Chih Ta Yao

Critical management in patients with severe enterovirus 71 infection

Objective: The aim of this study was to analyze clinical details occurring in children with severe enterovirus 71 (EV71) infection and synthesize the critical care experience for patients with severe EV71 infection.

Cardiac tumors in infants and children.

Cardiac tumors in infants and children are extremely rare. Their clinical manifestations vary widely from asymptomatic presentations to life-threatening cardiac events. Improvements in diagnostic techniques, such as those offered by echocardiography, have made early detection of cardiac masses possible, with or without the presence of clinical symptoms. Fifteen pediatric cases of cardiac tumor were diagnosed at our institution between July 1989 and July 2002 (male-female ratio, 10:5; age range, one day to nine years). Eleven of the cases involved primary cardiac tumors [rhabdomyoma (n = 10) and fibroma (n = 1)]. Ninety percent of the rhabdomyomas (9/10) were associated with tuberous sclerosis. Four of the fifteen cases were secondary metastatic tumors [hepatoblastoma (n = 2), hepatoma (n = 1) and rhabdomyosarcoma (n = 1)]. Clinical manifestations of the cardiac tumors included shortness of breath (n = 5), seizure (n = 4), cardiac murmur (n = 6), and cyanosis (n = 3). Surgery was performed for three of 11 patients with primary cardiac tumor (27%) due to severe obstruction of flow (n = 2) and other cardiac defects (n = 1). The primary cardiac tumor spontaneously regressed in five of the tuberous sclerosis patients. All four of the patients with secondary cardiac tumors continued to receive chemotherapy, and only one of them subsequently experienced regression. Based on our experiences, we conclude that: 1) rhabdomyoma is the most common primary cardiac tumor in children; 2) most pediatric tumors are associated with tuberous sclerosis; 3) clinical presentation is determined by the tumor size and number of tumors, and whether expansion of the malignancy has resulted in cardiac blood-flow obstruction; 4) there is a strong possibility of regression of the primary cardiac tumor, with surgery recommended only when cardiac symptoms are severe; and, 5) unless there is a significant obstruction of blood flow, chemotherapy is still the treatment of choice for secondary cardiac tumors.

Postoperative chylothorax: Differences between patients who received median sternotomy or lateral thoracotomy for congenital heart disease

Abstract  Background: Chylothorax after surgery for congenital heart disease is rare. We wanted to compare the different presentations of chylothorax in patients who received median sternotomy or lateral thoracotomy. Patients and Methods: We retrospectively studied pediatric patients with congenital heart disease who received palliative or corrective surgeries and developed postoperative chylothorax between January 1992 and July 2003. Patients were divided into two groups by the type of surgery: median sternotomy and lateral thoracotomy. The average daily fluid amount (mL/kg/24 hours), latency period, duration of chylothorax, and requirement for surgery were compared. Results: Seventeen patients (11 boys, 6 girls; mean age, 14.0 ± 12.8‐month‐old) were enrolled. Diagnoses were tetralogy of Fallot (n = 8), right isomerism with complex heart defects (n = 3), patent ductus arteriosus (n = 2), transposition of the great artery (n = 1), ventricular septal defect (n = 1), and endocardial cushion defect (n = 2). There were 9 in the lateral thoracotomy group and 8 in the median sternotomy group. Only one patient required surgery because of the failure of conservative treatment. The lateral thoracotomy group had a significantly lower average body weight (6.9 ± 2.9 kg vs. 11.0 ± 3.8 kg) and longer average latency period before postoperative chylothorax (15.1 ± 9.2 days vs. 7.2 ± 4.7 days). Conclusion: The majority of pediatric patients who develop chylothorax after cardiac surgery can be successfully managed by medical treatment only. To avoid complications in pediatric patients after cardiac surgery, chylothorax should be suspected for patients with unexplainable, prolonged, and abundant pleural effusion.

Once-daily vs. twice-daily intrapleural urokinase treatment of complicated parapneumonic effusion in paediatric patients : a randomised, prospective study

To evaluate the effective dose frequency (once daily vs. twice daily) of intrapleural urokinase treatment in children who required tube thoracostomy for drainage of a complicated parapneumonic effusion, we designed a randomised prospective study in a tertiary medical centre in Taiwan. From June 2002 to January 2005, 30 paediatric patients with complicated parapneumonic effusion who had received chest tube drainage were randomised 1 : 1 to the once‐daily (urokinase 5000–6000 IU/kg/dose) or twice‐daily (urokinase 2500–3000 IU/kg/dose) treatment. We compared clinical manifestations and outcomes in both groups. There were no differences in pleural effusion characteristics between the groups. Six patients had Streptococcus pneumoniae, one had Staphylococcus aureus, one had Group AStreptococcus, and 22 had unknown pathogens. There were no significant differences between the once‐ vs. twice‐daily group in the amount of drained pleural fluid (564.9 ± 422.1 ml vs. 560.5 ± 198.6 ml, respectively), fever duration after chest tube insertion (4.3 ± 3.2 days vs. 5.3 ± 2.7 days), or total admission days (14.3 ± 3.9 days vs. 14.6 ± 3.0 days) (p > 0.05 for all). Only two patients (one in each group) required the surgery. Thus, we found that both once‐ and twice‐daily administration of urokinase were similarly efficacious, and resulted in good clinical outcomes. Both obviated the need for surgery in most (93%) cases of pneumonia with complicated parapneumonic effusion in this series. A larger, multicentre study is necessary to verify our findings.

Coil embolization of pulmonary sequestration in two infants - A safe alternative management

Pulmonary sequestration is a rare congenital anomaly with nonfunctioning lung tissue, for which the arterial blood supply is usually derived from the thoracic or abdominal aorta. Surgical resection is the conventional treatment for pulmonary sequestration. The arterial embolization of pulmonary sequestration is an alternative technique and a less invasive treatment than conventional surgical resection. Here, we report two infants with intralobar and extralobar types of pulmonary sequestration, successfully treated with coil embolization of the feeding artery without any complications.

Prediction of outcome in infants with congenital diaphragmatic hernia or severe diaphragmatic eventration

Congenital diaphragmatic hernia (CDH) and severe congenital diaphragmatic eventration (SDE) still have high mortality. Our aims were to identify clinical prognostic factors for CDH and SDE, and to determine whether the size or area of the proximal bilateral pulmonary arteries (PA) correlate with the clinical outcome. We retrospectively analyzed medical charts of 26 patients--20 with CDH and 6 with SDE, but no obvious other associated anomalies--admitted over a 12-year period. We compared prenatal history, clinical manifestations, blood gas, and echocardiography before surgery in the survivors and the non-survivors. Ten patients (8 CDH, 2 SDE) died 2 to 16 days after birth, including 2 patients without surgery due to progressive hypoxemia. The survivors had significantly higher 1- and 5-min Apgar scores, higher the worst preductal arterial blood gas pH levels, lower oxygen indices, and lower PaCO2 (P < 0.05). The McGoon index of PA size measured by echocardiography was higher in survivors, but not statistically significant. Nakada PA index results, however, were statistically significant (93.07 +/- 32.02 vs. 121.07 +/- 27.08, P < 0.05) In conclusion, Apgar scores, preductal PaCO2, oxygen index, and pH level can predict prognosis in infants with CDH and SDE. The Nakada PA index, however, might be a useful prognostic marker for patients with CDH and SDE.