Infant Intensive Care Unit: Is it Time to Change?

OBJECTIVES: To assess the effect of the Infant intensive care unit (InICU), a specialized unit for critically ill infants established in 2016 in authors' hospital, on infant mortality and compare the outcome with the current Pediatric intensive care units (PICU). METHODS: In this retrospective cross-sectional study, two groups were defined; the first included expired patients aged 1 mo to 2 y admitted to PICU before the establishment of the InICU (the PICU group). The second included age-matched expired patients admitted to the InICU (the InICU group). Data were recorded using a questionnaire. RESULTS: The authors found that the age, sex, underlying diseases, the leading cause of admission to the ICU, time of death, hospital and ICU length of stay, and the pediatric index of mortality 2 (PIM 2) score were same between the two groups. The incidence of mortality in the PICU group was 10.66 in 1000 person-month. This value was 6.37 for the InICU group (P-value <0.001). The relative risk of mortality of patients admitted to the PICU group compared to the InICU group was 1.67 (P-value <0.001). CONCLUSIONS: Establishment of age specific InICU for infants may be beneficial in reducing infant mortality.

Arterial versus end-tidal carbon dioxide levels in children with congenital heart disease: a prospective cohort study in patients undergoing pulmonary catheterization.

Capnography has been the standard in the operating room for a long time now. When variable amounts of intrapulmonary shunt and intracardiac shunt are taken into account, arterial carbon dioxide (CO2) and end-tidal CO2 typically match rather well. The gap between arterial and end-tidal CO2 widens in patients with cardiopulmonary disorders. The current study sought to determine how arterial and end-tidal CO2 correlated with each other and with hemoglobin saturation both before and after pulmonary catheterization in a pediatric population with congenital heart disease. Methods: Fifty-seven children with congenital heart disease who underwent cardiopulmonary catheterization between March 2018 and April 2019 were included in a prospective cohort study at Children's Medical Center. Arterial and end-tidal CO2, and hemodynamic variables were assessed prior to the catheterization procedure. Then the patients underwent catheterization, and before being extubated, these variables were again assessed and compared to the baseline levels. Results: End-tidal CO2 increased significantly in cyanotic patients following the catheterization procedure, and the difference between arterial and end-tidal CO2 decreased significantly. End-tidal CO2, arterial CO2, and their difference did not significantly change in non-cyanotic patients following the catheterization procedure. End-tidal and arterial CO2 were not significantly correlated in cyanotic patients (r=0.411, P=0.128), but they were correlated after the catheterization procedure (r=0.617, P=0.014). Conclusions: End-tidal CO2 can estimate arterial CO2 in non-cyanotic patients reasonably. End-tidal CO2 cannot be used to estimate arterial CO2 in cyanotic patients since there is no association. After cardiac defect correction, end-tidal CO2 can be a reliable predictor of arterial CO2.

Comparison of four formulas for nasotracheal tube length estimation in pediatric patients: an observational study.

BACKGROUND: Correct endotracheal intubation results in better ventilation, prevents hypoxia and its possible damages, such as brain injury, and minimizes attempts for re-intubation. Up to now, several formulas have been published to estimate nasotracheal intubation tube length. This study aims to compare the accuracy of different suggested formulas to find the one that better estimates the tube insertion distance. METHODS: This cross-sectional retrospective study was carried out in 102 (51 female, 51 male) children who underwent cardiac surgery under general anesthesia. Inclusion criteria were correct nasotracheal intubation according to the postintubation chest X-ray (CXR). The estimated tracheal tube length was calculated by four different formulas. Pearson...s correlation coefficient was used to find the correlations between the estimated length of each formula and the correct nasotracheal tube length. Also, linear regression was used to obtain a formula to estimate nasotracheal tube length by weight, height, and age. RESULTS: The formula L=3*tube size+2 had the best correlation with tube length (r ...=...0.81, Confidence Interval: 0.732...0.878, p-value < 0.001). Among demographic variables, height had the highest correlation coefficient with the tube length (r...=...0.83, Confidence Interval: 0.788...0.802, p-value < 0.001). Therefore, considering the height as an independent variable and tube length as a dependent variable, using linear regression, the following formula was achieved for determining tube length: nasotracheal tube length...=...0.1*Height+7. CONCLUSIONS: The formula L=3*tube size+2 and the new suggested formula in this study can be used to estimate nasotracheal tube length in children under 4 years old. However, these formulas are only guides and require confirmation by auscultation and CXR.

Comparison of four formulas for nasotracheal tube length estimation in pediatric patients: an observational study

Abstract Background: Correct endotracheal intubation results in better ventilation, prevents hypoxia and its possible damages, such as brain injury, and minimizes attempts for re-intubation. Up to now, several formulas have been published to estimate nasotracheal intubation tube length. This study aims to compare the accuracy of different suggested formulas to find the one that better estimates the tube insertion distance. Methods: This cross-sectional retrospective study was carried out in 102 (51 female, 51 male) children who underwent cardiac surgery under general anesthesia. Inclusion criteria were correct nasotracheal intubation according to the postintubation chest X-ray (CXR). The estimated tracheal tube length was calculated by four different formulas. Pearson's correlation coefficient was used to find the correlations between the estimated length of each formula and the correct nasotracheal tube length. Also, linear regression was used to obtain a formula to estimate nasotracheal tube length by weight, height, and age. Results: The formula L=3*tube size+2 had the best correlation with tube length (r =0.81, Confidence Interval: 0.732-0.878, p-value < 0.001). Among demographic variables, height had the highest correlation coefficient with the tube length (r = 0.83, Confidence Interval: 0.788-0.802, p-value < 0.001). Therefore, considering the height as an independent variable and tube length as a dependent variable, using linear regression, the following formula was achieved for determining tube length: nasotracheal tube length =0.1*Height+7. Conclusions: The formula L=3*tube size+2 and the new suggested formula in this study can be used to estimate nasotracheal tube length in children under 4 years old. However, these formulas are only guides and require confirmation by auscultation and CXR.

The safety and efficacy of umbilical cord blood mononuclear cells in individuals with spastic cerebral palsy: a randomized double-blind sham-controlled clinical trial.

INTRODUCTION: The current multi-center, randomized, double-blind study was conducted among children with cerebral palsy (CP) to assess the safety and efficacy of umbilical cord blood mononuclear cell (UCB-MNC). We performed the diffusion tensor imaging to assess the changes in the white matter structure. METHODS: Males and females aged 4 to 14 years old with spastic CP were included. Eligible participants were allocated in 4:1 ratio to be in the experimental or control groups; respectively. Individuals who were assigned in UCB-MNC group were tested for human leukocyte antigen (HLA) and fully-matched individuals were treated with UCB-MNCs. A single dose (5 × 106 /kg) UCB-MNCs were administered via intrathecal route in experimental group. The changes in gross motor function measure (GMFM)-66 from baseline to one year after treatment were the primary endpoints. The mean changes in modified Ashworth scale (MAS), pediatric evaluation of disability inventory (PEDI), and CP quality of life (CP-QoL) were also evaluated and compared between groups. The mean changes in fractional anisotropy (FA) and mean diffusivity (MD) of corticospinal tract (CST) and posterior thalamic radiation (PTR) were the secondary endpoints. Adverse events were safety endpoint. RESULTS: There were 72 included individuals (36 cases in each group). The mean GMFM-66 scores increased in experimental group; compared to baseline (+ 9.62; 95%CI: 6.75, 12.49) and control arm (ß: 7.10; 95%CI: 2.08, 12.76; Cohen's d: 0.62) and mean MAS reduced in individuals treated with UCB-MNCs compared to the baseline (-0.87; 95%CI: -1.2, -0.54) and control group (ß: -0.58; 95%CI: -1.18, -0.11; Cohen's d: 0.36). The mean PEDI scores and mean CP-QoL scores in two domains were higher in the experimental group compared to the control. The imaging data indicated that mean FA increased and MD decreased in participants of UCB-MNC group indicating improvements in white matter structure. Lower back pain, headaches, and irritability were the most common adverse events within 24 h of treatment that were related to lumbar puncture. No side effects were observed during follow-up. CONCLUSIONS: This trial showed that intrathecal injection of UCB-MNCs were safe and effective in children with CP. TRIAL REGISTRATION: The study was registered with ClinicalTrials.gov ( NCT03795974 ).

Single-dose antibiotic prophylaxis compared with multiple-dose protocol in clean pediatric neurosurgical interventions: a nonrandomized, historically controlled equivalence trial.

OBJECTIVE: Guidelines recommend antimicrobial prophylaxis (AMP) preoperatively for "clean" spinal and cranial surgeries, while dose and timing remain controversial. The use of multiple-dose AMP for such surgeries is under debate in the pediatric context. In this clinical study, the authors aimed to compare single-dose with multiple-dose prophylactic antibiotic usage in cranial and spinal neurosurgical interventions of pediatric patients. METHODS: All neurosurgical patients aged 28 days to 18 years who underwent surgery at a single tertiary center were assessed. Three cohorts (noninstrumented clean spinal, noninstrumented cranial, and instrumented cranial interventions), each of which comprised two 50-patient arms (i.e., single-dose AMP and multiple-dose AMP), were included after propensity score-matched retrospective sampling and power analysis. Records were examined for surgical site infections. Using a previously published meta-analysis as the prior and 80% acceptance of equivalence (margin of OR 0.88-1.13), logistic regression was carried out for the total cohort and each subcohort and adjusted for etiology by consideration of multiple-dose AMP as reference. RESULTS: The overall sample included 300 age- and sex-matched patients who were evenly distributed in 3 bi-arm cohorts. There was no statistical intercohort difference based on etiology or type of operation (p < 0.05). Equivalence analysis revealed nondiscriminating results for the total cohort (adjusted OR 0.65, 95% CI 0.27-1.57) and each of the subcohorts (noninstrumented clean spinal, adjusted OR 0.65, 95% CI 0.12-3.44; noninstrumented cranial, adjusted OR 0.52, 95% CI 0.14-2.73; and instrumented cranial, adjusted OR 0.68, 95% CI 0.13-3.31). CONCLUSIONS: No significant benefit for multiple-dose compared with single-dose AMPs in any of the pediatric neurosurgery settings could be detected. Since unnecessary antibiotic use should be avoided as much as possible, it seems that usage of single-dose AMP is indicated.

Comparing topical administration of lidocaine alone and in combination with alfentanil in children undergoing bronchoscopy.

INTRODUCTION: Airway surgery and endoscopy in pediatric patients are always associated with challenges in anesthesia management. Deep anesthesia is required for preventing patient bucking during the procedure but patient breath should be maintained; in this regard, a combination of general and topical anesthesia can be beneficial. There is also evidence of the peripheral effects of opioids. The main objective of this study is to compare using lidocaine topically alone and combined with alfentanil opioids with respect to the central effects of opioids. METHODS: In this study, 40 ASA class I and II children, aged 1-6 years, who were candidates for flexible diagnostic bronchoscopy were divided into two groups through block randomization using the random number table after obtaining parents' consent in complete health conditions. In this clinical trial, for collecting the data a special data collection form was used at the bedside of patients undergoing bronchoscopy at Pediatric Medical Center in 2017. Data including demographic information (age, weight, gender), duration of anesthesia, blood pressure before and after drug administration, duration of bronchoscopy, and recovery time were recorded in a form. FINDINGS: In terms of demographic variables, there were not any significant differences between the two studied groups, indicating that the groups were matched and randomized appropriately. Although there were not any significant differences between the two groups of using lidocaine alone and in combination with alfentanil in other variables, in the recovery time a significant difference was observed between the two groups, with a mean of 13.05 min in the lidocaine group and 18.75 min in the lidocaine combined with alfentanil group. CONCLUSION: Topical administration of opioid with lidocaine through bronchoscopy had no impact on blood pressure, heart rate, anesthesia duration, and the frequency of perioperative complications.

Comparison of the Laryngoscopic View using Macintosh and Miller Blades in Children Less than Four Years Old.

This study aimed to compare Miller and Macintosh laryngoscopes in zero to 4-year-old children. A total of 72 children with a score of I and II, according to the American Society of Anesthesiologists (ASA) physical status classification, who were candidates for elective surgery with general anesthesia and tracheal intubation were enrolled in the study. The children were divided into two equal groups (36 persons) according to used laryngoscope: Miller laryngoscope (group 1) and Macintosh laryngoscope (group 2). Observations and all laryngoscopies were performed by a single experienced anesthesiologist. Heart rate, systolic blood pressure, non-invasive arterial blood pressure, and hemoglobin saturation were measured and recorded. The number of endotracheal intubation attempts and complications were also recorded for both groups. In terms of gender, the first group consisted of 88.9% boys and 11.1% girls, and the second group consisted of 66.6% boys and 33.3% girls (p-value=0.05). The mean age was 16.7 months in the first group and 17.7 months in the second group (p-value=0.5). The mean weight of the children was 16988.5 g and 16300 g in the Miller and Macintosh groups, respectively (p-value=0.9). Regarding the Cormack-Lehane classification system, 5 patients were classified as grade 1 (13.9%), 14 patients as grade 2 (38.9%), 15 patients as grade 3 (41.7%), and 2 patients as grade 4 (5.6%) in the Macintosh group. In contrast, in the Miller group, 5 patients were classified as grade 1 (13.9%), 27 patients as grade 2 (75%), and 4 patients as grade 3 (11.1%) (p-value=0.004). These results can provide more data about the tracheal intubation method with the Macintosh and Miller laryngoscopes, the ease of intubation, and the best laryngoscopic view with each blade.

Emergency separation of craniopagus twins: case report.

Craniopagus is a very rare congenital anomaly that tends to affect females more often than males. It is classified as partial or total. Most affected twins are either stillborn or die during the perinatal period. Those who survive birth should undergo detailed radiological evaluations soon after their condition becomes stable so that the precise anatomy of the conjoined part can be defined and surgery can be planned in detail by a multidisciplinary team. Recommendations for decreasing the risk of unsuccessful surgery include performing surgery on an elective basis after extensive preoperative radiological evaluations as well as when the twins are at an acceptable age and weight for a complex surgical separation, generally as staged procedures. In addition, the operation should be performed by a well-equipped expert multidisciplinary team. When one of the conjoined twins dies, however, surgical separation cannot be postponed because the shared circulatory system predisposes the alive child to life-threatening complications, including coagulopathy. The authors report on the successful separation of craniopagus twins performed on an emergency basis at 32 weeks of gestational age because of the sudden death of one of them. At the time of separation surgery, the twins each weighed 1250 g. To the best of the authors' knowledge, this is the youngest age and lowest weight yet reported for successful surgical separation. The surviving twin developed a pseudomeningocele, which required a second operation and placement of a cystoperitoneal shunt 4 months after the operation. Additional surgery is planned to repair a cranial defect that resulted from the pseudomeningocele, but his general physical and mental condition was otherwise good at latest follow-up (12 months after separation surgery).

Skin Temperature Over the Carotid Artery, an Accurate Non-invasive Estimation of Near Core Temperature.

BACKGROUND: During anesthesia, continuous body temperature monitoring is essential, especially in children. Anesthesia can increase the risk of loss of body temperature by three to four times. Hypothermia in children results in increased morbidity and mortality. Since the measurement points of the core body temperature are not easily accessible, near core sites, like rectum, are used. OBJECTIVES: The purpose of this study was to measure skin temperature over the carotid artery and compare it with the rectum temperature, in order to propose a model for accurate estimation of near core body temperature. PATIENTS AND METHODS: Totally, 124 patients within the age range of 2 - 6 years, undergoing elective surgery, were selected. Temperature of rectum and skin over the carotid artery was measured. Then, the patients were randomly divided into two groups (each including 62 subjects), namely modeling (MG) and validation groups (VG). First, in the modeling group, the average temperature of the rectum and skin over the carotid artery were measured separately. The appropriate model was determined, according to the significance of the model's coefficients. The obtained model was used to predict the rectum temperature in the second group (VG group). Correlation of the predicted values with the real values (the measured rectum temperature) in the second group was investigated. Also, the difference in the average values of these two groups was examined in terms of significance. RESULTS: In the modeling group, the average rectum and carotid temperatures were 36.47 ± 0.54°C and 35.45 ± 0.62°C, respectively. The final model was obtained, as follows: Carotid temperature × 0.561 + 16.583 = Rectum temperature. The predicted value was calculated based on the regression model and then compared with the measured rectum value, which showed no significant difference (P = 0.361). CONCLUSIONS: The present study was the first research, in which rectum temperature was compared with that of skin over carotid artery, to find a safe location with easier access and higher accuracy for estimating near core body temperature. Results obtained in this study showed that, using a model, it is possible to evaluate near core body temperature in children, by measuring skin temperature over carotid artery.

Comparing the efficacy of prophylactic p6 acupressure, ondansetron, metoclopramide and placebo in the prevention of vomiting and nausea after strabismus surgery.

To compare the efficacy of acupressure wrist bands, ondansetron, metoclopramide and placebo in the prevention of vomiting and nausea after strabismus surgery. Two hundred patients, ASA physical status I or II, aged between 10 and 60 years, undergoing strabismus surgery in Farabi Hospital in 2007-2008 years, were included in this randomized, prospective, double-blind and placebo-controlled study. Group I was the Control, group II received metoclopramide 0.2 mg/kg, group III received ondansetron 0.15 mg/kg iv just before induction, in Group IV acupressure wristbands were applied at the P6 points. Acupressure wrist bands were placed inappropriately in Groups I, II and III. The acupressure wrist bands were applied 30 min prior to the induction of anesthesia and removed six hours after surgery. Postoperative nausea and vomiting (PONV) was evaluated within 0-2 hours and 2-24 hours after surgery by a blinded observer. Results were analyzed by X(2) test. A P value of < 0.05 was taken as significant. The incidence of PONV was not significantly different in acupressure, metoclopramide and ondansetron during the 24 hours. Acupressure at P6 causes a significant reduction in the incidence of PONV 24 hours after strabismus surgery as well as metoclopramide 0.2 mg/kg and ondansetron 0.15 mg/kg iv for patients aged 10 or more.

Acupressure using ondansetron versus metoclopramide on reduction of postoperative nausea and vomiting after strabismus surgery.

OBJECTIVE: To compare the clinical efficacy of acupressure with treatment induced by ondansetron and metoclopramide on reduction of the severity of postoperative nausea and vomiting (PONV) after strabismus surgery. METHODS: There were 200 patients with ASA classes I-II, ages 10 to 60 years old, who underwent strabismus surgery that were included in this randomized, prospective, double-blind, placebo-controlled trial. Group I was the control, group II received metoclopramide 0.2 mg/kg, and group III received ondansetron 0.15 mg/kg intravenously immediately prior to anesthesia induction. In Group IV, acupressure wristbands were applied at the P6 points. Acupressure wrist bands were not placed appropriately for subjects of groups I-III. The acupressure wrist bands were applied 30 minutes before anesthesia induction and removed six hours after surgery completion. Anesthesia was standardized. PONV was evaluated within 0 - 2 hours and 2 - 24 hours after surgery by a blinded observer. Results were analyzed by the Chi-square or Fisher exact test. A P value of <0.05 was considered significant. RESULTS: The incidence of PONV was not significantly different among acupressure, metoclopramide and ondansetron groups during 24 hours. Also, the severity of PONV was not significantly different between acupressure, metoclopramide, and ondansetron in the recovery and ward. CONCLUSION: Acupressure at the P6 point causes a significant reduction in the incidence and severity of PONV 24 hours after strabismus surgery as well as metoclopramide (0.2 mg/kg) and ondansetron (0.15 mg/kg) intravenous for patients aged 10 or older. (Irct ID: IRCT138807152556N1).