Can Apparent Diffusion Coefficient Predict the Clinical Outcome in Drowned Children?

INTRODUCTION: Pediatric cerebral hypoxic-ischemic injury frequently results in severe neurological outcome. Imaging with diffusion-weighted magnetic resonance imaging (DWi) demonstrates that the acute cerebral injury and apparent diffusion coefficient (ADC) allow the assessment of the severity of brain damage. The main objective was to examine if spatial distribution of reductions in ADC values is associated with clinical outcome in drowned children. METHODS: This is a retrospective study of 7 children (7 examinations) suffering from a hypoxic-ischemic event who underwent DWi. Seven subjects with normal DWi served as controls. The mean patient age was 4.88 ± 2.93 years and the male-to-female ratio was 5:2. The neurological outcome was divided into 2 categories: 4 children with Apallic syndrome and 3 deaths. We analysed the differences between the drowned children and the control group regarding clinical data, DWi abnormalities, and ADC values. RESULTS: The ADC values in the occipital and parietal grey matter were significantly different between the drowned children (765.14 ± 65.47 vs 920.95 ± 69.62; P = .003) and the control group (670.82 ± 233.99 vs 900.66 ± 92.72; P = .005). The ADC showed low values in the precentral area also (P = .044). CONCLUSION: The ADC reduction may be useful to predict the poor outcome in drowned children and can be a valuable tool for clinical assessment.

Short-term intravenous fish-oil emulsions in pediatric oncologic patients--effect on liver parameters.

Pediatric oncologic patients often need parenteral nutrition (PN) during chemotherapy. Long-term use of soybean-based lipid emulsions is associated with progressive liver disease and cholestasis, whereas fish-oil based emulsions have anticholestatic effects. We studied the potentially hepato-protective effects of short-term use of SMOF lipids in children undergoing chemotherapy. Fifteen pediatric oncologic patients treated with SMOF lipids were retrospectively analyzed in respect to bilirubin and liver parameters and compared to matched-controls who had received soybean-based fat emulsions. For statistics the time-points baseline, Day 14 of PN (PN14), and post (Day+7) were chosen. None of the study patients developed cholestasis. Within the SMOF-lipid group there were no differences in the laboratory parameters between baseline, PN14, and post. In the control group, gamma glutamyltransferase (γGT) levels increased during PN (baseline vs. PN14, 26.43 vs. 63.00 U/l, P < 0.05). Lactate dehydrogenase (LDH) levels showed a significantly different behavior in the 2 groups: In the SMOF lipids group, LDH decreased whereas it increased in the controls (-32.75 U/l vs. + 29.57 U/l, P < 0.05). An advantage of fish oil-based fat emulsions can be shown even after short-term PN. In children undergoing chemotherapy the use of soybean-based fat emulsions but not SMOF lipids led to increased γGT levels.

Age- and gender-related differences in teicoplanin levels in paediatric patients.

OBJECTIVES: Teicoplanin is a glycopeptide antibiotic active against Gram-positive bacteria, including methicillin-resistant staphylococci. While teicoplanin trough levels (TTLs) >10 mg/L are commonly considered appropriate, levels >20 mg/L are aimed for in the treatment of severe infections. Due to toxicity, it is recommended to avoid levels >60 mg/L. PATIENTS AND METHODS: In our institution, the initial dosing schedule of teicoplanin (10-15 mg/kg every 12 h for three loading doses and every 24 h thereafter) is adapted according to TTLs analysed by a fluorescence polarization immunoassay on treatment days 2 to 4. Teicoplanin peak levels (TPLs) are analysed in selected cases 30 min after the end of infusion. In a retrospective analysis we evaluated 1357 TTLs and 333 TPLs from 410 treatment episodes from 2005 to 2011. RESULTS: Initial TTLs were <10 mg/L in 14.1% and <20 mg/L in 72.6% of episodes. Toddlers had significantly lower TTLs, with a 2-fold and 2.5-fold increased risk of having levels <10 mg/L (24.6%) and <20 mg/L (82.6%), respectively. For the entire cohort, follow-up TTLs were less likely to be <10 mg/L and more likely to be >20 mg/L when compared with initial TTLs (P < 0.001, each). Adolescent girls had significantly higher initial TPLs (P = 0.001) and significantly higher follow-up TTLs (P = 0.016) than adolescent boys. In parallel, adolescent girls had initial TPLs >60 mg/L significantly more frequently (P = 0.012) and follow-up TTLs <10 mg/L significantly less frequently (P = 0.005). CONCLUSIONS: More tailored dosing regimens with higher loading doses, especially for toddlers, should be considered. While further pharmacokinetic data in paediatric patients are pending, therapeutic drug monitoring is mandatory.

Hemodiafiltration in infants with complications during peritoneal dialysis.

End-stage renal disease (ESRD) in neonates still has a high mortality, particularly in the first year of life. We present the combination of peritoneal dialysis (PD) with intermittent hemodiafiltration (iHDF) in neonates with ESRD. Four infants younger than 28 days were treated with PD and iHDF. Renal diagnoses leading to ESRD were cortical necrosis, prune belly syndrome, neonatal hemolytic uremic syndrome, and autosomal recessive polycystic kidney disease. Initially, three patients were on iHDF until PD was started. At the time when complications occurred during PD, patients were switched back to iHDF. iHDF was used five times as a bridge to PD in case of abdominal surgery. Two of the four patients were switched to iHDF because of peritoneal ultrafiltration failure due to recurrent peritoneal leaks. Once, iHDF became necessary due to refractory peritonitis. All four patients survived the first year of life. Two patients were transplanted successfully at an age of 35 and 22 months, respectively. The others are on renal replacement therapy, one on PD at the age of 28 months and one on iHDF at the age of 25 months, respectively. In case of PD complications, iHDF may be an appropriate bridge to achieve long-term survival until kidney transplantation.

Continuous renal replacement therapy with Prismaflex HF20 disposable set in children from 4 to 15 kg.

Continuous venovenous hemodiafiltration (CVVHDF) in infants is challenging due to a lack of specific and widely available technology. There is need for high precision of fluid balance and hemodynamic stability. The aim of this study is to report the first experience with the newly developed Prismaflex HF20 disposable set (HF20 set) in infants with CVVHDF. We provided safe treatment in four infants (4-14 kg) suffering from acute renal failure with the HF20 set. Treatment monitoring included patients' blood pressure, patients' weight change, and fluid balance. The anticoagulation was performed with unfractionated heparin. We used commercially available bicarbonate-buffered solutions as dialysate fluid and substitution fluid. At start and during the treatment, the patients showed hemodynamic stability. Desired fluid balance was achieved in all patients during the treatment periods of 49-102 hours. No complications occurred. This report presents CVVHDF experience on the feasibility and safety of the HF20 set in infants. It can be used in CVVHDF or hemodialysis mode. Treatments were well tolerated in all patients, and flow rate adaptability to infants' needs was very acceptable, and the usage of this device was easy and safe.

First experience with the Prismaflex HF 20 set in four infants.

PURPOSE: Renal replacement therapy (RRT) in infants is challenging due to a lack of widely available technology that is specific to this patient population. We present our initial experience with the newly developed Prismaflex HF20 disposable set used on the Prismaflex device in infants with renal failure. PATIENTS: Four infants, age 5 to 24 months, were enrolled. Overall 120 treatment sessions were performed over 300 patient-days. Treatment monitoring included patient weight change and fluid balance, treatment efficacy, number of interventions, and alarms. RESULTS: Desired fluid balance according to the prescribed weight loss was achieved in all patients (R²=0.86, p<0.0001). Treatment efficacy was monitored by blood urea nitrogen (BUN) and serum creatinine values at the start of RRT (59 ± 17 mg/dL and 5.1 ± 1.1 mg/dL) and their decrease after 4 hours of RRT (23 ± 7 mg/dL and 2.2 ± 0.6 mg/dL). Measured urea and creatinine clearances for the HF20 filter were 23 ± 7 ml/min and 19 ± 4 ml/min, respectively. No complications occurred. CONCLUSION: This is the first report on the use of the Prismaflex HF20 set in infants. No adverse events were observed, treatments were well tolerated in all patients, and flow rate adaptability to infants' needs was good.

Two decades' experience of renal replacement therapy in paediatric patients with acute renal failure.

During the past 20 years, childhood renal replacement therapy (RRT) and the treatment of underlying diseases experienced extensive advances. We reviewed the data of our critically ill patients with acute renal failure (ARF) and RRT, comparing two decades from 1985 to 1994 and from 1995 to 2004. There were 87 patients with a mortality rate of 45% in the first decade, decreasing to 28 patients with a mortality rate of 39% in the second decade. The mortality rate decreased from 51% to 20% in patients older than one year, while the mortality rate in patients younger than one year increased from 38% to 88%. Yet, the absolute number of these non-survivors younger than one year decreased from 16 to seven patients. The decrease of RRT was mainly caused by a decrease of ARF secondary to heart surgery, oncologic disorders and sepsis. Whereas the majority of patients (75%) were treated with continuous haemofiltration in the first decade, 75% of patients were treated with continuous haemodiafiltration in the second decade. In conclusion, advances in the diagnosis and treatment of underlying disorders have reduced the need for RRT in critically ill paediatric patients during the past 20 years. In addition, there was a tendency for a decrease in the overall mortality, which might be caused by changing treatment policies and advances in RRT technology. Nevertheless, the high mortality rate in small infants is challenging.

Silver-coated dressing acticoat caused raised liver enzymes and argyria-like symptoms in burn patient.

BACKGROUND: Treatment of acute burn wounds with silver sulfadiazine (SSD) has raised concern about potential silver toxicity. Numerous adverse reactions and side effects have been reported and an increasing resistance to SSD, especially in Pseudomonas strains, have motivated researchers to search for an alternative wound dressing. METHODS: Recently, a silver-coated wound dressing Acticoat (Smith & Nephew, Inc.) has become available for use in burn patients. It is a three-ply dressing, consisting of an inner rayon/polyester absorptive core between two layers of silver-coated, high-density polyethylene mesh. In a moist environment, the nanocrystals of silver are released and improve the microbial control in the wound. RESULTS: After 1 week of local treatment with Acticoat in a young, previously healthy 17-year-old boy with 30% mixed depth burns, hepatotoxicity and argyria-like symptoms, a grayish discoloration of the patient's face, appeared. The silver levels in plasma (107 microg/kg) and urine (28 microg/kg) were clearly elevated, as well as the liver enzymes. As soon as the local application of Acticoat was aborted, the clinical symptoms and liver enzymes returned to the normal values. CONCLUSIONS: This is the first report on silver toxicity in a patient with 30% burns who received Acticoat for local treatment. Due to substantial experiences with adverse SSD reactions and side effects, it is appropriate to keep the possibility of a toxic silver effect in burn patients treated with Acticoat silver-coated wound dressing in mind. The silver levels in plasma and/or urine should be monitored.

Partial liquid ventilation combined with two different gas ventilatory strategies in acute lung injury in piglets: Effects on gas exchange, respiratory mechanics, and hemodynamics.

BACKGROUND/PURPOSE: Partial liquid ventilation (PLV) has been shown to improve oxygenation and lung mechanics in different models of acute lung injury. This study was designed to investigate the effects of 2 gas ventilatory strategies during PLV on gas exchange, respiratory mechanics, and hemodynamics in acute lung injury in piglets. METHODS: After induction of acute lung injury, the animals were assigned randomly to 2 groups with different positive end-expiratory pressure (PEEP) levels and tidal volumes (Vt) (group A, Vt > 12.5 mL/kg; PEEP = 6 cm H2O, n = 7; group B, Vt < 9 mL/kg, PEEP = 12 cm H2O, n = 7). Thereafter, the perfluorocarbon (PFC) liquid (30 mL/kg) was instilled into the endotracheal tube. Cardiorespiratory parameters were measured at baseline, after induction of acute lung injury, and every 30 minutes up to 120 minutes. RESULTS: During PLV, oxygenation significantly improved with no difference between both gas ventilatory strategies. The high PEEP-moderate Vt gas ventilatory strategy reduced the inspiratory airway resistance and was associated with moderate hypercapnia. There were no significant differences in hemodynamics and respiratory compliance between both gas ventilatory strategies. CONCLUSIONS: The results of this pilot study suggest that oxygenation was equally improved during PLV. This effect was independent of the mode of gas ventilation. However, the high PEEP-moderate Vt gas ventilatory technique resulted in moderate hypercapnia.

Partial liquid ventilation versus conventional mechanical ventilation with high PEEP and moderate tidal volume in acute respiratory failure in piglets.

This prospective randomized pilot study aimed to test the hypotheses that partial liquid ventilation combined with a high positive end-expiratory pressure (PEEP) and a moderate tidal volume results in improved gas exchange and lung mechanics without negative hemodynamic influences compared with conventional mechanical ventilation in acute lung injury in piglets. Acute lung injury was induced in 12 piglets weighing 9.0 +/- 2.4 kg by repeated i.v. injections of oleic acid and repeated lung lavages. Thereafter, the animals were randomly assigned either to partial liquid ventilation (n = 6) or conventional mechanical ventilation (n = 6) at a fractional concentration of inspired O(2) of 1.0, a PEEP of 1.2 kPa, a tidal volume < 10 mL/kg body weight (bw), a respiratory rate of 24 breaths/min, and an inspiratory/expiratory ratio of 1:2. Perfluorocarbon liquid 30 mL/kg bw was instilled into the endotracheal tube over 10 min followed by 5 mL/kg bw/h. Continuous monitoring included ECG, mean right atrial, pulmonary artery, pulmonary capillary, and arterial pressures, arterial blood gas, and partial pressure of end-tidal CO(2) measurements. When compared with control animals, partial liquid ventilation resulted in significantly better oxygenation with improved cardiac output and oxygen delivery. Dead space ventilation appeared to be lower during partial liquid ventilation compared with conventional mechanical ventilation. No significant differences were observed in airway pressures, pulmonary compliance, and airway resistance between both groups. The results of this pilot study suggest that partial liquid ventilation combined with high PEEP and moderate tidal volume improves oxygenation, dead space ventilation, cardiac output, and oxygen delivery compared with conventional mechanical ventilation in acute lung injury in piglets but has no significant influence on lung mechanics.