This Canadian multi-centre study on 65 children compared vasopressin infusions with placebo in children with vasodilatory shock who had already received fluid resuscitation and catecholamine infusions. No significant difference was observed in the primary endpoint of time to haemodynamic stability or the secondary endpoints of mortality, organ-failure–free days, length of critical care unit stay, and adverse events, although there was a trend toward increased mortality in the vasopressin group.
Vasopressin in Pediatric Vasodilatory Shock
Am J Respir Crit Care Med. 2009 Oct 1;180(7):632-9
Another paper shows hypotension in the ED is an ominous sign. Nonsustained hypotension – even a single episode – was associated with an three-fold increase in mortality in adult patients presenting the ED with sepsis.
The signiﬁcance of non-sustained hypotension in emergency department patients with sepsis
Intensive Care Med. 2009 Jul;35(7):1261-4
It is common for the infant trachea to deviate to the right, with a frequency of 50% at one year, 25% at two years, 15% at three years and 6% at four years (tending not to occur in the over fives), but it may be missed on inspiratory chest films with the head in extension. In a case report from India, authors point out that anaesthetists are often unaware of this normal variant. Since many tracheal tubes are designed with the bevel facing left, the angled tracheal wall may occlude the distal outlet of the tube, necessitating repositioning of the tube higher in the trachea above the bend.
Anaesth Intensive Care. 2009 Jan;37(1):144-5
Two guys from the States have proposed a modification to the FAST HUG mnemonic for reminding ICU teams of some of the evidence-based details to pay attention to every day in ICU patients. In fact, they propose patients receive FAST HUGS B.I.D:
T Thromboembolic prophylaxis
H Head of bed elevation
U Ulcer (stress) prophylaxis
G Glycemic control
S Spontaneous breathing trial
B Bowel regimen
I Indwelling catheter removal
D De-escalation of antibiotics
The original author of FAST HUG, the famous Belgian intensivist JL Vincent, replies that the expansion of the mnemonic could go on forever, but the challenge is to keep it memorable by all staff.
Vincent W, Hatton KW: Critically ill patients need “FAST HUGS BID” (an updated mnemonic)
Crit Care Med 2009; 37:2326 –2327
Vital signs from children seen at two emergency departments (but not admitted, so as to exclude those with serious illness) were examined to quantify the effect of temperature on heart rate (over 21000 cases) and respiratory rate (over 14000 cases).
A rule of thumb was derived showing an increase in heart rate of about 10 beats per minute for every 1 degree celcius above normal.
The relationship between temperature and respiratory rate was less easy to demonstrate because of the widening of the normal spread of respiratory rates as temperature increases. However, previous reports of an increase of 5-11 breaths per minute per degree are likely to be an over estimate; this study would suggest it is closer to 0.5-2 breaths per minute.
The authors plan further study to validate these findings.
The relationship between body temperature, heart rate and respiratory rate in children
Emerg Med J. 2009 Sep;26(9):641-3
An ultrasound study of 80 children from 5 pre-determined age groups showed that the femoral veins increased their diameter in the frog-leg compared with straight-leg positions. Left and right femoral veins were the same size. There was significant overlap of the femoral arteries and veins which increased with distance distal to the inguinal ligament.
The Anatomic Relationship between the Common Femoral Artery and Common Femoral Vein in Frog Leg Position Versus Straight Leg Position in Pediatric Patients.
Acad Emerg Med. 2009 Jul;16(7):579-84
Currently, critical congenital heart disease is not detected in some newborns until after their hospital discharge, but some may be detected by routine pulse oximetry performed on asymptomatic newborns after 24 hours of life. The American Academy of Pediatrics has published a statement on the topic.
Role of Pulse Oximetry in Examining Newborns for Congenital Heart Disease: A Scientific Statement from the AHA and AAP (Full Text)
A small study of 6 PICU patients requiring CPR for cardiac arrest due to primary cardiac disease showed that blood pressure as measured by an arterial line increased when the depth of chest compression was increased from one third to one half of the chest wall diameter (using the hand-encircling method). Systolic, mean, and pulse pressures increased significantly whereas diastolic blood pressure (a key determinant of coronary perfusion) did not.
Should the ILCOR guidelines be changed to recommend deeper chest compressions? More data are needed, but the take home message here may be that invasive arterial monitoring is a good guide to the effectiveness of CPR during cardiac arrest resuscitation.
Depth of sternal compression and intra-arterial blood pressure during CPR in
infants following cardiac surgery
A double blind randomised trial comparing amethocaine (Ametop) with EMLA was conducted on 679 kids in a New Zealand emergency department. No significant differences were seen in success rate of first-attempt cannulation, skin blanching, or pain scores. However the protocol required an unblinded triage nurse to remove the creams at 45 minutes for amethocaine and 90 minutes for EMLA. The faster acting amethocaine may therefore be more useful in acute care settings.
Amethocaine versus EMLA for successful intravenous cannulation in a children’s emergency department: a randomised controlled study
An interesting study on nine healthy volunteers demonstrated noradrenaline infusions to increase MAP without increasing cardiac output (by increasing systemic vascular resistance). Measures of cerebral (frontal lobe) oxygenation, jugular venous saturation, and mean flow velocity in the middle cerebral artery all reduced with increasing doses of noradrenaline. The authors conclude that doses greater than 0.1 mcg/kg/min may reduce cerebral oxygenation. However increases in noradrenaline lowered paCO2 (through increases pulmonary ventilation) and it is unknown whether this was the major contributor to reduced oxygenation. It is also hard to ascertain the relevance to patients receiving noradrenaline, who unlike the healthy volunteers are not driven to supranormal blood pressures. In the meantime we will continue to attempt to optimise cerebral perfusion pressure using vasoactive drugs, but should be mindful that gross estimates of CPP may not tell us what we’re doing to cerebral oxygenation.
Br J Anaesth. 2009 Jun;102(6):800-5