Pulmonary thromboembolism in childhood leukemia: 8-years' experience in a pediatric hematology center.

PURPOSE: To assess the occurrence and possible causes of pulmonary thromboembolism (PTE) in children with hematologic malignancies evaluated in a single pediatric hematology center. PATIENTS AND METHODS: Four hundred fifty-two patients admitted for leukemia in different stages of disease were evaluated whenever they presented with PTE-related acute respiratory failure (ARF). Diagnosis was based on a perfusional lung scan and a digital pulmonary angiography in most cases. When necessary, patients with ARF were transferred to the pediatric intensive care unit (ICU) for cardiorespiratory monitoring and support. Thrombolytic treatment was usually performed with urokinase at a loading dose of 2,000 to 4,560 IU/kg as single bolus followed by 2,000 to 4,530 IU/kg/h for 12 to 42 hours. Before thrombolytic therapy was discontinued, heparin was started at a daily dose of 100 to 500 IU/kg as a continuous infusion and continued for 6 to 26 days. RESULTS: Twelve of 452 children developed 17 PTE episodes, which were resolved completely after appropriate therapy in 15 cases. Univariate analysis showed a statistical correlation between PTE and the diagnosis of acute myeloid leukemia (AML) (P < .001). No major bleeding was observed after thrombolytic treatment. CONCLUSION: Our findings indicate that PTE is not an extremely rare event in children with leukemia and should be ruled out when sudden tachypnea develops in patients with risk factors such as previous tumor lysis, central venous catheter (CVC) malfunction, coagulation abnormalities, and drug-induced pulmonary toxicity. Complete resolution of PTE may be obtained in a high proportion of cases with early diagnosis and proper treatment.

Italian Intersociety Recommendations on pain management in the emergency setting (SIAARTI, SIMEU, SIS 118, AISD, SIARED, SICUT, IRC).

BACKGRAUND: Pain is the primary reason for admission to the Emergency Department (ED). However, the management of pain in this setting is often inadequate because of opiophagia, fear of excessive sedation, and fear of compromising an adequate clinical assessment. METHODS: An intersociety consensus conference was held in 2010 on the assessment and treatment of pain in the emergency setting. This report is the Italian Intersociety recommendations on pain management in the emergency department setting. RESULTS: The list of level A recommendations includes: 1) use of IV acetaminophen for opioid sparing properties and reduction of opioid related adverse events; 2) ketamine-midazolam combination preferred over fentanyl-midazolam fentanyl-propofol in pediatric patients; 3) boluses of ketamine IV (particularly in the population under the age of 2 years and over the age of 13) can lead to impairment of the upper airways, including the onset of laryngospasm, requiring specific expertise and skills for administration; 4) the use of ketamine increases the potential risk of psychomotor agitation, which can happen in up to 30% of adult patients (this peculiar side effect can be significantly reduced by concomitant systemic use of benzodiazepines); 5) for shoulder dislocations and fractures of the upper limbs, the performance of brachial plexus block reduces the time spent in ED compared to sedation; 6) pain relief and the use of opioids in patients with acute abdominal pain do not increase the risk of error in the diagnostic and therapeutic pathway in adults; 7) in newborns, the administration of sucrose reduces behavioural responses to blood sampling from a heel puncture; 8) in newborns, breastfeeding or formula feeding during the procedure reduces the measures of distress; 9) in pediatric patients, non-pharmacological techniques such as distraction, hypnosis and cognitive-behavioural interventions reduce procedural pain caused by the use of needles; 10) in pediatric patients, preventive application of eutectic mixtures of prilocaine and lidocaine allows arterial and venous samples to be taken in optimum conditions; 11) in pediatric patients, the combination of hypnotics (midazolam) and N2O is effective for procedural pain, but may be accompanied by loss of consciousness. CONCLUSION: The diagnostic-therapeutic pathway of pain management in emergency should be implemented, through further interdisciplinary trials, in order to improve the EBM level of specific guidelines.

Pulmonary thromboembolism in leukaemic children undergoing bone marrow transplantation.

Of 67 leukaemic children transplanted in our BMT unit 3 presented with severe acute respiratory syndrome associated with pulmonary thromboembolism (PTE) as diagnosed by scintiscan and/or angiography in the first month after BMT. Intervention with continuous positive pressure ventilation, urokinase (loading dose, then continuous infusion for 12-18 h) and heparin (continuous infusion for an average of 10 days) has been carried out successfully in two cases. In conclusion, when evaluating patients undergoing BMT and developing early pulmonary complications, PTE must be considered. The pathogenesis of PTE is still difficult to ascertain but urokinase therapy may reduce early morbidity.

Perfluorocarbon broncho-alveolar lavage and liquid ventilation versus saline broncho-alveolar lavage in adult guinea pig experimental model of meconium inhalation.

OBJECTIVE: This study compares perfluorocarbon broncho-alveolar lavage (PFC-BAL) with isotonic saline broncho-alveolar lavage (saline-BAL) in an experimental model of meconium aspiration in adult guinea pigs. DESIGN: Prospective controlled experimental study. PATIENTS AND METHODS: Ten male guinea pigs were given 1 ml of human meconium, diluted to 10% in isotonic saline, via tracheostomy and then artificially ventilated. After stabilization, five animals (control group) underwent BAL with 10 ml/ kg isotonic saline solution. After bronchial suctioning, a further BAL with 2 ml/kg saline was performed. The other five animals (study group) underwent BAL with 100 ml/kg of PFC (RIMAR 101). Bronchosuction was effected at 5 min and then a BAL with PFC 2 ml/kg was performed. Both groups received conventional mechanical ventilation during the lavage procedures. Within 20 min all the saline-BAL treated animals died, whereas the PFC-BAL treated animals survived and were then treated with total liquid ventilation (TLV) by gravity. MEASUREMENTS AND RESULTS: After meconium inhalation in both groups, a large alveolar-arterial oxygen difference, hypercarbia, severe acidosis and tachycardia were noticed. In PFC treated animals, an improvement in blood gases was noted and acid-base balance remained stable compared to saline-BAL treated animals. No haemodynamic change was observed during or after PFC-BAL, while during saline-BAL there was evidence of bradycardia, hypotension and respiratory failure, which led to the death of the animals. The histological lung sections in the PFC-BAL group showed evidence of normal alveolar expansion with a minimal presence of meconium debris in the small bronchioles. In saline-BAL treated animals, the lung structure appeared severely compromised with the presence of meconium in bronchioles and alveoli, intra-alveolar oedema and haemorrhagic areas. CONCLUSIONS: This study confirms the detrimental effects of meconium aspiration and the impairment of lung function following saline-BAL. By contrast, PFC-BAL and TLV by gravity seemed to prevent absorption of meconium, facilitate its removal, improve gas exchange and reduce lung barotrauma.

Simultaneous independent lung ventilation in pediatric patients.

Current methods of ventilation do not allow adequate ventilation of the affected lungs in the presence of unilateral disease, e.g., unilateral atelectasis, diaphragmatic hernia, or lobar emphysema. Using a bilumen endotracheal tube and two independent ventilators, synchronized simultaneous independent lung ventilation (SILV) can be achieved. This technique provides a method of treating unilobar, unilateral, or multifocal lung disease effectively. This article describes the author's methodology and clinical experience with SILV.

A prospective randomized double-blinded controlled study of ropivacaine 0.75% versus bupivacaine 0.5%-mepivacaine 2% for peribulbar anesthesia.

BACKGROUND AND OBJECTIVES: Ropivacaine 1% has recently been used in clinical trials for peribulbar anesthesia. This study aims to compare the safety and the efficacy of ropivacaine 0.75% with that of a 1:1 mixture of bupivacaine 0.5% and mepivacaine 2% for peribulbar anesthesia. METHODS: Two thousand patients undergoing peribulbar anesthesia for elective cataract phacoemulsification were prospectively studied over a 1-year period and randomly assigned to 1 of 2 groups according to the local anesthetic used. One thousand patients were administered peribulbar anesthesia with 9 mL of ropivacaine 0.75% plus 1 mL of hyaluronidase (group R), and 1,000 patients received peribulbar anesthesia with 4 mL of bupivacaine 0.5% plus 4 mL of mepivacaine 2% plus 1 mL of hyaluronidase plus 1 mL of sodium bicarbonate (group BM). Peribulbar anesthesia was always accomplished by the same physician by 2 injections of 5 mL each, with a 25-gauge 25-mm needle. Evaluation was performed by another physician blinded to the technique used and included assessment of pain on local anesthetic injection, ocular and eyelid akinesia, need for top-up injections, onset time and duration of anesthesia, intraoperative analgesia, duration of surgery, hemodynamic parameters, and incidence of perioperative complications. RESULTS: A greater incidence of pain on injection was found in group BM (P<.001). No difference between the groups was found regarding the onset time and the duration of anesthesia. Perioperative analgesia was satisfactory in both groups with no significant difference. Patients in group R showed a reduced need for top-up injection and a better ocular akinesia at 8 and 10 minutes (P<.01). The akinesia of the eyelid was comparable in the 2 groups and complete in all cases at 8 minutes. Cardiac arrhythmias were more frequent in group BM (P<.01). Local complications did not differ between the groups. An increase in mean artierial blood pressure and heart rate was observed in both groups 1 minute after injection of local anesthetic. CONCLUSIONS: Peribulbar anesthesia with ropivacaine provided better ocular akinesia 8 to 10 minutes after block insertion than a bupivacaine-mepivacaine mixture, which reduced the need for top-up injections. Ropivacaine also caused less pain on injection.

Perspectives for use of surfactant in children and adults.

After impressive results in the treatment of respiratory failure in premature babies, natural surfactant has been proposed in lung pathologies involving suspected surfactant deficiency. Apart from bronchiolitis, in which surfactant was used to stabilize small airways and for its possible antiviral action, research was directed towards pneumonia and sepsis, aspiration and chest trauma, which can lead to adult respiratory distress syndrome. Surfactant bronchoalveolar lavage has been used to 'cleanse' lungs, remove inhibitors and provide sufficient functional surfactant. Failure of surfactant therapy can be caused by insufficient dose, delayed administration, excessive inhibition and catabolism, or by type, severity and complexity of the lung disease (multi-organ failure).

Follow-up on infants treated with porcine surfactant replacement for severe neonatal and infant respiratory distress syndrome: antigenic reactivity evaluation.

A follow-up was carried out on twenty-two children (thirteen of whom were newborn) who had been treated with porcine surfactant (Curosurf) for respiratory distress syndrome. All the infants were enrolled in the follow-up at different times after surfactant replacement to evaluate the clinical status and the incidence (if any) of respiratory disease, adverse drug effects and allergic conditions. Twelve of the twenty-two children treated completed the follow-up. Seven prematurely-born children died of endocranial haemorrhage; two children died of malignant development of the basal pathology (leukaemia). Treatment with pig surfactant appears to cause no allergic side effects. Skin and laboratory tests performed were negative.

[Nipple discharge: indications for surgery]. / La mammella secernente: indicazioni alla chirurgia.

Nipple discharges are related to physiological events or due to benign lesions of the breast. Sometimes they can express mammary cancers. The authors report their experience of the diagnosis and treatment of 1241 patients with secreting breast. They underline the importance of a correct diagnostic protocol to select cases needing surgical treatment.

[Use of surfactant in respiratory diseases in neonates and infants]. / Emploi du surfactant dans la pathologie respiratoire du nouveau-né et du nourrisson.

Artificial surfactant therapy in hyaline membrane disease started in 1980 (Fujiwara). We used it in 10 children with acute respiratory distress syndrome (ARDS) and in 12 newborns suffering from massive aspiration syndrome (MAS). In ARDS, indication was PEEP > or = 8 cmH2O, PaO2 < or = 9 kPa with FiO2 > or = 0.6. Results were rapid. A steady improvement of PaO2 was obtained in 24 hours, generally after a single administration. Three children needed additional doses. In MAS (n = 12) with PaO2 > or = 70 mmHg for FiO2 > 0.6, improvement was obtained very rapidly. Only one newborn received a second dose of surfactant 12 hours after the first one. In MAS as in ARDS all children survived.

[The effects of administering surfactant to two adolescents with leukemia suffering from respiratory distress]. / Effets d'un apport de surfactant chez deux adolescents leucémiques atteints de détresse respiratoire.

Two adolescents (12 years old, suffering from acute lymphoid leukaemia (LLA) and 16 years old with acute myeloid leukaemia (LMA)) were treated with porcine surfactant (Curosurf). The indication for this treatment was a severe Respiratory Distress Syndrome (RDS) which appeared during leukaemia treatment. Pulmonary thrombo-embolism was suspected. The surfactant administered improved ventilation and oxygenation, enabling confirmation of the diagnosis which would otherwise have been impossible due to the seriousness of their condition.

Choices that have to be made by a doctor.

The Author analyses the technical and ethical choices the doctor who works in the Intensive Care Unit continually has to make when treating patients. Generally the doctor does not accept the concept that the available economic resources are not infinite, in that he sees himself as the patient's advocate. The ethical problem of whether or not to treat a given patient arises before the technical problem. Making a choice, it is necessary to know what benefits will derive from a given treatment in a certain ward and how successful a given operation will be. The doctor must evaluate the management costs but must also be the custodian of community funds.

Therapeutic process formalization in the treatment of respiratory failure in infants.

The model described formalizes the therapeutic process developed in the Pediatric Intensive Care Unit (PICU) of Merate's Hospital as a support of medical decisions and as a continuous control of the adequacy of the ventilatory therapy. Causal and temporal structure of the keypoints of the treatment are represented by Petri Nets. The model could be utilised in different pathologies and for different clinical approach giving a meaningful organizational impact.

[Artificial ventilation in children during anesthesia]. / La ventilazione artificiale in età pediatrica durante l'anestesia.

The authors describe the advantages and disadvantages, the indications and benefits on gas exchange as a result of mechanical ventilation during anaesthesia. The two models of ventilation most commonly used have been analyzed: pressure ventilators and volume preset ventilators. The former are used only in cases of short-term anaesthesia or when volume ventilators are not available. Both the most appropriate settings and ventilatory modes have been discussed regarding different paediatric ages. Particular attention has been given to the oxygen concentration in the ventilated gases (oxygen toxicity > 40%) and to barotrauma connected with high peak pressure (> 30 cm H2O). The authors suggest the type and caliber of endotracheal tube and the tidal volume for paediatric ages.