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D. Marik, M.B.A., M.B.B.S., M.H.S.

Clinical Director, University of Alabama School of Medicine

Toxicity may be either related to the agents used to treat the cancer or from the response of the cancer to the treatment. Fever and neutropenia and tumor lysis syndrome will be discussed here; others are discussed in Chap. When peripheral blood granulocyte counts are <1000/L, the risk of infection is substantially increased (48 infections/100 pts). If an obvious infectious site is found, the antibiotic regimen is designed to cover organisms that may cause the infection. Persistence of febrile neutropenia after 7 days should lead to addition of amphotericin B (or another broad spectrum antifungal agent) to the antibiotic regimen. The increased uric acid, especially in the setting of acidosis, can precipitate in the renal tubules and lead to renal failure. Manifestations include respiratory distress, pruritus, urticaria, mucous membrane swelling, gastrointestinal disturbances (including nausea, vomiting, abdominal pain, and diarrhea), and vascular collapse. Individuals should wear an informational bracelet and have immediate access to an unexpired epinephrine kit. Pasteurella multocida and Bartonella henselae, the agent of cat-scratch disease, are important cat-associated pathogens. Because of deep tissue penetration by narrow, sharp feline incisors, cat bites are more likely than dog bites to cause septic arthritis or osteomyelitis. Seals, walruses, polar bears: Bites may cause a chronic suppurative infection known as seal finger, which is probably due to Mycoplasma species. Small rodents (and their predators): Bites may transmit rat-bite fever, caused by Streptobacillus moniliformis (in the United States) or Spirillum minor (in Asia). Disease can progress to metastatic abscesses, endocarditis, meningitis, and pneumonia. Sometimesb Biting Species Dog Cat Commonly Isolated Pathogens Staphylococcus aureus, Pasteurella multocida, anaerobes, Capnocytophaga canimorsus P. These suggestions for empirical therapy need to be tailored to individual circumstances and local conditions. After thorough cleansing, facial wounds are usually sutured for cosmetic reasons and because the abundant facial blood supply lessens the risk of infection. Puncture wounds due to cat bites should be left unsutured because of the high rate at which they become infected. A tetanus booster for pts immunized previously but not boosted within 5 years should be considered, as should primary immunization and tetanus immune globulin administration for pts not previously immunized against tetanus. The victim must be carried to medical care, as walking will disperse venom from the bite site regardless of its anatomic location. Any evidence of systemic envenomation (systemic symptoms or signs, laboratory abnormalities) and significant, progressive local findings. Treating physicians should seek advice from snakebite experts regarding indications and dosing of antivenom. The duration of antivenom administration depends on the offending snake species, but multiple doses are not effective in reversing bite responses that have already been established. CroFab, an antivenom used in the United States against North American pit viper species, poses a low risk of allergy elicitation. A trial of acetylcholinesterase inhibitors should be undertaken for pts with objective evidence of neurologic dysfunction, as this treatment may cause neurologic improvement in pts bitten by snakes with postsynaptic neurotoxins. Systemic effects can include weakness, dysrhythmias, hypotension, paralysis, and rare deaths.

Furthermore, inappropriate positioning of the outflow ports may result in blood being directed away from the tricuspid valve, thus increasing the recirculation fraction. Poor cardiac output leads to greater recirculation because a smaller fraction of the oxygenated pump blood is propelled forward out of the right atrium. During this time, the ventilator settings are increased to levels expected to achieve normal gas exchange. The cumulative drop in survival over the years reflects a larger proportion of patients treated with high-mortality diagnoses. The registry also tracks cumulative survival rates for specific diseases: meconium aspiration syndrome, 94%; pulmonary hypertension, 78%; hyaline membrane disease, 84%; sepsis, 75%; pneumonia, 57%; airleak syndrome 74%; congenital diaphragmatic hernia, 51%; congenital heart defect 38%; cardiac arrest, 22%; cardiogenic shock, 39%; cardiomyopathy, 63%; myocarditis, 49%; cardiac transplant, 30%. Congenital diaphragmatic hernia and lower birthweight status in those patients treated for respiratory failure are variables associated with increased mortality and morbidity. There were no cognitive differences between the 2 trial groups (76% of the children available for follow-up testing in both groups were within the normal range, although they fell below population norms). Behavioral problems, particularly hyperactivity, were more common in the conventionally treated children. Progressive sensorineural hearing loss was found in both groups and could be late in onset and progressive. United Kingdom collaborative randomized trial of neonatal extracorporeal membrane oxygenation; follow-up to age 7 years. These infants need comprehensive neurodevelopmental evaluations and appropriate community services. Reassurance that their child is making good neurodevelopmental progress is always welcome, as this is a time of high anxiety for parents. Parents of children with developmental delay need realistic information about its significance, and advice about needed evaluations and interventions. Parents need to know as soon as possible if their child is demonstrating signs of neurodevelopmental impairment. Physical and occupational therapists provide valuable suggestions regarding positioning, handling, and feeding infants. Even if their infant does well, parents of high-risk infants should be warned about early signs of school or behavior problems. Feedback for neonatologists, pediatricians, obstetricians, pediatric surgeons, and others regarding neurodevelopmental outcomes, ongoing medical problems, and unusual or unforeseen complications in these infants is essential. Pediatricians, neurodevelopmental pediatricians, and neonatologists make up the regular staff of the clinic, and many clinics include neuropsychologists and physical, occupational, and/or speech and language therapists. In addition, some infants may need referrals to audiologists, ophthalmologists, neuropsychologists, social workers, respiratory therapists, nutritionists, gastroenterologists, orthopedic surgeons, or other subspecialists. It is virtually impossible to diagnose developmental disability with certainty in the neonatal period, but a number of perinatal risk factors have been identified for selecting high-risk infants for close follow-up. The risks of cerebral palsy and intellectual disability increase with decreasing gestational age. Children born preterm have higher rates of language disorders, visual perception problems, minor neuromotor dysfunction, attention deficits, executive dysfunction, and learning disabilities than full-term controls. Besides gestational age, predictors of neurodevelopmental disability include poor growth (especially head growth), asphyxia, sepsis (especially meningitis), chronic lung disease, and retinopathy of prematurity. Risk is highest in infants with signs of brain injury on neonatal neurodevelopmental examination and neuroimaging studies (see Chapter 16). Neonatal encephalopathy is a clinical syndrome characterized by a constellation of findings, including seizures and abnormalities of consciousness, muscle tone, reflexes, respiratory control, and feeding. Etiologies include infection, inflammation, metabolic errors, drug exposures, brain malformations, stroke, hypoxia, ischemia, or any combination of these conditions. Some late preterm and full-term infants develop respiratory failure that can be due to pulmonary hypoplasia, pneumonia, meconium aspiration, or persistent pulmonary hypertension. When followed to school age, many have problems with attention deficit, specific learning disability, minor neuromotor dysfunction, and behavior problems. Some survivors have demonstrated progressive hearing loss, so these children need serial hearing assessments. Maternal, fetal, and neonatal infection or inflammation has been implicated as etiologies of preterm birth, brain injury (eg, white matter injury), cerebral palsy, and cognitive impairments.

Hand hygiene is extremely important in the prevention and containment of infection. Nosocomial infections should be contained by a cohort of infants and the use of dedicated equipment and staff. Cranial ultrasonography maybe indicated during the first 7 days for possible intracranial hemorrhage. An exchange transfusion should be considered when the bilirubin approaches or exceeds 12 mg/dL (see Chapters 58 and 100). To reduce the serum bilirubin level, phototherapy may be needed and can be used to minimize the need for exchange transfusion. Some centers start phototherapy immediately after birth; others when approaching 5 mg/dL. Several multidimensional pain assessment tools are available that include both physiologic (heart rate, O2 saturation, respiratory rate, blood pressure) and behavioral indicators (facial expression, vocalization, and motor activity). Pain should be assessed as the fifth vital sign and more often as indicated by pain scores (see Chapter 14). Parent conferences involving the physician, social worker, and primary nurse help the family understand the complex extended care of their infant. Additional discussions may include quality of life, death, dying, withholding and withdrawal of support, and parental religious or spiritual beliefs. Routine tasks should be clustered to allow the infant undisturbed and prolonged periods of rest; each task should have a time limit as well. Care should be taken to simulate this positioning in the extremely premature infant. Many positioning aids are available and should be used per institution guidelines. This has been defined as "intrahospital maternal infant skinto-skin contact" (see Chapter 20). It promotes behavioral state organization, increased parental attachment/confidence, and nurturing behaviors that support growth and development. Temperature, heart rate, respiratory rate, and O2 saturation remain within normal limits during kangaroo care. Infants are unable to control their own environment, so efforts must be made to decrease ambient noise and provide cyclic lighting to support their circadian rhythms. Parents should be educated about behavioral cues that invite interaction or signal overstimulation. Interventions for treatment of neonatal hyperglycemia in very low birth weight infants. Use of polyethylene bags in extremely low birth weight infant resuscitation for the prevention of hypothermia. Changes in survival and neonatal morbidity in infants with a birth weight of 750 g or less. Vitamin A supplementation to prevent mortality and short and long-term morbidity in very low birthweight infants. Achievement of targeted saturation values in extremely low gestational age neonates resuscitated with low or high oxygen concentrations: a prospective, randomized trial. Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Improved care and growth outcomes by using hybrid humidified incubators in very preterm infants. The increasing number of babies who are delivered between 34 and 37 weeks is a vexing problem for pediatric and obstetric practitioners alike. These babies have an increased risk of short-term health problems and long-term health, behavioral, and learning issues. It has been the subject of growing interest and concern that has generated new research into the cause as well as the appropriate management of these patients. Recently, the consensus is to refer to these infants as "late preterm," which conveys an appropriate sense of their vulnerability. Although the exact cause of increased late preterm delivery remains elusive, the rate must be rising due to increased medical interventions at or beyond 34 weeks.