Background

Endotracheal intubation (ETI) is a routine procedure in the operating room and the Pediatric Intensive Care Unit (PICU) with frequent use of a stylet to facilitate successful intubation. Stylets are covered with a plastic sheath to prevent airway trauma and to assure easy removal of the stylet after intubation however the use of stylets has its complications.

Objectives

To raise awareness to a serious immediate complication of ETI using a stylet.

Methods

Case presentation and literature review.

Results

A 5 weeks old male baby suffering from severe cardiac failure due to myofibromatosis underwent intubation and anesthesia for tunneled central venous catheter insertion. In the pediatric intensive care unit, chest X-Ray revealed an elongated foreign body in the right main bronchus. When removed by the otolaryngologists, the foreign body was confirmed to be a severed tip of the stylet's plastic sheath. Sadly the patient passed away during the removal due to cardiac failure.

Reviewing the literature we found 16 case reports of stylet related complications of which 8 were neonates and premature babies and 8 adults. All cases required further invasive intervention to resolve endotracheal tube (ETT) or airway obstruction. A recent survey among neonatologists revealed that up to 3% personally experienced or witnessed a stylet breakage resulting in ETT occlusion or foreign body aspiration.

Conclusion

Retained sheared stylet plastic sheath causing airway obstruction is a rare ETI complication. Physicians should be aware of this complication hence, verify the stylet is complete upon removal. This potential complication should be emphasized in teaching ETI procedure.

Background

Tension gastrothorax is a life-threatening emergency that develops when the stomach is herniated through a congenital diaphragmatic defect into the thorax and it becomes massively distended by trapped air.

Objectives

To describe a rare and life-threatening clinical complication.

Methods

We present a 3-year-old male who presented with sudden onset of vomiting and respiratory distress.

Results

A previously healthy toddler presented with a few hours history of malaise,vomiting and respiratory distress so he was admitted to the paediatric clinic for possible gastroenteritis/dehydration.In the ward due to hypoxaemia and tachypnea the intensivists were asked for consultation and there was an immediate admission to our PICU due to strong clinical suspicion of tension pneumothorax.The patient was in a pre-arrest state with respiratory distress,tachypnea and absence of air entry in the left hemithorax,tachycardia(HR 190-200bpm),right precordial pulse,poor perfusion and altered level of consciousness.CXR showed distended stomach in the left hemithorax and mediastinal shift to the right.Due to strangulation of the stomach inlet it wasn’t possible to pass a nasogastric tube through and decompress the air so needle aspiration and chest tube placement were performed immediately.The patient stabilized and a CT scan of the thorax and the abdomen was performed to confirm the diagnosis and shortly after surgical repair of the hernia took place.

Conclusion

In a sudden onset of respiratory distress that resembles tension pneumothorax,the differential diagnosis must include tension gastrothorax,especially if the history reveals a trigger event associated with increased abdominal pressure(eg vomiting).Immediate radiographic evaluation is mandatory following stomach decompression via nasogastric tube and chest tube insertion before surgical repair of the defect.

Background

Treatment of pediatric acute respiratory distress syndrome (pARDS) in children is largely based on evidences that adopting a lung protective ventilation strategy reduces mortality in adult patients and Mangement of pARDS varies between different PICUs.

Objectives

This survey explores pediatric intensivists' knowledge and stated practice in the management of children with ARDS in Turkey, and compares these with international practice.

Methods

In May 2018, a questionnaire covering ventilation treatment strategies for children aged 1 month to 18 years of age with ARDS was sent to 100 pediatric intensive care units that treat children with ARDS. Preterms and children with congenital conditions were excluded.

Results

Fiftytwo of the 100 (52%) pediatric intensive care units responded to the questionnaire. Written guidelines (Berlin Criteria or The American-European Consensus Conference on ARDS) existed in 65,4% of the units. Ninety two per cent of the units frequently used cuffed endotracheal tubes. Ventilation was achieved by pressure control for 73,1% vs. volume control for 13,7% of units. Bronchodilators were used by all units, whereas steroids usage was 48,1% and surfactant 43,2%. Inhaled nitric oxide was available in 17,3% of the units and high frequency oscillation was used in 61,5% of the units . Neurally adjusted ventilator assist was used by only 2 % of the units. Extracorporeal membrane oxygenation could be started in 34,6 % of the units.

Conclusion

Management of pARDS in Turkish pediatric intensive care units are relatively uniform and largely in accordance with international practice. The use of surfactant is more frequent than in other studies.

Background

Tracheostomy is commonly indicated in intensive care (ICU) patients requiring prolonged intubation. Adult ICU data demonstrates early tracheostomies (within 10 days post-intubation) can reduce mortality rate, duration of mechanical ventilation (MV) and length of stay (LOS).

Objectives

To review tracheostomy practice in a UK Paediatric Critical Care Unit (PCCU) and compare outcomes between early tracheostomy (ET) and late tracheostomy (LT) in mechanically ventilated patients.

Methods

Medical records of PCCU patients who underwent tracheostomies from 2014 to 2018 were reviewed. Indications for tracheostomies were identified. Patients were divided into ET group (tracheostomy by 10 days post-intubation), and LT group (beyond 10 days). Clinical parameters between ET and LT groups were analysed.

Results

Twenty eight patients were identified; 18 male (64%) and 10 female (36%), with a mean age of 4.3 years. Indications for tracheostomies included; organic airway pathology (42.8%), access for ventilator dependence (28.6%), and airway protection following traumatic/neurological insult (28.6%). The ET group consists of 10 patients (36%); the LT group 18 patients (64%). No mortality was recorded in either group 30 days post-tracheostomy. 50% of the ET group was successfully weaned off MV compared to 39% from the LT group. The median LOS of the ET group was 21 days versus 52 days for the LT group.

Conclusion

Early tracheostomy contributed to higher rates of successful weaning off mechanical ventilation and reduced length of stay in PCCU. It does not affect mortality rate. However, due to small sample size, the results should be interpreted with care.

Background

Airway pressure release ventilation (APRV) is an inverse-ratio mode of ventilation which aims to maintain high mean airway pressures whilst minimising ventilator induced lung injury. APRV has been reported to be safe, well tolerated and in many cases improve haemodynamics.

Objectives

We aimed to identify if APRV has a role as a rescue therapy in paediatric ARDS to prevent escalation to HFOV.

Methods

Retrospective analysis of children with refractory hypoxaemia to conventional ventilation transitioned to APRV during period May 2014 - August 2018 at Nottingham Children’s Hospital, UK. Demographics, diagnosis, indication, PaO₂/FiO₂ (P/F ratio), mean duration of time on APRV, complications and outcomes were analysed.

Results

15 patients were identified; 4 were excluded. The mean age was 6.4 years (4 months – 17 years). On implementation of APRV, mean PaCO₂ was 8.36 kPA and mean P/F ratio was 68, where a P/F ratio of <100 indicates severe ARDS. 72% of patients remained on APRV for <1 hour. One patient received nitric oxide whilst on APRV. Only 10% de-escalated from APRV due to improvement in clinical status. 63% escalated to HFOV or ECMO. No complications were reported.

Conclusion

Our results only identified one patient in our sample who improved when APRV was used as a rescue therapy. However, as there were no complications observed whilst utilising APRV, we suggest it is a safe mode of ventilation to trial in paediatric patients with severe ARDS.

Background

Pulmonary haemorrhage is uncommon in children presenting to PICU with challenges in determining its causes and outcomes across diverse groups.

Objectives

Better understand the incidence, identified causes and outcome of pulmonary haemorrhage in children admitted to a tertiary level PICU over past 3 years.

Methods

3-year retrospective cohort study of children with pulmonary haemorrhage admitted to a PICU in a large tertiary care centre in North west region of England.

Results

Total 9 children with pulmonary haemorrhage were admitted to PICU in last 3 years. Among the 9 children, there were 5 males and 4 females. 4 patients were less than 1 year of age (44%), 3 were in the age group of 1-5 years (33%) and 2 were more than 12 years old (22%). The diagnoses in children with pulmonary haemorrhage were systemic vasculitis (22%), post bone marrow transplant thrombotic microangiopathy (22%), coagulation disorders (22%) and Non-accidental injury (11%). There was no identifiable cause in 2 children (22%) and they were classified as idiopathic pulmonary hemosiderosis. 5 children (55%) received high dose steroids, 4 (44%) received immunomodulating/immunosuppressive drugs and 2 (22%) underwent therapeutic plasma exchange. 7 out of the 9 children (77%) received some form of blood transfusion. 2 children (22%) died.

Conclusion

Pulmonary haemorrhage is an uncommon presentation in children admitted to PICU with varied aetiology. It needs multidisciplinary team effort for diagnosis and management of such children.