The variations in neurotrophic factor levels reflect an endogenous attempt at neuroprotection against biochemical and molecular changes after traumatic head injury. BDNF represents an early marker of brain injury, while NGF expression in the CSF was indicative of a good outcome and the role of this neurotrophin in the treatment of children with severe head injury may be hypothesized.
Bacterial translocation as a direct cause of sepsis is an attractive hypothesis that presupposes that in specific situations bacteria cross the intestinal barrier, enter the systemic circulation, and cause a systemic inflammatory response syndrome. Critically ill children are at increased risk for bacterial translocation, particularly in the early postnatal age. Predisposing factors include intestinal obstruction, obstructive jaundice, intra-abdominal hypertension, intestinal ischemia/reperfusion injury and secondary ileus, and immaturity of the intestinal barrier per se. Despite good evidence from experimental studies to support the theory of bacterial translocation as a cause of sepsis, there is little evidence in human studies to confirm that translocation is directly correlated to bloodstream infections in critically ill children. This paper provides an overview of the gut microflora and its significance, a focus on the mechanisms employed by bacteria to gain access to the systemic circulation, and how critical illness creates a hostile environment in the gut and alters the microflora favoring the growth of pathogens that promote bacterial translocation. It also covers treatment with pre- and pro biotics during critical illness to restore the balance of microbial communities in a beneficial way with positive effects on intestinal permeability and bacterial translocation.
Background: Over a 36-month study period, 10 nonconsecutive neuromuscular pediatric patients (6 infants, mean age 10.16 months, and 4 children, mean age 9.3 years) presenting with acute respiratory failure (ARF) were treated by noninvasive positive pressure ventilation (NPPV). All patients required immediate respiratory support and fulfilled our intubation criteria. Objective: The aim of the study was to verify if early NPPV was able to avoid endotracheal intubation and to improve both oxygenation and ventilation within 24 h from admission in this clinical setting. Patients andMethods: A prospective pilot study was carried out on neuromuscular patients admitted to the pediatric intensive care unit (PICU) of the Catholic University of Rome because of ARF and managed exclusively with NPPV for at least 24 h following admission. All patients were treated using a flow-triggered mechanical ventilator through a face mask or using the new helmet interface. Results: Eight patients were successfully ventilated during the observation period and 2 early failures occurred. Among children undergoing face mask NPPV, the PaO2/FiO2 ratio increased from a median value of 75 (range 48–149) to 240 (range 133–385; p < 0.001) and 328 (range 180–371; p < 0.001) at selected time points (3 and 12 h after NPPV introduction, respectively); the alveolar-to-arterial oxygenation difference showed a similar trend, i.e. decreasing from a median value of 589 (range 213–659) to 128 (range 62–527; p < 0.01) and 69 (range 45–207; p < 0.001), respectively. Hypercarbic ARF resolved within 6 h from admission even in the most severe cases. Conclusions: NPPV was a safe and effective first-line therapeutic approach in hypoxemic ARF children/infants with neuromuscular disease. It seems of importance to identify children with neuromuscular disorders who may be able to achieve residual ventilator-free breathing and to perform an NPPV trial avoiding tracheal intubation. Life-threatening respiratory distress and very young age should not preclude NPPV application in the PICU setting. The new helmet interface represents a promising tool for noninvasive ventilation in older children.
We are extremely grateful for the comments by Papoff et al concerning our report 1 on the propofol regimen, compared with the morphine, atropine, and suxamethonium regimens, as induction for neonatal endotracheal intubation. We are equally interested in the findings of their pilot trial, which are encouraging.Propofol, a general anesthetic agent, serves as a deep sedative and is amnestic at optimal dose. At hypnotic doses, propofol causes slowing of brain activity shown with electroencephalography. 2 We indeed had consid-
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