BACKGROUND:Infections represent a severe complication of extracorporeal membrane oxygenation (ECMO). Aim of the present study was to describe the epidemiology of infections acquired during ECMO in a ...tertiary care children’s hospital.
METHODS:Retrospective analysis of clinical records of patients undergoing ECMO between January 2009 and December 2016. For each patient, data were collected on clinical characteristics, modality of ECMO support, site and etiology of documented infections, survival within 1 week after ECMO weaning and/or at pediatric intensive care unit discharge. These data were employed to evaluate overall infection prevalence, infection rate expressed as episodes/1000 days of support and cumulative risk estimates of infections occurring during ECMO.
RESULTS:During the study period, a total of 46 ECMO procedures were performed. The overall prevalence of documented infections was 33%, with an infection rate of 27.22 and a cumulative risk of 55%. Bloodstream infection represented the most frequently documented (53%), followed by pneumonia (40%). Coagulase-negative staphylococci and Pseudomonas aeruginosa prevailed as isolated pathogens. Overall survival was 59%, and 46% among those developing infections during ECMO.
CONCLUSIONS:ECMO is a procedure at high risk for infections. Our data, limited to 1 center, represent a recent benchmark for further investigations.
Awake regional anesthesia (RA) is a viable alternative to general anesthesia (GA) for infants undergoing lower abdominal surgery. Benefits include lower incidence of postoperative apnea and avoidance ...of anesthetic agents that may increase neuroapoptosis and worsen neurocognitive outcomes. The General Anesthesia compared to Spinal anesthesia study compares neurodevelopmental outcomes after awake RA or GA in otherwise healthy infants. The aim of the study is to describe success and failure rates of RA and report factors associated with failure.
This was a nested cohort study within a prospective, randomized, controlled, observer-blind, equivalence trial. Seven hundred twenty-two infants 60 weeks or less postmenstrual age scheduled for herniorrhaphy under anesthesia were randomly assigned to receive RA (spinal, caudal epidural, or combined spinal caudal anesthetic) or GA with sevoflurane. The data of 339 infants, where spinal or combined spinal caudal anesthetic was attempted, were analyzed. Possible predictors of failure were assessed including patient factors, technique, experience of site and anesthetist, and type of local anesthetic.
RA was sufficient for the completion of surgery in 83.2% of patients. Spinal anesthesia was successful in 86.9% of cases and combined spinal caudal anesthetic in 76.1%. Thirty-four patients required conversion to GA, and an additional 23 patients (6.8%) required brief sedation. Bloody tap on the first attempt at lumbar puncture was the only risk factor significantly associated with block failure (odds ratio = 2.46).
The failure rate of spinal anesthesia was low. Variability in application of combined spinal caudal anesthetic limited attempts to compare the success of this technique to spinal alone.
Background
Veno-venous extracorporeal membrane oxygenation (ECMO) is probably the preferable configuration to assist children with respiratory failure who do not respond to maximized conventional ...therapies. The single-vessel, double-lumen approach through the internal jugular vein is extremely advantageous, especially in infants, where femoral access presents limitations related to the small dimensions of the veins. In case of emergencies, ECMO might need to be started at the bedside, without the availability of fluoroscopic guidance. To our knowledge, a completely percutaneous approach has not been reported before in children younger than 1 year and weighing less than 5 kg.
Methods
We describe 3 cases of emergency bedside, percutaneous, bicaval double-lumen cannulation under real-time transthoracic ultrasound control in 2 neonates and 1 infant.
Results
In our experience, this approach proved to be safe, effective and time saving, while minimizing bleeding from the cannula insertion site. Cannulation times, from decision making to the beginning of ECMO flow, were 30, 28, 25 minutes respectively, from patient 1 to 3. We do not report any cannula-related injury to vessels and heart structures.
Conclusions
Our preliminary data suggest that, with the described precautions, percutaneous, echo-guided, bicaval double-lumen cannulation in neonates and infants could be effective and free from major complications. Further evaluation should be warranted in the neonatal population.
The paper reports on the use of therapeutic drug monitoring for linezolid in the decision-making process to continue or not its administration in an infant. Linezolid is effective against ...methicillin-resistant Staphylococcus aureus but is off-label in pediatrics. The use of therapeutic drug monitoring, as in our case, allows an informed decision on administration of the drug (in this case on withdrawal) increasing patients safety.
Abstract
Background:
Postoperative apnea is a complication in young infants. Awake regional anesthesia (RA) may reduce the risk; however, the evidence is weak. The General Anesthesia compared to ...Spinal anesthesia study is a randomized, controlled trial designed to assess the influence of general anesthesia (GA) on neurodevelopment. A secondary aim is to compare rates of apnea after anesthesia.
Methods:
Infants aged 60 weeks or younger, postmenstrual age scheduled for inguinal herniorrhaphy, were randomized to RA or GA. Exclusion criteria included risk factors for adverse neurodevelopmental outcome and infants born less than 26 weeks gestation. The primary outcome of this analysis was any observed apnea up to 12 h postoperatively. Apnea assessment was unblinded.
Results:
Three hundred sixty-three patients were assigned to RA and 359 to GA. Overall, the incidence of apnea (0 to 12 h) was similar between arms (3% in RA and 4% in GA arms; odds ratio OR, 0.63; 95% CI, 0.31 to 1.30, P = 0.2133); however, the incidence of early apnea (0 to 30 min) was lower in the RA arm (1 vs. 3%; OR, 0.20; 95% CI, 0.05 to 0.91; P = 0.0367). The incidence of late apnea (30 min to 12 h) was 2% in both RA and GA arms (OR, 1.17; 95% CI, 0.41 to 3.33; P = 0.7688). The strongest predictor of apnea was prematurity (OR, 21.87; 95% CI, 4.38 to 109.24), and 96% of infants with apnea were premature.
Conclusions:
RA in infants undergoing inguinal herniorrhaphy reduces apnea in the early postoperative period. Cardiorespiratory monitoring should be used for all ex-premature infants.
To report the successful management of end-stage hypercapnic respiratory failure through the association of noninvasive mechanical ventilation and a novel automated device (Decapsmart) of low-flow ...veno-venous extracorporeal CO2 removal.
Case report.
Pediatric intensive care unit at a tertiary care children's hospital.
A pediatric patient affected by bronchiolitis obliterans with refractory hypercapnic respiratory failure. The patient received successful lung transplantation after respiratory support with noninvasive mechanical ventilation and a novel automated device of low-flow veno-venous extracorporeal CO2 removal.
Treatment of end-stage hypercapnic respiratory failure with the association of noninvasive ventilation and low-flow veno-venous extracorporeal CO2 removal as a bridge to lung transplantation.
Respiratory support controlling hypercapnia, limiting volutrauma, barotraumas, and preventing the incidence of ventilator-associated pneumonia/lung colonization.
Noninvasive mechanical ventilation and Decapsmart have proven efficacious in managing refractory hypercapnic respiratory failure in a pediatric patient awaiting lung transplantation.
To present and compare with literature our experience with an electronic anesthesia-related incident reporting form as a quality control measure at Gaslini Children's Hospital over a 19-month period.
...All events that occurred between March 2009 and September 2010 were recorded. We adopted an electronic reporting form included in the online recording process of every anesthetic procedure. Events were divided into near misses and adverse events. Adverse events were further divided into incidents, minor events, and major events. Patients were divided into three age-groups: <1, between 1 and 3, and >3 years.
A total of 12,850 anesthetics were performed. Eight (0.06%) near misses and 108 (0.8%) adverse events were reported. Adverse events occurred more frequently in infants. Of 108 events, 35 (32.4%), 61 (56.5%), and 12 (11.1%) were classified as incidents, minor, and major events, respectively. Of all the adverse events, 66 (61%) were respiratory, 27 (25%) organizational, six (5%) drug-related, four (4%) cardiocirculatory, and five (5%) miscellaneous.
Infants were at the highest risk to experience adverse events. Although experimental electronic incident reporting proved to be feasible, there is reason to suspect that there was underreporting of near misses. Overreporting of near miss events may be enhanced by easier and more straightforward reporting forms as well as by better education for anesthetic providers about the importance of recognizing and reporting near misses.
Summary
Background: Clonidine has the potential to significantly prolong the duration of caudal epidural anesthesia. We investigated the effect of the addition of clonidine to the MLAC of ...levobupivacaine in a randomized controlled dose–response trial.
Methods: A group of 120 children aged <6 years of age received caudal anesthesia with levobupivacaine and 1, 2, or 3 μg·kg−1 of clonidine. The MLAC was determined according to a Dixon‐Massey protocol. The primary outcome was effective surgical anesthesia. Secondary outcomes were the duration of postoperative analgesia, postoperative pain scores, clonidine side effects, and time to hospital discharge.
Results: The MLAC of caudal levobupivacaine was 0.106%, 0.077%, and 0.035% with 1, 2, and 3 μg·kg−1 of clonidine, respectively. There were significant dose‐dependent increases in median duration of analgesia. The incidence of delayed discharge, somnolence, and PONV was significantly increased in the 3 μg·kg−1 of clonidine group.
Conclusions: Clonidine produces a local anesthetic sparing effect with a dose‐dependent decrease in levobupivacaine MLAC for caudal anesthesia. In addition, there is a dose‐dependent prolongation of postoperative analgesia following lower abdominal surgery in children. A dose of 2 μg·kg−1 of clonidine provides the optimum balance between improved analgesia and minimal side effects.
Background: Human Cytomegalovirus (HCMV) is the main cause of congenital infections in industrialized countries, with incidence ranging between 0.3 and 2.4%. Complications of congenital HCMV ...infection may include deafness and mental retardation. Primary HCMV infection during pregnancy carries a high risk of vertical transmission. An uncontrolled, non-randomized study published in 2005 reported that the intravenous administration of anti-CMV immunoglobulin (Ig) reduced the maternal–fetal transmission of the virus from 40 to 16%. Design and population: This is an experimental non-randomized spontaneous monocentric study — Phase 2. Material and methods: Between 2003 and 2007: 26 pregnant women with primary CMV infection documented serologically and/or virologically between the 6th and 22nd weeks of pregnancy were enrolled to receive anti-CMV IgG (Cytotect) monthly from the moment of diagnosis until birth. Results: Children born to 15 mothers (57.96%) were uninfected, while the newborns of 8 mothers (30.76%) presented CMV infection; 2 of these were symptomatic (1 with hearing impairment, 1 with encephalopathy), while the third, although asymptomatic, showed neuroradiological alterations. The remaining 3 pregnancies were interrupted by miscarriage in 1 case and voluntary abortion in 2 cases because of signs of CMV infection-induced alterations on ultrasonography. Overall, 42.3% of newborns/fetuses were infected. None of the expecting mothers presented side effects. Conclusions: Our study revealed no advantage in the use of anti-CMV IgG. Nevertheless, controlled, and ideally, randomized trials are warranted to better clarify the usefulness of this therapeutic approach.
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