Outcome and cost at a children's hospital following resuscitation for out-of-hospital cardiopulmonary arrest.

OBJECTIVE: To determine the outcome and cost for children resuscitated following out-of-hospital cardiopulmonary arrest. DESIGN: Retrospective case series. SETTING: An organized prehospital emergency medical system within Birmingham, Ala, in a county with 150,493 children under the age of 15 years. PATIENTS: Sixty-three pediatric victims of out-of-hospital cardiopulmonary arrest of any cause presenting to the emergency department of a children's hospital. INTERVENTION: Standard resuscitative techniques were performed for all patients until resuscitative efforts were discontinued in the hospital emergency department or successful resuscitation was achieved. MAIN OUTCOME MEASURES: Successful resuscitation, survival to hospital discharge, neurological outcome, final disposition, and cost of hospital care. RESULTS: Of 63 children with out-of-hospital cardiopulmonary arrest treated in the emergency department of a children's hospital, 60 were pulseless and apneic on arrival, 18 (28.6%) were successfully resuscitated and admitted to the intensive care unit, and six (9.5%) were discharged from the hospital. Five of the survivors had severe neurological deficits and one appeared normal. On follow-up, two patients had died (1 month and 7 months after discharge), three were in a vegetative state, and one was normal. The normal patient had successful defibrillation prior to arrival at the emergency department. The average inpatient charge was $10,667 per patient for those who died and $100,000 for those discharged. CONCLUSIONS: Aggressive treatment does not lead to intact survival for victims of out-of-hospital cardiopulmonary arrest who present to the pediatric emergency department with a preterminal rhythm and absence of spontaneous circulation. Resuscitation efforts in the emergency department are commonly successful but lead to death or severe neurological sequelae at discharge with extremely high cost of care.

Viral respiratory infections.

Viral infections constitute more than 60% of acute lower respiratory illnesses. Respiratory syncytial virus (RSV) and parainfluenza viruses are the most frequent etiologic agents. After transmission by large droplet aerosol or direct contact, the viruses gain entry into host cells through specific viral surface proteins; subsequently, pathogenetic mechanisms cause tissue injury and result in clinical disease. In the intensive care unit the mainstay of treatment is primarily supportive. Nonspecific treatment may include nebulized beta-agonists, aminophylline, and steroids. Ribavarin is the only specific antiviral agent approved for respiratory syncytial virus infection but its efficacy remains controversial. New therapies and vaccines offer hope for improved outcome from viral respiratory infections such as RSV.

A clinically applicable technique to study cytoskeletal dynamics in normal and abnormal polymorphonuclear leukocytes isolated from small volume blood samples.

Shape change and motility of polymorphonuclear leukocytes (PMNs) are essential for host defense and require dynamic reorganizations of microfilamentous cytoskeleton by reversible polymerization of G-actin into filaments (F-actin). Although clinical disorders of actin polymerization are rare, recently described simple methodologies for assaying actin dynamics in PMNs make the technique readily applicable to clinical studies. To develop a clinically useful F-actin assay, the authors investigated the optimal preparation conditions for PMN isolation that resulted in the least in vitro cytoskeletal activation and evaluated the variability in actin dynamics in acutely and chronically infected patients. Basal and chemotactic factor-activated PMN F-actin content was measured by a previously described flow cytometric technique in fixed, permeabilized, NBDphallacidin-stained PMNs isolated by centrifugation in Percoll or Ficoll-Hypaque density gradients or by countercurrent elutriation. F-actin content is expressed as mean fluorescent channel or relative fluorescence intensity. Basal F-actin in PMNs prepared from countercurrent elutriation (mean fluorescent channel = 79.0 +/- 4.5, n = 6) or by Ficoll Hypaque (82.0 +/- 3.5, n = 4) was significantly higher than endotoxin free, Percoll purified PMNs, whether purified in bulk (56.1 +/- 7.9, n = 8) or by the small volume modification applicable to clinical studies (53.3 +/- 8.7, n = 15). Basal Ficoll Hypaque purified PMNs have evidence of shape change, whereas endotoxin free, Percoll purified PMNs are smooth and round and represent the most basal cell equivalent in F-actin content to a circulating PMN.(ABSTRACT TRUNCATED AT 250 WORDS)

Measured energy expenditure in pediatric intensive care patients.

Few data are available on energy requirements of mechanically ventilated, critically ill children. We measured the resting energy expenditure in 18 mechanically ventilated patients between ages 2 and 18 years, using indirect calorimetry. All patients had fractional inspired oxygen concentration less than 0.6, no spontaneous respirations, hemodynamic stability, and no fever or active infection, and were receiving 5% dextrose. All subjects were hypermetabolic, since the measured resting energy expenditure divided by the predicted basal energy expenditure from the Harris-Benedict equations was 1.48 +/- 0.09 (mean +/- SEM). The energy requirements calculated using "injury factors" and "activity factors" adapted for adults is 1.62 times basal energy expenditure. The injury factor for the pediatric multiple trauma patients should be 1.25 compared with 1.35 in adults. In these pediatric intensive care patients 33% +/- 8% of the energy is derived from carbohydrates, 53% +/- 8% from fat, and 14% +/- 2% from protein oxidation. In individual critically ill pediatric patients, energy requirements should be estimated by measuring their resting energy expenditure whenever possible and adding 5% for their activity. In the absence of the actual measurement of resting energy expenditure, the recommended energy requirement is 1.5 times basal energy expenditure. In this acute phase of injury, the daily nitrogen requirement is 250 mg per kilogram of body weight.

Hydrostatic pressure-induced colon trauma from a pool whip.

Hydrostatic pressure-induced colon injury is a rare occurrence in the pediatric population. We present a case of massive hydroperitoneum following a pool whip-induced injury. Although tension pneumoperitoneum or hydroperitoneum is rare, prompt recognition and surgical intervention are essential.

Local cerebral blood flow as assessed by xenon stable computed tomography in child drowning.

A comatose patient who nearly drowned was studied with xenon stable computed tomography (CT) to assess regional cerebral blood flow (rCBF) after a basic CT studied revealed bilateral lucencies in the basal ganglia. Xenon stable CT revealed increased rCBF in the lucent areas of the basal ganglia and previously unsuspected absence of flow in the posterior circulation. Xenon stable CT may be a more sensitive indicator of ischemic cerebral damage than basic CT.

Comparison of piperacillin alone versus piperacillin plus tobramycin for treatment of respiratory infections in children with cystic fibrosis.

Seventeen patients with cystic fibrosis (CF) and pulmonary exacerbations were randomly assigned to two treatment groups: piperacillin 600 mg/kg/day (P), and piperacillin 600 mg/kg/day plus tobramycin (PT), in order to determine the safety and pharmacokinetics of high-dose piperacillin and whether piperacillin alone was effective for the treatment of Pseudomonas infections. The mean half-life of piperacillin was 0.54 hours, with a peak concentration of 232 micrograms/ml. No differences between P and PT groups were noted in clinical assessment, as judged by Shwachman scores, pulmonary function testing, or weight gain. However, during the course of treatment, quantitative sputum cultures decreased by greater than 10(2) colony-forming units in only 5 out of 19 Pseudomonas isolates from the P group, compared with 12 of 19 isolates from the PT group (P less than 0.03, Chi-square). Although emergence of resistance was not seen, one isolate had an increase in minimum inhibitory concentration from 8 to 128 micrograms/ml. There were no serious adverse reactions to piperacillin; only one patient developed fever possibly related to piperacillin. Therapy with high-dose piperacillin was safe in children with CF. Treatment with piperacillin alone was less effective than combination therapy with gentamicin for reduction in titer of Pseudomonas in sputum. However, the role of antimicrobial agents in the treatment of CF remains undefined. A double-blind placebo-controlled trial is indicated.

Effects of OKY 1581 on bronchoconstrictor responses to arachidonic acid and PGH2.

The influence of OKY 1581, a thromboxane synthase inhibitor, on airway responses to arachidonic acid and endoperoxide, [prostaglandin (PG) H2], were investigated in anesthetized, paralyzed, mechanically ventilated cats. Intravenous injections of arachidonic acid and PGH2 caused dose-related increases in transpulmonary pressure and lung resistance and decreases in dynamic and static compliance. OKY 1581 significantly decreased airway responses to arachidonic acid but not to PGH2. Sodium meclofenamate, a cyclooxygenase inhibitor, abolished airway responses to arachidonic acid but had no effect on airway responses to PGH2. OKY 1581 or meclofenamate has no effect on airway responses to PGF2 alpha, PGD2, or U 46619, a thromboxane mimic. In microsomal fractions from the lung, OKY 1581 inhibited thromboxane formation without decreasing prostacyclin synthesis or cyclooxygenase activity. These studies show that OKY 1581 is a selective thromboxane synthesis inhibitor in the cat lung and suggest that a substantial part of the bronchoconstrictor response to arachidonic acid is due to thromboxane A2 formation. Moreover, the present data suggest that airway responses to endogenously released and exogenous PGH2 are mediated differently and that a significant part of the response to exogenous PGH2 may be due to activation of an endoperoxide/thromboxane receptor, since responses to PGH2 are blocked by the thromboxane receptor antagonist SQ 29548.

Prolonged use of high-frequency jet ventilation for a pediatric patient.

A 10-yr-old boy who developed postoperative respiratory failure with evidence of significant barotrauma was treated with high-frequency jet ventilation (HFJV). HFJV reduced peak inflation pressure, enhanced oxygenation, and improved ventilation. The patient could not be weaned from HFJV by decreasing drive pressure. Instead, he was successfully weaned by decreasing the HFJV rate to 80 cycle/min and then switching to conventional intermittent mandatory ventilation at initially similar rate and pressure levels.

Cutaneous necrosis associated with intravenous nafcillin therapy.

Four children had cutaneous necrosis associated with the administration of intravenous (IV) nafcillin sodium therapy. One patient required skin grafting. Hospitalization was prolonged with this patient and with one other in an effort to ensure healing. Adult rats, inoculated subcutaneously with nafcillin that was appropriately diluted according to manufacturer's recommendations, exhibited similar lesions. Oxacillin sodium, methicillin sodium, and cephalothin sodium, similarly diluted, did not necrose skin. Nafcillin should be added to the list of agents that produce similar toxic conditions. Frequent observation of the IV infusion site to detect extravasation may obviate this hazard.