Cost-benefit of trained transport teams: estimates for head-injured children

INTRODUCTION

Care during transport influences the outcome of head-injured children. Secondary adverse events, e.g., hypotension and hypoxia, worsen morbidity and mortality. Trained transport teams lower the incidence of such secondary "insults."

OBJECTIVE

To estimate the cost-benefit of improved care from trained escorts.

METHODS

The setting was a provincial air ambulance service during transition to trained pediatric escort paramedics. A retrospective review of transport and hospital records for a 12-month period was conducted. All children with head injuries (n = 43) transported to tertiary care [11 by untrained escorts (UE), 32 by trained escorts (TE)] were enrolled. Severity of injury was classified by Glasgow Coma Score (GCS); incidence of adverse events was counted and cost of change of severity resulting from preventable insults was estimated using published care costs.

RESULTS

There were 13 preventable insults in six patients (55%) in the UE group and five preventable insults in four patients (12%) in the TE group (p<0.05). Among those in the UE group, two changed in severity from moderate to severe, one moderate worsened (decrease in GCS of 2 or more), and two severe worsened. In the TE group, there were no changes >1. Cost-benefit estimates based on change in severity were $136,000 (median) to $238,000 (mean).

CONCLUSION

Significant cost-benefit likely accrues from training escorts who transport children with significant head injuries to tertiary care.

Peritoneal dialysis in children after cardiopulmonary bypass

OBJECTIVE

We reviewed 5 years' experience with peritoneal dialysis in children with acute renal failure after cardiac operations. We hypothesized that peritoneal dialysis is safe and effective in children with low-output cardiac failure after cardiac operations.

RESULTS

Mortality in these patients with renal failure (n = 32) was 46.9%. Fluid removed by peritoneal dialysis was 48 +/- 28 ml/kg per 24 hours. Most complications of peritoneal dialysis were minor, hyperglycemia being the most frequent (53.1%). Peritoneal infection was suspected in 25%. Bowel perforation developed in two patients. None of the complications required early termination of dialysis. Hemodynamics and pulmonary function improved continuously during the study period.

CONCLUSION

The early institution of peritoneal dialysis in acute renal failure and low cardiac output after cardiac operations not only removes fluid, thus easing fluid restriction, but may also improve cardiopulmonary function.

Unilateral cervical spinal cord lesion in a term newborn, associated with ipsilateral diaphragmatic atrophy and pulmonary hypoplasia

Two major factors can interfere with normal development of the fetal lungs: mechanical constriction resulting in decreased intrathoracic space and reduced or absent fetal breathing movements. We report a unique case in which both factors contribute to the development of lethal pulmonary hypoplasia. This full-term neonate had an isolated unilateral lesion in the cervical spinal cord resulting in ipsilateral neurogenic atrophy of the diaphragm, bilateral pulmonary hypoplasia, and lung immaturity. Evenetration of the atrophied diaphragm decreased intrathoracic space, compromising fetal lung growth. This was compounded by impaired fetal respiration due to the diaphragmatic atrophy, further aggravating pulmonary hypoplasia on the affected side. The other lung was also hypoplastic, although to a lesser degree, suggesting that its growth was also affected by either or both of these factors.

Spontaneous pneumothorax in paediatric patients

To obtain information to guide the management of children and early adolescents with apparent spontaneous pneumothorax the medical records of all patients over the age of 5 years presenting with this condition over a 25-yr period were reviewed. Twelve patients had a pneumothorax not associated with an acute episode of asthma. Six of these underwent thoracotomy at first presentation. Of the six who were initially treated conservatively five had a recurrence on the ipsilateral side. Seven patients developed a pneumothorax during an acute episode of asthma and none had a recurrence. Early intervention by either thoracotomy or some form of closed pleurodesis should be considered in paediatric patients presenting with an apparent spontaneous pneumothorax not associated with an acute episode of asthma. Pneumothorax complicating an acute episode of asthma is rare in the paediatric age group and is unlikely to recur.

Pilot study for the development of a monitoring device for ventilated children

Airway pressure and air flow were measured at the endotracheal tube in 13 children on a variety of ventilators. These signals were stored for analysis on a computer. Further data sets were obtained after 24 hours or following major interventions. Air flow rate was integrated to give volume. Pulmonary resistance and elastance were obtained by multiple linear regression. Pressure-volume, pressure-flow and flow-volume loops were plotted. "Closed" pressure-volume and pressure-flow loops (by subtraction of the resistive or elastic pressure components, respectively) were also displayed, giving compliance and resistance loops. The loops from the initial data set were taken as the baseline, and loops from later data sets were superimposed to provide visual comparisons. Change in clinical status was reflected by the change in slope of compliance and resistance loops. A 30% change in compliance or resistance was easily observed. There was minimal interference with patient care. This pilot study demonstrates that changes in respiratory mechanics can be displayed safely and easily in ventilated patients using resistance and compliance loops. Further work is necessary to confirm the usefulness of real time of these displays.

Expo '86, Vancouver: impact on British Columbia's Children's Hospital

Over 22 million visitors attended the 1986 world exposition in Vancouver, and this had a significant impact on the local pediatric facility. A total of 559 children visited the emergency department of British Columbia's Children's Hospital with injuries or illnesses resulting from the fair. Of these, 193 (34%) had come directly from the site. The children's ages ranged from 1 1/2 months to 18 years, 4 months (mean 6.99 years). Of the 559 children 31% were not covered by medical insurance. Twenty-four of the children were admitted to the hospital, and one died at the Expo site. Most of the illnesses were upper respiratory tract infections and gastroenteritis. The proportion of visits for trauma was 50%, compared with the yearly average of 25%. There was a 6% increase in the workload in the emergency department during the fair; the percentage was even higher during July and August, particularly after 1800 hours. Recommendations are made to aid with the planning of medical care for similar events.

Assessment of residual right ventricular outflow tract obstruction following surgery using the response to intravenous propranolol

The response to intravenous administration of propranolol hydrochloride was studied in 24 children undergoing operation for isolated or complex right ventricular outflow tract obstruction. Ten had pulmonary valve stenosis, 4 had pulmonary valve stenosis plus ventricular septal defect, 8 had tetralogy of Fallot, and 2 had complex lesions. Propranolol (0.01 to 0.2 mg per kilogram of body weight) was given to patients with a residual right ventricular to left ventricular systolic pressure ratio greater than 0.75. Four children did not respond to propranolol and required further surgical intervention. Twenty patients responded, 2 of whom died. Fifteen were restudied by cardiac catheterization 3 weeks to 27 months postoperatively. The right ventricle-pulmonary artery gradient was 25 mm Hg or less in 13 patients. We conclude that a small dose of propranolol given intraoperatively can identify patients in whom a reduction in the right ventricle-pulmonary artery gradient to acceptable levels will occur in the months following operation. This may reduce the need for placement of a subannular or transannular patch in some patients.