Poisonings requiring admission to the pediatric intensive care unit: A 5-year review.

BACKGROUND: Poisonings represent a significant number of preventable admissions to the pediatric intensive care unit (PICU), but data about poisonings requiring PICU-level care are limited. OBJECTIVES: To identify the demographics of patients admitted with poisonings and characterize their clinical courses related to their poisoning. METHODS: All poisonings over a 5-year period (2008-2012) at an academic medical center in New England were retrospectively reviewed using electronic medical records in an observational case series. Poisonings were identified using key search terms within an admissions database. RESULTS: There were 273 admissions for poisonings, which represent 8% of total PICU admissions over this time period. The poisonings were unintentional in 148 (54%) cases and intentional in 125 (46%). The vast majority of poisonings occurred in patients either 3 years or below (N = 121, 44%) or 13 years or above (N = 124, 45%). Most (96%) admissions were for less than 48 h and 41% were for less than 24 h. Mean PICU length of stay was 1.2 + 0.7 days. A total of 468 substances were ingested in 54 different drug classes, with analgesics and antidepressants being the most common. Eighty-five (31%) poisonings were polypharmaceutical. The most commonly used therapies were naloxone, activated charcoal, and benzodiazepines. Twenty-seven patients (10%) received mechanical ventilation. There was one fatality, an adolescent with a polypharmacy overdose in a suicide attempt. CONCLUSION: Pediatric poisonings are a significant percentage of admissions to the PICU. The majority of poisonings are non-fatal, require supportive care, close monitoring, and some specific treatment. Drug classes causing poisonings have changed to a higher percentage of opioids in younger patients and atypical antidepressants in adolescents.

Optimizing intrapulmonary perfluorocarbon distribution: fluoroscopic comparison of mode of ventilation and body position.

OBJECTIVE: Partial liquid ventilation with the perfluorochemical, perflubron, has been shown to improve lung mechanics and enhance gas exchange in the treatment of severe acute lung injury. However, the most effective strategy to provide optimal intrapulmonary distribution of perflubron has not been fully accessed. The objective of this study was to examine the effect of body position (supine vs. rotational) and mode of ventilation (conventional mechanical ventilation [CMV] vs. high-frequency oscillatory ventilation [HFOV]) on perflubron distribution and oxygenation improvement. DESIGN: Prospective, randomized, animal trial. SETTING: Research laboratory at a university medical center. SUBJECTS: Twenty healthy piglets (4.5-6.6 kg). INTERVENTIONS: Subjects underwent repetitive saline lavage to achieve a uniform degree of lung injury and then were randomized to either CMV or were converted to HFOV. Within each ventilator group, animals were randomized to supine positioning (S) or rotational positioning with alternation between supine and prone position (R) during incremental dosing of three 5-mL/kg doses of perflubron. MEASUREMENTS AND MAIN RESULTS: Arterial blood gas tensions, hemodynamic variables, and the oxygenation index were recorded after each dose of 5 mL/kg. Lateral cinefluoroscopic images after each dose were digitized for computer analysis of density. A density index was calculated for a 2-cm2 window in three dorsal and three ventral lung regions. Uniformity of distribution was calculated by comparing the mean density among the six regions. Oxygenation improvements were compared between groups. There were no significant differences in hemodynamic variables or gas exchange after lung injury in the four groups. Rotational positioning produced significantly more uniform perflubron distribution during both CMV and HFOV. This effect was independent of the mode of ventilation. The mean ventral density index was affected by rotating position and HFOV mode of ventilation after 10 mL/kg of perflubron, and rotating position was affected only after 15 mL/kg of perflubron. There was a significant reduction in the oxygenation index from baseline to end lavage in both CMV groups, as well as all of the animals that were rotated. CONCLUSION: Perflubron is more uniformly dispersed when dosed in a rotational fashion with alternation between supine and prone position during incremental dosing. This effect is independent of mode of ventilation. There was no relationship between oxygenation improvements and nondependent perflubron distribution. CMV and rotating dosing both led to a significant decrease in the oxygenation index after a 15 mL/kg dose of perflubron. This information has important impact on the future development of dosing strategies and clinical trial design.

Acute respiratory failure in children.

Recent studies in the treatment of acute respiratory failure in children have been targeted at reducing ventilator-induced lung injury, providing treatment adjuncts to mechanical ventilation, and assessing innovative therapies directed at immunomodulation. Ventilator-associated lung injury has been demonstrated in animal models during the delivery of moderate-to-large tidal volumes and has also been described in adult populations. Subsequently, a significant survival benefit of a low tidal volume, high positive end expiratory pressure strategy on the ventilatory was found in adults. Investigation of the effects of inhaled nitric oxide in acute respiratory failure patients continues to show transient improvements in oxygenation, but no evidence of improved outcomes. The use of intratracheal surfactant within 24 hours of intubation in pediatric respiratory failure may be beneficial in reducing the days of mechanical ventilation. Neutrophil oxidative damage has been demonstrated, but therapies directed at decreasing neutrophil adherence have failed to demonstrate improvements. Enteral anti-inflammatory and antioxidant therapy may be promising, because these modalities have been shown to improve a number of surrogate outcomes in patients with respiratory failure. The use of corticosteroids in the late stages of lung injury has also recently been shown to have promise.

Peripheral serotonergic inhibition of suckling.

Systemically administered serotonin, which does not pass the blood-brain barrier, inhibited nipple attachment behavior in 20- and 30-day-old rat pups. Xylamidine, a peripheral serotonin antagonist, attenuated the effects of serotonin, quipazine, and fenfluramine on nipple attachment behavior. Thus, serotonin receptors in the periphery may play an important role in the serotonergic inhibitory mechanism that has been hypothesized as the developing system leading to weaning. However, unlike more general 5-HT antagonists, xylamidine given alone failed to facilitate suckling, suggesting different sites of action for facilitation and inhibition of this infantile behavior.