Ming-Chou Chiang

Therapeutic Hypothermia Associated With Increased Survival After Resuscitation in Children

Brain injury after resuscitation is associated with high morbidity and mortality in children. Therapeutic hypothermia has theoretical benefits on brain preservation. It has been shown to be effective in improving neurological outcomes after adult ventricular arrhythmia-induced cardiac arrest and neonatal asphyxia. However, there have only been a few reports about therapeutic hypothermia after pediatric resuscitation. We conducted this retrospective cohort study in a tertiary pediatric intensive care unit between January 2010 and June 2012. All children from 2 months to 18 years of age with resuscitation and a history of at least 3 minutes of chest compressions with survival for 12 hours or more after return of circulation were eligible. Forty-three patients met the eligibility criteria for the study. Forty-two patients (97.6%) were asphyxial in etiology; 29 (67.4%) of them occurred out-of-hospital. Excluding one child with cardiac etiology, the overall survival rate to hospital discharge was 57.1%. Fourteen (33.3%) patients received hypothermia therapy and were cooled to 33°C for 72 hours. The survival rate was higher in the therapeutic hypothermia group (11/14, 78.6%) than in the normothermia group (13/28, 46.4%). In conclusion, therapeutic hypothermia was associated with increased survival rate after pediatric resuscitation.

Streptococcal toxic shock syndrome in children without skin and soft tissue infection: report of four cases.

UNLABELLED Streptococcal toxic shock syndrome is a fulminant, highly fatal disease characterized by evidence of group A beta-haemolytic streptococcus infection and early shock with consecutive organ failure. In adults, affected individuals usually have preceding skin or soft tissue infection. However, in paediatric patients, except for varicella, the background focus is usually respiratory tract infection, and early diagnosis of streptococcal toxic shock syndrome in such patients is difficult. We report four previously healthy children with streptococcal toxic shock syndrome. Pharyngitis was identified in three cases. All of them had constitutional symptoms such as fever, vomiting, diarrhoea, abdominal pain and physical findings of tachycardia and diffuse abdominal tenderness, but no concomitant skin infection. CONCLUSION Streptococcal toxic shock syndrome should be considered in paediatric patients with fever, vomiting, diarrhoea, abdominal pain and early shock. Early diagnosis, prompt initiation of antibiotics and aggressive fluid therapy are lifesaving for such patients.

Red Blood Cell Transfusion and Clinical Outcomes in Extremely Low Birth Weight Preterm Infants.

BACKGROUND Red blood cell (RBC) transfusion is often considered a life-saving measure in critically ill neonates. The smallest and least mature infants tend to receive the largest amount of transfusions. RBC transfusion itself has also been suggested as an independent risk factor of poor clinical outcome in critical patients. Our aim is to study if there are associations between RBC transfusion and in-hospital mortality, short-term morbidities, and late neurodevelopmental outcome in extremely low birth weight (ELBW) preterm infants. METHODS A cohort of ELBW preterm infants admitted to our neonatal intensive care unit from January 2009 to December 2010 were recruited. The number of RBC transfusions within 7 days, 30 days, and 60 days of life were recorded. Clinical outcomes including in-hospital mortality, development of retinopathy of prematurity (ROP), necrotizing enterocolitis, chronic lung disease, and later neurodevelopmental outcome were assessed with follow-up of up to 2 years of age. Multivariable logistic regression was used to estimate the associations between RBC transfusion and clinical outcomes. RESULTS A total of 98 ELBW preterm infants survived at the time of discharge. Of these survivors, the mean numbers of RBC transfusions were 2.5 ± 1.7, 7.4 ± 3.1, and 11.3 ± 4.5 times within 7 days, 30 days, and 60 days after birth, respectively. The number of transfusions within 7 days of life was correlated with risk of death before 1 month of age (odds ratio: 1.54, 95% confidence interval: 1.04-2.27, p = 0.03) and the number of transfusions within 30 days was correlated with risk of developing threshold ROP (odds ratio: 1.27, 95% confidence interval: 1.04-1.55, p = 0.02). The number of transfusions within 7 days of life was positively correlated with cognitive performance (Mental Developmental Index score) at 18-24 months of corrected age. CONCLUSION RBC transfusion has a negative impact on survival in ELBW infants. It increases the risk of developing ROP and affects late neurodevelopment. Decisions of blood transfusion in these very immature infants should be made cautiously taking these deleterious results into consideration.

Transcranial Doppler ultrasound in therapeutic hypothermia for children after resuscitation.

AIM OF THE STUDY The aim of the present study was to assess the cerebral flow in children receiving therapeutic hypothermia after resuscitation. The prognostic value of transcranial Doppler findings was correlated with the clinical outcomes in these children. METHODS A retrospective cohort study was conducted at the paediatric intensive care unit of Chang Gung Childrens Hospital between January 2011 and December 2012. All children from 1 month to 18 years of age who received therapeutic hypothermia after resuscitation were eligible. Serial transcranial Doppler examinations were performed and the findings were reviewed. RESULTS Seventeen children met the eligibility criteria for this study. Fourteen patients (82.3%) were asphyxial in aetiology, and 12 (70.5%) of these cases occurred outside of the hospital. Eight patients (47.1%) had a Paediatric Cerebral Performance Score of 1 or 2 at 3 months after the events. Reversal diastolic or undetectable flow patterns during therapeutic hypothermia were associated with unfavourable prognosis. Normal mean flow velocity in the rewarming phase and normal pulsatility index in the hypothermia and rewarming phases were associated with favourable outcome. CONCLUSION The transcranial Doppler examinations provided additional information for cerebral perfusion during therapeutic hypothermia, which may in the future be used to guide changes to hypothermia management. Mean cerebral blood flow velocity and pulsatility index by transcranial Doppler sonography can serve as a prognostic factor for children who receive therapeutic hypothermia after resuscitation.

Clinical Manifestations, Outcomes, and Etiologies of Perinatal Stroke in Taiwan: Comparisons between Ischemic, and Hemorrhagic Stroke Based on 10-year Experience in A Single Institute

BACKGROUND Perinatal stroke is a common cause of established neurological sequelae. Although several risk factors have been identified, many questions regarding causes and clinical outcomes remain unanswered. This study investigated the clinical manifestations and outcomes of perinatal stroke and identified its etiologies in Taiwan. METHODS We searched the reports of head magnetic resonance imaging and computed tomography performed between January 2003 and December 2012. The medical records of enrolled infants with perinatal stroke were also reviewed. RESULTS Thirty infants with perinatal stroke were identified; 10 infants had perinatal arterial ischemic stroke (PAIS) and 20 had perinatal hemorrhagic stroke (PHS). Neonatal seizure was the most common manifestation and presented in 40% of infants with PAIS and 50% of infants with PHS. All survivors with PAIS and 77% of the surviving infants with PHS developed neurological sequelae. Acute seizure manifestation was associated with poststroke epilepsy in infants with PHS but not in infants with PAIS (86% vs. 0%, p=0.005). PAIS was mostly caused by dysfunctional hemostasis (20%) and embolism (20%), whereas PHS was mostly attributable to birth asphyxia (30%). CONCLUSION Perinatal stroke is associated with high mortality and morbidity rates in infants. Clinically, it can be difficult to distinguish PAIS and PHS. One should keep a high level of suspicion, especially for PHS, if infants develop unexplained seizure, cyanosis, conscious change, anemia, and/or thrombocytopenia. A systematic diagnostic approach is helpful in identifying the etiologies of perinatal stroke.

Thermal Blanket to Improve Thermoregulation in Preterm Infants: A Randomized Controlled Trial.

Objective: To determine the effectiveness of temperature-controlled thermal blanket as additional thermoprotection. Design: Randomized controlled prospective study. Setting: Single-center tertiary neonatal unit. Patients: Inborn very low-birth-weight (< 1,500 g) infants. Interventions: Infants were prospectively assigned to thermal blanket group or control at 1:1 ratio. Additional to radiant warmers, a prewarmed blanket of Blanketrol II (Cincinnati Sub-Zero Products, Cincinnati, OH) was applied as mattress for thermal blanket group. The outcomes included temperature and blood pressure changes. We defined hypothermia as temperature less than 36°C and hypotension as mean arterial pressure less than index infant’s gestational age in weeks. Measurements and Main Result: Total 80 very low-birth-weight infants were allocated, and there was no between-group demographic dissimilarity. At 30th minute, fewer infants in thermal blanket group were hypothermic (43% vs 68%; p = 0.025). These infants had significantly lower prevalence of hypotension, which associated with less dopamine use in the first 6 hours of life (25% vs 50%; p = 0.016). There was no hyperthermia more than 37.5°C episode. Conclusions: By using thermal blanket to provide additional thermal protection for very low-birth-weight infants, the degree of hypothermia was improved, which related to fewer hypotensive cases and less dopamine usage.

Streptococcal toxic shock syndrome in children without skin and soft tissue infection: Report of four cases: Clinical observations

Streptococcal toxic shock syndrome is a fulminant, highly fatal disease characterized by evidence of group A β‐haemolytic streptococcus infection and early shock with consecutive organ failure. In adults, affected individuals usually have preceding skin or soft tissue infection. However, in paediatric patients, except for varicella, the background focus is usually respiratory tract infection, and early diagnosis of streptococcal toxic shock syndrome in such patients is difficult. We report four previously healthy children with streptococcal toxic shock syndrome. Pharyngitis was identified in three cases. All of them had constitutional symptoms such as fever, vomiting, diarrhoea, abdominal pain and physical findings of tachycardia and diffuse abdominal tenderness, but no concomitant skin infection.