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1/29. pulmonary embolism and myocardial hypoxia during extracorporeal membrane oxygenation.

    The treatment of a newborn with severe meconium aspiration by venoarterial extracorporeal membrane oxygenation (ECMO) was complicated by myocardial hypoxia with a marked decrease of myocardial contractility. The onset of the cardiac hypoxia was related to a pulmonary artery embolus. The origin of the embolus was a deep femoral vein thrombosis, caused by a central vein catheter, which was inserted 1 day before ECMO by venous cutdown. The possible pathophysiology of myocardial hypoxia in this patient is discussed, especially with regard to myocardial perfusion, supporting the hypothesis of coronary perfusion occuring with blood from the left ventricle and not from the arterial cannula in the aorta. ( info)

2/29. Chronic intrauterine meconium aspiration causes fetal lung infarcts, lung rupture, and meconium embolism.

    Three neonates with chronic intrauterine meconium aspiration are reported. All had distinctive subpleural plate-infarcts of the lungs caused by meconium-induced vasoconstriction of peripheral preacinar arteries. These vessels showed plexogenic arteriopathy with medionecrosis and obliterative hyaline sclerosis. Organized thrombi and systemic-pulmonary arterial anastomoses were numerous. The infarcts contained inspissated meconium with a granulomatous reaction.In one case, lung rupture occurred, causing meconiumthorax and meconium embolism to hilar lymphatics and lymph nodes; this suggests that particulate meconium may enter the circulation. This fetus had rubella and probable acute twin-twin transfusion following the intrauterine death of the co-twin. The cause of the hypoxia that led to intrauterine passage of meconium in the other cases is unknown. Meconium-stained amniotic fluid was noted in only one case. ( info)

3/29. Beat-to-beat changes in stroke volume precede the general circulatory effects of mechanical ventilation: a case report.

    BACKGROUND: The haemodynamic as well as the ventilatory consequences of mechanical ventilation can be harmful in critically ill neonates. Newly developed ventilatory lung protective strategies are not always available immediately and in an acute situation the haemodynamic changes caused by mechanical ventilation can affect the oxygen delivery considerably. We report the case of a male neonate who was treated with conventional pressure-controlled mechanical ventilation because of respiratory distress and progressive respiratory acidosis resulting from meconium aspiration. Because of poor arterial oxygenation despite 100% inspired oxygen and increased ventilator settings, echocardiography was performed to exclude central haemodynamic reasons for low oxygen delivery. METHOD: Doppler echocardiography was used for the measurement of stroke volume and cardiac output. pulse oximetry and aortic blood pressure were monitored continuously. RESULTS: echocardiography revealed no cardiac malformations or signs of persistent fetal circulation. When inspiratory pressures and duration were increased, beat-to-beat variation in stroke volume preceded decay in cardiac output. stroke volume variations and oxygen saturation values guided ventilator settings until extracorporal membrane oxygenation could be arranged for. After recovery and discharge 4 weeks later the boy is progressing normally. CONCLUSION: Because oxygen delivery is dependent on both blood flow and arterial oxygen content, measurement of cardiac output as well as left heart oxygen saturation is a useful guide to optimizing oxygen delivery. This case report demonstrates how Doppler echocardiographic monitoring of beat-to-beat changes in stroke volume can be used to detect early negative haemodynamic effects of increased mechanical ventilation settings before cardiac output is affected. ( info)

4/29. subcutaneous fat necrosis of the newborn following hypothermia and complicated by pain and hypercalcaemia.

    A female infant was delivered at term with complications of severe meconium aspiration and birth asphyxia. Surface cooling was performed in the first 24 hours as part of the management of her birth asphyxia. Woody erythema was noted at 24 hours, followed by the formation of red-purple nodules on the 6th day. Clinical findings in the first 24 hours were suggestive of cold panniculitis. However, clinical and histological findings progressed to be in keeping with the diagnosis of subcutaneous fat necrosis of the newborn (SCFN). Furthermore, the immediate postnatal period was complicated by pain resistant to treatment with opiates. Asymptomatic hypercalcaemia was noted on periodic testing at 7 weeks and treated by rehydration, diuretics, prednisolone, etidronate and a low-calcium and -vitamin d diet. A review of the clinical and histological findings of the relevant panniculitides occurring in the postnatal period is presented, as well as a review of the treatment of hypercalcaemia in SCFN. ( info)

5/29. Local interstitial emphysema caused by meconium aspiration: report of one case.

    A neonate of meconium aspiration syndrome presented with respiratory distress and bilateral pneumothorax. The image studies, including chest X-ray, chest computed tomography and operation finding all showed cystic changes in the right lung. Therefore congenital cystic lesions of lung was the first impression. However, the pathologic report disclosed meconium aspiration with interstitial emphysema. ( info)

6/29. Surfactant lavage and replacement in meconium aspiration syndrome with pulmonary hemorrhage.

    We reported two case studies of meconium aspiration syndrome (MAS) with pulmonary hemorrhage in which we applied surfactant lavage and replacement. Surfactant lavage and replacement of MAS with pulmonary hemorrhage appears to be effective and safe adjunctive therapy. The relatively small replacement doses of surfactant required may be attributed to surfactant lavage followed by surfactant replacement. We suggest that surfactant lavage and replacement of MAS with pulmonary hemorrhage should be further investigated by a randomized controlled trial. ( info)

7/29. diagnosis and management of clostridium perfringens sepsis and uterine gas gangrene.

    The progression of clostridium perfringens endomyometritis to gas gangrene is a rare, but greatly feared complication in the obstetrical patient. While endometritis following cesarean delivery is a common complication, recognition of C. perfringens as the pathogen as well as its progression to gas formation in the myometrium is essential to the survival of the patient. We present a patient that we recently cared for, and review the bacteriology, clinical diagnosis, and management. ( info)

8/29. Blood aspiration syndrome as a cause of respiratory distress in the newborn infant.

    Early-onset respiratory distress and a radiographic appearance of an aspiration syndrome occurred in three neonates who had not passed meconium before delivery. In each case there was evidence of inhalation of blood, associated with very high plasma protein concentration in lung fluid. Blood aspiration syndrome is a distinct diagnostic entity that can result in significant respiratory distress in the neonate. ( info)

9/29. Neonatal survival during a 2,500-mile flight.

    Neonatal respiratory failure, no matter what the cause, may not always respond to standard mechanical ventilation techniques. extracorporeal membrane oxygenation has emerged over the last 15 years as an adjunct to the treatment of these babies with a greater than 80% survival nationwide. Limited resources and personnel costs can be prohibitive, forcing regionalization of extracorporeal membrane oxygenation (ECMO) centers. Geographic distance from a center should not limit its potential application, however. Familiarity with the technique, early application of the modality and the availability of medical air transport, allows for referral and transfer of neonates over great distances with excellent results and outcomes. We present a case of respiratory failure in a neonate transported 2,500 miles for ECMO therapy with an excellent outcome and a rapid return home. ( info)

10/29. meconium aspiration syndrome--unusual features.

    A term infant with the meconium aspiration syndrome (MAS) is described. He had the typical clinical course of the disease despite appearing well nourished, and with good Apgar scores. At 5 months of age, he continued to do well with no sequelae. The reason for the initial passage of meconium in-utero remained speculative. The fact that the disease is preventable is emphasised. ( info)
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