Antonio G. Galvis

Perforation of the heart by central venous catheters in infants: Guidelines to diagnosis and management

The frequent use of central venous catheters has resulted in improved monitoring and parenteral nutrition. However, these catheters have also been a source of numerous complications, some of them lethal. Two cases of perforation of the heart that resulted in cardiac tamponade and death are reported. Early detection of this complication depends on a high index of suspicion, both clinical and radiographic. Measures such as securing the catheter tip in the superior vena cava can prevent this complication; immediate evacuation of the pericardial fluid by gentle aspiration or pericardiocentesis can prove life-saving.

Blunt cardiac injury in children

Thirty-nine children admitted to the pediatric intensive care unit with multiple injuries from blunt trauma underwent serial EKGs, determination of creatinine phosphokinase (CPK) isoenzymes, echocardiography, and radionuclide angiography studies. Motor vehicle injuries were responsible for 83% (32 of 39) of admissions, the remainder (7 of 39) caused by falls from heights. Thirteen children sustained serious (Modified Injury Severity Score [MISS] greater than 25) multiple system injury. Chest injuries were sustained by 12 children, nine being serious thoracic injuries (MISS chest score greater than 2). Three children (7.7%) showed elevations of MB fraction of CPK isoenzymes in addition to EKG abnormalities and/or ejection fraction depression on radionuclide angiography and were considered to have sustained cardiac contusion. Eight other children (20%) had normal or borderline elevation of CPK-MB fraction and EKG abnormalities combined with abnormal echocardiograms or radionuclide angiograms, and were considered to have sustained cardiac concussion. An additional 14 children (36%) had EKG or radionuclide angiography abnormalities alone. Two children required lidocaine therapy for cardiac irritability manifesting as multifocal PVCs and ventricular tachycardia. Based on this study, a comprehensive diagnostic evaluation of the heart in all children sustaining multiple injuries from blunt trauma cannot be justified. Continuous cardiac monitoring should be initiated in the emergency room and maintained throughout intensive care unit confinement to identify transient dysrhythmias. In patients with significant dysrhythmias and in those with obvious thoracic injuries serial EKG and cardiac isoenzyme assay should be obtained. Dysrhythmias should be man-aged with appropriate anti-arrhythmic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiological Manifestations in Patients on Continuous Positive-Pressure Breathing

Chest films of patients on continuous positive-pressure breathing (CPPB) occasionally prove difficult to interpret. Diaphragmatic paralysis may be masked, and lobar atelectasis may present with confusing findings. If the radiologist is not aware that the patient is receiving CPPB, two other findings may be confusing: (a) hyperinflation of the lungs and (b) unusually rapid clearing of pulmonary edema, atelectasis, or both. Complications of CPPB include acute gastric dilatation, oxygen toxicity, pneumothorax, pneumomediastinum, and pulmonary interstitial emphysema. In some cases, prolonged intubation may result in tracheal stenosis and/or malacia.

An improved technique for prolonged arterial catheterization in infants and children.

Arterial catheterization for blood gas analysis and direct monitoring of blood pressure in infants and children can be attended by a variety of complications, which limit its use to short periods of time. An improved technique, consisting of elimination of stopcocks, the use of a continuous flushing system adapted for infants and children, and meticulous care of the system, was used in 57 children whose ages ranged from the neonatal period to 16 years. The mean duration of cannulation was 5.5 days (range, 1-31 days). All but one of the catheters were functional at the time of discontinuation. There were no thromboembolic phenomena, local or systemic infections or accidental bleeding. We feel that our approach to prolonged arterial cannulation can be an extremely valuable aid in the management of critically ill children.

Use of continuous positive airway pressure breathing in the improved management of neonatal emergencies

Abstract A ventilatory system consisting of spontaneous breathing with continuous positive airway pressure has dramatically decreased mortality in newborn infants with hyaline membrane disease. 1 In the past 2 yr, we have applied this new technique in the management of noncardiac thoracic and abdominal emergencies in more than 25 small infants, most of whom were newborn. The purpose of this paper is to describe the use of continuous positive airway pressure breathing (CPAPB) in this group of babies with life-threatening conditions, which included intestinal atresia, meconium peritonitis, fecal peritonitis, gastroschisis, omphalocele, tracheoesophageal fistula, and diaphragmatic hernia (Table 1). As an adjunctive measure in the management of respiratory insufficiency associated with these conditions, we believe this new system has contributed importantly to the survival of these infants. A common denominator in this group of varied newborn emergencies was pulmonary dysfunction which was usually manifested by peripheral arterial unsaturation associated with right to left pulmonary shunting. The pulmonary abnormality was often a concomitant complication of severe metabolic acidosis, sometimes in the presence of gram-negative septicemia. Since these congenital anomalies all required urgent operative procedures, the above physiologic derangements were further distorted by anesthesia and the surgical trauma. In the past, pulmonary insufficiency, combined with severe sepsis and metabolic acidosis, was frequently lethal; but the postoperative courses in this group of infants have demonstrated improved respiratory function with the use of CPAPB. Selected cases have been chosen from this series to illistrate this experience.

Spontaneous Continuous Positive Airway Pressure (CPAP) Breathing in the Management of Acute Pulmonary Edema in Infants

This paper reports two cases of acute pulmonary edema successfully treated, when medical management failed, with continuous positive airway pres sure (CPAP) and spontaneous breathing. The clinical, laboratory, and radio logical findings indicate that this technic offers an alternative to mechanical ventilation when respiratory failure complicates pulmonary edema in infants.1. Self-Activated Behavior. E.g., breast-feeding rather than artificial feeding; walking rather than riding; not smoking; temperate use of food and drink. 2. Communal Behavior. E.g., caring by family members, neighbors and friends; promotion of feelings of belonging by voluntary associations. 3. Environmental Factors. E.g., physical factors including sanitation, transportation, protection against water and air pollution, lead poisoning, etc.: avoidance of unemployment and economic depressions; good conditions of work. 4. Therapeutic Information, Tools, and Skills. E.g., vaccines, home remedies, scapels, antibiotics, and knowing how to use them.

Use of Continuous Positive Airway Pressure in the Improved Postoperative Management of Neonatal Respiratory Emergencies

Abstract In newborns with hyaline membrane disease, spontaneous breathing with continuous positive airway pressure (Gregory technique) has dramatically decreased the mortality. We have applied this technique in the postoperative management of cardiac and noncardiac thoracic emergencies in more than 13 low-weight infants (2 to 6 kg.) from 12 hours to 6 months old. This type of ventilatory support raises the intraalveolar pressure throughout the respiratory cycle and appears to prevent lobular and segmental atelectasis. The physiological effect is to increase Pa o 2 by decreasing intrapulmonary shunting and improving the ventilation-perfusion abnormalities, possibly by changing the relationship of interstitial fluid to the respiratory membrane. This technique allowed us to eliminate the hazardous use of mechanical ventilators in these tiny infants.

Continuous dynamic monitoring of pressure and flow patterns during assisted ventilation.

A system for continuous, dynamic monitoring of children requiring ventilatory assistance has been developed and used in a critical care setting. Breath by breath airway pressure changes are measured on a specially adapted meter with high-and low-pressure limit alarms, and are displayed graphically on a bedside oscilloscope. This system has proved to be beneficial in detecting ventilator system malfunction; in adjusting ventilator settings, such as inspiratory/expiratory ratios, end-expiratory pressure, and phase duration and flow ratios; in assessing compliance of a child requiring ventilatory assistance and his capability for spontaneous breathing; and in the early recognition of potentially harmful problems attendant upon assisted ventilation. The system provides additional educational benefit for the I.C.U. personnel, who become more knowledgeable regarding ventilatory problems, and more apt to discover them promptly. The simplicity of the system, compatibility with other I.C.U. monitoring equipment, capability for continuous, dynamic monitoring, and broad scope recommended it for infants and children requiring assisted ventilation.