Pediatric Tube Research Articles

Effect of multifibre mixture with prebiotic components on bifidobacteria and stool pH in tube-fed children

The objective of the present study was to evaluate the effect of a paediatric tube feed supplemented with a multifibre mixture on the gut microbiota and nutritional and micronutrient status of children on long-term enteral nutrition (EN). A randomised, controlled, double-blind, cross-over trial (2 × 3 months) with a washout period of 1 month was carried out. Twenty-seven children (80% neurologically impaired) aged 11.9 (SD 3.9) years, on long-term EN (4.8 (SD 3.9) years) were recruited. The analyses of the children's faecal pH, microbiota along with anthropometric measures, bowel movements and markers of blood micronutrient status were made. Twenty children completed the study. A significant increase in the proportion of stool bifidobacteria (+16.6%, P < 0.05) was observed during the multifibre period than during the fibre-free period, together with a significant reduction in stool pH (P < 0.001). Stool frequency and consistency as well as growth did not differ between the two periods. There was a significant increase (P < 0.05) in plasma ferritin at the end of the fibre-free period, but plasma ferritin levels remained within normal ranges during both periods. No diet effects on other blood parameters were observed. In conclusion, addition of a multifibre mixture with prebiotic components to paediatric EN is well tolerated, promotes bifidobacteria and reduces stool pH, indicating an improved gut health.

Immediate postoperative airway obstruction secondary to airway edema following tumor excision from the neck

A 46-year-old woman was scheduled for excision of a malignant peripheral nerve sheath tumor from the neck. The tumor had caused deviation of the trachea to the left and partial obstruction of the superior vena cava. Her upper airway at laryngoscopy after induction of anesthesia was normal. During tumor resection there were transient phases characterized by the complete disappearance of the peripheral oxygen saturation (Sp(O2)) and radial artery tracings. At the end of the operation, the trachea was extubated after ensuring adequate antagonization of neuromuscular blockade. However, immediately post-extubation, she showed signs of acute airway obstruction that necessitated reintubation of the trachea. Laryngoscopy revealed significant edema of the upper airway and vocal cords, requiring a smaller size tracheal tube. Many reports suggest the development of significant airway edema 24 h after such surgery. Our report highlights the fact that this can happen in the immediate postoperative period also. Some authors suggest that, in such surgery, extubation should routinely be done over pediatric tube exchangers. Routine leak testing and direct laryngoscopic/fiberoptic evaluation of the upper airway prior to extubation may also help. While our report reaffirms these points, it also stresses the importance of intraoperative monitoring for the compression of the great vessels, which may serve as a useful indicator of the early development of airway edema.

The design of pediatric tracheal tubes

Differences in the anatomy and physiology of the young child necessitate specialist equipment and anesthetic equipment is constantly evolving. We will review the factors influencing the design of pediatric tubes and highlight those areas of special interest. There have been pleas for more standardization of tube markings, as this would help with positioning of tubes, especially in small babies, and there are recent advances in this area. Anesthetists need to be aware that there are important differences between tubes so that they take this into account when choosing an appropriate tube. In addition, developments in the design of cuffed tubes are increasingly being used both for routine care and specialist surgery.

Abstract P197: Feasibility of Prehospital Pediatric King Laryngeal Tube Use

Introduction- Prehospital endotracheal intubation (ETI) may lead to a worse outcome for pediatric patients. We evaluated prehospital use of the pediatric King laryngeal tube (KLT) as an alternative to ETI. Hypothesis - Prehospital providers can successfully place the KLT and ventilate a pediatric simulator in respiratory arrest. Methods - We studied the ability of forty-five (45) paramedics and flight nurses to place the pediatric KLT in a SimBaby manikin. We limited pediatric KLT training to selection of the correct size as the participants already had initial training and experience with the adult KLT. Outcomes included the rate of successful pediatric KLT placement, number of attempts to correctly place the KLT, and time to first ventilation. Subjects were evaluated on airway management using an 11-point skill test. Subjects indicated perceptions and preferences for the pediatric KLT using a 5-point Likert scale. Data were analyzed using descriptive statistics. Results - 96.5% (95%CI: 89.3–100) subjects successfully placed the pediatric KLT. Median number of attempts was one and mean time to placement was 34 seconds (95%CI: 26.4–67.3 sec). 90% of participants successfully completed the skill test and scored a mean score of 78.2% (95%CI: 73.6–82.7). Subjects strongly agreed (5, IQR: 4–5) that their previous training on the adult KLT and using it in the field adequately prepared them to use the pediatric KLT. Subjects agreed (4, IQR: 3–4) that the pediatric KLT was easier to place than a pediatric endotracheal tube; they strongly agreed (5, IQR: 5–5) that they would use the pediatric KLT as an alternative airway. Participants disagreed (2, IQR: 1–5) that they would prefer the pediatric KLT as a primary means of securing pediatric airways. Conclusions -The pediatric KLT was quickly and reliably placed. Providers perceived the pediatric KLT to be easier to use than pediatric ETI in this setting.

Best Method for Placing Pediatric Tubes to the Correct Depth

Endotracheal tubes ideally are placed with the tip near the midtrachea, thereby minimizing the likelihood that either endobronchial intubation or

Percutaneous endoscopic gastrostomy with T-bar fixation in children and infants

The standard for placement of pediatric gastrostomy tubes has been percutaneous endoscopic gastrostomy (PEG) using the Ponsky "pull" technique. This study evaluated the safety and efficacy of PEG placement using the "push" technique with T-bar fixation in pediatric patients. This technique generally is limited to the adult population. With this technique, endoscopy is performed. The stomach is insufflated, and the anterior abdominal wall is transilluminated. T-bar fasteners are sequentially deployed to secure the stomach to the anterior abdominal wall. Using a modified Seldinger technique, a gastrostomy tube is placed through the center of the T-bars. A retrospective review of all PEG tubes placed in pediatric patients from 1997 to 2003 using the T-bar gastroscopy "push" technique was conducted. Patients 18 years of age or younger were included in the study. Data collected included patient age, operative time, procedure location, and complications. The procedure was performed for 47 children (mean age, 6.4 years), including 15 infants younger than 1 year. The indications for long-term enteral access included failure to thrive (n = 11), feeding disorder secondary to neurologic dysfunction (n = 31), gastroparesis (n = 1), and dysphagia (n = 4). The operative time averaged 23 min (range, 12-45 min). One major complication occurred (gastrocolonic fistula). The one minor complication was early dislodgement of the gastrostomy tube, which required replacement. This study found the described technique to be safe and effective for the placement of gastrostomy tubes in infants and children.

Blood Management Strategies Effect on Hemoglobin Levels in Hospitalized Patients.

Phlebotomy for diagnostic testing is a notable source of blood loss, causing hospitalized patients to lose significant volumes of blood in a short period of time. Previous studies have documented correlations in phlebotomy blood loss, decline in hemoglobin and possible contributions to transfusion volume. One study reported average blood drawn for phlebotomy to be 12.4 mL/day for patients in medical wards, 33.5 mL/day in ICU patients, and 73.9 mL/day in patients with an arterial line (Smoller et al. NEJM. 1986; 314: 1233–1235). Another study concluded that an average hemoglobin decrease of .79 g/dL was due to a similar volume of phlebotomy blood loss (Thavendiranthan et al. J Gen Intern Med 2005; 20:520–524). Patients treated at the Center for Bloodless Medicine and Surgery (CBMS) at Pennsylvania Hospital decline blood products. Thus, to minimize iatrogenic blood loss, strategies were implemented including the use of pediatric tubes, reduced phlebotomy and the avoidance of central line wastage. In this study we attempt to analyze the adherence to and effectiveness of these strategies in preventing hemoglobin decline. We conducted a retrospective chart review of 46 out of 341 hospitalizations in the CBMS between October 2005 and July 2006, excluding ICU patients and those with blood loss such as surgical patients, patients with gastrointestinal bleeding, and dialysis patients. Erthropoietin (EPO) therapy was not given before or during the days evaluated. The analyzed population had a mean age of 58.7, an initial hemoglobin of 12.3 g/dL and a hospitalization period of 5.1 days. The absolute change between initial and final hemoglobin was on average .71 g/dL. Taking into account fluctuations during their stay, the average change from highest documented hemoglobin to lowest was 1.2 g/dL. In 30.4 percent of this population EPO therapy was subsequently initiated during their hospitalization. Therapy began at an average hemoglobin of 10.8 g/dL and was presumably the result of phlebotomy induced anemia. An average of 2.8 laboratory tests were ordered per day; 57 percent were chemistry panels or complete blood counts. These two tests were ordered almost daily. Thus, even at a CBMS where pediatric tubes are utilized and strict staff protocols are prescribed, the average iatrogenic blood loss is not appreciably different from a non-bloodless center without these regulations. Pediatric tubes can be costly and labor intensive and may not be the most important determinant of iatrogenic blood loss. Therefore, hospitals should work more diligently to eliminate daily and unnecessary phlebotomies by retraining house staff to keep patient blood loss at a minimum.

Pediatric Tube Direct Sampling by the Abbott Architect Integrated ci8200 Chemistry/Immunochemistry Analyzer

Handling and direct sampling from primary, barcode-labeled pediatric tubes is a challenge for laboratories processing substantial numbers of pediatric samples (1)(2). To prevent anemia as a result of frequent blood draws in pediatric patients, analyzers should be able to handle small sample volumes collected in pediatric tubes. However, most analyzers are developed for standard adult tubes and cannot handle primary pediatric tubes (1)(3). Pediatric samples therefore are often manually processed and transferred to sample cups (3); this process, however, is prone to errors and is time-consuming. In our study, we assessed the ability of the Abbott Architect ci8200 (Abbott Laboratories) to handle and directly sample from different types of primary, barcode-labeled pediatric lithium heparin gel tubes and determined the sample dead volumes of these tubes and the standard Abbott sample cup. Five types of tubes were tested: the Sarstedt Microvette® …

A New Tracheostomy Procedure

In a recent issue of CHEST (July 2004),1 Ferraro et al suggested using a pediatric uncuffed endotracheal tube that was 4 mm in the inner diameter to ventilate patients during either percutaneous dilational tracheostomy (PDT) according to Ciaglia et al2 or translaryngeal tracheostomy according to Fantoni and Ripamonti.3 This suggestion limits the risk of hypoventilation and allows the whole procedure to proceed under direct vision using a flexible bronchoscope that is inserted parallel to the pediatric tube.

Handling of and Direct Sampling from Primary Barcode-Labeled Pediatric Tubes on Vitros Clinical Chemistry Analyzers Integrated into an enGen Work Cell

Handling and directly sampling from primary barcode-labeled pediatric tubes is a challenge for laboratories receiving substantial numbers of samples from pediatric patients (1). To prevent iatrogenic anemia from frequent blood draws, preanalytical as well as analytical systems should be capable of handling small sample volumes collected in pediatric tubes (2). However, most analyzers and robotic systems have been developed for standard 5- to 7-mL test tubes and cannot handle small pediatric tubes. This incompatibility leads to manual processing of pediatric samples and transfer of samples to micro cups even in large automated laboratories. Manual handling of specimens and transfer of samples are laborious and may lead to errors in both the preanalytical and analytical phases. In most hospitals, blood of pediatric patients is collected in small pediatric tubes by heel puncture, in contrast to adult patients from whom blood is collected by venipuncture in 5- to 7-mL evacuated tubes. Although most instruments require that the barcode label be applied vertically for reading, regular barcode labels do not conveniently fit on small pediatric tubes (2). Because of the reduced size of the tubes, separate buckets are needed for centrifugation, and often the barcode labels, which are too large for the small tubes, interfere with proper fitting in the buckets; they can also get damaged and no longer be readable (1). Furthermore, standard analyzer sample racks and trays do not support the dimensions …

Assessment of Ventilation During the Performance of Elective Endoscopic-Guided Percutaneous Tracheostomy: Clinical Evaluation of a New Method

To evaluate the feasibility of uninterrupted translaryngeal open ventilation delivered through a pediatric, uncuffed endotracheal tube during percutaneous endoscopic tracheostomy (PET). Prospective, observational clinical study in a six-bed ICU of a university hospital. Forty consecutive adult patients requiring an elective tracheostomy. We employed the basic Ciaglia technique with multiple dilators (n = 10), a single dilator (n = 15), and the Fantoni method (n = 15). During PET, pressure-controlled ventilation was maintained through an uncuffed, 4-mm inner-diameter pediatric tube. The fraction of inspired oxygen was 1.0. Ventilator settings were as follows: pressure-controlled ventilation, 40 cm H(2)O; respiratory rate, 25/min; inspiratory time, 1.2 s of inspiratory time (inspiratory/expiratory ratio, 1:1); and positive end-expiratory pressure, 0 cm H(2)O. Measurements of arterial blood gas (ABG) tensions were obtained before the start of each tracheostomy and every 3 min during the procedure. An average of 8.28 +/- 2.28 ABG measurements were obtained from each patient (+/- SD). All patients were successfully assisted during performance of the tracheostomy, and no patient required ventilation through a cuffed endotracheal tube. The maximum increase in PaCO(2) was 8.49 +/- 5.50 mm Hg, and the maximum decrease in pH related to hypercarbia was 0.04 +/- 0.04. The PaO(2) increased in all patients (maximum change, 69.75 +/- 57.00 mm Hg; p < 0.01), and no patient had desaturation during the procedure. The technique that we propose for airway management during PET was safe and effective. A mild increase in PaCO(2) was not associated with significant metabolic and hemodynamic consequences, and an adequate PaO(2) was maintained throughout the study.

Babies With Tracheostomies

Babies With Tracheostomies

Laryngeal Trauma During Awake Fiberoptic Intubation

Laryngeal Trauma During Awake Fiberoptic Intubation

Arterial blood sampling practices in intensive care units in England and Wales.

A postal survey of arterial blood sampling practices in 280 intensive care units throughout England and Wales found that very few measures are taken to reduce diagnostic blood loss in adult intensive care patients from arterial sampling. The average volume of blood withdrawn to clear the arterial line before sampling is 3.2 ml; subsequently returned to the patient in only 18.4% of intensive care units. Specific measures to reduce the blood sample size by the routine use of paediatric sample tubes in adult patients occurs in only 9.3% of intensive care units. In paediatric units, the average volume withdrawn was 1.9 ml and this was routinely returned in 67% of units. Some aspects of arterial blood sampling practices identified in this survey may contribute to iatrogenic anaemia in intensive care patients.

Anaesthesia for insertion of ear tubes in children: comparison of propofol, thiopentone and halothane

To determine the quality of anaesthesia and speed of recovery after propofol anaesthesia for myringotomy in children, 100 children 2-12 years were randomized to one of four anaesthetic regimens for induction/maintenance: thiopentone (STP) (5 mg.kg-1)/halothane, propofol (3 mg.kg-1)/halothane, halothane/halothane or propofol (3 mg.kg-1)/propofol bolus (0.5 mg.kg-1 every 3 min (10 mg.kg-1.h-1)). Nitrous oxide (70%) in oxygen (30%) was used to facilitate insertion of an intravenous catheter and was continued throughout the anaesthetic. We found that the incidence of intraoperative movement in response to surgical stimulation was significantly greater in the prop/prop group 32%, compared with the three other groups (P < 0.02). Although some recovery variables (time to response to questions, sit unaided, tolerate oral fluids, and discharge with fluids) were achieved more rapidly by the prop/ prop group than the other three groups, the times to open eyes, obey commands and, most importantly, discharge from recovery without fluids did not differ between the prop/prop and the hal/ hal groups. We conclude that there is little benefit in using propofol as an induction agent alone or in combination with a propofol maintenance anaesthetic for paediatric myringotomy and tube surgery.

Detection of Bacteremia in Adults: Consequences of Culturing an Inadequate Volume of Blood

The yield of blood cultures depends on the volume of blood cultured. We recently discovered that 15% of blood-culture specimens from adults in our hospital were being collected in 3.5-mL pediatric tubes and that another 5%, drawn in 10-mL adult tubes, contained less than 5 mL of blood. A comparison of 829 matched pairs of standard-volume (mean, 8.7 mL) and low-volume (mean, 2.7 mL) blood cultures showed that standard-volume cultures had a substantially higher detection rate for bloodstream infection than did low-volume cultures (92% compared with 69%; difference, 23% [95% CI, 9% to 37%]; P < 0.001). Our data, together with an analysis of previous studies, show that the yield of blood cultures in adults increases approximately 3% per millilitre of blood cultured. A survey of 158 U.S. clinical microbiology laboratory directors in the American Society of Clinical Pathologists showed that only 20% of 71 responding laboratories record the volume of blood submitted for culture and that the practice of culturing suboptimal volumes of blood from adults is widespread. Clinical laboratories should routinely monitor the volume of blood cultured as a quality-assurance measure. Blood-culture specimens from adults should not be drawn using small pediatric tubes.

A guide to the selection of paediatric tracheostomy tubes

A large range of tracheostomy tube types and sizes are available for use in children. Regional preference, rather than individual patient assessment, tends to determine selection. We present a table designed to assist with appropriate size selection, and discuss the relative merits and shortcomings of the tubes currently available.

Endoscopic technique: Present state and trends of development

Leading positions in the market for rigid endoscopes continue to be occupied by West German companies. The largest manufacturer of endoscopes, "K. Storz" and "R. Wolf" presented endoscopes for almost all branches of medicine. Their instruments are characterized by wide choice of accessories and by very high quality of optical systems. For urological and gynecological applications, wide-angle optical systems with aperture angles of 70-90 ° and "plane" illumination fields are provided. For pediatric urology, otorhinolaryngoiogy, and arthroscopy optical tubes are offered with outer diameter of 1.9 mm. "K. 5torz" presented a surgical kit for laparoappendectomy. In addition to the two largest firms, some other West German manufacturers presented technologically less sophisticated types of endoscopes: "Wisap" laparoscopes and amnioscopes for gynecology and obstetrics; "Heiiing" esophagoscopes and rectoscopes for gastroenterology, laryngoscopes for otorhinolaryngoiogy, and amnioscopes for obstetrics; "Techno-Medical" arthroscopes for surgery and traumatology and instruments for endoscopy; "Leisegang" and "Opton" colposcopes for gynecology.

Loss of carbamazepine suspension through nasogastric feeding tubes

The apparent loss of carbamazepine suspension during administration through polyvinyl chloride nasogastric feeding tubes in vitro was studied. Twelve methods of administering carbamazepine suspension (100 mg/5 mL) were tested; the methods differed with respect to nasogastric tube size, presence and type of diluent, and type of flush solution. Undiluted or 50% diluted carbamazepine suspension 200 mg was drawn up in a syringe and forced through adult or pediatric nasogastric feeding tubes. The tubes were immediately flushed twice with 50 mL of sterile water, 0.9% sodium chloride solution, or 5% dextrose solution, by using the same syringe used to administer the suspension. Samples were collected and analyzed for carbamazepine concentration by high-performance liquid chromatography. Each administration method was tested six times, and the results were subjected to analysis of variance. Significant loss of carbamazepine was noted for four of the six methods in which undiluted suspension was administered. In these methods, adult and pediatric tubes were flushed with sterile water or 0.9% sodium chloride. No significant loss of drug occurred for any of the methods involving the use of diluent. Significant losses were associated with diluent and flush solution but not nasogastric tube size. Carbamazepine suspension should be mixed with an equal volume of diluent before being administered through nasogastric feeding tubes.

Inspiratory work and response times of a modified pediatric volume ventilator during synchronized intermittent mandatory ventilation and pressure support ventilation.

Volume ventilation by demand flow ventilators significantly increases work of breathing during inspiration. Although various ventilator modifications and different modes of ventilation have been developed, there have been few studies regarding imposed work of breathing in infants and children. This study was designed to evaluate several modifications of a commercially available demand flow ventilator designed to shorten response time (tr) and decrease the imposed work (Wi) involved in opening the demand valve. Minimum withdrawal volume (Vmin), maximum negative pressure (P mneg), and tr were measured. Wi was defined as the product of Vmin and P mneg. Seven Siemens Servo 900C ventilators were tested under 16 different trial conditions with four variables: 1) mode of ventilation (synchronized intermittent mandatory ventilation [SIMV] vs. pressure support ventilation [PSV]); 2) caliber of circuit tubing (adult vs. pediatric); 3) location of airway pressure monitor (distal vs. proximal); and 4) ventilator trigger sensitivity (0 cm H2O--high vs. -2 cm H2O--low). Vmin, Pmneg, and Wi were all decreased (P less than .05) while tr was unaffected by changing ventilator trigger sensitivity from low to high. Wi was decreased by pediatric tubing and proximal airway pressure monitoring only when low trigger sensitivity was used. PSV and proximal airway monitoring shortened tr. The authors conclude that the use of pediatric circuit tubing and proximal airway pressure monitoring with a Siemens Servo 900C ventilator significantly improved ventilator performance.