Journal of Pediatric Intensive Care - Volume 2, issue 3

Authors: Levin, Asher | Paret, Gideon

Article Type: Review Article

Abstract: We designed this review to examine the mechanism of action of levosimendan (Simdax® , Orion Pharma, Espoo, Finland) and its current clinical application in critically ill adults and children with acutely decompensated severe congestive heart failure and who require inotropic support. We applied Pubmed (primarily) and Google search engines for English-language papers whose main topic was the use of levosimendan in the general population and those that concentrated on pediatric cohorts aged 0 to 18-year-old. Levosimendan increases contractile force of the heart and improves vasodilation. It increases the heart's sensitivity to calcium, thereby increasing cardiac contractility. Its mechanism of action …is via the increased calcium sensitivity of myocytes by binding to cardiac troponin C in a calcium-dependent manner. Its opening of adenosine triphosphate-sensitive potassium channels in vascular smooth muscle leads to a vasodilatory effect and smooth muscle relaxation. Levosimendan was shown to be effective in the treatment of acute decompensated heart failure, rescue therapy for septic shock, weaning patients from assisted devices and weaning patients from inotropic therapy. Neonates with hypoplastic left heart syndrome who were treated by levosimendan showed improvement in systemic perfusion following cardiac surgery. Cost-effectiveness of this new drug is discussed. Show more

Keywords: Levosimendan, low cardiac output syndrome, mechanical circulatory support, acutely ill children, inotropic therapy, cost efficiency, cardiac surgery

DOI: 10.3233/PIC-13057

Citation: Journal of Pediatric Intensive Care, vol. 2, no. 3, pp. 95-103, 2013

Authors: Elbeleidy, Ahmed S. | El -Sherbeini, Seham A. | Algebaly, HebatAllah F. | Alkhatib, Nour M.

Article Type: Research Article

Abstract: The aim of this retrospective study is to evaluate the burden, characterize the demographics and visualize the final outcome of the critical neurological cases admitted to a tertiary pediatric intensive care unit in Cairo University Children Hospital. Data of 139 pediatric critical care patients admitted with neurological dysfunction were reviewed, retrospectively. Patients with critical neurological illness represented 30% of the total admissions (n = 139). Coma patients (n = 115, 83%) were divided into structural/intrinsic coma (n = 54, 47%) and metabolic/toxic (n = 61, 53%). Patients with neuromuscular disorders comprised 17% (24/139) of the cohort. Patients with toxic/metabolic coma …had higher Pediatric Risk of Mortality scores, higher inotrope scores, more organ system failures, a higher percentage of pre admission cardiac arrests and higher frequency of septic shock diagnosis. Predictors of death in the whole group included (a) Number of organ failure: patients with three or more organ systems failure were 3.1 times more liable to die (b) Glasgow Coma Scale (GCS): cases with GCS score less than eight were 4.2 times more prone to die, (c) Those who developed acute lung injury in less than 14 days of mechanical ventilation were 10.7 times more prone to die than those who had not. Patients with toxic/metabolic coma required more intensive support giving into consideration that advanced sepsis and presence of a family member with drug addiction played a big role as an underlying cause. National programs for implementation of sepsis goal directed therapy and health awareness about the hazards of accidental drug intake are of supreme importance. Predictive factors for death in coma patients on admission were low GCS score, presence of multiple organ system failure and acute lung injury. Show more

Keywords: Neurological dysfunction, PICU, critical pediatric patients, mortality

DOI: 10.3233/PIC-13058

Citation: Journal of Pediatric Intensive Care, vol. 2, no. 3, pp. 105-110, 2013

Authors: Pons-Odena, Marti | Palanca, Daniel | Modesto, Vicent | Esteban, Elisabet | González-Lamuño, Domingo | Carreras, Robert | Palomeque, Antonio

Article Type: Research Article

Abstract: Generally, monitoring of hypoxemia has been always based on partial pressure of arterial oxygen to fraction of inspired oxygen ratio; recently it was confirmed a good correlation between this ratio and a non-invasive alternative ratio of oxygen saturation to fraction of inspired oxygen (SF ratio = SpO2 /FiO2 ). The SF ratio has been studied and validated, especially in the intubated patients, however studies monitoring patients treated with non-invasive ventilation (NIV) are lacking. The aim of the study was to determine if the SF ratio is a reliable predictive factor for failure of NIV in pediatric patients diagnosed with hypoxemic …acute respiratory failure due to pneumonia. A five year retrospective study with consecutive sampling of patients diagnosed with hypoxemic acute respiratory failure due to pneumonia, admitted to the pediatric intensive care unit in a university hospital and treated with NIV was conducted. Physiological and ventilator variables were collected before starting NIV and at 2, 8 and 12 hours of treatment, and the corresponding SF ratios calculated. Thirty-four patients were studied. NIV failed in seven patients. Significant differences in SF ratio were observed between the successful and unsuccessful patients at the onset, 2 and 12 hours of treatment. Multivariable analysis revealed the SF ratio at two hours to be an independent predictor of NIV failure (odds ratio = 0.96, 95% confidence intervals 0.93–0.99; P = 0.015). Area Under Receiver Operating Characteristic curve = 0.90 (95% confidence interval = 0.79 to 1.000), optimal cut off value for SF at 2 hours ≤ 189; sensitivity = 86%, specificity = 74%. In conclusion, the SF ratio of 189 or less at 2 hours of NIV seems to be useful for predicting NIV failure in this cohort. Show more

Keywords: Pneumonia, non-invasive ventilation, acute hypoxemic respiratory failure, acute respiratory distress syndrome, intensive care unit, child

DOI: 10.3233/PIC-13059

Citation: Journal of Pediatric Intensive Care, vol. 2, no. 3, pp. 111-119, 2013

Authors: Traube, Chani | Witcher, Robert | Mendez-Rico, Elena | Silver, Gabrielle

Article Type: Research Article

Abstract: Delirium occurs in a substantial number of critically ill children and may contribute to increased hospital length of stay, and short- and long-term morbidity. Children with delirium may benefit from early pharmacologic treatment. In this case series, we describe four critically ill children, ranging from eight months to 14 years of age, who were prescribed quetiapine as treatment for delirium. In all four patients, delirium improved within 24 hours of initiation of quetiapine. With proven efficacy in adults with delirium, an established track record in children for indications other than delirium, and a favorable safety profile, quetiapine may be a …therapeutic option in treating delirium in critically ill children. The time has come for a prospective, blinded study of quetiapine as treatment for pediatric delirium. Show more

Keywords: Delirium, pediatrics, critical care, treatment, quetiapine

DOI: 10.3233/PIC-13060

Citation: Journal of Pediatric Intensive Care, vol. 2, no. 3, pp. 121-126, 2013

Authors: Claveria, Joanne K. | Meyer, Michael T. | Wakeham, Martin K. | Sato, Thomas T.

Article Type: Research Article

Abstract: Patients with severe hepatic trauma requiring damage control laparotomy and perihepatic packing are at risk for venous thromboembolism (VTE). Prevention and treatment of VTE in this population is problematic, especially in children for whom adult guidelines are often adapted. The following case report describes two children who developed VTE with associated pulmonary embolism after damage control laparotomy and perihepatic packing for hepatic trauma. The first patient had hemodynamically significant pulmonary emboli. He received catheter-directed thrombolysis with subsequent improvement in ventilation and need for inotropic support. The second patient had a vena caval thrombus detected on surveillance ultrasound and later developed …a pulmonary embolus, both of which were treated with heparin and enoxaparin. Our experience suggests that surveillance imaging of these patients may allow for prospective mobilization of specialized resources, such as interventional radiology support or cardiopulmonary bypass equipment, and that catheter-directed thrombolysis may be a viable treatment modality in these critically ill and injured children. Show more

Keywords: Pulmonary embolism, venous thromboembolism, thrombolytic therapy, tissue plasminogen activator, perihepatic packing, hepatic trauma

DOI: 10.3233/PIC-13061

Citation: Journal of Pediatric Intensive Care, vol. 2, no. 3, pp. 127-130, 2013

Authors: Lang, Kristin | Champion, Elizabeth | Cosper, Graham | Peeler, Benjamin | Maxey, Thomas

Article Type: Research Article

Abstract: Plastic bronchitis is a condition in which large, rubber-like, bronchial casts develop in the tracheobronchial tree causing airway obstruction. It is an unusual disorder that occurs in various disease states. Most case reports of plastic bronchitis associated with congenital heart disease are in patients palliated with Fontan physiology. We describe a 13-year-old girl with DiGeorge syndrome and truncus arteriosus who underwent an uneventful truncal valve replacement. The child developed plastic bronchitis on postoperative day eight requiring extra-corporeal membrane oxygenation support and daily bronchoscopy to remove bronchial casts. Our patient did not have elevated systemic venous pressures or Fontan physiology. We …speculate the etiology of plastic bronchitis may have been surgical trauma to the lymphatic channels surrounding the bronchi and disruption of pleural adhesions. A comprehensive evaluation revealed no specific cause and the diagnosis of idiopathic plastic bronchitis was made. Show more

Keywords: Plastic bronchitis, bronchial casts, congenital heart disease, truncus arteriosus, truncal valve replacement

DOI: 10.3233/PIC-13062

Citation: Journal of Pediatric Intensive Care, vol. 2, no. 3, pp. 131-135, 2013

Authors: Das, Suman | Chatterjee, Kaushani | Sarkar, Nirmalya | Aich, Bholanath | Dolui, Sanat

Article Type: Research Article

Abstract: Organophosphate poisoning is common in developing countries, more so in India. A 7-year-old boy with history of ingestion of unquantified amounts of malathion, presented to the pediatric emergency of Calcutta National Medical College, Kolkata in acute cholinergic crisis. He was treated with atropine and pralidoxime. The acute cholinergic crisis persisted for four days after admission, and as it subsided, the child developed respiratory distress, bulbar palsy, cyanosis, hypoxemia and hypercarbia. A diagnosis of intermediate syndrome was made and patient needed prolonged ventilation for 21 days for type II respiratory failure. Five days after discharge, the child developed distal weakness of …both lower limbs, which later involved the hands. There was associated gross sensory loss. Nerve conduction velocity study and sural nerve biopsy predominantly showed evidence of sensory-motor axonopathy with associated demyelination. The child was treated with physiotherapy, but was left with disabilities like claw hand, foot drop and the inability to walk. Show more

Keywords: Organophosphorus poisoning, cholinergic crisis, intermediate syndrome, organophosphate induced delayed neuropathy, malathion, acetylcholinesterase

DOI: 10.3233/PIC-13063

Citation: Journal of Pediatric Intensive Care, vol. 2, no. 3, pp. 137-141, 2013

Authors: Babbitt, Christopher J. | Lake, Jean | Levine, Glenn K.

Article Type: Research Article

Abstract: Anti-N-methyl-D-aspartate receptor encephalitis is a recently discovered disease that is more commonly being diagnosed in children. Patients often require intensive care and assisted ventilation due to agitation, abnormal movements, hypoventilation, seizures and autonomic instability. There is no consensus on which medicines are best suited to acutely treat this constellation of central nervous system symptoms. We present the first case report of using dexmedetomidine to treat this condition.

Keywords: Dexmedetomidine, encephalitis, seizures, anti-N-methyl-D-aspartate receptor

DOI: 10.3233/PIC-13064

Citation: Journal of Pediatric Intensive Care, vol. 2, no. 3, pp. 143-145, 2013