Emanuele Rossetti

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.

Non-invasive ventilation with balloon dilatation of severe subglottic stenosis in a 10-month infant

Dear Editors, We report the case of a 10-month infant who underwent II–III liver lobe split orthotopic transplantation (OLT), with congenital biliary atresia and Kasai portoenterostomy on his 75th day of life. In the following 10 pediatric intensive care unit (PICU) postorthotopic liver transplantation (OLT) days, he was still intubated (diameter 4,5 cuffed tube) and showed congestive pulmonary oedema, severe malnutrition, hypotonic status and a large abdomen hosting the graft, leading us to assess the diuretic therapy, early parenteral nutrition and enteral feeding. On the 11th and 13th days, we extubated him twice unsuccessfully: on both occasions, he rapidly started wheezing and developed hypercapnic respiratory failure, necessitating re-intubation. Fiber optic laryngoscopy (FOL) was decided upon, revealing a Myer–Cotton I subglottic stenosis (SGSI) (Fig. 1) [1]. The patient was once again extubated, and treatment consisting of non-invasive mask pressure support ventilation (NIV), corticosteroids and vasoconstrictors aerosol, endovenous corticosteroids and respiratory physiokinesis was initiated. One week later he was breathing spontaneously without respiratory efforts and complete enteral feeding; he was discharged to the ward on the 20th postoperative day. Unfortunately, a sudden intestinal occlusion occurred on the 24th postoperative day, and he underwent laparotomy: he was intubated using a smaller (diameter 3.5 mm), uncuffed tube that was removed after 18 h in the PICU. The patient was moved to the ward 4 days later. In the following 3 days expiratory efforts, tirage, wheezing and hypercapnic acidosis reappeared gradually, leading us to perform an emergency intubation with a 2,5-mm uncuffed tube through an evident very narrow SGSIII \1.0 cm of thickness (Fig. 1). He was admitted once again to the PICU and 12 h later we dilated the SGSIII using a progressive wider tube intubation from 2.5 to 4.0 of diameter. After 48 h of deep sedation to prevent vertical up-and-down movements of the tube through the lesion, the SGSIII was successfully treated by balloon dilation (BD) in the PICU [2]. With oxygen delivered by assisted mask ventilation (AV), a 7.0-mm angioplasty balloon catheter was inserted into the SGSIII under direct FOL; this was inflated with a pressure of 7 atm by using a 60-ml syringe with an attached pressure gauge until the patient’s SpO2 dropped to 90%, at which point the airway was reassessed using AV. During the following 5 days, NIV and medical therapy resulted in complete respiratory comfort, improved nutritional status and discharge of the patient to the ward. In selected SGS, NIV may represent a valuable tool to treat obstructive symptoms, improving the breathing pattern and reducing respiratory efforts in younger infants with severe upper airway obstruction [3, 4]. In our case, BD allowed controlled radial dilation with a minimal mucosal trauma, breaking the fibrin bridges inside the lesion and establishing a clear alternative to open surgery with acquired SGS in this infant. Our clinical practice did not prolong the infant’s length of stay in the PICU. Furthermore, according to the higher incidence of nosocomial pneumonia in tracheostomized patients and increased ward mortality in adult patients discharged from the ICU with tracheostomy [5], our approach may help avoid more potential complications in our pediatric patients. Studies in children are not yet available.

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.

Multimodal diaphragmatic monitoring in pediatric cardiac surgery

1. Bronco A, Pietrini D, Lamperti M, et al. Incidence of pain after craniotomy in children. Pediatr Anesth. 2014;24:781-787. 2. Rothera E, Chumas P, Liddington M, Russell J, Guruswamy V. Scalp blocks in nonsyndromic craniosynostosis surgery a retrospective case series review. Pediatr Anesth. 2014;24:894-895. 3. Pardey G, Grousson S, de Souza EP, Mottolese C, Dailler F, Duflo F. Levobupivacaine scalp nerve block in children. Pediatr Anesth. 2008; 18:271-272.

External cardiac massage in a fluid-overloaded infant: two-finger/two-thumb failure, one-hand chest compression effective resuscitation

SIR—Here we report a 10-day-old infant who was admitted in the pediatric intensive care unit (PICU) for fever, acidosis, dehydration, and respiratory failure. He received fluid replacement according to early goal-directed therapy parameters, vasoactive drug support, antimicrobial therapy, and oxygen via high flow nasal cannula promptly on PICU admission. Abdominal swelling ensued with acute renal failure, leading to emergency surgery which revealed a lifethreatening gangrenous appendicitis. In the first three postoperative days, the infant developed a multiple organ dysfunction due to gram negative bacterial translocation. He required ongoing inotropic drug support, prolonged invasive ventilation with an inspired fraction of oxygen 0.8 for acute respiratory distress syndrome (1). He was admitted to PICU at 3.5 kg of weight, but due to fluid overload, it rose to 5.2 kg by the 2nd postoperative day. Lactate elevation, hyperkalemia, and high level of serum creatinine made continuous renal replacement therapy (CRRT) essential to deal with capillary leak syndrome and acute respiratory distress syndrome (ARDS). Unfortunately, vascular access for dialysis took longer than usual and the child developed a mild hypothermia of 34°C. Slow CRRT by continuos veno-venous hemo-dialysis was initiated, but a sudden cardiac arrest occurred. Cardio-pulmonary resuscitation was performed immediately (2), and CRRT was put on standby. Despite our chest compressions with two-finger technique and then a two-thumb technique, we were not able to achieve adequate invasive systemic arterial pressure during the first two cycles of cardio-pulmonary resuscitation (4 min). There was no rhythm to defibrillate, nor extreme hyperkalemia, cardiac tamponade, or hypertensive pneumothorax. Then, we started pediatric one-hand technique chest compression and a systemic arterial waveform appeared, leading to sinus rhythm 1 min following this pediatric external cardiac massage technique. The infant was slowly rewarmed and CRRT could be started safety again. One week later, he was moved to the neonatology ward with spontaneous breathing, no kidney impairment, and no major neurologic lesion according to neurologic evaluation and encephalic ultrasound. We think this case report may be useful to all pediatric health care operators who face a cardiac arrest in a swollen infant: we were unable to compress the chest by two-finger or two-thumb technique because subcutaneous edema was very thick and stiff. Following the ineffective compressions, we observed a deep depression in the middle of the skin over the sternum. Hence, the pediatric one-hand technique allowed us to compress the whole middle area of the sternum to perform effective lifesaving external cardiac massage.

Percutaneous dilation tracheostomy by Melker cricothyrotomy set in PICU: retrospective evaluation of a new combined approach

well-defined external anatomical landmarks. The puncture of the sacrococcygeal ligament was also successful in every attempt and only during injection of the drug resistance was felt which was suggestive of decreased compliance and volume of sacral canal. Injection of contrast under fluoroscopic guidance can confirm the spread and anatomy but it is not routinely available, hence we were not able to perform. Ram Doo et al. (2) during fluoroscopic-guided injection of dye in the caudal space found an atypical pattern due to adhesions and fibrosis. Ultrasound guidance showed decreased volume of the sacral canal, and thus to avoid pressure injury to the nerves we abandoned the procedure. Whether local anesthetics will be effective in such a case is also a matter of debate because fibrosis of the caudal space and adjacent connective tissues can alter its action. A repeat spine MRI during follow-up in the postoperative period confirmed hyperechoic tissue in the caudal space suggestive of fibrosis (Figure 1) in the sacral canal. In conclusion, ultrasound-guided caudal block will be advantageous in patients with pelvic tumor where anatomy can be distorted. Caudal anesthesia after chemotherapy or radiotherapy in sacro-pelvic tumors has to be planned and considered carefully to prevent neurological injury and for a successful block.

Kikuchi-Fujimoto disease and life-threatening upper airway obstruction

1 Rekha A, Ravi A, Vijayaraghavan K. Paraganglioma neck – a neuroendocrine tumour revisited. Int J Angiol 2008; 17: 162– 165. 2 Colen TY, Mihm FG, Mason TP et al. Catecholamine-secreting paragangliomas: recent progress in diagnosis and perioperative management. Skull Base 2009; 19: 377–385. 3 Sinha R, Rewari V, Varma P et al. Successful use of C-Mac videolaryngoscope in a child with large parapharyngeal mass. Pediatr Anesth 2014; 24: 531–533.

Lung ultrasound assessment of influenza A(H1N1)-associated ARDS in a child with acute lymphoblastic leukemia outbreak undergoing extracorporeal membrane oxygenation.

1 Ibacache ME, Mu~ noz HR, Fuentes R et al. Dexmedetomidine-ketamine combination and caudal block for superficial lower abdominal and genital surgery in children. Pediatr Anesth 2015; 25: 499–505. 2 Bozdogan N, Sener M, Caliskan E et al. A combination of ketamine and dexmedetomidins sedation with caudal anesthesia during incarcerated inguinal hernia repair in three high-risk infants. Pediatr Anesth 2008; 18: 1009–1011. 3 McVey JD, Tobias JD. Dexmedetomidine and ketamine for sedation during spinal anesthesia in children. J Clin Anesth 2010; 22: 538–545. 4 Asadi P, Ghafouri HB, Yasinzadeh M et al. Ketamine and atropine for pediatric sedation. Pediatr Emerg Care 2013; 29: 136– 139. 5 Green SM, Roback MG, Krauss B; Emergency Department Ketamine Meta-analysis Study Group. Anticholinergics and ketamine sedation in children: a secondary analysis of atropine versus glycopyrrolate. Acad Emerg Med 2010; 17: 157–162.

Extracorporeal membrane oxygenation in a 10-year-old girl with macrophage activation syndrome

SIR—Macrophage activation syndrome (MAS) is a rare life-threatening disorder caused by uncontrolled proliferation and activation of macrophages and T-lymphocytes. Diagnosis is often difficult. We report a case of MAS in a 10-year-old girl who developed antipyretic resistant fever after undergoing Kirschner wire stabilization of a humerus fracture. Microbiology samples were sent and an early wide spectrum antibiotic therapy was started. Despite negative C-reactive protein and no developing microorganism, the patient continued to have fever and developed transaminase elevation (glutamic oxaloacetic transaminase 583 UIÆl, glutamicpyruvate transaminase 662 UIÆl), hepatomegaly, coagulopathy, hypofibrinogenemia (60 mgÆdl), thrombocytopenia (70 000 per mm), anemia (Hb 7.2 gÆdl), hyperferritinemia (4347 ngÆml), and hypertriglyceridemia (336 mgÆdl) over the next 6 days. The child was transferred to our third level pediatric hospital because of severe hypotension, hypoxemia, bilateral pleural effusion, and a reduced cardiac output (left ventricular ejection fraction <35%). Diuresis and creatinine values were still normal. Subsequently a cardiac arrest occurred and an effective cardiopulmonary resuscitation protocol was performed. She was given mechanical ventilation and inotropic support (dopamine 9 mcgÆkg per min, noradrenaline 0.4 mcgÆkg per min). We removed the Kirschner wire and sent it for microbiology studies. We performed a bone marrow biopsy to exclude the possibility of a MAS (1) diagnosis (Table 1). During the following 24 h, the patient developed bilateral interstitial pulmonary edema, elevated creatinine value (2 mgÆdl) and oliguria, and continuous renal replacement therapy (CRRT) was begun. In the first 24 h of ultrafiltration, the chest X-ray showed improvement. However, a 2nd cardiac arrest occurred. Despite continuous endovenous infusion of levosimendan, dopamine, and noradrenaline, a new transthoracic echocardiography showed ejection fraction lower than 20%. The lactate gap rose more than 0.75 mMÆh; the brain natriuretic peptide elevation was more than 4000 pgÆml, and the mixed venous oxygen saturation (SvO2) fell to <55%. In agreement with the cardiologist, the cardiovascular surgeons and parents, the patient underwent veno-arterial roller pump ECMO (2) through catheterization of the right jugular internal vein and common carotid artery (18 Fr catheters). The heparin infusion and the ventilator settings were delivered according to ELSO general guidelines for pediatric cardiac care (April 2009), and CRRT was continued. One day after ECMO was begun, wide spread hemophagocytic activity was reported on the bone marrow biopsy. A treatment protocol for MAS (30 mgÆkg per die of methylprednisolone) began, in accordance with HLH-2004: diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis (3). ECMO weaning was successful in 5 days. The immunosuppressive treatment was completed by oral cortisone therapy in <1 week. Both inotropic drugs and CRRT were titrated off in 3 days. Ninety-six hours of noninvasive full-face mask ventilation was effective to discharge the child from the PICU. The patient had no central neurologic complications or secondary renal impairment and began enteral feeding. The MAS is a pediatric disease with a high risk of mortality that shares clinical signs and diagnostic criteria with sepsis and multiple organ dysfunction syndromes. In our opinion, symptoms of sepsis should lead us to consider MAS as a possibility, when other bacteriological reasons do not apply. In this specific case, we could follow the current clinical practice in diagnosis and treatment for such hematologic nonmalignant disease, despite the evident delay in MAS diagnosis. According to the contemporary literature, ECMO has low indication in unknown etiology diseases, and Table 1 Diagnostic criteria for macrophage activation syndrome