Apnea is commonly encountered in children with bronchiolitis. Despite the lack of recommendations regarding bronchiolitis-related apnea (BRA) management, some pediatric intensive care unit (PICU) practitioners use caffeine treatment based on extrapolation from the recommendations for prematurity-related apnea management. The objectives of this study were to describe the management of BRA in our PICU, evaluate the caffeine prescription rate for this indication, and explore its potential effects on clinical outcomes.This was a retrospective study in a university hospital PICU between January 1st, 2009 and December 31st, 2016. All children under 1 year of age admitted to the PICU with a diagnosis of BRA were included. Patients were allocated to a control group or a caffeine group depending on the administration of caffeine.In total, 54 infants were included and caffeine treatment was administered to 49 (91%) of them. Patient characteristics were similar between the two groups. Ventilatory support was initiated for 50 patients (93%). Supportive care and length of PICU stay were similar between the two groups. Caffeine was not associated with adverse events.Caffeine treatment in BRA could be considered as a local standard practice. This retrospective study was underpowered to show any benefit of caffeine treatment on clinical outcomes. This treatment was not associated with significant adverse effects. We raised the question of the appropriate caffeine dosing regimen for BRA in this postterm population. Further studies on this topic are warranted.

A paediatric intensive care unit is a complex environment with many hazards for potential medical errors. Due to the high acuity of illness and the complexity of medical care with multiple disciplines and individuals involved, medical errors occur due to breakdowns in communication and teamwork. Medication errors are the most frequent errors in paediatrics. This chapter proposes some strategies to prevent medical errors in paediatric intensive care units.

Objective.-Usefulness of nasal continuous positive airway pressure (NCPAP) in severe acute bronchiolitis has been checked. The objective of this descriptive study was to evaluate the feasibility, safety and risk factors of NCPAP failure.Population and methods.-One hundred and forty-five infants were hospitalised in our intensive care unit during the 2 last epidemics (2003-2004, 2004-2005). Among them, 121 needed a respiratory support, either invasive ventilation (N=68) or NCPAP (N=53).Results.-General characteristics were similar during the 2 periods. Percentage of NCPAP failure, defined by tracheal intubation requirement during the stay in paediatric intensive care unit, was quite similar during the 2 periods (25%), but number of NCPAP increased twofold. Whatever the evolution was in the NCPAP group, we observed a significant decrease in respiratory rate (60 +/- 16 vs 47.5 +/- 13.7 cycle/min., P < 0.001) and PaCO2 (64.3 +/- 13.8 vs 52.6 +/- 11.7 mmHg, P=0.001) during NCPAP. Only PRISM calculated at day 1 and initial reduction of PaCO2 were predictive of NCPAP failure. Percentage of ventilator associated pnemonia was similar (22%) between the invasive ventilation group and infants who where intubated because of failure of NCPAP. Duration of respiratory support and stay were reduced in the NCPAP group (P < 0.002).Conclusion.-NCPAP appears to be a safe alternative to immediate intubation in infants with severe bronchiolitis. (c) 2006 Publie par Elsevier Masson SAS.

The authors describe 28 pediatric cases of foreign body inhalation requiring treatment in intensive care units between 1987 and 1999. The purpose of this study was: (1) to analyze the circumstances, diagnostic difficulties and initial treatment of serious foreign bodies and (2) to compare our series with other literature descriptions and define principles for optimal prevention and initial treatment.Twenty-one children presented a penetration syndrome, which was responsible in 13 cases for asphyxia with cardiorespiratory arrest. All these children died, regardless of the initial treatment. Seven children were hospitalized for apparent asthmatic symptoms that did not respond to traditional treatment.The inefficiency of external extraction methods like the Heimlich maneuver and the mean delay between clinical signs and initial treatment lead us to propose a new strategy for the emergency treatment of foreign bodies with asphyxia.We recommend that emergency teams promote the use of a laryngoscope and Magill forceps. Flexible endoscopy is still recommended as the appropriate diagnostic tool to eliminate doubt in the case of a first severe asthma attack.

OBJECTIVE:Usefulness of nasal continuous positive airway pressure (NCPAP) in severe acute bronchiolitis has been checked. The objective of this descriptive study was to evaluate the feasibility, safety and risk factors of NCPAP failure.POPULATION AND METHODS:One hundred and forty-five infants were hospitalised in our intensive care unit during the 2 last epidemics (2003-2004, 2004-2005). Among them, 121 needed a respiratory support, either invasive ventilation (N=68) or NCPAP (N=53).RESULTS:General characteristics were similar during the 2 periods. Percentage of NCPAP failure, defined by tracheal intubation requirement during the stay in paediatric intensive care unit, was quite similar during the 2 periods (25%), but number of NCPAP increased twofold. Whatever the evolution was in the NCPAP group, we observed a significant decrease in respiratory rate (60+/-16 vs 47.5+/-13.7 cycle/min., P<0.001) and PaCO2 (64.3+/-13.8 vs 52.6+/-11.7 mmHg, P=0.001) during NCPAP. Only PRISM calculated at day 1 and initial reduction of PaCO2 were predictive of NCPAP failure. Percentage of ventilator associated pneumonia was similar (22%) between the invasive ventilation group and infants who where intubated because of failure of NCPAP. Duration of respiratory support and stay were reduced in the NCPAP group (P<0.002).CONCLUSION:NCPAP appears to be a safe alternative to immediate intubation in infants with severe bronchiolitis.

Acyclovir-induced neurotoxicity is a rare adverse effect, found especially in adults with pre-existing renal failure. We report a case of neurotoxicity of acyclovir in a six-month-old liver transplant recipient. Case report and review of literature are discussed.

The aim of this study was to review our experience in orthotopic liver transplantation (OLT) for biliary atresia (BA) in children and analyze the survival and prognostic factors, and long-term outcome. We reviewed 332 OLTs performed in 280 children between the years 1986 and 2000. Univariate and multivariate analysis were performed on patient and graft survivals according to recipients' and donors' characteristics as well as intraoperative data. The long-term outcome among the 80 children living at 10 years after OLT was studied according to growth, immunosuppressive therapy, and liver and renal functions. Liver graft status was eventually documented by liver biopsy. Status of rehabilitation was assessed by reviewing school performance and employment. Overall patient survival rates at 1, 5, and 10 years were 85, 82, and 82%, respectively, and the corresponding overall graft survival rates were 77, 73, and 71%. In the multivariate analysis, we identified 4 independent prognostic factors: polysplenia syndrome (P = .03), United Network for Organ Sharing (UNOS) status (P = .05), donor's age (P = .01), and perioperative surgical complications (P = .03). At 10 years after transplant, 80 children were alive and had normal growth rates. Liver histology was abnormal in 73% of these long-term survivors, mainly due to chronic rejection and centrilobular fibrosis. A total of 63 of the 80 children attended normal school and in 55 children (69%) school performance was not delayed. In conclusion, we discovered that a good long-term survival could be achieved after liver transplantation for BA, with a 82% survival rate at 10 years with normal scholastic studies in the majority of recipients.

s Translations: Selected Abstracts from the Meeting of the European Society of Paediatric and Neonatal Intensive Care in Association with the UK Paediatric Intensive Care Society: Oral Presentations

UNLABELLED:Viral bronchiolitis is usually associated with favorable outcome as regard to mortality. Only few studies reported severe bronchiolitis requiring mechanical ventilation, and respiratory outcome is not well described.METHODS:Therefore, we conducted a retrospective study in a series of 135 children admitted in a single Pediatric Intensive Care Unit (PICU) over a four year period (1994-1998). All of them were admitted for viral bronchiolitis requiring mechanical ventilation.RESULTS:At admission, 83% of them were less than three months old. Prematurity at birth was present in 33,3%. Mortality was observed in four cases (2,9%), all premature babies with mechanical ventilation at birth. Univariate analysis showed as main factors associated to mortality: prematurity (P =0,056) and acute respiratory distress syndrome (P =0,017). Childhood asthma was observed in 40,4% of children without any associated factor wether at birth or in PICU related to such outcome.CONCLUSION:Bronchiolitis associated with mechanical ventilation is particularly observed in very young babies and prematurity is the main factor associated to mortality. Mechanical ventilation seems not to be associated with unfavorable respiratory outcome. Considering physiology and population, non invasive ventilation could be an effective alternative of mechanical ventilation.

.Viral bronchiolitis is usually associated with favorable outcome as regard to mortality. Only few studies reported severe bronchiolitis requiring mechanical ventilation, and respiratory outcome is not well described.Methods. - Therefore, we conducted a retrospective Study in a series of 135 children admitted in a single Pediatric Intensive Care Unit (PICU) over a four year period (1994-1998). All of them were admitted for viral bronchiolitis requiring mechanical ventilation.Results. - At admission, 83% of them were less than three months old. Prematurity at birth was present in 33,3%. Mortality was observed in four cases (2,9%), all premature babies with mechanical ventilation at birth. Univariate analysis showed as main factors associated to mortality: prematurity (P =0,056) and acute respiratory distress syndrome (P =0,01 7). Childhood asthma was observed in 40,4% of children without any associated factor wether at birth or in PICU related to such outcome.Conclusion. - Bronchiolitis associated with mechanical ventilation is particulary observed in very young babies and prematurity is the main factor associated to mortality. Mechanical ventilation seems not to be associated with unfavorable respiratory outcome. Considering physiology and population, non invasive ventilation could be an effective alternative of mechanical ventilation. (c) 2005 Elsevier SAS.

UNLABELLED:Idiopathic Reye syndrome is a rare disease revealed by unexplained encephalopathy and microvesicular liver steatosis. Some clinical and epidemiological studies mainly performed in English speaking countries questioned the reality of Reye syndrome because numerous know inherited metabolic diseases, and some of them unrecognized, could mimick this disorder. We focused in our study on severe forms of Reye syndrome admitted to a pediatric intensive care unit. METHODS:Retrospective study over the last eleven years (1991-2001) included all the pediatric patients admitted to our tertiary referral center with the classical American Reye syndrome criteria (e.g. CDC). Extensive metabolic screening was performed in all cases, except for the ultimately dead patients. RESULT:Fourteen patients (mean age 52 months) were included. Fever always occurred before their admission and aspirin (n = 12) or acetaminophen (n = 7) was prescribed. Median Glasgow scale was 7 on admission. Mean amoniac plasma level was 320 mumol/L and alanine-aminotransferase peak plasma level 1475 +/- 1387 IU/L. Mechanical ventilation was started in ten children and six of them underwent continuous venovenous hemofiltration. Three patients ultimately died and 11 survived with a mean five years follow-up without relapses or neurological impairment. Any of them demonstrated inherited metabolic disease except for one infant with hereditary fructose intolerance. CONCLUSION:Unlike widespread opinion, severe Reye syndrome without identified metabolic disorders seems to not disappear in our country. Reye syndrome remains a potentially life threatening disease and raises for aggressive treatment of brain edema. If aspirin and Reye syndrome association are not formally documented in France, cautiousness must be kept in mind and all the aspirin adverse effects notifications should be addressed to the public drugs survey network.

CASE REPORT:A two-month-old male child presented a severe heart failure associated with a malignant hypertension. Abdominal ultrasound revealed a mass connected to the left adrenal gland. CT scan showed a tumor of 7 x 6 x 8 cm, forcing back both the left kidney and the aorta. A biopsy allowed the diagnosis of neuroblastoma without MYCN oncogene amplification. Intensive care stabilized the hemodynamic situation. Under chemotherapy the tumor volume decreased significantly and complete surgical excision became possible. Three years after diagnosis, the patient remained in complete remission.CONCLUSION:Clinical presentation of this neuroblastoma was extremely uncommon. The catecholamines produced by the tumoral cells could induce an increase of the myocardiac work following the left ventricule post charge increase. Theses mechanisms could be synergistic for a myocardial exhaustion.

Case report. - A two-month-old male child presented a severe heart failure associated with a malignant hypertension. Abdominal ultrasound revealed a mass connected to the left adrenal gland. CT scan showed a tumor of 7 x 6 x 8 cm, forcing back both the left kidney and the aorta. A biopsy, allowed the diagnosis of neuroblastoma without MYCN oncogene amplification. Intensive care stabilized the hemodynamic situation. Under chemotherapy the tumor volume decreased significantly and complete surgical excision became possible. Three years after diagnosis, the patient remained in complete remission.Conclusion. - Clinical presentation of this neuroblastoma was extremely uncommon. The catecholamines produced by the tumoral cells could induce an increase of the myocardic work following the left ventricule post charge increase. Theses mechanisms could be synergistic for a myocardial exhaustion. (C) 2002 Editions scientifiques et medicales Elsevier SAS.

L’objectif de ce travail était d’apprécier la fréquence et la prise en charge des différentes complications vasculaires lors de l’activité de transplantation rénale.Étude rétrospective des patients transplantés rénaux de 2001 à 2006 dans notre centre hospitalo-universitaire. Nous avons recensé les caractéristiques de la population de donneurs et receveurs, du déroulement du prélèvement multi-organes (PMO) et de la transplantation, afin d’étudier les complications vasculaires et leurs conséquences. Les donneurs vivants ont été exclus.Cent soixante-dix-neuf dossiers ont été analysés avec un suivi moyen de 40 mois. Soixante-douze patients transplantés avaient eu au moins une complication vasculaire, dont 32 cas de sténose de l’artère du transplant, 28 cas d’hématome dont sept drainés chirurgicalement, quatre cas de thrombose artérielle, deux cas de thrombose veineuse et une dissection artérielle. L’analyse de notre série a mis en évidence que le tabagisme (p = 0,043) était un facteur de risque des donneurs et la néphropathie glomérulaire (p = 0,0185), les coagulopathies (p = 0,0165) et l’hémodialyse (p = 0,02) étaient des facteurs de risques vasculaires pour le receveur. Les transplants présentant des artères multiples (p = 0,03) et un patch aortique calcifié (p = 0,0274) seraient plus à risque de complications postopératoires. Nos résultats démontraient que le remplissage postopératoire (p = 0,011), l’héparinothérapie (p = 0,0085), l’immunosuppression (p = 0,0478), voire l’utilisation d’amines vasopressives en peropératoire (p = 0,086) seraient également impliqués dans l’incidence des complications vasculaires.La sélection des donneurs était indispensable pour la qualité des transplants, sans négliger la préservation de l’état artériel et le dépistage des coagulopathies des receveurs afin de diminuer la morbidité de la transplantation rénale. La coordination des équipes médicales impliquées était nécessaire pour optimiser les temps d’ischémie, minimiser les risques de complications vasculaires et améliorer la survie du transplant et du patient.The aim of this study was to evaluate frequency and management of vascular complications in renal allograft.We performed retrospective analysis of patients who underwent renal allograft from 2001 to 2006 at our university hospital center. In order to access peri- and postoperative vascular complications, data were also obtained from donors and receivers, as well as organ procurement and renal transplant procedure.One hundred and seventy-nine files were analyzed with a median follow-up of 40 months, mean age of donors was 40.4 ± 11.2 years and 46.01 ± 10.6 years for receivers. Seventy-two allograft patients had at least one vascular complication, with 32 cases of renal arterial stenosis, 28 cases of hematoma with surgical exploration required in seven cases, four cases of arterial thrombosis, two cases of venous thrombosis and one arterial dissection. Our series underlines that tobacco abuse in donors is a risk factor for vascular complication (p = 0.043), as well as glomerular nephropathy (p = 0.0185), coagulopathy (p = 0.0165) and hemodialysis (p = 0.02) are risk factors for receivers. Multiple arteries in renal allograft (p = 0.03) and calcification on aortic patch (p = 0.0274) would present a greater risk of postoperative complications. Our results demonstrate that the following parameters i.e., postoperative transfusion (p = 0.011), heparin therapy (p = 0.0085), immunosuppression (p = 0.0478), and peri-operative aminovasopressive drugs (p = 0.086) could also be implicated in vascular complication occurrence.A careful selection of donors remains a major factor for renal allograft quality, however arterial evaluation and coagulopathy detection in receivers must also be performed prior to transplantation procedure. A multidisciplinary approach (nephrologist, urologist, anesthesist) will optimize vascular ischemia delay and also reduce early and late vascular complications, which could have possible consequences on renal allograft and patient survival.

Idiopathic Reye syndrome is a rare disease revealed by unexplained encephalopathy and microvesicular liver steatosis. Some clinical and epidemiological studies mainly performed in English speaking countries questionned the reality of Reye syndrome because numerous known inherited metabolic diseases, and some of them unrecognized, could mimick this disorder. We focused in our study on severe forms of Reye syndrome admitted to a pediatric intensive care unit.Methods. - Retrospective study over the last eleven years (1991-2001) included all the pediatric patients admitted to our tertiary referral center with the classical American Reye syndrome criteria (e.g CDC). Extensive metabolic screening was performed in all cases, except for the ultimately dead patients.Result. - Fourteen patients (mean age 52 months) were included. Fever always occurred before their admission and aspirin (n=12) or acetaminophen (n=7) was prescribed. Median Glasgow scale was 7 on admission. Mean amoniac plasma level was 320 mumol/L and alanine-aminotransferase peak plasma level 1475 +/- 1387 IU/L. Mechanical ventilation was started in ten children and six of them underwent continuous venovenous hemofiltration. Three patients ultimately died and 11 survived with a mean five years follow-up without relapses or neurological impairment. Any of them demonstrated inherited metabolic disease except for one infant with hereditary fructose intolerance.Conclusion. - Unlike widespread opinion, severe Reye syndrome without identified metabolic disorders seems to not disappear in our country. Reye syndrome remains a potentially life threatening disease and raises for aggressive treatment of brain edema. If aspirin and Reye syndrome association are not formally documented in France, cautiousness must be kept in mind and all the aspirin adverse effects notifications should be addressed to the public drugs survey network. (C) 2002 Editions scientifiques et medicales Elsevier SAS.

OBJECTIVE:Neonatal vein of Galen malformation complicated by severe cardiac failure is a rare disease. The purpose was to assess the outcome of this life-threatening malformation and identify hemodynamic prognostic factors.DESIGN:Retrospective study.PATIENTS:Twenty-four newborns with cardiac failure requiring mechanical ventilation were consecutively admitted from 1986 to 2000.INTERVENTIONS:Cardiovascular evaluation including echocardiogram was performed in all cases. Eighteen transarterial shunt occlusions with glue were applied by the same team of three physicians.MEASUREMENTS AND RESULTS:Twelve babies survived and underwent one endovascular session at least (median age 20 days) with a mean 63 months follow-up. Embolization was not performed in 6 of the 12 nonsurvivors because of severe brain damage or profound hypotension Cardiogenic shock occurred in all nonsurvivors, but also in one long-term survivor (p<0.0001). Echocardiogram showed signs of right ventricular failure, most often in the dead babies (p=0.005). The pulmonary systemic arterial pressure ratio was significantly higher in the nonsurvivor group (p=0.031), and it decreased significantly after the first embolization only in patients who survived (p=0.01). Patent ductus arteriosus and a diastolic aortic reversed-flow were present in all nonsurvivors in contrast to 30% of the long-term survivors (p=0.003 ). There was no difference in the left ventricular contractility and mean cardiac output between the two groups.CONCLUSIONS:The outcome of vein of Galen malformation complicated by severe cardiac failure requiring mechanical ventilation remains poor. Neonatal embolization seems to be beneficial only in babies without suprasystemic pulmonary hypertension.