Neonatal pneumopericardium Cassandra
van
Nostrand,
b
sc, md; W. E. Beamish. md,
Summary: Pneumopericardium developed in three newborn infants, including a set of twins, with respiratory distress syndrome. The rarity of this condition and its occurrence an
anatomic
in twin newborns suggest
predisposition, especially
in premature infants requiring assisted ventilation. Two of the infants died; one had undergone pericardiocentesis. From a review of the literature and from our cases we conclude that conservative therapy appears warranted in cases of isolated pneumopericardium although the number of cases reported is too small to provide a definite answer.
Resume: PneumopEricarde nEonatal Chez trois nouveau-nes, dont deux jumeaux, en etat de souffrance respiratoire, s'est developpe un pneumopericarde. La rarete de cette condition et sa presence chez des nouveau-nes jumeaux permet de croire
predisposition anatomique, principalement chez des prematures exigeant une respiration artificielle.
a une
Deux des
nouveau-nes sont
a subi une revue de la
morts;
un
pericardrocentese. Une
litterature et nos propres observations nous permettent de conclure qu'un traitement conservateur est justifie dans le cas de pneumo¬ pericarde isole, bien que le nombre de cas rapportes soit trop faible pour nous permettre d'etre categoriques. From the departments of radiology and pediatrics, division of neonatal medicine, of University of Alberta, and University Alberta Hospital, Edmonton Reprint requests to: Dr. W. Beamish, Department of radiology, University of Alberta Hospital, Edmonton, Alta. T6G 2B7
frcp[c]; David Schiff,
In the newborn infant pneumoperi¬ cardium is an unusual condition, occur¬ ring usually as a complication of respirator therapy.1"7 Isolated pneumoperi¬ cardium without demonstrable pneumomediastinum is even more uncommon. The pathogenesis of pneumomediastinum and other forms of air-block com¬ plication has been well worked out,8 but the pathogenesis of pneumoperi¬ cardium remains unclear. The occur¬ rence of this condition in twin neonates is therefore of particular interest. Description of a third case, discovered at approximately the same time in the same hospital, is included in this report. Over a 3-year period beginning in July 1971, 83 newborn infants required assisted ventilation in the neonatal in¬ tensive care unit of the University of Alberta Hospital. The following three case reports represent all the cases of pneumopericardium observed in this period. Before 1971 pneumopericar¬ dium had not occurred in neonates in this hospital. In Edmonton seriously ill infants from outlying areas are transported to this hospital by the following mechan¬ ism: On receipt of a telephone call from the attending physician the hospital sends out an ambulance with a pediatric resident in attendance. Portable equip¬ ment for electrocardiographic monitoring, intubation and resuscitation, and a Transport Isolette are carried in the ambulance. The infants whose cases are reported here were all transported in this manner and were transferred because of deteriorating clinical condi¬ tion.
md, ph d,
frcp[c]
Case reports Case 1 Twin
A, a 1200-g girl, was born to a gravida III, para 2 woman following a 28-week gestation. Until the onset of pre¬ mature labour the. pregnancy had been uncomplicated. The presentation was breech; the delivery was assisted by the application of forceps to the aftercoming head. Two infants and two placentas were delivered. Because of apnea and prematurity twin A was transferred to the neo¬ natal intensive care unit of the University of Alberta Hospital. During the 3-hour transfer she required intubation and ma¬ nual intermittent positive-pressure ventila¬ tion (IPPV) with oxygen at 5 1/min. She arrived in poor condition, with grunting expiration and indrawing of the intercostal spaces on inspiration. The admission chest radiograph demon¬ strated changes in the appearance of the lungs characteristic of hyaline membrane disease. Because of hypoxia (Po2 with 80% 02, 34 mm Hg) assisted IPPV (Bird Mark IV respirator) with 100% oxygen was started, the initial inflating pressure being 16 cm H20 with a positive end-expiratory pressure (PEEP) of 5 cm H20. The baby's colour and arterial oxygen saturation then improved, but on the 2nd day she became cyanotic. At this time radiologic examina¬ tion demonstrated the additional finding of interstitial emphysema in the right lung. The baby responded to bicarbonate ad¬ ministration and blood transfusion, maintaining adequate arterial oxygen saturation, but did not improve greatly over the next few days. During this period ventilatory pressures were adjusted to a maximum of 20 cm H20 with PEEP of 8 cm H20. On the 4th day of life her condition suddenly deteriorated, as manifested by severe cyanosis and bradycardia of 40 beats/min. Radiologic examination at this time de-
FIG. 1.Case 1: Uniform pattern characteristic of moderately severe hyaline membrane disease in both lungs. pneumopericardium is present with no evidence of other air dissection. 186 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
A tension
monstrated pneumopericardium and hya¬ line membrane disease (Fig. 1). Imme¬ diate pericardiocentesis and aspiration of 15 to 20 ml of air failed to reverse the deterioration and the baby died within minutes. At autopsy no anatomic defect was de¬ monstrated in the pericardium to account for the presence of air. Significant findings were severe bilateral atelectasis, conges¬ tion in the lungs and a subdural hema-
IPPV (Bird Mark IV respirator) at an inflating pressure of 16 cm H20 with PEEP of 5 cm H20 was started, and sub¬ sequently some improvement was noted. On the 2nd day a rapid respiratory rate developed, overriding the respirator. Two hours later bigeminal pulse and cardiac irregularity developed. She became cyanotic and her condition deteriorated. Radio¬ logic examination demonstrated pneumo¬ pericardium and hyaline membrane disease toma. (Fig. 2). The skin was mottled and she died shortly thereafter without pericardio¬ Case 2 centesis being performed. At autopsy the only significant findings Twin B, a 1200-g girl, was the sister of the patient in case 1. During transfer to were signs of hyaline membrane disease. the University of Alberta Hospital she There was no evidence of an anatomic also required intubation and manual IPPV, pericardial defect.
shortly after birth and continued over the days despite oxygen therapy. He was transferred to the University of Al¬ berta Hospital. On admission he was moderately jaundiced and in severe respiratory distress, with grunting expiration, indrawing of the intercostal spaces on inspiration, circumoral cyanosis and a respiratory rate of 88/min. The admission chest radiograph demon¬ strated changes in lung appearance compatible with those of hyaline membrane disease. Because of hypoxia (Po2, 18 mm Hg) the infant was placed in a negative pressure respirator (Air Shields Isolette) that supplied a continuous negative pres¬ sure (CNP) of .5 cm H20. He improved with this therapy, but after 18 hours of CNP a pneumopericardium was noted on and she arrived in poor condition. Case 3 chest radiographs (Fig. 3). Because the in¬ An admission chest radiograph demon¬ strated the characteristic lung pattern seen A 2070-g boy was born at 34 weeks' fant was asymptomatic therapy was not in hyaline membrane disease. Blood gas gestation to a multiparous woman who changed and no pericardiocentesis was performed. Chest radiography 6 hours analysis showed hypoxia (Po2 with 60% had had several previous premature de- later the pneumopericardium 02, 19 mm Hg) and acidosis. Assisted liveries. Respiratory distress developed had showed thatresolved. After 2 days the completely CNP was discontinued and the infant was gradually weaned from oxygen. The hyperbilirubinemia present on admission never exceeded 11 mg/dl (total bilirubin) and was treated with phototherapy. The jaundice resolved and the baby started to gain weight. By the 2nd week he was discharged next 2
home in good condition.
Discussion To date 26
cases
of neonatal pneu¬
mopericardium have been reported in the English literature.1~7'9"11 Isolated pneumopericardium was mentioned in only 4 of these cases;2'4,6'9 in the remaining 22 cases there was some other evidence of air-block complication pneumomediastinum, pneumothorax or pulmonary interstitial emphysema, pneu¬ momediastinum being the most com¬ mon. Of the 26 infants with pneumo¬ pericardium 20 were premature and at least 18 had hyaline membrane dis¬ ease. All four infants with isolated pneumopericardium were premature and all survived; only one underwent pericardiocentesis. Of the 22 infants .
FIG. 2.Case 2: Uniform pattern characteristic of severe hyaline membrane disease in both lungs. A tension pneumopericardium is present. Other air dissection is present in the form of interstitial air and a pneumothorax, for which a chest drainage tube has been inserted.
FIG. 3.Case 3: Uniform pattern characteristic of moderately severe small pneumopericardium with no other evidence of air dissection.
hyaline membrane disease
in both
lungs. There is
a
CMA JOURNAL/JANUARY 25, 1975/VOL. 112 187
Tandearil® Brief Prescribing Information Dosage In arthritis, extra-articular rheumatism and superficial thrombophiebitis - 400-600 mg per day (4-6 tablets). When improvement is obtained (generally in 2 or 3 days), the dose should be reduced to the lowest effective level. In severe trauma and its sequelae - 400600 mg (4-6 tablets) daily in divided doses for 4 days to a week. For indications in surgery - 400-600 mg (4-6 tablets) daily in divided doses during the 24 hours prior to surgery. As soon as oral medication can be resumed after surgery, maintenance is 300-400 mg daily for 3-4 days. It is suggested that the maintenance level not exceed 400 mg per day. Tandearil should be taken with meals or with a glass of milk. In the absence of a favourable response after a one week trial period, it is recommended that administration of Tandearil be discontinued. Contraindications Tandearil is contraindicated in patients with a history of blood dyscrasia or drug allergy and in those with a history or symptoms of peptic ulcer. In addition, it should not be given to senile patients, to patients with clinical edema or to those with severe renal, hepatic or cardiac disease. Precautions A careful history, physician examination and complete blood count should be done before initiating therapy. Patients receiving this drug should be followed closely and should be warned to discontinue Tandearil and contact their physician immediately should any of the following signs or symptoms appear: fever, sore throat, lesions in the mouth, black or tarry stools, skin reactions or a sudden gain in weight. Patients undergoing long-term therapy should have blood counts done at monthly intervals. Care should be taken when prescribing for the elderly. As with any drug, Tandearil should not be used during the first trimester of pregnancy unless in the opinion of the prescribing physician, the potential benefits outweigh the possible risks. Tandearil may prolong the effect of other drugs taken concomitantly. Special attention should be paid to this fact when anticoagulants are prescribed. Side Effects Nausea, vomiting, abdominal discomfort, formation or activation of peptic ulcer and sodium retention with edema are known to occur. Although rarely observed, hypersensitivity reactions, dermatological reactions and blood dyscrasias have been reported. Availability Tandearil Tablets Each light brown, sugar-coated tablet, branded . in brown, contains 100 mg oxyphenbutazone Geigy Standard. Supplied in bottles of 50 and 500. Full information is available on request.
Geigy Dorval 780, Quebec
G-4063
13 had pericardiocentesis and 12 survived the acute episode; the other 9 died. There seems little doubt that positiveand negative-pressure assisted ventilation has resulted in an increased incidence of air-block complications.12 Few of the reports indicated the pressures used; those recorded were greater than 30 cm H20. The pressures used on our infants never exceeded 20 cm H20. Although it is frequently stated that pneumomediastinum in the neonate precedes pneumopericardium, there is no experimental or autopsy evidence to substantiate this. The pathogenesis, therefore, is largely speculative at this time. Shawker, Dennis and . in their elaborate pathological study of a case of pneumopericardium, failed to demonstrate any anomalous connection between pericardium and trachea, although a considerable amount of air was noted in the interstitium of the lungs. In early experimental studies on dogs Macklin8 was unable to induce pneumopericardium, although dissection along venous sheaths has been suggested by Grosfeld, Kilman and Frye.5 It seems unlikely that direct passage of air from the mediastinal interstitial tissues into the pericardium is the usual mechanism producing pneumopericardium. Pneumomediastinum does not result in pneumopericardium. Air in the mediastinum would be more likely, by increasing mediastinal pressure, to compress rather than rupture into the pencardium. Also, pneumomediastinum as a result of respirator therapy in neonates is a relatively more common complication than pneumopericardium. It therefore seems more likely that the association of pneumomediastinum and pneumopericardium is coincidental, each representing a different route of air dissention. No perforation of the pericardium was seen at autopsy in any of the cases reported by Loftis et al;10 in one case a direct communication between trachea and mediastinum was observed, but the communication was in a patient in whom an operation had been performed in that area. There were no cases of pneumopericardium among the older children in the series of Mansfield et al,13 despite prolonged ventilation at similar inflating pressures and higher end-expiratory pressures than used in the neonates. This paucity of cases in older children and in adults suggests better development of the pericardial reflection and vascular sheath or, conversely, some anatomic defect in the premature infant's pericardium that could predispose to air entry. The occurrence of this rare complication in twins further supports the possibility of an anatomic defect. Cimmino14 has
speculated that the serosal layers of the pericardium in young infants are usually susceptible to dissection and rupture. Conclusion Problems involving dissection of air are becoming more common as more infants with respiratory distress syndrome are being kept alive on respirators. These problems include pneumothorax, pneumomediastinum, pulmonary interstitial emphysema and even the rarer pneumopehcardium. Dissection into pulmonary veins has also been described11 and we have seen one definite case. Such problems are rarely seen in adults on respirator therapy. Pneumopericardium seems to be most common in newborns, particularly the premature. We have presented the first reported case of pneumopericardium developing in twins while on positive pressure ventilation in the treatment of hyaline membrane disease. One underwent pericardiocentesis; the other did not. Both twins died. The third patient was asymptomatic; pericardiocentesis was not performed and he lived. It appears from the literature reviewed that the prognosis in cases of pneumopericardium is much better when there is no other evidence of air block. For patients with isolated pneumopericardium conservative therapy appears warranted, although the number of cases reported is too small to provide a definite answer. References 1. MATTHIEU JM, NUSSLE D, TORRADO A, Ct al: Pneumopericardium in the newborn. Pedia-
trics 46: 117, 1970
2. SINGH KR, WIGLESWORTH FW, STERN L: Pneumopericardium in the newborn - a cornplication of respirator management. Can Med Assoc / 106: 1195, 1972 3. COHEN 5, LOCKHART CH: Pneumopericardium: a cornplication of prolonged ventilation. Anesthesiology 32: 465, 1970 4. MARKARIAN M, ABLOCO RC: Neonatal pneumopericardium. Pediatrics 47: 634, 1971 5. GROSFELD JL, KILMAN JW, FRYE TR: Spontaneous pneumopericardium in the newborn infant. J Pediatr 76: 614, 1970 6. SHAWKER TH, DENNIs JM, GAREIs JW: Pneumopericardium in the newborn. Am J Roent-
genol Radium Ther Nuci Med 116: 514, 1972
7. SAGEL SS, WIMBUsH P, GOLDENBERO DB: Tension pneumopericardium following assisted ventilation in hyaline membrane disease. RadIology 106: 175, 1973 8. MACRUN CC: Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum. Arch Intern Med 64: 913, 1939 9. GERSHANIK JJ: Neonatal pneumopericardium. Am J Dis Child 121: 438, 1971 10. LoFTIs JW, SusaN AF, MARCH JH, et al: Pneumopericardium in infancy. Am J Dis Child 103: 61, 1962 11. MACPHERSON RI, CHERNICK V, REED M: The complications of respirator therapy in the
newborn. J Can Assoc Radiol 23: 91, 1972
12. VINsTEIN AL, GsutssAM EL, LIM MO, et al: Pulmonary venous air embolism in hyaline membrane disease. Radiology 105: 627, 1972 13. MANSFIELD PB, GRAHAM GB, BECEWITH JB, et al: Pneumopericardium and pneumomediastinum in infants and children. J Pedlair Surg 8: 695, 1973 14. CIMMINO CV: Some radio-diagnostic notes on pneumomediastinum, pneumothorax, and pneumopericardium. Va Med Mon 94: 205,
1967
CMA JOURNAL/JANUARY 25, 1975/VOL. 112 189
van
Nostrand,
b
sc, md; W. E. Beamish. md,
Summary: Pneumopericardium developed in three newborn infants, including a set of twins, with respiratory distress syndrome. The rarity of this condition and its occurrence an
anatomic
in twin newborns suggest
predisposition, especially
in premature infants requiring assisted ventilation. Two of the infants died; one had undergone pericardiocentesis. From a review of the literature and from our cases we conclude that conservative therapy appears warranted in cases of isolated pneumopericardium although the number of cases reported is too small to provide a definite answer.
Resume: PneumopEricarde nEonatal Chez trois nouveau-nes, dont deux jumeaux, en etat de souffrance respiratoire, s'est developpe un pneumopericarde. La rarete de cette condition et sa presence chez des nouveau-nes jumeaux permet de croire
predisposition anatomique, principalement chez des prematures exigeant une respiration artificielle.
a une
Deux des
nouveau-nes sont
a subi une revue de la
morts;
un
pericardrocentese. Une
litterature et nos propres observations nous permettent de conclure qu'un traitement conservateur est justifie dans le cas de pneumo¬ pericarde isole, bien que le nombre de cas rapportes soit trop faible pour nous permettre d'etre categoriques. From the departments of radiology and pediatrics, division of neonatal medicine, of University of Alberta, and University Alberta Hospital, Edmonton Reprint requests to: Dr. W. Beamish, Department of radiology, University of Alberta Hospital, Edmonton, Alta. T6G 2B7
frcp[c]; David Schiff,
In the newborn infant pneumoperi¬ cardium is an unusual condition, occur¬ ring usually as a complication of respirator therapy.1"7 Isolated pneumoperi¬ cardium without demonstrable pneumomediastinum is even more uncommon. The pathogenesis of pneumomediastinum and other forms of air-block com¬ plication has been well worked out,8 but the pathogenesis of pneumoperi¬ cardium remains unclear. The occur¬ rence of this condition in twin neonates is therefore of particular interest. Description of a third case, discovered at approximately the same time in the same hospital, is included in this report. Over a 3-year period beginning in July 1971, 83 newborn infants required assisted ventilation in the neonatal in¬ tensive care unit of the University of Alberta Hospital. The following three case reports represent all the cases of pneumopericardium observed in this period. Before 1971 pneumopericar¬ dium had not occurred in neonates in this hospital. In Edmonton seriously ill infants from outlying areas are transported to this hospital by the following mechan¬ ism: On receipt of a telephone call from the attending physician the hospital sends out an ambulance with a pediatric resident in attendance. Portable equip¬ ment for electrocardiographic monitoring, intubation and resuscitation, and a Transport Isolette are carried in the ambulance. The infants whose cases are reported here were all transported in this manner and were transferred because of deteriorating clinical condi¬ tion.
md, ph d,
frcp[c]
Case reports Case 1 Twin
A, a 1200-g girl, was born to a gravida III, para 2 woman following a 28-week gestation. Until the onset of pre¬ mature labour the. pregnancy had been uncomplicated. The presentation was breech; the delivery was assisted by the application of forceps to the aftercoming head. Two infants and two placentas were delivered. Because of apnea and prematurity twin A was transferred to the neo¬ natal intensive care unit of the University of Alberta Hospital. During the 3-hour transfer she required intubation and ma¬ nual intermittent positive-pressure ventila¬ tion (IPPV) with oxygen at 5 1/min. She arrived in poor condition, with grunting expiration and indrawing of the intercostal spaces on inspiration. The admission chest radiograph demon¬ strated changes in the appearance of the lungs characteristic of hyaline membrane disease. Because of hypoxia (Po2 with 80% 02, 34 mm Hg) assisted IPPV (Bird Mark IV respirator) with 100% oxygen was started, the initial inflating pressure being 16 cm H20 with a positive end-expiratory pressure (PEEP) of 5 cm H20. The baby's colour and arterial oxygen saturation then improved, but on the 2nd day she became cyanotic. At this time radiologic examina¬ tion demonstrated the additional finding of interstitial emphysema in the right lung. The baby responded to bicarbonate ad¬ ministration and blood transfusion, maintaining adequate arterial oxygen saturation, but did not improve greatly over the next few days. During this period ventilatory pressures were adjusted to a maximum of 20 cm H20 with PEEP of 8 cm H20. On the 4th day of life her condition suddenly deteriorated, as manifested by severe cyanosis and bradycardia of 40 beats/min. Radiologic examination at this time de-
FIG. 1.Case 1: Uniform pattern characteristic of moderately severe hyaline membrane disease in both lungs. pneumopericardium is present with no evidence of other air dissection. 186 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
A tension
monstrated pneumopericardium and hya¬ line membrane disease (Fig. 1). Imme¬ diate pericardiocentesis and aspiration of 15 to 20 ml of air failed to reverse the deterioration and the baby died within minutes. At autopsy no anatomic defect was de¬ monstrated in the pericardium to account for the presence of air. Significant findings were severe bilateral atelectasis, conges¬ tion in the lungs and a subdural hema-
IPPV (Bird Mark IV respirator) at an inflating pressure of 16 cm H20 with PEEP of 5 cm H20 was started, and sub¬ sequently some improvement was noted. On the 2nd day a rapid respiratory rate developed, overriding the respirator. Two hours later bigeminal pulse and cardiac irregularity developed. She became cyanotic and her condition deteriorated. Radio¬ logic examination demonstrated pneumo¬ pericardium and hyaline membrane disease toma. (Fig. 2). The skin was mottled and she died shortly thereafter without pericardio¬ Case 2 centesis being performed. At autopsy the only significant findings Twin B, a 1200-g girl, was the sister of the patient in case 1. During transfer to were signs of hyaline membrane disease. the University of Alberta Hospital she There was no evidence of an anatomic also required intubation and manual IPPV, pericardial defect.
shortly after birth and continued over the days despite oxygen therapy. He was transferred to the University of Al¬ berta Hospital. On admission he was moderately jaundiced and in severe respiratory distress, with grunting expiration, indrawing of the intercostal spaces on inspiration, circumoral cyanosis and a respiratory rate of 88/min. The admission chest radiograph demon¬ strated changes in lung appearance compatible with those of hyaline membrane disease. Because of hypoxia (Po2, 18 mm Hg) the infant was placed in a negative pressure respirator (Air Shields Isolette) that supplied a continuous negative pres¬ sure (CNP) of .5 cm H20. He improved with this therapy, but after 18 hours of CNP a pneumopericardium was noted on and she arrived in poor condition. Case 3 chest radiographs (Fig. 3). Because the in¬ An admission chest radiograph demon¬ strated the characteristic lung pattern seen A 2070-g boy was born at 34 weeks' fant was asymptomatic therapy was not in hyaline membrane disease. Blood gas gestation to a multiparous woman who changed and no pericardiocentesis was performed. Chest radiography 6 hours analysis showed hypoxia (Po2 with 60% had had several previous premature de- later the pneumopericardium 02, 19 mm Hg) and acidosis. Assisted liveries. Respiratory distress developed had showed thatresolved. After 2 days the completely CNP was discontinued and the infant was gradually weaned from oxygen. The hyperbilirubinemia present on admission never exceeded 11 mg/dl (total bilirubin) and was treated with phototherapy. The jaundice resolved and the baby started to gain weight. By the 2nd week he was discharged next 2
home in good condition.
Discussion To date 26
cases
of neonatal pneu¬
mopericardium have been reported in the English literature.1~7'9"11 Isolated pneumopericardium was mentioned in only 4 of these cases;2'4,6'9 in the remaining 22 cases there was some other evidence of air-block complication pneumomediastinum, pneumothorax or pulmonary interstitial emphysema, pneu¬ momediastinum being the most com¬ mon. Of the 26 infants with pneumo¬ pericardium 20 were premature and at least 18 had hyaline membrane dis¬ ease. All four infants with isolated pneumopericardium were premature and all survived; only one underwent pericardiocentesis. Of the 22 infants .
FIG. 2.Case 2: Uniform pattern characteristic of severe hyaline membrane disease in both lungs. A tension pneumopericardium is present. Other air dissection is present in the form of interstitial air and a pneumothorax, for which a chest drainage tube has been inserted.
FIG. 3.Case 3: Uniform pattern characteristic of moderately severe small pneumopericardium with no other evidence of air dissection.
hyaline membrane disease
in both
lungs. There is
a
CMA JOURNAL/JANUARY 25, 1975/VOL. 112 187
Tandearil® Brief Prescribing Information Dosage In arthritis, extra-articular rheumatism and superficial thrombophiebitis - 400-600 mg per day (4-6 tablets). When improvement is obtained (generally in 2 or 3 days), the dose should be reduced to the lowest effective level. In severe trauma and its sequelae - 400600 mg (4-6 tablets) daily in divided doses for 4 days to a week. For indications in surgery - 400-600 mg (4-6 tablets) daily in divided doses during the 24 hours prior to surgery. As soon as oral medication can be resumed after surgery, maintenance is 300-400 mg daily for 3-4 days. It is suggested that the maintenance level not exceed 400 mg per day. Tandearil should be taken with meals or with a glass of milk. In the absence of a favourable response after a one week trial period, it is recommended that administration of Tandearil be discontinued. Contraindications Tandearil is contraindicated in patients with a history of blood dyscrasia or drug allergy and in those with a history or symptoms of peptic ulcer. In addition, it should not be given to senile patients, to patients with clinical edema or to those with severe renal, hepatic or cardiac disease. Precautions A careful history, physician examination and complete blood count should be done before initiating therapy. Patients receiving this drug should be followed closely and should be warned to discontinue Tandearil and contact their physician immediately should any of the following signs or symptoms appear: fever, sore throat, lesions in the mouth, black or tarry stools, skin reactions or a sudden gain in weight. Patients undergoing long-term therapy should have blood counts done at monthly intervals. Care should be taken when prescribing for the elderly. As with any drug, Tandearil should not be used during the first trimester of pregnancy unless in the opinion of the prescribing physician, the potential benefits outweigh the possible risks. Tandearil may prolong the effect of other drugs taken concomitantly. Special attention should be paid to this fact when anticoagulants are prescribed. Side Effects Nausea, vomiting, abdominal discomfort, formation or activation of peptic ulcer and sodium retention with edema are known to occur. Although rarely observed, hypersensitivity reactions, dermatological reactions and blood dyscrasias have been reported. Availability Tandearil Tablets Each light brown, sugar-coated tablet, branded . in brown, contains 100 mg oxyphenbutazone Geigy Standard. Supplied in bottles of 50 and 500. Full information is available on request.
Geigy Dorval 780, Quebec
G-4063
13 had pericardiocentesis and 12 survived the acute episode; the other 9 died. There seems little doubt that positiveand negative-pressure assisted ventilation has resulted in an increased incidence of air-block complications.12 Few of the reports indicated the pressures used; those recorded were greater than 30 cm H20. The pressures used on our infants never exceeded 20 cm H20. Although it is frequently stated that pneumomediastinum in the neonate precedes pneumopericardium, there is no experimental or autopsy evidence to substantiate this. The pathogenesis, therefore, is largely speculative at this time. Shawker, Dennis and . in their elaborate pathological study of a case of pneumopericardium, failed to demonstrate any anomalous connection between pericardium and trachea, although a considerable amount of air was noted in the interstitium of the lungs. In early experimental studies on dogs Macklin8 was unable to induce pneumopericardium, although dissection along venous sheaths has been suggested by Grosfeld, Kilman and Frye.5 It seems unlikely that direct passage of air from the mediastinal interstitial tissues into the pericardium is the usual mechanism producing pneumopericardium. Pneumomediastinum does not result in pneumopericardium. Air in the mediastinum would be more likely, by increasing mediastinal pressure, to compress rather than rupture into the pencardium. Also, pneumomediastinum as a result of respirator therapy in neonates is a relatively more common complication than pneumopericardium. It therefore seems more likely that the association of pneumomediastinum and pneumopericardium is coincidental, each representing a different route of air dissention. No perforation of the pericardium was seen at autopsy in any of the cases reported by Loftis et al;10 in one case a direct communication between trachea and mediastinum was observed, but the communication was in a patient in whom an operation had been performed in that area. There were no cases of pneumopericardium among the older children in the series of Mansfield et al,13 despite prolonged ventilation at similar inflating pressures and higher end-expiratory pressures than used in the neonates. This paucity of cases in older children and in adults suggests better development of the pericardial reflection and vascular sheath or, conversely, some anatomic defect in the premature infant's pericardium that could predispose to air entry. The occurrence of this rare complication in twins further supports the possibility of an anatomic defect. Cimmino14 has
speculated that the serosal layers of the pericardium in young infants are usually susceptible to dissection and rupture. Conclusion Problems involving dissection of air are becoming more common as more infants with respiratory distress syndrome are being kept alive on respirators. These problems include pneumothorax, pneumomediastinum, pulmonary interstitial emphysema and even the rarer pneumopehcardium. Dissection into pulmonary veins has also been described11 and we have seen one definite case. Such problems are rarely seen in adults on respirator therapy. Pneumopericardium seems to be most common in newborns, particularly the premature. We have presented the first reported case of pneumopericardium developing in twins while on positive pressure ventilation in the treatment of hyaline membrane disease. One underwent pericardiocentesis; the other did not. Both twins died. The third patient was asymptomatic; pericardiocentesis was not performed and he lived. It appears from the literature reviewed that the prognosis in cases of pneumopericardium is much better when there is no other evidence of air block. For patients with isolated pneumopericardium conservative therapy appears warranted, although the number of cases reported is too small to provide a definite answer. References 1. MATTHIEU JM, NUSSLE D, TORRADO A, Ct al: Pneumopericardium in the newborn. Pedia-
trics 46: 117, 1970
2. SINGH KR, WIGLESWORTH FW, STERN L: Pneumopericardium in the newborn - a cornplication of respirator management. Can Med Assoc / 106: 1195, 1972 3. COHEN 5, LOCKHART CH: Pneumopericardium: a cornplication of prolonged ventilation. Anesthesiology 32: 465, 1970 4. MARKARIAN M, ABLOCO RC: Neonatal pneumopericardium. Pediatrics 47: 634, 1971 5. GROSFELD JL, KILMAN JW, FRYE TR: Spontaneous pneumopericardium in the newborn infant. J Pediatr 76: 614, 1970 6. SHAWKER TH, DENNIs JM, GAREIs JW: Pneumopericardium in the newborn. Am J Roent-
genol Radium Ther Nuci Med 116: 514, 1972
7. SAGEL SS, WIMBUsH P, GOLDENBERO DB: Tension pneumopericardium following assisted ventilation in hyaline membrane disease. RadIology 106: 175, 1973 8. MACRUN CC: Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum. Arch Intern Med 64: 913, 1939 9. GERSHANIK JJ: Neonatal pneumopericardium. Am J Dis Child 121: 438, 1971 10. LoFTIs JW, SusaN AF, MARCH JH, et al: Pneumopericardium in infancy. Am J Dis Child 103: 61, 1962 11. MACPHERSON RI, CHERNICK V, REED M: The complications of respirator therapy in the
newborn. J Can Assoc Radiol 23: 91, 1972
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