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Biomedical subjects

W P Kanto

Publications and source records attributed to W P Kanto.

At least 19 recordsLinked to original sources
PubMed2000

Use of telemedicine for children with special health care needs.

OBJECTIVE: In 1995, the Children's Medical Services (CMS) of the State of Georgia contracted with the Department of Pediatrics of the Medical College of Georgia (MCG) and the MCG Telemedicine Center to develop telemedicine programs to provide subspecialty care for children with special health care needs. This article presents project statistics and results of client evaluation of services, as well as physician faculty attitudes toward telemedicine. DESIGN: A demonstration project using telemedicine between a tertiary center and a rural clinic serving children with special health care needs was established. Data were collected and analyzed for December 12, 1995 to May 31, 1997, during which 333 CMS telemedicine consultations were performed. RESULTS: Most CMS telemedicine consultations (35%) involved pediatric allergy/immunology. Other subspecialties included pulmonology (29%), neurology (19%), and genetics (16%). Overall, patients were satisfied with the services received. Initially, physician faculty members were generally positive but conservative in their attitudes toward using telemedicine for delivering clinical consultation. After a year's exposure and/or experience with telemedicine, 28% were more positive, 66% were the same, and only 4% were more negative about telemedicine. The more physicians used telemedicine, the more positive they were about it (r =.30). CONCLUSIONS: In terms of family attitudes and individual care, telemedicine is an acceptable means of delivering specific pediatric subspecialty consultation services to children with special health care needs, living in rural areas distant to tertiary centers. Telemedicine is more likely to be successful as part of an integrated health services delivery than when it is the sole mode used for delivery of care.

Adolescent↗
PubMed1998

Extracorporeal membrane oxygenation. Controversies in selection of patients and management.

This article reviews controversies associated with the selection of patients for extracorporeal membrane oxygenation (ECMO) and their management. Although there has been a raging debate regarding the use of ECMO in the management of hypoxic respiratory failure in the near-term and term newborn, the authors maintain that this issue is resolved and that ECMO is now a standard of care and should be offered to every neonate who is likely to fail conventional treatment. It is the authors' contention, that there is no apparent increase in morbidity associated with the use of ECMO and that better results might be achieved if ECMO were employed earlier in the patient's course, before hypoxic-ischemia organ damage occurs.

Extracorporeal Membrane Oxygenation↗
PubMed1997

Ventilator management of infants before extracorporeal membrane oxygenation.

The aim of this project was to review the course of infants referred for consideration of extracorporeal membrane oxygenation (ECMO) to identify maximal ventilator settings that, when exceeded, did not provide clinical benefit to the patient. These settings might then be used in defining failure of conventional mechanical ventilation. We reviewed referral records and hospital charts of all infants treated for severe respiratory failure due to meconium aspiration syndrome during the 52.5 month period from March 15, 1985, to August 1, 1989. At an inspiratory pressure > 35 cm H2O, 75% (43/57) of patients eventually required ECMO, and 28% (4/14) of the infants who did not receive ECMO died. When the inspiratory pressure was > or = 40 cm H2O, 39/49 patients required ECMO, and 30% (3/10) of those not treated with ECMO died. Once the inspiratory pressure was > 45 cm H2O, 91% (29/32) of patients required ECMO, and only one third of those not treated with ECMO survived. Although the limitations for conventional therapy suggested in this paper may be helpful to clinicians, each center needs to establish guidelines for maximal conventional ventilator support. If these guidelines are clearly defined, alternative methods of therapy can be used once these criteria are achieved.

Apgar Score↗
PubMed1994

Treatment of persistent pulmonary hypertension of the newborn without hyperventilation: an assessment of diffusion of innovation.

OBJECTIVE: The treatment of neonates with persistent pulmonary hypertension of the newborn (PPHN) is controversial with no consensus on diagnostic criteria or treatments. Hyperventilation has been the therapeutic mainstay. However, two widely variant alternative approaches have been proposed: ventilation without induced alkalosis, or more aggressive therapies such as high frequency ventilation or extracorporeal membrane oxygenation. We wished to determine the extent to which these alternative treatments have diffused into practice. METHODS: A forced choice questionnaire was mailed to a sample representing 10% of 3740 practicing neonatologists. Sixty percent of those surveyed responded. Data on treatment practices was tabulated. Subanalyses with respect to training era, practice site, and geographic region were performed. RESULTS: In patients with meconium aspiration syndrome, without evidence of PPHN, 36% described their initial management as hyperventilation. If PPHN was confirmed, hyperventilation was used in 90% of patients by 44% of the respondents. Muscular paralysis and inotropic support were also used frequently. Alkali and vasodilator infusion were used less frequently. The gentle ventilation strategy proposed by Wung and James at Columbia Babies Hospital was used infrequently by 47% of respondents. Gentle ventilation was used more frequently by board-certified neonatologists than those not certified. No significant differences in practice were identified by geographic region or era of training. When standard treatment failed, only 40% of the respondents utilized rescue treatments such as high frequency ventilation or extracorporeal membrane oxygenation. CONCLUSIONS: This study documents that gentle ventilation, an easily and inexpensively adopted innovation, has not diffused into practice significantly while more expensive high technology treatments, such as high frequency ventilation and extracorporeal membrane oxygenation, have penetrated more significantly.

Diffusion of Innovation↗
PubMed1994

Recognition and medical management of necrotizing enterocolitis.

The signs and symptoms associated with necrotizing enterocolitis (NEC) and the common scenarios in which NEC is observed are described to help physicians appreciate the breadth of this illness and to aid in the identification and diagnosis of those affected. An outline for medical management of infants with NEC is presented, based on the pathophysiology of this disease.

Enterocolitis, Pseudomembranous↗
PubMed1991

Significance of seizures associated with extracorporeal membrane oxygenation.

We previously reported a predominance of left focal motor seizures in infants receiving extracorporeal membrane oxygenation (ECMO), raising concerns about possible ischemia resulting from the right common carotid artery ligation. We therefore evaluated the neurologic and psychologic outcome at 2 years of age of all infants with ECMO-related seizures. Although 8 of 12 infants had left focal seizures in infancy, there was no lateralization of motor findings at 2 years of age; left hemiparesis was present in three of the infants and right hemiparesis in three. The developmental quotient was normal in 6 of 12 infants, low-average in three, borderline in two, and in the mentally handicapped range in one. We conclude that any ischemia resulting from carotid ligation is not great enough to produce long-term lateralizing findings but that seizures during ECMO are a risk factor for later cerebral palsy or developmental delay.

Child Behavior↗
PubMed1990

Compliance, alveolar-arterial oxygen difference, and oxygenation index changes in patients managed with extracorporeal membrane oxygenation.

Eighteen patients with meconium aspiration syndrome who failed conventional management were treated with extracorporeal membrane oxygenation (ECMO) for reversible respiratory failure. Dynamic lung compliance measurements were made prior to, during, and after ECMO support. P(A-a)O2 and oxygenation index (OI) measurements were calculated prior to and after ECMO support. Lung compliance decreased significantly comparing before-ECMO to during-ECMO, and increased significantly comparing during- to after-ECMO, but not comparing before- to after-ECMO measurements. P(A-a)O2 and OI decreased significantly from before to after ECMO. The improvement in oxygenation allowing removal from ECMO does not appear to be related to improved pulmonary mechanics, but may rather be secondary to increased effective pulmonary capillary blood flow.

Extracorporeal Membrane Oxygenation↗
PubMed1990

Incidence of hypertension in infants on extracorporeal membrane oxygenation.

Systemic hypertension has been associated with extracorporeal membrane oxygenation (ECMO) applied in neonatal respiratory failure. To determine the incidence of ECMO-related hypertension, we reviewed blood pressure measurements from indwelling aortic catheters in 31 infants consecutively placed on ECMO. Systemic hypertension (systolic blood pressures greater than 100 mm Hg for 4 or more consecutive hours) developed in 18 of the 31. Causes investigated included the roles of renin secretion, sodium, and colloid loads. There was no evidence of increased plasma renin activities in hypertensive infants (H), when compared with their own pre-ECMO controls or with the nonhypertensive infants (NH). Sodium and colloid loads and their rates of delivery were not different between H and NH. No consistent duration of ECMO was clearly associated with development of hypertension (mean time on ECMO at onset of hypertension, 43.8 +/- 38.5 hours; range, 1 to 142 hours). Demographic information was not statistically significant. Contrary to previous reports, H did not seem predisposed to an increased incidence of intracranial hemorrhage. Development of hypertension during ECMO is not related to increased plasma renin activity, sodium or colloid loads, or their rates of infusion.

Blood Pressure↗
PubMed1990

Hidden mortality rate associated with extracorporeal membrane oxygenation.

We reviewed the outcome of all infants referred to, and accepted in, our extracorporeal membrane oxygenation (ECMO) program during a 52-month period. One hundred sixty-seven referrals, representing 158 infants and nine mothers who had not yet delivered their infants, were accepted. Eighteen infants (11.3% of all neonates transported) died before leaving the referring hospital, during transport, or shortly after admission to our unit. Contraindications to ECMO excluded 17 (10.1%) of the 167 referrals. Sixty-two infants (37.1%) initially did not meet ECMO criteria. Two died before ECMO could be started. Sixty-eight infants (40.7%) were given ECMO therapy, and 11 died (16.1%). Nine mothers were referred because of fetal conditions that might require ECMO; of these infants, two died during delivery and three had contraindications to the use of ECMO. The four remaining infants were given ECMO therapy; three survived. The overall mortality rate was 27.5% (46/167); 18 (39.1%) of the 46 deaths were associated with transfer. The mortality rate associated with congenital diaphragmatic hernia was 63.6%. We recommend early transport of infants with this type of hernia during the postoperative "honeymoon" or during in utero transport with delivery at an ECMO center. We also recommend that infants with meconium aspiration syndrome be transported to an ECMO center when an oxygenation index of 25 is reached. The mortality rate associated with transport needs to be considered in evaluating ECMO programs. Earlier, expedited transfers may increase the survival rate.

Evaluation Studies as Topic↗
PubMed1990

Recent experience with diaphragmatic hernia and ECMO.

In the past 4 years at the Medical College of Georgia, a total of 74 patients underwent extracorporeal membrane oxygenation (ECMO) with 62 (84%) survivors. Forty-seven of these infants had meconium aspiration syndrome and 11 had diaphragmatic hernia. The use of ECMO, when indicated, after reduction and repair of the diaphragmatic hernia, results in normal oxygen delivery, allows time for pulmonary maturation, and increases survival. A total of 27 referrals for diaphragmatic hernia were studied. Six infants had surgical repair and did not require ECMO. Eleven patients, after surgical repair, were treated with ECMO and seven survived. More importantly 10 patients died before the use of ECMO. Six infants died either before or during transport from referring hospitals and four died while in the delivery room or neonatal unit before ECMO. Of these 10 infants, eight were potential candidates for ECMO. Thirteen of the twenty-seven (48%) infants survived. Seven of eleven (64%) infants who received the benefit of ECMO survived. Eight infants who met the criteria for ECMO died before its use. Had ECMO been used in those eight infants, our data suggests that at least four may have survived. The data from this report support the concept that infants undergoing surgical repair of diaphragmatic hernia, when ECMO is not available, should be referred to an ECMO center in the early postoperative period. Furthermore infants with prenatal diagnosis of diaphragmatic hernia should be delivered at a center where surgical as well as ECMO expertise are available.

Extracorporeal Membrane Oxygenation↗
PubMed1990

Need for and impact on neonatal mortality of extracorporeal membrane oxygenation in infants of greater than 2500-gram birth weight.

The use of extracorporeal membrane oxygenation (ECMO) has increased significantly during the last 4 years, with more than 2400 infants now having been treated with the technique. In spite of an ill-defined role for ECMO as well as the potential for neurologic sequelae for these patients, additional centers continue to be established across the United States. To provide information regarding the number of babies who could be expected to require ECMO, the early neonatal deaths for the state of Georgia were reviewed for the 2-year period 1983-1984. By means of both linked birth and death certificate analysis and chart review of infants with a birth weight of 2500 g or more, identification was made of 36 infants whom we classified as potential ECMO candidates. These infants were thought to represent 80% of all infants who would have received ECMO during the 2 years, resulting in an estimate of 1 patient receiving ECMO per 3717 live births for the state. With a predicted survival rate of 80% for this group, the state neonatal mortality rate would have declined by 0.13 per 1000 live births, a decrease of 1.4%.

Birth Weight↗
PubMed1989

The significance of ductal shunting during extracorporeal membrane oxygenation.

The purpose of this study was to evaluate the significance and direction of shunts at the level of the foramen ovale or ductus arteriosus in full-term newborns with neonatal respiratory failure who were placed on extracorporeal membrane oxygenation (ECMO). A decrease in left ventricular dimension was expected when infants were placed on ECMO but did not occur. A left-to-right shunt was demonstrated at the ductal level in nine of 12 infants early in the course of ECMO before pulmonary resistance decreased. Presumably, the lack of change in the left ventricular dimension when infants were placed on bypass was due to a left-to-right shunt at the ductal level with ductal flow replacing the right heart output, being drawn into the bypass circuit.

Ductus Arteriosus, Patent↗
PubMed1989

Bypass circuits as the source of thromboemboli during extracorporeal membrane oxygenation.

To determine the presence and extent of thrombus formation in the apparatus used for extracorporeal membrane oxygenation we studied various portions of the polyvinylchloride circuit from five infants who received extracorporeal membrane oxygenation for 70 to 330 hours. All infants had right-sided cannulation. Sections were cut from the circuit at the time of decannulation and subjected to light and scanning electron microscopy. The site that contained the most thrombus formation was the membrane oxygenator bypass circuit, which is subjected to repeated periods of unclamping and clamping to direct blood flow through the membrane oxygenator. Autopsy results from nonsurvivors showed evidence of pulmonary and renal infarcts, a left frontal lobe infarct, a thromboembolus of the left external and internal carotid arteries, and thrombi in the lungs, kidney, brain, and coronary arteries. One survivor had computed tomographic evidence of infarction of the left middle cerebral artery distribution. We suggest that the areas of the extracorporeal membrane oxygenation circuit subjected to repeated changes in flow dynamics may be the source of microemboli.

Catheters, Indwelling↗
PubMed1988

Successful gastrorrhaphy on ECMO.

From April 1985 to November 1987, over 100 infants were evaluated for extracorporeal membrane oxygenation (ECMO) in the treatment of respiratory failure. Of these infants, 40 underwent ECMO after failure of conventional treatment. Four developed gastroduodenal perforations. One developed a perforation prior to going on ECMO and died after several hours on ECMO, one developed a perforation while being treated conservatively for respiratory failure that never required ECMO, and two developed perforations requiring laparotomy while on ECMO. These two infants constitute the first report of successful gastrorrhaphy in infants while being supported by ECMO and anticoagulation with heparin. Particular measures helpful in the management of these infants included near-total cardiopulmonary bypass, reduction of the activated clotting time to 170 to 200, transverse abdominal incision for exposure, use of electrocautery, appropriate drainage of the operative site, insertion of a gastrostomy for gastric decompression and irrigation, rapid weaning from ECMO as soon as respiratory support could be provided by conventional methods, and the use of massive blood and platelet transfusions. In summary, 33 of 40 infants undergoing ECMO survived. Furthermore, two of the three infants with intestinal perforation who underwent ECMO have survived without significant short-term sequelae, and are 24 and 30 months of age, respectively. Therefore, we believe that despite severe respiratory failure requiring ECMO and anticoagulation with heparin, infants with intestinal perforation can be managed surgically with anticipated survival and good long-term prognosis.

Duodenal Diseases↗
PubMed1988

Right common carotid artery ligation in extracorporeal membrane oxygenation.

The effect of right common carotid artery ligation required for arteriovenous extracorporeal membrane oxygenation (ECMO) was investigated in 35 infants. Their neonatal course was reviewed for evidence of right-sided ischemia of the brain, as suggested by the presence of focal seizures, hemiparesis, focal abnormalities on electroencephalography, or infarct or hemorrhage demonstrable on neuroimaging studies. A significant incidence of left focal seizures (9/35) versus right focal seizures (2/35) was noted, suggesting an effect of the carotid ligation on right hemisphere function. Computed tomographic scans (20/35 infants), electroencephalograms (18/35), ultrasound scans (31/35), and neurologic examinations did not reveal an increased incidence of right hemisphere abnormalities. These data suggest that systematic evaluation of the effects of right common carotid ligation should proceed as discussion continues on expanding the use of ECMO.

Brain↗