Current opinion in pediatrics
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Anxiety-provoking and painful emergency department procedures such as laceration repair are made more tolerable to the pediatric patient and easier for the practitioner through the judicious use of pharmacologic agents for conscious sedation and analgesia. Both the American Academy of Pediatrics and the American College of Emergency Physicians have published documents that guide the physician in the use of these agents in the care of children. Most new information concerns the evaluation of new drugs for use in the pediatric emergency department, adverse effects of familiar products, and evaluation of sedative and analgesic antagonist medications that may increase a practitioner's control when conscious sedation is used. Large controlled trials of protocols and drugs are necessary to establish safe, appropriate standards for conscious sedation in the pediatric emergency department.
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Recent insights into the pathophysiology of acute lung injury have led to changes in our routine approach to mechanical ventilation in this population of patients. Heterogeneous alterations in the anatomy and function of the lung are characteristic of acute lung injury. Experimental evidence strongly suggests that traditional approaches to mechanical ventilation with normal tidal volumes applied uniformly to the injured lungs will result in repetitive alveolar overdistention in regions with normal compliance. ⋯ This realization has led to a strategy that is designed to avoid tidal alveolar collapse using physiologic transalveolar pressures while allowing alveolar hypoventilation and hypercapnia. Debate continues regarding the risks and benefits of pressure-limited versus volume-limited mechanical ventilation to achieve this goal. Research is ongoing regarding the role and techniques for nonconventional methods of cardiorespiratory support for this severely ill group of patients.
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A number of important developments concerning childhood pneumonia and empyema have received recent attention in the literature. Drug-resistant strains of the most common bacterial pathogen for childhood pneumonia, Streptococcus pneumoniae, have emerged in diverse geographic regions within the United States. ⋯ Promising new diagnostic methods for detecting difficult to culture pathogens in sputum using polymerase chain reaction technology are now available and undergoing critical evaluation in clinical use. The debate on how to best manage empyema continues, and the role of fibrinolytic therapy and thoracoscopy as a possible alternative to traditional thoracotomy and decortication are reviewed.