Critical Care Medicine

VIDYASAGAR, DHARMAPURI

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Bacterial colonization and morbidity and mortality from bacterial infection in a neonatal intensive care unit were studied for a 1-year period. Serious infection occurred in 5.7% of admissions with a mortality rate of 29% of infected infants. Staphylococci, streptococci, and

SIERRA, ALFREDO

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Polyuria, which frequently occurs in critically ill patients, requires early diagnosis in order to apply prompt and adequate therapy and to prevent further complications. Common syndromes include polyuria of recovery, acute nonoliguric renal failure, polyuria of sepsis, and inappropriate secretion of antidiuretic hormone. Illustrative cases of each syndrome are presented. The principal pathophysiology, diagnostic aspects, and therapeutic approaches are summarized.

GRACE, WILLIAM J.

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Hypercalcemia is a serious and potentially lethal complication of many diseases. As a result, it is important to understand and to be familiar with the appropriate management of this condition which often is identified only accidentally. The approach to therapy must be tempered by an appreciation of the underlying disease state as well as by knowledge of whether or not emergency reduction of serum calcium is required. In the latter case, no firm rules based on serum calcium values can be applied. Rather, it is important to recognize that individual tolerance to hypercalcemia is variable and, furthermore, that it may reflect the rapidity with which the concentration of serum calcium increases. It is not uncommon, for example, to observe nearly asymptomatic patients with primary hyperpara thyroidism and a serum calcium of 15 mg/100 ml, yet to also see virtually moribund patients with rapidly progressive cancer and a serum calcium of 12 mg/100 ml. In these two extremes, of course, other factors such as debility and impaired renal function, may contribute to the clinical manifestations observed. In any case, one must use judgment of the patient's clinical status in assessing therapeutic needs. Associated conditions, such as renal impairment or cardiac arrhythmias, may alter the approach to be used.

BROWN, ROBERT S.

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SAFAR, PETER

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Intracranial pressure (ICP) was monitored in 9 patients with coma due to Reye-Johnson syndrome. Clinically unrecognized elevations of ICP were found in all patients and treated with ventricular fluid drainage and conventional osmotherapy. This adequately controlled ICP in 2 patients. Intractable intracranial hypertension in 4 patients responded to continuous intravenous glycerol infusion, 1 g/kg every 2 hours, administered as a 10 g/100 ml solution modified to substitute for maintenance fluids. Two patients required the addition of moderate hypothermia (30–32° C) to other therapeutic measures. Three patients survived, one with severe neurological sequelae. Before monitoring, 3 patients were suspected of herniation on clinical grounds (before they were monitored) and subsequently died. ICP monitoring with the goal of titrated control of ICP elevations could have been added to their supportive therapy at an earlier stage, possibly with the onset of coma and grade 3 EEG changes.

SINGER, MORLEY M.

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Malposition of the endotracheal tube is a frequent complication in patients being treated for ventilatory failure. It was suspected that motion of the head might alter the position of the tube and result in malposition. Twenty adult patients with ventilatory failure, in tubated with an 8.0-mm endotracheal tube (5 oral and 15 nasal) were studied. The cuff was deflated in 10 of the 20 patients. With the patient in a semierect sitting position, standardized portable anterior-posterior chest roentgenograms were obtained with the neck in flexion, neutral, and hypertension and in 5 of the patients after right lateral head rotation. Movement of the endotracheal tube tip relative to the carina was measured from each roentgenogram. The endotracheal tube moved a similar distance regardless of the route of intubation or the inflation status of the cuff. Therefore, all groups were combined for analysis. The tube moved an average of 1.9 cm toward the carina with flexion from a neutral position, 1.9 cm away from the carina with extension, and 0.7 cm away with lateral head rotation. Malposition of the endotracheal tube may result from changes in head position. To minimize the possible injurious effects of that malposition, we recommend that the tip of the endotracheal tube be placed in the middle third of the trachea with the neck in a neutral position. Finally, knowledge of the head position is crucial to the proper radiographic interpretation of endotracheal tube position.

BREIVIK, HARALD

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Laboratory and clinical evaluation of a new self expanding pediatric ventilation bag in two sizes (Laerdal Infant and Child) verified the following safety features and functional characteristics. A pressurelimiting valve opens at 32–40 cm of H