Response of focal refractory status epilepticus to lacosamide in an infant.

Status epilepticus (SE) is a life-threatening medical emergency which is frequently encountered in the critical care setting and can be refractory to treatment. Refractory status epilepticus (RSE) is defined as SE that has failed to respond to adequately used first-line and second-line antiepileptic medications. Super refractory status epilepticus is defined as SE that persists for 24 hours or more after the use of an anaesthetic agent or recurs after its withdrawal.If SE persists beyond a period of 7 days it is referred to as prolonged, refractory status epilepticus (PRSE). There are limited data guiding treatment of RSE in the paediatric population.Lacosamide (LCM) is licensed as an adjunctive treatment for partial-onset seizures. Evidence for the efficacy of LCM in paediatric SE is scarce. This case report may suggest a synergistic effect of LCM on slow-activation sodium channels in conjunction with medications such as phenytoin that causes fast inactivation of sodium channels. The dual fast and slow inactivation of sodium channels may enhance the effectiveness in treatment of RSE. This is the first case report of PRSE in an infant, successfully treated with LCM. A brief review of literature is also a part of this report.

Basilar artery stroke in Crohn's disease treated with endovascular thromboembolectomy.

We describe a girl in middle childhood with newly diagnosed Crohn's disease, who presented with seizures and altered mental status. MRI showed an abnormal vascular signal at the basilar artery, but no evidence of acute ischaemia. Her weakness worsened over the next 8 hours to dense quadriplegia. CT angiography of the brain, approximately 24 hours after the initial onset of symptoms, identified an acute basilar artery occlusion with infarction. She received endovascular thromboembolectomy emergently. She showed significant improvement over 8-month period from quadriplegia to walking unassisted. This case highlights the importance of recognising stroke in patients with inflammatory bowel disease and the need for emergent radiological assessment and potential intervention.

Illustration of the current practice and outcome comparison of early versus late tracheostomy after pediatric ECMO.

OBJECTIVE: Pediatric extracorporeal membrane oxygenation typically necessitates protracted ventilator support, yet not much is known about the use of tracheostomy in the pediatric subpopulation. The study was designed with an objective to quantify the prevalence of tracheostomy in children with respiratory/cardiac failure requiring extracorporeal membrane oxygenation and to compare outcomes for patients undergoing early, late, and no tracheostomy. METHODS: Data of patients <18 years of age who underwent extracorporeal membrane oxygenation for respiratory/cardiac failure between 2009 and 2015 were obtained from the Virtual Pediatric Systems (VPS, LLC) Database. Patients who underwent post-operative cardiac ECMO were excluded. Early versus late tracheostomy was defined as ⩽21 or >21 days after intensive care unit admission. RESULTS: Data were analyzed for 2127 patients meeting inclusion and exclusion criteria. Five percent (107/2127) underwent a tracheostomy. Of these, 28% (30/107) underwent early and 72% (77/107) late tracheostomy. A higher mortality was found in the no tracheostomy group (41.3%) compared to early (13.3%) and late tracheostomy (14.3%) groups. Late tracheostomy was associated with 2.4 times the expected intensive care unit length of stay and 1.87 times the expected ventilator days as compared to patients with no tracheostomy. Early tracheostomy was associated with a shorter intensive care unit length of stay (p value < 0.001) and ventilator days (p value = 0.04) compared to late tracheostomy and no difference with the no tracheostomy group. CONCLUSIONS: Late tracheostomy (>21 days) is associated with worse outcomes in the cohort of children who underwent Pediatric extracorporeal membrane oxygenation compared to patients who did not undergo tracheostomy. Early tracheostomy is associated with shorter intensive care unit stay and ventilator duration when compared to late tracheostomy.

Comparison of Flow Resistance Characteristics and Placement of Two Endotracheal Tubes.

BACKGROUND: In a traditional endotracheal tube (ETT), there is a linear outward pull through its attachment to the ventilator tubing that leads to risk of accidental dislodgement. This study was conducted to assess the ETT flow characteristics and to evaluate providers' intubation experience using two ETT's in a simulated setting. METHODS: Respiratory pressure-volume dynamics for the 2 ETTs were studied in a simulation laboratory by using 3 different flow settings and 2 different test lungs. The time taken for successful intubation on a mannikin was compared by direct observation of 33 separate intubation attempts by 11 different providers. Comfort with intubation by using both tubes was assessed with a Likert scale-based survey. The potential increase in physical and cognitive work load of nurses and respiratory therapists was assessed by the NASA task load index. RESULTS: There were slightly lower average tidal volumes delivered with SecureTube compared with the standard tube at different peak inspiratory pressures. Similarly, the same tidal volume delivered with a different flow and bag compliance required slightly higher peak inspiratory pressure compared with the standard ETT. Among providers, there was no difference in the average time to intubate when using either tube. All survey respondents (N = 11) rated intubation attempts with the SecureTube to be very easy compared with the standard tube. The NASA task load index (N = 26) showed very low task loads on all the tasks. CONCLUSIONS: There was minimal impact on flow resistance on pressure or volume with the SecureTube compared with the standard tube. Most providers felt comfortable intubating with the SecureTube and took a comparable amount of time to intubate in a simulated setting. We observed low task load scores for securement, maintenance, and manipulation per nurses and respiratory therapists.

Successful Development and Implementation of Pediatric Sedation-Analgesia Curriculum for Residents.

Pediatric residency graduates are increasingly asked to provide procedural sedations. Currently, most programs provide minimal exposure to residents outside of PICU for procedural sedations. We describe the pediatric sedation and analgesia (PSA) evolution and resident experience over the past 6 years at our institution (fiscal year 2010-2015). Administrative database of the PSA team and resident evaluations obtained by respective residency programs were analyzed and presented with standard descriptive analysis. Commutative or where appropriate year-by-year data were analyzed. Over the past 6 years, 100 residents performed 1,742 sedations with 17 ± 6.4 sedations per resident. Lumbar puncture and MRI were the most frequent procedures for sedations performed by residents. There was no statistical difference in complication rates in sedations performed by residents (28.6 ± 16.6) versus those by attending only (36.2 ± 31.2). Overall, residents were satisfied with the educational experience with an average score of 6.1 ± 0.17 out of maximum 7. Resident involvement in PSA is well liked by residents and does not lead to an increase in sedation-related complications.

A presedation fluid bolus does not decrease the incidence of propofol-induced hypotension in pediatric patients.

BACKGROUND AND OBJECTIVE: Propofol is commonly used in pediatric sedation, which may cause hypotension during induction. Our goal was to determine the effect of a preinduction 20-mL/kg isotonic fluid bolus on propofol-induced hypotension, assess clinical signs of hypoperfusion during hypotension, and evaluate for age-related propofol dosing differences. METHODS: This prospective, randomized, controlled, nonblinded study was conducted at Children's Hospital of Illinois. Patients were children 6 to 60 months of age who needed sedation for MRI or auditory brainstem-evoked response testing. The treatment group received a preinduction 20-mL/kg isotonic saline bolus before procedure initiation. Patients were continuously monitored via cardiorespiratory monitor with pulse oximetry and end-tidal carbon dioxide measurements. Cardiovascular indices and clinical signs of hypoperfusion were compared between groups, and propofol dosing differences were compared between age groups. RESULTS: One hundred twenty-six patients were randomly assigned to treatment (n=52) or control (n=74) conditions. Twelve patients in the treatment group and 14 patients in the control group experienced postinduction hypotension, as defined by the Pediatric Advanced Life Support guidelines. One patient in each group was given volume resuscitation when blood pressure did not improve after a reduction in the propofol infusion rate. No hypotensive patients had physical signs of hypoperfusion, and patients≤1 year of age needed significantly more propofol. CONCLUSIONS: A 20-mL/kg preinduction isotonic saline bolus does not prevent propofol-induced hypotension. No clinical signs of hypoperfusion were noted with induced hypotension, and infants≤12 months old need significantly more propofol per kilogram for procedures.

Computerized pharmaceutical algorithm reduces medication administration errors during simulated resuscitations.

OBJECTIVE: Medication errors involving intravenous medications continue to be a significant problem, particularly in the pediatric population due to the high rate of point-of-care and weight-adjusted dosing. The pharmaceutical algorithm computerized calculator (pac2) assists in converting physician medication orders to correct volumes and rates of administration for intravenous medications. This study was designed to assess the efficacy of the pac2 in simulated clinical scenarios of point-of-care dosing. METHODS: The study design was a within-subject controlled study in which 33 nurses from pediatrics, pediatric critical care, or critical care (mean nursing experience of 10.9 years) carried out various point-of-care medication-dosing scenarios with and without the aid of the pac2. RESULTS: Use of the pac2 resulted in a significantly higher percentage (mean [95% CI]) of medication volumes calculated and drawn accurately (91% [87-95%] versus 61% [52-70%], p<0.0001), a higher percentage of correct recall of essential medication information (97% [95-99%] versus 45% [36-53%], p<0.0001), and better recognition of unsafe doses (93% [87-99%] versus 19% [12-27%], p<0.0001) as compared to usual practice. The pac2 also significantly reduced average medication calculation times (1.5 minutes [1.3-1.7 minutes] versus 1.9 minutes [1.6-2.2 minutes], p=0.0028) as compared to usual practice. CONCLUSIONS: The pac2 significantly improved the performance of drug calculations by pediatric and critical care nurses during simulated clinical scenarios designed to mimic point-of-care dosing. These results suggest that the pac2 addresses an area of safety vulnerability for point-of-care dosing practices and could be a useful addition to a hospital's overall program to minimize medication errors.

Bivalirudin for anticoagulation in children.

BACKGROUND: Thromboembolism in children is typically treated with unfractionated heparin (UH) or low molecular weight heparin (LMWH). Both rely on antithrombin (AT) for their action. In addition, heparin-induced thrombocytopenia (HIT) is a potentially serious complication of heparin use in children. Bivalirudin or other direct thrombin inhibitors may be a useful alternative to heparins in treating thrombosis in children. PROCEDURE: We report a retrospective review to assess the efficacy and safety of bivalirudin in pediatric patients with thrombosis. RESULTS: Sixteen children received bivalirudin for thrombosis or prevention of thrombosis at the Children's Hospital of Illinois from January 2005 to January 2007. Patients received a bolus dose of 0.25 mg/kg followed by a continuous infusion (0.16 +/- 0.07 mg kg(-1) hr(-1)) titrated to 1.5-2.5 times the baseline activated partial thromboplastin time (aPTT). Positive correlation between the bivalirudin average infusion rate and aPTT was observed in twelve patients. Ultrasonographic evidence of thrombus regression was noted at 72 hr in 10 of 10 patients. One patient experienced hematuria after catheterization of the urethra. CONCLUSION: Bivalirudin was effective and well-tolerated in these patients. Further studies should be conducted to better define safety and efficacy of bivalirudin in pediatric patients.