"Doctor, Is My Child Going to Survive?" Does a New Score to Predict Mortality Following Pediatric In-Hospital Cardiac Arrest "GO-FAR" Enough?

There is high variability in survival rates across different centers, partly attributable to variable hospital prevention strategies, resuscitation preparedness, performance, and quality of care. Nevertheless, approximately half of the children who have return of a sustained circulation following in-hospital cardiac arrest still die before discharge, and neurologic sequelae are observed in a substantial number of survivors. It is critically important for healthcare providers to have specific tools in the early postarrest phase capable to reliably predict patients with the best chance to survive to hospital discharge and those where continued aggressive care is likely to be futile

Pediatric Septic Shock in the Emergency Department: Can We Set the Alarm Clock a Little Forward?

Pediatric Septic Shock in the Emergency Departmen

Do-Not-Resuscitate Orders and Overall Goals of Care in Critically Ill Newborns

Do-Not-Resuscitate Orders and Overall Goals of Care in Critically Ill Newborns: Are We Always on the Same Page

What\u2019s new on NIV in the PICU: does everyone in respiratory failure require endotracheal intubation?

What\u2019s new on NIV in the PICU: does everyone in respiratory failure require endotracheal intubation

Neonatal resuscitation in the ward: The role of nurses

Cardiopulmonary resuscitation (CPR) is necessary in about 1-2% of all newly born infants in their first minutes of life. However, CPR may also be needed in newborns beyond the time of birth, particularly in high risk categories of infants admitted in the NICU or in other less specialised units. In all these scenarios, the role of nurses is essential for several aspects, including early recognition of a deteriorating infant, with the aim to prevent cardiac arrest, as well as the starting of immediate basic life support manoeuvres at the bedside, whenever needed. Furthermore, nurses have a special part in family care during cardiopulmonary resuscitation

Fiberoptic Endotracheal Intubation Through an Ultra-Thin Bronchoscope with Suction Channel in a Newborn with Difficult Airway

Management of the airway may be difficult in newborns with craniofacial and neck malformations (1). Previous experiences with flexible endoscopic intubation in neonates have shown encouraging results, but a number of limitations, such as no directional control at the tip or lack of an operative channel, were also reported (2,3). We describe a successful intubation by a new 2.5-mm fiberoptic bronchoscope with a 1.2-mm suction channel in a newborn with difficult airway. A 2300-g infant, born at 35 wk of gestation after an urgent cesarean delivery for fetal distress, needed cardiopulmonary resuscitation at birth. Endotracheal intubation was achieved only after several attempts with a 3.0-mm tube inserted nasotracheally. On arrival to our unit, physical examination showed dysmorphic face, micrognathia, and arthrogryposis. A gross air leak around the endotracheal tube (ETT) prevented an adequate ventilation of the patient. We decided to explore the patient’s larynx before exchanging the ETT with a larger one, but micrognathia did not allow proper visualization by conventional laryngoscopy. Thus, we inserted a 3.5-mm ETT using a fiberoptic flexible bronchoscope (Richard Wolf-GmbH, Knittlingen, Germany). This endoscope has a 2.5-mm outer diameter, a 1.2-mm instrument channel, an angle of deflection at the tip of 160° up and 130° down, and a working length of 450 mm. During the procedure, we could remove secretions and provide topical anesthesia via the suction channel of the endoscope. No complications were noted.We believe this new ultra-thin bronchoscope may be useful in newborns and small infants when a difficult intubation is anticipated or, alternatively, when lower airway evaluation, suctioning, bronchoalveolar lavage, or supplemental oxygen delivery during intubation is required

Transient phrenic nerve paralysis associated with status asthmaticus

Phrenic nerve paralysis is a condition typically occurring after invasive procedures in the chest and neck. Here we describe a case of transient unilateral diaphragmatic paralysis in a child with status asthmaticus complicated by complete right lung atelectasis. Common causes of this disorder and possible implications for our case are discussed

Comment on \u201cA new device for administration of continuous positive airway pressure in preterm infants\u201d by Trevisanuto et al

We read with interest the contribution by Trevisanuto et al. [1] on the effectiveness of a new device for administering continuous positive airway pressure (CPAP) as an alternative to conventional nasal CPAP in ameliorating comfort in preterm infants needing continuous distending pressure. The data which they present are intriguing, but a few points need to be further discussed. First, the use of a \u201ccomfort scale\u201d appears to be a surrogate end-point. To properly assess safety and efficacy of this new technique, even in a pilot study, the authors should have focused on more relevant clinical aspects or potential complications, such as level of respiratory distress, oxygen-dependency, rate of apnea, local damage, air leak, or need for mechanical ventilation. Second, the authors reported a marked reduction in the Neonatal Infant Pain Scale (NIPS) values, i.e., a better comfort status of patients, during treatment with helmet CPAP. Given the lower level of stress imposed by this technique, one might have expected some modifications in the main physiological parameters, such as heart rate, respiratory rate, and arterial blood pressure [2]. On the other hand, none of the investigated parameters differed between the two CPAP treatments, raising doubts about potential bias due to the nonblinded scoring method used in this study. Indeed, NIPS does require a close observation of the infant, making any blinding process quite complex. Such important limitation might be partially circumvented by simultaneous NIPS measurements performed by two independent observers or by video recording. Third, the small number of enrolled patients (powered only for the chosen end-point), the very brief duration of both CPAP treatments, and the relatively healthy status of the population studied preclude any definitive conclusion about this study. Indeed, how would this technique work in sicker infants who may require CPAP continuously for days or weeks? What are the possible effects of long-term application on abdominal distension, or in the prevention of apnea episodes? As regards the latter point, we have had the contrary findings in a single preliminary experience. A premature infant (31weeks of postconceptional age) treated with conventional nasal CPAP (Infant-Flow-Driver, EME) for apnea of prematurity, was shifted to helmet CPAP due to poor tolerance of nasal prongs. However, after 2 h of treatment he had to be returned to nasal CPAP for repeated episodes of apnea and arterial O2 desaturation. Interestingly, as soon as conventional nasal CPAP was applied, the apneic episodes virtually disappeared. Of note, we report some difficulties in maintaining CPAP levels above 3 cmH2O, despite flow rates set as high as 15 lpm and absence of major leaks in the system. We speculate that conventional nasal CPAP, successfully used for apnea of prematurity [3], would be more effective than the new technique in these circumstances. In summary, we congratulate the authors for their original study. Nonetheless, their conclusion that the helmet CPAP \u201cseems to guarantee a better tolerability and at least similar improvement in oxygenation\u201d may be misleading for the reader. We believe that larger randomized controlled studies are needed to better define the role of this new device and to verify its potential superiority over conventional CPAP by means of more appropriate end-points

A 5-Month-Old Infant with Diffuse Cyanosis and No Other Symptoms

A 5-Month-Old Infant With Diffuse Cyanosis and No Other Symptom

Early recognition and management of septic shock in children

Septic shock remains a major cause of morbidity and mortality among children, mainly due to acute hemodynamic compromise and multiple organ failures. In the last decade, international guidelines for the management of septic shock, as well as clinical practice parameters for hemodynamic support of pediatric patients, have been published. Early recognition and aggressive therapy of septic shock, by means of abundant fluid resuscitation, use of catecholamines and other adjuvant drugs, are widely considered of pivotal importance to improve the short and long-term outcome of these patients. The aim of this paper is to summarize the modern approach to septic shock in children, particularly in its very initial phase, when pediatric healthcare providers may be required to intervene in the pre-intensive care unit setting or just on admission in the pediatric intensive care unit