Pediatr Crit Care Me
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Intestinal mucosal ischemia can occur during and after cardiac surgery. Severe decreases in mucosal perfusion may be a causative factor for postoperative mortality or complications such as necrotizing enterocolitis. Mesenteric perfusion is challenged preoperatively due to an imbalance between the systemic and pulmonary circulations and challenged intraoperatively due to hypothermic circulatory arrest. We have investigated gut permeability in seven patients undergoing stage 1 of the Norwood procedure, applying the dual sugar permeability test with L-rhamnose and lactulose. ⋯ Gut permeability as assessed by the dual sugar permeability test is abnormal in patients with hypoplastic left heart syndrome before and after surgery. Lactulose/rhamnose ratios 46 times the normal value reflect a highly permeable small intestine. This may be a sign of a low output state and may help to identify patients at risk of developing necrotizing enterocolitis.
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To assess what independent influence, if any, weekend or evening admission to a pediatric intensive care unit (PICU) staffed 24 hrs/day, 7 days/wk by in-house, board-certified pediatric intensivists might have on mortality. ⋯ Using multivariate logistic regression to control for important clinical differences, neither weekend admission, weekend discharge/death, nor evening admission had a significant independent effect on mortality risk in the entire sample or for the emergency patient subset. Our findings are consistent with previous work demonstrating the benefit of intensive care units staffed 24 hrs/day, 7-days/wk by in-house, board-certified intensivists.
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Pediatr Crit Care Me · Sep 2005
What influences parents' decisions to limit or withdraw life support?
Decisions to forgo life support from critically ill children are commonly faced by parents and physicians. Previous research regarding parents' perspectives on the decision-making process has been limited by retrospective methods and the use of closed-ended questionnaires. We prospectively identified and described parents' self-reported influences on decisions to forgo life support from their children. Deeper understanding of parents' views will allow physicians to focus end-of-life discussions on factors important to parents and help resolve conflicts. ⋯ Prospective interviews with open-ended questions identified factors influencing parents' decision making not previously described in the critical care literature such as parents' past experiences with end-of-life decisions and their anticipated emotional adjustments and future resources. Inclusion of these factors into discussions is important to parents and may facilitate decisions regarding the limitation or withdrawal of life support.
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To report two cases of severe early-onset neonatal sepsis due to Streptococcus pneumoniae, including, to our knowledge, the first reported case of sepsis due to penicillin-resistant S. pneumoniae presenting as early-onset neonatal sepsis. ⋯ Clinicians should consider S. pneumoniae as a possible cause of fulminant nonresponsive sepsis in neonates. In areas where antimicrobial-resistant S. pneumoniae is prevalent, when culture results are known, or with a clinical course unresponsive to ampicillin, septic infants may require the addition of a penicillinase-resistant antibiotic to their therapeutic regimen until results of antibiotic sensitivity testing are known. Early transfer to a center with extracorporeal membrane oxygenation should be considered for symptomatic neonates.
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Pediatr Crit Care Me · Sep 2005
Case ReportsSevere lactic acidosis complicating metformin overdose successfully treated with high-volume venovenous hemofiltration and aggressive alkalinization.
In this report of a near-fatal metformin ingestion successfully treated with alkalinization and high-volume hemofiltration, we discuss the management of severe lactic acidosis and demonstrate that early aggressive intervention resulted in a positive outcome. ⋯ In this case, early and aggressive treatment of the acidosis and cardiovascular compromise with inotropes, venovenous hemofiltration, and large doses of sodium bicarbonate in metformin overdose resulted in a successful outcome even in the presence of severe acidosis and very high lactate levels.