Matthias Kumpf

Nurse-driven pediatric analgesia and sedation protocol reduces withdrawal symptoms in critically ill medical pediatric patients.

While several analgesia and sedation guidelines and protocols have been developed and implemented for adults, there is still little evidence of clinical use of analgesia and sedation protocols and the impact on withdrawal symptoms in critically ill children.

Clinical and in vitro Effect of Dornase Alfa in Mechanically Ventilated Pediatric Non-Cystic Fibrosis Patients with Atelectases

Introduction: At present no evidence-based medical treatment for persistent atelectasis in pediatric non-cystic fibrosis (CF) patients is available. Method: To evaluate the use of intratracheally instilled recombinant human deoxyribonuclease (rhDNase) in intubated and ventilated pediatric patients, we performed a single-center observational study on 46 pediatric intensive care patients who had received intratracheal DNase. Patients were classified, according to radiologic findings of atelectasis (group 1) or infiltrates. As controls we examined a historical control group of 17 patients with atelectasis after cardiac surgery, who had been treated with NaCl 0.9% and matched for age and diagnosis with 21 patients from group 1 (subgroup 1a). Radiologic improvement and inflammatory markers in both serum and tracheal aspirates were measured. Results: In group 1, 35 patients had 51 atelectases/dystelectases episodes at baseline. 67 % of patients showed radiologic signs of improvement after 24h treatment with rhDNase. In subgroup 1a, 16 patients had complete resolution of atelectases and minimal change in dystelectases after a treatment of 24 hours rhDNase, compared with the control group of 17 patients, who had 7 atelectases and 10 dystelectases at baseline and an improvement in only 1 out of 17 (6 %) patients after 24h. Conclusion: Intratracheal instillation of rhDNase is an effective adjunct to conservative therapy of atelectases in children. Further randomized controlled prospective studies are necessary.

Cervical origin of the subclavian artery as a specific marker for monosomy 22q11

In our study of 136 patients with conotruncal malformations, anomalies of the subclavian arteries were present in >60% of children with monosomy 22q11. Because cervical origin of the right subclavian artery was exclusively found in patients with monosomy 22q11, this anomaly might represent a specific marker for this microdeletion.

Anomalous origin of left coronary artery in young athletes with syncope

Possible causes of exercise induced syncope or sudden death in young athletes include undetected cardiomyopathies, myocarditis, arrhythmias (especially inherited arrhythmia syndromes—such as long QT syndrome, Brugada syndrome), coronary artery abnormalities and disease, and aortic rupture.1 2 3 Coronary artery anomalies are of special interest as they are potentially treatable lesions.4 5 The most frequent coronary artery anomaly is anomalous origin of the left coronary or the left anterior descending artery from the right coronary sinus of the aorta. According to a recent north Italian study, anomalous origin of left or right coronary artery from the opposite aortic sinus is the third most frequent cardiovascular cause of deaths associated with exercise among athletes aged 12-35 years.2 Fig 1 Coronary artery anatomy in case 1 as shown by echocardiography from the parasternal short axis: both the right and left coronary arteries originate from the right aortic sinus. The main left coronary artery courses between the aorta and pulmonary artery and divides into left anterior descending artery and left circumflex branch We report on two adolescents who presented with a history of recurrent exertional pain and syncope during exercise. The results of previous cardiological evaluation—including 12 lead electrocardiography, exercise testing, and echocardiography—had been normal. Both patients were admitted to our hospital after life threatening events of ventricular fibrillation. The diagnosis of the coronary artery anomaly was detected in both patients by transthoracic echocardiography. These two cases show that this potentially fatal anomaly cannot be excluded by a negative exercise test.1 4 ### Case 1 This 15 year old boy was a talented, competitive soccer player with a history of recurrent syncope during soccer training at the age of 6, 7, and 11. Previous …

Surgical correction of scoliosis in children with congenital heart failure (Fontan circulation): case report and literature review

Patients with Fontan circulation represent a significant cardiorespiratory risk during spinal surgery. We report about two patients with severe scoliosis and Fontan circulation and their successful operative treatment. The case report will be compared with the national and international literature.

Perioperative epidural analgesia in children undergoing major abdominal tumor surgery — a single center experience

PURPOSE The purpose of this study was to assess the use of continuous epidural analgesia in pediatric patients undergoing major abdominal tumor surgery. METHODS Children undergoing major abdominal tumor surgery at our institution between 2008 and 2012 (n=40) received continuous epidural analgesia via an epidural catheter. Surgical trauma scores, pain scores, and clinical data of the children were compared to a pair-matched historical control group operated on between 2002 and 2007 without epidural analgesia. RESULTS Pain levels in the study group on day 1 and 3 after surgery were lower compared to the control group. The differences did, however, not reach statistical significance (p=0.15 and 0.09). Children in the study group received significantly fewer additional doses of piritramide or morphine (45% versus 82%, p<0.001). Despite significantly higher surgical trauma scores in the study group (p=0.018), there were no statistical differences regarding clinical parameters, such as mechanical ventilation time, time on intensive care unit, and total hospital stay. There were no catheter-related complications. CONCLUSIONS Continuous epidural analgesia is beneficial for children undergoing complex abdominal tumor surgery with regard to pain levels, postoperative recovery, and general clinical course. Expertise of the managing team, a careful patient selection, and a continuous quality assessment are essential for success.

Serum Concentrations of Interleukin-6, Procalcitonin, and C-Reactive Protein: Discrimination of Septical Complications and Systemic Inflammatory Response Syndrome after Pediatric Surgery.

BACKGROUND Early differentiation between sepsis and systemic inflammatory response syndrome (SIRS) is useful for therapeutic management in neonates and infants after surgery. OBJECTIVE To compare the early (first 2 days) diagnostic value of interleukin-6 (IL-6), procalcitonin (PCT), and C-reactive protein (CRP) after surgery in the differentiation of subsequent SIRS and septic complications. METHODS IL-6, PCT, and CRP were measured 0, 24, and 48 hours after surgery in neonates and infants with clinical suspicion of postoperative sepsis. Sensitivity, specificity, and predictive values for SIRS/septic complications were calculated. RESULTS A total of 31 out of 205 neonates and infants showed clinical signs for postoperative sepsis and underwent sepsis work-up. Nine patients developed septic complications, sixteen patients met criteria for SIRS, and six patients showed an uneventful postoperative course during the first five postoperative days. IL-6, PCT, and CRP levels increased in all subgroups after surgery and were significantly higher in the sepsis group (p < 0.05). IL-6 peaked immediately, CRP at 24 to 48 hours, and PCT at 24 hours after surgery. Sensitivity and specificity (area under the curve) for IL-6 (cutoff 673 ng/dL) were 94.4 and 75% (86.2%), for CRP (cutoff 1.48 mg/dL) 76.2 and 75.0% (88.1%), and for PCT (cutoff 16.1 mg/L) 66.7 and 57.1% (65.6%). CONCLUSION IL-6 appears to be an early marker for severe bacterial infections with high sensitivity. IL-6 and CRP were the most reliable markers for the discrimination between SIRS and sepsis within the postoperative period.

Acquired von Willebrand syndrome in congenital heart disease surgery: results from an observational case-series

Essentials Bleeding complications during congenital heart disease surgery in neonatal age are very common. We report the perioperative incidence of acquired von Willebrand syndrome (aVWS) in 12 infants. aVWS was detected in 8 out of 12 neonates and infants intraoperatively after cardiopulmonary bypass. Ten patients received von Willebrand factor concentrate intraoperatively and tolerated it well.

Realistic 3D-Printed Tracheobronchial Tree Model from a 1-Year-Old Girl for Pediatric Bronchoscopy Training

rial (Materialise, Germany) ( Fig. 1 a, b). The model was evaluated by flexible and rigid bronchoscopy using the smallest fiberoptic bronchoscope with a working channel available for routine bronchoscopy with an outer diameter of 2.8 mm (11005 BC1 and 11278VS, Storz, Germany) and a video bronchoscope with an outer diameter of 3.7 mm (Pentax EB1170K, Pentax, Germany). Filling the model with water provided realistic conditions for examination, most notably through the reduction of light reflection of the inner surface of the model ( Fig. 2 , 3 and online suppl. videos; see www. karger.com/doi/10.1159/000459631). The possibility to train bronchoscopic procedures in a small anatomic model could increase the accuracy, speed, and safety of performance in neonates and small infants. In addition to training the procedure in normal anatomy, also rare airway pathologies in children or interventional procedures (e.g., foreign body removal) could be trained [2–5] .

Safety and Efficacy of Terlipressin in Pediatric Distributive Shock: A Retrospective Analysis in 20 Children

IntroductionData are still lacking about the use of terlipressin or vasopressin in the treatment of pediatric patients who are in a state of therapy-refractory shock.ObjectiveThe aim of this study was to evaluate the effect of terlipressin on hemodynamics in children with distributive shock and to describe any severe side effects.MethodsConsecutive patients (n = 20) with catecholamine-resistant distributive shock who were treated with terlipressin were retrospectively enrolled in this study. We analyzed response in terms of mean arterial blood pressure, heart rate, vasoactive inotropic score (VIS), urinary output, and serum lactate.ResultsThe hemodynamics of 12 children significantly improved within 6 h of commencing terlipressin (mean blood pressure increase of ≥20 % without VIS increase, or mean blood pressure increase of ≥10 % with VIS decrease of ≥10 %). The hemodynamics of eight patients did not improve, regardless of treatment dosage or duration. More children died in the responders group (n = 7 [58.3 %]) than in the non-responders group (n = 2 [25.0 %]), but this was not statistically significant. Two patients (one in each group) who received high dosages of terlipressin developed rhabdomyolysis. One case of Takotsubo cardiomyopathy was observed, which could be related to terlipressin.ConclusionsAlthough treatment with terlipressin resulted in rapid positive hemodynamic responses in some children, it did not seem to have a positive effect in other pediatric patients. Therefore, the possible benefits of terlipressin should be always weighed against potential severe adverse effects.