Prolonged per-laryngeal endotracheal intubation in children: 40 years on.

Because tracheostomy has a very high complication rate in small children, prolonged mechanical ventilation was not performed satisfactorily in infants until a technique was developed that allowed prolonged per-laryngeal endotracheal intubation in children. Plastic polyvinyl chloride endotracheal tubes were introduced in the 1950s; they soften at body temperature, and are much less likely to cause subglottic stenosis than endotracheal tubes made from metal or rubber. The first account of prolonged per-laryngeal intubation of infants using polyvinyl chloride tubes was written by Dr Bernard Brandstater, and this remarkable document is reproduced here. It sets out all the important principles of endotracheal intubation in children: the tube must fit easily through the cricoid ring, it must be firmly fixed in place with the tip in the mid trachea, meticulous humidification and suction are essential, and the tube should be changed only if there are signs of obstruction.

Transferred patients--more complex and more costly?

AN-DRGs have some splits which take illness severity and complexity into account. Age is also often used as a proxy for severity of illness. The need to transfer a patient may be a marker of illness severity or complexity and therefore resource utilisation. This is supported by studies of patients transferred to intensive care units. Data on the costs and outcomes of all transferred patients should be collected; depending on the results, refinements of DRGs may be indicated.

Placebo-controlled trial of prednisolone in children intubated for croup.

Many studies have attempted to find out whether steroid treatment is beneficial in children with croup, but the results have been inconclusive. We have done a prospective placebo-controlled study of the effect of prednisolone on two clinical endpoints--the duration of intubation and the need for reintubation. Reasons for exclusion were age under 6 months, congenital airway anomalies, and previous intubation. 70 eligible children were randomly assigned treatment with prednisolone 1 mg/kg (n = 38) or placebo (n = 32) every 12 h given by nasogastric tube until 24 h after extubation. 11 (34%) placebo-treated and only 2 (5%) prednisolone-treated patients required reintubation after accidental or elective extubation (p = 0.004, Fisher's exact test; odds ratio 8.9, 95% confidence interval 1.7-59.3). Survival analysis with log-normal regression showed that the duration of intubation was shorter with steroid therapy (p less than 0.003) and increasing age (p less than 0.02), but was not influenced by endotracheal tube size or abnormality on chest radiograph. The median duration of intubation was 138 (95% CI 118-160) h in children who received placebo and 98 (85-113) h in the prednisolone group. Steroid therapy reduces the duration of intubation and the need for reintubation in children intubated for croup.

Continuous venovenous hemofiltration in the management of acute decompensation in inborn errors of metabolism.

Continuous venovenous hemofiltration was used to treat two neonates, one with maple syrup urine disease and the other with an inborn error of long-chain fatty acid oxidation. The latter infant had hypoglycemia, hyperammonemia and lactic acidosis. In both cases, acceptable biochemical control was achieved within 8 hours. This therapy offers the potential to overcome acute crises rapidly in a wide range of inborn errors of intermediary metabolism.

Clinical findings and severity of acute bronchiolitis.

Clinical features on admission of 60 infants with acute bronchiolitis were related to disease severity. Crackles and cyanosis (which are related to oxygen requirements during the hospital stay) most closely correlated with severity, which was assessed by arterial blood gas analysis and pulse oximetry. Respiratory rate on presentation did not predict severity. Transcutaneous haemoglobin oxygen saturation on admission, measured by pulse oximetry, was closely related to cyanosis and maximum oxygen requirements. The best method for initial assessment of bronchiolitis was pulse oximetry.

Fluid management of shock in critically-ill patients.

This article summarizes the theoretical basis and practical applications of the fluid management of shock in critically-ill patients. It also draws attention to the differences in the aetiology and management of fluid disturbances in adult and paediatric practice. Some evidence suggests that colloidal solutions alone may be superior to crystalloid solutions alone in the resuscitation of patients with shock, but in most situations a combination of both types of fluid is more logical.

Developments in the management of oesophageal atresia and tracheo-oesophageal fistulas.

Since 1948, when the first patient with oesophageal atresia and a tracheo-oesophageal fistula was treated successfully at the Royal Children's Hospital, Melbourne, 569 infants with one or both conditions have been managed at that institution. The mortality rate in those in whom surgical repair of the oesophageal atresia and distal tracheo-oesophageal fistula was attempted has declined from 55% in the first 10 years to less than 1% in the last 10 years of the series. Earlier diagnosis and improvements in resuscitation, transport, neonatal intensive care, anaesthesia, the treatment of associated anomalies and surgical technique all are likely to have contributed to the decline in the mortality and morbidity rates. Problems which remain unresolved in part relate to the aetiology and embryogenesis of oesophageal atresia, the management of long-gap atresia, and the treatment of gastro-oesophageal reflux and tracheomalacia. This article outlines the improvements in management which have occurred already and speculates about what the future may hold.

Serum levels of quinine following intramuscular administration to children.

The serum quinine level was assayed in 31 children four hours after receiving an intramuscular injection of quinine dihydrochloride; in 14 children the level was also assayed 2 hours after the injection. The quinine was quickly absorbed from muscle, with serum quinine levels being significantly higher at 2 hours than at 4 hours. The injections were not particularly painful, and muscle necrosis was not observed. Quinine is rapidly absorbed following intramuscular injection, and is a safe and reliable method of administering the drug to children with severe malaria. In most situations in Papua New Guinea (PNG), intramuscular administration of quinine is preferable to intravenous infusion.

Epidemiology of rotavirus diarrhea in the Highlands of Papua, New Guinea, in 1979, as revealed by electrophoresis of genome RNA.

Results of gel electrophoresis of rotavirus genome RNA from feces of children in two provinces in Papua, New Guinea, suggest that the epidemiology of rotavirus infection in small communities with a total population of 3,000 may differ from that in urban or closely settled rural areas.

Rotavirus infection in young children in the highlands of Papua New Guinea.

Rotavirus infections were detected by electron microscopy examinations in 54 of 66 children (82%) with acute gastroenteritis which necessitated admission to hospital during April to July, 1979, in the Highlands of Papua New Guinea. Longitudinal epidemiological studies may confirm rotavirus infections to be more important aetiolgical agents of childhood gastroenteritis in this region than in many other countries studied to date.