John R. Wesley

Total parenteral nutrition catheter sepsis: impact of the team approach

For a period of 32 months from the inception of the Parenteral and Enteral Nutrition (PEN) Team at the University of Michigan, the infection rate (IR) related to central venous catheters (CVCs) for total parenteral nutrition (TPN) was prospectively evaluated. Six hundred twenty-two catheters were placed in 377 patients for a total of 9,200 patient days. The length of CVC stay ranged from 2 to 108 days with a mean of 14.5. CVC longevity was longer on units where certification of nurses by the PEN team was mandatory (mean 20.4 days, IR 3.5%) vs comparable units which utilized informal instruction (mean 14.4 days, IR 3.5%). Twenty-two catheters led to patient sepsis for a rate of 3.5%, or 2.39 CVC-related infections per 1000 patient days. The preteam infection rate was 24.0%, as determined by a 6-month prospective study. Infection rates for CVCs used for TPN only and those used for parenteral nutrition (PN) plus blood products, antibiotics, and CVP measurements were identical, 3.5%. The team approach can effectively increase PN catheter longevity and reduce infection rates. Conservative cost accounting of best and worst case scenarios determined a range of

Pulmonary embolism in children

3,700 to

Efficacy of the Nissen fundoplication in the management of gastroesophageal reflux following esophageal atresia repair

8,900 per episode of catheter sepsis.

Reversal of mortality for congenital diaphragmatic hernia with ECMO.

The diagnosis of pulmonary embolism (PE) is seldom considered in the pediatric patient; however, pulmonary embolic phenomenon occur with a greater frequency than is generally recognized. Reports of all autopsies performed at the University of Michigan during the 25-yr period 1955 through 1979 were reviewed. All cases of pulmonary thromboembolism in infants and children ranging in age from 0 to 19 yr were studied; patients with emboli from fat or tumors and patients with primary pulmonary artery thrombosis were excluded. The records of 116 children with PE were evaluated. The sex distribution was equal and the average age was 8.0 yr. Age itself was not an independent risk factor for the development of PE. The primary disease processes of shunted hydrocephalus (15.2%), accidental trauma (8.4%), heart disease (4.5%), infection (4.4%), neoplasia (4.0%), and general medical illness (1.8%) were identified as significant risk factors for the development of pulmonary emboli. In the group with neoplasia, children with solid tumors (6.7%) were at an increased risk over the lymphomaleukemia group (2.6%) for the development of emboli. Children who had operation exclusive of the risk factors noted above (7.2%) were at an increased risk when compared to the nonoperative medical group (1.7%). Other risk factors including immobility, central venous catheterization, pre-existing hematologic disorders, and secondary infection were frequently seen. These factors, however, were not able to be studied epidemiologically. Venous thromboses were found in 40% of those children who had pulmonary emboli at the time of autopsy. Iliofemoral venous thrombosis was infrequently seen. The PE was deemed to be clinically important in 30% of the total series. In patients with clinically significant PE, only 50% had documented signs and symptoms of embolization and an antemortem diagnosis was considered in only one-third of these symptomatic patients. The total incidence of PE did not change over the 25-yr period, nor were there any significant trends in the associated risk factors. This study supports the concept that PE occurs in children with a greater frequency than is commonly recognized. Signs and symptoms of clinically significant pulmonary emboli occur in only 50% of the patients and even when the event presents clinically, it is an underdiagnosed entity. A heightened index of suspicion for PE in children is warranted.

The need for evaluation of gastroesophageal reflux in brain-damaged children referred for feeding gastrostomy

From January 1974 to December 1988, 80 patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) were treated at the C.S. Mott Childrens Hospital with division of their TEF and esophagoesophagostomy. Thirty-four in this group developed gastroesophageal reflux (GER). After an unsuccessful trial of medical management, 21 underwent Nissen fundoplication, and an additional child with refractory GER died intraoperatively before completion of her fundoplication. Following fundoplication, only eight patients had an uncomplicated course with elimination of reflux and no postoperative dysphagia. Wrap disruption and recurrent reflux occurred in 7 of the 21 (33%), a markedly higher incidence than the 10% figure seen in 220 children without EA who have undergone fundoplication at this institution. Upward tension on the wrap due to the presence of a shortened esophagus probably predisposes to an increased frequency of fundoplication failure in the EA child. In addition, postoperative dysphagia requiring prolonged gastrostomy feedings complicated eight otherwise successful initial or redo-fundoplications. Prolonged dysphagia in this group is likely related to the inability of the dyskinetic esophagus, common in EA, to overcome the increased resistance caused by the Nissen fundoplication. Three deaths (14%) from complications related to antireflux surgery occurred in the series. Although 15 of the 21 children (71%) eventually had excellent long-term results following initial or redo-fundoplication with elimination of reflux and normalization of oral intake, morbidity and mortality were clearly significant. Due to the high incidence of postoperative dysphagia and recurrent reflux, the transabdominal Nissen fundoplication may not be appropriate in EA patients.

Cervical teratomas in the newborn

Extracorporeal Membrane Oxygenation (ECMO) has been available to neonates with respiratory failure at the University of Michigan School of Medicine since June 1981. In order to evaluate the impact of this type of pulmonary support, a retrospective analysis of 50 neonates with posterolateral congenital diaphragmatic hernia (CDH) who were symptomatic during the first hour of life and were treated between June 1974 and December 1987 was carried out. The patients were divided into two groups, those treated before June 1981 (16 patients) and those treated after June 1981 (34 patients). Overall survival improved from 50% (eight of 16 patients) during the pre-ECMO era to 76% (26 of 34 patients) during the post-ECMO period (p = 0.06). During the period after June 1981, 21 neonates were unresponsive to conventional therapy and were therefore considered for ECMO. Failure of conventional therapy was defined as acute clinical deterioration with an expected mortality of greater than 80% based on an objective formula previously reported. Six patients were excluded on the basis of specific contraindications to ECMO. Thirteen of 15 infants (87%) supported with ECMO survived. Three patients treated before 1981 met criteria for ECMO; all three died while receiving treatment using conventional therapy. These survival differences are significant (p less than 0.01). In addition, the survival of 87% for the infants treated with ECMO versus the expected mortality of greater than 80% for these same patients when treated with conventional therapy is highly significant (p less than 0.005). Based on this data, ECMO appears to be a successful, reliable, and safe method of respiratory support for selected, critically ill infants with CDH.

Hirschsprung's disease in the newborn

Recent experience in the management of gastroesophageal reflux (GER) has uncovered a group of brain-damaged children with this abnormality who are often referred to the surgeon for a feeding gastrostomy before the GER has been diagnosed. Thirty-three infants and children underwent a fundoplication for GER at our institution; 22 had significant preexisting brain damage. Although the patients with brain damage were referred to our service for a feeding gastrostomy, all of them had symptoms of GER. The presenting signs and symptoms included regurgitation and failure to thrive in 16 children, repeated bouts of aspiration pneumonia in five children, hyperextension posturing of the head and neck in two children, and severe dysphagia suggesting an esophageal stricture in one child. GER was documented in 19 of the 22 patients with a barium swallow. The barium examination showed the presence of a hiatus hernia in six, esophagitis in three, and esophageal strictures in two children. Intensive medical therapy in the hospital was universally unsuccessful, and a Nissen fundoplication with posterior gastropexy and gastrostomy were performed. In 18 (82%) children, the presenting symptoms disappeared postoperatively, and the barium swallow showed the fundoplication to be intact with no evidence of GER. In four patients, symptoms of GER recurred postoperatively and radiographic studies confirmed the presence of reflux. Two had disruption of their fundoplication and were rerepaired. There were four deaths in this series. Three occurred late and were unrelated to the operative procedure. The fourth death occurred in a child with severe malnutrition secondary to GER, who developed a wound dehiscence and sepsis during the second postoperative week and succumbed. Our results suggest that an antireflux procedure is often necessary along with a feeding gastrostomy to facilitate management of the brain-damaged child.

The development of necrotizing enterocolitis following repair of gastroschisis: A suprisingly high incidence

Cervical teratomas are rare neoplasms which have been infrequently reported. During the period of July 1974 to April 1982, six newborns with this lesion were seen at the Mott Childrens Hospital. There were three males and three females, all of whom presented at birth with large semicystic neck masses. In four infants, calcifications were seen on x-ray. Four patients required intubation within the first hours of life for respiratory distress. One child of 33 weeks gestation expired prior to operation because of a hypoplastic left ventricle and bilateral hypoplastic lungs. Cord blood T3 and T4 values were normal in three patients; the TSH was elevated 1.5 and 2 times normal in two of these infants. Four neonates were operated upon within 24 hours of birth and suffered no postoperative complications. One baby presented on the third day of life and expired three hours postoperatively from persistent respiratory distress. The tumors were well encapsulated and arose from or were surrounded by a lobe of the thyroid gland. In each case, the tumor was removed by performing a total thyroid lobectomy. The presence of normal thyroid tissue at the resection margin (in the isthmus) was verified by frozen section. One patient presented with cervical node metastases but is currently free of disease one year postoperatively. These six cases bring the total reported cases in the literature to 136. The 80% mortality in cases not operated upon has been reduced to 15% by prompt operation. This series substantiates the significant respiratory distress that can occur in newborns with cervical teratomas and confirms the need for emergency surgery in this group of patients.

Diagnosis and management of congenital cystic disease of the lung in children

Hirschsprungs disease has become a more common cause of newborn intestinal obstruction in the past 30 years. In a group of 137 newborns with intestinal obstruction the most common diagnosis was necrotizing enterocolitis. The second most common cause, however, was Hirschsprungs disease. We have reviewed 26 infants with aganglionosis who presented at 32 days of age or less between 1972 and 1978. The average age at presentation was 8.3 days. There were 21 males and five females. Five infants had long-segment or total colonic disease. There was only one premature infant (34 weeks, 1840 g). The mean birthweight in the series was 3.6 kg. Six children had a family history of a congenital anomaly (23%). Three of these had a family history of Hirschsprungs disease (12%). Nine infants (35%) had associated congenital anomalies. Four of these newborns had Downs syndrome, and all four had a cardiac anomaly as well. Fifteen newborns presented with emesis (58%) which was bilious in nine (35%) cases. Seventeen babies (65%) had abdominal distension at the time of presentation. Eleven infants passed a meconium stool by 24 hours of age (42%), and 15 had passed meconium by 48 hours (58%). Twenty-two of 24 (92%) barium enema examinations available prior to diagnosis were diagnostic of Hirschsprungs disease. All of the 23 suction rectal biopsies were positive. All 26 patients underwent a colostomy or ileostomy following diagnosis. There was no enterocolitis and no mortality. All 26 patients have had an endorectal pullthrough performed at a mean age of 11.8 months without major complications. This review highlights several features of Hirschsprungs disease, some of which refute, and some of which substantiate currently held concepts. The low incidence of prematurity and the increased incidence of Downs syndrome with aganglionosis is supported by this study. The high incidence (35%) of associated congenital anomalies has not been emphasized previously. Importantly, the passage of a meconium stool before 48 hours of life does not rule out Hirschsprungs disease.

Intragastric pressure measurement: A guide for reduction and closure of the silastic chimney in omphalocele and gastroschisis

We recently observed the development of necrotizing enterocolitis (NEC) in two consecutive newborn infants after gastroschisis repair. Because this association was unexpected, a retrospective review of our 11-year experience was performed using a multivariant computer analysis. The cohort consisted of 54 newborns with gastroschisis. All infants with omphalocele were excluded. Ten of 54 infants (18.5%) developed NEC as defined by classical clinical findings and pneumatosis intestinalis. Twenty-one distinct episodes of NEC occurred with up to three episodes (mean, 2.1) per patient. Twenty of the 21 episodes were successfully treated nonoperatively. Two infants developed pneumoperitoneum, one of whom underwent laparotomy upon which no perforation or intestinal infarction was found. Eight of the ten patients survived--a survival rate no different than for the remainder of the study group. Neither of the two deaths was attributable to NEC. The NEC was atypical in that no significant relationship was established with known predisposing conditions such as prematurity or low Apgar scores. Suspected risk factors such as time of feeding, type of closure, type of formula, total parenteral nutrition (TPN), and composition of TPN were not statistically related. Significant associations included concurrent TPN associated cholestatic liver disease in nine of the ten infants, antecedent intestinal surgery other than abdominal wall closure in five of the ten infants, and delay in initiation of enteral feedings (greater than 30 days) in eight of ten infants. In addition, the NEC occurred significantly later (range, 32 to 79 days; mean, 52 days) in the clinical course than usual; in fact, three of ten infants were rehospitalized with NEC following discharge. We conclude that a relationship exists between NEC and gastroschisis.(ABSTRACT TRUNCATED AT 250 WORDS)