Correlation of simultaneously obtained capillary, venous, and arterial blood gases of patients in a paediatric intensive care unit

AIMS

To investigate the correlation of pH, partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2), base excess (BE), and bicarbonate (HCO3) between arterial (ABG), venous (VBG), and capillary (CBG) blood gases.

METHODS

Patients admitted to the paediatric intensive care unit (PICU) in Cukurova University between August 2000 and February 2002 were enrolled.

RESULTS

A total of 116 simultaneous venous, arterial, and capillary blood samples were obtained from 116 patients (mean age 56.91 months, range 15 days to 160 months). Eight (7%) were neonates. Sixty six (57%) were males. pH, PCO2, BE, and HCO3 were all significantly correlated in ABG, VBG, and CBG. Correlation in PO2 was also significant, but less so. Correlation between pH, PCO2, PO2, BE, and HCO3 was similar in the presence of hypothermia, hyperthermia, and prolonged capillary refilling time. In hypotension, correlation in PO2 between VBG and CBG was similar but disappeared in ABG-VBG and ABG-CBG.

CONCLUSIONS

There is a significant correlation in pH, PCO2, PO2, BE, and HCO3 among ABG, VBG, and CBG values, except for a poor correlation in PO2 in the presence of hypotension. Capillary and venous blood gas measurements may be useful alternatives to arterial samples for patients who do not require regular continuous blood pressure recordings and close monitoring of PaO2. We do not recommend CBG and VBG for determining PO2 of ABG.

Neurological complications of pandemic influenza (H1N1) in children

The aim of this study was to determine the clinical characteristics of children demonstrating neurological complications with pandemic influenza (H1N1). We reviewed the medical and laboratory records of all children who were hospitalized with neurological symptoms and who had proven influenza virus infection by reverse transcriptase-polymerase chain reaction on nasal and throat swabs. Eight children aged between 10 months and 7 years had neurological complications due to pandemic influenza (H1N1) and five of them were female. Four of them were previously healthy; there was chronic renal failure (CRF) in one and neurologic disease in three patients. Seven of them had seizure and altered consciousness. Seven of them were followed in pediatric intensive care units. We performed lumbar puncture in four patients and their cerebrospinal fluid examinations showed pleocytosis in one and no cell in three specimens. Neuroimaging was performed in four patients and three of them had abnormalities. We diagnosed aseptic meningitis in one, acute disseminated encephalomyelitis (ADEM) in one, acute necrotizing encephalopathy (ANE) in one, meningoencephalitis in one, and status epilepticus in four patients. All patients were treated with oseltamivir and antiepileptic drugs. One patient with CRF died; four previously healthy patients recovered fully, and three patients who had neurologic disorder returned to their previous neurological status. In conclusion, during pandemic influenza (H1N1) infection, neurological complications may be seen in addition to the respiratory infection. The type of neurological involvement may be variable such as triggering seizure, aseptic meningitis, encephalitis, ADEM, and ANE. Neurological complications frequently recover fully especially in previously healthy children, but sometimes a severe clinical course occurs.

The use of surfactant in children with acute respiratory distress syndrome: efficacy in terms of oxygenation, ventilation and mortality

PURPOSE

The aim of this prospectively designed study was to investigate the efficacy of surfactant (S) for acute respiratory distress syndrome (ARDS) in children.

MATERIALS AND METHODS

Children with ARDS were included in this study. Surfactant (Survanta, Abbott, USA) was given intratracheally at a dose of 150 mg/kg every 12 h for a total of two doses. During the study period none of the patients received permissive hypercapnia, high frequency ventilation, nitric oxide or ECMO. Peak inspiratory pressure (PIP), positive end expiratory pressure (PEEP), ventilation rate, mean airway pressure, tidal volume (TV), Murray index, PaO2/FiO2, ventilation index (VI), oxygen index (OI) and arterial oxygen tension difference (A-aDO2) were measured before and 48 h after surfactant treatment. Duration of mechanical ventilation therapy, duration in paediatric intensive care unit (PICU) and mortality rate were recorded.

RESULTS

Among the 36 children who met the inclusion criteria, 12 were treated with surfactant. The mean age was 72.5+/-56.2 months; 47% of children were male. Infants were ventilated by pressure-controlled ventilators whereas for older children volume-controlled ventilators were used. Sepsis (42%) was the main predisposing factor followed by pneumonia (25%) and malignancy (17%). The baseline characteristics including age, predisposing factors, gender, PIP, PEEP, A-aDO2, PaO2/FiO2, OI, TV, VI and Murray index were similar in the surfactant and non-surfactant (NS) group (p>0.05). There were significant improvements in PIP, PEEP, A-aDO2, PaO2/FiO2, OI, TV, VI and Murray index in the surfactant group after surfactant treatment compared with NS group (p<0.05). Duration of PICU stay and ventilator treatment was longer in NS group (14+/-3.7, 1.8+/-3.2 days vs. 9.2+/-3.1, 8.6+/-1.9 days), (p<0.05). Mortality rate was 42% in surfactant compared with 63% in the NS group, (p>0.05). Children in the surfactant group lived significantly longer (p<0.05).

CONCLUSIONS

Modified natural surfactant is an effective treatment option in children with ARDS for improving gas exchange, decreasing the use of ventilatory support and increasing survival time.

Effect of pediatric advanced life support course on pediatric residents' intubation success

BACKGROUND

The Pediatric Advanced Life Support Program (PALS) course very important for teaching about intubation, resuscitation, shock, trauma, respiratory failure and rhythm disturbances. The aim of the present study was to evaluate the effect of the PALS course on pediatric residents' intubation success during their rotation, daytime and night-time practice in the pediatric intensive care unit (PICU).

METHODS

The study was carried out from 1 March 2005 to 28 February 2007. The study period had two parts, in that the number of attempts and successful intubations performed by pediatric residents, and the pediatric intensivist successful intubation ratio were evaluated in two different periods: before the PALS course, 1 March 2005-28 February 2006, and after the PALS course, 5 March 2006-28 February 2007. The participating residents' pediatric levels (PL) were classed as PL-1, PL-2, PL-3, PL-4, and all had first experience in the PICU at the PL-1 level. The PALS instructor was a pediatric emergency or intensive care doctor. We evaluated whether the PALS course influenced intubation success or not.

RESULTS

Sixteen residents participated in the study. The proportion of successful intubations was 110 (53.3%) and 104 (65.4%) attempts before and after the PALS course, respectively. The proportion of intubations done by intensivists decreased from 49.1% to 31.7% before and after PALS. The most frequently used endotracheal tube (ETT) internal diameter (ID) was 4.0 mm, and cuffed ETT was used 16% and 21% before and after the course, respectively. Appropriate placing of ETT tip occurred 70.4% and 82.2% of the time before and after the PALS course, respectively. Proportion of successful intubations by residents increased in all levels, except for PL-1. The most important reason for unsuccessful attempts was inappropriate patient position. Only one patient could not be intubated, and laryngeal mask airway was used in that case. During intubation, complications were broken teeth in two patients before the course, and subglottic stenosis developed in only one patient due to cuffed ETT.

CONCLUSION

Successful intubation is a life-saving intervention during resuscitation, ETT revision for extubation or obstruction for extubation or obstruction during mechanical ventilation. This skill can be developed in the PALS course and by clinical study in PICU and pediatric emergency services. The PALS course must be given to pediatric residents especially within the first year. Also, cuffed ETT can be used for infants and children.

Effects of Sodium Valproate on Renal Functions in Rats

In recent years, it has been reported that sodium valproate occasionally can cause renal tubular impairment. This study was designed to demonstrate the renal tubular and glomerular functions in rats given sodium valproate as monotherapy, as well as to determine any reversibility of dysfunctions. Female rats were randomly allocated to three groups: group 1 received sodium valproate 500 mg/kg/d intraperitoneal for six weeks; after the same injection period, group 2 was housed for another six weeks, after which laboratory investigations were completed; and group 3 served as a control group made up of 20 healthy rats living in same condition without any treatment. Serum ALT, total protein, uric acid, ALP, phosphorus, sodium levels, and urine Ca/cr ratio were significantly different between groups 1 and 3 (p < 0.025), but this difference was not seen between groups 2 and 3. On the other hand, other parameters such as TRP, Ccr, NAG, and MDA were not significantly different among the three groups ( p > 0.025) These results suggest that SV does not have a significant dose- or time-related side effect on renal functions. Minor biochemical dysfunctions related to long-term sodium valproate therapy is reversible, and the minimal renal fibrosis that showed histopathologically is not clinically important. The renal tissues of rats are known to show similar metabolic and histological patterns with human renal tissues. No renal dysfunction was expected in humans because there were no clinically statistically significant renal side effects in this study.

Somatic regional oxygen saturation as an early marker of intra-abdominal hypertension in critically ill children: a pilot study

Background/aim

Intraabdominal hypertension is a common clinical condition with high mortality and morbidity in pediatric intensive care units. The aim of this study was to test the feasibility of regional tissue oxygenation (rSO2) measurement using near-infrared spectroscopy and to assess the correlation between rSO2 and perfusion markers of intraabdominal hypertension in high-risk pediatric patients.

Materials and methods

In this prospective observational cohort study in a tertiary pediatric intensive care unit in Çukurova University Faculty of Medicine, a total of 31 patients who were admitted between May 2017 and May 2018 with a risk of intraabdominal hypertension were included. Mesenteric and renal rSO2 measurements were taken and correlations with other tissue perfusion markers including mean arterial pressure, pH, lactate, intraabdominal pressure, abdominal perfusion pressure, mixed venous oxygen saturation, vasoactive inotropic score were assessed. Intraabdominal pressure was measured as ≥10 mmHg in 15 patients (48.3%) and these patients were defined as the group with intraabdominal hypertension.

Results

In the group with intraabdominal hypertension, mixed venous oxygen saturation was lower (P = 0.024), vasoactive inotropic score was higher (P = 0.024) and the mean abdominal perfusion pressure value was lower (P = 0.014). In the ROC analysis, the mesenteric rSO2 measurement was the best parameter to predict intraabdominal hypertension with area under the curve of 0.812 (P = 0.003) 95% CI [0.652–0.973].

Conclusion

Monitoring of mesenteric rSO2 is feasible in patients at risk for intraabdominal hypertension. Moreover, both mesenteric regional oxygen and perfusion markers may be used to identify pediatric patients at risk for intraabdominal hypertension.

Evaluation of renal functions in children with congenital heart disease before and after cardiac angiography

Radiocontrast nephrotoxicity, which has increased in incidence with widespread use of radiological methods in medicine, is a serious complication of radiocontrast materials. In this study, we have prospectively investigated whether children with cyanotic congenital heart disease are at risk for radiocontrast nephrotoxicity with the use of a nonionic low osmolar contrast agent. Thirty-five children (17 cyanotic and 18 acyanotic patients) who underwent diagnostic cardiac catheterization were subjects of the study. The age range was from five days to 13 years. The volume of contrast material was 3.11 +/- 1.37 ml/kg in cyanotic patients and 2.67 +/- 0.86 ml/kg in acyanotic patients. Blood samples and timed urine samples were taken from all patients 24 hours before and 48 hours after cardiac catheterization. Blood urea nitrogen, creatinine, sodium, and phosphorus in serum, and creatinine and N-acetyl-beta-D-glucosamine in urine were analyzed. There was not a statistically significant difference between the values before and after angiography. As a result, we could find no evidence of radiocontrast nephrotoxicity with the use of a nonionic contrast agent in cyanotic and acyanotic patients who underwent cardiac angiography.

Genetic dilemma: eNOS gene intron 4a/b VNTR polymorphism in sepsis and its clinical features in Turkish children

The role of endothelial nitric oxide synthase gene intron 4 a/b (eNOS4a/b) variable number of tandem repeats (VNTR) polymorphism in various diseases was investigated. We investigated whether this polymorphism is associated with susceptibility to sepsis and its clinical features such as acute respiratory distress syndrome (ARDS), multiorgan dysfunction syndrome (MODS) and shock. eNOS4a/b VNTR polymorphism was determined by the polymerase chain reaction in 100 children with sepsis and in 134 healthy controls. The genotype distribution of eNOS4 was not different between the patients and controls (p=0.44). There was no statistically significant association between genotypes/allele frequency and outcomes like mortality, MODS, ARDS, and shock (p>0.05). This is the first study that evaluates the effect of eNOS4a/b polymorphism in sepsis. We were unable to show a relationship between eNOS gene intron 4 a/b VNTR polymorphism and MODS, ARDS, mortality and shock. Larger studies that do research on the interaction of such genes are needed to clarify the association between eNOS4a/b polymorphism and sepsis.

Klippel-trenaunay-Weber syndrome with hydronephrosis and vesicoureteral reflux: an unusual association

The Klippel-Trenaunay-Weber syndrome is a rare disorder characterized by congenital vascular hamartomas, limb hypertrophy, cutaneous manifestations, lymphangiomas and atresia of lymph vessels with non-pitting edema. A three-year-old boy was referred to our clinic for progressive hypertrophy of leg and feet with 32-month history. We diagnosed Klippel-Trenaunay-Weber syndrome, and determined vesicoureteral reflux in our patient. To our knowledge, hydronephrosis and vesicoureteral reflux have not been described previously in the KTWS.

The prevalence of atopy in children with antibodies against hepatitis A virus and hepatitis B virus

To investigate the relationship between atopy and hepatitis A virus (HAV) and hepatitis B virus (HBV) infections, we studied 42 children who had had HAV infection (Group I), 28 children who had had HBV infection (Group II), and 31 children who were seronegative for both HAV and HBV infection (Control group). Serological tests for HAV and HBV infections (anti-HAV IgG, HBsAg, anti-HBc IgG) and allergic skin tests and specific IgE investigations for the detection of atopy were carried out. In this study, there was no significant divergence in the socio-demographic characteristics among the three groups. The rates of specific IgE positivity in children in the HAV seropositive group (11.9%) and in children in the HBV seropositive group (17.8%) were lower than in the control group (35.4%) (p = 0.03 and p = 0.22, respectively). Also, the number of children with respiratory allergic diseases (allergic rhinitis and/or asthma) both in the HAV seropositive group and in the HBV seropositive group were significantly lower than in the control group (p < 0.05). When atopy in all of the groups was evaluated, the prevalence of atopy was found to be more widespread in HAV seronegative children (Adjusted OR, 9.2; 95% CI, 1.7-48.2) and HBV seronegative children (Adjusted OR, 5.9; 95% CI, 1.1-31.8) than in HAV and HBV seropositive children, after adjustment for age, number of older siblings and education of the father. In conclusion, in this study, the prevalence of atopy in children who had had HAV or HBV infection was found to be low, and this situation was considered to be related to the relationship of HAV and HBV infections to poor hygiene and to the fact that these infections occur at early ages in Turkey.

Schwartz-Jampel syndrome: three pediatric case reports

Schwartz-Jampel syndrome is a heterogeneous autosomal recessive syndrome defined by myotonia, short stature, bone dysplasia and growth retardation. Three types have been described: type 1A, usually recognized in childhood, with moderate bone dysplasia; type 1B similar to type 1A but recognizable at birth, with more prominent bone dysplasia and type 2, a rare, more severe form with increased mortality in the neonatal period. In this paper we report three pediatric cases, one with neonatal manifestation.