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Sepsis is a leading cause of global mortality in children, yet definitions for pediatric sepsis are outdated and lack global applicability and validity. In adults, the Sepsis-3 Definition Taskforce queried databases from high-income countries to develop and validate the criteria. The merit of this definition has been widely acknowledged; however, important considerations about less-resourced and more diverse settings pose challenges to its use globally. To improve applicability and relevance globally, the Pediatric Sepsis Definition Taskforce sought to develop a conceptual framework and rationale of the critical aspects and context-specific factors that must be considered for the optimal operationalization of future pediatric sepsis definitions. It is important to address challenges in developing a set of pediatric sepsis criteria which capture manifestations of illnesses with vastly different etiologies and underlying mechanisms. Ideal criteria need to be unambiguous, and capable of adapting to the different contexts in which children with suspected infections are present around the globe. Additionally, criteria need to facilitate early recognition and timely escalation of treatment to prevent progression and limit life-threatening organ dysfunction. To address these challenges, locally adaptable solutions are required, which permit individualized care based on available resources and the pretest probability of sepsis. This should facilitate affordable diagnostics which support risk stratification and prediction of likely treatment responses, and solutions for locally relevant outcome measures. For this purpose, global collaborative databases need to be established, using minimum variable datasets from routinely collected data. In summary, a “Think globally, act locally” approach is required.

To assess reproducibility and accuracy of left ventricular output (LVO) quantifications in neonates, when left ventricular outflow tract diameter (LVOTD) was measured at the hinges of the aortic valve (AV), at the aortic sinus (AS), and at the sinotubular junction (STJ). This was an observational study. In the first cohort of very preterm neonates, we assessed intraobserver and interobserver repeatability of LVOTD measured at the AV, AS, and STJ and of the corresponding LVO. In the second cohort of older neonates, we compared paired LVO measurements by echo and magnetic resonance imaging (MRI). In the first cohort of 48 neonates, mean (standard deviation) weight and age at scan were 1046 (302) g and 28.1 (2.7) weeks. Interobserver bias (95% limits of agreement [LOA]) for LVOTD at the AV, AS, and STJ was 0 (−0.3 to 0.3) mm, 0 (−0.7 to 0.7) mm, and 0 (−0.8 to 0.7) mm, respectively. Interobserver bias (95% LOA) for the corresponding LVO was −1.3 (−31 to 33) ml/kg/min, −0.5 (−88 to 87) ml/kg/min, and −7.2 (−83 to 69) ml/kg/min, respectively. In the second cohort of 10 neonates, median (range) weight and age at scan were 1942 (970–3640) g and 37.2 (31.7–39.8) weeks. LVO measured at the AV showed stronger agreement with MRI: bias (LOA) −10.6 (−74 to 52) ml/kg/min, compared to LVO measured at AS and STJ: 194 (−0.5 to 388) ml/kg/min and 43 (−72 to 159) ml/kg/min respectively. Reproducibility and accuracy of LVO quantification by echo were better when aortic diameter was measured at AV.

BackgroundThe thermal servo-controlled systems are routinely used in neonatal intensive care units (NICUs) to accurately manage patient temperature, but their role during the immediate postnatal phase has not been previously assessed.ObjectiveTo compare two modalities of thermal management (with and without the use of a servo-controlled system) immediately after birth.Study design and settingMulticentre, unblinded, randomised trial conducted 15 Italian tertiary hospitals.ParticipantsInfants with estimated birth weight <1500 g and/or gestational age <30+6weeks.InterventionThermal management with or without a thermal servo-controlled system during stabilisation in the delivery room.Primary outcomeProportion of normothermia at NICU admission (axillary temperature 36.5°C–37.5°C).ResultsAt NICU admission, normothermia was achieved in 89/225 neonates (39.6%) with the thermal servo-controlled system and 95/225 neonates (42.2%) without the thermal servo-controlled system (risk ratio 0.94, 95% CI 0.75 to 1.17). Thermal servo-controlled system was associated with increased mild hypothermia (36°C–36.4°C) (risk ratio 1.48, 95% CI 1.09 to 2.01).ConclusionsIn very low birthweight infants, thermal management with the servo-controlled system conferred no advantage in maintaining normothermia at NICU admission, while it was associated with increased mild hypothermia. Thermal management of preterm infants immediately after birth remains a challenge.Trial registration numberNCT03844204

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jtcvs.2008.03.066 Byline: Francesca Viscardi (a), Gabriella Errico (b), Nicola Schiavo (c), Paolo Biban (b), Alessandro Mazzucco (a), Giovanni Battista Luciani (a) Author Affiliation: (a) Division of Cardiac Surgery, University of Verona, Verona, Italy (b) Division of Pediatrics, University of Verona, Verona, Italy (c) Division of Pathology, University of Verona, Verona, Italy Article History: Received 17 November 2007; Accepted 23 March 2008

To assess how clinical practice of noninvasive ventilation has evolved in the Italian PICUs.

The diagnosis of congenital hypopituitarism is difficult and often delayed because its symptoms are nonspecific. To describe the different clinical presentations of children with congenital hypopituitarism to reduce the time for diagnosis and to begin a precocious and appropriate treatment. We analyzed a cohort of five children with congenital hypopituitarism, describing their clinical, biochemical and radiological characteristics from the birth to diagnosis. As first sign of the disease, all of five patients presented a neonatal hypoglycemia, associated in four cases with jaundice. In all these four cases, the clinicians hypothesized a metabolic disease delaying the diagnosis, which was performed in only two cases within the neonatal period. In the other three cases, the diagnosis was formulated at 2, 5 and 8 years of life because there was severe and precocious growth impairment. It is important to suspect congenital hypopituitarism in the presence of persistent neonatal hypoglycemia associated with jaundice and of a precocious and severe reduction of the growth velocity in childhood. In all these cases, it is necessary to undertake a hypothalamic–pituitary magnetic resonance imaging scan as soon as possible, and to start appropriate treatment.

Vasopressin and its analogue terlipressin are potent vasopressors which have been recently proposed in the treatment of catecholamine-resistant septic shock. We review the physiology, metabolism and pharmacology of vasopressin and terlipressin, as well as the available data on their efficacy and safety in neonates and children with septic shock. In adults, vasopressin deficiency can contribute to refractory shock states associated with sepsis. Differently, in children with septic shock vasopressin levels may be normal or even augmented. Nevertheless, low doses of vasopressin and terlipressin seem to have the potential to restore vasomotor tone in conditions refractory to catecholamines, improving organ perfusion with preservation of renal blood flow, while decreasing catecholamine requirements. Vasopressin and terlipressin produce vasoconstriction via stimulation of V1-receptors. In particular, terlipressin has a higher selectivity for V1-receptors and a longer half-life when compared to vasopressin, allowing for intermittent bolus doses. However, the pharmacology of vasopressin/terlipressin in newborns and children has not been sufficiently investigated and data on potential short and long-term adverse effects are still lacking. Further clinical, pharmacokinetic and pharmacodynamic studies are needed to better define the role of vasopressin and terlipressin in septic shock, as well as to prove their effectiveness and safety in infants and children.

Background: This study estimated in 7 Italian cities the prevalence of prenatal exposure to ethanol by determining fatty acid ethyl esters (FAEEs; palmitic, palmitoleic, stearic, oleic, linoleic, linolenic, and arachidonic esters) and ethyl glucuronide (EtG) in neonatal meconium samples.

We assessed the effectiveness of inhaled nitric oxide (NO) in two patients, of six and two months of age, who developed severe pulmonary hypertension after corrective cardiac surgery for a complete atrioventricular canal. In the post-op period, attempts to wean the patients from ventilatory support resulted in marked increase of pulmonary arterial pressure (PAP) to suprasystemic levels, with severe desaturation and metabolic acidosis. Two life-threatening episodes did need cardiac resuscitation in the second patient. Short administrations of inhaled NO, at 30 parts per million (ppm), dramatically reduced the PAP to about half the systemic values in the first patient (systemic arterial pressure (SAP)=35/24 and PAP=44/33 before NO, and SAP=58/38 with PAP=31/19 after five minutes of NO treatment), while in the second patient NO showed a slower effect on PAP, but an immediate improvement of hemodynamics. Thus, continuous inhaled NO, at 10-50 ppm, was administered through the ventilator, with good clinical response. Electrochemical analysis provided on line monitoring of NO and nitrogen dioxide (NO2) concentrations. NO2did not exceed 1.6 ppm. Inhaled NO was tapered to the minimal effective concentration able to maintain low pulmonary pressures and normal oxygenation. Treatment with NO was stopped after 55 and 62 hours, respectively. No complications were noted. Met hemoglobin levels ranged between 0.7-1.2% in case 1, and 0.1-5.1% in case 2. In the latter case, methemoglobin was directly correlated with NO concentration levels. Weaning was successful in both cases, with extubation performed on day 29 and day 17 post-op, respectively.CONCLUSIONS: Inhaled nitric oxide at concentrations of 10-50 ppm exerts a potent dilatory effect on pulmonary vascular bed in children with congenital heart disease who present pulmonary hypertension after surgical correction. Although toxicity by NO and NO2seems to be negligible at these dosages, continuous on-line gas monitoring is recommended.