Quantitative analysis of end-tidal carbon dioxide during mechanical and spontaneous ventilation in infants and young children.

Capnography provides a substitute for monitoring of arterial carbon dioxide tension (PCO(2)). We performed a prospective study to evaluate a new application of capnography, using quantitative curve analysis in the pediatric ICU. Twenty-five infants and children admitted to the pediatric ICU after cardiovascular surgery for congenital heart diseases were included in the study. Capnographic curves were recorded during 3 phases of mechanical and spontaneous ventilation: phase 1, immediate postoperative period; phase 3, preextubation period; and phase 2, period between phases 1 and 3. Each recording included 17 sec of capnographic tracings from consecutive spontaneous and/or ventilator-driven breaths. Quantitative curve analysis was made to define parameters including peak value of exhaled PCO(2) (P), mean rate of rise of PCO(2) (R), and area under each capnographic curve (A). Qualitative inspection of the wave contour showed no obvious difference in phase 3 during spontaneous and mechanically assisted ventilator breaths. However, an obvious difference existed between spontaneous and mechanically assisted breaths in phase 2. For each parameter (P, R, and A), there was a significant difference in phases 2 and 3 from spontaneous breaths. However, there was no significant difference in phases 2 and 3 from ventilator-assisted breaths. We further calculated the ratio of parameters of spontaneous breaths (S) and ventilator-assisted breaths (V) in phase 2 and phase 3. The ratio of S/V for P, R, and A showed significant differences between phase 2 and phase 3. We conclude that quantitative analysis of exhaled end-tidal PCO(2) curves revealed significant changes of specific parameters during the transition from the ventilator-dependent state to the spontaneously breathing ventilator-independent state. This new approach provides a new way to estimate respiratory status in infants and children receiving ventilator therapy. Through quantitative capnographic curve analysis, if P, R, and A from spontaneous breaths approached those of ventilator-assisted breaths, patients have resumed reasonable pulmonary mechanics, and extubation may then be considered.

Intestinal polyps in children and adolescents--a review of 103 cases.

Juvenile polyps are the most common tumors of the gastrointestinal tract in children and are the principal cause of hematochezia. A total of 103 children and adolescents with intestinal polyps have been treated in Veterans General Hospital-Taipei from March 1961 to March 1994. The diagnosis included 87 cases (84.5%) of juvenile polyps, 2 cases of isolated adenomatous polyp and 14 cases of inherited polyposis syndrome. Juvenile polyps most often occur in children between 2 to 10 years old, with a male-to-female ratio of 1.4:1. Rectal bleeding was the main symptom (97.7%). Of the 87 patients, 82.8% had isolated polyps and 83.3% of those were located in rectosigmoid colon. After extensive use of colonoscopy, the reported incidence of multiple polyps substantially increased, and more polyps were found proximal to the rectosigmoid colon. Most juvenile polyps were removed by colonoscopic polypectomy. The recurrent rate was 10.2%. One of the two cases of juvenile polyposis coli suffered from intussusception demanding partial colectomy. Recurrent polyps were found in the remaining colon and were removed by colonoscopic polypectomy. Seven patients of Peutz-Jeghers syndrome came from five families. At initial diagnosis, one case had no polyps and two presented with intussusception. A 19-year-old girl was found to have bilateral ovarian cysts. One of the three familial adenomatous polyposis had adenocarcinoma at initial evaluation. Two cases of Gardner's syndrome received sulindac treatment, and no evidence of malignancy was found after three years of follow-up.

Detection of airway CO2 partial pressure to avoid esophageal intubation.

During endotracheal intubation, checking the position of endotracheal tube is important in order to avoid accidental esophageal intubation. Exhaled CO2 pressures of 50 emergent intubation attempts were recorded in our pediatric intensive unit to evaluate the efficacy of capnography in the early detection of esophageal intubation. Adjustment of the tube position was performed when indicated. In successful endotracheal intubation, the end-tidal CO2 pressures (PetCO2) ranged from 10 mmHg to 80 mmHg with typical respiratory phasic waveforms. In cases of inadvertent esophageal intubation, the PetCO2 values were less than 5 mmHg and revealed no typical respiratory pattern. It was also observed that PetCO2 decreased during one lung intubation or when the tip of endotracheal tube was pulled above the glottis. Capnographic monitoring end-tidal CO2 pressure continuously may be a reliable, time-saving tool for the detection of inadvertent esophageal intubation and the evaluation of proper positioning of the endotracheal tube.

[Haemophilus influenzae cellulitis of the hand: report of one case].

Cellulitis of extremities due to Haemophilus influenzae is rare in children. Only 60 cases of Haemophilus influenzae cellulitis of the extremities have been reported. It usually affects young children between the ages of six and 24 months. The lesion often presents with a red-to-bluish-purple discoloration overlying the involved area. High fever and leukocytosis are commonly found. Culture of needle aspirate and blood with appropriate media is necessary for diagnosis. Early diagnosis is especially important because of associated bacteremia and the subsequent possibility of life-threatening complications such as meningitis. We reported a 8-month-old female infant with Haemophilus influenzae type b cellulitis over the right hand. She was admitted due to high fever and painful swelling of the right hand. Edematous right hand with dusky erythematous skin over the dorsum and swelling of the palm with limitation of range of motion were noted on admission. Smear of needle aspirate revealed gram negative bacilli and beta-lactamase(-) Haemophilus influenzae type b was cultivated in the blood culture. She was successfully treated with ampicillin and discharged with stable condition.

Defective response of plasma growth hormone to growth hormone releasing factor in growth hormone deficient children.

In an attempt to establish the reference pattern and the plasma growth hormone (GH) response to growth hormone releasing factor (GRF) (1-29)NH2, 5 normal stature with single kidney children and 14 with idiopathic GH deficient dwarfism received intravenous injections of 1 microgram/kg GRF(1-29)NH2. Plasma GH levels were measured at 0, 15, 30, 45, 60, 90, and 120 min after injection. The results showed that, first, in normal stature with single kidney children, each plasma GH reached peak level (80.31 +/- 19.28 ng/ml) at 45 min after injection. Second, the majority of those with GH deficient dwarfism also obtained maximal GH levels (13.10 +/- 10.78 ng/ml) at 45 min after injection but at significantly lower levels than the normal children (P < 0.01). To compare with that obtained after the insulin-induced hypoglycemia test, the peak GH level after GRF was higher but there was no significant correlation between them. The maximal GH level after GRF(1-29)NH2 injection did not show significant correlation with either chronological age or bone age. Third, 3 of 14 (21.4%) with GH deficient dwarfism had half response to GRF(1-29)NH2. It is reasonable to assume that out of these patients' GH deficiency is of hypothalamic origin. Therefore, GRF test is a safe and useful test for differential diagnosis of defect level in GH deficiency and may become a therapeutic regimen.