Julien Baleine

High-flow nasal cannula: recommendations for daily practice in pediatrics.

High-flow nasal cannula (HFNC) is a relatively new device for respiratory support. In pediatrics, HFNC use continues to increase as the system is easily set up and is well tolerated by patients. The use of nasal cannula adapted to the infant’s nares size to deliver heated and humidified gas at high flow rates has been associated with improvements in washout of nasopharyngeal dead space, lung mucociliary clearance, and oxygen delivery compared with other oxygen delivery systems. HFNC may also create positive pharyngeal pressure to reduce the work of breathing, which positions the device midway between classical oxygen delivery systems, like the high-concentration face mask and continuous positive airway pressure (CPAP) generators. Currently, most of the studies in the pediatric literature suggest the benefits of HFNC therapy only for moderately severe acute viral bronchiolitis. But, the experience with this device in neonatology and adult intensive care may broaden the pediatric indications to include weaning from invasive ventilation and acute asthma. As for any form of respiratory support, HFNC initiation in patients requires close monitoring, whether it be for pre- or inter-hospital transport or in the emergency department or the pediatric intensive care unit.

Perfusion index and its dynamic changes in preterm neonates with patent ductus arteriosus

The perfusion index (PI) and its dynamic change during respiration, and supressed the plethysmographic variability index (PVI), are calculated from pulse oximetry, and these indexes were recently proposed for continuous and noninvasive assessment of peripheral perfusion in neonates. We aimed to assess the effect of patent ductus arteriosus (PDA) on PI and PVI, according to ductal Doppler flow pattern.

Intubation in the delivery room: Experience with nasal midazolam ☆

BACKGROUND Neonates are often intubated in the delivery room (DR) without anesthesia because vascular access is impossible. AIMS To assess neonatal comfort and adverse events after use of nasal midazolam (nMDZ) for intubation in the DR. STUDY DESIGN Prospective data collection over 6months on the intubation of neonates with respiratory distress requiring tracheal instillation of surfactant. SUBJECTS Twenty-seven neonates with median (Q25-75) gestational age and birthweight of, respectively, 29 (27-33)weeks and 1270 (817-1942)g received a 0.1mg/kg dose of nMDZ, and intubation was performed at the onset of tonus resolution or apnea. OUTCOME MEASURES Comfort was assessed with a scale of hetero-pain assessment and electrical skin conductance monitoring. Continuous pulse oximetry was recorded in the first postnatal hour, with oscillometric blood pressure measurement every 10min. RESULTS Seventy percent of the patients required a single dose, with intubation performed 4.8 (3-9)min after administration. Combined electro-clinical assessment found adequate comfort during the procedure in 68% of neonates. Mean blood pressure decreased from 39 (34-44)mmHg before to 31 (25-33)mmHg 1h following nMDZ (p=0.011). CONCLUSION nMDZ provided rapid and effective sedation to intubate neonates in the DR but potentially exposed them to hypotension, thus requiring close hemodynamic monitoring.

Validation of nosocomial infection in neonatology: A new method for standardized surveillance

BACKGROUND Nosocomial infections (NIs) are a leading cause of mortality and morbidity in premature infants. We present a new method for detecting and confirming NIs in a neonatal intensive care unit. METHODS Newborns with birth weight < 1,500 g or gestational age (GA) < 33 weeks were included prospectively over 2 years in a single-center tertiary neonatal intensive care unit. The computerized physician order entry system (CPOE) generated alerts when antibiotics were prescribed for at least 5 consecutive days and these cases were reviewed by an expert group following international recommendations. RESULTS Four hundred sixty-one neonates were included, with a mean GA of 30 weeks (range, 26-32 weeks) and mean birth weight 1,270 g (range, 950-1600 g). The CPOE flagged 158 cases of potential NI, 85.1% of which were classified as true NI and 14.9% of which were false positive. Incidence and device-associated nosocomial bloodstream infection rates were 21.9% and 10.8 per 1,000 central venous catheter days, respectively. GA ≤ 28 weeks (odds ratio, 2.18; 95% confidence interval, 1.2-4) and > 7 central venous catheter days (odds ratio, 1.47; 95% confidence interval, 1.3-1.7) were independently associated with the risk of nosocomial bloodstream infection. CONCLUSION Combining CPOE and interdisciplinary review may improve the accuracy of NI recording in a neonatal intensive care unit.

Nasal midazolam vs ketamine for neonatal intubation in the delivery room: a randomised trial

Objective To compare the effectiveness of sedation by intranasal administration of midazolam (nMDZ) or ketamine (nKTM) for neonatal intubation. Design A multicentre, prospective, randomised, double-blind study. Setting Delivery rooms at four tertiary perinatal centres in France. Patients Preterm neonates with respiratory distress requiring non-emergent endotracheal intubation for surfactant instillation. Interventions Treatment was randomly allocated, with each neonate receiving a bolus of 0.1 mL/kg in each nostril, corresponding to 0.2 mg/kg for nMDZ and 2 mg/kg for nKTM. The drug was repeated once 7 min later at the same dose if adequate sedation was not obtained. Main outcome measures Success was defined by adequate sedation before intubation and adequate comfort during the procedure. Intubation features, respiratory and cardiovascular events were recorded. Results Sixty newborns, with mean (SD) gestational age and birth weight of 28 (3) weeks and 1100 (350) g, were included within the first 20 min of life. nMDZ was associated with a higher success rate (89% vs 58%; RR: 1.54, 95% CI 1.12 to 2.12, p<0.01) and shorter delays between the first dose and intubation (10 (6) vs 16 (8) min, p<0.01). Number of attempts, time to intubation, mean arterial blood pressure measures over the first 12 hours after birth and length of invasive ventilation were not different. Conclusions nMDZ was more efficient than nKTM to adequately sedate neonates requiring intubation in the delivery room. The haemodynamic and respiratory effects of both drugs were comparable. Clinical trial This clinical trial was recorded on the National Library of Medicine registry (NCT01517828).

Supraclavicular catheterization of the brachiocephalic vein: a way to prevent or reduce catheter maintenance-related complications in children

Placement of a central venous catheter (CVC) in the brachiocephalic vein (BCV) via the ultrasound (US)-guided supraclavicular approach was recently described in children. We aimed to determine the CVC maintenance-related complications at this site compared to the others (i.e., the femoral, the subclavian, and the jugular). We performed a retrospective data collection of prospectively registered data on CVC in young children hospitalized in a pediatric intensive care unit (PICU) during a 4-year period (May 2011 to May 2015). The primary outcome was a composite of central line-associated bloodstream infection (CLABSI) and deep-vein thrombosis (CLAT) according to the CVC site. Two hundred and twenty-five children, with respective age and weight of 7.1 (1.3–40.1) months and 7.7 (3.6–16) kg, required 257 CVCs, including 147 (57.2%) inserted in the BCV. The risk of the primary outcome was lower in the BCV than in the other sites (5.4 vs 16.4%; OR: 0.29; 95% CI: 0.12–0.70; p = 0.006). CLABSI incidence density rate (2.8 vs 8.96 per 1000 catheter days, p < 0.001) and CLAT incidence rate (2.7 vs 10%, p = 0.016) were also lower at this site. Conclusion: BCV catheterization via the US-guided supraclavicular approach may decrease CVC maintenance-related complications in children hospitalized in a PICU.What is Known:• Placement of a central venous catheter (CVC) in children is associated with mechanical risks during insertion, and with infectious and thrombotic complications during its maintenance.• Ultrasound (US)-guided supraclavicular catheterization of the brachiocephalic vein (BCV) is feasible in infants and children.What is New:• This observational study suggested that BCV catheterization via the US-guided supraclavicular approach was associated with a lower risk of CVC insertion and maintenance-related complications, compared with the other catheterization sites.

High flow on the rise-pediatric perspectives on the FLORALI trial.

Over the last decade, noninvasive positive pressure ventilation (NIV) has been increasingly used in adult and pediatric medicine to reduce the lung injuries, pneumonia, and denutrition associated with mechanical ventilation, which is implicated in the high mortality observed in these patients (1). For adults with acute exacerbations of chronic obstructive pulmonary disease (2) or severe cardiogenic pulmonary edema (3), it is now an evidence-based practice. It may also be an effective strategy in the perioperative period, provided that patients are carefully selected (4). The benefits of NIV have nevertheless not been clearly established in clinical situations like status asthmaticus (5) or acute hypoxemic respiratory failure (AHRF) or as a means to facilitate earlier extubation (6). The conflicting results for ARHF may be due to its several etiologies, which has prompted new trials with less heterogeneous patient groups (7).

Deep brain stimulation is effective in pediatric patients with GNAO1 associated severe hyperkinesia

BACKGROUND Exacerbation of hyperkinesia is a life-threatening complication of dyskinetic movement disorders, which can lead to multi-organ failure and even to death. GNAO1 has been recently identified to be involved in the pathogenesis of early infantile epileptic encephalopathy and movement disorders. Patients with GNAO1 mutations can present with a severe, progressive hyperkinetic movement disorder with prolonged life-threatening exacerbations, which are refractory to most anti-dystonic medication. OBJECTIVE The objective was to investigate the evolution of symptoms and the response to deep brain stimulation of the globus pallidus internus (GPi-DBS) in patients with different GNAO1 mutations. METHODS We report six patients presenting with global motor retardation, reduced muscle tone and recurrent episodes of severe, life-threatening hyperkinesia with dystonia, choreoathetosis, and ballism since early childhood. Five of them underwent GPi-DBS. RESULTS The genetic workup revealed mutations in GNAO1 for all six patients. These encompass a new splice site mutation (c.723+1G>T) in patient 1, a new missense mutation (c.610G>C; p.Gly204Arg) in patient 2, a heterozygous mutation (c.625>T; p.Arg209Cys) in patients 3 and 4, and a heterozygous mutation (c.709G>A; p.Glu237Lys) in patients 5 and 6. By intervention with GPi-DBS the severe paroxysmal hyperkinetic exacerbations could be stopped in five patients. One patient is still under evaluation for neuromodulation. CONCLUSION In complex movement disorders of unsolved etiology clinical WES can rapidly streamline pathogenic genes. We identified two novel GNAO1 mutations. GPi-DBS can be an effective and life-saving treatment option for patients with GNAO1 mutations and has to be considered early.

High flow nasal cannulae for acute viral bronchiolitis in young infants: evidence-based medicine is underway to define target populations and optimal flows

Over the last decade, high flow nasal cannulae (HFNC) have increasingly been used for oxygen delivery in neonatology departments, gradually replacing nasal continuous positive airway pressure (nCPAP).

Isolated methylmalonic acidemia: a case report.

Isolated methylmalonic acidemia (AMR) is an inborn error of metabolism due to an enzymatic deficit in methylmalonyl-CoA mutase. AMR lead to increased methylmalonic acid in plasma and urine without hyperhomocysteinemia. The clinical signs are recurrent episodes of ketoacidosis and bouts of vomiting, dehydration and mental retardation. These symptoms do not respond to the administration of vitamin B12. We report a case of a ten-months-old infant to whom the diagnosis was suspected in the presence of a metabolic acidosis, hyperammonemia, without hepatic impairment and ketosis. The chromatography of organic acids showed elevated methylmalonic acid levels. Molecular genetics allowed confirming the diagnosis of deficit in methylmalonyl-CoA mutase demonstrating the genetic abnormality of the gene MUT.