Andrzej Piotrowski

Procalcitonin in the early diagnosis of nosocomial sepsis in preterm neonates

Aim:  To examine the diagnostic usefulness of procalcitonin (PCT), C‐reactive protein and immature to total neutrophil ratio (I : T) in nosocomial sepsis among neonates treated in an intensive care unit.

Coagulation abnormalities and severe intraventricular hemorrhage in extremely low birth weight infants

BACKGROUND The association between intraventricular hemorrhage (IVH) and coagulation in infants has been a subject of controversy. Only few publications assessing risk factors for development of IVH reported results of coagulation studies. OBJECTIVES To evaluate the levels of coagulation and fibrinolysis systems in ELBW infants and determine their influence on IVH. PATIENTS AND METHODS Following IRB approval coagulation status of 38 ELBW infants was evaluated on first and second day of life. Severity of IVH assessed by cerebral ultrasonography was graded according to Papile classification. Newborns were assigned to either Group A--Grade III or IV, or Group B--Grade I-II, or no IVH. RESULTS Neonates with Grade III/IV IVH had significantly lower plasma Factor VII (FVII) level on first day of life and FVII differed significantly between Groups A and B with sensitivity of 100%, specificity 41% for a cut-off value of< 7%. In Group A there was no improvement of prothrombin and activated partial thromboplastin times on Day 2. A significant decline of platelet count was also observed. CONCLUSIONS High-grade IVH coincides with severe derangement of coagulation in ELBW infants with FVII level being the most sensitive, it is not clear what the reason for such low FVII concentration is. Further studies are indicated.

Hyperkalemia and cardiac arrest following succinylcholine administration in a 16-year-old boy with acute nonlymphoblastic leukemia and sepsis.

Objectives: To report a case of potentially lethal hyperkalemia related to succinylcholine administration. Design: Case report. Setting: A 13-bed pediatric intensive care unit in a tertiary level, university-based children’s hospital. Patient: A 16-yr-old boy treated in the intensive care unit due to Klebsiella pneumoniae sepsis, which developed after chemotherapy for nonlymphoblastic leukemia. Interventions: After admission to the intensive care unit, the patient required intubation (uneventful under ketamine and succinylcholine) and mechanical ventilation. On the 15th day of therapy, when his respiratory variables improved significantly, he was extubated. His cardiac rhythm, respiratory rate, arterial blood pressure, and hemoglobin oxygen saturation were continuously monitored. Several hours later, however, he required reintubation due to respiratory insufficiency. For intubation, precurarization with pancuronium, ketamine, propofol, and succinylcholine was used. Measurements and Main Results: Before and immediately after reintubation, serum potassium levels were measured. Two minutes after intubation, premature ventricular contractions, ventricular fibrillation, bradycardia, and finally cardiac arrest were recognized. An increase of serum potassium from 3.19 to 8.64 mmol/L was observed in arterial blood. The patient was immediately resuscitated with chest compressions, intravenous adrenaline, atropine, lidocaine, and sodium bicarbonate. Potassium values normalized within 30 mins. Further treatment in the intensive care unit was uneventful, and the patient was weaned from mechanical ventilation and discharged to a hematology clinic. At present his mental and physical state is satisfactory. Conclusions: Succinylcholine may cause dangerous arrhythmias in septic and immobilized children. The alternative nondepolarizing agents should be used in such cases.

Weekend Matters Friday and Saturday Admissions Are Associated With Prolonged Hospitalization of Children

Organizational factors and access to health care resources are of considerable importance in everyday medical practice and may influence the outcome of therapy. One manifestation of these issues is the socalled weekend effect, which was suggested to increase mortality rates of children and adults in some settings while showing no significant effects in others. We suspected that the weekend effect may not only manifest itself in most severely ill patients but also in the general population of hospitalized children, and we aimed to establish its impact on duration of hospital stay of children with diabetes. To investigate the potential of the weekend effect in a pediatric specialist hospital, we analyzed data on hospital admissions to a department specializing in treating patients with oncohematologic, diabetic, and nephrologic ailments.

Higher glycemic variability in very low birth weight newborns is associated with greater early neonatal mortality

Objective: To determine the association between mean glycemia and its variability with perinatal mortality in preterm newborns hospitalized in an intensive care unit (ICU). Methods: Patients admitted to the ICU within the first 12 hours of life, with birth weight <1500 g, at least three blood glucose measurements/day and lack of insulin treatment were evaluated. Association of mean glycemia and its standard deviation (SD) with death during initial 7 days of life was evaluated. Multivariate logistic regression analysis was performed twice, using continuous glucose concentrations and by means of a quintile-based approach correcting for nonnormal distribution and nonlinear effects. Results: A total of 95 newborns were enrolled. Eleven patients (11.5%) died during the initial 7 days of life, overall mortality equaled 22%. Multivariate analysis showed that 5 minute Apgar score and SD of glucose concentrations were significantly associated with increased mortality in both models. Odds ratios (ORs) equaled 0.44; 95% confidence interval (95% CI) 0.27–0.74 and OR 1.34; 95% CI 1.03–2.03 for the continuous model and 0.50 95% CI 0.34–0.75 and OR 1.82 95% CI 1.07–3.11 for the quintile-based model. In both cases, mean glycemia was removed during the stepwise model-building procedure. Conclusions: Higher glycemic variability may be associated with greater odds of perinatal mortality.

Stanowisko Sekcji Pediatrycznej Polskiego Towarzystwa Anestezjologii i Intensywnej Terapii w sprawie znieczulenia ogólnego dzieci do 3. roku życia

1Department of Anaesthesiology and Intensive Therapy, Children`s Memorial Health Institute in Warsaw, Poland 2Department of Paediatric Anaesthesiology and Intensive Therapy, Karol Marcinkowski University of Medical Sciences in Poznan, Poland 3Department of Paediatric Anaesthesiology and Intensive Therapy, University Hospital in Wroclaw, Poland 4Department of Anaesthesiology and Intensive Therapy, University Children Hospital in Cracow-Prokocim, Poland 5Department of Intensive Therapy and Anaesthesiology, Medical University in Łodz 6Department of Paediatric and neonatal Anaesthesiology and Intensive Therapy, Regional Medical Centre in Opole, Poland 7Department of Anaesthesiology, Intensive Therapy and Post-operative Care, University Children Hospital in Warsaw, Poland

Positive end-expiratory pressure during mechanical ventilation and noninvasive respiratory support in newborns and children

Positive end-expiratory pressure (PEEP) is used during non-invasive and invasive ventilation of newborns, infants and children. PEEP improves gas exchange by increasing the functional residual capacity, reduces the respiratory effort, lowers requirements for respiratory mixture oxygen, and enables to decrease the peak inspiratory pressure (PIP) without decreasing the mean airway pressure. Its effects on the cardiovascular system appear to be insignificant, particularly in patients with severe respiratory failure that is not accompanied by circulatory insufficiency. The value of PEEP enabling to provide the optimal conditions for improvement of gas exchange should be tailored individually for each patient under control of blood gas analysis, PIP and FiO₂. This strategy minimises ventilator-induced lung injury and prevents the development of circulatory failure associated with ventilation. Nasal continuous positive airway pressure (NCPAP) used with various PEEP values is a recognised treatment method of respiratory failure in newborns, especially in preterm infants.

Ascites in infants with severe sepsis - treatment with peritoneal drainage.

Background:  Ascites in neonates and infants is usually caused by cardiac failure and urinary or biliary tract obstruction. The objective of this study was to characterize our experience with ascites as a complication of sepsis.

Symptoms of hypovolemic shock during the induction of general anaesthesia in a patient with large vascular malformation--an adverse effect of propofol and sevoflurane?

BACKGROUND Venous malformations are the second most common congenital vessel anomaly. In our hospital, we conduct up to 30 sclerotherapies with 1-3% aethoxysclerol annually in children of all ages. The procedure is invasive and painful and therefore requires general anaesthesia. CASE REPORT A 16-year-old girl underwent sclerotherapy of a vast vascular malformation of her left leg, pelvis, abdominal cavity and thorax. After induction of general anaesthesia and positioning for the procedure, she presented with hypotonic shock with sinus tachycardia and sudden decrease in her ETCO₂. Her skin became pale and cold. The venous malformation became distended. The incident was caused by redistribution of the blood to the malformation, which is believed to have been triggered by the volatile anaesthetic. After discontinuation of the sevoflurane, modification of anaesthesia and the administration of ephedrine and fluids, hypotonia was successfully treated. The patients state was stabilised, her clinical measurements returned to normal, and the procedure was continued. Her later course was uneventful. Blood gas analysis in post-anaesthesia care unit revealed mild, compensated metabolic acidosis. No electrolyte abnormalities were present. CONCLUSION Volatile anaesthetics and propofol decrease the systemic vascular resistance and cause vasodilatation. Our patient presented with hypotonic shock due to the redistribution of blood to the dilated venous malformation, which developed after the use of standard concentration of sevoflurane. Intravenous anaesthetics were administered during induction and might have increased that effect. Although we found no similar reports, we believe that patients with vast venous malformations can experience such complications after the use of volatile anaesthetics, especially in high concentrations.

Unanticipated difficult airway management in children — the consensus statement of the Paediatric Anaesthesiology and Intensive Care Section and the Airway Management Section of the Polish Society of Anaesthesiology and Intensive Therapy and the Polish So

Tracheal intubation may be defined as an artificial airway established in order to provide mechanical ventilation of the lungs during surgical procedures under general anaesthesia, treatment in an intensive care unit, as well as in emergency situations. Difficulties encountered during intubation may cause hypoxia, hypoxic brain injury and, in extreme situations, may result in the patients death. There may be unanticipated and anticipated difficult airway. Children form a specific group of patients as there are significant differences in both anatomy and physiology. There are some limitations in equipment used for the airway management in children. There are only few paediatric difficult airway guidelines available, some of which have significant limitations. The presented algorithm was created by a group of specialists who represent the Polish Society of Anaesthesiology and Intensive Therapy, as well as the Polish Neonatology Society. This algorithm is intended for the unanticipated difficult airway in children and can be used in all age groups. It covers both elective intubation, as well as rescue techniques. A guide forms an integral part of the algorithm. It describes in detail all stages of the algorithm considering some modifications in a specific age group, e.g. neonates. The main aim of Stage I is to optimise conditions for face mask ventilation, laryngoscopy and intubation. Stage IIA focuses on maximising the chances of successful intubation when face mask ventilation is possible. Stage IIB outlines actions aimed at improving face mask ventilation. Stage IIIA describes the use of a SAD (Supraglottic Airway Device) during effective face mask ventilation or in a CICV (Cannot Intubate, Cannot Ventilate) situation. Stage IIIB outlines intubation through a SAD. Stage IV describes rescue techniques and outlines possible options of either proceeding with surgery or postponing it, depending on clinical situation.