Evaluating the long-term conformation and hoof growth effects of starting hoof trimming at 5 months of age in New Zealand dairy goats.

Hoof overgrowth is associated with poor conformation, an altered weight-bearing surface, and a reduction in the hoof's anatomic and functional integrity. As a result of housing systems that promote hoof overgrowth, hoof trimming is considered a priority in dairy goats. However, there are few data on the effects of the timing of first trimming on hoof conformation and growth rate. The aims of this study were (1) to evaluate the long-term effects of 2 different hoof trimming start times and (2) to investigate the pattern of hoof growth across the first 2 yr of life. Eighty 5-mo-old female Saanen-cross commercially housed dairy goats were allocated randomly to 1 of 2 treatments: (1) early trimmed (trimming beginning at 5 mo old; hooves were trimmed every 4 mo thereafter) and (2) late trimmed (trimming beginning at 13 mo old; hooves were trimmed every 4 mo thereafter). Using a combination of photographs and radiographs, hoof conformation, joint positions, and hoof wall length were assessed before the 13- and 25-mo trimming events. Hoof growth was assessed every 12 wk using caliper measurements. Overall, starting hoof trimming earlier had minor and inconsistent effects. However, detrimental changes in conformation and joint positions occurred between trimming events, particularly in the hind hooves, regardless of trimming treatment. At both assessments, there was a high percentage of overgrown toes and dipped heels, with the hind hooves being more affected compared with the front (overgrown toes at 13 mo, 97.1 vs. 79.1 ± 5.2%; overgrown toes at 25 mo, 91.7 vs. 56.3 ± 6.7%; dipped heels at 13 mo, 98.5 vs. 19.3 ± 5.0%; dipped heels at 25 mo, 88.3 vs. 4.9 ± 4.8%). In addition, at both assessments, the distal interphalangeal joint angle was greater in the hind hooves compared with the front (13 mo, 79.5 vs. 65.2 ± 1.7°; 25 mo, 79.0 vs. 66.7 ± 0.9°), whereas heel angles were less in the hind hooves compared with the front (13 mo, 41.8 vs. 57.1 ± 1.5°; 25 mo, 44.9 vs. 55.9 ± 1.1°). On average, the front hooves grew 4.39 mm/mo and the hind hooves grew 4.20 mm/mo. Early trimming did not have consistent effects on hoof growth rate. Importantly, our results suggest that trimming every 4 mo is not sufficient to prevent hoof overgrowth, the development of poor conformation, and detrimental changes in joint positions, particularly in the hind hooves. Furthermore, the detrimental changes may have masked any long-term treatment effects. Therefore, trimming frequency and age of first trimming should be considered when devising hoof care protocols for dairy goats housed in environments that do not offer opportunities for natural hoof wear.

Validation of Brix refractometers and a hydrometer for measuring the quality of caprine colostrum.

On-farm assessment of caprine colostrum quality is important for goat farmers; the ability to quickly recognize whether colostrum is suitable to feed to kids helps achieve successful passive transfer of immunity. The study compared the use of optical and digital Brix refractometers and a hydrometer against the international gold standard radial immunodiffusion (RID), using both fresh and frozen samples. A locally available ELISA methodology was included for comparison. A total of 300 samples were collected from 2 farms (farm 1: n = 157, collected by research staff within 24 h of parturition; farm 2: n = 143, collected by the farmer within 12 h of parturition). Farm 1 provided doe age for a subset of samples (n = 86). Samples were tested fresh and then frozen for shipment and repeated testing. Specific gravity was measured using a hydrometer in a subset of samples (n = 22) from farm 2. Because no gold standard thresholds are currently available for caprine colostrum, RID-derived values of 30, 40, and 50 g/L IgG were used as potential "good quality" thresholds. Pearson (ρ) and Lin's concordance correlation coefficients (CCC) were calculated for comparison of methods. Optimum thresholds were established maximizing the Youden index and minimizing the "distance closest to the top left corner" of the receiver operator characteristic curves. Brix values were correlated with RID (optical Brix, fresh: ρ = 0.73; digital Brix, fresh: ρ = 0.71; digital Brix, frozen: ρ = 0.76) and with each other (range: ρ = 0.93 to 0.99; CCC = 0.91 to 0.99). Specific gravity measured by the hydrometer yielded a strong relationship with RID (ρ = 0.83) and with Brix values (range: ρ = 0.88 to 0.90). The ELISA method was not correlated with Brix methods (range: ρ = 0.02 to 0.09) or RID (ρ = 0.20). Depending on the colostrum IgG threshold, the hydrometer yielded high Youden indices (range: 0.78 to 0.93) and low distance closest to the top left corner criteria (0 to 0.05) at a threshold of 1.047 specific gravity. For all RID IgG thresholds, the best Brix threshold (regardless of type or whether the sample was fresh or frozen) was 18 or 19%, with the highest Youden indices (range: 0.47 to 0.61) and lowest distance to the top left corner criteria (range: 0.09 to 0.16); however, we recommend 19%, because this reduces the potential of feeding poor-quality colostrum. The ELISA method was the poorest predictor of colostrum concentration. Age was not found to affect colostrum quality; however, the sample size of this subset was small. Hydrometers are inexpensive and easy to use, whereas Brix methods use only a small amount of colostrum; we suggest that either method could be used on-farm.

Short communication: Survival of replacement kids from birth to mating on commercial dairy goat farms in New Zealand.

Commercial dairy goat systems rely on the successful rearing of kids for herd replacement. The objectives of this study were to (1) determine survival from birth until mating for a large cohort of commercial dairy goat kids; (2) descriptively summarize the causes of mortality and removal from the herd during this period; and (3) compare actual (determined by postmortem examination) and suspected (farmer-reported) causes of mortality. A total of 1,262 female kids were enrolled at birth on 16 commercial dairy goat farms in New Zealand. Median ages at weaning and mating were 86 d [minimum = 54, quartile (Q)1 = 78, Q3 = 97, maximum = 144] and 223 d (minimum = 183, Q1 = 208, Q3 = 237, maximum = 310), respectively. Overall, 87.1% (1,099/1,262) of kids remained on farm at mating, 10.4% (131/1,262) died or were euthanized, and 2.5% (32/1,262) were lost to follow-up or sold. Mortality risk was greatest in early life, with more than 90% of deaths occurring before weaning. Mortality from enrollment to mating varied between farms (minimum = 0%, Q1 = 5.9%, median = 8.9%, Q3 = 15.8%, maximum = 20.5%). The leading cause of death was gastrointestinal disorders (33.6%, 36/107), followed by disbudding-related injury (15.9%, 17/107), and septicemia (12.1%, 13/107). Farmers correctly identified approximately half of the deaths attributed to gastrointestinal disorders (56.0%, 14/25) and disbudding-related injury (44.4%, 4/9), but were less successful at diagnosing septicemia (0%, 0/5), starvation or dehydration (0%, 0/4), and suffocation (18.8% 3/16). This is the largest cohort of dairy goat kids to be systematically followed over time to confirm survival until mating and to determine causes of death by postmortem examination. We found that kid mortality was highest during the preweaning period and there was often a discrepancy between farmer-perceived and actual cause of death. Postmortem examinations should be more widely used to establish causes of death and inform on-farm strategies to reduce kid mortality.

Technical note: The development of a reliable 5-point gait scoring system for use in dairy goats.

Numerical rating scales are frequently used in gait scoring systems as indicators of lameness in dairy animals. The gait scoring systems commonly used in dairy goats are based on 4-point scales that focus on detecting and judging the severity of a definite limp. An uneven gait, such as a shortened stride or not "tracking up," is arguably the precursor to the development of a limp; thus, identifying such changes in gait could provide opportunity for early treatment. The objectives of this study were (1) to develop a 5-point gait scoring system that included an "uneven gait" category and compare the distribution of gait scores generated using this system to scores generated using a 4-point system, and (2) to determine whether this system could be reliably used. Forty-eight Saanen cross 2- and 3-yr-old lactating does were enrolled from a commercial dairy goat farm. Two observers carried out weekly live gait scoring sessions for 7 wk using the developed 5-point scoring system. The first 2 wk were used as training sessions (training sessions 1-2), with the subsequent 5 wk completed as gait assessments (assessments 1-5). In addition to training session 1 being lived scored, the goats were also video-recorded. This allowed observer 1 to re-score the session 4 times: twice using the developed 5-point system and twice using the previously used 4-point system. Comparisons of score distributions could then be made. Using the 4-point system, 81% of the goats were assigned score 1 (normal gait). Using the 5-point system, only 36% of the goats were assigned score 1 (normal gait), with 50% assigned score 2 (uneven gait). High levels of intra-observer reliability were achieved by observer 1 using both gait scoring systems [weighted kappa (κw) = 1.00: 4-point, κw = 0.96: 5-point]. At training session 1 (wk 1), inter-observer reliability was only moderate (κw = 0.54), but this was improved during the subsequent training session 2 (κw = 0.89). Inter-observer reliability was high among assessments 1 to 5 (κw = 0.90-1.00). During the training sessions, sensitivity for gait scores 1 and 2 was 77 and 65% (training session 1) and 89 and 94% (training session 2), respectively. Sensitivity was high among assessments 1 to 5 (score 1: 83-100%, score 2: 97-100%). This highlights the likely reason why existing gait scoring systems for dairy goats do not include an "uneven gait" category, as distinguishing it from a normal gait was challenging without training. In conclusion, with training, a 5-point gait scoring system could be reliably used. The 5-point system was found to be more sensitive than the 4-point system, allowing for a potential precursor to lameness to be identified. Further work is needed to determine whether the score can be reliably used in an on-farm setting.

Invited review: Cessation of lactation: Effects on animal welfare.

The forced cessation of milk production, or dry-off, is a routine management practice in dairy cattle, sheep, and goats. This practice initiates a dry period, during which the animal is not milked. Milking begins again after parturition. Most of the literature on the dry period has focused on how various drying-off strategies affect milk production and disease; little work to date has addressed how dry-off affects the overall welfare of the dairy animal. The first aim of this review was to present an overview of the importance of dry-off and how it is commonly achieved. Our review shows that much scientific progress has been made in improving health status between lactations. The second aim was to identify important gaps in the literature, of which 2 key research disparities have been identified. We find that much of the work to date has focused on cattle and very little research has examined dry-off in dairy sheep and goats. We also find a lack of research addressing how common dry-off methodologies affect animal welfare on more than just a biological level, regardless of species.

Ketonemia in dairy goats: effect of dry period length and effect on lying behavior.

In dairy animals, a successful transition from one lactation to the next includes minimizing negative energy balance. Cows experiencing excessive negative energy balance typically develop metabolic complications following parturition (e.g., ketosis); does are also susceptible before kidding (e.g., pregnancy toxemia). It is not known to what extent the provision and the length of the dry period affect these conditions in does. Furthermore, whereas clinical symptoms of these conditions include lethargy, behavioral changes resulting from ketosis and pregnancy toxemia have not been quantified in small ruminants. The aims of this study were to (1) describe the relationship between the dry period and negative energy balance, and (2) determine if lying behavior changes are indicative of the metabolic status of dairy goats. A total of 420 does on 10 commercial dairy goat farms in southern Ontario, Canada, were enrolled in the study (mean ± SD: 42±18 does/farm). Each doe was affixed with a data logger to measure lying behavior from 12 d before to 12 d after kidding. Blood samples were collected at least once before and at least once following kidding to determine blood ß-hydroxybutyrate (BHBA) concentration as an indicator of negative energy balance. Does were categorized as healthy (HLTH; both pre- and postkidding samples BHBA <0.9 mmol/L), PREGTOX (prekidding BHBA ≥1.7 mmol/L), or KET (postkidding BHBA ≥1.7 mmol/L). Behaviors were analyzed according to 5 periods: P-2 (d -12 to d -2 relative to kidding), P-1 (d -1 relative to kidding), P0 (d 0, kidding day), P1 (d 1 relative to kidding), and P2 (d 2 to 12 relative to kidding). Dry period length and milk production after kidding were recorded when available. Farms ranged from 0 to 15% and 0 to 50% in prekidding and postkidding ketonemia, respectively. The HLTH does had shorter dry periods compared with PREGTOX and KET does (43 vs. 55 d, SE of the differences of means=4 d). One farm kept some does milking, while drying off others; on this farm more PREGTOX and KET does (11/28) were found in the dry group versus the continuously milked group (1/16). Overall, does that had ketonemia before kidding (PREGTOX) spent more time lying down compared with healthy does (16.1 vs. 12.7 h/d, SE of the differences of means=0.9). Both PREGTOX and HLTH does had increased lying bouts in P-2 compared with the day before (P-1) kidding [(mean (95% CI): 16.8 (15.8-17.8) vs. 20.5 (19.4-21.8) bout/d]. Compared with HLTH does, animals that were ketonemic following kidding (KET) had higher mean lying times throughout the study (14.5 vs. 13.5 h/d, SE=0.4). Previous work has shown a relationship between shorter and skipped dry periods and improved energy balance in dairy cows; the current study is the first to indicate a similar relationship in dairy goats. Furthermore, goats that developed ketonemia, particularly before kidding, displayed decreased activity, including longer lying times and fewer lying bouts in the days around kidding.

Technical note: validation of data loggers for recording lying behavior in dairy goats.

Changes in standing and lying behavior are frequently used in farm animals as indictors of comfort and health. In dairy goats, these behaviors have primarily been measured using labor-intensive video and live observation methodologies. The aim of this study was to validate accelerometer-based data loggers for use in goats. Two commercial dairy goat farms in Ontario were enrolled; goats were fitted with data loggers on their rear left legs and the pens were equipped with video. Data loggers compared well with video in identifying lying and standing events on both farms (farm 1 and 2, respectively: sensitivity=99.7 and 99.8%, specificity=99.5 and 99.4%, false readings=0.43 and 0.36%). The loggers were also able to record if the goat was lying on her left or right side (farm 1 only: sensitivity=99.9%, specificity=99.3%, false readings=0.38%), but these measures were only accurate if the loggers were attached with sufficient tension to prevent logger rotation. The mature does enrolled on farm 1 spent 14.5±1.0h/d lying down and frequently changed lying side even within a single lying bout (24±5 shifts/d between left and right sides and 16±5 lying bouts/d). The young goats on the second farm averaged just 8.5±3.2h/d in lying time, and spread this time over 8±4 bouts/d. Data loggers accurately measured lying time and lying bouts in mature does and younger goats on both farms, and lying laterality (e.g., left and right lying sides) in mature does on farm 1.

Evaluating the immediate effects of hoof trimming on dairy goat hoof conformation and joint positions.

Hoof overgrowth in commercial housed dairy goats is a major health and welfare concern; thus, it is important to better understand hoof trimming, a priority practice which addresses hoof growth. We evaluated the immediate effects of trimming on external conformation, internal joint positions, and hoof wall overgrowth of front and hind hooves. Eighty female goats were enrolled. Pre and post hoof trimming data were collected at 13, 17, 21 and 25 months of age. Overall, before trimming, a high percentage of hooves were scored as overgrown (77.8%). Trimming decreased the percentage of overgrown hooves (17.6%: P < 0.001) and other moderate/severe conformational issues: dipped heels (49.3% vs. 26.7; P < 0.001), misshaped claws (37.0% vs. 17.6%; P < 0.001), splayed claws (73.7% vs. 56.7%; P < 0.001). More hind than front hooves had dipped heels pre-trimming and (91.3% vs. 7.3%; P < 0.001) and post-trimming (52.8% vs. 0.6%; P < 0.001); over half of the hind heels were not restored to an upright position. A greater proportion of toe length was removed from the hind hooves compared to the front (0.50 vs. 0.43, P < 0.001), with the greatest proportion of hoof wall overgrowth removed from the hind hoof medial claw at the 13-month assessment (P < 0.001). Following trimming, distal interphalangeal joint angle decreased more in hind compared to front hooves (11.0° vs. 6.9°; P < 0.001); distal interphalangeal joint height decreased (0.21 cm, P < 0.001), and proximal interphalangeal joint, and heel, angles increased (7.76° and 8.93°, respectively; P < 0.001). Trimming did not restore conformation of all hooves when trimmed every 4 months, suggesting a need to investigate reasons for underlying poor conformation, including trimming frequency.

Gradual cessation of milking reduces milk leakage and motivation to be milked in dairy cows at dry-off.

The effects of gradual versus abrupt cessation of milking at dry-off in dairy cows are not well understood, but gradually reducing milk production in human mothers is known to reduce discomfort and milk leakage. This study compared the effects of abrupt versus gradual cessation of milking on milk leakage and dairy cow behavior. Holstein dairy cows were housed in groups of 6 and randomly assigned to either abrupt milk cessation (i.e., dry-off on d 0) or gradual milk cessation (i.e., skipped milkings beginning on d 0; dry-off on d 5). Four replicates were performed over time, for a total of 24 cows (mean ± SD; parity=2.3±1.2; milk production the day before d 0=24±5 kg/d). Intramammary antibiotic, internal teat sealer, and external teat sealant were administered at dry-off. Measurements were taken from d -3 to 8 relative to dry-off. Three periods were identified for behavior data: baseline (d -3 to 1), period 1 (abrupt cows dry, gradual cows milking; d 0-4), and period 2 (all cows dry; d 5-8). Lying time was recorded with data loggers. Video scan samples (5-min intervals) were used to measure feeding time and motivation to be milked (i.e., standing at the pen's exit gate). Milk leakage was monitored every 20 min during the 2-h period following the milking times of 0500 and 1500 h after complete cessation of milking (period 1 for abrupt vs. period 2 for gradual). Composite milk samples were taken before dry-off (d -1, 0, and 5) and at the start of the next lactation (colostrum, 24h and 7-10 d postcalving) to determine somatic cell score (SCS) and conduct bacteriological examinations in clinical mastitis cases. Regardless of treatment, dry-off resulted in reduced lying time [14.1 vs. 13.2h/d; standard error of the difference (SED)=0.2], reduced lying bouts (10.7 vs. 8.3 bouts/d; SED=0.2), increased lying bout duration (1.4 vs. 1.7h/bout; SED=0.03) and increased feeding time (5.0 vs. 5.9h/d; SED=0.2). Compared with baseline, the odds of standing at the gate increased for abrupt cows (period 1: odds ratio=6.2; 95% CI: 2.7-14.4; and period 2: odds ratio=5.2; 95% CI: 1.8-14.6). No increase in time spent standing at the gate was noted in gradual cows. Frequency of leakage was greater in abrupt versus gradual cows (75 vs. 27%). Although the gradual treatment showed an increase in SCS over the 5 d of reduced milking frequency, both treatments showed an increase in SCS at calving and both returned to pre-experiment levels within 7 to 10 d after calving. This work demonstrates that gradually reducing milking frequency in high-producing cows results in reduced time spent anticipating milking and reduced milk leakage after dry-off.

Prospective evaluation of clinical scoring systems in infants with bronchiolitis admitted to the intensive care unit.

The objective of this investigation was to compare different scoring systems to assess the severity of illness in infants with bronchiolitis admitted to a tertiary paediatric intensive care unit (PICU). Over an 18-year period (1990-2007), infants with bronchiolitis aged up to 12 months and admitted to the PICU were prospectively scored using the Pediatric Risk of Mortality III (PRISM III) score, the Organ System Failure (OSF) score and the Acute Physiologic Score for Children (APSC) within 24 h. Infants were compared as to whether or not bronchiolitis was associated with respiratory syncytial virus (RSV). There was no difference between 113 RSV-positive and 80 RSV-negative infants regarding gestational age, birth weight, rate of premature delivery or bronchopulmonary dysplasia (BPD). The PRISM III score differed significantly between RSV-positive and RSV-negative cases (3.27 ± 0.39 vs. 1.96 ± 0.44, p = 0.006), as did the OSF score (0.56 ± 0.05 vs. 0.35 ± 0.06, p = 0.049) and the APSC (5.16 ± 0.46 vs. 4.1 ± 0.53, p = 0.048). All scores were significantly higher in the subgroup with mechanical ventilation (p < 0.0001). The mean time of ventilation was significantly higher in the RSV-positive group compared to the RSV-negative group (6.39 ± 1.74 days vs. 2.4 ± 0.47 days, p < 0.001). Infants suffering from RSV-positive bronchiolitis had higher clinical scores corresponding with the severity of bronchiolitis.

Malignant stroke in an adolescent with a homozygous MTHFR 677CT mutation and intake of hormonal contraceptives.

UNLABELLED: Severe stroke in children and adolescents with its devastating long term consequences remains a rare disorder with many open questions. Beside the well known risk factors such as infection or congenital and acquired heart disease, coagulation disorders have to be considered in the differential work up of the underlying aetiology. Here we report the case of an adolescent with a homozygote MTHFR 677CT mutation suffering a malignant stroke shortly after the start of oral contraceptives. CONCLUSION: Since prevention seems easily feasible, general screening for MTHFR mutations might be worthwhile in women before starting oral contraceptives.

Pain sensitivity and injury associated with three methods of disbudding goat kids: Cautery, cryosurgical and caustic paste.

Pain sensitivity and skull/brain injury associated with cautery, cryosurgical and caustic paste disbudding were evaluated in goat kids. Kids (reared for meat; n=280) were randomly assigned to one of four treatments (n=70 per treatment): (1) sham-handling (SHAM) or (2) cautery (CAUT), (3) cryosurgical (CRYO) or (4) caustic paste (CASP) disbudding. A pain sensitivity test was carried out 15min pre-treatment and 1h post-treatment. Skull/brain injury was assessed at post-mortem examination. Kids with evidence of injury to the skull/brain, as well as a random sample of kids (n=15 per treatment) without evidence of skull/brain injury, were selected for histological examination of brain tissue. Average daily gains (ADG) were calculated from body weight measurements taken 10min pre-treatment and then at 2, 7 and 14days post-treatment as a measure of the potential effects of pain or injury on growth. CASP and CRYO kids displayed higher pain sensitivity post-treatment than CAUT or SHAM kids, suggesting that they experienced more acute pain 1h post-treatment. One of 70 CAUT kids had a perforated skull, but there was no histological evidence of brain injury in this animal; a further nine CAUT kids exhibited hyperaemia of the skull. The other treatments did not result in injury to the skull/brain. There was no evidence of a difference in ADG across treatments. Caustic paste and cryosurgical disbudding resulted in greater acute pain sensitivity than cautery disbudding; however, cautery disbudding has the potential to cause skull injury if performed incorrectly.

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.

Inhaled nitric oxide in patients with critical pulmonary perfusion after Fontan-type procedures and bidirectional Glenn anastomosis.

OBJECTIVE: The aim of this study was to evaluate the effects of inhaled nitric oxide in patients with critical pulmonary perfusion after Fontan-type procedures and bidirectional Glenn anastomosis. METHODS: Inhaled nitric oxide (mean 4.1 +/- 0.7 ppm, 1.5 to 10 ppm) was administered in 13 patients (mean age 5.6 +/- 1.6 years, 1.5 to 17 years) with critical pulmonary perfusion (central venous pressure > 20 mm Hg or transpulmonary pressure gradient > 10 mm Hg) in the early postoperative period after total cavopulmonary connection (n = 9) or after bidirectional Glenn anastomosis (n = 4). RESULTS: In patients after total cavopulmonary connection inhaled nitric oxide therapy decreased central venous pressure by 15.3% +/- 1.4% (p = 0.0001) and transpulmonary pressure gradient by 42% +/- 8% (p = 0.0008) and increased mean systemic arterial and left atrial pressures by 12% +/- 3.6% (p = 0.011) and 28% +/- 8% (p = 0.007), respectively. Arterial and venous oxygen saturations improved by 8.2% +/- 1% (p = 0.005) and 14% +/- 4.3% (p = 0.03), respectively. In patients after bidirectional Glenn anastomosis inhaled nitric oxide therapy resulted in a decrease of central venous pressure by 22% +/- 1% and of the transpulmonary pressure gradient by 55% +/- 6% and improved arterial and venous oxygen saturations by 37% +/- 29% and 11% +/- 3%, respectively. Mean systemic arterial and left atrial pressures remained nearly unchanged. No toxic side effect was observed in any patient. CONCLUSION: Inhaled nitric oxide may play an important role in the management of transient critical pulmonary perfusion caused by reactive elevated pulmonary vascular resistance in the early postoperative period after Fontan-type operations and bidirectional Glenn anastomosis.

Prolonged extracorporeal organ support in a 2-year-old boy after cardiac surgery.

A case report of a 2-year-old boy who developed severe post-operative low cardiac output, sudden cardiac arrest and consecutive multiple organ system failure after open heart surgery is described. Initially the hemodynamic situation was stabilized by extracorporeal membrane oxygenation (ECMO) combined with continuous hemofiltration (CHF) carried out for 7 days. Continuous veno-venous hemofiltration (CVVH) was necessary for further 17 days. One episode of plasmapheresis restored transiently a severe post-operative coagulopathy and enabled the removal of the pulmonary artery catheter and the chest tubes.

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.

Partial liquid ventilation combined with kinetic therapy in acute respiratory failure in piglets.

OBJECTIVE: To investigate the effect of the combination of kinetic therapy (KT) with partial liquid ventilation (PLV) on gas exchange, lung mechanics and hemodynamics in acute lung injury (ALI). DESIGN: Prospective, randomized, controlled pilot study. SETTING: University research laboratory. SUBJECTS: Eleven piglets weighing 8.3+/-0.9 kg. INTERVENTION: ALI was induced by the infusion of oleic acid (0.08 ml/kg) and repeated lung lavages with 0.9% NaCl (20 ml kg(-1)). Thereafter the animals were randomly assigned either for PLV or a combination of PLV with KT (PLV/KT). The dose of perfluorocarbon administered was 30 ml/kg, evaporative losses were substituted with 5 ml/kg per h. MEASUREMENTS AND MAIN RESULTS: Airway pressures, tidal volumes, dynamic compliance (Cdyn), expiratory airway resistance and arterial blood gases were measured. Hemodynamic monitoring included right atrial, mean pulmonary artery, pulmonary capillary wedge and mean systemic arterial pressures, and continuous flow recording of the pulmonary artery. In both groups the induction of ALI significantly reduced PaO2/FIO2 Cdyn and cardiac output, and significantly increased pulmonary artery pressure. After the initiation of PLV there was a significant increase of PaO2/FIO2, and Cdyn, and a significant decrease of pulmonary artery pressure in both groups. Except the PaCO2, which showed significantly lower values in the PLV/KT group, no variables showed any differences between the two groups. CONCLUSION: The additional use of KT did not show beneficial effects on oxygenation and lung mechanics during PLV. However, at constant minute ventilation PaCO2 levels were significantly lower during PLV/KT, indicating some positive influence on the ventilation/perfusion distribution within the lung. Extreme body positions during PLV/KT did not show any significant hemodynamic side effects.

Continuous renal replacement therapy in critically ill patients.

We describe our experience with continuous renal replacement therapy (CRRT) in critically ill neonates. From June 1995 to June 1997 36 critically ill oliguric or anuric infants and children underwent continuous arterio-venous (N = 17) or veno-venous (N = 15) renal support. In addition, four neonates were treated with continuous ultrafiltration (CUF) during extracorporeal membrane oxygenation (ECMO) because of severe diuretic-resistant hypervolemia. Their mean age was 9.8 +/- 1.5 days, their mean body weight 3.0 +/- 0.1 kg. The membrane surface area of the hemofilters ranged from 0.015 m2 to 0.2 m2 and the priming volume from 3.7 to 15 ml. For pump-driven hemofiltration a roller pump with pressure alarms, an air trap, an air bubble detector, and small blood lines was used. Fluid balance was controlled by a microprocessor controlled unit. The ultrafiltrate substitution fluid was based on bicarbonate in the majority of the patients and was partially or totally replaced according to the clinical situation. The mean duration of renal support was 97 +/- 20 hours, ranging from 14 to 720 hours. During arterio-venous and veno-venous hemofiltration the mean blood flow rates were 7.0 +/- 1.2 ml/min and 23.1 +/- 2.4 ml/min (P < 0.01), respectively, and the mean ultrafiltration rates 3.3 +/- 0.4 and 9.5 +/- 1.9 ml/min/m2 (P < 0.01), respectively. During continuous hemodiafiltration urea clearances increased by 300%. Overall survival rate was 66%. CRRT related complications included local bleeding at the catheter entrance site, partial thrombosis of the inferior or superior caval veins and transient ischemia due to femoral artery catheters. Continuous hemofiltration either driven in the arterio-venous or veno-venous mode is a very effective method of renal support for critically ill neonates to control fluid balance and metabolic derangement. Urea clearance can be improved by adding some dialysate fluid in a countercurrent direction to blood flow.

Transcatheter coil occlusion of residual interatrial communications after Fontan procedure.

OBJECTIVE: To assess the use of detachable coils as an alternative method to occlude interatrial communications after Fontan operations. DESIGN: Descriptive clinical study of selected patients after Fontan operation with interatrial communications inappropriate for transcatheter umbrella occlusion. SETTING: Tertiary paediatric cardiac referral centre. PATIENTS: Seven patients after Fontan operation with residual interatrial communications of various types producing a right to left shunt. INTERVENTIONS: Transcatheter placement of detachable coils with a diameter of 3 or 5 mm within the interatrial communication. RESULTS: A total of 14 coils were successfully placed within persistent patent fenestrations of the interatrial baffle, residual leaks at the suture line between the patch material and the right atrial wall, and unusual venous interatrial communications. The mean (SD) aortic oxygen saturation increased from 88 (1.1)% (range 86-89%) to 92 (1.3)% (range, 89-93%; p < 0.001) and the mean (SD) right atrial pressure rose from 9.7 (2) mm Hg (range, 6-11) to 10.6 (2.4) mm Hg (range, 6-13; p < 0.05) after coil implantation. In five patients, complete obliteration of the interatrial shunt was shown by angiography after coil implantation. At a mean (SD) follow up of 10 (4) months (range, 3-15) a residual interatrial shunt was detected by Doppler colour echocardiography in only one patient, and oxygen saturations ranged from 90% to 95% (mean, 92%). There were no late coil embolisations, thromboembolic events, or haemolysis in any patient. CONCLUSIONS: Detachable coils can be used successfully to occlude residual interatrial communications after the Fontan procedure. In selected cases, in whom intended transcatheter umbrella occlusion of residual interatrial leaks is not possible, the use of detachable coils might offer a safe alternative method to eliminate interatrial right to left shunting after the Fontan procedure.

Proximal and tracheal airway pressures during different modes of mechanical ventilation: an animal model study.

OBJECTIVE: To determine the differences between the mean proximal and tracheal airway pressures during 3 different modes of mechanical ventilation (MV) in an animal model of acute cardiac failure (CF) and respiratory failure (RF). DESIGN: Prospective, randomized, cross-over design. SETTING: University research laboratory. SUBJECTS: Twelve young pigs weighing 10-16 kg. INTERVENTIONS: The experimental protocol consisted of 3 stable 30 min conditions: when ventricular and pulmonary function was normal (control), after the induction of acute cardiac failure by a beta-blocking agent and after respiratory failure induced by repeated lung lavages. Modes of MV included controlled mechanical ventilation (CMV), high-frequency oscillation (HFO), and high-frequency jet ventilation (HFJV). MEASUREMENTS AND RESULTS: The tracheal mean airway pressure (P(aw)) was measured at the distal port of the Hi-lo jet tube using an air-filled pressure transducer. The mean transpulmonary P(aw) increased significantly from 0.41 +/- 0.14 kPa during the control period to 1.15 +/- 0.17 kPa (P < 0.0001) during the RF period. In all study periods both the proximal and tracheal P(aw) were lowest during HFJV. There was no difference between the proximal and tracheal P(aw) during CMV and HFJV throughout the protocol. In the cardiac and respiratory failure periods the proximal P(aw) (CF, 1.45 +/- 0.08 kPa; RF, 3.13 +/- 0.27 kPa) was significantly higher than the tracheal P(aw) (CF, 1.04 +/- 0.09 kPa, P < 0.01; RF, 2.18 +/- 0.3 kPa, P < 0.01) with HFO. When ventilated by HFO, the mean external oscillatory amplitude was 4.33 +/- 0.14 kPa and the intratracheal oscillatory amplitude was only 0.49 +/- 0.06 kPa (P < 0.0001). CONCLUSION: HFJV provides adequate respiratory support at lower P(aw) than CMV and HFO. Proximal P(aw) closely reflects tracheal P(aw) during CMV and HFJV. However, with HFO great pressure differences between the proximal and tracheal airways are evident. Therefore, additional intratracheal airway pressure monitoring seems to be very useful for optimizing ventilator settings during HFO.