Kevin Valentine

Ethanol lock therapy for catheter-associated blood stream infections in a pediatric intensive care unit

Objective: Ethanol locks are being used to prevent and eradicate central venous catheter infections. This study describes the efficacy of ethanol locks in clearing central venous catheter infections in a pediatric intensive care unit. Design: Retrospective chart review. Setting: Pediatric intensive care unit in a tertiary care childrens hospital. Patients: All patients who received ethanol lock therapy for the treatment of catheter-associated bloodstream infections from January 2008 through December 2009. Interventions: Ethanol locks of central venous catheters. Measurements and Main Results: The study period encompassed 26 catheter-associated bloodstream infections that were treated with ethanol lock therapy. Each catheter-associated bloodstream infection was defined by criteria set forth by the Centers for Disease Control/National Healthcare Safety Network 2008. Patients ranged in age from 77 days to 20 yrs. Of the 26 central venous catheters with associated bloodstream infections, 24 (92%) were sterilized as evidenced by negative repeat blood cultures obtained within 48 hrs of the initiation of the ethanol lock. Thirteen of the 26 treatment ethanol locks were single doses. The dwell times ranged between 4 and 48 hrs with a mean dwell time of 17 hrs. Twenty of the 26 catheters (77%) continued to be used, while six, which included the two treatment failures, were removed. Conclusions: Ethanol locks using 70% ethanol solution with dwell times as short as 4–6 hrs in conjunction with standard antibiotic therapy have 92% effective clearance of catheter-associated bloodstream infection and a 77% catheter salvage rate in our pediatric intensive care unit. The use of 70% ethanol locks appears to be well tolerated and represents a relatively inexpensive pharmacologic intervention that, along with systemic antibiotics, can help treat catheter-associated bloodstream infections and salvage central venous catheters.

Cumulative Corticosteroid Exposure and Infection Risk After Complex Pediatric Cardiac Surgery

BACKGROUND Children undergoing cardiac surgery may receive corticosteroids preoperatively to temper cardiopulmonary bypass-related inflammation, postoperatively for hemodynamic instability, and periextubation to reduce airway edema. Recent data have associated preoperative corticosteroids with infection. We aimed to determine if there is a relationship between cumulative corticosteroid exposure and infection. METHODS A retrospective review of children who underwent cardiac surgery at our institution from January 2009 to July 2010 was performed. To limit study heterogeneity, patients who were 5 years or younger with basic Aristotle score of 7 or higher and intensive care unit stay of 7 days or more were included. Infections during the first 30 postoperative days were recorded, defined as clinically relevant positive blood, urine, respiratory, or wound cultures, or culture-negative sepsis treated with 7 or more days of antimicrobial therapy. Multivariate logistic regression analysis was performed to determine independent risk factors for infection. RESULTS Seventy-six patients were reviewed. All patients received intraoperative methylprednisolone, 48% received postoperative hydrocortisone, and 86% received periextubation dexamethasone. Twenty-six patients (36%) had 58 infections. On univariate analysis, patients with infection had greater median comprehensive Aristotle score (14.5 [intraquartile range (IQR): 12.5 to 16] versus 11.5 [IQR: 10 to 13.1], p = 0.001), maximum vasoactive inotrope score (29 [IQR: 24 to 40] versus 24 [IQR: 17 to 31], p = 0.031, days endotracheally intubated (12 [IQR: 7 to 30] versus 5 [IQR: 4 to 6.5], p < 0.001), and days of corticosteroid exposure (7 [IQR: 5 to 12] versus 4 [IQR: 2 to 5), p < 0.001). Also, patients with infections more often underwent delayed sternal closure (p = 0.008). On multivariate analysis, days endotracheally intubated (p = 0.023) and days of corticosteroid exposure (p = 0.015) remained significant. CONCLUSIONS For children undergoing complex cardiac surgery, greater cumulative duration of corticosteroid exposure is independently associated with postoperative infection.

Early Administration of Intratracheal Surfactant (Calfactant) After Hydrocarbon Aspiration

Hydrocarbon ingestions account for a substantial number of accidental poisonings; when aspirated, it can lead to severe pneumonitis. Treatment for severe pneumonitis is generally supportive, and outcomes are frequently poor. We report here the case of a 19-month-old girl who was treated successfully with early administration of exogenous surfactant for acute respiratory distress syndrome secondary to aspiration of lamp oil. Approximately 7 hours after aspiration, she required mechanical ventilation and had an oxygenation index (OI) of 13.2. Approximately 10 hours after ingestion, exogenous surfactant (calfactant) was instilled intratracheally, after which her OI improved markedly to 4.3. She received a second dose ∼19 hours after ingestion, after which her OI remained at <5 and she was progressively weaned from mechanical ventilation. She was extubated 64 hours after the ingestion with no residual lung disease. This case illustrates the importance of considering exogenous surfactant therapy early in the course of acute respiratory failure secondary to hydrocarbon aspiration. Because of the putative mechanisms of lung injury involved in hydrocarbon aspiration, surfactant-replacement therapy is a reasonable therapeutic intervention based on pathophysiologic rationale.

Infantile iron poisoning: Challenges in diagnosis and management

Objective: To describe the clinical course and treatment of an infant with iron poisoning. Design: Case report. Setting: Pediatric intensive care unit in a tertiary care children’s hospital. Patient, Intervention, and Results: A 7-week-old, ex-28-week premature infant, was accidentally poisoned with ferrous sulfate. She recovered completely from metabolic acidosis and shock after treatment with inotropes and chelation with deferoxamine, but her management was complicated by challenges of physiologic immaturity of developing organs. This is the youngest infant reported, to date, with iron poisoning resulting in metabolic acidosis and shock. Conclusions: This case illustrates the importance of including toxic exposure in the differential diagnosis of neonatal shock of unknown etiology. Because of physiologic immaturity, iron poisoning in young infants poses special diagnostic and therapeutic challenges.