Daniela Perrotta

Relationship between global end-diastolic volume and cardiac output in critically ill infants and children

Objective:The objective of this study was to investigate possible correlations between the preload index global end-diastolic volume (GEDV) and the indexes of cardiac function, cardiac index, and stroke volume index in critically ill pediatric patients. The aim was to evaluate whether GEDV may help in the decision-making process concerning volume loading. Design:Prospective clinical study. Setting:Pediatric intensive care unit of the Bambino Gesù Children’s Research Hospital. Patients:Seventy patients, 40 male and 30 female, mean age 62 ± 41 months (range 5–156 months), divided into six groups: group A, hemorrhagic shock, ten cases; group B, head injury, 21 cases; group C, septic shock, ten cases; group D, encephalitis, ten cases; group E, respiratory failure, nine cases; group F, cardiogenic shock, ten cases. Interventions:All patients received volumetric hemodynamic monitoring following initial resuscitation and every 4 hrs thereafter or whenever a hemodynamic deterioration was suspected. During the cumulative in-hospital stay, a total 1,184 sets of measurements were done. Measurements and Main Results:Findings are consistent with a statistically significant linear correlation of GEDV with cardiac index and stroke volume index in hemorrhagic shock (group A) (R2 = .647, p < .0001; R2 = .738, p < .0001) and cardiogenic shock (group F) (R2 = .645, p < .0001; R2 = .841, p < .0001). Conclusions:GEDV may potentially be a useful guide to treatment in preload-dependent conditions, such as hemorrhagic and cardiogenic shock. In the other groups where there is little relationship between preload and cardiac function indexes, the influence of non-preload-dependent mechanisms on cardiac output is certainly more significant.

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.

Independent lung ventilation in a newborn with asymmetric acute lung injury due to respiratory syncytial virus: A case report

IntroductionIndependent lung ventilation is a form of protective ventilation strategy used in adult asymmetric acute lung injury, where the application of conventional mechanical ventilation can produce ventilator-induced lung injury and ventilation-perfusion mismatch. Only a few experiences have been published on the use of independent lung ventilation in newborn patients.Case presentationWe present a case of independent lung ventilation in a 16-day-old infant of 3.5 kg body weight who had an asymmetric lung injury due to respiratory syncytial virus bronchiolitis. We used independent lung ventilation applying conventional protective pressure controlled ventilation to the less-compromised lung, with a respiratory frequency proportional to the age of the patient, and a pressure controlled high-frequency ventilation to the atelectatic lung. This was done because a single tube conventional ventilation protective strategy would have exposed the less-compromised lung to a high mean airways pressure. The target of independent lung ventilation is to provide adequate gas exchange at a safe mean airways pressure level and to expand the atelectatic lung. Independent lung ventilation was accomplished for 24 hours. Daily chest radiograph and gas exchange were used to evaluate the efficacy of independent lung ventilation. Extubation was performed after 48 hours of conventional single-tube mechanical ventilation following independent lung ventilation.ConclusionThis case report demonstrates the feasibility of independent lung ventilation with two separate tubes in neonates as a treatment of an asymmetric acute lung injury.

Air‐oxygen helmet–delivered continuous positive airway pressure to manage respiratory failure due to bronchiolitis

Sir, We read with great interest the work of Dr. Mayordomo-Colunga et al. (1) regarding the use of helmet-delivered CPAP (H-CPAP) with heliox to manage children with respiratory syncytial virus (RSV) bronchiolitis. Their experience shows the complementary effects of both heliox mixture and H-CPAP to decrease the work of breathing and improve the gas exchange in children. Heliox mixture (30% O2 ⁄70% He) is a well-known resource used to manage pulmonary obstructive disease, but we retain it less indicated in case of severe hypoxic respiratory failure, because of the poor oxygen content of the heliox mixture. Higher oxygen concentrations (40% O2 ⁄ 60% He) limit the benefits of helium (2). We report our experience with ‘air-oxygen’ H-CPAP in 15 term neonates (mean age: 17 ± 2 days; mean body weight: 3.45 ± 0.4 kg) with RSV bronchiolitis. Before starting H-CPAP, the patients presented a mean PaO2 ⁄ FiO2 ratio of 170 ± 15 and a mean PaCO2 of 58 ± 2 mmHg. Additional interventions before H-CPAP (aerosolized beta2 agonists, intravenous steroids, antibiotics) were not performed in this population. HCPAP was delivered by an adjustable O2-air flow-meter blender connected to the inspiratory port by a low-compliance biocompatible corrugated PVC tube (3,4). The expiratory port was connected to a selected spring-loaded, positive end-expiratory pressure (PEEP) valve (StarMed, Mirandola, Italy). For all the patients, the fresh gas-flow was set at 30 L ⁄ min to avoid CO2 re-breathing and PEEP was empirically set at 5 cm H2O for all the patients. Physiologic and respiratory parameters [heart rate (HR), respiratory rate (RR), PaO2 ⁄ FiO2 ratio and PaCO2] were collected at the patient admission in pediatric intensive care unit (PICU) and during the following 48 h of support with H-CPAP (Fig. 1). Wilcoxon signed-rank test was performed in order to evaluate the differences between the median admission values of PaO2 ⁄ FiO2, PaCO2, HR and RR without H-CPAP treatment and their respective values at 2, 6, 12 and at 48 h after the beginning of H-CPAP. A p value < 0.05 was considered to indicate a statistical significance. The comparison showed a statistically significant reduction in PaCO2, heart rate and respiratory rate (p < 0.001) and a statistically significant increase in PaO2 ⁄ FiO2 (p < 0.001) at all the evaluations. In our population, three (20%) neonates required a single bolus of midazolam (0.1 mg ⁄ kg) at the insertion of the helmet to reduce discomfort. Only two (13%) patients that presented a progressive deterioration of the gas exchange during H-CPAP because of recurrent apnoea were managed with intubation. No neonates developed skin breakdown, conjunctivitis or pneumothorax during the study period of 48 h. Even though this experience has several limitations – the selected population studied, the small number of patient included, the lack of a control group – air-oxygen H-CPAP seems to be feasible and effective in terms of gas-exchange improvement in patients with both hypoxic and hypercapnic respiratory failure. Further studies are needed to evaluate whether H-CPAP could be used to manage respiratory diseases different from bronchiolitis in neonates.

The first five years of neonatal and pediatric transports on extracorporeal membrane oxygenation in the center and south of Italy: The pediatric branch of the Italian “Rete Respira” network:

Introduction: Neonatal and pediatric ECMO is a high-risk procedure that should be performed only in expert centers. Children who are eligible for ECMO and are managed in hospitals without ECMO capabilities should be referred to the closest ECMO center before the severity of illness precludes safe conventional transport. When the clinical situation precludes safe conventional transport, ECMO should be provided on site with the patient transported on ECMO. Methods: We retrospectively reviewed our institutional database of all ECMO transports for neonatal and pediatric respiratory failure from February 2013 to February 2018. Results: Over the last 5 years, we provided 24 transports covering all requests from the center and south of Italy except for the islands. Of these transports, 20 were performed on ECMO and 4 without ECMO. No patient died during transportation. Five complications were reported only during the ECMO transports, and all of these were managed without compromising the patient’s safety. The preferred modes of transport were by ambulance (70%) and ambulance transported into the fixed wing aircraft (30%) for longer national distances. The survival to hospital discharge of the patients transported with ECMO was 75% among the neonatal transports and 83.3% among the pediatric transports. The survival to hospital discharge of the four patients transported without ECMO was 100% for both neonates and children. Conclusions: Neonatal and pediatric ECMO transports can be safely performed with a dedicated team that maintains stringent adherence to well-designed management protocols.

Neonatal Care in Labor and Delivery Room

The transition from a fetus to a newborn is the most complex physiologic adaptation that occurs in human experience.

Treatment of boric acid overdose in two infants with Continuous Venovenous Hemodialysis.

There is no agreement on the treatment of this intoxication, mainly depending on the lack of correlation between blood levels and clinical outcome. To date, no cases of boric acid intoxication treated with Continuous Venovenous Hemodialysis (CVVHD) has been reported, despite the good hemodynamic tolerance provided by this modality. We present two infants treated with CVVHD after accidental ingestion of boric-acid-saturated water to prepare milk formula. Case 1: Nine hours after accidental ingestion of 655 mg/ kg of boric acid, a 3-month infant showed moderate dehydration, prolonged capillary refi ll time, tachypnea, tachycardia, and oliguria, requiring intravenous fl uid therapy. No organ failure occurred. Case 2: A 40-day-old girl was accidentally fed with 3 consecutive meals containing a total of 2570 mg/kg of boric acid. Third ingestion induced vomiting. After admission at local hospital, she looked responsive, with moderate dehydration and acidosis and was treated with intravenous fl uids to induce forced diuresis. At admission in our hospital, she was irritable, tachycardic, with elevated blood pressure, normal hydration, and no evidence of organ failure. Patients ’ blood analysis and vital signs at admission in pediatric intensive care unit (PICU) are shown in Table 1. Normalization of arterial blood gas occurred approximately 9 hours after the fi rst determination in both cases. Even if in small children HD provides highest boric acid clearance, it induces hemodynamic instability. 3 Given the high clearance by diffusion of CVVHD and the better hemodynamic tolerance provided by this modality, CVVHD was started 14 and 21 hours after last ingestion, respectively, considering persistent oliguria in fi rst case and the elevated amount of boric acid ingested in both patients. A 6.5F, 7.5-cm double-lumen catheter was placed into jugular vein after intubation and sedation with Midazolam and Remifentanil. In case 1, CVVHD was performed with blood fl ow (Qb) of 50 ml/min and dialysate fl ow (Qd) of 2000 ml/h for 36 hours with an Aquarius ® CRRT monitor equipped with a 0.3-m 2 polysulfone fi lter (Aquamax ® HF03, Edwards Lifesciences S.A — St Prex — Switzerland); in case 2, it was performed with Qb 30 ml/min and Qd 600 ml/h for 38 hours, using a 0.2-m 2 AN69 fi lter (HF20 ® , Gambro Lundia AB, Sweden) with Prismafl ex ® CRRT monitor equipped with pediatric software (Gambro Lundia AB, Sweden). During CVVHD, hemodynamic function was stable, except for a bradycardia at the start of CVVHD in patient 1, which required its temporary interruption. No neurological or other sequelae were observed and patients were discharged from PICU 7 and 9 days after the admission, respectively. Effl uent dialysate was collected in the bags provided in the circuit. Bags were weighted and total volume (V) was derived. Boric acid concentration was determined by an inductively coupled plasma mass spectrometer (ELAN 6100 DRCII ICP-MS; Perkin-Elmer SCIEX Instruments, Concord, Ontario, Canada) equipped with a dynamic reaction cell, a quadrupole mass fi lter, cyclonic spray chamber with a concentric nebulizer, and AS 90plus auto-sampler (Perkin-Elmer). Calibration was performed by “ standard addition ” method. Standard solutions were prepared from 1000 mg of L-1 boron calibration standard (VWR International LTD.), by dilution with water containing the same amount of acids as the samples. CVVHD clearance was calculated as V * BAd/BAp, where V * BAd (boric acid in the effl uent dialysate) is mass removal and BAp is the time average plasma concentration derived from the preand post-CVVHD boric acid concentrations. After oral ingestion, boric acid is rapidly and completely absorbed reaching the highest concentrations in brain and liver 2 . More than 90% is excreted unchanged by the kidneys within 96 hours. 2,4 – 5