Guidelines regarding ineffective maintenance of organ functions (futile therapy) in paediatric intensive care units.

In Poland, guidelines for the management of ineffective treatment of children in neonatal and paediatric departments developed by the Polish Neonatal Society and the Polish Paediatric Society, have been published. The specific problems of futile therapy in paediatric anaesthesiology and intensive care units should be defined and solved separately. For this purpose, the guidelines presented below were prepared. They present the principles for managing children for whom therapeutic options available in paedia-tric anaesthesiology and intensive care units have been exhausted and ineffectiveness of maintaining organ functions, i.e. futile therapy, has been suspected. The decision to withdraw futile therapy of a child is undoubtedly one of the most difficult for both doctors and parents, and for this reason, it should be made collectively, respecting the dignity of the child and his/her parents or legal representatives, and continuing the management aimed at relieving the child's pain and suffering, as well as minimising anxiety and fear. Due to the small amount of reliable evidence-based data, the guidelines constitute the consensus of the Group of Experts and are dedicated to minor patients treated in paediatric anaesthesiology and intensive care units.

A new endotracheal tube for infants--laboratory and clinical assessment: a preliminary study.

BACKGROUND: Conventional endotracheal pediatric tubes offer high resistance due to their small diameters and relatively high flow during ventilation. Any increase of the diameter of the tube lumen decreases the airway resistance and subsequently, the work of breathing (WOB). We compared ventilation mechanics using a new, cone-shaped endotracheal tube of our design to the Cole and standard tubes. METHODS: The study has been divided into three parts: (i) preliminary laboratory tests, (ii) in vitro study with infant lung model, and (iii) clinical study in infants. Flow resistance and WOB were compared, using standard, Cole (in experimental phase only) and cone tubes. RESULTS: We proved that inspiratory (Ri ) and expiratory (Re ) resistance, and WOB, were significantly lower in patients ventilated via a cone tube. Mean Ri decreased by 37%, compared with the baseline values, Re - by 35%, and total WOB - by 12%. CONCLUSION: The cone tube offers lower resistance to gas flow than the standard, used nowadays in clinical practice. It can be especially beneficial to spontaneously breathing patients reducing WOB and improving gas exchange.

Successful complex management of a congenital diaphragmatic hernia--a case report.

Congenital diaphragmatic hernia is a very serious congenital defect associated with high mortality rate. The syndrome is characterized by migration of abdominal viscera to thoracic cavity a variable degree of pulmonary hypoplasia associated with pulmonary hypertension caused by alteration of pulmonary vessels diameter increased muscularisation of pulmonary arteries and decreased compliance of the lungs resulting in increased afterload of the right ventricle, decreased cardiac output and impaired oxygenation. We describe a case of congenital diaphragmatic hernia with migration of the stomach, the small and the large bowels and the left hepatic lobe into the left pleural space, diagnosed by ultrasound in utero at 24 weeks of gestation. The child was initially placed on high-frequency oscillation and nitric oxide and required vigorous inotropic support. The defect was repaired after stabilization of the cardiac output and gas exchange. The patient made successful recovery.

The place of suxamethonium in pediatric anesthesia.

Suxamethonium is a drug that promotes very strong views both for and against its use in the context of pediatric anesthesia. As such, the continuing debate is an excellent topic for a 'Pro-Con' debate. Despite ongoing efforts by drug companies, the popular view still remains that there is no single neuromuscular blocking drug that can match suxamethonium in terms of speed of onset of neuromuscular block and return of neuromuscular control. However, with this drug the balance of benefit vs risk and side effects are pivotal. Suxamethonium has significant adverse effects, some of which can be life threatening. This is particularly relevant for pediatric anesthesia because the spectrum of childhood diseases may expose susceptible individuals to an increased likelihood of adverse events compared with adults. Additionally, the concerns related to airway control in the infant may encourage the occasional pediatric anesthetist to use the drug in preference to slower onset/offset drugs. In the current environment of drug research, surveillance and licensing, it is debatable whether this drug would achieve the central place it still has in pediatric anesthesia. The arguments for and against its use are set out below by our two international experts, Marcin Rawicz from Poland and Barbara Brandom from USA. This will allow the reader an objective evaluation with which to make an informed choice about the use of suxamethonium in their practice.

[Recommended treatment of apnea in premature infants. A review based on literature and own experience]. / Leczenie bezdechów u noworodków przedwczesnie urodzonych - zalecenia opracowane na podstawie danych z pismiennictwa i doswiadczen wlasnych.

The authors reviewed the literature concerning different methods of treatment of apnea in premature infants. The authors consider that, apart from pharmacological treatment, noninvasive respiratory support methods play an important role in the prevention and treatment of newborns with apnea. The aim of the study is to present current recommendations concerning the principles of prevention and treatment of apnea in premature infants. The compiled recommendations are based on the data from literature and from the authors' own experiences.

[Indications for endotracheal intubation]. / Wskazania do intubacji dotchawiczej.

The purpose of the study was to propose recommendations for endotracheal intubation and respiratory support in newborn and in infants. The recommendations for endotracheal intubation are preceeded by a short history of intubation, basic anatomy of the upper airway in infants and children and the most common methods of airway control. The main indications for intubation are airway protection and control of the airway. Such circumstances may be: general anaesthesia, congenital malformations and diseases of the upper airway, mechanical ventilation, perinatal resuscitation and various forms of acute respiratory distress. Endotracheal intubation is strongly recommended during general anaesthesia in infants, complete and almost complete obstruction of the upper airway (grade A). Intubation is also necessary when bag-mask ventilation is ineffective, and when external chest compressions are being delivered. The position of the tube must be confirmed by a capnometer or a disposable CO(2) sensor (Class A, LOE 1a and 1b). Endotracheal intubation and mechanical ventilation should be considered in cases of frequent, caffeine and nCPAP-resistant apnoeic episodes, in the ARDS and progressive ventilatory failure in sepsis. (Class B).

[Weaning newborns from noninvasive ventilation]. / Zasady uwalniania noworodków z wentylacji neinwazyjnej.

The purpose of the study was to propose the recommendations for weaning infants from nasal continuous positive airway pressure (nCPAP) and nasal intermittent positive pressure ventilation (NIPPV). Despite the fact that both methods are commonly used for respiratory insufficiency in infants, detailed recommendations for weaning have not been described so far. The proposed recommendations are based on previously described data and a wide survey conducted among Polish neonatologists and intensive therapy paediatricians.

[Recommendations for analgesia and sedation in neonatal intensive care]. / Zasady stosowania leków przeciwbólowych i sedacyjnych u noworodków i niemowlat leczonych w oddziale intensywnej terapii.

The purpose of the study was to present recommendations, relevant to the management of neonates and infants aged 0-1 years, treated in intensive care settings. They include general principles and recommendations for pain and sedation assessment, sedation and pain management and advice on the use of pharmacological strategies. The bolus (on demand) administration of sedative agents should be avoided because of increased risk of cardiovascular depression and/or neurological complications. Midazolam administration time should be limited to 72 hours because of tachyphylaxis, and the possibility of development of a withdrawal syndrome and neurological complications (grade A, LOE 1b). The level of sedation and pain should be regularly assessed and documented, using presented scales; the COMFORT scale is preferred. Opioids, given in continuous infusion, are the drugs of choice for neonatal sedation. To avoid withdrawal syndrome, the total doses and time of administration of sedative agents should be limited. Methadone is a drug of choice in the treatment of a withdrawal (Grade B, LOE 2). Intravenous ketamine is recommended, when short-term sedation/anaesthesia is required (Grade C, LOE 3) for painful and/or stressful intensive care procedures. (Grade C, LOE 2). Muscle relaxants should be used for endotracheal intubation and in the situations when mechanical ventilation is not possible due to maximal respiratory effort of the patient.

[Procedures for CV catheters insertion in children with congenital coagulation disorders]. / Zasady postepowania w zakladaniu cewnnikow centralnych u chorych na wrodzone osoczowe skazy krwotoczne- doswiadczenia wlasne.

UNLABELLED: The aim of this study is to present our experiences in inserting CV catheters in patients with congenital coagulation disorders. MATERIALS AND METHODS: Between 1997 and 2008 27 Port-a-cath catheters were inserted in our department in 20 patients with severe congenital coagulation disorders in order to infuse coagulation factor concentrates. 18 patients had haemophilia A, including 13 with factor VIII inhibitor, one haemophilia B and one von Willebrand's disease type 3. We present techniques for CV catheter insertion and procedures for ensuring haemostasis. CONCLUSIONS: 1. Procedures for CV catheter insertion in children with congenital coagulation disorders is safe provided that defective haemostasis is corrected. 2. Application of inserted Port-a-cath allows easy and painless IV treatment in patients needing multiple coagulation factors infusions.

Percutaneous tracheotomy in children.

We present three cases of the Fantoni percutaneous translaryngeal tracheostomy (TLT) performed under direct rigid bronchoscopy. The surgeries were performed in the near-drowned 5-year-old boy, and 15-year-old lupus erythematosus girl with a permanent brain damage resulted from a cardiac arrest, 11-year-old cardiac girl with postintubation laryngeal stenosis. In the first two cases, the procedure went uneventful; in one case the tube was accidentally pulled out during the rotation phase and surgical tracheostomy was performed. We describe the TLT procedure in details, calling special attention at the fact that the TLT is especially suitable for children below 10 years of age and is associated with very few complications.

Recombinant human activated protein C for severe sepsis in a neonate.

BACKGROUND: Neonatal sepsis is frequently associated with pathological activation of the coagulation system, leading to multiple organ dysfunction. Activated protein C has been shown to prevent thrombin generation during this process and improve microcirculation. CASE REPORT: We present the case of a full term septic neonate admitted for tertiary intensive care with multiple organ failure, including ARDS with severe pulmonary hypertension, renal failure, and disseminated intravascular coagulation. After initial resuscitation with volume expansion, catecholamines, pentoxifylline and nitric oxide, a diagnosis of severe systemic enteroccocal sepsis was made and vancomycin-meropenem therapy was started. Because available standard treatment, including platelet transfusion, did not improve the coagulation status, it was decided to give recombinant human activated protein C (drotrecogin alpha Xigris, Elli Lilly, USA - rhAPC) in 24 mcg kg(-1) h(-1) continuous four-day infusion. Six hours after the start of infusion all coagulation parameters returned to normal. No side effects were observed. Renal function was restored after 36-hr hemofiltration. Treatment success was due to several factors, including resuscitation from cardiogenic shock, effective antibiotic therapy, hemofiltration, and combined rhAPC-pentoxifylline therapy CONCLUSIONS: The positive outcome of this case indicates that rhAPC can be safely used in infants. A large-scale study of the effectiveness of drotrecogin alpha in pediatric population is indicated.