Etomidate for Rapid-sequence Intubation in Young Children: Hemodynamic Effects and Adverse Events

OBJECTIVES: Physicians commonly use etomidate for adult rapid-sequence intubation (RSI), but the manufacturer does not recommend its use for children under 10 years of age due to a lack of data. The authors present their experience with etomidate for pediatric RSI in order to further develop its risk-benefit profile in this age group. METHODS: Trained abstractors reviewed the medical records for all children under 10 years old who received etomidate for RSI between July 1996 and April 2001. RESULTS: 105 children, with an average age of 3 (+/-2.9) years, received a median dose of 0.32 (+/-0.12) mg/kg of etomidate. The systolic blood pressure increased an average of 4 mm Hg (95% CI = -3.3 to 9.2); the diastolic blood pressure increased 7 mm Hg (95% CI = -3.1 to 11) within 10 minutes of receiving etomidate. The heart rate increased an average of 10 beats/min (95% CI = 4.0 to 17.4). Complications included three patients who vomited within 10 minutes of etomidate administration. There were no cases of documented myoclonus, status epilepticus, or new-onset seizures. Thirty-eight patients received corticosteroids during the hospital course, none for suspected adrenal insufficiency. Three patients died, all from severe brain injury. CONCLUSIONS: In children less than 10 years old, etomidate seems to produce minimal hemodynamic changes, and appears to have a low risk of clinically important adrenal insufficiency, myoclonus, and status epilepticus. The association between etomidate and emesis (observed in less than 3% of enrolled patients) remains unclear. For clinical situations in which minimal blood pressure changes during RSI are critical, etomidate appears to have a favorable risk-benefit profile for children under 10 years old.     

The effects of hyponatraemia and subarachnoid haemorrhage on the cerebral vasomotor responses of the rabbit

Impairment of cerebral autoregulation and development of hyponatraemia are both implicated in the pathogenesis of delayed cerebral ischaemia and infarction following subarachnoid haemorrhage (SAH) but the pathophysiology and interactions involved are not fully understood. We have studied the effects of hyponatraemia and SAH on the cerebral vasomotor responses of the rabbit. Cerebrovascular reactivity to hypercapnia and cerebral autoregulation to trimetaphan-induced hypotension were determined in normal and hyponatraemic rabbits before and 6 days after experimental SAH produced by two intracisternal injections of autologous blood. Hyponatraemia (mean plasma sodium of 119 mM) was induced gradually over 48 h by administration of Desmopressin and intraperitoneal 5% dextrose. Sham animals received normal saline. The cerebrovascular reactivity (% change +/- SD in cortical CBF/mm Hg PaCO2, measured by hydrogen clearance) of hyponatraemic (4.8 +/- 3.0%) and SAH (1.3 +/- 2.0%) animals was significantly less (p less than 0.05) than control (11.6 +/- 4.0%) and sham (8 +/- 2.0%) animals, whereas the reactivity of hyponatraemic-SAH animals was preserved (9.8 +/- 6.0%). Hyponatraemia and SAH alone each significantly impaired CBF autoregulation but their combined effects were not additive. Systemic hyponatraemia impairs normal cerebral vasomotor responses but does not augment the effects of experimental SAH in the rabbit.     

Administration of kainic acid and colchicine alters mu and lambda opiate binding in rat hippocampus

Quantitative in vitro autoradiography was used to assess the effects of kainic acid (KA) and colchicine (COL) on mu and lambda opiate binding in the rat hippocampus. Rats were treated with either systemic KA, a neurotoxin that damages CA3 pyramidal cells and causes seizures and wet-dog shakes, or intrahippocampal COL to destroy dentate granule cells and their mossy fibers, or both toxins. Moderate levels of mu binding were detected in the pyramidal layer and in the stratum lacunosum-moleculare; binding was greater in the ventral hippocampus. Levels of mu binding were markedly increased in all regions 48 h after treatment with KA. Two weeks after COL treatment, there was a modest decrease in mu binding; COL plus KA gave results similar to COL alone. Dense lambda binding was present over the mossy fibers in the stratum lucidum, but was absent over the pyramidal layer. In contrast to mu binding, lambda binding was greater in the dorsal hippocampus. KA alone had little effect on lambda binding, whereas COL alone caused large decreases. KA plus COL caused even larger decreases in lambda binding, to as much as 85% below control. These results demonstrate that mu and lambda binding are localized to different parts of the hippocampus, respond differently to neurotoxin lesions, and likely serve different roles in this brain region. The number of mu sites is responsive to the release of enkephalin; these receptors appear to be linked to opiate-induced hippocampal seizure activity, especially wet-dog shakes. Lambda sites may serve as autoreceptors on mossy fibers.     

Castleman disease: surgical cure in pediatric patients

Castleman disease is a rare disorder characterized by lymphoid hyperplasia which rarely manifests in children. We present 2 cases which highlight both histologic variants of this disease, and provide suggestions regarding workup and treatment with the goal of making practitioners aware of Castleman disease in the differential diagnosis of a child presenting with vague symptoms.     

Surgical treatment of displaced olecranon fractures by tension band wiring technique

Forty-five displaced olecranon fractures including 14 accompanying dislocated radial heads and seven radial head fractures were treated over a 13-year period by the tension band wiring technique. The use of supplemental internal fixation when necessary allows excellent results with the use of this technique, even in the presence of severe comminution or radial head dislocation. Primary silicone radial head implants fractured in all three patients in which they were used, necessitating repeat surgery in two patients to date. While loss of motion in terminal extension was a common aftermath of displaced olecranon fracture (59%), it was usually minor and functionally insignificant. True Kirschner-wire migration was not a common problem and can probably be eliminated by proper technique. The presence of gaps in the intraarticular surface of the semilunar notch of the ulna produced no ill effects and was compatible with excellent results. If only those cases with isolated olecranon fractures in this series are considered, there were good and excellent results in 29 of 30 cases (97%). Excision of the olecranon fragment(s) should be reserved for those cases when anatomic restoration cannot be achieved with internal fixation.     

Results of prevention programs with adolescents

Programs for preventing smoking and alcohol and drug abuse have radically changed in the past decade. Instead of being regarded as a health or discipline problem that involves only a few deviant adolescents, drug use has begun to be viewed as social behavior that is functional for adolescents, not capricious, and is normative for that population. The most successful prevention programs have sought to delay the onset of tobacco use. Based on theoretical and etiological research, these programs target factors that have repeatedly been predictive of adolescent smoking, alcohol and drug use. The programs teach adolescents (1) why people their age smoke tobacco or use alcohol and drugs; (2) how these meanings get established by peers, older role models and advertising; (3) how to resist these influences to smoke or to use alcohol and drugs; and (4) life skills and competencies to counterbalance the functions that drug use serves. Because of the association with the onset of smoking and the onset of using other drugs, these strategies are being studied for alcohol use and other drugs. In addition, elected peer leaders are trained to conduct these activities with their classmates and act as new role models for non-use. Evaluations of these approaches are optimistic. Studies in northern California and Minnesota reveal 50-70% reductions in the onset of smoking. Botvin's 'Life Skills Training' program demonstrates success in delaying heavy alcohol and marijuana use.