Inappropriate Shocks and Power Delivery Using Adult Automatic External Defibrillator Pads in a Pediatric Patient.

ABSTRACT: The use of automatic external defibrillators (AEDs) during pulseless resuscitations is considered safe and reliable, and was established as part of the guidelines in out-of-hospital events. Based on extensive studies, the use of the standard AED is now indicated in every age group with a preference of pediatric pad application for small children and babies. If unavailable, adult pads are recommended. We report a case of 2 inappropriate AED shocks that were delivered to a neonate during a pulseless resuscitation after application of adult pads. The 3.6-kg patient received 2 shocks, over 200 J each, for sinus bradycardia that was not detected by the device. Although treated inappropriately with high voltage, no cardiac or skin sequelae were detected, and the patient had normal cardiac and neurological development later on.

Treatment Outcomes of Stenotrophomonas maltophilia Bacteremia in Critically Ill Children: A Multicenter Experience.

OBJECTIVES: Stenotrophomonas maltophilia is a gram-negative opportunistic bacterium that may cause a myriad of clinical diseases in immunocompromised individuals. We aimed to describe the clinical characteristics, risk factors, mortality, and treatment of S. maltophilia bacteremia in critically ill children, a topic on which data are sparse. DESIGN: A multicenter observational retrospective study in which medical charts of critically ill children with S. maltophilia bacteremia were reviewed between 2012 and 2017. SETTING: Data were collected from each of the four largest PICUs nationwide, allocated in tertiary medical centers to which children with complex conditions are referred regularly. PATIENTS: A total of 68 suitable cases of S. maltophilia bacteremia were retrieved and reviewed. MEASUREMENTS AND MAIN RESULTS: The total occurrence rate of S. maltophilia isolation had increased significantly during the study period (r = 0.65; p = 0.02). The crude mortality was 42%, and the attributed mortality was 18%. Significant risk factors for mortality were a longer length of hospital stay prior to infection (33 d in nonsurvivors vs 28 in survivors; p = 0.03), a nosocomial source of infection (p = 0.02), presentation with septic shock (p < 0.001), and treatment with chemotherapy (p = 0.007) or carbapenem antibiotics (p = 0.05) prior to culture retrieval. On multivariate analysis, septic shock (odds ratio, 14.6; 95% CI, 1.45-147.05; p = 0.023) and being treated with chemotherapy prior to infection (odds ratio, 5.2; 95% CI, 1.59-17.19; p = 0.006)] were associated with mortality. The combination of ciprofloxacin, trimethoprim-sulfamethoxazole, and minocycline resulted in the longest survival time (p < 0.01). CONCLUSIONS: The significant attributed mortality associated with S. maltophilia bacteremia in critically ill children calls for an aggressive therapeutic approach. The findings of this investigation favor a combination of trimethoprim-sulfamethoxazole, ciprofloxacin, and minocycline.

Spinal Epidural Hematoma Following Cupping Glass Treatment in an Infant With Hemophilia A.

A 6 months old infant, diagnosed with a rare mutation causing severe hemophilia A, presented with spinal epidural hematoma. Parents later admitted the infant had glass cupping therapy performed within 2 weeks of the onset of symptoms. The rare mutation, rare bleeding complication, and the eventual course of therapy applied in this case will be discussed in our case report.

Skin Necrosis and Purpura Fulminans in Children With and Without Thrombophilia--A Tertiary Center's Experience.

Purpura fulminans (PF) is a very rare clinicopathologic skin disorder comprising dermal microvascular thrombosis associated with perivascular hemorrhage of multiple origins. It may occur as the presenting symptom of severe congenital deficiency of protein C (PC) or protein S (PS) during the newborn period, or later in life following oral anticoagulant therapy with vitamin K antagonists, or of sepsis that may be associated with disseminated intravascular coagulation. Treatment consists of anticoagulants and PC concentrates during acute episodes. We report our experience in the diagnosis and management of pediatric PF. The medical records of the 6 children aged 2-16 years (median: 5 years) who presented with PF to our tertiary care center between 1996 and 2013 were studied. The thrombophilia workup revealed either the presence of congenital homozygous PC deficiency, prothrombotic polymorphisms (factor V Leiden and FIIG20210A heterozygosity), acquired PC/PS deficiency, or no discernible thrombophilia. The skin necrosis resolved following conservative fresh-frozen plasma/anticoagulant therapy in 2 cases, whereas 3 children required interventional plastic surgery. The sixth case, a 10-year-old child with severe PC deficiency, heterozygous factor V Leiden, and FIIG20210A, received recombinant activated PC. PF in childhood is rare and has multiple etiologies. Understanding of the variable pathogenesis and risk factors will facilitate diagnosis and appropriate clinical management.

[Severe and uncommon complications of anticholinesterase intoxication in children].

BACKGROUND: The Northern region of the Negev desert is an endemic area of organophosphate and carbamate intoxications in Bedouin children. Most victims are intoxicated by drinking the poisonous material kept by the parents in soft drink bottles. Signs and symptoms of intoxication are commonly known and generally include various effects on the central nervous system, usually a decreased level of consciousness in children, cholinergic muscarinic (sweating, rhinorrhea, miosis, vomiting) and nicotinic (weakness) effects. Specific therapy includes Atropine Sulphate and Oximes. PURPOSE AND RESULTS: To describe the course of disease of four (out of 47) children admitted to the Division of Pediatrics with organophosphate or carbamate poisoning during a two-year period. The four children 3-17 years of age ingested the poisonous material: organophosphate chlorpyrifos (2 children); carbamate methomyl (one child) and an unidentified compound in another child. Three of the four patients ingested the poison in a suicide attempt. All 4 children suffered from severe and uncommon complications, including severe respiratory failure from different etiologies. In addition, two of the four suffered from a neurological deficit causing prolonged disability. Three had renal failure necessitating hemofiltration in one case. One child had severe hemodynamic failure and arrhythmias necessitating, among other therapy, the insertion of a temporary pace maker. Two children had (laboratory) pancreatitis. One of the children with severe respiratory failure died after 38 days of extracorporeal membrane oxygenation. CONCLUSIONS: Intoxications by anticholinesterase compounds are not uncommon among Bedouin children in the Negev. This public health threat should be prevented and completely eradicated by the health authorities. Severe intoxication, especially in cases arising after suicide attempts, wherein the amount of the poisonous material is large, may be complicated by life threatening, multi-organ failure during and after the initial phase of poisoning and may progress into prolonged disability and death.

Thrombocytopenia and Bloodstream Infection: Incidence and Implication on Length of Stay in the Pediatric Intensive Care Unit.

The incidence and prognosis of thrombocytopenia in critically ill patients with bloodstream infection (BSI) is not well delineated in the pediatric intensive care unit (PICU) setting. We assessed these variables in our PICU and sought to determine whether thrombocytopenia could serve as a prognostic marker for length of stay (LOS). The study was conducted at the medical PICU of a university hospital, on all critically ill pediatric patients consecutively admitted during a 3-year period. Patient surveillance and data collection have been used to identify the risk factors during the study period. The main outcomes were BSI incidence and implication on morbidity and LOS. Data from 2,349 PICU patients was analyzed. The overall incidence of BSI was 3.9% (93/2,349). Overall, 85 of 93 patients (91.4%) with BSI survived and 8 patients died (8.6% mortality rate). The overall incidence of thrombocytopenia among these 93 patients was 54.8% (51/93) and 100% (8/8) for the nonsurvivors. Out of the 85 survivors, 27 thrombocytopenic patients were hospitalized for >14 days versus 14 of nonthrombocytopenic patients ( p = 0.007). Thrombocytopenia was associated with borderline significance with an increased LOS (adjusted odds ratio = 3.00, 95% confidence interval: 0.93-9.71, p = 0.066). Thrombocytopenia is common in critically ill pediatric patients with BSI and constitutes a simple and readily available risk marker for PICU LOS.

Management of Stenotrophomonas maltophilia Infections in Critically Ill Children.

BACKGROUND: Stenotrophomonas maltophilia is a life-threatening nosocomial pathogen with profound multidrug-resistant attributes. It is associated with high mortality, particularly in immunocompromised patients. Data on therapy for S. maltophilia infections are scarce, especially in children hospitalized in intensive care settings (pediatric intensive care unit). METHODS: A retrospective chart review of pediatric patients with isolates of S. maltophilia hospitalized over a 5-year period in 2 pediatric intensive care units. RESULTS: Thirty-one patients and 91 isolates from blood, respiratory secretions and soft tissues were identified and reviewed. The overall incidence of S. maltophilia infections increased during the study period (P = 0.003). The all-cause crude mortality was 61%, and the attributed mortality was approximately 16%. Risk factors associated with mortality included longer hospitalization before infection (P = 0.002), septic shock (P = 0.003), mechanical ventilation (P = 0.004), an indwelling central vein catheter (P = 0.03) and prior use of steroids (P = 0.04) and carbapenems (P = 0.004). On multivariate analysis, mortality was associated with mechanical ventilation (P = 0.02) and preinfection hospitalization days (P = 0.01). Combination treatment of trimethoprim and sulfamethoxazole, ciprofloxacin and/or minocycline significantly extended survival time (P < 0.001). The method of treatment did not significantly affect the interval between S. maltophilia isolation to resolution of infection (P = 0.200). CONCLUSIONS: Combinations of trimethoprim and sulfamethoxazole, ciprofloxacin and minocycline are proposed for pediatric intensive care unit patients harboring S. maltophilia. Meticulous evaluation of central vascular access and prior treatment with carbapenems are indicated, especially for mechanically ventilated and septic children.

Lactic Acidosis as Presenting Symptom of Thiamine Deficiency in Children with Hematologic Malignancy.

Thiamine is an essential component of cellular metabolism and its deficiency results in potentially life-threatening events and profound lactic acidosis through anaerobic metabolism. Acute decompensation in thiamine-deficient patients may manifest as neurologic or cardiovascular changes, with severe lactic acidosis as the presenting symptom. We describe two hematological pediatric patients with thiamine deficiency and hemodynamic instability who improved following thiamine supplements. Thiamine levels were inversely proportional to lactic acidosis; specifically, lower thiamine levels were related to higher lactate levels. We recommend that children with hematological malignancies admitted to a pediatric intensive care unit with low blood pressure and lactic acidosis should be considered for thiamine-level screening and receive supplementation accordingly.

A forgotten alternative: Bromides for refractory status epilepticus.

We present the cases of a 1-month-old infant diagnosed as having malignant migrating partial epilepsy of infancy and a 2-month-old infant with Ohtahara syndrome, who both presented with severe refractory status epilepticus and were treated with potassium bromide when all other antiepileptic drugs failed. Appropriate augmentation of the dosage of potassium bromide led to reduction in the frequency and duration of seizures in both patients. There was a notable reduction in the occurrence of epileptic seizures in both cases, with no apparent side effects. Potassium bromide was of significant benefit for seizure reduction in two infants with intractable seizures. It could be used safely and within a short period. Potassium bromide should be considered as a relatively safe therapeutic option for infants and children with severe intractable seizures when other antiepileptic drugs fail to control the seizures.

Common perinatal insults diminish cord blood RANTES.

We demonstrate that the cord blood RANTES concentrations are reduced in full-term newborns who were born from meconium-stained amniotic fluid as compared with full-term newborns born after normal delivery. Since RANTES inhibits immunodeficiency virus (HIV) entry into macrophages, thereby bestowing increased resistance to HIV (including protection in utero), we propose that common perinatal events might precipitate higher perinatal transmission of HIV.