Successful weaning from cardiopulmonary bypass after cardiac surgery using inhaled nitric oxide

Two cases of very difficult weaning from cardiopulmonary bypass after cardiac surgery in children with pulmonary hypertension and ventricular dysfunction are reported. Children fail to respond to conventional therapy combining nitrovasodilators and inotropic support and react successfully to combined inhaled nitric oxide (NO) and epinephrine or left atrial infused norepinephrine. Postoperative NO inhalation must be prolonged and no toxicity appears. Pulmonary endothelial function recovers only after several days.

Monosegmental liver transplantation from an adult to an infant

A shortage of small pediatric organ donors has led to the development of reduced size liver transplantation in children. However, the discrepancy between donor and recipient weight can limit the use of this procedure despite transplantation of the left lobe only. Monosegmental liver transplantation using segment III only was recently described. We report here the case of an 11 month old, 6.9 kg boy who received another monosegmental graft (segment II) from a 78 kg donor on an urgent basis. Because of the lack of parenchymal landmarks between segments II and III, sterile methylene blue solution was injected into the portal vein of segment III: parenchyma of this segment colored immediately and was resected accordingly. Three and a half years later, the growth, development, and nutrition of this child were normal. This procedure seems to be helpful when the left lobe of the graft is obviously too large.

Haemodynamic and renal effects of dopexamine after cardiac surgery in children

Dopexamine hydrochloride, a synthetic dopamine analog with predominantly beta and delta agonist properties, has been shown to improve cardiac performance and renal function in adults with heart failure. This study was designed to investigate the haemodynamic and renal effects of dopexamine in children after cardiac surgery. Seven children were selected in whom a need for postoperative vasodilation after cardiac surgery was anticipated. Haemodynamics and renal function were determined under baseline conditions and during a continuous infusion of dopexamine at 2 and 6 micrograms.kg-1.min-1 for 90 minutes, the sequence being randomized for the initial dose. Cardiac output was measured by thermodilution and glomerular filtration rate (GFR) and renal plasma flow (RPF) by the clearances of inulin and para-aminohippurate respectively. Dopexamine induced a dose-related increase in cardiac index (CI) expressed as mean (SD) from 3.5 (0.7) to 3.9 (0.76) and 4.5 (0.8) l.min.-1m-2 (both P < 0.05), and in heart rate (HR) from 107 (17) to 122 (17) and 136 (17) beats.min-1 (P < 0.05). Stroke volume index (SVI) and mean systemic pressure were unchanged, but pulmonary wedge pressure decreased from 14 (3) to 11 (4) and 12 (3) mmHg (both P < 0.05). Systemic vascular resistances (SVR) decreased from 24 (7) to 20 (5) mmHg.l-1.min-1.m-2 (P < 0.05), with dopexamine 6 micrograms.kg-1.min-1. Renal blood flow (RBF) increased from 319 (113) to 441 (230) and 410 (138) ml.min-1.m-2 (both P < 0.05), GFR from 115 (32) to 142 (34) and 146 (29) ml.min-1.1.73m-2 (both P < 0.05), urine output and fractional excretion of sodium respectively from 3.12 (2) to 7.16 (8) and 7.21 (6) ml.kg-1 (both P < 0.05) and from 2.24 (1) to 4.25 (3.4) (P < 0.05) and 3.15 (3.1)% (n.s.). The fraction of CI delivered to the kidneys, the fraction of RBF filtered in the kidneys, plasma renin activity and aldosterone levels remained unchanged. In children after cardiac surgery, dopexamine increases CI at the expense of a concomitant increase in heart rate and demonstrates few selective vascular systemic or intrinsic renal actions.

Inhaled nitric oxide to test the vasodilator capacity of the pulmonary vascular bed in children with long-standing pulmonary hypertension and congenital heart disease

Nitric oxide-induced vasodilator capacity greatly varies among children with pulmonary hypertension and elevated vascular resistance. The decline of this selective response seems to parallel the progression of established vascular disease and thus may be helpful for the selection of patients for operation.

The value of lymph node dissection in hereditary medullary thyroid carcinoma: a retrospective, European, multicentre study

Clinical data of 139 patients with hereditary medullary thyroid carcinoma (HMTC) from nine european centres surgically treated from 1980 to 1991 were reviewed retrospectively to analyse the value of systematic versus selective lymphadenectomy (LA). Biochemical cure rate was significantly higher in patients who underwent LA compared to patients who did not. In nodal-positive HMTC, systematic LA compared to selective LA improved biochemical cure in small but not large tumours. In nodal-negative HMTC, systematic LA compared to selective LA could not improve biochemical cure in either small or large primary tumours. To prevent local recurrences with the risk of increased surgical and tumour-related morbidity, systematic LA should be performed in all HMTC patients regardless of the primary tumour stage. However, an improvement of biochemical cure by systematic LA seems to be possible only in nodal-positive small primary tumours without distant metastases.

[Children's indoor environment. A study of Norwegian dwellings]

The indoor environment was investigated in 112 Norwegian dwellings where either healthy children or children with asthma were living. Compared with the official guidelines for indoor air quality, more than 50% of the children's rooms had unacceptable indoor air. Continuous monitoring of carbon dioxide showed unacceptably high levels in 69% of the children's bedrooms at night. Levels of volatile organic compounds exceeded the guideline in 53% of the dwellings. More than 60% of the children were exposed to environmental tobacco smoke, as identified by nicotine in hair and cotinine in urine samples. Levels of house dust mites in excess of the guideline were found in 45% of the dwellings. The results indicated a need to improve the indoor environment in the homes of children.

Continuous low dose inhaled nitric oxide for treatment of severe pulmonary hypertension after cardiac surgery in paediatric patients

OBJECTIVE

To assess the effect of inhaled nitric oxide (NO) on severe postoperative pulmonary hypertension in children after surgical repair of a congenital heart defect.

DESIGN

A pilot study of NO administration to 7 consecutive children who required adrenergic support and in whom postoperative mean pulmonary artery pressure was more than two thirds of mean systemic pressure and persisted despite alkalotic hyperventilation.

SETTING

Routine care after cardiac surgery for congenital heart disease in a multidisciplinary paediatric intensive care unit.

METHODS

Continuous inhalation of NO, initially at 15 ppm. Therefore, daily attempts at complete weaning or at reducing NO to the lowest effective dose.

RESULTS

In 6 of the 7 children NO inhalation selectively decreased mean (SD) pulmonary artery pressure from 51 (12) to 31 (9) mm Hg (P < 0.05) while mean systemic arterial pressure was unchanged (68 (10) v 71 (7) mm Hg) (NS) and the arteriovenous difference in oxygen content decreased from 6.7 (0.9) to 4.8 (0.8) vol% (P < 0.05). Concomitantly PaO2 increased from 158 (98) to 231 (79) mm Hg) (P < 0.05). The seventh child showed no response to NO up to 80 ppm, could not be weaned from cardiopulmonary bypass, and died in the operating room. In responders, attempts at early weaning from NO inhalation always failed and NO at concentrations of less than 10 ppm was continuously administered for a median of 9.5 days (range 4 to 16 days) until complete weaning was possible from a mean dose of 3.9 (2.9) ppm. Methaemoglobinaemia remained below 2% and nitrogen dioxide concentrations usually ranged from 0.1 to 0.2 ppm. One child later died and five were discharged. A few months after surgery Doppler echocardiography (and catheterisation in one) showed evidence of regression of pulmonary hypertension in all 5.

CONCLUSIONS

Inhalation of NO reduced pulmonary artery pressure in children with severe pulmonary hypertension after cardiac surgery and this effect was maintained over several days at concentrations carrying little risk of toxicity.

[Results of liver transplantations in Geneva or 32 consecutive transplantations without mortality in 2 years]

Between 1 january 1992 and 31 december 1993, 32 liver transplantations were performed in 29 patients (5 transplants in 3 children and 27 transplants in 26 adults) at Geneva University Hospital. Despite 5 super-urgent transplantations (3 fulminant hepatitis, 1 end-stage Wilson disease and 1 primary nonfunction), all patients are still alive and all have lived more than 10 months. On 1 october 1994, all patients were at home and 93% were in good general condition. No patient of this series had been transplanted for cancer and all patients positive for hepatitis B surface antigen receive long-term administration of anti-HBs immune globulin: in this respect, the long-term mortality risk of the present series of patients seems to be very low. Although these results highlight that liver transplantation can be performed safely by a competent medico-surgical team, two significant difficulties have to be outlined. First, patients are likely to die on the waiting list due to unavailable grafts, especially in emergency cases. Second, the postoperative period of patients with decompensated end-stage liver disease at the time of liver transplantation is still one of high morbidity. These facts underline that chronic liver disease patient should be evaluated for liver transplantation prior to the terminal decompensated stage of the disease, when the candidate's invariably poor general condition precludes successful liver transplantation.

Use of Gianturco Z stents in the treatment of vascular compression of the tracheobronchial tree in childhood. A feasible solution when surgery fails

Severe tracheomalacia secondary to extrinsic vascular compression following a switch operation for transposition is reported. Two attempts at surgical correction failed but successful treatment has been achieved by implantation of two endobronchial Gianturco Z stents. Nonabsorbable stenting in children should be used only in severe obstruction as a last resource, but this technique proved to be feasible in a child weighing 6.2 kg.

[Thoracoscopic treatment of recurrent pneumothorax]

Spontaneous pneumothorax (PNO) is usually due to rupture of a small subpleural bleb into the pleural cavity and affects mainly young men. After simple drainage, recurrence occurs in about 50% of cases. The risk of recurrence increases after each new PNO. Secondary PNO complicates an underlying pulmonary disease, especially chronic obstructive pulmonary disease with emphysema. A new form of secondary PNO has emerged in the recent years in AIDS patients with pneumocystis carinii pneumonia. We have shifted to a thoracoscopic therapy of PNO since May 1991. 25 PNO in 24 patients (1 bilateral) have been treated since that time up to April 1993. 19 PNO were primary, whereas 6 were secondary, included 3 iatrogenic PNO. Resection of the leaking parenchymal area was performed in 20 patients, and parietal partial pleurectomy was done in 20 cases. In the remaining cases, fibrin glue was applied on the lesion and in 3 cases, chemical pleurodesis was attempted using silver nitrate or talc. 1 AIDS patient died of ARDS. 3 patients had recurrent PNO and had thoracotomy without complication. 21 patients did well. Partial PNO recurred in one of them 4 months later, and was treated by simple needle aspiration. Thoracoscopy is a useful method to treat recurrent or persistent spontaneous PNO. After only 25 cases, our success rate in primary PNO is 90%. There should be a learning curve. On the basis of our experience, we believe that recognition of the lesion and its resection as well as apical parietal pleurectomy are necessary to obtain good results and a low recurrence rate.

[Are infant resistant to carbon monoxide poisoning?]

A 20 year old woman and her 13 weeks old infant were found in the same place close together in a house fire. As soon as possible, on-the-spot treatment was initiated simultaneously for both victims, i.e. oxygen (100% FIO2), using endotracheal intubation and mechanical ventilation for the mother, with hyperbaric oxygen when in the hospital, and by facial mask for the baby. On admission (35 minutes after discovery in the fire), the mother remained comatose, whereas the baby showed only moderate neurologic abnormalities. The initial laboratory assessment showed a pH of 7.12 for the mother and 7.06 for the baby.

[Digestive carcinoids and synchronous malignant tumors]

270 digestive carcinoid tumors have been diagnosed at the Pathology Institute of Lausanne between 1971 and 1990; of these 21 were associated with other, synchronous, tumors: 7 of the carcinoids were from the appendix (33%), 8 from the small bowel (38%), 4 were from the colorectum (25%), one from the duodenum (4.5%) and finally one from the stomach (4.5%). Two thirds (14) were associated with adenocarcinomas of the colon, the rest with 2 gastric tumors, 1 tumor of the appendix, 1 of the gallbladder, 1 of the small gut, 1 of the duodenum and 1 of the peritoneum. The mean age of the patients was 70 years, which correlates with the large proportion of carcinomas of the colon. The males (16) clearly outnumbered the females (5) for no obvious reason. 80% of the carcinoids were discovered during the treatment of the associated tumor. Survival was directly related to the stage and aggressivity of the malignant tumor. The carcinoid itself hardly changed the prognosis, except for one case of liver failure due to metastases from carcinoid of the stomach associated with an adenocarcinoma. The histologic features of the carcinoid tumors were unexceptional. Different hypotheses to explain the associations are formulated.

[Digestive system carcinoid tumor and synchronous malignant tumors]

270 digestive carcinoid tumors have been diagnosed at the Pathology Institute of Lausanne between 1971 and 1990; of these 21 were associated with other, synchronous, tumors: 7 of the carcinoids were from the appendix (33%), 8 from the small bowel (38%), 4 were from the colorectum (25%), one from the duodenum (4.5%) and finally one from the stomach (4.5%). Two thirds (14) were associated with adenocarcinomas of the colon, the rest with 2 gastric tumors, 1 tumor of the appendix, 1 of the gallbladder, 1 of the small gut, 1 of the duodenum and 1 of the peritoneum. The mean age of the patients was 70 years, which correlates with the large proportion of carcinomas of the colon. The males (16) clearly outnumbered the females (5) for no obvious reason. 80% of the carcinoids were discovered during the treatment of the associated tumor. Survival was directly related to the stage and aggressivity of the malignant tumor. The carcinoid itself hardly changed the prognosis, except for one case of liver failure due to metastases from carcinoid of the stomach associated with an adenocarcinoma. The histologic features of the carcinoid tumors were unexceptional. Different hypotheses to explain the associations are formulated.

Relief of severe pulmonary hypertension after closure of a large ventricular septal defect using low dose inhaled nitric oxide

A 16-month-old girl developed severe pulmonary hypertension after closure of a large ventricular septal defect. All conventional therapeutic measures failed; an attempt to add nitric oxide at a continuous low dose to the inspired gas allowed resolution of pulmonary hypertension and low cardiac output. This report documents that continuous inhalation of low dose nitric oxide is capable of selective resolution of pulmonary hypertension following cardiac surgery for a large septal defect in a child. This suggests that a transient dysfunction in the release of nitric oxide by the pulmonary endothelial cell is responsible for the vasoconstriction.

[Esophagogastroduodenoscpy by the surgeon]

In 1990, 123 gastroscopies were performed by surgeons in the Department of Surgery, General Hospital, La Chaux-de-Fonds, Switzerland. Seventy-five percent of these procedures were done on a diagnostic basis and twenty-five percent were controls. Endoscopy includes diagnostic, therapeutic and control procedures of numerous surgical diseases. It is thus important for the general surgeon to be committed in the endoscopic management of these pathologies. Furthermore, preoperative gastroscopy can influence or modify the operative technique. By his nearly inborn knowledge of anatomy, tissue consistency and texture, the surgeon has a priceless advantage to learn, practice and teach endoscopy. Therefore, teaching programs in surgical endoscopy should be widely created and developed in university and teaching hospitals to allow young surgeons a systematic and progressive training during their residency.

[The early bronze age graveyards of Franzhausen I, lower Austria. 2. Demographic analysis]

In a recent study of 714 graves of the Early Bronze Age cemetery, Franzhausen I, 658 individuals were demographically analysed. The masculinity rate and the mortality rate in the age groups were of similar order compared with estimates derived from other series of this period. On the base of a stationary population model, life tables were calculated showing life expectancy at birth to be 25.8 years and at the age of 20, 17.7 years. Also computed were: the crude death rate (Z = 38.8); and the population size (P = 31 or 65). The lack of infants were estimated by regressions (5q0 = 58%) and the results are discussed.

Hemodynamic effects of amrinone in children after cardiac surgery

The hemodynamic effects of amrinone were assessed in seven children following cardiac surgery. Amrinone was administered as a bolus of 1 mg kg-1 body wt., followed by continuous infusion at 10 micrograms kg-1 min-1 for 1 h and two stepwise increases to 20 and 40 micrograms kg-1 min-1 for 30 min each. Hemodynamic data were obtained and plasma concentrations of amrinone measured 1 h after the bolus dose and immediately before each increment of the infusion rate. Amrinone levels ranged from 0.7 to 2.3 mg l-1. Administration of amrinone lowered systemic vascular resistance from 20.0 +/- 4.3 to 16.5 +/- 4.6 mmHg l-1 min-1 m-2 (p less than 0.05) and reduced mean arterial pressure from 71.7 +/- 9.5 to 62.6 +/- 13.5 mmHg (p less than 0.05) at the highest infusion rate, confirming the known vasodilative effect of the drug. However, these effects did not result in a statistically significant increase in stroke volume (35.0 +/- 7.5 to 35.5 +/- 7.0 ml m-2, NS) or cardiac index (3.10 +/- 0.50 to 3.20 +/- 0.40 l min-1 m-2). One additional patient, in whom a higher loading dose was tried in order to achieve a higher plasma concentration, developed systemic hypotension. A correlation was established between the plasma concentrations of amrinone and the percentage decrease in systemic resistance (r = 0.70, p less than 0.05). These results suggest that in children after open heart surgery, amrinone acts primarily as a systemic vasodilator, with questionable inotropic effect. Accordingly, its use should be restricted to children with severe cardiac failure and documented highly elevated afterload.