John J. Downes

Congenital Diaphragmatic Hernia: Prediction of Survival

Abstract A wide range of survival rates have been reported in infants operated upon within the first 72 hr of life for congenital diaphragmatic hernia, 1–9 The highest mortality figures are in those infants with symptoms requiring correction in the first day of life. A better understanding of newborn physiology, vigorous preoperative management, improved surgical technique, and advances in respiratory support have been directed to improving survival with some success. 10 Acidemia and hypercarbia, often to a severe degree, occur in infants with congenital diaphragmatic hernia. 11,12 Murdock et al., 13 and Rowe and Uribe 14 have called attention to the differences in preductal and postductal aortic blood sampled for PaO 2 . Pulmonary hypoplasia, as expressed in terms of lung weights, is often severe in patients dying from this anomaly. 15–17 Lewis and Young 18 have reported an infant whose lungs weighed only 24% of the predicted combined lung weight. 19 The major histological abnormality appears to be a decrease in bronchial and bronchiolar branching and to a lesser degree a diminished number of alveoli. 20 To our knowledge no one has related the degree of acid-base and blood gas abnormality to survival or lung hypoplasia. The following presentation attempts to do this through a retrospective review of patients at Childrens Hospital of Philadelphia.

Intravenous isoproterenol in the management of respiratory failure in childhood status asthmaticus

Abstract Nineteen children in status asthmaticus and respiratory failure were treated with a continuous infusion of isoproterenol in doses ranging from 0.08 to 2.7 μg per kilogram per minute. In a mean time interval of 1.8 hours there was a 10 per cent or greater reduction in arterial P co 2 . In 10.2 hours the arterial P co 2 was 48 mm. Hg or less. The infusion could be discontinued in a mean time of 45.0 hours. Dosage was gradually decreased after the late response occurred. One child failed to respond to treatment and required mechanical ventilation. Another child experienced ventricular tachycardia at a dose of 0.2 μg per kilogram per minute, which subsided promptly when the infusion was discontinued. There was no evidence of myocardial damage.

Acute respiratory failure in infants and children.

Lack of published data on morbidity in relation to the treatment of respiratory failure in the pediatric age group, points up the need for agreement upon certain criteria for the diagnosis of acute respiratory failure in this age group and for a multi-institutional assessment of the effectiveness of intensive respiratory care in reducing the morbidity and mortality associated with respiratory failure.

The Relationship between Home Nursing Coverage, Sleep and Daytime Functioning in Parents of Ventilator-Assisted Children

This descriptive study examined the relationship between home-care nursing support, sleep, and daytime functioning in familial caregivers of ventilator-assisted children. Thirty-six primary caregivers (27 mothers, 7 fathers, 1 foster mother, and 1 grandmother) of ventilator-assisted children completed measures of home nursing support, sleep, depression, fatigue, and daytime sleepiness. Daytime nursing coverage was not related to caregiver sleep or daytime functioning, but caregivers with less nighttime nursing coverage had significantly shorter sleep onset latency than caregivers with some night nursing (16-48 hours/week). Caregivers with regular night nursing (>48 hours/week) had a total sleep time of almost 1 hour more than caregivers without regular night nursing (<or=48 hours/week). Caregivers with clinically significant symptoms of depression and sleepiness received significantly fewer hours of night nursing per week than caregivers without significant symptoms of depression or sleepiness. Home nursing support, in particular night nursing, is important for the health and well-being of familial caregivers of ventilator-assisted children.

Congenital diaphragmatic hernia: Deleterious effects of pulmonary interstitial emphysema and tension extrapulmonary air

Survival after repair of congenital diaphragmatic hernia (CDH) is limited by adequacy of prenatal pulmonary development. Ventilatory function may be compromised further by multiple adverse perinatal factors that necessitate intermittent pressure ventilation (IPPV). Barotrauma frequently complicates IPPV, and is observed in several forms. These complications lead to ventilatory and hemodynamic dysfunctions. Of 50 infants with CDH repaired in the first 24 hr of life, 36% survived. Infants operated in the first 8 hr had a lower survival rate (28%) than those operated between 8 and 24 hr (50%). Tension extrapulmonary air (TEPA) was observed in 30 infants (60%), was significantly higher in dying infants ( p p

Acute Respiratory Failure in Infants and Children with Bronchiolitis, Pneumonitis and Status Astmaticus

Respiratory failure associated with acute pulmonary disease is a common cause of death in infants and small children. Bronchiolitis, pneumonitis, and status asthmaticus are among those diseases which produce respiratory failure and yet carry an ultimately good prognosis if life can be supported during the acute phase of the illness. Recent data and experience have enhanced our understanding of the pathologic physiology, diagnosis, and management of respiratory failure associated with these diseases.

Development of Pediatric Critical Care Medicine—How Did We Get Here and Why?

The philosophical, scientifi c, and clinical concepts leading to the imperative for physicians, nurses, and other health professionals to rescue and care for critically ill and injured children has evolved in western culture over at least 2,000 years. In the biblical story of Elijah [1], the prophet resuscitated a young boy believed by his mother to be dead. Elijah lay upon the boy and breathed into him, and the boy began to breathe, awakened, and recovered. In 117 CE, the Greek physician Antyllus related in great detail the technique for tracheotomy with insertion of a hollow reed as the tube in a child with upper airway obstruction and the child’s recovery [2]. The French obstetrician Desault in 1801 [3] described in his obstetrics textbook how to successfully resuscitate the apneic or limp newborn by digital orotracheal intubation with a lacquered fabric tube and blowing into the tube. He also mentions using this technique of intubation for an older infant with life-threatening croup to relieve airway obstruction; the tube was left in place for several days to allow the obstruction to subside, then was removed and the infant recovered. Thus, prolonged tracheal intubation for croup, thought to be an innovation of the early 1960s, began much earlier. Unfortunately, this information about effective infant resuscitation and prolonged intubation remained buried in a textbook read by a limited group for over 150 years. This is only one of many examples of such failure of wide dissemination of vital information throughout medical history, even into the 20th century. These and other reports [4], however, refl ect the commitment of some physicians to the rescue of desperately ill children despite limited knowledge and resources. In order to understand why and how we got here in the current era, we need to consider certain monumental contributions to medicine occurring from 1540 to 1900 and then to examine in more detail the four areas of 20th century medicine that provided the basis for the development of pediatric critical care in the past 50 years. What follows refl ects my own reading and study, my personal observations and biases, and those persons and events I view as important to the development of modern medicine that forms the basis for the critical care of children. I also include some recollections of cherished colleagues who attended the birth of pediatric critical care medicine in the mid-20th century. Insofar as possible, these individuals are cited, as are the papers and chapters of which I am aware that deal with this part of medical history. My focus herein is on the subspecialty’s evolution in North America, although I cite its European roots. For a more complete story of this fi eld in Europe and elsewhere in the world, I refer the interested reader to Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Origins of Modern Medicine Before 1900 . . . . . . . . . . . . . . . . . . . 2 Origins of American Pediatrics—1860 to 1900 . . . . . . . . . . . . . . 7 The Twentieth Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 The Twenty-First Century: Pediatric Critical Care in the Current Era—2000 and Beyond . . . . . . . . . . . . . . . . . . . . . . . . . 24

Hemophilus influenzae Epiglottitis Occurring Concurrently in Two Siblings

Epiglottitis (more properly supraglottitis) is a potentially life-threatening infec tion of the supraglottic larynx that is most often caused by Hemophilus influenzae type B (HITB). Intrafamily spread of HITB disease has been described often for meningitis, but is rarely reported in epiglottitis. We describe two siblings seen concurrently with HITB epiglottitis and discuss prophylaxis of family members and close contacts.

History of pediatric critical care medicine

OBJECTIVES: to review and cite important individuals and events in the development of pediatric critical care medicine (PCCM). DATA SOURCES: A MEDLINE search was performed looking for citations of the history of PCCM. This yielded 85 citations of which 46 were obtained. Thirty nine of the 85 were rejected as inappropriate either by title (e.g., pediatric emergency medicine) or because they were in a foreign language only. After review of the 46, 21 were included in this review and the others rejected as inappropriate. Textbooks of PCCM were reviewed for chapters on the history of PCCM and four were included. Forty-eight personal communications were made to individuals and four to organizations to elicit and verify information. One speech is referenced and from these sources, a total of 37 additional textbooks, monographs and chapters and 47 journal manuscripts and reference sites were found and included. SELECTION AND EXTRACTION: Materials pertinent to the specific disciplines, individuals and events in the development of CCM(Critical care medicine) and PCCM were included in this review. CONCLUSIONS: PCCM owes a great debt to the expertise in anesthesiology, neonatology, pediatric cardiology, pediatric general and cardiovascular surgery and nursing for its evolution. The modern PCCM unit and service is more the result of the need to treat and organize care for critically ill and injured patients than to any developments in technology.