Pediatr Crit Care Me
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Pediatr Crit Care Me · Jul 2000
Biochemical, cellular, and molecular mechanisms in the evolution of secondary damage after severe traumatic brain injury in infants and children: Lessons learned from the bedside.
To present a state-of-the-art review of mechanisms of secondary injury in the evolution of damage after severe traumatic brain injury in infants and children. DATA SOURCES: We reviewed 152 peer-reviewed publications, 15 abstracts and proceedings, and other material relevant to the study of biochemical, cellular, and molecular mechanisms of damage in traumatic brain injury. Clinical studies of severe traumatic brain injury in infants and children were the focus, but reports in experimental models in immature animals were also considered. Results from both clinical studies in adults and models of traumatic brain injury in adult animals were presented for comparison. DATA SYNTHESIS: Categories of mechanisms defined were those associated with ischemia, excitotoxicity, energy failure, and resultant cell death cascades; secondary cerebral swelling; axonal injury; and inflammation and regeneration. ⋯ A constellation of mediators of secondary damage, endogenous neuroprotection, repair, and regeneration are set into motion in the brain after severe traumatic injury. The quantitative contribution of each mediator to outcome, the interplay between these mediators, and the integration of these mechanistic findings with novel imaging methods, bedside physiology, outcome assessment, and therapeutic intervention remain an important target for future research.
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Pediatr Crit Care Me · Jul 2000
Comparison of predictors of extubation from mechanical ventilation in children.
Unsuccessful extubation from mechanical ventilation increases mortality and morbidity. Therefore, the identification of an accurate predictor of successful extubation is desirable. This study was designed to determine whether the results of easily performed respiratory measurements, particularly if reported as "combined extubation" indices, were better predictors of extubation failure in a pediatric population than were readily available clinical data. DESIGN: Prospective observational study. SETTING: Tertiary pediatric intensive care unit. PATIENTS: All children who required mechanical ventilation for >/=24 hrs during a 12-month period and whose parents gave informed written consent. INTERVENTIONS: Respiratory function measurements were made (on average) 7 hrs (range, 0.2-25.0 hrs) before extubation. Arterial blood gas results were obtained immediately before extubation. The values of each predictor associated with maximum sensitivity and specificity were determined, and the areas under receiver operator characteristic curves were compared to determine the most accurate predictor of successful extubation. MEASUREMENTS AND MAIN ⋯ Volume measurements during pediatric mechanical ventilation may facilitate successful extubation.
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Pediatr Crit Care Me · Jul 2000
Comparison of plasma levels and pharmacodynamics after intraosseous and intravenous administration of fosphenytoin and phenytoin in piglets.
To compare plasma drug levels and pharmacodynamics of fosphenytoin or phenytoin when given intraosseously or intravenously in doses relevant to children. DESIGN: Prospective controlled randomized study. SETTING: University hospital animal laboratory. SUBJECTS: A total of 40 mixed-breed piglets (age, 4-6 months; weight, 20-40 kg). INTERVENTIONS: The animals were anesthetized, after which they underwent intubation, instrumentation, and mechanical ventilation. A central venous catheter and an arterial catheter were placed for monitoring and blood sampling. A peripheral intravenous catheter with a 15-gauge intraosseous needle was inserted for drug infusion. A total of 40 animals (ten per group) were randomly assigned to receive intravenous or intraosseous phenytoin or fosphenytoin infusions. Phenytoin (20 mg/kg) was infused over 20 mins, and fosphenytoin (20 mg phenytoin equivalent kg) was infused over 7 mins. All infusions were followed by the administration of a 5-mL normal saline flush. MEASUREMENTS AND MAIN ⋯ There is no need to adjust standard drug doses of phenytoin when given intraosseously. The initial high levels of phenytoin in the fosphenytoin groups are of concern because neurologic toxic effects may occur in humans at those levels. Slower infusion rates of fosphenytoin may be needed to avoid toxic levels.