Ruptured cerebral aneurysm in the early stage of life--a congenital origin?

We report the case of a large fusiform aneurysm of the anterior cerebral artery in a 3-month-old girl presenting with generalized seizures and complicated by a cardiorespiratory arrest needing resuscitation. The native cerebral CT scan revealed a diffuse subarachnoid hemorrhage (Fischer III grade); CT angiography showed an aneurysm of the distal A1 segment of the anterior cerebral artery (ACA). Successful treatment was achieved through surgical trapping of the aneurysm and sacrifice of the distal A1 segment. A histological study of the aneurysmal wall revealed the absence of elastic fibers in an otherwise fibromuscular media and showed no signs of previous hemorrhage. Intracranial aneurysms of the ACA are very rare in the early stage of life and their pathogenesis is not clear. This case is of interest as the location and shape of the aneurysm, the absence of relevant familial and medical history, and the histopathological findings raise the hypothesis of a congenital origin. It further describes the value of CT angiography for studying aneurysms in the very young.

Resuscitation, anaesthesia and analgesia of the burned patient.

Burns resuscitation has evolved over the past few decades towards more evidence-based management. It has been shown that patients with major burns (i.e. involving more than 30% of the body surface) benefit from invasive monitoring, and physiological variable targeted resuscitation using vasoactive agents for cardiovascular support. The invasive approach results in a reduction of mortality rates. Since the introduction of the Parkland formula in 1968, there has been a trend towards the administration of fluid resuscitation far in excess of the volume predicted with this formula. This has led to an increase in complication rates, with more pulmonary oedema, and the appearance of abdominal compartment syndrome. Hypertonic saline solutions, whether with dextran or not, have shown no advantage over the classic Ringer's lactate solution. The colloid controversy has reached burns resuscitation, with the demonstration that the liberal use of albumin is associated with higher mortality rates. Fresh frozen plasma should only be used for specific coagulation disorders. On the other hand, artificial colloids, particularly gelatine, remain a useful tool in patients with major burns and haemodynamic instability, particularly, and can be given as early as 6 h after injury. Considering the actual evidence, using inotropes and vasopressors to reach supranormal haemodynamic endpoints seems preferable to delivering unrestricted amounts of fluid.

Management of paediatric patients undergoing diagnostic and invasive cardiology procedures.

Since diagnostic cardiac catheterization in children with congenital heart disease was first reported in 1947, echocardiography has been used as a non-invasive diagnostic tool in congenital heart disease, resulting in a decrease in diagnostic cardiac catheterizations. However, the total number of cardiac catheterizations remained at a steady level until the mid-1980s and has since increased progressively. This is a result of the introduction of interventional transcatheter techniques to improve or correct congenital heart malformations. Since the first description of balloon atrial septostomy, the range of indications for such techniques has steadily increased, particularly in the past 15 years. 'Deep' sedation or general anaesthesia is essential for the conduct of cardiac catheterization in children, particularly in the younger age group.

Tracheal gas insufflation reduces requirements for mechanical ventilation in a rabbit model of respiratory distress syndrome.

Tracheal gas insufflation is known to lower PaCO2 in larger animal models of respiratory distress syndrome, but its ability to reduce the ventilator pressures and tidal volume needed to achieve an acceptable PaCO2 has not been examined in small animals using modes of ventilation employed in neonatal intensive care. In this study, the effect of insufflating humidified gas into the lower trachea was examined in a saline lung lavage model of respiratory distress syndrome in rabbits, while the peak airway pressure during conventional pressure-limited ventilation was adjusted to keep the PaCO2 approximately constant. Tracheal gas insufflation significantly reduced the peak airway pressure required and reduced the delivered tidal volume but did not affect the AaDO2. The effects were more marked at a ventilator rate of 30 breaths per minute than at 60 bpm and more during continuous insufflation than when gas was insufflated only during expiration. These results suggest that tracheal gas insufflation may reduce the risk of ventilation-induced lung disease in the newborn.