Resuecitation, 9 (1981) 323-330 o Elrxevier/North-Holland Scientific Publishers Ltd.
323
PSYCHOLOGICAL EVALUATION IN CHILDREN WHO HAD HAD ARTERIAL OXYGEN PARTIAL PRESSURES OF LESS THAN 63 TORR
LOURDES C. RANGEL,
ANA LILIA R. ASPRAa, IVONNE C. CUfiLLAR,
GRACIELA
M. LANDfN and CARLOS F. STRECKER Intensive Care Unit, Hospital de Pediatrta, Avenida Cuauht4moc 330, Mt!xico, 7, D.F. and aAguawalientes 201-203, Colonia Hipbdroma, Mexico 11, D.F. (Mexico)
SUMMARY
of this study was to examine the incidence and type of The purpose neurological sequelae in patients surviving after a severe acute episode of hypoxemia. We defined hypoxemia as Pa,% below 63 Torr. Twenty five patients, newborn to 11 years of age, who survived hypoxemia and respiratory or cardiac arrest, were included: three with Pa,Oz ranging from 40 to 49 Torr, two from 30 to 39 Torr and twenty with Pa,O, below 30 Torr. In five of them respiratory arrest occurred, and in two cases, the heart stopped twice. The psychological tests were chosen according to the patient’s age. The incidence of sequelae was 64% as follows; motor area, 28%; I.&. below 90, 20%; left hand dominance, 16%; language disabilities, 12%; disturbances of perception, 4%; and various other different minor findings, 12%. The frequency of sequelae according to the age was as follows: among children who were less than two years old 53% had sequelae; from 2 to 5 years, 66%; and older than five years, 83%. The lowest I.&. was found in a patient with hypoxemia grade 2; children with hypoxemia grade 4 did not have the lowest I.&., 80% of them had 1.Q.s of 90. It was concluded that hypoxemia is a potential factor in the development of brain damage, and that it has many behavioral or functional expressions. It seems to be more dangerous for older children. Patients having grade 4 hypoxia had a normal distribution of I.&., so that one can conclude that this type of illness does not necesarily interfere with intellectual capacity. We believe that these results could be improved if the patient is treated by modern methods of cerebral resuscitation. INTRODUCTION
In a retrospective study of 100 cases involving the management of respiratory failure that were treated in 1970 in the Hospital of Pediatrics at the Medical Center in Mexico City, we found a mortality of 72%, partly due to
324
the poor prognosis of the disease and partly because of: (a) late endotracheal intubation and assisted ventilation in 66%; (b) failure to estimate blood gases in 17%; (c) mistakes in the care of endotracheal or tracheostomy tubes in 65% of the cases. .These discouraging results motivated us to establish an intensive respiratory therapy unit, with the object of improving the effectiveness of the management of the respiratory failure and to use new methods on a rational basis&This unit helped us to improve our results so that in 1978 the mortality decreased to 46%, the late endotracheal-intubation and assisted ventilation decreased to 18%, the failure to determine blood gases decreased to 15% and the mistakes in the care of endotracheal and tracheostomy tubes to 30%. We also wanted to know the incidence and the type of brain damage in the survivors. There are few reports in the medical literature on the psychomotor development of patients surviving hypoxemia. Ambrus and Weistraub (1970) and Fisch and Bitek (1975) reported the results of the psychological evaluation in patients who survived hyaline membrane disease; neither of them found a significant difference compared with the control group, that they could attribute to the grade of hypoxemia, but the outcome was related to the prematurity, to the low birth weight and to the social class of the parents. Green and Richmond (1962) performed a similar study and found that signs of cerebral paralysis did not show up until 6 or 12 months later and the first manifestations were seen in the psychometric development. Safar (1978) made the point that the neurologic deficit of an adult patient who survived from acute hypoxia, depends on the delay between the recognition and efficient assistance and said that this time has been unnecessarily long in the past. Less than 10% of the patients who suffered cardiac arrest for 5-22 min and were assisted with the traditional therapy were expected to have a complete neurological recovery (Breivik, Safar, Sands, Fabritius, Lind, Lust, Mullie, Orr, Renck and Snyder, 1978). The purpose of this study was to know the incidence and the type of brain damage in the survivors of severe respiratory failure, treated as promtly and efficiently as possible in our respiratory therapy unit at a pediatric hospital. Our study was done with the hypothesis that hypoxemia is potentially dangerous to neurological function and a high incidence of sequelae would be expected. PATIENTS AND METHODS
We defined hypoxia as an arterial PO, below 63 Torr as a previous study had shown that this was the normal value in children living at an altitude over 7000 feet (Range1 and Bafiuelos, 1976). We excluded from the study those patients who had good response to the respiratory therapy and suf-
325
fered grade 1 hypoxemia ranging from 50 to 63 Torr, those with a history of previous brain damage; and five cases who did not survive long enough to attend their appointment at the outpatient clinic. Twenty five cases were considered to be ‘high risk’ in the period from January to December 1978; they were aged from newborn to 11 years, and had survived in good clinical condition for 6 to 12 months after the hypoxic episode. All of them were examined and their chest X-rays, EEG and psychological evaluation were made by the same authors. The patients were classified in three groups according to the grade of hypoxemia: (a) three patients with hypoxemia grade 2, with Pa,& ranging from 40 to 49 Torr; (b) two patients with grade 3, ranging from 30 to 39 Torr; (c) 20 patients with hypoxemia grade 4 with Pa,O? below 30 Torr. In five of them, respiration stopped and in two the heart stopped (Tables I-III). The psychological evaluation was designed to measure the intelligence quotient, the developmental quotient, the presence of minimal brain dysfunction, and motor, verbal, learning and emotional disabilities. The psychological tests were used according to the patient’s age as follows: from 1 to 24 months, developmental diagnosis; from 2 to 5 years 11 months, Stanford - Binet Intelligence Scale, form L-M; from 6 years to 15 years TABLE I PATIENTS WITH GRADE 2 HYPOXEMIA Pa,o,
ranging from 40 to 49 Torr.
CaSe number 1 2 3
48e
Diagnosis
Pa,o,
(Torr)
6 days 3 years 11 years
Bronchopneumonia Massive aspiration Polyneuritis Type IV*
42 40 40 Mean 40.6
aRavn (1967). TABLE II PATIENTS WITH GRADE 3 HYPOXEMIA Pa,o,
ranging from 30 to 39 Torr.
Case number
Age
Diagnosis
Pa,o,
1 2
2h 4 years
Pneumonia for aspiration Pol yneuritis Qpe IVB
32 37 Mean 34.5
*Ravn (1967).
Torr
326 TABLE III PATIENTS WITH GRADE 4 HYPOXBMIA Pa,o, less than 30 Torr. Case number
Age
Diagnosis
la
11 h
2 3 4 6a 6
15h 24 h 11 h 12h 30 days
Massive aspiration pneumonia and paralysis of the diaphragm Massive aspiration pneumonia Massive aspiration pneumonia Hyaline membrane disease Massive aspiration pneumonia Gastroenteritis, sepsis and pneumonia Extensive bilateral pneumonia Gastroenteritis and septic shock Pneumonia and cardiopathy Bxtensive bilateral pneumonia Bilateral pneumonia Gastroenteritis, sepsis and pneumonia Bronchiolitis, cardiac failure Bronchiolitis, pneumonia. Pneumonia, pneumothorax Epiglotitis Polyneuritis type IVc Polyneuritis type IV= Osteomyelitis, sepsis, massive pneumonia Polyneuritis type IVc
7 8a 9 10 lla 12b
10 19 27 30 1 3
days days days days month months
13 14 15 16a 17 lSb 19
3 4 2 3 6 6 10
months months years years years years years
2oa
10 years
Palo,
Torr
17 26 16 14 22 21 28 16 20 28 26 18 24 26 23 24 26 Mean 18.7
aRespiratory arrest. bCardiac arrest. ‘Ravn (1967). 11 months, Wechsler Intelligence Scale for Children; for children older than 24 months up to 4 years with severe language disabilities, developmental diagnosis; for children from 4 years to 12 years 3 months who had severe language impairment, Columbia Mental Maturity Scale. The classification according to their intelligence quotient was as follows:
Severe mental retardation III Severe mental retardation II Severe mental retardation I Moderate mental retardation Borderline Dull average
0- 25 26- 49 50- 59 60- 69 70- 79 80- 89
327
90-109 110-119 120-129 130 and above
Average Bright normal Superior Very superior
The following clinical criteria were used in the assesment of minimal brain dysfunction :
Lawawe
Motor area
Emotional
Others
Moderate retardation Omissions of letters Syllable inversion Inadequate articulation Visual motor incoordination Short attention span Poor success at school Visual perceptive changes Irritability Tantrums Aggressive behavior Diminished tolerance to frustration Problems during sleep Irregular sleep pattern
RESULTS
The physical exam and the chest X-rays were within normal limits. The EEG showed great variety of changes, none specifically arising from hypoxia. Results from psychological evaluation are shown in Tables IV, V, VI, VII and VIII. From them we found some points worthy of remark: the incidence of neurological sequelae was 64% (16 out of 25 cases); the frequency of the type of sequelae was: (a) intelligence quotient below 90 in 5 cases (20%); (b) motor impairment in 7 cases (28%) including the five cases of Guillain-
TABLE IV INCIDENCE OF NEUROLOGICAL HYPOXEMIA No. of cases Without sequelae With sequelae
9 16
Total
25
SEQUELAE IN 25 CHILDREN WHO SUFFERED
%
36.0 64.0 100
328 TABLE V INCIDENCE AND TYPE OF NEUROLOGICAL HAD HAD HYPOXEMIA
SEQUELAE IN 25 CHILDREN WHO
Sequeiae
No. of cases
%
Intelligence quotient of 90 Motor loss Language low Perceptual loss Left handedness Others
5 7 3 1 4 3
20.0 28.0 12.0 4.0 16.0 12.0
TABLE VI INTELLIGENCE
QUOTIENT
OF
Intelligence quotient
No. of
96
CWe8
75- 89 96-109 >llO
5 10 10
Total
25
25 CHILDREN
20.0 40.0 40.0 t
WHO HAD
HAD
HYPOXEMIA
80*o
100
TABLE VII INCIDENCE OF SEQUELAE ACCORDING TO AGE
Age bears)
No. of case8
No. of sequelae (So)
2 2-5 5+
13 6 6
7 (53.0) 4 (66.6) 5 (83.3)
Total
25
16 (64.0)
TABLE VIII INTELLIGENCE
QUOTIENT RELATED TO GRADE OF HYPOXEMIA No. of cases (%)
Grade of hypoxemia
Intelligence quotient 75 (%)
86-89
2 3 4
l(4) -
4 (16)
2 (8) 1 (4) 7 (28)
Total
1 (4)
4 (16)
10 (40)
(%)
96-109
(%)
>llO
(%)
1 (4) 9 (36) 10 (40)
3 2 20
(12) (8) (80)
25 (100)
329
Barre syndrome; (c) left handed 4 cases (16%); (d) language disabilities in 3 cases (12%); (e) other impairments 3 cases (12%); (f) some patients had one or more sequelae together. DISCUSSION
The incidence of neurological sequelae was high, 64%, as we had expected. This was in agreement with the view of Breivik et al. (1978) that only 10% of patients who suffered cardiac arrest for 5-22 min and were treated traditionally would have a complete neurological recovery. Our figures could probably be diminished in the future if we employ the modern methods of brain resuscitation proposed by Safar (1978). In the comparison of our results with those of Ambrus and Weistraub (1970) and Fisch and Bitek (1975), we found a great lack of correlation between the grade of brain damage with that of hypoxemia. One might have expected a high correlation between low I.&. and degree of hypoxia, so that the deeper the hypoxemia the greater intellectual deficit. Surprisingly, the lowest 1.8. (75%) was found in a child with grade 2 hypoxemia. One cannot compare the first two groups with the other groups because of the difference in the number of patients. It is our impression that grade 4 patients follow a normal distribution. If this were the case, we can conclude that this type of illness might not necessarily interfere with intellectual capacity but might interfere with other functions. In regard to the incidence of motor impairment, seven cases (28%), seemed to have these as the most important sequelae, but five out of these seven patients had a diagnosis of Guillain-Barre syndrome and therefore one would expect to find the motor system affected due to muscular dystrophy, rather than to hypoxia. The greatest number of sequelae was found in the older patients. This was probably due to the fact that brain damage might be more important when a child had already reached his maximum development. If hypoxia occurs in children below 2 years, there is a good possibility of mechanisms compensating for the functions affected. Changes in manual dominance, indicate that damage in the dominant cerebral hemisphere could have been compensated by the other hemisphere. We found perceptive dysfunction in one case, but we believe that this type of symptom is difficult to assess in early childhood, since it can only be determined on clinical grounds. In this kind of study the same patient would have been the ideal control, which means that he would have to have been evaluated prior to his illness to permit unequivocal conclusions, but this was obviously not possible. REFERENCES Ambrus, C.N. and Weistraub, P.N. (1970) Evaluation of survivors of respiratory distress syndrome at 4 years of age. Am. J. Dii. Child., 123,99-104.
330 Breivik, H., Safar, P., Sands, P., Fabritius, R., Lind, B., Lust, P., Mullie, A., Grr, M., Renck, H. and Synder, J.V. (1978) Clinical feasibility trials of barbiturate therapy after cardiac arrest. Crit. Care Med., 6, 228-244. Fisch, R.O. and Bitek, M.K. (1975) Physical and mental status at 4 years of age of survivors of the respiratory distress syndrome, J. Pediatr., 36,497-603. Green, M. and Richmond, J.S. (1962) Pediatric Diagnosis, p. 152. Saunders Company, Philadelphia and London. Rangel, C.M.L. and Bafiuelos, V.M.J. (1976) Normal values of blood gases in children living at an altitude over 7,000 feet. Crit. Care Med., 4, 311. Ram, H. (1967) The Landry-Guillain Barre Syndrome. A survey and a clinical report of 127 cases. Acta. Neurol. Stand., 43, Suppl. 30,9-64. Safar, P. (1973) Introduction: on the evolution of brain resuscitation. Crit. Care Med., 6,199-202.