[Revelation of the circumstances of the accident vascular arterial ischemic brain in at term or near-term and referral]. / Circonstances de révélation de l'accident vasculaire cérébral ischémique artériel chez le nouveau-né à terme ou proche du terme et orientation des patients.

The neonatal arterial ischemic stroke is an emergency. Recurrent focal seizures, generally occurring in the first 24-72 hours after birth, are the commonest first clinical signs. When neonatal arterial ischemic stroke is suspected, optimal initial management involves careful supportive care including treatment of clinical and frequent or prolonged subclinical seizures, correction of the possible metabolic disorders and their prevention. Contrary to hypoxic ischemic encephalopathy, therapeutic hypothermia is not indicated. This newborn requires emergent transfer to a neonatal intensive care unit for the confirmation of the diagnosis by means of a specialized neonatal transport team.

[Neonatal arterial ischemic stroke: Review of the current guidelines]. / Accidents vasculaires cérébraux ischémiques artériels néonatals : synthèse des recommandations.

Neonatal arterial ischemic stroke (NAIS) is a rare event that occurs in approximately one in 5000 term or close-to-term infants. Most affected infants will present with seizures. Although a well-recognized clinical entity, many questions remain regarding diagnosis, risk factors, treatment, and follow-up modalities. In the absence of a known pathophysiological mechanism and lack of evidence-based guidelines, only supportive care is currently provided. To address these issues, a French national committee set up by the French Neonatal Society (Société française de néonatologie) and the national referral center (Centre national de référence) for arterial ischemic stroke in children drew up guidelines based on an HAS (Haute Autorité de santé [HAS]; French national authority for health) methodology. The main findings and recommendations established by the study group are: (1) among the risk factors, male sex, primiparity, caesarean section, perinatal hypoxia, and fetal/neonatal infection (mainly bacterial meningitis) seem to be the most frequent. As for guidelines, the study group recommends the following: (1) the transfer of neonates with suspected NAIS to a neonatal intensive care unit with available equipment to establish a reliable diagnosis with MRI imaging and neurophysiological monitoring, preferably by continuous video EEG; (2) acute treatment of suspected infection or other life-threatening processes should be addressed immediately by the primary medical team. Persistent seizures should be treated with a loading dose of phenobarbital 20mg/kg i.v.; (3) MRI of the brain is considered optimal for the diagnosis of NAIS. Diffusion-weighted imaging with apparent diffusion coefficient is considered the most sensitive measure for identifying infarct in the neonatal brain. The location and extent of the lesions are best assessed between 2 and 4 days after the onset of stroke; (4) routine testing for thrombophilia (AT, PC PS deficiency, FV Leiden or FII20210A) or for detecting other biological risk factors such as antiphospholipid antibodies, high FVIII, homocysteinemia, the Lp(a) test, the MTHFR thermolabile variant should not be considered in neonates with NAIS. Testing for FV Leiden can be performed only in case of a documented family history of venous thromboembolic disease. Testing neonates for the presence of antiphospholipid antibodies should be considered only in case of clinical events arguing in favor of antiphospholipid syndrome in the mother; (5) unlike childhood arterial ischemic stroke, NAIS has a low 5-year recurrence rate (approximately 1 %), except in those children with congenital heart disease or multiple genetic thrombophilia. Therefore, initiation of anticoagulation or antithrombotic agents, including heparin products, is not recommended in the newborn without identifiable risk factors; (6) the study group recommends that in case of delayed motor milestones or early handedness, multidisciplinary rehabilitation is recommended as early as possible. Newborns should have physical therapy evaluation and ongoing outpatient follow-up. Given the risk of later-onset cognitive, language, and behavioral disabilities, neuropsychological testing in preschool and at school age is highly recommended.

[Risk of accumulation of CO2 in the oxygen chamber in "HOOD" (Experimental study on test bed)]. / Risque d'accumulation du CO2 lors de l'oxygénothérapie sous enceinte « HOOD ¼ (Étude expérimentale sur banc d'essai).

OBJECTIVES: Oxygen hood is largely used to deliver O2 to newborn infants with respiratory failure in the northern region of France. The oxygen flow is set to obtain the target arterial blood oxygen saturation. Thus, O2 flow delivers into the hood may be below the recommended gas flow of 6L/min. However, gas flow below 6L/min exposes to CO2 rebreathing. The aim of this study was to evaluate the effect of various rates of gas flows on the values of partial pressure of CO2 into the hood. MATERIAL AND METHODS: We measured CO2 and O2 partial pressure into hoods of two different volumes (4 and 10L) under two experimental bench test conditions. Protocol 1: gas flow was constant at 6L/min, while oxygen fraction varied from 0.21 to 1. Partial pressure of CO2 and O2 were recorded. Protocol 2: while O2 fraction was kept constant, oxygen flow varied from 0.5 to 7L/min (by step of 0.5L/min). Partial pressure of CO2 and O2 were recorded. RESULTS: Partial pressure of CO2 increases proportionally to the decrease in the gas flow delivered into the hood, and reached 14 mmHg at gas flow of 0.5L/min. CONCLUSION: Risk of CO2 rebreathing exists as soon as the gas is delivered into the hood at minimal flow rates below 6L/min.

[Umbilical and peripherally inserted venous central catheterization of the newborn]. / Le cathétérisme veineux ombilical et épicutanéocave chez le nouveau-né

Umbilical venous and peripherally inserted venous central catheters are widely used to perfuse low-weight preterm and term newborns in intensive care units. This catheter must be inserted carefully and monitored rigorously to prevent complications. This paper develops today's knowledge on the use and complications in the newborn population.

[Central venous catheters in pediatric patients]. / Le cathétérisme veineux central chez l'enfant.

Central venous catheterizations are often used in pediatric intensive care units or for long-term intravenous treatment. It consists in positioning the catheter extremity in the venous cava-right atrium junction. Adapted material and techniques are necessary for young children because of particularities in anatomy and the size of the different venous trunks. The aim of this paper is to present the different material and techniques and to show the indications, complications and follow-up in central venous catheterization for young children.

[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.

[Experimental study of changes in FiO2 during manual ventilation]. / Etude expérimentale des facteurs de variation de la FiO2 lors de la ventilation manuelle.

UNLABELLED: Discrepancies exist in the recommendations about the oxygen flow to deliver during manual ventilation. The aim of the present study was to determine the effects of ventilatory frequency (FR), inspiratory pressure (P) and oxygen flow on the concentration of the delivered oxygen (FiO2) to obtain FiO2 near 1. MATERIAL AND METHODS: Experimental study with self-inflating resuscitation bag (Ambu with oxygen reservoir) tested on a mono-compartmental test lung (resistant tube and elastic bag [Draeger]; characteristics: compliance = 0.6 mL/cmH2O; resistance = 85 cmH2O.L-1.s-1). Protocol 1: six neonatologists ventilated this model as if they were ventilating premature newborn infants with RDS at various ventilatory rates from 30 to 120 bpm and at various oxygen flows (from 2 to 12 L/min). Tidal volumes (Vt), inspiratory times (Ti), P and FiO2 were recorded continuously during the study. Protocol 2: a graduated manometer was added to visualize pressure. The same protocol was then applied. RESULTS: Protocol 1 (without visual control of the pressure): increase in oxygen flow delivered with the Ambu increases the FiO2 values (P < 0.0001); the higher the ventilatory frequency, the lower the FiO2 (P < 0.0001). The mean value of delivered FiO2 was related to the operator (extreme: 47-86%) (P < 0.001). Multivariate statistical analysis showed that O2 flow, ventilator rate and operator modulated independently the FiO2. Ti and Vt did not change the FiO2. Protocol 2 (with visual control of the pressure: the mean inflating pressures were less than those obtained without visual control of the pressure (26 vs 40 cmH2O respectively; P < 0.05). FiO2 was independent of O2 flow and ventilatory rate. CONCLUSIONS: A special device for continuous visual control of airway pressure is recommended during neonatal manual ventilation. It prevents ventilatory rate-induced FiO2 fluctuations and overdistention.

Are there specific haemostatic abnormalities in children surviving septic shock with purpura and having skin necrosis or limb ischaemia that need skin grafts or limb amputations?

UNLABELLED: More than 10% of children surviving septic shock with purpura have skin necrosis or limb ischaemia (SNLI.). Among 44 children consecutively admitted to our pediatric intensive care unit, 35 (80%) survived, 6 of them (17%) developed SNLI (defined as the need of a surgical procedure). Two timed haemostasis measurements included the determination of coagulation factors, protein C (PC), protein S (PS), C4b binding protein (C4bBP), antithrombin (AT), and plasminogen activator inhibitor 1 (PAI-1). Two severity scores and CRP levels were determined at admission. Children with SNLI and without SNLI were compared. On admission, severity scores, and AT, PC, PS, C4bBP levels were similar in both groups with and without SNLI. Prothrombin time (23% vs 34%; P < 0.01), factor VII+X (20% vs 31%; P = 0.05) and factor VII (0% vs 19%; P < 0.01) were lower in the group with SNLI. The 2nd sample showed no difference between the two groups. Kinetics of haemostatic abnormalities were no different between the two groups. CONCLUSION: In this series, the only difference between the two groups was lower factor VII levels in children with skin necrosis or limb ischaemia. This suggests the benefit of tissue factor pathway inhibitor administration as an adjunctive therapy to prevent skin necrosis or limb ischaemia. Further studies including more children are needed to determine the potential effects of treatments such as protein C, antithrombin, and plasminogen activator inhibitor antibody administration, and to advocate tissue factor pathway inhibitor in preventing skin necrosis or limb ischaemia.

[Is Ambu ventilation of newborn infants a simple question of finger-touch?]. / La ventilation à l'Ambu chez le nouveau-né: une simple question de doigté?

Insufflation pressures were measured during manual ventilation using a neonatal rebreathing bag (Ambu on a manikin. Maximal insufflation pressures were greater than that published or given by the manufacturer, theoretically limited to 30 cm of water at open valve, and that whatever the number of fingers used for the compression of the bag. These results indicate that Ambu ventilation, often mandatory for newborn resuscitation, does not simply rely upon the finger-touch of the operator and that it always has a risk of baro and/or volotraumatism.

[Modality and causes of 259 deaths in a pediatric intensive care unit]. / Modalités et causes de 259 décès dans un service de réanimation pédiatrique.

BACKGROUND: There are few data available from European pediatric intensive care units (PICU) regarding the modes of death and their causes. POPULATION AND METHODS: Two hundred and fifty nine children, not including neonates, died in the PICU over a 7-year period (1987-1993). Data were obtained from a computerized data base and the retrospective review of medical records by two intensivists. Deaths were classified into three groups according to the terminal event: brain death (BD), unsuccessful resuscitation (UR), do-not-resuscitate order and limitation and/or withdrawal of therapy (LWT). RESULTS: BD was the most common mode of death (38%); UR accounted for 34% and LWT for 28% of deaths. There was no significant annual variation in the proportion of BD, UR and LWT. Age and sex were similar in the three groups. The predominant organ system failure involved upon admission was the central nervous system (52%) in the LWT group, and the cardiovascular system (54%) in the UR group. Severe chronic disease (37%) and immunosuppression (19%) were more prevalent in the LWT group than in the BD group. Time from admission to death was longer in the LWT group (median = 119 hours) as compared to the UR group (10 hours) and the BD group (54 hours). Ten percent of the BD patients became organ transplant donors. Sixty-seven per cent of BD patients had medical contraindication for organ donation: parents did not accept organ donation in 61% of potential cases. Thirty deaths (12%) seemed to be avoidable; dehydration from acute infectious gastroenteritis (n = 7) was the most common cause of avoidable death. CONCLUSIONS: The modes of death in our PICU were statistically not different from those seen in two of four North-American PICUs; LWT was less prevalent than in the two other PICUs, but the patient populations were very different (presence of neonates and many cardiovascular surgery patients). Assessment of the severity of illness at admission and of functional outcome in the survivors are mandatory in future studies.

[Hemostasis anomalies and prognosis during severe infectious purpura in children. Retrospective study in 69 cases]. / Anomalies de l'hémostase et pronostic au cours du purpura infectieux sévère de l'enfant. Etude rétrospective de soixante-neuf observations.

In 69 children with severe infectious purpura (SIP), anomalies of hemostasis on admission were studied retrospectively. Forty-four children presented with disseminated intravascular coagulation (DIC) and 18 with factor VII deficiency +/- thrombocytopenia +/- antithrombin III deficiency. Seven patients were free of hemostasis anomalies. In 5 children, purpura was necrotic on admission, whereas in 9 additional patients skin necrosis occurred subsequently (5 patients with and 4 without DIC). Among the 18 children (26%) who died, 16 were in the DIC group. Factors II and V, fibrinogen and platelet counts were lower in children who died and were correlated with the prognostic score. In the DIC group, however, factor VII + X level was not correlated with the prognostic score and was equally low in fatal and non-fatal cases. Antithrombin III level was markedly decreased in patients who subsequently developed necrosis. These results indicate that factor VII level decreases early in the course of SIP and that consumption of physiologic coagulation inhibitors probably plays a central part in the development of necrotic purpura.

[Congestive cardiomyopathy after chronic inhalation of trichloroethylene]. / Myocardiopathie congestive après inhalation chronique de trichloréthylène.

A congestive cardiomyopathy (associated with an atrial flutter) was observed in a 14 year-old boy who was a regular trichlorethylene sniffer. Regression occurred after stopping exposition to the toxic chemical. This complication hitherto not reported in children, may be fatal. Its origin would be ischemic because trichlorethylene is known to potentiate the effects of circulating catecholamines. This toxic cardiomyopathy has to be added to the list of congestive cardiomyopathies in children and adolescents.

[Frequency of adrenal hemorrhage in fatal forms of purpura fulminans in children. Etiopathogenic and therapeutic considerations]. / Fréquence des hémorragies surrénaliennes au cours des formes fatales de purpura fulminans de l'enfant. Considérations étio-pathogéniques et thérapeutiques.

Between 1971 and 1985, 43 children died of purpura fulminans in our intensive care unit: 11 had autopsy and adrenal haemorrhage was observed in 8 (73%). All these patients had an extensive purpura and a severe disseminated intravascular coagulation. Our series confirms the findings of previous studies: 69 autopsies showed 51 cases (74%) of macroscopic adrenal haemorrhage. Adrenal haemorrhage may be only one manifestation of multiple system organ failure consecutive to septic shock; however, its association with low plasma cortisol levels (as previously reported) suggests that glucocorticoid replacement therapy should be reconsidered in purpura fulminans.