Treatment of cardiogenic pulmonary oedema by helmet-delivered non-invasive pressure support ventilation in children with scorpion sting envenomation.

INTRODUCTION: The aim of this study was to evaluate the feasibility of non-invasive positive pressure ventilation through a new interface helmet in the treatment of cardiogenic pulmonary oedema due to scorpion sting envenomation in children. CLINICAL PICTURE: Three patients presented with fever, and respiratory distress following scorpion sting. Their cardiac enzymes were abnormal. Electrocardiogram (ECG) of 3 patients showed features of myocardial strain with ST elevation. Bedside chest X-ray taken in emergency showed marked bilateral infiltrates suggestive of pulmonary oedema. M-mode, two-dimensional colour-flow Doppler echocardiogram showed left ventricular dysfunction. TREATMENT AND OUTCOME: At paediatric intensive care unit admission, they were treated with antivenom, prazosin (0.03 mg/kg/dose), dopamine (15 mcg/kg/ min), dobutamine (10 mcg/kg/min) and nitroprussid (1 mcg/kg/min). Epinephrine (0.1 mcg/kg/ min) were added later. They were hypoxic and dyspnoeic. A slight sedation was induced with ketamine and/or midazolam. Non-invasive pressure support ventilation (NPSV) was delivered via the helmet by means of an intensive care unit ventilator. We evaluated the effect of NPSV delivered by helmet on oxygenation, respiratory rate, haemodynamics, complications and outcome. An improvement of oxygenation was observed within 2 hours of treatment.The helmet was well tolerated by all the children. No complications occurred in the 3 patients. CONCLUSION: This new approach of delivering NPSV through a helmet allows the successful treatment of cardiogenic pulmonary oedema in children with scorpion sting envenomation, assuring a good tolerance without complications. Future studies are needed before recommending the extensive application of this technique in all cases of cardiogenic pulmonary oedema due to scorpion sting envenomation.

Interleukin-10 and -12 in human milk at 3 stages of lactation: a longitudinal study.

This study was undertaken to analyze postpartum changes in concentrations of interleukin (IL)-10 and IL-12 through the 3 stages of lactation. A total of 87 human milk samples were collected from 29 healthy mothers during the colostrum (0-3 days), early milk (14-17 days), and mature milk (44-47 days) phases. Enzyme-linked immunosorbent assay tests were performed on the milk samples. IL-10 was detected in 7 and IL-12 in 4 of the colostrum samples. In the transitional milk samples, IL-10 was present in 4 and IL-12 in 2; however, both of these cytokines became undetectable in mature milk samples. The decrease in concentrations of IL-10 and IL-12 was statistically significant during the postpartum period (P=.001 and P=.024, respectively). IL-10 levels in the colostrum samples were higher than in the transitional samples (P=.018, with use of the post hoc test). No statistically significant differences between IL-12 levels were noted in the colostrum samples and the transitional samples (P=.068, with use of the post hoc test). A negative correlation was observed between concentrations of IL-10 in colostrum and the total number of pregnancies (R=-.401; P=.031). The findings of the present study suggest that mean concentrations of IL-10 and IL-12 are decreased in human milk as lactation continues through its 3 phases.

Bone calcium changes during diabetic ketoacidosis: a comparison with lactic acidosis due to volume depletion.

In this study, we aimed to compare bone calcium system changes from children with diabetic ketoacidosis or acute metabolic acidosis due to dehydration to find out the relative contribution of metabolic acidosis and diabetes-related factors on expected negative calcium balance. We studied a set of non-invasive parameters of bone remodeling in 16 children with diabetic ketoacidosis due to new onset type 1 diabetes and 25 children with acute metabolic acidosis due to dehydration complicating acute gastroenteritis before and after the correction of acidosis. The two groups of subjects were matched for age, sex, pubertal status, and degree of metabolic acidosis and dehydration. A group of 18 age and sex-matched healthy children served as the control group. Plasma ionized calcium levels were increased in both groups, significantly more so in diabetic ketoacidosis. While osteoblastic markers, osteocalcin and alkaline phosphatase, were depressed to a comparable degree in both groups, urinary calcium/creatinine ratio and hydroxyproline excretion were significantly greater in diabetic ketoacidosis. No significant changes in calcitrophic hormone (intact PTH, calcitonin, 25-hydroxy vitamin D3) levels were observed. All study parameters except for serum phosphate levels behaved in parallel in both clinical conditions, and abnormalities disappeared with the correction of acidosis except for IGF-1, which remained low in diabetic subjects. In conclusion, our results suggest that, in diabetic ketoacidosis, the observed severe negative calcium balance occurred through diminished bone formation mediated by metabolic acidosis per se and increased bone mineral dissolution and bone resorption because of severe insulin deficiency and secondarily via metabolic acidosis. Observed changes appear to be independent of calcitrophic hormones.

The use of surfactant in children with acute respiratory distress syndrome: efficacy in terms of oxygenation, ventilation and mortality.

PURPOSE: The aim of this prospectively designed study was to investigate the efficacy of surfactant (S) for acute respiratory distress syndrome (ARDS) in children. MATERIALS AND METHODS: Children with ARDS were included in this study. Surfactant (Survanta, Abbott, USA) was given intratracheally at a dose of 150 mg/kg every 12 h for a total of two doses. During the study period none of the patients received permissive hypercapnia, high frequency ventilation, nitric oxide or ECMO. Peak inspiratory pressure (PIP), positive end expiratory pressure (PEEP), ventilation rate, mean airway pressure, tidal volume (TV), Murray index, PaO2/FiO2, ventilation index (VI), oxygen index (OI) and arterial oxygen tension difference (A-aDO2) were measured before and 48 h after surfactant treatment. Duration of mechanical ventilation therapy, duration in paediatric intensive care unit (PICU) and mortality rate were recorded. RESULTS: Among the 36 children who met the inclusion criteria, 12 were treated with surfactant. The mean age was 72.5+/-56.2 months; 47% of children were male. Infants were ventilated by pressure-controlled ventilators whereas for older children volume-controlled ventilators were used. Sepsis (42%) was the main predisposing factor followed by pneumonia (25%) and malignancy (17%). The baseline characteristics including age, predisposing factors, gender, PIP, PEEP, A-aDO2, PaO2/FiO2, OI, TV, VI and Murray index were similar in the surfactant and non-surfactant (NS) group (p>0.05). There were significant improvements in PIP, PEEP, A-aDO2, PaO2/FiO2, OI, TV, VI and Murray index in the surfactant group after surfactant treatment compared with NS group (p<0.05). Duration of PICU stay and ventilator treatment was longer in NS group (14+/-3.7, 1.8+/-3.2 days vs. 9.2+/-3.1, 8.6+/-1.9 days), (p<0.05). Mortality rate was 42% in surfactant compared with 63% in the NS group, (p>0.05). Children in the surfactant group lived significantly longer (p<0.05). CONCLUSIONS: Modified natural surfactant is an effective treatment option in children with ARDS for improving gas exchange, decreasing the use of ventilatory support and increasing survival time.