S Blanot

Mortality in Children With Severe Head Trauma: Predictive Factors and Proposal for a New Predictive Scale

BACKGROUND Traumatic brain injury is a public health problem around the world, and recognition of systemic sources of secondary brain lesions is crucial to improve outcome. OBJECTIVE To identify the main predictors of mortality and to propose a grading scale to measure the risk of death. METHODS This retrospective study was based on medical records of children with severe traumatic brain injury who were hospitalized at a level I pediatric trauma center between January 2000 and December 2005. Multiple logistic regression analysis was done to identify independent factors related to mortality. A receiver-operating characteristics curve was performed to verify the accuracy of the multiple logistic regression, and associations that increased mortality were verified. RESULTS We identified 315 children with severe head injury. Median Glasgow Coma Scale score was 6, and median Pediatric Trauma Score was 4. Global mortality rate was 30%, and deaths occurred despite adequate medical management within the first 48 hours in 79% of the patients. Age<2 years (P=.02), Glasgow Coma Scale≤5 (P<10), accidental hypothermia (P=.0002), hyperglycemia (P=.0003), and coagulation disorders (P=.02) were all independent factors predicting mortality. A prognostic scale ranging from 0 to 6 that included these independent factors was then calculated for each patient and resulted in mortality rates ranging from 1% with a score of 6 to 100% with a score of 0. CONCLUSION Independent and modifiable mortality predictors could be identified and used for a new grading scale correlated with the risk of mortality in pediatric traumatic brain injury.BACKGROUND: Traumatic brain injury is a public health problem around the world, and recognition of systemic sources of secondary brain lesions is crucial to improve outcome. OBJECTIVE: To identify the main predictors of mortality and to propose a grading scale to measure the risk of death. METHODS: This retrospective study was based on medical records of children with severe traumatic brain injury who were hospitalized at a level I pediatric trauma center between January 2000 and December 2005. Multiple logistic regression analysis was done to identify independent factors related to mortality. A receiver-operating characteristics curve was performed to verify the accuracy of the multiple logistic regression, and associations that increased mortality were verified. RESULTS: We identified 315 children with severe head injury. Median Glasgow Coma Scale score was 6, and median Pediatric Trauma Score was 4. Global mortality rate was 30%, and deaths occurred despite adequate medical management within the first 48 hours in 79% of the patients. Age < 2 years (P = .02), Glasgow Coma Scale ≤ 5 (P < 10−5), accidental hypothermia (P = .0002), hyperglycemia (P = .0003), and coagulation disorders (P = .02) were all independent factors predicting mortality. A prognostic scale ranging from 0 to 6 that included these independent factors was then calculated for each patient and resulted in mortality rates ranging from 1% with a score of 6 to 100% with a score of 0. CONCLUSION: Independent and modifiable mortality predictors could be identified and used for a new grading scale correlated with the risk of mortality in pediatric traumatic brain injury.

Anesthésie-réanimation des craniosténoses et dysmorphies craniofaciales de l'enfant

Craniosynostosis occurs in one out of 2,000 births. It results in primary skull deformations requiring surgical repair, in infants with a body weight of less than 10 kg. Pure craniosynostosis is the most frequent situation, where the risk for cerebral compression during brain development is the lowest. Therefore the aim of surgical correction in this case is mainly cosmetic. Conversely, in syndromic craniosynostosis, associated malformations are more common and cerebral, visual and respiratory consequences of complex facio-craniosynostosis are usually severe. Current surgical techniques consist of a total skull vault reconstruction which carry a high risk of sudden and major blood losses. Intraoperatively, whatever the type of craniosynostosis, mean blood losses corresponding to 90% of estimated red cell mass have to be anticipated. These blood losses vary according to the type of skull deformation and the type of surgery. Accurate evaluation is usually difficult and must be based more on calculation of red cell mass variations than on simple monitoring of surgical drainage. Invasive haemodynamic monitoring is always required. To reduce the amount of homologous blood transfusion, peroperative haemodilution seems to be the most suitable technique, due to unresolved technical difficulties in autotransfusion practice in infants. Severe facial deformities are associated with chronic hypoxaemia and cerebral compression representing major risk for these children in poor condition undergoing such major surgical procedures. With experienced teams, this high-risk surgery carries a low peroperative mortality (less than 1%) and morbidity rate. The latter includes essentially transient peroperative hypotension. The excellent final cosmetic and functional results justify the practice of this surgery in children with a bodyweight of less than 10 kg.

Listeria monocytogenes: a Rare Complication of Ventriculoperitoneal Shunt in Children

ABSTRACT We report a case of ventriculoperitoneal (VP) shunt infection in a 3-year-old boy caused by the food-borne pathogen Listeria monocytogenes, subsequent to acute peritonitis. This unusual presentation of central nervous system (CNS) listeriosis underlines the ability of the bacteria to form and survive within biofilms on indwelling medical devices. Bacterial persistence may lead to treatment failure and spreading. We highlight the helpfulness of specific quantitative real-time PCR for the hly gene (PCR-hly) for the diagnosis and follow-up of such infections in detecting bacterial persistence within medical devices despite effective antibiotic treatment. Only the surgical replacement of the VP shunt will resolve the infection.

Prise en charge anesthésique des craniosténoses

Resume La reparation de la craniostenose est une chirurgie majeure de reconstruction, dont le principal risque est hemorragique. L’evaluation preoperatoire comprend toujours la recherche de complications neurosensorielles et de l’integration de la craniostenose dans le cadre d’un syndrome polymalformatif craniofacial ou plus general. Il convient de depister l’hypertension intracrânienne, qui peut modifier la prise en charge anesthesique, en particulier l’induction. A cote du retentissement psychologique qui doit etre pris en compte, l’indication operatoire est le plus souvent fondee sur la prevention de la survenue des complications ou simplement, pour des raisons d’ordre fonctionnel. Dans tous les cas, les parents doivent etre informes des risques operatoires. La chirurgie est habituellement realisee chez le nourrisson, dont la tolerance a l’hemorragie est faible du fait de la valeur absolue de la masse sanguine. La surveillance hemodynamique invasive permet la compensation precise des pertes sanguines. La periode postoperatoire peut etre compliquee, en particulier par la persistance du saignement, qui se tarit le plus souvent dans les 12 heures.

Hémolyse aiguë au décours d’une chirurgie de correction d’une craniosténose utilisant l’autotransfusion périopératoire chez un nourrisson

We report the case of a 6-month-old child, who suffered from acute haemolysis following transfusion of salvaged blood. This complication, of favourable outcome, was related to the accidental aspiration of benzalkonium chloride into the cell saver. This case emphasizes that any adjunction of antiseptic solution is contraindicated during blood saving. The use of a cell saver must be associated with written protocols, describing clearly the contraindications, precautions of use, and the different steps of use of this method of autologous blood transfusion.

Current ciprofloxacin usage in children hospitalized in a referral hospital in Paris

BackgroundFluoroquinolones are used with increasing frequency in children with a major risk of increasing the emergence of FQ resistance. FQ use has expanded off-label for primary antibacterial prophylaxis or treatment of infections in immune-compromised children and life-threatening multi-resistant bacteria infections. Here we assessed the prescriptions of ciprofloxacin in a pediatric cohort and their appropriateness.MethodsA monocenter audit of ciprofloxacin prescription was conducted for six months in a University hospital in Paris. Infected site, bacteriological findings and indication, were evaluated in children receiving ciprofloxacin in hospital independently by 3 infectious diseases consultants and 1 hospital pharmacist.ResultsNinety-eight ciprofloxacin prescriptions in children, among which 52 (53.1%) were oral and 46 (46.9%) parenteral, were collected. 45 children had an underlying condition, cystic fibrosis (CF) (21) or an innate or acquired immune deficiency (24). Among CF patients, the most frequent indication was a broncho-pulmonary Pseudomonas aeruginosa infection (20). In non-CF patient, the major indications were broncho-pulmonary (25), urinary (8), intra-abdominal (7), operative site infection (5) and bloodstream/catheter (2/4) infection. 62.2% were microbiologically documented. Twenty-three (23.4%) were considered “mandatory”, 48 (49.0%) “alternative” and 27 (27.6%) “unjustified”.ConclusionIn our university hospital, only 23.4% of fluoroquinolones prescriptions were mandatory in children, especially in Pseudomonas aeruginosa healthcare associated infection. Looking to the ecological risk of fluoroquinolones and the increase consumption in children population we think that a control program should be developed to control FQ use in children. It could be done with the help of an antimicrobial stewardship team.

Anesthésie-réanimation des processus expansifs intracrâniens de l’enfant

Resume Les processus expansifs intracrâniens les plus frequents chez l’enfant sont les tumeurs cerebrales, notamment sous-tentorielles, et les hematomes resultant d’une rupture de malformation arterioveineuse (MAV). Ils comportent un risque d’hypertension intracrânienne (HIC), directe du fait de leur volume ou par hydrocephalie obstructive du fait de l’obstacle a l’ecoulement du LCR qu’ils entrainent. Leur localisation et la compression qu’ils engendrent sur les structures de voisinage sont responsables de signes neurologiques ou generaux specifiques. Ainsi les tumeurs de la region optochiasmatique et hypophysaire comportent des risques de cecite, d’insuffisance pan-hypophysaire et de diabete insipide, les lesions de la fosse posterieure un risque d’hydrocephalie et de compression des dernieres paires crâniennes et du tronc cerebral, et les lesions sus-tensorielles un risque de deficit moteur. L’ensemble de ces donnees est a prendre en compte pour le choix des techniques anesthesiques et l’evaluation des possibilites d’exerese. Lorsque l’HIC est menacante, une induction anesthesique rapide, une intubation tracheale et une ventilation controlee ne se discutent pas. Le traitement de l’HIC repose sur une derivation de l’hydrocephalie, un traitement medical par osmotherapie, ou plus rarement une exerese de la lesion. Dans les autres cas, une anesthesie profonde, stable, respectant l’hemodynamique cerebrale est necessaire. Les installations specifiques a cette chirurgie longue comportent des risques particuliers dont le plus classique est le risque d’embolie gazeuse en position assise qui doit etre prevenu par des mesures adequates. La periode postoperatoire comporte les memes risques de complications neurologiques que la periode preoperatoire. Une surveillance rigoureuse est necessaire, le reveil et l’extubation precoce se discutent au cas par cas.

Fulminant Nocardiosis Due to a Multidrug-Resistant Isolate in a 12-Year-Old Immunocompetent Child

This challenging form of invasive nocardiosis highlights the importance of promptly considering this diagnosis when facing a multiple-organ infection and identifying species for treatment optimization. Nocardiosis is a rare cause of infection that usually affects immunocompromised adult patients and might not be recognized by pediatricians. We report a fatal case of disseminated nocardiosis in a previously healthy child initially admitted for an abdominal mass with suspicion of a renal malignant tumor. The patient, originating from Mali without any medical history, displayed abdominal pain with progressive altered general status. Laboratory and imaging findings revealed lymphocytic meningitis and disseminated abscesses in the brain and the cerebellum and a large number of cystic lesions of the kidney. Despite being administered wide-spectrum antibiotics and antituberculous and antifungal therapies with an external ventricular drainage for intracranial hypertension, the patient died 6 days after his admission. Nocardia spp was cultured from a renal biopsy and the cerebrospinal fluid. Species identification and antibiotic susceptibility were obtained later, revealing a multidrug-resistant isolate of the Nocardia elegans/aobensis/africana complex. This case reveals the difficulties of diagnosing nocardiosis, in particular in children not known to be immunocompromised, because we face multiple differential diagnoses and the importance of treating nocardiosis appropriately because of intrinsic resistance issues.