Zohar Barzilay

Is propofol safe for procedural sedation in children? A prospective evaluation of propofol versus ketamine in pediatric critical care

ObjectivesTo compare propofol with ketamine sedation delivered by pediatric intensivists during painful procedures in the pediatric critical care department (PCCD). DesignProspective 15-month study. SettingAn 18-bed multidisciplinary, university-affiliated PCCD. InterventionsAll children were randomized to the propofol or ketamine protocol according to prescheduled procedure dates. Propofol was delivered by continuous infusion after a loading bolus dose and a minidose of lidocaine (PL). Ketamine was given as a bolus injection together with midazolam and fentanyl (KMF). Repeated bolus doses of both drugs were given to achieve the desired level of anesthesia. The studied variables included procedures performed, anesthetic drug doses, procedure and recovery durations, and side effect occurrence. The patient’s parents, PCCD nurse and resident physician, pediatric intensivist, and the physician performing the procedure graded the adequacy of anesthesia. Measurements and Main ResultsOf the 105 procedures in 98 children, PL sedation was used in 58 procedures, and KMF was used in 47. Recovery time was 23 mins for PL and 50 mins for KMF, and total PCCD monitoring was 43 mins for PL and 70 mins for KMF. Five children (10.6%) in the KMF group and in none in the PL group experienced discomfort during emergence from sedation. Transient decreases in blood pressure, partial airway obstruction, and apnea were more frequent in the PL than in the KMF sedation. All procedures were successfully completed, and no child recalled undergoing the procedure. The overall sedation adequacy score was 97% for PL and 92% for KMF (p < .05). ConclusionsBoth PL and KMF anesthesia are effective in optimizing comfort in children undergoing painful procedures. PL scored better by all evaluators, recovery from PL anesthesia after procedural sedation was more rapid, total PCCD stay was shorter with PL, and emergence from PL was smoother than with KMF. Because transient respiratory depression and hypotension are associated with PL, it is considered safe only in a monitored environment (e.g., a PCCD).

Terlipressin as rescue therapy for intractable hypotension due to septic shock in children.

Intractable hypotension due to septic shock is associated with high mortality rates in critically ill children worldwide. The use of terlipressin (triglycyl-lysine-vasopressin), an analog of vasopressin with a longer duration of action, recently emerged as a treatment of hypotension not responsive to vasopressors and inotropes. This was a retrospective study set in an 18-bed pediatric critical care department in a tertiary care children’s hospital. We reviewed the files of all children with septic shock who were treated with terlipressin between January 2003 and February 2004. Fourteen children (mean age, 5.6 years; range, 4 days to 17.7 years) were treated with terlipressin in 16 septic shock episodes. Significant improvements in respiratory and hemodynamic indices were noted shortly after treatment. Mean arterial blood pressure increased significantly from 54 ± 3 to 72 ± 5 mmHg 10 min after terlipressin administration (P = 0.001). Heart rate decreased from 153.0 ± 6.5 beats/min to 138.0 ± 7.5 beats/min 12 h after treatment onset (P = 0.003). Epinephrine infusion was decreased or stopped in eight patients after terlipressin administration. Urine output increased from 1.6 ± 0.5 mL/kg/h to 4.3 ± 1.2 mL/kg/h 1 h after treatment onset (P = 0.011). PaO2 increased from 95.1 ± 12.3 mmHg to 110.1 ± 20.5 mmHg, and the oxygenation index decreased from 10.2 ± 2.2 to 9.2 ± 1.7. Terlipressin treatment of hypotension due to septic shock was successful in eight out of 16 episodes. Six of the 14 patients with poor prognosis for survival recovered. We conclude that terlipressin improves hemodynamic indices and renal function in critically ill children. Terlipressin should be considered as a rescue therapy in intractable shock not responsive to catecholamines in children.

Terlipressin as rescue therapy for intractable hypotension during neonatal septic shock.

Objective To report the successful use of terlipressin in an 8-day-old infant for treatment of intractable hypotension caused by septic shock. Design Descriptive case report. Setting An 18-bed pediatric intensive care unit at a tertiary care children’s hospital. Patient An 8-day-old child with intractable hypotension due to septic shock after heart surgery. Interventions General supportive intensive care including mechanical ventilatory support, volume replacement, and inotropic support with dopamine 20 &mgr;g·kg−1·min−1, milrinone 0.75 &mgr;g·kg−1·min−1, and epinephrine 0.8 &mgr;g·kg−1·min−1. Measurements and Main Results Terlipressin (7 &mgr;g/kg per dose twice daily) was added as rescue therapy because of profound intractable hypotension. Shortly after the beginning of treatment, blood pressure and perfusion dramatically improved. Conclusions There is circumstantial evidence that the administration of terlipressin caused the increase in blood pressure. We suggest that terlipressin should be considered as rescue therapy when high-dose catecholamine therapy does not result in sufficient perfusion pressure. Further investigation is needed to prove terlipressin’s effectiveness and safety in infants and children.

Recombinant activated factor VII for life-threatening pulmonary hemorrhage after pediatric cardiac surgery.

Objective To report intractable life-threatening pulmonary hemorrhage after cardiac surgery in an infant who was treated successfully with recombinant activated factor VII (rFVIIa). Design Descriptive case report. Setting An 18-bed pediatric intensive care unit at a tertiary-care children’s hospital. Patient A 10-wk-old child with acute life-threatening pulmonary hemorrhage after cardiac surgery. Interventions General supportive intensive care. Measurements and Main Results Care included mechanical ventilatory support, inotropic support, and concurrent treatment with blood products (packed cells, platelet concentrates, and plasma-derived products), as well as aprotinin and desmopressin to improve hemostasis. The addition of rFVIIa resulted in complete resolution of the hemorrhage. Conclusions rFVIIa should be considered as a possible novel therapeutic approach to be used as rescue therapy for patients presenting with massive life-threatening hemorrhage progressing into hemorrhagic shock. Further controlled trials to elucidate the safety of this treatment are warranted.

Should vasopressin replace adrenaline for endotracheal drug administration

ObjectiveArginine vasopressin was established recently as a drug of choice in the treatment of cardiac arrest and in retractable ventricular fibrillation; however, the hemodynamic effect of vasopressin following endotracheal drug administration has not been fully elucidated. We compared the effects of endotracheally administered vasopressin vs. adrenaline on hemodynamic variables in a canine model, and we investigated whether vasopressin produces the same deleterious immediate blood pressure decrease as did endotracheal adrenaline in the canine model. DesignProspective controlled study. SettingAnimal laboratory in Tel-Aviv University, Israel. SubjectsFive adult mongrel dogs weighing 6.5–20 kg. InterventionsDogs were anesthetized; each dog was intubated orally, and both femoral arteries were cannulated for the measurement of arterial pressure and for sampling blood gases. Each dog was studied four times, 1 wk apart, by using the same protocol for injection and anesthesia: endotracheal placebo (10 mL NaCl 0.9%,), endotracheal vasopressin (1 units/kg), endobronchial adrenaline (0.1 mg/kg), and endotracheal adrenaline (0.1 mg/kg). Following placebo, vasopressin, and adrenaline instillation, five forced manual ventilations were delivered with an Ambu bag. Each dog was its own control. Measurements and Main ResultsFollowing placebo or drug administration, heart electrocardiography and arterial pressures were continuously monitored with a polygraph recorder for 1 hr. Endotracheal vasopressin produced an immediate increase of diastolic blood pressure (from 83 ± 10 mm Hg [baseline] to 110 ± 5 mm Hg at 1 min postinjection). This response lasted >1 hr. In contrast, both endotracheal and endobronchial administration of adrenaline produced an early and significant (p < .05) decrease in diastolic and mean blood pressures. The diastolic blood pressure increase from 85 ± 10 mm Hg to 110 ± 10 mm Hg took an ill-afforded 55 secs following endotracheal adrenaline. Diastolic blood pressure was significantly (p < .05) higher following vasopressin compared with adrenaline administration in both routes. ConclusionsVasopressin accomplishes its hemodynamic effect, particularly on diastolic blood pressure, more rapidly, vigorously, and protractedly and to a significant degree compared with both endotracheal and endobronchial adrenaline. Evaluation of the effects of endotracheal vasopressin in a closed chest cardiopulmonary resuscitation model is recommended.

Ethnic differences in lung function in Israeli children.

BACKGROUND--The population of Israel consists of immigrants from many different countries. It is not known whether a single nomogram can be used for spirometric values of children of different ethnic descent. METHODS--Spirometry was performed in 753 second or third generation Israeli children (7-14 years) of different ethnic groups. Both parents of 503 of the children were of the same ethnic background. Subjects were allocated to six ethnic groups (European, Iraqi, North African, Indian, Yemenite, and Georgian). RESULTS--Standing height contributed most to the prediction of spirometric values (forced expiratory volume in one second, forced vital capacity), whereas sitting height did not contribute further. Statistical analysis showed significant ethnic differences. The Georgians had higher spirometric values for FEV1 than all the other ethnic groups, and higher FVC values than those of the Yemenite, North African, and Indian groups. FVC was lower among the Indian than all other groups. CONCLUSION--Differences in normal spirometric values were found among second or third generation Israeli children of different ethnic origins. European, North African, Iraqi, and Yemenite children could be characterised by single equation, whereas children of Georgian and Indian descent needed different predicting equations.