The rising incidence of multi-drug resistant (MDR) gram-negative infections in the intensive care unit (ICU) continues to challenge clinicians and has resulted in reemergence of the glycopeptide antibiotic colistin. Over the past 11 years, 14 patients at a tertiary pediatric burn center were treated with colistin for gram-negative infections resistant to all tested antibiotics. This study reviews the safety of such treatment and the outcome for this cohort of patients. All hospitalized patients treated with intravenous colistin between 1990 and 2005 were identified. A retrospective chart review was performed for each patient. Demographic data, along with information regarding the type and severity of injury, were collected. Data with respect to microbiology, renal status, and neurological events were also noted. Over an 11-year period, we identified 14 children infected with pan-resistant gram-negative organisms requiring 16 courses of colistin. Two children (14.3%) developed significant rises in serum creatinine concentration; however, no child required renal replacement therapy or developed neurologic complications attributable to colistin. Favorable response rate was 78.6% (11/14), and overall mortality was 14.3% (2/14); both deaths were attributed to sepsis. In our experience with 14 children treated with intravenous colistin, two developed a significant elevation in serum creatinine concentration during the course of therapy and neurotoxicity was not reported. Colistin should be dispensed with great caution, but it appears to have an acceptable safety profile in children and may be used in select cases of infection with highly resistant gram-negative organisms.
Because of ineffectiveness and tolerance to benzodiazepines and opioids developing with time, drugs acting via other receptor systems (eg, α-2 agonists) have been advocated in burn patients to improve sedation and analgesia. This study in severely burned pediatric subjects examined the hemodynamic consequences of dexmedetomidine (Dex) administration. Eight intubated patients with ≥20 to 79% TBSA burns were studied between 7 and 35 days after injury. After baseline measurements of mean arterial blood pressure and heart rhythm were taken, each patient received a 1.0 µg/kg bolus of Dex followed by an ascending dose infusion protocol (0.7-2.5 µg/kg/hr), with each dose administered for 15 minutes. There was significant hypotension (27±7.5%, average drop in mean arterial pressure [MAP] ± SD), and a decrease in heart rate (HR; 19% ± 7, average drop in HR ± SD). The average HR decreased from 146 beats per minute to 120. No bradycardia (HR < 60) or heart blocks were observed. In three patients, the MAP decreased to <50mm Hg with the bolus dose of Dex. Of the remaining five patients, three patients completed the study receiving the highest infusion dose of Dex (2.5 µg/kg/hr), whereas in 2 patients the infusion part of the study was begun, but the study was stopped due to persistent hypotension (MAP < 50mm Hg). These observations indicate that a bolus dose of Dex (1.0 µg/kg for 10 minutes) and high infusion rates may require fluid resuscitation or vasopressor support to maintain normotension in critically injured pediatric burn patients.
Children who require intubation as a component of their burn management generally need heavy sedation, usually with a combination of opiate and benzodiazepine infusions with a target sensorium of light sleep. When extubation approaches, the need for sedation to prevent uncontrolled extubation can conflict with the desire to lighten sedation enough to ensure that airway protective reflexes are strong. The several hours' half-life of these medications can make this period of weaning challenging. Therefore, the hours preceding extubation are among the most difficult in which to ensure safe adequate sedation. The pharmacokinetics of propofol allow for the rapid emergence of a patient from deep sedation. We have had success with an extubation strategy using short-term propofol infusions in critically ill children. In this work, children were maintained on morphine and midazolam infusions per our unit protocol, escalating doses as required to maintain comfort. Approximately 8 hours before planned extubation, these infusions were decreased by approximately half and propofol infusion added to maintain a state of light sleep. Extubation was planned approximately 8 hours later to allow ample time for the chronically infused opiates and benzodiazepines to be metabolized down to the new steady-state level. Thirty minutes before planned extubation, propofol was stopped while morphine and midazolam infusions were maintained at the reduced level. When the children awakened from the propofol-induced state of light sleep, they were extubated while the reduced infusions of morphine and midazolam were maintained. These were subsequently weaned slowly, depending on the child's need for ongoing pain and anxiety medication, per our unit protocol to minimize the incidence of withdrawal symptoms. Data are shown in the text as mean +/- standard deviation. These 11 children (eight boys and three girls) had an average age of 6.6 +/- 5.6 years (range, 1.2-13 years), average weight of 36.9 +/- 28.7 kg (range, 9.3-95 kg), and burn size of 43 +/- 21.4% (range, 10-85%). Three children had sustained scald burns and eight had flame injuries with associated inhalation injury. They had been intubated for an average of 12.7 +/- 10.9 (range, 2-33 days). Morphine infusions immediately before the initiation of propofol averaged 0.26 +/- 0.31 mg/kg/hour (range, 0.04-1.29 mg/kg/hr) and midazolam averaged 0.15 +/- 0.16 mg/kg/hr (range, 0.06-0.65 mg/kg/hr). Morphine infusions after beginning propofol and at extubation averaged 0.16 +/- 0.16 (range, 0.04-0.65 mg/kg/hr) and midazolam averaged 0.09 +/- 0.08 mg/kg/hr (range, 0.02-0.32 mg/kg/hr). Propofol doses after initial titration during the first hour of infusion averaged 3.6 +/- 2.9 mg/kg/hr (range, 0.4-8.1 mg/kg/hr). Nine of the 11 children (82%) were successfully extubated on the first attempt. Two required reintubation for postextubation stridor 2 to 6 hours after extubation but were successfully extubated the next day after a short course of steroids, again using the same propofol technique. All were ...
Although pancreatitis is rare in pediatric burn patients, elevated pancreatic enzymes have been recently observed among toxic epidermal necrolysis (TEN) patients. This clinical phenomenon has implications particularly for the nutritional management of patients involved. The objective of this study was to assess the frequency of sustained, elevated amylase, and lipase enzymes among children with TEN or Stevens Johnson Syndrome (SJS) and to evaluate the utilization of enteral nutrition support in this population. Medical records of 24 patients admitted to our hospital between January 1994 and October 2008 with TEN or SJS were retrospectively reviewed. Only patients with > or =4 consecutive measures for both amylase and lipase were included in this study (n = 10). Serial laboratory values were collected during the first 30 days of disease. Four patients (40%) had elevated amylase and lipase values, whereas six patients had values within normal limits. Patients with elevated pancreatic enzymes were significantly younger in age (4.7 +/- 1.7 years) than patients without elevated enzymes (11 +/- 5.9 years) and also had a higher incidence of sepsis. All other characteristics were similar between the groups. Enteral nutrition support was initiated within 4 days of admission in all 10 patients and did not correlate with elevated enzymes. Our findings suggest that hyperlipasemia and hyperamylasemia can occur in the pediatric population with TEN or SJS. Although the sample size in this study makes it difficult to determine the cause, sepsis may have been a contributing factor. In the absence of symptomatic pancreatitis, patients with TEN can safely meet nutritional goals orally or with standard enteral nutrition support.
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