Gijs D. Vos

Gut mucosal cell damage in meningococcal sepsis in children: relation with clinical outcome.

Objective:The pathophysiological sequelae of meningococcal sepsis are mainly caused by deregulated microvasculature function, leading to impaired tissue blood flow. Because mature enterocytes are known to be susceptible to altered perfusion, we aimed to investigate: (1) the development of enterocyte damage; and (2) the relation between enterocyte damage and severity of disease and outcome in children with meningococcal sepsis. Design:Retrospective human study. Setting:Pediatric intensive care unit at a university hospital. Patients:Nineteen consecutive children with meningococcal sepsis were studied during their pediatric intensive care unit stay. Interventions:None. Measurement and Main Results:Circulating levels of intestinal fatty acid binding protein, a small cytosolic protein constitutively present in mature enterocytes and released on cell injury, were assessed. Severity of disease was represented by meningococcal-specific Rotterdam Score, generic Pediatric Risk of Mortality II score, and circulating interleukin-6. Clinical outcome was measured by length of pediatric intensive care unit stay and number of ventilator days. Highest plasma intestinal fatty acid binding protein values were measured on pediatric intensive care unit stay admission. At the time of admission, eight of 19 patients had higher intestinal fatty acid binding protein plasma levels than the upper reference limit of 30 healthy volunteers. In all survivors, intestinal fatty acid binding protein levels declined to normal values within 12 hrs after starting intensive treatment, whereas the three nonsurvivors maintained elevated intestinal fatty acid binding protein plasma levels. A significant correlation was found among intestinal fatty acid binding protein and Rotterdam Score, Pediatric Risk of Mortality II, interleukin-6 at admission (Spearmans r2 = 0.402, p = .006; r2 = 0.243, p = .045; r2 = 0.687, p < .001, respectively). Next, a significant correlation was found between intestinal fatty acid binding protein and clinical outcome. Conclusions:Elevated plasma intestinal fatty acid binding protein is found in eight of 19 children with severe pediatric intensive care unit stay at the time of clinical presentation, suggesting the presence of enterocyte damage. Furthermore, prolonged enterocyte damage is found in nonsurvivors. Further studies are needed to clarify the potential role for assessment of plasma intestinal fatty acid binding protein in monitoring treatment of pediatric intensive care unit stay.

Treatment of respiratory failure due to respiratory syncytial virus pneumonia with natural surfactant

We describe two infants suffering from severe pneumonia caused by respiratory syncytial virus (RSV) infection and needing mechanical ventilation with both high ventilator settings and a high fraction of inspired oxygen. The severity of the respiratory failure and the possibility of decreased and/or altered surfactant production led us to treat these infants with intratracheal instillation of natural surfactant. This resulted in an improvement of lung compliance and a decrease in the amount of oxygen required to maintain acceptable oxygen saturations. Intratracheal surfactant instillation might, therefore, be useful in the treatment of severe RSV pneumonia. Pediatr Pulmonol 1996; 22:412–415.

Effect of perfluorochemical liquid ventilation on cardiac output and blood pressure variability in neonatal piglets with respiratory insufficiency

Respiration and mechanical ventilation induce cyclic variation in cardiac output and blood pressure. We examined these phasic hemodynamic influences of mechanical ventilation during gas ventilation and partial and tidal liquid ventilation in 7 anesthetized and paralyzed young piglets (body weight, 3.0–4.9 kg) made respiratory‐insufficient by repeated saline lung lavage. Nonlinear regression analysis of cardiovascular parameters vs. time was done to quantify respiratory‐induced fluctuations in hemodynamic variables. The amplitude of oscillations was expressed as a percentage of the mean hemodynamic variable during the study period, and was called the relative oscillation amplitude.

Problems in interhospital pediatric intensive care transport in The Netherlands: results from a survey of general pediatricians

ObjectiveInterhospital pediatric intensive care transport accompanied by non-trained specialists usually occurs with inadequate equipment and has been associated with high incidence of complications. These facts have serious consequences for patients but also can be very disconcerting for specialists. This survey was undertaken to gain insight into the problems encountered in organizing pediatric intensive care transport in The Netherlands to measure the specialists satisfaction or dissatisfaction with the current state of affairs in the organization of such transports, and additional workload and feelings of insecurity experienced during self-organized transports.DesignSurvey, retrospective.SettingA postal questionnaire sent to all pediatricians of community hospitals in The Netherlands.MethodsResults of direct questioning are given as discrete frequencies. After factor and reliability analysis 5-point Likert scale items are summed up in scale constructions. Relationships between scales are examined in regression analysis.ResultsPediatricians appear to be satisfied with current specialist retrieval teams if these teams are available in their region, and highly dissatisfied if not available. Many nontrained specialists consider these transports burdening tasks with a high workload, and they feel insecure during these transports, especially if they report lack of knowledge of the transport equipment.ConclusionsThe need for pediatric specialist retrieval teams in The Netherlands is seen not only in the insufficient level of care delivered by accompanying nontrained specialists and the reported high incidence of complications as shown in the literature but also in the dissatisfaction and high stress of these specialists.

Assessment of whole body protein metabolism in critically ill children: can we use the [15N]glycine single oral dose method?

BACKGROUND & AIMS Most stable-isotope methods to evaluate whole body protein metabolism in patients are invasive and difficult to use in children. In this study protein metabolism was evaluated with the non-invasive [15N]glycine single oral dose method in critically ill children and the value of the method is discussed. METHODS [15N]glycine (100mg) was given orally to children (mean age 5.5 years; range 0.6-15.5 years) with meningococcal septic shock (MSS, n = 8), pneumonia (n = 5), and to healthy, fed and post-absorptive children (n = 10). Urine was collected during 9h, total amount of NH(3), labelled NH(3) and nitrogen were measured, and protein turnover, synthesis and breakdown were calculated using urinary NH(3) as end-product. RESULTS Mean protein turnover in children with MSS, pneumonia and fed and post-absorptive healthy children was 0.63+/-0.13, 0.38+/-0.10, 0.28+/-0.03 and 0.28+/-0.02g N/kg/9h, respectively. Mean protein synthesis was 0.55+/-0.12, 0.29+/-0.09, 0.18+/-0.02, 0.20+/-0.02g N/kg/9h, respectively. Mean protein breakdown was 0.56+/-0.14, 0.28+/-0.12, 0.08+/-0.03, 0.28+/-0.02g N/kg/9h, respectively. Protein turnover, synthesis and breakdown were significantly increased in MSS patients compared to fed healthy children (P <0.01) and post-absorptive children (P <0.05). Protein turnover, protein synthesis, protein breakdown were significantly correlated with disease severity and body temperature (P <0.05). CONCLUSION Results of whole body protein metabolism measured with the [15N]glycine single oral dose method in children with MSS and in healthy children were in line with expectations based on results obtained in earlier reports and with different methods.

Evaluation of a non-invasive bladder volume measurement in children

Objective. Postoperative urinary retention (PUR) is associated with overdistension of the bladder. The prevention of PUR by routine catheterization may increase the risk of urinary tract infection. Postoperative monitoring of the bladder volume by ultrasound to prevent PUR is reliable in adults, but has not been evaluated in children. Material and methods. The BladderScan® BVI 6200, an ultrasound device specifically designed for children, was assessed. Forty patients who required urinary catheter placement during surgery or during intensive care unit stay were entered into this blinded calibration study. An assessment of bladder urine volume by ultrasound was performed before and after catheterization in surgical patients. In these patients and intensive care patients 0, 2.5 or 5 ml/kg sterile normal NaCl was injected through the bladder catheter and the catheter was clamped. Volumes estimated with ultrasound were compared with measured catheter drainage or/and injected volume after the scan. Results. The mean relative difference (bias) between the ultrasound estimate and the injected volume was −20% (95% confidence interval 140 to −180%). Precision, estimated using the Wilcoxon signed ranks test, showed a significant difference (Z=−3.25, p=0.001) between the ultrasound-estimated volumes and the injected volumes. Conclusions. This study could not confirm good agreement between the ultrasound-estimated volumes and the injected volumes at volumes below 5 ml/kg. Bladder volumes were underestimated with a very broad 95% confidence interval. The ultrasound device should not replace current clinical assessment.

Point-of-care blood analyzer during the interhospital transport of critically ill children

Objectives To investigate the influence of point-of-care laboratory results (arterial blood gases, ionized calcium, potassium, sodium, glucose, hematocrit and hemoglobin) on therapeutic interventions during interhospital pediatric intensive care transport. Design Prospective observational study. Settings Specialist pediatric intensive care retrieval team of a university hospital. Participants Critically ill pediatric patients who were referred from a community hospital to a pediatric intensive care of a tertiary center. The retrieval team sampled arterial blood during the time of stabilization in the referring hospital and during transport. All results were recorded and for each result the physician of the specialist retrieval team wrote down the influence on the treatment (none, partly, only). The physician specified the kind of intervention. Results Point-of-care blood analyses influenced the therapeutic management in 76.5% of all blood samples and in 86.2% of the referred patients. Of all interventions, 42.9% were based only on the laboratory results. The majority of interventions were adjustments of the mechanical ventilation. Point-of-care blood analyses reduced the delay in treatment of potentially life-threatening abnormalities of laboratory results (severe hypokalemia and low hematocrit). Conclusions During interhospital pediatric intensive care transport, point-of-care blood analyses frequently led to therapeutic interventions. Some abnormal blood results were potentially life threatening and could not have been discovered without point-of-care measurement. We therefore recommend the use of a point-of-care blood analyzer during interhospital intensive care transports, not only for blood gases but also for electrolytes, glucose and hematocrit.

High-Frequency Oscillatory Ventilation, Partial Liquid Ventilation, or Conventional Mechanical Ventilation in NewbornPiglets with Saline Lavage-Induced Acute Lung Injury

It has been reported that, in diseased lungs, either partial liquid ventilation (PLV) or high-frequency oscillatory ventilation (HFOV) can improve oxygenation better and with less lung injury than conventional mechanical ventilation (CMV). This study was intended as a preclinical comparison between the effects of HFOV, PLV and CMV on gas exchange, lung mechanics and histology. Fifteen anesthetized newborn piglets, with respiratory insufficiency due to repeated saline lung lavage, were allocated to either a PLV, HFOV or CMV (n = 5 each) strategy, and treated for 4 h. Within 30 min of commencing therapy, PLV, HFOV, and CMV improved arterial Po2 (Pa,o2), alveoloarterial oxygen gradient (P(A-a),o2), oxygenation index (OI), venous admixture (va), and arterial Pco2 (Pa,co2). After 4 h, oxygenation parameters (Pa,o2, P(A-a),o2, OI and venous admixture) were significantly better in the HFOV group than in the PLV group; the CMV group showed a higher Pa,o2 and lower OI than the PLV group. Gas exchange at the end of the experiment was not different from baseline in the HFOV and CMV groups. Lung histology and morphometry were performed after perfusion-fixation at endotracheal deflation pressure corresponding to mean airway pressure at the end of the experiment. Lung injury score and mean linear intercept were not different between the three treatment groups. We conclude that in this model, gas exchange improved significantly in all three ventilation strategies. Indices of oxygenation improved less during PLV. The saline lavage-induced acute lung injury model used as in this study, is less stable than previously thought. The final lung injury is not influenced by the ventilation strategy. We speculate that the impaired gas exchange during PLV is an expression of diffusion limitation and ventilation-perfusion mismatch in a recovering lung.

Congenitally short trachea with compression of the left mainstem bronchus: MRI findings.

Abstract The MRI features of congenitally short trachea in a patient presenting with respiratory distress are presented. Compression of the left mainstem bronchus by the aortic arch, a recognised complication of this anomaly, could be demonstrated by MRI, obviating the need for other imaging modalities.

Partial liquid ventilation (PLV) and high frequency oscillatory ventilation(HFOV) in piglets with saline lavage-induced acute lung injury: gas exchange and lung histology. ♦ 1489

Partial liquid ventilation (PLV) and high frequency oscillatory ventilation(HFOV) in piglets with saline lavage-induced acute lung injury: gas exchange and lung histology. ♦ 1489