Journal of Pediatric Intensive Care - Volume 1, issue 2
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Journal of Pediatric Intensive Care is an English multidisciplinary peer-reviewed international journal publishing articles in the field of pediatric intensive care.
Journal of Pediatric Intensive Care is written for the entire intensive care team: pediatric intensivist, pediatricians, neonatologists, respiratory therapists, nurses, and others who deal with pediatric patients who are followed in neonatal and pediatric intensive care units.
Journal of Pediatric Intensive Care provides an in-depth update on new subjects, and current comprehensive coverage of the latest techniques in intensive care in childhood.
Journal of Pediatric Intensive Care encourages submissions from all authors throughout the world.
The following articles will be considered for publication: editorials, original and review articles, short report, rapid communications, letters to the editor, and book reviews. The aim of the journal is to share and disseminate knowledge between all disciplines that work in the field of pediatric intensive care.
Abstract: Dysfunction of pulmonary surfactant is one of the key pathogenic features in meconium aspiration syndrome. Surfactant function may be affected by components of meconium, by inflammatory mediators (e.g., tumor necrosis factor alpha and interleukin-1), proteolytic enzymes, phospholipase A2, reactive oxygen species, and by plasma proteins leaking into the alveolar space. Administration of exogenous surfactant may at least partially alleviate the inactivation of pulmonary surfactant present in meconium aspiration syndrome. In experimental and clinical studies, intratracheal administration of a surfactant bolus significantly improved both lung function and survival. However, some patients are non-responders and there is only transient improvement in oxygenation.…A repeat dose of surfactant may be required in these patients. Bronchoalveolar lavage with diluted exogenous surfactant is another technique for surfactant administration that may be more effective in partially removing meconium from the lungs, and thereby reducing surfactant inhibition, inflammation and mechanical obstruction of the airways. There is also a growing body of evidence suggesting that exogenous surfactant may be more effective when combined with pulmonary vasodilators, anti-inflammatory and antioxidant treatment.
Abstract: In preterm infants, lung function monitoring is important for lung-protective mechanical ventilation. In this study, we used a neonatal lung model to investigate the effect of endotracheal tube (ETT) leakage on the monitoring of tidal volume (VT ) and lung mechanics using different ventilators. A neonatal lung model was ventilated via a 3 mm ETT using three ventilators, Babylog 8000, Leoni, and Stephanie. ETT leakage was simulated by open silicone tubes with different lengths. The volume delivered to the lung model was measured and compared with the displayed expiratory VT of the three ventilators. The effect of ETT leakage…on lung mechanical parameters displayed by the ventilators was investigated for respiratory rates from 20 min−1 to 70 min−1 and a constant inspiratory time: expiratory time ratio of 1:1. The displayed ETT leakage depended on the size of the leak, ventilator settings, and the ventilator used. In the presence of ETT leakages, for all three ventilators, the displayed VT underestimated the true volume delivered to the lung. With increasing ETT leakage, displayed compliance was overestimated by Babylog 8000 and Stephanie, whereas Leoni underestimated compliance. The displayed resistance increased with increasing ETT leakage for the three ventilators, but quite different. The effect of ETT leakage on displayed VT and lung mechanical parameters is ventilator-dependent. ETT leakage can lead to incorrect measurements that indicate reduced VT , improvement of lung compliance, or ETT obstruction.
Abstract: Direct laryngoscopy (DL) is the most commonly used technique for tracheal intubation, but there is ongoing interest in new devices that have high success rates and are easily learned. The pediatric Airtraq (AT) is a recently developed intubation device that allows visualization of the glottis and intubation of the trachea without alignment of the oral, pharyngeal and tracheal axes. We studied the efficacy of the AT compared to the DL for laryngoscopy of young children with normal airway anatomy. In this prospective study, 49 children (5 yr and younger) scheduled for elective surgery under general anesthesia were randomized into two…groups: intubation using direct laryngoscopy (DL group) and laryngoscopy using the Airtraq (AT group). Time to best view, time to intubate, first attempt success rate (FASR), and percentage of glottic opening seen (percentage of glottis opening score) were recorded. Data are presented as median and interquartile range. Time to best view was five (4, 7) sec in DL and five (4, 7.5) sec in AT. Time to intubate was 18 (14.7, 21) sec in DL and 22.5 (19.5, 25.5) sec in AT (P = 0.002). FASR was 100% in the DL and 83% in the AT. The percentage of glottis opening score was 80% (range 60–100%) in the DL and 100% (range 100–100%) in the AT (P < 0.001). In young children with normal airway anatomy, the AT provides a better view of the glottis than the standard laryngoscope, but it takes longer to intubate the trachea and the FASR is lower.
Abstract: To determine clinical, anthropometric, metabolic, and nutritional factors affecting nitrogen balance somatic protein status and substrate utilization in critically ill children measured energy expenditure (MEE) was measured by indirect calorimetry within 24 hr of an acute illness, solid organ transplantation, or cardiovascular surgery. Predicted basal metabolic rate was calculated using the Schofield equation. Somatic protein was estimated by the creatinine-height index. Nitrogen balance (NB) was calculated by subtracting the total nitrogen input from output. The net substrate (fat, carbohydrate, and protein) oxidation rates were calculated using the Weir formula modified by Frayn. Sixty-eight NB studies, indirect calorimetric and anthropometric measurements…performed in 37 patients. Nitrogen balance was worse when the MEE/Predicted basal metabolic rate ratio was < 0.9 or > 1.1. The incidence of negative NB was 91% when the caloric intake was less than MEE and 9% when it was equal to or greater than MEE (P < 0.05). On day 1, 27% had mild to moderate somatic protein depletion and 5.4% had severe somatic protein depletion. Only the persistence of stress and co-morbidity were associated with the creatinine-height index (P < 0.001). Without Multiple Organ System Failure (MOSF), there was a trend toward positive nitrogen balance by day 7 while with MOSF, negative nitrogen balance persisted even by day 7 (P < 0.05). When caloric intake was less than MEE, mean substrate utilization was 48.6% from lipid, 37.1% from carbohydrate, and 14.3% from proteins. But, when caloric intake was greater than MEE, mean substrate utilization was 83.3% from carbohydrate and 16.7% from protein. Significant negative nitrogen balance and somatic protein depletion develops in critically ill pediatric patients, especially when they are inadequately fed, develop MOSF, or have previous chronic illness. Caloric intake and MOSF independently affect substrate utilization.
Keywords: Nitrogen balance, multiple system organ failure, pediatric risk of mortality score, energy expenditure, substrate utilization
Abstract: To understand the way pain is produced and perceived is very important for its relief. In recent years, important advances have been made regarding the evaluation of pain, with the validation of objective criteria such as Oucher pain scales, body diagrams, numerical scales, verbal descriptive scales and visual analogue scales. The objective evaluation of pain is of special importance in pediatrics given the difficulties inherent to the patients of this group. The purpose of this study was to determine how nursing professionals evaluate pain in hospitalized children. We employed a questionnaire to nursing professionals (nurse technicians, practical nurses and registered…nurses) that work in the pediatric service of a teaching hospital. Fifty-six professionals (100% women) answered the questionnaire. Of these, 55 (98.2%) stated that they knew the methods and cited vital signals, physical examination and patient behaviors as items for evaluation. Although the majority of professionals (98.2%) have reported knowledge of objective methods (scales) for pain assessment in children, there was a predominance of behavioral observation as a method of choice (prevalence ratio 2.27; 95% confidence interval: 0.9 to 2.38). No significant associations or differences were observed between professional category, time of experience, other variables, and the type of method employed. The selected professionals do not use scales or other objective methods to measure pain in children. Therefore, it is necessary to habilitate and train nursing professionals working with pediatric patients in pain so that they will be able to assess their pain in an adequate manner.
Keywords: Pain measurement, nursing care, quality of health care
Abstract: Young infants with bronchiolitis commonly present with apnea. Caffeine is effective in treating apnea of prematurity and has been used to treat apnea associated with bronchiolitis. To evaluate whether caffeine administration to infants presenting with apnea in the setting of bronchiolitis was associated with a decreased rate of endotracheal intubation and mechanical ventilation, compared to infants who did not receive caffeine. Retrospective cohort study. University affiliated tertiary care children's hospital. Twenty-eight infants less than 3 months of age, 13 of whom received caffeine. Fewer infants who received caffeine required endotracheal intubation and invasive mechanical ventilation (OR = 0.30…95% CI 0.07 to 1.4, p = 0.15), but this was not statistically significant. Infants who received caffeine were more likely to be treated with non-invasive ventilation than infants in the control group (OR = 14; 95% CI 2.1 to 98 p = 0.01). Only one patient who was initially managed with non-invasive ventilation was subsequently intubated. There was no difference in the duration of total respiratory support, duration of invasive mechanical ventilation, hospital and pediatric critical care unit stay. All infants survived. This study does not provide adequate evidence to support or refute the routine use of caffeine in bronchiolitis associated apnea.
Abstract: Evaluate the usage of octreotide for the control of acute upper gastrointestinal bleeding in children with portal hypertension. A retrospective electronic database analysis of these children was performed over a period of five years. Setting was a tertiary pediatric intensive care. Case notes of 18 encounters in 13 children were reviewed. A loading dose (1.27 ± 0.76 µg/kg) was administered in seven, with median starting dose of 1.44 ± 1.19 µg/kg/h in all other episodes. The mean maximum dose was 1.68 ± 1.38 µg/kg/h. Re-bleeding occurred in one third; hemostasis was eventually achieved in all. Octreotide infusion appears to be…safe and effective in controlling pediatric upper gastrointestinal bleeding due to portal hypertension. We also recommend its use in community and rural hospital settings prior to transfer of such patients to a tertiary care center.
Abstract: Methadone is commonly prescribed for prevention of iatrogenic opioid abstinence syndrome (IOAS) in critically ill children. However, there is a paucity of data on the recommended initial dosage requirements. Data was retrospectively collected from January--December 31, 2008 and included demographics, methadone regimen, and IOAS symptoms. The primary objective was to determine the initial methadone dosing utilized (i.e., mg/kg/day) and the impact that this had on the number of dosage changes required for prevention of IOAS in patients < 18 yr within 72 hr following discontinuation of opioid continuous infusion (CI). Secondary objectives included a comparison of methadone dose changes within…72 hr of intravenously opioid discontinuation and opioid CI requirements based on initial doses above and below the median level (i.e., mg/kg/day). Between-group analysis was performed using descriptive and inferential statistics. A step-wise regression was employed to assess relationships between the initial dose (mg/kg/day) and several independent variables. Fifty-five patients were included for analysis. The median initial dose was 0.84 mg/kg/day. The “low-dose” group included patients receiving < 0.84 mg/kg/day (n = 27); the “high-dose” group included patients receiving &≥; 0.84 mg/kg/day (n = 28). The majority of patients (81.8%) received doses every 6 hr. Twenty-three patients (41.8%) developed IOAS and required an increase in dose while six patients (10.9%) required a decrease. No significant differences were found between groups. The cumulative and peak fentanyl CI doses were the only significant predictors of total mg/kg/day dose of methadone (P < 0.01). The initial methadone dosage regimens varied greatly in our patients. Approximately half required a change in their methadone dose. Based on our findings and a review of the literature, there is not a one-size fits all approach for determination of the initial methadone dose. Adoption of a consistent monitoring tool should be utilized for all children across the continuum of care to prevent IOAS and the over-sedation noted with excessive methadone dosing.
Abstract: A 14-year-old female was brought to the emergency room with chest pain, shortness of breath and cyanosis. She was previously well with the exception of one previous post-exertion seizure-like event. On this day, she had been jogging when she complained of chest pain and collapsed. Her initial vital signs were heart rate 58/min, blood pressure 70/40 mmHg, respiratory rate 50/min, temperature 37 °C, and SaO2 68%. Electrocardiogram showed significant ST changes. She received multiple fluid boluses and dopamine was initiated (5–20 μg/kg/min). She was intubated and started on norepinephrine (0.05–0.5 μg/kg/min) for refractory hypotension. During the resuscitation, echocardiography showed poor…left ventricular function with an ejection fraction of 38%. The coronary arteries could not be visualized clearly. To maintain cardiac output, epinephrine by infusion (0.1–3.0 μg/kg/min) was added, and she received multiple epinephrine boluses. Despite maximum ventilatory support and escalating inotropes, cardiac output rapidly deteriorated, and she developed an agonal rhythm with non-reactive pupils. Resuscitation was discontinued. Autopsy demonstrated an anomalous origin of left coronary artery from the right aortic sinus of Valsalva with acute myocardial ischemia. We describe the sudden coronary death of a young patient, and we review congenital coronary artery pathophysiology, screening difficulties and potential interventions.