The immediate haemodynamic response to the initiation of extracorporeal membrane oxygenation in a piglet model of infant hypoxic respiratory failure.

There is evidence that haemodynamic fluctuations on extracorporeal membrane oxygenation (ECMO) increase the risk of cerebral damage. We hypothesized that initiation of venovenous (VV) or venoarterial (VA) ECMO itself causes haemodynamic fluctuations and, thus, established an infant animal ECMO model in order to discuss this hypothesis. Five piglets were cannulated using the jugular and femoral veins (VV group) and five using the jugular vein and carotid artery (VA group). All animals were subjected to hypoxic ventilation (FiO2 8%) for 10 min, leading to a PaO2 of < 40 mmHg, and subsequently rescued by ECMO. The heart rate (HR) and mean arterial blood pressure (MAP) were recorded at 5-min intervals; the arterial blood lactate was measured prior to and after 5 and 10 min of hypoxia, as well as 30, 60 and 120 min after initiation of ECMO. The response to initiation of ECMO was similar in the VV and VA groups with regard to HR and lactate, but differed significantly in MAP. HR decreased significantly from 135 +/- 7 to 103 +/- 6 beats/min (p < 0.05) and from 132 +/- 8 to 84 +/- 9 beats/min (p < 0.01) at 5 min (p = NS) after installation; lactate increased from 1.4 +/- 0.1 to 1.8 +/- 0.2 mmol/l (p = NS) and from 1.4 +/- 0.2 to 1.6 +/- 0.5 mmol/l (p = NS) after 30 min (p = NS); MAP decreased from 80 +/- 5 to 63 +/- 3 mmHg (p = NS) and increased from 75 +/- 4 to 84 +/- 3 mmHg (p = NS) at 5 min (p = 0.001), respectively. The initiation of ECMO is associated with haemodynamic fluctuations in both modalities, which differ with regard to blood pressure reaction.

Osteomyelitis at the injection site of adrenalin through an intraosseous needle in a 3-month-old infant.

Intraosseous (IO) puncture is considered for the administration of drugs and fluids when vascular access cannot be achieved rapidly. Adrenaline/epinephrine, adenosine, crystalloids, colloids and blood products can be applied and administered effectively using this route during resuscitation of children. This technique is relatively simple with complications of <1%. These may include tibial fracture, lower extremity compartment syndrome and osteomyelitis. A case is described in which a 3-month-old male infant presented for emergency resuscitation requiring IO infusion utilising both tibial bones. High doses of adrenaline (1:1000; 0.1 mg/kg) were administered in the right tibial epiphysis only after the standard initial concentration (1:10000; 0.01 mg/kg) had minimal effect. A local inflammatory reaction was noted 24 h later in the right tibial region, which developed into cutaneous necrosis, and was eventually resected. Radiologically, no osseous lesion could be demonstrated, however, a bone scintigram revealed osteomyelitis. Upon surgical revision, purulent destruction was evident requiring removal of the epiphysis and part of the metaphysis. Although osteomyelitis is a rare complication which may be caused by sepsis, or contamination during insertion, we speculate that adrenaline in high concentrations may promote the development of osteomyelitis and the drug should be applied cautiously in more diluted concentrations.

Severe respiratory failure following charcoal application in a toddler.

Charcoal has been commonly used for enteral detoxication with few adverse effects. In toddlers charcoal can often be simply applied via a gastric tube. Regurgitation and aspiration is considered a rare event. We report the case of a 19-month-old boy who suffered endobronchial charcoal contamination followed by acute airway obstruction and severe respiratory failure despite a commonly used tube placement verification technique. Immediate intubation, tracheal suctioning, intravenous bronchodilators, and high frequency oscillatory ventilation (HFOV) were used to control hypercarbia and hypoxia. Eventually charcoal removal by bronchoscopy was successful. Chest X-ray investigation did not reflect the true amount of charcoal deposited endobronchially at any time. We conclude that gastric tube application of charcoal in children carries a risk of aspiration. This may lead to life-threatening respiratory failure with the need to provide artificial ventilation and bronchial lavage.

Life threatening cardiopulmonary failure in an infant following protamine reversal of heparin after cardiopulmonary bypass.

Life threatening cardiopulmonary failure following protamine reversal of heparin after cardiopulmonary bypass (CPB) was reported to occur in adults but rarely in children. Atrial septal defect closure was performed in a 6-week-old infant erroneously suspected to suffer from right atrial thrombosis in addition. Protamine administration after CPB led to critical pulmonary hypertension and severe haemorrhagic pulmonary oedema resulting in severe hypoxia. Inhaled nitric oxide, together with high frequency oscillation ventilation supplemented by intravenous prostacycline, enabled complete recovery of cardiopulmonary and neurological function. Life threatening cardiovascular compromise after intravenous protamine can occur even in young infants which then require challenging paediatric critical care.

Permissive hypoxemia permitted postoperative weaning from artificial ventilation after repair of pulmonary atresia.

Survival after corrective surgery of pulmonary atresia was associated with low right ventricular pressure, indicating normal pulmonary vascular resistance. Therefore increased fractional inspiratory oxygen concentration, inhaled nitric oxide and intravenous prostacyclin were considered to be effective measures during postoperative intensive care. In a 20-year-old female, conduit repair and unifocalisation of pulmonary atresia with ventricular septal defect and systemic to pulmonary arterial collaterals were performed despite preexisting one-sided pulmonary hypertension. During the following postoperative period, normal arterial oxygen saturation aimed at by means of a high fractional inspiratory oxygen concentration, resulted in persistent pulmonary oedema despite fluid restriction. After several trials of weaning from artificial ventilation, permissive hypoxemia was eventually successful.

Acute clinical deterioration in a patient with end-stage dilated cardiomyopathy and left ventricular thrombus formation.

The case of a 17-year-old male patient with severe end-stage dilated cardiomyopathy and a large thrombus formation within the cavum of the left ventricle is reported. After an acute thrombectomia combined with a partial left ventriculectomy (Batista procedure), the patient was successfully treated with an appropriate left ventricular assist device (LVAD) system using a centrifugal nonocclusive pump (Biomedicus, Medtronic, Anaheim, CA, U.S.A.). Mechanical support was removed on Day 9, and the patient was discharged from the hospital on Day 19. The effectiveness of emergency mechanical support in patients with very unfavorable prognoses is discussed.

Pulmonary failure after Norwood procedure: indication for extracorporeal membrane oxygenation? A case report.

Today some authors consider univentricular repair a contraindication for postoperative cardiac extracorporeal membrane oxygenation (ECMO). The question is whether or not ECMO is indicated as pulmonary support in case of an overwhelming pulmonary infection during the postoperative course after a Norwood procedure. During the prolonged weaning period after a Norwood procedure using a 4 mm aortopulmonary shunt, proven respiratory syncytial virus (RSV) bronchiolitis occurred at the time of expected weaning from artificial ventilation. Venovenous ECMO was able to improve oxygenation, but when pulmonary opacification failed to resolve, ECMO was terminated after 12 days.