AP/HP Pôle 7

- Réanimation Polyvalente Pédiatrique -

Réponses affichées : 167

Lien PubMed [Virological tools for the diagnosis, the prognosis and the surveillance of congenital cytomegalovirus infections.]
AVETTAND-FENOEL V, MAGNY JF, VILLE Y, LERUEZ-VILLE M
2013 - Arch Pediatr 20(2):204-8
Cytomegalovirus (CMV) infection is the main cause of congenital infection in industrialized countries. The virological tools used for the diagnosis of congenital CMV are serology for diagnosis of primary infection in the mother, CMV PCR in amniotic fluid for diagnosis of fetal infection, PCR in urine or saliva for neonatal diagnosis and PCR in dried blood spots on Guthrie cards for retrospective diagnosis in young children. The prognostic value of viral load in amniotic fluid, fetal blood and neonatal blood will be discussed. The performance of the virological tests for antenatal or postnatal screening of congenital CMV will also be discussed.
Unité(s) : Réanimation Pédiatrique & Néonatologie, Obstétrique, Laboratoire de Microbiologie, EA 3620
 
Lien PubMed Premedication for Neonatal Endotracheal Intubation: Results From the Epidemiology of Procedural Pain in Neonates Study*
DURRMEYER X, DAOUD P, DECOBERT F, BOILEAU P, RENOLLEAU S, ZANA-TAIEB E, SAIZOU C, LAPILLONNE A, GRANIER M, DURAND P, LENCLEN R, COURSOL A, NICLOUX M, DE SAINT-BLANQUAT L, SHANKLAND R, BOELLE PY, CARBAJAL R
2013 - Pediatr Crit Care Med 14(4):e169-e175
OBJECTIVES:: To describe the frequency and nature of premedications used prior to neonatal endotracheal intubation; to confront observed practice with current recommendations; and to identify risk factors for the absence of premedication. DESIGN, SETTING, AND PATIENTS:: Data concerning intubations were collected prospectively at the bedside as part of an observational study collecting around-the-clock data on all painful or stressful procedures performed in neonates during the first 14 days of their admission to 13 tertiary care units in the region of Paris, France, between 2005 and 2006. INTERVENTION:: Observational study. MEASUREMENTS AND MAIN RESULTS:: Specific premedication prior to endotracheal intubation was assessed. Ninety one intubations carried out on the same number of patients were analyzed. The specific premedicationrate was 56% and included mostly opioids (67%) and midazolam (53%). Compared with recent guidance from the American Academy of Pediatrics, used premedications could be classified as "preferred" (12%), "acceptable" (18%), "not recommended" (27%), and "not described" (43%). In univariate analysis, infants without a specific premedication compared with others were younger at the time of intubation (median age: 0.7 vs. 2.0 days), displayed significantly more frequent spontaneous breathing at the time of intubation (31% vs. 12%) and a higher percentage of analgesia for all other painful procedures (median values: 16% vs. 6%). In multivariate analysis, no factor remained statistically significant. CONCLUSIONS:: Premedication use prior to neonatal intubation was not systematically used and when used it was most frequently inconsistent with recent recommendations. No patient- or center-related independent risk factor for the absence of premedication was identified in this study.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Interleukin 10 Antioxidant Effect Decreases Leukocytes/Endothelial Interaction Induced by Tumor Necrosis Factor alpha
HUET O, LAEMMEL E, FU Y, DUPIC L, APRICO A, ANDREWS KL, MOORE SL, HARROIS A, MEIKLE PL, VICAUT E, CHIN-DUSTING JP, DURANTEAU J
2013 - Shock 39(1):83-88
ABSTRACT: Little is known about the endothelial mechanisms involved in the anti-inflammatory effects of interleukin 10 (IL-10). The goal of this study was to evaluate the effects of IL-10 on endothelial oxidative stress and endothelial inflammation induced by tumor necrosis factor alpha (TNF-alpha). Production of reactive oxygen species (ROS) in perfused human umbilical vein endothelial cells (HUVECs) was studied by fluorescent microscopy using dichlorodihydrofluorescein diacetate. Tumor necrosis factor alpha (1 ng/mL) was added to the perfusion medium in the absence and presence of IL-10 (1 ng/mL). The role of phosphatidylinositol 3-kinase (PI3-kinase) was assessed using wortmannin and LY 2940002 (inhibitors of PI3-kinase). Specific inhibition of p110 alpha and p110 gamma/delta PI3-kinase subunits was studied using A66 and TG100-115. As well, levels of ceramide and intercellular adhesion molecule 1 (ICAM-1) expression were measured. Finally, the effect of IL-10 on TNF-alpha-induced leukocyte/endothelium interaction was examined using an ex vivo perfused vessel model. Interleukin 10 significantly reduced dichlorodihydrofluorescein diacetate fluorescence induced by TNF-alpha in HUVECs (12.5% +/- 3.2% vs. 111.7% +/- 21.6% at 60 min). Pretreatment by LY2940002 or wortmannin restored ROS production induced by TNF-alpha in the presence of IL-10. In HUVECs treated by TNF-alpha + IL-10, inhibition of p110 alpha PI3-kinase subunit significantly increased ROS production, whereas p110 gamma/delta inhibition did not have a significant effect. Pretreatment with IL-10 significantly decreased TNF-alpha-induced increased levels of ceramide (TNF-alpha vs. TNF-alpha + IL-10: 6,278 +/- 1,013 vs. 1,440 +/- 130 pmol/mg prot), as well as ICAM-1 expression and leukocyte adhesion (TNF-alpha vs. TNF-alpha + IL-10: 26.8 +/- 2.6 vs. 6.7 +/- 0.4 adherent leukocytes/field at 15 min). Interleukin 10 decreases the level of inflammation induced by TNF-alpha in endothelial cells by reducing the TNF-alpha-induced ROS production, ICAM-1 expression, and leukocyte adhesion to the endothelium. The antioxidant effect of IL-10 is mediated through PI3-kinase and is paralleled by a decrease in ceramide synthesis induced by TNF-alpha.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Feeding preterm infants today for later metabolic and cardiovascular outcomes
LAPILLONNE A, GRIFFIN IJ
2013 - J Pediatr 162(3 Suppl):S7-S16
Preterm birth continues to contribute disproportionately to neonatal morbidity and subsequent physical and neurodevelopmental disabilities. Epidemiologic studies have described additional long-term health consequences of preterm birth such as an increased risk of hypertension and insulin resistance in adult life. It is not known whether the influence of infant and childhood growth rates and early nutrition on long-term outcomes is the same or different among preterm infants and neonates with intrauterine growth restriction. Our goal is to review the effects of fetal growth, postnatal growth, and early nutrition on long-term cardiovascular and metabolic outcomes in preterm infants. Present evidence suggests that even brief periods of relative undernutrition during a sensitive period of development have significant adverse effects on later development. Our review suggests that growth between birth and expected term and 12-18 months post-term has no significant effect on later blood pressure and metabolic syndrome, whereas reduced growth during hospitalization significantly impacts later neurodevelopment. In contrast, growth during late infancy and childhood appears to be a major determinant of later metabolic and cardiovascular well being, which suggests that nutritional interventions during this period are worthy of more study. Our review also highlights the paucity of well-designed, controlled studies in preterm infants of the effects of nutrition during hospitalization and after discharge on development, the risk of developing hypertension, or insulin resistance.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Lipid needs of preterm infants: updated recommendations
LAPILLONNE A, GROH-WARGO S, LOZANO-GONZALEZ CH, UAUY R
2013 - J Pediatr 162(3 Suppl):S37-47
Long-chain polyunsaturated fatty acids (LCPUFAs) are of nutritional interest because they are crucial for normal development of the central nervous system and have potential long-lasting effects that extend beyond the period of dietary insufficiency. Here we review the recent literature and current recommendations regarding LCPUFAs as they pertain to preterm infant nutrition. In particular, findings that relate to fetal accretion, LCPUFA absorption and metabolism, effects on development, and current practices and recommendations have been used to update recommendations for health care providers. The amounts of long-chain polyunsaturated fatty acids (LCPUFAs) used in early studies were chosen to produce the same concentrations as in term breast milk. This might not be a wise approach for preterm infants, however, particularly for very and extremely preterm infants, whose requirements for LCPUFAs and other nutrients exceed what is normally provided in the small volumes that they are able to tolerate. Recent studies have reported outcome data in preterm infants fed milk with a docosahexaenoic acid (DHA) content 2-3 times higher than the current concentration in infant formulas. Overall, these studies show that providing larger amounts of DHA supplements, especially to the smallest infants, is associated with better neurologic outcomes in early life. We emphasize that current nutritional management might not provide sufficient amounts of preformed DHA during the parenteral and enteral nutrition periods and in very preterm/very low birth weight infants until their due date, and that greater amounts than used routinely likely will be needed to compensate for intestinal malabsorption, DHA oxidation, and early deficit. Research should continue to address the gaps in knowledge and further refine adequate intake for each group of preterm infants.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Nutritional recommendations for the late-preterm infant and the preterm infant after hospital discharge
LAPILLONNE A, O'CONNOR DL, WANG D, RIGO J
2013 - J Pediatr 162(3 Suppl):S90-S100
Early nutritional support of preterm infants is critical to life-long health and well being. Numerous studies have demonstrated that preterm infants are at increased risk of mortality and morbidity, including disturbances in brain development. To date, much attention has focused on enhancing the nutritional support of very low and extremely low birth weight infants to improve survival and quality of life. In most countries, preterm infants are sent home before their expected date of term birth for economic or other reasons. It is debatable whether these newborns require special nutritional regimens or discharge formulas. Furthermore, guidelines that specify how to feed very preterm infants after hospital discharge are scarce and conflicting. On the other hand, the late-preterm infant presents a challenge to health care providers immediately after birth when decisions must be made about how and where to care for these newborns. Considering these infants as well babies may place them at a disadvantage. Late-preterm infants have unique and often-unrecognized medical vulnerabilities and nutritional needs that predispose them to greater rates of morbidity and hospital readmissions. Poor or inadequate feeding during hospitalization may be one of the main reasons why late-preterm infants have difficulty gaining weight right after birth. Providing optimal nutritional support to late premature infants may improve survival and quality of life as it does for very preterm infants. In this work, we present a review of the literature and provide separate recommendations for the care and feeding of late-preterm infants and very preterm infants after discharge. We identify gaps in current knowledge as well as priorities for future research.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Bronchopulmonary dysplasia-associated pulmonary arterial hypertension of very preterm infants.]
MEAU-PETIT V, THOUVENIN G, GUILLEMOT-LAMBERT N, CHAMPION V, TILLOUS-BORDE I, FLAMEIN F, DE SAINT-BLANQUAT L, ESSOURI S, GUILBERT J, NATHAN N, GUELLEC I, KOUT S, EPAUD R, LEVY M
2013 - Arch Pediatr 20(1):44-53
Bronchopulmonary dysplasia (BPD) of very preterm infants is a multifactorial chronic lung disease and its incidence has not decreased despite improvements in neonatal intensive care, including lung protective strategies. Pulmonary hypertension (PH) can complicate the course of BPD. Mortality in infants with BPD-associated PH is thought to be very high, but its incidence is unknown and a standard diagnostic and therapeutic strategy has not been well defined. In this article, we will first describe the current knowledge on the BPD-associated PH and the current treatments available for this pathology. We will then present the HTP-DBP Study, carried out in Paris (France) starting in 2012. The diagnosis of PH is suspected on echocardiographic criteria, but cardiac catheterization is considered the gold standard for diagnosis and evaluation of the severity of PH. Moreover, pulmonary vasoreactivity testing is used to guide the management of patients with PH. The pathogenesis of BPD-associated PH is poorly understood and even less is known about appropriate therapy. Today, optimizing ventilation and reducing the pulmonary vascular tone with specific pulmonary vasodilatator drugs are the main goals in treating HTP-associated DBP. Animal studies and a few clinical studies suggest that medications targeting the nitric oxide (NO) signaling pathway (NO inhalation, oral sildenafil citrate) could be effective treatments for BPD-associated PH, but they have not been approved for this indication. The HTP-DBP study is a French multicenter prospective observational study. The objective is to evaluate the frequency of BPD-associated PH, to describe its physiopathology, its severity (morbidity and mortality), and the effectiveness of current treatments.
Unité(s) : Réanimation Pédiatrique & Néonatologie, Obstétrique, Chirurgie Cardiaque Pédiatrique
 
Lien PubMed [Zuclopenthixol benzoate poisoning in a child: Evidence from chromatography]
MENAGER C, BOIMOND N, CHERON G
2013 - Arch Pediatr 20(3):286-8
Zuclopenthixol is a thioxanthene-based neuroleptic. It may cause acute intoxication in children with neurological and consciousness disorders. Immunochromatography is unable to identify the molecule and diagnosis requires mass spectroscopy and HP chromatography. The short time needed for this technique significantly improves the exploration and treatment of Clopixol poisoning.
Unité(s) : Réanimation Pédiatrique & Néonatologie, CUDR
 
Lien PubMed Prognostic value of a hernia sac in congenital diaphragmatic hernia
SPAGGIARI E, STIRNEMANN J, BERNARD JP, DE SAINT-BLANQUAT L, BEAUDOIN S, VILLE Y
2013 - Ultrasound Obstet Gynecol 41(3):286-90
OBJECTIVE: To investigate the prognostic value of a hernia sac in isolated congenital diaphragmatic hernia (CDH). METHODS: Our database was searched to identify all consecutive cases of CDH referred to our fetal medicine unit between January 2004 and August 2011. Presence or absence of a hernia sac was assessed in liveborn cases using surgery or postnatal autopsy reports. We studied the correlation between the presence of a hernia sac and prenatal findings and perinatal morbidity and mortality. RESULTS: Over the study period, there were 70 cases with isolated CDH born alive in which either a surgery or autopsy report was available. Neonatal death, either preoperative or postoperative, occurred in 1/18 (5.6%) infants with a hernia sac and in 17/52 (32.7%) cases without a hernia sac (P = 0.03). Patients with a hernia sac had a significantly higher observed to expected pulmonary volume on prenatal magnetic resonance imaging (51.9 vs 39.3%, P = 0.01). Neonatal morbidity in surviving infants was lower in the group with a hernia sac, although not significantly. CONCLUSION: The presence of a hernia sac is associated with a higher pulmonary volume and a better overall prognosis for CDH. Copyright (c) 2012 ISUOG. Published by John Wiley & Sons, Ltd.
Unité(s) : Réanimation Pédiatrique & Néonatologie, Obstétrique, Chirurgie Viscérale Pédiatrique
 
Lien PubMed Mortality in severe traumatic brain injury
VERCHERE J, BLANOT S, VERGNAUD E, VECCHIONE A, ZERAH M, MEYER PG
2013 - Lancet Neurol 12(5):426-7
Unité(s) : Réanimation Pédiatrique & Néonatologie, Neurochirurgie Pédiatrique
 
Lien PubMed Fatal Rhabdomyolysis in 2 Children with LPIN1 Mutations
BERGOUNIOUX J, BRASSIER A, RAMBAUD C, BUSTARRET O, MICHOT C, HUBERT L, ARNOUX JB, LAQUERRIERE A, BEKRI S, GALENE-GROMEZ S, BONNET D, HUBERT P, DE LONLAY P
2012 - J Pediatr 160(6):1052-4
We report 2 cases of fatal rhabdomyolysis in children carrying an LPIN1 mutations preceded by similar electrocardiogram changes, including diffuse symmetrical high-amplitude T waves. Our report underlines the severity of this disease and the need for active management of episodes of rhabdomyolysis in a pediatric intensive care unit.
Unité(s) : Cardiologie Pédiatrique, Métabolisme, Réanimation Pédiatrique & Néonatologie, U781
 
Lien PubMed A glial origin for periventricular nodular heterotopia caused by impaired expression of Filamin-A
CARABALONA A, BEGUIN S, PALLESI-POCACHARD E, BUHLER E, PELLEGRINO C, ARNAUD K, HUBERT P, OUALHA M, SIFFROI JP, KHANTANE S, COUPRY I, GOIZET C, GELOT AB, REPRESA A, CARDOSO C
2012 - Hum Mol Genet 21(5):1004-17
Periventricular nodular heterotopia (PH) is a human brain malformation caused by defective neuronal migration that results in ectopic neuronal nodules lining the lateral ventricles beneath a normal appearing cortex. Most affected patients have seizures and their cognitive level varies from normal to severely impaired. Mutations in the Filamin-A (or FLNA) gene are the main cause of PH, but the underlying pathological mechanism remains unknown. Although two FlnA knockout mouse strains have been generated, none of them showed the presence of ectopic nodules. To recapitulate the loss of FlnA function in the developing rat brain, we used an in utero RNA interference-mediated knockdown approach and successfully reproduced a PH phenotype in rats comparable with that observed in human patients. In FlnA-knockdown rats, we report that PH results from a disruption of the polarized radial glial scaffold in the ventricular zone altering progression of neural progenitors through the cell cycle and impairing migration of neurons into the cortical plate. Similar alterations of radial glia are observed in human PH brains of a 35-week fetus and a 3-month-old child, harboring distinct FLNA mutations not previously reported. Finally, juvenile FlnA-knockdown rats are highly susceptible to seizures, confirming the reliability of this novel animal model of PH. Our findings suggest that the disorganization of radial glia is the leading cause of PH pathogenesis associated with FLNA mutations. Rattus norvegicus FlnA mRNA (GenBank accession number FJ416060).
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Struggling to do what is right for the child: pediatric life-support decisions among physicians and nurses in France and Quebec
CARNEVALE FA, FARRELL C, CREMER R, CANOUI P, SEGURET S, GAUDREAULT J, DE BERAIL B, LACROIX J, LECLERC F, HUBERT P
2012 - J Child Health Care 16(2):109-23
This study examined (a) how physicians and nurses in France and Quebec make decisions about life-sustaining therapies (LSTs) for critically ill children and (b) corresponding ethical challenges. A focus groups design was used. A total of 21 physicians and 24 nurses participated (plus 9 physicians and 13 nurses from a prior secondary analysis). Principal differences related to roles: French participants regarded physicians as responsible for LST decisions, whereas Quebec participants recognized parents as formal decision-makers. Physicians stated they welcomed nurses' input but found they often did not participate, while nurses said they wanted to contribute but felt excluded. The LST limitations were based on conditions resulting in long-term consequences, irreversibility, continued deterioration, inability to engage in relationships and loss of autonomy. Ethical challenges related to: the fear of making errors in the face of uncertainty; struggling with patient/family consequences of one's actions; questioning the parental role and dealing with relational difficulties between physicians and nurses.
Unité(s) : Pédo-Psychiatrie, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Bronchiolitis among infants under 1 year of age in France: Epidemiology and factors associated with mortality]
CHE D, NICOLAU J, BERGOUNIOUX J, PEREZ T, BITAR D
2012 - Archives Pédiatrie 19(7):700-6
Little information is available on the characteristics of infants hospitalized for acute bronchiolitis in France. An analysis of hospital records (PMSI) was conducted at the national level to describe the cases of bronchiolitis that require hospitalization among infants under 1year of age and the factors associated with death. The analysis of all admissions that occurred during 2009, for which the diagnosis of acute bronchiolitis was recorded in the PMSI database for infants aged less than 1year, was performed. Cases were described according to age, sex, underlying conditions (including bronchopulmonary dysplasia, cystic fibrosis, and congenital heart disease), length of hospital stay, recurrent admissions, admission to an intensive care unit (ICU), and use of assisted ventilation. Factors associated with death during hospitalization were studied by logistic regression. The hospitalization rate was 35.8 per 1000 infants under 1year in 2009 in France. Approximately 10% of hospitalized infants required ICU admission. Twenty-two infants died. The estimated case-fatality rate was 0.08% among hospitalized infants and 0.56% for those hospitalized in the ICU. Mortality among all infants under 1 year was 2.6/10(5) in France. Factors associated with death were bronchopulmonary dysplasia (OR=6.7, 95% CI [1.5-29.8]), hospitalization in an ICU (OR=6.46, 95% CI [2.4-17.4]), and the use of assisted ventilation (OR=6.2, 95% CI [2.2-17.1]). This study has enabled the quantification of the rate of hospitalization and mortality, and a better description of infants who need hospitalization. The results are consistent with international literature, but further prospective analysis will be needed to better describe the cases at higher risk, aiming to improve their management.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Sedation and analgesia in emergency structure. Which sedation and analgesia for the intubated patient under mechanical ventilation?]
COMBES X, MICHELET P
2012 - Ann Fr Anesth Reanim 31(4):322-6
Unité(s) : Médecine d'Urgence, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Sedation and analgesia in emergency structure. Which sedation and/or analgesia for the shocked patient?]
DAVID JS, WIEL E, VIVIEN B
2012 - Ann Fr Anesth Reanim 31(4):327-31
Unité(s) : Médecine d'Urgence, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Early lipid supply and neurological development at one year in very low birth weight (VLBW) preterm infants
ELENI-DIT-TROLLI S, KERMORVANT-DUCHEMIN E, HUON C, BREMOND-GIGNAC D, LAPILLONNE A
2012 - Early Hum Dev 88(Suppl 1):S25-9
BACKGROUND: The rapid growth of the developing brain during early post-natal life makes it particularly vulnerable to a nutritional deficit. The neurological development of the very low birth weight preterm infant could be related to early lipid supply. AIMS: To evaluate in preterm infants of gestational age
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Sedation and analgesia in emergency structure. Which are the properties and the disadvantages of the products used?]
FREYSZ M, ORLIAGUET G
2012 - Ann Fr Anesth Reanim 31(4):79-80
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Kawasaki disease: an unexpected etiology of shock and multiple organ dysfunction syndrome
GATTERRE P, OUALHA M, DUPIC L, ISERIN F, BODEMER C, LESAGE F, HUBERT P
2012 - Intensive Care Med 38(5):872-8
OBJECTIVE: Severe forms of Kawasaki disease (KD) associated with shock have recently been reported in which a greater number of coronary artery abnormalities (CAA) were observed. In this study, we analyzed organ involvement not restricted to cardiovascular aspects in severe KD and assessed whether their outcome is different than in common forms. DESIGN: Retrospective study. SETTING: A 12-bed pediatric intensive care unit (PICU) in a university hospital setting. PATIENTS: All patients managed in the PICU with a diagnosis of KD from 1 January 2001 to 30 April 2009. RESULTS: Eleven patients were admitted because of moderate febrile shock without initial KD diagnosis. Median age was 75 months (6-175) with a male:female ratio of 1.4. KD was diagnosed and treated after a delay of 1 day (0-2), for a total of 7 days (5-9) after fever onset. Seven patients (63%) developed CAA after 21 days (6-30) with complete regression within a delay of 120 days (18-240). Nonspecific encephalopathy (n = 6) as well as acute kidney injury (n = 10) were also observed. Multiple organ dysfunction syndrome (MODS) occurred in eight patients. Although predicted mortality according to the PELOD score [21 (10-43)] ranged from 20% to up to 50%, all 11 children survived with no sequelae. CONCLUSION: Moderate shock is the main reason for PICU admission in children suffering from KD. These forms can be associated with surprising MODS. Despite the severity of symptoms, all patients survived without any sequelae, hence the need for proper diagnosis and rapid treatment of these unusual severe forms.
Unité(s) : Cardiologie Pédiatrique, Dermatologie, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Cerebral vasculitis in severe Kawasaki disease: early detection by magnetic resonance imaging and good outcome after intensive treatment
GITIAUX C, KOSSOROTOFF M, BERGOUNIOUX J, ADJADJ E, LESAGE F, BODDAERT N, HULLY M, BRUGEL D, DESGUERRE I, BADER-MEUNIER B
2012 - Dev Med Child Neurol 54(12):1160-3
Kawasaki disease is an acute vasculitis, that has a classic complication of acquired coronary artery aneurysm. Severe forms with multi-organ involvement or neurological dysfunction are rare. Cerebral vascular involvement has been related to large-vessel injury or cardioembolism, leading to focal brain infarction. A 4-year-old female presented with unusual, rapidly catastrophic Kawasaki disease with refractory shock, acute renal failure, and coma, requiring intensive haemodynamic management. The observation of diffuse micro-haemorrhages (T2*-weighted sequence) associated with white matter injury on brain magnetic resonance imaging (MRI) pointed towards lesions of the medium/small blood vessels. Cerebral vasculitis was suspected and the immunosuppressive treatment was increased Subsequently, the patient's recovery was rapid. On follow-up severe, bilateral vitritis was evident and surgery improved visual outcome. Early recognition of severe or unusual forms of Kawasaki disease could lead to more favourable outcome using appropriate treatment strategies. Diffuse cerebral micro-haemorrhages on T2* brain MRI sequences might be a key sign for the diagnosis of medium or small cerebral vessel involvement.
Unité(s) : Immunologie-Hématologie Pédiatriques, Neurologie, Ophtalmologie, Radiologie Pédiatrique, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Unusual Muscular Injury in an Infant With Severe H1N1 Infection
GUEDJ R, DESGUERRE I, BRASSIER A, BODDAERT N, HUBERT P, OUALHA M
2012 - Pediatr Neurol 47(1):51-4
We report the first well-documented case of unilateral orbital myositis in an 8-month-old boy with life-threatening pandemic H1N1 infection. He presented with status epilepticus and hemodynamic failure associated with unusual right orbital myositis and acute rhabdomyolysis. Because of severe myolysis, metabolic screening was performed to exclude metabolic and genetic etiologies. After corticosteroid administration and symptomatic support, the disease evolution was favorable, without sequelae at hospital discharge. H1N1 influenza infection may be associated with multiple organ failure, and complicated by unusual muscle injury. The presence of intense myolysis should alert practitioners to potential metabolic and genetic etiologies.
Unité(s) : Métabolisme, Neurologie, Radiologie Pédiatrique, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Devenir des malades qui survivent apres une decision de limitation ou d'arret de traitements en reanimation
HUBERT P
2012 - Arch Pediatr 19(6S1):H137-H138
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Early chloride intake does not parallel that of sodium in extremely low birth weight infants and may impair neonatal outcomes
KERMORVANT-DUCHEMIN E, IACOBELLI S, DIT-TROLLI SE, BONSANTE F, KERMORVANT C, SARFATI G, GOUYON JB, LAPILLONNE A
2012 - J Pediatr Gastroenterol Nutr 54(5):613-9
BACKGROUND:: Accurate data on the optimal chloride intake in premature infants are scarce. OBJECTIVE:: To describe chloride (Cl) intakes in the first 10 days (D) of life and to assess the relationships between high Cl intakes and corrected serum chloride level or markers of severe acidosis in infants less than 28 weeks gestation. METHODS:: Retrospective cohort study including all infants < 28 weeks admitted to the neonatal intensive care unit over a 3-year period and cared for from birth until D10 or more. RESULTS:: Fifty-six infants were included. Cumulative total Cl intakes reached (mean +/- SD) 9.6 +/- 3.7 mmol/kg at day 3 and 49.2 +/- 13.5 mmol/kg at D10. Inadvertent intakes (from intravenous fluids other than parenteral nutrition) represented on average 70% of total Cl intakes in the first 3 days. Difference between Cl and sodium intakes reached (mean +/- SD) 7.8 +/- 4.8 mmol/kg at D10 and mainly originated from parenteral nutrition. By multivariate analysis, cumulative Cl intake > 10 mmol/kg during the first 3 days was an independent risk factor of base excess <-10 mmol/l. Cumulative Cl intake > 45 mmol/kg during the first 10 days was an independent risk factor of corrected chloremia > 115 mmol/l and of base excess <-10 mmol/l. CONCLUSIONS:: Cumulative Cl intake over 10 mmol/kg during the first 3 days (i.e. 3.3 mmol/kg/d on average) and over 45 mmol/kg during the first 10 days (i.e. 4.5 mmol/kg/d on average) may have unwanted metabolic consequences and should be avoided. Imbalance between electrolytes provided by the parenteral nutrition solution need to be detected and corrected.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Fatal parvovirus b19 myocarditis in children and possible dysimmune mechanism
KOEHL B, OUALHA M, LESAGE F, RAMBAUD C, CANIONI D, HUBERT P, LERUEZ-VILLE M
2012 - Pediatr Infect Dis J 31(4):418-21
We report 2 cases of previously healthy children, who developed, after a common parvovirus B19 infection, a sudden inflammatory response, involving predominantly T cell, directed against myocardium and leading to fatal outcome. These cases and several published case reports further our understanding of fulminating parvovirus myocarditis in children.
Unité(s) : Anatomie Pathologique, Laboratoire de Microbiologie, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Experts' recommendations: Stroke management in the intensive care unit. Pediatric specificities (excluding neonates).]
KOSSOROTOFF M, MEYER P, LEBAS A, CHABRIER S
2012 - Rev Neurol (Paris) 168(6-7):527-32
Stroke in children is not rare. Although there are no randomized trials on childhood stroke, except in sickle cell disease patients, several international guidelines have described quality criteria for stroke management in children. Age-adapted management is required, involving collaboration with a pediatric neurologist and hospitalization in a pediatric intensive care or continuous care unit. All symptomatic treatments used in adults can be recommended in children, including homeostasis assessment and maintenance or blood exchange in sickle cell disease patients. Specific treatments such as thrombolysis or mechanical thrombectomy are not recommended in children, except in the framework of clinical trials, but can be beneficial in adolescents. Multidisciplinary decision-making should be the rule in such situations. Adolescents may be managed in adult stroke units. Indications for surgery in children are adapted from adult guidelines. Appropriate management of cerebral venous thrombosis in children is similar to that in adults. The best management possible can be achieved through a multidisciplinary dialogue between the pediatric neurologist and the adult intensivist or neurologist.
Unité(s) : Neurologie, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Densite osseuse et marqueurs osseux du premature
LAPILLONNE A
2012 - Arch Pediatr 19(6S1):H180-H181
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Impact on parents of bronchiolitis hospitalization of full-term, preterm and congenital heart disease infants
LAPILLONNE A, REGNAULT A, GOURNAY V, GOUYON JB, GILET H, ANGHELESCU D, MILORADOVICH T, ARNOULD B, MORIETTE G
2012 - BMC Pediatr 12(.):171
ABSTRACT: BACKGROUND: The objective of this work was to explore the impact on parents of the bronchiolitis hospitalization of their infant using the Impact of Bronchiolitis Hospitalization Questionnaire (IBHQ(c)). METHODS: Four hundred sixty-three infants aged less than 1 year and hospitalized for bronchiolitis were included in a French observational study during the 2008-2009 season. Parents were asked to complete the IBHQ at hospital discharge and 3 months later. IBHQ scores, ranging from 0 (no impact) to 100 (highest impact), were compared according to gestational age (full-term, 33-36 wGA,
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Sedation and analgesia in emergency structure. Paediatry: Which sedation and analgesia for child tracheal intubation?]
ORLIAGUET G
2012 - Ann Fr Anesth Reanim 31(4):359-68
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Sedation and analgesia in emergency structure. Paediatry: Which sedation and analgesia for pediatric patients? Pharmacology.]
ORLIAGUET G
2012 - Ann Fr Anesth Reanim 31(4):377-83
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Local salicylate transcutaneous absorption: An unrecognized risk of severe intoxication: A case report.]
OUALHA M, DUPIC L, BASTIAN C, BERGOUNIOUX J, BODEMER C, LESAGE F
2012 - Arch Pediatr 19(10):1089-92
INTRODUCTION: Although rare, salicylate intoxication through the skin should not be ignored as it can be severely life-threatening. We describe an original case of accidental poisoning with salicylates topically applied to the scalp of a 6-week-old infant. CLINICAL REPORT: A 6-week-old infant, with no prior history, was admitted to the pediatric intensive care unit for treatment of severe disorders of consciousness associated with significant tachypnea. Laboratory results revealed metabolic acidosis with elevated anion gap, ketonuria, and normal glycemia. Initial assessment ruled out the hypothesis of accidental ingestion of salicylates. However, the presence of salicylic acid derivatives in organic acid chromatography, confirmed by plasma salicylate levels at 580mg/L, ultimately re-established the diagnosis. Further inquiry retrospectively highlighted the prolonged topical application in occlusion (3 days) of an extemporaneous preparation containing 23% salicylic acid on the scalp. The course after urine alkalinization was rapidly favorable without sequelae. COMMENT AND CONCLUSIONS: Salicylate intoxication is potentially lethal, particularly in infants under 12 months of age. The vast majority of these intoxications result from accidental ingestion. The present observation underscores the original and undescribed risk of intoxication due to a localized application to the scalp. In the presence of warning symptoms, salicylate poisoning should be investigated, including topical application of salicylic acid, even if localized. Careful attention should be paid to following the indications of use of this product in terms of concentration, characteristics of the infant, and exposed skin. The use of extended topical application of salicylic acid in concentrations greater than 3% should be avoided.
Unité(s) : Dermatologie, Réanimation Pédiatrique & Néonatologie
 
  Respiratory failure in cystic fibrosis: management in pediatric intensive care unit, lung transplantation recommendation
PELLUAU S, OUALHA M, SOUILAMAS R, HUBERT P
2012 - Archives Pédiatrie 19(Suppl.1):S40-S43
Admission to the ICU for respiratory failure of a child with cystic fibrosis is a telltale sign of the severity of the disease. Bronchopulmonary exacerbation, pneumothorax and hemoptysis are the primary causes, for which respiratory assistance is indispensable in these life-threatening situations. Non-invasive ventilation (NIV) has enabled significant progress in improving patient survival. The modalities of NIV must be tailored to both the patient and the cause of respiratory failure. Invasive ventilation, on the other hand, should be a treatment of last resort, because often associated with high mortality. It must be adapted to the therapeutic strategy involving an impending transplantation, including in critical situations where placement on a high emergency list is a possibility. Since admission to ICU is at times the reflection of the terminal evolution of the disease, ongoing treatment must hence be adapted to the comfort of the child.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Practical Handling, Ease of Use, Safety, and Efficacy of a New Pediatric Triple-Chamber Bag for Parenteral Nutrition in Preterm Infants
RIGO J, MARLOWE ML, BONNOT D, SENTERRE T, LAPILLONNE A, KERMORVANT-DUCHEMIN E, HASCOET JM, DESANDES R, MALFILATRE G, PLADYS P, BEUCHEE A, COLOMB V
2012 - J Pediatr Gastroenterol Nutr 54(2):210-7
OBJECTIVES:: To evaluate the efficacy, safety, flexibility, and ease of handling and use of the Ped3CB-A 300 mL, the first ready-to-use multi-chamber parenteral nutrition system, with optional lipid bag activation, specially designed for administration to preterm infants. METHODS:: In this prospective, open-label, multicenter, non-comparative, Phase III clinical trial, preterm infants were treated with Ped3CB-A for 5-10 consecutive days. RESULTS:: 113 preterm infants were enrolled in the study and 97 (birth weight: 1382 +/- 520 g; gestational age: 31.2 +/- 2.5 weeks; parenteral nutrition administration: 5.6 +/- 6.1 days) were included in the per protocol analysis accounting for 854 perfusion days. Double-chamber bag activation was used for 32 perfusion days. Macronutrient, electrolyte, and mineral supplements were primarily administered through a Y-line or directly in the activated bag. In all, 199 additions (mainly sodium, 95%) were made to the Ped3CB-A bags on 197 infusion days (23.1%) in 43 infants (44.3%). More than 1 of these nutrients was added to the bag on only 1 perfusion day. Mean and maximum parenteral nutrient intakes were 2.8 +/- 0.7 and 3.6 +/- 0.8 g amino acids/kg*day, and 80 +/- 20 and 104 +/- 22 kcal/kg*day. Mean weight gain represented 10.0, 21.5, and 22.6 g/kg*day according to age at inclusion (0-3, 4-7, or >7 days of life). A visual analog scale was completed and produced positive results. No adverse events were attributable to the design of the Ped3CB-A system. CONCLUSIONS:: Ped3CB-A provides easy-to-use, well balanced, and safe nutritional support. Nutritional intakes and weight gain were within the recent parenteral nutrition recommendations in preterm infants.
Unité(s) : Gastro-Hépatologie et Nutrition Pédiatriques, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Sedation and analgesia in emergency structure. Reactualization 2010 of the Conference of Experts of Sfar of 1999.]
VIVIEN B, ADNET F, BOUNES V, CHERON G, COMBES X, DAVID JS, DIEPENDAELE JF, ELEDJAM JJ, EON B, FONTAINE JP, FREYSZ M, MICHELET P, ORLIAGUET G, PUIDUPIN A, RICARD-HIBON A, RIOU B, WIEL E, DE LA COUSSAYE JE
2012 - Ann Fr Anesth Reanim 31(4):391-404
Unité(s) : Médecine d'Urgence, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Sedation and analgesia in emergency structure. How far is too far?]
VIVIEN B, DE LA COUSSAYE JE
2012 - Ann Fr Anesth Reanim 31(4):281-2
Unité(s) : Médecine d'Urgence, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Bordetella bronchiseptica-associated acute chest syndrome in a child with sickle cell disease.]
BILLE E, LESAGE F, GUISO N, QUESNE G, BERCHE P, LE MONNIER A
2011 - Arch Pediatr 18(1):41-44
We describe a case of acute chest syndrome associated with Bordetella bronchiseptica pneumonia in a child with sickle cell disease. B. bronchiseptica is recognized as an important pathogen of the respiratory tract for a large variety of animal species. This zoonotic agent has been frequently associated with chronic and recurrent infections. In humans, the bacterium acts as an opportunistic pathogen affecting mostly immunocompromised patients or those with preexisting respiratory diseases. This case and literature review provides an opportunity to discuss the risk factors, treatment, follow-up, and prevention of such zoonotic infections in the context of a lack of cross-protection of new pertussis vaccines.
Unité(s) : Laboratoire de Microbiologie, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Comparative study of the aristotle comprehensive complexity and the risk adjustment in congenital heart surgery scores
BOJAN M, GERELLI S, GIOANNI S, POUARD P, VOUHE P
2011 - Ann Thorac Surg 92(3):949-56
BACKGROUND: The Aristotle Comprehensive Complexity (ACC) and the Risk Adjustment in Congenital Heart Surgery (RACHS-1) scores have been proposed for complexity adjustment in the analysis of outcome after congenital heart surgery. Previous studies found RACHS-1 to be a better predictor of outcome than the Aristotle Basic Complexity score. We compared the ability to predict operative mortality and morbidity between ACC, the latest update of the Aristotle method and RACHS-1. Morbidity was assessed by length of intensive care unit stay. METHODS: We retrospectively enrolled patients undergoing congenital heart surgery. We modeled each score as a continuous variable, mortality as a binary variable, and length of stay as a censored variable. We compared performance between mortality and morbidity models using likelihood ratio tests for nested models and paired concordance statistics. RESULTS: Among all 1,384 patients enrolled, 30-day mortality rate was 3.5% and median length of intensive care unit stay was 3 days. Both scores strongly related to mortality, but ACC made better prediction than RACHS-1; c-indexes 0.87 (0.84, 0.91) vs 0.75 (0.65, 0.82). Both scores related to overall length of stay only during the first postoperative week, but ACC made better predictions than RACHS-1; U statistic = 0.22, p < 0.001. No significant difference was noted after adjusting RACHS-1 models on age, prematurity, and major extracardiac abnormalities. CONCLUSIONS: The ACC was a better predictor of operative mortality and length of intensive care unit stay than RACHS-1. In order to achieve similar performance, regression models including RACHS-1 need to be further adjusted on age, prematurity, and major extracardiac abnormalities.
Unité(s) : Chirurgie Cardiaque Pédiatrique, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Prevalence of questioning regarding life-sustaining treatment and time utilisation by forgoing treatment in francophone PICUs
CREMER R, HUBERT P, GRANDBASTIEN B, MOUTEL G, LECLERC F
2011 - Intensive Care Med 37(10):1648-55
PURPOSE: Our goal is to assess the prevalence of questioning about the appropriateness of initiating or maintaining life-sustaining treatments (LST) in French-speaking paediatric intensive care units (PICUs) and to evaluate time utilisation related to decision-making processes (DMP). METHODS: 18-month, multicentre, prospective, descriptive, observational study in 15 French-speaking PICUs. RESULTS: Among the 5,602 children admitted, 410 died (7.3%), including 175 after forgoing LST (42.7% of deaths). LST was questioned in 308 children (5.5%) with a prevalence of 13.3 per 100 patient-days. More than 30% of children survived despite the appropriateness of LST being questioned (23% despite a decision to forgo treatment). Median caregiver time spent on making and presenting the decisions was 11 h per child. CONCLUSIONS: In this study, on any given day in each 10-bed PICU, there was more than one child for whom a DMP was underway. Of children, 23% survived despite a decision to forgo LST being made, which underlines the need to elaborate a care plan for these children. Also, DMP represented a large amount of staff time that is undervalued but necessary to ensure optimal palliative practice in PICU.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Deciding to limit or stop acute care in paediatric intensive care]
FERREIRA P, FAURY F
2011 - Soins 754(.):42-4
Staff in paediatric intensive care departments are faced with ethical questioning concerning their healthcare practice. Collaborative meetings involving all relevant professionals are essential in order to ensure the most appropriate, often difficult, decision is made, when it involves limiting or stopping ongoing treatment. Two clinical situations illustrate this issue.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Adenoviral infection presenting as an isolated central nervous system disease without detectable viremia in two children after stem cell transplantation
FRANGE P, PEFFAULT-DE-LATOUR R, ARNAUD C, BODDAERT N, OUALHA M, AVETTAND-FENOEL V, BERNAUDIN F, AGUILAR C, BARNERIAS C, LERUEZ-VILLE M, TOUZOT F, LORTHOLARY O, FISCHER A, BLANCHE S
2011 - J Clin Microbiol 49(6):2361-64
We report two cases of adenoviral meningoencephalitis in children following allogeneic stem cell transplantation. These cases shared four similarities: isolated neurological involvement, infiltrating hyperintensities next to the third ventricle on the cerebral MRI, the absence of concomitant detectable adenoviral viremia and severe clinical outcome.
Unité(s) : Immunologie-Hématologie Pédiatriques, Laboratoire de Microbiologie, Maladies Infectieuses, Neurologie, Radiologie Pédiatrique, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed High levels and safety of oseltamivir carboxylate plasma concentrations after nasogastric administration in critically ill children in pediatric intensive care unit
GIRAUD C, MANCEAU S, OUALHA M, CHAPPUY H, MOGENET A, DUCHENE P, DUCROCQ S, HUBERT P, TRELUYER JM
2011 - Antimicrob Agents Chemother 55(1):433-35
During the 2009 H1N1 pandemics, the concentrations of oseltamivir (O) and its active metabolite (OC) were determined in 11 children (1 month - 16 years) admitted in intensive care unit for presumed severe H1N1. They received oseltamivir phosphate (OP) nasogastrically at doses between 1.5 and 6.8 mg/kg/dose. High OC concentrations were found, with a mean level of 678 +/- 535 mug/L. OP mean concentration was 27 +/- 52 mug/L. No marked side effect was reported.
Unité(s) : EA 3620, Médecine d'Urgence, Réanimation Pédiatrique & Néonatologie, CIC 0901, URC
 
Lien PubMed Neurologic Outcomes at School Age in Very Preterm Infants Born With Severe or Mild Growth Restriction
GUELLEC I, LAPILLONNE A, RENOLLEAU S, CHARLALUK ML, ROZE JC, MARRET S, VIEUX R, MONIQUE K, ANCEL PY
2011 - Pediatrics 127(4):e883-e891
OBJECTIVE: To determine whether mild and severe growth restriction at birth among preterm infants is associated with neonatal mortality and cerebral palsy and cognitive performance at 5 years of age and school performance at 8 years of age. METHODS: All 2846 live births between 24 and 32 weeks' gestation from 9 regions in France in 1997 were included in a prospective observational study (the EPIPAGE [Etude Epidemiologique sur les Petits Ages Gestationnels] study) and followed until 8 years of age. Infants were classified as "small-for-gestational-age" (SGA) if their birth weight for gestational age was at the <10th centile, "mildly-small-for-gestational-age" (M-SGA) if birth weight was at the >/=10th centile and <20th centile, and "appropriate-for-gestational-age" (AGA) if birth weight was at the >/=20th centile. RESULTS: Among the children born between 24 and 28 weeks' gestation, the mortality rate increased from 30% in the AGA group to 42% in the M-SGA group and to 62% in the SGA group (P < .01). Birth weight was not significantly associated with any cognitive, behavioral, or motor outcomes at the age of 5 or any school performance outcomes at 8 years. For the children born between 29 and 32 weeks' gestation, SGA children had a higher risk for mortality (adjusted odds ratio [aOR]: 2.79 [95% confidence interval (CI): 1.50-5.20]), minor cognitive difficulties (aOR: 1.73 [95% CI: 1.12-2.69]), inattention-hyperactivity symptoms (aOR: 1.78 [95% CI: 1.10-2.89]), and school difficulties (aOR: 1.74 [1.07-2.82]) compared with AGA children. Being born M-SGA was associated with an increased risk for minor cognitive difficulties (aOR: 1.87 [95% CI: 1.24-2.82]) and behavioral difficulties (aOR: 1.66 [95% CI: 1.04-2.62]). CONCLUSIONS: In preterm children, growth restriction was associated with mortality, cognitive and behavioral outcomes, as well as school difficulties.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Targeting the microcirculation in resuscitation of acutely unwell patients
HARROIS A, DUPIC L, DURANTEAU J
2011 - Curr Opin Crit Care 17(3):303-7
PURPOSE OF REVIEW: The ultimate goals of hemodynamic therapy in acutely unwell patients are to restore effective tissue perfusion and oxygen delivery to maintain cellular metabolism. Optimization of systemic hemodynamics may improve the time course of microcirculatory dysfunction and eventually the patient's outcome. However, relationships between systemic hemodynamics and microcirculatory changes during resuscitation are complex and underperfused microcirculation may persist, despite restored macrohemodynamics. Thus, targeting the microcirculation is a logical goal to obtain an adequate resuscitation. RECENT FINDINGS: The impact of systemic interventions such as fluid resuscitation, vasopressor therapy, and transfusion has been evaluated on microcirculatory perfusion in septic-shock patients. It demonstrated inconstant improvement according to time-course evolution of the underlying pathology with interindividual variability. Thus, therapy targeting the microcirculation should be adapted to individual microcirculatory monitoring. Specific therapy with nitroglycerin did not promote microcirculation in septic shock but was associated with microcirculatory improvement in cardiogenic shock. SUMMARY: Microcirculatory hemodynamics have to be restored as soon as possible during the early phase of the management of acutely unwell patients. Future trials should test whether microcirculation-guided strategy could better improve organ dysfunction than global hemodynamic-guided strategy. An optimal resuscitation has to restore the systematic hemodynamics and make sure of the quality of the microcirculation.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Postresuscitation syndrome: Potential role of hydroxyl radical-induced endothelial cell damage
HUET O, DUPIC L, BATTEUX F, MATAR C, CHEREAU C, LEMIALE V, HARROIS A, CONTI M, MIRA JP, VICAUT E, CARIOU A, DURANTEAU J
2011 - Crit Care Med 39(7):1712-20
OBJECTIVE:: After out of hospital cardiac arrest, it has been reported that endothelium dysfunction may occur during the postresuscitation syndrome. However, the consequences of the reperfusion phase on endothelial reactive oxygen species production and redox homeostasis have not been explored in out of hospital cardiac arrest patients. DESIGN:: Prospective, observational study. SETTING:: Medical intensive care unit in a university hospital. PATIENTS:: Twenty successfully resuscitated out of hospital cardiac arrest patients, seven septic shock patients, and ten healthy volunteers. INTERVENTION:: Plasma was collected from patients at admission and 12, 24, 36, 48, and 72 hrs after cardiac arrest. We studied the production of reactive oxygen species and cell survival during plasma perfusion using perfused endothelial cells (human umbilical vein endothelial cells) as a model. Cell antioxidant response was studied by measuring superoxide dismutase, glutathione peroxidase, and glutathione reductase activities and reduced and oxidized glutathione levels. Mitochondrial respiratory chain activity was assessed by measuring complex I, II, III, and IV activities and anaerobic glycolysis by measuring glucose-6-phosphate dehydrogenase activity. MEASUREMENTS AND MAIN RESULTS:: Using perfused endothelial cells as a model, we demonstrate that plasma from out of hospital cardiac arrest patients induced on naive human umbilical vein endothelial cells a significant and massive cell death compared to plasma from septic shock patients and healthy volunteers. An increase of reactive oxygen species production with a decrease in antioxidant defenses (superoxide dismutase, glutathione peroxidase, and glutathione reductase activities, reduced and oxidized glutathione levels) was observed. The metabolic consequence of plasma exposure showed that mitochondrial respiratory chain activity was significantly impaired and anaerobic glycolysis was significantly increased. Inhibiting hydroxyl radical production significantly decreased cell death, suggesting that plasma from out of hospital cardiac arrest induced significant cell death by triggering the Fenton reaction. CONCLUSION:: Plasma from out of hospital cardiac arrest induces major endothelial toxicity with an acute pro-oxidant state in the cells and impairment of mitochondrial respiratory chain activity. This toxicity could be due to hydroxyl radical production by activation of the Fenton reaction.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Oxidative stress and endothelial dysfunction during sepsis
HUET O, DUPIC L, HARROIS A, DURANTEAU J
2011 - Front Biosci 16(.):1986-95
Endothelial activation and dysfunction play a key role in the pathogenesis of sepsis. During septic shock, endothelial dysfunction is involved in microcirculation impairment and organ dysfunction. Reactive oxygen species (ROS) and reactive nitrogen species (RNS) have several potentially important effects on endothelial function and are implicated in physiological regulation and disease pathophysiology. The imbalance between the production of ROS and their effective removal by non-enzymatic and enzymatic antioxidants systems could induce endothelial dysfunction with alterations of vascular tone, increases in cell adhesion properties (leukocytes and platelet adhesion), increase in vascular wall permeability and a pro-coagulant state. Increasing evidence supports the idea that the principal cause of EC dysfunction during sepsis is cell injury. ROS and RNS contribute to mitochondrial dysfunction by a range of mechanisms and induce both necrotic and apoptotic cell death. Understanding the mechanisms underlying the generation of ROS and RNS in endothelial cells and the causes of endothelial dysfunction in sepsis may help provide therapeutic strategies to tackle endothelial dysfunction and microcirculatory failure in sepsis.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
  Epidemiology and pathophysiology of retinopathy of prematurity
KERMORVANT-DUCHEMIN E, SENNLAUB F, BEHAR-COHEN F, CHEMTOB S
2011 - Archives Pédiatrie 18(Supp.2):S79-S85
La rétinopathie du prématuré est responsable de la majorité des séquelles visuelles chez les anciens prématurés. Elle se développe en deux phases. La première est caractérisée par un arrêt du développement capillaire rétinien et une dégénérescence microvasculaire. La deuxième phase est caractérisée par la prolifération anarchique et excessive de néovaisseaux au niveau des zones avasculaires devenues ischémiques, pouvant se compliquer d’hémorragies et de décollement de rétine. La cascade à l’origine de la dégénérescence micro-vasculaire rétinienne initiale résulte à la fois de facteurs oxygéno-dépendants et de facteurs indépendants de l’oxygène. Les mécanismes oxygéno-dépendants comprennent les lésions induites par le stress oxydant et nitro-oxydant, et la suppression, via le facteur de transcription régulé par l’oxygène HIF-1?, de facteurs de croissance vasculaire comme le VEGF et l’érythropoïétine. Les facteurs indépendants de l’oxygène sont liés à la croissance et sont principalement dus à un déficit en hormones de croissance comme l’IGF-1. L’apparition des néovascularisations de la 2e phase de la maladie résulte d’une surexpression des facteurs de croissance vasculaire, mécanisme visant à compenser l’hypoxie rétinienne induite par la perte vasculaire initiale. Des mécanismes de réparation vasculaire nouveaux, impliquant une signalisation par les métabolites du cycle de Krebs d’une part, et une signalisation par les acides gras insaturés de la série ?-3 d’autre part, ouvrent de nouvelles perspectives thérapeutiques
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Impact of LCPUFA supplementation on body composition of girls born preterm
LAPILLONNE A
2011 - Arch Dis Child 96(2):206
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
  Intrauterin growth retardation and adult outcome
LAPILLONNE A
2011 - Bull. Acad. Natl. Méd. 195(3):477-484
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Use of Parenteral Lipid Emulsions in French Neonatal ICUs
LAPILLONNE A, FELLOUS L, KERMORVANT-DUCHEMIN E
2011 - Nutr Clin Pract 26(6):672-680
Objective: To determine the types of parenteral lipid emulsions currently used for preterm infants, their mode of delivery, and the main disease conditions that are considered by neonatologists as contraindications. Design: National survey using a questionnaire. Setting: 155 neonatal departments in France. Results: 100 (65%) neonatal departments participated in the survey. The most widely used lipid emulsion was the 20% soybean oil/coconut oil-based emulsion (68% of the units), followed by the soybean oil-based emulsion (28.5%) and the soybean oil/olive oil-based emulsion (3.5%). Peripheral venous access was considered to be a possible route for the infusion of lipid emulsions in only 58 (63.7%) of the units. In 80%-90% of the units, sepsis, hemodynamic failure, thrombocytopenia, disseminated intravascular coagulation, and hyperbilirubinemia were considered to be relative or absolute contraindications, whereas only hemodynamic failure, disseminated intravascular coagulation, and to a lesser extent sepsis were most often perceived as absolute contraindications. Conclusions: Neonatologists are somewhat reluctant to use parenteral lipids when only peripheral venous access is available, despite the low osmolarity of the emulsions. This may impair, at least temporarily, the adequate supply of energy and/or essential fatty acids in infants who do not have central venous access. This study also shows a large heterogeneity of responses with regard to the contraindications for parenteral lipids.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Nutrition of the preterm infant.]
LAPILLONNE A, RAZAFIMAHEFA H, RIGOURD V, GRANIER M
2011 - Arch Pediatr 18(3):313-323
The quality of nutritional support impacts not only the growth and quality of growth of preterm infants, but also all aspects of their development. In order to provide optimal nutrition, two main rules should be followed: optimise early parenteral nutrition and introduce appropriate enteral nutrition preferably with the mother's milk as early as possible. Recommendations have recently increased early energy and protein intake. The term "aggressive nutrition" has been introduced to qualify these changes, but we prefer the term "optimal nutrition," which more precisely reflects the physiology and needs of the preterm infant. Specific efforts should be continued to improve physician training in neonatal nutrition and to facilitate the dissemination of the most recent recommendations. Standardization of nutritional protocols in neonatal units should be promoted as a way to improve overall nutritional care. A full field of research remains open to determine the most effective nutritional strategy for preterm infants in order to maximize their growth and development.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Infections a risque epidemique et biologique. Enjeux de l'accueil et de la prise en charge initiale des patients suspects
LEPORT C, VITTECOQ D, PERRONNE C, DEBORD T, CARLI P, CAMPHIN P, BRICAIRE F
2011 - Presse Med 40(4P1):336-40
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Cloverleaf skull deformity and hydrocephalus
MACHADO G, DI ROCCO F, SAINTE-ROSE C, MEYER P, MARCHAC D, MACQUET-NOUVION G, ARNAUD E, RENIER D
2011 - Childs Nerv Syst 27(10):1683-91
OBJECTIVE: This article describes the clinical aspects for both operated and non-operated patients with a cloverleaf skull deformity treated in our service, focusing on hydrocephalus. METHODS: We describe 13 cases of cloverleaf skull deformity treated in our services between 1977 and 2008. Among them, ten were operated (9 out of 13 for the craniofacial stenosis and 7 out of 13 for hydrocephalus). RESULTS: Hydrocephalus was present in all patients with bilateral lambdoid stenosis. There was no case of hydrocephalus among the patients with unilateral or absent lambdoid stenosis. Associated malformations and severe faciostenosis were associated with higher mortality and morbidity. CONCLUSION: The development of hydrocephalus seems to be closely related to a bilateral lambdoid stenosis. The optimal treatment must be tailored individually considering the degree of the malformation and the presence of complications and comorbidities.
Unité(s) : Neurochirurgie Pédiatrique, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Emergency tracheal intubation of severely head-injured children: Changing daily practice after implementation of national guidelines
MARTINON C, DURACHER C, BLANOT S, ESCOLANO S, DE AGOSTINI M, PERIE-VINTRAS AC, ORLIAGUET G, CARLI PA, MEYER PG
2011 - Pediatr Crit Care Med 12(1):65-70
OBJECTIVE:: To report daily practice of scene emergency tracheal intubation performed by physicians and changes induced by implementation of national guidelines, with special attention to rapid sequence induction (RSI) and control of assisted ventilation. DESIGN:: Observational study. SETTING:: ------. PATIENTS:: A total of 296 children (age, 2-15 yrs old) referred to our center for severe traumatic brain injury (Glasgow Coma Scale score of
Unité(s) : Médecine d'Urgence, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Transcranial Doppler can predict intracranial hypertension in children with severe traumatic brain injuries
MELO JR, DI ROCCO F, BLANOT S, CUTTAREE H, SAINTE-ROSE C, OLIVEIRA-FILHO J, ZERAH M, MEYER PG
2011 - Childs Nerv Syst 27(6):979-84
PURPOSE: The purpose of this study is to evaluate the accuracy of emergency Transcranial Doppler (TCD) to predict intracranial hypertension and abnormal cerebral perfusion pressure in children with severe traumatic brain injury (TBI). PATIENTS AND METHODS: A descriptive and retrospective cross-sectional study was designed through data collected from medical records of children with severe TBI (Glasgow coma scale 1.31) or when no-flow/backflow was detected. Invasive intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring were considered as the gold standard to measure intracranial hypertension (ICH). Statistical analyses compared TCD profiles to increased ICP (>/=20 mmHg) and abnormal cerebral perfusion pressure (<50 mmHg) at admission. RESULTS: Non-invasive TCD and ICP monitoring were performed in 117 severe head-injured children. Mean age was 7.6 +/- 4.4 years, with a male prevalence (71%). Median initial Glasgow coma scale was 6. TCD had 94% of sensitivity to identify ICH at admission and a negative predict value of 95% to identify normal ICP at admission. Its sensitivity to predict abnormal cerebral perfusion pressure was 80%. CONCLUSIONS: The high sensitivity of admission TCD to predict ICH and abnormal CPP after trauma demonstrates that TCD is an excellent first-line examination to determine those children who need urgent aggressive treatment and continuous invasive ICP monitoring.
Unité(s) : Neurochirurgie Pédiatrique, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [About recommendations and experience in emergency paediatric anaesthesia : reply.]
ORLIAGUET G, DIEPENDAELE JF, CHERON G, VIVIEN B, DE LA COUSSAYE JE
2011 - Ann Fr Anesth Reanim 30(5):444-45
Unité(s) : CUDR, Médecine d'Urgence, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Mortality in Children With Severe Head Trauma: Predictive Factors and Proposal for a New Predictive Scale, in Reply
TUDE-MELO JR, DI ROCCO F, MEYER P, ZERAH M
2011 - Neurosurgery 69(3):e786
Unité(s) : Neurochirurgie Pédiatrique, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Palliative care in the neonatal period. Part one: general considerations]
BETREMIEUX P, GOLD F, PARAT S, CAEYMAEX L, DANAN C, DE DREUZY P, VERNIER D, VIALLARD ML, KUHN P
2010 - Arch Pediatr 17(4):409-12
In France, the law dated 22 April 2005 required that all practitioners offer palliative care to patients as an alternative to unreasonable obstinacy. The practical development of palliative care during the neonatal period is not easy, even though obstetricians and neonatologists have always been aware of the ethical necessity of comfort in the dying newborn. The decision leading to palliative care begins with the recognition of patent or potential unreasonable obstinacy, followed by withdrawing treatment and technical support, and finally a palliative care plan is drawn up with the medical team and the parents.
Unité(s) : Pédiatrie Générale, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Implementing palliative care for newborns in various care settings. Part 3 of "Palliative care in the neonatal period"]
BETREMIEUX P, GOLD F, PARAT S, FARNOUX C, RAJGURU M, BOITHIAS C, MAHIEU-CAPUTO D, JOUANNIC JM, HUBERT P, SIMEONI U
2010 - Arch Pediatr 17(4):420-5
Palliative care in newborns may take place in the delivery room and then continued either in maternity wards or in the neonatal unit. For babies developing a chronic condition, going home may be advantageous. The population concerned includes babies born with a severe intractable congenital malformation and certain extremely preterm newborn babies at the limits of viability. Care procedures as well as withholding and withdrawing treatments are reviewed.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Imagining a palliative care project for newborns. Part two of Palliative care in the neonatal period]
BETREMIEUX P, GOLD F, PARAT S, MORIETTE G, HUILLERY ML, CHABERNAUD JL, STORME L, NARCY P, DERUELLE P, KRACHER S
2010 - Arch Pediatr 17(4):413-9
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [What non invasive haemodynamic assessment in paediatric intensive care unit in 2009?]
BRISSAUD O, GUICHOUX J, VILLEGA F, ORLIAGUET G
2010 - Ann Fr Anesth Reanim 29(3):233-41
The haemodynamic assessment of the patients is a daily activity in paediatric intensive care unit. It completes and is guided by the clinical examination. The will to develop the least invasive possible coverage of the patients is a constant concern. The haemodynamic monitoring, all the more if it is invasive, ceaselessly has to put in balance the profit and the risk of beginning this technique at a fragile patient. In the last three decades, numerous non-invasive haemodynamic tools were developed. The ideal one must be reliable, reproducible, with a time of fast, easily useful answer, with a total harmlessness, cheap and allowing a monitoring continues. Among all the existing tools (oesophageal Doppler ultrasound method, transthoracic echocardiography, NICO, thoracic impedancemetry, plethysmography, sublingual capnography), no one allies all these qualities. We can consider that the transthoracic echocardiography gets closer to most of these objectives. We shall blame it for its cost and for the fact that it is an intermittent monitoring but both in the diagnosis and in the survey, it has no equal among the non-invasive tools of haemodynamic assessment from part the quality and the quantity of the obtained information. The learning of the basic functions (contractility evaluation, cardiac output, cardiac and the vascular filling) useful for the start of a treatment is relatively well-to-do. We shall miss the absence of training in this tool in France in its paediatric and neonatal specificity within the university or interuniversity framework.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Diagnostic and therapeutic management of inherited metabolic diseases in emergency and intensive care unit.]
DE LONLAY P, VALAYANNOPOULOS V, ARNOUX JB, SERVAIS A, CHARRON B, JACQMARCQ O, OTTOLENGHI C, HUBERT P
2010 - Arch Pediatr 17(6):947-8
Unité(s) : Métabolisme, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Skin tests with latex should always be performed following perioperative immediate hypersensitivity reaction
DEWACHTER P, APRIOTESEI R, MOUTON-FAIVRE C
2010 - Int J Obstet Anesth 19(2):239-240
Unité(s) : Médecine d'Urgence, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Pre-exposure to vasopressin potentiates the vasoconstrictive effect of epinephrine in rat aorta isolated during late anaphylaxis
DEWACHTER P, EMALA CW
2010 - Shock 33(6):655-61
Clinical guidelines for anaphylaxis recommend epinephrine as first-line therapy, but do not distinguish between early versus late stages of anaphylaxis. The delay between the onset of anaphylaxis and initiation of treatment may influence the choice of the optimal vasoconstrictor (epinephrine versus arginine vasopressin (AVP)).Anesthetized rats were allocated into: control and 3 anaphylaxis groups (n = 6/group). The aortas were removed at 5 min (control), at 5, 15 or 30 min during anaphylaxis and were contracted in organ baths by increasing concentrations of epinephrine or AVP. Following washout of the initial agonist, each ring was contracted with the alternative drug. Separately, aortic rings removed during early versus late anaphylaxis were contracted by AVP +/- pretreatment with N (G)-nitro-L-arginine methyl ester (L-NAME) (10 M), a nitric oxide synthase inhibitor.Aortic rings removed during late versus early anaphylaxis were less responsive to epinephrine (EC50 (5'): 8.4 nM [4.9-11.8], EC50 (30'): 18.2 nM [11.9-24.4]; p = 0.04) and AVP (EC50 (5'): 8.1 nM [4.9-11.3], EC50: (30') 19.7 nM [10.9-28.6]; p = 0.02). Pre-exposure to AVP enhanced the subsequent contractile effect of epinephrine in aortic rings removed during late anaphylaxis (Emax: 1.02 g [0.76-1.28]) versus early (Emax: 0.44 g [0.28-0.59], p = 0.005). In contrast to early, pretreatment with L-NAME decreased responsiveness to AVP during late (EC50: 2.47 nM [1.79-3.16], 1.55 nM [1.11-1.98] for +/- L-NAME, respectively; p = 0.03).During anaphylaxis, the vasoconstrictive effects of AVP or epinephrine are time-dependent. AVP might have beneficial effects during late anaphylaxis via mechanisms involving nitric oxide.
Unité(s) : Médecine d'Urgence, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Possible link between apical ballooning syndrome during anaphylaxis and inappropriate administration of epinephrine
DEWACHTER P, MOUTON-FAIVRE C
2010 - Mayo Clin Proc 85(4):396-7; author reply 398
Unité(s) : Médecine d'Urgence, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Allergic risk during paediatric anaesthesia]
DEWACHTER P, MOUTON-FAIVRE C
2010 - Ann Fr Anesth Reanim 29(3):215-26
OBJECTIVES: To propose the different modalities of management of the allergic risk occurring during paediatric anaesthesia. STUDY DESIGN: Literature analysis. METHODS: Literature research using the Medline((R)) database and MeSH format according to keywords, including publications in French and English since 1982. RESULTS: The overall incidence for anaphylactic reactions was estimated at one in 7741 anaesthetic procedures during paediatric anaesthesia. Latex anaphylaxis was mostly involved with an incidence at one in 10,159 anesthetic procedures. The risk factors of latex sensitization are known. Primary latex prophylaxis is efficient in patients at risk of latex sensitization. In contrast to adults, neuromuscular blocking agents (NMBAs) are rarely involved in children, with an incidence at 1 in 81,275 anaesthetic procedures. The Ring and Messmer clinical scale allows quantifying the severity and helps managing the care of immediate hypersensitivity reactions. Clinical symptoms associate cardiovascular, respiratory and cutaneous-mucous signs according to different severity grades. Epinephrine associated to fluid loading, remains the first-line agent in case of severe reactions. The allergological assessment is key to the management of these reactions and is required in order to identify the mechanism of the reaction and the culprit drug or substance involved. CONCLUSIONS: Allergic reactions to NMBAs occurring during paediatric anaesthesia are rare whereas those with latex are more frequent. Therefore, the reduction of the allergic risk during paediatric anaesthesia essentially requires a latex-free environment.
Unité(s) : Réanimation Pédiatrique & Néonatologie, Médecine d'Urgence
 
Lien PubMed The dose of epinephrine to treat anaphylaxis
DEWACHTER P, MOUTON-FAIVRE C, EMALA CW
2010 - Anesthesiology 112(6):1542-3
Unité(s) : Réanimation Pédiatrique & Néonatologie, Médecine d'Urgence
 
  Epidemiology and morbidity of regional anesthesia in children: a follow-up one-year prospective survey of the French-Language Society of Paediatric Anaesthesiologists (ADARPEF)
ECOFFEY C, LACROIX F, GIAUFRE E, ORLIAGUET G, COURREGES P
2010 - Pediatr. Anesth. 20(12):1061-1069
Background: The French-Language Society of Paediatric Anaesthesiologists (ADARPEF) designed a 1-year prospective, multicenter and anonymous study to update both epidemiology and morbidity of regional anesthesia in children. Methods: From November 2005 to October 2006, data from participating hospitals were recorded using an identification form, a data recording form, and a complication form. Information collected included the characteristics of the hospitals, the number and type of regional anesthetics (RA), the age of the involved children as well as the incidence, and type of complications. Results: Data collected in 47 institutions included 104 612 pure general anesthesias (GAs), 29 870 GAs associated with regional blocks, and 1262 pure regional blocks. Central blocks accounted for 34% of all RA. Peripheral blocks (66%) were upper or lower limb blocks (29% of peripheral blocks), trunk blocks, and face blocks (71%). In children aged ?3 years, the percentage of central blocks was similar to the peripheral ones (45% vs 55), while in older children, peripheral blocks were more than four times used than central ones. Complications (41 involving 40 patients) were rare and usually minor. They did not result in any sequelae. The study revealed an overall rate of complication of 0.12%; CI 95% [0.09–0.17], significantly six times higher for central than for peripheral blocks. Conclusions: As a result of the low rate of complications, RA techniques have a good safety profile and can be used to provide postoperative analgesia. In addition, the results should encourage anesthesiologists to continue to use peripheral instead of central (including caudal) blocks as often as possible when appropriate.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Haemorrhagic shock after severe abdominal trauma in children: knowing when to change from conservative to surgical management]
JOUFFROY R, BOURDAUD N, CUTTAREE H, SAUVAT F, CARLI P, ORLIAGUET G
2010 - Ann Fr Anesth Reanim 29(5):387-90
Abdominal vascular injuries following a serious falling out are quite rare in children. They can lead to haemorrhagic shock whose etiological diagnosis may be difficult in children in case of multiple trauma. The current management of abdominal injuries in the child is usually conservative, surgery being indicated in haemodynamically unstable patients. We report the case of a 7-year-old girl who presented with abdominal trauma with rupture of the hepatic artery and shredding of the splenic vein following a falling out of 10 meters. Aggressive resuscitation associated with early laparotomy for haemostasis, contrary to usual practices advocated in such a context, have helped control the hemorrhagic shock and stabilize the haemodynamic status of the child. The subsequent evolution was favourable, with full recovery. While a conservative attitude usually prevails in the management of traumatic intra abdominal bleeding in children an interventional attitude with emergency surgery must be sometimes considered.
Unité(s) : Chirurgie Viscérale Pédiatrique, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Postnatal docosahexaenoic acid deficiency is an inevitable consequence of current recommendations and practice in preterm infants
LAPILLONNE A, ELENI-DIT-TROLLI S, KERMORVANT-DUCHEMIN E
2010 - Neonatology 98(4):397-403
BACKGROUND: Very preterm infants are particularly susceptible to nutrient deficiencies. Although a lot of attention has been focused on the early nutrient supply, they are at high risk of long-chain polyunsaturated fatty acid deficiency. OBJECTIVES: To estimate docosahexaenoic acid (DHA) intake, the metabolizable (i.e. absorbed) DHA, the DHA available for accretion and to quantify the DHA deficit, if any, during the first month of life of preterm infants born
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Propofol infusion syndrome]
LAQUAY N, PRIEUR S, GREFF B, MEYER P, ORLIAGUET G
2010 - Ann Fr Anesth Reanim 29(5):377-86
OBJECTIVE: Propofol is commonly used for sedation of children or adult patients in intensive care unit as an alternative to benzodiazepines for the long-term sedation of mechanically ventiled patient. However, the life-threatening complication of propofol-infusion syndrome (PRIS) may in some case occur. The objective of this article is to review the clinical features, physiopathology and management of PRIS. DATA SOURCES: A PubMed database research in English and French languages published until December 2008. Keywords were propofol, propofol infusion syndrome (PRIS), rhabdomyolysis, heart failure, arrhythmias, metabolic acidosis, brain injury, sedation, intensive care. DATA SYNTHESIS: PRIS is a rare and potentially lethal complication, especially if there's no early identification of the syndrome. The physiopathology of PRIS mechanism remains unclear, however a dysfunction of mitochondrial respiratory chain could be involved and potential genetic factor may account. Clinical features consist of arrhythmias, metabolic acidosis, lipemia, rhabdomyolisis, myoglobinuria. PRIS has been described classically in children and adults undergoing a long term infusion with propofol (more than 48 hours) at doses higher than 4 mg/kg per hour. However, it can be observed with lower doses and after shorter duration of sedation. Steroids, vasopressors and low carbohydrate intake act as triggering factors. Early recognition of the syndrome improve patient's outcome. Propofol infusion must be avoided in susceptible patients and another sedative agent should be considered. When using prolonged sedation with propofol, arrhythmia and serum triglyceridemia level should be monitored.
Unité(s) : Médecine d'Urgence, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Acute hyperglycemia is a reliable outcome predictor in children with severe traumatic brain injury
MELO JR, DI ROCCO F, BLANOT S, LAURENT-VANNIER A, REIS RC, BAUGNON T, SAINTE-ROSE C, OLVEIRA-FILHO J, ZERAH M, MEYER P
2010 - Acta Neurochir (Wien) 152(9):1559-65
PURPOSE: Hyperglycemia in the acute phase after trauma could adversely affect outcome in children with severe traumatic brain injury (TBI). The goal of this study was to identify the relationship between acute spontaneous hyperglycemia and outcome in children with severe TBI at hospital discharge and 6 months later. METHODS: A retrospective analysis of blood glucose levels in children with severe TBI at a Pediatric level I Trauma Center, between January 2000 and December 2005. Hyperglycemia was considered for a cut-off value of 11.1 mmol/l (200 mg/dl). Outcome was measured with Glasgow Outcome Scale (GOS) at hospital discharge and at 6 months. A multiple logistic regression analysis, the Student's t test and the chi (2) test were done. RESULTS: Hyperglycemia was noted within the first 48 h in 34% of the patients. Mortality (70% vs 14%, p < 10(-5)) was more frequent in hyperglycemic children and bad outcome upon hospital discharge in those who remained hyperglycemic during the first 48 h of hospitalization. GOS after 6 months demonstrated that those normoglycemic children had a better outcome (95%) than those who developed hyperglycemia during the first 48 h (83%, p = 0.01) after trauma. CONCLUSION: Hyperglycemia could be considered as a marker of brain injury and when present upon admission, could reflect extensive brain damage with frequently associated mortality and bad outcome. The inability to maintain normal blood glucose levels during the first 48 h could be a predictive factor of bad outcome. Avoiding hyperglycemia in the initial phase could be a major issue in children with severe TBI.
Unité(s) : Neurochirurgie Pédiatrique, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Neonatal care in patients with giant ompholocele: arduous management but favorable outcomes
MITANCHEZ D, WALTER-NICOLET E, HUMBLOT A, ROUSSEAU V, REVILLON Y, HUBERT P
2010 - J Pediatr Surg 45(8):1727-33
OBJECTIVES: The objectives of the study were to provide a review of patients with giant omphalocele managed in a single institution (2001-2006), focusing on medical management in the neonatal period, and to evaluate short-term outcomes. METHODS: Data from 14 neonates with giant ompholocele (abdominal wall defect >5 cm and/or containing liver) and the absence of malformation and chromosomal anomalies during fetal screening were retrospectively reviewed. All were intubated and sedated before surgical treatment. Initial management consisted of progressive reduction of the herniated organs by gentle compression. After sequential reduction, abdominal wall closure was attempted at the skin and fascia level and, when necessary, with a Gore-Tex patch. RESULTS: Median gestational age was 39 weeks (38-40), and median birth weight was 3100 g (2470-3700). Median age at closure was 6 days (0-20). A central Gore-Tex patch was inserted in 10 cases. Median ventilation length was 26 days (2-78). Full enteral diet was achieved after an average of 33 days (8-82), and median time until discharge from the intensive care unit was 24.5 days (11-85). Nine patients developed sepsis in the postoperative course. In 10 patients, at least 1 associated malformation was diagnosed in the postnatal course, among which cardiac and diaphragmatic defects were the most common. Survival rate was 85.7%. CONCLUSION: Mortality rate of giant omphalocele without chromosomal anomaly or major malformations is low when treated by gradual reduction of the contents. Parents should be informed of the long hospitalization in the intensive care unit at birth, the potential nonthreatening associated malformations to be diagnosed after birth, and the high risk of sepsis.
Unité(s) : Chirurgie Viscérale Pédiatrique, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Efficacy of ketogenic diet in severe refractory status epilepticus initiating fever induced refractory epileptic encephalopathy in school age children (FIRES)
NABBOUT R, MAZZUCA M, HUBERT P, PEUDENNIER S, ALLAIRE C, FLURIN V, ABERASTURY M, SILVA W, DULAC O
2010 - Epilepsia 51(10):2033-37
Purpose: Fever induced refractory epileptic encephalopathy in school age children (FIRES) is a devastating condition initiated by prolonged perisylvian refractory status epilepticus (SE) triggered by fever of unknown cause. SE may last more than 1 month, and this condition may evolve into pharmacoresistant epilepsy associated with severe cognitive impairment. We aimed to report the effect of ketogenic diet (KD) in this condition. Methods: Over the last 12 years we collected data of nine patients with FIRES who received a 4:1 ratio of fat to combined protein and carbohydrate KD. They presented with SE refractory to conventional antiepileptic treatment. Results: In seven patients, KD was efficacious within 2-4 days (mean 2 days) following the onset of ketonuria and 4-6 days (mean 4.8 days) following the onset of the diet. In one responder, early disruption of the diet was followed by relapse of intractable SE, and the patient died. Epilepsy affected the other six responders within a few months. Discussion: KD may be an alternative therapy for refractory SE in FIRES and might be proposed in other types of refractory SE in childhood.
Unité(s) : Neurologie, Réanimation Pédiatrique & Néonatologie, U663
 
Lien PubMed [The role of neonatologist in perinatal care for congenital heart disease diagnosed in utero.]
PARAT S, GIUSEPPI A
2010 - Arch Pediatr 17(6):746-7
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Reduced monoamine oxidase A activity in pregnant smokers and in their newborns
BERLIN I, HEILBRONNER C, GEORGIEU S, MEIER C, LAUNAY JM, SPREUX-VAROQUAUX O
2009 - Biol Psychiatry 66(8):728-33
BACKGROUND: Tobacco smoking is associated with reduced monoamine oxidase A (MAOA) activity. Smoking-associated low MAOA activities in pregnancy and in newborns may have negative perinatal and postnatal consequences. We aimed to compare, in everyday clinical conditions, biomarkers of MAOA activity in smoking (SPW) and lifetime nonsmoking pregnant women (NSPW) and in cord blood and to assess the newborns' behavior during the first 48 hours of life. METHODS: Thirty SPW and 29 NSPW in their second trimester of pregnancy were included. Plasma MAOA dependent metabolites of norepinephrine: dihydroxyphenylglycol; dopamine: homovanillic and dihydroxyphenylacetic acid; and serotonin: 5-hydroxy-indol acetic acid were measured at the end of the second trimester, at delivery, and in arterial cord blood along with plasma cotinine. The newborns' discomfort was evaluated every 8 hours by a standardized questionnaire. RESULTS: The SPW smoked, on average, 73 cigarettes per week at the end of second trimester and 80 cigarettes per week at delivery. Mean plasma cotinine was 84 ng/mL, 105 ng/mL, and 95 ng/mL at the end of second trimester, at delivery, and in cord blood, respectively (NSPW < 10 ng/mL). Plasma markers of MAOA activity, in particular those reflecting dopamine's catabolism, were significantly lower in SPW and in the arterial cord blood of their newborns than in NSPW and their newborns. Newborns of SPW showed significantly more facial discomfort than those of NSPW. CONCLUSIONS: Smoking is associated with MAOA inhibition in pregnant women and in their newborns at birth. Further studies are needed to estimate the behavioral significance of these findings.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Nonbacterial purpura fulminans and severe autoimmune acquired protein S deficiency associated with human herpesvirus-6 active replication
BOCCARA O, LESAGE F, REGNAULT V, LASNE D, DUPIC L, BOURDON-LANOY E, PANNIER S, FRAITAG S, AUDAT F, LECOMPTE T, HUBERT P, BODEMER C
2009 - Br J Dermatol 161(1):181-183
Nonbacterial purpura fulminans (PF) is rare, usually follows viral infection in young children, and is characterized by specific coagulation disorders, requiring specific therapy. Following a transient rash, a 2-year-old previously healthy girl developed PF without haemodynamic impairment. Laboratory data revealed disseminated intravascular coagulation and a severe transient protein S deficiency. Antiprotein S autoantibodies and active human herpesvirus-6 (HHV6) replication were demonstrated. Purpuric skin lesions spread very rapidly despite broad-spectrum antibiotics and right leg amputation. Plasmapheresis and intravenous immunoglobulins gave complete clinical recovery and normalization of protein S level within 10 days, with progressive clearance of antiprotein S autoantibodies. Transient severe protein S deficiencies have previously been reported in patients with nonbacterial PF, usually after varicella infection. This is the first documented case of PF after HHV6 infection.
Unité(s) : Dermatologie, Laboratoire d'Hématologie, Réanimation Pédiatrique & Néonatologie, Anatomie Pathologique, Traumatologie et Orthopédie Pédiatriques, Transfusion Sanguine
 
Lien PubMed Anaphylaxis and anesthesia: controversies and new insights
DEWACHTER P, MOUTON-FAIVRE C, EMALA CW
2009 - Anesthesiology 111(5):1141-50
Unité(s) : Médecine d'Urgence, Réanimation Pédiatrique & Néonatologie
 
  Anaphylaxis to amidotrizoate proved by skin testing and flow cytometry-based basophil activation test
DEWACHTER P, NICAISE-ROLAND P, KALABOKA S, LEFEVRE J, CHOLLET-MARTIN S
2009 - Allergy 64(3):501-502
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Focus session on the changing "epidemiology" of craniosynostosis (comparing two quinquennia: 1985-1989 and 2003-2007) and its impact on the daily clinical practice: a review from Necker Enfants Malades
DI ROCCO F, ARNAUD E, MEYER P, SAINTE-ROSE C, RENIER D
2009 - Childs Nerv Syst 25(7):807-811
INTRODUCTION: The aim of this study was to evaluate the evolution in craniosynostosis in terms of incidence and management in the last 20 years and to discuss the clinical implications and future perspectives with regards to the practical organization of daily practice. METHODS: The relative incidence and management modalities of craniosynostosis hospitalized at the Craniofacial Unit of Necker, French National Referral Center for Faciocraniosynostosis, in two different quinquennia: 1985-1989 (group A) and 2003-2007 (group B) were reviewed. RESULTS: A total of 1,286 children were included in our study; group A 472, group B 814, that is an overall increase of 1.7-fold in the second period of the study. Sagittal synostosis remained the most frequent type (45% of cases in both groups). Conversely, the number of cases of Pfeiffer syndrome increased from seven patients to 20 (x2.8) and metopic synostosis cases increased from 49 to 193 (x3.9). Mean age at surgery in group A was 22.5 months and 13 months in group B. DISCUSSION: The comparison of the two quinquennia shows that there has been a change in the incidence of the different types of synostosis. The timing for surgery has also changed with the treatment of younger children in group B compared to group A. The principles of the surgical treatment of monosutural craniosynostosis have remained unmodified in our center. However, there has been an evolution in the techniques due to the introduction of new tools such as internal and external distractions, springs, and resorbable plates.
Unité(s) : Réanimation Pédiatrique & Néonatologie, Neurochirurgie Pédiatrique
 
  Spinal epidural hematoma in hemophilic children: controversies in management
DI ROCCO F, PEYRE M, MEYER P
2009 - Childs Nerv. Syst. 25(8):993
Unité(s) : Réanimation Pédiatrique & Néonatologie, Neurochirurgie Pédiatrique
 
  Intraoperative hyponatremia: is it related to surgical procedure or fluid maintenance ?
DURACHER C, BAUGNON T, BLANOT S, DI ROCCO F, MEYER PG
2009 - Pediatr. Anesth. 19(7):711-712
Unité(s) : Réanimation Pédiatrique & Néonatologie, Neurochirurgie Pédiatrique
 
Lien PubMed Admission base deficit as a long-term prognostic factor in severe pediatric trauma patients
HINDY-FRANCOIS C, MEYER P, BLANOT S, MARQUE S, SABOURDIN N, CARLI P, ORLIAGUET G
2009 - J Trauma 67(6):1272-7
BACKGROUND: Base deficit (BD) is a prognostic tool that correlates with trauma scores and mortality in adult trauma patients. Retrospective studies have shown that admission BD more than 8 mmol/L is associated with an increased risk of mortality. This is the first prospective European study aimed at evaluating the prognostic value of admission BD in traumatized children. METHODS: One hundred severely traumatized children were included if an arterial BD had been calculated on arrival in the trauma room of a university hospital. Epidemiologic, medical, and biological data (including admission BD and lactates concentration) were recorded and compared using a univariate analysis. The primary endpoint was in-hospital mortality. Secondary endpoints were outcome on discharge and at 6 months. Cutoff values for BD or lactates regarding outcomes were determined using receiver operating characteristic curves if these data had been isolated on multivariate analysis (p < 0.05). RESULTS: Sixty-eight boys and 32 girls, aged 6.7 years, were enrolled from March 2003 to December 2005, mainly after road traffic accidents. Twenty-two died at the hospital, 34 children and 51 children were classified as having a good outcome on hospital discharge and 6 months later, respectively. After the multivariate procedure and receiver operating characteristic curve analysis, admission lactates more than 2.94 mmol/L and admission BD more than 5 mEq/L were independent risk factors for mortality (odds ratio 2.4 [95% confidence interval 1.3-4.6]) and poor outcome at 6 months (odds ratio 2.5 [95% confidence interval 1.13-5.5]), respectively. DISCUSSION: BD could be used to predict the long-term morbidity and may not be related to morbidity and mortality at discharge.
Unité(s) : Réanimation Pédiatrique & Néonatologie, Médecine d'Urgence
 
  Pediatric Brain Death Diagnosis in the View of Organ Donation in France
HINDY-FRANÇOIS C, ORLIAGUET G, MEYER P, CARLI P, BLANOT S, HERTZ-PANNIER L, BRUNELLE F
2009 - Transplantation 87(4):616-617
Unité(s) : Radiologie Pédiatrique, Réanimation Pédiatrique & Néonatologie, Médecine d'Urgence
 
Lien PubMed [Management of convulsive status epilepticus in infants and children.]
HUBERT P, PARAIN D, VALLEE L
2009 - Rev Neurol (Paris) 165(4):390-7
Convulsive status epilepticus in childhood is a life threatening condition with serious risk of neurological sequelae which constitutes a medical emergency. Clinical and experimental data suggest that prolonged seizures can have immediate and long-term adverse consequences on the immature and developing brain. So the child who presents with a continuous generalized convulsive seizure lasting greater than five minutes should be promptly treated. The outcome is mainly determined by the underlying etiology, age and duration of status epilepticus. In children the mortality from status epilepticus ranges from 3 to 5% and the morbidity is two-fold higher. Mortality and morbidity are highest with status epilepticus associated with central nervous system infections, which is the most important cause of status epilepticus. There are few evidence-based data to guide management decisions for the child with status epilepticus. Immediate goals are stabilization of airways, breathing and circulation and termination of seizures. Benzodiazepines remain the first-line drugs recommended for prompt termination of seizures. As intravenous lorazepam is not available in France, we suggest clonazepam as the best choice for initial therapy. Rectal diazepam or buccal midazolam remain important options. Intravenous phenytoin/fosphenytoin and phenobarbital are the second-line drugs. Phenytoin is being increasingly substituted by fosphenytoin, but pediatric data are scarce and fosphenytoin is not authorized for use in France below five years old. In children, phenytoin is often preferred to phenobarbital, even though no comparative studies have demonstrated a better efficacy. To manage status epilepticus refractory to a benzodiazepine and administration of phenytoin and/or phenobarbital, many pediatricians today prefer high-dose midazolam infusion rather than thiopental to minimize serious side effects from barbiturate anesthesia. There is no benefit/risk ratio to support the use of propofol for children with refractory status epilepticus.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Humidification performance of 48 passive airway humidifiers: comparison with manufacturer data
LELLOUCHE F, TAILLE S, LEFRANCOIS F, DEYE N, MAGGIORE SM, JOUVET P, RICARD JD, FUMAGALLI B, BROCHARD L
2009 - Chest 135(2):276-86
INTRODUCTION: Heat and moisture exchangers (HMEs) are increasingly used in the ICU for gas conditioning during mechanical ventilation. Independent assessments of the humidification performance of HMEs are scarce. The aim of the present study was thus to assess the humidification performance of a large number of adult HMEs. METHOD: We assessed 48 devices using a bench test apparatus that simulated real-life physiologic ventilation conditions. Thirty-two devices were described by the manufacturers as HMEs, and 16 were described as antibacterial filters. The test apparatus provided expiratory gases with an absolute humidity (AH) of 35 mg H(2)O/L. The AH of inspired gases was measured after steady state using the psychrometric method. We performed three hygrometric measurements for each device, measured their resistance, and compared our results with the manufacturer data. RESULTS: Of the 32 HMEs tested, only 37.5% performed well (>/= 30 mg H(2)O/L), while 25% performed poorly (< 25 mg H(2)O/L). The mean difference (+/- SD) between our measurements and the manufacturer data was 3.0 +/- 2.7 mg H(2)O/L for devices described as HMEs (maximum, 8.9 mg H(2)O/L) [p = 0.0001], while the mean difference for 36% of the HMEs was > 4 mg H(2)O/L. The mean difference for the antibacterial filters was 0.2 +/- 1.4 mg H(2)O/L. The mean resistance of all the tested devices was 2.17 +/- 0.70 cm H(2)O/L/s. CONCLUSIONS: Several HMEs performed poorly and should not be used as HMEs. The values determined by independent assessments may be lower than the manufacturer data. Describing a device as an HME does not guarantee that it provides adequate humidification. The performance of HMEs must be verified by independent assessment.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
Lien PubMed Defenestration in children younger than 6 years old: mortality predictors in severe head trauma
MELO JR, DI ROCCO F, LEMOS-JUNIOR LP, ROUJEAU T, THELOT B, SAINTE-ROSE C, MEYER P, ZERAH M
2009 - Childs Nerv Syst 25(9):1077-83
PURPOSE: This study aims to describe the characteristics of severe head injuries in children less than 6 years old, victims of falls from windows, and identify the main predictive factors of mortality in this population. PATIENTS AND METHODS: A cross-sectional study was designed through data derived from medical records of less than 6-year-old children victims of falls from windows presenting with a severe head injury defined by an initial Glasgow coma scale (GCS) < or =8, hospitalized at a Pediatric Trauma center level III, between January 2000 and December 2005. Statistical analysis used univariate analysis and multiple logistic regressions. RESULTS: We identified 58 severe head injuries in children victims of falls from windows. The mean age was 2.8 +/- 1.4 years, with a male prevalence (64%); 48% of patients had a GCS < or =5; 62.1% had a Pediatric Trauma Score (PTS) < or =3 at hospital admission. The mortality rate was 41% (24/58) and most of them (88%; 21/24) died within 48 h. An increased death rate was noted in children admitted with hypoxemia (p = 0.001), low systolic blood pressure (p = 0.002), hypothermia (p = 0.0001), GCS < or =5 (p = 10(-5)), PTS < or =3 (p = 0.008), hyperglycemia (p = 0.023), coagulation disorders (p = 0.02), and initial intracranial pressure > or =20 mmHg (p = 0.03). Initial hypothermia, hyperglycemia, and coagulation disorders were the only independent predictive factors of mortality. CONCLUSION: Severe head injuries resulting from falls from windows carry a high risk of mortality in less than 6-year-old children. Hypothermia, hyperglycemia, and coagulation's disorders are independent predictive factors of mortality. Early deaths could be considered as direct consequences of uncontrollable brain lesions.
Unité(s) : Réanimation Pédiatrique & Néonatologie, Neurochirurgie Pédiatrique
 
Lien PubMed Pain in Children and Adults with Cystic Fibrosis: A Comparative Study
SERMET-GAUDELUS I, DE VILLARTAY JP, DE DREUZY P, CLAIRICIA M, VRIELYNCK S, CANOUI P, KIRZSENBAUM M, SINGH-MALI I, AGRARIO L, SALORT M, CHARRON B, DUSSER D, LENOIR G, HUBERT D
2009 - J Pain Symptom Manage 38(2):281-290
Pain is a potential complication of cystic fibrosis (CF), but its consequences on daily life and other issues of pain management are not yet clearly understood. We undertook a comparative study of children and adults with CF to assess the prevalence of pain symptoms, their characteristics and treatment, their impact on daily quality of life, and the occurrence of procedural pain. The study included 73 children (1-18 years) and 110 adults (18-52 years); 59% of the children and 89% of the adults reported at least one episode of pain during the previous month. Pain was significantly more intense and lasted significantly longer among adults, but its rate and recurrence did not differ significantly between the two populations and were not related to the severity of CF. The most prevalent locations were the abdomen for children, and the back, head, and chest for adults. Although pain significantly limited physical activity, only 15% of patients reported that it caused absenteeism, and 27% reported that it negatively affected their family life. The mean pain intensity rates on a visual analog scale for the episode that had caused the greatest pain during the past month were 4.9 (2) [mean (SD)] for children and 6 (2) for adults; however, only 40% and 50%, respectively, of those with pain reported the use of analgesic treatment, mainly paracetamol (acetaminophen). At least one episode of procedural pain during the previous month was reported by 85% of children and 78% of adults. Our study demonstrates the high incidence of undertreated pain in CF patients throughout their lives.
Unité(s) : Pédiatrie Générale, Pédo-Psychiatrie, Réanimation Pédiatrique & Néonatologie
 
Lien PubMed [Role of palliative approach in medical and nursing care practice]
VIALLARD ML, POURCHET S
2009 - Rev Prat 59(6):763-5
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
  Chronic disease and childhood: Image of the body, psychic stakes and therapeutic alliance
BOUQUINET E, BALESTRA J, BISMUTH E, BRUNA AL, GALLET S, HARVET G, JEAN S, JOUSSELME C
2008 - Archives Pédiatrie 15(4):462-468
The child is an individual in constant development, dependent on his/her parents with whom he interacts everyday to open out, and in particular, to construct a dependable image of his body for growing up comfortably. Announcement of a disease, real traumatism for the whole family, upsets these exchanges and can often induce psychological difficulties masked by the therapeutic somatic stakes placed at the foreground of concerns of each one: child, parents and doctors. The child's stakes are construction of a good image of the body (basis of his own) which can be deteriorated by the disease whatever it is (chronic disease, with relapse or vital prognosis engaged). The family's stakes are the perception of the disease by the parents (distress, culpability, depression) and sibling's reactions (aggressiveness, identification with the sick child, masked depression, functional troubles). Doctor's stakes in the chronic disease is to obtain therapeutic alliance of the child and his family to allow the good progress of the treatments. In front of the chronic disease's reality, it is essential to establish and maintain a multidisciplinary follow up. The child's psychiatrist role will be to take care of the exchanges and listening among the doctors, the patient and his family are favoured.
Unité(s) : Pneumologie et Asthmologie Pédiatriques, Réanimation Pédiatrique & Néonatologie
 
  Epidemiology and treatment of painful procedures in neonates in intensive care units
CARBAJAL R, ROUSSET A, DANAN C, COQUERY S, NOLENT P, DUCROCQ S, SAIZOU C, LAPILLONNE A, GRANIER M, DURAND P, LENCLEN R, COURSOL A, HUBERT P, DE SAINT-BLANQUAT L, BOELLE PY, ANNEQUIN D, CIMERMAN P, ANAND KJ, BREART G
2008 - JAMA 300(1):60-70
CONTEXT: Effective strategies to improve pain management in neonates require a clear understanding of the epidemiology and management of procedural pain. OBJECTIVE: To report epidemiological data on neonatal pain collected from a geographically defined region, based on direct bedside observation of neonates. DESIGN, SETTING, AND PATIENTS: Between September 2005 and January 2006, data on all painful and stressful procedures and corresponding analgesic therapy from the first 14 days of admission were prospectively collected within a 6-week period from 430 neonates admitted to tertiary care centers in the Paris region of France (11.3 millions inhabitants) for the Epidemiology of Procedural Pain in Neonates (EPIPPAIN) study. MAIN OUTCOME MEASURE: Number of procedures considered painful or stressful by health personnel and corresponding analgesic therapy. RESULTS: The mean (SD) gestational age and intensive care unit stay were 33.0 (4.6) weeks and 8.4 (4.6) calendar days, respectively. Neonates experienced 60,969 first-attempt procedures, with 42,413 (69.6%) painful and 18,556 (30.4%) stressful procedures; 11,546 supplemental attempts were performed during procedures including 10,366 (89.8%) for painful and 1180 (10.2%) for stressful procedures. Each neonate experienced a median of 115 (range, 4-613) procedures during the study period and 16 (range, 0-62) procedures per day of hospitalization. Of these, each neonate experienced a median of 75 (range, 3-364) painful procedures during the study period and 10 (range, 0-51) painful procedures per day of hospitalization. Of the 42,413 painful procedures, 2.1% were performed with pharmacological-only therapy; 18.2% with nonpharmacological-only interventions, 20.8% with pharmacological, nonpharmacological, or both types of therapy; and 79.2% without specific analgesia, and 34.2% were performed while the neonate was receiving concurrent analgesic or anesthetic infusions for other reasons. Prematurity, category of procedure, parental presence, surgery, daytime, and day of procedure after the first day of admission were associated with greater use of specific preprocedural analgesia, whereas mechanical ventilation, noninvasive ventilation and administration of nonspecific concurrent analgesia were associated with lower use of specific preprocedural analgesia. CONCLUSION: During neonatal intensive care in the Paris region, large numbers of painful and stressful procedures were performed, the majority of which were not accompanied by analgesia.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
  Experience in the management of eighty-two newborns with congenital diaphragmatic hernia treated with high-frequency oscillatory ventilation and delayed surgery without the use of extracorporeal membrane oxygenation
DATIN-DORRIERE V, WALTER-NICOLET E, ROUSSEAU V, TAUPIN P, BENACHI A, PARAT S, HUBERT P, REVILLON Y, MITANCHEZ D
2008 - J. Intensive Care Med. 23(2):128-135
The aim of this study is to analyze neonatal outcome of isolated congenital diaphragmatic hernia and to identify prenatal and postnatal prognosis-related factors. A retrospective single institution series from January 2000 to November 2005 of isolated congenital diaphragmatic hernia neonates was reviewed. Respiratory-care strategy was early high-frequency oscillatory ventilation, nitric oxide in pulmonary hypertension, and delayed surgery after respiratory and hemodynamic stabilization. Survival rate at 1 month was 65.9%. None of the prenatal factors were predictive of neonatal outcome, except an intra-abdominal stomach in left diaphragmatic hernia. Preoperative pulmonary hypertension was more severe in the nonsurvivor group and was predictive of length of ventilation in the survivors. During the first 48 hours of life, the best oxygenation index above 13 and the best PaCO2 above 45 were predictive of poor outcome. When treating isolated congenital diaphragmatic hernia with early high-frequency ventilation and delayed surgery but excluding extracorporeal membrane oxygenation, survival rates compare favorably with other reported series, and the respiratory morbidity is low.
Unité(s) : Biostatistique, Chirurgie Viscérale Pédiatrique, Obstétrique, Réanimation Pédiatrique & Néonatologie
 
  Prenatal diagnosis of dumbbell neuroblastoma
DELAHAYE S, DOZ F, SONIGO P, SAADA J, MITANCHEZ D, SARNACKI S, BENACHI A
2008 - Ultrasound Obstet. Gynecol. 31(1):92-95
A neuroblastoma that develops in the sympathetic nodes can infiltrate the intervertebral foramina and invade the spinal canal, leading to spinal cord and nerve root compression and neurological impairment. Dumbbell neuroblastomas are now considered to be unresectable tumors and preoperative chemotherapy is recommended. We report the prenatal diagnosis of a dumbbell neuroblastoma successfully managed through premature delivery followed by immediate chemotherapy. We suggest that delivering prematurely in such cases is only of benefit if chemotherapy can be administered under favorable conditions. Chemotherapy should proceed immediately after delivery in order to reduce the size of the tumoral mass and its effects on the spine. Copyright (c) 2007 ISUOG. Published by John Wiley & Sons, Ltd.
Unité(s) : Chirurgie Viscérale Pédiatrique, Obstétrique, Radiologie Pédiatrique, Réanimation Pédiatrique & Néonatologie
 
  Pivotal role of glutathione depletion in plasma-induced endothelial oxidative stress during sepsis
HUET O, CHERREAU C, NICCO C, DUPIC L, CONTI M, BORDERIE D, PENE F, VICAUT E, BENHAMOU D, MIRA JP, DURANTEAU J, BATTEUX F
2008 - Crit. Care Med. 36(8):2328-2334
OBJECTIVE: Plasma from septic shock patients can induce production of reactive oxygen species (ROS) by human umbilical vein endothelial cells (HUVEC) in vitro. How endothelial cells defend themselves against ROS under increased oxidative stress has not yet been examined. This study investigates the antioxidant defenses of HUVEC exposed to plasma obtained from either septic shock patients or healthy volunteers. DESIGN: Prospective, observational study. SETTING: Medical intensive care unit in a university hospital. PATIENTS: Twenty-five patients with septic shock and 10 healthy volunteers. INTERVENTIONS: Blood samples were collected within the first 24 hrs of septic shock. In vitro HUVEC production of ROS was studied by spectrofluorimetry using 2',7'-dichlorodihydrofluorescein diacetate fluorescent dye. Reactive nitrogen species were also assessed. Intracellular reduced glutathione (GSH) levels were measured using monochlorobimane fluorescent dye. Activity of catalase and superoxide dismutase in HUVEC were also measured. Cell death was assessed using YOPRO fluorescent dye and the MTT assay. MEASUREMENTS AND RESULTS: On admission, the septic shock population's mean age was 55 yrs old, the mean Sequential Organ Failure Assessment score was 12, mean simplified acute physiology score was 50, and intensive care unit mortality rate was 45%. Evaluation of HUVEC antioxidant defenses showed a significantly decreased GSH level, increased catalase activity, and unchanged superoxide dismutase activity. ROS levels and cell death were significantly reduced when cells were pretreated with N-acetylcysteine or GSH, but no changes in reactive nitrogen species were observed. CONCLUSION: This study demonstrates that plasma-induced ROS production by HUVEC is associated with an intracellular decrease in reduced GSH. Both ROS levels and cell death decreased when N-acetylcysteine or GSH were added before exposing the cells to plasma. These data suggest a pivotal role of alterations in GSH in damage caused by sepsis-generated ROS in endothelial cell.
Unité(s) : Réanimation Pédiatrique & Néonatologie
 
  Fusobacterium necrophorum Middle Ear Infections in Children and Related Complications: Report of 25 Cases and Literature Review
LE MONNIER A, JAMET A, CARBONNELLE E, BARTHOD G, MOUMILE K, LESAGE F, ZAHAR JR, MANNACH Y, BERCHE P, COULOIGNER V
2008 - Pediat. Inf. Dis. J. 27(7):613-617
BACKGROUND:: Fusobacterium necrophorum is associated with Lemierre syndrome (pharyngitis with septic thrombosis of the internal jugular veins) but it can also be involved in other head and neck infections, including sinusitis, parotitis, dental infections, and otitis media. METHODS:: This retrospective study analyzes a series of 25 pediatric cases of acute otitis media caused by F. necrophorum and treated in our institution between 1995 and 2006. RESULTS:: We observed 3 clinical presentations: (1) uncomplicated otitis media (44%; n = 11); (2) acute mastoiditis (40%; n = 10); and (3) otogenic variant of Lemierre syndrome (16%; n = 4) associating acute mastoiditis, suppurative thrombophlebitis of the lateral and/or cavernous sinuses, meningitis syndrome, and sometimes distant septic metastasis or extensive osteolysis of the temporal bone. Sixty percent of these cases were diagnosed during the last 4 years of the study. Children less than 1 year of age were at increased risk for Lemierre syndrome. Broad range 16S rDNA polymerase chain reaction and sequencing were used to confirm the identification of F. necrophroum and to detect secondary sites of infection. All patients had favorable clinical outcome, but complicated cases (mastoiditis and otogenic variant of Lemierre syndrome) required prolonged hospital stays and duration of treatment. CONCLUSIONS:: Based on bacteriologic investigation, we recommend systematic culture for anaerobes and that antibiotic treatment of F. necrophorum middle ear infections and subsequent complications includes coverage for anaerobic bacteria.
Unité(s) : Laboratoire de Microbiologie, ORL & Chirurgie Cervico-Faciale, Réanimation Pédiatrique & Néonatologie
 
  Predicting perinatal outcome in isolated congenital diaphragmatic hernia using fetal pulmonary artery diameters
RUANO R, AUBRY MC, BARTHE B, MITANCHEZ D, DUMEZ Y, BENACHI A
2008 - J. Pediat. Surg. 43(4):606-611
OBJECTIVE: The aim of the study was to evaluate the potential of fetal pulmonary artery (PA) diameters to predict perinatal death and pulmonary arterial hypertension (PAH) in congenital diaphragmatic hernia (CDH). STUDY DESIGN: In this prospective observational study, observed PA (main, right, and left) diameters were measured at the level of the 3 vessels in 21 fetuses with isolated CDH and in 85 controls at 22 to 36 weeks. The observed/expected (o/e) diameters of the main, contralateral, and ipsilateral PAs were calculated by comparing these measurements with reference values obtained in our previous study and correlated with perinatal death and postnatal PAH. RESULTS: The o/e PA diameters were significantly reduced in fetuses with CDH compared to controls (P < .001) and in fetuses with CDH who died (P < .050). However, there was no significant association between PA diameters and PAH (P >or= .050). CONCLUSIONS: The PA diameters might be useful to predict perinatal death in isolated CDH but not postnatal PAH, suggesting that PA diameters are probably related to the severity of pulmonary hypoplasia.
Unité(s) : Obstétrique, Réanimation Pédiatrique & Néonatologie
 
  Is Intestinal Transplantation the Future of Children with Definitive Intestinal Insufficiency ?
SAUVAT F, FUSARO F, LACAILLE F, DUPIC L, BOURDAUD N, COLOMB V, HUGOT JP, AIGRAIN Y, GOULET O, REVILLON Y
2008 - Eur. J. Pediatr. Surg. 18(6):368-371
Intestinal transplantation (IT) is the newest and most difficult of organ transplantations. The first ever (1987) and the longest surviving (1989) IT were performed in our institution. However, IT still has to demonstrate its benefit to children on long-term parenteral nutrition (PN). We tried to clarify this aspect by looking back at our 13 years' experience. PATIENTS: From 1994 to December 2007, 74 IT were performed in 69 children, 39 with an isolated small bowel (IT), 35 combined with a liver transplant (LITx). The indications were: short bowel syndrome (n = 25), congenital mucosal diseases (n = 22), and motility disorders (n = 22). Median age at transplantation was 5 years (1 - 17 years). Follow-up was 1 to 12 years (median 5 years). RESULTS: Thirty-one children have a functioning graft (42 %), 15/39 IT, 16/35 LITx. They are at home without PN, with a good quality of life. One child is PN-dependent 1.5 years post IT. Post IT, 16 children were detransplanted: 12 early on (1 for mechanical complications, 11 because of resistant rejection; 3 less than 3 years, one 9 years post SBT (chronic rejection). In 2 noncompliant teenagers, PN was reintroduced (one was detransplanted later on). Several years post LITx, 2 children underwent bowel detransplantation due to an acute viral infection complicated with rejection. Twenty-two children died (32 %, 8 IT, 14 LITx), 18 early on from infectious or surgical complications, 4 more than 1 year post IT, 3 after retransplantation (1 in another unit). Bad prognostic factors are multiple previous surgeries, an older age (> 7 y), and chronic intestinal pseudo-obstruction. DISCUSSION: Complications post IT are frequent and life-threatening, especially early on: rejection (IT), infections (LITx). Later on, the rate of complications decreases but remains significant, especially in noncompliant patients. However we describe here a 13-year learning curve; the recent results are encouraging with regard to control of rejection and viral infections. CONCLUSION: Intestinal transplantation is indicated only in selected patients in whom long-term PN cannot be performed safely any more. In every child with intestinal insufficiency, the therapeutic strategy must be discussed early on in order to perform IT at the right time under optimal conditions. IT should evolve from being a "rescue" procedure to becoming a true therapeutic option.
Unité(s) : Chirurgie Viscérale Pédiatrique, Gastro-Hépatologie et Nutrition Pédiatriques, Réanimation Pédiatrique & Néonatologie
 
  Multiple casualty incidents: the prehospital role of the anesthesiologist in europe
BAKER DJ, TELION C, CARLI P
2007 - Anesthesiol. Clin. 25(1):179-188
The recent increase in incidents involving mass casualties has emphasized the need for a planned and coordinated prehospital emergency medical response, with medical teams on-site to provide advanced trauma life support. The special skills of the anesthesiologist make his/her contribution to prehospital emergency care particularly valuable. The United Kingdom's emergency medical services system is operated paramedically like that in the United States, and is based on rapid evacuation of casualties to hospital emergency medical facilities. In contrast, the French approach is based on the use of its emergency care system SAMU, where both structured dispatching and on-site medical care is provided by physicians, including anesthesiologists. In this article, the lessons learned from multiple casualty incidents in Europe during the past 2 decades are considered from the standpoint of the anesthesiologist.
Unité(s) : Réanimation Pédiatrique, SAMU - SMUR
 
  Parental involvement in treatment decisions regarding their critically ill child: A comparative study of France and Quebec
CARNEVALE FA, CANOUI P, CREMER R, FARRELL C, DOUSSAU A, SEGUIN MJ, HUBERT P, LECLERC F, LACROIX J
2007 - Pediatr. Crit. Care Med. 8(4):337-342
OBJECTIVE:: To examine whether physicians or parents assume responsibility for treatment decisions for critically ill children and how this relates to subsequent parental experience. A significant controversy has emerged regarding the role of parents, relative to physicians, in relation to treatment decisions for critically ill children. Anglo-American settings have adopted decision-making models where parents are regarded as responsible for such life-support decisions, while in France physicians are commonly considered the decision makers. DESIGN:: Grounded theory qualitative methodology. SETTING:: Four pediatric intensive care units (two in France and two in Quebec, Canada). PATIENTS:: Thirty-one parents of critically ill children; nine physicians and 13 nurses who cared for their children. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Semistructured interviews were conducted. In France, physicians were predominantly the decision makers for treatment decisions. In Quebec, decisional authority practices were more varied; parents were the most common decision maker, but sometimes it was physicians, while for some decisional responsibility depended on the type of decision to be made. French parents appeared more satisfied with their communication and relationship experiences than Quebec parents. French parents referred primarily to the importance of the quality of communication rather than decisional authority. There was no relationship between parents' actual responsibility for decisions and their subsequent guilt experience. CONCLUSIONS:: It was remarkable that a certain degree of medical paternalism was unavoidable, regardless of the legal and ethical norms that were in place. This may not necessarily harm parents' moral experiences. Further research is required to examine parental decisional experience in other pediatric settings.
Unité(s) : Réanimation Pédiatrique
 
  Induced mild hypothermia reduces mortality during acute inflammation in rats
HUET O, KINIRONS B, DUPIC L, LAJEUNIE E, MAZOIT JX, BENHAMOU D, VICAUT E, DURANTEAU J
2007 - Acta Anaesthesiol. Scand. 51(9):1211-1216
Background: Hypothermia has been proposed as a therapeutic possibility in brain trauma, cardiac arrest and hemorrhagic shock. Experimental studies have shown that hypothermia may act by modulating the inflammatory response during endotoxemia. This study was carried out to test whether hypothermia could protect rats from endotoxemic insult. Methods: After general anesthesia and oro-tracheal intubation, Sprague-Dawley rats were randomly assigned to either a hypothermic group or normothermic group. In each group, rats received intraperitoneal lipopolysaccharide (LPS) (10 or 20 mg/kg). Blood samples were taken prior to and 2 h after LPS injection to measure blood gases, liver enzymes, muscular enzymes, tumor necrosis factor-alpha (TNF-alpha) and interleukin-10 (IL-10) plasma levels. After 2 h of hypothermia, the rats were extubated and brought back to their cages. The mortality rate was observed for 7 days following endotoxemia. In a second set of experiments, hypothermia was induced 1 h after endotoxemia (10 mg/kg of intraperitoneal LPS) and the mortality rate was observed for the following 7 days. Results: The survival rate was significantly increased in the hypothermic group relative to the normothermic group, regardless of LPS dose. This increased survival rate was also observed when hypothermia was induced 1 h after endotoxemia. In the hypothermic group, IL-10 and the DeltaIL-10/DeltaTNF-alpha ratio were significantly increased relative to those in the normothermic group. Conclusion: Induced mild hypothermia reduces mortality during endotoxemia in rats. The modulation of the inflammatory response, with an increase in anti-inflammatory cytokines, may be involved in this protective effect.
Unité(s) : Réanimation Pédiatrique
 
  Weaning children from mechanical ventilation with a computer-driven system (closed-loop protocol): A pilot study
JOUVET P, FARGES C, HATZAKIS G, MONIR A, LESAGE F, DUPIC L, BROCHARD L, HUBERT P
2007 - Pediatr. Crit. Care Med. 8(5):425-432
OBJECTIVE:: To evaluate the applicability, tolerance, and efficacy of a closed-loop protocol to wean children from mechanical ventilation. DESIGN:: Prospective single-center pilot study. SETTING:: Tertiary care university hospital. PATIENTS:: Twenty mechanically ventilated children aged between 1 and 17 yrs, with a body weight >/=10 kg, no inotropes, and no heavy sedation. INTERVENTIONS:: Patients were weaned in pressure support mode by a closed-loop computerized protocol (closed-loop protocol) that interprets clinical data in real time and controls pressure support levels. MEASUREMENTS AND MAIN RESULTS:: The closed-loop protocol applicability and tolerance were evaluated. The efficacy of this protocol was evaluated by comparing the duration of mechanical ventilation with a historical group of 20 patients weaned with a clinician-decision protocol. The closed-loop protocol successfully decreased pressure support ventilation in 16 children, recommended separation from the ventilator in 14 children, and did not cause any serious adverse events. Mechanical ventilation duration was 5.1 +/- 4.2 days in the closed-loop group and 6.7 +/- 11.5 days (mean +/- sd) in the clinician-decision group (p = .33) with no difference in the need for reintubation or noninvasive mechanical ventilation (one of 20 and four of 20, respectively; p = .20). CONCLUSIONS:: A closed-loop protocol was successfully used to wean children from mechanical ventilation. Further studies are required to assess the impact of this novel therapeutic strategy on the length of mechanical ventilation.
Unité(s) : Réanimation Pédiatrique
 
  Impact of inborn errors of metabolism on admission and mortality in a pediatric intensive care unit
JOUVET P, TOUATI G, LESAGE F, DUPIC L, TUCCI M, SAUDUBRAY JM, HUBERT P
2007 - Eur. J. Pediat. 166(5):461-465
The authors conducted a retrospective analysis of the patients admitted to a pediatric intensive care unit (PICU) during a five-year period, with specific focus on those with a suspected or confirmed diagnosis of inborn errors of metabolism (IEM), in order to ascertain the resources required to care for these patients. Medical records were reviewed for all admissions between January 1998 and December 2002 in a single metabolic referral center, and a subset of patients were identified with suspected IEM at admission or diagnosed IEM at hospital discharge. These patient charts were then further reviewed and the following information was extracted: IEM diagnosis, demographic data, biochemical characteristics at admission, need for mechanical ventilation, use of extracorporeal removal therapy, and outcome at PICU discharge. The study population comprised 70 patients (2.2% of all admissions during the study period) and included 33 neonates and 37 children aged >28 days. IEM diagnosis was known at the time of admission to the PICU in 9/33 of the neonates and 23/37 of the older children. Forty-three of the patients required invasive mechanical ventilation, while continuous extracorporeal removal therapy was used in 27 children. The median length of PICU stay was 3 days (range, 1 to 13 days) and 20 patients (28.6%) died. In conclusion, these observations show that inherited metabolic disease may be as frequent a primary diagnosis as septic shock in some PICUs. In neonates, these diseases are not usually diagnosed prior to PICU admission. Patients with IEM admitted to a PICU require aggressive support (including mechanical ventilation and extracorporeal removal therapies), and consume significant resources for relatively short PICU stays. These patients constitute a significant diagnostic and therapeutic challenge for pediatric intensivists.
Unité(s) : Métabolisme, Réanimation Pédiatrique
 
  A nutritional support team in the pediatric intensive care unit: Changes and factors impeding appropriate nutrition
LAMBE C, HUBERT P, JOUVET P, COSNES J, COLOMB V
2007 - Clin. Nutr. 26(3):355-363
BACKGROUND & AIMS: The aims of this study were to determine the impact of a nutritional support team (NST) intervention in a pediatric intensive care unit (PICU) and to identify the factors at admission that were associated to a delay to achieve a sustained optimal caloric intake (SOCI). METHODS: Caloric and protein intake and nutritional parameters were compared in 82 children in 2000 and 2003, respectively before and after the introduction of a NST. Predictive factors of a delay to achieve the SOCI were identified using multivariate analysis. RESULTS: There was no difference in 2000 and 2003, respectively, regarding cumulative caloric deficits (19+/-15.7 vs. 20.7+/-14.8kcal/kgday), cumulative protein deficits (0.26+/-0.31 vs. 0.22+/-0.20g/kgday), time to achieve a SOCI (7 vs. 7 days). Factors at admission associated with a delay to achieve a SOCI were a pediatric risk of mortality (PRISM) score > 10 (hazard ratio 0.58; 95% CI 0.44-0.77), a CRP > 50mg/L (hazard ratio 0.49; 95% CI 0.35-0.70), a fluid restriction (hazard ratio 0.51; 95% CI 0.37-0.71), and a weight for age > 3rd centile (hazard ratio 0.54; 95% CI 0.41-0.72). CONCLUSIONS: The intervention of a NST has not modified significantly the nutritional management. In pediatric intensive care, many factors identified at admission are associated with impairing appropriate nutrition.
Unité(s) : Gastro-Hépatologie et Nutrition Pédiatriques, Réanimation Pédiatrique
 
  The epidemiology of pediatric falls from heights
MEYER PG, THELOT B, BAUGNON T, RICARD C
2007 - Pediat. Surg. Int. 23(1):95-96
Unité(s) : Réanimation Pédiatrique
 
  Using a computer-driven system to wean children from mechanical ventilation
MORRIS AH
2007 - Pediatr. Crit. Care Med. 8(5):494-495
Unité(s) : Réanimation Pédiatrique
 
  Reply to cassano and milella
POUARD P
2007 - Eur. J. Cardio-Thorac. Surg. 31(4):755
Unité(s) : Réanimation Pédiatrique, Chirurgie Cardiaque Pédiatrique
 
  Reply to corno
POUARD P
2007 - Eur. J. Cardio-Thorac. Surg. 31(4):757
Unité(s) : Réanimation Pédiatrique, Chirurgie Cardiaque Pédiatrique
 
  Premedication before tracheal intubation in french neonatal intensive care units and delivery rooms
WALTER-NICOLET E, FLAMANT C, NEGREA M, PARAT S, HUBERT P, MITANCHEZ D
2007 - Archives Pédiatrie 14(2):144-149
Tracheal intubation is a painful procedure commonly used in the neonatal intensive care units and in the delivery rooms. It can be complicated by changes in vital signs. OBJECTIVE: To ascertain the use of sedatives and/or analgesics before tracheal intubation in French neonatal intensive care units and delivery rooms. METHODS: A survey by questionnaire sent to 58 neonatal intensive care units and 58 maternities. RESULTS: We obtained 46 responses (79,3%) from the neonatal intensive care units and 38 (65,5%) from the delivery rooms. In neonatal intensive care units, 74% of the newborns received a sedative and/or an analgesic before being intubated, and 60% of the units had specific written guidelines. Opioids and benzodiazepines were the main drugs used. In the delivery rooms, sedatives or analgesics were only used in 21% of the centres. CONCLUSION: The use of sedation-analgesia seems to improve in neonatology but is still insufficient in the delivery rooms. The development of specific guidelines and a best learning about the different drugs are necessary.
Unité(s) : Obstétrique, Réanimation Pédiatrique
 
  Identification of human herpesvirus 6 variants A and B by primer-specific real-time PCR may help to revisit their respective role in pathology
BOUTOLLEAU D, DUROS C, BONNAFOUS P, CAIOLA D, KARRAS A, CASTRO ND, OUACHEE M, NARCY P, GUEUDIN M, AGUT H, GAUTHERET-DEJEAN A
2006 - J. Clin. Virol. 35(3):257-263
BACKGROUND: Human herpesvirus 6 (HHV-6) isolates are classified into two variants, termed HHV-6A and HHV-6B, on the basis of distinct genetic, antigenic and biological characteristics, but the specific pathogenicity of each variant remains poorly understood. OBJECTIVES: To design a rapid, sensitive and specific real-time variant-specific PCR (VS-PCR) method to differentiate both variants in biological specimens. STUDY DESIGN: The VS-PCR was adapted from a real-time PCR assay, based on TaqMan technology, previously developed for the genome quantitation of both HHV-6 variants [Gautheret-Dejean A, Manichanh C, Thien-Ah-Koon F, Fillet AM, Mangeney N, Vidaud M, et al. Development of a real-time polymerase chain reaction assay for the diagnosis of human herpesvirus-6 infection and application to bone marrow transplant patients. J Virol Meth 2002;100:27-35], a consensual reverse primer (Taq2) being changed into two variant-specific primers named H6A and H6B. This method was applied to a large set of biological specimens obtained in different pathological contexts. RESULTS: The sensitivity threshold was about 10 copies/well for HHV-6A-specific PCR (PCR-A) and 1 copy/well for HHV-6B-specific PCR (PCR-B). Both assays showed a linear dynamic range from 10 to 100,000 copies of HHV-6 DNA. Regarding the specificity and the capacity of discrimination of each assay, one variant could be detected and identified in the presence of more than 1000 times higher concentrations of the other variant in virus mixtures. The comparison of the results obtained with this VS-PCR with those previously obtained with a classic PCR method allowed us to validate our new technique on a wide panel of biological samples, including numerous patients with severe HHV-6-related symptoms. The high prevalence of HHV-6B was confirmed in healthy individuals and immunocompromised patients. HHV-6A was identified in distinct samples from several patients exhibiting neurological disorders. CONCLUSIONS: We developed a new VS-PCR assay, able to differentiate HHV-6A and HHV-6B in biological samples, even in the case of mixed infections. Our study confirms the wide prevalence of HHV-6B and highlights the potential greater neuropathogenic role of HHV-6A in immunocompromised patients and young infants.
Unité(s) : Réanimation Pédiatrique - Néonatalogie
 
  Parental consent in paediatric clinical research
CHAPPUY H, DOZ F, BLANCHE S, GENTET JC, PONS G, TRELUYER JM
2006 - Arch. Dis. Child. 91(2):112-116
AIMS: To assess parental understanding and memorisation of the information given when seeking for consent to their child's participation to clinical research, and to identify the factors of significant influence on parents' decision making process. METHODS: Sixty eight parents who had been approached for enrolling their child in a clinical oncology or HIV study were asked to complete an interview. Their understanding was measured by a score which included items required to obtain a valid consent according to French legislation. RESULTS: Items that were best understood by parents were the aims of the study (75%), the risks (70%), the potential benefits to their child (83%), the potential benefits to other children (70%), the right to withdraw (73%), and voluntariness (84%). Items that were least understood were the procedures (44%), the possibility of alternative treatments (53%), and the duration of participation (39%). Less than 10% of the parents had understood all these points. Ten parents (15%) did not remember that they had signed up for a research protocol. Thirty three parents (48%) reported no difficulty in making their decision. Twenty four parents (38%) declared that they made their decision together with the investigator; 26 (41%) let the physician decide. Fifty four parents (78%) felt that the level of information given was satisfactory. CONCLUSION: There was an apparent discrepancy between parents' evaluation of the adequacy of the information delivered and evaluation of their understanding and memorisation. The majority of parents preferred that the physician take as much responsibility as possible in the decision making process.
Unité(s) : Immuno-Hématologie Pédiatrique, Réanimation Pédiatrique - Néonatalogie
 
  Epidemiology and early predictive factors of mortality and outcome in children with traumatic severe brain injury: Experience of a French pediatric trauma center*
DUCROCQ SC, MEYER PG, ORLIAGUET GA, BLANOT S, LAURENT-VANNIER A, RENIER D, CARLI PA
2006 - Pediatr. Crit. Care Med. 7(5):461-467
OBJECTIVE:: To describe the results of an integrated pre- and in-hospital approach to critical care in a large population of children with severe traumatic brain injury and to identify the early predictors of their outcome. DESIGN:: A 9-yr retrospective review of the data of a trauma data bank. SETTING:: Level III pediatric trauma center. PATIENTS:: All children (1 month to 15 yrs) with severe traumatic brain injury (Glasgow Coma Scale /=6 months after discharge. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Univariate and further multivariate analyses were performed to determine independent predictive factors of death and outcome at discharge and 6 months later. The Glasgow Outcome Scale was used to evaluate outcome; a poor outcome referred to Glasgow Outcome Scale >/=3. Receiver operating characteristic curves were drawn to determine the threshold values of predictors of death and outcome. Analysis concerned 585 children (67% male and 33% female). Mean age was 7 +/- 5 yrs. Predominant mechanisms of injury were road traffic accidents and falls. Mean values for Glasgow Coma Scale, Pediatric Trauma Score, and Injury Severity Score were 6 (3-8), 3 (-4,10), and 28 (4-75), respectively. Mortality rate was 22%; Glasgow Outcome Scale was <3 in 53% of the cases at discharge and 60% at 6 months. Multivariate analysis identified Glasgow Coma Scale, Injury Severity Score, and hypotension on arrival as independent predictors of death and poor outcome at discharge and at 6 months. Threshold values for death were 28 for Injury Severity Score and 5 for Glasgow Coma Scale. The same values were found for poor outcome, except for outcome at 6 months where threshold value for the Glasgow Coma Scale was 6. CONCLUSIONS:: Initial hypotension, Glasgow Coma Scale, and Injury Severity Score are independent predictors of outcome in children with traumatic brain injury. Threshold values can be calculated for predicting poor outcome. These variables can be easily and detected early in this population and used for quality assessment.
Unité(s) : Anesthésie Pédiatrique, Neurochirurgie Pédiatrique
 
  Child end of life: are guidelines useful ?
HUBERT P, CANOUI P
2006 - Archives Pédiatrie 13(6):623-625
Unité(s) : Réanimation Pédiatrique - Néonatalogie
 
  Hypothermia pediatric head injury trial: the value of a pretrial clinical evaluation phase
HUTCHISON J, WARD R, LACROIX J, HEBERT P, SKIPPEN P, BARNES M, MEYER P, MORRIS K, KIRPALANI H, SINGH R, DIRKS P, BOHN D, MOHER D
2006 - Dev. Neurosci. 28(4-5):291-301
BACKGROUND: The utility of a pretrial clinical evaluation or run-in phase prior to conducting trials of complex interventions such as hypothermia therapy following severe traumatic brain injury in children and adolescents has not been established. METHODS: The primary objective of this study was to prospectively evaluate the ability of investigators to adhere to the clinical protocols of care including the cooling and rewarming procedures as well as management guidelines in patients with severe traumatic brain injury (Glasgow Coma Scale
Unité(s) : Réanimation Pédiatrique - Néonatalogie
 
  Anaesthetic resuscitation in the treatment of craniostenoses
MEYER P, CUTTAREE H, BLANOT S, ORLIAGUET G, JARREAU MM, CHARRON B, PERIE-VINTRAS AC, BAUGNON T, CARLI P
2006 - Neurochirurgie 52 P2(2-3):292-301
Unité(s) : Anesthésie Pédiatrique
 
  Grand mal seizures: an unusual and puzzling primary presentation of ruptured hepatic hydatid cyst
MEYER PG, BONNEVILLE C, ORLIAGUET GA, DESSEMME P, BLAKIME P, CARLI PA, REVILLON Y
2006 - Paediatr. Anaesth. 16(6):676-679
We report a case of hepatic hydatidosis where the first clinical manifestations, generalized seizures after minor head and abdominal trauma, and delayed anaphylaxis, made the primary diagnosis difficult. Severe anaphylaxis has been reported as initial presentation of quiescent hepatic hydatidosis. In endemic areas, the diagnosis must be carefully ruled out in patients experiencing abrupt anaphylactic shock of uncertain etiology. The occurrence of unexplained vascular collapse after minor abdominal trauma in a patient originating from an endemic area should prompt the diagnosis and urgent treatment should be initiated; firstly emergency management of the anaphylactic shock and later, surgical treatment of the cysts.
Unité(s) : Anesthésie Pédiatrique, Chirurgie Pédiatrique, SAMU, Radiologie Pédiatrique
 
  Congenital chylothorax: what is the best strategy ?
MITANCHEZ D, WALTER-NICOLET E, SALOMON R, BAVOUX F, HUBERT P
2006 - Arch. Dis. Child. Fetal Neonat. Ed. 91(2):F153-F154
Unité(s) : Réanimation Pédiatrique - Néonatalogie, Département de Pédiatrie
 
  Duration of extracorporeal therapy in acute maple syrup urine disease: a kinetic model
PHAN V, CLERMONT MJ, MEROUANI A, LITALIEN C, TUCCI M, LAMBERT M, MITCHELL G, JOUVET P
2006 - Pediat. Nephrol. 21(5):698-704
Maple syrup urine disease (MSUD, MIM 248600) can be complicated by metabolic crises necessitating extracorporeal removal therapy (ECRT). Since leucine levels are usually not immediately available during therapy, an accurate kinetic model of leucine plasma levels during removal would be useful to establish the duration of ECRT. Such a kinetic model is available for neonates undergoing continuous ECRT (CECRT) with a leucine clearance >/=35 ml min(-1) 1.73 m(-2). The current study tests the validity of this model in older children. Plasma leucine levels were obtained from eleven ECRT sessions [seven CECRT and four intermittent hemodialysis (HDi) sessions] in seven children aged 1-14 years. No hemodynamic instability or neurological complications were observed during treatment. HDi provided a higher leucine clearance and required shorter sessions than CECRT (5.4+/-0.6 vs. 17.1+/-6.0 h). All patients regained precrisis neurological status except for one patient who had severe neurological damage (severe cerebral edema) at the time of dialysis and subsequently died despite efficient leucine removal. A leucine clearance >/=50 ml min(-1) 1.73 m(-2) is required to obtain a kinetic model similar to that reported in neonates, both with CECRT and HDi. This model should be helpful in predicting the duration of therapy needed to attain desired leucine levels.
Unité(s) : Réanimation Pédiatrique - Néonatalogie
 
  Quantitative analysis of fetal pulmonary vasculature by 3-dimensional power Doppler ultrasonography in isolated congenital diaphragmatic hernia
RUANO R, AUBRY MC, BARTHE B, MITANCHEZ D, DUMEZ Y, BENACHI A
2006 - Amer. J. Obstet. Gynecol. 195(6):1720-1728
OBJECTIVE: The purpose of this study was to evaluate the potential of 3-dimensional (3D) power Doppler imaging to predict neonatal outcome and pulmonary arterial hypertension (PAH) in congenital diaphragmatic hernia (CDH). STUDY DESIGN: In this prospective observational study, 3D-power Doppler ultrasonography was performed in 21 cases with isolated CDH between 23 and 33 weeks of gestation and in 58 controls between 20 and 40 weeks. Using the same preestablished settings for all cases, power Doppler was applied to each lung, and fetal lung volumes (FLV) were estimated using the rotational technique. The 3D power Doppler histogram was used to determine the vascular indices, which were plotted against gestational age and compared with neonatal outcome, PAH, gestational age, and FLV. RESULTS: Fetal pulmonary vascular indices showed a constant distribution throughout gestation, being significantly lower in cases with CDH than in controls (P < .001). Among CDH cases, the vascular indices were significantly lower in fetuses who died (P < .05), and in fetuses with neonatal PAH (P < .05). The severity of neonatal PAH was also associated with a progressive reduction in prenatal vascular indices (P < .05). All vascular indices correlated with o/e-FLV, but not with gestational age. CONCLUSION: All vascular indices seem to be constant throughout gestation. In isolated CDH, perinatal outcome and postnatal PAH can be predicted using the vascular indices assessed by 3D power Doppler histogram.
Unité(s) : Obstétrique, Réanimation Pédiatrique - Néonatalogie
 
  Factors influencing outcome after intestinal transplantation in children
SAUVAT F, DUPIC L, CALDARI D, LESAGE F, CEZARD JP, LACAILLE F, RUEMMELE F, HUGOT JP, COLOMB V, JAN D, HUBERT P, REVILLON Y, GOULET O
2006 - Transplant. Proc. 38(6):1689-1691
We evaluated 131 patients (6 months-14 years) who experienced 21 deaths before listing, 11 continuing on the waiting list, 38 well on home parenteral nutrition, 6 off parenteral nutrition and 59 transplanted (20 girls) aged 2.5 to 15 years, (18 >7 years). They received cadaveric isolated intestine (ITx, n = 31) or liver-small bowel (LITx, n = 32), including right colon (n = 43; 23 LITx) for short bowel (n = 19), enteropathy (n = 20), Hirschsprung (n = 14), or pseudo-obstruction (n = 6). Treatment included tacrolimus, steroids, azathioprine, or interleukin-2 blockers. After 6 months to 10.5 years, the patient and graft survivals were 75% and 54%. Sixteen patients (10 LITx) died within 3 months from surgery (n = 3), bacterial (n = 5) or fungal (n = 6) sepsis, or posttransplant lymphoproliferative disorder (n = 2). Rejection occurred in 27 patients, including 10 steroid-resistant episodes requiring antilymphoglobulins. The grafts were removed due to uncontrolled rejection in seven ITx recipients. Surgical complications were observed in 38 recipients (25 LSBTx) within 2 months, including bacterial (n = 22) or fungal (n = 11) sepsis, cytomegalovirus disease (n=12), adenovirus (n = 11), or posttransplant lymphoproliferative disorder (n = 12). Forty-two children (19 LSBTx) are alive. Weaning from parenteral nutrition was achieved after 42 days (median). Factors related to death or graft loss were pre-Tx surgery (P < .01), pseudo-obstruction (P < .01), age over 7 years (P < .03), fungal sepsis (P < .03), steroid resistant rejection (P < .05), hospitalized versus home patient (P < .01), and retransplantation (P < .05). Colon transplant did not affect the outcome. Interleukin-2 blockers improved isolated ITx (P < .05). Early referral and close monitoring of intestinal failure and related disorders are mandatory to achieve successful ITx.
Unité(s) : Chirurgie Pédiatrique, Gastroentérologie Pédiatrique, Réanimation Pédiatrique - Néonatalogie
 
  Methylmalonic and propionic acidurias: Management without or with a few supplements of specific amino acid mixture
TOUATI G, VALAYANNOPOULOS V, MENTION K, DE LONLAY P, JOUVET P, DEPONDT E, ASSOUN M, SOUBERBIELLE JC, RABIER D, OGIER DE BAULNY H, SAUDUBRAY JM
2006 - J. Inherit. Metab. Dis. 29(2-3):288-298
In a series of 137 patients with methylmalonic acidaemia (MMA) and propionic acidaemia (PA) diagnosed since the early 1970s, we report in more detail 81 patients (51 MMA and 30 PA) diagnosed between 1988 and 2005. In this series, 14% of patients died at initial access revealing the disease before or despite treatment, 18% died later, and the remainder (68%) are still alive. All patients were treated with the same protocol of enteral feeds with a low-protein diet adjusted to individual tolerance, carnitine, antibiotics, and only occasional use of an amino acid (AA) mixture. There was intensive follow-up and monitoring using measurements of urinary urea. Thirty-nine patients with severe forms, followed for more than 3 years, are analysed in particular detail. Of the 17 PA patients, 6 had moderate disability (all neonatal-onset forms), whereas 11 were normal or slightly delayed in their mental development. Four presented with cardiomyopathy, of whom 2 died. Of the 22 MMA patients, 13 presented in the neonatal period, of whom 3 died later, 2 are in renal failure and only 5 are still alive and have a normal or slightly delayed mental development. In the 9 patients with late-onset forms, there were no deaths and all patients but one have normal mental development. Among the 39 patients, only 40% were given an AA supplement at 3 years, and 50% between 6 and 11 years. The actual intake of natural protein was 0.92, 0.78 and 0.77 g/kg per day at 3, 6 and 11 years, respectively, in patients without AA supplementation, whereas it was 0.75, 0.74 and 0.54 g/kg per day in the group who received small quantities of AA (0.4-0.6 g/kg per day). In both groups, feeding disorders were frequent: 55% at 3 years, 35% at 6 years and 12% at 11 years. Many patients were given a food supplement by tube overnight or were even exclusively tube fed: 60% at 3 years, 48% at 6 years and still 27% at 11 years. Growth velocity was near the normal values. Plasma valine and isoleucine were low to very low, as were leucine and phenylalanine but to a lesser extent. Albumin, vitamins, trace elements and markers of bone metabolism were within the normal values. IGF1, 24-hour urine calcium and body mass density were low. Body composition showed a normal to low lean mass and a normal to high fat mass.
Unité(s) : Métabolisme-Neurologie, Explorations Fonctionnelles, Biochimie Médicale, Réanimation Pédiatrique - N
 
  Larrey and Percy-A tale of two Barons
BAKER D, CAZALAA JB, CARLI P
2005 - Resuscitation 66(3):259-262
Unité(s) : Anesthésie Pédiatrique, SAMU
 
  Withholding or withdrawing life saving treatment in pediatric intensive care unit: GFRUP guidelines
HUBERT P, CANOUI P, CREMER R, LECLERC F
2005 - Archives Pédiatrie 12(10):1501-1508.
Several recent French studies have revealed that 40% of death in pediatric intensive care units are associated with withdrawal or limitation of life saving treatments. Because such decisions are common, the Groupe francophone de reanimation et urgences pediatriques (GFRUP) has decided to publish recommendations in order to help paediatricians dealing with those difficult issues and to improve their decisions. In a first part of the document the ethical principles that imply those guidelines are recalled, followed by definitions of the terms currently employed. The second part contains guidelines regarding decision making process, the way it is applied and organisation of relatives as well as paramedical and medical staff support when the death of a child occurs.
Unité(s) : Réanimation Pédiatrique
 
  Medication errors among hospitalized children
HUBERT P, TRELUYER JM
2005 - Archives Pédiatrie 12(6):915-917
Unité(s) : Réanimation Pédiatrique
 
  Effects of inhaled nitric oxide administration on early postoperative mortality in patients operated for correction of atrioventricular canal defects
JOURNOIS D, BAUFRETON C, MAURIAT P, POUARD P, VOUHE P, SAFRAN D
2005 - Chest 128(5):3537-3544
OBJECTIVE: Postoperative pulmonary hypertension (POPH) substantially increases mortality after repair of congenital heart diseases. Inhaled nitric oxide (NO) has been reported as an effective and specific means of controlling POPH crisis. No randomized, placebo-controlled study has addressed the ability of NO administration to reduce mortality. Such a trial could raise ethical questions. DESIGN: Observational study with historical control subjects based on multivariate confounder scores. SETTING: Surgical pediatric ICU in a university hospital. PATIENTS: Two hundred ninety-four records of patients operated on for atrioventricular (AV) canal between 1984 and 1994 who presented with severe POPH. INTERVENTIONS: All variables found to be predictive for death by univariate tests were entered in a multivariate forward stepwise logistic regression model. Two paired groups regarding risk factors for death and only differing for POPH treatment (NO or conventional treatment) were constructed on the basis of predicted values obtained from this model. Twenty-five patients received NO, and 39 control patients, operated on between 1984 and 1994, received conventional treatment for POPH. MEASUREMENTS AND RESULTS: Postoperative pulmonary pressure, date of operation, and occurrence of an infectious complication were retained in the model. The comparison between the two paired groups showed a significant difference in mortality (24%; 95% confidence interval [CI], 7 to 41%; vs 56%; 95% CI, 37 to 75%, respectively; p = 0.02). CONCLUSIONS: This study suggests that there is a high probability for postoperative mortality reduction associated with administration of inhaled NO when severe POPH occurs in children operated for complete repair of AV canal.
Unité(s) : Anesthésie Pédiatrique, Chirurgie Cardiaque Pédiatrique
 
  Kinetic modeling of plasma leucine levels during continuous venovenous extracorporeal removal therapy in neonates with maple syrup urine disease
JOUVET P, HUBERT P, SAUDUBRAY JM, RABIER D, MAN NK
2005 - Pediat. Res. 58(2):278-282
A kinetic modeling of leucine plasma concentration changes is proposed to describe the plasma leucine reduction rate during continuous extracorporeal removal therapy (CECRT) in neonates with maple syrup urine disease. Data were obtained from seven neonates using a bicompartmental model for the best fitted curve of plasma leucine decrease during CECRT. During the first 3 h, leucine plasma levels decreased according to an exponential curve: [Leu](t) = [Leu](i) x 0.95 x 10(-0.09t) where [Leu](t) is the leucine plasma level (mumol/L) at time t (h) during CECRT and [Leu](I) is the initial plasma level. From h 4 to the end of CECRT, a second exponential curve was observed: [Leu](t) = [Leu](i) x 0.74 x 10(-0.05t). Plasma leucine levels obtained from three other neonates were similar to those predicted by the model. The apparent distribution volumes for leucine that correspond to the two exponential equations obtained were calculated from the leucine mass removal collected in the spent dialysate and ultrafiltrate. The distribution volume was 34 +/- 3% of body weight during the first 3 h of CECRT and 72 +/- 7% from h 4 to the end of CECRT. These figures are similar to known values for the extracellular water compartment and for total body water in the newborn. The findings suggest that leucine handling during CECRT is similar to that of nonprotein-bound small-molecular-weight solutes such as urea.
Unité(s) : Biochimie Générale, Néphrologie Adulte, Réanimation Pédiatrique, U507, Métabolisme-Neurologie
 
  Cumulative influence of organ dysfunctions and septic state on mortality of critically ill children
LECLERC F, LETEURTRE S, DUHAMEL A, GRANDBASTIEN B, PROULX F, MARTINOT A, GAUVIN F, HUBERT P, LACROIX J
2005 - Amer. J. Respir. Crit. Care Med. 171(4):348-353
The interaction between sepsis and multiple organ dysfunction syndrome is poorly defined in children. We analyzed by Cox regression models the cumulative influence of organ dysfunctions, using the pediatric logistic organ dysfunction (PELOD) score, and septic state (systemic inflammatory response syndrome or sepsis, severe sepsis, and septic shock) on mortality of critically ill children. We included 593 children (mortality rate: 8.6%) from three pediatric intensive care units; 514 patients had at least a systemic inflammatory response syndrome and 269 had two or more organ dysfunctions. Hazard ratio of death significantly increased with the severity of organ dysfunction, as estimated by the PELOD score, and the worst diagnostic category of septic state. Each increase of one unit in the PELOD score multiplied the hazard ratio by 1.096 (p < 0.0001); hazard ratio of diagnostic category was 9.039 (p = 0.031) for systemic inflammatory response syndrome or sepsis, 18.797 (p = 0.007) for severe sepsis and 32.572 (p < 0.001) for septic shock. Cumulative hazard ratio of death = (hazard ratio of PELOD score) x (hazard ratio of diagnostic category). We conclude that there is a cumulative accrual of the risk of death both with an increasing severity of organ dysfunction and an increasing severity of the diagnostic category of septic state.
Unité(s) : Réanimation Pédiatrique
 
  Surgical evacuation of acute subdural hematoma improves cerebral hemodynamics in children: a transcranial Doppler evaluation
MEYER PG, DUCROCQ S, RACKELBOM T, ORLIAGUET G, RENIER D, CARLI P
2005 - Childs Nerv. Syst. 21(2):133-137
OBJECTIVE. The objective was to evaluate cerebral hemodynamics in young children with acute subdural hematoma (SDH) and the impact of surgical treatment using transcranial Doppler (TCD). DESIGN. The design was a prospective study of infants with SDH requiring surgical evacuation. SETTING. The setting was the neuro intensive care unit of a university hospital. INTERVENTIONS. Indications for surgical evacuation were based upon clinical and radiological arguments. Surgery included emergency needle aspiration followed by external or/and internal shunting as required. A TCD evaluation was performed before needle aspiration, and after each surgical drainage procedure. It included a pressure provocation test to assess cerebral compliance. Preoperative and postoperative middle cerebral artery (MCA) velocities, Gosling pulsatility (PI) and Pourcelot resistivity (RI) indexes and compliance were compared with Student's t-test, or Fisher's exact test as indicated. MEASUREMENTS AND MAIN RESULTS. Out of 26 infants, 23 (88%) had injuries that had possibly been inflicted, and 3 had accidental injuries. Initial TCD evaluation demonstrated intracranial hypertension with decreased diastolic velocity, increased PI and RI, and decreased compliance. Surgical evacuation resulted in statistically significant improvement in cerebral hemodynamics (diastolic velocity: 17.2+/-10 cm/s vs. 31.1+/-10 cm/s, p<0.0015, PI: 2.5+/-1.3 vs. 1.4+/-0.8, p<0.002, RI: 0.8+/-0.2 vs. 0.6+/-0.1, p<0.005) in all but 3 infants, who eventually died. Surgical drainage (primary shunting or external drainage) was needed in 23 infants and resulted in further improvement in cerebral hemodynamics. Finally, 73% of the infants made a good recovery. CONCLUSIONS. Children with acute bilateral HSD have a high incidence of increased intracranial pressure as assessed by TCD. Surgical evacuation improves cerebral hemodynamics. TCD could be used for assessing the need for, and the efficiency of surgical drainage.
Unité(s) : Anesthésie Pédiatrique, Anesthésie Réanimation
 
  Combined high cervical spine and brain stem injuries: a complex and devastating injury in children
MEYER PG, MEYER F, ORLIAGUET G, BLANOT S, RENIER D, CARLI P
2005 - J. Pediat. Surg. 40(10):1637-1642
BACKGROUND: In young children, high cervical spine injuries (HCSI) can result in inaugural reversible, cardiac arrest or apnea. We noted in children sustaining such injuries an unusual incidence of associated brain stem injuries and defined a special pattern of combined lesions. METHODS: Children with HSCI surviving inaugural cardiac arrest/apnea were selected for a retrospective analysis of a trauma data bank. Epidemiologic, clinical, and radiological characteristics, and outcome were reviewed and compared with those of the rest of the trauma population with severe neurologic injuries (defined by a Glasgow Coma Scale < 8). RESULTS: Thirteen children with HCSI above the C3 spinal level and inaugural cardiac arrest/apnea were identified and compared with 819 severely head injured children without HSCI. Mean age was 4.7 +/- 2.9 years, and median Glasgow Coma Scale was 3 (3-6) after resuscitation. Initial standard x-ray views missed spine injuries in 6 patients. Spiral computed tomographic (CT) scan showed cervical fracture-dislocations associated with diffuse brain lesions and brain stem injury in all patients. Children with combined lesions had more frequent severe facial and skull base fractures compared with the rest of the population. They also were younger and sustained more frequent severe distracting injury to the neck than the rest of the population. Mortality rate (69%) was 2.6-fold higher than that observed in children without HCSI. In survivors, none demonstrated spinal cord injury resulting in persistent peripheral neurologic deficits, but only one achieved a good recovery. CONCLUSIONS: Combined HCSI and brain stem injuries must be suspected in young children sustaining a severe distracting injury to the craniocervical junction. Early recognition of these catastrophic injuries by systematic spiral cervical spine and brain stem computed tomographic scan evaluation is mandatory.
Unité(s) : Anesthésie Pédiatrique, SAMU
 
  Delayed surgery in pericardial teratoma with neonatal hydrops
MITANCHEZ D, GREBILLE AG, PARAT S, VOUHE P, SIDI D, DOMMERGUES M, HUBERT P
2005 - Eur. J. Pediatr. Surg. 15(6):431-433
Timing of neonatal surgery in cases of pericardial teratoma with hydrops is not standardised. We report two cases of hydropic premature newborns with pericardial teratoma in which surgery was delayed until respiratory and haemodynamic stabilisation. Mature teratoma was removed on day 3. The newborns were weaned from the ventilator on postoperative day 5 and 10, respectively. Both infants were doing well at 18 months, suggesting delayed surgery may be feasible and effective.
Unité(s) : Cardiologie Pédiatrique, Chirurgie Cardiaque Pédiatrique, Réanimation Pédiatrique, Maternité
 
  Management of chest pain by the emergency ambulance service: the DOLORES register
SAUVAL P, BOUT H, OHANESSIAN A, DANCHIN N, MONSEGU J, VARENNE O, CARLI P, SPAULDING C
2005 - Arch. Mal. Coeur Vaisseaux 98(11):1095-1099
Pre-hospital management of chest pain is a difficult problem. The emergency doctor has to take triage decisions based on instantaneous data whereas the decisional rationale of the many pathologies concerned, including acute coronary syndromes, is often based on observation over several hours. There have been few studies of the efficacy of pre-hospital management of chest pain by an emergency ambulance service. Therefore, the DOLORES register was set up to assess this problem over a 6 month period by the emergency ambulance service of Necker Hospital in Paris. Between January and June 2004, the Necker emergency ambulance service was called out on 205 occasions for chest pain. Forty-three patients had acute coronary syndromes (ACS) with ST elevation. Of the remaining 162 patients, 32 stayed at home, 2 were admitted the following day by cardiologists for coronary angiography, 52 were admitted for observation to the emergency unit and 76 were admitted to the coronary care unit. In the latter two groups, the final diagnosis of ACS without ST elevation was retained in 11/52 and 57/76 patients respectively. Finally, 2 patients were admitted directly to the catheter laboratory. The clinical and paraclinical data noted by the emergency ambulance service and at hospital admission was concordant in all cases. Pre-hospital triage by the emergency ambulance service seems to be effective. These results require confirmation with a large scale study.
Unité(s) : Réanimation Pédiatrique, SAMU
 
  Minimum effective dose of midazolam for sedation of mechanically ventilated neonates
TRELUYER JM, ZOHAR S, REY E, HUBERT P, ISERIN F, JUGIE M, LENCLEN R, CHEVRET S, PONS G
2005 - J. Clin. Pharm. Therap. 30(5):479-485
Objective: To determine the minimal effective dose (MED) of intravenous midazolam, required for appropriate sedation in 95% of patients, 1 h after drug administration. Methods: A double-blind dose-finding study using the continual reassessment method, a Bayesian sequential design. Twenty-three newborn infants hospitalized in intensive care unit participated. Inclusion criteria were: (i) post-natal age <28 days, (ii) gestational age >33 weeks, (iii) intubation and ventilatory support required for respiratory distress syndrome, (iv) need for sedation (i.e. one of the six following criteria: agitation or grimacing or crying facial expression before tracheal suctioning, agitation or grimacing or crying facial expression during tracheal suctioning). Each neonate was allocated to a loading dose, ranging from 75 to 200 mug/kg, and a maintenance dose ranging from 37.5 to 100 mug/kg/h. Results: The primary endpoint was the level of sedation 1 h after the onset of infusion. The sedation procedure was classified as a success if all the following clinical criteria were met: no agitation, no grimacing and no crying facial expression before as well as during tracheal suctioning. Based on the 23 patients, the final estimated probability of success was 76.9% (95% credibility interval: 56.6-91.4%) for the 200 mug/kg loading dose. No significant adverse effect was observed. Conclusions: Continual reassessment is a new approach, suitable for dose-finding study in neonates. This method overcomes some of the ethical, statistical and practical problems associated with this population. Using this method, the MED was estimated to be the 200 mug/kg loading dose of midazolam.
Unité(s) : Cardiologie Pédiatrique, Réanimation Pédiatrique
 
  Difficulties told by a nurse at the end of the life of an infant during resuscitation
BRUNET V, GRELLETY S, NEDONCELLE I
2004 - Rev. Infirm. 98):44-46
Unité(s) : Réanimation Pédiatrique
 
  Child's and parents' information: How do they live it? What do they need ?
CANOUI P
2004 - Archives Pédiatrie 11(Sup.1):32S-41S
Unité(s) : Réanimation Pédiatrique
 
  Severe traumatic brain injury in children
CARLI P, ORLIAGUET G
2004 - Lancet 363(9409):584-585
Unité(s) : Anesthésie Pédiatrique, Réanimation Pédiatrique
 
  Outbreak of Burkholderia cepacia bacteremia in a pediatric hospital due to contamination of lipid emulsion stoppers
DOIT C, LOUKIL C, SIMON AM, FERRONI A, FONTAN JE, BONACORSI S, BIDET P, JARLIER V, AUJARD Y, BEAUFILS F, BINGEN E
2004 - J. Clin. Microbiol. 42(5):2227-2230
We describe a 7-month outbreak of nosocomial Burkholderia cepacia bacteremia involving eight children in a pediatric hospital and the results of epidemiological investigations. A B. cepacia strain genotypically identical to the blood isolates was recovered from the upper surface of capped rubber stoppers of bottles of a commercial lipid emulsion used for parenteral nutrition.
Unité(s) : Laboratoire de Microbiologie, Maternité, Pharmacie, Réanimation Pédiatrique
 
  Novel mutations in the PEX2 gene of four unrelated patients with a peroxisome biogenesis disorder
GOOTJES J, ELPELEG O, EYSKENS F, MANDEL H, MITANCHEZ D, SHIMOZAWA N, SUZUKI Y, WATERHAM HR, WANDERS RJ
2004 - Pediat. Res. 55(3):431-436
The peroxisome biogenesis disorders (PBDs) form a genetically and clinically heterogeneous group of disorders due to defects in at least 11 distinct genes. The prototype of this group of disorders is Zellweger syndrome (ZS) with neonatal adrenoleukodystrophy (NALD) and infantile Refsum disease (IRD) as milder variants. Common to PBDs are liver disease, variable neurodevelopmental delay, retinopathy and perceptive deafness. PBD patients belonging to complementation group 10 (CG10) have mutations in the PEX2 gene (PXMP3), which codes for a protein (PEX2) that contains two transmembrane domains and a zinc-binding domain considered to be important for its interaction with other proteins of the peroxisomal protein import machinery. We report on the identification of four PBD patients belonging to CG10. Sequence analysis of their PEX2 genes revealed 4 different mutations, 3 of which have not been reported before. Two of the patients had homozygous mutations leading to truncated proteins lacking both transmembrane domains and the zinc-binding domain. These mutations correlated well with their severe phenotypes. The third patient had a homozygous mutation leading to the absence of the zinc-binding domain (W223X) and the fourth patient had a homozygous mutation leading to the change of the second cysteine residue of the zinc-binding domain (C247R). Surprisingly, the patient lacking the domain had a mild phenotype, whereas the C247R patient had a severe phenotype. This might be due to an increased instability of PEX2 due to the R for C substitution or to a dominant negative effect on interacting proteins.
Unité(s) : Réanimation Pédiatrique
 
  Both relative insulin resistance and defective islet beta-cell processing of proinsulin are responsible for transient hyperglycemia in extremely preterm infants
MITANCHEZ-MOKHTARI D, LAHLOU N, KIEFFER F, MAGNY JF, ROGER M, VOYER M
2004 - Pediatrics 113(3 Pt 1):537-541
OBJECTIVE: Many extremely preterm infants develop hyperglycemia in the first week of life during continuous glucose infusion. The objective of this study was to determine whether defective insulin secretion or resistance to insulin was the primary factor involved in transient hyperglycemia of extremely preterm infants. METHODS: A prospective comparative study was conducted in appropriate-for-gestational-age preterm infants <30 weeks of gestational age with the aim specifically to evaluate the serum levels of proinsulin, insulin, and C-peptide secreted during transient hyperglycemia by specific immunoassays. Three groups of infants were investigated hyperglycemic (n = 15) and normoglycemic preterm neonates (n = 12) and normal, term neonates (n = 21). In addition, the changes in beta-cell peptide levels were analyzed during and after intravenous insulin infusion in the hyperglycemic group. Data were analyzed using analysis of variance and analysis of variance for repeated measures. RESULTS: At inclusion, insulin and C-peptide levels did not differ in hyperglycemic subjects and in preterm controls. Proinsulin concentration was significantly higher in the hyperglycemic group (36.5 +/- 3.9 vs 23.2 +/- 0.9 pmol/L). Compared with term neonates, proinsulin and C-peptide levels were higher in normoglycemic preterm infants (23.2 +/- 0.9 vs 18.9 +/- 2.71 pmol/L and 1.67 +/- 0.3 vs 0.62 +/- 0.12 nmol/L, respectively). During and after insulin infusion in hyperglycemic neonates, plasma glucose concentration fell and proinsulin and C-peptide levels were lowered (18.4 +/- 7.6 and 20.7 +/- 4.5 pmol/L, respectively). CONCLUSION: These data suggest that 1) preterm neonates are sensitive to changes in plasma glucose concentration, but proinsulin processing to insulin is partially defective in hyperglycemic preterm neonates; 2) hyperglycemic neonates are relatively resistant to insulin because higher insulin levels are needed to achieve euglycemia in this group compared with normoglycemic neonates. These results also show that insulin infusion is beneficial in extremely preterm infants with transient hyperglycemia.
Unité(s) : Réanimation Pédiatrique
 
  Practice for insulin infusion in preterm infants
MITANCHEZ-MOKHTARI D, WALTER-NICOLET E, FARGES C, EGROT F, TRELUYER JM, HUBERT P
2004 - Archives Pédiatrie 11(9):1054-1059
Transient neonatal hyperglycemia is commonly observed during the first week of life in the preterm infants less than 30 weeks of gestational age. Continuous insulin infusion is an effective treatment in this situation. Objective. - To ascertain how insulin is administered in different french neonatal intensive care units. Material and methods. - We surveyed 49 neonatal intensive care units with a questionnaire. Response rate was 77.5% (38/49). Results. - Thirty four of 38 neonatal intensive care units reported the use of insulin infusions in this setting. Glucose level indicating insulin therapy and the initial insulin doses were quite variable according to the different units (respectively 7-16.5 mmol/l and 0.01-0.1 U/kg/h). A range of minimal insulin concentrations was used (0.01-0.1 U/ml), 57% utilizing concentration between 0.05 and 0.2 U/ml. Flow rates below 0.3 ml/h were used at time by 76%. Albumin was rarely added. Fifty seven percent of the neonatal intensive care units took counter-measures such as preconditioning and flushing the tubing to control insulin loss due to adsorption. The counter-measures were differently applied. Despite these measures, hyperglycemia and insulin resistance were frequently observed (respectively 30% and 47%). The different practices are discussed according to the literature. Conclusion. - In order to deliver insulin reliably, we suggest an insulin delivery method for the preterm infants.
Unité(s) : Réanimation Pédiatrique
 
  Volume expansion in children
ORLIAGUET G
2004 - Archives Pédiatrie 11(6):714-715
Unité(s) : Réanimation Pédiatrique
 
  Death of a child in the intensive care unit: manifestations from the family
CANOUI P
2003 - Archives Pédiatrie 70(Suppl.1):173S-176S
Unité(s) : Réanimation Pédiatrique
 
  Whole-body cooling after perinatal asphyxia: a pilot study in term neonates
DEBILLON T, DAOUD P, DURAND P, CANTAGREL S, JOUVET P, SAIZOU C, ZUPAN V
2003 - Dev. Med. Child Neurol. 45(1):17-23
In order to test the practicability and safety of whole-body cooling in term neonates with moderate-to-severe hypoxic-ischaemic encephalopathy (HIE) and to report outcomes, a prospective pilot study was carried out in 25 term infants (median postmenstrual age 38 weeks, range 36 to 41 weeks; 20 males, five females). Whole-body cooling, to a target core temperature of 33 to 34 degrees C, started within 6 hours of birth and was maintained for 72 hours. Of the 25 newborn infants (19 Sarnat II and six Sarnat III, 18 outborn), 18 survived, including 13 (72%) with normal cerebral signal by MRI. Temperature instability occurred during cooling in 15 infants, but neither severe haemodynamic instability nor renal failure was seen. Thrombocytopenia developed in 12 infants, including seven with biological disseminated intravascular coagulation. One patient had hypoxaemia with right-to-left shunting through the ductus arteriosus, and seven had limited meningeal or subdural bleeding. Whole-body cooling is feasible in term neonates, with no life-threatening adverse events. Improvements are needed to obtain stable hypothermia for 72 hours.
Unité(s) : Réanimation Pédiatrique
 
  Allergy to neuromuscular blocking agents in children
KARILA C, BRUNET-LANGLOT D, LABBEZ F, PAUPE J, DE BLIC J, SCHEINMANN P
2003 - Rev. Fr. Allergol. Immunol. Clin. 43(7):463-469
Neuromuscular blocking agents are the agents most frequently involved in peri-operative anaphylaxis, being more important than other drugs or latex; the incidence of these reactions is reported to be 1/6500 operations under anaesthesia. Suxamethonium and rocuronium are muscle relaxants with the highest risk of anaphylaxis. Their divalent ammonium quaternary ionic molecular structure of curate favours allergic sensitisation. The symptoms of anaphylaxis due to muscle relaxants are usually severe. Risk factors are a previous sensitisation and the female sex. The diagnosis of an allergic reaction is made with blood tests (plasma tryptase and histamine levels and specific IgE antibody assays) and skin prick and intradermal tests. The results of these tests must always be considered along with the clinical history, even if a coherent clinical history is not obtained. The recommendations for a subsequent anaesthesia in a child allergic to a curate relaxant should be based on the results of the skin tests, including those obtained with cross-reacting agents. All curate relaxants eliciting a positive skin test should be avoided. (C) 2003 Editions scientifiques et medicales Elsevier SAS. Tous droits reserves.
Unité(s) : Réanimation Pédiatrique, Pneumologie-Allergologie Pédiatrique
 
  Intrapericardial teratoma in newborn babies
LAQUAY N, GHAZOUANI S, VACCARONI L, VOUHE P
2003 - Eur. J. Cardiothorac. Surg. 23(4):642-644
We report two cases of intra pericardial tumor with pericardial effusion, diagnosed in utero by echocardiography at 21 and 28 weeks of gestation. Both fetuses underwent an intra uterine pericardiocentesis to treat a hydrops fetalis. Surgical resection of the tumor was undertaken immediately after birth and histological description reported cystic teratoma. Both babies had a favorable post operative course.
Unité(s) : Anesthésie Pédiatrique, Chirurgie Cardiaque Pédiatrique
 
  Emergency management of neonates with suspicion of inborn errors of metabolism
MITANCHEZ D, VALAYANNOPOULOS V
2003 - Archives Pédiatrie 10(Suppl.1):40S-42S
Unité(s) : Réanimation Pédiatrique
 
  Update on criteria for cadaveric donor selection for liver transplantation
YANDZA T, AUBERT F, FOURCADE L, JAN D, LACAILLE F, HUBERT P, REVILLON Y
2003 - Gastroentérol. Clin. Biol. 27(2):163-175
Unité(s) : Réanimation Pédiatrique, Chirurgie Pédiatrique
 
  Fulminant coma: think hyperammonemia and urea cycle disorders
AUGRIS C, JOUVET P, BENABDELMALEK F, VAUQUELIN P, CARAMELLA JP
2002 - Ann. Fr. Anesth. Réanim. 21(10):820-823
The authors report the case of 14-year-old boy admitted for acute coma without neurological focal symptom. The only relevant finding was the death of one uncle after a coma in the year 1992. This coma was associated with an ammonia blood level of 344 mumol l-1 and it rapidly lead to cerebral death despite a symptomatic treatment. The diagnosis of hereditary ornithine transcarbamylase deficiency was confirmed by liver biopsy in the immediate post-mortem period. The authors recommend the measurement of blood ammonia in every coma without diagnosis, whatever patient's age.
Unité(s) : Réanimation Pédiatrique
 
  Management of casualties from terrorist chemical and biological attack: a key role for the anaesthetist
BAKER DJ
2002 - Br. J. Anaesth. 89(2):211-214
Unité(s) : Anesthésie Pédiatrique, SAMU
 
  Professional practice of pediatrics in French hospitals is severely threatened
JOUVET P
2002 - Arch. Pediatr. 9(6):654
Unité(s) : Réanimation Pédiatrique
 
  Reperes ethiques dans la mucoviscidose
CANOUI P
2001 - Archives Pédiatrie 8(920s-923s
Unité(s) : Réanimation Pédiatrique
 
  Le psychologique et le social dans la mucoviscidose en forme de recommandations pour les centres de soins
CANOUI P, SIMON G
2001 - Archives Pédiatrie 8(906s-919s
Unité(s) : Réanimation Pédiatrique
 
  Long term results of liver-kidney transplantation in children with primary hyperoxaluria
GAGNADOUX MF, LACAILLE F, NIAUDET P, REVILLON Y, JOUVET P, JAN D, GUEST G, CHARBIT M, BROYER M
2001 - Pediat. Nephrol. 16(12):946-950
From 1990 to 2000, we performed eight liver-kidney transplants in eight children, aged 1-16 years, with end-stage renal failure (ESRF) due to primary hyperoxaluria (PHI). The duration of dialysis before transplantation ranged from 2 to 42 months (mean 14 months) and was <1 year in four patients. Only the first patient underwent postoperative hemodialysis; in the other five, we chose to induce maximal diuresis from the first hours with intravenous and intragastric hyperhydration (greater than or equal to3 1/m(2) per day). High water intake with nocturnal tube hydration was maintained for 6 months to 5 years, as long as oxaluria exceeded 0.5 mmol/day. A quadruple sequential immunosuppressive regimen was used. Two patients died during liver graft surgery. The other six patients are alive and well, with a mean follow-up of 7.4 years (range 5-11 years). Patient and graft survival is 75% at 5 years. At latest follow-up, liver tests were normal in all six patients; creatinine clearance ranged from 55 to 95 ml/min per 1.73 m(2) (mean=74). Oxaluria was lower than 0.4 mmol/day in all patients (mean=0.22). The six patients underwent 15 renal biopsies, 1-11 years after transplantation. Chronic transplant nephropathy was present in four patients and mild cyclosporin nephrotoxicity in another. No oxalate crystals were seen and repeat ultrasonography has been consistently normal in all patients. The three patients with bone oxalosis showed progressive complete healing of bone lesions. All six children or adolescents now live a normal life. From this series, we conclude that early combined liver-kidney transplantation is the treatment of choice for children with ESRF due to primary hyperoxaluria. [References: 16]
Unité(s) : Hépatologie Adulte, Néphrologie Pédiatrique, Chirurgie Pédiatrique, Réanimation Pédiatrique
 
  Combined nutritional support and continuous extracorporeal removal therapy in the severe acute phase of maple syrup urine disease
JOUVET P, JUGIE M, RABIER D, DESGRES J, HUBERT P, SAUDUBRAY JM, MAN NK
2001 - Intens. Care Med. 27(11):1798-1806
Objective: The authors assessed the efficiency, tolerance and outcome of neonates and children with maple syrup urine disease (MSUD) in acute decompensation managed by endogenous and extra- corporeal removal of accumulated MSUD metabolites. Design: Single center cohort study. Setting: Pediatric and neonatal intensive care unit in a tertiary care hospital. Patients: Between January, 1991, and June, 1999, six neonates and six children in acute decompensation of MSUD were included in the study. Each of them had two of the three following criteria: comatose state, gastrointestinal intolerance, leucine plasma levels over 1700 mu mol/l. Interventions: Patients were treated by combined nutrition manipulation and continuous venovenous extracorporeal removal therapies (CECRT) including hemofiltration, hemodialysis or hemodiafiltration. A clinical and biological evaluation was performed before., during and following the treatment. Results: Eleven out of the 12 patients survived. One child had two acute episodes at 6.5 and 9 years old. Eight patients recovered a normal cerebral performance category score. In all cases, plasma leucine level decreased according to a logarithmic mode within 11-24 h hemodiafiltration combined with nutritional support whereas, with nutrition alone after stopping CECRT, the decrease in leucine plasma levels was slower, following a linear mode. Eight patients were supplemented with valine and isoleucine for mean plasma values of 177 +/- 92 and 68 +/- 66, respectively. Conclusion: In severe acute decompensation of MSUD. CECRT combined with nutritional support limit central nervous system damage, by dramatically decreasing branched chain amino and keto acid levels. [References: 23]
Unité(s) : Métabolisme-Neurologie Génétique Pédiatrique, Réanimation Pédiatrique, U507, Biochimie Médicale
 
  Severe anaphylactic reaction to cisatracurium in a child
LEGROS CB, ORLIAGUET A, MAYER MN, LABBEZ F, CARLI PA
2001 - Anesth. Analg. 92(3):648-649
Unité(s) : Anesthésie Pédiatrique, SAMU
 
  Validity of applying triss analysis to paediatric blunt trauma patients managed in a french paediatric level 1 trauma centre
ORLIAGUET G, MEYER P, BLANOT S, SCHMAUTZ E, CHARRON B, RIOU B, CARLI P
2001 - Intens. Care Med. 27(4):743-750
Objective: Using a weighted combination of the Revised Trauma Score (RTS), the Injury Severity Score (ISS), the type of injury (blunt or penetrating) and patient age, the TRISS method is used to calculate the probability of survival (ps) in trauma patients. The goal of this study was to compare the ability of the American Major Trauma Outcome Study (MTOS) norm for adult blunt trauma patients (ADULT) and the specific norm for paediatric patients (PED) to estimate the ps of injured children using TRISS methodology. Design: Retrospective analysis using a paediatric trauma patient database. Setting: a French level 1 paediatric trauma centre. Patients: Four hundred seven consecutive paediatric blunt trauma patients, treated over a 3-year period. Measurements: The observed and expected survivals were compared, using the M, Wand Z scores, with both ADULT and FED. The W score is the number of survivors more or less than expected from the MTOS predictions for 100 patients. A Z score, which measures the significance of W, between -1.96 and +1.96, indicates no significant difference between observed and expected survivors. A value of M less than 0.88 indicates a disparity in the severity match between the study group and the MTOS group. We calculated the standardised W score (Ws), which represents the W score that would have been observed if the case mis of severity was identical to that of the MTOS group. Accordingly, a standardised Z score (Zs) was also calculated. In addition, we calculated the area under the receiver operating curve (aROC) using both norms, while calibration was also assessed by calculation of the Hosmer-Lemeshow goodness-of-fit tests. Results: Using FED, the number of actual survivors (n = 364) was not significantly different from the MTOS (n = 358). The value of M: 0.65, indicated a disparity in the severity match between the study group and the MTOS group, due to a higher proportion of patients with lower ys (TRISS < 0.95, 52 vs 27 %. Ws was +1.06 % (95 % confidence interval -0.34 to 2.08) and Zs was 1.48, indicating no significant difference from the MTOS. Using ADULT, the number of observed survivors (n = 364) was significantly higher than that expected (n = 354), with a W score of +2.70% (Z = +1.98, p < 0.05). There was a disparity in the severity match (M = 0.67) between the study group and the MTOS group: due to a higher proportion of patients with lower ps. Ws was +1.32 % (95 % confidence interval -0.12 to 2.37) and Zs = +1.79 (NS), indicating no significant difference from the MTOS. The Hosmer-Lemeshow statistics indicated that ADULT (Cg = 7.24, p = 0.51; Hg = 4.45, p = 0.81) and PED (Cg = 6.08, p = 0.64; Hg = 3.55. p = 0.90) provided sufficient goodness-of-fit. There was no significant difference in the aROC of the TRISS between the two norms (0.935 0.050 vs 0.936 +/- Q.O50: NS), Conclusion: Both adult and paediatric norms were equally good predictors of the probability of survival of injured children, provided that Ws and Zs are used when there is a disparity in the severity match between the study group and the MTOS group. [References: 45]
Unité(s) : Anesthésie Pédiatrique, SAMU
 
  Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity
POCHARD F, AZOULAY E, CHEVRET S, LEMAIRE F, HUBERT P, CANOUI P, GRASSIN M, ZITTOUN R, LE GALL JR, DHAINAUT JF, SCHLEMMER B
2001 - Crit. Care Med. 29(10):1893-1897
Objective., Anxiety and depression may have a major impact on a person's ability to make decisions. Characterization of symptoms that reflect anxiety and depression in family members visiting intensive care patients should be of major relevance to the ethics of involving family members in decision-making, particularly about end-of-life issues. Design., Prospective multicenter study. Setting: Forty-three French intensive care units (37 adult and six pediatric); each unit included 15 patients admitted for longer than 2 days. Patients. Six hundred thirty-seven patients and 920 family members. Interventions. Intensive care unit characteristics and data on the patient and family members were collected. Family members completed the Hospital Anxiety and Depression Scale to allow evaluation of the prevalence and potential factors associated with symptoms of anxiety and depression. Measurements and Main Results. Of 920 Hospital Anxiety and Depression Scale questionnaires that were completed by family members, all items were completed in 836 questionnaires, which formed the basis for this study. The prevalence of symptoms of anxiety and depression in family members was 69.1% and 35.4%, respectively. Symptoms of anxiety or depression were present in 72.7% of family members and 84% of spouses. Factors associated with symptoms of anxiety in a multivariate model included patient-related factors (absence of chronic disease), family-related factors (spouse, female gender, desire for professional psychological help, help being received by general practitioner), and caregiver-related factors (absence of regular physician and nurse meetings, absence of a room used only for meetings with family members). The multivariate model also identified three groups of, factors associated with symptoms of depression: patient-related (age), family-related (spouse, female gender, not of French descent), and caregiver-related (no waiting room, perceived contradictions in the information provided by caregivers). Conclusions: More than two-thirds of family members visiting patients in the intensive care unit suffer from symptoms of anxiety or depression. Involvement of anxious or depressed family members in end-of-life decisions should be carefully discussed. [References: 36]
Unité(s) : LEM, Réanimation Pédiatrique
 
  Natural history of the disease
TIMSIT S
2001 - Archives Pédiatrie 8(Suppl 1):186S-196S
Unité(s) : Réanimation Pédiatrique
 
  Half the families of intensive care unit patients experience inadequate communication with physicians
AZOULAY E, CHEVRET S, LELEU G, POCHARD F, BARBOTEU M, ADRIE C, CANOUI P, LE GALL JR, SCHLEMMER B
2000 - Crit. Care Med. 28(8):3044-3049
Objective: Effective communication of simple, clear information to families of intensive care unit (ICU) patients is a vital component of quality care. The purpose of this study was to identify factors associated with poor comprehension by family members of the status of ICU patients. Design: Prospective study. Setting: University-affiliated medical intensive care unit. Patients and Methods: A total of 102 patients admitted to an ICU for >2 days. Intervention: The representatives of 76 patients who were visited by at least one person during their ICU stay were interviewed. Results: Mean patient age was 54 +/- 17 yrs and mean Simplified Acute Physiology Score II at admission was 40 +/- 20. The representative was the spouse in 47 cases (62%). Among representatives, 25 (33%) were of foreign descent and 12 (16%) did not speak French. Mean duration of the first meeting with a physician was 10 +/- 6 mins. In 34 cases (54%), the representative failed to comprehend the diagnosis, prognosis, or treatment of the patient. Factors associated with poor comprehension by representatives included patient-related, family-related, and physician-related factors. Patient-related factors included age <50 yrs (p = .03), unemployment (p = .01), referral from a hematology or oncology ward (p = .006), admission for acute respiratory failure (p = .005) or coma (p = .01), and a relatively favorable prognosis (p = .04). Family-related factors were foreign descent (p = .007), no knowledge of French (p = .03), representative not the spouse (p = .03), and no healthcare professional in the family (p = .01). Physician-related factors were first meeting with representative <10 mins (p = .03) and failure to give the representative an information brochure (p = .02). Moreover, after the first meeting, caregivers accurately predicted poor comprehension by representatives (p = .03). Conclusions: Patient information is frequently not communicated effectively to family members by ICU physicians. Physicians should strive to identify patients and families who require special attention and to determine how their personal style of interrelating with family members may impair communication. [References: 34]
Unité(s) : Réanimation Pédiatrique
 
  Percutaneous replacement of pulmonary valve in a right-ventricle to pulmonary-artery prosthetic conduit with valve dysfunction
BONHOEFFER P, BOUDJEMLINE Y, SALIBA Z, MERCKX J, AGGOUN Y, BONNET D, ACAR P, LE BIDOIS J, SIDI D, KACHANER J
2000 - Lancet 356(9239):1403-1405
Background Valved conduits from the right ventricle to the pulmonary artery are frequently used in paediatric cardiac surgery. However, stenosis and insufficiency of the conduit usually occur in the follow-up and lead to reoperations. Conduit stenting can delay surgical replacement, but it aggravates pulmonary insufficiency. We developed an innovative system for percutaneous stent implantation combined with valve replacement. Methods A 12-year-old boy with stenosis and insufficiency of a prosthetic conduit from the right ventricle to the pulmonary artery underwent percutaneous implantation of a bovine jugular valve in the conduit. Findings Angiography, haemodynamic assessment, and echocardiography after the procedure showed no insufficiency of the implanted valve, and partial relief of the conduit stenosis. There were no complications after 1 month of follow-up, and the patient is presently in good physical condition. Interpretation We have shown that percutaneous valve replacement in the pulmonary position is possible. With further technical improvements, this new technique might also be used for valve replacement in other cardiac and non-cardiac positions. [References: 20]
Unité(s) : Cardiologie Pédiatrique, Anesthésie Pédiatrique
 
  Impact of delayed repair and elective high-frequency oscillatory ventilation on survival of antenatally diagnosed congenital diaphragmatic hernia: first application of these strategies in the more "severe" subgroup of antenatally diagnosed newborns
DESFRERE L, JARREAU PH, DOMMERGUES M, BRUNHES A, HUBERT P, NIHOUL-FEKETE C, MUSSAT P, MORIETTE G
2000 - Intens. Care Med. 26(7):934-941
Objective: a) To analyze the influence of a new management strategy on the outcome of neonates with antenatally diagnosed congenital diaphragmatic hernia (CDH); b) to determine early prognosis respiratory factors with the new strategy. Design: Retrospective study. Setting: Level III perinatal center. Patients and method: Between 1985 and 1997, 51 consecutive neonates with antenatally diagnosed CDH were admitted to our level III neonatal intensive care unit. Before 1992 (period 1; n = 19), we used conventional mechanical ventilation and early surgery requiring transfer. Since 1992 (period 2; n = 32), we prospectively tested a new approach including (a) systematically use of high-frequency oscillatory ventilation (HFOV) regardless of the initial clinical severity, (b) delayed surgery following stabilization requiring transfer to a different surgical unit, but (c) no transfer of unstable patients with surgery under HFOV in our neonatal intensive care unit (n = 10). The two cohorts were comparable in terms of potential ante and postnatal prognostic indicators. Results: Survival was improved with the new strategy: 21/32 (66 %) vs. 5/19 (26 %); P < 0.02. This improvement between periods 1 and 2 was due to a decrease in both preoperative and postoperative deaths in the later period. The better survival during period 2 was associated with the appearance of very late deaths, frequent pleural effusions, and the survival of more severe forms having evolved to a chronic respiratory insufficiency. Survivors were ventilated for longer time with longer duration of oxygen supplementation. The best oxygenation index (OI), alveolar arterial difference and oscillation amplitude (PIP) during the first 24 h, but not the best PaCO2, were the most reliable prognostic indicators during period 2. An OI less than or equal to 10 with a P/P less than or equal to 55 cmH(2)O was associated with a very good prognosis (94 % survival). Conclusions: The prognosis of antenatally diagnosed CDH was improved by systematic HFOV on admission, no systematic transfer, and delayed surgery. This improvement is associated with modification of postnatal outcome. [References: 33]
Unité(s) : Réanimation Pédiatrique, Chirurgie Pédiatrique
 
  Emergency management of deeply comatose children with acute rupture of cerebral arteriovenous malformations
MEYER PG, ORLIAGUET GA, ZERAH M, CHARRON B, JARREAU MM, BRUNELLE F, LAURENT-VANNIER A, CARLI PA
2000 - Can. J. Anaesth. 47(8):758-766
Purpose: To assess the impact of emergency management on mortality and morbidity of acute rupture of cerebral arteriovenous malformations resulting in deep coma in children, and the factors predicting outcome. Methods: Retrospective chart review of 20 children with a Glasgow Coma Scale less than or equal to 8 with acute hemorrhagic stroke from a cerebral arteriovenous malformation rupture was conducted. Protocol included: early resuscitation with tracheal intubation and ventilation after induction of anesthesia with sufentanil, and benzodiazepine, and mannitol 20% or hypertonic saline 7,5% infusion for life-threatening brain herniation. Radiological exploration was limited to contrast-enhanced CT scan preceding immediate surgical decompression. Postoperatively, children were deeply sedated and intracranial pressure monitoring allowed titration with osmotherapy, vasopressors, hyperventilation or barbiturate coma to control cerebral perfusion pressure. Analysis used stratification of the type of hemorrhage (supra or infra tentorial), location (intraparenchymal and subarachnoid, intraparenchymal and intraventricular or intraventricular alone) and relationship between presentation, evolution with resuscitation, type of cerebral lesion, and outcome. Results: Patients had a severe initial presentation (median Glasgow Coma Scale five), eight had unilateral and eight bilateral third nerve palsy. Compressive hematoma in supratentorial localisation represented 75% of the cases. Global mortality was 40%. Persistence of mydriasis after resuscitation increased mortality to 75%. Massive intraventricular flooding was associated with increased mortality. Good functional outcome was achieved in survivors, Conclusion: Acute rupture of an AVM can result in rapidly progressing coma. Emergency management with early resuscitation, minimal radiological exploration before rapid surgical decompression results in a mortality rate of 40%, but a good functional outcome can be expected in the survivors. [References: 32]
Unité(s) : Radiologie Pédiatrique, Anesthésie Pédiatrique, Anesthésie Réanimation, Neurochirurgie Pédiatrique
 
  Non-invasive aortic blood flow measurement
ORLIAGUET GA, GUEUGNIAUD PY
2000 - Curr. Opin. Anaesthesiol. 13(3):307-312
Invasive monitoring is rarely used for children undergoing routine anaesthesia, whereas usual non-invasive haemodynamic measurements such as heart rate and blood pressure monitoring are unable to detect cardiovascular changes rapidly and precisely. In contrast, oesophageal aortic blood flow echo-Doppler is an easy, non-invasive and accurate method to monitor cardiac performance properly and continuously. Therefore, it could represent a useful addition to peri-anaesthetic monitoring techniques, particularly in infants and small children.
Unité(s) : Anesthésie Pédiatrique
 
  Diaphragmatic hernias
JARREAU PH, DESFRERE L, DOMMERGUES M, NIHOUL-FEKETE C, HUBERT P, MORIETTE G
1999 - Archives Pédiatrie 6(Suppl 2):235S-237S
Unité(s) : Réanimation Pédiatrique, Chirurgie Pédiatrique
 
  Blind protected specimen brush and bronchoalveolar lavage in ventilated children
LABENNE M, POYART C, RAMBAUD C, GOLDFARB B, PRON B, JOUVET P, DELAMARE C, SEBAG G, HUBERT P
1999 - Crit. Care Med. 27(11):2537-2543
OBJECTIVE: To determine whether nonbronchoscopic protected specimen brush (PSB) and bronchoalveolar lavage (BAL) are contributive for diagnosing ventilator-associated pneumonia in mechanically ventilated children. DESIGN: Prospective study. SETTING: Fifteen-bed pediatric intensive care unit in a university hospital. PATIENTS: A total of 103 mechanically ventilated children, ranging in age from 7 days to 8.8 yrs, most with a high clinical suspicion for bacterial pneumonia. INTERVENTIONS: All the children underwent nonbronchoscopic PSB and BAL. Nonbronchoscopic PSB was performed with a plugged double-sheathed brush and BAL with a double-lumen plugged catheter. Endotracheal secretions and blood cultures were also collected. Open-lung biopsy was performed for any child who died within 7 days after the inclusion in the study, according to the parental consent. MEASUREMENTS AND MAIN RESULTS: The PSB specimens were submitted for bacteriologic quantitative culture (positive threshold, 10(3) colony-forming units [cfu]/mL). The BAL samples were processed for microscopic quantification of the polymorphonuclear cells containing intracellular bacteria (positive threshold, 1%) and quantitative culture (positive threshold, 10(4) cfu/mL). According to diagnostic categories based on clinical, biological, radiologic, and pathologic criteria, 29 children had bacterial pneumonia and 64 did not Ten children were classified as having an uncertain status. Of the 29 children with bacterial pneumonia, 26 (90%) met one of the following three criteria: a) PSB specimen culture, > or =10(3) cfu/mL; b) intracellular bacteria in cells retrieved by BAL, > or =1%; and c) BAL fluid culture, > or =10(4) cfu/mL. In contrast, 56 (88%) of the 64 patients without pneumonia did not. CONCLUSION: The results of this study indicate the following: a) nonbronchoscopic PSB and BAL were feasible in a large population of mechanically ventilated children; b) nonbronchoscopic techniques were contributive for diagnosing ventilator-associated pneumonia in children; and c) a combined diagnostic approach, using nonbronchoscopic PSB and BAL, was superior to using either test alone.
Unité(s) : Anatomo-Pathologie, Radiologie Pédiatrique, Biostatistique, Anesthésie Pédiatrique, Laboratoire de M
 
  Liver transplantation with a living related donor in children
LACAILLE F, BELGHITI J, SAUVAT F, MICHEL JL, FARGES O, RENGEVAL A, SARNACKI S, SAYEGH N, JAN D, REVILLON Y
1999 - Gastroentérol. Clin. Biol. 23(6-7):710-716
Objectifs - Liver transplantation with living related donor has been recently developed to compensate for the insufficient number of liver grafts for children. The major problem is ethical because it implies voluntary mutilation of a healthy person This paper report results in 37 living related donors.
Unité(s) : Département de Pédiatrie, Radiologie Pédiatrique, Anesthésie Pédiatrique, Chirurgie Pédiatrique
 
  The effects of dantrolene on the contraction, relaxation, and energetics of the diaphragm muscle
LANGERON O, COIRAULT C, FRATEA S, ORLIAGUET G, CORIAT P, RIOU B
1999 - Anesth. Analg. 89(2):466-471
Dantrolene is used in patients with muscle spasticity and is the only known effective treatment for malignant hyperthermia. However, its effects on muscle relaxation and energetics are unknown and may have important consequences in diaphragmatic function. We studied the effects of dantrolene (10(-8) to 10(-4) M) on diaphragm muscle strips (n = 12) in the hamster in vitro (Krebs-Henseleit solution, 29 degrees C, 95% oxygen/5% carbon dioxide) in response to tetanic stimulation (50 Hz). We studied contraction and relaxation under isotonic and isometric conditions, as well as energetics. Data are mean +/- so. Dantrolene induced a negative inotropic effect in the hamster diaphragm (active force at 10(-4) M: 34% +/- 7% of baseline; P < 0.05) but did not significantly modify the curvature of the force-velocity relationship. Dantrolene did not significantly modify isotonic relaxation. Dantrolene, up to 10(-5) M, did not significantly impair isometric relaxation. In conclusion, dantrolene induced a marked negative inotropic effect on diaphragm muscle without affecting myothermal efficiency and relaxation. Implications: Dantrolene induced a significant and concentration-dependent negative inotropic effect on diaphragm muscle but did not modify isotonic relaxation, which suggests no alteration of the calcium reuptake by the sarcoplasmic reticulum; up to 10-5 M dantrolene did not alter isometric relaxation, i.e., myofilament calcium sensitivity. Dantrolene did not modify the energetics of diaphragm muscle. [References: 26]
Unité(s) : Anesthésie Pédiatrique
 
  Critical care management of neurotrauma in children: new trends and perspectives
MEYER P, LEGROS C, ORLIAGUET G
1999 - Child Nerv. Syst. 15(11-12):732-739
Secondary brain lesions resulting from cerebral metabolic and hemodynamic reactions can be prevented by neurocritical care management. It must be initiated as soon as possible, ideally in a prehospital setting. Tracheal intubation, controlled ventilation and hemodynamic stabilization are the prerequisites. Beside intracranial and cerebral perfusion pressure, monitoring must evaluate the coupling between cerebral metabolic demand and blood flow. Jugular bulb oximetry is the most reliable approach to global cerebral coupling. Transcranial Doppler evaluates cerebral blood flow indirectly and noninvasively. Technological developments have led to local metabolic evaluation that does not yet have any clinical relevance. Therapeutic developments are more a new approach to the use of old drugs. Controlled hyperventilation, mannitol and, more recently, hypertonic saline solutions, used for restoring cerebral metabolic coupling, are the foundations of treatment. Thiopental, revisited as a vasoconstrictive agent, the "Lund" vasoconstrictive approach with anti-hypertensive drugs and cerebral vasoconstrictors, must be further evaluated in children, as must therapeutic hypothermia. Finally, what we probably need for the immediate future is a noninvasive and easily reproducible method of monitoring cerebral metabolic coupling that will allow precise therapeutic adaptation of multimodal therapy to the individual needs of the child. [References: 42]
Unité(s) : Anesthésie Pédiatrique
 
  Critical care management of severe paediatric trauma: a challenge for anaesthesiologists
MEYER PG
1999 - Paediatr. Anaesth. 9(5):373-376
Unité(s) : Réanimation Pédiatrique
 
  Fiche Adarpef/Sfar. Medical information before anesthesia for your child
ORLIAGUET G, MAYER MN
1999 - Ann. Fr. Anesth. Réanim. 18(9):FI120-FI121
Unité(s) : Anesthésie Pédiatrique
 
  Pharmacokinetics and tolerance of flunitrazepam in neonates and in infants
PARIENTE-KHAYAT A, TRELUYER JM, REY E, MOKHTARI M, WERNER E, JOUVET P, D'ATHIS P, WOOD C, HUBERT P, HOTELLIER F, OLIVE G, PONS G
1999 - Clin. Pharmacol. Ther. 66(2):136-139
Objective: To study the pharmacokinetics of flunitrazepam (used for sedation in neonates and infants), to determine the influence of both gestational and postnatal age on the pharmacokinetic parameters, and to analyze the relationship between the hemodynamic parameters and flunitrazepam plasma concentration.
Unité(s) : Réanimation Pédiatrique
 
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