Biomedical subjects

R M Filler

Publications and source records attributed to R M Filler.

At least 73 records · Page 4Linked to original sources

PubMed1989

Metabolism of intravenous fat emulsion in the surgical newborn.

The metabolism of an intravenous (IV) fat emulsion was investigated by the combination of chemical balance and computerized indirect calorimetry techniques in 21 newborns (birth weight, 3.0 +/- 0.1 kg; mean +/- SE). All babies were appropriate for gestational age and received total parenteral nutrition after a major surgical procedure. The study was divided into two consecutive periods. Phase 1 consisted of infusion of 10% glucose and 2% amino acid solutions for 24 hours, and phase 2 involved the "Intralipid utilization test" (isocaloric and isovolemic infusion of Intralipid 10% for four hours). The caloric intake was 67.1 +/- 1.9 kcal/kg/d during both phases of the study. The resting energy expenditure was 44.8 +/- 1.6 and 46.5 +/- 1.8 kcal/kg/d during phases 1 and 2 respectively. During glucose/amino acid infusion, 12 patients oxidized endogenous fat, and de novo lipogenesis from glucose was observed in nine. During the Intralipid infusion, there was a significant and progressive decrease of carbon dioxide production, respiratory quotient, and carbohydrate utilization (oxidation plus conversion to fat). Net lipogenesis ended and fat utilization significantly increased. By the second hour of Intralipid infusion, 58% of energy expenditure was derived from fat oxidation. The drop in carbon dioxide production correlated positively with the decrease in carbohydrate utilization (r = .07; P less than .001). During the third and fourth hours of phase 2, the percentage of fat utilized was negatively correlated with the amount of fat given (r = -.07; P less than .01). The surgical neonate showed rapid metabolic adaptation to Intralipid infusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Dietary Carbohydrates↗

PubMed1989

Preventable pediatric trauma deaths in a metropolitan region.

All pediatric trauma deaths occurring in metropolitan Toronto (population, 2.2 million) in 1986 were analyzed from the regional coroner's records. Injuries sustained were scored using the Abbreviated Injury Scale (1985; AIS) and Injury Severity Score (ISS). Victims with injuries graded AIS 6 (any region), AIS 5 head/neck (excluding acute epidural hematoma), or ISS greater than 59 were deemed unsalvageable. All other injuries were considered survivable and the deaths from them preventable. Use of these objective criteria indicated that 8/38 of the children (21%) who died from trauma had survivable injuries. Since in three cases medical aid was not sought because of social circumstances, 5/38 (13%) was considered a realistic estimate of preventable death rate (PDR). These results suggest that when objective criteria are used, the PDR in pediatric trauma may be less than that reported in adult trauma victims. Defining the PDR on the basis of objective criteria may prove useful in the conduct of further studies of this kind and permit valid comparisons to be made.

Adolescent↗

PubMed1989

Splenic injury: a 5-year update with improved results and changing criteria for conservative management.

The policy of conservative nonoperative management of the injured spleen is reviewed, and recommendations are made to improve this mode of therapy. From 1981 to 1986, 75 patients were admitted with diagnosed splenic injury. Of thes, ten were operated on (four splenorrhaphies, three total splenectomies, one partial splenectomy; in two, the spleen had stopped bleeding spontaneously) and three died, all from causes unrelated to splenic trauma. Only 23% of the patients treated nonoperatively required blood transfusions, and the length of both hospital stay and time spent in the ICU was reduced. The results of this review show that, in comparison with our previous 5-year report, the number of patients treated without surgery increased from 70% to 87%, those receiving blood transfusions decreased from 36% to 23%, and the number undergoing a splenectomy decreased from 24% to 4%. These data suggest that almost all children with splenic injury can be successfully treated without an operation, those who are hemodynamically stable do not require ICU care, and the total hospital stay for uncomplicated splenic injury can be limited to seven days. A laparotomy can be safely reserved for patients with immediate massive hemorrhage or with transfusion requirements of greater than 40 mL/kg.

Adolescent↗

PubMed1989

Splenic injury: a 5-year update with improved results and changing criteria for conservative management.

The policy of conservative nonoperative management of injured spleens is reviewed and recommendations are made to improve this mode of therapy. From 1981 to 1986, 75 patients were admitted with diagnosed splenic injury. Of these, ten were operated on (4 splenorrhaphies, 3 total splenectomies, 1 partial splenectomy) and three died, all from causes unrelated to splenic trauma. Only 23% of the patients treated nonoperatively required blood transfusions, and the length of both hospital stay and time spent in the intensive care unit (ICU) was reduced. The results of this review show that, in comparison with our previous 5-year report, (1) the number of patients treated without surgery rose from 70% to 87%, (2) those receiving blood transfusions dropped from 36% to 23%, and (3) the number undergoing a splenectomy fell from 24% to 4%. These data suggest that (1) most children with splenic injury can be successfully treated without operation, (2) those who are hemodynamically stable do not require ICU care, and (3) the total hospital stay for uncomplicated splenic injury can be limited to seven days. A laparotomy can be safely reserved for patients with immediate massive hemorrhage or with transfusion requirements of greater than 40 mL/kg.

Adolescent↗

PubMed1989

Resting energy expenditure is increased in infants and children with extrahepatic biliary atresia.

To determine if liver dysfunction in children affects energy and macronutrient homeostasis, we performed 13 metabolic studies in 11 patients (age, 17.8 +/- 5.9 months [mean +/- SEM]) with extrahepatic biliary atresia (EHBA). Nutritional balance, indirect calorimetry, anthropometry, and biochemical liver function tests were utilised. Sixty-four percent of the energy losses were in the form of stool fat. Energy expenditure (68 kcal/kg/d) was 29% higher than normal (P less than 0.0025). Only one third of the metabolisable energy intake (37 kcal/kg/d) was stored in the body for new tissue synthesis. In spite of the bountiful protein intake for age, the increased protein oxidation (2g/kg/d) resulted in a virtually zero mean nitrogen balance. In addition, four patients oxidised endogenous protein as well. The respiratory quotient was 0.96, and did not change significantly between pre- and post-meal measurements, suggesting a predominant utilisation of carbohydrate for energy metabolism. Net lipid oxidation was severely diminished. We found that the higher the serum aspartate aminotransferase level (previously named SGOT), the lower the net fat oxidation, and the higher the conversion of glucose to fat. These data suggest that markedly increased energy expenditure contributes to the malnutrition of patients with EHBA. We characterised for the first time how severe liver disease in infants and children affects carbohydrate, fat, and protein metabolism, thus inducing protein-energy malnutrition.

Basal Metabolism↗

PubMed1989

Analysis of energy and macronutrient balance in the postoperative infant.

The purpose of this study was to better define the energy and macronutrient balance of infants after major surgery. Forty studies were conducted in 29 full-term surgical infants (mean weight, 3.27 +/- 0.19 kg; mean days postsurgery, 8 +/- 1). Nineteen infants were receiving total parenteral nutrition, 13 were orally fed, and eight received a combination of intravenous and oral nutrition (mean caloric intake, 84 +/- 4 kcal/kg/d). Each study was comprised of a three-day nutritional balance measuring energy intake and energy losses in excreta. Metabolizable energy intake (MEI) was determined by subtracting losses from gross intake. Energy expenditure and macronutrient oxidation were determined on the second day of the balance using continuous open-circuit indirect calorimetry in combination with timed urinary nitrogen excretion. Energy and macronutrient storage were calculated by subtracting oxidation and losses from measured intake. The mean global energy expenditure was 57 +/- 1 kcal/kg/d. Linear regression analysis of the nutritional balance data allowed estimates of energy, fat, and protein storage at various MEI. The data suggest that in the surgical infant, protein balance is maintained, even during hypocaloric nutritional regimens. In infants receiving adequate calories to maintain energy balance, maintenance metabolism is supported by the oxidation of endogenous fat. Net fat deposition will predictably only occur at metabolizable intakes of greater than 71 kcal/kg/d.

Energy Metabolism↗

PubMed1989

Late gastrointestinal bleeding and protein loss after distal small-bowel resection in infancy.

Four children who underwent extensive small-bowel resection in infancy developed recurrent iron deficiency anemia due to gastrointestinal bleeding between 4 and 12 years later. The initial resections were required for multiple ileal atresia (n = 2) and gastroschisis (n = 2). Three patients have had melena and one had persistently guaiac-positive stools. Three patients had protein-losing enteropathy, and in one there was persistent hypoalbuminemia. Colonoscopy identified circumferential ulcerative lesions at the surgical anastomosis (n = 2) and at laparotomy another patient had well-defined linear ulcers close to the surgical anastomosis. Histology demonstrated focal ulceration with chronic inflammation, but did not show granulomata, crypt abscesses, or malignancy. Multiple imaging procedures and gastroduodenoscopy failed to identify an alternative bleeding source. Medical therapy including iron, antacids, sucralfate, H2 antagonists, and cholestyramine was ineffective. Two patients have undergone anastomotic resection. One experienced symptomatic recurrence 4 months after surgery. Repeat colonoscopy found ulceration at the new anastomosis with similar histology. The other patient remains asymptomatic 7 months postsurgery. Recurrent gastrointestinal hemorrhage due to anastomotic ulceration, of unknown etiology, appears to be a late complication of small-bowel resection in infancy.

Abdominal Muscles↗

PubMed1989

Functional outcome in pediatric trauma.

Two hundred fifty consecutive children hospitalized with severe injuries (at least one injury with an Abbreviated Injury Score [AIS] greater than or equal to 4 or two or more injuries with AIS scores greater than or equal to 2) were studied to determine their functional status at discharge and 6 months later using questions from the RAND Health Insurance Study (HIS) and the Glasgow Outcome Scale (GOS). Of the 217 surviving patients, 190 (88%) had one or more functional limitations by the HIS scale at discharge. Ten (5%) were in a vegetative state, 40 (18%) severely disabled, 97 (45%) moderately disabled, and 70 (32%) healthy by the GOS. Six-month followup was complete for 156 patients. Of these, 84 (54%) had one or more functional limitations by the HIS scale. Seven (4%) were in a vegetative state, 17 (11%) severely disabled, 50 (32%) moderately disabled, and 82 (53%) healthy by the GOS. A substantial proportion of the whole group of children hospitalized for the treatment of severe injuries had ongoing physical disabilities that limited their participation in normal activities 6 months after they were discharged. This suggests a need for greater emphasis on the rehabilitation of pediatric trauma patients.

Activities of Daily Living↗

PubMed1988

A new intratracheal stent for tracheobronchial reconstruction: experimental and clinical studies.

An intraluminal tracheal stent (ITS) was used experimentally in rabbits and piglets, as well as clinically in infants with tracheal stenosis, to facilitate airway reconstruction. The ITSs were constructed of stainless-steel springs covered with silicone rubber. They were implanted in seven piglets (6 to 8 kg), five rabbits (3 to 5 kg) and three infants. No animals developed severe respiratory distress and all appeared to tolerate the ITS. Postmortem examinations 1 to 8 weeks after surgery showed (1) loss of stent fixation (one pig), (2) increased tracheal secretions, (3) pneumonia (one pig, two rabbits), and (4) focal squamous metaplasia of tracheal mucosa. Stents used to treat three infants (2 to 5 months of age) with complex tracheobronchial stenosis were placed at the time of periosteal tracheoplasty in two. Recurrent stenosis necessitated a second tracheoplasty and stenting in one, and a long tracheostomy tube and balloon dilatations in the other. The third child had endoscopic stent insertion to alleviate severe airway collapse after esophageal tracheoplasty. The child died from progressive respiratory failure after stent dislodgment. Although the stents were well tolerated in animals and they enhanced critical ventilation of all pulmonary lobes in infants after tracheal reconstruction, certain modifications such as alternative methods of fixation, accommodation for tracheal growth, and reduction in tissue reactivity are necessary before further use of the ITS can be advocated.

Animals↗

PubMed1988

Central venous catheters--no X-rays needed: a prospective study in 50 consecutive infants and children.

A technique of central venous line (CVL) placement using ECG guidance is described. The method utilizes equipment found in most operating room departments, is easily learned and taught, and obviates the need for x-rays. CVL placement in 50 consecutive infants and children was performed over a 4-month period by the ECG-guided method, with catheter tip position subsequently determined by x-ray study. The technique demonstrated a 96% success and 100% accuracy rate. The two technical failures were both preventable. Equipment malfunction was responsible for one failure. The second failure was secondary to a preexisting supraventricular arrhythmia, and patients with arrhythmias or pacemakers are not suitable candidates for this technique of central venous catheterization. Radiologic methods of CVL placement were necessary in these two patients.

Adolescent↗

PubMed1988

Characteristics of protein sparing effect of total parenteral nutrition in the surgical infant.

To determine the best formula to prevent protein depletion, 31 surgical infants on intravenous (IV) diet were studied. The study was divided into two phases. Phase I diet included 5% glucose and 1.5% or 2% amino acid infusion; phase II diet consisted of 5% glucose and 1.5% or 2% aminoacid plus 10% Intralipid. In each phase, oxygen consumption, carbon dioxide production, and energy expenditure were determined. The utilization of carbohydrate, fat, and protein was calculated from urinary nitrogen excretion and nonprotein respiratory quotient. The mean caloric intake during phase I and phase II was 62 and 94 kcal/kg/d, respectively. A positive nitrogen balance was obtained in infants receiving fat-free total parenteral nutrition (TPN) with a mean protein intake of 2.6 g/kg/d and a mean energy intake exceeding the energy expenditure by 24%. Infusion of more calories as Intralipid (phase II) caused a significant reduction in protein oxidation, thus protein contribution to the energy expenditure and an increase in protein retention. We conclude that supplementation of low-calorie TPN diets with Intralipid increases protein sparing and is preferable to the administration of very high glucose loads.

Amino Acids↗

PubMed1988

Timing of surgery for congenital diaphragmatic hernia: is emergency operation necessary?

Congenital diaphragmatic hernia (CDH) is considered by most researchers to be a surgical emergency. However, early repair does not necessarily improve respiratory function or reverse fetal circulation, and many patients deteriorate postoperatively. As a result, in 1985, we began to employ a protocol in which surgery was delayed until the PCO2 was maintained below 40 and the child was hemodynamically stable; children in whom these criteria could not be achieved died without surgical repair. Sixty-one consecutive infants with CDH were managed over 4 years; 31 from 1983 to 1984 (group 1) and 30 from 1985 to 1986 (group 2). The groups were similar with respect to sex, side of the defect, birth weight, gestational age, incidence of pneumothorax, and blood gases. High frequency oscillation was used with increasing frequency during the study period, for patients with refractory hypercarbia (13% in group 1, 30% in group 2). All patients were initially paralyzed and ventilated. Mean time from admission to surgery was 4.1 hours in group 1 and 24.4 hours in group 2 (P less than .05). In group 1, 87% of patients had surgical repair (77% within eight hours of admission, 10% after eight hours), and in group 2 only 70% of patients had surgery (10% within eight hours, 60% after eight hours). All patients who were not operated on died. Overall mortality was 58% in group 1 and 50% in group 2; this difference was not statistically significant. These data indicate that our current approach has not increased overall mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergencies↗

PubMed1988

Congenital tracheal stenosis: a review of 22 patients from 1965 to 1987.

Twenty-two infants with congenital tracheal stenosis (CTS) were treated in our hospital between 1965 and 1987. Diagnosis was confirmed by endoscopic and radiographic methods. Patients had a spectrum of tracheobronchial lesions from localized stenosis to more complex deformities involving the carina and bronchi. Other anomalies were found in all patients with the occurrence of vascular slings or rings in 11 patients (50%). Six infants treated nonoperatively died from severe CTS and other lethal anomalies. Five of 16 patients (31%) treated surgically survived. Localized CTS in four cases was treated by dilatation, tracheostomy, or tracheal resection with primary anastomosis (two survivors, 2 non-survivors). Funnel-shaped deformities and extensive tracheobroncial stenosis were treated by tracheal reconstruction using a variety of autogenous tissue and prosthetic grafts (three survivors, nine non-survivors). The overall mortality was 77%. A new intratracheal stent was used in two patients. The stent was a flexible steel spring covered with a silicone rubber sheath. In one patient, it was placed within the trachea at the time of repair and removed later with the bronchoscope. A stent was used in a second patient with intermittent airway obstruction following an esophageal tracheoplasty. In this case, the device failed to alleviate the obstruction, and the infant expired from progressive respiratory failure. Issues of importance in the management of infants with CTS are: (1) adequate evaluation of the tracheobronchial tree, (2) awareness that tracheobronchography may precipitate further respiratory decompensation, (3) assessment of vascular and other anomalies requiring surgical correction, and (4) selection of an appropriate therapeutic approach.

Female↗

PubMed1988

Plication of the diaphragm for infants and young children with phrenic nerve palsy.

Phrenic nerve palsy (PNP) is seen in infants and young children usually resulting from operative trauma or birth injury. Spontaneous recovery usually occurs, but occasionally surgical plication is necessary. Twenty-three cases of PNP over a 10-year period were managed surgically. Patient ages ranged from 1 day to 30 months (median, 4 months), 18 were male and five female. Cause was operative trauma in 18 (17 cardiac surgery, one neuroblastoma), birth trauma in two, and idiopathic in three. The right side was involved in 14, the left in eight, and both in one. Indications for plication were inability to wean from the ventilator (group 1, 16 patients), recurrent pneumonia (group 2, four patients), and respiratory distress (group 3, three patients). The 16 patients in group 1 were intubated for a median of 18.5 days from onset of PNP to plication. Postoperatively, three had continuing congestive heart failure (one died at 16 days of age, one was still chronically ventilated at 22 months, one was extubated at nine days); the other 13 were extubated at a median of two days postoperatively. All the patients in groups 2 and 3 were extubated within two days of surgery. Twelve plications were transthoracic and 11 were transabdominal. Postoperative complications included pneumonia (2), wound infection (1), pneumothorax (2), and mucous plug with pulmonary collapse (1). One patient died of cardiac failure at 16 days. One patient in group 3 developed recurrent respiratory distress 4 months postoperatively; he had a recurrent elevated hemidiaphragm requiring a second plication.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac Surgical Procedures↗

PubMed1988

Evaluation of doubly labeled water for measuring energy expenditure during changing nutrition.

Change in abundance of 2H and 18O in dietary water during a doubly labeled water energy period may introduce error into the calculated carbon dioxide production rate (RCO2). To examine the accuracy of 2H2(18)O during changing nutritional regimens, we compared 2H2(18)O and periodic open-circuit respiratory gas exchange (RGE) in postsurgical infants who were changing from parenteral to alternative parenteral and/or oral nutrition. The two methods were compared before and after correction for shifts in isotopic abundance of the infant water pools during the energy-expenditure period. Baseline corrections were predicted using the difference between abundances of the initial body water and final nutrient solutions. Before isotopic correction, 2H2(18)O underestimated RCO2 in eight subjects by 11.8 +/- 20.1% (mean +/- SD). After correction, agreement between the two methods improved; the underestimate was then -8.7 +/- 12.9%. To obtain maximum precision of 2H2(18)O, subjects should be maintained on the same nutritional regimen before and during the study unless valid correction formulae are used.

Algorithms↗

PubMed1988

Evaluating a pediatric trauma program: effectiveness versus preventable death rate.

We compared effectiveness (E), the proportion of severely injured patients who were salvageable and survived, to the preventable death rate (PDR) over three consecutive 1-year periods. Severely injured patients were those with at least one injury with an Abbreviated Injury Score (AIS) of greater than or equal to 4. Those with one fatal injury (AIS greater than or equal to 6), a critical head injury (AIS greater than or equal to 5) apart from acute epidural hematoma, or massive multiple injuries (Injury Severity Score greater than 59) were considered nonsalvageable; the remainder were considered salvageable. In the first year, six of 74 salvageable patients died, in the second year five of 76, and in the third year one of 69. The PDR rates were 0.32 (6/19), 0.23 (5/22), and 0.06 (1/17), respectively. There was no significant difference in the E of our trauma program over the 3 years. The apparent improvement in PDR in the second and third years resulted from an increased number of deaths among nonsalvageable patients and fewer deaths among salvageable patients. This finding demonstrates that PDR is sensitive to case mix and not just quality of care, and confirms the superiority of E over PDR for assessing a trauma program.

Child↗

PubMed1987

Interposition of the gallbladder--or the absent common hepatic duct and cystic duct.

Interposition of the gallbladder is a rare anomaly, but its diagnosis is important since it represents a surgically correctable cause of jaundice. The patients present with jaundice, abdominal pain and sometimes an enlarged gallbladder. Radiological diagnosis may be difficult since the condition may be mistaken for a choledochal cyst, hydrops of the gallbladder or Caroli's disease. The ultrasound, cholangiogram and surgical findings of dilated intrahepatic ducts adjacent to a normal or enlarged gallbladder with no dilatation of the common bile duct are presented in two children with this condition.

Child, Preschool↗

PubMed1987

Tracheomalacia: an experimental animal model for a new surgical approach.

Tracheomalacia was created by removing the posterior 50% of the circumference of eight cartilage rings (5-6 cm in length) from the intrathoracic trachea in each of 12 piglets while leaving the mucosa intact. In 6 animals an autologous, free tibial periosteal graft was applied over the defect (graft group). The remaining 6 piglets served as the control group. In all animals, a silastic stent was left in the trachea for 2 weeks to prevent immediate tracheal collapse. The presence of tracheomalacia was assessed 6-8 weeks after surgery. At bronchoscopy total tracheal collapse during coughing occurred only in the controls. As the animals went from quiet breathing to coughing, mean intrathoracic pressure increased from 5 to 80 cm H2O in both groups, and average sagittal tracheal diameter decreased by 10% in the graft group and 71% in the controls. During coughing, mean resistance to airflow across the defect increased by 0.005 +/- 0.002 cm H2O/liter/min in the graft group, by 0.083 +/- 0.96 cm H2O/liter/min in the controls (P less than 0.005), and by 0.027 cm H2O/liter/min at the same tracheal level in two normal pigs. At sacrifice 12 weeks postoperatively, bone and collagenized fibrous tissue had been produced by all grafts, without evidence of stricture. This study shows that experimentally induced tracheomalacia can be treated successfully by the application of an autologous periosteal tibial graft, which becomes incorporated into the weakened tracheal wall.

Airway Resistance↗