Bilateral Diaphragmatic Paralysis Following Paediatric Cardiac Surgery: Experience of four cases at the Royal Hospital, Muscat, Oman.

Bilateral diaphragmatic paralysis (BDP) is a rare complication of paediatric cardiac surgery. We report four children who developed BDP following cardiac surgery who were managed at the Royal Hospital, Muscat, Oman, between 2009 and 2014. All four children suffered severe respiratory distress soon after extubation and required re-intubation within two hours. In addition, all of the children underwent a tracheostomy as an interim method for ventilation. The four children were successfully weaned from positive pressure ventilation following the functional recovery of at least one side of the diaphragm.

Mechanical cause for acute left lung atelectasis after neonatal aortic arch repair with arterial switch operation: Conservative management.

Respiratory complications due to mechanical obstruction of the airways can occur following pediatric cardiac surgery. Clinically significant intrathoracic vascular compression of the airway can occur when extensive dissection and mobilization of arch and neck vessels is involved as in repair of interrupted aortic arch. This case report describes a neonate who underwent interrupted aortic arch repair along with an arterial switch operation and developed a left lung collapse immediately after tracheal extubation. Fiber-optic bronchoscopy revealed vascular compression as the real culprit. The child was successfully managed conservatively.

Two Cases of Pneumatoceles in Mechanically Ventilated Infants.

Pulmonary pneumatocele is a thin-walled, gas-filled space within the lung that usually occurs in association with bacterial pneumonia and is usually transient. The majority of pneumatoceles resolve spontaneously without active intervention, but in some cases they might lead to pneumothorax with subsequent hemodynamic instability. We report two cases presented to the pediatric intensive care unit at the Royal Hospital, Oman with pneumatoceles. The first was a 14-day-old baby who underwent surgical repair of total anomalous pulmonary venous connection (TAPVC) requiring extracorporeal membrane oxygenation (ECMO) support following surgery. He was initially on conventional mechanical ventilation. Seven days after the surgery, he started to develop bilateral pneumatoceles. The pneumatoceles were not regressing and they did not respond to three weeks of conservative management with high-frequency oscillation ventilation (HFOV). He failed four attempts of weaning from HFOV to conventional ventilation. Each time he was developing tachypnea and carbon dioxide retention. Percutaneous intercostal chest drain (ICD) insertion was needed to evacuate one large pneumatocele. Subsequently, he improved and we were able to wean and extubate him. The second case was a two-month-old male admitted with severe respiratory distress secondary to respiratory syncytial virus (RSV) pneumonitis. After intubation, he required a high conventional ventilation setting and within 24 hours he was on HFOV. Conservative management with HFOV was sufficient to treat the pneumatoceles and no further intervention was needed. Our cases demonstrate two different approaches in the management of pneumatoceles in mechanically ventilated children. Each approach was case dependent and could not be used interchangeably.

Severe Pertussis Pneumonia managed with Exchange Transfusion.

We describe in this case report one month old baby admitted to our Pediatric Intensive Care Unit (PICU) with severe pertussis pneumonia. The baby was deteriorating despite being on supportive management including High Frequency Oscillator ventilation (HFOV). However, she showed dramatic improvement after exchange blood transfusion (ET) and was discharged home. We hope that this report will add to the previously published experiences in management of severe pertussis. It will also alert general physicians about pertussis pneumonia and the importance of early referral and abrupt management for a better prognosis.

Late Onset Central Hypoventilation Syndrome due to a Heterozygous Polyalanine Repeat Expansion Mutation in the PHOX2B Gene.

This report describes a 6 year old girl with late onset central hypoventilation syndrome due to a heterozygous polyalanine repeat expansion mutation in the PHOX2B gene. This report aims to increase the awareness of this condition among physicians to allow earlier clinical and genetic diagnosis and management of cases of unexplained hypoventilation.

Insulin infused at 0.05 versus 0.1 units/kg/hr in children admitted to intensive care with diabetic ketoacidosis.

OBJECTIVE: To compare the effects of infusing insulin at 0.05 units/kg/hr rather than 0.1 units/kg/hr in children admitted to the intensive care unit with diabetic ketoacidosis. DESIGN: A retrospective observational study. SETTING: A tertiary pediatric intensive care unit. PATIENTS: All children with diabetic ketoacidosis admitted during the 6-yr period from 2000 to 2005. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The effective plasma osmolality (plasma glucose concentration in mmol/L + twice the plasma sodium concentration in mmol/L), plasma glucose, plasma sodium, fluid intake, and acid-base status 12 hrs after the commencement of the insulin infusion. Compared to the 34 children who received 0.1 units/kg/hr of insulin, the 33 children who received 0.05 units/kg/hr of insulin were younger (median age, 25 mos vs. 62 mos, p = .024) and had a more gradual reduction in the effective plasma osmolality over the first 12 hrs (p < .0005); this was because plasma glucose decreased more slowly (p = .004) and plasma sodium increased faster (p < .0005). Both groups had a satisfactory improvement in acidosis and ketosis, and they had a similar length of stay in the intensive care unit. CONCLUSIONS: Further studies are needed to evaluate the role of using 0.05 units/kg/hr of insulin to treat children with diabetic ketoacidosis. The smaller dose of insulin may make it easier to lower the effective plasma osmolality gradually and might, therefore, reduce the risk of cerebral edema.