The "3R Team" in action! Implementation of a program of learning from excellence in a neonatal and pediatric intensive care unit in France.

BACKGROUND: The pursuit of improving quality of care and of patient safety is a crucial objective in intensive care units (ICUs). Classically, safety is characterized by analyzing adverse events. Neonatal and pediatric ICUs (NICUs/PICU) are highly technological units, with evidence of risk for elevated levels of emotional exhaustion and thus a significant level of staff turnover. We hypothesized that appreciative inquiry (AI), currently used in many organizations, could be introduced in our ICU. In the PICU and NICU, this new concept is termed "learning from excellence" (LFE). OBJECTIVE: To assess the impact of the implementation of an LFE program on well-being and on an educational program in the NICU/PICU of a tertiary care center in France. METHODS: We created a workgroup composed of caregivers called the "3R team" for "right resuscitations reviews," based on the concept of AI. Before and 1 year after implementation, we administered two validated surveys-the Maslach Burnout Inventory and the Siegrist survey-to the entire staff of the 22-bed unit. RESULTS: The questionnaire on satisfaction revealed a high percentage (93%) of satisfaction with the work of the 3R team and that scores of well-being and burnout were improved. The educational program was highly enhanced, especially simulation. Benevolence and happiness were increased. CONCLUSION: Implementation of an LFE program in a NICU and PICU is feasible, and tends to increase the well-being and self-confidence of all categories of caregivers. It promotes educational programs of dynamic learning, including simulation. The next important step will be to study the impact on staff turnover and on quality of care.

[Alveolar capillary dysplasia and persistent pulmonary hypertension of the newborn]. / La dysplasie alvéolo-capillaire: une cause exceptionnelle d'hypertension artérielle pulmonaire persistante du nouveau né. A propos d'un cas.

Alveolar capillary dysplasia is a rare cause of persistent pulmonary hypertension of the newborn. The diagnosis of this condition is made by histological study of a pulmonary biopsy. Familial forms and associated genitor-urinary and gastrointestinal malformations have been reported. Despite optimal management, the prognosis remains poor. The authors report the case of a neonate who developed cyanosis and cardiogenic shock on the 10th day of life. There was no associated neonatal pathology. Echocardiography showed supra-systemic pulmonary hypertension with normal cardiac structure. Pulmonary vasodilator therapies (inhaled NO, prostacyclin, sildenafil, bosentan) were ineffective and the child died on the 25th day of life. Autopsy revealed alveolar capillary dysplasia.

How to assess hemodynamic status in very preterm newborns in the first week of life?

BACKGROUND: Assessing hemodynamic status in preterm newborns is an essential task, as many studies have shown increased morbidity when hemodynamic parameters are abnormal. Although oscillometric monitoring of arterial blood pressure (BP) is widely used due to its simplicity and lack of side effects, these values are not always correlated with microcirculation and oxygen delivery. OBJECTIVES: This review focuses on different tools for the assessment of hemodynamic status in preterm newborns. These include the measurement of clinical (BP, capillary refill time and urinary output (UO)) or biological parameters (lactate analysis), functional echocardiography, and near-infrared spectroscopy (NIRS). We describe the concepts and techniques involved in these tools in detail, and examine the interest and limitations of each type of assessment. CONCLUSIONS: This review highlights the complementarities between the different parameters used to assess hemodynamic status in preterm newborns during the first week of life. The analysis of arterial BP measured by oscillometric monitoring must take into account other clinical data, in particular capillary refill time and UO, and biological data such as lactate levels. Echocardiography improves noninvasive hemodynamic management in newborns but requires specific training. In contrast, NIRS may be useful in monitoring the clinical course of infants at risk of, or presenting with, hypotension. It holds the potential for early and noninvasive identification of silent hypoperfusion in critically ill preterm infants. However, more data are needed to confirm the usefulness of this promising tool in significantly changing the outcome of these infants.

[B-natriuretic peptide and cardiological emergencies in childhood]. / Peptide natriurétique de type B et urgences cardiologiques chez l'enfant.

The increase in B-natiuretic peptide (BNP) is well correlated with cardiovascular symptoms in adults. Its use in children is recent and only partially evaluated. The authors undertook a prospective study of BNP concentrations and its kinetics in 54 children with an average age of 15 months (5 days to 11 years) admitted as paediatric emergencies. The symptoms were dyspnoea (60%), shock (15%), suspicion of Kawasaki disease (15%) and other (10%). Twenty children had BNP levels of more than 100 pg/ml related to decompensation of known congenital heart disease in 7 patients (average BNP 462 +/- 323 pg/ml), due to neonatal coarctation in 2 patients (BNP > 3000 pg/ml), due to cardiomyopathy in 6 patients (BNP= 2576 +/- 1215 pg/ml), due to an arrhythmia in 1 patient (BNP= 3754 pg/ml) and to Kawasaki disease in 4 patients (BNP= 521 +/- 448 pg/ml). Thirty-four children had BNP values of less than 100 pg/ml; 29 had no cardiac disease and 5 had known congenital heart disease with other symptoms. Measuring BNP is quick and economical and is a valuable aid in the diagnosis of cardiac dysfunction in symptomatic children in the emergency room. High BNP values seem to be correlated with the severity of the cardiac disease. Low BNP values seem to have a good negative predictive value in children without underlying cardiac disease. The interpretation of intermediary values, especially when there is previous cardiac disease, is more difficult in view of the absence of known threshold values for different haemodynamic situations. Further studies are required to determine the value of this test for the follow-up and setting up of prognostic values in children with congenital heart disease.

[Antenatal closure of ductus arteriosus following maternal intoxication by niflumic acid]. / Fermeture anténatale du canal artériel chez un foetus suite à une intoxication maternelle par acide niflumique.

Antenatal closure of the ductus arteriosus is an uncommon event that has been considered as a risk factor for development of congestive heart failure and persistent pulmonary hypertension of the newborn. We report here on a case of antenatal ductus arteriosus closure due to niflumic acid maternal intoxication at 32 weeks of gestation. Fetal extraction was performed few days later because of echographic signs of congestive heart failure. The child survived after 3 days of severe persistent pulmonary hypertension. This case emphasizes the potential risk of niflumic acid during pregnancy and the need of antenatal echographic monitoring for optimal management.

[Fulminant myocarditis presenting like acute myocardial infarction in a 6-year-old girl]. / Myocardite aiguë fulminante mimant un infarctus du myocarde chez une enfant de 6 ans.

Acute myocarditis is a rare inflammatory cardiac disease in children with potentially fatal issue. Clinical findings are very variable from nausea and vomiting to acute cardiovascular collapse. The cardiac function can be reversible with circulatory support. We report the case of a 6-year-old girl with ECG changes like myocardial infarction and diagnosis of fulminant myocarditis. She developped rapidly a cardiogenic shock and died before treatment with mechanical circulatory support.

[Severe chloralose intoxication in a toddler]. / Intoxication sévère par le chloralose chez un nourrisson.

UNLABELLED: We report a case of an accidental intoxication in a 20-month-old boy resulting from the ingestion of a rodenticide containing alpha-chloralose. CASE REPORT: Three hours after initial admission to the pediatric emergency department for wheezing bronchitis, this patient was readmitted with a clinical presentation of respiratory insufficiency, a Glasgow coma score of 9 alternating with agitation, areflexia and unilateral mydriasis. Parental interview revealed he had episodes of shaking in the afternoon. Chest x-ray showed thoracic distension. Blood investigations, electrocardiogram, cardiac echography, brain CT scan and CSF were normal. Electroencephalography registered slow delta waves 2-3 cycles/min and an aspect of degraded waves and spikes. The patient was transferred to the intensive care unit where he fully recovered within 48 hours. A second parental interview and clinical presentation confirmed an intoxication with a rodenticide containing alpha-chloralose. The late clinical orientation did not allow us to perform a urinanalysis. DISCUSSION: Clinical association of coma, spontaneous or triggered myoclonias and bronchial hypersecretion are indicative of chloralose intoxication. Presence of specific abnormalities on electroencephalogram and a positive Fujiwara-Ross reaction in an urine sample are additional elements for the diagnosis. The prognosis is usually good after early management which combines gastric lavage, activated charcoal, sedation with benzodiazepines, tracheal intubation and artificial ventilation if required. Severe clinical cases described in voluntary intoxications in adults and teenagers occur very rarely in toddlers.

[Very large cardiac tumor revealed by ventricular arrhythmia in a 18-month-old infant]. / Volumineuse tumeur cardiaque révélée par un trouble du rythme ventriculaire chez un nourrisson de 18 mois.

Cardiac tumors are rare in childhood and can be revealed by arrhythmias. We report the observation of an 18-month-old infant who had an episode of ventricular tachycardia (VT) which resulted in a large intramyocardic tumour diagnosis evocating a left ventricular fibroma. A treatment by amiodarone allowed a stable reduction of the VT. The presence of an intracardiac obstruction or uncontrollable arrhythmias would lead to a surgical resection.

[Cor triatriatum sinister: unusual cause of neonatal respiratory distress]. / Coeur triatrial gauche: une cause inhabituelle de détresse respiratoire néonatale.

We report the case of a newborn presenting with neonatal respiratory distress due to acute pulmonary edema, the underlying diagnosis being cor triatriatum sinister. This rare anomaly can be lethal in the short term. However, it can be completely cured surgically provided that diagnosis is made on time.

[Necrotizing pneumonia and arthritis due to Staphylococcus aureus producing Panton and Valentine leukocidin in a 10-year-old boy]. / Pneumonie nécrosante et ostéoarthrite multifocale à Staphylococcus aureus producteur de la leucocidine de Panton et Valentine chez un garçon de 10 ans.

Staphylococcal necrotizing pneumonia producing the Panton Valentine leukotoxin (PVL) has been described for many years. The french reference center for staphylococcal toxaemia defined it with precision in 1999. A 10-year-old child, died in 36 hours from respiratory distress and shock. Staphylococcal pneumonia was suspected then confirmed: S. Aureus producing PVL was isolated in lung, blood and articulations.

[Lethal aortic dissection in a 13-year-old boy with a vascular Ehlers-Danlos syndrome]. / Dissection aortique fatale chez un garçon de 13 ans atteint d'un syndrome d'Ehlers-Danlos vasculaire.

UNLABELLED: Vascular Ehlers-Danlos syndrome(EDS) is at high risk of death by arterial rupture. CASE REPORT: A 13-year-old boy with vascular EDS and aortic dissection was admitted in pediatric emergency care unit. The children died after surgery by massive hemorrhage and prosthetic rupture. DISCUSSION: The precocity of this vascular accident EDS is uncommon. It occurred despite clinical and echocardiographic follow-up. The death of the children confirmed the difficulties in surgery of vascular manifestation, even if appropriate and rapid management was already done. CONCLUSION: Patients with vascular EDS must be identified because of its lethal complications. Friability of the vessels makes surgical treatment difficult. A trial using beta blockers therapy is ongoing.

[Congenital galactosaemia: an unusual presentation]. / La galactosémie congénitale: une révélation singulière.

Congenital galactosaemia reveals usually in the second and third weeks of life with a severe liver dysfunction. We report on a case of congenital galactosaemia with, on the one hand, an early onset liver failure, without any free interval, and on the other hand, an hemophagocytic syndrome as a severe secondary outbreak with pulmonary haemorrhage. Appropriate diet led to normalisation of liver function. Hemophagocytosis, probably linked to an associated Klebsiella Pneumoniae sepsis, had a favourable outcome after antibiotic and corticosteroid therapy.

[Prenatal diagnosis of a right thoracic congenital ectopic kidney with a diaphragmatic hernia: a combination with a good prognosis]. / Diagnostic anténatal d'un rein droit thoracique et d'une hernie de coupole diaphragmatique droite: une association de bon pronostic.

Ectopic intrathoracic kidney is a rare congenital anomaly, usually asymptomatic. This anomaly is sometimes associated with a diaphragmatic hernia. Few cases of this combination have been described, often in the absence of a prenatal diagnosis. We report on the case of a female newborn infant who was diagnosed with an ectopic intrathoracic right kidney and a diaphragmatic hernia upon 33 weeks of gestation. The patient underwent surgery on the first day of life and the respiratory and renal outcomes were simple. We review the literature and discuss the seemingly good prognosis of this combination.

Long-term effects on tibial growth after intraosseous infusion: a prospective, radiographic analysis.

BACKGROUND: Evaluate, by radiographic analysis, tibial growth after an intraosseous infusion (IOI) in a pediatric population. METHODS: We performed a prospective simple blind study, between January 1, 1994, and July 1, 2001, which included pediatric patients who needed an intraosseous trocar in emergency situations. During the follow-up, roentgenographs were performed. On each radiologic view, different measurements were carried out: anterior and lateral tibial length, anterior and lateral width at 2 diaphyseal levels. We compared the anterior length values to those published in the Anderson et al tables. When only one tibia was punctured, the mean measurements were compared with the control leg measurements using a paired t test. RESULTS: The initial population included 78 patients. Of these 78 subjects, 42 died, 10 families could not be contacted, and one refused to participate. Two children were excluded because they had other conditions that could influence tibial growth. The study included 23 children. The puncture site was the proximal tibia. The mean age was 18.6 months at the time of IOI, the mean time of infusion was 5 hours, and the mean perfused volume was 225 mL. The mean radiologic follow-up time was 29.2 months. When compared with the Anderson et al tables, all the anterior length values were within the 95% confidence interval. For the other measurements, the statistical analysis showed no significant difference between punctured and control legs. CONCLUSION: There is no long-term effect on tibial growth after an IOI when the IO trocar is properly placed.

[Neonatal cellulitis caused by group B Streptococcus]. / Cellulite néonatale à streptocoque du groupe B.

Dermohypodermitis (cellulitis) in newborn infants and in infants aged up to 3 months is uncommon and often not typical. Because group B Streptococcus is known to induce rapid life-threatening complications, early diagnosis leading to emergency treatment is of utmost importance. We report on the case of a 14-day-old girl, initially admitted for viral bronchiolitis with suspected bacterial pulmonary infection, in the absence of any cutaneous injury. The disease actually was cellulitis of the face, caused by group B Streptococcus. The baby presented with a severe septic clinical condition. Early treatment with antibiotics (intravenous amoxicillin for 10 days) allowed a favorable course, with rapid control of the sepsis and regression of the submandibular tumefaction.

[Severe hydrogen sulfide intoxication: a pediatric case of survival]. / Intoxication accidentelle grave à l'hydrogène sulfuré: un cas pédiatrique de survie.

We report a paediatric case of survival following severe hydrogen sulfide (H2S) gas intoxication. A 13-year-old boy was found submerged to the neck in a manure tank. He was hypothermic, unresponsive with bilateral mydriasis, and had poor oxygen saturation. After intubation, he was transferred to the paediatric intensive care unit of a tertiary care children's hospital. He developed acute respiratory distress syndrome (ARDS) requiring high frequency percussive ventilation. Cardiac evaluation was significant for myocardial infarction and left ventricular function impairment. He completely recovered from the respiratory and cardiac failure. Neurological examinations showed abnormal signals on MRI in the semi-oval center and in the frontal cortex. Follow-up detected partial impairment of axonal fibers of the right external popliteal sciatic nerve. Paediatric cases of survival after H2S intoxication have been rarely reported. Such exposures can evolve to severe ARDS and benefit from high frequency percussive ventilation. Hypothermia and other metabolic abnormalities are now better explained thanks to actual knowledge about endogenous H2S function. Lessons learned from paediatric accidents should result in better information about this threat for farmers and families living in houses with septic tanks, reducing the risk to their own and their children's safety.

[Circular shunting of blood: a complication of neonatal Ebstein anomaly]. / Le shunt circulaire: complication de la maladie d'Ebstein de forme néonatale.

We report a severe neonatal presentation of Ebstein anomaly with homodynamic aggravation at birth attributed to patent ductus arteriosus and circular shunt. Prenatal diagnosis of Ebstein anomaly of the tricuspid valve with functional pulmonary atresia was made at 37 weeks gestation by fetal two- and three-dimensional echocardiography. A cesarean section was performed in view of poor fetal tolerance. The newborn was born with hydrops and multivisceral failure. A post-natal echocardiography demonstrated a left-to-right shunt across the patent ductus arteriosus and functional pulmonary atresia with severe pulmonary insufficiency with absent forward flow. This created a circular shunt, where blood flowed through the ductus to the pulmonary arteries, retrograde through the pulmonary artery and Ebstein valve, across the patent foramen ovale and out the aorta. Prostaglandin E1 infusion was stopped, resulting in clinical and echocardiographic improvement. The management of the phenomenon of a circular shunt across a patent ductus arteriosus with Ebstein malformation involves promoting early ductal closure by stopping prostaglandin therapy.

[Evidence versus experience in neonatal practice: the example of extremely premature infants]. / Niveaux de preuves versus pratiques cliniques: l'exemple de l'extrême prématurité

We focused on current nutritional and ventilation strategies of extremely preterm infants and reviewed the evidence and the practical experience in four French neonatal intensive care units. The recommendations from reviews and the local clinical guidelines were compared and were overall in agreement. We wanted then to evaluate if different ventilatory and nutritional styles existed between four French intensive neonatal units, and if these approaches had an effect on short term outcomes. 399 infants delivered at a gestational age <28 weeks between January 2005 and December 2006 were retrospectively studied (unit I = 141, unit II = 97, unit III = 85, unit IV = 76). Data were collected from birth to discharge. The study groups were similar with regard to gestational age, birth weight, gender, prenatal steroids, rate of inborn. There were significant differences in ventilatory and nutritional strategies between the units. Incidence of NEC, IVH grade 3-4 and PVL were similar between the units. Mortality rate during the hospitalization stay was 14.9 %, 35.0 %, 29.4 % and 29 % (p<0.05). A national database would be useful to analyse differences in strategies and long term outcomes.