Pediatric infection and sepsis in five age subgroups: single-center registry.

BACKGROUND: Sepsis is, worldwide, one of the leading causes of death among infants and children. Over the past two decades, mortality rates have declined due to advanced treatment options; however, the incidence of sepsis and septic shock is still on the rise in many hospital settings. The objective of this study was to evaluate the course of this disease in pediatric intensive care patients. METHODS: An evaluation of pediatric patients in the intensive care unit diagnosed with infections or sepsis between 2005 and 2015 was performed via a retrospective exploratory data analysis. RESULTS: During the observational period, 201 patients were diagnosed with infection or sepsis. The study population was divided into five age subgroups. The majority of patients were newborns, infants, and toddlers. Forty percent had sepsis; 6% had septic shock. Viral infection was the most prevalent (59%). The overall survival rate was 83%; newborns and adolescents had the lowest survival rates. CONCLUSION: With this registry, children divided into five age subgroups with infection or sepsis were evaluated and treatment strategies were examined. We have shown that our findings on children treated in our pediatric intensive care unit conform with current literature about pediatric sepsis. In addition to maintaining strict hygiene standards, optimal aspects of sepsis care should be stringently observed, such as the quick administration of empirical broad-spectrum antibiotics, initial adequate fluid resuscitation, and a reliable and frequent routine of source control.

Chylothorax and Chylous-Like Diseases in Children: Clinical Management.

Background: Chylothorax and chylous-like diseases are rare conditions and difficult to treat. But they may represent potentially life-threatening disorders and important causes of morbidity and prolonged hospitalization, especially in critically ill children. Conservative as well as surgical therapeutic management strategies are continuously performed at our institution, however the results have never been evaluated and no guidelines for treatment recommendations have been put into practice so far. The objective of this retrospective study was to present a comprehensive and substantial evaluation of all relevant demographic data from children with the chylothorax and chylous-like diseases and their clinical management. Methods: We retrospectively analyzed data from all children with diagnoses of chylothorax and chylous-like diseases admitted to our pediatric intensive care unit between the years 1999 and 2012. Results: Data of 34 patients were analyzed for this study. Gender distribution (M/F) was almost equal (19/15; 56%/44%). Thirty-one children (91%) developed chylothorax after surgery. Two children (6%) had idiopathic chylothorax and in one child (3%) congenital chylothorax was diagnosed. All study patients (n = 34; 100%) received MBF/MCT therapy. We were quite successful in treating 14 children who received only this therapy, with chest tube output dropping from 100 to 4.7%. But only 11 (32%) children received somatostatin and 7 (20%) children received beta-isodona. Different surgical interventions were performed in 6 patients (17%). All study patients received chest tubes to drain the pleural fluid and hence to relieve the chyle related symptoms. Conclusion: A combination of different conservative therapies was successful in most of our patients. Prevention, early diagnosis and treatment of potential complications may further improve the success rate of conservative therapy especially in patients with postoperative chylothorax. In summary, appropriate therapy of this condition may be lengthy but can prevent significant morbidity and mortality.

Gas concentrations in expired air during basic life support using different ratios of compression to ventilation.

AIM: In cardiopulmonary resuscitation, different ratios of compression to ventilation with regard to optimal oxygen transport are considered. We hypothesised that the end tidal fraction of oxygen might increase from levels found in the conventional compression-ventilation ratio of 15:2 if more consecutive ventilations are given because the rescuer would hyperventilate. The second hypothesis was that the air blown into an infant with mouth to mouth ventilation consists of rescuer's dead space air only, meaning that the fraction of oxygen should increase. METHODS: In a basic life support simulation, we measured the expired air of rescuers using a VmaxST (Sensormedics, USA) respiratory gas analyser connected to an adult and to an infant resuscitation manikin. Fourteen participants performed five different compression-ventilation ratios (30:2, 30:5, 50:5, 100:10 and 5:1). These were compared to a ratio of 15:2 (control group). RESULTS: We found a significant increase in end tidal oxygen in 30:2 (16.3%), 30:5 (16.8%), 50:5 (16.8%), 100:10 (17.0%) compared to 15:2 (15.9%), p< or =0.004 for all groups versus control; p for trend: 0.014. In the infant CPR observation (ratio 5:1), the difference with the adult control group (15:2) also reached statistical significance (17.9% versus 15.9%, p=0.0005). CONCLUSION: Increasing consecutive compressions and ventilations above 15:2 leads to a statistically significant increase in expired fraction of oxygen. In infant ventilation, the air exhaled into a victim contains some dead space air with a higher end tidal oxygen fraction than in adults.

Bridging to transplantation in acute liver failure in a 7-month-old infant.

BACKGROUND: Acute liver failure (ALF) in children is a rare but often fatal event. At present, liver transplantation is the only successful therapy in most cases. In the face of deteriorating hepatic encephalopathy in these children, some bridging therapy using artificial detoxification can be necessary to enable successful transplantation. In adults, albumin dialysis using the molecular absorbent recycling system (MARS) has been described as effective for bridging to liver transplantation. CASE REPORT: A previously healthy 7-month-old infant was admitted with ALF due to autoimmune hepatitis. King's College criteria for children with ALF indicated the need for transplantation (bilirubin 13.7 mg/dl, leukocytes 18,980/mm3, INR 5.83, age<2 years). Despite moderate hyperammonemia (75 microm/l) along with the development of pneumonia, the child deteriorated hemodynamically and neurologically, showing grade III encephalopathy proven by EEG. Albumin dialysis using MARS was used to bridge 36 hours to successful living-donor split-liver transplantation, and resulted in improvements in EEG, plasma levels of amino acids and hemodynamics. Twenty-four months after transplantation the child shows normal liver function and normal neuropsychological development. The explanted liver showed 80 % tissue destruction from autoimmune hepatitis. CONCLUSION: Albumin dialysis as described can be used successfully in infants < 1 year old for bridging to liver transplantation in cases of acute hepatic failure with deteriorating encephalopathy.

Surfactant application during extracorporeal membrane oxygenation improves lung volume and pulmonary mechanics in children with respiratory failure.

INTRODUCTION: This study was performed to determine whether surfactant application during extracorporeal membrane oxygenation (ECMO) improves lung volume, pulmonary mechanics, and chest radiographic findings in children with respiratory failure or after cardiac surgery. METHODS: This was a retrospective chart review study in a pediatric intensive care unit (PICU). Seven patients received surfactant before weaning from ECMO was started (group S). They were compared to six patients treated with ECMO who did not receive surfactant (group C). These control patients were matched based on age, weight, and underlying diagnosis. Demographic data, ventilator settings, tidal volume, compliance of respiratory system (calculated from tidal volume/(peak inspiratory pressure - positive end-expiratory pressure), and ECMO flow were extracted. Chest radiographs were scored by two blinded and independent radiologists. Changes over time were compared between groups by repeated-measures analysis of variance (time*group interaction). Values are given as percentages of baseline values. RESULTS: The groups did not differ with regard to demographic data, duration of ECMO, ventilator settings, PICU and hospital days. After application of surfactant, mean tidal volume almost doubled in group S (from 100% before to 186.2%; p = 0.0053). No change was found in group C (100% versus 98.7%). Mean compliance increased significantly (p = 0.0067) in group S (from 100% to 176.1%) compared to group C (100% versus 97.6%). Radiographic scores tended to decrease in group S within 48 h following surfactant application. ECMO flow tended to decrease in group S within 10 h following surfactant application but not in group C. Mortality was not affected by treatment. CONCLUSION: Surfactant application may be of benefit in children with respiratory failure treated with ECMO, but these findings need confirmation from prospective studies.

Should dermal scald burns in children be covered with autologous skin grafts or with allogeneic cultivated keratinocytes?--"The Viennese concept".

The treatment of scald burns in children is still under discussion. The aim of the present study was to evaluate an optimised treatment regime for scald burns in children. Between 1997 and 2002, 124 children underwent surgical intervention due to burn injuries. Thirty-six out of these 124 children were enrolled into the evaluation of our recent treatment protocol. Twenty-two children with scald burns covering an average body surface area (TBSA) of 18.5% were treated by early excision and coverage with allogeneic keratinocytes in case of partial thickness lesions (keratinocyte group). Fourteen children with a TBSA of 17.2% were treated with autologous skin grafts alone (skin graft group). Both groups were comparable according to age, burn depth and affected TBSA. The complete clinical follow-up examination of at least 17 months was performed in 12 out of 22 children of the keratinocyte group and in 9 out of 14 patients of the comparative group. Visible scar formations were classified according to the Vancouver Scar Scale (VSS) in each patient. The use of allogeneic keratinocytes led to complete epithelialisation within 12 days in 20 of the 22 cases. No secondary skin grafting procedures had to be done. Skin take rate at the sixth postoperative day was 100% in the skin graft group. Blood transfusions were administered intraoperatively according to the clinical need of the patients by the responsible anaesthesiologist. The mean volume of blood, which had to be transfused was 63.9 ml in the keratinocyte group and significantly lower than the volume of 151.4 ml, which was administered in the skin graft group (p=0.04). At follow up the VSS observed in areas covered by keratinocytes was 2.33 on the average and therefore, significantly lower than the VSS of 5.22 in skin grafted areas of the comparative group (p=0.04). In children the use of cultivated keratinocytes in partial thickness scald burns is a procedure, which renders constantly reliable results. It minimizes the areas of autologous skin harvesting and reduces the amount of blood transfusions. The fact that less scarring is observed after keratinocyte grafting leads to the conclusion that skin grafting in children should be restricted to scalded areas, which have to be excised to the subcutaneous fat tissue.

Surfactant therapy in infants and children: three years experience in a pediatric intensive care unit.

Despite the established success of surfactant application in neonates, the use of surfactant in older children is still a matter of discussion. We hypothesized that surfactant application in children with acute respiratory distress syndrome (ARDS) secondary to a pulmonary or systemic disease or after cardiac surgery improves pulmonary function. We also asked whether repeated treatment could further improve pulmonary function. To answer these questions, we measured oxygenation index (OI) and hypoxemia score after the first and after a second application of surfactant (50-100 mg/kg body wt) at least 24 h later. We enrolled 19 children (older than 4 weeks) for a retrospective chart review study, and six of them underwent cardiac surgery. Demographic data were extracted. OI and hypoxemia score were estimated before and 2 and 24 h after surfactant application. Lung injury score was calculated before and 24 h after surfactant application. Outcome measures included survival, duration of mechanical ventilation, and pediatric ICU and hospital stay. The median patient age was 9.0 (quarter percentile 3.7/25) months. The median weight was 8.4 (4.1/11.5) kg. The median lung injury score before the first surfactant application was 2.3 (2.3/2.6). Hospital duration and pediatric ICU stay for all patients was 31.0 (20.0/49.5) days and 27.0 (15.5/32.5) days, respectively. The duration of mechanical ventilation was 24.0 (18.5/31.0) days. The overall mortality was 53%. Twenty-four hours after the first surfactant application, pulmonary function significantly improved. The median OI was 14 (5.5/26) before and 7 (4.5/14.5) 24 h after surfactant application (P= 0.027). The hypoxemia score was 91.7 (69.9/154.2) before and 148.4 (99.2/167.6) 24 h after surfactant application (P = 0.0026). Seven children received a second application, which did not further improve pulmonary function. The lung injury score was not influenced by either surfactant application. We conclude that a single surfactant application improves pulmonary function in children with ARDS. A second application of surfactant showed no further benefit. Outcome was not affected in our study population.

Methemoglobin formation in children with congenital heart disease treated with inhaled nitric oxide after cardiac surgery.

OBJECTIVE: Inhaled nitric oxide (NO) is used as a therapy of pulmonary hypertension in children after cardiac surgery. Hemoglobin binds to NO with great affinity and forms methemoglobin by oxidation in the erythrocyte. Once produced, methemoglobin is unable to transport and unload oxygen in the tissues. The amount of available hemoglobin in the body for oxygen transport is thereby reduced. Anemia, acidosis, respiratory compromise and cardiac disease may render patients more susceptible than expected for a given methemoglobin level. The goal of the present study was to review the cumulative effect of inhaled NO on methemoglobin formation in critically ill children. We therefore looked for methemoglobin levels in children with congenital heart disease after cardiac surgery who were treated with inhaled NO in a range of 5-40 ppm. METHODS: We retrospectively reviewed the medical charts of 38 children with congenital heart disease after cardiac surgery. We extracted demographic data and physiological measurements at the following time points: (1) T0 = before starting inhaled NO therapy, (2) T1 = 24 h after the beginning of inhaled NO therapy, (3) T2 = half-time therapy, (4) T3 = end of therapy, (5) T4 = 24 h after finishing inhaled NO therapy. RESULTS: The median duration of inhaled NO therapy was 5.5 days (interquartile range 6, range 2-29), NO concentrations at T1 and T2 were 16 ppm (10, 5-40) and 12.5 ppm (12.3, 2-40), respectively. The median cumulative dose of inhaled NO was 1699 ppm (2313, 193-7018). Methemoglobin levels increased moderately, but significantly, during therapy ( T0 vs T1 p<0.05 and T0 vs T2 p<0.001). The highest methemoglobin level measured was 3.9%. Methemoglobin levels correlated positively with the inhaled NO doses applied at T1 ( r(2)=0.8376; p<0.01) and at T2 ( r(2)=0.8945; p<0.01). At T1 the methemoglobin level correlated negatively with the T1 blood pH value. The overall mortality rate was 13.2% (5 of 38 study patients died). There was no significant difference in methemoglobin levels between survivors and non-survivors. CONCLUSION: We conclude from our data that the use of inhaled NO therapy for children with congenital heart disease after cardiac surgery in the described range of 5-40 ppm, resulting in a maximum of 4% methemoglobin blood level, is feasible and safe. However, we recommend the use of the minimal effective dose of inhaled NO and continuous monitoring of methemoglobin levels, especially in cases of anemia or sepsis in critically ill children.

Early postoperative prediction of cerebral damage after pediatric cardiac surgery.

BACKGROUND: Cerebral damage is a serious complication of pediatric cardiac surgery. Early prediction of actual risk can be useful in counseling of parents, and in early diagnosis and rehabilitation therapy. Also, if all children at risk could be identified therapeutic strategies to limit perioperative cerebral damage might be developed. The aim of this study is to create a mathematical model to predict risk of neurologic sequelae within 24 hours after surgery using simple and readily available clinical measurements. METHODS: The hospital records of 534 children after cardiac surgery were reviewed. Variables examined were age at operation, diagnosis, use of cardiopulmonary bypass, arterial and central venous oxygen saturation, serum glucose, lactate and creatine kinase, mean arterial pressure, and body temperature. The endpoint for each study patient was the occurrence or lack of occurrence of seizures, movement or developmental disorders, cerebral hemorrhage, infarction, hydrocephalus, or marked cerebral atrophy. Univariate and multivariate regression analyses were used to evaluate the predictive power of the investigated factors as well as to create a predictive model. RESULTS: In 6.26% of children symptoms of cerebral damage were found. Significant risk factors were age at surgery, more complex malformations, metabolic acidosis, and increased lactate (odds ratio: age, 0.882/yr [0.772-1.008]; complex malformations, 10.32 [1.32-80.28]; arterial pH more than 7.35 to 0.4 [0.18-0.89]; lactate -1.018 per mg/dL [1.006-1.03]). CONCLUSIONS: It is possible to quantify the risk of appearance of symptoms of cerebral damage after cardiac surgery within 24 hours using simple and readily available clinical measurements.

Predictors of mortality at initiation of peritoneal dialysis in children after cardiac surgery.

BACKGROUND: The development of renal dysfunction in the postoperative course of cardiac surgery is still associated with high mortality in pediatric patients. In particular for small infants peritoneal dialysis offers a secure and useful treatment option. The aim of the present study was to investigate if routinely used laboratory and clinical variables could help predict mortality at initiation of peritoneal dialysis. METHODS: We performed a retrospective chart analysis of pediatric intensive care unit patients with renal dysfunction who were treated with peritoneal dialysis after cardiac surgery between 1993 and 2001 and analyzed variables obtained 3 hours or less before starting peritoneal dialysis. RESULTS: Results are documented as means and standard errors. A total of 1141 children underwent a cardiac operation on cardiopulmonary bypass. Sixty-two children (5.4%) were treated with peritoneal dialysis. Mortality was 40.3% (37 survivors, 25 nonsurvivors). The pH in survivors was 7.35 (0.01); in nonsurvivors it was 7.23 (0.03; p = 0.0037). Base excess in survivors was -1.37 mmol/L (0.61); in nonsurvivors it was -7.17 mmol/L (1.49; p = 0.0026). Lactate in survivors was 4.5 mmol/L (0.60); in nonsurvivors it was 10.5 mmol/L (1.78; p = 0.0089). Positive inspiratory pressure in survivors was 24.6 cm H(2)O (0.78); in nonsurvivors it was 28.9 cm H(2)O (1.08; p = 0.0274). Tidal volume per kilogram bodyweight in survivors was 11.0 mL/kg (0.48); in nonsurvivors it was 8.7 mL/kg (0.50; p = 0.0493). CONCLUSIONS: We conclude from our data that the consideration of pH, base excess, lactate, positive inspiratory pressure, and tidal volume per kilogram bodyweight help predict mortality at initiation of peritoneal dialysis. We were able to observe significant differences between survivors and nonsurvivors using these variables.

Monitoring of cerebral oxygen saturation with a jugular bulb catheter after near-drowning and respiratory failure.

We report on monitoring oxygen saturation with a jugular bulb fiber-optical catheter in an 18-month-old girl after fresh water near-drowning followed by acute respiratory failure. The first measured cerebral oxygen saturation was 22% despite normal values for arterial and central venous oxygen saturation. After conventional therapy had failed to improve cerebral oxygen saturation, we started veno-venous extracorporeal membrane oxygenation. Normal levels of cerebral oxygen saturation were achieved after six hours. The girl was extubated after seven days and discharged after twenty-five days in good general condition and without obvious evidence of neurological damage. We believe that in this case of near-drowning, monitoring cerebral oxygen saturation with a jugular bulb catheter was important for surveillance of cerebral hypoxia.

Peritoneal dialysis for continuing renal support after cardiac ECMO and hemofiltration.

Postoperative acute renal insufficiency after cardiac surgery in neonates is associated with increased mortality and is usually treated (while using ECMO, extracorporeal membrane oxygenation) with hemofiltration. Renal support has to be continued after weaning from ECMO when oliguria persists. When using hemofiltration, prolonged anticoagulation and a vascular access is needed, which, however, carries the risk of hemorrhagic as well as thromboembolic complications. Alternatively, peritoneal dialysis (PD) can be performed. We report data from 5 infants treated with ECMO after corrective cardiac surgery, who experienced oliguria after ECMO weaning and were consequently treated with PD. Arterial and central venous pressures, inotropic demand, urinary output, blood urea nitrogen, creatinine and survival were investigated. All patients survived. Installation of PD resulted in stable hemodynamics in all patients, despite continued oliguria. Normal renal function was established in four patients. One patient, suffering from persistent renal insufficiency, remained on PD. PD effectively supports insufficient renal functioning after ECMO weaning without the need for anticoagulation or a vascular access. Acute renal insufficiency may be reversible even after weeks and, if necessary, PD also enables prolonged treatment until renal transplantation.

Differences in hippocampal protein expression at 3 days, 3 weeks, and 3 months following induction of perinatal asphyxia in the rat.

Perinatal asphyxia (PA) was induced in Sprague-Dawley rats; pups were sacrificed 3 days, 3 weeks, and 3 months following the asphyctic insult, and hippocampal protein levels were determined by a gel-based proteomic method. Levels of antioxidant, metabolic, cytoskeleton, signaling, channel, proteasomal, chaperone, splicing, and synaptosomal proteins were dysregulated depending on the age following induction of PA. These proteins are proposed to be potential markers or pharmacological targets for PA.

Vacuum assisted closure therapy for the treatment of sternal wound infections in neonates and small infants.

Sternal wound infections occur with an incidence between 0.4 and 5% in the adult as well as the pediatric population. However, in contrast to the adults, established treatment options do not exist in the pediatric population. We evaluated our preliminary results with 3 neonates, respectively, small infants (mean age 20.3+/-6 days) who underwent vacuum assisted closure (VAC) therapy for the treatment of sternal wound infections with the intention to enable secondary closure and preservation of the sternal bone. The mean VAC duration was 11.3 days, ranging from 10 to 12 days. After three dressing changes (every 48 to 72 h) the infection resolved and a secondary closure was feasible in all three patients. Isolated specimens were Candida albicans, Staphylococcus aureus and MRSA, respectively. These preliminary results show that VAC therapy is a promising alternative to the current treatment options available to neonates. Especially, the preservation of the sternal bone which enables normal thoracic cage stability and growth, is a clear advantage over the currently used muscle flaps.

Quantitative electroencephalography values of neonates during and after venoarterial extracorporeal membrane oxygenation and permanent ligation of right common carotid artery.

Venoarterial extracorporeal membrane oxygenation (ECMO) in neonates commonly needs neck vessel cannulation leading to ligation of right common carotid artery (RCCA) in some cases. Quantitative electroencephalography (EEG) measurements provide reproducible data of cerebral function. The aim of this case-control study was to test whether ligation of the RCCA results in EEG changes after ECMO weaning. Ten mechanically ventilated neonates not treated with ECMO were eligible as control patients. Seven ECMO patients receiving similar sedoanalgesia were investigated during and after ECMO and RCCA ligation. Dominant frequency, absolute alpha, theta, delta, and total powers of right and left frontocentral and temporooccipital derivations were calculated. Dominant frequency did not differ among groups. Power was found to be significantly decreased in all frequency bands during ECMO. After weaning from ECMO, EEG differences between the ECMO and control groups disappeared in spite of permanent RCCA ligation. It is concluded that ligation of the RCCA per se does not result in quantitative EEG changes.

Testing of extracorporeal membrane oxygenation circuit related hemolysis using long-term stored packed red cells and fresh frozen plasma.

BACKGROUND: The resistance of blood used in these studies to hemolysis differs markedly from that used in neonatal extracorporeal circulation under clinical circumstances. In this study, the possibility of using expired packed red cells to determine hemolysis caused by mechanical and/or environmental factors was investigated. METHODS: Packed red blood cells stored for 42 days were mixed with fresh frozen plasma and the resultant mixture was divided into three groups, two study groups and a control. For the study groups, two different centrifugal pump heads (Medtronic BP 50 and Jostra RF 32) were used in an extracorporeal membrane oxygenation (ECMO) circuit. Free hemoglobin, lactate dehydrogenase, lactic acid, pH, potassium, and glucose were investigated at various time intervals. RESULTS: Hemolysis did not differ between the groups. Free hemoglobin increased in all groups after 12 h. Lactic acid increased linearly in all groups up to 12 h. Glucose and pH decreased steadily in all groups. Hemolysis created during mock ECMO did not differ between the circuits using the two different pump heads noted. CONCLUSION: Human donor blood stored up to its expiration date is a feasible medium for mock circulation tests of up to 12 h duration under the circumstances described.

Low-volume peritoneal dialysis in 116 neonatal and paediatric critical care patients.

UNLABELLED: Acute renal insufficiency accounts for high mortality in paediatric intensive care patients, particularly in infants. Peritoneal dialysis, usually carried out with dialysate volumes of >20 ml/kg body weight, increases pulmonary artery pressure, which may compromise myocardial function in critical illness. In this paper we report our experiences with the use of lower dialysate volumes in the treatment of critically ill children with renal impairments. We suggest that low-volume peritoneal dialysis is able to achieve adequate ultrafiltration, which relieves overhydration in ventilated and haemodynamically compromised children. A total of 116 paediatric intensive care patients treated between 1992 and 2000 was the subject of this investigation. Diagnosis, indication for dialysis, arterial and central venous pressure, blood gases, creatinine, blood urea nitrogen, urinary output at installation, ultrafiltration, fluid balance, duration and complications during dialysis as well as survival were investigated. The overall mortality was 53%. The respective diagnoses and mortality rates were as follows: 65% of the patients suffered from cardiac diseases (54% mortality), 7% from renal diseases (13%) and 28% from multi-organ system failure (62%). Low-volume peritoneal dialysis was started at evidence of total body fluid overload with inadequate urinary output and resulted in a mean ultrafiltration of 2.8 ml/kg body weight per h. A negative fluid balance was achieved in 53% of patients, mainly in those suffering from hypervolaemia and minor oliguria. None of the complications resulted in death. CONCLUSION: early installation of low-volume peritoneal dialysis offers a safe and adequate ultrafiltration procedure for paediatric critical care patients suffering from minor oliguria and fluid overload.