G. P. Hadley

Raised intracompartmental pressure and compartment syndromes

Raised intracompartmental pressure (ICP) has become recognized as the final common pathway of a variety of pathologies which lead to failure of the microcirculation with resultant tissue hypoxia and cell death. While commonly seen after trauma, either accidental or operative, raised ICP may result from either an increase in the volume of tissue within a closed osseo-fascial or fascial compartment or by the application of an external force compressing a compartment, and it is associated with a wide variety of insults. The advent of reproducible techniques of measuring ICP has added science to a well-recognized clinical picture and allowed a rational approach to management. Controversies still remain, particularly in regard to the level of pressure at which intervention becomes mandatory, and the role of prophylactic interventions. This review attempts to present current thinking on the pathophysiology of the microcirculation and the background to these controversies.

Failure of pulse oximetry in the assessment of raised limb intracompartmental pressure.

Pulse oximetry has been proposed as an aid to monitoring raised intracompartmental pressures (ICPs). ICP and percentage haemoglobin oxygen saturation in the affected limb were studied in 10 consecutive patients with raised ICP. Compartment pressures ranged from 28 to 64 mmHg (mean 40.9 mmHg). In two patients with absent pulses, pulse oximetry failed to detect pulsatile flow and recorded 0 per cent saturation. The remaining eight patients, including four with absent peripheral pulses, all had percentage haemoglobin saturations within 2 per cent of the opposite normal limb. Arterial haemoglobin desaturation was not associated with raised ICP. The presence of an oximeter signal and a normal reading does not necessarily imply adequacy of tissue perfusion. Pulse oximetry does not appear to be a reliable aid in the diagnosis or monitoring of impaired perfusion due to raised ICP.

Oesophageal atresia: caudo-thoracic epidural anaesthesia reduces the need for post-operative ventilatory support

The mortality of neonates with oesophageal atresia in the Third World remains high because of delays in presentation and diagnosis. Lack of appropriate intensive care facilities is a further contributing factor. Caudothoracic epidural anaesthesia was used during surgical repair of oesophageal atresia in 35 patients in an attempt to minimise the need for post-operative ventionally support. This group was compared with 36 patients whose surgery was performed under general anaesthesia. The age at the time of referral, sex ratio, and weight were comparable in both groups. Using the Waterson classification, a greater number of poorer prognostic patients were seen in the epidural group (P <0.02). In all Waterson risk categories fewer patients required ventionally support post-operatively, which was statistically significant (P <0.01) when all categories were combined. We are encouraged by our results and believe this technique has a rôle in the management of neonates undergoing major surgery, both where neonatal intensive care exist or is deficient as in many parts of the Third World.

Raised compartmental pressure in children: a basis for management

In children, raised intracompartmental pressure which may lead to a compartment syndrome is relatively common and follows a wide variety of insults. Cell viability is compromised at much lower compartmental pressures than in adults, and clinical awareness must be heightened, especially in the hypotensive child. Suspicion follows an awareness of clinical situations associated with the risk of raised compartmental pressure. Clinical confirmation may be difficult in the context of the uncooperative child. Diagnosis is established by invasive pressure monitoring. Intervention becomes mandatory when the compartmental pressure has risen to within 30 mmHg of the mean arterial pressure, which varies with the age and clinical status of the child. Management is by fasciotomy which should be wide and open and decompress all affected compartments. Thirty children with raised intracompartmental pressure are reported: 21 children were managed non-operatively and nine underwent fasciotomy. Two children with absolute intracompartmental pressures of 28 mmHg and 35 mmHg required fasciotomy, whereas five children with intra-compartmental pressures between 30 mmHg and 44 mmHg were managed non-operatively. In this latter group this policy resulted in no demonstrable morbidity.

Prediction of neonatal sepsis by thromboelastography

The thromboelastogram (TEG) measures functional defects in coagulation, from fibrin formation through platelet aggregation to fibrinolysis. It is comparable with standard laboratory tests of coagulation; however, it provides additional useful qualitative information. This prospective study documents the TEG findings in 103 neonates: 60 were normal and healthy and provided a reference range; 12 surgical babies had established sepsis, 15 had early sepsis, and 16 were non-septic. TEG abnormalities were detected only in those patients with early and established sepsis. Abnormalities were found in all but 1 of this group of 27 patients (96%), whereas only 16 (59%) had thrombocytopenia, 2 (6%) had leukocytosis, and 6 had leukopenia. The TEG had a sensitivity for sepsis of 96% and a specificity of 96%. This exceeds the values for routine full blood-count parameters and other laboratory indicators of sepsis. It was found to be a simple, quick, and sensitive indicator of early sepsis that enabled the clinicians to manage septic newborns earlier.

Intralingual cysts of foregut origin

Intralingual cysts lined by epithelium of foregut origin are rarely reported. We present 16 patients seen over an 8-year period (1983 to 1990) with such lesions. Respiratory and squamous epithelium were the most commonly encountered. These unusual cysts generally presented in the neonatal period with feeding difficulty. Two children had multiple cysts. Histological varieties of epithelia are described and the clinical features are discussed. From our experience we conclude that these cysts are adequately treated by complete surgical excision through a sagittal glossal split. This can be safely done electively in the neonatal period. Cyst aspiration was found to be inadequate definitive treatment.

A comparison of colo-colic and ileo-colic intussusception

There are many differences in the clinical features of intussusception between African and temperate countries. The records of 192 patients with intussusception who presented to the Pediatric Surgical Service at King Edward VIII Hospital, Durban, South Africa during a 10-year period were reviewed. Compared with temperate countries, the patients were older (median, 1 year 7 months), presented later (median, 4.2 days), had a higher proportion of colo-colic lesions (17%), had absence of primary bowel pathology, and had a high surgical rate (82%). To define clinically important differences, the clinical and pathological features of 158 cases of ileo-colic intussusceptions were compared with 34 colo-colic cases. Compared with the ileo-colic group, colo-colic lesions occurred in older children (median, 3.8 years) (v 1.5 years; P < .001). In the colo-colic group, there were fewer shocked and pyrexial patients, and the rate of successful nonoperative reduction was higher. The groups had a similar incidence of surgical intervention (82%). In the ileo-colic group, there was a higher mortality rate and more complications, but only the higher resection rate (P < .001) was statistically significant.

Waugh's syndrome : a report of six patients

Abstract Waughs syndrome (WS) is the association of intussusception and intestinal malrotation. The association has not been widely reported in the literature. In the only prospective study, Brereton et al. reported a high frequency of the association, which suggests nonrandom association. Six patients with this association presented to our unit over a 4-month period. The clinical findings and management are presented and discussed. We suggest that malrotation by its very nature is associated with a mobile right colon, which may be a prerequisite for intussusception.

Internal drainage of pancreatic pseudocysts in children using an endoscopically-placed stent.

Abstract. Persistent pseudocysts, which are rare in children, have traditionally been managed by open surgery. We describe two children who presented with large, established psuedocysts of the pancreas. They were successfully treated in the short term by minimally-invasive stent placement to create an internal cyst-gastric communication. This approach merits comparison with open surgical techniques.

Primary lumbosacral Wilms tumour associated with occult spinal dysraphism.

Abstract A 4-year-old child presenting with sudden- onset paraplegia and a sacral tumour in association with spina bifida occulta is reported. There were no stigmata of spinal dysraphism at birth. Imaging studies confirmed a sacral tumour with extradural extension up to T10 and spinal dysraphism. The histological features of the extradural and sacral components of the tumour were consistent with a Wilms tumour. The differential diagnosis included a primary sacral teratoma containing Wilms tumour elements or a primary extrarenal Wilms tumour arising in association with a spinal dysraphism. There was no clinical response to chemotherapy or radiotherapy.