Adult respiratory distress syndrome.
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Adult↗
Biomedical subjects
D H Fiser
Publications and source records attributed to D H Fiser.
Behavioral changes in pediatric intensive care units.
OBJECTIVE: The purposes of this study were to compare the frequency and severity of manifestations of anxiety, depression, delirium, and withdrawal in pediatric patients hospitalized in intensive care unit vs ward settings and to evaluate the impact of preexisting psychopathologic disorders on the expression of these symptoms. RESEARCH DESIGN: Prospective patient series. SETTING: Tertiary care pediatric center. PATIENTS: Forty-three subjects aged 6 to 17 years hospitalized in either the pediatric or cardiovascular intensive care unit (n = 18) or on the general wards (n = 25) were recruited to participate. Subjects were excluded if their parents were unavailable for diagnostic interview or if they could not answer interview questions themselves. SELECTION PROCEDURES: Consecutive sample. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The Hospital Observed Behavior Scale, developed for this study, was used to describe objectively subjects' manifestations of anxiety, depression, delirium, and withdrawal. The Diagnostic Interview for Children and Adolescents and Diagnostic Interview for Children and Adolescents-Parents were used to determine the presence of preexisting psychopathologic disorders. As measured by the Hospital Observed Behavior Scale, subjects in the intensive care unit exhibited apprehension, anxiety, detachment, sadness, and weeping more often than did patients in the ward. Behavior was also significantly influenced by severity of illness, duration of hospitalization, number of previous hospitalizations, and presence of a preexisting anxiety or mood disorder. We found the Hospital Observed Behavior Scale to have good interrater reliability. CONCLUSIONS: Our data indicate that critically ill children in the intensive care unit, children with prolonged or repeated hospitalizations, and children with preexisting anxiety and mood disorders are at greater risk than other hospitalized pediatric patients for psychological trauma and/or behavior problems that may warrant psychiatric intervention. The Hospital Observed Behavior Scale is a reliable tool to quantitate behaviors in hospitalized children.
Adolescent↗
Assessing the outcome of pediatric intensive care.
To describe the short-term outcome of pediatric intensive care by quantifying overall functional morbidity and cognitive impairment, I developed the Pediatric Overall Performance Category (POPC) and the Pediatric Cerebral Performance Category (PCPC) scales, respectively. A total of 1469 subjects (1539 admissions) were admitted to the pediatric intensive care unit of Arkansas Children's Hospital from July 1989 through December 1990. Patients were assigned baseline POPC and PCPC scores derived from historical information and discharge scores at the time of discharge from the hospital (or from the pediatric intensive care unit for patients with multiple hospitalizations). Delta scores were calculated as the difference between the discharge scores and the baseline scores. The changes in POPC and PCPC scores were associated with several measures of morbidity (length of stay in the pediatric intensive care unit, total hospital charges, and discharge care needs) and with severity of illness (pediatric risk of mortality score) or severity of injury (pediatric trauma score) (p less than 0.0001). Interrater reliability was excellent (r = 0.88 to 0.96; p less than 0.001). The POPC and PCPC scales are apparently reliable and valid tools for assessing the outcome of pediatric intensive care.
Activities of Daily Living↗
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.
Humans↗
Communication, decision making, and perception of nursing roles in a pediatric intensive care unit.
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Adult↗
Phenytoin protein binding in pediatric patients with acute traumatic injury.
Phenytoin (DPH) is commonly used to treat seizures associated with acute head injury. Consequent to decreases in DPH protein binding in such patients, the DPH free fraction (DPHff) may increase and thereby produce symptoms compatible with DPH toxicity despite the presence of total serum concentrations within the usually accepted therapeutic range. We examined the effect of acute traumatic injury on DPH protein binding in 13 hospitalized pediatric patients. In addition to total and free DPH serum concentrations, biochemical variables including blood pH, total and direct bilirubin, serum urea nitrogen, creatinine, albumin, gamma glutamyltransferase (GGT), and free fatty acid concentrations were measured serially over 10 days. The DPHff was compared between selected time intervals in hospitalized patients and data obtained in a control population of 27 epileptic outpatients who were maintained on DPH. Additionally, a multiple regression model was used to examine for covariance between the DPHff and the respective biochemical variables in the hospitalized patients. In the study patients, the DPHff progressively increased, attaining a maximum value (8.5 +/- 0.7%) on the fifth hospital day which was significantly greater (6.4 +/- 0.7%, p less than .05) than that on day 1 and also in the control group (6.1 +/- 0.3%; p less than .01). Blood pH, serum albumin, free fatty acids, creatinine and bilirubin concentrations did not change, but GGT did increase significantly over the 10-day sampling period. A significant (r = .51, p less than .0001) linear relationship was found between the DPHff and the serum albumin concentration.(ABSTRACT TRUNCATED AT 250 WORDS)
Acute Disease↗
Critical care for clonidine poisoning in toddlers.
Clonidine may be a source of serious toxicity when ingested by toddlers. We describe 11 cases of clonidine ingestion by toddlers (mean dose 0.15 mg/kg; range 0.01 to 0.57). The source of the clonidine was a grand-parent in six of 11 cases. Symptoms included altered level of consciousness (n = 11), miosis (n = 5), bradycardia (n = 8), hypotension (n = 5), apnea and respiratory depression (n = 6), hypothermia (n = 5) and hypertension (n = 3). Therapeutic interventions included naloxone (n = 8) and atropine (n = 4), dopamine (n = 1), fluid resuscitation (n = 4), and endotracheal intubation (n = 1). There were no deaths. Symptoms of clonidine ingestion were typically mild if the dose ingested was less than 0.01 mg/kg, while bradycardia and hypotension occurred usually with doses of greater than 0.01 mg/kg. Apnea and respiratory depression were common when the dose exceeded 0.02 mg/kg. More effective measures are needed to prevent these potentially serious intoxications.
Atropine↗
Septic shock in children: bacterial etiologies and temporal relationships.
In a retrospective analysis of 2110 admissions to the pediatric intensive care unit, 564 cases of septic shock were identified (26.7% of the total admissions). Septic shock was defined in patients with: (1) clinical evidence of sepsis; (2) fever (greater than 38.3 degrees C) or hypothermia (less than 35.6 degrees C); (3) tachycardia; (4) tachypnea; and (5) inadequate organ perfusion. Inadequate perfusion was defined as hypotension or evidence of peripheral hypoperfusion (poor capillary refill or cyanosis with hypoxemia, oliguria, acidosis or altered mentation). Inotropic support was required to maintain an adequate blood pressure and perfusion in 268 of 564 patients (47.5%). Septic shock with confirmed bacterial infection occurred in 143 patients (143 of 564, 25.2%); these cases were caused by Haemophilus influenzae, type b (59 of 143, 41.3%), Neisseria meningitidis (26 of 143, 18.2%) and Streptococcus pneumoniae (16 of 143, 11.2%). Eight of 564 (1.4%) cases of septic shock were not clinically apparent on initial evaluation and were diagnosed within 24 hours after admission to the hospital. We conclude that septic shock occurs more frequently in children than previously appreciated and may develop after admission to the hospital.
Adolescent↗
Adoption of intraosseous infusion technique for prehospital pediatric emergency care.
A telephone survey was conducted, contacting 51 designated state EMS offices, to determine the extent of use of intraosseous (IO) infusions in prehospital pediatric emergency care nationally and to identify common means of promoting IO adoption, training EMS personnel, and monitoring intraosseous field use. Less than half of the respondents reported actual prehospital use of IO infusions in pediatric patients, and an additional third indicated that they were unaware of any future plans for introducing the technique into EMS practice. This study's documentation of the current limited prehospital use of intraosseous infusions indicates a need for concerted efforts to promote broad adoption and continued evaluation of the IO technique in prehospital pediatric emergency care. Suggestions to enhance adoption include increased utilization of existing successful IO teaching approaches, development of national EMS standards regarding intraosseous infusions, active involvement of EMS regulatory agencies for widespread practice changes, and consistent quality assurance activities.
Bone and Bones↗
Sleep-associated breathing disorders in morbidly obese children and adolescents.
Forty-one children and adolescents with a history of breathing difficulty during sleep and morbid obesity, defined as greater than 150% ideal body weight, underwent polysomnography to determine the incidence of sleep-associated breathing disorders. Seventeen patients also performed pulmonary function testing. The mean patient age was 10.3 +/- 4.4 (SD) years, and mean percent of ideal body weight was 208 +/- 42.2. A sleep history questionnaire showed that all patients snored, but frank apnea was reported in only 32%. The pulmonary function tests showed 18% (3/17) with a restrictive defect and 47% (8/17) with obstructive changes. The polysomnograms in 37% (15/41) of the patients were abnormal because of apnea, hypopnea, excessive arousals, or abnormalities in gas exchange. Multiple regression analysis demonstrated no significant association between weight, age, or gender and any physiologic measure on the polysomnogram. Most of the abnormal polysomnograms (13/15) were mildly abnormal, but two showed sufficiently severe abnormalities to require clinical intervention. We conclude that children and adolescents with morbid obesity are at risk for sleep-associated breathing disorders; their polysomnographic abnormalities are usually mild but rarely may be severe enough to require clinical intervention.
Adolescent↗
Cardiovascular and renal effects of dopamine and dobutamine in healthy, conscious piglets.
The pharmacologic effects of dopamine and dobutamine (2 to 32 micrograms/kg.min) were evaluated in 12 1 to 2-month-old piglets. Dopamine increased cardiac output at 16 to 32 micrograms/kg.min (p less than .05) and increased heart rate (HR) at 4 to 32 micrograms/kg.min (p less than .05). Dobutamine produced an increased cardiac output at doses of 16 to 32 micrograms/kg.min (p less than .05), and increased HR at 32 micrograms/kg.min (p less than .05), decreased systemic arterial pressure and systemic vascular resistance at 16 to 32 micrograms/kg.min (p less than .05), decreased renal vascular resistance at 16 to 32 micrograms/kg.min, and increased renal blood flow at 4.8 and 32 micrograms/kg.min (p less than .05). We conclude that dopamine and dobutamine increase cardiac output in healthy, conscious piglets primarily by increasing HR. Neither agent was effective in increasing stroke volume, although a positive inotropic effect obscured by tachycardia cannot be ruled out. Dobutamine was the superior agent for renal vasodilation, whereas neither agent produced significant pulmonary vasodilation.
Animals↗
Metoclopramide-induced methemoglobinemia.
The case of a 3-week-old male infant is described. After receiving an iatrogenic overdose of metoclopramide (1.0 mg/kg every six hours) throughout a 36-hour period for the treatment of suspected gastroesophageal reflux, he became cyanotic, lethargic, and irritable, he fed poorly, and he had diarrhea and respiratory distress. Methemoglobinemia (20.5%) and reduced oxyhemoglobin saturation (79%) were identified. The patient had an excellent clinical response following a single IV dose of methylene blue. Subsequently, methemoglobin reductase activity was normal and there was no measurable hemoglobin M. The diagnosis of methemoglobinemia should be considered in any infant receiving large doses of metoclopramide who has clinical findings of cyanosis, ashen color, or a history of lethargy and/or motor restlessness.
Gastroesophageal Reflux↗
Diabetes insipidus in children with brain death.
Central diabetes insipidus (DI) occurs in patients suffering from overwhelming CNS injuries leading to brain death. The purpose of this study was to describe the clinical presentation of DI in children with brain death. The medical records of 34 patients with a diagnosis of brain death were reviewed. Diuresis was present in 76% of patients; however, DI was only present in 38% of patients. On autopsy, the pituitary gland in six patients revealed varying degrees of edema, congestion, hemorrhage, and coagulative necrosis. We concluded that DI is present in many, but not all, patients who experience brain death and therefore, cannot be relied on solely as a marker of brain death.
Adolescent↗
Outcome of cardiopulmonary resuscitation in children.
A study was undertaken in order to identify factors correlated with the outcome of pediatric cardiopulmonary resuscitation (CPR). A total of 35 children who experienced a total of 41 cardiopulmonary arrests were included. Sixteen of 41 patients (39%) could not be resuscitated; 16/41 (39%) were resuscitated temporarily but did not survive to discharge; 9/41 (22%) survived to discharge. Patients arresting outside the hospital who received early basic CPR at the scene were significantly more likely to be resuscitated, at least temporarily, than those who did not (8/8 vs 5/11; P = 0.02). A statistically significant difference in outcome was also demonstrated between patients with an initial arterial blood pH greater than 7.0 and those with an initial arterial blood pH less than 7.0 (P less than 0.05). We conclude that an initial arterial blood pH less than 7.0 predicts a poor outcome from cardiopulmonary arrest in children. Access to early basic CPR may improve the initial pH and the ability of the patient to be resuscitated.
Adolescent↗
Water intoxication and death associated with the use of posterior pituitary injection for surgical hemostasis.
Posterior pituitary injection is an extract prepared from the dried posterior lobe of the pituitary gland from domestic animals containing two octapeptide hormones, oxytocin and vasopressin. Posterior pituitary injection carries an approved therapeutic indication as an adjunct measure for achieving surgical hemostasis. We report a case of cerebral edema and death attributed to water intoxication in a child who had received a large volume of free water concurrent with posterior pituitary injection to control bleeding after tonsillectomy and adenoidectomy.
Adenoidectomy↗
Family acceptance of home apnea monitors.
Home monitoring for apnea patients has been called a stressful situation for family members. A 28-item questionnaire was used to ascertain the impact of home monitoring on the families of children with infantile apnea. Forty of 71 families returned the questionnaire. The majority of respondents felt the stress of home monitoring to be minimal (42.5%) to moderate (37.5%). All respondents favored home monitoring with 80% of parents reporting that the monitor had alerted them to at least one significant apnea or bradycardia episode during the first month of use. Half of parents reported more than five significant alarms in the first month of use. Financial hardship on the family was reported to be minimal. A few parents related significant strain on marital and other sibling-parent relationships. Concerns most commonly voiced were mechanical problems (70%), difficulty in locating qualified and willing babysitters (62.5%), and desire for more concrete information from the physician regarding the child's medical problem (40.0%). These results confirm good acceptance of home monitors by the family and offer direction in dealing with the families' primary concerns.
Family↗
Catheters for arterial pressure monitoring in pediatrics.
To evaluate the accuracy of an underdamped catheter transducer recorder used to measure arterial blood pressure, natural frequency and damping ratio were determined by transient testing with two types of 22-ga and 24-ga catheters. Damping coefficients were considerably higher and resonant frequencies lower with the 24-ga catheters. The difference between waveforms of known pressure and HR and the output waveforms produced by the catheter transducer systems was determined by using a BP systems calibrator. Catheter size did not affect the difference in recorded pressures.
Blood Pressure Determination↗