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Gideon Paret

Publications and source records attributed to Gideon Paret.

33 records · Page 2Linked to original sources
PubMed2003

[ECMO--extra corporeal membrane oxygenation as a bridge to recovery, following surgery for complex congenital cardiac anomalies, in children and neonates].

BACKGROUND: ECMO is used as a method for mechanical life support in the face of extreme cardiopulmonary failure. Most children and neonates that require ECMO do so because of respiratory failure unresponsive to conventional supportive measures. Less then 16% of the patients require ECMO support for the failing heart. The Sheba Medical Center, is one of two centers in Israel authorized by the Ministry of Health to use ECMO technique and is the only center that also performs pediatric cardiac surgery. OBJECTIVES: To present our experience with ECMO support in patients with low cardiac output syndromes following open-heart surgery for congenital cardiac anomalies as compared to international experience. METHODS: The charts of all pediatric and neonatal patients requiring ECMO support following cardiac surgery for complex congenital cardiac anomalies were reviewed. Patient and ECMO characteristics were compared, as well as the success rates. RESULTS: Between 1995 and 2001, sixteen neonates and children were treated at our institution by ECMO for low cardiac output syndromes following heart surgery. Twelve were operated on at our institution, and four were referred to the ECMO unit of our pediatric critical care ward from other hospitals. ECMO support resulted in full recovery in seven of the sixteen patients, cardiac function returned to normal and the patients were discharged home in good condition, nine patients died. CONCLUSIONS: Our experience is in accord with the reported international experience. Following cardiac surgery for congenital cardiac anomalies, low cardiac output, unresponsive to maximal conventional medical support, is a rare but life threatening condition. Extracorporeal membrane oxygenation serves as a rescue mechanical support for these patients and due to improved and sophisticated intensive care, can serve as a bridge to recovery. The availability of ECMO provides an extra margin of safety in the very complex cases of open-heart surgery.

Cardiac Output, Low↗
PubMed2002

Inadequate asthma treatment practices and noncompliance in Israel.

Childhood asthma morbidity and mortality are increasing despite improvements in asthma therapy. The changes over the past decade in the guidelines for treatment of children with severe asthma have led to a reduction in admissions and readmissions to the pediatric intensive care unit (PICU). The Israeli medical infrastructure is exemplary in its capability of extending appropriate medical services to its entire population. Our objective was to look at the background of preventive maintenance treatment and treatment during an acute episode in children admitted to PICUs with severe asthma, and to identify areas that could be targeted for change. A 5-year retrospective chart audit on acute asthma admissions was conducted in two PICUs of general community hospitals representative of the provision of medical care in Israel. The prehospitalization preventive management and acute treatment prior to PICU admission were evaluated, and the number of admissions and readmissions was recorded. The index admission was the first episode of acute asthma for only 3% of the children: 25% of patients required readmission, and 15% of these to the PICU. In spite of a proven history of acute exacerbations of the disease, only 60% were on continuous treatment between attacks, and 29% of them had abruptly discontinued treatment, most of them shortly before the onset of the index attack. Inhaled steroids were used as maintenance and preventive treatment by less than one-third of the children, with the other two-thirds receiving mainly beta-2 agonists drugs. In conclusion, an unacceptably large proportion of asthmatic children do not receive the recommended maintenance and preventive treatment because of poor compliance, lack of education, or insufficient healthcare provision. This has probably led to avoidable recurrences of acute asthma exacerbations and unnecessary use of PICU facilities. These findings suggest that steps for implementing recommended guidelines and an educational program are needed.

Acute Disease↗
PubMed2002

Interleukin-8 secretion following cardiopulmonary bypass in children as a marker of early postoperative morbidity.

BACKGROUND: Interleukin (IL)-8, an 8 kDa peptide, is the first chemoattractant identified as being specific for neutrophils. Its possible association with early postoperative morbidity following cardiopulmonary bypass (CPB) in infants and children is unknown. This prospective cohort study sought possible roles of IL-8 in the inflammatory response to CPB and investigated if changes in IL-8 levels and clinical course and outcome were related. METHODS: IL-8 levels were measured in 16 children undergoing CPB. Systemic blood was collected after induction of anaesthesia (baseline), at 15 min after CPB onset and cessation, and at 1, 4, 8, 12 and 24 h thereafter. RESULTS: Correlation coefficients between IL-8 levels and CPB time ranged from 0.45 to 0.55, heart rate 0.41--0.44, surgical time 0.41--0.63 and pH --0.56 to --0.50 (P < 0.05 for all parameters). Univariate analyses showed that patients requiring inotropic support and those with tachycardia had significantly higher postoperative IL-8 levels (P < 0.05). Furthermore, IL-8 levels were significantly higher in patients with surgical times > 200 min and in patients with an aortic clamp in place for > 65 min. CONCLUSIONS: There was an association between IL-8 and early postoperative heart rate, and the need for inotropic support IL-8 correlated positively with surgical time, CPB time and heart rate and negatively with pH. IL-8 release may be related to some of the haemodynamic changes in the early postoperative course following CPB. The relationship between IL-8 and late markers of patient outcome in high-risk infants awaits further studies.

Cardiac Surgical Procedures↗
PubMed2002

Do isolation rooms reduce the rate of nosocomial infections in the pediatric intensive care unit?

PURPOSE: To determine the effect of isolation rooms on the direct spread of nosocomial infections (NIs) owing to cross-colonization in a pediatric intensive care unit (PICU). MATERIALS AND METHODS: This 6-month comparative clinical study used retrospective data from 1992 (an open single-space unit) and prospective surveillance from 1995 (individual rooms) to assess the effectiveness of the latter design on the control of NIs in critically ill pediatric patients. Patients admitted to the PICU for at least 48 hours underwent a microbiologic survey. RESULTS: The average number of NIs per patient was higher in 1992 (3.62 +/- 0.7, 78 patients) compared with 1995 (1.87 +/- 0.2, 115 patients). Bacterial NIs were caused by gram-positive cocci (33.3%) and aerobic gram-negative bacilli (66.6%). Fungemia in all cases was caused by Candida albicans. Similarly, length of stay was significantly higher in 1992 compared with 1995 (25 +/- 6 and 11 +/- 6 days, respectively; P <.05). There was a significant reduction of respiratory and urinary tract episodes of NI as well as catheter-related infections in the separate room arrangement. CONCLUSIONS: Our preliminary analysis suggests a possible beneficial effect of single isolation rooms in reducing NI rate in the PICU. Hence, the influence of room isolation on NIs in pediatric intensive care warrants further investigation.

Candidiasis↗
PubMed2002

Predictors for mortality after prolonged mechanical ventilation after cardiac surgery in children.

PURPOSE: To identify early mortality-associated clinical risk factors preceding, during, and after cardiac surgery in children. MATERIALS AND METHODS: Of the 722 children admitted to our pediatric intensive care unit (PICU) from January 1992 to January 1997 after repair of congenital heart defects, 70 required 48 hours or more of mechanical ventilation. Their clinical records were analyzed for perioperative predictors of mortality. RESULTS: The children's ages were 3.6 +/- 4.1 years (range, 4 d-16 y). The overall mortality was 5.9%. Eleven of the 70 children (15.7%) who required mechanical ventilation for 48 hours or more did not survive compared with 30 of the 652 (4.6%) children ventilated for less than 48 hours. The preoperative predictors identified as being significantly associated with increased mortality were younger age (P <.05) and the presence of congestive heart failure (P <.01). The main cause of early postoperative mortality was multiorgan dysfunction (9 children, 81.8%), whereas septic complications also were responsible for late (< 1 wk postoperatively) death (the other 2 children, 17.2%). CONCLUSIONS: Younger age and congestive heart failure were the main preoperative predictors of mortality. Multiorgan dysfunction and septic complication were predictive of an increased risk for death after cardiac surgery. These factors should be investigated in greater depth to assist in guiding aggressive therapeutic approaches for combating early signs of organ system dysfunction and infectious complications in these high-risk patients.

Adolescent↗
PubMed2002

Tumor necrosis factor and clinical and metabolic courses after cardiac surgery in children.

OBJECTIVE: This study was undertaken to determine the relationship between plasma tumor necrosis factor concentrations and hemodynamic and metabolic parameters during the postoperative clinical course in children undergoing cardiac surgery. METHODS: Tumor necrosis factor levels of 10 consecutive children undergoing surgery for repair of congenital heart defects were analyzed in blood samples drawn at predetermined time points during surgery and up to 24 hours thereafter. Clinical data were collected at these times for correlation to tumor necrosis factor levels. RESULTS: All the patients survived. Tumor necrosis factor was detected in all 10 children. Tumor necrosis factor levels declined after induction of general anesthesia (201 +/- 65 pg/mL) steadily decreasing during surgery, reaching 80 +/- 50 pg/mL at 24 hours after the operation. Tumor necrosis factor levels were found to be inversely correlated with mean blood pressure values and indicators of acidosis (bicarbonate levels and base excess, P <.03). They were not correlated with the durations of cardiopulmonary bypass and aortic crossclamping. CONCLUSIONS: Tumor necrosis factor released into the circulation during and after pediatric cardiac surgery under cardiopulmonary bypass may be related to the hemodynamic and acid-base changes observed after cardiac surgery. Elucidation of the relationship between tumor necrosis factor and patient outcome in high-risk patients awaits further studies.

Adolescent↗
PubMed2002

Endotracheal epinephrine: a call for larger doses.

UNLABELLED: Endotracheal administration of epinephrine 0.02 mg/kg (twice the IV dose) is recommended when IV access is unavailable during cardiopulmonary resuscitation. The standard IV dose has been considered too small for the endotracheal route by causing a detrimental decrease of arterial blood pressure (BP), presumably mediated by the beta-adrenergic receptor unopposed by alpha adrenergic vasoconstriction. We conducted a prospective, randomized, laboratory comparison of increasing doses of endotracheal epinephrine to ascertain the yet undetermined optimal dose of endotracheal epinephrine that would increase BP. After injecting normal saline (control), saline-diluted epinephrine (0.02, 0.035, 0.1, 0.2, and 0.3 mg/kg) was injected into the endotracheal tube of five anesthetized dogs at least 1 wk apart. Arterial blood samples for blood gases were collected before and at 14 time points up to 60 min after the drug administration. Heart rate and arterial BP were continuously monitored with a polygraph recorder. Only the 0.3 mg/kg dose successfully caused an increase in BP, observed 2 min after administration, and lasting for 10 min. An early decrease in BP was obviated only at a dose equivalent to 10-fold the currently recommended one. IMPLICATIONS: We conducted a prospective, randomized, laboratory comparison of increasing doses of endotracheal epinephrine to ascertain the yet undetermined optimal dose of endotracheal epinephrine that would increase arterial blood pressure (BP). A decrease in BP was obviated only at a dose equivalent to 10-fold the currently recommended one. Clinical studies using larger doses of endotracheal epinephrine and their use as first-line therapy in cardiac arrest are warranted.

Animals↗
PubMed2002

Is propofol safe for procedural sedation in children? A prospective evaluation of propofol versus ketamine in pediatric critical care.

OBJECTIVES: To compare propofol with ketamine sedation delivered by pediatric intensivists during painful procedures in the pediatric critical care department (PCCD). DESIGN: Prospective 15-month study. SETTING: An 18-bed multidisciplinary, university-affiliated PCCD. INTERVENTIONS: All children were randomized to the propofol or ketamine protocol according to prescheduled procedure dates. Propofol was delivered by continuous infusion after a loading bolus dose and a minidose of lidocaine (PL). Ketamine was given as a bolus injection together with midazolam and fentanyl (KMF). Repeated bolus doses of both drugs were given to achieve the desired level of anesthesia. The studied variables included procedures performed, anesthetic drug doses, procedure and recovery durations, and side effect occurrence. The patient's parents, PCCD nurse and resident physician, pediatric intensivist, and the physician performing the procedure graded the adequacy of anesthesia. MEASUREMENTS AND MAIN RESULTS: Of the 105 procedures in 98 children, PL sedation was used in 58 procedures, and KMF was used in 47. Recovery time was 23 mins for PL and 50 mins for KMF, and total PCCD monitoring was 43 mins for PL and 70 mins for KMF. Five children (10.6%) in the KMF group and in none in the PL group experienced discomfort during emergence from sedation. Transient decreases in blood pressure, partial airway obstruction, and apnea were more frequent in the PL than in the KMF sedation. All procedures were successfully completed, and no child recalled undergoing the procedure. The overall sedation adequacy score was 97% for PL and 92% for KMF (p <.05). CONCLUSIONS: Both PL and KMF anesthesia are effective in optimizing comfort in children undergoing painful procedures. PL scored better by all evaluators, recovery from PL anesthesia after procedural sedation was more rapid, total PCCD stay was shorter with PL, and emergence from PL was smoother than with KMF. Because transient respiratory depression and hypotension are associated with PL, it is considered safe only in a monitored environment (e.g., a PCCD).

Adolescent↗
PubMed2002

Predictors of outcome in the pediatric intensive care units of children with malignancies.

PURPOSE: Children with malignancies in whom life-threatening complications develop are traditionally considered as having a grim prognosis. Clinical predictors of short-term outcome for rational triage to pediatric intensive care units (PICU) were retrospectively assessed. PATIENTS AND METHODS: The records of 94 children consecutively admitted to the PICU at the authors' institution between January 1989 and January 1999 were reviewed, and predictors of 30-day mortality rates were delineated using stepwise logistic regression. RESULTS: The children's mean age was 7.3 years (range, 2-21). Their diseases included hematologic malignancies 45 (48%), extracranial solid tumors 21 (22%), and intracranial tumors 28 (30%). The overall 30-day survival rate was 66%. Mortality was highest among children admitted for respiratory failure (40%). High mortality was also found for those with circulatory collapse (33.3%) and neurologic deterioration (31%). The admitting pediatric risk of mortality score (PRISM) among the survivors was 6.6 +/- 1.3, compared with 15.2 +/- 3 among nonsurvivors (P < 0.01). The number of organ system failures was higher among the nonsurvivors on admission (P < 0.001). The need for ventilatory or inotropic support corresponded to worse outcome (P < 0.001 or P < 0.01, respectively). Overall, 36 (38%) of the children had sepsis during their PICU stay, with a mortality rate of 50% compared with 24% among nonseptic children (P < 0.01). Sepsis present on admission was later correlated with the development of organ system failure (P < 0.01). CONCLUSIONS: New trends in therapeutic approaches to children with malignancies can clearly improve outcome. The high (66%) survival rate justifies policy of early admission to the PICU of children in whom signs of multiorgan involvement start to develop, as reflected by high PRISM and the need for ventilatory or inotropic support. Further refinement of reliable clinical predictors of survival will enable better triage of these children to the PICU for possible prevention of systemic complications and reduction of mortality rates.

Adolescent↗
PubMed2002

Common perinatal insults diminish cord blood RANTES.

We demonstrate that the cord blood RANTES concentrations are reduced in full-term newborns who were born from meconium-stained amniotic fluid as compared with full-term newborns born after normal delivery. Since RANTES inhibits immunodeficiency virus (HIV) entry into macrophages, thereby bestowing increased resistance to HIV (including protection in utero), we propose that common perinatal events might precipitate higher perinatal transmission of HIV.

Amniotic Fluid↗
PubMed2002

Religious sensitivity pitted against the need to know: autopsy of Jewish children in Israel.

BACKGROUND: The aim of the study was to compare autopsy findings with antemortem findings in children who died in a pediatric intensive care unit. MATERIAL/METHODS: Consecutive series of patients who died in the pediatric intensive care unit during 2-year period were used. The study was conducted as a retrospective chart review at community, regional-referral, university-affiliated tertiary medical center of 1200 bed in Israel. RESULTS: Permission was given to perform autopsies on only 10 children (23.8%, mean age 85.7 months) out of the 42 who died during the study period. The mean length of stay in the pediatric intensive care unit prior to death was 13.3 days. Cardiac or hemato-oncologic diseases comprised the major pre-admission diagnoses. The autopsy revealed a major finding that, if known before death, would have altered clinical management in 50% of the patients: pneumonia, pneumonitis as well as intestinal perforation or necrosis. No correlation was found between patient length of stay in the intensive care unit and the autopsy disclosed information. CONCLUSIONS: Our findings support the importance of autopsy assessment in the pediatric intensive care setup. We believe that postmortem examination is also essential for improving the quality of pediatric patient care.

Adolescent↗
PubMed2002

Long-term assessment of pulmonary function tests in pediatric survivors of acute respiratory distress syndrome.

BACKGROUND: The aim of the study was to evaluate long-term pulmonary function tests in pediatric survivors of acute respiratory distress syndrome (ARDS). MATERIAL/METHODS: Observational study based on a telephone poll of retrospectively identified post ARDS children who were hospitalized in a pediatric intensive care unit (PICU) in a general 1200-bed teaching, tertiary, regional referral center for children. RESULTS: Follow-up pulmonary function tests were achieved in only 7 children, with a mean age of 7.3+/-4.3 years (range 3-12) and following 5.6+/-4.3 years after PICU discharge. The etiology for ARDS included: lymphoma (n=2), pneumonia (n=2), aspiration (n=1), petrol ingestion (n=1) and snake envenomation (n=1). The children had been ventilated for 9.4+/-7.3 days and their worst PaO2/FiO2 ratio was 65.1+/-17.0 mm Hg. The follow-up pulmonary functions in all the children was within normal limits except for one child who had mildly reduced DLCO and one who had mild exercise-induced hypoxemia (oxyhemoglobin saturation of 94%). Neither of the two nor the others showed subjective symptoms or clinical physical limitations. CONCLUSIONS: Children who survive ARDS apparently enjoy long-term normal pulmonary function. Some, however, may present subclinical dysfunction that persists for many years after the acute episode and evoked only by sophisticated lung tests.

Child↗
PubMed2002

Plasma soluble L-selectin following cardiopulmonary bypass (CPB) in children: is it a marker of the postoperative course?

BACKGROUND: There is increasing evidence that cytokine-inducible leukocyte-endothelial adhesion molecules are instrumental in the postoperative inflammatory response following cardiopulmonary bypass (CPB). L-selectin was shown to be one of those neutrophil-endothelial cell adhesion molecules. This study aimed to investigate the relationship of the soluble adhesion molecule, sL-selectin, and the postoperative course in children undergoing CPB. MATERIAL/METHODS: To determine the time course of sL-selectin after CPB, serial blood samples of 9 children undergoing CPB were collected from the arterial line or from the bypass circuits preoperatively, on initiation of CPB and 1, 6, 12, 18, 24, and 48 hours postoperatively. Plasma was recovered immediately, aliquoted and frozen at -70 degrees C until use. Circulating sL-selectin molecules were measured with a sandwich enzyme-linked immunoabsorbent assay (ELISA) technique. There were significant changes in plasma levels of sL-selectin in patients following CPB, and these levels were associated with patient characteristics, operative variables and postoperative course. Low values of sL-selectin significantly correlated with inotropic support, low PRISM score, postoperative hypotension and fever. There was a significant association between the development of postoperative sepsis and low sL-selectin levels. No correlation was found between sL-selectin values and lactate concentration or neutrophil count. CONCLUSIONS: Our results suggest a relation between CPB-induced mediators and both early and late clinical effects. Although the mechanism for the changes of sL-selectin remains undetermined, the down-regulation of sL-selectin indicates neutrophil activation and supports the possibility that anti-adhesion therapies might participate in the prevention and treatment of the inflammatory response associated with CPB.

Biomarkers↗
PubMed2002

Red blood cell intracellular electrolyte concentration in children with acute hyponatremia.

OBJECTIVE: To determine the relationship between intra- and extracellular red blood cell (RBC) sodium and potassium concentration in children with acute hyponatremia. DESIGN: Prospective case control study. SETTING: Pediatric intensive care unit of a tertiary care university-affiliated community hospital. PATIENTS AND METHODS: Plasma and RBC sodium and potassium concentrations were measured in nine consecutive children with acute hyponatremia (sodium <136) (hyponatremic group) and compared to those in nine healthy children with normal plasma sodium levels (control group). Measurements were taken on admission and after 12, 24, 36 and 48 hours by means of an atomic absorption spectrophotometric method. RESULTS: An inverse correlation was found between RBC intracellular sodium concentration and plasma levels in the acute hyponatremic group (p < 0.016, r = -0.76). CONCLUSIONS: Plasma levels of sodium may not accurately reflect intracellular concentration in the assessment of acute hyponatremia in children. Further studies on the relationship between acute hyponatremia and red blood cell sodium concentration are warranted.

Acute Disease↗