Hans Stannigel

Efficacy and outcome of intensive care in pediatric oncologic patients.

Objective Because the long-term survival of children with cancer has dramatically improved because of multimodal treatment strategies, intensive care medicine has become more relevant for these patients. This study was performed to assess the efficacy of intensive care medicine in newly diagnosed pediatric oncologic patients and in patients under ongoing oncologic treatment. Design A retrospective analysis of children admitted to the pediatric intensive care unit (PICU) of the University Hospital Duesseldorf for life-threatening conditions between 1995 and 1999 was performed to identify those patients with an oncologic condition. Setting University hospital. Patients A total of 123 patients were identified. Children admitted for uncomplicated postoperative care and children admitted after bone marrow transplantation were excluded from this analysis. Forty-eight patients could be divided into two groups. Group A contained children admitted to the PICU at the time of cancer diagnosis and group B children receiving ongoing oncologic treatment. Interventions The evaluation included diagnosis, risk factors, complications leading to PICU admission, PICU therapy, and outcome. Statistical analysis included evaluation of Pediatric Risk of Mortality (PRISM) and Therapeutic Intervention Scoring System (TISS) scores. Measurements and Main Results Respiratory insufficiency was the leading diagnosis for PICU admission, whereas in the remaining children cardiovascular insufficiency, renal failure, neurologic impairment, ileus, and tumor-associated complications led to PICU admission. The number of organ failures was correlated to outcome. All children but one of group A could be discharged from the PICU, whereas 12 of 35 children in group B died, despite intensive care treatment attempts. The PRISM and TISS scores at admission to the PICU were significantly higher in children who did not survive the period of intensive care treatment in group B. However, all patients with a PRISM score of >20 died. Conclusions Diagnosis of cancer does not exclude potential benefit from intensive care medicine in these children, although severe complications might affect the prognosis.

Definition of a new score for severity of generalized Neisseria meningitidis infection

Neisseria meningititidis infection may present as meningitis or as severe, fulminant sepsis. In order to classify individual patients early according to the expected course of the disease, we developed a score named Neisseria sepsis index [NESI]. The NESI was defined using the parameters heart rate, mean arterial blood pressure, base excess and presence of acute subcutaneous bleeding and/or skin necroses (minimal value [=no evidence for sepsis] NESI 0; maximum value [=most severe sepsis] NESI 8). Seventeen patients with documented, systemicN. meningitidis infection were prospectively assessed for the terminal complement complex (TCC), serum tumour necrosis factorα (TNFα) levels (as laboratory parameters for severity of sepsis) and NESI score. The evaluation was immediately performed when the patients were admitted to the hospital. The 17 patients showed the following distribution of data: NESI 0 (n=4), NESI 1 (n=6), NESI 2 (n=0), NESI 3 (n=1), NESI 4 (n=2), NESI 5 (n=1), NESI 6 (n=0), NES( 7 (n=1), NESI 8 (n=1). Mortality was 4/17 patients, all had NESI ≧5. TCC values ranged from 647–6461 ng/ml (normal range: 130–360 ng/ml); and was not correlated to NESI. TNFα values ranged from 10–910 pg/ml and were correlated to NESI (r2=0.71,n=17,P<0.001). In patients with fatal outcome, TNFα was 600±160 pg/ml (mean±SEM) and in surviving patients 130±50 pg/ml (mean ± SEM). TNFα was increased in 15/17 patients when compared to normal controls (<27 pg/ml).ConclusionThe NESI is based on few clinical, objective data, that are available in every hospital. NESI appears to offer an instrument: (1) for making decisions in regard to appropriate monitoring and treatment of vital organ function; and (2) for assessing the quality of care for this life-threatening infection.

Correlation between severity of disease and reimbursement of costs in neonatal and paediatric intensive care patients

Aim: The aim of the present study was to investigate the correlation between neonatal, paediatric and adult disease severity scores and reimbursement by health insurances.

Effect of the introduction of diagnosis related group systems on the distribution of admission weights in very low birthweight infants

Background Admission weight to neonatal intensive care units is used in several diagnosis related group (DRG) systems to assess reimbursement by health insurance programs for premature infants. Modifications of admission weights could significantly affect reimbursement in either direction. Objective Whether the introduction of the German DRG system in 2004 influenced the distribution of admission weights of premature infants was investigated. Design/methods All very low birthweight infants in the most heavily populated German federal state, North Rhine-Westphalia, born in 1999–2001 and 2004–2006, were investigated. Data were retrieved from the medical association of North Rhine-Westphalia on 13 180 very low birthweight infants (VLBW; birth weight <1500 g). These data included admission weight and gestational age. Results In 2004–2006 compared to 1999–2001, there were significantly more infants with admission weights below 1000 g (2004–2006; 949–999 g: 460 infants, p=0.007) and 1500 g (2004–2006; 1449–1499 g: 815 infants, p=0.0019), and fewer infants with documented weights above these cut-off values (1999–2001; 1000–1049 g: 346 infants and 2004–2006; 1500–1549 g: 658 infants). Conclusions The introduction of the DRG system in Germany has affected the distribution of admission weights of premature infants. Potential reasons for this effect including upcoding are discussed.

Perinatal hemorrhagic shock after fetal scalp blood sampling.

BACKGROUND: Fetal scalp blood sampling is commonly used for fetal monitoring during labor to identify intrapartum fetal hypoxia. CASE: A male term neonate was monitored by fetal scalp blood sampling because of abnormal cardiotocographic recordings. After emergency cesarean delivery, the newborn presented with severe hemorrhagic shock as a result of fetal anemia from the scalp blood sampling. Two scalp incisions were identified as the bleeding source. The underlying reason for the development of hemorrhagic shock was factor IX-deficiency resulting from spontaneous mutation. The neonate was subsequently discharged a week later without further complications. CONCLUSION: Complications during fetal scalp blood sampling are very rare, but obstetricians and neonatologists should be aware of the potential presence of coagulopathies, especially with the persistence of scalp bleeding after delivery.

Risk adapted transmission prophylaxis to prevent vertical HIV-1 transmission: Effectiveness and safety of an abbreviated regimen of postnatal oral Zidovudine

BackgroundAntiretroviral drugs including zidovudine (ZDV) are effective in reducing HIV mother to child transmission (MTCT), however safety concern remains. The optimal duration of postnatal ZDV has not been established in clinical studies and there is a lack of consensus regarding optimal management. The objective of this study was to investigate the effectiveness and safety of a risk adapted two week course of oral postnatal ZDV as part of a combined intervention to reduce MTCT.Methods118 mother infant pairs were treated according to the German-Austrian recommendations for HIV therapy in pregnancy and in HIV exposed newborns between 2000–2010. In the absence of factors associated with an increased HIV–1 transmission risk, children were assigned to the low risk group and treated with an abbreviated postnatal regimen with oral ZDV for 2 weeks. In the presence of risk factors, postnatal ZDV was escalated accordingly.ResultsOf 118 mother-infant pairs 79 were stratified to the low risk group, 27 to the high risk group and 11 to the very high risk group for HIV–1 MTCT. 4 children were lost to follow up. Overall Transmission risk in the group regardless of risk factors and completion of prophylaxis was 1.8% (95% confidence interval (CI) 0.09–6.6). If transmission prophylaxis was complete, transmission risk was 0.9% (95% CI 0.01-5.7). In the low risk group receiving two week oral ZDV transmission risk was 1.4% (95% CI 0.01–8.4)ConclusionThese data demonstrate the effectiveness of a short neonatal ZDV regimen in infants of women on stable ART and effective HIV–1 suppression. Further evaluation is needed in larger studies.

Exchange transfusion in a preterm infant with hyperbilirubinemia, staphylococcal scalded skin syndrome (SSSS) and sepsis

Staphylococcal scalded skin syndrome (SSSS) describes a blistering skin disorder caused by exfoliative toxins (ET) of Staphylococcus aureus. Infants and young children are particularly susceptible [2, 5]. We report on a preterm infant with hyperbilirubinemia, SSSS and sepsis in which a red blood cell exchange transfusion had been performed. A 2,300 g premature male infant was born at 33 weeks of gestation by Cesarean section after premature uterine contractions. Apgar score was 8 and 10 at 1 and 5 minutes, respectively. Table 1 shows a synopsis of the clinical course, treatment and laboratory chemistry values and hematology values. On day 3 after birth the infant developed an unconjugated hyperbilirubinemia for which he received phototherapy. On day 5, skin lesions with blisters and epidermal peeling in the axillae, groins, ano-genital region, and feet appeared. The mucous membranes were not involved. Nikolsky’s sign was positive. Within 6 hours the infant developed clinical signs of sepsis. A skin biopsy taken directly after onset of blistering at the margin of a skin lesion showed a separation in the superficial epidermis at the stratum granulosum characteristic of SSSS. Swabs obtained from the affected skin lesions, a throat swab, as well as blood cultures grew methicillin-sensitive S. aureus. The isolated S. aureus was positive for the presence of exfoliative toxin A (ETA) and B (ETB) genes by polymerase-chain reaction. Infection control measures were implemented including isolation of infant and personnel hand-hygiene. Because of increasing unconjugated hyperbilirubinemia despite phototherapy the patient received an exchange transfusion to prevent kernicterus and additional harm by phototherapy to the already affected skin. There was no ABO or Rh incompatibility, Coombs-Test was negative and no other risk factors for jaundice other than sepsis. Manual blood exchange transfusion was performed through the combined use of umbilical vein and artery and an exchange set from Vygon, Ecouen, France (Ref. Nr. 275.00). The patient received on the basis of the patient’s weight about 500 ml of packed red blood cells. Additional fresh frozen plasma, platelet transfusion and sodium-bicarbonate were administered. On day 10, the infant required re-intubation for 6 days due to another episode of severe sepsis. Oxacillin-resistant coagulase-negative staphylococcus (CoNS) was recovered from peripheral blood cultures as well as from the umbilical vein catheter. After intensive care treatment the infant’s clinical status improved gradually and could be discharged on day 35. At follow-up the patient was documented to have neurological sequelae with Eur J Pediatr (2007) 166:733–735 DOI 10.1007/s00431-006-0291-0

Severe Hypernatremia in an Extremely Low Birth Weight Infant with Subsequent Normal Neurological Development

Severe preterm hypernatremia is a life-threatening electrolyte disorder which mainly causes neurological complications such as brain edema, intracranial hemorrhages, hemorrhagic infarctions and thromboses. We report the case of an extremely low birth weight infant (520 g, 24+6 weeks of gestation) with severe hypernatremia of 199 mmol/l due to a failure in the preparation of an infusion on the 7th day of life. The infant subsequently showed no signs of central nervous system complications and no neurological symptoms due to this mishap so far. MRI scan performed after 4 months showed no evidence of cerebral complications including white matter injury. Even severe hypernatremia might not inevitably lead to central nervous system dysfunction and seizures in extremely low birth weight infants.

Petechien und intrazerebrale Verkalkungen

Ausgeprägte Stauungsblutungen im Gesicht. Multiple Petechien am gesamten Körper. Respiratorische Anpassungsstörung mit rascher Besserung im Verlauf. Keine Hepatosplenomegalie. Geringfügige Hyperexzitabilität, leicht gesteigerter Muskeltonus. Keine äußeren Fehlbildungen. Erhöhte Echogenität im Bereich von Thalamus und Stammganglien, mäßige Erweiterung der Seitenventrikel (. Abb. 1).