Évolution de la qualité de vie après un traumatisme crânien par accident de la route : un suivi à cinq ans de la cohorte ESPARR

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La récupération de l état de santé et le stress post-traumatique chez les enfants accidentés de la route (une étude de cohorte)

Cette thèse étudie les facteurs prédictifs et les facteurs associés à la récupération de l état de santé et au stress post-traumatique chez l enfant après un accident de la route. Il s agit d une étude de cohorte prospective mise en place en 2004 composée de 204 enfants de moins de 16 ans, hospitalisés dans les hôpitaux publiques et privés du département du Rhône à la suite d un accident de la route. Un an après l accident, parmi les 127 enfants évalués par questionnaires, 78 (75,0 %) enfants légèrement ou modérément blessés et 8 (34,8%) enfants gravement blessés estimaient avoir complétement récupéré leur état de santé. Après ajustement, le score de gravité (M-AIS>=3) et les lésions des membres inférieurs (AIS>1) étaient associés à la non récupération de l état de santé : Odds Ratio pondérés (ORw) respectifs de 4,3 [IC 95%, 1,3-14,6] et 6,5 [IC 95%, 1,9-21,7]. L état de récupération était significativement corrélé au score physique de la qualité de vie (r=0,46) et dans une moindre mesure au score psychosocial de qualité de vie (r=0,21). D importants symptômes de stress post-traumatique étaient présents chez 26 (27,7%) enfants un an après un accident de la route et cela indépendamment de la gravité des lésions initiales. Dans cette cohorte pédiatrique d accidentés de la route, les enfants ayant des lésions graves (M-AIS>=3) ou des lésions des membres inférieurs avaient une moins bonne récupération de l état de santé à un an. Un état de santé altéré était associé à une qualité de vie plus faible à un an. Il parait important de ne pas négliger les conséquences que peuvent avoir les accidents de la route sur la santé physique et psychique des enfants légèrement blessés.The aim of this thesis was to evaluate predictive factors of recovery and post-traumatic stress in children one year after road traffic injuries. This prospective cohort study was composed of 204 children aged =3) and lower limb injury (AIS>=2) were associated with no full recovery of health status: Weighted Odds Ratio (ORw) : 4.3 [95% Confidence Interval (95% CI) : 1.3-14.6] and ORw : 6.5 [95% CI : 1.9-21.7] respectively. The recovery status was significantly correlated to quality of life Physical scores (r=0.46) especially to Body Pain (r=0.48) and Role/Social physical (r=0.50) and to a lesser extent to quality of life Psychosocial scores (r=0.21). Important post-traumatic stress symptoms were present in 27.7% of children one year after a road traffic accident. In a cohort of children injured in a road accident, those with high injury severity score and those with lower limb injuries are more likely to not fully recover their health status at 1 year. Altered health status was associated with a lower physical quality of life score at 1 year. It seems important to consider psychological consequences road traffic accidents may have on children even after mild or moderate injuries.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Type I Interferon in Children with Viral or Bacterial Infections.

BACKGROUND: Fever is one of the leading causes of consultation in the pediatric emergency department for patients under the age of 3 years. Distinguishing between bacterial and viral infections etiologies in febrile patients remains challenging. We hypothesized that specific host biomarkers for viral infections, such as type I-interferon (IFN), could help clinicians' decisions and limit antibiotic overuse. METHODS: Paxgene tubes and serum were collected from febrile children (n = 101), age from 7 days to 36 months, with proven viral or bacterial infections, being treated at pediatric emergency departments in France. We assessed the performance of an IFN signature, which was based on quantification of expression of IFN-stimulated genes using the Nanostring® technology and plasma IFN-α quantified by digital ELISA technology. RESULTS: Serum concentrations of IFN-α were below the quantification threshold (30 fg/mL) for 2% (1/46) of children with proven viral infections and for 71% (39/55) of children with bacterial infections (P 0.91 for both) between viral and bacterial infection in febrile children, compared to C-reactive protein (0.83). CONCLUSIONS: IFN-α is increased in blood of febrile infants with viral infections. The discriminative performance of IFN-α femtomolar concentrations as well as blood transcriptional signatures could show a diagnostic benefit and potentially limit antibiotic overuse. CLINICAL TRIALS REGISTRATION: clinicaltrials.gov (NCT03163628)

Elevated monocyte HLA-DR in pediatric secondary hemophagocytic lymphohistiocytosis: a retrospective study

IntroductionHemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition, and its diagnosis may be challenging. In particular, some cases show close similarities to sepsis (fever, organ failure, and high ferritin), but their treatment, while urgent, differ: prompt broad-spectrum antibiotherapy for sepsis and immunosuppressive treatment for HLH. We questioned whether monocyte human leucocyte antigen (mHLA)–DR could be a diagnostic marker for secondary HLH (sHLH).MethodsWe retrospectively reviewed data from patients with a sHLH diagnosis and mHLA-DR quantification. mHLA-DR data from healthy children and children with septic shock, whose HLA-DR expression is reduced, from a previously published study were also included for comparison.ResultsSix patients with sHLH had mHLA-DR quantification. The median level of monocyte mHLA-DR expression in patients with sHLH [79,409 antibodies bound per cell (AB/C), interquartile range (IQR) (75,734–86,453)] was significantly higher than that in healthy children and those with septic shock (29,668 AB/C, IQR (24,335–39,199), and 7,493 AB/C, IQR (3,758–14,659), respectively). Each patient with sHLH had a mHLA-DR higher than our laboratory normal values. Four patients had a second mHLA-DR sampling 2 to 4 days after the initial analysis and treatment initiation with high-dose corticosteroids; for all patients, mHLA-DR decreased to within or close to the normal range. One patient with systemic juvenile idiopathic arthritis had repeated mHLA-DR measurements over a 200-day period during which she underwent four HLH episodes. mHLA-DR increased during relapses and normalized after treatment incrementation.ConclusionIn this small series, mHLA-DR was systematically elevated in patients with sHLH. Elevated mHLA-DR could contribute to sHLH diagnosis and help earlier distinction with septic shock

Refractory septic shock in children: a European Society of Paediatric and Neonatal Intensive Care definition

PURPOSE: Although overall paediatric septic shock mortality is decreasing, refractory septic shock (RSS) is still associated with high mortality. A definition for RSS is urgently needed to facilitate earlier identification and treatment. We aim to establish a European society of paediatric and neonatal intensive care (ESPNIC) experts' definition of paediatric RSS. METHODS: We conducted a two-round Delphi study followed by an observational multicentre retrospective study. One hundred and fourteen paediatric intensivists answered a clinical case-based, two-round Delphi survey, identifying clinical items consistent with RSS. Multivariate analysis of these items in a development single-centre cohort (70 patients, 30 % mortality) facilitated development of RSS definitions based on either a bedside or computed severity score. Both scores were subsequently tested in a validation cohort (six centres, 424 patients, 11.6 % mortality). RESULTS: From the Delphi process, the draft definition included evidence of myocardial dysfunction and high blood lactate levels despite high vasopressor treatment. When assessed in the development population, each item was independently associated with the need for extracorporeal life support (ECLS) or death. Resultant bedside and computed septic shock scores had high discriminative power against the need for ECLS or death, with areas under the receiver operating characteristics curve of 0.920 (95 % CI 0.89-0.94), and 0.956 (95 % CI 0.93-0.97), respectively. RSS defined by a bedside score equal to or higher than 2 and a computed score equal to or higher than 3.5 was associated with a significant increase in mortality. CONCLUSIONS: This ESPNIC definition of RSS accurately identifies children with the most severe form of septic shock

Enhance quality care performance: Determination of the variables for establishing a common database in French paediatric critical care units

Abstract Selected variables for the French Paediatric Intensive Care registry. Rationale, aims, and objectives Providing quality care requires follow-up in regard to clinical and economic activities. Over the past decade, medical databases and patient registries have expanded considerably, particularly in paediatric critical care medicine (eg, the Paediatric Intensive Care Audit Network (PICANet) in the UK, the Australian and New Zealand Paediatric Intensive Care (ANZPIC) Registry in Australia and New Zealand, and the Virtual Paediatric Intensive Care Unit Performance System (VPS) in the USA). Such a registry is not yet available in France. The aim of this study was to determine variables that ought to be included in a French paediatric critical care registry. Methods Variables, items, and subitems from 3 foreign registries and 2 French local databases were used. Items described each variable, and subitems described items. The Delphi method was used to evaluate and rate 65 variables, 90 items, and 17 subitems taking into account importance or relevance based on input from 28 French physicians affiliated with the French Paediatric Critical Care Group. Two ratings were used between January and May 2013. Results Fifteen files from 10 paediatric intensive care units were included. Out of 65 potential variables, 48 (74%) were considered to be indispensable, 16 (25%) were considered to be optional, and 1 (2%) was considered to be irrelevant. Out of 90 potential items, 62 (69%) were considered to be relevant, 23 (26%) were considered to be of little relevance, and 5 (6%) were considered to be irrelevant. Out of 17 potential subitems, 9 (53%) were considered to be relevant, 6 (35%) were considered to be of little relevance, and 2 (12%) were considered to be irrelevant. Conclusions The necessary variables that ought to be included in a French paediatric critical care registry were identified. The challenge now is to develop the French registry for paediatric intensive care units

Thigh Ultrasound Monitoring Identifies Decreases in Quadriceps Femoris Thickness as a Frequent Observation in Critically Ill Children.

OBJECTIVES: Significant muscle wasting develops in critically ill adults, with subsequent worse outcomes. In the pediatric setting, occurrence and effects of muscle wasting are undescribed; this is in part due to a lack of validated, objective methods for assessing muscle wasting. A single measurement of quadriceps femoris thickness has failed to show consistent reproducibility. We hypothesized that averaging repeated measurements could afford good reproducibility to allow for quadriceps femoris thickness decline detection and monitoring. DESIGN: A prospective bedside observational study. SETTING: Two PICUs. PATIENTS: Mechanically ventilated critically ill children were 15 years and younger. INTERVENTIONS: Transverse and longitudinal axis measurements of quadriceps femoris anterior thickness were undertaken using bedside ultrasound. The average of four measurement values was recorded. The location of measurement was marked for consistency within subsequent measurements by the same or another trained operator, to assess intra- and interoperator repeatability and reproducibility of the technique. Where feasible, serial measurements were undertaken until the time of extubation in a group of children with prolonged PICU stay (> 5 d). MEASUREMENTS AND MAIN RESULTS: Seventy-three children were enrolled to assess intra- and interoperator ultrasound reliability. Their median (25-75 interquartile range) age and weight were 30 months (4.5-96) and 10 kg (5-23.5). In the intraoperator repeatability study, mean relative difference in quadriceps femoris muscle thickness was 0.36% ± 2.5% (lower and upper limits of agreement: -4.5/+5.2%). In the interoperator reproducibility study, intraclass correlation coefficient was 0.998. In the 17 children monitored over their PICU stay, quadriceps femoris thickness significantly decreased at day 5 by 9.8% (p = 0.006) and by 13.3% (< 0.001) at the last performed measurement. CONCLUSIONS: Quadriceps femoris thickness decrease, proposed as a surrogate for muscle mass, is an early, frequent, and intense phenomenon in PICU. Quadriceps femoris ultrasonography is a reliable technique to monitor this process and in future could help to guide rehabilitation and nutrition interventions.The study was founded by ALLP (Association Lyonnaise de Logistique posthospitalière) 2015 grant. FVV has received consultant honoraria from Nutricia and Baxter and grants from Baxter, Nestle, Institut Aguettant, ALLP and Fresenius Kabi. For the remaining authors none were declared

Translational gap in pediatric septic shock management: an ESPNIC perspective

Background: The Surviving Sepsis Campaign and the American College of Critical Care Medicine guidelines have provided recommendations for the management of pediatric septic shock patients. We conducted a survey among the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) members to assess variations to these recommendations. Methods: A total of 114 pediatric intensive care physicians completed an electronic survey. The survey consisted of four standardized clinical cases exploring seven clinical scenarios. Results: Among the seven diferent clinical scenarios, the types of fuids were preferentially non-synthetic colloids (albumin) and crystalloids (isotonic saline) and volume expansion was not limited to 60 ml/kg. Early intubation for mechanical ventilation was used by 70% of the participants. Norepinephrine was stated to be used in 94% of the PICU physicians surveyed, although dopamine or epinephrine is recommended as frst-line vasopressors in pediatric septic shock. When norepinephrine was used, the addition of another inotrope was frequent. Specifc drugs such as vasopressin or enoximone were used in <20%. Extracorporeal life support was used or considered by 91% of the physicians audited in certain specifc situations, whereas the use of high-fow hemofltration was considered for 44%. Conclusions: This pediatric septic shock management survey outlined variability in the current clinician-reported practice of pediatric septic shock management. As most recommendations are not supported by evidence, these fndings outline some limitation of existing pediatric guidelines in regard to context and patient’s specifcity

Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review

Noninvasive positive pressure ventilation (NPPV) refers to the delivery of mechanical respiratory support without the use of endotracheal intubation (ETI). The present review focused on the effectiveness of NPPV in children > 1 month of age with acute respiratory failure (ARF) due to different conditions. ARF is the most common cause of cardiac arrest in children. Therefore, prompt recognition and treatment of pediatric patients with pending respiratory failure can be lifesaving. Mechanical respiratory support is a critical intervention in many cases of ARF. In recent years, NPPV has been proposed as a valuable alternative to invasive mechanical ventilation (IMV) in this acute setting. Recent physiological studies have demonstrated beneficial effects of NPPV in children with ARF. Several pediatric clinical studies, the majority of which were noncontrolled or case series and of small size, have suggested the effectiveness of NPPV in the treatment of ARF due to acute airway (upper or lower) obstruction or certain primary parenchymal lung disease, and in specific circumstances, such as postoperative or postextubation ARF, immunocompromised patients with ARF, or as a means to facilitate extubation. NPPV was well tolerated with rare major complications and was associated with improved gas exchange, decreased work of breathing, and ETI avoidance in 22-100% of patients. High FiO2 needs or high PaCO2 level on admission or within the first hours after starting NPPV appeared to be the best independent predictive factors for the NPPV failure in children with ARF. However, many important issues, such as the identification of the patient, the right time for NPPV application, and the appropriate setting, are still lacking. Further randomized, controlled trials that address these issues in children with ARF are recommended