Potassium disorders in pediatric emergency department: Clinical spectrum and management.

INTRODUCTION: Potassium abnormalities are frequent in intensive care but their incidence in the emergency department is unknown. AIM: We describe the spectrum of potassium abnormalities in our tertiary-level pediatric emergency department. METHODS: Retrospective case-control study of all the patients admitted to a single-center tertiary emergency department over a 2.5-year period. We compared patients with hypokalemia (<3.0mEq/L) and patients with hyperkalemia (>6.0mEq/L) against a normal randomized population recruited on a 3:1 ratio with potassium levels between 3.5 and 5mEq/L. RESULTS: Between January 1, 2013 and August 31, 2016 we admitted 108,209 patients to our emergency department. A total of 9342 blood samples were tested and the following potassium measurements were found: 60 cases of hypokalemia (2.8±0.2mEq/L) and 55 cases of hyperkalemia (6.4±0.6mEq/L). In total, 200 patients with normokalemia were recruited (4.1±0.3mEq/L). The main causes of the disorders were non-specific: lower respiratory tract infection (23%) and fracture (15%) for hypokalemia, lower respiratory tract (21.8%) and ear-nose-throat infections (20.0%) for hyperkalemia. Patients with hyperkalemia had an elevated creatinine level (0.72±1.6 vs. 0.40±0.16mg/dL, P<0.0001) with lower bicarbonate (19.4±3.8 vs. 21.8±2.8mmol/L, P=0.0001) and higher phosphorus levels (1.95±0.6 vs. 1.42±0.27mg/dL, P=0.0001). Patients with hypokalemia had an elevated creatinine level (0.66±0.71 vs. 0.40±0.16mg/dL, P<0.0001) and a lower phosphorus level (1.12±0.31 vs. 1.42±0.27mg/dL, P=0.0001). We did not observe significant differences in pH, PCO2, base excess and lactate, or in the mean duration of hospitalization in general wards and pediatric intensive care units according to the PIM and PRISM scores. DISCUSSION: Dyskalemia is rare in emergency department patients: 0.64% for hypokalemia and 0.58% for hyperkalemia. This condition could be explained by a degree of renal failure due to transient volume disturbance. The main mechanism is dehydration due to digestive losses, polypnea in young patients, and poor intake. In the case of hypokalemia, poor intake and digestive losses could be the main explanation. These disorders resolve easily with feeding or perfusion and do not impair development. CONCLUSION: Dyskalemia is rare in emergency department patients and is easily resolved with feeding or perfusion. A plausible etiological mechanism is a transient volume disturbance. Dyskalemia is not predictive of poor development in the emergency pediatric population.

[Infants poisoned with cannabis]. / L'intoxication au cannabis chez le nourrisson.

We reported three cases of infants poisoned with cannabis. These patients presented with acute neurological disorders such as drowsiness accompanied by hypotonia, mydriasis and seizure. Cannabis was found in all children either in the urine or in the blood. These cases illustrated that young age should not exclude toxicologic analysis in acute neurological disorders. Cannabis poisoning in infants is a rare reason for consultation. Clinical signs and symptoms are unspecific and severe manifesta- tions in pediatric age are not well known by emergency physicians and paediatricians.

Nous rapportons trois cas de nourrissons intoxiqués au cannabis. Ces patients s'étaient présentés avec des troubles aigus du comportement de type somnolence accompagnés d'hypotonie, de mydriase et de convulsions pour l'un d'eux. Du cannabis était présent soit dans les urines soit dans le sang dans les trois cas. Ces cas illustrent que le jeune âge ne doit pas exclure la recherche de toxiques dans les mises au point de troubles neurologiques aigus. L'intoxication au cannabis du nourrisson est un motif rare de consultation. La clinique est aspécifique et les manifestations sévères plus fréquentes à l'âge pédiatrique sont peu connues.

Sudden deaths in adult-worn baby carriers: 19 cases.

Soft infant carriers such as slings have become extremely popular in the west and are usually considered safe. We report 19 cases of sudden unexpected death in infancy (SUDI) linked to infant carrier. Most patients were healthy full-term babies less than 3 months of age, and suffocation was the most frequent cause of death. CONCLUSION: Infant carriers represent an underestimated cause of death by suffocation in neonates. WHAT IS KNOWN: • Sudden unexpected deaths in infancy linked to infant carrier have been only sparsely reported. WHAT IS NEW: • We report a series of 19 cases strongly suggesting age of less than 3 months as a risk factor and suffocation as the mechanism of death.

Paediatric community-acquired septic shock: results from the REPEM network study.

UNLABELLED: INTRODUCTION AND PURPOSE OF THE STUDY: With this study we aimed to describe a "true world" picture of severe paediatric 'community-acquired' septic shock and establish the feasibility of a future prospective trial on early goal-directed therapy in children. During a 6-month to 1-year retrospective screening period in 16 emergency departments (ED) in 12 different countries, all children with severe sepsis and signs of decreased perfusion were included. RESULTS: A 270,461 paediatric ED consultations were screened, and 176 cases were identified. Significant comorbidity was present in 35.8 % of these cases. Intensive care admission was deemed necessary in 65.7 %, mechanical ventilation in 25.9 % and vasoactive medications in 42.9 %. The median amount of fluid given in the first 6 h was 30 ml/kg. The overall mortality in this sample was 4.5 %. Only 1.2 % of the survivors showed a substantial decrease in Paediatric Overall Performance Category (POPC). 'Severe' outcome (death or a decrease ≥2 in POPC) was significantly related (p < 0.01) to: any desaturation below 90 %, the amount of fluid given in the first 6 h, the need for and length of mechanical ventilation or vasoactive support, the use of dobutamine and a higher lactate or lower base excess but not to any variables of predisposition, infection or host response (as in the PIRO (Predisposition, Infection, Response, Organ dysfunction) concept). CONCLUSION: The outcome in our sample was very good. Many children received treatment early in their disease course, so avoiding subsequent intensive care. While certain variables predispose children to become septic and shocked, in our sample, only measures of organ dysfunction and concomitant treatment proved to be significantly related with outcome. We argue why future studies should rather be large multinational prospective observational trials and not necessarily randomised controlled trials.

[Post-cardiac arrest syndrome in children]. / Le syndrome post-arrêt cardiaque chez l'enfant.

The occurrence of post-cardiac arrest syndrome may lead to death in some children who have recovered from a cardiac arrest. The post-cardiac arrest syndrome includes systemic ischaemia/reperfusion response, brain injury, myocardial dysfunction, and persistence of the precipitating pathology. The main cause of death is brain injury. Management includes strictly control of ventilation, oxygen therapy and haemodynamics associated with protection of the brain against any secondary injury: management of seizures, control of glycaemia and central temperature. Mild hypothermia should be considered in comatose children after cardiac arrest.

[The future of pediatric intensive care]. / Le futur des soins intensifs pédiatriques.

Paediatric intensive care is born 40 years ago. It has been shown that admission of critically ill children in intensive care (ICU) where no paediatric intensivists worked increased significantly the mortality and the length of stay. The recognition of Paediatric Intensive Care (PICU) does not exist in Belgium and children are admitted in both adult and paediatric intensive care units. It is mandatory to recognise the PICU specificity and the usefulness of a fellowship in paediatric intensive care. Development of molecular biology and genetics will permit in the near future to understand reversible and irreversible cellular processes of the majority of problems responsible for mortality in critical care and to allow the development of new diagnostic and therapeutic techniques. Rapid development of information will permit the creation of multicenter databases including all PICU's data. The final goal is an intelligent tool for making decision process. Telemedecine is born which permits a virtual consultation of the patient. Technological progress must not impair the wellbeing of the child and its family. The PICU of the future must be "parents admitted". PICU profile is progressively changing, the way of taking care of the critically ill child and its family is also changing and improving. An ethical reflexion among the health care providers' team and a dialogue with parents will blossom.

[Non-invasive bi-level ventilation in paediatric status asthmaticus]. / Ventilation non invasive chez un nourrisson en état de mal asthmatique.

Invasive ventilation in status asthmaticus is associated with an increased mortality and morbidity. To avoid intubation associated complications, non-invasive bi-level ventilation is often used in adults and children. We report the clinical history of an 11-month old infant, which encountered intubation criteria but was treated successfully by full-face mask non-invasive bi-level ventilation. Despite difficulties in application due to young age and lack of age related material, non-invasive bi-level ventilation is a good tool in the treatment of children with status asthmaticus.

Meningitis following basal skull fracture in two in-line skaters.

INTRODUCTION: In-line skating has been reported to cause severe head injury. Basilar skull fracture (BSF) is associated with a high risk of complication. CASE REPORT: We report two children who had bacterial meningitis following seemingly trivial in-line skating injuries. In both, anterior BSF was diagnosed retrospectively following occurrence of Streptococcus pneumoniae meningitis. DISCUSSION: The clinical signs indicating BSF depend on the fracture location. Plain skull radiography and computed tomography (CT) are not sensitive enough to detect thin fractures in the anterior cranial fossa. We argue that high resolution multiple-plane CT and coronal T2-weighted magnetic resonance imaging are indicated to diagnose BSF.

Endogenous endothelins and nitric oxide in hypoxic pulmonary vasoconstriction.

The effects of endothelin receptor blockade on the pulmonary circulation have been reported variably, possibly in relation to a more or less important associated release of endogenous nitric oxide (NO). The aim of this study was to test whether endothelin antagonism would inhibit hypoxic pulmonary vasoconstriction, and if it would not, then would it do so after NO synthase inhibition. Hypoxic pulmonary vasoconstriction (HPV) was evaluated in anesthetised dogs by the increase in the mean pulmonary artery pressure (Ppa) minus occluded Ppa (Ppao) gradient in response to hypoxia (inspiratory oxygen fraction of 0.1) at constant pulmonary blood flow. Bosentan, an endothelin A and B receptor antagonist, did not affect baseline Ppa, Ppao or systemic arterial pressure (Psa) and did not alter HPV (n=8). The NO synthase inhibitor N(G)-nitro-L-arginine (L-NA) did not affect baseline Ppa and Ppao, but increased Psa and enhanced HPV (n=12). The addition of bosentan in these dogs did not affect baseline Ppa or Ppao, but decreased Psa and inhibited HPV. Exhaled NO was decreased by L-NA and by bosentan and abolished by L-NA+bosentan (n=9). The authors conclude that endogenous nitric oxide is released by, and opposes the vasoconstricting effects of, endothelins in vivo, reducing systemic blood pressure and limiting hypoxic pulmonary vasoconstriction.

Resuscitation of the newly born.

International guidelines developed recommendations in the resuscitation of the new-born: at least one person trained in resuscitation of the newly born should attend every delivery. A minority of the new-borns require active resuscitation to achieve regular respiration, heart rhythm above 100/min, pink colour and adequate tone. Establishment of adequate ventilation should be of primary concern. Most new-borns who require positive-pressure ventilation can be adequately ventilated with a bag and mask. All healthcare providers, who may be asked to deal with an emergency delivery, should master such technique. In case of meconium-stained amniotic fluid, thorough oropharyngeal suctioning should be perform before the delivery of the chest. Tracheal aspiration of mecomium should be perform only in depressed child. Very few infants require chest compressions and much less administration of drugs. Umbilical access remains the most widely recommended access in new-born. Adequate transfer to Neonatal Unit improves outcome.

The use of dipyridamole to wean from inhaled nitric oxide in congenital diaphragmatic hernia.

A full-term neonate with a left-sided congenital diaphragmatic hernia (CDH) was ventilated mechanically by high-frequency oscillatory ventilation (HFOV). Despite inhaled nitric oxide (iNO) at a dose of 15 ppm, the neonate had severe respiratory acidosis and was placed on extracorporeal membrane oxygenation (ECMO) for 2 days. On day 7 of life, surgical repair of the CDH was performed. After the intervention, iNO (20 ppm) had to be restarted because of severe pulmonary hypertension (PHT). Ventilatory support and iNO then were weaned progressively. However, each daily attempt to discontinue iNO (from 2 ppm to 0 ppm), led to severe desaturation with significant right-to-left shunting. At the age of 33 days, dipyridamole (persantin) was administered intravenously at a dose of 0,4 mg/kg/min over 10 minutes and repeated every 12 hours for a total of 3 doses. After the second administration of dipyridamole, iNO could be stopped without rebound of PHT, and the neonate was extubated 1 week later. The authors report the use of dipyridamole for successful withdrawal of iNO. By inhibition of phosphodiesterase type 5, dipyridamole has the potential to increase the level of cyclic guanosine monophosphate in vascular smooth muscle cells, permitting vasodilation and restoration of endogenous NO. J Pediatr Surg 36:1864-1865.

Therapeutic strategies in near fatal asthma in children.

Status asthmaticus in children is associated with non-decreasing morbidity and mortality. Oxygen, beta2-agonists and corticosteroids remain the mainstay of therapy. Other therapies may be of help although their efficacy remains anecdotal. The development of new methods of ventilation for children with status asthmaticus is of utmost importance.