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Biomedical subjects

I D Todres

Publications and source records attributed to I D Todres.

At least 55 records · Page 3Linked to original sources
PubMed1979

Coping with poor prognosis in the pediatric intensive care unit. The Cassandra prophecy.

The intensive-care pediatrician who prophesies to parents that their child's illness is irreversible may encounter denial and hostility. The physician may compare his plight to that of Cassandra--the mythical Greek prophetess of doom, who was cursed to see into the future and not be believed. Four cases are reported in which parents rejected their child's hopeless prognosis, counterprophesied miraculous cures, resolved to obtain exorcism, criticized the care, or accused nurses of neglect. This produced a painful breakdown in the usually harmonious relationships between doctors, nurses, and parents. Parental denial as a coping mechanism is discussed. Guidelines are presented for the prevention and/or early recognition and management of the Cassandra Prophecy phenomenon. A miraculous recovery in one case is a potent reminder to physicians and nurses that they do not have the gift of divine prophecy and cannot see with certainty into the future.

Adaptation, Psychological↗
PubMed1979

Swan-Ganz catheterization in the critically ill newborn.

The authors placed Swan-Ganz catheters in 11 preterm and 2 term infants with severe cardiopulmonary distress. The infants ranged in weight from 1100-4000 g. The procedure was performed in the neonatal ICU by jugular venous cutdown. Intracardiac pressures and oxygen saturations were measured in each chamber entered. The authors also evaluated the presence of right to left shunting through the patent ductus arteriosus and assessed the degree of pulmonary arterial hypertension. In 5 hypoxemic infants, the authors found a patent ductus arteriosus with pulmonary hypertension. Intermittent measurement of PAP served as a guide to further therapy. In 2 infants, the unexpected diagnosis of cyanotic congenital heart disease was made. The placement of flow directed pulmonary arterial catheters in critically ill infants can be performed safely at the bedside and can provide useful diagnostic and therapeutic information.

Blood Gas Analysis↗
PubMed1979

Neurologic sequelae in the survivors of neonatal intraventricular hemorrhage.

We report our experience with the neurologic sequelae (at a mean follow-up of 24 months) among the 15 surviving infants who have had neonatal intraventricular hemorrhage (IVH) documented by computerized tomographic (CT) brain scan. Neurologically six infants (40%) are normal, six infants (40%) mildly impaired, and three infants (20%) moderate to severely impaired. The neurologic outcome correlated to the degree of hemorrhage seen in the CT scans when IVH was classified into four grades. None of the other neonatal factors examined showed significant correlation with the outcome.

Cerebral Hemorrhage↗
PubMed1978

Inappropriate antidiuretic hormone secretion in premature infants with cerebral injury.

We describe 11 premature infants with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The syndrome is far more common than the single case report in the literature would indicate. All the infants had either asphyxiation at birth, intracranial hemorrhage, or meningitis. Of the nine children available for follow-up observation, seven demonstrated serious neurological sequelae. The diagnosis of SIADH in the premature neonate may be difficult to establish due to the complexity of precipitating factors.

Brain Diseases↗
PubMed1978

Monitoring occlusion and accidental extubation of tracheostomy tubes in children.

Twelve infants and children with tracheostomies have been monitored for occlusion or accidental extubation in hospital and at home using a thermistor-electronic monitor. The patients ranged from 1 month to 6 years of age and have been monitored for 1 to 16 months. The device sounds an alarm when it fails to sense the warming of air on expiration. It is electrically safe, simple to operate and has been well accepted by parents. The thermistor-monitor has permitted the psychologic and economic advantages of earlier hospital discharge especially for the smaller infants. In two infants, and on three occasions in one, use of the device was life-saving. The device is applicable for use in patients of any age, with endotracheal or tracheostomy tubes.

Child, Preschool↗
PubMed1977

Evaluation of neonatal intracranial hemorrhage by computerized tomography.

Computerized tomographic (CT) brain scan was performed on 28 infants with unexplained cardiorespiratory and neurologic deterioration and bloody lumbar cerebrospinal spinal fluid. Fourteen of 20 with intraventricular hemorrhage (IVH) died; the six infants with lesser degrees of IVH survived. Significant subarachnoid hemorrhage (SAH) was demonstrable in three infants and three had negative scans despite bloody CSF. We have found that CT scans provide useful information about the size and extent of neonatal IVH and distinguished it from SAH. It also confirms the diagnosis of post-hemorrhagic hydrocephalus in these infants. Continued use of the CT scan will help us to understand the natural history and the effects of neonatal intracranial hemorrhage among the survivors of intensive care.

Cerebral Hemorrhage↗
PubMed1977

Infantile lobar hyperinflation: expectant treatment.

Arterial blood gases and regional lung function, measured with a 133xenon technique, were used to evalute the physiological defects and follow the natural history of 16 infants with lobar hyperinflation ("emphysema"). Hypoxemia was due to V/Q inequality at rest. Worsening of hypoxemia (mean Pao2 delta--26 mm Hg) with crying was due to shunting as a consequence of cessation of ventilation in the involved lobe. Surgery was necessary in three patients. Two deaths were caused by bronchopulmonary dysplasia after respiratory distress syndrome (RDS). In 12 of 14 infants, lung function was normal between the ages of 5 days and 1 year. Pediatrics, 59:1012-1018, 1977, LOBAR EMPHYSEMA, BLOOD GASES, REGIONAL LUNG FUNCTION.

Blood Gas Analysis↗
PubMed1977

Pulmonary edema associated with croup and epiglottitis.

Two children, ages 9 and 2 1/2 years, with clinical diagnoses of laryngotracheitis (croup) and epiglottis, respectively, developed florid pulmonary edema without evidence of cardiac enlargement. Both children responded to vigorous therapy, which included endotracheal intubation, mechanical ventilation with high oxygen concentrations and positive end expiratory pressure, diuretics, and support of the intravascular volume with colloid infusions. Swan-Ganz catheterization was performed in the child with epiglottitis to elucidate any hemodynamic malfunction. Pulmonary artery occluded pressure was found to be normal. We postulate that pulmonary edema may be the result of any of three major physiologic alterations: alveolar hypoxia, increased alveolar-capillary transmural pressure gradient, and a catechol-mediated shift of blood volume from the systemic to the pulmonary circulation. These alterations acting in concert would increase the volume of blood presented to the pulmonary capillaries, the pore size in those capillaries, and the hydrostatic pressure gradient promoting transduation. Failure of pulmonary lymphatics to effectively clear this fluid would result in pulmonary edema. Although pulmonary edema associated with acute upper airway obstruction is unusual, physicians should be altered to its possible appearance and the need for early and vigorous therapeutic measures.

Airway Obstruction↗
PubMed1977

Pediatricians' attitudes affecting decision-making in defective newborns.

A questionnaire designed to identify the factors that influence the resolution of ethical dilemmas was returned by 230 (57% of the total) Massachusetts pediatricians. The decision to recommend surgery for an infant with Down's syndrome with duodenal atresia when the parents had refused surgery was influenced by religious affiliation (P less than .01), religious activity (P less than .04), and sex (P=.05). Of those favoring surgery, 40.2% would pursue a court order. The decision to recommend surgery for an infant with severe meningomyelocele when the parents' position was not stated was influenced by age (P less than .01), religious activity (P less than .02), and specialization (P less than .008). When the parents' wishes were expressed, the majority of the pediatricians modified their decision in accord with these wishes. In response to general ethical questions, 79.6% of all pediatricians thought that parents should have the right to withold consent for surgery. Equal numbers thought that psychosocial reasons justified witholding lifesaving procedures. Among a variety of factors, they thought that willingness of the parents to care for the child would influence the decision to take heroic measures. There were 90.4% who thought that ethics should be part of medical education; 55.7% indicated this need throughout their careers.

Adult↗
PubMed1976

Central hypoventilation during quiet sleep in two infants.

Expired ventilation (VE), tidal volume (VT), frequency (f), and alveolar PCO2 (PACO2) were examined in six normal infants at 41 to 52 weeks post-conceptional age and in two infants who were apneic at birth. Their response to breathing 5% carbon dioxide in air and to 100% oxygen in quiet sleep were compared to those in rapid eye movement (REM) sleep. VE in normal infants was 259 ml/kg/min in REM and 200.2 ml/kg/min in quiet sleep with the difference being due to decreased carbon dioxide production and to decreased dead space. VE increased 34.4 ml/kg/min/mm Hg of PCO2 elevation with 5% carbon dioxide breathing during REM and was not significantly different during quiet sleep. During oxygen breathing VE fell by 32.7% at 30 seconds before increasing again. In the affected infants, VE and PACO2 during REM at 1 and 4 months were normal. At 1 month, during quiet sleep, each infant became apneic and PACO2 rose 9 and 8 mm Hg/min respectively. At this time mechanical ventilation was begun. At 4 months, during quiet sleep, VE was 0.064 and 0.063 ml/kg/min at PACO2 of 66 mm Hg in each infant. The change was due entirely to a decrease in VT to 2.3 and 2.5 ml/kg. At this time 5% carbon dioxide breathing given during normal ventilation in REM produced an abrupt fall in VT to 2.0 and 2.2 ml/kg with no change in frequency. Oxygen breathing during REM at one month had no effect but at 4 months produced apnea requiring mechanical ventilation after one minute. The findings suggest that the ventilatory response to carbon dioxide is (1) important in initiation of extrauterine ventilation and (2) in sustaining ventilation particularly in quiet sleep. It is not necessary in sustaining ventilation awake or in REM sleep and it represents a balance between the stimulatory and depressant effects of carbon dioxide on the central nervous system.

Apnea↗
PubMed1976

Paraplegia associated with umbilical artery catheterization in the newborn.

Major complications have followed the use of umbilical artery catheterization in the newborn. The procedure is often a vital part of the monitoring of the critically ill infant and efforts are therefore made to reduce these risks. Recently, we have encountered two newborn infants who developed paraplegia for which no definite etiology could be uncovered. However, their management was attended by the use of umbilical artery catheters and it is postulated that the etiology of paraplegia may have resulted from embolization from these potential thrombogenic sources. The blood supply of the spinal cord and the site of possible embolization are discussed.

Catheterization↗
PubMed1975

Percutaneous catheterization of the radial artery in the critically ill neonate.

Percutaneous catheterization of the radial artery appears to be a simple and safe alternative to catheterization of the umbilical artery for monitoring critically ill neonates. This avoids the serious and potentially fatal complications associated with use of the umbilical arterial catheter, and it is also applicable to monitoring of neonates in whom the umbilical artery is no longer patent. We observed no serious sequelae in cannulation of the radial artery and think that the technique should be used more widely.

Arm↗
PubMed1975

Studies on the pathophysiology of encephalopathy in Reye's syndrome; Hyperammonemia in Reye's syndrome.

The initial acid-base status of eight survivors of Reye's syndrome was characterized by acute respiratory alkalosis (Pco2=32 mm Hg; Hco3-=22.0 mEq/liter) while that of eight children who died was associated with metabolic acidosis as well (HCO3-=10.0 mEg/liter). Arterial-internal jugular venous ammonia concentration differences on day 1 (299 mg/100 ml) and day 2 (90 mg/100 ml) reflected cerebral uptake of ammonia while those on days 3 and 4 (-43 and -55 mg/100 ml) demonstrated cerebral release. Arterial blood hyperammonemia can be detoxified safely in the brain as long as the levels do not exceed approximately 300mug/100 ml. Beyond that level lactic acidosis is observed, particularly in cerebral venous drainage. Arterial blood hyperammonemia was also related to the extent of alveolar hyperventilation. These findings are very similar to those seen in experimental hyperammonemia and support the concept that neurotoxicity in children with Reye's syndrome is at least partly due to impaired oxidative metabolism secondary to hyperammonemia.

Acid-Base Imbalance↗