Serious complications of an obstructive upper airway infection in a young child

A 15-month old boy was admitted to our intensive care unit (ICU) cyanotic, unresponsive, apneic, pulseless, with fixed, dilated pupils and a Glasgow Coma Score (GCS) of 3/15. Prompt cardiopulmonary resuscitation (CPR) was initiated and cardiac function was resumed after 10 minutes. The boy was intubated but could not be ventilated because of a thick, viscous secretion obstructing the trachea and causing total airway obstruction. Bronchoscopy revealed laryngotracheitis as the reason for airway obstruction. A computed tomography (CT) scan of the brain showed diffuse edema and ischemic brain injury, which were considered responsible for the boy\u27s comatose situation. Clinical status remained unchanged for 11 days, after which the boy was transported to another hospital. In children presenting with upper airway obstructing syndromes, not responding to therapy, the diagnosis of bacterial tracheitis should be considered and the child should be monitored in a pediatric intensive care unit

Zbrinjavanje otežanog dišnog puta – vječni izazov: prikaz bolesnika

Introduction: Obtaining a secured airway is a vital aspect during reconstructive surgery in patients with extensive post-burn mentosternal scar contractures. Such contractures can potentially lead to a “can’t intubate, can’t ventilate” scenario, otherwise rare but life-threatening situation. We present a case of successful management of a paediatric case of anticipated difficult airway due to burn injury. Case description: A 14-year-old boy presented for repair of an extensive skin contracture of the neck, thorax and face due to mutilating scarring. The boy was treated for 80% burn caused by gasoline flame 14 months prior to this surgery. Burn healing and scarring resulted in massive distortion of the facial and cervical anatomy, all implying difficult airway with a high probability of “can’t intubate, can’t ventilate” situation. Flexible fiberoptic bronchoscope with loaded cuffed endotracheal tube N° 6.0 was used for visualisation of vocal cords through the mouth in light sedation with spontaneous breathing. After visualisation of the vocal cords, fentanyl (Fentanyl, GlaxoSmithKline) and thiopental (Thiopental, Rotexmedica) were administered and the trachea was intubated at the first attempt. Balanced general anaesthesia was initiated and planned surgical procedure was successfully completed. The trachea was extubated on the first postoperative day without any complication. Conclusion: Difficult paediatric airway and particularly “can’t intubate, can’t ventilate” situation is a problem associated with significant risks and complications. Anticipating a difficult airway, having a structured approach with appropriate preparation, and understanding of difficult airway management algorithms are essential for success.Uvod: Zbrinjavanje dišnog puta od vitalne je važnosti za bolesnika kod kojeg je indiciran rekonstruktivni zahvat nakon opsežnihopeklina lica i vrata. Kontrakture koje nastaju nakon takvih ozljeda mogu dovesti do nemogućnosti intubacije i ventilacije, što predstavljarijetku ali životno ugrožavajuću situaciju. Prikazati ćemo uspješno zbrinjavanje pedijatrijskog bolesnika sa očekivano otežanimzbrinjavanjem dišnog puta.Prikaz slučaja: Četrnaestogodišnji dječak sa opsežnom opeklinom lica, vrata i prsnog koša bio je predviđen za rekonstruktivni zahvat.Cijeljenje opekline, koja je nastala 14 mjeseci prije planiranog zahvata, rezultiralo je opsežnom kontrakturom i promjenom anatomijelica i vrata. Radi promijenjenih anatomskih odnosa bilo je očekivano da će zbrinjavanje dišnog puta biti otežano. Za vizualizacijuglasnica korišten je fleksibilni fiberoptički bronhoskop s pripremljenim endotrahealnim tubusom dok je bolesnik bio u plitkoj sedacijii disao spontano. Nakon vizualizacije glasnica bolesnik je dobio fentanil (Fentanyl, GlaxoSmithKline) i tiopental (Thiopental, Rotexmedica)te je potom intubiran iz prvog pokušaja. Nastavljena je balansirana opća anestezija, planirani zahvat je uspješno dovršen.Bolesnik je ekstubiran prvi postoperativni dan bez ikakvih komplikacija.Zaključak: Otežani dišni put u pedijatrijskih bolesnika je problem povezan s brojnim rizicima i komplikacijama. Prepoznavanje otežanogdišnog puta uz adekvatnu pripremu i poznavanje algoritama za zbrinjavanje otežanog dišnog puta ključno je za sigurnostbolesnika

AIRWAY MANAGEMENT IN A CHILD WITH EDWARD’S SYNDROME

Prikazujemo zbrinjavanje dišnog puta u djevojčice s mozaičnim tipom Edwardsovog sindroma za planirani zahvat laparotomije u općoj anesteziji. Manifestacije Edwardsovog sindroma među ostalima su kraniofacijalne malformacije te je moguća otežana ventilacija i intubacija. U našem slučaju djevojčica je, ovisno o potrebi zahvata, imala postavljeno supraglotično pomagalo tijekom anestezije za dijagnostičku pretragu magnetskom rezonancijom (MR), intubirana je fi berbronhoskopski za elektivni zahvat laparoskopije, a u jedinici intenzivne medicine direktnom laringoskopijom. Ventilacija i intubacija protekle su bez komplikacija. Poslijeoperacijski oporavak komplicirao se hipotonijom, pneumonijom te potrebom za reintubacijom i mehaničkom ventilacijom.We report on airway management in a girl with mosaic type of Edward’s syndrome for elective surgery, laparotomy in general anesthesia. In Edward’s syndrome, among other manifestations, craniofacial anomalies are expressed and there is a possibility of diffi cult ventilation and intubation. In this case, we secured the airway with supraglottic airway device during diagnostics (anesthesia for magnetic resonance imaging), we performed fi beroptic intubation for elective laparoscopy, and in the intensive care unit, she was intubated with direct laryngoscopy. Ventilation and intubation were accomplished without problems. Postoperative recovery was complicated with hypotonia, pneumonia and the need of reintubation and mechanical ventilation

Multidisciplinarno zbrinjavanje kongenitalnog teratoma vrata - prikaz slučaja

UVOD: Kongentinalni teratom je najčešći tumor neonatalne dobi s prevalencijom od 2 do 9% u području glave i vrata. Dijagnoza se može postaviti prenatalno ultrazvučnim (UZV) pregledom ili magnetskom rezonancijom (MR-om). Postpartalno, veliki teratomi u regiji vrata mogu uzrokovati kompresiju dišnog puta, te je njihovo zbrinjavanje potrebno provoditi u centrima koji mogu pružiti akutno zbrinjavanje mogućih komplikacija tijekom poroda i adekvatnu postpartalnu njegu. PRIKAZ SLUČAJA: Radi se o djetetu kojemu je intrauterino verificirana velika tumorska tvorba u području desne strane vrata. Po porodu je novorođenče bilo bez spontane akcije i respiracija, te je intubirano i mehanički ventilirano. U kliničkom statusu je dominirala tumorska tvorba desne strane vrata, promjera 5 cm, a radiološkom dijagnostikom (UZV i MR) postavljena je sumnja na limfangiom vrata veličine 7x7 cm. Učinjena je punkcija i klinasta biopsija tumora, te je inicijalni patohistološki nalaz govorio u prilog neuroblastoma. S obzirom na patohistološki nalaz, provedeno je kemoterapijsko liječenje, no unatoč terapiji došlo je do daljnjeg rasta tumorske mase i posljedične kompresije dišnog puta. Nakon dodatne radiološke evaluacije (CT vrata s angiografijom) u dobi od šest tjedana učinjena je kirurška ekstirpacija tumora. Operativni zahvat je protekao uredno, a patohistološki nalaz potvrdio je da se radi o nezrelom teratomu, te je onkološko liječenje završeno. Bolesnica je zahtijevala potporu mehaničkom ventilacijom do 60. dana života, nakon čega je disala samostalno, uz trahealnu kanilu. Posljedično osnovnoj bolesti i dugotrajnoj mehaničkoj ventilaciji, praćena je zbog laringotraheomalacije i suspektne pareze desne glasnice, te je uspješno dekanilirana u dobi od dvije godine. ZAKLJUČAK: Većina kongenitalnih teratoma je benigna, a mogu se prepoznati tijekom prenatalnog ultrazvučnog pregleda, te potvrditi fetalnim MR-om kojim je moguće prikazati odnos tumora prema vitalnim strukturama. Primarno liječenje uključuje resekciju tumorske tvorbe u cijelosti, a pojava rekurentnog teratoma je vrlo rijetka

Multidisciplinarno zbrinjavanje kongenitalnog teratoma vrata - prikaz slučaja

UVOD: Kongentinalni teratom je najčešći tumor neonatalne dobi s prevalencijom od 2 do 9% u području glave i vrata. Dijagnoza se može postaviti prenatalno ultrazvučnim (UZV) pregledom ili magnetskom rezonancijom (MR-om). Postpartalno, veliki teratomi u regiji vrata mogu uzrokovati kompresiju dišnog puta, te je njihovo zbrinjavanje potrebno provoditi u centrima koji mogu pružiti akutno zbrinjavanje mogućih komplikacija tijekom poroda i adekvatnu postpartalnu njegu. PRIKAZ SLUČAJA: Radi se o djetetu kojemu je intrauterino verificirana velika tumorska tvorba u području desne strane vrata. Po porodu je novorođenče bilo bez spontane akcije i respiracija, te je intubirano i mehanički ventilirano. U kliničkom statusu je dominirala tumorska tvorba desne strane vrata, promjera 5 cm, a radiološkom dijagnostikom (UZV i MR) postavljena je sumnja na limfangiom vrata veličine 7x7 cm. Učinjena je punkcija i klinasta biopsija tumora, te je inicijalni patohistološki nalaz govorio u prilog neuroblastoma. S obzirom na patohistološki nalaz, provedeno je kemoterapijsko liječenje, no unatoč terapiji došlo je do daljnjeg rasta tumorske mase i posljedične kompresije dišnog puta. Nakon dodatne radiološke evaluacije (CT vrata s angiografijom) u dobi od šest tjedana učinjena je kirurška ekstirpacija tumora. Operativni zahvat je protekao uredno, a patohistološki nalaz potvrdio je da se radi o nezrelom teratomu, te je onkološko liječenje završeno. Bolesnica je zahtijevala potporu mehaničkom ventilacijom do 60. dana života, nakon čega je disala samostalno, uz trahealnu kanilu. Posljedično osnovnoj bolesti i dugotrajnoj mehaničkoj ventilaciji, praćena je zbog laringotraheomalacije i suspektne pareze desne glasnice, te je uspješno dekanilirana u dobi od dvije godine. ZAKLJUČAK: Većina kongenitalnih teratoma je benigna, a mogu se prepoznati tijekom prenatalnog ultrazvučnog pregleda, te potvrditi fetalnim MR-om kojim je moguće prikazati odnos tumora prema vitalnim strukturama. Primarno liječenje uključuje resekciju tumorske tvorbe u cijelosti, a pojava rekurentnog teratoma je vrlo rijetka

High-dose ifosfamide and mitoxantrone (HDIM) in patients with relapsed or refractory Hodgkin's lymphoma

Relapsed/refractory Hodgkin's lymphoma (HL) is treated with salvage chemotherapy and autologous stem cell transplantation (ASCT). Optimal chemotherapy is unknown. We retrospectively analyzed outcomes of 58 patients treated with 2 cycles of high-dose ifosfamide and mitoxantrone (HDIM). HDIM consisted of ifosfamide 5 g/m(2)/day and MESNA 5 g/m(2)/day in continuous 24-h infusion (days 1 and 2), MESNA 2.5 g/m(2) over 12 h (day 3), and mitoxantrone 20 mg/m(2) (day 1) administered every 2 weeks. Stem cells were collected after the first cycle. Responding patients proceeded to ASCT. Toxicity was acceptable. Stem cell mobilization was successful in 96 % of patients. Overall response rate was 74 % (89 % in relapsing and 45 % in refractory patients) with 31 % complete remissions. After a median follow-up of 54 months, 5-year event-free survival was 56 % (69 % for relapsing and 35 % for refractory patients), and 5-year overall survival was 67 % (73 % for relapsing and 55 % for refractory patients). Significant adverse prognostic factors were refractoriness to previous therapy and HDIM failure. No differences in outcomes were noted between patients with early and late relapses or between complete and partial responders. HDIM is a well-tolerated and effective regimen for relapsed and refractory HL with excellent stem cell mobilizing properties. Patients failing HDIM may still benefit from other salvage options

High-dose ifosfamide and mitoxantrone (HDIM) in patients with relapsed or refractory Hodgkin’s lymphoma

Relapsed/refractory Hodgkin's lymphoma (HL) is treated with salvage chemotherapy and autologous stem cell transplantation (ASCT). Optimal chemotherapy is unknown. We retrospectively analyzed outcomes of 58 patients treated with 2 cycles of high-dose ifosfamide and mitoxantrone (HDIM). HDIM consisted of ifosfamide 5 g/m(2)/day and MESNA 5 g/m(2)/day in continuous 24-h infusion (days 1 and 2), MESNA 2.5 g/m(2) over 12 h (day 3), and mitoxantrone 20 mg/m(2) (day 1) administered every 2 weeks. Stem cells were collected after the first cycle. Responding patients proceeded to ASCT. Toxicity was acceptable. Stem cell mobilization was successful in 96 % of patients. Overall response rate was 74 % (89 % in relapsing and 45 % in refractory patients) with 31 % complete remissions. After a median follow-up of 54 months, 5-year event-free survival was 56 % (69 % for relapsing and 35 % for refractory patients), and 5-year overall survival was 67 % (73 % for relapsing and 55 % for refractory patients). Significant adverse prognostic factors were refractoriness to previous therapy and HDIM failure. No differences in outcomes were noted between patients with early and late relapses or between complete and partial responders. HDIM is a well-tolerated and effective regimen for relapsed and refractory HL with excellent stem cell mobilizing properties. Patients failing HDIM may still benefit from other salvage options

Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Azimuthal anisotropy of charged jet production in root s(NN)=2.76 TeV Pb-Pb collisions

We present measurements of the azimuthal dependence of charged jet production in central and semi-central root s(NN) = 2.76 TeV Pb-Pb collisions with respect to the second harmonic event plane, quantified as nu(ch)(2) (jet). Jet finding is performed employing the anti-k(T) algorithm with a resolution parameter R = 0.2 using charged tracks from the ALICE tracking system. The contribution of the azimuthal anisotropy of the underlying event is taken into account event-by-event. The remaining (statistical) region-to-region fluctuations are removed on an ensemble basis by unfolding the jet spectra for different event plane orientations independently. Significant non-zero nu(ch)(2) (jet) is observed in semi-central collisions (30-50% centrality) for 20 <p(T)(ch) (jet) <90 GeV/c. The azimuthal dependence of the charged jet production is similar to the dependence observed for jets comprising both charged and neutral fragments, and compatible with measurements of the nu(2) of single charged particles at high p(T). Good agreement between the data and predictions from JEWEL, an event generator simulating parton shower evolution in the presence of a dense QCD medium, is found in semi-central collisions. (C) 2015 CERN for the benefit of the ALICE Collaboration. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).Peer reviewe