Ketamine Use for Tracheal Intubation in Critically Ill Children Is Associated With a Lower Occurrence of Adverse Hemodynamic Events.

OBJECTIVES: Tracheal intubation in critically ill children with shock poses a risk of hemodynamic compromise. Ketamine has been considered the drug of choice for induction in these patients, but limited data exist. We investigated whether the administration of ketamine for tracheal intubation in critically ill children with or without shock was associated with fewer adverse hemodynamic events compared with other induction agents. We also investigated if there was a dose dependence for any association between ketamine use and adverse hemodynamic events. DESIGN: We performed a retrospective analysis using prospectively collected observational data from the National Emergency Airway Registry for Children database from 2013 to 2017. SETTING: Forty international PICUs participating in the National Emergency Airway Registry for Children. PATIENTS: Critically ill children 0-17 years old who underwent tracheal intubation in a PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The association between ketamine exposure as an induction agent and the occurrence of adverse hemodynamic events during tracheal intubation including dysrhythmia, hypotension, and cardiac arrest was evaluated. We used multivariable logistic regression to account for patient, provider, and practice factors with robust SEs to account for clustering by sites. Of 10,750 tracheal intubations, 32.0% (n = 3,436) included ketamine as an induction agent. The most common diagnoses associated with ketamine use were sepsis and/or shock (49.7%). After adjusting for potential confounders and sites, ketamine use was associated with fewer hemodynamic tracheal intubation associated adverse events compared with other agents (adjusted odds ratio, 0.74; 95% CI, 0.58-0.95). The interaction term between ketamine use and indication for shock was not significant (p = 0.11), indicating ketamine effect to prevent hemodynamic adverse events is consistent in children with or without shock. CONCLUSIONS: Ketamine use for tracheal intubation is associated with fewer hemodynamic tracheal intubation-associated adverse events.

Analyses of the temperature and pH effects on the complexation of magnesium and calcium in human blood plasma: an approach using artificial neural networks.

The temperature and pH effects on the equilibrium of a blood plasma model have been studied on the basis of artificial neural networks. The proposed blood plasma was modeled considering two important metals, calcium and magnesium, and six ligands, namely, alanate, carbonate, citrate, glycinate, histidinate and succinate. A large data set has been used to simulate different concentrations of magnesium and calcium as a function of temperature and pH and these data were used for training the neural network. The proposed model allowed different types of analyses, such as the effects of pH on calcium and magnesium concentrations, the competition between calcium and magnesium for ligands and the effects of temperature on calcium and magnesium concentrations. The model developed was also used to predict how the variation of calcium concentration can affect magnesium concentrations. A comparison of neural network predictions against experimental data produced errors of about 3%. Moreover, in agreement with experimental measurements (Wang et al. in Arch. Pathol. 126:947-950, 2002; Heining et al. in Scand. J. Clin. Lab. Invest. 43:709-714, 1983), the artificial neural network predicted that calcium and magnesium concentrations decrease when pH increases. Similarly, the magnesium concentrations are less sensitive than calcium concentrations to pH changes. It is also found that both calcium and magnesium concentrations decrease when the temperature increases. Finally, the theoretical model also predicted that an increase of calcium concentrations will lead to an increase of magnesium concentration almost at the same rate. These results suggest that artificial neural networks can be efficiently applied as a complementary tool for studying metal ion complexation, with especial attention to the blood plasma analysis.

Favorable outcome of neonatal aortic thrombosis and renovascular hypertension.

Fifteen children with renovascular hypertension as a result of aortic thrombosis were followed for a mean of 26 months (range 5 to 58 months) to determine outcome. As neonates, all patients had hypertension and elevated plasma renin activity. Of 11 patients studied with radionuclide renography and scintigraphy, 10 had abnormal renal blood flow; three had complete absence of unilateral perfusion. On follow-up examination all children were normotensive; five children ages 5 to 24 months required antihypertensive medication. Of 15 children, 14 had normal statural growth; all had normal serum creatinine, plasma renin activity, and calculated glomerular filtration rate values. Patients with complete absence of renal perfusion unilaterally remained functionally anephric; children with less severe perfusion deficits had improved perfusion as shown by radionuclide renography and scintigraphy. We believe that many patients with aortic thrombosis and renovascular hypertension who have had aggressive antihypertensive therapy in the neonatal period will have good renal function and increased perfusion to the affected kidney 2 years later.

Occupational health risks for Mexican women: the case of the maquiladora along the Mexican-United States border.

International reports of morbidity among female workers in Mexico's border zone have raised concern about the occupational health of female workers in maquiladora plants (foreign-owned border industries with special tariff benefits). Commentators have suggested that U.S. industries may be exploiting workers by transferring work to nations with less stringent health and safety regulation through the maquiladora program. Using data from a larger evaluation of the effectiveness of Project Concern and a specially developed questionnaire, this study investigated the extent to which female workers reported higher morbidity rates than women with other employment and women not employed outside the home in seven colonias (communities) in Tijuana, Baja California, Mexico. Results showed essentially no difference in many short-term self-reported symptoms of illness among maquiladora workers and two other groups. Women who worked exclusively in the home reported the greatest number of symptoms. These results suggest that additional primary care services may be needed for women who have primarily domestic responsibilities. Additional research is needed to assess the risks for long-latency morbidity.

Cooperation in health affairs between adjacent international communities: a successful model.

The border between the United States and Mexico presents a number of problems related to health that are simultaneously local and international. Large-scale government-to-government interactions have generally failed to achieve lasting cooperation on important health issues, with a few important exceptions. One reason for this may be that the issues have been complicated by much larger and more complex social, cultural, economic, and political differences. Another is that large organizations must each function according to their own mandates, goals, and procedures and may not mesh well with others, even with nominal counterparts. In 1981 we conceptualized a model for encouraging binational cooperation on small-scale local projects. The model incorporates three elements: a significant and difficult but soluble technical problem affecting both sides of the border (the "technocratic factor"), a mutually respected individual or team whose function is to facilitate communication and prevent misunderstandings (the "human factor"), and the actions of governments or institutions larger than the working groups (the "institutional factor"). Subsequently, we applied the model to water quality and to the distribution of sources of toxic substances in the border area, which met the criteria for the technocratic factor. Two highly respected figures in environmental health, one American and one Mexican, mediated between colleagues on either side of the border and facilitated the development of projects. Finally, after the projects had been under way long enough to have demonstrated their viability and personal interactions among the principals had become trusting and collegial, the institutional factor was admitted and major financial and administrative support obtained.(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal aortic thrombosis: recent experience.

To evaluate the course, use of diagnostic modalities, management, and outcome of aortic thrombosis associated with umbilical artery catheterization, we reviewed 20 cases of aortic thrombosis diagnosed by ultrasonography (n = 16) or aortography (n = 4) over 4 years. Fourteen of 20 infants had severe perinatal asphyxia, suggesting that asphyxia predisposes to aortic thrombosis. Ultrasonography provided information about the size, location, and configuration of the thrombus and was useful in following thrombus size with therapy. Radionuclide renography-scintigraphy demonstrated abnormal renal function in all 11 patients scanned. Six patients with minor thrombosis (hypertension as the only sign) improved without specific therapy. Nine infants had moderate thrombosis (multiple signs but normal urine output); all survived with a variety of therapies; two were not given anticoagulant or fibrinolytic agents; three improved with heparin alone; and one had surgery without recurrence of the thrombus. Resolution of moderate thrombosis followed streptokinase therapy in two of three infants. All five babies with anuria from major thrombosis died. Hepatic infarction associated with aortic thrombosis was found in three of three autopsies.