Intrapulmonary drug administration in neonatal and paediatric critical care: a comprehensive review.

Administration of drugs directly into the respiratory tree first was proposed a long time ago. Surfactant is the paradigmatic example of such therapies. Many other drugs have been used in the same way and further compounds are under investigation for this aim. In the last two decades, despite the wide number of drugs available for direct lung administration in critical care patients, few controlled data exist regarding their use in neonates and infants. This review will focus on drugs clinically available in a critical care setting for neonates and infants, including bronchodilators, pulmonary vasodilators, anti-inflammatory agents, mucolytics, resuscitative anti-infective agents, surfactants and other drugs. We provide an evidence-based comprehensive review of drugs available for intratracheal administration in paediatric and neonatal critical care and we examine possible advantages and risks for each proposed indication.

Measles-induced respiratory distress, air-leak and ARDS.

Young infants with measles requiring respiratory support have a significant risk for death and long-term complications. Even in developed countries, the occurrence of spontaneous air-leaks and acute respiratory distress syndrome (ARDS) still represent the most severe clinical presentation in early childhood, with a high fatality rate. A clinical series review from a tertiary university paediatric intensive care unit (PICU) was undertaken. During the 2006-2007 outbreak in Rome, Italy, a young infant presented with ARDS/spontaneous air-leak and needed aggressive ventilatory management and haemodynamic support. Both nebulised iloprost and intravenous pentoxifylline were administered during the acute hypoxaemic phase; the role of this pharmacologic approach in critically ill patients is still under debate. We observed four further cases of respiratory impairment requiring a non-invasive approach. Clinical-radiological findings ranged from interstitial pneumonia to bronchiolitis-like pictures. All patients were imported cases, representing an important epidemiological factor and future medical issue, though they were not malnourished nor affected by chronic diseases. We conclude that early respiratory assessment and timely PICU referral is of mainstem importance in the youngest infants with measles-induced respiratory failure. The protean nature of clinical presentation and the possibility of rapid respiratory deterioration should be highlighted, and infants from immigrant families may represent a susceptible high-risk group.

Safety and efficacy of ultrasound assistance during internal jugular vein cannulation in neurosurgical infants.

OBJECTIVE: Ultrasound guidance (USG) for internal jugular cannulation is the best solution in difficult settings where paediatric patients are involved. This is an outcome study on efficacy and complications of the USG for the internal jugular vein (IJV) cannulation in neurosurgical infants as well as an ultrasound study of anatomical findings of the IJVs in infants. DESIGN AND SETTINGS: A prospective study conducted in two Academic Neurosurgical hospitals. PARTICIPANTS: In 191 babies (body weight <15 kg), anatomical findings were studied. We performed CVC echo guided placement in 135/191 infants (weighting <10 kg). RESULTS: After a brief training period, both institutions adopted a common protocol and USG device. We obtained successful cannulation in all patients. Carotid puncture (1.5%) was the only main complication registered and minor complications were poor. Time required for cannulation was 12.5 +/- 5.7 min. Anatomical findings (in 191 patients) were IJV laterality in 34.6% cases, IJV antero-lateral in 59.7% and anterior in 5.7%. A linear relation was found between weight and internal jugular vein diameter even if R(2) = 0.43 and the model cannot be used to predict the exact size of the vein. In 62/135 babies weighting <10 kg, anatomical measurements were done in supine and Trendelemburg position. Trendelemburg position increases significantly (P < 0.001) IJV diameter, but not IJV depth. CONCLUSIONS: We considered ultrasound guidance as the first choice in infants because it can enhance IJV cannulation success, safety, and allows one to measure relationships and diameter of the IJV and optimise the central line positioning.

Anaphylactic reactions during cesarean section.

Sensitization to latex seems to occur more frequently in women than in men. Obstetric and gynecological surgical procedures have recently been shown to be a common setting for latex anaphylaxis. We analyzed all the cases of anaphylactic reactions during 1240 cesarean sections in 2004; the patients were questioned for risk factors and underwent allergy testing for drugs and latex. Four patients had anaphylaxis under spinal anesthesia and in all cases it was due to latex allergy. Reported symptoms included facial edema, profuse sweating, itching, generalized erythematous rash and hypotension. Only one patient manifested a severe reaction which included bronchospasm, dyspnea, tachypnea and anaphylactic shock, requiring orotracheal intubation and epinephrine. Our data showed a high incidence (1:310) of intraoperative latex anaphylactic reactions in the one-year study period. This may be related to the very specific population (all women) in a very specific setting (obstetrics). To prevent anaphylactic reactions during obstetric surgery it is important to identify potential risk factors to include, for example atopy, adverse reactions to foods and latex items. If latex allergy is confirmed or strongly suspected, patients should be managed in a latex-safe environment. Premedication with antihistamines and steroids might be useful to further reduce the risk. After the delivery, specific desensitization may represent a good therapeutic option.

An attempt of specific desensitising treatment with gliadin in celiac disease.

Gluten-free diet is the current treatment of celiac disease. We decided to verify the occurrence of histological and serological modification and/or clinical manifestations during a gradual and progressive introduction of gliadin in the diet and if it may induce a tolerance to food, as it occurs in allergic patients. We studied the case of a celiac woman with complete clinical and histological remittance after 10 years of gluten free diet. She took increasing daily doses of gliadin, reaching the final dose of 9 g of gliadin (15 g of gluten) in 6 months. Then she started a free dietary regimen. During the 15-month follow-up period esophago-gastro-duodenoscopy showed normal Kerckring folds and villi. Anti-gliadin, anti-endomysium and anti-tissue-transglutaminase antibodies, as well as the haematological and biochemical parameters remained normal. Our results represent a new approach in research concerning celiac disease, and could provide a future line of study for its management.

[ISO 9001-2000 certification for refractive laser treatment]. / Certification ISO 9001-2000 des traitements réfractifs par laser cornéen.

PURPOSE: To obtain ISO 9001-2000 certification for laser corneal refractive treatment, never before sought in Europe. MATERIAL AND METHODS: The consulting firm Veritas led the certification process with the clinic's staff manager. This ISO norm is dedicated to the implementation of a quality management system. We assessed and optimized all necessary resources, evaluating customer satisfaction using patient and referring-physician surveys. We started quality rounds including surgeons, nurses, and technicians. Based on this preparation, we redefined and explained all processes including staff responsibilities and necessary resources in the quality manual. The procedure lasted 14 months with substantial involvement on the part of the management. RESULTS: Unconditional ISO 9001-2000 certification was granted by the independent audit firm, BVQI, in december 2003 for refractive laser treatment. CONCLUSION: The 2000 version of the new ISO 9001-2000 seeks to meet the demand for improving health care delivery in this field, most particularly by establishing a clear procedural orientation. Such certification enhances team work, stabilizes methodologies, and reinforces cohesion and self-audit. Patients notice that the center follows a consistent quality policy and are assured that the clinic respects rules and regulations. Certification is an advantageous alternative when accreditation cannot be considered. Our article discusses the steps taken in upper management, quality management, procedural guidance, as well as customer and staff counselling. It also discusses the project's cost/benefit ratio for the organization.

Macular hemorrhage after laser in situ keratomileusis for high myopia.

We describe 2 women with high myopia of -12.0 and -18.0 diopters who presented with myopic macular hemorrhages 1 and 4 days, respectively, after being treated by laser in situ keratomileusis (LASIK). One hemorrhage was related to a pre-existing choroidal neovascularization and the other to the presence of lacquer cracks. The hemorrhages resolved but resulted in a permanent decrease in vision. A careful fundus examination should be conducted before performing LASIK in highly myopic patients. In cases of similar macular pathology, fluorescein angiography should be done before LASIK.

An attempt to control cerebrospinal fluid acidosis in coma due to head injury.

The acid-base status of the arterial blood, jugular venous blood, peripheral venous blood and lumbar cerebrospinal fluid and the free amino acids in the cerebrospinal fluid have been studied in 12 patients suffering from coma due to head injury. They were given S adenosyl-methionine (10 mg/kg/day). Significant statistical differences of acid-base balance and CSF free amino acids have been obtained after the administration of te compound. The clinical and biochemical significance of the use of S adenosyl-methionine in severe brain injuries is discussed

Blood sparing in craniosynostosis surgery.

One of the main risks of craniosynostosis surgery is the possible need for an allogenic blood transfusion (ABT). Most patients are operated on in the first months of life, when physiological conditions are particularly sensitive to even limited blood losses. Furthermore, most surgical techniques proposed in the past were based on extensive craniectomies and cranial remodeling. Because of the known infective and immunologic risks of ABT, in recent years more attention has been dedicated to factors that might help reduce the risk of ABT. We review recent preoperative (ie, erythropoietin administration), intraoperative (ie, acute normovolemic hemodilution, intraoperative blood salvage), and postoperative (ie, clinical monitoring, postoperative blood salvage) anesthesiologic procedures developed with this aim in mind. We also consider operative techniques and technical apparatus that reduce surgical invasiveness, particularly preoperative planning, age selection, and the role of endoscopic assistance and gradual distraction devices.

Pediatric neuroanesthesia computerized monitoring system.

The authors describe the development of a computerized on-line monitoring system and its application during major pediatric neurosurgical procedures. The system acquires from monitor by serial communication the values of heart rate, systemic pressures, intracranial and central venous pressures, peripheral and central body temperatures and stores all these data on hard-disk. The system allows the collecting of clinical information, and other data concerning the metabolic and hemodynamic perioperative status of the patient. It also calculates in real time many derived parameters and stores all the measured data, the therapeutical administrations and their temporal relationship with the various surgical procedures on disk for statistical evaluation.

[Anterior cellular proliferation and silicone implant. Apropos of a case]. / Prolifération cellulaire antérieure et implant en silicone. A propos d'un cas.

We reported a case of pigmentary glaucoma in an elderly black patient, treated surgically with phacoemulsification associated with automatised trabeculectomy. The patient was implanted with a silicone foldable lens introduced in the capsular bag. Three months post-operatively, visual acuity, well restored after surgery, decreased progressively and, biomicroscopic exam revealed a pigmented cellular membrane. Pathogeny of this membrane is discussed.

[Phacoemulsification and topical anesthesia. Apropos of 40 cases]. / Phacoemulsification et anesthesie topique. A propos de 40 cas.

BACKGROUND: To evaluate topical anaesthesia for cataract surgery. METHODS: Thirty-nine patients (40 eyes) underwent cataract surgery by phacoemulsification with topical anaesthesia consisting in instillations of tetracaine eyedrops. Thirty-four eyes were implanted with a foldable lens and 6 eyes received a PMMA lens. Final visual acuity (1 month minimum follow-up), patients reactions (sensibility, pain), anaesthetic and surgery difficulties were specially studied. RESULTS: Mean initial corrected visual acuity was 0.21. Mean final corrected visual acuity was 0.72; 90 % of the subjects experienced no pain. Implantation was the most sensitive moment. Eye mobility was not a problem except during capsulhorexis which had to be done with forceps. CONCLUSION: Simplicity of topical anaesthesia eliminates the complications of the other anaesthetic methods. It is necessary to have a close patient-surgeon relationship. Carefully chosen topical anaesthesia is an interesting alternative.

[Anesthesia in the early surgical therapy of myelomeningocele]. / L'anestesia nella terapia chirurgica precoce del mielomeningocele.

Anaesthetic procedures in surgical repair of meningomyelocele in pediatric patients with particular reference to the problems concerning the specific pathology and the newborn age are reported. Authors consider that surgical repair in the first days of life assures a lesser incidence of leptomeningeal infections and a better functional improvement without an important increase of the anaesthetic risk.

Antitoxin use and pediatric intensive care for viper bites in Rome, Italy.

In Italy viper bites represent an uncommon event, though envenomation can cause severe complications, more in children than adults, because of dose/body size ratio. We present a case series within a selected population: 10 Italian cases (from Rome surroundings) of viperbites requiring PICU admission, over a 5-year interval. Five children showed a systemic involvement, whereas the remaining patients showed a damage. All were managed and closely monitored in an ICU setting. Relevant clinical findings and therapeutic approach, ICU course and complications have been recorded. Age range was 3-15 years with mean age of 6,9 (SD±4,58) years; 2 patients needed respiratory support beyond oxygen supplementation. Most patients underwent fluid loading, while hemodynamic support was given to4/10. Median PICU stay was 60 hours (IQR=24.0-75.5). No mortality was reported. Indications and precautions for administration of antivenom in the last years have been reviewed: early treatment seems to reduce mortality/morbidity, though representing a threat for children. Current recommendations for the treatment of viper envenomation have been described, based on a literature's review and the application of these knowledges to clinical reality of our PICUs. Therefore, paediatric patients with systemic or rapidly evolving symptoms should be monitored carefully for the development of bite-related complications in an ICU setting mostly in younger children.

Non-invasive ventilation for severe TRALI and myocardial stunning: report and literature review.

Transfusion-related acute lung injury (TRALI) is a frequently under-diagnosed, although potentially fatal, condition that represents a leading cause of transfusion-related morbidity and mortality even in pediatric patients. Its main clinical features are characterized by rapidly evolving respiratory distress, hypoxia, pulmonary edema, and bilateral infiltrates on chest radiograph during or within 6 h of transfusion. We present a case of severe TRALI associated with myocardial stunning that occurred in a 14-year-old girl, and review the existing literature of pediatric TRALI. Our report suggests a potential role for NIV in the management of TRALI as the best profile both in terms of safety and effectiveness for hematologic patients.

New trends in pediatric anesthesia.

The authors illustrate some relevant emerging topics in pediatric anesthesia. Endotracheal cuffed tubes have entered into routine clinical practice in younger patients. Concerns about tracheal stenosis were overcome when manufactures began to produce a new class of high volume, low pressure endotracheal tubes. Ultrasound-guided central venous cannulation helped anesthesiologists and intensivists to more efficaciously and safely perform the invasive monitoring required by ever more invasive surgical procedures. The utility of ultrasonography in peripheral nervous blocking has also been demonstrated. Better knowledge of the pathophysiology of both hypovolemic shock and coagulation dysfunction helped made it possible to face and successfully perform even major surgical procedures and treat more dramatic trauma. The introduction of devices to monitor anesthesia depth helped clinicians to better understand the pharmacodynamic effects of anesthetics, resulting in the maintenance of a more stable level of narcosis and the reduction of the incidence of awareness.

Severe hyperleukocytosis and multifocal intracranial haemorrhage: not always a fatal outcome.

Severe hyperleukocytosis caused by acute lymphoblastic leukaemia (ALL) is associated with an increased risk of early death due to the intracranial haemorrhage. We report on a boy who presented with ALL with an extremely high leukocyte count, who developed neurological deterioration due to multiple intracerebral haemorrhages. Adequate measures for managing this medical emergency include appropriate supportive measures and initiation of therapy to prevent symptoms of leukostasis. Aggressive measures as a decompressive craniectomy should be considered to improve the poor outcome observed in this subset of patients.