Tiziana Zangardi

Mixed exhaled nitric oxide and plasma nitrites and nitrates in newborn infants.

Plasma nitrite (NO2-) and nitrate (NO3-) are the stable end-products of endogenous nitric oxide (NO) metabolism. NO is present in the exhaled air of humans, but it is not clear if exhaled NO may be an indicator of the systemic endogenous NO production. The aims of the study were to determine the levels of exhaled NO and plasma NO2-/NO3- in healthy term and preterm newborns, and to assess if exhaled NO correlates with plasma NO2-/NO3- at birth. After the stabilization of the newborn, we measured by chemiluminescence the concentration of NO in the mixed expired breath of 133 healthy newborns. Measurement of exhaled NO was repeated after 24 and 48 hours. Plasma NO2-/NO3- levels at birth were measured by the Griess reaction. NO concentrations were 8.9 (CI 8.1-9.8) parts per billion (ppb), 7.7 (CI 7.2-8.3) ppb and 9.0 (CI 8.4-9.6) ppb at birth, 24 and 48 hours, respectively. At birth, exhaled NO was inversely correlated with gestational age (p=0.008) and birth weight (p<0.001). Plasma NO2-/NO3- level was 27.30 (CI 24.26-30.34) micromol/L. There was no correlation between exhaled NO and plasma NO2-/NO3- levels at birth (p=0.88). We speculate that the inverse correlation between exhaled NO and gestational age and birth weight may reflect a role of NO in the postnatal adaptation of pulmonary circulation. At birth, exhaled NO does not correlate with plasma NO2-/NO3- and does not seem to be an index of the systemic endogenous NO production.

Predicting severe bacterial infections in well-appearing febrile neonates: laboratory markers accuracy and duration of fever.

Objectives: To assess the diagnostic accuracy of white blood cell count (WBC), absolute neutrophil count (ANC), and C-reactive protein (CRP) in detecting severe bacterial infections (SBI) in well-appearing neonates with early onset fever without source (FWS) and in relation to fever duration. Methods: An observational study was conducted on previously healthy neonates 7 to 28 days of age, consecutively hospitalized for FWS from less than 12 hours to a tertiary care Pediatric Emergency Department, over a 4-year period. Laboratory markers were obtained upon admission in all patients and repeated 6 to 12 hours from admission in those with normal values on initial determination. Sensitivity, specificity, positive and negative likelihood ratios, and receiver operating characteristic analysis were carried out for primary and repeated laboratory examinations. Results: Ninety-nine patients were finally studied. SBI was documented in 25 (25.3%) neonates. Areas under receiver operating characteristic curves were 0.78 (95% CI, 0.69–0.86) for CRP, 0.77 (95% CI, 0.67–0.85) for ANC and 0.59 (95% CI, 0.49–0.69) for WBC. Sixty-two patients presented normal laboratory markers on initial determination. Of these, 58 successfully underwent repeated blood examination at >12 hours from fever onset. Five of them had an SBI. The area under curve calculated for repeated laboratory tests showed better values, respectively of 0.99 (95% CI, 0.92–1) for CRP, 0.85 (95% CI, 0.73–0.93) for ANC and 0.79 (95% CI, 0.66–0.88) for WBC. Conclusions: In well-appearing neonates with early onset FWS, laboratory markers are more accurate and reliable predictors of SBI when performed after >12 hours of fever duration. ANC and especially CRP resulted better markers than the traditionally recommended WBC.

Oral ondansetron versus domperidone for symptomatic treatment of vomiting during acute gastroenteritis in children: multicentre randomized controlled trial

BackgroundVomiting in children with acute gastroenteritis (AG) is not only a direct cause of fluid loss but it is also a major factor of failure of oral rehydration therapy (ORT). Physicians who provide care to paediatric patients in the emergency department (ED) usually prescribe intravenous fluid therapy (IVT) for mild or moderate dehydration when vomiting is the major symptom. Thus, effective symptomatic treatment of vomiting would lead to an important reduction in the use of IVT and, consequently, of the duration of hospital stay and of frequency of hospital admission. Available evidence on symptomatic treatment of vomiting shows the efficacy of the most recently registered molecule (ondansetron) but a proper evaluation of antiemetics drugs largely used in clinical practice, such as domperidone, is lacking.ObjectivesTo compare the efficacy of ondansetron and domperidone for the symptomatic treatment of vomiting in children with AG who have failed ORT.Methods/DesignMulticentre, double-blind randomized controlled trial conducted in paediatric EDs. Children aged from 1 to 6 years who vomiting, with a presumptive clinical diagnosis of AG, and without severe dehydration will be included. After the failure of a initial ORS administration in ED, eligible children will be randomized to receive: 1) ondansetron syrup (0,15 mg/Kg of body weight); 2) domperidone syrup (0,5 mg/Kg of body weight); 3) placebo. The main study outcome will be the percentage of patients needing nasogastric or IVT after symptomatic oral treatment failure, defined as vomiting or fluid refusal after a second attempt of ORT. Data relative to study outcomes will be collected at 30 minute intervals for a minimum of 6 hours. A telephone follow up call will be made 48 hours after discharge. A total number of 540 children (i.e. 180 patients in each arm) will be enrolled.DiscussionThe trial results would provide evidence on the efficacy of domperidone, which is largely used in clinical practice despite the lack of proper evaluation and a controversial safety profile, as compared to ondansetron, which is not yet authorized in Italy despite evidence supporting its efficacy in treating vomiting. The trial results would contribute to a reduction in the use of IVT and, consequently, in hospital admissions in children with AG. The design of this RCT, which closely reflect current clinical practice in EDs, will allow immediate transferability of results.Trial RegistrationClinicalTrials.gov: NCT01257672

Oral ondansetron versus domperidone for acute gastroenteritis in pediatric emergency departments: Multicenter double blind randomized controlled trial

The use of antiemetics for vomiting in acute gastroenteritis in children is still a matter of debate. We conducted a double-blind randomized trial to evaluate whether a single oral dose of ondansetron vs domperidone or placebo improves outcomes in children with gastroenteritis. After failure of initial oral rehydration administration, children aged 1–6 years admitted for gastroenteritis to the pediatric emergency departments of 15 hospitals in Italy were randomized to receive one oral dose of ondansetron (0.15 mg/kg) or domperidone (0.5 mg/kg) or placebo. The primary outcome was the percentage of children receiving nasogastric or intravenous rehydration. A p value of 0.014 was used to indicate statistical significance (and 98.6% CI were calculated) as a result of having carried out two interim analyses. 1,313 children were eligible for the first attempt with oral rehydration solution, which was successful for 832 (63.4%); 356 underwent randomization (the parents of 125 children did not give consent): 118 to placebo, 119 to domperidone, and 119 to ondansetron. Fourteen (11.8%) needed intravenous rehydration in the ondansetron group vs 30 (25.2%) and 34 (28.8%) in the domperidone and placebo groups, respectively. Ondansetron reduced the risk of intravenous rehydration by over 50%, both vs placebo (RR 0.41, 98.6% CI 0.20–0.83) and domperidone (RR 0.47, 98.6% CI 0.23–0.97). No differences for adverse events were seen among groups. In a context of emergency care, 6 out of 10 children aged 1–6 years with vomiting due to gastroenteritis and without severe dehydration can be managed effectively with administration of oral rehydration solution alone. In children who fail oral rehydration, a single oral dose of ondansetron reduces the need for intravenous rehydration and the percentage of children who continue to vomit, thereby facilitating the success of oral rehydration. Domperidone was not effective for the symptomatic treatment of vomiting during acute gastroenteritis.

Nationwide study of headache pain in Italy shows that pain assessment is still inadequate in paediatric emergency care

Italian national guidelines on pain management were published in 2010, but there is little information on how effective pain management is in paediatric emergency care, with other countries reporting poor levels. Using headache as an indicator, we described pain assessment in Italian emergency departments and identified predictors of algometric scale use.

Procalcitonin as diagnostic marker of severe bacterial infections in febrile infants in the emergency department

302 Procalcitonin as diagnostic marker of severe bacterial infections in febrile infants in the emergency department B.Andreola,S.Bressan,S.Callegaro,T. Zangardiand L.Da Dalt Pediatric Emergency Department, Department of Pediatrics, University of Padova, Padova, Italy Introduction Procalcitonin (PCT) is a good predictor of severe bacterial infections (SBI), but its role in the approach to the febrile child in the setting of a Pediatric Emergency Department (PED) is not yet well defined [1]. Objectives To assess PCT diagnostic value as predictor of SBI in febrile children, comparing its diagnostic accuracy with C-reactive protein (CRP) and white blood cell (WBC) count. To evaluate PCT diagnostic accuracy in the early detection of SBI. Methods In all, 369 febrile children aged 7 days to 36 months, admitted to our PED, were prospectively enrolled. Ninety-two had the final diagnosis of severe bacterial infection. PCT, CRP, WBC counts were determined at admission and compared. Specificity, sensitivity, multilevel likelihood ratios, receiver operator characteristic (ROC) curve analysis were performed. Results Areas under the ROC curve (AUC) were 0.80 [confidence interval (CI) 95% 0.77–0.84] for PCT, 0.85 (CI 95% 0.80–0.88) for CRP and 0.74 (CI 95% 0.69–0.78) for WBC count. The optimum cutoff value for detecting SBI was 0.52 ng/ml (sensitivity 70.7%, specificity 79.8%) for PCT, 30mg/l (sensitivity 82.6%, specificity 74.0%) for CRP and 12650/mm (sensitivity 74.7%, specificity 64.5%) for WBC count. For children with fever duration o8 h (n1⁄436), the AUC for PCT and CRP were 0.90 (CI 95% 0.75–0.97) and 0.77 (CI 95% 0.60–0.89), respectively (P1⁄40.227). Conclusion Diagnostic performance of PCT is quite similar to CRP in the whole population of febrile children admitted to PED. WBC count proved to be the least accurate test. PCT shows the best AUC in children with fever evolution o8 h. Reference 1. Lacour AG, Gervaix A, Zamora SA, Vadas L, Lombard PR, Dayer JM, Suter S. Procalcitonin, IL-6, IL-8, IL-1 receptor antagonist and C-reactive protein as identificators of serious bacterial infections in children with fever without localising signs. Eur J Pediatr 2001; 160:95–100. From the emergency department to the intensive care unit Abstract 147 Noninvasive ventilation in an emergency department: 3 years of experience A.Olaizola,V.Cabriada,A.Garc|¤ a Montero,A.Ferna¤ ndez, M.Garmendia,L.Lopezand A.Etxeberria147 Noninvasive ventilation in an emergency department: 3 years of experience A.Olaizola,V.Cabriada,A.Garc|¤ a Montero,A.Ferna¤ ndez, M.Garmendia,L.Lopezand A.Etxeberria Emergency Department, Hospital de Cruces, Barakaldo, Basque Country, Spain Introduction Noninvasive ventilation (NIV) was started as a therapy for acute hypercapnic respiratory failure (AHRF) at our emergency department (ED) in mid-2001. Our aim is to analyse our results after 3 years of experience. Methods Retrospective analysis of all the cases in which NIV was used between July 2001 and June 2004. A gasometric comparison was carried out among three different intervals: before NIV (V0), 1 hour after NIV (V1) and at 6 hours with NIV (V2), using paired t-test. Results NIV was used on 107 occasions. Mean age: 73.36 years. Forty-nine cases had a previous diagnosis of chronic obstructive pulmonary disease. At V0 patients showed: a mean cardiac frequency (RF) of 31.87 and a mean cardiac frequency (CF) of 106.78. Gasometric parameters at V0 were: PO2 40.86; PCO2 89.5 and pH 7.24. At V1 there was an improvement in the gasometric parameters (PCO2 75.44; pH 7.30); at V2 a bigger improvement of these parameters was met: pH 7.34 and PCO2 68.74. NIV at the ED was successful in 83 occasions (77.6%). Five patients were admitted to intensive care unit (three treated with OTI) and the rest to normal facilities. Conclusion 1-NIV had a successful outcome in 77.6% of the patients. These results are positively evaluated owing to the severe condition of our patients (pH V0 7.24). 2-NIV is a consolidated therapy for AHRF in our ED. 3-NIV should be considered as a frontline therapy for these kind of patients in every ED. Abstract 466 Rapid sequence Intubation using theMcGrath videolaryngoscope B.Shippey,D.McKeownand D.Ray466 Rapid sequence Intubation using theMcGrath videolaryngoscope B.Shippey,D.McKeownand D.Ray Department of Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh,

La pédiatrie d’urgence en Europe

Pour reduire la morbidite et la mortalite des enfants gravement malades et blesses, il faut les prendre en charge d’une maniere complete. Cela implique des soins efficaces et un traitement precoce de la maladie ou de la blessure jusqu’a l’intervention des medecins specialises en medecine pediatrique d’urgence (MPU). La medecine pediatrique d’urgence est en train d’emerger comme une sous-specialite unique et independante aux Etats-Unis, au Canada et en Australie. En Europe, le nombre des pediatres s’interessant a la MPU et le nombre d’hopitaux se consacrant aux maladies aigues des enfants ont augmente depuis les dix dernieres annees, mais la croissance de la MPU n’a pas ete la meme dans tous les pays, ce qui explique les differences parfois importantes que l’on peut observer au niveau professionnel ou scientifique d’un pays a l’autre. Il faut esperer que les pediatres auront de plus en plus un role-cle dans le developpement, l’amelioration et l’evaluation des progres des services de medecine pediatrique d’urgence et qu’ils seront impliques de maniere croissante dans le controle de la qualite, la redaction des protocoles cliniques, le soutien et la recherche en MPU.