Gregory L. Stidham

Alveolar-arterial oxygen gradient as a predictor of outcome in patients with nonneonatal pediatric respiratory failure

Although the mortality rate for acute respiratory failure has been estimated to be as high as 60%, predicting outcome is very difficult. 1 The alveolar-arterial oxygen gradient (A-aDo2) has become widely accepted as a predictor of outcome in the neonatal population; however, its value for assessing outcome in older children with respiratory failure remains unknown. 2-7 Additionally, few data are available to suggest other criteria for assessing outcome in older children with severe respiratory failure. With the development of unconventional techniques for the treatment of respiratory failure, the need for such criteria has become paramount. In an attempt to assess the value of the A-aDO2 as an early predictor of risk of death, we performed a 4-year analysis of all nonneonatal patients admitted to the pediatric intensive care unit with severe respiratory failure. METHODS

Novel therapies for acute respiratory failure.

Mortality in acute respiratory failure in the non-neonatal pediatric patient has not changed substantially in 20 years, despite advances and refinements in conventional therapeutic strategies and technology. A host of innovative therapies are currently in various stages of investigation, including high frequency ventilation, pressure control ventilation, permissive hypercapnia, extracorporeal membrane oxygenation, exogenous surfactant administration, inhaled nitric oxide, and liquid ventilation. While none of these therapies has yet been prospectively studied in non-neonatal pediatric patients, all show much promise by virtue of their emphasis on either directly addressing pathophysiologic derangements associated with acute respiratory failure or by reducing the complications associated with conventional therapy.

Paediatric cardiac assistance in developing and transitional countries: the impact of a fourteen year effort.

BACKGROUND Paediatric cardiac services are poorly developed or totally absent in underdeveloped countries. Institutions, foundations and interested individuals in those nations in which sophisticated paediatric cardiac surgery is practised have the ability to alleviate this problem by sponsoring paediatric cardio-surgical missions to provide care, and train local caregivers in developing, transitional, and third world countries. The ultimate benefit of such a programme is to improve the surgical abilities of the host institution. The purpose of this report is to present the impact of our programme over a period of 14 years. METHODS We specifically reviewed our database of patients from our missions, our team lists, surgical results, and the number and type of personnel trained in the institutions that we have assisted. In order for the institution to be entered into the study, the foundation had to provide at least 2 months of training. In addition, the institution had to respond to a simple questionnaire concerning the number and types of surgery performed at their facility before and after intervention by the foundation. RESULTS We made 140 trips to 27 institutions in 19 countries, with 12 of the visited institutions qualifying for inclusion. Of these, 9 institutions reported an increase in the number and complexity of cases currently being performed in their facility since the team intervened. This goal had not been accomplished in 3 institutions. The reasons for failure included the economic situation of the country, hospital and national politics, personality conflicts, and continued lack of hardware and disposables. CONCLUSIONS Paediatric cardiac service assistance can improve local services. A significant commitment is required by all parties involved.

Association between the inception of a SAFE KIDS Coalition and changes in pediatric unintentional injury rates

Objective: To assess the relationship between the implementation of a SAFE KIDS Coalition and pediatric unintentional injury rates. Setting: Shelby County, Tennessee. Design: Retrospective observational analysis. Patients: County residents nine years of age or younger presenting to the children’s medical center, its emergency department, or its outpatient clinics from 1990–97. Intervention: Implementation of a SAFE KIDS Coalition. Main outcome measures: Rates of unintentional injuries targeted by the SAFE KIDS Coalition that resulted in hospitalization or in death. Rates of motor vehicle occupant injuries that resulted in hospitalization or in death. Rates of non-targeted unintentional injuries, namely injuries secondary to animals and by exposure to toxic plants. Rates of severe injuries (defined as those targeted injuries that required hospitalization or resulted in death), and specifically, severe motor vehicle occupant injuries were compared before and after the inception of the coalition using Poisson regression analysis. Results: The relative risk of targeted severe injury rates decreased after implementation of the coalition even after controlling for changes in hospital admission rates. Specifically, severe motor vehicle occupant injury rates decreased 30% (relative risk 0.70; 95% confidence interval 0.54 to 0.89) after initiation of the coalition. Conclusions: The implementation of a SAFE KIDS Coalition was associated with a decrease in severe targeted injuries, most notably, severe motor vehicle occupant injuries. Although causality cannot be determined, these data suggest that the presence of a coalition may be associated with decreased severe unintentional injury rates.

Emergencies in international child health.

Emergencies in the pediatric populations of third world and developing countries are of a much different sort than those to which pediatricians in developing countries are familiar. Many of these emergencies derive from conditions, situations, and etiologies that no longer represent a threat to children in developed countries: malnutrition, immunizable illnesses, infectious diseases from pathogenes easily treated or prevented, urbanization, and armed conflict. Programs directed at improving basic public health, health education, access to basic health care, and immunization have been shown to have a major and positive impact on childrens health status in these countries. Because of the vastness of these health problems, a growing number of volunteer organizations offer opportunities for pediatricians to contribute to improvement and they have an impact on the health of children considerably less fortunate than those in developed countries.

Plasmapheresis for Guillain-Barré syndrome

Guillain-Barré syndrome is the most common cause of paralytic illness in children. An 8-month-old infant presented with severe Guillain-Barré syndrome associated with parainfluenza 3 infection, was treated with plasmapheresis, and had complete recovery. Plasmapheresis can be technically difficult to perform in small children and infants, but should be considered. Controlled trials should be performed to determine the indications for plasmapheresis in children with Guillain-Barré syndrome.