Mariano Fiallos

Use of intraosseous blood to assess blood chemistries and hemoglobin during cardiopulmonary resuscitation with drug infusions.

OBJECTIVE To compare intraosseous with central venous blood samples for biochemical analyses and hemoglobin levels during cardiopulmonary resuscitation (CPR) and during cardiopulmonary resuscitation with infusion of sodium bicarbonate, epinephrine, and saline boluses through the intraosseous site. DESIGN Prospective, complete repeated measures study. SETTING An animal laboratory at a university medical center. SUBJECTS Thirty-two piglets (mean weight, 30 [range, 24-35] kg). INTERVENTIONS Animals were anesthetized, instrumented, and subjected to hypoxic cardiac arrest. An intraosseous cannula was inserted into the tibia, and animals were randomly assigned to one of five groups: heparinized saline (n = 6), epinephrine infusions only (n = 6), saline infusions only (n = 6), sodium bicarbonate infusions only (n = 8), and epinephrine, saline, and sodium bicarbonate infusions through the same site (n = 6). CPR (chest compressions and mechanical ventilation) was performed in all groups. Simultaneous blood samples were taken from the central venous and intraosseous sites before arrest and after 5 and 30 mins of CPR. MEASUREMENTS AND MAIN RESULTS There were no differences (p < .05) in sodium, potassium, magnesium, lactate, and calcium values of intraosseous and central venous blood at the baseline and during 5 mins of CPR with infusions through the intraosseous cannula. At 30 mins, differences were apparent in magnesium, potassium, and sodium values between groups when the intraosseous cannula was used for infusions as well as sampling. Intraosseous potassium, glucose, and magnesium values were lower and sodium values were higher than central venous blood levels. No differences were seen at all sampling intervals if small-volume heparinized saline was given through the intraosseous site. Hemoglobin values were lower in the intraosseous group after 30 mins of CPR and infusions through the intraosseous site. After 30 mins of CPR, all hemoglobin values from the intraosseous site were <10 g/100 mL. CONCLUSION Intraosseous and central venous blood biochemical and hemoglobin values were similar during hemodynamic stability and throughout 30 mins of resuscitation if no drugs were given through the intraosseous site. However, differences existed after 30 mins of CPR and infusions through the intraosseous site. Laboratory values may be erroneous when intraosseous blood is used during periods of resuscitation of >5 mins if drugs and fluid boluses have also been infused through the site. For reliable values, an intraosseous site for sampling only may be reasonable.

Acid-base status of blood from intraosseous and mixed venous sites during prolonged cardiopulmonary resuscitation and drug infusions.

OBJECTIVES a) To determine the relationship of acid-base balance (pH, PCO2) of blood samples from the intraosseous and the mixed venous route during prolonged cardiopulmonary resuscitation; b) to compare the effect of separate infusions of epinephrine, fluid boluses, or sodium bicarbonate through the intraosseous sites on the acid-base status of intraosseous and mixed venous blood during cardiopulmonary resuscitation; and c) to compare pH and Pco2 of intraosseous and mixed venous blood samples after sequential infusions of fluid, epinephrine, and sodium bicarbonate through a single intraosseous site. DESIGN Prospective, randomized study. SETTING Animal laboratory at a university center. SUBJECTS Thirty-two mixed-breed piglets (mean weight, 30 kg). INTERVENTIONS Piglets were anesthetized and prepared for blood sampling and cardiopulmonary resuscitation. After anoxic cardiac arrest, ventilation was resumed and chest compression was resumed. Blood gas samples from the pulmonary artery and both intraosseous sites were obtained simultaneously at baseline, at cardiac arrest, and at 5, 10, 15, 20, and 30 mins of cardiopulmonary resuscitation for group 1 (control group) and after drug (epinephrine and sodium bicarbonate) and saline infusions via one of the intraosseous cannulas in groups 2 through 5. MEASUREMENTS AND MAIN RESULTS We found no differences between intraosseous and mixed venous pH and Pco2 during periods of <15 mins of cardiopulmonary resuscitation. However, this relationship was not maintained during prolonged cardiopulmonary resuscitation and after bicarbonate infusion. After large volume saline infusion, the pH and Pco2 of mixed venous and intraosseous blood were similar. During epinephrine infusion, the relationship between intraosseous and mixed venous pH and Pco2 was similar to that found in the control group. CONCLUSIONS The intraosseous blood sample could be used to assess central acid-base balance in the early stage of arrest and cardiopulmonary resuscitation of <15 mins. However, during cardiopulmonary resuscitation of longer duration, drug infusions may render the intraosseous site inappropriate for judging central acidosis.

Is Aspirin a Cause of Reye’s Syndrome?

Reye’s syndrome was a rare disease which appeared suddenly in the early 1950s and disappeared just as suddenly in the late 1980s. An association between Reye’s syndrome and the ingestion of aspirin (acetylsalicylic acid) was claimed, although no proof of causation was ever established. The presence of salicylates in the blood or urine of Reye’s syndrome patients has not been demonstrated, and no animal model of Reye’s syndrome has been developed where aspirin causes the disease. It is clear from epidemiological data that the incidence of Reye’s syndrome was decreasing well before warning labels were placed on aspirin products. Reye’s syndrome disappeared from countries where aspirin was not used in children as well as from countries which continued to use aspirin in children. Reye’s syndrome was probably either a viral mutation which spontaneously disappeared, or a conglomeration of metabolic disorders that had not been recognized or described at that time.

Diabetic Ketoacidosis in the Pediatric ICU

Diabetic ketoacidosis (DKA) is a common, life-threatening complication of diabetes mellitus in children. Central nervous system changes seen in DKA include the altered sensorium seen commonly in DKA and loosely characterized as diabetic coma and the uncommon but worrisome progressively deepening coma caused by cerebral edema, which has both a high morbidity and mortality. This article discusses the assessment and treatment of DKA in the setting of the pediatric ICU.

Association of Mycoplasma Pneumoniae Infections with Status Asthmaticus

Background & Objective: Viral respiratory infections (VRI) have been commonly associated with exacerbation of wheezing in asthmatic children. Mycoplasma pneumoniae (MP) causes many respiratory syndromes that clinically mimic VRI. Due to the nature of the organism, cultures are of no practical value and the diagnosis is usually made by serology. Only a few studies have associated mycoplasma infections with acute exacerbations of wheezing in the asthmatic patient. This study was an attempt to assess the incidence of recent mycoplasma infections in patients with status asthmaticus and to review their laboratory, clinical and radiological findings. Methods: Retrospective review of all patients admitted to PICU over 12 month period with status asthmaticus. Recent mycoplasma infection was determined utilizing the Immunocard Mycoplasma Enzyme Immunoassay (EIA) for detection of MP IgM antibodies (Meredian Diagnostics, Inc., Cincinnati, OH) Results; The records of 44 patients were reviewed. 9 were excluded because MP tests were never obtained during hospitalization. 15/35 (42%) were MP Positive. There were no statistically significant differences (P>0.05) in length of hospitalization (LOH), ICU days, duration of continuous albuterol aerosol hours (cont. Nebs hrs.), days on O2 (02 days) or WBC between the two groups, however patients who were mycoplasma positive were treated with a macrolide antibiotic in addition to their standard asthma therapy. Patients with evidence of recent MP infection were more likely to have one or more infiltrates on their CXR (13/15 vs 7/20; P= 0.002). Conclusion: Our study suggests that recent MP infections play a significant role in exacerbations of asthma and occurrence of status asthmaticus in children. The presence of infiltrates on CXR in status asthmaticus warrants tests for MP.

POINT-OF-CARE TESTING

Point-of-care testing technology rapidly is changing the way physicians practice medicine by facilitating the availability of biochemical parameters immediately or almost immediately. The constant evolution and developments in [figure: see text] microchemistry and computer technology will make this area a dynamic part of medicine with the constant emergence of improved and newer technologies. Clinicians must not forget, however, that the best analyzer and monitor is the physician, nurse, or other health care worker in direct contact with the patient, constantly reassessing, re-examining, and integrating all of the physiologic and biochemical data in the context of the history and physical examination. If POC testing is implemented, its goal should be to improve and assist in patient care.

Supraventricular Tachycardia With Underlying Atrial Flutter in a Diabetic Ketoacidosis Patient

Diabetic ketoacidosis (DKA) is one of the most common complications in adolescents and young adults with type 1 diabetes. Type 1 diabetes with childhood onset has an incidence that fluctuates from 0.1 to 57.6 per 100,000 and is on the rise (1). In children with type 1 diabetes, the incidence of DKA has been reported to be >30% (2). In a study conducted by Dabelea et al. (3), a higher prevalence of DKA was reported in patients who were younger, male, or of a minority race/ethnicity. Complications of DKA are multiple and include electrolyte disturbances, acute kidney failure, and respiratory distress. The most serious DKA complication is cerebral edema (4). The incidence of cerebral edema in DKA patients is 1%, but the associated mortality rate is 20–25% (5–7). Although electrolyte abnormalities are common, arrhythmias are a rare complication of DKA. We report here the case of a 12-year-old girl who presented with DKA and subsequently developed supraventricular tachycardia (SVT) with an underlying atrial flutter rhythm. A 12-year-old girl with a known history of type 1 diabetes presented with altered mental status of 1 day’s duration. The event was precipitated by the consumption of a large quantity of sugar-sweetened beverages. Her vital signs in the emergency department showed a respiratory rate of 32 breaths/min, heart rate of 204 bpm, and blood pressure of 135/115 mmHg. The patient was tachycardic with Kussmaul respirations and lethargic, and she only responded to deep painful stimuli. Although the patient was diagnosed with type 1 diabetes at the age of 10 years and had experienced previous episodes of DKA, cardiac abnormalities had never occurred before. Except for a maternal great grandmother with type 2 diabetes, her family history was noncontributory. The patient received 2,000 mL of normal saline boluses and 2 units of regular …

ROLE OF INTRAOSSEOUS SITE IN ASSESSING CENTRAL ACIDOSIS DURING CARDIOPULMONARY RESUSCITATION. 239

ROLE OF INTRAOSSEOUS SITE IN ASSESSING CENTRAL ACIDOSIS DURING CARDIOPULMONARY RESUSCITATION. 239

INTRAOSSEOUS BLOOD UTILIZATION TO ASSESS SODIUM, POTASSIUM AND GLUCOSE DURING PROLONGED CARDIOPULMONARY RESUSCITATION AND DRUG INFUSIONS 283

Intraosseous (IO) blood samples can be used for routine laboratory studies. However, whether intraosseous samples are useful during CPR and drug infusions is unknown. We compared Na+, K+ and glucose levels from an IO cannula with central venous (CV) samples during CPR and after drug infusions. Piglets were mechanically ventilated and IO, carotid and PA cannulas inserted. Following hypoxic arrest, chest compressions and mechanical ventilation was resumed. During CPR, at 5, 10 and 15 min, animals received normal saline (NS, n=6), epinephrine (Epi, n=6), and sodium bicarbonate (NaHCO3, n=8) via IO. Blood from IO and CV were obtained pre-arrest (xx),and 5 min and 30 min of CPR. The table shows mean and r values at specified times. (p <.05 statistically significant)

INCIDENCE OF FAT AND BONE MARROW EMBOLISM WITH THE USE OF INTRAOSSEOUS INFUSION DURING CARDIO-PULMONARY RESUSCITATION. † 264

INCIDENCE OF FAT AND BONE MARROW EMBOLISM WITH THE USE OF INTRAOSSEOUS INFUSION DURING CARDIO-PULMONARY RESUSCITATION. † 264