Imaging of cerebral complications of extracorporeal membrane oxygenation in infants with congenital heart disease - ultrasound with multimodality correlation.

Cranial ultrasound on neonatal intensive care units is generally performed by intensive care physicians, but radiologists often provide this crucial bedside test to children on specialist paediatric cardiac intensive care units. On a paediatric cardiac intensive care unit, complex congenital cardiac conditions are commonly encountered in both pre- and postoperative scenarios, often with the use of extracorporeal membrane oxygenation (ECMO), which both increases the risks of a number of neurologic complications and results in significant changes in vascular physiology. The aim of this pictorial essay is to discuss cranial ultrasound technique, demonstrate the changes in Doppler flow profiles resulting from veno-arterial extracorporeal membrane oxygenation and congenital cardiac conditions, and illustrate commonly encountered intracranial complications of extracorporeal membrane oxygenation support in congenital cardiac care.

Metabolic Profiling of Children Undergoing Surgery for Congenital Heart Disease.

OBJECTIVE: Inflammation and metabolism are closely interlinked. Both undergo significant dysregulation following surgery for congenital heart disease, contributing to organ failure and morbidity. In this study, we combined cytokine and metabolic profiling to examine the effect of postoperative tight glycemic control compared with conventional blood glucose management on metabolic and inflammatory outcomes in children undergoing congenital heart surgery. The aim was to evaluate changes in key metabolites following congenital heart surgery and to examine the potential of metabolic profiling for stratifying patients in terms of expected clinical outcomes. DESIGN: Laboratory and clinical study. SETTING: University Hospital and Laboratory. PATIENTS: Of 28 children undergoing surgery for congenital heart disease, 15 underwent tight glycemic control postoperatively and 13 were treated conventionally. INTERVENTIONS: Metabolic profiling of blood plasma was undertaken using proton nuclear magnetic resonance spectroscopy. A panel of metabolites was measured using a curve-fitting algorithm. Inflammatory cytokines were measured by enzyme-linked immunosorbent assay. The data were assessed with respect to clinical markers of disease severity (Risk Adjusted Congenital heart surgery score-1, Pediatric Logistic Organ Dysfunction, inotrope score, duration of ventilation and pediatric ICU-free days). MEASUREMENTS AND MAIN RESULTS: Changes in metabolic and inflammatory profiles were seen over the time course from surgery to recovery, compared with the preoperative state. Tight glycemic control did not significantly alter the response profile. We identified eight metabolites (3-D-hydroxybutyrate, acetone, acetoacetate, citrate, lactate, creatine, creatinine, and alanine) associated with surgical and disease severity. The strength of proinflammatory response, particularly interleukin-8 and interleukin-6 concentrations, inversely correlated with PICU-free days at 28 days. The interleukin-6/interleukin-10 ratio directly correlated with plasma lactate. CONCLUSIONS: This is the first report on the metabolic response to cardiac surgery in children. Using nuclear magnetic resonance to monitor the patient journey, we identified metabolites whose concentrations and trajectory appeared to be associated with clinical outcome. Metabolic profiling could be useful for patient stratification and directing investigations of clinical interventions.

[Bacteraemia risk criteria in the paediatric febrile neutropenic cancer patient]. / Criterios de riesgo de bacteriemia en el paciente oncológico neutropénico febril pediátrico.

INTRODUCTION: Cancer patients with febrile neutropenia are not a homogeneous group with respect to risk of bacterial infections. Some authors have proposed that febrile cancer patients with low risk factors of bacteraemia could be managed at home with domiciliary antibiotic treatment. The objectives are: to determine the incidence of bacteraemia in our cancer patients who have febrile neutropenia; and to identify the low-risk factors so that the patients can be managed at home using domiciliary antibiotic treatment. MATERIAL AND METHODS: Clinical review of paediatric haemato-oncology disease admitted to our hospital in 2002 suffering from febrile neutropenia. RESULTS: We describe a total of 62 episodes of febrile neutropenia in 30 patients; 24 episodes in haematology patients and 38 episodes in oncology patients. High-risk criteria are age <1 year, poor bone-marrow recovery, chemotherapy within 10 days of the episode, rapid fast neutropenia, leukaemia in relapse, uncontrolled solid cancer, and cardiac or nephrology disease. Based on the number of risk-factors, patients with two or less risk-factors have an incidence of bacteraemia of 6.7% (1/16) and patients with three or more risk factors have an incidence of bacteraemia of 32.6% (15/46); p<0.05. CONCLUSIONS: Incidence of bacteraemia is similar to the reviewed literature; probability of bacteraemia increases with the number of individual risk factors, and patients with low risk of bacteraemia could be managed on an outpatient basis using domiciliary antibiotic treatment.

Criterios de riesgo de bacteriemia en el paciente oncológico neutropénico febril pediátrico / Bacteraemia risk criteria in the paediatric febrile neutropenic cancer patient

Introducción. Los pacientes oncológicos con neutropenia febril no constituyen un grupo de riesgo homogéneo. Algunos investigadores han propuesto que los pacientes oncológicos con neutropenia febril que reúnen criterios de bajo riesgo de bacteriemia pueden ser tributarios de tratamiento antibiótico domiciliario. Los objetivos son: conocer la incidencia de bacteriemia en nuestra población de pacientes oncológicos febriles y determinar la existencia de criterios de riesgo de bacteriemia de forma que pueda considerarse el manejo extrahospitalario en pacientes seleccionados. Material y métodos. Se efectúa una revisión de las historias clínicas de los enfermos con patología hematooncológica ingresados en nuestro centro con fiebre y neutropenia, durante el año 2002. Resultados. Se describen un total de 62 episodios febriles en 30 pacientes. En 24 casos los pacientes presentaban un tumor de origen hematológico y 38 un tumor sólido. Se definen como criterios de alto riesgo: ser menor de 1 año, escasa respuesta medular, quimioterapia en los 10 días previos, neutropenia de rápida evolución, leucemia en recidiva, tumor sólido no controlado y enfermedad cardíaca o renal asociada. En función del número de criterios de riesgo de cada paciente, se observa que los pacientes que tienen dos o menos criterios de riesgo tienen una incidencia de bacteriemia del 6,7% (1/16), mientras que los que tienen tres o más tienen una incidencia de bacteriemia del 32,6% (15/46) con p<0,05. Conclusiones. La incidencia de bacteriemia en nuestra serie es algo mayor que la bibliografía con predominio de bacilos gramnegativos; la probabilidad de presentar bacteriemia se incrementa de forma proporcional a los criterios de riesgo individuales, y la existencia de subgrupos de pacientes de menor riesgo posibilita que puedan definirse unos criterios de selección para el manejo extrahospitalario de estos pacientes

Introduction. Cancer patients with febrile neutropenia are not a homogeneous group with respect to risk of bacterial infections. Some authors have proposed that febrile cancer patients with low risk factors of bacteraemia could be managed at home with domiciliary antibiotic treatment. The objectives are: to determine the incidence of bacteraemia in our cancer patients who have febrile neutropenia; and to identify the low-risk factors so that the patients can be managed at home using domiciliary antibiotic treatment. Material and methods. Clinical review of paediatric haemato-oncology disease admitted to our hospital in 2002 suffering from febrile neutropenia. Results. We describe a total of 62 episodes of febrile neutropenia in 30 patients; 24 episodes in haematology patients and 38 episodes in oncology patients. High-risk criteria are age <1 year, poor bone-marrow recovery, chemotherapy within 10 days of the episode, rapid fast neutropenia, leukaemia in relapse, uncontrolled solid cancer, and cardiac or nephrology disease. Based on the number of risk-factors, patients with two or less risk-factors have an incidence of bacteraemia of 6.7% (1/16) and patients with three or more risk factors have an incidence of bacteraemia of 32.6% (15/46); p<0.05. Conclusions. Incidence of bacteraemia is similar to the reviewed literature; probability of bacteraemia increases with the number of individual risk factors, and patients with low risk of bacteraemia could be managed on an outpatient basis using domiciliary antibiotic treatment