I.

Mechanical circulatory support is an invaluable tool in the care of children with severe refractory cardiac and or pulmonary failure. Two forms of mechanical circulatory support are currently available to neonates, infants, and smaller children, namely extracorporeal membrane oxygenation and use of a ventricular assist device, with each technique having unique advantages and disadvantages. The intra-aortic balloon pump is a third form of mechanical support that has been successfully used in larger children, adolescents, and adults, but has limited applicability in smaller children. In this review, we discuss the current experiences with extracorporeal membrane oxygenation and ventricular assist devices in children with cardiac disease.A variety of forms of mechanical circulatory support are available for children with cardiopulmonary dysfunction refractory to conventional management. These devices require extensive resources, both human and economic. Extracorporeal membrane oxygenation can be effectively used in a variety of settings to provide support to critically-ill patients with cardiac disease. Careful selection of patients and timing of intervention remains challenging. Special consideration should be given to children with cardiac disease with regard to anatomy, physiology, cannulation, and circuit management. Even though exciting progress is being made in the development of ventricular assist devices for long-term mechanical support in children, extracorporeal membrane oxygenation remains the mainstay of mechanical circulatory support in children with complex anatomy, particularly those needing rapid resuscitation and those with a functionally univentricular circulation.As the familiarity and experience with extracorporeal membrane oxygenation has grown, new indications have evolved, including emergent resuscitation. This utilization has been termed extracorporeal cardiopulmonary resuscitation. The literature supporting emergent cardiopulmonary support is mounting. Reasonable survival rates have been achieved after initiation of support during active compressions of the chest following in-hospital cardiac arrest. Due to the limitations of conventional circuits for extracorporeal membrane oxygenation, some centres have developed novel systems for rapid cardiopulmonary support. Many centres previously considered a functionally univentricular circulation to be a contraindication to extracorporeal membrane oxygenation, but improved results have been achieved recently with this complex subset of patients. The registry of the Extracorporeal Life Support Organization recently reported the outcome of extracorporeal life support used in neonates for cardiac indications from 1996 to 2000. Of the 740 neonates who were placed on extracorporeal life support for cardiac indications, 118 had hypoplastic left heart syndrome. There was no significant difference in survival between these patients and those with other defects. It is now common to use extracorporeal membrane oxygenation to support patients with a functional...

We compared labor induced by vaginal misoprostol versus a supracervical Foley catheter and oral misoprostol. Singleton pregnancies at > or = 24 weeks' gestation were randomized to either an initial 25-microg dose of intravaginal misoprostol, followed by 50-microg intravaginal doses at 3- to 6-hour intervals, or a supracervical Foley balloon and 100 microg of oral misoprostol at 4- to 6-hour intervals. Primary outcome was time from induction to delivery. One hundred twenty-six women were randomized to vaginal misoprostol alone (group I) and 106 women to Foley and oral misoprostol (group II). The groups were similar in age, weight, gestational age, parity, indication for induction of labor, and oxytocin use. Cesarean delivery rates at 37% and cesarean indications were similar ( P = 0.25). The time from induction to delivery in group II (12.9 hours) was significantly shorter than that in group I (17.8 hours, P < 0.001). Uterine tachysystole occurred less often in the vaginal misoprostol group (21% versus 39%, P = 0.015). Compared with vaginal misoprostol, delivery within 24 hours was significantly more likely with a Foley balloon and oral misoprostol. The use of terbutaline and peripartum outcomes were similar in the two groups.

The purpose of this study was t o determine the duration of action of a single dose of hetastarch. a synthetic colloid, in hypoalbuminemic dogs. Thirty hypoalbuminemic dogs (albumin concentration, 52.0 g/dL) received l dose of hetastarch each, with an average dose of 18.1 mL/kg. Doses ranged from 7.7 t o 43.9 mL/kg, with the majority of doses (n = 26) in the range of 10 t o 25 mL/kg. Dogs were allotted t o one of several groups: all dogs, dogs with acute gastrointestinal protein loss, dogs with chronic gastrointestinal protein loss, all dogs with gastrointestinal protein loss, and dogs with nongastrointestinal protein loss. Colloid oncotic pressure was measured immediately before and immediately after hetastarch administration, and 12 hours after hetastarch administration. There was a significant ( P < .001) increase in the mean colloid oncotic pressure after hetastarch treatment in all groups, except in the group with acute gastrointestinal protein loss. Twelve hours after hetalbumin (69,000 d) is the principal oncotic protein in A blood, contributing about 75% of normal colloid oncotic pressure; globulins and fibrinogen contribute the remainder.'.' Oncotic pressure of the interstitium of the lung is approximately 50% to 70% that of plasma.' The plasma colloid oncotic pressure helps maintain vascular volume and prevent edema formation, but vascular integrity and normal lymphatic drainage are also important. Interstitial edema will result if the plasma colloid oncotic pressure approaches or decreases below that of the interstitium, or if vascular permeability is altered or lymphatic drainage is compromised. The sequelae to a decrease in colloid oncotic pressure, such as pulmonary or cerebral edema, can be life threatening.Both crystalloid and colloid fluids have been used therapeutically to increase plasma volume.'^' Only about 30% of crystalloid fluids remain in the vascular space 30 minutes after admini~tration.~.' The amount of crystalloid fluid that remains in the vascular space is even less (as low as 10%) in hypo-oncotic patient^.^.' Therefore, treatment of hypooncotic patients with crystalloid solutions increases the risk of development of pulmonary and cerebral In fact, low plasma colloid oncotic pressure has been shown to be associated with increased mortality in critically ill people.',' In light of these findings, colloid solutions are being used to treat hypovolemia, especially in hypo-oncotic patients.Hetastarch is a synthetic polymer of amylopectin that has been hydroxylated,'.' and was originally developed for the effective treatment of hyp~volemia.~ During the past 20 years, hetastarch has been used in humans as an adjunct to pressure was not significantly ( P < ,001) different from the baseline mean colloid oncotic pressure in any of the groups. Twenty-three dogs (77%) survived their illness and were sent home, whereas, 7 (23%) died or were euthanized. The effect of a single dose of hetastarch on raising colloid oncotic pressure in dogs with hypoalbuminemia decreases significantly within 12 hour...

The use of telepathology for clinical applications in Canada has steadily become more attractive over the last 10 years, driven largely by its potential to provide rapid pathology consulting services throughout the country regardless of the location of a particular institution. Based on this trend, the president of the Canadian Association of Pathologists asked a working group consisting of pathologists, technologists, and healthcare administrators from across Canada to oversee the development of guidelines to provide Canadian pathologists with basic information on how to implement and use this technology. The guidelines were systematically developed, based on available medical literature and the clinical experience of early adopters of telepathology in Canada. While there are many different modalities and applications of telepathology, this document focuses specifically on whole-slide imaging as applied to intraoperative pathology consultation (frozen section), primary diagnosis, expert or second opinions and quality assurance activities. Applications such as hematopathology, microbiology, tumour boards, education, research and technical and/or standard-related issues are not covered.