Lead in the marine environment: concentrations and effects on invertebrates.

Lead (Pb) is a non-essential metal naturally present in the environment and often complexed with other elements (e.g., copper, selenium, zinc). This metal has been used since ancient Egypt and its extraction has grown in the last centuries. It has been used until recently as a fuel additive and is currently used in the production of vehicle batteries, paint, and plumbing. Marine ecosystems are sinks of terrestrial contaminations; consequently, lead is detected in oceans and seas. Furthermore, lead is not biodegradable. It remains in soil, atmosphere, and water inducing multiple negative impacts on marine invertebrates (key species in trophic chain) disturbing ecological ecosystems. This review established our knowledge on lead accumulation and its effects on marine invertebrates (Annelida, Cnidaria, Crustacea, Echinodermata, and Mollusca). Lead may affect different stages of development from fertilization to larval development and can also lead to disturbance in reproduction and mortality. Furthermore, we discussed changes in the seawater chemistry due to Ocean Acidification, which can affect the solubility, speciation, and distribution of the lead, increasing potentially its toxicity to marine invertebrates.

Withholding and withdrawing treatment in pediatric intensive care. Update of the GFRUP recommendations.

In 2005, the French-speaking task force on pediatric critical and emergency care [Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP)] issued recommendations on withholding and withdrawing treatments in pediatric critical care. Since then, the French Public Health Code, modified by the laws passed in 2005 and 2016 and by their enactment decrees, has established a legal framework for practice. Now, 15 years later, an update of these recommendations was needed to factor in the experience acquired by healthcare teams, new questions raised by practice surveys, the recommendations issued in the interval, the changes in legislation, and a few legal precedents. The objective of this article is to help pediatric critical care teams find the closest possible compromise between the ethical principles guiding the care offered to the child and the family and compliance with current regulations and laws.

Noradrenaline use for septic shock in children: doses, routes of administration and complications.

AIM: To report our 10 year experience with noradrenaline use in children with septic shock focusing on doses, routes of administration and complications. METHODS: Retrospective single-centre review of children with septic shock who received noradrenaline between 2000 and 2010. RESULTS: We identified 144 children with septic shock treated with noradrenaline, in 22% as the first-line drug. The median volume resuscitation before vasoactive agent administration was 50 mL/kg interquartile range [IQR: 30-70]. Mean doses of noradrenaline ranged from 0.5 ± 0.4 µg/kg per min (starting dose) to 2.5 ± 2.2 µg/kg per min (maximum dose). Noradrenaline was administered via peripheral venous access or intra-osseous route in 19% of cases for a median duration of 3 h [IQR: 2-4] without any adverse effects. The use of noradrenaline increased over the study period. Mortality rate was 45% with a significant decrease over the study period. Adverse effects included arrhythmia in two children and hypertension in eight children. None of these arrhythmias required treatment and hypertension resolved with the noradrenaline dose reduction. CONCLUSION: Higher doses of noradrenaline than those suggested in the literature may be necessary to reverse hypotension and hypoperfusion. The use of noradrenaline through peripheral venous access or intra-osseous route was safe, without any adverse effects.

[Two children with cerebral and retinal hemorrhages: do not diagnose shaken baby syndrome too rapidly]. / Association hémorragies cérébrales et rétiniennes chez 2 enfants : ne pas conclure trop vite au diagnostic d'enfant secoué.

We report on 2 cases associating retinal (RH) and cerebral hemorrhages (CH), which first suggested the diagnosis of shaken baby syndrome (SBS). After an etiologic search, the diagnosis was corrected: the first case was a late hemorrhagic disease of the newborn and the second case hemophilia A. RH is a major feature of SBS, although not pathognomonic. There is no specific RH of SBS but they usually affect the posterior retinal pole. Typically, RHs of SBS are present in both eyes, although unilateral RHs do not exclude the diagnosis of SBS. The relationship between RH and CH has been reported in SBS but also in other diseases. Thus, one must search for hemostasis abnormalities, even though the clinical presentation suggests SBS. Ignoring SBS as well as coming to the conclusion of SBS too quickly should be avoided. Diagnostic difficulties may be related to the number of physicians involved and their interpretation of the facts. These 2 cases underline the need for working as a team that includes hematologists able to interpret coagulation parameters.

[Weaning from invasive mechanical ventilation in pediatric patients (excluding premature neonates)]. / Le sevrage de la ventilation mécanique invasive en réanimation pédiatrique (à l'exclusion des prématurés).

The process of weaning from mechanical ventilation (WMV) is the same in children as in adults. In the pediatric literature, weaning failure rate ranges from 1.4 to 34%. So far, no indices of weaning success have been demonstrated to be sufficiently accurate. The criteria for assessing readiness to wean, which must be screened daily, have neither been validated nor adapted to the pediatric population. The spontaneous breathing test (SBT), the reference screening test for weaning, precedes extubation; it can be achieved with pressure support ventilation or spontaneous breathing (T piece or canopy or flow-inflating bag). A standardized weaning protocol (which can be computer driven) was used in only three pediatric studies and the impact on shortening the duration of mechanical ventilation has not yet been demonstrated. It should be paired with a sedative interruption protocol. Weaning criteria, SBT criteria, and/or protocol tolerance are guides, but clinicians must individualize decisions to use these criteria. The use of noninvasive ventilation is increasing and its place in weaning protocols for children needs to be determined; it might modify the definitions of weaning failure and weaning success in the future.

[Use of midazolam for refractory status epilepticus in children]. / Utilisation du midazolam dans l'état de mal épileptique réfractaire de l'enfant.

UNLABELLED: Morbidity and mortality are high in children with refractory status epilepticus (RSE). Here, we assess the efficacy of midazolam for RSE in children. METHODS: This was a retrospective analysis of 29 children admitted to the Lille University Hospital pediatric intensive care unit (PICU) for RSE between May 2006 and July 2008. The onset of the study corresponded with a new therapeutic protocol applied in the PICU for RSE where midazolam was proposed as the first-line treatment (bolus ten continuous infusion until control) to be replaced by thiopenthal in case of failure. RESULTS: We recorded 29 patients with RSE during the study period: 26 were treated with midazolam, including two where midazolam replaced thiopenthal because of hypotension. Midazolam successfully controlled RSE in 58% of patients. Mean delay to cessation of RSE was 48+/-65 minutes. Hypotension was observed in 8% of midazolam-treated patients and 71% of thiopenthal-treated patients. Overall mortality was 15% (4/26). Two deaths occurred long after the cessation of RSE. None of the deaths occurred in midazolam-treated patients. CONCLUSION: Midazolam is an efficient treatment for RSE in children. Morbidity and mortality appear to be lower with midazolam compared with other antiepileptic drugs used for the treatment of RSE.

[Why teams in charge of children after a pediatric intensive care unit stay do not take into account the treatment limitation decisions previously made by intensivists]. / Pourquoi les décisions de limitation des traitements en réanimation ne sont-elles pas partagées avec les professionnels assurant les soins de l'enfant avant et après la réanimation?

UNLABELLED: The fact that some children may survive despite a limitation of treatment decision (LTD) made in the pediatric intensive care unit (PICU) is a recent concern. A previous study pointed out that the teams in charge of children after the PICU stay did not take previous PICU LTDs into account. PURPOSE: To identify the problems different units experience in cooperating with the PICU team, in order to increase the continuity of care for these children. STUDY DESIGN: Qualitative single-center study, using semi-structured interviews with physicians in charge of children who were discharged from the PICU even though a LTD was made. RESULTS: Nine pediatric subspecialists (hemato-oncologists, neurologists, and neurosurgeons) were interviewed, producing a corpus of approximately 80 pages of typed text. Three conflictual situations were identified by these physicians. The most frequently reported situation was being asked by the PICU team to give expert advice on a patient's prognosis, before a LTD was made. The 2 others had to defend a true care plan for children who were transferred to the PICU and designing a new care plan for children who were discharged from the PICU after a LTD was made. CONCLUSION: The medical reasoning model that is used for LTDs in the PICU generates conflictual situations when compared to the models that are used in other specialties. These models represent various expressions of subjectivity, as in any medical decision. Acknowledging this fact could facilitate its integration into clinical practice and should improve authentic debates that are necessary to ensure continuity of care for these children.

[What become the decisions of limitation of treatments after discharge from the paediatric intensive care unit?]. / Que deviennent les décisions de limitation ou d'arrêt des traitements actifs à la sortie de réanimation pédiatrique ?

UNLABELLED: The fact that some children may survive despite a decision of limitation of treatments (DLT) is taken in Paediatric Intensive Care Unit (PICU) is a recent data. Although the French-speaking Group of Paediatric Intensive and Emergency Care (GFRUP) has published guidelines for limitation of treatments in PICU, outcome of these surviving children has not yet been studied. PURPOSES: To evaluate transmission of data concerning DLT in PICU toward teams in charge of children after the PICU stay and to evaluate perennility of these decisions. METHOD: Cohort study in children for whom DLT was discussed and who were discharged from PICU between 2002 and 2006. The study included an analysis of the medical files and discussions with the physicians in charge of children at the time of the study, including their responses to standardised scenarios concerning the outcome of their patients. RESULTS: Among the 96 children for whom DLT was discussed in PICU, 37 were discharged toward another unit. Only 1 discharge letter mentioned the DLT. At the time of the study, the Pediatric Overall Performance Category (POPC) score had increased in 16 children and was stable in 12. All the 6 children with a worsening POPC score died, without PICU readmission. The physicians in charge of children after the PICU stay did not remember any DLT. For 18 children (including 8 with previous DLT) PICU readmission would be proposed in case of life-threatening event. Their median POPC score at the time of study was lower than that of other children (3 versus 4; p=0.001). CONCLUSION: This study shows a lack of DLT data transmission, which is in contradiction with the GFRUP's guidelines. Correction of this lack is essential to improve cooperation between units in charge of these children.