Philip Bernard

Use of azithromycin for the prevention of bronchopulmonary dysplasia in preterm infants: a randomized, double‐blind, placebo controlled trial

Since preventive therapies for bronchopulmonary dysplasia (BPD) are limited we treated preterm infants with azithromycin to decrease the incidence of BPD.

Azithromycin Protects Against Hyperoxic Lung Injury in Neonatal Rats

Bronchopulmonary dysplasia (BPD) is a pulmonary disorder that causes significant morbidity and mortality in premature infants. BPD is pathologically characterized by inflammation, fibrosis, and mucosal necrosis, which leads to emphysematous coalescence of alveoli. We tested the hypothesis that azithromycin, a macrolide antibiotic, would decrease the severity of lung injury in an animal model of BPD. Sixty-three rat pups were randomly divided equally into control, hyperoxia, and hyperoxia plus azithromycin groups. The hyperoxia groups were exposed to > 95% oxygen from days of life 4 to 14. On day 14, the animals were processed for lung histology and tissue analysis. Lung morphology was assessed by mean linear intercept, a measure of alveolar size, with larger values corresponding to lungs that are more emphysematous. The degree of lung inflammation was assessed by quantifying interleukin-6 (IL-6) from lung homogenate. Fifty pups survived to day 14 (control = 21, hyperoxia = 11, hyperoxia + azithromycin = 18). Mortality was increased in the hyperoxia group versus the control group (p < .0001). Treatment with azithromycin improved survival in animals subjected to hyperoxia (p < .05). Azithromycin significantly decreased lung damage as determined by the mean linear intercept in the hyperoxia groups (p < .001). Finally, azithromycin-treated pups had lower levels of IL-6 in lung homogenate from the hyperoxia groups (p < .05). Azithromycin treatment resulted in improved survival, less emphysematous change, and decreased IL-6 levels in an animal model of BPD.

Variability of ASA physical status class assignment among pediatric sedation practitioners.

Our goal was to determine the consistency of the Society of Anesthesiologists Physical Status (ASA-PS) Classification Scale with respect to different training, experience, and activity levels. A questionnaire comprised of 10 pediatric sedation scenarios was distributed via electronic mailing lists. Data were collected on training, experience, annual sedations performed, and ASA-PS score assigned. 100 questionnaires (38 anesthesiologists, 8 advanced nurses, 14 hospitalists, 22 intensivists, 15 registered nurses (RN), 3 others) were returned. Ratings for four scenarios varied significantly with respect to practitioner (p < .05). In one of the scenarios, pediatric hospitalists were more likely to rank a higher ASA-PS score, whereas registered nurses were more likely to rate patient scenarios at a lower ASA-PS (OR = 11.78, 95% CI = (2.10, 66.07), p-value = .0051). Number of annual sedations and practicing years were different among practitioner groups (p-values = .0019 and < .0001 respectively). In three scenarios, practitioners rated a lower ASA-PS score for each additional year in practice. The ASA-PS scores for two scenarios were marginally lower if the practitioner performed greater than 1000 sedations each year (p < .1). Our results indicate that the type of training and experience affect a practitioners view of the severity of a patients condition.

Hypoglycemia associated with dexmedetomidine overdose in a child

The case of an asymptomatic 20 month-old, 10.7-kg girl, scheduled for interventional cardiac catheterization to close a patent ductus arteriosus, who suffered significant hypoglycemia possibly related in part to an overdose of dexmedetomidine, is reported. An infusion of dexmedetomidine was started using a programmable syringe pump at the intended administration rate of one mcg/kg/hr, but was actually incorrectly programmed at the rate of one mcg/kg/min. The infusion continued for 36 minutes until a total of 380 mcg (36 mcg/kg) had been given, and was stopped when the error was discovered. A peripheral blood sugar level was found to be 26 mg/dL. The significant hypoglycemia likely was due to substrate deficiency, with a possible dexmedetomidine effect.

Acyclovir Use in Sick Infants

Background: Infantile herpes simplex virus encephalitis (HSVE) infection remains a significant cause of morbidity and mortality. Diagnosis is often difficult in this population, where a specific pattern of clinical and laboratory signs are lacking. This often results in unnecessary treatment of infants with empiric acyclovir. This study evaluates the use of empiric acyclovir at the Kentucky Childrens Hospital and attempts to correlate any laboratory or clinical findings that may be highly suggestive of HSVE. Methods: Medical records of infants younger than 1 year admitted and treated with acyclovir were evaluated for any consistent pattern of clinical findings suggestive of HSVE. Specifically, serum and cerebrospinal fluid (CSF) white blood cell counts, red blood cell counts, cerebrospinal glucose and protein, and clinical neurological findings upon admission were evaluated. Results: Two hundred eighteen infants were identified and included in the study. Three infants were identified with polymerase chain reaction-positive HSVE. Only CSF leukocytosis was consistent among HSVE-positive infants. All infants with HSVE exhibited generalized neurological findings. Neither hemorrhagic CSF nor focal neurological findings were indicative of HSVE infection. Discussion: Herpes simplex virus encephalitis has a very low prevalence within this population. Clinically significant neurological findings as well as specific risk factors must be present to consider treatment with empiric acyclovir. Apnea and focal seizures are not specific risk factors for herpetic meningitis in infants. Lack of a CSF leukocytosis is a strong negative predictor for HSVE, and hemorrhagic fluid is not specific for HSVE.

Successful treatment of ifosfamide neurotoxicity with dexmedetomidine.

Neurotoxicity related to the use of ifosfamide is a well-known complication. While the use of methylene blue is a known antidote, symptomatic treatment of the central nervous system (CNS) effects can be challenging. We present a case of class IV neurotoxicity with the successful treatment of symptomology. In this case report we present a 2-year-old female with relapsed alveolar rhabdomyosarcoma undergoing palliative chemotherapy. Patient received ifosfamide in addition to etoposide and mesna. The patient developed acute hallucinations, agitation, and delirium. The patient was transferred to the pediatric intensive care unit where she was administered dexmedetomidine overnight in addition to methylene blue. The patient awoke the next morning following discontinuation of the dexmedetomidine infustion and subsequently had no further central nervous system effects. This case demonstrates the novel use of an alpha-2 agonist in the treatment of neurotoxicity related to ifosfamide administration.

Use of conivaptan for refractory syndrome of inappropriate secretion of antidiuretic hormone in a pediatric patient.

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is the most common form of hyponatremia in hospitalized patients. The available treatment options for SIADH are limited and not completely effective. A more recent and specific option for treatment of hyponatremia secondary to SIADH are the vasopressin-receptor antagonists. Conivaptan, an intravenous vasopressin-receptor antagonist, is Food and Drug Administration approved for the treatment of euvolemic and hypervolemic hyponatremia in adults; however, data regarding its use in pediatric patients are extremely limited. Conivaptan played an integral role in the treatment of hyponatremia in this situation when conventional treatment modalities were ineffective. This patient did not experience any adverse effects, and his sodium level corrected slowly over a 24-hour period, avoiding complications of rapid sodium correction.

Current approaches to pediatric heart catheterizations

Sedation for pediatric cardiac catheterization is a common requirement in many institutions. As the field of cardiac catheterization has evolved, the provision of sedation for these procedures has been varied. Increasingly the demand is for dedicated personnel focused on monitoring and delivery of sedation while in the catheterization suite. This article describes the considerations one must use when undertaking these cases.

Prolonged Electrical Quiescence After Direct Current Cardioversion for Atrial Flutter in Congenital Heart Disease

Elective direct current cardioversion is considered first-line treatment in many cases of atrial flutter and fibrillation. This also is true in the pediatric population. This report describes a case of successful cardioversion that resulted in a very prolonged electrical quiescence.

Lumbar Punctures: Always Use a Stylette:

I read Dr Bernard’s criticisms carefully. He stated that literature about the subject was not mentioned, but especially in the introduction and discussion parts of the study, the subject had been mentioned twice and literature had been given. Furthermore, the sentence “LPs performed without stylettes lays the ground for it” was mentioned at least 5 times during the study. Although it is necessary to use needles with stylettes in lumbar puncture, unfortunately, because of neonatal practical usage, injection shots without stylettes are still being used. And, with regard to his last criticism, we had written the sentence, “Stylettes certainly should be used in lumbar puncture needles” at the end of the article to further stress the importance of the subject.