Respiratory depression following epidural morphine in an infant of three months of age.

Epidural administration of combinations of opioids and a local anaesthetic provides prompt and effective analgesia and is increasingly used in paediatric anaesthesia. However, respiratory depression by rostral spread of opioid in the CSF is by far the greatest concern after epidural morphine. An infant of three months of age underwent portoenterostomy (Kasai's operation) for extrahepatic biliary duct atresia. A median approach at the L3-L4 epidural interspace was used and a dose of 1 ml.kg-1 of 0.125% bupivacaine with adrenaline 1:400000 mixed with 50 micrograms.kg-1 morphine was injected using a 19 gauge Tuohy needle. Six h after epidural morphine, the infant developed respiratory depression with an increase in drowsiness, miosis and decreased respiratory rate. Low arterial saturation (SpO2) was detected by pulse oximetry and confirmed by blood gas analysis. An intravenous bolus of 5 micrograms.kg-1 naloxone followed by a 3-h infusion of 2 micrograms.kg-1.h-1 resulted in complete reversal of signs and symptoms of respiratory depression. Epidural opioids should be limited to paediatric patients admitted to specialized recovery units for the first postoperative day.

[7 years' experience with hepatic transplantation in children]. / Experiencia de 7 años en el trasplante hepático pediátrico.

UNLABELLED: Between the 7th of June 1985 and december 1991, 71 liver transplants (LTx) were performed in 60 patients (pts) with ages ranging from 8 months to 14 years and weight between 4 and 38 kg. Sixty-two percent were cholestatic diseases (32 biliary atresia, 3 sclerosing cholangitis and 2 biliary paucity), 25% metabolic hepatic-based diseases (6 glycogen storage disease, 4 Byler disease, 3 tyrosinaemia and 2 alpha-1-antitrypsin deficiency) and 13% miscellaneous diagnosis (2 post-hepatitic cirrhosis, 2 autoimmune hepatitis, 2 fulminant hepatitis and one case of cholesteryl ester storage disease and one case of Budd-Chiari disease). Primary non-function was observed in 4 cases (5.5), severe bacterial infection in 4 pts. (5.5%), severe viral infection in 2 (3%), arterial thrombosis in 2 (3%), arterial rupture in 1 (1.5%), recurrence in 3 cases (5%) and chronic rejection in two (3%). Two patients were in III and IV coma respectively prior to surgery. Intraoperative mortality was nil. Total mortality was 19 cases, which represents an actuarial survival rate of 70%. Our philosophy has always been to offer this treatment to all patients candidates for LTx. In some end-stage situation it is very difficult to objectively assess their possibilities and when necessary refuse the only opportunity the patient has. Nevertheless, results are satisfactory. IN CONCLUSION: 1. LTx in children has been confirmed in our programme over 7 years as efficient treatment for end-stage liver diseases. 2. Advances in the therapeutic arsenal and increased experience have notably improved the progress of these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Changes in blood calcium during liver transplant in children]. / Variaciones de la calcemia durante el trasplante hepático pediátrico.

We have evaluated the changes in plasma total and ionic calcium levels in twenty hepatic transplantations in pediatric patients. Direct intraoperative monitoring of ionic calcium is fundamental, because its variability is unrelated with total calcium levels; in addition, normal ionic calcium levels contribute to the hemodynamic stability of the patient. Although at the end of the operation total and ionic calcium levels were similar to the postinduction measurement, their values were dissociated in the perianhepatic period. In the anhepatic phase ionic calcium reached its lowest value (1.00 mmol/l) although total calcium increased above postinduction level from 2.13 to 2.46 mmol/l (p less than 0.05). In hepatic transplantation in pediatric patients calcium administration is indicated during the transfusion of citrated blood, being particularly necessary during the anhepatic phase to prevent ionic hypocalcemia.

[First infantile liver transplants in Spain]. / Primeros trasplantes hepáticos infantiles en España.

For the first time in Spain, authors report the experience, started by the Hospital Infantil "Valle de Hebron" of Barcelona on pediatric liver transplant in terminal liver disease in childhood which means a new opportunity for these patients otherwise facing a fatal out come in a short time. We show the 4 first pediatric liver transplants performed in our country and we point out some of the most important factors of a pediatric liver transplant program in a consolidation phase.

Occurrence of oxalyl-CoA synthetase in Indian pulses.

The presence of oxalyl-CoA synthetase was observed in common edible pulses. Excepting in chick pea, the changes in oxalyl-CoA synthetase activity of winter pulses proceeded in stages. The enzyme remained more active in late strains than in early strains of winter pulses. Unlike the activity of the enzyme in winter pulses, that in summer pulses behaved differently.

The influence of carboxyhaemoglobin on the oxygen-binding capacity of blood. A comparison of manometric (Van Slyke) and optical (Co-Oximeter) measurements.

Oxygen content measurements determined optically by the Co-Oximeter correlated closely with those obtained using the manometric technique of Van Slyke. In those samples with a high content of carbon monoxide, the agreement between the two methods could be improved, by taking into consideration the concentration of carboxyhaemoglobin (COHb), since this plays no part in oxygen transport. The calculated values of the oxygen-binding capacity varied widely, with mean values less than the theoretical figure of 1.39 ml O2/g Hb. This difference was greater in those samples with a higher content of COHb. When the amount of haemoglobin combined with COHb was taken into consideration the mean corrected values approximated to the theoretical value of 1.39, thus supporting this as the mean value for the oxygen-binding capacity of haemoglobin, although the large individual variability persisted.

Positive end-expiratory pressure. Effect on arterial oxygenation during respiratory failure in chronic obstructive airway disease.

Changes induced in arterial oxygenation by positive end-expiratory pressure (PEEP) were analysed in twenty-nine instances in seven patients with chronic obstructive airway disease and acute respiratory failure, who were receiving IPPV. A significant decrease in mean PaO2 was found 4 hours after the removal of PEEP (P smaller than 0-01), but after its addition during the same period the PaO2 change was not significant. PaCO2 values were not modified by PEEP. The slight increase in mean PaO2 (20-9 mmHg) encountered during controlled ventilation with PEEP seems of doubtful clinical value. Alveolar-arterial oxygen gradient, while breathing oxygen 100%, was found to be elevated with a mean value of 276 mmHg. It appears from our results that PEEP is of little or no value in the routine ventilatory treatment of patients with chronic obstructive airway disease unless hypoxaemia is believed to be caused by a large intrapulmonary shunt.