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Background: Hypertension occurs in up to 3% of neonates admitted to the Neonatal Intensive Care Unit (NICU), and is a potentially under-recognized condition. The aim of this study was to examine the incidence of documented and undiagnosed hypertension from the 24-center Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) database, and to assess risk factors for hypertension according to gestational age., Methods: Diagnosed hypertension was documented if an infant had a discharge diagnosis of hypertension and/or discharged on antihypertensive medications. Undiagnosed hypertension was defined when infants did not have a diagnosis of hypertension, but >50% of the lowest mean, diastolic and systolic blood pressure recordings were >95 th percentile for gestational age., Results: Of the 2162 neonates enrolled in the study, hypertension was documented in 1.8%. An additional 3.7% were defined as having undiagnosed hypertension. There was a significant correlation with neonatal hypertension and acute kidney injury (AKI). Additional risk factors for neonatal hypertension were hyperbilirubinaemia, Caucasian race, outborn, vaginal delivery, and congenital heart disease. Protective factors were small for gestational age, multiple gestations, and steroids for fetal maturation., Conclusions: Neonatal hypertension may be an under-recognized condition. AKI and other risk factors predispose infants to hypertension.

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Background: Previous methods described to measure bladder pressure require additional setup, making these techniques complex and time consuming. We describe a simple U-tube technique and investigate its accuracy for measuring intra-abdominal pressure (IAP)., Methods: Warm saline was infused into the peritoneum of five pigs to increase IAP. Indirect methods of measuring IAP included bladder, inferior vena cava (IVC), and gastric pressures. Bladder pressure was measured by both the standard and U-tube technique. IVC pressure was measured via a femoral line and gastric pressure was transduced through an orogastric tube. In addition, 30 patients undergoing laparoscopy were prospectively investigated. Insufflated abdominal pressure readings were obtained and compared with bladder pressures measured by the U-tube technique (n = 20) and standard technique (n = 10)., Results: In the animal study, U-tube manometry had the highest degree of correlation (r(2) = 0.98) and the lowest bias (0.51 +/- 1.63 mm Hg). The bladder pressure measured by the U-tube technique was between 0.1 and 0.9 mm Hg less than the directly measured IAP (95% confidence interval). There was a high degree of correlation between IAP and the standard technique for bladder pressure (r(2) = 0.93), IVC pressure (r(2) = 0.93), and gastric pressure (r(2) = 0.90). Strong correlation also existed between the U-tube and standard techniques for measuring bladder pressure (r(2) = 0.96). In humans, a strong correlation between insufflated abdominal pressure and bladder pressure (U-tube technique, r(2) = 0.79; standard technique, r(2) = 0.53) was also encountered., Conclusion: The accuracy of the U-tube manometry technique for measuring intra-abdominal pressure is comparable to previously described techniques. The U-tube technique is simple, does not require additional equipment, and can be performed by any member of the medical team.

Background: Depression of myocardial contractility occurs in septic shock., Methods: Fourteen pigs were instrumented to measure cardiopulmonary dynamics after a challenge of Escherichia coli endotoxin (lipopolysaccharide endotoxin, LPS). A volumetric Swan-Ganz catheter was placed via the jugular vein, and a carotid arterial line was placed into the aortic root. Eight pigs received LPS alone and six pigs received tumor necrosis factor monoclonal antibody (TNF MAb) 15 minutes before the administration of LPS. Pulmonary artery and aortic root blood were sampled for amounts of TNF. Ninety minutes after LPS administration, thoracotomy was performed to biopsy the right and left ventricles for TNF levels. Contractility was determined from the end systolic pressure-volume relationships of pressure-volume diagrams., Results: Right ventricular end diastolic volume index nearly doubled and myocardial contractility decreased by 40% from baseline in the pigs receiving only LPS. Pigs that received TNF MAb had no change in myocardial contractility or right ventricular end diastolic volume index from baseline. There was a higher level of TNF in the aortic sample than in the pulmonary samples at 60 minutes. Right ventricular tissue TNF levels were significantly higher in the LPS-alone group. There was no such difference in left ventricular tissue., Conclusion: The left and right ventricles have different susceptibilities to TNF MAb. TNF may decrease myocardial contractility in sepsis. Blockade of TNF with TNF MAb reverses the depression of myocardial contractility and the right ventricular dilatation associated with septic shock.

Background: The cardiopulmonary effects of the combination of abdominal and thoracic pressures in humans have not been well delineated., Objective: To study the cardiopulmonary effects of 15 mm Hg of intra-abdominal pressure in the presence and absence of 10 cm H20 of positive end-expiratory pressure (PEEP)., Design: Prospective., Setting: University hospital., Methods: Nine patients undergoing laparoscopic cholecystectomy had pulmonary compliance, cardiac output, exhaled carbon dioxide, and preload (left ventricular end-diastolic volume) determined at 4 points while undergoing ventilation with (1) no PEEP before pneumoperitoneum; (2) 10 cm H20 of PEEP and no pneumoperitoneum; (3) no PEEP and 15 mm Hg of pneumoperitoneum; and (4) 10 cm H20 of PEEP and 15 mm Hg of pneumoperitoneum. Preload and cardiac output were determined by means of transesophageal echocardiography. Pulmonary compliance and exhaled carbon dioxide were determined by an attachment to the end of the endotracheal tube., Main Outcome Measures: Preload, cardiac output, exhaled carbon dioxide, and pulmonary compliance., Results: There was no significant change from baseline in preload, cardiac output, or pulmonary compliance when either PEEP or pneumoperitoneum was applied separately. However, there was a significant decrease in preload (P<.01), cardiac output (P = .01), and exhaled carbon dioxide (P =.04) when PEEP and pneumoperitoneum were applied together. Pulmonary compliance was not significantly affected at any of these points., Conclusions: There was a significant reduction in preload and cardiac output when there was intra-abdominal pressure of 15 mm Hg in the presence of 10 cm H20 of PEEP. This combination of pressures may pose a contraindication to laparoscopic surgery.

Background: Studies have shown right ventricular end-diastolic volume (RVEDV) to be a more accurate estimate of left ventricular preload than pulmonary artery wedge pressure. We prospectively evaluated the ability of RVEDV to predict left ventricular end-diastolic volume (LVEDV) in critically ill patients., Methods: Thirty critically ill patients in the surgical intensive care unit underwent concurrent measurement of RVEDV and LVEDV. RVEDV was measured using a residual fraction Swan-Ganz catheter (RF Swan). LVEDV was measured using transesophageal echocardiography with acoustic quantification. Intracardiac, intra-abdominal, and ventilatory pressures were also measured., Results: RVEDV as measured by the RF Swan was significantly larger (by a factor of 2) than LVEDV (p < 0.0001 analysis of variance). However, the RVEDV and LVEDV were strongly correlated (r = 0.71, p < 0.0001, Pearson's correlation)., Conclusions: RVEDV from the RF Swan markedly overestimated left ventricular preload. If RVEDV is used as an absolute value for determining preload, patients may be underresuscitated. Transesophageal echocardiography in conjunction with RF Swan can be used to more accurately determine preload and cardiac performance than RF Swan alone in critically ill patients.

A case of isolated blunt rupture to the infrarenal vena cava secondary to assault is reported. This case report is presented to heighten awareness of an unusual presentation of this potentially lethal injury and to emphasize that diagnostic modalities may offer subtle or indirect indications of an injury that, when coupled with clinical signs and symptoms, prompt surgical intervention necessary for patient salvage.

Ischemic necrosis of the upper extremities caused by invasive mucormycosis developed in a patient with soil contamination of severe burn wounds. An arteriogram of the arm showed complete obstruction of blood flow in the forearm. Histologic specimens showed nonseptate branching hyphae obliterating the arterial lumens. Cutaneous mucormycosis affects patients who are immunocompromised, including victims of multiple trauma and burns. This case represents a previously undescribed clinical presentation in a patient with major burns. Because of its lethal nature, mucormycosis in a patient with burns must be treated with aggressive surgical debridement, including amputation, and with parentral amphotericin B at the earliest sign of cutaneous presence.