Shirley A. Graves

Incidence of aspiration with endotracheal tubes in children

tion in one; it probably was not significantly contributory to the fat malabsorption. Bile acid loss persisted despite dietary and pancreatic extract therapy and the resulting correction of steatorrhea, indicating that the unhydrolysed triglycerides were not the main reason for impaired ileal bile acid absorption. The spontaneous recovery in both children toward the end of the first year of life indicated to us that a transient delay in maturation of exocrine pancreatic function was probably responsible for the malabsorption. Absent lipolytic and amylolytic activity and blunted response to hormonal stimulation have been described in premature and newborn infants. 2,a2 These functions were found to be normal and comparable to those of adults by 2 years of age. The exact timing of maturation is unknown. The malabsorption syndrome caused by pancreatic insufficiency may easily be missed if it is transient or masked by the liberal use of infant formulas containing simple sugars, hydrolyzed protein, and medium-chain triglycerides.

A model for educational simulation of infant cardiovascular physiology.

Full-body patient simulators provide the technology and the environment necessary for excellent clinical education while eliminating risk to the patient. The extension of simulator-based training into management of basic and critical situations in complex patient populations is natural. We describe the derivation of an infant cardiovascular model through the redefinition of a complete set of parameters for an existing adult model. Specifically, we document a stepwise parameter estimation process, explicit simplifying assumptions, and sources for these parameters. The simulated vital signs are within the target hemodynamic variables, and the simulated systemic arterial pressure wave form and left ventricular pressure volume loop are realistic. The system reacts appropriately to blood loss, and incorporation of aortic stenosis is straightforward. This infant cardiovascular model can form the basis for screen-based educational simulations. The model is also an essential step in attaining a full-body, model-driven infant simulator.

Preparation for Surgery and Medical Procedures

There are large numbers of children for whom the hospital experience results in transient or moderately severe behavioral distrubances (Cassell, 1965). The stress of hospitalization includes fears related to separation from the parents, the distress of unfamiliar surroundings, anxiety about painful procedures, and the discomfort of the recovery from surgery or illness. Behavioral disturbances occurring in as many as 92% of hospitalized children include regressive behaviors such as increased dependency, loss of toilet training, excessive fears, and sleep and eating disturbances (Chapman, Loeb, & Gibbons, 1956; Gellert, 1958; Goffman, Buckman, & Schade, 1957). Since there is such a wide range of reported disturbances, there is a need to identify the population at risk for emotional stress related to hospitalization. Some researchers report that only about 10% to 35% of the problems precipitated by the hospital experience lead to serious long-term disturbances (Prugh, Staub, Sands, Kirschbaum, & Lenihan, 1953).

Pulse oximetry monitoring can change routine oxygen supplementation practices in the postanesthesia care unit.

Routine use of supplemental oxygen (O2) in the post‐anesthesia care unit (PACU) traditionally has been used to minimize the incidence of hypoxemia. However, with the advent of continuous noninvasive monitoring by pulse oximetry, is routine administration of O2 necessary? We hypothesized that administering O2 as needed, based on pulse oximetry data, would effect considerable cost savings without compromising patient care. Five hundred adult (≥18 yr) patients breathing room air when arriving in the PACU were enrolled in the study. During PACU care, when O2 saturation (Spo2) was continuously more than 94%, no supplemental O2 was given. When Spo2 was less than 94%, supplemental O2 was given at an inspired O2 concentration (Fio2) that would increase it to above 94%. Also, when preoperative Spo2 was less than 94% and postoperative Spo2 was more than the preoperative Spo2 no supplemental O2 was given. Supplemental O2 was unnecessary in 63% of patients for the duration of their PACU stay. Cost savings to the 307 patients in one study not receiving O2 was

Perioperative management of total parenteral nutrition, glucose containing solutions, and intraoperative glucose monitoring in paediatric patients: a survey of clinical practice.

31,928 if it had been billed separately from the PACU global charge. The annualized figure for patients in our hospital (approximately 10,000 cases) would be an additional

Intramuscular atropine sulfate in children: Comparison of injection sites

623,272. Inasmuch as pulse oximetry monitoring is now standard in the PACU, perhaps it is time to apply the objective data it supplies, thereby creating cost savings while maintaining patient care standards.

Umbilical catheters and arterial blood pressure monitoring

Infants and children, particularly those who are chronically ill and maintained on total parenteral nutrition (TPN), are at risk for perioperative hypoglycaemia [blood glucose < 2.2 mmol·l–1 (40 mg·dl–1)] and hyperglycaemia [blood glucose > 11 mmol·l–1 (200 mg·dl–1)]. We surveyed paediatric anaesthesiologists regarding their perioperative management of blood glucose and TPN in paediatric patients to determine the current practice and its perceived success. Questionnaires were mailed to all members of the Study Group on Pediatric Anesthesia and the response rate was 70%. Results indicate that the current perioperative management of blood glucose and TPN is somewhat varied. Furthermore, greater than 10% of those surveyed report that their management results in a variable response in the maintenance of normoglycaemia. While the detrimental effects of perioperative hypoglycaemia and hyperglycaemia are rare, they are serious. A Medline search shows that no studies have been published regarding perioperative management of paediatric patients receiving TPN, although it appears that clinical study is warranted.

Prolonged use of high-frequency jet ventilation for a pediatric patient.

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)

Classifications of Drowning

The natural frequencies, damping coefficients, and accuracies of umbilical artery catheters were determined. The damping coefficients for the 3.5, 5.0, and 8.0 French catheters were 0.40 ± 0.04 (mean ± SD), 0.42 ± 0.05, and 0.19 ± 0.02, respectively. The natural frequencies were 24.2 ± 3.2 Hz (mean ± SD), 18.4 ± 3.5 Hz, and 26.8 ± 2.9 Hz, respectively. Measurements obtained with 3.5 and 8.0 French catheters were within 6% of the reference pressure at all pressures and rates tested. With the 5.0 French catheter, however, error greater than 10% from the reference pressure occurred when the rate was 200 pulses per minute or greater and the applied maximum pressure was 100 mm Hg or more.

Aspiration in intubated premature infants

A 10-yr-old boy who developed postoperative respiratory failure with evidence of significant barotrauma was treated with high-frequency jet ventilation (HFJV). HFJV reduced peak inflation pressure, enhanced oxygenation, and improved ventilation. The patient could not be weaned from HFJV by decreasing drive pressure. Instead, he was successfully weaned by decreasing the HFJV rate to 80 cycle/min and then switching to conventional intermittent mandatory ventilation at initially similar rate and pressure levels.