RESUMO
An 8-year-old girl had a 5-month history of recurrent rectal prolapse. On colonoscopy, two submucosal masses were noted in the distal rectum and diagnosed by biopsy as benign lymphoid hyperplasia. These were excised by limited dissection superficial to the submucosa, and the histologic diagnosis was confirmed. The child has done well after removal of the nodules, with no subsequent prolapse for more than 2 years.
Assuntos
Linfonodos/patologia , Prolapso Retal/etiologia , Reto/patologia , Biópsia , Criança , Colonoscopia , Feminino , Humanos , Hiperplasia , Linfonodos/cirurgia , Reto/cirurgia , RecidivaRESUMO
OBJECTIVE: To assess the efficacy of inhaled nitric oxide (NO) in reducing pulmonary hypertension in a porcine model of adult respiratory distress syndrome. DESIGN: Nonrandomized, controlled experiment without blinding. SETTING: Surgical research laboratory. PARTICIPANTS: Twelve pigs, matched equally for body weight. INTERVENTION: Acute lung injury was induced by intravenous injection of oleic acid. Animals were then divided into either a control group, for monitoring without any further intervention, or a NO-treatment group, in which NO was administered at concentrations of 10 to 80 ppm, with each step separated by a NO-free interval to assess duration of effect. MAIN OUTCOME MEASURES: Pulmonary artery pressure, systemic blood pressure, PaO2, intrapulmonary shunt fraction, and extravascular lung water. Nitrosylated hemoglobin, arterial methemoglobin, and plasma nitrite and nitrate concentrations. RESULTS: All animals responded to oleic acid injection with rapid development of pulmonary hypertension and deterioration of PaO2 and intrapulmonary shunt fraction. Inhaled NO reversed these changes in a concentration-dependent manner. Cessation of NO administration led to a prompt return of pulmonary hypertension. A small but significant drop in systemic blood pressure was observed only at the highest concentration of NO administered (80 ppm). Extravascular lung water almost doubled following oleic acid injury. This increase was sustained in all animals for the remainder of the experiment. Significant increases in circulating methemoglobin and plasma nitrite and nitrate concentrations were measured during NO inhalation. CONCLUSION: Inhaled NO appears to be a selective pulmonary vasodilator and may prove to be useful in improving gas exchange in adult respiratory distress syndrome.
Assuntos
Hipertensão Pulmonar/prevenção & controle , Óxido Nítrico/uso terapêutico , Síndrome do Desconforto Respiratório/tratamento farmacológico , Administração por Inalação , Animais , Pressão Sanguínea/efeitos dos fármacos , Relação Dose-Resposta a Droga , Água Extravascular Pulmonar/efeitos dos fármacos , Hemoglobinas/análise , Complacência Pulmonar/efeitos dos fármacos , Metemoglobina/análise , Nebulizadores e Vaporizadores , Nitratos/sangue , Óxido Nítrico/administração & dosagem , Óxido Nítrico/sangue , Nitritos/sangue , Ácido Oleico , Ácidos Oleicos/efeitos adversos , Oxigênio/sangue , Artéria Pulmonar , Troca Gasosa Pulmonar/efeitos dos fármacos , Síndrome do Desconforto Respiratório/patologia , SuínosRESUMO
OBJECTIVE: To determine whether abnormalities in lung mechanics detected in infants during the acute phase of meconium aspiration syndrome persist after treatment with extracorporeal membrane oxygenation (EMCO). DESIGN: Prospective, descriptive study. Prospective evaluation of airway function and lung mechanics during and after ECMO by pulmonary function testing at 1.8 +/- 0.5 days of EMCO (period 1), follow-up at 1.4 +/- 0.2 days (period 2), and 7.0 +/- 0.9 days (period 3) after decannulation from ECMO. SETTING: Tertiary care neonatal/pediatric ICU. PATIENTS: Twelve neonates undergoing ECMO treatment for severe meconium aspiration syndrome that was refractory to conventional mechanical ventilation. INTERVENTIONS: Maximum expiratory flow-volume curves were studied with the deflation flow-volume curve technique, and compliance and resistance of the respiratory system were studied with partial passive flow-volume curves. MEASUREMENTS AND MAIN RESULTS: Respiratory system compliance was the only index of respiratory mechanics that was significantly (p less than .05) improved (0.96 +/- 0.1 vs. 0.61 +/- 0.1 mL/cm H2O/kg) immediately after decannulation from ECMO compared with period 1. Clinically important (p less than .05) improvement in forced vital capacity (28.0 +/- 5.5 vs. 16.1 +/- 1.9 mL/kg), respiratory system compliance (1.01 +/- 0.2 vs. 0.61 +/- 0.1 mL/cm H2O/kg), and maximum expiratory flow at 25%/forced vital capacity (1.0 +/- 0.3 vs. 2.2 +/- 0.3) was evident only during period 3 compared with period 1. CONCLUSIONS: We conclude that improvements in the clinical condition and oxygenation, permitting successful decannulation from ECMO, are achieved before clinically important improvements in lung mechanics.
Assuntos
Oxigenação por Membrana Extracorpórea , Síndrome de Aspiração de Mecônio/fisiopatologia , Mecânica Respiratória/fisiologia , Doença Aguda , Resistência das Vias Respiratórias/fisiologia , Feminino , Humanos , Recém-Nascido , Masculino , Síndrome de Aspiração de Mecônio/epidemiologia , Síndrome de Aspiração de Mecônio/terapia , Estudos Prospectivos , Ventilação Pulmonar/fisiologia , Testes de Função Respiratória/estatística & dados numéricos , Fatores de TempoRESUMO
OBJECTIVE: To describe the pathophysiology of surgical conditions that are associated with respiratory insufficiency in the newborn infant. DESIGN: Survey. SETTING: Newborn ICU in a children's hospital. PATIENTS: Twenty-four newborn infants (1 to 28 days old) who required endotracheal intubation and mechanical ventilation for operative procedures or postoperative ventilatory support. INTERVENTIONS: Flow-volume curves obtained by manual inflation of the lungs, followed by forced deflation by negative pressure, and by passive expiration, under sedation and pharmacologic paralysis. MEASUREMENTS: Deflation flow-volume curves and passive expiratory curves were measured. Pulmonary function testing before and after bronchodilator administration (n = 11) began midway during the study period. Term and preterm groups served as controls. MAIN RESULTS: Forced vital capacity (FVC) was decreased in all groups with surgical disease as follows: abdominal wall defects and necrotizing enterocolitis groups to 48.3% and 62.1% that of preterm, respectively; pulmonary hypoplasia group to 55.5% that of term (p less than .05). Maximal expiratory flow at 25% of FVC decreased in all groups: abdominal wall defects and necrotizing enterocolitis group, to 36.8% and 37.9% that of preterm, respectively (p less than .05); pulmonary hypoplasia group, 20.0% that of term (p less than .05). The ratio of maximal expiratory flow at 25% of FVC divided by FVC was significantly decreased in necrotizing enterocolitis and pulmonary hypoplasia groups compared with that of preterm and term groups, respectively, but not in the abdominal wall defects group. Maximal expiratory flow at 25% of FVC, but not FVC, increased significantly (36%, p less than .05) after bronchodilator nebulization, indicating the presence of airway reactivity. Respiratory system compliance was decreased significantly (p less than .05) in all surgical disease groups compared with the term group. CONCLUSIONS: Bronchial reactivity contributes to decreased maximal expiratory flow at 25% of FVC, a feature also seen in premature infants with respiratory distress syndrome who later develop bronchopulmonary dysplasia. Babies who require chronic ventilatory support after operation and who have developed reactive airways may benefit from the administration of bronchodilators during postoperative ventilatory management.
Assuntos
Enterocolite Pseudomembranosa/fisiopatologia , Hérnia Diafragmática/fisiopatologia , Complicações Pós-Operatórias/etiologia , Insuficiência Respiratória/etiologia , Resistência das Vias Respiratórias , Broncodilatadores/uso terapêutico , Enterocolite Pseudomembranosa/cirurgia , Idade Gestacional , Hérnia Diafragmática/cirurgia , Hérnias Diafragmáticas Congênitas , Humanos , Recém-Nascido , Complacência Pulmonar , Medidas de Volume Pulmonar , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/terapiaRESUMO
To determine whether preoperative stabilization and delay of operative repair of congenital diaphragmatic hernia (CDH) may decrease operative risk, we performed serial pulmonary function tests on 22 newborn infants with CDH and on four infants without pulmonary hypoplasia (two with ileal atresia and two with tracheoesophageal anomalies) who served as control subjects. We used 2 passive respiratory mechanics technique to measure respiratory system compliance. All patients with CDH had respiratory distress immediately after birth, and required mechanical ventilation. Thirteen babies underwent emergency repair (six survived, seven died); nine of them received extracorporeal membrane oxygenation (ECMO) after the operation (two survived, seven died). Operative repair was delayed deliberately for 2 to 11 days in nine infants with severe hypoxemia. Six immediately received ECMO for 4 to 10 days; one died of intraventricular hemorrhage, and five survived and later underwent surgical repair. The seventh patient did not receive ECMO but appeared to have respiratory distress syndrome of infancy and improved after administration of synthetic surfactant. Improvement was seen in two additional infants who received conventional assisted ventilation during a 48-hour delay before surgery, and survived. In all, eight of nine infants who underwent preoperative stabilization survived (p less than 0.05 compared with survival after emergency surgery). Following surgical repair immediately after birth, respiratory system compliance improved only slightly during the first week of life, a time when control infants had a rapid increase in respiratory system compliance (p less than 0.001). In contrast, respiratory system compliance increased nearly twofold in the nine patients undergoing preoperative stabilization (p less than 0.02). Preoperative ECMO was associated with an increase in respiratory system compliance of more than 60% for 1 week, a significant difference from respiratory system compliance among patients undergoing emergency CDH repair (p less than 0.05). These observations provide physiologic evidence of possible benefits of preoperative stabilization before repair of CDH.
Assuntos
Hérnias Diafragmáticas Congênitas , Complacência Pulmonar/fisiologia , Cuidados Pré-Operatórios , Oxigenação por Membrana Extracorpórea , Fluxo Expiratório Forçado , Volume Expiratório Forçado , Hérnia Diafragmática/mortalidade , Hérnia Diafragmática/fisiopatologia , Hérnia Diafragmática/terapia , Humanos , Recém-Nascido , Oxigênio/sangue , Pressão Parcial , Cuidados Pós-Operatórios , Respiração Artificial , Síndrome do Desconforto Respiratório do Recém-Nascido/mortalidade , Síndrome do Desconforto Respiratório do Recém-Nascido/fisiopatologia , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Mecânica Respiratória/fisiologia , Fatores de TempoRESUMO
Fatal hematemesis occurred in a 3-month-old boy due to erosion by a nasogastric tube into the right component of an unrecognized double aortic arch. This is the youngest of six reported patients with arterioesophageal fistula in the literature. Including this patient, five of six had nasogastric tubes in place. The tube may have led to fistula formation by compression of the esophageal wall against an anomalous vessel. When a vascular ring is suspected, indwelling esophageal tubes such as nasogastric tubes should not be used.
Assuntos
Aorta Torácica/anormalidades , Doenças da Aorta/etiologia , Fístula Esofágica/etiologia , Fístula/etiologia , Intubação Gastrointestinal/efeitos adversos , Hematemese/etiologia , Humanos , Lactente , MasculinoRESUMO
A commitment to the maintenance of a comprehensive trauma registry can provide numerous benefits, both administrative and clinical. Uses of the information collected can vary in nature and scope based on the needs of the facility and the requirements of external regulatory bodies. Ultimately, the choice of data applications rests with the facility collecting the information. As the facility grows and evolves, so can--and must--its registry.
Assuntos
Sistema de Registros , Centros de Traumatologia , Ferimentos e Lesões/epidemiologia , Adolescente , Criança , Hospitais com 100 a 299 Leitos , Hospitais Pediátricos/organização & administração , Humanos , Pennsylvania/epidemiologia , Estatística como AssuntoRESUMO
We studied 24 human fetuses with cerebral ventriculomegaly by serial obstetric ultrasound to define the natural history of fetal ventricular enlargement and to develop a management strategy. In 10 fetuses, ventriculomegaly was associated with other severe anomalies; nine of these families chose to terminate the pregnancy. In three other severely affected fetuses in whom ventriculomegaly was detected serendipitously late in gestation, routine obstetrical management was performed; none survived. Eleven fetuses had ventriculomegaly without associated severe anomalies. Ventriculomegaly remained stable or of moderate severity throughout gestation in nine, resolved gradually in one, and progressed in one who did not have signs of increased intracranial pressure at birth. All of these fetuses were viable; three patients required shunting in the neonatal period, and two others by 5 months of age. Although obstetric ultrasound usually can detect anomalies associated with fetal ventriculomegaly, three fetuses with isolated ventriculomegaly had midline brain malformations that could not be distinguished in utero from hydrocephalus, even in retrospect. Prenatal diagnosis improves perinatal management by allowing counseling, and selective pregnancy termination, or selection of the timing, mode, and place of delivery to optimize outcome. Most fetuses with ventriculomegaly do not require intervention before birth.