Showing papers on "Nasal cannula published in 2009"

Children With Respiratory Distress Treated With High-Flow Nasal Cannula

Abstract: High-flow nasal cannula (HFNC) therapy is a treatment for respiratory distress in neonates and children. In the present study, we assessed its effectiveness, comfort, and possible mechanism of action. Methods: We reviewed records of 46 patients treated with HFNC and estimated the modified COMFORT score (7 to 35 units), the respiratory clinical scale (0 to 12 units), and the oxygen saturation level. Data were collected at time 0 (before the use of high-flow), time 2 (60 to 90 min post-application), and at time 3 (8 to 12 hours post-application). Furthermore, we measured the nasopharyngeal pressure while on continuous positive air pressure (CPAP) as well as the differences in ‘‘lung expansion’’ demonstrated by the prestudy and post-study chest x-ray. Results: There were significant improvements in the modified COMFORT score (F1,45 = 40.03, P < .05), respiratory clinical scale (F1.69,76.15 = 121.19, P < .05), and oxygen saturation (F2,90 = 101.54, P < .05). Application of HFNC therapy created a significant a...

High Flow Nasal Cannula Therapy as Respiratory Support in the Preterm Infant

Abstract: We reviewed the literature on the effects of high flow nasal cannula (HFNC) and heated, humidified, high-flow, nasal cannula (HHHFNC) treatment in preterm infants. We found nine studies, but only two were randomized controlled trials. These studies show that: HFNC application is associated to the delivery of continuous distending pressure (CDP) in patients with closed mouth, whose value is proportional to the delivered flow only in smaller infants; the CDP delivered by HFNC is unpredictable and present large inter-patient and intra-patient variability; the use of recently available HHHFNC devices is effective in minimizing nasal mucosa injuries compared to traditional HFNC; the effectiveness of HHHFNC versus NCPAP for the treatment of apnoea of prematurity, respiratory distress syndrome, and the prevention of extubation failure, has been poor investigated and firm conclusions cannot be drawn on this matter. In conclusion, on the basis of published data, the routinary application of HFNC should be limited to patients requiring oxygen-therapy, HHHFNC devices should be preferred to HFNC, but their employment as an alternative to NCPAP should wait for the conclusion of randomized controlled trials.

Effect of a high-flow open nasal cannula system on obstructive sleep apnea in children

Abstract: Obstructive sleep apnea (OSA) in children is attributed to upper airway collapse1–3 that is associated with intermittent hypoxemia, neurocognitive dysfunction,4–8 and cardiovascular morbidity.9–12 Moreover, recent data suggest that milder degrees of obstructive sleep-disordered breathing are associated with neurobehavioral deficits,13,14 highlighting the social and medical burdens of sleep-disordered breathing in children. Treatment of sleep apnea in children includes both medical15 and surgical options.16 Adenotonsillectomy is the treatment of choice for the presence of adenoid and tonsillar hypertrophy with OSA. For children who are not suitable candidates for surgery, refuse adenotonsillectomy, or have residual sleep apnea after surgical intervention, continuous positive airway pressure (CPAP)17 is the most effective treatment option. CPAP, however, is encumbered by suboptimal adherence,18 leaving a large number of children untreated. Therefore, alternative therapeutic strategies to CPAP are required to treat OSA in children more effectively. Recently, we demonstrated that air delivered at a high flow rate through a nasal cannula (treatment with nasal insufflation [TNI]) alleviated upper airway obstruction in adults with OSA.19 Children with upper airway obstruction during sleep, however, differ markedly with regard to the distribution of obstructive events. They have obstructive apneas predominantly during rapid eye movement (REM) compared with nonrapid eye movement (NREM) sleep.20 In contrast to adults, children commonly exhibit periods of prolonged stable partial upper airway obstruction during sleep, including during NREM sleep.21 Thus, whereas the rate of obstructive events per hour of sleep (apnea-hypopnea index [AHI]) allows for quantification of changes in upper airway obstruction for REM sleep, other measures are needed to assess upper airway obstruction during NREM sleep. It has been demonstrated previously that the inspiratory time relative to the duration of the respiratory cycle, the inspiratory duty cycle, increases linearly with the degree of upper airway obstruction.22–24 Therefore, we determined the effect of TNI on upper airway obstruction in children by assessing both the AHI and the inspiratory duty cycle. We hypothesized that TNI would alleviate upper airway obstruction during both REM and NREM sleep and that, in a significant proportion of children, improvements in the AHI would be similar to CPAP.

Unobtrusive interface systems

Abstract: An apparatus for delivering a flow of breathable gas to a patient for the treatment of Sleep Disordered Breathing (SDB) that is less obtrusive includes a nasal cannula, cannulae (2a, 2b), prongs, or pillows and may be sealed or unsealed with the nares of the patient in use. The cannula, pillows or prongs may be positioned on the face of the patient by a headgear (6). The cannula, pillows or prongs may be smaller, lighter, and/or less visible than other nasal cannula, cannulae, pillows or prongs and may therefore be less obtrusive to the patient.

Accuracy of postoperative end-tidal Pco2 measurements with mainstream and sidestream capnography in non-obese patients and in obese patients with and without obstructive sleep apnea.

Abstract: BACKGROUND Obtaining accurate end-tidal carbon dioxide pressure measurements via nasal cannula poses difficulties in postanesthesia patients who are mouth breathers, including those who are obese and those with obstructive sleep apnea (OSA); a nasal cannula with an oral guide may improve measurement accuracy in these patients. The authors evaluated the accuracy of a mainstream capnometer with an oral guide nasal cannula and a sidestream capnometer with a nasal cannula that did or did not incorporate an oral guide in spontaneously breathing non-obese patients and obese patients with and without OSA during recovery from general anesthesia. METHODS The study enrolled 20 non-obese patients (body mass index less than 30 kg/m) without OSA, 20 obese patients (body mass index greater than 35 kg/m) without OSA, and 20 obese patients with OSA. End-tidal carbon dioxide pressure was measured by using three capnometer/cannula combinations (oxygen at 4 l/min): (1) a mainstream capnometer with oral guide nasal cannula, (2) a sidestream capnometer with a nasal cannula that included an oral guide, and (3) a sidestream capnometer with a standard nasal cannula. Arterial carbon dioxide partial pressure was determined simultaneously. The major outcome was the arterial-to-end-tidal partial pressure difference with each combination. RESULTS In non-obese patients, arterial-to-end-tidal pressure difference was 3.0 +/- 2.6 (mean +/- SD) mmHg with the mainstream capnometer, 4.9 +/- 2.3 mmHg with the sidestream capnometer and oral guide cannula, and 7.1 +/- 3.5 mmHg with the sidestream capnometer and a standard cannula (P < 0.05). In obese non-OSA patients, it was 3.9 +/- 2.6 mmHg, 6.4 +/- 3.1 mmHg, and 8.1 +/- 5.0 mmHg, respectively (P < 0.05). In obese OSA patients, it was 4.0 +/- 3.1 mmHg, 6.3 +/- 3.2 mmHg, and 8.3 +/- 4.6 mmHg, respectively (P < 0.05). CONCLUSIONS Mainstream capnometry performed best, and an oral guide improved the performance of sidestream capnometry. Accuracy in non-obese and obese patients, with and without OSA, was similar.

Supplemental oxygen delivery system

Abstract: A supplemental oxygen delivery system is described in which Aerosol is delivered into a housing (10, 20,) which sits in the circuit from the supplemental oxygen supply and optional humidifier. The supplemental oxygen passes through this chamber (10, 20) in which the aerosol is located, and collects the aerosol transporting it to a patient via a nasal cannula (3) or a face mask (4). An aerosol generator (9) is mounted to the housing (10, 20) and delivers aerosol into an oxygen stream (13) flowing between an inlet (14) and an outlet (15) of the housing (10). The housing (10) also has a removable plug (16) in the base (17) thereof for draining any liquid that accumulates in the housing (10). There is no disruption of oxygen delivery to patients using nasal cannulas who currently have to use a separate face-mask when receiving nebulized medication.

Flow-through versus sidestream capnometry for detection of end tidal carbon dioxide in the sedated patient

Abstract: Background End tidal carbon dioxide (ETCO2) in non-intubated patients can be monitored using either sidestream or flow-through capnometry [Yamamori et al., J Clin Monit Comput 22(3):209–220, 2008]. The hypothesis of this validation study is that, flow-through capnometry will yield a more accurate estimate of ETCO2 than sidestream capnometry when evaluated in a bench study during low tidal volumes and high oxygen administration via nasal cannula. Secondarily, when ETCO2 from each is compared to arterial CO2 (PaCO2) during a study in which healthy, non-intubated volunteers are tested under normocapnic, hypocapnic and hypercapnic conditions, the flow-through capnometer will resemble PaCO2 more closely than the sidestream capnometer. This will be especially true during periods of lower minute ventilation and high oxygen flow rates via mask in non-intubated, remifentanil sedated, healthy volunteers whose physiologic deadspace is small.

Effect of nasal cannula oxygen administration on oxygen concentration at facial and adjacent landmarks.

Abstract: An oxygen-enriched atmosphere enhances the potential for operating-room fires. We thus determined oxygen concentrations at various facial landmarks during oxygen administration via nasal cannulae. Thirteen supine volunteers were draped similarly to patients undergoing a cervical-node biopsy. Oxygen was delivered in random order through nasal cannulae at rates of 2, 4, and 6 l x min(-1). Oxygen concentration was measured at pre-determined facial landmarks and also distal to the drape at non-facial sites. At a flow of 2 l x min(-1), oxygen concentrations exceeded 23% only within a few centimetres of the nasal cannula. Concentration increased as a function of flow, but rarely exceeded 26%. At all flow rates, concentrations distal to the drape were or = 4 l x min(-1).

Fibroscopy in patients with hypoxemic respiratory insufficiency: Utility of the high-flow nasal cannula

Abstract: Summary We report the first case of a patient with severe acute respiratory failure who underwent fibrobronchoscopy with oxygen administration provided by high-flow nasal cannula. We present the case of a patient with severe myasthenia gravis who was admitted to the Department of Intensive Care Medicine of our hospital with severe acute respiratory failure. The muscle weakness inherent to the patient's underlying condition made expectoration of respiratory secretions difficult and led to the development of bilateral atelectasis. Non-invasive mechanical ventilation sessions were established, but there was no significant clinical improvement; hence, oxygen administration by humidified high-flow nasal cannula (Optiflow™, Fisher & Paykel, New Zealand) was decided. The patient experienced a subjective improvement, a decrease in respiratory rate, and an improvement in oxygenation, which, following appropriate premedication, allowed diagnostic–therapeutic bronchoscopy to be performed at bedside, without requiring endotracheal intubation or mechanical ventilation for the procedure. The improvement experienced by the patient with high-flow nasal cannula, following appropriate premedication, allowed diagnostic–therapeutic bronchoscopy to be performed.

Supplemental oxygen and the incidence of perioperative nausea and vomiting in cesarean sections under subarachnoid block

Abstract: Summary Background and objectives Supplemental oxygen can reduce the incidence of postoperative nausea and vomiting in patients under general anesthesia. The objective of the present study was to determine the efficacy of supplemental oxygen to reduce the incidence of perioperative nausea and vomiting in elective cesareans under subarachnoid block. Methods After induction of standardized subarachnoid block, 94 parturients undergoing surgical delivery were randomly divided to receive 4 L.min -1 of oxygen (Group O) or medical air (Group S) under nasal cannula throughout the procedure. Patients were questioned on the development of nausea and vomiting during the surgery and in the first six and 24 hours after the procedure. Results Demographic and perioperative parameters, as well as the data on the newborn, were comparable in both groups. In Group O, the incidence of nausea during the surgery, in the first 6 hours afterwards, and between 6 and 24 hours was 35%, 30%, and 19%, respectively, while in Group S, it was 35%, 30%, and 19%, respectively. In Group O, the incidence of vomiting was 9%, 11% and 6% in the corresponding periods, and in Group S, 21%, 7% and 7%, respectively. Those differences were not statistically significant. Conclusions The administration of supplemental oxygen from anesthetic induction until the end of the surgery did not reduce the incidence of intra- and postoperative nausea or vomiting in women undergoing cesarean section under subarachnoid block.

Oxygen delivery system

Abstract: Disclosed are apparatus and method for delivering oxygen from an oxygen supply to a person in a convenient, sanitary and organized manner. The oxygen delivery system includes a rail attached to a surface of the room and a sliding trolley attached to the rail. An oxygen supply tube is attached to the oxygen supply and the trolley for transferring oxygen from the oxygen supply to the trolley. The system enables the person to move to various locations in the room while receiving oxygen from the oxygen supply through the oxygen supply tube, the trolley, a drop tube and a nasal cannula, or other breathing device connected to the trolley. The person may guide the trolley around the room by pulling the drop tube in the desired direction of travel.

Oral-nasal cannula system enabling CO2 and breath flow measurement

Abstract: An oral-nasal cannula comprising at least one nasal breath inlet for carbon dioxide (CO2) sampling; and at least one nasal breath inlet for flow measurement, wherein said at least one nasal breath inlet for flow measurement is separated from said at least one nasal breath inlet for CO2 sampling, such that said cannula is configured to facilitate CO2 sampling and flow measurement essentially without cross-interference.

High-Flow Nasal Cannula: A Kinder, Gentler CPAP?

Abstract: 1 he Kaiser HMO system may limit the generalizability of heir results. It is possible that the observed risks are understimates of those that would be observed in a less-advantaged opulation. In conclusion, Petrini et al have provided important ew information about the long-term prognosis of infants orn at late preterm gestational ages. Pediatricians and other roviders of care to late preterm infants should be more igilant for potential neurocognitive problems in their folow-up of such infants. But this new information should also ive us cause for concern about ovulation stimulation and ultiple embryo transfer, and particularly about the rising rate f labor induction. We need to pose the question of whether ore frequent induction might be doing more harm than ood. Future observational studies with clinically detailed atabases from HMOs and other health care systems should ttempt to fill gaps with respect to additional potentially onfounding factors—particularly pregnancy complications, abor induction, and other underlying maternal and fetal auses of preterm birth. It may be, however, that the issue of ow much labor induction is too much can be adequately ddressed only with a randomized trial of labor induction at 4 to 36 weeks for specific maternal or fetal indications. In the eantime, obstetricians, pediatricians, and other care providrs should inform pregnant women of the long-term risks

Prongs for nasal cannula arrangement

Abstract: A nasal cannula arrangement for use as part of systems for delivery respiratory gases to a patient is disclosed. The nasal cannula arrangement includes a manifold part 35 adapted to receive gases from a delivery conduit 62. The manifold 35 includes one and preferably a pair of prongs 33,34 extending upward and curving towards the rear of the manifold 35. The prongs 33,34 are inserted into the nostrils of the patient and deliver gases to a patient. The prongs 33,34 have a cut out on the real side. The cut out forms a gases outlet 41 in the prongs 33,34 and are shaped such that the area of the cut out area is greater than the cross sectional area of the prongs 33,34 at the entry point to the prongs 33,34. The prongs 33,34 may include a reinforcing feature 100.

65-Year-Old Man With Persistent Fever

Abstract: © 2009 Mayo Foundation for Medical Education and Research A 65-year-old man was transferred to our institution for evaluation of fever. His symptoms included subjective fever, cough productive of creamy white sputum, and nasal congestion of 3 months’ duration. He denied dyspnea, hemoptysis, weight loss, or night sweats. Approximately 10 days before admission, he had been seen by his primary care physician for worsening of symptoms and was treated empirically with an undefined antibiotic. Subsequently, palpitations and severe fatigue developed, and the patient was admitted to a local hospital, where he was noted to be febrile and hypoxic with pulse oximetry readings in the high 80% range. Acute coronary syndrome was excluded, and ceftriaxone and moxifloxacin were initiated empirically. Computed tomography (CT) of the chest without intravenous contrast was performed. Compared with chest CT performed 4 years earlier, no new pulmonary infiltrate was evident; however, both the superior and the lateral aspect of the right hilum were more prominent than in the previous study and were suspicious for adenopathy. The patient was transferred to our institution approximately 2 days later for further evaluation. On admission, the patient’s main symptoms were fever, fatigue, palpitations, mild chest discomfort, cough, and nasal congestion. Findings on the rest of the systems review were unremarkable. The patient had a history of asthma, chronic sinusitis, seasonal allergic rhinitis, aspirin intolerance, nasal polyposis with multiple prior polypectomies, and benign prostatic hypertrophy. His medical regimen consisted of omeprazole, atorvastatin, doxazosin, irbesartan-hydrochlorothiazide, montelukast, and fluticasone-salmeterol. His family history was notable for a sibling’s death due to lung cancer at age 28 years. On physical examination, the patient had a temperature of 37.9 °C, heart rate of 95 beats/min (regular), blood pressure of 149/74 mm Hg, respiratory rate of 18 breaths/min, and pulse oximetry of 94% while breathing 3 L of oxygen via nasal cannula. He appeared comfortable and had palpable anterior cervical chain and submandibular lymph nodes, jugular venous distension 3 cm above the clavicle, faint inspiratory crackles at both lung bases, and a grade 2/6 systolic murmur best heard at the apex. Findings on the rest of the physical examination were normal. Laboratory results are listed in the Table.

Flexible upper videoendoscopy through a modified endoscopy mask in infants and young children.

Abstract: UNLABELLED Esophagogastroduodenoscopy (EGD) is considered an essential diagnostic and therapeutic procedure in the pediatric population. Although generally safe, EGD has the potential for airway complications. We routinely use general anesthesia to carry out EGD in patients younger than 10 years. In the past, these patients received oxygen either through a nasal cannula or were intubated; both modalities have drawbacks and may be associated with complications. Here we report our experience using a modified endoscopy mask, devised primarily for bronchoscopy, for upper endoscopy in children under general anesthesia. RESULTS Two hundred forty children (122 boys and 118 girls) participated in the study. Age range was 7 to 135 months (mean 60.7 +/- 34.4 months). All patients maintained a stable hemodynamic status throughout the procedure. Ventilation was satisfactory in 230 patients. It was difficult in 9 patients, and external airway maneuvers had to be applied. Ventilation was impossible in only 1 patient (10 months old), and endotracheal intubation was performed. There were no procedure-related complications. CONCLUSION The modified endoscopy mask is efficient and safe and should be recommended for routine use for upper endoscopy under general anesthesia in children older than 6 months.

Fatal pneumoperitoneum caused by nasopharyngeal oxygen delivery after transoesophageal echocardiography for cardiac surgery.

Abstract: We report a case of fatal post-operative pneumoperitoneum in a patient who had undergone urgent mitral valve surgery. In the absence of a proven cause of the pneumoperitoneum (refusal by the family of an autopsy), we can only propose a hypothesis for its origin. The most probable one is that forceful or sustained retrograde flexion of the transoesophageal echocardiographic probe created a lower oesophagus or gastric rupture and that oxygen flow administered by the nasal cannula went straight to the abdominal cavity, leading to tension pneumoperitoneum.

Humidified high flow nasal cannula for respiratory support in infants

Abstract: Humidified high flow nasal cannula (HHFNC) has been suggested as an alternative form of respiratory support for preterm infants with apnea, respiratory distress syndrome or chronic lung disease, they appear to be easy to apply and care for. Although, HHFNC may provide positive end-expiratory pressure (PEEP), limited evidence is available to support the specific role, efficacy, and safety of HHFNC in newborns. The evidence suggests that HHFNC provides inconsistent and relatively unpredictable positive airway pressure, but may be effective in the treatment of some neonatal respiratory conditions while being more user-friendly for caregivers than conventional nCPAP. Caution should be exercised in the use of HHFNC in neonates until further evidence is available to clearly delineate its role and support its safety and efficacy. The current controversy and the available data regarding the use of HHFNC in providing noninvasive respiratory support in newborn infants are reviewed and presented herein.

Urgent hyperbaric oxygen therapy (HBO2) for acute carbon monoxide poisoning.

Abstract: BACKGROUND A case with severe acute carbon monoxide poisoning is presented the 17-year-old female was previously healthy and non-smoker. She was found lying unconscious on the floor. Although her father smelled a pungent odor and felt headache, dizziness, agitation, and dyspnea after entering the room, he had realized that she was apneic and than he gave her mouth-to-mouth respiration for 10 minutes before breathing resumed. She was taken to a local hospital and received oxygen via nasal cannula (10 L/minute) within 30 minutes. First cranial tomography (CT) findings were unremarkable other than brain edema. She was admitted to an intensive care unit. No verbal communication was present. Her Glascow score was 6, modified APACHE II score was 24 and MODS score was 6. Arterial blood gas (ABG) sample analysis revealed metabolic acidosis and hypoxemia with pH 7.2. Carboxyhemoglobin (COHb) level was 51.4 % and electrocardiography showed a mild ST-segment depression over anterior leads, suggestive of myocardial ischemia. Routine chest X-ray, serum biochemistry and complete blood counts were unremarkable. HBO2 therapy was immediately initiated within 4 hours after exposure to CO in a multiplace chamber. HBO2 therapy was withheld after completing ten session. Her symptoms improved after first HBO2 therapy and COHb level was 24%. She was discharged on day 4. She had a normal follow-up six weeks after discharge. It has been shown that HBO2 therapy has provided prominent improvement in the early and late effects of carbon monoxide poisoning and this improvement is more quick and more effective in acute phase (Ref. 10). Full Text (Free, PDF) www.bmj.sk.

Index of Suspicion in the Nursery

Abstract: A female infant presents with extreme tachycardia and tachypnea on the sixth day after birth. She was born at 35–1/7 weeks’ gestation dated by the mother's last menstrual period and first trimester ultrasonography. The 26-year-old G1P0 mother has a history of anemia and fibroids. Prenatal laboratory results were: AB+ blood type, syphilis screen-nonreactive, hepatitis B surface antigen-negative, human immunodeficiency virus-negative, rubella-immune, and gonorrhea- and chlamydia-negative. Group B streptococcal culture was pending at delivery. The mother presented in preterm labor several hours after rupture of membranes at home with clear amniotic fluid. The infant was delivered by cesarean section due to progressing preterm labor and a frank breech presentation. The infant initially had poor color, tone, heart rate, and respiratory effort, necessitating neonatal resuscitation. After 2 minutes of positive pressure ventilation, the infant stabilized. Apgar scores were 5 at 1 minute and 8 at 5 minutes after delivery. After resuscitation, the infant continued to have nasal flaring and increased work of breathing and was transferred to the neonatal intensive care unit (NICU) for further management. Initial vital signs were: On physical examination, the infant had mild respiratory distress and a soft 2/6 systolic murmur over the apex, but other findings were normal. She was placed on oxygen via nasal cannula while an initial chest radiograph and blood gas were obtained. An intravenous catheter was placed and infusion of a 10% dextrose solution at 60 mL/kg per day was started. A complete blood count and blood culture were obtained and empiric antibiotic therapy with ampicillin and gentamicin for possible sepsis was initiated. The infant's respiratory …

Nasal cannula oxygen administration and oxygen concentration around the face

Abstract: 1 Machotta A, Hoeve H. Airway management and fiberoptic tracheal intubation via the laryngeal mask in a child with Marshall-Smith syndrome. Pediatric Anaesthesia 2008; 18: 341–2. 2 Hung KC, Shiau JM, Yang YL, Tseng CC. Fiberoptic tracheal intubation through a classicial laryngeal mask airway under spontaneous ventilation in a child with Treacher Collins Syndrome. Acta anaesthesiologica Taiwanica 2006; 44: 223–6. 3 Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult airway society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59: 675–94. 4 Panjwani S, Seymour P, Pandit JJ. A manoeuvre for using the flexible fibreoptic bronchoscope through the intubating laryngeal mask airway. Anaesthesia 2001; 56: 696–7.

25-year-old woman with new-onset seizures.

Abstract: © 2009 Mayo Foundation for Medical Education and Research A 25-year-old woman presented to the emergency department (ED) with a history of 2 seizures before presentation. According to the family, the first seizure occurred around 3 PM on the day of presentation. It was described by the paramedics and bystanders as a generalized tonic-clonic event lasting about 3 minutes. The patient had a second seizure en route to the hospital and another in the ED. She exhibited confusion between episodes. The third episode occurred about 3:30 PM and was witnessed by ED physicians who described generalized body stiffening followed by left upper extremity elevation, left lower extremity straightening, rightward head turn, urinary incontinence, and an oxygen desaturation to 67% on pulse oximetry. Subsequently, the patient was confused and unable to detail her medical history. Her parents provided her history, which was notable for acute myelogenous leukemia (AML) diagnosed at 18 months of age and treated with radiation and chemotherapy (systemic and intrathecal). The patient had had a basal cell carcinoma surgically excised from the right posterior portion of her scalp in 2006. She was taking no medications, and the family history was negative for seizures, endocrine disorders, or neoplasms. She had no history of tobacco or illicit drug use, falls, or head trauma. Her parents reported no preceding fever, infectious symptoms, or other systemic complaints. Physical examination revealed the following: temperature, 36.4oC; blood pressure, 108/61 mm Hg; heart rate, 112 beats/min (sinus tachycardia); respiratory rate, 21 breaths/ min; and oxygen saturation, 100% on 3 L/min of oxygen via nasal cannula. The patient was young and well-nourished but unable to cooperate or follow commands. Head and neck examination revealed a supple neck and no evidence of tongue lacerations or oropharyngeal lesions. Hair loss and a scar from previous excision of the basal cell carcinoma were evident on the posterior aspect of the scalp. Lung sounds were notable for rhonchi bilaterally, which were transmitted from the oral airway. Cardiovascular examination revealed tachycardia but no appreciable murmurs, rubs, or gallops. Abdominal examination findings were unremarkable. Examination of the extremities revealed no cyanosis, edema, or skin lesions. Neurologically, the patient was unresponsive verbally and did not obey commands. Her eyes were closed and did not open to noxious stimuli. There was no evidence of facial asymmetry. Cranial nerve examination revealed 6mm pupils that were briskly reactive to light bilaterally. Funduscopic examination yielded normal findings and no papilledema. The remainder of the patient’s brainstem reflexes, including cough and gag, were intact. Segmental motor strength could not be assessed. However, noxious stimuli elicited purposeful localizing and withdrawal responses in upper and lower extremities symmetrically. Deep tendon reflexes were 2+ (Medical Research Council scale) and symmetric in the biceps, triceps, patella, and Achilles tendon. The left toe was upturning (Babinski sign), while responses in the right toe were equivocal.

Index of Suspicion in the Nursery

Abstract: Twins conceived by in vitro fertilization are delivered at 25–5/7 weeks’ gestation. Twin A has a birthweight of 1,025 g, receives surfactant at 12 hours after birth for respiratory distress syndrome, and is extubated to nasal continuous positive airway pressure (CPAP) on the second postnatal day. She receives ampicillin and cefotaxime for 10 days due to suspected sepsis and placental cultures positive for viridans group streptococci. Gavage feedings using the mother's milk are initiated on postnatal day 4 and increased gradually over 5 days. On postnatal day 9, the baby is transferred to the neonatal intensive care unit (NICU) for evaluation of apnea, continued respiratory distress, and feeding intolerance. She is maintained on caffeine therapy. On postnatal day 12, nasal CPAP is discontinued; she is placed on nasal cannula oxygen and later is weaned to room air. Gavage feedings using expressed mother's milk are continued and slowly advanced to full-volume feedings over 14 days. On postnatal day 16, human milk fortifier is added to expressed human milk. On postnatal day 28, a premature formula is used in addition to human milk for caloric supplementation. On postnatal day 34, because of insufficient lactation, the infant receives premature formula (24 cal/oz). She continues to tolerate her feedings, showing adequate weight gain. On postnatal day 55 (33 weeks postconception), the infant begins having frequent oxygen desaturations detected by pulse oximetry, loss of head control, reduced swallowing with retained oral secretions, and choking. Her symptoms persist despite supplemental oxygen by nasal cannula and head positioning. Bowel movements decrease from her usual three to four per day to one to two small smears. The baby's respiratory status continues to decline, with worsening episodes of apnea, bradycardia, and oxygen desaturations, and she is placed on nasal CPAP. She appears mottled and lethargic, with global hypotonia. Sepsis …