Adult respiratory distress syndrome and artificial surfactant replacement in the pediatric patient.

Adult respiratory distress syndrome (ARDS) frequently develops after near-drowning, smoke inhalation, burns, blunt trauma to chest, and overwhelming sepsis. Surfactant depletion, inactivation or destruction by the accumulation of proteinaceous material in the alveoli, and changes in the relative composition of phospholipids or protein component have been associated with ARDS. Artificial surfactant reverses these changes in experimental animals. Seven cases of ARDS have been treated on an experimental basis with artificial surfactant after approval and in accordance with ethical standards of the institution's committee on human experimentation. Informed consent was obtained from parents prior to administering artificial surfactant. We identified five cases of ARDS in retrospective analysis and used them as historical controls. Mortality between these two groups was analyzed with Fisher's exact test. One of seven (14.2%) children treated with surfactant died of overwhelming infection, and 2/5 (40%) of the historical controls died of pulmonary causes (P = 0.523). Statistically, surfactant therapy did not improve survival in patients with ARDS; however, ARDS patients receiving surfactant improved in their pulmonary dynamic compliance and had a tendency to stabilize earlier in gas exchange, allowing us to decrease ventilatory support.

Sudden death in neonate with staphylococcal endocarditis.

A 27-week-old girl, 936 gm, with initial diagnosis of birth asphyxia resulting from prolapse of the umbilical cord, respiratory distress syndrome, and suspected neonatal sepsis received antibiotics for the first 7 days of life. On day 24, evidence developed of acute Staphylococcus aureus endocarditis of the anterior leaflet of the mitral valve, and she died 4 days later. We believe that a rapid enlargement of the endocardial vegetation caused acute occlusion of the small mitral valve and was the cause of sudden death in this infant.

Persistent pulmonary hypertension of the newborn infant. Comparison of conventional versus extracorporeal membrane oxygenation in neonates fulfilling Bartlett's criteria.

Persistent pulmonary hypertension of the newborn (PPHN) is a challenge for the neonatologist and a common indication for treatment with extracorporeal membrane oxygenation (ECMO) when medical management fails. We observed 132 neonates born between January 1985 and December 1988 with the diagnosis of persistent pulmonary hypertension of the newborn: 73 (55%) met the Bartlett criteria for treatment with ECMO with 80% predicted mortality; 21 (29%) deteriorated despite conventional medical treatment, were thought to be dying, and were sent for ECMO. Among the 52 patients who were medically treated 40 (77%) survived, a marked difference compared with a predicted 20% survival. All ECMO-treated neonates survived. Although conventionally treated infants showed a trend toward less dependence on supplemental oxygen at > 28 days of life, this study failed to detect a significant difference between those two groups. We conclude that mortality was lower for ECMO-treated infants than for those who were medically treated (0 of 21 vs 12 of 52, p < 0.05); mortality for infants with persistent pulmonary hypertension of the newborn who met Bartlett's criteria and were medically treated was lower than published data; and there was no significant difference in oxygen dependence at > 28 days between the survivors who received ECMO and those who received medical therapy.