Infant Caudate Lobe Injury With Retroperitoneal Hematoma: A Case Report.

Liver injury, especially caudate lobe injury, is an extremely rare form of injury in infants. In most cases, liver injury results in intraperitoneal hemorrhage when the capsule is ruptured, and circulatory dynamics deteriorate early. Caudate lobe injuries, however, often present with a high retroperitoneal hematoma. The diagnosis is difficult to identify with a focused assessment with sonography for trauma (FAST) in the initial treatment of trauma and may even be delayed without contrast-enhanced CT imaging. A one-month-old postoperative boy with congenital heart disease was involved in a motor vehicle accident and presented with a single caudate lobe injury. He was not wearing a seatbelt, and it was thought that the caudate lobe was injured due to shearing forces in the cephalocaudal direction at the time of the accident. The patient did not go into shock when he first came to our hospital, but a few hours after admission, he went into shock and required surgical hemostasis. The postoperative course was good, and the patient was discharged alive one month later. The lesson to be learned from this case is that caudate lobe injuries are often associated with retroperitoneal hematoma and slow deterioration of hemodynamics, so it is important not to miss small changes in the child's vitals and to be willing to perform contrast-enhanced CT imaging depending on the type of injury.

Contrast Echocardiogram for the Evaluation of Streaming in a Single-Ventricle Patient.

In cases involving single ventricles, predicting streaming characteristics is difficult. Unfavorable streaming can cause decreased oxygen saturation. Judging whether desaturation results from decreased pulmonary flow or unfavorable streaming is critical. A 20-day-old infant with a single left ventricle underwent ductus arteriosus ligation and pulmonary artery banding to control high pulmonary flow. Severe desaturation presented postoperatively, which worsened to 68% despite pure-oxygen ventilation. A bedside contrast echocardiogram helped determine whether unfavorable streaming caused desaturation. It revealed systemic venous streaming predominantly directed to the aorta. Emergent balloon atrial septostomy facilitated mixing at the atrial level. Oxygen saturation promptly increased to 85%.

Inherited catecholaminergic polymorphic ventricular tachycardia due to RYR2 mutation.

We report the case of an 11-year-old boy who was diagnosed with catecholaminergic polymorphic ventricular tachycardia (CPVT). The patient had a medical history of three episodes of syncope. The last episode was cardiac arrest while swimming. After resuscitation using automated external defibrillator, he was placed under cerebral hypothermia, examined for long QT syndrome, and underwent insertion of implantable cardioverter defibrillator. He was subsequently discharged from hospital without any adverse sequelae. The patient was diagnosed with CPVT after detection of ryanodine receptor 2 mutation. His father also carried the same mutation, although he did not have any symptoms nor did he have a history of syncope. We propose that CPVT should be included in the differential diagnosis in children with recurrent episodes of syncope.

Postoperative complications associated with extubation strategies following palatoplasty: a single-center retrospective analysis.

PURPOSE: Palatoplasty carries a high risk of airway obstruction as a postoperative complication. Since 2007, the protocol in our hospital has been to leave an endotracheal tube in place after surgery while the patient is moved to the pediatric intensive care unit. Extubation is then performed after achievement of hemostasis and recovery of consciousness. We compared the cases over the 5-year periods before and after the introduction of this revised postsurgical management plan to investigate its effect on postoperative complications. METHODS: This was a retrospective cohort study involving a single pediatric hospital. The subjects were 199 children aged 1-3 years, who underwent palatoplasty between January 2002 and July 2012. Changes in the incidence rates of postoperative complications were statistically examined. RESULTS: There were significantly more postoperative complications among the patients who were extubated in the operating room than among those extubated in the intensive care unit (operating room group, 22/94 cases; intensive care unit group, 10/105 cases; P < 0.01). Serious complications, such as hypoxemia and airway obstruction, also occurred more frequently in the operating room group. CONCLUSION: Extubation in an intensive care unit was possibly associated with a reduction in postoperative complications.

Hemodynamic changes in child acute respiratory distress syndrome with airway pressure release ventilation: a case series.

BACKGROUND: Airway pressure release ventilation (APRV) is widely used in adult critical care settings. However, information on the use of APRV in the pediatric population is limited. METHODS: All patients admitted to the medical-surgical pediatric intensive care unit with a diagnosis of acute respiratory distress syndrome (ARDS) who received APRV for at least 12 h between 2007 and 2009 were reviewed. RESULTS: Thirteen patients with a variety of etiologies of ARDS were included, with a mean weight of 18.2 ± 15.0 kg, a mean age of 68 ± 57 months and a predicted mortality (based on Pediatric Index of Mortality version 2) of 23.9 ± 13.8%. Patients were placed on APRV for a median of 4 days (range 1-10 days). There was no change in blood gas parameters after 1 h or 12 h of APRV when compared with pre-APRV. There was no statistical difference in hemodynamic parameters, including mean arterial blood pressure, central venous blood pressure and heart rate, while the patients were on APRV. CONCLUSION: APRV could be safely used in pediatric ARDS patients, without significant hemodynamic compromise or side effects.

Secondary pseudohypoaldosteronism causing cardiopulmonary arrest and cholelithiasis.

A 4-month-old boy presented with cardiopulmonary arrest on arrival after a brief period of lethargy. Laboratory examination indicated severe hyperkalemia, hyponatremia, metabolic acidosis, and slightly elevated C-reactive protein. Whole body computed tomography identified left-dominant hydronephrosis, hydroureter and cholelithiasis. Despite cardiac arrest >30 min, he was successfully resuscitated and treated with therapeutic hypothermia. Escherichia coli was detected on urine culture. Renal ultrasound showed bilateral hydronephrosis, grade II in the right and grade IV in the left. Retrospective analysis of the blood sample at admission indicated a high level of aldosterone. The patient recovered almost fully with no electrolyte imbalance and normal plasma renin and aldosterone, leading to the diagnosis of secondary pseudohypoaldosteronism associated with bilateral infected hydronephrosis. In this case, cholelithiasis, which may account for chronic dehydration, was a diagnostic clue in the absence of information of pre-existing situations.

Mechanically ventilated children with 2009 pandemic influenza A/H1N1: results from the National Pediatric Intensive Care Registry in Japan.

OBJECTIVE: To outline the characteristics, clinical course, and outcome of pediatric patients requiring mechanical ventilation with influenza A/H1N1 infection in Japan. DESIGN: Prospective case registry analysis. SETTING: Eleven pediatric or general intensive care units in Japan. PATIENTS: Consecutive patients infected with A/H1N1, aged from 1 month to 16 yrs old admitted to the intensive care unit for mechanical ventilation between July 2009 and March 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eighty-one children, aged 6.3 [0.8-13.6] (median [interquartile range]) years, were enrolled. Seventy-four (91%) had mechanical ventilation with tracheal intubation. Median duration of mechanical ventilation was 4 days (range 0.04-87) and 18 patients (23%) required mechanical ventilation >7 days. Two patients (2%) required extracorporeal membrane oxygenation. The in-hospital mortality was 1%. Forty-one patients (50%) had at least one underlying chronic condition, including 31 with asthma. Associated clinical symptoms and diagnosis were as follows: acute respiratory distress syndrome (9%), asthma or bronchitis (37%), pneumonia (68%) with 8 (14%) having bacterial pneumonia, neurological symptoms (32%), myocarditis (2%), and rhabdomyolysis (1%). Therapeutic interventions include inotropic support (21%), methylprednisolone therapy (33%), and antimicrobial therapy (88%). Multivariate analysis revealed that inotropic support was the only statistically significant factor associated with mechanical ventilation for more than a week (odds ratio 5.5, 95% confidence interval 1.5-20.5, p = .005). CONCLUSIONS: The clinical presentations of pediatric patients requiring mechanical ventilation for A/H1N1 in Japan were diverse. In-hospital mortality of this population was remarkably low. Rapid access to medical facilities in combination with early administration of antiviral agents may have contributed to the low mortality in this population.

Survey of Japanese infants younger than 3 months who were treated with oseltamivir for influenza: safety of oseltamivir treatment.

BACKGROUND: Young infants with influenza virus infection are frequently hospitalized, and are at risk of serious complications including death. With the emergence of pandemic influenza A/H1N1 2009, oseltamivir was approved for use in Europe and the USA, including use in infants aged < 3 months. However, few data are available regarding the safety of oseltamivir treatment for influenza in infants aged < 3 months. METHODS: The clinical data from Japanese infants aged < 3 months with laboratory-confirmed influenza virus infections, who were treated with oseltamivir between October 2009 and April 2011, were collected and analyzed. RESULTS: Forty-four infants were included in the study. The median age was 1 month (range 4 days to 2 months) and median body weight was 4.5 kg (range 2.6-7.6 kg). Thirty-eight infants (86%) had no underlying diseases. The most common presenting symptom was fever (42 infants, 95%). There were no cases of influenza-associated encephalopathy or myocarditis. The median time between the onset of influenza symptoms and initiation of oseltamivir treatment was 0 days (range 0-7 days), with treatment initiated within 1 day in 40 infants (91%). The oseltamivir dose was 1.5-2 mg/kg twice daily in 98% of infants. No serious adverse events were identified during treatment. All infants recovered completely. CONCLUSIONS: Treatment of influenza with oseltamivir 1.5-2 mg/kg twice daily may be safe in infants aged < 3 months.

Incidence and risk factors for mortality in paediatric severe sepsis: results from the national paediatric intensive care registry in Japan.

PURPOSE: To assess the incidence, background, outcome and risk factors for death of severe sepsis in Japanese paediatric intensive care units (PICUs). METHODS: A data analysis of a prospective, multicentre, 3-year case registry from nine medical-surgical Japanese PICUs. Children with severe sepsis, aged 0-15 years, who were consecutively admitted to the participating PICUs from 1 January 2007 to 31 December 2009 were enrolled. The incidence, background, causative pathogens or infective foci, outcome and risk factors for death caused by severe sepsis were analysed. RESULTS: One hundred forty-one cases were registered. After the exclusion of 14 patients because of incomplete data or inappropriate entry, 127 patients were eligible for the analysis. There were 60 boys and 67 girls, aged 23 [5-68] (median [IQR]) months and weighed 10 [5.5-16.5] kg. The incidence was 1.4 % of total PICU admissions. Sepsis was community-acquired in 35 %, PICU-acquired in 37 % and acquired in hospital general wards in 28 %. Methicillin-resistant Staphylococcus aureus was the most frequent pathogen. The crude 28-day mortality was 18.9 %, comparable to the mean PIM-2 predicted mortality (17.7 %). The mortality rate in patients with shock was significantly increased to 28 % compared to those without shock (5 %). The presences of existing haematological disorders (OR 8.97, 95 % CI, 1.56-51.60) and shock (OR 5.35, 1.04-27.44) were significant factors associated with mortality by multivariate analysis. CONCLUSIONS: The mortality from severe sepsis/septic shock in Japanese PICUs was ~19 %. Haematological disorders and presence of shock were associated with death.

[Family issues around brain death in children].

Introducing brain death of children in Japan, there are three major concerns such as a) difficulty of diagnosing brain death in children, b) difficulty of taking care of family of the brain dead, c) difficulty of eliminating child abuse victims from donors, which are expressed by hospitals and health care providers. These issues are strongly connected to scarce resources of pediatric intensive care medicine and PICUs in Japan. They handle most of these tasks in the United States. Not only facilitating transplant medicine, but providing appropriate medical care for children, PICUs are essential and indispensable.

Capillary and arterial blood gases in hemorrhagic shock: a comparative study.

OBJECTIVES: To determine whether capillary blood gas samples accurately reflect the information obtained from arterial blood gas samples in a porcine hemorrhagic shock model. DESIGN: Randomized prospective study. SETTING: Animal research laboratory at a children's hospital. SUBJECTS: Fifteen adult Yorkshire pigs. INTERVENTIONS: Tracheally intubated, ventilated, and anesthetized pigs were randomly assigned to either a control group (n = 10) or a hemorrhagic shock group (n = 5). After instrumentation, the hemorrhagic shock group underwent a 40-mL/kg hemorrhage over 2 hrs, while the control group did not. Animals were then monitored over a 3-hr period. MEASUREMENTS AND MAIN RESULTS: Simultaneous arterial blood gas and capillary blood gas samples were obtained from each animal by using standardized technique. Capillary blood gas pH accurately predicted arterial blood gas pH in both control and hemorrhagic shock groups (r = .94, p < .01, and r = .78, p < .01, respectively). Bland-Altman analysis revealed a mean difference between arterial blood gas pH and capillary blood gas pH of 0.016 (95% limit of agreement, +/-0.037) in the control group vs. a mean difference between arterial blood gas pH and capillary blood gas pH of 0.075 (95% limit of agreement, +/-0.142) in the hemorrhagic shock group. Capillary blood gas Pco2 accurately predicted arterial blood gas Pco2 in the control group but not in the hemorrhagic shock group (r = .80, p < .01, and r = .13, p = .41, respectively). By Bland-Altman analysis, the mean difference between arterial blood gas Pco2 and capillary blood gas Pco2 was 3.9, with a 95% limit of agreement of +/-3.61 in the control group. In the hemorrhagic shock group, the mean difference between arterial blood gas Pco2 and capillary blood gas Pco2 was 11.7 with a 95% limit of agreement of +/-38.8. Hemorrhagic shock group capillary blood gas samples significantly overestimated Pco2 (Delta = 11.7, p < .01) and underestimated pH (Delta = 0.075, p < .01) compared with arterial blood gas samples. CONCLUSIONS: Capillary blood gas samples are poor predictors of Pco2 and pH in porcine hemorrhagic shock. These findings should be taken into account when capillary blood gas samples are used in the monitoring and management of subjects diagnosed with shock.