Pierantonio Santuz

Procalcitonin for the diagnosis of early-onset neonatal sepsis: a multilevel probabilistic approach.

OBJECTIVES To compare the accuracy of procalcitonin (PCT) in early-onset neonatal sepsis (EOS) using standard cut-off values and a multilevel probabilistic approach. DESIGN AND METHODS A retrospective study of PCT was performed in 149 newborns at risk of EOS, including preterm or prolonged rupture of membranes, chorioamnionitis or maternal infection, GBS colonization and signs of fetal distress. PCT values were analysed according to time of assay, i.e. at birth and at 24 and 48 h. We estimated sensitivity, specificity, positive (LR+) and negative likelihood ratio (LR-), diagnostic odds ratio (DOR) and number needed to diagnose (NND) using traditional and optimal (derived from ROC analysis) PCT cut-off values. RESULTS Using optimal cut-off, the LR+, DOR and NND at birth were 10, 18.9 and 2.2, at 24 h they were 5.3, 11.2 and 2.1, and at 48 h they were 5.6, 18.1 and 1.7, respectively. The multilevel analysis generated three post-test probabilities for each time of assay. At 24 h post-test probabilities of EOS were 78% for PCT >90, 11% for PCT 10.1-90 and 3% for PCT <10.1 mg/L, respectively. Similar results were found in the other time points, with a wide range of intermediate PCT concentrations that did not change the post-test probability. CONCLUSIONS The multilevel probabilistic approach was more effective in assessing the diagnostic power of PCT in EOS, showing that a wide range of intermediate PCT values was not able to discriminate between presence and absence of infection.

Early recognition and management of septic shock in children

Septic shock remains a major cause of morbidity and mortality among children, mainly due to acute hemodynamic compromise and multiple organ failures. In the last decade, international guidelines for the management of septic shock, as well as clinical practice parameters for hemodynamic support of pediatric patients, have been published. Early recognition and aggressive therapy of septic shock, by means of abundant fluid resuscitation, use of catecholamines and other adjuvant drugs, are widely considered of pivotal importance to improve the short and long-term outcome of these patients. The aim of this paper is to summarize the modern approach to septic shock in children, particularly in its very initial phase, when pediatric healthcare providers may be required to intervene in the pre-intensive care unit setting or just on admission in the pediatric intensive care unit.

Neurally adjusted ventilatory assist: a new approach to mechanically ventilated infants

Neurally adjusted ventilator assist (NAVA) is a new mode of partial ventilatory support, in which neural inspiratory activity is monitored through the continuous esophageal recording of the electrical activity of the diaphragm. Assistance is triggered and cycled off in according to this signal and is delivered in proportion to its intensity. NAVA can improve patient-ventilator synchrony while maintaining spontaneous breathing. Small preliminary studies have shown that NAVA can be successfully used also in term and preterm infants, being safe and well tolerated. However, much additional work is still needed before NAVA can be recommended in the everyday practice of the neonatologist.

Correspondence: Ultrasound-guided lung recruitment in a young infant with ARDS

SIR—Acute respiratory distress syndrome (ARDS) affects children with an incidence of 3–10 cases per 100 000 person-years (1). In this condition, the lungs are under recruited owing to inflammatory edema and lung recruitment maneuvres (LRMs) are often performed by the critical care physician (2). This is a challenge especially for pediatric intensivists, which cannot easily employ computed tomography (CT) or pulmonary mechanics measurements, unlike adult critical care specialists. In the last few years, lung ultrasonography (LUS) has been applied successfully in critical care patients with the aim to obtain reliable, fast and repeated information at bedside (3,4). Very scarce data are available in the pediatric population, although LUS is increasingly used also in children (5). We present a case of severe ARDS in which a lung recruitment maneuvre was assisted by LUS. A 2monthold 4.6 kg Caucasian female infant, admitted 2 days before to a community pediatric ward with a diagnosis of bronchiolitis, was referred to our Paediatric Intensive Care Unit (PICU) for increasingly severe respiratory distress. On admission to our Unit, the patient was immediately intubated owing to impending respiratory failure, and synchronized intermittent mandatory ventilation was initiated. Chest X-ray revealed a partial nontension pneumothorax in the right hemithorax, with pulmonary consolidation in the upper right apex. In the next few hours oxygenation deteriorated, despite the increase in fraction of inspired oxygen (FiO2) from 70% to 100% and positive end-expiratory pressure (PEEP) from 5 to 10 cmH2O (PEEP was eventually set back at 5 cmH2O because of concern about air leak). At 7 h following admission, blood gas analysis showed pH 7.26, pCO2 75 mmHg, pO2 50 mmHg and hemoglobin oxygen saturation (SaO2) 90%. A second chest X-ray showed a picture typical of ARDS, with diffuse bilateral infiltrates but no progression of air leak. A LUS examination was then performed with a 7.5to 10 MHz linear probe (Vivid 7 Sonographer; GE Healthcare, USA), showing in the anterior lung fields signs of diffuse alveolar interstitial syndrome (AIS), i.e., diffuse B-lines or comet tail hyperechoic vertical artifacts (3). In the dependent fields, we observed diffuse and irregular consolidations, i.e., hypoechoic areas with a parenchymal pattern resembling that of liver or spleen, containing several air bronchograms. Interestingly, a sign of partial pneumothorax, the so-called lung point, was evident in the anterior right chest. No spared areas containing only A-lines, i.e., echoic horizontal lines reflecting the pleura and indicating a normal air content, were present (3). A LUS-guided LRM was performed, aiming at reducing FiO2 requirement while preventing a worsening of the air leak. The PEEP was gently increased at 1 cmH2O step every 1–2 min, while imaging the consolidations and the pneumothorax. The time courses of ventilation parameters, oxygenation indexes and US imaging are summarized in the Table 1. Briefly, we observed a progressive reaeration within the consolidated areas as shown by the appearance of B-lines and, eventually, A-lines (see Figure 1). In the meantime, FiO2 was decreased below 50% while maintaining SaO2 at 92–96%. No increase of air leak occurred. Following the recruitment procedure, PEEP was gradually decreased concomitantly with FiO2, and the clinical course was uneventful. The baby was successfully extubated on the fourth day of PICU stay and discharged after 7 days from admission with a diagnosis of respiratory syncytial virus infection. To our knowledge, this is the first report of a successful LRM using LUS in pediatric ARDS. Although this has been anecdotally reported in adults (4), chest CT scan has been for several years the standard tool for titrating PEEP during lung recruitment (2). However, such a technique, which also requires transportation of a critical patient to another facility, is not deemed as ideal in children, given the much higher risk of radiation compared to adults. Other bedside methods rely on pulmonary mechanics measurements, but are cumbersome and currently indicated for research purpose, rather than for clinical practice. Some potential advantages of LUS during an LRM should be stressed. First, LUS is a bedside reliable and noninvasive method for providing a three-dimensional visualization of the lungs, information otherwise not easily achievable by other techniques. Secondly, LUS seems to be capable to provide a real-time response, in that it shows breath-by-breath variation of lung aeration much faster

Ultrasound-guided lung recruitment in a young infant with ARDS.

SIR—Acute respiratory distress syndrome (ARDS) affects children with an incidence of 3–10 cases per 100 000 person-years (1). In this condition, the lungs are under recruited owing to inflammatory edema and lung recruitment maneuvres (LRMs) are often performed by the critical care physician (2). This is a challenge especially for pediatric intensivists, which cannot easily employ computed tomography (CT) or pulmonary mechanics measurements, unlike adult critical care specialists. In the last few years, lung ultrasonography (LUS) has been applied successfully in critical care patients with the aim to obtain reliable, fast and repeated information at bedside (3,4). Very scarce data are available in the pediatric population, although LUS is increasingly used also in children (5). We present a case of severe ARDS in which a lung recruitment maneuvre was assisted by LUS. A 2monthold 4.6 kg Caucasian female infant, admitted 2 days before to a community pediatric ward with a diagnosis of bronchiolitis, was referred to our Paediatric Intensive Care Unit (PICU) for increasingly severe respiratory distress. On admission to our Unit, the patient was immediately intubated owing to impending respiratory failure, and synchronized intermittent mandatory ventilation was initiated. Chest X-ray revealed a partial nontension pneumothorax in the right hemithorax, with pulmonary consolidation in the upper right apex. In the next few hours oxygenation deteriorated, despite the increase in fraction of inspired oxygen (FiO2) from 70% to 100% and positive end-expiratory pressure (PEEP) from 5 to 10 cmH2O (PEEP was eventually set back at 5 cmH2O because of concern about air leak). At 7 h following admission, blood gas analysis showed pH 7.26, pCO2 75 mmHg, pO2 50 mmHg and hemoglobin oxygen saturation (SaO2) 90%. A second chest X-ray showed a picture typical of ARDS, with diffuse bilateral infiltrates but no progression of air leak. A LUS examination was then performed with a 7.5to 10 MHz linear probe (Vivid 7 Sonographer; GE Healthcare, USA), showing in the anterior lung fields signs of diffuse alveolar interstitial syndrome (AIS), i.e., diffuse B-lines or comet tail hyperechoic vertical artifacts (3). In the dependent fields, we observed diffuse and irregular consolidations, i.e., hypoechoic areas with a parenchymal pattern resembling that of liver or spleen, containing several air bronchograms. Interestingly, a sign of partial pneumothorax, the so-called lung point, was evident in the anterior right chest. No spared areas containing only A-lines, i.e., echoic horizontal lines reflecting the pleura and indicating a normal air content, were present (3). A LUS-guided LRM was performed, aiming at reducing FiO2 requirement while preventing a worsening of the air leak. The PEEP was gently increased at 1 cmH2O step every 1–2 min, while imaging the consolidations and the pneumothorax. The time courses of ventilation parameters, oxygenation indexes and US imaging are summarized in the Table 1. Briefly, we observed a progressive reaeration within the consolidated areas as shown by the appearance of B-lines and, eventually, A-lines (see Figure 1). In the meantime, FiO2 was decreased below 50% while maintaining SaO2 at 92–96%. No increase of air leak occurred. Following the recruitment procedure, PEEP was gradually decreased concomitantly with FiO2, and the clinical course was uneventful. The baby was successfully extubated on the fourth day of PICU stay and discharged after 7 days from admission with a diagnosis of respiratory syncytial virus infection. To our knowledge, this is the first report of a successful LRM using LUS in pediatric ARDS. Although this has been anecdotally reported in adults (4), chest CT scan has been for several years the standard tool for titrating PEEP during lung recruitment (2). However, such a technique, which also requires transportation of a critical patient to another facility, is not deemed as ideal in children, given the much higher risk of radiation compared to adults. Other bedside methods rely on pulmonary mechanics measurements, but are cumbersome and currently indicated for research purpose, rather than for clinical practice. Some potential advantages of LUS during an LRM should be stressed. First, LUS is a bedside reliable and noninvasive method for providing a three-dimensional visualization of the lungs, information otherwise not easily achievable by other techniques. Secondly, LUS seems to be capable to provide a real-time response, in that it shows breath-by-breath variation of lung aeration much faster

Neonatal resuscitation in the ward: the role of nurses.

Cardiopulmonary resuscitation (CPR) is necessary in about 1-2% of all newly born infants in their first minutes of life. However, CPR may also be needed in newborns beyond the time of birth, particularly in high risk categories of infants admitted in the NICU or in other less specialised units. In all these scenarios, the role of nurses is essential for several aspects, including early recognition of a deteriorating infant, with the aim to prevent cardiac arrest, as well as the starting of immediate basic life support manoeuvres at the bedside, whenever needed. Furthermore, nurses have a special part in family care during cardiopulmonary resuscitation.

Weaning newborn infants from mechanical ventilation

Invasive mechanical ventilation is a life-saving procedure which is largely used in neonatal intensive care units, particularly in very premature newborn infants. However, this essential treatment may increase mortality and cause substantial morbidity, including lung or airway injuries, unplanned extubations, adverse hemodynamic effects, analgosedative dependency and severe infectious complications, such as ventilator-associated pneumonia. Therefore, limiting the duration of airway intubation and mechanical ventilator support is crucial for the neonatologist, who should aim to a shorter process of discontinuing mechanical ventilation as well as an earlier appreciation of readiness for spontaneous breathing trials. Unfortunately, there is scarce information about the best ways to perform an effective weaning process in infants undergoing mechanical ventilation, thus in most cases the weaning course is still based upon the individual judgment of the attending clinician. Nonetheless, some evidence indicate that volume targeted ventilation modes are more effective in reducing the duration of mechanical ventilation than traditional pressure limited ventilation modes, particularly in very preterm babies. Weaning and extubation directly from high frequency ventilation could be another option, even though its effectiveness, when compared to switching and subsequent weaning and extubating from conventional ventilation, is yet to be adequately investigated. Some data suggest the use of weaning protocols could reduce the weaning time and duration of mechanical ventilation, but better designed prospective studies are still needed to confirm these preliminary observations. Finally, the implementation of short spontaneous breathing tests in preterm infants has been shown to be beneficial in some centres, favoring an earlier extubation at higher ventilatory settings compared with historical controls, without worsening the extubation failure rate. Further research is still required to identify the best practices capable to shorten the duration of mechanical ventilation in term and preterm infants, at the same time keeping to a minimum the risk of extubation failure. Proceedings of the 9 th International Workshop on Neonatology · Cagliari (Italy) · October 23 rd -26 th , 2013 · Learned lessons, changing practice and cutting-edge research

Sodium Nitroprusside Toxicity in a Young Infant Following Cardiac Surgery

Adverse effects associated with sodium nitroprusside (SNP) administration are rarely observed in children. Monitoring of metabolic changes appears to be the most sensitive and accurate indicator of early toxicity. We report a case of acute toxicity in a 3-month-old boy treated with high-dose SNP infusion for systemic hypertension after elective coarctectomy, who developed seizures and severe lactic acidosis. We suggest blood lactate levels and base excess levels should be carefully monitored during SNP treatment in children, in order to detect early signs of toxicity, particularly when using high infusion rates. Case Study Silvagni et al.; IJMPCR, 2(5): 122-125, 2015; Article no.IJMPCR.2015.024 123

Correspondence: Ultrasound-guided lung recruitment in a young infant with ARDS: CORRESPONDENCE

SIR—Acute respiratory distress syndrome (ARDS) affects children with an incidence of 3–10 cases per 100 000 person-years (1). In this condition, the lungs are under recruited owing to inflammatory edema and lung recruitment maneuvres (LRMs) are often performed by the critical care physician (2). This is a challenge especially for pediatric intensivists, which cannot easily employ computed tomography (CT) or pulmonary mechanics measurements, unlike adult critical care specialists. In the last few years, lung ultrasonography (LUS) has been applied successfully in critical care patients with the aim to obtain reliable, fast and repeated information at bedside (3,4). Very scarce data are available in the pediatric population, although LUS is increasingly used also in children (5). We present a case of severe ARDS in which a lung recruitment maneuvre was assisted by LUS. A 2monthold 4.6 kg Caucasian female infant, admitted 2 days before to a community pediatric ward with a diagnosis of bronchiolitis, was referred to our Paediatric Intensive Care Unit (PICU) for increasingly severe respiratory distress. On admission to our Unit, the patient was immediately intubated owing to impending respiratory failure, and synchronized intermittent mandatory ventilation was initiated. Chest X-ray revealed a partial nontension pneumothorax in the right hemithorax, with pulmonary consolidation in the upper right apex. In the next few hours oxygenation deteriorated, despite the increase in fraction of inspired oxygen (FiO2) from 70% to 100% and positive end-expiratory pressure (PEEP) from 5 to 10 cmH2O (PEEP was eventually set back at 5 cmH2O because of concern about air leak). At 7 h following admission, blood gas analysis showed pH 7.26, pCO2 75 mmHg, pO2 50 mmHg and hemoglobin oxygen saturation (SaO2) 90%. A second chest X-ray showed a picture typical of ARDS, with diffuse bilateral infiltrates but no progression of air leak. A LUS examination was then performed with a 7.5to 10 MHz linear probe (Vivid 7 Sonographer; GE Healthcare, USA), showing in the anterior lung fields signs of diffuse alveolar interstitial syndrome (AIS), i.e., diffuse B-lines or comet tail hyperechoic vertical artifacts (3). In the dependent fields, we observed diffuse and irregular consolidations, i.e., hypoechoic areas with a parenchymal pattern resembling that of liver or spleen, containing several air bronchograms. Interestingly, a sign of partial pneumothorax, the so-called lung point, was evident in the anterior right chest. No spared areas containing only A-lines, i.e., echoic horizontal lines reflecting the pleura and indicating a normal air content, were present (3). A LUS-guided LRM was performed, aiming at reducing FiO2 requirement while preventing a worsening of the air leak. The PEEP was gently increased at 1 cmH2O step every 1–2 min, while imaging the consolidations and the pneumothorax. The time courses of ventilation parameters, oxygenation indexes and US imaging are summarized in the Table 1. Briefly, we observed a progressive reaeration within the consolidated areas as shown by the appearance of B-lines and, eventually, A-lines (see Figure 1). In the meantime, FiO2 was decreased below 50% while maintaining SaO2 at 92–96%. No increase of air leak occurred. Following the recruitment procedure, PEEP was gradually decreased concomitantly with FiO2, and the clinical course was uneventful. The baby was successfully extubated on the fourth day of PICU stay and discharged after 7 days from admission with a diagnosis of respiratory syncytial virus infection. To our knowledge, this is the first report of a successful LRM using LUS in pediatric ARDS. Although this has been anecdotally reported in adults (4), chest CT scan has been for several years the standard tool for titrating PEEP during lung recruitment (2). However, such a technique, which also requires transportation of a critical patient to another facility, is not deemed as ideal in children, given the much higher risk of radiation compared to adults. Other bedside methods rely on pulmonary mechanics measurements, but are cumbersome and currently indicated for research purpose, rather than for clinical practice. Some potential advantages of LUS during an LRM should be stressed. First, LUS is a bedside reliable and noninvasive method for providing a three-dimensional visualization of the lungs, information otherwise not easily achievable by other techniques. Secondly, LUS seems to be capable to provide a real-time response, in that it shows breath-by-breath variation of lung aeration much faster