Wide fluctuations in partial pressure of carbon dioxide (PaCO 2 ) can potentially be associated with neurological and lung injury in neonates. Blood gas measurement is the gold standard for assessing gas exchange but is intermittent, invasive, and contributes to iatrogenic blood loss. Non-invasive carbon dioxide (CO 2 ) monitoring has become ubiquitous in anesthesia and critical care and is being increasingly used in neonates. Two common methods of non-invasive CO 2 monitoring are end-tidal and transcutaneous. A colorimetric CO 2 detector (a modified end-tidal CO 2 detector) is recommended by the International Liaison Committee on Resuscitation (ILCOR) and the American Academy of Pediatrics to confirm endotracheal tube placement. Continuous CO 2 monitoring is helpful in trending PaCO 2 in critically ill neonates on respiratory support and can potentially lead to early detection and minimization of fluctuations in PaCO 2 . This review includes a description of the various types of CO 2 monitoring and their applications, benefits, and limitations in neonates.

The 7th edition of the Textbook ofNeonatal Resuscitation recommends administration of epinephrine via an umbilical venous catheter (UVC) inserted 2–4 cm below the skin, followed by a 0.5-mL to 1-mL flush for severe bradycardia despite effective ventilation and chest compressions (CC). This volume of flush may not be adequate to push epinephrine to the right atrium in the absence of intrinsic cardiac activity during CC. The objective of our study was to evaluate the effect of 1-mL and 2.5-mL flush volumes after UVC epinephrine administration on the incidence and time to achieve return of spontaneous circulation (ROSC) in a near-term ovine model of perinatal asphyxia induced cardiac arrest. After 5 min of asystole, lambs were resuscitated per Neonatal Resuscitation Program (NRP) guidelines. During resuscitation, lambs received epinephrine through a UVC followed by 1-mL or 2.5-mL normal saline flush. Hemodynamics and plasma epinephrine concentrations were monitored. Three out of seven (43%) and 12/15 (80%) lambs achieved ROSC after the first dose of epinephrine with 1-mL and 2.5-mL flush respectively (p = 0.08). Median time to ROSC and cumulative epinephrine dose required were not different. Plasma epinephrine concentrations at 1 min after epinephrine administration were not different. From our pilot study, higher flush volume after first dose of epinephrine may be of benefit during neonatal resuscitation. More translational and clinical trials are needed.

No abstract

Introduction Although sickle cell trait (SCT) is considered a benign condition, evidence has been accumulating for related complications, including isothenuria, hematuria, exercise-induced death and splenic infarction.Most splenic infarctions are reported during a hypoxic state.Non-hypoxic related splenic infarction in a patient with SCT and EBV infection has been reported once.Here we present the second case of such association. Case Report An otherwise healthy 7-year-old African American male presented with worsening LUQ abdominal pain associated with emesis, dark-colored urine and low-grade fever. There was no history of trauma. Family history was positive for SCD. On presentation, the patient had a temperature of 38.2 °C and was tachycardic. Physical examination revealed scleral icterus and conjunctival pallor. Abdomen was soft, but the spleen was tender and palpable 6 cm below the costal margin. Laboratory studies showed hemoglobin of 7.2 g/dL, MCV 72.6 fL, leukocytes 14 X 109/L with 73% neutrophils, platelet count 136 X 109/L, and reticulocyte count 8%. Peripheral blood smear didn't reveal sickling, spherocytosis nor elliptocytosis. Total bilirubin was 3.5 mg/dL, direct bilirubin 0.6 mg/dL, ALT 13 U/L, AST 57 IU/L, LDH 476 IU/L. The Direct Coombs were negative. The D-dimer was positive. The Abdominal X-ray was negative, however abdominal ultrasound showed an enlarged spleen, 13.1 cm in longitudinal diameter. An Abdominal MRI showed splenic enlargement, 13 cm in longitudinal diameter, with non-enhancing 4 cm density in anterior aspect and minimal left pleural effusion. The thrombophilia work-up was negative. EB VCA IgG and IgM antibodies levels were high (> 8 and 1 AI, respectively), consistent with late acute infection. The CMV serology was negative. G6PD screening was negative. Hemoglobin electrophoresis revealed HbA 63.9%, HbA2 3.1%, HbF 0.0%, and HbS 33%. Patient was managed conservatively with RBCs transfusion, hydration and pain control and discharged home once stable. Discussion SCT is generally considered a benign hematological condition, still evidence has been accumulating for related complications. In United States, SCT affects 6-9% of the African American population, and 0.01-0.05% of the remaining population. Splenic infarction is commonly associated with SCD, but rarely with SCT. Reported cases of splenic infarction in SCT have been predominantly related to hypoxic states, primarily in a high altitude setting. Still there have been limited reports in non-hypoxic conditions. (Kark JA and Ward FT Semin Hematol1994).One case of non-hypoxic related splenic infarction in a patient with SCT and acute EBV infection was reported (Symeonidis A et al Acta Haematol 2001). Here we report the second case. We present a non-obese, previously healthy male with no evidence of hypoxia, high altitude setting, or intensive exercise. He suffered a splenic infarction during the acute phase of EBV infection. His initial presentation was consistent with hemolytic anemia and indirect hyperbilirubinemia, which led to further work-up and the diagnosis of SCT. We postulate that hemolysis resulted from hypersplenism. Possible factors leading to infarction in SCT are the induction of sickling and the presence of a hypercoagulable state. The exposure of these HbAS erythrocytes to lower pH and hypoxia in the splenic circulation likely promotes sickling and, as a consequence, splenic infarcts. Subjects with HbAS have significantly increased levels of D-dimer, thrombin-antithrombin TAT complexes, prothrombin fragment 1.2 (F1.2) and absolute monocytosis. The African American population has a 7% risk of VTE attributable to HbAS compared to an attributable risk of 3% for prothrombin G20210A mutation in the Caucasian population. Contributing factors to splenic infarction in the presence of acute EBV infection can be thrombophilia, thrombotic microangiopathy and rapid splenic enlargement. Moreover, during an EBV infection, acute expansion of splenic red and white pulp, as well as increased blood flow and loosening of the reticular network, make the organ friable. HbS existing under such conditions may be quite unstable, which can induce sickling. Disclosures No relevant conflicts of interest to declare.

The yield of outpatient echocardiograms varies based on the indication for the echocardiogram and the age of the patient. The purpose of this study was to determine the cumulative yield of outpatient echocardiograms by age group and reason for the test. A secondary aim was to determine the predictors of a positive echocardiogram in an outpatient cardiology clinic at a large community teaching hospital. We retrospectively reviewed the charts of 891 patients who had a first-time echocardiogram between 2011 and 2015. Positive yield was defined as echocardiographic findings that explained the reason for the echocardiogram. The overall positive yield was 8.2%. Children between birth and 3 months of age had the highest yield (34.2%), and children between 12 and 18 years of age had the lowest yield (1%). Patients with murmurs (18.1%) had the highest yield compared with patients with other signs or symptoms. By age group and reason, the highest yields were as follows: 0 to 3 months of age, murmur (39.2%); 4 to 11 months of age, >1 symptom (50%); and 1 to 5 years of age, shortness of breath (66.7%). Based on our study, the overall yield of echocardiograms in the outpatient pediatric setting is low. Age and symptoms should be considered before ordering an echocardiogram.