Effect of corticosteroids on survival of children with acquired immunodeficiency syndrome and Pneumocystis carinii-related respiratory failure.

The medical records of patients with acquired immunodeficiency syndrome were reviewed to evaluate the effect of our adoption to the pediatric population of the National Institutes of Health recommendation for adjunctive corticosteroid therapy in adults with Pneumocystis carinii pneumonia. In 21 episodes of P. carinii-related respiratory failure, only adjunctive corticosteroids were associated with a significant improvement in survival to successful removal of the tracheal tube, from a historical rate of 11% to 91%.

Respiratory failure in children with acquired immunodeficiency syndrome and acquired immunodeficiency syndrome-related complex.

Acute respiratory failure has a high mortality in patients with acquired immunodeficiency syndrome (AIDS). This study was undertaken to determine the etiology of acute respiratory failure and the outcome of children with AIDS and AIDS-related complex. Records of 31 children with AIDS or AIDS-related complex admitted to the pediatric intensive care unit for acute respiratory failure throughout a 46-month period were reviewed. Acute respiratory failure was due to Pneumocystis carinii pneumonia in 13, cytomegalovirus pneumonia in six, bacterial pneumonia in five, severe bacterial sepsis in four, Candida pneumonia in two, and a giant cell pneumonia in one patient. In addition, 11/19 patients with acute respiratory failure due to P carinii pneumonia or cytomegalovirus had superinfections with bacteria or Candida. Of the total of 19 primary and secondary bacterial infections, Pseudomonas aeruginosa was responsible in ten and Klebsiella pneumoniae in three children. Five children (16%) survived until pediatric intensive care unit discharge; three died within 6 months. The causes of acute respiratory failure were not significantly different in survivor and nonsurvivor groups. It is concluded that, in addition to P carinii pneumonia and cytomegalovirus pneumonia, bacterial infections (especially due to Pseudomonas and other Gram-negative organisms) are important causes of respiratory failure. The high mortality and grim ultimate prognosis seen may have implications for pediatricians attempting to identify the proper limits of medical intervention for this group of patients.

Brain death: considerations for pediatrics.

During the past 15 years, the concept that irreversible cessation of brain function is synonymous with death of the individual has become generally accepted, both by medical professionals and by society at large. We review the rationale and evidence supporting this principle, with special attention to pediatric applications. The use and reliability of various confirmatory tests are discussed, and specific brain death criteria are suggested.

Central nervous system anoxic-ischemic insult in children due to near-drowning.

An analysis of admission and follow-up CT examinations of the brains of 17 children who had nearly drowned (15 of whom were comatose and two of whom were conscious on admission) indicated that a normal initial CT scan is common in the majority of comatose patients, a severe neurologic outcome may develop in spite of a normal initial CT examination, and abnormal initial or follow-up CT findings indicate the strong but not inevitable probability of a severe neurologic outcome. We conclude that when there is no head trauma, an initial CT examination is not necessary. Prediction of the clinical outcome cannot be made on the basis of the initial CT findings.

Radionuclide cerebral perfusion scintigraphy in determination of brain death in children.

We evaluated a radionuclide scintigraphic technique for imaging relative cerebral perfusion in 18 children who had no evidence of cortical and brainstem function. Patients without scintigraphic evidence of cerebral perfusion all later met criteria for diagnosis of brain death. Patients who failed to satisfy brain-death criteria had persistent scintigraphic evidence of cerebral perfusion. Seven patients with normal scintigraphic studies were being treated with barbiturates and hypothermia at levels that attenuated or completely suppressed EEG activity. Four patients without scintigraphic evidence of cerebral perfusion had mean arterial pressures (MAP) higher than (54.8 +/- 7.6 torr) intracranial pressures (ICP) at the time of scintigraphic study, suggesting that ICP in excess of MAP is not the sole explanation for the absence of cerebral perfusion. Radionuclide cerebral perfusion scintigraphy (RCPS) is a rapid, portable, accurate test that appears to be useful in the diagnosis of brain death in the pediatric population.

Paraldehyde therapy in childhood status epilepticus.

Intravenous (IV) diazepam or phenobarbital is generally accepted as the initial treatment of choice for status epilepticus in children. The risk of severe respiratory depression with either drug is a major problem, particularly in emergency centers that do not have appropriate equipment or personnel for rapid endotracheal intubation of infants. While some pediatric centers are not reluctant to recommend paraldehyde for secondary therapy in status epilepticus, most texts and publications recommend it only as a last resort because of reported complications. We investigated the benefits and complications from varied dosing regimens in 16 trials. The results indicated no significant complications in patients who did not receive an initial IV bolus. Even though treatment with phenobarbital or diazepam and phenytoin sodium had failed, 37% had a good therapeutic response.

Surveillance study of pediatric patients receiving respiratory therapy, using the Bain circuit system.

The Bain circuit, which has been used previously for anesthesia, was adopted for long-term mechanical ventilation for infants and children in a pediatric intensive care unit. When this ventilation system is used, humidifier temperatures must be kept at temperatures significantly lower than the recommended 50 degrees C to avoid excessive airway temperatures and thermal injury. Routine infection control measures such as daily changing of respiratory therapy equipment and the use of sterile water in Cascade humidifiers were enforced. It was demonstrated that the use of the Bain circuit with a Cascade humidifier kept at a temperature of 36.9 degrees +/- 1.9 degrees C was not associated with nosocomial infection of the lower respiratory tract.

Control of infection and techniques of isolation in the pediatric intensive care unit.

The control of nosocomial infection in a pediatric intensive care unit is important not only because of the serious nature of the patient's condition, but also because of the greater staff-patient contact and inevitable crowding of patients, staff, and equipment. In order to control the spread of nosocomial infection, the modes of transmission and the principles of infection control must be understood. Each patient with an infectious disease must be considered to be a potential source of nosocomial disease, and measures of infection control must be individualized for the infectious disease and for the level of intensive care required. The infection control committee of the hospital is an excellent source of advice in formulating care plans. Although compromises will inevitable be made between the ideals of infection control and intensive care needs, certain principles must be followed, the most important of which is proper handwashing between contacts and with patients.

Modified Mapleson D system for long-term mechanical ventilation of infants and children.

The Bain circuit, a modified Mapleson D system, is a lightweight, simple circuit which has been used primarily for anesthesia. This report describes its use for long-term mechanical ventilation for infants and children. The use of this circuit improved warming of inspired gas reducing patient heat loss and, additionally, it was believed to have resulted in increased humidity of the inspired gas. There were no instances of accidental extubation nor were any of the endotracheal tubes blocked by inspissated secretions. Temperatures of the humidifiers had to be lower than conventionally recommended but this did not result in any nosocomial infections. This circuit is an effective and safe circuit to use for long-term mechanical ventilation of children.