Various methods to insert postpyloric feeding tubes at the bedside have been reported, but the optimal method remains controversial. The objective of this study was to evaluate the effect of ultrasoundguided postpyloric feeding tube placement in critically ill children. DESIGN:Single-center retrospective observational study. SETTING: PICU of tertiary children's hospital. PATIENTS:Children under the age of 16 who underwent postpyloric feeding tube placement in our PICU between September 2017 and August 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:A total of 115 patients were included in this study: 30 patients underwent ultrasound-guided postpyloric feeding tube placement and 85 patients underwent blind postpyloric feeding tube placement; the insertion attempts were 32 and 93, respectively. There were no significant differences in patient demographics between the ultrasound-guided group and the blind group. The first-pass success rate of the ultrasound-guided group was higher than that of the blind group (94% [30/32] vs 57% [53/93]; p < 0.001). The median insertion time in the ultrasound-guided group with successful postpyloric feeding tube insertion was 18 minutes (interquartile range, 15-25; range, 8-45; n = 21). There were no complications or adverse events during the placement. CONCLUSIONS:In this single-center study, ultrasound-guided postpyloric feeding tube placement was feasible and a significantly high first-pass success rate was observed for critically ill children. Additional investigation with a larger pool of operators and randomized controlled patient assignment is required.

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Introduction: Childhood Takayasu arteritis (c-TA) often shows nonspecific symptoms, such as fever of unknown origin (FUO). Delay of diagnosis may result in organ dysfunction by arterial occlusion; therefore, early diagnosis is very important. Although ultrasonography is the first-line screening tool for children with FUO, its diagnostic efficacy of evaluation of systemic arteries in c-TA that presents as FUO remains unclear. We evaluated the suitability of ultrasonography evaluation that included systemic vessels for the early diagnosis of c-TA initially presenting as FUO. Methods: We review five patients who received a diagnosis of c-TA in our institution and also performed a literature review regarding TA cases with FUO and diagnosed on the basis of initial ultrasonography. Results: As in our cases, the median period from onset to diagnosis was 25 days (interquartile range [IQR], 21-35). Comparing the initial ultrasonography findings with later contrast-enhanced computed tomography (CECT) findings in the abdominal aorta, celiac artery, superior mesenteric artery, bilateral renal arteries, and bilateral common carotid arteries, the concordance rate between ultrasonography and CECT was moderate (Kappa coefficient was 0.50). All the patients were successfully treated without severe vascular damage. The literature review revealed 12 articles; although 9 of the 13 patients did not show the characteristic features (such as blood pressure discrepancy, bruit, or pulse deficiency), the median time to diagnosis was still 5 months (IQR, 3-12). Conclusions: During initial screening for patients with FUO, ultrasonography including evaluation of systemic vessels could contribute to earlier diagnosis of c-TA.

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From the perspective of the Stewart approach, it is known that expansion of the sodium chloride ion difference (SCD) induces alkalosis. We investigated the role of SCD expansion by furosemide-induced chloride reduction in pediatric patients with acute respiratory failure. We included patients admitted to our pediatric intensive care unit intubated for acute respiratory failure without underlying diseases, and excluded patients receiving extracorporeal circulation therapy (extracorporeal membrane oxygenation and/or renal replacement therapy). We classified eligible patients into the following two groups: case—those intubated who received furosemide within 24 hours, and control—those intubated who did not receive furosemide within 48 hours. Primary outcomes included SCD, partial pressure of carbon dioxide (PaCO2), and pH results from arterial blood gas samples obtained over 48 hours following intubation. Multiple regression analysis was also performed to evaluate the effects of SCD and PaCO2 changes on pH. Twenty-six patients were included of which 13 patients were assigned to each of the two groups. A total of 215 gas samples were analyzed. SCD (median [mEq/L] [interquartile range]) 48 hours after intubation significantly increased in the case group compared with the control group (37 [33–38] vs. 31 [30–34]; p = 0.005). Although hypercapnia persisted in the case group, the pH (median [interquartile range]) remained unchanged in both groups (7.454 [7.420–7.467] vs. 7.425 [7.421–7.436]; p = 0.089). SCD and PaCO2 were independently associated with pH (p < 0.001 for each regression coefficient). As a result, we provide evidence that SCD expansion with furosemide may be useful in maintaining pH within the normal range in pediatric patients with acute respiratory failure complicated by concurrent metabolic acidosis.