Characterising the Long-Term Language Impairments of Children Following Cerebellar Tumour Surgery by Extracting Psycholinguistic Properties from Spontaneous Language.

Following cerebellar tumour surgery, children may suffer impairments of spontaneous language. Yet, the language processing deficits underlying these impairments are poorly understood. This study is the first to try to identify these deficits for four levels of language processing in cerebellar tumour survivors. The spontaneous language of twelve patients who underwent cerebellar tumour surgery (age range 3-24 years) was compared against his or her controls using individual case statistics. A distinction was made between patients who experienced postoperative cerebellar mutism syndrome (pCMS) and those who did not. Time since surgery ranged between 11 months and 12;3 years. In order to identify the impaired language processing levels at each processing level (i.e., lexical, semantic, phonological and/or morphosyntactic) nouns and verbs produced in the spontaneous language samples were rated for psycholinguistic variables (e.g., concreteness). Standard spontaneous language measures (e.g., type-token ratio) were calculated as well. First, inter-individual heterogeneity was observed in the spontaneous language outcomes in both groups. Nine out of twelve patients showed language processing deficits three of whom were diagnosed with pCMS. Results implied impairments across all levels of language processing. In the pCMS-group, the impairments observed were predominantly morphosyntactic and semantic, but the variability in nature of the spontaneous language impairments was larger in the non-pCMS-group. Patients treated with cerebellar tumour surgery may show long-term spontaneous language impairments irrespective of a previous pCMS diagnosis. Individualised and comprehensive postoperative language assessments seem necessary, given the inter-individual heterogeneity in the language outcomes.

Spoken verb learning in children with language disorder.

The current study examined spoken verb learning in elementary school children with language disorder (LD). We aimed to replicate verb learning deficits reported in younger children with LD and to examine whether verb instrumentality, a semantic factor reflecting whether an action requires an instrument (e.g., "to chop" is an instrumental verb), influenced verb learning. The possible facilitating effect of orthographic cues presented during training was also evaluated. In an exploratory analysis, we investigated whether language and reading skills mediated verb learning performance. General language skills and verb learning were assessed in Dutch children with LD and age-matched typically developing controls (n = 25 per group) aged 8 to 12 years (M = 9;9 [years;months], SD = 1;3). Using video animations, children learned 20 nonwords depicting actions comprising 10 instrumental and 10 noninstrumental verbs. Half of the items were trained with orthographic information present. Verb learning was assessed using an animation-word matching and animation naming task. Linear mixed-effects models showed a main effect of group for all verb learning measures, demonstrating that children with LD learned fewer words and at a slower rate than the control group. No effect of verb instrumentality, presence of orthographic information, or the included mediators was found. Our results emphasize the importance of continued vocabulary instruction in elementary school to strengthen verb encoding. Given that our findings are inconsistent with the overall literature showing an orthographic facilitation effect, future studies should investigate whether participants pay attention to the written word form in learning contexts with moving stimuli.

Developmental language disorder in sequential bilinguals: Characterising word properties in spontaneous speech.

The current study sought to investigate whether word properties can facilitate the identification of developmental language disorder (DLD) in sequential bilinguals by analyzing properties in nouns and verbs in L2 spontaneous speech as potential DLD markers. Measures of semantic (imageability, concreteness), lexical (frequency, age of acquisition) and phonological (phonological neighbourhood, word length) properties were computed for nouns and verbs produced by 15 sequential bilinguals (5;7) with DLD and 15 age-matched controls with diverse L1 backgrounds. Linear mixed modelling revealed a significant interaction of group and word category on phonological neighbourhood values but no differences across imageability, concreteness, frequency, age of acquisition, and word length measures in spontaneous speech. Outcomes suggest that group-level differences may not be apparent at the word-level, due to the heterogeneous nature of DLD and potential similarities in production during early L2 acquisition.

Language processing from the perspective of electrical stimulation mapping.

Electrical Stimulation (ES) is a neurostimulation technique that is used to localize language functions in the brain of people with intractable epilepsy and/or brain tumors. We reviewed 25 ES articles published between 1984 and 2018 and interpreted them from a cognitive neuropsychological perspective. Our aim was to highlight ES as a tool to further our understanding of cognitive models of language. We focused on associations and dissociations between cognitive functions within the framework of two non-neuroanatomically specified models of language. Also, we discussed parallels between the ES and the stroke literatures and showed how ES data can help us to generate hypotheses regarding how language is processed. A good understanding of cognitive models of language is essential to motivate task selection and to tailor surgical procedures, for example, by avoiding testing the same cognitive functions and understanding which functions may be more or less relevant to be tested during surgery.

Does Tracheal Lidocaine Instillation Reduce Intracranial Pressure Changes After Tracheal Suctioning in Severe Head Trauma? A Prospective, Randomized Crossover Study.

OBJECTIVES: Tracheal suctioning is a routine procedure in mechanically ventilated children, however, in severe head-injured patients it can result in potential deleterious increase in intracranial pressure. We aimed to assess the effect of tracheal lidocaine administration on intracranial pressure during tracheal suctioning. DESIGN: Prospective randomized controlled crossover study. SETTING: PICU of a tertiary hospital. PATIENTS: Eleven patients with severe head trauma (Glasgow Coma Scale score 4-8) INTERVENTIONS:: Lidocaine (1.5 mg/kg) or saline solution was endotracheally instilled before a standardized tracheal suctioning maneuver. Each patient received both treatments in a crossover design. Cerebral hemodynamic and systemic and ventilatory effects were assessed at four time points: in baseline (T0), within 2 minutes (T1), 5 minutes (T2), and 15 minutes after tracheal instillation (T3). The 2-minute time interval around tracheal suctioning was used to assess each treatment efficacy MEASUREMENTS AND MAIN RESULTS:: The time course of intracranial pressure was different throughout the study in both treatment groups, with a significant increase of intracranial pressure from 14.82 ± 3.48 to 23.27 ± 9.06 with lidocaine (p = 0.003) and from 14.73 ± 2.41 to 30.45 ± 13.14 with saline (p = 0.02). The mean variation in intracranial pressure immediately after tracheal suctioning was smaller with lidocaine instillation than saline (8.45 vs 15.72 mm Hg; p = 0.006). Patients treated with lidocaine returned to baseline intracranial pressure value at 5 minutes after tracheal suctioning whereas those receiving saline solution returned to baseline intracranial pressure value at 15 minutes. Although patients treated with lidocaine had no significant hemodynamic changes, patients receiving saline solution experienced a higher mean value of mean arterial pressure (99.36 vs 81.73 mm Hg; p = 0.004) at T1. CONCLUSIONS: This preliminary study showed that tracheal lidocaine instillation can attenuate increase in intracranial pressure induced by tracheal suctioning and favor a faster return to the intracranial pressure baseline levels without significant hemodynamic and ventilatory changes.

Imageability ratings across languages.

Imageability is a psycholinguistic variable that indicates how well a word gives rise to a mental image or sensory experience. Imageability ratings are used extensively in psycholinguistic, neuropsychological, and aphasiological studies. However, little formal knowledge exists about whether and how these ratings are associated between and within languages. Fifteen imageability databases were cross-correlated using nonparametric statistics. Some of these corresponded to unpublished data collected within a European research network-the Collaboration of Aphasia Trialists (COST IS1208). All but four of the correlations were significant. The average strength of the correlations (rho = .68) and the variance explained (R 2 = 46%) were moderate. This implies that factors other than imageability may explain 54% of the results. Imageability ratings often correlate across languages. Different possibly interacting factors may explain the moderate strength and variance explained in the correlations: (1) linguistic and cultural factors; (2) intrinsic differences between the databases; (3) range effects; (4) small numbers of words in each database, equivalent words, and participants; and (5) mean age of the participants. The results suggest that imageability ratings may be used cross-linguistically. However, further understanding of the factors explaining the variance in the correlations will be needed before research and practical recommendations can be made.

Survey on current cognitive practices within the European Low-Grade Glioma Network: towards a European assessment protocol.

BACKGROUND: The European Low-Grade Glioma network indicated a need to better understand common practices regarding the managing of diffuse low-grade gliomas. This area has experienced great advances in recent years. METHOD: A general survey on the managing of diffuse low-grade gliomas was answered by 21 centres in 11 European countries. Here we focused on specific questions regarding perioperative and intraoperative cognitive assessments. RESULTS: More centres referred to the same speech and language therapist and/or neuropsychologist across all assessments; a core of assessment tools was routinely used across centres; fluency tasks were commonly used in the perioperative stages, and object naming during surgery; tasks that tapped on attention, executive functions, visuospatial awareness, calculation and emotions were sparsely administered; preoperative assessments were performed 1 month or 1 week before surgery; timing for postoperative assessments varied; finally, more centres recommended early rehabilitation, whenever needed. CONCLUSIONS: There is an emerging trend towards following similar practices for the management of low-grade gliomas in Europe. Our results are descriptive and formalise current discussions in our group. Also, they contribute towards the development of a European assessment protocol.

The Eating Assessment Tool-10 Predicts Aspiration in Adults with Stable Chronic Obstructive Pulmonary Disease.

Adults with COPD frequently present with dysphagia, which often leads to clinical complications and hospital admissions. This study investigates the ability of the Eating Assessment Tool (EAT-10) to predict aspiration during objective dysphagia evaluation in adults with stable COPD. Thirty adults (20 male, 10 female; mean age = 69.07 ± 16.82) with stable COPD attended an outpatient dysphagia clinic for a fiberoptic endoscopic evaluation of swallowing (FEES) in an acute teaching hospital (January 2015-November 2016). During evaluations, individuals completed an EAT-10 rating scale followed immediately by a standardised FEES exam. Aspiration status during FEES was rated using the penetration-aspiration scale by clinicians blinded to EAT-10 scores. Data were retrospectively analysed. Significant differences in mean EAT-10 scores were found between aspirators (16.3; SEM = 2.165) and non-aspirators (7.3; SEM = 1.009) (p = 0.000). The EAT-10 predicted aspiration with a high level of accuracy (AUC = 0.88). An EAT-10 cut-off value of >9 presented a sensitivity of 91.67, specificity of 77.78 with positive and negative likelihood ratios of 4.12 and 0.11, respectively. Positive and negative predictive values were 73.30 and 93.30, respectively. Diagnostic odds ratio was 38.50 (p < 0.01, CI 3.75-395.42). EAT-10 is a quick, easy to administer tool, which can accurately predict the presence of aspiration in adults with COPD. The scale can also very accurately exclude the absence of aspiration, helping clinicians to determine the need for onward referral for a comprehensive dysphagia evaluation. This may ultimately reduce clinical complications and hospital admissions resulting from dysphagia in this clinical population.

A minimal standardization setting for language mapping tests: an Italian example.

During awake surgery, picture-naming tests are administered to identify brain structures related to language function (language mapping), and to avoid iatrogenic damage. Before and after surgery, naming tests and other neuropsychological procedures aim at charting naming abilities, and at detecting which items the subject can respond to correctly. To achieve this goal, sufficiently large samples of normed and standardized stimuli must be available for preoperative and postoperative testing, and to prepare intraoperative tasks, the latter only including items named flawlessly preoperatively. To discuss design, norming and presentation of stimuli, and to describe the minimal standardization setting used to develop two sets of Italian stimuli, one for object naming and one for verb naming, respectively. The setting includes a naming study (to obtain picture-name agreement ratings), two on-line questionnaires (to acquire age-of-acquisition and imageability ratings for all test items), and the norming of other relevant language variables. The two sets of stimuli have >80 % picture-name agreement, high levels of internal consistency and reliability for imageability and age of acquisition ratings. They are normed for psycholinguistic variables known to affect lexical access and retrieval, and are validated in a clinical population. This framework can be used to increase the probability of reliably detecting language impairments before and after surgery, to prepare intraoperative tests based on sufficient knowledge of pre-surgical language abilities in each patient, and to decrease the probability of false positives during surgery. Examples of data usage are provided. Normative data can be found in the supplementary materials.

How the modified Clinical Pulmonary Infection Score can identify treatment failure and avoid overusing antibiotics in ventilator-associated pneumonia.

AIM: Although the modified Clinical Pulmonary Infection Score (CPIS) has been used to guide treatment decisions in adults with ventilator-associated pneumonia (VAP), paediatric studies are lacking. We assessed a modified CPIS tool to define VAP resolution and identify treatment failure at an early stage. METHODS: We identified 70 mechanically ventilated children with VAP according to the Center for Disease Control criteria. Modified CPIS was initially measured at VAP onset and then three and five days afterwards. Children were defined as low risk or high risk based on a cut-off score of six. RESULTS: There were 50 high-risk and 20 low-risk patients. Culture results were positive in 64% of the high-risk patients and just 10% of the low-risk patients. Patients on adequate therapy significantly improved their CPIS scores by day three, regardless of the likelihood of VAP. A lack of score improvement demonstrated sensitivity of 100% and specificity of 83% when it came to detecting treatment failure. The area under the receiver operating curve was 0.92. CONCLUSION: Serial modified CPIS measurements showed that low-risk patients with negative cultures at day three should be considered for a short course of antibiotics. In contrast, high-risk patients with no score improvement were potentially failing their treatment.

Pediatric surgeon vs general surgeon: does subspecialty training affect the outcome of appendicitis?

BACKGROUND: The absence of pediatric surgeons in many centers results in restriction of patient access to pediatric subspecialty care. The aim of this study was to compare the outcomes of children treated for appendicitis by pediatric surgeons (PS) and by general surgeons (GS). METHODS: This was a retrospective review of the charts of all consecutive patients <16 years old who underwent appendectomy during 2 years The primary outcome measure was the overall rate of complications. Secondary outcome measures included length of hospital stay (LOS), symptom duration, time from emergency department diagnosis to surgery, and readmission rate within 30 days. RESULTS: A total of 94 patients (PS group, n = 66; GS group, n = 28) were included. PS patients were younger. For patients with complicated appendicitis, complications were significantly more prevalent in the GS group (57% vs 15%; P = 0.0001). Median LOS was not significantly different between the two groups for complicated appendicitis, but patients with non-complicated appendicitis had a significant longer LOS when treated by PS (3.74 ± 1.5 vs 2.57 ± 1.21 days; P = 0.0041). Patients in the PS group had a prolonged use of antibiotics (2 vs 4 days; P = 0.001), and longer LOS (3 vs 4 days; P = 0.0018). CONCLUSIONS: Overall complication rates were similar between PS and GS. Complications were significantly more prevalent in patients with complicated appendicitis who were treated by GS.

Language outcomes in children who underwent surgery for the removal of a posterior fossa tumor: A systematic review.

BACKGROUND: Children who underwent posterior fossa tumor removal may have spoken or written language impairments. The present systematic review synthesized the literature regarding the language outcomes in this population. Benefits of this work were the identification of shortcomings in the literature and a starting point toward formulating guidelines for postoperative language assessment. METHODS: A systematic literature search was conducted, identifying studies with patients who had posterior fossa surgery before 18 years of age. Included studies were narratively synthesized to understand language outcomes by language function (e.g., phonology, morphosyntax) at a group and individual level. Furthermore, the influence of several mediators (e.g., postoperative cerebellar mutism syndrome (pCMS), tumor type) was investigated. A critical evaluation of the language assessment tools was conducted. RESULTS: The narrative synthesis of 66 studies showed that a broad spectrum of language impairments has been described, characterized by a large interindividual heterogeneity. Patients younger at diagnosis, receiving treatment for a high-grade tumor and/or radiotherapy and diagnosed with pCMS seemed more prone to impairment. Several gaps in language assessment remain, such as a baseline preoperative assessment and the assessment of pragmatics and morphosyntax. Further, there were important methodological differences in existing studies which complicated our ability to accurately guide clinical practice. CONCLUSION: Children who had posterior fossa surgery seem to be at risk for postoperative language impairment. These results stress the need for language follow-up in posterior fossa tumor survivors.

Risk factors and outcomes of unplanned PICU postoperative admissions: a nested case-control study.

BACKGROUND: Although unplanned postoperative admission to PICUs (unplanned intensive care admission [UIA]) is uncommon, it might be associated with increased costs, morbidity, and mortality. However, detailed knowledge of risk factors and outcomes after UIA in children is still lacking. OBJECTIVES: To determine prevalence, risk factors, and outcomes of UIA patients compared with non-UIA patients. DESIGN: Case-control study. SETTING: A tertiary university-affiliated hospital. PATIENTS: All postoperative children admitted to the PICU were monitored for UIA. About 28 cases and 88 controls were included. INTERVENTIONS: none. MEASUREMENTS AND MAIN RESULTS: The overall prevalence of UIA was 2.6%. About 28 patients (24.1%) of 116 had unplanned admission. Multiple logistic regression revealed that factors predicting UIA were airway abnormality (odds ratio 16.2, 95% confidence interval 2.65-99.6), anesthetic factors (odds ratio 5.8, 95% confidence interval 1.06-32.2), and hypoxia intraoperative (odds ratio 7.4, 95% confidence interval 1.21-46.24). Procedures on abdomen, emergency surgery, combined anesthesia, and occurrence of intraoperative adverse events were also risk factors for an UIA. Patients with UIA had longer duration of mechanical ventilation than non-UIA patients (4.5 vs. 2 days, p = 0.01), but there were no differences in length of PICU and hospital stays. Preventable adverse events were detected in 25% of UIA children. CONCLUSIONS: Airway abnormality, anesthetic factors, and hypoxia intraoperative were risk factors associated with UIA. Although preventable events contribute significantly to unplanned PICU admissions, they constitute a room of opportunity in quality improvement programs.

The 10-Word Auditory Verbal Learning Test and Vocabulary Performance in 4- and 5-Year-Old Children.

BACKGROUND: Understanding the different factors that determine vocabulary development in young children is essential for the diagnosis and rehabilitation of language disorders in children. Language development is closely related to other cognitive processes such as auditory verbal learning and memory. This research focuses on the development of a novel auditory verbal learning test (AVLT) for 4- and 5-year-old children within the Dutch population. This new test is an adaptation of the common AVLT for both older children and adults, usually including a list of 15 words. Considering the lower attention span and limited executive functioning in young children, the word list of this new instrument is reduced to 10 words. Besides, a second recognition form has been developed to improve the ability to distinguish between possible underlying learning and memory deficits. METHOD: Ninety-five preschool children (ages 4;0-5;12 [years;months]) were tested with this new AVLT 10-word test for kids (10WT-K), yielding different measures of verbal auditory memory. Forty-eight of 95 children received a recognition task with semantically unrelated items, and 47 of 95 received a recognition task with semantically related items. Three additional language skills were assessed to establish test validation: receptive and expressive vocabulary performance and nonword repetition. Outcome of the 10WT-K was related to scores on the language measures. RESULTS: Positive correlations were found between the total score of the 10WT-K and all three aforementioned language skills. We found no correlations between frequency of error types (intrusions and repetitions) and language measures. Furthermore, children who were administered the recognition list with semantically related items showed fewer correct answers and more false-positive and false-negative responses than children who received a recognition list with semantically unrelated items. CONCLUSIONS: The 10WT-K for young children can be used to (a) measure different aspects of auditory verbal learning and memory, (b) clarify the nature of possible verbal learning difficulties, and (c) identify a possible nature of language disorders. The word recognition task tested with semantically related items provides a more accurate measurement of individual differences, namely, in distinguishing retrieval and storage abilities. The significant relation found between auditory verbal short-term memory capacity and vocabulary performance in preschool children is a first step toward establishing test validity.

Assessing outcome in interhospital infant transport: the transport risk index of physiologic stability score at admission.

OBJECTIVE: To evaluate the performance of the Transport Risk Index of Physiologic Stability (TRIPS) score at admission for early mortality prediction. METHODS: The study included all consecutive outborn infants admitted to a single neonatal intensive care unit (NICU) over a 3-year period. The data collected included demographic variables, 7-day NICU mortality, and severe (≥ grade 3) intraventricular hemorrhage (IVH), TRIPS score at admission, and Score for Neonatal Acute Physiology II (SNAP-II) and SNAP-Perinatal Extension-II (SNAPPE-II) scores. RESULTS: A total of 175 neonates were enrolled. TRIPS at admission discriminated 7-day mortality from survival with a receiver operating characteristic (ROC) area of 0.80, and predictive performance of TRIPS for severe IVH showed a ROC area of 0.67. The TRIPS had good calibration for all strata (p = 0.49). For gestational age (GA) >32 weeks, the area under the curve (AUC) for TRIPS was 0.71, whereas the AUC for GA ≤32 weeks was 0.99 for 7-day mortality. Predictive performance of TRIPS for 7-day mortality was similar to that of SNAP-II and SNAPPE-II. CONCLUSION: TRIPS score at admission had a good performance to discriminate high-risk patients for 7-day mortality, mainly infants with GA ≤32 weeks. TRIPS might be a useful triage tool if applied at the time of first contact with a transport service.

Additive diuretic response of concurrent aminophylline and furosemide in children: a case series and a brief literature review.

Aminophylline exerts a renovascular effect, acting by adenosine receptor blockade or type IV phosphodiesterase inhibition. Clinically, these drugs have been used with furosemide to induce diuresis in adults and neonates. However, reports on use of aminophylline in diuretic-dependent children are limited to a few studies. We report a case series of four critically ill children unresponsive to furosemide continuous infusion who were subsequently given aminophylline as an adjunct diuretic in the treatment of fluid overload. No side effects were evident. Administration of aminophylline at low doses (3 mg/kg) successfully promoted increased urine output over the 6-h study period in all four children.

The noun-verb distinction.

The comparison between nouns and verbs has been a topic of interest for many researchers over the last 50 years. This comparison, and subsequent behavioral and (partly) anatomic dissociation, has allowed researchers to delve into many topics including the behavioral architecture of the language system and its neural correlates, the underlying nature of the linguistic impairment in individuals with different neurologic disorders, the assessment of language treatment protocols, and the proposal of new protocols aimed to protect the language system of individuals undergoing surgery for brain tumors and epilepsy. Specific to the left temporal lobe, classic accounts have shown its relevance for the processing of nouns and less for the processing of verbs. Nonetheless, more recent accounts indicate that different areas in the left temporal lobe can subserve different functions for the processing of both nouns and verbs. In this chapter, we outlined an overview of key findings of the study of nouns and verbs, with a particular focus on the left temporal lobe. This chapter contextualizes the literature on category-specific impairments and neural correlates of nouns and verbs with linguistic and psycholinguistic theories, and provides new ways to investigate and understand the intricacies of this comparison.

Treating lexical retrieval using letter fluency and tDCS in primary progressive aphasia: a single-case study.

Background: In early stages, individuals with Primary Progressive Aphasia (PPA) report language symptoms while scoring within norm in formal language tests. Early intervention is important due to the progressive nature of the disease. Method: We report a single case study of an individual with logopenic variant PPA (lvPPA). We tested whether letter fluency, used as a therapy task, can improve lexical retrieval when combined with tDCS to either the left inferior-frontal gyrus (IFG) or the left inferior parietal lobe (IPL), administered in two separate therapy phases separated by a wash-out period of three months. Outcomes and results: We observed increases in number of words retrieved during a letter fluency task in trained and untrained letters, when letter fluency therapy (LeFT) was administered with anodal tDCS. When LeFT was combined with left IFG stimulation, words produced in a letter fluency task were lower frequency and higher age of acquisition after treatment, compared to before treatment and there was also an increase in accuracy and response times in an untrained picture-naming task. Conclusions: The results indicate that letter fluency therapy combined anodal tDCS is effective in improving lexical retrieval, particularly when left IFG stimulation was used. Effects generalize beyond the trained task, albeit slowing down of responses in picture naming. This task may provide a useful clinical intervention strategy for patients with mild anomia, who are not challenged enough by traditional naming therapies.

Use of ketofol for procedural sedation and analgesia in children with hematological diseases.

BACKGROUND: The aim of this study was to evaluate the effectiveness and safety of intravenous ketamine-propofol admixture ("ketofol") in the same syringe for procedural sedation and analgesia in children undergoing bone marrow aspiration. METHODS: This was a prospective, observational pilot study. Patients aged between 4 and 12 years requiring sedation for bone marrow aspiration were included. Ketofol (1:1 mixture of ketamine 10 mg/mL and propofol 10 mg/mL) was given intravenously in 0.5 mg/kg aliquots each with a 1-min interval and titrated to reach sedation levels of 3 or 4 (Ramsay score). The primary outcome was patient satisfaction with the degree of sedation. Secondary outcomes included injection pain, total sedation time, recovery time, hemodynamic and respiratory parameters, and adverse events. RESULTS: A total of 20 patients were enrolled in the study. The median total dose of ketofol administered was 1.25 mg/kg each of propofol and ketamine (95%CI 0.77-2 mg/kg). The median score on the visual analog scale was 0 (extremely comfortable) (0-1.5; 95%CI 0.2-2.2). Median recovery time was 23 min (20.5-28 min; 95%CI 17.1-51.2). The incidence of injection pain was 2/20. Two patients had transient diplopia and one child reported dreams. No patients had hypotension, vomiting or required airway intervention. CONCLUSION: Ketofol provided effective sedation, which was reflected in the high degree of satisfaction recorded by children requiring procedural sedation and analgesia for bone marrow aspiration. We also observed rapid recovery and no clinically significant complications. A large number of patients is required to evaluate and validate these findings.

Impact of sustained neuromuscular blockade on outcome of mechanically ventilated children.

BACKGROUND: Neuromuscular blocking agents (NMBA) are commonly administered to critically ill children in pediatric intensive care units (PICU) in the USA and Europe. Although NMBA are frequently used in PICU patients, their role in the PICU setting has not yet been clearly defined. The aim of this study was to describe the sustained administration of NMBA and its impact on outcome of PICU patients. METHODS: A 3-year retrospective cohort study was conducted to compare mechanically-ventilated patients who received NMBA for at least 12 h with patients who did not (control group). RESULTS: A total of 317 consecutive patients were ventilated over 3473 days. Patients were similar in age, weight and severity scores. Thirty-four children (10.7%) received NMBA. Compared with controls, the neuromuscular blockade (NMB) group had a longer duration of mechanical ventilation (13.7 vs 5.5 days, P= 0.000), longer PICU stay (20 vs 11 days, P= 0.000) and increased occurrence of ventilator-associated pneumonia (6.6 vs 4.1/1000 ventilator days, P= 0.010). The NMB use was not associated with higher mortality (8.8% vs 17.6%, P= 0.287) or longer hospital stay (30.5 vs 23 days, P= 0.117). CONCLUSION: Although the use of NMBA was not associated with greater mortality, we found that sustained use of NMBA is associated with prolonged mechanical ventilation, longer PICU stay and higher incidence of ventilator-associated pneumonia when compared with controls. Larger studies are necessary to confirm these findings.