Biomedical subjects
Publications and source records attributed to L N Cook.
With the use of ethanol in hyperalimentation regimens and for the inhibition of premature labor, there is increased opportunity for exposure of the fetus to this potentially toxic substance. We reviewed the literature regarding the effects of ethanol on the fetus and neonate, and illustrate its potential toxicity by the report of a case of neonatal depression secondary to acute maternal ethanol ingestion.
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This study was conducted to determine the timing of intracranial hemorrhage (ICH) in patients on extracorporeal life support (ECLS) to improve the use of the head ultrasound in the detection of ICH. A review was conducted of all neonatal ECLS patients at the neonatal intensive care nursery at Kosair Children's Hospital in Louisville, Kentucky, from May, 1985 through November, 1994 to establish a study group of infants in whom an ICH developed while on ECLS. Thirty infants who had an ICH (excluding subarachnoid hemorrhage and infarction) on ECLS were included in the study. Data were collected that included patients demographics, age at initiation of ECLS, duration of ECLS, type of ECLS support (venoarterial or venovenous), oxygenation index and last arterial blood gas before ECLS, hours of ECLS before ICH, and grade of ICH. ICH occurred in 9.9% of the neonatal patients requiring ECLS. These included 8 infants with a Grade I bleed, 1 infant with a Grade II, 4 infants with a Grade III, and 17 infants with a Grade IV. Ten of the 30 patients had sepsis as their primary diagnosis, and these infants were more likely to have an ICH while on ECLS compared to nonseptic infants (p < 0.02). The Kaplan-Meier curve showed that 50% of ICHs occurred in the first 24 hours of ECLS, 75% by 48 hours, and that 85% of ICHs occurred within 72 hours of initiation of bypass. There was no difference in timing of ICH in the septic infants compared to the nonseptic infants. The late occurring bleeds (> 72 hours) were all associated with significant neurologic changes or with multiorgan failure. It is concluded that daily head ultrasounds should be performed during the first 3 days of ECLS because most ICHs (85%) occur in the first 72 hours of cardiopulmonary bypass. In this era of cost containment, subsequent head ultrasounds should be obtained with changes in the infant's neurologic status or with the development of multiorgan failure.
The purpose of this study was to evaluate all post extracorporeal membrane oxygenation (ECMO) tests for their ability to detect any change in the incidence of unanticipated medical problems, and their charge to the patient. The current post ECMO protocol consists of the following tests: brain stem auditory evoked response, head computed tomography, cerebral blood flow, head ultrasonography, electroencephalography, eye examination for retinopathy of prematurity, and pneumocardiography. A retrospective review was conducted for all surviving neonatal ECMO patients treated from January, 1985, to December, 1994. The results of each test were classified as either normal, having a minor abnormality, or having a major abnormality. Statistical analyses were performed on each test comparing the incidence of minor and major abnormalities to all neonates in the neonatal intensive care nursery. Two hundred ninety-six infants survived their course on ECMO, and composed the study population. There were no significant differences between the incidence of abnormal results compared with the expected values for the following tests: cerebral blood flow (p=0.13), the eye examination (p=0.54), and pneumocardiography (p=0.22). The analyses for the brain stem auditory response, head computed tomography, head ultrasonography, and electroencephalography showed higher than expected incidences of abnormal results (p < 0.01). The data also were evaluated for major abnormalities on computed tomography and head ultrasonography. Of 161 infants who had both tests performed, 11 (6.8%) had normal head ultrasonography results, yet had a major abnormality noted on computed tomography (p < 0.01). This study is the first to review the current post ECMO protocol comprehensively, and the results suggest excluding the cerebral blood flow, eye, and pneumocardiography tests. This would result in a significant savings of $1,400 without compromising patient care. In addition, comparisons of neuroradiographic studies indicate that computed tomography of the head is sensitive enough to detect all central nervous system abnormalities that were found by ultrasonography. Excluding the post ECMO head ultrasonography, an additional savings of $300 would occur. These recommended changes reflect the current post ECMO protocol at Kosair Children's Hospital.
The objective of this study was to determine the efficacy of two-dimensional and contrast echocardiograms to identify venous cannula position. Sequential sampling of 20 infants was evaluated by contrast echocardiography after meeting institutional criteria for extracorporeal life support. Each infant was placed on venovenous extracorporeal life support using a double-lumen cannula. After surgical placement was thought to be satisfactory, optimal two-dimensional images of the cannula were obtained via a subxiphoid or apical view and 2 ml agitated normal saline were injected rapidly into the nearest infusion port. Patient demographics and mixed venous saturations were noted. Distance of the venovenous cannula to tricuspid valve and distance of the venovenous cannula from the intra-atrial septum was recorded. Echocardiograms were available for review on 18 of the 20 patients. Position of the venovenous cannula in relationship to the tricuspid valve was as follows: < 5 mm (8); 5-10 mm (5); > 10 mm (5). Mixed venous saturations decreased, which indicated less recirculation when the orientation of the tip of the cannula was toward the lateral wall in those who required repositioning. The authors conclude that two-dimensional and contrast echocardiography aid in the positioning of the venovenous cannula. Satisfactory position is approximately 5 mm from the tricuspid valve, with orientation toward the lateral wall of the right atrium.
OBJECTIVE: The objective of this study was to analyze the clinical course and neurodevelopmental outcome of infants with total anomalous pulmonary venous drainage (TAPVD) who were treated with venoarterial extracorporeal life support (ECLS). STUDY DESIGN: The study was done by retrospective national survey of ECLS centers located in the United States and Australia. Sixty-six patients from 28 centers that reported cases from 1976 to October 1992 to the Extracorporeal Life Support Organization registry were included in the study. Data regarding type of TAPVD, whether the diagnosis was known or suspected before the initiation of ECLS, method of diagnosis, timing of repair if done, outcome, and follow-up were collected. RESULTS: Fifty-six of the patients were placed on ECLS at ages < 14 days (neonatal) and 10 patients underwent ECLS at ages > or = 14 days (pediatric). TAPVD was known or suspected before the initiation of ECLS in 35 (53%) of 66 and was most commonly diagnosed by color-flow Doppler echocardiography if initially missed. Surgical repair was not attempted in four of the 66 patients, leaving a total of 62 patients for comparison. The overall operative survival for both neonatal and pediatric patients was 24 (39%) of 62. The survival rate for neonates who underwent repair before ECLS was seven (54%) of 13, for those who underwent repair after ECLS it was six (60%) of 10, and for those who underwent repair during ECLS survival was seven (24%) of 29. Neonatal survival (20/52, 38%) was statistically more likely (p = 0.05) if the repair was done before or after ECLS rather than during ECLS, with each group compared separately. Follow-up data were available on 13 of 20 neonates and three of four pediatric patients. Bayley Scales of Infant Development scores were normal in only six (54%) of 11 survivors who returned for testing. CONCLUSIONS: The diagnosis of TAPVD was often known before the initiation of ECLS. Neonates were more likely to survive if the repair could be done before or after ECLS rather than during ECLS. The lower survival of infants who underwent repair during ECLS reflects the degree of illness in many of these infants who were placed on ECLS on an emergency basis because their condition was too unstable to permit detailed cardiac evaluation. The survival rate of infants with TAPVD requiring ECLS is poor, with approximately one half of the survivors having mental and motor deficiencies; however, these infants represent a subset of patients with TAPVD who probably would have died without ECLS. We recommend that infants who are not starting to wean from ECLS at 7 days undergo reevaluation with color-flow Doppler echocardiography with consideration for cardiac catheterization if the diagnosis is in doubt. We also recommend that before infants with known TAPVD are placed on ECLS parents should be informed that survival with the use of ECLS is no different from survival with operation alone and that many of the survivors are impaired. Each active ECLS center should periodically review its accuracy in making this definitive diagnosis.