At the Beach: To Jump or Not to Jump?

Splenic injury due to blunt abdominal trauma is an emergency condition in pediatrics. We present a case of a 10-year-old girl who presented to the emergency department 12 hours after a fall from height with abdominal pain, vomiting, and left upper quadrant tenderness and was found to have splenic rupture. Because of extensive bleeding and hemodynamic instability, emergency exploratory laparotomy was performed. Splenic bleeding lacerations were controlled by sutures and tamponade, and ipsilateral intrathoracic hemorrhagic fluid was drained with a good recovery. In this article, we emphasize the importance of early recognition, proper imaging, and splenic conservation where possible in pediatric blunt trauma.

CD64-Neutrophil expression and stress metabolic patterns in early sepsis and severe traumatic brain injury in children.

BACKGROUND: Critical illness constitutes a serious derangement of metabolism. The aim of our study was to compare acute phase metabolic patterns in children with sepsis (S) or severe sepsis/septic shock (SS) to those with severe traumatic brain injury (TBI) and healthy controls (C) and to evaluate their relations to neutrophil, lymphocyte and monocyte expressions of CD64 and CD11b. METHODS: Sixty children were enrolled in the study. Forty-five children with systemic inflammatory response syndrome (SIRS) were classified into three groups: TBI (n = 15), S (n = 15), and SS (n = 15). C consisted of 15 non- SIRS patients undergoing screening tests for minor elective surgery. Blood samples were collected within 6 hours after admission for flow cytometry of neutrophil, lymphocyte and monocyte expression of CD64 and CD11b (n = 60). Procalcitonin (PCT), C-reactive protein (CRP), glucose, triglycerides (TG), total cholesterol (TC), high (HDL) or low-density-lipoproteins (LDL) were also determined in all groups, and repeated on day 2 and 3 in the 3 SIRS groups (n = 150). RESULTS: CRP, PCT and TG (p < 0.01) were significantly increased in S and SS compared to TBI and C; glucose did not differ among critically ill groups. Significantly lower were the levels of TC, LDL, and HDL in septic groups compared to C and to moderate changes in TBI (p < 0.0001) but only LDL differed between S and SS (p < 0.02). Among septic patients, PCT levels declined significantly (p < 0.02) with time, followed by parallel decrease of HDL (p < 0.03) and increase of TG (p < 0.02) in the SS group. Neutrophil CD64 (nCD64) expression was higher in patients with SS (81.2%) and S (78.8%) as compared to those with TBI (5.5%) or C (0.9%, p < 0.0001). nCD64 was positively related with CRP, PCT, glucose, and TG (p < 0.01) and negatively with TC, LDL, and HDL (p < 0.0001), but not with severity of illness, hematologic indices, length of stay or mechanical ventilation duration. CONCLUSIONS: In sepsis, the early stress-metabolic pattern is characterized by a high (nCD64, glucose, TG) - low (TC, HDL, LDL) combination in contrast to the moderate pattern of TBI in which only glucose increases combined with a moderate cholesterol - lipoprotein decrease. These early metabolic patterns persist the first 3 days of acute illness and are associated with the acute phase CD64 expression on neutrophils.

The effects of endotracheal suctioning on the accuracy of oxygen consumption and carbon dioxide production measurements and pulmonary mechanics calculated by a compact metabolic monitor.

BACKGROUND: Open endotracheal suctioning (ETS), which is performed regularly in mechanically ventilated patients to remove obstructive secretions, can cause an immediate decrease in dynamic compliance and expired tidal volume and result in inadequate or inaccurate sidestream respiratory monitoring, necessitating prolonged periods of stabilization of connected metabolic monitors. We investigated the immediate effect of open ETS on the accuracy of oxygen consumption (VO2) and carbon dioxide production (VCO2) measurements and calculated lung mechanics, respiratory quotient, and resting energy expenditure in mechanically ventilated children without severe lung pathology, when using a compact modular metabolic monitor (E-COVX) continuously recording patient spirometry and gas exchange measurements. METHODS: Open ETS was performed when clinically indicated in 11 children mechanically ventilated for sepsis or head injury. A total of 2800 pulmonary 1-min gas exchange measurements were recorded in 28 ETS instances for 50 consecutive minutes before and 50 min after the standardized procedure. RESULTS: Pulmonary mechanics and indirect calorimetry did not differ between pre- and postsuction sets of measurements. Pre- and postsuction VO2, VCO2, dynamic airway resistance, dynamic compliance, and expiratory minute ventilation remained stable from 5 to 55 min after tracheal suctioning and did not differ among different ventilatory modes. Average paired differences of sequential pre- and postsuction VO2, VCO2, respiratory quotient, and resting energy expenditure were -0.6%, -1%, -0.1%, and -0.3%. Ratio differences between the first and the second periods of measurements (1-25 vs 26-50 sets of 1-min measurements) did not differ in the two groups. CONCLUSIONS: Pulmonary mechanics and indirect calorimetry measurements are not influenced after uneventful open ETS in well-sedated patients. The E-COVX is able to reliably record spirometry and metabolic indices as early as 5 min after suctioning at different ventilator modes.

Heat shock protein 72 expressing stress in sepsis: unbridgeable gap between animal and human studies--a hypothetical "comparative" study.

Heat shock protein 72 (Hsp72) exhibits a protective role during times of increased risk of pathogenic challenge and/or tissue damage. The aim of the study was to ascertain Hsp72 protective effect differences between animal and human studies in sepsis using a hypothetical "comparative study" model. Forty-one in vivo (56.1%), in vitro (17.1%), or combined (26.8%) animal and 14 in vivo (2) or in vitro (12) human Hsp72 studies (P < 0.0001) were enrolled in the analysis. Of the 14 human studies, 50% showed a protective Hsp72 effect compared to 95.8% protection shown in septic animal studies (P < 0.0001). Only human studies reported Hsp72-associated mortality (21.4%) or infection (7.1%) or reported results (14.3%) to be nonprotective (P < 0.001). In animal models, any Hsp72 induction method tried increased intracellular Hsp72 (100%), compared to 57.1% of human studies (P < 0.02), reduced proinflammatory cytokines (28/29), and enhanced survival (18/18). Animal studies show a clear Hsp72 protective effect in sepsis. Human studies are inconclusive, showing either protection or a possible relation to mortality and infections. This might be due to the fact that using evermore purified target cell populations in animal models, a lot of clinical information regarding the net response that occurs in sepsis is missing.

Influence of different ventilator modes on Vo(2) and Vco(2) measurements using a compact metabolic monitor.

OBJECTIVE: We assessed the influence of different ventilator modes on carbon dioxide elimination (Vco(2)) and oxygen uptake (Vo(2)) using a new compact modular metabolic monitor (E-COVX) and its impact on calculated respiratory quotient (RQ) and resting energy expenditure (REE) in critically ill children. METHODS: Sequential 30-min ventilation by pressure-regulated volume controlled ventilation (PRVC), synchronized intermittent mandatory ventilation (SIMV), and biphasic intermittent positive airway pressure/airway pressure release ventilation (BiVent) in mechanically ventilated critically-ill children was assessed. To determine within- or between-day variations, 30-min Vo(2) and Vco(2) measurements were repeated at four separate occasions. RESULTS: A total of 3960pulmonary 1-min gas exchange measurements were recorded in the 44 sessions for the three ventilator modes. Vo(2), Vco(2), and REE did not differ significantly among the PRVC, SIMV, and BiVent sequence of measurements. RQ (0.86+/-0.1) in the SIMV and Vco(2) (113+/-55mL/min) in the BiVent mode had a higher trend compared with PRVC (0.82+/-0.01, P<0.05, and 103+/-49mL/min, P<0.2, respectively). All three modes displayed good agreement and there were no significant differences between the first and second same-day or between the first- and second-day measurements or sequentially changed ventilator modes. Bland-Altman plots comparing the means of sequential REE, Vo(2), Vco(2), and RQ during the PRVC, SIMV, and BiVent modes of ventilation indicated that the average paired differences were <-5.5%. CONCLUSION: The influence of different ventilator modes on Vo(2) and Vco(2) measurements in adequately sedated critically ill children is not significant. The E-COVX metabolic module is suitable for repeated measurements in well-sedated mechanically ventilated children with stable respiratory patterns using the PRVC, SIMV, or BiVent modes of ventilation.