mercredi 5 février 2020 

14h10 - 15h10


 
733-734

Pédiatrie I

MODÉRATEUR(S) :  Bénédicte GAILLARD-LE ROUX (Nantes), Etienne JAVOUHEY (Lyon)  
  

Weaning from noninvasive ventilation and high flow nasal cannula in patients with severe bronchiolitis

Orateur(s) :   Julie CASSIBBA (Grenoble) 

Auteur(s) :  Anne EGO (Grenoble)   Isabelle PIN (Grenoble)   Guillaume MORTAMET (Grenoble)  

14h10 - 14h25
Durée de la présentation : 10 min
Durée de la discussion : 5 min


Abstract : 
Weaning from noninvasive ventilation and high flow nasal cannula in patients with severe bronchiolitis

Introduction / Rationale :
Non Invasive Ventilation (NIV) and High Flow Nasal Cannula (HFNC) are the first-line therapies for the most severe patients with acute bronchiolitis. Unlike invasive mechanical ventilation, there is no consensus with regards to weaning from NIV/HFNC. The main objective of this study is to describe the weaning practices from NIV/HFNC in patients with acute bronchiolitis.

Méthodes / Patients and Methods :
A single-center prospective study. Patients younger than 6 months with severe bronchiolitis and supported by NIV or HFNC were included. NIV/HFNC was discontinued according to the local practices and no protocol existed. Expect the principal investigator, the attending team was blinded to the study. Weaning failure was defined as the need to reinstate NIV/HFNC in the 48 hours after discontinuation. Ethical approval was not necessary for this study in accordance with the French data protection autority methodology reference number MR-004.

Résultats / Results :
A total of 95 patients (median age 47 days, 53 (56%) males) were included. Respectively, 72 (76%) and 23 patients (24%) were supported by NIV and HFNC at admission. Regarding the mode of NIV, a bilevel mode was used in 46 patients (48%)(Figure 1). In patients supported by HFNC, the ventilatory support was discontinued progressively decreasing air flow in 9 patients (39%) while it was stopped abruptly in 5 (22%). In patients supported by NIV, the respiratory support was stopped abruptly in 5 (19%) of them while HFNC was used as a weaning method for 17 (65%) patients. A total of 22 (23%) patients experienced a weaning failure. Patients supported by NIV/HFNC who experienced a prompt weaning had a lower Pediatric Intensive Care Unit (PICU) length of stay as compared to patients in whom HFNC was used as a weaning method (78 +/- 27 versus 112 hours +/- 112, p=0,01). However, the hospital length of stay was similar according to the weaning method (6 +/- 3 versus 7 +/- 3 days for prompt and progressive methods respectively, p=0,07). The duration of the weaning process did not differ according to the bed-availability in PICU.

Discussion / Discussion :


Conclusion / Conclusion :
In patients with severe bronchiolitis, a prompt weaning from NIV/HFNC was associated with a lower length of stay in PICU. However, the hospital length of stay was similar according to the weaning method. We suggest that a prompt weaning should be preferred in order to reduce the risk of PICU related complications.
 

Influenza-associated encephalitis: a french multicentric retrospective study in pediatric intensive care units

Orateur(s) :   Pierre CLEUZIOU (Paris) 

Auteur(s) :  Florence RENALDO (Paris)   Sylvain RENOLLEAU (Paris)   Isabelle DESGUERRE (Paris)   Etienne JAVOUHEY (Lyon)   Pierre TISSIÈRES (Le Kremlin Bicêtre)   Pierre-Louis LEGER (Paris)   Stéphane DAUGER (Paris)   Michaël LEVY (Paris)  

14h25 - 14h40
Durée de la présentation : 10 min
Durée de la discussion : 5 min


Abstract : 
Influenza-associated encephalitis: a french multicentric retrospective study in pediatric intensive care units

Introduction / Rationale :
Influenza-associated encephalitis (IAE) is a very rare disease with poorly understood pathophysiology. It has mainly been described in Japan, where the death rate is around 8 % and where one third of the survivors suffer from neurological sequelae. The objective of this study was to describe severe forms of the disease among children hospitalized in pediatric intensive care unit (PICU) and to estimate the death rate in this population.

Méthodes / Patients and Methods :
By using consensus definition criteria, we retrospectively identified children hospitalized between 2010 and 2018 in 12 french PICU for an encephalitis associated with a laboratory-proven acute infection to Influenzae virus. Patients with preexisting neurological chronic disorder or presenting a co-infection potentially responsible of the disease were excluded. We collected data describing clinical presentation, cerebro-spinal fluid (CSF) results, electroencephalographic and MRI findings, therapeutics used in PICU and outcome at discharge.

Résultats / Results :
41 patients were included with 4.7 years old as median age (range 0.8–15.4 years old). Most of the patients were admitted in ICU less than 48h after the first symptoms (62%, n=25). The main clinical features were fever (93%, n=38), vomiting (44%, n=18), altered consciousness (100%, n=41), epileptic seizures (88%, n=36), status epilepticus (54%, n=22) and motor weakness or pyramidal signs (71%, n=29). 48 % of patients had a meningitis (n=16) and the virus was never found in the CSF (n=0/13). One third of the children (n=13) presented MRI lesions compatible with acute necrotizing encephalitis. Regarding therapeutics, 80% of patients required mechanical ventilation, especially for neurologic dysfunction, and the use of specific treatments was very heterogeneous: 68% had oseltamivir, 49% boluses of corticosteroids, 24% intravenous immunoglobulins and 10% plasmatic exchanges. The median length of stay (LOS) in PICU was 7 days (range 1–87 days) and there were 7 fatalities (17 %). Among survivors, 35 % had severe neurological sequelae at discharge from the hospital (n=11). A predisposing mutation in the RANBP2 gene was rarely sought (15%, n=6) but was positive in one out of two patients.

Discussion / Discussion :


Conclusion / Conclusion :
Patients requiring PICU for an IAE still have an extremely severe prognosis with a high mortality rate and frequent neurological sequelae. It appears that patients’ therapeutic management is still heterogeneous because of the lack of consensual guidelines. The research of a predisposing genetic mutation in RANBP2 is not yet part of the systematic etiologic assessment although it is known to be an important risk factor for the severe form of the disease.
 

Population pharmacokinetics of Cefazolin in critically ill children infected with methicillin-sensitive Staphylococcus aureus

Orateur(s) :   Elodie SALVADOR (Paris) 

Auteur(s) :  Elodie SALVADOR (Paris)   Mehdi OUALHA (Paris)   Emmanuelle BILLE (Paris)   Olivier BUSTARRET (Paris)   Agathe BÉRANGER (Paris)   Guillaume GESLAIN (Paris)   Florence MOULIN (Paris)   Julie TOUBIANA (Paris)   Sihem BENABOUD (Paris)   Sylvain RENOLLEAU (Paris)   Jean-marc TRÉLUYER (Paris)   Déborah HIRT (Paris)  

14h40 - 14h55
Durée de la présentation : 10 min
Durée de la discussion : 5 min


Abstract : 
Population pharmacokinetics of Cefazolin in critically ill children infected with methicillin-sensitive Staphylococcus aureus

Introduction / Rationale :
Cefazolin is one of curative treatments for infections with methicillin-sensitive Staphylococcus aureus (MSSA) which may occur in critically ill children. Both growth and critical illness may impact of pharmacokinetics (PK) in this vulnerable population. We aim to establish a PK model for cefazolin, using a population approach, and in turn to optimize individual dosing regimens.

Méthodes / Patients and Methods :
We included all children (age < 18 years, bodyweight (BW) > 2.5 Kg) receiving cefazolin and infected with MSSA. Cefazolin serum total concentrations were quantified by high-performance liquid chromatography. Data modelling process has been done with a non-linear mixed-effect modeling software MONOLIX. Monte Carlo simulations were used to optimize individual dosing regimens in order to attain the target of 100% [fT(4×MIC)].

Résultats / Results :
Thirty-nine patients with a median age of 7 years (0.1-17), a body weight (BW) of 21 kg (2.8-79) and an estimated glomerular filtration rate (eGFR) of 189 mL/min/1.73m² (66- 486) were included. The PK was ascribed a one-compartment model with first-order elimination, where clearance and volume of distribution estimated were 1.4 L/h and 3.3 L respectively, normalized to a median subject of 21 kg and e GFR of 189 mL/min/1.73m². BW, according to the allometric rules, and eGFR were the significant covariates. Under simulations, continuous infusion with a dose of 100 mg/kg/day was the best scheme to reach the target of 100% [fT(4×MIC)]. A dose of 150 mg/kg per day by continuous infusion is more appropriate for children with BW < 10 kg or eGFR > 200 mL/min, while also limiting side effects.

Discussion / Discussion :


Conclusion / Conclusion :
In critically ill children infected with MSSA, BW with allometric scaling and eGFR were the main influential covariates on cefazolin PK parameters. Current and recommended dosing regimens of cefazolin may be not sufficient to reach the target of 100 % [fT(4×MIC)] in all children. Continuous infusion with a dosing of 100 to 150 mg/kg/day seems to be the best scheme to achieve the target of 100 % [fT(4×MIC)] in children with normal and augmented renal function, respectively.
 

Factors influencing unplanned extubations in a pediatric intensive care unit: a 9-year prospective study

Orateur(s) :   Guillaume GESLAIN (Paris) 

Auteur(s) :  Jeanne MAYEUR (Paris)   Michaël LEVY (Paris)   Géraldine PONCELET (Paris)   Fleur LE BOURGEOIS (Paris)   Arielle MARONI (Paris)   Camille DOLLAT (Paris)   Jérôme NAUDIN (Paris)   Stéphane DAUGER (Paris)   Maryline CHOMTON (Paris)   Anna DEHO (Paris)  

14h55 - 15h10
Durée de la présentation : 10 min
Durée de la discussion : 5 min


Abstract : 
Factors influencing unplanned extubations in a pediatric intensive care unit: a 9-year prospective study

Introduction / Rationale :
Unplanned extubation (UE) is a potentially serious complication that can contribute to increase patient morbidity, mortality and length of stay in pediatric intensive care unit (PICU). The most frequent risk factors reported in literature are younger age, patient agitation, inadequate tube fixation, copious secretions, procedures performed during medical or paramedical care and nursing workload.
The aim of our study is to determine incidence and contributing factors of UE in our PICU.

Méthodes / Patients and Methods :
We conducted a prospective monocentric study from January 1, 2010, to December 31, 2018 in a tertiary PICU. All mechanically ventilated children less than 18 years-old admitted to our PICU were included except for patients with tracheotomy. We monitored all cases of UE occurred during PICU stay. Demographic and clinical data were collected using an event report form including patient characteristics, a description of the extubation circumstances and the outcomes.

Résultats / Results :
We reported 102 UE in 9-years for 14661 days of mechanical ventilation. The overall UE incidence was 6.96 per 1000 ventilation days.
Characteristics of patients and UE circumstances are reported in Table 1. Some data on events after UE are missing.
Thirteen patients on 82 (15.9%) needed non-invasive ventilation after UE, 4 of them needed reintubation (30.8%). Sixty patients on 97 (61.9%) needed reintubation, and 47 of them required immediate reintubated (78.3%).
Over the study period, the number of UE is stable per year. Presence of physical restraints, nasally inserted endotracheal tubes and cuffed tubes seemed not to prevent patients from self-extubating.

Discussion / Discussion :
In North America, the nurse-to-patient ratio in PICU is 1:1, in our unit this ratio is at 1:2.29. A reorganization of the PICU staff for intubated patients should be redesigned in our unit. It would also be interesting to study the kinetic of sedation decreasing and to collect the presence or absence of a withdrawal syndrome for its potential implication in UE.

Conclusion / Conclusion :
Areas for potential improvement seem to lie in implementation of monitoring and staff education program. Iterative intubations can cause laryngeal and tracheal trauma and prolong length of mechanical ventilation and PICU stay. Our aim is to implement strategies to reduce the occurrence of UE.