Yoke Hwee Chan

Noninvasive ventilation in children: a review

OBJECTIVE To assess the use of noninvasive ventilation (NIV) in children and its application in the acute and chronic setting of pediatric respiratory failure. SOURCES Search of pertinent articles within PubMed, Cochrane and Ovid MEDLINE databases from 1950 to 2007, using the keywords pediatrics, noninvasive ventilation and positive airway pressure. SUMMARY OF THE FINDINGS There is a paucity of published data on pediatric NIV. The majority of the data available are case reports or small case series, with a number of small, randomized studies reported. CONCLUSION Although the use of NIV is increasingly recognized in pediatrics, there are currently still no generally accepted guidelines for its use. In the chronic setting, its use has mainly been proven in obstructive sleep apnea and respiratory failure secondary to neuromuscular disorders. It would appear that the major challenge is ensuring compliance, and this can be enforced by patient/caregiver education, use of a suitable interface, heated humidifiers and by minimizing the side effects of NIV. In the setting of acute respiratory failure, it would appear from available data that success is usually predicted by the rapidity of response. Patients placed on NIV should be monitored closely and this mode of ventilation should be reviewed if there is a lack of response within a few hours after commencement of therapy.

Cor Triatriatum: Clinical Presentation of 18 Cases

From 1985 to 1999, 18 patients with cor triatriatum underwent surgical correction. Their ages ranged from 3 months to 9 years (mean, 32.5 months). Eight patients were cyanosed; the other 10 presented with congestive heart failure. Recurrent chest infection was observed in 10 cases, and failure to thrive in 7. One patient had isolated cor triatriatum, and 17 had an associated atrial septal defect. Other associated anomalies included patent ductus arteriosus, ventricular septal defect, and partial and total anomalous pulmonary venous connection. Two deaths occurred perioperatively in patients with associated severe heart defects. Follow-up ranged from 1 month to 10 years. No late events occurred among the survivors, and all were in New York Heart Association functional class I. Their most recent echocardiograms showed no residual obstruction or shunt and good development of the left cardiac chambers. Echocardiography is recommended as the diagnostic modality of choice. Cor triatriatum can be corrected surgically with low mortality and good long-term results.

Use of Magnesium Sulfate Infusion for the Management of Febrile Illness-Related Epilepsy Syndrome A Case Series

Febrile illness-related epilepsy syndrome is a catastrophic epileptic encephalopathy that is highly refractory to most antiepileptic drugs leading to high morbidity and mortality. The authors report the use of a pediatric infusion protocol of continuous intravenous magnesium sulfate for the control of seizures in 2 children with febrile illness-related epilepsy syndrome refractory to multiple antiepileptic drugs in a pediatric intensive care unit of a tertiary care children’s hospital. Both patients, 2 and 16 years of age, respectively, were treated with continuous magnesium sulfate infusion. Serum magnesium concentrations ranging from 2.1 to 5 mmol/L were achieved. Seizure reduction and cessation were noted in 1 patient with magnesium more than 3.0 mmol/L. No significant adverse effects were observed. Magnesium sulfate infusions can be safely used in pediatric refractory status epilepticus. Magnesium sulfate can be considered in the management of children with febrile illness-related epilepsy syndrome.

Impact of a nurse-led feeding protocol in a pediatric intensive care unit:

Background: To determine effectiveness of a nurse-led, volume-based feeding protocol in our pediatric intensive care unit (PICU), we evaluated patients’ nutrition adequacy pre- and post-protocol implementation. Methods: We conducted an observational study of patients admitted for more than three days in the PICU during pre- and post-feeding protocol periods. We recorded energy and protein intake and feed interruptions in patients started on enteral nutrition over the first seven days of admission. We excluded patients with septic shock requiring more than two inotropes, post-cardiac and post-gastrointestinal surgeries. To determine nutrition adequacy, actual energy and protein intakes were compared with calculated requirements, expressed as percentages. Results: We had a total of 40 patients (20 in the pre- and post-protocol groups, respectively) with median age of 9.4 (interquartile range (IQR) 2.8, 57) months. Median time to feed initiation was similar between groups (20.0 (IQR 17.0, 37.5) vs. 21.5 (IQR 10.5, 27.0) hours, p = 0.516). There was no difference in median energy (55 (IQR 12, 102) vs. 59 (IQR 25, 85) %, p = 0.645) and protein intake (53 (IQR 16, 124) vs. 73 (IQR 22, 137) %, p = 0.069) over the seven-day period between groups; the proportion of patients meeting their energy (10 vs. 35%, p = 0.127) and protein goal (15 vs. 30%, p = 0.451) by day three also did not differ significantly pre- and post-protocol implementation. The most common reasons for feed interruption were intubation/extubation and radiological procedures. Conclusion: Our current feeding protocol did not improve nutrient adequacy. The effectiveness of a more aggressive protocol in units where enteral nutrition is initiated within 24 hours should be investigated.