Positive end-expiratory pressure during mechanical ventilation and noninvasive respiratory support in newborns and children.

Positive end-expiratory pressure (PEEP) is used during non-invasive and invasive ventilation of newborns, infants and children. PEEP improves gas exchange by increasing the functional residual capacity, reduces the respiratory effort, lowers requirements for respiratory mixture oxygen, and enables to decrease the peak inspiratory pressure (PIP) without decreasing the mean airway pressure. Its effects on the cardiovascular system appear to be insignificant, particularly in patients with severe respiratory failure that is not accompanied by circulatory insufficiency. The value of PEEP enabling to provide the optimal conditions for improvement of gas exchange should be tailored individually for each patient under control of blood gas analysis, PIP and FiO2. This strategy minimises ventilator-induced lung injury and prevents the development of circulatory failure associated with ventilation. Nasal continuous positive airway pressure (NCPAP) used with various PEEP values is a recognised treatment method of respiratory failure in newborns, especially in preterm infants.

Coagulation abnormalities and severe intraventricular hemorrhage in extremely low birth weight infants.

BACKGROUND: The association between intraventricular hemorrhage (IVH) and coagulation in infants has been a subject of controversy. Only few publications assessing risk factors for development of IVH reported results of coagulation studies. OBJECTIVES: To evaluate the levels of coagulation and fibrinolysis systems in ELBW infants and determine their influence on IVH. PATIENTS AND METHODS: Following IRB approval coagulation status of 38 ELBW infants was evaluated on first and second day of life. Severity of IVH assessed by cerebral ultrasonography was graded according to Papile classification. Newborns were assigned to either Group A--Grade III or IV, or Group B--Grade I-II, or no IVH. RESULTS: Neonates with Grade III/IV IVH had significantly lower plasma Factor VII (FVII) level on first day of life and FVII differed significantly between Groups A and B with sensitivity of 100%, specificity 41% for a cut-off value of< 7%. In Group A there was no improvement of prothrombin and activated partial thromboplastin times on Day 2. A significant decline of platelet count was also observed. CONCLUSIONS: High-grade IVH coincides with severe derangement of coagulation in ELBW infants with FVII level being the most sensitive, it is not clear what the reason for such low FVII concentration is. Further studies are indicated.

[New opioids for general anaesthesia and in- and out-hospital analgesia]. / Zastosowanie nowych opioidów podczas znieczulenia ogólnego oraz analgezji wewnatrz- i pozaszpitalnej.

Over the last 30 years, three new opioids of the piperidine family have been introduced to anaesthesia clinical practice: sufentanil, alfentanil and remifentanil. Alfentanil is a derivative of fentanyl, with quicker onset than that of fentanyl and with shorter duration and more intense vagomimetic properties than those of fentanyl and sufentanil. It may cause less intense respiratory depression than equianalgesic doses of fentanyl. Clinical trials indicate that alfentanil can be used effectively as an analgesic, as an analgesic supplement to anaesthesia, and as the major component of a general anaesthetic. Its short duration of effect makes it attractive as an analgesic supplement for short ambulatory surgical procedures. Sufentanil is a more potent and more lipophilic analgesic than fentanyl. It would appear to maintain haemodynamic stability during surgery better than other opioids. Epidural sufentanil produces a rapid onset and good quality of analgesia. In addition, low doses administered intravenously via a PCA pump seem to have a potential role for analgesia during labour. Remifentanil is an opioid analgesic that is rapidly metabolized by non-specific blood and tissue esterases. According to its unique pharmacokinetic profile, remifentanil-based anaesthesia combines high-dosage opioid analgesia intraoperatively with a rapid and predictable postoperative awakening, even after long procedures. Its vagomimetic properties are especially pronounced in small children, the elderly and hypovolaemic patients, and in these groups atropine should be always given before remifentanil administration. Remifentanil also minimises the adrenergic response to endotracheal intubation. Three mju agonist-antagonists have been used for pain treatment: nalbuphine, butorphanol and buprenorphine. They can be used in ambulatory settings. Nalbuphine can be used parenterally. It reverses morphine-induced respiratory depression while maintaining adequate analgesic effect. Buprenorphine can be given sublingually, percutanenously, epidurally and parenterally. It is a potent analgesic, recommended for strong postoperative pain. Butorphanol is a potent analgesic that increases heart rate, arterial and pulmonary blood pressures and cardiac output. It should be given carefully in patients with coronary disease.

[Acute respiratory failure caused by tuberculosis]. / Niewydolnosc oddechowa u dziecka z nierozpoznana gruzlica.

BACKGROUND: In Poland today, tuberculosis is rarely considered as a primary cause of respiratory distress and/or multiple organ failure. We describe a case in which tuberculosis was diagnosed after admission to the ICU following three months of treatment at various health facilities. CASE REPORT: A 13-yr-old boy was admitted to the ICU with acute respiratory distress due to a right-sided multi-focal pneumonia, pleural effusion, and mediastinitis. He also had acute renal failure and was in shock. He had been treated for three months with various antibiotics. A skin TB-test was negative, as were blood and sputum cultures. Mediastinoscopy revealed enlarged lymph nodes in the anterior and posterior mediastinum and in the right pulmonary hilus. A lymphoma was suspected and steroids were commenced.The boy was critically ill, requiring mechanical ventilation (PIP 46 cm H2O, PEEP +7), extensive inotropic support and fluid resuscitation. By using polymerase chain reaction (PCR) on material from a bronchial lavage, infection of Mycobacterium tuberculosis was revealed, and anti-TB multi drug treatment was instituted (oral pyrazinamide, ethambutol, isoniazide and iv rifampicin). The oral treatment was complicated by dysenteric diarrhea, so enteral drugs were stopped and streptomycin instituted. Intravenous isoniazide was reinstituted later because of TB-meningitis. The treatment resulted in steady improvement and the boy was discharged from the ICU after 6 weeks of treatment. Six months later he was discharged home in a satisfactory condition, without signs of neurological damage. CONCLUSION: Tuberculosis can be very difficult to diagnose and may lead to multiple organ failure. PCR tests of specimens taken from affected body areas, should be made as early as possible.

Ascites in infants with severe sepsis - treatment with peritoneal drainage.

BACKGROUND: Ascites in neonates and infants is usually caused by cardiac failure and urinary or biliary tract obstruction. The objective of this study was to characterize our experience with ascites as a complication of sepsis. METHODS: We retrospectively collected and analyzed data of patients treated in the intensive care unit (ICU) of the university-based children's hospital, in whom ascites developed during nosocomial sepsis. Ten infants admitted to the ICU in the first 2 days of life developed sepsis on the mean 31.5 (+/-21.9) postnatal day. Gram-negative bacteria were the causative organism in nine cases, and Staphylococcus hemolyticus in one. Because of sepsis, reintubation and mechanical ventilation were necessary. All patients received broad spectrum antibiotics (including meropenem and ciprofloxacin), blood transfusions, catecholamines and intravenous immunoglobulin preparations. Ascites was observed on the median 13.5 day of sepsis (range 3-36), and severely compromised gas exchange. Continuous peritoneal drainage was applied by means of an intravascular catheter placed in the right lower abdominal quadrant. RESULTS: The mean drained fluid volume was 44.7 (+/-20.4) ml.kg(-1).day(-1), drainage was continued for a median of 5.5 (range 1-56) day, and enabled significant reduction of ventilator settings 24 h after its implementation. No severe complications related to drainage occurred; six of 10 babies survived. CONCLUSIONS: Ascites can develop in infants with sepsis and cause respiratory compromise. Continuous drainage of ascitic fluid by means of an intravenous catheter is relatively safe and can improve gas exchange.