Endotracheal intubation can be difficult in the emergent situation, and it is important to have an appropriate backup strategy. Supraglottic airway devices have provided an alternative method for pediatric airway management that is relatively easy to learn, with a high success rate. This issue reviews the use of supraglottic airway devices in pediatric patients including common devices, indications and techniques for placement, and complications associated with their use. The use of supraglottic airway devices in the patient with a difficult airway is also discussed.
Objective: To characterize the cohort of missed sepsis patients since implementation of an electronic sepsis alert in a pediatric emergency department (ED).
Methods: Retrospective cohort study in a tertiary care children’s hospital ED from July 1, 2014, to June 30, 2017. Missed patients met international consensus criteria for severe sepsis requiring intensive care unit admission within 24 hours of ED stay but were not treated with the sepsis pathway/order set in the ED. We evaluated characteristics of missed patients compared with sepsis pathway patients including alert positivity, prior intensive care unit admission, and laboratory testing via medical record review. Outcomes included timeliness of antibiotic therapy and need for vasoactive medications.
Results: There were 919 sepsis pathway patients and 53 (5%) missed patients during the study period. Of the missed patients, 41 (77%) had vital signs that flagged the sepsis alert. Of these 41 patients, 13 (32%) had a documented sepsis huddle where the team determined that the sepsis pathway was not indicated and 28 (68%) had no sepsis alert-related documentation. Missed patients were less likely to receive timely antibiotics (relative risk, 0.4; 95% confidence interval, 0.3-0.7) and more likely to require vasoactive medications (relative risk, 4.3; 95% confidence interval, 2.9-6.5) compared with sepsis patients.
Conclusions: In an ED with an electronic sepsis alert, missed patients often had positive sepsis alerts but were not treated for sepsis. Missed patients were more likely than sepsis pathway patients to require escalation of care after admission and less likely to receive timely antibiotics.
Mannitol is a commonly used osmotherapy agent in raised intracranial pressure. However, the side effects of mannitol are significant. In traumatic brain injury (adult and pediatric), hypertonic saline (3%) shows varied results in comparison with 20% mannitol. We compared the effect of 3% hypertonic saline versus 20% mannitol (using common dosing strategies) on raised intracranial pressure in pediatric acute CNS infections.
Design:
Open-label randomized controlled trial.
Setting:
PICU of a quaternary care academic institute.
Patients:
Children 1–12 years old, with raised intracranial pressure and modified-Glasgow Coma Scale scores less than or equal to 8, were enrolled.
Interventions:
Patients were randomly assigned to 20%-mannitol (n = 28), 0.5 gram/kg/dose versus 3%-hypertonic saline (n = 29), 10 mL/kg loading followed by 0.5–1 mL/kg/hr infusion. An intraparenchymal catheter was used to monitor the intracranial pressure. The primary outcome was the proportion of patients achieved target average intracranial pressure less than 20 mm Hg during 72 hours. Secondary outcomes were interventions, morbidity, and mortality.
Measurements and Main Results:
The proportion of patients with target average intracranial pressure (< 20 mm Hg) was higher in hypertonic saline-group as compared to mannitol-group (79.3% vs 53.6%; adjusted hazard ratio 2.63; 95% CI: 1.23–5.61). Mean (± SE) reduction of intracranial pressure (–14.3 ± 1.7 vs –5.4 ± 1.7 mm Hg; p ≤ 0.001) and elevation of cerebral perfusion pressure (15.4 ± 2.4 vs 6 ± 2.4 mm Hg; p = 0.007) from baseline were significant in hypertonic saline-group. Mean (± SE) intracranial pressure over 72 hours was lower (14 ± 2 vs 22 ± 2 mm Hg; p = 0.009), and cerebral perfusion pressure was higher (65 ± 2.2 vs 58 ± 2.2; p = 0.032) in hypertonic saline-group. Hypertonic saline-group had higher modified-Glasgow Coma Scale score at 72 hours (median, interquartile range 10; 7–11 vs 7; 3–9; p = 0.003), lower mortality (20.7% vs 35.7%; p = 0.21), shorter duration of mechanical ventilation (5 vs 15 d; p = 0.002), and PICU stay (11 vs 19 d; p = 0.016) and less severe neurodisability at discharge (31% vs 61%; p = 0.049).
Conclusions:
In pediatric acute CNS infections, 3%-hypertonic saline was associated with a greater reduction of intracranial pressure as compared to 20% mannitol.
Pancreatic injury is multifactorial and potentially devastating for critically ill children. We aimed to evaluate whether serum amylase and lipase among critically ill children could serve as an independent biomarker to predict pancreatic injury.
Design:
Retrospective cohort.
Setting:
PICU of a tertiary, pediatric medical center.
Patients:
Seventy-nine autopsies.
Interventions:
None.
Measurements and Main Results:
A group of 79 children who died of different causes were investigated by autopsy. They were divided into pancreatic injury group and pancreatic noninjury group according to autopsy findings. Data based on patients’ demographics, vital signs, laboratory findings, and clinical features at admission were collected and compared. Logistic regression was used to identify predictive factors for pancreatic injury. Receiver operating characteristic curve was constructed for assessing serum amylase and serum lipase to predicting pancreatic injury. Forty-one patients (51.9%) exhibited the pathologic changes of pancreatic injury. The levels of lactate, erythrocyte sedimentation rate, alanine transaminase, aspartate transaminase, and troponin-I in the injury group were significantly higher than that in the noninjury group, whereas the level of calcium was significantly lower than that in the noninjury group (p < 0.05). Multivariable logistic regression analysis showed that serum amylase, serum lipase, and septic shock were significantly associated with the occurrence rate of pancreatic injury. The statistically significant area under the curve results were as follows: serum amylase: area under the curve = 0.731, at a cutoff value of 97.5, sensitivity = 53.7, and specificity = 81.6; and serum lipase: area under the curve = 0.727, at a cutoff value of 61.1, sensitivity = 36.6, and specificity = 92.1.
Conclusions:
Serum amylase and lipase could serve as independent biomarkers to predict pancreatic injury in critically ill children.
Critically ill children with sepsis may develop catastrophic thrombotic and hemorrhagic syndrome of disseminated intravascular coagulopathy as a final common pathway.
Objectives:
Evaluation of the outcome of early hemostatic management of disseminated intravascular coagulopathy in patients with severe sepsis/septic shock admitted to PICU, before the development of clinically overt disseminated intravascular coagulopathy.
Design:
Prospective interventional, open label randomized controlled clinical trial.
Setting:
PICU at Alexandria University Children’s Hospital.
Patients:
The study included 80 patients with proven severe sepsis/septic shock in nonovert disseminated intravascular coagulopathy stage. They were randomly assigned into two groups (group 1 and group 2).
Interventions:
Specific intervention was applied for group 1 (plasma transfusion, low-dose unfractionated heparin, and tranexamic acid).
Measurements:
All patients had assessment of Pediatric Index of Mortality 2 score, Pediatric Logistic Organ Dysfunction score, inotropic score, routine laboratory, and hemostatic tests including fibrin degradation products and D-dimers. Disseminated intravascular coagulopathy risk assessment scores were calculated on daily basis.
Results:
Mortality rate was significantly higher in group 2. Progression to overt disseminated intravascular coagulopathy was significantly more common among group 2 patients than group 1 (45% and 10%, respectively) (p < 0.0001). Disseminated intravascular coagulopathyRisk Assessment Scores were significantly higher on the second and fifth days among group 2 patients. The initial specific hemostatic intervention was the only significant predictor of survival and prevention of progression to overt disseminated intravascular coagulopathy.
Conclusions:
Our results suggest that early use of a combination of fresh frozen plasma transfusion, low-dose heparin, and tranexamic acid in children with severe sepsis/septic shock in the “window of opportunity” before the development of overt disseminated intravascular coagulopathy stage was associated with better outcome for survival and prevention of progression to overt disseminated intravascular coagulopathy, with no increase in bleeding risk. Larger multicenter studies are needed to further prove this practice.
entrectinib (Rozlytrek) authorized by European Commission in adults and children ≥ 12 years old for treatment of solid tumors in patients who are NTRK gene fusion-positive who have disease that is locally advanced, metastatic or where surgical resection may result in severe morbidity, and who have no history of NTRK inhibitor therapy and no other satisfactory treatment options (European Medicines Agency [EMA] 2020 Sep 11)
wide spectrum of clinical features in children and adolescents with SARS-CoV-2 infection admitted to intensive care in United Kingdom (BMJ 2020 Aug 27)
low platelet count, fatigue, headache, myalgia, sore throat, reduced consciousness, lymphadenopathy, obesity, and composite of Black, South Asian, and unspecified race/ethnicity may each be associated with MIS-C in children hospitalized with COVID-19 (BMJ 2020 Aug 27)
zinc sulfate 5 mg and 10 mg are as effective for resolving diarrhea as 20 mg dose and reduce risk of vomiting within 30 minutes of treatment in children < 5 years old with acute diarrhea (N Engl J Med 2020 Sep 24)
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Paediatrics and Child Health Volume 30, Issue 10, October 2020, Pages 361-363
Abstract
Children die from asthma. When this happens, in almost all cases, there are avoidable and modifiable risk factors. Healthcare professionals can take simple steps, when we see children with asthma, that may prevent a death. These include identifying risk from a good history, ensuring children have the right treatment (and that they know how to take it), seeing hospitalisation as a trigger to educate children and families, and addressing wider determinants of health.
Paediatrics and Child Health Volume 30, Issue 10, October 2020, Pages 356-360
Abstract
Approximately 25% of children with epilepsy are drug-resistant. Lack of seizure control in infants impacts developmental outcome and places a large burden on NHS services, but there are few data to guide optimal treatment in infants with drug-resistant epilepsy. Ketogenic diet therapy is an effective non-pharmacological treatment option for individuals with drug-resistant epilepsy and reports of its use in infants have increased over the last decade. This article gives an overview of use of ketogenic diet therapy in infants with epilepsy, including a history of dietary treatment, evidence for efficacy in infants, patient selection and clinical and dietetic management.
Paediatrics and Child Health Volume 30, Issue 10, October 2020, Pages 350-355
Abstract
Cyclical vomiting syndrome (CVS) was described over 100 years ago, but it is often underdiagnosed and undertreated, even after a diagnosis is made. It is relatively common, affecting almost 2% of school-age children in some studies. Although it is traditionally seen as a childhood disease related to migraine, CVS does occur in adults. The main characteristic of CVS is the stereotypical recurrent nature of episodes of intense nausea and vomiting lasting from few hours to few days and followed by a complete resolution of symptoms. The diagnosis is predominantly a clinical one and there are internationally accepted criteria for diagnosis. The management of acute attacks of CVS aims to relieve symptoms, reduce the duration of attacks and prevent dehydration and hospital admission. Management also includes appropriate counselling on healthy lifestyle, provision of individual management plans and preventive medications. The aim of management is to reduce the number of attacks and improve quality of life. About half the children with CVS start to have migraine with or without aura in late adolescence and around 40% continue with CVS into early adult life. This article is aimed at healthcare professionals looking after children with CVS and describes the clinical presentation, the criteria required for diagnosis and outlines the different treatment options.
To explore the imaging features, key diagnostic points, classification, treatment, and prognosis of cervical lymphatic malformation.
Methods
Overall, 320 patients diagnosed with cervical lymphatic malformation were retrospectively analysed in our hospital between 1 January 2014 and 31 December 2017. Imaging modalities included colour Doppler ultrasound, magnetic resonance imaging, and contrast-enhanced computed tomography. Cervical lymphatic malformations were classified by cyst diameter. Treatments included interventional therapy, surgery, and expectant treatment.
Results
Cervical lymphatic malformation was identified in 320 of 1192 patients with lymphatic malformation. Four were excluded due to misdiagnosis by ultrasonography. Cervical lymphatic malformation was classified as mixed, macrocystic, and microcystic in 184 (57.5%), 117 (36.56%), and 19 (5.94%) patients, respectively. Sixty-four (20%), ten (3.12%), seven (2.19%), and three (0.94%) patients experienced intracystic haemorrhage, infection, concurrent intracystic haemorrhage and infection, and calcification, respectively. Among 260 (81.25%) patients who underwent interventional sclerotherapy, 163 (50.94%) received it once and 96 (30%) received it two or more times. Twenty-eight (8.75%), five (1.56%), and 27 (8.44%) patients underwent surgical resection, interventional sclerotherapy plus surgery, and expectant management, respectively.
Conclusions
Ultrasonography is useful for diagnosing definite cervical lymphatic malformation. Interventional therapy is the first choice for children with confirmed cervical lymphatic malformation.
Paediatrics 