Care of the potential pediatric organ donor.

Although all of this information may create the impression that caring for a potential organ donor is an exceedingly complex task, in the authors' experience, this often is not true, and much energy can--and should--be devoted to the care of the bereaved family. Of crucial importance are the early recognition of brain death and the consequent radical switch of the treatment goal from preservation of the patient's brain and life to preservation of organs for the lives of others. Care for the donor is the natural extension of care for a critically ill or injured patient. During the foregoing discussion, the authors had to stress the absence of sound evidence on many points. Because many reports originate from transplant centers dedicated to a specific organ, gaining a comprehensive view on management options in the ICU further is hampered. Thus, this situation leaves another field in which investigations originating from pediatric intensivists could provide evidence urgently needed to make optimal choices. The next decade should see the thyroid hormone controversy solved by at least one controlled prospective study and the differential applicability of inotropic, vasoactive, or fluid-centered strategies. It seems self-evident that only graft survival and related parameters can form adequate endpoints for future studies.

Fibre optic versus conventional phototherapy for hyperbilirubinaemia in preterm infants.

UNLABELLED: Studies comparing efficacy of fibre optic phototherapy to conventional phototherapy are performed mostly in term infants and give conflicting results. This randomized prospective study compares efficacy of fibre optic phototherapy using the Ohmeda Biliblanket device to conventional fluorescent phototherapy in preterm infants. A total of 124 preterm infants with a nonhaemolytic hyperbilirubinaemia were evaluated. Stratification at randomisation was performed according to birth weight ( < 1000 g, 1000-1500 g or 1500-2000 g). Fifty-six infants received fibre optic and 68 conventional phototherapy. Efficacy was assessed by comparing the required duration of phototherapy. Median duration of phototherapy was 118 h and 114 h in the fibre optic and conventional groups respectively, the difference in which was not statistically significant. The median durations were also not significantly different within the separate weight groups. The number of infants requiring exchange transfusions was similar in both treatment groups. CONCLUSION: The efficacy of fibre optic phototherapy in preterm infants is comparable to conventional phototherapy.

Wilms' tumour presenting as a pulmonary embolism.

Wilms' tumour (nephroblastoma) is one of the most common solid malignant tumours in infancy and childhood. In about 40% of cases, invasion of the renal vein is present. Rarely, these tumours extend into the inferior vena cava and right atrium. We discuss a 7-week-old girl who presented with acute massive pulmonary embolism, and was found to have a large tumour of the left kidney. Later on, the diagnosis of Wilms' tumour was confirmed. Wilms' tumour presenting as massive pulmonary embolism is extremely rare; to our knowledge this is the fourth case described in literature. We review the cases previously described, and comment on the diagnostic and therapeutic features of this clinical entity.

Advantages of HCO3 solution with low sodium concentration over standard lactate solutions for acute peritoneal dialysis.

The aim of this study was to identify the advantages of a bicarbonate solution with a low sodium concentration. Twelve children (3 days-6 years) with acute renal failure (ARF), positive fluid balance, and lactate acidosis (> 40 mg/dL) were treated by automated peritoneal dialysis (APD) with frequent exchanges of small fill volumes of a hypertonic solution. For Day 1 we used PD1/PD4 Dianeal (3.86%) (Baxter). After 24 hours we switched to a HCO3 solution: 38 mmol/L, Na 128 mmol/L. As the control group, we studied retrospectively the last 12 children of the previous period who were treated with APD. The age distribution was 4 days to 4 years. No significant differences were found between the groups for serum creatinine, blood urea nitrogen, and fluid overload (Day 1 to Day 4). Although the values for lactate and Na were not different before the start of the study (Day 1) and after 24 hours of Dianeal (Day 2), they were significantly lower in the study group on Day 4 [HCO3 53 (23-83), Na 148 (137-136) mEq/L] than in the control group [lactate 148 (137-156), Na 154 (142-165) mEq/L]. A low sodium concentration results in higher sodium extraction, which is important for patients with fluid overload. Low sodium concentrations in APD are needed because the peritoneal membrane "sieves" the sodium during short dwells. HCO3 dialysis is a logical choice for patients with lactate acidosis, resulting in a significant lower serum lactate and increase of BE after 48 hours of treatment.

New perspectives for PD in acute renal failure related to new catheter techniques and introduction of APD.

Acute renal failure remains a major problem in pediatric intensive care unit (PICU) patients. Although in most handbooks peritoneal dialysis (PD) is still considered to be the first choice for children < 20 kg and there is some evidence that PD may preserve and/or favor recuperation of renal function, most PICU departments are using continuous veno-venous hemofiltration and dialysis or hemodialysis as treatment. The main reasons for this are workload for the PICU nurses, catheter problems, the risk of peritonitis, and limited ultrafiltration. In a retrospective study (1992-1995) in 46 patients (age 3 days to 14 years), automated PD (APD) was the initial treatment in 44 patients. Complications of the Seldinger-placed Cook (pleuropericard) catheter were limited: leakage (1/44); bleeding: n = 0; obstruction or dislocation: n = 4; peritonitis: n = 1 (Candida); ultrafiltration (UF) problems: n = 3. APD in children with acute renal function (ARF) is a good alternative for continuous veno-venous dialysis. Placement of a pigtail (Cook) catheter is a quick (10 min), safe procedure, with low leakage risk. This, together with the low manipulation rate, gives a low peritonitis rate. The use of the cycler makes frequent changes of small volumes possible, resulting in better clearance, good UF, no interference with hemodynamic or respiratory stability, and a reduced workload.

[Liver and liver segment transplantation in adults and children. Experiences with the first 50 cases]. / Leber- und Lebersegmenttransplantation bei Erwachsenen und Kindern. Erfahrungen mit den ersten 50 Fällen.

The experience with 50 liver transplants performed in 42 patients within a 16 months period is reviewed. There were 15 transplantations in 12 children and 35 in 30 adults. The series was analysed regarding the source of transplant, i.e. living related (LR) n = 2 or cadaver (CAD) n = 48, graft size i.e. full size (FS) n = 34, reduced size (RED) n = 12 and split grafts (SG) n = 4. Regarding the preservation time or operating time there was no statistically significant difference between the groups. The overall function rate was 88%, 94% for FS and 73.4% for the remaining partial grafts (RED and SG). The difference was not significant (p = 0.062). Biliary leakage occurred in one (2%) reduced graft. Hepatic artery complications (kinking, intima dissection) were encountered in two (4%) patients receiving a FS. It is concluded that the use of partial liver grafts is a safe procedure to alleviate organ shortage while preservation time and operating time are not prolonged as compared to the transplantation of full size grafts.