Abstract: GOAL: This study had for aim to determine the mortality rate and the factors affecting mortality among 70children admitted for septic shock secondary to a community acquired infection. PATIENTS AND METHODS: A retrospective analysis was made of patients admitted between January 1998 and August 2005, in a pediatric ICU for septic shock secondary to a community-acquired infection. Neonates under 7days of age were excluded from the study. RESULTS: Seventy cases were included and 32 (45.7 %) of them died. Their average age was 3.8+/-4.2years and their PRISM during the first 24hours was 19.2+/-8.4. Sixty-nine children (98.6 %) presented with multivisceral failure and 60 (85.7 %) with more than two deficient organs. The average time between the observation of first hemodynamic disorders and admission to ICU was 9.4+/-11.3hours. Three independent mortality risk factors were identified: failure of more than two organs on admission (OR, 4.4; 95 % CI [2.1-9.4]), an infusion volume superior to 20ml/kg on the second day of resuscitation (OR, 3.4; 95 CI % [1.1-10.3]), and the use of more than two vasoactive drugs (OR, 3.3; 95 CI % [1.2-9]).
Abstract: AIM: To evaluate the diagnostic delay and therapeutic insufficiencies delay before the transfer in ICU of the children admitted in the ICU of the children's hospital of Tunis with a purpura fulminans (PF). METHODS: A retrospective, descriptive study, of children with PF referred between January 2000 and January 2006 to a the paediatric intensive care unit (PICU) of the children's hospital of Tunis. The PF diagnosis was retained in any child presenting a feverish purpura and circulatory insufficiency signs. The optimal diagnostic and therapeutic charge taking was defined in three levels: parental, the first line doctors, and the hospital doctors. The symptoms' duration and the various treatments which were lavished to the patients were taken from the medical observations of the patients transferred in our PICU. RESULTS: Twenty one observations were collected. Twelve patients (57.1%) were addressed by a doctor exerting in a dispensary or by a free practicing doctor, 5 patients (23.8%) were transferred from a regional hospital and 4 children (19.1%) directly consulted the children hospital of Tunis urgencies delayed parental recognition occured in 11 children. The PF diagnosis was not evoked by the first line doctor in 62%. Eleven (52.4%) of the children with meningococcal disease were seen but not admitted by a doctor in the 48 hours before admission. Apart from 2 patients (9.5%) who were hospitalized in reanimation directly of the urgencies, all the other patients forwarded by a general pediatry service. In general pediatry, the PF diagnosis was not evoked in 3 cases (15.8%), 31.6% of patients had unnecessary a lumbar punctures and shock was not recognised or treated in 26.3%. Twelve patients (52.2%) died. The duration of hospitalization in general pediatry is significantly higher among deceased patients (5.5 +/- 6.6 hours) than among the surviving patients (2.6 +/- 1.5 hours); p < 0.05. CONCLUSION: Suboptimal treatement in PF is due to failure of parents, general practioners and hospital doctors to recognise specific features of the illness. Improvement in outcome could be achieved by public education and better training of clinicians in recognition, resuscitation, and stabilisation of seriously ill children.
Abstract: AIM: to precise the incidence of acute respiratory distress syndrome in infants at term and near term and the clinical characteristics of this disease not yet well recognised. METHODS: Retrospective study of the medical records of infants admitted in the paediatric intensive care unit for ARDS along a period of 4 years. Diagnosis of ARDS was based on the following criterias: (1) Gestational age > or =35 weeks of gestation; (2) Severe and immediate respiratory distress requiring mechanical ventilation with PEEP > or =4 cmH2O and FiO2 > or = 0.5 during at least 6 hours; (3) Dependence on oxygen > or =48 hours ; (4) Diffuse alveolar damage in the chest radiograph; (5) PaO2 < or =60 mmHg under FiO2 > or = 0.5. RESULTS: During the period of the study, 23 infants (gestational age = 36 +/- 1.1 weeks of gestation; birth weight = 2756 +/- 453 gr) were included in the study. Their mean age at admission was 16.5 +/- 14.6 hours. The majority of infants (91.3%) were born by caesarean section before the onset of labour in 78.3% cases. All infants had a severe acute hypoxemic respiratory failure (D(A -a)O2 = 468 +/- 165; OI = 19 +/- 8.4). Five infants (21.7 %) improved their oxygenation parameters under conventional mechanical ventilation (CMV) (p < 0.001; p = 0.002 et p = 0.003 respectively for D(A - a)O2, OI and PaO2/FiO2). Eighteen infants (78.2%) required high frequency oscillatory ventilation (HFOV)with a rapid and persistant improvement of oxygenation parameters. Five patients (21.7%) developed pulmonary air leak. One infant died. CONCLUSION: ARDS represents 6.8% of etiology of respiratory distress in infants at term and near term. Caesarean section before the onset of labour seems to be a triggering factor. The outcome seems to be favourable (rate of survival = 95.7%) if the management is suitable.
Abstract: BACKGROUND: There are few data providing rates of nosocomial bloodstream infections (NBI) in pediatric intensive care patients from developing regions of the world. OBJECTIVES: To describe the epidemiology of NBI in a Tunisian pediatric intensive care unit (PICU). METHODS: A prospective surveillance study from January 2004 through December 2005 was performed in the PICU of the Children's Hospital of Tunis. All patients who remained in the PICU for more than 48 hours were included. Centers for Disease Control and Prevention criteria were applied for the diagnosis of NBI. RESULTS: Six hundred forty-seven patients aged 0 to 15 years were included. Forty-one NBIs occurred in 38 patients. The NBI rate was 7/1000 patient days (6.3/100 admissions). Twenty-seven NBIs (66%) occurred in patients with central venous catheter (CVC). CVC-associated infection rate was 14.8 per 1000 catheter days. Gram-negative rods were involved in 53.6% of NBIs. The most common organisms causing NBIs were Staphylococcus aureus (26.8%), Klebsiella pneumoniae (19.5%) and Coagulase-negative staphylococci (17%). Staphylococcus aureus was methicillin-resistant in 9.1% of cases. Eighty-seven percent of Klebsiella pneumoniae isolates had extended-spectrum beta-lactamases. The PICU crude mortality rate of infected patients was 42% (versus 5.9% in noninfected patients; P< .001). Multivariate logistic regression analyses demonstrated device utilization ratio greater than 1 (odds ratio [OR]=8.46; 95% confidence interval [CI] 3.11-23; P< .001) and previous colonization with multidrug resistant gram-negative rods (OR=2; 95% CI 1.39-2.89; P< .001) significantly related to NBI. CONCLUSIONS: Considering the high incidence of NBI resulted from multiple drug-resistant gram-negative rods in our center, implementation of improved infection control practices is required.
Abstract: AIM: The purpose of this study was to assess the current management practices of acute bronchiolitis by tunisian paediatricians. METHODS: A questionnaire was sent by mail to all tunisian paediatricians, about the most widely used drugs during the first stage of acute bronchiolitis. The answers were sent to us by mail in pre-stamped envelopes. RESULTS: Out of total of 420 questionnaires sent, 180 (42.8%) were returned, out of which 177 (42%) were analysed. Of the respondents, 117 (66%) were working in hospitals and, 60 (34%) were working in the private sector. Bronchodilatators were used by 93.3% of peadiatricians either routinely (35.6%) or occasionally (44.1%). Steroids were used by 88.7% of pediatricians either routinely (28.8%) or occasionally (43.5%) Nasal drops, were prescribed routinely by 80.2% of the pediatricians. Physiotherapy was performed routinely or occasionally in 91.5% of the cases. Oygen and antibiotics were respectively used by 92% and 70% of the paediatricians. A comparaison between the practices of the hospital paediatricians and their private sector conterparts showed that private practitioners, statistically, prescribe more bronchodilatators (42.7% vs 21.7%) (p < 0.05) and corticosteroids (36.8% vs. 13.3%) (p < 0.05) than their hospital colleagues. Hospital physicians, more than the private sector ones, tend to never prescribe bronchodilatators ,2 (15% vs. 2.6%) (p < 0.05) and steroids (25% vs. 4.3) (p < 0.05). CONCLUSIONS: Despite the absence of the scientific evidence showing a beneficial effect of the pharmaceutical agents, most paediatricians, during the initial phase of acute bronchiolitis, resort to prescribing bronchodilators (93.3%) and corticosteroids (88.7%). There is a great variety of therapeutic practices among hospital paediatricians and private practitioners. National guidelines could be helpful in reducing this disparity.
Abstract: OBJECTIVE: To evaluate the effectiveness of high-frequency oscillatory ventilation (HFOV) in pediatric patients with acute respiratory failure, failing conventional ventilation. DESIGN: A prospective, clinical study. SETTING: Tertiary care pediatric intensive care unit. PATIENTS: Twenty pediatric patients (ages 12 days to 5 yrs) with acute respiratory failure (pneumonia, 14; sepsis with acute respiratory distress syndrome, 3; pulmonary edema as a complication of upper airway obstruction, 2; salicylate intoxication with acute respiratory distress syndrome, 1), failing conventional ventilation (median alveolar-arterial oxygen difference [P(A-a)O2] 578 [489-624] torr, median oxygenation index 26 [21-32]. INTERVENTIONS: HFOV was instituted after a median length of conventional ventilation of 15.5 (3.3-43.5) hrs. MEASUREMENTS AND MAIN RESULTS: Ventilator settings, arterial blood gases, oxygenation index, and P(A-a)O2 were recorded before HFOV (0 hrs) and at predetermined intervals during HFOV and compared using the one-way Friedman rank-sum procedure and a two-tailed Wilcoxon matched-pairs test. Initiation of HFOV caused a significant decrease in FiO2 at 1 hr that continued to 24 hrs (p <or= .04). In all patients, target ventilation was achieved, and 19 had improved oxygenation. After 1 hr, PaCO2 significantly decreased (p = .002) and remained within the target range thereafter. There were significant decreases in P(A-a)O2 and oxygenation index at 1 and 4 hrs, respectively, that were sustained up to 12 hrs (p <or= .04). No significant complications associated with HFOV were detected. Fifteen patients (75%) survived to hospital discharge. Only one patient died from respiratory failure. CONCLUSIONS: In pediatric patients with acute respiratory failure, failing conventional ventilation, HFOV improves gas exchange in a rapid and sustained fashion. However, randomized controlled trials are needed to identify its benefits over conventional modes of mechanical ventilation.
Abstract: OBJECTIVE: The authors had for aim to describe the epidemiology of nosocomial bacterial infections in the neonatal and pediatric intensive care unit of the Tunis children's hospital. DESIGN: A prospective surveillance study was made from January 2004 to December 2004. All patients remaining in the intensive care unit for more than 48 h were included. CDC criteria were applied for the diagnosis of nosocomial infections. RESULTS: 340 patients including 249 (73%) neonates were included. 22 patients presented with 22 nosocomial bacterial infections. The incidence and the density incidence rates of nosocomial bacterial infections were 6.5% and 7.8 per 1,000 patient-days, respectively. Two types of infection were found: bloodstream infections (68.2%) and pneumonias (22.7%). Bloodstream infections had an incidence and a density incidence rate of 4.4% and 15.3 per 1,000 catheter-days, respectively. Pneumonia had an incidence and a density incidence rate of 2% and 4.4 per 1,000 mechanical ventilation-days, respectively. The most frequently isolated pathogens were Gram-negative bacteria (68%) with Klebsiella pneumoniae isolates accounting for 22.7%. The most common isolate in bloodstream infections was K. Pneumoniae (26.7%), which was multiple drug-resistant in 85% of the cases, followed by Staphylococcus aureus (20%). Pseudomonas aeruginosa was the most common isolate in pneumonia (28.6%). Associated factors of nosocomial infection were invasive devices and colonization with multiple drug-resistant Gram-negative bacteria. CONCLUSIONS: The major type of nosocomial bacterial infections in our unit was bloodstream infection and the majority of infections resulted from Gram-negative bacteria. Factors associated with nosocomial bacterial infections were identified in our unit.
Abstract: This study describes a high-frequency oscillatory ventilation (HFOV) protocol for term and near-term infants with acute respiratory failure (ARF) and reports results of its prospective application. Neonates, with gestational age >or= 34 weeks, were managed with HFOV, if required, on conventional ventilation (CV), a fraction of inspired oxygen (F IO(2)) 0.5, and a mean airway pressure > 10 cm H (2)O to maintain adequate oxygenation or a peak inspiratory pressure > 24 cm H (2)O to maintain tidal volume between 5 and 7 mL/kg of body weight. Seventy-seven infants (gestational age, 37 +/- 2,3 weeks), received HFOV after a mean duration of CV of 7.5 +/- 9.7 hours. Arterial blood gases, oxygenation index (OI), and alveolar-arterial difference in partial pressure of oxygen (P AO(2) - Pa O(2)) were recorded prospectively before and during HFOV. There were a rapid and sustained decreases in mean airway pressure (MAP), F IO(2), OI, and P AO(2) - Pa O(2) during HFOV ( P <or= 0.01). Seventy infants (91%) were weaned successfully from HFOV. Seven infants (P AO(2) - Pa O(2) prior to HFOV, 601 +/- 89 mm Hg) were classified as having experienced treatment failure and died from their underlying disease. Treatment failure was associated with lack of improvement in P AO(2) - Pa O(2) at 1 hour of HFOV ( P < 0.01). Early rescue intervention with HFOV is an effective protocol for term and near-term infants with ARF. Failure to improve P AO(2) - Pa O(2) rapidly on HFOV is associated with HFOV failure. Randomized controlled trials are needed to identify benefits of HFOV versus conventional modes of mechanical ventilation.
Abstract: In order to determine the response to high-frequency oscillatory ventilation (HFOV), used as an "early rescue" therapy, in a cohort of paediatric patients with acute respiratory distress syndrome (ARDS), a prospective clinical study was performed in a tertiary care paediatric intensive care unit. Ten consecutive patients, aged 12 days to 5 years with ARDS and hypoxaemic respiratory failure on conventional ventilation (CV), using a lung protective strategy, were managed with HFOV early in the course of the disease process (median length of CV 4 h). Arterial blood gases, oxygenation index (OI), alveolar-arterial oxygen difference (P(A-a)O2) and PaO2/FIO2 ratio were prospectively recorded prior to HFOV (0 h) and at predetermined intervals throughout the course of the HFOV protocol. There was a significant improvement in PaCO2 4 h after institution of HFOV (P = 0.012). A significant and sustained increase (P < 0.001) in PaO2/FIO2 ratio and a significant and sustained decrease (P < 0.001) in OI and P(A-a)O2 were demonstrated during the HFOV trial. These improvements were achieved 4 h after initiating HFOV (P < 0.05). Eight patients survived. There were no deaths from respiratory failure. CONCLUSION: In paediatric patients with acute respiratory distress syndrome and hypoxaemic respiratory failure on conventional ventilation, using a lung protective strategy, high-frequency oscillatory ventilation used as an "early rescue" therapy, improves gas exchange in a rapid and sustained fashion and provides a good outcome. Use of this therapy should probably be considered early in the course of the disease process.
