14 research outputs found
Fluid therapy in mechanically ventilated critically ill children: the sodium, chloride and water burden of fluid creep
No full textBackground: Fluid therapy is a cornerstone of pediatric intensive care medicine. We aimed at quantifying the load of water, sodium and chloride due to different fluid indications in our pediatric intensive care unit (PICU). We were particularly interested in the role of fluid creep, i.e. fluid administered mainly as the vehicle for drugs, and the association between sodium load and water balance.
Methods: Critically ill children aged ≤3 years and invasively ventilated for ≥48 h between 2016 and 2019 in a single tertiary center PICU were retrospectively enrolled. Need for renal replacement therapy, plasmapheresis or parenteral nutrition constituted exclusion criteria. Quantity, quality and indication of fluids administered intravenously or enterally, urinary output and fluid balance were recorded for the first 48 h following intubation. Concentrations of sodium and chloride provided by the manufacturers were used to compute the electrolyte load.
Results: Forty-three patients (median 7 months (IQR 3-15)) were enrolled. Patients received 1004 ± 284 ml of water daily (153 ± 36 ml/kg/day), mainly due to enteral (39%), creep (34%) and maintenance (24%) fluids. Patients received 14.4 ± 4.8 mEq/kg/day of sodium and 13.6 ± 4.7 mEq/kg/day of chloride, respectively. The majority of sodium and chloride derived from fluid creep (56 and 58%). Daily fluid balance was 417 ± 221 ml (64 ± 30 ml/kg/day) and was associated with total sodium intake (r2 = 0.49, p < 0.001).
Conclusions: Critically ill children are exposed, especially in the acute phase, to extremely high loads of water, sodium and chloride, possibly contributing to edema development. Fluid creep is quantitatively the most relevant fluid in the PICU and future research efforts should address this topic in order to reduce the inadvertent water and electrolyte burden and improve the quality of care of critically ill children
Resting Energy Expenditure assessment in mechanically ventilated critically ill children: the importance of Indirect Calorimetry
No full textIntroduction. Malnutrition is common in critically ill children, and is considered a negative prognostic factor for their clinical outcomes1,2. Traditionally, Resting Energy Expenditure (REE) is calculated using predictive equations. These equations might be inaccurate in the critical scenario. Indirect Calorimetry (IC) is the gold standard to measure REE and allows tailored nutrition support3 .
Aim of the study was to evaluate the accuracy of commonly employed equations as compared to IC-derived values in critically ill children.
Methods. Children admitted to our unit between January 2017 and March 2019, aged <18 years and mechanically ventilated were enrolled. Endotracheal tube leak >10% and/or a fraction of inspired oxygen ≥0.6 constituted exclusion criteria. Harris-Benedict, Schofield and WHO formulae were applied to estimate REE. We performed IC for 30 minutes and REE was measured. The agreement between IC- and equation-based values of REE was assessed via paired t-test and BlandAltman analysis. Data are expressed as mean and standard deviation. Statistical significance was defined as p<0.05.
Results. Forty-four critically ill children (4.3±4.2 years, 18.1±16.4 kg) admitted for acute respiratory failure (n=24), neurological (n=13) or other diseases (n=7) were studied. Measured REE ranged between 16 and 89 kcal/kg/die (mean 43±15). Typically, all formulae significantly over-estimated the REE, as compared to IC (Table 1). Furthermore, the Bland-Altman analysis revealed wide limits of agreement, suggesting low accuracy of the prediction equations.
Conclusions. In critically ill, mechanically ventilated patients REE is on average significantly lower than predicted by currently applied equations. This finding might be explained by a reduced work of breathing and/or the use of sedatives and paralyzing agents. Measurement of REE through IC is essential to avoid over/underfeeding in this population.
References
1. Agostoni C et al. JPGN 2016
2. Taku Oshima et al. Clinical Nutr 2017
3. Smallwood CD et al. J Pediatr. 201
Identification of Biological Phenotypes in Acute Respiratory Distress Syndrome. From Biomarkers to Clinical Outcome
No full textPostoperative analgesia after laparoscopic ovarian cyst resection: Double-blind multicenter randomized control trial comparing intraperitoneal nebulization and peritoneal instillation of ropivacaine
No full textSTUDY OBJECTIVE: To compare the effects of local anesthetic intraperitoneal nebulization with intraperitoneal instillation during laparoscopic ovarian cystectomy on postoperative morphine consumption and pain.
DESIGN: Multicenter, randomized, case-control trial.
DESIGN CLASSIFICATION: Canadian Task Force Classification I.
SETTING: University hospitals in Italy.
PATIENTS: One hundred forty patients scheduled for laparoscopic ovarian cystectomy.
INTERVENTIONS: Patients were randomized to receive either nebulization of ropivacaine 150 mg before surgery or instillation of ropivacaine 150 mg before surgery. Nebulization was performed using the Aeroneb Pro device (Aerogen, Galway, Ireland).
MEASUREMENTS AND MAIN RESULTS:
One hundred forty patients were enrolled, and 123 completed the study. There was no difference between the 2 groups in average morphine consumption (7.3 ± 7.5 mg in the nebulization group vs 9.2 ± 7.2 mg in the instillation group; p = .17). Eighty-two percent of patients in the nebulization group required morphine compared with 96% in the instillation group (p < .05). Patients receiving nebulization had a lower dynamic Numeric Ranking Scale compared with those in the instillation group in the postanesthesia care unit postanesthesia care unit and 4 hours after surgery (p < .05). Ten patients (15%) in the nebulization group experienced shivering in the postanesthesia care unit compared with 2 patients (4%) in the instillation group (p = .035).
CONCLUSION:
Nebulization of ropivacaine prevents the use of morphine in a significant proportion of patients, reduced postoperative pain during the first hours after surgery, and was associated with a higher incidence of postoperative shivering when compared with instillation
Effects of Noninvasive Respiratory Support on Ventilation Distribution During Spontaneous Breathing Sedation in Preschool/School-Aged Children: An Electrical Impedance Tomography Study
No full textBackground: Procedural sedation interferes with respiratory dynamics in pediatric patients. It reduces lung compliance, causing the closing volume to exceed the functional residual capacity, which can result in airway collapse, atelectasis, and periods of silent desaturation. Aim: Aims of the study were to clarify the impact of intravenous propofol sedation on ventilation distribution and to evaluate the potential benefits of noninvasive respiratory support (NRS) in restoring the original ventilation distribution pattern by applying the electrical impedance tomography technology. Methods: Single-center physiological randomized crossover study comparing two 20-min steps of NRS delivered as continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) at different time points: (1) spontaneous breathing (SB-1); (2) spontaneous breathing during sedation (SB-2); (3) CPAP during sedation; (4) NIV during sedation; (5) spontaneous breathing after sedation discontinuation (SB-3). Primary endpoint was regional ventilation delay 40% (RVD40%). Secondary outcomes were global index (GI), end-expiratory lung impedance (EELI), and center of ventilation (CoV). Results: Thirteen children were enrolled. RVD40% increased during SB-2 compared to SB-1 (p = 0.014). NIV was effective in reducing it compared to CPAP (p = 0.009) and SB-3 (p = 0.015). NIV was also effective in restoring ventilation homogeneity and lung volume compared to SB-2 by decreasing GI (p = 0.035) and restoring EELI (p = 0.002). During NIV, the center of ventilation increased compared to SB-1 (p = 0.001), SB-2 (p = 0.004), and CPAP (p = 0.004), suggesting that ventilation was shifted toward the ventral areas of the lungs. On the other hand, CPAP was not effective in restoring RVD40, GI, and EELI to SB1 values following the induction of intravenous anesthesia with propofol at SB-2. Conclusions: In this specific ventilatory setting, spontaneous breathing sedation resulted in enhanced ventilation inhomogeneity and a reduction in EELI that could be reversed by NIV but not by CPAP. Clinical Trials Registration: The trial was registered prior to patient enrollment at Clinicaltrials.gov (NCT05495477; principal investigator: Giovanna Chidini; date of registration: August 10, 2022). Consolidated Standards of Reporting Trials guidelines were followed, and the study was conducted according to the Helsinki 1964 Ethical Declaration Standard, revised in 2008
Therapeutic effect of Anakinra in the relapsing chronic phase of febrile infection–related epilepsy syndrome
No full textFebrile infection–related epilepsy syndrome (FIRES) is a severe epileptic encephalopathy with presumed inflammatory origin and lacking effective treatments. Anakinra is the human recombinant interleukin 1 receptor antagonist clinically used in autoinflammatory or autoimmune conditions. We report a case of FIRES for which the spatial and temporal match between electroencephalography (EEG) and magnetic resonance imaging (MRI) focal alterations provides support for the detrimental synergic interplay between seizures and inflammation that may evolve to permanent focal lesions and progressive brain atrophy in weeks to months. Brain biopsy showed aspects of chronic neuroinflammation with scarce parenchymal lymphocytes. We report the novel evidence that anakinra reduces the relapse of highly recurrent refractory seizures at 1.5 years after FIRES onset. Our evidence, together with previously reported therapeutic effects of anakinra administered since the first days of disease onset, support the hypothesis that interleukin 1β and inflammation-related factors play a crucial role in seizure recurrence in both the acute and chronic stages of the disease
Clinical Study Peritoneal Nebulization of Ropivacaine during Laparoscopic Cholecystectomy: Dose Finding and Pharmacokinetic Study
No full textBackground. Intraperitoneal nebulization of ropivacaine reduces postoperative pain and morphine consumption after laparoscopic surgery. The aim of this multicenter double-blind randomized controlled trial was to assess the efficacy of different doses and dose-related absorption of ropivacaine when nebulized in the peritoneal cavity during laparoscopic cholecystectomy. Methods. Patients were randomized to receive 50, 100, or 150 mg of ropivacaine 1% by peritoneal nebulization through a nebulizer. Morphine consumption, pain intensity in the abdomen, wound and shoulder, time to unassisted ambulation, discharge time, and adverse effects were collected during the first 48 hours after surgery. The pharmacokinetics of ropivacaine was evaluated using high performance liquid chromatography. Results. Nebulization of 50 mg of ropivacaine had the same effect of 100 or 150 mg in terms of postoperative morphine consumption, shoulder pain, postoperative nausea and vomiting, activity resumption, and hospital discharge timing (>0.05). Plasma concentrations did not reach toxic levels in any patient, and no significant differences were observed between groups ( > 0.05). Conclusions. There is no enhancement in analgesic efficacy with higher doses of nebulized ropivacaine during laparoscopic cholecystectomy. When administered with a microvibration-based aerosol humidification system, the pharmacokinetics of ropivacaine is constant and maintains an adequate safety profile for each dosage tested
Peritoneal Nebulization of Ropivacaine during Laparoscopic Cholecystectomy: Dose Finding and Pharmacokinetic Study
No full textBackground. Intraperitoneal nebulization of ropivacaine reduces postoperative pain and morphine consumption after laparoscopic surgery. The aim of this multicenter double-blind randomized controlled trial was to assess the efficacy of different doses and dose-related absorption of ropivacaine when nebulized in the peritoneal cavity during laparoscopic cholecystectomy. Methods. Patients were randomized to receive 50, 100, or 150 mg of ropivacaine 1% by peritoneal nebulization through a nebulizer. Morphine consumption, pain intensity in the abdomen, wound and shoulder, time to unassisted ambulation, discharge time, and adverse effects were collected during the first 48 hours after surgery. The pharmacokinetics of ropivacaine was evaluated using high performance liquid chromatography. Results. Nebulization of 50 mg of ropivacaine had the same effect of 100 or 150 mg in terms of postoperative morphine consumption, shoulder pain, postoperative nausea and vomiting, activity resumption, and hospital discharge timing (>0.05). Plasma concentrations did not reach toxic levels in any patient, and no significant differences were observed between groups (P>0.05). Conclusions. There is no enhancement in analgesic efficacy with higher doses of nebulized ropivacaine during laparoscopic cholecystectomy. When administered with a microvibration-based aerosol humidification system, the pharmacokinetics of ropivacaine is constant and maintains an adequate safety profile for each dosage tested
Validation of Indirect Calorimetry in Children Undergoing Single-Limb Non-Invasive Ventilation: A Proof of Concept, Cross-Over Study
No full textBackground. The accurate assessment of resting energy expenditure (REE) is essential for personalized nutrition, particularly in critically ill children. Indirect calorimetry (IC) is the gold standard for measuring REE. This methodology is based on the measurement of oxygen consumption (VO2) and carbon dioxide production (VCO2). These parameters are integrated into the Weir equation to calculate REE. Additionally, IC facilitates the determination of the respiratory quotient (RQ), offering valuable insights into a patient’s carbohydrate and lipid consumption. IC validation is limited to spontaneously breathing and mechanically ventilated patients, but it is not validated in patients undergoing non-invasive ventilation (NIV). This study investigates the application of IC during NIV-CPAP (continuous positive airway pressure) and NIV-PS (pressure support). Methods. This study was conducted in the Pediatric Intensive Care Unit of IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, between 2019 and 2021. Children < 6 years weaning from NIV were enrolled. IC was performed during spontaneous breathing (SB), NIV-CPAP, and NIV-PS in each patient. A Bland–Altman analysis was employed to compare REE, VO2, VCO2, and RQ measured by IC. Results. Fourteen patients (median age 7 (4; 18) months, median weight 7.7 (5.5; 9.7) kg) were enrolled. The REE, VO2, VCO2, and RQ did not differ significantly between the groups. The Limits of Agreement (LoA) and bias of REE indicated good agreement between SB and NIV-CPAP (LoA +28.2, −19.4 kcal/kg/day; bias +4.4 kcal/kg/day), and between SB and NIV-PS (LoA −22.2, +23.1 kcal/kg/day; bias 0.4 kcal/kg/day). Conclusions. These preliminary findings support the accuracy of IC in children undergoing NIV. Further validation in a larger cohort is warranted
