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

Management of meconium aspiration syndrome with high frequency oscillatory ventilation

High-frequency oscillatory ventilation [HFOV] has been advocated for use to improve lung inflation while potentially decreasing lung injury. There were few data on the early use of HFOV in hypoxemic term neonates. To evaluate the effectiveness of HFOV, used as the initial mode of ventilation, in neonates with severe meconium aspiration syndrome [MAS]. In a tertiary care paediatric intensive care unit, 17 term neonates with severe MAS were managed with HFOV, used as the initial mode of ventilation, and prospectively evaluated. Ventilator settings, blood gases, oxygenation index [OI] and alveolar-arterial oxygen difference [P[A-a]O2] were prospectively recorded during HFOV treatment and compared at the multiple time intervals. Target ventilation was easily achieved with HFOV. Initiation of HFOV caused a significant decrease in FIO2, achieved as early as 1 hour [from 0.93 +/- 0.11 to 0.78 +/- 0.25; p=0.031] and the improvement was sustained during the 1-32 hours period. There were a significant decreases in P [A-a] O2 and OI, respectively, at 4 hours [from 562.5 +/- 71.7 to 355.4 +/- 206 mm Hg; p=0.03] and 8 hours [from 23.3 +/- 17 to 14.6 +/- 16.3; p=0.04], that were sustained up to 16 and 40 hours. Three neonates [17.6%] developed pneumothorax on HFOV. One patient required oxygen support at 28 days. No significant others complications associated with HFOV were detected. Sixteen infants [94%] were successfully weaned from HFOV and 15 [88%] survived to hospital discharge. Use of HFOV as the initial mode of ventilation in neonates with severe MAS is an effective strategy

[Outcome at 2 years of very premature infants. a tunisian series]

Neurodevelopmental outcome of very premature infant can be associated with a high rate of cerebral palsy. To assess the impact of very preterm birth on neurological outcome at the age of two years. Retrospective study of all cases of very premature infants born at less than 33 weeks of gestational age, during the years 2005 to 2007. Neurodevelopmental outcome is reported. During the study period, the very premature infant rate was 1.5%. A complete information about neurological outcome at the age of two years, was obtained in 60 cases. Eight infants [13.4%] showed major handicap [cerebral palsy] and four others infants developped neurosensoriel difficulties. The incidence of neurosensoriel handicap in our population seems relatively high. A strong effort must be made for identification of risk factors of neurodevelopmental disability

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

[Neonatal respiratory morbidity after elective caesarean section at term]

Incidence of elective caesareans at term is increasing these last decades with an associated increase of neonatal respiratory morbidity. To analyse the influence of elective Caesarean delivery at term on the incidence of neonatal respiratory distress in order to propose an effective strategy of prevention. It is an analytical study compiling all births resulting from elective Caesarean at term [gestationnel age ranging between 37 and 41+6 GA], reported over two years period at the Charles Nicolle hospital [Tunis-Tunisia]. We compared 250 live births, without maternel risk factors, delivered by elective Caesarean to 250 births delivered by vaginal way. Frequency of the elective Caesarean at term was of 3.6% live births; it was mainly indicated in the presence of a cicatricial uterus. The incidence of respiratory morbidity was 6% [15/250] in the group exposed to the elective caesarean versus 1.6% [4/250cas] in the reference group, OR = 3.9; 95%CI: [1, 28-11, 99] p<0.01. Before the term of 39 GA, OR = 5.22; 95%CI: [1.14-23.87] p=0.01. After 39 GA, the risk of respiratory distress decreased: OR = 1.86 95%CI: [0.30, 11.35] NS. The principal etiology of respiratory distress in the exposed group was the transitory tachypnea of the newborn. Incidence of respiratory distress was higher at newborn babies born from elective Caesarean with a significant reduction in this incidence after the term of 39 GA

[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

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