Forty-four percent of pediatric patients who failed conventional cardiopulmonary resuscitation from in-hospital cardiopulmonary arrest and who were reported to the National Registry of CardioPulmonary Resuscitation database as treated with extracorporeal cardiopulmonary resuscitation survived to hospital discharge. The majority of survivors with recorded neurologic outcomes were favorable. Patients with cardiac illness category were more likely to survive to hospital discharge after treatment with extracorporeal cardiopulmonary resuscitation. Extracorporeal cardiopulmonary resuscitation should be considered for select pediatric patients refractory to conventional in-hospital resuscitation measures.

The objective of this study was to characterize the transfer of flecainide across the placenta and determine the fetal: maternal ratio of flecainide in the gravid baboon. Flecainide acetate has been especially successful for the treatment of fetal supraventricular tachycardia associated with hydrops fetalis. However, the degree of transplacental transmission remains unknown. In this study, all animals were placed under general anesthesia. Flecainide 2.5 mg/kg was administered intravenously. Percutaneous umbilical blood sampling was performed simultaneously with maternal sampling. Flecainide levels were measured using high-performance liquid chromatography with ultraviolet detection. A total of six gravid baboons were studied at an average gestational age of 132 days. The mean maternal volume of distribution at steady state was 5.1 +/- 1.8 L/kg. The mean combined elimination constant (k(el)) was 0.79 +/- 0.19 hr(-1) [95% confidence interval (CI), 0.64-0.93]. There was a linear relationship between maternal and fetal concentrations, with a ratio of fetal-to-maternal serum levels of 0.49 +/- 0.05 (95% CI, 0.39-0.59). At steady state, fetal flecainide levels are approximately 50% of maternal flecainide levels. Flecainide is rapidly distributed in the mother and fetus following a single intravenous dose with a maternal volume of distribution similar to that reported in normal healthy human adults. Since fetal levels correlate closely with maternal levels, we propose that it is possible to estimate fetal levels by monitoring maternal levels.

Pentobarbital (PB) contains 40% propylene glycol (PG) and could result in lactic acidosis (LA). Previous reports have indicated PG-induced LA following PB continuous infusion (CI), but there are no reports in young children. A 3-year-old male was admitted for new-onset seizures. After failing conventional therapy, he was initiated on intravenous PB on hospital day (HD) 3. The seizures continued, and he was initiated on a PB CI on HD 5 to achieve burst suppression. His CI was titrated to 10 mg/kg/hr. On HD 15, he developed hypotension with a mean arterial pressure (MAP) in the 40's and venous lactate of 3.01 mmol/L (normal range: 0.4?2.0 mmol/L). He received epinephrine, and his PB was decreased to 8 mg/kg/hr. Over the next few weeks, he continued to have subclinical seizures and PB was increased to 10 mg/kg/hr. On HD 37, he developed hypotension with a lactate of 6.28 and osmolar gap of 20.4 mOsm/kg. He received a fluid bolus, sodium bicarbonate, and his PB was decreased to 5 mg/kg/hr. His PB was tapered off, and the decision was made to treat clinical seizures only. The World Health Organization recommends a maximum of 25 mg/kg of PG. On HD 15 and 37, our patient received more than this threshold, 1398 and 1604 mg/kg, respectively. The Naranjo probability scale supports a high-probable drug-related adverse event. Practitioners should be aware of this potential adverse event with medications containing PG. Routine monitoring of osmolar gap should be performed for patients with prolonged use or higher PB doses.

cause of morbidity and mortality in immunocompromised children with highest incidence found in children with Wiskott-Aldrich syndrome and a very low incidence of 0.6% in children with ALL. Aspergillus fumigatus is the most common cause of IA followed by aspergillus flavus, aspergillus niger, aspergillus terreus. Clinical practice guidelines of the Infectious disease society of America does not recommend empirical therapy in shorter duration of neutropenia <10days unless there are findings of invasive fungal infections. Our patient presented with hyperleukocytosis and likely had dysfunctional neutrophil function thus predisposing him to IA. He also progressed to absolute neutropenia in rapid fashion within 3days of initiation of chemotherapy. The most significant risk factor contributing to his development of IA may have been his home environment. The family lived and worked in Avondale Pennsylvania, a suburb of Philadelphia in chester County with close proximity to Kennet Square and its large mushroom farming industry. Kennet Square is noted as "The Mushroom Capital of the World" supplying over 51% of the nation's mushroom crop. Mushrooms as with other fungi, thrive in warm moist dark environment and are frequently fertilized with a soil/ manure compost that is frequently rotated by heavy equipment. This compost rotation releases spores into the air that are harmless when inhaled by immunocompetent individuals. Our patient living in this endemic area was likely exposed to high spore content of pathogenic Aspergillus species environmentally and so rapidly developed brain abscess when chemotherapy was initiated. Our case is unique as he had very rapid onset of CNS aspergillosis, with history of agricultural exposure in the setting of Pre B cell ALL. Given our hospital's geographic location, questions remain whether consideration should be given to initiate empirical antifungal therapy at treatment doses with initiation of chemotherapy.