Neuromonitoring in Children with Traumatic Brain Injury.

Traumatic brain injury remains a major cause of mortality and morbidity in children across the world. Current management based on international guidelines focuses on a fixed therapeutic target of less than 20 mm Hg for managing intracranial pressure and 40-50 mm Hg for cerebral perfusion pressure across the pediatric age group. To improve outcome from this complex disease, it is essential to understand the pathophysiological mechanisms responsible for disease evolution by using different monitoring tools. In this narrative review, we discuss the neuromonitoring tools available for use to help guide management of severe traumatic brain injury in children and some of the techniques that can in future help with individualizing treatment targets based on advanced cerebral physiology monitoring.

Conservative approach of a paediatric tracheal rupture.

A girl was brought into the emergency room after a non-penetrating cervical trauma. On physical examination, a rapidly progressing chest subcutaneous emphysema was denoted. The child was immediately intubated and mechanical ventilation was initiated. The CT-scan revealed a rupture to the posterior wall of the trachea and a pneumomediastinum. The child was transferred to the paediatric intensive care unit. A conservative approach was chosen, including tracheal intubation as a bypass through the tracheal injury, sedation to reduce the risk of further tracheal trauma and prophylactic antibiotic therapy. Twelve days after the incident, a bronchoscopy demonstrated the integrity of tracheal mucous and the child was successfully extubated. Three months after hospital discharge she was asymptomatic. In this clinical case, the conservative approach presented a successful outcome, avoiding the risks associated with surgery.

Extracorporeal Membrane Oxygenation in an Adolescent with Multisystem Inflammatory Syndrome in Children.

Multisystem inflammatory syndrome in children is a rare and potentially life-threatening disease that is associated with SARS-CoV-2 infection, characterized by hyperinflammation and multiorgan involvement. Cardiovascular involvement is common, including myocardial dysfunction often leading to cardiogenic shock. We present the case of a 17-year-old boy with fever, odynophagia, maculopapular rash and abdominal pain who developed a cardiogenic shock. Due to progressive deterioration of cardiac function despite optimized vasoactive support, veno-arterial extracorporeal membrane oxygenation support was initiated 12 hours after admission, with successful decannulation after seven days and discharge after 23 days, with normal cardiac function. The patient received corticosteroids and intravenous immunoglobulin. Early recognition and intensive care support are crucial for ensuring a successful outcome in severe cases of multisystem inflammatory syndrome. In cases of severe cardiogenic shock, extracorporeal membrane oxygenation support can be critical for survival and rapid recovery.

The parental psychological distress caused by separation from their critically ill child during the COVID-19 pandemic: A tale of two cities.

Introduction: A child's critical illness is a stressful event for the entire family, causing significant emotional distress among parents and changes to family functioning. The Severe Acute Respiratory Syndrome-Related Coronavirus 2 (SARS-CoV-2) pandemic has abruptly caused modifications in visitation policies of Pediatric Intensive Care Units (PICUs) in many countries. We hypothesized that caregivers with no or severely restricted access to PICUs would demonstrate increased psychological distress as compared to those who had limitless access (LA) to PICUs. Methods: Sociodemographic variables, levels of psychological distress, ratings of family functioning, and ability to cope with stressful events were collected with an online survey in a group of caregivers after their child's hospitalization. Ratings of psychological distress were compared between caregivers with no/severely restricted (NA) and with LA to PICUs. Results: Measures of depression, anxiety, and global severity index (GSI) of psychological distress were significantly higher in NA caregivers as compared to LA. Among demographic characteristics of the sample, only gender influenced the severity of psychological symptoms: women showed an increased score on levels of somatization, depression, anxiety, and GSI. Avoidant coping style positively correlated with measures of depression. Univariate General Linear Model (GLM) analyses of the effects of sex, age, visitation policies of PICUs, and score of avoidant coping strategies on measures of psychological distress confirmed a significant univariate effect of no access to PICUs on parents' psychopathological scores. Conclusion: Restrictions imposed on visitation policies in PICU during the pandemic negatively impacted families' psychological wellbeing. A balance between the safety of patients, families, and health care professionals and meeting the needs of families is of utmost importance.

Inborn Errors of Metabolism in a Tertiary Pediatric Intensive Care Unit.

Few studies exist describing resources and care of pediatric patients with inborn errors of metabolism (IEM) admitted to pediatric intensive care unit (PICU). This study aims to characterize the PICU admissions of these patients to provide better diagnostic and therapeutic care in the future. Retrospective analysis of pediatric patients with IEM admitted to the PICU of a tertiary care center at a metabolic referral university hospital from 2009 to 2019 was included. Clinical information and demographic data were collected from PICU clinical records. During this period, 2% ( n = 88 admissions, from 65 children) out of 4,459 PICU admissions had clinical features of IEM. The median age was 3 years (range: 3 days-21 years) and 33 were male. Median age at diagnosis was 3 months; 23/65 patients with intoxication disorders, 21/65 with disorders of energy metabolism, 17/65 with disorders of complex molecules, and 4/65 with other metabolic diseases (congenital lipodystrophy, Menkes' disease, hyperammonemia without a diagnosis). From a total of 88 admissions, 62 were due to metabolic decompensation (infection-38, neonatal period decompensation-14, external accident-5, prolonged fasting-2, and therapeutic noncompliance-3) and 26 elective admissions after a scheduled surgery/elective procedure. The most frequent clinical presentations were respiratory failure (30/88) and neurological deterioration (26/88). Mechanical ventilation was required in 30 patients and parenteral nutrition in 6 patients. Extracorporeal removal therapy was required in 16 pediatric patients (12 with maple syrup urine disease and 4 with hyperammonemia) with a median duration of 19 hours. The median length of PICU stay was 3.6 days (3 hours-35 days). Eight patients died during the studied period (cerebral edema-2, massive hemorrhage-5, and malignant arrhythmia-1). Acute decompensation was the main cause of admission in PICU in these patients. The complexity of these diseases requires specialized human and technical resources, with an important impact on the recovery and survival of these patients.

Transfusion policy in pediatric extracorporeal membrane oxygenation patients: Less could be more.

OBJECTIVE: To evaluate a restrictive transfusion policy of red blood cells (RBC) and platelets in pediatric patients submitted to extracorporeal membrane oxygenation (ECMO). METHODS: Retrospective descriptive study of pediatric patients supported with ECMO, from January 2010 to December 2019. Hemoglobin, platelet, lactate and mixed venous oxygen saturation (SvO2) values of each patient while on ECMO, were collected. Transfusion efficiency and tissue oxygenation were statistically evaluated comparing pre-transfusion hemoglobin, lactate and SvO2 with post-transfusion values. Ranges of hemoglobin and platelets were established, and the number of transfusions registered. The bleeding complications and outcome were documented. RESULTS: Of a total of 1016 hemoglobin values, the mean value before transfusion was 8.6 g/dl. Hemoglobin and SvO2 increased significantly post-transfusion. Red blood cell transfusion varied with hemoglobin values: when hemoglobin value was less than 7 g/dl, 89% (41/46) were transfused but just 23% (181/794) when greater or equal to 7 g/dl. In the presence of active bleeding, the frequency of RBC transfusion increased from 32% to 62%, with hemoglobin between 7 g/dl and 8 g/dl.The mean value for platelet transfusion was 32 x 109/L. Thirty-eight (43%) platelet values between 20 x 109/L and 30x109/L, and 31 (40%) between 30 x 109/L and 40 x 109/L led to platelet transfusion; between 40 x 109/L and 50 x 109/L, only 7 (9%) prompted platelet transfusion.Comparing the 2010-2015 to 2016-2019 periods there was a decrease in RBC and platelet transfusion threshold with similar survival (p = .528). Survival to discharge was 68%. CONCLUSIONS: Using a restrictive RBC and platelet transfusion policy was safe and allowed a good outcome in this case series. The presence of active bleeding was an important decision factor when hemoglobin was above 7 g/dl and platelets were above 30 x 109/L.

Posterior reversible encephalopathy syndrome: characteristics, diagnostic accuracy, prognostic factors and long-term outcome in a paediatric population.

Posterior reversible leukoencephalopathy syndrome (PRES) is a rare entity among children, characterised by acute neurological symptoms and radiological findings. The role of clinical symptoms and neuroimaging in predicting the prognosis of PRES have not been well-characterised. A retrospective descriptive study of children with PRES, admitted to a Paediatric Intensive Care Unit during a 10-year period, was performed to describe its characteristics, compare the accuracy of computed tomography (CT) scan and MRI on diagnosis and identify prognostic factors on paediatric population. Sixteen cases were identified. Most patients (13; 81%) presented underlying disorders, including malignancies (5; 31%), chronic kidney disease (3; 19%) and post-transplant status (3; 19%). Hypertension (15; 94%) was the most common trigger. All patients had seizures, 9 patients (56%) altered state of consciousness, 8 (50%) headache. CT scan was performed in 15 patients (94%) and MRI in 13 (81%); 1 patient underwent only MRI. MRI allows the identification of new areas of vasogenic oedema and a correct diagnosis of PRES when CT scan was inconclusive. Two patients (13%) remained with neurological sequelae and one died. In two patients (13%) cognitive disorders (specific learning disorder, intellectual disability, motor tic disorder) were diagnosed during follow-up period. Clinical presentation was not statistically associated with outcome. Also, atypical neuroimaging (haemorrhagic and unilateral lesions) were not statistically related with poor neurological or cognitive outcome. However, prospective studies with a larger cohort are needed to establish prognostic factors of PRES in the paediatric population.

Extracorporeal Membrane Oxygenation: The First 10 Years Experience of a Portuguese Pediatric Intensive Care Unit.

INTRODUCTION: In Portugal, extracorporeal membrane oxygenation (ECMO) is used in pediatric patients since 2010. The aim of this study was to describe the clinical characteristics of patients, indications, complications and mortality associated with the use of ECMO during the first 10-years of experience in the Pediatric Intensive Care Unit located in Centro Hospitalar Universitário Lisboa Norte. MATERIAL AND METHODS: Retrospective observational cohort study of all patients supported with ECMO in a Pediatric Intensive Care Unit, from the 1st of May 2010 up to 31st December 2019. RESULTS: Sixty-five patients were included: 37 neonatal (≤ 28 days of age) and 28 pediatric patients (> 28 days). In neonatal cases, congenital diaphragmatic hernia was the main reason for ECMO (40% of neonatal patients and 23% of total). Among pediatric patients, respiratory distress was the leading indication for ECMO (47% of total). The median length of ECMO support was 12 days. Clinical complications were more frequent than mechanical complications (65% vs 35%). Among clinical complications, access site bleeding was the most prevalent with 38% of cases. The overall patient survival was 68% at the time of discharge (65% for neonatal and 71% for pediatric cases), while the overall survival rate in Extracorporeal Life Support Organization registry was 61%. The number of ECMO runs has been increasing since 2011, even though in a non-linear way (three cases in 2010 to 11 cases in 2019). DISCUSSION: In the first 10 years we received patients from all over the country. Despite continuous technological developments, circuitrelated complications have a significant impact. The overall survival rate in the Pediatric Intensive Care Unit was not inferior to the one reported by the Extracorporeal Life Support Organization. CONCLUSION: The overall survival of our Pediatric Intensive Care Unit is not inferior to one reported by other international centers. Our experience showed the efficacy of the ECMO technique in a Portuguese centre.

Introdução: Em Portugal, a oxigenação por membrana extracorporal (ECMO) é utilizado em doentes pediátricos de forma consistente desde 2010. O nosso objetivo é descrever as características clínicas, indicações, complicações e sobrevivência associadas à utilização da ECMO nos primeiros 10 anos de experiência na nossa unidade. Material e Métodos: Estudo de coorte retrospetivo dos doentes tratados com ECMO na Unidade de Cuidados Intensivos Pediátricos do Hospital de Santa Maria, de 1 de maio de 2010 a 31 de dezembro de 2019. Resultados: Foram incluídos 65 doentes: 37 neonatais (≤ 28 dias de idade) e 28 pediátricos (> 28 dias). Nos neonatais, a hérnia diafragmática congénita foi a principal indicação (40% dos recém-nascidos e 23% do total). Relativamente aos doentes pediátricos, a insuficiência respiratória constituiu a principal indicação para ECMO (47% do total). A mediana de duração da técnica foi de 12 dias. As complicações clínicas foram mais frequentes do que as mecânicas (65% vs 35%). Entre as complicações clínicas, a hemorragia no local de acesso foi a mais frequente (38% dos casos). A sobrevivência global do total da amostra foi de 68% no momento da alta (65% nos neonatais e 71% nos pediátricos), enquanto que a sobrevivência descrita no registo da Extracorporeal Life Support Organization é de 61%. O número de casos de utilização de ECMO tem vindo a aumentar desde 2011, embora de forma não linear (três casos em 2010 para 11 casos em 2019). Discussão: Nos primeiros 10 anos de experiência em ECMO na Unidade de Cuidados Intensivos Pediátricos recebemos doentes oriundos de várias partes do país. Apesar da evolução tecnológica contínua, as complicações relacionadas com o circuito têm um impacto significativo. A taxa de sobrevida global no nosso centro não foi inferior à reportada no relatório da Extracorporeal Life Support Organization. Conclusão: A sobrevida global na Unidade de Cuidados Intensivos Pediátricos não é inferior à descrita no registo internacional. A nossa experiência demonstra a eficácia da ECMO num centro Português.

Monitoring cerebrovascular reactivity in pediatric traumatic brain injury: comparison of three methods.

PURPOSE: To study three different methods of monitoring cerebral autoregulation in children with severe traumatic brain injury. METHODS: Prospective cohort study of all children admitted to the pediatric intensive care unit at a university-affiliated hospital with severe TBI over a 4-year period to study three different methods of monitoring cerebral autoregulation: pressure-reactivity index (PRx), transcranial Doppler derived mean flow velocity index (Mx), and near-infrared spectroscopy derived cerebral oximetry index (COx). RESULTS: Twelve patients were included in the study, aged 5 months to 17 years old. An empirical regression analyzing dependence of PRx on cerebral perfusion pressure (CPP) displayed the classic U-shaped distribution, with low PRx values (< 0.3) reflecting intact auto-regulation, within the CPP range of 50-100 mmHg. The optimal CPP was 75-80 mmHg for PRx and COx. The correlation coefficients between the three indices were as follows: PRx vs Mx, r = 0.56; p < 0.0001; PRx vs COx, r = 0.16; p < 0.0001; and COx vs Mx, r = 0.15; p = 0.022. The mean PRx with a cutoff value of 0.3 predicted correctly long-term outcome (p = 0.015). CONCLUSIONS: PRx seems to be the most robust index to access cerebrovascular reactivity in children with TBI and has promising prognostic value. Optimal CPP calculation is feasible with PRx and COx.

The Impact of Focused Cardiac Ultrasound Performed by Pediatric Intensivists: A Prospective Study.

OBJECTIVES: Focused cardiac ultrasound is an echocardiographic method used by medical intensivists for fast and reliable hemodynamic assessment. Prospective studies and guidelines have defined its role in adult critical care. Data regarding its use in pediatric critical care are scarce. This is the first prospective study that aims to evaluate its impact in this setting. METHODS: This is a single-center prospective study performed in a tertiary referral hospital pediatric intensive care unit (PICU). For a period of 6 months, when performing an echocardiogram, pediatric intensivists filled out a questionnaire that included the patient's clinical data and indication for the examination. The intensivists had to record both the clinical impression regarding that indication and therapeutic plan before and after the echocardiogram. All the patients with an echocardiogram performed by the pediatric intensive care unit medical staff were included. RESULTS: There were 80 echocardiograms performed on 35 patients during the study period. The most common patient diagnostic groups were respiratory infections (38%, n = 30) and septic shock (21%, n = 17). The main indication for the examination was assessment of intravascular volume status and left ventricular systolic function. After the echocardiogram, the clinical impression was maintained in 49% (n = 39) and changed in 44% (n = 35). There were new findings unrelated to the initial evaluation in 7% (n = 6). The planned treatment was maintained in 55% (n = 44) and changed in 45% (n = 36). CONCLUSIONS: The echocardiogram changed the clinical impression and therapeutic plan in almost half of the patients. These data show the value of focused cardiac ultrasound as a diagnostic and hemodynamic monitoring tool in pediatric intensive care and emphasize the importance of a rigorous training program.

[ECMO in Neonates with Congenital Diaphragmatic Hernia: The Experience of a Portuguese ECMO Referral Center]. / ECMO em Recém-nascidos com Hérnia Diafragmática Congénita: A Experiência de um Centro de Referência de ECMO em Portugal.

INTRODUCTION: The use of extracorporeal membrane oxygenation (ECMO) is considered by many authors as one of the most important technological advances in the care of newborns with congenital diaphragmatic hernia. The main objective of this study was to report the experience of a Portuguese ECMO center in the treatment of congenital diaphragmatic hernia. MATERIAL AND METHODS: Descriptive retrospective study of newborns with congenital diaphragmatic hernia requiring ECMO support in a Pediatric Intensive Care Unit from January 2012 to December 2019. Data collection using the Extracorporeal Life Support Organization registration and unit data base. RESULTS: Fourteen newborns were included, all with left congenital diaphragmatic hernia, in a total of 15 venoarterial ECMO cycles. The median gestational age was 38 weeks and the median birth weight was 2.950 kg. Surgical repair was performed before entry into ECMO in six, during in seven and after in one newborn. The average age at placement was 3.3 days and the median cycle duration was 16 days. Prior to ECMO, all newborns had severe hypoxemia and acidosis despite optimized ventilatory support, with nitric oxide and inotropic therapy. After 24 hours on ECMO, there was correction of acidosis, improvement of oxygenation and hemodynamic stability. All cycles presented mechanical complications, the most frequent being the presence of clots in the circuit. The most frequent physiological complications were hemorrhagic and embolic (three newborns suffered an ischemic stroke during the cycle). Five newborns (35.7%) died, all associated with complications (two strokes, two massive bleedings and one accidental decannulation). Chronic lung disease, poor weight gain and psychomotor developmental delay were the most frequent long-term morbidities. DISCUSSION: Despite technological advances in respiratory care and improved safety of the ECMO technique, the management of these newborns is complex and there are still several open questions, including the appropriate selection of patients, the best approach and time for surgical correction, and the treatment of pulmonary hypertension in the presence of persistent fetal shunts. CONCLUSION: Survival rate was higher than reported in 2017 Extracorporeal Life Support Organization report (64% versus 50%). Mechanical and hemorrhagic complications were very frequent.

Introdução: A utilização de oxigenação por membrana extracorporal (ECMO) é considerada por muitos autores como um dos maisimportantes avanços tecnológicos nos cuidados de recém-nascidos com hérnia diafragmática congénita. O principal objetivo deste estudo foi reportar a experiência de um centro de oxigenação por membrana extracorporal português no tratamento de hérnia diafragmática congénita.Material e Métodos: Estudo retrospetivo descritivo dos recém-nascidos com hérnia diafragmática congénita com necessidade de suporte de ECMO, numa unidade de Cuidados Intensivos Pediátricos de janeiro de 2012 a dezembro de 2019. Colheita de dados com recurso ao registo da Extracorporeal Life Support Organization e registo da unidade.Resultados: Incluídos 14 recém-nascidos, todos com hérnia diafragmática congénita esquerda, num total de 15 ciclos de ECMO veno-arterial. Mediana de idade gestacional de 38 semanas e de peso ao nascer de 2,950 kg. A correção cirúrgica foi realizada antes da entrada em ECMO em seis, durante em sete e após ciclo em um caso. A mediana de idade de colocação foi de 3,3 dias e a média de duração do ciclo foi de 16 dias. Previamente à ECMO, todos os recém-nascidos apresentavam hipoxemia e acidose grave apesar de suporte ventilatório otimizado, com terapêutica com oxido nítrico e inotrópicos. Após 24 horas em ECMO, verificou-se correção de acidose, melhoria de oxigenação e estado hemodinâmico. Todos os ciclos apresentaram complicações mecânicas, sendo a mais frequente a presença de coágulos no circuito. As complicações fisiológicas mais frequentes foram as hemorrágicas e embólicas (três recém-nascidos sofreram acidente vascular cerebral isquémico durante o ciclo). Cinco crianças (35,7%) morreram, estando todos os casos associados a complicações (duas com acidente vascular cerebral, duas com hemorragia maciça e uma descanulação acidental). A doença pulmonar crónica, má progressão ponderal e atraso do desenvolvimento psicomotor foram as morbilidades a longo prazo mais frequentes.Discussão: Apesar dos avanços tecnológicos nos cuidados respiratórios e melhoria da segurança da técnica ECMO, o manuseamento destes recém-nascidos é complexo e existem ainda várias questões em aberto, incluindo a selecção apropriada dos doentes, amelhor abordagem e tempo de correcção cirúrgica, e o tratamento da hipertensão pulmonar na presença de shunts fetais persistentes.Conclusão: A taxa de sobrevivência foi superior à reportada no relatório da Extracorporeal Life Support Organization de 2017 (64% vs 50%). As complicações mecânicas e hemorrágicas foram muito prevalentes.

Ultrasound non-invasive intracranial pressure assessment in paediatric neurocritical care: a pilot study.

BACKGROUND: The assessment of intracranial pressure (ICP) is essential in the management of neurocritical care paediatric patients. The gold standard for invasive ICP is an intraventricular catheter or intraparenchymal microsensor but is invasive and carries some risks. Therefore, a non-invasive method for measuring ICP (nICP) would be desirable especially in the paediatric population. The aim of this study is to assess the relationship between ICP and different ultrasound-based methods in neurocritical care paediatric patients. METHODS: Children aged < 16 years with indication for invasive ICP monitoring were prospectively enrolled. The following non-invasive methods were compared with the invasive gold standard: optic nerve sheath diameter ultrasound (ONSD)-derived nICP (nICPONSD); arterial TCD-derived pulsatility index (PIa) and a method based on the diastolic component of the TCD cerebral blood flow velocity and mean arterial blood pressure (nICPFVd). RESULTS: We analysed 107 measurements from 10 paediatric patients. Results from linear regression demonstrated that, among the nICP methods, ONSD has the best correlation with ICP (r = 0.852 (p < 0.0001)). Results from receiving operator curve analysis demonstrated that using a threshold of 15 mmHg, ONSD has and area under the curve (AUC) of 0.94 (95% CI = 0.892-0.989), with best threshold at 3.85 mm (sensitivity = 0.811; specificity = 0.939). CONCLUSIONS: Our preliminary results suggested that ONSD ultrasonography presents the best accuracy to assess ICP among the methods studied. Given its non-invasiveness, repeatability and safety, this technique has the potential of representing a valid option as non-invasive tool to assess the risk of intracranial hypertension in the paediatric population.

Transcranial Doppler as a non-invasive method to estimate cerebral perfusion pressure in children with severe traumatic brain injury.

INTRODUCTION: Cerebral perfusion pressure (CPP) is one of the most important parameters in preventing ischemic brain insults. Guidelines have used CPP values to guide treatment of traumatic brain injury (TBI) for many years. We tested the feasibility of a novel non-invasive method for CPP estimation (nCPP) in children with severe TBI. METHODS: Retrospective analysis of prospectively monitored pediatric TBI patients with invasive intracranial pressure (ICP) monitoring, arterial blood pressure, and Transcranial Doppler (TCD) studies was performed daily. A novel estimator of CPP (nCPP) was calculated using TCD-spectral accounting method. We analyzed the correlation coefficient and correlation in time domain between CPP and nCPP, prediction ability of nCPP to detect low CPP, and the confidence intervals for CPP prediction (95% CI). RESULTS: We retrospectively analyzed 69 TCD recordings from 19 children (median age 15 years, range 3-16 years). There was a good correlation between CPP and nCPP (Spearman correlation coefficient, R = 0.67 (p < 0.0001), and a good mean correlation in time domain (R = 0.55 ± 0.42). The ability of nCPP to predict values of CPP below 70 mmHg was excellent as demonstrated by an area under the curve of 0.908 (95% CI = 0.83-0.98) using a receiver operating curve analysis. Bland-Altman analysis revealed that nCPP overestimated CPP by 19.61 mmHg with a wide 95% CI of ± 40.4 mmHg. CONCLUSIONS: nCPP monitoring with TCD appears to be a feasible method for CPP assessment in pediatric TBI. The novel spectral CPP tested in this study has a decent correlation with invasive CPP and can predict low CPP with excellent accuracy at the 70-mmHg threshold.

Transcranial Doppler in pediatric emergency and intensive care unit: a case series and literature review.

PURPOSE: Transcranial Doppler (TCD) has been used for more than 30 years in clinical practice. Although adult intensive care is relatively well covered, pediatric cases are still underrepresented. We intend to review a series of pediatric cases where TCD was determinant in clinical decisions and a literature review on this topic. METHODS: We describe cases with different pathologies where TCD had an important role in clinical management of the patients. We discuss TCD utility and potential role both in the emergency department and the intensive care unit. RESULTS: Five patients with different neurologic insults are presented. TCD was useful in the identification of intracranial hypertension in traumatic brain injury, hydrocephalus and central nervous system infection; identification of decreased cerebral perfusion pressure in hypovolemic shock and the diagnosis of impending cerebral circulatory arrest in a child with meningococcal septicemia. We discuss how TCD can be used in emergency and intensive care settings, reviewing relevant literature and our own experience. CONCLUSIONS: Non-invasive testing using TCD can aid clinical decisions. More widespread use of this technique will allow for better care of children with neurologic insults.

[Erratum to "Translation and Validation of the FOUR Scale for Children and its Use as Outcome Predictor: A Pilot Study"]. / Errata a "Tradução e Validação da Escala FOUR para a Pediatria e o seu Uso Como Indicador Prognóstico: Um Estudo Piloto".

The article "Translation and Validation of the FOUR Scale for Children and its Use as Outcome Predictor: A Pilot Study", published by Acta Médica Portuguesa on September 2017 [Acta Med Port 2017 Sep;30(9):599-607] exhibited the mistake detailed here below: On page 600, paragrapah 4, where it reads: "(...) only the last two are assessed by the GCS and depth of coma may not be accurately detected.4" It should read: "(…) GCS does not include important indicators for an adequate evaluation of coma severity, that is, it only evaluates the cortical function, not including brainstem function evaluation parameters such as respiratory pattern, pupil size and reflexes, nor eye movements; as such it may not detect the coma depth properly.4" Article published with the error: https://www.actamedicaportuguesa.com/revista/index.php/amp/article/view/8052.

O artigo "Tradução e Validação da Escala FOUR para a Pediatria e o seu Uso Como Indicador Prognóstico: Um Estudo Piloto", publicado na edição da Acta Médica Portuguesa de Setembro de 2017 [Acta Med Port 2017 Sep;30(9):599-607] incluía o erro que passamos a descrever: Na página 600, parágrafo 4, onde se lê: "Porém, a GCS avalia apenas os dois últimos, podendo não detetar devidamente a profundidade do coma.4" Deverá ler-se: "A GCS não inclui indicadores importantes para uma avaliação adequada da gravidade do coma, isto é, avalia apenas a função cortical, não incluindo parâmetros da avaliação da função do tronco cerebral, tais como o padrão respiratório, o tamanho e os reflexos pupilares e os movimentos oculares, podendo não detetar devidamente a profundidade do coma. 4" Artigo publicado com erro: https://www.actamedicaportuguesa.com/revista/index.php/amp/article/view/8052.

Salicylate Intoxication in an Infant: A Case Report.

In children, the most common cause of an elevated anion gap (AG) with ketonemia, ketonuria, hyperglycemia, and glycosuria is diabetic ketoacidosis. However, when the clinical history is not clear, other causes must be considered. A 9-month-old girl was transferred to our pediatric intensive care unit (PICU) because of severe metabolic acidosis. On admission, she presented with Kussmaul breathing, tachycardia, irritability, and fever. Blood gasses revealed metabolic acidosis with superimposed respiratory alkalosis and elevated AG. Fluid replacement and bicarbonate for urine alkalinization were started. Ketonemia, acidic urine with glycosuria, ketonuria, and high blood glucose prompted an insulin infusion. Measurement of plasma salicylate confirmed toxic levels. When confronted, the parents admitted to accidentally preparing the child's bottle with water containing salicylic acid 1000 mg. Although the incidence of salicylate intoxication has declined, it remains an important cause of pediatric morbidity and mortality.

[Translation and Validation of the FOUR Scale for Children and its Use as Outcome Predictor: A Pilot Study]. / Tradução e Validação da Escala FOUR para a Pediatria e o seu Uso Como Indicador Prognóstico: Um Estudo Piloto.

INTRODUCTION: The Full Outline of UnResponsiveness - FOUR scale has been previously validated to assess impaired consciousness in the adult population. The aim of this study is the translation into Portuguese and validation of the FOUR scale in the pediatric population. The study also compares the FOUR scale and Glasgow coma scale score ratings and the clinical outcome of patients hospitalized in Pediatric Intensive Care Units. MATERIAL AND METHODS: This study prospectively rated patients admitted to the Pediatric Intensive Care Units with impaired consciousness during one year. Both scales were applied daily to patients by three types of examiners: intensivists, residents and nurses, from the moment of admission until clinical discharge. Neurological sequelae was evaluated using the King's Outcome Scale for Childhood Head Injury - KOSCHI. RESULTS: Twenty seven patients between one and 17 years of age were included. Both scales are reliable and inter-rater reliability was greater for the FOUR score. Glasgow coma scale showed a minimum score in eight evaluations, whereas the FOUR scale obtained the minimum score in only two of these evaluations. In both scales there was a strong association between the admission score and the patient's outcome (area under curve FOUR = 0.939, versus Glasgow coma scale = 0.925). DISCUSSION: The FOUR scale provides more neurological information than Glasgow coma scale in patients with impaired consciousness and has prognostic interest. CONCLUSION: The FOUR scale can be applied in patients admitted with impaired consciousness in Pediatric Intensive Care Units. We think that a multicenter study would be very beneficial for confirming and generalizing these results.

Introdução: A escala FOUR - Full Outline of UnResponsiveness, já validada na população adulta, avalia a depressão do estado de consciência. O objetivo deste estudo consiste na tradução para português e validação da escala FOUR na população pediátrica, assim como na comparação da pontuação obtida e da evolução clínica dos doentes entre a escala FOUR e a escala de coma de Glasgow, nos doentes internados numa unidade de cuidados intensivos pediátricos. Material e Métodos: Estudo observacional prospetivo, envolvendo os doentes internados na unidade de cuidados intensivos pediátricos com depressão do estado de consciência, durante um ano. Ambas as escalas foram aplicadas diariamente aos doentes, por três avaliadores (médicos especialistas, médicos internos e enfermeiros), desde a admissão até à alta clínica, e as sequelas neurológicas foram avaliadas através da escala King's Outcome Scale for Childhood Head Injury - KOSCHI. Resultados: Foram incluídos 27 doentes com idades compreendidas entre um e 17 anos. Ambas as escalas são fiáveis e a concordância inter-avaliador foi superior na escala FOUR. A escala de coma de Glasgow apresentou pontuação mínima em oito avaliações. No entanto, a escala FOUR apresentou o score mínimo em apenas duas dessas avaliações. Em ambas as escalas verificou-se uma forte associação entre o valor obtido à entrada e a evolução clínica do doente (escala FOUR: área sob a curva =0,939; escala de coma de Glasgow: área sob a curva = 0,925). Discussão: A escala FOUR fornece mais informação sobre o estado neurológico dos doentes do que a escala de coma de Glasgow e tem interesse prognóstico. Conclusão: A escala FOUR pode ser aplicada nos doentes internados com depressão do estado de consciência na unidade de cuidados intensivos pediátricos. Consideramos que um estudo multicêntrico seria importante para confirmar estes resultados.