Supplemental Oxygen Requirement Research Articles

The 13-Valent Pneumococcal Conjugate Vaccine Is Effective Against Hypoxic Pneumonia in Children in Lao PDR: A Novel Method Using a Hospital-Based Observational Study

Background: Pneumococcal pneumonia is a leading cause of childhood mortality. Pneumococcal conjugate vaccines (PCVs) have been shown to reduce hypoxic pneumonia in children. However, there are no 13-valent PCV (PCV13) vaccine effectiveness (VE) studies on hypoxic pneumonia from Asia. We describe a novel approach to determine the effectiveness of PCV13 against hypoxic pneumonia in children admitted with pneumonia in the Lao People's Democratic Republic, a low-resource setting. Methods: A prospective hospital-based observational study of children up to 59 months old admitted with pneumonia to a single tertiary hospital in Vientiane was undertaken over 54 months. Pneumonia was defined using the 2013 WHO definition. Hypoxia was defined as an oxygen saturation <90% in room air or requiring oxygen supplementation during hospitalisation. PCV13 status was determined by written record. VE was calculated using logistic regression comparing the odds of hypoxia between vaccinated and undervaccinated pneumonia cases. To handle potential confounders a propensity score (PS) analysis using inverse probability of treatment weighting was used; for missing data, multiple imputation (MI) analysis was undertaken. Findings: There were 826 children admitted with pneumonia, 285 had hypoxic pneumonia and 377 were PCV13-vaccinated. The unadjusted, PS adjusted and MI adjusted VE against hypoxic pneumonia were 23% (95% confidence interval [CI]: -9, 46%; p=0·14); 37% ([CI]: 6, 57%; p=0·02) and 35% ([CI]: 7, 55%; p=0·02) respectively. Interpretation: This is the first apparent study to show PCV13 is effective against hypoxic pneumonia in Asia. This single hospital-based approach will enable other similar settings to test for VE. Funding Statement: This study received funding from the Bill & Melinda Gates Foundation (OPP1115490). Declaration of Interests: KM and CN receive grants from Pfizer, outside the submitted work. The Institute of Research for Development (IRD) and Aix-Marseille University funds both ADP and the HRSV testing. PN receives grants from the Wellcome Trust. JL receives funding from Bill and Melinda Gates foundation. All other authors declare no competing interests. The opinion presented in this paper is that of the authors and does not reflect Pfizer. We have not been paid by a pharmaceutical company to write this article. Ethics Approval Statement: This study was conducted according to the study protocol approved by the Oxford Tropical Research Ethics Committee (OxTREC reference:1050-13), Laos Ministry of Health National Ethics Committee for Health Research (No 061NECHR), the Ethics Review Committee of the WHO Regional Office for the Western Pacific Region (WPRO-ERC) (reference ID:2013.30.LAO.2.EPI) and by The Royal Children’s Hospital Human Resources Ethics Committee (HREC) (reference number:33177B).

Respiratory Syncytial Virus Prophylaxis in Neurologic and Muscular Disorders in the Canadian Respiratory Syncytial Virus Evaluation Study of Palivizumab

This study aimed to examine the risk of respiratory-related hospitalization in children with neurologic and muscular disorders (NMDs) who received respiratory syncytial virus (RSV) prophylaxis in the Canadian RSV Evaluation Study of Palivizumab. Canadian RSV Evaluation Study of Palivizumab is a prospective registry of children who received ≥1 palivizumab injection among 32 Canadian sites. Demographic data were collected at enrollment, and respiratory events were documented monthly. Cox proportional hazard analyses were conducted to compare respiratory illness-related hospitalization (RIH) and RSV-related hospitalization (RSVH) among children with NMD and those prophylaxed for standard indications (SI) and complex medical disorders. Group differences were found in enrollment age and weight, birth weight, household crowding, neonatal stay and supplemental oxygen requirement (all P < 0.05). RIH and RSVH incidences were 19.2%, 3.3% (NMD, n = 605); 6.0%, 1.5% (SI, n = 20,335), 9.4%, 1.6% (complex medical disorders, n = 4063), respectively. Children with NMD had a higher risk of RIH (hazard ratio [HR]: 1.90; 95% confidence interval (CI): 1.41-2.56; P < 0.0005) than those with SI. RSVH risk was greater in children with NMD compared with both the SI (HR: 2.26; 95% CI: 1.38-3.72; P = 0.001) and complex medical disorders groups (HR: 2.74; 95% CI: 1.55-4.84; P = 0.001). Children with more severe infantile onset NMD had a higher risk of RIH than those with general hypotonic disorders (HR: 1.69; 95% CI: 1.06-2.68; P = 0.027) but not RSVH. Children with NMD who received palivizumab had a higher risk of both RIH and RSVH. Our results imply that all children with NMD, regardless of disease severity, are at risk for respiratory-related illness and RSV infection.

Safety and Efficacy of Acute Pulmonary Embolism Treated via Large-Bore Aspiration Mechanical Thrombectomy Using the Inari FlowTriever Device.

To report initial experience with safety and efficacy in the treatment of pulmonary embolism (PE) using the FlowTriever device. A single-center retrospective study was performed in all patients with acute central PE treated using the FlowTriever device between March 2018 and March 2019. A total of 46 patients were identified (massive= 8; submassive= 38), all with right ventricular (RV) strain and 26% with thrombolytic contraindications. Technical success (according to SIR reporting guidelines) and clinical success (defined as mean pulmonary artery pressure intraprocedural improvement) are reported, as are major device and procedure-related complications within 30 days after discharge. Technical success was achieved in 100% of cases (n= 46). Average mean pulmonary artery pressure improved significantly from before to after the procedure for the total population (33.9 ± 8.9 mm Hg before, 27.0 ± 9.0 mm Hg after; P < .0001; 95% confidence interval [CI], 5.0-8.8), submassive cohort (34.7 ± 9.1 mm Hg before, 27.4 ± 9.2 mm Hg after; P < .0001; 95% CI, 5.2-9.5) and massive cohort (30.4 ± 6.9 mm Hg before, 25.4 ± 8.2 mm Hg after; P < .05; 95% CI:0.4-9.6). Intraprocedural reduction in mean pulmonary artery pressure was achieved in 88% (n= 37 of 42). A total of 100% of patients (n= 46 of 46) survived to hospital discharge. In total, 71% of patients (n= 27 of 38) experienced intraprocedural reduction in supplemental oxygen requirements. Two major adverse events (4.6%) included hemoptysis requiring intubation, and procedure-related blood loss requiring transfusion. No delayed procedure-related complications or deaths occurred within 30 days of hospital discharge. Initial clinical experience using the FlowTriever to perform mechanical thrombectomy showed encouraging trends with respect to safety and efficacy for the treatment of acute central, massive, and submassive pulmonary embolism.

ARAF recurrent mutation causes central conducting lymphatic anomaly treatable with a MEK inhibitor.

The treatment of lymphatic anomaly, a rare devastating disease spectrum of mostly unknown etiologies, depends on the patient manifestations1. Identifying the causal genes will allow for developing affordable therapies in keeping with precision medicine implementation2. Here we identified a recurrent gain-of-function ARAF mutation (c.640T>C:p.S214P) in a 12-year-old boy with advanced anomalous lymphatic disease unresponsive to conventional sirolimus therapy and in another, unrelated, adult patient. The mutation led to loss of a conserved phosphorylation site. Cells transduced with ARAF-S214P showed elevated ERK1/2 activity, enhanced lymphangiogenic capacity, and disassembly of actin skeleton and VE-cadherin junctions, which were rescued using the MEK inhibitor trametinib. The functional relevance of the mutation was also validated by recreating a lymphatic phenotype in a zebrafish model, with rescue of the anomalous phenotype using a MEK inhibitor. Subsequent therapy of the lead proband with a MEK inhibitor led to dramatic clinical improvement, with remodeling of the patient's lymphatic system with resolution of the lymphatic edema, marked improvement in his pulmonary function tests, cessation of supplemental oxygen requirements and near normalization of daily activities. Our results provide a representative demonstration of how knowledge of genetic classification and mechanistic understanding guides biologically based medical treatments, which in our instance was life-saving.

Preoperative Evaluation of Patients With Interstitial Lung Disease

Preoperative Evaluation of Patients With Interstitial Lung Disease

Trajectories of functional exercise capacity in patients undergoing pulmonary rehabilitation.

Background: Pulmonary rehabilitation (PR) is now considered fundamental when managing patients with chronic respiratory disease. The individual variation in functional exercise capacity (FEC) response to PR within the cohort is unknown. The purpose of this study was to identify FEC patterns in response to PR in patients with chronic respiratory disease using the trajectory modeling method.Methods: The data of 67 patients with the chronic respiratory disease were retrospectively reviewed and analyzed in this study. All patients received once-weekly supervised training for 8 weeks. Six-minute walk distance (6MWD) was used to measure FEC. Muscle strength and 6MWD were assessed at baseline, Week 4, Week 8 and monthly for two months after PR completion. Group-based trajectory modeling (GBTM) was used to identify patterns in 6MWD in response to PR. The generalized estimating equation method was then used to detect the differences within and between the trajectories of identified groups across time.Results: Patients were grouped into low- (n=13), moderate- (n=34) and high- (n=20) FEC group based on GBTM analysis. All groups demonstrated significant improvements in 6MWD and leg muscle strength after 8-week PR. Compared to the high-FEC group, a greater proportion of the patients in the low-FEC group required oxygen supplementation during training and had worse baseline leg muscle strength.Conclusions: Patients showed distinct patterns of 6MWD changes in response to 8-week PR. Distinct characteristics for the low-FEC group included poor lower extremity strength and a greater proportion of required oxygen use at home and during training.

Metabolic Perturbations Include Homocysteine Degradation and Polyamine Synthesis in Pathogenesis of Bronchopulmonary Dysplasia

IntroductionChanges in dynamic metabolic processes during lung development is not well known, particularly during the saccular and alveolar stages. Lungs of infants prematurely born during either stage have underdeveloped alveolar sacs with arrested growth and frequently require oxygen supplementation, which can result in lung disease of prematurity (bronchopulmonary dysplasia, BPD). Oxidation‐reduction (redox) processes are important in both lung development and pathogenesis; however, clinical studies attempting to limit BPD pathogenesis targeting redox processes have not been promising. In this study, metabolomics were utilized to identify alternative metabolic perturbations during the two lung development stages in an established murine model of hyperoxia‐induced BPD.MethodsPostnatal day (PN) 3 mice from pairs of pregnant dam mice were pooled, randomized, and left at normoxia (room air, 21% O2) or exposed to hyperoxia (85% O2) in a tight‐sealed, plexiglass chamber until PN 15. Nursing dams were rotated every 24 hours to limit oxygen toxicity. Lungs were isolated from mice on PN 1, 3, 5, 7, 10, and 15 within two minutes then snap frozen in liquid nitrogen. Following methanol extraction, metabolites were detected by liquid chromatography‐mass spectrometry. Statistics including partial least squares – discriminant analysis (PLS‐DA) and Variable Importance in Projection (VIP), i.e. a quantitative measure of discriminating metabolites, were performed using Python 2.7/3.0 and R.ResultsA series of analysis were performed to validate, identify, and characterize both significant metabolites and their involved pathways. Samples could be separated by both time and oxygen‐level using PLS‐DA. Enrichment analysis of metabolites with VIP ≥ 1 indicated that both the methionine‐homocysteine degradation cycle (p ≤ 1e‐4) and downstream of it, polyamine synthesis was perturbed (p ≤ 1e‐4). Components of both the arginine and glutathione metabolism pathways were also significantly enriched (p ≤ 1e‐4). Metabolites specifically found in the prior enrichment analysis (e.g., cystathione in glutathione metabolism, spermine, spermidine in polyamine synthesis) were significantly elevated in hyperoxic lung tissues on PN 5, 7, and 10 (one way ANOVA, p ≤ 1e‐2). Metabolites with a fold change of ≥ 1.3 from only day 5 lung tissues were significantly enriched for methylhistidine metabolism (p ≤ 1e‐5).ConclusionSignificant alterations of redox process such as glutathione or arginine metabolism were found which corroborate current studies in lung development and BPD. Yet other metabolic processes such as methionine‐homocysteine degradation and polyamine synthesis were discovered. Deregulation of the recycling of homocysteine into methionine and how it is further metabolized into polyamines is common in other pathogenesis. Further examination to intervene the deregulation in BPD pathogenesis may be attractive.Support or Funding InformationNIH Grant to MAS (R21 HD090227) and fellowship to DL (T32 HL091816‐09)This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

The association between high-volume intraoperative fluid administration and outcomes among pediatric patients undergoing large bowel resection.

Traditional intraoperative fluid administration practices have been challenged this century with data suggesting improved outcomes with restrictive or goal-directed fluid administration during adult bowel surgery. Minimal data on outcomes associated with differing intraoperative fluid administration practice exists for pediatric patients. We assessed factors and outcomes associated with high-volume fluid administration in pediatric patients undergoing colectomy. We hypothesized that high-volume fluid administration is associated with impaired recovery and, thus, increased length of stay. A database of perioperative practice and postoperative outcomes at a tertiary pediatric hospital was queried for colectomy encounters between July 2012 and March 2017. Data extracted included patient characteristics, perioperative clinical data, and postoperative outcomes. Encounters were stratified into two groups: greater than 90th percentile fluids administered (high-volume fluid administration group) vs less than 90th percentile fluids administered. Univariable tests, multivariable logistic regression, and propensity score matched group comparisons were used to asses outcomes associated with high-volume fluid administration. A total of 209 colectomy encounters were identified from which 12 were excluded based on predetermined criteria. High-volume fluid administration was associated with length of stay >6days (AOR 8.14, CI 1.75-37.8, P=0.007), time to first meal >4days (AOR of 5.91, CI 1.30-27.17, P=0.02), and supplemental oxygen requirement >24 hours (AOR 3.60, CI 1.25-10.39, P=0.02) after adjusting for ASA status, blood loss, transfusion, and open surgery. Similarly, propensity score matched patients with high-volume fluid administration vs controls were more likely to have length of stay >6days (93% vs 54%, P=0.007), time to first meal >4days (93% vs 57%, P=0.009), and supplemental oxygen requirement >24 hours (36% vs 12%, P=0.033). High-volume fluid administration during colectomy for pediatric patients is associated with worsened postoperative outcomes suggestive of impaired recovery.

Black Race Is Associated with a Lower Risk of Bronchopulmonary Dysplasia

To use a large current prospective cohort of infants <29 weeks to compare bronchopulmonary dysplasia (BPD) rates in black and white infants. The Prematurity and Respiratory Outcome Program (PROP) enrolled 835 infants born in 2011-2013 at <29 weeks of gestation; 728 black or white infants survived to 36 weeks postmenstrual age (PMA). Logistic regression was used to compare BPD outcomes (defined as supplemental oxygen requirement at 36 weeks PMA) between the races, adjusted for gestational age (GA), antenatal steroid use, intubation at birth, and surfactant use at birth. Of 707 black or white infants with available BPD outcomes, BPD was lower in black infants (38% vs 45%), even though they were of significantly lower GA. At every GA, BPD was more common in white infants. The aOR for BPD was 0.60 (95% CI, 0.42-0.85; P = .004) for black infants compared with white infants after adjusting for GA. Despite the lower rate of BPD, black infants had a higher rate of first-year post-prematurity respiratory disease (black, 79%; white, 63%). In this large cohort of recently born preterm infants at <29 weeks GA, compared with white infants, black infants had a lower risk of BPD but an increased risk of persistent respiratory morbidity.

Acute undifferentiated febrile illness in the elderly: A clinical profile

Introduction: Geriatric patients are more prone to have serious viral or bacterial infections that may present with acute febrile illness (acute undifferentiated febrile illness [AUFI]) and have significantly increased the risk for morbidity and mortality. It is important for the community to know the clinical presentation and local etiology of AUFI. Methodology: This is a subgroup analysis of a large prospective study on determining the etiology of AUFI. We included geriatric population (>60 years) for our analysis. Results: This cohort study included 126 elderly patients who presented with AUFI, in which 56.3% were men. Scrub typhus (57.4%) was the most common cause of AUFI followed by dengue (19.1%), malaria (3.2%), enteric fever (1%), and leptospirosis (0.8%). Both scrub typhus and dengue fever peaked during the monsoon season and the cooler months, whereas no seasonality was observed with enteric fever and malaria. The requirement of supplemental oxygen, invasive ventilation, and inotropes was highest among the scrub typhus patients followed by leptospirosis and malaria. Bleeding manifestations were seen in scrub typhus (6.8%), dengue (14.2%), and malaria (25%). The overall mortality rate was 6.3% and was highest with scrub typhus 5.4%. Conclusion: The similarity in clinical presentation and diversity of etiological agents demonstrate the complexity of diagnosis and treatment of AUFI in South India. Even though respiratory tract, urinary tract, and skin infections present with acute febrile illness in the elderly, other undifferentiated causes such as scrub typhus, dengue, malaria, enteric fever, and leptospirosis should also be considered while treating the elderly, especially in developing nations. Once a clinical profile is formed, the local population can be educated to identify the possible life-threatening complications based on endemicity and seasonal trends.

Initial Oxygen Use for Preterm Newborn Resuscitation: A Systematic Review With Meta-analysis.

This systematic review and meta-analysis provides the scientific summary of initial Fio2 in preterm newborns (<35 weeks' gestation) who receive respiratory support at birth. Medline, Embase, Evidence-Based Medicine Reviews, and Cumulative Index to Nursing and Allied Health Literature were searched between January 1, 1980 and August 10, 2018. Studies were selected by pairs of independent reviewers in 2 stages with a Cohen's κ of 0.8 and 1.0. Pairs of independent reviewers extracted data, appraised the risk of bias (RoB), and assessed Grading of Recommendations Assessment, Development and Evaluation certainty. Ten randomized controlled studies and 4 cohort studies included 5697 patients. There are no statistically significant benefits of or harms from starting with lower compared with higher Fio2 in short-term mortality (n = 968; risk ratio = 0.83 [95% confidence interval 0.50 to 1.37]), long-term mortality, neurodevelopmental impairment, or other key preterm morbidities. A sensitivity analysis in which 1 study with a high RoB was excluded failed to reveal a reduction in mortality with initial low Fio2 (n = 681; risk ratio = 0.63 [95% confidence interval 0.38 to 1.03]). The Grading of Recommendations Assessment, Development and Evaluation certainty of evidence was very low for all outcomes due to RoB, inconsistency, and imprecision. The ideal initial Fio2 for preterm newborns is still unknown, although the majority of newborns ≤32 weeks' gestation will require oxygen supplementation.

An Experience on Normothermic Beating Heart Pulmonary Thromboendarterectomy

Objective: To study the outcome of normothermic beating heart pulmonary thromboendarterectomy (PTE) performed in patients with chronic pulmonary thromboembolism. Methodology: A retrospective analysis of 15 patients who underwent PTE under normothermic beating heart cardio-pulmonary bypass from July 2009 to September 2018 was done. The patients were followed up with clinical assessment, transthoracic echocardiography and computerized tomographicangiography (CTA) for 1 month to 82 months. Results: Data were analysed for 15 consecutive patients. Mean age of the patients was 35.28 years and 10 patients were male. Pre-operatively 6 (40%) patients presented with New York Heart Association (NYHA) class II dyspnoea on exertion symptomatology, 7 (47%) were in NHYA class III, and 2 (13%) were in NYHA class IV. The preoperative and postoperative mean pulmonary artery pressures (mPAP) (mmHg) were 36.50 ± 11.3 and 20.21 ± 7.19, the systolic PAPs (mmHg) were 73.35 ± 14.12 and 35.21 ± 7.89 and the diastolic PAPs (mmHg) were 19.28 ± 8.60 and 12.85 ± 7.26 respectively. 2 (13%) patients had Jamieson’s type I and 12 (87%) had Jamieson type II disease. One patient (7%) expired on 9th postoperative day. All the patients had improved pulmonary gas exchange and did not require oxygen supplementation from 5th postoperative day; symptoms improved to NYHA class I & II in 12 (80%) & 3 (20%) of patients respectively. There was no reperfusion pulmonary edema or any neurologic complications. Postoperative echocardiogram showed improved right ventricular function and Computerised Tomographic Angiogram showed completeness of the procedure. Conclusion: Pulmonary thromboendarterectomy under normothermic beating heart cardiopulmonary bypass has good immediate postoperative results with significant progressive improvement in hemodynamics and quality of life during the course of follow-up. The results were not only comparable to those of the procedure done under deep hypothermic circulatory arrest by other centres but also without its associated adverse events. This technique requires more expertise but gives equivalent good results in immediate and short- to mid-term follow-up with less morbidity than the standard procedure, but it requires long-term follow-up to substantiate the evidence.

Traumatic lung herniation after ATV rollover

Traumatic pulmonary hernia is a rare entity that often presents immediately after the trauma but may appear years after the incident. We report a case of a 53-year-old female with polytrauma including a traumatic pulmonary hernia following an all-terrain vehicle (ATV) rollover. Left pulmonary hernia reduction, rib plating, and pectoralis flap were performed. After the surgery, the patient's pain and respiratory status drastically improved, and the patient was able to leave the hospital without any supplemental oxygen requirements. Pulmonary hernia is a rare etiology seen in blunt traumas involving the chest. These often can be associated with rib fractures, pulmonary contusions, and clavicular fractures. There are multiple techniques for surgical repair including using autologous tissues, synthetic materials, and even minimally invasive techniques. Although pulmonary hernia is rare, every trauma and thoracic surgeon should be aware of the etiology of this condition and the options available for surgical repair.

Spectrum of Influenza B Viral Infection in Indian Children: A Tertiary Centre Experience

&#x0D; &#x0D; &#x0D; &#x0D; Introduction: Influenza viral infection in children can range from subclinical illness to multi system involvement. The morbidity associated with influenza B viral infection is often overlooked. India being the second most populous country, accounts for 20% of global childhood deaths from respiratory infections. There is paucity of data on the clinical features and complications of influenza B viral infections in children from the Indian subcontinent. Our objective was to study the clinical profile, seasonality, complications and outcome associated with Influenza B viral infection in children &lt; 18 years of age.&#x0D; Material and Methods: We conducted a retrospective observational study at a tertiary care hospital in South India. Children less than 18 years of age admitted to our paediatric unit were included in the study. We reviewed the case sheets of 56 patients who tested positive for influenza B virus during the study period and recorded their clinical and laboratory data. Throat swab obtained from cases were tested by RT-PCR. The illness was classified as upper respiratory tract infection, pneumonia and severe pneumonia. Outcome measures analysed were- mortality, need for oxygen supplementation or assisted ventilation, duration of oxygen support, duration of ICU/ hospital stay and time for defervescence following initiation of oseltamivir therapy.&#x0D; Results: The mean age of the study population was 6.98 years. Majority of the affected children were &gt; 5 years of age in the school going category with a male to female ratio of 3:2. The diagnosis based on clinical and radiological findings included upper respiratory tract infection (URTI) in 44 (78.5%) cases followed by pneumonia in 11(19.6%) and severe pneumonia in one (1.7%) child. The peak incidence was in the month of March. Malnutrition was the most common risk factor affecting 22 (39.3%) cases followed by history of asthma in eight (14.3%). Three children required oxygen supplementation at admission. The median duration of hospital stay was seven days. The median duration for defervescence following initiation of oseltamivir therapy was 24 hours. Mortality was recorded in one infant who died of acute respiratory distress syndrome.&#x0D; Conclusions: Influenza B virus should be screened in all children having underlying high risk medical condition, presenting with pneumonia or upper respiratory tract infection. Oseltamivir therapy should be initiated early in the management of influenza B viral infections to prevent complications.&#x0D; &#x0D; &#x0D; &#x0D;

Critical care resources utilized in high-risk adenotonsillectomy patients.

Children at high risk for respiratory complication after adenotonsillectomy are often admitted to a pediatric intensive care unit (PICU) postoperatively. Although many patients receive care in such units, it is unknown how many utilize critical care resources. A review was conducted to audit intensive care needs of postadenotonsillectomy patients admitted to the PICU at a tertiary, academic, pediatric hospital between July 2013, and March 2017. Demographic information, ICU indication, polysomnogram results, and comorbidities were collected. Patients were defined as needing ICU resources based on supplemental oxygen requirements greater than 2 L between 2 to 24 hours postoperatively, more than two desaturation events in a 2-hour period, or more than hourly nursing intervention. Factors associated with utilization of ICU resources were assessed. One hundred and ten patients were admitted to the PICU after adenotonsillectomy. Median age was 4.2 years, median body mass index was 90.8 percentile, and median apnea hypopnea index (AHI) was 34.3. Twenty patients (18.2%) utilized ICU resources by criteria defined. Of these patients, 14 were known to need such resources by 2 hours postoperatively (70%, negative predictive value 93.8%). Neither AHI nor obesity status was correlated with need for resources; however, resource need was associated with young age, gastrostomy tube status, and neuromuscular disorders (P = 0.048, P = 0.002 and 0.013, respectively). Most high-risk adenotonsillectomy patients do not utilize critical care resources despite their increased perioperative risk. Patients with respiratory complications are frequently identifiable within the first 2 hours of surgery. 4 Laryngoscope, 129:1229-1234, 2019.

Remifentanil patient-controlled analgesia in labour: six-year audit of outcome data of the RemiPCA SAFE Network (2010–2015)

BackgroundThe RemiPCA SAFE Network was established to set standards and monitor maternal and neonatal outcomes when using remifentanil for labour analgesia. The aim of this analysis was to describe the development of the network standard and to report maternal and neonatal outcome data, including severe adverse events. MethodsData sets of the RemiPCA SAFE Network database from the initial six consecutive years (2010–2015) were retrospectively analysed. The data were analysed on an annual basis and set in context with changes of the network standard, i.e. adaptations of the network’s standard operating procedure. Main outcomes reported are maternal and neonatal data regarding effectiveness and safety, such as satisfaction, need for bag/mask ventilation and/or cardiopulmonary resuscitation. ResultsAmong 5740 data sets, no need for maternal ventilation or cardiopulmonary resuscitation was registered. Neonatal cardiopulmonary resuscitations, potentially related to remifentanil, occurred in 0.3%. In parallel with adaptations of the network standard, a moderate rate of maternal hypoxia (oxygen saturation <94% in 24.7%) was found, together with a low rate of supplemental oxygen requirement in neonates (5.0%). ConclusionThe RemiPCA SAFE Network data show that remifentanil patient-controlled analgesia can be applied safely. There is bias when data from real clinical settings are analysed retrospectively. Notwithstanding, the approach taken by the RemiPCA SAFE Network, with constant, systematic and standardised evaluation of multiple parameters during the course of labour, might identify trends and anomalies and guide the development and application of safety standards, when translating knowledge from scientific trials into clinical practice.

Complicaciones intrahospitalarias en ancianos con fractura de cadera: estudio transversal para determinar los factores asociados

BackgroundThis study aims to determine the factors associated with the presence of in-hospital complications in elderly patients with hip fracture. MethodsA retrospective, observational study of patients older than 65 years admitted to the San Ignacio University Hospital (Bogotá, Colombia) with hip fracture in the period between January 2013 and December 2015. A review of the clinical history of each patient was carried out by extracting demographic data, disease history, geriatric syndromes, status on admission, date of the surgical procedure, and the presence of complications. A multivariate analysis was subsequently performed in order to determine the risk factors associated with the presence of in-hospital complications. ResultsAn analysis was carried out on the data collected from 141 patients. The mean age was 80.3 years (SD 7.86), with 62.4% of the sample being women, and the mean hospital stay was 7.89 days (SD 5.65). The three most frequent geriatric conditions were malnutrition, polypharmacy, and falls, Just over half (53%) of the patients were independent for basic activities of daily living (Barthel> 90). During the hospital stay, 54.6% of the sample had some complication. Mortality in the hospital period was 9.9%. DiscussionFunctional dependence, increased anaesthetic risk, supplementary oxygen requirement during the post-operative period, and length of hospital stay were independent factors for the presence of in-hospital complications.Evidence Level: III.

Randomized Study of Early Continuous Positive Airways Pressure in Acute Respiratory Failure in Children With Impaired Immunity (SCARF) ISRCTN82853500.

Previous trials in adults with impaired immunity and respiratory failure suggest that early noninvasive ventilation avoids endotracheal intubation and improves survival. No randomized clinical trials have addressed this question in children. We undertook an open, parallel-group randomized trial in three pediatric hospitals. Children with impaired immunity and acute respiratory failure defined as tachypnoea (> 90th centile); a new requirement for supplemental oxygen; and new chest radiograph infiltrates. Children were randomly assigned to early PICU admission for continuous positive airways pressure (early continuous positive airways pressure) or to standard care. The primary outcome was endotracheal intubation by 30 days. One-hundred fourteen children met inclusion criteria of whom 42 were randomized between January 2013 and January 2016. There was no significant difference in endotracheal intubation by 30 days with early continuous positive airways pressure (10/21; 48%) compared with standard care (5/21; 24%), odds ratio 2.9 (0.8-10.9), p value equals to 0.11. However, 30-day mortality was significantly higher with early continuous positive airways pressure (7/21; 33%) compared with standard care (1/21; 5%), odds ratio 10.0 (1.1-90.6), p value equals to 0.041. Mortality at 90 days was early continuous positive airways pressure (11/21; 52%) versus standard care (4/21; 19%), odds ratio 4.7 (1.2-18.6), p value equals to 0.029, whereas mortality at 1 year was similar early continuous positive airways pressure (13/21; 61.9%) versus standard care (9/21; 42.7%), odds ratio 2.2 (0.6-7.4), p value equals to 0.22. There were two serious adverse events: early continuous positive airways pressure (pneumothorax) and standard care (hemothorax). This study provided no evidence to support early PICU admission for continuous positive airways pressure in children with acute respiratory failure and impaired immunity. There was a trend toward increased endotracheal intubation and a higher early mortality in the early continuous positive airways pressure group.

Diffuse Large B-Cell Lymphoma: A Rare Cause of Lung Consolidation.

Diffuse large B-cell lymphoma (DLBCL) is the commonest sub-type of non-Hodgkin lymphoma. However, lung consolidation is a rare presentation of DLBCL. Moreover, in view of poor general condition, it poses clinical dilemma of when to start chemotherapy and whether chemotherapy should be given at full dose or truncated doses till improvement in general condition. A 48-years-old lady was admitted with complaints of non-productive cough for 2months duration. She was febrile and hypoxemic requiring oxygen supplementation. She had bilateral axillary lymphadenopathy, and bronchial breath sounds on chest auscultation. Chest X-ray showed non-homogenous opacities involving bilateral lower zones. A diagnosis of DLBCL was confirmed on lymph node biopsy and Immunohistochemistry. She received chemotherapy, following which a gradual, improvement in her breathlessness and cough was noted over ensuing week and she got discharged from the hospital and received rest of her chemotherapy on outpatient basis. In a case of DLBCL with lung consolidation, a high index of suspicion can clinch the diagnosis of secondary lymphomatous involvement. Presence of respiratory failure at presentation doesn't necessarily warrants truncation of chemotherapy doses.

Initial Characteristics and Clinical Severity of Hemophagocytic Lymphohistiocytosis in Pediatric Patients Admitted in the Emergency Department.

The diagnosis and management of children with hemophagocytic lymphohistiocytosis (HLH) admitted in the emergency department (ED) are challenging. The present study aimed at describing the initial characteristics of pediatric patients with HLH upon admission in the ED. Moreover, the clinical severity of the condition was assessed. We performed a retrospective study of patients who visited the pediatric ED and were newly diagnosed with HLH during hospitalization between February 2012 and January 2017. The patients were classified in the clinically unstable group if at least 1 of the following conditions was observed upon admission in the ED: hypoxia requiring oxygen supplementation, hypotension requiring inotropic support, coagulopathy with prothrombin time (international normalized ratio, ≥1.5), and seizures or altered consciousness. We enrolled 31 pediatric patients with HLH, with a median age of 6.53 years (interquartile range, 1.35-13.24 years). Abdominal discomfort along with fever (74.2%) was the most common presenting symptom in patients admitted in the ED. Based on the HLH-2004 diagnostic criteria, fever (96.8%), hyperferritinemia (96.8%), splenomegaly (74.2%), hypertriglyceridemia and/or hypofibrinogenemia (67.7%), and bicytopenia (41.9%) were observed in the patients. However, only 8 patients (25.8%) met the criteria. Nineteen patients (61.3%) were included in the clinically unstable group. This group had lower albumin (2.3 vs 3.3 g/dL, P = 0.002) and fibrinogen levels and higher ferritin level and neutrophil count than the clinically stable group. Meanwhile, the number of clinical findings that met the diagnostic criteria was not different between the 2 groups. Lower albumin level was a significant risk factor in the clinically unstable group (odds ratio, 0.040; P = 0.004). Pediatric patients with HLH often have clinically unstable conditions upon admission in the ED. However, only few patients meet the HLH-2004 diagnostic criteria. Lower albumin level may be useful in assessing clinically unstable patients and preparing for possible deterioration.