Chloramphenicol toxicity revisited: a 12-year-old patient with a brain abscess.

Chloramphenicol, a broad-spectrum antibiotic, is rarely used in the United States due to its well-described adverse effects. Because of its limited use, many clinicians are unfamiliar with its indications, spectrum of activity, and potential adverse drug effects. We describe a 12-year-old patient who presented after two craniotomies for a persistent brain abscess complicated by long-term chloramphenicol administration. Findings for this patient were consistent with many of the adverse drug effects associated with chloramphenicol, including elevated chloramphenicol serum concentrations, anemia, thrombocytopenia, reticulocytopenia, and severe metabolic acidosis. Rare manifestations of chloramphenicol toxicity that developed in this patient included neutropenia, visual field changes, and peripheral neuropathy. Chloramphenicol administration was discontinued, and hemodialysis was initiated for severe metabolic acidosis. The patient recovered with severe visual field deficits. Although chloramphenicol is rarely indicated, it remains an effective antibiotic. Healthcare providers should become familiar with the pharmacology, toxicology, and monitoring parameters for appropriate use of this antibiotic.

Central venous access via external jugular vein in children.

OBJECTIVE: To determine the success rate and complications of using the external jugular (EJ) vein for central venous access in pediatric patients. METHODS: Prospective cohort study of children who underwent attempts at EJ vein central venous access while receiving care in an 11-bed pediatric intensive care unit at an urban children's hospital. RESULTS: Over a period of 15 months, 50 patients had EJ venous cannulation attempts. Central venous access was achieved in 45 patients (90%). Successful central venous access was performed in 4 children (50%) younger than 1 year and in 36 older children (98%). Catheter-tip malposition on chest radiograph required subsequent line manipulation in 2 patients. No complications of pneumothorax or carotid artery puncture occurred during line insertion. The catheters were used for an average of 7.5 days (range, 1-28 days). Catheter malfunction occurred in 4 (1.21/100 catheter-days), and catheter-related bloodstream infections occurred in 2 patients (6.04/1000 catheter-days). No thrombotic complications were clinically detected. CONCLUSIONS: The EJ vein is a viable site for central venous access with a low complication rate in pediatric patients.

Anti-N-methyl-D-aspartate receptor encephalitis associated with an ovarian teratoma in an adolescent female.

Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis is a recently described paraneoplastic syndrome with prominent neuropsychiatric symptoms. We report a case of NMDA receptor encephalitis in a 15-year-old female related to the development of NMDA receptor autoantibodies triggered by an ovarian teratoma. Removal of the mature teratoma proved curative with eventual resolution of the paraneoplastic disease process and associated psychiatric symptoms. Increasingly, reports of anti-NMDA receptor encephalitis associated with ovarian teratomas in pediatric patients, as well as a novel assay to measure these antibodies, suggest an etiology for this disease process that may be amenable to prompt surgical excision. The clinical presentation, diagnosis, and surgical management of the disease, as well as a review of the literature, are included.

Blunt laryngeal trauma in children: case report and review of initial airway management.

Blunt neck trauma is not common in children, but these injuries can be potentially life-threatening. Presenting symptoms and signs of laryngeal injuries are often subtle, and poor outcomes in regard to voice and airway function are associated with delayed diagnosis. The purpose of this report was to present a pediatric case that illustrates the subtle symptoms and signs of a laryngeal laceration. In this case, the appearance of the laryngeal laceration was similar to the glottis, highlighting the importance of developing airway management guidelines for blunt laryngeal injuries in children.

Late postpartum eclampsia in adolescents.

We present 2 cases of late postpartum eclampsia in adolescents presenting to the pediatric emergency department, neither of whom had any antepartum symptoms of preeclampsia. The purpose of this report is to discuss the importance of a high index of suspicion for preeclampsia in the postpartum adolescent who complains of headache as well as a need to recognize that seizures and more severe neurological sequelae occurring up to 3 weeks postpartum may be eclamptic in origin.

Intrapleural instillation of fibrinolytic agents for treatment of pleural empyema.

OBJECTIVE: To describe the use of intrapleural instillation of fibrinolytic agents as adjunctive therapy for children with complicated pleural effusions and empyema. DESIGN: Retrospective chart review. SETTING: Tertiary care children's hospital in an academic medical center. PATIENTS: Nineteen consecutive patients (median age, 36 months; range, 9 months to 13 yrs) with complicated pleural effusion or empyema by clinical, radiographic, and laboratory criteria who failed to have adequate drainage of the fluid collection by tube thoracostomy. INTERVENTIONS: Patients who remained symptomatic with fever or respiratory distress and who had pleural fluid that could not be drained by tube thoracostomy were treated by intrapleural instillation of either urokinase (13 patients) or streptokinase (six patients) 8-72 hrs after chest tube insertion. MEASUREMENTS AND MAIN RESULTS: Fibrinolytic therapy increased the volume of chest tube drainage in 15 (79%) of 19 patients. Fourteen of the 19 patients were successfully managed without referral for surgical drainage. No significant adverse events or side effects were noted. CONCLUSION: Intrapleural instillation of fibrinolytic agents appears to be an effective and less invasive alternative to surgical drainage for children who have complicated pleural effusions or empyemas that do not drain adequately with tube thoracostomy alone.

Success factors and hurdles in quality improvement in a children's hospital.

A set of nurse/respiratory therapist-driven algorithms developed by a multidisciplinary team with the goal of "liberating" mechanically ventilated pediatric patients more rapidly from the ventilator resulted in sustained improvement over a 47-month period. The difference between expected and observed billed ventilator hour totals was over 22,000 hours (475 hours per month), a 17.5% reduction, which was significant at the P =.03 level by multiple linear regression analysis. Length of stay and mortality rate were unchanged. This difference represents a measure of the unrecognized cost of a nonstandardized approach to the weaning process. This reports reviews this team's success factors and hurdles and offers practical suggestions for pediatric surgeons interested in leading quality improvement initiatives.