[Pediatric perspectives on medical transport]. / Visión pediátrica del transporte medicalizado.

OBJECTIVE: To highlight the need for the organization and development of pediatric medical transport systems in Spain. METHODS: Analysis of the different types of pediatric medical transport, with a brief historical introduction and theoretical-practical discussion of the different types of transport team, their human and material resources and systematic organization. RESULTS AND CONCLUSIONS: The retrospective experience of a state medical emergency team is reported. The need for multidisciplinary coordination among pediatricians, critical care pediatricians, neonatologists, emergency physicians and nurses is identified as crucial in order to optimize resources and achieve the proposed objectives.

Transporte de pacientes pediátricos críticos: entrando en una nueva era / Transport of critically ill pediatric patients

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Visión pediátrica del transporte medicalizado / Pediatric perspectives on medical transport

Objetivo: Significar la necesidad de estructuración y desarrollo de sistemas de transporte pediátrico medicalizado en España. Métodos: Se han analizado los diferentes tipos de transporte pediátrico medicalizado, con una breve introducción histórica y posterior desarrollo teórico-práctico de las diferentes modalidades de equipo de transporte posibles, dotación de recursos humanos y materiales en éstos y su sistematización. Resultados y conclusiones: Se aporta la experiencia retrospectiva de un equipo de emergencias médicas estatal y basándose en ella, la necesidad de la coordinación multidisciplinaria (pediatras, intensivistas pediátricos, neonatólogos, médicos de urgencias y enfermería), para lograr una optimización de recursos, para la consecución de los objetivos propuestos (AU)

Use of an optical fiber scope to confirm endotracheal tube placement in pediatric patients.

OBJECTIVE: To determine the efficacy of a portable optical fiber scope to confirm endotracheal tube (ETT) placement. DESIGN: A prospective, nonrandomized, blinded study. SETTING: Pediatric intensive care unit in a children's hospital. PATIENTS: Thirty mechanically ventilated patients with an ETT in place. INTERVENTIONS: Patients entered into the study underwent ETT placement determination by chest roentgenogram (CXR) and by the optical fiber scope. MEASUREMENTS AND MAIN RESULTS: Thirty patients were entered into the study, for a total of 46 measurements (n = 46). ETT size ranged from 3.0 to 6.0 mm internal diameter. Distance from the ETT and the carina was determined by the scope and compared with the distance measured on the CXR. No statistical difference was found between the two methods. None of the patients experienced clinically significant side effects from the procedure. On three occasions, the presence of secretions in the ETT did not allow for the visualization of the carina by the scope. CONCLUSION: The use of a flexible optical fiber scope is an accurate, fast, and practical method to determine ETT placement in pediatric patients on mechanical ventilation.

Evaluating the frequency rate of hypomagnesemia in critically ill pediatric patients by using multiple regression analysis and a computer-based neural network.

OBJECTIVES: To determine the frequency rate of hypomagnesemia in patients admitted to the pediatric intensive care unit (ICU), and to identify subsets of patients (grouped by disease) who are at greatest risk of hypomagnesemia. We also compared a neural network model with multiple regression analysis to identify independent variables that would correlate with hypomagnesemia and to predict serum magnesium values in critically ill pediatric patients overall. DESIGN: Prospective, multicenter study. SETTING: Tertiary level medical/surgical pediatric ICUs. PATIENTS: Data were obtained at admission to the pediatric ICU for 463 patients from newborn to 18 yrs old who were admitted with a variety of surgical and nonsurgical conditions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Total serum magnesium values were obtained within the first 24 hrs after admission in 463 pediatric patients admitted to four pediatric ICUs. Hypomagnesemia (defined as total serum magnesium <0.75 mmol/L) was found in 51 (11%) of the 463 patients, with the highest frequency rate (72%) and lowest mean serum magnesium level (0.66 +/- 0.17 mmol/L) in patients admitted after surgery with extensive osseous involvement (spinal fusion and craniofacial reconstruction). To determine whether hypomagnesemia could be predicted on the basis of other laboratory and clinical criteria, multiple regression analysis was performed and showed age, weight, and albumin levels weakly associated (r2 = .14, p < .001) with magnesium levels within the different diagnostic groups. These data were used to produce a mathematical model able to predict magnesium levels within 5% of the actual values in 23% of patients. A neural network was also created to compare its predictive capabilities to those of the multiple regression model. Once trained on a random subset (85%) of the patient population, the neural network was able to predict magnesium levels to within 5% of actual values for 88% of the remaining 15% of patients, comparing favorably with the predictions derived from the multiple regression model. CONCLUSIONS: Hypomagnesemia is not uncommon (11%) in critically ill pediatric patients, but is very common (72%) in patients admitted after surgery for spinal fusion or craniofacial reconstruction. Patients who undergo surgery for correction of scoliosis and craniofacial anomalies should have serum magnesium levels monitored closely after surgery. In other patients, a neural network or multiple regression model could help predict which patients would be at risk of developing hypomagnesemia, thereby focusing testing on patients likely to benefit from such testing.

[High-frequency oscillatory ventilation in pediatric patients. protocol and preliminary results]. / Ventilación de alta frecuencia oscilatoria en pacientes pediátricos. Protocolo de aplicación y resultados preliminares.

BACKGROUND: High-frequency oscillatory ventilation (HFOV) constitutes an important advance in the management of children with respiratory failure. Although it has been used mainly as "lung rescue therapy", pediatric indications for HFOV can be broader. The principal advantages of this modality compared with conventional ventilation are the lower incidence of barotrauma, volutrauma, atelectrauma and biotrauma. To date, experience with HFOV in our country has been scarce and limited to neonatal patients. AIM: To describe the HFOV protocol for pediatric patients and to report the preliminary results of its prospective application. MATERIALS AND METHODS: An HFOV protocol was established with the following inclusion criteria: severe respiratory insufficiency of any origin (infectious, inhalatory, etc.) with an oxygenation index (OI) > 13 in two arterial blood gases within a 6-hour interval, refractory acute respiratory distress syndrome (ARDS), severe respiratory syncytial virus pneumonia, and gross airleak syndromes (pneumothorax, pneumoperitoneum, pneumomediastinum, etc.). Conventional and HFOV ventilatory, gasometric and hemodynamic parameters of patients included in the protocol during a 5-month period were registered, and the first 24 hours were analyzed. RESULTS: Six patients aged between 3 days and 8 years, weighing between 4 and 80 kg met the inclusion criteria. In all patients HVOF was indicated due to severe refractory ARDS. The pre-HFOV mean OI was 45.9. After 1 hour of HFOV mean OI decreased to 23.9 and continued to improve during the first 24 hours. In all patients, normal arterial PO2 and PCO2 were obtained and FiO2 could be set below 0.6 within the first 3 hours of HFOV. No complications associated with HFOV were detected. Outcome was satisfactory in two patients while four patients died secondary to multiorgan failure. CONCLUSIONS: HFOV is a safe and effective ventilatory modality in critically ill pediatric patients in whom conventional ventilation is not effective. To obtain better results, HFOV should be started early. Every child with refractory respiratory failure should be referred early to centers where HFOV can be offered.

Ventilación de alta frecuencia oscilatoria en pacientes pediátricos. Protocolo de aplicación y resultados preliminares / High-frequency oscillatory ventilation in pediatric patients. Protocol and preliminary results

ANTECEDENTES: La ventilación de alta frecuencia oscilatoria (VAFO) constituye un avance significativo en el manejo de niños con enfermedades respiratorias críticas. Aunque utilizada fundamentalmente como técnica de "rescate pulmonar", las indicaciones pediátricas de la VAFO pueden ser más amplias. Sus ventajas fundamentales sobre la ventilación convencional son la menor incidencia de barotrauma, volutrauma, atelectrauma y biotrauma. La experiencia con VAFO en nuestro país es escasa y limitada a pacientes neonatales. OBJETIVO: Presentar el protocolo de VAFO y analizar los resultados preliminares de su aplicación prospectiva. MATERIAL Y MÉTODOS: Se estableció un protocolo de aplicación de VAFO con los siguientes criterios de inclusión: insuficiencia respiratoria grave de cualquier etiología (infecciosa, inhalatoria, etc.) con un índice de oxigenación superior a 13 en dos muestras arteriales con un intervalo de 6 h, síndrome de distrés respiratorio agudo (SDRA) refractario, infección pulmonar grave por virus respiratorio sincitial y síndromes de amplio escape aéreo (neumotórax, neumoperitoneo, neumomediastino, etc.). Se recogieron los parámetros ventilatorios, gasométricos y hemodinámicos en modalidad convencional y en VAFO en los pacientes a los que se aplicó durante un período de 5 meses, y se analizaron las primeras 24 h. RESULTADOS: Se aplicó la VAFO a 6 pacientes de edades comprendidas entre 3 días y 8 años, con pesos comprendidos entre 4 y 80 kg. Su indicación fue la presencia de SDRA refractario en todos los casos. El índice de oxigenación medio pretratamiento fue de 45,9. Tras una hora de VAFO, este índice presentó un valor medio de 23,9. La mejoría progresiva del índice de oxigenación se mantenía a las 24 h. En todos los casos se consiguieron valores normales de PCO2 y fue posible disminuir la FiO2 por debajo de 0,6 antes de las 3 h de tratamiento. No se detectaron efectos adversos relacionados con la VAFO. La evolución clínica global fue satisfactoria en 2 casos, mientras que los otros cuatro fallecieron por fracaso multiorgánico. CONCLUSIÓN: La VAFO constituye una clara opción para el soporte ventilatorio de niños en estado crítico en los que las modalidades convencionales no resultan eficaces. Para obtener los mejores resultados, debería utilizarse de forma precoz. Todo niño con fracaso respiratorio refractario subsidiario de VAFO debe ser trasladado lo más pronto posible a un centro que disponga de esta técnica (AU)

Transport management of the patient with acute poisoning.

Poisoning in children is a common clinical problem encountered by pediatricians, general practitioners, and emergency room physicians. Poisoning in children less than 5 years of age is usually accidental, whereas, in young adults, any disparity between expected history and clinical findings should suggest poisoning. It is imperative that the treating physician expeditiously recognize, begin treating, and plan to transfer, when indicated, by specialized pediatric transport team the critically ill poisoned child to a tertiary care facility.

Influenza B virus infection associated with non-bacterial septic shock-like illness.

We report the details of four children aged between 6 months and 5.5 years who had underlying chronic disease and who developed life-threatening illness in association with influenza virus B infection. Influenza has received relatively little attention, yet its morbidity and mortality in children can be considerable. This report emphasises the need to vaccinate the population groups at high risk, such as children with cardiovascular disorders, chronic bronchopulmonary, metabolic and renal disease and chronic neurological disorders.

Comparison of intravenous and endotracheal administration of midazolam and the effect on pulmonary function and histology in the lamb model.

OBJECTIVES: To determine the effect of endotracheal administration of midazolam on pulmonary function and histology in lambs. DESIGN: Prospective, randomized, controlled study. SETTING: Laboratory of the UpJohn Pharmaceutical Company. TYPES OF PARTICIPANTS: Twenty male and female lambs weighing 10 to 20 kg. INTERVENTIONS: The animals were anesthetized and placed on controlled ventilation. The animals were divided into four groups. The first two groups received endotracheal midazolam 0.1 and 0.2 mg/kg. The other two groups received IV midazolam 0.1 and 0.2 mg/kg. The endotracheal group had a catheter placed through the endotracheal tube, and midazolam was rapidly injected through the catheter followed by a 2-mL normal saline flush. Two rapid insufflations were administered, and the animals were then returned to the ventilator. Serum midazolam levels were drawn at one, two, five, ten, 15, and 20 minutes after both IV and endotracheal administration. Heart rate, respirations, SaO2 by oximetry, peak and mean airway pressure, compliance, airway resistance, and end-tidal CO2 were measured throughout the experiment. Lung sections were taken from control and treated animals receiving 0.1 and 0.2 mg/kg endotracheal midazolam, respectively. Sample lung sections were taken at 24, 48, and 120 hours after endotracheal midazolam administration. MEASUREMENTS AND MAIN RESULTS: There were no statistical or clinically significant differences for pulmonary function between endotracheally and IV-administered midazolam. Histologic examination of the lungs at 24, 48, and 120 hours after endotracheal midazolam showed no pathologic changes in the control and study animals. Acceptable serum midazolam levels were achieved endotracheally with no clinically deleterious effects. CONCLUSION: Endotracheal midazolam showed no significant deleterious effect on pulmonary function or histology in the lamb model.

Evaluation of intraosseous vs intravenous antibiotic levels in a porcine model.

OBJECTIVES: To compare intraosseous vs intravenous routes of administration and their effects on serum levels of four antibiotics in an animal model. DESIGN: Prospective controlled study comparing two routes of drug administration. SETTING: Research laboratories of a large pharmaceutical company. PARTICIPANTS: Twenty male and female domestic swine weighing 10 to 20 kg. INTERVENTIONS: The animals were anesthetized and treated with controlled ventilation. The animals were divided into one of four groups: (1) intravenous and intraosseous cefotaxime sodium (50 mg/kg), (2) intravenous and intraosseous chloramphenicol sodium succinate (25 mg/kg), (3) intravenous and intraosseous vancomycin hydrochloride (15 mg/kg), or (4) intravenous and intraosseous tobramycin sulfate (2.5 mg/kg). There was a 24-hour clearance period for groups 1 and 2 and a 48-hour clearance period for groups 3 and 4. Serum drug levels were measured at 1, 15, 30, 45, 60, 90, and 120 minutes after intravenous and intraosseous administration of the respective antibiotics. Control and treated tibias were sampled for drug levels at the end of the experiment. MEASUREMENTS AND MAIN RESULTS: - Peak serum concentrations for intravenously administered antibiotics were within the therapeutic range. Peak serum levels after intravenous and intraosseous administration were 102 and 82 mg/L, respectively for cefotaxime; 13.9 and 6.3 mg/L, respectively, for chloramphenicol; 24.5 and 3.8 mg/L, respectively, for vancomycin; and 7.1 and 1.3 mg/L, respectively, for tobramycin. CONCLUSIONS: Cefotaxime may be administered intraosseously when intravenous access is not possible. We cannot recommend chloramphenicol or vancomycin for intraosseous administration, because serum levels were not comparable with those following intravenous administration. Findings with tobramycin suggested a lack of achievement of serum levels comparable with those following intravenous administration.

Intraosseous infusion: a re-discovered procedure as an alternative for pediatric vascular access.

The intraosseous infusion has numerous advantages over other techniques that provide vascular access during emergencies. It is a rapid and safe alternate route for fluid and certain drug administration in the infant or child. Few contra-indications or restrictions exist and the success rate for the technique is very high, even when performed by paramedical personnel, and the rate of complications is very low. At this time the technique should be reserved for children in crisis such as cardiac arrest, shock, trauma, life threatening status epilepticus, or any situation in which the potential benefit of rapid venous access outweighs the low incidence of complication. Intraosseous infusion is intended only for emergency resuscitation and stabilization, after which another route of vascular access should be sought. The technique may offer even more promise for those who rarely care for critically ill children, because this skill is easily mastered with even limited opportunity for practice.

Functional outcome of pediatric trauma patients identified as 'non-salvageable survivors'.

A retrospective study of 305 pediatric trauma patients seen over 17 months was undertaken to evaluate the functional outcome of patients categorized as "non-salvageable survivors" (NSS). Functional outcome was determined by Denver Developmental Screen Tests (DDST) for children less than 5 years of age and Rappaport Severity Rating Scale (RDRS) for those 5 years old and older. Each patient was assigned Abbreviated Injury Scores (AIS). Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and Trauma Score (TS). The total number of patients classified as severe was 65 (21%), and 13 were classified as non-salvageable, with seven non-salvageable survivors and six non-preventable deaths. Our study suggests that current trauma scoring systems tend to overestimate the non-salvageable population. Those identified as non-salvageable and who survived have a high probability of meaningful functional recovery. Current trauma scoring systems are in need of revision to better identify non-salvageable survivors and those children who will not make a meaningful neurologic recovery.

In vivo evaluation of simultaneous administration of incompatible drugs via a double-lumen peripheral catheter.

For the critically ill patient with complex and prolonged needs, multiple drug infusions and, when indicated, peripheral hyperalimentation require simultaneous administration through a simple peripheral catheter site with a multilumen catheter. We studied a double-lumen peripheral venous catheter. Ten domestic swine, 10 to 20 kg, were divided into two groups of five each. Total parenteral nutrition was administered through the distal port and phenytoin was administered as a bolus and as an infusion in each group. Samples were taken from two sites during the bolus and at 1, 5, and 15 min during phenytoin infusion. Electromagnetic flowmeter measurements were obtained for validation of flow. In all instances, our study showed that either the particle size was too small or the concentration of particles was less than 3 X 10(3)/microL: too small to be recovered in the study samples.

Intravenous midazolam suppression of pentylenetetrazol-induced epileptogenic activity in a porcine model.

Generalized tonic-clonic seizures are a neurologic emergency. Duration of ictal activity has been associated with neurologic sequelae. The purpose of this study was to determine if midazolam, a short-acting benzodiazepine, could effectively ablate ictal activity in an animal model without significant cardiorespiratory compromise. Ten domestic swine (10 to 20 kg) were ventilated and hemodynamically monitored. Bifrontal craniotomies were performed and electrocortical activity was recorded throughout the experiment. Pentylenetetrazol (100 mg/kg) was administered iv to induce seizures. Midazolam (0.1 mg/kg) was administered iv and serum levels were drawn at 1, 2, 5, 10, 15, and 20 min after administration. There was no significant difference between the baseline and postmidazolam vital signs. Seizure activity was seen periodically as generalized spikes, as well as individual spikes for 29 +/- 5 sec after midazolam administration. A period of attenuation of 24 +/- 7 sec was seen before returning to baseline electrocortical activity. Our study demonstrates that midazolam effectively ablated induced ictal activity without significant cardiorespiratory depression and with similar EEG effect as other benzodiazepines.

Comparison of intraosseous and intravenous routes of anticonvulsant administration in a porcine model.

During status epilepticus, rapid IV access for the administration of anticonvulsant drugs can be a very difficult and time-consuming procedure. Our study evaluated whether therapeutic serum levels of phenobarbital and phenytoin could be obtained by the intraosseous route. Twenty domestic swine weighing 10 to 20 kg were divided into two groups (ten each). In one group, phenobarbital 20 mg/kg was administered either intravenously (five) or intraosseously (five). The second group received phenytoin 15 mg/kg either intravenously (five) or intraosseously (five). All animals had samples for anticonvulsant levels drawn from an indwelling arterial cannula at one, three, five, seven, ten, 15, and 30 minutes after dosing. Anticonvulsant levels were found to be statistically significantly higher with IV administration (P less than .01). However, phenobarbital levels were therapeutic by the intraosseous route, while phenytoin levels were below the therapeutic range after the ten-minute interval. Bone marrow levels 45 minutes after infusion were 13.5 micrograms/mL (phenobarbital) and 11.5 micrograms/mL (phenytoin). Our study demonstrates that current IV dosing of phenobarbital 20 mg/kg given intraosseously obtains and maintains therapeutic serum levels. Phenytoin 15 mg/kg does not maintain therapeutic levels and cannot be recommended for intraosseous administration.