Asma Hamdi

High-frequency oscillatory ventilation in pediatric patients with acute respiratory failure.

Objective: To evaluate the effectiveness of high-frequency oscillatory ventilation (HFOV) in pediatric patients with acute respiratory failure, failing conventional ventilation. Design: A prospective, clinical study. Setting: Tertiary care pediatric intensive care unit. Patients: Twenty pediatric patients (ages 12 days to 5 yrs) with acute respiratory failure (pneumonia, 14; sepsis with acute respiratory distress syndrome, 3; pulmonary edema as a complication of upper airway obstruction, 2; salicylate intoxication with acute respiratory distress syndrome, 1), failing conventional ventilation (median alveolar-arterial oxygen difference [P(a-a)o2] 578 [489–624] torr, median oxygenation index 26 [21–32]. Interventions: HFOV was instituted after a median length of conventional ventilation of 15.5 (3.3–43.5) hrs. Measurements and Main Results: Ventilator settings, arterial blood gases, oxygenation index, and P(a-a)o2 were recorded before HFOV (0 hrs) and at predetermined intervals during HFOV and compared using the one-way Friedman rank-sum procedure and a two-tailed Wilcoxon matched-pairs test. Initiation of HFOV caused a significant decrease in Fio2 at 1 hr that continued to 24 hrs (p ≤ .04). In all patients, target ventilation was achieved, and 19 had improved oxygenation. After 1 hr, Paco2 significantly decreased (p = .002) and remained within the target range thereafter. There were significant decreases in P(a-a)o2 and oxygenation index at 1 and 4 hrs, respectively, that were sustained up to 12 hrs (p ≤ .04). No significant complications associated with HFOV were detected. Fifteen patients (75%) survived to hospital discharge. Only one patient died from respiratory failure. Conclusions: In pediatric patients with acute respiratory failure, failing conventional ventilation, HFOV improves gas exchange in a rapid and sustained fashion. However, randomized controlled trials are needed to identify its benefits over conventional modes of mechanical ventilation.

Findings of the International Nosocomial Infection Control Consortium (INICC), part III: effectiveness of a multidimensional infection control approach to reduce central line-associated bloodstream infections in the neonatal intensive care units of 4 developing countries.

OBJECTIVE To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach to reduce central line-associated bloodstream infection (CLABSI) rates. SETTING Four neonatal intensive care units (NICUs) of INICC member hospitals from El Salvador, Mexico, Philippines, and Tunisia. PATIENTS A total of 2,241 patients hospitalized in 4 NICUs for 40,045 bed-days. METHODS We conducted a before-after prospective surveillance study. During Phase 1 we performed active surveillance, and during phase 2 the INICC multidimensional infection control approach was implemented, including the following practices: (1) central line care bundle, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of CLABSI rates, and (6) performance feedback of infection control practices. We compared CLABSI rates obtained during the 2 phases. We calculated crude stratified rates, and, using random-effects Poisson regression to allow for clustering by ICU, we calculated the incidence rate ratio (IRR) for each follow-up time period compared with the 3-month baseline. RESULTS During phase 1 we recorded 2,105 CL-days, and during phase 2 we recorded 17,117 CL-days. After implementation of the multidimensional approach, the CLABSI rate decreased by 55%, from 21.4 per 1,000 CL-days during phase 1 to 9.7 per 1,000 CL-days during phase 2 (rate ratio, 0.45 [95% confidence interval, 0.33-0.63]). The IRR was 0.53 during the 4-12-month period and 0.07 during the final period of the study (more than 45 months). CONCLUSIONS Implementation of a multidimensional infection control approach was associated with a significant reduction in CLABSI rates in NICUs.

Épidémiologie des infections bactériennes nosocomiales dans une unité de réanimation néonatale et pédiatrique tunisienne

OBJECTIVE The authors had for aim to describe the epidemiology of nosocomial bacterial infections in the neonatal and pediatric intensive care unit of the Tunis childrens hospital. DESIGN A prospective surveillance study was made from January 2004 to December 2004. All patients remaining in the intensive care unit for more than 48 h were included. CDC criteria were applied for the diagnosis of nosocomial infections. RESULTS 340 patients including 249 (73%) neonates were included. 22 patients presented with 22 nosocomial bacterial infections. The incidence and the density incidence rates of nosocomial bacterial infections were 6.5% and 7.8 per 1,000 patient-days, respectively. Two types of infection were found: bloodstream infections (68.2%) and pneumonias (22.7%). Bloodstream infections had an incidence and a density incidence rate of 4.4% and 15.3 per 1,000 catheter-days, respectively. Pneumonia had an incidence and a density incidence rate of 2% and 4.4 per 1,000 mechanical ventilation-days, respectively. The most frequently isolated pathogens were Gram-negative bacteria (68%) with Klebsiella pneumoniae isolates accounting for 22.7%. The most common isolate in bloodstream infections was K. Pneumoniae (26.7%), which was multiple drug-resistant in 85% of the cases, followed by Staphylococcus aureus (20%). Pseudomonas aeruginosa was the most common isolate in pneumonia (28.6%). Associated factors of nosocomial infection were invasive devices and colonization with multiple drug-resistant Gram-negative bacteria. CONCLUSIONS The major type of nosocomial bacterial infections in our unit was bloodstream infection and the majority of infections resulted from Gram-negative bacteria. Factors associated with nosocomial bacterial infections were identified in our unit.

Datura stramonium L. poisoning in a geophagous child: a case report

Datura stramonium L. (DS) is a wild-growing plant widely distributed and easily accessible. It contains a variety of toxic anticholinergic alkaloids such as atropine, hyoscamine, and scopolamine. Voluntary or accidental ingestion can produce severe anticholinergic poisoning. We report an unusual case of DS intoxication occurring in a geophagous young child after accidental ingestion of the plant. Our case is original because of the young age of the victim and the underlying geophagia facilitating the occurrence of poisoning.

Lidocaine Toxicity Secondary to Local Anesthesia Administered in the Community for Elective Circumcision

We report three previously healthy infants aged, respectively, 23 days, 6 weeks, and 3 months with systemic lidocaine toxicity following administration of subcutaneous lidocaine for regional anesthesia during an elective circumcision. The patients developed a generalized seizure requiring endotracheal intubation but recovered fully with supportive care. We report the clinical details of these cases as well as a review of lidocaine toxicity.

Hepatorenal injury induced by cutaneous application of Atractylis gummifera L

Introduction. In Mediterranean countries, intoxication by Atractylis gummifera L. is frequent and characterized principally by hepatorenal injury, often fatal. Its toxicity after a cutaneous application is unknown. We report a case of poisoning by A. gummifera L. induced by repeated cutaneous application. Case report. A 30-month-old boy was admitted in our pediatric intensive care unit in coma (Glasgow Coma Scale 8). Investigations showed hepatic cellular injury, cholestasis, decreased prothrombin level, and increased creatinine. History from the parents revealed repeated and occlusive cutaneous application of A. gummifera L. on a skin burn. Qualitative analysis of urine confirmed the diagnosis of A. gummifera poisoning. The child was discharged after 16 days of hospitalization with residual renal insufficiency. Discussion. Poisoning by A. gummifera L. after cutaneous application has not previously been reported in the literature. The prevention of this poisoning, particularly frequent in Mediterranean countries, is mainly based on the education of the public concerning the dangers of this plant.

[Mortality rates in pediatric septic shock secondary to community-acquired infection: about 70 cases].

GOAL This study had for aim to determine the mortality rate and the factors affecting mortality among 70 children admitted for septic shock secondary to a community acquired infection. PATIENTS AND METHODS A retrospective analysis was made of patients admitted between January 1998 and August 2005, in a pediatric ICU for septic shock secondary to a community-acquired infection. Neonates under 7 days of age were excluded from the study. RESULTS Seventy cases were included and 32 (45.7 %) of them died. Their average age was 3.8+/-4.2 years and their PRISM during the first 24 hours was 19.2+/-8.4. Sixty-nine children (98.6 %) presented with multivisceral failure and 60 (85.7 %) with more than two deficient organs. The average time between the observation of first hemodynamic disorders and admission to ICU was 9.4+/-11.3 hours. Three independent mortality risk factors were identified: failure of more than two organs on admission (OR, 4.4; 95 % CI [2.1-9.4]), an infusion volume superior to 20ml/kg on the second day of resuscitation (OR, 3.4; 95 CI % [1.1-10.3]), and the use of more than two vasoactive drugs (OR, 3.3; 95 CI % [1.2-9]).

??pid??miologie des infections bact??riennes nosocomiales dans une unit?? de r??animation n??onatale et p??diatrique tunisienne

OBJECTIVE The authors had for aim to describe the epidemiology of nosocomial bacterial infections in the neonatal and pediatric intensive care unit of the Tunis childrens hospital. DESIGN A prospective surveillance study was made from January 2004 to December 2004. All patients remaining in the intensive care unit for more than 48 h were included. CDC criteria were applied for the diagnosis of nosocomial infections. RESULTS 340 patients including 249 (73%) neonates were included. 22 patients presented with 22 nosocomial bacterial infections. The incidence and the density incidence rates of nosocomial bacterial infections were 6.5% and 7.8 per 1,000 patient-days, respectively. Two types of infection were found: bloodstream infections (68.2%) and pneumonias (22.7%). Bloodstream infections had an incidence and a density incidence rate of 4.4% and 15.3 per 1,000 catheter-days, respectively. Pneumonia had an incidence and a density incidence rate of 2% and 4.4 per 1,000 mechanical ventilation-days, respectively. The most frequently isolated pathogens were Gram-negative bacteria (68%) with Klebsiella pneumoniae isolates accounting for 22.7%. The most common isolate in bloodstream infections was K. Pneumoniae (26.7%), which was multiple drug-resistant in 85% of the cases, followed by Staphylococcus aureus (20%). Pseudomonas aeruginosa was the most common isolate in pneumonia (28.6%). Associated factors of nosocomial infection were invasive devices and colonization with multiple drug-resistant Gram-negative bacteria. CONCLUSIONS The major type of nosocomial bacterial infections in our unit was bloodstream infection and the majority of infections resulted from Gram-negative bacteria. Factors associated with nosocomial bacterial infections were identified in our unit.

Predictors of Mortality in Mechanically Ventilated Critical Pertussis in a low Income Country

Background Critical pertussis is characterized by severe respiratory failure, important leukocytosis, pulmonary hypertension, septic shock and encephalopathy. Aim To describe the clinical course of critical pertussis, and identify predictors of death at the time of presentation for medical care. Methodology Retrospective study conducted in children’s hospital Tunisian PICU between 01 January and 31 October 2013. Patients with critical pertussis confirmed by RT-PCR and requiring mechanical ventilation were included. Predictors of death were studied. Results A total of 17 patients was studied. Median age was 50 days. Mortality was 23%. Predictors risk of mortality were : high PRISM score (Pediatric Risk of Mortality Score) (p=0,007), shock (p=0,002), tachycardia (p=0,005), seizures (p=0,006), altered mental status (p=0,006), elevated WBC count (p=0,003) and hemodynamic support (p=0022). However, the difference did not reach statistical significance in comorbidity, pneumoniae, high pulmonary hypertension or exchange transfusion. Concomitant viral or bacterial co-infection was not related to poor outcome. Conclusion Young infants are at high risk to have critical pertussis. Despite advances in life support and the treatment of organ failure in childhood critical illness, critical pertussis remains difficult to treat.

Toxic epidermal necrolysis complicated by small bowel intussusception: a case report

Intestinal involvement in toxic epidermal necrolysis (TEN) has been identified only rarely. We report a case of TEN complicated by small bowel intussusception. The patient was a previously healthy 8-year-old boy who presented with TEN and extensive lesions, including up to 40% of the body surface area as well as conjunctival, oropharyngeal, respiratory, and genital mucosa. Rapidly after the onset of a constant rate of enteral feeding, he developed bilious vomiting, diarrhea, and significant abdominal distension. Abdominal sonography showed a small bowel intussusception. At abdominal exploration, an ileoileal intussusception was observed with a viable but inflamed bowel wall. Manual reduction was performed. During the postoperative clinical course, the patient was managed with total parenteral nutrition and local care of the skin and mucous membranes. Enteral feeding was introduced on the sixth postoperative day, and the child left the hospital 15 days after his admission. The association of TEN and small bowel intussusception has not been previously reported in the literature.