Evaluation of central veno-arterial carbon dioxide difference as a valid resuscitation tool in pediatric septic shock

Objectives: To test the hypothesis that central venous to arterial carbon dioxide difference [Pcv-a CO[2]] may help as a global marker of tissue perfusion in resuscitated pediatric septic shock patients when the central venous oxygen saturation [ScvO[2]] goal has been reached

Study design: A prospective randomized observational study was conducted in a 9 -bedded pediatric intensive care unit. 49 patients aged from 1 month to 4 years with a new episode of septic shock were included. Patients were categorized into four predefined groups according to the Pcv-a CO[2] gap to a threshold of 6 mmHg evaluated on admission [T0] and six hours after early goal-directed therapy [EGDT] resuscitation protocol [T6]: [I] persistently high Pcv-aCO[2] [high at T0 and T6]; [II] increasing Pcv-aCO[2] [normal at T0, high at T6]; [III] decreasing Pv-aCO[2] [high at T0, normal at T6]; and [IV] persistently normal Pv-aCO[2] [normal at T0 and T6]. Patients were resuscitated according to the international guidelines for management of severe sepsis and septic shock using a 6 hour EGDT and 1 ry, 2ry outcomes were evaluated

Results: There was a significant difference among groups as regard Pcv-a CO[2] at T0, T6 [both p <0.001], ScvO[2] at T6 [p 0.003], T24 vasopressor inotrope score [VIS] among category I and II regarding failure to fulfill shock reversal [p <0.001] with T24 VIS AUC on ROC curve 0.960, [p <0.001] to predict failure of shock reversal among category I, II with 88.89% sensitivity and 100% specificity to predict failure of shock reversal. No significant difference among categories concerning demographic data, clinical, ICU mortality, and 28 day mortality rates

Conclusion: Despite of near normalization of oxygen parameters, that does not guarantee adequate tissue perfusion, and still high mortality rates among pediatric septic shock patients. We would advise to measure continuously all parameters [i.e. clinical, oxygen markers, Pcv-aCO[2], lactate] until proper resuscitation by early goal-directed therapy [EGDT] and reversal of shock. Further investigations are recommended to look for other markers of impaired microcirculatory or mitochondrial dysfunction as well as therapeutic approaches targeting these deficiencies

Study of Pneumothorax in Alexandria University Pediatric Intensive Care Unit: a 5 year retrospective study

Objectives: The aim of this work is to estimate the incidence of pneumothorax among Pediatric Intensive Care Unit admissions in five years period 1[st] of January 2008-31[st] December 2012] and to study the risk factors that may affect the development of pneumothorax in these cases

Study design: The medical records of all children admitted to Alexandria University Pediatric Intensive Care unit from 1[st] of January 2008 to 31[st] of December 2012 were reviewed retrospectively

Results: In this study, of 1298 admitted cases, 135 [10.4%] developed 151 episodes of pneumothorax. The most common cause for pneumothorax was found to be barotraurna related to mechanical ventilation [about 70% of cases of pneumothorax and central venous catheterization coming next [13.2% of cases of pneumothorax]. Mechanical ventilation was needed in 92.5% of cases of pneumothorax compared to 52.7% of cases without pneumothorax .We found significant statistical difference between cases with and without pneumothorax as regards age, weight, PIM2 score, PELOD score, Length of stay, mortality rate, diagnostic category[p<0.001], need for mechanical ventilation, duration of mechani ventilation, ventilator settings [PEEP,PIP ,Fio[2][P<0.001]. There was no significant statistical difference among cases with and without pneumothorax as regards sex and referral site

Conclusion: Iatrogenic pneumothorax is the most common cause of pneumothorax. Need for mechanical ventilation, high ventilator settings and longer duration of ventilation are considered as risk factors in addition to underlying illness, so it is very important to strictly apply protective lung strategies to minimize risk of pneumothorax in ventilated cases