Current opinion in pediatrics
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The pediatric metabolic response to injury and operation is proportional to the degree of stress and causes an increase in the turnover of proteins, fats, and carbohydrates. Thereby, substrates are made readily available for the immune response and wound healing. Because this process requires energy, the resting energy expenditure of ill patients increases. ⋯ An appropriately designed mixed fuel system of nutritional support replete in protein does not quell this metabolic response but can result in anabolism and continued growth in ill children. In addition, the use of adequate analgesia and anesthesia is a readily available and proven means of reducing the magnitude of the catabolism associated with operation and injury. Finally, as hormonal- and cytokine-mediated metabolic alterations are better understood, therapeutic interventions may become available to directly modulate the metabolic response to illness, thus potentially further improving clinical outcome in pediatric surgical patients.
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Cerebral edema is the leading cause of death in children presenting in diabetic ketoacidosis and occurs in 0.2 to 1% of cases. The osmolar gradient caused by the high blood glucose results in water shift from the intracelluar fluid (ICF) to the extracellular fluid (ECF) space and contraction of cell volume. Correction with insulin and intravenous fluids can result in a rapid reduction in effective osmolarity, reversal of the fluid shift and the development of cerebral edema. The goals for treatment should be a combination of intravenous fluid and insulin that results in a gradual reduction of the effective osmolarity over a 36- to 48-hour period, thereby avoiding rapid expansion of the ICF compartment and brain swelling.
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Flexible airway endoscopy has been used in clinical and research investigations of pediatric airway and pulmonary disorders for nearly 25 years. Not only has clinical use of the flexible bronchoscope improved our evaluation and management of a variety of airway and pulmonary diseases in children, but also research investigations using lavage and biopsy specimens obtained with the flexible bronchoscope have contributed extensively to our understanding of lung inflammation and infection. Improvements and new developments in fiberoptic endoscope technology, training of airway endoscopists, preoperative and sedative medications, patient monitoring, and airway endoscopic techniques, as well as adjunctive minimally invasive and noninvasive diagnostic modalities, continue to refine and enhance the pediatric clinical and research applications of flexible airway endoscopy.