Incidence of pain after craniotomy in children.

BACKGROUND: There is very few information regarding pain after craniotomy in children. OBJECTIVES: This multicentre observational study assessed the incidence of pain after major craniotomy in children. METHODS: After IRB approval, 213 infants and children who were <10 years old and undergoing major craniotomy were consecutively enrolled in nine Italian hospitals. Pain intensity, analgesic therapy, and adverse effects were evaluated on the first 2 days after surgery. Moderate to severe pain was defined as a median FLACC or NRS score ≥ 4 points. Severe pain was defined as a median FLACC or NRS score ≥ 7 points. RESULTS: Data of 206 children were included in the analysis. The overall postoperative median FLACC/NRS scores were 1 (IQR 0 to 2). Twenty-one children (16%) presented moderate to severe pain in the recovery room and 14 (6%) during the first and second day after surgery. Twenty-six children (19%) had severe pain in the recovery room and 4 (2%) during the first and second day after surgery. Rectal codeine was the most common weak opiod used. Remifentanil and morphine were the strong opioids widely used in PICU and in general wards, respectively. Longer procedures were associated with moderate to severe pain (OR 1.30; CI 1.07-1.57) or severe pain (OR 1.41; 1.09-1.84; P < 0.05). There were no significant associations between complications, pain intensity, and analgesic therapy. CONCLUSION: Children receiving multimodal analgesia experience little or no pain after major craniotomy. Longer surgical procedures correlate with an increased risk of having postoperative pain.

Effects of positive end expiratory pressure (PEEP) on intracranial and cerebral perfusion pressure in pediatric neurosurgical patients.

BACKGROUND: Positive end expiratory pressure (PEEP) improves oxygenation by optimizing alveolar recruitment and reducing intrapulmonary shunt. Unfortunately, PEEP can interfere with intracranial pressure (ICP) by increasing intrathoracic pressure. We hypothesized that the use of different PEEP levels could have an effect on intracranial and cerebral perfusion pressure (CPP), gas exchange, respiratory system mechanics, and hemodynamics in pediatric patients undergoing major neurosurgical procedures. METHOD: Twenty-one consecutive pediatric patients undergoing surgical procedure for intracranial tumors were enrolled in this study, conducted between April 2008 and August 2009. Invasive radial pressure, central venous pressure (CVP), arterial oxygen saturation, ICP, and CPP were monitored. The middle cerebral artery mean velocity (V(med)) was determined by transcranial Doppler. At 0 cm H2O (ZEEP), the following parameters were recorded: systolic, mean, and diastolic arterial pressure, CVP, ICP, CPP, V(med), and arterial blood gases. After assessment at 0 PEEP (ZEEP), PEEP 4 and PEEP 8 were applied: all parameters were recorded at each level. RESULTS: The application of PEEP (from ZEEP to PEEP 8) significantly increased compliance of the respiratory system indexed to the weight of the patients (CrsI) (P=0.0001) without ICP modifications. No significant variations were observed in values of arterial pressure (MAP), CPP, V(med), total resistance of the respiratory system indexed to the weight of the patients (RRS(maxI)), and ohmic resistance of the respiratory system indexed to the weight of the patients (RRS(minI)). CVP significantly increased between ZEEP and PEEP 8 (P=0.02), and between PEEP 4 and PEEP 8 (P<0.05). Partial arterial pressure of oxygen (PaO2), partial arterial pressure of carbon dioxide (PaCO2), partial arterial pressure of oxygen/inspiratory fraction of oxygen (PaO2/FiO2), and pH were not significantly modified. CONCLUSION: We describe cerebral hemodynamic responses to PEEP application in pediatrics. PEEP values up to 8 cm H2O seem to be safe in pediatric patients with intracranial neoplasm, and, in our opinion, PEEP should be applied immediately after surgery to restore lung recruitment.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES).

BACKGROUND: In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases. METHODS: Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011. RESULTS: A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer). CONCLUSIONS: Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Rescue hypothermia for refractory hypercapnia.

Hypothermia may reduce the CO(2) production by decreasing the metabolism of the cooled tissue. We describe the first clinical use of hypothermia to lower hypercarbia in a case of bronchiolitis related respiratory failure unresponsive to maximal respiratory support. In this case, hypothermia allowed sparing the use of extracorporeal life support. Conclusion Hypothermia might be useful for severe acute respiratory failure unresponsive to aggressive respiratory support.

Plasma substitutes therapy in pediatrics.

Hypovolemia is the most common cause of circulatory failure in children and may lead to critical tissue perfusion and eventually multiple-organ failure. Administration of fluids to maintain or restore intravascular volume represents a common intervention after hemorrhagic shock occurring during surgical procedures or in patients with trauma. Notwithstanding, there is uncertainty whether the type of fluid may significantly influence the outcome, especially in pediatrics. Both human albumin and crystalloids are usually administered: the advantages of crystalloids include low cost, lack of effect on coagulation, no risk of anaphylactic reaction or transmission of infectious agents. However, large amount of crystalloid infusion has been correlated with pulmonary oedema, bilateral pleural effusions, intestinal intussusception, excessive bowel edema, impairing closure of surgical wounds and peripheral edema. Moreover, intravascular volume expansion obtained by crystalloids is known to be significantly shorter and less efficacious than colloids. Among synthetic colloids, gelatins have been used for many years in children, also in early infancy, to treat intravascular fluid deficits. Hydroxyethylstarch (HES) preparations have been introduced recently, becoming very popular for vascular loading both in adults and children. However, the number of pediatric studies aimed at evaluating HES efficacy and tolerance is limited. Given the ongoing controversies on the use of colloids in childhood, this review will focus on the pharmacodynamics of synthetic and non synthetic colloids for the treatment of critical blood loss in pediatrics.

Inotropic and vasoactive drugs in pediatric ICU.

Circulatory failure recognition and treatment represents an important issue in critically ill infants and children. Early diagnosis and prompt institution of adequate treatment may be life-saving for pediatric patients with cardiocirculatory instability in the setting of intensive care. However, the hemodynamic status of the critically ill child is poorly reflected by baseline vital parameters or laboratory blood tests. A reliable tool for diagnosis and monitoring of evolution of both heart performance and vascular status is strictly needed. Advanced hemodynamic monitoring consists - among others - of measuring cardiac output, predicting fluid responsiveness and calculating systemic oxygen delivery. Identification and quantifying of pulmonary edema has also been recently appreciated in pediatric critical care. In the last decade, the number of vasoactive drugs has increased, together with a better understanding of clinical application of both different monitoring devices and treatment strategies.

Pharmacological therapies for pediatric and neonatal ALI/ARDS: an evidence-based review.

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life-threating conditions still lacking a definite therapy and carrying a high mortality and morbidity, especially in children and infants. Albeit respiratory assistance and supportive therapies are crucial for ALI/ARDS, many drugs have been proposed to treat such syndromes through various mechanisms of action. On the whole the pharmacological therapy might play an important role in such a complex clinical situation but few evidence based data are available in pediatric and neonatal critical care. This review will focus on drugs directly available on the bedside, that is, medicines already administered in the practice or investigated in at least one clinical study. We will value the differences due to patient's age and the various causes of the syndrome, that may affect the response to the pharmacological therapy. A special attention will be given to the drugs directly deliverable into the lungs, as this strategy allows a total availability to the lung tissue. The experimental background behind each drug will be discussed and then clinical data in neonates and infants will be presented, if available. Data coming from adult critical care and thought to be somehow pertinent for the pediatric setting will otherwise be reviewed. Quality and evidence for or against each therapy will be evaluated according to the Scottish Intercollegiate Guidelines Network statement and practical reminders for clinicians will accordingly be provided.

Neuroprotection and hypothermia in infants and children.

Brain injury is the leading cause of death in pediatric ICU. Current evidence supports the use of therapeutic hypothermia (TH) in unconscious patients after out-of-hospital cardiac arrest when the initial heart rhythm was ventricular fibrillation. TH has been proved to be also beneficial in term neonates after hypoxic-ischemic encephalopathy (HIE) and in children with traumatic brain injury (TBI). Recent reports have also investigated TH for the treatment of superrefractory status epilepticus. The clinical application of TH is based on the possibility to inhibit or lessen a myriad of destructive processes (including excitotoxicty, neuroinflammation, apoptosis, free radical production, seizure activity, blood- brain barrier disruption, blood vessel leakage) that take place in the injured tissue following ischemia-reperfusion. TH may also represent a useful tool when conventional therapy fails to achieve an effective control of elevated intracranial pressure. This review is aimed to provide an update of the available literature concerning this intriguing topic.

Effect of amplitude and inspiratory time in a bench model of non-invasive HFOV through nasal prongs.

BACKGROUND AND OBJECTIVES: Non-invasive high frequency oscillatory ventilation through nasal prongs (nHFOV) has been proposed to combine the advantages of oscillatory pressure waveform and non-invasive interface. We studied the effect of oscillation amplitude and inspiratory time on the pressure transmission and tidal volume delivery through different nasal prongs. METHODS: In vitro mechanical study on a previously described bench model of nHFOV. The model was built connecting SM3100A tubings to a neonatal lung model, via two differently sized binasal prongs. A circuit with no nasal prongs was used as control. Tidal volume (T(v) ), oscillatory pressure ratio (ΔP(dist) /ΔP(prox) ), and ventilation (DCO(2) ) were measured across a range of amplitudes and inspiratory times (I(T) ). Measurements were performed with a low-dead space hot wire anemometer coupled with a pressure transducer. RESULTS: Using both nasal prongs, T(v) , ΔP(dist) /ΔP(prox) , and DCO(2) were 83%, 40%, and 71%, respectively, of those provided with the control circuit. No differences were noticed between small and large prongs. T(v) and ΔP(prox) were linked by a quadratic relationship. T(v) plateaus for amplitude values >65 cmH(2) O. ΔP(dist) /ΔP(prox) shows same tendency. Same results were obtained with both types of prongs and with increasing I(T) . On the whole, mean T(v) was higher with I(T) at 50% than at 33% (2.4 ml vs. 1.4 ml; P < 0.001). CONCLUSIONS: Changing oscillation amplitude and I(T) has a significant effect on ventilation. Varying these two parameters provides a theoretical T(v) within the ideal values for HFOV also using the smallest nasal prongs.

Nebulized iloprost and noninvasive respiratory support for impending hypoxaemic respiratory failure in formerly preterm infants: a case series.

OBJECTIVE: To describe a series of ex-preterm infants admitted to pediatric intensive care unit due to impending hypoxaemic respiratory failure complicated by pulmonary hypertension (PH) who were treated electively combining noninvasive ventilation (NIV) and nebulized iloprost (nebILO). DESIGN: Open uncontrolled observational study. SETTING: Pediatric Intensive Care Unit, University Hospital. PATIENTS: Ten formerly preterm infants with impending hypoxaemic respiratory failure and PH, of whom eight had moderate to severe bronchopulmonary dysplasia. MEASUREMENTS AND MAIN RESULTS: Median age and body weight were 6.0 (2.75-9.50) months and 4.85 (3.32-7.07) kg, respectively. We observed a significant early oxygenation improvement in terms of PaO(2) /FiO(2) increase (P = 0.001) and respiratory rate reduction (P = 0.01). Hemodynamic also improved, as shown by heart rate (P = 0.002) and pulmonary arterial pressure systolic/systolic systemic pressure (PAPs/SSP) ratio reduction (P = 0.0137). NebILO was successfully weaned in positive response cases: 4 infants were discharged on oral sildenafil. Three patients failed noninvasive modality and needed invasive mechanical ventilation; hypoxic-hypercarbic patients were most likely to fail noninvasive approach. Only one patient requiring invasive ventilation died and surviving babies had a satisfactory 1-month post-discharge follow-up. CONCLUSIONS.: The noninvasive approach combining NIV and nebILO for ex-preterm babies with impending respiratory failure and PH resulted to be feasible and quickly achieved significant oxygenation and hemodynamic improvements.

The number of failing organs predicts non-invasive ventilation failure in children with ALI/ARDS.

PURPOSE: Non-invasive positive pressure ventilation (NIV) is being increasingly used in paediatric critical care, although its use in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) is still debated. No definite data are available for the prediction of NIV outcome in such selected populations. We aimed to identify which factors might affect NIV failure in paediatric ALI/ARDS patients. METHODS: A retrospective cohort study using comprehensive predictivity analysis was performed. All children admitted to our paediatric intensive care unit over a 4-year period for ALI/ARDS were reviewed. Basic, clinical, physiological parameters and their change after 1 h of NIV were considered and subjected to univariate analysis. Candidate prognostic variables were then subjected to multicollinearity scrutiny and logistic regression. Finally, variables significant in the logistic regression were subjected to predictivity analysis. RESULTS: The number of organ failures at admission (NOF) is a strong predictor of NIV failure (odds ratio 5.26; p = 0.004). Having only one organ failure provides a probability of NIV success of 85.7% (sensitivity 87%; specificity 49%). One NIV failure will be predicted and avoided for every four cases in which the presence of other organ failures is incorporated into the clinical decision. CONCLUSIONS: NOF significantly predicts the NIV failure. Children with no organ failures other than ALI/ARDS may safely be treated with NIV.

Role of distinct phospholipases A2 and their modulators in meconium aspiration syndrome in human neonates.

PURPOSE: Meconium aspiration syndrome (MAS) is a life-threatening neonatal lung injury, whose pathophysiology has been mainly studied in animal models. In such models, pancreatic secretory phospholipase A2 (sPLA2-IB) and proinflammatory cytokines present in meconium challenge the lungs, catabolising surfactant and harming the alveoli. Locally produced phospholipases might perpetuate the injury and influence clinical pictures and therapeutic approaches. Our aim is to verify whether pulmonary phospholipase A2 (sPLA2-IIA) is involved in the damage and to determine if phospholipases and their modulators are associated with MAS clinical pictures. METHODS: We studied distinct phospholipases A2 and their modulators in broncho-alveolar lavage (BAL) fluids and in meconium of five MAS neonates and in five control neonates ventilated for extrapulmonary reasons. RESULTS: MAS patients have higher amounts of pulmonary phospholipase (sPLA2-IIA; P = 0.016) and Clara cell secretory protein (CCSP; P = 0.032). The local production of such proteins by the lung is confirmed by their very low levels in meconium. sPLA2-IIA contributes to the higher total enzyme activity in MAS patients, as compared to controls (P = 0.008). Cytosolic phospholipase was not detected in meconium or alveolar fluid. sPLA2 activity and sPLA2-IIA concentrations are correlated with the TNFα and with the release of CCSP. sPLA2 total activity, sPLA2-IIA and TNFα concentrations in BAL fluids correlate with the oxygenation impairment and haemorrhagic lung oedema. CONCLUSIONS: Pulmonary sPLA2 is locally produced and contributes to the total sPLA2 activity during MAS. CCSP is also produced in trying to lower the inflammation. Both sPLA2 activity and sPLA2-IIA are significantly correlated with oxygenation impairment and haemorrhagic lung oedema.

Tension chylothorax complicating acute malignant airway obstruction.

Acute upper airway obstruction represents one of the most challenging emergencies in pediatric practice. In particular, a tension chylothorax complicating a malignant airway obstruction is a rare and life-threatening complication. We report a rapidly progressing tension chylothorax associated with a cervical mass in a 10-month-old male infant. To our knowledge, the extension of a cervical mass to the supraclavear region resulting in a compressive chylothorax represents an exceptional event in pediatrics. Early recognition and prompt treatment resulted to be essential to relieve the compression and to avoid end-stage hemodynamic and respiratory function derangement.

Neurogenic stunned myocardium presenting as left ventricular hypertrabeculation in childhood: a variant of Takotsubo cardiomyopathy?

OBJECTIVE: To report the first case of neurogenic stunned myocardium presenting with heart left ventricle noncompaction requiring intensive care in the perioperative period of tension tumor-induced hydrocephalus. METHODS AND DESIGN: Case report and literature review. Our Institutional Review Board waived the need for consent. PATIENT: A 12-yr-old female with intracranial astrocytoma and hypertensive hydrocephalus presented with severe heart dysfunction and life-threatening ventricular ectopies intraoperatively. A severe heart failure developed requiring hemodynamic and ventilatory support for 10 days. Echocardiography showed a transient noncompaction aspect of the left ventricular wall, further confirmed by a cardiac magnetic resonance image. The noncompaction aspect lasted until 15 days postadmission, as was the case for the QT interval prolongation; no life-threatening ectopies were demonstrated on the subsequent Holter electrocardiogram monitoring. CONCLUSIONS: This report describes a unique presentation of myocardial stunning in association with an intracranial illness, namely, a hypertensive hydrocephalus complicating an intracranial neoplasm.

Secretory phospholipase A2 pathway during pediatric acute respiratory distress syndrome: a preliminary study.

OBJECTIVE: To verify if secretory phospholipase A2 (sPLA2) is increased in pediatric acute respiratory distress syndrome (ARDS) triggered or not by respiratory syncytial virus infection and to clarify how the enzyme may influence the disease severity and the degree of ventilatory support. DESIGN: Prospective pilot study. SETTING: Two academic pediatric intensive care units. PATIENTS: All infants < 6 months old hospitalized for severe respiratory syncytial virus bronchiolitis, who developed ARDS (respiratory syncytial virus-ARDS group); all infants < 6 months old diagnosed with ARDS secondary to other causes (ARDS group); and infants < 6 months old who needed ventilation for reasons other than any lung disease (control group). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We enrolled six respiratory syncytial virus -ARDS babies, five ARDS babies, and six control infants. The sPLA2 activity and tumor necrosis factor (TNF)-α were significantly higher in the bronchoalveolar lavage of ARDS infants. Worst oxygenation, ventilation, and longer pediatric intensive care unit stay and ventilation time were present in ARDS babies. No differences were found in Clara cell secretory protein and in serum cytokines levels. Because there is no correlation between bronchoalveolar lavage protein content (a marker of permeability) and sPLA2, the enzyme seems mainly produced in the alveoli. TNF-α, the main inductor of sPLA2 expression, significantly correlates with the enzyme level in the bronchoalveolar lavage. Significant positive correlations exist between sPLA2, TNF-α and oxygen need, mean airway pressure, ventilatory index, and the Murray's lung injury score. Negative correlations were also found between sPLA2, TNF-α, and Pao2/Fio2 ratio. CONCLUSIONS: The sPLA2 and TNF-α are increased in ARDS and seem correlated with clinical severity, higher oxygen requirement, and more aggressive ventilation. This correlation confirms findings from adult experience and should guide further investigations on pediatric ARDS pathophysiology.