Noninvasive cardiac output measurement using bioreactance in postoperative pediatric patients.

BACKGROUND: Thoracic bioreactance is a noninvasive and continuous method of cardiac output (CO) measurement that is being developed in adult patients. Very little information is available on thoracic bioreactance use in children. OBJECTIVE: The aim of the study was to evaluate the ability of a bioreactance device (NICOM(®) ; Cheetah Medical, Tel Aviv, Israel) to estimate CO and to track changes in CO induced by volume expansion (VE) in children. METHODS: Cardiac output values obtained using the NICOM(®) device (CONICOM ) and measured by trans-thoracic echocardiography (COTTE ) were compared in pediatric neurosurgical patients during the postoperative period. RESULTS: Seventy-three pairs of measurements of CO obtained in 30 children were available for analysis. The bias (lower and upper limits of agreement) between CONICOM and COTTE was -0.11 (-1.4 to 1.2) l·min(-1). The percentage error (PE) was 55%. The precision of the NICOM(®) device was 45%. A significant correlation was observed between the CO values obtained using the two methods (r = 0.89, <0.001). The concordance percentage between changes in COTTE and CON icom induced by VE was 84% following exclusion of patients with changes in CO <15% (n = 5). CONCLUSIONS: The PE observed is too large, and the limits of agreement too wide, to enable us to comment on the equivalence of the two techniques of CO measurements. However, the NICOM(®) device performs well in tracking changes in CO following VE.

MORPHIT: an observational study on morphine titration in the postanesthetic care unit in children.

BACKGROUND: Little information is available on the titration of morphine postoperatively in children. This observational study describes the technique in terms of the bolus dose, the number of boluses required, the time to establish analgesia, and side effects noted. METHODS: Morphine was administered if pain score (VAS or FLACC) was >30. Patients weighing less than 45 kg received a 50 µg·kg(-1) bolus of morphine with subsequent boluses of 25 µg kg(-1) as required. Patients weighing over 45 kg received boluses of 2 mg. Pain and Ramsay scores were recorded up to 90 min after the end of the titration and any side effect or complication was noted. Data are presented as the median [interquartile Q1-Q3 range]. RESULTS: Overall, 103 children were studied. The median age was 4.2 years [0.8-12.2 years]. The median weight was 15.5 kg [8.2-35.0 kg]. The protocol was effective for pain control with a significant decrease in pain scores over time. The median pain score (VAS or FLACC) was 70 [50-80] prior to the initial bolus and 0 [0-10] 90 min after the last bolus. Median Ramsay score was 1 [1-2] before the initial bolus administration and 4 [2-4] at 90 min. The median total dose of morphine was 100 [70-140] µg·kg(-1) , and the median number of boluses was 3 [2-5]. Side effects were observed in 17% of cases. No serious complications were observed. CONCLUSIONS: Our study of morphine titration for children shows that our protocol was effective for pain control with a significant decrease in pain scores over time. No serious complications were encountered. More studies on larger cohorts of patients are needed to confirm the efficacy and safety of this protocol.

A pan-European study of capabilities to manage mass casualties from the release of chemical agents: the MASH project.

The European Union (EU) Mass Casualties and Health (MASH) project that ran between 2008 and 2010 was designed to study the management of mass casualties from chemical and radiological releases and associated health implications. One area of study for this project concerned arrangements within EU Member States for the management of mass casualties following a chemical release. This was undertaken via a confidential online questionnaire that was sent to selected points of contact throughout the EU. Responses were obtained from 18 states from respondents holding senior positions in chemical planning and incident response. Information gathered shows a lack of uniformity within the EU about the organization of responses to chemical releases and the provision of medical care. This article presents the overall findings of the study demonstrating differences between countries on planning and organization, decontamination, prehospital emergency medical responses, clinical diagnoses, and therapy and aftercare. Although there may be an understandable reluctance from national respondents to share information on security and other grounds, the findings, nevertheless, revealed substantial differences between current planning and operational responses within the EU states for the management of mass chemical casualties. The existing international networks for response to radiation incidents are not yet matched by equivalent networks for chemical responses yet sufficient information was available from the study to identify potential deficiencies, identify common casualty management pathways, and to make recommendations for future operations within the EU. Improvements in awareness and training and the application of modern information and communications will help to remedy this situation. Specialized advanced life support and other medical care for chemical casualties appear lacking in some countries. A program of specialized training and action are required to apply the findings revealed by the MASH study into a unified cross-border emergency medical response.

Intra- and postoperative adverse events in children with nephrotic syndrome requiring surgery under general anesthesia.

BACKGROUND: There are few data regarding perioperative adverse events in children with nephrotic syndrome. OBJECTIVES: The aim of this study was to describe the nature and frequency of perioperative adverse events in children with nephrotic syndrome. MATERIALS AND METHODS: This is a retrospective study from a large university pediatric hospital. All procedures under general anesthesia in children with nephrotic syndrome between January 1995 and May 2007 were included, with the exception of renal transplantation. Data were collected on demographics, etiology of nephrotic syndrome and related treatments, surgical procedures and anesthetic techniques, and pre- and postoperative treatments. Adverse events occurring during the intraoperative period and up to the fifth postoperative day were recorded. RESULTS: Data on eight patients who underwent 24 surgical or interventional procedures under general anesthesia over the study period were reviewed. Three patients had steroid-resistant nephrotic syndrome and five patients had congenital or infantile nephrotic syndrome. Five patients had progressed to end-stage renal failure requiring dialysis. General anesthesia was performed for: nephrectomy (n = 9), central venous catheter insertion (n = 8), peritoneal dialysis catheter insertion (n = 5), and emergency surgery in two cases (acute intestinal intussusception and hemodialysis catheter insertion). Three patients were receiving aspirin and one anticoagulant therapy. No postoperative thrombosis or infections, bleeding, peripheral edema or ascites, and increase in kalemia were noted. There was no significant postoperative increase in median serum creatinine level. CONCLUSIONS: Surgical procedures were seldom associated with the occurrence of perioperative adverse events. However, larger studies are needed to confirm these results.

Emergency tracheal intubation of severely head-injured children: changing daily practice after implementation of national guidelines.

OBJECTIVE: To report daily practice of scene emergency tracheal intubation performed by physicians and changes induced by implementation of national guidelines, with special attention to rapid sequence induction (RSI) and control of assisted ventilation. DESIGN: Observational study. SETTING: Pediatric intensive care unit of a university hospital. PATIENTS: A total of 296 children (age, 2-15 yrs old) referred to our center for severe traumatic brain injury (Glasgow Coma Scale score of ≤ 8), with spontaneous cardiac rhythm. INTERVENTIONS: Scene RSI practice by field physicians was compared before (n = 188), and after (n = 108) publication of national guidelines. Emergency tracheal intubation conditions, RSI use, immediate complications, assisted ventilation efficiency on blood gases measurements upon arrival, and, in the later period, physician's knowledge, and observance to published guidelines were analyzed. MEASUREMENTS AND MAIN RESULTS: After publication of guidelines, tracheal intubation was performed at the scene in 100% of the cases (vs. 88%, p = .05); RSI practice was more standardized, with an increased use of succinylcholine (10% to 80%, p = .0001), and a concomitant decreased use of nondepolarizing muscle relaxant (20% vs. 0%, p = .005), and opioids (70% vs. 36%, p = .05). Recommended RSI protocol (etomidate and succinylcholine) was effectively used by 64% of the physicians (vs. 2.8%, p = .001), and rate of immediate complications upon tube insertion (mainly cough reflex) decreased to 8% (vs. 25%, p = .0015). Scene emergency tracheal intubation, when ordered, resulted in a 100% success rate and adequate oxygenation within the two groups. Despite increasing the use of portable capnograph in the later period, Paco2 was measured outside the tight target range (35-40 torr, 4.6-5.3 kPa) in 70% of the cases upon arrival. CONCLUSIONS: Scene emergency tracheal intubation was effectively performed by trained careproviders in children with traumatic brain injury. Implementation of guidelines led to a more standardized practice of RSI, decreased rate of immediate complications, but insufficient control of Paco2 during transport.

Hemorrhagic shock and encephalopathy syndrome in a quadriplegic child: an argument for the triggering role of impaired thermoregulatory response.

STUDY DESIGN: A case presentation of hemorrhagic shock and encephalopathy syndrome (HSES). OBJECTIVE: To describe an unusual complication of uncontrolled fever in a tetraplegic child and to discuss possible pathophysiological mechanisms in these circumstances. SUMMARY OF BACKGROUND DATA: HSES is a rare and dramatic disorder of unknown origin occurring mainly in infants and young children. Clinical features of HSES associate hyperpyrexia, acute diarrhea, circulatory collapse, coma, convulsions, and multiple organ failure (MOF). Altered physiologic thermoregulatory response in infants exposed to abruptly increased core temperature or altered thermal environment, and links with heat stroke, have been mentioned in previous publications. METHODS: We report a case of HSES occurring in a 6-year-old girl with post-traumatic C4 quadriplegia. She eventually experienced hyperpyrexia, deep shock, watery diarrhea, and severe MOF developed rapidly. Despite rapidly resolving MOF, severe brain lesions consistent with HSES were observed and resulted in permanent neurologic impairment. RESULTS: Negative bacterial and viral screening eliminated a septic origin. In this child, impaired thermoregulatory response to acute hyperpyrexia resulting from complete quadriplegia could be the necessary condition for the development of HSES in the presence of acute hyperpyrexia of unknown origin. CONCLUSION: Quadriplegic patients, especially young children, could be considered at increased risk of developing severe MOF and acute central nervous system impairment consistent with HSES, when exposed to heat stress and should be treated promptly.

Thrombolysis during resuscitation for out-of-hospital cardiac arrest.

BACKGROUND: Approximately 70% of persons who have an out-of-hospital cardiac arrest have underlying acute myocardial infarction or pulmonary embolism. Therefore, thrombolysis during cardiopulmonary resuscitation may improve survival. METHODS: In a double-blind, multicenter trial, we randomly assigned adult patients with witnessed out-of-hospital cardiac arrest to receive tenecteplase or placebo during cardiopulmonary resuscitation. Adjunctive heparin or aspirin was not used. The primary end point was 30-day survival; the secondary end points were hospital admission, return of spontaneous circulation, 24-hour survival, survival to hospital discharge, and neurologic outcome. RESULTS: After blinded review of data from the first 443 patients, the data and safety monitoring board recommended discontinuation of enrollment of asystolic patients because of low survival, and the protocol was amended. Subsequently, the trial was terminated prematurely for futility after enrolling a total of 1050 patients. Tenecteplase was administered to 525 patients and placebo to 525 patients; the two treatment groups had similar clinical profiles. We did not detect any significant differences between tenecteplase and placebo in the primary end point of 30-day survival (14.7% vs. 17.0%; P=0.36; relative risk, 0.87; 95% confidence interval, 0.65 to 1.15) or in the secondary end points of hospital admission (53.5% vs. 55.0%, P=0.67), return of spontaneous circulation (55.0% vs. 54.6%, P=0.96), 24-hour survival (30.6% vs. 33.3%, P=0.39), survival to hospital discharge (15.1% vs. 17.5%, P=0.33), or neurologic outcome (P=0.69). There were more intracranial hemorrhages in the tenecteplase group. CONCLUSIONS: When tenecteplase was used without adjunctive antithrombotic therapy during advanced life support for out-of-hospital cardiac arrest, we did not detect an improvement in outcome, in comparison with placebo. (ClinicalTrials.gov number, NCT00157261.)

Use of recombinant activated factor VII in intractable bleeding during pediatric neurosurgical procedures.

OBJECTIVE: To report the use of recombinant activated factor VII (NovoSeven; Novo Nordisk A/S, Bagsvaerd, Denmark) in children undergoing major neurosurgical procedures and experiencing massive uncontrolled hemorrhagic shock. DESIGN: Retrospective review of patients and analysis of clinical and biological effects of an intravenous administration of recombinant activated factor VII. SETTING: Neurosurgical anesthesia and critical care unit of a pediatric university hospital. PATIENTS/SUBJECTS: Four children, <12-kg body weight, experiencing life-threatening perioperative hemorrhage required conventional treatment (massive red blood cells, fresh frozen plasma, platelet transfusion, and surgical hemostatic maneuvers) that failed to obtain definite hemostasis. INTERVENTIONS: Intravenous administration of recombinant activated factor VII (100 microg/kg). RESULTS: Intravenous administration resulted in a significant decrease in blood loss within minutes (preventing further need of transfusion), normalization of biological hemostasis markers, and improved surgical hemostasis. No side effects of recombinant activated factor VII were noted, and all patients, except one, had a good recovery. CONCLUSIONS: These four patients support the use of recombinant activated factor VII as a useful adjunct to control massive life-threatening bleeding during pediatric neurosurgical procedures when other means failed. However, the data are still limited in children, and more extensive research is needed to define the indications of recombinant activated factor VII in massive surgical hemorrhage in low-weight children.

Use of recombinant activated factor VII in intractable bleeding during pediatric neurosurgical procedures.

OBJECTIVE:: To report the use of recombinant activated factor VII (NovoSeven; Novo Nordisk A/S, Bagsvaerd, Denmark) in children undergoing major neurosurgical procedures and experiencing massive uncontrolled hemorrhagic shock. DESIGN:: Retrospective review of patients and analysis of clinical and biological effects of an intravenous administration of recombinant activated factor VII. SETTING:: Neurosurgical anesthesia and critical care unit of a pediatric university hospital. PATIENTS/SUBJECTS:: Four children, <12-kg body weight, experiencing life-threatening perioperative hemorrhage required conventional treatment (massive red blood cells, fresh frozen plasma, platelet transfusion, and surgical hemostatic maneuvers) that failed to obtain definite hemostasis. INTERVENTIONS:: Intravenous administration of recombinant activated factor VII (100 mug/kg). RESULTS:: Intravenous administration resulted in a significant decrease in blood loss within minutes (preventing further need of transfusion), normalization of biological hemostasis markers, and improved surgical hemostasis. No side effects of recombinant activated factor VII were noted, and all patients, except one, had a good recovery. CONCLUSIONS:: These four patients support the use of recombinant activated factor VII as a useful adjunct to control massive life-threatening bleeding during pediatric neurosurgical procedures when other means failed. However, the data are still limited in children, and more extensive research is needed to define the indications of recombinant activated factor VII in massive surgical hemorrhage in low-weight children.

Epidemiology and early predictive factors of mortality and outcome in children with traumatic severe brain injury: experience of a French pediatric trauma center.

OBJECTIVE: To describe the results of an integrated pre- and in-hospital approach to critical care in a large population of children with severe traumatic brain injury and to identify the early predictors of their outcome. DESIGN: A 9-yr retrospective review of the data of a trauma data bank. SETTING: Level III pediatric trauma center. PATIENTS: All children (1 month to 15 yrs) with severe traumatic brain injury (Glasgow Coma Scale /=6 months after discharge. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Univariate and further multivariate analyses were performed to determine independent predictive factors of death and outcome at discharge and 6 months later. The Glasgow Outcome Scale was used to evaluate outcome; a poor outcome referred to Glasgow Outcome Scale >/=3. Receiver operating characteristic curves were drawn to determine the threshold values of predictors of death and outcome. Analysis concerned 585 children (67% male and 33% female). Mean age was 7 +/- 5 yrs. Predominant mechanisms of injury were road traffic accidents and falls. Mean values for Glasgow Coma Scale, Pediatric Trauma Score, and Injury Severity Score were 6 (3-8), 3 (-4,10), and 28 (4-75), respectively. Mortality rate was 22%; Glasgow Outcome Scale was <3 in 53% of the cases at discharge and 60% at 6 months. Multivariate analysis identified Glasgow Coma Scale, Injury Severity Score, and hypotension on arrival as independent predictors of death and poor outcome at discharge and at 6 months. Threshold values for death were 28 for Injury Severity Score and 5 for Glasgow Coma Scale. The same values were found for poor outcome, except for outcome at 6 months where threshold value for the Glasgow Coma Scale was 6. CONCLUSIONS: Initial hypotension, Glasgow Coma Scale, and Injury Severity Score are independent predictors of outcome in children with traumatic brain injury. Threshold values can be calculated for predicting poor outcome. These variables can be easily and detected early in this population and used for quality assessment.

Grand mal seizures: an unusual and puzzling primary presentation of ruptured hepatic hydatid cyst.

We report a case of hepatic hydatidosis where the first clinical manifestations, generalized seizures after minor head and abdominal trauma, and delayed anaphylaxis, made the primary diagnosis difficult. Severe anaphylaxis has been reported as initial presentation of quiescent hepatic hydatidosis. In endemic areas, the diagnosis must be carefully ruled out in patients experiencing abrupt anaphylactic shock of uncertain etiology. The occurrence of unexplained vascular collapse after minor abdominal trauma in a patient originating from an endemic area should prompt the diagnosis and urgent treatment should be initiated; firstly emergency management of the anaphylactic shock and later, surgical treatment of the cysts.

Early hypocalcemia in severe trauma.

OBJECTIVES: We tested the hypothesis that colloid-induced hemodilution can induce hypocalcemia in the early phase of severe trauma resuscitation and tried to assess other potential causative factors of that hypocalcemia. DESIGN: Prospective cohort. SETTING: Level I academic trauma center. PATIENTS: Consecutive severe trauma patients (n = 212, mean Injury Severity Score 34) resuscitated in the prehospital phase without any blood transfusion. INTERVENTIONS: At admission, ionized calcium (corrected to an arterial pH = 7.40) was measured. MEASUREMENTS AND MAIN RESULTS: Hypocalcemia was defined as a value <1.15 mmol/L and severe hypocalcemia as a value <0.9 mmol/L. A normal ionized calcium concentration was observed in 56 (26%) patients, a mild ionized hypocalcemia (1.05 +/- 0.06 mmol/L) in 135 (64%) patients, and a severe ionized hypocalcemia (0.77 +/- 0.10 mmol/L) in 21 (10%) patients. There were significant correlations between ionized calcium concentration with the amount of infused colloid (R = .658, p < .001) and arterial pH (R = .760, p < 0.001) but not with the amount of infused crystalloid (R = .007, not significant). Despite taking into account hemodilution, arterial pH, binding of calcium to lactates, and colloids, some patients had marked differences (>15%) between calculated and observed ionized calcium, and these patients had more severe trauma and more frequently had acidosis and/or prehospital cardiac arrest. Using the TRISS methodology, survival was not significantly different from that expected in this trauma population. CONCLUSION: Hypocalcemia frequently occurs on arrival at the hospital in severe trauma patients, and colloid-induced hemodilution and severe shock and/or ischemia-reperfusion appear to be important causative factors.

The prognostic value of transcranial Doppler studies in children with moderate and severe head injury.

OBJECTIVE: To assess the potency of transcranial Doppler (TCD) to predict prognosis in children with moderate and severe head trauma. DESIGN AND SETTING: Prospective single-center study in a level I pediatric trauma center. PATIENTS: Thirty-six consecutive patients with a prehospital diagnosis of moderate or severe head trauma admitted over a 6-month period. INTERVENTIONS: On arrival in the emergency room, TCD was performed and peak systolic velocities, end-diastolic velocity and time-averaged mean velocity in the middle cerebral artery were recorded. Pulsatility and resistance index were calculated. The Pediatric Trauma Score (PTS), Glasgow Coma Scale (GCS) score and Injury Severity Score (ISS) were also calculated. Patient neurological outcome was determined using the Glasgow Outcome Scale (GOS) at discharge from hospital. GOS 1-2 were considered as "good prognosis" (group 1) and GOS 3-5 were considered as "poor prognosis" (group 2). RESULTS. Compared with group 1 patients, group 2 patients had a significantly lower mean GCS (5+/-3 vs 8+/-4, p<0.05) and PTS (2+/-2 vs 5+/-2), and a higher mean ISS (32+/-8 vs 19+/-11, p<0.05). An end-diastolic velocity less than 25 cm/s and a pulsatility index more than 1.31 were associated with a poor prognosis (p<0.05). CONCLUSION: In children with moderate and severe head trauma, our data suggest an association between the results of TCD assessment on arrival in the emergency room and the outcome at discharge from the hospital.

Endotracheal tube cuff pressure is unpredictable in children.

UNLABELLED: The use of cuffed tracheal tubes in children younger than 8 yr of age has recently increased, although cuff hyperinflation may cause tracheal mucosal damage. In this study, we sought to measure the cuff pressure (P(cuff)) after initial free air inflation (iP(cuff)) and to follow its evolution throughout the duration of 50% nitrous oxide (N(2)O) anesthesia. One-hundred-seventy-four children, aged 0 to 9 yr, fulfilling the following criteria, were studied: 1). weight of 3-35 kg; 2). ASA physical status I or II; 3). elective surgery; 4). anesthesia with tracheal intubation using a cuffed tube and lasting at least 45 min; and 5). gas mixture containing 50% N(2)O. Free air inflation results in variable iP(cuff), with hyperinflation in 39% of cases. Numerous gas removals were required to maintain P(cuff) less than 25 cm H(2)O in 85% of the patients. The number of deflations decreased with the duration of mechanical ventilation and was small after 105 min. No difference was observed among the different cuffed tube sizes. We conclude that iP(cuff) is unpredictable after free air inflation and that numerous gas removals are required to maintain P(cuff) less than 25 cm H(2)O during N(2)O anesthesia in children. IMPLICATIONS: Free inflation of the tracheal tube cuff, controlled only by the palpation of the pilot balloon, is not reliable and results in extremely variable (and sometimes very high) initial cuff pressures in children. In addition, nitrous oxide anesthesia may result in cuff hyperinflation requiring numerous gas removals.

Comparison of perioperative blood salvage and postoperative reinfusion of drained blood during surgical correction of craniosynostosis in infants.

BACKGROUND: The surgical correction of craniosynostosis may be associated with extensive blood loss and transfusion. The aim of this study was to compare the efficacy of the perioperative use of the continuous autotransfusion system (CATS group) and of the postoperative use of the CBCII ConstaVac(R) system (CV group) to reduce homologous transfusion in infants during repair of craniosynostosis. METHODS: Two groups of consecutive infants, weighing <10 kg, and scheduled for the surgical correction of craniosynostosis, were compared retrospectively according to the blood salvaging system used: CATS group and CV group. The primary endpoint was the comparison of the total volume of homologous blood transfused. RESULTS: There was no significant difference between the CV (n = 69) and the CATS (n = 135) groups with regard to physical, preoperative and postoperative data, except for the type of craniosysnostosis with more scaphocephaly in the CV group (P = 0.03). No significant difference in blood loss and homologous transfusion was observed between the two groups during the perioperative period. Two subgroups of patients were also compared: a subgroup including patients operated on with a linear craniectomy for scaphocephaly, and a subgroup including all other patients. There was also no significant difference in blood loss and homologous transfusion between the CV and the CATS groups for these two subgroups of patients. CONCLUSION: Our results suggest that the postoperative use of the CBCII ConstaVac(R) system is as efficient as the perioperative use of the CATS(R) system for reducing homologous blood transfusion during repair of craniosynostosis in infants weighing <10 kg.