L Desmet

An Analysis of Reliability and Accuracy of Muscle Thickness Ultrasonography in Critically Ill Children and Adults.

BACKGROUND Muscle wasting starts already within the first week in critically patients and is strongly related to poor outcome. Nevertheless, the early detection of muscle wasting is difficult. Therefore, we investigated the reliability and accuracy of ultrasonography to evaluate skeletal muscle wasting in critically ill children and adults. METHODS This prospective observational study enrolled 30 sedated critically ill children and 14 critically ill adults. Two independent investigators made 210 ultrasonographical assessments of muscle thigh thickness. Inter- and intraobserver reliability and cutoff levels were calculated as a function of muscle thickness and the expected reduction in muscle size (predefined at 20% and 30%). RESULTS Mean ± SD muscle thickness was 1.67 ± 0.55 cm in the pediatric and 2.10 ± 0.85 cm in the adult population. The median absolute interobserver variability was 0.07 cm (interquartile range [IQR], 0.04-0.20 cm) in the pediatric population and 0.05 cm (IQR, 0.03-0.09 cm) in the adult population. However, the absolute intraobserver accuracy had a 95% confidence interval of 0.43 cm in children and 0.22 cm in adults. Only a 30% decrease (0.50 cm) in muscle thickness can be detected in critically ill children. CONCLUSION Although the interobserver variability is acceptable in the pediatric population, the intraobserver variability is too large with respect to the expected reduction in muscle thickness. In adults, ultrasonography may be a reliable tool for early detection of muscle mass wasting.

Alpers syndrome presenting with anatomopathological features of fulminant autoimmune hepatitis

A 6-month-old girl with normal psychomotor development presented with fulminant hepatitis. Interestingly, liver biopsy demonstrated features of autoimmune hepatitis, whereas autoantibodies and raised immunoglobulin G (IgG) were absent. There was extensive centrolobular necrosis with bridging (Fig. 1a) and ductular reaction (Fig. 1b). There were numerous lymphocytes and plasmocytes (polyclonal on kappa and lambda stain) (Fig. 1c). Biochemical investigations excluded alternative causes of fulminant hepatitis. Steroid treatment was started, but the patient soon evolved to liver failure and received a liver transplantation. Three months posttransplant, the patient developed myoclonic and generalized tonic-clonic fits. Computed tomography (CT) scan, normal at presentation, revealed evolution toward severe brain atrophy. Mitochondrial assays on postmortem muscle biopsy revealed normal activity of respiratory chain complex II and decreased I, III, and IV activity. This is indicative of mitochondrial DNA (mtDNA) depletion in this clinical setting (Hargreaves et al. 2002). DNA analysis revealed two known POLG mutations (p.Ala467Thr and p. Gly848Ser), diagnostic for Alpers syndrome. We show here for the first time that a mtDNA-depletion syndrome can present with the anatomopathological features of autoimmune hepatitis. Alpers syndrome therefore should not be excluded from the differential diagnostic list based on these features. Whether this is also the case in older children, or even adults, presenting with cryptogenic acute liver failure and pathological features of autoimmune hepatitis remains to be determined.

The value of the fore-sight TM monitor in the postoperative phase after congenital cardiac surgery. a descriptive statistical interim-analysis

The FORE-SIGHTTM monitor measures absolute cerebral tissue oxygen saturation (SctO2) of the frontal lobes of the brain, in a non-invasive way, through near-infrared spectroscopy (NIRS) [1]. Its value for early detection of hemodynamic deterioration in the postoperative phase after congenital cardiac surgery has never been examined. In a prospective observational study [2], 300 mechanically ventilated patients younger than 12 years after cardiac surgery will be monitored with NIRS, in addition to their routine haemodynamic monitoring. The NIRS monitor is blinded to clinicians, and its predictive value to detect predefined critical hemodynamic events will be analysed.

PO-0333 MUSCLE THICKNESS ULTRASONOGRAPHY IN CRITICALLY ILL CHILDREN: ANALYSIS OF ACCURACY

Background and aims Critical illness results in muscle wasting, typically within the first week of admission. However, its quantification is difficult. Ultrasonographical evaluation has already been tested in adult patients. Here we aim to assess of the accuracy of this methodology in critically ill children. Methods Two independent investigators made ultrasonographical assessments of muscle thickness. A linear array commercial real time ultrasound scanner (Vivid S6) was used with a 12-MHz transducer. The transducer was placed perpendicularly to the long axis of the tight on three fifths of the distance from the anterior superior iliac spine to the superior patellar border. An excess of contact gel was applied to minimise image distortion. During the first week of critical illness we hypothesised a reduction in muscle size of 30% based on literature of critically ill adult patients. Results A group of 43 patients (newborns to 4-years old children) were included in the study. The average muscle thickness was 1.67 cm (SD: 0.52 cm). Hence 30% reduction would equal 0.50 cm. The intra-observer variability, as expressed by the limits of agreement (± 1.96 SD, containing 95% of the samples for normally distributed samples), was 0.61 cm for operator 1 and 0.83 cm for operator 2. Both distributions are visualised in a Bland-Altman plot in Figure 1. Combining both operator data revealed an observer variability of 0.72 cm. The median absolute inter-observer variability was 0.085 cm [IQR 0.040–0.20 cm]. Conclusions Although the inter-observer variability among the two operators is acceptable, the intra-observer variability may be too large with respect to the limited expected muscle reduction. Therefore, ultrasonographical analyses of muscle wasting need more standardisation for use in critically ill children. Abstract PO-0333 Figure 1

Liver Transplantation in a Patient With an Intraabdominally Located Left Ventricular Assist Device: Surgical Aspects—Case Report

The presence of a cardiac assist device in a liver transplantation candidate should not be considered to be an absolute contraindication to transplantation. In this first case report of liver transplantation in a patient with an intraabdominally located left ventricular assist device, we have described the surgical aspects and discussed the timing of the liver transplantation and the removal of the left ventricular assist device.