Percutaneous central venous catheterization through the external jugular vein in children: is inserting the guide wire into the superior vena cava essential for successful catheterization?

BACKGROUND/PURPOSE: The external jugular vein (EJV) is an attractive alternative for percutaneous central venous catheterization (PCVC), with fewer complications. The inability to pass the guide wire into the superior vena cava (SVC) is, however, a major reason for the failure of this approach. The authors report a modification of the Seldinger technique to increase the effectiveness of this procedure in children. METHODS: Between May 2008 and June 2009, we performed 100 PCVCs consecutively in children using the Seldinger technique through the EJV (Step 1). In cases in which the guide wire could not be passed into the SVC, the guide wire was kept in the EJV; and only the catheter was introduced into the central venous position (Step 2). Differences between the standard and modified Seldinger techniques were analyzed. RESULTS: The procedure with the standard Seldinger technique (Step 1) was successful in 13 (13%) out of 100 patients. In 84 (96.5%) of the 87 remaining patients, PCVC was achieved with the modified Seldinger technique, without the insertion of the guide wire until the SVC (Step 2). Altogether, 97 catheters (97%) were successfully inserted, with 85 (87.6%) correctly positioned in the SVC. In addition, there were 7 (7%) clinically irrelevant hematomas during catheterization. CONCLUSIONS: The EJV is an excellent alternative anatomical location for the completion of PCVC in children. Placing the guide wire in a central position is not essential to the success rate of this approach. The proposed modified Seldinger technique allowed PCVC to be performed through the EJV safely and with a high success rate in children and adolescents.

Assessing clinical and spirometric control and the intensity of the inflammatory process in asthma.

OBJECTIVES: To review the role of clinical assessment, quality of life assessment, spirometry, bronchial responsiveness test and inflammatory markers for asthma assessment. SOURCES: Search run on MEDLINE and LILACS. SUMMARY OF THE FINDINGS: Clinical assessment aids with assessing asthma control and is widely recommended. However, patients may have airway inflammation and obstruction despite normal clinical findings. Spirometry quantifies the degree of airway obstruction and helps with diagnosis, while the bronchial responsiveness test may be indicated for when asthma is suspected but spirometry is normal. The results of assaying the inflammatory markers in exhaled breath condensate, induced sputum, bronchoalveolar lavage and bronchial biopsy specimens are abnormal in asthma patients, but these are complex techniques almost always restricted to research. Fractional exhaled nitric oxide (FeNO) is elevated in patients with asthma, is reproducible and noninvasive and reduces with treatment. Studies have investigated using FeNO to help with adjusting inhaled corticoid dosages, but the benefits are not clear. CONCLUSIONS: A range of different methods are needed to accurately assess disease control, all with their advantages and limitations. Clinical and functional assessment is useful for diagnosing asthma, but is of limited use for precisely evaluating the intensity of the inflammatory process in the airways. More randomized and controlled studies with adequate statistical power should be carried out to investigate the true utility of noninvasive inflammatory markers, especially FeNO, for asthma management.

Avaliação do grau de controle clínico, espirométrico e da intensidade do processo inflamatório na asma / Assessing clinical and spirometric control and the intensity of the inflammatory process in asthma

OBJETIVOS: Revisar o papel da avaliação clínica, da qualidade de vida, da espirometria, do teste de broncoprovocação e dos marcadores inflamatórios na avaliação da asma. FONTES DOS DADOS: Pesquisa nas bases MEDLINE e LILACS. SÍNTESE DOS DADOS: A avaliação clínica auxilia na avaliação do controle da asma e é amplamente preconizada. No entanto, os pacientes podem apresentar obstrução e inflamação das vias aéreas a despeito da normalidade clínica. A espirometria quantifica o grau de obstrução das vias aéreas e auxilia no diagnóstico, enquanto a broncoprovocação pode ser indicada na suspeita de asma com espirometria normal. Já os marcadores inflamatórios do condensado do ar exalado, do escarro induzido e do lavado broncoalveolar, além dos fragmentos da biópsia brônquica, encontram-se alterados na asma e são métodos complexos, quase sempre restritos às pesquisas. A fração exalada de óxido nítrico (FeNO) é elevada nos pacientes com asma, reprodutível e não invasiva, reduzindo-se com o tratamento. O uso da FeNO como auxiliar no ajuste de doses do corticoide inalatório tem sido estudado, mas as vantagens ainda não estão claras. CONCLUSÕES: Vários métodos são necessários para avaliar de forma acurada o controle da asma, e todos têm vantagens e limitações. A avaliação clínico-funcional é útil para o diagnóstico de asma, porém limitada para avaliar de forma precisa a intensidade do processo inflamatório nas vias aéreas. É necessário que mais estudos controlados, randomizados, com adequado poder estatístico sobre a utilidade dos marcadores inflamatórios não invasivos, especialmente a FeNO, no manejo da asma, sejam realizados para determinar sua utilidade clínica.

OBJECTIVES: To review the role of clinical assessment, quality of life assessment, spirometry, bronchial responsiveness test and inflammatory markers for asthma assessment. SOURCES: Search run on MEDLINE and LILACS. SUMMARY OF THE FINDINGS: Clinical assessment aids with assessing asthma control and is widely recommended. However, patients may have airway inflammation and obstruction despite normal clinical findings. Spirometry quantifies the degree of airway obstruction and helps with diagnosis, while the bronchial responsiveness test may be indicated for when asthma is suspected but spirometry is normal. The results of assaying the inflammatory markers in exhaled breath condensate, induced sputum, bronchoalveolar lavage and bronchial biopsy specimens are abnormal in asthma patients, but these are complex techniques almost always restricted to research. Fractional exhaled nitric oxide (FeNO) is elevated in patients with asthma, is reproducible and noninvasive and reduces with treatment. Studies have investigated using FeNO to help with adjusting inhaled corticoid dosages, but the benefits are not clear. CONCLUSIONS: A range of different methods are needed to accurately assess disease control, all with their advantages and limitations. Clinical and functional assessment is useful for diagnosing asthma, but is of limited use for precisely evaluating the intensity of the inflammatory process in the airways. More randomized and controlled studies with adequate statistical power should be carried out to investigate the true utility of noninvasive inflammatory markers, especially FeNO, for asthma management.

Basal cortisol in asthmatics on two different doses of fluticasone propionate.

OBJECTIVES: To evaluate basal plasma cortisol in persistent asthmatics on inhaled fluticasone propionate 200 mcg/day and 300 mcg/day. METHODS: Asthma diagnosis and classification was based on Global Initiative for Asthma recommendations. Patients aged 11 years old or less received fluticasone propionate 200 mcg/day and those older than 11 years received 300 mcg/day. After 10 weeks of treatment, plasma cortisol levels were monitored to evaluate the hypothalamic-pituitary-adrenal axis. RESULTS: Forty-one patients (65.9% males) aged 6 to 18 years old were evaluated. No statistical differences were found between plasma cortisol levels in patients who received 200 mcg/day (n = 13) and those who received 300 mcg/day (n = 28). CONCLUSIONS: Our results show that low and moderate doses of fluticasone propionate do not cause adrenal suppression.

Cortisol basal em asmáticos em uso de duas diferentes doses de propionato de fluticasona / Basal cortisol in asthmatics on two different doses of fluticasone propionate

OBJETIVOS: Avaliar os valores de cortisol basal em asmáticos persistentes em uso de propionato de fluticasona inalatório na dose de 200 ou 300 mcg/dia. MÉTODOS: O diagnóstico e a classificação da gravidade da asma basearam-se nas recomendações do Global Initiative for Asthma. Pacientes menores de 11 anos receberam fluticasona na dose de 200 mcg/dia, e aqueles com mais de 11 anos receberam 300 mcg/dia. Após 10 semanas de tratamento, a dosagem do cortisol foi realizada para avaliação da função adrenal. RESULTADOS: Foram avaliados 41 pacientes (65,9 por cento do sexo masculino) entre 6 e 18 anos. Não houve diferença significativa entre as médias de cortisol basal nos pacientes que receberam 200 mcg/dia de propionato de fluticasona (n = 13) e naqueles que receberam 300 mcg/dia (n = 28). CONCLUSÕES: Os achados mostram que doses baixas a moderadas de propionato de fluticasona não causam supressão adrenal.

OBJECTIVES: To evaluate basal plasma cortisol in persistent asthmatics on inhaled fluticasone propionate 200 mcg/day and 300 mcg/day. METHODS: Asthma diagnosis and classification was based on Global Initiative for Asthma recommendations. Patients aged 11 years old or less received fluticasone propionate 200 mcg/day and those older than 11 years received 300 mcg/day. After 10 weeks of treatment, plasma cortisol levels were monitored to evaluate the hypothalamic-pituitary-adrenal axis. RESULTS: Forty-one patients (65.9 percent males) aged 6 to 18 years old were evaluated. No statistical differences were found between plasma cortisol levels in patients who received 200 mcg/day (n = 13) and those who received 300 mcg/day (n = 28). CONCLUSIONS: Our results show that low and moderate doses of fluticasone propionate do not cause adrenal suppression.

Early diagnosis of streptococcal pharyngotonsillitis: assessment by latex particle agglutination test.

OBJECTIVES: Acute pharyngitis is one of the most common diseases in pediatric practice, and the most common bacterial etiology is group A beta-hemolytic streptococcus (GABHS). Correct diagnosis and treatment are primarily of importance to the prevention of non-suppurative sequelae. Rapid tests for detecting the antigen of group A streptococcus are a useful tool for the diagnosis of streptococcal pharyngotonsillitis, due to the speed of results, accuracy and low cost; however, in our country they are little used and have been little studied. The objective of this study was to evaluate the accuracy of a GABHS rapid antigen detection test kit, in comparison with oropharynx swab culture. METHODS: Children aged 1 to 18 years with clinical diagnoses of acute pharyngitis were chosen at public emergency and private clinical services in Belo Horizonte, Minas Gerais, Brazil, with children being excluded if they had taken antibiotics within 30 days of their consultation. The final sample consisted of 229 patients, each of whom had two oropharynx swabs taken, one for rapid GABHS testing and the other to be sent for culture. RESULTS: We observed sensitivity of 90.7%, specificity of 89.1%, a positive predictive value of 72.1%, a negative predictive value of 96.9% and a positive likelihood ratio of 9.0 for the rapid test used here, compared with culture. CONCLUSIONS: The rapid test studied exhibited a good correlation with culture and is, therefore, of great use in clinical practice for detection of GABHS.

Diagnóstico precoce das faringoamigdalites estreptocócicas: avaliação pelo teste de aglutinação de partículas de látex / Early diagnosis of streptococcal pharyngotonsillitis: assessment by latex particle agglutination test

OBJETIVOS: A faringoamigdalite aguda é uma das doenças mais freqüentes na prática pediátrica, sendo o estreptococo beta-hemolítico do grupo A (EBHGA) o agente etiológico bacteriano mais comum. O seu diagnóstico e tratamento adequados são importantes principalmente para a prevenção de seqüelas não-supurativas. Testes rápidos de detecção de antígenos do estreptococo do grupo A são uma ferramenta útil no diagnóstico das faringoamigdalites estreptocócicas, pela rapidez dos resultados, acurácia e baixo custo; no entanto, são pouco utilizados em nosso meio e pouco estudados em nosso país. O objetivo deste estudo foi avaliar a acurácia de um kit de teste rápido de detecção de antígeno do EBHGA comparado à cultura de suabe de orofaringe. MÉTODOS: Foram selecionadas crianças de 1 a 18 anos com diagnóstico clínico de faringoamigdalite aguda em serviços públicos de urgência e clínica privada de Belo Horizonte (MG), sendo excluídas as que haviam utilizado antibióticos até 30 dias antes da consulta. A amostra final incluiu 229 pacientes, que foram submetidos a coleta de dois suabes de orofaringe, um para o teste rápido para EBHGA e o outro enviado para cultura. RESULTADOS: Encontrou-se sensibilidade de 90,7 por cento, especificidade de 89,1 por cento, valor preditivo positivo de 72,1 por cento, valor preditivo negativo de 96,9 por cento e razão de verossimilhança positiva de 9,0 para o teste rápido utilizado comparado à cultura. CONCLUSÃO: O teste rápido utilizado apresentou boa correlação com a cultura, sendo, portanto, de grande utilidade na prática clínica para detecção do EBHGA.

OBJECTIVES: Acute pharyngitis is one of the most common diseases in pediatric practice, and the most common bacterial etiology is group A beta-hemolytic streptococcus (GABHS). Correct diagnosis and treatment are primarily of importance to the prevention of non-suppurative sequelae. Rapid tests for detecting the antigen of group A streptococcus are a useful tool for the diagnosis of streptococcal pharyngotonsillitis, due to the speed of results, accuracy and low cost; however, in our country they are little used and have been little studied. The objective of this study was to evaluate the accuracy of a GABHS rapid antigen detection test kit, in comparison with oropharynx swab culture. METHODS: Children aged 1 to 18 years with clinical diagnoses of acute pharyngitis were chosen at public emergency and private clinical services in Belo Horizonte, Minas Gerais, Brazil, with children being excluded if they had taken antibiotics within 30 days of their consultation. The final sample consisted of 229 patients, each of whom had two oropharynx swabs taken, one for rapid GABHS testing and the other to be sent for culture. RESULTS: We observed sensitivity of 90.7 percent, specificity of 89.1 percent, a positive predictive value of 72.1 percent, a negative predictive value of 96.9 percent and a positive likelihood ratio of 9.0 for the rapid test used here, compared with culture. CONCLUSIONS: The rapid test studied exhibited a good correlation with culture and is, therefore, of great use in clinical practice for detection of GABHS.

Central venous catheter placement in children: a prospective study of complications in a Brazilian public hospital.

Central venous access is frequently used in infants and children with a wide variety of conditions. This report evaluates our experience and the complications from central venous catheters (CVC) placed percutaneously in children at a public hospital of a developing country-Brazil. To identify associated complications, data were collected prospectively and 155 consecutive catheterizations in children at a public hospital over a nearly 8-month period were analyzed. Data collected included sex, age, weight, primary diagnosis, indication for placement, presence of blood coagulation disturbance, hospital department for procedure, type of anesthesia, type of catheter (diameter, lumen number, material), site of catheterization, number of attempts, number of puncture sites, complications during puncture, the time catheter remained in place, later complications (mechanical, infectious) and reason for catheter removal. A total of 155 catheters were placed in 127 patients. There were 130 neck lines and 25 groin lines. The success rate was 81.9% at the initially chosen puncture site and rose to 100% with the inclusion of the second site. Perioperative complications occurred in nine (5.8%) cases, including six (3.9%) hematomas and three (1.9%) arterial puncture. There was no pneumothorax, hemothorax or hydrothorax. During the time the catheter remained in place, there were 51 (32.9%) complications, of which 33 (21.3%) were mechanical and 18 (11.6%) suspected catheter-related infection. These complications were responsible for the removal of the catheter. Despite the relatively high complication rate there were no catheter-related deaths. Body weight was significantly lower for children who underwent more than one puncture site (P=0.01). Age, sex, type of catheter and primary diagnosis were not associated with complications. Knowledge of anatomy and familiarity with the Seldinger technique highly increase the catheterization success rate, with few surgical complications. A better nursing care of CVC is emphasized. The available modern venous catheters at a public hospital in Brazil have contributed to improve the quality of pediatric medical care. Nowadays, the percutaneous CVC is the preferred method in pediatric patients.