Pregnant mothers out of the perinatal regionalization's reach.

INTRODUCTION: Birth of very low birth weight (VLBW) infants outside subspecialty perinatal centers increases risk for death and major morbidities. OBJECTIVE: The purpose of this study is to evaluate barriers to utilizing a regional perinatal center for the birth of VLBW infants to mothers not living in the immediate vicinity of the center. METHODS: We conducted a retrospective cohort study of VLBW infants residing in the catchment area of a community level II, Specialty Neonatal Unit (SN) admitted to a Regional Subspecialty Neonatal Intensive Care Unit (RC) between January 1999 and December 31, 2004. Maternal demographics and prenatal care as well as outcomes were compared by place of birth. RESULTS: Out of 98 VLBW infants admitted to the RC, 49 (50%) were delivered outside the RC (out-born) and 49 (50%) were born at the RC (in-born). There was no statistical difference in insurance coverage, race, gestational age, severity of illness or maternal demographic factors between out-born and in-born infants. Less than adequate prenatal care rather than distance of maternal residence from the RC was associated with birth outside the RC. Adjusting for prenatal care, distance of residence from the RC increased the risk for delivering outside the center in the subset of mothers insured by Medicaid. CONCLUSIONS: Mothers of VLBW infants who received less than adequate prenatal care and did not live in the vicinity of a subspecialty center had an increased risk for delivery outside that center compared to those with adequate care. Appropriate place of birth for VLBW infants to low-income mothers may be influenced by the distance of their residence to an RC.

Using characteristic changes in laboratory values to assist in the diagnosis of hemorrhagic shock and encephalopathy syndrome.

OBJECTIVES: (1) To determine whether the laboratory abnormalities in hemorrhagic shock encephalopathy syndrome (HSES) follow a characteristic pattern of evolution; and (2) to describe the clinical characteristics and outcome of this group of children. DESIGN: Retrospective review of hospital records. SETTING: Pediatric intensive care unit in an academic children's hospital. PATIENTS: Seventeen children who received the diagnosis of HSES. MEASUREMENTS: (1) To support the diagnosis of HSES, the following laboratory tests were obtained: creatine phosphokinase, alanine aminotransferase, aspartate aminotransferase, blood urea nitrogen, creatinine, anemia, thrombocytopenia, coagulation abnormalities, and a metabolic acidosis; and (2) patient characteristics at the time of admission and during the illness and patient outcome were recorded. RESULTS: The median time for laboratory abnormalities in HSES to reach the most aberrant levels was 1.2 to 1.4 days. After reaching maximal deviation, the laboratory values gradually returned to normal. The severity of laboratory abnormalities was not predictive of mortality. All patients were comatose, had seizures, and required fluid resuscitation. Respiratory failure occurred in 12 (71%) of 17 patients. Vasopressor infusions were used for 8 (47%). Viral cultures were performed in 15 patients and were positive in 8 (53%). Eleven (64%) patients survived. CONCLUSIONS: The laboratory abnormalities that are characteristic of HSES follow a distinctive pattern of evolution during the course of the illness. Although the sensitivity, specificity, and predictive value of this pattern of laboratory abnormalities are not known, it might provide a useful tool in diagnosing HSES and excluding other illnesses. Viral illness is common in HSES. The severity of illness and mortality in this group of patients is similar to other descriptions of HSES.

Acute appendicitis risks of complications: age and Medicaid insurance.

OBJECTIVES: To describe the epidemiology of acute appendicitis in children from Washington State, and to determine important risk factors for complications. DESIGN: Retrospective cohort study. SETTING: All children (<17 years old) treated in Washington State who were identified by hospital discharge diagnosis codes from 1987 through 1996. METHODS: The hospital discharge data were reviewed for all children with a primary diagnosis code for acute appendicitis. Complicated disease was defined as perforation or abscess formation. RESULTS: Young children (0-4 years old) had the lowest annual incidence of acute appendicitis, but they had a 5-fold increased risk of complicated disease (odds ratio: 4.9; 95% confidence interval: 4.0-5.9), compared with teenagers. Children with Medicaid insurance had a 1.3-fold increased risk of complicated disease, compared with children with commercial insurance (odds ratio: 1.3: 95% confidence interval: 1.2-1.4). Children with Medicaid insurance had significantly longer average length of stay (4.0+/-3.7 days) than all other payers (commercial insurance: 3.3+/-4.0 days; health maintenance organization: 3.5+/-3.1 days; and self-insured: 3.7+/-5.8 days). CONCLUSIONS: Very young children had the greatest risk of complicated disease. Children with Medicaid insurance had increased risk of complicated disease, compared with children with commercial health insurance and longer length of stay. Additional studies are needed to evaluate barriers to care for children with Medicaid insurance.

Severe dog bites in children.

OBJECTIVE: We evaluated children less than 16 years of age who had dog bite injuries that resulted in hospitalization or death to determine the typical characteristics of the children, the dogs, and the injuries suffered. DESIGN: Retrospective chart review. SETTING: Three large city hospitals including Harborview Medical Center, Seattle, Washington; Children's Mercy Hospital, Kansas City, Missouri; and Mary Bridge Hospital, Tacoma, Washington. METHODS: Charts were reviewed for patient demographic data and canine data. Hospitalization data included total length of stay, need for intensive care, Injury Severity Score, the nature and extent of the injuries, procedures performed, complications, and outcome. RESULTS: Forty cases were reviewed. Most children were boys (60%) and were white (87%). The median age was 50 months. There were three deaths. Most dogs were medium-sized or large breeds and were familiar to the victim. The average hospital stay was 6 days (SD = 5), and 12 (30%) patients required a stay in the intensive care unit. Injuries to the face, head, and neck area were most common (82%). Major surgical procedures included craniotomy, exploration of the neck or abdomen, ocular procedures, and repair of fractures. CONCLUSIONS: Severe dog bites in children occur most frequently in those younger than 5 years old and involve the head and neck. Large dogs that are familiar to the child are usually involved. Young children should be closely supervised when around any dog.

Colloid volume expanders. Problems, pitfalls and possibilities.

Colloid solutions have been developed and used over the past 70 years as expanders of the intravascular space, based on an understanding of Starling's law. Increasing osmotic pressure with colloidal products has remained an attractive theoretical premise for volume resuscitation. Indeed, colloids have been shown to increase osmotic pressure in clinical practice; however, the effects are short-lived. Lower molecular weight colloids exert a larger initial osmotic effect, but are rapidly cleared from the circulation. Larger molecules exert a smaller osmotic pressure that is sustained longer. The main drawback to colloid therapy lies in pathological states with endothelial injury and capillary leak, precisely the clinical scenario where colloids are commonly given. The colloid solution may leak into the interstitium and remain there exerting an osmotic gradient, pulling additional water into the interstitium. There are 4 general types of colloid products available for clinical use. Albumin is the predominant plasma protein and remains the standard against which other colloids are compared. Albumin, pooled from human donors, is in short supply and remains expensive. Dextrans have been used to prevent deep venous thrombosis and to lower blood viscosity during surgery. Hetastarch has been widely used as a plasma volume expander. It provides equivalent plasma volume expansion to albumin, but has been shown to alter clotting parameters in studies (prolonging the activated partial thromboplastin time and prothrombin time). Although severe coagulopathies have been reported in sporadic cases, hetastarch has not been shown to increase postoperative bleeding compared with albumin therapy, even in large doses (3 L/day). Despite some theoretical advantages compared with crystalloid therapy, colloid administration has not been shown to decrease the risk of acute lung injury or to improve survival. Specific indications for colloid products include hypoproteinaemic or malnourished states, patients who require plasma volume expansion who are unable to tolerate larger amounts of fluid, orthopaedic and reconstructive procedures requiring prevention of thrombus formation and leukapheresis.

Routine chest radiographs following repositioning of endotracheal tubes are necessary to assess correct position in pediatric patients.

Attempts to correctly reposition endotracheal tubes (ETTs) are not always successful in pediatric patients, even when chest radiographs (CXRs) are measured to determine the distance that the ETT deviates from the correct position. We determined the frequency of continued ETT malposition after repositioning in a pediatric intensive care unit (PICU). Forty children with malpositioned ETTs were identified during a 4-month period. After repositioning, ten (25 percent) continued to be malpositioned on the next CXR. Of 47 children with correctly positioned ETTs, only one ETT (2 percent) was found to be incorrectly positioned on the next routine CXR obtained 24 h later. The difference in frequency of ETT malposition between these two groups of children is significant (p < 0.0001). The children were similar in weight and age. Despite repositioning based on measurements taken from a CXR, a large percentage of pediatric patients had continued ETT malposition. However, after radiographic documentation of correct position, we demonstrated that significant movement was uncommon. Routine confirmation of ETT position by CXRs should be considered after repositioning ETTs in pediatric patients.

Use of cardiopulmonary bypass during bronchoscopy following sand aspiration. A case report.

A 6-year-old boy with massive sand aspiration was effectively treated with femoral vein to femoral artery cardiopulmonary bypass (CPB), saline bronchial lavage, and exogenous surfactant. The patient was discharged the 9th hospital day without apparent sequelae. CPB should be considered for cases of sand or gravel aspiration when gas exchange is compromised.

Efficacy and complications of percutaneous pigtail catheters for thoracostomy in pediatric patients.

OBJECTIVE: To describe the efficacy of percutaneous pigtail catheters in evacuating pleural air or fluid in pediatric patients. DESIGN: A case series of children with percutaneous pigtail catheters placed in the pediatric ICU between January 1996 and August 1997. SETTING: Urban pediatric teaching hospital in Seattle, WA. METHODS: A retrospective chart review. RESULTS: Ninety-one children required 133 chest catheters. Most patients were infants with congenital heart disease (80%). One hundred thirteen of the catheters (85%) were placed for pleural effusion, with 20 tubes (15%) placed for pneumothorax. Efficacy of drainage of pleural fluid was significantly greater in serous (96%) and chylous (100%) effusions compared with empyema (0%) or hemothorax (81%). Evacuation of pneumothorax was achieved by a pigtail catheter in 75% of patients. Resolution of pleural air or pneumothorax was significantly greater in patients < 10 kg compared with larger children. Complications due to placement of the pigtail catheters included hemothorax (n=3, 2%), pneumothorax (n=3, 2%), and hepatic perforation (n= 1, 1%). There were also complications arising from the use of the catheters, including failure to drain, dislodgment, kinking, loss of liquid ventilation fluid, empyema, and disconnection in 27 of 133 catheters (20%). Significantly more complications during catheter use occurred in patients <5 kg than in larger children. CONCLUSIONS: Percutaneous pigtail catheters are highly effective in drainage of pleural serous and chylous effusions, somewhat less efficacious in drainage of hemothorax or pneumothorax, and least efficacious in drainage of empyema. Infants and smaller children had higher rates of resolution of pleural air and fluid from placement of a pigtail catheter than larger children. Complications from catheter placement were uncommon (5%) but serious, whereas complications associated with continued use of the catheters were more common (20%) but less grave. Strict attention to anatomic landmarks and close monitoring may reduce the number of complications.

Severe paroxysmal sinus bradycardia associated with high-frequency oscillatory ventilation.

OBJECTIVE: To determine the incidence of and risk factors for unexplained paroxysmal bradycardia in children treated with high-frequency oscillatory ventilation (HFOV). DESIGN: A nested case-control study. SETTING: A university-affiliated children's hospital. SUBJECTS: All children treated with HFOV for at least 3 days during a 2-year period and a randomly chosen comparison group of 50 children treated with only conventional mechanical ventilation (CMV) for at least 3 days during the same time period. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Unexplained paroxysmal sinus bradycardia occurred in six children (12%) receiving HFOV, and was significantly more common than in children treated with CMV (0%). The bradycardic events occurred after the lung disease started to improve, and the mean airway pressure (mPaw) at the time of the bradycardias was significantly decreased from the child's maximal mPaw. The bradycardic events were effectively treated acutely with manual ventilation or atropine sulfate, and resolved completely after the patient was changed to a regimen of CMV. CONCLUSION: Unexplained paroxysmal bradycardia associated with HFOV in children is not uncommon. It completely resolves with conversion to CMV and may be related to overdistention of alveoli as compliance improves.

Hospitalizations for pediatric intoxication in Washington State, 1987-1997.

BACKGROUND: Intoxication (or poisoning) that necessitates hospitalization remains an important source of morbidity in children. OBJECTIVE: To determine changes, during an 11-year period (1987-1997), in the incidence of hospitalization due to intoxication among children in Washington State and circumstances of ingestion, agents used, hospital length of stay, charges, and mortality. METHODS: A computerized database of all hospital discharges (Comprehensive Hospital Abstract Reporting System [CHARS] database) in Washington was used. Cases included all children younger than 19 years with a primary or secondary diagnosis for an intoxication or with an external cause of injury code (E code) for an intoxication from 1987 to 1997. RESULTS: There were 7322 hospitalizations (45 per 100 000 children per year); the annual rate significantly decreased during the study period. Most patients (75%) were teenagers. Sixty-five percent were female. Pharmaceutical agents were used in 80% of cases. Analgesics were the most commonly used (34%), followed by antidepressants (12%) and psychotropic drugs (8%). Nonpharmaceutical agents were more prevalent in children younger than 12 years than in teenagers. Self-inflicted intoxication was the most frequent cause identified by E codes (47%). Median length of stay was 1 day, and median hospital charges were $2096. Mortality was low (0.2%) and did not change significantly over time. CONCLUSIONS: Acute intoxication continues to be an important cause of hospitalization in children. The type of agent involved did not change significantly over time. Teenage girls continue as the highest risk group for suicide attempt from ingestions. Self-inflicted intoxications were associated with higher costs, length of stay, and readmissions. Although preventive measures and development of poison centers have contributed to decrease mortality from acute intoxication in children in the last 50 years, efforts need to be targeted toward suicide prevention, especially among teenage girls.

Serial neurologic examinations after near drowning and outcome.

OBJECTIVE: We evaluated serial neurologic examinations after warm water near drowning to determine how rapidly survivors with poor neurologic outcome could be identified. RESEARCH DESIGN: Retrospective chart review. SETTING: University-affiliated pediatric hospital. PATIENTS: Forty-four children admitted to the pediatric intensive care unit with an abnormal mental status after near drowning during a 5-year period. Follow-up was a minimum of 6 months. INTERVENTIONS: None. MEASUREMENTS: A 14-point coma scale was used to evaluate both cortical and brain-stem function at the time of hospital admission and then daily afterward. The Mann-Whitney U Test was used to compare patients grouped as having satisfactory outcomes (those who returned to their presubmersion baseline or had very mild deficits) and unsatisfactory outcomes (total custodial care or death). Significance was defined as P < .05. CONCLUSION: All satisfactory survivors were sufficiently awake to have spontaneous, purposeful movements 24 hours after near drowning and had normal brain-stem function. All children without spontaneous, purposeful movements and normal brain-stem function 24 hours after near drowning suffered severe neurologic deficits or death. In this retrospective investigation of 44 children, the cortical examination 24 hours after warm water near drowning distinguished satisfactory survivors from children who required total custodial care or died.

Efficacy of peripherally inserted central venous catheters placed in noncentral veins.

BACKGROUND: Peripherally inserted central venous catheters (PICCs) are commonly used intravenous access devices in children. Although PICCs are intended to be placed in central veins, many fail to reach this location. These noncentral PICCs are used for administration of medications and isotonic solutions. OBJECTIVES: To examine the efficacy of noncentral PICCs for completion of therapy, the complications associated with their use, and the effectiveness of noncentral PICCs as compared with PICCs placed in a central vein. DESIGN: A prospective cohort study of children in whom PICCs were inserted, from January 1, 1994, to January 1, 1996. SETTING: A university-affiliated teaching institution. MAIN OUTCOME MEASUREMENT: Completion of intravenous therapy. RESULTS: A total of 587 PICCs were studied. Thirty-nine percent of PICCs were placed in noncentral veins. Centrally placed PICCs had significantly longer catheter duration compared with those placed noncentrally (16.6 vs 11.4 days, respectively). However, central and noncentral PICCs had similar therapy completion rates (73% and 69%, respectively). Catheter failure because of occlusion and accidental dislodgment were similar for central and noncentral PICCs. Likewise, complications caused by exit-site infection, phlebitis, and catheter-associated sepsis were also similar for catheters in the 2 locations. Catheter survival curves were similar for central and noncentral PICCs. CONCLUSIONS: Our study demonstrates that PICCs placed in noncentral veins provide reliable and safe intravenous access for administration of many medications and isotonic solutions for about 2 weeks' duration. The placement of PICCs in central veins may be restricted to those children who need central vascular access because of the type of intended therapy.

Pediatric acetaminophen overdose: risk factors associated with hepatocellular injury.

OBJECTIVES: To characterize demographic and clinical factors associated with pediatric acetaminophen overdose and identify risk factors for hepatocellular injury. DESIGN: Retrospective 10-year chart review. SETTING: Two regional children's hospitals. MATERIALS AND METHODS: Records of patients examined because of acetaminophen ingestion from January 1, 1988, through December 31, 1997, were reviewed. Hepatocellular injury was defined as elevation of serum aminotransferase levels greater than 2 times the reference values. Severe hepatotoxic effect was defined as hepatotoxic effect with evidence of encephalopathy and/or coagulopathy. RESULTS: Data from 322 patients (208 girls and 114 boys, aged 1-17 years) were obtained. Ingestions were intentional in 140 patients (median age, 14 years) and unintentional in 172 (median age, 2 years). Another 10 cases represented dosing errors with therapeutic intent (median age, 3.5 years). Twenty-seven patients had hepatocellular injury; of these, 4 had severe hepatotoxic effects and 1 died. Hepatocellular injury occurred in 10.0% of the dosing error group, 17.9% of the intentional group, and 0.6% of the unintentional group. No patients underwent liver transplantation. Hepatocellular injury was associated with presentation longer than 24 hours after ingestion (odds ratio [OR], 335.0; 95% confidence interval [CI], 40.8-275.0), age 10 to 17 years (OR, 36.9; 95% CI, 4.9-275.4), intentional overdose (OR, 37.2; 95% CI, 5.0-278.2), dose greater than 150 mg/kg (OR, 17.9; 95% CI, 2.3-139.2), and white race (OR, 2.8; 95% CI, 1.1-7.2). CONCLUSIONS: Intentional and unintentional acetaminophen overdoses occurred with similar frequency. Therapeutic misadventure was relatively uncommon, as was hepatocellular injury. Practitioners should have greater suspicion of acetaminophen-associated hepatocellular injury in patients who present more than 24 hours after ingestion, older children, and those who have intentional ingestion.

A prospective study of femoral catheter-related thrombosis in children.

OBJECTIVES: To establish the incidence and correlate clinical findings of femoral venous catheter-related thrombus formation in critically ill children. RESEARCH DESIGN: Observational prospective blinded study. SETTING: University-affiliated pediatric hospital intensive care unit. PATIENTS: Twenty children admitted to the pediatric intensive care unit who had percutaneous femoral venous catheters placed while in the pediatric intensive care unit. INTERVENTIONS: None. MEASUREMENTS: Duplex Doppler ultrasonography evaluation of femoral vein catheters at 1 to 2, 3 to 5, and 7 to 10 days after placement was used to detect the presence of thrombus formation and venous occlusion. Demographic patient data, pediatric risk of mortality scores, and clinical findings, including leg swelling and whether catheters would aspirate blood, were also recorded. Continuous data were analyzed using the Mann-Whitney U Test, and categorical data were compared with Fisher's Exact Test. Statistical significance was assigned at a P value of .05 or less. CONCLUSIONS: The overall incidence of catheter-related femoral vein thrombus formation was 35% (7/20). Ipsilateral leg swelling and the inability to aspirate blood from the catheter were significantly associated with thrombus formation. Patients who developed thrombi were younger and smaller than those who did not. In six of seven patients, thrombus formation was clinically occult when first demonstrated by ultrasonography.

Association between age and blood loss in children undergoing open heart operations.

BACKGROUND: Although recent studies indicated young children are at risk for increased perioperative hemorrhage after open heart operations, the associations between patient age, blood loss and blood product transfusions have not been fully defined in children. METHODS: Perioperative blood loss and blood product transfusion data were recorded for 414 consecutive children undergoing open heart procedures. The children were in the following age groups: 1 month or younger, group 1; older than 1 month to 12 months, group 2; older than 1 year to 5 years, group 3; and older than 5 years, group 4. RESULTS: Postoperative blood loss and blood product transfusions were inversely related to age and differed significantly between the four age groups. Multiple preoperative and intraoperative factors that possibly influence hemostasis also differed significantly between age groups. Median units transfused within 72 hours differed significantly with age (p < 0.0001): group 1, 8 units (range, 1 to 19 units); group 2, 6 units (range, 0 to 21 units); group 3, 2 units (range, 0 to 23 units); and group 4, 0 units (range, 0 to 38 units). CONCLUSIONS: Blood loss and transfusions vary inversely with age. Per kilogram of body weight, neonates bled more and received more donor products than any other age group.

Acute lung injury in isolated traumatic brain injury.

OBJECTIVE: To determine the incidence of acute lung injury (ALI) in comatose patients after isolated traumatic brain injury, to determine whether specific brain lesions diagnosed by cranial computed tomographic scans are associated with ALI, and to determine the outcome of patients with head injuries who developed ALI. METHODS: Descriptive epidemiology and a case-control study using the Traumatic Coma Data Bank was performed to evaluate clinical features and brain lesions associated with ALI in patients with isolated head trauma. Patients with ALI were defined as those who demonstrated a ratio of partial pressure of arterial oxygen to fractional expired oxygen of 300 or less. RESULTS: Twenty of 100 comatose patients developed ALI. Patients with ALI were almost three times more likely to die or survive in a vegetative state (odds ratio, 2.8; 95% confidence interval, 1.6-4.9). Specific anatomic brain lesions diagnosed by cranial computed tomographic scans were not associated with ALI. However, patients with more severe injuries, i.e., large nonevacuated mass lesions, and those with midline shift demonstrated a 10- and 5-fold increased risk of ALI (odds ratio, 9.9; 95% confidence interval, 1.2-217.1; and odds ratio, 5.5; 95% confidence interval, 1.5-20.0). CONCLUSIONS: ALI was common in comatose victims with an isolated traumatic brain injury and was associated with an increased risk of death or a severe neurological morbidity. ALI was associated with the global severity of head injury but not with specific anatomic lesions diagnosed by cranial computed tomographic scans.

A child with valproic acid-associated carnitine deficiency and carnitine-responsive cardiac dysfunction.

Valproic acid enhances renal losses of carnitine esters and leads to decreased plasma free carnitine concentrations in many patients receiving valproic acid therapy. However, decreased serum carnitine levels are of unclear pathologic significance, and most children manifest no symptoms of carnitine deficiency. We report a child with valproic acid-associated carnitine deficiency who had severe cardiac dysfunction develop that resolved with carnitine replacement therapy.

Nonpulmonary organ failure and outcome in children treated with high-frequency oscillatory ventilation.

PURPOSE: The purpose of this study was to quantitate the contribution of nonpulmonary organ failure to mortality of patients treated with high-frequency oscillatory ventilation (HFOV) and to determine which gas-exchange differences are associated with improvement on HFOV. MATERIALS AND METHODS: Charts of all patients treated with HFOV in our pediatric intensive care unit from January 1992 until January 1997 were retrospectively reviewed. RESULTS: Sixty-six patients were treated and 21 patients improved during HFOV (group 1); 45 patients did not improve (group 2). Seventeen patients (26%) had isolated respiratory failure and their mortality was 12%. Percentages of patients with 2, and 3 or more organ failure were 45%, 29%, and their mortality was significantly higher, 67% and 95%, respectively. Patients with primary respiratory failure demonstrated a significantly greater risk of improvement on HFOV (RR ratio of 2.5, 95% CI 1.5 to 4.2). There was a significantly greater proportion of patients with primary cardiac failure who did not improve on HFOV compared with all other patients. Oxygenation index significantly improved over the first 72 hours for both groups, but then significantly worsened over the next 48 hours in group 2 but not in group 1. CONCLUSION: Patients with nonpulmonary organ failure were significantly less likely to improve on HFOV and had a significantly higher mortality than patients with isolated respiratory failure. Children who do not improve on HFOV appear to reach a plateau in oxygenation indices after 3 days of HFOV.

Delivery of hyperbaric oxygen therapy to critically ill, mechanically ventilated children.

PURPOSE: The purpose of this article is (1) to describe our method of mechanical ventilation and monitoring of critically ill children during administration of hyperbaric oxygen therapy (HBO2) in a multiplace chamber; and (2) to review the complications they experienced during transport to the HBO2 chamber and HBO2 treatment. MATERIALS AND METHODS: A case series from a university-affiliated children's hospital and regional hyperbaric medicine treatment facility. Patients studied included all children who required HBO2 therapy while mechanically ventilated at any time between April 1985 and June 1995. RESULTS: Thirty-two children were treated with HBO2 while mechanically ventilated. Ages ranged from 3 days to 11.3 years (mean 4.8+/-3.5 years). There were 22 males. Twenty-one children had necrotizing infections, 9 had carbon monoxide (CO) poisoning, and 2 had iatrogenic arterial air embolism. Complications or events occurring during HBO2 therapy included hypotension (63%), bronchospasm (34%), hemotympanum (13%), and progressive hypoxemia (6%). The only complication during transport was one accidental extubation (3%). CONCLUSION: Hyperbaric oxygen therapy can be administered safely to most critically ill children in a multiplace chamber if they are monitored closely. Although complications are not uncommon, most can be managed easily by a team skilled in treating ill children and knowledgeable of possible complications of HBO2 therapy.

A comparison of oral transmucosal fentanyl citrate and oral hydromorphone for inpatient pediatric burn wound care analgesia.

The ideal oral wound care analgesic for children should be palatable, provide potent analgesia of rapid onset and short duration, and require minimal, yet appropriate, monitoring. With use of a double-blinded crossover design, we compared the efficacy and safety of oral transmucosal fentanyl citrate (OTFC) (approximately 10 micrograms/kg) with the efficacy and safety of oral hydromorphone (60 micrograms/kg) in 14 pediatric inpatients (ages 4 to 17 years) undergoing daily burn wound care in a ward setting. Pulse oximetry, vital signs, side effects, patient pain scores, and observer scores for cooperation, anxiety, and sedation were recorded. Pulse oximetry, vital signs, cooperation, sedation, incidence of nausea or vomiting, and the amount of time it took to resume normal activities were similar in both treatment groups. OTFC resulted in improved pain scores before wound care and improved anxiolysis during wound care, but at other points it was similar in effect to hydromorphone. We conclude that OTFC is a safe and effective analgesic, that it may provide minor improvements in analgesia and anxiolysis compared with hydromorphone, and that it offers a palatable alternative route of opioid administration without intravenous access for wound care procedures in children.