The addition of ketamine to a morphine NCA/PCA improves analgesic efficacy in children with mucositis pain with no increase in the incidence of side effects.

BackgroundA double aortic arch (DAA) is increasingly identified before birth; however, there are no published data describing the postnatal outcome of a large prenatal cohort.ObjectiveTo describe the associations, symptoms and impact of prenatally diagnosed DAA.MethodsRetrospective review of consecutive cases seen at two fetal cardiology units from 2014 to 2019. Clinical records including symptoms and assessment of tracheobronchial compression using flexible bronchoscopy were reviewed. Moderate–severe tracheal compression was defined as >75% occlusion of the lumen.ResultsThere were 50 cases identified prenatally and 48 with postnatal follow-up. Array comparative genomic hybridisation (aCGH) was abnormal in 2/50 (4%), aCGH was normal in 33/50 (66%) and of those reviewed after birth, 13 were phenotypically normal. After birth, there was a complete DAA with patency of both arches in 8/48 (17%) and in 40/48 (83%) there was a segment of the left arch which was a non-patent, ligamentous connection.Stridor was present in 6/48 (13%) on the day of birth. Tracheo-oesophageal compressive symptoms/signs were present in 31/48 (65%) patients at median age of 59 days (IQR 9–182 days). Tracheal/carinal compression was present in 40/45 (88%) cases. Seven of 17 (41%) asymptomatic cases demonstrated moderate–severe tracheal compression. All morphologies of DAA caused symptoms and morphology type was not predictive of significant tracheal compression (p=0.3).ConclusionsGenetic testing should be offered following detection of double aortic arch. Early signs of tracheal compression are common and therefore delivery where onsite neonatal support is available is recommended. Significant tracheal compression may be present even in the absence of symptoms.

OBJECTIVES:Neonates with respiratory failure are ideally supported with veno-venous rather than veno-arterial extracorporeal membrane oxygenation due to the reduced rate of neurologic complications. However, the proportion of neonates supported with veno-venous extracorporeal membrane oxygenation is declining. We report multisite veno-venous extracorporeal membrane oxygenation, accessing the neck, returning to the inferior vena cava via the common femoral vein in neonates and children less than 10 kg. DESIGN:Retrospective case series with 1 year minimum follow-up.PATIENTS: Patients less than 10 kg supported with veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein SETTING: A 30-bed pediatric intensive care delivering extracorporeal membrane oxygenation to approximately 20 children annually. INTERVENTIONS:Veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein was delivered using two single lumen cannulae. MEASUREMENTS AND MAIN RESULTS:January 2015 to August 2019, 11 patients underwent veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein with median weight of 3.6 kg (interquartile range 2.8-6.1 kg), and median corrected gestational age of 13 days (interquartile range, 2-175 d). The smallest patient weighed 2.1 kg. Seven patients had comorbidities. Extracorporeal membrane oxygenation was technically successful in all patients with median flows of 126 mL/kg/min (interquartile range, 120-138 mL/kg/min) and median arterial oxygenation saturation of 94% (interquartile range, 91-98%) at 24 hours. Nine survived to home discharge, and two were palliated. Common femoral vein occlusion was observed in all patients on ultrasound post decannulation. There was no clinical or functional deficit in the cannulated limb at follow-up, a minimum of 1 year post extracorporeal membrane oxygenation. CONCLUSIONS:Veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein was performed safely in patients under 10 kg with the smallest patient weighing 2.1 kg. Although occlusion of the common femoral vein was observed in patients post decannulation, subsequent follow-up demonstrated no clinical implications. We challenge current practice that veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein cannot be performed in nonambulatory patients and suggest that this strategy is preferred over veno-arterial extracorporeal membrane oxygenation in infants requiring extracorporeal membrane oxygenation for respiratory failure.

Lemierre's syndrome is a potentially life-threatening consequence of oropharyngeal and ear infections and often results in critical care admission and even intubation. Due to the multisystem manifestation, multiple teams may initially be involved in the care, some of which may be unfamiliar with the features and usual clinical course. This report describes a case in a 36-year-old woman with the classic features of internal jugular vein thrombosis and septic emboli to the lungs secondary to an oropharyngeal infection. Treatment comprised antibiotic therapy, anticoagulation and fluid resuscitation, and was carried out in a high dependency unit setting. At follow-up 3 months after discharge, the patient was well with no residual symptoms off all treatment. During the events of this case, it became apparent that while ear, nose and throat and infectious diseases team members were relatively familiar with the condition, other departments including the critical care team were less so.

Difficulty in tracheal intubation in paediatric intensive care patients is associated with increased morbidity and mortality. Delays to intubation and interruption to oxygenation and ventilation are poorly tolerated. We developed a safe and atraumatic tracheal intubation technique. A floppy-tipped guidewire and airway exchange catheter were placed to a pre-determined length under bronchoscopic guidance while oxygenation and ventilation was maintained via a supraglottic airway device (SAD). We performed a retrospective review of this technique on patients who were either known to have or who had an unexpected difficultly in intubation. We describe the safety and experience of this in a broad range of critically ill children. Thirteen patients, median (IQR [range]) (9.0 (5.0-10.0 [4.0-12.0]) kg and 15.4 (12.1-23.2 [3.3-49.7]) months) underwent emergency tracheal intubation using this technique, after unsuccessful attempts at intubation using standard laryngoscopy blades. All intubations were successful at the first attempt using this technique and no airway trauma or significant clinical deteriorations were recorded.