COVID-19 pneumonia successfully managed with high-flow nasal cannula in a 15-year-old boy.

We report an otherwise healthy, fully immunised 15-year-old boy who was transferred to our Pediatric intensive care unit with 4 days of fever, dry cough, increased work of breathing and impending respiratory failure. Two days prior, amoxicillin/clavulanic acid was prescribed for lower airway symptoms resembling pneumonia. PCR of the nasopharyngeal swab revealed an active COVID-19 infection (Ct 19). The CT scan showed significant ground-glass opacities highly associated with COVID-19 (COVID-19 reporting and data system 4). Antibiotics were continued and chloroquine was given for 5 days. High-flow nasal cannula (HFNC) was started as respiratory support therapy with rapid decrease of tachypnoea and oxygen demand. HFNC was successfully stopped after 7 days. The patient made full clinical recovery. This case illustrates HFNC as a successful respiratory support therapy in a paediatric patient with an active COVID-19 pneumonia.

A comparison of four different models of acute respiratory distress syndrome in sheep.

BACKGROUND: Acute respiratory distress syndrome (ARDS) can have various causes. The study objective was to investigate whether different pathophysiologic models of ARDS would show different respiratory, cardiovascular and inflammatory outcomes. METHODS: We performed a prospective, randomized study in 27 ventilated ewes inducing ARDS using three different techniques to mimic the pulmonary causes of ARDS (ARDSp): warm saline lavage (n = 6), intratracheal hydrochloric acid (HCl; n = 6), intratracheal albumin (n = 10), and one technique to mimic an extrapulmonary cause of ARDS (ARDSexp): intravenous lipopolysaccharide (LPS iv; n = 5). ARDS was defined when PaO2 was < 15 kPa (112 mmHg) when ventilated with PEEP 10 cm H2O and FiO2 = 1.0. The effects on gas exchange were investigated by calculating the oxygenation index (OI) and the ventilation efficacy index (VEI) every 30 min for a period of 4 h. Post mortem lung lavage was performed to obtain broncho-alveolar lavage fluid (BALF) to assess lung injury and inflammation. Lung injury and inflammation were assessed by measuring the total number and differentiation of leukocytes, the concentration of protein and disaturated phospholipids, and interleukine-6 and -8 in the BALF. Histology of the lung was evaluated by measuring the mean alveolar size, alveolar wall thickness and the lung injury score system by Matute-Bello et al., as markers of lung injury. The concentration of interleukin-6 was determined in plasma, as a marker of systematic inflammation. RESULTS: The OI and VEI were most affected in the LPS iv group and thereafter the HCl group, after meeting the ARDS criteria. Diastolic blood pressure was lowest in the LPS iv group. There were no significant differences found in the total number and differentiation of leukocytes, the concentration of protein and disaturated phospholipids, or interleukin-8 in the BALF, histology of the lung and the lung injury score. IL-6 in BALF and plasma was highest in the LPS iv group, but no significant differences were found between the other groups. It took a significantly longer period of time to meet the ARDS criteria in the LPS iv group. CONCLUSIONS: The LPS model caused the most severe pulmonary and cardiovascular insufficiency. Surprisingly, there were limited significant differences in lung injury and inflammatory markers, despite the different pathophysiological models, when the clinical definition of ARDS was applied.

The effects of dexamethasone and oxygen in ventilated adult sheep with early phase acute respiratory distress syndrome.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is a life-threating condition with high morbidity and mortality. Inflammation is the main factor in the pathogenesis of ARDS. Therefore systemic corticosteroids are a rational therapeutic approach, but the effect of corticosteroids is still unclear. In this study, we looked at the effects of corticosteroids in ventilated sheep with ARDS, induced by lung lavage. METHODS: We performed a prospective, randomised study in 64 ventilated sheep with ARDS, to evaluate the effect of corticosteroids and oxygen concentration on gas exchange and lung injury. Oxygenation index (OI) and ventilation efficacy index (VEI) were calculated to evaluate gas exchange. Lung injury was assessed by inflammatory response in broncho-alveolar lavage fluid (BALF) and plasma and histology of the lung. RESULTS: OI, VEI, lung inflammation, surfactant production, or lung histology was not influenced by corticosteroids. In the 100 % oxygen groups, OI was higher and total number of cells and disaturated phospholipids were lower in BALF. CONCLUSION: Our study showed that corticosteroids did not influence inflammation in early phase ARDS and that hyperoxia aggravated lung injury which could not be modulated by dexamethasone in early phase ARDS.

Comparison of recruitment manoeuvres in ventilated sheep with acute respiratory distress syndrome.

BACKGROUND: Recruitment manoeuvres are widely used in clinical practice to open the lung and prevent lung injury by derecruitment, although the evidence is still discussed. In this study two different recruitment manoeuvres were compared to no recruitment manoeuvres (control) in ventilated sheep with acute respiratory distress syndrome (ARDS), induced by lung lavage. METHODS: We performed a prospective, randomised study in 26 ventilated sheep with ARDS, to evaluate the effect of two different recruitment manoeuvres on gas exchange, blood pressure and lung injury. The two different recruitment manoeuvres, the high pressure recruitment manoeuvre (HPRM), with high peak pressure, and the smooth and moderate recruitment manoeuvre (SMRM), with lower peak pressure, were compared to controls (no recruitment) after disconnection. Oxygenation index and ventilation efficacy index were calculated to evaluate gas exchange. Lung injury was assessed by inflammatory response in broncho-alveolar lavage fluid (BALF) and blood and histology of the lung. RESULTS: Oxygenation index improved significantly after both recruitment manoeuvres compared with controls, but no significant difference was found between the recruitment manoeuvres. Blood pressure decreased after HPRM but not after SMRM. HPRM induced a higher number of total cells and more neutrophils in the BALF. In the histology of the lung, mean alveolar size was increased in the dorsocranial region of the lung of SMRM compared to controls. CONCLUSION: Recruitment manoeuvres improved oxygenation, but SMRM was superior, with respect to hemodynamics and pulmonary inflammation, in ventilated sheep suffering from ARDS induced by lung lavage.

Salpingitis. A rare cause of acute abdomen in a sexually inactive girl: a case report.

Salpingitis is an acute inflammation of the fallopian tubes, most commonly caused by sexually transmitted micro-organisms in adolescent and adult women. It is rarely found in sexually inactive girls and generally the result of a blood-borne or genitourinary infection. In young girls without a history of consensual sexual contact, the possibility of sexual abuse should be considered.Salpingitis usually presents as an acute abdomen. Appendicitis presents with almost the same symptoms as salpingitis. The diagnosis of salpingitis is often delayed until the presumed appendicitis is surgically explored.We describe an 11-year-old girl with salpingitis caused by Streptococcus pneumoniae.

Plasma arginine and citrulline concentrations in critically ill children: strong relation with inflammation.

BACKGROUND: The amino acid arginine plays a key role in many metabolic processes in health and disease. Low arginine concentrations are found in various illnesses in children. OBJECTIVE: The objective was to investigate the relation between plasma concentrations of arginine (and precursor amino acids) and severity of inflammation in critically ill children. DESIGN: This was an observational cohort study in children with viral respiratory disease (n = 21; control group), accidental or surgical trauma (n = 19), or sepsis (n = 19) who were admitted to a pediatric intensive care unit. RESULTS: Plasma arginine and citrulline concentrations were lower in subjects with sepsis and trauma than in those with viral disease (arginine: 33 +/- 4, 37 +/- 4, and 69 +/- 8 micromol/L, respectively, P < 0.01 for both; citrulline: 10 +/- 1, 14 +/- 1, and 23 +/- 2 micromol/L, respectively, P < 0.01 for both) and correlated strongly and inversely with severity of inflammation as indicated by plasma CRP concentration (r = -0.645 and r = -0.660, respectively; P < 0.001 for both). During recovery, plasma arginine and citrulline concentrations increased and were strongly related to the reduction in inflammation as shown by the inverse correlation between arginine and citrulline concentrations and the CRP concentration on days 3 (r = -0.832 and r = -0.756, P < 0.001 for both) and 7 (r = -0.784 and r = -0.694, P < 0.001 for both). CONCLUSIONS: Plasma concentrations of arginine and citrulline are low during the acute phase of critical illness in children and normalize again during recovery. Plasma arginine and citrulline are strongly related to the severity of inflammation indicated by plasma CRP concentrations.

Point-of-care blood analyzer during the interhospital transport of critically ill children.

OBJECTIVES: To investigate the influence of point-of-care laboratory results (arterial blood gases, ionized calcium, potassium, sodium, glucose, hematocrit and hemoglobin) on therapeutic interventions during interhospital pediatric intensive care transport. DESIGN: Prospective observational study. SETTINGS: Specialist pediatric intensive care retrieval team of a university hospital. PARTICIPANTS: Critically ill pediatric patients who were referred from a community hospital to a pediatric intensive care of a tertiary center. The retrieval team sampled arterial blood during the time of stabilization in the referring hospital and during transport. All results were recorded and for each result the physician of the specialist retrieval team wrote down the influence on the treatment (none, partly, only). The physician specified the kind of intervention. RESULTS: Point-of-care blood analyses influenced the therapeutic management in 76.5% of all blood samples and in 86.2% of the referred patients. Of all interventions, 42.9% were based only on the laboratory results. The majority of interventions were adjustments of the mechanical ventilation. Point-of-care blood analyses reduced the delay in treatment of potentially life-threatening abnormalities of laboratory results (severe hypokalemia and low hematocrit). CONCLUSIONS: During interhospital pediatric intensive care transport, point-of-care blood analyses frequently led to therapeutic interventions. Some abnormal blood results were potentially life threatening and could not have been discovered without point-of-care measurement. We therefore recommend the use of a point-of-care blood analyzer during interhospital intensive care transports, not only for blood gases but also for electrolytes, glucose and hematocrit.