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Biomedical subjects

F Shann

Publications and source records attributed to F Shann.

At least 37 records · Page 2Linked to original sources
PubMed1999

Continuous plasmafiltration in sepsis syndrome. Plasmafiltration in Sepsis Study Group.

OBJECTIVE: To assess the effect of plasmafiltration (PF) on biochemical markers of inflammation, cytokines, organ dysfunction, and 14-day mortality in human sepsis. DESIGN: Multicenter, prospective, randomized, controlled clinical trial. SETTING: Seven university-affiliated intensive care units. PATIENTS: Thirty patients (22 adults, eight children) with new (<24 hrs) clinical evidence of infection and sepsis syndrome were enrolled. Fourteen of 30 (nine adults, five children) were randomized to PF. INTERVENTIONS: All patients received protocol-driven supportive intensive care, and those randomized to PF received continuous plasma exchange for 34 hrs using a hollow-fiber plasma filter. MEASUREMENTS AND MAIN RESULTS: Illness severity and risk of death were calculated with the Pediatric Risk of Mortality (children) and the Acute Physiology and Chronic Health Evaluation II (adults) scales. Plasma samples (0, 6, 24, and 48 hrs) were assayed for acute-phase proteins (albumin, globulin, C-reactive protein, alpha1-antitrypsin, haptoglobin), inflammatory mediators (complement fragment C3, thromboxane B2), and cytokines (interleukin-6, granulocyte colony-stimulating factor, leukemia inhibitory factor). Sieving coefficients were estimated from filtrate concentrations at 3 hrs. The two groups were matched for incidence of septic shock (13 of 14 vs. 11 of 16), refractory shock (three of 14 vs. six of 16), bacteremia (six of 14 vs. five of 16), severity of illness, and calculated risk of death (0.68 vs. 0.64). There was no difference in mortality. Eight of 14 PF patients (57%) and eight of 16 controls (50%) survived for 14 days (p = .73, Fisher's exact test). Multiple logistic regression revealed age (odds ratio, 16.4:1; 95% confidence interval, 2.12-infinity) and shock (10.6:1; 1.32-infinity) as significant predictors of death; plasmafiltration was associated with a nonsignificant reduction in the risk of death (odds ratio, 1.78:1; 95% confidence interval, 0.20-18.1). The mean (SD) number of organs failing in the first 7 days in the PF group was 2.57 (0.94) vs. 2.94 (0.85) in controls (p = .37, Mann-Whitney U test). Both groups had similarly elevated plasma concentrations of all inflammatory mediators except complement fragment C3 at study entry. Leukemia inhibitory factor was detectable in four patients only. PF did not influence mean concentrations of interleukin-6, granulocyte colony-stimulating factor, thromboxane B2, total white cell count, neutrophil count, or platelet count, but it was associated with significant reductions of alpha1-antitrypsin, haptoglobin, C-reactive protein, and complement fragment C3 in the first 6 hrs (p < .05). The sieving coefficients for all inflammatory mediators approached unity. CONCLUSIONS: PF caused a significant attenuation of the acute-phase response in sepsis. There was no significant difference in mortality, but there was a trend toward fewer organs failing in the PF group that suggests that this procedure might be beneficial.

Acute-Phase Proteins↗
PubMed1999

Tracheobronchial malacia and stenosis in children in intensive care: bronchograms help to predict oucome.

BACKGROUND: Severe tracheobronchial malacia and stenosis are important causes of morbidity and mortality in children in intensive care, but little is known about how best to diagnose these conditions or determine their prognosis. METHODS: The records of all 62 children in whom one or both of these conditions had been diagnosed by contrast cinetracheobronchography in our intensive care unit in the period 1986-95 were studied. RESULTS: Seventy four per cent of the 62 children had congenital heart disease; none was a preterm baby with airways disease associated with prolonged ventilation. Fifteen of the children had airway stenosis without malacia; three died because of the stenosis and two died from other causes. Twenty eight of the 47 children with malacia died; only eight children survived without developmental or respiratory handicap. All children needing ventilation for malacia for longer than 14 consecutive days died if their bronchogram showed moderate or severe malacia of either main bronchus (15 cases), or malacia of any severity of both bronchi (three additional cases); all children needing ventilation for malacia for longer than 21 consecutive days died if their bronchogram showed malacia of any severity of the trachea or a main bronchus (three additional cases). These findings were strongly associated with a fatal outcome (p<0.00005); they were present in 21 children (all of whom died) and absent in 26 (of whom seven died, six from non-respiratory causes). They had a positive predictive value for death of 100%, but the lower limit of the 95% confidence interval was 83.9% so up to 16% of patients meeting the criteria might survive. CONCLUSION: In this series the findings on contrast cinetracheobronchography combined with the duration of ventilation provided a useful guide to the prognosis of children with tracheobronchomalacia. The information provided by bronchoscopy was less useful.

Bronchial Diseases↗
PubMed1998

Cardiac failure in children with pneumonia in Papua New Guinea.

BACKGROUND: Cardiac failure is suspected of contributing to mortality from pneumonia in children in developing countries, but its role has not been clearly defined. METHODS: A convenience sample of 47 children admitted to Goroka Hospital in Papua New Guinea was studied prospectively with ultrasound, chest radiographs and assays of creatine kinase and lactate dehydrogenase. Results. Seven (15%) of the 47 children died. Of the 43 children who had a chest radiograph, 31 (72%) had severe or very severe pneumonia. No child had poor contractility of the heart on ultrasound examination or unequivocally raised cardiac isoenzymes; therefore no evidence of myocardial injury from sepsis was found. However, ultrasound examination showed dilatation of the right ventricle or hepatic veins in 12 (26%) of the children (both were dilated in 7 children) and 4 (33%) of these children died; this suggests that right ventricular cardiac failure secondary to pulmonary hypertension was present in 26% (95% confidence interval, 14 to 40%) of these children with severe pneumonia. Tachycardia was not associated with right ventricular dilatation on ultrasound, but 3 of the 4 children with more than 3 cm of liver palpable in the abdomen had right ventricular dilatation. Only 4 of the 12 children with right heart failure had hepatomegaly, tachycardia, raised jugular venous pressure or peripheral edema. CONCLUSIONS: Right ventricular failure is common in children with severe pneumonia, and it is probably caused by pulmonary hypertension rather than septic toxemia. The clinical signs of heart failure are unreliable. There is no evidence that digoxin is effective treatment for right ventricular failure secondary to pulmonary hypertension.

Cause of Death↗
PubMed1997

Should paediatric intensive care be centralised? Trent versus Victoria.

BACKGROUND: The mortality rate is lower among children admitted to specialist paediatric intensive care units (ICUs) than among those admitted to mixed adult and paediatric units in non-tertiary hospitals. In the UK, however, few children receive intensive care in specialist paediatric units. We compared the ICU mortality rate in children from the area the Trent Health Authority, UK, with the rate in children from Victoria, Australia, where paediatric intensive care is highly centralised. METHODS: We studied all children under 16 years of age from Trent and Victoria who received intensive care between April 1, 1994, and March 31, 1995. Children younger than 1 month were excluded unless they had cardiac disorders. We developed a logistic regression model that used information gathered at the time of admission to ICU to adjust for risk of mortality. FINDINGS: The rates of admission of children to intensive care were similar for Trent and Victoria (1.22 and 1.18 per 1000 children per year), but the mean duration of an ICU stay was 3.93 days for Trent children compared with 2.14 days for children from Victoria. 74 (7.3%) of the 1014 children from Trent died, compared with 60 (5.0%) of the 1194 children from Victoria. With adjustment for severity of illness at the time of admission to ICU, the odds ratio for the risk of death for Trent versus Victoria was 2.09 (95% CI 1.37-3.19, p < 0.0005). There were 31.7 (14.0-50.4) excess deaths in Trent children, which is equivalent to 42.8% of the deaths in ICU, and 11.1% of all deaths in children between the ages of 1 month and 16 years in Trent. INTERPRETATION: If Trent is representative of the whole country, there are 453 (200-720) excess deaths a year in the UK that are probably due to suboptimal results from paediatric intensive care. If the ratio of paediatric ICUs to children were the same in the UK as in Victoria, there would be only 12 paediatric ICUs in the country. Our findings suggest that substantial reductions in mortality could be achieved if every UK child who needed endotracheal intubation for more than 12-24 h were admitted to one of 12 large specialist paediatric ICUs.

Adolescent↗
PubMed1997

Meta-analysis of trials of prophylactic antibiotics for children with measles: inadequate evidence.

OBJECTIVE: To assess whether antibiotics should be given to all children with measles in communities with a high case fatality rate. DESIGN: Meta-analysis of randomised controlled trials that compared routine antibiotic prophylaxis with no antibiotic treatment or selective treatment of pneumonia or sepsis. SUBJECTS: Six trials of children admitted to hospital with measles: five in Glasgow, London, or New York between 1939 and 1954; and one in India in 1967. MAIN OUTCOME MEASURES: Incidence of pneumonia or sepsis, and mortality. RESULTS: All but one of the trials were unblinded, and randomisation was either not described or was by alternate allocation. In four studies, the incidence of pneumonia or sepsis in the control group was similar to that in the antibiotic prophylaxis group; in the other two studies, the incidence of pneumonia or sepsis was unusually high in the control group so these children had a higher complication rate than the antibiotic group. Four of the 764 children given antibiotics died compared with one of the 637 controls (exact odds ratio 4.0, mid-P corrected 95% confidence interval 0.5 to 101.6). CONCLUSION: The quality of the trials reviewed was poor, and they provide weak evidence for giving antibiotics to all children with measles. Available evidence suggests that, when mortality from measles is high, all children with measles should be treated with vitamin A but antibiotics should be given only if a child has clinical signs of pneumonia or other evidence of sepsis.

Antibiotic Prophylaxis↗
PubMed1997

Paediatric index of mortality (PIM): a mortality prediction model for children in intensive care.

OBJECTIVE: To develop a logistic regression model that predicts the risk of death for children less than 16 years of age in intensive care, using information collected at the time of admission to the unit. DESIGN: Three prospective cohort studies, from 1988 to 1995, were used to determine the variables for the final model. A fourth cohort study, from 1994 to 1996, collected information from consecutive admissions to all seven dedicated paediatric intensive care units in Australia and one in Britain. RESULTS: 2904 patients were included in the first three parts of the study, which identified ten variables for further evaluation. 5695 children were in the fourth part of the study (including 1412 from the third part); a model that used eight variables was developed on data from four of the units and tested on data from the other four units. The model fitted the test data well (deciles of risk goodness-of-fit test p = 0.40) and discriminated well between death and survival (area under the receiver operating characteristic plot 0.90). The final PIM model used the data from all 5695 children and also fitted well (p = 0.37) and discriminated well (area 0.90). CONCLUSIONS: Scores that use the worst value of their predictor variables in the first 12-24 h should not be used to compare different units: patients mismanaged in a bad unit will have higher scores than similar patients managed in a good unit, and the bad unit's high mortality rate will be incorrectly attributed to its having sicker patients. PIM is a simple model that is based on only eight explanatory variables collected at the time of admission to intensive care. It is accurate enough to be used to describe the risk of mortality in groups of children.

Adolescent↗
PubMed1997

The DCO2 measured by gastric tonometry predicts survival in children receiving extracorporeal life support. Comparison with other hemodynamic and biochemical information. Royal Children's Hospital ECMO Nursing Team.

STUDY OBJECTIVE: To assess the role of gastric tonometry in monitoring children receiving extracorporeal life support (ECLS) and to determine if DCO2 or pHi in the weaning phase of ECLS predicts survival. DESIGN: A prospective study of consecutive patients treated with ECLS. SETTING: A tertiary pediatric ICU that is the ECLS referral center for Australia. PATIENTS: Twenty consecutive children receiving ECLS for cardiovascular or respiratory failure. INTERVENTIONS: All children were monitored throughout their ECLS course using a tonometer inserted into the stomach via the orogastric route. The PCO2 in the tonometer balloon was measured every 4 to 6 h and the pHi was calculated using the Henderson-Hasselbalch equation. The DCO2, which is the difference between PCO2 in tonometer saline solution and arterial blood, was calculated. We compared the ability of pHi, DCO2, heart rate, mean arterial pressure, arterial pH, base deficit, and blood lactate to predict death or survival during the weaning phase. Measurements were taken on the lowest level of support, which for veno-arterial extracorporeal membrane oxygenation and ventricular assist device was defined as the lowest ECLS pump flows, and on veno-venous extracorporeal membrane oxygenation was defined as the time of lowest ECLS gas flow. Predictive power was assessed using the receivor operating characteristic (ROC) analysis on the data collected at these times. RESULTS: In the weaning phase of ECLS, the pHi was significantly lower in children who died (pHi = 7.21; 95% confidence intervals, 7.14 to 7.28) than in those who survived (pHi = 7.38; 95% confidence intervals, 7.28 to 7.47). The DCO2 was significantly higher in children who died (23.6 mm Hg; 95% confidence intervals, 14.3 to 33.1) compared with survivors (4.7 mm Hg; 95% confidence intervals, -0.78 to 10.1). The area under the ROC curve was 0.95 for DCO2 (and 0.88 for pHi). pHi and DCO2 predicted survival better than base deficit (area under ROC curve, 0.82), blood lactate level (0.29), arterial pH (0.65), heart rate (0.62), and mean arterial pressure (0.74). CONCLUSIONS: DCO2 is a clinically meaningful measurement in children receiving ECLS. A high DCO2 was a good predictor of death in this series. Gastric tonometry may provide a useful measure of the adequacy of regional perfusion and oxygenation in this group of patients.

Acidosis↗