EXPERIENCE AND REASON-BRIEFLY RECORDED 145
distinct advantages over tracheostomy in
cer-tam situations. Obviously, it bypasses the
well-known surgical complications of tracheostomy,
pneurnothorax, and pneumomediastinum . It
ProvideS for easier artificial ventilation, when re(Iuired, and avoids the difficulties of decan-Ilulation in tile younger child. The polyvinyl
tubes available for nasotracheal intubation
fllOtild to the contours of the respiratory tract
at body temperatures and are non-toxic to tile
mucosa of the larynx and trachea. Care must
be taken, however, to avoid a tightly fitting
tube which could result in pressure necrosis of
the nlucosa overlying the cricoid cartilage, the
narrowest part of tile childs larynx.’
Management of the intubated patient is
al-most identical to management of the
trache-ostomy. Intense nursing care is required! to
prevent accumulation of secretions and their
inspissation, with subsequent atelectasis.
Proper humidification of inspired gases is
es-sential in eitller case. Our protocol of puimo-nary toilet consists of hourly changes of
posi-tion, chest percussion, instillation of small
vol-times (2 to 4 ml) of ilormal saline into the
trachea, careful aspiration of secretions from
each main bronchus, and manual
hyperinfla-tioll of the lungs, in that order.
It flltiSt be stressed that the aspirating
cathe-ter be placed beyond the bevel of the
endo-tracileal tube for suction to be effective.
Polyvi-nyl catheters pass more readily than rubber
ones. Enclotracheal suctioning may be
some-what more difficult than aspirating tile
trache-OstOIllV. For this reason we prefer to
demon-strate personally tile technique to our nursing
personnel and observe them directly during
their first attempts at it. Once demonstrated,
endotracheal toilet presented no problems to
our nursing personnel in the cases reported,
nor has it been a problem in tile postoperative
patients so managed.
The nasal route is preferred to tile oral for prolonged intubation because it is more readily tolerated by the patient, minimizes salivation,
may be fixed more securely to the face, and
avoids the danger of the child biting the tube.
SUMMARY
The use of prolonged nasotracheal
intuba-tion in the nlanagement of two cases of acute
epiglottitis is described. Some of the
advan-tages of intubation over tracheostomy are
out-litled. In any given clinical situation, the
ex-pected duration of respiratory disability and
the amount of traclleobronchial secretion
antic-ipated will influence tile choice between
naso-tracheal intubation and tracheostomy.
ROBERT P. GERACI, M.D.
Department of Anesthesiology Naval Hospital
Port$moutlz, Virginia
Present Address:
Department of Anesthesiology
University of Rochester
School of Medicine and Dentistry
Rochester, New York 14620
The Opinions or assertions contained herein are
those of the author and are not to be construed
as official or reflecting the views of the Navy De-partment or of the Naval Service at large.
The author wishes to thank Dr. R. A. Malone
for Per11lissi11 to report Case 2.
REFERENCES
1. Vetto, R. R. : Epiglottitis. J.A.\I.A., 173:990,
1960.
2. Matteson, A. R. : Acute epiglottitis. Arch. Oto-laryng., 76:465, 1962.
3. Rosales, A. K., and Davenport, ii. T.: Acute
laryngotracheobronchitis and epiglottitis. Can-ad. Anaesth. Soc. J., 9:467, 1962.
4. Poole, C. A., and Altman, D. H.: Acute
epiglot-titis in children. Radiology, 80:798, 1963.
5. McDonald, I. H., and Stocks, J. C. : Prolonged
nasotracheal intubation. Brit. J. Anaesth., 37:
161, 1965.
6. Allen, T. H., and Steven, I. M. : Prolonged
endotracheal intubation in infants and
chil-dren. Brit. J. Anaesth., 37: 566, 1965.
Chlorpropamide
Poisoning
Prolonged hypoglycemia developed in a
3J-year-old boy who found his aunt’s “blue sugar
pills” irresistible.
CASE REPORT
The patient ate an unknown number of 250 mg chlorpropamide tablets (Diabinese). He remained
well for the next 24 hours. Then he became
ir-ritable, ataxic, and delirious and he fainted
sev-eral times. Thirty-six hours after the ingestion of
chlorpropamide, he was admitted to the hospital semicornatose and with athetotic movements.
Otherwise, the physical examination was normal.
Blood sugar was 28 mg/100 ml. Other laboratory
studies done on blood, serum, and urine were
normal.
146 CHLORPROPAMIDE POISONING
CI 1SO2NH-C-NHCH2CH2CH3
________________
II
0
FIG. 1.
started. Within 30 minutes, the athetotic
move-ments ceased and the boy became alert. During
the first 24 hours, the patient received 600 cc of
10% glucose intravenously and 1,500 cc of milk
and orange juice by mouth. He remained
asympto-matic during this period; but, the blood sugar
concentration did not rise above 48 mg/100 ml,
with values as low as 32 mg/100 ml. During the
second 24 hours, similar therapy was continued
and blood sugar concentrations of 20 mg/100 ml
and 26 mg/100 ml were obtained, again without
clinical symptoms. Forty-eight hours after admis-sion, the liver had become enlarged with its edge
palpable 6.5 cm below the costal margin in the
mid-clavicular line. A serum sample drawn at this
time had an insulin concentration of 90 tu/cc
(normal below 25 pu/ce) with a sugar
concentra-lion of 20 mg/100 ml (Table I). Intravenous
in-fusion was terminated on the third hospital day;
instead, tile boy drank 200 cc of 10% glucose every
2 hours. Ten hours later, or 94 hours after the
ingestion of chlorpropamide, the blood sugar
con-centration rose to 140 mg/100 ml. It did not fall
below 121 mg/100 ml during the next 42 hours,
at which time the boy was released from the
hos-pital at the request of his parents. At the time of
discharge, the hepatomegaly had disappeared and
studies on senim and urine for liver disease and
diabetes were negative. At home, the boy has
re-mained vell. Physical examinations on days 15,
36, 57, and 71 post-ingestion were normal, as
were post-breakfast concentrations of serum insulin
and serum sugar (Table I). Although not
previ-TABLE I
CoscExTIATIox OF SERUM INSULIN AND SERUM
SIG%n AFFER CHLORPROPAMIDE INGESTION
Days .lfter Serum insulin Serum. Sugar
(‘hiorpropamide Conceniration Conceal ration
ingestion gzu/cc mg/100 cc
3 90 0
15 9 86
36 23 104
.57 30 126
71 21 104
ously examined by the authors, he appears
devel-opmentally normal for 3i years. No change in
mental or motor ability has been noted by the
mother.
METHODS
Blood sugar was determined according to
Somogyi-Nelson. Concentration of serum
in-sulin was measured as reported by Soeldner
and Sloane.1#{176}Normal values in our laboratory
are 25 u of insulin per cubic centimeter of
serum or less.
COMMENT
Chlorpropamide is a hypoglycemic
arylsul-fonylurea compound of the formula given in
Figure 1.2 After ingestion of the drug, a drop
in blood sugar occurs within 2 to 4 hours.
Chlorpropamide is excreted by the
kidneys-80% of a single dose within 32 hours and the
remainder over a period of 16 days.
Hypo-glycemia is effected through the ability of the
drug to release insulin from the pancreas.4
This might explain the drug’s failure to lower
the blood sugar in patients with juvenile
dia-betes, since they have little or no insulin in
their pancreas.5 Healthy children, however,
can respond with insulin release which might
be sustained for a long period consistent with
the slow urinary excretion of the drug. Thus,
our patient had hypoglycemia for 94 hours
after the ingestion of chlorpropamide and the
serum insulin concentration was elevated
three-fold 84 hours after the ingestion. Although
this increased insulin and the therapeutically
administered glucose could have combined to
produce a temporary glycogenosis of the liver,
the degree of transient hepatomegaly observed
84 hours after the ingestion might not be
ex-plained completely on this basis. Since
chior-propamide may not produce maximal effect
0 The materials for the determination of insulin
were purchased from Nuclear-Chicago
Corpora-tion, 333 East Howard Avenue, Des Plaines,
EXPERIENCE AND REASON-BRIEFLY RECORDED 147
for over 24 hours, observations of patients
who have ingested this drug must be
pro-longed.
SUMMARY
Clinical signs of hypoglycemia developed in
a 33-year-old boy 24 hours after he had eaten
some of the attractively blue-colored
chlorpro-pami(le tablets. Low blood sugar values
per-sisted for 4 days after the ingestion
coilcOmi-tant with an increase in serum insulin
concen-tration. On the fifth day, the blood sugar rose
to normal levels. The serum insulin
concentra-tion was not significantly out of the normal
raiges Ofl each of the four follow-up
examina-tiolls.
BARRY GREENBERG, M.D.
CARL WEIHL, M.D. GEORGE Huc, M.D.
Department of Pediatrics
University of Cincinnati
College of Medicine
Cincinnati, Ohio 45229
ADDRESS FOR REPRINTS: (C. H.)
The Children’s Hospital Researcil Foundation
Elland and Bethesda Avenues
Cincinnati, Ohio 45229
Supported in part by Grants No. AM 08528 and
FR 00123, National Institutes of Health, and by
the Children’s Hospital Research Foundation.
We thank Miss Kathy Goertemiller for valuable technical assistance.
REFERENCES
1. Socldner, J. S., and Sloane, D. : Critical
varia-bles in the radioimmunoassav of serum in-sulin using the double antibody technic.
Dia-betes, 14:771, 1965.
2. Root, M. A., Sigal, M. V., and Anderson, R. C.: Pharmacology of
1-(p-chlorobenzenesulfonyl)-3-n-propvlurea (chiorpropamide). Diabetes, 8:7, 1959.
3. JOilnSOn, P. C., Hennes, A. R., Driscoll, T.,
and \Vest, K. M. : Metabolic fate of
chlor-propamide in man, Ann. N.Y. Acad. Sci.,
74:459, 1959.
4. Loubati#{232}res,A.: General Pharmacodynarnics of
the Flypoglycelflic Arylsulfonamides, Ann.
N.Y. Acad. Sci., 74:413, 1959.
5. Wrenshall, C. A., and Best, C. H.:
Extract-able insulin of the pancreas and effectiveness of oral hypoglycemic sulfonylureas in the
treatment of diabetes mellitus in man-a
comparison. Canad. Med. Ass. J., 74:968,
1956.
Screening
for
Hidden
Congenital
Anomalies
The principles of examining the newborn
infant for hidden malfoi-mations, particularly
of the gastrointestinal tract, have been
de-scribed by Apgar and co-workers’ 2and are well
known to pediatricians. Although Apgar and
James’ advocate performing these studies on
all infants, the examination is usually not done
routinely, and from our experience it is often
not done even in high risk infants.
During recent years a large number of
in-fants with obstructive gastrointestinal
anoma-lies have been transferred to us at several
days of age in a moribund state. Survival of
these infants would have been increased by
earlier diagnosis. This brief report describes
our experience with a survey in 2,000
consecu-tive births for detecting infants likely to have
anomalies. Our purpose is to emphasize the
importance of performing these procedures
early and routinely.
METHODS AND RESULTS
The survey is described in Table I. A soft,
No. 8 feeding catheter was used. All
examina-tions were done under the supervision of a
pediatric house officer. Deviations from normal
were confirmed by the senior author. Results
are given in Table II, which indicates that
about one in three of the infants thus
deviat-ing proved to have an anomaly; the total
coilgenital anomalies encountered in the 2,000
infants are listed in Table III.
COMMENT
Tile incidence of major and minor anomalies
in this study is comparable to that described
by others.’’
Five of the 12 infants whose mothers had
polyhydramnios died. Three deaths were due
TABLE I
DESCRIPTION OF TIlE CONGENITAL
ANOMALY APPRAISAL
Inquiry for polyhydramnios.
Appearance of abdomen. Passage of riam-gastric tube.
Aspiration of stomach with recording
of color and amount of fluid.
