Angela Amigoni

Brain Auditory Activation Measured by Near-Infrared Spectroscopy (NIRS) in Neonates

This study presents a new measure of the hemodynamic changes to an auditory stimulus in newborns. Nineteen newborns born at 28-41 wk and aged 1 to 49 d were studied in waking and/or sleeping state, for a median time of 4 min 40 s before, 2 min 40 s during, and 3 min 5 s after an acustic stimulus (tonal sweep of frequency increasing from 2 to 4 kHz, intensity 90 dB SPL) originating 5 cm from the external auditory meatus. The emitter and detector optodes were placed over the left or right temporal region, corresponding to T3 or T4 EEG electrodes. The concentration changes in cerebral chromophores Δ[HbO2], Δ[Hb] and Δoxidized-reduced cytochrome aa3 were recorded every 5 s. Changes in cerebral blood volume were calculated from the changes in total Hb × 0.89/large vessel Hb concentration. Increased oxyhemoglobin, Δ[HbO2], total Hb, Δ[Hb sum], and cerebral blood volume, ΔCBV, were found in 13/19 neonates, with the exception of a neonate who only had increased in Δ[Hb], Δ[Hb sum] and ΔCBV. During the stimulation phase there was a significant increase in ΔCBV (t test, p = 0.00006) in the responsive newborns from a mean value of 0.006 (±0.02) mL/100 g in the pretest phase to 0.09 (±0.06) mL/100 g during the auditory stimulus. After the test ΔCBV decreased to 0.04 (±0.07) mL/100 g (t test, p = 0.01), so did Δ[Hb sum] (p = 0.02). Hemodynamic responses of the subjects who showed increases in Δ[Hb sum] and Δ[HbO2] were analyzed to study the Δ[Hb]. The responder subjects could be classified into two groups according to Δ[Hb] changes: 8/13 (61.5%) showed an increase of Δ[Hb] (pattern A), while 5/13 (38.4%) showed a decrease (pattern B) (t test, p = 0.03). These two patterns did not show differences related to Δ[HbO2] and Δ[Hb sum]. The ΔCBV changes in nonresponders presented a decrease during the test phase (t test, p = 0.04). CBV did not return to pretest values, suggesting a fronto-temporal brain pathway for storing unusual sounds. The increase in CBV followed the local increase in oxyhemoglobin and total Hb concentrations due to a greater use of oxygen in the homolateral temporal cortex of the newborns.

Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report.

Objective Administering medication to hospitalised infants and children is a complex process at high risk of error. Failure mode and effect analysis (FMEA) is a proactive tool used to analyse risks, identify failures before they happen and prioritise remedial measures. To examine the hazards associated with the process of drug delivery to children, we performed a proactive risk-assessment analysis. Design and setting Five multidisciplinary teams, representing different divisions of the paediatric department at Padua University Hospital, were trained to analyse the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure and plan changes in practices. Primary outcome To identify higher-priority potential failure modes as defined by RPNs and planning changes in clinical practice to reduce the risk of patients harm and improve safety in the process of medication use in children. Results In all, 37 higher-priority potential failure modes and 71 associated causes and effects were identified. The highest RPNs related (>48) mainly to errors in calculating drug doses and concentrations. Many of these failure modes were found in all the five units, suggesting the presence of common targets for improvement, particularly in enhancing the safety of prescription and preparation of endovenous drugs. The introductions of new activities in the revised process of administering drugs allowed reducing the high-risk failure modes of 60%. Conclusions FMEA is an effective proactive risk-assessment tool useful to aid multidisciplinary groups in understanding a process care and identifying errors that may occur, prioritising remedial interventions and possibly enhancing the safety of drug delivery in children.

The Importance of Mortality Risk Assessment: Validation of the Pediatric Index of Mortality 3 Score.

Objective: To evaluate the performance of the newest version of the Pediatric Index of Mortality 3 score and compare it with the Pediatric Index of Mortality 2 in a multicenter national cohort of children admitted to PICU. Design: Retrospective, prospective cohort study. Setting: Seventeen Italian PICUs. Patients: All children 0 to 15 years old admitted in PICU from January 2010 to October 2014. Interventions: None. Measurement and Main Results: Eleven thousand one hundred nine children were enrolled in the study. The mean Pediatric Index of Mortality 2 and 3 values of 4.9 and 3.9, respectively, differed significantly (p < 0.05). Overall mortality rate was 3.9%, and the standardized mortality ratio was 0.80 for Pediatric Index of Mortality 2 and 0.98 for Pediatric Index of Mortality 3 (p < 0.05). The area under the curve of the receiver operating characteristic curves was similar for Pediatric Index of Mortality 2 and Pediatric Index of Mortality 3. The Hosmer-Lemeshow test was not significant for Pediatric Index of Mortality 3 (p = 0.21) but was highly significant for Pediatric Index of Mortality 2 (p < 0.001), which overestimated death mainly in high-risk categories. Conclusions: Mortality indices require validation in each country where it is used. The new Pediatric Index of Mortality 3 score performed well in an Italian population. Both calibration and discrimination were appropriate, and the score more accurately predicted the mortality risk than Pediatric Index of Mortality 2.

Four-side near-infrared spectroscopy measured in a paediatric population during surgery for congenital heart disease.

In this study we monitored renal, hepatic and muscular oxygen saturations by near-infrared spectroscopy and we evaluated the correlation with variables that could affect tissue oxygenation in 16 paediatric patients during surgical heart procedure. We considered the following phases: 1) basal time (after induction of anaesthesia and before median sternotomy), 2) before starting cardiopulmonary bypass, 3) 15 min after starting it, 4) at half time, 5) 15 min before the end, 6) at the end, 7) 15 min after the end, and 8) 10 min before paediatric intensive care unit admission. Heart rate, mean arterial pressure, peripheral oxygen saturation, serum lactate, haemoglobin, blood gas analysis, and rectal temperature were registered. We found a decrease of all monitored regional saturations (rSO(2)) (cerebral P = 0.006, hepatic P = 0.005) before starting the bypass. After this time, cerebral saturation gradually increased without reaching the basal value; renal and liver saturations increased after starting bypass; muscular rSO(2) increased in the second half (P = 0.005). A statistically significative inverse correlation between cerebral rSO(2) and pH was observed. In conclusion, during paediatric heart surgery a vulnerable period was identified. We underline the necessity to monitor this phase.

Successful use of inhaled nitric oxide in a child with fat embolism syndrome.

Posttraumatic fat embolism syndrome (FES) is a severe complication occurring more frequently in adult population, after long bone or pelvic fracture. Classical clinical signs (respiratory failure, neurologic dysfunction, and petechial rash 12–72 hours after bone trauma) are rarely entirely found1; biological tests (fat globules in blood and urine, high serum lipase, thrombocytopenia, and disseminated intravascular coagulation) have demonstrated poor sensitivity and specificity.2 Bronchoalveolar lavage cellular analysis, performed within the first 3 days after injury, has been proposed as suggestive of FES if percentage of lipid-laden cells is above 30%.2 Pathophysiology of FES is not well understood. Pulmonary failure seems to be caused by massive fat embolization (mechanical theory) that leads to vascular obstruction and intravascular coagulation.3,4 According to biochemical theory, free fatty acids (converted from triglycerides by circulating lipoprotein lipase) can directly damage both pneumocytes and alveolar architecture, whereas hypoxic-induced endothelial lesion can cause liberation or modification of humoral mediators leading to acute changes of pulmonary vascular response.5 Many therapeutic strategies have been used to treat acute respiratory distress in FES: anticoagulation or antiplatelets aggregation agents, steroids, vasodilator agents, but no evidence-based effect was proven.6 We report a pediatric case of FES who showed a positive responsive to inhaled nitric oxide (INO) treatment.

Successful use of extracorporeal membrane oxygenation for severe interstitial lung disease in a child with dermatomyositis

Juvenile dermatomyositis (JDM) is a multisystemic disease of children that affects primarily muscle and skin. The prevalence of pulmonary involvement is not well known but seems to be rarer than in adult patients with dermatomyositis/polymyositis (DM/PM) [1–3]. A wide spectrum of clinical presentations have been described, ranging from asymptomatic patients with merely abnormal pulmonary function tests [4] to severe, potentially fatal cases refractory to immunosuppressive and supportive therapy [5-9]. Here we present the case of a child with JDM and severe interstitial lung disease (ILD) successfully treated with immunosuppressive drugs and extracorporeal membrane oxygenation (ECMO).

Withdrawal Assessment Tool-1 Monitoring in PICU: A Multicenter Study on Iatrogenic Withdrawal Syndrome.

Objectives: Withdrawal syndrome is an adverse reaction of analgesic and sedative therapy, with a reported occurrence rate between 17% and 57% in critically ill children. Although some factors related to the development of withdrawal syndrome have been identified, there is weak evidence for the effectiveness of preventive and therapeutic strategies. The main aim of this study was to evaluate the frequency of withdrawal syndrome in Italian PICUs, using a validated instrument. We also analyzed differences in patient characteristics, analgesic and sedative treatment, and patients’ outcome between patients with and without withdrawal syndrome. Design: Observational multicenter prospective study. Setting: Eight Italian PICUs belonging to the national PICU network Italian PICU network. Patients: One hundred thirteen patients, less than 18 years old, mechanically ventilated and treated with analgesic and sedative therapy for five or more days. They were admitted in PICU from November 2012 to May 2014. Interventions: Symptoms of withdrawal syndrome were monitored with Withdrawal Assessment Tool-1 scale. Measurements and Main Results: The occurrence rate of withdrawal syndrome was 64.6%. The following variables were significantly different between the patients who developed withdrawal syndrome and those who did not: type, duration, and cumulative dose of analgesic therapy; duration and cumulative dose of sedative therapy; clinical team judgment about analgesia and sedation’s difficulty; and duration of analgesic weaning, mechanical ventilation, and PICU stay. Multivariate logistic regression analysis revealed that patients receiving morphine as their primary analgesic were 83% less likely to develop withdrawal syndrome than those receiving fentanyl or remifentanil. Conclusions: Withdrawal syndrome was frequent in PICU patients, and patients with withdrawal syndrome had prolonged hospital treatment. We suggest adopting the lowest effective dose of analgesic and sedative drugs and frequent reevaluation of the need for continued use. Further studies are necessary to define common preventive and therapeutic strategies.

Failure mode and effective analysis ameliorate awareness of medical errors: a 4-year prospective observational study in critically ill children.

Errors in are estimated to occur with an incidence of 3.7–16.6% in hospitalized patients. The application of systems for detection of adverse events is becoming a widespread reality in healthcare. Incident reporting (IR) and failure mode and effective analysis (FMEA) are strategies widely used to detect errors, but no studies have combined them in the setting of a pediatric intensive care unit (PICU).

Children With Convulsive Epileptic Seizures Presenting to Padua Pediatric Emergency Department The First Retrospective Population-Based Descriptive Study in an Italian Health District

Convulsive epileptic seizures in children represent a common cause of admission to pediatric emergency department. Data about incidence, etiology, and outcome are still lacking in literature. We retrospectively reviewed medical records of children presenting to our pediatric emergency department with convulsive seizures during a 12-month period and collected their diagnoses over the following year. In all, 182 children met the inclusion criteria, for a total of 214 visits (1.2% of all attendances, n = 24 864). Seizures lasted less than 5 minutes in 76%, 5 to 30 minutes in 20%, 30 to 60 minutes in 2%, and over 60 minutes in 2% visits (“early,” “established,” “refractory,” convulsive status epilepticus, respectively). Incidence of “early” (seizure lasting 5-30 minutes) and “established” (seizure lasting 30-60 minutes) status epilepticus was 52/100 000/year and 7/100 000/year respectively. Most common causes were febrile seizures (56%) and remote symptomatic seizures (19%). Knowing the epidemiology of convulsive seizures in children is important to guide appropriate management and individualized follow-up.

Surfactants in Acute Respiratory Distress Syndrome in Infants and Children: Past, Present and Future

There is a lack of definitive data on the effective management of acute respiratory distress syndrome (ARDS) in infants and children. The development and validation of the Berlin definition (BD) for ARDS and the Pediatric Acute Lung Injury Consensus Conference (PALICC) recommendations in children represented a major advance in optimizing research and treatment, mainly due to the introduction of a severe ARDS category. Proposed reasons for the lack of consistent results with surfactants in children and infants compared with neonates include different causes, type of lung damage (direct or indirect), timing and mode of administration as well as the type of surfactant used. Secretory phospholipase A2 plays an important role in inflammation and possible dysfunction of surfactants in ARDS. Bronchoalveolar lavage (BAL) with normal saline and surfactant allows the removal of inhaled material, the recruitment of non-ventilating areas and the maintenance of the surfactant pool size. BAL with diluted surfactant allows rapid absorption of the surfactant at the air/liquid interface, which blocks the progression of pathological lung disease and in turn disrupts the inflammatory cycle. Importantly, it is now recognized that the type of surfactant, the time of administration and the method of administration could all play an important role in the management of ARDS, and there is evidence that surfactant is effective and well tolerated in children and infants with ARDS.