A Need for a Novel Survival Risk Scoring System for Intensive Care Admissions Due to Sepsis in Pediatric Hematology/Oncology Patients

Background: Children with hemato-oncological diseases or following stem cell transplantation (SCT) are at high risk for life-threatening infections; sepsis in this population constitutes a substantial proportion of pediatric intensive care unit (PICU) admissions. The current pediatric prognostic scoring tools to evaluate illness severity and mortality risk are designed for the general pediatric population and may not be adequate for this vulnerable subpopulation. Methods: Retrospective analysis was performed on all PICU admissions for sepsis in children with hemato-oncological diseases or post-SCT, in a single tertiary pediatric hospital between 2008 and 2021 (n = 233). We collected and analyzed demographic, clinical, and laboratory data and outcomes for all patients, and evaluated the accuracy of two major prognostic scoring tools, the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) and the Pediatric Risk of Mortality III (PRISM III). Furthermore, we created a new risk-assessment model that contains additional parameters uniquely relevant to this population. Results: The survival rate for the cohort was 83%. The predictive accuracies of PELOD-2 and PRISM III, as determined by the area under the curve (AUC), were 83% and 78%, respectively. Nine new parameters were identified as clinically significant: age, SCT, viral infection, fungal infection, central venous line removal, vasoactive inotropic score, bilirubin level, C-reactive protein level, and prolonged neutropenia. Unique scoring systems were established by the integration of these new parameters into the algorithm; the new systems significantly improved their predictive accuracy to 91% (p = 0.01) and 89% (p < 0.001), respectively. Conclusions: The predictive accuracies (AUC) of the PELOD-2 and PRISM III scores are limited in children with hemato-oncological diseases admitted to PICU with sepsis. These results highlight the need to develop a risk-assessment tool adjusted to this special population. Such new scoring should represent their unique characteristics including their degree of immunosuppression and be validated in a large multi-center prospective study.

Therapeutic plasma exchange for neonatal hepatic failure

We report a case of therapeutic plasma exchange in a neonate with fulminant liver failure. A six-day old, 2800-gram baby was referred to our medical center for evaluation and treatment of fulminant hepatic failure. The working diagnosis at admission was gestational alloimmune liver disease, and therapeutic plasma exchange was proposed. A double volume plasma exchange was successfully performed, using the Spectra Optia apheresis system, primed with packed red blood cells. Access was obtained via a radial artery catheter and a peripheral intravenous line. On hospital D-14 a diagnosis of E3 deficiency was confirmed, and disease-specific therapy was started. Automated TPE using peripheral arterial and venous catheters may be safely performed in neonates, and should be considered in the treatment of a variety of disorders including neonatal fulminant hepatic failure.

Acute kidney injury in pediatric toxic shock syndrome is associated with worse clinical course in the intensive care unit

To explore the prevalence, severity, nature, and significance of acute kidney injury (AKI) among children admitted to the pediatric intensive care unit (PICU) with toxic shock syndrome (TSS). Bi-center, retrospective observational study. Children admitted for TSS to two intensive care units from 2009-2022 were included. We identified 41 children (median age 5 years, 46% females) who met the Centers for Disease Control and Prevention (CDC) definitions of TSS. Staphylococcal TSS accounted for 63% of the patients and Streptococcal TSS accounted for the remaining 37%. AKI was diagnosed in 24 (59%) (stage 1: n = 6 [15% of total], stage 2: n = 10 [24%], and stage 3: n = 8 [20%]). The worst creatinine level was measured during the first day of admission in 34 (83%) patients. The median duration of AKI was 2 days. Creatinine normalized by hospital discharge in all cases. Patients with AKI had a longer intensive care unit stay than those without AKI (6 vs. 3 days, respectively, p = 0.01), needed more respiratory support (87% vs. 47%, p = 0.002), had fewer 28 ventilation-free days (25 vs. 28, p = 0.01), fewer vasopressor-free days (25 vs. 28, p = 0.001), and received more blood products (p = 0.03).    Conclusion: Children admitted to the PICU with TSS, show a high prevalence of AKI at presentation. Creatinine levels and clearance normalize by hospital discharge in most cases. AKI in the setting of TSS could be used as an early marker for illness severity and a predictor of a more complex course. What is Known: • TSS is characterized according to the CDC by specific sets of clinical signs and symptoms in conjunction with specific laboratory findings one of which is AKI. • AKI is associated with worse outcomes in critically ill patients in general and in septic patients in particular. What is New: • AKI is found in about 60% of all patients admitted to the PICU with a diagnosis of TSS and hence is an important defining criteria. • AKI in the setting of TSS is associated with a more complex illness course and can serve as an early marker predicting such a course.

Blood pressure monitoring following kidney transplantation in children: a comparison of invasive and noninvasive measurements using Doppler as a benchmark technique

BACKGROUND

Blood pressure (BP) monitoring following pediatric kidney transplantation is essential for optimizing graft perfusion. Differences between invasive BP and noninvasive BP (NIBP) measurements are sometimes considerable. We aimed to assess agreement between invasive BP and NIBP in pediatric patients after kidney transplantation and compare with measurements obtained by systolic Doppler with manual sphygmomanometer as a reference technique.

METHODS

A prospective, observational cohort study, of children aged 18 years or younger, admitted immediately following kidney transplantation to the pediatric intensive care unit of a tertiary, university-affiliated medical center, between May 2019 and June 2021.

RESULTS

Eighty-two paired simultaneous measurements of invasive BP, NIBP, and Doppler BP in 18 patients were compared. Patients were significantly hypertensive, with mean systolic NIBP above the 95th percentile (96 ± 6%). Systolic invasive BP measurements were significantly higher than NIBP (149 ± 20 vs. 136 ± 15 mmHg, p < 0.001). Substantial differences (≥ 20 mmHg) were found in 23% (95% CI 15-34%). Similar disagreement was found between systolic invasive and Doppler BP (150 ± 23 and 137 ± 17 mmHg, respectively, p < 0.001). In contrast, systolic NIBP was in good agreement with Doppler BP (135 ± 17 and 138 ± 18, respectively, p = 0.27). A moderate to strong correlation was found between higher systolic invasive BP and the difference to systolic Doppler BP (Spearman's ρ = 0.63, p < 0.001).

CONCLUSIONS

In children immediately following kidney transplantation, clinically significant disagreement was found between invasive and noninvasive BP measurements. Invasive BP values were significantly higher than those obtained by Doppler. Better agreement was found between NIBP and Doppler. These issues should be considered when interpreting BP measurements in this sensitive patient population. A higher resolution version of the Graphical abstract is available as Supplementary information.

Clinical improvement of a toddler with COVID-19 focal cerebral arteriopathy possibly due to intra-arterial nimodipine

Pediatric stroke is considered an infrequent complication of COVID-19. Focal cerebral arteriopathy (FCA) is one of the most common causes of arterial ischemic stroke in a previously healthy child. The present report describes a toddler with FCA most likely induced by SARS-CoV-2 infection who showed significant clinical improvement that may be related to injection of intra-arterial nimodipine. To our knowledge, this is the first reported use of nimodipine in this setting.

Early post-liver transplant thrombocytopenia in children: Clinical characteristics and significance

BACKGROUND

Post-liver transplant thrombocytopenia is common and associated with worse outcome in adults. In children, however, the prevalence, course, and significance of post-liver transplantation thrombocytopenia are not described. Therefore, we aimed to assess this phenomenon in children.

METHODS

A retrospective chart review of children who underwent liver transplantation at a single tertiary center between 2004 and 2021.

RESULTS

Overall, 130 pediatric liver transplantations were reviewed. During the first 28 POD, thrombocytopenia was evident in 116 (89%, 95% CI 83%-94%). The median nadir platelet count was 54 K/μl (IQR: 37-99). Nadir platelet count was reached in half the patients by the third POD (IQR: 1-6). In multivariate analysis, preoperative platelet count (p = .024), volume of intraoperative packed cell transfusion (p = .045), and hypersplenism (p = .007) were associated with lower postoperative platelet counts. Patients with platelet count lower than the 50th centile on the first POD suffered from a more complicated course leading to a longer PICU admission (p = .039).

CONCLUSIONS

Early post-liver transplant thrombocytopenia appears to be common in children and associated with preoperative thrombocytopenia, hypersplenism, and higher intraoperative blood transfusion volumes. A low first POD platelet count (<86 K/μl) was found to be independently associated with a more complicated postoperative course, suggesting the need for heightened surveillance.

Hyperlactatemia in children following brain tumor resection: prevalence, associated factors, and clinical significance

PURPOSE

Hyperlactatemia is associated with worse outcome among critically ill patients. The prevalence of hyperlactatemia in children following craniotomy for intracranial tumor resection is unknown. This study was designed to assess the prevalence, associated factors, and significance of postoperative hyperlactatemia in this context.

METHODS

A retrospective study was conducted at an intensive care unit of a tertiary, pediatric medical center. Children younger than 18 years admitted following craniotomy for brain tumor resection between October 2004 and November 2019 were included.

RESULTS

Overall, 222 elective craniotomies performed in 178 patients were analyzed. The mean age ± SD was 8.5 ± 5.5 years. All but two patients survived to discharge. All were hemodynamically stable. Early hyperlactatemia, defined as at least one blood lactate level ≥ 2.0 mmol/L during the first 24 h into admission, presented following 74% of the craniotomies; lactate normalized within a mean ± SD of 11 ± 6.1 h. The fluid balance per body weight at 12 h and 24 h into the intensive care unit admission was similar in children with and without hyperlactatemia [7.0 ± 17.6 vs 3.5 ± 16.4 ml/kg, p = 0.23 and 4.0 ± 27.2 vs 4.6 ± 29.4 ml/kg, p = 0.96; respectively]. Hyperlactatemia was associated with higher maximal blood glucose, older age, and a pathological diagnosis of glioma. Intensive care unit length of stay was similar following craniotomies with and without hyperlactatemia (p = 0.57).

CONCLUSIONS

Hyperlactatemia was common in children following craniotomy for brain tumor resection. It was not associated with hemodynamic impairment or with a longer length of stay.

Adenovirus can be a serious, life-threatening disease, even in previously healthy children

AIM

Adenovirus infections are exceedingly common in childhood. However, little is known of the clinical characteristics of children admitted with severe infection to the paediatric intensive care unit (PICU).

METHODS

Clinical data on children hospitalised with adenovirus infection between January 2005 and March 2020 were collected. We compared data between children hospitalised in the PICU and those who were not in a 1:2 ratio.

RESULTS

During the study period, 69 children with adenovirus infection were admitted to the PICU, representing 5% of all hospitalised children with adenovirus. Thirty-four (49%) were previously healthy children. Mortality occurred in 5 patients, and all had an underlying illness. Cidofovir was used in 21 children, including 11 who were previously healthy. No side effects were attributed to the treatment. During 2005-2014, viral co-infection rates were 42% in the PICU group and 11% in the control group (p = 0.002). However, during 2015-2020, when the viral panel became widespread in our institution, the rates of co-infection were similar in the two groups (32% and 34%, p = 1.0).

CONCLUSION

Our findings suggest that adenovirus may present as a serious, life-threatening disease even in previously healthy children.

Intranasal dexmedetomidine vs oral triclofos sodium for sedation of children with autism undergoing electroencephalograms

BACKGROUND

Sedation may be necessary for performing electroencephalograms in children with autistic spectrum disorder, however, our sedation success rate using triclofos sodium (TFS) is limited. Intra-nasal dexmedetomidine (IN-DEX) may be a superior sedative for these children.

OBJECTIVE

Compare IN-DEX with TFS for sedation efficacy, resistance to drug delivery and adverse events in children with autism undergoing an electroencephalogram.

STUDY DESIGN

A single center, prospective observational study of children with autism sedated for electroencephalograms using IN-DEX compared to an age matched, historic group of children with autism, sedated for electroencephalograms using TFS.

RESULTS

Characteristics of 41 IN-DEX sedations were compared to 41 TFS sedations in 82 ASD children. Epileptiform discharges were demonstrated in 23/82 (28%) of children in the cohort. Sedation depth by UMSS was significantly deeper in the IN-DEX group (2.49 ± 0.78 vs. 1.41 ± 0.89, p < 0.001). Electroencephalogram quality demonstrated less motion artifact in the IN-DEX group (1.75 ± 0.76 vs. 2.18 ± 0.88, p < 0.001). The rate of very poor or sedation failure was significantly lower in the IN-DEX group (17% vs 56.1%, p < 0.001), RR = 0.3 (95% CI 0.15 to 0.63, p < 0.001). No major adverse events were documented in either group. Bradycardia occurred in 8/41(19.5%) of children in IN-DEX group and none in TFS group (p = 0.003). Hypotension or poor perfusion were not demonstrated in either group.

CONCLUSION

In children with autism undergoing electroencephalograms, IN-DEX was more tolerable than TFS, induced deeper sedation with a greater success rate, and improved electroencephalogram quality. Both sedatives were equally safe in this population.

Persistent pulmonary air leak in the pediatric intensive care unit: Characteristics and outcomes

BACKGROUND

Persistent air leak (PAL) complicates various lung pathologies in children. The clinical characteristics and outcomes of children hospitalized in the pediatric intensive care unit (PICU) with PAL are not well described. We aimed to elucidate the course of disease among PICU hospitalized children with PAL.

METHODS

A retrospective cohort study of all PICU-admitted children aged 0-18 years diagnosed with pneumothorax complicated by PAL, between January 2005 and February 2020 was conducted at a tertiary center. PAL was defined as a continuous air leak of more than 48 h.

RESULTS

PAL complicated the course of 4.8% (38/788) of children hospitalized in the PICU with pneumothorax. Two were excluded due to missing data. Of 36 children included, PAL was secondary to bacterial pneumonia in 56%, acute respiratory distress syndrome (ARDS) in 31%, lung surgery in 11%, and spontaneous pneumothorax in 3%. Compared to non-ARDS causes, children with ARDS required more drains (median, range: 4, 3-11 vs. 2, 1-7; p < .001) and mechanical ventilation (100% vs. 12%; p < .001), and had a higher mortality (64% vs. 0%; p < .001). All children with bacterial pneumonia survived to discharge, with a median air leak duration of 14 days (range 3-72 days). Most of which (90%) were managed conservatively, by continuous chest drainage.

CONCLUSION

Bacterial pneumonia was the leading cause of PAL in this cohort. PAL secondary to ARDS was associated with a worse outcome. In contrast, non-ARDS PAL was successfully managed conservatively, in most cases.

Clinical Features and Comparison of Kingella and Non-Kingella Endocarditis in Children, Israel

Kingella spp. have emerged as an important cause of invasive pediatric diseases. Data on Kingella infective endocarditis (KIE) in children are scarce. We compared the clinical features of pediatric KIE cases with those of Streptococcus species IE (StIE) and Staphylococcus aureus IE (SaIE). A total of 60 patients were included in the study. Throughout the study period, a rise in incidence of KIE was noted. KIE patients were significantly younger than those with StIE and SaIE, were predominately boys, and had higher temperature at admission, history of oral aphthae before IE diagnosis, and higher lymphocyte count (p<0.05). Pediatric KIE exhibits unique features compared with StIE and SaIE. Therefore, in young healthy children <36 months of age, especially boys, with or without a congenital heart defect, with a recent history of oral aphthae, and experiencing signs and symptoms compatible with endocarditis, Kingella should be suspected as the causative pathogen.

Ultrasound Cardiac Output Monitor (USCOM™) Measurements Prove Unreliable Compared to Cardiac Magnetic Resonance Imaging in Adolescents with Cardiac Disease

The purpose of this stuy is to prospectively assess the reliability of the ultrasound cardiac output monitor (USCOM™) for measuring stroke volume index and predicting left ventricular outflow tract diameter in adolescents with heart disease. Sixty consecutive adolescents with heart disease attending a tertiary medical center underwent USCOM™ assessment immediately after cardiac magnetic resonance imaging. USCOM™ measured stroke volume index and predicted left ventricular outflow tract diameter were compared to cardiac magnetic resonance imaging-derived values using Bland-Altman analysis. Ten patients with an abnormal left ventricular outflow tract were excluded from the analysis. An adequate USCOM™ signal was obtained in 49/50 patients. Mean stroke volume index was 46.1 ml/m² by the USCOM™ (range 22-66.9 ml/m²) and 42.9 ml/m² by cardiac magnetic resonance imaging (range 24.7-59.9 ml/m²). The bias (mean difference) was 3.2 ml/m²; precision (± 2SD of differences), 17 ml/m²; and mean percentage error, 38%. The mean (± 2SD) left ventricular outflow tract diameter was 0.445 ± 0.536 cm smaller by the USCOM™ algorithm prediction than by cardiac magnetic resonance imaging. Attempted adjustment of USCOM™ stroke volume index using cardiac magnetic resonance imaging left ventricular outflow tract diameter failed to improve agreement between the two modalities (bias 28.4 ml/m², precision 44.1 ml/m², percentage error 77.3%). Our study raises concerns regarding the reliability of USCOM™ for stroke volume index measurement in adolescents with cardiac disease, which did not improve even after adjusting for its inaccurate left ventricular outflow tract diameter prediction.

Routine chest X-ray following ultrasound-guided internal jugular vein catheterization in critically ill children: A prospective observational Study

BACKGROUND

Recent studies in adults have shown that routine chest X-ray following ultrasound-guided central venous catheter insertion through the internal jugular vein is unnecessary due to a low rate of complications.

AIMS

To assess the usefulness of routine chest X-ray following ultrasound-guided central venous catheter insertion through the internal jugular veins in critically ill children.

METHODS

A prospective observational study was conducted at a pediatric intensive care unit of a tertiary, university-affiliated pediatric medical center. All children under the age of 18 who underwent ultrasound-guided central venous catheter insertion through the right or left internal jugular vein between May 2018 and November 2019 were evaluated for eligibility. Procedures were prospectively documented, and chest X-ray was screened for pneumothorax, hemothorax, central venous catheter tip position, and resultant corrective interventions.

RESULTS

Of 105 central venous catheter insertion attempts, 99 central venous catheters (94.3%) were inserted. All were located within the venous system. None were diagnosed with pneumo/hemothorax on chest X-ray. Twenty (20.2%; 95% CI 12.8%-29.5%) were defined as malpositioned by strict criteria; however, only one (1%) was judged significantly misplaced by the clinical team leading to its repositioning.

CONCLUSIONS

In this critically ill pediatric cohort, all central venous catheters inserted under ultrasound guidance could have been used with safety prior to acquiring chest X-ray. Overall chest X-ray impacted patient management in only 1% of cases. Our results do not support delaying urgent central venous catheter use pending chest X-ray completion in critically ill children.

Hemodynamic effects of intravenous paracetamol in critically ill children with septic shock on inotropic support

Background

Treatment with intravenous paracetamol may impair hemodynamics in critically ill adults. Few data are available in children. The aim of this study was to investigate the frequency, extent, and risk factors of hypotension following intravenous paracetamol administration in children with septic shock on inotropic support.

Methods

We retrospectively reviewed the electronic medical charts of all children aged 1 month to 18 years with septic shock who were treated with intravenous paracetamol while on inotropic support at the critical care unit of a tertiary pediatric medical center in 2013–2018. Data were collected on patient demographics, underlying disease, Pediatric Logistic Organ Dysfunction (PELOD) score, hemodynamic parameters before and up to 120 min after paracetamol administration, and need for inotropic support or intravenous fluid bolus. The main outcome measures were a change in blood pressure, hypotension, and hypotension requiring intervention.

Results

The cohort included 45 children of mean age 8.9 ± 5.1 years. The mean inotropic support score was 12.1 ± 9.5. A total of 105 doses of paracetamol were administered. The lowest mean systolic pressure (108 ± 15 mmHg) was recorded at 60 min (p = 0.002). Systolic blood pressure decreased at 30, 60, 90, and 120 min after delivery of 50, 67, 61, and 59 drug doses, respectively. There were 5 events of systolic hypotension (decrease of 1 to 16 mmHg below systolic blood pressure hypotensive value). Mean arterial pressure decreased by ≥ 15% in 8 drug doses at 30 min (7.6%, mean − 19 ± 4 mmHg), 18 doses at 60 min (17.1%, mean − 20 ± 7 mmHg), 16 doses at 90 min (15.2%, mean − 20 ± 5 mmHg), and 17 doses at 120 min (16.2%, mean − 19 ± 5 mmHg). Mean arterial hypotension occurred at the respective time points in 2, 13, 10, and 9 drug doses. After 12 drug doses (11.4%), patients required an inotropic dose increment or fluid bolus.

Conclusions

Hypotensive events are not uncommon in critically ill children on inotropic support treated with intravenous paracetamol, and physicians should be alert to their occurrence and the need for intervention.

Triclofos Sodium for Pediatric Sedation in Non-Painful Neurodiagnostic Studies

AIM

Triclofos sodium (TFS) has been used for many years in children as a sedative for painless medical procedures. It is physiologically and pharmacologically similar to chloral hydrate, which has been censured for use in children with neurocognitive disorders. The aim of this study was to investigate the safety and efficacy of TFS sedation in a pediatric population with a high rate of neurocognitive disability.

METHODS

The database of the neurodiagnostic institute of a tertiary academic pediatric medical center was retrospectively reviewed for all children who underwent sedation with TFS in 2014. Data were collected on demographics, comorbidities, neurologic symptoms, sedation-related variables, and outcome.

RESULTS

The study population consisted of 869 children (58.2% male) of median age 25 months (range 5-200 months); 364 (41.2%) had neurocognitive diagnoses, mainly seizures/epilepsy, hypotonia, or developmental delay. TFS was used for routine electroencephalography in 486 (53.8%) patients and audiometry in 401 (46.2%). Mean (± SD) dose of TFS was 50.2 ± 4.9 mg/kg. Median time to sedation was 45 min (range 5-245), and median duration of sedation was 35 min (range 5-190). Adequate sedation depth was achieved in 769 cases (88.5%). Rates of sedation-related adverse events were low: apnea, 0; desaturation ≤ 90%, 0.2% (two patients); and emesis, 0.35% (three patients). None of the children had hemodynamic instability or signs of poor perfusion. There was no association between desaturations and the presence of hypotonia or developmental delay.

CONCLUSION

TFS, when administered in a controlled and monitored environment, may be safe for use in children, including those with underlying neurocognitive disorders.

The Hemodynamic Effect of Intravenous Paracetamol in Children: A Retrospective Chart Review

AIM

Studies in adults have reported frequent episodes of blood pressure drops following intravenous paracetamol administration. We aimed to investigate the hemodynamic effects of intravenous paracetamol in critically ill children.

METHODS

The charts of 100 pediatric intensive care patients (age range 0.1-18 years) who were treated with intravenous paracetamol between March and September 2017 were retrospectively reviewed. A hemodynamic event was defined as a drop of > 15% in systolic or mean arterial blood pressure within 120 min after drug administration. Hypotension was defined as either a drop in systolic blood pressure (SBP) below the 5th percentile for age or a hemodynamic event associated with tachycardia, increased lactate level, or treatment with a fluid bolus or vasopressors.

RESULTS

A hemodynamic event was observed in 39 patients (39%). In these patients, SBP was in the pre-hypertension or hypertension values in 36/39 patients before paracetamol administration, median (IQR) SBP decreased from the 99th (95-99) percentile for age before to the 50th (50-95) percentile after paracetamol (p < 0.001) and mean heart rate was 137 bpm before treatment and 115 bpm after (p = 0.002). SBP values did not drop below the 5th percentile in any patient. In 15 patients diagnosed with shock on admission, paracetamol treatment did not cause an increase in vasopressor treatment after drug administration.

CONCLUSIONS

In the present study of critically ill pediatric patients, intravenous paracetamol administration was associated with a drop in SBP from high to normal values for age, possibly due to pain relief, with no evidence for a negative hemodynamic event.

Risk factors for early invasive fungal infections in paediatric liver transplant recipients

Invasive fungal infections (IFIs) postliver transplantation are a frequent cause of morbidity and mortality; however, studies reporting on these infections in the paediatric population are scarce. To investigate the incidence and risk factors of IFIs in paediatric liver transplant recipients during the early posttransplantation period (≤3 months). Data were collected for all paediatric liver transplant recipients registered in a national transplantation center from 2004 to 2014. Using a stepwise logistic regression to identify independent risk factors for IFIs, a predictive model was formulated. Ten IFIs were identified in 81 liver transplant recipients (12.3%) all occurring during the first month posttransplantation. Candida species were responsible for nine cases (90%), of which four were non-albicans Candida (44%). Significant risk factors were identified; recipient of multiple blood product transfusions during transplantation, prolonged use of indwelling intravenous catheter, prolonged IV antibiotic treatment, surgical complications, pulse steroid treatment and living donor liver transplantation. The predictive model used two clinical parameters to define high-risk patients: a living donor transplantation and duration of IV antibiotic treatment (area under the ROC curve 0.918). IFIs are a significant complication occurring in the first month posttransplantation. Future studies are required to assess efficacy of targeted antifungal prophylaxis in high risk patients.

Case Not Closed: Prescription Errors 12 Years after Computerized Physician Order Entry Implementation

OBJECTIVE

To assess the prolonged impact of computerized physician order entry (CPOE) on medication prescription errors in pediatric intensive care patients.

STUDY DESIGN

This observational study was conducted at a pediatric intensive care unit in which a CPOE (Metavision, iMDsoft, Israel) with a limited clinical decision support system was implemented between 2004 and 2007. Since then, no changes were made to the systems. We analyzed 2500 electronic prescriptions (1250 prescriptions from 2015 and 1250 prescriptions from 2016). Prescription errors were identified by a pediatric intensive care physician and classified as potential adverse drug events, medication prescription errors, or rule violations. Their prevalence was compared with the rate in 2007, reported in a previous study from the same unit. A randomly selected 10% of the prescriptions were also analyzed by the pediatric intensive care unit pharmacist, and the level of agreement was determined.

RESULTS

The rate of prescription errors increased from 1.4% in 2007 to 3.2% in 2015 (P = .03). Following revision of the clinical decision support system tools, prescription errors decreased to 1% in 2016 (P < .0001). The potential adverse drug event rate dropped from 2% in 2015 to 0.7% in 2016 (P = .006), and the medication prescription error rate, from 1% to 0.2% (P = .01). The agreement between the 2 reviewers was excellent (k = 0.96).

CONCLUSIONS

The rate of prescription errors may increase with time from implementation of a CPOE. Repeated surveillance of prescription errors is highly advised to plan strategies to reduce them. This approach should be considered in quality improvement of computerized information systems in general.

Blood Transfusion Policy among European Pediatric Intensive Care Physicians

The objective of this study was to define current blood transfusion practices among European pediatric intensive care physicians treating critically ill children. A questionnaire of case scenarios was administered to members of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). Of the 258 members of the ESPNIC, 134 (51.9%) pediatric intensive care physicians completed the questionnaire. The suggested blood transfusion thresholds for case scenario 1 (post–orthopedic surgery child) ranged from <7.0 g/dl to 11 g/dl. A total of 57.3% suggested 7 g/dl, 33.6% suggested 8 g/dl, and 6.9% suggested 9 g/dl as a hemoglobin threshold for transfusion (mean, 7.54 ± 0.75). For case scenarios 2 to 4, the suggested hemoglobin thresholds were 7 g/dl to 12 g/dl. For case scenario 2 (a child with acute respiratory distress syndrome), 22.4% suggested 8 g/dl, 15.7% suggested 9 g/dl, and 41% suggested 10 g/dl as a hemoglobin threshold for transfusion (mean, 9.40 ± 1.27 g/dl). For case scenario 3 (a post–cardiac surgery infant), 20.1% suggested 7 g/dl, 24.6% suggested 8 g/dl, 21.6% suggested 9 g/dl, and 23.9% suggested 10 g/dl as a hemoglobin threshold for transfusion (mean, 8.72 ± 1.24 g/dl). For case scenario 4 (a child with septic shock), 23.1% suggested 8 g/dl, 16.4% suggested 9 g/dl, and 41% suggested 10 g/dl as a hemoglobin threshold for transfusion (mean, 9.45 ± 1.24 g/dl). The threshold for transfusion was not statistically different ( P> .05) between the physicians according to their subspecialty, years of experience, or country of origin. The suggested volume of transfused blood was 10 to 15 ml/kg in 427 responses (82.6%) and 20 ml/kg in 89 responses (17.2%). Most physicians, 78/128 (60.9%), did not consider the age of the transfused blood an important factor in their decision to transfuse. Of the 106 (79.1%) physicians who detailed their considerations for elevating the thresh- old for transfusion, 82 (77.3%) gave a general nonspecific indication, 47 (44.3%) stated hemodynamic instability and shock, and 40 (37.7%) an ongoing bleeding. The hemoglobin threshold for blood transfusion and transfusion volume varies among European pediatric intensive care physicians, for the same patient.

Adrenal insufficiency in children undergoing heart surgery does not correlate with more complex postoperative course

Although some evidence suggests benefit of steroid supplementation after pediatric cardiac surgery, data correlating adrenal function with the postoperative course is scarce. This study sought to determine if adrenal insufficiency (AI) after cardiac surgery is associated with a more complicated postoperative course in children. A prospective study was performed during a 6-month period at a pediatric medical center. Included were 119 children, 3 months and older, who underwent heart surgery with cardiopulmonary bypass. Cortisol levels were measured before and 18 h after surgery. Patients were divided into two groups by procedure complexity (low or high), and clinical and laboratory parameters were compared between patients with and without AI within each complexity group. In the low-complexity group, 45 of the 65 patients had AI. The normal adrenal function (NAF) subgroup had greater inotropic support at 12, 24, and 36 h after surgery and a higher lactate level at 12 and 24 h after surgery. There were no significant differences between subgroups in duration of ventilation, sedation, intensive care unit (ICU) stay, or urine output. In the high-complexity group, 27 patients had AI, and 27 did not. There were no significant differences between subgroups in inotropic support or urine output during the first 36 h or in mechanical ventilation, sedation, or ICU stay duration. Children with AI after heart surgery do not have a more complex postoperative course than children with NAF. The adrenal response of individual patients seems to be appropriate for their cardiovascular status.

Polymerase-chain-reaction-based diagnosis of viral pulmonary infections in immunocompromised children

Aim

Viral pneumonia is a serious complication in immunocompromised children. Its aetiology is difficult to identify owing to the limitations of conventional microbiological tests. The aim of this study was to determine whether polymerase chain reaction (PCR) assays for respiratory viruses increase the diagnostic yield of bronchoalveolar lavage (BAL) in immunocompromised children.

Methods

BAL samples obtained from immunocompromised children hospitalized with pneumonia were processed for respiratory viruses by viral culture, rapid antigen test and PCR (for CMV, adenovirus, influenza, parainfluenza, herpesvirus, RSV and hMPV).

Results

The study group included 42 patients (mean age 7.2 ± 5.1 years) with 50 episodes of clinical pneumonia (50 BAL samples). Forty viral pathogens were identified in 30 episodes (60%). PCR increased the diagnostic rate by fourfold (75% identified by PCR alone, p < 0.0001). When viral culture and rapid antigen test were used as the gold standard, PCR was found to have high sensitivity (86–100% when assessed) and specificity (80–96%). The PCR results prompted the initiation of specific antiviral therapy and the avoidance of unnecessary antibiotic treatment in 17 (34%) episodes.

Conclusion

PCR‐based diagnosis from BAL may increase the rate of pathogen detection in immunocompromised children, decrease the time to diagnosis and spare patients unnecessary antimicrobial treatment.

Enhanced proton acceleration by an ultrashort laser interaction with structured dynamic plasma targets

We experimentally demonstrate a notably enhanced acceleration of protons to high energy by relatively modest ultrashort laser pulses and structured dynamical plasma targets. Realized by special deposition of snow targets on sapphire substrates and using carefully planned prepulses, high proton yields emitted in a narrow solid angle with energy above 21 MeV were detected from a 5 TW laser. Our simulations predict that using the proposed scheme protons can be accelerated to energies above 150 MeV by 100 TW laser systems.

Predictive value of B-type natriuretic peptide level on the postoperative course of infants with congenital heart disease

BACKGROUND

B-type natriuretic peptide (BNP) has been shown to have prognostic value for morbidity and mortality after cardiac surgery. Less is known about its prognostic value in infants.

OBJECTIVES

To investigate the predictive value of BNP levels regarding the severity of the postoperative course in infants undergoing surgical repair of congenital heart disease.

METHODS

We conducted a prospective comparative study. Plasma BNP levels in infants aged 1-12 months with congenital heart disease undergoing complete repair were measured preoperatively and 8, 24 and 48 hours postoperatively. Demographic and clinical data included postoperative inotropic support and lactate level, duration of mechanical ventilation, intensive care unit (ICU) and hospitalization stay.

RESULTS

Cardiac surgery was performed in 19 infants aged 1-12 months. Preoperative BNP level above 170 pg/ml had a positive predictive value of 100% for inotropic score > or = 7.5 at 24 hours (specificity 100%, sensitivity 57%) and 48 hours (specificity 100%, sensitivity 100%), and was associated with longer ICU stay (P = 0.05) and a trend for longer mechanical ventilation (P = 0.12). Similar findings were found for 8 hours postoperative BNP above 1720 pg/ml. BNP level did not correlate with measured fractional shortening.

CONCLUSIONS

In infants undergoing heart surgery, preoperative and 8 hour BNP levels were predictive of inotropic support and longer ICU stay. These findings may have implications for preplanning ICU loads in clinical practice. Further studies with larger samples are needed.

Polymerase-chain-reaction-based diagnosis of invasive fungal pulmonary infections in immunocompromised children

OBJECTIVE

Fungal pneumonia is a serious complication in immunocompromised children. It is difficult to diagnose because of the low sensitivity of clinical and standard laboratory tests. The aim of this study was to investigate the diagnostic impact of polymerase chain reaction (PCR) assays for fungal pathogens in bronchoalveolar lavage (BAL) fluid.

STUDY DESIGN

BAL samples obtained from hospitalized immunocompromised patients with clinical pneumonia between January 2007 and June 2009 were processed for microscopy and cultures in addition to PCR-based fungal assays. The results were compared between the standard and PCR methods.

RESULTS

Seventy-seven children with 100 episodes of pneumonia were included in the study. Fungal pathogens were detected by standard microbiological investigations in 10 episodes (10%) and by PCR-based assays alone in 20 episodes (20%). There was no significant difference in clinical improvement or mortality rate between patients diagnosed by the different methods. In 61 episodes, no fungal pathogen was identified by either method. Prolonged antifungal therapy was avoided in 43 episodes.

CONCLUSION

PCR-based assay for the diagnosis of fungal pulmonary infections may be a useful adjunct to clinical and standard microbiological techniques. The use of PCR may decrease the time to diagnosis, increase the rate of detection of fungal pathogens, and spare patients unnecessary antifungal treatment.

Severe abdominal pain as a presenting symptom of probable catastrophic antiphospholipid syndrome

Catastrophic antiphospholipid syndrome (APS) in pediatric medicine is rare. We report 3 adolescents who presented with acute onset of severe abdominal pain as the first manifestation of probable catastrophic APS. The 3 patients, 2 male patients and 1 female patient were 14 to 18 years old. One had been diagnosed with systemic lupus erythematosus in the past, but the other 2 had no previous relevant medical history. All presented with excruciating abdominal pain without additional symptoms. Physical examination was noncontributory. Laboratory results were remarkable for high inflammatory markers. Abdominal ultrasonography was normal, and abdominal computed tomography scan showed nonspecific findings of liver infiltration. Only computed tomography angiography revealed evidence of extensive multiorgan thrombosis. All patients had elevated titers of antiphospholipid antibodies. The patients were treated with full heparinization, high-dose steroids, and intravenous immunoglobulin with a resolution of symptoms. One patient was resistant to the treatment and was treated with rituximab. In conclusion, severe acute abdominal pain can be the first manifestation of a thromboembolic event owing to catastrophic APS even in previously healthy adolescents. Diagnosis requires a high index of suspicion with prompt evaluation and treatment to prevent severe morbidity and mortality.

Procalcitonin level as an aid for the diagnosis of bacterial infections following pediatric cardiac surgery

PURPOSE

The aim of the present study was to determine if blood procalcitonin can serve as an aid to differentiate between bacterial and nonbacterial cause of fever in children after cardiac surgery.

MATERIALS AND METHODS

A nested case-control study of children who underwent open cardiac surgery in critical care units of fourth-level pediatric hospital was performed. Blood samples for procalcitonin level were collected 1 day before operation; 1 hour postoperation; on postoperative days 1, 2, and 5; and on the day of fever, when it occurred.

RESULTS

Of 665 children who underwent cardiac bypass surgery, 126 had a febrile episode postoperatively, 47 children with a proven bacterial infection and 79 without bacterial infection. Among the 68 children in whom fever developed within the first 5 postoperative days, procalcitonin level at fever day was significantly higher in those with bacterial infection (n = 16) than in those without infection (n = 52). Similarly, among the 58 children in whom fever developed after day 5 postoperation, a significant difference was found in procalcitonin level at fever day between those with (n = 31) and without (n = 27) bacterial infection.

CONCLUSION

During the critical early and late periods after cardiac surgery in children, procalcitonin level may help to differentiate patients with bacterial infection from patients in whom the fever is secondary to nonbacterial infectious causes.

Role of C-reactive protein velocity in the diagnosis of early bacterial infections in children after cardiac surgery

Fever after cardiac surgery in children may be due to bacterial infection or noninfectious origin like systemic inflammatory response syndrome (SIRS) secondary to bypass procedure. A marker to distinguish bacterial from nonbacterial fever in these conditions is clinically important. The purpose of our study was to evaluate, in the early postcardiac surgery period, whether serial measurement of C-reactive protein (CRP) and its change over time (CRP velocity) can assist in detecting bacterial infection. A series of consecutive children who underwent cardiac surgery with bypass were tested for serum levels of CRP at several points up to 5 days postoperatively and during febrile episodes (>38.0°C). Findings were compared among febrile patients with proven bacterial infection (FWI group; sepsis, pneumonia, urinary tract infection, deep wound infection), febrile patients without bacterial infection (FNI group), and patients without fever (NF group). In all, 121 children were enrolled in the study, 31 in the FWI group, 42 in the FNI group, and 48 patients in the NF group. Ages ranged from 4 days to 17.8 years (median 19.0, mean 46 ± 56 months). There was no significant difference among the groups in mean CRP level before surgery, 1 hour, and 18 hours after. A highly significant interaction was found in the change in CRP over time by FWI group compared with FNI group (P < .001). Mean CRP velocity ([fCRP - 18hCRP]/[fever time (days) - 0.75 day]) was significantly higher in the infectious group (4.0 ± 4.2 mg/dL per d) than in the fever-only group (0.60 ± 1.6 mg/dL per d; P < .001). A CRP velocity of 4 mg/dL per d had a positive predictive value (PPV) of 85.7% for bacterial infection with 95.2% specificity. Serial measurements of CRP/CRP velocity after cardiac surgery in children may assist clinicians in differentiating postoperative fever due to bacterial infection from fever due to noninfectious origin.

Postoperative thrombotic thrombocytopenic purpura in an infant: case report and literature review

Thrombotic thrombocytopenic purpura is caused by an imbalance of von Willebrand factor and its cleaving protease, which leads to the formation of microthrombi in end-organs. It rarely occurs in the pediatric population. Plasma exchange can significantly reduce mortality and morbidity. We present a 14-month-old infant in whom clinical and laboratory abnormalities compatible with thrombotic thrombocytopenic purpura were noted several days after resection of a large pelvic tumor. Treatment with double volume plasma exchange on postoperative day 5 led to complete resolution of the renal failure, thrombocytopenia, anemia, and neurological manifestations. ADAMTS13 inhibitors were negative and no mutations were found in factor H, factor I, membrane cofactor protein, and thrombomodulin to account for genetic predisposition to thrombotic thrombocytopenic purpura or atypical hemolytic uremic syndrome. Postoperative anemia, thrombocytopenia, fever, and neurological deficits in children should raise the suspicion of thrombotic thrombocytopenic purpura. Early diagnosis is important because the disorder is readily and efficiently treated with plasma exchange.

Central apnoeas in infants with bronchiolitis admitted to the paediatric intensive care unit

AIM

To further characterize apnoea(s) complicating bronchiolitis because of respiratory syncytial virus (RSV), to describe the incidence of this complication and identify possible risk factors for apnoea(s) and its development.

METHODS

The files of infants admitted to the paediatric intensive care unit (PICU) for RSV bronchiolitis during three bronchiolitis seasons (2004-2007) were reviewed for demographic, clinical and laboratory parameters. Parameters were compared between patients with and without apnoeas.

RESULTS

Seventy-nine patients met the study criteria: 43 were admitted to the PICU for central apnoeas and the remainder for respiratory distress or failure. The percentage of infants admitted for apnoea increased during the study period (28.6 to 77.1%, p = 0.004). The overall prevalence of apnoea in this population was 4.3%. Possible risk factors for apnoea(s) were younger age (1.3 vs. 4.3 months, p = 0.002), lower admission weight (3.3 vs. 5 kg, p < 0.001), lower gestational age (35.8 vs. 37.8 weeks, p = 0.01), admission from the emergency room (50% vs. 9.1%, p < 0.001) and lack of hyperthermia (p < 0.001). Respiratory acidosis was found to be a protective factor on logistic regression analysis.

CONCLUSION

The prevalence of apnoea in infants admitted to the PICU for RSV bronchiolitis in our centre may be increasing. Preterm, younger infants with no fever are at relatively high risk of apnoea at presentation, while older infants with fever are at lower risk.

Bi-Level Positive Airway Pressure Ventilation in Pediatric Oncology Patients With Acute Respiratory Failure

The aim of the study was to describe our experience with bi-level positive airway pressure (BiPAP) ventilation in oncology children with acute respiratory failure, hospitalized in a single tertiary pediatric tertiary center. This was a retrospective cohort study of all pediatric oncology patients in our center admitted to the intensive care unit with acute hypoxemic or hypercarbic respiratory failure from January 1999 through May 2006, who required mechanical ventilation with BiPAP. Fourteen patients met the inclusion criteria with a total of 16 events of respiratory failure or impending failure: 12 events were hypoxemic, 1 was combined hypercarbic and hypoxemic, and 3 had severe respiratory distress. Shortly after BiPAP ventilation initiation, there was a statistically significant improvement in the respiratory rate (40.4 ± 9.3 to 32.5 ± 10.1, P < .05] and a trend toward improvement in arterial partial pressure of oxygen (PaO 2; 71.3 ± 32.7 to 104.6 ± 45.6, P = .055). The improvement in the respiratory status was sustained for at least 12 hours. In 12 (75%) events there was a need for sedation during ventilation; 12 children needed inotropic support during the BiPAP ventilation. Bi-level positive airway pressure ventilation failed in 3 (21%) children who were switched to conventional ventilation. All of them have died during the following days. One child was recategorized to receive palliative care while on BiPAP ventilator and was not intubated. In 12 of 16 BiPAP interventions (75%; 11 patients), the children survived to pediatric intensive care unit (PICU) discharge without invasive ventilation. No major complications were noted during BiPAP ventilation. Bi-level positive airway pressure ventilation is well tolerated in pediatric oncology patients suffering from acute respiratory failure and may offer noninferior outcomes compared with those previously described for conventional invasive ventilation. It appears to be a feasible initial option in children with malignancy experiencing acute respiratory failure.

Computerized order entry with limited decision support to prevent prescription errors in a PICU

OBJECTIVE

The value of computerized physician order entry (CPOE) and clinical decision support systems (CDSSs) in preventing prescription errors in pediatrics is unclear. We investigated the change in prescription error rates with the introduction of CPOE with and without a CDSS limited to weight-based dosing in a PICU.

METHODS

In a PICU of a major tertiary-care pediatric medical center, 5000 orders were reviewed, that is, 1250 orders from each of 4 periods: period 1, before CPOE implementation; period 2, 1 year after CPOE implementation; period 3, after CDSS implementation; and period 4, after a change in prescription authorization. Prescription errors were identified and classified into: potential adverse drug events (ADEs), medication prescription errors (MPEs), and rule violations (RVs).

RESULTS

We identified 273 errors (5.5%). The rate of potential ADEs decreased slightly between periods 1 and 2 (from 2.5% to 2.4%) and significantly in periods 3 and 4 (to 0.8% and 0.7%, respectively; P < .005). The rate of MPEs decreased slightly between periods 1 and 2 (from 5.5% to 5.3%), but new types of MPEs appeared. There was a significant decrease in period 3 (to 3.8%; P < .05) and a dramatically significant decrease in period 4 (to 0.7%; P < .0005). Only 3 RVs were found. Interrater agreement (kappa statistic) was 0.788 between evaluators.

CONCLUSIONS

CPOE implementation decreased prescription errors only to a small extent. However, the addition of a CDSS that limits doses by weight significantly reduced prescription error rates and, most importantly, potential ADEs. This finding emphasizes the major impact of weight-based calculation errors in pediatrics.

Pulmonary embolism following successful thrombectomy of an arteriovenous dialysis fistula

A hemodialysis patient was diagnosed with pulmonary embolism, shortly after successful thrombectomy of an autogenous arteriovenous fistula. Diagnostic testing revealed no alternative source for thromboembolism. Increased recognition of hypercoagulability as a common consequence of end-stage renal disease would suggest that dialysis patients would be at risk for thromboembolic events. A fully developed dialysis fistula may have sufficient luminal diameter to harbor subclinical or clinically significant venous thrombi. Clinicians should be alert to the possibility of venous emboli after fistula manipulation.

Computerized Scoring System for the Diagnosis of Foreign Body Aspiration in Children

Objectives:

Foreign body aspiration (FBA) is a life-threatening event in children. The gold standard for diagnosis is bronchoscopy, but there is no consensus regarding indications for the procedure. The aim of this study was to formulate a predictive model for assessing the probability of FBA in suspected cases as an aid in the decision to perform diagnostic bronchoscopy.

Methods:

The files of 150 patients who underwent bronchoscopy for suspected FBA at our center between 1996 and 2004 were reviewed for medical history, physical examination, and radiologic studies. The findings were analyzed by logistic regression.

Results:

Using the file data, we formulated a predictive model wherein each parameter received a numeric coefficient representing its significance in evaluating suspected FBA. The most significant parameters were age 10 to 24 months, foreign body in the child's mouth and severe respiratory complaints during the choking episode, hypoxemia, dyspnea or stridor following the acute event, unilateral signs on lung auscultation, abnormal tracheal radiogram, unilateral infiltrate or atelectasis, and local hyperinflation or obstructive emphysema on chest radiogram.

Conclusions:

In our predictive model, every case of suspected FBA can be assigned a score based on the specific parameters present, which is then entered into a probability formula to determine the likelihood of a positive diagnosis. This model may serve as a useful tool for deciding on the use of bronchoscopy in all children with suspected FBA.

Correlation of transcutaneous hepatic near-infrared spectroscopy readings with liver surface readings and perfusion parameters in a piglet endotoxemic shock model

PURPOSE

To determine whether transcutaneous liver near-infrared spectrophotometry (NIRS) measurements correlate with NIRS measurements taken directly from the liver surface, and invasive blood flow measurements.

PROCEDURE

Laparotomy was performed in 12 Yorkshire piglets, and ultrasound blood flow probes were placed on the hepatic artery and portal vein. Intravascular catheters were inserted into the hepatic and portal veins for intermittent blood sampling, and a pulmonary artery catheter was inserted via the jugular vein for cardiac output measurements. NIRS optodes were placed on skin overlying the liver and directly across the right hepatic lobe. Endotoxemic shock was induced by continuous infusion of Escherichia coli lipopolysaccharide O55:B5. Pearson's correlations were calculated between the NIRS readings and the perfusion parameters.

FINDINGS

After endotoxemic shock induction, liver blood flow, and oxygen delivery decreased significantly. There were statistically significant correlations between the transcutaneous and liver-surface NIRS readings for oxyhemoglobin, deoxyhemoglobin, and cytochrome c oxidase concentrations. There were similar significant correlations of the transcutaneous oxyhemoglobin with both the mixed venous and hepatic vein saturation, and mixed venous and hepatic vein lactate.

CONCLUSIONS

Transcutaneous NIRS readings of the liver, in an endotoxemic shock model, correlate with NIRS readings taking directly from the liver surface, as well as with global and specific organ-perfusion parameters.

Correlation of near-infrared spectroscopy with perfusion parameters at the hepatic and systemic levels in an endotoxemic shock model

BACKGROUND

To determine the correlation of near-infrared spectrophotometry (NIRS) readings from the liver surface with invasive measurements of blood flow and tissue perfusion parameters in an animal model of endotoxemic shock.

MATERIAL/METHODS

Laparotomy was performed in 12 Yorkshire piglets, and ultrasound blood flow probes were placed on the hepatic artery and portal vein. Hepatic vein, portal vein, and femoral artery catheters were inserted for intermittent blood sampling, and a pulmonary artery catheter was inserted via the jugular vein for cardiac output measurements. Near-infrared spectrophotometry optodes were placed across the right hepatic lobe. Endotoxemic shock was induced by continuous infusion of Escherichia coli lipopolysaccharide 055: B5. Pearson correlations were calculated between the perfusion parameters and the near-infrared spectrophotometry (NIRS) readings.

RESULTS

After endotoxemic shock induction, liver blood flow decreased from 144 +/- 36 to 62 +/- 24 ml*min(-1)*100 g(-1) and oxygen delivery to the liver decreased from 20 +/- 6 to 7 +/- 4 ml*min(-1)*100 g(-1). Near-infrared spectrophotometry readings of oxyhemoglobin concentration decreased by 11.7+/-15.1 micromol*L(-1), and readings of deoxyhemoglobin concentration increased by 12.3 +/- micromol*L(-1). There were significant correlations (p < 0.05 for r2 > 0.11) between the oxyhemoglobin readings and liver oxygen delivery (r2 = 0.58), liver blood flow (r2 = 0.73) and cardiac output (r2 = 0.80). Deoxyhemoglobin readings highly correlated (p < 0.05 for r2 > 0.11) with mixed venous lactate (r2 = 0.87) and with hepatic vein lactate (r2 = 0.82).

CONCLUSIONS

Noninvasive near-infrared spectrophotometry measurements of hepatic oxyhemoglobin and deoxyhemoglobin correlate with liver hemodynamics as well as with global and specific organ perfusion parameters and may serve, in the future, as a useful tool to monitor tissue perfusion in septic patients.

Oral amphotericin B for the prevention of Candida bloodstream infection in critically ill children

OBJECTIVES

To determine the efficacy of oral amphotericin B for the prevention of Candida bloodstream infection in the pediatric intensive care unit.

DESIGN

Retrospective, nonrandomized, historic-control study.

SETTING

Multidisciplinary pediatric intensive care unit at a university-affiliated children's medical center.

PATIENTS

Study group included all patients admitted to the pediatric intensive care unit from January 1, 1998, to December 31, 1999, who required mechanical ventilation and who were admitted for >7 days. The control group included all patients admitted for >7 days who needed mechanical ventilation from January 1, 1994, to December 31, 1997.

INTERVENTIONS

Oral amphotericin B suspension, 50 mg every 8 hrs, administered to all study group patients soon after initiation of mechanical ventilation and terminating after weaning.

MEASUREMENTS

The rates of Candida bloodstream infection were compared between the study and control groups.

MAIN RESULTS

Candida species were isolated from blood cultures in 5 of 185 (2.1%) and 21 of 196 (10.7%) patients in the study and control groups, respectively (p= .0038). There was also a statistically significant (p= .017) decrease in Candida bloodstream infection rate in all patients admitted to the pediatric intensive care unit for >7 days during the study period compared with the Candida bloodstream infection rate during the control period.

CONCLUSION

Prophylactic administration of oral amphotericin B may lead to a significant decrease in the rate of Candida bloodstream infection in ventilated pediatric intensive care unit patients.

Thiamine deficiency in infants: MR findings in the brain

BACKGROUND AND PURPOSE

Thiamine deficiency is extremely rare in infants in developed countries. To our knowledge, its MR findings in the brain have not been reported. The purpose of this study was to investigate the brain MR findings in infants with encephalopathy due to thiamine deficiency.

METHODS

The study group included six infants aged 2-10 months with encephalopathy who had been fed with solely soy-based formula devoid of thiamine from birth. All underwent MR evaluation at admission and follow-up (total of 14 examinations). In one patient, MR spectroscopy (MRS) was performed.

RESULTS

In five patients T2-weighted, fluid-attenuated inversion recovery, or proton-attenuated sequences showed bilateral and symmetric hyperintensity in the periaqueductal area, basal ganglia and thalami. Five had lesions in the mammillary bodies, and three, in the brain stem. In all six patients, the frontal region (cortex and white matter) was clearly involved. At presentation, MRS of the periaqueductal area showed a lactate doublet. On long-term follow-up, three of four patients had severe frontal damage; in two, this occurred as part of diffuse parenchymal loss, and in one, it was accompanied by atrophy of the basal ganglia and thalami.

CONCLUSION

Thiamine deficiency in infants is characterized by involvement of the frontal lobes and basal ganglia, in addition to the lesions in the periaqueductal region, thalami, and the mammillary bodies described in adults. MRS demonstrates a characteristic lactate peak.

Use of the NOW Streptococcus pneumoniae urinary antigen test in cerebrospinal fluid for rapid diagnosis of pneumococcal meningitis

Streptococcus pneumoniae is one of the most common pathogens in bacterial meningitis. Rapid diagnosis is critical for effective treatment. The aim of this study was to assess the accuracy of the NOW S. pneumoniae Urinary Antigen Test, (Binax, Portland, ME, USA) originally developed for urine testing, in detecting the S. pneumoniae antigen in cerebrospinal fluid (CSF). The study included 519 patients with suspected meningitis. CSF, blood and urine samples were cultured according to standard methods. CSF viral culture was also performed. CSF and urine specimens were tested for pneumococcal antigen with the NOW S. pneumoniae test.S. pneumoniae was isolated from the CSF of 22 patients. The direct antigen test was positive in CSF in 21/22 patients (95.4% sensitivity), and in urine, in 12/21 (57.1% sensitivity). Direct CSF smear was positive in 15/22 (68% sensitivity). CSF samples that cultured negative for S. pneumoniae (n = 470) or positive for other bacteria (n = 27) were also negative on the NOW test (100% specificity). By contrast, urine samples of 63/470 of patients with negative CSF culture were positive on the NOW test, as were 5/27 urine samples of patients with CSF culture positive for other bacteria (p = 0.45). The NOW S. pneumoniae antigen test in CSF yields a rapid and very reliable diagnosis of pneumococcal meningitis, enabling prompt and adequate treatment. Its low sensitivity in urine indicates that this mode of testing is not useful for the diagnosis of pneumococcal meningitis. These data have been included in the FDA application for approval of the NOW test for use in the CSF for the diagnosis of pneumococcal meningitis.

Blood transfusion practice indicated by paediatric intensive care specialists in response to four clinical scenarios

OBJECTIVE

Several clinical guidelines exist for blood transfusion in adults but only one refers to children. There are no guidelines for blood transfusion in critically ill children and the paediatric intensive care specialist's approach is unknown. We wished to evaluate the approach toward blood transfusion among a group of paediatric intensive care specialists.

METHODS

All certified paediatric intensive care specialists from the Israeli society of pediatric intensive care medicine were requested to complete a questionnaire, which described four hypothetical common scenarios in paediatric intensive care units. In each case, the physicians were asked to denote the haemoglobin threshold at which they would prescribe a blood transfusion and the transfusion volume they would use. The specialists were also asked for their reasons for increasing their haemoglobin threshold for blood transfusion.

RESULTS

The questionnaire was posted to twenty six paediatric intensive care specialists, twenty one of whom responded (i.e. 80.8%). There was a wide variation for each scenario in both the suggested haemoglobin thresholds for transfusion (varying by 20-50 g/L) and the transfusion volume (varying by 10-20 mL/kg). The reasons given for increasing their blood transfusion threshold included, in order of importance, shock, haemodynamic instability and hypoxaemia.

CONCLUSIONS

There is a marked variability among paediatric intensive care specialists regarding both the threshold haemoglobin level at which blood transfusion is prescribed as well as the volume used.

Efficacy of subcutaneous tunneling for prevention of bacterial colonization of femoral central venous catheters in critically ill children

BACKGROUND

Blood stream infections are a common and serious complication of central venous catheters (CVCs). To decrease catheter colonization, some authors advocate tunneling the catheter in the subcutaneous tissue during insertion. This technique has proved effective in adults, but there are no data on its safety and efficacy in critically ill children. Our objective was to evaluate the efficacy and safety of subcutaneous tunneling of short term, noncuffed CVCs for the prevention of CVC-related infections in critically ill children.

METHODS

A prospective randomized controlled trial was performed at a tertiary children's medical center in Israel and included children ages 0 to 18 years admitted to the pediatric intensive care unit or the pediatric cardiac intensive care unit from September 2000 to April 2001 who required placement of a femoral central venous catheter for >48 h. The children were randomized for tunneled or nontunneled insertion. The main outcome measures were bacterial colonization of proximal and distal catheter segments tested by semiquantitative technique and infectious or noninfectious complications of the CVC.

RESULTS

Of 98 eligible children, 49 received tunneled catheters and 49 received nontunneled catheters. Patients' age ranged from 1 month to 16.5 years (mean, 3.07 +/- 2.48 years). There were no significant differences between the groups in age, sex, disease severity [Pediatric Risk of Mortality III (PRISM) score], duration of catheterization and underlying diseases. Bacterial colonization was found in 11 (22.4%) catheters in the nontunneled group compared with 3 (6.1%) in the tunneled group (P = 0.004). Proximal segment colonization occurred in 7 (14.2%) nontunneled catheters and 2 (4.8%) tunneled catheters (P = 0.07), and distal segment colonization occurred in 3 (6.1%) and 9(18.3%) tunneled and nontunneled catheters, respectively (P = 0.053). The main pathogens were coagulase-negative staphylococci, Pseudomonas spp. and Klebsiella spp. There was no statistically significant difference between the groups in the rate of bloodstream infection (2 in the tunneled group, 3 in the nontunneled). Except for 1 case of subcutaneous hematoma, which resolved, there were no immediate or late complications of the tunneling procedure.

CONCLUSION

Subcutaneous tunneling of CVCs in the femoral site is a safe procedure and decreases significantly the rate of CVC colonization in critically ill children.

Acute diaphragmatic paralysis caused by chest-tube trauma to phrenic nerve

A 3 1/2-year-old child developed unilateral diaphragmatic paralysis after chest drain insertion. Plain chest X-ray demonstrated paravertebral positioning of the chest-tube tip, and magnetic resonance imaging revealed hematomas in the region of the chest-tube tip and the phrenic nerve fibers. The trauma to the phrenic nerve was apparently secondary to malposition of the chest tube. This is a rare complication and has been reported mainly in neonates. Radiologists should notify the treating physicians that the correct position of a chest drain tip is at least 2 cm distant from the vertebrae.

Benign occipital epilepsy mimicking a catastrophic intracranial event

OBJECTIVE

To describe the rare, dramatic, presentation of benign occipital epilepsy.

METHODS

We describe three children who presented to the pediatric emergency department from 1992 to 1996 with a clinical picture of catastrophic intracranial event.

RESULTS

The main signs and symptoms were loss of consciousness in all patients, apnea in two, hemiclonus in two, general hypertonicity in two, eye deviation in two, fixed dilated pupils in one, and decorticate rigidity in two. All underwent emergency intubation, brain scan, and lumbar puncture, and all were treated with antibiotics, in addition to antiviral drugs in two. Two patients were also treated for suspected increased intracranial pressure. Two patients recovered within a few hours and one within 24 hours of admission without any residual neurologic deficit. Electroencephalograms, done within 48 hours after the event, revealed the classic pattern of occipital epilepsy in two patients and bilateral occipital slow wave in one. A 3- to 5-year clinical and electroencephalographic follow-up supported the diagnosis.

CONCLUSION

Benign occipital epilepsy in children can mimic a catastrophic intracranial event. Electroencephalography, performed early in the Pediatric Intensive Care Unit, may avoid or shorten unnecessary and aggressive treatments such as hyperventilation, diuretic agents, and prolonged antiviral therapy.

Yield of bronchoalveolar lavage in ventilated and non-ventilated children after bone marrow transplantation

A study was undertaken to retrospectively evaluate the yield of bronchoalveolar lavage (BAL) in a single-institution series of children after bone marrow transplantation (BMT) and to compare the yield of BAL between the ventilated and nonventilated patients. We reviewed charts of 52 consecutive children after BMT who underwent BAL. Thirty patients (41 BALs) were nonventilated (group 1) and 33 patients (45 BALs) were ventilated for respiratory failure (group 2). Eleven patients were included in both groups. BAL was performed a median of 255 and 28.5 days after BMT in groups 1 and 2, respectively (P < 0.001). Group 1:17 pathogens were isolated from 13 BALs; a single pathogen from 10 BALs. Group 2:15 pathogens were isolated from 14 BALs (31.1% positive). Viruses were isolated from 13 BALs in group 2. A severe complication of BAL occurred in only one patient from group 1 (1.1%). Open lung biopsies were performed in one patient in group 1 and eight patients in group 2. The histological findings correlated with the BAL findings in 66.7%. In conclusion, there was no difference in the yield of BAL between the groups. Therapy was changed in one third of the patients dictated by the BAL findings. The risk of severe complications was relatively low. A good correlation between open lung biopsy (OLB) and BAL was found.

Hemophagocytic lymphohistiocytic syndrome: Unrecognized cause of multiple organ failure

OBJECTIVE: To describe an often-unrecognized clinical picture of multiple organ failure in hemophagocytic lymphohistiocytic syndrome (HLS). DESIGN: Retrospective chart review. SETTING: A ten-bed pediatric intensive care unit (PICU) in a tertiary children's university hospital. PATIENTS: A total of 11 children (age, 5 months to 13 yrs) who fulfilled the criteria for the diagnosis of familial- or infectious-associated hemophagocytic lymphohistiocytosis and who required intensive care support for organ failure. INTERVENTION: None. MAIN RESULTS: During a 10-yr period, 5,439 children were hospitalized in our PICU. A total of 11 children were diagnosed as suffering with HLS. Of these 11 patients, three (27%) had the familial form and eight had the infectious-associated form. After admission to the PICU, seven patients (63%) were diagnosed as suffering with HLS and each had one or more organ failures (patients 3-7, 9, and 10). All presented with fever, hepatomegaly, and splenomegaly; in addition, all had at least two of the following: anemia, neutropenia, or thrombocytopenia. All 11 had lymphohistiocytic accumulation in bone marrow (n = 10), lymph node (n = 2), lung (n = 2), and/or liver (n = 1). Organ failure was noted most often in the respiratory system (n = 7) attributable to severe, acute respiratory distress syndrome and pleural effusion. Of the 11 patients, six had cardiovascular involvement that manifested as shock in three and as capillary leak syndrome in three. Renal failure occurred in four patients. Of these, two required hemodiafiltration and one required peritoneal dialysis. Liver failure occurred in three and central nervous system involvement and coma in three. Most of the patients required massive therapeutic intervention, including assisted ventilation (n = 6), inotropic support (n = 3), and hemofiltration (n = 3). A total of seven patients (63%) died. CONCLUSIONS: Hemophagocytic lymphohistiocytic syndrome in the pediatric population may have a dramatic clinical picture, with multiple organ failure as a presenting symptom or early in the disease course, mandating intensive support in the PICU.

A comparison between continuous central venous pressure measurement from right atrium and abdominal vena cava or common iliac vein

OBJECTIVE

To determine the accuracy of mean continuous central venous pressure (CVP) measurements in the abdominal vena cava.

DESIGN

We simultaneously measured the CVP at the superior vena cava or right atrium and at the abdominal vena cava or common iliac vein. The study was conducted at the pediatric intensive care unit of a major university-affiliated medical center.

PATIENTS

Nine patients, aged 6 months to 14 years, were included in our study.

MEASUREMENTS AND RESULTS

Eleven continuous recordings of 12 to 68 min were taken, eight of them while the children were mechanically ventilated. Mean overall CVP ranged from 3 to 30 mmHg. A total of 519 simultaneous recordings were made, of which 515 (99.2%) were within the accepted limits of agreement of +/- 2 mmHg: 301 (58%) with delta CVP of +/- 0 mmHg, 189 (36,4%) with delta CVP of +/- 1 mmHg, and 25 (4.8%) with delta CVP of +/- 2 mmHg. The mean pressure difference was -0.22 +/- 1.52 mmHg. Accuracy was maintained within all ranges of CVP (3-10, 11-20, and 21-30 mmHg) and was not influenced by mechanical ventilation or abdominal fluid collection.

CONCLUSION

In children with no obstruction of blood flow from the abdominal vena cava to the right atrium, the pressure in the abdominal vena cava or common iliac vein accurately reflects the pressure in the right atrium.