Caterina Tomasello

Ultrasound-guided central venous cannulation in infants weighing less than 5 kilograms

Purpose Recent reports suggest that ultrasound-guided central venous cannulation may also be safe and effective in infants. This study aimed to evaluate the success and complications rate of this technique in infants weighing less than 5 kg. Methods We studied 45 infants, weighing less than 5 kg (mean weight: 2.9 ± 1.1 kg, median: 3.1) needing a central venous access for intensive care treatment. In all patients, venous access was obtained by ultrasound-guided cannulation of the internal jugular vein (IJV). Results Central venous cannulation was successful in all 45 infants. The right internal jugular vein (IJV) was used in most cases (92%). The IJV was antero-lateral to the carotid artery in 66% of patients, lateral in 28% and anterior in 6%. Although we recorded 10 complications (22.2%), only one was clinically relevant (one pneumothorax). The other complications were repeated venipunctures (n=4), kinking of the guidewire (n=3) and local venous hematomas (n=2). The time required for completing the procedure was 7 ± 4.3 min, while the mean time of central venous catheter permanence was 5.5 ± 8 days. There was a negative correlation between the patients weight and the time needed for cannulation (p<0.01). Complications occurred in infants with a lower body weight (p<0.01). Conclusions Our experience suggests that ultrasound-guided central vein cannulation can be performed by well-trained physicians in infants weighing less than 5 kg without relevant risks.

Scrambler Therapy® MC‐5A for Complex Regional Pain Syndrome: Case Reports

Complex regional pain syndrome (CRPS) is a disorder that is often challenging to treat and can be associated with a prolonged course of severe pain. Therapy of CRPS remains controversial; the pain often can be very difficult to control, and treatment includes medications, physical therapy, regional anesthesia, and neuromodulation.

Nationwide study of headache pain in Italy shows that pain assessment is still inadequate in paediatric emergency care

Italian national guidelines on pain management were published in 2010, but there is little information on how effective pain management is in paediatric emergency care, with other countries reporting poor levels. Using headache as an indicator, we described pain assessment in Italian emergency departments and identified predictors of algometric scale use.

Case 1: Chocolate-coloured blood in infant with shock (Case Presentation)

CASE PRESENTATION We report the case of a 6-month-old infant (body weight 6 kg), transferred to our intensive care unit (ICU) from a district general hospital with the diagnosis of septic shock. Upon arrival at our institution she was ventilated in a pressure-controlled mode reaching a peripheral Spo2 of 90% with a Fio2 of 100%, associated with a peripheral pallid cyanosis. Haemodynamic conditions were unstable: blood pressure 60/20 mmHg, heart rate 170 beats/min, refill capillary time >4 sec, reduced cardiac inotropic performance at trans-thoracic echocardiography without congenital anomaly. Neurologic examination showed a paediatric Glascow coma score (GCS) of 8, isocoric and isociclic pupils scarcely reacting to light bilaterally. Arterial blood gases showed a severe metabolic acidosis: pH: 7, Pao2, 218 mmHg, PaCo2, 14 mmHg, EB, −25. Blood haemoglobin was 9 g/L, leukocyte count 35 000/103 mcL, serum levels of sodium, potassium, calcium, phosphorus, urea, creatinine, liver enzymes, reactive C protein were within normal limits. A chest X-ray showed normal cardiac silhouette and clear lung fields. No signs of infections seemed to be present. Blood samples were brown coloured. After fluid administration of 20 mL/kg in 20 min of cristalloids and inotropic support (dopamine 10 g/kg/min) haemodynamic conditions progressively worsened leading to a cardiac arrest with asystolia. Cardiopulmonary resuscitation was successfully performed with a ROSC time of 100 sec. At this moment we were able to perform a better evaluation of patient’s clinical case history taken from the parents (they referred that the infant, previously healthy, progressively decreased her consciousness and that she was fed with a vegetable soup prepared in advance and stored in the refrigerator 2 days before admission to ICU). What caused her symptoms?

Scrambler therapy efficacy and safety for neuropathic pain correlated with chemotherapy-induced peripheral neuropathy in adolescents: A preliminary study

Chemotherapy‐induced peripheral neuropathy (CIPN) is a common side effect of chemotherapy, in need of effective treatment. Preliminary data support the efficacy of scrambler therapy (ST), a noninvasive cutaneous electrostimulation device, in adults with CIPN. We test the efficacy, safety, and durability of ST for neuropathic pain in adolescents with CIPN.

Case 1: Chocolate-coloured blood in infant with shock (Discussion and Diagnosis)

DISCUSSION The data presented and the clinical history of the infant are difficult to interpret in a situation of emergency, especially when there is a situation of haemodynamic instability of the patient. However some details led us to make diagnosis. A septic shock is almost unusual with a low level of reactive C protein and normal blood temperature, even in presence of high leukocyte count (35 000/103 mcL); at the same time, the age of the patient and her nutrition with a vegetable soup stored in the refrigerator and defrosted several times, the absence of a cyanotic heart disease and the brown-coloured blood samples, allowed us to suspect that we were dealing with a disorder of haemoglobin that was confirmed by a methemoglobinemia of 76% at co-oximetry. Methemoglobin, a derivative of haemoglobin in which the iron component has been oxidized from Fe 2+ to the Fe 3+ state, imparts a characteristic brownish colour to the blood. This molecule is unable to transport oxygen to tissues leading the patients to death if their blood percentage is over 70% (over 10 mg/dL) (1). Under physiologic conditions, methemoglobin reduction is accomplished primarily by red cell-reduced nicotinamide adenine dinucleotide reductase (NADH) so efficiently that there is <1% in the circulating blood. Hereditary methemoglobinemia is attributable either to deficiency of eritrocyte methemoglobin reductase or to the presence of one of the M-haemoglobins. Acquired methemoglobinemia is induced by oxidizing agents, particularly chlorates and inorganic and organic nitrites or by exposure to certain drugs or their metabolites (1,2). Infants less than 6 months are particularly susceptible to nitrate-induced methemoglobinemia because of low gastric pH inducing proliferation of large numbers of nitritereducing bacteria, the persistence of foetal haemoglobin until 3 months of age and immaturity of reduced NADH system (3,4). The most common sources of nitrate exposure in the paediatric field are well water with high nitrate concentrations, which is mixed in infant formula, consumption of some vegetables (spinach, carrots, squash, beets) with high nitrate concentrations and oxidant drugs intake. Furthermore nitrates and nitrites are often used as food preservatives because they inhibit the growth of Clostridium botulinum. Actually no information regarding the appropriate nitrate content in food is available for childhood. Anyway, a concentration of nitrate nitrogen <100 parts per million would be desirable below 3 months of age and some vegetables (carrots, spinach, squash, beets) should be avoided in this period (4). Our report shows how an alteration in the biochemical composition of some vegetables may occur in a soup prepared in advance, stored in a refrigerator and defrosted several times (3). This led to methemoglobin production and metabolic acidosis, probably as a consequence of the low oxygen-carrying capacity of blood to tissue. The instability of our patient’s health condition did not allow us to perform the correct diagnosis and treatment at arrival in the intensive care unit and only after having achieved stable haemodynamic condition, we were able to analyze the patient history and start the correct therapy with intravenous methylene blue (after having excluded Glucose-6-Phosphate Dehydrogenasy Deficiency) slowly administered at a dose of 1 mg/kg and repeated after 1 h, allowing the reduction of methemoglobinemia to less than 1%. Infant methemoglobinemia even if rare, should be suspected in all infants after having excluded a cyanotic heat disease or a lung disease. Diagnosis maybe sometimes difficult because arterial blood gases and pulse oximetry may be normal or near normal in cases of significant methemoglobinemia (MHb). When significant concentrations of methemoglobin are present (> 30%), the pulse oximeter is very misleading and will detect only mild-to-moderate oxygen desaturations because pulse oximeter light absorbance is at 660 nm and 940 nm. MHb absorbs light almost equally at both 660 nm