Edwin L. Gresham

An evaluation of methods to monitor infants receiving intravenous lipids.

Nephelometric measurement of light-scattering index and visual estimates of turbidity have been advocated to monitor serum Intralipid levels. This study describes a simple modified fluorometric method for accurately measuring lipid particles in serum and examines the reliability of such estimates compared with other chemical measurements. Ten percent IL was diluted with either saline or serum to various concentrations (0 to 250 mg/dl). The LSI showed an excellent correlation with known IL standard solutions in saline or serum (R = 0.99) and with triglyceride concentrations (R= 0.98). One hundred nine blood samples were obtained from 35 patients (28 neonates) receiving IL. An elevated TG, free fatty acid, or cholesterol level could not be reliably predicted from the LSI. The ability of clinical personnel to visually grade the degree of turbidity was evaluated by having them assign a turbidity score of 0 to 4+ to 39 hematocrit tubes which contained clear, hemolyzed, or icteric serum, each of which had IL concentrations varying from 0 to 292 mg/dl. The 15 tubes of identical IL concentration of 99 mg/dl were graded from 0 to 4+ by two of the observers, from 1 to 4+ by three of the observers, and 0 to 3+, 1 to 3+, and 2 or 3+ by one each of the observers. This study shows that (1) in vitro fluorometric LSI correlates well with IL concentrations; (2) in vivo correlations of LSI with FFA, cholesterol, and TG are poor; and (3) personnel are unable to reliably grade turbidity by visual examination of hematocrit tubes. Infants on IL should be monitored by TG and FFA levels.

Pulmonary venous air embolism in hyaline membrane disease.

Two cases of pulmonary venous air embolism (PVAE) as a complication of mechanical ventilation during the course of hyaline membrane disease are presented. PVAE in these cases, as well as in those previously reported was associated with pulmonary interstitial emphysema (PIE). The pathophysiology of PIE and of pVAE is discussed. Radiographic recognition of PVAE depends upon visualizing gas within the vascular system and especially within hepatic veins. The value of postmortem radiographs in the detection of this entity is emphasized.

The use of metrizamide (amipaque) to visualise the gastrointestinal tract in children: A preliminary report

Metrizamide (amipaque) has not been used previously as a diagnostic contrast agent in the gastrointestinal tract. Metrizamide is a water-soluble isotonic contrast material having many advantages over barium and existing hypertonic water-soluble agents. There are many clinical situations in children in which metrizamide should be the contrast agent of choice for investigating the gastrointestinal tract. Four neonates are presented in whom barium or gastrografin were absolutely contraindicated. In each case metrizamide gave excellent visualization of the gastrointestinal tract. It could be followed through be bowel giving excellent visualisation even up to 120 h after ingestion. No harmful effects were noted in the four cases studied.

Nutritional Management of the Chronically III Child: Congenital Heart Disease and Myelomeningocele

We have presented some of the nutritional complications encountered in two major pediatric congenital disorders. Although these conditions represent two more common major defects, it is unlikely that many health care providers will manage large numbers of these patients. Nevertheless, the nutrition principles apply to other nutritional dilemmas of chronically ill children. When an infant consumes a low volume intake, regardless of etiology, concerns such as provision of adequate nutrition, within the confines of the infants water balance, become paramount. Methods have been discussed for increasing caloric density and for monitoring dietary safety and adequacy. When an infant has a propensity for becoming obese one needs to consider preventive measures such as providing sound nutrition information, support, and follow-up for both patient and family. Nutritional problems can become magnified unless adequate support is provided for total health and social needs of the family. The role of the dietitian must be one active participation within the the framework of an interdisciplianry team so that appropriate innovative nutrition programs can be developed and implemented.

A Practical Method for Monitoring Diagnostic Radiation Dosage in the Newborn Nursery

Diagnostic radiation exposure in 133 consecutive newborns was studied using a TLD monitoring system. Eighty-eight per cent of dosimeters received less than 1 mSv (100 mrem) total exposure. The mean exposure per chest radiograph was 0.044 +/- 0.023 mSv (4.4 +/- 2.3 mrem). Abdominal surface exposure was 0.053 +/- 0.03 mSv (5.3 +/- 3.0 mrem) for boys and 0.044 +/- 0.021 mSv (4.4 +/- 2.1 mrem) for girls. The gonadal exposure, which was calculated from the abdominal exposure data, was 0.053 +/- 0.030 mSv (5.3 +/- 3.0 mrem) for boys and 0.026 +/- 0.012 mSv (2.6 +/- 1.2 mrem) for girls. The correction factor for beam attenuation over gonads in girls was 0.58. In general, the radiation received by these infants did not exceed the currently published protection limits.

Metabolic and Hormonal Response to Chronic Maternal Fasting in the Ewe

The purpose of this study was to investigate the metabolic adaptations of the fetus during maternal starvation and to determine the changes of plasma insulin and glucagon concentrations in the fed state and during severe maternal fasting in the chronic fetal sheep preparation. Maternal fasting resulted in a decrease in maternal and fetal plasma glucose as well as a decrease in fetal plasma fructose. Fetal-maternal arterial urea concentration differences increased with maternal fasting, suggesting increased fetal amino acid catabolism. Both maternal anf fetal plasma insulin decreased parallel to the decrease in plasma glucose concentration. Maternal glucagon did not change significantly during fasting and with a short-term fast there was no change in fetal glucagon concentration. However, by 6 days of fasting, the fetal glucagon concentration tended to increase.

Umbilical vessel catheterization. A teaching simulator.

From the Departments of Pediatrics and Medical Illustrations, Indiana University School of Medicine and The James Whitcomb Riley Hospital for Children, Indianapolis, Indiana. * Assistant Professor of Pediatrics. t Professor of Pediatrics. ‡ Assistant Professor of Pediatrics. § Director, Medical Illustrations Department. Supported in part by National Foundation March of Dimes Medical Service Grant C117 and Mead Johnson Laboratories, Evansville, Indiana. Correspondence to: Richard L. Schreiner, M.D., Department of Pediatrics, Indiana University School of Medicine, The James Whitcomb Riley Hospital for Children, 1100 West Michigan Street, Indianapcslis, IN 46202. * Medical Plastics Laboratory, Inc., P.O. Box 38, Gatesville, Texas 76528. UMBILICAL VEIN CATHETERIZATION is used for exchange transfusions and for rapid procuring of blood specimens during resuscitation of the newborn in the delivery room and later in the neonatal intensive care unit. The procedure, though relatively easy to perform, carries the risk of significant major complications, especially when performed by inexperienced personnel. In the presence of neonatal respiratory distress it is imperative to determine the arterial partial pressure of oxygen in order to provide the correct amounts of supplemental oxygen to prevent hypoxia or hyperoxia. The advantage of umbilical artery catheterization is the ready accessibility of blood for both blood gas analysis and blood pressure monitoring. This route is frequently used, therefore, in infants who need frequent measurements of these physiologic variables. Every physician and nurse caring for newborn infants should have the training and dexterity to perform umbilical vein catheterization. Yet surprisingly large numbers of these have never performed the procedure themselves, even though they have listened to didactic sessions describing the technique. The technique of umbilical catheterization is easy to demonstrate on live patients. But personnel at community hospitals may have to wait to acquire the necessary skills until a sick newborn requires umbilical catheterization at a time when an instructor is available