Fernando Stein

Infrared tympanic thermometry in the pediatric intensive care unit

ObjectivesTo determine the performance of two different commercially available, noncontact infrared tympanic thermometers in predicting core body temperature as measured by pulmonary artery catheters in pediatric intensive care unit (ICU) patients. The performance of the tympanic thermometers was compared with the performance of an indwelling rectal probe and digital axillary temperature determinations. DesignProspective, consecutive sample, unblinded study. SettingPediatric ICU of a tertiary care childrens hospital. PatientsTwenty patients requiring pulmonary artery catheter monitoring for clinical management. InterventionsTemperature measurements were made using each infrared tympanic thermometer unit in the core mode. These values were compared with simultaneously obtained pulmonary arterial, digital axillary, and rectal probe temperatures. Measurements and Main ResultsBias and variability of each method compared with the pulmonary arterial temperature were calculated. Bias did not vary with temperature measured or age of the patient. Indwelling rectal probes showed the least bias and variability and axillary temperature the most. Neither infrared tympanic thermometer had clinically important bias; one model had variability similar to that of the rectal probes, and the other model had significantly greater variability. ConclusionsIn a pediatric ICU population, rectal probes reflect core temperature better than axillary determinations and both infrared tympanic models estimated core body temperature better than digital axillary temperature. One of the tympanic systems (Thermoscan Pro-1 infrared tympanic thermometer) performed in a similar way to the indwelling rectal probes and may be used to estimate core temperature in situations where a pulmonary artery catheter is not in place. The other test tympanic system (First Temp) had greater variability than the rectal probes. (Crit Care Med 1993; 21:1181–1185)

Nosocomial Infections in the Pediatric Intensive Care Unit

Pediatric intensive care units have contributed considerably to the management of children with severe diseases and life-threatening conditions. The use of mechanical ventilation, invasive monitoring, and indwelling catheters increase the risk for nosocomial infection. Improving infection control practices and surveillance can significantly reduce the incidence of nosocomial infections.

Recurrent conjunctivitis as a presentation of munchausen syndrome by proxy

PURPOSE To report a case of Munchausen syndrome by proxy, which manifested as recurrent bilateral keratoconjunctivitis in an infant. DESIGN Interventional case report. INTERVENTION The patient underwent numerous diagnostic studies, including two endoscopies, skin biopsy, conjunctival pH measurement, and a skeletal survey. She underwent daily eye examinations until the corneal and conjunctival epithelial defects resolved. MAIN OUTCOME MEASURE Resolution of cutaneous, mucosal, corneal, and conjunctival epithelial defects. RESULTS A punch biopsy of the right postauricular area was performed, and pathology subsequently determined that the findings seemed to be the result of an exogenous injury. The conjunctival pH was 8.0, consistent with exposure to an exogenous, caustic agent. The acute ocular lesions resolved. CONCLUSIONS Munchausen syndrome by proxy can be seen with ophthalmic manifestations and should be considered in the differential diagnosis when ocular abnormalities cannot be explained after a thorough and methodical evaluation.

Management of postoperative chylopericardium in childhood.

1. Josephson ME, Kastor JA. Paroxysmal supraventricular tachycardia. Is the atrium a necessary link? Circulation 1976;54:430-435. 2. Miller JM, Rosenthal ME, Vasallo JA, Josephson ME. Atrioventricular nodal reentrant tachycardia: studies on upper and lower “common pathways”. Circulation 1987:75:930-940. 3. Ross DL, Johhson DC, Denniss AR, Cooper MJ, Richards DA, Uther JB. Curative surgery for atrioventricular junctional (“AV nodal”) reentrant tachycardia. JACC 1985,6:1383S1392. 4. Cox JL, Holman WL, Cain ME. Cryosurgical treatment of atrioventricular node reentrant tachy-

Barbiturates and hyperventilation during intracranial hypertension

OBJECTIVE The purpose of this study was to determine the effect of hyperventilation alone and hyperventilation plus barbiturate therapy on intracranial pressure, global and regional cerebral blood flow rates, cerebrovascular resistance, and cerebral perfusion pressure in adult dogs with and without intracranial hypertension induced by epidural balloon. DESIGN Prospective, randomized, controlled study. SETTING An animal laboratory of a university hospital. Four sequential global and regional cerebral blood flow determinations were made in each animal during monitoring of heart rate and systemic arterial pressure, during respiratory control and arterial blood gas monitoring, intracranial pressure monitoring, and with or without inflation of an epidural balloon catheter. SUBJECTS Acute mongrel dogs obtained from the Baylor Center for Comparative Medicine. Five groups of animals were studied. In group 1, the response to hyperventilation was assessed in dogs without increased intracranial pressure. In group 2, the response to hyperventilation was assessed in animals with acute intracranial hypertension. In group 3, the response to hyperventilation plus barbiturate therapy was assessed in dogs without increased intracranial pressure. In group 4, the response to hyperventilation plus barbiturate therapy was assessed in dogs with acute increased intracranial pressure. In group 5, a group of dogs with increased intracranial pressure was treated with neither hyperventilation nor barbiturates. INTERVENTIONS Hyperventilation, hyperventilation plus barbiturate therapy, or no interventions were studied in these experimental paradigms. MEASUREMENTS AND MAIN RESULTS The main outcome measures were changes in intracranial pressure and/or changes in regional or total cerebral blood flow. A significant decrease in intracranial pressure and cerebral blood flow rate was produced by hyperventilation alone in groups with intracranial hypertension. Combined hyperventilation and barbiturate therapy resulted in a significant further decrease in cerebral blood flow rate in animals with normal and increased intracranial pressure, but no greater decrease in intracranial pressure was seen compared with treatment with hyperventilation alone. Cerebral perfusion pressures remained normal despite significant decreases in cerebral blood flow rates. CONCLUSIONS These studies suggest that barbiturate administration in this model of intracranial hypertension was no more effective in reducing increased intracranial pressure than hyperventilation alone.

Respiratory system mechanics in patients receiving aerosolized ribavirin during mechanical ventilation for suspected respiratory syncytial viral infection.

Respiratory syncytial virus (RSV) is an important respiratory pathogen for infants. Aerosolized ribavirin (AR) has been used in mechanically ventilated (MV) patients with RSV bronchiolitis. The purpose of this study was to measure respiratory system mechanics (RSM) in pediatric patients requiring MV and receiving AR for suspected RSV. Patients were prospectively randomized to receive AR, either at a regular dose (RD) (6 g/300 mL over 18 hr/day) or a high dose (HD) (6 g/100 mL over 2 hr, three times a day). To measure changes in RSM, a passive exhalation technique was used before and after each dose of AR; time constant (tc) in s, resistance (Rrs) in cmH2O/mL/kg/s, and quasistatic compliance (Crs) in mL/cmH2O/kg were measured. Airway pressure and flow signals were obtained and analyzed using a pneumotachograph, a differential pressure transducer, and a computer interface. Statistical analysis was done by Mann‐Whitney and Wilcoxon rank tests.

A decade of pediatric tracheostomies: Indications, outcomes, and long-term prognosis

To define the mortality and long‐term outcomes of children undergoing tracheostomy.

Rectal-scalp temperature difference predicts brain death in children

When brain death in children occurs, commonly the scalp feels cold despite a normal core temperature. This phenomenon might reflect absent cerebral blood flow and metabolic activity. The authors, therefore, measured rectal-scalp temperature differences in critically ill comatose children to test the hypothesis that a particular temperature difference may correlate with clinical brain death. In a prospective cohort study set in a pediatric intensive care unit, rectal-scalp, rectal-abdomen, and rectal-mastoid temperatures in critically ill comatose children older than 18 months of age were measured before and during brain death evaluations. Twelve children were enrolled. Clinical criteria for brain death were met by seven patients, and five patients survived. All of the seven children who died had rectal-scalp temperature differences greater than 4 degrees C (mean = 6.7, range = 6.0-7.4) at the time of clinical brain death. No survivor had a rectal-scalp temperature difference of 4 degrees C at any time (mean = 3.4, range = 2.9-3.9). Rectal-scalp temperature differences of those who died and those who survived were significantly different at the P < 0.005 level. Rectal-abdomen and rectal-mastoid temperature differences did not correlate with clinical brain death or rectal-scalp temperature difference. In this preliminary study a rectal-scalp temperature difference of greater than 4 degrees C correlates with clinical criteria for brain death in children.

Device for extradural monitoring of intracranial pressure: technical note.

An ICP-monitoring device utilizing an extradural method is described. Clinical and laboratory use has shown it to be easily installed, safe, accurate, and reliable. It can be used with currently available transducers and monitoring equipment. It is hoped that this simple device will encourage the increased use of ICP monitoring.

Update on Prevention Efforts for Pneumonia Attributed Deaths in Children Under 5 Years of Age

Purpose of ReviewTo update the knowledge base and effectiveness of clinical interventions to prevent death from pneumonia.Recent FindingsIntegrated management, early identification of danger signs, appropriate care at the appropriate time, and the use of vaccines against respiratory diseases have proven to reduce mortality drastically.SummaryMost deaths in children less than 5 years of age are from pneumonia in resource-limited environments. Effective strategies such as early detection of signs of danger, access to appropriate care in a timely manner, appropriate antibiotics administered early on, the use of Kangaroo mother care, supplementation of zinc, vaccination and community interventions must to be considered in order to reduce the burden of childhood mortality due to respiratory diseases.