European journal of pediatrics
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Case Reports
Respiratory muscle rigidity in a preterm infant after use of fentanyl during Caesarean section.
Fentanyl is in many neonatal intensive care units the sedative of choice. One side-effect is, however, the possibility of muscle and/or chest wall rigidity. A pregnant woman with a critical pulmonary valve stenosis had a balloon dilatation at 26 weeks of gestation. She was put on propranolol, but went into a severe cardiac failure. In week 31, she developed pregnancy induced hypertension. Periodically absent diastolic flow in the umbilical cord was demonstrated. A Caesarean section was performed using fentanyl as analgesia. A boy weighing 1440 g, had a 1 min Apgar score of 3 without respiratory movements. Mask ventilation was tried, but chest wall expansion was not achieved despite using high pressures. He was intubated and positive pressure ventilation attempted, with the same result. Despite the use of high pressures up to 60-70 cm H2O, no chest movement could be achieved. An intravenous line was established in order to give naloxone and pancuronium. Just before the drugs were given, chest wall movements were achieved and the heart rate normalized. ⋯ This is the first report on chest wall rigidity in a neonate after administration of fentanyl to the mother during Caesarean section.
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Septic shock with purpura is a syndrome frequently diagnosed in children and predominantly caused by Neisseria meningitidis. Despite improvements in management and therapy the mortality and morbidity in these patients are still high. During the last few years much effort has been put into understanding of the systemic host response during this acute infectious disease. This host response can be divided into the process of recognition of endotoxin, the cascade of pro- and counter inflammatory mediators, the endothelial damage resulting in capillary leakage and inappropriate vascular tone, and the procoagulant state. ⋯ This paper reviews the recent insights in the pathophysiology of the host response and their possible consequences for novel therapies in meningococcal sepsis.
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The diagnoses, transfer, management and outcome of patients with upper airway obstruction (UAO) admitted from district general hospitals (DGH) to a regional paediatric intensive care unit were retrospectively reviewed over a 3.5-year period. Sixty-seven patient episodes were analysed. Fifty-two cases (78%) underwent tracheal intubation prior to transport with a low morbidity for both procedures. The most common diagnosis was viral croup (n = 34, 51%) with a median duration of intubation of 5 days, with subglottic stenosis being the next most common category (n = 10, 15%), median duration of intubation 7 days. Inhaled budesonide was used prior to intubation in 12 (35%) of those with croup, and inhaled bronchodilators in 28%, possibly reflecting diagnostic uncertainty. Patients with croup treated with budesonide were significantly less likely to require intubation (P = 0.04). The re-intubation rate for patients with viral croup was uncomfortably high at 16% (4/25) despite the routine use of prednisolone throughout the intubation period. Successful extubation of patients with viral croup could not be predicted by age (P = 0.31), length of intubation (P = 0.94), endotracheal tube size, (P = 0.60) abnormalities on the chest X-ray (P = 1.0), or presence of secondary bacterial infection (P = 0.23). ⋯ Although viral croup remains the most common diagnostic category presenting at the DGH level with severe UAO, a wide range of other diagnoses is seen. Despite clear evidence of benefit, steroid administration to children presenting at the DGH with viral croup has not become routine practice. Once intubated, no reliable predictors of successful extubation were found amongst this patient group.
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In mechanical ventilation of preterm infants, positive endexpiratory pressure (PEEP) is widely used to prevent alveolar collapse, maintain functional residual capacity (FRC) and improve oxygenation. Prolongation of inspiratory time (ti) and increase of peak inspiratory pressure (PIP) are also used for this purpose. We investigated the effect of variations of PEEP, PIP and ti on FRC in ten infants with hyaline membrane disease and onset of bronchopulmonary dysplasia (BPD, n = 7), pulmonary hypertension (n = 1), pulmonary hypoplasia (n = 1) or severe BPD (n = 1) (gestational age 24-39 weeks, median 26 weeks; birth weight 590-2960 g, 785 g; chronological age 7 84 days, 19 days; weight 689-4650 g, 1185 g). FRC, measured using the sulphur hexafluoride washout technique, was between 6.2 and 48.3 ml/kg (median 21.5 ml/kg). PEEP was changed stepwise 2-5 times in each patient (median 3) and mean airway pressure (MAP) was modified independently of PEEP by changing PIP 0 2 times (median 1) and ti 0(2 times (median 2). Changes of FRC correlated well with modifications of PEEP in each patient (r = 0.90, range 0.71 0.99). The slope factors of linear correlations had a median value of 2.94 ml/cm H20 per kg, which was significantly different from zero (P < 0.01) and significantly higher than the slope factors of linear correlations between FRC and MAP after modifications of PIP or ti (P < 0.01). The latter two were statistically not different from zero. The quotients deltaFRC/deltaMAP were significantly higher after adjustments of PEEP than after adjustments of PIP or ti (P < 0.01). The time lag between the change of PEEP and the stabilization of FRC on a new level ranged from 2 to 14 min (median 5). ⋯ FRC is mainly determined by PEEP but not by PIP or ti. Stabilization of FRC after a change of PEEP can last up to 14 min. Its duration is unpredictable and has to be waited for when testing pulmonary function in ventilated preterm infants.
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Randomized Controlled Trial Comparative Study Clinical Trial
Comparison of the efficacy and side-effects of ondansetron and metoclopramide-diphenhydramine administered to control nausea and vomiting in children treated with antineoplastic chemotherapy: a prospective randomized study.
Nausea and vomiting following antineoplastic therapy in patients receiving chemotherapy remains a problem. To prevent nausea and vomiting due to antineoplastic therapy, many types of drugs have been used. Ondansetron and the combination metoclopramide-diphenhydramine have been widely used in children. In this prospective randomized study these drugs were compared both for their efficacy and side-effects in children treated with antineoplastic chemotherapy (with and without cisplatin) the number of chemotherapy courses being equal in both groups. Ondansetron gave complete anti-emetic cover in five of nine courses in patients treated with cisplatin. Metoclopramide-diphenhydramine gave complete anti-emetic cover in one out of nine courses, and 17 out of 23 courses in patients treated without cisplatin. Metoclopramide-diphenhydramine produced side effects in nine courses whereas ondansetron produced side-effects in three courses. ⋯ Ondansetron appeared to be superior to metoclopramide-diphenhydramine in the control of emesis induced by chemotherapy regimens containing cisplatin. The results of the present prospective randomized study indicate that ondansetron is a useful anti-emetic in the treatment of chemotherapy-induced emesis.