Paula Alonso-Quintela

Ascending aorta elasticity in children with isolated bicuspid aortic valve

BACKGROUND Aortic dilation is common in children with bicuspid aortic valve (BAV) but aortic complications are infrequent. The aim of this study was to investigate elastic properties of the ascending aorta (AAo) and its relation to AAo size in children with isolated BAV without significant valve dysfunction. METHODS 24 children with isolated BAV and 24 healthy controls with tricuspid aortic valve (TAV) matched by gender, age and body surface area (BSA) were studied. Aortic strain (AS), aortic distensibility (DIS) and aortic stiffness index (SI) were derived from M-mode echocardiography at the AAo together with cuff blood pressure recordings. BAV children with dilated AAo (z score ≥ 2) and non dilated (z score<2) were compared. RESULTS BAV children had larger aortas than controls at the sinuses of Valsalva, sinotubular junction and AAo (p<0.05). AS was lower in BAV than in controls (10.15 ± 4.93 vs 16.93 ± 5.17 p=0.000), DIS was lower in BAV than in controls (8.51 ± 3.90 vs 14.37 ± 4.20 p=0.000) and SI was higher in BAV than in controls (7.19 ± 4.45 vs 4.05 ± 2.33 p=0.04). There were no significant differences in AS, DIS and SI between children with dilated and non-dilated AAo. AS, DIS and SI were not related to BSA, age or AAo size. CONCLUSIONS AAo elasticity assessed by transthoracic echocardiography is impaired in BAV children without significant valve dysfunction compared to TAV children. Impaired elasticity seems to be independent from aortic dilation. Measuring aortic elasticity may help to identify children at greater risk for complications as adults.

Is ultrasound a feasible tool to verify endotracheal tube position in neonates

Tracheal intubation (TI) is a common procedure in neonatal ntensive care unit. Esophageal intubation may occur depending n operator’s experience and clinical setting (e.g. during resusitation) with significant morbidity. Clinical signs alone are not eliable to confirm endotracheal tube (ETT) position and a secndary method is needed. Capnography is mostly used. However, it s not 100% accurate and may yield false negative results in case of ow pulmonary blood flow during cardiopulmonary arrest1. Chest adiography is usually performed after TI to discard misplacement f ETT, mainly right mainstem intubation (RMI). Ultrasound is an lternative and complementary method that may permit both verfication of TI and ETT insertion depth2,3. We checked ETT position with ultrasound and capnography uring 10 intubations in 7 newborns. Patient’s weight and gesational age ranged from 530 to 3150 gram and 24–40 weeks espectively. All patient were intubated for respiratory distress nd were in a stable hemodynamic condition. A 8 Hz microconvex robe was placed in the longitudinal (L) and transversal (T) planes bove the supraesternal notch during insertion of ETT. TI was onfirmed if ETT was clearly identified within the trachea immeiately posterior to anterior tracheal wall in L and a characteristic omet tail artefact arising from ETT surface was seen in T4 (Fig. 1). fter intubation, the patient was bagged and the ultrasound probe as placed in the thorax to check the presence of lung sliding ign (LSS). A bilateral LSS indicates correct TI while unilateral right SS indicates RMI. After intubation radiography was performed.

Verification of endotracheal tube placement using ultrasound during emergent intubation of a preterm infant.

Endotracheal tube (ET) verification in newborns is usually chieved primarily by direct visualization of the ET passing through he vocal cords by direct laryngoscopy. This is the preferred ethod by most experienced neonatologists. However, there is vidence indicating that incidental oesophageal intubation is freuent leading to potential serious harm for the baby so a secondary erification method may be necessary.1 As clinical signs such as uscultation alone may be inaccurate in the preterm, an end tidal arbon dioxide (ETCO2) detector is usually recommended. Howver, in the setting of low or absent pulmonary blood flow such as uring resuscitation or severe hypotension capnography may yield alse negative results.2 Ultrasound is an alternative and compleentary method for ET verification shown to be at least as rapid nd accurate as capnography for emergent intubation in children nd adults.3,4 Here we communicate its use in a very low birth eight preterm infant and illustrate the technique. A 31 week estation and 1.410 g 5-days old female baby was being treated or severe sepsis and necrotizing enterocolitis in our NICU. He as on high ventilatory support (Peak pressure 27 mmHg, PEEP mmHg, FiO2 60%) because of respiratory failure needing surfacant replacement. He suffered an accidental extubation with rapid oss of lung recruitment, severe desaturation (Sat 70%), bradycardia nd hypotension that did not respond to bag mask ventilation. She as reintubated with a 2.5 mm uncuffed tube without improveent (Sat 75%). Capnography was not readily available and we ecided to check ET location by ultrasound. We used an 8-Hz icroconvex transducer in the longitudinal and transversal plane bove the suprasternal notch. We were able to clearly see the T within the trachea immediately posterior to tracheal anterior ings (Fig. 1). We then added a PEEP valve to the bag and venilated the baby with an increasing level of PEEP (max. 8 mmHg) xygen saturation slowly raised in two minutes and the baby tabilized. Ultrasound may be useful to verify ET during emergent intubaion of preterm babies. The most important technical issue is the use f a small sized transducer suitable for the preterm’s neck. A secorial or microconvex high frequency transducer may be optimal. ransducer should be placed 1–2 cm above the suprasternal notch cricotiroid membrane) in the longitudinal and transversal planes. ongitudinal plane may be more useful as we can see echogenic nterior tracheal rings with the ET lying just beneath them as two chogenic lines. With minimal caudal angulation of the transducer oward the suprasternal notch we may be able to identify the ET ip (Fig. 1). Ultrasound is an alternative and adjunct method to verfy ET that in neither case substitutes direct laryngoscopy or

Comparison of ultrasound guided brachiocephalic and internal jugular vein cannulation in critically ill children

PURPOSE To determine whether ultrasound (US)-guided longitudinal in-plane supraclavicular cannulation of the brachiocephalic vein (BCV) improves cannulation success rates compared to transverse out-of-plane internal jugular vein (IJV) cannulation in urgent insertion of temporary central venous catheters (CVC) in critically ill children. MATERIALS AND METHODS Prospective open pilot (non-randomized) comparative study carried out in a pediatric intensive care unit (PICU) of a university-affiliated hospital. Newborns and children aged 0 to 14 years admitted to the PICU in whom an urgent CVC was clinically indicated and was inserted in the IJV or BCV by US guidance were eligible. First-attempt success rate, overall success rate, number of puncture attempts, and cannulation time were compared between IJV and BCV techniques. RESULTS Forty-six procedures (24 IJV and 22 BCV) in 38 patients were included. Full-sample median (range) age and weight were 13 (0.6-160) months and 9.5 (0.94-50) kg. No significant differences between IJV and BCV groups were observed for sex, age, weight, admission diagnosis, intra-procedural mechanical ventilation and sedation protocol. First attempt success rate was higher in the BCV than the IJV group (73 vs 37.5%, P= .017). Overall success rate was slightly higher in the BCV group (95 vs 83%, P = nonsignificant). Median (range) number of cannulation attempts [1 (1-3) vs 2 (1-4)] and cannulation time [66 (25-300) vs 170 (40-500) seconds] were significantly lower in the BCV group (P< .05). Patients weight was inversely related to the number of cannulation attempts (Pearson coefficient -0.537, P= .007) and cannulation time (Pearson coefficient -0.495, P= .014) in the IJV but not in the BCV group. No major complications were observed. CONCLUSIONS Ultrasound-guided supraclavicular in-plane BCV cannulation improved first attempt CVC cannulation success rates and reduced puncture attempts and cannulation time compared to US-guided out-of-plane IJV in critically ill children. A large randomized clinical trial is warranted to confirm our results.

N-terminal-probrain natriuretic peptide as a biomarker of moderate to severe bronchopulmonary dysplasia in preterm infants: A prospective observational study

N‐terminal‐probrain natriuretic peptide (NT‐proBNP) is a marker of hemodynamically significant patent ductus arteriosus (HsPDA) in preterm infants. In this study, we assessed whether NT‐proBNP levels could predict the risk of moderate to severe bronchopulmonary dysplasia (BPD) and/or death.

Test de elevación pasiva de las piernas y respuesta a líquidos en un niño politraumatizado

Fusobacterium necrophorum infections at a Children’s Hospital. Pediatrics. 2003;112:e380. 5. Karkos PD, Asrani S, Karkos CD, Leong SC, Theochari EG, Alexopoulou TD, et al. Lemierre’s syndrome: asystematic review. Laryngoscope. 2009;119:1552--9. 6. Alvarez A, Schreiber JR. Lemierre’s syndrome in adolescent children–anaerobic sepsis with internal jugular vein thrombophlebitis following pharyngitis. Pediatrics. 1995;96 2 Pt 1:354--9. 7. Le Monnier A, Jamet A, Carbonnelle E, Barthod G, Moumile K, Lesage F, et al. Fusobacterium necrophorum middle ear infections in children and related complications: report of 25 cases and literature review. Pediatr Infect Dis J. 2008;27:613--7. 8. Rodríguez J, Fernández J, García MJ, Borque C, del Castillo F. Infección otomastoidea por Fusobacterium necrophorum en niños: presentación de dos casos. Enferm Infecc Microbiol Clin. 2001;19:241--2. 10. Goldenberg NA, Knapp-Clevenger R, Hays T, Manco-Johnso MJ. Lemierre’s and Lemierre’s-like syndromes in childre survival and thromboembolic outcomes. Pediatrics. 2005;11 e543--8.

Ultrasound-Guided Cannulation of the Brachiocephalic Vein in Neonates and Preterm Infants: A Prospective Observational Study

Introduction Percutaneous central venous catheter (CVC) insertion is a challenging procedure in neonates, especially in preterm infants. Objective This study aims to describe the technical success and safety profile of ultrasound (US)‐guided brachiocephalic vein (BCV) cannulation in neonates. Methods Prospective observational study. Neonates admitted to the neonatal intensive care unit (NICU) in whom US‐guided cannulation of the BCV was attempted were eligible. Outcomes included first attempt success rate, the overall success rate, the number of attempts, the cannulation time, immediate mechanical complications, catheter indwelling days, and late complications. Results A total of 40 procedures in 37 patients were included. Median weight and age at the time of cannulation were 1.85 kg (0.76–4.8) and 13 days (3–31), respectively. First attempt and overall success rates were 29 (72.5%) and 38 (95%), respectively. No major complications were observed. Catheter‐associated infection rate was 2.4/1,000 catheter days. There were no difference in outcomes between low weight preterm infants (<1.5 kg) and the rest of the cohort. There was no linear relationship between weight at time of insertion and the number of puncture attempts (r = 0.250; p = 0.154) or cannulation time (r = 0.257; p = 0.142). Conclusion US‐guided cannulation of the BCV may be considered in acutely ill neonates, including small preterm infants, who need a large bore CVC.