Chylothorax: a novel therapy.

OBJECTIVE: To report a novel therapy for chylothorax. DESIGN: Case report. PATIENT: Severely ill neonate with congestive heart failure and high surgical risk. INTERVENTIONS: Standard therapy for chylous effusion with the addition of pressure control ventilation and positive end-expiratory pressure (high mean airway pressure). RESULTS: Rapid resolution of effusion with elimination of excessive fluid needs and correction of coagulation profile. CONCLUSION: Increasing mean airway pressure by pressure control ventilation and positive end-expiratory pressure should be considered as a therapeutic intervention in patients with persistent chylous effusions.

Revisiting epiglottitis: a protocol--the value of lateral neck radiographs.

A retrospective review was done on the medical records (March 1986 through December 1989) of patients referred to Pittsburgh Children's Hospital with the presumptive diagnosis of epiglottitis. Data obtained included age, final diagnosis, referring physician's radiographic evaluation/interpretation, procedures (intubation, IV administered, aerosol, cultures obtained), transport times, and long-term morbidity and mortality. The diagnostic value of lateral neck radiographs was analyzed. Lateral neck radiographs were found to be of little value in the primary evaluation of epiglottitis. Rather, skilled personnel, using an established protocol, did limit morbidity and mortality in patients with symptoms consistent with epiglottitis. All medical centers should develop a protocol for management of patients presenting with symptoms suggestive of epiglottitis.

Protamine and acute depletion of magnesium limit bone response to parathyroid hormone.

The effect of protamine on calcium homeostasis was studied in nine pediatric patients undergoing cardiopulmonary bypass. Total serum calcium decreased from 8.44 mg/dL to 7.49 mg/dL (P < 0.05) after protamine. Ionized calcium decreased from 1.39 to 1.31 mmol/L (P < 0.05). A bioassay determined the etiology of this response. Bone disks were placed in sera, protamine, parathyroid hormone, parathyroid hormone antibody, or magnesium-depleted solutions, then were incubated in solutions with known calcium content. The change in the media's calcium concentration reflects the bone's response to the initial stimulus. Calcium change is expressed as Experimental delta/Control delta (E/C). Normal bone responds to parathyroid hormone, E/C = 0.59 (P < 0.001). Protamine-treated bone loses this response, E/C = 0.9 (P = not significant [NS]). A parathyroid-hormone-induced osteoblast messenger was found. Protamine-treated bone continued to respond to this messenger, E/C = 0.42 (P < 0.001). Bone showed reversible loss of response to parathyroid hormone after incubation in magnesium-free solution, E/C = 0.93 (P = NS). With reincubation in magnesium, E/C = 0.69 (P < 0.01). Since protamine blocks parathyroid receptors, and magnesium depletion limits the bone's response to parathyroid hormone, this may explain the persistent hypocalcemia seen in some patients undergoing cardiopulmonary bypass.