Expiratory braking defines the breathing patterns of asphyxiated neonates during therapeutic hypothermia.

Introduction: Although neonatal breathing patterns vary after perinatal asphyxia, whether they change during therapeutic hypothermia (TH) remains unclear. We characterized breathing patterns in infants during TH for hypoxic-ischemic encephalopathy (HIE) and normothermia after rewarming. Methods: In seventeen spontaneously breathing infants receiving TH for HIE and in three who did not receive TH, we analyzed respiratory flow and esophageal pressure tracings for respiratory timing variables, pulmonary mechanics and respiratory effort. Breaths were classified as braked (inspiratory:expiratory ratio ≥1.5) and unbraked (<1.5). Results: According to the expiratory flow shape braked breaths were chategorized into early peak expiratory flow, late peak expiratory flow, slow flow, and post-inspiratory hold flow (PiHF). The most braked breaths had lower rates, larger tidal volume but lower minute ventilation, inspiratory airway resistance and respiratory effort, except for the PiHF, which had higher resistance and respiratory effort. The braked pattern predominated during TH, but not during normothermia or in the uncooled infants. Conclusions: We speculate that during TH for HIE low respiratory rates favor neonatal braked breathing to preserve lung volume. Given the generally low respiratory effort, it seems reasonable to leave spontaneous breathing unassisted. However, if the PiHF pattern predominates, ventilatory support may be required.

Analysis of Knowledge, Attitudes and Behaviours of Health Care Workers towards Vaccine-Preventable Diseases and Recommended Vaccinations: An Observational Study in a Teaching Hospital.

Background: Recommended vaccinations are the cheapest and most effective measure to reduce the risk of transmission and related complications, especially in high-risk healthcare settings. This study aimed to evaluate the knowledge, attitudes and behaviours of HCWs in relation to national recommendations. Methods: A transversal study was conducted through administration of a questionnaire by personal interview. The following care units were involved: Paediatric, Neonatal, Cardiac Surgery and General Intensive Care Units and Infectious Diseases Unit. Results: The study sample comprised 308 HCWs. Half the sample were aware of the vaccination recommendations, with occupation and age found to be predictive factors (OR = 9.38, 95%CI: 2.07−42.41; OR = 0.36, 95%CI: 0.22−0.60). A higher percentage defined the diseases as a risk for their patients' health, although this perception was lower in the over-40 age group. In several cases, there were statistically significant differences between the care units (p < 0.001). Around three-quarters of the sample agreed that vaccination should be mandatory; willingness to undergo a future booster vaccination was statistically correlated with the variables of age and care unit (p < 0.001, p = 0.03). Conclusion: The protection of health in the workplace can be achieved through some strategic actions, such as the implementation of educational strategies, and protocols for the monitoring of immunocompetence and the improvement of vaccination.

The starting rate for high-flow nasal cannula oxygen therapy in infants with bronchiolitis: Is clinical judgment enough?

OBJECTIVES: To determine whether in infants with bronchiolitis admitted to a pediatric intensive care unit (PICU) the starting rate for high-flow nasal cannula (HFNC) therapy set by the attending physicians upon clinical judgment meets patients' peak inspiratory flow (PIF) demands and how it influences respiratory mechanics and breathing effort. METHODOLOGY: We simultaneously obtained respiratory flow and esophageal pressure data from 31 young infants with moderate-to-severe bronchiolitis before and after setting the HFNC rate at 1 L/kg/min (HFNC-1), 2 L/kg/min (HFNC-2) or upon clinical judgment and compared data for PIF, respiratory mechanics, and breathing effort. RESULTS: Before HFNC oxygen therapy started, 16 (65%) infants had a PIF less than 1 L/kg/min (normal-PIF) and 15 (45%) had a PIF more than or equal to 1 L/kg/min (high-PIF). Normal-PIF-infants had higher airway resistance (p < .001) and breathing effort indexes (e.g., pressure rate product per min [PTP/min], p = .028) than high-PIF-infants. Starting the HFNC rate upon clinical judgment (1.20-2.05 L/kg/min) met all infants' PIFs. In normal-PIF-infants, the clinically judged flow rate increased PIF (p = .081) and tidal volume (p = .029), reduced airway resistance (p = .011), and intrinsic positive end-expiratory pressure (p = .041), whereas, in both high-PIF and normal-PIF infants, it decreased respiratory rate (p < .001) and indexes of breathing effort such as PTP/min (in normal-PIF infants, p = .004; in high-PIF infants, p = .001). The 2 L/kg/min but not 1 L/kg/min rate induced similar effects. CONCLUSIONS: The wide PIF distribution in our PICU population of infants with bronchiolitis suggests two disease phenotypes whose therapeutic options might differ. An initial flow rate of nearly 2 L/kg/min meets patients' flow demands and improves respiratory mechanics and breathing effort.

Three-dimensional airways volumetric analysis before and after fast and early mandibular osteodistraction.

PURPOSE: Newborns with Pierre Robin sequence (PRS) and syndromic micrognathia show microgenia and glossoptosis, which cause reduction of the airway and breathing difficulty from birth. Our goal is to analyze quantitative and qualitative volumetric changes before and after fast and early mandibular osteodistraction (FEMOD) and to compare radiological data. METHODS: The sample was composed of 4 patients, who satisfied inclusion criteria for completeness of data. Computed tomography pre- and post-operation were performed, then a volumetric assessment was made with Dolphin Imaging. Polysomnography was performed before and after FEMOD. RESULTS: Pre- and post-operative CT scan data were compared. The analysis of all three sections showed a significant increase of volumetric parameters. The retroglossal volume average increase was 346%, and the retropalatal volume average increase was 169%. These data matched the improvement recorded by polysomnography. CONCLUSIONS: The data confirm FEMOD as an efficient treatment to improve airways and breathing problem in patients affected by Pierre Robin sequence and syndromic micrognathia. The three-dimensional volume rendering could be a useful method to evaluate and quantify the increase in airways volume.

The role of vancomycin in addition with colistin and meropenem against colistin-sensitive multidrug resistant Acinetobacter baumannii causing severe infections in a Paediatric Intensive Care Unit.

BACKGROUND: Acinetobacter baumannii has been associated with high morbidity and mortality rates, even in pediatric patients. Therapeutic options are limited, especially when the strain is multidrug resistant. METHODS: Clinical and microbiological analyses of 4 cases of systemic infections caused by multi drug resistant A. baumannii treated with colistin/vancomycin combination at a Pediatric Intensive Care Unit were performed in order to explore the potential synergistic activity of colistin plus vancomycin. All the patients were treated with colistin, meropenem and vancomycin. RESULTS: Four severe infections due to MDR A. baumannii were observed. All patients treated with colistin/vancomycin combination had a positive outcome with no infection relapses. Most importantly, no significant adverse events related to the simultaneous administration of COL plus VAN were observed. In our in-vitro experiments, the synergistic effect of the combination COL plus VAN showed an early bactericidal activity even at VAN concentration of 16 mg/L, which reflects the serum trough concentrations obtained in patients. DISCUSSION: An antimicrobial strategy based on the activity of colistin plus vancomycin was in-vitro and in-vivo effective in life-threatening infections caused by multidrug-resistant A. baumannii in a Pediatric Intensive Care Unit, in the absence of adverse effects. Colistin plus vancomycin were highly synergic and bactericidal against carbapenem-resistant, colistin sensitive A. baumannii whereas the addition of meropenem did not enhance the in-vitro activity of colistin plus vancomycin. CONCLUSIONS: Our results confirm existing data on the potential synergistic activity of a therapeutic strategy including colistin plus vancomycin and provide important new clinical information for its potential use as a therapeutic option against MDR A. baumannii infections, especially in the pediatric population.

Proven Epstein-Barr encephalitis with negative EBV-DNA load in cerebrospinal fluid after allogeneic hematopoietic stem cell transplantation in a child with acute lymphoblastic leukemia.

We report a case of EBV encephalitis in a seven-yr-old child with Ph+ ALL. Two months after an allogeneic HSCT from his HLA mismatched mother, the patient showed an altered sensorium, generalized seizures, and a left hemiparesis. Brain MRI demonstrated multiple lesions highly suggestive for viral encephalitis. Blood and CSF PCR analyses were negative for the most common viruses involved in immunocompromised patients including EBV. A cerebral biopsy was performed, which showed intense gliosis and perivascular lymphocytic cuffing. PCR analysis performed on brain tissue was positive only for the EBV genome, while extensive investigations for other viral infections were negative. The patient's neurological symptoms rapidly worsened and he died two months later. This case report suggests that in patients presenting neurological and radiological signs of encephalitis after an HSCT, an EBV involvement should be considered, even in the absence of CSF and blood PCR virus detection.

Beneficial effects of levosimendan in infants with sepsis-associated cardiac dysfunction: report of 2 cases.

Although international guidelines for hemodynamic support of pediatric septic shock suggest considering the potent calcium sensitizer inodilator levosimendan as a second-line inotropic agent to treat cold hypodynamic shock resistant to catecholamines, clinical experience in septic infants is lacking. We report the beneficial effects of levosimendan infusion in 2 infants (39 and 64 days old) with low cardiac output septic shock (ejection fraction, 29% and 33%; fractional shortening, 10% and 16% respectively) refractory to volume replacement and to the catecholamines dopamine and dobutamine. Levosimendan infusion (0.15 µg/kg/min) promptly increased both patients' myocardial contractility and improved tissue perfusion, thereby reducing lactate levels and increasing urine output. The only adverse effect was moderate hypotension in one infant, who reversed by adding norepinephrine to levosimendan. This clinical experience confirms the potential beneficial effects of levosimendan infusion to restore hemodynamics in infants with low cardiac output septic shock resistant to catecholamines.

Current strategies for treating infants with severe bronchopulmonary dysplasia.

Advances in neonatal intensive care have markedly improved survival rates for infants born at a very early lung development stage (<26 weeks gestation). In these premature infants, even low inspired oxygen concentrations and gentle ventilatory methods may disrupt distal lung growth, a condition described as "new" bronchopulmonary dysplasia (BPD). BPD usually develops into a mild form, with only few infants requiring ventilator support and oxygen supplementation at 36 weeks post-conception. No magic bullets exist for treating infants with established severe BPD. Current management of the disease aims at maintaining an adequate gas exchange while promoting optimal lung growth. Prolonged oxygen therapy and ventilator support through nasal cannulae or a tracheotomy are often required to maintain blood gases. Short-course, low-dose corticosteroids may improve lung function and accelerate weaning from oxygen and mechanical ventilation. Pulmonary hypertension is a major complication in infants with severe BPD. Pulmonary vasodilators, such as sildenafil followed by bosentan, may improve the oxygenation and pulmonary outcome.

Mandibular distraction osteogenesis for neonates with Pierre Robin sequence and airway obstruction.

Neonates with Pierre Robin Sequence (PRS) usually present with varying degrees of upper airway obstruction and difficulty feeding. Early treatment is important for such children in order to prevent impaired cognitive development resulting from hypoxemic episodes. Various procedures aimed at widening the pharyngeal space have been proposed, including prone position, tongue-lip adhesion, mandibular traction, non-invasive ventilation and palatal plates. Mandibular distraction osteogenesis (MDO) using external or internal devices has become increasingly popular as an alternative treatment option when other medical or surgical techniques do not prove to be satisfactory. This review summarizes current evidence on the effectiveness of MDO in infants with PRS. Because of a lack of studies comparing this treatment with other procedures, general recommendations cannot be drawn and treatment of infants with PRS still requires individualization.

Gut microbial translocation in critically ill children and effects of supplementation with pre- and pro biotics.

Bacterial translocation as a direct cause of sepsis is an attractive hypothesis that presupposes that in specific situations bacteria cross the intestinal barrier, enter the systemic circulation, and cause a systemic inflammatory response syndrome. Critically ill children are at increased risk for bacterial translocation, particularly in the early postnatal age. Predisposing factors include intestinal obstruction, obstructive jaundice, intra-abdominal hypertension, intestinal ischemia/reperfusion injury and secondary ileus, and immaturity of the intestinal barrier per se. Despite good evidence from experimental studies to support the theory of bacterial translocation as a cause of sepsis, there is little evidence in human studies to confirm that translocation is directly correlated to bloodstream infections in critically ill children. This paper provides an overview of the gut microflora and its significance, a focus on the mechanisms employed by bacteria to gain access to the systemic circulation, and how critical illness creates a hostile environment in the gut and alters the microflora favoring the growth of pathogens that promote bacterial translocation. It also covers treatment with pre- and pro biotics during critical illness to restore the balance of microbial communities in a beneficial way with positive effects on intestinal permeability and bacterial translocation.

What's new in the treatment of neonatal shock.

Shock is a clinical disorder that challenges caregivers in the neonatal intensive care unit. The predominant cause of shock in neonates is sepsis. This article provides an overview of the current treatment of septic shock with particular emphasis on newer vasoactive drugs (milrinone, levosimendan and vasopressin) to support cardiovascular dysfunction.

Blood loss and short-term outcome of infants undergoing brain tumour removal.

OBJECTIVE: To evaluate perioperative management, early outcomes and hemocoagulative disorders in infants up to 1 year old, undergoing neurosurgery for brain tumors removal. DESIGN: Retrospective evaluation of prospectively collected data regarding all infants aged <1 year admitted to PICU from 1994 to 2004, following intracranial mass removal. INTERVENTIONS: none. SETTING: University Hospital PICU in a tertiary neurosurgical referral centre. PATIENTS AND PARTICIPANTS: All eligible infants were enrolled in the study. Population was constituted by 43 infants and subdivided in two groups, according to their intra-operative blood loss. Babies having blood loss exceeding the preoperative estimated volemia were classified in group A; the remaining babies were included in group B. RESULTS: Intraoperative transfusions, PICU length of stay, need for post-operative mechanical ventilation and cardiovascular support were all significantly higher in group A than in group B. No early postoperative mortality occurred. ROC analysis and multiple logistic regression showed the age as the only variable independently associated with blood loss exceeding preoperative volemia (cut-off 60.3 days; OR = 0.11, CI 0.02-0.55, sensitivity 82.4%; specificity 67%). Postoperatively, platelet count, prothrombin activity and fibrinogen resulted significantly depressed in group A, representing a dilutional coagulopathy. A marked dispersion of aPTT values was recorded in group B, where most infants exhibit aPTT shortening, suggesting a hypercoagulability status. Three episodes of clinical disseminated intravascular coagulation (DIC) were registered in group B. CONCLUSIONS: We illustrated the relationships between intraoperative blood loss, transfusions and haemostatic impairment in babies following brain tumor removal. Youngest infants had the higher risk to experience hemocoagulative disorders. These infants showed significantly higher impact on the global PICU burden of care, as represented by the need of mechanical ventilation, cardiovascular support and PICU length of stay.

Massive blood transfusion in choroid plexus tumor surgery: 10-years' experience.

STUDY OBJECTIVE: To describe our 10 years of experience with childhood choroid plexus tumors (CPTs). DESIGN: Retrospective chart analysis. SETTING: Operating room and pediatric intensive care unit (PICU) of a university hospital. PATIENTS: 18 infants and children undergoing CPT surgery from 1995 to 2004, 11 of whom were younger than 12 months. MEASUREMENTS: Perioperative hematologic and coagulation data were measured as well as estimated red cell volume variations (as a reliable index of blood loss) in the perioperative period, together with coagulation parameters. RESULTS: Greater blood loss was recorded in the infant group vs older children (percentage of estimated red cell volume loss, 1.31 +/- 1.79% vs 0.20 +/- 0.17% [P < 0.01] and 1.50 +/- 1.86% vs 0.29 +/- 0.21% [P < 0.01] on PICU admission and after 72 hours, respectively). Platelet count decrease was similarly noted (51.60 +/- 28.06 vs 27.57 +/- 11.98, P < 0.05, as percentage of preoperative count). Patients operated on in the neonatal period showed the highest blood loss and related coagulation impairment. CONCLUSION: Younger CPT surgery patients present an increased risk versus their older counterparts of massive bleeding resulting in hemodynamic instability and coagulative impairment.

Oxidation of intravenous lipid in infants and children with systemic inflammatory response syndrome and sepsis.

During sepsis in adults, fat becomes a preferred fuel; however, oxidation may be impaired relative to the circulating fatty acid levels. Little is known about the ability of infants and children to oxidize lipids during systemic inflammation (SIRS) and sepsis. The aim of this study was to examine the oxidation of exogenous lipid in these patients. Sixteen patients with SIRS/sepsis and eight controls with no evidence of sepsis were studied by indirect calorimetry during an i.v. lipid utilization test (1 h of 0.3 g/kg/h glucose followed by 3 h of 0.1 g/kg/h glucose plus 0.15 g/kg/h lipid). The respiratory quotient (RQ) (1.0 for carbohydrate utilization and 0.7 for fat utilization) was measured. Results were compared by repeated-measures analysis of variance (ANOVA), paired or unpaired t tests. There was no difference in baseline RQ between controls and patients with SIRS/sepsis (mean +/- SD; 0.82 +/- 0.08 versus 0.82 +/- 0.04). The RQ of controls dropped significantly to 0.78 +/- 0.08 at 240 min (p < 0.001). The RQ of patients with SIRS/sepsis also fell to 0.78 +/- 0.06 (p < 0.01). Infants and children with SIRS/sepsis are able to oxidize i.v. lipid.

Sharing features of uncommon respiratory syncytial virus complications in infants.

We describe 4 nonconsecutive cases of infants admitted to Catholic University pediatric intensive care unit (PICU) because of complicated respiratory syncytial virus (RSV) infection during winter RSV outbreaks from the year 2000 to the year 2003. A hyponatremic epileptic status (as in the first case) has been reported by several authors as a rare RSV complication, potentially leading to death. The second infant developed a serious pulmonary edema after a subglottic obstruction (croup) associated with RSV infection. The remaining 2 infants developed a pneumothorax and subcutaneous emphysema while breathing spontaneously during an RSV bronchiolitis. In all infants, a full recovery and PICU discharge was achieved despite the need for mechanical ventilation in cases 1 and 2. Increased intrapleural negative pressure or its combination with hypoxia/hypercapnia has been suggested as the common factor possibly joining these different clinical pictures.