[The importance of amino acids in the nutrition of patients with multiple traumas or sepsis].
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Amino Acids↗
Biomedical subjects
Z Barzilay
Publications and source records attributed to Z Barzilay.
Fibrothorax associated with a ventriculopleural shunt in a hydrocephalic child.
Ventriculopleural (VPL) shunts are considered a safe alternative to peritoneal shunts in the management of hydrocephalus. Occasionally, however, they are associated with persistent pleural effusion. We report a child, aged 3 1/2 years, who developed severe fibrothorax following the use of a VPL shunt. The shunt was removed and decortication had to be performed to alleviate his respiratory symptoms. This serious complication, never reported previously, should be borne in mind when the pleural cavity is chosen for deviation of the cerebrospinal fluid in hydrocephalic children.
Cerebrospinal Fluid Shunts↗
Epinephrine blood concentrations after peripheral bronchial versus endotracheal administration of epinephrine in dogs.
BACKGROUND AND METHODS: Emergency endotracheal drug administration has become an acceptable route for drug delivery during cardiopulmonary resuscitation. The purpose of the present study was to determine whether the site of endotracheal epinephrine injection is an important factor in its absorption. Epinephrine (1:1000), in a dose of 0.02 mg/kg diluted in 2 mL of saline, was given to ten anesthetized mongrel dogs. Each dog was studied twice: once when the epinephrine was injected into the endotracheal tube, and on another day, through the endotracheal tube via a flexible catheter wedged into a peripheral bronchus. Arterial blood samples for plasma epinephrine concentration determinations were collected, before and at 1, 2, 5, 10, 15, and 30 mins after each intratracheal drug administration. RESULTS: Both routes of epinephrine administration significantly increased plasma concentrations within 1 min of injection. Higher plasma epinephrine concentrations were achieved after peripheral bronchial epinephrine administration (maximal concentration 8.9 +/- 3.2 vs. 2.0 +/- 0.4 ng/mL), and the total dose absorbed was significantly (76.5 +/- 13.5 vs. 36.7 +/- 6.5 ng/min/mL, p < .05) higher. The time interval to reach maximal concentration was significantly shorter with the peripheral bronchial dosing than with the endotracheal route (1.3 +/- 0.2 vs. 2.7 +/- 0.5 min, p < .05). Neither group demonstrated a significant change in heart rate, and both had similar, minor decreases in BP for > 2 to 5 mins. There were no significant differences between the arterial blood gases of the two groups at various stages of the experiment. CONCLUSIONS: In dogs, epinephrine administered via the peripheral bronchial route has a clear pharmacologic advantage over the endotracheal route. This advantage may be more important during cardiopulmonary resuscitation conditions and other low flow states, and may account for the failure observed with the endotracheal route in recently published clinical reports.
Animals↗
Postoperative unilateral diaphragmatic paralysis in children, a plea for early plication.
Unilateral diaphragmatic paralysis (UDP) is not an uncommon occurrence after cardiovascular operations. Its incidence in the pediatric age group is at least 1.5%, and severely symptomatic (for example: requiring mechanical ventilation) patients account for about one third of the cases. We have encountered four such cases among 850 children (0.5%) undergoing cardiovascular procedures, and have treated two additional patients. All required prolonged intubation and mechanical ventilation. Diaphragmatic plication in five was performed rather late in the course of their illness, after 21-120 days mechanical ventilation, and was successful in three who survived, allowing weaning from ventilation within 3-6 days. The procedure itself is simple and safe. We recommend that diaphragmatic plication be performed early in children with UDP and weaning difficulties.
Adolescent↗
Management of upper airway obstruction in the Pierre Robin syndrome.
Eight patients with Pierre Robin syndrome (PRS), were treated according to our management protocol. All our patients initially were given a trial of conservative, positional treatment, with high caloric gavage feeding. In five patients this therapeutic approach resulted in a good weight gain, with no significant respiratory distress. The remaining three patients showed no improvement, failed to thrive and therefore underwent the tongue to lip adhesion (TLA) procedure. Two patients then improved dramatically; whereas one continued with respiratory distress and failure to thrive and required tracheostomy. We conclude that when symptoms of respiratory distress and failure to thrive coexist in patients with PRS despite conservative management, surgical intervention to the airway is mandatory. TLA should be the first surgical procedure considered and if the ultimate goals of weight gain and respiratory comfort are still not achieved then tracheostomy seems inevitable.
Airway Obstruction↗
Varicella and perforation of the stomach.
Involvement of the gastrointestinal tract is rare in varicella. We report a previously healthy young girl with perforation of the stomach that appeared to be a complication of varicella. Varicella inclusion bodies were demonstrated at the site of gastric perforations. On surgery, an organoaxial volvulus of the stomach was demonstrated.
Chickenpox↗
Calcium blocking agents in pediatric emergency care.
Blocking calcium ion entry into tissue cells appears to have therapeutic benefits in various diseases and symptoms. In the emergency department, as well as in the pediatric intensive care unit, the pediatrician often encounters life-threatening clinical episodes for which the safest, quickest, and most efficient treatment is required. Thus, being familiar with a large variety of emergency therapeutic options, including the use of CBAs, is important. In many medical centers, CBAs have already become the first line of drugs for converting PSVT into normal sinus rhythm (verapamil) and for ameliorating malignant hypertension (nifedipine). The increasing evidence that nimodipine effectively decreases the cerebral damage after head trauma and intracranial hemorrhage will also probably turn this compound into one of the drugs readily available in the emergency department. CBAs will continue to be thoroughly investigated, allowing more new therapeutic applications in pediatric emergency care.
Adolescent↗
A method of macro-auditing and assessing the preventability of infant mortality using large volume computerized files.
We present a method for auditing and evaluating infant mortality with the aid of a preventability grading system, based on national computerized files of livebirths and infant deaths. Diagnostic categories and specific causes of deaths were classified into one of the following three preventability grades: Preventable (P), Possibly Preventable (PP) and Non Preventable (NP). This classification was then applied to two different scales: Preventability of Condition (PC) and Preventability of Death (PD) from which a third scale--Preventability of Mortality (PM)--was derived. The method was then applied to matched records of 39,786 livebirth and 452 infant death certificates between 1977 and 1984, in a semi-urban region in Israel encompassing 220,000 inhabitants. Comparison of mortality rates, according to the proposed preventability scores, demonstrated that higher infant mortality rate in non-Jewish population, or in Jewish mothers with a lower educational, was present only in the preventable categories (P or PP), while death rates due to non preventable causes were identical for all groups. The suggested macro-auditing method facilitates the assessment of large scale infant mortality rates in terms of preventability.
Congenital Abnormalities↗
Multifocal necrotizing fasciitis in varicella.
We describe a two-year-old patient who developed severe necrotizing fasciitis in three nonadjacent sites of his extremities during varicella. The recovery of purulent material by aspiration of deep soft tissues after seven days of fever, leukocytosis, and no response to antimicrobial therapy raised the suspicion of this diagnosis. The patient recovered following surgical drainage, debridement, and subsequent skin grafts. It is emphasized that early diagnosis of this severe complication is important since early surgical intervention decreases morbidity and facilitates recovery.
Chickenpox↗
Branhamella catarrhalis pneumonia in non-immunocompromised pediatric patients: report of three cases and review of the literature.
Branhamella catarrhalis (B.c.) is found as a commensal in the upper respiratory tract of a healthy individual. We report three pediatric patients with bronchopneumonia allegedly caused by B. catarrhalis. All of them were intubated and on a mechanical ventilation (following either elective surgery or trauma) while the infection developed. Although B. catarrhalis has been thought to be penicillin sensitive, an increased frequency of beta-lactamase producing B. catarrhalis has been noted recently. beta-lactamase positive B. catarrhalis is uniformly resistant to ampicillin and its susceptibility to the cephalosporins is quite variable. All the isolated strains were found susceptible to vancomycin. The three patients improved while being on therapy with vancomycin and peripheral airway cultures became sterile.
Adolescent↗
Effectiveness of vitamin E and colchicine in amelioration of paraquat lung injuries using an experimental model.
The major cause of death in paraquat poisoning is a rapidly progressive respiratory failure due to an oxidative insult to the alveolar epithelium with subsequent fulminant obliterating fibrosis. The present study evaluates the effectiveness of vitamin E in combination with colchicine in ameliorating paraquat lung injuries in rats. Vitamin E is a biologic antioxidant interfering with lipid peroxidation, and colchicine reduces collagen synthesis which is significantly augmented in pulmonary fibrosis. Eight normal rats were given a single i.p. dose of paraquat at 15 mg/kg. The treated group included eight animals that received, in addition to i.p. paraquat (15 mg/kg), daily doses of vitamin E (100 mg/kg i.p.) and colchicine (0.1 mg/kg i.p.). All the rats in the paraquat group died within 42 to 96 h, six of them within 60 h, following severe respiratory failure. The treated rats developed a somewhat milder form of respiratory insufficiency, six of them dying within 48 to 72 h. Less severe intra-alveolar hemorrhages were observed in this group. Two rats survived, and these had only mild emphysema on autopsy at 21 days. Our preliminary results suggest that the combination of vitamin E with colchicine may be effective in ameliorating lung injuries caused by paraquat, and warrant further studies.
Animals↗
The admission cardiorespiratory performance in relation to outcome in pediatric ICU patients.
We tested the hypothesis that the admission cardiorespiratory performance determines the outcome in pediatric intensive care unit (PICU) patients. We studied 331 patients who were assigned to one of the three commonly encountered PICU clinical entities: respiratory disease, cardiovascular disease and head trauma. All patients were evaluated by a simple cardiorespiratory scoring system which we named "Rule of 60" (RO60), and their highest score within the first 24 h of arrival in the PICU was used for the study. This scoring system includes 6 cardiorespiratory parameters where a value of 60 represents a cut-off point above or below which 0 points (low risk) or 10 points (high risk) are assigned. The relationship between score and mortality rate revealed that the higher the score the higher is the mortality rate. We determined two categories of severity of illness in our patients. Patients at severity level A had scores ranging from 0 through 30 and the mortality rate in this category ranged from 2% to 5%. Patients at severity level B had scores ranging from 40 through 60 and had a higher mortality rate: 30% to 80%. The overall mortality rates for patients at severity level A and B were 2% and 54% respectively. Patients with respiratory disease at severity level B had the lowest mortality rate (20%), whereas patients with cardiovascular disease and head trauma had mortality rates of 52% and 80% respectively. We found that our cardiorespiratory scoring system was as good as the Glasgow Coma Scale for indicating prognosis and outcome in head trauma patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Variables affecting outcome from severe brain injury in children.
This study evaluates the outcome of 56 severely brain injured children (mean age 6.2 +/- 2.1 years) and relates the Initial Glasgow Coma Scale (IGCS), initial intracranial pressure (ICP int), maximal intracranial pressure (ICP max) and minimal cerebral perfusion pressure (CPP min) to quality of survival. Forty-one children sustained head trauma, five severe central nervous system infections and 10 were of miscellaneous etiology. Therapy consisted of mechanical hyperventilation, moderate fluid restriction, dexamethasone and diagnosis specific measures when indicated. Outcome was categorized according to the Glasgow outcome scale at discharge from the hospital. An IGCS of 3 was associated with 100% mortality, 7 and above resulted in 72% good recovery, 28% poor outcome and no mortality. ICP int of less than 20 torr was noted in (67%) of the patients, and did not correlate with ICP max or outcome. Conversely, ICP int in excess of 40 torr correlated well with ICP max and outcome. ICP max of less than 20 torr resulted in 57% good recovery, 36% poor outcome and 7% mortality. ICP max greater than 40 torr resulted in 7% poor outcome and 93% mortality (p less than 0.001). In head trauma, 32 patients (78%) were alive with mean ICP max 16.9 +/- 3.1 and CPP min 65.5 +/- 8.5 torr compared to 9 patients (22%) who died with mean ICP max 53.7 +/- 10.8 and CPP min 6 +/- 3.9 torr, (p less than 0.01). In children with infectious etiology 60% survived with mean ICP max 16 +/- 3 and CPP min 96 +/- 16 torr.(ABSTRACT TRUNCATED AT 250 WORDS)
Brain Injuries↗
Pneumatic rupture of the esophagus caused by carbonated drinks.
Pneumatic rupture of the esophagus occurs when gas under pressure is accidentally delivered into the oral cavity. To the 4 cases previously described we add 2 pediatric patients and in both the source of the offending gas was a bottle of carbonated drink. The mild initial symptoms were followed in both by physical and radiographic findings suggesting pharyngoesophageal perforation. Early radiologic findings included free subcutaneous and mediastinal air, followed later by hydropneumothorax and mediastinal widening as well as leak of contrast material on gastrografin swallow. CT findings contributed to patient evaluation and management.
Adolescent↗
Computed tomography in children with esophageal and airway trauma.
Computed tomography (CT) was used in five children, four with esophageal and one with airway trauma. The examination contributed valuable information that aided in planning and evaluating therapy: (1) it assessed mediastinal and pleural cavity involvement prior to surgery or drainage; (2) it evaluated the efficacy of drainage; (3) it gave excellent information about the position of chest tubes; and (4) it demonstrated unsuspected pneumothoraces, pleural effusion, pulmonary infiltrates, and lung perforation by a chest tube. In the postoperative assessment of laryngotracheal fracture, neck radiographs were useless since the airways were obliterated by hematomas and edema. In this situation, CT showed the position and state of the laryngeal cartilages. However, CT findings were not pathognomonic for esophageal tears or airway fractures. The primary diagnosis was still made by conventional radiography. Esophageal tears were accurately demonstrated by gastrografin swallow and the tracheolaryngeal fracture was diagnosed by a lateral neck radiograph--the state of the child permitting no lengthy workup. CT and conventional radiography with contrast studies play a complementary role in esophageal and airway trauma in children.
Child↗
Nosocomial bacterial pneumonia in ventilated children: clinical significance of culture-positive peripheral bronchial aspirates.
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Bronchi↗
Foreign body aspiration in childhood.
We studied 149 children aged seven months to 13 years (mean age 2.9 +/- 0.2 years) who had aspirated foreign bodies for age, sex, and type of foreign body. Symptoms, physical findings, chest x-ray, and fluoroscopy were compared with different sites of enlodgement. Positive history was obtained in 135 (91%). In 133 children, the diagnosis was made on admission. Frequent symptoms were cough (80%) and cyanosis (27%) following aspiration, while prevalent emergency department symptoms were cough (33%) and dyspnea (30%). Common physical findings on admission were decreased breath sounds (65%), tachypnea (43%), and fever (36%). Admission chest radiographs revealed emphysema (43%) and infiltrates or atelectasis (29%). Forty-one children (27%) were asymptomatic, and 43 children had normal chest x-ray. Fluoroscopy showed inspiratory mediastinal shift in 57%. Bronchoscopy performed within 48 hours of admission was successful in removing the foreign material in 88% of the children. Food particles were the most common type of foreign body. Hoarseness and stridor were significantly more common in upper airway enlodgement (P less than 0.01). Decreased breath sounds were significantly more common among children with lower airway enlodgement (P less than 0.001). A delay in diagnosis of longer than three weeks was associated with equivocal history of aspiration (P less than 0.05), and with significantly more wheezing (P less than 0.02) and atelectasis (P less than 0.01). Our study reemphasizes the importance of integrating various diagnostic tools in order to accurately evaluate and manage these children.
Adolescent↗
The diagnosis and management of acid-base imbalance.
The ability to obtain an arterial blood gas analysis within a few minutes in most medical facilities enables the clinician to rapidly evaluate the acid-base status of his or her critically ill patients and to treat disorders as they appear. Although acid-base charts, graphs, and nomograms are available and can help to establish a diagnosis of acid-base disorders, the common practice is that most emergency and critical care clinicians tend to interpret acid-base data rapidly, usually without using any of these tools. The intent of this discussion is to provide the clinician with the pathophysiologic background of acid-base imbalance, the diagnostic criteria for acid-base disturbances, and the clinical approach to management. The standard arterial blood gas analysis, serum and urine electrolytes, and clinical assessment of the alveolar ventilation are the only data upon which this discussion is based.
Acid-Base Imbalance↗