Search

Advance in the science and technology of neonatal and pediatric critical care have resulted in improved outcome for high risk newborn and children. Effective interhospital transport programmes are necessary for the appropriate use of resources and has become an integral component of regionalized perinatal care. It is now well established that use of an organized neonatal and pediatric transport team results in a fall in mortality and morbidity of infant. The American College of Obstetrician and Gynecologist and, recently, American Academy of Pediatrics published guidelines and recommendations for safe interhospital transfer of neonates, infants and children. Training of personnel, selection of equipment, organization and communication between hospitals are critical elements of a successful transport system. We present an overview of the role, principles and operating procedures of such neonatal-pediatric transport team and the basis of clinical stabilization before and during transfer. We also discuss data of the first 17 month experience of the Neonatal-Pediatric Transport Service of the Department of Pediatrics, University of Padua.

Pediatric intensive care units (PICUs) have been developed to provide intensive care for children between post-neonatal age and adolescence. These units have largely been developed in North America, mainly in tertiary hospitals. In Italy, critically ill children are still often nursed on adult ICU's, where medical and nursing staff often lack pediatric training. Here we report the first 5-year experience of the multidisciplinary PICU developed at the Department of Pediatrics, University of Padua, focusing on PICU and patients characteristics, as well as on the evaluation of outcome by means of the Pediatric Risk of Mortality (PRISM) score.

Extracorporeal membrane oxygenation (ECMO) has become a nearly standard treatment for neonates with refractory hypoxemic respiratory failure due to various disease. Even though in the non-neonatal age the experience is less extensive, an increased widespread interest on the possible applications in children with severe life-threatening respiratory or cardiovascular insufficiency is well documented in the literature. General contraindications include presence of active bleeding, underlying lethal disease, congenital malformations, or severe brain damage. Whilst in the neonatal population common entry criteria have been widely accepted, the identification of precise parameters capable to predict mortality and thus indicating an ECMO support in older patients are still lacking. At present, nonetheless, more than 10.000 newborns and 1.000 children with severe respiratory insufficiency at high mortality risk have received an ECMO treatment, with a survival rate of more than 80% and 50%, respectively. The initial results of our ECMO program for both neonatal and pediatric patients with refractory respiratory failure are encouraging, both in terms of mortality and morbidity, and they will be briefly discussed.

Inhaled nitric oxide (NO) has been recently proposed as a new treatment in newborns and children with severe hypoxemic respiratory failure. Differently from other vasodilators, inhaled nitric oxide selectively lowers pulmonary vascular resistance and pulmonary arterial pressure, and improves the ventilation/perfusion matching by directing pulmonary blood flow toward better ventilated areas, ultimately improving systemic oxygenation. In our experience, we have observed that inhaled NO may acutely ameliorate gas exchange in patients with severe respiratory failure. This may allow a reduction of both ventilatory parameters and fraction of inspired oxygen, thus limiting further damage to the lungs. Nonetheless, the underlying disease and the clinical conditions before NO treatment seem to maintain a crucial role in the ultimate prognosis of these patients. Further studies are needed in order to better define indications, dosages, and safety of nitric oxide treatment, and to verify its authentic prognostic value in neonates and children with acute respiratory failure.

A computerized protocol, PADOVA-BPD, has been set-up to study prematures affected by RDS, PDA and/or BPD. This protocol consists of a Data Bank, BPDdata, where the information of traditional clinical chart has been stored and of the BPDPadova program, written for this purpose in FORTRAN 77, that allows a wide band of clinical and statistical analysis.

Eighty-seven pediatric patients with suspected acute appendicitis underwent high-resolution US with graded abdominal compression. The study was limited to the patients with a questionable clinical diagnosis, accounting for about 40% of the patients examined for acute appendicitis in our Institution. US had 87.3% accuracy, 81.5% sensitivity, and 90% specificity. The main US findings in the positive cases were: visualization of the appendix as a tubular non-compressible structure, with a diameter of 5 mm or more, symmetric/asymmetric wall thickening, possible presence of appendicoliths and variable appearance of the central echogenic layer (preserved, doubled for lumen dilatation, partially/totally lost). The above US findings were grouped in 3 basic patterns: type I (thickened appendix with no structural abnormalities) appeared to be related to non-suppurative and phlegmonous acute appendicitis; type II (detectable appendiceal abnormalities) was observed both in phlegmonous and in suppurative acute appendicitis; type III (pericecal complex mass, frequently with appendicoliths) was found in all cases of periappendiceal abscess. In our experience, the use of US in the diagnosis of acute appendicitis in children allowed a reduction by about 2/3 in the rate of unnecessary laparotomies. Such a finding emerges from the comparison with the results obtained in the 2 years prior to the use of US. The technique also allowed an unquestionable diagnosis of acute appendicitis or periappendiceal abscess to be made in a number of clinically equivocal cases, thus avoiding potentially harmful delays in diagnosis. On the other hand, the incidence of false-negatives on US is not negligible, which calls for a cautious clinical and US evaluation of all equivocal cases following no typical US pattern.

The van de Kamer titrimetric method for the determination of fecal fatty acids has been compared with the colorimetric technique described by TOMASZEWSKI. Reproducibility and accuracy as well as the applicability in a clinical laboratory service are discussed. The AA. point out that van de Kamer method still remains the method of choice for diagnostic purposes.

The concentration of free aminoacids in plasma and urine were estimated in 10 patients suffering from Werdnig-Hoffmann's disease of long duration. The age of the patients was between 5 and 14 years. Estimations were also made in 10 patients with Kugelberg-Welander's disease aged between 11 and 34 years. The aminoacid concentrations were estimated on samples of plasma and 24 hours samples of urine by means of chromatography on ion-exchange resins. The data obtained were compared respectively with groups of thirty and ten healthy subjects of the same age. In the group of patients with Werdnig-Hoffmann's disease a significant increase of taurine (p less than 0.001) and of glutamic acid (p less than 0.001) was found in the plasma. The urinary excretion of glutamine was increased in the same group of patients (p less than 0.001) and in the group with Kugelberg-Welander's disease (p less than 0.005). These aminoacid levels are interpreted as an expression of a reduced oxygen metabolism and increased proteolysis in the skeletal muscles in conditions of chronic denervation.

Automated analysis of aromatic and branched chain amino acids was performed in plasma and in four cerebral regions of rats submitted to chronic porto-caval shunt. Compared to controls, plasma of the operated animals exhibited a significant diminution of valine, leucine, isoleucine, a net increase of phenylalanine and tyrosine, with unchanged tryptophan levels. Brain valine, leucine and isoleucine were either increased or unchanged, whereas an enormous increase of aromatic amino acids, uniform in the four cerebral regions, was observed. The lack of correlation between plasmatic and cerebral levels of these essential amino acids leads to the hypothesis that cerebral permeability to amino acids is modified after experimental portocaval anatomosis: we recent confirmed that blood-brain mediated transport of the neutral amino acids is increased in this condition. A slower cerebral turnover of these metabolites could also contribute to elevate their cerebral concentrations after portocaval shunt.