Effects of fluid resuscitation on cerebral tissue oxygenation changes in a piglet model of hemorrhagic shock

AbstractBackgroundAcute blood loss linked to severe hypovolemia and hemorrhagic shock is a critical condition in pediatric intensive care. This study was to investigate the role of various fluid resuscitation approaches to cerebral tissue oxygenation using a piglet model of hemorrhagic shock.MethodsThirty piglets received blood removal to induce hemorrhagic shock, and then were randomly assigned to a control group (no treatment), a control-normal saline (NS) group (treated with bolus normal saline 10mL/kg only), or one of three treatment groups treated with 15mL/kg/dose fluid every 30min with either whole blood (WB), lactated Ringer’s solution (LR), or NS in addition to an initial bolus of saline. The piglets’ physiological profiles, arterial blood gases, and regional cerebral oxygen saturation (rScO2) levels were recorded, fractional tissue oxygen extraction was calculated, and blood hemoglobin levels were measured.ResultsThe results showed that no matter whether treated with only one dose of bolus NS (control-NS group) or with extra WB, LR, or NS, all the treated animals had a significantly higher survival rate, mean arterial blood pressure (MAP), arterial oxygen tension, arterial oxygen saturation, and rScO2 than the control group (p<0.05). Animals treated with WB all survived the full experimental period, and their hemoglobin levels, MAP, and rScO2 were the highest comparing to all other groups (p<0.05).ConclusionEffective resuscitation using a high concentration of inspired oxygen and adequate fluid infusion, either as a single-dose bolus of NS or combining this with a subsequent transfusion of WB, LR, or NS, helped to stabilize the cardiovascular condition of the tested young subjects and improved cerebral tissue oxygenation over the emergent first four hours. Furthermore, WB was the best fluid choice when used in addition to the bolus NS challenge for maintaining better brain tissue oxygenation when treating hemorrhagic shock

Risk of death in patients with post-traumatic cerebrospinal fluid leakage—Analysis of 1773 cases

AbstractBackgroundPost-traumatic cerebrospinal fluid (CSF) leakage is one of the most troublesome conditions associated with head trauma. CSF fistulae, meningitis/central nervous infection, or even death may accompany it. Few studies have discussed post-traumatic CSF leakage as a risk factor in mortality following head trauma. We conducted this cohort study to examine the issue.MethodsWe reviewed the records in the Taiwan Traumatic Brain Injury (TBI) Registry System between 1993 and 2008. The study group included patients with acute TBI and post-traumatic CSF leakage, and the control group included cases with TBI but without CSF leakage, selected randomly at a 5:1 ratio with respect to the study group. The demographic data, Glasgow Coma Scale, brain computerized tomography, association of skull fractures and intracranial lesions, and 1-year mortality rates between these two cohorts were reviewed meticulously and analyzed statistically.ResultsOf 174,236 cases, 1773 with post-traumatic CSF leakage were included in the study group, and 8865 cases in the control group. Of the total 10,638 sampled cases, 406 (3.8%) died during the 1-year follow-up period, 159 (9.0%) cases in the CSF leakages group, and 247 (2.8%) in the control group. The patients with CSF leakage had a significantly higher mortality rate within 1 year (adjusted hazard ratio = 1.44, p < 0.001) than those without. We divided the CSF leakage group into three subgroups: otorrhea (n = 568), rhinorrhea (n = 302), and tension pneumocephalus (n = 903). The mortality rates were 8.5% (48/568) in the otorrhea subgroup, 10.9% (33/302) in the rhinorrhea subgroup, and 8.6% (78/903) in the tension pneumocephalus subgroup. The cases with CSF rhinorrhea had a significantly higher mortality rate than the other two subgroups (p < 0.05). All three subgroups had significantly higher mortality rates than the control group during the 1-year follow-up period (adjusted hazard ratios = 2.29, 1.35, and 1.32 in the rhinorrhea, tension pneumocephalus, and otorrhea subgroups, respectively).ConclusionPost-traumatic CSF leakages had higher mortality rates than those without CSF leakages in TBI cases, and the cases with CSF rhinorrhea had worse outcomes compared with CSF leakages with pneumocephalus or otorrhea

Therapeutic Lung Lavage with Diluted Surfactant in Neonates with Severe Meconium Aspiration Syndrome

Meconium aspiration syndrome (MAS) may result in considerable morbidity and mortality in newborn infants. The current standard treatment is still in need of improvement for the most severe patients. We report 3 cases with devastating MAS that was successfully treated with therapeutic lung lavage. These cases were all delivered in local obstetrics clinics or hospitals with meconium-stained amniotic fluid and non-vigorous appearance at birth. However, no endotracheal suction was performed when they were born. All of them suffered from severe hypoxia and unstable vital signs despite there being high ventilatory settings when they were transferred to the tertiary medical center. Therapeutic lung lavage with diluted surfactant (Survanta, 5 mg/mL, 30 mL/kg in 2 aliquots) was performed within 24 hours of age. Bloody fluid (about 40–50% of total lavage amount) was recovered in all 3 cases. Although brief desaturation and bradycardia were observed during the procedures, 2 of them tolerated the procedures well and improved soon after lavage. The other patient received lung lavage in a relatively unstable condition and needed chest tapping to relieve bilateral pleural effusion. Their respiratory condition improved after the procedures, and they were all discharged within 1 month without major respiratory complications. These successful experiences are compatible with previous animal studies and other case reports with different lavage protocols. We conclude that therapeutic lung lavage may improve the outcome in newborn infants with severe MAS, and there were no significant adverse side effects observed. Before performing lung lavage, stabilization and optimal support may prevent unexpected results during and after lavage

Hyperbilirubinemia with urinary tract infection in infants younger than eight weeks old

AbstractBackgroundHyperbilirubinemia is one of the most common causes for hospital admission in neonatal infants. Previous studies have found that jaundice may be one of the initial symptoms related to urinary tract infection (UTI) in infants. This study is to evaluate the incidence and related factors of neonatal infants with the initial presentation of hyperbilirubinemia and final diagnosis of UTI in a tertiary teaching hospital.MethodsWe retrospectively investigated the medical records of admitted infants younger than 8 weeks old with hyperbilirubinemia between January and December 2008. The jaundiced infants having tests of urinalysis were enrolled into our study and grouped into UTI or no UTI group according to the findings of urinary culture.ResultsA total of 217 neonatal jaundiced infants were enrolled. Among them, 12 cases (5.5%) were grouped into the UTI group, and the most common cultured bacterium from their urine was Escherichia coli. There was no significant difference in the babies’ birth weight, maternal conditions, or total bilirubin levels between the two groups. There was also no significant difference between the two groups in their admission age (9.7 ± 13.5 days vs. 6.1 ± 6.7 days in UTI and no UTI groups, respectively) or the ratio of outpatients (50% vs. 25% in UTI and no UTI groups, respectively) (p > 0.05). The cases of UTI group had significantly lower hemoglobin (15.2 ± 2.7 g/dL vs. 17.2 ± 2.3 g/dL, respectively) and higher formula feeding rate (8.3% vs. 2.9%, respectively) than the no UTI group (p < 0.05).ConclusionThe incidence of UTI in the admitted infants with hyperbilirubinemia was as high as approximately 5.5%. The most common cultured bacterium in urine was E coli. Therefore, performing urinary tests to exclude the possibility of coincidental UTI may be necessary for admitted jaundiced infants younger than 8 weeks old

Elevation of serum S100 protein concentration as a marker of ischemic brain damage in extremely preterm infants

AbstractBackgroundPeriventricular leukomalacia (PVL) is serious ischemic brain damage that occurs in extreme preterm infants. It is traditionally diagnosed by cranial echography. The purpose of this study was to investigate the relationship between serum S100 calcium-binding protein B (S100B) concentrations and ischemic brain damage, and to find the cutoff value for the early identification of ischemic brain damage in high-risk preterm infants.MethodsAt the age of 3 days, 7 days, 14 days, and 21 days, and before discharge, 22 extremely premature infants (i.e., gestational age <33 weeks) underwent blood sampling to determine the S100B concentrations and cranial echography examinations. The severity of ischemic brain damage in echographic images was scored on a scale of 0–11, and was recorded as the brain echography index (BEI). If the last BEI value was ≥7, the enrolled infants were grouped in the brain damage group.ResultsEight infants were assigned to the brain damage group and 14 infants were assigned to the no brain damage group. At each age point of the blood samplings, the serum S100B concentrations were significantly higher in the brain damage group than in the no brain damage group. There was a significantly positive correlation between the serum S100B concentrations and the BEI on the same day (r = 0.738, p < 0.001) and 7 days later (r = 0.774, p < 0.001). The receiver operating characteristic curve for the serum S100B concentrations showed that the area under curve was 0.985 (p < 0.001). The cutoff value of serum S100B of 1.0 μg/L had a sensitivity of 93.8% and specificity of 90.5% for the diagnosis of ischemic brain damage.ConclusionAn elevation in the serum S100B concentration is highly associated with ischemic brain damage in extreme preterm infants. Ischemic brain damage in a high-risk preterm infant is strongly suggested if the early serum S100B concentration is > 1.0 μg/L