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Pain is one of the most common complaints leading to a pediatric emergency department visit and is associated with various painful procedures, leading to increased anxiety and stress. Assessing and treating pain in children can be challenging, so it is crucial to investigate new methods for pain diagnosis. The review aims to summarize the literature on non-invasive salivary biomarkers, such as proteins and hormones, for pain assessment in urgent pediatric care settings. Eligible studies were those that included novel protein and hormone biomarkers in acute pain diagnostics and were not older than 10 years. Chronic pain studies were excluded. Further, articles were divided into two groups: studies in adults and studies in children (<18 years). The following characteristics were extracted and summarized: study author, enrollment date, study location, patient age, study type, number of cases and groups, as well as tested biomarkers. Salivary biomarkers, such as cortisol, salivary α-amylase, and immunoglobulins, among others, could be appropriate for children as saliva collection is painless. However, hormonal levels can differ among children in different developmental stages and with various health conditions, with no predetermined levels of saliva. Thus, further exploration of biomarkers in pain diagnostics is still necessary.
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Background and objectives: Local anesthetic systemic toxicity (LAST) in children is extremely rare, occurring at an estimated rate of 0.76 cases per 10,000 procedures. However, among reported cases of LAST in the pediatric population, infants and neonates represent approximately 54% of reported LAST cases. We aim to present and discuss the clinical case of LAST with full clinical recovery due to accidental levobupivacaine intravenous infusion in a healthy 1.5-month-old patient, resulting in cardiac arrest necessitating resuscitation. Case presentation: A 4-kilogram, 1.5-month-old female infant, ASA I, presented to the hospital for elective herniorrhaphy surgery. Combined anesthesia was planned, involving general endotracheal and caudal anesthesia. After anesthesia induction, cardiovascular collapse was noticed, resulting in bradycardia and later cardiac arrest with EMD (Electromechanical Dissociation). It was noticed that during induction, levobupivacaine was accidentally infused intravenously. A local anesthetic was prepared for caudal anesthesia. LET (lipid emulsion therapy) was started immediately. Cardiopulmonary resuscitation was carried out according to the EMD algorithm, which lasted 12 min until spontaneous circulation was confirmed and the patient was transferred to the ICU. In ICU, the girl was extubated the second day, and the third day she was transferred to the regular pediatric unit. Finally, the patient was discharged home after a total of five days of hospitalization with full clinical recovery. A four-week follow-up has revealed that the patient recovered without any neurological or cardiac sequelae. Conclusions: The clinical presentation of LAST in children usually begins with cardiovascular symptoms because pediatric patients are already under general anesthesia when anesthetics are being used, as was the case in our case. Treatment and management of LAST involve cessation of local anesthetic infusion, stabilization of the airway, breathing, and hemodynamics, as well as lipid emulsion therapy. Early recognition of LAST as well as immediate CPR if needed and targeted treatment for LAST can lead to good outcomes.
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Anestésicos Locales , Paro Cardíaco , Recién Nacido , Lactante , Niño , Humanos , Femenino , Anestésicos Locales/efectos adversos , Levobupivacaína/uso terapéutico , Infusiones Intravenosas , Emulsiones/uso terapéutico , Paro Cardíaco/terapia , Paro Cardíaco/tratamiento farmacológico , LípidosRESUMEN
UNLABELLED: The aim of this study was to estimate direct costs related to nosocomial infection in three pediatric intensive care units in Lithuania and to overview the effectiveness of preventive programs of nosocomial infections. MATERIAL AND METHODS: A prospective empirical surveillance study was launched in 3 Lithuanian pediatric intensive care units during the period of January 2005 to December 2007. Using the method of targeted selection, all children aged from 1 month and 18 years, treated in pediatric intensive care units for more than 48 hours, were enrolled into the study. Direct costs of nosocomial infections in pediatric intensive care units were calculated for each patient and each case of nosocomial infection. For calculation of average expenditures per patient-day, data from nosocomial infection registry and from analysis of hospital income for services provided at pediatric intensive care units according to price-list of health care price approved by the order of the Minister of Health of the Republic of Lithuanian (No. V-802, October 27, 2005) were used. According to length of stay, costs of intensive care services, and costs caused by nosocomial infections, all the patients were divided into two groups: those who did and did not acquire an infection. For the evaluation of economic efficiency, the patients were divided into other two groups: pre- and postintervention groups. All economic evaluation was made in national currency (litas). RESULTS: The data of 755 patients were used. Multiple linear regression analysis (R(2)=0.47) revealed a 6.32-day increase (95% CI, 4.32-8.33; P=0.003) in hospital stay in a pediatric intensive care unit if a patient acquired nosocomial infection. Costs related to nosocomial infections for one patient made up 5215.47 litas (95% CI, 3565.00-6874.19). Average costs caused by one nosocomial infection case were 4070.61 litas (95% CI, 2782.44-5365.22). Nosocomial infection prevention programs (interventions) gave a total economical effect of 20046.14 litas. Prevention of one patient from nosocomial infection caused a reduction of 1336.41 litas, and one avoided nosocomial infection case resulted in a 1113.67-litas reduction; cost-to-effect ratio was 1:4. CONCLUSIONS: Total costs related to nosocomial infections in pediatric intensive care units were high. The implementation of nosocomial infection prevention program resulted in a positive economic effect - 1 litas spent for the prevention of nosocomial infections saved 4 litas.
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Infección Hospitalaria/economía , Control de Infecciones/economía , Unidades de Cuidado Intensivo Pediátrico/economía , Adolescente , Niño , Preescolar , Costos de la Atención en Salud , Humanos , Lactante , Lituania , Estudios ProspectivosRESUMEN
AIM: To determine the safety and effectiveness of mild induced hypothermia in children after traumatic or posthypoxic brain injury. Thirteen patients after traumatic or poshypoxic brain injury were involved in the study. Mean age was 11.1 +/- 5.7 years. Median GCS 6 (3-8), PIM2 20.3 +/- 28.2%. RESULTS: GOS 5 was assigned for six (46%) patients and GOS 4 for seven (54%) patients. Average GOS in patients after severe head trauma was 4.1 points; in patients with posthypoxic brain injury 5 points (p < 0.05). No life threatening complications occurred. CONCLUSION: Mild induced hypothermia can be safely used in pediatric patients after severe traumatic or posthypoxic brain injury. This method may be of benefit while improving outcomes in children.
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Lesiones Encefálicas/terapia , Hipotermia Inducida/métodos , Adolescente , Niño , Preescolar , Femenino , Escala de Coma de Glasgow , Humanos , Masculino , Evaluación de Resultado en la Atención de Salud , Estudios Prospectivos , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Estadísticas no ParamétricasRESUMEN
The aim of the study was to evaluate outcome of children after severe traumatic brain injury treated according to intracranial pressure (ICP)-targeted protocol, to define threshold values of peak ICP and minimal cerebral perfusion pressure (CPP) for decompressive osteoplastic craniotomy, and to determine the relationship between ICP, CPP and long-term outcome in these children. All children admitted to Pediatric Intensive Care Unit of Kaunas University of Medicine Hospital after severe head injury from January 2004 to June 2006 and treated according to ICP-targeted protocol for the management of severe head trauma were prospectively included in the study. Raised ICP was defined as a level higher than 20 mmHg. Minimal CPP was considered to be at a level of 40 mmHg. Outcome was defined using Glasgow Outcome Scale (GOS) at discharge from the hospital and after 6 months. Forty-eight patients (32 boys and 16 girls) were included into the study. Favorable outcome (GOS score of 4 and 5) after 6 months was achieved in 43 (89.6%) cases. Mean peak ICP was 24.2+/-7.2 mmHg and mean minimal CPP - 53.1+/-14.7 mmHg. Decompressive craniotomy was performed in 13 cases. Threshold values of peak ICP and minimal CPP for decompressive craniotomy were 22.5 mmHg (area under the curve, 0.880) and 46.5 mmHg (area under the curve, 0.898), respectively. The differences in peak ICP and minimal CPP in groups of favorable and unfavorable outcomes were not statistically significant. Treating children after severe traumatic brain injury according to the ICP-targeted protocol for the management of severe pediatric traumatic brain injury resulted in a favorable long-term outcome.
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Lesiones Encefálicas , Circulación Cerebrovascular , Presión Intracraneal , Adolescente , Factores de Edad , Lesiones Encefálicas/mortalidad , Lesiones Encefálicas/fisiopatología , Lesiones Encefálicas/cirugía , Circulación Cerebrovascular/fisiología , Niño , Preescolar , Protocolos Clínicos , Craneotomía , Interpretación Estadística de Datos , Descompresión Quirúrgica , Femenino , Estudios de Seguimiento , Escala de Consecuencias de Glasgow , Humanos , Lactante , Unidades de Cuidado Intensivo Pediátrico , Presión Intracraneal/fisiología , Masculino , Estudios Prospectivos , Curva ROC , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: To determine the threshold values of Pediatric Index of Mortality 2 (PIM 2) score, Pediatric Trauma Score (PTS), and Glasgow Coma Scale (GCS) score for mortality in children after severe head injury and to evaluate changes in outcomes of children after severe head injury on discharge and after 6 months. MATERIAL AND METHODS: All children with severe head injury admitted to the Pediatric Intensive Care Unit of Kaunas University of Medicine Hospital, Lithuania, from January 2004 to June 2006 were prospectively included in the study. The severity of head injury was categorized according to the GCS score < or =8. As initial assessment tools, the PTS, postresuscitation GCS, and PIM 2 scores were calculated for each patient. Outcome was assessed according to Glasgow Outcome Scale on discharge and after 6 months. RESULTS: The study population consisted of 59 children with severe head injury. The group consisted of 37 (62.7%) boys and 22 (37.3%) girls; the mean age was 10.6+/-6.02. The mean GCS, PTS, and PIM 2 scores were 5.9+/-1.8, 4.8+/-2.7, and 14.0+/-19.5, respectively. In terms of overall outcome, 46 (78.0%) patients survived and 13 (22.0%) died. All three scales appeared to be significant predictors of death. Threshold values for which potential mortality in children after severe head injury increased were 10.75 for PIM 2, 3 for PTS and 5 for GCS. PIM 2 score provided the best discrimination between survivors and nonsurvivors. CONCLUSIONS: The threshold values for mortality in children after severe head trauma were PIM 2> or =10.75%, PTS< or =3 and GCS< or =5, and these values were significant risk factors of death in severely head injured children. The changes in outcome for survivals on discharge and after 6 months were statistically significant.
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Traumatismos Craneocerebrales/diagnóstico , Traumatismos Craneocerebrales/mortalidad , Accidentes de Tránsito , Adolescente , Factores de Edad , Niño , Preescolar , Traumatismos Craneocerebrales/clasificación , Interpretación Estadística de Datos , Femenino , Estudios de Seguimiento , Escala de Coma de Glasgow , Escala de Consecuencias de Glasgow , Humanos , Lactante , Puntaje de Gravedad del Traumatismo , Unidades de Cuidado Intensivo Pediátrico , Masculino , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Curva ROC , Sensibilidad y Especificidad , Factores Sexuales , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
This article reviews scientific literature data of the last decade and analyses the possibilities to evaluate functional brain state in comatose children. Observations after the development of coma, its short-term and long-term outcomes show that when duration of coma is over 30 days, the chances to regain consciousness and autonomy are decreased. Coma of hypoxic origin has more complicated course, and its prognosis is worse compared to the one of a traumatic origin. Vegetative condition is observed more frequently as a consequence of hypoxic brain damage. Survival in vegetative condition without recovery of consciousness raises medical, psychological, social, and patient care problems. The article reviews different methodical approaches for the evaluation of functional brain state. Various methods of brain bioelectric evaluation are analyzed, including routine and qualitative methods of electroencephalography, possibilities of its spectral analysis and evoked potentials of various types. The results of the observation that evaluate the changes of brain structure and neurophysiological parameters are reviewed. The analysis of 48 articles draws a conclusion that the most objective criteria for evaluation the prognosis of coma can be achieved while following the clinical condition of the patient in parallel with the brain neuroimaging studies and evaluation of neurophysiological parameters, such as electroencephalography spectral analysis and evoked potentials of brainstem and cortex. The best evaluation of the functional brain state and prognosis of coma can be achieved with repeatable investigations during coma development and comparison of the results of several parameters.
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Encéfalo/fisiopatología , Coma/fisiopatología , Hipoxia Encefálica/fisiopatología , Factores de Edad , Daño Encefálico Crónico/fisiopatología , Tronco Encefálico/fisiopatología , Corteza Cerebral/fisiopatología , Niño , Coma/diagnóstico , Coma/diagnóstico por imagen , Coma/mortalidad , Electroencefalografía , Potenciales Evocados Somatosensoriales , Escala de Coma de Glasgow , Humanos , Presión Intracraneal , Imagen por Resonancia Magnética , Estado Vegetativo Persistente/fisiopatología , Pronóstico , Factores de Tiempo , Tomografía Computarizada de Emisión de Fotón Único , Tomografía Computarizada por Rayos XRESUMEN
Traumatic brain injury in children is a worldwide problem. The incidence of trauma cases is increasing over the world, and in Lithuania it is several times higher than in the most developed European countries. The article reviews data about the most modern means of managing pediatric traumatic brain injury. The role of prehospital care, emphasizing on airway management, adequate ventilation, oxygenation, and perfusion in order to preclude secondary brain injury, which begins straight after trauma, is being noted. Establishing trauma system and patient's treatment in pediatric trauma centers, where child gets urgent and sufficient help, reduces mortality and improves outcomes. Pediatric patient's triage using patient's status scoring and trauma scoring systems is recommended. The role of intracranial pressure and cerebral perfusion pressure is crucial. Immediate management of intracranial pressure reduces mortality and improves outcomes. Techniques of intracranial pressure monitoring and management strategies of intracranial hypertension, their advantages and possible disadvantages are described.