The Microcirculation Is Unchanged in Neonates with Severe Respiratory Failure after the Initiation of ECMO Treatment

Purpose. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is known to improve cardiorespiratory function and outcome in neonates with severe respiratory failure. We tested the hypothesis that VA-ECMO therapy improves the microcirculation in neonates with severe respiratory failure. Methods. This single-center prospective observational pilot study took place in an intensive care unit of a level III university children's hospital. Twenty-one-term neonates, who received VA-ECMO treatment, were included. The microcirculation was assessed in the buccal mucosa, using Orthogonal Polarization Spectral imaging, within 24 hours before (T1) and within the first 24 hours after initiation of ECMO treatment (T2). Data were compared to data of a ventilated control group (N = 7). Results. At baseline (T1), median functional capillary density (FCD), microvascular flow index (MFI), and heterogeneity index (HI) did not differ between the ECMO group and the control group. At T2 the median FCD was lower in the control group (median [range]: 2.4 [1.4–4.2] versus 4.3 [2.8–7.4] cm/cm2; P value <0.001). For MFI and HI there were no differences at T2 between the two groups. Conclusion. The perfusion of the microcirculation does not change after initiation of VA-ECMO treatment in neonates with severe respiratory failure

Inhaled nitric oxide improves systemic microcirculation in infants with hypoxemic respiratory failure

To investigate the effect of inhaled nitric oxide on the systemic microcirculation. We hypothesized that inhaled nitric oxide improves the systemic microcirculation. Inhaled nitric oxide improves outcome in infants with persistent pulmonary hypertension of the newborn diagnosed by improving pulmonary blood flow and oxygenation. It reduces pulmonary vascular resistance without decline in systemic blood pressure. Inhaled nitric oxide is also utilized in the treatment of acute hypoxemic respiratory failure in children and adults. It is thought to improve regional ventilation perfusion by regional selective pulmonary vasodilation. Pilot study. Intensive care unit of a level III university children's hospital. Consecutive ventilated patients who were treated with inhaled nitric oxide (20 ppm) were enrolled in this study. Eight patients (five boys, three girls) were included; five had congenital diaphragmatic hernia diagnosed, one had persistent pulmonary hypertension of the newborn diagnosed, one had acute respiratory distress syndrome diagnosed, and one had bronchiolitis diagnosed. The median age was 0 months (range, 0-38 months). Inhaled nitric oxide administration. The microcirculation was assessed in the buccal mucosa within 1 hr before and within 1 hr after the start of inhaled nitric oxide using orthogonal polarization spectral imaging. The median functional capillary density before the inhaled nitric oxide was started was 4.0 cm/cm (range, 1.8-5.6 cm/cm) and improved to 4.9 cm/cm (range, 2.8-6.6 cm/cm; p = .017) after the start of inhaled nitric oxide. Inhaled nitric oxide improves the systemic microcirculation in children with hypoxemic respiratory failur

The Maxillary Nerve Block in Cleft Palate Care: A Review of the Literature and Expert’s Opinion on the Preferred Technique of Administration

Maxillary nerve; Cleft palateNervio maxilar; Paladar hendidoNervi maxil·lar; Paladar esquerdatIntroduction: Although the maxillary nerve block (MNB) provides adequate pain relief in cleft palate surgery, it is not routinely used globally, and reported techniques are heterogeneous. This study aims to describe relevant anatomy and to present the preferred technique of MNB administration based on the current literature and the expert opinion of the authors. Method and materials: First, a survey was sent to 432 registrants of the International Cleft Palate Master Course Amsterdam 2023. Second, MEDLINE (PubMed interface) was searched for relevant literature on maxillary artery (MA) anatomy and MNB administration in pediatric patients. Results: Survey response rate was 18% (n=78). Thirty-five respondents (44.9%) used MNB for cleft palate surgery before the course. A suprazygomatic approach with needle reorientation towards the ipsilateral commissure before incision was most frequently reported, mostly without the use of ultrasound. Ten and 20 articles were included on, respectively, MA anatomy and MNB administration. A 47.5% to 69.4% of the MA’s run superficial to the lateral pterygoid muscle and 32% to 52.5% medially. The most frequently described technique for MNB administration is the suprazygomatic approach. Reorientation of the needle towards the anterior aspect of the contralateral tragus appears optimal. Needle reorientation angles do not have to be adjusted for age, unlike needle depth. The preferred anesthetics are either ropivacaine or (levo)bupivacaine, with dexmedetomidine as an adjuvant. Conclusion: Described MNB techniques are heterogeneous throughout the literature and among survey respondents and not routinely used. Further research is required comparing different techniques regarding efficacy and safety

Early microcirculatory impairment during therapeutic hypothermia is associated with poor outcome in post-cardiac arrest children: a prospective observational cohort study

This study aimed to evaluate if the microcirculation is impaired during and after therapeutic hypothermia (TH) in children with return of spontaneous circulation after cardiac arrest (CA) and to assess if microcirculatory impairment predicts mortality. This has been reported for post-CA adults, but results might be different for children because etiology, pathophysiology, and mortality rate differ. This prospective observational cohort study included consecutive, non-neonatal post-CA children receiving TH upon intensive care admission between June 2008 and June 2012. Also included were gender-matched and age-matched normothermic, control children without cardiorespiratory disease. The buccal microcirculation was non-invasively assessed with Sidestream Dark Field Imaging at the start of TH, halfway during TH, at the start of re-warming, and at normothermia. Macrocirculatory, respiratory, and biochemical parameters were also collected. Twenty post-CA children were included of whom 9 died. During hypothermia, the microcirculation was impaired in the post-CA patients and did not change over time. At normothermia, the core body temperature and the microcirculation had increased and no longer differed from the controls. Microcirculatory deterioration was associated with mortality in the post-CA patients. In particular, the microcirculation was more severely impaired at TH start in the non-survivors than in the survivors - positive predictive value: 73-83, negative predictive value: 75-100, sensitivity: 63-100%, and specificity: 70-90%. The microcirculation is impaired in post-CA children during TH and more severe impairment at TH start was associated with mortality. After the stop of TH, the microcirculation improves rapidly irrespective of outcom

Factors influencing plasma transfusion practices in paediatric intensive care units around the world

Background and Objectives Plasma transfusions are a frequent treatment worldwide, but many studies have reported a wide variation in the indications to transfuse. Recently, an international paediatric study also showed wide variation in frequency in the use of plasma transfusions: 25% of the centres transfused plasma to >5% of their patients, whereas another 25% transfused plasma to <1% of their patients. The objective of this study was to explore the factors associated with different plasma transfusion practices in these centres. Materials and Methods Online survey sent to the local investigators of the 101 participating centres, in February 2016. Four areas were explored: beliefs regarding plasma transfusion, patients’ case‐mix in each unit, unit's characteristics, and local blood product transfusion policies and processes. Results The response rate was 82% (83/101). 43% of the respondents believed that plasma transfusions can arrest bleeding, whereas 27% believe that plasma transfusion can prevent bleeding. Centres with the highest plasma transfusion rate were more likely to think that hypovolaemia and mildly abnormal coagulation tests are appropriate indications for plasma transfusions (P = 0·02 and P = 0·04, respectively). Case‐mix, centre characteristics or local transfusion services were not identified as significant relevant factors. Conclusion Factors influencing plasma transfusion practices reflect beliefs about indications and the efficacy of transfusion in the prevention and management of bleeding as well as effects on coagulation tests. Educational and other initiatives to target these beliefs should be the focus of research