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Biomedical subjects

M L Cullen

Publications and source records attributed to M L Cullen.

At least 19 recordsLinked to original sources
PubMed2001

Pulmonary and respiratory complications of pediatric trauma.

Pediatric trauma management requires both operative and nonoperative (supportive) care. Fewer than 15% of pediatric trauma patients require surgery (Children's Hospital of Michigan Registry Data, excluding fractures), and the primacy of closed head injury and the multisystem nature of pediatric trauma dictate assessment and therapy. Complications arise at every level, including fluid resuscitation (too much or too little), antibiotics (too late), or pain control (inadequate). The institution of mechanical ventilation that is usually life-saving carries its own risks including those associated with intubation (perforation, aspiration, pro longed endotracheal intubation (stricture, pneumonia), and barotrauma (ventilator-induced lung injury). Minor procedures, such as thoracentesis, chest tube insertion, and pericardiocentesis, can all be complicated by perforation and hemorrhage. Major interventions, including laparotomy and thoracotomy, can result in hemorrhage, air leak, abdominal compartment syndrome, phrenic nerve and thoracic duct injury, postoperative abscess, and septicemia. Transfusion, cardiopulmonary bypass, and invasive monitoring can result in coagulopathy and vascular injury. Prolonged resuscitation and operative explorations can cause hypothermia and coagulopathy and initiate a cascade of multiorgan failure and ARDS. There is no doubt that rapid evacuation, prompt resuscitation, and organized systems of pediatric trauma care have reduced the overall mortality of childhood trauma. The higher velocity of travel and an increasingly chaotic urban environment have resulted in more multitrauma cases and in injuries of higher severity requiring more sophisticated and complicated diagnostic and therapeutic modalities. Our ability to identify life-threatening injuries, to provide expedited and definitive care, and to reduce and detect the complications predicted by these injuries and their treatment will result in long-term improvements in survival and significant reductions in morbidity.

Child↗
PubMed1998

Firearm ownership in households with children.

BACKGROUND/PURPOSE: Increased morbidity and mortality rates in children injured by firearms has been well documented during this past decade. The aim of this study was to determine the socioeconomic factors affecting firearm ownership in families with children living in suburban/rural versus inner-city environments, and to identify predictors of firearm ownership in these families. METHODS: Parents of children less than 19 years old seen in a suburban (n = 751) or inner-city hospital (n = 406) anonymously completed a questionnaire regarding firearm ownership. RESULTS: Firearm ownership was 54% in rural locations, versus 18% among inner-city residents (P< .05). Firearm ownership in white households was 45% versus 20% in African-American households (P< .05). Mean number of all types of firearms in white households was 3.38 versus 1.78 in black households (P< .001). Firearm ownership was 19% in the less than $20,000 income bracket, significantly lower than households with greater incomes, and was significantly lower in households in which parents had the least education (19.7%) versus those with college degrees (38.5%; P< .05). Firearm owners of rifles and shotguns significantly more often cited hunting, collection, and target shooting as reasons for owning firearms, in contrast to revolver owners who cited protection and collection as reasons for firearm ownership (P < .05). CONCLUSIONS: Firearm ownership is higher in rural, caucasian versus inner-city African-American residents and is significantly less in households with lower income and educational levels. Significant predictors for firearm ownership were number of parents in households, educational level of parents, and population of residence.

Adult↗
PubMed1997

Evaluation of contrast media for bronchography.

BACKGROUND: Bronchography is occasionally needed for the evaluation and management of some congenital pulmonary anomalies as well as some acquired diseases, usually of the tracheo- bronchial tree. There is currently no effective, approved contrast agent for this imaging techniq ue. OBJECTIVE: We evaluated five agents (barium sulfate, iohexol, propyliodone oily, propyliodone aqueous, and perflubron) in terms of image quality, histologic changes, and effects on hemodynamics, blood gases, and standard laboratory tests in New Zealand White rabbits. MATERIALS AND METHODS: Animals were anesthetized and intubated. Each contrast agent (0.25 ml/kg) was administered intratracheally. Three animals in each group had intravenous lines placed for blood sampling and blood pressure monitoring and were sacrificed at 1 h. An additional three animals for each agent were sacrificed at 24 h and 1 week after imaging. Blood samples were taken immediately before contrast instillation and at 1 h postbronchography. Fluoroscopic images were recorded on standard VHS video tape and evaluated in blind fashion. Segments of lung tissue and bronchi were obtained for histologic examination. RESULTS: Necrosis and/or inflammatory infiltrates were noted in 78 % of the bronchograms performed with propyliodone aqueous, 67 % with propyliodone oily, 55 % with perflubron, and 33 % with iohexol 120, 240 and 350. No histologic damage was observed with barium. The propyliodones gave the best-quality imaging results and the most histologic changes. Iohexol, in any concentration, gave the least acceptable images and a moderate number of histologic changes. Barium sulfate demonstrated acceptable images with virtually no histologic changes. CONCLUSION: From the histologic and imaging results, barium is the best available contrast material for bronchography.

Animals↗
PubMed1996

Extracorporeal membrane oxygenation in pediatric respiratory failure secondary to smoke inhalation injury.

Extracorporeal membrane oxygenation (ECMO) was used successfully in two children who had respiratory failure secondary to smoke inhalation injury. The first involved a 20% body surface area burn with initial carboxyhemoglobin of 26%. The patient developed varicella pneumonia, which complicated his respiratory failure; he was placed on ECMO for 7 days. The second infant had a 35% body surface area burn and carboxyhemoglobin of 30%. He underwent debridement and allografting while on ECMO, and was decannulated after 13 days. Anticoagulation for ECMO did not significantly interfere with dressing changes. Both patients had definitive autografting and were discharged home breathing room air.

Carboxyhemoglobin↗
PubMed1996

Congenital diaphragmatic hernia: operative considerations.

Despite significant changes and improvement in diagnosis and postnatal care, the mortality rate in congenital diaphragmatic hernia (CDH) remains high. Individual surgical series are small and include heterogeneous groups of patients and diverse management strategies. Collected data suggest that delayed repair, and repair performed on extracorporeal membrane oxygenation (ECMO) may confer a survival advantage. As the timing of surgery has changed, so have the techniques required for successful operative repair. The use of ECMO has required modification in operative techniques to respond to altered coagulation. Surgical conduct directly effects morbidity and mortality rates, and our experience in managing the last 53 patients (1989 through 1995) has led to new operative protocols that have reduced complications. The details of operative repair and strategies to reduce postoperative hemorrhage and recurrence are emphasized.

Extracorporeal Membrane Oxygenation↗
PubMed1995

Extracorporeal membrane oxygenation as salvage in pediatric surgical emergencies.

Extracorporeal membrane oxygenation (ECMO) has become an established therapy for acute neonatal and pediatric respiratory failure. On an institutional level, once an ECMO program is well established, ECMO can be viewed as a logical extension of critical care for multisystem organ failure. The question left unanswered is "Should anyone die without being offered ECMO?" The authors reviewed a 10-year clinical experience with ECMO and its application as salvage therapy in pediatric surgical emergencies. Eight patients with life-threatening multisystem organ failure, from diverse causes, were treated; the survival rate was 50%. All survivors were neurologically intact at the time of discharge. The success of ECMO, coupled with improvements in technique, apparatus, and expertise, has allowed application of ECMO as an invasive extension of intensive care to diverse patient groups. These results have encouraged the authors to expand their indications and to push the "envelope" in offering ECMO to critically ill infants and children with life-threatening organ failure.

Critical Care↗
PubMed1995

Congenital diaphragmatic hernia with or without extracorporeal membrane oxygenation: are we making progress?

BACKGROUND: Congenital diaphragmatic hernia (CDH) continues to have a high mortality rate (24 to 57 percent) despite changing management schemes, which include extracorporeal membrane oxygenation (ECMO) for treatment of associated persistent pulmonary hypertension of the newborn. STUDY DESIGN: The medical records of 123 acutely symptomatic newborns with CDH treated from 1972 to 1994 were retrospectively reviewed. Patients were divided into three groups to compare historical treatment modalities: group 1, no ECMO available; group 2, postoperative ECMO if necessary; and group 3, delayed repair with preoperative ECMO if necessary. The blood gas values, alveolar-arterial oxygen gradient (A-aDO2), mean airway pressure (MAP), and oxygenation (OI) and ventilation indices (VI) prior to treatment were compared between survivors and nonsurvivors. Chi-square and Student's t tests were used to determine statistical significance. RESULTS: The overall survival rate was 41 percent: 27 percent in group 1, 45 percent in group 2, and 39 percent in groups 3. If those who were not candidates for ECMO were excluded from analysis, the survival rate improved to 35 percent in group 1, 51 percent in group 2, and 50 percent in group 3. No published prognostic scoring system, such as arterial blood gas values, A-aDO2 gradient, MAP, OI, or VI consistently distinguished survivors from nonsurvivors. Extracorporeal membrane oxygenation decreased the mortality rate of patients having large defects. CONCLUSIONS: Prognostic scoring systems do not predict which patients with CDH should be treated. Extracorporeal membrane oxygenation has improved survival in newborns with CDH who present in early respiratory distress. There is no advantage or disadvantage to using ECMO prior to repair of CDH.

Extracorporeal Membrane Oxygenation↗
PubMed1993

Delayed repair of congenital diaphragmatic hernia.

Early reports of improved survival in newborns with congenital diaphragmatic hernias (CDH) utilizing extracorporeal membrane oxygenation (ECMO) and/or a delayed repair (DR) approach have been tempered by recent failures to document such an improvement. We have used ECMO to salvage emergently repaired patients with CDH since January 1984. From January 1990 to January 1991, we treated 16 CDH patients with mechanical ventilation and other supportive techniques until persistent pulmonary hypertension of the newborn resolved. We compared this DR group to 19 patients emergently repaired from February 1987 to December 1989. Of the 19 emergently repaired patients, 16 had a best post ductal (BPD) PO2 > 50 mm Hg. Eight patients survived (42 per cent of all and 50 per cent of those with a BPD PO2 > 50). Thirteen required ECMO and six of these survived. Five of six ECMO survivors had significant ECMO complications, and ECMO was "inappropriately" performed on three of six nonsurvivors. Of the 16 DR patients, nine achieved a BPD PO2 > 50 mm Hg and seven survived (44 per cent of all and 78 per cent of those with a BPD PO2 > 50). Seven required ECMO and four of these survived. All survivors in both groups had a BPD PO2 > 90 mm Hg. Delayed repair did not improve survival statistics for CDH with early respiratory distress at our hospital but it has allowed stratification of potential survivors, fewer inappropriate ECMO cannulations, and many fewer ECMO complications.

Emergencies↗
PubMed1987

Experience with renal failure during extracorporeal membrane oxygenation: treatment with continuous hemofiltration.

We use extracorporeal membrane oxygenation (ECMO) to treat respiratory and cardiac failure in children who are unresponsive to standard ventilator and pharmacologic management. All patients have cardiac and abdominal ultrasonography prior to ECMO to identify major structural anomalies and anatomically normal kidneys. Despite this, oliguric renal failure is seen in a number of patients. Acute renal failure (ARF) developed in two of the first 20 patients we placed on ECMO and both of these patients died. Six of the last 27 patients (22%) also developed ARF and were treated with continuous hemofiltration (CH) placed in-line with the extracorporeal circuit. The technique of CH removes plasma water and dissolved solutes while retaining proteins and cellular components of the intravascular space. The duration of CH ranged from 9 to 112 hours (mean 57.5 hours). Indications for CH were hypervolemia, hyperkalemia, and azotemia. The mean serum potassium prior to CH was 5.6 (range 4.3 to 7.0) compared with 4.5 after filtration. We filtered 5 to 10 mL/kg/h and replaced it with crystalloid chosen on the basis of serum and filtrate electrolytes. These six patients had a 33% mean weight gain prior to CH. We were able to remove as much as 2,200 g in the most edematous patient with significant improvement in cardiopulmonary status. Four of the patients on CH died of their primary pulmonary or cardiac disease without specific problems related to ARF. The other two patients were successfully weaned from ECMO, extubated, and have not needed further therapy for renal failure. We conclude that CH is useful in managing the complications of oliguric renal failure during ECMO.

Acute Kidney Injury↗
PubMed1987

Spontaneous resolution of acid gastric injury.

While alkali ingestion nearly always injures the esophagus, acid usually spares the esophagus and damages the gastric outlet. Most reported cases of acid gastric injury have required resection. We report a case of acid ingestion managed with parenteral nutrition and histamine blockers in which healing is documented without operation.

Acids↗
PubMed1987

Hypertension during extracorporeal membrane oxygenation: cause, effect, and management.

The major complication of extracorporeal membrane oxygenation (ECMO) for the treatment of neonatal respiratory failure is bleeding related to heparinization. Systolic hypertension has emerged as another serious side effect in our experience. Thirty-eight of the first 41 newborns we treated with ECMO developed a systolic blood pressure greater than 90 mm Hg. The mean hypertension index (HI blood = hours greater than 90/hr on ECMO) was 0.17 +/- 0.16. Possible biochemical mediators were assayed in 17 patients. Plasma renin activity (PRA), aldosterone, epinephrine, norepinephrine, prostaglandin E2, thromboxane, and antidiuretic hormone were elevated. Angiotensin-converting enzyme (ACE) and prostacyclin were not elevated. Eighteen patients (44%) had intracranial hemorrhage (ICH), and 11 patients (27%) had clinically significant ICH. The HI was significantly (p less than 0.005) lower in those patients without ICH (0.11 +/- 0.01) than in those patients with ICH (0.25 +/- 0.04). PRA at hour 12, day 2, and day 3 was significantly higher (p less than 0.05) in patients experiencing ICH (62 +/- 42; 93 +/- 15; 73 +/- 30 ng/ml/hr) than in those without ICH (27 +/- 25; 14 +/- 8; 12 +/- 4 ng/ml/hr). An aggressive approach to medical management evolved that included hydralazine, nitroglycerine, and captopril, which protected against ICH. Two of 23 patients (9%) treated with the protocol sufferred clinically significant ICH, whereas nine of 18 patients (50%) treated before implementation of the protocol experienced ICH. The ACE inhibitor captopril was most effective in the control of hypertension. We conclude that systolic hypertension is common during neonatal ECMO, is associated with ICH, and is related to a high PRA. Aggressive management of hypertension during ECMO can reduce the incidence of ICH, and captopril is an important component of this aggressive medical management.

Aldosterone↗
PubMed1986

Hemorrhagic complications during extracorporeal membrane oxygenation: prevention and treatment.

Hemorrhage related to systemic heparinization is the major complication of extracorporeal membrane oxygenation (ECMO). Intracranial hemorrhage (ICH) is the most devastating complication. ICH developed in 13 of our 25 ECMO patients (52%). Six died, six survived with normal neurologic function, and one is severely impaired. In nine of 13 patients (69%) ECMO was discontinued when serial cranial ultrasounds showed progressive ICH. Seizures developed in six infants while receiving ECMO, and ICH developed in all. There is a correlation between hypertension and ICH. A hypertension index (hours systolic BP greater than 90/hours receiving ECMO) was 0.1 +/- 0.12 for infants without ICH and 0.37 +/- 0.28 for infants with ICH (P less than .05). ICH developed in 79% of the patients with an index greater than 0.1. Twenty neck explorations were required in the first 20 patients for incisional bleeding (mean blood loss, 21.9 +/- 18.0 mL/kg/d). We now use fibrin glue following cannulation and have done only one neck exploration in the last five patients (mean blood loss, 2.8 +/- 2.2 mL/kg/d, P less than .05). Endobronchial bleeding has responded to phenylephrine lavage and increased positive end-expiratory pressure. We have controlled pleural space bleeding with topical thrombin. None of the hemorrhagic complications encountered correlate with the activated clotting time or the amount of heparin used. There is an increased risk of hemorrhage associated with platelet counts less than 100,000/microL for 75% of a day (P less than .05) so that aggressive platelet transfusion remains important in preventing hemorrhagic complications during ECMO.

Cerebral Hemorrhage↗
PubMed1986

Epidural catheter analgesia for the management of postoperative pain.

Since its introduction to North America in 1942, the use of epidural catheter analgesia has increased dramatically. Improved equipment, methods and medications have broadened its application to include among others, surgical anesthesia, chronic pain relief and the management of postoperative pain. Numerous techniques for epidural puncture and insertion of the catheter have been described. Although complications have been associated with placement of an epidural catheter, these are rare when performed by an experienced anesthesiologist. Epidural analgesia was first accomplished by blockade with local anesthetics. Bupivacaine has been called the local anesthetic of choice for epidural infusion. Bolus administration of epidural local anesthetics gives effective analgesia; however, its use is limited by brief duration and occasionally severe hypotension. Epidural local anesthetics have been administered by continuous infusion in an attempt to minimize side effects. Nevertheless, hypotension, as well as motor block, numbness, nausea and urinary retention have occurred. Epidural analgesia with local anesthetics is effective in relieving postoperative pain, but its safety and feasibility have been questioned because of the frequent, potentially serious side effects. These problems led to trials of epidural narcotics for postoperative pain management. The exact site of action of epidural narcotic analgesics is debatable; however, the bulk of evidence supports a direct spinal action. Epidural narcotics appear to specifically inhibit nociceptive stimuli. The prolonged and profound analgesia that occurs with epidural narcotics relative to parenteral administration is due to a higher concentration of drug reaching the CSF through the epidural route. Since nervous transmission is not completely blocked this technique cannot provide anesthesia during operation. Morphine has been the most frequently used narcotic for epidural analgesia. Results of several recent, randomized double-blind studies have shown that epidural narcotics give adequate analgesia comparable with that observed with epidural bupivacaine. Epidural morphine provides a greater duration of analgesia and may cause fewer side effects. Improved analgesia has been reported when epidural narcotics are used in combination with local anesthetics. Continuous administration of low dosage epidural narcotics has been shown to have less frequent side effects than bolus administration. Nevertheless, pruritus, urinary retention, hypotension and severe respiratory depression have been reported with both methods.(ABSTRACT TRUNCATED AT 400 WORDS)

Analgesia↗
PubMed1985

Congenital diaphragmatic hernia.

Congenital diaphragmatic hernia continues to be a critical problem in neonatal surgery. Despite the apparent simplicity of the anatomic defect, the physiology is complex, and survival remains uncertain. Surgical success has been achieved, but we recognize that the barrier to survival is pulmonary parenchymal and vascular hypoplasia as well as the complex syndrome of persistent fetal circulation. In many ways the problem of diaphragmatic hernia is as much of an enigma to today's physician-scientist as it was to Bochdalek in the nineteenth century. The treatment of respiratory distress after repair of congenital diaphragmatic hernia has brought out the most creative and innovative efforts of pediatric surgeons in both the laboratory and the intensive care unit.

Animals↗
PubMed1985

Continuous epidural infusion for analgesia after major abdominal operations: a randomized, prospective, double-blind study.

We performed a prospective, randomized, double-blind study of continuous epidural analgesia for 72 hours after major abdominal procedures. Patients were randomly assigned to one of five treatment groups: epidural morphine, epidural bupivacaine, a combination of morphine and bupivacaine, epidural saline solution, and no epidural catheter. All patients received supplemental morphine sulfate or meperidine hydrochloride, intramuscularly or intravenously, as needed. Epidural infusion was begun at 2 to 4 ml/hr, depending on age and height, with two increments of 1 ml/hr allowed if pain relief was insufficient. All pain management decisions were made by nurses, who also monitored epidural function. Performance was measured four ways: pain as measured at regular intervals in the 72-hour period with a visual analog, pain as measured after 72 hours with the McGill Pain Questionnaire, amount of supplemental narcotics needed, and recovery of respiratory function and ambulation as percent of preoperative levels. The group that received the combination of morphine and bupivacaine did best on all measures; in most instances the difference between the results seen with the combination regimen and those seen with saline solution or no catheter were significant at the 0.05 level. With the exception of pruritus, complications were evenly distributed among all treatment groups, including noncatheterized controls. We conclude that epidural analgesia with the combination of morphine and bupivacaine is safe, is easily managed, and gives pain relief superior to that provided by traditional, systemic administration of narcotics.

Abdomen↗
PubMed1985

Pheochromocytoma: operative strategy.

We studied 28 patients who had undergone 30 operations for pheochromocytoma since 1964. The tumor types included bilateral, extra-adrenal, malignant, recurrent, and multiple endocrine neoplasia, with 20 tumors confined to the adrenal gland. The preoperative studies used to localize the tumor included ultrasonography, intravenous urography, angiography, and computed tomography. Patients underwent exploratory operations via flank, subcostal, bilateral subcostal, midline, or thoracoabdominal approaches. In one case, that of a recurrence after bilateral adrenalectomy, surgical exploration discovered a tumor that had not been localized during the preoperative workup. Two patients underwent splenectomy because of injury incurred during operative exploration. Our experience suggests that preoperative localization is highly reliable, and therefore the benefits of extensive surgical exploration may be outweighed by its risks. We believe that with the exception of tumors that occur in association with childhood or pregnancy, multiple endocrine neoplastic syndromes, or recurrent disease, a direct approach to the tumor, possibly via the flank, is justified. Our results suggest that exploration of the contralateral adrenal or periaortic area is not so important as to be worth jeopardizing the spleen or other organs by a complex or extensive dissection.

Adolescent↗