A substantial proportion of parents used measures of alternative medicine in the intensive care unit, or would have like to do so. However, few had the confidence to discuss this wish with the medical personal. This suggests that alternative medicine is of great interest, even on an intensive care unit. Nevertheless, discussion about alternative medicine seems to be taboo in doctor-patient relations.

A 4-year old boy with D-transposition of the great arteries, pulmonary atresia with intact ventricular septum, and a hypoplastic left ventricle with mitral atresia underwent a Fontan operation. He had previously been treated with neonatal balloon atrial septostomy followed by a left modified Blalock-Taussig shunt and, at the age of 2 years, a Hemi-Fontan operation was performed. The Fontan operation was completed with an extracardiac conduit (Goretex) from the inferior vena cava to the superior vena cava. High central venous pressures and bilateral chylothoraces complicated the postoperative course. Despite 6 weeks of conservative treatment with fat-free nutrition and subsequent total parenteral nutrition, pleural fluid loss remained excessive, and a pleurodesis was performed bilaterally. A few days postoperatively, acute respiratory failure occurred due to bronchial casts. Cast analysis showed high triglyceride and protein concentrations (cast triglyceride, 0.96 mmol/L; cast protein, 66 g/L; serum triglyceride, 0.36 mmol/L; and serum protein, 47 g/L). Bronchoscopic attempts to remove the bronchial casts failed, and the child died of cardiorespiratory failure.At autopsy, the bronchial system was completely plugged by casts resembling bronchial tree anatomy (Figure 1). Thromboses obliterated the left innominate vein partially and reduced the lumen of the extracardiac conduit by 50%. These thromboses occurred despite full anticoagulation and were not detected by previous transthoracic echocardiography. Histopathology demonstrated massively dilated pulmonary lymph vessels within the whole lung (Figure 2). Ruptures of lymphatic vessels and the influx of chyle into the alveoli could clearly be demonstrated (Figure 3). The material in the alveoli was proven to be chyle by lipid staining (Figure 4). The mechanism of lymphatic leakage leading to the formation of bronchial casts has been discussed, 1 but it had not been demonstrated histologically before. This condition must be distinguished from mucus hypersecretion as an unusual response of the pulmonary epithelium to elevated venous pressure (classified as type II or as acellular mucin casts by Seear et al), 2 where no alveolar flooding with chyle is present. Respir Crit Care Med. 1997;155:364 -370.

Early detection of pathophysiological factors associated with permanent brain damage is a major issue in neonatal medicine. The aim of our study was to evaluate the significance of the CO₂ reactivity of cerebral blood flow (CBF) in neonates with perinatal risk factors. Fourteen ventilated neonates with perinatal risk factors (pathological cardiotocogramm, low cord pH, postpartal encephalopathy) were enrolled into this prospective study. The study was performed 18–123 h after birth. CBF was measured using the nonivasive intravenous ¹³³Xe method. Two measurements were taken with a minimal PaCO₂-difference of 5 mm Hg. From the two CBF values the CO₂ reactivity was calculated. Outcome was evaluated 1 year after birth. The CBF values at a lower PaCO₂ ranged from 6.6 to 115.2 ml/100 g brain issue/min (median = 18.2) and at a higher PaCO₂ level from 7.1 to 125.7 ml/100 g brain tissue/min (median = 18.75). The calculated CO₂ reactivity ranged from –9.6 to 6.6% (median 1.1%) change in CBF/mm Hg change in PaCO₂. CO₂ reactivity correlated with lowest pH (r² = 0.35, p = 0.02). Two infants died, one of neonatal sepsis, the other of heart failure. Neurological outcome at the age of 1 year was normal in 11 patients, 1 had severe cerebral palsy. From the 12 surviving patients the patient with severe neurological deficit showed the highest CBF values (125.7 ml/100 g/min). Impaired chemical coupling of cerebral blood flow is compatible with intact neurological outcome in neonates with perinatal risk factors. CO₂ reactivity in these newborns correlates with the lowest pH and may reflect the severity of perinatal asphyxia.

These preliminary data suggest the occurrence of EEG-abnormalities after application of inhaled NO in critically ill children. We found no correlation with other potential EEG-influencing parameters, although clinical state, medication, or hypoxemia might contribute. Comprehensive, prospective, clinical assessment regarding a causal relationship between NO-inhalation and EEG-abnormalities and their clinical importance is needed.