Hemodynamic monitoring by transpulmonary thermodilution and pulse contour analysis in critically ill children.

OBJECTIVES: To summarize the physiologic principles underlying the hemodynamic monitoring using the PiCCO device (Pulsion, Munich, Germany) incorporating the transpulmonary thermodilution technique, the pulse contour cardiac output, and estimation of the arterial pressure variation method. Analysis and review of the current literature. DESIGN: A MEDLINE-based literature search using the key words transpulmonary thermodilution, pulse contour analysis, cardiac output, animal models, and child. MEASUREMENTS AND MAIN RESULTS: The bias and precision of cardiac output measured by transpulmonary thermodilution are reliable. The reproducibility for repeated measurements is approximately 5% and the percentage error is approximately 15%. Transpulmonary thermodilution may adequately track changes in cardiac output in animals submitted to hypovolemic conditions and during volume loading. Conversely, data from experimental and clinical studies suggest that continuous monitoring of cardiac output using pulse contour analysis requires careful interpretation because periodic recalibration with transpulmonary thermodilution is necessary. Transpulmonary thermodilution-derived static indicator of cardiac preload (global end-diastolic volume, intrathoracic blood volume) may be more sensitive than conventional measurements of vascular filling pressure. However, the value of stroke volume variation or pulse pressure variation have not been evaluated in pediatric patients. Further studies are needed to determine whether theoretical assumptions underlying the measurement of extravascular lung water are valid in children. CONCLUSIONS: The PiCCO device may be a useful adjunct for hemodynamic monitoring in critically ill children. Further studies are needed to clarify the reliability and clinical value of pulse contour method and extravascular lung water measurement.

Association between length of storage of transfused red blood cells and multiple organ dysfunction syndrome in pediatric intensive care patients.

BACKGROUND: The objective was to determine if there is an association between red blood cell (RBC) storage time and development of new or progressive multiple organ dysfunction syndrome (MODS) in critically ill children. STUDY DESIGN AND METHODS: This was an analytic cohort analysis of patients enrolled in a randomized controlled trial, TRIPICU (Transfusion Requirements in Pediatric Intensive Care Units; ISRCTN37246456), in which stable critically ill children were randomly assigned to a restrictive or liberal strategy. Transfused patients were analyzed using three different sliding time cutoffs (7, 14, and 21 days). Storage time for multiply transfused patients was defined according to the oldest unit transfused. RESULTS: A total of 455 patients were retained (liberal, 310; restrictive, 145). Multivariate logistic regression was performed to determine independent associations. In the restrictive group, a maximum RBC storage time of more than 21 days was independently associated with new or progressive MODS (adjusted odds ratio [OR], 3.29; 95% confidence interval [CI], 1.21-9.04). The same association was found in the liberal group for a storage time of more than 14 days (adjusted OR, 2.50; 95% CI, 1.12-5.58). When the two groups were combined in a meta-analysis, a storage time of more than 14 days was independently associated with increased MODS (adjusted OR, 2.23; 95% CI, 1.20-4.15) and more than 21 days was associated with increased Pediatric Logistic Organ Dysfunction (PELOD) scores (adjusted mean difference, 4.26; 95% CI, 1.99-6.53) and higher mortality (9.2% vs. 3.8%). CONCLUSION: Stable critically ill children who receive RBC units with storage times longer than 2 to 3 weeks may be at greater risk of developing new or progressive MODS.

Multidisciplinary prospective study of mother-to-child chikungunya virus infections on the island of La Réunion.

BACKGROUND: An outbreak of chikungunya virus affected over one-third of the population of La Réunion Island between March 2005 and December 2006. In June 2005, we identified the first case of mother-to-child chikungunya virus transmission at the Groupe Hospitalier Sud-Réunion level-3 maternity department. The goal of this prospective study was to characterize the epidemiological, clinical, biological, and radiological features and outcomes of all the cases of vertically transmitted chikungunya infections recorded at our institution during this outbreak. METHODS AND FINDINGS: Over 22 mo, 7,504 women delivered 7,629 viable neonates; 678 (9.0%) of these parturient women were infected (positive RT-PCR or IgM serology) during antepartum, and 61 (0.8%) in pre- or intrapartum. With the exception of three early fetal deaths, vertical transmission was exclusively observed in near-term deliveries (median duration of gestation: 38 wk, range 35-40 wk) in the context of intrapartum viremia (19 cases of vertical transmission out of 39 women with intrapartum viremia, prevalence rate 0.25%, vertical transmission rate 48.7%). Cesarean section had no protective effect on transmission. All infected neonates were asymptomatic at birth, and median onset of neonatal disease was 4 d (range 3-7 d). Pain, prostration, and fever were present in 100% of cases and thrombocytopenia in 89%. Severe illness was observed in ten cases (52.6%) and mainly consisted of encephalopathy (n = 9; 90%). These nine children had pathologic MRI findings (brain swelling, n = 9; cerebral hemorrhages, n = 2), and four evolved towards persistent disabilities. CONCLUSIONS: Mother-to-child chikungunya virus transmission is frequent in the context of intrapartum maternal viremia, and often leads to severe neonatal infection. Chikungunya represents a substantial risk for neonates born to viremic parturients that should be taken into account by clinicians and public health authorities in the event of a chikungunya outbreak.

[Vertical maternal fetal transmission of the chikungunya virus. Ten cases among 84 pregnant women]. / Transmission verticale materno-foetale du virus chikungunya. Dix cas observés sur l'île de la Réunion chez 84 femmes enceintes.

INTRODUCTION: In March 2005, an epidemic of chikungunya virus began in the southern portion of Reunion Island (French overseas district in the Indian Ocean) and spread to the northern part of the island at the end of 2005. The Reunion-South Hospital Group observed the first cases of pregnant women infected with the virus in June 2005. We report here for the first time maternal-fetal transmission of this virus. CASES: From June 2005 through the end of January 2006, 84 pregnant women had acute chikungunya infections during pregnancy. In 88% of these cases (n=74)--all involving infections relatively distant from delivery--the newborns appeared asymptomatic. Conversely, 10 newborns had severe attacks (4 with meningoencephalitis and 3 with intravascular coagulations) after birth and required prolonged neonatal hospitalization (6 in the neonatal intensive care unit with intubation and assisted ventilation). No infants died, but there was one case of severe intracerebral hemorrhage after severe thrombocytopenia. These cases were confirmed by specific serology testing or PCR or both for mothers and newborns. We note that all severe cases involved women with viremia and fever in the intrapartum period.