Economics and ethics of paediatric respiratory extra corporeal life support.

Extra corporeal membrane oxygenation (ECMO) is a form of life support, which facilitates gas exchange outside the body via an oxygenator and a centrifugal pumping system. A paediatric cardiac ECMO programme was established in 2005 at Our Lady's Children's Hospital, Crumlin (OLCHC) and to date 75 patients have received ECMO, the majority being post operative cardiac patients. The outcome data compares favourably with international figures. ECMO has been most successful in the treatment of newborn infants with life threatening respiratory failure from conditions such as meconium aspiration, respiratory distress syndrome and respiratory infections. There is no formal paediatric respiratory ECMO programme at OLCHC, or anywhere else in Ireland. Currently, neonates requiring respiratory ECMO are transferred to centres in Sweden or the UK at an average cost of 133,000 Euros/infant, funded by the Health Service Executive E112 treatment abroad scheme. There is considerable morbidity associated with the transfer of critically ill infants, as well as significant psycho-social impact on families. OLCHC is not funded to provide respiratory ECMO, although the equipment and expertise required are similar to cardiac ECMO and are currently in place. The average cost of an ECMO run at OLCHC is 65,000 Euros. There is now a strong argument for a fully funded single national cardiac and respiratory paediatric ECMO centre, similar to that for adult patients.

Epidemiology of major paediatric trauma.

In Europe injury is the leading cause of death in those aged between 1 and 14 years. In Ireland over 800,000 people are aged less than 14 years. There is currently no national trauma register to collect data on the morbidity and mortality associated with major trauma in the paediatric population in Ireland. We prospectively collected data on 153 patients admitted to our hospital with major trauma. There were 99 males and 54 females. The majority of patients were transported by ambulance (n= 138). Road traffic accidents (n=69) and thermal injuries (n=49) represented the majority of admissions. 68% (n=47) of the vehicle occupants in this study were either unrestrained or incorrectly restrained. Most patients (n=133) had an in patient stay of <50 days, with only 4 patients staying >100 days. 14 patients died. A paediatric trauma register as well as a level 1 paediatric trauma centre are required in Ireland.

Clinical audit in intensive care--the Meath Intensive Care Audit.

Audit is now recognised as being an essential component of clinical practice. We report on the first year of the Meath Intensive Care Audit (MICA). This audit was instituted to investigate the activity of the unit, to assess the feasibility of continuous audit in our ICU and to provide data for future development of ICU facilities. Two hundred and fifty four patients were admitted between July 1st 1990 and June 30th 1991. The mean age at admission was 58 years and the mean length of stay 5.2 days. The mean APACHE II score was 16. Thirty four patients (13.4%) died in the ICU and 17 patients died in hospital following discharge from the unit bringing the hospital mortality rate to 20%. The audit proved feasible to implement and data collection is now accepted as a routine part of our ICU work.

General anaesthesia and the environment.

Theatre pollution by anaesthetic agents has been the subject of considerable study and discussion. However the environmental effects of these agents has received little attention. In this paper we review the environmental effects of anaesthetic agents. Volatile anaesthetic agents such as halothane, isoflurane, and enflurane would appear to have minimal atmospheric polluting potential. Nitrous oxide however is a greenhouse gas and can also indirectly contribute to ozone layer depletion. We would suggest that the continued use of nitrous oxide in large quantities must be viewed with concern.

Paediatric near-drowning: mortality and outcome in a temperate climate.

The decision whether to continue to resuscitate the paediatric victim of near-drowning is influenced by potential poor neurological outcome. A low core body temperature at presentation is frequently cited as a reason to continue resuscitation. We report the case of an 11 month old infant admitted to the intensive care unit following near-drowning and a prolonged resuscitation. The infant's core body temperature was 29 degrees C. Cardiac output was restored, but the child remains in a persistent vegetative state. We present the results of a ten year review of near-drowning in a tertiary referral institution, to evaluate the mortality and outcome in a temperate climate. Thirteen patients were identified in the review. The mortality was 23%. The incidence of a persistent vegetative state was 15%. Asystole, immersion time greater than 15 minutes, resuscitation time longer than 30 minutes, the administration of epinephrine, and a low core body temperature were associated with a poor outcome.

Health spending, illicit financial flows and tax incentives in Malawi.

This analysis examines the gaps in health care financing in Malawi and how foregone taxes could fill these gaps. It begins with an assessment of the disease burden and government health expenditure. Then it analyses the tax revenues foregone by the government of Malawi by two main routes: Illicit financial flows (IFF) from the country, Tax incentives. We find that there are significant financing gaps in the health sector; for example, government expenditure is United States Dollars (USD) 177 million for 2013/2014 while projected donor contribution in 2013/2014 is USD 207 million and the total cost for the minimal health package is USD 535 million. Thus the funding gap between the government budget for health and the required spending to provide the minimal package for 2013/2014 is USD 358 million. On the other hand we estimate that almost USD 400 million is lost through IFF and corporate utilization of tax incentives each year. The revenues foregone plus the current government health spending would be sufficient to cover the minimal public health package for all Malawians and would help tackle Malawi's disease burden. Every effort must be made, including improving transparency and revising laws, to curtail IFF and moderate tax incentives.

A pilot study to determine if nurses trained in basic neonatal resuscitation would impact the outcome of neonates delivered in Kampala, Uganda.

AIMS AND OBJECTIVES: To determine if a team dedicated to basic neonatal resuscitation in the delivery ward of a teaching hospital would impact the outcome of neonates delivered in Kampala, Uganda. METHODS: A five-member team of nurses, trained in basic neonatal resuscitation attended 1046 deliveries over a thirty-one day pilot period. They were available in the delivery ward twenty-four hours each day. Outcomes studied included the number of stillbirths recorded on the delivery ward, the number of neonates admitted to the special care baby unit (SCBU), the number of babies admitted to SCBU who died and the mortality in the different weight categories. APGAR scores before and after intervention was also compared. Admission diagnoses between the two groups were also compared. Outcome data collected during this pilot period was compared with historic controls from the previous 31 days in the same unit. PATIENTS AND SETTING: A delivery ward, 22,000 deliveries per year. RESULTS: The stillbirth rate and admission rate to the SCBU were unchanged. Basic neonatal resuscitation in this setting decreased the incidence of asphyxia (defined as failure to initiate and sustain breathing or an APGAR score of <7 at 5 min), improved APGARS and a decrease in the mortality of babies weighing more than 2 kg. CONCLUSION: The resuscitation team reduced the incidence of and mortality from asphyxia and improved the outcome of babies greater than 2 kg. This pilot study provides evidence of the beneficial effect of basic neonatal resuscitation in this setting.

Home-based care for orphaned children infected with HIV/AIDS in Uganda.

The primary aim of this paper is to describe an outreach programme from a main state hospital in sub-Saharan Africa, which has been running for three years. This programme is based in Mulago Hospital, Kampala, Uganda and cares for up to 200 children infected with HIV/AIDS in their home. We describe the clinic and how we meet the families and enrol them, the infrastructure of the programme and the personnel involved. Children and their families receive physical, psychological and social care and we describe each aspect of this. The knowledge base about older children with AIDS in Africa is scarce and the secondary aim of this paper is to publish observations that were made while providing care. This includes demographics and the health problems encountered among children living with HIV/AIDS in a resource-poor setting who do not receive antiretroviral medication. Finally, we discuss the strengths and weaknesses of this model of care and the prerequisites to setting up a similar model.

Comparison of exogenous surfactant and positive end-expiratory pressure therapies in a model of human breast milk-induced acute lung injury in rabbits.

To evaluate surfactant and positive end-expiratory pressure (PEEP) as potential therapies for the acute lung injury after tracheal instillation of 0.8 ml kg-1 human breast milk (HBM) acidified to pH 1.8, adult white rabbits were anaesthetized, tracheostomized, ventilated and randomized to (six rabbits per treatment): (i) no treatment after HBM (control); (ii) exogenous Bovine surfactant (100 mg kg-1) 1 h after HBM; (iii) PEEP-pre (0.5 kPa PEEP) before and after HBM; or (iv) PEEP-post (0.5 kPa PEEP) after HBM. A fifth group of six rabbits received no tracheal instillate (no aspirate). The alveolar to arterial oxygen tension gradient (A-aDO2) and dynamic compliance were measured pre-injury and hourly for 4 h. At post-mortem, the lungs were examined histologically. A-aDO2 in all four HBM-injured groups increased to a maximum at 1 h post-injury; A-aDO2 then returned towards the baseline in the surfactant and PEEP-post groups, but remained increased in the PEEP-pre and control groups. Dynamic compliance decreased in all four HBM-injured groups. A-aDO2 and compliance were unchanged in the no aspirate group. Bronchoalveolar architecture after surfactant therapy was normal. We conclude that surfactant is a more effective therapy for HBM-induced lung injury than either 0.5 kPa PEEP-post or PEEP-pre injury.

Acute lung injury after instillation of human breast milk into rabbits' lungs: effects of pH and gastric juice.

BACKGROUND: The authors compared the lung injury in rabbits that occurred after tracheal instillation of human breast milk (HBM) acidified to pH 1.8 with hydrochloric acid (HCl), HBM at its native pH (7.0), and HBM acidified with gastric juice to pH 1.8 and 3.0. METHODS: The alveolar-to-arterial oxygen tension gradient and dynamic compliance were recorded before and hourly for 4 h after intratracheal instillation of 0.8 ml/kg HBM acidified with HCI (pH 1.8), HBM at its native pH (7.0), HBM acidified with gastric juice (pH 1.8 or 3.0), or 5% dextrose solution acidified with gastric juice (pH 1.8) as a control in 30 adult rabbits. The circulating neutrophil count and phagocyte oxidant activity were determined before and 1 and 4 h after instillation. RESULTS: The alveolar-to-arterial oxygen tension gradient increased and dynamic compliance decreased significantly in all groups after instillation of HBM compared with baseline values and those in the control group. The severity of the lung injury after instillation of HBM at all pH values (1.8, 3.0, and 7.0) and after acidification with gastric juice or HCl was similar. The circulating neutrophil count increased steadily for 4 h after instillation (P < 0.013), whereas spontaneous phagocyte oxidant burst activity peaked at 1 h (P < 0.007) and returned to baseline by 4 h after instillation. CONCLUSIONS: The severity of the lung injury after tracheal instillation of 0.8 ml/kg HBM in rabbits is similar at pH values between 1.8 and 7.0 after acidification with HCl or gastric juice. Tracheal instillation of HBM increases the circulating neutrophil count and phagocyte oxidant burst activity.

Shoshin beri-beri precipitated by intravenous glucose.

A thiamine deficient patient presented to the emergency department with an acute confusional state, becoming unconscious and hypotensive following the administration of 32 g of intravenous glucose over 4 hr. A dramatic clinical improvement in his cardiovascular and neurological status followed a single intra-venous dose of 250 mg of thiamine. Profound thiamine deficiency was confirmed on biochemical testing. A substantial proportion of hospital patients are thiamine deficient and intravenous dextrose may precipitate cardiovascular collapse and lactic acidosis due to the development of 'shoshin' beriberi. A rapid response to intravenous thiamine may confirm the diagnosis. All patients presenting with acute neurological dysfunction should receive thiamine before glucose-containing solutions are administered.

A case of pneumomediastinum in paediatric ARDS: to oscillate or not?

An 18-month-old was transferred (intubated and ventilated) to our hospital with staphylococcal tracheitis, which progressed to a necrotizing pneumonitis, complicated by surgical emphysema and pneumomediastinum. Maximum conventional ventilation on a Servo 300 failed. Treatment with high frequency oscillatory ventilation (for 10 days) with a permissive hypercarbia and hypoxaemia strategy to limit mean airway pressure facilitated recovery in our patient.

Acute lung injury after instillation of human breast milk or infant formula into rabbits' lungs.

BACKGROUND: Recent interest in shortening the fasting interval after ingestion of milk products demonstrated large volumes of breast milk in the stomach 2 h after breastfeeding. Although aspiration is a rare event, if it were to occur with human breast milk, it is important to understand the extent of the lung injury that might occur. Therefore, the response to instillation of acidified breast milk and infant formula in the lungs of adult rabbits was studied. METHODS: In 18 anesthetized adult rabbits, 1 of 3 fluids (in a volume of 0.8 ml.kg-1 and pH level of 1.8, acidified with hydrochloric acid); saline, breast milk, or infant formula (SMA, Wyeth, Windsor, Ontario), was instilled into the lungs via a tracheotomy. The lungs were ventilated for 4 h after instillation. Alveolar-to-arterial oxygen gradient and dynamic compliance were measured before and at hourly intervals after instillation. After 4 h, the rabbits were killed and the lungs were excised. Neutrophil infiltration was quantitated by a pathologist blinded to the instilled fluid. A histologic control group of four rabbits was ventilated under study conditions without any intratracheal fluid instillation. RESULTS: Alveolar-to-arterial oxygen gradient increased and dynamic compliance decreased significantly during the 4 h after instillation of both breast milk and infant formula compared with baseline measurements and with saline controls (P < 0.05). The neutrophil counts in the lungs from the saline, breast milk, and formula rabbits were significantly greater than those in the control group. CONCLUSIONS: Instillation of acidified breast milk or infant formula (in a volume of 0.8 ml.kg-1 and pH level of 1.8) into rabbits' lungs induces acute lung injury of similar intensity that lasts at least 4 h.

Persistent low cerebral blood flow velocity following profound hypothermic circulatory arrest in infants.

Acute neurological morbidity following repair of congenital heart disease (CHD) in infancy is well recognized, particularly with the modalities of hypothermic cardiopulmonary bypass (CPB) and profound hypothermic circulatory arrest (PHCA). Reduced O2 delivery (perfusion defect) during rewarming following PHCA has been shown in the operating room. This reduction in cerebral blood flow coincides with disordered cerebral metabolism and oxygen utilisation after PHCA. The objective of this study was to extend the period of investigation of cerebral blood flow velocity (CBFV) behaviour in infants following PHCA to determine if hypoperfusion persisted in the paediatric intensive care unit (PICU). Ten patients undergoing CHD surgery were divided, based on the pump modality employed, into either mild hypothermic CPB or profound hypothermic CPB with circulatory arrest. Following admission to the PICU, sequential recordings of the mean CBFV in the middle cerebral artery, anterior fontanelle pressure, haemodynamic variables, tympanic membrane temperature, haematocrit and PaCO2 were performed. The PHCA group had a consistently reduced CBFV compared with the control group (P < 0.05). The CBFV values at one, two and four hours were 60 +/- 11, 51.8 +/- 11.4 and 52.6 +/- 11.9 respectively in the mild hypothermic CPB group. The CBFV values at one, two and four hours were 26.6 +/- 6.8, 32.6 +/- 10 and 34 +/- 8 respectively in the PHCA group. There was no difference in cerebral perfusion pressure between both groups. Tympanic temperature, haematocrit and PaCO2 did not vary between groups at any interval. This study demonstrates a sustained reduction in the CBFV pattern following PHCA into the postoperative period despite adequate cerebral perfusion pressures. This abnormality correlates with electroencephalographic aberrations documented after PHCA. It supports the concept of a prolonged unreactive cerebrovascular bed which could potentially contribute to the acute neurological morbidity following PHCA in neonates.