[Propranolol therapy to treat problematic hemangiomas : a new standard therapy makes its debut]. / Die Propranolol-Therapie in der Behandlung problematischer Hämangiome : Eine neue Standardtherapie kündigt sich an.

Small hemangiomas sometimes produce large findings. Depending on localization, local therapy is not always possible. According to a case described in the literature, a hemangioma in an infant regressed following cardiologically indicated Propranolol. This experience has been used in numerous other cases since then and Propranolol has been administered for the indication of a hemangioma. Even in cases of very large hemangiomas rapid improvement has been observed; successful results persisted even after discontinuation. Particularly in cases of problematic localisation, such as in the eye area, prompt therapeutic success is important in order to prevent blindness. Relevant studies are in the preparatory phase.

Inhaled nitric oxide for avoidance of extracorporeal membrane oxygenation in the treatment of severe persistent pulmonary hypertension of the newborn.

UNLABELLED: Inhaled nitric oxide (NO) is thought to provide a noninvasive therapeutic alternative to extracorporeal membrane oxygenation (ECMO) in the treatment of persistent pulmonary hypertension of the newborn (PPHN). OBJECTIVE: Since January 1993, we have studied inhalation of NO in PPHN patients meeting the ECMO criteria of our institution. We focused on the questions of whether or not the need for ECMO could be obviated and whether differences could be found between NO responders and nonresponders. DESIGN: NO gas was delivered via conventional IPPV ventilation in incrementally increasing concentrations from 20 to 80 ppm. PATIENTS: NO therapy was attempted in ten ECMO candidates with clinical and echocardiographical evidence of PPHN (mean OI 51.9, SD 10.4). RESULTS: At various NO levels (30-60 ppm), five patients showed a significant increase in mean PaO2 (range 32.9-85.9 mmHg). Improvement was transient in three patients (6-10 h) and prolonged in two others (54-80 h); in the latter cases, ECMO was avoided. Five patients did not respond at all to treatment. Responders and nonresponders differed in their mean respiratory tidal volume (8.9 vs 4.18 ml/kg, P <0.05). CONCLUSIONS: In our study, inhalation of NO obviated the necessity of ECMO therapy in only two out of ten PPHN patients. Thus, we would discourage any overoptimistic expectations about the effectiveness of NO therapy in PPHN until larger clinical trials have been performed.

A new side effect of inhaled nitric oxide in neonates and infants with pulmonary hypertension: functional impairment of the neutrophil respiratory burst.

INTRODUCTION: Inhaled nitric oxide (NO) may be beneficial in the treatment of pulmonary hypertension, both of the newborn and in the adult respiratory distress syndrome. Up to now, serious systemic side effects have not been reported. OBJECTIVE: The effect of inhaled NO on superoxide anion production by neutrophils. DESIGN: Prospective study of a consecutive series of 15 neonates and infants. SETTING: Neonatal and paediatric ICUs with a total of 17 beds (university hospital). MEASUREMENTS AND RESULTS: Superoxide anion production was determined by a flow cytometric method using dihydrorhodamine 123 (DHR) as an oxidative probe after the priming of neutrophils with N-formyl-methionyl- leucylphenylalanine (fMLP) or with Escherichia coli. The generated fluorescence was expressed as relative fluorescence intensity (RFI). Inhalation of NO for more than 24 h reduced the superoxide anion production by neutrophils stimulated with E. coli to below baseline values before NO inhalation (mRFI = 158 +/- 25 vs 222 +/- 24; P = 0.03). This decrease was more pronounced after more than 72 h (mRFI = 133 +/- 17). At this time, superoxide anion production by fMLP-stimulated neutrophils was also decreased (mRFI = 40 +/- 3, vs 57 +/- 5; P = 0.03). The reduced capacity of superoxide production persisted throughout therapy with NO and lasted up to more than 4 days after the end of NO inhalation. CONCLUSION: The results suggest that inhalation of NO in patients with pulmonary hypertension causes reduced superoxide anion production by neutrophils stimulated with E. coli or with fMLP. To determine the clinical importance of this systemic side effect with respect to bacterial infections, a randomized controlled study is necessary.

Prognosis and outcome of neonates treated either with veno-arterial (VA) or veno-venous (VV) ECMO.

A comparison was done between neonates requiring veno-arterial (VA) ECMO (too small jugular vein, inability to insert a 12 Fr double lumen catheter or cardio-circulatory instability) and neonates treated with veno-venous (VV) ECMO in the same period of time. From 1991-1995 ECMO was done in 48 neonates after failure of maximum conventional treatments, NO-inhalation and HFOV. 30/48 babies were treated with VV-ECMO, with a switch to VA-ECMO later on in 3 of them. In 18 infants VA-ECMO was installed primarily. Differences between the VA- and VV-ECMO group were: the OI was higher in the VV-treated babies (62 +/- 20 vs. 48 +/- 13, p < 0.03), as were birth weight (3385 +/- 570 vs. 2963 +/- 653 g, p < 0.04), gestational age (39.7 +/- 1.6 vs. 37.9 +/- 2.7 weeks, p < 0.01) and MAP (18.7 +/- 2.2 vs. 17.1 +/- 2.4 cm H2O, p < 0.05). Severe ICH's occurred more frequently in the VA-treated babies (29 vs. 7%, p < 0.05), the rate of other complications was equal. The mortality rates were 43% (VA) and 15% (VV), p < 0.05. About one third of neonatal ECMO candidates will be treated with VA-ECMO, even if the VV-ECMO technique is available. Need for VA-ECMO implies--due to a higher number of preterm babies and a greater severity of illness before ECMO--a higher incidence of ICH's and a higher mortality rate.

High-frequency oscillatory ventilation and nitric oxide: alternative or complementary to ECMO.

One hundred and seventy-seven term or near-term neonates were referred to an ECMO center for severe PPHN-associated diseases. In 2 time periods from 1987 to 1991 and from 1992 to April 1995 alternative treatment modes were tried in an attempt to obviate ECMO. During the first time period patients underwent trial high-frequency oscillatory ventilation before ECMO. In the second time period patients first received inhaled NO followed by HFOV in a non-responders. If this also failed HFOV was combined with INO. In both time periods about 40% of the patients were spared ECMO treatment by these alternative treatment modalities. INO only benefited 15% of the ECMO candidates who apparently had fared just as well on HFOV alone in the preceding time period. While patients who were improved by INO were spared HFOV with its potential severe complications, i.e. air leaks and cardiocirculatory instability, more extended long-term studies will have to show which of these 2 treatment modalities (INO or HFOV) should be given first priority in an attempt to avoid ECMO in neonates with severe respiratory failure.

Reconstruction of the arteria carotis communis in newborn following extracorporeal membrane oxygenation (ECMO).

With the help of ECMO it is possible to save the lives of newborn infants suffering from severe respiratory distress syndrome not responding to conservative treatment. Using Bartlett's classic venous-arterial perfusion technique in ECMO the right arteria carotis communis had to be sacrificed. Thus, despite the life-saving character of this new method, the ligation of the carotid with all its possible complications had often been a major argument against using this therapy. We are now therefore trying to reconstruct the arteria carotis after decannulating the vessel after extracorporeal membrane oxygenation. In our 8 cases so far, post-op examinations showed no obstruction of blood flow in the vessel. No neurological deficiencies were recorded.

Indication for using extracorporeal membrane oxygenation in congenital diaphragmatic hernias and pulmonary hypoplasia.

Despite the apparent surgical simplicity of the anatomic defect, congenital diaphragmatic hernia continues to be a critical problem in neonatal surgery, so that survival is still uncertain. Therefore, we must realize that the barriers to survival are pulmonary parenchymal and vascular hypoplasia as well as the complex syndrome of persisting fetal circulation. However, new treatment methods, such as extracorporeal membrane oxygenation (ECMO), although controversial, may improve survival. We believe that no infant should be excluded from diaphragmatic repair or consideration for ECMO-support before accurate predictive parameters have been developed that take both pulmonary hypoplasia and pulmonary hypertension into account. ECMO additionally enables us to postpone the operation until stabilization of the newborn (Late Operation Protocol). Apart from this, we can probably improve the long-term results after ECMO by reconstructing the common carotid artery.

[Eye manifestations of shaken baby syndrome. A case presentation]. / Augenbefunde beim Shaken-baby-Syndrom. Eine Falldemonstration.

UNLABELLED: Violent shaking is a type of child abuse which may cause intracranial hemorrhages combined with retinal and vitreous bleeding. Fundus bleeding is similar to that in Terson syndrome. However, in the shaken baby syndrome the intraocular hemorrhages may precede both the clinical and radiologic recognition of subdural haematoma. CASE REPORT: We present a 4-months-old baby with convulsions and additional extensive bleeding of the fundus. Neither the ocular findings nor the seizures could be explained by minimal lesions of external trauma. Repeated cranial computed tomography showed increasing intracerebral bleeding with consecutive brain atrophy. Fundus bleeding completely disappeared. CONCLUSION: When child abuse is suspected, ophthalmological examination is most important to detect fundus bleeding, which, in the absence of birth trauma or any other supportive evidence of external trauma or other diseases, is the leading symptom of the shaken baby syndrome.

[Persistent pulmonary hypertension of the newborn infant (PPHN)]. / Die persistierende pulmonale Hypertension des Neugeborenen (PPHN).

Persistent pulmonary hypertension of newborn (PPHN) is due to a defect in the adaptation of pulmonary resistance. The primary form occurs idiopathically, with meconium aspiration syndrome and with hypoplasia of the lung and is characterised by excessive muscular hyperplasia of pulmonary arteries. Secondary PPHN following hypoxia, septicaemia and shock is due to pulmonary vasoconstriction whereby thromboxane, leukotrienes and prostaglandins play a decisive role. Diseases of the pulmonary parenchyma and congenital cardiac malformations have to be excluded. The increased pulmonary resistance can be demonstrated by two-dimensional cardiography. The therapy consists of hyperventilation and tolazoline, which can be complicated by severe side-effects. High frequency oscillation and jet-ventilation are employed experimentally, Extracorporeal Membranoxygenation is a promising new method.

[Quantitative prognosis of mortality in newborn infants treated with artificial respiration]. / Quantitative Prognose der Mortalität beim beatmeten Neugeborenen.

Among the 5 indexes to estimate the mortality rate of ventilated newborns the alveolar-arterial oxygen gradient was elaborated as the best statistical model. By means of the probit method a quantitative estimation regarding mortality prognosis became possible. We could demonstrate that already mean values of the first 6 hours are able to give a very precise prognosis of mortality. Among the variables considered, a reduction of gestational age demonstrated a significant influence on the mortality rate. In contrary diagnoses of respiratory problems showed no influence. An increase in D(Aa)O2 raised mortality rate significantly. Using the D(Aa)O2-model the individual mortality rate for any ventilated newborn within an interval of (0.1) can be given.

[Dopamine-induced secondary cardiomyopathy (author's transl)]. / Dopamin-induzierte sekundäre Cardiomyopathie.

When myocardial fibre necrosis was produced experimentally in rats by high doses of dopamine, the main lesions were found in the left ventricular and septal myocardium. They could also be demonstrated in the left atrium. This report, which concerns clinical observations, is suggestive of a secondary cardiomyopathy in humans due to dopamine. The following pathogenetic mechanism is envisaged. The effects of dopamine are due to myocardial depletion of high energy phosphates following maximal stimulation and the increased, though inadequate adaptation of coronary resistance. The release of norepinephrine is also important. Aggravating factors may include the disturbed relationships of pulmonary ventilaltion to perfusion and the opening and dilatation of arterio-venous shunts in the lung, with subsequent hypoxaemia.

Fate of hydrocarbons during oily sludge disposal in soil.

A 1,280-day laboratory simulation of the "landfarming" process explored the fate in soil of polynuclear aromatics (PNAs) and total extractable hydrocarbon residues originating from the disposal of an oily sludge. In addition to the measurement of CO(2) evolution, periodic analyses of PNAs and hydrocarbons monitored biodegradation activity. The estimation of carbon balance and of soil organic matter assessed the fate of residual hydrocarbons. Seven sludge applications during a 920-day active disposal period were followed by a 360-day inactive "closure" period with no further sludge applications. A burst of CO(2) evolution followed each sludge addition, but substantial amounts of undegraded hydrocarbons remained at the end of the study. Hydrocarbon accumulation did not inhibit biodegradation performance. Conversion of hydrocarbons to CO(2) predominated during active disposal; incorporation into soil organic matter predominated during the closure period. In this sludge, the predominant PNAs were degraded more completely (85%) than total hydrocarbons. Both biodegradation and abiotic losses of three- and four-ring PNAs contributed to this result. Some PNAs with five and six rings were more persistent, but these constituted only a small portion of the PNAs in the sludge. The study confirmed that the microbially mediated processes of mineralization and humification remove sludge hydrocarbons from soils of landfarms with reasonable efficiency.

Neurological findings in newborn infants after extracorporeal membrane oxygenation, with special reference to the EEG.

Seventeen newborn infants were treated with extracorporeal membrane oxygenation (ECMO). Two died shortly after the start of ECMO due to the underlying disease, two died later in the course due to a lack of recovery of lung function and two others died weeks after ECMO from renal damage and a cardiac defect. Of the survivors, nine are developing normally (aged between one and four years) and two are severely disabled because of infarctions of the left hemisphere, acquired before and after ECMO. Intermittent-discontinuous EEGs did not indicate a poor prognosis if normalization of the EEG occurred within seven days. However, infarcted areas on ultrasonography, persistent EEG changes or deteriorating findings indicated disability or early death.

Neonatal neutropenia in low birthweight premature infants.

Neutropenia, as defined by common reference values, occurs often in neonates. Its incidence, causes, and clinical consequences have not been studied extensively in premature neonates. Of 208 consecutive infants with birthweight up to 2000 g, 121 (58%) had neutropenia. Low gestational age and low birthweight correlated with the incidence of neutropenia. Less than half of the neutropenic episodes could be attributed to infections, the others were related to specific perinatal events and due to drug therapy or were of unknown cause. Neutropenia following treatment with certain antibiotics was the most common cause of neutropenia occurring after the second week of life. The high incidence of neutropenia in premature neonates raises questions about application of these reference ranges to low birthweight infants and suggests the need for new reference values.

[Cardiac parameters of the newborn after tocolysis (author's transl)]. / Kardiale Parameter beim Neugeborenen nach Tokolyse.

Since 1971 premature labor has been treated with Fenoterol and Verapamil in the Department of Obstetrics and Gynecology of the University in Mannheim. In animal experiments as well as in the isolated fetal cardiac muscle elective myocardial necroses were observed following stimulation with beta-sympathomimetics. These lesions are prevented by additional application of Ca++-antagonists. Fenoterol and Verapamil are capable of passing through the placenta. To evaluate the question whether a possible cardiac lesion of the infant is caused by tocolysis, 31 newborns of mothers after tocolysis were compared to a group of 19 infants without tocolysis. At the first day of life as well as at the age of 2 and 4 weeks ECG was registered, and the serum electrolytes K+, Ca++ and Mg++ were determined. At day 1 and day 4 as well as during the 2nd and 5th week CK and CK-MB were measured, and during the 2nd week the size of heart was registered. We were unable to demonstrate pathological cardiac findings in newborns following tocolysis which were related to the preceding medication.

[Ultrasonics in the differential diagnosis of space-occupying lesions of the kidney in children]. / Sonographie in der Differentialdiagnose raumfordernder Nierenerkrankungen bei Kindern.

During the last few years the coordination of ultrasound, radiology and urologic surgery led to the diagnosis and treatment of numerous diseases of the kidney. From 1976 till the beginning of 1979 we were able to diagnose 50 expanding retroperitoneal processes. These were hydronephroses, malignant tumors and enlargement of the kidney due to inflammatory affections ensuing nephrolithiasis as well as urosepsis and shock. The fact that sonography is a harmless, non invasive, simple and often repeatable examination is the most important advantage. Provided that ultrasound diagnosing is performed by an experienced person, there is a good correlation to the common x-ray methods and specially recommended for postoperative controls.

[Clinical application of extracorporeal membrane oxygenation (ECMO) in neonatal respiratory failure]. / Klinische Anwendung extrakorporaler Membran-Oxygenierung (ECMO) beim Neugeborenen mit respiratorischer Insuffizienz.

ECMO is a therapeutic alternative for newborns with respiratory insufficiency unmanageable by artificial ventilation. A modified heart-lung machine well suited for long-term application is used both to support life and to take over organ function, allowing this organ to rest and to recover. The ECMO-technique as practised in our group is equivalent to the venous-arterial bypass initiated by the Bartlett-team. Venous blood is drained from the right atrium via the right internal jugular vein. After passage through a membrane oxygenator and a heat exchanger it is returned in an arterialized state to the ascending aorta via the right carotid artery. Cannulation is followed by systemic heparinization. With a roller pump extracorporeal circulation is installed for 3-6 days with flow-rates of 80-120 ml/kg/min. The operation is performed under local anesthesia in the neonatal intensive care unit. The typical course of ECMO is stabilization for the first 24-48 hours on high bypass flow rates keeping paO2 at 50-60 mmHg with minimal ventilator settings (Pmax 20 mmHg. FiO2 0.3-0.4). Bypass flow rates can be reduced for the next 24 h and the patient is taken off and decanulated while on similar ventilator settings. Because of systemic heparinization intracranial bleeding is the main complication for a newborn child on ECMO. The incidence is about 10%. Premature infants per se have a high risk of major intracranial bleeding without ECMO. Therefore contraindications are infants under 35-weeks gestation, and a hemorrhage diagnosed by ultrasound prior to ECMO. Prediction of mortality is estimated by the alveoloarterial oxygen gradient (D [Aa] O2).(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of extracorporeal membrane oxygenation (ECMO) and perspectives for the asphyctic newborn infant]. / Ergebnisse der extrakorporalen Membranoxygenierung (ECMO) und die Perspektiven für das asphyktische Neugeborene.

Extracorporeal life support with membrane oxygenation (ECMO) has been successfully introduced into the management of asphyctic neonates. Two case studies are given to show the importance of this method in antenatal obstetric management.