Salvatore R. Goodwin

Nitric oxide successfully used to treat acute chest syndrome of sickle cell disease in a young adolescent.

OBJECTIVES To report a case of acute chest syndrome (ACS) of sickle cell disease treated successfully with nitric oxide and to review the physiologic effects of nitric oxide and its potential ability to improve outcome in ACS. DESIGN Descriptive case report. SETTING Eighteen-bed pediatric intensive care unit in a university childrens hospital. PATIENT A 15-yr-old black male with sickle cell disease, bilateral pulmonary infiltrates, refractory hypoxemia, and unstable hemodynamics. INTERVENTION In addition to exchange transfusion, invasive hemodynamic monitoring, and aggressive ventilatory support, inhaled nitric oxide was administered in the gas mixture in a concentration of 20 ppm for 72 hrs. MEASUREMENTS AND MAIN RESULTS Cardiac output, pulmonary arterial pressure, pulmonary artery occlusion pressure, systemic vascular resistance, pulmonary vascular resistance, shunt fraction, and alveolar-arterial oxygen gradient were compared with and without inhaled nitric oxide. Marked reductions in pulmonary arterial pressure and pulmonary vascular resistance were noted. Cardiac output improved, and shunt fraction and alveolar-arterial oxygen gradient were markedly reduced. The patient required decreased ventilator and hemodynamic support and rapidly made a complete recovery. CONCLUSIONS Nitric oxide may be beneficial for patients with ACS because of its ability to ameliorate pulmonary hypertension and ventilation/perfusion mismatch. Nitric oxide may confer some protection against polymerization of sickle hemoglobin and exert a reversible antiplatelet effect that may be beneficial in ACS. Further study is necessary to determine the safety and efficacy of inhaled nitric oxide as a treatment for ACS.

Bedside placement of transpyloric feeding tubes in the pediatric intensive care unit using gastric insufflation.

Objective To test the effectiveness of gastric insufflation as an adjunct to placement of feeding tubes in the small bowel. Design Prospective, randomized, controlled study. Setting Pediatric intensive care unit in a tertiary children’s hospital. Patients A total of 50 children requiring enteral nutrition via a nasoenteral feeding tube in the small bowel. Interventions An unweighted nasoenteral feeding tube attached to a three-way stopcock and a 60 mL syringe was inserted through the nares into the stomach. After 10 mL/kg of air was injected, the tube was advanced a distance estimated to position the tip of the tube proximal to the pylorus. An additional 10 mL/kg of air was then injected, and the tube was advanced a distance needed to place the tube in the fourth part of the duodenum. In the control group, feeding tubes were inserted through the nares and into the stomach. The tube was then advanced a distance estimated to place the tube in the fourth part of the duodenum. No air was injected in the control group. Measurements and Main Results When gastric insufflation was used, 23 of 25 feeding tubes were successfully placed in the small bowel on the first attempt compared with 11 of 25 in the control group (p = .001). All feeding tubes were successfully placed after two attempts in the gastric insufflation group compared with 18 of 25 in the control group (p < .001). The time between the first attempt at placement of a transpyloric feeding tube and the initiation of feeding was significantly shorter in the study group than in the control group. There were no complications in either group. Conclusion Gastric insufflation allows rapid placement of feeding tubes into the small bowel with fewer attempts compared with a standard insertion technique in children.

Traumatic Epiglottitis Following Blind Finger Sweep to Remove a Pharyngeal Foreign Body

The patient, an 8-month-old female, was in good health until the day before admission to the hospital. At that time, the baby-sitter found the baby choking on a piece of paper napkin. The child did not stop breathing and was not cyanotic during the incident. The baby-sitter, who had long fingernails, attempted to remove the fragment of napkin from the infant’s mouth with one blind finger sweep without success. She then used two fingers to sweep the back of the mouth and throat. She was

End-tidal carbon dioxide monitoring in pediatric emergencies

End-tidal carbon dioxide (CO2) monitoring is useful in the prehospital setting, emergency department, intensive care unit, and operating room. Capnography provides valuable, timely information about the function of both the cardiovascular and respiratory systems. End-tidal CO2 monitoring is the single most useful method in confirming endotracheal tube position. It also provides information about dead space, cardiac output, and airway resistance. A thorough understanding of cardiopulmonary physiology and the technical nuances of capnometry is required for its optimal use in children. This review examines the basic physiology pertinent to end-tidal CO2 monitoring, its clinical applications, and evidence supporting its use in infants and children.

Artificial surfactant for therapy in hydrocarbon-induced lung injury in sheep

OBJECTIVE To document the effect of administering artificial surfactant into the trachea, either by instillation or aerosolization, on acute lung injury experimentally induced with kerosene in sheep. DESIGN Randomized, prospective, controlled study. SETTING Research laboratory. SUBJECTS Sheep (n = 24), weighing 8.5 to 25.2 kg (average 16.6). INTERVENTIONS In anesthetized, tracheally intubated sheep with pulmonary and femoral artery catheters inserted, lung injury was induced by instilling kerosene (0.3 mL/kg) into the trachea. After 15 mins of spontaneous breathing, mechanical ventilation was instituted with a uniform F10(2) and a tidal volume of 10 mL/kg. Sheep were then assigned randomly to one of four regimens as follows: exogenous surfactant or saline (5 mL/kg each) was administered as a bolus intratracheally or by aerosolization for 6 hrs. MEASUREMENTS AND MAIN RESULTS Arterial and mixed venous blood gases, pH, airway pressure, and static respiratory system compliance were measured and compared between aerosol saline and aerosol surfactant and between bolus saline and bolus surfactant. For all variables except static respiratory system compliance, the hourly rate of change from 15 mins, 1 hr, and 6 hrs after kerosene instillation was determined for each animal, and group rank sums of hourly rates of change were compared. For static respiratory system compliance, the slope of the pressure-volume curve with volumes of 100, 200, 300, 400, and 500 mL was computed for each animal at baseline and at 3 and 6 hrs after kerosene instillation. Group rank sums for static respiratory system compliance at 3 and 6 hrs were compared. Also, the 3- and 6-hr static respiratory system compliance values at each of the volumes were compared. With saline, six of eight sheep died; with surfactant, no sheep died (p = .001). When compared with saline at 15 mins, 1 hr, and 6 hrs after kerosene instillation, surfactant, regardless of whether administered by aerosol or bolus, significantly increased rate of change of arterial oxygen saturation, mixed venous oxygen saturation, and PO2. CONCLUSIONS In the present animal study, artificial surfactant was an effective treatment for hydrocarbon aspiration. Aerosolized surfactant achieved results similar to instilled surfactant but at a lower total dose.

Recurrent Acute Life-threatening Events and Lactic Acidosis Caused by Chronic Carbon Monoxide Poisoning in an Infant

Acute severe carbon monoxide poisoning is usually easy to recognize and diagnose. However, chronic or less severe exposure may produce more subtle symptoms. We report on a 3½-year-old girl who was admitted to the hospital several times with acute, life-threatening events, acidosis, and flu-like symptoms. The diagnosis was elusive, but after careful questioning of family members and a home visit, chronic carbon monoxide poisoning was diagnosed.

A survey of perioperative management of sickle cell disease in North America

Background:  Children with sickle cell disease frequently undergo surgical procedures that are associated with acute exacerbations of the disease. Current perioperative management practices are unclear.

Critical care of the pediatric hematopoietic stem cell recipient in 2005

Abstract:  Among the most challenging patients cared for in critical care medicine are the recipients of hematopoietic stem cell transplantation (HSCT). HSCT is now widely used as a definitive therapy for the treatment of pediatric malignancies and inborn errors of metabolism. Critical care services are required for treatment of complications of HSCT. Formerly thought to have an essentially futile prognosis, outcomes from critical care of HSCT patients have demonstrated steady improvement in many areas during the past two decades. Improvements in the management of respiratory failure, sepsis, and multiple organ system failure have resulted from improvement in oncology and critical care practices. Herein, we review the methods available for outcomes prediction, recent advances in critical care of HSCT patients, and possible directions for future investigation.

Myocardial Ischemia Complicating Therapy of Status Asthmaticus

Received for publication November 1986, revised January 1987, and accepted March 1987. THE EFFICACY of intravenous isoproterenol for severe status asthmaticus in children is well documented. 1-5 Intravenous sympathomimetics can often alleviate problems associated with intubating and mechanically ventilating such patients. Toxicity with these drugs, however, has induced myocardial ischemia6 and fatal myocardial infarction7 in two children with asthma who had no history of heart disease. This report describes the occurrence of severe myocardial ischemia in a child with asthma during the treatment of severe status asthmaticus.

Intramuscular atropine sulfate in children: Comparison of injection sites

In children undergoing inhaled induction of anesthesia with halothane who suffer bradycardia, submental glossal injection of atropine may result in more rapid onset of vagolysis than traditional intramuscular sites.We compared the intervals between injection and onset of heart rate acceleration (tHR [arrow up]) after intramuscular injection of atropine into the deltoid, vastus lateralis, and glossa in children between 1 mo and 10 yr of age scheduled for elective surgery. The tHR [arrow up] was determined by measuring the interval between atropine injection and the time point at which the slope of the heart rate curve initially became positive. To ensure that the drug had taken effect before surgical stimulation, heart rate observation was continued until it increased at least 5% above baseline with evidence of continuing acceleration. Anesthesia was induced in all subjects by mask with nitrous oxide and halothane. After tracheal intubation, constant inspired concentrations of the anesthetics were administered for 3 min. While heart rate was monitored, atropine (0.02 mg/kg) was injected into one of the three sites. Each patients end-tidal anesthetic concentrations were recorded, and minimum alveolar anesthetic concentrations (MAC) were subsequently calculated and adjusted for age. The tHR [arrow up] was recorded and averaged for each group. The study groups did not differ by age, weight, end-tidal anesthetic concentrations, age-adjusted MAC, or heart rate at the time atropine was administered. After submental glossal injection (n = 11), tHR [arrow up] increase was fastest (3.0 +/- 1.1 min) and was significantly faster than that found with deltoid injection (n = 16; 4.4 +/- 1.1 min) or vastus lateralis injection (n = 8; 6.4 +/- 2.4 min) (P < 0.05 compared with both). The tHR [arrow up] also differed significantly between the deltoid and the vastus lateralis (P < 0.05). We conclude that submental glossal injection of atropine results in a more rapid onset of vagolysis than injection at traditional intramuscular sites. (Anesth Analg 1997;84:54-8)