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Chest injuries in children
826
INTERNATIONAL ABSTRACTS
epinephrine, normal saline, or no injection at all. The authors apparently felt that a circumferential injection, even of nonepinephrine containing anesthetic, around the entire base of the penis would possibly cause circulatory embarrassment to the penis and might be dangerous. The lidocaine injection was found to be safe and easy. It was effective, not only in reducing statistically analyzed objective indicators of pain, such as crying, but also resulted in lower plasma cortisol levels in the lidocaine group. The authors concluded by endorsing the American Academy of Pediatrics' policy statement recommending the use of local or systemic anesthesia to neonates undergoing surgical procedures, including circumcision. The final sentence in their paper was, "If we are willing to take the time to anesthetize an infant animal undergoing a painful surgery, are we not morally obligated to do the same for the young of our human species?"--David L. Collins
Length-tension characteristics were examined in tracheal rings excised from preterm lambs (n = 8) and adult sheep (n = 7) to determine developmental differences in the mechanical properties of tracheal cartilage. Tension was measured in both the complex (comprised of the pars membranacea and its cartilagenous insertion) and the cartilage alone (by severing the pars membranacea) as the ring was lengthened in order to increase the distance between the points of insertion. Analysis of regression lines showed significantly greater slopes for both the complex and the cartilage in the adult group compared with the preterm group. These data show that age-related differences in tracheal cartilage mechanics parallel and may contribute to age-related differences previously determined in tracheal compliance.--Prem Purl
Fasting in Children for Day Case Surgery. P.E. O'Flynn and C,A.
Emergency Lung Biopsy in Immunocompromised Pediatric Patients. R.P. Foglia, J. Shilyansky, and E. W. Fonkalsrud. Ann Surg
Milford. Ann R Coil Surg 71:218-219, (April), 1989.
210:90-92, (July), 1989.
The period of preoperative fasting (the time from last food or drink to induction of anesthesia), was assessed for 34 children, age range 11 to 99 months, attending for insertion of grommets on a day case basis. In each case, at induction, a blood sample was obtained for glucose estimation. The mean preoperative fasting time was 14 hours, and in all cases the fasting time was much longer than the recommended 4 to 6 hours. Three children had blood sugar levels greater than 3.0 mmol/L (one with mild and two with moderate hypoglycemia), although there were no associated symptoms. The authors conclude that prolonged periods of abstinence in children (as in overnight fasting) is undesirable, if not hazardous. One solution may be to have midday lists, commencing at 11 AM and finishing at 1 PM. This would allow a light breakfast to be taken at 7 AM. In this way, no child would fast for more than 6 hours (reducing the risk of hypoglycemia), and there would be ample time for postoperative recovery.--S. IV. Alexander
Interstitial pneumonia may be life-threateningto the immunocompromised child. Twenty-six open-lung biopsies were performed on 25 immunocompromisedchildren (aged 3 months to 17 years; mean, 5.5 years). Immunocompromisingdiseases included bone marrow transplant (35%), immunodeficiency syndromes (23%), leukemia (19%), liver transplant recipients (12%), and malignant tumors (8%). Chest radiographs showed bilateral pulmonary interstitial infltrates in all. Biopsies were performed through a limited anterior tboracotomy from the lung with the most prominent infiltration. Specific infectious diagnosis was made in 65% of patients. Biopsy results caused a change in therapy in 58%. Mortality was 54%. Three children died within 72 hours of surgery of problems unrelated to the biopsy itself. Seven ventilator-dependent patients (27%) developed pneumothorax. Ventilator support was required in 24% of children who had not been intubated before surgery. The historical rational for not performing open-lung biopsy in immunocompromised patients in based on the relatively high incidence of Pneumocystic carinii and a lack of available treatment for viral pneumonitis. Twenty-eight percent of the children in this study had P carinii. With the current availability of treatment for viral pneumonitis (DHPG, ribavirin) and the high yield of information that changed management in this series, the authors support openlung biopsy in the immunocompromised child with interstitial pneumonitis.--Edward G. Ford
THORAX Structural Changes in the Tracheae of Preterm Lambs Induced by Ventilation, K.S. Deoras, M.R. Wolfson, V.K. Bhutani, et al. Pedi-
atr Res 26:434-437, (November), 1989. Compliant immature airways sustain significant deformation following positive pressure ventilation (PPV). To evaluate the structural changes induced by in vivo PPV, tracheae of preterm lambs (107 to 116 days' gestation) were studied histologically. Nonventilated (group I, n = 7) and ventilated (group II, n = 7) tracheal segments were excised and studied by histological and morphometric techniques. Computerized image analysis was used to measure dimensions of tracheal wall components and of the tracheal section. The Circumference, diameter, and cross-sectional area of the section as well as the length of the trachealis muscle were significantly greater, whereas the thickness of the muscle and cartilage were significantly lower in group II sections compared with group I sections. Also, in comparison to group I, in group II sections there was lesser overlap of the posterior free ends of tracheal cartilage, and the epithelial layer was flattened and focally abraded. These findings demonstrate structural changes in the airway of preterm animals and characterize alterations in the geometric arrangement of muscle and cartilage after PPV. These results suggest possible structural mechanisms for the functional changes noted during and subsequent to mechanical ventilation.--Prem Purl Developmental Differences in Tracheal Cartilage Mechanics. R.B.
Penn, M.R. Wolfson, and T.H. Shaffer. Pediatr Res 26:429-433, (November), 1989.
Chest Injuries in Children. D.K. Nakayama, M.L. Ramenofsky, and M.L Rowe. Ann Surg 210:770-775, (December), 1989.
A 7~/2-yearexperience of 105 children with traumatic chest injuries is reviewed. Three percent of injuries were penetrating. Rib fractures and contusion occurred with nearly equal frequency of 50%. Pneumothorax occurred in 37%, hemothorax in 13%, and tension pneumothorax in 23% of those with pneumothorax. Fiftythree percent of children had more than one chest injury. Twentyone percent required endotracheal intubation and ventilatory support. Seven children died, one of penetrating injury and five of blunt injury. Mechanism of injury paralleled age-related causes of injury. Significant intrathoracic injury was noted without bony injuries. Pulmonary contusion occurred because of the pliability of the chest wall. Ventilatory support was used in 21% of cases but was of short duration (average, 4.9 days). As expected, pneumothorax and hemothorax increased hospital stays whereas rib fractures did not. The authors discuss anatomical and physiological reasoning for the unique spectrum of diseases in children, as compared with adults.--Edward G. Ford
INTERNATIONAL ABSTRACTS
epinephrine, normal saline, or no injection at all. The authors apparently felt that a circumferential injection, even of nonepinephrine containing anesthetic, around the entire base of the penis would possibly cause circulatory embarrassment to the penis and might be dangerous. The lidocaine injection was found to be safe and easy. It was effective, not only in reducing statistically analyzed objective indicators of pain, such as crying, but also resulted in lower plasma cortisol levels in the lidocaine group. The authors concluded by endorsing the American Academy of Pediatrics' policy statement recommending the use of local or systemic anesthesia to neonates undergoing surgical procedures, including circumcision. The final sentence in their paper was, "If we are willing to take the time to anesthetize an infant animal undergoing a painful surgery, are we not morally obligated to do the same for the young of our human species?"--David L. Collins
Length-tension characteristics were examined in tracheal rings excised from preterm lambs (n = 8) and adult sheep (n = 7) to determine developmental differences in the mechanical properties of tracheal cartilage. Tension was measured in both the complex (comprised of the pars membranacea and its cartilagenous insertion) and the cartilage alone (by severing the pars membranacea) as the ring was lengthened in order to increase the distance between the points of insertion. Analysis of regression lines showed significantly greater slopes for both the complex and the cartilage in the adult group compared with the preterm group. These data show that age-related differences in tracheal cartilage mechanics parallel and may contribute to age-related differences previously determined in tracheal compliance.--Prem Purl
Fasting in Children for Day Case Surgery. P.E. O'Flynn and C,A.
Emergency Lung Biopsy in Immunocompromised Pediatric Patients. R.P. Foglia, J. Shilyansky, and E. W. Fonkalsrud. Ann Surg
Milford. Ann R Coil Surg 71:218-219, (April), 1989.
210:90-92, (July), 1989.
The period of preoperative fasting (the time from last food or drink to induction of anesthesia), was assessed for 34 children, age range 11 to 99 months, attending for insertion of grommets on a day case basis. In each case, at induction, a blood sample was obtained for glucose estimation. The mean preoperative fasting time was 14 hours, and in all cases the fasting time was much longer than the recommended 4 to 6 hours. Three children had blood sugar levels greater than 3.0 mmol/L (one with mild and two with moderate hypoglycemia), although there were no associated symptoms. The authors conclude that prolonged periods of abstinence in children (as in overnight fasting) is undesirable, if not hazardous. One solution may be to have midday lists, commencing at 11 AM and finishing at 1 PM. This would allow a light breakfast to be taken at 7 AM. In this way, no child would fast for more than 6 hours (reducing the risk of hypoglycemia), and there would be ample time for postoperative recovery.--S. IV. Alexander
Interstitial pneumonia may be life-threateningto the immunocompromised child. Twenty-six open-lung biopsies were performed on 25 immunocompromisedchildren (aged 3 months to 17 years; mean, 5.5 years). Immunocompromisingdiseases included bone marrow transplant (35%), immunodeficiency syndromes (23%), leukemia (19%), liver transplant recipients (12%), and malignant tumors (8%). Chest radiographs showed bilateral pulmonary interstitial infltrates in all. Biopsies were performed through a limited anterior tboracotomy from the lung with the most prominent infiltration. Specific infectious diagnosis was made in 65% of patients. Biopsy results caused a change in therapy in 58%. Mortality was 54%. Three children died within 72 hours of surgery of problems unrelated to the biopsy itself. Seven ventilator-dependent patients (27%) developed pneumothorax. Ventilator support was required in 24% of children who had not been intubated before surgery. The historical rational for not performing open-lung biopsy in immunocompromised patients in based on the relatively high incidence of Pneumocystic carinii and a lack of available treatment for viral pneumonitis. Twenty-eight percent of the children in this study had P carinii. With the current availability of treatment for viral pneumonitis (DHPG, ribavirin) and the high yield of information that changed management in this series, the authors support openlung biopsy in the immunocompromised child with interstitial pneumonitis.--Edward G. Ford
THORAX Structural Changes in the Tracheae of Preterm Lambs Induced by Ventilation, K.S. Deoras, M.R. Wolfson, V.K. Bhutani, et al. Pedi-
atr Res 26:434-437, (November), 1989. Compliant immature airways sustain significant deformation following positive pressure ventilation (PPV). To evaluate the structural changes induced by in vivo PPV, tracheae of preterm lambs (107 to 116 days' gestation) were studied histologically. Nonventilated (group I, n = 7) and ventilated (group II, n = 7) tracheal segments were excised and studied by histological and morphometric techniques. Computerized image analysis was used to measure dimensions of tracheal wall components and of the tracheal section. The Circumference, diameter, and cross-sectional area of the section as well as the length of the trachealis muscle were significantly greater, whereas the thickness of the muscle and cartilage were significantly lower in group II sections compared with group I sections. Also, in comparison to group I, in group II sections there was lesser overlap of the posterior free ends of tracheal cartilage, and the epithelial layer was flattened and focally abraded. These findings demonstrate structural changes in the airway of preterm animals and characterize alterations in the geometric arrangement of muscle and cartilage after PPV. These results suggest possible structural mechanisms for the functional changes noted during and subsequent to mechanical ventilation.--Prem Purl Developmental Differences in Tracheal Cartilage Mechanics. R.B.
Penn, M.R. Wolfson, and T.H. Shaffer. Pediatr Res 26:429-433, (November), 1989.
Chest Injuries in Children. D.K. Nakayama, M.L. Ramenofsky, and M.L Rowe. Ann Surg 210:770-775, (December), 1989.
A 7~/2-yearexperience of 105 children with traumatic chest injuries is reviewed. Three percent of injuries were penetrating. Rib fractures and contusion occurred with nearly equal frequency of 50%. Pneumothorax occurred in 37%, hemothorax in 13%, and tension pneumothorax in 23% of those with pneumothorax. Fiftythree percent of children had more than one chest injury. Twentyone percent required endotracheal intubation and ventilatory support. Seven children died, one of penetrating injury and five of blunt injury. Mechanism of injury paralleled age-related causes of injury. Significant intrathoracic injury was noted without bony injuries. Pulmonary contusion occurred because of the pliability of the chest wall. Ventilatory support was used in 21% of cases but was of short duration (average, 4.9 days). As expected, pneumothorax and hemothorax increased hospital stays whereas rib fractures did not. The authors discuss anatomical and physiological reasoning for the unique spectrum of diseases in children, as compared with adults.--Edward G. Ford