Acute life-threatening presentation of vitamin D deficiency rickets.

CONTEXT: Clinical manifestations of vitamin D deficiency rickets are widely described; however cardiorespiratory arrest is an extremely rare presentation. OBJECTIVE: The aim of this paper is to present the symptoms of severe vitamin D deficiency rickets and to highlight the importance of vitamin D prophylaxis in infants. RESULTS: We report a case of a 16-month-old infant who presented to emergency room with a stridor that evolved into a full cardiorespiratory arrest secondary to hypocalcemia. Medical history revealed that the infant was exclusively breastfed without vitamin D supplementation until the age of 10 months. Due to cultural habits, his diet was also grossly deficient in dairy products. Physical exam revealed clinical signs of rickets. Laboratory test showed severe hypocalcemia, elevated alkaline phosphatase, normal serum phosphorous, decreased 25(OH) cholecalciferol, increased intact parathyroid hormone level, and normal urine calcium excretion. The radiography of the wrist showed evidence of cupping, fraying, metaphyseal widening, and demineralization of the distal radial and ulnar metaphyses. The bone mineral density of the lumbar spine measured by dual x-ray absorptiometry showed a Z-score below -2 SD. His cardiorespiratory arrest secondary to hypocalcemia was therefore attributed to severe nutritional rickets. CONCLUSION: Vitamin D deficiency rickets can be life threatening. Vitamin D supplementation is therefore crucial, especially in breastfed infants and some ethnic minorities (dark-skinned people, poor sun exposure), more at risk for developing severe rickets if not supplemented.

[Management of pediatric septic shock]. / Prise en charge du choc septique chez l'enfant.

Septic shock is a frequent admission cause in intensive care unit. In spite of the important progresses in the understanding of his physiopathology, mortality due to septic shock is about 20%. Recently, it has been demonstrated that an early goal-directed therapy permitted to improve the patient prognosis. With a good hemodynamic management and early antibiotherapy, mortality could be reduced.

The role of posterior fossa decompression in acute cerebellitis.

BACKGROUND: We present two cases of children who were diagnosed with cerebellitis with acute cerebellar swelling. This rare pathology is potentially fatal, and no clear treatment guidelines are described in the literature. DISCUSSION: Considering our experience, we discuss the different therapeutic strategies and propose aggressive surgical measures consisting of external ventricular drainage and posterior fossa decompression in case of failure of early response to medical treatment to limit secondary cerebellar and brainstem lesions.

[Starting experience with non-invasive ventilation in paediatric intensive care unit]. / Ventilation non invasive en réanimation pédiatrique: un début d'expérience.

Non-invasive ventilation in pressure support (NIV) is well described in the adult and child over 5 years. However, its use in children less than 1 year of age remains anecdotal. We report our preliminary experience with the use of NIV in six children aged from 5 days to 10 months. NIV was delivered with a flow generator (VPAP IIST, Resmed Ltd, North Ryde, NSW, Australia) in association with specific tubings and a nasal mask. The use of NIV resulted in a significant decrease of both the respiratory rate (from 53 to 39 breaths per min, p < 0.01) and the PvCO(2) (from 9.33 to 6.28 kPa, p < 0.01). These results show that NIV can be used in children under 1 year of age with improvement of physiological parameters.

Imaging of cavitary necrosis in complicated childhood pneumonia.

The aim of this study was to illustrate the chest radiographs (CR) and CT imaging features and sequential findings of cavitary necrosis in complicated childhood pneumonia. Among 30 children admitted in the Pediatric Intensive Care Unit for persistent or progressive pneumonia, respiratory distress or sepsis despite adequate antibiotic therapy, a study group of 9 children (5 girls and 4 boys; mean age 4 years) who had the radiographic features and CT criteria for cavitary necrosis complicated pneumonia was identified. The pathogens identified were Streptococcus pneumoniae( n=4), Aspergillus( n=2), Legionella( n=1), and Staphylococcus aureus( n=1). Sequential CR and CT scans were retrospectively reviewed. Follow-up CR and CT were evaluated for persistent abnormalities. Chest radiographs showed consolidations in 8 of the 9 patients. On CT examination, cavitary necrosis was localized to 1 lobe in 2 patients and 7 patients showed multilobar or bilateral areas of cavitary necrosis. In 3 patients of 9, the cavitary necrosis was initially shown on CT and visualization by CR was delayed by a time span varying from 5 to 9 days. In all patients with cavities, a mean number of five cavities were seen on antero-posterior CR, contrasting with the multiple cavities seen on CT. Parapneumonic effusions were shown by CR in 3 patients and in 5 patients by CT. Bronchopleural fistulae were demonstrated by CT alone ( n=3). No purulent pericarditis was demonstrated. The CT scan displayed persistent residual pneumatoceles of the left lower lobe in 2 patients. Computed tomography is able to define a more specific pattern of abnormalities than conventional CR in children with necrotizing pneumonia and allows an earlier diagnosis of this rapidly progressing condition. Lung necrosis and cavitation may also be associated with Aspergillus or Legionella pneumonia in the pediatric population.

Reliable tidal volume estimates at the airway opening with an infant monitor during high-frequency oscillatory ventilation.

OBJECTIVE: To assess the suitability of a hot-wire anemometer infant monitoring system (Florian, Acutronic Medical Systems AG, Hirzel, Switzerland) for measuring flow and tidal volume (Vt) proximal to the endotracheal tube during high-frequency oscillatory ventilation. DESIGN: In vitro model study. SETTING: Respiratory research laboratory. SUBJECT: In vitro lung model simulating moderate to severe respiratory distress. INTERVENTION: The lung model was ventilated with a SensorMedics 3100A ventilator. Vt was recorded from the monitor display (Vt-disp) and compared with the gold standard (Vt-adiab), which was calculated using the adiabatic gas equation from pressure changes inside the model. MEASUREMENTS AND MAIN RESULTS: A range of Vt (1-10 mL), frequencies (5-15 Hz), pressure amplitudes (10-90 cm H2O), inspiratory times (30% to 50%), and Fio2 (0.21-1.0) was used. Accuracy was determined by using modified Bland-Altman plots (95% limits of agreement). An exponential decrease in Vt was observed with increasing oscillatory frequency. Mean DeltaVt-disp was 0.6 mL (limits of agreement, -1.0 to 2.1) with a linear frequency dependence. Mean DeltaVt-disp was -0.2 mL (limits of agreement, -0.5 to 0.1) with increasing pressure amplitude and -0.2 mL (limits of agreement, -0.3 to -0.1) with increasing inspiratory time. Humidity and heating did not affect error, whereas increasing Fio2 from 0.21 to 1.0 increased mean error by 6.3% (+/-2.5%). CONCLUSIONS: The Florian infant hot-wire flowmeter and monitoring system provides reliable measurements of Vt at the airway opening during high-frequency oscillatory ventilation when employed at frequencies of 8-13 Hz. The bedside application could improve monitoring of patients receiving high-frequency oscillatory ventilation, favor a better understanding of the physiologic consequences of different high-frequency oscillatory ventilation strategies, and therefore optimize treatment.

[Acute respiratory distress syndrome in children]. / Le syndrome de détresse respiratoire aiguë (SDRA) chez l'enfant.

The acute respiratory distress syndrome (ARDS) encountered in a child may be either due to a primary lung infection or may be secondary to a systemic inflammatory response of varying origin. Therapy is based on: 1) the mechanical ventilation strategy aimed at maintaining the functional residual capacity by alveolar recruitment using positive end expiratory pressure and to limit secondary pulmonary lesions by using small tidal volumes, 2) prone positioning as soon as sufficient stability is achieved; 3) optimizing tissue oxygen delivery by cardiac support; 4) correction of any other organ dysfunction. If this conventional approach is not sufficient experimental therapies may be tempted given the vital risk. For instance inhaled nitric oxide and high frequency oscillation ventilation may be a valuable support. Newer techniques, such as partial liquid ventilation, are being developed and could become useful therapeutic options. After the acute phase a close medical follow-up is mandatory. Because of the possibility of a chronic respiratory insufficiency with negative consequences on the right ventricular function, these patients may need long term oxygen therapy and diuretics. Cardiac echography helps orientation in maintaining or discontinuing this long term therapy by estimating the arterial pulmonary pressure.

Nitric oxide added to the sweep gas infusion reduces local clotting formation in adult blood oxygenators.

Nitric oxide (NO) is an inhibitor of platelet aggregation. We analyzed the effect of direct infusion of NO into adult blood oxygenators on local clot formation. Nonheparinized calves in a control group (n = 3) and NO group (n = 4) were connected to a jugulocarotid cardiopulmonary bypass (CPB; centrifugal pump) for 6 hours. The venous line and pumphead were heparin coated, whereas the oxygenator, the heat exchanger, and the arterial line were not. A total of 80 ppm of NO was mixed with the sweep gas infusion in the NO group. The pressure gradient through the oxygenator (deltaP.Ox.) was monitored, and its evolution was compared between groups. Oxygenators membranes were analyzed and photographed, allowing for calculation of the percentage of surface area covered with clots by using a computer image analysis program. The deltaP.Ox. reached a plateau of 193 +/- 26% of the basal value in the NO group after 120 minutes, whereas a similar plateau of 202 +/- 22% was reached after only 20 minutes in the control group (p < 0.05). The surface area of the oxygenator covered with clots was significantly reduced in the NO group (0.54 +/- 0.41%) compared with the control group (5.78 +/- 3.80%, p < 0.05). However, general coagulation parameters were not modified by local NO administration. The activated coagulation time remained stable between 110 and 150 seconds in both groups (p = not significant [ns]), and there were no differences in hematocrit, thrombin time, partial thromboplastin time, or fibrinogen between groups during the 6 hours of CPB. Thus, the mixed infusion of a continuous low dose of NO into adult oxygenators during prolonged CPB prevented local clot formation, whereas the general coagulation pattern remained unchanged.

Evaluation of physicochemical incompatibilities during parenteral drug administration in a paediatric intensive care unit.

Patients in paediatric intensive care units (PICU) often receive numerous medications by the parenteral route. Frequently two or more drugs are delivered simultaneously through the same line and the risk of physicochemical incompatibilities is thus important. The objectives of this study were 1) to identify prospectively the combinations of injectable drugs administered in the PICU of our university hospital and 2) to analyze them according to information found in the literature. The data were collected by a pharmacist over a 30-day period and classified in three categories: compatible, incompatible and undocumented. Nineteen patients were included in the study with a median age of 3.2 years. The mean number (+/- SD) of injectable drugs per patient and per day was 6.5 (+/- 2.8), for a total of 26 drugs and 7 solutes. 64 combinations of drugs were observed with 2 (31.3%), 3 (45.3%), 4 (10.9%) or 5 (12.5%) drugs. 81 drug-drug and 94 drug-solute combinations were recorded. Among these, 151 (86.3%) were compatible, 6 (3.4%) incompatible and 18 (10.3%) undocumented. The incompatibilities included furosemide (Lasix), a drug in alkaline solution and Vamina-Glucose, a total parenteral nutrition solution. No clinical consequences resulting from drug incompatibilities were shown in this study. We suggest that in vitro compatibility tests on standard drug combinations, as well as a training program for nurses on drug incompatibility problems would sensitively increase the security of parenteral drug administration.

[Carbon monoxide poisoning in children: never trivialize]. / Intoxication par le monoxyde de carbone chez l'enfant: ne jamais banaliser.

The risks linked to tissular hypoxemia after carbon monoxide (CO) poisoning are well known. Unawareness of CO exposure and of its complex pathophysiology may delay appropriate treatment and lead to long term neuropsychological sequelae. We report two cases of children treated in our institution and review the main issues regarding the optimal management. A high index of suspicion for carbon monoxide poisoning when dealing with an unclear neurological clinical presentation is mandatory. Classical therapy with normobaric 100% oxygen has to be instaured immediately. Hyperbaric oxygen therapy must be considered when anamnestic symptoms or clinical signs suggest neurological involvement even when carboxyhemoglobin values are low or already normalized.

In vitro assessment of an ultrasonic flowmeter for use in ventilated infants.

An ultrasonic flowmeter could be advantageous over a differential pressure pneumotachograph having a constant error in varying conditions. The in vitro accuracy of ultrasonic tidal volume (VT) estimates for ventilated infants were evaluated. Flow linearity and frequency response were tested, as was the influence of humidity and oxygen content on the accuracy of VT estimates. The linearity was within the 5% limits between -350 and 350 mL x sec(-1) and was not affected by the presence of an endotracheal tube (ET). The frequency response was flat and unaffected by an ET up to 4.5 Hz. The VT in the range 7-100 mL, in air showed a mean error of 0.1% (95% confidence interval (CI) -0.2-0.4%) with a maximum and minimum of 6.5 and -3.5% respectively. Humidity did not affect accuracy. After calibration in air, the maximal mean error for measurements in pure oxygen was 3.0% (95% CI 1.9-4.1%). Repeated measurements over 5.5 h had a mean error of 0.4% (95% CI -0.7-0.1%). The in vitro evaluation of an ultrasonic flowmeter showed stable accuracy in mechanical ventilation conditions. Changing connection geometry and oxygen content did not increase the error to a clinically relevant degree. The flowmeter could therefore be a better alternative than the pneumotachograph for ventilated infants.

Long-term effects of neonatal hypoglycemia on brain growth and psychomotor development in small-for-gestational-age preterm infants.

OBJECTIVE: To investigate the effects of neonatal hypoglycemia on physical growth and neurocognitive function. STUDY DESIGN: A systematic detection of hypoglycemia (<2.6 mmol/L or 47 mg/dL) was carried out in 85 small-for-gestational-age preterm neonates. Prospective serial evaluations of physical growth and psychomotor development were performed. Retrospectively, infants were grouped according to their glycemic status. RESULTS: The incidence of hypoglycemia was 72.9%. Infants with repeated episodes of hypoglycemia had significantly reduced head circumferences and lower scores in specific psychometric tests at 3.5 years of age. Hypoglycemia also caused reduced head circumferences at 18 months and lower psychometric scores at 5 years of age. Infants with moderate recurrent hypoglycemia had lower scores at 3.5 and 5 years of age compared with the group of infants who had 1 single severe hypoglycemic episode. CONCLUSION: Recurrent episodes of hypoglycemia were strongly correlated with persistent neurodevelopmental and physical growth deficits until 5 years of age. Recurrent hypoglycemia also was a more predictable factor for long-term effects than the severity of a single hypoglycemic episode. Therefore repetitive blood glucose monitoring and rapid treatment even for mild hypoglycemia are recommended for small-for-gestational-age infants in the neonatal period.

Evaluation of nurses' errors associated in the preparation and administration of medication in a pediatric intensive care unit.

The objectives of this study were to determine the frequency and the types of errors which occur regarding the preparation and the administration of medication and to identify the main causes of these errors in a pediatric intensive care unit (PICU) at the University Hospital in Lausanne (Switzerland). In this prospective study, based on the observation of nurses' activities, the data were collected over a period of 10 weeks. The error classification was based on the American Society of Hospital Pharmacy (ASHP) definitions. The frequency of errors was calculated as the sum of all noted errors divided by the total administered drugs, plus the sum of all omitted drugs, multiplied by 100. The sum of all given doses plus all omitted doses gives the 'total opportunity for errors'. This total was 275 and the total frequency of errors was 26.9%. The most frequent errors were wrong-time errors (32.4%), wrong-administration-technique errors (32.4%) and preparation errors (23.0%). In relation with other studies conducted under comparable conditions, a lesser number of omissions and wrong-time errors were observed. On the contrary, administration-technique and dose-preparation errors were more frequent at our hospital. A program of systematic assistance and survey by professional pharmacists could improve the quality of the preparation and administration of medication in the PICU.

[Is the use of ribavirin aerosols in respiratory syncytial virus infections justified? Clinical and economic evaluation]. / L'emploi d'aérosols de ribavirine lors d'infection à virus respiratoire syncytial est-il justifié? Evaluation clinique et économique.

UNLABELLED: The controversy about the use of ribavirin aerosol for children at risk (cardiopathy, pneumopathy, premature and immunodeficient patients), in case of respiratory syncytial virus (RSV) infection, led us to stop its prescription in 1993 and study prospectively the patients admitted during the following winters. METHODS: Criterias of inclusion for this study were those of the Committee on Infectious Diseases of the American Academy of Pediatrics concerning the use of ribavirin aerosol. Two cohorts of patients were studied: the first group included treated patients (ribavirin group: n = 22, ribavirin and support treatment: salbutamol aerosols, respiratory physiotherapy and oxygen-therapy; winters 1989-1990 to 1992-1993); the second group included patients with support treatment only (control group: n = 22; winters 1993-1994 and 1994-1995). RESULTS: The clinical gravity score at admission (4.55 vs 5.23, P = 0.46) and the risk factor scores (3.05 vs 3.27, P = 0.69) of the two groups were identical. Results showed that the children of the ribavirin group stayed much longer in hospital (14.2 vs 8.2 days, P = 0.002) and in the intensive care unit (7.2 vs 0.2 days, P < 0.001) than those of the control group. More support treatment was necessary for the ribavirin group as regard respiratory physiotherapy (3.8 vs 2.7 sessions a day, P = 0.026), the duration of oxygen-therapy (7.3 vs 3.7 days, P = 0.030) and the number of children requiring respiratory assistance (4 vs 0 children, P = 0.116). Administration of ribavirin aerosols (480 US$ a dose) and the way in which such treatment was carried out meant high daily costs for the ribavirin group (1,076 vs 604 US$, P < 0.001). As hospitalization was longer for children treated with ribavirin, the global cost was therefore much higher (15,552 vs 5,156 US$, P < 0.001). CONCLUSION: The antiviral effect of ribavirin is undeniable. However ribavirin is known to be the cause of severe bronchospasms (two cases in our study) and can also cause moderate and long term bronchospasms, aggravating therefore the clinical evolution of the disease. Our experience shows that administration of ribavirin aerosols in case of RSV infection of inferior respiratory airways seems not to be justified.