[Sodium dichloroisocyanurate-induced acute lung injury in a child]. / Œdème pulmonaire lésionnel par intoxication au dichloro-isocyanurate de sodium.

Intoxication, by cyanurate and its chlorated derivatives in children, is increasingly reported in the literature due to accidental ingestion compared to accidental inhalation. We report a case in a 5-year-old child who presented with acute lung injury due to accidental inhalation of gas formed after a reaction of sodium dichloroisocyanurate tablets with water. Prevention remains the best way to reduce the risk of children being intoxicated by inhalation of the gas formed after contact of tablets with water.

[Weaning from invasive mechanical ventilation in pediatric patients (excluding premature neonates)]. / Le sevrage de la ventilation mécanique invasive en réanimation pédiatrique (à l'exclusion des prématurés).

The process of weaning from mechanical ventilation (WMV) is the same in children as in adults. In the pediatric literature, weaning failure rate ranges from 1.4 to 34%. So far, no indices of weaning success have been demonstrated to be sufficiently accurate. The criteria for assessing readiness to wean, which must be screened daily, have neither been validated nor adapted to the pediatric population. The spontaneous breathing test (SBT), the reference screening test for weaning, precedes extubation; it can be achieved with pressure support ventilation or spontaneous breathing (T piece or canopy or flow-inflating bag). A standardized weaning protocol (which can be computer driven) was used in only three pediatric studies and the impact on shortening the duration of mechanical ventilation has not yet been demonstrated. It should be paired with a sedative interruption protocol. Weaning criteria, SBT criteria, and/or protocol tolerance are guides, but clinicians must individualize decisions to use these criteria. The use of noninvasive ventilation is increasing and its place in weaning protocols for children needs to be determined; it might modify the definitions of weaning failure and weaning success in the future.

[Why teams in charge of children after a pediatric intensive care unit stay do not take into account the treatment limitation decisions previously made by intensivists]. / Pourquoi les décisions de limitation des traitements en réanimation ne sont-elles pas partagées avec les professionnels assurant les soins de l'enfant avant et après la réanimation?

UNLABELLED: The fact that some children may survive despite a limitation of treatment decision (LTD) made in the pediatric intensive care unit (PICU) is a recent concern. A previous study pointed out that the teams in charge of children after the PICU stay did not take previous PICU LTDs into account. PURPOSE: To identify the problems different units experience in cooperating with the PICU team, in order to increase the continuity of care for these children. STUDY DESIGN: Qualitative single-center study, using semi-structured interviews with physicians in charge of children who were discharged from the PICU even though a LTD was made. RESULTS: Nine pediatric subspecialists (hemato-oncologists, neurologists, and neurosurgeons) were interviewed, producing a corpus of approximately 80 pages of typed text. Three conflictual situations were identified by these physicians. The most frequently reported situation was being asked by the PICU team to give expert advice on a patient's prognosis, before a LTD was made. The 2 others had to defend a true care plan for children who were transferred to the PICU and designing a new care plan for children who were discharged from the PICU after a LTD was made. CONCLUSION: The medical reasoning model that is used for LTDs in the PICU generates conflictual situations when compared to the models that are used in other specialties. These models represent various expressions of subjectivity, as in any medical decision. Acknowledging this fact could facilitate its integration into clinical practice and should improve authentic debates that are necessary to ensure continuity of care for these children.

[What become the decisions of limitation of treatments after discharge from the paediatric intensive care unit?]. / Que deviennent les décisions de limitation ou d'arrêt des traitements actifs à la sortie de réanimation pédiatrique ?

UNLABELLED: The fact that some children may survive despite a decision of limitation of treatments (DLT) is taken in Paediatric Intensive Care Unit (PICU) is a recent data. Although the French-speaking Group of Paediatric Intensive and Emergency Care (GFRUP) has published guidelines for limitation of treatments in PICU, outcome of these surviving children has not yet been studied. PURPOSES: To evaluate transmission of data concerning DLT in PICU toward teams in charge of children after the PICU stay and to evaluate perennility of these decisions. METHOD: Cohort study in children for whom DLT was discussed and who were discharged from PICU between 2002 and 2006. The study included an analysis of the medical files and discussions with the physicians in charge of children at the time of the study, including their responses to standardised scenarios concerning the outcome of their patients. RESULTS: Among the 96 children for whom DLT was discussed in PICU, 37 were discharged toward another unit. Only 1 discharge letter mentioned the DLT. At the time of the study, the Pediatric Overall Performance Category (POPC) score had increased in 16 children and was stable in 12. All the 6 children with a worsening POPC score died, without PICU readmission. The physicians in charge of children after the PICU stay did not remember any DLT. For 18 children (including 8 with previous DLT) PICU readmission would be proposed in case of life-threatening event. Their median POPC score at the time of study was lower than that of other children (3 versus 4; p=0.001). CONCLUSION: This study shows a lack of DLT data transmission, which is in contradiction with the GFRUP's guidelines. Correction of this lack is essential to improve cooperation between units in charge of these children.

Are the GFRUP's recommendations for withholding or withdrawing treatments in critically ill children applicable? Results of a two-year survey.

OBJECTIVE: To evaluate feasibility of the guidelines of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) for limitation of treatments in the paediatric intensive care unit (PICU). DESIGN: A 2-year prospective survey. SETTING: A 12-bed PICU at the Hôpital Jeanne de Flandre, Lille, France. PATIENTS: Were included when limitation of treatments was expected. RESULTS: Of 967 children admitted, 55 were included with a 2-day median delay. They were younger than others (24 v 60 months), had a higher paediatric risk of mortality (PRISM) score (14 v 4), and a higher paediatric overall performance category (POPC) score at admission (2 v 1); all p<0.002. 34 (50% of total deaths) children died. A limitation decision was made without meeting for 7 children who died: 6 received do-not-resuscitate orders (DNROs) and 1 received withholding decision. Decision-making meetings were organised for 31 children, and the following decisions were made: 12 DNROs (6 deaths and 6 survivals), 4 withholding (1 death and 3 survivals), with 14 withdrawing (14 deaths) and 1 continuing treatment (survival). After limitation, 21 (31% of total deaths) children died and 10 survived (POPC score 4). 13 procedures were interrupted because of death and 11 because of clinical improvement (POPC score 4). Parents' opinions were obtained after 4 family conferences (for a total of 110 min), 3 days after inclusion. The first meeting was planned for 6 days after inclusion and held on the 7th day after inclusion; 80% of parents were immediately informed of the decision, which was implemented after half a day. CONCLUSIONS: GFRUPs procedure was applicable in most cases. The main difficulties were anticipating the correct date for the meeting and involving nurses in the procedure. Children for whom the procedure was interrupted because of clinical improvement and who survived in poor condition without a formal decision pointed out the need for medical criteria for questioning, which should systematically lead to a formal decision-making process.

[Non-invasive ventilation in infants with severe infection presumably due to respiratory syncytial virus: feasibility and failure criteria]. / Ventilation non invasive des nourrissons ayant une infection respiratoire sévère présumée à virus respiratoire syncitial: faisabilité et critères d'échec.

UNLABELLED: Beneficial effect of continuous positive airway pressure (CPAP) during non invasive ventilation (NIV) has been reported in infants with respiratory syncytial virus (RSV) infection, but no study has analyzed the predictors of its failure. OBJECTIVE: To evaluate the feasibility of NIV and to determine NIV failure criteria. POPULATION AND METHODS: All infants hospitalized in one PICU with presumed RSV infection between 2002 and 2006 were prospectively included. When respiratory support was needed, NIV was first started according to a pre-established protocol. RESULTS: One hundred and one infants, 43 females, 58 males, median age 49 days (range: 10-334), median weight 3.9 kg (range: 2,4-12) were included. RSV infection was confirmed in 84/101. Sixty-seven infants were transported by the paediatric medical transport system, 27 with NIV and 15 with invasive ventilation (IV). Fifteen infants were in IV at admission, 69 received NIV during their PICU stay (12 secondarily requiring IV) and 17 were never ventilated. A significant decrease in PCO2 with increase in pH was observed within 2 hours of NIV. Parameters associated with NIV failure were apneas, high values of admission PCO2 and H24 PRISM score. The 17 non-ventilated infants were older and had a lower severity score than those who were ventilated. CONCLUSION: In infants with RSV and needing respiratory support, NIV represented the sole method of respiratory support in 68% of cases. NIV failure criteria were apneas, high values of admission PCO2 and H24 PRISM score.