I. David Todres

Life-threatening Apnea in Infants Recovering from Anesthesia

To determine whether prematurely born infants with a history of idiopathic apneic episodes are more prone than other infants to life-threatening apnea during recovery from anesthesia, the authors prospectively studied 214 infants (173 full term, 41 premature) who received anesthesia. Fifteen premature infants had a preanesthetic history of idiopathic apnea. Six of these required mechanical ventilation because of idiopathic apneic episodes during emergence from anesthesia. Two were ventilated for other reasons, and seven recovered normally. Infants ventilated for apnea were younger (postnatal age 1.6 +/- 1.2 months, mean +/- SD; conceptual age 38.6 +/- 3.0 weeks) than those who recovered normally (postnatal age 5.6 +/- 2.7 months; conceptual age 55.1 +/- 11.3 weeks) (P less than 0.01). No other premature or full-term infant was ventilated because of postoperative apneic episodes. The authors conclude that anesthetics may unmask a defect in ventilatory control of prematurely born infants younger than 41-46 weeks conceptual age who have a preanesthetic history of idiopathic apnea.

Hypocalcemia in critically ill children

To determine the prevalence and clinical consequences of hypocalcemia in pediatric intensive care unit patients, we prospectively studied calcium homeostasis in 145 of these patients. The total serum calcium concentration was measured in all patients. The serum ionized calcium concentration was measured in blood samples collected from those 71 (49%) patients who had low total serum calcium values (less than 8.5 mg/dl (2.12 mmol/L). Of the 71 patients, 26 (36.6%) had ionized hypocalcemia. Therefore the prevalence of ionized hypocalcemia was at least 17.9% (26/145). Death occurred in 8 (31%) of 26 patients with ionized hypocalcemia versus 3 (2.5%) of 119 patients with normocalcemia (p less than 0.0001). However, the severity of illness score was higher (p less than 0.05) in the children with ionized hypocalcemia than in normocalcemic children (mean Therapeutic Intervention Scoring System score 33 +/- 17 vs 22 +/- 11, respectively). More of the children with ionized hypocalcemia had sepsis (p = 0.0299) and they required the administration of vasopressor agents more often (p = 0.0002) than their normocalcemic counterparts. Of the 26 patients with ionized hypocalcemia, 17 (65.4%) had biochemical evidence of either absolute or relative hypoparathyroidism, determined by means of an immunoradiometric assay that measures only biologically active parathyroid hormone. We conclude the following: (1) ionized hypocalcemia is common in severely ill children. (2) Patients with ionized hypocalcemia have a higher mortality rate than those with normocalcemia; however, because the former are more severely ill, no causality is apparent or suggested. (3) Functional hypoparathyroidism may occur in critically ill children.

Percutaneous catheterization of the radial artery in the critically ill neonate.

Percutaneous catheterization of the radial artery appears to be a simple and safe alternative to catheterization of the umbilical artery for monitoring critically ill neonates. This avoids the serious and potentially fatal complications associated with use of the umbilical arterial catheter, and it is also applicable to monitoring of neonates in whom the umbilical artery is no longer patent. We observed no serious sequelae in cannulation of the radial artery and think that the technique should be used more widely.

The intensivist in a spiritual care training program adapted for clinicians

Background:Critical illness is a crisis for the total person, not just for the physical body. Patients and their loved ones often reflect on spiritual, religious, and existential questions when seriously ill. Surveys have demonstrated that most patients wish physicians would concern themselves with their patients’ spiritual and religious needs, thus indicating that this part of their care has been neglected or avoided. With the well-documented desire of patients to have their caregivers include the patient’s spiritual values in their health care, and the well-documented reality that caregivers are often hesitant to do so because of lack of training and comfort in this realm, clinical pastoral education for health care providers fills a significant gap in continuing education for caregivers. Objectives:To report on the first 6 yrs of a unique training program in clinical pastoral education adapted for clinicians and its effect on the experience of the health care worker in the intensive care unit. We describe the didactic and reflective process whereby skills of relating to the ultimate concerns of patients and families are acquired and refined. Design and Setting:Clinical pastoral education designed for clergy was adapted for the health care worker committed to developing skills in the diagnosis and management of spiritual distress. Clinician participants (approximately 10–12) meet weekly for 5 months (400 hrs of supervised clinical pastoral care training). The program is designed to incorporate essential elements of pastoral care training, namely experience, reflection, insight, action, and integration. Results:This accredited program has been in continuous operation training clinicians for the past 6 yrs. Fifty-three clinicians have since graduated from the program. Graduates have incorporated clinical pastoral education training into clinical medical practice, research, and/or further training in clinical pastoral education. Outcomes reported by graduates include the following: Clinical practice became infused with new awareness, sensitivity, and language; graduates learned to relate more meaningfully to patients/families of patients and discover a richer relationship with them; spiritual distress was (newly) recognizable in patients, caregivers, and self. Conclusions:This unique clinical pastoral education program provides the clinician with knowledge, language, and understanding to explore and support spiritual and religious issues confronting critically ill patients and their families. We propose that incorporating spiritual care of the patient and family into clinical practice is an important step in addressing the goal of caring for the whole person.

Intubation of Newborns

Sir .—Newborns admitted to the neonatal intensive care unit (NICU) frequently require laryngoscopy and endotracheal intubation. These procedures may be associated with detrimental physiologic alterations, including bradycardia, hypoxemia, systemic hypertension, and increased intracranial pressure (ICP). 1,2 In addition, they are uncomfortable and at times painful procedures with the potential for traumatic injury to the upper airway. It is standard practice in pediatric and adult intensive care units to premedicate patients undergoing non-emergency endotracheal intubation. Various medications are used, including atropine sulfate combined with a sedative and, sometimes, a muscle relaxant. The use of these medications provides more favorable conditions for intubation and ensures patient comfort. Studies of neonates have shown that some of the adverse physiologic consequences of laryngoscopy and intubation can be attenuated with the use of these agents. 2-4 In our NICU, we routinely use atropine and a sedative, which is usually a short-acting barbiturate or a narcotic,

Failure to Clinically Predict NICU Hearing Loss

Neonatal intensive care unit (NICU) survivors demonstrate handicapping sensorineural hearing loss up to 50 times more frequently than normal newborns, yet little is known about the etiology of the hearing loss. Theoretically, accurate identification and triage of a particular infant based on a clinical profile would be useful. Forty NICU graduates of The Massachusetts General Hospital were selected for a detailed retrospective chart review evaluating prenatal, perinatal, and NICU medical conditions and treatment. Twenty-three patients identified with hearing loss and 17 infants with normal hearing were compared clinically. Univariate and multivariate analysis was performed on a subpopulation of patients (20 with hearing loss and 16 with normal hearing). A history of ventilation was associated with hearing loss (P=.0023), but this factor was not absolute. No other clinical parameters were convincingly linked to hearing loss. We conclude that reliance on risk factors is an inadequate clinical method to select a patient for a hearing test and that each NICU survivor deserves audiometric evaluation.

Moral and Ethical Dilemmas in Critically Ill Newborns: A 20-Year Follow-Up Survey of Massachusetts Pediatricians

Surveys of Massachusetts pediatricians in the 1970s and 1980s indicated changing attitudes concerning life-saving treatment of newborns, from less to increased intervention.OBJECTIVE:To replicate the 1987 survey, referring to the original 1977 study, regarding opinions about treatment for critically ill neonates.STUDY DESIGN:A long-term follow-up survey of American Academy of Pediatrics Massachusetts membership, maintaining the 1987 instrument, was initiated.RESULTS:A notable demographic shift in respondents from a majority of male practitioners in 1977 (89.6%), to 73% in 1987, to more equal numbers of men and women in 1997 (55% and 45%, respectively; p < 0.001; 1987 vs 1997) was apparent. Pediatricians’ attitude changes over the 20-year period were relatively modest and were statistically associated with active medical intervention. In 1997, 75% of respondents rejected review committees as mediators, a marked change from 1987. Regardless of healthcare maintenance organization affiliations, 95% indicated that restrictive fiscal policies would not affect decision-making.CONCLUSION: This study indicates stability and consensus in pediatricians’ attitudes toward active intervention for critically ill neonates compared with 1977 and 1987 surveys and reveals several claims to professional autonomy.

The treatment of pneumopericardium in the newborn infant

Pneumopericardium with cardiac tamponade is a life-threatening emergency in the newborn infant. The case fatality rate is high (75% in 41 documented cases in the English literature), and diagnosis often delayed (in 13 of 29 deaths the pneumopericardium was diagnosed postmortem). Treatment is frequently unsatisfactory, and recurrence of the pneumopericardium with tamponade is likely after initial pericardial needle aspiration--an incidence of 53%. A case of pneumopericardium in a critically ill newborn is reported; the details of successful management, using a large bore intrapericardial catheter with continuous drainage, are discussed.

Music is medicine for the heart

References 1. Mataloun MM, Rebello CM, Mascaretti RS, Dohlnikoff M, Leone CR. Pulmonary responses to nutritional restriction and hyperoxia in premature rabbits. J Pediatr (Rio J). 2006;82:179-85. 2. Massaro D, Massaro GD. Hunger disease and pulmonary alveoli. Am J Respir Crit Care Med. 2004;170:723-4. 3. Coxson HO, Chan IH, Mayo JR, Hlynsky J, Nakano Y, Birmingham CL. Early emphysema in patients with anorexia nervosa. Am J Respir Crit Care Med. 2004;170:748-52. 4. Massaro GD, Radaeva S, Clerch LB, Massaro D. Lung alveoli: endogenous programmed destruction and regeneration. Am J Physiol Lung Cell Mol Physiol. 2002;283:L305-9. 5. Massaro D, Massaro GD, Baras A, Hoffman EP, Clerch LB. Calorie-related rapid onset of alveolar loss, regeneration, and changes in mouse lung gene expression. Am J Physiol Lung Cell Mol Physiol. 2004;286:L896-906. 6. Sakuma T, Zhao Y, Sugita M, Sagawa M, Toga H, Ishibashi T, et al. Malnutrition impairs alveolar fluid clearance in rat lungs. Am J Physiol Lung Cell Mol Physiol. 2004;286:L1268-74. 7. Jobe AH. The new BPD: an arrest of lung development. Pediatr Res. 1999;46:641-3. 8. Ehrenkranz RA, Ablow RC, Warshaw JB. Prevention of bronchopulmonary dysplasia with vitamin E administration during the acute stages of respiratory distress syndrome. J Pediatr. 1979;95:873-8. 9. Tyson JE, Wright LL, Oh W, Kennedy KA, Mele L, Ehrenkranz RA, et al. Vitamin A supplementation for extremely-low-birth-weight infants. National Institute of Child Health and Human Development Neonatal Research Network. N Engl J Med. 1999;340:1962-8. 10. Frank L, Sosenko IR. Undernutrition as a major contributing factor in the pathogenesis of bronchopulmonary dysplasia. Am Rev Respir Dis. 1988;138:725-9.

Coping with Poor Prognosis in the Pediatric Intensive Care Unit.

The intensive-care pediatrician who prophesies to parents that their childs illness is irreversible may encounter denial and hostility. The physician may compare his plight to that of Cassandra--the mythical Greek prophetess of doom, who was cursed to see into the future and not be believed. Four cases are reported in which parents rejected their childs hopeless prognosis, counterprophesied miraculous cures, resolved to obtain exorcism, criticized the care, or accused nurses of neglect. This produced a painful breakdown in the usually harmonious relationships between doctors, nurses, and parents. Parental denial as a coping mechanism is discussed. Guidelines are presented for the prevention and/or early recognition and management of the Cassandra Prophecy phenomenon. A miraculous recovery in one case is a potent reminder to physicians and nurses that they do not have the gift of divine prophecy and cannot see with certainty into the future.