A model for in situ plan of care for a critically unstable pediatric patient following I-131 MIBG infusion.

Recent clinical trials have moved iodine-131 (I-131) metaiodobenzylguanidine (MIBG) therapy into frontline management of high-risk neuroblastoma. With this expansion, it is reasonable to anticipate the need for intensive care level resuscitations. Radiation exposure remains the greatest risk to health care professionals managing these patients. We combined shock simulation scenario data with actual radiation dosimetry data to create a care model allowing for aggressive, prolonged in situ resuscitation of a critically ill pediatric patient after I-131 MIBG administration. This model will maintain a critical care provider's radiation level below 10% of the annual occupational dose limit (5 mSv, 500 mrem) per patient managed.

Tele-Pediatric Intensive Care for Critically Ill Children in Syria.

BACKGROUND: Armed conflicts can result in humanitarian crises and have major impacts on civilians, of whom children represent a significant proportion. Usual pediatric medical care is often disrupted and trauma resulting from war-related injuries is often devastating. High pediatric mortality rates are thus experienced in these ravaged medical environments. INTRODUCTION: Using simple communication technology to provide real-time management recommendations from highly trained pediatric personnel can provide substantive clinical support and have a significant impact on pediatric morbidity and mortality. MATERIALS AND METHODS: We implemented a "Tele-Pediatric Intensive Care" program (Tele-PICU) to provide real-time management consultation for critically ill and injured pediatric patients in Syria with intensive care needs. RESULTS: Over the course of 7 months, 19 cases were evaluated, ranging in age from 1 day to 11 years. Consultation questions addressed a wide range of critical care needs. Five patients are known to have survived, three were transferred, five died, and six outcomes were unknown. DISCUSSION: Based on this limited undertaking with its positive impact on survival, further development of Tele-PICU-based efforts with attention to implementation and barriers identified through this program is desirable. CONCLUSION: Even limited Tele-PICU can provide timely and potentially lifesaving assistance to pediatric care providers. Future efforts are encouraged.

Extracorporeal Life Support as a Rescue Measure for Managing Life-Threatening Arrythmia and Brugada Syndrome.

We describe the use of extracorporeal cardiopulmonary resuscitation (E-CPR) to transiently stabilize a 3-month-old patient who presented with ventricular tachyarrhythmias leading to spontaneous cardiac arrest. The patient required 4 days of extracorporeal life support (ECLS) where he was diagnosed with probable Brugada syndrome (BS). The patient was discharged home in stable condition after implantable cardioverter defibrillator placement. This case highlights the importance of early transfer to extracorporeal membrane oxygenation (ECMO) center in the setting of unexplained cardiac arrhythmia in a pediatric patient. BS is an autosomal dominant genetic disorder with variable expression characterized by abnormal findings on electrocardiogram (ECG) in conjunction with an increased risk of ventricular tachyarrhythmias and sudden cardiac arrest (SCA). Early management is critical and early consideration to transfer to an institution where extracorporeal life support (ECLS/ECMO) is present to support the patient while further diagnostic work up is in progress is lifesaving.

Successful conservative management of a rare complication of tracheostomy; extensive posterior tracheal false pouch.

INTRODUCTION: With the advent of improved neonatal and pediatric intensive care management, tracheostomy is increasingly performed in children requiring prolonged ventilation. Even though tracheostomy is generally a safe procedure, there remains mortality and morbidity associated with it. OBJECTIVE: We report a rare complication of a tracheostomy tube resulting in extensive erosion and posterior tracheal false pouch secondary to a large tracheostomy tube and high positive end expiratory pressure in a 12-month-old infant. This was managed successfully with conservative treatment. RESULTS: A former 34-week premature infant was transferred to our pediatrics intensive care unit (PICU) with recurrent episodes of cardiopulmonary arrests due to suspected severe tracheobronchomalacia. The patient has bronchopulomonary dysplasia, severe restrictive lung disease and thoracic insufficiency from skeletal dysplasia requiring tracheostomy tube (TT) at two-month-old and mechanical ventilation. The 3.5 NEO TT was gradually upsized to a 5. The PEEP setting at transfer was 18cmH2O. The direct laryngoscopy and bronchoscopy showed moderate tracheomalacia at the innominate artery with a false pouch in the posterior tracheal wall that was 1.1cm below the tracheostomy stoma. A multi-disciplinary discussion including otolaryngology, PICU, Pulmonary Medicine, and Pediatric Surgery decided on conservative management. The false pouch healed and she was transferred back to referring PICU after a 46-day. CONCLUSION: Tracheal wall erosion resulting in a pouch formation is a rare complication, but it should be considered in patients with long term tracheostomy with difficulty ventilation and oxygenation with positional change. DLB is a useful tool in its diagnosis and conservative management can be successful.

Case Report: Neonate With Stridor and Subcutaneous Emphysema as the Only Signs of Physical Abuse.

A stridulous, dysphonic cry with no external signs of trauma is a unique and unusual presenting sign for physical abuse. We report a previously healthy neonate with unremarkable birth history and medical history who presented with stridor and hypopharyngeal perforation due to physical abuse. This case highlights the need for further evaluation for traumatic injuries in the setting of unexplained new-onset stridor and consideration of physical abuse in the differential diagnosis.

Current knowledge of acute lung injury and acute respiratory distress syndrome.

Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) continues to be a major cause of mortality in adult and pediatric critical care medicine. This article discusses the pulmonary sequelae associated with ALI and ARDS, the support of ARDS with mechanical ventilation, available adjunctive therapies, and experimental therapies currently being tested. It is hoped that further understanding of the fundamental biology, improved identification of the patient's inflammatory state, and application of therapies directed at multiple sites of action may ultimately prove beneficial for patients suffering from ALI/ARDS.

Familial clustering of habitual constipation: a prospective study in children from West Virginia.

OBJECTIVE: To investigate familial clustering of habitual constipation in pediatric patients who attended our medical facilities. PATIENTS AND METHODS: Children with the diagnosis of functional, habitual constipation or patients without constipation and their respective family members were prospectively recruited to our study. Constipation was established in all participants using a standard questionnaire (Rome criteria). RESULTS: A total of 112 children and their families participated in the study, of which 37 were probands families (test) and 75 children and their respective family members constituted the control group. A total of 310 family members completed the questionnaire. No significant differences were found between the study and the control groups in age, sex, or family size. Siblings or parents from the study group (probands) had significantly higher rates of constipation compared with the control group (30% vs 7% and 42% vs 9%, respectively; P = 0.001). CONCLUSIONS: Habitual constipation in children seemed to cluster in families. The pathophysiology behind this phenomenon is yet unknown.