Prospective, randomized evaluation of the efficacy of fibrin sealant as a topical hemostatic agent at the cannulation site in neonates undergoing extracorporeal membrane oxygenation.

BACKGROUND: The topical hemostatic effect of fibrin sealant that has been solvent/detergent treated and plasminogen depleted was evaluated in a multicenter prospective, randomized controlled study at the cannulation site wound of infants undergoing extracorporeal membrane oxygenation (ECMO). METHODS: The test group received standard cauterization and Fibrin sealant, while the control group was given cauterization alone to control hemostasis at this site. Efficacy data were available on 173 randomized study subjects of whom 149 met study entry criteria. All were managed according to standard ECMO practice. RESULTS: Fibrin sealant reduced the risk of bleeding, was associated with less shed blood, and was associated with shorter duration of hemorrhage. Further, control infants showed an increased bleeding risk with less depressed fibrinogen levels and prothrombin time elevations >18 seconds prior to ECMO. CONCLUSION: Fibrin sealant is useful as a topical hemostatic agent in patients with coagulopathy not responding to standard surgical techniques.

A second course of extracorporeal membrane oxygenation in the neonate--is there a benefit?

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is an effective therapy for infants with severe respiratory failure and pulmonary hypertension. In most patients once the disease reverses, it does not recur. However, in some patients pulmonary hypertension recurs and these infants meet criteria for a second course of ECMO. We evaluated the survival rate and feasibility of a second course of ECMO in neonates. METHODS: A questionnaire was sent to all active ECMO programs that requested data about patients who received two courses of ECMO. A retrospective review of the results from responding centers was performed to evaluate indications and outcome. RESULTS: The overall survival rate for the 58 neonates was 40%. Thirty-four patients with congenital diaphragmatic hernia had a survival rate of 47%, and 12 infants with primary persistent pulmonary hypertension had an 8% survival rate (p < 0.05). Most patients were treated with venoarterial ECMO for both courses. CONCLUSIONS: There is a reasonable survival rate for selected neonates who are treated with a second course of ECMO. Infants with primary persistent pulmonary hypertension should be carefully examined before institution of a second course of ECMO.

An analysis of feeding regimens after pyloromyotomy for hypertrophic pyloric stenosis.

We retrospectively reviewed 223 infants who underwent pyloromyotomy for hypertrophic pyloric stenosis (HPS) at our institution from January 1984 to May 1990. Each patient's postoperative feeding regimen was determined by the attending surgeon. The four distinct regimens used were as follows: A (n = 66): NPO overnight (> 10 h) with cautious feeding advancement every 4 hours x 2, then every 2 hours x 2, then every 1 1/2 hours x 8, then ad lib; B (n = 46): NPO until 6 to 8 hours postoperatively with the same cautious feeding advancement as in A; C (n = 42): NPO until 6 hours postoperatively with accelerated feeding advancement every 2 hours x 8, then ad lib; D (n = 69): NPO until 6 hours postoperatively with accelerated feeding advancement every 1 hour x 12, then ad lib. There were no significant differences in age at diagnosis or degree of dehydration among groups. From group A to group D, there was a progressive increase in amount and incidence of postoperative vomiting, both after the first three feedings and in the total postoperative period. However, patients in groups C and D had a shorter postoperative hospital stay and lower charges than did patients in groups A and B. Following discharge, no patient was readmitted for vomiting or dehydration. We conclude that feedings started 6 hours after pyloromyotomy for HPS with accelerated feeding advancement every 2 hours increases the incidence and frequency of postoperative vomiting, but not unacceptably, and results in a significantly shorter postoperative stay.

Congenital diaphragmatic hernia. Stabilization and repair on ECMO.

Availability of extracorporeal membrane oxygenation (ECMO) support and the potential advantages of delayed repair of congenital diaphragmatic hernia (CDH) have led several centers to delay CDH repair, using ECMO support if necessary. This study reviews the combined experience of five ECMO centers with infants who underwent stabilization with ECMO and repair of CDH while still on ECMO. All infants were symptomatic at birth, with a mean arterial oxygen pressure (PaO2) of 34 mmHg on institution of bypass despite maximal ventilatory support. A total of 42 infants were repaired on ECMO, with 18 (43%) surviving. Seven infants had total absence of the diaphragm, and 28 required a prosthetic patch to close the defect. Only five infants ever achieved a best postductal PaO2 over 100 mmHg before institution of ECMO. Prematurity was a significant risk factor, with no infants younger than 37 weeks of age surviving. Significant hemorrhage on bypass was also a hallmark of a poor outcome, with 10 of the 24 nonsurvivors requiring five thoracotomies and six laparotomies to control bleeding, whereas only one survivor required a thoracotomy to control bleeding. In follow-up, nine of the 18 survivors (50%) have developed recurrent herniation and seven (43%) have significant gastroesophageal reflux. Importantly, five of the 18 survivors were in the extremely high-risk group who never achieved a PaO2 over 100 mmHg or an arterial carbon dioxide pressure (PaCO2) less than 40 mmHg before the institution of ECMO. In conclusion, preoperative stabilization with ECMO and repair on bypass may allow some high-risk infants to survive. Surviving infants will require long-term follow-up because many will require secondary operations.

Congenital diaphragmatic hernia in an era of delayed repair after medical and/or extracorporeal membrane oxygenation stabilization: a prognostic and management classification.

In November 1987 we began to practice delayed repair of acutely symptomatic congenital diaphragmatic hernia (CDH) following medical and/or extracorporeal membrane oxygenation (ECMO) stabilization. We reviewed 23 consecutive patients with CDH symptomatic at birth treated over the ensuing 2 1/2 years. The mean age at admission, age at repair, and interval from admission to repair were 4.9, 37.0, and 32.6 hours, respectively. Overall survival was 52% (12/23). ECMO was used in 14 patients with 7 survivors (50%); 4 of these patients underwent repair prior to ECMO and 10 while on ECMO. The patients were retrospectively grouped into three classes based on postductal arterial blood gas (ABG) response to conventional medical management: class A (n = 8), able to achieve and sustain adequate oxygenation (PO2 greater than 60 mm Hg) and hyperventilation (PCO2 less than 40 mm Hg); class B (n = 10), unable to sustain adequate oxygenation (PO2 less than 60 mm Hg) but able to be hyperventilated (PCO2 less than 40 mm Hg); and class C (n = 5), unable to be oxygenated (PO2 less than 60 mm Hg) or hyperventilated (PCO2 greater than 40 mm Hg). The interval from admission to repair was 13.6, 53.5, and 25.4 hours for classes A, B, and C, respectively. Two class A (25%), nine class B (90%), and three class C patients (60%) were placed on ECMO. Survival rates were 88%, 50%, and 0% for classes A, B, and C, respectively. We propose the following management protocol. Class A patients are stable and can be repaired at any convenient point after admission without prerepair ECMO; few will need it afterward.(ABSTRACT TRUNCATED AT 250 WORDS)

Outcome and intestinal adaptation in neonatal short-bowel syndrome.

We reviewed 52 consecutive patients with short-bowel syndrome (SBS) treated with long-term parenteral nutrition (PN) from 1978 through 1990. The SBS etiologies included necrotizing enterocolitis (NEC) in 26 patients (50%), abdominal wall defects in 11 (22%), jejunoileal atresia in 6 (12%), midgut volvulus in 4 (8%), Hirschsprung's disease in 3 (6%), and segmental volvulus and cloacal exstrophy in 1 (2%) each. The average initial small bowel length was 48.1 cm, and only 31% of the patients retained an ileocecal valve (ICV). The mean duration of PN therapy was 16.6 months, and 39 patients (75%) were successfully weaned from it. Forty-three patients (83%) survived. Significant differences between the initial 20 patients treated from 1978 through 1984 and the next 32 from 1985 through 1990 were duration of PN therapy (25.1 v 11.4 months; P = .04), incidence of PN-associated jaundice (80% v 31%; P = .001), and survival (65% v 94%; P = .02). NEC patients had a significantly lower mean birthweight than those with other etiologies (mean, 1,367 v 2,544 g; P less than .0001) but did not differ in initial small bowel length, ICV retention rate, duration of PN treatment, incidence of successful PN weaning, or outcome. The presence of an ICV did not correlate with successful PN weaning but did affect the mean duration of PN therapy (7.2 months with ICV v 21.6 months without; P = .03).(ABSTRACT TRUNCATED AT 250 WORDS)

Improvement in survival of patients with congenital diaphragmatic hernia utilizing a strategy of delayed repair after medical and/or extracorporeal membrane oxygenation stabilization.

Patients with congenital diaphragmatic hernia (CDH) symptomatic at birth treated at this institution over the past 6 years were reviewed. The patients were divided into two chronological groups for analysis: group 1, consisting of 15 patients treated from January 1984 through October 1987, a period during which acute CDH was considered to be a surgical emergency; and group 2, comprising 20 patients treated from November 1987 through October 1989 using a management protocol of delayed repair following medical and/or extracorporeal membrane oxygenation (ECMO) stabilization. These two groups did not differ significantly in gestational age, birth weight, Apgar scores, hernia side, or age at admission. Group 2 had a longer mean interval from admission to repair (26.5 v 1.8 h, P = .01) and average age at repair (31.0 v 6.5 h, P = .02) than did group 1. Prosthetic closure of the diaphragmatic defect was required more frequently in group 2 then in group 1 (63% v 31%, P = .07). Survival in group 2 was significantly greater than in group 1 (55% v 20%, P = .04). Seven group 2 patients (35%) achieved a prerepair or pre-ECMO PO2 greater than 100 mm Hg and all survived; four of the 13 "nonresponders" also survived. ECMO was used in 11 group 2 patients with five survivors (45%); four of these patients underwent repair prior to ECMO and seven underwent repair while on ECMO.(ABSTRACT TRUNCATED AT 250 WORDS)

The first two years' experience with major trauma at a pediatric trauma center.

We reviewed the records of 233 patients with major trauma admitted to The Children's Hospital of Alabama during the first 2 years of operation of its Pediatric Trauma Center. The male-to-female ratio was 1.7:1. The highest incidence of trauma occurred in the spring (88 patients, 38%) and the lowest in the winter (36 patients, 15%). Most children (184, 79%) were injured between noon and midnight. Blunt mechanisms of injury accounted for 206 patients (88%), penetrating for 17 (7%), and burns for ten (4%). The distribution of injuries by organ system was head/neurologic, 185 patients (79%); musculoskeletal, 83 (36%); thoracic, 57 (24%); abdominal, 29 (12%); major soft-tissue, 26 (11%), genitourinary, 11 (5%); and vascular, 11 (5%). Surgery was required at some point during the hospitalization in 89 patients (38%). Seventy-two patients (31%) experienced 115 complications. The mean length of time spent for resuscitation and stabilization in the trauma room was 49 min. The mean ICU stay was 3.2 days. Total length of hospitalization averaged 11.2 days. Twenty-six patients (11%) died. The Pediatric Trauma Score and the Pediatric Coma Score were found to be predictive of outcome. The organization and function of the trauma team is described, and public health concerns are discussed.

The significance of alkalosis and hypochloremia in hypertrophic pyloric stenosis.

Hypochloremic alkalosis is the "classical" electrolyte abnormality seen in hypertrophic pyloric stenosis (HPS), yet it occurs in only about half the patients. To define the clinical differences between infants who were alkalotic or hypochloremic and those who were not, we reviewed the records of 216 patients treated for HPS over a recent 5-year period at our institution. The 202 patients who had a full set of serum electrolytes drawn on admission were divided into nonalkalotic and alkalotic bicarbonate groups A (less than or equal to 25 mEq/L, n = 105) and B (greater than 25 mEq/L, n = 97) and also nonhypochloremic and hypochloremic chloride groups A (greater than or equal to 99 mEq/L, n = 117) and B (less than 99 mEq/L, n = 85). The alkalotic group B had a significantly higher proportion of black patients (17.5% v 8%), longer mean duration of illness (17.8 v 9.4 days), higher incidence of palpable pyloric mass (97% v 82%), greater degree of dehydration, lower mean serum sodium (136.3 v 137.7 mEq/L), lower mean serum potassium (4.50 v 5.15 mEq/L), and lower mean serum chloride (92.4 v 102.3 mEq/L) than did the nonalkalotic group A.(ABSTRACT TRUNCATED AT 250 WORDS)

Changing patterns in the diagnosis of hypertrophic pyloric stenosis.

The records of 216 infants who had surgical correction of hypertrophic pyloric stenosis between 1980 and 1984 at the Children's Hospital of Alabama were reviewed. A significant increase in the reliance on upper gastrointestinal roentgenographic series and abdominal sonography for confirmation of the diagnosis of hypertrophic pyloric stenosis was noted in our patients when compared to previous reports. Despite the preoperative presence of a palpable pyloric mass in 192 (89%) of the patients, 174 (81%) had a diagnostic imaging procedure. Similar high rates of imaging studies were noted when the records of patients with hypertrophic pyloric stenosis from 1980 and 1984 were reviewed at three other institutions. Palpation of a hypertrophied pylorus is diagnostic of hypertrophic pyloric stenosis. Careful physical examination makes diagnostic imaging unnecessary in the majority of infants with symptoms suggesting hypertrophic pyloric stenosis. Diagnostic imaging for suspected hypertrophic pyloric stenosis should be used only for those infants with persistent vomiting in whom careful and repeated physical examinations fail to detect a palpable pyloric mass.

Calcium phosphate crystal occlusion of central venous catheters used for total parenteral nutrition in infants and children: prevention and treatment.

Calcium phosphate crystal occlusion is a complication occasionally encountered with long-term indwelling Silastic central venous catheters used for total parenteral nutrition (TPN) in infants and children. These occluded catheters are usually treated by removal. We have successfully treated six patients who experienced seven episodes of calcium phosphate crystal central venous catheter occlusion by irrigating their catheters with a hydrochloric (HCl) acid heparin solution. Although temporary febrile reactions occurred in three cases (42%), no serious complications were encountered. An average of 46 catheter-days per patient episode were preserved. By paying close attention to the calcium and phosphate concentrations in a patient's TPN solution, the clinician can minimize the risk of calcium phosphate precipitation. If central venous catheter occlusion does occur due to precipitation of calcium phosphate crystals, then HCl-heparin irrigation is a safe and effective method for salvaging such catheters.

Penetrating neck injuries: experience with selective exploration.

Although many authors have stated that surgical exploration should be mandatory for all neck wounds that penetrate the platysma, recent reports from many centers now claim that selective exploration is both safe and reasonable. A policy of selective exploration based on clinical presentation, anatomic location, and results of diagnostic studies has been followed at The Cooper Green Hospital in Birmingham, Alabama, for the past 13 years. We report a study of penetrating neck wounds in 136 consecutive patients admitted to The Cooper Green Hospital from 1972 to 1984. Seventy-seven patients (57%) had exploration immediately, with one death, while the remaining 59 (43%) were admitted and observed. Of these 59 patients, ten had arch aortography and nine had esophagography, all of which yielded normal results. The remainder of the patients observed had no clinical signs or symptoms to suggest a major injury. There were no deaths or complications related to the neck wounds in the 59 patients observed. Results of 27 explorations (35%) were negative. We conclude that selective exploration of penetrating neck wounds is both safe and reasonable.