SECTION ON CRITICAL CARE

(1)

SECTION ON CRITICAL CARE

SATURDAY,OCTOBER 9,1999 Section onCriticalCare 2:00-4:15 pm

Room 30,Washington Convention Center Afternoon-Joint Sessionwith Cardiology

SUNDAY,OCTOBER10, 1999 Section onCriticalCare 8:30 am-5:00 pm

FarragutSquareRoom,TheGrandHyatt 8:30 am Continental Breakfast 8:45 am Introduction and Welcome:

Niranjan Kissoon, MBBS, FAAP, FCCM, FRCP(C)

Morning-AbstractSession I Moderators: TBA

1) 9:00 am Intraosseousis Fasterand Easier than Um-bilical Venous Catheterization in New-bornEmergencyVascularAccessModels K.K.Abe, MS; G.T.Blum, BS; L.G.Yamamoto, MD, MPH, FAAP. Departmentof Pediatrics, Universityof Hawaii, JohnA.BumsSchool of MedicineEmergency Services,Kapiolani Medical Center for Women and Children, Honolulu,HI.

2) 9:15 am Comparing a New Screw-Tipped In-traosseousNeedleVersus aStandardBone marrowAspirationNeedlefor Speed and Easeof EstablishingIntraosseousInfusion in TwoDifferentBoneModels

H.W. Jun; A.Z. Haruyama; K.Chang; L.G. Yamamoto, MD, MPH,FAAP.Departmentof Pediatrics, University of Hawaii, John A. Bums School ofMedicine Emergency Ser-vices,Kapiolani Medical Center forWomen andChildren, Honolulu,HI.

3) 9:30am lonised Magnesium inPatients Admitted to Pediatric Intensive Care Unit: Do We NeedIt?

P.S. Shah, MD, MRCP, MRCPCH, DCH; P. Baines,MRCP, FRCA. Department of Pedi-atric Intensive Care Unit, Royal Liverpool ChildrenHospital, Liverpool, United King-dom.

4) 9:45 am AreInfantTransport PatientsatIncreased Risk forlatrogenicRelated Complications WhileatReferralFacilities?

G.B. Zuckerman, MD; B.J. Grossman, MD; F.V. Castello, MD; P.M. Gregory, PhD. De-partment of Pediatrics and Family Medi-cine,RobertWoodJohnsonMedicalSchool, NewBrunswick, NJ

10:00 am Coffee Break andPosterReview Morning-AbstractSession II

Moderators:TBA

5) 11:00am Intravenous Nicardipine forTreatmentof Systemic HypertensioninChildren S.C.Sartori, MD;T.A.Nakagawa, MD, FAAP; M.J. Solhaug, MD; A.Morris, RN, BSN;R.D. Adelman, MD Children's Hospital of the

Kings'Daughters, DivisionofPediatric Crit-ical CareMedicine and Pediatric Nephrol-ogy,DepartmentofPediatrics,Eastem Vir-giniaMedicalSchool,Norfolk,VA. 6) 11:15 am ACostSavings Projection for Respiratory

Syncytial Virus Immunization of Older Children withaHistoryof Bronchopulmo-naryDysplasia

L.Passerotti,MS,ARNP; W.Walters, RN,MS II; V. Desai, MD; A. Otegbeye, MD Depart-ment of Pediatrics, Florida Hospital, Or-lando, FL; and MCP-Hahnemann Univer-sitySchool ofMedicine, Philadelphia, PA. 7) 11:30 am AutonomicManifestations of Spinal

Mus-cularAtrophy

S.Da-Silva, MD, FAAP; J. Weingarten-Arams, MD, FAAP. Division of Pediatric Critical Care,Departmentof Pediatrics, Montefiore MedicalCenter, AlbertEinstein College of Medicine,WestOrange,NJ.

8) 11:45am VariationinAsthmaCare in TenU.S. Chil-dren'sHospitals

A. Torres, MD,FAAP;S. Horn,PhD; J. Gas-saway; R. Smout. DepartmentofPediatrics, Universityof Illinois College of Medicineat Peoria, IL;andISIS,Inc.,Salt Lake City,UT. 12:00pm Lunch andSection BusinessMeeting 1:30pm Presentation of Distinguished Career

Award

Recipient: George Lister,MD 2:00pm Coffee Break

AfternoonAbstract Session-BestAbstract/Physicianin Training

Moderator: NiranjanKissoon,MD 9) 2:30pm

10) 2:45pm

11) 3:00pm

12) 3:15pm

EnergyMetabolism, Nitrogen Balance and Substrate UtilizationinCriticallyIll Chil-dren

J.A. Coss-Bu, MD;W.J. Klish, MD, FAAP;F. Stein, MD, FAAP;D. Walding, BSBE;R. Sa-chdeva,MD,FAAP; L.S.Jefferson, MD,FAAP. Departmentof Pediatrics,BaylorCollege of Medicine, Houston,TX.

Safe Restraint of PediatricPatientsfor Am-bulance Transport: Interdisciplinary Col-laboration in Pediatric Ambulance Trans-port Safety

N.R. Levick, MD, FACEM.Divisionof Pedi-atric Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Epidural Analgesia in Newboms After Congenital Diaphragmatic Hernia Repair Facilitates Pulmonary Preservation Strat-egy.

S.M. Goobie, MD; C.S. Houck, MD, FAAP; C. Seefelder, MD. Department of Anesthesia andCriticalCare, Children'sHospital, Bos-ton,MA

Contribution of Intraosseous Infusion RatetoFatEmbolism

(2)

Murphy, PhD. University of Florida Health ScienceCenter/Jacksonville; Nemours Chil-dren's Clinic; and Wolfson ChilChil-dren's Hos-pital, Jacksonville,FL.

13) 3:30pm Comparison of Plasma Levels and Pharma-codynamics After Intraosseous and Intra-venous Administration of Fosphenytoin andPhenytoin inPiglets

T.M.Khan, MD; N. Kissoon, MBBS; M.Y. Hasan, MD; V.Saldajeno,MD;S.P.Murphy, PhD; J. Lima, PharmD. University of Flor-idaHSC; NemoursChildren's Clinic; and Wolfson Children's Hospital,Jacksonville, FL.

3:30 pm Best Abstract & Physician In Training AwardsPresentation

5:00 pm Adjourn

AbstractsAccepted P1)

P2)

P3)

P4)

P5)

P6)

ForPoster Presentations

Association of Mycoplasma Pneumonia Infections with Status Asthmaticus U. Hanhan, MD, FAAP; J. Orlowski, MD, FAAP; M. Fiallos, MD. University Commu-nityHospital, Tampa, FL.

UseofAminophylline in the Pediatric Pa-tient with Moderate and Severe Status Asthmaticus

L. Torero, MD, FAAP;

J.Carlos-Maggi,

MD, FAAP.Departmentof Pediatric Critical Care andPulmonary Medicine, Miller Children's at Long Beach Memorial Medical Center, Long Beach,CA.

Complications of NifedipineUse in Chil-dren

D.W. Egger, MD; R.M. Perkin, MD, MA, FAAP, FCCM; S.Sahney, MBBS, FAAP; N.Hamada, PharmD. Department of Pediat-rics,LomaLinda UniversityMedical Center, LomaLinda, CA.

Use of Milrinone inthe Pediatric Critical CareUnit(PCCU)

S. Watson, MD; K. Christian, MD; K.B. Churchwell, MD, FAAP. Department of Pe-diatrics, Vanderbilt University School of Medicine,Nashville,TN.

Methemoglobinemia: Toxicity of Inhaled Nitric Oxide(NO) Therapy

M.B. Taylor, MD; K. Christian, MD; K.B. Churchwell, MD, FAAP. Department of Pe-diatrics, Vanderbilt University School of Medicine,Nashville,TN.

International SurveyontheUseof Cuffed vs. Uncuffed Endotracheal Tubes G.Reyes, MD,

FAAP';

M.J.

Lorente,MD2;I.N. Horowitz, MD,FAAPI;T.S.Huseyni,MD';R. Sulayman,

MD';

D.G.Jaimovich,MD,

FAAP'.

'Division

of Critical Care, Hope Children's Hospital, Oak Lawn, IL; and 2hospital Tor-recardenas,Almeria,Spain.

MONDAY,OCTOBER11,1999 SectiononCritical Care 9:00 am-12:00pm

Room37,Washington Convention Center JointSessionwithHomeHealth

1

INTRAOSSEOUS IS FASTER AND EASIERTHAN

UMBILICAL VENOUS CATHETERIZATIONINNEWBORN EMERGENCY VASCULARACCESS MODELS.

Keith K. Abe,MS,Gary T. Blum, BS, Loren G. Yamamoto, MD, MPH,FAAPDepartmentof Pediatrics, University of Hawaii John A.BurnsSchool of Medicine Emergency Services, Kapiolani Med-ical Center for Women and ChildrenHonolulu,HI

Background: Intraosseous(10) infusion and umbilical vein cath-eterization (UVC) aretwomethods ofobtaining emergency vas-cular accessinnewboms. Both aretaughtinpediatric resuscitation courses butUVCisdonelessfrequently by pre-hospital providers andemergencyphysicians. The purposeof this studyis to com-pare thespeed and ease of establishing newborn emergency vas-cularaccessusing10versusUVC.

Methods: Thestudy is anexperimental design.Atotalof42 medical students, without prior 10 andUVC experience, were recruited as study subjects. All subjects performed the UVC procedure and wererandomized (by a coin flip)toperform the IOprocedure in oneof twomodels: 1) turkey bone or 2) plastic infant leg. Each subjectperformedaninitial trial for both the 10 and UVC procedures without practice ("Inexperienced at-tempt") and a second trial in both procedures after practice ("Experienced attempt"), such thatin total, eachsubject com-pleted 4 attempts (2 IO and 2UVC). 10 and UVC placement times were measured, and placement difficulty scores for 10 and UVC were measured using a 10 cm visual analog scale (VAS).

Results: Theaveraged elapsedtime to successful accesswas significantly shorter for the IO procedure onboth the initial "inexperienced" attempt (52 vs. 134 seconds, p<0.001)aswell as the "experienced" attempt (45 vs. 95 seconds, p =0.011). Proceduredifficulty scoreswerelowerinthe IOprocedure for both"inexperienced" and "experienced" attempts (3.5 vs. 5.5, p=0.001 and2.6 vs.4.7,p<0.001)asmeasuredon a 10 cm VAS. Resultsin theturkey bone and plastic infantleg models were similar.

Conclusion: WhileUVCmaybepreferred by neonatologists, this model suggests thatIOresultsineasierand morerapid vascular accessachieved by those who donotfrequentlyperformnewborn resuscitation. As such, the benefit ofteaching UVC inpediatric resuscitation coursesshould be reconsidered. The recommended methodof emergency newbom vascularaccess should be recon-sideredpendingfurther studiesonthissubject.

The authors wish to thank the Chun Foundation for their financial support of thisstudy.

2

COMPARINGA NEWSCREW-TIPPED INTRAOSSEOUS NEEDLEVERSUS ASTANDARDBONE MARROW ASPIRATIONNEEDLE FOR SPEED AND EASE OF ESTABLISHING INTRAOSSEOUS INFUSION IN TWO DIFFERENT BONEMODELS.

HyeWonJun, AtsukoZ.Haruyama,KimberlyChang,LorenG. Yamamoto, MD, MPH, MBA, FAAPDepartment of Pediatrics, University of HawaiiJohnA. Burns School of Medicine Emer-gencyServices,Kapiolani Medical CenterFor Women And Chil-drenHonolulu,HI

(3)

needle (Sur-Fast, $42). Methods: The study is an experimental design. Atotal of42medicalstudents, without prior 10 experi-ence,wererecruitedasstudy subjects. Subjectswererandomized toperform the IO procedures in one oftwo models: 1) turkey femuror2)porkribs. Eachsubject performedaninitial trialusing both10 needles without practice (inexperienced attempt) and a second trial using both IO needles after practice (experienced attempt),such thatintotal,eachsubject completed 4attempts(2 witheach needletype). 10placementtimes weremeasured, and placement difficultyscores weremeasured using a 10 cmvisual analog scale (VAS). Results: The averaged elapsedtime to success-ful IOcompletionwassignificantly shorter for the SBMNinthe initial"inexperienced" attempt (33vs.54seconds, p=0.019), but therewas nosignificant difference in the post-practice "experi-enced" attempt. VASdifficultyscores werelower(easier) for the SBMNfor bothinexperiencedandexperiencedtrials.Successrates weresignificantly higherfor the Sur-Fast needleduring the expe-rienced attempt(95%vs. 79%, p<0.05), but therewas no signifi-cantdifferencein success ratesduringtheinexperienced attempt. Foreach needle type, theplacementtimes, VASscoresandsuccess ratesdid not differ significantly between the twobone models whichwereused suggesting that thetwobone modelsaresimilar, thoughthisisinconclusivesincethesamplesize issmall. Conclu-sion:The Sur-Fastscrew-tippedintraosseousneedle doesnot dem-onstratesuperiorityoverthe standard bonemarrowneedleinthis intraosseousmodel,thereforeitshighercostisdifficulttojustify based onthisstudy.The authors wish tothankthe Chun Foun-dation for theirfinancial support of thisstudyand Cook Critical Careforsupplyingmaterials for thisstudy.

3

IONISEDMAGNESIUMIN PATIENTS ADMITTED TO PEDIATRICINTENSIVE CARE UNIT:DOWENEED IT? PrakeshSShah, MD, MRCP, MRCPCH,DCHand Paul Baines, MRCP,FRCA.DepartmentofPediatric Intensive CareUnit,Royal LiverpoolChildrenHospital, Liverpool,UnitedKingdom.

Background:Toevaluate the incidence and biochemical correlate of ionizedhypomagnesemiaincriticallyill childrenweundertook aprospective, observationalstudy.Westudiedatotal of82 spec-imen collected from 82 patients admittedto Pediatric Intensive CareUnit(PICU).Methods:Concentrations of ionizedmagnesium, ionized calcium andpHwasmeasuredintheintensive care unit byion sensitiveelectrodeanalyzer.Concentrationsof total mag-nesiumwasmeasuredinthelaboratoryusingspectrophotometric analysisand correctedcalcium,creatinine, urea, albumin and total proteinweremeasuredinthebiochemistry laboratoryusing con-ventional methods. Results: Ionized Magnesiumwasdetermined inallsamples. Eight (9.75%)patients demonstratedserumionized hypomagnesemiaof whichonedemonstratedabnormalityof car-diac rhythm. 33 (40.25%) demonstrated total serum hypomag-nesemia.Allthepatients who had ionized hypomagnesemiahad totalhypomagnesemia.Therewasgoodcorrelation(r2=0.66) be-tweenionized and total magnesium.There was no relationship betweenionized calcium and ionizedmagnesiuminour observa-tions. Patient's cardiopulmonary bypass status, albumin status, pH orcreatinine level of thepatients did notaffect ionized and totalmagnesium.Conclusions: Ionizedhypomagnesemiaisan im-portant

finding

in patients admittedto Pediatric IntensiveCare Unit(PICU). Higherincidence of totalhypomagnesemiashould be confirmed

by

ionized

hypomagnesemia

to avoid unnecessary treatment.Wedidnotobserve theimpactof other factorsplaying roleintheseriouslyillchildrenasfarasmagnesiumconcentration isconcerned. Immediate andearlyevaluationof magnesium

sta-tusisextremely helpful inPICUpatients. Acknowledgement: Au-thorsacknowledgeAVL MedicalInstruments LTDforinstalling andrunning theanalyzerformeasuring ionized magnesium.

4

AREINFANT TRANSPORT PATIENTS AT INCREASED RISKFOR IATROGENIC RELATED COMPLICATIONS WHILE AT REFERRALFACILITIES?

Gary B. Zuckennan MD*, Bruce J. Grossman MD*, Frank V. Castello MD*,Patrice M.GregoryPhDt Depts of Pediatrics* and Family Medicinet, Robert Wood Johnson Medical School, New Brunswick, NJ

Background: Pediatric patients often arrive at non-tertiary care facilities requiring transportto a Pediatric Intensive Care Unit. While at the referral facilities, iatrogenic related complications (RF-IRC) mayarise.Suchcomplications may impactonmorbidity andmortality. Norecentlypublished studies have soughtto de-termine whether infant transport patients are athigher risk for RF-IRCs thanaretheir older pediatric counterparts. The objective of thisstudyis todetermine whether theincidenceof RF-IRCsis greater in infants less than 6 months than in the rest of the pediatric transport patientpopulation. Methods: The chartsof all patients,less than18yearsof age,transported to the Robert Wood Johnson University Hospital Pediatric Intensive Care Unit from 7-1-95 through 6-30-98, were retrospectively analyzed. Demo-graphic datawasabstracted and theoccurrenceof RF-IRCs noted. RF-IRCs were definedas referralfacility patient assessments or managementdecisions whichwerenotinaccordance with Pedi-atricAdvancedLife Support Guidelines. RF-IRCsweregroupedas follows: Triage Errors; Airway, Breathing, Circulation, Neuro-logic, and Metabolic management errors. Patients were divided into 2 groups: < 6 months and 6 months to < 18 years. The average Pediatric Risk of Mortality (PRISM) scores for the 2 groupswerecalculated andcompared using thetTest. The inci-denceof each IRC categorywascalculated andcompared between the2groups using thechi-squaretest. Pvaluesof less than0.05 wereconsideredtobestatisticallysignificant.Results:Duringthe studyperiod,564patientsweretransportedto ourfacility.

<6 mos. 6 mos to <18 yrs (n = 116) (n = 448)

PRISM Score 5.9 4.0

TriageErrors(%) 13.8* 7.1*

Airway (%) 12.9 7.6

Breathing (%) 23.3* 12.3*

Circulation (%) 7.8 4.5

Neurologic (%) 1.7 1.1

Metabolic (%) 13.8 8.7

Total(%) 66.4* 38.6*

*P

< 0.05.

Conclusions: The total incidence of RF-IRCs was significantly higherfor infants than for olderpediatrictransportpatients. RF-IRCs related to TriageErrors and Breathing management were significantly higherinthe infantgroup.Infants hadhigher inci-dencesof all otherRF-IRCs, however, statisticalsignificancewas

notachieved. Thisstudysuggeststhatinfants requiring interhos-pitaltransport maybeathigher riskfor RF-IRCs than their older pediatriccounterparts.

5

INTRAVENOUS NICARDIPINE FOR TREATMENTOF SYSTEMIC HYPERTENSION IN CHILDREN.

(4)

Background: To determine the efficacy and safety of intravenous (IV)nicardipinefor the treatment of acute systemic hypertension in children. Setting: 13 bed PediatricIntensiveCareUnit(PICU)at a 152 bed tertiary care children's hospital. Methods:Aretrospective review wasconductedof children admitted to the PICU who developed systemichypertension and were treated withIVnicardipine. Inclu-sion criteriawere:systolic blood pressure>95th percentilefor age, and documentation of arterial blood pressures by an indwelling arterial catheter. Data collection included: patient age, diagnosis, dose and response to nicardipine, duration of therapy, and any adverseeffects such as hypotension. Results: Overafour year period, 15children met study criteria. The median agewas9 years (range 19 days to17years). Ninechildren were treated post-operatively for hypertension: 4had coarctationof the aorta,2hadintracranial tu-mors,2had cerebral arteriovenousmalformations, and1had spinal surgery.The remaining6children had: renalinsufficiency/failure with encephalopathy (2), leukemia, intra-abdominal tumor, GI bleed-ing,and cardiac transplant. Followingan initial median dose of1

/Lg/kg/min

(range0.5to4,ug/kg/min)ofIVnicardipine, median treatmentdosewas1.5 ,g/kg/min (range 0.15to 6,ug/kg/min). Median duration oftherapywas41hours, (range3.75 to 187hours). Mean arterial pressure (MAP)over time isshown inGraph1. No significantchangeinmeanheartrate(HR)wasnoted. Tenchildren were receivingadditional anti-hypertensive therapy when IV nicar-dipinewasinitiated. One child with leukemia and centralnervous systemdisease becamehypotensive4hours after initiation of therapy while receiving1 ,ug/kg/min of nicardipine. Noother adverse ef-fectswerenoted.

70.2

I

1br 2hr 3h, 4i. 5~i. 6 7i. *'h

Conclusion:IVnicardipine reducedMAPwith minimalchange in mean HRandnoadverseeffectsin adiverse patientpopulation. Additionally, children receiving prior anti-hypertensive therapy exhibitedareductioninMAPwithIVnicardipineIVnicardipine isasafe and effective agent fortreatment ofacutesystemic hy-pertensioninchildren.

6

ACOST SAVINGSPROJECTION FOR RESPIRATORY SYNCYTIALVIRUS IMMUNIZATION OFOLDER CHILDRENWITH AHISTORY OF

BRONCHOPULMONARY DYSPLASIA.

LeeAnn Passerotti MS, ARNP, William Walters RN, MS II*, Vivek Desai MD,Ayodegi OtegbeyeMDDepartmentof Pediat-rics,Florida Hospital, Orlando, FL, and MCP-Hahnemann Uni-versitySchool ofMedicine, Philadelphia, PA*.

Background: Currentrecommendations for Respiratory Syncy-tial Virus (RSV)immunizationinclude children withahistoryof Bronchopulmonary Dysplasia (BPD) duringtheir first24months of life. This retrospectivestudyseekstoprojectacostcomparison between thehospitalizationofchildren, age2-5years, withBPD complicated by RSV and the immunization of these children. Methods: Allchildren, age2-5 years, withhistory ofBPD or ad-missionfor RSV relateddisease, admitted to apediatric referral centerbetween 1/96 and 12/98were identified. A chartreview wasconducted toidentify those patients withBPDadmitted for

RSVbronchiolitis or pneumonia. Patient weight (kg), age (yrs), admission date, hospital length of stay (LOS), intensive care length of stay (ILOS), and total hospital charges (HC$) were collected. HC$ did not include physician fees. Cost of immunization was calculated using a 15 mg/kg monthly dose (Palivizumab, Ross Pharmaceuticals), a 6 month (Oct.-Mar.) RSV season,and an ac-quisition cost of $901.17 per vial (100 mg/vial). Results are re-ported as mean± SD, with rangeasappropriate.Results: 8 chil-dren, ages 2-4 years, with ahistory of BPD, were admitted to our facility for treatment of RSV bronchiolitis or pneumonitis during the 36 month period,for a total of 73 hospital days. Average LOS was 9.13 ± 8.29 days (range3-26 days). 5 of these children re-quired intensive care treatmentwith anaverageILOSof10.4±7.4 days. Total HC$ were $270,012.86, with an average HC$ of $33,751.61 ± $40,046.18 (range $6500.24-$120,629.71). BPD/RSV admissions wereresponsiblefor 34.8% ofBPDadmissions, 34.9% ofBPDLOS days, 21.6%of RSV admissions and 39.2% of RSV LOS days. AverageBPD/RSV HC$ were 103.8% and 324.5% of average BPD and RSV HC$,respectively. Cost for RSV vaccination of the BPD/RSV patientswasprojected at $91,919.34. Assuminga20% failure rate in immunoprophylaxis, HC$ would be reduced to $54,002.57, yieldinga total projected cost of $145,921.91, and a savingsof$124,090.45 (46%). Conclusions:Aconsiderable savings maybe realizedthrough continued vaccinationof these children beyond the current recommendations of 24 months of age. A prospectivestudy may be warranted to evaluate these projections.

7

AUTONOMIC MANIFESTATIONS OF SPINALMUSCULAR ATROPHY.

Da-Silva S,MD FAAP,Weingarten-Arams J,MDFAAP. Divi-sionof Pediatric Critical Care, Department ofPediatrics, Monte-fiore Medical Center, AlbertEinsteinCollege of Medicine.

Objectives: To confirmanobservationof persistent tachycardia in patients with Spinal Muscular Atrophy (SMA) type I. The tachycardia was unresponsivetoadequate pain control, manage-mentof fever andcorrectionofanemia.Methods:Aretrospective reviewof the medical records of patients admittedtothepediatric intensive care unitbetween January1994and December1998with the diagnosis of SMA. Data collected included ageatdiagnosis, method of diagnosis, ageatadmission andchest x-rayfindings. Age matched patients that were intubated and ventilated for between1-5dayswereusedascontrols. Patients whowere post-operative,onbeta agonistsor oninotropic supportwereexcluded. Othervariables that affect heart ratesuch asanemia andfever werenotdifferent between the two groups. Vital sign recordsfor the thirdday of admissionwereused for comparison. The vital signs chosenwere heart rate, respiratoryrateandmeanarterial blood pressure. Patientswho died during thehospitalization or hada DNRorderwereexcluded from the analysis. Results:Data fromsevenpatientswereanalyzed. All the patients had manifes-tationsof SMAbeforesixmonthsand werecategorizedastypeI. DiagnosiswasbyDNA(5),electromyography (3), muscle biopsy (2) and CTscan(1).Meanageatadmissionwas24.6months. Six patients hadapositivechest x-rayfindingandonepatient hada positiveblood culture. Six age-matched controlswere analyzed. Meanageatadmissionwas27.8months. Five had airway obstruc-tionandonehad abraintumor. All patients hada hemoglobin level that was normal for age and had not required a blood transfusion withintwodays of data collection. Graphic compari-sondemonstratesadifferenceinthe heartratebetween thestudy andthe control patients. Thisdifferencewas morepronouncedin the younger patients. There was also a statistically significant difference inthe heart rate inthe SMA group compared to the control group (table) withap= < 0.01.Therewas astatistically significance difference in the respiratory rate between the two groups.Thiswas notof clinicalsignificanceintherawdata.

(5)

HEART RESPIRATORY MEAN

RATE RATE ARTERIAL

PRESSURE

SMA 142±20 28±9 74±9

CONTROL 100±20 21±5 72±8

p-VALUE <0.01 <0.01 NOT SIGNIFICANT Average values (± standard deviation) of heart rate, respiratory rate and mean arterial pressureofSMA and control groups.

Conclusion: The data from this study is consistent with the observation of tachycardia seenin our experience with patients with SMA. This tachycardia is only transiently responsive to se-dation and analgesia and unresponsive to blood transfusion. Our theory isthat continuing apoptosis of themotorneurons of the anterior horn cellsin the spinal cord results in anelevationof circulation catecholamines causing the tachycardia in these pa-tients.Theobservation of greatertachycardiainthe younger pa-tients is consistent with the pathologyof SMA, with the progres-siveloss of neuronal cells resultingindepletion of anterior horn cellsasthe patients get older.Aprospectivestudy toassess serum catecholamine levels andtheir degradation products is warranted inthese patients.

8

VARIATIONINASTHMA CAREINTENU.S.CHILDREN'S HOSPITALS.

Adalberto Torres*, MD, FAAP, Susan Horn, PhD, Julie Gas-saway, Randall Smout. *DeptofPeds, Univ. ofIllinois

Coil.

of MedicineatPeoria,ILand ISIS, Inc. Salt Lake City, UT

Background: Guidelines from the National Heart, Lung, and Blood Institute (NHLBI) onthe managementof asthma arewell accepted and readily available. The purpose of this studywas to examinethe practiceof asthmacare at10 U.S.children'shospitals forvariationand fordifferences from theNHLBIguidelines. Meth-ods:Datawerecollected retrospectivelyon762 children with the principal diagnosis of asthma admittedto 10USchildren's hospi-tals from April 1st, 1995 to September 30th, 1996. These data documented patient variables(demographics, severity of illness), process variables(therapeutic interventions includingPICUuse), andoutcomevariables(morbidity,mortality,length of stay [LOS], cost). Severity of illnesswasmeasured using theComprehensive Severity Index (CSI), anage-specific severitymodel designedto assess thephysiologic derangements ofa patient's diseases and theirinteractions.Multiple logistic regressionmodelingwasused todetectsignificant (p<0.05)variation inasthma practiceswhile controllingfor severity of illness. Results: The median(range) age of the 762 asthmatic children was 5.3 yr (0.33-28.3). One-third (251/762) of these childrenwereadmittedtothe PICU. The me-dian LOS in PICU was 1.8 d (0.12-10.6). PICU LOS did not correlate with mean CSI for a site. The majority of asthmatic children admitted to the PICU,95.2%, had a severity of illness ranging from normal/mild (CSI I) tomoderate disease (CSI II). Twopatientsdied.Only 4%(32/762)hadin anincrease inseverity during their hospital stay. Continuous nebulized delivery of albu-terolwasperformedin9/10PICUsdespite the low overall sever-ity. Continuous sedation, aminophylline, chest physiotherapy, beta agonistfrequency 2 5 h, ipratropium bromide, and anti-bioticusehad significant institutional variability,were associ-atedwithincreased LOS and cost,andarenotrecommendedby theNHLBIguidelines. Metered dose inhaler form of albuterol andpeak expiratory flowmeasurements inchildren>5yrold wereonly usedin 1/3 of asthmatic children. Conclusion: Med-icaloutcomeof inpatient asthmaisgood. Significantvariation in asthma careexists despite the availabilityof sound clinical practice guidelines. Implementing clinicalprotocols, based on these data, supported by the medical literature, and recom-mended by the NHLBI guidelines, will likely improve

out-comesinhospitalized children with asthma. Fundedinpartby anAHCPRSmallBusinessContract.

9

ENERGYMETABOLISM,NITROGENBALANCEAND SUBSTRATE UTILIZATIONINCRITICALLYILL CHILDREN

JorgeA.Coss-Bu, MD; William J.Klish, MD, FAAP; Femando Stein, MD, FAAP; DavidWalding, B.S.B.E.; RameshSachdeva, MD,FAAP; LarryS.Jefferson, MD,FAAP.Department of Pedi-atrics,Baylor College of Medicine,Houston TX.

Background: Criticallyillpatientsarecharacterizedbya hyper-metabolic state, an increased catabolic response asassessed by nitrogen balance (NB) studies, higher nutritional needs, and a decreased capacityfor utilization ofparenteral substrate. Theaim of thisstudywastoevaluate the effect of energyexpenditureand substrate intakeonNBandsubstrate utilization(SU)inthis pop-ulation.Methods: This cross-sectionalstudymeasuredNBand SU in 33critically ill children onmechanical ventilation (MV) and receivingtotalparenteralnutrition(TPN). Resting energy expen-diture (REE) was measured by indirectcalorimetry (IC) with a metabolic cart. Expected energy requirements (EER) were ob-tainedfrom Talbot's tables.REE/EERindex> 1.1 defined a hy-permetabolic state. Caloric intake (Tcal/kg) wascalculated and NB wascalculated basedonnitrogen intake(NI)and totalurinary nitrogen(TUN) measuredby theKjeldahlmethod. Tcal/NIand non-protein calories to NI (npTcal/NI) ratios were calculated. Adjusted REE, non-proteinRQ (npRQ),carbohydrate(CHO), pro-tein(PROT), and (FAT) utilizationrates were calculatedbythe Consolazio formulas. The percentageof relativeusefor each sub-strate was calculated as (Amount oxidized-amount ingested/ amountoxidized). Lipogenesiswasdefined:npRQ>1.00. Ahigh CHO intakewasdefinedas> 8mg/kg/min.Statistical analysis wasdone by unpairedt-testandsimple regressionanalysis. Re-sults: Valuesare mean+ SD.N= 33

Age(yr.) Weight (kg.) PRISM

5±5 21±17 10±7

Tcal/kg NImg/kg TUNmg/kg

60±33 334± 153 347± 142

AREEcal/kg TUNmg/min NpRQ

53±24 5±5 1.01±0.31

TISS REEcal/kg REE/EER

31±6 54±24 1.20±0.5

NBmg/kg Tcal/NI npTcal/NI

-89±166 190±84 165±84

CHOmg/min PROmg/min FATmg/min

119±115 32±31 6±61

(6)

correlate with rate of oxidation (r= 0.29, p=0.09). Conclusions: Critically ill children on mechanical ventilation are hypermeta-bolic, andinnegative nitrogenbalance. Thispopulation preferen-tiallyusesfatforoxidation,carbohydrateispoorly utilized, with higher intake associated with lipogenesis and less oxidation of FAT.Ahigher PRO intakewasassociated withapositive NB and effective oxidationrates. Anegative NBinduceshigher levels of PROoxidation.

Grant support: GenevieveR.McClellandFundfor PediatricIntensive CareResearch

10

SAFERESTRAINTOF PEDIATRICPATIENTS FOR AMBULANCE TRANSPORT: INTERDISCIPLINARY COLLABORATIONIN PEDIATRICAMBULANCE TRANSPORT SAFETY.

Levick, Nadine R., MD, FACEM, Division of Pediatric Emergency Medicine Johns Hopkins University School of Medicine, Balti-more,Maryland, USA

Background: Ambulance crash fatalities have been reported in-temationally,someinvolving children.Approximately oneinten patient transports involves a child. The special needs of trans-ported pediatricpatientsraiseuniquesafetyissuesbeyond those of domesticpediatrictransport. Testing standards anddesign of child restraints for domestic vehiclesarewelldeveloped,however thereis nofederal standardortesting requirementfor ambulance pediatricrestraintdevicesorpractices. Commonly usedrestraint practicesfor children inambulanceshave not been subjected to comprehensive dynamic safetytestingtovalidate occupantsafety. Thisstudy describesin aninterdisciplinary framework, the safety testingofcurrently available devices and practicesinaddition to prototypedevicescurrently beingdevelopedtoaddress this prob-lem.Aims: Topilot dynamic safety testsof devices for pediatric patient transport. Methods:Arangeofcurrently usedoravailable restraintdevices for the transportofpediatric patients were as-sembled, as well as prototype devices. A standard ambulance gurneywas secured to an approved sled test rig. Allrestraint devicesweretested securedtothe gumeyas in currentambulance practice. These devicesweretestedinasimulated30mph frontal impact, equivalent to a deceleration force of 24 G. Crash test dummies of 3, 9 and 15 kilograms, were used in the testing. Endpointswere

ejection

of thedummy ordisruption of the re-straintdevice.High speedvideo anddigitalimaging and comput-erizedanalysisof the crashimpact datawereperformed.Results: Therestraintsystemstestedwhichwereavailablefor transportor in current use, failed preliminary dynamic testing, some cata-strophically. Outcomes included either ejection of the occupant, disruption of the device or both. Incontrast, newly developed prototype restraint systems adequately restrained the occupant and maintained structural integrity during testing. Conclusions: This preliminary study suggests that some currently available ambulancepediatricrestraint devices may beineffective.A mul-tidisciplinary approach to the development of such devices is needed, with a focus on clinical needs and safety engineering expertise. Thedirection of future research anddevelopmentinthe safetyof all ambulance patients, occupants and equipment should be reviewed. Videofootagewilldemonstrate testing.

11

EPIDURALANALGESIAINNEWBORNSAFTER CONGENITALDIAPHRAGMATIC HERNIA REPAIR FACILITATES PULMONARYPRESERVATIONSTRATEGY. S.M.Goobie, M.D.,C.S.Houck, M.D., FAAP,C.Seefelder,M.D Department of Anesthesia and Critical Care, Children's Hospital, Boston,MA.

Background: Although the early perioperative survival after congenital diaphragmatic hemia (CDH) repair improved mark-edly with the availability of extracorporeal membrane oxygen-ation (ECMO) in the 1980's, long term survival remained un-changedatapproximately 50%. (1) Autopsy studies showed that inthe absence of othercongenital anomalies, the leading causes of death were pulmonary hypoplasia and iatrogenic barotrauma. A strategy aimed atpulmonary preservation was instituted atthis hospitalinthe early 1990's,which allowed permissive hypercap-niaandpromoted spontaneous ventilation with neonatal pressure supportventilation. (2) As apartof this, perioperative analgesia wasprovided with thoracicepidural analgesia in an effort to avoid the respiratorydepressionassociated with opioid analgesics and theineffective ventilation noted with inadequate pain relief. Meth-ods:After approval from the Committee on Clinical Investigation, we retrospectively reviewed the hospital records of all infants undergoing CDH repair between August 1995 and January 1998. Demographic data such as age, weight, estimated gestational age, associateddiagnoses, and need for preoperative ECMO were re-corded. Theepidural insertionsite, tip locationby radiographic study, type and infusionratesof local anestheticsadministered, duration of epidural infusion and need for additional analgesicsor anxiolyticswererecorded.Time to returnof spontaneous ventila-tionand duration ofmechanical ventilationwerenoted. Results: During the study period a total of 38 infants with congenital diaphragmatic hemia wereidentified. Thirteeninfants (34%) re-quired ECMO preoperatively and were removed from further analysis. Of the remaining25infants,21 infants hadanepidural catheterplacedjust priortosurgical repair,2hadacatheterplaced atthe conclusion of surgery and2didnothaveacatheter placed due to technical difficulties with placement. Epidural infusions consisted of 0.05%bupivacaine with 1 mcg/cc fentanylatrates between0.1 and 0.3ml/kg/hour. With the exception ofoneinfant who developed profound hypoxia and shunting at the end of surgeryandrequiredemergent ECMO support, allinfants who receivedepidural analgesiawerebreathing spontaneouslyon neo-natal pressure support on the day of surgery. There were no episodesof apnea recordedduring epiduraluse.Fiveinfantswere given either fentanyl or midazolam while the catheter was in place; 3 infants were given single doses for procedures and 2 infants received midazolam for agitation. All of the infants sur-vived andwereextubatedsuccessfullyanaverageof12daysafter surgery.Median duration of mechanical ventilation after surgery was6days witharangeof1 to 55days. Conclusion: Continuous epidural analgesiawas aneffective method toprovide analgesia and promote spontaneous ventilation in neonates undergoing congenitaldiaphragmatic hernia repair. Further investigationsare neededto determine if this strategy of permissive hypercapnia and neonatal pressure support ventilation will leadtoimproved outcomesand lessmorbidityfrom iatrogenic barotrauma.(1) J Pe-diatrSurg 1997;32:401-405. (2)J PediatrSurg1995;30:406-409.

12

CONTRIBUTION OF INTRAOSSEOUSINFUSION RATETO FATEMBOLISM

M.Yousuf Hasan, MD,Niranjan Kissoon, MD, Virgilio Salda-jeno,MD, Taj Khan,MD, KevinSullivan,MD, Suzanne Mur-phy, PhD. University of Florida Health Science Center/ Jacksonville,NemoursChildren'sClinic,and Wolfson Children's Hospital, Jacksonville,Florida.

(7)

betweenthese two methods. Methods: Twelve mixed breed piglets (average weight 30.9 kg) weredivided into two groups. They were anesthetized, intubated, mechanically ventilated, and instru-mented. IO needles were placed in the tibial bone. Group 1 re-ceived fluid under 300mmHg pressure and Group 2 received infusion at free flow under gravity (infusion bags were suspended atone meterabove the animal for both groups). Buffy coat sam-ples were obtained frompulmonary arterial catheter at baseline, IO placement,and at the end of infusion. Following infusion, the animals were euthanized and both upper and lower lung sections were obtained from each lung. Buffy coats were kept uncoagu-lated and lungsections were snap frozen on dry ice for transport. Specimenswerestained with Oil red 0 stain and reviewed bya pathologist blinded to experimental conditions. Specimens were graded for the number of fatemboliseen perhigh powerfield. The groups werecompared using studentttestand analysisof vari-ance asappropriate.Results: Fatemboli were foundinabout 30% of the lung specimens, with the number ranging between1to3 emboli perhigh powerfield.Inboth groups receivingfluid, either under 300mm of Hg pressure or free flow under gravity, the difference innumber of fat emboli seen was notstatistically sig-nificant. Buffy coat stains yielded fat emboli in very small amounts, which were sporadically distributed in both groups. Conclusion: The risk for fat embolism is minimal and independent of whether IO fluidisadministered under gravityorpressure. Our study therefore implies that the intraosseousroute issafe and may be usedinchildren untilmorestable access is obtained. Funded by the Nemours Children'sClinicandGroh Foundation.

13

COMPARISONOF PLASMALEVELSAND

PHARMACODYNAMICSAFTERINTRAOSSEOUSAND INTRAVENOUSADMINISTRATION OF FOSPHENYTOIN ANDPHENYTOIN IN PIGLETS.

TajMKhan, MD, Niranjan Kissoon, MBBS, MYHasan, MD, Virgilio Saldajeno, MD, S P Murphy, PhD, J Lima, PharmD. Universityof Florida HSC, Nemours Children'sClinic, and Wolf-sonChildren'sHospital, Jacksonville, Florida.

Introduction:Difficultyinachievingtherapeutic drug levelsvia the IOroutemaybe duetofailuretostandardizedrugs and flush solutions. Wecompared druglevels andpharmacodynamics in standard doses offosphenytoin and phenytoin givenviathe in-traosseousand intravenous route.

Methods:Piglets(30-40kg)wereanesthetized, intubated, instru-mented and mechanically ventilated. A peripheral intravenous line and intraosseous needle (15 gauge SurFastrmCookInc.)was inserted for drug infusions. Forty animals (10 per group) were randomly assigned for intravenous and intraosseous phenytoin and fosphenytoin infusions. Phenytoin (20mg/kg) was infused over20minutesandfosphenytoin (20mg PE/kg)over7minutes. Allinfusionswerefollowedby 5ml normal saline flush (as done clinically).Bloodsamples(3mls)fordrug levelswerethen drawn before infusion (base line) andat0, 5, 10, 15, 20, 30, 40,50, 60 and 75 minutes following infusion. Repeated measures Analysis of variance (ANOVA) was used toevaluate statistical significance (p<.05). Results:Phenytoin levelswere undetected atbase line. Free(10-20mcg/ml)andtotal (80-110mcg/ml)werewell above therapeutic range (free 1-2mcg/mlandtotal 10-20mcg/ml)post infusioninfosphenytoin groupsascomparedtophenytoin. From 20-75minutes, all groups hadfree andtotal levels within thera-peutic range.Significant differencesinvalues were seenin free phenytoin at0-10minutes (p<0.05) and totalphenytoinat0-20 minutes(p<0.05) betweenintraosseousphenytoin and fospheny-toin.Similarly,differenceswerealsoseenwhenintravenous phe-nytoin andfosphenytoin groups werecompared. There wasno significant difference in heartrate andblood pressure between groups.Conclusion: Thereis noneedtoadjuststandarddrugdoses ofphenytoinwhen givenviatheintraosseous routeiffollowedby

adequate flush of 5ml. The initialhighlevelsofphenytoininthe fosphenytoingroupsareofconcemsinceneurologicaltoxiceffects mayoccur attheselevels. Slower infusionratesmaybeneeded for fosphenytointoavoidtoxiclevels. Fundedbythe Nemours Chil-dren'sClinic and Groh Foundation.

P1

ASSOCIATION OFMYCOPLASMA PNEUMONIA INFECTIONSWITH STATUS ASTHMATICUS.

UsamaHanhan, M.D., FAAP, JamesOriowski,M.D., FAAP, and Mariano Fiallos,M.D.,FAAP, UniversityCommunityHospital, Tampa,FL.

Background: Viral respiratoryinfections(VRI) have been com-monly associated with exacerbation of wheezing in asthmatic children. Mycoplasma pneumonia (MP) causes many respiratory syndromes that clinicallymimic VRI. Due to the nature of the organism, culturesareofnopracticalvalueand thediagnosisis usuallymadebyserology.Thisstudywasanattempttoassessthe incidence ofrecentmycoplasma infectionsinpatients withstatus asthmaticus andtoreviewtheirlaboratory,clinical and radiolog-icalfindings.Methods: Retrospectivereviewof all patients admit-tedtoPICUover12monthperiodwithstatusasthmaticus. Recent mycoplasma infectionwasdeterminedutilizingtheImmunocard mycoplasma EIA for detection of MP IgM antibodies (Meredian Diagnostics, Inc., Cincinnati,OH) Results: 44patients reviewed. 9 wereexcludedbecause MPtests were neverobtainedduring hospi-talization.15/35(42%)wereMPPositive.Therewere nostatistically significantdifferences(P>0.05) inlengthofhospitalization (LOH), ICUdays, duration ofcontinuousalbuterol hours(cont.Nebs), days on02 (02days) orWBC between the twogroups. Patients with evidenceofrecentMPinfectionweremorelikelytohaveoneor more infiltratesontheir CXR(13/15vs7/20)P=0.002.

Conclusion: Recent MP infections play a much greater role in exacerbationof asthma andoccurrenceofstatusasthmaticus. Pres-enceofinfiltratesonCXRinstatusasthmaticuswarrantstestsfor MP.

Pts Sex **Age LOH

(Yrs) (Days)

MP+ 15* 8M 9.4 5.2

MP - 20 14 7.5 4.65

P-value NS NS NS NS

ICU

02

Cont WBC ***CXR+

(Days) Days Nebs

(Hrs)

2.75 3.5 27.7 15.2 13

2.65 3.35 29 13.6 7

NS NS NS NS 0.002

*15/35 (42%).

**Age Range2-19 years.

***Presenceofone or moreinfiltrates.

P2

USE OFAMINOPHYLLINE IN THEPEDIATRICPATIENT WITHMODERATE ANDSEVERE STATUS ASTHMATICUS. Luis Torero, MD, FAAP AND J. Carlos Maggi, MD, FAAP, FCCP.Departmentof Pediatric Critical Care andPulmonary Med-icine, Miller Children'satLongBeachMemorial MedicalCenter, LongBeach,CA.

(8)

ago-nists, inhaled anticholinergics and intravenous steroids. When expected improvement doesnotoccur,aminophyllineis consid-eredas anadjunctive therapy, but thereis noscientificallyproven benefitinthis addition. Itishoped that this study will provide objective data to answer this question. Methods: A prospective, randomized,double blind, placebo controlled trialinpatients>30 days and up to 18 years of age, with status asthmaticus and admitted to the PICU. The clinical severity of the event was assessed before andduring therapeutic interventions by using the Woods-Downes-Lecks clinical asthma score. Patients were ran-domized to treatment and placebo groups. The patients in the treatment groupreceive aloading dose ofaminophyllinefollowed byacontinuousinfusionof this drug. Patientsinthe control group receive abolus of Normal Saline followed by a continuous infu-sionof this solution.Aclinicalpharmacist adjusted the infusion of aminophyllineinthetreatmentgroup patientstoachievealevel between 13-18 mcg/ml. Similar adjustments were made in the Normal Saline infusionsinthe control groupto ensurethe blind-ing.Results:Atotal of 21 patients have been includedinthe study. Elevenof the21patientsreceivedaminophylline and10received placebo. Variablesfrom both groups were statistically compared. 1.Therewas asignificant differenceinthe numberof PICU days, withthe aminophylline treated group requiring less days in the PICU(logrankand Wilcox test).

(P.0.04

.0.04).

2.Nosignificant differenceininitialasthmascoreandadverse effects during infu-sionofaminophylline orplacebo.

(P.0.28

and

.0.30).

3. There was nosignificant differenceinthe timeof continuous albuterol required to achievea clinical asthma scoreequal orless than 4 (significant clinical improvement), using log rank and Wilcox tests.(P.0.3220.22).4. Nodifferenceincomplications (respira-tory failure) or use of other medications such as intravenous Terbutaline or Magnesium Sulphate. Conclusions: Our study sug-geststhataminophylline use may shorten thelength of stayinthe PICU, maynotdecrease the interval between admission and sig-nificant clinical improvement, and maynotdecrease the incidence ofcomplications. Thecostof hospitalization may be decreasedby usingaminophyllineinthis patientpopulation. The final analysis will beperformed whenatotal of25patientsareincludedineach group.

P3

COMPLICATIONS OF NIFEDIPINEUSEINCHILDREN. David W. Egger, MD, Ronald M. Perkin, MD, MA, FAAP, FCCM, ShobhaSahney, MBBS, FAAP,NormanHamada,Pharmn D.Deptof Peds, LomaLindaUniversity MedicalCenter, Loma Linda, CA.

Background: Concerns regarding the safety of Nifedipine emergedin 1995, with the reportof increased risk ofmyocardial infarction associated with adult patients receiving short acting calcium channel blockers. Cerebrovascular ischemia, stroke, se-vere hypotension, and death, have also been reported adverse effects ofNifedipine. Given the seriousness ofreported adverse effects, avoiding the use ofNifedipine has been proposed. We soughttoinvestigatethe incidence ofcomplications of Nifedipine use inthepediatric population. Methods: We conducted a retro-spective chartreviewof patients who receivedNifedipine during theperiodof 1995-1998. For each patient anddoseadministered, all reported adverse outcomes, and allBPmeasurementsreported uptosixhours after the dosewereobtained. Results: 2,438 doses ofNifedipine in182pediatric patientswere reviewed.Effect on blood pressure: In10.4% of theadministered doses there was a decrease in systolic blood pressure (sbp) of 30% or more. The maximumfallinsbpwas66%(159to54).In36.1%of doses there was adecreaseindiastolic blood pressure(dbp) of 30%orgreater. Themaximumfallindbpwas89.2%(120to13). Adverse Effects noted:a)ChangeinCNSstatus,6 cases(stroke 1, altered level of consciousness 4;seizure 1);b) Hypotension requiringchange in therapy, 4 cases;c) Chestpain without evidence of myocardial

ischemia, 3 cases; d) Hypoxemia, 24 cases. Conclusion:Nifedipine is associated with unpredictable and sometimes, profound changesinbloodpressure. Although we did not find any patients who experienced myocardial ischemia associated withNifedipine, we did find that itis associated with significant adverse effectsin children, including severe hypotension and CNS events. Nifedi-pine mustalways be used with caution, especially in children with underlying CNS disease.

P4

USE OF MILRINONE IN THE PEDIATRICCRITICALCARE UNIT.

Sally Watson, MD, Karla Christian, MD, Kevin B. Churchwell, MD, FAAP. Dept,of Peds, Vanderbilt UniversitySchool of Med-icine,Nashville, TN.

(9)

represented 10%of children receiving milrinone. Conclusion: These preliminary data suggest that milrinone-related arrhythmias are less common in children than in adults (6.6% vs. 16.2%), whereas milrinone-related thrombocytopenia is more commoninchildren than in adults (10% vs. 0.4%). Larger patientnumbers are needed to moreclearly detect and define an accurate milrinone pediatric side effect profile.

P5

METHEMOGLOBINEMIA: TOXICITY OFINHALED NITRIC OXIDE (NO) THERAPY.

Mary B. Taylor, MD, Karla Christian, MD,Kevin B. Churchwell, MD,FAAP.Dept. of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN.

Background: Elevations in methemoglobin (METH) is a known toxicity of inhaled NO therapy, although in clinical practice the incidence is rare. Most studies of the use of NO have not shown significant METH inmoderate tolow concentrations. Wehave en-rolled over 100 pediatric patients with congenital heart disease (CHD) thathave identified or suspectedpulmonaryhypertensionin aNOdose response protocol. Doses of NO used range from80 to 5 ppm. Wemonitored NO andNO2 concentrations continuously (Pul-monox II system/Inovent system) and monitor METH levels on a daily basis. This abstract describes two significant episodes of Met-hemoglobinemia requiring treatment. Method:Patients were prospec-tively assigned to a dose response NO protocol who hadclinical and or hemodynamic evidence of pulmonary hypertension. Patient# 1:status post repair of total anomalouspulmonaryveins (TAPVR) developed profound cyanosis after completion of the protocol. 02 saturation was86%, pO2-185 with measured arterial saturationof 67%. Methemoglobin level was31.7%. Treatmentincluded discon-tinuationof NO, bloodtransfusion, methylene blue andVitamin C. Rapiddeclineinthe METH level occurred; 4.4% at 40minand 0.5% at 12 hours. Patient.#2: Presented after aFontan procedure with cyanosis after receiving NO at 60 ppm for over 40 minutes. 02 saturation was86%, pO2-78, measured arterial saturation not ob-tained.METHlevel was 14.3%. Treatment was as above with prompt reduction inMETH level; 7.6%in60 minutes, 4% in 120 minutes. There were no adverse sequelae from either event and both patients weredischarged homeingood condition. Both patients'measured methemoglobin reductase activity was withinnormallimits. Conclu-sion:All equipment usedinthedeliveryof NO wasexamined, dry lab tested and found to befunctioning properly. Although the etiol-ogyof theMETHemia observedremainsunclear,webelievedead spaceaccumulation of NO,intheventilatorcircuit notdetected by the analyzer contributed to the METHemia observed. With these observations,wehave changed the ventilatorcircuitsetupto mini-mizethis potential problem. Our experience demonstrates that the potential for inadvertent overdosing of NOresultingin methemo-globinemia existswithmoderate concentrationsof delivered NO.We have shown that despite high levels of METH,therapies aimedat reducingMETHarerapid and effective.

P6

INTERNATIONAL SURVEY ON THE USE OFCUFFEDVS UNCUFFED ENDOTRACHEAL TUBES.

Gerardo Reyes, MD, FAAP1, Manuel J. Lorente, MD2, Ira N. Horowitz, MD,FAAP1,TarekS.Huseyni,MD1,RabiSulayman, MD1,and DavidG.Jaimovich,MD,FAAP1. 'Division of Critical

Care, Hope Children's Hospital and the University of Illinois School of Medicine, Chicago, IL and 2Hospital Torrecardenas, Almeria, Spain.

Background: There has been much discussion among pediatric criticalcarephysiciansontheuseof cuffedvsuncuffed endotra-cheal tubes (ETT)inpediatric patients.Areviewof the literature found onlyonearticleinhumansbyDeakersetaladdressing this issue'. The article concluded that high-volume/low-pressure cuffedETTs are notassociated withsignificant shortorlongterm side-effects. However, the American Heart Association and the AmericanAcademyof Pediatricsintheir Pediatric AdvancedLife Support Textbook advocate the use of uncuffed ETTs in chil-dren s 8 years of ageeventhough thereis noliteraturetosupport this practice2. We decided to undertake anintemational survey through the Intemet on the use of cuffed vs uncuffed ETTs. Methods:Aquestionnairewaselectronically submittedtothe fol-lowing addresses:

[email protected]

anducip-net@listserv. rediris.es. These addresses were created to facilitate theexchange of information among healthcare personnel in pediatric critical careworldwide. Participantswereaskedto answerthefollowing questions:1)Doyouusecuffedoruncuffed tubes?2)Isthere any age group inwhich you donot usecuffed tubes, and why? 3) Have you experienced any complications directly related to the use of cuffed tubes? 4) Do you use high-volume/low-pressure cuffs? Results: Eighty intensivists (N=80) answered the survey with thefollowing geographical distribution: Argentina 6, Austra-lia 5,Belgium 1, Canada 2, Colombia 1, CostaRica1,GreatBritain 1, Israel 3,Italy 2, Netherlands 1, South Africa 1, Spain 10, and U.S.A. 46. The responseswere as follow: Question#1: Cuffed-5 (6.25%), uncuffed-7 (8.75%), both-68 (85%). Question #2: 71 (N=71) responded as follow: Patients c 6-8 years of age-1l (15.5%), c8years-23(33%), c5years-7(10%),'6years-7(10%), c1year-3(4%), c30kgs-1 (1.5%),ETTc-4.0-2(3%), andETTc 5.5-8 (12%). Most respondents (> 90%) said thatifthe patient developsan airleak(or thepotential for one),orifthe patientcan develop aspiration pneumonia, they would switch to a cuffed ETT. Reasons for using uncuffed ETTs were: a) Lack of cuffed tubes smaller than 5.5. b) Recommendation from P.A.L.S. c) Potential damage to the subglottic area. d) The anatomical narrowingatthe level of the cricoidcartilageinchildren func-tions as a "natural" cuff. Question#3: No complications with theuseof cuffed ETTs-69 (86%),complications-1l (14%) (stri-dor and/or subglottic/tracheal stenosis). Question #4: All re-spondents said they always use high-volume/low-pressure cuffs. Conclusions:1)Thereiswidediscrepancyamongpediatric intensivistsregardingtheuseof cuffedvsuncuffed ETTsinthe different age groups. 2) Despite the lack of evidence in the literature, many respondents feel cuffed tubescan causeairway damage. 3) With the advent of high-volume/low-pressure ETTs, P.A.L.S. recommendations on cuffed vs uncuffed ETTs may need to be reviewed. 4) The Internet can be a valuable medium for clinical research projects.

REFERENCES

1. DeakersTW,Reynolds G,StrettonM, NewthCJL.Cuffed endotracheal tubesinpediatricintensive care.JPeds1994;125:57-62

(10)

1999;104;674

Pediatrics

Niranjan Kissoon