Perspectives on the Management of Children in a Biocontainment Unit: Report of the NETEC Pediatric Workgroup.

During the outbreak of Ebola virus disease that struck West Africa during 2014-2016, a small handful of expatriate patients were evacuated to specialized high-level containment care units, or biocontainment units, in the United States and Western Europe. Given the lower mortality rate (18% versus 40% for those treated in Africa) among these patients, it is likely that high-level containment care will be used in the future with increasing frequency. It is also likely that children infected with Ebola and other highly hazardous communicable diseases will someday require such care. The National Ebola Training and Education Center convened a pediatric workgroup to consider the unique and problematic issues posed by these potential child patients. We report here the results of those discussions.

Management of the Pediatric Patient Following Upper Extremity Replantation or Revascularization: A Suggested Protocol.

BACKGROUND: Traumatic pediatric amputations of the hand and upper extremity can have long-term financial, psychological, developmental, and functional consequences that readily extend beyond the realm of that which is normally encountered in comparatively injured adults. These factors, along with a paucity of medical comorbidities, have guided a more liberal and aggressive approach to treating pediatric amputations in hopes of optimizing psychosocial, aesthetic, and developmental outcomes. Furthermore, advances in pharmacology and microsurgical replantation techniques have allowed what were otherwise exceedingly rare surgeries to become commonplace in hospitals all over the world. Despite these gains, vascular thrombosis remains the leading cause of failure in microvascular surgeries. A recent survey showed that 96% of reconstructive surgeons use some form of anticoagulation therapy in their treatment, but no consensus regarding pharmacologic agents, dosing, or efficacy exists. The risk of thrombosis is further complicated by the dynamic nature of vasculature in response to stressors such as sympathetic tone, decreased intravascular volume, and response to external temperature. Given the lack of a higher-level evidence to guide the replantation surgeon in postoperative orders, we created an inclusive protocol, outlining complete and proper management of the pediatric patient following revascularization or replantation surgery. METHODS: We reviewed the methods employed by our microvascular surgeons and consulted with board-certified pediatricians to produce a final document that was adopted ubiquitously among our providers. RESULTS: We do not have head-to-head data demonstrating improved outcomes with use of the protocol. Nonetheless, the original document has been modified and reproduced here for your consideration and use. CONCLUSIONS: Since initiating the protocol, we feel it has helped standardize our practice, avoid instances of incomplete or missed order sets, and facilitate interdisciplinary management through decreased gaps in communication, especially in those surgeries terminating in the middle of the night.

Sustained hypoxia promotes the development of a pulmonary artery-specific chronic inflammatory microenvironment.

Recent studies demonstrate that sustained hypoxia induces the robust accumulation of leukocytes and mesenchymal progenitor cells in pulmonary arteries (PAs). Since the factors orchestrating hypoxia-induced vascular inflammation are not well-defined, the goal of this study was to identify mediators potentially responsible for recruitment to and retention and differentiation of circulating cells within the hypoxic PA. We analyzed mRNA expression of 44 different chemokine/chemokine receptor, cytokine, adhesion, and growth and differentiation genes in PAs obtained via laser capture microdissection in adjacent lung parenchyma and in systemic arteries by RT-PCR at several time points of hypoxic exposure (1, 7, and 28 days) in Wistar-Kyoto rats. Analysis of inflammatory cell accumulation and protein expression of selected genes was concomitantly assessed by immunochemistry. We found that hypoxia induced progressive accumulation of monocytes and dendritic cells in the vessel wall with few T cells and no B cells or neutrophils. Upregulation of stromal cell-derived factor-1 (SDF-1), VEGF, growth-related oncogene protein-alpha (GRO-alpha), C5, ICAM-1, osteopontin (OPN), and transforming growth factor-beta (TGF-beta) preceded mononuclear cell influx. With time, a more complex pattern of gene expression developed with persistent upregulation of adhesion molecules (ICAM-1, VCAM-1, and OPN) and monocyte/fibrocyte growth and differentiation factors (TGF-beta, endothelin-1, and 5-lipoxygenase). On return to normoxia, expression of many genes (including SDF-1, monocyte chemoattractant protein-1, C5, ICAM-1, and TGF-beta) rapidly returned to control levels, changes that preceded the disappearance of monocytes and reversal of vascular remodeling. In conclusion, sustained hypoxia leads to the development of a complex, PA-specific, proinflammatory microenvironment capable of promoting recruitment, retention, and differentiation of circulating monocytic cell populations that contribute to vascular remodeling.

[Management of the acute respiratory distress syndrome]. / O manejo da síndrome do desconforto respiratório agudo.

OBJECTIVE: To review the current support and treatment strategies of the acute respiratory distress syndrome. DATA SOURCES: Original data from our research laboratory and from representative scientific articles on acute respiratory distress syndrome and acute lung Injury searched through Medline. SUMMARY OF THE FINDINGS: Despite advances in the understanding of the pathogenesis of acute respiratory distress syndrome, this syndrome still results in significant morbidity and mortality. Mechanical ventilation, the main therapeutic modality for acute respiratory distress syndrome, is no longer considered simply a support modality, but a therapy capable of influencing the course of the disease. New ventilation strategies, such as high-frequency oscillatory ventilation appear to be promising. This text reviews the current knowledge of acute respiratory distress syndrome management, including conventional and non-conventional ventilation, the use of surfactant, nitric oxide, modulators of inflammation, extracorporeal membrane oxygenation and prone position. CONCLUSIONS: The last decade was marked by significant advances, such as the concept of protective ventilation for acute respiratory distress syndrome. The benefit of alternative strategies, such as high-frequency oscillatory ventilation, the use of surfactant and immunomodulators continue to be the target of study.

O manejo da síndrome do desconforto respiratório agudo / Management of the acute respiratory distress syndrome

OBJETIVO: Revisar as atuais estratégias de suporte e de tratamento da síndrome do desconforto respiratório agudo (SDRA). FONTE DOS DADOS: Dados próprios de nosso laboratório de pesquisa e bibliografia relacionada às áreas de SDRA e lesão pulmonar aguda, pesquisados através do Medline. SíNTESE DOS DADOS: Apesar de avanços no entendimento da sua patogênese, a SDRA ainda resulta em significativa morbidade e mortalidade. A ventilação mecânica é a principal modalidade terapêutica na SDRA, sendo atualmente considerada não mais apenas uma medida de suporte, mas sim uma terapia capaz de alterar o curso da patologia. Novas estratégias ventilatórias, como a ventilação oscilatória de alta freqüência (VOAF), têm-se mostrado promissoras. Neste texto, revisamos o conhecimento atual no manejo da SDRA, incluindo ventilação mecânica convencional e não convencional, uso de surfactante, óxido nítrico, moduladores do processo inflamatório, oxigenação extracorpórea e posição prona. CONCLUSÕES: A última década foi marcada por avanços significativos, como o conceito de ventilação mecânica protetora na SDRA. O benefício da aplicação de estratégias alternativas, como a VOAF, assim como do uso do surfactante exógeno e moduladores de inflamação continuam sendo alvo de estudo.

[Treatment of intracranial hypertension]. / Tratamento da hipertensão intracraniana.

OBJECTIVES: To review the current therapeutic approach of intracranial hypertension in pediatric patients admitted to intensive care unit. SOURCES OF DATA: Bibliographic review of the subject based on Medline. SUMMARY OF THE FINDINGS: The authors noticed that some measures to control intracranial hypertension are consensual, and others remain controversial. CONCLUSION: The goals of management of pediatric patients with intracranial hypertension include: normalizing the intracranial pressure, optimizing cerebral blood flow and cerebral perfusion pressure, preventing second insults that exacerbate secondary injury, and avoiding complications associated with the various treatment modalities employed.

Tratamento da hipertensäo intracraniana / Treatment of intracranial hypertension

OBJETIVO: revisar a abordagem terapêutica atual nos pacientes pediátricos com hipertensäo intracraniana, internados em unidade de terapia intensiva. FONTE DE DADOS: revisäo bibliográfica sobre o tema, utilizando como base de dados o Medline. SíNTESE DOS DADOS: a partir da literatura levantada pode-se observar a existência de medidas de monitorizaçäo e tratamento da hipertensäo intracraniana aceitas como consenso pelos diferentes autores, assim como abordagens que ainda motivam controvérsias. CONCLUSÕES: os objetivos no manejo do paciente pediátrico com hipertensäo intracraniana incluem a normalizaçäo da pressäo intracraniana, a otimizaçäo do fluxo sangüíneo cerebral e pressäo de perfusäo cerebral, prevenindo o segundo insulto que exacerba a lesäo secundária, evitando as complicações associadas com as várias modalidades de tratamento empregadas.

Hipertensao intracraniana em pediatria revisao sobre fisiopatologia, monitorizacao e tratamento / Intracranial hypertension in pediatrics review about physiopathology, monitoring and treatment

Os autores revisam os mecanismos fisiopatológicos da hipertensäo intracraniana e as indicações de monitorizaçäo e tratamento em diversas situações clínicas