Implementing a physician-driven feeding protocol is not sufficient to achieve adequate caloric and protein delivery in a paediatric intensive care unit: A retrospective cohort study.

BACKGROUND AND AIMS: Daily caloric and protein intake is crucial for the management of critically ill children. The benefit of feeding protocols in improving daily nutritional intake in children remains controversial. This study aimed to assess whether the introduction of an enteral feeding protocol in a paediatric intensive care unit (PICU) improves daily caloric and protein delivery on day 5 after admission and the accuracy of the medical prescription. METHODS: Children admitted to our PICU for a minimum of 5 days who received enteral feeding were included. Daily caloric and protein intake were recorded and retrospectively compared before and after the introduction of the feeding protocol. RESULTS: Caloric and protein intake was similar before and after introduction of the feeding protocol. The prescribed caloric target was significantly lower than the theoretical target. The children who received less than 50% of the caloric and protein targets were significantly heavier and taller than those who received more than 50%; the patients who received more than 100% of the caloric and protein aims on day 5 after admission had a decreased PICU length of stay and decreased duration of invasive ventilation. CONCLUSION: The introduction of a physician-driven feeding protocol was not associated with an increase in the daily caloric or protein intake in our cohort. Other methods of improving nutritional delivery and patient outcomes need to be explored.

Intra-arterial vasodilators infusion for management of reversible cerebral vasoconstriction syndrome in a 12-year-old girl: A case report.

Reversible cerebral vasoconstriction syndrome (RCVS) is a vascular disease characterized by diffuse transient vasoconstriction and vasodilatation of the cerebral arteries. It is commonly associated with recurrent severe acute headaches with or without focal neurological deficits due to hemorrhages, infarcts, and even posterior reversible encephalopathy syndrome. The optimal management of acute neurologic deficits caused by RCVS is still uncertain. Calcium channel blockers (CCBs) such as nimodipine or verapamil have been reported to be effective in adult series. Intra-arterial injection of nimodipine, verapamil, and milrinone has recently been demonstrated to be safe and effective for treating severe segmental vasoconstriction in adults. CCBs are the most used treatment in the available pediatric literature. Intra-arterial vasodilators have been reported in some rare pediatric reports with more severe diseases, but their utility is still under investigation. We report a case of a 12-year-old girl who underwent a severe course of RCVS complicated by multiple cerebral infarcts, treated by several sessions of intra-arterial vasodilators infusion.

Suspected Case of Drug-Induced Acute Respiratory Distress Syndrome following Trimethoprim-Sulfamethoxazole Treatment.

In this article, we reported the case of a child patient who was admitted to our PICU for severe acute respiratory distress syndrome (ARDS) while being treated with trimethoprim-sulfamethoxazole (TMP-SMX) for osteomyelitis. Based on the timing of exposure, lack of alternative explanations, and clinical course similar to previously described cases, we suspect that TMP-SMX may have triggered ARDS. Despite meeting criteria for extracorporeal membrane oxygenation cannulation, conservative management and lung recruitment with high-frequency percussive ventilation could avoid the latter.

Severe Lactic Acidosis in a Critically Ill Child: Think About Thiamine! A Case Report.

In this article, we presented a teenager, in maintenance chemotherapy for leukemia, who was admitted for digestive symptoms related to a parasitic infection and required nutritional support with parenteral nutrition. After 6 weeks, his condition worsened with refractory shock of presumed septic origin, necessitating extracorporeal membrane oxygenation. Despite hemodynamic stabilization, his lactic acidosis worsened until thiamine supplementation was started. Lactate normalized within 12 hours. Thiamine is an essential coenzyme in aerobic glycolysis, and deficiency leads to lactate accumulation through anaerobic glycolysis. Thiamine deficiency is uncommon in the pediatric population. However, it should be considered in patients at risk of nutritional deficiencies with lactic acidosis of unknown origin.

Case Report: Colchicine Toxicokinetic Analysis in a Poisoned Child Requiring Extracorporeal Life Support.

Colchicine poisoning is associated with a poor prognosis, especially when leading to shock and multi-organ failure, and management is limited to supportive care, including multiple-dose activated charcoal. At therapeutic concentrations, colchicine elimination occurs mainly through hepatic metabolism and involves an enterohepatic circulation, with a small contribution of renal elimination (10-30%). Colchicine toxicokinetics is however rarely described, especially in children. We present the case of a 4-year-old patient who survived a severe iatrogenic colchicine intoxication with a dose of 0.5 mg/kg. She developed multi-organ failure and shock, but recovered after receiving aggressive resuscitation, including extracorporeal life support. Close monitoring of colchicine blood levels showed a plateau for 6 days, indicating impeded elimination resulting from liver failure. We observed no significant clearance from renal replacement therapy, nor activated charcoal, during this period. Extracorporeal life support may play a supportive role in the management of severe colchicine poisoning. However, extracorporeal techniques do not seem to improve colchicine elimination.

Extracorporeal cardiopulmonary resuscitation for severe chloroquine intoxication in a child - a case report.

BACKGROUND: Chloroquine use has increased worldwide recently in the setting of experimental treatment for the novel coronavirus disease (Covid-19). Nevertheless, in case of chloroquine intoxication, it can be life threatening, with cardiac arrest, due to its cardiac toxicity. CASE PRESENTATION: This case study reports on a 14-years-old girl who presented in cardiac arrest after an uncommon suicide attempt by ingesting 3 g of chloroquine. After 66 min of cardio-pulmonary resuscitation (CPR), extracorporeal cardiopulmonary resuscitation (ECPR) was initiated, allowing cardiac function to recover. CONCLUSIONS: Chloroquine intoxication is a rare but serious condition due to its cardiac toxicity. Use of ECPR in this case of transient toxicity allowed a favorable evolution with little neurological impairment.

Point-of-care hemostasis in children with congenital heart disease, the POCHEMO study: baseline reference values of thromboelastometry and impedance aggregometry.

: Viscoelastic tests and impedance aggregometry allow coagulation evaluation at the bedside, but reference values are scarce in pediatrics. The aim of this study was to establish reference values of thromboelastometry and impedance aggregometry for this population and compare it between age groups. This prospective, single-center, observational study evaluates viscoelastic tests and impedance aggregometry in children with congenital heart disease. A total of 204 children were included with a median age of 3.6 years old. We provide references values for this population with median, percentile 2.5 and percentile 97.5. Infants demonstrate for extrinsic activity a shorter coagulation time (52 [49-55] vs. 56 [51-62] s, P = 0.007) and clot formation time (90 [71-118] vs. 113 [93-146] s, P < 0.0001) so as for intrinsic activity a shorter clot formation time (53 [44-69] vs. 75 [59-92] s, P < 0.0001). The maximal clot firmness was significantly stronger in infants for extrinsic (65 [61-69] vs. 59 [54-63] mm, P < 0.0001), intrinsic (68 [64-70] vs. 61 [57-65] mm, P < 0.0001), and fibrinogen (12 [9-16] vs. 10 [8-13] mm, P = 0.02) activities. Platelet aggregation was significantly higher in infants with an amplitude at 6 min of 28 [23-34] vs. 22 [15-27] Ω, P less than 0.0001, a maximum speed of 11 [9-13] vs. 7 [5-10] Ω/min, P less than 0.0001, and an area under the curve of 120 [92-135] vs. 86 [59-112] Ω min, P less than 0.0001. We provided the first reference values for impedance aggregometry and thromboelastometry in children with congenital heart disease. We showed that these infants tend to have accelerated coagulation and stronger clot firmness compared with older children, but this finding may have only minimal relevance when treating a bleeding child. Trial registration number: ClinicalTrials.gov (clinicaltrials.gov/ct2/show/NCT02387944).

CytoSorb® hemoadsorption and mechanical circulatory support in a newborn with refractory shock after congenital heart surgery.

Refractory cardiogenic and vasoplegic shock after congenital heart surgery is a threatening condition leading to high morbidity and mortality. Control of hemodynamic and inflammatory response is fundamental in medical strategy. We report the case of a newborn with cardiogenic and vasoplegic shock secondary to cardiopulmonary bypass for atrioseptostomy and prostaglandin treatment in the context of hypoplastic left heart syndrome, successfully treated with a combination of mechanical circulatory support and cytokine hemoadsorption column (CytoSorb®). Vasopressor support was weaned during the time of treatment without multiple organ failure occurrence. The use of CytoSorb® cartridge inserted in an extra-corporeal circuit even in a newborn is easy and feasible, as long as some precautions are considered. Routine monitoring of drugs levels is mandatory during the use of the cartridge and immediately after.

Clindamycin clearance during Cytosorb® hemoadsorption: A case report and pharmacokinetic study.

Panton-Valentine leucocidin producing methicillin-resistant Staphylococcus aureus infections are rare but associated with very high mortality rates. We report the case of a 14-year-old patient with Panton-Valentine leucocidin producing methicillin-resistant Staphylococcus aureus infection and Influenza B pneumonia requiring veno-arterial extra-corporeal membrane oxygenator for refractory shock. In the absence of response to conventional therapy, we have inserted a Cytosorb® cartridge within the extra-corporeal membrane oxygenator circuit. A spectacular decrease in vasopressor requirements followed. Since clindamycin, a key component of Panton-Valentine leucocidin producing methicillin-resistant Staphylococcus aureus treatment, might be removed by Cytosorb® hemoadsorption, we have performed serial plasma concentrations measurements of the drug. Based on these measurements, we were able to develop a pharmacokinetic model incorporating variable plasma clearance. Patient's exposure was estimated before, during and after Cytosorb® hemoadsorption. According to this model, Cytosorb® hemoadsorption did not seem to result in significant clindamycin removal. Cytosorb® hemoadsorption during Panton-Valentine leucocidin producing methicillin-resistant Staphylococcus aureus infection appears safe and feasible and no adaptation of clindamycin dosage seems necessary.

Leukemoid Reaction in Infant Pertussis: Is There a Place for Hydroxyurea? A Case Report.

A 73-days old infant of 34 weeks' gestation was hospitalized with a co-infection of respiratory syncytial virus (RSV) and Bordetella pertussis (BP). She required invasive ventilation for 9 days in the context of malignant pertussis with persistent hypoxemia and hypercapnia secondary to a leukemoid reaction. Despite an increase of white blood cell (WBC) count up to 70 G/L and ensuing pulmonary hypertension, no hemodynamic compromise occurred. Without clear indication for leukapheresis nor exchange transfusion, an off-label treatment with hydroxyurea was given for 5 days with gradual decrease of WBC count, without any complication and hospital discharge on day 29. To our knowledge, no effective therapy for malignant pertussis has been described in the literature and complications are frequent with leukoreduction procedures. We discuss an alternative to invasive procedures in young infants to fulfill the need to decrease rapidly leukocyte counts in a leukemoid reaction associated with Bordetella pertussis infection. To our knowledge, hydroxyurea has never been used in malignant pertussis but is a well-known medication for oncologic and hematologic diseases such as acute myeloid leukemia or sickle cell anemia. Its effects in this setting are not well understood but the positive outcome in our patient supports the need for further studies.

[Varicella during pregnancy: consequences for the mother and the newborn]. / Varicelle pendant la grossesse: quelles conséquences pour la mère et l'enfant?

In our area, varicella is a frequent and essentially benign childhood disease. In contrast, the disease course is likely to be more severe or complicated in the adult, particularly so in the pregnant woman. There is a definite risk of congenital varicella syndrome when the chickenpox occurs during the first 20 weeks of pregnancy. This syndrome predominantly affects the skin, the subcutaneous tissue, muscles and bones, as well as the central nervous system, and can bring about major functional sequellae. In case of chickenpox occurring at the very end of pregnancy, transplacental transfer of the virus may result in a perinatal varicella disease. We propose a approach of each of these different situations.