Spontaneous spinal epidural haematoma mimicking meningitis in a 2-year-old child--a case report and literature review.

INTRODUCTION: We report the case of a 2-year-old boy with suspected meningitis who presented with acute onset neck pain and stiffness associated with right-sided weakness and ataxia. MANAGEMENT: Despite intravenous antibiotics and antiviral treatment, his condition deteriorated. Magnetic resonance imaging demonstrated spontaneous cervical epidural haematoma (C4-C7) extending down to thoracic (T7) level with associated compression of the spinal cord. He was treated successfully by neurosurgical decompression and made a complete recovery. DISCUSSION: Spinal epidural haematoma is a neurosurgical emergency characterised by extravasation of blood in the spinal epidural space. The clinical presentation particularly in young children can masquerade other conditions such as meningitis. In this article, we discuss our case and review the literature on spontaneous spinal epidural hematoma with an aim to improve awareness of this condition which if not recognised and treated early can lead to significant lifelong morbidity.

Microbial gut overgrowth guarantees increased spontaneous mutation leading to polyclonality and antibiotic resistance in the critically ill.

Polyclonality is defined as the occurrence of different genotypes of a bacterial species. We are of the opinion that these different clones originate within the patient. When infections and outbreaks occur, the terms of polyclonal infections and polyclonal outbreaks have been used, respectively. The origin of polyclonality has never been reported, although some authors suggest the acquisition of different clones from different animate and inanimate sources. We think that the gut of the critically ill patient with microbial overgrowth is the ideal site for the de-novo development of new clones, following increased spontaneous mutation.

Handwashing in the intensive care unit: a big measure with modest effects.

Handwashing is widely accepted as the cornerstone of infection control in the intensive care unit. Nosocomial infections are frequently viewed as an indicator of poor compliance of handwashing. The aim of this review is to evaluate the effectiveness of handwashing on infection rates in the intensive care unit, and to analyse the failure of handwashing. A literature search identified nine studies that evaluated the impact of handwashing or hand hygiene on infection rates, and demonstrated a low level of evidence for the efforts to control infection with handwashing. Poor compliance cannot be blamed as the only reason for the failure of handwashing to control infection. Handwashing on its own does not abolish, but only reduces transmission, as it is dependent on the bacterial load on the hand of healthcare workers. Finally, recent studies, using surveillance cultures of throat and rectum, have shown that, under ideal circumstances, handwashing can only influence 40% of all intensive care unit infections. A randomised clinical trial with the intensive care as randomisation unit is required to support handwashing as the cornerstone of infection control.

Infection in prolonged pediatric critical illness: A prospective four-year study based on knowledge of the carrier state.

OBJECTIVE: This study was performed to determine the rate, timing, and incidence density of infections occurring in a subgroup of patients requiring a prolonged stay in a regional pediatric intensive care unit. DESIGN: Prospective, observational cohort study over 4 yrs. SETTING: This epidemiologic descriptive study was performed in a university hospital 20-bed pediatric intensive care unit. PATIENTS: Critically ill children requiring > or = 4 days of intensive care. INTERVENTIONS: The microbial carrier state of the children was monitored by surveillance cultures of throat and rectum, obtained on admission and twice weekly afterward. MEASUREMENTS AND MAIN RESULTS: Data are presented on a total of 1,241 children, accounting for 1,443 admissions to the unit, corresponding to 18,203 patient days. The median pediatric index of mortality was 0.063 (interquartile range, 0.025-0.131), and the mortality rate in this subset of children was 9.6%. Five hundred twenty children had infections, an overall infection rate of 41.9% (520 of 1,241); 14.5% (180 of 1,241) of the children developed viral and 33.0% (410 of 1,241) developed bacterial/yeast infections. The incidence of bloodstream infection was 20.1 and lower airway infection 9.1 episodes per 1,000 patient days. We found that 13.3% of the children were infected with a bacterial/yeast microorganism acquired on the pediatric intensive care unit; 4.0% (50 of 1,241) of children developed infections due to resistant microorganisms. There were a total of 803 bacterial/yeast infectious episodes, of which 59.8% (480) were due to microorganisms imported in the patients' admission flora. These primary endogenous infections predominantly occurred within the first week of pediatric intensive care unit stay. The other 38.9% (312) were caused by microorganisms acquired on the pediatric intensive care unit. A total of 38 viral infections (24.5%) were acquired during pediatric intensive care unit stay. CONCLUSIONS: Two thirds of all infections diagnosed in children with prolonged illness on pediatric intensive care unit were due to microorganisms present in the patients' admission flora.

Oropharyngeal carriage and lower airway colonisation/infection in 45 tracheotomised children.

BACKGROUND: A study was undertaken to determine the oropharyngeal carrier state of potentially pathogenic microorganisms (PPM) and the magnitude of colonisation and infection rates of the lower airways with these PPM in children requiring long term ventilation first transtracheally and afterwards via a tracheotomy. METHODS: A 5 year, prospective, observational cohort study was undertaken in 45 children (33 boys) of median age 6.4 months (range 0-180) over a 5 year period at the Royal Liverpool Children's NHS Trust of Alder Hey, a university affiliated tertiary referral centre. The children were first admitted to the 20-bed paediatric intensive care unit (PICU) and, following placement of a tracheotomy, they were transferred to a four bedded respiratory ward. The two main indications were neurological disorders and airway obstruction. All children were ventilated transtracheally for a median period of 12 days (range 0-103) and, after placement of the tracheotomy, for a similar period of 12 days (range 1-281). Surveillance cultures of the oropharynx were taken on admission to the PICU and on the day of placement of the tracheotomy. Throat swabs were taken twice weekly during ventilation, both transtracheal and via the tracheotomy. Tracheal aspirates were taken once weekly and when clinically indicated (in cases where the lower airway secretions were turbid). RESULTS: Twenty five patients (55%) had abnormal flora, mainly aerobic Gram negative bacilli (AGNB), particularly Pseudomonas aeruginosa, while the community PPM Staphylococcus aureus was present in the oropharynx of 37% (17/45) of the study population. The lower airways were sterile in six children; the other 39 patients (87%) had a total of 82 episodes of colonisation. "Community" PPM significantly increased once the patients received a tracheotomy, independent of the number of patients enrolled, episodes of colonisation/infection, and the number of colonised/infected patients. "Hospital" PPM significantly decreased after tracheotomy only when episodes were compared. CONCLUSIONS: While P aeruginosa present in the admission flora caused primary endogenous colonisation/infection during mechanical ventilation on the PICU, S aureus not carried in the throat was responsible for the exogenous colonisation/infection once the patients had a tracheotomy. This is in sharp contrast to adult studies where exogenous infections are invariably caused by AGNB. This discrepancy may be explained by chronic underlying conditions such as diabetes, alcoholism, and chronic obstructive pulmonary disease which promote AGNB, whereas the children were recovering following tracheotomy.

Most nosocomial pneumonias are not due to nosocomial bacteria in ventilated patients. Evaluation of the accuracy of the 48 h time cut-off using carriage as the gold standard.

A prospective observational cohort study was undertaken with two endpoints: (1) to compare the time cut-off of 48h and the carrier state criterion for classifying lower airway infections in adult and paediatric long-term ventilated patients, and (2) to evaluate the potential of optimized time cut-offs for characterizing imported and ICU-acquired lower airway infections. All patients admitted to the general and paediatric intensive care units and expected to require mechanical ventilation for a period > or = 3 days were enrolled. Surveillance cultures of throat and rectum were obtained on admission and thereafter twice weekly to distinguish micro-organisms that were imported into the unit from those acquired during the stay on the unit. A total of 130 adults and 400 children were studied. In the adult population, 70% of lower airway infections were classified as ICU-acquired by the 48 h cut-off and 48% by the criterion of carriage; on the paediatric ICU the percentages were 65% and 20%, respectively. To separate imported from ICU-acquired infections, eight days was optimal in the adult population and 10 days in the paediatric population. Sensitivity, specificity, positive predictive value and negative predictive value for a time cut-off of eight days for adults were 86, 77, 80, 83%, respectively, and using 10 days for children were 87, 62, 90, 56%, respectively. The use of the 48 h cut-off rule classifies patients as having nosocomial pneumonia, when in fact the infections are commonly caused by microorganisms carried in by the patients. In contrast, using the carriage method, the proportion of lung infections due to nosocomial bacteria was relatively small and was a late phenomenon. Although in prolonging the time cut-off the difference between the two types of classification was shorter, time cut-offs were still found to be unreliable for distinguishing imported from unit-acquired lower airway infections.

Use of methadone in the morphine-tolerant burned paediatric patient.

We describe the successful use of methadone in the restoration of sedation and provision of analgesia in two morphine-tolerant, paediatric patients who had suffered significant thermal injuries and were undergoing mechanical ventilation. Both patients had exhibited escalating requirements for sedative drugs while undergoing ventilation yet remained inadequately sedated. The introduction of i.v. methadone in place of i.v. morphine in the sedative regimen rapidly and effectively restored a state of sedation. Hyperalgesia and morphine tolerance appear to be associated; it is proposed that methadone acts primarily, under these circumstances, by re-establishing the analgesic state. Such use of methadone in the morphine-tolerant patient also afforded a concomitant sedative-sparing effect.

Gastric pressure response to low dose dopamine infusion in normal man.

The gastric pressure response to distension was measured during intravenous infusion of dopamine at a rate of 2 mug min(-1)kg(-1) over 2h 50min in 5 normal volunteers to determine whether dopamine at this dose potentiated gastric adaptive relaxation, leading to a fall in gastric pressure and thus a potential delay in gastric emptying. This would be of obvious importance in patients being given dopamine at this dose to support renal function and at the same time being fed by nasogastric tube. The pressure response decreased during the first hour in all five subjects (p < 0.01). In 2 it recovered during the third hour to pre-infusion values, but in 2 it remained diminished; in 1 subject the results were equivocal. Circulating dopamine, noradrenaline and adrenaline concentrations all increased during dopamine (p < 0.05), but compared with control there was no difference in plasma free fatty acids, glycerol, cortisol or glucose concentrations. Dopamine at 2 mug min(-1) kg(-1) produced a transient fall in gastric pressure in all subjects, and a persistent fall in some. The changes in gastric pressures were seen at infusion rates that produced no metabolic or inotropic effects.

Pain following thoracotomy. A randomised, double-blind comparison of lumbar versus thoracic epidural fentanyl.

Fifty-eight patients scheduled for elective thoracotomy were randomly allocated to receive fentanyl by either the thoracic or the lumbar epidural route for postoperative analgesia. The infusion rate was adjusted to optimise analgesia. Dose adjustment, pain assessment and the incidence of side effects were monitored by a blinded observer at set times over the 24 hour study period. Similar pain scores were obtained in both groups at all assessment times. In addition, there was no significant difference in dose requirements or incidence of side effects between the two groups. There appears little justification for the use of the generally less familiar, and potentially more dangerous, thoracic approach when fentanyl alone is infused into the epidural space following thoracotomy.