The Chiari network is an embryonic remnant of the right venosus, consisting of a thin, mobile structure connected to the right atrium. Neonates with the Chiari network may present with hypoxemia. We report a case of a neonate with persistent hypoxemia despite improvement in respiratory distress symptoms and increased supplemental oxygen that was diagnosed using real-time telemedicine.

Hypoxemic patients often desaturate further with movement and transport. While inhaled epoprostenol does not improve mortality, improving oxygenation allows for transport of severely hypoxemic patients to tertiary care centers with a related improvement in mortality rates. Extracorporeal membrane oxygenation (ECMO) use is increasing in frequency for patients with refractory hypoxemia, and with increasing regionalization of care, safe transport of hypoxemic patients only becomes more important. In this series, four cases are presented of young patients with severe hypoxemic respiratory failure from Legionnaires’ disease transported on inhaled epoprostenol to ECMO centers for consideration of cannulation. With continued climate changes, Legionella and other pathogens are likely to be a continued threat. As such, optimizing oxygenation to allow for transport should continue to be a priority for critical care transport (CCT) services.

In diffuse forms of arteriovenous malformation following Fontan procedure, “classical” medical therapy, inhaled nitric oxide and sildenafil, may play a role, until re-direction of hepatic flow to pulmonary circulation cures it. However, in refractory cases, as reported in our 2-year-old patient, unusual medications such as calcium channel blockers can be tried and continued if patients respond adequately.

Obstructive sleep apnea (OSA) is characterized by disrupted breathing and hypoxemia during sleep, daytime sleepiness, and changes in cognition and mood. One important question is regarding the reversibility of cognitive deficits after treatment with continuous positive airway pressure (CPAP). Here, we report the outcomes of CPAP treatment as measured by tests of attention and executive function. Thirty-seven individuals with moderate to severe OSA and compliant on CPAP treatment were studied with working memory tasks, neuropsychological testing, and overnight polysomnographic sleep study and compared to 27 healthy controls. CPAP improved the respiratory disturbance index, minimum and mean oxygen saturation (SpO2), subjective sleep quality, and daytime sleepiness ratings compared to pre-treatment values. In terms of current neurocognitive function, treated individuals with OSA performed at a comparable level to controls on basic working memory storage functions but still showed a significant reduction on tests of working memory requiring the central executive. The OSA group also performed worse on neuropsychological measures of complex attention, executive function, and psychomotor speed. While CPAP is an effective treatment for OSA in terms of ameliorating breathing disruption and oxygen desaturation during sleep, as well as daytime sleepiness, some cognitive deficits may be more resistant to treatment. (JINS, 2010, 16, 1077–1088.)

Acute hypoxemia (low PaO2) leads to changes in oxygen consumption and electrical responses of the outer retina of cats, but inner retinal ERG components and ganglion cell responses have been shown to be quite resistant to hypoxemia. The purpose of this study was to determine whether the resistance of the inner retina depends on (1) the stimulus conditions, specifically the degree of light adaptation; and (2) the ability of the photoreceptors to increase glycolysis during hypoxemia. To address these issues, recordings of single ganglion cell action potentials and of the b-wave and scotopic threshold response (STR) of the electroretinogram (ERG) were made from the eyes of anesthetized cats during hypoxemia alone and hypoxemia plus hypoglycemia. Ganglion cells appeared to be equally resistant to hypoxemia at high and low backgrounds (3.3 to 9.7 log equivalent quanta(555 nm)-deg-2-s-1), and the STR, recorded with dim stimuli during dark adaptation, when photoreceptor oxygen consumption is most susceptible to hypoxemia, was unchanged until PaO2 was below 30 mm Hg. The amplitude of the b-wave was similarly resistant to hypoxemia when the animal was normoglycemic. During hypoglycemia, however, both the b-wave and the STR became more sensitive to hypoxemia, beginning to change at PaO2s as high as 50 mm Hg when blood glucose was 40–50 mg/dl. It is argued that hypoglycemia limits or prevents the increased glycolytic ATP production that would ordinarily occur when the photoreceptor oxygen supply decreases, and that increased photoreceptor glycolysis is essential in the protection of the retina against mild hypoxemia.

We treated a neonate with pulmonary atresia and a ventricular septal defect complicated by straddling of the atrioventricular valves by constructing a central aorto-pulmonary shunt. The postoperative course was complicated by obstruction of the shunt, which was treated by implantation of a coronary stent. Six months after the stenting, a Glenn anastomosis was created and the stented shunt removed. Analysis showed that the shunt was completely covered by a vascularized neointima. The stent had not produced injury to the shunt, with struts of the stent covered nicely by neoendothelium, with sparse inflammation surrounding the artificial implants.

Acute Respiratory Distress Syndrome (ARDS) is characterized by lung injury and hypoxemia, has a high mortality rate, and is associated with significant morbidity including cognitive and emotional sequelae and decreased quality of life. There is limited information regarding which of these factors are associated with decreased quality of life. This study assessed the relationships between quality of life, cognitive and emotional function in ARDS survivors at 1-year post-hospital discharge. Sixty-six ARDS survivors were administered a battery of neuropsychological tests, measures of emotional function and quality of life 1 year post-hospital discharge. At 1 year 45% of the ARDS patients had cognitive sequelae and 29% had mild to moderate symptoms of depression and anxiety. Depression, anxiety, and intensive care unit length of stay were significantly correlated with decreased quality of life. Cognitive impairments did not correlate with decreased quality of life. Illness severity and emotional function, but not cognitive sequelae, are associated with decreased quality of life 1 year following ARDS. ARDS is common and may result in significant cognitive and emotional morbidity and decreased quality of life. (JINS, 2004, 10, 1005–1017.)

Kang Derwent and Linsenmeier (2000) reported that the a- and b-waves of the cat electroretinogram (ERG) are resistant to hypoxemia, at least for PaO2 above 40 mm Hg. The a-wave may be resistant because the photoreceptor can increase glycolysis during hypoxemia. This hypothesis was tested by making the animal hypoglycemic, which should minimize the ability of the photoreceptor to switch to glycolysis. The ERG of dark-adapted anesthetized cats was recorded between an Ag/AgCl electrode in the vitreous humor and a reference electrode near the eye. Responses to bright flashes of diffuse white light were recorded at 3-min intervals during hypoxic episodes at three levels of blood glucose. The moderate hypoglycemia (50 to 70 mg/dl) had a relatively small effect on the a-wave amplitude. Furthermore, the a-wave amplitude increased transiently by 16 ± 7% within 30–40 min of the start of severe hypoglycemia (20 to 40 mg/dl), before recovering to near normal. Severe hypoglycemia alone decreased the b-wave amplitude by 15 ± 13%. Combined hypoxemia and hypoglycemia decreased the b-wave amplitude more than the a-wave amplitude. At all levels of blood glucose, b-wave decreases began at a higher PaO2 than the a-wave changes. For both the a- and b-waves, hypoxemic effects began at higher PaO2 when the animal was hypoglycemic. The increased sensitivity to hypoxemia during severe hypoglycemia suggests that a switch from oxidative to glycolytic metabolism ordinarily protects the retina from moderate hypoxemia. Because the a- and b-waves were affected to different degrees and at different PaO2s, it is unlikely that inner retinal changes are caused completely by changes in the photoreceptor.