable. In this study, the authors questioned if the aggressive use of extracorporeal life support (ECLS) could salvage this condition and improve the chances of survival for babies born with NIHF. METHODS: The Extracorporeal Life Support Organization's (ELSO) neonatal registry was searched for all available information on babies treated for hydrops fetalis. The ELSO records of all hydropic babies were then reviewed to exclude those babies who had identifiable causes of hydrops. Survival statistics were then calculated for the remaining core group of idiopathic NIHF babies before separating them into two groups based on survival. A detailed analysis comparing the survivors with nonsurvivors was then performed. RESULTS: A total of 28 hydropic babies were identified in the ELSO registry. Four babies were excluded from analysis because of identifiable causes of hydrops (two with congenital diaphragmatic hernia, one with Rh incompatibility, and one with fetal anemia). Of the remaining 24 babies who had NIHF, 54% (13 babies) survived the neonatal period and were discharged from the hospital. Analysis comparing the survivors with the nonsurvivors in our study showed that the groups were similar in their gestational ages, birth weights, Apgar scores and the time to initial intubation. The most distinguishing factor of survival in our study was that the survivors, on average, received ECLS support 3 days sooner than nonsurvivors (mean, 17.5 +/- 1.3 hours of life for survivors v 105 +/- 36.6 hours for nonsurvivors, P < or = .05). CONCLUSION: Idiopathic NIHF should no longer be considered an untreatable condition but a new indication for ECLS that, when begun early, may significantly improve the chances of survival for these babies previously considered "unsalvageable."

Treating the snakebitten child in North America: a study of pit viper bites.

BACKGROUND/PURPOSE: Snakebite envenomation is a potentially life-threatening form of trauma, the dangers of which are amplified in children because their smaller size increases the relative dose of venom received. The authors reviewed a large series of snakebitten children to address the medical and fiscal issues of treating these patients. METHODS: The records of 37 snakebitten children (1987 through 1997) were analyzed for demographic data, signs of envenomation, use of specific therapies (antivenin, blood products, or surgery), length of hospitalization, complications, and cost of care. RESULTS: Fifty-four percent of the children had a major envenomation demonstrated by systemic symptomatology, laboratory analysis, or need for surgery. All children made full recoveries with most receiving only supportive care (92%). The average time to emergency department presentation was 8 hours, where all children with major envenomations and those requiring specific therapies (surgery, clotting factors) were identified. Cost analysis showed an average of $2,450 dollars per child with the majority of expenses attributable to length of hospitalization. CONCLUSIONS: Most snakebitten children completely recover with minimal supportive care, and they can be cared for safely and cost effectively as outpatients if no signs of major envenomation are noted within 8 hours of the bite.

End-tidal carbon dioxide for monitoring primary closure of gastroschisis.

Previous criteria for primary reduction of the herniated viscera in newborn infants with gastroschisis included intraoperative respiratory rate, cardiac indices, degree of viscero-abdominal disproportion, size of defect, and lower extremity turgor. From 1976 through 1993, 129 neonates with gastroschisis were treated at Children's Hospital of Oklahoma. Intraoperative end-tidal carbon dioxide (ETCO2) monitoring was standard therapy beginning in 1985. The authors evaluated the effect of abdominal closure on ETCO2 to determine if there was a particular ETCO2 level at which closure was not feasible. There was no difference in overall mortality, birth weight, or postoperative ventilation requirements between children who had closure before 1985 (ie, without ETCO2 monitoring) and those who had repair after 1985. However, more cases in the 1985-1993 group had primary closure, and none of these required conversion to a staged procedure. An ETCO2 of > or = 50 suggests that primary closure may be unsafe. These data suggest that infants with gastroschisis can have primary closure based on intraoperative ETCO2 monitoring; no additional invasive monitoring would be necessary to assess closure.