[A Uncommon Case: Kasabach-Merritt syndrome with VACTERL Association]. / Ein seltener Fall: Kasabach-Merrit-Syndrom bei VACTERL-Assoziation.

The Kasabach-Merrit syndrome is characterized as the association of a vascular tumor, typically a caposiform hemangioendothelioma and rarely a tufted hemangioma, and a severe consumptive coagulopathy with potentially life-threatening thrombocytopenia. The severe coagulopathy with increased bleeding tendency must be considered before invasive procedures and often requires repeated platelet concentrate substitutions. We present a case of a mature male neonate with Kasabach-Merritt- Syndrome as well as VACTERL association. The VACTERL association describes a group of malformations. Our patient presented with anal atresia combined with tethered cord, and left renal agenesis. The VACTERL association as well as Kasabach-Merritt syndrome were found to be independent pathologies within this patient. A common occurrence or an association with each other has not been described in the literature so far. The challenging coagulation setting due to severe thrombocytopenia complicated the surgical management so far. Finally, mTOR-inhibitor sirolimus was successful in terms of tumor reduction and especially reduction of platelet consumption.

Blood transcriptomics mirror regulatory mechanisms during hibernation-a comparative analysis of the Djungarian hamster with other mammalian species.

Hibernation enables many species of the mammalian kingdom to overcome periods of harsh environmental conditions. During this physically inactive state metabolic rate and body temperature are drastically downregulated, thereby reducing energy requirements (torpor) also over shorter time periods. Since blood cells reflect the organism´s current condition, it was suggested that transcriptomic alterations in blood cells mirror the torpor-associated physiological state. Transcriptomics on blood cells of torpid and non-torpid Djungarian hamsters and QIAGEN Ingenuity Pathway Analysis (IPA) revealed key target molecules (TMIPA), which were subjected to a comparative literature analysis on transcriptomic alterations during torpor/hibernation in other mammals. Gene expression similarities were identified in 148 TMIPA during torpor nadir among various organs and phylogenetically different mammalian species. Based on TMIPA, IPA network analyses corresponded with described inhibitions of basic cellular mechanisms and immune system-associated processes in torpid mammals. Moreover, protection against damage to the heart, kidney, and liver was deduced from this gene expression pattern in blood cells. This study shows that blood cell transcriptomics can reflect the general physiological state during torpor nadir. Furthermore, the understanding of molecular processes for torpor initiation and organ preservation may have beneficial implications for humans in extremely challenging environments, such as in medical intensive care units and in space.

Pilot study of an interprofessional pediatric mechanical ventilation educational initiative in two intensive care units.

INTRODUCTION: Inappropriate ventilator settings, non-adherence to a lung-protective ventilation strategy, and inadequate patient monitoring during mechanical ventilation can potentially expose critically ill children to additional risks. We set out to improve team theoretical knowledge and practical skills regarding pediatric mechanical ventilation and to increase compliance with treatment goals. METHODS: An educational initiative was conducted from August 2019 to July 2021 in a neonatal and pediatric intensive care unit of the University Children's Hospital, Hamburg-Eppendorf, Germany. We tested baseline theoretical knowledge using a multiple choice theory test (TT) and practical skills using a practical skill test (PST), consisting of four sequential Objective Structured Clinical Examinations of physicians and nurses. We then implemented an educational bundle that included video self-training, checklists, pocket cards, and reevaluated team performance. Ventilators and monitor settings were randomly checked in all ventilated patients. We used a process control chart and a mixed-effects model to analyze the primary outcome. RESULTS: A total of 47 nurses and 20 physicians underwent assessment both before and after the implementation of the initiative using TT. Additionally, 34 nurses and 20 physicians were evaluated using the PST component of the initiative. The findings revealed a significant improvement in staff performance for both TT and PST (TT: 80% [confidence interval (CI): 77.2-82.9] vs. 86% [CI: 83.1-88.0]; PST: 73% [CI: 69.7-75.5] vs. 95% [CI: 93.8-97.1]). Additionally, there was a notable increase in self-confidence among participants, and compliance with mechanical ventilation treatment goals also saw a substantial rise, increasing from 87.8% to 94.5%. DISCUSSION: Implementing a pediatric mechanical ventilation education bundle improved theoretical knowledge and practical skills among interprofessional pediatric intensive care staff and increased treatment goal compliance in ventilated children.

Recommendations for endotracheal tube insertion depths in children.

BACKGROUND: Endotracheal tube (ETT) malposition is frequent in paediatric intubation. The current recommendations for ETT insertion depths are based on formulae that hold various limitations. This study aimed to develop age-based, weight-based and height-based curve charts and tables for ETT insertion depth recommendations in children. METHODS: In this retrospective single-centre study, we determined the individual optimal ETT insertion depths in paediatric patients by evaluating postintubation radiographic images. Age-based, weight-based and height-based ETT insertion depth recommendations were developed using regression analysis. We compared the insertion depths predicted by the models with previously published formulae. RESULTS: Intubations of 167 children (0-17.9 years) were analysed. Best-fit curves generated with logistic regression analysis revealed R2 values between 0.784 and 0.880. The insertion depths predicted by the models corresponded well with published age-based and height-based formulae. However, they demonstrated the unsuitability of weight-related linear formulae to predict ETT depth in children. CONCLUSION: The recommendations developed in this study facilitate a fast and accurate determination of recommended ETT insertion depths in children. Our recommendations provide greater accuracy than previously published formulae and demonstrate that weight-related linear formulae are unsuitable for predicting ETT depth in children.

Outcomes of extracorporeal membrane oxygenation and cardiopulmonary bypass in children after drowning-related resuscitation.

Drowning is one of the leading causes of accidental deaths in children worldwide. However, the use of long-term extracorporeal life support (ECLS) in this setting is not widely established, and rewarming is often achieved by short-term cardiopulmonary bypass (CPB) treatment. Thus, we sought to add our experience with this means of support as a bridge-to-recovery or to-decision. This retrospective single-center study analyzes the outcome of 11 children (median 23 months, minimum-maximum 3 months-6.5 years) who experienced drowning and subsequent cardiopulmonary resuscitation (CPR) between 2005 and 2016 and who were supported by veno-arterial extracorporeal membrane oxygenation (ECMO), CPB, or first CPB then ECMO. All but one incident took place in sweet water. Submersion time ranged between 10 and 50 minutes (median 23 minutes), water temperature between 2°C and 28°C (median 14°C), and body core temperature upon arrival in the emergency department between 20°C and 34°C (median 25°C). Nine patients underwent ongoing CPR from the scene until ECMO or CPB initiation in the operating room. The duration of ECMO or CPB before successful weaning/therapy withdrawal ranged between 2 and 322 hours (median 19 hours). A total of four patients (36%) survived neurologically mildly or not affected after 4 years of follow-up. The data indicate that survival is likely related to a shorter submersion time and lower water temperature. Resuscitation of pediatric patients after drowning has a poor outcome. However, ECMO or CPB might promote recovery in selected cases or serve as a bridge-to-decision tool.

Experience of early motherhood during the first wave of the COVID-19 pandemic in Northern Germany: a single-centre before and after comparison.

PURPOSE: To assess maternal mental health during the first weeks after birth including birth experience, postpartum adjustment to early motherhood and the perception of newborn behaviour, and how this may be influenced by the first wave of the COVID-19 pandemic. METHODS: Ninety women who gave birth after the first enforcement of nation-wide disease control restrictions in Germany between 16 March and 10 May 2020 were surveyed and compared with 101 women who had given birth before the pandemic. Information on maternal mental health and maternal perception of early motherhood and neonatal behaviour were assessed at 3-8 weeks postpartum. RESULTS: Mothers who gave birth under the COVID-19-associated disease control restrictions did not show significant differences in depression, anxiety and social support scales compared to mothers before the pandemic. Birth experience was similar, while support during birth was perceived to be higher under the COVID-19 restrictions. Confidence in caretaking of the newborn and perception of neonatal behaviour were comparable between the two groups. Mothers expressed significantly higher dissatisfaction with the maternal role during the pandemic. CONCLUSIONS: Overall, maternal mental health and the perception of the newborn and early caretaking during the first COVID-19 wave did not substantially differ from the perceptions of mothers before the pandemic. A potential influence of the pandemic on higher dissatisfaction with the maternal role may be associated with the pandemic conditions affecting everyday life and should be addressed in postpartum care and in future qualitative and longitudinal studies.

Anatomic accuracy, physiologic characteristics, and fidelity of very low birth weight infant airway simulators.

BACKGROUND: Medical simulation training requires realistic simulators with high fidelity. This prospective multi-center study investigated anatomic precision, physiologic characteristics, and fidelity of four commercially available very low birth weight infant simulators. METHODS: We measured airway angles and distances in the simulators Premature AirwayPaul (SIMCharacters), Premature Anne (Laerdal Medical), Premie HAL S2209 (Gaumard), and Preterm Baby (Lifecast Body Simulation) using computer tomography and compared these to human cadavers of premature stillbirths. The simulators' physiologic characteristics were tested, and highly experienced experts rated their physical and functional fidelity. RESULTS: The airway angles corresponded to those of the reference cadavers in three simulators. The nasal inlet to glottis distance and the mouth aperture to glottis distance were only accurate in one simulator. All simulators had airway resistances up to 20 times higher and compliances up to 19 times lower than published reference values. Fifty-six highly experienced experts gave three simulators (Premature AirwayPaul: 5.1 ± 1.0, Premature Anne 4.9 ± 1.1, Preterm Baby 5.0 ± 1.0) good overall ratings and one simulator (Premie HAL S2209: 2.8 ± 1.0) an unfavorable rating. CONCLUSION: The simulator physiology deviated significantly from preterm infants' reference values concerning resistance and compliance, potentially promoting a wrong ventilation technique. IMPACT: Very low birth weight infant simulators showed physiological properties far deviating from corresponding patient reference values. Only ventilation with very high peak pressure achieved tidal volumes in the simulators, as aimed at in very low birth weight infants, potentially promoting a wrong ventilation technique. Compared to very low birth weight infant cadavers, most tested simulators accurately reproduced the anatomic angular relationships, but their airway dimensions were relatively too large for the represented body. The more professional experience the experts had, the lower they rated the very low birth weight infant simulators.

Fatal outcome of SARS-CoV-2 infection (B1.1.7) in a 4-year-old child.

This case report highlights details of a case of critical acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) with B1.1.7 variant in a 4-year-old girl who died due to pneumonia and pulmonary hemorrhage. The girl was referred to our University ECMO Center from another University hospital for veno-arterial extracorporeal membrane oxygenation (VA-ECMO). In the clinical course, superinfection with Pseudomonas aeruginosa was detected. Virological evidence of herpes simplex sepsis was also obtained in blood samples on her day of death. Transcription polymerase chain reaction (PCR) confirmed SARS-CoV-2 infection in lung tissue. Postmortem computed tomography showed pulmonary hemorrhage with inhomogeneous density values in both lungs. Lung tissue showed no ventilated areas. Autopsy revealed a massively congested lung with evidence of acute respiratory distress syndrome (ARDS) and pneumonia with multiple abscesses. Histopathology showed a mixture of diffuse alveolar injury with hyaline membranes, massive hemorrhage, and bronchopneumonia with multiple granulocytic abscesses. Cardiac examination revealed pericarditis. Suspicion of myocarditis or myocardial infarction could not be confirmed microscopically. To our knowledge, this is the first autopsy-based case report of the death of a previously healthy child due to the new variant B 1.1.7 in Germany.

Therapeutic Management of COVID-19 in a Pediatric Patient with Neurodegenerative CLN2 Disease and ICV-Enzyme Replacement Therapy: A Case Report.

The 12 years old male patient presented here suffers from neuronal ceroid lipofuscinoses 2 (CLN2) (MIM# 204500) and receives intracerebroventricular enzyme replacement therapy (ICV-ERT) every 14 days. After the emergence of the coronavirus disease 2019 (COVID-19) pandemic, routine care of children and adolescents with rare chronic diseases has become challenging. Although, in general, children do not develop severe COVID-19, when severe acute respiratory syndrome coronavirus 2 infection was detected by polymerase chain reaction-screening examination in our CLN2 patient before hospital admission for ICV-ERT, he was regarded to be at risk. Upon diagnosis, the patient developed respiratory deterioration symptoms and was admitted to our pediatric intensive care unit to receive oxygen, remdesivir, and steroids. As far as we know, this is the first CLN2 patient receiving intraventricular enzyme therapy with COVID-19 who required intensive care treatment and specific therapy.

[Transient Ischemia of One Leg in a Very Low Birthweight Infant]. / Transiente Ischämie eines Beines bei einem Frühgeborenen der 31+0 Schwangerschaftswoche.

Ischemias in the extremities are rather rare in the neonatal period. Both intrauterine and postnatal factors can cause ischemias. We present the diagnostic procedure and the course in a female very low birthweight (VLBW) infant with transient ischemia in the lower extremity.

T cell cytokines in the diagnostic of early-onset sepsis.

BACKGROUND: Early-onset sepsis (EOS) remains a substantial cause of morbidity and mortality among neonates. Yet, currently available biological parameters have not proven to be accurate enough to predict EOS reliably. This study aimed to determine serum concentrations of 13 cytokines in umbilical cord blood and evaluate their diagnostic value for EOS. METHODS: A prospective single-center study that included analysis of umbilical cord blood of term and preterm neonates who were born from March 2017 to November 2017. Using ELISA analysis, 13 cytokines were simultaneously quantified and correlated with the development of EOS. RESULTS: Four hundred and seventy-four neonates were included, of which seven met the criteria for culture-positive EOS. Interleukin (IL)-6 (p < 0.001), IL-9 (p = 0.003), and IL-21 (p < 0.001) were significantly increased in neonates with EOS compared to controls. Sensitivity and specificity for IL-6, IL-9, and IL-21 at the defined cut-off points were 85.7 and 77.3%, 71.4 and 62.5%, and 71.4 and 52.0%, respectively. CONCLUSIONS: In neonates with EOS, IL-9 and IL-21 are significantly elevated and may be employed in the diagnostic of EOS. However, diagnostic accuracy remains lower than with IL-6. Values of 13 T cell cytokines may be used as reference values for future studies in neonates. IMPACT: Interleukin-9 (IL-9) and interleukin-21 (IL-21) are significantly elevated in neonates with early-onset sepsis. IL-9 and IL-21 have been shown to play a specific role in neonatal sepsis. Neonatal reference values were generated for several cytokines. IL-9 and IL-21 might be attractive biomarkers for neonatal sepsis in future. This study is likely to promote further research in this area. Values of several T cell cytokines may be used as reference values for future studies in neonates.

Prediction of Nociception in Children Using the Nociceptive Flexion Reflex Threshold and the Bispectral Index-A Prospective Exploratory Observational Study.

OBJECTIVES: The prediction of patient responses to potentially painful stimuli remains a challenge in PICUs. We investigated the ability of the paintracker analgesia monitor (Dolosys GmbH, Berlin, Germany) measuring the nociceptive flexion reflex threshold, the cerebral sedation monitor bispectral index (Medtronic, Dublin, Ireland), the COMFORT Behavior, and the modified Face, Legs, Activity, Cry, Consolability Scale scores to predict patient responses following a noxious stimulus. DESIGN: Single-center prospective exploratory observational study. SETTING: Fourteen-bed multidisciplinary PICU at the University Children's Hospital, University Medical Center Hamburg Eppendorf, Germany. PATIENTS: Children on mechanical ventilation receiving analgesic and sedative medications. INTERVENTIONS: Noxious stimulation by way of endotracheal suctioning. MEASUREMENTS AND MAIN RESULTS: Two independent observers assessed modified Face, Legs, Activity, Cry, Consolability and COMFORT Behavior Scales scores during noxious stimulation (n = 59) in 26 patients. Vital signs were recorded immediately before and during noxious stimulation; bispectral index and nociceptive flexion reflex threshold were recorded continuously. Mean prestimulation bispectral index (55.5; CI, 44.2-66.9 vs 39.9; CI, 33.1-46.8; p = 0.007), and COMFORT Behavior values (9.5; CI, 9.2-13.2 vs 7.5; CI, 6.7-8.5; p = 0.023) were significantly higher in observations with a response than in those without a response. Prediction probability (Pk) values for patient responses were high when the bispectral index was used (Pk = 0.85) but only fair when the nociceptive flexion reflex threshold (Pk = 0.69) or COMFORT Behavior Scale score (Pk = 0.73) was used. A logistic mixed-effects model confirmed the bispectral index as a significant potential predictor of patient response (p = 0.007). CONCLUSIONS: In our sample of ventilated children in the PICU, bispectral index and nociceptive flexion reflex threshold provided good and fair prediction accuracy for patient responses to endotracheal suctioning.

Reference ranges for sphingosine-1-phosphate in neonates.

OBJECTIVES: Sphingosine-1-phosphate (S1P) is a signalling lipid involved in embryonic development, physiological homeostasis, and pathogenic processes in multiple organ systems. Disturbance of S1P homeostasis has been associated with various human diseases in which the immune response and vascular integrity are severely compromised. Up-to-date, no study has analyzed S1P levels in neonates. The objective of this study was to determine S1P serum concentrations in neonates and establish S1P reference ranges. METHODS: S1P levels in the umbilical cord blood of 460 term and preterm neonates were compared to a previously described cohort of healthy adult blood donors. S1P levels were further correlated with demographic characteristics, cellular sources of S1P, and inflammatory markers. RESULTS: The median S1P serum level in neonates was 1.70 µmol/L (IQR 1.41-1.97 µmol/L) and significantly higher than normal values reported in adults. S1P levels correlated positively with the number of red blood cells (p<0.001) and negatively with neutrophil precursors (p=0.028). CONCLUSIONS: Elevated S1P levels in neonates compared to adults possibly result from higher S1P content in its cellular sources due to the essential role of S1P during embryogenesis. Generated S1P ranges may be used as reference ranges for future studies in neonates.

[Surviving the Lack: Natural Adaptations in Newborns]. / Den Mangel überleben: Natürliche Anpassungen bei Neugeborenen.

Newborns are equipped with a number of natural adaptation mechanisms preventing them from impaired energy supply, despite their elevated (size-related) metabolic rate. These include the diving response known from aquatic mammals, which - being composed of apnea, bradycardia, and vasoconstriction - ensures an economical use of O2 reserves and results in a subsequent influx of lactate out of peripheral tissues. From a metabolic point of view, mammalian fetuses behave "like an organ of the mother" and thus exhibit a hibernation-like deviation from the overall metabolic size relationship that adapts them to the limited intrauterine O2/substrate availability. In case of lacking supply, they can reduce their energy demands even further by foregoing growth, with the placenta acting as a gatekeeper. Postnatal hypoxia does not only result in the suppression of non-shivering thermogenesis, but also in a hypoxic hypometabolism that otherwise has only been known from poikilothermic animals. After prolonged apnea, gasps do occur that maintain a rudimentary heart action through short elevations in pO2 (autoresuscitation). Overall, these mechanisms postpone a critical O2 deficit and thereby provide a "resistance" rather than a "tolerance" to hypoxia. As they are based on an (active) reduction in energy demand, they are not easy to distinguish from the (passive) breakdown of metabolism resulting from hypoxia.

Sicherer Babyschlaf: Europäische Empfehlungen auf dem Prüfstand.

das "Bed-sharing", mitunter auch als "Co-sleeping" bezeichnet, also der gemeinsame Schlaf von Mutter/Vater und Kind (<1 Jahr) im gleichen Bett, gilt - unter anderem wegen der drohenden Behinderung der freien Atmung - als Risikofaktor für den plötzlichen Säuglingstod, sodass in vielen Empfehlungen zum "sicheren Babyschlaf" mehr oder weniger pauschal davon abgeraten wird. Dies steht in gewissem Kontrast zu der Tatsache, dass das Bed-sharing weltweit enorm verbreitet ist, und lässt vielleicht auch andere Faktoren, wie die Rolle des kindlichen Alters oder die Auswirkungen auf die mütterliche Stillbereitschaft, zu sehr außer Acht. In einer interessanten Übersichtsarbeit im "Fokus Hebammenwissenschaft" dieser Zeitschrift werden daher die Empfehlungen zur Prophylaxe des Sudden Infant Death Syndrome (SIDS) in Europäischen Ländern mit besonders niedriger (Griechenland, Italien, Niederlande) und besonders hoher SIDS-Inzidenz (UK, Österreich, Frankreich) analysiert und der aktuellen Evidenzlage gegenübergestellt. Es zeigt sich, dass, was empfohlen bzw. NICHT: empfohlen wird, nicht immer der wissenschaftlichen Evidenz entspricht, und dass ein sorgfältigerer Abgleich, so zumindest die Folgerung der Autorinnen, auch differenziertere Empfehlungen gerade zum Thema Bed-sharing erlauben würde.

[Effects of Obstetric Analgesia with Systemic Opioids on the Newborn - A Review]. / Auswirkungen geburtshilflicher Analgesie mit systemischen Opioiden auf das Neugeborene ­ eine Übersichtsarbeit.

INTRODUCTION: Three-quarters of all women receive analgesia during labor. There are regional and systemic analgesia procedures available. In this review, we investigate the impact of obstetric analgesia using systemic opioids on neonatal outcomes. METHODS: We searched the PubMed and Cochrane Library databases using the following search terms: "meptazinol", "meptide", "analgesia", "painkiller", "pain reliever", "obstetrics", "labor", "labour", "delivery", "neonate", "newborn", "child", "baby", "infant", "fetus", "fetal", "opioid" and "opiate" as well as performed an additional MeSH Terms search in PubMed. RESULTS: Of 355 potentially relevant studies, we included 23 studies in this review. The studies varied widely in quality, sample size, and outcome criteria. Neonatal outcome was often only a secondary endpoint. Rarely were significant differences related to neonatal outcome reported between the different systemic opioids or compared with control groups. Twelve studies compared neonatal APGAR scores between treatment groups, with ten (83%) of these studies showing no differences. DISCUSSION/OUTLOOK: In summary, we assess the evidence as limited and ambiguous as to whether systemic obstetric opioid therapy negatively affects the newborn. Studies regarding the long-term outcome of the newborns are lacking. A statement regarding the necessity of postnatal monitoring of newborns after maternal obstetric opioid therapy cannot be concluded. Further studies, ideally with a prospective study design and control group, should be considered.

Intravesical monitoring of intra-abdominal pressure after renal transplantation in children: A safety and feasibility study.

IAH after RTX can threaten graft viability. This study aimed to assess the feasibility and safety of longitudinal IAP measurements as an IAH screening method in children after RTX. A cohort of eight children with a mean ± SD [range] age 9.6 ± 6.2 [2-17] years who underwent RTX and 18 control patients were evaluated between May 2017 and February 2018. We compared longitudinal IAP measurements using a Foley manometer to other clinical monitoring data. In total, 29 IAP measurements were performed in RTX patients and 121 in controls. The mean post-operative IAP was 7.4 ± 4.3 [1-16] mm Hg following RTX and 8.1 ± 3.7 [1-19] mm Hg in controls. We noted IAH in 9 (31%) of 29 IAP measurements after RTX and in 41 (34%) of 121 IAP measurements in controls. No graft dysfunction occurred in RTX patients despite elevated IAP values. The mean ± SD [range] time expenditure for IAP measurement was 2.1 ± 0.4 [0.6-3.2] minutes. No severe complications occurred during the IAP measurements. Analysis of longitudinal IAP measurements demonstrated that IAP measurement is safe and feasible in children recovering from renal transplantation in the PICU.

Effect of hemodialysis on impedance cardiography (electrical velocimetry) parameters in children.

BACKGROUND: Pediatric hemodialysis (HD) patients have a high incidence of cardiovascular morbidity and mortality. The study aim was to investigate whether impedance cardiography (electrical velocimetry, EV) is suitable as a hemodynamic trend monitoring tool in pediatric patients during HD. METHODS: Measurements by EV were obtained before, during, and after HD in a prospective single-center pediatric observational study. In total, 54 dialysis cycles in four different pediatric patients with end-stage kidney disease on chronic HD were included. EV parameters analyzed were heart rate (HR), stroke volume (SV), stroke volume index (SI), cardiac output (CO), cardiac index (CI), thoracic fluid content (TFC), index of contractility (ICON), stroke volume variation (SVV), variation of ICON (VIC), R-R interval (TRR), pre-ejection period (PEP), left ventricular ejection time (LVET), and systolic time ration (STR). Systemic vascular resistance index (SVRI) was calculated. RESULTS: EV did measure significant changes in cardiovascular parameters associated with HD. The following parameters increased after HD: HR (9%), SVV (19%), VIC (33%), PEP (8%), and STR (18%). A decrease after HD was measured in SV (18%), SI (18%), CO (10%), CI (10%), TFC (10%), ICON (7%), TRR (7%), LVET (8%), and LVET (8%). SVRI was not affected by HD. The changes were correlated to ultrafiltration. HD cycles without fluid withdrawal also altered cardiovascular parameters. CONCLUSIONS: Pediatric HD with and without fluid withdrawal changes hemodynamic EV monitoring parameters. Possibly EV may be useful to optimize HD management in pediatric patients.

A prospective observational trial evaluating factors predictive of accurate endotracheal tube positioning in neonates and small infants.

BACKGROUND: There is a high incidence of endotracheal tube malposition in neonates and small infants. Yet, verification of accurate endotracheal tube location via radiographic imaging involves radiation exposure. AIMS: This study aimed to identify demographic and clinical parameters associated with accurate endotracheal tube positioning. METHODS: We conducted a prospective single-center study with term and preterm neonates and small infants between January 2018 and November 2019. We investigated correlations between ten variables and accurate endotracheal tube position. RESULTS: One hundred and sixty eight nasal intubations in 139 patients (weight 390-5000 g) were analyzed. An accurate tube position was confirmed by radiographic imaging in 71.4% of the intubations. The endotracheal tube was high in 8.3% and low in 20.2% of the cases. Male gender was the only variable that significantly correlated with an accurate endotracheal tube position (OR 2.5; 95% CI: 1.3, 5.0; P = .010). CONCLUSION: So far, no parameter has proven to be able to predict accurate endotracheal tube position in neonates reliably. These findings emphasize the indispensability of postintubation imaging in neonates and small infants.

[Chorangioma of the Placenta - A Rare Placental Cause of Fetal High Output Cardiac Failure]. / Chorioangiom der Plazenta ­ eine seltene Ursache fetaler High-Output-Herzinsuffizienz.

Chorangiomas of the placenta, benign tumors of chorionic tissue, are a rare placental cause of adverse fetal and maternal outcomes. We describe the case of a large placental chorangioma leading to polyhydramnios as well as consecutive preterm birth and high output cardiac failure of the newborn. Derived from a literature review, we suggest instructions for diagnosis and optimal prenatal care in case of a a suspected placental chorangioma.