Characteristics of patients who die of necrotizing enterocolitis.

OBJECTIVE: Necrotizing enterocolitis (NEC) is associated with high morbidity and mortality among infants admitted for intensive care. The factors associated with mortality and catastrophic presentation remain poorly understood. Our objective was to describe the factors associated with mortality in infants with NEC and to quantify the degree to which catastrophic presentation contributes to mortality in infants with NEC. Catastrophic NEC was defined before data analysis as NEC that led to death within 7 days of diagnosis. STUDY DESIGN: We performed a retrospective review of the Pediatrix's Clinical Data Warehouse (1997 to 2009, n=560,227) to compare the demographic, therapeutic and outcome characteristics of infants who survived NEC vs those who died. Associations were tested by bivariate and multivariate analysis. RESULT: We compared the 5594 infants diagnosed with NEC and who were discharged home with 1505 infants diagnosed with NEC who died. In multivariate analysis, the factors associated with death (P<0.01 in analysis) were lower estimated gestational age, lower birth weight, treatment with assisted ventilation on the day of diagnosis of NEC, treatment with vasopressors at the time of diagnosis, and Black race. Patients who received only ampicillin and gentamicin on the day of diagnosis were less likely to die. Two-thirds of NEC deaths occurred quickly (<7 days from diagnosis), with a median time of death of one day from time of diagnosis. Infants who died within 7 days of diagnosis had a higher birth weight, more often were on vasopressors and high frequency ventilation at the time of diagnosis compared with patients who died at 7 or more days. Although mortality decreased with increasing gestational age, the proportion of deaths that occurred within 7 days was relatively consistent (65 to 75% of the patients who died) across all gestational ages. CONCLUSION: Mortality among infants who have NEC remains high and infants who die of NEC commonly (66%) die quickly. Most of the factors associated with mortality are related to immaturity, low birth weight and severity of illness.

Do relatives have a right to witness resuscitation?

A relative's right to witness resuscitation is the subject of considerable discussion and debate. This paper explores the presence of relatives in the resuscitation room from a moral and ethical perspective. The focus of discussion is essentially upon the principle of respect for autonomy vs. what appears to be the counter-argument, benevolent paternalism. It is concluded that recognition of a relative's right to witness resuscitation is dependent upon health care professionals' willingness to promote the principle of respect for autonomy.

Tibial length following intraosseous infusion: a prospective, radiographic analysis.

Intraosseous infusion is a well accepted means of obtaining emergency intravascular access in children. Despite the low incidence of serious complications from intraosseous infusions, the potential exists for growth plate injury and subsequent growth disturbance following intraosseous infusion. We conducted a prospective, blinded observational study of 10 subjects to evaluate tibial length discrepancy radiographically one year or more following intraosseous infusion. We found no significant difference in mean tibial length between the legs that had intraosseous infusions and the opposite legs, which served as controls. We conclude that intraosseous infusion does not appear to produce subsequent leg length discrepancy one year after infusion.

Long-term functional outcome of inpatient pediatric cardiopulmonary resuscitation.

OBJECTIVE: There is limited information published regarding the long-term outcome of pediatric survivors of inpatient cardiopulmonary resuscitation (CPR). The purpose of this study was to document the long-term (i.e., > or = 1 year after the arrest) functional outcome of children surviving inpatient CPR. METHODS: We reviewed the medical records of children (i.e., less than 18 years of age) receiving advanced CPR (i.e., chest compressions, assisted ventilation, and resuscitation medications) as inpatients in a tertiary care children's hospital. Prospective telephone follow-up of the survivors a minimum of one year after the arrest was performed. A change in the survivors' Pediatric Cerebral Performance Category (PCPC) scale was determined. RESULTS: Approximately half of the 92 subjects were diagnosed with sepsis syndrome. None (0/44) of the patients with sepsis syndrome survived at one year. None (0/24) of the patients who experienced a single episode of advanced CPR > or = 30 min in duration survived one year. Although 36% (33/92) of the patients resuscitated were alive 24 h after their arrest, the proportion surviving fell steadily to 10% (9/92) at one year. Although five of the nine survivors were moderately to severely disabled at one year, the majority (8/9) had little or no change in their PCPC score at one year compared to their prearrest level of function. CONCLUSION: Survival of inpatient pediatric CPR is small. Children surviving inpatient advanced CPR may have little or no change from prearrest function. The survival of hospitalized children with sepsis syndrome requiring CPR or receiving greater than > 30 min of advanced CPR is extremely low.

Tension pneumopericardium in an infant.

Pneumopericardium in newborns is most often a complication of mechanical ventilation and frequently results in fatal cardiac tamponade. We report the case of a mechanically ventilated 33-day-old full-term gestation infant with interstitial pneumonitis who developed tension pneumopericardium. Treatment includes lowering peak inspiratory pressure and decompressing the pericardial space with tube drainage following pericardiocentesis.

Physiological response of two soybean cultivars to simulated acid rain.

Simulated acid rain has been reported to cause physiological changes in various plant species. Studies were conducted in 1983, 1984, and 1985 to determine the effect, of acid rain on physiological parameters in two soybean [Glycine max (L.) Merr.] cultivars. Simulated acid rain of pH 3.0, 4.2 and 5.6 was applied throughout the growing season to plots protected from ambient rain and grown on a Flanagan silt loam (fine, montmorillonitic, mesic Aaquic Argiudoll). Individual plants were evaluated for CO2 fixation, leaf water potentials, and leaf chlorophyll content. Microplots were evaluated for flowering and podding patterns, and dry matter and N partitioning. Rain pH did not affect CO2 fixation, water potentials, chlorophyll content, seed yield, shoot dry weight, or N accumulation. At pH 4.2 Amsoy 71 produced fewer flowers and pods than at pH 3.0 or 5.6. Abscised leaf dry weight of Amsoy 71 was greater at pH 3.0 and 4.2 than at pH 5.6 pH effects were detected for N partitioning, but these responses were dependent on year and cultivar. No physiological basis for reported soybean yield responses to acid rain of pH 3.0 was identified.