Complications associated with prolonged hypertonic saline therapy in children with elevated intracranial pressure.

OBJECTIVES: Safe upper limits for therapeutic hypernatremia in the treatment of intracranial hypertension have not been well established. We investigated complications associated with hypernatremia in children who were treated with prolonged infusions of hypertonic saline. DESIGN: Retrospective chart analysis. SETTING: PICU in university-affiliated children's hospital. PATIENTS: All children from 2004 to 2009 requiring intracranial pressure monitoring (external ventricular drain or fiberoptic intraparenchymal monitor) for at least 4 days who were treated with hypertonic saline infusion for elevated intracranial pressure and did not meet exclusion criteria. INTERVENTION: Continuous hypertonic saline infusion on a sliding scale was used to achieve target sodium levels that would keep intracranial pressure less than 20 mm Hg once the conventional therapies failed. MEASUREMENTS AND MAIN RESULTS: Eighty-eight children met inclusion criteria. Etiologies of elevated intracranial pressure included trauma (n = 48), ischemic or hemorrhagic stroke (n = 20), infection (n = 8), acute disseminated encephalomyelitis (n = 5), neoplasm (n = 2), and others (n = 5). The mean peak serum sodium was 171.3 mEq/L (range, 150-202). The mean Glasgow Outcome Score was 2.8 (± 1.1) at time of discharge from the hospital. Overall mortality was 15.9%. Children with sustained (> 72 hr) serum sodium levels above 170 mEq/L had a significantly higher occurrence of thrombocytopenia (p < 0.001), renal failure (p < 0.001), neutropenia (p = 0.006), and acute respiratory distress syndrome (p = 0.029) after controlling for variables of age, gender, Pediatric Risk of Mortality score, duration of barbiturate-induced coma, duration of intracranial pressure monitoring, vasopressor requirements, and underlying pathology. Children with sustained serum sodium levels greater than 165 mEq/L had a significantly higher prevalence of anemia (p < 0.001). CONCLUSIONS: Children treated by continuous hypertonic saline infusion for intracranial hypertension whose serum sodium levels exceeded certain thresholds experienced significantly more events of acute renal failure, thrombocytopenia, neutropenia, anemia, and acute respiratory distress syndrome than those whose sodium level was maintained below these thresholds.

Assessing pediatric trauma specimen integrity.

OBJECTIVE: This study investigated the quality of trauma specimens by comparing line draws to venipuncture. DESIGN: The draw type (line or venipuncture); container type (Vacutainer or Microtainer); and suitability for processing (processed/hemolyzed/clotted) of routinely collected trauma specimens was analyzed. SETTING: The clinical laboratory of a Level I Pediatric Trauma Center. MAIN OUTCOME MEASURE: Hemolyzed trauma specimens were analyzed according to method of collection, collector, and type of container to identify issues resulting in unusable samples. RESULTS: The data shows that for 13% of all draws, portions of the results were affected by hemolysis. Sixteen percent of line draws and 6% of venipunctures were hemolyzed (p = 0.04). There was no statistical association with who collected the sample (p = 0.07) or type of container (p = 1.00). CONCLUSION: Based on this sample of data, the laboratory recommends that, whenever possible, venipunctures be performed for laboratory testing of blood specimens to improve trauma specimen integrity.

A male adolescent with left iliac thrombophlebitis and heterozygosity for factor V Leiden mutation.

The epidemiology of deep vein thrombosis in adolescents has 2 potential associations. First, there is a demonstrated association with a congenital anomaly of the inferior vena cava (Dean SM, Tytle TL. Vas Med. 2006;11:165-169; Schnieider JG, Eynatten MV, Dugi KA, et al. J Intern Med. 2002;252:276-280). Secondly, resistance to activated protein C as a result of factor V Leiden is associated with thromboembolic disease at an early age (Price DT, Ridker PM. Ann Intern Med. 1997;127:895-903). Imaging modalities, central venous catheters, and improved life expectancy for critically and chronically ill children have resulted in an increased diagnosis of thromboembolic disease in the pediatric population (Journeycake MM, Manco-Johnson MJ. Hematol Oncol Clin N Am. 2004;18;1315-1338), and evaluation for thrombophilia should be performed for any child with thromboembolic disease.

Postoperative outcomes of extremely low birth-weight infants with necrotizing enterocolitis or isolated intestinal perforation: a prospective cohort study by the NICHD Neonatal Research Network.

OBJECTIVE: Purposes of this study were: 1) to compare mortality and postoperative morbidities (intra-abdominal abscess, wound dehiscence, and intestinal stricture) in extremely low birth weight (ELBW) infants who underwent initial laparotomy or drainage for necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP); 2) to determine the ability to distinguish NEC from IP preoperatively and the importance of this distinction on outcome measures; and 3) to evaluate the association between extent of intestinal disease determined at operation and outcome measures. BACKGROUND: ELBW infants who undergo operation for NEC or IP have a postoperative, in-hospital mortality rate of approximately 50%. Whether to perform laparotomy or drainage initially is controversial. Also unknown is the importance of distinguishing NEC from IP and the current ability to make this distinction based on objective data available prior to operation. METHODS: A prospective, multicenter cohort study of 156 ELBW infants at 16 neonatal intensive care units (NICU) within the NICHD Neonatal Research Network. RESULTS: Among the 156 enrolled infants, 80 underwent initial peritoneal drainage and 76 initial laparotomy. Mortality rate was 49% (76 of 156). Ninety-six patients had a preoperative diagnosis of NEC and 60 had presumed IP. There was a high level of agreement between the presumed preoperative diagnosis and intraoperative diagnosis in patients undergoing initial laparotomy (kappa = 0.85). The relative risk for death with a preoperative diagnosis of NEC (versus IP) was 1.4 (95% confidence interval, 0.99-2.1, P = 0.052). The overall incidence of postoperative intestinal stricture was 10.3%, wound dehiscence 4.4%, and intra-abdominal abscess 5.8%, and did not significantly differ between groups undergoing initial laparotomy versus initial drainage. CONCLUSIONS: Survival to hospital discharge after operation for NEC or IP in ELBW neonates remains poor (51%). Patients with a preoperative diagnosis of NEC have a relative risk for death of 1.4 compared with those with a preoperative diagnosis of IP. A distinction can be made preoperatively between NEC and IP based on abdominal radiographic findings and the patient's age at operation. Future randomized trials that compare laparotomy versus drainage would likely benefit from stratification of treatment assignment based on preoperative diagnosis.