Marcel J. I. J. Albers

Glutamine Supplementation of Parenteral Nutrition Does Not Improve Intestinal Permeability, Nitrogen Balance, or Outcome in Newborns and Infants Undergoing Digestive-Tract Surgery: Results From a Double-Blind, Randomized, Controlled Trial

Objective:To assess the effect of isocaloric isonitrogenous parenteral glutamine supplementation on intestinal permeability and nitrogen loss in newborns and infants after major digestive-tract surgery. Summary Background Data:Glutamine supplementation in critically ill and surgical adults may normalize intestinal permeability, attenuate nitrogen loss, improve survival, and lower the incidence of nosocomial infections. Previous studies in critically ill children were limited to very-low-birthweight infants and had equivocal results. Methods:Eighty newborns and infants were included in a double-blind, randomized trial comparing standard parenteral nutrition (sPN; n = 39) to glutamine-supplemented parenteral nutrition (GlnPN; glutamine target intake, 0.4 g kg−1 day−1; n = 41), starting on day 2 after major digestive-tract surgery. Primary endpoints were intestinal permeability, as assessed by the urinary excretion ratio of lactulose and rhamnose (weeks 1 through 4); nitrogen balance (days 4 through 6), and urinary 3-methylhistidine excretion (day 5). Secondary endpoints were mortality, length of stay in the ICU and the hospital, number of septic episodes, and usage of antibiotics and ICU resources. Results:Glutamine intake plateaued at 90% of the target on day 4. No differences were found between patients assigned sPN and patients assigned GlnPN regarding any of the endpoints. Glutamine supplementation was not associated with adverse effects. Conclusions:In newborns and infants after major digestive-tract surgery, we did not identify beneficial effects of isonitrogenous, isocaloric glutamine supplementation of parenteral nutrition. Glutamine supplementation in these patients therefore is not warranted until further research proves otherwise.

Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study

Objectives To evaluate the outcome of drowned children with cardiac arrest and hypothermia, and to determine distinct criteria for termination of cardiopulmonary resuscitation in drowned children with hypothermia and absence of spontaneous circulation. Design Nationwide retrospective cohort study. Setting Emergency departments and paediatric intensive care units of the eight university medical centres in the Netherlands. Participants Children aged up to 16 with cardiac arrest and hypothermia after drowning, who presented at emergency departments and/or were admitted to intensive care. Main outcome measure Survival and neurological outcome one year after the drowning incident. Poor outcome was defined as death or survival in a vegetative state or with severe neurological disability (paediatric cerebral performance category (PCPC) ≥4). Results From 1993 to 2012, 160 children presented with cardiac arrest and hypothermia after drowning. In 98 (61%) of these children resuscitation was performed for more than 30 minutes (98/160, median duration 60 minutes), of whom 87 (89%) died (95% confidence interval 83% to 95%; 87/98). Eleven of the 98 children survived (11%, 5% to 17%), but all had a PCPC score ≥4. In the 62 (39%) children who did not require prolonged resuscitation, 17 (27%, 16% to 38%) survived with a PCPC score ≤3 after one year: 10 (6%) had a good neurological outcome (score 1), five (3%) had mild neurological disability (score 2), and two (1%) had moderate neurological disability (score 3). From the original 160 children, only 44 were alive at one year with any outcome. Conclusions Drowned children in whom return of spontaneous circulation is not achieved within 30 minutes of advanced life support have an extremely poor outcome. Good neurological outcome is more likely when spontaneous circulation returns within 30 minutes of advanced life support, especially when the drowning incident occurs in winter. These findings question the therapeutic value of resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia.

Introduction of enteral feeding in neonates on extracorporeal membrane oxygenation after evaluation of intestinal permeability changes

BACKGROUND/PURPOSE Neonates meeting criteria for extracorporeal membrane oxygenation (ECMO) often suffer from variable periods of hypoxia. During ECMO, starvation of the gut is common practice in many centres as splanchnic ischemia results in loss of intestinal integrity, which in turn predisposes for bacterial translocation and sepsis and eventually necrotizing enterocolitis (NEC) and multiorgan failure. However, minimal enteral feeding is thought to be of benefit in the critically ill. Data on intestinal integrity in newborns on ECMO and the effects of enteral nutrition are not available. This study prospectively evaluates the changes in small intestinal integrity in 16 neonatal ECMO patients. METHODS With 2-day intervals, excretion percentages of lactulose/L-rhamnose (nonmediated diffusion), D-xylose (passive), and 3-O-methyl-D-glucose (active carrier-mediated transport) were measured by gas-liquid chromatography in a 4-hour urine sample. After obtaining baseline data in nine patients, enteral feeding was started in the next seven patients between the third and the ninth day of ECMO. RESULTS Thirteen patients had increased lactulose/L-rhamnose ratios (>0.05) consistent with increased intestinal permeability. In three patients the lactulose/L-rhamnose ratios were within the normal range. D-xylose excretion percentages were normal (or slightly increased) in 11 patients consistent with normal (or increased) passive carrier-mediated transport. 3-O-methyl-D-glucose excretion percentages were decreased (<10%) in all but one patient, consistent with decreased active carrier-mediated transport. After introduction of enteral nutrition no significant changes of these parameters were seen. CONCLUSIONS The authors conclude that intestinal integrity is compromised in neonates on ECMO and that introduction of enteral nutrition does not result in further deterioration. This conclusion does not support the practice of withholding enteral nutrition in critically ill newborns supported by ECMO.

Perceptions of parents on satisfaction with care in the pediatric intensive care unit: the EMPATHIC study

PurposeTo identify parental perceptions on pediatric intensive care-related satisfaction items within the framework of developing a Dutch pediatric intensive care unit (PICU) satisfaction instrument.MethodsProspective cohort study in tertiary PICUs at seven university medical centers in The Netherlands.ParticipantsParents of 1,042 children discharged from a PICU.ResultsA 78-item questionnaire was sent to 1,042 parents and completed by 559 (54%). Seventeen satisfaction items were rated with mean scores <8.0 (1, completely unimportant, to 10, very important) with standard deviations ≥1.65, and thus considered of limited value. The empirical structure of the items was in agreement with the theoretically formulated domains: Information, Care and Cure, Organization, Parental Participation, and Professional Attitude. The Cronbach’s α of the domains ranged between 0.87 and 0.94.ConclusionsParental perceptions on satisfaction with care measures were identified and prioritized. Reliabilities of the items and domains were of high level.

Tidal Volume and Mortality in Mechanically Ventilated Children: A Systematic Review and Meta-Analysis of Observational Studies

Objective:To determine whether tidal volume is associated with mortality in critically ill, mechanically ventilated children. Data Sources:MEDLINE, EMBASE, and CINAHL databases from inception until July 2013 and bibliographies of included studies without language restrictions. Study Selection:Randomized clinical trials and observational studies reporting mortality in mechanically ventilated PICU patients. Data Extraction:Two authors independently selected studies and extracted data on study methodology, quality, and patient outcomes. Meta-analyses were performed using the Mantel-Haenszel random-effects model. Heterogeneity was quantified using I2. Study quality was assessed using the Newcastle-Ottawa Score for cohort studies. Data Synthesis:Out of 142 citations, seven studies met the inclusion criteria, and additional two articles were identified from references of the found articles. One was excluded. These eight studies included 1,756 patients. Mortality rates ranged from 13% to 42%. There was no association between tidal volume and mortality when tidal volume was dichotomized at 7, 8, 10, or 12 mL/kg. Comparing patients ventilated with tidal volume less than 7 mL/kg and greater than 10 mL/kg or greater than 12 mL/kg and tidal volume less than 8 mL/kg and greater than 10 mL/kg or greater than 12 mL/kg also showed no association between tidal volume and mortality. Limiting the analysis to patients with acute lung injury/acute respiratory distress syndrome did not change these results. Heterogeneity was observed in all pooled analyses. Conclusions:A relationship between tidal volume and mortality in mechanically ventilated children could not be identified, irrespective of the severity of disease. The significant heterogeneity observed in the pooled analyses necessitates future studies in well-defined patient populations to understand the effects of tidal volume on patient outcome.

Transfusion of Leukocyte-Depleted RBCs Is Independently Associated With Increased Morbidity After Pediatric Cardiac Surgery

Objective: To test the hypothesis that transfusion of leukocyte-depleted RBC preparations within the first 48 hours of PICU stay was independently associated with prolonged duration of mechanical ventilation, irrespective of surgery type and disease severity. Design: Retrospective, observational study. Setting: Single-center PICU in The Netherlands. Patients: Children less than 18 years consecutively admitted after pediatric cardiac surgery between February 2007 and February 2010. Interventions: None. Measurements and Main Results: Data from 335 patients were used for analysis of whom 86 (25.7%) were transfused during the first 48 hours of PICU stay. Duration of mechanical ventilation (115 ± 19 hours vs. 25 ± 4 hours, p < 0.001) was longer among transfused patients. Ventilator-associated pneumonia (10.5% vs. 1.6%, odds ratio 7.2; 95% confidence interval 1.92–32.47; p < 0.001) was more frequent among transfused patients. New acute kidney injury after 48 hours of PICU admission (23.9% vs. 15.4%, p = 0.18) and mortality were comparable (2.3% vs. 4%, p = 0.16). The number of discrete transfusion events was significantly correlated with the duration of mechanical ventilation (Spearman’s rho 0.617, p < 0.001). Transfusion remained independently associated with prolonged duration of mechanical ventilation after adjusting for confounders using Cox proportional hazards regression analysis. Conclusions: Transfusion of leukocyte-depleted RBCs within the first 48 hours of PICU stay after cardiac surgery is independently associated with prolonged duration of mechanical ventilation.

Routine enteral nutrition in neonates on extracorporeal membrane oxygenation

Objectives: To evaluate over a 5-yr period the feasibility and tolerance of a protocol of routine enteral nutrition in neonates requiring extracorporeal membrane oxygenation (ECMO). Design: Retrospective medical chart review. Setting: Level III children’s hospital, pediatric surgical intensive care unit. Patients: Neonates treated with venoarterial ECMO (VA-ECMO) between January 1997 and January 2002. Patients with congenital diaphragmatic hernia were excluded. Interventions: None. Measurements and Main Results: Charts of all neonates treated with VA-ECMO were reviewed. Feasibility was evaluated by recording the time period needed for enteral nutrition to reach 40% of total fluid intake; tolerance was evaluated by reviewing data on enteral nutrition related morbidity. Sixty-seven of the 77 eligible patients received enteral feeding during ECMO. Thirty-six of these patients (54%) received 40% of total fluid intake as enteral nutrition within a median of 3 (range, 2–4) days. Over the years there was a trend toward an increasing usage of enteral nutrition from 71% to 94% (p = .07). Enteral nutrition was temporarily discontinued in 16 patients, with 14 showing gastric retentions, one showing discomfort, and one showing aspiration. Symptoms of bilious vomiting, blood-stained stool, or abdominal distention were not present. Conclusion: Neonates on ECMO in this series tolerated enteral feeding well and did not show serious adverse effects. Overall, it is our experience that routine use of enteral feeding in critically ill neonates on VA-ECMO is feasible.

Infants with severe respiratory syncytial virus needed less ventilator time with nasal continuous airways pressure then invasive mechanical ventilation

Nasal continuous positive airway pressure (NCPAP) has been proposed as an early first‐line support for infants with severe respiratory syncytial virus (RSV) infection. We hypothesised that infants <6 months with severe RSV would require shorter ventilator support on NCPAP than invasive mechanical ventilation (IMV).

Buccal vs. nasogastric tube administration of tacrolimus after pediatric liver transplantation

Abstract:  Tacrolimus is an important drug for immunosuppression after liver transplantation. Bioavailability of enterally administered tacrolimus is poor, and further reduced by gastric residuals or by enteral nutrition. Buccal administration might be an alternative route especially in children. Tacrolimus trough levels (TTLs) obtained after buccal administration of tacrolimus after liver transplantation have not been reported. The aim of this study was to determine whether buccal administration of tacrolimus is feasible and to compare TTLs after nasogastric tube (NGT) administration with buccal administration. TTLs after NGT or buccal administration during the first week after pediatric liver transplantation were analyzed from 28 cadaveric liver transplants in 23 pediatric recipients between June 2002 and March 2004. Each level was scored within, under or above the target range. Buccal administration was well tolerated in all patients. A total of 149 TTLs were obtained of which nine were excluded because of incomplete information on target levels. Overall 27% of TTLs was adequate. The percentage of levels under, within and above the target range were comparable in both groups (chi‐square test; p = 0.64). Both groups had a decrease in percentages within the target range on day 3 and 4 after liver transplantation with a subsequent rise. Buccal tacrolimus administration is feasible. Similar TTLs are achieved compared with NGT tacrolimus administration during the first week after pediatric liver transplantation.

Children's opinions about organ donation: a first step to assent?

BACKGROUND Parents have to decide about organ donation after the death of their child. Although most parents probably would like to respect their childs intentions, parents often are not aware of their childs wishes. This requires insight into childrens opinions about donation. METHODS An internet survey that investigated whether Dutch children in the age range of 12 through 15 years had heard about organ donation, what their opinions were on donation and whether the topic had been discussed at home. Questionnaire response rate 38%. RESULTS Around 99% of 2016 responders had heard about organ donation and about the possibility of becoming a donor, 75% preferred to decide for themselves about donation, 43% had discussed organ donation more than once at home, 66% were willing to donate. The willingness to donate was positively associated with age and socio-economic status. CONCLUSION This survey indicates that these children at 12 through 15 years of age are capable and willing to think about organ donation. Thought should be given about how to raise awareness and how to enable parents and children to develop some sort of health literacy concerning the concept of organ donation. Children and their parents should be given adequate opportunities to receive appropriate information, suited to their psychological and moral developmental status.