[Effect of implementation of a trauma leader on process parameters for polytrauma treatment in the shock room of a tertiary care hospital]. / Auswirkung der Implementierung eines Schockraumkoordinators auf Prozessparameter der Polytraumaversorgung im Schockraum eines Maximalversorgers.

BACKGROUND: In patients up to the age of 40 years old severe trauma is the most frequent cause of death in Germany. According to the current S3 guidelines on treatment of polytrauma and the severely injured, since 2011 the presence of a shock room coordinator should be considered, who can improve the survival of patients by optimized treatment quality and times. The aim of the present study was to analyze various parameters of shock room treatment for polytraumatized patients before and after implementation of a shock room coordinator for treatment of polytrauma. MATERIAL AND METHODS: To ensure an adequate period of time between the implementation of the shock room coordinator in 2011, data from 2009 and 2012 were included for comparative purposes. All scanned protocols of shock room treatment in the period from 1 January 2009 to 31 December 2009 and from 1 January 2012 to 31 December 2012 were inspected and evaluated. RESULTS: In total 213 shock room treatments from 2009 and 420 from 2012 were included. The mean number of shock room treatments in 2009 was 17.8 per month and in 2012 the mean number was 35 per month. The mean number of shock room treatments was nearly doubled in comparison (p < 0.001). The mean time for shock room treatment in 2009 was 74.8 min and in 2012 the mean time was 69 min and was therefore reduced by 5.8 min (p = 0.56). CONCLUSION: The treatment of polytraumatized patients in the presence of a shock room coordinator and after implementation of the standard operating procedure (SOP) was neither statistically nor clinically relevantly shortened.

[Correct positioning of central venous catheters in pediatrics : Are current formulae really useful?] / Sichere Platzierung von zentralen Venenkathetern im Kindesalter : Sind aktuelle Formeln wirklich sinnvoll?

BACKGROUND: Correct positioning of a central venous catheter (CVC) tip in pediatric patients is very important. Malpositioning may lead to direct complications, such as arrhythmia and increase the risk of thrombosis, infections, valve failures or pericardial tamponade. OBJECTIVE: The aim of this review was to identify and summarize published formulae for the correct positioning of the CVC tip in children and to discuss the benefits of these formulae for the daily routine. MATERIAL AND METHODS: A systematic and standardized search in Medline and PubMed was performed to identify published formulae. Formulae for insertion depth of the CVC tip over the right internal jugular vein are discussed. The keywords "pediatric" or "pediatric", "children", "central venous catheter", "CVC", "central venous", "length", "insertion", "optimal", "formula", "depth", "correct position" and "right position", "internal jugular vein" were used to identify the formulae. RESULTS: A total of 854 publications were found and 127 publications were analyzed. The publications were subsequently assessed and classified independently by a specialist in anesthesiology and a specialist in pediatrics. A total of six publications described different body height-based formulae for calculation of a CVC insertion depth. No prospective evaluation of these formulae was performed to show if it is possible to place a CVC tip at the optimal position. CONCLUSION: The benefit of a formula for daily practice is very limited due to the problem of choosing the right insertion point. The recommended insertion depth should be considered as an indicator and a verification of the CVC tip position should be done using an imaging technique.

Investigation of umbilical venous vessels anatomy and diameters as a guideline for catheter placement in newborns.

Umbilical cord catheters (UCC) are important for the primary care of critically ill newborns. To analyze anatomical variations of the umbilical vein (UV) and its further course, we performed abdominal spiral-CT examinations on stillborns. The aim of the study was to explore the high incidence of mal-positioned UCCs and to improve their positioning. Eighteen stillborns were investigated (29.2 weeks ± 6.7 weeks (IQR)). CTs were performed using either air or contrast medium injection into the UV. We measured the diameter at the narrowest points of (i) the umbilical vein, (ii) the segmental portal vein, (iii) the left portal vein, (iv) the umbilical recess, and (v) the ductus venosus. The branching angles between (a) the umbilical vein and intrahepatic veins and (b) the ductus venosus and umbilical recess were measured. The diameter of the UV increases from 3.4 to 11 mm (median [IQR]:4.6 mm [4.2-6.9]: r2 = 0.64). The left portal vein has a larger diameter (3.6 mm [2.6-4.55]; r2 = 0.43) than the left segmental portal vein (2.3 mm [1.8-2.75]; r2 = 0.23). The diameter of the ductus venosus (2.5 mm [1.6-3.4]; r2 = 0.59) is half that of the umbilical recess (5.1 mm [3.3-6.2]; r2 = 0.43). The most obtuse angle is formed by the junction between the umbilical recess and ductus venosus (151° [133-159]; r2 = 0.001). The branch angle from the outgoing UV into the left portal vein is more obtuse (128° [123-144]; r2 = 0.0001) than that of the segmental portal vein (115° [105-119]; r2 = 0.0001). To avoid mal-positioning, our data suggest the use of a soft catheter. The UV and its extensions are wide enough to admit a 4 Fr. catheter without complete obstruction. Clin. Anat. 31:269-274, 2018. © 2017 Wiley Periodicals, Inc.

Observations on the effects of inhaled isoflurane in long-term sedation of critically Ill children using a modified AnaConDa©-system.

Long-term intravenous sedation may present problems due to dependence and side effects. Medical records of children who were administered isoflurane were reviewed. 15 patients (9 boys, 6 girls) with a mean age of 11.8 month (+2.4) were analysed.Analgesia and sedation was given in mean 9.7+1.1 days before commencing inhalation using a modified application device (AnaConDa©). Administration was given over a period of 7.2+1.4 days. Depth of sedation was monitored by using Comfort- and Hartwig-scores. Observations included continuous monitoring of heart-rate, pulse oxymetry, blood pressure and cerebral tissue oxygenation.Within 4 h post administration of isoflurane a satisfactory increase in the depth of sedation was seen and kept till extubation. 6/15 patients received tracheostomies during the observation period. None of the patients observed suffered life-critical events of the modified application of isoflurane proceeded without complications. Ketamine and clonidine infusion rates were significantly reduced (p<0.005) as well as the use and overall infusion rate of midazolam, γ-hydroxy butyrate, fentanyl and morphine (p<0.05).Isoflurane inhalation may provide an additional option for long-term sedation in a specific group of critically ill infants but neurodegenerative toxic effects will have to be taken into account when using volatile anesthetics at any time during infancy.

Hemolytic anemia and methemoglobinemia in a preterm baby as a complication of antenatal intraamnial injection of toluidine blue.

A late preterm infant was born 4.5 h after intraamniotic injection of 90 mg of Toluidine blue to confirm premature rupture of membranes. Due to the fetal exposition to the dye, the entire body of the patient was blue stained and the baby suffered from methemoglobinemia, Heinz' body positive hemolytic anemia and hyperbilirubinaemia requiring exchange transfusion. These complications underline that antenatal exposition of toluidine blue may result in considerable postnatal infant morbidity. Therefore intraamniotic application of toluidine blue should be discouraged.

Topographical anatomy of central venous system in extremely low-birth weight neonates less than 1000 grams and the effect of central venous catheter placement.

Central venous catheterization is widely used in neonatology. Although ultrasonic guidance for central venous catheter placement is available, complications occur significantly more frequently in infants, especially neonates, than in adults. This study seeks to determine the characteristics, topographical conditions, regional relationships, and diameters of the venous structures of the upper extremity and the thoracic central venous system in extremely small preterm neonates (mean: 900 g). Nine formaldehyde-fixed preterm stillborns were prepared (mean 27 2/7 weeks' gestational age). The anatomical preparation involved the complete thoracic wall, neck and shoulder region, and preparation of the upper extremities. It was shown that the course of the internal jugular vein can be influenced by rotation of the head. Maximum head rotation (80°) to the contralateral side leads the internal jugular vein to overlap the common carotid artery and sharpens the confluence angle of the internal jugular into the brachiocephalic vein. We propose that this has the potential to result in dislocation of the catheter. Less rotation of the head (<30°) is favorable as the internal jugular vein and common carotid artery run in parallel. Commonly used central venous catheters (2F-4F) may not occlude the vascular lumen completely. Small central venous cannulation using a single-orifice catheter through arm veins (1F) may also not occlude peripheral vessels of the upper extremity (cephalic and basilic veins). The right internal jugular vein has a straight course, appears suitable for central venous access and less hazardous, especially when using stiff catheters. The use of small straight wire guides is recommended.

Life-threatening hypernatremic dehydration in a 7-week-old exclusively breastfed infant as a cause of a decline in breastmilk volume and parental language barriers in a North African family.

Breast-feeding is regarded as the most appropriate source of nutrition for healthy, full-term newborns and infants. Here, we present the case of a full-term, seven week old male infant who was exclusively breast-fed but who developed severe hypernatremic dehydration as a result of declined breast milk volume that was not recognized by the parents. In order to prevent serious therapy-associated side effects due to rapid rehydration, we performed a rehydration regime providing a slow decrease of serum sodium levels by carefully infusing hypertonic saline solution. Following this approach, the patient could be discharged without any noticeable disorder. As the incidence of breast-feeding associated hypernatremic dehydration in the developed countries is increasing, strategies of prevention are discussed.

Remifentanil for INSURE in preterm infants: a pilot study for evaluation of efficacy and safety aspects.

AIM: To evaluate intubating conditions, extubation times and outcome in preterm infants receiving remifentanil as induction agent for the INSURE procedure. METHODS: In twenty-one preterm infants of 29 to 32 weeks gestation and signs of respiratory distress, we utilized remifentanil as induction agent for the INSURE procedure. Following intubation and surfactant application, the infants were mechanically ventilated until respiratory drive was judged to be satisfactory for continuing CPAP therapy. Intubating conditions were classified by our own scoring system by rating limb movements, coughing and breathing. Heart rate, blood pressure and oxygen saturation were recorded during the entire INSURE procedure. RESULTS: Remifentanil provided excellent or good intubating conditions in all patients. We observed no serious side effects after remifentanil infusion, in particular, no thorax rigidity, clinically significant bradycardia or arterial hypotension. Average extubation time after surfactant administration was 16.9 min (1-45 min); none of the infants had to be reintubated. Following extubation, the infants required only 3.3 days (1-8 days) of CPAP therapy. None exhibited serious complications of prematurity like periventricular leucomalacia, intraventricular haemorrhage >I degree, necrotizing enterocolitis or retinopathy. CONCLUSION: In this pilot study, INSURE with remifentanil was associated with good intubating conditions and early extubation resulting in an excellent neonatal outcome.

Rapid development of life-threatening complete atrioventricular block in Kearns-Sayre syndrome.

Kearns-Sayre syndrome is a rare mitochondrial disorder with defined diagnostic criteria. Knowledge of these diagnostic criteria and early diagnosis are important to ensure periodic electrocardiograms for identification of cardiac conduction disorders, which are the most important prognostic factor of the disease. We report on a 9-year-old girl with rapid development of a life-threatening complete atrioventricular block within 10 months and discuss the importance and time interval of regular electrocardiograms. Our patient survived by placing a temporary transvenous pacemaker lead followed by permanent pacemaker implantation a few days later.

Aerosolized iloprost in the treatment of pulmonary hypertension in extremely preterm infants: a pilot study.

BACKGROUND: In premature infants with preterm prolonged rupture of membranes, death after birth is often due to persistent pulmonary hyper-tension. PATIENTS: Aerosolized iloprost was used to treat pulmonary hypertension due to prolonged preterm rupture of fetal membranes (7-56 days) in four extremely low-birthweight neonates (23-25 weeks' gestation, weight 448-645 g) under spontaneous breathing supported by nasal continuous positive airway pressure. METHOD: Inhalation dose was 2 microg/kg b.w. and between 44 and 65 inhalations were performed in each patient starting within the first hour of life over a total of several days. Single inhalations lasted 5 min and were not repeated until 60 min had elapsed. RESULTS: After the first inhalation, the PaO2/FiO2 mean ratio increased from 65 (range 35-114) to 194 (148-250) mmHg and oxygenation requirements decreased within the next 7 days. Echocardiography similarly showed reduction in pulmonary resistance. We observed no severe side effects on blood pressure or prolonged bleeding time during inhalation. CONCLUSIONS: Iloprost inhalation might therefore be an additional treatment for improving oxygenation in cases of persistent pulmonary hypertension in extremely low-birthweight infants under spontaneous breathing. Further randomized clinical studies are required to establish the role of iloprost in this setting.

[Chemotherapy-induced fetal anemia in maternal acute myelocytic leukemia]. / Chemotherapieinduzierte fetale Anämie bei akuter myeloischer Leukämie der Mutter.

This article discusses the management of a pregnancy of a 32-year-old primigravida with acute myelocytic leukemia treated with induction chemotherapy starting in the 20 + 5 week of gestation. Sonographic monitoring showed evidence of fetal ascites and anemia that could be treated with an intrauterine fetal transfusion. After maternal recovery, a caesarean section was performed in the 27 + 5 week of gestation. We delivered a vivid eutrophic female prematurely. The infant showed persisting signs of myelosuppression. Two further transfusions had to be performed. The present report describes the interdisciplinary therapeutic management when polychemotherapy during pregnancy is necessary for the mother. Cases of acute leukemia in pregnancy are complicated by severe prenatal risks caused by the hematologic illness and by the immediate beginning of chemotherapy. In the third trimester premature delivery is preferable to intrauterine exposition to cytostatic agents. In the second trimester the pregnancy has to be monitored for the typical risks and complications of chemotherapy. Fetal cytotoxic myelosuppression is detectable by prenatal observation so that interventional strategies are feasible.

Primary respiratory support in preterm infants with cleft lip and palate.

OBJECTIVE: Preterm infants with respiratory distress are routinely treated by application of nasal mask continuous positive airway pressure. In preterm infants with cleft lip and palate, nasal mask attachment is not feasible due to air leakage through the cleft defect. Here, we describe a modified continuous positive airway pressure application method that overcomes this problem. DESIGN AND SUBJECTS: Observation study, university neonatal intensive care unit. The neonates (n = 4) were between 28 and 33 weeks' gestation and weighed 1160 to 1680 g at birth. Immediately after birth, infants with unilateral cleft lip and palate (n = 3) were respiratory stabilised by a Medijet generator using a nasal tube. To minimise the pressure cap, hydrocolloid bandages were adhered over the total cleft defect. Immediately after orthodontic passive palatal plates insertion (within 27 hours of life), the nasal tube was removed and continuous positive airway pressure was applied through a nasal mask covering the complete nose of the infant. RESULTS: The system proved suitable for patients with unilateral cleft lip and palate for whom the generated nasal mask continuous positive airway pressure remained constant between 5 to 7 cm of water but failed in the patient with bilateral cleft lip and palate. None of the patients had to be ventilated due to respiratory failure, and all survived to discharge. CONCLUSION: Preterm infants with unilateral, but not bilateral cleft lip and palate, can be successfully stabilised using the described nasal mask continuous positive airway pressure system, thereby avoiding primary intubation and its associated risk of complications.

The Uromodulin C744G mutation causes MCKD2 and FJHN in children and adults and may be due to a possible founder effect.

Autosomal dominant medullary cystic kidney disease type 2 (MCKD2) is a tubulo-in terstitial nephropathy that causes renal salt wasting, hyperuricemia, gout, and end-stage renal failure in the fifth decade of life. This disorder was described to have an age of onset between the age of 20-30 years or even later. Mutations in the Uromodulin (UMOD) gene were published in patients with familial juvenile hyperuricemic nephropathy (FJHN) and MCKD2. Clinical data and blood samples of 16 affected individuals from 11 different kindreds were collected. Mutational analysis of the UMOD gene was performed by exon polymerase chain reaction (PCR) and direct sequencing. We found the heterozygous C744G (Cys248Trp) mutation, which was originally published by our group, in an additional four kindreds from Europe and Turkey. Age of onset ranged from 3 years to 39 years. The phenotype showed a variety of symptoms such as urinary concentration defect, vesicoureteral reflux, urinary tract infections, hyperuricemia, hypertension, proteinuria, and renal hypoplasia. Haplotype analysis showed cosegragation with the phenotype in all eight affected individuals indicating that the C744G mutation may be due to a founder effect. Moreover, we describe a novel T229G (Cys77Gly) mutation in two affecteds of one kindred. Three of the affected individuals were younger than 10 years at the onset of MCKD2/FJHN. Symptoms include recurrent urinary tract infections compatible with the published phenotype of the Umod knockout mouse model. This emphasizes that MCKD2 is not just a disease of the young adult but is also relevant for children.

Recombinant activated factor seven in acute life-threatening bleeding in neonates: report on three cases and review of literature.

INTRODUCTION: Acute bleeding of different genesis can be a severe, life-threatening problem in neonatology. Recombinant factor seven (rFVIIa) is known to have unique hemostatic properties in adults and older children. CASE PRESENTATION: Three cases of acute life-threatening peri- and postnatal hemorrhage were successfully controlled after the application of fFVIIa. All infants were first treated with vitamin K, fresh-frozen plasma and platelet transfusion. CONCLUSION: The cases substantiate other reports that rFVIIa is an effective treatment for acute, refractory and life-threatening bleeding in neonates and premature infants.

Severe primary cutaneous aspergillosis refractory to amphotericin B and the successful treatment with systemic voriconazole in two premature infants with extremely low birth weight.

Primary cutaneous aspergillosis is a rare, life-threatening, infectious complication in premature infants that may result in fulminant sepsis and subsequent multi-organ failure. In the past decade, the incidence of primary aspergillosis has increased significantly, whereas the high morbidity and mortality of invasive aspergillosis remains unaltered. In vitro studies reveal that more and more Aspergillus species seem to be refractory to the classical treatment with fluconazole or amphotericin B. This case report presents two extremely low birth weight infants (ELBW) with primary cutaneous aspergillosis, which was refractory to amphotericin B. Both patients were successfully treated with systemic voriconazole, an extended-spectrum triazole antifungal, supported by topical care. This paper provides the clinical manifestation, diagnostics and pharmacotherapy of primary cutaneous aspergillosis, as well as pharmacokinetic aspects of voriconazole in ELBW infants.

A stepwise approach to the treatment of early onset nephrotic syndrome.

We have retrospectively reviewed our single-center experience of the treatment of early onset nephrotic syndrome (NS). From 1991 to 1998, ten children with NS were treated. Kidney biopsy showed focal sclerosis (n=1), diffuse mesangial sclerosis (n=7), and congenital NS of the Finnish type (n=2). Associated conditions included incomplete Drash syndrome (n=1), Galloway-Mowat syndrome (n=1), and severe mental and motor retardation of unknown origin (n=3). From 1991 to 1997, five children with NS were treated. Bilateral nephrectomy (NX) was performed in three, one patient with severe retardation died at 4 years and NX was not performed in one patient who showed satisfactory growth and development. Three of these children were dialyzed and two were successfully transplanted. One patient was transplanted without previous dialysis. From 1997 to 1998, five children were treated with a regimen that included captopril and indomethacin (CAPTO/INDO). CAPTO/ INDO was successful in increasing serum protein in all patients and producing growth and development in four patients. In two patients CAPTO/INDO was successful only after unilateral NX. Our experience indicates that CAPTO/INDO may be a valuable treatment in patients with early onset NS. An individualized stepwise approach including unilateral NX should be considered to achieve optimal results.

Antagonistic effects of vitamin D and parathyroid hormone on lipoprotein lipase in cultured adipocytes.

The effects of 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) (calcitriol) and parathyroid hormone (PTH) on synthesis and secretion of lipoprotein lipase (LPL) were studied in 3T3-L1 adipocytes. Expression of the vitamin D receptor was demonstrated by saturation kinetics with radiolabeled calcitriol. Incubation with calcitriol (10(-8) M) for up to 4 d resulted in a time-dependent significant increase in heparin-releasable LPL activity (LPLa) accompanied by a significant increase in LPL mRNA. In contrast, incubation with intact (1-84) PTH (10(-6) to 10(-9) M) produced a time- and dose-dependent significant decrease in LPLa, but no change in LPL mRNA. The effect of PTH (24-h incubation, 10(-8) M) could be prevented by the calcium channel blocker verapamil. Coincubation with both calcitriol and PTH at equimolar concentration (10(-8) M) resulted in an increase in LPLa and LPL mRNA. These data indicate an antagonistic role for calcitriol and PTH in the regulation of LPL, possibly mediated by intracellular calcium, which may contribute to the alterations in lipoprotein metabolism occurring in uremia.

[Neuropathy of the gingival autonomous nerve system in inflammatory diseases of the periodontium. Ultrastructural analysis]. / Neuropathie des autonomen Nervensystems in der Gingiva bei entzündlichen Parodontopathien. Eine ultrastrukturelle Analyse.

In a comparative study the influence of periodontal disease on the autonomous nerve-system of human attached gingiva was analysed ultrastructurally in 20 gingiva specimens. The test group was formed by 10 patients with adult periodontitis (AP) and compared with 10 patients with clinically healthy gingiva. The specimens were prepared for ultrastructural evaluation. The autonomous nerve fibres near the epithelium, in the connective tissue, and at the blood vessels were qualified and quantified by means of electron microscopy. In the test group clear signs of neuropathy of the autonomous nerve system like lysis of axoplasm, evagination of axons from their Schwann's sheaths, de- and regeneration pistons and reduction of axons were found. The possible pathogenic significance of this neuropathy of the autonomous nerve system in periodontal disease is discussed.