Antibiotic prophylaxis for surgical procedures on children.

The aim of this study was to evaluate adherence to current local antimicrobial prophylaxis guidelines for children requiring different surgical procedures. One hundred and fifty consecutive surgical procedures on children were included in this retrospective study of adherence. The indication, choice of antibiotic, timing, dose, duration and dosing interval were evaluated and found to be concordant with present local guidelines in 97.3%, 83.3%, 66%, 92%, 40.7% and 94.1% of cases, respectively. Adherence to all parameters was achieved in only 25.3% of cases. Although the overall adherence to antibiotic prophylaxis guidelines was relatively low, the majority of children (84.6%) received an appropriate antibiotic (90.6%) at the appropriate dose (92%) and at appropriate intervals (94.1%). The most discordant duration of prophylaxis was due to controversies in urological prophylaxis guidelines.

Adenylate kinase activity in the cerebrospinal fluid of hypoxic newborns.

Adenylate kinase (AK) activity in the cerebrospinal fluid (CSF), described as a marker of brain edema and lesions in adults, was studied in 79 newborns with severe respiratory distress within 24 h after admission to the Intensive Care Unit (ICU). The CSF-AK activity was compared with CSF lactate concentration, CSF lactate dehydrogenase activity (LDH), and CSF and serum creatine kinase isoenzyme BB (CK-BB) activity. Newborns were divided into Group I with moderate to severe brain dysfunction and Group II with mild or no detectable brain dysfunction on discharge from the ICU. Mean CSF-AK activity (11.31 U/L) in Group I was significantly (p less than 0.001) higher than in Group II (2.82 U/L). Correlation between CSF-AK and CSF lactate was r = 0.714, p less than 0.01 and between CSF-AK activity and CSF-LDH activity was r = 0.550, p less than 0.01 in Group I. Preliminary data indicate that CSF-AK activity within 24 h after ischaemia is an indicator of hypoxic brain lesions in newborns. Its prognostic value for the infant's development remains to be determined by further study.

Recording conventional and amplitude-integrated EEG in neonatal intensive care unit.

Neonatal electroencephalography (EEG) presents a challenge due to its difficult interpretation that differs significantly from interpretation in older children and adolescents. Also, from the technological point of view, it is more difficult to perform and is not a standard procedure in all neonatal intensive care units (NICUs). During recent years, long-term cerebral function monitoring by the means of amplitude-integrated EEG (aEEG) has become popular in NICUs because it is easy to apply, allows real-time interpretation by the neonatologist treating the newborn, and has predictive value for outcome. On the other side, to record conventional EEG (cEEG), which is still considered the gold standard of neonatal EEG, the EEG technician should not only be well trained in performing neonatal EEG but also has to adapt to suboptimal working conditions. These issues need to be understood when approaching the neonatal cEEG in NICU and the main structure of the article is dedicated to this technique. The authors discuss the benefits of the digitalization and its positive effects on the improvement of NICU recording. The technical aspects as well as the standards for cEEG recording are described, and a section is dedicated to possible artifacts. Thereafter, alternative and concomitant use of aEEG and its benefits are briefly discussed. At the end there is a section that presents a review of our own cEEG and aEEG recordings that were chosen as the most frequently encountered patterns according to Consensus statement on the use of EEG in the intensive care unit.

Changes in serum procalcitonin, interleukin 6, interleukin 8 and C-reactive protein in neonates after surgery.

INTRODUCTION: Aim of this study was to determine the kinetics of procalcitonin (PCT), interleukin-6 (IL-6), interleukin-8 (IL-8) and C-reactive protein (CRP) serum concentrations after different types of neonatal surgery. MATERIAL AND METHODS: We conducted a prospective, observational study in a level III multidisciplinary neonatal intensive care unit. We enrolled twenty-five (n=25) neonates undergoing major surgery (for gastroschisis, atresia of the small intestine, congenital diaphragmatic hernia, esophageal atresia, coarctation of the aorta, neurosurgical procedures). Serum PCT, IL-6, IL-8 and CRP were measured before surgery, immediately after surgery (POD 0) and on the first and second day after surgery (POD 1, 2). RESULTS: Median preoperative serum concentrations were: PCT 1.3 microg/l, IL-6 985 fmol/l, IL-8 51 pg/ml, CRP 6 mg/l. PCT increased insignificantly after surgery with a peak median concentration on POD 1 (2.0 microg/l), but concentrations varied considerably between patients in the same category of surgery. IL-6 significantly increased on POD 0 (median 2 262 fmol/l), with a peak median concentration on POD 1 (3 410 fmol/l), and decreased thereafter. IL-8 increased significantly after surgery with a peak median concentration on POD 0 (125 pg/ml) and decreased thereafter. IL-8 response was very consistent after all types of surgery. CRP only began to increase on POD 1 (median 20 mg/l) with a peak median concentration on POD 2 (21 mg/l). CONCLUSIONS: The physiological increase in PCT after birth and the impact of underlying disease make the interpretation of postoperative values in the immediate postnatal period difficult. IL-6 is a very sensitive marker of neonatal surgical injury with considerable variation between different types of surgery. IL-8 response after neonatal surgery is similar after all types of surgery, very rapid and transient with relatively low concentrations. CRP response to surgery is slow with persistence of elevated levels throughout the study period. IL-8 could potentially be a useful marker for monitoring infection in the immediate postoperative period in neonates.

Interleukin-6 and lipopolysaccharide-binding protein in acute appendicitis in children.

The aim of the study was to evaluate the diagnostic accuracy of interleukin-6 (IL-6) and lipopolysaccharide-binding protein (LBP) in children with acute appendicitis (AA) and to compare this with the diagnostic accuracy of routinely used C-reactive protein (CRP) and white blood cell (WBC) count. Eighty-two consecutive children admitted to our Department because of suspected AA were enrolled in this prospective study and classified into two groups: group 1 (49 children who underwent surgery for AA) and group 2 (33 children with no surgery with diagnosis of non-specific abdominal pain or sonographic mesenteric lymphadenitis). There were no negative appendectomies during the time of the study. The patients were further classified into three subgroups: subgroup 1A (43 patients with advanced AA), subgroup 2A (11 patients with mesenteric lymphadenitis) and subgroup 2B (10 patients with non-specific abdominal pain). The perforation rate was 32.7 %. WBC count and serum CRP, IL-6 and LBP were measured on admission. Area under receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity and predictive values were evaluated. Serum IL-6 and LBP were significantly higher in group 1 than in group 2. The highest AUC for AA was that for IL-6 (0.776), followed by WBC count (0.684), CRP (0.637) and LBP (0.635). In conclusion, only IL-6, determined on admission, showed medium diagnostic accuracy, while other laboratory markers showed low diagnostic accuracy for AA in children. The new laboratory markers therefore do not significantly improve the diagnosis of AA.

Parenteral nutrition in severely burned children.

In adults supplemental parenteral nutrition (PN) is advisable in burns over 40% especially when weight loss exceeds 10% of body weight. In children with smaller reserves and higher requirement of proteins and energy no rigid scheme for parenteral supplementation is used at our unit. In a young infant it may be added already at a 20-30% deep burn, especially with connected gastrointestinal tract problems, infection etc. Metabolic and protein requirements are estimated 50-100% in addition to their normal needs. Hypertonic glucose (gradually increased from 20-40%), covered with insulin in the early phase, is used as source of carbohydrates. L-amino acid mixture containing the "pediatric essential amino acids" histidine and cysteine is given as a nitrogen source. 20% Intralipid is given in a gradually increased amount of 2-4 g/kg per day to provide calories and essential fatty acids. Among electrolytes K, Ca, P and Mg must be added. Increased amounts of vitamin C and folate are needed by burned children. Vitamin E is also required during prolonged lipid administration. Trace elements (Zn. Fe, etc.) are supplied orally or i.v. with special solutions or fresh plasma infusions. Our experience with parenteral nutrition in severely burned children will be presented. There were no severe metabolic side-effects but sepsis represented the major problem. The concomitant heat preservation by warming the room and use of infra-red heaters is emphasized.

Phosphate metabolism in red blood cells of critically ill neonates.

Very few data exist on phosphate metabolism in critically ill neonates. Therefore we studied the incidence of hypophosphataemia, the intracellular metabolism of phosphate by measuring adenosine 5'-triphosphate (ATP) and 2,3-diphosphoglycerate (2,3-DPG) in red blood cells, and excretion of phosphate in urine. The aims of the study were early detection of changes in phosphate metabolism as possible diagnostic markers of sepsis and defining the cause of hypophosphataemia. Neonates, treated in multidisciplinary paediatric intensive care unit (PICU), included in the study, were less than three days of age. Eighteen of them had respiratory distress syndrome (RDS) and 16 had microbiologically confirmed or clinical sepsis. The overall incidence of hypophosphataemia in critically ill neonates was over 80%, and was more common (88%) and more profound in those with sepsis than in those with RDS (79%). Therefore the septic neonates needed significantly larger amounts of phosphate to maintain normophosphataemia. In septic neonates ATP concentration in red blood cells was significantly lower than in neonates with RDS and controls, while the 2,3-DPG concentration was increased as a result of compensation. In septic neonates urinary losses of inorganic phosphate (Pi) were significantly higher than in neonates with RDS. Hypophosphataemia in critically ill neonates is at least partly due to higher urinary losses of phosphate.

Measurement of purines in urine by capillary electrophoresis for estimating the degree of hypoxia in infants.

We describe a simple, rapid and reproducible method for measuring hypoxanthine, xanthine and uric acid in urine samples of infants by capillary electrophoresis with an uncoated fused silica capillary and ultraviolet detection. Conditions were 40 mmol/l borate buffer pH 9.4 with sodium dodecyl sulphate (0.1 mol) 3 s hydrodynamic load and the voltage 20 kV. The calibration curves for hypoxanthine and xanthine were linear to 150 micromol/l and for uric acid to 300 micromol/l. The limits of detection for hypoxanthine, xanthine and uric acid were 0.5, 2.0 and 20 micromol/l, respectively. Analytical recovery of the three purines ranged from 93 to 105%. Overall CVs were < 5.2%. Using this method, we measured purine concentrations in the urine samples of 103 infants, divided into three groups, according to different degrees of hypoxia. There was a significant difference among the three groups only in hypoxanthine concentrations. In 35 urine samples from the control group, 43 urine samples from infants with a history of an apparent life threatening episode and in 25 urine samples from infants with infantile apnoea, the mean concentrations of hypoxanthine (mean +/- SD) were 13.1 +/- 4.0, 25.1 +/- 8.1 and 58.2 +/- 17.4 micromol/mmol creatinine, respectively. The diagnostic accuracy of the purine measurement was evaluated by receiver-operating characteristic curve analysis.

Interleukin-8 and procalcitonin in early diagnosis of early severe bacterial infection in critically ill neonates.

We studied the value of serum interleukin-8 (IL-8) and procalcitonin (PCT) in the early diagnosis of early severe bacterial infection in 58 critically ill ventilated neonates. ELISA was used for determining IL-8 and immunoluminometric assay for PCT. IL-8 and PCT were compared with routinely used serum C-reactive protein (CRP). Neonates were divided into four groups: Ia--proven severe bacterial infection (n = 9), Ib--clinical sepsis (n = 16), II--respiratory distress without bacterial infection (n = 12), and III--various types of neonatal distress (n = 21). Sera were collected on admission, at 24 h and 48 h after admission. There was no significant difference between groups Ia and Ib for either parameter at any time interval. Significant difference was found between group Ia+b (septic neonates) and group II for PCT and CRP at 24 and 48 h, but not for IL-8. There was no difference between group Ia+b and group III except for CRP at 24 h. Diagnostic accuracy was best for PCT on admission and for CRP at 24 h. Serum PCT and IL-8 are not specific markers for early severe bacterial infection in critically ill neonates and are not better than CRP.

Interleukin-6 (IL-6) and soluble receptors for interleukin-2 (sIL-2R) in the diagnosis of early severe infection in the critically ill newborns.

The aim of our study was to evaluate the diagnostic accuracy of serial determination of interleukin-6 (IL-6) and soluble receptors of interleukin-2 (sIL-2R) in the diagnosis of early infection in the critically ill newborns and compare it with the routinely used C-reactive protein (CRP). Fourty-six critically ill newborns (median age 8 h, range 1-96 h), treated at the multidisciplinary intensive care unit, Division for Paediatric Surgery and Intensive Care, University Medical Centre Ljubljana, were included in the study. Newborns were divided into three groups: group I microbiologically confirmed severe infection (n = 14), group II suspected but not confirmed infection (n = 12) and group III respiratory distress syndrome without laboratory signs of infection. Serum concentrations of IL-6, sIL-2R and CRP were determined on admission and at 12 and 24 h after admission. On admission the concentrations of IL-6 and sIL-2R were significantly higher in group I than in group III, but there was no difference between groups I and II. On admission area under receiver operating characteristic (ROC) curve for IL-6 was 0.756, for IL-2R 0.821 and for CRP 0.799. Repeated determination at 12 h improved diagnostic accuracy for sIL-R and CRP but not for IL-6.

Brain temperature discriminates between neonates with damaged, hypoperfused, and normal brains.

Brain temperature depends on the balance of cerebral heat production and heat loss via cerebral circulation and head surface. We investigated whether brain temperature and heat loss via the head surface differed in neonates with abnormal cerebral metabolism or circulation. We measured the core temperature of the head noninvasively by the zero-gradient method, skin temperature of the head, the heat flux from the head, and esophageal and operative environmental temperature in seven healthy neonates, seven neonates with cerebral damage, and two neonates with cerebral hypoperfusion caused by an incurable congenital heart disease. Cerebral blood flow velocity in the anterior cerebral artery and systemic blood pressure were also measured. Brain temperature profile was measured in two premature infants with external ventricular drainage. Core temperature of the head, considered to represent brain temperature, was up to 1.5 degree C higher in infants with cerebral hypoperfusion than in normal neonates. The core temperature of the head was higher than the esophageal temperature in all except two infants with the most severe cerebral damage. The difference between core temperature of the head and esophageal temperature was 0.72 +/- 0.12 degree C in normal neonates, 0.16 +/- 0.4 degree C in infants with cerebral damage, and ranged from 0.9 to 1.2 degree C in infants with cerebral hypoperfusion. The relationship of core of the head to esophageal temperature discriminated between all 16 newborn infants according to their brain pathologic condition, except one infant with a mild ischemic-hypoxic encephalopathy. In conclusion, brain temperature depends on cerebral perfusion and level of brain injury.(ABSTRACT TRUNCATED AT 250 WORDS)

The bactericidal mats in the pediatric intensive care unit.

An evaluation of dry adhesive bactericidal mats S-Entry was conducted in pediatric intensive care unit (ICU). From April to June 1981 192 floor and 48 shoe samples were taken in three parallels in the periods with the mats used and in the periods without the mats for bacteriological control. The statistical analysis of the number of CFU showed no significant difference between the two periods. Under the conditions of work in the ICU the bactericidal mats cannot play an expected role. The bacterial flora of the floor and shoe soles had no influence on the degree of hospital infections in the ICU.