Jennifer Reikes Willert, MD Associate Clinical Professor, Department of Pediatrics, Division of Pediatric Hematology/Oncology, Section of Stem Cell Transplantation, Stanford University Medical Center, Lucile Packard Children's Hospital
Jennifer Reikes Willert, MD is a member of the following medical societies: American Academy of Pediatrics , American Society of Hematology , American Society for Blood and Marrow Transplantation , Children's Oncology Group , American Society of Pediatric Hematology/Oncology
Disclosure: Nothing to disclose.
This increase in leukocyte (primarily neutrophils) is usually accompanied by a "left upper shift" in the ratio of immature to mature neutrophils and macrophages. The proportion of immature leukocytes decreases due to proliferation and inhibition of granulocyte and monocyte precursors in the bone marrow which is stimulated by several products of inflammation including C3a and G-CSF. Although it may indicate illness, leukocytosis is considered a laboratory finding instead of a separate disease . This classification is similar to that of fever , which is also a test result instead of a disease. [ citation needed ] "Right shift" in the ratio of immature to mature neutrophils is considered with reduced count or lack of "young neutrophils" (metamyelocytes, and band neutrophils ) in blood smear , associated with the presence of "giant neutrophils". This fact shows suppression of bone marrow activity, as a hematological sign specific for pernicious anemia and radiation sickness . 
Tracheoesophageal fistula is a devastating but rare complication of endotracheal intubation. It should be suspected in intubated patients with recurrent pneumonias. Adding methylene blue to the enteral feed and finding it in the endotracheal aspirate supports the diagnosis, however, does not confirm it. This should be followed with a barium swallow, esophagoscopy or bronchoscopy. The fistula needs to be repaired surgically which may not be feasible in the critically ill. Until it is, conservative management involves frequent suctioning, elevation of the head end of the bed and advancing the ET tube distal to the opening of the fistula.