Andrea Moscatelli

Home mechanical ventilation in children: retrospective survey of a pediatric population.

Background: Home care support is beneficial for children needing mechanical ventilation, when clinically stable.

Noninvasive ventilation and low-flow veno-venous extracorporeal carbon dioxide removal as a bridge to lung transplantation in a child with refractory hypercapnic respiratory failure due to bronchiolitis obliterans.

Objective: To report the successful management of end-stage hypercapnic respiratory failure through the association of noninvasive mechanical ventilation and a novel automated device (Decapsmart) of low-flow veno-venous extracorporeal CO2 removal. Design: Case report. Settings: Pediatric intensive care unit at a tertiary care childrens hospital. Patient: A pediatric patient affected by bronchiolitis obliterans with refractory hypercapnic respiratory failure. The patient received successful lung transplantation after respiratory support with noninvasive mechanical ventilation and a novel automated device of low-flow veno-venous extracorporeal CO2 removal. Interventions: Treatment of end-stage hypercapnic respiratory failure with the association of noninvasive ventilation and low-flow veno-venous extracorporeal CO2 removal as a bridge to lung transplantation. Measurements and Main Results: Respiratory support controlling hypercapnia, limiting volutrauma, barotraumas, and preventing the incidence of ventilator-associated pneumonia/lung colonization. Conclusion: Noninvasive mechanical ventilation and Decapsmart have proven efficacious in managing refractory hypercapnic respiratory failure in a pediatric patient awaiting lung transplantation.

Intensive Care Unit Admission in Children With Malignant or Nonmalignant Disease: Incidence, Outcome, and Prognostic Factors: A Single-Center Experience

Objective: To investigate pediatric intensive care unit (PICU) admission in children with malignant and nonmalignant diseases who developed life-threatening complications. Patients and Methods: Between 1999 and 2010, of the 1278 eligible pediatric patients treated for a malignant or nonmalignant disease, 54 were admitted to the PICU for respiratory distress (40.7%), neurological events (33.3%), severe sepsis (14.8%), and organ failure (11.2%). Results: Rate of PICU admission was 4.2%, with a 2-year cumulative incidence of 4.5%. Risk factors associated with higher cumulative incidence of PICU admission were older age at study entry (P=0.003), nonmalignant underlying disease (P=0.015), and hematopoietic stem cell transplantation (P<0.001). Patients with leukemia/lymphoma were more likely to be admitted to the PICU compared with patients with solid tumors (P<0.001). Patients admitted because of organ failure had the highest frequency of death within 90 days. Factors significantly associated with survival at 90 days from PICU admission included: no mechanical ventilation (P<0.001), nonmalignant underlying disease (P=0.030), and year of PICU admission after 2005 (P=0.038). Conclusions: Nonmalignant disease and use of alternative hematopoietic stem cell transplantation were associated with higher risk of PICU admission. Close cooperation between hematologists and intensivists and definition of criteria for PICU admission and discharge contributed to increase in survival of these patients.

Noninvasive ventilation in a child affected by achondroplasia respiratory difficulty syndrome

Achondroplasia can result in respiratory difficulty in early infancy, from anatomical abnormalities such as mid‐facial hypoplasia and/or adenotonsillar hypertrophy, leading to obstructive apnea, or to pathophysiological changes occurring in nasopharyngeal or glossal muscle tone, related to neurological abnormalities (foramen magnum and/or hypoglossal canal problems, hydrocephalus), leading to central apnea. More often, the two respiratory components (central and obstructive) are both evident in mixed apnea. Polysomnographic recording should be used during preoperative and postoperative assessment of achondroplastic children and in the subsequent follow‐up to assess the adequacy of continuing home respiratory support, including supplemental oxygen, bilevel positive airway pressure, or assisted ventilation.

Role of management strategies in reducing mortality from invasive fungal disease in children with cancer or receiving hemopoietic stem cell transplant: a single center 30-year experience.

Background: In the last decades, several diagnostic and therapeutic strategies have been implemented for management of invasive fungal diseases (IFD) in patients with cancer or receiving allogeneic hemopoietic stem cell transplant. Few data are available on their impact on mortality in children. Methods: All IFD episodes diagnosed at tertiary care center during a 30-year period between 1983 and 2012 were analyzed for 90-day mortality and risk factors. Diagnoses were coded according to international (European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group) criteria. Four treatment eras (1983–1990, 1991–1999, 2000–2005 and 2006–2012) were defined according to availability of diagnostic technologies, new antifungal drugs and use of a diagnostic-driven approach without empiric antifungal therapy. Results: A total of 198 IFD were diagnosed in 191 patients; 71.2% were proven/probable infections; 39.9% were caused by yeasts and 31.3% by molds. Within 90 days from IFD diagnosis, 58 (30.4%) patients died for a 28.3% cumulative probability of death. A multivariable analysis showed that the highest risk of death was associated with alternative donor-hemopoietic stem cell transplant [hazard ratio (HR): 3.96] and mold etiology (HR: 1.34). The risk of death significantly decreased across the treatment eras, with almost a 3-fold reduced risk for patients diagnosed during the 2006–2012 period (HR: 0.24). Also if the variable year of diagnosis was considered as continuous, the hazard of death significantly decreased by 5% per year (HR: 0.95). Conclusions: New management strategies resulted in a better prognosis of IFD in children with cancer or hemopoietic stem cell transplant. A diagnostic-driven approach was not associated with an increase in mortality.

Volumetric adsorptive microsampling-liquid chromatography tandem mass spectrometry assay for the simultaneous quantification of four antibiotics in human blood: Method development, validation and comparison with dried blood spot

HighlightsA new VAMS‐LC–MS/MS method for quantification of antibiotics from 10 &mgr;L blood is shown.The new method has been validated following international guidelines.The absence of HCT on the method performance has been verified in comparison with a DBS method.The method has been applied on samples derived from pediatric patients under therapy. Summary In this paper we show the development and validation of a volumetric absorptive microsampling (VAMS™)‐LC–MS/MS method for the simultaneous quantification of four antibiotics: piperacillin‐tazobactam, meropenem, linezolid and ceftazidime in 10 &mgr;L human blood. The novel VAMS‐LC–MS/MS method has been compared with a dried blood spot (DBS)‐based method in terms of impact of hematocrit (HCT) on accuracy, reproducibility, recovery and matrix effect. Antibiotics were extracted from VAMS and DBS by protein precipitation with methanol after a re‐hydration step at 37 °C for 10 min. LC–MS/MS was carried out on a Thermo Scientific™ TSQ Quantum™ Access MAX triple quadrupole coupled to an Accela ™UHPLC system. The VAMS‐LC–MS/MS method is selective, precise and reproducible. In contrast to DBS, it allows an accurate quantification without any HCT influence. It has been applied to samples derived from pediatric patients under therapy. VAMS is a valid alternative sampling strategy for the quantification of antibiotics and is valuable in support of clinical PK/PD studies and consequently therapeutic drug monitoring (TDM) in pediatrics.

Candida infections in paediatrics: Results from a prospective single-centre study in a tertiary care children's hospital

To describe the epidemiology of invasive Candida infection in a tertiary care paediatric hospital. Prospective single‐centre survey on all Candida strains isolated from normally sterile fluids and urines in the period 2005‐2015 . A total of 299 ICI were documented in 262 patients. Urinary tract infection represented the most frequent diagnosis (62%), followed by fungaemia (34%) and peritonitis (4%). Fungaemia was most frequent in children with cancer (59%) or in low birth weight neonates (61%), while urinary tract infections were more frequent in patients with urinary tract malformation. C.albicans was the most frequently isolated species (60%) compared with C. non‐albicans, but differences were present according to the site of isolation and underlying conditions. Overall 90‐day mortality was 7%, 13% in fungaemias, 8% in peritonitis and 2% in urinary tract infections. The rates of invasive Candida infection increased during the study period. Invasive Candida infection is diagnosed with increasing frequency in children. Site of isolation and aetiology are frequently related with the presence of underlying, favouring conditions. Mortality was not negligible, especially in the presence of more invasive infections and specific underlying conditions.

Severe Neonatal Legionella Pneumonia: Full Recovery After Extracorporeal Life Support.

Legionella pneumophila is responsible for hospital or community-acquired pneumonia. Neonatal legionellosis is associated with rapidly severe clinical course and high mortality rates. We describe a case of hospital-acquired Legionella pneumonia in a newborn with undiagnosed tracheoesophageal fistula and acute respiratory failure requiring venovenous extracorporeal membrane oxygenation support before fistula repair. Standardized multiplex polymerase chain reaction assay allowed early diagnosis. Extracorporeal life support associated with appropriate antibiotic therapy, surfactant, and steroid therapy was effective in achieving complete recovery. This is the first report of successful neonatal extracorporeal life support for respiratory failure secondary to L pneumophila.

Emergency percutaneous, bicaval double-lumen, ECMO cannulation in neonates and infants: Insights from three consecutive cases

Background Veno-venous extracorporeal membrane oxygenation (ECMO) is probably the preferable configuration to assist children with respiratory failure who do not respond to maximized conventional therapies. The single-vessel, double-lumen approach through the internal jugular vein is extremely advantageous, especially in infants, where femoral access presents limitations related to the small dimensions of the veins. In case of emergencies, ECMO might need to be started at the bedside, without the availability of fluoroscopic guidance. To our knowledge, a completely percutaneous approach has not been reported before in children younger than 1 year and weighing less than 5 kg. Methods We describe 3 cases of emergency bedside, percutaneous, bicaval double-lumen cannulation under real-time transthoracic ultrasound control in 2 neonates and 1 infant. Results In our experience, this approach proved to be safe, effective and time saving, while minimizing bleeding from the cannula insertion site. Cannulation times, from decision making to the beginning of ECMO flow, were 30, 28, 25 minutes respectively, from patient 1 to 3. We do not report any cannula-related injury to vessels and heart structures. Conclusions Our preliminary data suggest that, with the described precautions, percutaneous, echo-guided, bicaval double-lumen cannulation in neonates and infants could be effective and free from major complications. Further evaluation should be warranted in the neonatal population.

Activity of linezolid and daptomycin against methicillin-resistant coagulase-negative staphylococci with increased MIC for vancomycin isolated from blood cultures in pediatric patients

Abstract We evaluated minimal inhibitory concentration (MIC) for vancomycin, daptomycin, and linezolid in methicillin-resistant coagulase-negative staphylococci (MR-CoNS). Minimal inhibitory concentration of 2–4 mg/l for vancomycin was observed in 16% of strains, and among them 19% had MIC at breakpoint for daptomycin or linezolid. Among strains completely susceptible to vancomycin, 16% had MIC at breakpoint for daptomycin and 11% had for linezolid. This large proportion of pathogens with MIC around the breakpoint suggests a possible risk of treatment failure with these drugs. This phenomenon is worth further and constant monitoring.