Epinephrine induced cardiomyopathy in a child with anaphylaxis

Transient cardiomyopathy is an uncommon occurrence in patients with anaphylaxis. Catecholamine induced direct toxicity is one of the proposed mechanisms. We report a case of cardiomyopathy in a child with anaphylaxis who was treated with multiple doses of epinephrine as well as a continuous infusion of epinephrine. A twenty one month old girl with egg allergy presented to our hospital with anaphylaxis, after multiple doses of epinephrine injections, developed cardiorespiratory dysfunction and required endotracheal intubation and mechanical ventilation. Work up showed depressed cardiac function, which improved with milrinone and furosemide infusions. Conclusion: Epinephrine is the treatment of choice for anaphylaxis however caution should be exercised when administering multiple doses of epinephrine. Myocardial function needs to be assessed in children with persistent hypotension after anaphylaxis and catecholamine-induced cardiomyopathy should be considered in children with anaphylaxis when severe myocardial dysfunction is present

Esophageal capnometry during hemorrhagic shock and after resuscitation in rats

BACKGROUND: Splanchnic perfusion following hypovolemic shock is an important marker of adequate resuscitation. We tested whether the gap between esophageal partial carbon dioxide tension (PeCO(2)) and arterial partial carbon dioxide tension (PaCO(2)) is increased during graded hemorrhagic hypotension and reversed after blood reinfusion, using a fiberoptic carbon dioxide sensor. MATERIALS AND METHOD: Ten Sprague–Dawley rats were anesthetized, tracheotomized, and cannulated in one femoral artery and vein. A calibrated fiberoptic PCO(2 )probe was inserted into the distal third of the esophagus for determination of luminal PeCO(2 )during maintained anesthesia (pentobarbital 15 mg/kg per hour), normothermia (38 ± 0.5°C), and fluid balance (saline 5 ml/kg per hour). Three out of 10 rats were used to determine the limits of hemodynamic stability during gradual hemorrhage. Seven of the 10 rats were then subjected to mild and severe hemorrhage (15 and 20–25 ml/kg, respectively). Thirty minutes after severe hemorrhage, these rats were resuscitated by reinfusion of the shed blood. Arterial gas exchange, hemodynamic variables, and PeCO(2 )were recorded at each steady-state level of hemorrhage (at 30 and 60 min) and after resuscitation. RESULTS: The PeCO(2)–PaCO(2 )gap was significantly increased after mild and severe hemorrhage and returned to baseline (prehemorrhagic) values following blood reinfusion. Base deficit increased significantly following severe hemorrhage and remained significantly elevated after blood reinfusion. Significant correlations were found between base deficit and PeCO(2)–PaCO(2 )(P < 0.002) and PeCO(2 )(P < 0.022). Blood bicarbonate concentration decreased significantly following mild and severe hemorrhage, but its recovery was not complete at 60 min after blood reinfusion. CONCLUSION: Esophageal–arterial PCO(2 )gap increases during graded hemorrhagic hypotension and returns to baseline value after resuscitation without complete reversal of the base deficit. These data suggest that esophageal capnometry could be used as an alternative for gastric tonometry during management of hypovolemic shock

Parents’ Acute Illnesses, Hospitalizations, and Medication Changes During the Difficult First Year After Infant or Child NICU/PICU Death

Infant/child death is described as a most stressful life event; however, there are few reports of effects on parent physical health during the first year after the death. The study\u27s purpose is to examine the patterns of parent acute illnesses, hospitalizations, and medication changes over 1 to 13 months after neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU) infant/child death in 3 racial/ethnic groups. METHODS: Secondary analyses were conducted with longitudinal data on parent health and functioning 1 to 13 months after infant/child NICU/PICU death. Parents (176 mothers, 73 fathers; 44% Hispanic, 35% black non-Hispanic, and 21% white non-Hispanic) of deceased infants/children were recruited from 4 children\u27s hospitals and state death records. Inclusion criteria-parents understood English or Spanish and had a deceased neonate/child ≤ 18. Exclusion criteria -deceased newborn from multiple gestation pregnancy, child in foster care, child\u27s injury due to suspected abuse, or parent death in illness/injury event. Parents reported numbers and types of acute illnesses, hospitalizations, and medication changes 1 to 13 months postdeath. RESULTS: Parents\u27 acute illnesses, hospitalizations, and medication changes were greatest between months 1 and 6, with relative quiescence in months 7 to 10, and an increase in months 11 to 13. Mothers (aged 32 ± 7.8 years) reported 300 acute illnesses (primarily colds/flu, headaches, anxiety/depression, and infections) and 89 hospitalizations (primarily infections, chest pain, and gastrointestinal problems). Fathers (aged 37 ± 8.8 years) reported 104 acute illnesses (colds/flu and headaches) and 9 hospitalizations. CONCLUSION: After infant/child NICU/PICU death, mothers had greater morbidity than fathers, with no significant differences by race/ethnicity. Parents\u27 health needs to be monitored in months 1 to 6 and months 11 to 13, and interventions targeted to parents in these months

Cardiovascular stability during arteriovenous extracorporeal therapy: a randomized controlled study in lambs with acute lung injury

INTRODUCTION: Clinical application of arteriovenous (AV) extracorporeal membrane oxygenation (ECMO) requires assessment of cardiovascular ability to respond adequately to the presence of an AV shunt in the face of acute lung injury (ALI). This ability may be age dependent and vary with the experimental model. We studied cardiovascular stability in a lamb model of severe ALI, comparing conventional mechanical ventilation (CMV) with AV-ECMO therapy. METHODS: Seventeen lambs were anesthetized, tracheotomized, paralyzed, and ventilated to maintain normocapnia. Femoral and jugular veins, and femoral and carotid arteries were instrumented for the AV-ECMO circuit, systemic and pulmonary artery blood pressure monitoring, gas exchange, and cardiac output determination (thermodilution technique). A severe ALI (arterial oxygen tension/inspired fractional oxygen <200) was induced by lung lavage (repeated three times, each with 5 ml/kg saline) followed by tracheal instillation of 2.5 ml/kg of 0.1 N HCl. Lambs were consecutively assigned to CMV treatment (n = 8) or CMV plus AV-ECMO therapy using up to 15% of the cardiac output for the AV shunt flow during a 6-hour study period (n = 9). The outcome measures were the degree of inotropic and ventilator support needed to maintain hemodynamic stability and normocapnia, respectively. RESULTS: Five of the nine lambs subjected to AV-ECMO therapy (56%) died before completion of the 6-hour study period, as compared with two out of eight lambs (25%) in the CMV group (P > 0.05; Fisher's exact test). Surviving and nonsurviving lambs in the AV-ECMO group, unlike the CMV group, required continuous volume expansion and inotropic support (P < 0.001; Fisher's exact test). Lambs in the AV-ECMO group were able to maintain normocapnia with a maximum of 30% reduction in the minute ventilation, as compared with the CMV group (P < 0.05). CONCLUSION: AV-ECMO therapy in lambs subjected to severe ALI requires continuous hemodynamic support to maintain cardiovascular stability and normocapnia, as compared with lambs receiving CMV support

Case Report Spurious Hyperchloremia and Negative Anion Gap in a Child with Refractory Epilepsy

We report a case with spurious hyperchloremia with negative anion gap in a child who was taking potassium bromide for refractory epilepsy. Blood chemistry showed a high chloride level (171 mEq/L) and a negative anion gap (−52 mEq/L). Plasma chloride concentration is measured by an ion-selective electrode method; however the presence of other anions like bromide and iodides can interfere with chloride level and largely overestimates the chloride concentration. Thus hyperchloremia with a negative anion gap is a clue to the diagnosis of halides like bromide and iodide ingestion

Spurious Hyperchloremia and Negative Anion Gap in a Child with Refractory Epilepsy

We report a case with spurious hyperchloremia with negative anion gap in a child who was taking potassium bromide for refractory epilepsy. Blood chemistry showed a high chloride level (171 mEq/L) and a negative anion gap (−52 mEq/L). Plasma chloride concentration is measured by an ion-selective electrode method; however the presence of other anions like bromide and iodides can interfere with chloride level and largely overestimates the chloride concentration. Thus hyperchloremia with a negative anion gap is a clue to the diagnosis of halides like bromide and iodide ingestion

Do Racial/Ethnic and Economic Factors Affect the Rate of Complicated Appendicitis in Children?

Introduction. Appendicitis continues to be one of the most common surgical conditions in the pediatric population. We set out to determine demographic and practice variations among children admitted with appendicitis and highlight the racial/ethnic and healthcare access role in relation to the rate of complicated appendicitis using the 2012 Kids’ Inpatient Database (KID). Methodology. A retrospective cross-sectional database study was performed using the 2012 KID. All children (age 1 months to 20 years) with appendicitis were identified using the ICD-9 diagnosis codes. Children with a diagnosis of appendicitis were compared with all other discharges. Among children with appendicitis, demographic and practice variations and the rate of complicated appendicitis were evaluated. Univariate and multivariate analyses were done to analyze the data. Sample weighing was done to present national estimates. Results. In 2012, a total of 89, 935 out of 2.7 million pediatric hospital discharges (3.3%) had a diagnosis of appendicitis. The incidence of appendicitis was higher in males (4.7%), 6–15-year age group (7.43%), Hispanics (5.2%), and in the Western region (5.2%) and was lower in infants (0.02%) and African American children (1.2%) (p<0.0001). The proportion of children with peritonitis or abscess was higher in children’s hospitals (48.2% vs. 29.0%; OR 2.3, 95% CI: 2.2–2.4). The risk of complicated appendicitis was inversely related to age, while racial and ethnic minority status, bottom quartile of the income group, and government insurance increased the risk. Laparoscopic appendectomy was performed more frequently at children’s hospitals (84.8% vs. 74.3%; p<0.0001). Conclusions. Appendicitis is more common in Hispanics, males, older children, and in the Western region. Complicated appendicitis is more common in younger children, minority groups, low-income group, and children with government insurance. Children’s hospitals manage more children with complicated appendicitis and are more likely to perform laparoscopic appendectomy

Management of Anticoagulation during Extracorporeal Membrane Oxygenation in Children

Extracorporeal Membrane Oxygenation (ECMO) is often used in critically ill children with severe cardiopulmonary failure. Worldwide, about 3600 children are supported by ECMO each year, with an increase of 10% in cases per year. Although anticoagulation is necessary to prevent circuit thrombosis during ECMO support, bleeding and thrombosis are associated with significantly increased mortality risk. In addition, maintaining balanced hemostasis is a challenging task during ECMO support. While heparin is a standard anticoagulation therapy in ECMO, recently, newer anticoagulant agents are also in use. Currently, there is a wide variation in anticoagulation management and diagnostic monitoring in children receiving ECMO. This review intends to describe the pathophysiology of coagulation during ECMO support, review of literature on current and newer anticoagulant agents, and outline various diagnostic tests used for anticoagulation monitoring. We will also discuss knowledge gaps and future areas of research

Epidemiology and short-term surgical outcomes of children presenting with cerebellar tumors

•The prevalence of children with cerebellar tumors is 1.7 per 10,000 discharges.•Many children (37%) presenting with cerebellar tumors required EVD and/or VP shunt.•The hospital mortality is low (<1%) in children presenting with cerebellar tumors.•12% of these children are discharged to skilled nursing facilities. Posterior fossa tumor surgery in children poses a significant morbidity and mortality. Large multi-institutional datasets characterizing the epidemiology and morbidity of children undergoing posterior fossa tumor surgery are lacking. The objective of this study is to describe the epidemiology and short term surgical outcomes of children presenting with cerebellar tumors. A retrospective review of the Kids Inpatient Database (KID) for all hospital discharges in 2012 with a diagnosis of cerebellar tumor (ICD-9 diagnosis code 191.6) was performed and filtered with the ICD-9 procedure code 01.59 (other excision or destruction of lesion or tissue of brain). All children in this cohort were compared with all other children discharged without cerebellar tumors recorded in the database. A total of 461 (1.7/10,000 discharges) children with a diagnosis of cerebellar tumor who had surgical resection of their tumor were discharged during 2012. Compared with the control group, children undergoing cerebellar tumor excision had an increased length of hospital stay (8 vs. 2 days, p < 0.001), discharge to skilled nursing home facilities/home health care (12% vs. 4.6%, p < 0.001), increased hospital charges ($125,747 vs.$14,018, p < 0.001), and mortality (0.87% vs. 0.3%, p = 0.028). Hydrocephalus was treated via external ventriculostomy (EVD) (31%, n = 143) and/or shunt (17%, n = 78), and patients who required an EVD were more likely to receive a shunt (56% vs. 26%, p < 0.001). Mechanical ventilation (7.8%) and ultimately tracheostomy (1.5%) was necessary in few children following cerebellar tumor excision. As expected, surgical treatment of cerebellar tumors in children may pose significant morbidity. Our exploratory study identifies these patients as a potential high-risk cohort in the United States that may require intensive airway management, treatment of hydrocephalus and long-term nursing support