RESUMO
Extracorporeal membrane oxygenation (ECMO) for neonates is applied routinely at major children's hospitals around the world. While the practice seems routine, the peculiar physiology of the small human imposes particular constraints on selection of equipment, performance of the circuit, and risks to the child. The physiology of small patients and physics of circuit elements leave many areas opaque and far from optimal, but still allow assembly of a set of useful heuristics for good practice. Here, we examine individual mechanical components of the ECMO circuit with attention to selection, pitfalls, and peculiarities of each when applied to the neonate.
Assuntos
Cuidados Críticos , Desenho de Equipamento/instrumentação , Oxigenação por Membrana Extracorpórea/instrumentação , Fidelidade a Diretrizes , Humanos , Recém-Nascido , Terapia Intensiva Neonatal , Guias de Prática Clínica como AssuntoRESUMO
BACKGROUND/PURPOSE: Blunt cerebrovascular injury (BCVI) is clinically challenging because these injuries are hard to detect and can have serious neurological consequences, and optimal screening criteria have not been established for children. This study aims to determine risk factors for BCVI in pediatric patients and to evaluate screening practices in a single institutional series. METHODS: A retrospective review of all pediatric blunt trauma patients evaluated over a 10-year period was performed. Demographic, clinical, and radiographic data were reviewed, including the presence of adult risk factors for BCVI. Logistic regression analyses were performed with statistical significance established at p<0.05. RESULTS: Of the 11,596 patients evaluated during the study period, 1018 (8.8%) had at least one adult risk factor for BCVI, but only 62 (6.1% of those with risk factors) underwent angiographic evaluation. Overall, 11 BCVIs were observed, resulting in an incidence of 0.095%. All 11 patients with BCVI had at least one risk factor. Multivariate logistic regression analysis identified cervical spine fracture (OR 36.88 [8.36, 169.95]), GCS score ≤ 8 (OR 16.42 [2.16, 102.33]), male gender (OR 10.52 [1.33, 363.30]), Le Fort II or III facial fracture (OR 63.71 [2.16, 1124.68]), and ISS (unit OR 1.10 [1.04, 1.17]) as independent risk factors for BCVI. CONCLUSION: Adult screening criteria for BCVI appear appropriate for pediatric patients, but most at-risk children are not being screened. LEVEL OF EVIDENCE: Level III (retrospective case-control study).
Assuntos
Fístula Anastomótica/diagnóstico por imagem , Doenças dos Ductos Biliares/diagnóstico por imagem , Ductos Biliares/diagnóstico por imagem , Atresia Biliar/cirurgia , Meios de Contraste/administração & dosagem , Portoenterostomia Hepática/efeitos adversos , Fístula Anastomótica/etiologia , Fístula Anastomótica/metabolismo , Fístula Anastomótica/fisiopatologia , Doenças dos Ductos Biliares/etiologia , Doenças dos Ductos Biliares/metabolismo , Doenças dos Ductos Biliares/fisiopatologia , Ductos Biliares/metabolismo , Ductos Biliares/cirurgia , Sistema Biliar/diagnóstico por imagem , Sistema Biliar/metabolismo , Meios de Contraste/farmacocinética , Extravasamento de Materiais Terapêuticos e Diagnósticos/diagnóstico por imagem , Extravasamento de Materiais Terapêuticos e Diagnósticos/etiologia , Extravasamento de Materiais Terapêuticos e Diagnósticos/metabolismo , Feminino , Gadolínio DTPA/administração & dosagem , Gadolínio DTPA/farmacocinética , Humanos , Iminoácidos/administração & dosagem , Lactente , Ligamentos/diagnóstico por imagem , Ligamentos/metabolismo , Fígado/diagnóstico por imagem , Fígado/metabolismo , Imageamento por Ressonância Magnética , Distribuição TecidualRESUMO
OBJECTIVE: To evaluate the prevalence of postprandial hypoglycemia (PPH) after fundoplasty after the initiation of a universal postoperative glucose surveillance plan in the neonatal intensive care unit (NICU). STUDY DESIGN: This was a retrospective chart review of children (newborn to 18 years) who underwent fundoplasty at The Children's Hospital of Philadelphia during the 2-year-period after the launch of a surveillance protocol in the NICU and other units. The rate of screening, frequency of PPH (postprandial blood glucose <60 mg/dL [3.3 mmol/L] on 2 occasions), frequency of postprandial hyperglycemia preceding PPH, timing of PPH presentation, and related symptoms were evaluated. RESULTS: A total of 285 children were included (n = 64 in the NICU; n = 221 in other units). Of the children screened in all units, 24.0% showed evidence of PPH, compared with 1.3% of unscreened children. Hyperglycemia preceded PPH in 67.7% (21/31) of all screened children. Within the NICU, most children had PPH within 1 week, but only 53.3% exhibited symptoms of dumping syndrome. CONCLUSIONS: This study supports the use of universal postoperative blood glucose surveillance in identifying PPH in children after fundoplasty. Earlier identification of PPH would lead to earlier treatment and minimize the effects of unidentified hypoglycemic events.