COX-2-specific inhibition: implications for clinical practice.

Although conventional nonsteroidal anti-inflammatory drugs (NSAIDs) have long been a major therapeutic choice for the management of arthritic conditions, the potential adverse effects of these agents sometimes compromise their clinical utility. New modes of therapy have recently been introduced, and data on the cyclooxygenase-2 (COX-2)-specific inhibitors celecoxib and rofecoxib suggest that these agents will meet the need for safe and effective therapeutic alternatives to conventional NSAIDs.

Effects of fentanyl administration on respiratory system compliance in infants.

OBJECTIVE: To determine if the analgesic doses of fentanyl used in a pediatric intensive care unit (ICU) setting adversely affect dynamic total respiratory system compliance in awake, intubated infants. DESIGN: Prospective case-control study. SETTING: Pediatric and pediatric cardiac ICUs of a tertiary university hospital. PATIENTS: Thirteen awake and mechanically ventilated children < 6 months of age. INTERVENTIONS: Measurements of dynamic total respiratory system compliance were obtained during steady-state conditions for 6 mins and continued for 10 mins after the rapid, intravenous administration of 4 micrograms/kg of fentanyl. No patient had received a narcotic, benzodiazepine, or muscle relaxant within the previous 4 hrs. MEASUREMENTS AND MAIN RESULTS: After fentanyl administration, dynamic total respiratory system compliance was unchanged in three patients, improved in nine patients, and deteriorated in one patient. The mean value for the entire group increased from 0.76 mL/cm H2O/kg before infusion to 0.82 mL/cm H2O/kg after infusion (p < .02), representing a 9.6% increase. None of the patients showed oxygen desaturation as assessed by continuous pulse oximeter, or episodes of chest wall rigidity. CONCLUSIONS: This work corroborates our clinical impression that rapid infusions of fentanyl at the dose tested in small infants do not adversely affect dynamic total respiratory system compliance. To the contrary, the sedating and analgesic effects may improve synchronous breathing and decrease voluntary muscle tone, resulting in improved dynamic total respiratory system compliance.

[Obesity among patients admitted to a medical department at the Terni Hospital]. / L'obesità nei ricoverati presso un reparto medico dell'Ospedale di Terni.

The Authors report the results of a study intended to asses the prevalence of obesity in Terni's medical department. Body mass index (BMI) was used as a measure of obesity: it can easily be calculated from weight and height (W/H2) for any individual. A sample of 1195 patients (569 males and 626 females) was studied; obesity was found in 30% of the females and in 10% of the males.

Chest wall motion of infants during spinal anesthesia.

To test the extent to which diaphragmatic contraction moves the rib cage in awake supine infants during quiet breathing, we studied chest wall motion in seven prematurely born infants before and during spinal anesthesia for inguinal hernia repair. Infants were studied at or around term (postconceptional age 43 +/- 8 wk). Spinal anesthesia produced a sensory block at the T2-T4 level, with concomitant motor block at a slightly lower level. This resulted in the loss of most intercostal muscle activity, whereas diaphragmatic function was preserved. Rib cage and abdominal displacements were measured with respiratory inductance plethysmography before and during spinal anesthesia. During the anesthetic, outward inspiratory rib cage motion decreased in six infants (P less than 0.02, paired t test); four of these developed paradoxical inward movement of the rib cage during inspiration. One infant, the most immature in the group, had inward movement of the rib cage both before and during the anesthetic. Abdominal displacements increased during spinal anesthesia in six of seven infants (P less than 0.05), suggesting an increase in diaphragmatic motion. We conclude that, in the group of infants studied, outward rib cage movement during awake tidal breathing requires active, coordinated intercostal muscle activity that is suppressed by spinal anesthesia.

Comparison of a sidestream and mainstream capnometer in infants.

This study was designed to compare capnograms obtained from a sidestream and mainstream capnometer during rapid mechanical ventilation in infants. Ten infants were studied during elective anesthesia and surgery. Simultaneous recordings of exhaled CO2 were made with a sidestream and a mainstream machine; arterial blood gases were measured for comparison. The mean arterial to end-tidal CO2 difference (PaCO2-PetCO2) was approximately 5 torr with either technique; the correlation of PetCO2 with PaCO2 was slightly better with the mainstream analyzer (r2 = .895 vs. .654). The recordings obtained with the sidestream machine were grossly distorted, with flattening of the ascending limb (slope 37.3 vs. 153.3 torr/sec, sidestream vs. mainstream, p less than .001) and absence of the alveolar plateau. The mainstream analyzer gives a more accurate representation of the expired CO2 waveform in small children at rapid respiratory rates.

Head trauma in the child.

Head injury, either alone or in combination with multiple injuries, is common in children. Its pattern is different in children compared to adults, with diffuse cerebral swelling rather than localized hematoma being most common. The pathophysiology of pediatric head trauma is not yet clearly elucidated, but may be closely related to changes in the regulation of cerebral blood flow. The initial management and subsequent care of the child with severe brain injury are discussed from a multisystem viewpoint. The prognosis for children with severe head injury seems brighter than for adults, but there are not yet enough data to allow prediction of outcome in any individual case. Efforts to prevent, rather than treat, head injury in childhood are more likely to be beneficial.

Reye's syndrome.

Although most cases of Reye's syndrome that were initially reported were fatal, the overall mortality is now 20 to 30 per cent, with an even lower rate in some series. Improvement is due to both increased awareness of this disease and advances in care for the critically ill child. A good outcome depends on recognition of the early manifestations of the syndrome and appropriate initial therapy based on the stage of the disease.