key: cord-0005802-xhx9pzhj authors: nan title: 2nd World Congress on Pediatric Intensive Care 1996 Rotterdam, The Netherlands, 23–26 June 1996 Abstracts of Oral Presentations, Posters and Nursing Programme date: 1996 journal: Intensive Care Med DOI: 10.1007/bf02316512 sha: 7d67e9230359eff642324861fb5776764a13d6f8 doc_id: 5802 cord_uid: xhx9pzhj nan We present the results of a prospective population-based audit of paediatric intensive care activity in two comparable communities with markedly different delivery systems. In the Trent region of the UK (4.2 million people), children receive intensive care largely without the supervision of a paediatric intensivist in a variety of hospitals, few of which have designated Paediatric Intensive Care Units (PICUs). Critically ill children otherwise receive intensive care in children's wards, special care baby units (SCBUs) or adult intensive care units. In the Australian State of Victoria (4.5 million people), children receive intensive care almost exclusively in one centre -a PICU staffed by full time paediatric intensivists. The two regions are otherwise demographically comparable. In both groups, data were collected on all children admitted to an intensive care unit between 1/4/94 and 31/3/95 and children who received intensive care (defined by levels of intervention and nurse dependency) in other sites during the same period. Values of each variable at first contact with the ICU, and the highest and lowest values over the first 24 hours were recorded. The principal outcome was survival to discharge from the intensive care unit. Severity of illness was assessed using PIM (Paediatric Index of Mortality) and PRISM. Risk-adjusted mortality was compared using Flora's Z test and logistic regression. The rate of utilisation of intensive care (>1000 admissions in each region) were similar. There was some variation in case mix between the two groups, but crude mortality rates were similar (7.4% in Trent and 6.6% in Victoria). However severity corrected data and other measures of PICU performance were dramatically better in' the centralised delivery system. The substantial excess mortality in the Trent region provides strong evidence for the benefits of centralisation of paediatric intensive care services. There are considerable difficulties in evaluating the efficiency and effectiveness oflcare in children presenting with respiratory failure during acute medical illness. Optimal outcomes for such episodes include survival and the shortest length of stay (LOS) in intensive care with negligible risk of readmission. We have tried to determine whether or not the time course of acute severe medical illness with respiratory failure is predictable. Study I (n=1000): A retrospective study of intubated and mechanically ventilated children (>28 days, <17 years) with acute severe medical illness. Measures: Diagnosis, intensive care LOS in calender days, and survival. Results: The underlying diagnosis fell within one of three broad categories: respiratory disease (n=521, mortality 19.2%), central nervous system (CNS) disease (n=342, mortality 38.7%), and systemic inflammation or multisystem (SIMS) disease (n=137, mortality 47.5%. The LOS in survivors was: respiratory -median (interquartile range) 8(4-16) days, CNS 4(3-8) days, £p,4£ 5(7-g) days. 5:i'~'-+cen diag~,~is-rc!ated-grnnp~ (DRGs) were identified (8 respiratory, 5 CNS, 3 SIMS disease) and each have been characterised by mortality and LOS. Study II (n=300): A prospective study of patients supported by the hypothesis that LOS for the above DRGs was predictable (compared with Study I data). In certain instances attributable causes for variances in LOS were identified: e.g. disease severity, timing ofdrug therapy, and associated disease. With daily paediatric risk of morality scoring within each DRG, four profiles of instability were identified. Discussion: The time course of acute severe medical illness with respiratory failure is predictable and variance may be attributable to specific care or diagnostic factors. We are now developing a means of linking DRG-specific clinical care pathways with an integrated computerised decision support and education facility at the bedside. The objective of this open, prospective study was to assess the relation between basic patient characteristics as well as effectiveness of treatment on the one hand and resource utilization in pediatric intensive care on the other. As universal, non-monetary indicators of resource utilization we used the Therapeutic Intervention Score System (TISS) and length-ofstay (LOS), from which indicators for total resource utilization per admission (TISSTOT) and average daily resource utilization (TISS-MEAN = TISSTOT/LOS) were obtained. Overall 593 admissions, totalling 3130 days, were included. Mortality was 8.4%; non-survivors accounted for 14.1% of overall resource utilization. In non-survivors, both total resource utilization per admission and average daily resource utilization were higher, whereas LOS was not different from survivors'. Severity of illness, surgical status, the presence of substantial chronic comorbidity, emergency admission and transfer from another hospital constituted the major predictive determinants of TISSTOT (r:=0.19) and TISSMEAN (ra=0.45) in multiple regression analysis (p<0.0001). Hence these indicators are appropriate non-monetary measures of resource utilization, a considerable proportion of which are determined by a concise set of basic clinical characteristics. Subsequently we analysed the relation between effectiveness of care and resource utilization by assessing severity of illness corrected mortality in low, medium and high resource users, respectively. These 3 categories were delineated by percer/tiles of resource utilization (< P20, P20-PS0, > Ps0). Despite on average long LOS and high resource utilization in the high risk group, a relatively low standardized mortality was found, probably warranting prolonged intensive treatment in this patient category. SUMMARY: Objective:The primary purposes of intensive care are to provide treatments to patients with life-threatening physiological dysfunction or to monitor and observe patients perceived to be at significant risk of dying. This collaborative study was performed to describe our patients and their outcome. In order to improve our results we tried to identit~ high risk groups, Patients and Methods: 13 PICUs entered the study, The data included all the admissions with >12 hs. during a 60 days period between the l°June and the 30th September 1993. The records included: age, sex, weight, mechanical ventilation (MV), post-operative condition (P.Op), malnutrition, diagnosis, length of stay, PRISM score and outcome. Student test, Mann-Whitney or Wileoxon were performed for univariate analysis. Fisher Exact test or Chi square for dicotomic variables. Risk group analysis was performed by logistic regression, odds ratio and 95% confidence interval. Results: 650 patients entered the study. Mean age was 47.6 months (DS hh¢# 60) and median 18 months. We found significant statistical differences in calculated ,is observed mortality rate comparing malnourished with euthrofic patients; Mechanical ventilated (MV) with non MV patients. No differences in ter ~,h of stay or di~ noses were found. Effect of the UN Sanctions on the Morbidity rate araong the iraqi small children ( below 3 years old of age ) in Bagdad. Abdulsamad A.Abood / Institute of Medical Technology, Bagdad. Meningitis is essentially a childhood disease (I). The risk of infection are increased by powerty and overcrowding (7). The impah'ed Immunity may be an important pathogenic factor underlying the susceptibility to infections in undernourished subjects (5). In general, malnutrition is a man made disease and it begins quite in the womb and ends in the grave (I). 1918 small children, below 3 years of age were admitted to the pediatric Hospital in Washash with meningitis over 4 cold months in I994, in contrast to only 176 child admitted with meningitis over the same period in1989. All of the children who admitted in 1994 were frankly undernourished, 45% of them were infected with Enterobacteriae, because they were exposed to faulty Hygiene and lack of Asepsis. These facts showed precisely that our small children had suffered at most from the UN_ Sanctions against Iraq, because of food, milk and drug shortage, since 4 years which had resulted a severe undernutrition among them, which impaired their immune status. M Wells, OF Riera-Fanego, J Lipman. Baragwanath Intensive Care Unit, University of the Witwatersrand, South Africa. Background The use of PRISM or other scoring systems in the ICU is of great importance for evaluating the efficacy and efficiency of a particular ICU, The PRISM score was developed and validated in the USA and Europe but has recently been shown to be inaccurate in a South American population, a South African population as well as several European studies. Part of the poor performance of the PRISM score is as a result of differences in the case mix between the reference population and other paediatric ICUs. Since scoring systems should generally be used only in populations similar to the reference population from which the prediction model was developed, a modification of the PRISM score is necessary to improve its discriminatory ability in a wide range of patient groups, Aim To improve the predictive power of the PRISM score in a South African paediatdc ICU population. Patients & Methods We analysed PRISM, demographic and clinical data collected prospectively from 1528 consecutive paediatrie ICU admissions. The prediction of actual mortality by PRISM was evaluated by standard statistical methodology (goodness-of-fit test and receiver operating characteristic (ROC) analysis), The components of the PRISM logistic regression equation (PRISM score, operative status and age) and the 14 physiological variables making up the PRISM score in addition 10 new variables analysed (nutritional index, the need for inotropes and institution of mechanical ventilation) were subjected to discriminant analysis to determine their association with outcome. Results The goodness-of-fit test showed a significant failure of PRISM to accurately predict mortality over a wide range of expected mortality (Chi2[8] = 195, p = 0). PRISM underpredicted mortality at lower PRISM scores, but overpredicted mortality in patients with high PRISMs. Similarly ROC anNysis indicated apoor predic~Jve power (Az = 0.73 ± 0.01), with an area under the curve significantly less than that for the PRISM reference population (p = 0), PRISM showed equally poor discriminatory function at all age groups and diagnosfic categories. '~Mth the addition of an index of nutrifional status (proportional weight-far-age), and indicators of early respiratory and cardiovascular failure to the logistic regression formula, and a recalibration of the acute physiological score component, the ROC can be improved to 0.83 ± 0.02, with a good fit described by the goodness-of-fit test (CN218] = 3, p = 0.89). Discussion The PRISM score is not accurate in our patient population has been recalibrated in view of the poor discriminatory function that we have shown. Part of the inaccuracy derives from the different demographic characteristics of our ICU population and a different pattern of diseases. In addition to assessments of acute physiological aberrations, an assessment of nutritional status and early respiratory and cardiovascular failure significantly improve the discriminatory ability of the PRISM score, These parameters have been devised with a view to improving the accuracy of PRISM in our population, while not decreasing its accuracy in ICUs similar to the reference population. In interviewing parents regarding how physicians have communicated bad news, the response I have received is that it has not infrequently been done without appropriate care, understanding and compassion. Personal experience and the lessons learned from parents, chaplains and others who deal extensively with these situations have provided me with an approach that has been supportive, compassionate, and caring. An especially difficult communication situation for the intensivist occurs when the parents have to be informed of the death of their child. For the parent, death is the hardest loss of all -the ultimate unalterable loss. Circumstances surrounding the death are an important consideration (e.g., a fatal crash caused by a drunken driver, a prolonged illness, a suicide, AIDS). Each produces a different grief reaction. The physician needs to inform parents of their child's death sympathetically coming right out with the news and leaving details until later. Allow pauses and time for the paren~ to express sorrow and grief, The best communication may be thoughtful silence and a tender touch. There is disbelief that this happened. It is necessary to repeat oneself. Acknowledgment of the parent's "feeling terrible" and the physician's acknowledgment of how terrible he/she feels that the life of the child could not be saved is an important first step in the parent's dealing with this tragic loss. With prolonged resuscitation, it is helpful to have a member of the ICU team talk to the parents while the resuscitative efforts are ongoing so that the parents are not left unsupported at this time. A progress report should be delivered in a caring, lucid, and sensitive.manner, indicating that every effort is being made to save the life of their desperately injured child. After a child has died, it is helpful to the family if the physician maintains some contact with them. This should take the form of follow-up telephone calls at approximately 6, 12, and 24 months. This can help to screen for depression in the parents. In giving bad news to the family and making every effort to support them through this tragic time, it is necessary to remind oneself that the intensivist has personal needs for dealing with grief and will also require support to pass through this stage. Direct evidence that child mortality is lower in specialist pediatric ICUs comes from 3 studies. A study in Oregon (CCM 1981; 19:150-9) found that mortality adjusted for severity of illness was 102% of expected in 3 pediatric units and 139% of expected in 71 general units (p<0.05). A study in Holland (CCM 1995; 23:238-45) found that mortality in high risk patients was 85% of expected in 6 tertiary pediatric units, and 143% of expected in 4 nontertiary units (p<0.05). A third unpublished study, has found that children in Victoria (who almost all receive intensive care in a pediatric ICU) have a much lower standardised mortality rate than children in the Trent region of the UK (where many children receive intensive care in adult ICUs). There is indirect evidence that ICUs looking after many children are likely, on average, to perform better than ICUs looking after few children: numerous studies in many specialities have found that units looking after many cases of a particular disease have better results than units with few cases. See Luft HS, "Hospital Volume, Physician Volume, and Patient Outcomes", HAPP, 1990; and Farley D, Medical Care 1992; 30:77-94. Compared to general ICUs, medical and nursing staff in pediatric ICUs are likely to be better at looking ~fter children, and PlCU RMOs have greater skills in pediatric intubation, ventilation, IV drip insertion and drug doses. PICUs are more likely to have appropriate equipment to manage children -especially for uncommon but life-threatening situations. ICUs in pediatric hospitals are more likely to have physicians and surgeons with pediatric expertise available for consultation at all times. The American Academy of Pediatrics, the Society of Critical Care Medicine, the British Paediatric Association and the Australian NH&MRC have all said that children should receive intensive care in'specialist pediatric units. The weight of authoritative opinion, and direct and indirect evidence is strongly in favour of looking after children in dedicated pediatric ICUs. neurological deficit showed higher CBF values (125.7/115.2 ml/100g/ rain.) than the 11 patients with good outcome (mean CBF 1 17.5 SD +8.1; CBF 2 19.9 SD _+9.1 ml/100g/rain}. Discussion: In asphyxia decrease of pH is due to reduced tissue oxygenation and indicates the severity of metabolic derangements. CO2reactivity in newborns with perinatal asphyxia correlates with the lowest pH and therefore may reflect severity of asphyxia. Continuous monitoring of cerebral activity is carried out in our unit on all admissions at risk of cerebral dysfunction, A number of monitors are commercially available and we report our experience with the CFAM2 which provides in addition to amplitude integrated EEG analysis, continuous raw EEG display and frequency distribution. Bilateral recordings are commenced as soon as possible and continued while clinically indicated. Forty one children ranging in ages from 4 weeks to 16 years were monitored for periods from 3 hours to I0 days, Diagnoses included traumatic brain injury (11), sepsis/meningitis/encephalitis (1 t), status epilepticus (8) and miscellanous others (11). Results are tabulated below. Patients 13 12 16 Status epilepticus 10 4 1 * Beta activity 1 8 15 * Background voltage 10 3 1 * < I O/zV 2 or more of above 12 2 1 * (*Z2 p < 0,001) Asymmetry developed in 4 children, all of whom died. Positive predictors of good outcome included a mean background activity of >10zzV, the presence of faster frequencies (usually 13) in response to sedative drugs and the absence of seizures. All monitoring is performed by the PICU staff and increasing expertise in interpretation has resulted in earlier therapeutic and diagnostic interventions. Regional It was previously found that histamine, a vasoactive mediator, accumulated in brain compartments (Kov~ics et aL 1995 Neurosci Lett 195:25) , and antihistamines prevented brain edema formation (Dux et al. 1987 Neuroscience 22:317) in asphyxiated newborn pigs. In the present study we investigated the effect of intracarotid histamine injection on the blood-brain barrier (BBB) permeability, Left internal carotid artery of 30 newborn pigs (4-8 h; 1,180-1,530g; ketamine anesthesia, 10 mg x kg 4) was catheterized through the external branch and different doses of histamine (0, 10 -6, 5xi0 -6, 10 -5, 5x104, 104 M, respectively, in 6 groups of animals; n=5 in each) diluted in 1.0 ml isotonic saline was injected into the vessel through 1 rain. BBB permeability was determined for a small (sodium fluorescein, SF, 376 Da) and a large (Evans blue/albumin, EBA, 67 kDa) tracer (2%, 5 mLxkg 4, 30 rain circulation time for both dyes) concomitantly in frontal, parietal and occipital cortex, hippocampus, and periventrieular white matter both on left and right sides 1 h after the challenge. Then, intravascular dyes were removed by perfusion and BBB permeability for both tracers was quantified by fluorescence spectrophotometry (wavelengths for excitation and emission were 440 nm and 525 nm for SF; and 620 nm and 680 nm for EBA, respectively). Histamine injection, in doses higher than 10 .6 M, significantly (P<0.05; Kruskal-Wallis one way ANOVA on ranks followed by Dunn's test) increased BBB permeability for both tracers in each brain region. Changes in left hemisphere were more intense (P<0.05) than those in right one after the doses of 5xi0 -6 and 10 -5 M in each region, i0 4 M histamine administration induced similar edema in both sides. Increased intracarotid histamine levels resulted in a dose-dependent vasogenic brain edema formation. Histamine might have a pathogenetic role in neonatal hypoxicischemic cerebral injuries. Supported by OTKA F-12722 and H-U.S,-JFNo.392, $162 In coma caused by traumatic brain Jnjury, an indication of the likely outcome is provided by the best motor response to pain in the first .$ hours after the insult. In a study in our PICU, the proportion of children who died or had a severe disability was 100% in 35 who had no response to pain, 40% in 47 with an extensor response, 14% in 64 with a flexor response, and 1% in 61 who localized in response to pain. The long term outcome of traumatic brain injury appears to be worse in children <4 years old. Other risk factors in traumatic brain injury are absent basal cisterns, midline shift or subdural haemorrhage on CT scan (or loss of grey-white differentiation in nontraumatic injury); or an intracranial pressure >30 mmHg despite hyperventilation, mannitol and barbiturate infusion. Apart from brain death, there are two findings implying such a poor prognosis that consideration should be given to stopping treatment: first, after traumatic injury, the absence of any motor response to painful stimulus in the cranial nerve distribution (providing drug effects and a post-ictal state have been excluded); and second, in acute brain injury from trauma, infection, hypoxia, or ischaemia, the b{lateral absence of short-latency somatosensory evoked potentials (providing brain stem haemorrhage, subdural and extradural effusions, and decompressive craniectomy have been excluded). In children over 2 months of age, recovery from prolonged coma or a vegetative state is exceedingly rare when more than 12 months have elapsed after traumatic brain injury, and when more than 3 months have elapsed after nontraumatic injury. Overproduction of nitric oxide (NO) via an inducible isoform of" NO synthasc (iNOS) produces profound vasodilatation in adult septic shock. High nitrate levels have been reported in hypotensive children with sepsis syndrome ]. Cardiovascular collapse is a prominent feature of severe meningocoecaI disease (MCD). However, systemic vascular resistance (SVR) was slightly higher in a group of non-survivors ~ and the rote of NO in IvICD remains unclear. Children with a presumptive diagnosis of MCD were enrolled. Parental consent was obtained. Blood was drawn on admission and 12hrly thereafter. Plasma was separated immediately and stored at -80°C. The final concentrations reported represent the product of nitrite and nitrate (NOx). NOx was measured spectrophotometrically using the Greiss reaction. 21 children were studied (median age (range); 27m (5-203)). The diagnosis of MCD was confirmed in 18 children, 12 of whom had a Glasgow Meningococcal Score (GMS) of" ~8. In this group with severe MCD there were 3 deaths. Peak NOx was significantly higher (,.54(27-78) vs 96(50-363)nmol/ml, median) and systolic btood pressure was significantly lower in children with severe MCD than mild MCD (p<0.05. Wilcoxon rank test). There was a significant correlation between peak NOx and GMS (Spearman's rank correlation r=0.6 (p=0.01)) and PRISM (r=0.6 (p:0.01)). NOx production from adm.ission onwards was also higher in the severe MCD group (p:0.002, Kmskal ~Wallis). We have demonstrated that plasma NOx levels are elevated in children with MCD, correlate directly with the severit 3' of disease and are inversly related to systolic blood presssure. Similar to hypotensive septic syndrome, MCD appears to be associated with an up-regulation of the L-arginine-NO pathway.. Non-survivors with MCD have higher SVRs and may be relatively hypovolaemic. In our group of severe MCD there was a significantly lower systolic pressure and increased NO formation. Excess iNOS expression at different stages in MCD may contribute to the pathology of the disease. The identification of agents which can boost and/or inhibit NO reiease may therefore represent different treatment strategies for MCD. U. Merz, Th. Peschgens, G. Kusenbach, M. B6hle, H. H6rnchen In this controlled, prospective study 30 ventilated premature infants with a birth weight < 1250 g were randomized to receive treatment with dexamethasone (DEX) either on day 7 of life or on day 14 of life. DEX was given over 16 days tapering from 0.5 mg/kg/day to 0.1 mg/kg/day. The infants treated with DEX on day 7 of life could be weaned earlier from the ventilator -in median after 14 days (range 10 -34) versus 24 days (range 8 -44) in the [ate treatment group (p = 0.01). The need for supplemental oxygen was shorter in the early treatment group -in median 24 days (range 10 -50) versus 40 days (range 10 -70) (p = 0.2, ns). The incidence of chronic lung disease was lower in the early treatment group -6 of 14 infants (42.9%) versus 10 of 16 patients (62.5%) (ns). To evaluate the long-term efficacy of early DEX treatment we performed a respiratory function test in the age of 3 -6 months using an infant whole body-plethysmograph. The intrathoracic gas volume (ITGV), the airway resistance (R.w) and the airway conductance (Gaw) were measured and no significant differences could be detected between the groups. The frequency of adverse effects due to DEX therapy was found to be without significant differences between the early and the late treatment group. We conclude that early DEX treatment had short-term improvements in pulmonary outcome in our study population, long-term efficacy however, remained unproven. Several factors contribute to the development of chronic lung disease (CLD) in premature infants including structural immaturity of the lung, mechanical ventilation, and oxidative stress. Reactive oxygen species are formed during normal cellular metabolism but they are generated in higher concentrations during inflammation or inhalation of high oxygen concentrations. To study the relationship between increased oxidative stress, antioxidants and the development of CLD we examined 102 ventilated premature infants with birth weights below t500g. 32 infants developed severe chronic lung disease of prematurity (CLD), defined by radiological signs of CLD and an increased oxygen requirement at a postconceptional age of 36 weeks, and 29 infants had moderate CLD with an increased oxygen requirement on day 28 but not at an age of 36 weeks. Ventilator settings (FiO2, peak inspiratory and mean airway pressure) and the incidence of early-onset-sepsis were significantly higher in the severe CLD group than in infants with moderate CLD or without CLD (n=41) during the first week of life. Plasma concentrations of the two antioxidative substances bilirubin and uric acid (UA) were comparable in all groups during the first days of life. However, on day seven bilirubin and UA were significantly decreased in the plasma of infants with severe and moderate CLD compared to the non CLD group (p15 cm H20 or b) there was an unexplained increase in ventilatory requirement. METHODS : High resolution CT was performed in 3 patients and spiral CT in 7 patierits, To ensure minimal transport related morbidity, patients were transferred to the CT scanner by a specialised mobile intensive care team. RESULTS: In 2/10 patients CT demonstrated greater extent of disease than appreciated on CXR but did not significantly alter clinical management. In 7/10 patients CT provided additional information regarding the nature of disease present, In 2/7 children this involved a further diagnosis and in 5/7 children the exclusion of a suspected pathology. New information led to a positive therapeutic intervention in 2 children, prevented inappropriate manoeuvres in 3, and had no significant effect on acute management in 2 children. CONCLUSIONS: Initial data suggests that in a selected group of mechanically ventilated children chest CT can add to the sensitivity and specificity of intrathoracic diagnosis provided by the chest radiograph and directly influence acute management. Case selection criteria and choice of the most appropriate protocol requires further study. Pressure control ventilation (PCV) utilizes a decelerating flow pattern which may improve gas distribution and lead to alveolar recruitment. In contrast, volume control ventilation (VCV) employs a constant flow. In children, the effects of PCV as compared to VCV are unclear. The purpose of this study was to determine how these two modes compare in terms of dynamic compliance (Cdyn). peak iaspiratory pressure (PIP), and mean airway pressure (Paw) at equivalent minute ventilation. Methods: Sixteen infants and pediatric patients ranging in age from 1 day to 13 years were studied. Diagnoses included ARDS (6), postoperative cardiac surgery (7), head trauma (1), and resfrictive lung disease (2). Patients were randomized to PCV (9) or VCV (7). Initial measurements of gas exchange (ABG's) and respiratory mechanics (Ventrak, Novametrix Medical Systems) were obtained after a 20 minute stabilizadon period. Respiratory mechanics included PIP, PEEP, Paw, delivered tidal volume, and Cdyn (Avolume/Apressure). The patients were then crossed over to the alternate mode of ventilation holding delivered tidal volume, PEEP, inspiratory time, minute ventilation, and FiO2 constant. Data were collected after 20 minutes, In each mode the absence of intrinsic PEEP was confirmed. To assure that the measurements were not affected by changes in clinical status, the patients were returned to the initial mode of ventilation and measurements repeated (Final) . Patients were ventilated with a Siemens 900C or SV300. Reselts: Data were analyzed using 2-way analysis of variance with repeated measures. ~ <0.05 vs. VCV) VCV PCV ~ Initial ] Final ! CdlJn 3.5_+0.7 4.3_+0.8 * 3.7_+0.6 3.9_+0.7 I , PIP 32+1.0 30L-_t.0 * 31_+1,0 31+-1,0 Paw 9.2_+0.6 10.9i-_0.7 * 9.7+0.7 10.0-!-_0.8 PaO2 97_+14 92+-10 87_+9 97_+14 Discussion: At the same minute ventilation, the decelerating flow pattern of PCV resulted in a 23% increase in Cdyn and an 18% increase in Paw while decreasing PIP by 6%. The lack of a significant change in oxygenation may be a result of the limited time in each ventilator mode as well as the inclusion of patients with both normal and abnormal lungs. There was no significant difference in initial and final measurements indicating patient stability. The beneficial effects of iecre~L~iug Cdyn and Paw while decreasing PIP indicate that PCV may be a preferable mode of ventilation in patients with lung injury. Further randomized studies examining the effect of PCV on respiratory outcome measures in pediatrics are indicated. Prolonged positive pressure ventilation following repair of CDH is associated with a high prevalence of iatrogenic lung injury, in our unit dudng 1981-1990 314 late deaths after repair of CDH were due to chronic lung disease. Since 1990 babies requiring assisted ventilation for more than 7days following surgery were transferred to a CNEP chamber to limit lung injury. CNEP of -6cm of H20 was combined with positive pressure ventilation via an endotracheal tube dudng the transition phase. Immediate reduction of peak inspiratory and positive end pressures were possible and following extubation respiratory support was maintained by CNEP v~th appropriate inspired oxygen. Overall outcome: [1981] [1982] [1983] [1984] [1985] [1986] [1987] [1988] [1989] [1990] n=68 Deaths before surgery (%) 11 ( ECMO During 1990 -1995 /16 who were ventilated for more than 7 days received CNEP and there were no deaths and no chronic lung disease in that group. CNEP assisted ventilation may be an important management option for babies who require prolonged respiratory support to avoid the adverse effects of chronic positive pressure ventilation, Introduction So far 2 modes of liquid ventilation (LV) have been used in experimental animals and, exceptionally, in humans: 1. total liquid ventilation (TLV)-functional residual capacity (FRC) is filled by perfluorocarbons (PFC), and slow tidal volume (Tv) breathing is performed by PFC. 2. partial liquid ve,0ti,la~ion (PAGE) -only FRC is filled by PFC. Gas Tv is delivered by conventional mechanical ventilation (CMV), high frequency jet ventilation (HFJV) or high frequency oscillation (HFO). The aim of our study is to present our limited experience with PAGE in newborns and infants. PAGE was used in two groups of infants: 1, in 2 infants with brain death before disconnection from CMV, because recipients for organ transplantation were not available. These infants have relatively normal lungs (FiO~ less than 0.4). Infants stayed on PAGE for 1 hour, during that period no ventdator manipulations were made. After PAGE, infant were switched to CMV for next 6 hours. 2. very critically diseased infants with ARDS (RDS) -2 on ECMO more than 5 days, 1 before cannulation for ECMO, 4 on HFO because of intractable respiratory failure, Preoxygenated RM 101 (Miteni, Italy) was used in the doses up to 40 ml/kg intratrachealy. Blood gases and parameters of pulmonary mechanics were followed (dynamic compliance -C dyn, airway resistance -Raw, Bicore monitor). PAGE was combined with NO inhalation (5-80 p.p.m, in 2 infants). In both groups ad hoc an approvement from e local ethical commission and informed parental consent were obtained. In the first QrouD with relatively normal lung parameters of oxygenation drops after PFC instilation intratracheally and stayed depressed for 4-6 hours. Slight pCO2 retention occured in both cases during PAGE. C dyn increased almost double during PAGE period, Raw drops transitorily after PFC instilation but in 10 minutes they were identical like in prePAGE period, Parameters of oxygenation (PeO2/FiO2) after 4-6 hours after PAGE improved and were better than in prePAGE period. After that time infants were disconnected and died. In the second group no improvement of oxygenation was seen in one ECMO baby, in spite ()f transient improvement of C dyn. In the second ECMO baby, oxygenation improved and flow of pump could be decreased by more than 20%. None of these babies, however, survived, improvement was only transient in spite of repeated dosis of PFC. In these babies serious problems were to maintain the adequate FRC by liquid, because of severe air leak, In 5 babies on HFO/HFJV with severe ARDS/RDS the improvement of oxygenation were seen in all the cases immediately after PFC instiletion for the period of 4-5 hours. After that period, PFC dose had to be repeated. Two babies of this group survived. Conclusion. PAGE is going steadily from tabs to clinical practice. It is simple, could be performed anywhere, cheaper than TLV. However, because Liquivent -Perflubren (Aliance Pharmaceutical) is not available in Europe, RM 101 of 82 (Mitenti, Italy) is the only solution, which could be currently used here. Before the widespread use of PAGE in clinics, liquid network among most NICUs and PICUs must be built up, the criteria for PAGE must be defined and ethinal-legal problems resolved as well. After resolution of these particular problems PAGE can be life saving procedure for very special part of critically ill newborns end infants. Catherine Caronia, Peter Silver, Laura Nimkoff, Cad Quinn, Jack Gorvoy, and Mayer SaN. Division of Pediartic Critical Care, Medici,, Schneider Children's Hospital, New Hyde Park, NY 11040, Imroduetiun: Cystic fibrosis (CF) patients awaiting lung transplantation present a therapeutic dilenuna when severe respir, aory decompemalion occurs, Endotracheal intubation and mechanical ventilation is known to have no long term benefits and is associated with high morbidity and mortality. Noninvasive respiratory support appears to be a beneficial alternative. Methods: We instituted BIPAP (Respironics, Inc,, Murrayville, PA) in 9 end-stage CF patients who were admitted to the Pediatric ICU with severe respiratory decompeusation. All patients were awaiting tung transplantation. After a control period, BIPAP was applied via a tight fitting nasal or facial mask, using the spo~aneous breathing mode, Expiratory pressures were set at 4-8 cm HHzO. Inspiratory pressures were started at 8 cm ~I O and increased in 2 cm I-I20 increments until the patient's respiratory comfort was achieved and substantiated by non-invasive monitoring. Patients were instructed to use BIPAP during night sleep and whenever subjectively required, Data are reported as mean _+ S.D. Results: All 9 patiems utilized nocturnal BIPAP for 6-10 hours/day during a follow-up period of 2-19 months. Compared to their pre-BIPAP status, the patiems' oxygen requirement and respiratory rate both Oz~ Cundusion: BIPAP tl~rapy improves the respiratory status of decompeusatir!g end-stage CF paacnts. It is well tolerated for long term use at home, and provides an extended period of respiratory comfort and stability for CF patients awaiting lung transplantation. L. Bindl*, G. Kiihl**, P. Lasch***, Appel**, J.M611er**** and the "Arbeitsgemeinschaft ARDS im Kindesalter" Background Acute respiratory distress syndrome (ARDS) is a therapeutic challenge in pediatric intensive care in view of the high mortality, In 1992 about 50 German paediatlic hospitals founded a working group aiming on collaborative clinical research in this field. Aims and methods The aim of both a prospective and retrospective survey conducted in German pediatric intensive care units in 1993 was to accumulate data on the epidemiology, risk factors, natural history and treatment strategies in a large group of pediatric ARDS patients who were treated in the tt~ee year period from 1991 to 1993.All patients had acute bilateral alveolar infiltration of noncardiogenic origin and a pO2~iO2 ratio < 150mmHg. The influence of sex, underlying disease and single organ failure was analyzed using the Fischer's exact test, the influence of additional organ failure on mortality was tested with the Cochran-Mantel-Haenszet statistics. Results 112 patients were reported giving an incidence of 7 cases per 1000 admissions to pediatric ICUs. Median age was 24 month. In 43% of the cases, ARDS was associated with a pulmonary, in 39% with a systemic underlying disease. In 20% immunocompetence was impaired. Mortality was 46% and not dependent on age, sex and triggering event. The number of associated organ failures, however, strongly influenced mortalib,. Mortafity in immuno-compromised patients was 8 t %. The Analysis of treatment modalifies employed in the patients revealed a lack of uniform therapeutic strategies. On the other hand, the patients were exposed to interventions not yet supported by controlled trials. Conclusions The observation of the lack of uniform treatment strategies led to the elaboration of recommendations on ventilator therapy and patient monitoring within the working group. The data gathered in this survey provide the basis for the design of prospective multicenter studies urgently needed to evaluate innovative treatment modafities in pediatric ARDS. Recurrent apnea and respiratory failnre due to severe lower respiratory tract disorders such as bronchiolitis or pneumonia are the most common reasons for mechanical ventilation during respiratory syncytial virus (RSV) infection. Acute respiratory distress syndrome (ARDS) has been described as a complication of severe RSV infectionJ In contrast to the low mortality rates associated with RSV infection (< 5 %), mortality rates in the range of 40-70 % have been reported in pediatric patients with ARDS. However, studies on ARDS are usually lumped in respect to causation and the disease course of RSV induced ARDS has not been previously studied. We examined the lung function abnormalities of 37 infants with RSV induced respiratory failure requiring assisted ventilation, Measurements included respiratory mechanics, maximal expiratory flow-volume curves and lung volumes, ARDS was defined clinically using the criteria which were recently proposed by the American-European Consensus Conference on ARDS~: acute disease onset, PaO2/FiO~ ratio _< 200 mrn Hg, bilateral infiltrates on chest radiograph and absence of clinical evidence of left atrial hypertension. We calculated the Murray lung injury scores modified for use in pediatric patients 3 from total respiratory system compliance, radiographic findings, ventilator settings and blood gas results. We identified 10 infants with severe restrictive lung disease that fialfilled the clinical criteria fbr classification as ARDS. All had lung injury scores above 2.5 which is the recommended cut-off for a diagnosis of ARDS, Twenty-seven infants had obstructive disease consistent with a clinical diagnosis of bronchiolitis. The ARDS patients were significantly younger, had a longer time of assisted ventilation (p <0.05) and a greater proportion of infants with preexisting illnesses (p=0.023, Odds ratio =6.67) when compared to the patients with obstructive disease. With the exception of one immunodeficient patient, none of these infants died. Given the low mortality despite a clinical picture of severe lung injury, there is evidence that RSV induced respiratory failure may represent a relatively benign cause of ARDS in pediatric patients, Bachmann An audit of patients with severe acute bypoxic respiratory failure (AHRF) receiving highfrequency oscillatory ventilation (HFOV) in our unit ( n=32, mortality 75%) revealed that sub-groups with severe underlying disease (n=14, mortality 100%)and those with mu~pie organ failure ( > 2 systems failing, n=7 mortality 100%) accounted for all the deaths beyond the neonatal period. V~ therefore hypothesized that in a modem paedistric intensive care unit (PICU): a) children greater than one month of age with AHRF do not die in the absence of severe, pre-existing disease or multi-organ dysfunction syndrome, b) respiratory parameters alone will predict outcome poorly in AHRF. Method Prospect~/e sty/of all adm~ns to our tertiary PICU. Data it, citing the respiratory parameters (oxygena~n index [Ol] , aiveolar-artedal oxygen tension gradient , PaO2/FiO2 ratio) were collected hourly from the bedside charts throughout admission. Patients were included in the study if AHRF was present at admission either None or in combination with other organ dysfun~on. AHRF was defined as the acute (<48hour) onset of respiratory dysfunctk:~l with a PaO2/FiO2 ratio.< 200 for six consecutive hours dunng the first 24 hours of admission (with no evidence of left anal hypertension), X-ray review defined a sub-group of patients with Acute Respiratory Distress Syndrome (ARDS) by the presence of bilateral interstitial infiltrates. Results To date 59 children (ages 1-168 months, weight 1.2-70 kg) have been admitted in AHRF. 18 of these also had ARDS. The overall mortality was 23.7% (14/59), and greater in the ARDS group than the non-ARDS group (10t18, 55.5% Vs, 4141, 9.7%, p< O.01) . It was not possible to predict survivors from non-survivors on the basis of the seventy of the respiratory failure alone, The A-aDO2 on the day of admission (best in 24 hours) was not significantly different between survivors and non-survivors: (mean, + sd)(174 mmHg +_108, Vs 304 mmHg _+_156). kdl non-survivors were immunodeficient (n=8), previously extmrnsly premature infants (<28140),(n=3) or suffedng fcom chronic metabolic or gastrointestinal disease (n=3). No previously normal child died. Conclusion The severity of respiratory failure does not allow prediolJon of outcome in our patients. We believe that this reflects that modem PICU is so effective at providing respiratory support that pre-existing pathology alone de~ prognosis. This suggests that an abnormally regulated host response or abnormal persistence of a pathogen may be required to induce lung injury of sufficient severity that the resulting respiratory failure cannot be supported in a modem PICU. Introduction: Postural changes (supine to prone) is a therapeutic intervention that could be useful in children with adult respiratory distress syndrome. Objective: To determine the effects of postural changes in the oxygenation of young children with ARDS. Method,s: A prospective stud3," was performed in eleven subjects aged 6 to 120 months (mean=33) with the diagnosis of ARDSreceiving vendlatory support. (mean PEEP and FiO2 of 9 and 0.75 respectively). Postural changes was performed every 8-12 hours, during a period of time ranging from 5 to 16 days. Arterial blood gases were determined before and 30-60 n~n after the postural change, No modification in the mechattical ventilation other that changes in the FiO2 were performed. The oxygenation was determined by the index PaO2/Fi02 (P/F). To study the differences between the oxygenation mean, before and after the postural changes the Wilcoxon test for paired samples was used, Results: 184 changes were performed (104 from supine to prone and 80 from prone to supine). A9% increased P/F ratio was obtained after the change from supine to prune. Although, not all the patients receiving postural changes improved their P/F. Six of them (Group I) showed an improve in the P/F when changed from supine to prone, returning to their base line when positioned from prone to supine. No improvement on the P/F was observed in the remaining 5 subjects (Group II)after postural changes (Table 1) . During the maneuver no complications were observed. Two patients had a pneumothorax, not related with the postural change. Conclusions: Postural changes (supine to prone) is an easy way to improve oxygenation in some children with ARDS. Change to prone Change to supine Introduction: The common noninvasive diagnostic efforts to identify possible obstruction of the intrathorucic airway, are of limited value. Invasive procedures such as bronchoscopy and bronchography may also be noncontributory and entail risks. We evaluated the usefulness of 3D-CT in the diagnosis and management of pediatric patients with suspected intrathoracic airway obstruction (ITAO). Methods: We used a diagnostic algorithm (see diagram) in patients with suspected ITAO resulting in respiratory distress. Three-dimensioual imaging of the tracheobronchial tree was reconstructed, following high speed spiral CT scan, by specific computer software (Advantage Window Computer Work Station, General Electric, Milwaukee, Wisconsin). Non-ionic contrast medium was injected, in some patients, to delineate the intrathoracie large vessels.. Results: Eight patients were studied. In 5 patients the 3D-CT revealed intrathoracic airway abnormalities. These patients underwent further invesive studies which confirmed the following diagnoses: 2 patients had bronchomalacia, 1 had bronchial stennsis due to a dilated pulmonary artery mad 2 patients had subglottie stenosis extending to the thoracic cavity. Three patients had no significant disruption in the configuration of the tracheobronchial tree and thus did not require invasive diagnostic procedures. Conclusion: Computer reconstruction of three dimensional images of the tracheobronehial tree is a safe and reliable diagnostic tool for ITAO. ARDS and ECMO; preliminary data from a randomized clinical trial. J Fackler, C Steinhart, D Nichols, D Bohn, M Heulitt, T Green, L Martin, K Newth, M Klein, J Ware. Many suggest ECMO be considered experimental for ARDS and undertaken only with careful data collection and reporting. A mtflticenter pediatric RCT is in progress to determine whether 1) ECMO and/or 2) permissive hypercapnia, offer significant advantage for the treatment of ARDS. Methods: All patients aged 2 wk to 18 yr (without congenital heart disease) are eligible for study. Data collection begins when a patient receives at least 50% oxygen and a PEEP of 6 cm H20 for 12 hours (stage t). If the predicted mortality reaches 60% within 7 days (stage 2), eligible patients are asked for written consent for randomization. Patients are excluded from randomization with significant chronic lung disease, immune compromise, cardiac disease; or profound acute central nervous system damage. The prime outcome variable is survival. At the studies onset, 400 pts were estimated to be required so that 65 pts were randomized per arm. Results: 131 patients are enrolled from 9 centers. Data are complete on 85. 66 patients never reached Stage 2 (i.e. 60% mortality). 47 patients improved and 19 died. Of the latter, 13 had randomization exclusion criteria even if Stage 2 was reached. 19 patients reached Stage 2. 11 had exclusions from randomization and all died. Eight patients (4 survivors were eligible for randomization; consent was obtained in no case. Two patients received ECMO. Overall survival is 60% (51/85). In patients without randomization exclusions, survival is 77% (34/44). Morbidity m survivors (discharge -admission POPC or PCPC score >_2) was seen in none of the 4 Stage 2 surviviors and 15% (7/41) of those who reached only Stage !. Conclusion: The RCT requires completion. The records of hospital in-patients at King Faisal Specialist Hospital and Research Center who received external cardiac massage as part of their cardiopulmonary resuscitation were reviewed. Success of resuscitation was analyzed as (1) short term (restoration of spontaneous circulation), and (2) long term (discharge from hospital). Of 234 such patients, 171 (73.1%) survived the initial resuscitation, and 66 (28.2%) were discharged. Success of outcome was not related to age, location of patient, time of day, or rhythm at arrest, including asystole. Longer resuscitation time was associated with less chance of restoration of spontaneous circulation (p<0.001), but not associated with Hospital discharge rate. Results for patients with congenital heart disease were similar to those with other medical or surgical conditions. In this series, 36.7% of ward in-patients survived to discharge, compared to two 5"*;'~r ~r;~'9 ,.,.'her,, the r-e~ult~ were 0c/ "'~d ~, ~,°(. Overall, 39 7% of patients who survived the initial resuscitation were discharged from hospital. Where resuscitation continued for more than 30 minutes, 18.9% of patients had tong term survival. Outcome from asystole was no worse than for other cardiac rhythms, We believe that previous reports of poor outcome from asystole in pediatric cardiac arrest should noI influence decisions to stop resuscitation for pediatric in-patients prematurely. Successful restoration of spontaneous circulation with long term survival can be achieved after prolonged resuscitation. Abdelmoniem~ Lindsey Jahusou~,Mariano Fiallos, University of Florida, 820 Prudential Drive, Suite 203 Jacksonville, Florida 32207 USA Central acidosis is well recognized as a marker of inadequate tissue perfusiou, and ventilation. However, obtaining central venous blcod is difficult and fraught with complications in the child undergoing cardiopuimonary resuscitation. Intraosseous blood may be used instead of central venous blood to judge pH and pCOz during short durations of cardiopulmonary resuscitation and during hemorrhagic shock. The purpose of this study is to compare the pH and pCOz status of intraosseous and central venous during prolonged cardiopulmonary resuscitation after fluid and drug infusion. We hypotbesized that there would be no difference in pH and pCO2 values of simultanecusly obtained intraosseous and central venous blood samples. Eighteen (18) INTRODUCTION: Cardiopulmonary arrest (CPA) in children is usually preceded by a deterioration of cardiac or respiratory function due to sepsis, dehydration and hypovolemia. Early recognition of clinical and laboratory signs followed by immediate intervention are essential for prevention of CPA. The purpose of the present study was to identify factors which contributed to high rates of mortality from CPA in patients admitted to a Paediatric Intensive Care Unit (P1CU). METHODS: A prospective study was done of all non-surgical patients with CPA who were admitted to the PICU, Hospital Baca Ortiz, Quito Ecuador from January to October 1995. Clinical and laboratory variables before and after admission to the PICU, time from hospital admission to PICU admission and the Pediatric Risk of Mortality score (PRISM) were recorded on a questionnaire designed specifically for this study. RESULTS: Of the 70 non-surgical patients admitted to the PICU, 14 (20%) were admitted after developing CPA on the general pediatric wards. Mean age was 16 + 19.1 months, with 13 of 14 patients under 20 months of age. Initial diagnoses upon PICU admission included meningitis (n=3), respiratory failure (n=2), congenital heart disease (n=2), severe neurological impairment (n=2), end stage neoplastic disease (n=2), hypovolaemic shock (n=l), peritonitis (n=l) and sepsis (n=l). Mean time from hospital admission to P1CU admission was 16 _+ 19.2 hours. The mean PRISM score upon hospital admission was 30+ 13.7 (score > 20 = > 50% mortality). 79% (11/14) of the patients died. One of the three survivors had severe neurologie injury. Prior to PICU admission, patients experienced tac~,cardia (n=9), hypotension (n=8), neurological deterioration (n=8), respiratory, distress (n=7), oliguria (n=5), bradycardia (n=3), metabolic acidosis (n=7), hyponatremia (n=4), hypokalemia (n=2), hypocalcemia (n=2) and severe hypoglycemia (n=2). There were serious delays from the time of development of clinical and laboratory abnormalities to the time of admission to PICU. CONCLUSION: In the critically ill pediatric patient, rapid recognition of clinical and laboratory signs of deterioration, followed by immediate intervention, are required to prevent end stage shock and CPA. We found serious delays in intervention following development of important premonitory clinical and laboratory abnormalities in patients less than 20 months of age on the general pediatric wards, which Iikely contributed to the dismal 79% mortality rate. Hospitals throughout Ecuador should institute immediate improvements in ctinical supervision, and provide training in paediatric advanced life support (PALS) to decrease excessively high rates of and mortality from CPA. intraosscous access is recommended by the American Heart Association and American Academy of Pediatries as a means of rapid access to the vascular system for childhood emergencies. Bone marrow and fat embolism is a concern and has been reported post intraosseous infusion in stable animals but has never been studied in animals subjected to cardiopuimonary resuscitation. We undertook this study to investigate the incidence and magnitude of lat and bone marrow embolism with the use of intraosseous infusion during prolonged cardiopuhaonary resuscitation and after fluid and drug infusion. We hypothesized that there will be no difference in the magnitude of fat embolism between cardiopulmonary resuscitation only and other cxperirnental conditions. Thirty-one (31) piglets were anesthetized, mechanically ventilated, and instrumented (carotid artery, pulmonary artery and intraosseous earmulas ). The animals then underwent bypoxic cardiac arrest followed by chest compressions with the mechanical thumper (Michigan Insmunents) and mechanical ventilation for a minimum of 45 minutes. The animals were divided in groups: A (n=5) which had no intraosseous, ~'oup B (n=6) had intraosscous with no infi~ion, and groups C (n=6), D (n=6), E (n=8) had intraosseous with infusion of adrenaline, normal saline and sodium bicarbonate, At cessation ofcardiopulmonary resuscitation, representative lung samples were collected fi'om upper and lower lobes of each lung, embedded in OCP and firozen immediately. Ltmg specimens were stained using Oil Red-O dye and observed for fat globules and bone marrow elements. The amount of emboli present was rated as a percentage in relationship to Iung tissue, by a pathologist blinded to the experimental groups. Buffy coat specimens were collected before and at cessation of cardiopuimonary resuscitation, stained with Oil Red-O dye and observed for fat globules. Percentage of fat present were compared using analysis of variance. Fat globules were seen in the prebronchial blood vessels and in intravascular areas throughout all lung fields. There was no difference in appearance or distribution of fat globules between groups. Quantity varied in the different groups[(A) 45%, (B) 44%, (C) 30% (D) 23%, (E) 25%], but were not statistically significant (p = .097). Fat globules in the buffy coat were few and inconsistent with lung findings. Fat and bone marrow emboli were present in all experimental conditions, The use of the intraosseous cannula does not increase the magnitude of embolization during cardiopuimonary resuscitation. The decision to use the intraosscous route should not be influenced by the risk of embolization. Tzareva IV/,, MD*, Nedialkova R, MD**, *Dept. of PathophysioL, *~Dept. of Child Surg. and ICU, Emergency Medical Institute PIrogov, Sofia, Among 566 children with blunt abdominal trauma, treated in EMI Pirogov during the last five years, 79 children had serious disturbances of the basic vital functions, connected with the trauma, and most often with massive haemorrhage, for this reason being an object of reanimation and intensive care. In the group of children who survived -37, predominated the trauma of only one abdominal organ (mainly the spleen, rarely the kidneys, the intestine) and only 15 children had injuries of more than one abdominal organ. In the same group, in 15 children the abdominal trauma was combined with chest or head trauma or bone fractures. In the group of children who died -12, a profound combined trauma was present. The haemodynamic parameters in all children showed a characteristically significant tachycardia along with normal or even high blood pressure, while hypotonia was present in only 64% of the children on the first trauma day. Despite the fact that only 13.4% of the children had direct chest injury as well, the gas exchange was considerably disturbed -899'0 of the children were hypoxemic during the first, and 100% during the third trauma day -in 25% significant -below 8.0 kPa (60 mmHg). Together with the markable decrease in haemoglobin levels, this determines the pronounced disturbance in oxygen transport. During the first trauma day all the children were acldo~c, and a metabolic alkalosis was present during the following days. Twelve of the children with severe combined trauma died within several hours, with the symptoms of irreversible haemorrhagic shock, or in the next 2-3 days, developing multiple organ failure. In conclusion, the intensive therapy of children with severe abdominal and combined trauma, should take in consideration the special haemodynamical trauma answer in children, and requires dynamic monitoring of the most influenced homeostatic parameters -blood gases, acid-base metabolism, haemostasis. Introduction: Endocrine emergencies, other than diabetic ketoacidosis, are uncommon causes of Pediatric Intensive Care Unit (PICU) admissions. We report our experience of children diagnosed of adrenal insuficiency (AI) admitted in the PICU, during the last four years. Subjects: Five eases of AI requiring 7 intensive care unit admissions are presented. Four females anna 1 male, with ages ranging from 11 days to 7 years, None of them had a previous systemic or endocrine diseases that could suggest AL The initial clinical manifestations were: dehydration (5), vomits (3), abdominal pain (2), seizures (2), lethargy (2) and hyperpigmentation in the muco-genitat area in a newborn male and ambigna genitalia in a newborn female. The reason for their admission in the P1CU were: shock in two subjects; three because of hyperkalemia and hyponatremia (K/Na: 5.6/123; 9/126; 7,1/134 mEq/L); and two with severe hyponatremia (Na: 117; 113 mEq/L). Laboratory findings: severe hyponatremia (5), increased concentration of urinary sodium and chloride (4); metabolic acidosis (4); hyperkalemia (3); increased levels of urea (3) and hypoglycemia (2). In all of them, the electrolytes abnormalities did not normalize with replacement and only normalized after the administration of hydrocortisone. Tile AI was due to: autoimmtme disease in two subjects, congenital adrenal hypoplasia, congenital adrenal hyperplasia secondary to 21 alia hydroxylase deficiency and in one no etiology was found, at the present time, Comments: AIis an uncommon disease in the pediatric age. Anearly diagnosis is crucial, as if the treatment is delayed could lead to patients death. In subjects with arterial hypotension and electrolytes abnormalities refractory to the usual treatment, they should be treated with corticosteroids, if no etiology is found. Although, previously samples must be obtained to make the diagnosis, 0: denotes the number of cases. GERBAKA B; HAKME C; AKATCHERIAN C. Toxics are frequently involved in domestic accidents during childhood; among non medical products ingestion, carbohydrate poisoning is a serious injury often made possible by inadequate stocking. Over 10 years, 43 children aged 10 years and less were examined in the emergency department of Hotel-Dieu de France Hospital for carbohydrate ingestion. 62,8% are boys; age goes from 13 months to 6 years (moan = 2,5years). Kerosene is found in 35,8% of cases; all were admitted (mean = 2,8 days). 79,1% were symptomatic on first examination but 93% of all children presented signs of gastric (58%) or respiratory (69,8%) irritation sometime during their history; 37,2% had neurological signs and 41,9% presented some fever. Leucocytosis is found in 65% of cases; 25,6% of the children received antibiotics. Chest X Ray was abnormal in 48,8% of cases: mainly parahilar infiltrates were found, All children survived; 76,7% with a normal course (1,9 days of hospital stay) whereas those who presented complications (severe pneumonia, coma) stayed in the hospital for 6 days (mean) with short course of assisted ventilation for two of them; long term follow up was not possible. We fonnd Nick's criteria for hospital admission to be of value: -symptomatic children with normal X Ray } 6 to 8 hours monitoring -asymptomatie children with X Ray abnormality } -symptomatic children with X Ray abnormality: Hospital admission -asymptomatic children with normal X Ray : no admission. These criteria would have helped to avoid admission in 8 children and would have allowed a short t2 hours stay for 6 more. We found chest X Ray to be mandatory in carbohydrate ingestion; other tests were not helpful, aside arterial blood gases measurement in case of respiratory involvement; we now also advocate more restriction in antibiotic use. Prevention remains efficient and should be stressed on. Severe liver failure [SLF] is a rare but severe condition in infants. We report our experience. Patients: SLF was defined as liver insufficiency with hepatic encephalopathy and a decrease in the level of factor V to below 25 %. Between 1984 and 1996, 29 infants (mean : 4 mo) were admitted for SLF (neonates excluded). Main causes were metabolic disorders (41.3%) (tyrosinemian=5, hemochromatosis n=2, Reye's syndrome n=2, other n=3), virus-induced FLF (20.6%) and hematologic diseases (13.7%). In 4 cases, the causes remained undetermined. Results: OLT was contraindicated in 12 cases because of multiple organ failure (n=10), or underlying disease. All of them died within 6 days after admission. 7 patients had no indications for OLT, all but one are alive. (1 of them was transplanted later for tyrosinemia and 1 died lately (virus induced-SLF). Among the t0 infants who underwent emergency OLT, 6 are alive and 4 died because of primary non function of the graft. Conclusion: SLF in infants admitted before their first birthday is a severe condition with an overall mortality rate reaching 60%. Inherited metabolic disorders are the first cause of SLF at this age. Contraindications for OLT are frequent because of underlying disease or multiple organ failure. A number of children undergo primary graft failure after liver transplantation. It is unknown if there is any increased morbidity or mortality following retransplantation. This study seeks to explore these issues. Methods: A pediatric intensive care/Iiver transplant database is in formation. Records of all liver transplant patients are reviewed and abstracted. This data is then computerized to allow analysis. This data provides the source for this study. Statistical analysis was performed via Student's t-test where appropriate. Results: Of the 350 patients who have thus far received at our center orthotopic liver ransplants, the records of 112 who underwent 140 transplants form the basis for this review. Twenty-three patients underwent multiple transplants, 19 required one additional, three required 3 organs, and one patient survived after a fourth organ transplant, There was no significant difference in age at first transplant between those who received multiple organs and those who did not (40 vs, 44 months, p=NS). The anesthesia time for the procedure did not significantly increase tbr subsequent transplants (8.3 vs, 7,3 hours), nor did time in the intensive care unit (t6.6 vs. 22.2 days), nor did time on the ventilator (8.4 vs. 15.3 days) Subsequent transplants did not predispose to having more bleeding in the intensive care unit for usage of packed red blood cells or platalets was not significantly altered (299 vs 306 ml and 127 vs 207 ml respectively). Patients who required retransplantatior~ did receive mere fresh frozen plasma (FFP)daring their first transplant than in the subsequent ones (275 vs 81 ec, p < 0.05). However FFP use was not significantly different than patients who did not require retransplant. Patients who underwent retransplant had a markedly increased mortality (47%) than the overall mortality for liver transplants at our center (20%), Conclusion: Children who require another liver transplant have a markedly increased mortality. Bleeding and prolonged ICU stay is not significantly different between the first and subsequent transplants, FULMINANT HEPATIC FAILURE AND ORTOTHOPIC LIVER TRANSPLANTATION.Dr.Sasb6n,J;Centeno,M;Entin,E;Acarenza,M;Ciocca, M:Gofii,J;Bianco,G;Weller, G;Imventarza,O. Unidad de Cuidados Intensivos.Hospital de Pediatria "Dr.J.P. Garrahan"1245.Buenos Aires.Argentina. Introduction:Fulminant Hepatic Failure (FHF) is a clinical syndrome, defined by the development of hepatic encefalopathy within 8 weeks from onset of illness in a previously healthy person.By far,the most comun cause of pediatric FHF in all series, is acute viral hepatitis.We report our experiences with the pediatric FHF and ortothopic liver transplantation (OLT) as attemative of treatment. Patients:30 childrens with FHF diagnosis were admitted at the PICU from 1/1/1993 to 1/12/1995.Symptomatic treatment was given to all children and all were put on list for OLT,) following the King's College criterion (Protrombina time,age,atiologies,bilirrubin,and encefalopathy state). Results:Etiologic causes corresponded to the 30 childrens were:23, HAV (76%); 6, NoA NoB (20%);1 ,autoinmune (4%).The age was mean:4 years (Range:16 month-10 years).Seventeen patients were transplanted,13 chidmn were discarded because:no donors:5;withdrow of the list:3,because sepsis in 2 and bleeding of CNS 1;and no admission at list:5 because genetic syndrome 1 ,massive intestinal necrosis, 1 ,mitral valvulopathy 1 and sepsis,2. 25 patients (86%) had at least one complication dudng the post operative period.The most frequent was the acute renal insufficiency(ARI) and 4 patients requiered continuos hemofiltration.The gtobal mortality rate was 75%.The mortality of patients without OLT was 100% and the mortality of patients with OLT was 41%,4 patients dayed because sepsis, (2 candidiasis) and the others 3 because MOF.The actuarial survival at 1 year is 54% and the follow up of 8 months. Conclusions:The FHF is a very severe and frequent disease at PICU. Supportive treatment only is associated with a very poor prognosis and high mortality rate.The most frequent etiology in our country is the HAV. The OLT is applicable in this cases and is a valid alternative of treatment (mortality in our series 41%).The ARI is the most frequent complication during the post opeative period.In Argentina,due the high prevalence of HAV,prevention must be considered the main and only way to avoid this catastrophic illness.- To assess the efficacy of gastric intramucosal pH (pHi) for evaluation of tissular perfusion and prediction of hemodynamic complications m critically ill children. PATIENTS AND METHODS: Thirty critically ill children (16 boys and 14 girls) whose age ranged from 3 month and 12 years old were studied. A tonometry catheter was placed in the stomach of all patients at their °admission in Pediatric ICU. Intramucosal pH measures were made at the admission and each 6-12 hours during the study: a total of 202 determinations were made. The catheter was removed after extubation and/or checking of hemodyrmmic stability of the patient. The intramucosal pH was derived from application of the Henderson-Hasselbaeh formula using the pCO2 value from the tonometer and the arterial bicarbonate. Values of pHi between 7.30 and 7.45 were considered normal. The relationship between pHi and severity of patient measured through PRISM, presence of major (cardiorespiratory arrest, shock) and minor (hypotension, hypovolemia or arrhytlmtias) hemodynamic complications, mortality and stay in the PICU, was analysed. RESULTS: The admission value of pHi was 7.48 -t-0.15 (range 7.04-7.68). Five patients (16%) had an admission pHi < 7.30. No relationship was found between an admission pHi < 7.30 and a higher incidence of hemodynamic complications. Sixteen patients (53%) showed some values of pHi < 730 during their evolution. Patients with pHi < 7.30 had a higher number of hemodynanuc complications than the rest (p< 0.0001). Every cardiorespiratory arrest (CRA) and shock cases were related to a pHi < 7.30. Patients with major complications (CRA and shock) had a pHi lower (p= 0.03), as well as a higher number of measurements of low phi (p= 0.003) than patients with minor hemodynamie complications. The value of pHi lower than 730 presented a 90% of sensibility and 98% of specificity with regard to hemodymanic complications. There was no relationship between pHi < 7.30 and PRIMS score and stay in PICU. Patients with pHi < 7.20 presented a PRIMS higher than the rest of patients (p< 0.05). CONCLUSIONS: The pHi value may be an early sign of presence of hem0dyaaimc complications in the critically ill child. We tested the hypothesis that Gastric intramural pH (pHi) can be used as an early sign of failure m weaning pediatric patients because the blood flow from nonvital areas is diverted to meet the increased demands of respiratory muscles. METHODS: 24 children (mean age (4.2_+0.3) years + SD) who were thought by their physicians to be weanable from Mechanical ventilation (MV.). These patients were ventilated on Serve 900C ventilators, receiving ranitidine, and had intestinal tonometer (tonometrics, inc.) 60 minutes before obtaining a sample.. All children were placed on pressure support (PS) at levels judged to overcome the resistance of the endotracheal tube and ventilatory circuit (2 em H.,O). A sample of arterial blood and a sample oftonometer were obtained during VM and weaning (PS). pHi, hemodynamic and respiratory data were recorded during VM and weaning We did not interfere with the primary caretaker's decisions regarding extubation. Patients were considered to be successfully weaned if they were able to sustain spontaneous ventilation for more than 24 hours after extubation. Paired t-test were used to compare the values obtained during mechanical ventilation with those obtained during weaning trials. Unpaired ttest were used to compare values from the group that was successfully weaned (A=I5) with those from the group that were not (B=9). RESULTS: We did not find statistical differences in any of those variables mesured during MV for patients who were successfully weaned(group A) and those who were not (group B). Gastric phi was in group A: 7.35 + 0.03 (VM) and 739 + 0.02 (weaning); in group B: 7.40 _+ 0.04 (VM) and 7.4t _+ 0.02 (weaning). DISCUSSION: Although we did not find differences in gastric pHi during VM, the group A had a lower value than group B because of the number of cardiac patients (70%) and transfusion therapy, in fins group. In group B 75% of patients showed a problem in upper airway (subglottic edema, and enlarged tonsils). We found it after extubation. CONCLUSION: 1) Gastric phi is a good predictor of risk in critically ill patients but maybe because of the small size of the sample, in our study is not of practical value as a predictor of failure in weaning pediatric patients from VM. 2) This test is not a predictor of problems in upper airway~ important etiology of failure weaning in children. Objectives: I-To determine the prognostic value of the gastric intramueesal pHi in mortality and multiple organ dysfunction (SDMO) in critically ill children. 2-To compare this value, with the Pediatrics Risk Index Mortality Score (PRIMS). Methods: Aprospective study was performed with 51 critically illcbildren, aged from 1 mouth to 16 years. The athnittiug diagnosis was: 26 post-surgery (13 neurosurgery, 9 spinal fusion and 4 thoracic or abdominal surgery), 7 sepsis, 6 polytraumatism, 5 adult respiratory distress syndrome and 8 with miscellaneous. All the subjects were monitorized on PICU admission and treated for their underlying condition. Gastric intramucnsal pt{ was measured following the tonometric method, ou admission and every 4-8 hours depending on the patients state. The severity of the clinical condition was evaluated using the the PRIMS, on admission (PRIMS-I) and during the first 24 hours, when the clinical condition deteriorate, the worse score was utilized for the statistical analysis (PRIMS-2). To perform the statistical analysis the subjects were divided in two groups, one with the pHi<7.30and the other with pHi>7.30.Aunivariate analysis (Student's tand Wilcoxon two tailed test, chi-square) and multivariate analysis were used. Results: 12 out of the 51 subjects dyed. Of 14 children developing multiorgan failure (MOF) 9 expired. 50% of the patients admitted to the PICU with sepsis, ARDS and miscellaneous had a pHi < 7.30. In contrast, with 27 % of post-surgical and none of the postqraan~atism. The mortaliry rate, in children with a pHi<7.30was 47% (CI 95%:26.16; 69,04) and 11.76% (CI 95%:4,67; 26.62) in children with phi>7.30 (p=0.011). MOFwas observed in41,18% of children withpHi<7.30v.s, 20.6% with phi >7.30.No relatiouship was observed between the pHi and the score of PRIMS-I and 2. Perforating an unconditional logistic regression analysis, two independent variables have mortality predictive value: the phi and the PRISM-2. (Table I) Following induction of anaesthesia, a laser Doppler probe (Moorsoft Instruments Ltd) was inserted 7cm into the patient's rectum, the probe's special design ensuring that the optical prism lay against the mucosa. Continuous monitoring of rectal mucosal perfusion ("flux") was continued throughout the operation. After 10 rain CPB at 35°C, "steady state" readings of nasopharyngeal temperature, mean femoral arterial pressure (MAP) and flux were recorded over a further 5 min before CPBinduced core cooling to 14-24°C. Steady state was defined as a 5 rain period with no change in core temperatures or MAP. Other 5 rain steady state recordings were taken immediately prior to low flow, immediately prior to rewarming and after rewarming to 35°C, before initiation of any vasoactive drugs. The CPB flow rate was kept at 100 m l k g -1 min q, the PCV at 25_+3%, the P~CO 2 at 5.3+0.5 kPa and the PrO2 at 20+5 kPa. Results: Initial warm and rewarm MAP (both 46 mmHg) were significantly lower (19=0.008) than during the 2 cold CPB periods (63 & 64 mmHg). The mean cold flux before (152) and after (159) low flow were both significantly lower (p=0.001) than the mean initial warm CPB flux (211). The mean rewarm CPB flux (127) was significantly lower than all other flux values (p=0.001). There were no siglaificant correlations between MAP and flux except at the first warm CPB period (r=0,33, p=0.04). Conclusions: Although hypothermia significantly reduces rectal mucosal perfusion, rewarming produces an even greater reduction in gut perfusion which, considering that mucosal oxygen constmaption is highest during this time, may prove crucial in the postoperative development of MOF. Therapy aimed at improving gut perfusion during CPB should be directed at the rewanning period in particular. ABSTRACT This work is aimed at establishing a clinical procedure for the diagnosis of Enteritis necroticans (EN), even at the communal level, and to define criteria for diagnosis able to distinguish between acute forms. SUBJECTS AND METHOD : 100 cases admitted at the Institute for Protection of Children's Health dPCH), having characteristic symptoms, were examined clinically, by roentgenography of the abdominal cavity, with the analysis of the blood (total protein, electrolytes, hematocrite) and cultures of intestinal fluid and faeces. Through surgical operations, the pathological lesions were observed and recorded. RESULTS: Common epidemiological features: the average age is 6-8 years old (3-15) ; male/female : 1.85; In 70% of the cases, the disease occurred after a meal rich in protides. The acute toxic form accounted for 15% : severe shock appearing early, with very severe dehydration associated with profoundly decreased blood protein concentration and lowered natriemia as well. The lesions of the small intestine were expanded, all of them were necrotic. In the surgical form (20%), the predominant feature was an obstruction -peritonitis syndrome, the peritoneal fluid showed a characteristic inflammatory reaction. For the rest of cases 65% were the internal form, the shock syndrome was less severe, the abdominal distention was light and disappears gradually, the inflammatory reaction of the peritoneal fluid was not so characteristic. CONCLUSION (INO) is a selective pulmonary vesodilator that is rapidly inactivated compared to intravenous vasodilators. These qualities make INO an attractive agent for the treatment of pulmonary hypertension (PItTN). The efficacy of INO has been studied in persistent fetal circulation, acute respiratory distress syndrome (ARDS), and congenital heart disease (CHD). Potential adverse effects oflNO include: nitrogen dioxide (NO0 toxicity, methemoglobinemia, and platelet dysfimction. Our objective was to evaluate the safety of INO in pediatric patients (pts). Methods: Pediatric pts. with PHTN from ARDS or CHD were studied under an established, approved protocol conforming to FDA guidelines tbr an investigational new drug. Informed consent was obtained for each child prior to treatment. 1NO was sequentially titratad from 10 parts per million (ppm) to 20, 40, 60, and 80 ppm at ten minute intervals. Parameters monitored before and during therapy included nitric oxide (NO) and NO~ concentrations (cone.), mean arterial blood pressure (MAP), and percent methemoglobin (MHG). NO and NOz levels were continuously monitored using an inline Dr~ger electrochemical detection device. ~,Litp was continuously measured with an indwelling arterial catheter. MHG was measured by co-oximetry. A MHG level e 5% or NO2 cone. ~ 5 ppm were considered adverse effects by study criteria. Pretreatment MAP was compared to MAP at 40 and 80 ppm INO using paired t-tests. Ap value < 0.05 was considered statistically significant. Results: Thirty-two mechanically ventilated children with PHTN (16 with ARDS, 16 with CHD) were studied. Five pts. were treated following cardiopulmonary bypass. Methemoglobin (Met-Hb) levels were routinely measured in two prospective clinical studies on NO inhalation in 25 pediatric patients with pulmonary hypertension following heart surgery with extracorporeal circulation and in 19 pediatric and neonatal ARDS patients, The observed differences between the groups prompted in an in vitro study, Red blood cells (RBC) of 20 patients sampled before and after surgery with and without extracorporeal circulation (ECC), respectively, were incubated with 32 ppm NO for 100 rain, Met-Hb, ATP, and NADHt NADPH concentrations were compared, During therapeutic exposure NO increased Met-Hb from 0.2 -2-_ 0.1 to 1.2 _+ 0.7 % in cardiac surgery patients and from 0.2 ± 0,1 to 0.5 ± 0.4 % in ARDS patients (p < 0.01 ). RBC's having undergone ECC were more susceptible to Met-Hb formation (p< 0,001 ) whereas intracellular coenzymes did not differ neither between the groups (table) nor before and after NO exposure. ECC predisposes to increased methemoglobinemia upon exposure to NO both in vivo and in vitro. Our data suggest a reduced activity of Met-Hb reducing enzymes rather than diminished availability of energetic substrates, Variation of the inhaled nitric oxide concentration with the use of a continuous flow ventilator. Anne PMC De Jaegere ~, Frans IM Jacobs 2, Nico GC Laheij 2, John N van den Anker t . Dept. of Paediatrics ~, Central instrumentation 2, Sophia Children's Hospital, Erasmus University Rotterdam, Rotterdam, the Netherlands. Objective: To investigate the homogeneity of nitric oxide (NO) concentration in a delivery system with a continuous flow ventilator. Design: Bench study, Setting: Biomedical laboratory. Interventions: A nitrogen/nitric oxide (NJNO) gas mixture was injected at three different sites in the patient circuit: just before and just behind the humidifier, and 20 centimetres before the Y-connector. Ventilator flow (12, 15, 20 L/rain), ventilator rate (40 to 110, increments of 10) and compliance of the testlung (0.36; 0.5; 1.0 ml/cm H20) were changed. Carbon dioxide (CO2) instead of N2/NO was injected at the same points in the circuit. Measurements and main results: A) Though the flow ratio of the NJNO and the ventilator gas were kept constant, the NO concentration ([NO]) raised with increasing ventilator rates. The increase in [NO] was up to 40% when the N2/NO injection site was close to the Y-connector of the ventilator circuit. Minimal changes in [NO] were noticed when the N~/NO was mixed to the ventilator gas before the humidifier. B) Analysis of the ventilator flow pattern showed variations at different places in the ventilator circuit. The magnitude cf the P, ow change depended on the meas~:rement site. The closer to the expiratory valve the highest the flow change was. The duration of the flow change was inversely proportional to the adjusted ventilator flow. C) Real time measurements of the CO 2 concentration ([COz]) showed variations during tile respiratory cycle. These [CO2] variations were higher when the CO2 gas was blended closer to the Yconnector. Conclusions: The ventilator flow variations in relation to the fixed side flow of the N2/NO gasmixture result in changes of the inhaled [NO] during the respiratory cycle. The NO concentration during inspiration is always higher then during expiration. This could not be detected with the available monitoring system. To ensure a constant [NO] by blending a NJNO gas balance in a continuous flow ventilator, the site of injection should be as close as possible to the inspiratory outlet. Nitric oxide, a potent and selective pulmonary vasodilator, has recently been successfully used to treat pulmonary hypertension of variable etiology in infants and children. Side-effects and complications in infants are so far not well known. We describe here two cases in which prolonged (5 and-7 days respectively) high-dose (50 -80 ppm) nitric oxide was used to treat refractor~¢ pulmonary hypertension. One patient was a newborn infant with pulmonary hypertension secondary to a large leftsided diaphragmatic hernia. Nitric oxide was begun under conventional ventilation (Babylog 8000) at 7 hours of life with a slight initial improvement in oxygenation. He was then placed on oscillation with the same nitric oxide concentration due to worsening respiratory failure. He died on 5th day of life. Monitored nitric dioxide concentration never exceeded 4 ppm. The other patient was a 3 months old infant with severe pulmonary hypertension due to a complete atrioventricular septal defect. He required high-dose nitric oxide to come off cardiopulmonary bypass after surgical repair of his heart defect. He slowly improved over the week following surgery but developped suddenly respiratory failure due to massive pulmonary hemorrhage and died. Surprisingly, a particular autopsy finding in both infants was a massive acute necrotizing tracheobronchitis. We conclude that nitric oxide is an excellent and sometimes lifesaving treatment of pulmonary hypertension in infants. Tracheobronchitis has not yet been reported as a possible complication of nitric oxide administration. We suggest that caution needs to be taken with prolonged high-dose administration and this possible complication to be looked for at autopsy. Introduction: Permissive hypereapnia (PH) is a beneficial strategy for patients with acute respiratory distress syndrome (ARDS) to minimize barotrauma by decreasing the peak inspiratory pressure (PIP). Hypercapnia and hypoxia cause pulmonary vasoconstriction, pulmonary artery (PA) hypertension, and, thus, an increased afterload to the right ventricle. This increased afterload may result in increased right ventricular (RV) work load and subsequent RV dysfunction. One therapeutic approach is the use of inhaled nitric oxide (iNn), a selective PA vasodilator. The objectives of this study were to test the hypothesis that in a swine model of ARDS with PH, iNn would improve RV work load and not change intrinsic RV contractility. Methods: In 11 swine (25-35 kg), ARDS was induced by surfactant depletion. Hypercapnia was achieved by decreasing the PIP while increasing the PEEP to maintain a constant mean airway pressure, inn was administered in concentrations of 2, 5, and 10 ppm in a random order. Pulmonary blood flow (Qpa) was determined by an ultrasonic flow probe. RV total power (TP) and stroke work (SW) were calculated by Fourier transformation of the PA pressure (Ppa) and Qpa data. Preload recruitable stroke work (PRSW), a preload and afterload independent measure of ventriculur contractility, was determined by a shen-subtraction method and vena caval occlusion. Respiratory Failure with Pulmonary Hypertension in Piglets Gerfried Zobel*, Bernd Urlesberger*, Drago Dacar**, Siegfried Rtdl*, Fritz Reiterer* and Ingeborg Friehs** Depamnents of Pediatrics* and Cardiac Surgery**, University of Graz,Austria Objective: To evaluate gas exchange, pulmonary mechanics and bemodynamic data during partial liquid ventilation (PLV) combined with inhaled nitric oxide (NO) in acute respiratory failure with pulmonary hypertension. Design: Prospecfive~ randomized, controlled study. Setting: University research laboratory. Subjects: Twelve piglets weighing 9 to 13 kg. Interventions: Acute respiratory failure with pulmonary hypertension was induced by repented lung lavages and a continuous infusion of the stable endoperoxane analogue of thromboxane. Thereafter the animals were randomly assigned either for PLV or conventional mechanical ventilation. Initially perfhiorocarbon liquid (30ml/kg) was instilled into the endotracheal tube over 5 min followed by 5-10ml/kg~. All animals were treated with different concentrations of NO ( 1-10-20 ppm) inhaled in random order. Measurements and results: Continuous monitoring included ECG, CVP, MPAP, MAP, San2 and SvO2 measurements. During PLV PaO2/FiO2 increased significantly from 62_+3.2 mmHg to 193±44 mmHg (p<0.01) within 10 rain, while PaO2]FiO2 remained constant at 61 -+3.3mmHg. Qs/Qt decreased significantly from 48-+4% to 25-+5% (p<0.01) during PLV and did not change during conventional mechanical ventilation. Static pulmonary compliance (Cstat) increased significantly ff~m 0.4R±0.07 to 0.75_+0.03 ml/cmH20/kg (p<0.01) during PLV and decreased slightly from 0.58_+0.08 to 0.46e0.04 ml/cmH20/kg during conventional mechanical ventilation. The infusion of the endoperoxane analogue resulted in a sudden decrease of PaO2/FiO2 from 262_+44 to 106_+8.0 mmHg in the PLV group and from 71±7 to 52+_2.0 mmHg in the control group. Inhaled NO significandy improved oxygenation in both groups (PaO2/FiO2:344_+38 mmHg during PLV and 196+_.56 mmHg during conventional mechanical ventilation). During inhalation of NO MPAP decreased significantly from 57-+2 m 35±2 mmHg (p<0.01) in both groups. There was no significant change in oxygenation and MPAP during inhalation of 1 and 20 ppm NO. Conclusions : PLV significantly improves oxygenation and pulmonary compliance in acute respiratory failure. The additional application of inhaled NO further improves oxygenation and pulmonary hemodynamics when acute respiratory failure is associated with severe pulmonary hypertension. Inhaled NO is very effective in improving oxygenation and pulmonary blood flow even at low doses. The work was supported in part by grants of the Austrian Nationalbank Nr 5545. As in neonates, severe respiratory failure in infants and children can be aggravated by pulmonary hypertension, resulting in further deterioration of oxygenation due to increasing intrapulmonary shunting. We analysed the influence of inhalational nitric oxide (iNO) in treatment, course and outcome of severe ARDS in a pediatric population. Since 1993 20 infants and children (age: 1-107 months) with ARDS and OI > 15 (mean value: 32.5± 11) underwent a trial with iNO (concentration: 3, 10, 30, 60 and 100 ppm) to prevent further respiratory failure. 11 patients had a significant improvement of their oxygenation (rise of pa09 > 15 mm Hg) for at least 24 hours (responders); mean best ~fficient NO dose: 24.6 ppm. The non-responders had only a short-term improvement or iNO had no effect. In responders and nonresponders there was no significant difference with regard to age, underlying disease, ARDS severity, time on mechanical ventilation, blood gases and ventilator settings before NOtrial, nor was there a different grade of pulmonary hypertension (estimated by echocardiography). The only difference was an higher Ol in the group of the non-responders: 40.9 ± 9.I vs. 25.6 ~ 6.7, p < 0.002. In the group of the 11 respenders there was a secondary deterioration of lung function after I -6 days on iNO in 5 children (transient responders): in these patients, as well as in the group of the non-responders, alternative modalities of treatment (HFOV and/or ECMO) became necessary. 6 children (30 %) died: 2 transient respenders and 4 non-responders. In infants and children with ARDS due to different underlying diseases iNO can acutely lead to a significant improvement of oxygenation in about 50 % of the cases. The right selection of patients for NO therapy and the influence of iNO on the survival rate of ARDS in childhood has to be evaluated in further studies. and Pediatric Cardiology, University of Graz, A-8036 Graz Purpose: After Fontan procedure cardiac output is critically dependent on the pulmonary vascular resistance. Even minor elevations of the pulmonary vascular resistance may significantly decrease cardiac output. Inhaled NO is an effective, selective pulmonary vasodilator in experimental and clinical situations of pulmonary hypertension. The aim of this study is to evaluate the effects of inhaled NO on oxygenation and pulmonm 3, circulation in children after a bidirectional Glenn-anastomosis (n-~) or a Fontan-like operation (n=9). Material and methods: From June t993 to January 1996 13 children with a mean age of 7.1+~2.1 (SEM) yrs and a mean body weight of 24.3-+5.8 (SEM) kg were treated with inhaled NO after Glenn-or Fontan-like operations. All but one had complex cardiac malformations with single ventricle. All children were mechanically ventilated with an Fin2 >0.75. Inhaled (NO) was applied using a rrdcrdproeessor based system which additionally allowed measurement of NO/NOx using the chemihimniscence method. Methemogtobin concentrations were determined 3 times a day. The major indication for postoperative inhalation of NO was a high (>10mmHg) transpulmonary pressure gradient (TPG--CVP-LAP). Severe myocardial dysfunction of the single ventricle was excluded by echocardiography. Results: The mean duration of mechanical ventilation was 8.1_+2.2 (SEM) days The. mean dose of inhaled NO was 4.4-+0.8 (SEM) ppm, the mean duration of NO-inhalation was 106_+19 (SEM) hours. The mean methemoglobin concentration was 1.2-+0.2 (SEM)%. Hemodynamic data and arterial oxygen saturation before inhaling NO and 15 minutes later are given in Table 1 Acute hypoxaemic respiratory failure (AHRF) in children occurs in a heterogenous group of diseases with pulmonary pathophysiological processes ranging from reversible physiological intrapulmonary shunting to fixed structural lung damage. We hypothesized that inhaled nitric oxide (iNO), a selective pulmonary vasodilator, might identify those patients with potentially reversible disease, i,e, large response may indicate a greater likelihood ef reversibility and thus survival. A retrospective review of the early response to iNO in 30 infants and children (aged 1 month to 13 years, median 7 months) with severe AHRF(18 with ARDS). The mean P(A-a)O2, PaO2 / FiO2, oxygenation index (OI) and acute lung injury (ALl) score prior to the commencement of iNO were 568 +_9.3, 56 +_2.3, 41 _+3,8 and 2.8 +_0.1 respectively, The magnitude of response to iNO was quantified as the % change in OI occurring within 60 minutes of 20 ppm iNO therapy. This response was compared to patient outcome data. Results. There was a significant correlation between response to iNO and patient outcome, Kendall tau B r=0,43, p<0.02 (table) Conclusion. In AHRF response to iNO appears te define a subgroup of patients with improved outcome compared to nonresponders. We speculate that response to iNO may be useful in selecting patients with potentially reversible lung disease for special support therapies such as ECMO. Randomised controlled trials are needed to define the role of iNO in paediatric AHRF. Between May 1994 and December 1995, 22 patients (pts) were treated for MAS. Treatment groups were: group I only 02:6 pts; group I1 conventional mechanioal ventilation (CMV): 11 pts; group II1 HFO: 1 pt; group IV HFO+NO: 4 pts. Therapy was stepwise intensified until oxygenation improved ( I -) II -) III --) IV). "High volume strategy" was used with HFO (MAwP 18-24 cm H20). The initial NO-concentration was 20-30 ppm, with rapid reduction down to 5-10 ppm once oxygenation improved. Results: One pt (group It) died of hypoxic-ischemic encephaiopathy (termination of therapy); all other newborn babies survived. In group IV pt 1 and 2 showed barotrauma prior to HFO. Pt 1,2 and 4 were treated with additional MgCI2 (max. Mg serum concentration 2.8 -6.5 mmol/I). Following the identification of inhaled nitric oxide 0"NO) as a selective pulmonary vasodilator (Frostell et al 1992) [ 617 .+6,3 626+6.3 Data are compared to baseline values within each group. *=p<0.05, **=p<0.03, ***=p<0.0l Among 12 patients who fulfilled ECMO criteria, 6 improved with NO and did not required extracorporeal life support. Tltree out of 6 ECMO patients eventually survived. Conclusions: m our study low-dose of irthaled NO showed a variable effect on oxygenation in newborns with acute respiratory failure. An acute response to NO appeared to be correlated with a better short-term outcome and the avoidance of extracorporeal support in Ecmo candidates. Differently, lack of acute and/or sustained response was associated with death or need for ECMO. Although the nature and severity of the underlying disease or the degree of prematurity may play an important role in these patients, we believe lack of acute response to NO may be an early predictor of bad outcome, prompting toward alternative treatments such as ECMO or liquid ventilation. *Picea S., °Bartuli A.,°Dionisi-Vici C., *Dello Strologo L., §Villani A., §Bianchi R., ^Salvatori G.,*Rizzoni G, °Sabetta G. *Div. of Nephrology, °Div. of Metabolism, §Intensive Care Unit, ^Div. of Neonatology. "Bambino Gesfl" Children Research Hospital. ROME, Italy. Successful prevention of handicaps or death in newborns with ~ depends on rapidity and efficiency of treatment. Poor response to nutritional and/or pharmacological treatment requires extracorporeal removal of NH4. Efficiency and cardiovascular tolerance are often difficult to obtain with peritoneal or hemodialysis in neonates. We report the results of CAVHD in 3 newborns with HC. Methods: vascular access: femoral vessels. Blood flow: 10-35 ml/min, Dialysate flow: 200-500 ml/h. Filter: Amicon Minifilter PlusrM(polysulfone membrane; 0.08 sq.m.). No ultrafiltrate(UF) production, Patients: Case 1 with carbamoytphosphate synthetase deficiency (body weight -bw-: 3.2 kg) showed HC at day 4, A relapse of HC occurred at day 14 due to an infectious event. Case 2 and 3 (bw: 3.0 and 2.8 kg), both affected by propionic aeidemia, showed HC at day 5 and day 7, respectively. Plasma NH4 (~tg/dl) decrease is shown in the Complications: transitory ischemia of arterial cannulation limb and transitory thrombocytopenia occurred in case 1; surgical repairing of artery after CAVt-ID was necessary in case 3; no cardiovascular instability was observed during CAVHD . Outcome,'all patients recovered from HC in less than 1 day: case 1: alive, mild b)Iootonia at 34 mos; case 2: dead after 10 days from CAVHD withdrawal for pulmonary hemorrhage; case 3: alive, normal development at 7 mos. Conclusions: 1) In newborns with HC, CA~q-ID provides good cardiovascular tolerance,high efficiency and quick removal of NH4, even without UF production (i.e. only by diffusion). This allows easier management (no need of fluid and electrolyte balance). 2) Arterial complications seem frequent in neonates treated by CAVHD. Venovenous circulation could overcome this problem. VB Nguyen, M Jokie, C Leeaeheux Paediatric Intensive Case Service, Hospital University Centre, Avenue C6te de Nacre, 14033 Caen Cedex, France Background, The implication of polymorphonuclear neutrophils (PMNs) in the physiopathology of children's haemolytic.uraemie syndrome (HUS) becomes more and more evident. The purpose of the present study is to role out their impact among other pronostie elements during the course of the disease. Patients and methods. Diarrheal prodrome and its duration, patient's age, maximal blood nitrogen level, anuria and dialysis time, extra.renal involvements, white enll and PMN counts and thrombopenia duration have been retrospectively analysed in 18 infants with good outcome and in 8 another children with unfavorable outcome. Results. Neither diarrhoea or its duration, nor children's age, nor blood nitrogen level, nor anuria or dialysis time had any predictive value for the disease evolution in the acute phase of our patients. Adversely, extra-nenal involvements was accompanied by severe and complicated courses of the disease (p<0,02). The elevation of white cells and PMNs (heyon 20 x 109/i) and PMNs (more than 15 x 109/1) as well as its persistence beyon a week were most frequently observed in complicated forms (p<0,001, p<0,001 and p<0,01, respectively). A transient thrombopenia (less than 5 day@ in patients with elevated counts of white cells may be a filrther obvious sign of an unfavorable course of the disease (13<0,02). Conclusion. The elevated count of white cells and PMNs, either alone or associated to one rapid regeneration of platelets, seems enabled to predict an unfavorable evolution of the HUS in children. MSUD results from an inherited impairement of catabolic pathway of branch chain amino-acids. High leucine blood levels may induce acute brain dysfunction. This dramatic complication led us to propose leucine removal procedures as continuous hemofiltration. Patients and methods Three newborns in acute MSUD onset were treated by HF, HDF and HD. Extracorporeal circulation was performed through a 6.5 Fr catheter, a circuit with a blood pump (priming volume = 40 ml). Patients and procedures characteristics are summarized below in the Sucralfate (an aluminium salt of sucrose octa sulfate) is used to prevent and treat upper gastrointestinal bleeding in critically ill patients. With minimal absorption, the potential for side effects is thought to be limited, though aluminium toxicity has been reported in patients with chronic renal failure. These patients may already have had high body stores of aluminium. We report 5 critically ill children with high serum concentrations of aluminium following sucralfate therapy. All 5 had renal impairment. The normal aluminium level is < 0.4 gmol/L and in patients with chronic renal failure < 2.2 ].tmol/L. None of these patients had known preexisting chronic renal disease. CPB was conducted under deep hypothermia (T,°16°C) and cardiocirculatory arrest (CCA) or under hypothermia (T,°24°C) and low-flow perfusion. Continuous Holter-electrocardiograms (H-ECG) were recorded from the ilranediate postoperative (PO) period on for 72 hours. H-ECG were also recorded prior to the operation and before discharge. Following DR were observed: snpraventricutar (SV) and ventricular (V) extrasystoles (ES) (>50/24h), SV and V tachycardia (SVT and VT), accelerated junctional rhythm (AJR) and junctional ectopic tachycardja (JET), and 2nd and 3rd degree atrioventricular block (AVB2 and AVB3). The incidence of PO DR was 20% in the pre-op H-ECG, 74% on the 1st, 33% on the 2rid, 34% on the 3rd PO day and 21% befbre discharge. Compared to the pre-op findings, an increased incidence of SVES, VES, SVT and AVB3 on the 1st PO day was observed, whereas VT and A JR or JET were exclusively observed PO. All types of DR were observed up to the 3rd PO day. Ty23e of DR before discharge was similar to pre-op findings and there was no definitive AVB3. Considering patient groups according to the most frequent isolated op-procedure, the incidence of DR on the first PO day was 56% after ASD II-closure (n=23), 74% after stthaortal VSD-closure (n=lg), 75% after correction of a complete AVSD (n=8), 80% after correction of a tetralogy of Fallot (n=20) and 100% after Fontan-operation (n=10). Incidence and type of DR were not significantly different between groups. Longer CPB-dttration and use of CCA were risk factors for PO VES and VT (p<0,005 and p<0,05, respectively) whereas use of CCA and degree of hypothermia were risk factors for the development of A JR and JET (p<0,02 and p<0,0001, respectively). -Our results indicate that PO DR after CPB in children m'e frequent but mainly transient. In our series, specific CPB-related parameters are of greater influence than surgical procedure itseif for the development of DR and are discriminant risk factors for particular types of DR. The course of ANP, cGMP/ANP (as indicator for atrial natriurefic peptide biological activity), and NO2 and NO3 (as indicator for endogenous nitric oxide (NO) synthesis) was investigated in I9 infants (median age 4 months) undergoing cardiopulmonary bypass (CPB). Patients were divided into 2 groups according to whether they had (group 1, n=13) or not (group 2, n=6) preoperative heart failure (HF) and pulmonary hypertension (PHT). Group 1 patients had preoperatively significantly higher levels of ANP (p<0.005), cGMP (p<0.02) and NO2 and NO3 (,p<0.02) but had significantly lower cGMP/ANP (I0<0.05) than group 2 patients. During CPB, ANP was significantly higher in group 1 patients ~<0.02). As compared with prebypass values, cGMP/ANP was reduced in both groups during CPB (p<0.0001). cGMP/ANP inversely correlated with duration of CPB and aortic clamping time (p<0.001, respectively). NO2 and NO3 were significantly higher in group 1 than in group 2 patients (p<0.05) without any intraindividual change during CPB. From the early postoperative period on ANP, cGMP/ANP and NO2 and NO3 were similar in both groups. After CPB, ANP correlated in both groups with blood pressure (p<0,001) and diuresis (p<0.05). NO2 and NO3 inversely correlated with pulmonary arterial pressure immediately after CPB (19<0.05 Patients after a Fontan-type of procedure have elevated central venous pressures (cvp) leading to congestion in the gastrointestinal system and often ascites. Purpose of this study was to evaluate whether this causes a different postoperative gastric mucosal pH (pHi). Methods: We evaluated a series of 35 patients, who underwent cardiac surgery with cardiopulmonary bypass (age: 5 days to 16 years (mean 2,2 yrs), weight: 3.2 to 37kg (mean 10.2 kg). A commercially available tonometer (Tonometics®) for sigmoidal use in adults was inserted into the stomach after induction of anesthesia. The pHi measurements were done according to manufacturer recommendations We compared three groups of patients: 1) aeyanotic (n=20), among them 9 P with VSD and 5 P with AVSD; 2) cyanotic (n=10): TOF: 6P, TGA: 4P; 3) cyanotic after a Fontan-type procedure (n=5). Phi were measured at PICU arrival and after 6h. Fudhermore we compared lactat levels at these time points. Differences between the groups were evaluated with one way ANOVA on ranks with pairwaise multiple comparisons (Dunn's method). The relationship between CVP and pHi was investigated by regression analysis. Results: The median pHi for groups I, 2 and 3 were 7.28, 7.27 and 7.13 at ardval and 7.30, 7.25 and 7.21 after 6h respectively. At PICU arrival group 3 was significantly (p<0.05) different from groups 1 and 2. There was no significant difference between the latter two groups, After 6h group 1 was different from group 3, there were no other significant differences. The median lactate levels for groups t, 2 and 3 were 2.2, 3,2 and 4.1 at ardval and 1.6, 3.1 and 3.3 after 6h respectively. At PtCU arrival group 3 was significantly (p<0.05) different from group 1, after 6h there were no significant differences. There was a weak negative correlation between cvp and pHi: r= -0.21; p<0.05. Conclusion: Patients after a Fontan-type of procedure have lower pHi than patients after other cardiac surgical procedures, However, this is only in part due to the elevated cvp and venous congestion. Eleven children were investigated 32 months (median) after postoperative MOF. IVIOF was defined as the failure of at least two vital organ systems (kidney, liver, lung, central nervous system) in addition to cardiac insufficiency and high fever. Underlying surgical procedure was repair of Tetralogy of Fallot (n=3), Fontan-(n=7) or Seuning procedure (n=l). All patients fulfilled criteria for MOF in the 3 first postoperative (PO) days. Six patients needed peritoneal or hemodialysis for 31 days (median) during the PO period. One patient showed cerebral infarction due to thromboembolism in the territory of the right internal carotid artery immediately after the operation. The follow-up protocol consisted of extensive investigations of heart-, renalliver-, and lung functions as well as complete neurological and psychological examinations. All patients had adequate cardiac examination. Lung function was normal in all but 2 patients who had an obstructive syndrome. Only 1 patient showed an isolated decreased creatinine clearance. Abnormalities of the liver ftmction tests were only noticed in patients after Fontan procedure. Severe neurological sequels such as paraplegia (n = 1) and diplegia (n-i) were observed in 2 of the 11 patients. The remaining 9 children presented with a delayed graphomotorical and speech development associated with normal intelligence. -In our series the most frequent and severe sequels after postoperative MOF were neurological. -Abnormal liver fimction tests are more likely to be a consequence of the Fontan hemodynamics than a sequel of MOF. The optimal dosing schedule of surfactant therapy for the treatment of neonatal respiratory distress syndrome (RDS) remains unclear. Goal: Surfaetant function and the concentration of phospholipids (PL) in tracheal aspirates are compared in a prospective randomized trial involving neonates with RDS who received either TWO or MORE (3 or 4) doses of Survanta. Methods; Ventilated neonates <35w with RDS were treated with Survanta 1OO mg/kg if FiO 2 >_40% or mean airway pressure _>7,5 cm HzO, After 6h a 2nd dose was given (same criteria), If the support still exceeded the criteria 12h after the 2nd dose, the patient was randomized to no extra dose (TWO}, or to an extra dose of Survanta (MOREl (and a 4th dose 12h later; same criteria), PL was measured in tracheal aspirates and corrected for dilution with the urea method. "Active" large aggregates and "non-active" small aggregates of surfactant were separated by centrifugation and quantified. Surface tension of the large aggregate fraction was measured by pulsating bubble surfactometer, Results: 13 neonates were randomized, 6x TWO and 7x MORE (5x3 and 2x4 doses), Gestational age was 31,7±2,4w and birth weight 1582±568g. Most patients had severe RDS with initial ventilation: rate 63.1_+11,1, peak inspiratory pressure (PIP) 24,3-+6.4 cm HzO, FiO 2 75.3±21.0%. At randomization: rate 63.5±6.9, PIP 20.3-+2.5 cm HzO, FiO 2 29.5±15.7%, and 24 h after randomization: rate 45.9±17.1, PIP 18.7_+2.2 cm HzO, FiO 2 26.8±6.6%, without signif, differences between the groups. There was 1 relapse (again FIO2_>60% within 72h) in group TWO and t BPD in group MORE. In total, 112 tracheal aspirates were analyzed. PL was not signif, different before randomization (TWO 27.5 ± 15.7 vs MORE 24.5 ± 11.4 /Jmol/ml), but neither after randomization (TWO 21.2-+ 11.0 vs MORE 19.3±7,O /~mol/ml). There was no difference in the % small aggregates (TWO 4.2±1.9 vs MORE 6.9±5.5%), The surface tensions (raN/m) were not signif, different (each time TWO vs MORE): before randomization 10.0±2,3 vs 14.2-+7.2, in the 24h after randomization 12.6±5.0 vs 11.2-+3,8, or 24-48h after randomization 17.0-+5.5 vs 12.8±9.8, or 48-72h after randomization 15.7_+0.4 vs 13.7-+5.6. Conclusion: Neonates who received more than two doses of Survanta did not have higher PL, nor a better surfactant function than neonates who received only two doses of Survanta. Continuation of the trial is necessary to evaluate clinical outcome. MAY NOT INDICATE NEED FOR TREATMENT P.C. Clemens S.J. Neumann University of Hamburg, Department of Pediatrics, Klinikum Schwerin, Wismarsche Str.. 397, D-19049 Schwerin. Aim of the study: The finding of elevated TSH and decreased T4 in the newborn usually is classified as "transient hypothyroidism", thus the elevation of TSH is classified as consequence of the lowered T4. But on the other hand several data sets show that TSH elevation as well as low T4, one independently of the other one, are associated with different kinds of perinatal stress. Each of these laboratory deviations, if not associated with the other value being abnormal too, is generally accepted not to be an indication for treatment. From this we conclude, that more pefinatal stress, as in intensive care neonates, may produce TSH elevation as well as low T4, but only coincidentially, not the TSH elevation being the consequence of low T4, thus not to be classified as "hypothyroidism", thus not indicating treatment. If this hypothesis is right, we should find an association of increasing pefinatal stress with an increasing number of neonates from TSH and T4 normal via TSH or T4 abnormal to high TSH and low T4. Method: In the newborn screening program in Germa W we determine primarily TSH, and only in the neonates with elevated TSH, in addition we determine T4. Thus in our study we asked whether we find an association of increasing perinatal stress with an increasing number of neonates from TSH normal via TSH abnormal while T4 normal to high TSH and low T4. Definitions for this study were: TSH elevation = >20 mU/1 (as usual in the German screening programs), T4 lowered = < 6 p_g/dL Perinatal stress score was 0 or 1 or 2 or 3 in dependency of the neonate having stress in none to all of the following three categories: (a) forceps or vacuum extraction or sectio Co) birth weight below 2500 g (c) at the 5th day existence of a relevant neonatal disorder (RDS, ictems gravis, infection/sepsis, vitium cordis with hemodynamic relevance, severe malformation). Results: Our data of 1131 neonates show a high significant association (chi2 = 84, p <0.001) of, on one hand, perinatal stress score 0 with normal TSH, versus, on the other hand, perinatal stress score 2 or 3 with high TSH and low T4. Discussion: Facing the background given above, in the intensive care newborn, the constellation of high TSH and low T4 may be only a coincidential addition of two independent abnormalities. In tbese cases -the high TSH not being the consequence of low T4 -the classification as "hypothyroidism" is not justified, thus a therapy not indicated. On the other hand of course there exist rare cases with high TSH as consequence of low T4 thus with hypothyroidism tlms with indication for therapy. Unfortunately we have no criteria, that enable a certain discrimination of these two categories thus in respect to the question of therapy or not. Conclusion: Further research has to be done to learn how to discriminate the coincidential high TSH and low T4 from the causal constellation of high TSH and low T4. Until we have certain discrimination criteria we have to treat both groups of neonates. Few studies have focused on FA composition of surfactant PC in preterm infants before and after surfactant therapy. Methods: Tracheal aspirates were collected in 7 venttlated mfants from birth until extubatlon (27/7_1 /TWk GA, 859.+ 155g BW). After lipid extraction, t.l.c,, and methylation, FAs of PC were quantified by gaschromatography. Intralipid a (53.2 % linoleic acid,18:2•6) was started 48h after birth. Results: Six infants developed respiratory distress syndrome (RDS) and received Survanta R i00mg/kg (SR), all doses within 18h after birth (Ix S R n=l, 2x S r~ n=3, 3x S R n=2). One child did not develop RDS. In alt patients, the patmitate % in PC was ~ 65% (before Sr<=natural composition), increased to ~ 85% after S R, and remained >80% for i5h after lx S a, 22.3.+I1.8h after 2x, and 38.5.+3.3h after 3 doses. In 4 patients, intubated long enough, the palmitate % decreased with a half-life of 78.7_+42.8h to a new plateau which was still higher than baseline after 1 week. Linoleic acid % was 5.85_+2.3 (with RDS), decreased after S r~ and returned to baseline due to the decrease in patmitate %. Thereafter the linoleic acid % increased linearly with 0.021% per h, in 1 patient even up to 15.1%. Other FAs did not increase after return to baseline. In neonatal medicine the current parameters, arterial oxygen saturation and arterial oxygen pressure, are poor indicators for oxygen delivery and oxygen demand. The purpose of this study was to obtain venous blood samples from the inferior vena cava in stable neonates with respiratory failure and to determine a parameter that reflects more adequately the balance between oxygen delivery and oxygen demand. "l~e study included 22 neonates requiring mechanical ventilation tbr severe respiratory insufficiency. An umbilical venous and arterial catheter were inserted in the inferior vena cava and in the aorta respectively. Paired blood samples were obtained at the time that the patients were hemodynamically stable. Fifty paired arterial and mixed venous blood samples were analyzed. 1Jnear regression analysis showed the following correlations: In a neonatal intensive care unit adjacent to a delivery room caring for 4000 mothers per year, (with a referral of 400 mostly for preterm delivery), virtually every neonate network was created to implement a nosecomial infections (NI) quality care program in NICU and PICU, The first objective was to describe the annual NI incidence rate in each ICU population : all patients stayed more than 48 hours in ICU. Methods : N] criteria were defined by the Reaped group according to CDC criteria. All data were collected by a medical and nursing team. All infection data were validated by an external investigator. Results : 4525 patients were admitted over a 14 months period. 68% were newborns. 371 NI were identified among 311 patients. The overall NI incidence rate (IR) was 8.2% and 5.9°/00 person day (from 5.0 to 8.2°/00 according to age, lowest rate for newborns). Septicemia (50% of NI) and pneumonia (41% of NI) were the two main NI. According to age, the septicemia IR varied from 6.8 to 10.9°/oo catheter day (lowest rate for newborns) and the pneumonia IR from 3.9 to 7.4°/00 ventilator day (lowest rate for newborns). There were very few other infections (UTI : 4%, IR : 7.4°/00 catheter day). Gram positive cocci were isolated in 73% of septicemia ( 70% of them were coagulase negative staphylococcal). Gram negative bacilli were isolated in 53% of pneumonia (40% of them were pseudomonas). 5% of NI were caused by candida, mostly septicemia. The septicemia and pneumonia IR varied according to unit even after adjustment for age. Discussion The aminoglycoside antibiotics are frequently used in newborns for the treatment of severe infection and sepsis due to Gram-negative microorganisms. The currently recommended dosage schedule for TOBRA (2.5 mg/kg q18h) does not take into account differences in gestational or postnatal age during the first 4 weeks of life. We questioned the validity of these recommendations and studied the population kinetics of tobramycin to establish predictive equations that enables the clinician to select the appropriate initial dosing schedule. Methods TOBRA trough (t=0) and peak values (t= 1) were taken on day 2-4 after birth in 460 newborns. TOBRA was administered as a 30-minute intravenous infusion already in an adapted dosage schedule: 3.5 mg/kg q24h in infants with GAs < 28 weeks; 2.5 mg/kg q18h in infants with GAs between 28-36 weeks and 2.5 mg/kg q12h in infants with GAs > 36 wks, TOBRA concentrations were analyzed by TDX-assay, A one-compartment model was assumed and non-linear mixed effect modelling (using NONMEM) was applied to the data, A trough level < 2 mg/L and a peak level between 6 and 10 mg/L was required, With the present dosage scheme 40% of the trough levels were too high and almost 60% of the peak levels too low. Calculations showed that the following dosage schedule should result in optimal levels of TOBRA. preterm infants GAs < 28 wks: 6 mg q48h preterm infants GAs 28-36 wks: 4.5 mg q36h preterm infants GAs > 36 wks: The currently recommended dosage schedules for TOEiRA result in high trough and low peak levels. Prolongation of the dosing interval and increasing the amount of drug per dose according to the above scheme will improve TOBRA level control. Since January 1993 British clinicians have been conducting a randomized controlled trial of neonatal ECMO. Mature infants (>-35 weeks gestation and birthweight 2 2 kg) with severe cardiopulmonary failure have been randomized to receive continued care in their referring institution or referral to a designated ECMO centre for further management. We now present the preliminary results which have prompted closure of recruitment to this trial. The final outcome will be assessed as intact survival against death or severe disability at one year of age for all the recruited patients. Patients were categorised by diagnosis such as isolated persistent fetal circulation, secondary persistent pulmonary hypertension of the newborn or congenital diaphragmatic hernia and by severity of illness at the point of first contact with the clinical coordinators of the trial -judged primarily by the oxygenation index (240 before randomization). 180 patients were randomized (90 in each arm). Hospital outcome data are reported for all patients and 1 year outcomes on t18 (65 survivors). At this stage 26 of the babies allocated to ECMO are known to have died compared to 52 of those allocated to conventional management (RR 0.5; 95% CI 0.35-0.72; P=0.0002). Fewer deaths have been obsea-ved amongst ECMO allocated babies in all the diagnostic categories used. A 28% incidence of disability and impah~nent has been observed amongst survivors. This rate is similar in both groups and the survival advantage is not offset by an increased rate of disability or impairment following allocation to ECMO. We consider that these data combined with those available from other studies provide conclusive evidence that the survival to discharge from hospital is substantially higher in patients allocated to ECMO than in comparable infants not so allocated. Therefore recruitment to this trial has been closed whist awaiting complete one year outcome data. Sigston PE, Goldman AP. #Keating J. Crook R. ~e DJ~. Great Ormond Street Hospital for Children NHS Trust, and ~Biochemistry Department, Kings College Hospital, London, United Kingdom. Isoflurane is a safe and effective means of long term sedation in both children and adults in the intensive care setting. The use of isoflurane, by adding it to the sweep gas allows the use of this volatile anaesthetic agent in patients on ECMO, enabling rapid control and weaning of sedation. A potential problem with the long term use of isoflurane is fluoride ion accumulation with the possibility of renal toxicity, The purpose of this study was to assess plasma fluoride levels in patients receiving prolonged isoflurane on ECMO. Method: Fifteen infants and children (aged 1 day -10 years, median 2 weeks) receiving ECMO support for either cardiac or respiratory failure were recruited to this study. The patients were sedated with isoflurane as well as intravenous agents (morphine and midazolam). Isoflurane was administered (0% -3%) via a calibrated vaporiser to the sweep gas, adjusting the level to maintain adequate sedation. Blood samples were obtained on a daily basis for plasma inorganic fluoride assay. The relationship between plasma fluoride and amount of isoflurane administered, as %-hours (vaporiser setting in % x hours) was calculated by linear regression. Results: The duration of ECMO ranged from 42 to 532 (mean 207) hours, during which the amount of isoflurane administered varied from 7 to 418 (mean 168) %-hours. 75 blood samples were anaiysed, demonstrating individual peak plasma fluoride levels of 2.7 to 16.5#mol/1, mean 7,1p.mollI (toxic threshold = 50gruel/f). The plasma fluoride positively co;related with the %-hours of isoflurane (r = 0.65, p = < 0.001). Conclusion: This study shows that although there is a dose related accumulation of inorganic fluoride ions in patients sedated with isoflurane on ECMQ, the peak fluoride levels are well below the suggested toxic threshold. Merzel Y, Lev A, Bar Yosef G, Halbertal M, Lorber A ECMO Center, PICU, Emek Medical Center, Israel. The mortality rate of pediatric patients with acute myocarditis is 20-60% according to the severity of myocardial damage. A 15 month old gzrl presented with high fever, respiratory and cardiac failure. Diagnosis of acute myocarditis was made and the patient was ventilated with high pressures and FIO2 of 1.0. She required high doses of inotropes. Echocardiography revealed a dilated LA and LV with severe MR. LVEDD was 41 mm and LVSF 9%. Calculated oxygenation index was 55. She was resuscitated after a cardiac arrest. She was commenced on ECMO (using Biomedicus centrifugal pump and Avecor 800 oxygenator) at a flow of 100 ml/kg/mm with immediate improvement of hemodynamlcs, oxygenation and pC02. Resptratory assistance and vasoactive drugs were reduced. The patient was transported by air, on ECMO, to the ECMO cevter. She developed ARF and CVVH-D was performed. Cardiac fimction started to improve after 12 days. ECMO was discontinued on day 18. Echo revealed LVEDD 34 mm and LVSF 24%. IPPV was discontinued on day 20. On discharge, a month later, her LVEDD was 29 mm and LVSF 28%. She behaves normally for age without neurologic or other medical sequellae. Literature search revealed no case of acute myocarditis, as severe, that was treated successfully. Survavors of disease this severe usually suffer dilated cardiomyopathy and permanent disability. The use of ECMO allows myocardial rest which prevents long term myocardial damage. Introduction ECMO is increasingly used in the care of critically ill newborns. Despite the frequent use of betalactam antibiotics in the treatment of these infants there are no data available on the dispbsition of cefotaxime (CTX) and amoxicilfin (AM) d0ring ECMO. The purposes of this study were to determine the pharmacokinetics of these two drugs in infants on ECMO and consequently formulate appropriate dosing regimens. We therefore studied the pharmacokinetics of CTX (100 mg/kg ql 2h) and AM (50 mg/kg q6h) in 8 term infants on day 3 after birth, Blood samples were taken before (t-O) and 0.5,1,2,4,6 (AM) and t2 h (CTX) after the intravenous bolus injection and analyzed by HPLC-assays. 2. CTX 100 mg/kg q12h results in adequate serum levels of CTX in fullterm infants on ECMO, AM 50 mg/kg q6h results in very high serum trough levels. Recalculation based on the known volume of distribution and elimination serum half-life of these infants resulted in the following dosage recommendation: 50 mg/kg q12h. Persistent pulmonary hypertension of the new-born (PPHN) is characterised by rapid fluctuations in pulmonary artery pressure (PAP) and a clinical impression of stifflungs. Lung mechanics were measured in 35 term infants, mean age 1.5 +_ 0.7 days who were paralysed and ventilated within the first three days of life. Fourteen infants had PPHN with systemic or suprasystemic PAP measured by echocardiography. In these patients, the respiratory system resistance was 29.4% higher (p < 0.001) and compliance 22.4 % lower (p = 0.03) during systemic or suprasystemic PAP compared to when the pulmonary hypertension had resolved. In contrast, there were no changes in resistance in the 14 infants with respiratory distress syndrome (RDS) and no pulmonary hypertension or in the seven infants with normal lungs, where two readings were taken 24 hours apart. The changes in lung mechanics interfered with mechanical ventilation, resulting in a 12.5 mmHg rise in PaCO2 (p=0.007) during pulmonary hypertension. Inhalation of nitric oxide 10 PPM resulted in a 16% decrease in respiratory system resistance and an improvement in oxygenation. The bronchial and vascular smooth muscle was increased by 120% in postmortem lung samples from eight infants with PPHN compared to six age matched post-mortem controls with normal lungs (p<0.001). These findings suggest a co-constriction and co-hypertrophy of bronchial and vascular smooth muscle during PPHN. Anatomically the pulmonary vasculature and bronchi lie in close proximity to each other. Thus mediators such as Endothelin-1 released locally may act on both vascular and bronchial smooth muscle to produce the observed vasoconstriction, bronchoconstriction and smooth muscle hypertrophy. Prince of Wales Children's Hospital University of New South Wales, Randwick, N.S.W. Australia. INTRODUCTION An increasing mortality in asthmatic children has been reported. The increased severity of asthmatic illness leads to an increased demand for ICU admission, and a corresponding increased need for mechanical ventilation. Geographic end environmental factors are thought to be partly responsible for differences in disease sevedty throughout the wodd. For this reason, epidemiological studies from diverse areas are important, Risk factors for ICU admission, and for the institution of mechanical ventilation should be identified, to optimise ICU admission criteria and to avoid unnecessary delays in admitting at-risk patients. AIM To document the clinical characteristics of ventilated and non-ventilated asthmatic patients admitted to ICU. METHODS This is a retrospective study of all paediatric asthma ICU admissions from January 1990 to December 1995. RESULTS There were 65 patients admitted to the ICU for acute severe asthma in the study period. The male:female ratio was 33:32, the mean age 76.1 • 57.3 months, the mean PRISM 8.5 4-11.1%, and the mean duration of admission 135 4. 129 hours. There was no seasonal variation in admissions. Only 40% (26/65) patients required mechanical ventilation. In 22% of all patients this was the first presentation with asthma. There were some significant differences between ventilated and non-ventilated patients (see Table) . There was a significantly higher incidence of concomitant and nosocomial pneumonias in the ventilated patients (84.0% vs 21.1%) as well as segmental lung collapse (68.0% vs 26.3%). There were no deaths. DISCUSSION The need of mechanical ventilation significantly increases the morbidity of and duration of ICU stay of asthmatic patients. Younger asthmatic paediatdc patients have a significantly higher risk of ventilation. The need for ventilation is predicted principally from a worsening pCO2 and respiratory acidaemia, which is often independently interpreted by the clinician as respira4ory exhaustion. This study has shown that ICU admission is important in the management of young paediatdc patients with acute severe asthma and respiratgry fa!!ure. Intravenous salbutamoi in the emergency, department management of severe asthma in children. G.J.Browne,A. Perma,X. Phung,M.Soo Westmead Hospital, Sydney, Australia. It is postulate that if an initial intravenous loading dose of salbutamol is given in severe asthma, a more rapid clinical response will occur, reducing requirements for continued high doses of nebulised salbutamoi with fewer side effects. This double blinded study was conducted in the Emergency department of Westmead Hospital a university hospital in Sydney, Australia. All children with severe asthma had initial nebuliser therapy (5rag of salbutamol with 4mL of saline). If asthma remained severe 20 minutes later, they were given a dose of intravenous hydrocortisone (5mg/kg) and either normal saline or salbutamol 15microgm/kg intravenously. Frequent nebulised salbutamoi therapy continued during the initial first hour if clinically indicated. Continuous respiratory and haemodynamic monitoring occurred in the first 2 hours. Serum potassium and glucose determinations were made at study commencement and 1 hour after intravenous therapy. Salbutamol determination was made at study commencement. Children remained clinically monitored for the next 22 hours, with their ongoing treatment determined by clinical response. 29 children with severe asthma 12 months to 12 years of age were studied, with 14 given intravenous salbutamol and 15 given intravenous saline. The intravenous satbutamol group (IVSG) showed rapid reduction in asthma severity scale in the first 2 hours, with reduced need for high frequency nebuliser therapy ( _<2 hourly), occurring 8.78 hours.earlier. No clinically significant side-effects were found in either group, although, tremor more frequent in the [VSG. Biochemistry and salbutamol concentrations were similar in both groups. The use of intravenous salbutamol (I5 microgm/kg) in the management of severe childhood asthma is a safe and effective therapy with no significant side-effects and the potential to abort severe asthma attacks in the emergency department. INTRAVENOUS TERBUTALINE IN PICU Piva J., Amantra S, Rosso A., Zambonato S, Giugno K, Maia T. Introduction: The admission to a PICU of children with respiratory failure secondary to an acute obstructive lower airway disease is a common event, especially during winter seasons. These diseases have several causes, but most of them (especially asthma and chronic airway disease) have a good response to the administration of B2-adrenergic drugs. Objective: To find the dosis of intravenous terbutaline that is safe, efficient and with minimal adverse effects when used in children admitted to a PICU with acute obstructive lower airway disease and respiratory failure. Material and Methods: We study the records of all children that were admitted to our PICU during the winter of 1995. Only the patients that had respiratory failure and acute lower airway disease and who needed the use of IV terbutaline were selected. The records were divided in two groups: less than 12 months and more than a year old These two groups were compared in the following aspects: the minimal and maximal dosis, and the length of time of use of IV terbutaline, frequency of tachycardia, hypokalemia, and mechanical ventilation. To establish any difference in the two groups we use the T exact test of Fisher and X2, with p< 0.05, Results: During the period of study were admitted 367 patients to the PICU, and 38 (10,3%) of them used of iv terbutaline. The mean age was 14.2 +12.2 month, used iv terbutaline during 7.24 +3.75 days (0.5 to 17 days), the initial rate was 0.55 +0.26p~g/kg/min, and the means of therapeutic dosis was 2.48 +l.181~g/kg/min (ranged from 0.5 to 4.4). Twelve (31.5%) patients had tachycardia art obstacle to the increases in the rate of use of iv terbutaline during any time. Mechanical ventilation was necessary in 22 patients (57.8%) and 11 (28.9%) patients died. The children under 1 year of age used initial dosis of iv terbutaline lower than the children up of 1 year old (0.45 p.g/ kghnin x 0.57 ~tg &g/rain, p<0.001), but without difference in the length of use, the maximal dosis, the rate of mechanical ventilation and tachycardia. The frequency of hypokalemia was most common in the group of children under year of age. Acute respiratory failure during status asthmaticus may require mechanical ventilation. Current therapy includes paralysis, pressure control ventilation (PCV) and permissive hypercapnia to limit pulmonary barotranma and its hemodynamic consequences. Asthmatic children exert a significant amount of respiratory effort during exhalation. With paralysis, this expiratory effort is lost. Unloading the inspiratory work of breathing while maintaining the patient's expiratory eftbrt using pressure support ventilation (PSV), may be beneficial. Methods: Children receiving PCV (peak inspiratory pressure (PIP) = 4 kPa. rate 10 breaths/min) and PCO2 > 8 kPa were switched to PSV. Children were initially ventilated with PSV 3.7 kPa and PEEP = 0.3 kPa (Servo 900C). All children received beta agonist therapy, ipratropium and anesthesia with ketamine or inhalational anesthesia, and were breathing spontaneously. Respiratory parameters and blood gases are shown be~bre PSV, within 30 minutes (Start) and when the pH had normalized (During). Data are presented as median and range, * p < 0.03 compared to before PSV. Results: Children with hypercarbia during PCV responded to PSV, normalizing PCOs and pH within 6 hours. The mean respiratory rate decreased from a median of 45 (31-46) to 35 (22-35) while the PIP was decreased to 3.2 (2.5-4.0) kPa within 6 hours. The I:E ratio also significantly decreased. Conclusion: PSV permitted patients to active/y exhale while unloading the inspiratory work of breathing. Perhaps this strategy shifts the patient's respiratory effort from inspiration to exhalation, thus permitting the child to meet the excess work of breathing caused by bronchoconstriction. Maged Z. Youssef, Peter Silver, Laura Nimkoff, and Mayer Sagv. Division of Pediatric Critical Care Medicine, Schneider Children's Hospital, New Hyde Park, NY 11040. Introduction: Mechanical vemiladon of patients with severe bronchospasm can be difficult, due to poor chest compliance and increased airway resistance. Ketarmne is a cormnonly used anesthetic agent that has been shown to have bronchodilator properties. The purpose of this study was to determine ifa continuous infusion of ketamine had an effect on the oxygenation and chest compliance of children with severe lironchospasm who were mechanically ventilated. Methods: A retrospective chart review was conducted of pediatric patients in severe bronchospasm who were mechanically ventilated in our PICU and treated with a continuous ketamine infusion. All patients were receiving aggressive bronchodilator therapy and adequate sedation prior to keramine. Patients were excluded if any new bronchodilator or sedative agents were started within 24 hours of initiation of ketamine treatment. All patients were simultaneously treated with benzodiazepines. For each patient, the PaO2/FiO ~ ratio and dynamic compliance [tidal volume/(peak imp. pressure -PEEP)] was determined immediately prior to ketamine, and at 1, 8, and 24 hours post-ketsmine initiation. Data are presented as mean ± S.D., and were a~yzed using one way ANOVA and the multiple comparison method of Bonferroni. patients (age 6.0 ± 5.7 yrs.) received * p<0.05 ketamine for severe bronchospastu during mechanical ventilation in our PICU. Both . .XTO-* * the PaO2/FiO2 ratio and dynamic . . -.... . compliance increased significantly following initiation of the ketamine 200infusion (see figure) . The mean ketamine dose was 32 ± 10 mcg/kg/min, and the -, mean infusion duration was 40 ± 31 too-[/ hours. One patient required glycopyrrotate 6 ~' to control excessive airway secretions, and " one patient required an additional dose of O--J I ~-~4 ~/me diazepam to control hallucinations after i 8 cessation of ketamine. All patients were t~n~,mr~ *~am~ successfully weaned off mechanical ~l~s ~,~s~on ventilation and discharged from the PICU. Conclusion: Continuous ketamine infusion to mechanically ventilated pediatric patients with refractory broncliospasm results in a significant improvement in oxygenation and dynamic compliance of the chest. Reports of adults with status nsthraaticus document significant morbidity and mortality, whereas studies in children have had more varied results. Different centers report mechanical ventilation (MV) in 10 to 33% of admissions, occurrence of pneumothoraces or paeutuomediastinums in 2 to 11%, and mortality in up to 7% of patients ~'t3. We retrospectively reviewed 113 status asthmaticus admissions to the pediatric intensive care unit (PICU) between January 1993 and December 1995. Seventy-five of these patients were admitted fr~an the emergency department of CHLA (ER Admit). The mean length of stay in the PICU was 2.1 days and the mean length of stay in the hospital was 4.6 days. Based on 95 patients who had arterial blood analyses, 36 patients had hyperoapnia (pCO2 > 45). All patients received oxygen, inhaled albuterol (Alb), and cortieosteroid therapy. Ninety-five percent of patients also received methylxanthine (MX) therapy. Of the 113 admissions, 12 patients (11%) required MV. Only 4 of these patients were admitted through our emergency department, whereas the remaining 8 patients were intuhated at outside facilities. Twenty-three cases required intr:wenous beta-agonist therapy, either isoproterenol Osop) or terbutaline (Terb). H~ff of the ea.~es re~%wed were complicated with hypokalemia (K+< 3.5). C,', ,~lications ofpoeumothoraces or pneumomediastinums were seen in 10% of ,'r:u~ported patients, but in only 4% of ER Admit patients. Only 2% of these were in mechanic.all, )atients. There were no deaths in the review. Respiratory mechanics measurements 'are useful in mechanically ventilated children to optimize ventilator settings. Nevertheless, the transducers used to measure flow (F) and pressure (P) remain expensive. Objective. To evaluate the performances of piezoelectric P transducers (350 US Dollar) in measuring F and P. Methods. We used a previously described monitoring system measuring respiratory parameters [ 1] . In this study F was obtained by a differential piezoelectric P transducer (_+ 12.7 cmI-I20, Honeywell) whose sensitivity has been reduced to +_ 2 cmH20 by an electronic amplification equipment and P by a piezoelectric P transducer (_+ 7().3 cmHzO, Honeywell) connected to a grid pneumotachymeter &NT) ffleisch 0 or 1 ). Volume (V) (5 to 400 ml) obtained by numeric integration ofF (0.125 to 10 L/rnin ) and P (2 to 70 cmH20) were respectively delivered through a calibrated seringe and an electronical manometer (Pic 400 Premier) and calculated by the computer. Bland and Altman analysis was used for assessment of results bias. Coefficient of repeatability (CR) was estimated by the standard deviation of repeated measurements of the parameters as calculated in a oneway analysis of variance. Results. Mean difference (Mdi 0 between injected V (5 to 50 ml) and measured V using PNT 0 was 0.15 ml, SD = 0.13 ml. Difference and mean V were not correlated. SD of repeated V measurements were not correlated to V. CR was 0.4 ml. Mdif between injected V (25 to 400 ml) and measured V using PNT 1 was 3 lrd, SD = 6 mL SD of repeated V measurements were not correlated to mean V. CR was 6 ml. Mdif between injected P and measured P was 0.3 cmI-I20, SD 0.4 cm H20 SD of repeated P measurements were not correlated to mean P. CR was 0.3 cmH20. Conclusion. Inexpensive piezoelectrical transducers can be used to measure F and P and evaluate respiratory mechanics in ventilated children. Previous studies have already shown the problem of the reproducibility of PFT in preterm ventilated babies. Were studied 10 preterm ventilated babies {mean weight 1128 gr) in the first week of life in clinically stable condition, measuring flow, airway pressure and esophageal pressure simultaneously. Each baby was studied twice with an interval of one hour and each study was done increasing the rate till 60 to inhibit spontaneous breaths. None sedative has been used. Only mechanical breaths were analyzed. Compliance and resistence were calculated with a computer system using the linear regression method. We expressed quantitatively the intrapatient variability as the percentage of variation of tidal volume, compliance and resistence between the two studies in each baby. Then Intraclass correlation coefficient test (ICC) was applied to confirm qualitatively our results (total agreement =1, good reproducibJtity > 0.75). We h~£ed, an a6Eept~ble ~Efiabirl¢, ~-~r;= '~ . During mechanical ventilation, an air leak (AL) and plateau phase duration (PL) may influence dynamic and static compliance (Cdy and Cst, respectively). This study evaluated the effect of AL and PL on two methods of measuring C.dy and est. Methods. 13 intubated, ventilated patients in a Pediatric Intensive Care Unit were evaluated after obtaining Informed consent. Patients were intuhated with a cuffed endotracheal tube and ventilated with a Serve 900(2 ventilator. Cdy and Cst were determined using the Serve andS~rMedics 2600. Objective: evaluate the repercussion in respiratory mechanics and arterial blood gases and the impact of the ventilator adjustments on the auto-PEEP magnitude. Material and Methods: the measurement of the auto-PEEP was performed using an eletronic-pneumatic controlled device with a oclasion valve installed between endotracheal canutla and the ventilator circuit. The d~'ice was connected to a solenoid to detecte the end of inspiratuo phase and thus, the activation of the oclusion valve. The signs of pressure and flow were monitorized using a diferential transducer and it was processed using a PC computer and tMeumoview® software. The stud3 were divided in 2 phases: phase A. where the ventilator adjustments was performed using the routine of the unit and phase B, where the targets of mechanical ventilation were to minimize the auto-PEEP. Static compliance (Crs) was ineasured by the single-breath occlusion technique, using a mean of ten occlusions for analysis. Passive respiratory resistance measurements and the tidal breathing flow-volume loops were also obtained., while the ventilatory settings were siguificantly reduced soon atier ECMO was started. Before ECMO Crs measured in all patienls was 0.23_+t).03 ml/cmH20/kg (mean_+SEM). For each patient the ECMO course was divided into four periods, proportional to the duration of the treatment, and the best ~alue of Crs in each period was chosen for analysis. As shown on the figure. Crs significantly improved (*p<0,05) from the second half of the ECMO course in the group of patient that finally were successfidly weaned from ECMO. No change ill compliance was measured in the group of patients who failed to respond to the extracorporeal hmg support Our data suggest that compliance measurements during ECMO can be useful togelher with overall clinical evaluation to predict both outcome and duration of cxtracorporeaI support in the neonatal and pediatric population. Objectives: Brain temperature determines the amount of neuronal damage caused by hypoxic insults. Thus measuring brain temperature at standardised conditions is in request. We investigated whether brain temperature of neonates varies with head insulation environmental temperature, body activity and time course. Patients and Methods: We investigated non-invasive brain temperature analogues in 19 healthy prematures tess than two weeks of age in an incubator (gestational age 31.5 + 2.1 wks; x + SD, weight 1653 + 370 g). We measured nasopharyngeal temperature (Tnasoph) by a thermistor placed in the nasopharynx via a feeding tube, zero-Heatflux Temperature (zHT) at the temple by a thermistor and healflux transducer, insulated by two pads, as well as rectal and incubator temperatures. Patient activity was documented by video taping. Measurements were performed during periods of increased insulation 1) by turning the head with its measuring site on to the mattress ( (5) 3 (5) -2 (6) 4 (5) 0 (6) 4 (3) 2.5 2 4(5) 25(10) 20{12) 8(5) 5(10) -2(7) 5 6 38 (22) 112(34)I70 (48)51(27) 20 (18) 5(15) 7.5 3 38 (19) 125(21) t85(29) 120(30) 70(30) 30(20) 10 4 53 (30) 133(28) 182(33) 157(24) 154(34) 110(45) WEB 2170 (lmg/Kg) 5 at 30 rain 3 3 (5) -4 (6) 5 (6) 4 (3) 5 (4) -3 (6) The vehicle had no effect. PAF caused dose dependent rise in AO and PA pressure and reduction in flow to LPA (up to 80% Like the vascular endothelium, the endocardial endothelium (EE) has a significant impact on adjacent myocytes, and may critically alter myocardial function.~ We have previously shown that EE cells are capable of sensing and responding to hypoxia by the release of prostacyclin (PGL). 2 Potassium channels in other cell types have been reported to be oxygen sensitive. To determine whether potassium channels modulate the EE hypoxic response, we investigated the effects of three potassium channel inhibitors on hypoxia-induced PG] 2 release from EE cells. Methods: Ovine endothelial cells were harvested and passaged onto 30 ,~ microcarriers. Cells were constantly perfused with normoxic and hypoxic Kreb's solution, and with three potassium channel blockers: glibenclamide (GB, 3 #g/ml), tetraethyl-antmonium (TEA, 10 raM) and 4 aminopyridine (4AP, I0 mM), Perfusate was assayed for prostacyclin (RIA). Data were compared by analysis of variance. * p<.05 compared to 3normoxic control; # p< .05 compared to hypoxic control. Adrenaline is extensively used for resuscitation in neonates with RDS. However, effects of adrenaline on systemic, pulmonary and cerebral hemodynamics have not been defined in newborns with RDS. Thirteen anesthetized, and ventilated newborn piglets were subjected to repeated saline lung-lavage series while mean systemic arterial pressure (ABP), mean pulmonary arteriat pressure (PAP), mean left atrial pressure (LAP) and mean central venous pressure (CVP), cardiac output and blood flow in the internal carotid artery (ICA) were measured. Systemic vascular resistance (S~), pulmonary vascular resistance (PVR) and cardiac index (CI) were calculated. Sixty minutes after luug-lavage, the adrenaline group (A) (n=6) received adrenaline as a continuous infusion of 1.2 lag/kg/mi, while the control group (C) (n=7) received saline. None of the varlables were changed by saline. However, significant increases in ABP (p<0.0001), PAP (p<0.0001), CI (p<0.001) and SVR (p<0.01) were observed after administration of adrenaline, whiIe PVR and ICA were not modified. Mean±SD for ABP/PAP (P/A), FVR/SVR (P/S) and CI (ml/mirdkg) were: Ratios of PAP/ABP and PVPJSVR significantly increased following infusion of adrenaline. These data suggest: 1) the cerebral perfusion is preserved during the infusion of adrenaline; 2) effect of the adrenaline infusion on the systemic circulation is more pronounced than its effect on the pulmonary circulation in newborn piglets with surfactant deficiency. S Demirak~a, Ch Knothe, KJ Hagel, J Bauer Department of Pediatrics, Justus-Liebig-University Giessen, FRG Inhaled NO is a short acting selective pulmonary vasodilator. We studied the effects of 80 ppm NO and 100% oxygen during heart catheterization in 16 children (age 1 -6 years, median 9 years) with heart defects and elevated pulmonary vascular resistance index (PVRi) in order to asses the value of NO as a tool of decision making for corrective cardiac surgery. Patients were eligible for testing when they were more than one year old and had a pathologically elevated PVRi in a previous heart catheterization. Intubation, 'anesthesia and muscle paralysis were performed in all patients during testing of pulmonary reagibility. Calculations of pulmonary vascular resistance and flow were based on the Fick method. Response to NO was assumed when PVRi declined more than 30%, 9 of the 16 patients were responders to NO. Effects of NO and oxygen on PVRi, mean pulmonary arterial pressure (mPAP) and pulmonary vascular flow (Qp) in all responders are described in the table below. Cardiac surgery was offered to all responders, and 5 of them were successfully operated. Surgery is planned in another 3 patients and parental consent for surgery was not given in one patient. In Ebstein disease, during the first days of life, the ability of right ventricle to propel blood to the pulmonary artery is impaired due to high pulmonary vascular resistances. The flow is mainly directed to left atrium through tricuspid insufficiency, right atrium and foramen ovale. To decrease pulmonary resistances and increase pulmonary blood flow, high frequency oscillations, mechanical ventilation, nitric oxide and prostaglandin are required. After few days, a forward circulation is normally established. We cared two newborns with Ebstein disease where this approach was hindered by a large pulmonary valve insufficiency. Both of them were diagnosed in utero, showing a large tricuspid insufficiency with a non opened pulmonary valve and a ductal left to right shunt. One fetus was hydropic. At birth, blood stream from the ductus arteriosus was directed to the right ventricle through the pulmonary valve insufficiency then to right atrium, left atrium and ventricle, aorta and ductus arteriosus. A low pulmonary blood flow was demonstrated by low mean velocities (10cm/sec). A high reverse flow was seen in descending aorta with a negative flow in the renal artery. Both of these newborns were oliguric because of ductus arteriosus steal. Pulmonary blood flow Doppler evaluation allowed different strategies of ventilation, switching between HFO and conventional ventilation, modulation of PGE1 doses, inhaled pulmonary vasodilators (nitric oxide) and surfactant. The hydropic baby died, the other survived after 3 weeks of intensive care complicated by supraventricular arythmia (WPW). In conclusion, during neonatal period, in Ebstein disease, a large pulmonary insufficiency leads to a vicious circle where lungs are excluded, inducing severe asphyxia and high pulmonary resistances. The blood is backward propeled from the aorta through the ductus arteriosus to the right ventricle and atria, then left cavities to aorta. AREC must be considered when pulmonary blood flow does not increase despite optimal therapy. Guti~rrez-Larraya F*, Mandoza A*, Velasco JM*, ZavaneUa (3**, Gatindo A ~, S&nchez-Andrede R, S&nchez Jl***, MellOn A***, Mar F***. Pediatric Cardiology*, Pediatric Cardiac Surgery**, Pediatric Intensive Care Unit***. Hospital 12 De Octubre. Madrid. BACKGROUND: Transesophageal pacing (TP) is effective and sate both for diagnosis and treatment of pediatric arrhythmias. MATERIAL AND METHODS. Eleven consecutive patients are included. A tri or quaddpolar 6 or 7F temporal transvenous catheter with an interpolar distance of 13 to 22 mm was advanced through the nares and positioned to the point with the largest amplitude of atrial deflection, Surface ECG and a bi or monopolar electregram were recorded simultaneously, selecting filters when needed (5 to 100 MHz). Pacing was performed with a programmable stimulator (Medtronic 5328) beginning with 2 ms and increasing mA to 10 and then increasing up to 9.9 ms. Narula method was selected to diagnose sinusal node disfunction (SND) and overdrive pacing to treat tachyarrhythmias. RESULTS. TP was useful in all the 11 patients and no complications were observed: in 3 patients a SND was diagnosed (one needing a definitive pacemaker), in two patients with Atrial Ratter (ripe 1) sinus rhythm was recovered, in one patient with a postoperative Junctional Ectopic Tachycadia we were able to get atrial synchrony with marked bemodinamic improvement, and 5 patients with Paroxysmal Supraventricular Tachycardia sinus rhythm was easily and quickly restored (2 of them recquirad repited episodes of TP until pharmacelogycal levels of antiarrhythmic drugs were raised). Mean age and weight were 31 months and 12.7 kg (one patient had 2.1 kg). There was a close relation between height and depht insertion (r= 0.98). Mean stimulation parameters were 9,1 ms and 13.5 mA. DISCUSSION. In experiencied hands TP is an effective and safe way to treat and diagnose cardiac arrhythmias even in newborns. It should be tried before endovenous pacing is stablished and it is faster than pharmacologycal treatment. Bailing G., Eicken A., Sebening W., Vogt M., Schumacher G., BL~hlmeyer K.; Kinderkardiologie, Deutsches Herzzentrum M0nchen, Germany To assess the outcome of balloon valvuloplasty in infants with cardiac failure caused by critical aortic stenosis a retrospective study was performed. Between 1986 and 1995 33 neonates, aged 1 -28 days (median 9 d), weight 2.t -4,1 kg (median 3,3 kg) with critical valvar aortic stenosis were dilated by balloon (AoVP) as the first line treatment. 21 patients received Prostaglandin El, 18 needed inotropic drugs and 16 mechanical ventilation. Associated cardiac lesions : Persistent ductus arteriosus (PDA) in 27 patients (restrictive PDA in 8 cases), a mitral regurgitation (MiVR) in 27 cases (15 severe and 12 moderate or mild MiVR), angiographic findings of endocardial fibroelastosis (EFE) in 12 patients, mitral stenosis (MiVS) in 8, coarctation of the aorta (CoA) in 2, and finally a small musculary ventricular septum defect (VSD) in I patient. Vascular approach for ballooning : A. axitfaris in 20 cases (61%) a. femoralis in t 0 (30%) and v. femoralis in 3 cases (9%). The median ratio between inflated balloon and aortic valve diameter was 0,99. Dilatation was achieved in all 33 cases. The peak systolic gradient across the aortic valve (pre AoVP) ranged from 0 to 137 mmHg (median 50 mmHg) and was reduced to 0 to 55 mmHg (median 15; gradient reduction is significant (p < 0,01)). Aortic regurgitation (AoVR) was absent or mild in 30, moderate in 2 and severe in 1 patient after AoVP. 23 children survived (actual suwival rate: 70%; early mortalffy: n = 3; late mortality: n = 7). Mid term follow up (0-8,8 years; mean 2,7 years) showed an increase of the systolic peak doppler gradient across the aortic valve (median 41 mmHg) but no increase of AoVR. 10 re-interventions (Re-AoVP: n = 3, commissurotomy: n = 2, mitral valve replacement n = 2, resection of subaortic stenosis: n = 1, resection of coarctation: n = 2,VSD-closura: n = 1 ) were performed in 6 patients. RV contractility and pulmonary vascular mechanics(PVM) in immature animal models are poorly underslood. We developed an acute RV injury model to measure RV contractility and PVM in response to commonly used cateehalamines. Ten anesthetized piglets (9-12kg) were instrumented with micromanometers in the LV, RV, PA, and LA. A pulmonary artery flow probe was placed to measure cardiac output(Qpa). Ultrasonic dimension crystals were sutured to the myocardium and dynamic chamber volumes estimated using shell subtraction methodology. RV injury was induced with 3-7 cryoprobe injuries at -50 to -70°C for 3-4 minmes each. DA at 10mg/kg/min, DB at 10mg/kg/min, and EP at 0.1 mg/kg/min were infused in random order. RV contractility was evaluated by calculating a load independent measure of contractility, the preload recmitable stroke work(PRSW), during vena caval occlusions. To describe PVM, input resistanceS), characteristic impedance(Z0), total pewer(TP), and efficieacy 03f=QimO"P) were measured. Measurements were made pre-and post-injury, during infusions, and between infusions. Clyoablation decreased PRSW (22.8_+7.8 to 13.8+4.1, p<0.001). At the end of the experiment, PRSW remained depressed to this level indicating stability of the model. One factor contributing to organ dysfunction for infants undergoing repair of congenital heart defects (CHD) is their "inflammatory response" to cardiopulmonary bypass (CPB). This response is characterized by an increase in cytokine release, complement activation and endothelial injury. Modified ultrafiltration (MUF) is a method for removing tissue water and inflammatory mediators by rapid ultrafiltration followin~ CPB, MUF may acutely improve post-operative end organ function. In this study, we evaluated the effects of MUF on the pulmonary and cerebral function of infants undergoing CPB for repair of CHD. We prosnecrivety randomized 30 infants (.~ 5 mos) to either MUF (n=16) or no MUF (n=14)(Control) following correction for CHD. The study intervals were 1) before CPB, 2) immediately after CPB, and 3) 20minutes after CPB. Pulmonary function was evaluated by measuring dynamic compliance (Cdyn) and airway resistance (Raw). For 13 pts (MUE=6 pts; Control=7 pts) exposed to a period of deep hypothermie circulatory arrest (DHCA), cerebral metabolism (CMRO2) was calculated at each interval using the Xe 133 clearance technique for cerebral blood flow measurements and arterial and jugular bulb saturation measurements to calculate CMRO2. A reduction in CMRO2 has been consistently demonstrated after DHCA. The effects of MUF on Cdyn and on CMRO2 are shown below: p<0.05 vs pre-CPB; # p<0.05 vs post-CPB • p--O.06 vs. post-CPB This study demonstrates that immediately following exposure to CPB, MUF will improve pulmonary compliance. Raw was not different between groups. There was no significant difference in hours of post-op ventilation for either group. In those pts exposed to DHCA a trend towards better cerebral metabolic recovery compared to control was demonstrated. This is the first technique applied to infants undergoing DHCA where CMRO2 after CPB was greater than preCPB measm~s. Although this may be beneficial to postoperative hemodynamics, ventilatory management and long-term neurologic recovery, more patients and longer follow up will be necessary to verify such an effect. The effects of conventional mechanical ventilation (CMV) on left ventricular (LV). diastolic filling in neonates are not well established. One approach to improve LV filling is the use of CMV to provide a phasic increase in airway pressure {thoracic augmentation). This phasic increase in airway pressure may result in an increase in LV filling similar to that which occurs with CPR. Thoracic augmentation has not been evaluated in neonates with ventricular dysfunction who frequently demonstrate increased heart rates. Attempts to maintain low peak airway pressures during CMV may result in a prolonged inspiratory time that occurs over multiple cardiac cycles. This may alter LV filling in the later cardiac cycles. To determine the effects of inspiratory time on LV diastolic filling, 10 infants were examined with Doppler echocardiography less than 24 hrs after surgery for the arterial switch procedtme. Pulsed Doppler recordings of the millal valve (MV) were obtained with the inspiratory time adjusted to occur over 3 cardiac cycles (21 sec.). A pressure transducer was placed in line with the ventilator, and the respiratory cycle was recorded superimposed on the Doppler tracing to provide accurate determination of inspiration and expiration. Doppler recordings were obtained from the apical 4-chamber view and the following measurements were made: peak E and peak A velocities, EIA ratio, and deceleration time. Compared to the expiratory phase of CMV, the initial beat during the iuspiratory phase of CMV resulted in an increase in MV peak E (.53 +-.06 vs .65 -+ .08 m/s, p<0.05) and peak A (.47 + .07 vs .63 -+ .09 m/s, p<0.05) velocities with no change in MV deceleration times (p<.01). Compared to the initial beat during tile inspiratory phase, the third beat during the inspiratory phase resulted in decreased peak E (.65 + .08 vs .40 + .05 m/s, p<0.05) and peak A (.63 + .09 vs .40 + .05 m/s, p<0.05) velocities with no difference in deceleration times. Thus, CMV augments LV filling during the initial phase of inspiration. However, as the increase in airway pressure is distributed over multiple cardiac cycles, LV filling falls below baseline levels. These observations indicate that while thoracic augmentation may be beneficial, to optimize LV filling the inspiratory time of CMV must be < 3 cardiac cycles. Energy expenditure in pediatric orthotopic liver tranaplantat~on, To determine the actual calorie requirements of critically ill children and evniuate the correlations between measured, stress-p~lictod and repleted energy exponditttm and the severity of illness. Des/gn: A prospective, dinlcal study. Se~ng: Tertiary care pediatric ICU in a university hospital. Patients: Ten patients aged 6 to 210 months with disorders prompting PICU admission, including sepsis, respiratory failure, solid organ transplantation, and cardiovascular surgery. Inta~entions: All patients were studied within 24 hrs of major surgery or transplantation, or following acute illness. All patienls were severely stressed clinically and all but two were intubated by cuffed tubes, In three of them, still in a stress state, the study repeated on the third day of the disease, Energy expenditure mensurements (MEE), as well as illness seventy scoring systems, mtfltisystern organ failure scores and various anthropemetric and clinical indices of nutritional status, the stress-predicted energy expenditure (S-PEE), the basal metabufie rote (PBMR), the repleted energy (RE) and the recommended dietary allowances (RDA) were measured or calculated in each patient. Multiple regression analysis was used to analyze the data. Measurements and Main Results: Although the mean MEE was significantly lower than the mean S-PEE (37.6+11 kcal/kg/day vs. 50.35:16 kcal/kg/day, p<.002), it did not differ significantly from the PBMR (mean difference -2.62 kcal/kg/day, range -10.07 to +9.06 kcal/kg/day). The S-PEE/MEE ratio ranged from 1.04 to 2.07, while the RE/RDA ratio (21.25:4 kcal/kg/day)/(75.85:7 kcal/kg/dny) ranged from only .1 to .5. The PRISM/TISS ratio was not correlated better with MEE than the diagnostic category (r~=.36 vs..38, respectively). The RE was positively correlated withthe MEE (rZ=.65, I)=.07) while negative oarrelatian has been found between MEE and age, mid-arm circumference, triceps skinfotd and the use of vaseactive agents (r~.81, -88, -.67, p<.005 and -.71 resp~lively). Concl.m~: If S-PEE is used for caloric repletion in the stressed oritic~ly fll el~d, these patients will be substantially overfed by as much as 100%. Although PBMR appears to approximate the MEE by ±10%, other clinical and nutritional indices should also be ennsidered. Objective: To deter .mine..t.he metabpli.c and.nutritional state of mechanically ventilated intants and children m relatmn wlm severity or msease. Patients and methods: 37 Mechanically ventilated infants and children, median age 7 months (range 3 days to 13years), were studied. Severity of illness was assessed using PRISM, PRISM-II~ and fISS-scores. Oxygen consumption (VO2), energy expenditure (MEE) and respiratory quotient (RQ) were determmed by mdirect calorimetry. Total urinary nitroger(TUN) and creatinine excretion, levels of albumin and CRP were aetermmed in 16 patients. In these patients daily caloric intake and substrate utilization were assessed. They were categorized in subgroups: A partial feeding (recent admission to P1CU); B complete feeding. Results: MEE of the total group (n=37) 0A) I=intake g/kg/day (% total intake); U=utilization g/kg/day (% total production). Nitrogenba]ance was negative in all patients in group A (mean -227.7 --176:4 mffkg/day) and positive in all but one patient in group B (.mean 84.9±109.D n~g/..kg/day;p=0.001). No significant correlations were round between creatinine height index, CRP, albumine, JUN vs v u2/Kg Conclusions: The mean measured energy expenditure does not exceed predicted resting energy expenditure, but ~ere is a wide range. In a majority ot patients with complete feeding h.igh carbohydrate intake resulted, in High KQ and lipogenesis. In patients witla partial teeding the highly negatwe nitrogen'balance suggests that in the early phase of diseasean higher protein intake should be provided. Severity of illness scores ann oiocnemicm markers of physiologic stress correlatedpoorly with oxygen consumption. LEITE,HP; IGLESIAS, S; FARIA, C; IKEDA, A; ALBUQUERQUE, MP; CARVALHO, WB Pediatric ICU -S~o Paulo Federal University -S~o Paulo, Brazil Objectives: 1 ) to evaluate patterns of use and monitoring of nutritional support in critically ill children; 2) to evaluate an education program in nutrition support given throughout the resident physician training in the Pediatric ICU. Patients and methods: records of 37 patients receiving nutritional support during 1993 were reviewed. Aider this first phase, knowledge and understanding of the role of nutrition support was conveyed to the residents through didactic lectures. In a second phase thedata were reevaluated in 35 children who were given nutrition support in 1995. Results: From a total of 425 days ofthempy, the single parenteral route was utilized in 80,5%, the digestive route (tube feeding or oral route) in 19,5%. of this time. A previous nutr~ional assessment was performed in 3 children; no patient had the nutr~on goals set. The nitrogen to nonprotein calories ratio ranged among 1:80 and 1:250. Only 29,7% of the patients had their estimated caloric needs supplied and this goal was achieved only in those patients who were on enteral tube feeding. Patients did not achieved their goals for vitamins. The supply ofoligonleme~s was adequate except the zinc. Nutritional monitoring parameters including weight, serum albumin and serum triglycerides were performed in almost all the patients but without uniformity. The reevaluation ofthase parameters showed adequacy of protein and micronutrients supply; however deficiency in nutritional monitoring and infrequent enteral feeding were still detected. Conclusion: There were lacks in the implementation of nutritional support, which were partially corrected in the 2rid phase of the study, Although the training of residents may have contributed to give them cognitive skills, it didn't changed policies and procedures as desired. We recommend reinforcement of the education program concerning basic nutritional aspects, and the organization ofa multidisciplinary team in charge of coordinating the providing of nutritional support. Plasme free fatty acids (FFA) are the meier energy source for mast tissues. During fasting FFA are released from the breakdown af triglycefides in edipose lissue (AT). Lipalysis, Le. the rote of release o/ FFA, has been meGsured in humans by means of stable isotope techniques using labeled PA or glyeerd as traces. No information is avoilob!e Io dale on the Ro of LA. We infused albumin hound U13C-PA and U13C-LA in 7 critically ill infants, receiving 20 kcel/kg/doy of IV glucose end na oral feeding (weight 3.6,i.,3 kg;, range 1.9-5.8; ego 57:64 days, range 1 149) and measured simultaneously the Ra of PA and LA from (he isotopic enrichment of plasma FEA by gas chromatography-mass speclrome|ry ai 1:50, 2:00 and 2:10 hours from tile shod of the infusion. A subcutaneous gluted AT biopsy was obtained far fatty acid (FA) composition. We intended to (1) In fie infants sbJdied ATIPA ~'os hi9her than ATtLA (~pP>0.05) Reasons for the higher mortality rate on the paediatric ward likely include the higher patient:nurse ratio, and more limited resources. A predictor of mortality based on simple physiological observations without the need for expensive blood tests and including chronic health status would be a useful tool. The establishment of a paediatric intensive care unit is proposed to redress the balance of care. To assess the performance of the Pediatric Intensive Care Unit of Hospital Dona Estef~nia by an international standard score, the authors did a prospective study of 1149 consecutive admissions to the Unit during a period of 29 months. Mean age was 50.63 _+ 54.07 months; mean lengh of stay was 3.16 + 5.59 days. The effectiveness and efficiency were determined by the admission PRISM. Admission efficiency was defined by two criteria: a) mortality risk > 1% or b) the administration of at least one Intensive Care Unit-dependent therapy. The cumulative observed mortality was 5.57% and the expected mortality was 5.97%, with a Standardized Mortality Ratio (SMR) = 0.933. The overall performance of the PRISM score-based predictive model was found to be good (goodness-of-fit test x2 [5] = 6.387;p=0.271). Of 1149 patients admitted, combining the two criteria (ICUdependent therapy and mortality risk) an admission efficiency of 825 (71.8%) was found, equating to 3263 (89.94%) of 3628 1CU days. CONCLUSION: In our study the assessment of the admission efficiency and of the effectiveness of the Unit was possible by using the PRISM score of admission. There was no significant difference between mean values for OTISS and NTISS)in Level l patients (P=0.12 paired t-test).For level 2 and 3 patients mean value of NTISS was greater than OTISS (P<0.0001). There was a significant correlation between levels using either NTISS or OTISS (mean difference Level 1 and 2, Level 2 and 3, ( P < o.oool). Conclusions: A new TISS has been developed and used in a PICU. Nurses were able to accurately score the interventions on their shift. The assignment of patients to intensive care levels correlates with TISS values allowing a quantitative measure of severity. Objective : to compare the rate of cerebral palsy (CP) between monochorionic-twins, dichorionic-twins and singletons born at 25 to 32 weeks' gestation. Design : two-year prospective cohort study. Setting : geographically defined study (region of Franche-Comt~., FRANCE). Main outcome measures : type of plasentation was obtained by anatomopathological, or macroscopic examination of placenta and comparison of 6 twins' blood-groups. Neurological assessment was performed at two years of age (uncorrected for gestational age) by family doctor (pediatrician or physician), or neonatologist of the ICU at tertiary center. Sample : 167 of 17I survivors aged of two years (98% follow-up rate), born between 09/30/90 and 10/01192. Triplets and chromosomic malformation were non included. Results : Thirteen (11%) of the 119 singletons had CP.vs 3/29 (10%) of dichorionic twins and 6/19 (32%) of monochorionic twins (p=0.04). Four of the 19 monochorionic twins (21%), 2/29 dichorionic twins (10%) and 4/119 (3%) Nngletons suffer from quadriplegia (p<0.01).In a multivariate approach, monochorionic twin placentation was the strongest risk-factor of cerebral palsy (OR=9.7, IC 95% = 2A-39, p<6.01). Others risk-factors of CP were : lack of father's profession (OR 11, p<0 .03), maternal antecedent of abortion (OR 3.2, 1-10, p<0.04), vaginal delivery (OR 3.4, 1-11, p<0.03), hyaline membrane disease (OR 3.4, 1.2-t0, ~0.02). Discussion : this is the first population-based study to uplight the role of monochorial twin-placentation as a strong risk factor of CP for premature infants. CP is more severe in monochodonic twins than in other infants. Mecanism of cerebraT deficiency is not clear since none of our infants with CP was survivor of an in utero cotwin's death, and none of these infants was exposed to twin to twin transfusion syndrome. Were these monochorionic-twins affected by an undiagnosed neurological structural defect that could lead both to prematurity and handicap remains an open question, A vital role of the intensivist is to ensure that knowledge and practice are imparted to trainees in the ICU so that patients receive optimal care. Teaching effectiveness varies widely leaving gaps in knowledge and practice in the trainee. Being an effective teacher should not be a "gift" of a privileged few. The ICU provides a fertile ground for using a variety of methods for teaching, e.g. didactic, at the bedside, emergencies, and in the performance ofproeeAures. In this environment, much can be learned. We have embarked upon a program to facilitate this learning process. I) Teaching needs to be recognized as the foundation of good clinical care, i.e., patient related, and in its ability to generate discussion and research investigation. 2) Teaching structurally has many components including the speaker, audience, varying situations, and the message delivered. 3) Establishment of a program using these components to enhance teaching abilities at all levels, a) Evaluate base-line teaching skills initially, b) Individualize interventions to improve teaching skills, e) Demonstration of learned skills with re-evaluation. This process is analogous to the analysis of a clinical disorder in a patient which, once recognized, interventions are then instituted and then re-evaluated. 4) Instill the desire to use these attained skills to teach and interest others to teach. Teaching excellence should be recognized through awards, honors, and academic advancement. A major emphasis of this program is to provide participants with skills necessary to teach thought processes, decision-making skills (what to do, what to avoid) and implementing appropriate management during stressful emergency situations common to the PICU. Introduction: Many" e-mail based discussion groups exist on the Internet to provide medical professionals with a rapidly responsive medium for the international exchange of ideas relating to patient care. Several such lists each serve more than a thousand professionals in more than 30 countries, each distributing a dozen or more messages each day to every subscriber. There is very little known about the time being spent by professionals interacting with these lists, and very little known about the impact of the discussions on patient care. We wished to test the hypothesis that these discussion groups provide infortuation which is being used to change the care of individual patients and the general approach to patient problems. Methods: In early January 1996 a pilot electronic survey was sent to a small fraction (N=63) of the memberships of 2 e-mail discussion groups, PICU@its.mew.edu, and NICU-NET@u.washington.edu (the full memberships of both. groups (N=t439 for NICU-NET, N=1045 for PICU) will be surveyed in early February of 1996). Participants were asked for demographic information, experience and skill level relating to e-mail, time spent with the discussion groups, perceived usefulness of different types of discussions, and the ways in which the discussions were used clinically. The pilot study was analyzed for construct validity by correlating an overall assessment question with a summary of the specific questions. Scale reliability was measured by Cronbach's alpha statistic. Results: The pilot survey response rate was 30163 (48%). The majority of respondents were male physicians, with an average age of 39+_5 years, who had completed subspecialty training in intensive care, and were working at a university-affiliated hospital. Most had been using e-malt for more than 6 months, and considered themselves moderately adept in that use. 63% felt that the list helped weekly to keep them informed about current issues and practices in their field(s), and 57% felt that, at least monthly, they used information from the list(s) that was not readily available in medical journals. Overall, 75% agreed that the list improved their professional competency. When asked to compare the value of 6 months of membership on an e-mail discussion group with more traditional educational media, 34% compared it with attending a national conference, and 26% compared it to a journal subscription. Cronbach's alpha was .76, Construct validity testing yielded coeff=.50, p <.05. Conclusior~: Internet-based e-mail discussion groups for health care professionals can be an important part of a strategy for maintaining professional competency. Despite the very low cost of this medium for most, the value is felt to be comparable to that of t~r more expensive forums for education. Further study will include distribution of the full survey in early February of 1996. Fronk Shann, Tony Slater, Gale Pearson and the PIM Study Group We have developed a new score for predicting the risk of mortality in children admitted to intensive care. The score is calculated from only seven variables collected at the time of admission to ICU: mechanical ventilation (yes/no), booked admission after elective surgery (yes/no), the presence of any one of 14 specified underlying conditions, both pupils fixed to light (yes/no), the base excess, the PaO 2 divided by the FiO2, and the systolic blood pressure. Most scores used to predict outcome in intensive care require the collection of a large number of variables (so many ICUs do not calculate them routinely), and they use the worst value of each variable in the first 24 hours in intensive care. This means they appear to be more accurate than they really are (about 40% of child deaths in ICU occur in the first 24 hours -so they are diagnosing these deaths rather than predicting them), and they blurr the differences between traits (a child admitted to a good unit who recovers will have a low score; but the same child who is mismanaged in a bad unit will have a high score -the bad unit's high mortality rate will be incorrectly attributed to its having sicker patients). PIM was developed in the PICU at the Royal Children's Hospital in Melbourne, and has been tested in six other PICUs in Australia and one in the UK. Objectives: To study the characteristics of the muhiorgan dysfunction syndrome (MDS) in children. Methods: A retrospective study with all the children with MDS diagnosed from January 1990 to June 1995 is presented. 173 children fulfilled the Wilkinson criteria (I). In all of them the number of organs affected and the PRIMS score were determined during the first 24 hours. Several groups were performed according to the clinical diagnosis, the hospital of origin and the order of organs affected. Results: The 173 subjects studied were an 8% of the Pediatric Intensive Care Unit admissions. 100 of them expired (58%). No differences in age, sex and weight were observed between the children dying and the survivals. The most common causes of MDS were sepsis, both nosocomial (25%) and medingococcal (I4%) and acute respiratory failure. Sixty-fivepercent of the patients were from the hospital wards and the remaining were directly admitted to the PIGU from the Emergency room. The systems affected were: respiratory (93%), cardiovascular (92%), hematologic (61%), central nervous system (52%), renal (43%) and (hepatic) liver (28%). The organs initially failing were: heart (39%), tung (28%) and central nervous system (18%). The children dying had a larger number of organs with failure than the survivors (3.89 v,s. 3.34, p<0.001).The PRMIS score was higher in the children expiring than in the survivors (22.4 v.s. 17, p <0.001). S.mmary: The MDS is a common pathology in PICU, with a high mortality, The mortality is higher in children with a larger number of organs affected and a higher PRISM score. Sepsis is the most common etiulogy. Methods : From June Ist to July 15th 1995, all patients admitted to the pediatric ICU were included. The score was measured at day 1 (D1) and day 3 (D3) and we used 10 variables. For each organ system, we defined 2 categories : dysfunction or failure, which we respectively confered 1 or 4 points. Results : 56 patients were admitted : 22 newborns, 34 children. 23 were medical and 33 were surgical patients. 36 (64 %) patients had two or more organ failure at the admission, 12 (21,4 %) patients died, which 6 (50 %) in the first 48 hours. The mortality rate was the same for children with two or more organ faiIure at D1 and D3 : 6/36 (16,6 %) at D1, 4/22 (18,2 %) at D3. The mean score is different for children who survived or who died : 8,6 versus 17,9 at D1 ; 10,6 versus 18,2 at 133. When the score is > 15, the mortality rate is significant. Conclusion : In this study, there is a good correlation between the score of severity and the mortality rate but we have few included patients. We need a prospective multicentric study to assess these results and we must compare this score to other scores of severity used in PICU. Back.qround: Injury to the Central nervous system is the cause of death in the majority of pediatric trauma victims, Studies have identified a wide range of factors associated with poor outcome from brain injury. However, when single features are analyzed, they are not sufficiently accurate predictors. Few studies have used a multivariate analysis of these factors and pediatric outcome, Methods: Clinical and radiographic features of 164 comatose children after traumatic brain injury were analyzed, Clinical parameters, the initial cranial CT scan, and demographic characteristics were analyzed for an association with death or vegetative survival at 6 months. A tree diagram in which risk factors may differ within the study subpopulations was constructed using recursive partitioning. Results: Chitdren with a motor score _<2 had an 11-fold increased risk of poor outcome compared to those with motor scores >2. Among patients with scores of _<2, those with abnormal pupillary reflexes experienced a 13-fold increased risk of death compared to those with normal pupillary reflexes. Among patients with a motor score >2, an intracranial diagnosis code (no pathology, mild shift _<5 mm, swelling, shift >5 mm, surgical mass lesions, or non-operative mass lesions) was highly predicative of poor outcome at 6 months. Children with CT findings other than normal or mild swelling had a 4-fold increased risk of poor outcome. Of children with swelling, shift or mass lesions, the pupillary light reflex was associated with outcome. Children with abnormal pupils had a 6-fold increased risk of poor outcome. Discussion: A few clinical and radiographic features stratified comatose children into fairly distinct risk groups. Information available early after traumatic brain injury in comatose children provides useful prognostic information on the likelihood of death or devastating injury. A retrospective study of 70 children with the diagnosis of epidural hematoma was made during 1990-1995 period. Ages ranged between 7 days and 17 years (18% less than 1 year, 40% between 1 and 10 years, and 42% older than 10 years), 82% of them were admitted at the PICU. 51% of the cases were due to falls, 35% to road traffic accident and 14% to other causes. On admission GCS was less than 8 in 19% of the cases and more than 14 in 53%. Diagnosis was made during first 4 hours in 63% of patients and delayed more than 12 hours in 28% of them. Neurologic impairment was present at admission in 33% of patients, and delayed in 30%. Even so,27% remained without impairment. Radiological findings at first CT were skull fracture (68%); epidural hematoma localization was: in the right side (63%), frontal area (24%), temporoparietal (66%) and occipital (t0%). Associated lesions were: several (13%) or unilateral (51%) cerebral contusions, diffuse brain oedema (10%), unilateral hemispheric oedema (14%) and 38% showed shifted middle line. Four patients died, half of them during the first 24 hours. 41 fully recovered (58.6%) and 25 have sequelae of different nature :7 were left with severe motor disability (10%); at the follow-up t3 have some degree of neurodisability. Next datas keep correlation with death or neurosurgical impairment: only were significative multiple cerebral contusion (p=0.002) and brain oedema (p=0.05), GCS less than 8 at the admission (p--0.002), shock (p=0.003) and remaining cerebral contusion in control CT correlated with death or diasability at discharge. On the other hand, neither surgical drainage volume nor first or highest levels of ICP (12 cases),nor pupillary abnormalities (10 cases) correlated with worse prognosis. Conclusion: GCS equal or less than 8 an shock are main factors related to worse prognosis, also multiple cerebral contusions in CT and diffuse brain oedema. The results of a modified GCS were compared to outcome and intensive therapy in 78 children (mean age 8,5t4,7 years) with head and associated injuries (53,6% of all cases) of different causes (traffic accidents, falls). The GCS was regularly used inn the course of intensive therapy. According to our own and other experiences the GCS was divided in 3 stages: stage 1 (4-8 points), stage 2 (9-12 points) und stage 3 (13-19 points) palhuiugy wile sP, tdhlg c~'lcb1al blood ~0w. Sabgcqucntl}. rhc slat,: reRltncd to t1011tl,91 Iiltlils. the p0st,~pem~v~ b}i~g wiJ!!,:q1! ,:_a!~p!ica!J0n~:. 4 ri~;¢ ill the level of sensibflizatJou lo tile cerebn~ anhgrns up to 1t.4-o7 was flofcd iu 9 I,alicnts. There wa.~ al~ iuclt~a~e ill cerebral vdociiJ,. ~m d~;'ati0a il~ p¢fiphc~ai re~ista/isc of the large ce~'bral ve~ds. Neur0h;~c ~:yn'.pt,m~at0!a~, (s::mno!en~', _r_uscu!~r l~:pot0ni& !ryper*'flema) was nbserwed tu lt~ese pal~enls o. cbruc~l ~0nnds. rile ple~c.ut abse~vafion~ suggesl ihal die ~tttdy at" Ihe stale ~f hematocr~chcplm/itic bm~ic~ in ckil&en with 31110oN emergensy is of abviou.~ !?ece~siB; in cO~.Te ctin g severe pa~0lo2~-i~mnediately f0U0wing Ne ,:~per,'~fion. Background: Reconstruction of the heart by three-dimensional (3D) echocardiography provided new information on anatomy of complex congenital heart defects, We assessed the utility of 3D ultrasound in detecting morphological changes in cerebral anatomy in newborns before and after cardiac surgery. Methods: Transfontanel cross-sectional ultrasound, scans were obtained in standardized coronal and median sagittal planes. Subsequently, rotational scanning was used to acquire the multiple sequential crosssections of the brain. For rotational scanning, a conventional 5 MHz transducer was rotated 180 degrees.Scanning took less than one minute and required no sedation, Data was stored in the image processing computer which allowed for off-line three dimensional reconstruction of different brain regions.Twelve infants aged 3 -21 (median 7) days were assessed before and after cardiac surgery, Results: Cavity of lateral ventricle, choroid plexus and the periventricular brain parenchyma could be reconstructed in all. Accurate estimation of size and volume of lateral ventricle, aqueduct, and other ultrasonographic visible pathological brain lesions could be performed. Reconstruction of various brain areas was accomplished in 3-10 minutes. The localisation and extension of severe periventricular hemorrhage which was detected preoperatively in one infants was better visualized than in conventional ultrasonography. Epicortical and subarachnoidal space could be reconstructed in all and allowed detection of hemorrhage in one case which was not detected by conventional ultrasound. Conclusion: 3D reconstruction of different areas of the brain may provide additional quantitative information on size and volume of the internal ventricle and choroid plexus, and better understanding of the topographical aspects and the extension of intra-and periventricular hemorrhage than conventional cross-sectional ultrasound. Introduction: Intracranial cerebral blood has been estimated to be 70% venous, The invasive measurment of venous blood saturation in the jugular bulb provides quantitative information on cerebral oxygen supply and consumption. However, routine oxymetric measurement of blood saturation in the jugular bulb by insertion of a catheter line into the internal jugtdar vein is an invasive procedure which has limited use especially in infants and young children. Thus the aim of this study was to investigate the correlation between the non-invasive spectroscopic measurement of rSO2 and the oxymetric determination of the blood saturation in the jugular bulb in infants and children undergoing routine cardiac catheterization.. Methods: During routine cardiac catheterization 30 infants and children (age 5 day-16 year, median 4,5 year) the rSO2 was measured continuously using a two chanel cerebral oxymeter (INVOS 3100A). The sensor was placed in standardized location at the left temporal head side. After the routine oxymetric blood sampling in the superior vena cava the oxymetric catheter was manupilated into the left jugular bulb. After control of the catheter position simultenuous values of the rSO2 were documented. Results: Over a range of (33-87%) SjO2, a significant linear correlation was found between the spectroscopic measurement of rSO2 and the oxymetric determination of venous blood saturation in the jugular bulb (r=0,83, p<0,001) and the superior vena cava (r=0,65, p<0,05). No significant correlation was found between rSO2 and the arterial blood saturation in the descending aorta and as well as to the standared hemodynamic parameters. Conclusion: Meusurement of rSO2 by MRS may provide continuous non-invasive information on cerebral venous blood saturation and thereby possibly on cerebral oxygen supply and consumption in infants and children. These may be of clinical value particulary during and immediately after heart surgery by means of non-pulsatile cardiopulmonary bypass. Information on refractory status epilepticus (RSE) from developing countries is scarce. We analysed 43 cases of RSE admitted over last 2 yrs. The objective was to study etiology end evaluate efficacy of diezepam infusion. Median age of the patients was 1.25 years Irange 1.5 months to t 1.5 yrs); 70% were boys. Onset of seizures was 1-t44 hours (median 24 hours) prior to hespitalisation. The Glasgow Coma Scale score ranged from 3.11 (mean+SD 5 + 2). The commonest underlying causes were acute CNS infections (26/43, 60%; bacterial meningitis, 16, encephalitis, 10) and epilepsy (8/43, 10%). Oiazepam infusion in incremental dose (range 0.01-0.025 mg/kg/min) was used in 38 patients over 3.4_+2.1 days. Seizures were controlled n 31 (82%), Mechanical ventilation was required in 10 (26%)only, while none had hypotension; 84% patients survived. Thiopental infusion (holus 5 mg/kg followed by 0.2 mglkg/min, and increments of 0.1 mg/kg/min till seizure control) was used in 8 patients over 1.7_+0.7 days; seizure were controlled in all, but five patients needed mechanical ventilation, six developed hypotension needing infusion of vasopressoi drugs, 3 out of 8 (38%) died, Overall mortality was 26%, mainly due to acute CNS infections (n-6) and prolonged SE. The patient was a 2-year-old gift di~aosed of Dov,~'s s~drom¢, Tetralogy of Fallot. (T.F.) Before admission a vasovagal crisis after coughing and vomiting was seen, and she was taken to the emergency room. Mother said she had eyanosis in the mucous membranes of the mouth with exercise.On physical examination, she ~as afebrile, normal fundi and neurologic examination was normal. A harsh systolic murmur was hear~ with decrased intensity during bradycardia. Chest RX disclosed a decreased pulmonary vascular markings. ECG: synus rhythm, with bradycardia and nodal escape rhyflmas. She was transferred to our PICU because of severe h3,pertomc seizure, lost conciousness, and deeembrate poslamng~ ~t cyancx~is. The episode lasted for ~weral seconds, and ceased v~th diazepam. On admission she was lethargy, and neurologlc exammation showed weakness of left leg without Babinski, and normal funduscopic. The patient had two episodes of bradycardia and isoproterenol was begun. During those episodes the patient was cyanotic, and the murmur was heard with the same intensity. ACT scan disclosed a tight parieto-temporai abscess with midline shift, lnmediately after the diagnostic CT, we administered antibiotics, antiedema treatment and it was drained. The abscess culture was negative. A CT control disclosed air and midlme shift. ~ the next two days she had three episodes of h39oxia and c'yauosis ceased with o@gen, morphine and propanoloL The patient died during a fourth episode. DISCUSSION: Arrhytmias are uncommon in patients with Tetralogy of Fallot before surgery. In our case the first diagnosis was sick sinus syndrome vs bradycardia secondary to cyanotic episodes. The incidence of cerebral abscess in children with congenital heart disease (CHD) is approximately 5%. Tetralogy of Fallot is the most common associated lesion, and is unusual in children under 2 years of age. CONCLUSION: 1) Brain abscess is a rare complication of patients with cyanotic CHD, but should be suggested in patients with °'apparent" sick sinus syndrome. In patients with Down's syndrome, T.F.,with cyanotic episodes, and difficult neurologic exploration, a brain CT scan is recommended. Guillain-Ba~re syndrome (GBS) is an acute autoimmune reaction, directed primarily toward the myelin encasing the peripheral motor nerves= This reaction causes a delay or block in nerve conduction. The presentation often can be very subtle but is followed by rapid loss of neuromuscular power, leading to acute respiratory distress, resulting from weakness of muscles and aspiration pneumonia. There were 3 boys -4, 8, and I I years old with GBS, treated in our ICU. Two of them due to the respiratory distress were intubated nasotracheally and ventilated mechanically with SERVO-9OOC (Siemens-Elema, Sweden) ventilator. Duration of ventilation was I I and 34 days, respectively. Plasma exchange was performed in all cases. The numbers of plasma exchange sessions were 2-4 in each case. Mean amount of plasma exchanged per session was 28,24 ml/kg. Plasma was substituted with albumin, plasma or saline. The most important aspect of the management of patients with GBS in the ICU involves the airway care, prevention and treatment of aspiration pneumonia and the mechanical ventilation if respiratory distress presents. Endotracheal intubation should be performed whenever there is evidence of retention of pulmonary secretions, refractory to chest physical therapy, weakness of protective reflexes of the airway, leading to aspiration pneumonia and (or) atelecr~sis. Cardiac arrhithmias too, is a main threat to the circulatory stability in GBS. Therapeutic plasmapharesis has been shown to be beneficial, reducing the time for weaning from the ventilator and for achieving independent ambulation. However, plasma exchange is expensive and not without significant risks for the patient. Some authors find that plasmapheresis is not effective for patients with fulminant course of GBS and blocking of nerve conduction. Recent studies have demonstrated that intravenous high-dose immunoglobulin can be equally effective. There were no significant complications associated with plasma exchange. All presented patients survived without residual disability. Tetraparesis associated with long-term Paneuronium use in an infant. Paneuronium is a muscle relaxant used in ventilatory management of patients with respiratory distress in intensive care unit. After the end of sedation some patients were found to have severe tetraparesis. Paresis was accompanied by complete areflexia and diffuse atrophy of alt extremity muscles. This neuromuscular complication is caused by prolonged high-dosage pancuronium treatment. In the last 5 years, numerous reports have linked the use of pancuronium bromide with prolonged paralysis, disuse atrophy and areflexia. This side-effect is well known in adults patients but rare in a pediatric intensive care unit. We describe one pediatric observation of tetraparesis after prolonged pancuronium treatment in a 9-month-old girl, This female infant developed respiratory distress syndrome and was intubated and mechanically ventilated. To decrease chest wall rigidity pancuronium bromide was administered during 11 days. (she received approximately 120 mg of pancuronium bromide). On day 12 the drug was discontinued and the patient had severe tetraplegia and areflexia with normal head movements. Electromyograpliy showed absence of any disorder of neuromuscular transmission. This infant showed a recoveLy of muscles after 3 months. The other causes of peripheral neuropathies were eliminated. Electroencephalograms and head scans were normal. The recovery pattern observed in our patient correspond to the process of regeneration after axonal degeneration. It is suggested that these neuromuscular complications were caused by prolonged high-dosage pancuronium treatment (associated with cortieoid and aminoglucosides). Polyneuropathy syndrome in adult LC.U. appeared in literature in 1984 and is extremely common in long stay cases. The etiology of these disorders remains elusive. It is tempting to ascribe them to administration of drugs (muscle relaxants, steroids, aminoglycosidea), plolonged immobility, malutrition, sepsis and ischemia associated with reperfusion injury. To our knowledge there is only one case report of similar condition in a children I.C.U. (Pascucci 1990) We present a serie of 16 previously healthy children, aged 9 months to 13 years, who admitted in I.C.U with respiratory failure and who following weaning from M.V, remained in profound diffuse hypotonia with proximal and distal muscle weakness for various length of time, Recovery of muscle strength occured in a week or months {the longest I0 months), All children, except one, 3-4 days before admission developed symptoms of either respiratory or upper airway infection with fever. On admission viral and bacterial cultures were positive in 2 cases (Haemophilus influenze, Herpes virus). During treatment 9 patients became septic. Muscle histological and Neurophusiological investigations have not been done. Considering the multifactorial nature of the aquired NMD in adult critically ill pts, is impossible to attribute the muscle weakness of our pts to any specific cause, In conclusion, our findings suggest the need for further investigation of NMD in critically ill children treated in I.C.U. A van Esch, HA van Steen~l-M011, IR Ramtal, G Derksen-Lubsen, IDF Habbema. Febrile Status Epilepticus (FSE) is a prolonged and serious febrile seizure. Little is known about the outcome of FSE in neurologically normal children. This survey involved patients between 6 months and 6 years of age who had visited due to their first FSE, the Sophia Children's Hospital during the period of january 1981 till december 1991. Patients with a history of neurologic disorders were excluded. 57 Patients were identified, 65% were male. The cause of the fever remained unknown in 51% of the cases. In all case the FSE was generalized and it most frequently occurred at night (47%). The mean age at FSE was t.6 years (0.5-4.7), the mean temperature 39.6°C (38.5-40°C). The mean follow up time was 1.7 year. Twelve children (21%) had neurologic sequelea. The neurologic sequelae varied from speech deficit (4 case mild, V2 -1 year delayed; 4 case moderate > 1 year delayed) to severe retardation and epilepsy (4 cases). Speech deficit was detected after a mean period of 6 months (range 0-18), Age, gender, temperature, family history and time of onset were no significant risk factors for neurologic sequelae. Duration of seizure [RR 3.0 (0.8-11.3)] and more than two drugs to treat FSE (RR 5.2 (t.5-18.1) were related to neurologic sequelae. We recommend that FSE children should be followed for at least a year to detect possible speech disorders properly and start early intervention. UNUSUAL PRESENTATION OF MYASTHENLg GRA%qS IBtZA E. MODESTO ,V~ ABE~GOCHEA A, SANCH]S 1L AlL, GO L VARAS K FOLGADO S, GARCIA E. P.1.C.U. LA FE, Valencia. Spain CASE REPORT: The patient was a 2-year-o!d gift transferred to our PIC because of severe respiratory failure. The patient, convaleseem of ehiekenpox, came into contact with horse manure previous afternoon. In the morning, she was lethargy, and irritability, with poor finding, and ~ an episode of coughing, cyanosis and acute respiratory failure after mucous vomiting when she was drinking milk. On admission she had severe respiratory distress, respiratory acidosis, and the Sat 02 was 86%. She was mtubated without difficulty, and was transferred to our P.I.C.U. Physical examination reveals stable hemodynamies, pupils equal, round, reactive to light, normal fandi, and muscle relaxation. Crusted vesicles diseminats~d. Rhonehi over both lungs. Hepatomegaly (+) and splenomegaly (+). ~lhe urine, hematologic, and C.S.F. laboratory findings were normal. C.T. scan of the brain, E.E.G., and EKG. revealed no'abnormalities. Rx chest disclosed a retrocardiac atelectasis. Speci~ts of stool and blood were obtained for cultures and study of C. botul#num toxins. Pending receipt of these results, a broad-speotmm antibiotic and acyctovir was begun. The initial differennal diagnosis consisted of LARYNGOSPASM ASSOCIATED WITH ASPIRAqlON, botulism, and postmfecfious varicella encephalitis. After 15 hours, weatm~ was begun. The neurologic examination showed a low Modified Glasgow Coma ~ale (MGCS), generalized hypotouia and muscle weakness. These data suggested three diagnoses, posfnfecfious encephalitis, residual neuroumsoAar blockade, and excessive doses of sedative and analgesic drugs. After 20 hours she regained skeletal muscle poxver and ufltlcient respiratory effort, the MCGS was acceptable, and blood gases were normal. She was given n~-tigmine and atropine, and her tr~ma was extubated. An acute respiratory failure ocurrs 120 ram. after. Chest radioga'aph disclosed a left inferior lobe atelectasis. After 20 hours weaning begun~and the same episode w~as seen. At this point her mother stated that the girl showed weakness of the eyelids or extraneular muscles. It suggested myasthenic syndrome vs ~-Barr6 syndrome. C. botul#num toxins were negative, chotinesterase level ~as normal. Edrofoinum test ~as positive. Anti-acetyleholine receptor antibodies were negatives. E.M.G. confirmed MYASTHENIA GRAVIS (CONGENITAL vs JUVENILE serenegative). Pyridostigmine was begun and the trachea was extubated without complications. CONCLUSION: Din the differential diagnosis of weamng failure we must consider ~c gravis~ 2)Myasthenia Gravis could resemble encephalitis, because of low OCS, overall if is triggered by viral infection. 3)In some diseases (this case) GCS could not he an aemuate index of mental state. A BURGUET*, A MENGET*, E MONNET**, A GASCA-AVANZI*, C FROMENTIN*, H ALLEMAND**, JY PAUCHARD*, ML DALPHIN*. * R4animation Infantile Potyvaiente CHU St JACQUES 25030 BESANCON Cedex. ** D~padement de Sant6 Publique 25030 BESANCON Cedex, FRANCE, Objective : to point out that strabism iS) of one-year-old premature is a good predictor of a poor neurological outcome at two years of age. Design and setting : two-year prospective cohort study and geographically defined study (region of Franche-Comte, FRANCE). Main outcome measures : neurological assessment was performed at one and two years of age (uncorrected for gestationnal age). A mailing questionnaire was sent to the famity and fuU-filled by thefamily doctor (pediatrician or physician), or neonatologist of the ICU at tertiary center, S was diagnosed at one year of age by the examinator but S was not used to diagnose cerebral palsy (CP). Sample : 161 of 171 survivors (94%) evaluated at one and two years of age. Results : correlation of one and two years neurological evaluation is weak (kappa=0.5). Correlation of S at one year and CP at two year is fair (kappa=0,72). The goal of this paper is to review evidence related to hypothesis that the "waiting" axons and cells of the transient subplate zone may participate in the structural plasticity of the human cerebral cortex after perinataI brain damage (Kostovic et aL, Metabot Brain Res4:17, t989) and to correlate this phenomenon with different forms and mechanisms of structural plasticity. It is our basic assumption that all lesions occuring during cortical histogenesis will lead to more or less pronounced structural reorganization. Here we show that various components of the subplate zone participate in several forms of the structural "plastic" responses in the human cortex: modification of convolutional pattern, changes in size of cytoarchitecturat areas~ columnar reorganization, dendritic and synaptic plasticity. The etiological factors which induce lesions and subsequent plastic changes act via the following pathogenetic mechanisms: * disturbances of radial unit formation (Rakic); * changes in ingrowth of afferent fibres; * changes in the rate of normally occuring reorganisational events, depending on the critical period for a given histogenetic event. In the present study developmental lesions (localized perlventricular leukomalacia and haemorrhages) were demonstrated by ultrasound in live-born infants ranging between 26 to 40 weeks of gestation. In younger infants (24-34 w) who died shortly after birth, examination revealed lesions of the white matter with the preservation of the subplate zone. In infants who died one week of more after the lesion, we have observed localized micropolygyria, cavities, condensed layer VI -subplate zone, and columnations of the cortical plate. These changes are less prominent if the lesion occurs after diminishment of the subplate zone (after 34 w). Since in the fetal cortex the subplate zone serves as predominant source of growing fibers, transient neurons, trophic factors and contains cellular substrata for migration, this zone is the most likely candidate for major types of structural plasticity. In conclusion, cerebral cortex of the low -birthweight infants is more susceptible to the various lesions but shows vigorous structural plasticity and conspicuous functional recovery due to the growing, transiently located neuron at elements. The mortality due to meningoccocal sepsis is high in spite of important progress in emergency and intensive care medicine. During the last decade multiple scoring-systems have been developed in order to establish a therapeutic approach and to evaluate the final outcome of a meningococcal infection. Different clinical and biological data (shock, ecchymosis, peripheral WBC and platelet count, coagulopathy, acidosis, meningism, etc) are taken into consideration and the importance given to these data depends on the scoring-system used. A review of the different scoring-systems is given and a clinical case is presented. We report the case of a 4 year old male, who was transfered to our ICU 12 hours after onset of temperature and skin rash. The parents described a fast deterioration of his condition. The boy presented wide spread ecchymosis, high temperature, no signs of meningism, circulatory insufficiency and shock, coagulopathy and low peripheral WBC and platetet count. Disseminated intravascular coagulopathy developed promptly. The Glasgow Meningococcal Septicemia Prognostic Score (GMSS) was used and the obtained score reached the highest level (15/15). This corresponds to a 100% mortality. The patient required mechanical ventilation for 5 days. At admission he received human albumine, fresh frozen plasma, dexamethason, dopamine, dobutamine and a continuous infusion of adrenaline. Antibiotical treatment consisted of ceftdaxone. The evolution was favorable and the infant fully recovered. Retrospectively the GMSS was compared to other meningococcal scoring scales which gave the same mortality (100%). We conclude that the scoring-systems are important to evaluate the seriousness and to assess the therapeutic approach, but they should be used cautiously even when 100% mortality is predicted by several risk evaluations scoring-systems. The aim of this study was to assess the haemodynamic status on admission and the critical care management of children presenting with meningococcat infection. This was a retrospective study of the charts of 46 consecutive admissions. Mean age was 3.43 years (+/-3.46). The average duration of symptoms prior to admission was 20.4 hours (+/-14.09). On admission 17.4% were hypotensive, 45.6% had clinical signs of haemodynamic instability and 54.8% of cases that had a blood gas analysis on admission had a metabolic acidosis (Bases excess < -5.Q): The mortality rate was 10.9%. 80% of patients that died were hypotensive on admission and all had a metabolic acidosis. Of the 41 survivors 9.7% were hypotensive on admission, 39% had clinical signs of haemodynamic instability, 25% required invasive pressure monitoring and 7.3% were ventilated and received inotropic support. This study demonstrates that at the time of presentation with meningococcal infection children had a high incidence of established haemodynamic instability. Successful management of this infection is dependent on early presentation and initiation of therapy and on aggressive support of the cardiovascular and vital organ systems. Dept. of Intensive Care Medicine and Dept of Infectious Diseases, Our Lady's Hospital for Sick Children, Crumlin, Dublinl2, Ireland. Jude. Pediatric Intensive Care Unit, CH&U, 59037 LILLE-France. More than 10% of children surviving SIP (defined as purpura with shock) have SNLI. Objective. To search for a specific hemostatic profile in children with SNLI. Patients and methods. Between May 1989 and March 1995, 34 children with SIP were admitted to our PICU : 6 (17.6%) died and 28 (82.4%) ranged in age from 1 to 185 months (mean : 29) survived, 5 of them (17.8%) with SNLI (defined as the need of a surgical procedure). In survivors, two hemostasis studies (between H0 and H12, and 24 H later) included the determination of coagulation factors (routine tests), protein C (PC : amidolytic activity, Biogenic), total protein S (PS : ELISA, Stago), C4b binding protein (C4bBP : Laurell's technique, Stago), antithrombin3 (AT3 : chomogenic test, Stago), and plasminogen activator inhibitorl (PAIl : chromogenic test, Biopool). Three severity scores were determined at admission : French Group of Pediatric Intensive Care, Gedde-Dahl, and CRP. Statistical analysis used the Wilcoxon's test. Results. At admission (lst sample) severity scores and AT3, PC, PS, C4bBP levels were not different between the group with SNLI and the group without SNLI ; Quick time (22 4-5% vs 35 ± 14% ; p = .025), VtI+X (20 4. 3% vs 30 4-10% ; p = .04I) and PAll (105 4-157 UI/m! vs 580 4. 570 UI/ml ; p = .028) were lower in the group with SNLI. On the 2nd sample there was no difference between the two groups. Kinetics of hemostatic abnormalities was not different between the two groups. Conclusion. In the literature, intravascular coagulation (DIC), low fibronectin and AT3 were identified as predictors of SNLI, and a negative correlation was found between the mean size of the skin lesions and PC activity, AT3, and total PS. In this series, apart from DIC, there were no specific hemostatic abnormalities that support the use of treatments such as PC, AT3, and PAIl antibodies administration to prevent SNLI. Further studies including more children are needed. The aim of study was to investigate the efficacy of intravenous immunglobulin with enriched IgM content Pentaglob/n /Biotest/. In our pediatric intensive care unit ten septic children /group I/-their average age 2,6 years /SD:O,6/, 7 of them with Gramm negative and one with Gramm positive blood cultures, and two with unindentified bacteria-were treated with basis sepsis therapy and Pentaglobin. The application of Pentaglobin was as follows: 1,5 ml/kg loading dose for one hour, followed by a continuous intravenous infusion 0,1-0,4 ml/kg/hour depending on body temperatura /Lanser scheme/ for 72-96 hours. Another ten septic patients /control-group II/the mean age 2,5 years/SD:O,65/, their blood cultures were Gramm negative bacteria 6, positive 2, and the bacteria was not indentified in two cases -were treated with only the basis therapy. Results: the duration of intensive treatment decreased from an average 22,7 days /SD:8, min 12-max 38 days/ to 19,5 days /SD:5,2 min 9-max 25 days/ in the group treated wit Pentaglobin. The difference was significant /X 2 p<0,01/. In the group I nobody died, but three in the group II. Conclusion: the Pentaglobin therapy can improve the efficacy of the basis therapy of sepsis. Sinus bradycardia after an episode of sepsis is a rare symptom complex decribed in children with hematologic malignancies. We present a case of postsepsis bradycardia following severe typhlitis and septic shock in a 12 year old boy with relapse common ALL. Blood and ascitic fluid specimen grew Clostridium species and Pseudomonas aeruginosa. At surgery there was a necrotic gangrenous terminal ileum and cecum, requiring ileocecal bowel resection with ileostoma. While clinically recovering from sepsis he developed bradycardia for 120 hours. Extensive diagnositic procedures was given and the heart rate slowly increased to normal range of age. Postsepsis bradycardia in children with hematologic malignancies after an episode of sepsis is self-limiting and after careful differential diagnostics warrants an expectative attitude. Nitrate level is known to be enhanced during sepsis. Serum nitrate is the stable metabolic end-product of endogenous nitric oxide generation. Nitric oxide has demonstrated to be a powerful anti microbial final mediator and also a key molecule driving to the lethality of one of the most common complication of sepsis; the endotoxic shock. Such facts prompted us to investigate the possible diagnostic and/or prognostic value of monitoring serum level in high risk, presumptive and confirmed sepsis patients. Additionally we have explored the usefulness of this mediator as index of therapeutic response. In our study it is demonstrated that there is an important relationship between nitrate level and the occurrence of neonatal sepsis. Septic newborn group showed 6 fold higher nitrate level than that of healthy control group. In addition, the group of patients with high risk of sepsis which finally became septics, exhibited 3 fold higher nitrate level at 24-72 hours before the first symptoms appeared, when compare with those who did not develop sepsis. However in the presumptive sepsis group, there was no difference between the patients which finalIy ,&'ere considered septics and those which not. In all septic cases, after 7 days of a successful therapy with antibiotics, the level of nitrate diminish 3 fold. Our results suggest the utility of monitoring nitrate as index for the diagnosis of neonatal sepsis. The potential benefits of exchange transfusion, plasma exchange, and haemofiltration have all been described in children with overwhelming sepsis. However, little hard evidence exists to prove the benefits of any of these techniques. I have treated five patients with plasma exchange (PE), having been asked to see all these patients at a point when it was felt death was inevitable. Two of the patients had staphylococcal, two meningococcal and one enterococcal septicaemia. All patients showed a dramatic haemodynamic improvement following PE with improvement in blood pressure, reduction in inotrope requirement and improvement in tissue perfusion. Three patients survived. One of the patients with staphylococcal sepsis and both of the patients with meningococeal sepsis had developing gangrene of the limbs which showed remarkable reperfusion with PE. In two of the patients measurements of cardiac output (CO) and systemic vascular resistance (SVR) showed ~a reduction in CO and a rise in SVR over the course of a PE despite the reduction or cessation of vasoconstricting inotropes. Many believe haemofiltration is of value in septic shock. A trial with a no treatment limb is difficult to achieve. I believe we now have enough evidence to justify a controlled trial of haemofiltration versus plasma exchange in patients with septic shock and unstable haemodynamic status whilst on inotropic support. During the next several days, cough and chest pain suggested pulmonary embolism confirmed by radiologic evaluation. Echocardiographic examination showed multiple thrombosis of the superior vena cava, right atrium and ventricle and pulmonary artery. Estimated protein C level was 50.7 % (nOrmal range 70-140%); identical deficiency was found in patient's mother and elder sister. CVC was removed, and alter 2-month Heparin therapy and supstitution OF protein C with fresh frozen plasma, there was almost complete thrombolysis of the great vessels and cardiac chambers. We conclude that invasive diagnostic and therapeutic procedures in such patients may result in higher risk for severe thrombosis at unusual sites, and numeuos further complications Bronchopulmonary dysptasia (BDP) is a chronic pulmonary disease of preterm and term babies treated with mechanical ventilation for respiratory problems of different origin and requiring oxygen therapy 28 days after birth. BPD is a disease affecting the growth and development of pulmonary tissue. Such pulmonary }esions heal by squamous metaplasia leading to scar formation and fibrous tkssue r~growth, The Pediatric Intensive Care Unit makes the survival of babies w~h very low birth weight (500 -999 g) possible. With the increase in their aulyival, the number of complications in low birth weight babies increases as well. BDP is a very serious complication. Therefore the importance of early diagnosis and treatment of BDP must be stressed in order to reduce the consequences. Babies with BDP must be under medical suveillance for at least 3 years as the disease needs at least that long for complete resolution. tn the ICU of Pediatric Department at Madbor Teaching Hospital: during the past two years (1994-95) 154 newborns were treated with mechanical ventilation. The neonatal and postnatal death rate of all newborns admitted to our ICU was 7,1%o.ln the two years from 1994 to 1995, 16 newborns were admitted to our ICU (2 %~ of all newborn babies at Maribor Teaching Hospital), with birth weight 500-999 g. In the ICU, the survival of these babies and parallel to it the number of complications is increasing. During the mentioned 2-year period, 8 babies with very low birth weight (500-999 g) survived: 5 in 1994 and 3 in t995. In 45-50 %, first or second stage BDP was treated,there was no case of third of fourth stage BDP. The treatment consisted of eary removal from mechanical ventilation, oxygen therapy~ intensive treatment of infection, volume and caloric intake contro}, corticosteroid treatment throught 6 weeks with decreasing doses, diuretic end antioxydant therapy. The children are to be reevaluated at the age of 3 and 6 months and again at I and 3 years. oeure J van der, Markhorst DO, Haasnoot K Department Of pediatrics, pediatric intensive care unit, Free University Hospital, Amsterdam, the Netherlands. Case Summary A 4%-month 6.5 Kg girl of African origin was admitted to the Pedfatric IRtensive Care Unit with pneumonia and progressive respiratory irlsuffJdeRey. She was intubated and ventilated by pressure regulated volume controiJed ventilation (Servo 300C, siemens, Soma, Sweden). Maximum conditions were InspiratorY Minute volume 3.2 l, PEEP 10 cm H~O ahd 100% 0~. Chest X-ray ShOwed bilateral interstitial consolidation. Material obtained by broncho-alveolar lavage showed PReumocystis Car}niL Htv-serology (Elisa and Westerll blott) and p24-antigerl were positive, confirming the diagnosis Of Pediatric AIDS. She was then treated with high dose Co-tllmoxazoie, Penthamldine, Z{(~ovudiRe and steroids iv. Because of thee x-ray features, high need for O 2 (100%, pad 2 56 mm Hg), not responding to elevatiofi of PEEP (max 10 cm H=O) and PaO2/FiO = <200 (S6). m Acute Respiratory Distress Syhdrome (ARDS) was diagnosed. Because conventional ventilation (cv) failure, HFO-V (31OOA, Serisor Medics,Yorba Linda, Ca) was initiated. Starting Mean Airway Pressure (MAP) of 19 cm H~O was based OR MAP of the CV, Oscillatory pressure amplitude (dP) Of 47 was, at ii~itial frequency of 7.5 Hz, adjusted ur~til chest wall vibrations were visible, it was required to raise MAP to 26 cm H20 and dP to 66 before optimal lung volume and ventilation were achieved and need for O 2 reduced within hours, This was monitored by frequent blood-gas analysis and chest x-rays. MAP and dP could slowly be reduced, After a good response the first day, gradually 02demand reduced and the patient could be weaned from the ventilation. MAP, dP, Fi02 and Oxygenation index (MAP X Pa0~JFiO 2) are shown in table I. Chest X-ray follow-up showed gradually improving lung features, with marked improvement of aereation. After 10 days HF0-V she could be succesfully detubated when a MAP of 10 cm H20 was acmeved. Results : Sianificant increase in ventilato~ rate and mean airway pressure was noticed after the change to SAVI. No differences in oxygenation, CO 2 partial pressure and systolic, diastolic or mean blood pressure between IMV and SAVI periods were noted. In 6 infants however an improvement in PaO2/P43.Ol/ and decrease in PaCO 2 was observed after the switch to SAVI. These babies had a lower initial a/A oxygen tension ratio and required higher initial ventilator rate /p25 mbar, Fi02>0,7, PEEP=4-7 mber, C-from 0.3 to 1.2 ml/cm H20, effectivity of Exosurf Therapy was studied. In 4 newborns in 4-12 hours of therapy PIP decreased to 0.3-0.4, and C increased to 1,7-2.4 ml/cm H20. in 2 newborn infants with AaD02>500 mmHg and C from 0,3 to 0.8 mltcm H20 positive effects of Exosurf on lung compliance were not observed. In 3 newborns the monitor had revealed decreased of C (from 3.4-2.9 to 1,8-1.3 ml/cm H20), manifested clinically by pneumothorax. In general, monitor HTM 902 made possible; 1), to estimate the adequacy of CMV-parameters and regimes in newborn infants; 2). to select optimal T and AH values in the respiratory outline in dependence on lung damage severity and infused volume; 3). to reveal RDSN severity; 4), to optimize indications and adequacy of surfactaot therapy; 5). to diagnostieate the air leakage syndrome; 6). to effects to some agents (broncholytics, spasmolytics); 7). to obtain objective indications for IMV/SIMV and CPAP regimes. Albano Communication is an important aspect of human development and existence, and an inability to vocalise can be a problem in ventilatordependent patients. We present our experience with speaking aids as a means of enhancing verbal communication in four ventilatordependent children in our Paediatric Intensive Care Unit. The age of the children ranged from 7 months to 5 years, and the period of ventilation ranged from 3 months to 21 months via a tracheostnmy. They require continuous flow generated pressure limited or control ventilation at rates of 13-20 bpm. The reasons for ventilation include tetraptegia following a shrapnel injury; tetraplegia following congenital cervical spine damage; tetraplegia following atlanto-axial subluxation; and critical illness polyneuropathy following adult respiratory distress syndrome from prolonged ventilation for a severe head injury. The first three patients have Passy-Mnir one-way speaking valves and the final patient has a Bivona foam cuffed tmcheostomy tube with a talk attachment in view of recurrent aspiration. An improvement in quaIity of speech has been shown by independent assessment. We will review the present literature on this subject and discuss the advantages and disadvantages of these two types of speaking aids in the light of our experience. The prognosis of antenatally diagnosed CDH is closely related to the degree of PH. There have been attempts to correlate antenatal or postnatal criteria to mortality: none have been demonstrated to be predictive of lethal PH. The aim of this retrospective study was to determine whether antenatal or early postnatal data could correlate with the findings of post-mortem examinations. Patients and methods: Between July 1990 and July 1994, 32 CDH patients have been antenatally and postnatally managed at our institution. Twentythree infants underwent a post-mortem examination. PH was assessed by using the lung weight to body weight ratio (LW/BW) and the radial alveolar count (RAC). Antenatal results: CDH diagnosis was made at 24 weeks of gestation (wg) (15-37). Twenty-eight patients had a left sided CDH, 3 had a right sided CDH, and one had a bilateral CDH. Herniated organs were stomach None (n=21), or liver alone (n=4), or both stomach and liver (n=5 The patient was a 3-yenr-old girl with chronic renal insufficiency see~ to renal dysptasm, Two months before admission a kidney trar~ptant was performed. One morah later she showed acute graft rejection with serum ereafinine (Cr) level of 0.7 mg%. The rejection was unreslxmsive to an increased steroid dosage, and OKT3 was begun with resolution of the rejection. One week aRer, new rejection episode was seen marestxmsive to an increased steroid dosage, and transp~ ~s performed five days before admission to our PtC. Hemedialysis and Peritoneal dialysis (P.D.) each other day, was indicated (G.R.F.< 10 ml/rnin). Four days before admission T ~ rose to 38°C. "lhe diagnosis of opporttmistic pneumoma was made on the basis of tach3,pr',e~ hypoxi~ and diffuse interstitial infiltrates. Senma ~ was positive for cytomegaloviras (CMV), and stool culture for C ALbicans. Pentamidine, ganciclovir (DHPG), arai-CMV gamma globulin, eritromicine and amphotericin B was administered. On admission in our PICU, trachea was mmbated, (A-a) O2 gradient was 600, PaOffFiO~: 65, Lung Injury Score > 3 with PEEP level of 8 cm HzO. She had normal fiver function. During te next days she had fever and developed ARDS. BAL was negative. P.D. was of little efficiency. We adjusted pentanfdine, and DHPG doses for severe renal failure, with supplements after herO, sis, and at~rP.D.. During ~ next days she was afebrile, and the chest became radiologlcally normal. After ten days on Menhani~al Ventilation (MV.), the patient was extubated. Cr. level was 3.2 rag%, (A-a) Oz gradient was 20, and PaOyFiOz was 375, The patiem was discharged with chronic ambulatory P.D. DISCUSSION: OPPORTUNISTIC PNEUMONIA is a major complicalaou in imm~romised children, specially after kidney tvansplaraafion. C M.V. infection can result at~r OKT3 administration. In the treatment DHIK} dose muSt be adapted to the degree of renal insu~cieney, with supplements after hemedialysis, and after PD. Pneu~y~tis cann# tmeumov~ is ehemeterized by ventilafion-perfusion mistmaeh, decreased pulmonary compliance, hypoxia arld elevated (A-a) Oz gradient, with diffuse interstitial infiltrates. In our ease BAL was negative. Although we did not find the etiology the prevoclons eombh~ation of arairmcrobiat therapy, along with M.V., and supportive measures were the most effective trealme~. CONCLUSION: 1) In patients with severe renal failure and life-threatening infections, we must co~ider drug adjuslments. 2) In our patient we gave DHPG supplements at~r PD. with excett~at results, although P.D. was of little effiele~. Introduction: Endotracheal intubation and mechanical ventilation have become an important treatmem for many diseases accompanied by respiratory failure. With the frequent use of this treatment modality, an increasing number of complications associated with endotracheal intubation have gained clinical significance. Material and Methods: A transversal study was realized to find the prevalence of pulmonary aspiration with endotracheat tubes in 36 infants and children. Aspiration was assessed by applying two dyes (Evans Blue, Er)¢rosine Sodic) on the tongue and searching for the dye during suctioning in the endotracheal aspirate. The factors, that potentially have influenced the aspiration, including weight, age, sex, cause of respiratory failure, main pressure airway (MAP), level of consciousness, presence of swallowing and body position were evaluated. All the variables studied had their association with aspiration tested by chi-square Method with Relative Risk considering a Confidence Interval of 95%. The results were adjusted by multivariate analysis. Results: The overall prevalence of aspiration was 36.1%. Among all children who aspirated, compared to those who did not, there was a statistically significant difference in the presence of swallowing (p=0.005). The odds ratio to aspiration in the presence of swallowing was 38.4 (t.75 -100 C.I.95%) and the relative risk 55.5. Aspiration was not significantly affected by sex, weight, age, cause of respiratory failure, MAP, level of consciousness and position of the body during the ventilation. Conclusion: The endotracheal intubated children frequently aspirate as intubated adults and that preventive measures are ineffective. The presence of swallowing movements is the main risk factor to aspiration of oropharingeal content in intubated patients. CLINICAL FEATURES AND SHORTTERM OUTCOME SKling, RP Gie Pneumonia is the second most important cause of death in young South African children. The clinical features, intensive care course and outcome of children being ventilated for pneumonia in the developing world is unreported. AIM: To describe the clinical findings, aetiology and shortterm outcome of children younger than 6 months with pneumonia requiring ventilation. The data of all babies under the age of six months with a lower respiratory tract infection admitted to the Paediatric ICU for ventilation were prospectively collected over a period of 14 months. Tracheal aspirates and blood specimens were submitted for viral and bacterial cultures. RESULTS: Forty-seven babies aged 14 to 174 days were ventilated for pneumonia. Twenty-six infants had been born prematurely; t2 had been ventilated during the neonatal period and 4 had BPD. The median duration of symptoms was 1 day, the most common being cough, tachypnoea, apnoea and cyanosis. Five babies (10%) died. The mean duration of ventilation was 8 days (range 1-85 days) and of ward stay after ICU discharge 19 days (range 1-161 days), Blood euttures were positive in 7 children (15%). Viruses were cultured in 14 children (30%). CONCLUSION: 1) Fifty-five percent of children below 6 months requiring ventilation for pneumonia were premature infants, of whom 46% had been ventilated during the neonatal period. 2) The median duration of symptoms prior to admission was 1 day. 3) Ninety percent of the children survived and were discharged from hospital. 4) Viral pneumonia was responsible for 30% of the admissions. MECHANICAL VENTILATION AND ATRIAL NATRIURETIC FACTOR RELEASE Ulloa Santamarfa, E, p6rez Navero JL, Ibarra de la Rosa I, Espino HernLadez M, Velasco Jabalquinto MJ, Frfas P6rez M. PICU. Reina Sofia Children's llospital. C6rdoba. Spain. Mechanical ventilation effects on renal function decreased diuresis and natriuresis due several factors including ANF. Several studies have demostrated ANF released due increaasing pressure in right atrium. On the other hand, mechanical ventilation, overall PEEP modality, inhibits peptide release althougt CVP increased is found. This study was designed to demostrate ANF stimulation is due rigth atrium stretch which be higher during mechanical ventilation instead of atrium pressure. We desing a prospective study including 14 patients, age range 16 months-13 years with congenital heart disease. All of them were admitted at Pediatric Intensive Care Unit after extracorporeal surgery and were assisted by mechanical ventilation. Hemodinamic state was stabilized in all patients and nor renal neither neurological diseases were found. After 24 hours with mechanical ventilation, plasmatic levels of ANF were measurement, PVC, pericardical pressure were assessment; all patient were sedated with midazolan and paralized with neuromuscular blocking agent; mechanical ventilation technique was as follow: IMV between 20 and 30, tidal volume and Fi O2 enough to mantain respiratory parameters in normal range. Afterwards, at least twentyfour hours in spontaneous breathing, the study was made again in each patient. Atrial stretch was assesssment according to following equation: Transmural pressure= CVP -Pericardial pressure. CVP were significantly higher with mechanical ventilation than when the patient was breathing by himself. (5.4+__ 2.2 vs 3.8 + 1.8 mm Hg; p<0.01). However, transmural pressure during mechanical ventilation were lower than during spontaneous breathing (8.92 +__ 3.86 vs 11.76 +__ 3.32 mm Hg; p < 0.01) Equal, plasmatic ANF levels were lower during mechanical ventilation ( 87.77 + 46.55 vs 108.92 + 49.06 pg/rnl; p<0.01). In conclusion, ANF secretion decreases during mechanical ventilation, even with CVP higher. ANF release would depend on atrial stretch meassured by transmural pressure, lower in patients with mechanical ventilation and it would not depend on atrial pressure. The Paediatric intensive care unit Shaikh Zayed Hospital, Lahore is an acute care area devoted to the care of critically sick children upto the age of 13 years. In a 6 bedded unit with limited equipment, constant care is ensured by the presence of at least one nurse aed one doctor round the clock. In this setup we have the facility to ventilate 2-3 children at one time, Between Sep. 93 and Dec. 95, out of 885 patients admitted to ICU, 171 (19.32%) were below 1 yr of age, while 48 (28%) were below 1 month of age. Life support was discontinued in 17 (9.9%). Total mortality was 56 (32.7%), Major mortality was in 0-1 month age group 22 (12.8%), and 1 month to 6 month 15 (8.7%). Majority of the patients were of sepsis (36.2%), CNS disorder (22,2%) followed by respiratory problems (14.6%). It seems therefore that the major indicatiou for ventilation was overwhelming septicemia leading to multiple organ failure, rather than purely respiratory problems. High frequency oscillation (HFO) in the therapy for ARDS in pediatric patients requiring aggressive conventional mechanical ventilation (CMV) -routine or experimental mode ef pre ECMO therapy. Fedora M., Nekvasi~ R, Vobruba V., Srnsky P,, Zapadlo M. Dpt. Critical Care Medicine, NICU and ECMO Center, University Children's Hospita! Brne, NICU of University Hospital Prague, Czech Republic. Introduction: 9 pediatric patients (8 males, 1 female, average age 4.7 months, average body weight 5,8 kg) with severe ARDS ventilated with aggressive regimen of PCV or PRVC were connected to HFO (Sensormedics 3100) as the last "rescue" therapy due to uncontrollable respiratory failure before intended ECMO. In the course of HFO 2 of them were given NO in the concentrations of 5-80 p.p.m., 3 were subjected repeatedly to surfactant replacement therapy (Alveofact). Results: ECMO was needed in no patient, 8 patients survived, 1 patient was disconnected from the ventilator because of brain death in spite of conspicuous improvement of oxygenation and other parameters, Some relevant parameters 48 hours before and 48 hours after starting HFO are given in table 1~ In all the cases, the disconnection from HFO was carried out through the SIMV regimen, never directly to CPAP. Table 1 : The levels of blood gases, oxygenation index (OI), AaDO2,MAP,FiO2 and PaO2/FiO2 ratio 48 hours before and 48 hours after starting HFO. Conclusion: Although none of the patient had to be subjected to pediatric ECMO, HFO should be carried out only in workplaces having the immediate possibility of using this method in the case of HFO failure. Speculation: Should not HFO be used ir pediatric patients with ARDS earlier than aggressive CMV? Can HFO ce considered standard, not experimental method of therapy? Refractory hypoxemia in premature patients is characterized in a persistent elevation of pulmonary vascular resistance, with right to left shunt through the ductus arteriosus and or foramen oval. We report the case of a VLBW patient (GA 27W, BW 1010g) who present a severe hypoxemia related to hyaline membrane disease and a pulmonary and systemic infection to group B streptococcus, refractory to conventional ventilatory support and surfactant therapy, associated to hemodynamic failure falling in ECMO criteria used for term infants. A rescue therapy with HFOV (Sensor Medics 3100A) is decided at 5 h of live, The table resume the patient's evolution before and after HFOV. At 36W of postgestational age the patient present a FiO2 of 0.23 with a chest X ray compatible with a CLD type L At discharge no oxygen requirements was needed and actually he's doing well. CONCLUSION: HFOV, using an adequate alveolar recruitment strategy, was effective in the rescue of a severe hypoxemic respiratory failure with a rapid off of ECMO criteria entry in our VLBW premature patient, During the United Nmioffs embargo ~nst Yugoslavia the prevalence of the ast}nnafic ~acks in c~dldren aratsed. The mo~t common causes have beem dramm~e worsening of life standard, ecom~c disaster in global community, gr~ number of refugees from the other parts of former Yugodavia. It wm obviom that mcio-ecoumnical conditions took a part in the exacerbations of previously known cldldhood asthra~, ~av~ of micro-and m~mclimaflc changes, psychosocis] and emotional cryses, lack of medics-m~nts for p~ve~on and tl~rspy of acute asflanatic attacks. About 10% of d-dldv~ tmslod in our PICU for these year~ exp~dvncod ~vcr~ attack for the flint time iu ~Jzeir lifts. It has been cu~ 1~%~ children in mspir~ry PICU of our Hos~mt. The scut~ revere attack (more ~asn ~/o of hight clinical score) was detected in 62% of all children admitted with respirak~ problems. From tl~ mmlysss we exclu&d: bmncldolifis, ~I anomalies, ~eve~ i~ccqions. Concerning our drug supplies (which wc~e reduced), we started our therapy by administration of oxygen, ~ta2-ago~dst inhalations (but sometimes we had the solution for jet nebulizcm only for o~e inhalation per p~cnt), mwinophyllin and mefl~ylpr~Ini~done in/ravenously. 48% of ih~ asthmatics needed repea~ doses of muinophyl~n pinch.ally, tnch.,ding the fluids. The bronchodilak)r msponm was poor ~r~cl slow, hospital stay in PICU was for 4 days and for 14 days in other units sl~rwsvds. Tim ~ of their stable condifio~ was hard at borne (or refugees camps), without p~ventkm, so they came bsvk to hospital for morn than 3 times in 27% of cases, Dtrdng ~e4Je last motlfl~s file dtustion improved, concerning tim drugs supply for prevention, and we hope that these lifc~restening conditions wouldd~ Introduction: The incidence of ARDS is increasing as survival of critically ill patients is higher. The application of new therapeutic modalities have increased the survival rates in (ARDS) adult patients. Objective: To study the therapeutic efficacy of new tleamlents in children with ARDS Material and methods: A retros~ctive study was conducted from 1990 to 1995. 17 children with severe ARDS, (lung severity score > 2,5) (R), aged 15 days to 16 years, were included. The diagnosis were as follows: 9 interstitial pneumonitis, 5 non interstitial lung infection, 2 with lung aspiration and 1 with clinical sepsis. 5 patients had different tipes of cancer and 4 to suffer inmunodeficiency disease, The first 8 subjects (Group t) were treated with conventional measures. From October of 1994new therapeutic modalities were introduced, including: less agressive ventilatory support, postural changes (prone to supine) in 9 subjects, administration of corticosteroids in 8 patients, rfitric oxide in 3, pe~ssive hypercapnia and administration of exogeans sarfactant in one, PaO2/FiO2, D(A-a)O2, oxigenation index (OI) and the score of respirator), severity disease were similar in both groups. The two groups evolntiou was compared. Results: -Ten patients died, 6 from group I and 4 from group II (75% v.s.44:4%,NS). -The evolution time, either to exitus or weaning from ventilatory support was higher in group II (22.9 v.s. 13.6days in group I, NS), -The incidence of barotrauma was observed in 12 subjects (70.6%), 6 from group I and 6 from II. Of these patients 75% expired. -During the course of the disease, 15 (88%) patients had more than one damaged organ. Only in one subjet MOF was considered to be the main cause of death. The majority of the patients expired because of their respiratory disease, although, 80% of them met criteria of MOF. -Fifty percent of the subjects were infected at the time of death. Stmmry: a trend toward a higher survival rate is observed in the subjects receiving the new modalifies therapeutic intervention (corticosteroides, postural changes and permissive hypercapnia). Our results are not significative,probably because of the small number of subjects studied. A new doubleAurae~t two-stage ET-tube (DL-ETT) was desig~aed and tested in the rabbits with acute king injury under conventional mechanical ~entilation_ Ventilation efficiency of DL-ETT was emrrpared with that of canveniionally t~sed single lumen ET-tube (SL-ETT). Meth~s: DL-ETT was specially made out of two SL-ETT. Vertical crosssections at the distal end of two ET-tube (tD 3_0 rmn Portax) were adhered with each other to form a tracheal stage lumen wifu ID 3.0mm The two remained uncut parts of the tubes corLntithted the oval s~ge with two separate Imnens. DL-ETT and SL-ETT were randomly applied to five adult paralyzed rabbits with acute lung injury (by 0.1 nffkg oleic acid. iv). A Bird inter 3 vetffttator (Bird products corporation) was used for time-cycled pressure-limited ventilation at 40/min of respiratory rate, 10 ern H20 of peak i_~piratory pressure, l: 1 of IrE ratio, 6 LJmin. of flow rate and 0.21 of FiCh. Peak inspirntory pressure, mean mrway pressure, posi6ve end-expiratory pressure at tip of ET-mbe and bemodynamics were measured and recorded continuously. Arterial blood and expired gas were measured ~by AVL 993 blood gas analyzer) after each stabilization t.~iod of 30 minntes. _Analysis w~as by prated t test. Result: DL-ETT acaltety improve COs removal at all ammaN. Pa(?Oz was decreased by t0.6+_t.5 (p<0.0l) and physiologic dead space fraction (V~zVT) reduced by 22% +-1.8% (p<0.0t), compared with DL-ETT. There were no significant change in arterial oxygenation. Conelus|on: The double-lumen two-stage ET-tabe significantly increases ventilation effmiency with simple operation in rabbits v, ith acute hmg injury, lts availability may influence future clinical management of ~enNated patient~. This ~muly was fimded by the Science and Technology. CommiUee of Beijing Municipality. Analis of hemostasis alterations on different coagulation cascades in 46 children with septic shock has shown that coagulation disorder character is dependent on lung affection rate. The initial manifestation of the respiratory distress-syndrome (RDS) are characterized by the obvious activation of blood thrombin potential, moderate coagulopathy and not sharply marked endoteliosis, the Witlebrand's factor (WF) increase tot 140-220%. Progress in the clinical picture of "shock lung" leads to chronometric and structural hypocoagulation with potential hypercoagulation in "mix-test", high level of firbin derivative, thrombocytopenia with thrombocytopaty and the WF increase to 210~315%, Terminal stages of the RDS, as a rule, are characterized by potential hypercoaguletion absense, depletion of AT-lit and plasminogen, prevalence of antithrombin and antiaggregating activity, obvious endoteliosis (the WF to increase250-540%). The arteriowenous difference according to index of the thromboelastography (TEG) in the RDS Ill-IV rates was 69,8% less than in the 1-11 rates, Disorder of lung filtering ability in severe RDS is confimed also by minimal arterio-venous difference of activated euglobulin lyses (AEL) in children with the RDS Ill-IV rates is only 11,4%, while the patients whit RDS I-I1 rates have the AEL-activity in arterial blood 2,1 times as much than in venous blood. The use of then allows to determine the potential hypercoagulation rate, the AT-Ill level and fibrinogen quantity during the anticoagulant therapy and also the character of the X-factor activation and thrombocytic hemostasis. The effective therapy component of septic genesis RDS in children is the controled coagulation method with the use of the individual selected heparin doses in according to desagregants, kryoplasma, proteolisis inhibitors and trombolytics. It is necessary to avoid the heparintherapy for children with the RDS complicated with producting coagulopaties and termal phases of blood disseminated intravascular coagulation (DIC). Bronchoseopy has been used for evaluation of the potential problems of the airways and for investigation the bronchial specimens for diagnostic purposes. Regent technical advances result in performing this procedure at the bedside manner and in critically ill patients. We have performed 150 hronehoaeopy during last three years on 1362 pediatric patients with respiratory problems, In 90% of cases the opentube hroneh0seopy was performed (for diagnostic as well as for therapeutic reasons) and collected secretions or bioptic material were examined. The indieatiuns were: acute upper respiratory problems, chronic wheezing, inspiratory strider, tracheal or bronchial bleeding, chronic eongh, retractable atelectssis, severe pulmonary infections, lymph node perforation in lung tuberculosis and soquells like bronehiectssis and fibrosis. Our results were: anatomical malformations in 10%, mueosal oedema with chronic inflammation and thick secretions in 56%, easuos masses in 11%, granulation tissue and purulent secretions in foreign bodies and bronehieetasis in 16%, and only 7% of eases were normal finding. Our eXlXdenees pointed that this invasive procedure in carefully selected patients has important role in establishing the diagnosis and in the- Introduction: TBG has been a useful investigation in the management of ventilator-dependent infants in our experience. One ml of contrast was hand ventilated into the respiratory tree via their nasotracheal tubes and their anatomy and dynamics demonstrated on radiological screening. Case Descriptions: Three infants who were difficult to ventilate requiring high airway pressures, high PEEP and a significant oxygen requirement had TBGs. The ages ranged from 3 to 9 months. Two cases were complicated by complex cardiac lesions. In all cases there were frequent episodes of desaturation, where hand ventilation proved difficult and various intermittent lobar collapses occurred. Microlaryngobronchoscopies (MLB) performed on the infants by experienced paediatric ENT surgeons failed to identify the airway problems. More than one MLB was frequently done. Concern about introducing contrast into the airways of infants with limited cardiorespiratory reserve combined with an uncertainty about how much extra intbrmafion would be gained often led to a delay in investigation. When performed these fears proved groundless, the anatomy and pathology of the airways were demonstrated in full and the correct therapeutic plan started. In two cases tracheostomy and PEEP producing patency of bronchomalacic segments allowed weaning to low levels of ventitatory support. In one case tracheal reconstruction was undertaken and in the cardiac cases the respiratory component of the ventilatory dependence was fully assessed. At the age of 4 months, a baby boy with a history of minor respiratory problems, was admitted to hospital with an upper airway infection and severe dyspnoea. Shortly after arrival at the ICU he had a total airway obstruction. After intubation there were still difficulties to establish a normal gas exchange, and he was tranferred to the regional PICU. CT scan and bronchoscopy verified a congenital tracheal stenosis affecting the whole trachea except the upper 15 mm below the vocal cords. The diameter was estimated to less than 2 ram. An unsuccessful attempt was made to dilate the extremely rigid stenosis with a balloon. After the procedure he had a respiratory and circulatory arrest, and he was put on ECMO as a bridge to surgical correction. After 4 stable days on ECMO, surgery was performed during ECMO with a tracheal homograft transplantation. Immediately after surgery, ECMO was discontinued. A silastic Dumont type stcnt was inserted inside the homogra~, and a nasotracheal tube was placed inside the stent for assisted intermittent mechanical ventilation. Repeated bronchoscopies were performed to remove granulation tissue and secretions. At 9 months of age, the stem was removed with an endoscopic procedure. However, the trachea was still soft and collapsable, and another silicon stent was placed inside the trachea for another 4 months period, After removal he had some respiratory problems and he was treated with nebulized salbutamol, mcemic epinephrine and steroids. He was discharged from the hospital at 14 months of age and his condition is now stable. This is the first procedure of its kind in Sweden. It was accomplished by international and multidisciplinary collaboration. ECMO may be a bridge to corrective surgery and long time stenting may be necessary in the postoperative period. Post mtubation Laryngitis ( PIL ) is still a frequent complication, occurmg in l -6 % of intubated patients. Inhaled racemic epinephrine has for long been used as an accepted therapy, but this drug is not always available. The authors undertook a randomized, double-blind, placebo-controlled trial to determine the efficacy of inhaled L-epinephrine(LE) in the treatment of PlU In the period between july/93 and may/95, 289 patients were submitted to endotracheal intubation for ventilatory support. Atter the extubation procedure patients were considered for enrollement if they met the following criteria: clinical signs of laryngeal estridor and a Downes and Rafaelly score for upper respiratory obstruction equal to or higher than 4 Patients with primary upper respiratory disease were excluded All patients enrolled reeieved either inhaled L-epinephrine 1% or normal saline. Dexametasene ( 0,6 mg/Kg/day) was given to all patients in both groups. After 2 inhalations, aU patients were monitored for a period of 1-20 minutes and monitoring included cardiac and respiratory rate, mean arterial blood pressure, arterial blood gases and the Dowries and Rafaelly score. Statistical analysis included, Qui-square with the Fisher correction test and the Z-test for paired variables. Thirty eight patients ( 13,1% ) met the criteria for enrollment, 18 to the LE group and 20 to the placebo group.There were no significant differences in both groups in regard to age, sex, initial score ( 5,05 x 5,1 ) and endotracheal tube diameter. The period of ventilatory support and tracheal intubation was significantly higher in the LE group (8,06 x 4,54, p = 0,01). The follow-up score showed a significant drop only at 30 minutes after the inhalations (p = 0,03). Re-intubation due to laryngitis, occured in 1 patient of the LE group and in 4 of the placebo group with no statistical sxgnificance (p = 0,2). No difference was observed on the monitored hemodynamic variables during the 120 minutes, except for the mean arterial pressure at 60 minutes, being heighar on the placebo group (p = 0,05). We concluded that, although the L-epinephrine group showed a trend in better scores post-inhalation and fewer re-intubations due to laryngitis, the results were not statistically significant. We especulate that the period of intubation may have affected our results. Similarlly there were no differences in the incidence of adverse effects between both groups. Objectives:To evaluate the complications of endotracheal intubation in children with upper airway obstruction due to epiglottitis or croup. Methodes: During a 5 year period (1991 -1995) all patients with epiglottifis or croup were reviewed to determine the complications of endotracheal intubation, especially upper airway obstruction due to granulomas. Results: 33 Patients were reviewed. In 17 children (mean age 2.5 years) with epiglottitis the mean duration of intubation was 4.0 days (3 -5). No complications were seen. In 16 patients (mean age 2.3 years) with croup the mean duration of intubation until the first extubation was 8.1 days (1 -15 days). Elective extubation was performed if an airleak was present or after 7 days without airleak but in the absence of fever and obvious secretion. Reintubation was not necessary in 10 children (62.5%). In this group the mean duration of intubation was 6.4 days (1 -12). In 6 patients (37.5%) reintubation was necessary because of severe upper airway obstruction due to granulomas. Mean duration of intubation until the first extubation was 10.8 days (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) . There seems to be a difference in duration of intubation between these two groups with croup, however it is not significant (p > 0.1). All the patients with granulomas could be successfully extubated after microlaryngeal surgery, with a mean intubation period of 35.3 days (21 -47). revealed no complications, where as endotracheal intubation in children suffering from croup showed a high incidence (37.5%) of granulomas. However1 laryngeal steepsis and other serious complications were not sesn~ 3 patients (42 days averagely] was obviously seen in ~he peak =one of fl, f2 resonance and in the zone of high freq,-~ncy :r, ~;~e composition while 12 cases(3 day~ average;y] :~bowed no abnormality both clinically and Isryngoscopica!~y. 7/10 patients with catheter placement for more than 6 week~ end 1126 p~tie,~ts for less than 5 weeks had t;~ryngeal abnormal change in their larynges,Abnormal changes of sound spectrogram were all seen in 3 patients with placement for mope than 5 weeks. Our data suggest= Ca] the complication of endotracheal intubation was increases with increasing length of time of catheter placsm. entjbut aeriuoa complication is rare i (b] the time limit of pernasal endotraoheal catheter placement is 5 weeks within which the procedure is • comparatively safe and effective means for maintaining e tong term artificial airway. In a 6-year period (1986) (1987) (1988) (1989) (1990) (1991) (1992) we diagnosed TBM as an apparent dilatation of the trachea and main bronchi ih four premature infants on continued MV for respiratory distress syndrome (RDS). The infants were three boys and one girl with gestational age (GA) 26-33 weeks and body weight (BW) 1100-1965 g. MV was provided by Bourns 2001 CUB time-cycled and pressure-limited ventilator to attain normal gas tensions. No jet ventilation was used. Chest radiographs were reviewed for a complete evaluation, and for the evaluation of the airway. After the intial subjective diagnosis of TBM, the width of the tracheal and main bronchial air column was measured at the lower level of the first and the third thoracic vertebal body iT1, T3) and near the carina; the width of the main bronchi below the carina was also measured. In all infants, TBM became apparent close to the 20lh day, that is, after 2-3 weeks of MV. Therefore, for the time period from birth to the 20th day the following ventilatory parameters were reviewed and analyzed: (1) the percentage of total ventilation time when more than 40% O2 concentration was required, (2) the peak inspiratory pressure, (3) the positive end-expiratory pressure, and (4) the duration of high frequency ventilation (80-160 breaths per minute). Also noted were the Apgar scores (1 and 5 min after birth), the duration of hypotension (systolic BP below 40 mmHg) and circulatory instability, the presence of systemic or tracheal conatal or later infection, the duration of MV, and the final clinical outcome. The records were also reviewed for other possible pertinent data. RIGID RESPIRATORY ENDOSCOPY IN CHILDREN Fraga J, Amant6a S, Piva J, Nogueira A, Palombini B. Introduction: The respiratory endoscopy is an important procedure to diagnose and treat many airway's diseases in children. Although have had advances in radiologic investigation exams and pulmonary function tests, the direct anatomic visualization of airway is important to the management of many respiratory problems. Objective: Evaluation the respiratory endoscopies performed with a rigid bronchoscope in a pediatric reference hospital. Material and Methods: We study the records of all children that were submitted to respiratory endoscopy under general anesthesia from march 1989 to march 1992. Age, sex, clinical to indicate the procedure, diagnosis and complications of endoscopy were registered. Results: Three hundred and fifty six respiratory endoscopies were performed. The most common indications for endoscopy were strider (52%), suspected foreign body (16%), atelectasis (16%) and difficult tracheal extubation (8%). The most frequent diagnosis were laryngomalacia (36%) and subglottic stenosis (6%) in the glottic and subglottic areas, and foreign body (9%) and tracheomalacia (7%) in the tracheobronchial area. Normal endoscopy was performed in 54 (21%) of the children. Only three slight complications of the endoscopy were observed. Two patients presented bradycardia during the exam, and the third need tracheal intubation due to post-endoscopic subglottic edema. Conclusion: The rigid endoscopy in children is efficient and has no serious complications. Near drowning; Indicators of acute and long term prognosis Bernardien T.MJ. Thunnissen t, Reinoud J.B.J. Gemke 1, Loes Veenhuizer?, Krijn Haasnoot 3, A.Johannes van Vugh0 Department of pediatrics, ~Wilhelmina Children's Hospital, Utrecht, 2Sophia Hospital, Zwolle, and ~Free University Hospital, Amsterdam, The Netherlands. In this retrospective study factors that affect short and long term prognosis after submersion were analysed. All patients that were admitted to a tertiary pediatric ICU between january I, 1986 and january I, 1992 were included. Of 34 patients, aged 0-13 years, 8 died in the ICU, one after hospital discharge. Survivors and non-survivors showed significant differences with respect to central temperature, pupillary reactions, arterial pH, Pediatric Risk of Mortality (PRISM) score and Therapeutic Intervention Scoring System (TISS) upon admission (p < 0.05). Non-survivors more frequently required mechanical ventilation, bicarbonate administration and active reheating. ARDS was seen in 22 patients (65 %), invariably within 6 hours after admission. No patients with cardiac arrest on" admission snrvived without sequelae. Hypothermia appeared to have no protective effect on hypoxic damage. Survivors with persistent sequelae _> 6 months after discharge had significantly higher PRISM and T1SS scores (mean 27 and 34, respectively) than those with complete recovery (mean 14 and 23, respectively). Long term cognitive problems were present in 7/25 survivors (28%) and emotional disturbances in 5/25 (20%). In conclusion, a concise number of clinical and laboratory parameters, representing acute severity of illness, are important prognostic indicators for survival and health status of children after submersion. There were 59 (91%) bronchoscopies, and 6 (9%) were oesophagoscopies.The average age was 2,8 years for bronchoscopies, and 4 years for oesophagoscopies. The outcome of the patients was good. No complications were observed. Extraction is recomended in every symptomatic patient. Orphenadrine is an anticholinergic drug mainly used to decrease symptoms of Parkinson disease. Orphenadrine has a peripheral and central effect and overdose can result in athetoid movements, convulsions, cyanosis, coma, arrhythmias, shock and cardiac arrest. Physostigmine is a specific antagonist of the peripheral and central effects and can be a useful antidote. We report the case of a two and a half year old female who was transfered to our ICU for general convulsions. The little girl had, three hours before admission, accidently ingested 400rag of orphenadrinehydrochlodde (Disipal®), which was her grandmothers anti-parkinson medication. Three hours after ingestion she presented neurological signs: confusion, unstable walking, and periods of aggression. Generalized tonic-clonic seizures appeared who were rebel to administration of multiple anti epileptica but ceased after IV administration of diazepam and endotracheal intubation and ventilation. An episode of ventdcular tachycardia responded well to the IV administration of tidocaine. The levels of orphenaddne in the serum were high at admission (3550pg/L) and were present in the blood up to 96 hours after ingestion. High serum levels are, in the literature, associated to a high mortality rate. Physostigmine was administered three times at a 0.02mg/kg dose in the first 24 hours. We decribe the noted effects of physostigmine on the different symptoms. The patient survived and could leave the ICU after one week. In conclusion: orphenadrine poisoning is a very complicated medical problem associated with high mortality. In severe intoxication, the benefit of physostigmine more than counterbalances its side effects. Objective: To define the optimal volume of dilution for endotracheal (ET) administration of epinephrine (EPI) Design: Prospective, randomized, laboratory comparison of four different volumes of dilution of endotracheal epinephrine (1.2, 5, and 10 ml of saline) Setting Large animal research facility ofa universi~ medical center Subjects and interventions: Epinephrine (0.02 mg/kg) diluted with four different volumes ( 1, 2.5. and I 0 rot) of normal saline was injected into the ET tube of five anesthehzed dogs. Each dog served as its own control and received all four volumes in different sequences at Ieast one week apart. Arterial blood samples for plasma epinephrine concentration and blood gases.were collected before and 0.25, 0.5. 0.75_ 1.2.3, 4. 5. 10, 15.20, 25.30 , and 60 minutes after drug administration. Heart rate and arterial blood pressure were continuously monitored. Measurements and Main Results: Higher volumes of diluent (5 and I0 ml) caused a significant decrease of PaO2, from 147:!:8 tort to 106±I0 torr, compared to the tower volumes of diluent (1 and 2 ml), from 136±10 torr tu135+_7 torr (p<0.05). These effects persisted for over 30 minutes. Mean plasma epinephrine concentrations significantly increased within 15 seconds following administration for all the volumes of diluent. Mean plasma epinephrine concentrations, maximal epinephrine concentration (Cmax), and the coefficient of absorption (Ka) were higher in the 5 ml and 10 ml groups. The time interval to reach maximal concentration (Tmax) was shorter in the 5 ml and 10 ml groups. Yet these results were not significantly different. Heart rate. systolic and diastolic blood pressures did not differ significantly between the groups throughout the study. Conclusions: Dilution of endotracheal epinephrine into a 5 ml volume with saline optimizes drug uptake and delivery, without adversely affecting oxygenation and ventilation. The aetiology and outcome of paediatric out-of-hospital cardiac arrest was studied during a 10-year period in Southern Finland served by physician staffed emergency care units. The files of 100 prehospital patients less than 16 years old without palpable pulse and spontaneous respiration were analysed retrospectively. Fifty patients were declared dead on the scene (DOS) and resuscitation (CPR) was initiated in 50 patients. The sudden infant death syndrome was the most common cause of arrest (68%) in the DOS patients as well as in patients receiving CPR (36%). Asystole was the initial cardiac rhythm in 70% of the patients in whom CPR was attempted. Eight of the 13 hospitalised patients were discharged, 6 of them with mild or no disability, 1 with moderate disability and one in vegetative state. In multivariate analysis the short duration of CPR (<16 minutes) was the only factor significantly associated with better survival. Due to various aetiologies the survival rate from prehospital paediatric cardiac arrest is quite low. On the other hand, hypothermic near-drowning victims seem to have a relatively good prognosis. Duration of CPR less than 16 minutes was the best predictor of intact survival, Our study supports the previous findings of the importance of early and effective resuscitation efforts for establishing ventilation and perfusion on the scene. In our system well trained physician staffed emergency care units are able to provide immediate and effective ALS on the scene. On the other hand, these units also appear to be able to refrain from resuscitation when the prognosis is pessimistic. Objective: To assess the normal ,gastric intramucosal pH ~Hi) by tonometry in healthy children Patients and methods: Twelve healthy children (6 males and 6 females) with age rmaged from 6 months to 12 years scheduled for minor plastic or urologic surgery. Children were previously medicated with midazolam (0.25 mg/kg) and atropine (0.02 mg~) both i.m.. Anaesthetic induction was standardized with 02 -N20 (75%) administered via facial mask and increased halotane concentrations (up to 2%). All patients got an endotraeheal tube after iv. administration of femanile (2 mcg:Jkg) and vecuronium (0.1 mg/kg) or suxametonio (1 mg/kg), Pmaesthesia was maintained with O 2 -N20 (60-75%) and isofluorane (0.5-1%). During surgery, 8 children needed mechanical ventilation and the others maintained spontaneous breathing. EKG, heart rate, blood pressure, and pulse oximetry were moniterized. After anaesthesia, a sigmoid tenometry catheter (Tonometrics, Inc.) was inserted in the stomach of the patients by direct visualization with laryngoscope and Magyll clamps. Children were all maintained normoventilated and with normal cardiorespiratery variables. Cadet's balloon was £~led with 2.5 ml of saline. Thirty minutes after the insertion 1 rrd was extracted and rejected, just afterwards the remanent 1.5 ml was extracted and immediately analyzed. Simultaneously an arterial gasometry by puncture was performed. Gastric pHi was calculated by the Henderson-Hasselbalch's equation using the pCO 2 obtained from the tenometry catheter and the bicarbonate value obtained from the arterial gasometry. Results: Average gastric phi was 7.34 -I-0.027, range (7.29-7.46). Objective: Demons~ating intramucesaI pH (pHi) alterations during transport of patients from operative room to pediatric intensive care unit (PICU), Material and methods: pHi measurements were performed with gastric tonometer catheter in t4 patients undergoing cardiac surgery with cardiopulmona D" bypass (CPB), There was 9 mate and 5 female, the average age = 3yl0ra, average weight = 12,5 kg, average time of CPB = 70 rain. The measurements were made at the end of the surgeD' and when the patients had arrived in the PICU Statistical aualysis: Average and ~andart deviation and test "t" Student. Objetive: To asses the efficacy of gastric iatramucosad ptt (pHi) and arterial lactate levels to evaluate splacalc tissular perfusion in an experimental model of intestinal ischemia. SuNeets ~nd methods: twelve piglets weights t3-20 Kgs. undergoing orthot~ie liver trasplantation. The intestinal ischemia was induced by aortic damping. Tonometry catheter (Tonometrics Inc.) w~s placed in the stomach after artaesthesia and OT intubation. PHi ~s determined 7 times and lactate levels was determined fi times in 3 stages: I) Pre-AE~hepatic stage (twice: before surgery and before aortic clamping ); II) End anhepatic stage (only phi): III) Reperfusion stage (a 30, 90, 120 and 180 minutes). The phi was derived from application of the Henderson-Hassdbach formula using the pCO2 value from the tonometer and the arterial bic~rbonate. All pipets received raaitidiila before sttrgery. Values of pHi above 7,35 and lactate levels between 6 and 15 mg/dl were considered nortrM. The results were statistically anaJ.izated with ANOVA and Bonferroni tests. Results: The phi was normal on pre anhepatic stage (> 7,35) and lactate levels were slightly increased (21, 5 +_ 8, 9 and 19, 5 ±5, 9mg/dL NS) . In relalion to we-anhepatics values, pHi decreased signNcatly at the mid of anhevatic stage (7,39_+0,14 vs 6,94_+0,1 p<0,001), phi remain low in stage III, at 30 rain (6,86+0,12 p< 0,001) and 90 min(G94-+O, 12 p< 0,001). Arterial lactate levels increased significatly in relation to levels in stage I, at 30 rain (63,6_+9,7 p<0,O01) arid 90 rain (65,8±9,9 p<0,001) of reperfusion stage. There is a slight improvement on phi and lactate Ievels at 120 and t80 rain althought the differences did not reach significance. Cnmments: phi and arterial lactate levels propperly reflect hypoperfusion on the experimental model of acute intestinal isdlemia. B~kground : The paediatrie gallbladder diseases generally described are calculous ¢hol~Tstitis, cystic duct obstruction, congenital anomaly of the biliary tract, and inflammation. In the neonatal period, noulithogenie gallbladder disease could be also due to erythroblastosis or hyperalimentation. Obieetive : We describe an other type of disease affecting the gallbladder in neonates thought to be related to their vascular vulnerability. Methods : Four patients with abnormal gallbladder ultrasound not related to classical observations were included. We have studied and reviewed the biological and clinical data, the ultrasound findings and their evolutions. Results : Four patients, 30 to 32 ~.k-old neonates ~ffth a birthweight be~,een 1,3 and 1,9 kg, were intubated and under total parenteral nutrition for 10 to 35 days. None of them were symptomatic on repeated clinical evaluations. One newborn developped hypotensien on umbilical bleeding at 3 hours of life. In two cases, signs of cholestasis were discovered : the total bilirubin level has risen to 5 mg/dl; the direct bilirubin level was 1,5 mg/dl while the urina were dark and the ~o~,ls :mcolour~. The c~mplct~ ~crology as a!! the culVare~ remained negative. The ultrasound explorations were atypical : in the four eases, an initial increasing broad and thickness of the wall of the gallbladder with an hyperecbogenie inside content, which was not sludge, was discovered. In three eases the images resolved in ten to fifteen days. In one ease, an asymptomatie thrombosis of the vena portu which remained patent was discovered. In this case, at one month, the ultrasound showed images encountered in chronic ebolecystitis and, at one year, the gallbladder appeared atrophic. None of them underwent surgery. Conelusiou : The gallbladder diseases are multifactorial. Besides the prematurity, the infections, the total parenteral nutrition, the premature neonate is exposed to vascular vulnerability affecting also the gallbladder and this may explain our findings. Progress in prognosis of pts with B-NHL had followed the use of multimodality chemotherapy (CT). With the prolonged survival, there are comlications due to myetosupression & desease process. The syndrome of Neutropenic Enterocolitis (NE) is one of the ominous problems because ofpts increased susceptibility to infection & overwhelming sepsis. This material included 25 neutropenic pts (4-14 years) with the stages IIl& IV of B-NHL who were treated with the modifired BFM-90 (MTX 1 g/m 2 in 24-h inf.); 22 males, 3 females. Seventeen episodes of NE were observed & only after the first 2 courses of CT (13 of 25 after tst, 53%; 4 of 24 after 2nd, 17%). The symptoms existed 3 to 14 days. WBC ranged from 50 to 600 in l~tl (median, 100). The first signs of NE were directly correlated to the beginning of the neutropenia & the recovery of neutrophils led to the disappearance of abdominal recovery of neutrophils led to the disappearance of abdominal pain. The conservative treatment included gastrointestinal tract decompression, broad spectrum antibiotics initially, volume & electrolyte substitution, nutritional support, correction of acid-base balance, symptomatic treatment. Sixteen pts were treated nonoperatively, 1 died. On autopsy the transmural bowel necrosis due to thrombosis of branches of a.mes.sup, was found. The bowel perforation occurred in one patient, he was undergone laparotomy & hemicolonectomy & survived. We conclude that NE is a frequent complication in neutropenic pts with the st. lII& IV of B-NHL. It occurs after the induction courses of CT. Close observation by surgeons, oncologists & pediatric intensivists is mandatory. Conservative treatment is effective & more preferable until leucopenia resolves. Operation is necessary only for those.with perforation. Near Infrared Spectroscopy as a tool for evaluation of intestinal perfusionpresentation of an animal model. C. Scheibenpflug, P. Buxbaum and A.M. Rokitansky The recent development of and investigations in the so called Near Infrared Spectroscopy ( NIRS --transcutanous emission and simultaneous registration of intensity of spectralcolours depending upon modulations of tissue perfusion ) enable physicians to measure and qualify organ perfusion and nowadays is mainly used to control cerebral as well as skeleton muscular blood flow in trauma patients at intensive care units ( ICU ). Today intestinal perfusion, hypoperfusion , cell damage caused by reperfusion injury, bacterial and toxin translocation are serious problems in critically ill patients at an ICU. Paediatric intensive care physicians put major concern on intestinal perfusion, which for. instance gains more and more importance, especially in the neonatal period for example as an etiologic factor for necrotizing enterocolitis. We established an animal model, in which we measured intestinal perfusion by NIRS under various invasive and noninvasive conditions. Methods and results will be referred. For preliminary conclusion we propose Near Infrared Spectroscopy ( NIRS ) also as a potent diagnostic tool to determine early intestinal malperfusion in order to prevent lethal outcome. Fm'ther investigations in animals as well in paediatric iritensive care patients should be done to estimate our efforts. Introduction: Following the acute phase of necrotising enterocolitis (NEC) starvation of the gut for a period up to 3 weeks is a generally accepted treatment modality in many centres. Objective criteria to refeed these patients are hardly available. Recently the double sugar test has become available as a parameter for (ab)normal gut permeability ~'2. Aim of the study: To evaluate the changes in permeability of the small bowel in patients with NEC and controls before introduction of enteral feeding. Methods: A lactulose! rbarrmose (I/r) test was performed in two groups. Group 1 was studied 2-3 times within a 5-week period of starvation (n=5, mean gest. age 35, range 31-40 weeks). In group 2 seven different control patients were studied (mean gest.age 33, range 28-38 weeks). The test was performed by giving a patient after at least a 4 hour fast 1 ml/kg bodyweight l/r solution and determination of the 1/r ratio in a 4-hour urine sample by chromatography. Results: Objective: To evaluate the prognostic factors in the response to nitric oxide (NO) in children with Acute Respirator/ Distress Syndrome (ARDS) and/or pulmonary hypertension (PHT). Patients and methods: 23 critically ill children received NO inhaled for AnDS and/or PHT treatment. 14 patient before and after cardiac surgery (2 cardiac transplants), 5 with bronchopneu~onia, 2 multiple trauma, 1 sepsis and 1 cardiorespiratory arrest. 15 patients showed /J~DS and 8 PHT, in 4 with associated ARDS. We analyzed age, sex, diagnosis, PaO2, Pa02/Fi02, Oxygenation Index, PHT, shock, and sepsis as prognostic factors and response factors to N0. Results : After NO administration oxygenation did not improve in 2 patients (8.6 %) and PHT did not diminishe in one children (12 %). 12 patients survived (52 %), 8/15 (53.3 % with /d%DS) and 4 /8 (50 %) with PHT. The four patients with isolated PHT survived , and the 4 patients with PHT and ARDS dead. Patients after cardiac surgery presented less mortality (35.7 %) than the rest of patients (66.6 %). Patients with shock presented higher mortality (64.2 %) than the rest of patients (22.2 %). There are no differences in response to NO in respect of sex, age, diagnosis, shock, and sepsis. Survivors showed higher increase of PaO2/Fi02 64.3 ± 58.4 to NO than non-survivors 48.4 ± 51.1 (N.S). Patients with PHT showed higher increase in Pa02/Fi02 to NO administration ( 88 ± 47.1) than patients with ARDS (43.4 ± 50.8), (N.S), but patients with ARDS showed a higher increase in 0!, 15 ± 6.7, than patients with PHT 4.8 ± 4 (p < 0.05). Patients with Pa02/Fi02 < I00 showed less increase in Pa02/Fi02, 47.8 ± 46.3, than the rest of patients 82.8 ± 65.5 (N.S) Conclusions: i. Mortality of isolated PHT treated with NO is less than patients with AP~S. Patients with shock and those with PHT and ARDS showed higher mortality. 2. We have not found any clinical or analytical factor to predict clinical response to NO administration. 14 patients showed ARDS, and 9 severe PHT after cardiovascular surgery, in 5 with associated ARDS. We registered respiratory assistance, blood gases, PaO2/Fi02, the oxygenation index (Oil, and mean pulmonary pressure/ mean systemic pressure (PAP/SAP) before and after NO inhalation. We measured continuous concentration of NO and NO2 by electrochemical method (NoxBOX, Bedfont, Airliquide). Results: NO administration improved oxygenation mean PaO2 from 74 ± 17 Tm~g to i19 ± 54 ~g (p < 0.01), mean Pa02/Fi02 fr 25 for twelve hours and echocardiographic demonstration of persistent pulmonary hypertension of the newborn. Patients were classified into two groups based on the availability of iNO at the time of their hospitalization. Results: In the time period of the study, 105 patients were referred for possible ECMO therapy. Twelve patients greater than 4 weeks old, 31 with congenital diaphragmatic hernia and 12 with congenital heart disease were excluded from this analysis, leaving 50 patients for study, iNO availability reduced ECMO use from 16 of 34 (47%) patients in the ~iNO unavailable" group to 2 out of 16 (12.5%) patients in the "iNO available" group, p=&026 by Fisher's exact test. The fact that the two groups were composed of patients of similar severity of illness is reflected by comparable rates of ECMO and iNO rescue therapy (47% vs. 56%). Conclusion: By providing an alternative rescue therapy, iNO has reduced the need for ECMO in this group of neonates referred for respiratory failure. Introduction: true hepatnrenal syndrome (HIS) is defined an acute renal failure {ARF) in the presence of severe liver disease without other known causes of renal failure. HRS is frequently seen in the course of hepatic cirrhosis• In children, cirrhosis is rare; however, ARF can be seen in combination with aseites and liver dysfunction• We describe 3 patients with hepatic dysfunction and aseites in combination with AR~ and abnormal sodium-water handling, leading to the diagnosis of HRS. Pathophysiology: three factors are considered in the pathogenesis of HR~: I) hepatic dysfunction, 2) deranged hemodynamics, including abnormal blood pressure, reduced effective arterial blood volume and abnormal blood flew distribution, and 3) neuro-humoral dysrsgulatiom, including elevated levels of aldosteron, renin, angiotensin-ll, ADE, vasodilatim 9 nitric oxide and vasoconstrictor peptide endothelin-l. The main pathogenetic feature is decreased cortical renal blood flow, decrease of glomerulur filtration rate (GFR), vastly increased sodium retention, uliguria, and azotemia. Treatment: therapy is based on counteracting sodium and fluid retention by highdose aldosteron antagonists and loop diuretics, improving renal perfusion by lowdose dopamin, and strict restriction of fluid and sodium. Interventions as paracenteals of aacites or n peritoneo-systemic shunt are associated with high morbidity and poor outcome in children. Reversal of HEm by conservative measures can only be attained at early stages of HRL Liver transplantation is the only definitive treatment that can reverse ERE at advanced stages. Patients: the described patients developed severe ascites with insidious renal dysfunction and abnormal sodium-water handling during admission at PICU and fullfilled clinical criteria fur HRS. Treated according to the cited principles, all patients showed improvement of GFR, with increased natriuresis and gradual decrease of ascites. Eventually, renal function normalised completly. Conclusion: ERE deserves greater recogmitimn in the PICU population; diagnosis can be suspected on clinical criteria. With this increased awareness, therapy tun be instituted at an early phase, with better prospects for recovery. Positive outcome of HEm depends on early recognition of the clinical picture, understanding of the pathophysiology, and early institution of consistent treatment. MTX is an antimetatxflite widely used as chemotherapeutic agents. High dose iVITX (I to 30~m2) administered as a prolonged intravenous infusion (over 4-42 hours), is often used to treat malignant paediatric diseases. Major complications of this treatment are myelosuppression, orointestinal mucositis, dermatitis and impairment of anal function. We report two cases of MTX overd~age occurred in two children (5-year-old. 14 month-old) t~ted for acute lymphoblastic leukaemia. They were treated by CAVH and the MTX bhK~d levels rapidly decreasedavoiding multisystemic involvement. Establishment of alkaline diuresis and monitoring of plasma MTX levels during treatment is essential to prevent nephrotoxicity. However. leuco',cnn rescue may not prevent the development of potentially lethal toxicities in patients with MTX concentrations persistantl} exceeding t0mM. In theses cases, em'ly treatment of MTX intoxication may pm~cnt myelosuppression and reducerenal damage. The goal is to lower the concentration to below 10 mmoLL, at which time rescue agents aleme would be expected to be cllcctive. Respective indications of these remo',at mctNy.:is are still discussed : Hacmt~ialysis t~ eharc(~l haemoperfusion should be prolx',sed for massive and acute intoxication. However, rebound has been reported after combined hcmodialysis and hemoperfusion. Exchange transfusion may be proposed as a treatment for prolonged and moderate intoxication. Peritoneal dialysis is an incflbedve method for remo~ al of MTX. CAVH was used in our ICU. CAVH is a simple method for blood purification and N':dy iluid control. Use of CAVH was never be reported in this indication to our knowledge. Simplicity, rap~d application and gco.l clinical tolerance are the main advantages of this technique. The technique presents ~peclal advantages in terms of low priming volume of extracorporeal circuit, low blood flow, low rate heparinisation. Our results show a decreaseof plasma MTX concentration and a rapid reduction of halfqite of elimination (t5 hours over the period of CAVH). Moreover, we didn't delec~d rebound after stopping prc,xedure. Small size of the I:ratients may present sometime special problems, but these technical problems can be overcome, No severe complication (Needing, inlection) were observed during filtration, In summary, aggressive intravenous fluid hydration and alkaliniaation of the urine coupled with careful monitoring of renal function and plasma MTX concentrations during and al'tcr infusion along with lem~overin rescue has reduced the inNdcace of life-threatening toxicity after highdose MTX. However, some MTX inu>xication still occurred, leading to se~em toxicity, particularly nephrotoxicity. In these cases, we think that CAVH (or CAVHD) is a reliable, rapid method without rcIx~und increase in plasma MTX concentration or important adverses effects compared to other procedure removal. Gouyon JB, Germain JF, Semama D, Pr6vot A, Desgres J Preliminary limited data suggested that hemofiltration and hemodiafiltration may be valuable in some neonates with decompensation of maple syrup urine disease (MSUD). Venovenous hemofiltration (VVHF) and hemodiafiltration (VVHDF) were performed with a new neonatal hemo(dia)filter (Miniflow 10, Hospal) on 8 anesthetized rabbits infused with branched-chain amino acids (leucine, isoleucine and valine) and c~-keto-isocaproate. The BCAA and aketo-isocaproate blood levels were close to those previously observed in neonates with MSUD when extracorporeal blood purification was required. VVHF and VVHDF performances were assessed with two different blood flows (Qb = 8.3 and 16.6 mL/min). VVHDF was performed with 4 dialysate flow rates (Qd = 0,5, 1.0, 2.0 and 3.0 L/h). Thus, each animal was submitted to 10 successive procedures. Within each studied period, clearances of the 3 BCAA were strictly similar. BCAA clearances obtained by VVHF were similar to ultrafiltrate rates (respectively, 0.78 4-0.14 and 1.79 4-0.28 mL/min at high and low Qb ; p < 0.05). The ~x-keto-isocaproate clearances obtained by VVHF were 0.39 4-0.17 and 0.92 4-0.43 mL/min at low and high Qb (not significantly different). Whatever Qd value, the VVHDF procedures always allowed higher BCAA and c~-keto-isocaproate clearances as compared with the corresponding V'~HF period with similar Qb. BCAA clearances obtained by VVHDF with a 0.5 L/h dialysate flow, were 4.1 4-0.5 mlJmin and 5.4 4-0.5 mL/min at Iow and high Qb, respectively. The concurrent a-keto-isocaproate clearances were 2.5 4-,. 0,8 mL/min and 2.9 _+ 1,0 mL/min. At both Qb regimens, BCAA clearances provided by VVHDF were markedly higher than values previously obtained with peritoneal dialysis in human neonates with MSUD. The management of renal failure in the newborn is difficult. When dialysis is instituted peritoneal dialysis (PD) is usually the technique of choice. This is can be problematic and impossible in some patients with pre-existing intra-abdominal pathology. Continuous arterio-venous haemofiltration (CAVH) has been described in infants but sick preterm infants are not able to support the circuit. I have devised a means of having pumped haemofiltration in small/preterm infants (PHIS/PI) and describe its use in nine patients ranging in size from 750 to 3000gms for periods of 1 to 7 days. Vascular access was achieved through 24 or 22 guage cannulae in either a peripheral artery and a central vein or through two central veins. Blood was pumped out using an IVAC 572 infusion pump and through a Gambro FH22 haemofilter. A second IVAC pump was used to remove haemofiltrate from the filter and a third to infuse replacement solution. Removal rate was set to give a clearance of 15mls/min/1.73sq.m and blood flow rate set to between 5 and 10 times the removal rate. Heparin was infused into the circuit to prevent clotting of the filter. Biochemical and fluid balance control was achieved in all infants. Guaranteed fluid removal allowed the administration of full nutritional support. Four patients died when treatment was withdrawn because of an untreatable underlying problem. One recovered renal function but died some weeks later from unrelated problems, three survived and recovered renal function and one patient is still on treatment. This system allows a secure means of achieving fluid and electrolyte control in the preterm infant. The use of this technique may allow haemofiltration to become as applicable to preterm infants as it is to older children and adults. Unibrtunately, children often receive no treatment, or inadequate treatment for pain and painful procedures. This prospective, multicentric study focuses on the efficacy, safety and side effects of Novalgin (Metamizol sodium) for this indication. PATIENTS AND METHOD: Novalgin was administered to 56 children, aged between 6-16 years, with acute, postoperative or procedural pain. Novalgin (10-15 mg/kg) was given 6-8 hourly IV or IM respectively, in some cases (15) in combination with opioids (Tramadol 10, Piritramid 3, Butorphanol 2). The pain relief was assessed by six-step Verbal Rating Scale (VRS) from 0 to 5, Vital signs were monitored, the side effects, that occured were recorded. RESULTS: Pain relief was good (VRS less 2) in 53 children -94.6 % of study patients. Novalgin was very well tolerated, only one patient had adverse reaction -hyperpyrexia following intravenous application of the drug. DISCUSSION: Novalgin (Metamizol sodium) is safe and effective drug in the management of acute pain in children with low incidence of side effects. Obie~qve: a prostx~tive study comparing simultaneous, indepeadent ratings conducted by intensi~4sts using an american (COMFORT) and an european CHARTWIG) sedation scale for mechanically ventilated pediatric patients. Measurements and results: the study comprised 30 observations in 18 mechanically ventilated pediatric patients (aged 16 days to 5 years) in a pediatric intensive care unit (from March 1995 to January 1996 . Each patient was sedated by his/her managing physician with opiates, benzodiazepines, barbiturates, used isolated or in combination. Each observation consisted of a 3-miD period of oly~ervatien of the patient in his or her pediatric ICU bed, After each observation, the COMFORT (analyses 8 dimensional physiologic and behavioral subscores -range 8 to 40 paints) and HARTWIG (analyses 4 dimensional behavioral subsenres -range 8 to 25 points) were performed by the intensivist. We established the COMFORT scores ~ correspanding to adequate (range 17 to 26), excessive (range 8 to 16), and inadequate (range 27 to 40) sedation; and, HARTWlG scores z correslxmding to adequate (range 15 to t8), excessive (range 8 to 141, and inadequate (range 19 to 25). Statistical mmlysisJ: agreement rate (kappa) and p <.01 was considere d s!l~nificant. COMFORT 18 (60.9%) 2 (6,6%/ 10 (33.4%) HAP, TWIG , 17 (56.6%) 7 (23.4%) 6 (20.0%) To the COMFORT score, the average for adequately sedated, inadequately sedated, and too sedated was 20.28+-2.78, 2Z5_+0.70, and 15A.+_L10, respectively. And to the HA~TWIG scorn, the average for adequately sedated, inadequately sedated, and too sedated was 16.35:k-'0.77, 20.85-&L57, and 13.0L-0.89, respectively. Conclnsion: in our study there were no significantly statistical difference when you apply a more complex scale (CONff'ORT) or a less complex scale (HARTWIG) to assess the sedation of mechanically vemilated pediatric patients. The application of local and intravenous morphine infusion after surgery of urinary tract Eva Nemeth , M.D. Semmelweis Medical University , First Oepartment of Paediatrics , Budapest , Hungary In±roduction:Continuous analgesia with morphine may be ~egarOed as a safe and effective method of pain relief during postoperative period. Subjects and methods: 24 children /mean age 2.3 years/ underwent elective ureteroneoimplanta±ion were randomly selected to receive either morphin intravenously of lo ug/kg/h /Group One/ or bladder morphineinfusion 50 ug/kg/h /Group Two/ after surgery. All patients were prospectively evaluated during their s±ay in the postanaesthetic care unit. Cardiac and respirafory rates,blood pressure,Sa 02 ~,degree of alertness,pain perception and complaints of the paticnto ~cr~ recorded hourly. Pruritus,nausea and vomiting,voiding difficul-±ies,sedation,dysphoria were systematically sough and quoted. Statistical analysis was performed by chi square test. Results:Postoperative analgesia was the same in the two groups,but side effects were less in the bladder morphine group,because of the lower Se morphine concentration.The differentes weren't significant in two groups. Conclusions:The administration of bladder morphine infusion is a safe and effective method in children. Objetive: compare the evaluations of sedation level made by physicians and nurses with the Visual Analog Scale (VAS) and the COMFORT Scale (CS) in pediatrics patients receiving difforents modes of intravenous sedation. Material ~ Method." file evaluations were made by an attending physician and nurse with the VAS and by another physician (always the same) using the CS. The observations were divided following the sedation mode: one drug (Fentanyl or Midazolan), two continuous drugs, one continuous and one intermi~ent drug and two intermittent drug (Fentanyl and Midazolan). The groups were compared using the t-Student test. The groups also were compared between the percentual of agreement of the evaluations of sedation level made by physicians and nurses with the CS and VAS using the X 2 . Results: we didnk find any statistical difference between the observations made by physicians and nurses with the VAS in the differmts modes of intravenous sedation, The average of the observations using the CS betwom one drug and two drugs modes didnk exhibit also statistical difference. The observations made by physicians mad nurses using the the VAS when compared with the CS didn't show statistical difference between the sedation level. We found statistical difference only in percentual of concordance of sedation level between physicians and nurses when compared the one and two drugs modes of sedation. Conclusion: we didn't find differences in the observations made by physicians and nurses in the sedation level, only in concordance pereentua/ of observations when compared two modes of sedation. The observations using the CS (more complex) didnk show differences when compared with the VAS. Effects of age, concurrent administration of other pharmacologic agents, and disease [cardiac(n=31) & pulmonary(n=22)] on the PK & PD of B were evaluated in volume overloaded infants aged 4 days-6 mo (n=53). Single doses of 0.005,0.01,0.015,0.02,0.025, 0,03, 0.035,0.05 & 0.10 mg/kg IV were given over 1-2 min after baseline evaluation. Age was used as a continuous vadable to determine its effects on the variability in the PK & PD of B. Values for PK parameters were compared between patients in cardiac and pulmonary disease groups. Hierarchical multiple regression analyses were used to determine the effects of age, disease and other pharmacologic agents on the variability of bumetanide excretion rate (BER) and PD responses, e.g. urine flow rate (UFR) & electrolyte excretion. CIT, CIR & CINR increased with age (p<0.05) while t,2decreased markedly in the first monthe of life (p<0.05). BER normalized for dose increased with increasing age. Patients with pulmonary disease exhibited significantly greater clearance and shorter t~= (p<0.05) than those with cardiac disease whereas Vd~ was similar in both groups. The administered dose of B was the primary determinant of BER but increasing age also contributed. Penicillin antibiotics decreased BER. Dose response curves for UFR and electrolyte excretion were similar between disease groups. More of the variability in BER and PD responses could be accounted for in the pulmonary group than the cardiac group but this was not statistically significant. Conclusion: The PK of bumetanide were influenced significantly by age and disease. Differences in PK between patients with pulmonary and cardiac disease were primarily due to differences in total clearance. Age and the administered dose of B were positive determinants of BER and PD responses while penicillin antibiotics had a negative impact on both, Once B reached its site of action, no differences in PD responses were detected between disease groups. The pharmacodynamic effects of bumetanide were evaluated in volume overloaded infants (n=56) aged 4 days-6 months. Single doses of 0.005, 0.01,0.015, 0.02, 0,025, 0.03, 0.035, 0.05 & 0.10 mg/kg IV were given over 1-2 rain. Bumetanide concentration in blood (n=l 0) & urine (n=6) samples were quantified by HPLC. Baseline urine samples were collected over 2-4 hours prior to drug administration. Determinations of urine volume, electrolytes (Na ", K +, CI, Ca ++ and Mg++), creatinine and osmolality were performed before and at 0-1, 1-2, 2-3, 3-4, 4-6 and 6-12 hours after bumetanide dosing. Changes in urine flow rate and electrolyte excretion were plotted as a function of bumetanide excretion rate which was considered the effective dose of the drug. Peak bumetanide excretion rate increased linearly with increasing doses of drug and showed no evidence of approaching a maximum. Time course patterns for urine flow rate and electrolyte excretion were similar for all dosage groups. Urine flow rate and electrolyte excretion increased lineady up to a bumetanide excretion rate of approximately 7 #g/kg/hr and either plateaued (urine flow rate) or declined at bumetanide excretion rates > 10 #g/kg/hr. Bumetanide had no detectable effect on serum electrolyte concentrations, Conclusion: Maximal diuretic responses occurred at a bumetanide excretion rate of about 7 ;~g/kg/hr. Higher bumetanide excretion rates produced no increased diuretic effect. Peak bumetanide excretion rate of about 7 #g/kg/hr corresponded to bumetanide doses of 0.035-0.050 mg/kg. Neonates Using An Electrical Syringe-Pump. authors: Tr~luyer J.M., Sertin A., Bastard V., Settegrana, C., Bourget P., Hubert P. Background and objective: many problems can be observed with drug administration by i.v. route, especially in neonates. So we evaluate different protocols of Teico delivery using an electrical syringe-pump. Methods: we simulate infusion of Teico with a syrlnge-pump (Pilot C, Becton & Dickinson Lab.) trough d standart neonatal I.V. system. For 2 weights (1 or 3 kg) we used 2 doses of Teico (8 mg and 16 mg/kg) and a dose volume _<4.2 ml. Our goal was to perform a complete infusion in 10 minutes. The infusion system consisted of an Life Care 4 infusion pump (ABBOTT Lab.) with its LV. set for maintenance intravenous fluid (flow _< 6 ml/h) connected to a 3-way stopcock. An 1 meter extension tubing was placed between the stopcock and a neonatal catheter. An another 1 meter tubing (injection tubing) connected the Teicoplanine syringe to the stopc, ock. The volume of the injection circuit (from the syringe to the distal part of the catheter was 2.6 mL 4 methods of injections were assessed: A: Injection of the predetermined volume of Teico in 10 minutes with no wash out. B: Idem as A but the Teico was injected in 5 minutes, followed by a wash out (5 ml / 5 minutes). C: Twice the required volume was introduced in the syringe and the volume to infuse was programed in 5 minutes, followed by a wash out (5 ml/5 minutes). D: ]dem as C but a priming was performed before connecting theTeico syringe to the tubing. During each run, serial samples were collected every ten minutes over a one hour period. The samples were assessed using HPLC method. Results: the amount of drug delivred at 10 minutes were calculated. The results are a mean of 2 to 6 runs and expressed as the percentage of the total amount of Teico prescribed. A 2,8 % 6,4 % B 47 % 62,3 % C 82A % 86,8 % D 94,2% 95 % Conclusiom for accurate and reliable intermittent drug infusion with a syringe pump it is mandatory to use a precise protocol of administration and to take in account 1) a priming (for immediate starting of infusion), 2) a drug volume greater than the dose prescribed and a programmed volume injected, 3) a wash out of the tubing (with a volume ~ 1,5 x volume of tubing injection) CAZ is an antibiotic with activity against the major pathogens responsible for neonatal bacterial infections. We previously reported the pharmacokinetics of CAZ in 136 preterm infants on day 3 of life which showed that the clearance of CAZ increased with increasing gestationat age (GA). Mean serum half-life of infants with GAs < 32 wks was 8.7 h. We wanted to investigate the effect of postnatal age on CAZ pharmacokinetics, We therefore studied CAZ pharmacokinetics on day 19-21 of life in 10 preterm infants with GAs < 32 wks. CAZ (25 mg/kg) was administered as an intravenous bolus injection. Blood samples were coIlected before (t =0), and 0.5,1,2,4,8 and 12 h after the CAZ dose and analyzed by HPLCassay, The pharmacokinetics of CAZ followed a one-compartment open model. During 1995 11 newborns with complex congenital heart defects requiering either HTX or palliative staged single ventricle repair were admitted to our hospital: HLH n=8, unbalanced CAVSD, TGA with hypopl. RV and hypoplastic AOA. TGA with hypopl. RV, SAS and dextrocardia. 8/I 1 children had been admitted with cardiogenic shuck and mukiorgan failure due to intermittend closure ofDuctus arteriosus; in 3/8 stabilization failed. Parents were informed about the known and unknown risks of the always palliative surgery; in 2 cases parents denied further therapy. One pafiem with HLH underwent orthotopic HTX at the age of 5 month after the Ducms art. had been stunted in the newborn period. 9 month later he is still in favourable condition and without any sign of acute organ rejection. 5/11 underwent first stage of paLliative single ventricle repair: Norwood -Op. ( 3 ) ( n=3 ), Damus-Kaye-Stansel -Procedure ( 2 ). The clue to adequate postoperative management was to archieve a balanced distribution of flow to systemic and pulm circulation, that is to protect the single ventricle from volume overload and to guarantee sufficient oxygenation and pulmonary development as well. With the centralvenous SatO2 at about 50% provided maintaining the arterial SatO2 at about 75_+5% is corresponding with a Qp/Qs of 1:1. Using modified BT-shunts of3.5mm resp. a central anrtopulm, shunt of 4mm in one case l severe puim. hypertension, surgery at 6 weeks of age ) there was no excessive pulm. blood flow and no need to increase PVR with inspired CO2. One child ( Norwood at 5 weeks, preexisting pnim_ edema ) developed severe pulur hypertension and parenchymal pulm. dysfunction after prolonged bypass and multiple transfusions due to intraoperative bleeding: hypoxemia could be managed successfully by implanting a second shunt of4mm 18hh later and temporarily using Prostacyclin and NO; at sternum closure 6 dd later the second shtmt was banded to 3ram. Follow-up ranges 5-5 month: all 5 children are at home being assigned for second stage operation at about 6 month of age. Establishing clinical practice guidelines has become increasingly important in the current health care environment. Significant effort has been focused upon development of post-operetive critical care pathways. However, benchmark data upon which such pathways should be based has not been well reported. Length of mechanical ventilation (LMV) and length of stay (LOS) for children following cardiac surgery, for example, is poorly described. We prospectively recorded the LMV and LOS in 168 patients who underwent cardiothoracic surgery between 9/1/93 to 6/30/95. Only patients who belonged in any one of five categories of congenital heart disease (ventricular septal defect _+ other septal defects (VSD), atrioventricular (AV) canal, Tetralogy of Fallot (TOF), transposition of great arteries (TGA), and single ventricle physiology (Fontan)) were included. Eight non-survivors were excluded from the analysis. All patients were admitted to an Intensive Care Unit 0CU) post-operatively where mechanical ventilation was managed by 4 pediatric intensivists. LMV was defined as the period from post-operative admission to planned extubation. Length of stay (LOS) was defined to be from le from the ICU. Cytokine patterns during and after cardiac surgery in young children. Especially in children, cardiac surgery with cardiopulmonary bypass (CPB) can cause a systemic inflammatory response. This process is thought to be mainly a result of inflammation induced by surgery and exposure of blood to an artificial surface, and of reperfusion injury during weaning of bypass. Complement activation, degranulation of granulocytes, induction of free oxygen radicals, endotoxemia and release of cytokines, are important contributing factors. We studied cytokine patterns before, during and after CPB in young children admitted for complex surgery or for septal defect correction. In the first group, significant amounts of IL-6 and IL-lra could be detected preoperatively. These findings could reflect the already existing hemodynamic dysregutation. In both groups, CPB procedure upregulated the circulating pro-inflammatory cytokines IL-6/8, but not IL-1B. At the same time, IL-lra became detectable. Therefore, we suggest that in these patients the production of the anti-inflammatory cytokine IL-ira was not induced by the preceding acnvity ot pro-inflammatory cytoidnes. During CPB, we noticed a sharp decline in the capacity of the leucocytes to secrete IL-6/8. The ex-vivo production of IL-lra however, was only slightly attenuated. We conclude that there is a differential regulatory pathway for the induction of IL-6/8 and IL-lra. In addition, we studied the influence of dexamethasone administration on the cytokine pattern. Administration delayed the appearance of IL-6/8 and IL-Ira in the plasma, Interestingly, it did only interfere with the ex-vivo production of pro-inflammatory cytokines. The latter supports our hypothesis that production of IL-6/8 and of IL-lra is regulated by two independent pathways, (60%) of 43 pts. 82% ofpts < 12 months of age developed metabolic alkalosis as compared with 38% ofpts > 12 months of age.The infants with metabolic alkalosis received more citrated blood products and furosemide. Following cardiac pulmonary bypass the highest pH-values and BE-values were observed 24-48 hours and 48-72 hours, respectively. II. prospective study: Metabolic alkalosis was registerd in 2t children (70%), 8 of those <12 month (75%) developed metabolic alkalosis and 67% of those elder than 12 monms.Durmg the postoperative course patients younger than 12 months developed the highest pH-and base excess values after 102 and t05 hours, in the subset of the older patients maximum pH and base excess was found after 48 and 81 hours, respectively. In one case the top level ofpH-value exceeded 7.6, the base excess +20 mvalB. Conclusion: Children undergoing cardiac surgery with cardiopulmonary bypass often develop metabolic alkalosis.In contrast to previous reports, we did not observe an association between metabolic alkalosis and mortality, nor greater frequency of cardiac arrythmias or prolonged mechanical ventilation. In context with decreasing serum lactate levels, our data show positive correlation of metabolic alkalosis with postoperative improvement of liver function. Respirator, mechanics and weaning outcome in children undergoing cardipvascular surgery. Vassallo J., Cernadas C., Saporiti A., Landry L., Rivello G., Buamsha D., Rufach D., Magliola R. Mechanical ventilation (MV) and acute respiratory failure are common events in children unergolg cardiovascular surgery (CVS), The development of new techniques helped to measure some of the main respiratory mechanics (RM) in a non invasive fashion. Our goal was to evaluate the predictive value of these measurements in weaning (W) outcome in these patients, Patients and methods: we prospectively evaluated children considered clinically to be ready for W with < 20 kg and > 24 hs MV. Patients with diaphragm paralysis and those who failed W because of upper airway obstruction were excluded. Before patient extubation the following measurements were recorded during spontaneous ventilation (CPAP/T piece) using the CP 100 Neonatal Pulmonary Monitor BICORE (lrvine, CA): total respiratory system static compliance (CSSR) and resistance (RTS), rapid shallow breathing index (RSBI). Maximal inspiratory negative pressure (Pi max) was measured using an unidirectional expiratory valve. Threshold values predicting W success (Ws) were: CSSR > 0.5 ml/cm H20, RTS < 75 cm H20 /L/sec, RSBI 160 and Pi max > -30 cm t120. W failures (Wf) -patient reintubation within the following 48 hs, These values were compared between W success and failures using Fisher exact test. An apriori level of statistical significance was chosen at p < 0.05. 4 considered, an increase in TNF-a levels is observed after cardiac surgery (p<0.001) with a return to previous values after 24 hours (p<0.005). 72 hours after CPB, similar values are observed in groups II and Ill, but there is a further increase in serum TNF-a levels in group I when compared with both other groups (p<0.03). We found no statistically differences in any other moment. There was a significant correlation between serum TNF-o levels determined 72 hours after surgery and CPB duration (p<0,003). Conclusions: CPB in childhood provokes a significant increase in serum TNFa levels, In newborns the inflammatory response is maintained 72 hours after surgery. This enhancement of serum TNF-e levels indicates the existence of a relevant inflammatory response in these patients. Introduction: Cardiac surgery appears to induce a systemic inflammatory response. We have investigated the behaviour of IL-1 I~ and IL-6 before and after cardiac surgery. Patients and methods: We studied serum IL-1 6 and IL-6 levels from 20 children with congenital heart disease (10 boys and 10 girls), aged from 7 days to 14 years, undergoing open heart surgery, before CPB (D We found no statistically differences in the IL-I levels in the different groups and moments. There is a significant increase in IL-6 immediately after surgery (p<0,01) with similar levels 24 hours after CPB and a significant decrease (p<0.01) 72 hours after CPB. Preoperatory IL-6 levels were higher in the groups I and tl than in group I11 (p<0.05). 24 hours after CPB serum IL-6 levels in group 1 were significantly higher when compared with group 111 (p<0.05). Conclusions: CPB in childhood induces a significant transient increase in serum IL-6 levels, strongly relevant in newborns. CPB was not associated to a significant modification in serum IL-1 6 levels. Thus, CPB in childhood induces a dissociated behaviour in the proinflammatory IL-6 and IL-1 & pathways. Obiective, To evaluate the effects of AMG receipt on the clinical condition during the first 12 hours after birth (t2), the morbidity and mortality in immature outborn neonates. Methods. We studied 44 outborn neonates with GA 26 to 29 wks, admitted during the years 1993 to 1995. Eighteen neonates exposed to AMG (GA:27,6+lwks, BW: 1066_+195g) and 26 neonates did not (GA: 27,7_+1wks, BW: 1042_+187g). Results. AMG-exposed neonates compared to those not exposed had lower incidence of Apgar score at 5 min _< 3 (6% vs 35%, p<.05), lower incidence of PH t2 <7.20 (11% vs 48%, p<.05), decrease need of bicarbonate 12 (22% vs 54%, p<.05), lower FIO212 (FiO212min>40: 17% vs 48%, p<.05 and FiO212max >80: 17% vs 52%, p<.05), lower incidence of intubation (67% vs 92%, p<.05), lower requirements of surfactant (50% vs 79%, p<.05) and lower mortality (11% vs 50% p<.01). There were no differences between the two groups for the following parameters: type of delivery, hypothermia hypoglycemia and anemia during admission, hypernatremia, hypotension 12 (MAP<30mmHg), need of dopamine and or plasma 12, incidences of PTX PDA sepsis NEC severe ROP major IVH (plus PVL) and BPD and duration of intubation. Conclusions. The main beneficial effects of AMG receipt on the immature outborn neonates were the decrease of mortality and the decrease of surfactant need. There was no effect of AMG receipt upon other severe morbidity in this high risk group of neonates. Premature babies are very sensitive on homeostatic disturbances, and often develope intracranial haemorrhage (ICH). Ultrasound scan of the bram shows four grades of ICH: -Grade I -only periventricular hyperechogenic areas -Grade II -haemorrhage ham the lateral ventricles -Grade IlI-dilated lateral ventricles -Gtrade IV -intracerebral haemorrhage. The purposes of this study were: 1 To show the incidence of ICH in premature babies and its correlation with the gestational age, 2. To determine the severity of ICH 3. To present the outcome &those babies. In the study were included 393 premature babies successively-born at the Department of Gynecology and Obstetrics before 37 gestational week (g.w.) and grouped in three groups: less than 28 g.w., 28-32 g.w., 33-36 g.w. To all of them was performed ultrasound scan of the brain. Results : 1. The incidence of ICH hi premature babies is 49 % and there is ingh level of correlation with the gestational age: -Babies born before 28 t~ g.w. have 100% incidence of ICH and graduated : I grade -5%, II grade -65%, III grade -25%, IV grade -5% -Babies old between 28-32 g.w. have incidence of 61% : I grade -24%, I[ grade -62%, III grade -14%. -Babies older than 32 g.w. have incidence of 33%: I grade -46%, Ii grade 48%, III grade -6% 2. Sixty of 393 premature babies have died and it is 15.2% lethality. In all died ilffant was confirmed the grade of ICH diagnosed by ultrasotmd scan of the brain. D. Maksimo~5c. Z.Braiko~ic, N.Vunjak. P. Ivanovski (5~iversi~, Children's hospital. Belgrade, Yugosla~, ia Infantile intracranial hemorrhage is the most frequent and serious manifestation of late hemorrhagic disease of the newborn caused by ,,~tamm K deficiency in earl?,, ti~fancy. In the last two years, we recorded five cases of infantile intracranial hemorrhage due to "dtamin K deficiency, despite routine prophylax~s (intramuscular Vitamin K, 1 mg) , with Bpieal clinical presentation: age was 18 -65 days (average 40 days): vomiting, poor feeding, lethar~'irritabilJty, palor, bulging t0ntanelle and convatsiones were present in most cases.Two patients developed signs of hemorrhagic shock, with hemoglobin level less than 70 g.1. In 3~5 F \qI level was less than 30 % of predicted value. There was no evidence of head trauma or liver disease in none of patients. Four inlants were breast fed, while one, who had diarrheal disea.se, was on adapted milk formula. Routine therapy wa.s given (including Vitamin K and fresh frozen plasma). Two patients were discharged with no sequellae, one developed posthemon'hagic hydrocephalus as a complication and two patients died. Late hemorrhagic diseo.se of the newborn is sill/ a significant cause of morbidiB' and mortality in earl3' infancy, despite different approaches to prophylaxis developed in recent years. Background: Neonatal hearing screening in at risk newborns can detect 50% of the children with a congenital hearing loss. Automated ABR hearing screening (ALGO-1) has been introduced for healthy newborns. The aim of this study is to test the validity of this ALGO-1 screener in at risk newborns in a neonatal intensive care unit. Subjects: 250 at risk newborns (median gest.age: 30.0 wks, median birthweight 1350 g) selected according to the criteria of the American Joint Committee on Infant Hearing. Interventions: ALGO-I automated ABR-hearing screening at a level of 35 dB was performed in the neonatal intensive care unit. When bilaterally referred, further audiologic screening and/or therapeutic intervention took place. When passed uni-or bilaterally, children enrolled in a) a nation wide screening programme (EWlNG) at the age of 9 months and b) in a half yearly follow-up programme in which hearing and speech-and language development were observed according to Egan an Illingworth. Results: Screening without disturbance from ambient noise or from routine technical equipment was possible in the incubator, even during nasal CPAP therapy. 245 (98%) Newborns passed ALGO-1 screening. 5 (2%) did not pass bilaterally. 1 of 5 with a congenital rubella died shortly after screening.In 4 of 5 bilateral congenital hearing loss of ->35 dB was confirmed. 235 of the newborns passed were still alive at the age of 1 year. Ewing screening was performed in 183 of 235 (77,9%). 161/183 passed, 15 of 183 had passagere conductive hearing loss, in 7/183 no further investigation was performed. All 235 children enrolled in the I/2 yearly follow-up programme had normal speech-and language development. In this study all 4 at risk newborns with bilateral congeni "tai hearing loss were detected with ALGO-1 screening. Screening results showed no false negatives at follow-up. The ALGO-1 infant hearing screener can be used as an valid automated ABR-screener to detect hearing loss in at risk newborns in a neonatal intensive care unit. Gancia GP, Bruschi L Pnlito E, Ferrari G, Rondini G -Divisione di Patologia Nc~matate e Turapia Intensiva -IRCCS Policlinico S. Mattco -Pavia, Italy latrogenic esophageal perforations (IEP) in preterm and term infants are seldom reported in litteraturc, in association with difficult endotracheal (ET) intubation (with or without stylets), insertion of gastric tube, and pharyngeal suctioning with stiff catheters. Crieopharyngeal muscle spasm caused by instrumentation may also lead m a narrowing of lumen, with increased risk of local injury. We report 4 IEP observed in intubatcd, mechanically ventilated newborn infants (2 male, 2 female, all outborn). A common feature of IEP was inability to pass a nasogastric (NG) tube into the stomach, mimicking e~)phageal atresia.~se 1: birth weight (BW) 185(I g, gestational age (GA) 37 wk, sepsis. Before admission to N1CU, the baby underwent multiple ET inmbations, because of inappropriate securing of ET robe. Bloody secretions in pharynx were observed. The endoscopy showed a large lesion at the end of proximal third of the esophagus, Case 2: BW 1080 g, GA 32 wk, RDS. Chest X-ray (CXR) showed a retrostcrnal air leak: the NG tube was stopped }~etwcen D8 and D9 and soluble contrast was seen in upper mediastinum.Case 3: BW 76(/g, GA 26 wk, RDS. The endo~opy showed an esophageal lesion. CXR showed a paravertebral route of NG tube and a right pneumothorax.Case 4: BW 102(I g, CZ 22 ,.v!:. RD c. ~!,'.::;;: ::':'_'rvt!~'2s L" ~k':.rvRx. cwr, d,,,,vs ~,,mr~e, ~n rhe upper mediastinum and abnormal route of NG tube through a false passage. Surgical intervention is needed in case of mediastinitis or mediastinal abscess: conservative management included broad spectrum antibiotics, total parenteral nutrition, antireflux therapy and, if necessary, drainage of air leaks. Enteral feeding has been stopped lor 15 days and cautiously resumed after radiographic study. [x~cal sequelae and death are uncommon, but IEP occur in newborns with high risk of death due to prematurity and other diseases. In our patients, ET intubation has been performed by experienced personnel: therefore the lack of skills in resu~itative procedures is not always the main factor of IEP. Prevention of IEP requires appropriate materials (ET tubes, laryngoscope blades, suction catheters), and procedures (positioning of the infant with correct neck estension, firm ET placement). Sedation and pain control may help to prevent the muscle spasm. Aggressive treatment has improved the tong-term outcome of extremely low birth weight neonates (ELBW) but it has also increased the chances of iatrogenic lesions. Reviewing the charts of our neonates we observed a high number of vascular injuries. From 1987 to 1994, 2898 neonates were admitted to the neonatal intensive care unit (NICU); 335 of them were ELBW (11.5%). Studying the charts of these ELBW we observed 9 cases (4 M -5 F) with vascular lesions (2.6%). Mean gestational age of these patients was 28.7 weeks (rain 24-max33). Mean weight at birth was 880g . Mean weight at diagnosis was 1825g (1230-2700). In the same period 10 patients with vascular injuries were reported in the 2563 neonates over 1500g (0.3%). The injuries observed in ELBW group were: 6 arteriovenous fistula (2 bilateral) at femoral,level, 1 carotid lesion and 2 limb ischemic lesions. Aetiology was in 7 cases by venipuncture, in one case umbilical catheter and in the case of carotid lesion a wrong surgical maneuver. No general simptoms were observed. The vessels were repaired with microsurgical technique in six cases: the carotid lesion and five arteriovenous fistula; one case was solved with thrombolitic drugs; an amputation at knee level was required in one case after a long period of medical treatment. The last neonate with an arteriovenous fistula was only observed for parent's will. At follow-up (clinical and by ecodoppler) 7 out of 9 neonates presented normal vascular function without sequelae. From our experience ELBW neonates have more chances than older neonates to develop iatrogenic vascular lesions. We advocate an aggressive microsurgery and/or medical treatment to obtain good results and prevent late sequelae. A RETROSPECTIVE COMPARISON BETWEEN 2 NATURAL SURFACTANTS L.J.I.ZimmermanG M.C.M,van Oosten. Dept. Pediatrics, Div. Neonatofogy, Sophia Children's Hospital/Erasmus University, Rotterdam, The Netherlands. Aim: Retrospective comparison of Alvofact (in 1993) versus Survanta (in 1994) as rescue treatment for neonatal respiratory distress syndrome (RDS). Methods: Both surfactants were given at an initial dose of 100 mg/kg (except for Alvofact 50 mg/kg for mild RDS grade MI). Repeat doses were attowed (Survanta 100 mg/kg, Alvofact 50 mg/kg) up to a maximum of 200 mg/kg, All parameters and outcome criteria were strictly defined beforehand. The initial response (good,mild,no response,relapse) to surfactam therapy was defined on the basis of the decrease in FiO 2. Results: There were no signif. differences in patient population and initial parameters: GA (29.9+_2.2 vs 29A _+2,6 wks), birth weight (t332_+431 vs 1227-+444 g), severity of RDS (grade Ill-IV: 78.6% vs 80.3%), Apgar scores, cord blood gases, initial ventilatory settings. In '93 however, the initial surfactant dose was administered earlier than in '94 (14.4-+ 17.4 vs 6.5_+7.8 hrs postpartum, p= 0.025). Although the average total cumulative dose was equal in '93 and '94 (169.3-+65,8 vs 167.4_+69 .4 mg/kg), more doses of Alvofact were given compared to Survanta {2.3_+1.1 vs 1.7_+0.6, p=O.O01) and more patients in '93 received more than two doses than in '94 (46% vs 18 % of patients). There was no difference in the incidence of non-putmonarycomplications. AIvofact ( There was a better initial response to Survanta and a better respiratory outcome in 1994: in the group < 1250g the duration of ventilation was half in 1994, and in the group >~125Og the duration of extra O 2 need was half in 1994 as compared to 1993. We speculate that the main reason for this difference is the earlier and initially higher dosing used with Survanta compared to that used with Alvofact which was given in the same total cumulative dose but over a larger time span. Background: E×ogerlous sur&ct~t raplacem~t treatmem has become rou~ne k~ the t~eatme~t of respira~"¢ dim'~ syndrome (I~DS) of pr~e~tur~, wh~eas its effica W th odi~ respiratory diseoses is sdi1 being wader mvesUgatio~. Objective: "Eac~ mt ereat isto report ottr results of prospect/re, non-randomized "re~-o.e" study oE suffact~t replacement in outhom premamae infa~t~ with RDS reRuirmg me~aical ventilatioa (NfV). P~tien~ and metho0.s: From J-aly 1993 tO June 1995, 18/58; (31%) out~ ~¢ infaats, at a mesa age of 22 z 2,7 horn's ( 13 boys, 5 ~rls; ~ gestafioaN age 32-+2.8 weeks, mera~ birth weight 1846 _+ 544 g, ~ 7.2 i" 17 at 5 minutes) with RDS, requiring MV, received bov~e-suff~amt (Survanta, Ros~/AbotI, Laboratotie~ Columbus, Ohio) eadotracheally, as was recomm~aded by maaufacturer. As the c,~:ttrol group 19 o~bom premature infants (ot~ of 49; 39%, admitted with RDS from Euiy 1991 to Eune 1991) were saelected ~d who did not receive surfaaam, Compared with ~hctant ~'oup they were admitted for treatmeat e~'li~" aft~" daliv~:y (at the age 6.4::2.2 hours vs. 11.7+-13 hours), but they did not diff~ in othe~ baseline dam'a~eri~cs at ~ti~ion. Entry crkeda for ~¢fa~aut ~hcadou were fractional i~firat o~ oxTgem r~emeats -FiO2 > 0.50 -0.60, ratio au-lerlal to alveolar oxygea pre~are~aO2~AO2 < 0,20 ~ad oxyge~at,~ i~.dex -Ol > 10. Primary o~comes were deter~caned by ~hanges m exs'ge~ab, c~ ~r~d vmtilatic~ ~ the following variable~; (1) fi'aaic~ of i~spired oxTge~ (FiO2); (2) mesa Nnvay presmzre (MAP) (3) paG2 ~AO2 ratio, (4) oxyge~ion index (OI). Commo~ compHcadces of prem,muSty ~d con~ol mechamcal v~ati]al~on (pater dumas merios.s, intracr~nlal haemcrn:hage, air leak, br onchop ulmrmm'y dy~pl~a ~d death) were reg~ded as sec~d,~y outcomes. R~suas: In warfactaat group we observed slg~5.c~t improve~aeat (p<0.05) in oxygea~thia md veaatilation at 24 hours all~ e~try k~tO the m~dy in compari~ion to nons~fa~m" group. Compa~on of secondao' outcomes in ~ts with P,.DS showes Table l We did not observe ~y major acute hfe fl:u-eattming complicatlola,s m sxlrlhct~mt grou~ tr/lmediately after stu'~actsmt rcplacemev_t therapy. The duramm of mechmucal ven~ation ~ad oxygen Lreau~ent m survivals of both groups did not dafter 51gmficautl y a-ore ead~ other. Condusion: L!a premature mthats with RDS treated with surfaaaat replacemeaat therapy we observed decrease m mc~de~ce of tme'~m~o~oraces add de~th (p<0.01 and p<0.05), whe~e~s m othe~ observed variables thee was uo ,igmfi~t d~=ecce Infectious complications during the therapy of respiratory insufficiency in neonates with birth weight less than 1500 g in the course of 3 yearsretrospective study. Zitek Infants on CMV, CPPV, and IMV were administered EXOSURF in dose of 50-60 mg/kg twice endotracheally (see Table) . In 32 newborns (86.4%) 2 hours after surfactant admin Fi02 value decreased by 20.8%, and after 6 hours -by 28.1% compared with initial value; PIP and PEEP values decreased by 3-5 cm H20 and 1-2 cm H20 after 6 hours, and by 4-7 cm H20 and 2-3 cm H20 after 1 day, respectively accompanied by mean decrease of AaDO2 from 486,2 to 240.2 mmHg, Qs/Qt decrease from 24.9 to 13.2% (see Table) . Mean time of CMV, CPPV was 7.8 days, IMV-14-36 hours, CPAP -10-24 hours. Respiratory therapy in 5 newborns (13.5%) was complicated by pneumothorax (bilateral -in 2 infants Chorioangioma is a rela~ively rare placentaI malformation associated with considerable mortality and morbidity. A chorioangioma can be regarded as an arterio-venous shunt in the circulatory system of the fetus. This causes volume loading eventually resulting in cardiomegaly and high output cardiac failure. A female neonate (gest age 40 wk, birth weight 2290 g, -2.6 SD) was born with an apgar score of 4 and 7 after 1 and 5 rain respectively. The placenta showed multiple chorioangioma. Ultrasound of the heart showed a hypertrophic cardiomyopathy. She developed severe hypertension (100/70 mm Hg), treated with nitroglycerine and nitropruside. Finally blood pressure decreased when enalaprillic acid was given (0.15 mg.kg4). We measuered the activity of the renin-angiotensinsystem. An elevation in renin-angiotensin system is shown probably to compensate for the low resistance circulation before birth, Hypothesis: The instantaneous cut off of a large arteriovenous shunt did not result in a fast downregulation of the renin-angiotensin system resulting in hypertension. Hypertension should be added to the list of complications of chorioangioma of the placenta. The authors studied 75 cases of children's septicemia with blood culture yielding Staphylocucetts aurens. The age of patients varied from 2 months to 15 years (51,3% from 3 years downward), 74% of the children caught their disease in the hot season (May to October). The deaths also occured in this season: 87,5% (21/24). Following were the anatomo-dinical lesions. -Skin 42%, muscle 60,0%, bone 21,3%, Joint 9.3%. -Viscera : lung 50%, heart 33.3%, cerebrum 22.6%, kidney 60.6%, fiver 17,3%. -Simple lesion skin-muscle-bone joint: 12%, no death in this group. The concomitant lesions of the soft tissue,bone-joint and viscera : 34% with one viscera, 26% with two viscera, 18% with three viscera and 9% with four viscera. -Bone lesion : Mainly on the long bones (50% on the tibia, 25% on the femur, the remainder being the mandible (3) and the humerus), inflammation of' the hip joint was the main one. -I,ung lesion had forms pneumatocele (4 cases), bronchopneumonia (6 cases), pleural effusion (7 cases), multimicroabcess bursting into the pleura (8 cases), most multimicroabcesses were lethal : 20/22 (90,9%), -Heart: all thethreelay~rs got le@~r~, 20% had 2 or 3 layers aLrected and death ensued. -Cerebrum : the meninges had three forms of lesions purulent meningitis (13 cases), obturafing embolns of brain vessels (2 cases) and cerebral abcess (one case). The characteristic clinical sign was paralysis and meningismus, phlebothrombosis of eavcrnous finus (13 cases)was mually ther~sultofalxil vdfi:h burst There were 6 cases of death with lesion of the meninges and 2 cases of obturating embolns of brain vessels. -The main sign of lesion of the kidney was a change in the components of urine: 60% got proteinuria, 75% had leucocytes in their urine, 42% had erythrocytes in their urine, the urea in their blood increased (over 60rag%) in 21.4% of cases.The lesion of the kidney seemingly had little relation to death. Seven cases of ictertts due to an increase of direct bilirubinemia and a decrease of blood-albumin. -The biological characteristics of the pathogen staphylococci showed that all the 75 isolated specimens had positive coagulaza ; the specimens from the dead patients were less semiti~e to, mad ~t to mali~ Overag death rate was 34.7 % (24/75). The fungal infection to fusariun species in immunocompromissed child have been reported in the literature with a rare, severe and high, mortality rate in spite.of the use of antifungal drugs. We report a case of successful treatment of a severe disseminated fusariun infection in a ll-year-old boy with acute lymphocytic leukemia (LLA-L3), after use a chemotherapy followed by absolute granuloeytopenia. The patient developed fever, skin lesions, pneumonia and fungaemia. Fusariun species was cultured from the blood, necrotic skin lesions and lung secretion. The child developed multiple organ system disfunctiou in spite of use broad spectrum antibiotcs and antimycotic therapy needing. UCI during 18 days. The patient receive suport treatment (mechanical ventilation, Inotropie d~.ugs, Diuretics, Imunestimulants, Blood Components, a broad spectrum antibiotes and antifungal agents). We absorved a gradual recovery in the white blood cell count and regression on the sites of infection. The association of preeoce diagnostic and the terapentic with increase in the white blood cell count was the most important in a successful treatment. A 5 year old African-American child suffered a severe pulmonary injury in a house fire. Initial survey revealed 1% total body surface burns, soot on the face, and bloody endotracheal secretions. Initial chest radiograph revealed diffuse, bilateral infiltrates. Severe respiratory failure with an oxygenation ratio of 73 rapidly developed. He developed a pneumomediastinum and subcutaneous emphysema. Although transient improvement occurred with inverse I:E ventilation and surfactant, he became more hypoxic (SAC2 as low as 47%) and acidotic. On day 2 post injury, he was placed on venc~venous extracorporeal life support (ECLS). On ECLS day 30 he was decannulated. Chest radiograph on ECLS day 15 showed an opacity in the left chest. Ultrasound of the left chest was consistent with atelectasis rather than pleural fluid. Flexible bronchoseopy failed to reveal any obstruction in the left lung. A computed tomography (CT) seen of the chest, which was performed after decannulation, revealed a large loculated collection of fluid in the left, anterior chest. Under CT guidance, a 14 F cope loop catheter was inserted and 40 cc of thick blood was removed, Follow-up CT performed immediately after this procedure revealed minimal change in the size of the fluid cavity. Over the next 48 hr, we instilled urokinase 20,000 units over 20 minutes every two hours. A 30 minute dwell time was allowed before draining the fluid. Repeat CT scan done at the end of the urokinase infusion showed a marked decrease in the size of the fluid cavity. ACT scan was not performed prior to decarmulation because the ECLS circuit tubing was too short to allow appropriate positioning of the child in the CT scanner. After a CT scan revealed loculated pleural fluid, a simple drainage procedure was diagnostic but inadequate treatment. We were able to successfully dissolve the thrombus after 48 hr of urokinase therapy even though the thrombus was > 14 days old. We suggest that large loculated plenral thrombi which develop as a complication of ECLS therapy may be successfully managed with urokinase infusion. Introduction: Haemorrhages, particularly intracranial, are major complications experienced in 10-35% of neonates treated with extracorporeal circulation. An induced thrombocytopenia and impaired platelet function play a key role in the increased bleeding tendency observed in these patients. The aim of the present study was to establish a dose-respons curve for the effect of a synthetic protease inhibiting agent, Nafamostat Mesilate (FUT-175), on platelet membrane glycoprotein density and platelet activation during experimental perfusion. Methods: Two identical Extracorporeal Life Support (ECLS) circuits were primed with fresh, heparinized human blood and circulated for 24 h. Four different concentrations of FUT-175 (7.12 mg/L blood/h; 14.25 mg/L/h; 14.25 mg/L/h+25% bolus at the start of the perfusion and 2&5mg/L/h+25% bolus) were used in different perfusion experiments. A total of eight paired experiments were performed. Platelet count, plasma betathromboglobulin levels and platelet membrane density of glycoprotein Ib and lib/Ilia were followed as well as plasma concentration of haemoglobin. Results: A protective effect of the agent on platelet count, plasma concentration of BTG and platelet membrane GPIb could be observed during the first 3 hours of the perfusion when a bolus dose was added. No positive effect could be recorded with the two lower doses used. Plasma concentration of haemoglobin was higher in all the FUT-circuits compared to the control circuits. Conclusion: The addition of a bolus dose of FUT-175 at the start of the perfusion seem to induce a protective effect on platelets during the first hours of perfusion. Extracorporeal membrane oxygenation (EMCO) is a form of invasive cardiopulmonary support that can provide imporary physiologic stabilisation in reversible circulatory failure and or respiratory failure. We reviewed our expierence with extra corporeal membrane oxygenetion in 4 children aged 1 day to 4 year between 1991 and 1995. Two neonates was succesfully decanulated, but died 1-2 well after decanulation due to septic complictions. One child 4 years old, one neonates died on day 5 and day" 7 respectively while still on EMCO. Complication which were and encountered were heavy bleeding in case 1 (child), 4 (neonate) and raceway rupture in case 2 (neonate). Problems which are specific developing countries like Indonisia are: high cost (20.000 US for 7 days) difficulty in transportation (transporting intubated baby) from the orgin hospital, lack of knowledge and understanding of the primary physician and nm-ses and difficulty organizing in 24 hours EMCO team. RESNRATORY MON1TOR/NG IN PICU Z,ZJVKOVIC, S. MIHAILOVIC, O, TOSEV Respiratory monitoring in Pediatric Intensive Care Unit 0PICU) provide the importartt informations for understanding of the pathophysiology of the clinical signs, aid with the diagnosis, and assist in therapeutic management and predicting prognosis. Pien in Children's Hospital for ~flmonary Diseases and Tuberentosis remained for the t~s't two end a half years relatively limited for diagnoMic tools and therapeutic regimens, mostly because of the poor fmnaeial suptx~rt. The number of children admitted for aurae asthmatic at.lzek~ severe pneumonias, bronehiolitis, complicated pulmonary tuberculosis, foreign bodies and exacerbations of ehronit'. pulatonary diseases was t362. For all patients the respirator' monitoring system means: physie~d examination, ehe~ X rays, capillary bltxxl gas mmlyses (vevv few ehiktren experienced itwasive arterial blt~.~'i gases), noninvasive oxyntctry, measuring of the vital capacity in coopo-able patients, as~d capnography. Later on, after the imtial critical illness, a complete hmg fimction tests was performed, as well ,~s bronehoscopy in selected eases, (~lr experience revealed that abotrt 60% of ehil&en heos suecessthl outcome, without S~lllens , instead they had been tremted in limited conditions. ']'he rest of our patients were previously diagnosed ~s ettronie pulmonary patients, with high risk score system ibr having seqnells 'llae mortality rate were 0,5%. The continuous blood gas monitor, Pasatrend 7 (Biomedical Sensors, Ltd., High Wycombe, Bucks, England) has the capability of measuring pH, pCO2, and pO2 via an indwelling optical absorption optodelClark electrode sensor that is placed through an intra-arterial catheter. We evaluated the accuracy of the sensor in radial and femoral locations in critically ill pediatric patients. Methods: The simultaneous values of pH, pCOz, and pO2 recorded from the Paratrend 7 monitor were compared to values measured by standard arterial blood gas analyzer (Coming 278, Ciba-Corning Diagnostics, Medfield, MA). Criteria for the elimination of data points included a core vs. sensor temp. gradient, and sensor pulled back beyond accepted insertion distance. Mean time of monitoring per sensor was 108 hours (range 0.75-403.7 hrs). Mean time of radial monitoring was 35 hrs (range 0.75-160.5hrs) and of femoral monitoring was 137.2 hrs (range 12.8-403.7 hrs.). Linear regression and Bland-Altman analysis for bias and precision for each parameter were calculated. Results: A total of 49 patients (age range 2 weeks to 18 years) had paired samples of pH, pens, and pOz made by the sensor and blood g&s analyzer. The range of measurements were pH 6.99-7.66, pCO, 16.0-I14.2 t(n r, and pO2 34-480 torr. The Paratrend 7 monitor demonstrated accuracy that is comparable to the accepted standard of blood gas analysis in a group of critically ill pediatric patients manifesting wide variation in pH, pen2, and pOz..This technique appears m be very useful especially in the extreme values of the parameters measured. Funding provided by Biomedical Sensors. UNDERSTANDING OF PULSE OXIMETRY D.SEMPLE, L.E.WILSON. Royal Hospital for Sick Children, Edinburgh, EH9 1LF, Scotland, UK. Pulse oximetry is a useful, non-invasive monitor, routinely used on the ITU and increasingly often on the general wards. We used a questionnaire incorporating questions on the theory and clinical uses of the pulse oximeter to assess understanding of pulse oximetry in medical and paramedical staff Doctors indicated grade, speciality, pulse oximetry tuition and neonatology experience. 45 doctors, 15 ITU nurses, t9 medical students and 4 physiotherapists completed the questionnaire. Some confusion existed between the principles of pulse oximetry and transcutaneous oxygen measurement. Wide variations in the lowest acceptable saturation in fit children were seen (80-95%), with around 20% of respondents in all groups accepting values of 90% or less. Some potentially serious mistakes were made in the evaluation of oxygen saturations in the clinical scenarios. There were widespread variations in correct responses at all grades of medical staffing. Nurses scored well on more clinically-orientated questions but relatively poorly on theory. Only 15% of doctors (mostly senior grades) had received tuition in putse oximetry. Neonatology rotations appeared to confer little additional knowledge on pulse oximetry. Few doctors and nurses receive tuition in the use of pulse oximetry A significant proportion of nurses and doctors, of all grades, exhibited a lack o{" understanding of the principles of pulse oximetry. This may result in unsafe use of the equipment and put patients at risk. One can see from the table that blood composition in Uv and Ua differens in some characteristics, and similar in SGP magnitude. Venous-asterlal gradients "gas functiomals" between Uv and Ua represent the measure of difference in this characteristics. The gradient cari be positive, zero -order or negative and change both in value and in sign but not reach APO2 (positive) and APCO2 (negative) in absolute significance.Minimization of "gas functionals" deviations atom the zero is achieved due to"mutual replacement acts" between PO2 and PCO2 in Uv and Ua blood. We suggest that presented tests can be useful in full evaluation of gas exchange in newborns. (PAP) in the context of pulmonary hypertension is oft desired but rarely achieved. inhaled nitric oxide (NO) has been shown to produce this desirable effect, but is relatively difficult to administer or monitor. We wondered whether NP, chemicaIly related to NO but more stable in solution, would produce similar physiologic effects when administered in the convenient modality of nebulization. Methods: 9 piglets were anesthetized, mechanically ventilated, and surgically instrumented. Systemic blood pressure (BP), PAP, and cardiac output (CO) were monitored continuously. After postoperative stabilization, 0.9% NaC} nebulization was begun, and pulmonary hypertensiorr was induced by reducing FiO2 from 0.30 to 0.07. The piglets were monitored for 15 minutes during this hypoxic phase, Next, without altering FiO2 or ventilator settings, NP (10 mg/ml, dissolved in 0.9% NaCl, flow 4 Ipm) was substitued for 0.9% NaCl in the nebulizer circuit. NP was nebulized for 15 mins. Results: During hypoxia, PaO2 fell from 159 to 29 mm Hg. PAP rose during hypoxia from 14 to 31 torr (p< 0.01). ,^fhile BP and CO did not change significantly. PAP fell during nebulized NP in each piglet, (mean APAP = 31 to 21 torr; p< 0.01; mean reduction of hypoxia-induced rise in PAP = 61%; range: 36 to 78%; p < 0.01). PVR/SVR fell by 28% during NP nebulization (p< 0.01), while BP and CO did not fall significantly (90 to 86 tort; 653 to 636 mLlkg-min), The reduction in PAP began within 2 minutes of the onset of nebulized NP, and appeared to reach a plateau by 15 minutes. No tachyphylaxis to nebulized NP was noted. Nebulized NP did not significantly affect PAP, BP, or CO under normoxic conditions. Conclusions: 1) Like NO, NP selectively reduced hypoxia-induced pulmonary hypertension without altering systemic BP, 2 ) Unlike NO, NP can be administered by nebulizer, a technique familiar to virtually all health-care providers, and potentially adaptable to both intubated and non-intubated patients. 3 } Nebulized NP may be beneficial in clinical contexts where inhaled NO is impractical. Dang Phuong Kiet and Nguyen Xuan Thu Examining 6 cases of purulent pericarditis with various clinical forms treated by surgery, the authors drew the following experiences for their diagnosis. t. Clinical factors. Purulent pericarditis appeared like a cardiac tamponade in a septicemia due to staphylococci with dassieal symptoms: severe dyspnea, tachycardia, faint heartsound, big liver, prominent cervical vein ; rentgenography of the chest showing enlargement of the cardiac silhouette, a diminution of ventricular pulsations, ~i clear lung field. By an emergency operation, 500ml of diluted blood were drained. Purulent pericarditis and pleural effusion appeared at the same time but at first tile symptoms of purulent pericarditis were masked by the predominant symptoms of plearal efihsion. After the pleura was drained, its pus was no more, the general state was relatively stabilized but there still were big liver, dyspnea, enlargement of the cardiac silhouette while central venous pressure increased. Purulent pericarditis appeared late. In the first stage (about 2 weeks) there was no suspected sign. Later on gradually appeared such symptoms as dyspnea (during serum transfusion for instance). Central veinous pressure also raised. The heart chest diametre increased at first (up to 60-65%) then decreased (down to below 50% ) but the liver kept on swelling together with the particular changes of electroeaediegramme. Now the pericardium had no more pus but get fibrous (up to 3ram) thus constricting the heart and its main arteries 0ike Pick syndrome). 2. Diagnostic values of electrocardiograms : Common signs of ECG related of these purulent pericarditis were: a diminution of voltage, a widespread elevation of the ST segment, the TF wave flattened and inverted. However, what should be stressed was : the diagnostic values of an electrocardiogram for purulent pericarditis was mainly in the dynamics of their signs: in the first week, the voltage diminished corresponding to a pericardium containing pus, while the ST segment went up then seemed parallel to the fibrosis of the epicardium, the liver swelled, the central velnous pressure increased, the heart/chest dimension ratio decreased, the ST segment went down, the T wave became more flat and inverted. Between 1986 and 1995 23 neonates, aged 2 -23 days (median 5), weight 2,38 -4kg (median 3,28) with critical valvar pulmonary stenosis were scheduled for balloon dilation (PSVP), 19 children (83%) were on PGE1 and 13 (57%) needed mechanical ventilation. After stepwise dilation a final balloon : pulmonary valve (PaV) ratio of 114% (25-150) was achieved, There was a significant correlation (p<0,01) between an adequately sized balloon and freedom of reintervention. Two valves could not be passed, four neonates underwent surgical procedures (brock n = 3, commissurotomy n = 1), two children (10%) died of sepsis. 17/23 patients (73%) were successfully palliated by PSVP in the first month of life. The RV : systemic pressure value fell from 132% (75-231) to 58% (40-87), Complications included 2 transient dysrhythmias, 1 transient hypoxia, 3 vessel occlusions;-1 right ventricular outflow tract perforation. In 16/17 patients follow up data is available. The residual systolic peak doppler gradient over the PaV on the last out patient visit (5-103 months after PSVP) was 10-41 mmHg (median 20). Four children needed repea.ted PSVP 26 to 72 months after the initial intervention. Conclusion: PSVP of critically ill newborns is possible. The risk of mortality is relatively low. PSVP in neonates with an adequately sized balloon is a challenging alternative to surgical treatment. Post hypoxic-ischemic (HI) reperfusion induces the formation of non protein bound iron (NPBI), leading to production of the reactive hydroxyl radical. It was investigated if the ironchelator deferoxamine (DFO) could reduce free radical production and improve neonatal myocardial performance after HI. Severe HI was produced in 13 newborn lambs and changes from pre-Hl values were measured at 15, 60 and 120 min post-HI for (mean) aortic pressure (mean Pao), cardiac output (CO) and stroke work (SW). Left ventricular (LV) contractility and CO were assessed by measuring LV pressure (tip-manometer) and volume (conductance catheter), using inferior caval vein occlusion to obtain slope (Ees) and intercept of the end systolic PV relationship (V10). NPBI, reduced and oxidized vitamine C ratio (VCred/ox) and lipid peroxidation (MDA) were measured from sinus coronarius blood. 7 Lambs received DFO (10 mg/kg i.v.) immediately post-HI, control lambs (CONT) received a placebo. Results: Mean Pao was stable, CO and SW decreased up to 60 and 40% respectively in CONT as compared to pre-HI. In both DFO-groups CO and SW remained within the normal range. Ees and V10 decreased in all groups post HI, but did not differ between groups. NPBI and MDA were higher at 15 min post HI (pC. AmJkacine concentration were measured by fluorescence process (TDX ABBOTT) after sample dilurion. On a 10 mg/l sample, tovhnical reliahility show~ > 9~ % Of result mpmductlon and < 5 % of variation due to dilutions. Results : when Amikacine injection werv pro.pared from Araikacme 5/) mg for 1 mt vial > 10 % do~ge, ermr~ were found in 19/40 cases ; ~ 30 % in ,t1,tO cases. if preparation is done from Amikacine "~it'st SOltltion", les.--ConcenVr~tcd, it i~ more preci,,,e and only one dosage error ~ 5 % (6,3 %} is found in eli 30 studied doses. In add)inn to )hal if 10 doses were wep,m-'d from one "first soiatiol~' bag, the cost economy sl~ouid b~" of 32 fr~, and ii 20 dos~$ Were prepared tram the same bag the saving mtmey should be o{ I72 Its .Cencluslon : .ur survey shows th~t h' ntu)nato|ogy the u~ of a "first sohation which can be kept fi~r one week Is enable to reduce dosage erroes and i~ co,~tsavmg, Regarding [,V. admimst'rahon method the survey is still on, INTRODUCTION: So-called vein of Galen m~Iformations ale rare in~racranial embryologycal anomalies, repl~senti~g tess Than 1 of symptomatic intracranied artefiovenoas l~alform~tions. The spontLneous prognosis is ~s~u~lly fatal, because of cardiac fRilure due to left-to-right shunt thrQ~ugh the fistula. Recent developments of new techniques of treatment of the malformation and its cardiac consequence have led to a revolution in the practical approach of children w~th Galen malformation. OUR FUKFOSE is to contribute, with our persoaal series of 7S newborns and infal~ts admitted in our unit after endov~,scular embolization, to a better management of these children. Such a management requ!res a rnultidisciplinary approach. Intensive care are required prior to embollzation for patients with cardiac failure or cardiogenic shock and after cmbolization in order to insure cardiac and cerebral hemodyna.mic stabilities. This overlooking suppose for the nursing team to understand: prior to embolization : heart failure and cardiogenic shock. after cmbolization : evaluation of neurological and hemodynamic consequences of this proccdure, without forgetting the nursing and psychologic aspects, IN CONCL'IISION, this last ten yeRrs, these new approaches give to the patients and their famitiy a good reason to hope a total recovew, In our exl)erience, the global mortality is 9 % aad 66 % of children #j-e neurologically normal after embolizafion, ii ii~ i ~ii i ii i i L i iiii~ i ~i iii i Background: Venous oxygen saturation (SvO z) reflects the residuaI oxygen after tissue oxygen extraction and represents the relation between tissue oxygen supply and demand. We studied SvO 2 and arterial lactate during progressive isovolemic anemia to assess the relation between SvO2 and tissue hypoxia. Subjects: Ten 8-10 day old anesthetized ventilated piglets SaO 2 and SvQ were measured continuously by a fiberoptic catheter (Oximetrix, Abbott Lab.) in the carotid and pulmonary a~epy Tissue hypoxia was confirmed by a reduced VO, and an increase in lactate. Conclusion: SvO 2 reflects better a reduced Dp obtained by progressive anemia Surfactant replacement improves gas exchange in early-stage adult respiratory syndrome (ARDS) [1,2], but not in late-stage ARDS [3] . We report the first case of successfull treatment of ARDS after repeated instillation of surfactant.A ten year old boy, weighing 32 kg, presented with hemorragic shock. Biphasic-Positive-Airways-Pressure ventilation was performed (Evita II, Dr~ger, Germany). He had recieved nine units of packed red blood cells and underwent surgical exeresis of two bleeding gastric ulcus. Post-operatively, a cardiac arrest required cardiopulmonary resuscitation for three minutes. Hemodynamic status was subsequently stabilised. The chest-radiograph showed infiltrates of both lungs without signs of cardiac failure. On the third day, the patient became severely hypoxic with a PaO2/FiO 2 ratio of 30. Gas exchange was not improved by high ventilator settings. Peak inspiratory pressure (PIP) and ventilatory rates were 40 cmH~O and 18 breaths/min respectively. Inspiratory:expiratory time was 1:1 and the positive end expiratory pressure (PEEP) 8 cmH20. After increasing the PEEP level to 11 cmH20, we instilled over 2 minutes, 80 mg/kg of porcine surfactant (Curosurf, Serene France), in two equal volumes in both main bronchus,The SpO~ rose to 97% within 15 rain, the Fie 2 could be reduced to 0.6. Twenty four hours later, gas exchange worsened again (PaO2/FiO2 ratio 90). We increased the PEEP from 8 to 11 cmH20, and instilled a second dose of surfactant (60 mg/kg). Again, Fie 2 could be reduced within 15 minutes (SpO 2 95; Fie 2 0.6.). The patient was weaned from the ventilator and extubated on the tenth day. Follow-up at four month showed normal lung function.We demonstrate improvement in oxygenation after repeated exogenous surfactant administrations. We assume that in early-stage ARDS, surfactant may potentiate shunt-reducing effect of PEEP as it has been demonstrated in experimental model of ARDS [4] , and allow decrease in Fie2. In case of secondary deterioration, we think that a second dose of surfactant should be administered. 1. Weg JG, Balk RA, Tharratt RS, et al. ,lAMA 1994 : 272: 1433 -8. 2. Spragg RG, Gillard N, Pdchman P, et al. Chest t994: 105: 195-202. 3. Haslam PL, Hughes DA, McNaughton PD. et al. Lancet 1994 343:1009 -11. 4. Huang YC, Caimulti SP, Fawcett TA, et al. JAppl Physiol 1994 76:991-1001 43% (Ref) . The aim of this study was to verify these data: Patients/~lethods: All pts admitted to our multidisciplinary NICU/PICU in 1995 were included if they were in respiratory failure recruiting conventional mechanical ventilation (CMV) with PEEP >_ 6 and 'FIG2 -:2 50% or high-frequency oscillation ventilation (HFO) with mean airway pressure _> t8cm H20 for 12 or more houm. Diagnosis, maximal ventilatory parameters, barotrauma, organ/ system failures, mechanism of death and Glasgow Oulcome Scale (GOS) 1 and 6 months after study entry were prospectively collected. Results: 685 patients were admitted to the unit, o1 whom 337 required mechanical ventilation for a mean duration of 4.0 days. Overall mortality was 5%, 22 patients fulfilled study criteria. 17 survivors had GOS 5, 2 pts with preexisting neurological impairment survived with GOS 3. Neonatal diseases included hyaline membrane disease (7), meconium aspiration syndrome (4) and cardiovascular surgery (1), Pediatric diseases included bacterial (1) and viral (5) pneumonia, aspiration (1) and cardiovascular surgery beyond the neonatal period (3). 1990 -1994) . PATIENTS AND METHODS: Cefotaxim was used as a prophylactic agent in 43 patients in life threatening situations (e.g. multitrauma, neurosurgery atc.). More than 85 % children required Cefotaxim for the treatment of severe infections (epiglotitis, meningitis, sepsis, pneumonia mainly in immunodeficient and neutropenic patients) in monotherapy or in the combination with the other antimicrobial agents. RESULTS: Cefotaxim as a prophylactic drug was successful in all 43 cases (100 %). The effectivity of treatment of infections was 82.8 % (313 patients). The change of antibiotic therapy required 9 patients (2.4 %). 40 patients (10.6 %) died, but only in 12 of them (3.2 %) the obduction confirmed infection. CONCLUSION: We conclude that Cefotaxim is very effective and safe antibiotic and represents "golden standard" in the treatment of severe infections in childhood. In order to improve nursing quality, we recently adapted nursing care to the "five nursing functions" (activities of daily living, accompagnment in crisis, treatment, prevention and research) as described by the Swiss Red Cross in accordance to the new educational guidelines of the European Community, The aim of this study was to document complications of "treatment nursing function".Methods: All treatment complications were prospectively collected by the nursing and medical staff. The nursing staff included patient (pt) name, time of occurence and exact description of complication, proposal for prevention and information of parents. The medical staff reported type of complication together with pt information, diagnosis, medication, treatment and interventions, outcome and referral, All complications were discussed in monthly meetings including nursing and medical staff.Results: From January until December 1995, 685 pts were admitted to the PICU/NICU for 3233 nursing days (81% of total bed occupancy). 337 pts needed endotracheal intubation for an average of 4.0 days and 47 pts required nasal CPAP. 26 complications in 21 pts were noted (1 per 26 pI): inadequate check-up of equipment 11; accidental extubation 4 (1 in 85 intubated pts); bedsores 3; false drug dosing 2; wrong drug 2; umbilical bleeding 2; wrong transfusion setup 1; nasal septal necrosis 1). There was no mortality due to these complications. Exact documention of treatment complications and their meticulous discussion within the medical and nursing staff may improve "treatment nursing function". However, documentation and evaluation of nursing within all "five nursing functions" will be nessecary in order to achieve optimal nursing care. Cardiac output determination by thermodilution, using iced injectate has been shown to be valid and reliable in pediatric patients. It has been demonstrated in adult patients that there is no difference in cardiac output values when using room temperature injectate as compared to iced temperature injectate. The purpose of this study is to examine the effect of injectate temperature on cardiac output values in pediatric patients. Our study consisted of sixteen pediatric patients who had oximetric thermodilution catheters in place after cardiac surgery and who had cardiac output determined using both iced and room temperature injectate. With each patient, cardiac output was measured once on the day of surgery and again the following day. In each case cardiac output was measured using both iced and room temperature injectate. Statistical analysis included a two-way, repeated measures analysis of variance for each individual injectate administered and no significant differences were found in cardiac output. No statistically significant differences were found between groups with regard to the order of injectate administration or volume of injectate used (i,e., 3 or 5 cc's). The correlation coefficients between groups for cardiac output measurements at each injectate administration time, and for the average measurements across times, ranged between 0.81 to 0.94 (p < .0005). Preliminary data analysis suggests that cardiac output measurements for children are not effected by the temperature of injectate. A lenghty stay at a Paediatric Intensive Care Unit will always have sideeffects on a child's well-being and will put a high strain on the parents. In order to minimize the side-effects Longterm Intensive Care Unit opened in 1990 at the Childrens' Hospital. Admitted children are all ~ongterm-ill and technically-dependent and the ventilatory support can alter from a tracheostoma to CPAP or Portable Volume Ventilator. Nutritional support is applied by gastrostomies. A homelike atmosphere surrounds the children, they share a dormitory, a living-room and a dining-room The main purpose is to send the child home with or without technical equipment. This can only be implemented by giving structured education (theory and practice) to all categories involved. The multi-disciplinary team consists of one anaesthesiologist, head nurse, clinical specialist, RN nurses, nurses, one habilitation doctor, one social worker and therapists. Twenty-four patients have been admitted to LICU during these six years. Length of stay was from one day to four years. Four are presently staying at the trait. The assessment of pain in children (0-3 yrs) is still difficult, because children of this age have limited language and cognitive skills. To standardize the assessment of postoperative pain and distress in the intensive care unit an observational mstrument was needed that met several criteria. It should be easy to use in daily routine care. be suitable for the i.c. situation, and in children of 0-3 hrs of age. The COMFORT scale, an observational instrument designed to assess distress in infants in i.c. units, met these criteria. To accommodate the use of the COMFORT scale in the i.c. units and in research, nurses should be trained to use the scale. An additional requirement was that the inter-rater reliability should be sufficiently high, (Cohen's kappa > .60). Objectives: 1) To introduce the COMFORT scale in the I.C.U.; 2) to examine whether this instrument can easily, be incorporated into routine care; 3) to investigate the inter-rater retiabtlity. Methods: The COMFORT scale is an 8-item instrument specifically designed for use in pediatric i,c, units and contains both physiological items (heart rate, blood pressure) and behavioral items (e.g., alertness behavior, calmness/agitation, body movement, facial expression respiratory response, muscle tension). The observation period is 2 minutes. The scale is supplemented with an item on crying tbr children who are not mechanically ventilated. Groups of 8 t.c. nurses were trained by means of video's and observations at the wards. After the training, each nurse completed 10 scores with other nurses, after which the Cohen's kappa was computed. When the kappa's for the items met or exceeded our .60 criterium, a new group of nurses was trained. Results: To date, 30 nurses have been trained. Nurses find the COMFORT scale easy" to administer and a valuable addition to routine care in the i.c. unit. The Cohen's kappa's were higher than .60 for all items that the inter-rater reliability was high. The COMFORT scale is feasible in postoperative care in the i.v. and is considered a valuable instrument to improve and maintain high postoperative quality of care in the i.c. unit. Introduction:Children with neuro-muscular disease are believed to have a higher Resting Energy Expenditure (REE), because of their increasedwork of breathing.The influence of nocturnal nasal mask ventilation on energy metabolism and nutritional state of these children has not been studied so far.Objective:l,ls the REE inereased?2.1s there an influence of nasal mask ventilation on the REE?3.What is the nutritional state?4.What is the estimated total energy expenditure(ETE) in relation to the caloric intake? Methods:A pilot study of 4 patients(12-16 years) .The following measurements were performed:l.Anthropometry.2.Bioelectric impedance-3.REE was measured by indirect calorimetry during the day (in bed) with and without nasal mask ventUation,REE was compared with predicted REE according to Schofield(PEE),4.Caloric-intake and activities were recorded during 48 hour before measurement.5.Total energy expenditure was calculated as follows:measured REE x estimated activity factor. Results:tin all children weight for height was too low,