Prise en charge de la bronchiolite aiguë grave chez le nourrisson de moins de 12 mois hospitalisé en soins critiques pédiatriques

International audienceLe Groupe francophone de réanimation et d’urgences pédiatriques (GFRUP) publie des recommandations concernant la prise en charge des enfants de moins de 12 mois présentant une bronchiolite aiguë grave, sous-groupe de patients mal individualisé dans les recommandations nationales et internationales. Vingt-cinq experts francophones réanimateurs pédiatres issus du GFRUP ont collaboré de 2021 à 2022 au travers de réunions en téléconférence et présentielles. Ces recommandations recouvrent cinq champs : premièrement, critères d’admission en unité de soins critiques ; deuxièmement, conditionnement, examens paracliniques et modalités de surveillance ; troisièmement, modalités d’alimentation et d’hydratation ; quatrièmement, choix et mise en place du support ventilatoire, et cinquièmement, place des thérapeutiques adjuvantes. Les questions ont été élaborées sous le format PICO (patient intervention comparison outcome). Une recherche bibliographique extensive de la littérature anglophone et francophone indexée dans les bases de données MEDLINE via PubMed, Web of Science, Cochrane et Embase a été réalisée à partir de mots clés préétablis. Les articles ont été analysés et classés selon la méthodologie GRADE. Lorsque cette méthode ne s’appliquait pas, un avis d’expert était donné. Chacune de ces recommandations a fait l’objet d’un vote par l’ensemble des experts selon la méthodologie Delphi. Le groupe a formulé 40 recommandations. La méthodologie GRADE a pu s’appliquer à 17 d’entre elles (3 forts, 14 faibles) et un avis d’expert a été donné pour les 23 autres. Toutes ont reçues un accord fort lors du premier tour de vote

Implementation of a neonatal pain management module in the computerized physician order entry system.

International audienceABSTRACT: BACKGROUND: Despite the recommended guidelines, the neonatal management of pain and discomfort often remains inadequate. The purpose of the present study was to determine whether adding a pain and discomfort module to a computerized physician order entry (CPOE) system would improve pain and discomfort evaluation in premature newborns under invasive ventilation. METHODS: All newborns <37 weeks gestational age (GA) and requiring invasive ventilation were included in a prospective study during two 6-month periods: before and after the inclusion of the pain and discomfort evaluation module. The main outcome measure was the percentage of patients having at least one assessment of pain and discomfort per day of invasive ventilation using the COMFORT scale. RESULTS: A total of 122 patients were included: 53 before and 69 after the incorporation of the module. The mean age was 30 (3) weeks GA. After the module was included, the percentage of patients who benefited from at least one pain and discomfort assessment per day increased from 64% to 88% (p < 0.01), and the mean number (SD) of scores recorded per day increased from 1 (1) to 3 (1) (p < 0.01). When the score was not within the established range, the nursing staff adapted analgesia/sedation doses more frequently after module inclusion (53% vs. 34%, p < 0.001). Despite higher mean doses of midazolam after module introduction [47 (45) vs. 31 (18) mug/kg/hr, p < 0.05], the durations of invasive ventilation and hospital stay, and the number of nosocomial infections, were not significantly modified. CONCLUSIONS: Adding a pain and discomfort tool to the CPOE system was a simple and effective way to improve the systematic evaluation of premature newborns who required ventilatory assistance

Intrahospital transport of critically ill patients (excluding newborns) recommendations of the Société de Réanimation de Langue Française (SRLF), the Société Française d'Anesthésie et de Réanimation (SFAR), and the Société Française de Médecine d'Urgence (SFMU)

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15‐Year trends in respiratory care of extremely preterm infants: Contributing factors and consequences on health and growth during hospitalization

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Assessment of Peak Inspiratory Flow in Young Infants with Acute Viral Bronchiolitis: Physiological Basis for Initial Flow Setting in Patients Supported with High-Flow Nasal Cannula

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Continuous positive airway pressure ventilation with helmet in infants under 1 year

International audienceObjective: To report the feasibility of helmet use in infants between 1 and 12 months old with acute respiratory failure.Design and setting: Observations were made before and 2 h after helmet CPAP of 6 cm H 2 O. Failure was defined as recourse to intratracheal ventilation. Patient stabilization or improvement was defined as a variation \10% or a decrease [10% in one of the following: respiratory rate, inspired oxygen fraction, or capillary partial pressure of CO 2. Tolerance was assessed by the pain and discomfort score, the systematic search for pressure sores, and the measurement of helmet humidity and noise level.Results: Twenty-three infants with a median age of 5 (2-8) months were included. Helmet CPAP failed in two (9%) patients. Stability or improvement occurred in 16 (70%) patients. The pain and discomfort score was stable or improved in 22 (96%). Pressure sores were found in three (13%) infants. Humidity was 98% (98-99%) and fell to 40% (39-43%) after the humidifier was stopped. The noise level in the helmet was 81 (77-94) dB-SPL.Conclusions: The helmet was a satisfactory interface for CPAP delivery in young infants in more than two-thirds of the cases. Pressure sores can be prevented by placing a cushion in the helmet. Caregivers need to take into account the high humidity and noise levels of this interface

Interest of high‑flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) during the initial management of severe bronchiolitis in infants: a multicenter randomized controlled trial

International audienceIntroduction The aim of this study was to evaluate the long-term effects of the implementation of “good laboratory test practices” pro-cedure on blood test prescription, cost cutting laboratory test and patient outcome and red cells transfusion needs. In addition, we looked for factors associated with transfusion.Patients and methods This is a retrospective, single-center study.Considering that prescription of laboratory tests was excessive in our ICU, we developed in 2009 a procedure aiming at limiting assays and blood sampling. All adult patients over 18 years admitted in the ICU from January 1, 2008, to December 31, 2012, were consecutively included. For each patient, the following data were retrospectively obtained from medical records and institutional databases: demo-graphic and severity of illness parameters, the amount and costs of laboratory tests, daily blood volume drawn, number of red cells trans-fusions and ICU and in-hospital outcomes.Results A total of 3568 patients were included between January 1, 2008, and December 31, 2012. Patient’s characteristics were similar during the study with respect to overall severity and vital organ sup-port, except the need for vasoactive drugs which increased across time. After implementation of guidelines, the total number of labora-tory tests decreased from 78,406 in 2008 (18.1 tests/patient/day) to 27,514 in 2012 (6.4 tests/patient/day). 318,000€ were saved in 2012 on the five more expensive tests as compared to 2008. Average daily blood drawn volume decreased from 29.2 ± 13 ml/day in 2008 to 22.4 ± 10.1 ml/day (p < 0.001) in 2012 in the whole population. The decline was larger for transfused patients (33.8 ± 15.6 ml/day in 2008 to 23.6 ± 10.7 ml/day in 2012 p < 0.001). We observed a nonsignifi-cant reduction in PRBC administered after the institution of guidelines. Hemoglobin threshold for blood transfusion remained unchanged over time. There was a significant relationship between daily blood volume loss and blood transfusion [OR 1.012 per ml volume drawn CI (1.009–1.014), p < 0.001], but mechanical ventilation, renal replace-ment, invasive monitoring and use of vasoactive drugs were more potent independent factors for transfusion. ICU and in-hospital mor-tality did not change across time (p= 0.367 and p= 0.361)Conclusion Guidelines of laboratory tests prescription led to a sus-tained reduction in the number of laboratory tests and related costs, the average daily blood volume drawn, without changing the ICU and in-hospital mortality. Although there was a correlation between the amount of blood sampled and the transfusion of PRBC, the number of patients transfused and the amount of red blood cells transfused did not significantly decrease

Isolated neonatal bilateral vocal cord paralysis revealing a unilateral medullary defect: a case report

International audienceBackground : Congenital bilateral vocal cord paralysis is a rare occurrence. Approximately half the cases areassociated with a major comorbidity, usually neurological, neuromuscular or malformative. Case presentation : In a male newborn, respiratory distress syndrome and stridor were observed immediatelyfollowing birth. The cause was bilateral vocal cord paralysis in the adducted position. Neuroradiologicalinvestigation revealed a unilateral discontinuity between the upper pons and the right medulla oblongata. Hypoplasia of the right posterior hemiarches of C1-C2and the right exo-occipital bone was observed, as wasa small clivus. MR angiography showed the absence of the distal right vertebral artery, with hypoplasia andparietal irregularities of the proximal segments. Respiratory autonomy was not obtained despite endoscopiclaser cordotomy, corticosteroid therapy and nasal continuous positive airway pressure. The infant died at theage of 4 weeks after treatment was limited to comfort care. Conclusions : A medullary lesion is an exceptional cause of congenital bilateral vocal cord paralysis. The strictlyunilateral neurological and vascular defect and the absence of associated intracranial or extracranial malformationmake this clinical case unique and suggest a disruptive mechanism. This case also highlights the help provided byadvanced neuroimaging techniques, i.e. fibre tracking using diffusion tensor imaging, in the decision-making process