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Biomedical subjects

J B Pietsch

Publications and source records attributed to J B Pietsch.

At least 19 recordsLinked to original sources
PubMed1995

Pentobarbital sedation for patients in the pediatric intensive care unit.

We present our experience with pentobarbital for sedation during mechanical ventilation in six infants when fentanyl and midazolam failed. The patients ranged in age from 2 to 17 months and in weight from 3.0 to 11.4 kg. Before the switch to pentobarbital, the maximum doses of fentanyl ranged from 7 to 13 micrograms/kg/hr and the midazolam infusions, from 0.2 to 0.4 mg/kg/hr. Pentobarbital was administered as a bolus dose followed by a continuous infusion. The hourly infusion rates ranged from 1 to 4 mg/kg. Adequate sedation was achieved in all six patients. In the four patients who required neuromuscular blocking agents, their use was discontinued after pentobarbital was given. The antihypertensive agents (diazoxide and nitroprusside) required by the two patients receiving extracorporeal membrane oxygenation were also discontinued after pentobarbital administration. Although we continue to use fentanyl and benzodiazepines as first-line drugs for sedation, pentobarbital may be an effective alternative when these agents fail.

Administration, Oral↗
PubMed1994

Laparoscopic cholecystectomy in infants and children: modifications and cost analysis.

Between June 1990 and February 1993, 26 children underwent laparoscopic cholecystectomy. Their ages ranged from 25 months to 19 years (mean, 12.3 years; median, 13 years). Only six of them had hemolytic diseases associated with gallstones. Five presented with acute cholecystitis. Laparoscopic cholecystectomy was performed on these five, within 5 days of admission; the mean postoperative hospital stay was 2.5 days. The other 21 patients underwent elective cholecystectomy; their mean postoperative stay was 1 day. Several modifications have been made in our technique. Three 5-mm ports and one 10-mm umbilical port are used. In addition, direct incision of the umbilical fascia is performed with insertion of a blunt trocar and cannula rather than using the Veress needle for insufflation. The importance of positioning the epigastric cannula in the left upper quadrant in small children cannot be overemphasized. Cholangiography is now attempted in all patients and is easier with the Kumar cholangioclamp and sclerotherapy needle, under fluoroscopy. The total hospital charges for the patients who underwent elective laparoscopic cholecystectomy are compared retrospectively with those of seven children who had elective open cholecystectomy during the same period. In addition, a comparison is made between the two groups with respect to the costs of operating room equipment and postoperative pain control.

Child↗
PubMed1994

Laparoscopy for the nonpalpable testis.

Between 1988 and 1992, 287 infants and children have been evaluated for an undescended testis. In 35, the testis was not palpable. These 35 patients ranged in age between 10 months and 14 years, with a mean of 44 months and a median of 15 months. Thirteen patients had a nonpalpable right testis, 18 had a nonpalpable left testis, and four had bilateral nonpalpable testes. Diagnostic laparoscopy was performed in these 35 boys with a nonpalpable testis to allow a planned approach to management of this condition. In 11 children, a testis was visualized. The testis was in an inguinal hernia sac in seven, and single stage conventional orchiopexy was performed. In four children an intra-abdominal testis was seen, and three infants underwent laparoscopic clip ligation of the testicular vessels. One teenager underwent orchiectomy. In 21 of the remaining 24 boys, small, attenuated testicular vessels were noted to pass into the inguinal canal and inguinal exploration was required. A small testicular remnant was excised in 15 patients, but orchiopexy was possible in six boys. Diagnostic laparoscopy takes 7 to 10 minutes and enables the surgeon to develop a planned approach to this condition. With the information gathered at laparoscopy, the surgeon is best able to decide if an inguinal exploration is necessary or if a single-stage orchiopexy is possible. If a two-stage orchiopexy is required for an intra-abdominal testis, then clip ligation of the testicular vessels can be performed laparoscopically as the first stage, followed by Fowler-Stephens orchiopexy 6 to 9 months later.

Adolescent↗
PubMed1993

Continuous regional anaesthesia in infants.

Physiological immaturity of the respiratory musculature and central respiratory control centres leads to an increased risk of apnoea and respiratory complications following general anaesthesia in neonates. Regional anaesthetic techniques may obviate the need for general anaesthesia and lessen the risks of perioperative morbidity. Although these techniques have been described in infants, previous reports have dealt with single-shot techniques for brief surgical procedures (< 60 min). Experience with prolonged operative cases using regional anaesthesia via indwelling catheters in infants is limited. We present our experience with four infants in whom either caudal epidural or spinal anaesthesia was administered via indwelling catheters for operative procedures that lasted 90 to 180 min. We believe this technique is an alternative to general anaesthesia in these patients.

Anesthesia, Caudal↗
PubMed1991

Parapneumonic empyema in children: decortication hastens recovery in patients with severe pleural infections.

The medical records of 61 children 0 to 18 years of age treated for empyema complicating pneumonia from 1977 to 1989 were reviewed with attention to clinical presentation, bacteriology, treatment and outcome. Streptococcus pneumoniae was the most common infecting organism, followed by Staphylococcus aureus, other streptococcal species, anaerobes, Haemophilus influenzae type b, Pseudomonas aeruginosa, and Eikenella corrodens. No organisms were recovered in 39% of patients. Twelve patients were treated successfully with antibiotics and thoracentesis alone, 23 patients underwent close tube thoracostomy and 26 required decortication. A thickened pleural "peel," scoliosis and opacification of a hemithorax on chest radiograph, as well as low pleural pH and glucose concentration, were associated with a poor response to medical management. A scoring system was developed to define the severity of pleural disease. In patients with severe pleural infections, decortication allowed more rapid defervescence (2.2 vs. 6.5 days) and earlier hospital discharge (4.4 vs. 12.4 days) than did closed tube thoracostomy (P less than 0.001).

Adolescent↗
PubMed1989

Burn injury alters intestinal glutamine transport.

Several studies have established that intestinal glutamine (GLN) metabolism is altered during catabolic states. It remains unclear whether these alterations are due to a defect in metabolism or in transport of the amino acid. The present study examines the kinetics of GLN transport across basolateral membrane vesicles (BLMV) of enterocytes obtained from control rats and rats subjected to 20% full-thickness scald burn, 48 hr previously. BLMV were prepared from freshly isolated enterocytes using differential centrifugation with separation on a Percoll density gradient. BLMV were enriched (10- to 12-fold) with Na+-K+-ATPase while markers for brush border membranes were impoverished. Previous studies from our laboratory indicated that, in this preparation, GLN transport is into an osmotically sensitive space, dependent on GLN concentration, linear up to 30 sec, and both temperature and Na+ dependent. Our results indicate that in thermal injury, initial rates of GLN uptake were depressed (y = 3.67 + 0.435X for burned rats vs y = 18.7 + 0.907X for controls, P less than 0.01). Kinetic analysis of GLN uptake showed a marked decrease in transport Vmax (81.8 +/- 15 nmole/mg protein/15 sec for burned rats vs 185 +/- 17 nmole/mg protein/15 sec for controls, P less than 0.001). Transport Km also decreased from 0.25 +/- 0.004 mM for controls to 0.08 +/- 0.03 mM glutamine for burned rats (P less than 0.001). Kinetic studies performed at GLN levels greater than 0.6 mM showed that GLN uptake proceeded by a nonsaturable process in both the control and burned rats. No significant alteration in this nonsaturable component was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1989

Postpneumonic empyema in childhood: selecting appropriate therapy.

In order to identify appropriate treatment options for postpneumonic empyema, we reviewed the medical records and, when possible, obtained long-term follow-up chest radiographs and pulmonary function tests on children treated for empyema during the past 11 years. Fifty-one patients were treated in various ways, with antibiotics alone (N = 10), or in combination with tube thoracostomy (N = 23) or decortication (N = 18). Despite administration of appropriate antibiotics and establishment of pleural drainage, many children required prolonged hospitalization and eventual decortication. Based on this review, a scoring system was developed allowing early classification by severity of pleural disease. Factors found to be predictors of severe pleural disease include (1) low pleural fluid pH or (2) glucose; (3) presence of moderate or severe scoliosis or (4) pleural peel or parenchymal entrapment by chest radiography; and (5) infection due to anaerobes, gram-negative organisms, or mycoplasma. Complete opacification of a hemithorax on chest radiography and a pleural peel to thoracic ratio greater than 40% were also associated with severe pleural disease. In patients with mild disease (N = 7), response to antibiotics alone, rapid resolution of fever, and shorter hospital stays were observed. In patients with more severe infections (moderate = 22, severe = 22), decortication accomplished earlier defervescence, radiographic improvement, and hospital discharge than simple tube thoracostomy. No deaths or morbidity were associated with decortication, which could often be accomplished through a minithoracotomy. Follow-up chest radiographs and pulmonary fuction tests showed a prompt return to normal after decortication. This experience indicates utility of a pleural disease severity scoring system in selection of treatment options for children with postpneumonic empyema.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1989

Budd-Chiari syndrome secondary to hepatic vein thrombus from Wilm's tumor. Case report and literature review.

We describe a case of Budd-Chiari Syndrome in a 6-year-old boy secondary to Wilm's tumor. The patient had a right nephrectomy and mediastinotomy with removal of the tumor from the right atrium, inferior vena cava, and hepatic vein. Postoperatively, the patient had chemotherapy consisting of Actinomycin-D to be followed by radiation to the tumor bed to a total dose of 2000 rads in 10 fractions by using AP/PA field on 6 MeV Linear Accelerator. Currently, the child is receiving combination chemotherapy.

Budd-Chiari Syndrome↗
PubMed1989

Capillary hemangioma of the vagina and urethra in a child: response to short-term steroid therapy.

Short-term oral steroid therapy was used to treat a capillary hemangioma of the vagina and urethra in a young child. After 8 weeks of prednisolone therapy (40 mg every other day decreasing to 2.5 mg every other day), vaginal bleeding has not recurred. At 2 years and 8 months, the patient presented with severe hematuria. Visualization revealed hemangioma within the bladder, but the urethra and vagina were normal by cystoscopy and vaginoscopy, respectively. After cauterization of a single bleeding point, the patient again received prednisolone. She has had no hematuria for 4 months. Steroid therapy should be considered for the management of genitourinary hemangiomas.

Child, Preschool↗
PubMed1988

Acute abdominal conditions in children and adolescents.

Evaluation and management of the acute abdomen in childhood require a thorough familiarity with the numerous disorders that may cause abdominal emergencies. Many of these entities are rarely seen in adults or have clinical features that are very different from those observed in adults. Diagnosis is often confounded by difficulties in obtaining an accurate history and physical examination. In infants and young children, complications of various congenital abnormalities are more common causes of abdominal pain, whereas acquired disorders are observed more frequently in older children and adolescents.

Abdomen, Acute↗
PubMed1988

Right atrial thrombus formation screening using two-dimensional echocardiograms in neonates with central venous catheters.

Two-dimensional echocardiograms were used to prospectively screen 49 patients with 56 central venous catheters for right atrial thromboses from October 1985 to May 1986. All but four patients received a two-dimensional echocardiogram prior to insertion of the catheter. Once the catheters were in place, two-dimensional echocardiograms were performed no later than 3 weeks after insertion and then every 14 days until the catheter was removed. A single thrombus was detected 79 days after catheter placement (an incidence of 1.8%). Previous recommendations for weekly screening with two-dimensional echocardiogram were based on case reports alone. The 95% confidence limits for a negative two-dimensional echocardiogram result suggest that the initial two-dimensional echocardiogram screen for thrombus be obtained no sooner than 3 weeks after catheter insertion. In addition, significant gastrointestinal disease requiring operative intervention was present in 10 of 11 previous case reports as well as in our patient. Further studies with larger sample sizes are needed to determine whether subgroups of infants exist who are at a relatively higher risk for right atrial thrombus formation.

Catheterization, Peripheral↗
PubMed1985

Inguinal hernias in premature infants operated on before discharge from the neonatal intensive care unit.

Sixteen premature infants were operated on during the two-year period from 1981 through 1982 for inguinal hernia prior to discharge from the hospital. There were no complications from the hernias before surgery and during administration of anesthesia and postoperative recovery, and no recurrences, would infections, or testicular atrophy was noted in long-term follow-up. In contrast to a controlled group of 11 full-term patients of this same age who were operated on as outpatients, the operating room time, operation time, and time in the recovery room were significantly increased for the premature infants. This resulted in a 22% increase in cost for the correction of the premature inguinal hernias. Analysis of the factors in repair of these hernias indicates that this increased cost will have to be accepted as part of the care of premature infants in neonatal intensive care units.

Hernia, Inguinal↗
PubMed1985

Early excision of major burns in children: effect on morbidity and mortality.

The advantage of early excision and grafting in the treatment of limited full-thickness burns has been clearly established. The goal of the present study was to evaluate the role of early burn wound excision in major pediatric burns. Of the 470 pediatric burn admissions between 1979 and 1984 that were reviewed, 53 patients met the criteria of deep second or third degree burns greater than 25% total body surface area (TBSA). Of these, 20 had burn wound excision within 7 days (Early) and 33 had delayed excision and grafting (Late). The Early group, despite having greater transfusion requirements (69.4 v 36.2 cc/kg), had shorter hospital stays (35.3 v 49.1 d, P less than 0.05), fewer metabolic complications (20% v 79%, P less than 0.001), and less burn wound contamination (55% v 90%, P less than 0.01) than the Late group. Mortality was lower in the Early group (0% v 12%), but this was not statistically significant. Early excision and grafting are therefore recommended in the care of major burns in children.

Adult↗
PubMed1985

Necrotizing tracheobronchitis: a new indication for emergency bronchoscopy in the neonate.

Necrotizing tracheobronchitis (NTB) is a recently recognized cause of tracheal obstruction in the mechanically ventilated neonate. This process involves inflammation and necrosis of the mucosa of the distal trachea and mainstem bronchi. The sloughing of this material into the tracheal lumen results in plugging and acute respiratory distress. We documented this diagnosis in 19 infants. Four were diagnosed at autopsy. Fifteen had emergency bronchoscopy performed in the neonatal intensive care unit with removal of the obstructing debris. Ten of these 15 neonates survived (66.7%). The diagnosis of necrotizing tracheobronchitis should be suspected in those neonates requiring positive pressure ventilation in whom a sudden unexplained increase in ventilatory requirements develops. This is often associated with hypercarbia and a history of high-peak inspiratory pressures with or without hypoxia. Emergency bronchoscopy in these neonates is necessary both for diagnosis and treatment of the necrotizing tracheobronchitis.

Bronchitis↗
PubMed1984

Simplified insertion of central venous catheter in infants.

A technique for insertion of central venous catheters in infants is described. A needle is percutaneously positioned into the subclavian vein. Through this, a guide wire is passed and a catheter introduced over the wire. This method has proved to be safe and effective in over 100 infants.

Catheterization↗