Akute Fremdkörperverlegung der Atemwege bei Kindern

Zusammenfassung: Hintergrund: Die Fremdkörperverlegung der Atemwege beim Kind stellt eine akut lebensbedrohliche respiratorische Notfallsituation dar. Es sind v.a. Kleinkinder in den ersten 3 Lebensjahren betroffen. Esswaren, insbesondere Nüsse, sind die am häufigsten aspirierten Fremdkörper. Akute Erstickungsgefahr besteht bei laryngealer und trachealer Lage des Fremdkörpers. Klinik und Differenzialdiagnose: Typisch für eine Fremdkörperaspiration ist der plötzlich einsetzende Husten und/oder Würgen, ggf. begleitet von Atemnot und Stridor. Persistiert der Fremdkörper, resultiert ein beträchtlicher Husten. Laryngeal und tracheal gelegene Fremdkörper können zur respiratorischen Insuffizienz, Bewusstlosigkeit und Kreislaufstillstand führen. Differenzialdiagnostisch muss an eine schwere bronchiale, infektiöse oder allergische Obstruktion der oberen Atemwege oder an einen großen Fremdkörper im Ösophagus gedacht werden. Erstversorgung: Kinder mit akuter Fremdkörperverlegung der Atemwege mit oder ohne Dyspnoe/Erstickungsgefahr, jedoch noch mit effektivem Husten und Atmung, sollen ohne Extraktionsmanöver vor Ort baldmöglichst der Bronchoskopie zugeführt werden. Bei wachen Kindern mit ineffektivem Hustenstoß muss mit Rückenschlägen, Thoraxkompression beim Säugling bzw. abdomineller Kompression beim  > 1Jahr alten Kind versucht werden, den Fremdkörper in eine günstigere Lage zu dislozieren. Das bewusstlose, ateminsuffiziente Kind wird beatmet. Erfolgt damit keine Reaktion, wird mit der Herzmassage bzw. der kardiopulmonalen Reanimation begonnen. Der erfahrene Ersthelfer sollte mittels Laryngoskopie einen laryngealen Fremdkörper entfernen bzw. mit einem Endotracheltubus einen trachealen Fremdkörper tiefer in einen Hauptstammbronchus schieben und das Kind unilateral beatmet der Notfallendoskopie zuführen. Jedes Kind muss nach einem akuten schweren Hustenanfall - auch wenn die Symptome verschwunden sind - einer Bronchoskopie unterzogen werden, um potenzielle Fremdkörper zu entfernen und damit eine sekundäre Dislokation in die oberen Atemwege bzw. poststenotische Komplikationen zu verhinder

Das zyanotische Kind mit kardialer Erkrankung im Notfalldienst

Zusammenfassung: Im Gegensatz zu Erwachsenen mit vorwiegend pulmonalen Erkrankungen wie der chronisch obstruktiven Lungenerkrankung, entsteht bei Kindern eine zentrale Zyanose meist durch angeborene Herzfehler. Zyanotische Herzfehler kommen mit einer Häufigkeit von ca.13 pro 10.000Lebendgeburten vor. Dadurch, dass heutzutage auch komplexe Herzfehler erfolgreich palliiert werden, steigt die Wahrscheinlichkeit stetig an, im Rettungsdienst Kindern mit einer zentralen Zyanose zu begegnen. Ursachen für das untersättigte Blut in den großen Arterien können eine Minderperfusion der Lungen oder eine vermehrte Durchmischung von arteriellen mit venösem Blut über einen Rechts-Links-Shunt sein. Der beste Indikator einer zentralen Zyanose ist die Zunge, da sie reichlich vaskularisiert und frei von Pigmenten ist. Je nach Altersklasse ist eher eine primäre Volumentherapie oder eine großzügige Sauerstoffapplikation essenziell, oder aber auch keine Notfalltherapie notwendig. Nach der präklinischen Versorgung ist eine stationäre Einweisung unabdingbar, bevorzugt in ein Zentrum mit der Option der kinderintensivmedizinischen oder kinderkardiologischen Betreuun

Intravenöse Midazolam-Ketamin-Anästhesie zur geschlossenen Reposition der Vorderarmfraktur bei Kindern: Bringt eine zusätzliche axilläre Plexusblockade Vorteile?

Zusammenfassung: Hintergrund: Das Ziel dieser Studie war es zu vergleichen, ob der intravenöse Ketaminbedarf bei Midazolam-Ketamin-Anästhesie durch die Kombination mit einer axillären Plexusblockade zur geschlossenen Reposition einer Vorderarmfraktur bei Kindern reduziert werden kann. Methoden: Mit dem Einverständnis der Ethikkommission wurde eine retrospektive Gruppenanalyse bei Kindern durchgeführt, die in den Jahren 2000-2001 eine Midazolam-Ketamin-Anästhesie (GruppeA) oder in den Jahren 2002-2004 eine Midazolam-Ketamin-Anästhesie in Kombination mit einer axillären Plexusblockade (GruppeB) zur geschlossenen Reposition einer Vorderarmfraktur erhielten. Der Bedarf an Ketamin und postoperativen Analgetika wurde erfasst. Die Daten der Gruppen wurden mit dem Mann-Whitney-U-Test (nichtnormalverteilte Daten) oder dem T-Test (normalverteilte Daten) und dem χ2-Test verglichen (p<0,05). Ergebnisse: Insgesamt wurden 455Kinder (GruppeA: 225, GruppeB: 230) in die Studie aufgenommen. Der Bedarf an intravenösem Ketamin differierte statistisch nicht signifikant zwischen den beiden Gruppen (p=0,154). Der Ketaminbedarf in GruppeB wurde jedoch signifikant geringer, wenn das Zeitintervall zwischen dem Beginn der Plexusanästhesie und dem Beginn der Intervention mehr als 15min betrug (p<0,05). Patienten der GruppeB benötigten weniger Analgetika in der postoperativen Phase (p<0,01). Schlussfolgerung: Durch die Kombination der Midazolam-Ketamin-Anästhesie mit der axillären Plexusblockade zur geschlossenen Reposition einer Vorderarmfraktur bei Kindern ließ sich der Bedarf an Ketamin in der klinischen Routine einer Notfallstation nicht reduziere

Effect of statins on venous thromboembolic events: a meta-analysis of published and unpublished evidence from randomised controlled trials

Background - It has been suggested that statins substantially reduce the risk of venous thromboembolic events. We sought to test this hypothesis by performing a meta-analysis of both published and unpublished results from randomised trials of statins. Methods and Findings - We searched MEDLINE, EMBASE, and Cochrane CENTRAL up to March 2012 for randomised controlled trials comparing statin with no statin, or comparing high dose versus standard dose statin, with 100 or more randomised participants and at least 6 months' follow-up. Investigators were contacted for unpublished information about venous thromboembolic events during follow-up. Twenty-two trials of statin versus control (105,759 participants) and seven trials of an intensive versus a standard dose statin regimen (40,594 participants) were included. In trials of statin versus control, allocation to statin therapy did not significantly reduce the risk of venous thromboembolic events (465 [0.9%] statin versus 521 [1.0%] control, odds ratio [OR] = 0.89, 95% CI 0.78–1.01, p = 0.08) with no evidence of heterogeneity between effects on deep vein thrombosis (266 versus 311, OR 0.85, 95% CI 0.72–1.01) and effects on pulmonary embolism (205 versus 222, OR 0.92, 95% CI 0.76–1.12). Exclusion of the trial result that provided the motivation for our meta-analysis (JUPITER) had little impact on the findings for venous thromboembolic events (431 [0.9%] versus 461 [1.0%], OR = 0.93 [95% CI 0.82–1.07], p = 0.32 among the other 21 trials). There was no evidence that higher dose statin therapy reduced the risk of venous thromboembolic events compared with standard dose statin therapy (198 [1.0%] versus 202 [1.0%], OR = 0.98, 95% CI 0.80–1.20, p = 0.87). Risk of bias overall was small but a certain degree of effect underestimation due to random error cannot be ruled out. Please see later in the article for the Editors' Summary. Conclusions - The findings from this meta-analysis do not support the previous suggestion of a large protective effect of statins (or higher dose statins) on venous thromboembolic events. However, a more moderate reduction in risk up to about one-fifth cannot be ruled out

The Fate of Children with Microdeletion 22q11.2 Syndrome and Congenital Heart Defect: Clinical Course and Cardiac Outcome

Background: This study aimed to evaluate the cardiac outcome for children with microdeletion 22q11.2 and congenital heart defect (CHD). Methods: A total of 49 consecutive children with 22q11.2 and CHD were retrospectively identified. The CHD consisted of tetralogy of Fallot and variances (n = 22), interrupted aortic arch (n = 10), ventricular septal defect (n = 8), truncus arteriosus (n = 6), and double aortic arch (n = 1). Extracardiac anomalies were present in 46 of 47 children. Results: The median follow-up time was 8.5 years (range, 3 months to 23.5 years). Cardiac surgical repair was performed for 35 children, whereas 5 had palliative surgery, and 9 never underwent cardiac surgery. The median age at repair was 7.5 months (range, 2 days to 5 years). The mean hospital stay was 35 days (range, 7-204 days), and the intensive care unit stay was 15 days (range, 3-194 days). Significant postoperative complications occurred for 26 children (74%), and surgery for extracardiac malformations was required for 21 patients (43%). The overall mortality rate was 22% (11/49), with 1-year survival for 86% and 5-year survival for 80% of the patients. A total of 27 cardiac reinterventions were performed for 16 patients (46%) including 15 reoperations and 12 interventional catheterizations. Residual cardiac findings were present in 25 patients (71%) at the end of the follow-up period. Conclusions: Children with microdeletion 22q11.2 and CHD are at high risk for mortality and morbidity, as determined by both the severity of the cardiac lesions and the extracardiac anomalies associated with the microdeletio

Cardiac output measurement in children: comparison of Aesculon® cardiac output monitor and thermodilution

Background We compared cardiac output (CO) measurements by the non-invasive electrical velocimetry (Aesculon®) monitor with the pulmonary artery catheter (PAC) thermodilution method in children. Methods CO values using the Aesculon® monitor and PAC thermodilution were simultaneously recorded during cardiac catheterization in children. Measurements were performed under general anaesthesia. To compare, three consecutive measurements for each patient within 3 min were obtained. The means of the three values were compared using simple regression and Bland-Altman analysis. Data were presented as mean (sd). A mean percentage of <30% was defined to indicate clinical useful reliability of the Aesculon® monitor. Results A total of 50 patients with a median (range) age of 7.5 (0.5-16.5) yr were enrolled in the study. Mean CO values were 3.7 (1.5) litre min−1 (PAC thermodilution) and 3.1 (1.7) litre min−1 (Aesculon® monitor). Analysis for CO measurement showed a good correlation between the two methods (r=0.894; P<0.0001). The bias between the two methods was 0.66 litre min−1 with a precision of 1.49 litre min−1. The mean percentage error for CO measurements was 48.9% for the Aesculon® monitor when compared with PAC thermodilution. Conclusions Electrical velocimetry using the Aesculon® monitor did not provide reliable CO values when compared with PAC thermodilution. Whether the Aesculon® monitor can be used as a CO trend monitor has to be assessed by further investigations in patients with changing haemodynamic

Tracheal tube-tip displacement in children during head-neck movement—a radiological assessment

Background. Aims of this study were to assess the maximum displacement of tracheal tube tip during head-neck movement in children, and to evaluate the appropriateness of the intubation depth marks on the Microcuff Paediatric Endotracheal Tube regarding the risk of inadvertent extubation and endobronchial intubation. Methods. We studied children, aged from birth to adolescence, undergoing cardiac catheterization. The patients' tracheas were orally intubated and the tracheal tubes positioned with the intubation depth mark at the level of the vocal cords. The tracheal tube tip-to-carina distances were fluoroscopically assessed with the patient supine and the head-neck in 30° flexion, 0° neutral position and 30° extension. Results. One hundred children aged between 0.02 and 16.4 yr (median 5.1 yr) were studied. Maximum tracheal tube-tip displacement after head-neck 30° extension and 30° flexion demonstrated a linear relationship to age [maximal upward tube movement (mm)=0 0.71×age (yr)+9.9 (R2=0.893); maximal downward tube movement (mm)=0.83×age (yr)+9.3 (R2=0.949)]. Maximal tracheal tube-tip downward displacement because of head-neck flexion was more pronounced than upward displacement because of head-neck extension. Conclusions. The intubation depth marks were appropriate to avoid inadvertent tracheal extubation and endobronchial intubation during head-neck movement in all patients. However, during head-neck extension the tracheal tube cuff may become positioned in the subglottic region and should be re-adjusted when the patient remains in this position for a longer tim

Chronic ventricular pacing in children: toward prevention of pacing-induced heart disease

In children with congenital or acquired complete atrioventricular (AV) block, ventricular pacing is indicated to increase heart rate. Ventricular pacing is highly beneficial in these patients, but an important side effect is that it induces abnormal electrical activation patterns. Traditionally, ventricular pacemaker leads are positioned at the right ventricle (RV). The dyssynchronous pattern of ventricular activation due to RV pacing is associated with an acute and chronic impairment of left ventricular (LV) function, structural remodeling of the LV, and increased risk of heart failure. Since the degree of pacing-induced dyssynchrony varies between the different pacing sites, ‘optimal-site pacing’ should aim at the prevention of mechanical dyssynchrony. Especially in children, generally paced from a very early age and having a perspective of life-long pacing, the preservation of cardiac function during chronic ventricular pacing should take high priority. In the perspective of the (patho)physiology of ventricular pacing and the importance of the sequence of activation, this paper provides an overview of the current knowledge regarding possible alternative sites for chronic ventricular pacing. Furthermore, clinical implications and practical concerns of the various pacing sites are discussed. The review concludes with recommendations for optimal-site pacing in children

Cost impact of procalcitonin-guided decision making on duration of antibiotic therapy for suspected early-onset sepsis in neonates

Abstract Backgrounds The large, international, randomized controlled NeoPInS trial showed that procalcitonin (PCT)-guided decision making was superior to standard care in reducing the duration of antibiotic therapy and hospitalization in neonates suspected of early-onset sepsis (EOS), without increased adverse events. This study aimed to perform a cost-minimization study of the NeoPInS trial, comparing health care costs of standard care and PCT-guided decision making based on the NeoPInS algorithm, and to analyze subgroups based on country, risk category and gestational age. Methods Data from the NeoPInS trial in neonates born after 34 weeks of gestational age with suspected EOS in the first 72 h of life requiring antibiotic therapy were used. We performed a cost-minimization study of health care costs, comparing standard care to PCT-guided decision making. Results In total, 1489 neonates were included in the study, of which 754 were treated according to PCT-guided decision making and 735 received standard care. Mean health care costs of PCT-guided decision making were not significantly different from costs of standard care (€3649 vs. €3616). Considering subgroups, we found a significant reduction in health care costs of PCT-guided decision making for risk category ‘infection unlikely’ and for gestational age ≥ 37 weeks in the Netherlands, Switzerland and the Czech Republic, and for gestational age < 37 weeks in the Czech Republic. Conclusions Health care costs of PCT-guided decision making of term and late-preterm neonates with suspected EOS are not significantly different from costs of standard care. Significant cost reduction was found for risk category ‘infection unlikely,’ and is affected by both the price of PCT-testing and (prolonged) hospitalization due to SAEs

Machine learning used to compare the diagnostic accuracy of risk factors, clinical signs and biomarkers and to develop a new prediction model for neonatal early-onset sepsis

Background: Current strategies for risk stratification and prediction of neonatal early-onset sepsis (EOS) are inefficient and lack diagnostic performance. The aim of this study was to use machine learning to analyze the diagnostic accuracy of risk factors (RFs), clinical signs and biomarkers and to develop a prediction model for culture-proven EOS. We hypothesized that the contribution to diagnostic accuracy of biomarkers is higher than of RFs or clinical signs. Study Design: Secondary analysis of the prospective international multicenter NeoPInS study. Neonates born after completed 34 weeks of gestation with antibiotic therapy due to suspected EOS within the first 72 hours of life participated. Primary outcome was defined as predictive performance for culture-proven EOS with variables known at the start of antibiotic therapy. Machine learning was used in form of a random forest classifier. Results: One thousand six hundred eighty-five neonates treated for suspected infection were analyzed. Biomarkers were superior to clinical signs and RFs for prediction of culture-proven EOS. C-reactive protein and white blood cells were most important for the prediction of the culture result. Our full model achieved an area-under-the-receiver-operating-characteristic-curve of 83.41% (±8.8%) and an area-under-the-precision-recall-curve of 28.42% (±11.5%). The predictive performance of the model with RFs alone was comparable with random. Conclusions: Biomarkers have to be considered in algorithms for the management of neonates suspected of EOS. A 2-step approach with a screening tool for all neonates in combination with our model in the preselected population with an increased risk for EOS may have the potential to reduce the start of unnecessary antibiotics