Rationale: Indices that assess the load on the respiratory muscles, such as the tension-time index (TTI), may predict extubation outcome. Objectives: To evaluate the performance of a noninvasive assessment of TTI, the respiratory muscle tension time index (TTmus), by comparison to that of the diaphragm tension time index (TTdi) and other predictors of extubation outcome in ventilated children. Methods: Eighty children (median [range] age 2.1 yr [0.15-16]) admitted to pediatric intensive care units at King's College and St Mary's Hospitals who required mechanical ventilation for more than 24 hours were studied. Measurements and Main Results: TTmus, maximal inspiratory pressure, respiratory drive, respiratory system mechanics, and functional residual capacity using a helium dilution technique, the rapid shallow breathing and CROP indices (compliance, rate, oxygenation, and pressure) indexed for body weight were measured and standard clinical data recorded in all patients. TTdi was measured in 28 of the 80 children using balloon catheters. Eight children (three in the TTdi group) failed extubation. TTmus (0.199 vs. 0.09) and TTdi (0.157 vs. 0.07) were significantly higher in children who failed extubation. TTmus greater than 0.18 (n 5 80) and TTdi greater than 0.15 (n 5 28) had sensitivities and specificities of 100% in predicting extubation failure. The other predictors performed less well. Conclusions: Invasive and noninvasive measurements of TTI may provide accurate prediction of extubation outcome in mechanically ventilated children.Keywords: diaphragm; respiratory muscles; pediatric critical care; weaningPatients are extubated when assessed to be capable of sustaining spontaneous ventilation without respiratory support. Premature extubation leading to cardiorespiratory compromise necessitates reintubation and reinstitution of mechanical ventilation and increases mortality and morbidity (1), whereas prolonged ventilatory support exposes the child to increased risk of nosocomial infection and lung injury (2). Extubation failure has been reported to occur in 4 to 10% of children (3, 4), hence an accurate predictor of extubation outcome would be of significant clinical value (1).Univariate indices that examine a single aspect of physiological function often have poor predictive power probably because they do not fully reflect all the pathophysiological processes affecting extubation outcome (5). Accurate prediction is more likely using multivariate indices that integrate a number of physiological functions (6). Studies of multivariate indices in children, such as the rapid-shallow breathing index (RSB) (respiratory rate [RR] divided by tidal volume [VT]) (5) and the CROP index (compliance, RR, oxygenation, and inspiratory pressure [PI]), however, have been limited and yielded contradictory results. We (7) and others (8, 9) have shown that the predictive power of those indices in children is poor, whereas Baumeister and colleagues (10), demonstrated that the CROP index discriminated strongly between successful an...
In all children with fulminant hepatic failure, the differential diagnosis of leukaemia should be considered, particularly if there is hepatosplenomegaly, pancytopenia and a high lactate dehydrogenase. Early bone marrow aspiration should be performed to confirm diagnosis, as peripheral blood smears may often be normal.Hepatomegly is a common feature of leukaemia but acute liver failure as the first presentation is extremely uncommon [1,2].We report a 4-year-old girl with a 2-week history of lethargy, vomiting and fluctuating sensorium for 2 days. There was no history of drug or toxin ingestion. She was icteric with liver 15 cm and spleen 9 cm below the costal margin respectively. Due to grade 3 encephalopathy, she was mechanically ventilated on the liver intensive care unit.Laboratory investigations revealed the following: haemoglobin 91 g/l (reference range 115-155 g/l), WBC 0.85·10 9 /l (reference range 5.5-15.5·10 9 /l), neutrophil count 0.5·10 9 /l (reference range 3-5.8·10 9 /l), platelet count 29·10 9 /l (reference range 150-400·10 9 /l) and no blasts were seen in the peripheral smear. Furthermore, INR 2.6 (reference range 0.8-1.2), D-dimer 1925 ng/ml, AST 714 IU/l (reference range 15-55 IU/l), total bilirubin 6 mg/dl (103 lmol/l; reference range 3.4-17 lmol/ l), LDH 4289 IU/l (reference range 150-500 IU/l), ammonia 102 lmol/l (reference range 34-47 lmol/l), lactate 9 mmol/l (reference range 0.9-1.7 mmol/l) and creatinine 94 lmol/l (reference range 27-62 lmol/l).Ultrasonography revealed a heterogeneous liver with multiple hypoechoic areas. Viral screen was negative. Bcell ALL, type L3 (Burkitt) was diagnosed from bone marrow examination done at 12 h.Early haemofiltration was started because of fulminant hepatic failure (FHF) and to prevent tumour lysis syndrome. Following pre-hydration and rasburicase, intravenous vincristine (1 mg/m 2 ) on days 1 and 8; and oral prednisolone (60 mg/m 2 ) daily (day 2 onward) was started. On day 4, after correction of her coagulopathy, a first dose of triple intrathecal chemotherapy (methotrexate 15 mg, cytosine arabinoside 30 mg and hydrocortisone 15 mg) was administered. The cytospin of the CSF was clear of leukaemic cells.
SummaryWe retrospectively audited children with sickle cell disease (SCD) admitted to paediatric intensive care (PICU) at King’s College Hospital between January 2000 and December 2008. Forty‐six children with SCD were admitted, on 49 separate occasions. Ages ranged from 4 months to 15 years (median 7·6 years). Three children died in PICU, however two presented to hospital in cardiorespiratory arrest; overall mortality was 6%. The most common reason for admission was acute chest syndrome (43%). 88% of admissions required blood transfusion, of which 74% had exchange blood transfusions. The mortality among children with SCD admitted to PICU is low.
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