Assessing fluid balance in critically ill pediatric patients.

UNLABELLED: Monitoring fluid balance (FB) in a pediatric intensive care unit (PICU) is crucial to assess fluid overload. Pediatric intensivists (PI) frequently use the fluid intake minus output (FIMO) or FIMO with adjustments for insensible fluid loss (AFIMO). However, the accuracy of FIMO/AFIMO has never been tested in critically ill children. We designed a prospective, monocentric cohort study in a PICU of a university hospital. Body weight (BW) was measured in all children consecutively admitted to PICU and 24 h later. Every 12 h, the nurses calculated FIMO/AFIMO. Time burden and convenience of each procedure (median; [interquartile range]) were recorded and compared using a Wilcoxon test. Data were analysed using linear regression (r (2) coefficient) and the Bland-Altman plot (mean difference ± standard deviation; absolute mean difference), with a 300-ml variation of FB considered clinically relevant. Sixty consecutive patients, 304-day [39-1,565] old with admission weight of 9.2 kg [4.4-17.8] were included. Although correlations between FIMO/AFIMO and BW changes (BWC) were strong (r (2) FIMO = 0.63, p < 0.0001 and r (2) AFIMO = 0.72, p < 0.0001, respectively), agreement between FIMO/AFIMO and BWC were over 300 mL (-0.305 ± 0.451, 0.382 L and -0.007 ± 0.447, 0.302 L, respectively). No significant differences were noted between FIMO/AFIMO and BWC measurements for time burden (5 min [5-10] vs. 5 min [5-10], p = 0.84) or convenience (1 min [1-2] vs. 1 min [0-1.3], p = 0.13). CONCLUSION: Because agreement between FIMO/AFIMO and BWC is poor during the first 24 h after admission into PICU, PIs may reserve FIMO/AFIMO to monitor FB in patients with absolute contraindications of BW measurements.

Does neonatal pain management in intensive care units differ between night and day? An observational study.

OBJECTIVE: To determine whether analgesic use for painful procedures performed in neonates in the neonatal intensive care unit (NICU) differs during nights and days and during each of the 6 h period of the day. DESIGN: Conducted as part of the prospective observational Epidemiology of Painful Procedures in Neonates study which was designed to collect in real time and around-the-clock bedside data on all painful or stressful procedures. SETTING: 13 NICUs and paediatric intensive care units in the Paris Region, France. PARTICIPANTS: All 430 neonates admitted to the participating units during a 6-week period between September 2005 and January 2006. DATA COLLECTION: During the first 14 days of admission, data were collected on all painful procedures and analgesic therapy. The five most frequent procedures representing 38 012 of all 42 413 (90%) painful procedures were analysed. INTERVENTION: Observational study. MAIN OUTCOME ASSESSMENT: We compared the use of specific analgesic for procedures performed during each of the 6 h period of a day: morning (7:00 to 12:59), afternoon, early night and late night and during daytime (morning+afternoon) and night-time (early night+late night). RESULTS: 7724 of 38 012 (20.3%) painful procedures were carried out with a specific analgesic treatment. For morning, afternoon, early night and late night, respectively, the use of analgesic was 25.8%, 18.9%, 18.3% and 18%. The relative reduction of analgesia was 18.3%, p<0.01, between daytime and night-time and 28.8%, p<0.001, between morning and the rest of the day. Parental presence, nurses on 8 h shifts and written protocols for analgesia were associated with a decrease in this difference. CONCLUSIONS: The substantial differences in the use of analgesics around-the-clock may be questioned on quality of care grounds.

Abdominal Cellulitis following a Laparoscopic Procedure: A Rare and Severe Complication.

Advantages of laparoscopic approach in Hirschsprung disease have been already published decreasing the hospital stay and postoperative adhesions. To our knowledge, we report the first case of postoperative abdominal cellulitis after laparoscopic procedure. A laparoscopic Duhamel pull through was done on a 3-month-old child. Full-thickness biopsy under laparoscopy was performed with intraperitoneal inoculation. Large peritoneal irrigation was used. Abdominal necrotizing cellulitis starting from a port site occurred few days after the procedure requiring repeat surgical excision, broad spectrum antibiotics, and hyperbaric oxygen.

Treatment failure of nosocomial pertussis infection in a very-low-birth-weight neonate.

We describe a case of nosocomial maternal transmission of Bordetella pertussis to a very-low-birth-weight (VLBW) neonate in whom treatment was unsuccessful. This case underscores the need for rapid and sensitive PCR diagnosis in VLBW neonates and in parents with clinical signs of pertussis and suggests that standard treatment may not be appropriate for VLBW neonates.

The management of long gap esophageal atresia.

BACKGROUND: Present management of esophageal atresia has enabled the survival rate to approach 95%. Controversy remains concerning the many options for the surgical management of long gap esophageal atresia without tracheoesophageal fistula and represents the difficulty of this pathology. In the last couple of years, we have had a nonexplained outbreak of cases of long gap esophageal atresia without tracheoesophageal fistula. This article reports our experience in the management of these children. MATERIAL AND METHODS: It is a retrospective study of all cases of long gap esophageal atresia without tracheoesophageal fistula managed in our institution since 1992, focusing on the antenatal period, delivery with weight and term, the associated malformations, the initial management, and the definitive surgery. Mann-Whitney U test was used for statistical analysis. RESULTS: Ten cases (8.7%) of long gap esophageal atresia according to Ladd's classification, 6 during the past 2 years, were taken in charge at Robert Debré Hospital between 1992 and 2002. There were 4 girls and 6 boys. Ten had a prenatal diagnosis of esophageal atresia. The average birth weight was 2496 g (range, 1400-3400 g) with an average term of 36.6-week gestation (range, 31.5-39.6). Delayed reconstruction was done in all children between 41 and 147 days of life (average of 102 days). Six had a direct anastomosis and 4 had a colonic esophagoplasty (3 with an esogastric disconnection during the same procedure). The average follow-up was 60 months (range, 27-133). There was 1 death owing to adenovirus infection at 5 years of age. Four children required a Nissen fundoplication for severe gastroesophageal reflux. At least, 2 children presented an anastomotic stricture which required pneumatic dilatations. CONCLUSION: Treatment options for long gap esophageal atresia generally require several stages over several months. We propose, for their management, a direct anastomosis at 4 months of age whenever it is possible. If not, we use a colonic esophagoplasty with an esogastric disconnection to control the gastroesophageal reflux which is responsible for strictures and respiratory impairment and does not obstruct the aperistaltic tube.

Ventilatory responses to hypercapnia and hypoxia in heterozygous c-ret newborn mice.

The c-ret proto-oncogene encodes a tyrosine-kinase receptor involved in survival and differentiation of neural crest cell lineages. Previous studies have shown that homozygous c-ret-/- mice die soon after birth and have impaired ventilatory responses to hypercapnia. Heterozygous c-ret +/- mice develop normally, but their respiratory phenotype has not been described in detail. We used whole-body flow plethysmography to compare baseline breathing and ventilatory and arousal responses to chemical stimuli in unrestrained heterozygous c-ret +/- newborn mice and their wild-type c-ret +/+ littermates at 10-12 h of postnatal age. The hyperpnoeic and arousal responses to hypoxia and hypercapnia were not significantly different in these two groups. However, the number and total duration of apnoeas and periodic breathing episodes were significantly higher in c-ret +/- than in c-ret +/+ pups during hypoxia and post-hypoxic normoxia. These results are further evidence that respiratory control at birth is heavily dependent on genes involved in the neural determination of neural crest cells.