Heloisa Amaral Gaspar

Miocardite fulminante associada ao vírus influenza H1N1: relato de caso e revisão de literatura

A case of fulminant myocarditis associated with the H1N1 influenza virus. This case report describes the patients clinical course and emphasizes the importance of bedside echocardiography as an aid in the early diagnosis and management of children with severe myocardial dysfunction. It also discusses aspects relevant to the treatment and prognosis of fulminant myocarditis. The patient was a female, 4 years and 8 months old, previously healthy and with a history of flu symptoms in the past two weeks. The patient was admitted to the emergency room with signs of hemodynamic instability, requiring ventilatory support and vasoactive drugs. The laboratory tests, chest X-ray and echocardiogram suggested the presence of myocarditis. The test for H1N1 in nasopharyngeal secretions was positive. The patient evolved to refractory cardiogenic shock despite the clinical measures applied and died 48 hours after admission to the intensive care unit. The H1N1 influenza virus is an etiological agent associated with acute myocarditis, but there are few reported cases of fulminant myocarditis caused by the H1N1 virus. The identification of signs and symptoms suggestive of fulminant progression should be immediate, and bedside echocardiography is a useful tool for the early detection of myocardial dysfunction and for therapeutic guidance. The use of immunosuppressive therapy and antiviral therapy in acute myocarditis of viral etiology is controversial; hence, the treatment is based on hemodynamic and ventilatory support. The use of hemodynamic support by extracorporeal membrane oxygenation emerges as a promising treatment.Caso de miocardite fulminante asso- ciada ao virus influenza H1N1, em que foi descrita a evolucao clinica do paciente e enfatizada a importância do ecocardio- grama a beira do leito como auxilio no diagnostico precoce e manejo de crian- cas com disfuncao miocardica grave, alem de terem sido discutidos aspectos relevantes relacionados a terapeutica e ao prognostico da miocardite fulminante. Trata-se de paciente do sexo feminino, 4 anos e 8 meses, previamente higida, com historia de quadro gripal ha 2 semanas. Admitida no pronto-socorro com sinais de instabilidade hemodinâmica, neces- sitando de suporte ventilatorio e drogas vasoativas. Exames laboratoriais, radio- grafia de torax e ecocardiograma suges - tivos de miocardite. Pesquisa positiva para H1N1 em secrecao de nasofaringe. Evoluiu com choque cardiogenico re- fratario a despeito das medidas clinicas,

The Role of Focused Echocardiography in Pediatric Intensive Care: A Critical Appraisal

Echocardiography is a key tool for hemodynamic assessment in Intensive Care Units (ICU). Focused echocardiography performed by nonspecialist physicians has a limited scope, and the most relevant parameters assessed by focused echocardiography in Pediatric ICU are left ventricular systolic function, fluid responsiveness, cardiac tamponade and pulmonary hypertension. Proper ability building of pediatric emergency care physicians and intensivists to perform focused echocardiography is feasible and provides improved care of severely ill children and thus should be encouraged.

New approach to insert peripherally inserted central catheter in critically ill pediatric patients.

www.pccmjournal.org March 2013 • Volume 14 • Number 3 New Approach to Insert Peripherally Inserted Central Catheter in Critically Ill Pediatric Patients To the Editor: The central venous access is essential in management of most patients in the ICU. Peripherally inserted central catheter (PICC) has less risk associated with placement and is an attractive option in pediatric patients, where the difficulties related to central venous catheter (CVC) are higher (1). The rate of CVC-related infection in the pediatric population, reported by the National Healthcare Safety Network, was 1.9 Epidemiologic Challenges in Sepsis to the Developing Countries

Zinc deficiency in systemic inflammatory response syndrome: cause or consequence?

Zinc is an essential element that facilitates the coordination of immune activation during the host’s response to infection, and mortality is strongly associated with the overactivation of the inflammatory response in severe sepsis (1, 2). The role of zinc metabolism, as it relates to inflammation and disease severity in infected and uninfected critically ill adults during the early period after ICU admission, has been investigated, and lower plasma concentrations of zinc were more pronounced in septic patients (3). Duncan et al (4) state that low zinc concentrations are independent of nutritional status and that this is a consequence and a frequently occurring process of the systemic inflammatory response in a critically ill patient. Zinc supplementation has been shown to reduce the prevalence of pneumonia and diarrhea in children in a low-income population, and malnutrition can acutely decrease zinc concentrations in infected children (5). We performed a study in 15 critically ill children and adolescents with severe sepsis/septic shock in a level I PICU in a developing country (as defined by the Society of Critical Care Medicine). These children demonstrated a significantly low zinc concentration on the first day (acute phase) compared with the seventh day (recovery phase), and the zinc concentration was inversely correlated with the C-reactive protein inflammation marker (data not published). Nutritional analysis showed that the majority of the patients had some degree of malnutrition on the first day of hospitalization. Despite the limited population, the majority of these patients had lymphopenia and a significant increase in lymphocytes over time between the first and seventh day. Cvijanovich et al (1) had similar results with low plasma zinc concentrations in 20 children (median age, 2.9 yr) that correlated with higher measurements of inflammation markers (C-reactive protein and interleukin-6) on day 3, the degree of which were associated with organ failure. Heydemann et al (6) demonstrated that low serum zinc levels are associated with lymphopenia in critically ill children after PICU admission (in the first 48 hr), whereas low selenium and prolactin levels are not. These are relevant data when considering the potential association between low zinc concentrations and lymphopenia and its immune response consequences. Children were eligible if they were between 1 and 18 years old, but only 31.3% had sepsis, and 8.8% were immunocompromised. There was no description regarding nutritional status. A large sample size was the primary strength of the study by Heydemann et al (6). In a mouse model study, Bao et al (2) demonstrated that zinc modulates the innate immune response to polymicrobial sepsis in vivo through the regulation of nuclear factor kappa B and its supplementation immediately before the initiation of sepsis reversed these effects. Low concentrations of zinc can inappropriately be used to indicate a zinc deficiency, but the implications of these finding and the mechanisms by which it occur, as well as the benefits of zinc supplementation, require further study. The data of Heydemann et al (6) can serve as a basis for future randomized trials that explore zinc and immune response and that identify potential supplementation strategies to prevent sepsis-mediated morbidity and mortality. The authors have disclosed that they do not have any potential conflicts of interest.

The worth of the guidelines: pediatric considerations in severe sepsis and septic shock.

e488 www.ccmjournal.org December 2013 • Volume 41 • Number 12 The Worth of the Guidelines: Pediatric Considerations in Severe Sepsis and Septic Shock These updated guidelines are very relevant, and we would like to acknowledge the members of the pediatric subgroup’s great work (1). The recommendations target rich settings, but they also have great importance for developing countries and will guide the therapeutic in children with severe sepsis in these locations, despite the known limitations that may be present. We would like to add some comments that may aid the dynamic process of the surviving sepsis guidelines and help with its applicability in developing countries. As the target population of the pediatric guidelines, we believe that children (excluding newborns) should be the focus. It has already been established that volume resuscitation in newborns, as opposed to children, should be performed in lower rates (10 mL/kg) and longer times (2). Differences in management of vasoactive drugs, antibiotic therapy, and pulmonary hypertension also differ greatly (3). Thus, it is potentially hazardous to standardize their treatment. The authors reply: We appreciate the commentary by Viswesh et al (1) elucidating potential confounders that may lead to a positive β-glucan serum assay, as well as finer points relating to the use of the test, for example, impact of timing. Some of these factors mentioned were the reasons that the recommendation is a grade 2 (suggestion). It carries essentially no risk to the patient and in the appropriate clinical scenario may be useful. Dr. Opal served as board member for Arsanis, BioAegis, and Sciclone; consulted for Amplimmune; received royalties from Elsevier; and served on the data monitoring committee for Spectral, Achaogen, and Tetraphase. His institution received grant support from GlaxoSmithKline (preclinical research on genomics regulation), Asahi Kasei (Clinical coordinating center for clinical trial), and Cardeas (Clinical coordinating center for clinical trial). Dr. Dellinger disclosed that he does not have any potential conflicts of interest.