first hour resuscitation of pediatric septic shock

The pediatric septic shock mortality in Tunisia remains high [50%] and was markedly higher than in western countries [10%]. The decrease in septic shock mortality has been obtained with the advent of the early goal directed therapy. The aim of this paper is to propose to the first line practitioners in Tunisia, during the first hour after establishing the diagnosis of septic shock practical clinical guidelines based on earlier consensus recommendations. Literature review. Septic shock must be rapidly suspected and early recognized. Adequate oxygenation and prompt correction of hemodynamic derangements has been shown to improve outcome through aggressive volume resuscitation, early empiric antibiotherapy and early initiation of vasopressor agents. Frequent reassessment has been emphasized to ensure appropriate management. This treatment must take into consideration the resources available in our area. We can reasonably hope to decrease mortality of patients with septic shock if the first line physicians keep in mind specific therapeutic goals

Early neonatal infection caused by Streptococcus pneumonias: report of 3 cases

S pneumoniae is a rare cause [1-8%] of maternofetal infection causing an important morbi-mortality in the newborn and the mother. To report 3 cases of early neonatal infection due to S pneumonia. Three cases of early neonatal infection due to S pneumoniae are reported. The three newborns were at term or near term babies with a vaginal delivery in two cases and a caesarean section in one case. They presented severe symptoms, with a progressive onset after birth, leading to hypoxemic pneumonia in one case and to septic shock in two newborns associated with meningitis in one case. S pneumoniae was isolated in the blood culture in two patients with positive soluble antigens in the cerebrospinal fluid in one case and positive peripheral bacteriological swabs in the other case. In the third case, S pneumoniae was isolated in the tracheal sample of the newborn and his mother. S pneumoniae was sensitive to ampicillin in two patients and of decreased sensitivity to ampicillin in one patient. The clinical course was favourable in the three patients after hospitalization in the intensive care unit. Early neonatal infections caused by S pneumonia are rare and are an important cause of morbi-mortality in the newborn and the mother

Community-acquired methicillin-resistant Staphylococcus aureus infections requiring admission to a Tunisian paediatric intensive care unit

There is limited literature describing severe community acquired methicillin-resistant S aureus [CA-MRSA] in children admitted to an intensive care unit. To review clinical features and outcome of children admitted in a Tunisian pediatric intensive care with CA-MRSA. Retrospective chart review of patients coded for CAMRSA over 10 years. There were 14 [0.32% of all admissions] patients identified with severe CA-MRSA. The median age was 3 months [range, 0.5-156 months]. All patients had pulmonary involvement. Six children [42.8%] developed septic shock. Two [14.3%] patients had multifocal infection with deep venous thrombosis. Two [14.3%] patients died. Severe CA-MRSA pneumonia dominated presentation. The mortality of CA-MRSA infection in our series is lower than reported in the literature

[Acute disseminated encephalomyelitis associated with mycoplasma pneumoniae infection in children 2 case report]

Extrapulmonary complications of Mycoplasma pneumoniae infection are rare and dominated by nervous system disorders. Two patients suffering from acute disseminated encephalomyelitis associated with M. Pneumoniae infection are reported. Report of two new cases the 2 cases, M. Pneumoniae infection was documented by the positivity of serology, polymerase chain reaction and culture in the respiratory tract. Patient I recovered after prolonged mechanical ventilation in the paediatric intensive care unit. He was fully conscious I month alter admission and able to walk with help 2.5 months after the onset of the disease. The 2nd patient died after 9 days of hospitalisation in the intensive care unit. The death was caused by neurovegetative disorders. Acute disseminated encephalomyelitis associated with Mycoplasma pneumoniae infection in children 2 case reports

Management of purpura fulminans about 21 cases: diagnostic delay and therapeutic problems

To evaluate the diagnostic delay and therapeutic insufficiencies delay before the transfer in ICU of the children admitted in the ICU of the children's hospital of Tunis with a purpura fulminans [PF] A retrospective, descriptive study, of children with PF referred between January 2000 and January 2006 to a the paediatric intensive care unit [PICU] of the children's hospital of Tunis. The PF diagnosis was retained in any child presenting a feverish purpura and circulatory insufficiency signs. The optimal diagnostic and therapeutic charge taking was defined in three levels: parental, the first line doctors, and the hospital doctors. The symptoms' duration and the various treatments which were lavished to the patients were taken from the medical observations of the patients transferred in our PICU. Twenty one observations were collected. Twelve patients [57,1%] were addressed by a doctor exerting in a dispensary or by a free practicing doctor, 5 patients [23,8%] were transferred from a regional hospital and 4 children [19,1%] directly consulted the children hospital of Tunis urgencies .delayed parental recognitionoccured in 11 children. The PF diagnosis was not evoked by the first line doctor in 62%. Eleven [52,4%] of the children with meningococcal disease were seen but not admitted by a doctor in the 48 hours before admission. Apart from 2 patients [9,5%] who were hospitalized in reanimation directly of the urgencies, all the other patients forwarded by a general pediatry service. In general pediatry, the PF diagnosis was not evoked in 3 cases [15.8%], 31,6% of patients had unnecessary a lumbar punctures and shock was not recognised or treated in 26,3%. Twelve patients [52,2%] died. The duration of hospitalization in general pediatry is significantly higher among deceased patients [5,5 +/- 6,6 hours] than among the surviving patients [2,6 +/- 1,5 hours]; p<0,5. Suboptimal treatement in PF is due to failure of parents, general practioners and hospital doctors to recognise specific features of the illness. Improvement in outcome could be achieved by public education and better training of clinicians in recognition, resuscitation, and stabilisation of seriously ill children

[Acute respiratory distress syndrome in infants at term and near term about 23 cases]

Aim: to precise the incidence of acute respiratory distress syndrome in infants at term and near term and the clinical characteristics of this disease not yet well recognised

Methods: retrospective study of the medical records of infants admitted in the paediatric intensive care unit for ARDS along a period of 4 years. Diagnosis of ARDS was based on the following criterias: 1] Gestational age >/= 35 weeks of gestation; 2] Severe and immediate respiratory distress requiring mechanical ventilation with PEEP >/=4 cm H2O and FiO[2] >/= 0.5 during at least 6 hours ; 3] Dependence on oxygen >/= 48 hours; 4] Diffuse alveolar damage in the chest radiograph; 5] PaO[2] /= 0.5

Results: During the period of the study, 23 infants [gestational age = 36 +/- 1.1 weeks of gestation; birth weight = 2756 +/- 453 gr] were included in the study. Their mean age at admission was 16.5 +/- 14.6 hours. The majority of infants [91.3%] were born by caesarean section before the onset of labour in 78.3% cases. All infants had a severe acute hypoxemic respiratory failure [D[A- a]O2 = 468 +/- 165; OI = 19 +/- 8.4]. Five infants [21.7%] improved their oxygenation parameters under conventional mechanical ventilation [CMV] [p<0.001; p = 0.002 et p=0.003 respectively for D[A - a] O[2], OI and PaO2/FiO[2]]. Eighteen infants [78.2%] required high frequency oscillatory ventilation [HFOV] with a rapid and persistant improvement of oxygenation parameters. Five patients [21.7%] developed pulmonary air leak

One infant died

Conclusion:ARDS represents 6.8% of etiology of respiratory distress in infants at term and near term. Caesarean section before the onset of labour seems to be a triggering factor. The outcome seems to be favourable [rate of survival = 95.7%] if the management is suitable

[Current management of acute bronchiolitis in Tunisia]

The purpose of this study was to assess the current management practices of acute bronchiolitis by Tunisian paediatricians. A questionnaire was sent by mail to all Tunisian paediatricians, about the most widely used drugs during the first stage of acute bronchiolitis. The answers were sent to us by mail in pre-stamped envelopes. Out of total of 420 questionnaires sent, 180 [42,8%] were returned, out of which 177[42%] were analysed. Of the respondents, 117 [66%] were working in hospitals and, 60[34%] were working in the private sector. Bronchodilators were used by 93,3% of peadiatricians either routinely [35,6%] or occasionally [44,1%]. Steroids were used by 88.7% of pediatricians either routinely [28.8%] or occasionally [43.5%] Nasal drops, were prescribed routinely by 80,2% of the pediatricians. Physiotherapy was performed routinely or occasionally in 91.5% of the cases. Oxygen and antibiotics were respectively used by 92% and 70% of the paediatricians. A comparaison between the practices of the hospital paediatricians and their private sector conterparts showed that private practitioners, statistically, prescribe more bronchodilatators [42,7% vs 21,7%] [p < 0.05] and corticosteroids [36.8% vs 13.3%][p < 0.05] than their hospital colleagues. Hospital physicians, more than the private sector ones, tend to never prescribe bronchodilatators, 2 [15% vs 2,6%] [p < 0.05] and steroids [25% vs4,3][p<0,05]. Despite the absence of the scientific evidence showing a beneficial effect of the pharmaceutical agents, most paediatricians, during the initial phase of acute bronchiolitis, resort to prescribing bronchodilators [93,3%] and corticosteroids [88,7%]. There is a great variety of therapeutic practices among hospital paediatricians and private practitioners .National guidelines could be helpful in reducing this disparity