Alvin Hackel

Neonatal hypoxia and pulmonary vasospasm: response to tolazoline.

Forty-six neonates with hypoxemia were treated with tolazoline, a pulmonary vasodilator, within the first two days of life. Eight of ten (80%) infants without apparent lung disease responded with a mean increase in PaO2 of 116 torr within one hour of beginning tolazoline infusions. One of the responding infants and two nonresponders died. Thirty-six additional infants with a variety of pulmonary disorders had severe hypoxemia which was refractory to mechanical ventilation. Twenty-one (58%) responded with a mean increase in PaO2 of 130 torr within one hour after beginning tolazoline and 13 (62%) of these survived. Fifteen patients had little or no improvement in PaO2 following tolazoline and only three (20%) of these infants survived. Responders could not be distinguished from nonresponders by clinical or laboratory features prior to therapy with tolazoline. Fourteen infants experienced complications possibly related to tolazoline.

Transport of critically ill adults

Interhospital transport can be hazardous because of rapid changes in a patients physiologic status and the use of monitoring systems. A retrospective study evaluated the first 204 critically ill adult patients transported from community hospitals to Stanford Medical Center by a special transport team. To relate the risk of transport to severity of illness, a retrospective scoring system was devised. Sixty-one percent (n = 125) of the patients were at high risk for transport. The patients were stabilized at the referring hospital, and invasive monitoring was used as mandated by the patients condition. The average transport distance was 133 km, and the average duration of transport was 4.38 h. One hundred and five patients (51.5%) were transported by air, and the remaining patients were transported by surface ambulance. All patients survived the transport, and 71.6% were eventually discharged from the hospital. Hospital mortality correlated with the risk-scoring system (p < .01) and increased five-fold as severity of illness increased. This study demonstrates that, with appropriate hemodynamic stabilization and monitoring, severely ill patients can be transported safely.

Tourniquet release: Systemic and metabolic effects

The pneumatic tourniquet produces ischemic changes in limbs. The effects of tourniquet release on systemic blood pressure and metabolic parameters were studied in 11 adult patients undergoing total knee replacement under general anesthesia. Mean arterial pressure (MAP) decreased rapidly after the release of the tourniquet, becoming significant at 3 min and remaining significantly depressed up to 15 min post release. Arterial pH, PaO2, PaCO2, lactate acid, and potassium changed significantly after the release, but normalized within 30 min. These results are notably different from a previous study in a similar patient population undergoing knee replacement under epidural anesthesia. Compared to patients under epidural anesthesia, patients receiving general anesthesia with mechanical ventilation are unable to compensate for the metabolic load caused by the tourniquet release, as the latter group are unable to alter their ventilatory rate. In elderly patients with decreased cardio‐pulmonary reserve, this may be of clinical importance.

Endocarditis Complicating Open-Heart Surgery

BACTERIAL ENDOCARDITIS following intracardiac surgery for congenital defects with use of extracorporeal circulation is a new entity, as old only as open intracardiac surgery. The reported experience is therefore meager. Suggestions regarding its pathogenesis, recognition, behavior, management, and prevention are few. Heins and Lindel reported five cases of bacterial endocarditis in a series of 205 heart defects repaired with extracorporeal circulation. They stress the facts that the classical signs usually associated with bacterial endocarditis are absent and that the bacterial flora encountered is unusual and frequently antibiotic resistant. Two of their patients acquired their infection with achromobacter from a contaminated heart-lung machine when ethylene oxide sterilization rather than autoclaving was employed. One of their five cases died. Of additional interest, fever occurring shortly after surgery was the only clue that ultimately led to diagnosis. Mandel et al.2 first reported a case of bacterial endocarditis following repair of an interventricular septal defect. The operation was performed under hypothermia and coronary perfusion. The infecting organism was Staphylococcus aureus, and the patient died. Their review of the literature revealed 30 cases of endocarditis following operations for repair of congenital and acquired cardiac lesions but none of these was done with extracorporeal circulation. Teitel and Florman3 reported an unusual case of Pseudomonas aeruginosa infection on a silk suture used in the repair of an atrial septal defect with extracorporeal circulation. The infection resisted medical therapy until

Paediatric selective bronchial blocker

Optimal conditions for pulmonary lobectomy requires the use of a ventilation system which allows the collapse of the ipsilateral lung. In infants and small children, a double lumen tracheal tube cannot be used because an appropriately sized tube is not widely available. We report the successful use of a tracheal tube, along which a Fogarty arterial catheter was passed and inflated in a mainstem bronchus, thus providing adequate ventilation and oxygenation as well as optimal surgical conditions for a left lower lobe lobectomy.

Selection criteria for pediatric critical care transport teams

The primary goal of an interhospital critical care transport program is to provide quality medical care during transit as close as possible to that available in the receiving ICU. Critically ill pediatric patients are transported between hospitals by a variety of transport teams. The skills possessed by physicians, nurses, respiratory therapists, and paramedics overlap. To determine the criteria for selection of the team members for these patients, we reviewed the medical records of 115 pediatric patients transported to this facility in 1978 and 1979. Patients were categorized by diagnosis, severity of illness at the time of transport, and the monitoring and life support required during transport. Our data indicate the medical transport team members should have skills required for pediatric critical care diagnosis and management including endotracheal intubation and assisted ventilation; insertion of peripheral, central venous, and arterial catheters; fluid and electrolyte therapy; antibiotic therapy; cardiovascular monitoring; and pharmacological life support. The team members should be chosen based on the particular skills needed for a transport with a goal of providing the patient care required on a consistent basis.

Therapeutic hypothermia during neonatal transport: data from the California Perinatal Quality Care Collaborative (CPQCC) and California Perinatal Transport System (CPeTS) for 2010

Objective:To evaluate cooling practices and neonatal outcomes in the state of California during 2010 using the California Perinatal Quality Care Collaborative and California Perinatal Transport System databases.Study Design:Database analysis to determine the perinatal and neonatal demographics and outcomes of neonates cooled in transport or after admission to a cooling center.Result:Of the 223 infants receiving therapeutic hypothermia for hypoxic ischemic encephalopathy (HIE) in California during 2010, 69% were cooled during transport. Despite the frequent use of cooling in transport, cooling center admission temperature was in the target range (33–34 °C) in only 62 (44%). Among cooled infants, gestational age was <35 weeks in 10 (4.5%). For outborn and transported infants, chronologic age at the time of cooling initiation was >6 h in 20 (11%). When initiated at the birth hospital, cooling was initiated at <6 h of age in 131 (92.9%).Conclusion:More than half of the infants cooled in transport do not achieve target temperature by the time of arrival at the cooling center. The use of cooling devices may improve temperature regulation on transport.

Estimating the quality of neonatal transport in California

Objective:To develop a strategy to assess the quality of neonatal transport based on change in neonatal condition during transport.Study Design:The Canadian Transport Risk Index of Physiologic Stability (TRIPS) score was optimized for a California (Ca) population using data collected on 21 279 acute neonatal transports, 2007 to 2009, using models predicting (2/3) and validating (1/3) mortality within 7 days of transport. Quality Change Point 10th percentile (QCP10), a benchmark of the greatest deterioration seen in 10% of the transports by top-performing teams, was established.Result:Compared with perinatal variables (0.79), the Ca-TRIPS had a validation receiver operator characteristic area for prediction of death of 0.88 in all infants and 0.86 in infants transported after day 7. The risk of death increased 2.4-fold in infants whose deterioration exceeded the QCP10.Conclusion:We present a practical, benchmarked, risk-adjusted, estimate of the quality of neonatal transport.

Laboratory and Clinical Studies during Prolonged Partial Extracorporeal Circulation Using the Bramson Membrane Lung

The survival rate, electrolyte changes, hematological changes, arterial gas analysis, and pulmonary compliances in 14 prolonged venovenous perfusions with the Bramson membrane oxygenator are presented. The Bramson membrane oxygenator functioned efficiently. There were two deaths in the series, neither attributable to the perfusion. Arterial gas studies and pulmonary compliance studies indicated no measurable detrimental effect on the lungs. Platelet counts decreased and white blood cell counts increased during perfusion. A clinical prolonged veno-venous perfusion is reported.

Regional disaster planning for neonatology.

pointed out a significant problemfor neonatology: when patients of different ages, but similarprognoses, were triaged, neonates fared significantly worse thanolder children and adults. The neonatal patients fared less wellthan all age groups except 80-year-old patients. Existing neonatalscoring systems designed for research or outcomes prediction donot work well when applied after the first hours of life.