Continuous extracorporeal fluid removal in children with low cardiac output after cardiac operations.

Eleven hypervolemic and oliguric children with low cardiac output after cardiac operations were treated by slow continuous ultrafiltration or continuous arteriovenous hemofiltration. A mean negative fluid balance of 1.63 +/- 0.37 ml/kg/hr (standard error of the mean [SEM]) significantly improved the hemodynamic status within 59 +/- 6.1 hours (SEM). Although the central venous pressure decreased significantly from 15.2 +/- 0.84 to 8.8 +/- 0.92 mm Hg (p less than 0.0001), the mean arterial pressure increased significantly from 41.5 +/- 2.54 to 53.5 +/- 2.21 mm Hg (p less than 0.001). In addition, pH increased significantly from 7.31 +/- 0.01 (SEM) to 7.43 +/- 0.001 (SEM) (p less than 0.001) and oxygenation index (arterial oxygen tension/inspired oxygen fraction) from 119 +/- 15.2 (SEM) to 214 +/- 27.0 (SEM) (p less than 0.001). Hemodynamic improvement during slow continuous extracorporeal fluid removal allowed a significant decrease of the catecholamine infusion rate. After normovolemia had been achieved, continuous arteriovenous hemofiltration had to be continued in four children because of persistent anuria. Eight patients could be weaned from artificial ventilation and vasopressor support. Two patients died without recovery of renal function and one with restored renal function. Slow continuous ultrafiltration and continuous arteriovenous hemofiltration improve the cardiovascular function in children with low cardiac output by optimizing the preload conditions of the failing heart. In addition, they improve acid-base balance and pulmonary gas exchange.

Five years experience with continuous extracorporeal renal support in paediatric intensive care.

Continuous arterio-venous haemofiltration (CAVH) and continuous veno-venous haemofiltration (CVVH) were used as renal support in 52 critically ill infants and children with acute renal failure. The majority of the patients were on mechanical ventilation (90%) and needed vasopressor support (85%). Uraemia was satisfactorily controlled with both treatment modes. Post-treatment serum urea levels were not different between survivors (94 +/- 8.8 mg/dl) and non-survivors (99.5 +/- 8.8 mg/dl). There were significant differences between survivors and non-survivors in the mean arterial pressure (64.7 +/- 3.8 vs 48.0 +/- 2.2 mmHg, p less than 0.001), the number of organ system failures (2.9 +/- 0.16 vs 3.8 +/- 0.21, p less than 0.025), and the severity of illness assessed by the acute physiologic score for children (APSC 19.4 +/- 1.9 vs 26.3 +/- 1.9, p less than 0.01). The overall mortality was 48%. The mortality in the CVVH group (65%) was higher than in the CAVH group (40%). Death was significantly related to sepsis (p less than 0.005) and multiple system organ failure (p less than 0.005). A major complication during CAVH was one femoral artery thrombosis after 12 days of treatment. Technical problems were only observed during CVVH. CAVH and CVVH are safe and effective methods of continuous renal support for critically ill paediatric patients with multiple system organ failure. CAVH is simpler, needs no specially trained staff and seems to the ideal renal replacement system for critically ill infants.

Differentiation of lymph-node metastases by anti-CEA immunoscintigraphy in a patient with follicular thyroid and breast cancer.

Supraclavicular lymph node metastases appeared in a female patient six years after thyroidectomy, radioiodine therapy and external radiation for a follicular thyroid carcinoma and four years after mastectomy and lymphadenectomy for an invasive ductal breast cancer. It was not possible either by conventional imaging methods or by serological methods, to assign the metastases to one of the two primary tumors. Anti-CEA immunoscintigraphy and SPECT of the cervicothoracic region showed a circumscribed pathological uptake of 99mTc-labeled anti-CEA antibodies in the area of the supraclavicular lymph nodes. The preoperative suspicion of lymph-node infiltration by CEA-expressing breast cancer cells was confirmed histologically after surgical removal of the lymph nodes.

Mechanical support of the left ventricle in ischemia induced left ventricular failure: an experimental study.

OBJECTIVE: this study compares the hemodynamic effects of intra-aortic balloon pumping (IABP), left ventricular assist device (LVAD), and extracorporeal membrane oxygenation (ECMO) in left ventricular failure in pigs. METHODS: In 29 pigs weighing 12 +/- 0.7 kg left ventricular failure was induced by ligating the left anterior descending coronary artery. Eight animals served as controls. Eight pigs were treated by IABP, seven by LVAD, and six by ECMO. The study period lasted four hours. Hemodynamic and oxygen transport/uptake parameters were measured continuously or intermittently. RESULTS: Six animals of the ECMO and LVAD groups survived the 4 hour period, but only 3 and 4 animals of the IABP and control groups survived (p less than 0.05). Cardiac index decreased about 48% and 22% in the control and IABP groups (p less than 0.05), whereas there was only a slight decrease in the ECMO (9%) and LVAD (14%) groups. Oxygen delivery fell significantly in the control and IABP groups (p less than 0.05), compared with only a slight change in the LVAD and ECMO groups. CONCLUSION: ECMO is the most effective system for temporary circulatory support in severe ventricular failure. LVAD maintains cardiac output when pulmonary blood flow is provided. IABP is less efficient in supporting the failing heart, especially in the presence of severe ventricular arrhythmias.

[Acute interstitial nephritis in childhood]. / Die akute interstitielle Nephritis im Kindesalter.

Acute tubulointerstitial nephritis (TIN) was diagnosed during a 10-year period in 6 previously healthy children (4 boys) with a mean age of 10 years (range 2.5-14 years). All presented with a non-specific history. First laboratory findings were nearly identical, with a raised erythrocyte sedimentation rate and non-oliguric renal failure; the urine contained protein, glucose, and leucocytes, but no bacteria. A serologically proven infection (streptococcal infection 2x; mononucleosis 1x) or drug-related TIN (penicillin) was present in 4 children; in one, both conditions could have been responsible. One girl suffered from idiopathic TIN with uveitis. Rapid progression of renal failure occurred in 3 children, but the response to steroid therapy was satisfactory. No dialysis was necessary and all patients showed a complete recovery. We think that acute TIN occurs more frequently than suggested previously. Many episodes are probably mild or subclinical and the rate of spontaneous remission is high. The results of initial laboratory evaluation in conjunction with acute renal failure and predominantly proximal tubular dysfunction, are sufficiently typical to arouse suspicion of acute TIN at an early stage, although they do not permit any conclusion as to the aetiology.

Continuous arteriovenous hemodialysis in critically ill infants.

Continuous arteriovenous hemofiltration (CAVH) and continuous arteriovenous hemodialysis (CAVHD) were performed in 6 critically ill infants with hypervolemia and anuria using the Amicon Minifilter and Minifilter plus. The ultrafiltration rates produced during CAVH and CAVHD were 2.1 +/- 0.3 and 1.7 +/- 0.4 ml/min/m2 and the urea clearances were 2.0 +/- 0.4 and 6.6 +/- 1.4 ml/min/m2. Serum creatinine and urea levels increased during CAVH and decreased during CAVHD. Both treatment modes were well tolerated by all infants. CAVHD is superior to CAVH in terms of urea clearance and maintains all advantages of CAVH such as simplicity and safety.

[Sex education, sex behavior, contraception]. / Sexualaufklärung, Sexualverhalten, Kontrazeption.

Sexual behavior has changed during the last decades. Teenage fertility rate, and the number of gonococcal infections are both extremely high; the incidence of HIV-infections is increasing. Preventive measures include sex education. Sex education may help the adolescents to identify their own goals for sexual behavior, to avoid unintended and unwanted pregnancy, and to avoid sexually transmitted diseases.

PIP: Data indicate that in the US 10-20% of boys and 5-10% of girls have their 1st sexual intercourse at age 14 and 50% at age 17 during which 70% do not use safe contraception. In 1981 a total of 1 million teenagers became pregnant, and 400,000 underwent abortion. The incidence of gonorrhea is 1300/100,000 among adolescents aged 15-19, and AIDS is spreading among this age group. The role of sex education is vital in providing the right information mainly through the school, as parents often feel uneasy about the topic, and youth organization and religious community groups tend to be too ideological. The teachers have to be well-versed in the topic, but teams of doctors and social workers can also help with practical experience. The curriculum includes the biological basics, sexually transmitted diseases and their prevention, contraceptives, and responsible sexual behavior. Topics for discussion consist of choosing a partner, risk groups, prostitutes, promiscuity, drug use, homosexuality, condoms, and nonoxynol-containing vaginal sponges. Contraceptives include conventional methods (coitus interruptus, Knaus-Ogino, Billings, and basal temperature methods); barrier methods (condom, diaphragm, cervical cap); the IUD; highly effective hormonal contraception (low-dose estrogen and gestagen-containing pills are especially suitable for young people, but cyproteroneacetate-containing combination pills, pure gestagen-component minipills, and depot-gestagen pills also have to be considered); and postcoital measures (day-after pill, Yuzpe method, day-after IUD) that are least used because of moral and religious reasons.

[A clinical score system for children with ARDS]. / Klinische Score Systeme bei Kindern mit ARDS.

In a retrospective study we developed a simple acute respiratory distress syndrome (ARDS) scoring system in order to analyze the severity of ARDS as precisely as possible. From March 1983 to May 1990, 17 children with ARDS were admitted and treated at the pediatric intensive care unit of the University Hospital of Graz. The ARDS score was evaluated as a predictor of outcome. The score is based on four variables: mean airway pressure, oxygenation index, additional number of organ system failure and a radiological score, each of which was assigned a score between 0 and 3 (Table 3). The score was recorded on admission or immediately after respiratory failure and after 24, 48 and 72 h. The patients were divided into survivors and non-survivors. After 24 h of mechanical ventilation the ARDS score was 7.16 +/- 0.79 in survivors and 10.4 +/- 0.4 points in non-survivors (P less than 0.0006). Similar differences were found after 48 and 72 h of therapy. In addition, the predictive power of the ARDS score after 24 h was tested at a level of 8 points. The sensitivity and the positive predictive value were 90%, while specificity and negative predictive value were 85.7%. The correct prediction was 88.2%. We conclude that this simple ARDS score can be an useful prognostic factor in patients with ARDS.

Clinical scoring systems in children with continuous extracorporeal renal support.

Three physiologic scoring systems, the Physiologic Stability Index (PSI), the Pediatric Risk of Mortality (PRISM), the Acute Physiologic Score for Children (APSC), and the Therapeutic Intervention Scoring System (TISS) were applied to 32 critically ill infants and children with acute renal failure or multiple organ system failure undergoing continuous extracorporeal renal support. APSC was developed from the Apache II score. It describes 6 organ systems with 14 variables. PSI describes 7 organ systems with 34 variables, PRISM 5 organ systems with 14 variables. Simultaneously, the TISS was recorded at admission, 24, 48, 96 and 144 h later. All physiologic scores showed significant differences between survivors (S) (n = 18) and nonsurvivors (NS) (n = 14) from admission on. The highest significance was obtained with the APSC (admission score: S: 17.8 +/- 7.4 vs. 27.1 +/- 11.4 NS; p = 0.01; day 4: S: 10.3 +/- 6.1 vs. 26.1 +/- 10.8 NS; p = 0.0001). No significant differences in TISS and in the number of organ system failure were observed during the first 4 days of intensive care.

Evaluation of clinical scoring systems in critically ill infants and children.

Four scoring systems, the Acute Physiologic Score for Children (APSC), the Physiologic Stability Index (PSI), the Paediatric Risk of Mortality (PRISM) and the Therapeutic Intervention Scoring System (TISS), were evaluated for 103 critically ill infants and children according to the Clinical Classification System (CCS) class IV. The admission scores were higher for children who died than those who lived (APSC, PSI, PRISM p less than 0.001, TISS p <0.025). In addition, the mean APSC and PSI showed significant differences (p less than 0.01) between survivors (S) and nonsurvivors (NS) in all patients, mean PRISM showed significant differences (p less than 0.01) between S and NS in all but renal failure patients and the mean TISS showed only significant differences (p less than 0.01) between S and NS with primary cardiovascular and respiratory diseases. The mortality rate was 30%. Using the 0.5 predicted risk rate, total correct prediction of admission APSC, PSI, and PRISM was 80%, 80.5% and 80% respectively. Receiver Operating Characteristic (ROC) curves drawn for each severity index were in a discriminating position. There were no significant differences between the areas under the ROC curves of the physiological scores. However, there was a significant difference between the physiologic scores and TISS (p less than 0.001). Admission APSC, PSI and PRISM excellently describe severity of illness and give prognostic information in critically ill paediatric patients. In addition, TISS gives information about the therapeutic support needed.

Reduction of colonization and infection rate during pediatric intensive care by selective decontamination of the digestive tract.

OBJECTIVE: To compare the effects of two different antibiotic regimes on the colonization and infection rates of critically ill pediatric patients. DESIGN: A prospective randomized trial. SETTING: A pediatric ICU in a university hospital. PATIENTS: Fifty critically ill pediatric patients who required intensive care for at least 4 days were randomly allocated to either the selective parenteral and enteral antisepsis regimen (treatment group, n = 25) or the control group (n = 25). INTERVENTIONS: The treatment group received oral nonabsorbable antimicrobial agents (polymyxin E, gentamicin, and amphotericin B) and parenteral cefotaxime, whereas the control group received either perioperative antibiotic prophylaxis or antibiotic therapy according to clinical or microbiological evidence of infection. RESULTS: Both groups were comparable for age, body weight, sex, and severity of illness. Colonization with Gram-negative microorganisms and yeasts in the oropharynx, and digestive and respiratory tracts increased rapidly up to 52% in the control group, whereas there was no colonization with these microorganisms in the treatment group. The occurrence rates of acquired secondary infections in the control and treatment groups were 36% and 8%, respectively (p less than .025). There were no differences between groups in the duration of intensive care or mortality rate. CONCLUSION: Selective oropharyngeal and gastrointestinal decontamination combined with systemic cefotaxime application allows for a significant reduction of the colonization rate with Gram-negative bacteria and yeasts in critically ill pediatric patients undergoing prolonged intensive care. In addition, it significantly reduces the Gram-negative infection rate of the respiratory system. However, this therapeutic approach does not alter ICU length of stay or mortality rate.

Nitrogen and amino acid balance during total parenteral nutrition and continuous arteriovenous hemofiltration in critically ill anuric children.

Amino acid balance and nitrogen balance during total parenteral nutrition (TPN) and continuous arteriovenous hemofiltration (CAVH) were investigated in 11 critically ill anuric patients during the first 7 days after onset of anuria. Nitrogen intake ranged from 0.115 +/- 0.013 (SEM) g/kg/day on day 1 to 0.291 +/- 0.029 (SEM) g/kg/day on day 7. After 7 days of TPN, 9 patients had a positive cumulative protein-N balance of 287.52 +/- 68.52 (SEM) mg/kg, 2 patients had a negative balance of 781.8 and 1,103.2 mg/kg, respectively. Mean amino acid loss in ultrafiltrate was 0.159 +/- 0.008 (SEM) g/kg/day. Four patients died without recovery of renal function.

Urinary excretion of N-acetyl-beta-D-glucosaminidase in proteinuric states.

Urinary excretion of N-acetyl-beta-D-glucosaminidase (NAG) was studied in 22 children with proteinuria and a normal glomerular filtration rate. Twelve patients had minimal change nephrotic syndrome (MCNS), 10 children suffered from different types of glomerulonephritis (GN) without tubulointerstitial renal disease. Sixty-six random urine samples were analyzed for protein, creatinine and NAG. There was a strong positive correlation between proteinuria and urinary NAG activity (r = 0.79, p = 0.0001). The raised NAG activities in proteinuric states turned to normal during remission of the disease. Patients with MCNS and GN did not differ significantly and had nearly identical correlation curves. Our results seem to indicate that functional changes in the renal tubular cells probably caused by protein resorption are responsible for this association. Raised NAG activities in proteinuria reflect the activity of the disease but cannot distinguish patients with MCNS and GN.

[An asphyctic newborn infant with sonographically dilated ventricles]. / Ein asphyktisches Neugeborenes mit sonographisch weiten Ventrikeln.

Brain edema causes severe cerebral defects after perinatal asphyxia. In managing children with asphyxia adequate therapy of brain edema is most important for the neurological outcome. Usually estimation of the width of the ventricular system is initially used for sonographical classification or suspicion of brain edema. We present a case with the unusual aspect of wide cerebral liquor system in spite of severe asphyxia and severe brain edema with consecutive cerebral atrophy. In this case brain edema could only be recognised by the use of doppler sonography of the cerebral vessels and was confirmed by brain pressure monitoring. We therefore suggest that sonographic diagnostic workup of newborns with asphyxia must include a doppler-sonography of the cerebral vessels as well as a brain pressure monitoring.

[Prenatal diagnosis of primary megaureter]. / Der pränatal diagnostizierte primäre Megaureter.

22 of 114 infants with prenatal diagnosis of urinary tract malformations (15 boys) had obstruction of the ureterovesical junction caused by primary megaureter (n = 14), ureterocele (n = 7), or ectopic ureter (n = 1). Infants with infravesical obstruction or refluxing systems were excluded. All infants had a normal renal function and probably only 5 of them (23%) would have been diagnosed during infancy without prenatal diagnosis. A total number of 26 renal units was evaluated. Six infants had ipsilateral duplication with additional contralateral duplication (n = 2) or vesicoureteric reflux (n = 2). A nonfunctioning kidney or upper pole of duplication was noted in 7 units (5 with ureteroceles); in two instances a moderately dysplastic kidney was present. One boy with urinary infections developed renal scarring during follow-up. Conservative treatment was performed in 14 renal units while 12 units of 11 children had 22 operations (9 temporary diversions) at a mean age of 4,6 months. A severe operative complication was noted in one infant. Conservative treatment is justified in many infants with primary obstructive megaureters but severe renal dysplasia may be present even neonatally. Yet we feel that prenatal diagnosis benefitted most infants, especially those with the most severe malformations.

Primary vesicoureteral reflux in infants with a dilated fetal urinary tract.

Vesicoureteral reflux (VUR) was recognized neonatally by voiding cystography in 25 of 117 infants with a dilated fetal urinary tract. There was a male preponderance (76%) and a high percentage (40%) of associated urinary malformations. Thirty-nine refluxing units were studied. All grades of VUR were detected but gross dilating VUR dominated (59%). Spontaneous resolution was excellent in lower grades of VUR but was poor in gross VUR. Surgery was successfully performed in 13 renal units of nine patients with gross reflux, additional ipsilateral malformations, or pyelonephritis during antibiotic prophylaxis. Segmental renal scars developed in four kidneys after urinary infections, and a diffuse parenchymal lesion was noted in nine kidneys even at birth. One boy with duplication had a non-functioning refluxing system. Our results in a small number of infants show differences to children with VUR detected after urinary infections and seem to support the existence of a congenital reflux nephropathy.