Gideon Paret

The improving outcome of triplet pregnancies.

During the period 1975 to 1988, 78 triplet pregnancies that reached a gestational age greater than or equal to 20 weeks were treated in our department--a prevalence of 1/849 deliveries. A total of 69 (88%) of the pregnancies occurred after treatment with ovulation-induction agents. The most common complication of pregnancy was premature contractions. Elective cervical cerclage neither prolonged gestation nor decreased fetal loss. The mean gestational age at delivery was 33.2 weeks + 3.8 weeks and 86% of the patients were delivered of premature infants. The perinatal and neonatal mortality rates were 93/1000 and 51/1000, respectively. Our results show a higher proportion of low Apgar scores and respiratory disorders in the third vaginally delivered infants. Follow-up of very low birth weight infants revealed four infants (10.5%) with severe neurologic handicaps. Results of this study suggest that cesarean section is the preferred mode of delivery in triplet pregnancies. Maternal, fetal, and neonatal risks of triplet gestations are relatively low and compare favorably with recent reports on twin pregnancies.

Is propofol safe for procedural sedation in children? A prospective evaluation of propofol versus ketamine in pediatric critical care

ObjectivesTo compare propofol with ketamine sedation delivered by pediatric intensivists during painful procedures in the pediatric critical care department (PCCD). DesignProspective 15-month study. SettingAn 18-bed multidisciplinary, university-affiliated PCCD. InterventionsAll children were randomized to the propofol or ketamine protocol according to prescheduled procedure dates. Propofol was delivered by continuous infusion after a loading bolus dose and a minidose of lidocaine (PL). Ketamine was given as a bolus injection together with midazolam and fentanyl (KMF). Repeated bolus doses of both drugs were given to achieve the desired level of anesthesia. The studied variables included procedures performed, anesthetic drug doses, procedure and recovery durations, and side effect occurrence. The patient’s parents, PCCD nurse and resident physician, pediatric intensivist, and the physician performing the procedure graded the adequacy of anesthesia. Measurements and Main ResultsOf the 105 procedures in 98 children, PL sedation was used in 58 procedures, and KMF was used in 47. Recovery time was 23 mins for PL and 50 mins for KMF, and total PCCD monitoring was 43 mins for PL and 70 mins for KMF. Five children (10.6%) in the KMF group and in none in the PL group experienced discomfort during emergence from sedation. Transient decreases in blood pressure, partial airway obstruction, and apnea were more frequent in the PL than in the KMF sedation. All procedures were successfully completed, and no child recalled undergoing the procedure. The overall sedation adequacy score was 97% for PL and 92% for KMF (p < .05). ConclusionsBoth PL and KMF anesthesia are effective in optimizing comfort in children undergoing painful procedures. PL scored better by all evaluators, recovery from PL anesthesia after procedural sedation was more rapid, total PCCD stay was shorter with PL, and emergence from PL was smoother than with KMF. Because transient respiratory depression and hypotension are associated with PL, it is considered safe only in a monitored environment (e.g., a PCCD).

The role of dextromethorphan in pain control

Purpose: To review the clinical benefits of dextromethorphan (DM) in pain management, describe its neuropharmacological properties.Source: A Medline search was made for experimental and clinical data on DM use from 1967 to date using keywordsnociception, acute and chronic pain control, N-methyl-D-aspartate, antagonists, dextromethorphan.Principle findings: The 930 DM citations mostly described its antitussive, metabolic and toxicological aspects, animal studies and its possible role in minimizing post-brain ischemia complications in humans. The use of DM inacute pain revealed eight original studies involving 443 patients, as well as two preliminary reports and our own unpublished data on 513 patients. Most of the 956 patients had general anesthesia. Eight studies (154 patients) and one case report dealt withchronic pain management. This N-methyl-D-aspartate (NMDA) receptor antagonist binds to receptor sites in the spinal cord and central nervous system, thereby blocking the generation of central acute and chronic pain sensations arising from peripheral nociceptive stimuli and enabling reduction in the amount of analgesics required for pain control. DM attenuated the sensation ofacute pain at doses of 30–90 mg, without major side effects, and reduced the amount of analgesics in 73% of the postoperative DM-treated patients. Studies in secondary pain models in healthy volunteers and in various types ofchronic pain showed DM to be associated with unsatisfactory pain relief.Conclusion: DM attenuatesacute pain sensation with tolerable side effects. Its availability in oral form bestow advantages over other NMDA antagonists.RésuméObjectif: Passer en revue les bénéfices cliniques du dextrométhorphane (DM) et décrire ses propriétés neuropharmacologiques.Source: Une recherche dans Medline a fourni des données expérimentales et cliniques sur le DM, utilisé de 1967 à aujourd’hui, à l’aide des mots-clésnociception, soulagement de la douleur aiguë et chronique, N-méthyl-D-aspartate, antagonistes, dextrométhorphane.Constations principales: Les 930 références trouvées décrivent surtout les aspects antitussifs, métaboliques et toxicologiques du DM, les études sur des animaux et le rôle possible dans la réduction des complications de l’ischémie cérébrale chez l’humain. Huit études originales auprès de 443 patients, deux rapports préliminaires et nos propres données non publiées sur 513 patients concernent le soulagement de la douleuraiguë. La majorité des 956 patients ont eu une anesthésie générale. Huit études (154 patients) et une observation portent sur le traitement de la douleurchronique. Cet antagoniste des récepteurs N-méthyl-D-aspartate (NMDA) se fixe sur les sites récepteurs dans la moelle épinière et le système nerveux central. Il empêche ainsi la propagation centrale des sensations de douleurs aiguës et chroniques provenant de stimuli nociceptifs périphériques, et contribue à la réduction de la quantité d’analgésiques nécessaires au traitement. Des doses de 30–90 mg de DM atténuent la sensation de douleuraiguë, sans produire d’effets secondaires importants, et permettent de réduire la quantité d’analgésiques chez 73 % des patients traités avec du DM après une intervention chirurgicale. Les études de modèles de douleurs secondaires chez des volontaires sains et de différents types de douleurschroniques, ont révélé que le DM n’apporte pas de soulagement de la douleur satisfaisant.Conclusion: Le DM atténue la sensation de douleuraiguë et présente des effets secondaires acceptables. Son conditionnement sous forme orale lui confère des avantages sur d’autres antagonistes de NMDA.

Local application of honey for treatment of neonatal postoperative wound infection

Honey has been described in ancient and modern medicine as being effective in the healing of various infected wounds. In this report we present our experience in nine infants with large, open, infected wounds that failed to heal with conventional treatment. Conventional treatment was defined as having failed if after ≥14 d of intravenous antibiotic and cleaning the wound with chlorhexidine 0.05% W/V in aqueous solution and fusidic acid ointment the wound was still open, oozing pus, and swab cultures were positive. All infants showed marked clinical improvement after 5d of treatment with topical application of 5–10 ml of fresh unprocessed honey twice daily. The wounds were closed, clean and sterile in all infants after 21 d of honey application. There were no adverse reactions to the treatment. We conclude that honey is useful in the treatment of post‐surgical wounds that are infected and do not respond to conventional systemic and local antibiotic treatment.

Terlipressin as rescue therapy for intractable hypotension due to septic shock in children.

Intractable hypotension due to septic shock is associated with high mortality rates in critically ill children worldwide. The use of terlipressin (triglycyl-lysine-vasopressin), an analog of vasopressin with a longer duration of action, recently emerged as a treatment of hypotension not responsive to vasopressors and inotropes. This was a retrospective study set in an 18-bed pediatric critical care department in a tertiary care children’s hospital. We reviewed the files of all children with septic shock who were treated with terlipressin between January 2003 and February 2004. Fourteen children (mean age, 5.6 years; range, 4 days to 17.7 years) were treated with terlipressin in 16 septic shock episodes. Significant improvements in respiratory and hemodynamic indices were noted shortly after treatment. Mean arterial blood pressure increased significantly from 54 ± 3 to 72 ± 5 mmHg 10 min after terlipressin administration (P = 0.001). Heart rate decreased from 153.0 ± 6.5 beats/min to 138.0 ± 7.5 beats/min 12 h after treatment onset (P = 0.003). Epinephrine infusion was decreased or stopped in eight patients after terlipressin administration. Urine output increased from 1.6 ± 0.5 mL/kg/h to 4.3 ± 1.2 mL/kg/h 1 h after treatment onset (P = 0.011). PaO2 increased from 95.1 ± 12.3 mmHg to 110.1 ± 20.5 mmHg, and the oxygenation index decreased from 10.2 ± 2.2 to 9.2 ± 1.7. Terlipressin treatment of hypotension due to septic shock was successful in eight out of 16 episodes. Six of the 14 patients with poor prognosis for survival recovered. We conclude that terlipressin improves hemodynamic indices and renal function in critically ill children. Terlipressin should be considered as a rescue therapy in intractable shock not responsive to catecholamines in children.

Repeat computed tomographic scan within 24-48 hours of admission in children with moderate and severe head trauma.

Objective: To asses the yield and contribution of a routine predetermined repeat head computed tomographic (CT) scan within 24‐36 hrs in pediatric patients with moderate to severe head trauma. Design: Records review. Setting: Five pediatric intensive care units. Patients: We reviewed the charts of 173 consecutive pediatric patients with moderate to severe head trauma (Glasgow Coma Scale score of ≤ 11) that survived the first 24 hrs after being admitted to five Israeli trauma centers. Clinical data collected included status at admission, at the time between the first and second CT scans, and after the second scan. Head details of the first, second, and, if performed, third CT scan were collected. Treatment strategy during each period was recorded, including any change in treatment after each CT scan. Measurements and Main Results: A total of 47 (27%) of the second CT scans showed new lesions including six intracranial hemorrhages, 17 cases of worsening brain edema, and 18 newly diagnosed brain contusions. However, none of these findings necessitated surgical intervention or any change in therapy. Of the 67 patients who underwent a third CT scan, two cases required surgical intervention because of new findings in the third CT. Conclusions: A second routine prescheduled head CT scan within 24‐36 hrs after admission in pediatric patients with moderate to severe head trauma is unlikely to yield any change in therapy. Clinically and intracranial pressure‐oriented CT scan may better select and diagnose patients who require changes in therapy, including surgery. Studies aimed to determine the ideal timing for the second are warranted.

Retropharyngeal and parapharyngeal abscess in children--epidemiology, clinical features and treatment.

OBJECTIVE To describe the clinical presentation, diagnosis, management and complications of children with retropharyngeal abscesses (RPAs) and parapharyngeal abscesses (PPAs). METHODS A retrospective chart review was conducted at two tertiary care, pediatric hospitals in Israel. The medical records of all children <18 years who had been admitted with a diagnosis of RPA or PPA during an 11-year period (January 1997 to February 2008) were reviewed. Data on demographics, presenting symptoms, physical examination findings, imaging studies and interpretation, laboratory results, hospital course, medical treatment and surgical interventions were retrieved. RESULTS A total of 39 children were diagnosed as having RPA (n=26, 67%) or PPA (n=13, 33%). There was a predominance of boys (61.5%). The mean age of all the children at diagnosis was 4 years. The annual incidence increased over the 11-year period. The most common symptoms at presentation included fever (n=27, 70%) and neck pain (n=24, 62%). The physical examination revealed cervical lymphadenopathy in 30 children (77%), limitation of neck movements in 25 (64%), torticollis in 21 (54%), drooling in three (8%), and stridor in two (5%). Computerized tomographic (CT) scanning with contrast was performed in 37 patients (95%), of whom 17 underwent surgical drainage. Thirteen children were positively diagnosed as having an abscess by the finding of pus at surgery, of whom 12 had been found to have an abscess on their CT scan. All the patients received intravenous antibiotics. There was no significant difference in the duration of hospital stay between those who underwent surgery and those who were treated with antibiotics alone. There were no treatment failures and no complications in either of the two groups. CONCLUSION Children with RPA most commonly present with restricted neck movements, fever and cervical lymphadenopathy, and rarely with respiratory distress or stridor. Many patients with RPA and PPA can be treated successfully without surgery. CT scans are helpful in diagnosing and assessing the extent of the infection, but they are not always accurate.

Beneficial effects of terlipressin in prolonged pediatric cardiopulmonary resuscitation: a case series.

Objective:Arginine vasopressin was found in experimental and clinical studies to have a beneficial effect in cardiopulmonary resuscitation. The American Heart Association 2000 guidelines recommended its use for adult ventricular fibrillation arrest, and the American Heart Association 2005 guidelines noted that it may replace the first or second epinephrine dose. There is little reported experience with arginine vasopressin in cardiopulmonary resuscitation of children. Terlipressin, a long-acting analog of arginine vasopressin, has recently emerged as a treatment for vasodilatory shock in both adults and in children, but evidence of its effectiveness in the pediatric setting is sparse. The objective of this retrospective study is to describe our experience in adding terlipressin to the conventional protocol in children with cardiac arrest. Design:Retrospective case series study. Setting:An 18-bed pediatric critical care department at a university-affiliated tertiary care childrens hospital. Patients:Seven pediatric patients with asystole, aged 2 months to 5 yrs, who experienced eight episodes of refractory cardiac arrest and did not respond to conventional therapy. Interventions:Addition of terlipressin to epinephrine during cardiopulmonary resuscitation of children. Measurements and Main Results:Return of spontaneous circulation was monitored and achieved in six out of eight episodes of cardiac arrest. One patient died 12 hrs after return of spontaneous circulation, and four patients survived to discharge with no neurologic sequelae. Conclusions:The combination of terlipressin to epinephrine during cardiopulmonary resuscitation may have a beneficial effect in children with cardiac arrest. More studies on this drugs safety and efficacy in this setting are mandated.

Transillumination of the palm for venipuncture in infants

Aim To assess the efficacy of transillumination of the palm of the hand in establishing venous access in small infants. Methods One hundred infants aged 2 to 36 months were considered for venipuncture under transillumination following failure to find an accessible vein or a failed venipuncture attempt. Results In 40 of the 100 infants, a vein was visible with transillumination. In 22 of these children, previous attempts to achieve a venous line failed (mean number of failed venipunctures 2.11 ± 0.6) and in 18 infants, no vein could be identified. Using transillumination, venous access was established with just one venipuncture in 39 of the 40 patients. Conclusions Transillumination of the palm can aid in establishing venous access in infants. This can be easily carried out using a common otoscope.

Terlipressin as rescue therapy for intractable hypotension during neonatal septic shock.

Objective To report the successful use of terlipressin in an 8-day-old infant for treatment of intractable hypotension caused by septic shock. Design Descriptive case report. Setting An 18-bed pediatric intensive care unit at a tertiary care children’s hospital. Patient An 8-day-old child with intractable hypotension due to septic shock after heart surgery. Interventions General supportive intensive care including mechanical ventilatory support, volume replacement, and inotropic support with dopamine 20 &mgr;g·kg−1·min−1, milrinone 0.75 &mgr;g·kg−1·min−1, and epinephrine 0.8 &mgr;g·kg−1·min−1. Measurements and Main Results Terlipressin (7 &mgr;g/kg per dose twice daily) was added as rescue therapy because of profound intractable hypotension. Shortly after the beginning of treatment, blood pressure and perfusion dramatically improved. Conclusions There is circumstantial evidence that the administration of terlipressin caused the increase in blood pressure. We suggest that terlipressin should be considered as rescue therapy when high-dose catecholamine therapy does not result in sufficient perfusion pressure. Further investigation is needed to prove terlipressin’s effectiveness and safety in infants and children.