[Hemolytic uremic sydrome associated with streptococcus pneumoniae meningitis report of one case]

A previously healthy eleven months infant was admitted for fever and a status epilepticus. He was found to have purulent meningitis due to streptococcus pneumoniae, complicated by acute renal failure due to hemolytic uremic syndrome. He received peritoneal dialysis and recovered with normalization of renal function but his mental status deteriorated with severe neurologic sequelae. This case illustrates the need of rapid diagnosis and treatment of invasive pneumococcal disease and the necessity to introduce the conjugate pneumococcal vaccination to the Tunisian standard vaccination schedule to reduce the incidence of pneumococcal infection and its associated morbidity and mortality

Gender differences in the surgical management and early clinical outcome of coronary artery disease: Single centre experience

To investigate the gender disparity in the distribution of patient-related risk factors and their effect on the surgical management and clinical outcome of coronary artery disease in Saudi population. We carried out a retrospective analysis of prospectively collected data of 971 patients undergoing isolated coronary artery bypass grafting [CABG] at our institution between January 2005 and December 2008. Seven hundred and eighty seven patients [81%] were males and 184 patients [19%] were females. We analyzed gender-based difference in clinical presentation and patient-related pre-operative risk factors and studied their impact on surgical management and clinical outcome. The mean age was 59.5 years in males and 63.4 years in females [p = < 0.0001]. Associated co-morbidities were higher in females. Prevalence of diabetes mellitus was 61.2% in males and 78.8% in females [p-value < 0.0001]; hypertension 61.9% in males and 79.9% in females [p-value < 0.0001]; hyperlipidemia 66.7% in males and 77.7% in females [p-value 0.0035]; morbid obesity 24.7% in males and 45.1% in females [p-value < 0.0001]; and Hypothyroidism 2.5% in males and 13.6% in females [p-value < 0.0001]. Smoking was the only risk factor with higher prevalence in males compared to females [44.2% v/s 2.2%; p-value < 0.0001]. The mean logistic euro-SCORE was 3.94 in males and 5.51 in females [p < 0.0003]. On-pump and off-pump CABG was carried out in equal numbers in two groups. Females required urgent surgery and less than 3 grafts more frequently while males underwent elective surgery and more than 3 grafts in greater numbers. No significant difference was present between the two gender groups in aortic occlusion times and bypass times. Univariant analysis revealed females gender as an independent risk factor for higher in-hospital mortality [1.1% versus 4.9% p = 0.0026] and higher incidence of post-operative complications like surgical wound infection, need for prolonged ventilation, low cardiac output state and multi-organ failure [p-values 0.01 or less]. Female gender is an independent predictor of adverse outcome after isolated CABG due to significantly higher co-morbidities and acute presentation and independent of their peri-operative management. Therefore, major socioeconomic education and preventive measures are needed to reduce the burden of major co-morbidities in females and to seek early cardiac advice and care

[Acute transverse myelitis in pediatric intensive care: a 3 cases report]

Acute transverse myelitis [ATM] is a rare disorder caused by an inflammatory syndrome of the spinal cord. We report 3 cases of ATM managed in the intensive care unit of the Children's hospital of Tunis in order to precise clinical, therapeutic and prognostic particularities of the severe forms of ATM complicated with acute respiratory insufficiency [ARI]. Cases: the three patients were aged respectively of 6, 9 and 13 years. The 3 girls presented with ARI requiring mechanical ventilation in 2 cases. The diagnosis was confirmed by the cerebrospinal MRI in the 3 cases. The etiological research was negative in all cases. Intravenous methylprednisolone was given in the 3 cases. One patient died. The death was caused by acute neurovegetative disorders. At 6 months follow up, one patient was asymptomatic. The other patient had urinary incontinence and a partial lower limb weakness

[Epidemiology profile and mortality factors of the septic shock subordinate to a community infection among children in a developing country]

Goal: To determine the epidemiology profile of the septic shock subordinate to a community infection among children, admitted to an intensive care unit in a developing country, and the factors affecting mortality

Patients and Methods: Retrospective analysis of all the observations of the children, admitted between january 1998 and august 2005, in a children's intensive care unit and among whom septic shock subordinate to a community infection was diagnosed. The criteria adopted to diagnose the septic shock are those of the American College of Critical Care Medecine. The multivisceral deficiency was defined by the simultaneous presence of 2 deficient organs [Wilkinson Criteria]. Babies of less than 7 days old and shock subordinate to a nosocomial infection were excluded from this study. The data taken for every patient was: the age, gender associated pathology, the time duration between the symptoms of circulatory failure, the PRISM score, the other deficient organs, the results of the microbiological tests, the filling volume, the nature, the amount, the duration and the number of the vasoactive drugs used, the use of hydrocortisone and the lack there of, and transfer to an intensive care unit. Forthe survivors, the duration of mecanical ventilation and the duration of stay were noted. The time and cause of death were also precisely noted for the deseased patients

Results: Seventy cases were observed, representing 2,8% of the admittions. The average age patients was 3, 8 +/- 4, 2 years and their PRISM during the first 24 hours was 19,2 +/- 8,4. Thirteen children [18, 6%] had a co-morbidity associated to the septic shock. Sixty-nine children [98, 6%] have a multivisceral deficiency and 60 of them [85,7%] have more than 2 deficient organs. An Acute Respiratory Distress Syndrome [SDRA] was associated to the septic shock in 5,7% of the cases. For 17 patients [24, 3%], the shock state was declared after the admission to the intensive care unit. For the 53 patients who were in a state of shock on admission, the average time between the noting of the first hemodynamic troubles and the admission to intensive care was 9,4 +/- 11,3 hours. The identification of an infection agent was only possible for 27 children [38, 6%]. The most frequently responsible germs were the Staphylocoque Aureus [13%], the Meningocoque [11, 5%] and the Pneumocoque [4, 3%]. Thirty two patients [45, 7%] died after 18 +/- 2 days from the time ressucitation started. For the survivors, the average duration of hospitalization and ventilation was respectively of 7,8 +/- 7 days and 4,3 +/- 3 days. An analysis indentified six factors significantly assciated to the death: the age > 30 month [p = 0,03], an intensive care transfer time > 4 hours [p = 0,03], a failure of more than 2 organs on admission [p < 0,001], a filling volume > 20 ml/kg to days 2 of resus sitation [p = 0,002], the use of epinephrin [p < 0,001], the use of more than 2 vasoactive drugs[p < 0,001].A multivariate analysis revealed 3 independant mortality risk factors: a failure of more than 2 organs on admission [OR, 4,4 ; 95 % CI [2,1 - 9,4]], a filling volume > 20 ml/kg after 2 days of resuscitation [OR , 3,4'; 95 Cl % [1,1 - 10,3]] and the use of more than 2 vasoactive drugs [OR, 3,3 ; 95 CI % [1,2 - 9]]

Conclusions: The septic shock subordinate to a community infection is a frequent cause of admission into children's intensive care unit. The Staphylocoque Aureus and the Meningocoque are the pathological agents the most frequently identified. Mortality is high [45, 7 %]. A failure of more than 2 organs upon admission, a filling volume > 20 ml/kg after 2 days of intensive care and the use of more than 2 vasoactive drugs are independant mortality risk factors

[Effects of high frequency oscillatory ventilation on gas exchanges in pediatric patients with acute respiratory failure]

There is increasing use of high frequency oscillatory ventilation [HFOV] in [rescuing] pediatric patients with acute respiratory failure [ARF], failing conventional ventilation [CV]. Because HFOV is considered to be a [rescue] therapy, intervention with HFOV is usually in the later stages of respiratory failure, after a prolonged CV. The objective of this study was to evaluate the effectiveness of HFOV, used as [early rescue] therapy, on gas exchanges in pediatric patients with ARF and diffuse alveolar disease. An HFOV protocol for pediatric patients with ARF was established with the following entry criteria: body weight of /= 90% and PaO[2]

[Early high frequency oscillatory ventilation in infants with severe meconium aspiration syndrome]

Objective of the Study: to evaluate the effectiveness of early high frequency oscillatory ventilation [HFO] in the management of infants with severe meconium aspiration syndrome [MAS]. Patients and methods 26 infants [gestational age: 40 weeks +/- 2 days, birth weight: 3460 g +/- 497] with MAS and acute hypoxemic respiratory failure requiring mechanical ventilation [oxygenation index [OI]: 13, 5 +/- 8, alveolo-arterial difference of oxygen [D[A-a]O2]: 455 +/- 159 mmHg] were included in the study. Fourteen [54 per cent] of them had a pulmonary air leak at admission. Seven infants [group 1], admitted before the year 2000, were managed with conventional mechanical ventilation [CMV] and were evaluated retrospectively. Nineteen patients [group 2], managed after the year 2000, were treated with HFO only, or with CMV relayed very early by HFO when CMV failed [FiO2>50 percent and/or peak inspiratory pressure >24 cmH2O].This group was evaluated prospectively. In the two groups, NOi was associated to the treatment when the FiO2 required remained superior to 60 per cent after 1 hour of mechanical ventilation. The two groups were comparable concerning their initial oxygenation parameters, and the percentage of patients with pulmonary air leak. The course of the oxygenation parameters, in the two groups, was studied using the test of Spearman

Results: 17 infants [65, per cent] were survived, 7 patients [26, 9 per cent] were died of refractory hypoxemia, and 2 patients [7, 7 percent] were died of septic chock. The study of the course of the mean oxygenation parameters during the trial showed, in the group 2, a significant decrease in D[A-a]O2, OI and FiO2 [p = 0,0001;0,002 and 0,0001 respectively].However, there isn't any significant improvement of these parameters in the group 1. NOi was necessary in 5 patients [71, 4 per cent] in the group 1, and in 9 patients [47, 3 per cent] in the group 2 [p = 0, 39].Death by refractory hypoxemia was occurred in 4 patients in the group1 [57 per cent] and in 3 patients [15, 8 per cent] in the group2 [p = 0, 05]. The duration of mechanical ventilation in the survivals was similar in the two groups

Conclusion: the early use of HFO in infants with severe MAS seems to improve oxygenation and tend to decrease mortality caused by refractory hypoxemia