key: cord-0005790-v9qgvfll
authors: nan
title: ESPNIC 2013: 24th Annual Meeting of the European Society of Paediatric and Neonatal Intensive Care
date: 2013-06-11
journal: Intensive Care Med
DOI: 10.1007/s00134-013-2950-8
sha: b72f23fcec99c8a904a8e863888c8fc25dc2903b
doc_id: 5790
cord_uid: v9qgvfll

nan

Moral distress in the hospital setting is defined as 'pain affecting the mind, the body, or relationships, resulting from patient care situations in which nurses experience a moral problem'. It also involves acknowledging responsibility and making a moral judgment about the correct action, but as a result of perceived constraints acting in a way that is perceived as morally wrong. Sources of moral distress vary from pain and suffering for the patient and aggressive care without perceived benefit to end-of-life care issues. More and more sophisticated treatment options for extremely premature neonates or children with congenital anomalies for example, have become available. The often complicated clinical courses and the children's suffering, however, are typical situations that may induce moral distress. Also, insufficiently skilled colleagues, conflicts, high workload, or lack of clear policies may be sources of moral distress. Studies have reported that half to one third of nurses experienced moral distress. As a result of moral distress, nurses may face lower work satisfaction and even burnout; consequently, some will resign, or even leave their profession. Moral distress can also negatively affect patient outcomes, in that nurses become emotionally detached and cynical, and are no longer really involved with patients.

The available studies demonstrate that new interventions should be developed and tested. Possible components are: facilitating nurses to express their moral concerns and involving them in moral decision making, educating them on ethical issues, and establishing a clear policy guiding moral practice. As the number of adult and child intensive care transfers increases each year in the UK, transfer teams are progressively exposed to the stressful situations associated with the transfer of unstable patients. The use of specialised teams whose prime focus is the transportation of critically ill children is now prevalent within the UK. What enables these teams to function in sometimes highly stressful situations and spend the majority of their working lives in unpredictable environments including the back of ambulances and onboard aircrafts?

The moral fibre required to be a member of a transportation team will be extrapolated and examples will be used to illustrate the differing situations these teams may encounter. The current infra structure that is in place to facilitate the safe transportation of critically ill children and contributes to reducing the stress of these situations for team members will be examined. The use of multidisciplinary team simulation training will be discussed and the effects of this on both team function and dynamics.

At the same time families report fear, miscommunication indifferent or inconsistent care In order to preserve dignity as much as possible we can insure privacy, cultural observations, discussion with families in order to relieve guilt feelings insure proper documentation so that each shift of nurses knows what the families have been through including the decision process through to ''good ICU death''. We should all be aware of our actions which lead to grieving period for family. The principles of a good death are to have emotional and spiritual support. In almost all circumstances we are able to have access to hospice care, have control over who is present at death, to respect the wishes of the dying, to have time to say goodbye, to be able to die rather than pointlessly prolonging life.

One of the tools we can use while caring or the dying is spirituality. We can frame spirituality to mean meaning, connection, integrity and hope. This talk will discuss how we can promote dying with dignity and the ways nurses can introduce spirituality in all crisis situations including caring for the dying patient and his family.

Participants: 91 participants (junior doctors, medical students, nurses and healthcare assistants) undertook the RESPOND course over four separate days. Results: Overwhelmingly participants found the course very useful; valuing the use of real cases and multi-professional group work. Improvement was perceived to be in communication between professional, and a proactive approach to patient assessment. The second survey, had poorer response but respondents were still positive about the impact of the course, advocating for it to be mandatory for all new clinical staff to the hospital. Conclusions: Our preliminary evaluations combined with the reduction of in-hospital cardiac arrest rates, suggest that the multidisciplinary RESPOND course (in conjunction with the Trust paediatric early warning system) is successful as a targeted strategy to promote patient safety. Introduction: For management of quality and safety, reliable and upto-date information on the actual harm inflicted on patients is vital. However, a gold standard for detection thereof is lacking.

Objectives: To determine the best feasible method for the detection of adverse events (AEs). Methods: The Trigger Tool methodology for the detection of AEs, as developed by the Institute for Healthcare Improvement, was adapted for use in the PICU of the Erasmus MC Sophia Children's Hospital. The triggers were collected for all admitted PICU patients from the electronic databases used in our hospital, rather than by a targeted search of randomly selected patient records. During a 2-year period, the AEs detected by the physicians were also recorded. The AEs found with both methods were collected and analyzed. Results: In 1,223 patients and 11,101 patient days, 804 adverse events were detected in 279 patients which amounts to a ratio of 0.66 AE per patient, and 7.2 AE per 100 patient days. 70 % of the AEs were detected with the Trigger Tool, 35 % were detected by the physicians. There were 244 AEs (30 %) detected by physicians that were not found with the Trigger Tool.

Conclusions: By combining different instruments for detection of AEs, the maximum yield can be achieved, thus creating the best possible overview of the actual harm inflicted on our patients. Further finetuning of the Trigger Tool methodology will likely improve the yield of this method and reduce the need for detection of AEs by healthcare workers.

Intensive Care Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands

Introduction: Every year over many patients die in hospitals around the world due to medical errors while many more patients suffer from permanent or temporary physical damage. An important part of these errors are attributable to ''Human Factors''. Ineffective communication and incorrect preparation for invasive procedures may expose patients to unnecessary risks. The intensive care unit (ICU) environment is especially prone to these errors. Since three decades commercial and military aviation have adopted the Crew Resource Management (CRM) approach to mitigate the negative effects of unavoidable ''Human Errors''. The adult and pediatric intensive care department of the Radboud University Nijmegen Medical Centre has adopted the CRM principles. Implementation: Since 2010 more than 350 medical and nursing ICU staff members completed a two-day awareness course into CRM principles and human factors. Simultaneously, important local obstructions in patient care with regard to communication and patient safety were identified. The most important obstructions were addressed by assigning specific safety tools. Examples are: checklists, briefing and debriefing procedures and a structured patient handover form. Furthermore a system was designed to assure continuous development and adherence to CRM rules. Since the introduction, checklist procedures are felt to provide improved safety and support. At the same time professional communication between medical and nursing staff can still be improved. The CRM approach described represents a new culture that also requires a new professional behavior, the acceptance of which is not without challenges. We have learned that implementation is a difficult process that requires constant vigilance.

Infection, Systemic Inflammation and Sepsis (11-14)

Sepsis is an important cause of morbidity and mortality in the paediatric population and early recognition with appropriate antibiotic therapy are crucial for successful management. On the other hand, inappropriate and prolonged exposure to antimicrobial agents adversely affect patient outcome and antibiotic resistance. Therefore, accuracy in early diagnosis of sepsis and definition of needed duration of antibiotic therapy are key questions in clinical practice. Procalcitonin (PCT) is a surrogate biomarker for estimating the likelihood of a bacterial infection. PCT-guided therapy is a novel approach to optimize antibiotic therapy management. Postnatal and gestational age dependent normal values of PCT challenge the accurate use of PCT in neonatal sepsis. Variable clinical settings influence diagnostic accuracy of PCT and make a context dependent interpretation mandatory. Keeping this in mind, separate evaluation of neonatal early-onset sepsis, neonatal late-onset sepsis and sepsis/meningitis in children are required. In general, PCT shows a higher accuracy in sepsis diagnosis compared to other infection markers and PCT-guided therapy is able to reduce duration of antibiotic therapy. Combination biomarker scores were proposed to overcome some of the limitations of PCT with promising results in preliminary studies. Strengths and limitations of PCT used in different clinical settings and paediatric populations need to be known for appropriate interpretation.

14.6 years (all medians)]: 120 visited the follow-up clinic, whereas 25 preferred to complete the questionnaires at home.

-48 % skin scarring due to purpura -8 % amputation(s); 6 % lower limb-length discrepancy (important long-term morbidity). -35 % neurological impairment(s). -1/16 patients with MSS-associated acute renal failure mild chronic renal failure. -significantly lower scores on nearly all Health Utilities Index attributes, indicating poorer health status. -significantly unfavourable health-related quality of life scores mainly on physical domains. -cognitive functioning similar to those of normative reference groups, but impairments on social and practical understanding, visual-motor integration, attention and executive functioning. -no significant differences between the proportions of patients scoring in the deviant psychopathological range for problem behaviour and same-aged reference groups. -adolescents, especially those with skin scarring, lower selfesteem.

Conclusions: A considerable number of MSS survivors showed longterm physical and/or (neuro)psychological problems. A standard follow-up clinic by a multidisciplinary team should be organized for MSS survivors in order to provide adequate quality of care. Background: Limited information is available on long-term outcome of lung function, maximal exercise capacity, severity of fatigue, and level of daily physical activity in young adults treated for neonatal respiratory failure. Methods: We studied 27 young adults [mean (SD) age: 26.8 years (2.9)] with congenital diaphragmatic hernia (CDH) and 30 matched controls. Controls were matched for age at follow-up, gestational age, birth weight, duration of mechanical ventilation and supplemental oxygen. Lung volumes and diffusion capacity were measured and expressed as mean (SD) standard deviation scores. Prevalence of respiratory symptoms was evaluated with the European Community Respiratory Health Survey. Exercise capacity was measured by cycle ergometry; daily physical activity with an accelerometry-based activity monitor; and fatigue by the Fatigue Severity Scale. Results: Mild airflow obstruction and reduced diffusion capacity was found in both groups with significantly more peripheral airflow obstruction in CDH and -0.2 (1.3) in controls, p = 0.006] in CDH patients. Airflow obstruction mildly increased from adolescence into adulthood in CDH patients [FEV 1 , and -1. 3 (1.4) respectively, p \ 0.04]. Both groups had a significantly higher prevalence of doctor-diagnosed asthma (27.6 % in CDH, 30 % in controls, p \ 0.001). Lung volumes, exercise capacity, daily activity and fatigue were similar in both groups. Conclusions and recommendations: We found minor differences between groups indicating that residual lung hypoplasia did not play an important role in this cohort. With increased survival rate in CDH patients, long-term longitudinal follow-up of lung function and exercise capacity is important.

LONG TERM COGNITIVE OUTCOME OF TBI SURVIVORS

Psychology & Deputy Director Integrated Mental Health Program, The Royal Children's Hospital, Melbourne, NSW, Australia

Childhood head injury is amongst the most common causes of childhood mortality and morbidity. Until quite recently there has been a perception that early injury is related to better outcome than at any other tie during the lifespan. However, recent research findings question this view, suggesting that early insults can derail normal developmental processes and lead to a range of functional consequences that impact on the child and his/her family in an ongoing way, with significant cost to the victim, family and community. This paper will describe findings from a prospective, longitudinal study of children with head injury, with the primary aims being: (1) to plot recovery trajectories through childhood and into adolescence and early adulthood; and (2) to characterise the nature of residual impairments. Findings indicated that children with head injury are at risk for serious and permanent functional impairments. Several risk and resilience factors were also identified which suggest the importance of a number of factors, other than injury characteristics, for determining outcome. These include developmental stage, environmental factors (parent function, SES), and pre-injury function and provide direction for designing effective interventions for these children and their families.

patients are from retrospective studies and case reports; RCT's are scarce. Current state of research in children with SBS was published and evidence-based recommendations where possible were given. In absence of evidence, clinical recommendations were based on expert opinion. Evidence-based recommendations:

-Enteral nutrition should be initiated a.s.a.p. to promote intestinal adaptation. -Breast milk or standard polymeric formula (depending on age) is the recommended initial feed.

Clinical experience based recommendations:

-Enteral nutrition should be administered continuously.

-Bottle-feeding (small volumes) should be started a.s.a.p. in neonates to stimulate suck and swallow reflexes. Solid foods may be introduced at the age of 4-6 months to stimulate oral motor activity and to avoid feeding aversion behavior.

Overall, it can be concluded that there is a significant lack of controlled studies for supporting nutritional management of SBS. Such studies are difficult to perform, since the incidence of the disorder is low and its manifestation may vary in every patient. Consequently, dietary management is highly variable. Critical illness can be defined as a life threatening condition mostly resulting from infection, sepsis and trauma and accompanied by similar physiological and biochemical responses, which have been termed the systemic inflammatory response syndrome (SIRS). The associated metabolic, endocrine, nervous and immunological changes are also known as the acute stress response. Depending on the severity of initial insult pronounced neuroendocrine and metabolic alterations will occur. A key feature is increased sympathetic nervous system activity, resulting in increased levels of adrenaline and glucocorticoids. Subsequently, immune cells are activated and pro-inflammatory cytokines secreted, which trigger further metabolic changes. In addition, insulin secretion is increased as well as the counter regulatory hormones glucagon, catecholamines, cortisol and growth hormone. As a result, glucose production is increased via increased glycogenolysis and gluconeogenesis and insulin resistance develops, leading to hyperglycemia. Also, fat is mobilized (lipolysis) and fat oxidation and ketone body formation are increased, while muscle protein breakdown is stimulated to provide amino acids for protein synthesis in proliferating cells, the production of acute phase proteins and other peptides (e.g. cytokines) and for gluconeogenesis. Traditionally, in critically adult patients the metabolic response to injury and sepsis is characterized by an ebb and flow phase. The course of critical illness in children differs from adults because critical illness may develop quickly and also recovery can be rapidly. Understanding the metabolic, endocrine nervous and immunological changes of pediatric critical illness is important and may improve outcome, as it allows the rational use of pharmaceutical interventions. Doppler Ultrasound of the cerebral arteries is an easily available bedside method. It is useful after hyoxaemic ischaemic insult, cerebral vascular surgery or head trauma. Resistive and pulsatile Index are the most frequent taken measurements but cannot be used as single value to judge adequate or failing cerebral perfusion or intracranial pressure. As shown in figure 1 changes in body homeostasis can alter the results.

Therefore an accurate and careful interpretation of Tc DU results needs to consider, blood pressure, general vessel filling, cardiac output, body-temperature, pH and PCO2.

promote the systematic uptake of clinical research findings, guidelines and other evidence-based practices into routine practice. Given the complex and dynamic ICU environment, simple implementation efforts that are effective in other clinical areas may, however, not result in meaningful change in the ICU.

In an effort to bridge the gap between evidence-based nursing and effective implementation of guidelines and protocols I will (1) give an overview of current developments in implementation science and ways to apply these to nursing;

(2) describe a general framework for implementation projects; (3) discuss barriers and facilitators for implementation, and describe current evidence for implementation strategies; and (4) discuss strategies to facilitate successful implementation in nursing ICU practice. Often seen barriers and facilitators for implementation relate to knowledge, cognitions, attitudes, routines, social influence, care provided by multidisciplinary teams, organization, and resources. Strategies focused on individual professionals and voluntary approaches currently dominate implementation research. Recent reviews also signaled education as a dominant strategy for implementation. Although education and related strategies (e.g. feedback, reminders) can be effective, other strategies such as decision support, use of information and communication technology and patient involvement are still left unexplored. Implementation strategies based on barriers/facilitators and are more effective.

In conclusion, clarifying implementation determinants and choosing the most effective strategies is needed to improve ICU-nursing. Critically ill children requiring mechanical ventilation almost always receive sedative and analgesic drugs. These will reduce possible distress, anxiety, pain, and facilitate intensive care therapy and nursing care. While undersedation will fail to produce the desired effects, oversedation will lead to prolonged PICU-stay and drug tolerance possibly with withdrawal syndrome. Therefore, sedation and analgesia are recognized as important areas of PICU nursing practice. The Pain and Sedation nursing study group of the ESPNIC-Nursing Science section developed a concept position statement Sedation and Withdrawal Assessment in PICU patients. In addition an extensive search of the available literature was performed for supporting evidence. Relevant published studies were identified through broad searches of the MEDLINE, EMBASE and CHINAL databases. Based on this several, recommendations were defined for domains: (1) pain assessment (type of instrument, frequency of assessment), (2) sedation assessment, (3) withdrawal assessment, and (4) non-pharmacological interventions.

Prior to the ESPNIC congress 2013, we will send a draft version of the recommendations for pain, sedation and withdrawal assessment in PICU patients to nurse attendees to indicate their agreement. During the congress, the results will be discussed in a 1-hour interactive session. Recommendations that do not achieve consensus will be rewritten with feedback of the individuals.

This consensus statement aims to help standardize the assessment processes used for pain, sedation and withdrawal by all nursing staff across PICU's within Europe in order to deliver best practice to our patients. Weaning from ventilatory support is the transition to spontaneous breathing and has traditionally been undertaken by the medical staff. A randomised controlled study was set up to compare doctors with nurse-led protocol-directed weaning with respect to outcomes including weaning time, PICU length of stay, complications and parental satisfaction with care. Method: Setting: One single 17 bedded PICU at the Leeds General Infirmary during two winter periods October-March 2001 -2002 and 2002 -2003 . Patients: Infants \1 year (n = 7). Intervention: A concealed random allocation process assigned infants to medical-led (n = 4) or nurse-led protocol-directed weaning (n = 3). Primary outcome: number of hours weaning on a ventilator from time of entry to the trial to extubation. A parental satisfaction with care questionnaire was mailed at 3 months post discharge from PICU. Results: Nurse-led protocol-directed weaning took longer than in the doctor-led group (mean 56 vs. 38 h) but mean total length of stay was less (135 vs. 155 h). No differences in complications were associated with either study group. Parental satisfaction with care achieved 85 % response rate. Parents of children receiving nurse-led weaning (n = 3) appeared to be more satisfied with care than the doctor-led group (n = 3) (median score n = 37 vs. n = 32). Conclusion: Few firm study inferences can be made because of the small sample size. This trial struggled to recruit. A restrictive randomisation service and limiting the ventilator type were some of the lessons learned from this trial.

Participation in an ancillary study is subject to the approval of (1) the parent study protocol committee (2) the parent study steering committee; and (3) the primary funding agency. Funding for an ancillary study must be secured and can include investigator-initiated research awards, grants from academic institutions, private sources or those performed at no cost. Sufficient funding for all aspects of the ancillary study including cost incurred by the parent study, the Data Coordinating Center (DCC; sample selection, preparing and documenting analysis files, participating in statistical analysis, and integrating the new ancillary data back into the combined parent study database), and to the Clinical Sites for personnel (obtaining consent, collecting and transmitting data and samples) must be provided by the ancillary study investigators. Ancillary studies are subject to the same policies, reviews, and approvals as the parent protocol. In addition, ancillary studies should not cause a deviation from the defined study protocol; complicate the interpretation of the study results; potentially affect subject cooperation or interest in the study; jeopardize the public image of the study; create a significant diversion of study resources locally or at the DCC; in any way negatively influence the cooperative spirit of the collaborating investigators or otherwise compromise the scientific integrity of the study Objectives: The aims of this project were to describe whether or not pediatric clinical staff believe that a donation after cardiac death (DCD) program could be consistent with the mission and core values of a children's hospital and to identify what staff consider essential to the acceptability of such a program. Methods: Qualitative study in which data were gathered from pediatric clinical staff during eight focus groups conducted in one US children's hospital. Measurements and Main Results: Eighty-eight staff members participated. Six major themes emerged from qualitative analysis of the data: (1) identifying children who could be candidates for DCD; (2) considering the best interests of the dying child; (3) approaching parents about DCD; (4) preparing parents for their child's DCD; (5) the need to do DCD well; and (6) maintaining program integrity. Themes were used to construct a conceptual framework describing a model pediatric DCD program. Pediatric staff voiced numerous concerns. However, they identified ''making it happen for families'' who voice a desire to participate in organ donation as the primary reason for program adoption.

Conclusions: This study provides a framework for understanding pediatric staff perspectives on DCD programs in children. Results suggest several possible elements that may be helpful in framing interdisciplinary dialogue and informing institutional practices in the design of a pediatric DCD program. Pressure ulcers (PU) represent a serious yet preventable iatrogenic injury. Most healthcare organizations track their PU prevalence rates to describe the quality of care they provide within their institution. These data are also used to benchmark care quality across healthcare organizations. To better understand an institution's PU rate, it is important to understand their patient populations' level of risk for PU. Successful PU prevention programs should be assessed from a perspective of identifying at-risk patients who remain PU free. Tools that describe PU risk should predict patients at risk and patients not at risk for PU development. The Braden Q Scale for predicting pediatric PU risk is a widely used valid and reliable pediatric-specific PU risk assessment tool. Since its publication in 1996, requests for clarification on how best to use the tool across the spectrum of pediatric patients commonly cared for in healthcare organizations have been received. Common clarifications include using the Braden Q Scale as originally designed; specifically, not using untested derivations of the tool and not using the Braden Q Scale to predict medical devicerelated PU. Validation of a new tool, the Braden Q + D Scale for predicting both immobility-related and medical device-related pediatric PU risk, is currently underway. This session will provide information on how best to score a patient's risk for PU. Accurate assessment of patient risk is the first step in guiding appropriate interventions that prevent PU. Initiating PU prevention strategies for at-risk patients, rather than all patients, will optimize the appropriate use of resources.

Pharmacology ( In the last decade a number of questions about the safety dosage and long term effects of opioids have been raised resulting in the following actual research questions: Does early pain especially in the preterm infant result in long term behavioral effects? What are the consequences of the off-label and/or unlicensed use of drugs throughout childhood? What is the relation between experimental findings suggesting increased neuroapoptosis in animals following exposure opioids c.q. benzodiazepines and human data?

With regards to neurotoxicity conflicting results have been published in a variety of animal models using different experimental approaches.

To date no human long term data have provided convincing evidence that early pain with or without adequate analgesia results in significant behavioral problems in children up till the age of 9 years. Innovative ways of investigation to evaluate pain threshold as well as nociceptive responses such as quantitative sensory testing in combination with fMRI will potentially answer these questions. Welldefined cohorts of former newborns especially preterm borns with detailed knowledge of opioids/benzodiazepine dosages in the newborn period are now available for evaluation with the focus on abnormal executive functions.

Pharmacotherapy aims to attain safe and effective drug prescription, including in preterm infants. This should be based on integrated knowledge concerning the evolving physiological characteristics of the infant who will receive the drug and the pharmacokinetic and pharmacodynamic characteristics of a given drug. Consequently, clinical pharmacology in preterm neonates is as dynamic and diverse as the neonates we have in our units.

Covariates explaining the variability are at least as relevant as the median estimates. Covariates of pharmacokinetics (PK, i.e. concentration-time profiles) can predict the exposure time course reasonable accurate. However, maturational trends are not similar for all maturational changes. This will be illustrated based on the differences between hepatic and renal maturation, and on the impact of pharmacogenetics on drug disposition and effects in early life. The subsequent link between PK and PD, (i.e. pharmacodynamics, concentration effect profile) remains much less explored. We aim to illustrate the complexity and the need for neonatal clinical pharmacology based on the gap between current and likely best clinical practice for two commonly administered compounds (aminoglycosides for infection and ibuprofen for patent ductus arteriosus) and one new compound (bevacizumab, to treat threshold retinopathy of prematurity). Finally, when we prescribe specific compounds, we also should take into account issues related to formulations available. In contrast to dedicated ventilations, infusion equipment and incubators for neonates, we still use untailored formulations, containing either very high concentrations of the therapeutic compounds or potential toxic excipients.

Background and aims: Trisomy 18 (T18) is one of the commonest major chromosomal abnormalities. In many parts of the world the majority of affected pregnancies are terminated. This study aimed to examine obstetric management of T18, and the factors influencing practice Methods: Fellows/members of RCOG were contacted by email and invited to take part in an anonymous electronic survey. The survey asked basic demographic information, experience, attitudes and knowledge relating to T18, and response to a hypothetical case.

Questions about religion were based on the British Social Attitudes survey.

Results: 666/2,885 (23 %) practising obstetricians/gynaecologists answered the survey. Most had managed a case of T18 in the last 2 years. 53 % (275) respondents indicated that they were somewhat, very or extremely religious, while 20 % (101) were somewhat, very or extremely non-religious, and 27 % (139) were neither religious nor non-religious (neutral). Religious obstetricians were more likely than non-religious to cite an ethical or moral objection to termination of pregnancy (TOP) (32 vs 3 %, p \ 0.0001), and less likely to offer TOP following antenatal diagnosis of T18 (92 vs 99 %, p = 0.03). Non-religious respondents were more likely to support non-resuscitation at birth (75 %) than religious (44 %) or neutral (56 %) respondents (p \ 0.0001). Religious respondents had similar expectations about outcome for fetuses and infants with T18 to nonreligious respondents. The religion of obstetricians was not associated with provision of maternal-focused or fetal-oriented obstetric care.

Conclusions: There is variability in UK obstetricians' knowledge of and attitudes towards T18, and this appears to be influenced by obstetrician religion. Method: In a retrospective multicenter study all preterm infants born between 24 +0 to 27 +6 weeks of gestation in 2010 and 2011 were included. Results: The investigated NICU's had comparable extreme preterm birth. However significant differences were observed in incidence of PDA, drug treatment and need for surgical ligation. Furthermore there were significant differences in adjusted mortality for gestational age and early treatment. No difference in adjusted mortality between the centers was found (Tables 1 and 2) . was assessed by PIM2 and PRISM3-24 after re-estimating riskcoefficients for both models to the average mortality rate in the overall study population (PIM2NL and PRISM3-24NL). PICU outliers were detected using funnelplots. Results: 12,040 Consecutive admissions to 7 PICUs with 421 deaths. National re-estimated models, PIM2NL and PRISM3-24NL detected different outliers. Mortality ratios after adjustment with PRISM3-24NL lay closer to each other than after adjustment with PIM2NL and all within 2SD limits to the national average. After adjustment to PIM2NL three PICUs were detected lying outside 2SD limits but within 3SD limits: one PICU above and two PICUs below 2SD from the national average (figure 1). Background and aim: Neonates have limited antioxidant protective capacity. It has recently been demonstrated that phototherapy used for treatment of neonatal jaundice produces oxidative stress. Various phototherapy devices using different light sources are available for phototherapy. We aimed to investigate effects of phototherapy applied with different light sources on the global oxidant/antioxidant status in neonates.

Method: A prospective controlled study was conducted. Otherwise healthy term and late-preterm ([35 weeks) neonates younger than 10 days postnatal age hospitalized to receive phototherapy for nonhemolytic jaundice were enrolled. Infants who received conventional phototherapy with fluorescent lamps were defined as group 1, those who received intensive light emitting diode (LED) phototherapy as group 2, and fiberoptic phototherapy as group 3. The serum total antioxidant capacity (TAC) and total oxidant status (TOS) were measured before and 24 h after phototherapy. Oxidative stress index (OSI) was calculated.

Results: Twenty nine patients were included in each group. At the beginning of phototherapy serum TAC, TOS and OSI levels were similar in all groups. After phototherapy serum TAC decreased significantly in all three groups (p \ 0.001). Total oxidative stress increased significantly in group 1 (p \ 0.001) and group 2 (p = 0.001) where as a statistically insignificant increase was observed in group 3 (p = 0.057). After phototherapy OSI increased significantly in group 1 (p \ 0.001), group 2 (p = 0.001), and group 3 (p = 0.038).

Conclusion: These results suggest that oxidative stress increases after phototherapy with fluorescent lamp and LED devices, and to a lesser extend with fiberoptic devices. Phototherapy decreases antioxidant capacity regardless of the light source and intensity

Objectives: This study evaluated the occurrence of adrenal insufficiency and the effect of hydrocortisone in term neonates with vasopressor resistant septic shock on cumulative dose and duration of inotropes compared with administration of placebo (controls).

Methods: This pilot randomized placebo controlled open label trial was conducted in a tertiary referral neonatal unit and was approved by institutional ethical committee. Neonates with major congenital malformations were excluded. Eighty term neonates with septic shock requiring dopamine 15 lg/kg/min were randomized (computer generated with concealed sequence) to receive hydrocortisone or placebo (equal volume saline).

Result: The baseline characteristics of both groups were comparable. Occurrence of relative adrenal insufficiency (serum cortisol \18 lg/ dl) was 29 % (16 % in study group and 13 % in controls). Mean duration of dopamine, dobutamine and adrenaline was lesser in hydrocortisone group (21 ± 14 versus 23 ± 20 h, 22.9 ± 13.3 versus 24.6 ± 21.6 h and 12.9 ± 9 versus 25.5 ± 23 h respectively). Cumulative doses of dopamine, dobutamine and adrenaline were lesser in hydrocortisone group. Dobutamine was required in only 21 cases in hydrocortisone group versus 29 in controls. Adrenaline was required in only 13 cases in hydrocortisone group versus 19 in controls. However, the differences were not significant.

Conclusions: Adrenal insufficiency was observed in 29 % term neonates with vasopressor resistant septic shock. There was earlier reversal of shock with lower dose, duration and number of inotropes required in the hydrocortisone group. However, the differences were not significant. Larger multicentric trials are recommended. Group 2 3.10 (3.00-3.60) 2.80 (1.70-3.50) .001 6.4 (2. 1-37.5 Background and aims: Invasive ventilation (IV) of extremely premature infants harbours potentially harmful effects, such as decreased cerebral blood flow, ventilator-induced lung injury, and increased risk of nosocomial infections. We assessed the impact of the duration of IV on outcome at 2 years of age in a recent national cohort of extremely premature infants.

Methods: This study is based on the national registry of preterm infants born in Switzerland between 24 0/7 and 27 6/7 weeks during 2000-2008. Neurodevelopmental disability (ND) was assessed using Bayley Scales of Infant Development-II and the Gross Motor Function Classification System. Adverse outcome (death or severe ND), and unfavourable outcome (death or any ND) were analysed using multivariable logistic regression with adjustment for perinatal factors known to affect outcome. Results: Of 856 infants surviving to 36 weeks postmenstrual age, follow-up information was available in 81 %. 74 % of infants required IV (median duration 4 days), and 21 % developed bronchopulmonary dysplasia (BPD). 440 (63 %) showed normal development, 246 (37 %) unfavourable outcome, and 90 (13 %) adverse outcome. IV duration was one of the strongest predictors of BPD (p \ 0.001). The duration of IV was significantly associated with adverse outcome (per day of IV: multivariate OR 1.03; 95 % CI 1.01-1.05, p = 0.005) and with unfavourable outcome (OR 1.02, 95 % CI 1.00-1.04, p = 0.03).

Conclusions: Prolonged duration of IV increased the risk for poor outcome of extremely premature infants independently of other neonatal morbidities. Whether IV duration is primarily a marker of disease severity, or whether it may directly contribute to poor outcome merits further investigation.

Methods: Participants (born 1993-2002) joined our structured longitudinal follow-up program. We used the Movement-Assessment-Battery for Children (M-ABC), the Bruce protocol, and the m-CBSK questionnaire.

Results: Primary diagnoses were: meconium aspiration syndrome (MAS; n = 54), congenital diaphragmatic hernia (CDH; n = 17); persistent pulmonary hypertension (PPHN; n = 17); other diagnoses (n = 12). M-ABC: 68/97 (70.1 %) had a normal overall percentile score, 13/97 (13.4 %) were classified as borderline, and 16/97 (16.5 %) had a definite motor problem (distribution differed from reference population, p \ 0.001). Subgroups: normal in 40/52 (76.9 %) with MAS, 9/17 (52.9 %) with CDH, 11/17 (64.7 %) with PPHN and 8/11 (72.7 Background: After preterm birth mothers are at high risk for postnatal depression. We studied the effect of maternal depression as well as infant and environmental characteristics on later child outcome. Method: The study group consisted of all Dutch native speaking mothers of surviving very preterm infants of gestational age \32 weeks, born from January 2007 to January 2009 (n = 316). At 6 weeks of corrected age maternal depression was assessed by the Edinburgh Postnatal Depression Scale. Child characteristics were gestational age, birthweight (SGA \ -2 SD) and gender. Environmental factors were SES and HOME environment. At 2 years of age mental development (MDI) was assessed by the Bayley Scales of Infant Development BSID III), attention and internalizing behavior by the Child Behavioral Check List (CBCL). Results: Depressive symptoms (EPDS score [12) were found in 75 of the 316 (24 %) mothers and was higher with lower gestational age (\27 weeks 40 %, 27-29 weeks 24 %, [29 weeks 17 %). Follow-up was available for 85 % of the children. Children of mothers with an EPDS score = \12 scored lower for internalizing (T score mean = 44.3 SD 9.5 vs 47.9 SD 8.7) as well as for attention problems (T score mean = 55.0 SD 6.2 vs. 57.0 SD 7.0) and had better mental development (MDI mean = 102.9 SD 9.5 vs 97.4 SD 10.9) at 2 years of age than depressive mothers (EPDS score [12) .

In the NICU maternal depression should be systematically assessed and adequately treated for a better outcome of mother and child. Objectives: Glucocorticoid treatment during pediatric cardiac surgery may negatively affect protein metabolism. We evaluated the effect of glucocorticoid treatment on per-operative serum amino acid concentrations.

Methods: Arterial blood was sampled in children with congenital heart disease before cardiac surgery (t = -5 min), directly after surgery (t = 0) and at t = 12 h and t = 24 h after surgery. Serum cortisol and amino acid concentrations were determined. Patients who received glucocorticoids (G+) were compared with patients who did not (G-). Results as median (IQR), Mann-Whitney U test.

Results: 67 % of the 49 included children [age 1.7 (0.5-8.7) year] received glucocorticoids. Baseline characteristics were not different between groups. Serum cortisol concentrations were significantly higher at t = 0 in the G+ group (G+, 6,953 (4,734-8,154 ); G-, 242 (111-517) nmol/L; p \ 0.001). The sum of all amino acids at t = 12 h (G+, 2,384 (2,120-2,763); G-, 2,049 (1, 230) lmol/ L; p = 0.016) and t = 24 h (G+, 2,465 (2,333-3,050); G-, 2,294 (2,077-2,353) lmol/L; p = 0.001) were significantly higher with glucocorticoids. Of special interest, citrulline concentrations were significantly higher in the G+ group at t = 12 h [G+, 26 (21-29) ; G-, 19 (12-24) lmol/L; p = 0.034] and t = 24 h [G+, 22 (17-29) ; G-, 14 (10-19) lmol/L; p \ 0.001], as well as arginine concentrations at t = 12 h [G+, 74 (64-86) ; G-, 65 (60-67) lmol/L; p = 0.017].

Conclusions: Glucocorticoid treatment during cardiac surgery in children blunts the reduction in serum amino acid concentrations post-surgery. Especially citrulline concentrations, the sole precursor of de novo arginine production, were preserved. This may prevent arginine, needed for nitric oxide production and immune function, from becoming an essential amino acid.

seems to remain. The aims of the present study were to examine the prevalence of underfeeding, adequate feeding, and overfeeding in mechanically ventilated children and to identify barriers to the delivery of nutritional support. Methods: Children aged 0-14 years who fulfilled the criteria for indirect calorimetry were enrolled in this prospective, observational study and were studied for up to 5 consecutive days. Actual energy intake was recorded, and compared with the required energy intake (measured energy expenditure plus 10 %); energy intake was classified as underfeeding (\90 % of required energy intake), adequate feeding (90-110 %), or overfeeding ([110 %). The reasons for interruptions to enteral and parenteral nutrition were recorded. Results: In total, 104 calorimetric measurements for 140 total days were recorded for 30 mechanically ventilated children. Underfeeding, adequate feeding, and overfeeding occurred on 21.2, 18.3 and 60.5 % of the 104 measurement days, respectively. There was considerable variability in the measured energy expenditure between children, (median, 37.2 kcal/kg/day: range 16.81-66.38 kcal/kg/day), but the variation within individual children was small. Respiratory quotient had low sensitivity of 21 and 27 % for detecting underfeeding and overfeeding, respectively. Fasting for procedures was the most frequent barrier that led to interrupted nutritional support.

Conclusions: The high percentage of children (*61 %) who were overfed emphasizes the need to measure energy needs by using indirect calorimetry. Introduction: Extremes of ''weight-for-age'' are common in children admitted to intensive care. Recent literature suggests poorer outcomes in children who are significantly underweight. For overweight children, the effect is less clear. Weight-for-age may be an independent risk factor for mortality. We investigated the following null hypotheses:

1. weight distribution of the PICU population does not differ from that of the general population 2. weight-for-age does not influence risk-adjusted mortality.

Methods: We retrospectively calculated weight-for-age z-scores for all admissions to GOSH PICU between March 2003 and December 2011. Risk-adjusted SMRs were calculated using PIM2 (estimate of expected probability of mortality) and observed mortality. Results: 14,205 records were analysed. The mean z-score weight-forage was -1.11 (p = 0.009). Extremes of weight-for-age were more prevalent in the PIC cohort than the reference population. A plot of weight-for-age z-score vs. SMR (figure 1) demonstrated increased mortality at both extremes of weight-for-age. Mean and moderately raised weight-for-age were associated with the lowest mortality. Conclusion: We have demonstrated that the PIC population weightfor-age distribution does differ from that of the general population, with a significantly lower mean. Furthermore, extremes of weight-forage at admission are a risk factor for mortality. These findings were consistent across age and gender sub-groups. Objectives and study: To investigate the efficacy of zinc in reducing morbidity and mortality of preterm neonates. Methods: Prospective, double-blind, randomized controlled study enrolling very low birth weight neonates randomly allocated at 7 days of life to ''active treatment'' (oral zinc supplementation at 10 mg/kg/day, in a multivitamin preparation) or to ''placebo'' (similar multivitamins preparation without zinc). The main endpoint was morbidity, defined by the presence of at least one of the following conditions: late-onset sepsis, necrotizing enterocolitis, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leucomalacia and retinopathy of prematurity. Secondary outcomes were mortality and growth at discharge. Results: We enrolled 97 neonates in the active treatment group and 96 in the placebo group. Morbidity was significantly reduced for the neonates receiving oral zinc supplementation (44.3 %) compared with placebo (61.5 %, p = 0.017). Occurrence of necrotizing enterocolitis was higher in the placebo group (6.3 %) compared with active treatment group (0 %, p = 0.014). Mortality risk was increased in neonates receiving placebo compared to those supplemented with zinc (2.37, 95 % CI 1.08-5.18, p = 0.006). Body-weight at discharge was higher in the zinc-group (2,208 ± 501 g) compared with placebo-group (1,889 ± 639 g, p = 0.001).

Conclusion: Zinc reduces morbidity and mortality and improves body growth in preterm neonates. Objectives: High-dose barbiturates may be used to treat intractable raised intracranial pressure (ICP) following traumatic brain injury (TBI) when maximal first-tier interventions have failed. However paediatric studies are limited with no consensus regarding optimal monitoring. We sought to describe current thiopental coma practice in UK paediatric intensive care units (PICUs). Methods: An online survey was distributed via UK Paediatric Intensive Care Society Study Group (PICS-SG), registered as an audit. Mandatory multiple-choice and open questions covered indications for thiopental coma, administration methods, monitoring effectiveness, side-effects and thiopental cessation. Results: Fifteen of 32 UK PICUs completed the survey including 11/16 (69 %) PICUs admitting [10 children annually requiring ICP monitoring. Thiopental coma for intractable intracranial hypertension following TBI is used in 12/15 responder units. Five units (42 %) do not use a protocol to guide management. Response in ICP is the main outcome measure to monitor effectiveness of thiopental coma in 8 (66 %) units; this is combined with EEG monitoring in 6 units. Three units specified administering thiopental boluses to desired ICP response, then titrating infusions to achieve burst suppression on EEG. Recognised side-effects include hypotension (11/ 12), infection (7/12) and gastrointestinal disturbance (5/12). Reasons to stop thiopental coma include adequate ICP control (10/12), achieving burst suppression (7/12) and unacceptable side-effects (7/12). Conclusions: There is wide variation in practice in thiopental coma use in intractable raised ICP in UK PICUs. This study highlights the need for collaboration to rationalize thiopental use in intractable intracranial hypertension in paediatric brain injury. Acknowledgements: UKPICS-SG and participating units. Background & aim: In adults receiving therapeutic hypothermia (TH) following cardiac arrest (CA), deteriorated microcirculatory perfusion (MP) and peripheral capillary refill time (pCRT) are associated with mortality. We aimed to study MP and pCRT during and after TH in pediatric CA patients in relation to mortality. Methods: Buccal MP (Sidestream Dark Field Imaging) and pCRT (evaluated by nursing staff) were measured at 0-12 (T1) and 12-24 h (T2) following start of TH, during re-warming (T3), and at normothermia (T4). Primary parameters were small (S; Ø: 0-10 lm) and non-small (NS; Ø: 11-100 lm) perfused vessel density (PVD-S, PVD-NS), microvascular flow index (MFI-S, MFI-NS), and normal pCRT (\2 s). Data are presented as median (IQR) or number (%) and analyzed using non-parametric tests (*p \ 0.05 vs. T1, # p \ 0.05 vs. T2, p \ 0.05 vs. T3). Results: Twenty-three patients, 11 non-survivors, were included. From T1 to T2, PVD-S and PVD-NS were unaltered ( Figure 1 ). T3 PVD-NS and T3 and T4 PVD-S were increased compared to T1 and T2. MFI-S and MFI-NS increased at T2-T4. Compared to T1-T3, pCRT normalized at T4. Non-survivors had lower T1 PVD-NS (4.9 vs. 6.6, p = 0.035), MFI-S (2.08 vs. 2.69, p = 0.037), and MFI-NS (2.38 vs. 2.73, p = 0.048). Conclusions: Low MP early after TH start is associated with mortality. After TH stop, MP and pCRT increased and remained increased irrespective of outcome. Institute for Women's Health/Neonatal Intensive Care, 2 Institute for Women's Health, University College London Hospital, 3 Wellcome Centre for Imaging Neuroscience, University College London, London, UK Background: Exposure of the neonatal brain to a variety of anaesthetics is associated with neuroapoptosis in rodent and non-human primate experiments with clinical studies being suggestive of cognitive impairment. These data has worried the anaesthetic community especially with growing numbers of surgery during this vulnerable period. The neonatal piglet model closely mirrors the period of rapid brain growth in the human brain.

Aims: To investigate if the newborn piglet brain is vulnerable to anaesthetic exposure with isoflurane during a clinically relevant period. Methods: 12 newborn piglets (aged \24 h) randomised to: (i) naïve (nai) (n = 6) (ii) anaesthesia (ane) (n = 6) Anaesthesia induced with IM midazolam followed by intubation and ventilation with 2 % isoflurane as well as IV fentanyl (3-6 mcg/kg/h) for 6 h. Tight (invasive) monitoring of physiological parameters and bloodgases. Piglets were sacrificed either immediately (i) or 6 h afterwards (ii). Immunohistochemistry on the brain was performed for TUNEL (cell death) and Iba-1 (microglial activation) and cells were counted in 9 brain areas. Results: Compared to naïve, 6 h exposure to 2 % isoflurane, was associated with an increase in TUNEL + cells (p \ 0.05; Mann-Whitney test) and Iba-1 stained cells (p \ 0.05).

Conclusion: Six hours of anaesthesia with isoflurane increased cell death and microglial activation in the newborn piglet brain. Further research on brain protective strategies is required. Design: A prospective, randomized, double-blinded study. Setting: Pediatric Day Care Unit (DCU), King Abdul Aziz Medical City, Riyadh, Saudi Arabia. Patients: Two hundred seventy five pediatric who needed sedation for diagnostic procedures. Intervention: After meeting inclusion criteria and getting informed consent, patients were given the study drug. Patients were monitored for sedation outcomes. Measurement and main results: A total of 292 sedations performed between July 2005 and October 2006 were included in the study. Due to missing data, 286 sedations were included in the final analysis 144 were in the CH arm, and 142 were in the MD arm. Both the MD and CH groups were comparable with respect to demographic and baseline characteristics (p values [0.05) . Compared with the MD group, the CH group had a higher sedation success rate, diagnostic procedure completion, and sedation adequacy rate (p values .05). Also CH had a shorter time to sedation, a shorter length of stay in DCU, and longer sedation duration (p values .05). In both study groups, patients who required a 2nd dose tended to be older and heavier. No major side effects were encountered. Conclusion: CH achieved a shorter time to sedate, a higher success rate, less need for a 2nd dose, and decreased the time spent in the DCU compared to sedation using MD. Older and heavier patients are more likely to require a 2nd dose of the study drug to be sedated. Background: Breastfeeding is the feeding practice recommended for late preterm newborns, nevertheless neonatal factors and maternal factors can delay or prevent the initiation of breastfeeding. Feeding difficulties (easy fatigability, inadequate autoregulation skills, uncoordination of oropharyngeal movements) require great competence for suction. Aims: To investigate breastfeeding rates in a population of late preterm newborns in association with principal neonatal factors (gestational age, birth weight, birth weight for gestational age, unit of hospitalization) at Neonatal care unit and Neonatal sub intensive care unit of San Paolo Hospital, University of Milan. Methods: This observational study recruited a sample of late preterm newborns (G.A. 34-36 +6 weeks) born between January 1st 2010 and June 30th 2012 (n = 194). Results: Breastfeeding initiation is lower for late preterm population (78.4 %) than term newborns (94.3 %). Late preterm newborns in Neonatal care unit, also because of the possibility to practise rooming in, have increased exclusive breastfeeding rates.

Breastfeeding rates are directly proportional to gestational age and to birth weight. Low birth weight is a risk factor for unsuccessfully exclusive breastfeeding. Breastfeeding rates in SGA newborns are lower than in AGA newborns.

LGA newborns have increased rates of exclusive breastfeeding. Conclusions: Late preterm newborns are at greater risk of being artificially fed.

Findings of this study agree with other scientific evidences (Arch Dis Child Fetal Neonatal Ed. 2008; 93(6) : F448-50) . Promotion of WHO/UNICEF ten steps, a personalized nutritional plan and an evidence based time of discharge could be strategies to improve breastfeeding rates in late preterm newborns. Background and aim: Amplitude-integrated electroencephalography (aEEG) is a bedside single lead EEG monitoring tool to assess neonatal brain function and evaluate the presence of neonatal seizures. The aim of this project was to improve the current level of knowledge in nursing staff concerning the use of the digital aEEG monitor (Olympic CFM 6000). Main teaching targets were the assessment and classification of known background patterns (BP) and sleep-wake cycling (SWC); dealing with pitfalls (PF) and recognizing the presence of neonatal seizures (S). Methods: This research was performed from September 2011 to October 2012 within the tertiary NICU of the Academic Medical Centre, Amsterdam, the Netherlands. A working group obtained expert knowledge in handling the aEEG monitor and correct interpretation of results. Clinical lectures for the nursing staff (N = 58) were implemented through theoretical background-and bedside teaching. A pre-lecture baseline (N = 35) and post-lecture test (N = 24) were held by written exam. Results: The level of knowledge in recognizing BP, SWC, S and PF showed a clinically significant improvement (respectively 56. 3, 84.7, 91 .0, and 100 %) compared to the baseline measurement (respectively 34.8, 80.0, 89, and 97.1 %) . General knowledge of aEEG showed also significant improvement. Conclusion: This study underlines the value of clinical training for nursing staff to improve daily care for NICU patients. BP recognition remained the most difficult to recognize. Motivating nursing staff to complete and participate in essential post test evaluation proved difficult and possibly influenced the results. Objective: To study the effect of 0.2 ml of 12 and 24 % oral sucrose on reducing pain during venepuncture in ELBW infants and the side effects associated with this administration.

Methods: A Double blind RCT was conducted on clinically stable ELBW (\1,000 g) neonates regardless of gestational age within first 48 h of life. Neonates were divided into two study groups (30 neonates in each group) and administered either 0.2 ml of 24 % sucrose (active control) or 0.2 ml of 12 % sucrose 2 min prior to venepuncture. The entire procedure was video-recorded and Neonatal Facial Coding System (NFCS) used to evaluate pain. The NFCS was coded at pre-procedure, intra-procedure, post 30 s, 1 min and 2 min of procedure. The side effects were noted. Results: 60 ELBW neonates were enrolled, randomized and analyzed. The baseline characteristics of the group were comparable. The NFCS scores (Mean ± SD) in 12 versus 24 % sucrose were 0.63 ± 1.35 and 0.46 ± 0.86 in the pre-procedure observation the intraprocedure observation was 4.8 ± 1.18 in 12 % and 4.46 ± 1.5 in 24 % sucrose. Post 30 s observation was 1.1 ± 1.64 in 12 % and 0.7 ± 1.2 in 24 % sucrose No statistically significant difference between the NFCS scores was observed even at Post 1 min & Post 2 min of the procedure. 5 immediate adverse effects were observed (HR changes, transient desaturations and vomiting) however, no significant difference observed in adverse effects across the two study limbs. Conclusions: 0.2 ml of 12 % oral sucrose appears to be not-inferior to 0.2 ml of 24 % oral sucrose in reducing pain during venepuncture in ELBW neonates. There is no difference in side effects with either concentration of sucrose. Pain and sedation assessment in PICU is particulary important for nursing care and therapeutic success since it prevents risks associated to insufficient or excessive analgosedation. Optimal levels of mechanically ventilated children's comfort is an every day challenge for PICU staff. The objective of this study is to evaluate the validity and reliability of CBS in the Italian pediatric context. 24 patients admitted at one of the Intensive Care Units of the Emergency Department of Bambino Gesù Children's Hospital have been observed. The patients were mechanically ventilated and analgosedated through continuous infusion of ipnotics and oppiods. Two nurses observed together, but independently each patient before and after the procedure of tracheal suctioning, assessing vital signs, pain and sedation through the CBS and the Nurse Interpretation of Sedation Scale. In 14 cases there was a third nurse assessing the patient through the CBS with the objective to test the scale's reproducibility. A total of 50 observations was made. The study has been approved by the Ethics Committee and parent's of patients have signed informed consent. The 24 observed patients had a mean age of 7.46; 54 % were female, reason for admission was major surgery and acute respiratory failure. Median value of PIM was 2.1. The level of agreement between the two scales was high (88-78 %) . Comparison between vital signs and CBS values variations indicates that there isn't a total and continuous expected increase or reduction. Inter rater reliability was high (K = 1, K = 0.558). Internal consistency was positive (Cronbach's alpha 0.8). Objectives: A recent study in the NICU of Lille University Hospital showed the inaccuracy when preparing of vancomycin syringes by nurses. The objective of this study is to assess the impact of reconstitution solvent on the accuracy of vancomycin syringes. Methods: The commercial drug used was formulated as a powder for solution for intravenous infusion (vancomycin 250 mg, Mylan, France). We evaluated two types of solvent for the reconstitution of the vancomycin powder: 0.9 % sodium chloride (solvent used in the unit) and water for injections (solvent recommended by the manufacturer). Vancomycin syringes dosed at 40 mg were prepared according to the NICU protocol. Vancomycin amounts were determined by an UV spectrophotometric method. A Kruskal-Wallis test was used to compare the impact of two solvents with or without stirring of vials after reconstitution (n = 6). Results: Our results expressed as median values [min-max] in mg showed a significant difference between water for injection versus with 0.9 % sodium chloride and with or without stirring (p \ 0.001). Zekai Tahir Burak Maternity Teaching Hospital, 2 Yildirim Beyazit University, Ankara, Turkey

Aim: The incidence of hypernatremic dehydration due to lactation failure in newborns that causes higher morbidity and mortality has been increased in recent years. The aim of the study was to identify the preventive approaches for hypernatremic dehydration by determining demographic characteristics and epidemiologic risk factors in newborns with hypernatremic dehydration. Methods: In this study, 87 term neonates with serum sodium level C150 mEq/L admitted to our clinic between January 2009 and June 2012 were evaluated retrospectively.

Results: Of the study infants mean birth weight were 3,424.5 ± 395 g. Mean age of the infants and mean weight loss at admission were 4.3 ± 2.8 days and 12.2 ± 4.2 %; respectively. The percentage of spontaneous vaginal delivery and primiparous mothers were 51.7 and 75.8 %; respectively. Ninety-seven percentages of the infants fed with breast milk exclusively. The most common complaints of babies were fever, jaundice, and poor absorption, while did not have symptoms when the time of hospital admission. During the study period, one infant had the diagnosis of intra cranial venous thrombosis and one infant had the diagnosis of lower extremity venous thrombosis. The mean sodium, urea and creatinine levels at admission were 155.2 ± 6.2 mEq/L, 89.1 ± 73.9 mg/dl and 0.89 ± 0.65 mg/dl; respectively. Conclusion: Hypernatremic dehydration due to lactation failure mains to be serious problem in newborns. Routine newborn examination in the first few days is important for early diagnosis and prevention of hypernatremic dehydration. Infants with fever, jaundice and poor sucking, hypernatremic dehydration should be considered. Moreover, determination of Na level should be helpful in requisite cases. Background: Critically ill children frequently receive inadequate nutritional support. Feeding protocols have been shown to help achieve optimal nutritional care. We aim to evaluate critical care nurses' understanding and preferred teaching methods before introduction of a nurse-led feeding protocol in our pediatric intensive care unit (PICU). We hypothesized that nursing experience and education level are important factors in readiness to adopt this protocol. Method: All PICU nurses were invited to participate in an online survey (19 questions) to investigate perceptions on implementation of a feeding protocol and preferred teaching methods. Simple logistic regression and Fisher exact test were used for analysis with statistical significance taken as p \ 0.05. Results: Seventy-four nurses completed the survey. Fifty-four had nursing degrees. Mean years of PICU experience was 6.2 (5th, 95th percentile: 1, 15) . 74 % (n = 55) felt that they did not have sufficient knowledge of a feeding protocol; 86 % (n = 64) were keen to explore implementing a feeding protocol. There was no association between readiness to adopt the feeding protocol with ICU nursing experience (OR: 0.99; 95th CI 0.84-1.18) and education level (OR 1.43; 95th CI 0.31-6.68). Preferred teaching methods are bedside teaching (61 %), didactic lectures (51 %) and distribution of protocol manuals (50 %) . Conclusion: Nursing experience and education level are not significant factors in adoption of a feeding protocol in the PICU. Understanding preferred teaching methods is necessary to help enhance effectiveness of teaching prior to introduction of a new protocol in the PICU. The aim of this study was to determine how the implementation of analgesia and sedation guidelines in PICU affected:

• The amount of analgesics and sedatives administered to selected post-operative cardiac patients • Their length of ventilator dependence and PICU stay • Staff approaches to analgesia and sedation practices and guideline compliance.

Methods: A mixed methods, before and after design was employed. Data from cardiac non-equivalent control (n = 61) and intervention (n = 64) patient groups were collected for the first 72 h post-op. Before and after guideline implementation staff surveys were conducted. Chi square tests, t-tests and Mann-Whitney U tests were used for group comparisons.

Results: The mean morphine infusion rate on admission to PICU was significantly reduced after the intervention for these post-operative cardiac patients (Before: 69.5 (SD 28.9) vs after: 55.4 mcg/kg/h SD 19.5) (p = 0.002). PICU staff satisfaction increased after guideline introduction (satisfaction before 26.9 % vs after 59.7 %, p \ 0.001) consistent with 70.3 % compliance with the key elements of the guidelines. Conclusion: The introduction of analgesia and sedation guidelines are synonymous with a significant reduction in morphine infusion rates in the initial post-op period. Clinical staff value and adhere to the guidelines. Background: Opioids are frequently used for analgesia and sedation in the NICU. An exposure of C5 days can lead to physiologic dependence; the abrupt discontinuation or rapid tapering may result in iatrogenic neonatal abstinence syndrome (NAS). The modified Finnegan Scale (MFS) is the most commonly used screening tool for NAS but was designed for prenatally opioid exposed term infants. Its validity in premature and/or critically ill NICU patients remains unknown.

Objective: To determine the effect of gestational age on NAS scoring as measured on the MFS among NICU patients. Methods: In a retrospective cohort study, we included all consecutively infants, admitted to a level III NICU between August 2008 and December 2011, who were exposed for C5 days to fentanyl or morphine infusions and were scored on a MFS.

Results: A total of 68 infants were included. Birth weight was 1,817 (g) ± 935; 470-3,800 with gestational ages 32.4 (weeks) ± 5.4; 23.7-40.9 (mean ± SD; range). The total number and frequency of each item are shown in figure 1.

Conclusions: NAS scores are GA dependent. Since the MFS was designed for term infants it is important to adjust NAS scores for infants that are either still premature or already beyond 44 weeks. Background: Psychological problems are common in parents after preterm birth, and they are known to affect parenting on a long-term basis. Research about experiences after preterm birth and parenting stress in early childhood focused predominantly mothers while relatively neglecting fathers.

Objectives: This study aimed at exploring mothers' and fathers' experiences after preterm and term birth and at comparing their parenting stress 2-3 years after birth.

Methods: A mixed methods study with quantitative data embedded in a major qualitative approach was used. Parenting stress was compared between mothers and fathers of 54 families after preterm birth and 65 families after term birth. Interviews were conducted within a purposive subsample.

Results: The different experiences of parents after preterm birth included losing a taken-for-grantedness regarding a healthy child, the development of the parental role, and their expectations of being a family. To regain this taken-for-grantedness the parent's confidence had to be rebuilt, and external empowerment was needed. Birth, hospitalisation, discharge and the first weeks at home emerged as highly vulnerable phases. Parents of preterm and full-term children reported similar parenting challenges 2-3 years after birth and no difference was found in parenting stress (F(101.324) = .629, p = .430). (Table) were programmed in an in vitro GI-tract model 'TIMpaediatric'. After administration with water or age-related foods, the availability for absorption of drugs from (manipulated) dosage forms was investigated. Results: Fast stomach emptying for pre-term neonate resulted in early absorption of caffeine, corresponding with in vivo (r = 0.99). Paracetamol showed a similar dose-response effect and t max compared to in vivo. Manipulation of esomeprazole tablets lead to early release and low availability due to degradation by gastric acid. Introduction: Validated morphine dosing algorithms are lacking for neonates and infants. A paediatric population pharmacokinetic model showed morphine clearance to non-linearly increase with bodyweight and be reduced by 50 % in neonates younger than 10 days [1, 2] . We prospectively evaluated the efficacy of the resulting age-adjusted morphine dosing algorithm in term neonates up to infants of 1 year of age. Methods: After major non-cardiac surgery, continuous morphine IV infusion of 2.5 lg/kg 1.5 /h was given in neonates younger than 10 days and 5 lg/kg 1.5 Methods: In this observational cohort study buccal MP (Sidestream Dark Field Imaging) was assessed before start of both dopamine and norepinephrine (T0), after start of dopamine (T1), and subsequently after start of norepinephrine (T2). Small (S; Ø: 0-10 lm) and nonsmall (NS; Ø: 11-100 lm) perfused vessel density (PVD-S, PVD-NS) and microvascular flow index (MFI-S, MFI-NS) were determined. MAP and heart frequency (HF) were recorded at T0-T2. Data are presented as median (IQR) and analyzed using parametric tests. Results: We included 10 CDH patients receiving 7 (5) mcg/kg min dopamine at T1 and 13 (5) mcg/kg min dopamine and 0.1 (0.2) mcg/ kg min norepinephrine at T2. MAP increased from T0 to T2 (see Table 1 ; A p \ 0.05 vs. T0, B p \ 0.05 vs. T1). HF remained unaltered between T0 and T1, but increased thereafter. In contrast, there were no changes over time in PVD-S, PVD-NS, MFI-S, or MFI-NS. Conclusion: Targeting MAP with dopamine and norepinephrine does not result in microcirculatory improvement in CDH patients. Background & aim: Extracorporeal membrane oxygenation (ECMO) should not only provide macrocirculatory and/or respiratory support, but also microcirculatory support. Because venoarterial ECMO (VA) differs intrinsically from venovenous ECMO (VV) and different patient selection criteria apply, we hypothesized that microcirculatory perfusion (MP) is decreased before cannulation and increases immediately thereafter in VA whereas in VV there are no longitudinal differences. Methods: Buccal MP was assessed using Sidestream Dark Field Imaging before start (T0), at day 1-3 (T1-T3), and before (T4) and after stop (T5) of VA or VV. Small (S; Ø: 0-10 lm) and non-small (NS; Ø: 11-100 lm) perfused vessel density (PVD-S and PVD-NS) and microvascular flow index (MFI-S and MFI-NS) were determined. Data are presented as median (range) and analyzed using non-parametric tests (*p \ 0.05). Results: We included 31 VA and 17 VV patients. From T0 to T1, PVD-S, PVD-NS, MFI-S, and MFI-NS were neither increased in VA nor in VV ( Figure 1 ). Background and aims: Ventilator-induced lung injury (VILI) may be caused by inadequate lung strain of the ratio of tidal volume (V T ) over functional residual capacity. It was reported that infant rats were less susceptible than adult rats when ventilated with a V T of 30 mL/ kg. We hypothesized that differences in lung strain explained the different occurrence of VILI between infant and adult rats. Methods: Infant (±26 days), juvenile (±6 weeks) and adult (±12 weeks) male Sprague-Dawley rats were studied in an ex vivo lung model. Height and weight were measured. Lungs were excised, total lung capacity (TLC) measured. Data are expressed as mean ± standard error. Statistical analysis was done using one-way ANOVA with post hoc testing to compare between groups. P \ 0.05 were accepted as statistically significant. Results: N = 79 rats were studied. TLC and total lung weight were not proportional to bodyweight (p \ 0.001), but were proportional to height (p \ 0.001). As such, the V T -to-TLC ratio was weight-dependent at a V T of 30 mL/kg (p \ 0.001), signifying less strain in the infant rat (0.47 ± 0.04) compared with the adult rat (0.91 ± 0.02).

Conclusions: Lung strain (V T -to-TLC ratio) at constant transpulmonary pressure was different between infant and adults rats when the delivered V T was dictated by 30 mL/kg, suggesting it is an inadequate surrogate for lung strain in the context of studying VILI throughout different age categories. VTV and FiO 2 titrated to maintain Pa CO2 45-60 mmHg and SpO 2 88-94 %. Lung mechanics and regional volumes (V L : Electrical Impedance Tomography) were recorded with arterial blood gases. Results: SEP resulted in better oxygenation and mechanics than SI and Control (Table) , and lower lung protein compared to all groups (mRNA and histology data to be presented at meeting). At 5-min, all groups had more uniform V L than Control. Gravity-dependent decrecruitment was evident by 60-min in all groups. Intensive Care Med (2013) 39 (Suppl 1):S1-S200 S33

Conclusions: Using our NeoGame we observed that inflation breaths were too short and ventilation rates too low. Furthermore compressions were inadequate in majority of cases. We will study interventions to improve performance. Results: 17/59 (28.8 %) discussions regarding limits to resuscitation were deemed to be unclear. 3/17 specified a time limit to resuscitation: 5 cases either specified resuscitation till parents present, or discontinuation after discussion with parents by the bedside. 8/17 cases specified that the child was not a candidate for ICU, despite 2 recommending full resuscitation.

Conclusions: Limits to resuscitation are often made without clarity with regards to their aims. CETs should be involved in decision making regarding limits to resuscitation and be allowed to express clinical or moral objections to any such decisions. Results: When we are certain that further resuscitation is futile and is a waste of resources for many cases such as (sever congenital anomalies, etc.) most of the parents refused DNR initially, but after discussing the islamic Perspective and DNR, 16 of them agreed for DNR. Conclusion: The opinion of the majority of the scholars of Islam is that the treatment of diseases or medication is not obligatory, A DNR order is permissible (mobah) in cases of a high degree of certainty that resuscitation is futile and will not result in net and lasting benefit to the Patient, but does not mean to stop the fundamental support like antibiotic, feeding, and IV fluid. Background: The complaints against unethical behavior of medical students/professionals are proliferating. Though bioethics has gained priority in formal medical education, but is not much recognized everywhere. To design an ethical curriculum, it is necessary to assess the basic knowledge and attitude of medical teachers regarding bioethics, and equip them to impart same skills to the students to workout ethical dilemmas. Objectives: To assess knowledge, attitude and practice of medical teachers regarding medical ethics, and to sensitize the academicians for training of the teachers and making bioethics an integral part of the curricula. Background: Sildenafil is used to treat pulmonary hypertension (PAH) in infants with congenital diaphragmatic hernia (CDH). However there is limited data to guide sildenafil dosing and weaning rate in CDH. This is of concern in light of a recent report of increased risk associated with high dose sildenafil regimens in non-CDH PAH [1] . Methods: Retrospective cohort study of sildenafil usage, dosing and weaning in infants with CDH at our institution. A sildenafil dose of 1.5 mg/kg/day was considered to be within safe limits based on current evidence [1] . Results: Seventeen percent (19/122) infants were discharged on sildenafil of median dose of 8 mg/kg/day (2.91-5.78 mg). Weaning rate was 0.1 (0.01-0.5) mg/kg/week. Infants ceased therapy at 343 days median duration. At 1 year of age 29 % were receiving a dose of sildenafil [1.5 mg/kg/day ( Figure 1 ). One infant died from severe PAH. Discussion: Sildenafil therapy at discharge is common in severe CDH. Variation in dosing and weaning rates highlights the need for To investigate the effect of the administration time of antenatal steroids (ANS) on blood pressure in very low birthweight infants, 120 infants weighing \1,500 g were evaluated retrospectively. The study groups were classified as Group I (n = 40, without ANS), Group II (n = 40, ANS \48 h before birth) and Group III (n = 40, ANS between 48 h and 7 days before birth). Systolic, diastolic and mean pressures measured by oscillometric method during the first 72 h after birth (with 2-h intervals) and heart rates were recorded. There was no difference among the study groups in terms of antenatal, perinatal and neonatal factors which can effect blood pressure except for respiratory distress syndrome which was less frequently seen in Group III (p = 0.016). Systolic pressure was higher on the 42nd and 48th hours (p = 0.046, p = 0.006), and diastolic pressure during the 6th-12th hour (p = 0.005, p = 0.022) and mean pressure on the 48th hour (p = 0.013) in Group II. During the first 72 h, the mean diastolic pressure was found to be lower in Group III (p = 0.034). whereas mean peak heart rate was lower among those in group I (p = 0.035) all of which were clinically irrelevant. Although clinically insignificant, systolic, diastolic and mean blood pressure values were found to be higher in infants whose mothers received ANS \48 h before birth, close monitoring may be required for these infants during the first 48 h of life. Conclusions: STE is feasible in preterm infants, but optimal image acquisition is paramount. Longitudinal parameters in 4CH and circumferential in SAX were most robust.

Introduction and objectives: Measuring blood pressure is integral to perioperative monitoring in anaesthetic practice. When for patient, surgical or equipment reasons upper arm blood pressure measurements may be difficult we postulate that forearm blood pressure (BP) measurements would provide an accurate and reliable alternative. Previous adult data did not support our hypothesis; paediatric data is lacking 1 . Methods: Institutional review board approval was granted and full informed consent sought from all participants. A calibrated GE Critikon DINAMAP DPC101 X-EN oscillometer was used to compare BP measurements in the arm and forearm of anaesthetised children prior to the commencement of the procedure. The upper arm followed by the forearm was measured, with an appropriately sized cuff. 3 systolic, diastolic and mean BPs were measured. An appropriately powered study required 34 subjects, 35 were recruited.

Results: 35 ASA 1-2 elective surgical patients in a paediatric tertiary centre whose ages ranged from 1 to 10 years and weights ranged from 8 to 53 kg were studied. Bias, precision and spread data are presented in Table 1 .

Discussion and conclusion: Our data would suggest that although there is a statistical difference between upper arm and forearm measurements of BP, this may not be clinically relevant, specifically for mean arterial pressure measurements. In anaesthetised, haemodynamically stable children mean blood pressure readings derived from the same side upper arm and forearm may be used interchangeably. There is more work to be completed, but there is potential for this to be used in a critical care setting. Background and aims: Neonates with congenital heart disease (CHD) with low cardiac output and diminished perfusion states resulting in redistribution of cardiac output away from the mesenteric circulation are at risk of intestinal ischemia. Our objective was to evaluate feasibility of regional mesenteric oxygenation monitoring as an indicator of mesenteric perfusion. Methods: Two term newborns with CHD and low cardiac output were followed clinically and monitored by NIRS to detect possible mesenteric ischemia. Two sets of optodes were placed on the forehead (cerebral SO 2 -cSO 2 ), one on the abdomen, 2 cm left to umbilicus (mesenteric SO 2 -mSO 2 ), and one on the back lumbally, 3 cm from the midline (kidney SO 2 -kSO 2 ). SO 2 was measured in the acute phase of necrotizing enterocolitis and in the reconvalescent phase. Relative values of cSO 2 and mSO 2 were expressed as cerebro-mesenteric oxygenation ratio (CMOR). Readings were compared to recordings of a healthy newborn. Results: Mean mSO 2 values in the two patients with CHD were lower in the acute phase of necrotizing enterocolitis in comparison to values in the reconvalescent phase. Mean mSO 2 values in both phases were lower in comparison to values in a healthy term newborn. Mean CMOR in two newborns with CHD were higher in the acute phase of necrotizing enterocolitis in comparison to values in the reconvalescent phase and in a healthy newborn. Conclusions: NIRS may be used for monitoring mesenteric perfusion in newborns with CHD and low cardiac output but further studies are needed to establish the value of our results. Background and aims: One of the major concerns in patients at high risk of bleeding is to detect it and optimize hemoglobin (Hb), leading to repeated blood tests. Our objective is to describe our experience with a new method of a noninvasive continuous measurement of Hb concentration in these patients. Methods: Prospective observational study in children at risk of bleeding in a PICU, from January to December 2012. SpHb monitoring was performed continuously (Pulse Co-Oximeter Radical/ 7.8.0.1, Masimo Corp., Irvine, CA). When each blood sample was taken, we collected the data from Radical-7, using the automated Hb measurement in the laboratory as a reference method (SiemensAD-VIA2120i). The agreement between two methods was evaluated by Pearson correlation and Bland-Altman analysis. Data are reported as mean values and SD (normally distributed) and median values and interquartile range (distribution non-normal).

Results: 284 samples were drawn from 80 sedated patients, with a median age of 14.5 months , and a median weigh of 8.5 kg (4.4-18.5 ). SpO 2 was 98 % (96-100 %), heart rate 123.5 ± 24.2 bpm, rectal temperature 36.2 ± 2°C and perfusion index median of 1.5 (0.93-3.32) . Mean Hb on the laboratory analyzer was 11.7 ± 2.05 g/dl and mean Hb on the pulse oximeter (SpHb) was 12.32 ± 2 g/dl, with a correlation coefficient 0.72 (p \ 0.05). The median of differences between both methods was 0.66 ± 1.4 g/dl. Limits of agreement of Bland-Altman plot were -3.7 and 2.4. Conclusions: SpHb offers moderately acceptable accuracy although the limits of agreement are wide. The primary benefit is the continuous monitoring of the trend in patients at risk of bleeding. Backgrounds and aims: Serum creatinine is a delayed marker for acute kidney injury (AKI) after cardiac surgery. Rapidly detectable AKI biomarkers could allow early intervention and improve outcomes. We investigated the temporal pattern and predictive value of urine neutrophil gelatinase-associated lipocalin (uNGAL), for early identification of AKI in children undergoing cardiac surgery. Methods: Prospective observational cohort study involving 106 children undergoing surgery for congenital cardiac lesions. Urine samples were obtained before and at intervals postoperatively. AKI was defined according to pediatric RIFLE criteria. The temporal patterns of both uNGAL absolute concentration and the normalized to urine creatinine concentration (uNGAL/cr) were correlated with the development of AKI and other clinical outcomes. We evaluated the predictive ability of uNGAL and of uNGAL/cr by area under the curve (AUC), when added to an AKI clinical predictive model. Results: AKI occurred in 42 patients (39.6 %). uNGAL significantly increased in AKI patients at 1 h, 3 h and 15 h postoperatively. Optimal cutoff for uNGAL at 1 h was 100 ng/ml. uNGAL and uNGAL/cr correlated with surgical variables and clinical outcomes. AKI prediction improved when uNGAL was added to a clinical model (AUC increased at 1 h from 0.85 to 0.91, at 3 h to 0.92). uNGAL and uNGAL/cr values were not significantly different between patients with prerenal and sustained AKI. Conclusions: uNGAL is a predictive biomarker for AKI after pediatric cardiac surgery and may permit earlier intervention improving outcome of AKI. uNGAL normalized to urine creatinine improves the prediction of AKI severity, but offers no advantage in AKI diagnosis. Objective: To evaluate the effect of high altitude on the cardiopulmonary transition immediately birth. Methods: The arterial oxygen saturation were recorded by Pulse oximetry immediately after birth and continuously until the time at which the upper and lower limp saturation were equal. Data were compared with similar work done at sea. Results: At altitude of 1,640 m the mean SpO 2 in right hand was 68 % and in the right foot the mean SpO 2 was 60 % immediately after birth. SpO 2 values reached equality point after 20 min (8-45 min). Data was compared with similar studies done at sea level which was found to be significantly delayed at high altitude. Conclusion: At high altitude neonatal cardiopulmonary transition is significantly delayed compared with sea level. A lower preductal and postductal oxygen saturation cut-off levels than those used at sea level should be adopted when dealing with neonates born at high altitude. Interventions: Arterial and central venous blood samples were collected as needed. Patients clinical and laboratory data were collected at the time of each data collection. Results: A total of 369 data collection set collected from 120 patients, age 9.6 ± 15.9 months, weight 5.7 ± 3.6 kg. Upper body CV saturation was lower than lower body CV saturation 64.0 ± 11.8 vs. 71 Introduction: Vascular access in pediatric age group is a challenging procedure especially in compromised children and those who require multiple vascular cannulations. We reported our experience in vascular access under ultrasound guidance in children with congenital heart disease and we discussed the technique of line insertion and its difficulties in small infants. Methods: In pediatric cardiac intensive care unit we enrolled prospectively all trials of vascular access guided by ultrasound from January 2010 till September 2010. Age, weight, the time from first needle puncture to wire insertion, site of insertion, number of attempts, type of the line and complications were documented. Results: 77 vascular access trials were performed in 43 patients. They included 15 arterial and 62 venous cannulations. Mean age and weight of patients were 15 months (6 days-11 years, median 2.5 months) and 7.2 kg (2-46 kg, median 3.8) respectively. Success rates were 93 and 95 % for arterial and venous cannulation respectively. Mean time from first needle puncture to wire insertion was 3.9 min (0.5-15 min, median 2 min). 55 central lines cannulation (75 %) were successful from the first puncture, 17 (23 %) were successful from the second puncture and one case (2 %) required 3 punctures. Lower body weight did not affect success rate as 30 patients (45 %) were \3.5 kg with 96.6 % success cannulation rate. There were no associated complications. Conclusion: Ultrasound guided vascular cannulation in critically ill pediatric patients is very useful. It is associated with high success rate and minimal complications. Pediatric Intensive Care, 2 Pediatric Surgery, University Children's Hospital, 3 Internal Diseases, Riga Stradins University Hospital, Riga, Latvia Introduction: Cardiac surgery with cardiopulmonary bypass (CPB) is commonly perceived as a risk factor for decline in renal function. Hypothermia, hypoxia, hypotension, non-pulsatile blood flow during CPB, use of ACE inhibitors, inotropic and (or) vasoactive support affects kidney and contributes to the acute kidney injury (AKI). Objective: To evaluate the incidence and outcome of AKI in children with congenital heart disease (CHD). Methods: We enrolled 30 patients, 12 boys and 18 girls with CHD. Their median body weight was 6.8 kg, and median age 7 months. SCr was determined and preoperative and postoperative creatinine clearance (ClCr) was estimated using Schwarz formula (eClCr). Urine was collected to measure ClCr, using the difference in urine (UCr) and SCr concentrations (mClCr). Urine output, body temperature, duration of aortic cross clamping and cardiopulmonary bypass was recorded. Background and aims: Patent Ductus Arteriosus (PDA) in preterm infants is associated with numerous morbidities and increased mortality. Treatment with cyclooxygenase inhibitors and/or surgical ligation has failed to show major improvements in short term or long term outcomes. Our objective was to document PDA course in a cohort of patients managed conservatively, with a high threshold for medical or surgical treatment using the addition of regular functional echocardiography. Methods: This was a retrospective chart review between January 2011 and December 2011 in Coombe Women and Infants University Hospital. Functional echocardiography was introduced as a standard investigation for all neonates born below 1,500 g within the first week of life, commencing in January 2011. Further reviews were done according to the PDA significance. Results: One hundred and thirty-nine infants with birth weight below 1,500 g were admitted during the study period. Two infants with congenital abnormalities were excluded. Eighty-eight infants (64 %) were diagnosed with PDA and 11 patients (8 %) had a PDA at discharge from the hospital. We performed 387 functional echocardiography investigations. Only one patient required surgical ligation (0.7 %) and four patients were treated with Ibuprofen (3 %). Ten patients (7 %) did not survive to discharge. Seventeen (12 %) had chronic lung disease, four (3 %) developed surgical necrotising enterocolitis, five (4 %) had severe peri/intraventricular haemorrhage or cystic periventricular leukomalacia. These results compare favourably to the Vermont-Oxford database with a significant reduction in PDA treatment. Conclusions: A conservative approach to PDA treatment is a feasible option, reducing PDA treatment while using functional echocardiography. Backgrounds and aims: Non invasive pressure recording analytical method (PRAM) for measuring cardiac index (CI) has recently appeared. The aim of this study is to compare PRAM with femoral artery thermodilution (FATD) in a pediatric animal model of hypoxia. Methods: Thirty five mechanically ventilated piglets with a median (inter-quartile) weight of 9 (8.5-10.8) kg were studied. Femoral artery and vein were canalized under sedation. CI was measured simultaneously using PRAM and FATD, after calibration with two infusions of 5 ml-cold saline (\8°C). Measurements were repeated before and 5 min after ventilator withdrawal to induce asphyxia. Results: Thirty two paired measurements were compared. The mean (SD) CI was 4.27 (1.54) L min -1 with FATD as opposed to 4.10 (1.59) L min -1 using PRAM. The mean bias was -8.3 % (95 % Limits of agreement 118.6 to -135.2 %) with a percentage error of 104 %. Before ventilator withdrawal (24 paired measurements), the CI was 4.04 (0.94) L min -1 with FATD and 4.46 (1.42) L min -1 using PRAM. The mean bias in this case was -15.2 % (67.4 to -97.7 %) with a percentage error of 82 %. After ventilator withdrawal (8 paired measurements), the CI was 4.97 (2.62) L min -1 with FATD and 3.04 (1.66) L min -1 using PRAM. The mean bias was 12.3 % (227.7 to -203.2 %) with a percentage error of 117 %. Conclusions: In this experimental infant animal model, poor agreement existed between PRAM and FATD CI measurements. Background: Determining optimum timing for surgical repair in congenital diaphragmatic hernia (CDH) is challenging. Pulmonary hypertension (PAH) is a determinant of disease severity in CDH, and leads to secondary right ventricular (RV) dysfunction. This study investigated patterns of RV dysfunction in CDH before and after surgery, using Tissue Doppler Imaging (TDI).

Method: In 20 infants with CDH, TDI RV E 0 velocities were measured to assess RV diastolic function, on paired days in the first week of life and post-op period. Infants were grouped by disease severity according to duration of respiratory support: DRS \ 25 and DRS [25 days. Results: In infants with more severe disease (DRS \ 25) RV E 0 was significantly lower in the first week of life, except day 3-4 ( Figure 1 ). After surgery RV E 0 deteriorated and was significantly lower in the DRS [25 group on day 3-4 post op ( Figure 2 ). Conclusions: RV diastolic dysfunction identifies infants with severe CDH. Delaying surgery until day 3-4 allows improvement of RV function prior to post-operative deterioration. Introduction: Advanced simulation facilitates the training on the management of complex life support procedures without risks to patients. Until now, the only way to train the management of continuous veno-venous hemofiltration (CVVHF) was the direct learning on real patients. Our objective was to create a simulator of CVVHF that could be integrated with current advanced simulators to permit the repetitive and effective training of providers and improve patient safety. Methods: A device to simulate CVVHF related clinical conditions was invented. It permits the control ''on the fly'' of all the pressures measured by the CVVHF monitor, separately or in combination. The instructor simultaneously could manipulate the CVVHF and the patient simulator. Specific scenarios were designed. Results: 80 participants in 4 courses on renal replacement therapies were included (RRT). Lectures, workshops, skillstations, animal laboratory (rabbits and pigs) and high-fidelity simulation (Simbaby Ò ) scenarios were included. 32 scenarios that generated usual conditions and complications related to the therapy with CVVHF, were carried out. Our device permitted the change of the CVVHF monitor pressures in real time according to clinical situation and participants' actions. No device failures were observed and no scenario needed to be halted. Participants considered our device a useful training tool. Scenarios reproduced correctly clinical conditions. Discussion: CVVHF control simulator allows a realistic generation of RRT scenarios. It permits abrupt or progressive, individual or combined, circuit pressure changes, giving to the instructor a total control of the scenario. This device could be integrated in the software of these simulators. Background and aims: The Noonan syndrome (NS) is an autosomal dominant genetic disorder with a very heterogeneous clinical picture, comprising a congenital heart defect (CHD) in 50-80 % of affected individuals. The phenotype diversity is a consequence of nine different genes (PTPN11, SOS1, KRAS, RAS, RAF1, BRAF, SHOC2, MEK1, CBL) involved in the pathogenesis of NS. The most common CHD are pulmonary valve stenosis and hypertrophic cardiomyopathy (HCM), which is present in about 20 % of NS patients. The rapidly progressive HCM, resulting in early death or need for heart transplantation, occurs only sporadically in NS. Methods: A DNA genotyping of a NS patient with rapidly progressive HCM and lethal exitus at the age of 4 months due to a cardiorespiratory failure was performed. Results: A heterozygous unclassified missense variant in exon 3: c.179G [ T (p.Gly60Val) was detected in the KRAS gene.

The KRAS mutation is a rare cause of NS with a usually mild clinical course and an infrequent association with CHD. There are some exceptions, when a specific mutation of this gene causes a severe phenotype with a malignant clinical course.

A novel KRAS mutation in exon 3: c.179G [ T (p.Gly60Val) should be recognised as a unique malignant form of NS. The lethal clinical course in our NS patient with KRAS mutation may be connected with RAS-MAPK pathway hyperactivation, consequently promoting cell growth and proliferation, leading to a rapidly progressive HCM. Background and aims: Treatment options for the closure of a haemodynamically significant patent ductus arteriosus (hsPDA) include medical therapy such as ibuprofen and indomethacin and surgical ligation. To evaluate the efficacy of intravenous paracetamol in preterm infants with hsPDA whose feeding was contraindicated or had feeding intolerance.

Methods: Preterm infants with hsPDA who were started on intravenous paracetamol treatment with parental consent. Paracetamol was administered at a dose of 60 mg/kg/day, in 4 divided doses, for a period of 3 days. In the absence of closure of hsPDA, treatment was extended up to 6 days, after which echocardiographic examination was performed.

Results: A total of 10 preterm infants were included in the study with a median gestational age of 27 4/7 weeks (minimum-maximum: 24-29) and a median birth weight of 775 g (590-990). The first dose of intravenous paracetamol was given after a median of 6 days (2-15). On echocardiographic examination, median internal ductal diameter was 2 mm (1.5-3) , with a median left atrium-to-aortic root ratio of 1.95 (1.6-2.2). Intravenous paracetamol resulted in successful closure of hsPDA in all patients. Conclusions: This study is the first case series in the literature, which is used intravenous paracetamol treatment of hsPDA. We believe that intravenous paracetamol could be used as an alternative drug for infants. Further prospective randomized-controlled trials are needed to evaluate the efficacy of intravenous paracetamol for the closure of hsPDA. Pediatric Intensive Care Unit, 2 Research Support Unit, Hospital Infantil Virgen del Rocio, Seville, Spain Objective: Regional cerebral oxygen saturation (rSO 2 ) is a measure of the general state of perfusion and oxygenation. We aim to analyze the relationship between this and various hemodynamic and respiratory parameters. Patients and methods: Forty-three patients, operated on between October 2011 and July 2012, were included in this prospective observational descriptive study. The following parameters were measured: mean arterial pressure, both arterial and central venous oxygen saturation and partial pressures of oxygen and carbon dioxide, and lactate levels. From these parameters, the oxygenation index and the oxygen extraction ratio were calculated. These measurements were studied to evaluate whether rSO 2 correlated significantly with the other parameters. Results: The average age and weight of the patients were 27.3 months and 9.2 kg respectively. The rSO 2 correlated positively with both central venous oxygen saturation (r = 0.73, p \ 0.01) and mean arterial pressure (r = 0.59, p \ 0.01), and negatively with the oxygen extraction ratio (r = -0.7, p \ 0.01). No correlation was found with the respiratory parameters. Concordance analysis established an acceptable Kappa index ([0.4) between the rSO 2 and central venous oxygen saturation, and between the rSO 2 and oxygen extraction ratio. Conclusion: Regional cerebral oxygen saturation correlates well with hemodynamic parameters-mean arterial pressure, venous saturation, and the tissue oxygen extraction. However, it does not correlate with respiratory parameters.

VOCAL CORD PALSY FOLLOWING AORTIC ARCH SURGERY: INCIDENCE, DIAGNOSIS AND IMPLICATIONS

Bristol Children's Hospital, Bristol, UK Vocal cord paralysis is a known entity often described as a complication of neck surgery, mainly thyroidectomy. A less frequent site of injury to the recurrent laryngeal nerve is the chest during cardiac surgery, particularly involving the aortic arch. Recurrent laryngeal injury after cardiac surgery is often overlooked as a cause of postoperative respiratory insufficiency or hoarseness. The true incidence of vocal cord dysfunction may be hard to draw in case of lack of a routine post-operative laryngeal examination for patients with dysphonia. In the paediatric population it significantly affects feeding, with many babies requiring NG feeds and prolonged hospital admission. Patients with unilateral vocal cord paralysis present with respiratory insufficiency, stridor and obstructive symptoms. The reported incidence of vocal cord palsy following cardiac surgery via median sternotomy ranges between 1.7 and 67 % depending on the type of surgery and the weight of the infant at the time of surgery. We conducted an audit of aortic arch surgery, looking at incidence of vocal cord palsy, its detection and outcome. Analysing 115 aortic arch surgeries we found our local rate was 19 %, most of these detected during inpatient admission. Some cases however were diagnosed following discharge. Most cases had symptoms of stridor or respiratory distress. However, cases missed were described only as poor feeders. This raises the possibility of screening all cases of aortic arch surgery in paediatric patients with elective laryngoscopy. Background: Ultrasound (US) guidance is becoming the standard technique for central venipuncture in neonates, infants and children. Though much of the initial experience in this field has been carried out with internal jugular vein (IJV) and subclavian vein (SV), in neonates and in small children the largest vein to access may be the brachio-cephalic vein (BCV), which can be easily visualized in the superior mediastinum and punctured 'in-plane' by US guidance. Methods: We have reviewed all US guided insertions of central venous catheters (CVC) performed in neonates and in children \6 years in our Pediatric Intensive Care Unit and in our Pediatric Oncology Department. PICCs were excluded from the analysis. The vein to puncture was chosen after US evaluation. Kits for microintroduction (21 G needles, soft straight tip 0.018 guide-wire, 3-4 Fr micro-introducer-dilator) were used in all patients. Results: In 165 patients (age: 15 \ 1 month, 70 1-12 months, 80 1-6 years), we inserted 183 CVC: in 167 cases, after US examination of all possible vein approaches, we esteemed that BCV was the largest and easiest vein to access. All insertions were successful, with no punctured-related complications (no pneumothorax, no accidental arterial punctures). In most cases (95 %), the BCV was punctured at first pass of the needle. Conclusion: In the vast majority of patients \6 years, the BCV is the vein with the largest caliber and the easiest and the safest for US guided venipuncture. Background and aims: In healthy term neonates, pulmonary pressures fall rapidly following birth and first breaths. However in the extremely low birth weight (ELBW; below 1,000 g) infants, there is very little information about the pattern of this physiological adaptation. The aim of our study was to prospectively measure pulmonary pressures following delivery. Methods: All ELBW infants admitted to the neonatal intensive care unit in the Coombe Women and Infants University hospital were eligible for enrolment. Targeted echocardiography was performed at three, six and 12 h of age to measure the size and flow pattern in the PDA and the tricuspid regurgitation (TR) in m/sec as an indirect assessment of pulmonary hypertension (PH).

Results: Between November 2012 and January 2013 12 infants were enrolled. The mean gestational age of our cohort was 26.5 weeks of gestation and the mean birth weight was 832.5 g. All infants had a PDA present on all measurements with mean ductal size 2.5 mm at 3 h of age, decreasing to 1.9 mm at 12 h of age (p = 0.02). Mean TR at 3 h of age was 1.6 m/s, falling to 1.2 m/s at 12 h of age (p = 0.15). Five infants had TR above 2 m/s (estimated pulmonary pressure above 20 mm Hg) after 3 h of age, suggestive of delayed transition. Conclusions: PH with impaired transition could play a role in stabilisation of extremely preterm neonates. Further data are needed to confirm this finding with possible targeted approach to infants with delayed transition. Objectives: Extracorporeal Membrane Oxygenation (ECMO) is a proven, beneficial therapy amongst neonatal, paediatric and adult patients. Being able to offer a mobile ECMO (mECMO) service across the United Kingdom allows greater and earlier access to this life saving therapy. Our aim is to review our experience of this unique service. Methods: Between January 2009-December 2012, all patients accepted for mECMO support in whom conventional transfer was deemed too high risk, were enrolled. Demographic data, diagnosis, adverse events, clinical details, transport times and outcome were analysed. Results: 100 patients (101 mECMO transfers) matched the inclusion criteria (42 neonates, 17 children and 41 adults). Seven were transferred between other institutions. The commonest neonatal conditions included;

Meconium aspiration syndrome (n = 15, 15 %, Survival 100 %) Congenital diaphragmatic hernias (n = 12, 12 %, Survival 75 %) Bronchiolitis (n = 7, 7 %, Survival 86 %) In the paediatric subgroup; Pneumonia (n = 4, 4 %, Survival 100 %) Pertussis (n = 4, 4 %, Survival 25 %) Whilst in the adult population, Pneumonia/ARDS (n = 36, 36 %, Survival 94.4 %) H1N1 positive (n = 7, 19.4 %, 86 % Survival). Survival amongst all mECMO patients treated at Glenfield was 88.2 % which is in keeping with the unit ECMO mortality. Proportionally more mECMO patients died in the paediatric subgroup due to the high frequency of pertussis (mECMO, Glenfield and ELSO survival data all 20-30 %). No patients died during transport. Conclusions: Glenfield Hospital is the largest UK provider of mobile ECMO and this report details one of the largest mobile ECMO programmes and series in the world. It is a safe, valuable resource that in this format provides earlier access to ECMO and potentially safer transport of critically ill patients. Length of unit stay in days 7 (4-10)

Length of invasive ventilation in days 4 (3) (4) (5) (6) (7) (8) Length of vasoactive agents in days 2.5 (1) (2) (3) (4) (5) Discharged alive from PICU* 34 (89.5 %) S48 Intensive Care Med (2013) 39 (Suppl 1):S1-S200

PS. Reintervention was more inpatients with PA/IVS than those with critical PS (P 5 0.003). Other predictors for reintervention included hospital stay 7.5 days (P 5 0.001) and tricuspid valve regurgitation peak gradient in day one post first intervention (TR1) 43 mmHg (P 5 0.03). For nearly 20 years the Norwood procedure was the only approach for palliation of hypoplastic left heart. Despite modifications in term of right-ventricle-to-pulmonary-artery-conduit instead of modified Blalock-Taussig-shunt the risks and complications resulting from cardiopulmonary bypass (CPB) and circulatory arrest in early neonatal period remained unsolved. They still impact unfavorably longterm success and overall morbidity and mortality. The alternative ''hybrid procedure'' for hypoplastic left heart avoids open heart surgery in the vulnerable early neonatal period by banding the pulmonary arteries and subsequent percutaneous stenting of the ductus arteriosus (comprehensive stage I). Major open heart surgery with neoaortic reconstruction and bidirectional cavopulmonary connection (comprehensive stage II) is shifted into later life (4-6 month of age).

In the postoperative phase adequate hemodynamic monitoring, early extubation and non-invasive respiratory support, eligible analgesia, deliberate pharmacotherapy focusing optimal ventricular preload and function and a balanced fluid management represent the cornerstones of therapy. The presented postoperative protocol reflects our center experience to optimize cardiac function and enhance pulmonary blood flow in face of counteracting factors as systemic inflammatory response, pain, insufficient spontaneous breathing after comprehensive stage-IIoperation. Methods: Ninety-five measurements in forty-seven patients between 1 and 168 months of age and with no severe hemodynamic disturbances were studied. Heart rate (HR), mean arterial pressure (MAP), and cardiac index (CI) measurements were registered by PRAM every 6-8 h, with a maximum of 4 measurements per patient. Additionally, core-to-skin temperature gradient and vasoactive-inotropic score (VIS) were measured. Results: Dicrotic notch was detected in 62 % of the measurements. CI was 4.1 ± 1.4 L/min/m 2 (range 2.0-7.0 L/min/m 2 ). There was a weak negative correlation between CI and height (r = -0.247, P = 0.017), and a moderate correlation between CI and temperature gradient (r = 0.471, P = 0.000 Objectives: The functional changes in the cardiovascular system are common side effects of the phototherapy. Short-term heart rate variability (HRV) may be used for evaluation of cardiac regulation even in newborns. The main aim was to evaluate changes in HRV during phototherapy using nonlinear mathematical methods.

Methods: Twenty full-term newborns undergoing phototherapy were studied. In each enrolled baby three ECG recordings (before, during and after phototherapy, each with min. 3,000 RRs) were obtained. The complexity of time series was analysed using symbolic dynamics method (Porta et al. 2001) . RR intervals were transformed into alphabet of 6 symbols. Normalized complexity index (NCI), normalized unpredictability index (NUPI) and pattern classification were used for analysis. Results: Symbolic dynamics analysis showed a reduction in NCI and NIPU of HRV during phototherapy. From pattern classification analysis, the 0 V% index increased while the indices 2 LV% and 2 UV% decreased during the treatment procedure. The changes remained significant at least 20 min after phototherapy. The loss of complexity and unpredictability of the heart rate can indicate changes in cardiac regulation associated with pathological states described in adult patients at risk of sudden death (Voss et al., 1996) Background and aims: It is widely acknowledged that working on N/PICU has an emotional impact on staff. Reflective Practice (RP) groups provide space to explore and share feelings and experiences, manage stress, and facilitate the development of effective coping styles. These groups are not routinely held; it is therefore important to gain feedback on how, and if, these groups are helpful.

Methods:

• 25 RP groups were held with the N/PICU Registrars (weekly).

• 3 RP groups were held with the N/PICU Consultants (bimonthly).

• Groups were facilitated by the N/PICU Clinical Psychologist.

• Feedback was received from Registrars after 5 pilot sessions (n = 15) and then after the 22nd session (n = 12); feedback is currently being collated from the Consultants.

• 88 % of respondents reported that they felt 'okay' or 'very comfortable' discussing feelings and reactions with colleagues. • On a scale of 1-10 (10 = very helpful), 82 % rated the groups as 7 or above. • 62 % reported that they would have attended even if the groups were not compulsory.

• When asked what difference these groups have made, responses included:

-Chance to reflect on, and learn, from clinical experiences (91 %) -Increased peer support and opportunity to share experiences (82 %) -Increased understanding of psychological ideas and approaches (73 %) Conclusions: Doctors on N/PICU value the opportunity to regularly reflect on their practice with peers through a facilitated RP group. More research is needed to assess the impact on staff's emotional well-being, sickness rates and clinical practice. Current international resuscitation guidelines emphasis the importance of initial respiratory care including oxygen, CPAP and surfactant judiciously. Although international newborn resuscitation guidelines have been implemented more than 15 years in Saudi Arabia, there are no data on current respiratory practice for delivery room resuscitation of newborn infants in this region.

Objectives: To study current practices and available equipment for initial respiratory care for newborn resuscitation in the delivery room in Saudi Arabia. Aims: Post Traumatic Stress Disorder (PTSD) requires the presence of a traumatic event that threatens the emotional or physical integrity. This study evaluated the incidence and factors contributing to PTSD in mothers of infants attending a neonatal intensive care unit (NICU) and compared to mothers of healthy infants of a well baby nursery (WBN) at the same hospital facility. Methods: Prospective study was performed in 113 mothers, 48 of the control group (WBNg) and 27 of the NICU group (NICUg). We applied the Perinatal Posttraumatic Stress Disorder Questionnaire (PPQ) to all mothers by delivery time and 6-8 weeks after. Statistical analyses were performed using Chi square test, multiple Poisson regression with robust variance, and analysis of variance with repeated measures. Results: By the first interview, suggestive scores of PTSD were present in 42.3 % of NICUg and 8.3 % of WBNg (p \ 0.01). By the second interview, PTSD was present in 38.4 and 6.2 %, respectively, and NICUg showed a score 1.53 points higher than mothers of WBNg (p = 0.04). Moreover, NICUg had lower education level (p \ 0.05) and prevalence of PTSD was higher in mothers of infants more ill and with higher gestational age. Conclusions: PTSD had higher incidence at NICUg, though also present at the WBNg and both groups showed no significant symptoms improvement after 6-8 weeks time. It is important to investigate this disorder in all postpartum women in a way the proper treatment could be offered to them preventing suffer and negative impact at the infant's development. Introduction and aims: It remains controversial whether adolescent pregnancy is associated with adverse events such as premature delivery and neonatal mortality. The objective of this study was to evaluate the profile of newborns' death in a neonatal unit of a tertiary hospital and its relation to maternal age and other covariates and associated factors. Methods: Retrospective descriptive study conducted in the neonatal unit of a tertiary hospital evaluated all births and deaths of neonates in the Neonatal Intensive Care Unit (NICU), verifying the relationship among the occurrence of death and clinical and demographic variables. Statistical analysis was run using ANOVA, Two-way ANOVA, post hoc by Sidak, and Bivariate Correlation of Spearman two-tail. Results: We analyzed data from 4,827 births (755 in teenage mother's group and 4,072 in adult mother's group) at the database of the Department of Neonatology, referring to attended population from 2000 to 2007. The mortality rate was 1.1 % (57 neonates). Neonates' death was related with lower: gestational age, Apgar scores and birth weight and was highly associated with teenager's pregnancy (t = 2.5, p \ 0.05), health care-associated infections (p = 0.003) and hemorrhagic disorder (p = 0.03). Teenager mothers had babies with lower birth weights, lower Apgar score at 5 min, more vaginal delivery and fewer regular antenatal visits. Conclusions: Teenagers' newborns had higher tendency to lower birth weight, lower score of Apgar in the fifth minute and higher mortality. Data suggests preventive awareness campaigns and intensive follow up of teenage pregnancy by health professionals. 1) To ascertain prevalence of symptoms of burnout in a mixed staff group working in a paediatric intensive care setting. 2) To examine associations between symptoms of burnout, demographic factors, resilience and stress. 3) To determine whether the use of particular coping strategies was associated with lower risk of burnout.

Design: Cross-sectional questionnaire study Participants: Fifty-eight health professionals working on a Paediatric/Neonatal Intensive Care Unit.

Measures: Abbreviated Maslach Burnout Inventory (aMBI) which is made up of 3 subscales, Emotional Exhaustion, Depersonalisation and Personal Achievement, each scored 0 = never to 18 = everyday; Brief Resiliency Scale (BRS); Trauma Screening Questionnaire (TSQ); list of coping strategies. Results: All staff admitted to symptoms of Emotional Exhaustion on some level, mean score = 8.0; 22 experienced some Depersonalisation, mean score = 2.6 and scores for Personal Achievement ranged from 2 to 18, mean score = 12.5, although there was no association with gender, length of service, living alone, having children or profession (doctor/nurse). Burnout was associated positively with TSQ score (p \ 0.05), and negatively with BRS score (p \ 0.01) and some coping strategies, including meeting with a mentor (p \ 0.01) and having hobbies (p \ 0.01). Objectives: Admissions to paediatric intensive care (PIC) appear to be increasing in England and Wales (E&W). We aimed to identify whether this increase was due to an increasing need for PIC or changing population demographics. Methods: Anonymised data from the Paediatric Intensive Care Audit Network (PICANet) was analysed for all PIC admissions to NHS Trusts in E&W between 2004 and 2011 including sex, age, diagnostic group, mode of ventilation and deaths. This was compared with 2011 census data and live birth rates over the same period from the Office of National Statistics. Results: The number of patients admitted to PIC in E&W increased by 27 % between 2004 and 2011. The most significant increase was in children under 5 years of age (34 %). Over the same period there was a 13.2 % increase in live births with a mean annual increase of 2 % over the past 10 years. The number of individual children with respiratory admission diagnoses has risen most (39 %) with increasing numbers receiving ventilatory support during the study period (42 %). Additionally more patients each year have multiple PIC admissions, particularly those with cardiac and respiratory diagnoses. The male preponderance of patients overall remained unchanged (M:F ratio 1:2). There was also a 10 % decrease in the number of deaths over the 8 years. Conclusions: Demand for PIC beds in England and Wales is increasing with an expanding younger patient population, particularly those with respiratory diagnoses requiring ventilation, significantly affecting admission rates. Awareness of these demographic trends is necessary to optimise available PIC resources. Objectives: There are substantial challenges to conducting randomized controlled trials (RCTs) in pediatric critical care. Pilot RCTs can be used to evaluate the feasibility of, and inform the design and conduct of, larger RCTs. Our objective was to systematically identify and describe pilot RCTs in pediatric critical care. Methods: We searched the Evidence in Pediatric Intensive Care database (epicc.mcmaster.ca) for published trials (1986 to July 1, 2012) that were described by the authors as pilot, feasibility, proof-ofconcept, phase 2 or preliminary studies. We then used Web of Science Ò and the World Health Organization's Clinical Trials Search Portal to search for trials informed by these pilot trials. Results: We identified 20 pilot RCTs out of a total of 225 RCTs. The number of children randomized ranged from 6 to 56; the median number was smaller than non-pilot RCTs (26 vs. 50, p \ 0.001). Three trials (15 %) explicitly reported feasibility as an outcome and none reported criteria for success. Blinding was reported in 9 RCTs (45 %). We found 3 registered trials (2 listed as recruiting and 1 as terminated) in trial registries that were similar to 4 pilot trials. 17 pilot trials were indexed in Web of Science; these were cited a median number of 15 (IQR 4-30) times in total and 2.7 (IQR 0.9-6.9) times per year since publication. With the recent introduction of a high-quality, reasonably priced, and completely portable neonatal ultrasound machines, a new paradigm shift also emerged in the philosophy of ultrasound imaging in PICU which is the philosophy of ''critical ultrasound''. This is a shift from being organ based, systematic, comprehensive exam done by radiologists to a new concept of problem based, goal directed, focused multi-organ, time dependent, exam done by the treating neonatologist. The new paradigm is not trying to describe an organ pathology but rather involves ''focused-simple yes/now'' exams for the airway, lung, heart, abdominal or limbs that directed to answer specific clinical problem (like hypoxia-hypotension….etc.) and performed not only for diagnosis but also for monitoring the management. The presentation will give the results of 4-years' experience of our center with regards to this new essential skill in PICU in obtaining hour-by-hour information to help the management of the critically ill pediatric cardiac patients, in addition to the multiple procedures that was guided by ultrasound such as vascular access, lumbar puncture or pleural tap. It will also shed light on its important application in the telemedicine filed. Intensive Care Med (2013) 39 (Suppl 1):S1-S200

In the past few decades, an exponential increase in the costs of PICU was observed across the globe. The high cost extends almost to all aspects of PICU including the infrastructure, medications, imaging, monitoring, machines, devices in addition to the staffing costs. There are a many consequences and ramifications of this phenomenon particularly in limited resource countries. Among the important effects is the marked limitation of providing PICU care to many patients due to the high cost if there is an alternative low cost PICU, it would be feasible to provide PICU care a larger pool of patients. PICU drains great percentage of overall budget of any hospital. On a population based perspective, a state or country health care system can be severely affected with such high cost PICUs. The lecture will shed light on strategies for establishing low cost PICUs that can perform efficiently in managing critically ill patients. Through evidence based method, it will give several examples that clearly shown lack of benefits of utilization of high cost drugs, lab, ventilators, machines and other devices commonly used in PICU. It will explain strategies for managing patients outside PICU such as ''critical care outreach'' programs. Results: 6 studies were identified. The published reports consists of retrospective studies and surveys. Except one, all of the papers reported a possible link between recent red cell transfusion and development of NEC. Notably, a recent large randomised multicentric randomised study has underlined this possible association.

One study also noted that cessation of feeding during transfusion reduced the incidence of NEC. Introduction: Computerized paperless progress note in pediatric ICU is challenging task. The aim of this study is to assess the impact of introducing paperless computerized progress note to high volume Pediatric cardiac ICU (PCICU). The study looks to the impacts of computerized progress note on work flow, documentation and outcome of PCICU. Methods: Retrospective study was conducted from 1/1/2012 till 31/12/2012 in 12-beds PCICU of tertiary hospital. The hospital is JCI accredited institute. The study looked to the effects of introduction of computerized progress note on work flow, time to finish progress note, time to train new staff and outcome of PCICU pre and post implementation of computerized progress system. Results: 450 admissions were documented utilizing computerized progress note during study period. The notes were documented by PCICU staff with 3 physician covering daytime working hours and 2 physician covering night duty and weekends. New staff required 2 weeks + 2 weeks to become familiar and learned the system. The system that is coded with IACS international coding system, successfully documented progress status of patients and maintained good work flow without compromise in quality or patient's care. Improvement in documentation was associated with improvement in outcome with more than 99 % post-surgical repair survival.

Conclusion: Computerized progress note that has interfaced with patient monitored biological data, ventilator setting and lab results were successfully implemented in high volume PCICU with improvement in quality of documentation, accuracy in data acquisition, and improvement in outcome. Background and aims: Although pediatric triage system, such as Ped-TTAS, was widely adopted in many countries. Over-triage among children with high reaction of vital signs was observed. This study aims to investigate the over-triage phenomena and to provide amendments. Aim: The aim of this presentation is to present the challenges and solutions of service user engagement within the context on two case studies.

Based on their involvement in multiple qualitative and quantitative research studies, the presenters will explore practical, ethical and methodological issues that they have experienced during studies in child health care research involving small and large cohorts of parents.

Background: Nationally and internationally the importance of user involvement in health care research is emerging and having meaningful user contributions is becoming central to good research practice and clinical governance. The level of user involvement and contribution is also often the focus of interest of ethics committees and research funders. However, the interpretation and importance of user involvement can vary and the realities of user involvement can raise methodological and practical issues in a research study. In this presentation these challenges will be discussed as well as strategies that can promote active and meaningful involvement. Findings: A brief overview of varying levels of service user engagement will be presented. Two case studies one in children with complex needs and one with parents who misuse drugs will be presented. Specific challenges will be highlighted and recommendations on how active and meaningful contributions were obtained will be reported.

Conclusions: Key issues in user involvement and how they may be resolved will be fully explored from the perspective of experienced researchers in health care and nursing research. Objectives: To evaluate variations in prenatal counselling of obstetric physicians (OP) and paediatric physicians (PP) in predicting probability of primary postnatal surgical closure of an omphalocele. To establish which prenatal information guides that judgment. Methods: Cases with an isolated omphalocele or with minor additional anomalies and between 12 and 23 weeks of gestation were included. A standardized presentation form per case provided ultrasound images, defect diameter, cele content and 2 ratios: cele circumference/abdominal circumference and defect diameter/ abdominal diameter. Ten OP and nine PP assessed the probability of primary closure quantitatively and qualitatively and stated which information was most important for their assessment. The specialists were blinded towards patients and postnatal outcome. Results: Primary closure was observed in 13/21 cases, and predicted correctly by the majority of the specialists in 5/13 cases. The number of correct assessments per case ranged from 12 to 17/19. In the 8 cases not closed primarily, closure was predicted correctly in 7/8. The number correct assessments per case ranged from 11 to 16/19 specialists. Prediction failure did not differ significantly between specialties. Individual accuracy ranged from 2 to 13/21 cases. Qualitative terms mostly paralleled the quantitative terms, but appeared to be more positive overall. Most of the specialists (34 %) stated that the most important information was cele content.

Conclusions: Specialists did not differ in antenatal judgment on primary closure of an omphalocele; the majority of specialists assessed the probability of primary closure overall to be \60 %. Cele content was the key information guiding that judgment. Specialists tended to be too pessimistic, affecting prenatal counselling. Critical cares for young children are usually provided in Paediatric Intensive Care Units (PICUs) by anaesthesiologists trained in adult anaesthesia residency programs. In Southern Italy, the shortage of PICU beds has led to an increased number of critically ill infants being admitted to Neonatal Intensive Care Units (NICUs). Whilst many aspects of neonatal care resemble those of paediatric critical care medicine (PCCM), several disorders are unique to each respective discipline. To meet the needs of neonatologists to learn basic notions of PCCM, we devised a two-day course with four main handson sessions. The first session aims to provide the basic and advanced ABC resuscitation skills of the critically ill child, the second teaches how to manage lung failure with invasive and non-invasive ventilation strategies, while the third provides guidelines for hemodynamic support of paediatric septic shock, including a practical session on the ultrasound-guided central venous catheterization and radial arterial cannulation techniques; finally, the last session includes high fidelity simulation scenarios to practice non-technical skills. All course teachers are neonatologists with PCCM field experience. At the end of the course, participants performed an anonymous evaluation of all aspects of the course. The students found the course to be well suited to their training needs and indicated a high level of satisfaction (73 % of trainers marked the highest score for the acquisition of new theoretical knowledge, and 86 % for procedural skills). They suggest that the course should be available to all neonatologists dealing with critically ill young infants. Background: Diaper dermatitis (DD) represents a classical irritative contact dermatitis. It's prevalence is estimated between 25 and 65 % of children with a peak around 6-12 months of life. Zinc oxide is generally recommended as the best first choice for DD. Pure topical vitamin E has an emollient effect on the skin and the absence of water also prevents bacterial proliferation, enhancing the barrier function of the skin. Besides Vitamin E has been promoted to help wound healing. Aim: To evaluate the effectiveness of vitamin E and zinc oxide in neonates affected by DD. To compare the efficacy of two treatments for DD: zinc oxide ointment and zinc oxide and tocoferol, to evaluate the efficacy after 5 days of treatment in infants born at 34 weeks or more of gestation.

To establish the rate of complete healing after 5 days of treatment.

Methods: A total of 182 infants will be recruited from the Pediatric Unit of Major City Hospital in Verona (Italy) and included in this controlled, randomized trial. They will be treated with topical ointment containing either Zinc Oxide 10 % (91) Background and aim: Seven body segments measures are not routinely used in clinical and research contexts, but which can provide data about growth patterns. The aim was to obtain and verify whether there are differences in these measures between genders and correlate them with the traditional measures-weight, length and head circumference-during the first year of life.

Methods: Cross-sectional study in which measures were obtained from 250 infants, whose ages ranged from 11 days to 12 months, 58.8 % male and 41.2 % female. The measurements recorded were the segments skull's vertex-gluteus, popliteal crease-gluteus, popliteal crease-heel's plantar aspect, hallux's distal extremity-heel, middle finger's distal extremity-midpoint of the wrist's anterior surface, ulnar styloid process-olecranon process and olecranon process-acromion.

Results: The measures of the seven body segments were established in this study. There were no statistically significant difference in measures between males and females. The head circumference measurement was the least correlated with the seven segments studied when compared with weight and length. Among the segments, the skull's vertex-gluteus showed the best statistical correlation with weight and length (r = 0.894 and r = 0.832, respectively).

The segment skull's vertex-gluteus showed to be a good collaborative measure for child's growth evaluation in their first year of life. Staff members of the NICU play a crucial role in supporting parents during the first weeks of the infant's life. The work of the Neonatal Intensive Care staff involves close interaction with parents and infant during a most vulnerable time. The formation of the bond between mother and infant is underway and through their interactions with parents and with infants this process may be facilitated and supported. Staff may also encounter emotionally distressing situations on a daily basis. This may lead to stress and secondary trauma. This complex interplay of factors relating to the developing attachment between infant and parent in the setting of the NICU has important implications for the infant, parents and for staff. Our objectives were to identify NICU staff attitudes to and perceptions of attachment and social-emotional development of infants admitted to a tertiary referral NICU at a teaching hospital, to enquire about previous education and training in this area and to explore staff perceptions of the emotional impact of the work on staff. Methodology: The study is an observational study. A questionnaire was administered to staff of the NICU and results analysed using SurveyMonkey tm. Results: The most frequent contact with parents was discussing the infant's medical condition. The least frequent contacts were psychological support, assessment of parent's emotional state and social support. Staff believed that discussing parent's emotional states was part of their role and these states affected infant development and infantparent relationship, but staff had received little training in the area. Objective: To investigate the prognostic predictive value of prenatal ultrasound measurements of omphaloceles in the second trimester of pregnancy for the expected type of postnatal surgical closure.

Methods: Retrospectively we collected data on 13 fetuses diagnosed with an omphalocele before 23 weeks gestational age, without major additional anomalies (period 2003-2009 ). We retrieved prenatal and postnatal data, and images of the axial plane of the abdomen at the level of the defect. Two potential prognostic ratios were calculated which reflect the viscero abdominal disproportion: the defect diameter/abdominal diameter (DD/DA) ratio, and the omphalocele circumference/abdominal circumference (OC/AC) ratio. Prognostic outcome was primary closure. The sensitivity and specificity of these ratios, and the area under the ROC curve were calculated as measures of prognostic accuracy. Results: Primary closure was performed in 8/13 cases. A cut-off value of 0.61 for the DD/DA-ratio successfully predicted type of closure in 10/13 cases; for the OC/AC-ratio a cut-off value of 0.82 successfully predicted outcome in 12/13 cases. In all cases without eviscerated liver tissue, the defect was primarily closed. Conclusion: Particularly the OC/AC-ratio represents an accurate counseling tool to inform parents in case of an omphalocele detected in the second trimester of pregnancy. Objective: In order to improve the management of pediatric emergencies we started a training program including high-fidelity simulation PALS training on a regular basis. Due to limited financial resources we developed a simulator which can be used on multiple sites and clinical settings, is transportable and affordable for other hospitals.

Methods: In cooperation with the University of applied Sciences Bonn Rhein-Sieg we developed a new simulation device. Beside heart rate and ECG we needed authentic simulation of blood pressure and oxygen saturation. In order to raise the level of authenticity we developed a simulation device which can be plugged into any clinical monitoring systems. All relevant vital parameters can be seen by the participants on ''their monitors'' and can be changed online by the instructors. Using this novel simulator we trained 217 participants in Pediatric Advanced Life Support.

Results: Confidence score before the courses for all skills was 3.3 ± 0.6 (scale 1-6). 34 % of all participants attended at least 5 or more CPA resuscitation. To most of the participants scenarios with our novel simulator were authentic (1.8 ± 0.3, scale 1-6). After the training confidence score raised to 1.6 ± 0.4 (scale 1-6). Participants welcomed the novel training program as very useful and necessary (1.2 ± 0.3).

Conclusions: Our self constructed simulator shows no lack of authenticity in different simulation of pediatric emergencies. By using a system which is independent of the available monitoring system it is possible to improve acceptance and clinical performance. Objectives: Telemedicine has become popular as a means to support clinical care, yet few studies have measured the reliability of the physical assessment obtained via telemedicine. In a previous study including 55 patients, we found there was low agreement for respiratory variables (kappa -0.02 to 0.34). In our current study, we aimed to further investigate the reliability of telemedicine in assessing respiratory variables in critically ill pediatric patients. Methods: Study providers included pediatric intensivists and pediatric critical care fellows. Phase I: Two providers were randomly assigned to perform a patient examination in-person or via telemedicine. Assessments were completed consecutively. Phase II: Two providers were randomly assigned to perform an examination inperson or via telemedicine. Assessments were done simultaneously. Phase III: One provider completed the patient examination via telemedicine and immediately after, the same provider completed the patient examination in person.

Results: Regarding pulmonary assessment, we found good agreement among respiratory variables when the assessments were done simultaneously (Phase II) as opposed to consecutively (Phase I). We found 100 % agreement when the same provider conducted the patient examination via telemedicine and subsequently in person (Phase III).

Conclusions: Telemedicine is a powerful tool to aid in assessment of critically ill patients. It can be used to reliably identify normal and abnormal findings on the circulatory, neurologic and pulmonary examinations. One needs to be aware of certain limitations of telemedicine and strategies to overcome them for its optimal use. Introduction and objectives: Mental retardation (MR) is a generalized disorder appearing before adulthood, characterized by significantly impaired cognitive function and deficits in two or more adaptive behaviors. The prevalence and severity of dental caries'gingivitis and periodontitis is high in patients with mental retardation. This shift to a diseased state may lead to the experience of a high mortality from septicemia' sepsis' pneumonia and endocarditis. Our purpose is study of oral and gingival microbial flora in institutionalized mentally retarded patients of Sari and to estimate D % (percentage with untreated decayed teeth) and DMFT % (percentage of population affected with dental caries).

This study was descriptive cross-sectional type in which Plaque samples were collected from the mouth and gingival of 138 institutionalized mentally retarded patients of Sari to culture in specific media to identify the microorganisms. In this study anaerobic bacteria were not isolated because the instrument was not available in the laboratory. The information has been analyzed by v 2 T test methods by SPSS 17 software.

Results: The isolated microorganisms were: pnuemococ(37/7 %)_ streptococcisp(18/8 %)_(16/7 %)_staphylococcisp(1/4 %)_niseriasp (45/6 %)_salmonella(8/7 %)_proteus(3/6 %)_diftroid(4/2 %)_pseudomonas(0/7 %). The percentage of resistant strains was found to be highest with penicillin(67/9 %) and lowest with vancomycin(11 %). Conclusion: D % between all the patients were (66/66 %). Bacterial flora in mentally retarded patients were significant normal persons, so with improve in the mouth health care, we can decrease these undesirable changes. (30 %, n = 176), medicine given correctly but prescription written contained an error (24 %, n = 141), prescribing errors (17 %, n = 95), CD balance discrepancies or storage (11 %, n = 64), TPN (10 %, n = 59) and pharmacy-related incidents (8 %, n = 48). Number of reports is lowest during weekend days and holiday periods. Graph illustrates the nature of incidents for administration errors, prescribing errors and prescription administered containing an error. Antimicrobials are associated with the highest number of medication errors. Major harm is in 12 incidents and moderate harm in 39 incidents. Incidence for administration errors, prescribing errors and both prescribing and administration errors from 2007 to 2011 is 2.4, 1.2 and 2.3 per 100 admissions respectively, prevalence of 3.7, 1.8 and 3.4 per 1000 bed days respectively.

Conclusions: Considerable number of incidents are occurring due to medication use in PICU, predominantly, medication administration errors. Root cause analysis is required to establish causes of errors. Aims: To analyze the frequency of thrombotic complications in children with malignancies during treatment of the underlying disease.

Methods: An retrospective analysis cases of venous thrombosis in children and adolescents with malignancies was made. All patients received treatment in our centre from 2002 to 2011. In protocols of ultrasound and medical histories found 74 patients with first diagnosed venous thrombosis aged 0.7-21 years for both sexes (median 12 years). The data were processed from patients who had ultrasound symptoms the presence of thrombotic masses in lumen of superficial and deep venous. Results: When analyzing the frequency characteristics was revealed that venous thrombosis by ultrasound diagnosed an average in 2.6 % of patients (0.7-5.7 %) per year from such who first time during of year were receiving treatment. A comparative analysis of similar data for 2002/06 and 2007/11 showed an increase in the frequency diagnoses of thrombotic complications (Chi-square 9.28; p = 0.002) for patients receiving treated in these periods. The average annual growth rate of detection this pathology for ten-year period was 14 %. Such situation in the last time may be linked with the growth attention of clinicians to identify thrombotic complications, by increasing in the number catheterizations of central and peripheral veins and improving the quality of primary diagnosis of thrombosis.

Conclusions: During last 10 years was established the rising incidence of diagnosis of venous thrombosis in children with malignancies, which is consistent with global trends. Ultrasonography is informative method of diagnosis of this pathology in pediatric cancer patients. Objectives: Embrace, the Yorkshire and Humber Infant and Children's Transport Service, performed 2,236 transfers in the year 2011/12. Embrace is collaborating with aeromedical providers to enable access to air transport for their patients. Process improvement tools and techniques have been shown to improve operational efficiency and effectiveness in health services. But these techniques are unable to fully explain the inter relationship between fluctuating demand and resource availability that can be modelled in a simulation study. Methods: Journey timings from the transport database were analysed. Transports with a travel time [90 min were reviewed to assess suitability for transfer by helicopter. The daily activity of the transport service was overlaid with local emergency medical helicopter availability in a simulation study to further understand utilisation. A scenario was also considered where a dedicated helicopter was utilised and other restrictions were lifted. Results: Database analysis showed the potential for Embrace to transfer patients by helicopter was around 50 occasions per year. After reviewing the cases, this was reduced to 38 occasions per year. The simulation study demonstrated 47 opportunities for Embrace to transfer patients by helicopter. However for 29 of these transports a helicopter could not be accessed. If a dedicated aircraft was available 112 transfers could have been by helicopter, 9 would have been eligible for air transport but were transferred by road due to service limitations.

Conclusions: This information is useful for developing Embrace aeromedical services. The analysis may be relevant to other transport services with similar regional coverage. We undertook a retrospective case series in a neonatal surgical unit with 700 admissions per year. Clinical information from the patients' medical records and the NICU clinical information system was reviewed for infants \1.5 kg who underwent a contrast enema within the past 5 years.

Results: 25 contrast enemas were performed in 24 infants with a mean weight of 0.96 kg, a mean gestation at birth of 27 weeks + 2 days and a mean postnatal age at study of 17 days. 11/25 procedures were judged by radiologist to have been diagnostic, of which 8 were reported as normal and 3 pathological. 14 studies were non-diagnostic, of which 8 were inadequate, and in 6 the study was adequate but non-diagnostic. 3 serious complications were attributable to the procedure: 1 study was abandoned because the patient became too unstable, 1 resulted in caecal perforation, 1 died of sepsis and multiorgan failure within 6 h. In all 3 cases the infants weighed 700 g or less at time of study. Conclusions: Neonatal contrast enemas are frequently non-diagnostic. They are, not infrequently, associated with serious complications. These observations should be validated with a larger, multi-centre review in order to stratify risk and better inform clinical decisionmaking. Background and aims: Readmission after paediatric intensive care nit (PICU) discharge is an important problem. It may be associated with an increased mortality, morbidity and length of stay (LOS). It is therefore imperative to identify risk factors for readmission following PICU discharge. We tested the hypothesis that children discharged during non-office hours (i.e. 5 pm to 8 am the following day) were at higher risk of readmission than children who are discharged during office hours (8 am to 5 pm). Methods: We retrospectively retrieved all demographical and clinical data from children admitted between 2006 and 2012 to our PICU. Patients were labelled readmission if they were readmitted to our PICU within 48 h of discharge. Data are presented as mean ± standard deviation or percentage of total. Statistical analysis was done using the Mann-Whitney test for continuous data and Chi square test for dichotomous variables. P values.05 were accepted as statistically significant.

Results: A total number of N = 3,368 children were studied, of whom N = 30.4 (%) were readmitted. Baseline demographical data was not different between children who were readmitted or not. Children who were readmitted were more often discharged during non-office hours (13.4 vs 9.2 %, p = 0.04). The mean length of PICU stay in the readmission group was significantly longer (7.7 ± 12.383 vs 5.6 ± 14.104 days, p B 0.001).

Conclusion: Our study showed that PICU readmission occurred more often in children who were discharged during non-office hours. PICU readmission was associated with prolonged length of stay. Preterm infants are exposed to loud noises during their stay in the neonatal intensive care unit which can lead to physiologic and behavioral alterations and even hearing loss. The use of earmuffs can reduce sound level and these changes. To evaluate the effectiveness of the earmuffs in preterm infants solely cared for in closed incubators, a comparative prospective study comprising 20 clinically stable preterm infants weighing \1,500 g was conducted. Preterm infants acted as their own controls whereby they were observed without earmuffs (Group 1) for 2 days and with earmuffs (Group 2) on consecutive 2 days. The preterm infants' physiologic responses and Anderson Behavioral State Scoring System (ABSS) scores were assessed over 30 s every 2 h for 8 h during daytime for 4 days. Out of 20 preterm infants, 6 were male and 14 female with a mean birth weight of 1,220 ± 209 g, gestational age of 29.9 ± 2.1 weeks. The total number of measurements was 320. The mean ABSS scores of Group 1 and 2 were 3.07 ± 1.1 and 1.34 ± 0.3, respectively. Statistically significant difference was noted between the means of ABSS scores (p \ 0.001). Preterm infants with earmuffs (87.5 %) were more frequently observed in a quiet sleep state of ABSS compared with those without earmuffs (29.4 %). In conclusion, noise reduction in preterm infants by earmuffs may be helpful by improving sleep efficiency and increasing time of quiet sleep. Objectives: Timely recognition of seriously ill children is important to prevent complications and death. Recognition is complicated because of ranging age-related vital norm parameters and warrants sufficient knowledge amongst healthcare professionals. Though paediatric literature provides data of early changes in vitals, only few fully operational and clinically validated warning systems exist.

To prove the value of such a system in the European setting, we developed the Radboud Paediatric Early Warning Score (PEWS) and studied its effect upon patients' safety and healthcare quality.

Methods: The Radboud PEWS was constructed from international literature. It added up to a card set consisting of 8 parameters in 5 different age categories (Fig. 1 ). Clear instructions are given towards professionals what actions need to be taken at different scores. We validated the Radboud PEWS by studying baseline scores, chosen cut-off points and effects upon knowledge and self-efficacy amongst professionals. Results: We analysed 118 admittances on the paediatric oncology ward providing 1,115 separate scores. In 91 (77 %) admittances all the scores were B4 (baseline score). A PEWS C 8 was scored 56 times in 15/118 admittances (13 %). The corresponding clinical condition was ascertained retrospectively as 'critically-ill' in 40/56 (71 %) scores. ICU involvement was only seen in patients with PEWS C 8. Professionals embraced the PEWS praising its simplicity and effectiveness. Effects upon knowledge improvement and self-efficacy are currently studied.

The Radboud PEWS is the first fully operational scoring system in the Netherlands providing sufficient sensibility to promptly identify critically ill patients. Background and objectives: Now a days many Emphases on the quality of life. The complex nature of hemophilia negative effects on the patient's body and spiritual Affect quality of life these patients. The aim of this study was to compare the different dimensions of quality of life of healthy adolescents with hemophilia were teenagers. Materials and methods: Observational study-an analysis of casecontrol between two groups sampling was simple random sampling, samples were 64 teenagers with similar demographic characteristics like age, sex, socioeconomic situation, neighborhood that allocated in two groups. Data collection was the through questionnaire that completed in two steps by researcher. The data were analyzed using spss 15 software and statistic tests paired t test, two independent samples, Chi square, and Spearman and Pearson correlation coefficients.

Results: Scores of physical, psychological and environmental quality of life and quality of life of the average total score in the control group (both measured at the time) was significantly different from each other (p [ 0/001) and the average score quality of life community in the first two measurements (p = 0/27) Second measure (p = 0/53) was not significantly different from each other.

Regarding to poor quality of life in teens with hemophilia in compare with healthy teens, Measures to improve the quality of life in all its aspects seem to be essential. Background and aims: Family-centred care is an expected standard in PICU and parent reported outcomes are rarely measured. The Dutch validated EMPATHIC questionnaire provides accurate measures of parental perceptions of family-centred care in PICU. A French version would provide an important resource for quality control and benchmarking with other PICUs. The study aimed to translate and to assess the French cultural adaptation of the EMPATHIC questionnaire. Methods: In September 2012, following approval from the developer, translation and cultural adaptation were performed using a structured method (Wild et al. 2005) . This included forward-backward translation and reconciliation by an official translator, harmonization assessed by the research team, and cognitive debriefing with the target users' population. In this last step, a convenience sample of parents with PICU experience assessed the comprehensibility and cultural relevance of the 65-item French EMPATHIC questionnaire. The PI-CUs in Lausanne, Switzerland and Lille, France participated. Results: Seventeen parents, including 13 French native and 4 French as second language speakers, tested the cognitive equivalence and cultural relevance of the French EMPATHIC questionnaire. The mean agreement for comprehensibility of all 65 items reached 90.2 %. Three items fell below the cut-off 80 % agreement and were revised for inclusion in the final French version. Conclusions: The translation and the cultural adaptation permitted to highlight a few cultural differences that did not interfere with the main construct of the EMPATHIC questionnaire. Reliability and validity testing with a new sample of parents is needed to strengthen the psychometric properties of the French EMPATHIC questionnaire. The aim was to evaluate possible changes in temperature, heart &breath rate, breastfeeding, sleeping rate, and attachment of mother and infant A randomized controlled trial was performed in which 60 LBW neonates with weight B2 kg. Subjects were matched by sex, gestational age, mother's delivery type, Apgar score, mother's education, age, occupations. The subjects were randomized into three equal groups, one intervention group (KMC-20) received KMC in hospital, the other (KMC-20) received KMC at home. The control group (CMC-20) received conventional care. KMC groups received kmc for 6 h per day in 6 consecutive days and control group received standard care. The results showed breathing rate, Heart rate, temperature and Sleeping time in study groups had significant differences (p \ 0.001) and the mean of the study groups were more than control group, Also the result showed nutrition rate in study groups had significant statistical differences after applying KMC (p \ 0.001) and in relation to mother and infant attachment, comparing these three groups showed significant differences (p \ 0.05) and the Levene Statistic test showed that the variance of three groups are equal (F(2,57) = 1.67, p [ 0.05), and an ANOVA test showed there are significant differences between three groups. KMC at home results are significantly increased in neonates when they are given KMC at home. The present study has important implications in the care of LBW in developing countries, where expensive facilities for conventional care may not be available and where a neonate is kept in the hospital just because he or she is a LBW. Background and aims: The pediatric intensive care unit (28-beds, level 3 IC unit with 1,400 admissions annually) in the Erasmus MC-Sophia Children's Hospital Rotterdam runs a Patient Safety Management System since 2004. It includes incident reporting, adverse event detection, team training and risk management. To justify our activities we needed to quantify the effects on patient outcome in terms of occurence of adverse events. Adverse events (AE's) are reported voluntary in two ways; complication registration by physicians and digital incident reporting mainly by nurses. We assume that there is underreporting of AE's. Methods: AE's can be detected and monitored with the trigger tool methodology. A trigger is an occurence, prompt or flag found on review of a medical record that 'triggers' further investigation into the possibility of an AE. In our PICU we used the PICU trigger tool from the Institute of Healthcare Improvement and some items from their NICU trigger tool. Consensus was reached about definitions, how to identify a trigger and how to determine the occurence of an AE. We applied the trigger tool on medical records, the hospital electronic database and the unit data management system. Results: Application of the trigger tool on a random sample of 25 % of all patients discharged in 2011 yielded 249 AE's in 106 patients (32.5 %). In 2012 we considered all discharged patients in the first 6 months. We identified 456 AE's in 216 patients (23.6 %). Conclusions: We detected far more AE's with the trigger tool than reported by physicians using complication registration only.

A. Khan 1 , T. Radia 2 , M. Lane 3 1 Anaesthesia, Great Ormond St Hospital, 2 Paediatrics, Evelina London Children's Hospital, 3 Anaesthesia, Royal Brompton Hospital, London, UK Introduction: There is limited data regarding standard contents of a paediatric difficult airway trolley (DAT) and no specific paediatric difficult airway algorithm exists to guide development [1, 2] . The report, Major Complications of Airway Management in the UK, has recommended the immediate availability of a DAT in intensive care units. We surveyed current practice in UK Paediatric Intensive Care Units (PICU) and high-dependency units (HDU) regarding availability of a DAT to highlight the need. Methods: We identified 31 PICU and HDUs. A telephone survey was conducted and questions identified the presence of a DAT, its contents, location and on-going management. Data was analysed using Excel. Results: We achieved a 100 % response rate. 42 % (13 units) had a paediatric DAT. 58 % (18 units) did not. Standard airway equipment was similar. Additional visualisation aids were the Glidescope and Airtraq. 3 units had a fiberoptic bronchoscope. 23 % of units had Quicktrach sets and 46 % cricothyrotomy needle kits. Discussion: Unanticipated difficult airway in the paediatric population is uncommon and this may be why less than half of the PICU (42 %) have a DAT. We agree with the recommendation that a dedicated paediatric DAT in PICU is essential for the provision of high quality care [2] . Background and purpose: 40 % of all initial infections with Toxoplasma gondii during pregnancy develop into connatal toxoplasmosis, which is associated with the risk of severe damage to the CNS, frequent premature deliveries, and stillbirths. In Germany, toxoplasmosis immunity screenings are not covered by the state health insurance as a general preventive care service, in contrast to screening for rubella immunity. Therefore, we analyzed the impact of socioeconomic factors on the efficiency of private toxoplasmosis screening during pregnancy in a population-based study. Materials and methods: Toxoplasmosis and rubella screening data were collected from 5,736 mothers during the period from May 2002 to June 2008 within the population-based Survey of Neonates in Pomerania (SNiP). Results: At the first screening, 34.2 % of expecting mothers were immune to toxoplasmosis, 75.2 % had immunity against rubella after active immunization. Negative immunity for toxoplasmosis was found in 39.7 % and in 7.7 % for rubella (missing information: toxoplasmosis: 25.8 %; rubella 17.2 %). Less than 10 % (n = 282) of the women without immunity participated in a second toxoplasmosis screening. An active toxoplasmosis infection was found in 0.3 % (n = 17) women during pregnancy. There were no infections with the rubella virus. Pregnant women with a higher socioeconomic status participated in screenings considerably more frequently. Conclusion: Our population-based sample demonstrated a substantial risk of toxoplasmosis infection during pregnancy in contrast to the rubella risk. Furthermore, lower socioeconomic status adversely affects the rate of toxoplasmosis screening. This data support the need for toxoplasmosis screening for pregnant women as a general health care benefit covered by insurance.

Objective: To evaluate the benefits of lycopene supplementation in prevention of pre-eclampsia and the perinatal outcome in women at high risk of developing pre-eclampsia. Materials and methods: A pilot study comprising 107 pregnant women (13-28 gestational weeks) with factors considered high risk for pre-eclampsia were considered and randomly allocated into two groups : I (n = 55) and II (n = 52), with or without lycopene supplementation, respectively. Lycopene in a dose of 4 mg once daily starting from the date of entry was given to the antenatal subjects of the study group (Group-I) and took the drug regularly until delivery. Women of Group-II were not provided with lycopene. Main observation measures: development of preeclampsia and its severity, period of gestation at delivery, mode of delivery, fetal weight and perinatal outcome as regards to admission to neonatal intensive care unit and neonatal death.

Observations: There were no significant differences in development of preeclampsia but severity was more in the group-II. Significant adverse finding noticed, having no mention in the literature earlier, was: one case of eclampsia. Women in the lycopene supplementation group had not only significantly lesser incidence of growth restricted babies but also significantly healthier babies and had a better perinatal outcome compared to women in non-supplemented group. Conclusion: Supplementation of Lycopene although does not decrease the incidence of preeclampsia in high risk women but may help in reducing its severity and there is reduced incidence of intrauterine growth restriction with better perinatal outcome. Objectives: Healthcare-associated infections (HAI) are a major and potentially preventable cause of morbidity and mortality, especially in the acute care setting. The main objective of this study is the implementation of a deviceassociated infections surveillance system, including central line-, urinary tract catheter-and endotracheal tube-associated infections, in a French neonatal and paediatric intensive care unit. Methods: All children consecutively admitted to our unit, from July to December 2011, for more than 48 h, were prospectively included. The data were separately analyzed for the neonatal (1-28 days old) and the paediatric population ([28 days old). All above mentioned devices were registered. The definitions used for HAI were those elaborated by the Center for Diseases Control. All data were treated anonymously. A linear regression analysis was performed to point out the main risk factors of HAI. Results: We assessed 303 consecutive admissions. Of them, 181 children were included in the surveillance: 129 neonates (median weight: 1,730 g; median gestational age: 32 weeks), wearing 199 central lines, 116 endotracheal tubes and 26 urinary tract catheters. Seventeen central line-associated bloodstream infections and 5 endotracheal tube associated infections were found. Fifty two children (median age: 3 months) having had 31 central lines, 23 endotracheal tubes and 14 urinary tract catheters were also enrolled. Conclusions: The implementation of a HAI surveillance system is feasible. An additional surveillance period is planned to allow the analysis of the device-associated infections incidence rates. This surveillance system will help us to improve our healthcare practices. Objectives: To assess the safety and fiscal implications of using High Flow Nasal Cannula (HFNC) therapy in a paediatric ward (PW) for treating infants with bronchiolitis. Methods: 61 infants aged B12 months with bronchiolitis and oxygen requirement were enrolled in the emergency department (ED) and transferred to the PW on HFNC. Comparison group of 33 patients retrospectively identified, but managed with standard sub nasal oxygen therapy. Results: Admission demographics and heart rate (HR), respiratory rate (RR) and physiological score (CEWT) were similar in both groups. Patients requiring PICU admission showed no change of HR, RR and CEWT after 1 h on HFNC compared to a significant decrease in the patients remaining on PW (p \ 0.02). Patients receiving HFNC were 4 times less likely to need PICU admission than the comparison group (OR 4.086, p = 0.043). There were no serious adverse events or intubations. Median length of stay of both groups was 92 h. Current costs for a combined PICU/PW admission are AU$ 15,517/pp, compared to AU$ 4,992/pp on PW alone. Predicted annual cost saving for a 19 bed mixed medical/surgical PICU with 1,300 admissions/year is AU$ 1.2 Mio. Conclusions: HFNC treatment on the PW for bronchiolitis is safe. Non-responders requiring PICU admission can be identified by no S68 Intensive Care Med (2013) 39 (Suppl 1):S1-S200 reduction in HR, RR and CEWT within the first hour of HFNC treatment. The early use of HFNC in ED may lead to a significant decrease in the admission of infants with bronchiolitis to the PICU and hence represent significant health care cost savings. Introduction: Prescribing errors are a major problem in the healthcare environment with paediatrics presenting challenges from offlabel and weight based prescribing. In the Paediatric Intensive Care Unit (PICU) additional factors such as the severity of illness and the involvement of multiple specialist teams may predispose to greater numbers of errors. Aims: The aims of this audit were to assess the level of adherence to hospital prescribing guidelines in the PICU, identifying the areas of greatest and least adherence, and trying to identify possible patient factors that may predispose to a higher incidence of non-adherence. Methodology: A prospective, observational audit was carried out in the PICU in Alder Hey Children's Hospital with bedside data collection, using a template based on hospital guidelines. Results: 988 prescriptions were reviewed during the study period comprising a mean of 20 prescriptions per patient with a mean of 24 drug administrations per patient over a 24 h period. The overall adherence in the five individual prescription sections was 91.62 %.

No correlation was noted between adherence and patient factors such as Paediatric Multiple Organ Deficiency Score. The critical incident rate was 5.06 per 1,000 prescriptions; none of these caused permanent harm because of early detection.

Conclusions: This audit helped to raise awareness of key areas that are to be targeted as part of an action plan to improve adherence. The detailed data collected in the various prescription sections showed a high adherence rate reflecting the competency of the staff prescribing within the very challenging PICU environment. Aim: Illness severity scores were described to estimate mortality and morbidity risks based on data obtained shortly after birth. Aim of this study was to evaluate Score for Neonatal Acute Physiology-Perinatal Extension (SNAPPE-II) as a predictor of neonatal morbidities such as bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), intraventricular hemorrhage (IVH).

Methods: A prospective cohort study was conducted including 278 infants with gestational age (GA) B32 weeks and/or birth weight (BW) \1,500 g. SNAPPE-II based on data collected in first day of life and risk factors for ROP requiring laser photocoagulation, BPD and IVH (Cgrade 3) were studied in univariate analysis and significant variables were further evaluated in logistic regression. Receiver-operating characteristics (ROC) curve analysis was performed for SNAPPE-II and GA, and areas under the curve were compared.

Result: Mean GA and BW of the cohort were 29.2 weeks (±2.15) and 1.323 g (±331.4), respectively. SNAPPE-II was significantly higher among patients with BPD, ROP and IVH (p \ 0.001, p \ 0.001, p = 0.002, respectively). After logistic regression SNAPPE-II was independent risk factor for BPD (OR = 1.04, p = 0.005), ROP (OR = 1.05 p = 0.034) and IVH (OR = 1.04, p = 0.022). The best discriminative cutoff value of SNAPPE II for BPD was 14.5 (sensitivity 92.7 %, specificity 68.3 %), for ROP was 23.5 (sensitivity 80 %, specificity 79 %), for IVH was 13.5 (sensitivity 100 %, specificity 57.5 %). GA alone had a similar discriminative power to SNAPPE II.

Conclusion: High SNAPPE-II at admission is an independent risk factor for BPD, ROP and IVH. SNAPPE-II is not better than GA for predicting these neonatal morbidities. Background and aims: A child's admission to the CICU requires a sudden re-adaptation of the entire family to a new situation, full of risks and uncertainties. The purpose of our study was to identify parents' needs, and their perceptions, and expectations regarding the pediatric intensive care services.

Methods: A 14-item self report questionnaire was given by the bedside nurse to all parents upon admission to the CICU from September to December 2012. A modified version of the Critical Care Family Needs Inventory was utilized. Questionnaires' items were analyzed according to nationality, length of CICU stay, age of the child and number of CICU admissions, expressed as dichotomous variables. Differences were assessed by Chi square test and p \ 0.05 was considered as statistically significant.

Results: A total of 120 questionnaires were given to the parents and forty (33 %) were available for the analysis. Twenty-four were answered by mothers (60 %) and 31 were Italian (77.5 %). There were significant differences between the Italian and immigrant parents about satisfaction of medical care and CICU facilities (waiting room). Parents of children [1 year of age, parents whose child was admitted for [7 days, and parents whose child was admitted [1 time to CICU scored the hospital personnel care and medical communication significantly less compared with the respective other group. Conclusions: 'Dissatisfaction' was highest among families of Italian origin, and in older children, with longer or multiple admissions, suggesting that communication and care should be modulated and centered on family and child needs. Background and aims: Hospitalization due to a critical illness is a stressful situation and there is a growing interest in parents satisfaction as indicator of quality of care. It is essential that both physicians and nurses attempt to identify and meet the needs of parents of critically ill children. The purpose of this study was to identify the impact of the implementation of a continuity of physician care in the CICU and the evaluation of this role on the parents' perception of the quality of care given.

Methods: This is an ongoing study, started in September 2012, that will be completed at the end of April 2013. A modified version of the ''Critical Care Family Needs Inventory'' questionnaires will be prospectively collected to assess the parent's satisfaction of the quality of care before and after the implementation of a continuity physician, introduced in our CICU at the 1st of January 2013. This attending physician is in charge of the communications with all the parents. Results: The study will report on the effect of the implementation of the continuity of medical care in a CICU. Data are not available yet for the second part of the study, as the continuity of care has been implemented only at the beginning of this month.

Conclusions: New policies, such as continuity of medical and nursing care, will most likely improve the degree of satisfaction of parents and help the family to learn from the PICU experience and facilitate adaptation to a stressful and difficult situation. Objectives: We studied the pattern of blood transfusions administered to very preterm neonates, in an attempt to rationalise transfusion practices on our NNU. Methods: 96 consecutive admissions to our Level 3 NICU, born at 23-28 weeks gestation, were retrospectively evaluated between 12/3/ 2010 and 11/3/2012. Data on timing and frequency of blood transfusions against gestational age, in survivors, were analysed using Kendall's tau-b correlation coefficient. Results: 369 transfusions were administered to 80 (83.3 %) neonates. All-cause mortality was 23/96; 7 died without receiving a blood transfusion. 9 survivors (26-28 weeks) did not require transfusions; the remaining 64 required a median of 4 transfusions each. 86 neonates were ventilated in the first 24 h, with the remaining 10 receiving CPAP/BiPAP support. Birth haemoglobin increased with increasing birth gestation (p = 0.001; 12.6 g/dl in 23 +0 -23 +5 weeks and 15.7 g/dl in 27 +0 -27 +5 weeks survivors). Median day of first transfusion was sooner in those born earlier (2 days in 23 +0 -24 +5 weeks vs 8 days in 27 +0 -27 +5 weeks; p \ 0.001). Neonates born at earlier gestation required more frequent transfusions in the first 2 weeks of life (p \ 0.001; 3 and 1.5 in the first and second week of life in 23 +0 -23 +5 weeks). Intervals between multiple transfusions were shorter in those born earlier (p \ 0.01).

Conclusion: The lower the gestational age of the NICU survivor, the sooner, more frequent, and quicker succession of blood transfusion was needed. This data has helped formulate a single donor multi-pack blood transfusion programme for our high risk NICU residents, and enlightens our parent counselling. Pediatric Surgery, Esfahan University, Esfahan, 2 Emergency, Isfahan University, 3 Nursing, Nursing University, Isfahan, Iran

Background: Intestinal stomas are produced when a section of gastrointestinal tract is opened on to the skin surface to drain the stoma effluents. Most surgically formed stomas are colostomies, ileostomies, and urostomies. However, there are some The commonest postsurgical problem for ostomy patients is peristomal skin damage. Aim: To evaluate the effect of Acacia senegal gum in treatment/ management of the ostomy complications of the peristomal skin.

Methods: Clinical observation methods with especial assessment tools (DET and get photograph) were used. DET (ostomy skin tools) was used for the evaluation of treatment and software (Auto CAD2010) to calculate the wound size in order to understand the effectiveness of Acacia senegal gum in treatment of wounds. 10 patients were observed for 8 months (5-under effect of Acacia senegal gum, 5-under effect of zinc oxide ointment). In this study, examined Effects of Acacia senegal gum in prevention and treatment of children peristomal skin disorders as compared to zinc oxide. Results: The peristomal complications were positively influenced by the use of the Acacia senegal gum with in period of 8 days. The total DET score in all domain effectively reduce from 7.60 (3.05) on day 0 to 3.00 (2.34) on days 8. The size of discolouration skin area in mm 2 on 0 day was 1,433.5 (1,037.83) mm 2 that decreased to 654.3 (446.78) mm 2 on 8th day. Conclusion: In this study, it was found that Acacia senegal gum is useful remedy in the peristomal complications and may act as a good barrier to treatment of complications. Background: Ultrasound (US) guided central venous cannulation is becoming common in the pediatric intensive care unit. Since many veins can be cannulated by US (internal jugular vein-IJV, external jugular-EJV, brachio-cephalic vein-BCV, subclavian vein-SV, axillary vein-AV), we propose a protocol for a standardized evaluation of all possible veins, the RaCeVA (Rapid Central Vein Assessment), already used in adult patients in our institution.

Methods: The US evaluation starts at mid-neck (visualization of IJV in short axis). The probe is moved to the anterior mediastinum (visualization of BCV). Moving the probe laterally above the clavicle, SV and EJV are visualized. Finally, we scan the infraclavicular area (visualization of AV and cephalic vein in short and in long axis). Background: The number of newborn with congenital abnormalities that survive their life threatening condition and remaining dependent on the hospital after discharge is increasing. In fact general paediatricians have limited knowledge of these rare conditions and parents may feel it difficult to rely on them after discharge. Furthermore even for parents with uneventful pregnancies, and especially for strangers, daily care of the neonate can be perceived stressful due to the lack of a familial environment. Aims: Our telephone counselling aims at supplying with extra support both parents of neonates with congenital abnormalities and parents of healthy newborns.

Dedicated telephone helpline Campaign directed to parents of neonates hospitalised in our Hospital Specific link on the Hospital web page and activation of an e-mail inbox Expert team of nurses with specific knowledge of medical and psychological problems.

Conclusions: The telephone helpline promotes wellness after discharge by strengthening parents and reducing the stress burden of parents of neonates discharged after congenital abnormalities correction. Telephone counselling can furthermore reduce rehospitalisations as well as after hour consultations and accesses to the emergency department. Swaddling is a traditional practice of wrapping infants in swaddling clothes so that movement of the legs and foot are tightly restricted.

Despite of these advantages, if swaddling use inappropriately, would result in Dislocation of Hip. In this research we assess the Mothers' knowledge and performance about application of swaddling.

Methods: This is a descriptive-analytical research. Data gathered through a researcher-administered questionnaire and interview by professional midwife. The validity of questionnaire confirmed through experts (Pediatricians, Faculty members in nursing and midwifery, orthopedist) and its reliability after distributed in a sample of 30 mothers gained 91 % through Cronach's alpha. Data analyzed by expert through SPSS version 16.00.

Results: Finding showed that the majority of mothers (65 %) have not knowledge about benefits and pitfall of swaddling. 86 % of them knew that it was good for calming babies, sleeping and warming. 16 % of them knew that swaddling may lead in dislocation of hip. Educated mothers and housekeepers swaddled their babies less than others. Educated mothers told in the interview that they did not receive information about swaddling much from media and doctors (65%).

Conclusions: With regards of weak results about knowledge and performance of mothers on swaddling and its consequences such as adult emotional health and dislocation of hip, promotion of mothers' knowledge suggested through health workshop and practical teaching sessions by professional and governmental official is necessary. Respiratory distress syndrome (RDS) is the most frequent pathology in preterm infants and the short and long term outcome of this condition is often influenced by its' severity and management. Aim: Implementation of a national database for respiratory distress syndrome in preterm infants B 32 weeks gestation.

Materials and methods: An on-line national database was started in 2010 in order to collect, on voluntary basis, data regarding the management of the respiratory distress syndrome in preterm infants B 32 weeks gestation. A review of the steps taken in order to implement, extend and develop this database was done after 2 years. Results: In 2010 the database comprised 673 preterm infants, born in 9 maternity hospitals and covered 14.28 % from all the births in Romania. In 2011, the database increased to 1309 preterm infants admitted in 15 neonatal units (13 level III and regional and 2 level II maternities), covering 23.41 % of the births at national level. Also, in 2011, the database was enlarged to collect, above epidemiological data and information regarding birth management and respiratory care, data about nutrition and infections. Also, 38 presentations and papers were done or published using the collected data. Conclusion: The national Registry for RDS offered a great opportunity to improve the quality of care, collect important epidemiological data, promote the new national guidelines, encourage the implementation of protocols according to each unit level, disseminate information and stimulate research based on the collected data. Background and aims: Birth before 28 weeks of gestation is associated with a high mortality and morbidity. The purpose of this study was to examine characteristics associated with in-hospital mortality and morbidity among extremely-low-birth-weight neonates admitted to three tertiary care centers in Romania. Methods: The study was conducted in three Romanian hospitals with Level III Neonatal Intensive Care Units. We studied singleton live births at the established Romanian limit of viability (i.e., 25-28 weeks gestational age) born between January 2007 and December 2010 (n = 227). Infants born in non-Level III facilities transferred to these three centers were included in our study (n = 39). Descriptive and multivariate statistical analyses were used to describe the population and examine outcomes and risk factors. Background: Mothers are exposed to many toxins that can reach their infants through breast milk. One of these toxins is aflatoxins, produced by Aspergillus fungus which colonizes grains, especially in tropical regions. Aflatoxins are highly toxic, mutagenic, teratogenic, and carcinogenic. One of these is aflatoxin B1 that is excreted in breast milk as aflatoxin M1 (AFM1). Aim of work: Assessment of exposure of Egyptian infants to aflatoxin M1 through breast milk. Methods: This cross-sectional study included 150 mother-infant dyads. All the infants were exclusively breastfed. Infant weights' standard deviation scores were documented at birth and at 6 months. At 6 months, before starting weaning, AFM1 was measured in breast milk and liver enzymes; alanine aminotransferase (ALT) and aspartate aminotransferase were assessed for all mothers and infants. Results: Ninety-eight mothers (65.3 %) had AFM1-positive breast milk samples (AFM1 [ 0.05 mg/l according to the European Community and Codex Alimentarius). AFM1 levels ranged between 0.2 and 19.0 mg/l (mean: 7.1 ± 5.0 mg/l). In cases considered negative, AFM1 levels ranged between 0.01 and 0.05 mg/l (mean: 0.04 ± 0.01 mg/l). Infants of AFM1-positive mothers had lower weight standard deviation scores at birth and at 6 months (P = 0.04 and 0.0001). ALT and aspartate aminotransferase of mothers and ALT of infants were significantly higher in dyads having AFM1-positive breast milk (P = 0.0001, 0.0001, and 0.03, respectively). Conclusion: Aflatoxins represent a real threat in Egypt. The higher liver enzymes in AFM1-positive cases might represent an alarm toward future development of hepatocellular carcinoma. Aims: The main objective of this study was to examine the incidence and risk factors associated with aggravated general statement, residual impairment and death post PICU hospitalization. Methods: Retrospective study between 1/1/2011-25/02/2012 in a PICU located in a tertiary pediatric hospital. Patients younger than 2 years, with underlying oncological disease and those who died within the first 12 h after admission were excluded. Results: Overall, from a total number of 315 admissions, 58 patients were included. The median age was 7 years old. A significant proportion of our cohort needed rehabilitation post PICU discharge, eighteen patients (31 %), while two children (3, 4 %) died.

[i2] Factors associated with aggravated general statement, residual disease and death included: head injury (34.5 %), delayed PICU admissionfor clinical admissions over 24 h (41 %),for posttraumatic admissions over 3 h (19 %), pediatric risk of mortality (PRISM) score at the first 24 h of the admission [ 8 (38 %), underlying neurological disease(17.2 %), duration of mechanical ventilation [ 7 days (12 %), use of vasoactive drugs at the admission (5.17 %), hospital-acquired infection (17 %) correlated with prolonged hospitalization [ 10 days (17 %). Conclusions: Although there has been significant improvement in the provided care by PICU, still survival as well as post discharge impairment and quality of life depend on the critical care support provided before admission in PICU. Secondary, severity of illness, estimated by PRISM score is the key factor for the prognosis of the critical ill children. Objectives: Staff in PICU and NICU are required to undertake a wide variety of written tasks, yet few have received formal writing training since leaving school. Complex cases can involve correspondence with parents and professionals unfamiliar with the jargon and practices of ICU. Poor communication can be dangerous, and when things go wrong, written records may be crucial to the outcome of legal cases. Methods: In Late 2012, in collaboration with the Royal Literary Fund, Great Ormond Street Hospital ICU began a brief pilot project to see whether staff would welcome the opportunity to receive one-toone advice from a professional writer. Medical, nursing, and administrative staff at all levels took advantage of the scheme. Topics ranged from everyday written work, and the challenges faced by those for whom English is not their first language, to the refinement of articles for learned journals. Results: Close examination of how and why familiar writing tasks were performed brought suggestions for changes and developments in custom and practice. Unexpected areas for attention, such as potential pitfalls in email correspondence, were highlighted and addressed. Conclusion: Our presentation will describe how the project was conducted, outline the response of individual members of staff to the scheme, and attempt to assess its impact on the written output of the unit. We will explore the potential for future developments, and for implementing similar schemes elsewhere, with a view to enhancing the professional skills of individuals and reducing the reputational and legal risks for institutions in which they work. Background and aim: Adverse events are of major interest, not only because of their impact on patients but also because they provide a measure of quality of health care and opportunity for improvement. This study aimed to identify, at admission, patients at increased risk to experience one or more adverse events in PICU. Methods: All adverse events were registered prospectively during a 13 month period in a 14-bedded PICU. Univariate and multivariable logistic regression analysis was conducted, to identify at admission patients who will suffer from one or more adverse events. Results: During the study period the PICU had 658 admissions, with a total of 4,380 patient days. The overall adverse event rate was 0.45 per admission and 68 per 1,000 patient days. Independent positive predictors were PRISM 2 score (truncated above 10) and TISS score (truncated above 25) at admission, significant past medical history and invasive ventilation at admission. Increasing age was a positive predictor above the age of seven and a negative predictor below seven years. Independent negative predictors were transport by PICU retrieval team and immediate postoperative admissions. Conclusion: We identified in our PICU which patients are at risk to experience adverse events. This will hopefully facilitate targeted interventions to prevent adverse events.

A. Wagh, G. Sefton, E. Scott, P. Baines PICU, Alder Hey Children's Hospital NHS Trust, Liverpool, UK Background and aims: Readmissions within 48 h of PICU discharge are a measure of quality of intensive care service. With ever increasing bed pressure, concerns have been raised that OOH PICU discharge is becoming more frequent. We aim to study effect of OOH discharge on readmissions (rate/morbidity/mortality). Methods: A single centre (PICU, Alder Hey Children's NHS Trust) retrospective review of prospectively collected database over 10 years (January 2003 . The PICU is a 22 bed cardiac and general unit with around 1,100 admissions per year. OOH were defined as hours between 17:00 and 08:00 hours, weekends, and bank holidays. Results: Of the total 9,471 PICU episodes eligible, 330 were admitted with in 48 h (3.36 %). 4,910 (50 %) were discharged OOH and 4,890 office hours. The 48 h readmission rate did not differ between the groups (3.1 vs 3.6 %). However, readmission PICU mortality rate was significantly higher with OOH discharge as compared to office hours discharge (7.86 vs 1.31 %, P value 0.006). PIM2, ventilation days and PICU length of stay for the readmission episodes were not different between the two groups. Conclusions: Readmission rate at our institution is comparable to the published data. There is no difference in 48 h PICU readmission rate between discharge during office hours or OOH time. However, with out of hours discharge there is significantly increased readmission mortality. Objectives: Aim of the study was to assess usefulness of extracorporeal liver support-albumin dialysis with the molecular adsorbent recirculating system (MARS) for treatment of paediatric patients with acute or acute-on-chronic liver failure. Methods: Study was conducted in tertiary pediatric hospital (national reference centre for paediatric liver transplantations). Retrospective search on medical records of all MARS procedures performed since July 2001 until December 2010 in intensive care unit patients have been performed. All patients treated with at least 1 procedure of MARS, were included into analysis. Results: During 10 years period MARS procedures were used for treatment of 68 patients (37 girls, 31 boys). Age of patients varied from 13 months to 23 years (mean age 10.7 years). Among patients treated with MARS procedures most frequent diagnosis were: acute intoxication (drugs/mushrooms)-19 children and Wilson disease-10 children. During analyzed period 188 MARS procedures were performed, in 48 patients more than one. Mean number of procedures per patient was 2.8 with highest number 9 procedures in one patient. Among all 68 patients treated with MARS 47 children survived (69 %): successful liver transplantation was performed in 26 children, in 21 patients liver functions and clinical status improved significantly without further need for liver transplantation. Conclusions: Results of our study have shown that MARS albumin liver dialysis is effective tool for treatment of paediatric patients with acute liver failure or decompensated chronic liver disease bridging those patients to liver transplantation. The MARS treatment can contribute also to liver regeneration. Objective: Serum procalcitonin has been reported as a marker in the inflammatory response to the infection. The aim of the study was to assess the role of procalitonin (PCT) level as a marker in the early diagnosis of neonatal sepsis.

Methods: This prospective study was conducted at Neonatal Intensive care unit of BIRDEM Hospital, Dhaka from July to December 2012. Procalcitonin level was measured in 70 neonates who were clinically suspected as sepsis. Leukocyte count, serum CRP, and blood culture were also performed. Results: The results of blood culture showed that 46 (65.7 %) of samples were positive. Among them, 18 (39.1 %) had bacterial growth and 28 (60.8 %) fungal. The most frequent bacteria isolates were Klebsiella (38.8 %) and Acinatobactor (22.2 %). Leucopenia was found in both groups. Fifty-two percent had raised CRP in culture positive and 33.3 % in culture negative cases, the differences were statistically significant (p \ 0.05). Regarding procalcitonin (PCT), 76.1 % in culture positive and 79.2 % in culture negative cases were positive, the differences were not significant and when PCT [5,000 pg/ml, the differences were statistically significant in culture positive and culture negative cases (p \ 0.05). Nine cases died, of them all had PCT [500 pg/ml. Four of them had culture positive and had PCT [5,000 pg/ml. Conclusion: PCT increase in neonates with suspected sepsis, but significantly increase in culture positive cases and mortality was seen with high PCT level in culture positive cases. It could be a sensitive marker in early diagnosis of sepsis in neonates. Respiratory viral infections account for significant morbidity and mortality especially in young children worldwide. Human metapneumovirus (hMPV) causes illnesses ranging from mild respiratory problems to bronchiolitis and severe pneumonia. From January to December 2007, 220 nasopharyngeal aspirates were collected from children younger B13 years old hospitalized with lower respiratory tract infection to detect hMPV by reverse transcription-polymerase chain reaction and to clone and sequence the hMPV-positive samples. Human metapneumovirus was detected in 28 (12.7 %) specimens with a median age of 7 months (range 1.3-24 months). Human metapneumovirus type A and type B were detected in 26 (93 %) and 8 (28.6 %) of specimens, respectively. Coinfection with hMPV type A and type B was detected in 6 (21.4 %) specimens positive for hMPV. The major clinical diagnosis of hMPV-positive patients was bronchiolitis (75 %). Human metapneumovirus and hMPV type B were found to be significantly associated with bronchiolitis (P = 0.03 and 0.01, respectively). Human metapneumovirus and hMPV type A were found to be significantly associated with pneumonia (P = 0.004 and 0.002, respectively). The main symptoms in patients infected with hMPV were cough (92.9 %), fever (82.1 %), and wheezing (78.6 %), with a significant association of hMPV type A with fever (P = 0.018). Aim: Nitric oxide (NO) formed in endothelium by the enzyme NO synthase (NOS) from L-arginine, is an important mediator for patogen elimination. Being a potent vasodilator NO is also implicated in patogenesis of hypotension and decreased organ perfusion in sepsis. Asymmetric dimethylarginine (ADMA) is an endogenous NOS inhibitor shown to contribute to regulation of vascular tone. We aimed to investigate ADMA and L-arginine levels in neonatal sepsis and their relation to disease severity.

Methods: A prospective controlled study was conducted including 31 neonates with sepsis and 20 healthy controls. Serum ADMA and L-arginine levels were measured within 24 h of sepsis diagnosis. Clinical and laboratory data including clinical risk index for babies (CRIB) score, presence of septic shock, severe sepsis, multi organ dysfunction syndrome (MODS) and death were recorded. Presence of severe sepsis, MODS or death was defined as poor outcome.

Results: L-arginine and ADMA levels were significantly higher in neonates with sepsis compared to controls (p = 0.029 and p = 0.001, respectively). Neonates with septic shock (n = 9) had higher L-arginine (p = 0.012) and ADMA (p = 0.026) levels. L-arginine and ADMA levels were similar among patients with clinical, gram positive and gram negative sepsis. Patients with poor (n = 6) and good outcome (n = 25) had similar L-arginine and ADMA levels. ADMA levels were correlated with CRIB score (q = 0.320, p = 0.025).

Conclusion: L-arginine and ADMA levels are increased in neonatal sepsis and even higher levels are observed in infants with septic shock. Further studies with larger sample size are needed to investigate their relation to organ failure and prognosis. Background: Infused particles induce thrombogenesis, impair microcirculation and modulate immune response. We have previously shown in critically ill children, that particle-retentive in-line filtration reduced the overall complication rate of severe events, length of stay and duration of mechanical ventilation. We now evaluated the influence of in-line filtration on different organ function and thereby elucidated the potential underlying pathophysiological effects of particle infusion.

Methods: In this single-centre, prospective, randomized controlled trial 807 critically ill children were assigned to either control (n = 406) or filter group (n = 401), the latter receiving in-line filtration for complete infusion therapy. Both groups were compared regarding the differences of incidence rates and its 95 % confidence interval ( Objective: To compare characteristics and prognosis factors associated with Toxic Shock Syndrome (TSS) in children and analyze toxinic profile and Vb T cell signatures in order to identify early diagnostic criteria of TSS.

Methods: A monocenter retrospective evaluation of bioclinical data and treatment outcomes was performed including 30 children with a definite or a probable case of Staphylococcal (n = 15) or Streptococcal TSS (n = 15), according to CDC criteria. Results: The most frequent origins of Streptococcal and Staphylococcal TSS were lower respiratory tract and genital tract, respectively. Streptococcal TSS cases showed higher severity score (PIM2), higher organ dysfunction score (Pelod), more ventilatory support requirement, longer duration of intubation, and a trend of increased mortality when compared to Staphylococcal TSS cases. The absence of antitoxinic therapy was associated with mortality. Non-menstrual Staphylococcal TSS cases were associated with more neurological disorders while menstrual Staphylococcal TSS presented more digestive disorders. We identified a significant precocious decrease and a later increase in T cell Vb 2 signature of Staphylococcal TSS patients specifically associated with the presence of TSST-1. The level of activation of Vb 2 repertoire and the number of organ failures were linked by a linear correlation in these latter patients.

Conclusions: This study helps to better define the circumstances of diagnosis and the clinical profiles of Staphylococcal and Streptococcal TSS. Diagnosis of TSS could then be evoked earlier and antibiotic treatment adapted faster. Further studies should evaluate the impact of precocious administration of specific treatment like intravenous immunoglobulins. The present study includes:

1. role of CRP, haematological parameter & blood culture in early diagnosis of neonatal sepsis 2. significance of serial CRP in diagnosis of neonatal sepsis 3. prognostic value of CRP in neonatal sepsis. This is a prospective study done in neonatal unit, CMCH. The study was carried out from January 2008 to January 2011. Sample size was 300. 150 neonates with suspected sepsis as cases and 150 healthy babies as control were enrolled in this study. Of 150 cases of suspected neonatal sepsis total 80.7 % had raised CRP. In initial sample 70.39 % were CRP positive and in 2nd sample additional 9.31 % case were CRP positive. In control group 91 % were CRP negative. CRP was positive in 100 % of culture proven sepsis. Sensitivity of CRP was 80.67 % and specificity of CRP was 76.44 %. Leucocytosis was observed in 7 % of cases and leucopenia was found in 11 % of case. Sensitivity of leucocyte count was 18 % and specificity was 20.68 %. Thrombocytopenia was found in 28 % of case group. Out of 150 cases only 15.33 % yielded growth of organisms in blood culture. In culture positive cases, 87 % were found gram negative and 13 % were gm. positive. Sensitivity of blood culture was 15.33 % and specificity was 100 % CRP is the most sensitive method for early diagnosis of neonatal sepsis and found to be 100 % in culture proven sepsis and 80.7 % in suspected sepsis. Therefore, serial CRP can be taken as alternative method for diagnosis of neonatal sepsis specially in developing countries. Early deaths in paediatric severe sepsis will limit the impact of novel therapies that can only be provided on the paediatric intensive care unit (PICU) and the relevance of randomised trials employing standard consent procedures. We hypothesised that the majority of deaths in children with severe sepsis occur very early (within 24 h of referral to intensive care). Methods: Consecutive referrals to the Children's Acute Transport Service (CATS), London, UK between 1 January 2005 and 31 December 2011 were reviewed. Cases aged 0-15 years with a working diagnosis of 'sepsis', 'severe sepsis', 'meningococcal sepsis' or 'septic shock' were studied. Age, sex, PIM-2 score, infectious organism, severity of sepsis, distance to PICU, times of referral and death, and survival status to 1 year were recorded. Results: Out of 13,409 referrals made to CATS, 703 (5.3 %, 95 %CI) met inclusion criteria. Survival data were not available for 81 patients. 133 (21 %, 95 % CI 17-23 %) died in the first year after referral. Of these, 68/133 (54 %, 95 % CI 46-63 %) children died in the first 24 h after referral.

The survival curve for the whole cohort is presented showing survival in the first month by hour. The Majority of deaths occur within the first 48 h.

Discussion: This large observational study demonstrates that the majority of deaths in paediatric sepsis occur very early in the clinical course. This has important implications for clinical trial and service developments. There is also significant late mortality [28 days.

PERSISTENTLY POSITIVE BLOOD CULTURE: SEARCH FOR ETIOLOGY K. Demova, F. Bauer

Background and aim: Persistently positive blood culture, persistent thrombocytopenia in the investigation of neonates leads us to search for the etiology and should alert to the possibility of serious diagnosis. Case report: We report an infant born at 28 w.g. by cesarean section due to maternal bleeding. Birth weight 1,100 g, Apgar score 8/8. ANS prophylaxis was not done, without PPROM. On day of life 7 sepsis was developed. Empiric ATB was started (vancomycin, gentamycin). CONS was isolated from blood culture repeatedly despite of appropriate ATB therapy. Central line was not present. The CSF was negative; the child was without focal infections. Chest radiograph and the cranial ultrasound were normal. The echocardiography examination in structurally normal heart demonstrated tricuspid valve endocarditis with right ventricular partial inflow obstruction, vegetation on the tricuspid valve and moderate tricuspid valve regurgitation. Cardiac murmur was present. We changed the empiric therapy to targeted (teicoplanin, gentamycin). Hospitalization was complicated by an episode of pulmonary embolism with signs of respiratory failure and required mechanical ventilation. We treated the baby with antibiotics for 6 weeks.

Conclusion: In the investigation of neonates with persistently positive blood culture and persistent thrombocytopenia despite of absence of CVC or CHD echocardiography should be valuable tool. Dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) are caused by increasing in vascular permeability which leads to plasma leakage into extravascular compartment. Previous research in vitro and in vivo showed overproduction of MMP-2 and MMP-9 causing leakage in vascular endothelial. This has not been proved in human, therefore it needs to be tested the relation between serum MMP-2 and MMP-9 in various clinical spectrum of dengue and acute phase hematocrite. This was an analytical observational study, a cross sectional design, involved 1 month-14 years old admitted to Hasan Sadikin Hospital with diagnosis dengue fever (DF), DHF, or DSS from February 2010 to December 2012. There were 80 children included, 26 with DF, 29 with DHF, and 25 with DSS. The result showed a significant serum MMP-2 level in acute and convalesence phase at all spectrum of dengue (p \ 0.005), and in groups there were significant differences between DHF (p = 0.020) and DSS (p \ 0.001). Serum MMP-9 level also showed a significant differences in acute and convalescence phase at all spectrum of dengue (p \ 0.001). In groups, there were also significant differences in each group DF, DHF, and DSS (p \ 0.001). However, MMP-2 and MMP-9 level in convalescence phase were higher than in the acute phase. Linier regression analysis showed a significant relationship between serum MMP-2 and MMP-9 and hematocrite in acute phase. Conclusion: Serum MMP-2 level was higher than MMP-9. Background: Heat shock protein 70 (Hsp70) exhibits a protective role by facilitating immunological responses during times of increased risk of pathogenic challenge and/or tissue damage. Purpose: To ascertain Hsp70 protective effect differences between animal and human studies in sepsis. S80 Intensive Care Med (2013) 39 (Suppl 1):S1-S200 Background: Oral nystatin prophylaxis was routinely administered for very low birth weight infants in our NICU.

Objective: This study aimed that compare the antifungal resistance and the change of fungal ecology in the case of IFI between the preprophylaxis and the prophylaxis periods. Methods: We retrospectively evaluated all the invasive fungal infections (IFI) determined in VLBW infants in our NICU. Infants infected with Candida spp. and antifungal resistance were identified and the incidence rates of infection by these Candida spp. were calculated. A comparison was made of the prophylaxis period with the pre-prophylaxis period.

Results: The rate of IFI per year was 0.5 % in the pre-prophylaxis period and 0.2 % in prophylaxis period (p = 0.01). Although the incidence of IFI-related C. albicans during the prophylaxis period was lower than that of pre-prophylaxis period (70.6-58.8 %), C. albicans was the leading pathogen in the two groups. There were no significant differences in the infants in pre-prophylaxis group compared to prophylaxis group with regard to susceptibility to fluconazole, itraconazole, variconazole, and amphotericin (p [ 0.05). Conclusion: In our study, we observed that nystatin was effective for prophylaxis, and that it decreased the incidence of IFI without causing resistance in Candida spp. or alteration of fungal ecology in VLBW infant admitted to the NICU. Results: There were a 29 PICU patients with streptococcal isolations including Streptococcus pyogenes (Group A streptococcus, GAS, n = 5), Streptococcus agalactiae (Group B streptococcus, GBS, n = 5), Streptococcus pneumoniae (SP, n = 16), Streptococcus bovis (n = 1), Streptococcus intermedius (n = 1) and alpha-hemolytic streptococcus (n = 1). Comparing GAS, GBS and SP, the pulmonary system (pneumonia, pleural effusion) was more likely affected by GAS or SP (p = 0.033), whereas GBS more often caused meningitis (0.008). All GAS and GBS and the majority of SP (86 %) were sensitive to penicillin (minimum inhibitory concentrations 0.06-2.0 lg/ml). All SP specimens were sensitive to cefotaxime and vancomycin. These infections were associated with high PICU mortality of 40, 20, 13 %, respectively. Among the SP, the majority (70 %) were healthy children younger than 5 years (median 2.1 years), whereas children older than 5 years (median 10.1 years) had significant higher prevalence of premorbid conditions such as malignancy, mental retardation/cerebral palsy (MRCP) ± seizure disorders, chromosomal or genetic disorders (p = 0.003). Serotypes were obtained in some of these specimens which included 19A, 19F, 6B, 3 and 6C. There were two SP deaths with multi-organ system failure and hemolytic uremic syndrome. • 5 month old-PVL Staphylococcus aureus septic shock.

• 4 year old-Femoral artery embolus.

• 16 year old-Traumatic subdural haematoma who developed polymorphic VT secondary to propofol syndrome.

• 14 year old-Malignant hyperthermia with a 30 min VT/asystolic arrest and placed on venoarterial ECMO. • 10 year old-Malignant neuroleptic syndrome. • 3 month old-Toxic shock from necrotising fasciitis with a 32 min asystolic arrest.

We only investigate high-risk patients and those with macroscopically suspected myoglobinuria. It is likely we fail to diagnose many cases. Morbidity and mortality will be multifactorial and predominantly diagnosis-dependent. Two patients rapidly died due to conditions that caused widespread rhabdomyolysis and intractable ARF despite maximal treatment. All survivors received urinary alkalinisation (never adequately achieved in any patient), diuresis and hyperhydration; and some responded to this treatment. Two patients needed CVVH to treat ongoing rhabdomyolysis and ARF with good effect. We suggest that rhabdomyolysis is under-recognised and that CVVH should be considered earlier in the management. Background and aim: Extracorporeal membrane oxygenation (ECMO) elicits a systemic inflammatory response syndrome (SIRS).

Our aim was to compare mediators of SIRS (complement activation markers (C3b/c), human neutrophil elastase-a1AT (HNE-a1AT) and plasminogen-activator inhibitor-I (PAI-I) with or without hemofiltration in newborns on ECMO.

Methods: In this prospective study, newborns on ECMO were randomised to the treatment group (hemofiltration during ECMO) or the control group. Clinical data were collected from the Patient Data Management System. Blood samples were collected at t = 0 (before cannulation) and at 1, 3, 6, 12 and 48 h after cannulation. ELISA was performed to measure levels of IL-6, C3b/c, HNE-a1AT and PAI-I. Results: A total of 17 children (HF n = 11 and control n = 6) were included. Mortality was equal in both groups. Both the IL-6 and HNE-a1AT response showed a comparable pattern in both groups with an initial increase followed by a decrease to baseline levels after 12-24 h. The C3b/c and PAI-I response did differ between both groups, with lower C3b/c levels at t = 3 and t = 6 (both ns). Objective: Evaluation of the clinical data from infants admitted to the PICU due to bronchiolitis. Patients-methods: Retrospective survey of bronchiolitis patients admitted to two PICUs, which are being analyzed for risk factors (prematurity, CLD, congenital heart disease, chronic oxygen dependence) and need for mechanical ventilation. Results: 120 infants with bronchiolitis were recorded during 2007-2012. 70 % were C36 weeks gestational age (GA), 20 % 32-35 weeks and 11 % B32 weeks. Mean age on admission was the 77 days (44 % B30 days old). Males: females ratio = 75:45. 76 % were admitted between January and March. RSV infection was found in 77 % infants. Risk factors had 13 % of the infants. Palivizumab was administered in 7 infants (6 %). Intubation-mechanical ventilation was needed in 32 infants (27 %), 26 of which had RSV (81 %) and 4 had received palivizumab. 12 infants of the 32 had GA B35 weeks (37 %) and 6 had CLD (19 %). 4 deaths ( Background: Acute epiglottitis occurs rarely in pediatrics, since the systematic vaccination against Haemophilus influenza type b. Surprisingly, the last decades, other pathogens such as Neisseria meningitidis, are reported to cause acute epiglottitis in children but in adults as well. Case report: A 4.5 years old male, previously healthy toddler, from Russia, was on summer vacations in Greece. He experienced sudden onset of intense sore throat and the following day, high fever (40 o C) and respiratory distress emerged. Primary diagnose was bacterial pharyngotonsillitis, thus azithromycin was initiated, but as his condition worsened, he was treated for laryngitis with oxygen, nebulized adrenalin and iv dexamethasone. Ten hours later, the boy's condition was critical, with emerging respiratory failure. A lateral neck roentgenogram confirmed the diagnose of epiglottitis, showing diffuse soft tissue cervical and epiglottic swelling (thumb sign). He was intubated in the operating room, he was given iv ceftriaxone and he was transferred to the PICU. Initial laboratory findings were WBC = 12 9 10 9 /L (51 % polymorphonuclears, 26 % bands), PLT = 188 9 10 9 /L and CRP = 11 mg/dl. Cultures from blood, sputum (via endotracheal tube), pharyngeal smear, after the onset of antibiotics were negative. PCR from sputum (via endotracheal tube) and blood sample, reviled presence of N. meningitidis (non A, B, C, Y, W135), but not H. influenza. The child hadn't been immunized against both organisms, since they are not included in Russia's obligatory vaccination program. Conclusion: N. meningitidis has been reported to cause epiglottitis since 1995. Though few cases are reported globally, surveillance is needed for better awareness of the disease. 3 Tergooiziekenhuizen, Hilversum, The Netherlands

Objectives: During sepsis, mechanical ventilation (MV) is thought to contribute to the development of acute kidney injury (AKI) and renal apoptosis may be involved. Methods: Sepsis was induced in 36, male Spraque-Dawley rats by cecal ligation and perforation (CLP). Six rats served as healthy controls. Animals were randomly assigned to three groups: 1) low tidal volume (V T ) 6 ml/kg, and positive end-expiratory pressure (PEEP) 5 cm H 2 O (LV T ), 2) high V T 15 ml/kg and PEEP 3 cm H 2 O (HV T ), and 3) non-ventilated controls. Rats were ventilated for 4 h. Macrophage inflammatory protein-2 (MIP-2), interleukin (IL)-6, tumor necrosis factor-a and the endothelial markers intercellular adhesion molecule-1 and active plasminogen activator inhibitor-1 (PAI-1) were measured in plasma. Renal function was measured and lung and kidney injury were assessed by microscopy. Apoptosis was quantified using TUNEL staining.

Results: An increase in renal medullary apoptotic index (51.7 ± 10.5 vs. 26.4 ± 5.6 %, p = 0.01) and concurrent 40 % decrease in glomerular filtration rate was observed in the HV T group as compared to the LV T and the non-ventilated sepsis groups, in the absence of hypotension (p = 0.01). This was associated with minimal lung injury. Renal medullary apoptosis best correlated with increased active PAI-1 (correlation coefficient 0.46, p = 0.03). Conclusions: During sepsis induced by CLP, lung injurious MV has profound effects on kidney apoptosis and impairs kidney function, with only minimal lung injury. The data suggest that inhibition of intrarenal fibrinolysis may be involved. Results: 2,086 infants were treated at the Center of Neonatology during the period of 2002 -2004 were 1391, and preterm (NPT) were 682. In 528 NT were proven infections: omphalitis 44.9 %, sepsis and/or meningitis 10.9 %, pneumonia 18.5 %, cutaneous infections 8.7 %, conjunctivitis 5.5 %, otitis media 3.8 %, mastitis 1.7 %, diarrhea 0.2 %, UTI 5.5 %. In 98 PNB were proven infections :omphalitis 36.7 %, sepsis and/or meningitis 30.6 %,pneumonia 15.3 %,cutaneous infections 12.2 %, conjunctivitis 2.0 %, diarrhea 2.0 %, UTI 1 %, UTI was observed in 28 newborn. Overall rate in all hospitalisated infants was 1.3, and 4.6 % of all proven infections. Of the total UIT, 96.5 % occurs in NT, usually in period of 2-4 weeks of life (v 2 = 18.721; p \ 0.01). The most common cause UTI is Escherichia coli (E. coli), and it is proven in 19 children, or 67.8 %, followed by Enterococcus in 7 children, or 25 %, Pseudomonas and Enterobacter in 1 newborn, or 3.5 %. In 3 NT E. coli was isolated in blood and urine culture, and in 2 NT was associated with meningitis.

Conclusions: E coli is dominant pathogen and in 3 NT associated with sepsis and in 2 NT with meningitis. Background: Apnea is frequently observed early in RSV infection when symptoms are confined to the upper airways, suggesting inflammatory response induced autonomic dysfunction. Objective: The aim of the study is to assess autonomic dysfunction as indexed by Heart Rate Variability (HRV) in acute RSV infection and its correlation with disease severity and inflammatory profiles. Methods: Prospective study in infants with moderate and severe RSV infection admitted to an university hospital. Controls were age matched infants without signs of infection. Autonomic function was assessed via HRV, monitoring low frequency (LF) and high frequency (HF) indices. In addition levels of serum SAA-1 (HK333), serum amyloid P (HK331), Pentraxin 3 (HK347), properdin (HK334) and C-reactive protein (HK358) were determined by ELISA. Results: In 15 severely affected patients, 6 moderately affected patients and 72 healthy controls a total of 207 recordings were analyzed. Total HRV, LF and LF/HF ratios were significant lower in severely affected RSV patients versus moderately affected patients (p \ 0.00045, p \ 0.002 and p \ 0.0025, respectively) and severely affected patients and controls (p \ 0.0002, p \ 0.0002 and p \ 0.0001, respectively). Also CRP, properdin and SAA were significantly correlated with disease severity. PTX3 levels were correlated with need for supplemental oxygen. Conclusion: RSV infection in infants is associated with inflammatory response induced autonomic dysfunction of central origin. This may be correlated with an increased risk for serious apnea or ALTE, for which prolonged cardio respiratory monitoring is indicated. S86 Intensive Care Med (2013) 39 (Suppl 1):S1-S200 Background and aims: Sepsis is a leading reason for admission on pediatric intensive care units worldwide and a leading cause of morbidity and mortality in the pediatric population. We aim to objectify our hypothesis that there is a shift in causal organisms from N. meningitidis towards Group A Streptococcus (GAS). Methods: We reviewed our database for the previous 4 years and selected those patients with community-acquired sepsis due to Neisseria meningitidis and to Group A Streptococcus (GAS), since these two organisms cause the most significant morbidity in our patients with sepsis. Clinical data were collected and are presented.

Results: 27 patients were identified. Most children were previously in good health. In 15 patients, N. meningitidis was isolated, in 12 GAS. Mortality in our cohort was fully contributable to the subgroup with GAS infection. Children with Meningococcal disease had more chance to have a relatively uneventful course (6/15 vs 2/12). There appears to be a shift towards more frequent isolation of GAS compared with N. meningitidis over the years, though numbers are to small to be statistically significant. Remarkably, GAS-infection in our cohort only occured as a surinfection during the course of acute infection with varicella zoster virus (VZV). Conclusion: A genuine increase of community-acquired sepsis caused by GAS compared to N. meningitidis needs to be confirmed in a multi-centre analysis. Our findings may add fuel to the debate wether to vaccinate our children against VZV or not. Conclusions: Early ferritin estimation of above 10,000 ng/ml following admission is clearly diagnostic, but not predictive of a negative outcome in HLH; probably due to prompt and effective management of the disease process in its early stages with well proven treatment modalities. Background and aims: Early recognition of serious bacterial infections (SBI) is essential for better treatment outcomes. Flow cytometry analysis of neutrophil surface molecules is increasingly investigated as a tool for diagnosis. The aim of this prospective observational study was to compare the diagnostic performance of various biomarkers in detection of SBI.

Methods: The infants under 6 months of age presenting with fever without apparent source to the emergency department who were hospitalized with suspicion of having SBI were enrolled, 69 into the training and 36 in the validation set. Based on the final diagnosis they were classified into SBI or viral infection group. Input measures were white blood cells count, absolute neutrophil count (ANC), C-reactive protein (CRP), procalcitonin (PCT), neutrophil CD11b, CD15s and CD64 expression level, percentage (%CD15s + ) and the absolute count (AC-CD15s + ) of CD15s + neutrophils.

Results: In the infants with SBI, %CD15s + was 10.5 times more likely to be higher than the cut-off value. ANC, CRP, PCT, CD64, and AC-CD15s + were also found as useful biomarkers for differentiation between bacterial and viral infection. The-best-fit multivariate logistic regression model included CRP, PCT, and (37), gastro-enterology (6), endocrine-metabolic (5), haemato-oncology (5), neurology (15), transplant (2) and others (19) . Median duration of the lines was 2 weeks (interquartile range 14-33 days). Indications included long-term antibiotics in 69 (64 %), infusions of drugs 8 (7 %), chemotherapy 2 (2 %), parenteral nutrition 11 (10 %), difficult access 12 (11 %) and blood sampling 6 (6 %). Complications were uncommon, 8 (7 %) cases of infection and 3 (3 %) blocked lines. These were too infrequent to be significantly associated with any disease group or usage pattern. Conclusion: PICCs were most commonly used for long-term antibiotic therapy. There was a 10 % complication rate, mainly due to infection and blockage. There was no obvious association between complications and underlying disease or line usage. Background and aims: Positioning of newborns for lumbar puncture (LP) is not standardized. This study aims to establish the optimal position and needle penetration angle for conducting LP with less disturbance in oxygen saturation and heart rate. . Baseline HR and OS were 142 ± 20 bpm and 97 ± 2 %. Neck flexion was associated with significant lower saturation (l3: 91 ± 7 and s3: 90 ± 6). With slight differences among them, all positions increased HR compared to baseline. A NEA around 658-708 is optimal without significant differences between positions. 02 Sat. 97 ± 2 9 7± 3 9 5± 4 9 1± 7 9 5± 3 9 2± 6 9 0± 6

Sat \85 % (n) 0 0 2 17 1 11 17

Conclusions: s2 seems to be the most suitable position for LP. Neck flexion does not improve anatomical view and may cause more physiological disturbance. NEA is independent from patient's positioning. We report prospective study conducted on MSF in children. Our cases were confirmed to be caused by R. conorii using immunofluorescence methods completed by Western blot and cross-absorption. Cases were encountered in the summer. Two children presented with two eschars. This is quite unusual in MSF. However, particular climate, including higher temperature, reported in Oran in recent years, may have led to an increased proclivity of ticks to bite. Although 62.5 % of the children, were hospitalised, only two (with seizures). Cases were particularly severe in adults; 49 % of 167 patients diagnosed with MSF were hospitalised with a severe form. Cases of MSF seem to be milder in children than in adults. In adults, the eschar is most often observed on the trunk and legs. Herein, the eschar is frequently localised on the cephalic area. When they initially sought medical care, children were prescribed drugs that were ineffective to treat rickettsiosis. It should be remembered that doxycycline remains the treatment of choice for all patients. The risk of dental staining by doxycycline is negligible when a single (short course of therapy). Chloramphenicol continues to be used as the empirical parenteral treatment of severe cases if presence vomiting and lack of intravenous doxycycline. Josamycin can be used in children, but newer macrolides are also of interest, particularly azithromycin. MSF seems to be still misdiagnosed in children as other eruptive febrile diseases. The consequences of this include delays in appropriate therapy and a risk of a severe form and even a fatal outcome. Background and aims: To evaluate and compare the effects of a short cervix (\25 mm) on neonatal morbidity and mortality as opposed to a normal cervical length (C25 mm). The predictive value of a short cervix on neonatal outcome is also investigated.

Methods: Preterm infants who were admitted to the neonatal intensive care unit and whose mothers had undergone a pre-delivery evaluation for cervical length (CL) and cervical cultures were included in the study. Infants were stratified into two groups based on CL measurements (Group 1, CL \25 mm; Group 2, CL 69 hemofilter membrane. The median duration of CVVH was 48 h. Hemodynamic parameters were hourly recorded during the intervention. Cytokines were measured by enzyme-linked immunosorbent assay. All survivors were assessed for neurodevelopment at 1 year of follow-up by physical examination and Denver Developmental Screening Test. Results: There were no differences in baseline characteristics between two groups. The mortality rate was significantly lower in the CVVH group (16.7 vs 87.5 %, p = 0.003). Hemodynamic parameters and body temperature improved quickly 6 h after CVVH commenced. Ejection fraction of left ventricles improved after 48-72 h post-CVVH. A decreased serum IL-8 level was seen after 24 h of CVVH. At 1 year of follow-up, eight out of ten survivors in CVVH group had normal neurodevelopment, one infant required ventilation support, and another infant has mild upper limb weakness. Conclusion: Children with HFMD-related cardiopulmonary failure treated with CVVH had better outcomes than those who received only conventional therapy. Objective: To evaluate procalcitonin kinetics as marker of inflammation severity and its specificity in discriminating between sepsis and systemic inflammatory response syndrome after pediatric open heart surgery. Design: Prospective, observational, clinical study in 17 bedded tertiary pediatric intensive care unit. Materials and methods: PCT kinetics was evaluated at 1.3 and 7th day in thirty pediatric patients undergoing open heart surgery with cardiopulmonary bypass (CPB) (SIRS model:group 1, n = 15) and patients with clinical sepsis (SIRS + sepsis, group 2, n = 15). Postoperative data included fever, requirement and duration of inotropic support, duration of mechanical ventilation, length of ICU and hospital stays along with laboratory parameters. Results:

• In Group 1, PCT median concentration was 0.24 ng/ml(reference value \ 2.0 ng/ml).Average PCT concentration was 0.47 ng/ml at 24 h; 0.33 ng/ml at 72 h and then decreased to 0.12 ng/ml at 7 th postoperative day. All patients had favourable outcome. • In Group 2, average PCT was 1.02 ng/ml at 24 h which increased to 4.15 ng/ml at 72 h. It decreased in 12/15 patients who progressed favourably (average 0.61 ng/ml) .6/15 patients had culture positive septicemia. 2/3 patients with persistent elevated PCT at 7th postoperative day expired.

• PCT kinetics is able to differentiate between SIRS and postoperative infection (sepsis) during postoperative follow-up period. Introduction: Acute lymphocytic meningitises are most frequent in the child, generally of viral etiology, the enteroviruses prevail. Their evolution is generally benign with cure without after-effects.

Objective: To evaluate the frequency of lymphocytic meningitises at the department of paediatrics to study their profile epidemiologic, clinical, biological and evolutionary. Materials and methods: Retrospective study made on the files of the children hospitalized for a lymphocytic meningitis at the department of paediatrics of the CHU of Batna during one 3 years period (1/1/ 2009 at the 31/12/2011). Results: We colligé 191 cases of lymphocytic meningitis with a hospital incidence of 1.98 lymphocytic meningitis accounts for 55.5 % of the whole of meningitides of the child. The 28 day old older child to 10 years is most concerned by far of which 53.9 % of the cases are older children \5 years. The boys are touched by lymphocytic meningitis in our series (67.5 %) with a sex-ratio of 2.08A high incidence of the new cases during the summer period (in connection with the frequency of viral meningitises)The child touched by lymphocytic meningitis presented a pleocytose of 10-500 elements/mm 3 Background: Enterovirus infection is common in the neonatal period with a characteristic seasonal pattern (June-October) and variable clinical presentation ranging in severity from benign febrile illness to severe forms including meningoencephalitis, myocarditis and ALF. The identification of risk factors for severe disease (prematurity, maternal symptomatic infection at the time of delivery, early onset and viral serotype) is crucial for appropriate management. Case series: We describe three cases of late preterm newborns, occurred between June 2012 and January 2013, with onset in the first week of life with coagulopathy, ALF and mothers febrile before delivery. The first and the third patient died at 27 and 13 days of life, respectively, despite prompt aggressive supportive care and massive transfusion therapy. The second one, after a critical initial phase and liver biopsy, improved and was removed from the transplant list. In the first two cases Coxackie B viral genome (serotype B3 and B4, respectively) was detected on blood, cerebrospinal fluid and bone marrow. In the last one an Enterovirus was also identified (serotyping in progress at the moment). Neonatal hemochromatosis, initially suspected in the first case because of intra and extra hepatic siderosis, was not confirmed on histological examination. Discussion: Enterovirus can lead to severe ALF and death in newborns and must be always considered in the differential diagnosis of neonatal ALF. We underline the importance of early recognition of risk factors in pregnant women and of clinical manifestations in newborn infants. Background: Heme oxygenase-1 (HO-1) controls heme degradation, and the products of this process confer anti-inflammatory and immunomodulatory effects. Recently, we demonstrated that HO-1 deficiency promotes NEC-like intestinal injury in mice. A decreased ratio of T-regulatory (Treg) to T-effector (CD4, CD8, Teff) cells in necrotizing enterocolitis (NEC) has been reported. Aim: To study whether a deficiency in HO-1 affects neonatal adaptive immunity by modulating T cell populations. Methods: 7-10 day-old HO-1 heterozygous (HO-1 +/-) and wild-type (Wt) mice were given vehicle (Con) or 5 mg LPS/kg IP. To induce NEC-like injury, 7 day-old Wt pups were fed 200 lL formula/4 h orally for 30 h. On D1.5 and 7, pups were exposed to 5 % O 2 . For flow cytometry analyses, intestinal lamina propria (ILP) cells were stained with CD45, CD3, CD8, CD4, CD25, and FOXP3 antibodies. Results: Preliminary studies show a similar number of FOXP3 hiexpressing CD4 + CD25 + Tregs in Con HO-1 +/-(88 ± 3 %) and Wt pups (93 ± 1 %). 12 h after LPS, FOXP3 hi expression decreased to 79 ± 0.1 % and 85 ± 3 % in CD4 + CD25 + T cells of HO-1 +/and Wt pups, respectively. The Treg/Teff ratio in HO-1 +/pups was 11 ± 6 % (Treg/CD4) and 22 ± 2 % (Treg/CD8) lower than in Wt pups 12 h post-LPS treatment, decreasing further in HO-1 +/pups after 24 h [39 ± 7.5 % (Treg/CD4), 35 ± 14 % (Treg/CD8)]. After NEC induction in Wt pups, FOXP3 hi expression in CD4 + CD25 + T cells decreased by 30-40 %. Conclusion: FOXP3 hi CD4 + CD25 + Tregs and the Treg/Teff ratio in the ILP are compromised in HO-1 +/pups after LPS treatment. If the reduction of Tregs in Wt pups after NEC induction is more severe in HO-1 +/mice will be further studied. Background and aims: To investigate associations between polymorphism of GSTM1, GSTT1, GSTP1 genes and the development of pneumonia in premature born babies during their treatment in neonatal intensive care units. Methods: We investigated associations between polymorphisms of GSTM1, GSTT1 and GSTP1 genes and the development of pneumonia amongst 120 premature newborns at \36 weeks gestation (median birthweight 1,475 g, range 700-2,480 g; gestation 30.8 weeks, range 27-36; 68 male). In these children we measured the rate of use of oxygen support, CPAP, and mechanical ventilation.

Differences between groups were determined by parametric (independent t test) or non-parametric techniques (Mann-Whitney U test) depending on their distribution. Analysis was performed using SPSS. Results:The AG and GG GSTP1 genotypes were associated with the development of pneumonia in premature newborns. In premature born babies with genotype GG gene GSTR1 the duration of mechanical ventilation was significantly greater than in newborns with AG or AA genotypes (Me = 8.0 and 4.4, 3.5 days). Babies with a combination of non-functional alleles of the GSTM1 gene and the A313G single nucleotide change of GSTP1 gene required the use of oxygen support significantly more than babies with functional genotypes (51.5 and 4.8 %, p \ 0.01).

Conclusions: These data to support a role of polymorphism of GSTP1 in the development of pneumonia in premature newborns. Objectives: Hyperosmolar sodium lactate (HSL) solution can be used for small volume resuscitation. Endothelial leakage in dengue shock syndrome (DSS) is caused by the increased of adhesion molecules and matric metalloproteinases (MMP) activity. The purpose of this study was to compare the MMP-2 plasma level after fluid resuscitation with HSL or Ringer's lactate (RL) in DSS as a marker of endothelial leakage. Methods: Single blind randomized clinical trial was done to compare HSL and RL in DSS. Data were collected on January-June 2010 and were analyzed between June and December 2010. Group I (23 subjects) received HSL and group II (22 subjects) received RL. Serial blood sampling were obtained for MMP-2 plasma level measurement on admission, 6, 12, 24, and 48 h after fluid resuscitation. The capillary refill time (CRT) \2 s was used as a clinical marker of shock recovery. Results: No decrease in MMP-2 plasma level until 48 h after resuscitation, Mann-Whitney test showed no significant difference between two groups (p [ 0.05). This study showed that neither HSL nor RL did not decreased the MMP-2 plasma level within 48 h after fluid resuscitation, but CRT \2 s as a clinical marker of shock recovery were reached faster within 30 min in group I, Fisher Exact test showed significant difference between two groups (p \ 0.05). Conclusions: The MMP-2 plasma level can not be used as marker of endothelial leakage, CRT \2 s can be used as clinical marker of shock recovery and HSL can recover shock faster in DSS. Background: One of the major organs affected in neonatal sepsis is the heart. Echocardiogram provides real-time information on the cardiovascular performance rather than dependence on the clinical signs alone, which might lead to misjudgment. Aim of the work: To assess left ventricular (LV) functions in septic neonates early after admission using transthoracic color Doppler Echocardiography. Patients and methods: Echocardiography was done to 30 septic and 30 nonseptic newborns who were divided among 4 groups (septic full-term, 14; septic preterm, 16; nonseptic full-term, 21; and nonseptic preterm, 9). Comparisons were made among the 4 groups using analysis of variance and post hoc test regarding the systolic function (using ejection fraction and fractional shortening), the diastolic function (using the early atrial peak/atrial peak flow velocity ratio), and the global LV function (using myocardial performance index).

Results: The E-wave and the early peak flow velocity/atrial peak flow velocity ratio were significantly lower in the septic neonates, whether full-term or premature, compared to their corresponding age groups in the nonseptic newborns, suggesting LV diastolic dysfunction (P G 0.001 and P G 0.014, respectively). No difference was found in the diastolic function between the full-term and the preterm neonates whether lying within the septic group or in the nonseptic group. Myocardial performance index was significantly higher in the septic neonates who died than in the survivors (P G 0.001).

Conclusion: Neonatal sepsis is associated with LV diastolic dysfunction. On day seven, the patient developed subfebrile temperature and irritability. In addition CRP increased combined with extreme leukocytosis (94.6 9 10 9 /l). MRI was performed to investigate the presence of cerebral empyema. The MRI revealed multiple hyperintensities, focal and bilaterally, located in the white matter of both hemispheres (Fig. 1) . Cerebral fluid was without abnormalities. A control MRI showed some reversibility of the lesions. At follow up after 4 weeks, no gross neurological impairments were observed.

Conclusions: This is to our best knowledge the first report of borderzone infarction in a child with meningococcal septic shock. This, probably underreported finding, underscores the importance of multidisciplinary follow up of MSS patients. Methods: Retrospective analysis of case records of VLBW infants over a period of a year, who received parenteral nutrition and had serum triglyceride levels measured. Clinical, epidemiological and laboratory parameters (birth weight, gestation, inflammatory markers and blood culture, serum triglycerides) were obtained and analysed for their association with incidence of LOS.

Results: 274 VLBW infants who were admitted to the unit during the study period received PN. 133 infants had serum triglycerides estimated while on PN (mean gestational age-27 weeks, mean birth weight 1,029 g). 64 infants (48 %) of the infants had raised serum triglyceride levels and 69 (51 %) had at least one episode of LOS during their hospital stay. On uni-variate analysis, lower gestational age, longer duration of parenteral nutrition and raised serum triglycerides were significantly associated with incidence of LOS. The duration of parenteral nutrition and lower gestational age remained significant on multivariate logistic regression analysis. Birth weight and gender did not appear to be significantly associated with an increased incidence of LOS. Conclusion: Lower gestational age and longer duration of parenteral nutrition were significantly associated with increased incidence of LOS in VLBW infants. A significant proportion of parenterally fed infants had high serum triglycerides and their association with LOS needs further evaluation.

Introduction and aims: In critically ill patients, sepsis can be difficult to distinguish from other situations with SIRS, like extensive surgical interventions. Procalcitonin is considered a useful marker of severe bacterial infection and sepsis in these situations. The aims were to assess the profile of procalcitonin and C-reactive protein (CRP) in the postoperative period of children admitted to PICU, and to compare them as markers of systemic bacterial infection. Table 1 . A nearly significant decrease in in-hospital mortality is observed while less neonates had a high-risk-CRIB-score. Logistic regression analysis adjusting for risk factors for death confirmed that survival improved over time (cf. Table 2 ). Conclusion: In-hospital mortality in patients with HABSI decreased with time. A CRIB-score lower than five and admission in a more recent period of time, was protective for mortality. Infantile botulism is a rare cause of paralysis in infants. The vast majority of cases of infant botulism are caused by botulinum toxin types A and B and only few cases of type F neurotoxin has been identified in infant botulism and reported. We report a severe case of infant botulism caused by botulinum toxin types B and F in a 5 months old baby. Case report: NP, female, 6.2 kg of body weight. She presented in the ED of a regional hospital with a 2-days story of constipation, poor feeding, and lethargy, poor respiratory effort and hypotonia since 12 h. Due to child deterioration, intubation and ventilation were required and she was transferred in our PICU. Botulism was clinically suspected and confirmed by EMG and by the presence in stool sample of toxin B and F producing Clostridium botulinum on PCR. Because of the lack of efficacy of botulism immunoglobulin (BabyBig) for type F toxin, we administered supportive therapy and tried to eradicate the clostridium strains from the intestine through bowel irrigation. The present study showed that gram negative organisms, in particular, E. coli are the most common causes of sepsis in this region. It also indicated that gram negative strains causing septicemia showed most common resistance to current antibodies, so that more than 50 % resistance was observed in most of these organisms. Severe head trauma is a significant cause of mortality and morbidity in childhood. The aim of this retrospective study was to put forward the outcomes of patients with severe traumatic brain injury and the factors effective on these outcomes. A total of 61 with severe brain injury were included in the study. Endotracheal intubation and mechanical ventilation were applied to 45 ( Background and aims: In a previous study we validated the QS4-G designed to evaluate the neuropsychological and behavioural developmental status of four-year-old children and to identify children in need of further evaluation. The validation of the QS4-G was conducted on a sample of preterm and at-term children (263 as a whole) and was focused on reliability, internal consistency, concurrent validity and discriminant validity. We present here the accuracy of the QS4-G in predicting cognitive, neuropsychological, and academic performance at school age 4/6 years later. Methods: Fifty-one children were consecutively recruited from September 2007 to December 2008 at Bambino Gesù Children's Hospital in Rome and in a primary school. They were selected from the original sample and were representative of it. The sample was assessed with standardized test in cognitive, neuropsychological, and academic performances. According to the results obtained in the QS4-G, the sample was divided into two groups: at-risk and not-at-risk. Crosstabs were used to assess if the at-risk and the not-at-risk group presented difficulties as to cognitive, neuropsychological and academic performances 4-6 years later. Results: Children in the at-risk group, 4-6 years later, presented difficulties in neuropsychological abilities (0.000) and academic performances (0.035); 43.7 % of them improved their cognitive abilities. Not-at-risk group presented adequate cognitive (0.000) and neuropsychological (0.000) performances; almost half of them developed difficulties in academic performances. Conclusions: QS4-G has a good predictive validity as to neuropsychological abilities. Clinicians should follow up carefully children identified as at-risk by the questionnaire. Objective: Hyperglycemia can occur in the patients affected by any kind of critical illnesses. It has been recently shown that treatment of hyperglycemia with insulin administration significantly reduces the prevalence of critical illness polyneuropathy and myopathy and on the other hand reduces the demand for long-term mechanical ventilation in the patients admitted in ICU for more than 1 week. The aim of this study was to determine the therapeutic effect of Insulin in reduction of the incidence of critical illness polyneuropathy and myopathy in pediatric intensive care unit. Materials and methods: In this study we recruited 30 patients admitted in the PICU of Tabriz Pediatric Hospital and evaluated incidence of CIPNM following hyperglycemia in these patients. The patients were categorized into two groups. In the case group blood sugar was controlled in the range of 140-180 mg/dl by administration of insulin (in the form of drips and in the account of 0.05 U per each kilogram of body weight in hour) and in the control group placebo was used, and then the incidence of CIPNM, duration of PICU and duration of mechanical ventilation were compared between two groups. Results: In this study the incidence of CIPNM and duration of PICU stay and duration of mechanical ventilation were significantly reduced in the patients treated with Insulin compared to the control group. Conclusion: This study shows that controlling of blood sugar results in reduction of incidence of critical illness polyneuropathy and myopathy. Background and aims: Intraventricular hemorrhage (IVH) is an important cause of brain injury in premature infants. This study aimed to assess early development in very low birth weight and/or very premature infants who had IVH in the neonatal period and to compare their neurodevelopment with their IVH grade. Methods: A retrospective review of medical records was performed for all newborns treated in a neonatal intensive care unit, between 2003 and 2009, who weighted \1,500 g and/or who were born before the 32th gestational week. Only the infants with IVH were enrolled in this study. Results: Among the 63 infants, 54 % were female, the median gestational age was 28 weeks and mean birth weight 1,074 ± 335 g. The IVH was bilateral in 71 % of the patients. Mild IVH was more prevalent than severe (Grade 1: 42 %, 2: 19 %, 3: 18 % and 4: 21 %).

Patients with IVH grade 4, when compared with patients with IVH grade 1, had higher mortality rate (69 versus 3.7 %), higher prevalence of periventricular leukomalacia (100 versus 9 %), posthemorrhagic hydrocephalus prevalence (50 versus 4.5 %), cerebral palsy (50 % versus 4.5 %) and cognitive disfunction. Conclusions: Although our study has a small sample, the long-term outcome of infants who survive with IVH worsens with increasing severity of IVH. Severe (grade 4) IVH is related to higher mortality rate, higher prevalence of periventricular leukomalacia and posthemorrhagic hydrocephalus and lower scores in neurodevelopment outcome. Many factors which are independent from the grade of the IVH seem to influence the neurodevelopment outcome. Introduction: In this study we presented etiological factors, clinical course and prognosis of rhabdomyolysis in nontraumatic critically ill children who are admitted to Akdeniz University PICU. Method: Total 219 patients laboratory data were screened retrospectively who are admitted to PICU in 2011 using with electronic records and who has 5 folds acute increased serum Creatin Kinase levels enrolled the study. Demographic data, laboratory values, organ failures, and prognosis of these patients were recorded. Results: Rhabdomyolysis established at eleven patients (5 %). In most of the patient, asphyxia and perfusion abnormalities were the reason of rhabdomyolysis. Average length of stay in PICU was 10 days (range 2-34 days) and average length of mechanical ventilation was 8 days (1-34 days). Eight of them had known chronic illness on the admission of PICU. None of them developed serious hypocalcaemia or hyperkalemia. Eight of the 11 (72 %) patient had acute renal injury according to RIFLE criteria and hemodialysis used three of them. Six of the 11 (54 %) patient died. Three of the patient died had physical findings of acute congestive heart failure. Discussion: According to this retrospective analysis; rhabdomyolysis mostly associated with perfusion disabilities at the nontraumatic critically ill child who needs PICU admission. Length of PICU admission and mechanical ventilation is not different from general population at present study. When acute renal injury and acute congestive heart failure accompany the rhabdomyolysis, they increase the mortality. Presence of the congestive heart failure was the factor that limited to use standard treatment options like urine alkalization, hydration and mannitol.

Pediatric Cardiac Intensive Care, KACC, Riyadh, Saudi Arabia Decisions in critical care setting frequently can be difficult and involve several tradeoffs and multiple risk-benefit ratios. In the face of this dilemma, the currently most commonly used methods to take a decision in these circumstances are depending on the personal knowledge or experience, nihilism, defer to other experts, defer to patients, dogmatism or just blindly follow a policy. These methods are not scientifically sound. They are not only lacking objectivity but more importantly lacking evidence supporting it. It may also minimize patient/family adequate involvement. This situation is frequently encountered in making decisions of management of critically ill children and neonates. In the recent era of evidence based medicine, full arrays of decision support aids were developed. Among which an important method, unfortunately infrequently used, the evidence based decision analysis (DA). In this presentation, we will explain this important tool for decision aids and how it can help in making difficult decisions by utilizing the best available scientific evidence (to elicit probability factors) together with incorporating the patient/family own preferences and values (to elicit disutility factors). This scientifically validated method is assure maximum objectivity by expressed numerical values of disutility and probability and re-computing it in a backpropagation manner. The presentation will also explain the various models that can be utilized to achieve a proper patient/family shared medical decision making. Results: At 2.2 ± 0.3 years of age 16 children were assessed. Mean birth weight was 2.6 ± 0.8 kg and gestational age was 37.8 ± 2.6 weeks. Median age at surgery was 4 (IQR 3-6) days and ventilation time was 10 (8-14) days. Inhaled nitric oxide was administered to 7 infants, PGE1 infusion in 11 infants and sildenafil in 3. No infants had received ECMO. Pre-operative cranial ultrasound occurred in 15, 2 of whom had grade 1 IVH. Post-operative MRI brain occurred in 12 at 35 days (24-52), 5 with abnormalities identified. Mean cognitive, language and motor composite scores were 99 ± 17, 98 ± 25 and 96 ± 19, respectively. Three (19 %) children had severe developmental delay, one of whom was unable to be assessed at all. All three had abnormal post-operative MRI scans.

Conclusions: Neurodevelopment at 2 years in survivors of CDH is not different from test norms. Post-operative MRI may identify infants at higher risk of subsequent impairment. Background and aims: The neurodevelopmental trajectory of children with oesophageal atresia (OA) is largely unknown. We undertook evaluation of two-year neurodevelopmental outcome in neonates undergoing OA repair. Methods: 50 neonates (28 male) underwent repair of OA (1 long-gap) from 2009 to 2010. Pre-operative cranial ultrasound was routinely performed. Three (6 %) died and six interstate patients were not offered follow-up. Ten children were lost to follow-up and five are awaiting assessment. Twenty-six two-year-olds were assessed using the Bayley Scales of Infant Development, 3rd edition. Results: At 2.3 ± 0.2 years of age 26 children were assessed. Mean birth weight was 2.8 ± 0.9 kg and gestational age was 37.9 ± 2.7 weeks. Median age at surgery was 1 (IQR 0-2) day and hospital length of stay (LOS) was 26 (14-37) days. Pre-operative cranial ultrasound occurred in 24, all of which were normal. At least one post-operative cranial ultrasound occurred in all patients and no significant abnormalities were identified. Mean cognitive, language and motor composite scores were 100 ± 10, 99 ± 14 and 98 ± 12, respectively. Six (23 %) had developmental delay, most commonly motor delay. Two each had cognitive and/or language delay. One child was unable to be assessed due to profound deafness and CHARGE Syndrome. Children with delays were smaller and more premature at birth and had longer LOS than those with normal developmental scores. Conclusions: Neurodevelopment at 2 years in survivors of OA is not different from test norms. Intrinsic patient factors are likely important contributors to developmental outcome.

Introduction: One of the most common causes of seizure in childhood is febrile convulsion (FC). Diazepam or midazolam oral recommended for FC prevention, but the effectiveness of prophylactic treatment with medication remains controversial. Prophylactic use of oral anticonvulsant drugs is thus a questionable practice. We designed this article to survey the effect of diazepam in prevention of seizure in FC. Methods and materials: We conducted this study upon 186 child 6-60 mo in Imam Reza hospital in Kermanshah from 1,386 and followed those 24 months. Patients studied in three groups: group A: if had fever received oral diazepam 1 mg/kg/day, group B received oral diazepam 0.4-0.6 mg/kg/day, group C: when had fever did not received diazepam, then recurrence rate of seizure and demographic data were documented and analyzed. Results: Group A (n = 76), Group B (n = 77), Group C (n = 33). Recurrence rate of febrile seizure were in (group A: 23.7 %, group B: 23.4 %, group C: 24.2 %). There was no statistically significant difference between 3 groups (p value = 0.930).Recurrent rate of seizure in patients with positive family history of febrile convulsion were more common. Conclusion: Results of this study showed use of oral diazepam in begin of fever couldn't decrease the recurrent rate of seizure in febrile convulsion. Objectives: We investigated the pattern of mortality at a PICU and explored if any unusual pathogens are associated with these deaths. Methods: Demographic data of all PICU deaths were analyzed. Results: There were 81 deaths (males 59 %; infants 25 %) over the 10-year period between 2002 and 2012. The mean annual mortality rate of PICU admissions was 5.7 %. Septicemia with common gram positive (commonest coagulase negative staphylococcus), gram negative (commonest pseudomonas) and fungal (commonest candida species) pathogens were present in 12 (15 %), 13 (16 %) and 5 (6 %) of these patients, respectively. Viruses (commonest CMV) were isolated in 20 patients (25 %). 91 % of these patients were ventilated, 73 % required inotropes, 91 % received broad spectrum antibiotic coverage, 31 % received systemic corticosteroids, 52 % blood transfusion and 38 % anticonvulsants. 36 patients (44 %) had a DNAR (Do-Not-Attempt-Resuscitation order) prior to their death at the PICU. Oncological diagnoses (n = 24) were predominant diagnoses. In the trauma category (n = 9), patients were more likely to present with cardiac arrest preceding ICU admission, and to have brain death subsequently. Trauma deaths typically affected healthy boys and not involving any pathogens. There was no gunshot or asthma death. Postmortem examination was performed in 30 % deaths. Conclusions: Death in the PICU is a heterogeneous event that involves infants and children of both genders. These patients may have a premorbid condition but healthy children are not spared.

Infections are important associations only in non-traumatic PICU mortality. Nearly half of the patients did not receive active resuscitation against medical futility in honor of caregivers' wishes. The Pediatric Organ Dysfunction (PELOD)-2 score has been recently developed and validated, and allows assessment of the severity of cases of MODS in PICU with a continuous scale. The objective of the study was to validate the daily PELOD-2 score using the set of 7 days proposed with the previous version of this score. Methods: We conducted a prospective multicenter cohort study. All consecutive children admitted in nine multidisciplinary hospitals in France and Belgium (June 2006-October 2007) were included. We collected data on variables considered for the PELOD-2 score during PICU stay up to seven time-points: days 1, 2, 5, 8, 12, 16 and 18. The outcome was vital status at PICU discharge. We used areas under receiver operating characteristic curve (AUC) to evaluate discrimination. Results: The median number of admissions per PICU during the study period was 442 (IQR: 132-581). We enrolled 3671 consecutive patients (median age: 15.5 months; IQR: 2.2-70.7). Mortality rate was 6.0 % (222 deaths).

Conclusion: Discrimination of the daily PELOD-2 scores was good or moderate. Background and aims: This nationwide multicenter study reports neurodevelopmental outcome of children treated with neonatal extra-corporeal membrane oxygenation (ECMO) by evaluating intelligence, type of education, concentration and eye-hand coordination at 8 years of age. Methods: A follow-up study was conducted in 135 8-year-olds who received neonatal ECMO between 1996 and 2001. The children underwent a structural psychological assessment for intelligence (Revised Amsterdam Intelligence Test), concentration (Bourdon-Vos) and eye-hand coordination (Developmental Test of Visual-Motor Integration). Results: Intelligence (n = 125) did not differ from reference norm with a mean (SD) IQ of 99.9 (17.7); 91 % attended regular education. Significantly more children needed extra support (39 %) at regular education compared with reference norms. The children had significantly slower working speed (v 2 = 132.36, p \ 0.001) and were significantly less accurate (v 2 = 12.90, p \ 0.001) on the Bourdon-Vos (n = 123) compared to reference norms. Eye-hand coordination was within normal range with a [mean (SD)] score 97.6 (14.3); n = 126. Children with congenital diaphragmatic hernia scored lowest for eyehand coordination but within normal range [91.0 (16.4); n = 28]. Conclusions: Eight-year-old children, treated with neonatal ECMO, experience average intelligence with subtle problems in the area of concentration and behavior, with increased need for extra support at regular education. Decreasing mortality and increasing morbidity necessitates long-term follow-up of these children to detect early signs of subtle learning deficits and to provide adequate interventions at early age. The infected children become symptomatic in a mean age of 23 months. Lymph-nodes, respiratory and digestive signs were the most frequent signs. Parotiditis, Pneumonia, Molluscum contagiosum and the tooth decays were signs which characterized these children. In front of child's chronic symptomatology, don't limit to classical diseases (allergy; coeliac). 22 % of them died. The forecast of these children was clearly improved thanks to HAART.

A. Pahuja, C. Ramesh

Background: There is enormous evidence showing association between maternal epilepsy, use of antiepileptic medication during pregnancy and foetal malformation, demise and developmental delay in children later in life. So far there are no special arrangements to follow up these children until concerns are raised by school authorities in various aspects of development. The objective of the survey was to ascertain the developmental outcome of children born to mothers on anti epileptic drug (AED) during pregnancy and also to observe the trend of s AED prescribed during pregnancy at Watford general hospital. We performed the development assessment of children born to epileptic mothers between 2008 and 2010 in our county. Development assessment was performed over telephonic consultation using Stages and Ages module for development assessment: easy to use and can be used by parents at home. Results:

• There is strong association of increased risk of delayed neurodevelopment in children exposed to either NaV or CBZ monotherapy • Lamotrigine-less incidence of development delay • AED exposed children had smaller head circumference and Increased risk of febrile convulsions.

• It would be ideal to have a regular follow up and development assessment of all babies born to mothers with epilepsy or on AED and to have a local policy for this. • Involve parents in regular assessment of childs development by using stages and ages development assessment tool and perform detailed assessment if needed (Cost effectiveness 

NEONATAL APSTINENTIAL SYNDROME R. Rudanovic, L. Dragas, M. Rudanovic, L. Globarevic

Introduction and aim: Addictive illnesses represent a very difficult social and medical problem having the characteristic of epidemic in some countries. Introduction of therapy with methadone in treatment of heroin addicts, the fertility has been restored to women. Addiction of mothers to drugs is very much related to the greater prenatal morbidity and mortality. Problems combined with the usage of heroin during pregnancy are miscarriage in the first trimester, preterm delivery, infections of mothers and unborn babies and neonatal apstinential syndrome (NAS). Surgical and neonatal complications are less frequent with women who were treated with substitution therapy methadone. Less complications were noted with mothers and babies who were treated with small doses of Methadone (\60 mg daily) than with high doses (80-150 mg daily) Strength of NAS directly depends on the dose of methadone.

Method: Perspective observation of the newborns whose mothers were taking drugs. Period of observation 4 years. Results: 14 newborns were observed who were exposed to drugs during pregnancy. 6 mothers were on Methadone therapy, 2 on heroin, benozodiazapinim, cocaine and marihuana. 10 were combining different kinds of drugs. Out of total of 14 newborns 8 newborns had clinical signs of NAS. For evaluation of signs of NAS and therapy of Finnegan score was used. Background: There has been growing concern that general anesthesia during early childhood might affect the neurological outcome. This clinical research investigated the effect of general anesthesia during early childhood on the long term neurological outcome of the extremely and very low birth weight infants. Subject and method: The subjects are 176 extremely and very low birth weight infants who have been followed up neurologically. The exclusion criteria are neonatal asphyxia (Apgar \7), cerebral hemorrhage, sepsis, anomaly syndrome, chromosomal abnormality, postcardiac surgery, and post-brain/spinal surgery. The subjects are divided into the control group and the anesthesia group who underwent general anesthesia during early childhood. The neurological outcome was evaluated at 3 years old with Kyoto scale psychological development and at 6 years old with WISC-III. T test and Spearman's rank correlation coefficient were applied for the statistical analysis. Result: One hundred sixty cases were the control group and sixteen cases were the anesthesia group. There is no significant difference in the scores of both Kyoto scale psychological development and WISC-III between the two groups. There is no significant co-relation between the scores of Kyoto scale psychological development and the total amount of sevoflurane, total amount of nitrous oxide and total anesthesia duration in the anesthesia group. There is also no significant co-relation with WISC-III. Discussion: The general anesthesia with sevoflurane during 2-3 h in early childhood might not affect the neurological outcome at 3 and 6 years old in the extremely and very low birth weight infants. Introduction: Retinopathy of prematurity (ROP) is a leading cause of visual impairment and blindness in premature babies. Yearly 3.5 million premature babies are born in India (global 25 %) but due to lack of national ROP screening program, the incidence and specific risk factors are unknown. Methods: All babies \35 weeks, and between 35 and 37 weeks with risk factors were studied. Data collection of profile variables and ophthalmic check was done prospectively for 3 years.

Results: Out of 87 babies, the incidence of ROP, according to severity was: Stage 1-ROP-26 %, pre-threshold-ROP-20 % and threshold-ROP-15 %. The association of birth weight (\1,500 g), gestational age (\35 weeks), ventilation duration, RDS requiring surfactant, Culture positive sepsis, shock requiring inotropes, duration of supplemental oxygen therapy, saturation fluctuations, apnea and blood transfusions with ROP were statistically significant(all P values .05).

Incidence of severe ROP (prethreshold, threshold) was 2 times higher in outborn, compared to inborn babies (P value .001).

The incidence of threshold ROP in neonates whose mothers received antenatal steroids was significantly less (P value .001).

The requirements of multiple sittings of laser therapy was higher (84.62 %) when the babies were treated in threshold stage vs. 26.67 % when babies were treated in pre-threshold stage (P value = 0.002).

Conclusion: The incidence of ROP was very high in outborn babies. Evidence based protocolised care is associated with significantly reduced ROP rates. Early Laser photocoagulation in pre-threshold stage was an effective treatment of ROP with no short term complications and reduced need for multiple laser sittings. Background: Due to size disadvantage and tendency to fluid overload, intensive care follow-up of kidney transplantation in small children is a complex task for any pediatric intensivist. Cases: During 2012 in our hospital, 8 of total 232 patients undergoing kidney transplantation were \15 kg with 6 adult and 2 elder child donor. All of these patients were transferred to pediatric intensive care after operation. Central venous pressure (CVP) over 6-8 mmHg and invasive systolic blood pressure over 100 mmHg is targeted for every patient. Besides 30 cc/h D 5 W infusion, hourly urine output is added to the total fluid as D 5 -0.45 % sodium chloride. When hypotension or low CVP was detected, 20 cc/kg nomal saline bolus was performed. Persistent blood glucose over 250 mg/dl was treated by insulin infusion. Most frequent side effect of our treatment was hyperglycemia. (2), 44 (2) and 27 (4), respectively; with significantly lower scores at 12 years than at 5 and 8 (p = 0.002 and.001). Time on ECMO (p = 0.02), chronic lung disease (p = 0.001) and abnormal cranial ultrasound (p = 0.007) were of significant negative influence.

Conclusions: Motor-problems in children treated with neonatal ECMO persist throughout childhood. Further studies with more children assessed at 12 years and older are needed to place our results of deterioration into perspective. The participants of this study represent all VLBW-infants born within a 3-years period in Hamburg/Germany enrolled in a longitudinal program. At the age of 20-22 years a detailed questionnaire was sent to the former VLBW-infants. Those with cerebral palsy were excluded. We still reached 135 of the former 329 infants (41 %). The participants were representative in terms of neurological outcome at the age of 6 years. 58 additional participants of the former control group could be evaluated in the same manner. Former preterm participants showed significant lower values compared with control participants concerning body length, weight and head circumference. BMI was significantly reduced only in female participants. Significant more preterm participants underwent surgical procedures, Refractive errors were more frequent in preterm participants. Only two still suffered from epilepsy. Recurrent pain episodes were, however, found more frequently in the control participants. 75 % of the preterm participants were living still together with their parents. Preterm participants more often had to repeat a school year and reached a lower level of education, pronounced in male, AGA-, very preterm (GA \31 weeks) participants and those with neurological abnormalities other than CP at 6 years of age. Regarding health situation of former not disabled VLBW-infants our results should be considered in the aspect of transition. A major percentage of those with later low educational level could be recognized already in childhood. Infants born very preterm (\32 weeks gestational age) are at risk of development problems including motor, cognitive, and visual impairments. We developed a quantitative test, using remote eyetracking, to assess higher-order visual functions in young infants. The aim of our study was to investigate visual development in very preterm infants compared to controls at 12 and 24 months of age. Methods: We included 17 very preterm infants without any brain injury on repeated ultrasound and MRI scans (low-risk very preterms). Visual processing was assessed in terms of oculomotor reaction time to make an eye movement towards a stimulus displayed in the quadrants of a monitor with an integrated remote eye-tracker system. Conclusion: These results suggest that, at the age of 2, no difference in visual processing is present between low-risk very preterms and controls. In the future we will also assess visual information processing in high-risk very preterms, and we will correlate the visual assessment to the degree and location of neonatal brain damage. Methods: We reviewed all the echocardiograms performed on our neonatal unit in 2011 and 2012 to identify babies born at \32 weeks gestation who had an echocardiogram for assessment of CLD. Results: In 2011 and 2012 a total of 52 echocardiograms were done in babies born at \32 weeks gestation as part of assessment of CLD. Median gestational age was 25 weeks (range 23-30), median birth weight was 785 g (range 500-1,688 g). Two babies were found to have significant pulmonary hypertension (PH) requiring multidisciplinary management and subsequently died due to respiratory failure secondary to PH. Five babies needed referral to paediatric cardiology services for congenital heart defects. Five babies had persistent ductus arteriosus (PDA) which was felt to be haemodynamically significant at that age. Five babies had evidence of hypertrophy of ventricular myocardium. Four babies had evidence of moderate tricuspid regurgitation which prompted further follow-up. Conclusions: Our retrospective review found that echocardiogram is a very useful tool for the assessment of babies with CLD. The incidence of significant pulmonary hypertension in our cohort of babies is around 4 % which is much less than previously quoted in other studies. 40 % of the babies in this cohort had other significant findings on echocardiograms performed at 36 weeks CGA that prompted change in management. Objectives: Recent evidence favors primary role of cellular autoimmunity and its humoral mediators in pathogenesis and following type 1 diabetes mellitus (IDDM). The present study is carried out to investigate serum concentration of tumor necrosis factor-alfa (TNFa), interleukin-6 (IL-6) and soluble interleukin-2 receptor (sIL-2R) in children with (IDDM). Potential role of glycemic control, body mass index and disease duration were evaluated. Designes and methods: Thirty-five children with IDDM and 30 age and six matched non diabetic healthy subjects were recruited for this study from the outpatient clinic of diabetes of National Institute of Diabetes and Endocrinology. Results: Circulating level at TNF-a, IL-6 and sIL-2R were elevated in children with type 1 DM (39.91 ± 17.46, 14.89 ± 10.69 and 779.0 ± 467.06 pg/ml, respectively). Compared with non diabetic controls (5.67 ± 1.88, 6.23 ± 2.78 and 254.33 ± 173.6 pg/ml, respectively). These differences were statistically highly significant (.0001). Glycemic control, Insulin dose and disease duration were not significant predictors of cytokines concentration in children with IDDM. A significant negative correlation was obtained between TNFa with age, weight and BMI and sIL-2R in diabetic patients. However there was a significant positive correlation between IL-6 with weight and BMI in those children.

Conclusion: Circulating levels of inflammatory cytokines were elevated in patients with IDDM suggesting activation of the inflammatory immune response. There levels were not affected by glucose level, insulin dose or duration of the disease. Results: The prevalence of vitamin D deficiency in maternal and cord blood was 69.6 and 58.2 %, respectively. There was significant correlation between maternal and cord blood serum concentration of Vitamin D 3 . In mothers who were deficient in Vitamin D 3 , cord blood Vitamin D 3 levels were lower than those from normal mothers. (P = .001). A significant direct correlation was also found between parda/veil observers mothers and levels of Vitamin D 3 (P \ 0.002). Conclusion: Keeping in view the high prevalence of vitamin D deficiency, considerations should be made for its supplementation in antenatal period to prevent hypovitaminosis in both mother and baby.

COMPARISON BETWEEN SOME CONTENTS OF HUMAN MILK AND SOME ARTIFICIAL FORMULAS USING LIBS J. Alsharnoubi, Z. Abdelsalam

This study was done to use laser induced breakdown spectroscopy (LIBS) as diagnostic tool for identification and determination of many minerals as Mg, Ca, Na and Fe in milk samples and also to compare between different milk formulas to find the nearest in its composition to the mother 0 s milk among most commonly used milk formulas at Egypt. Sixty milk samples were collected from nursing mothers (in first 6 months) and divided into two groups above and below 30 years old mothers. The two groups were analyzed by LIBS then compared with artificial milk in relation to Mg, Ca, Na and Fe. Mothers milk has higher intensity than the artificial formulas in Mg, Ca, Na and Fe. S26 formulas was the nearest to the mother's milk in the intensity level for Mg, Ca, Na and Fe. LIBS is a quick and simple non invasive method for identification of many minerals as Mg, Ca, Na and Fe in milk samples. Mother's milk is the optimum for babies needs and S26 formula is the nearest to it. Objective: To characterize aspects of postoperative intensive care after pancreatectomy in CHI. Patients and methods: 25 patients (11 girls; median age 10 months, range 7 weeks-10 years) with CHI were included in a retrospective chart review. 12 underwent laparoscopic and 13 open approach pancreatectomy. 18 patients showed a genetic pre-disposition for focal HI and 7 for the diffuse form. Postoperative glucose infusions were adjusted to permissive hyperglycemia (up to 14 mmol/l). CHI medications were not supported. Drainage fluids, urine production, the amount of intravenous glucose and concentrations of plasma lipase were recorded. Results: Intensive care stay was between 2 and 62 days (median 6). Three patients were on ventilatory support for 3 days (one after CPR). Postoperative need for glucose did not exceed 4.5 mg/kg/min. Thereafter, glucose administration was increased due to hypoglycemia and showed individual latency (2-5 days). Plasma lipase levels differed from 30 lkatal/l to 1.73 (median 6.8). Drainage fluid was neglectable, except in 1 case. Arterial hypotension requiring dopamine and norepinephrine was noted in 2 patients. Renal function was normal in all patients. The routine pain management with metamizole and piritramid was sufficient. Tolerance of oral feeds was delayed in all patients. Conclusion: Postoperative intensive care after pancreatectomy in CHI was uncomplicated in most of the cases. The main focus should be on glucose control.

A. Baig

Objectives: Several studies regarding Breastfeeding have been done in Pakistan and around the world. We have also done such a study in Isra University Hospital. Breast feeding is perfectly suited to nourish infants. It is truly said that what is good for babies is good for mother. Our objectives were to determine knowledge about optimum breast feeding practices, benefits of breast feeding and pre-lacteal feeds, to evaluate the awareness of breast feeding through demographic parameters and to determine the causes of failure of breast feeding among mothers. Methods: Questionnaire based hospital survey was conducted among 150 mothers, based on objectives which depended on certain variables: demographic variables like age, education, socio economic status, occupation, address. It also had questions about duration of marriage, number of kids. Study design was Cross Sectional Study and was done using SPSS. Results: Breast feeding was initiated by 89.33 % (134) of mothers. 10.67 % (16) of mothers, who failed to breastfeed their babies, had mainly the reason of milk not being produced (50 %). Later we specifically asked the breastfeeding mothers certain questions. It was revealed that they were breast feeding their babies because breast milk is the best/balanced diet. 84 % recommended breastfeeding for today's mothers.

Conclusions: According to our study Illiterate females and house wives were breast feeding more. Economically deprived mothers tended to breastfeed their babies for longer period as compared to economically well-off or educated mothers. We came to the conclusion that awareness programs regarding correct breastfeeding practices be conducted. Results: ProPICCs were inserted by ultrasound guidance in the brachio-cephalic vein (3 cases: 1, 6 and 11 year old) or in the femoral vein (1 case: 20 days old). All catheters were inserted without complications and tunneled to the infraclavicular area (if inserted in the brachio-cephalic) or to the thigh. The average dwell time of the devices was 54 ± 31 days. All PICCs were easily used for AP (one patient, 6 year old, graft vs host disease) or HDF (three patients, renal failure). There were no episodes of flow occlusion or of persistent difficulty in performing the procedures. The protocols of our institution consist in 4-6 ml/kg/min of blood flow rate and 10-20 ml/kg/h of infused fluid rate for HDF, and 1 ml/kg/min for AP. We reported no catheter-related bacteremia and no catheter-related thrombosis.

Conclusions: We suggest that double lumen power injectable PICCs can be used as multi-purpose central line, even for AP and HDF in neonates and in small children. Background and aim: Breast milk is considered the optimal nutrition for all newborn infants. The thought of breastfeeding multiples fills most of the mother with apprehension but adequate quantity and quality of milk production has been documented even for high multiples. This study is conducted to determine the expecting mothers' opinions about breastfeeding their multiples to be born. Method: Women pregnant with multiples who are in their 2nd or 3rd trimester were informed about the study and after their consent the filled in a questionnaire inquiring about breastfeeding. The study was conducted in Sakarya-Turkey in 2012 between May and November. Results: The mean age of the pregnant women was 29.94 ± 5.2 (min 18, max 38) years and 77 (1 %; n = 27) of them were primary school graduates. 42.9 % (n = 15) of them had at least one elder child. 42.9 % (n = 15) of mother's had no notion of breast milk sufficiency for multiples. Nevertheless 94.3 % (n = 33) of the expectant women declared intention to breastfeeding their multiples and 5%. 7 (n = 2) claimed formula preference.

The women expecting multiple babies should be encouraged and be assured regarding the breast milk sufficiency for their babies. Background: Recents studies suggest that supplementation with probiotics may inhance intestinal function in premature infants and also prevent necrotising enterocolitis. Objective: To evaluate the efficacy of probiotics on the digestive tolerance to enteral feeding in very low birth weight premature babies. Materials and methods: We conducted a study over 10 months period in a tertiary intensive care unit. The trial included 60 low birth weight premature babies. Thirthy one babies(group A) received human milk and probiotics-Lactobacillus reuteri-and 29 babies (group B) received human milk alone, for their duration of staying in intensive care unit. Results: In the group of infants who received oral probiotic, gastrointestinal tolerance improved and the time of reaching full enteral feeding was shorter. No adverse reaction or infection was observed.

Conclusions: Supplementation with may improve intestinal tolerance to enteral feeding in low birth weight premature babies, allowing an early reach of full feeds. Fig. 1 for average enrichments. There was an upward trend in tracer enrichments, especially for phenylalanine. This indicates tracer recycling, which is a methodological problem inherent to prolonged tracer studies.

Conclusions: In continuously fed stable critically ill children amino acid appearances and protein kinetics do not show a circadian rhythm.

Whether this is an adaptive mechanism or pathologic remains to be studied. We recommend not extending stable isotope tracer protocols longer than 10 h, because of potential tracer recycling which may result in underestimation of protein kinetic indices. The low birth weight infants require many blood transfusions (BTs) despite the progress of clinical medicine. BTs up to 28th postnatal day are labeled early (EBTs), and those after-late. EBTs are due to haemolysis and haemorrhage, late BTs are almost exclusively due to anaemia of prematurity.

Objective: To study the influence of EBT over the iron indices in premature infants. Materials and methods: 102 infants born before 33rd gestational week (GW) were surveyed. They are divided in two groups: control (group 0) without EBT (35 babies) and group 1 with EBT (67 babies). The iron indices (serum levels of ferritin-Ferr, transferrin-Tf, soluble transferrin receptors-sTfR, iron-Fe, total iron binding capacity-TIBC, saturation of transferrin-SatTf) are examined up to the discharge.

Our results: Group 1: Ferr levels are higher throughout the entire study period, Fe is higher in 30th, 33rd and 36th GW, TIBC is lower in 33rd and 36th GW. Group 0: Tf rises sharply in 36th and 39th GW and sTfR is higher. Iron deficiency (SatTf B20 %) is more often found in group 0 in 30th GW (56 vs. 5 %), but iron status normalizes to the discharge. More than 1/3 of the patients have iron overload, that latter is 3 times more common in group 1.

Conclusion: EBT in preterm infants leads to serious disorders of iron metabolism. This results in high risk of iron overload to the discharge. Results: During study period, 136 patients were admitted to our PICU and 36 of them were included. We started continuous and intermittent feeding in 17 (46 %), 20 (54 %) patients, respectively. There wasn't significant difference between two groups for ages, initiation feeding volume, the time of the feeding initiation and time of reaching total volume. There were 15 (75 %) and 15 (88.2 %) mechanical ventilated patients in IF and CF group, respectively (p = 0.306). There weren't statistical difference in adverse effects of feeding methods as residual volume, distension, vomiting and diarrhea between IF and CF group. The tolerability ratio of initiation feeding methods was same in both groups (87.5 %). In IF group, 5 of them were couldn't tolerate to feeding and changed to CF and they tolerated to this method. Their PICU LOS were 15.5 ± 12.3 and 23.1 ± 14.6 day in IF and CF group, respectively (p = 0.033). Conclusion: Both intermittent and continuous enteral feeding methods are useful in critically ill children. Background and aims: Adequate enteral nutritional intake is difficult to achieve in critically ill children. The aim of this study was to investigate if administration of a proteinenergy enriched formula (PE-formula) may help to achieve nutritional targets earlier.

Methods: Observational, retrospective study. Total daily intakes were determined in the first week after admission in infants B1 year admitted to the PICU for at least 4 days. Infants receiving exclusively enteral feeding with a standard or PE-formula at day 4 of admission were included. Target goals for energy and protein were: resting calculated energy expenditure +10 % for the first 2 days; recommended dietary allowances (RDA) for day 3-7, and protein 1.8 g/kg/ day. Actual intakes were compared to nutritional goals and differences between the groups were calculated. Results: Forty infants with various diagnoses (53 % male, median age 0.16 years) were included, 14 received PE-formula. The study comprised 219 complete feeding days (77 PE and 142 standard). Using a PEformula, on significantly more days the targets for energy (58 vs. 39 %) and protein (69 vs. 37 %) were achieved. Overall, compared with target goals, significantly higher median percentages of energy and protein intake were obtained with a PE formula than with a standard formula (energy 114 vs. 96 % and protein 130 vs. 92 %, respectively). Conclusion: Achievement of nutritional goals in critically ill children remains difficult. In daily practice, administration of a PE-formula can promote the achievement of nutritional goals, especially protein targets. 1. Preliminary dot-blotting detection of rhEPO using pH treatments was developed. Thermoprobing, also cases of concentrate gelling (homogeneous or biphasic from healthy or anemia donors) increased EPO resolution. 2. Expansion into other tracks resulted in track side arcs near start (semidry gel). 3. Durapore (semidry) resulted in weakened (compared to control) spots in the rhEPO containing region. Track tree branching on Immobillon at the level of expected rhEPO beginning (from cathode) was registered.

and appearance own track rhEPO external spots. 5. Peroxidase transfer improved EPO bands distribution. 6. Washings at C50°C resulted in excellent background. 7. BioWest (peroxidase chemiluminescent substrate) at C50°C and pH C8.5 increased EPO discrimination picture. Stepwise kinetic luminescence optimum registration allowed sharp rhEPO detection. 8. In accordance to our conception of visual rhEPO-ehEPO conversion, monitoring coefficients for calculation of rhEPO relative levels in urine of patients with renal insufficiency were proposed.

Conclusion: Indicator features and improvements allow successful EPO detection (also in special cases). Objectives: Early feeding strategy in infants has a positive effect not only on their physical development but also on their brain development. This study was designed to evaluate the incidence of extrauterine growth restriction (EUGR) in premature neonates at time they are discharged from the hospital and determine the factors associated with the occurrence of EUGR in Xi'an City of China.

Methods: Weight, length and head circumference of 104 premature infants in the Neonatal ICU of our hospital were serially measured from birth till discharge. The infants were classified into three birth weight groups and five gestational age groups. Results: Of the 104 preterm infants, the percentage number of small for gestational age (SGA) at birth was 15.3, 14.4, and 8.6 % for weight, head circumference and length, respectively. At discharge from hospital, the incidence of EUGR was 49.0, 27.8, and 27.8 %, respectively. Duration of parenteral nutrition (PN), time to achieve total calorie of 120 kcal/kg/d, time to reach full feed, birth weight and length of hospital stay were significantly different between non-EUGR and EUGR groups(P \ 0.05). Through logistic regression analysis, birth weight, length of hospital stay, gender and duration of PN were found to be significantly associated with growth retardation (P \ 0.05).

Conclusions: Early intravenous nutrition and enteral feeding can reduce the incidence of EUGR. Birth weight, length of hospital stay, gender, and duration of PN are risk factors for EUGR. Acknowledgements: This work was supported by the National Natural Science Foundation of China (No. 81070883). Pediatric Intensive Care Unit, 2 Pediatric Nephrology, 3 Neonatalogy and Pediatric Intensive Care Unit, Hopital Me`re-Enfant CHU Nantes, Nantes, France

Background and aims: In continuous veino-venous hemofiltration (CVVH), regional citrate anticoagulation offers an attractive alternative to systemic heparinization, especially in high bleeding risk patients. We report the implementation of this alternative in a university affiliated 12-bed PICU. Methods: We used a commercially available hemofilter with automated procedures. Only standard solutions were employed to reduce complexity. Hemofiltration was performed with pre-filter citrate anticoagulation, postfilter reinjection, and no dialysis. Citrate rate was set to meet a circuit citrate concentration of 2.2 mmol/L, that could be modified to obtain circulating ionized calcium.5 mmol/L. CVVH was performed using an 18 mmol/ L citrate solution and a phosphate-containing post-dilution solution.

Beyond the filter, calcium was continuously infused to maintain systemic ionized calcemia 1.1-1.25 mmol/L. Results: We studied seven children 10 ± 8 years old (weight range 15-66 kg), admitted over a 14-month period. All patients were critically ill and underwent a course of CVVH, as part of their management. Disease categories included sepsis with multiorgan dysfunction, two children; and haemolytic uremic syndrome, five children. Average time of therapy was 3.6 ± 1.1 days. Participation of IL-1b in implementing stress reaction determined by its influence on the level of glucocorticoids and central brain structures. This cytokine is one of the main triggers of the neuro-endocrine stress response.

Objectives: To examine the neuro-endocrine stress response on the basis of study of the dynamics of interleukin-1b (IL-1b) and cortisol in serum during the neonatal period in newborns with kidney disturbance after asphyxia. Methods: The study involved 100 full-term infants with signs of nephropathy: 50 children who had severe asphyxia, and 50 children with moderate asphyxia. Comparison group included 20 children without asphyxia at birth. Disturbance of kidney function diagnosed if blood creatinine level over 89 lmol/l, blood urea more than 8 mmol/l, urine output \1 ml/kg/h. Serum IL-1b and cortisol levels were determined at 1-2, 7-8 and 25-30 days of life by ELISA.

Results: Asphyxia, regardless of its severity, stimulates the production of IL-1b, enhances strength and correlation between IL-1b and cortisol, which causes an increase its level in the serum. Continuous stimulation of the adrenal cortex by cytokine in case of severe asphyxia leads to a change in the correlation's character (-0.328, p \ 0.05) and inhibition of cortisol production by the end of the neonatal period.

Conclusions: Cortisol level in children with disturbance kidney function during the neonatal period depends on the severity of asphyxia and levels of IL-1b. Depletion of hypothalamic-pituitaryadrenal system in case of severe asphyxia disrupts stress-induced response and adaptation newborn to extrauterine life. Background and aims: Nutritional status has significant effects on morbidity and mortality in the general population. Our aim was to evaluate the relationship between weight on admission and risk of mortality in PICU patients. Methods: All children admitted to the PICU between 2007 and 2011 were included. The following variables were analysed: gender, age, weight and weight-for-age z-score, prognostic scores (PIM-2 and PRISM), diagnosis and outcome. Upper extreme of weight-for-age z-score was defined C1.881 (P97) and lower extreme B-1.881 (P3).

Results: Overall 1804 children were included. Median age was 11.7 months (IQR 0.8 -97.0). Median weight-for-age z-score was -0.78 (IQR -1.92 to 0.16). 2 % had z-score C1.881. Mortality was 3.7 % and standardized mortality by PIM-2 and PRISM was 0.8 and 0.9, respectively. When comparing children who died (n = 67) with the surviving ones (n = 1,737) no significant differences were found regarding the median weight-for-age z-score (-0.94 vs -0.78; p = 0.565). However, the mortality rate in the upper extreme z-score was significantly higher than the remaining children (12.1 vs 3.6 %; p = 0.032). In the lower extreme of z-score (3.9 vs 3.6 %; p = 0.802) no differences were observed. Through logistic regression analysis, the upper extreme of weight-forage z-score was proved to be an independent risk factor for mortality. Conclusions: Patients in the lower extreme of the weight-for-age z-score were over-represented. A significant relationship between mortality and upper extreme of weight-for-age z-score was observed in PICU patients, confirming the initial hypothesis. These results need further validation, in order to allow inclusion of weight-for-age z-score in prognostic scores. The babies in KMC group had significantly better weight gain (P value = 0.034), thermal regulation, fewer episodes of hypothermia and the need for overhead warmers in this group was also significantly shorter (P value = 0.036). The mothers in KMC group were significantly more comfortable and confident in nursing, providing care after discharge and breast feeding their babies (all P values .005). They were significantly less stressed and were likely to continue KMC at home because of the observed advantages (P value .001).

Conclusion: Protocol based KMC provision is extremely beneficial to the baby and the mother. Apart from various benefits to the neonate, it also improves maternal confidence. Results: All newborns were exclusively breast fed since birth with all mothers had low 25 hydroxy vitamin D (25OHD) level \10 ng/ml. FT VDD newborns with hypocalcemia secondary to VDD presented with generalized convulsions (10/10) craniotabes (8/10) but none had rachitic chest rosaries or joint broadening. Cranial ultrasonographic evaluation was normal. They had serum 25OHD concentrations = 9.8 ± 1 ng/ml. 6/0 % had increased PTH concentrations ([60 ng/ml) and 60 % had decreased magnesium concentrations (.7 mmol/L). Serum ALP concentrations were significantly higher than normal newborns. All other laboratory results (liver function tests, urea and electrolytes, C reactive protein, lumbar puncture, blood culture, lactate) were normal. In all patients, seizures ceased within 2 days of starting treatment with alphacalcidol and calcium. Radiological manifestations included metaphyseal band of relative lucency (osteopenia), just under the line of provisional calcification, within distal radius (7/10), femur (4/10) and tibia (3/10), mild cupping and haziness of distal radius (1/10).

The manifestations of VDD differ considerably in newborns compared to older infants. VD supplementation for mothers and newborns should be considered to avoid short and long term complications of VDD in countries with high prevalence of VDD. Conclusions: Babies needing TPN have been adequately recognised and the decision to start is made appropriately. However, there is significant delay in premature babies receiving TPN, the commonest reason for this appears to be venous access (5/12). Unavailability of TPN service from pharmacy accounted for delay in a quarter of the babies studied. We recommend increasing the use of umbilical catheters for commencement of TPN. We also suggest that premade standard bags of TPN are made available to minimise the delay for times when pharmacy service is unavailable. We plan to re-audit this in 6 months time. Objectives: It was frequently pointed out in recent days that trace elements were playing an important role in neonates. For instance, some neonatologists reported the possibility of relation between serum selenium concentration and bronchopulmonary dysplasia. The main objective of this study is to examine the difference of serum level of trace elements between healthy/mature neonates and sick/ premature neonates. Methods: From January to December 2012, 44 neonates born in National Center for Global Health and Medicine (NCGM), Tokyo, Japan, were enrolled and serum specimens were collected in order to measure serum level of iron, zinc, copper, and selenium at the point of day 5. We compare the results between healthy/mature babies who did not admit during their mother's admission and sick/premature babies who admitted to NICU or nursery room soon after birth by unpaired two tailed t test.

Results: 26 admitted babies showed lower serum selenium concentration than 18 healthy babies did (45.7 vs. 54.4 lg/l, respectively, Background and aim: Use of feeding protocols to provide timely enteral feeding can potentially prevent malnutrition in the paediatric intensive care unit (PICU). However, the efficacy has not been well established. This systematic review aims to assess the impact of feeding protocols on clinical outcomes in critically ill children.

Methods: We searched four major databases using predetermined keywords and MESH terms. We included feeding protocol studies conducted in a PICU that reported at least one of the following outcomes: mortality, length of stay, duration of mechanical ventilation, gastrointestinal intolerances, infective complications, time to initiate and achieve goal feeds. Results: We screened 854 citations. Nine studies (one randomised controlled study and eight observational studies) were included. The randomised controlled study compared two different timings of initiation of feeding protocols in children with burns. Two studies were conducted among children with hypoplastic left heart syndrome and have significant risk of bias because there was a change in surgical technique during the conduct of the studies. Six studies were in multidisciplinary PICUs, of which four did not have a control arm.

There is weak evidence that the use of feeding protocols improves the timeliness of feed initiation, achievement of goal feeds and enhances feed tolerance; evidence for improvement in clinical outcomes is not robust.

Conclusions: Current medical literature lacks strong data on protocol driven feeding in critically ill children. There is urgent need to conduct more studies to determine clinical benefits. Background and aims: The establishment of a branch in the peritoneum may be complicated by purely abdominal problems (10 % of cases). Migration are rare, they represent 8.8 % of these complications. Peritonitis associated with occlusion clamp is also rare. Methods: Case 1: There is a newborn female who was transferred to 20 days life for treatment of hydrocephalus. Ventriculoperitoneal derivation (VPD) was set up in 45 days living with suites and a single output of 2 months. She was readmitted at the age of 4 and a half months for exteriorization of the catheter distal anal valve justified the withdrawal and the establishment of an external bypass. The child died 2 days after. Case 2: There is a newborn female who was hospitalized 19 days for life support with a paralyzed myelomeningocele. Neurosurgical intervention with a VPD took place at age 3 months. The VPD was removed 12 days after surgery because a refractory sepsis with progressive abdominal distension. 13 days post operative, laparotomy performed three intra peritoneal abscess and colonic occlusion clamp. The patient is still hospitalized. Conclusion: Mechanical complications valves DVP appear dependent on the type of material implanted. We discuss the main mechanical and infectious complications DVP, their mechanisms of occurrence and prevention. Introduction: Oxidative Stress is considered to be involved in a number of human diseases including ischemia. Preliminary studies confirmed reduction of cell death in brain following treatment with antioxidants.

Aim: According to this finding, we study the relationship between consumption of olive oil on cell death and memory disorder in brain ischemia. We studied the protective effect of olive oil against ischemia-reperfusion.

Materials and methods: Experimental design includes three groups: intact (n = 8), ischemic control (n = 8) and treatment groups with olive oil (n = 8).the mice treated with olive oil as pre-treatment for a week. Then, ischemia induced by common carotid artery ligation and following the reduction of inflammation (a week after ischemia), the mice post-treated with olive oil. Nissl staining applied for counting necrotic cells in hippocampus CA1. Tunnel kit was used to quantify apoptotic cell death while to short term memory scale, we apply y-maze and shuttle box tests and for detection the rate of apoptotic and treated cell, we used western blotting test for bax and bcl2 proteins.

Results: High rate of apoptosis was seen in ischemic group that significantly associated with short-term memory loss. Cell death was significantly lower when mice treated with olive oil. The memory test results were adjusted with cell death results and bax and bcl2 expression in all groups' comparison. Ischemia for 15 min induced cell death in hippocampus with more potent effect on CA1.

Conclusion: Olive oil intake significantly reduced cell death and decreased memory loss. Conclusions: The present data confirm the existence of neurovascular coupling in healthy premature brain. It also shows that ill premature neonates are unable to process syllabic stimuli, a step for language acquisition ability. These results demonstrate that particular regions of the cortex, critical for language acquisition and processing, contain innate language specific representations in early infancy. In addition, the approaches we developed provide early diagnosis of auditory neurovascular coupling impairment in IVH preterms which is known to induce learning disabilities. Duke-National University of Singapore, 3 Yong Loo Ling School of Medicine, National University of Singapore, Singapore, Singapore

Background: aEEG is increasingly commonly used in NICUs worldwide in screening, diagnosis, monitoring and prognostication of various neurological conditions. However, teaching of aEEG interpretation is highly variable in methodology, quality and effectiveness worldwide. Online teaching ensures consistently high quality, labour efficient teaching which can be accessed by students at their own convenience and pace of learning. Aim: To assess aEEG interpretation skills before and after an online, structured aEEG teaching programme, and to gather feedback about its effectiveness. Methods: Surveys were performed on nurses and doctors, both before and after 3 sessions of online aEEG teaching. Baseline characteristics of participants were gathered, as well as subjective and objective criteria for effectiveness. Results: A total of 37 NICU staff were involved, including 32 nurses and 5 doctors. Statistically significant improvement in subjective knowledge score (p = 0.01) was found pre and post online teaching. There was a high incidence of appreciation for the need to know aEEG (93.1 %). There was also an improvement in knowledge of the indications, although this was not significant. Passing rates for correct aEEG interpretation of tracings, (defined as 3 or more out of 5 correct answers) improved from 13.6 to 81.8 % (p = 0.047). Post teaching, 96.0 % felt the teaching was well structured and 77.8 % felt duration was optimal. In addition, 80.0 % felt they were able to systematically approach aEEG interpretation and 70.4 % felt they could interpret normal aEEG with confidence. Conclusion: Online, structured aEEG teaching effectively improves aEEG interpretation and should be considered as the method of choice. Results: Seroprevalence of cysticercosis in children presenting with seizure was found to be 8 % (4 out of 50 children) and none were positive for Ag-ELISA in controls. The risk factors significantly associated with a positive Ag-ELISA were pork consumers and pig rearers. ELISA positivity were more in consumers of raw vegetables. CT scan head of 31 children showed 25 % with features suggestive of neurocysticercosis. Kappa measurement of agreement between CT scan head showing live cysts and Ag-ELISA positive was found to be 76.3 %.

Conclusion: The seroprevalence of cysticercosis in children presenting with seizure was found to be 8 %. Pork consuming and pig rearing were significantly associated with them. As cysticercos is a common problem in Eastern Nepal, emphasis should be on appropriate intervention, prevention and health education at all levels. The aim of the study: The purpose of this study was to investigated the relationship between S100B concentrations within gestational age in normal preterm and term infants. Methods: 119 neonates were recruited, divided into a control group (N = 48) and an overall risk group (N = 71). The risk neonates were categorized into subgroups according to their clinical presentation. A serum blood sample was obtained from each patient at three different time-points: 24 h post-injury, 4th and 7th day after the admission. S100B levels were measured using electro-chemi-luminescence Immuno Assay. We used SPSS 16.0 statistical programme. ANOVA was for repeated measures and statistical analysis of the S100B measurements taken for the preterm neonates. Friedman's non-parametric test was taken for statistical analysis of the values acquired from the serum S100B in the term neonates with asphyxia at three measuring time intervals.

Results: We see that the two risk subgroups in term and in preterm infants have average levels of measured S100B protein above the cut-off point at each measuring time-point. Furthermore, these levels increase along the following two measurements starting at the 24 h time-point after injury (AI) which is the 3rd and the 7th day after the admission. Conclusion: S100 B protein in term and preterm infants is significantly higher in the first 24 h after birth. Thus, S100B protein is a good indicator of starting brain damage in term neonates, in the first 24 h after birth and is a indicator for early intervention. In preterm neonates it is indicator for possible early brain damage. The aim of study: To determine whether S100b, an acidic calciumbinding protein previously demonstrated as a reliable indicator of a brain lesion, could be helpful in detection of brain distress in intrauterine growth-retarded fetuses, as well as in neonates born with neurological deficit.

Methods: A total of 90 neonates were recruited from the Neonatal Intensive Care Unit of the Pediatric Clinic A serum blood sample was obtained from each patient at 24 h after admission: 4th and 7th S100B levels were measured using ECLIA method.

Results: The Friedman test value x 2 (2; N = 9) is 3.46 (p [ 0.05) not statistically significant and therefore the within-subject differences in all measurement time-points are not significant. The Friedman test value x 2 (2; N = 3) is 0.67 (p [ 0.05) not statistically significant and therefore the within-subject differences in all measurement time-points are not significant. The monitoring of the level of S100 B protein on the 3rd, and the 7th day and not elevating from the level measured the first day also represents that the damage was done prior to the delivery. Conclusion: This study provides evidence that circulating S100b protein is increased in IUGR and the one with neurological defects fetuses and correlates with cerebral hemodynamics, suggesting that it may represent an index of cerebral cell damage in the perinatal period (although is not statistically significant as in asphyxiated neonates where is a parameter of early brain damage. To determine the efficacy of Tau and S100B proteins, promising biomarkers in the detection and prediction of outcome in hypoxic or traumatic neuronal injury, in early detection of bilirubin-induced neurological dysfunction (BIND) in newborn infants with hyperbilirubinemia, 20 term infants with a diagnosis of hyperbilirubinemia requiring phototherapy and/or exchange transfusion and 20 term infants with normal findings were included as the control group. Blood samples were collected on admission during venipuncture for bilirubin level or biochemical tests both in study and control groups, a second sample was taken 48 h after admission only in the study group. Tau and S100B proteins were measured by enzyme-linked immunosorbent assay. A complete neurologic examination and BIND scoring was performed in all infants on admission and otoacoustic emissions (OAE) were measured. Both Tau and S-100B protein levels were higher in those with total serum bilirubin levels over 20 mg/dl. Serum Tau protein levels were elevated in exchange-transfused ones, in those with a bilirubin/albumin ratio [7, with abnormal scoring of BIND on admission and after 48 h; and at 48th hours in those whose OAE results were abnormal. S-100B protein levels at admission were only higher in those with blood group incompatibility, and exchange-transfused ones. The sensitivity and specificity of Tau protein in the detection of abnormal BIND scoring on admission (cut-off 22 pg/ml) and 48 h (cut-off 772.2 pg/ml) were 83.3, 62.5 and 58.3, 100 %, respectively. In conclusion, serum Tau protein as a biomarker may be useful in determining BIND in term newborn infants. Objectives: Evaluate the milk production of the mothers of premature newborn infants hospitalized in the NICU. Methods: Pilot with ten mothers and newborns premature infants in a maternity school from Brazil. Data collected during 1 month, with four interviews with each mother at intervals of 7 days (±2 days). Variables studied: socio-demographic mother data; newborn characteristics, skin-to-skin contact; non-nutritive sucking; starting time of extraction after delivery; strategies for increasing production, support network, participation in child care, time that the mother spent in neonatal unit and volume of expressed breast milk delivered to the human milk bank. Data were collected from July to October 2012. Results: Adult mothers, married, with good educational level, resident in the metropolitan area of Campinas; premature low weight newborns; 70 % female. Low milk production, late start of extraction, low frequency of milk expression. Mothers mostly absent and not participating in the care of their children.

The results are similar to other studies showing the need of research for intervention.

A. Arbabisarjou, M. Imani

Diaper rash is one of the most common skin disorders, occurring in 50 % of infants. The peak incidence is between 9 and 12 months. The aim of this research is assess the Mothers' knowledge and performance about caring diaper rash in infants' with diarrhea.

Methodology: This is a descriptive-analytical research. We assess 231 mothers whom have infants 6-60 months with diarrhea. Data gathered by questionnaire and interview l. The validity of questionnaire confirmed through experts (Pediatricians, Faculty members in nursing, health professionals) and its reliability after distributed in a sample of 30 mothers gained 93 % through Cronach's alpha. Data analyzed by experts through SPSS version 16.00.

Findings: Finding showed that the majority of mothers (90 %) have not knowledge about caring of diaper rash after diarrhea. Their knowledge was weak and they did not know how they treat or behave with diaper rash. About gaining information about skin care of diaper said we have not more information and knowledge to care it effectively (76 %). Analysis of questions about knowledge and performances highlighted that the mothers' knowledge about care of diaper rash was weak and their performances was weaker. Those mother who had diploma and higher, have more knowledge.

Considering the weak result about knowledge and performance of mothers about diaper rash in infants with diarrhea and its complications, promotion of their knowledge suggested through health workshop and others training meeting by professional and governmental official is necessary. Background and aims: Child abuse is one of the most common health and social problem. The aim of this study was to determine relation between child abuse by parents with chronic illness and some of the demographics characters.

Methods: This is a descriptive-comparative study. One hundred and six 11-18 years old children with a chronic illness(such as Asthma, epilepsy, leukemia, diabetes and etc.) referred to health care center of Isfahan university of medical science were selected by convenient sampling. A questionnaire including demographic data and child abuse scale consist of questions in four domains (neglect, emotional, physical and sexual) used for data collection. The questionnaire validated by content validity and reliability of questionnaires was estimated 0.78 by Cronbach's alpha. Data analysis were done by SPSS and using t test, correlation coefficient Pierson and spearman. Results: Result contained a relation between sex, physical and emotional abuse (p \ 0.05). A direct relation between age and neglect (p = 0.002) and also a direct relation between duration of disease and sexual abuse (p = 0.01), but there was a reverse relation between number of days of being Absent from school and neglect, physical abuse and total score of abuse (p \ 0.05). Also result showed that there was a significant relation between neglect and total score of being abused and father's addiction. Conclusion: Significant meaningful between demographic characters such as, sex, age and duration of children's illness with child abuse in one side and parent's drug addiction on the other side was found. This reveals that some cultural points in community gives an important role to chronic illness in children to prepare doing abuse. Background: A wide variety of factors are considered to contribute to the initiation of drug use. Among them parenting and early childhood experiences are thought to be particularly important.

Aims: This paper aims to report on the results of a qualitative inquiry that explored the early childhood experiences of current substance-dependent young adults in Tehran, Iran, and the roles of nurses in the field of addictions in settings such as Iran were assessed.

Design and methods: The study was qualitative in nature. Forty-four in-depth interviews were conducted with young men and women who were either in treatment for their addiction or were active drug users at the time of the interviews their parents and family members and nurses.

Results: The analysis of this study implicates traumatic childhood experiences, dysfunctional family dynamics, disconnect between parents and children, as well as parents' knowledge and attitudes about drug use and prevention as the determinants of initial drug use. Also analysis of interviews with nurses reveled categories like unfamiliar world of addiction and prejudgment. Conclusion: All determining factors identified by the participants of this study are within the scope of current nursing practice such as early childhood, community or school nursing, where there are great opportunities and unmet need for greater nursing involvement. Nurses who work with adolescents and families have a unique opportunity for prevention, early detection and timely intervention for drug dependency among at risk children. Significant newborn's weight loss may lead caregiver for offering other milk to complement feeding, plus breast milk, as intervention. If nurses identify predictors of weight loss, they can perform early interventions to prevent this. Objective: to evaluate factors related to weight loss of healthy newborns at a public teaching hospital, in Brazil. Methods: A cross-sectional study, with 455 mothers and their babies, at Rooming-in care. Descriptive analysis was performed, with the intersection of variables of interest, using Chi square and Fisher's Exact Test (significance level 5 %). Results: Newborns with birth weight loss over 10 and 8 % were 6.4 and 26.2 %, respectively. Majority of women were adult, multiparous, with partner, studied up to high school and presented at least one comorbidity related to lactogenesis II failure. Prevalence of induced labor and cesarean section was 43.7 %.

Have reported milk letdown within 48 h, 15.6 % of women; 47 % have had nipple trauma and 11 % used some device (silicone nipple or shell). The middle-weight of the neonates was 3,237 g (min. 2,151-4,520 g max); 37.4 % suffered some kind of tocotraumatism; 30 % were kept in skin-to-skin contact with mother and 15.1 % presented poor sucking. Variables with possible association with greater weight loss: number of deliveries (p \ 0.003), type of delivery (p \ 0.000), use of devices (p \ 0.029), birth trauma (p \ 0.018) and small for gestational age newborns (p \ 0.06).

Conclusions: Weight loss greater than expected may be related of delivery health care aspects, as well as maternal and newborn characteristics. Background: Behavioural responses to painful events are limited in preterm newborns. Physiological measures (HR, SpO 2 ) are commonly used. They have limited clinical use due to low specificity. Skin conductance (SC) can be used as a measure of neurophysiological arousal that follows activity in the sympathetic nervous system. For that SC can be used to evaluate reactions to pain. The aim of this study was to discover what is known about SC and how to value the measurement of SC in preterm's. Methods: A systematic review of the literature until January 2013 was performed. Skin conductance was used as MESH term and newborn: birth-1 month as limit.

Results: The search resulted in 37 hits; 20 not relevant, one concerned the technique of measurement, four described the feasibilities of measuring SC, three used a before-during-after design and nine compared de SC with other pain indicators. Most studies used observational cohort designs, the number of included newborns were small (N = 10-71) and age differed from 22 weeks to term. SC appeared to be sensitive, distinguished pain from tactile stimuli, term had higher SC values compared to preterm newborns and a maturing pattern was visible with aging. SC seemed objective, variability between individuals was minimal, and it was not influenced by circulatory changes, cardiovascular drugs, environmental temperature, or changes in respiratory rhythm.

Conclusions: SC seems a promising tool. It is more sensitive and specific to pain than other available methods. It is not yet fully error proof, it is simple and easily performed. In our Department about 1000 newborn infants are followed every year because of extreme prematurity, major malformations or peri-and post-natal severe complications. A specific field of our intervention is aimed to encourage breast feeding, kangaroo care and to reach good skills of mothers of these critical newborns. We have a specific area dedicated to breast collection and education of mothers in lactation and feeding (9200 accesses per year) managed by a nurse lactant consultant. During 2012 we discharged 700 patients, all of mothers have been educated before discharge; in particular the following activities (number of lessons) have been organized and performed: 615 on how to consider each breastfeeding, 420 on how to attach the baby to the breast, 220 on how to manage continuous or intermittent enteral feeding at home, 55 on kangaroo mother care, 220 on how to increase milk production, 35 on how to restart milking, 120 on how to store and utilize breast milk at home. Our project will continue following the infants through an outpatient nursing follow up completely dedicated to nutrition, breast milk and development. This program will interface with all the others outpatient clinic for these classes of newborns affected by severe neonatal, often chronic, diseases. Our experience show that not only healthy infant can and must be breastfed and that nurse lactant consultant may play a key role in helping mothers and improving baby-family link in patients with critical neonatal period experiencing life threatening events.

School of Therapeutic Sciences, University of the Witwatersrand, Johannesburg, South Africa

Background: Breastfeeding is the nutritional gold standard for at risk newborns. Not all newborns have access to breastmilk. Donor breast milk banks play a role in providing breast milk to those at risk neonates whose mothers are unable to provide them with adequate volumes of breast milk. Objectives: Understanding the motives of lactating women who donate breast milk to a milk bank may be useful in ensuring adequate volumes of donated breast milk are available for such neonates.

Methods: The study consisted of a non-experimental descriptive survey that utilized a self administered questionnaire, consisting of three parts. The Volunteer Functions Inventory (VFI) formed one part of the questionnaire. The VFI is a validated tool used to examine six possible motives for participating in any voluntary activities, such as donation of breast milk. Donors of breast milk to seven breast milk banks were invited to participate in the study. Sampling was purposive as donors were self selected. A total of 91 questionnaires were received. The VFI was marked in accordance with the marking sheet. Data is presented graphically using descriptive statistics.

Results: Six possible motives are listed in the VFI as to why women donate breast milk to a milk bank. These include the values motive, defined as donating breast milk in order to express altruism and show humanitarian concern for others. This motive scored highest by the majority of participants, indicating that women who donate breast milk to a milk bank do so out of concern for others. Objectives: The antibiotic prescription in intensive care units (ICUs) is frequent using often broad-spectrum antibiotics. The total antibiotic consumption is approximately ten fold greater in ICU wards than in general hospital wards. The aim of this study was to evaluate the current use of antibiotics in a pediatric ICU in Tunisia.

Methods: A prospective study for a 1 year period from November 2009 to October 2010 was conducted. Antibiotic prescription and patient records were reviewed and analyzed. Rationality of antibiotic usage was also evaluated by analyzing the drug prescriptions. Results: Of 768 patients admitted, 334 received antibiotic treatment during the study period (43.4 %), 27 cases (8.1 %) were due to nosocomial-acquired infections. Third-generation cephalosporins were the antibiotics most frequently prescribed (170/334, 50.9 %), followed by ampicillin (128/334, 38.3 %) imipenem (25/334, 7.5 %), fosfomycin/vancomycin (19/334, 5.7 %). Monotherapy represented 33.5 % of the prescriptions of antibiotics. Mean duration of antibiotherapy was 5.3 ± 3.6 h (1-39 h).The most common indication of antibiotherapy was community acquired respiratory infections. The empirical prescriptions were documented afterward in 67 % of cases. Eighty-two percent of the initial prescriptions seemed to be adapted to the identified or suspected bacteria. Conclusion: interventional programs based on rational antibiotic prescription and aiming to minimize unnecessary cost of antibiotherapy and emergence of bacterial resistance should be implemented in our clinical settings. 

Results: The mortality in this group of newborns with placenta praevia is 17.39 %. The gestational age of all deceased newborns is \33 weeks. During the first 12 h the percentage of deaths is 50 %, from 13 to 24 h 25 %, from 25 to 48 12.5 % and after 48 h 12.5 %. According to patho-histological analysis that were done on 100 % of the deceased newborns, 38.1 % from this risk group of newborns died from hyalinomembrane disease as the main cause of death, 14 % from intercranial hemorrhage. 42 % had as a main cause of death hyalinomembrane disease and intercranial hemorrhage, and 6 % fall in the group of rare other causes. The high percentage of death of these newborns is determined by maturity and adaptability of these newborns. Background and objective: Pulmonary agenesis is a very rare embryological defect (1 per 25,000-35,000 live births) defined as complete absence of bronchus, parenchyma, and vessels. Pulmonary agenesis is often associated with acute respiratory distress and high mortality usually o due to retention of bronchial secretions and inflammation.

Methods: We report one case of congenital right pulmonary agenesis with dextrocardia and compensatory hyperinflation of the opposite lung diagnosed antenatal (second trimester) during ultrasound examination and confirmed postnatal by chest X-ray, echocardiography, and CT examination. A 3,500 g male neonate with a gestational age of 38 weeks was born by cesarean section to a 39-year-old woman whose pregnancy was complicated with oligohydramnios. The mother had a previous pregnancy history of fetal death with cardiac defects and Down syndrome. The mother did not use any drugs during her pregnancy. Results: Postnatal clinical examination and radiographic examinations confirmed the prenatal diagnosis of isolated unilateral rightsided pulmonary agenesis with dextrocardia. A neonatal chest X-ray showed complete opacification of the right hemithorax with ipsilateral mediastinal displacement toward the agenetic lung, hyperexpansion of the left lung and dextrocardia. An echocardiographic and CT examination revealed right pulmonary agenesis with hypoplasia of the right pulmonary artery and dextrocardia. The infant was discharged on day 5 in good clinical condition. The authors proposed identification of postnatal growth differences rate in prematures under 32 weeks gestational age depending on the type of nutrition. Methods: The lot included 30 prematures with a birth weight of 550-1,500 g, delivered under 32 weeks. Daily measurements of body weight, proteins and calories provided by enteral nutrition were made and also serial metabolic blood analysis, weekly: glucose, urea, creatinine, electrolytes, proteins, blood and stool cultures. The postnatal age when enteral feeding was started, clinical status, mechanical ventilation support were noted. The enteral feeding was monitorized-gastric residue, regurgitations, vomiting and stools depending on nutrition type. Collected data were processed by SPSS. Results: Weight gain was observed after increasing calories and proteins intake. Formula feeding was associated with stationary weight curve. Growth gain was observed when increasing the caloric and proteic intake by enrichment of the breast milk with fortifiants.

The values of the weight curve at discharge are situated between percentiles 10-25 %.

1. Prematures under 32 weeks and under 1,500 g, remained a challenge of nutritional prescription, the purpose of every neonatologist being to avoid the postnatal growth restriction. 2. Enteral nutrition with breast milk alone is a gold standard for obtaining a healthy growth and development.

3. Breast milk fortifiers induce an accelerate growth similar to intrauterine gain, 10 g/24 h, removing RCIU risk. 4. The formula an alternative for avoiding the risk of postnatal growth restriction. 5. The continuous growth gain has the advantage of shortening hospitalisation, costs, complications. Introduction: Oxygen supplementation is frequently needed during newborn care. Pulse oximetry is a convenient method of monitoring oxygen (SpO 2 ). But partial pressure of oxygen in arterial blood (PaO 2 ) is considered to be the gold standard. Work on SpO 2 and PaO 2 on Bangladeshi neonate is lacking.

Objectives: Was to examine SpO 2 and PaO 2 values on hospitalized neonates and to observe normal SpO 2 values in relation to PaO 2 values.

Methodology: This was a cross sectional analytical study, carried out in BSMMU, Dhaka over a period of 1 year. Here, 140 hospitalized neonates were included. Pulse oximetry oxygen saturation readings (SpO 2 ) were taken on neonates. Blood samples from radial artery for partial pressure of oxygen (PaO 2 ) were taken during monitoring of SpO 2 from those neonates where consent for blood sampling was available.

Results: The mean SpO 2 reading was 94.3 ± 3.3 %. Simultaneous mean PaO 2 value was observed to be 121.6 ± 77 mmHg. Correlation was observed between PaO 2 and SpO 2 (r = 0.598) readings. It was observed that when PaO 2 value was [100 mmHg, the observed mean SpO 2 value was (97.3 ± 1.3) %. When the mean SpO 2 readings were 94.8 ± 4.3 and 92.8 ± 2.6 %, the observed PaO 2 values were 100-80 and 80-50 mmHg, respectively. If PaO 2 value was \50 mmHg, the observed mean SpO 2 value was 85.5 ± 2.8 %. It was seen that SpO 2 at 94 and 87 % were the cut-off values to screen hyperoxic and hypoxic neonates, respectively. Conclusion: The study concluded that SpO 2 readings between 87 and 94 % should be maintained to have normal PaO 2 value on neonate. Background and aims: HFOV is used when conventional ventilation is failing to provide respiratory support for neonates. Pressure amplitude (DP) is set by visually assessing the chest wall oscillations (chest wiggle). This measurement is subjective and can be difficult to assess clinically. The aim of this study was to develop a device and software that could quantify chest wiggle. Methods: A custom built device with analysis software was developed to non-invasively measure chest wiggle in real-time. A resuscitation mannequin with the device attached was ventilated with HFOV. HFOV frequency and MAP remained unchanged. Clinical staff experienced with HFOV (EXP) were blinded to the DP settings and the devices output and were asked to identify when ''adequate'' chest wiggle (CWa) occurred. The devices output and DP were recorded. The device output at CWa was determined. A ''No clinical HFOV experience'' group (N-EXP) were then shown a graphical representation of the devices output at CWa. N-EXP, blinded to the DP and the chest wiggle, used the graphical representation to determine CWa. DP and the devices output were then recorded. Results: 22 EXP and 7N-EXP each undertook three trials. EXP mean DP at CWa by observation was 44 cmH 2 O (9.4) and N-EXP mean DP at CWa by graphical representation was 41 cmH 2 O (7.4) (p = 0.21).

Conclusions: The custom built device and software successfully monitored the HFOV chest wiggle on a mannequin. It was also demonstrated that the device could be used to successfully gauge CWa. The Tracheal Team at Great Ormond Street Hospital is a unique service and the patients under our care will require a well prepared admission to an intensive care area due to the complexity and rarity of the disease. Currently there is limited availability of paediatric intensive care (PICU) beds in the United Kingdom (UK) due to service competition for beds, as well as reduced availability of paediatric intensive care nurses and a lack of access to highly skilled medical doctors due to current European Working Time Directives. As a small specialist team functioning within a quaternary hospital we are continually required to look at new ways of delivering PICU care. One of these approaches is through developing autonomous intensive care nursing practice using the advanced skill model. The tracheal clinical nurse specialist (CNS), who has extensive intensive care experience, uses a combination of communication, service knowledge and advanced skills (to Masters level) to keep the use of PICU beds to a safe minimum whilst still maintaining high quality care (supported by PREMS). Areas of advanced nurse practice include triaging PICU patients from national and international destinations, expert communication with referrers, requesting investigations such as bronchoscopies and bronchograms, nurse led ward round and decision making, new prescriptions and medication modifications, leading discharge planning, ongoing communication and treatment plans, audit and data collection. If this model continues to optimize the access and use of PICU beds for a patient group this model of Advanced Nursing Practice should continue to develop further. Objectives: This study aimed to assess the impact of heat and ultraviolet exposures on the final amount of vancomycin delivered to the patient in neonatal intensive care unit (NICU). Methods: We performed the study according to the NICU administration conditions. The infusion lines passed through an incubator thermostated at 33°C and also irradiated with a neonatal phototherapy lamp. Vancomycin syringes (40 mg in 14.4 mL) were infused at 0.3 mL/h over a 24-h period (n = 9). The same tests were replicated at the room temperature (20°C) and ambient light. For both tests, two types of infusion lines were tested:

(1) opaque infusion lines in polyvinyl chloride (Ø = 1.5 9 3.0 mm, L = 150 cm, Vol = 3.10 mL),

(2) non-opaque infusion lines in polyethylene (Ø = 1.0 9 2.0 mm, L = 150 cm, Vol = 1.5 mL). Vancomycin amounts were measured at the outlet of lines by an UV spectrophotometric method. A Mann-Whitney 0 s test was used to S136 Intensive Care Med (2013) 39 (Suppl 1):S1-S200 compare the vancomycin amounts at the outlet of the opaque and nonopaque lines.

Results: Our results expressed as median values [min-max] in milligrams showed a significant difference between the two types of infusion lines for the two infusion conditions. Background and aims: Mechanical ventilation is one of the most common indications for children to be admitted to the pediatric intensive care unit (PICU). In adults it has been shown that patient-ventilator asynchrony (PVA) occurs frequently and is associated with increased morbidity. To date, PVA in children has little been studied. The aim of this study was to test the hypothesis that PVA in mechanically ventilated children occurs frequently but is less prominent during the weaning phase.

Methods: All mechanically ventilated children aged 0-18 years who initiated and maintained spontaneous breathing were eligible for inclusion. Excluded where patients with nervous system and neuromuscular disorders. Patient-ventilator asynchrony was identified by a random 15-min continuous recording and off-line analysis of the pressure-time and flow-time waveforms using Ventview 2 (Dräger, Lubeck, Germany). Patient-ventilator asynchrony was categorized and labeled into four different groups: (1) trigger asynchrony, (2) flow asynchrony, (3) termination asynchrony and (4) expiratory asynchrony. Baseline demographic and clinical data were recorded. Data were expressed as mean ± standard deviation (SD), or percentage (%) of total. Results: So far, N = 8 patients have been included. The total number of studied breaths was N = 5,621. PVA occurred in 27 % of all breaths during the acute phase, and in 19 % of all breaths during the weaning phase.

The preliminary results of our study suggest that the prevalence of PVA during paediatric mechanical ventilation may be similar between the acute and weaning phase. This abstract of an interesting case is presented due to its rarity and potential complications of missing a timely diagnosis. A term female infant weighing 3.77 kg born by LSCS for pathological CTG was admitted at 40 h of age, due to presence of blood in the nappy. Her mother was on Aspirin during pregnancy for high BMI and h/o three spontaneous miscarriages. Baby had a palpable left flank mass, macroscopic and microscopic haematuria and thrombocytopenia (platelet count 41) on admission. She was started on IV fluids for probable renal vein thrombosis. Renal ultrasound 12 h later showed enlarged left kidney with loss of cortico-medullary differentiation. IV fluids were discontinued after 24 h and hydration maintained by breast and top up feeds. Platelet count normalized and gross haematuria resolved within 48 h. Repeat ultrasound after 3 days showed improving but unresolved renal changes. Her blood pressure and renal function tests remained within normal range. Relevant thrombophilia screen was negative for Factor V Leiden mutation and anti phospholipid antibody. Repeat ultrasound after 3 weeks showed normal kidney with signs of full recovery. She is for long term follow up and assessment of protein C and S at a later stage.

Renal vein thrombosis accounts for 10 %of neonatal thrombosis and is associated with morbidity and mortality. RVT typically presents with one of the cardinal features; flank mass, haematuria or thrombocytopenia. Our child had all the three features and ultrasound findings suggestive of RVT with signs of full recovery at 3 weeks. Background: Neonatal postoperative pain management often is not yet sufficient. A standardised postoperative pain management was implemented for the NICU using an escalation scheme. Aim: To identify side effects when using metamizol in postoperative pain management for neonates. Methods: ''Off-label-use'' was discussed with the parents, written consent was given. 70 neonates (ranging from 22 6/7 to 41 4/7 weeks of gestation), were operated between 1st day of life and 3 months, weighing 470-9,900 g (median 2,712 g) between 1/2010 and 12/2012. Surgery included laparotomy, craniotomy and ductus ligation. The neonatal infant pain score (NIPS) was used to assess pain. Postoperatively, all children were given metamizol (40 mg/kg per day) or a combination of metamizol/morphine (40/0.1 mg/kg/day) for 3 days or until pain score was negative. Side effects such as hypotension (necessity of inotropes) or changes in blood, count were compared preoperatively with postoperative measurements at day 1, 3 and 7.

Vomiting and constipation were registered, both being common postoperative complications and difficult to verify after abdominal surgery. Results: 54 children only had metamizol, 10 morphine and 4 a combination of metamizol/morphine. All infants had increased postoperative NIPS (Mean 1.34-1.43 at day 1), reduced to 0.49 at day 7. Medication was given mean 3.42 days. None showed negative side effects, compared to preoperative measurements. Blood glucose concentrations and electrolytes were stable. Conclusion: The postoperative use of metamizol in preterm infants and term neonates seems to be feasible regarding short-term complications. Further studies need to identify possible long-term effects. Results: The incidence of paediatric chronic kidney disease native to Hanoi City was estimated to be 5.1 per million-child population (pmcp). Median age was 11.29 years; 60.5 % were boys and 39.5 % were girls; 65 % of patients were in end-stage renal disease. Cause of chronic kidney disease included glomerulonephritis (66.4 %) and congenital/ hereditary anomalies (13 %). In 19.8 % of children, the aetiology was unavailable. During hospitalization, 5 patients died and 76 patients (50 %) refused the treatment although beneficiary of health insurance. Thirty patients (19.74 %) received peritoneal dialysis and hemodialysis, seven patients received renal transplantation with a familial living donor. Conclusion: Late referral and limited facilities for renal replacement therapy explain the poor outcome in this study. We need a program to delineate the burden of chronic kidney disease and improve primary health care for health promotion and prevention of paediatric chronic kidney disease. Immunosuppressive (IS) therapy in transplantation is mainly empiric. Over immunosuppression leads to side effects, especially virus proliferation.

Objective: EBV and BKV PCR monitoring experience in kidney transplantation in Pediatrics Hospital in Toulouse France. Methods: We report 12 children, out of 70 successive kidney transplantation, who experienced prolonged positive blood PCR test for 7 EBV (4 reactivation, 3 primary infection) and 5 BK virus (3 proven BKV nephropathy) undergoing classical triple IS therapy (steroid/ AZA or MMF/CsA or FK). In these patients we prospectively decided to decrease the drug dosage, first anti metabolite and second anticalcineurin, until a negative PCR test was obtained.

Results: The lowering of the IS drugs allowed to negative clinical virus symptoms and PCR test in all of the patients without any rejection (follow up from 1 to 5 years) and lymphoma. The drug dosage was continuously adapted to the level of PCR test and today four patients remain free of anticalcineurin, and one of them had only low dose of steroid, eight continue triple therapy with half dosage of AZA or MMF and low level of anticalcineurin trough level in sera (CsA 60-70 ng/ml, FK 3-5 mg/l). Conclusion: Routinely virus detection is mandatory in transplantation. An EBV or BK virus blood PCR positive test is a sign of over IS and allows to decrease the IS regimen with no risk of rejection and to cure the viral disease and avoid EBV B lymphoma that we had previously experienced. Background: A method of MV is continuous positive airway pressure (CPAP) especially for neonates is Nasal CPAP in which surfactant is administered to them via tracheal instillation. The aim of present study was comparing nasal continuous positive airway pressure NCPAP therapy with and without prophylactic surfactant in preterm neonates. Patients and methods: This is a randomized clinical trial study performed on 80 newborns (28-34 weeks) whom were born in Aliebne-Abitaleb hospital affiliated to Zahedan University of Medical Sciences. Subjects were randomly classified in two groups. The data collected through direct observation and 14 purposeful items by researcher. Both groups received surfactant (Curosurf, Parma, Italy) at 100 mg/kg/24 h or 4 ml/kg/24 h with NCPAP and NCPAP alone.

Results: Results revealed that six neonates who received only NCPAP and four patients who received NCPAP and surfactant underwent MV. After a week follow up, 33 neonates who received only NCPAP and 36 patients who received CPAP and prophylactic surfactant remained alive. There was no significant difference between the groups regarding adverse outcomes (P = 0.518).

Conclusions: According to the results of this study, NCPAP is indictable as a safe protocol for RDS in preterm neonates. Further research is required to clarify and validate our findings. Obstetrics & Gynecology, Guilan University of Medical Sciences/ Alzahra Hospital, Rasht, Iran

Objective: Recent data suggest that during mechanical ventilation, lateral patient position (in which the endotracheal tube is horizontal) decreases the incidence of bacterial colonization of ventilated neonates. The objective of this study was to evaluate the influence of lateral and supine position on bacterial colonization of endotracheal tube in neonates.

We conducted a prospective, randomized, clinical trial with 31 intubated neonates (intubated within 48 h after birth); 16 neonates were positioned supine (supine group), and 15 were maintained in the lateral position (lateral group).Tracheal aspirates were cultured in second and fifth days of mechanical ventilation. Data were analyzed with SPSS version 16.

Results: In the 2nd day of ventilation, positive cultures were recognized in 6.2 % of supine group and 6.7 % of lateral group. After 5 days, tracheal cultures were positive in 25 % (4 neonates) of supine group and 13.3 % (2 neonates) of lateral group that was not statistically significant (P = 0.9 in second day and P = 0.9 in the fifth day). The most common organisms isolated from tracheal aspirates were Gram-negative rods (Klebsiella). Conclusion: Since respiratory contamination is very common among ventilated neonates and the effect of lateral position on bacterial colonization of endotracheal tubes of intubated neonates was not established in our study, further studies are required to suggest ways to decrease bacterial colonization of intubated neonates. Background: Excessive auditory stimulation is well-known to cause stress response in premature infants. An exposure to continuous and loud noise is also associated with hearing loss of premature infants with the immature auditory system. Objective: The purpose of this study is to investigate short and long term effects of a noise recognition educational program (NREP) on noise levels in the NICU. Design/methods: To decrease noise level in NICU environment, we provided NREP with all nurses and nurse aids working in the NICU for 2 weeks. The hourly average noise levels in decibels (dB) was measured 2 days and 2 weeks after education for short term effect and 1 year after education for long-term effect.

Results: Mean noise-levels before education was 66.8(±2.94) dB. The mean noise level decreased to 61.5(±0.55) dB in 2 days(p \ 0.001), and 61.3(±0.95) dB in 2 weeks after education (p \ 0.001). There was no difference in noise levels between 2 days and 2 weeks (p = 0.010). One year after education, the noise levels slightly increased to 64.25(±1.09) dB compared with the noise level on 2 weeks after education(p \ 0.001), but the noise level measured 1 year after education was still lower than mean noise-level before education (p \ 0.001).

Conclusion: Noise recognition educational program is found to assist to reduce noise levels about 8.2 % for short term and 3.9 % for long term. Education effect lasted for 1 year (p \ 0.001). We suggest that a regular periodic monitoring and education for nurses may be required to reduce the noise level in NICU. Aim: To quantify the impact of two different methods of manipulating PEEP on EEL and regional gas distribution as measured by electrical impedance tomography (EIT). Method: A randomised crossover clinical trial in 60 intubated and mechanically ventilated children in a PICU. Forty children underwent two methods of lung recruitment following endotracheal suctioning: a double baseline PEEP manoeuvre-held for 2 min and an incremental PEEP manoeuvre, each step held for 1 min. Twenty children acted as controls. EIT measurements to quantify EEL were taken at baseline and at 15 min intervals throughout the study period.

Results: The Double PEEP manoeuvre showed significant and sustained improvement in global EEL from baseline up to 120 min (P \ 0.01 ANOVA ). Global EEL did not change with the Incremental PEEP manoeuvre or in the control group. The Double PEEP manoeuvre also demonstrated preferential ventilation distribution towards the dependent regions of the lung (P = 0.03 ANOVA ). Nil adverse events were observed. Conclusion: Significant increases in EEL were achieved globally with a simple Double PEEP manoeuvre. Distribution of ventilation in dependent regions also increased, suggesting genuine alveolar recruitment that was sustained for up to 120 min. Background: Corneal abrasion is a concern for all children who are deeply sedated or receiving neuromuscular blocking agents whilst being ventilated. It is possible that the risks are increased during the transport process due the increased frequency of patient intervention and patient movement during this time. A variation in practice has been observed in corneal abrasion prevention strategies within Embrace Transport Service*. There are no guidelines within this area of practice. Objectives: To establish the incidence and type of corneal abrasion strategy use within critical care transport. Provide evidence for the formation of guidelines. Method: All Embrace medical and nursing staff were given a questionnaire to complete consisting of 10 questions.

Results: There were 39 replies (100 % response rate). 97 % of staff can list corneal abrasion strategies, but currently only 3 % consider it for neonates and 18 % consider it for children they transfer ventilated.

For both neonates and paediatrics six different varieties of eye protection are currently used including passive closure, no eye protection, Geliperm, lacrilube, tape and eye drops. No consultants or medical trainees had received education on corneal abrasion prevention. Conclusions: Inadequate eye protection is used in both neonatal and paediatric transport. Guidelines are required for consistency. Education and training is required within this area. *Embrace is Yorkshire and Humber Infant and Children's Transport Service. Knowledge and experience of participants on preparatory activity prior to open-system suctioning varied: half of them carried out the appropriate hand hygiene, however, all subjects used gloves prior to suctioning; None of them performed newborns' chest auscultation in practice to comprehend pulmonary assessment; Majority of them performed preoxygenisation prior to the suctioning process, but mistakes occurred in using higher oxygen value than prescribed in current research recommendations. Most participants chose appropriately sized catheter for the size of endotracheal tube. Most participants used saline prior to suctioning; completed the procedure in 15 s and made up to three passes per episode to remove tracheal secretions. Observation revealed that all participants started the suctioning process when the catheter felt resistance and, according to questionnaire, knew to advance the catheter to the carina and withdraw it 1 cm before applying suction. All used negative pressure only in withdrawing catheter from the endotracheal tube. After suctioning no nurse performed newborns' chest auscultation to assess the efficacy of the suctioning. Almost all assessed newborns' cardiopulmonary status before, during and after the endotracheal suctioning procedure; increased FiO 2 levels to pre-suctioning value after the stabilization of newborns' cardiopulmonary status.

Objectives: Nurse led weaning and extubation is established on our PICU with 40 nurses having completed comprehensive training. Nevertheless, there is a perception that it is underutilized. The process is being reviewed to identify problems with the process and barriers to greater implementation. As part of this review we carried out a survey of medical staff perceptions on our PICU. Methods: An electronic survey consisting of open and close ended questions was sent to our medical staff. Results: The response rate was 46 % with responses from PIC consultants (n = 5), speciality trainees (n = 3), registrars (n = 5) and advanced nurse practitioners (n = 4). Median experience on PICU was 3.5 years (range 1 month-25 years). All respondents were aware of the process. Only 2/17 (12 %) expressed concern-relating specifically to extubation. Most (15/16 (94 %)) stated that ventilator duration might be reduced by more nurse led weaning. Several important qualitative themes emerged. Nurses qualified to wean were infrequently identified at the start of shift. Low awareness often results in difficulty in encouraging and supporting the processsuggestions including greater nursing and medical proactivity and implementing organisational changes. Other themes were-the protocol itself is too restrictive and that partnership/communication during the process is vital.

Conclusions: Medical staff view nurse led weaning positively but identified that the process, communication and partnership could be improved. Together with a similar survey of nursing staff, we hope to improve the process for all involved. We hope that this will result in improved patient care. Background and aims: Congenital diaphragmatic hernia (CDH) is an anatomical defect of the diaphragm, frequently associated with significant pulmonary complications and mortality, due to protrusion of abdominal viscera into the chest cavity. We aim to describe the case of a 38-week-old female child with prenatal diagnosis of left-sided CDH with hypoplastic left lung and pulmonary hypertension. High frequency oscillatory ventilation and inhaled nitric oxide were started at birth, but she maintained persistent hypoxemia. By the 12-h of life, she was started on veno-arterial extracorporeal membrane oxygenation (ECMO-VA) and transferred to Paediatric Intensive Care Unit (PICU). On day-4 she underwent CDH repair surgery. On day-12 she was submitted to thoracotomy because of thoracic hematoma. ECMO was delivered for 27 days, two circuit changes were necessary due to coagulopathy issues. Nurses maintained closed monitoring with checklist verification at least every 2 h to assure that the extracorporeal technique was uneventfully.

The child left the PICU after 2 months and 12 days, with non-invasive ventilation support and a normal neurological status. Method: Analyse the importance of nursing interventions in ECMO through a case study format.

Conclusion: This case demanded for a highly skilled multidisciplinary team. Nurses, on their on, have very important roles in different steps of the treatment, from the ECMO cannulation to the systematic evaluation of the newborn's overall condition, the treatment and the life support efficiency. Moreover, nursing interventions are directed to promote the child's rest and well-being in a safe environment, allowing time for healing. The application of protocols in a Paediatric Intensive Care Unit (PICU) improves the critical care and promotes a better outcome in different areas of interventions. The aims of these protocols are to define a set of procedures that, when implemented together and involving the multidisciplinary team, can further enhance patient care. In our PICU we are currently implementing three new performance protocols, namely Enteral Feeding, Pain Management and Fever Management. The first one provides a focused approach to reach children's individual nutritional needs according to their clinical condition and to allow greater autonomy for professionals in order to achieve nutritional objectives in a more effective way. The second one aims a faster and more efficient pharmacological intervention towards pain according to the score determined by the different scales evaluation. The last one was implemented to better treat fever according to the specific disease, recognizing that in some cases higher temperatures can have a protective role, while in other cases it should be aggressively treated. In the future we want to assess how these protocols can change our daily practice. Identify the main benefits of protocol implementation in our PICU. Using guidelines and evidence-based interventions to design unit protocols. Based in scientific knowledge, on bundles research and in our practice results, three protocols were developed in our PICU in order to standardize the procedures in enteral feeding and in pain and fever management. The success of this implementation relies on the effort of all the health professionals. Background and aims: The International Association for the Study of Pain (IASP) defines pain as ''an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.'' Whether acute or chronic pain, health professionals should be aware that this induces unbearable suffering that reflects negatively in the child's welfare. Its treatment is, therefore, clinically and ethically required. Given the importance of an effective pharmacological intervention towards pain in a Paediatric Intensive Care Unit (PICU) setting, pain management guidelines were developed by a multidisciplinary team of paediatric intensive care professionals and are being implemented since December 2012. It is our purpose to reduce the incidence and severity of pain in all paediatric patients admitted in the PICU. Methods: The guidelines are based on both behavioral and self report evaluation of pain using different scales according to the child's age, development and clinical status. Such instruments allow the record of a pain score as the fifth vital sign, supplemented by its subjective characterization, pharmacological and non-pharmacological interventions undertaken and their effectiveness.

Results: Based on the resulting score, the nurse is free to change the prescribed analgesic therapy infusion within a pre-established range.

Conclusion: With the implementation of these guidelines we hope to achieve a faster and more efficient pain management as it focus on a systematic and reproducible evaluation process. Obstetrics and Gynaecology, Aberdeen Royal Infirmary, Aberdeen, UK Introduction: Preterm prelabour rupture of membranes (PPROM) before 24 weeks complicates \1 %of pregnancies. This study was conducted to identify risk factors that predispose to PPROM, the survival rates, short term outcomes and complications in neonates.

Methods: A retrospective case note review of all singleton pregnancies complicated by PPROM between 15 + 2 and 24 + 0 weeks of gestation between Jan 2008 and Nov 2012.

Results: A total of 32 cases were identified. The median gestation at PPROM was 21 weeks. Six patients opted for termination of pregnancy. Of the 18 live births, all received antibiotics and most (83 %) received a full course of steroids. Three patients received only one dose of steroids. 61 % had spontaneous vaginal delivery. The average gestation at birth was 26 + 4 weeks. Mean interval from PPROM to delivery was 35 days. All of the 18 babies suffered from RDS at birth. Of the 12 survivors to discharge, 64 % had chronic lung disease, 25 % developed seizures and 20 % had a significant intracerebral bleed. Only 2 patients went home with no co-morbidities. Discussion: Preterm previable rupture of membranes is associated with high perinatal morbidity and mortality. Survival is more directly related to the timing of delivery, than the specific gestation of PPROM, providing PPROM occurs beyond 18 weeks gestation. Multidisciplinary counselling is essential so that patients can make informed decisions regarding their pregnancies. Reference: 1. Azria E et al (2012) Comparison of perinatal outcome after previable preterm prelabour rupture of membranes in two centres with different rates of termination of pregnancy. BJOG 119:449-457.

Pediatrics, Mashhad University of Medical Sciences, Mashhad, Iran Introduction: Male circumcision practice is an invasive procedure that is using worldwide. It makes challenges to haemostatic system and its possible haemorrhagic side effects are more serious in bleeding individuals than normal subjects. Aim: We aim to documentation type of coagulation therapy and post circumcision practice haemorrhagic presentation among 463 bleeder males of both common and rare bleeding disorders in north eastern part of country.

Methods: We retrospectively gathered information using evaluation medical records in three major hospitals during last 15 years and list of patients with bleeding disorders that obtained from haemophilia center. Also a call phone established for each bleeder person to complete data and updating of them. The survey took time from September 2009 to March 2011. The designed question form included data on doing circumcision or not, types of treatment before and post the procedure and occurrence of bleeding episodes after the surgery.

Results: Overall among 424 cases with various common and rare bleeding disorders who had circumcised, 239 cases (56.3 %) had passed the procedure with bleeding experience (indication of undiagnosed cases who underwent circumcision or inadequacy of coagulation therapy), while 185 cases (43.7 %) had passed it successfully and without noticeable bleeding experience. The types of coagulation therapy in each group have been cited.

Conclusion: The circumcision practice in unequipped medical center for bleeder ones may make challenges for them and medical services. Also it needed supervision of expert haematologist for adjusting treatment to ensure control of unwanted bleeding. Background and aims: Government policy and research evidence supports the suggestion that to maintain ICU skills and competency, nursing staff must care for a sufficient number of children needing level 2 care or above (DH 1997 , Reddish & Kaplan 2007 . The aim of this study was to investigate the exposure of senior PICU nurses to this group of patients and other role in a tertiary level PICU. Methods: Routinely collected nurse allocation data from the paediatric intensive care unit (PICU) at the Evelina London Children's Hospital was retrospectively analysed for two time periods in 2005 and 2010. The frequency the roles: In-charge Nurse, Cardiac Bay Coordinator, Retrieval Nurse, Looking after level 2 and level 3 patients, were undertaken by each Senior Staff Nurses and Sisters were specifically studied.

Findings: The analysis exposed inconsistencies in nursing exposure to different roles. While this exposure improved in 2010 this did not reach statistical significance (p = 0.42). Notably the most senior nurses had reduced exposure to some roles, particularly caring for patients with increased acuity levels (2 % of allocations).

Conclusions: The inconsistency in role exposure has highlighted the need for greater consideration of roles undertaken by staff in performance management. Presentation of role exposure has become a routine part of the annual appraisal and review process. It is hoped that this will result in staff having a greater awareness of their practice. Objectives:

(1) To explore attitude and beliefs of neonatal clinicians toward nursing care for dying neonates;

(2) To estimate the influence of neonatal clinicians' personal and professional characteristics on their attitudes towards end-of life care for dying infants;

(3) To compare the attitudes and beliefs of neonatologists and nurses towards providing end-of-care for dying neonates. Design: A cross-sectional design was used. A questionnaire was used to collect data from 103 neonatal clinicians in neonatal intensive care units (NICU).

Research results: A total of 24 physicians and 79 neonatal nurses were recruited from three level III NICUs at three medical centers.

Research findings identified nine barriers hindering neonatal palliative care practice. 68 % participants agreed their personal attitudes about death affected their willingness to deliver palliative care (n = 71). Nurses more often than physicians agreed that staff go beyond what they feel comfortable with in using technological life support (Z = -2.017, p = 0.044). Compared with nurses, physicians slightly more often noted the lack of in-service education for offering support and communicating with parents of dying babies (Z = -1.956, p = 0.05).

Research also found that cultural issues and religion were considered important by the majority of respondents in their effect on the neonatal clinicians' attitudes and beliefs towards caring for dying infants.

Conclusion: Further studies are needed to explore each barrier and to provide the in-service neonatal palliative care educational programs that are needed to decrease these barriers. Object: The research aims are to explore the energy expenditure in a group of preterm infants during the periods of environmental stress and to explore the relationship between energy expenditure and physiological signals of preterm infants. Methods: Research design was an explorative secondary analysis research data from 37 preterm infants which included physiological signals and environmental stressors in neonatal intensive care units. The current study investigated the data of energy expenditure calculated using the heart-beats of preterm infants during the periods of environmental stress.

Results: A significant positive relationship between energy expenditure and different levels of nursing intervention was found (intervention 2, p = 0.011; intervention 3, p \ 0.0001; intervention 4, p \ 0.000; intervention 5, p = 0.016). The energy expenditures for different levels of nursing interventions were higher than for no intervention status, after adjusting for the effects of other factors. In addition, there was a significantly negative relationship between energy expenditure and oxygen saturation (p \ 0.001), after adjusting for the effects of time, incubator noise, and light. Conclusion: These research results confirmed that environmental stressors may impact the outcomes of growth and developmental outcomes in preterm infants by increasing their energy expenditure. Neonatal clinicians should minimize the environmental stressors in NICUs for decreasing the energy expenditure in preterm infants. Objective: The purpose of this study was to explore neonatal nurses' experiences caring for dying neonates and their educational backgrounds regarding the palliative care, and to assess their educational needs of neonatal nurses regarding the neonatal palliative care. Methods: A cross-sectional survey was used for this research. A research structural questionnaire was used to investigate different the different research goals. Results: Research participants were 115 nurses in this survey. Few participants indicated having received neonatal palliative care education (13 %). Most participants responded that palliative care is necessary in neonatal nursing education (97.4 %). Participants responded that they were often or always exposed to death in NICU (62.6 %). However, few participants reported that they provided pain management to dying neonates (8.7 %) and also had few experiences on providing symptomatic care for dying neonates (19.1 %). fifty percent ranked ''pain control'' as the area in which they most require neonatal palliative care training. Another highly-ranked item was the discussion with parents and families about the outcomes of CPR and their neonate's progress.

Research results indicate that the education provided to neonatal nurses did not meet their distinctive needs. Neonatal nurses in Taiwan expressed an urgent desire for training in pain control and communication. Research results suggest that the most important topics to trainees are pain management and end-of-life communication; additionally, non-pharmacologic pain control interventions may be important to learn and should be included in an educational program. Background and aims: Newborn in the NICUs undergo painful and stressful procedures and pain experienced during the neonatal period may lead to negative outcomes, especially in preterm neonates. Many studies have shown that pain induced by these procedures is not effectively prevented or is inadequately treated. The purpose of our study was identify the current medical and nursing practices in the assessment, management and treatment of procedural pain in premature newborn in same Italian NICUs. Methods: A 35-item self report questionnaire was sent to 75 NICUs in Italy from October 2010 to October 2011. The main sections of the questionnaire were the following: information about hospital, assessment, management and treatment of pain. Frequency distribution, average value, median and range were computed.

Results: A total of 22 NICU (29 %) responded to the questionnaire. Data showed that the systematic evaluation of pain in premature newborn is still limited, non-pharmacological techniques are more prevalent than previous studies, but the use of kangaroo position and participation of parents are still not widespread, the use of analgesia and sedation is still rather low. Conclusions: Hospitals should promote new policies and improve pain protocols in premature newborn with non-pharmacologic pain management techniques as the saturation sensory, non-nutritive sucking, breast-feeding or Kangaroo Mother Care. Furthermore the pharmacological treatment for pain by procedure should ensure both a sedation that effective analgesia, and nurses should always apply strategies such minimal touch, gentle handing, wrapping.

Binghamton University, Oxford, NY, USA

In 2008 a survey was conducted among obstetricians and neonatologists in administrative roles in New York City maternity hospitals that have neonatal intensive care units. The survey compared the physicians' definitions of live birth and fetal death, the gestational age at which they consider infants viable, their resuscitation practices for infants born at \28 weeks gestation and their practices for extremely premature labor and delivery. This study uses the result of the 2008 survey and specified variables from the linked live birth/infant death data sets for 2007-2009 from New York City Department of Health and Mental Hygiene to examine the impact of physicians' live birth definitions on the infant mortality rate in New York City maternity hospitals. Hospitals whose neonatologists report that they follow the New York City reporting requirement and report all live births regardless of gestational age had mortality rate for infants born at \23 weeks gestation that was six times that of hospitals whose neonatologists reported that they include gestational age as part of their live birth criteria and as a result do not follow the New York City reporting requirement. This study highlights the impact of the gap between clinical practices and reporting requirements for live birth. Whereas reporting requirements are based on definitions of live birth and fetal death, physicians make resuscitation and other clinical decisions regarding extremely premature infants based on definitions of viability and these resuscitation practices can impact infant mortality data. Objectives: This study answered the question which occupational needs nurses have in the working relationship with the unit management on the Neonatal Intensive Care Unit (NICU), of the Emma Children's Hospital (ECH). Answering this question will be the first step for the unit management to reduce the distance and estrangement that now exists within the work relationship with the nurses. Methods: Focus group interviews (12 participants), personal interviews (12 participants) and a questionnaire among 100 nurses (82 % response) led to the composition of a top ten work-related needs.

Results: This study revealed that the unit management hardly meets the occupational needs of nurses within the work relationship. The main needs are clustered around the themes 'focus on the individual', 'focus on employability' and 'focus on communication' and serve as a basis for unit policy.

Conclusion: Based on this study the unit management should take the responsibility to meet the needs of the nurses by focusing on duty roster, a shared vision and an age-conscious human resource policy. On the other hand the unit management should point out the nurses own responsibility and the importance of a proactive attitude. An open discussion with the nurses, based on the revealed needs and awareness of interdependence, is an important first step. Not only to reduce the distance but also to restore the individual contact and thereby improving the team development and spirit.

N. Sajjadian 1 , R. Jahadi 2 , N. Sajjadian 1 1 Pediatric, Tehran University of Medical Sciences, 2 Surgery, Hormozgan University of Medical Sciences, Tehran, Iran

Hyperbilirubinemia is a common problem during neonatal period especially for preterms. Transcutaneous bilirubin measurement (TCB) by special devices had been documented as an effective tool for predicting neonatal jaundice in full term neonate, but for preterm infant the present evidences are controversial. We carried out a prospective study in Shariati Hospital NICU. 126 paired TCB/TSB measurements were obtained.TCB (on forehead and sternum) were obtained by JH2-1A device for every admitted preterm infant who clinically showed jaundice and total serum bilirubin (TSB) measurements was obtained within 30 min of TCB. 58 (46 %) were male and 68 (54 %) were female. The mean gestational age was 31 week and mean birth weight was 1,728 ± 60 gr. 30 % of neonates were ill. The mean value obtained by TBS was 8.8 mg/dl and for frontal TCB was 8.2 mg/ dl and for sternal TCB was 7.4 mg/dl. There were good correlation between TBS and TCB and the maximum correlation were seen in 33-37 weeks of gestation and birth weight more than 2,500 gr with forehead TCB measurement. Healthy preterms had significant correlation of TSB and TCB (r = 0.56, p \ 0.001) and ill preterm neonate had r = 0.82, P \ 0.001. The correlation between TBS and TCB with and without phototherapy was r = 0.66, p = 0.000 and r = 0.69, p = 0.000, respectively. Although TCB measurement may underestimate TBS but there is significant correlation between TCB and TBS in preterms even in ill neonate or who receiving phototherapy and so reduces the number of blood sampling in preterm. Results: Infants gestational ages were mean 27, 1 weeks and mean postnatal age was 10, 8 days. Correlations were calculated between PIPP and EDIN on NCR 1 and NCR 2, and Spearman's rho were 0, 60 (p \ 0, 01) and 0, 57 (p \ 0, 01) respectively. The Intraclass Correlation Coefficient was used to calculate inter-rater reliability, and was moderate to poor. The highest ICC was found for the variable ''quality of sleep'' and the lowest for the variable ''quality of contact with nurses''. 20 of 33 had skin-to-skin contact with a parent (mean 129, 8 min) on observation day. The low EDIN scores suggest infants in non-pain situations. Conclusion: The Norwegian version of the EDIN scale is recommended for assessing prolonged pain and discomfort in preterm neonates on ventilator support. When implementing EDIN in clinical practice, nurses should perform paired assessments during the implementation period to improve reliability. The efficiency of antenatal corticotherapy in reducing RDS incidence, severity, and perinatal mortality in preterm infants has been clearly demonstrated.

Aim: Evaluation of the antenatal corticosteroid prophylaxis in preterm neonates B32 weeks gestation. Materials and methods: We analyzed the data reported prospectively by three regional hospitals (A, B, C) between 01.01.2010 and 31.12.2011. The data of all preterm infants B32 weeks gestation were collected in the National Registry for RDS. The outborns were excluded from the analysis. The efficiency of antenatal corticotherapy in reducing RDS incidence and severity and perinatal mortality in preterm infants has been clearly demonstrated. Aim: Evaluation of the impact of prenatal corticosteroids on the short term outcome in preterm neonates B32 weeks gestation. Materials and methods: We analyzed the data reported prospectively by three regional hospitals (A, B, C) between 01.01.2010 and 31.12.2011. The data of all preterm infants B32 weeks gestation were collected by the National Registry for RDS and analysed using IBM SPSS Statistics 19. P was considered statistically significant when .05.

The study group comprised 513 infants (100 were outborns, therefore excluded), had mean GA of 29.44 ± 2.31 weeks, mean BW of 1,338.94 ± 401.56 g, and 36.31 % received prenatal corticosteroids. No differences were found between preterm infants with or without antenatal corticosteroid prophylaxis as regards prenatal characteristics, pregnancy complications, birth resuscitation and incidence of perinatal complications except the need for surfactant administration, CPAP support, incidence of maternal fetal infections, ROP and severe ROP, all of which more frequently encountered in the group receiving corticosteroid prophylaxis (p \ 0.05). Given these conflicting data, the analysis was done comparing only the infants that received a complete course of corticoids with those without any prophylaxis and we found decreased duration of CPAP and MV (p \ 0.5), decreased need for CPAP and MV, reduced incidence of PDA, PVL, BPD, severe ROP and neonatal sepsis (p [ 0.05) in those receiving prophylaxis. Conclusion: Only a complete course of corticosteroids has significant favourable effects on the perinatal course of the small preterm infants.

Medical Faculty, University of Oslo, Oslo, Norway

Background and objective: In the US it is mandatory to assess and treat pain. Similar guidelines are established in Europe. The objective is to discuss the physiological pain assessment tools for infants and S146 Intensive Care Med (2013) 39 (Suppl 1):S1-S200 children and to conclude if they can fulfil a validated standard for pain assessment.

Methods: The physiological pain assessment tools for infants and children; heart rate (HR), peripheral oxygen saturation (only for infants), and emotional sweating (skin conductance responses/s (SCR/s)) are discussed according to the criteria from Berede (1) . Results: HR is influenced from respiratory rhythm, changes in blood volume status, drugs acting on the blood circulation, environmental temperature, and emotional stress, and is therefore less specific to pain than the SCR/s which only is influenced from emotional stress. For infants and children, the inter-individual variation for SCR/s is low compared to HR and peripheral oxygen saturation when the patients are at the same pain/discomfort level. Different from HR, SCR/s is not dependent of age. Both HR and SCR/s reacts immediately and works in real time. At patients postoperatively, at the intensive care units, and at the neonatal units, SCR/s has high sensitivity to monitor pain, but lower specificity. SCR/s is therefore most accurate to assess pain when compared to HR and peripheral oxygen saturation. All physiological pain tools should be used as adjunctive warning tools to correct against the lower specificity. • Tip positions after adjusting/'pull-back'.

• Complications of sub-optimal tips.

Methods:

• Retrospective Review in a Tertiary NICU.

• From: January 2010 to June 2012.

• Review of initial and final positions after 'pull-back'.

• Definitions used: Accepted tip =0.5 cm from Diaphragm; Malpositioned tip is defined as[0.5 cm above or below Rt. Hemi-diaphragm.

Results:

• UVCs done =209.

• Tip positions-15 % 'ideal', 23 % high, 62 % low.

• 47 High tips 'pulled-back': 10.6 % same, 40.4 % 'ideal', 48.9 % low. • Complications observed: 1 rupture of the catheter into heart, 1 TPN-ascites, 4 cases of atrial thrombi, 1 case of 2 UVCs in same patient. Conclusions:

• Poor 'ideal position success rate.

• Tips around T8-T9 were in correct position (IVC diaphragmatic aperture). • *1/2 of high UVCs were 'pulled-back' into the liver.

• Very minimal complication rates.

• Care when estimating length to pull out. Background: The study aimed to review the effect of two open and close suctioning methods on respiratory parameters of infants undergoing mechanical ventilation. Methods: In this cross-sectional clinical trial study, forty-four infants among the infants underwent mechanical ventilation in NICU of Isfahan's Al-Zahra Hospital were selected by simple continuous sampling method. The samples randomly divided into two groups. In the first group; first, open suctioning and then after 3 h of cleaning, closed suctioning was done and in the second group, first closed suctioning and after 3 h of cleaning, open suctioning was implemented and respiratory rate (RR) and percentage of arterial blood oxygen saturation was reviewed and compared before, during and after each type of suctioning. Data were analyzed using ANOVA with repeated measures and independent t test through Software SPSS 16. Results: There was a significant difference between mean respiratory rate and arterial blood oxygen saturation in infants before, during and after the closed and open suctioning. The percentage of arterial blood oxygen saturation had a significant reduction in open method compared to closed method on the same time and immediately after suctioning and RR in 3 min after suctioning in both steps in open method. Conclusion: Results showed that close method causes fewer changes in hemodynamic status of infants. Therefore, in order to prevent from respiratory complications in infants, nurses are recommended to perform the endotracheal tube suctioning in closed method.

Aim: Determination of predictors of hospital mortality in early infants with sepsis. Materials and methods: The study included 68 preterm infants, 28-32 weeks of gestation, which are bacteriologically examined for the purpose of diagnosis of sepsis. The study group included 38 children with sepsis, and the control group included 30 children without sepsis. The results: Between the groups, there was no significant difference with DAP (39.5 vs. 43.3 %, p = 0.48) . Patients with sepsis were more likely to have anemia (100 vs. 86.7 %, p = 0.020) and were more likely reanimated (52.6 vs. 10.0 %, p \ 0.0001) than patients in the control group. Patients with sepsis had a higher heart rate (195.55 ± 11.80/min to 154.75 ± 27 .52/min, p \ 0.0001), higher levels of CRP (15.13 ± 10.93 to 3.45 ± 2.49 mg/l, p \ 0.0001), higher EDD (14.99 + 2.10 to 13.66 ± 2.33 mm, p = 0.016) and left ventricular EDS (11.02 ± 1.19 to 10.80 ± 1.12, p = 0.005), lower blood pH by Astrup (7.09 ± 0.12 to 7.28 ± 0.04 mm, p \ 0.0001), higher WBC count (18.68 ± 5.76 to 13.25 ± 3.58, p \ 0.0001), lower hemoglobin (155.95 ± 15.25 to 185.55 ± 41.76, p \ 0.0001) and a lower number of platelets in the blood (132 ± 41.76 to 201.97 ± 47.87, p \ 0.0001) than patients in the control group. Patients with sepsis had significantly higher hospital mortality (36.8 vs. 0 %, p \ 0.0001) than patients without sepsis. In multivariate logistic regression, independent predictors of hospital mortality were resuscitation (OR = 7.91, p = 0.049), lower pH levels (OR = 0.10, p = 0.039) and a lower number of platelets in the blood (OR = 0.88, p = 0.001). Conclusion: Independent predictors of increased hospital mortality in early infants with sepsis were resuscitation, lower blood pH and a low number of platelets in the blood. Shaanxi Provincical People's Hospital, 3 Xi'an Jiaotong University, Xi'an, China

Background and objective: HBV vertical transmission is the main reason for chronic HBV infection, but there is no systemic conclusion about the effect of HBV infection on pregnancy outcome. This experiment is aimed to study the effect of HBV infected embryos on pregnancy outcome. Methods: 75 couples who received ART treatment were followed up, among which 25 couples with at least husband or wife infected with HBV were group A, and 50 couples with negative serum HBV markers of both husband and wife were group B. The clinical pregnancy rate, early abortion rate, neonatal malformation rate, neonatal HBV infection rate, and HBV infection rate of 6-month-old infant of these two groups were compared, and Fisher 0 s exact test was applied. HBV mRNA in abandoned embryos of the patients was detected by single-cell RT-PCR. Results: Both early abortion rate and abortion rate with mother infected HBV in group A were significantly higher than that in group B (P = 0.043, P = 0.030), respectively. The clinical pregnancy rate, neonatal malformation rate, neonatal HBV infection rate, and HBV infection rate of six-month-old infants in group A and group B were all 0. Specific HBV mRNA fragments were detected in 6 cases of 62 cleavage embryos in group A, and the positive rate was 9.7 % (6/62). The positive rate with mother and father infected with HBV were 13.2 % (5/38) and 5.6 % (1/18), respectively. Conclusion: HBV infection can increase the early abortion rate of pregnancy, and the reason may be related with HBV infected embryos. Background and aim: Staphylococcus coagulase negative strains are colonized on epiderm and distribute in environment and outer bodies apparatus such as protez and intera-venous catheters. The aim of this study was the frequency of Staphylococcus coagulase negative isolated from venous and catheters children hospitalized in NICU of Hamadan hospitals and determination of antibiotics resistance patterns in Hamadan, the west of Iran.

Methods: We collected 108 samples randomly from patients who were hospitalized in NICU hospitals of Hamadan and they needed to venous or urinary catheters. One specimen of each patient was taken and inoculated into carrier transported media and transferred to bacteriology laboratory to identification of strains. Antibiogram was performed by Kirby-Bauer method. Data was analyzed using SPSS 15 software.

Results: Out of 108 tested samples, 32.7 % of patients had urinary catheter and 67.3 % had venous catheter. 28 % of tested samples had positive culture. The positive cases were significantly found in those children who had been used catheter more than 48 h (P = 0.00). From the positive cases, Staphylococcus epidermidis (40.4 %), Acinetobacter baumannii (10.6 %) and E. coli (8.5 %) were the most common isolates. The most rate of resistance of Staphylococcus epidermidis was against to erythromycin and ampicillin. The most rate of sensitivity of E. coli was against to gentamicin and Pseudomonas aeruginosa to ciprofloxacin. Conclusion: Our results showed the high contamination in used catheters particularly in those patients who needed to catheter for long time. We also indicated the high drug resistance in strains isolated from catheters.

Infection Control, Org PF Teaching Hospitals, Institutes, Alexandria, Egypt Introduction: It is unrealistic to hope for a germ free NICU. The NICU hygiene is affected drastically by the medical staff and the internal environment. This study will describe some of interactions between the laboratory and the improper housekeeping procedures. Methods: The present study was conducted in NICU Damanhour Teaching Hospital. Where the cleanliness and sanitation was evaluated by bacteriological examination of the umbilical stump and the internal environment of the wards represented by floor, air, baby balance, baby heater, air condition device and baby care units. Disinfectant till the air wards rapidly becomes saturated with H 2 O 2 aerosol. Also suggested a safe new technique for cleaning and sanitation of baby incubators by washing and drying then using stabilized hydrogen peroxide/silver ions which changing to water and oxygen after use instead of formalin gas or other toxic disinfectants as glutaraldehyde 2 % or hypochlorite solution (125 ppm available chlorine) which they should be rinsed thoroughly with water. H 2 O 2 process takes 45 min only instead of 48 h in case of formalin so we can save more lives by our limited number of baby incubators, also this safe technique succeeded 100 % in removing all pathogenic microorganism. Conclusion: The study revealed failure of routine housekeeping process, and suggests protocol to control and prevent NICU nosocomial infections, it also proposed a new technique, for cleaning and disinfecting Wards and baby incubators which decreased the mortality and morbidity rates among neonates. In situ simulation, simulation that is physically integrated into the clinical environment, provides a method of experiential learning to improve teamwork skills in high-risk areas. The purpose of the present study was to evaluate the impact of using in situ simulation on time response of the team to clinical emergency situations. Simulations training took place in actual clinical settings and the participants were on-duty during their actual workday. Every day an emergency practice took place based on advanced scenarios, in a designated room. The room is equipped with video cameras and a pediatric human patient simulator to create a realistic experience. 150 trainings were conducted and videotaped for documentation and debriefing. Each in situ simulation takes about 10-15 min. Training for the emergency situations became a daily routine. Response time decreased from a mean of 1 min 11 s. to a mean of 32 s. In situ simulation contributes to high-level team performance. Training for the emergency situations became a daily routine. Response time decreased from a mean of 1 min 11 s. to a mean of 32 s. In situ simulation contributes to high-level team performance.

Intensive Care Unit, Wuhan Asia Heart Hospital, Wuhan, China

Objective: To evaluate the effectiveness and safety of continuous intravenous pumping of heparin for the prevention of deep venous thrombosis related with central venous catheter after cardiac operation. Methods: 112 infants of congenital heart disease (CHD) after surgery were divided randomly into two groups: experimental group and control group (age range: 0*3 months). Experimental group were treated with continuously intravenous pumping of heparin. The initial dose was 5 U/kgh. Adjust the dose of heparin to maintain APTT from 55 to 60 s. Control group received intravenous pumping of physiological saline. Deep vein thrombosis were detected with Color Doppler ultrasound after 3, 7, 9, 14 Objectives: Infant mortality rate in developing countries is 15-30 per 1,000 birth. Regarding World Health Organization know essential practicable standards to provide for accurate practice in hospital and health centers so, Creating national care standards in intensive infant units are essential. Methods: This is a multiple triangulation study done in the nursing and midwifery faculty of medical sciences of Isfahan University. First of all, international care standards were extracted from the net, of 10 different countries. Second, by using Delphe method, these standards were selected by a questionnaire as well as the viewpoints of 42 clinical experts in the country, and their suggestions regarding desirability and applicability of these standards and according to the executive and sociocultural situation in the country, were investigated through a descriptive method. Results of this stage were analyzed via descriptive statistics. Results: Majority of the participants(40.5 %) had master degree 45.2 % of them were 36-45 years old, in addition, the majority of them had the practical experience of 2-10 years generally and 6-10 years particulary in the NICU. Finally, 14 standards related to caring during the phototherapy, according 97.5-100 % desirability rate were achieved. Conclusions: In this study, final standards have been created. The results will be presented on site. Creating nursing standards by experts and deserved people, leads to the increase in the quality of nursing care. Background and aims: Labetalol is thought to be safe and effective to treat hypertension during pregnancy. Nevertheless, beta-adrenergic blockade of labetalol can result in hypotension, bradycardia and hypoglycemia in the newborn. Care-takers should be aware of these potential complications. However, unnecessary admission of the neonate should be avoided. This study evaluates possible neonatal effects after maternal use of labetalol. Methods: All infants born alive in the VU University Medical Center between 1 January 2011 and 1 September 2012, with a gestational age of C36 weeks exposed to labetalol B48 h prior to delivery were included. Labetalol dosage and route of administration, gestational age, birth weight, maximum carbohydrate intake (MCHI) and the incidence of hypotension, bradycardia and hypoglycemia were obtained from maternal and neonatal records. Results: In this period, 37 neonates were exposed to labetalol. Seven patients were excluded because of incomplete data. Labetalol was administered orally in 27 (200-1,800 mg/day) and intravenously in 3 (480-2,400 mg/day) mothers. Hypoglycemia occurred in 13 infants (43 %), in which 8 infants needed intravenously administration of glucose (mean MCHI 6.5 mg/kg/min). 8 of 13 infants with hypoglycemia were born at term and appropriate for gestational age (AGA). Hypoglycemia occurred \10 h after birth. Conclusions: Hypoglycemia occurred in 43 % of prenatally exposed (pre) term neonates, possibly due to decreased gluconeogenesis. Adequate monitoring of blood glucose during day 1 in (term and preterm) neonates after prenatal exposure of labetalol is therefore recommended. Introduction: Despite limited information on the pharmacokinetics of excipients, propylene glycol (PG) is often used as a co-drug both in adults and children. The aim of this study is to characterize renal elimination in relation to hepatic clearance of propylene glycol in preterm and term neonates. Methods: The pharmacokinetic analysis of PG was performed in NONMEM 6.2. on the basis of PG concentrations in plasma and/or urine samples for a total of 69 (pre)term neonates (birth weight 630-3,980 g, gestational age 24-41 weeks, postnatal age 1-29 days) who received PG co-administered with IV paracetamol (5-10 mg/kg/ 6 h) or phenobarbital (5 mg/kg/day) or both. Results: A one compartment model parameterized in terms of renal clearance, hepatic clearance and volume of distribution was found to adequately describe the observations in both plasma and urine. After the first dose, renal elimination of propylene glycol was 15 % of total clearance which increased over time to 25 % at 24 h after the first dose. This increase was best described by a hyperbolic function based on time after the first dose. Conclusions: Renal elimination of PG in (pre)term neonates is low compared to hepatic clearance, particularly compared to the reported percentage of 45 % in adults. To evaluate whether the reported increase in renal elimination of PG over time after first dose indicates an auto-induced increase in renal secretion or failure of tubular reabsorption of PG, further research is needed. Objectives: Clonidine is often used as a sedative in critically ill children, but its effectiveness has not been tested in a large, rigorous randomized controlled trial (RCT). Our objectives in this pilot RCT were to assess the feasibility of a larger trial with respect to: (1) Timely enrollment, (2) Effective screening, (3) Protocol adherence, and (4) Recruitment. Methods: Randomized, concealed, blinded, placebo-controlled, pilot trial. Eligible patients were hemodynamically stable children aged 1 month-18 years who were expected to require at least 2 days of mechanical ventilation and who required an opioid or benzodiazepine infusion for sedation. Children were randomized to enteral clonidine 5 mcg/kg or placebo every 6 h in addition to usual sedation. Results: We enrolled 50 children in 2 centres. The median (IQR) age was 2.5 (0.7-5.2) years and PRISM score on PICU admission was 12 (8-15). In terms of feasibility outcomes: 35 (70 %) were enrolled within 1 day of becoming eligible (mean 1.2 days). 91 (88 %) of 104 eligible patients were approached for consent, 87.5 % of doses were administered according to protocol and on average 1.7 children were enrolled/month. The median (IQR) duration of ventilation and PICU stay was 6 (3-11) and 10 (7-21) days, respectively. 6 (12 %) children had doses held or modified due to hypotension and the incidence of clinically diagnosed withdrawal was 32 %. Conclusions: This pilot trial suggests that a larger RCT to evaluate the effect of clonidine on clinically important outcomes is feasible. Objectives: Many drugs are prescribed to children and substrate to drug transporters. Transporters are membrane-bound proteins involved in drug absorption and disposition. Variation in transporters may affect drug levels and efficacy. However little is known about developmental changes of transporter expression during childhood. These changes may impact drug levels resulting in over-or underdosing when unaccounted for. Aim: To assess whether intestinal and hepatic transporter expression is age-related. Methods: Expression was determined using postmortem liver (fetuses n = 9, neonates n = 21 [birth-1 month], infants n = 8 [1 month-12 months], children n = 3 [1 year-17 years], adults n = 11) and surgical small bowel samples (neonates n = 21, infants n = 7, children n = 1, adults n = 11). Target gene expression was determined using real time RT-PCR compared to adult expression using the DDCt-method. Significance level was set at p \ 0.05. Results: Hepatic expression of MDR1 was significantly lower in fetuses, neonates and infants compared to adults. Hepatic expression of MRP2, OATP1B1 and OATP1B3 in all age groups was significantly lower compared to adults. Intestinal expression of MDR1 and MRP2 was comparable with adults. However, intestinal OATP2B1 expression was significantly higher in neonates and infants compared to adults. Conclusion: Hepatic and intestinal drug transporter expression show organ-and transporter-specific maturation patterns. Suggesting substrate drugs to transporters may be subject to age-related changes in absorption. Studies on protein expression and in vivo activity are needed to predict the clinical relevance. This may impact dosing of substrate drugs to children of different ages. Supported by Novartis investigator-initiated grant. Introduction: As delirium in critically ill children is increasingly recognized, more children are treated with the antipsychotic drug haloperidol. Little is known on its safety in this context. Objective: To investigate the incidence and nature of adverse events associated with administration of haloperidol and its relationship with dose. Methods: All patients admitted to the PICU between January 2000 and July 2011 who received haloperidol for delirium were included. Charts were evaluated using a predefined list of adverse events. Symptoms possibly related to haloperidol were evaluated for probability of causality using the Naranjo score, by two clinical pharmacologists and the Netherlands Pharmacovigilance Institute (lareb.nl). Results: Fifty-two patients [median (range) age 10.6 (0. 3-18.8) years] received the drug for treatment of delirium. In six patients (11 %) seven adverse events were documented. These included extrapyramidal reactions (n = 2), extrapyramidal reactions + hyperpyrexia (n = 1), neuroleptic malignant syndrome (n = 1), long QT (n = 1), and isolated muscle rigidity (n = 1). Adverse events were rated as doubtful (n = 1), possible (n = 2), probable (n = 2) and definite (n = 1). The median (range) haloperidol dose was similar between patients with and without adverse events [0.03 (0.02-0.06) mg/kg/day vs 0.02 (0.003-0.08) mg/kg/day, p = 0.08]. Conclusion: To our knowledge this is the largest pediatric cohort studied for haloperidol-related adverse events. A significant proportion of patients develop adverse events. As haloperidol adverse events are correlated with dose in adults, our findings suggest that dosing in our pediatric population is suboptimal. Studies are needed to determine the optimal haloperidol dose for ICU delirium in children. Background and aim: Sugammadex is a new and novel agent that reverses muscle relaxation of the amino steroid neuromuscular blocking drugs (NMBD). Vecuronium is an amino steroid NMBD commonly used as an infusion in paediatric and neonatal intensive care units. Infants are at risk of prolonged effect due to the combination of low neonatal acetyl choline production, large volume of distribution and reduced excretion of the drug and its metabolites. Prolonged muscle relaxation may require a lengthened period of ventilation with an associated increase in morbidity. Currently there are no suitable agents available to reverse profound and prolonged muscle relaxation. Acetyl choline esterase inhibitors (AChEI) cannot be used until there is 75-80 % recovery in neuromuscular function. Significant stimulation at muscarinic receptors by AChEI's causes bradyarrhythmia, salivation and bronchoconstriction therefore need to be given with anticholinergic drugs which in turn can cause tachycardia's. Method: We describe the use of sugammadex in four neonates who received prolonged infusions of vecuronium following surgery and in whom the use of sugammadex immediately reversed the effects of profound muscle relaxation allowing weaning of ventilation and extubation. Conclusion: The use of sugammadex to reverse profound and prolonged neuromuscular block may reduce length of stay in the intensive care unit, morbidity of prolonged ventilation and be cost effective. Background and aims: About 50 % of the children with Down syndrome undergo surgery for congenital anomalies. They are often seen as more agitated but less sensitive for pain. The aim was to retrospectively and prospectively evaluate analgesia and sedation requirements in children with Down syndrome. Methods: Retrospective analysis of analgesia/sedation requirements and pain/distress scores in 15 children with Down syndrome and 30 without after surgery for congenital duodenal obstruction. Prospective analysis of analgesia/sedation requirements, pain/distress scores and morphine pharmacokinetics in 18 children with Down syndrome and 16 without after congenital heart surgery. Local ethics approval was obtained for both studies. Results: Both the retrospective and the prospective analysis did not show any differences in the pain scores of both groups. The percentage of scores indicating oversedation was 18 % in children with Down syndrome after cardiac surgery and 7 % in controls (P \ 0.001). Analgesia and sedation requirements were comparable between both groups in the retrospective as well as the prospective analysis. Population pharmacokinetic analysis revealed no statistically significant differences in pharmacokinetic parameters of morphine between the children with and without Down syndrome. Conclusion: Children with Down syndrome are not more agitated after surgery for congenital anomalies. There is no reason to adjust postoperative analgesia and sedation in these children. The next step is to develop and investigate evidence-based analgesia and sedation guidelines for children undergoing surgery for congenital anomalies. Objectives: Sedation is part of routine care in pediatric intensive care. In recent years, there is growing attention for the use of less sedatives, or daily interruption of sedation. In our perception, however, we used more sedatives over time. We therefore investigated trends in the use of sedatives in our pediatric intensive care unit (PICU). Methods: We performed a retrospective cohort study in a PICU at an academic hospital in the Netherlands. All admissions between January 2003 and January 2012 were included. Length of stay in PICU and total number of ventilation days were compared with the pharmaceutical database of medication delivery. Results: A total 5,785 patients were admitted to the PICU during the years 2003-2012 with a mean of 643 patients per year. These patients received 26,713 days of mechanical ventilation. The use of benzodiazepines decreased significantly over the years from 92 mg per day of ventilation to 66 mg per day of ventilation (beta-coefficient -0.92, p = 0.01, R 2 0.84; Fig. 1 ).

The use of morfine en clonidine remained constant over the years. The use of propofol increased until 2006 thereafter a sudden decrease was seen. Conclusions: Our findings show that in our PICU significantly less benzodiazepines have been used over time. There was no shift towards other types of sedatives. Background and aim: Midazolam is a short-acting benzodiazepine and directly acts on targets in the central nervous system (CNS). The effect of midazolam in the CNS depends on the concentration of the drug at the site of action. Since there is no possibility of direct measurement of brain concentrations of drugs, cerebrospinal fluid (CSF) drug concentrations may be an alternative matrix. However, data on CSF pharmacokinetics are scarce. Our aim was to determine midazolam and metabolites concentrations in serum and CSF after rectal administration in children. Methods: Pediatric oncology patients (0-17 years) scheduled for lumbar puncture were included. During induction, midazolam 0.2-0.5 mg/ kg was administered rectally. Blood and CSF samples were drawn after administration. Midazolam and metabolites were determined by a validated liquid chromatography tandem mass spectrometry method. Results: 16 patients were included: 9 boys and 7 girls. Mean (SD) age was 7.6 (5.3) years. In 11 patients midazolam was found in CSF. The concentrations of midazolam in serum and CSF are shown in Table 1 . Valproic acid (VPA) is still an important antiepileptic drug with the broadest spectrum used in all types of seizures and syndromes. It has serious adverse effects such as hepatotoxicity, hyperammonemic encephalopathy, coagulation disorders and pancreatitis. The incidence of VPA-associated pancreatitis has been estimated to be 1:40,000. We present a 6-year-old boy who developed acute pancreatitis (AP) and multiple organ failure after 3 months of VPA therapy. Patient's laboratory values showed that his kidney and hepatic function had impaired and thrombocytopenia and coagulopathy had developed. Patient's abdominal tomography showed a suspected appearance which was consistent with pancreatitis. Since amylase and lipase levels were found to be high acute pancreatitis was considered. Patient improved after cessation of VPA treatment. Ten days later patient recovered both clinically and laboratorial. Consequently, patient was discharged with cure. In conclusion, AP is a rare, severe adverse reaction to VPA treatment. If a child who is receiving VPA, develops abdominal pain and vomits, VPA-associated pancreatitis must be considered. The aim of this study was to identify the incidence of lactic acidosis following salbutamol therapy and how this relates to patient characteristics (age, weight, ethnicity) Introduction: Craniofacial microsomia (CFM) is a congenital anomaly affecting the first and second pharyngeal arches and is characterized by asymmetric underdevelopment of the mandible, the maxilla, the ear and the soft tissues. According to a few studies children with CFM are more likely to have airway difficulties as a result of the underdevelopment of the mandible. It is unknown how many of these children are admitted to the PICU for respiratory distress.

Objective: To identify the number of patients with CFM who were admitted to the PICU for respiratory distress.

Methods: Clinical data of 90 CFM patients born between 1993 and 2012 were retrospectively screened for demographic data, affected side, history presence, outcome of the sleep study and treatment of the airway difficulties.

Results: In 88 of 90 CFM children the mandible was involved unilaterally, in 1 bilaterally and in 1 the affected side was unknown. Because of the clinical history of respiratory distress in 5 children a sleep study was performed (mean age 2.2 years (range 8 days-7 years)). In four of these five children an obstructive sleep apnea syndrome was diagnosed (3 male, 1 female) (3 severe, 1 moderate). In 1 child central apnea syndrome was diagnosed. These 5 children were admitted to the PICU for respiratory support, which consisted of CPAP for a prolonged period of time.

Conclusions: In this study the incidence of respiratory distress was low in CFM, but a few have severe respiratory distress necessitating respiratory support. Background and aims: Early fluid resuscitation improves outcome but later a positive fluid balance is harmful [1] [2] [3] [4] North American studies demonstrate that ventilator free days (VFD) are inversely related to day 3 cumulative fluid balance [1] Our UK practice includes wider diuretic use. We hypothesised that day 3 fluid balance has no detectable influence on VFD. Background and aims: Assessment of lung recruitability during paediatric high-frequency oscillatory ventilation (HFOV) is difficult and at present guided by clinical surrogate parameters including the transcutaneously measured oxygen saturation (SpO 2 ). We hypothesized that respiratory inductance plethysmography (RIP) may be a useful bedside tool during the staircase recruitment manoeuvre. Methods: Children with moderate-to-severe acute hypoxemic respiratory failure who were oscillated with the Sensormedics 3100A or B oscillator were eligible for inclusion. Two RIP bands were placed: one around the patient's chest just below the inframammary line, and the second around the abdomen. The SpO 2 was continuously measured using Masimo technology. Each patients was routinely subjected to a staircase recruitment manoeuvre (i.e. stepwise increase and decrease of the continuous distending pressure (CDP) to identify the point of maximal compliance change of the pressure-volume loop on both the inflation and deflation limb). Data are expressed as mean ± standard error, and were analyzed using the student t test. P \ 0.05 was accepted as statistically significant.

Results: So far, N = 23 patients have been enrolled. Sixteen of these (69.6 %) showed an increase in RIP arbitrary units (AU), suggestive for an increase in aerated lung volume. In nine of these (56.3 %) patients this coincided with an increase in SpO 2 .

Conclusions: Our study suggests that RIP may be useful to identify recruitability during the staircase recruitment manoeuvre in paediatric HFOV. Lung recruitability was not associated with improved oxygenation in all patients. Results: Of the 3,934 admissions, 77 babies were treated with iNO. After exclusion of 31 babies with congenital diaphragmatic hernia (CDH), 46 babies were included in the study. Objectives: To assess the feasibility, stability and predictability of CO 2 measurement using a main stream capnograph in a high frequency oscillatory ventilation circuit. Methods: A commercially available capnography was mounted into a high frequency oscillatory ventilator patient circuit, adjustable CO 2 flow was introduced into an artificial lung and the output of the CO 2 sensor assessed under varying ventilator settings. Influence of oxygen content, pressures, heat and moisture were recorded. Results: A linear relationship between CO 2 flow rate and measured CO 2 concentration was found. Varying ventilator settings influenced the measurements, but the results remained within a range of 1.5 mmHg above or under the mean measurement value (Fig. 1) . Measurements remained stable despite humidification, heat, pressure amplitudes or mean airway pressure changes.

Conclusions: From this bench test, we conclude it is feasible to measure CO 2 using a main stream capnography during high frequency oscillatory conditions, these measurements were stable during the experiment. Changes in CO 2 production or output can be detected.

The system may prove to be of clinical value, but further vivo measurements are warranted. Objectives: Pneumothorax is acute lung injury which sometimes requires the emergency diagnosis and treatment. The aim of study was to determine whether ultrasound can be used in diagnosis of pneumothorax in newborn infants. Methods: In 16 newborn infants with gestation age (range 27-39 weeks) and birth weight (1,000-4,150 g) pneumothorax was suspected on the basis of lung ultrasound findings. All newborns had respiratory distress in the time of ultrasound. A high-resolution linear probe 10 MHz was used for lung examination. After lung ultrasound X-ray was done in all infants.

Results: In 16 neonates with suspected pneumothorax on the basis of lung ultrasound findings the diagnosis of pneumothorax was confirmed by the X-ray in 15 infants and only in 1 was hyperinflation. In 16 infants were present A lines, there were no sliding of pleura in any case and lung point were in 9 infants. Purpose: Although prematurity of the lung is the primary cause of neonatal respiratory distress syndrome (RDS), several factors including inflammatory response may contribute to the pathogenesis. Interleukin-10 (IL-10) is an important anti-inflammatory cytokine, and -1082 G allele is associated with higher IL-10 production. We investigated whether IL-10 -1082 polymorphism G is associated with the severity of RDS in the preterm Korean infants. Methods: 64 preterm infants who developed RDS and delivered at CHA Bundang Medical Center between July 1, 2011 and June 30, 2012 were analyzed for IL-10 -1082 genotype. We reviewed the records and compared the differences in the perinatal characteristics and variables relating to RDS severity and neonatal pulmonary outcomes.

Results: Patients with IL-10 -1082 G/A genotype were 6 (9.4 %) and those with A/A genotype were 58 (90.6 %). (4), acute cardiac failure due to myocarditis (2), postoperative atelectasis (3), myasthenic crisis (1), acute upper airway obstruction (1), fat embolism (1) and congenital heart disease-bronchopulmonary dysplasia (1) . We selected the NIV/Pressure Control ventilation mode. Respiratory rate, heart rate, arterial pH, pO 2 and pCO 2 were recorded before, 2 h after the initiation of NIV/PC and then, when needed. Results: NIV/PC was well tolerated without complications and was associated with improved gas exchange, decreased work of breathing and endotracheal intubation avoidance in 24 patients (medium ventilation time 2 days). Seven patients did not improve so they had to be intubated. The underlying disease was the main factor for NIV failure in children with ARF (metabolic disorders or neuromuscular diseases). Conclusion: NIV/PC ventilation seemed to be effective in the treatment of children with ARF. As literature suggests NIV is a safe method of treatment and diminishes intubation rate in children with ARF. (2) Time staying in intensive care prior to ALI diagnosis;

(3) The presence of non-pulmonary organ system dysfunction within 24 h of ALI onset; (4) The initial severity of hypoxemia, as measured by PaO2/FiO2 ratio;

(5) The presence of non-pulmonary organ system dysfunction on day 3 from ALI onset, and (6) The presence of any hospital acquired infection during admission were independent factors associated with mortality and prolonged mechanical ventilation. Conclusions: We found a high case mortality and prolonged mechanical ventilation among a cohort of pediatric ALI patients in a low-resource critical care setting. Factors that independently predicted the adverse outcomes were identified easily. Identifying these factors early in the course of ALI will help to determine appropriate treatment modalities and improve outcomes of children with ALI. Background and aim: PH is a complication of BPD and is associated with increased morbidity and mortality. Its incidence is unknown and treatment is not yet standardized.

We evaluated the incidence of PH related to BPD and our experience with Sildenafil. Results: Prone position was successful in 69 % whereas 31 % of the children needed respiratory support because of (severe) respiratory distress. In the majority of children more modes of respiratory support were used. Respiratory support consisted of a nasopharyngeal airway (n = 3), oxygen supplementation (n = 9), continuous positive airway pressure (n = 4) and a tracheostomy (n = 7). Eight children underwent additional treatment by mandibular distraction.

The overall need for respiratory support differed between children with isolated RS compared to children with non-isolated RS (17 vs. 52 %). Only 5 % of the children were in need of long term respiratory support. Introduction: Bladder perforation following direct umbilical artery catheterisation (UAC) is an extremely rare complication. Described below is a case of bladder injury following multiple unsuccessful attempts that resulted in urinary ascites, which was managed conservatively.

Case report: A 28 week preterm baby having normal anomaly scans was delivered by emergency caesarean section for pre-eclampsia and absent end diastolic flow. Direct umbilical artery catheterization was attempted through an apparently normal 3-vessel umbilical cord, but unsuccessful. Progressive distension and discolouration of the anterior abdominal wall with oliguria and microscopic hematuria was noted. X-ray revealed a ground glass appearance with loops of bowel in the midline. Abdominal ultrasound showed a 2 mm defect in the bladder wall. It was managed conservatively with transurethral bladder catheterisation with good recovery. Discussion: Literature review revealed only seven reports of bladder injury following attempts at direct UAC. The author found that in six of these instances urinary ascites were managed by surgical exploration, except in one case report making this the second case to be managed conservatively. We opted for conservative management because of significant improvement in the abdominal distension after urinary catheterisation and no significant bleeding from the tear, sepsis or bowel protrusion into the bladder. The likely mechanism of bladder perforation was either the umbilical catheter entering through a patent urachus or by directly perforating the bladder passing through the fascia.

Intensivists inserting UACs need to have a high index of suspicion of bladder perforation especially if associated with abdominal distension, oliguria and haematuria. Results: Of 17,040 patients, 3,128 met the criteria for multiple injuries, 55.5 % (1,720) were male and 44.5 % (1,408) female, the oldest age range was 18 years and the minimum of 0.08 with a mean of 9.6. The most often found lesion was head injury in 75 % associated with other serious chest injuries in 29 %, abdomen 17 %, pelvis and extremities in 39 %, mortality was 12 %. 55 % of patients admitted to the pediatric intensive care unit as priority 1, and of these 11.5 % died.

The multiple injuries annually produced as many deaths as all other causes, the etiology varies with age, patients under 3 years old falls from their own height are the most common, between 4 and 8 years old head injury was associated with thoracoabdominal injury and femur fracture(Waddell 0 s triad). Mortality has a biphasic pattern, 32 % (being 1 in 4). It is also important to note that interdisciplinary communication is required to further promote the survival prevalence. But the only possible strategy to reduce these risks and improve the quality of life is to promote a culture of prevention. Conclusions: Trauma-induced coagulopathy appears to occur predominantly in younger male patients and is strongly associated with a higher 28-day mortality. In 2009, we introduced a paediatric major haemorrhage protocol at our institution to facilitate the early correction of coagulopathy with a balanced ratio of blood products. Further studies are needed to evaluate whether this has subsequently improved morbidity and mortality in this population. We will report preliminary information on the implementation and results of this structured approach in our ECMOSim training. Conclusions: Burns are presented in a similar percentage of boys and girls, the etiology and age group was the most common in infants and scald, which is consistent with that reported nationally and globally. Mortality in this study agrees with our report. Burns are common in our environment in children due to lack of development in the culture of prevention, so the psychological, physical and family are more than 90 % of patients, leading to a poor quality of life. Objective: This study aims to determine the relationship between fluid balance and outcome among critically ill patients independent of severity of illness.

Methods: This is a retrospective case control, chart review conducted in a tertiary-care hospital from January 2002 to December 2011. Daily fluid balances and the cumulative fluid balance, and fluid overload during PICU stay were recorded. Statistical analysis for the fluid balance was obtained using the mean and standard deviation. Relationship between variables was ascertained through the Chi square test.

Result: A total of 51 patients fulfilled the criteria of shock. The biggest fluid balance was observed on the first and second PICU day. The mean value of the fluid overload of those who expired was 14.9 % obtained from values that ranged from 3.8 to 31.2 %. Evidently the fluid overload of those who expired were much higher than those who improved. The result of the Chi square test indicate that the positive and negative fluid balance on the first 2 days at PICU are not significant together with the cumulative fluid balance. The fluid balance on the third and succeeding days and fluid overload showed significant results. Conclusion: There is no relationship on the cumulative fluid balance and outcome of critically ill pediatric patients. However, positive fluid balance on the third to succeeding days can have a poorer prognosis and negative fluid balance with a better prognosis. The fluid overload is a better predictor and has a greater impact in the outcome as compared to the cumulative fluid balance. Objectives: Current guidelines state that asphyxiated neonates should primarily be resuscitated with air ventilation. The minute ventilation with air or oxygen needed for restoration of spontaneous circulation (ROSC) was assessed. Method: Asphyxia was induced through hypoventilation, followed by apnea lasting until heart rate was\50 bpm and mean arterial pressure was \25 mmHg. Ventilation was then resumed and investigators, unaware of the composition or minute volume (MV) of inspired gas, gave closed chest cardiac massage. MV was varied between animals, and the one achieving ROSC by 10 min of resuscitation in 50 % of cases (Emv50) and the corresponding oxygen supply rate, Eosr50, were determined by fitting the parameters of the Hill equation to the observed dose-response. Results: Median arterial pH and BE were 6.68 and -18 mmol/L at the end of asphyxia induction. ROSC occurred in 12 of 32 piglets. Emv50 with air and oxygen was 10.9, and 3.4 mL/kg/min, respectively (SE of difference 1.8; p \ 0.001). Eosr50 was 3.6 and 2.8 mL/ kg/min (not significant). Conclusion: The rates of oxygen supply, required for ROSC, were similar whether the oxygen was delivered to the lungs as a component of air or in pure form. Emv50 with air was a small fraction of normal minute ventilation. This supports the view that ventilation with air is usually sufficient in asphyxia. Backgrounds and aims: International guidelines recommend 10-12 breaths per minute (bpm) during advanced pediatric resuscitation. We hypothesize that this respiratory rate (RR) could be insufficient. The aim of this study is to compare ventilation, oxygenation and recovery of spontaneous circulation (ROSC) with three different RR (10, 20 and 30 bpm).

Methods: An experimental model of asphyctic cardiopulmonary arrest (CA) in 35 piglets (median weight of 9 kg) was performed. Resuscitation with the three different RR was carried out. Achievement of ROSC and arterial blood gases profiles obtained at 3, 9, 18, 24 min after CA were compared.

Results: There were no statistical differences in pH although those with 30 bpm had higher values. Lower PaCO 2 was observed in the 30 bpm group ( Paediatrc and Neonatal Transport, Sheffield Children's NHS Trust, Sheffield, UK Introduction: The American College of Critical Care Medicine guidelines for management of neonatal septic shock recommends commencing prostaglandin infusion within 10 min of suspecting duct dependent cardiac disease. Our experience revealed delays in commencement of prostaglandin infusion. A survey of health professionals involved aided the introduction of a Yorkshire Neonatal Network and Yorkshire Paediatric Cardiology Network guideline regarding the use of Alprostadil in probable duct dependent congenital heart disease in Jan 2012. Objective: To audit the management of suspected duct dependent cardiac disease in the Yorkshire and Humber region. Methods: Prospective audit of all neonates transferred on prostaglandin infusion with no previous cardiac diagnoses between April 2011 and September 2012. Cases were identified from the Embrace [2] database and Echo diagnosis was confirmed from Leeds Paediatric Cardiology Department. Results: During the study period all 61 patients were transferred successfully by Embrace on prostaglandin infusion (no adverse side effects). 18 (25 %) patients presented in shock and 36 (61 %) patients were ventilated. However, only 9(50 %) of the shocked patients were started on the guideline recommended dose of prostaglandin. Overall 24 (39 %) patients were already started on prostaglandin at the time of referral and 9 of remaining 37 (24 %) patients had prostaglandin started in \20 min. Since the introduction of regional guideline 59 % were already on prostaglandin at referral. Conclusion: Guideline introduction has led to a greater proportion of patients on prostaglandin infusion in suspected duct dependent lesion at referral. On going training and a reaudit 12 months post guideline introduction is needed. Introduction: New videolaryngoscopes and other devices designed to facilitate tracheal intubation (TI) have been released, offering significant advantages in terms of efficacy and safety. Their role in practice is unknown. Advanced simulation could offer a preliminary tool to test new devices before their trial in real patients. Resident 0 s ability was tested for TI in infant and child manikins during continuous chest compressions (CC) with videolaryngoscope (Glidescope Ò ). Methods: 23 residents trained on infant (SimBaby Ò , Laerdal) and child intubation (Megacode Junior Ò , Laerdal) manikins participated. TI was performed by both standard laryngoscopy (SL) and Glidescope Ò while a colleague delivered continuous CC. Sequence of use of devices was randomized. Primary endpoints were the rate of successful placement of the tube in the trachea and the total TI time (TTI in seconds). Results: In infant scenario, the median (IQR) TTI was significantly shorter with ) s] than with Glidescope Ò [38.0 (25.3-50.5) s] (p = 0.021). Participants who needed more than 30 s to intubate was also significantly higher with Glidescope (n = 13) than with SL (n = 7) (p = 0.01). In child scenario, the TTI [20.2 (18.6-25.1) vs. 22. 3 (19.8-28.6 ) s] and number of intubation failures (3 vs 4) were similar with SL and Glidescope Ò laryngoscope. Discussion: Glidescope Ò increases TTI when compared with SL and doubles the number of participants who would need more than 30 s to perform the procedure. Results with this device and SL are similar in child scenario. Testing with advanced simulation may be considered the first step in assessment of new medical devices. Background and aim: Postischemic hyperoxia promotes free-radical generated injury contributing to neurologic injury and cardiac dysfunction and is associated with increased mortality after cardiac arrest (CA). Therapeutic hypothermia (TH) has shown to improve neurological outcome after CA in adults and birth asphyxia. We aimed to determine whether hyperoxia was associated with increased in-hospital mortality in children treated with TH after CA. Staff may be first at the scene and required to help at road traffic accidents (RTAs). While staff are highly trained in neonatal and paediatric resuscitation of hospital patients, their training is not that of stabilisation in a field setting. We aimed to quantify the involvement of staff in unexpected incidents involving the public while on transport in order to analyse training gaps and ensure that safety for both staff and patients is maintained.

Methods: Retrospective analysis of incident reports and records from January 2010-January 2013.

Results: During the study period, 6,329 patients were transferred. Total number of incidents was 11 (0.17 % of transfers). Four incidences involved teams becoming involved with victims of RTAs. Six incidences were helping motorists or pedestrians and one incident delivering a baby on hospital grounds. One incident involved smoke in an Embrace ambulance requiring evacuation onto the hard shoulder.

Conclusion: Involvement with accidents/incidents involving the public is a rare event and therefore riskier as teams are much less used to dealing with them. Our team has learned that better personal protection equipment is needed such as helmets to go into cars during RTAs. High visibility jackets are required to be seen at sufficient distances to keep staff safe and more training is required to minimise the dangers of traffic. Objectives: In pediatric patients with cardiogenic shock (CS)/or acute cardiac failure (CF) extracorporeal membrane oxygenation (ECMO) is often used as a bridging procedure to recovery or further implantation of an ventricular assist device (VAD). Although ECMO has been established as a routine procedure in pediatric tertiary care centers, the clinical pathway guiding these patients to fully recovery or further VAD implantation is one of the most challenging for pediatric intensivists. Methods: We describe the use of veno-arterial ECMO (VA-ECMO) as a treatment strategy for acute cardiac failure in spontaneously breathing and conscious pediatric patients. It presents our experiences with the first three children treated using this concept. The mean age of the patients was 2.4 months (range 0-5 months). Mean amount of time on ECMO was 47.7 days (range 6.9-94.2 days). Results: One patient fully recovered with his cardiac function while being treated on ''Awake-VA-ECMO'', one was bridged to LVAD and one was successfully bridged to transplantation. Two of the three patients are alive without any recurrences. One patient died prior to further heart transplantation while being on intracardiac rotation pump. Although reintubation was necessary in two of our patients (due to interventional heart catheter) total time breathing sponteanously and being conscious while on ECMO was [80 %. Conclusion: We conclude that the concept of ''Awake VA-ECMO'' is feasible and safe for the treatment of acute cardiac failure and can be used as a ''bridging strategy'' to recovery or further VAD implantation in pediatric patients. Background and aims: To study associations between polymorphism of ACE gene and the development of asphyxia as well as to investigate the state of hemodynamics on the 1st day of life in the term newborns, stratified in accordance to genotypes of the ACE gene.

Methods: We investigated the associations between polymorphisms of the angiotensin converting enzyme-1 (ACE-1) and the course of asphyxia in 70 term newborns. Thirty-eight healthy controls were also genotyped. We measured the heart rate, blood pressure, urine output during the first day of life in newborns with different genotypes ACE gene. Statistical package for social science (SPSS) program version 16.0 was used for analysis of data. Multiple regression analysis was performed to assess the combined influence of variables on asphyxia and hemodynamics values.

Results: The differences of D allele and D/I genotype of ACE gene were found significant between asphyxia group and the controls (p = 0.004). Score of the Apgar scale on the 1st min was significantly lower in babies with genotype D/D, than in children with genotype I/D. The absence of significant differences in heart rate, blood pressure, urine output during the 1st day of life in newborns with different genotypes of ACE gene was shown.

Conclusions: ACE D/D genotype implicated possible roles in the severe asphyxia among term neonates. This result might be useful in planning therapeutic strategies for individual patients. Objective: To describe two cases of child abuse that have caused brain death and subsequently were subsidiary for organ donation.

Clinical cases: A 4-year-old child was transferred to our PICU, unconscious. The parents reported that he had fallen to the ground when leaving the bath. At admission he presented Glasgow score 3/15, mydriatic pupils without light reaction; multiple bruises in different stages of evolution and blunt wounds. He was put on mechanical ventilation. Brain tomography showed a subdural hematoma and brain swelling. Abdominal tomography showed pancreatic contusion. He also presented retinal hemorrhages. Brain death was diagnosed. A 54-day-old infant was transferred to our PICU due to severe intracranial lesions. The parents reported a history of hypo-activity without history of trauma or shaking. He presented Glasgow score 3/15, anisocoria with mydriatic right pupil and generalized hypertonia. He was intubated and mechanically ventilated. He presented different stages of injuries in the neck, mandibula, nasal outer wing, mastoid region and parieto-occipital areas. Measures to control intracranial hypertension were performed but the patient progressed to brain death. In both cases, a probable diagnosis of child abuse was made and the appropriate legal steps were taken to obtain organ donation that finally was successfully performed.

Commentaries: Brain death is very uncommon in young children and, therefore there is a shortage of organ donation. Unfortunately, as we described in these cases child abuse can be a cause of brain death. Therefore, we must be aware to optimize the medical and legal management of these potential donors. Background: Hemodynamic monitoring (HM) is an indispensable part of managing critically ill children and needs to be part of a strategy to provide an improvement in outcome. We conducted a survey to assess the use of various HM modalities and protocols for hemodynamic monitoring by pediatric intensive care unit (PICU) physicians.

Methods: 400 PICU physicians in 29 countries were sent a webbased survey.

Results: 83 physicians in 83 PICUs in 15 countries responded. Heart rate, blood pressure and lactate were considered the most important parameters of 21 clinical, biochemical or HM derived variables (Fig. 1) . Central venous oximetry (ScvO 2 ) and lactate were considered important by, respectively, 71 and 79 % of respondents (percentage attributing a value [7 on a 0-10 scale). 57 % of respondents indicate their PICU does not have or does not commonly use a protocol for hemodynamic management. 55 % of respondents indicate to sometimes or frequently use cardiac output (CO) monitoring (Fig. 2) .

Conclusions: 1. ScvO 2 and lactate are valued parameters, but despite international campaigns promoting an end-goal-directed approach to hemodynamic management using these parameters, such protocols are used infrequently. 2. CO monitoring is not widely used. Septal defect (DIA, DIV, A-V defect) are the most frequent congenital heart defect, near 35-40 % of all of them. Prevalence is 7/1,000 live birth, and often are associated with other congenital heart defects. Large and not treated defects in the right moment are associated with serious complication. A systolic murmur can be the first sign of the congenital heart defect in a newborn babies, and in the same time the most commune reason of for a cardio-paediatric consultation. Prevalence of presence of a systolic murmur neonatal period is different in different articles and is published from 0.9 to 77.4 %. This difference in prevalence seems to be related to with the size of the study. Aim: To assess the frequency of congenital heart septal defect in neonate referred to our pediatric cardiology service, the single pediatric cardiac tertiary center in Albania. Methods: Were analysed retrospectively the data-base of the outpatient clinic of our service, all neonates during June 2009-June 2012, referred for evaluation by the Pediatric community. Referral reasons was a systolic murmur 80 %.

Results: A systolic murmur often is not associated with clinical manifestations, but is strongly related with a DIV. More affected are male neonates. The high incidence of these defects draws attention to a careful examination of newborns in terms of time to capture the heart defects that would later complicate the future of healthy children. Diagnosis and timely correction of congenital heart diseases, cures or improves quality of life. Objectives: To determine the effects of prophylactic compared to selective treatment with Indomethacin on the rate of PDA surgical ligation, the incidence and severity of intraventricular hemorrhage (IVH), as well as other associated neonatal morbidities.

Methods: A change in practice from prophylactic Indomethacin to selective treatment with Indomethacin based on echocardiogram evidence of a hemodynamically significant PDA (hsPDA) was made in our institution. Retrospective chart review was conducted on all infants born \30 weeks of gestation from June 2010 to June 2012. Data collected included: demographics, incidence of hsPDA, PDA ligation rate, intraventricular hemorrhage and other secondary outcomes. Statistical analysis was performed using the Chi square test and the Fisher's exact test.

Results: A total of 118 infants met inclusion criteria; 61 received prophylactic Indomethacin and 57 infants received selective treatment. The groups had comparable baseline characteristics. Compared to the prophylactic group, the selective treatment group had a higher rate of surgical PDA ligation (14.6 versus 4.5 %, P = 0.15) and a higher incidence of severe IVH (36.6 versus 15.9 %, P = 0.05). All other outcomes including the incidence of PVL, pulmonary hemorrhage, pulmonary hypertension, CLD, SIP, NEC, sepsis, ROP, renal insufficiency and NICU length of stay were not statistically significant. Conclusion: Prophylactic Indomethacin decreases the severity of IVH among infants\28 weeks of gestation at birth. Although the rate of surgical ligation of PDA did not reach statistical significance, there was an increase in trend with the selective treatment group. Background: Congenital heart defects (CHD) are a leading cause of infant mortality. It has been suggested that newborn screening with pulse oximetry may be a screening test which is both clinically and cost-effective. Objectives: We aimed to quantify the detection rate of major CHD in babies born at our regional perinatal centre and to describe the timing of diagnosis.

Methods: Information about babies born with cardiac anomalies was cross referenced against fetal and cardiac databases over a 12 month period in 2010. Major cardiac defects comprised 'critical' anomalies (those needing intervention in the first 28 days of life) and 'serious' cardiac anomalies (those needing intervention in the first year of life). Results: 154 babies were admitted to the cardiac centre with critical (120) and serious (34) cardiac anomaly, of whom 20 babies were born at our centre. Of these 20 babies, 14 were diagnosed antenatally (11 critical, 3 serious) and five babies were diagnosed postnatally prior to discharge (3 critical, 2 serious). One critical lesion was not diagnosed prior to early transfer for intestinal surgery. The overall rate of major CHD in our cohort was approximately 2.4 per 1,000 livebirths. Conclusion: The antenatal detection rate of major CHD at our centre was higher than in recently published reports. High antenatal detection rates are likely to reduce the clinical and cost-effectiveness of postnatal screening interventions for major CHD.

Healthcare ( Objectives: Use of tobacco is a worldwide problem that begins early in childhood and builds up to lifelong habit. This study determined the perception of school students regarding the health related risks associated with various forms of tobacco. Materials and methods: This cross-sectional study was conducted among school students from Ajman, UAE. Student's perspective of health risk associated with various forms of tobacco was assessed using a self-administered questionnaire. Descriptive and inferential analysis of the data was performed using SPSS.19. Results: 229 male and 182 female students (mean age: 15.6 ± 1 years) of Grade IX-XII, participated. More than 80 % were aware of health risks associated with tobacco use. Moderate-severe level of health risk was attributed to cigarette smoking, chewing tobacco, dokha, and sniffing tobacco by 93. 4, 92.5, 89.9 , and 89.1 %, respectively. About 78.6 % attributed moderate-severe health risk and 21.4 %, no/mild health risk with smoking shisha/hookah compared to other forms of tobacco (p \ 0.001). Female students were more aware than males about health risks with shisha/hookah smoking (p \ 0.001). There was no association between parent's educational qualification and student's perception of tobacco-related health risks.

The common source of their information included television, internet and newspapers.

Conclusion: Students were aware of tobacco related health risks. Lower level of health risk was attributed to smoking shisha compared to other forms of tobacco. School-based programs with active involvement of adolescents could increase the awareness of tobacco related health risks especially the water pipe smoking. Prenatal Searching Tests are suggested to the pregnant women in many countries as a part of routine care before the birth and these tests are giving approximative informations about whether the baby has anomaly or not. These qualitative research was conducted with 33-45 aged 11 women who have babies in risk of congenital anomaly. The data were obtained with half configured interview form. The women's marriage years were 13.45 ± 2.97, birth numbers were 3.09 ± 1.37, alive children numbers were 2.45 ± 0.52, birth weeks were 15.55 ± 3.88. It has been determined that the factors that affect mothers of babies with congenital anomaly risks are ignorance, fear-worry-anxiety (of complications of interventions, of missing malformations and of detection of malformations) and religious beliefs. Nurses and midwives can help in evaluating test programs and assessments or planning, application and management or can nurture assessed patients according to the results. Nurses can provide the information and help necessary in all stages of the process in order to minimise psychological costs. Objective: We analysed changes in the demographics of patients admitted to our Neonatal and Paediatric Intensive Care Unit between 1st January and 31st July 2009 compared with the similar period of 1999. Materials and methods: Retrospective analysis of all charts of children admitted in the above mentioned periods. We performed a descriptive analysis of demographic data, reasons for admission, length of hospital stay and mortality. SPSS 13.0 was used for data analysis. A p value of .05 was considered statistically significant.

Results: A total of 511 patients had 561 records: 257 patients were from 1999, and 304 from 2009. In 2009 more patients came from rural areas (p \ 0.025). Most of the patients were referred from another hospital; within the studied periods more came directly from home and less from the family doctor (p \ 0.001).There were more newborns and less infants in 2009 vs 1999 (p \ 0.001). There was a slight but not significant decrease in mortality rates (4.7 % in 1999 vs 4.3 % in 2009) , mainly because of a significant and constant increase in case complexity in recent years and the availability of mechanical ventilation in 2009. Conclusion: Within a period of only 10 years we observed an increased number of patients and a wider range of referral centres, especially those from rural areas; a similar trend was noted in the percentage of newborns in the total admissions and in the case complexity, which required the adaptation of our resources to the new conditions. Background and aim: The 65-item EMPATHIC questionnaire measures parental experiences and satisfaction. A shortened version is recommended to facilitate routinely use, to benchmark European PICU services, and to increase response rates. This study aimed to statistically shorten the EMPATHIC questionnaire and to validate the short version. Methods: The 8 Dutch PICUs participated in the study. Multiple regression analysis was applied to eliminate redundant items and evaluating the explained variances. Pearson's product moment correlation coefficient was used for the linear association between the reduced domains. Validity was evaluated by R 2 -adjusted for internal cross-validations. Reliability was assessed by internal consistency. Results: 3,354 (55.4 %) parents completed the 65-item EMPATHIC questionnaire. Statistical redundancy resulted in 30 items over five different domains: Information (5); Care and cure (8); Organization (5); Parental participation (6); and Professional attitude (6). Explained variance of the total scores was 97 % and within the individual domains ranged from 85 to 95 %. The domains of the 65-item and 30-item EMPATHIC questionnaires showed strong correlations (r = 0.92-0.97; p \ 0.001). On domain level, crossvalidation among 8 centres and across two time periods provided R 2 -adjusted values between 85 and 95 %. Cronbach's a reliability estimates on domain levels were between 0.73 and 0.93 and of the 30-item scale was 0.93. Conclusions: The statistically shortened EMPATHIC-30 provides parents a feedback form taking less time to complete and the outcome covers at least 97 % of the variances of the 65-item EMPATHIC questionnaire. Benchmarking parent satisfaction outcomes facilitate European PICU healthcare professionals to identify quality of care improvements.

Intensive Care Med (2013) 39 (Suppl 1):S1-S200 Introduction: Recently the process of study and exploration of learning disorders had been developed remarkable and specialists concentrate it more than past and they believe that specific learning disorders cause to make low performance in necessary skills to communicate with others and its result are social relationship disorders, self-esteem reduction, victim and low performance of children and students in different levels. However some children have normal or high normal intelligence and also well hearing and visual perception but they can not learn educational subject by using of educational standard method so they were sent to education and habilitation specific learning disorder centers by pre-schools or consulters and child psychiatrist. At first these children have enough confidence to educational improvement but gradually they understand that other children are better than themselves in learning aspects. They feel they are differ from others by passing few months of academic year and their self-confidence become low. They hate school and their parent force them and make the condition difficult because their parents are not well informed and these parents and teachers compare them with others unjustly or humiliating. Gradually these children become depressed, anxious, victim and we cannot solve their problems completely. Therefore, pediatricians can help parents who are the first people on delay of motor or speech growth, impaired cognitive skills (visual, auditory), visual memory weakness, impaired speech or language skillsÁÁÁshare with their children. Introduction: 200 million pregnancies occur each year worldwide, that about 1/3 are unintended, and half of them will lead to abortion. Materials and methods: Sectional study on 105 pregnant women referred to health centers that were selected cluster randomization. Results were analyzed in SPSS11.5 with appropriate analytical test.

Results: Mean maternal attitudes about unwanted pregnancy and its complications was 2.845 ± 5.495 of total score 10 and mean knowledge was 3.543 ± 12.085 of total score 20. Prevalence of Unwanted Pregnancy in women was 29.5 and 28.3 % had a tendency to abortion. And contraception before pregnancy in 46.2 % was natural method and 30.8 % was condom. Significant association was found between mothers 0 education and unwanted pregnancy, Thus the incidence of unwanted pregnancy in women who their husbands and their had a university education was higher than at other women. (p \ 0.05). Results showed that unwanted pregnancy in working mothers was higher than the housewives (p \ 0.05). There is a significant relation between the number of children and unwanted pregnancy, Thus the incidence of unwanted pregnancies in women who had three or more children was higher (p \ 0.05). Prevalence of unwanted pregnancy in mothers who higher than 35 years was the most (p \ 0.05). Conclusion: About training different methods of contraception and the risks of unwanted pregnancy, especially among working women with higher education level and age be planned. Our aim was to analyse the role of a video laryngoscope in the intubation of neonates amongst new Paediatric trainees and also its role in cases of difficult intubation.

Methods: A Storz C-MAC video laryngoscope along with Size 0 and Size 1 Miller blades, was purchased for the Exeter Neonatal Unit, using funds from the Peninsula Deanery Innovation Fund. The laryngoscope's use was analysed over a 10 week period in order to assess the success of neonatal intubations along with trainee and consultant feedback. Results: The laryngoscope was used by three ST1 Paediatric trainees for their first attempts at neonatal intubation. Six out of six intubations were successful (four emergency and two elective). Both trainees and Consultants felt the laryngoscope facilitated the teaching and process of neonatal intubation. It was used successfully in a case of neonatal subglottic stenosis, aiding intubation and enabling video footage to be sent to the receiving unit.

The video laryngoscope is an effective intubation tool. It enables greater visualisation of the laryngeal structures, thus facilitating teaching and improving technique of neonatal intubation amongst Paediatric trainees. This in turn has the potential to improve patient safety through fewer oesophageal intubations and faster procedure times. CenTre Neonatal Transport Service, 2 University Hospitals Leicester NHS Trust, 3 University of Leicester, Leicester, UK Background and aims: In our area babies requiring patent ductus arteriosus (PDA) ligation require inter-hospital transfer to specialist paediatric cardiac hospitals. The CenTre transport team picks-up the baby from the referring neonatal unit, transfers to the cardiac PICU, takes the baby to surgery, reviews the baby post-operatively to ensure stability and transfers back to the referring unit. We describe a 3 year experience with this type of transport, reviewing transport logistics and complication rates. Methods: A retrospective review of all PDA transports conducted from 1st April 2010 to 31st March 2013. Results: 41 PDA transfers were conducted, 1 baby was unfit for surgery when assessed on arrival and another was medically unfit to be transferred back the same day. The logistics of these transfers are shown in Table 1 . The greatest proportion of transport time was spent from arrival at the cardiac centre to transfer into theatre at a median time of 2 h 50 min. Median total transport time was 11 h 24 min. Complications, defined as reintubation, hypotension, hypothermia, or acidosis (pH \ 7.2) occurred in 19 (48 %) infants. These were all managed successfully. Background: Bronchopulmonary dysplasia (BPD) is one of the most challenging and persistent problems of modern neonatal medicine. Use of dexamethasone is accompanied by adverse neurological outcomes, in particular hippocampal atrophy and cerebral palsy.

There is an important perceived need for a safe and efficacious steroid preparation. Surprisingly, betamethasone is not commonly used as a postnatal glucocorticoid. Antenatal betamethasone has been associated with a decreased risk of cystic PVL. The penetration of dexamethasone into the CNS is higher compared to betamethasone. Betamethasone has been used in pregnancy for over 20 years with high level of safety and efficacy. Recent animal studies suggest its vasoconstrictor effect and thus it might affect the incidence of IVH and PVL.

Methods: This prospective audit was approved by Nepean Human research Ethics committee in 2012. Dose: 0.125 mg/kg IM for 3 days The changes in FiO 2 and MAP after starting Betamethasone were recorded every 6 h till 120 h after the first dose. For the safety data mean BP (invasive and non invasive) was recorded every 6 h for 120 h as also the blood glucose readings.

Results: This was a short experience of Betamethasone use in an Australian NICU. It suggests that betamethasone is useful and very well tolerated without any significant adverse events. Out of five infants, three were successfully extubated. In case of two infants it was changed to dexamethasone within 24 h of the first dose. Current policy in our NICU is to consider Betamethasone as a first line for postnatal steroids wherever possible.

Results of the review/audit of betamethasone use Background and aims: Hypocarbia reduces cerebral blood flow, potentially impairing neurodevelopmental outcome. Avoiding hypocarbia in the ventilated infant during transport can be challenging. Physiology is changing with stabilisation, there are fewer opportunities for regular blood gas analysis, and transport ventilators are less sophisticated e.g. Babypac.

We sought to determine the scale of the problem and characterize babies most at risk. Methods: Data from transports during the year 2011/12 were reviewed retrospectively. Babies with a pCO 2 \4 kPa at completion of transport were identified and their notes reviewed for additional data regarding diagnosis and respiratory status.

Results: There were 256 ventilated patients transferred of whom 32 (12.5 %) arrived at the receiving hospital with a pCO 2 below 4 kPa, and 5 (2 %) of those had a pCO 2 below 3 kPa. The majority of affected patients had HIE (25 %) or were premature (44 %). The category of transport was important with a trend for over-ventilation in the resource rather than uplift subgroup (20.9 vs 10.8 %). Babies with hypocarbia had minimal ventilator requirements during the transfer (FiO 2 21-28 %, PEEP 5-6 mmHg, PIP 16-21 mmHg). Trajectory of pCO 2 from referral to departure was negative in 6/21 (29 %) patients. There was no association with gestation, weight or age in days. Conclusion: Over-ventilation is a significant problem. We found no single factor identifying patients at risk. Until patient characteristics of at risk populations can be accurately defined any ventilated patient should be considered at risk of over-ventilation during transport. Clinical strategies to address this problem are required.

L. Pritchard

Objective: Unplanned extubation in PICU is an untoward event leading to increased duration of ventilation and hospital stay. As part of a drive to reduce the number of unplanned extubations, staff opinions were sought on factors leading to unplanned extubations and methods of decreasing the risk. Method: An online survey was distributed amongst all medical and nursing staff. Responses were encouraged by word of mouth and posters in the staffroom.

Results: 28 responses were obtained. 28 % of respondents were consultants, 18 % junior doctors and the remainder nursing staff. 78 % of respondents had cared for a patient who had accidentally extubated. The main risk factors for unplanned extubations were felt to be training in endotracheal tube (ETT) taping methods, frequency of retaping, inexperience of the nursing staff and low staffing levels in the unit. Suggestions to reduce the risk of unplanned extubations included training in taping methods and handling of intubated patients for both nursing and medical staff, regular ETT re-taping, review of the sedation scoring method and case reviews of unplanned extubations.

Conclusions: Based on the results of this questionnaire the following recommendations were made.

• Training sessions on ETT taping.

• Review of tapes every shift to assess need for re-taping.

• Improvement of sedation scoring method and review of sedation methods. • Regular case reviews of unplanned extubation with feedback circulated in the staff newsletter. Introduction: Vitamin deficiency and iron deficiency anemia are common nutritional problems, at least in children under 5. These materials shortage, especially in the first 2 years of life, impair physical and brain growth, reduces the child 0 s learning ability, reduces body resistance against infections, behavioral changes, apathy and finally social and economic adverse consequences would be followed.

Methods: This study is a cross sectional descriptive study interviewing 300 mothers with their children from 6 to 24 months which referred to selected health centers. Information obtained from research tools was added into the SPSS11.5 software.

Results: In growth chart, 86.7 % of children showed appropriate growth, 10.3 % had delayed growth and 3 % had horizontal growth curve. In 80.7 %t of families, maternal multivitamin and iron drops have been used to their children regularly, 1.7 % did not believe in these supplements and 17.7 % of mothers sometimes used these supplements for their children. Statistical correlation significant variables of parental education, family income, mothers referred to health centers for monitoring the growth and get face to face training of personnel center drops of multivitamin with iron and growth status of children variable is available, so children who regularly have used supplements and income level and above are literate parents have grown more favorable than the other kids. (P \ 0.05). Conclusion: Regarding the importance of iron and multivitamin use in children under 2 years, necessary training must be provided to mothers in this field by health centers personnel. Objectives: Pneumonia is a major cause of morbidity and mortality in children under-5 year age in developing countries. Cytomegalovirus is associated with serious morbidity and mortality in children with pneumonia. The purpose of the study was to determine the incidence of CMV associated pneumonia in children with severe lower respiratory tract infection (LRTI).

Methods: Under-5 year children with severe LRTI were enrolled over 12 months. Criteria for severity were respiratory distress, supplemental oxygen, or assisted ventilation. Anthropometry and HIV status were recorded. Throat swabs were taken for CMV PCR. Results: 107 children, aged 2 weeks-46 months (mean 5.96 months) participated The incidence of CMV-associated pneumonia was 40 % (35/87); 67 % among HIV-infected and 28 % among HIV-uninfected children (p \ 0.05). Of 100 children tested for HIV infection, 30 % were positive. Mean ages of HIV-infected and uninfected children were similar (5.83 ± 5.77 vs. 5.99 ± 5.43 respectively). There was a slight difference in height-for-age Z-scores between HIV-infected (-2.51 ± 3.22) and uninfected (-1.17 ± 3.41) (p = 0.07). Incidence of CMV was not associated with age or nutritional status. There were 18 deaths, 17 % (18/107) mortality; this was higher among HIV-infected children (40 %) than in HIV-uninfected (9 %) (p \ 0.01) ( Table 1) . Mortality was higher amongst those with positive CMV PCR (20 %) compared to negative CMV PCR (12 %) (p \ 0.002) ( Table 2) .CMV PCR positive participants were likely to receive assisted ventilation (17 %) versus those with negative CMV PCR (11.5 %); (p \ 0.058). Conclusion: Incidence and mortality rate of CMV-associated pneumonia is higher in HIV-infected children and these children are likely to require ventilation. Methods: Over 8-weeks period, 50 of 150 infants admitted with acute gastroenteritis were found to have rotavirus (RV) antigen in stool and in their serum using ELISA. Sera 150 infants were analyzed for cardiac troponin-I (cTnI) creatine phosphokinase (CPK), lactate dehydrogenase (LDH). Results: Thirty-four infants (22.6 %) had elevated cTnI (0.06-2.5 ng/ ml)).Infants \1 year, and those with dehydration or acidosis were more prone to have elevated cTnI. Infant with severe dehydration had an estimated 190 fold higher odds of having elevated cTnI compared with those with no dehydration. A border line significant association was detected between RV positivity and elevated cTnI (odd ratio = 2.1 95 % CI 0.98-4.6. p = 0.054). Multivariate logistic regression analysis, showed that severe dehydration and acidosis are still significantly associated with elevated cTnI levels (adjusted OR, CI = 22.9, 2.19-239 and 20.76, 6.15-70 respectively. cTnI levels normalized within 24-72 h). Conclusion: Our data suggest that cardiac injury during gastroenteritis in infants is quit frequent but always self limiting if the underlying perfusion disturbance caused by severe dehydration is corrected. 

Herpes simplex virus (HSV) infection in the neonatal period is usually caused by type 2 virus following maternal peripartum genital HSV infection. Type 1 HSV usually affects infants after 3 months of age. Neonatal HSV infection can be localized to skin, eye and mouth, involve the central nervous system or manifest as disseminated infection involving multiple organs. Illustrative case: A full term male baby; birth weight of 3.25 kg, was born vaginally to a primiparous mother with uncomplicated pregnancy and no known history of HSV infection. Intrapartum and postpartum period were uneventful with normal physical examination. At 20 days of life, the neonate presented with lethargy, poor feeding and later developed generalized tonic-clonic seizures. Initial workup showed metabolic acidosis with normal septic screen, glucose, calcium and electrolytes. Neuro-sonogram showed diffuse cerebral edema without gross structural malformation or intracranial hemorrhage. Seizures were not controlled with intravenous phenobarbitone, phenytoin and pyridoxine. On starting intravenous midazolam baby developed poor respiratory efforts and was intubated. Baby was started on cefotaxime and ampicillin after drawing blood for culture. Serum ammonia and lactate levels were mildly elevated. Lumbar puncture attempted after seizure control showed 93 WBCs, 90 % lymphocytes, normal glucose and mildly elevated proteins. With possibility of viral encephalitis; intravenous acyclovir was started. EEG showed PLEDS and CSF HSV-PCR detected Type 1 HSV. This case illustrates the nonspecific presentation of neonatal HSV infection without maternal history of HSV and complexity in the management. Early initiation of acyclovir reduces HSV associated morbidity and mortality in neonates.

ANTIBIOTIC PROPHYLAXIS AND VESICOURETERAL REFLUX S. Brahmi, N. Righi, H. Zerguine

For years before and the fear of danger that can cause reflux in the renal parenchyma, practitioners prefer to establish a long-term antibiotic prophylaxis soon discover this malformation. And without paying attention to the drawbacks of this therapy in the emergence of bacterial resistance to antibiotics and the difficulty of adherence to treatment long enough.

Since the advent of scintigraphy has allowed a better understanding of the mechanisms of reflux nephropathy and before the outbreak of an epidemic of bacterial resistance, the effectiveness of this antibiotic is reconsidered by several international experiences. Department of Pediatrics at the University Hospital of Batna, a city inside of Algeria, we collected 26 patients with mean age of 3.7 ± 0.6 and sex ratio of 0.86 (14 files/12 boys) with a reflux primitive 73 % of cases and grade 2 and 3 in the majority of cases. We performed a comparative study between the number of urinary tract infection home for a year and a year without antibiotic cotrimoxazole preventive dose.

We have no significant difference T = 1.43, 0.1 \ P \ 0.2. There was no real change in the distribution of germs against a higher resistance to cotrimoxazole was noticed. Conclusion: Our results are similar to those defending the hypothesis of non-effectiveness of antibiotic prophylaxis of reflux especially low-grade and especially after first pyelonephritis.

PYELONEPHRITIS, DIAGNOSIS REMAINS DIFFICULT S. Brahmi, N. Righi, H. Zerguine

Pyelonephritis is considered the most serious urinary tract infections because of the possibility of formation of parenchymal scar and therefore likely evolution towards achieving renal function. In Algeria and in a city before (Batna), rapid diagnosis of this disease entity is very difficult to the unavailability of several elements (biological and radiological) currently considered the most reliable. What motivates as in many countries around the world reflect on a diagnostic score.

In this interest, we performed a prospective study over 2 years in the only pediatric ward of the city (CHU). The prevalence of urinary tract infections was 3.19 % while the diagnosis of pyelonephritis as service specialists were chosen over examinations is generally beyond the acute phase in 2.25 %. We collected 209 patients with an average age of 2 ± 0.4 year and a sex ratio of 0.48. And 29 % of them brought uropathy malformations. The clinical presentation was nonspecific outside of high fever ([38.5°) very significant in cases of pyelonephritis (p = 0.00013), the parasite was glued to cystitis (p = 0.0112).

In lack of procalcitonin The hyperleukocytosis NSF was highly significant for the diagnosis of PNA (p = 0.0000) followed by CRP C 20 mg/l (p = 0.00056) and ESR (p = 0.0056). In our study, the sensitivity of ultrasound in the topographic diagnosis was higher (p = 0.00347). Altogether, our results support the theory of clinical score, biological and radiological because there is not enough evidence available for regular initial topographical orientation. Fungal colonization remains an important risk factor for future invasive fungal infections among ICU patients.

Objectives: To determine the pattern of fungal colonization in patients admitted in pediatric ICU, to evaluate biofilm production by acquired candida species and compare their antifungal susceptibility.

Methods: The pattern of fungal colonization, biofilm production and quantification of antifungal activity was studied and identified in fifty critically ill patient admitted to pediatric intensive care of Ain Shams University hospital with mean age of 85 + 51.67 months. They were swabbed from 3 different sites; oropharyngeal area, axillary folds, and rectal area and urine sample was collected. They were swabbed at the first day and at the third day of PICU admission.

Results: The rate of colonization among studied patients was found to be 74 % at day one with predominance of C. albicans (32 % of the studied patients). In Pediatric Intensive Care Unit (day 3); 70 % of patients acquired additional fungal colonization with predominance of nonalbicans candida. In PICU (day 3); nonalbicans candida was isolated from 38 % of patients, candida albicans was found among 10 % of patients. Age below 1 year old, insertion of central venous cannulation, receiving more than three antibiotics and use of carbapenems were the risk factors for fungal colonization (P \ 0.05). Ability of biofilm formation was detected in 90 % of all candidal strains acquired from PICU. Conclusion: Critically ill pediatric patients are at risk to be colonized with highly resistant candidal strains with ability of biofilm formation. Introduction: Clinical signs and laboratory tests of neonatal sepsis are non-specific and diagnosis is difficult. Early antibiotic therapy is follow-up. IMA levels were significantly higher in infants with stage III NEC than those in infants with stage II NEC at the 1st day, 3rd and 7th days (P \ 0.001). The area under curve (AUC) for IMA (0.815 at diagnosis, 0.933 at the 3rd day, 0.935 at the 7th day) were significantly higher than CRP and IL-6 at all days for predicting perforation in infants with NEC (P \ 0.001). Similarly, the AUC for IMA (0.952 at diagnosis, 0.929 at the 3rd day, 0.971 at the 7th day) were significantly higher than CRP and IL-6 at all consequent days of diagnosis for predicting mortality in infants with NEC (P \ 0.001). Conclusion: Ischemia modified albumin was found to be superior to CRP and IL-6 at both diagnosis and follow-up of NEC.

Long term Outcome ( There are around 56 reported cases in English literature. Though the lesion is usually present t birth it may be often overlooked or misdiagnosed. The review of literature shows a mild female preponderance and noted more commonly among Caucasians. Congenital midline cervical cleft (CMCC) is characterized by an atrophic mucosal plaque with a cranial nipple-like skin tag, a short caudal sinus, and may be attached to a subcutaneous fibrous cord of variable length. CMCC can prevent full extension of the neck resulting in micrognathia and torticollis; may predispose to infection, and maybe associated with other clefting defects or cysts. Embryologically, CMCC is hypothesized to be due to impaired midline fusion of first or second branchial arches; exteriorization of thyroglossal duct remnant, or due to increased pressure by pericardial structures on the cervical area in the developing embryo. We describe a newborn female born to non-consanguineous parents of Pakistani origin weighing 3.65 kg at birth with CMCC, retrognathia, bifid uvula and recurrent gastro-esophageal reflux resulting in failure to thrive. An extensive review of literature focusing on embryo pathogenesis, histopathology, diagnosis, and treatment of this rare condition are also discussed. Prompt diagnosis and treatment during early infancy leads to a better functional and aesthetic outcome with the least complicated surgical intervention. Objectives: Our aim was to assess the pre, intra and post operative management and review morbidity following anaesthesia and surgery.

Methods: 45 children were highlighted from surgical operating lists with a code of muscular dystrophy during the period of April 2009 until April 2012. Results: 35.5 % of patients were part time and 40 % full time wheelchair users. The group had a mean weight of 41 kg and 8.8 % were gastrostomy fed. 8.8 % of the patients required non-invasive home ventilation and 28 % of patients required cardiac medication. Pre-operative cardiorespiratory testing was variable. 66.6 % had an intravenous induction and in 80 % anaesthesia was maintained intravenously compared to 33 % who underwent a gas induction and 20 % who received gas as their maintenance anaesthetic agent. There were 13 elective postoperative admissions to PICU and no unplanned admissions. 3 (6.6 %) children died within 10 days of their surgery, of these, 2 children died within 24 h, both had intraoperative cardiac arrhythmias which progressed to PEA. The 3rd child died 9 days after surgery following a respiratory arrest.

Conclusions: A more uniform approach to pre-operative assessment is needed, as it appears that not every child receives the same cardiac or respiratory investigations. It should also be highlighted that negative results do not necessarily rule out cardiorespiratory disease and thus risk. Anaesthetic technique remains varied and is a controversial issue. Preoperative assessment, intra and post operative planning should have an emphasis on cardiac and respiratory optimisation and support.

Metabolism Endocrinology and Nutrition (565-572) 

Tyrosinemia type I is the most severe disease of the tyrosine catabolic pathway resulting from deficiency in fumarylacetoacetate hydrolase (FAH) leading to elevation of tyrosine in liver, kidney and peripheral nerves. It is characterized by hepatic failure, cirrhosis, renal dysfunction, hepatocarcinoma, and neurologic crisis. The estimated prevalence of type-1 tyrosinemia worldwide is \1 in 1,00,000. We present a rare case of tyrosinemia presenting with abdominal distension and shock. A 2 month old female child of 2nd degree consanguineous marriage was born prematurely and was small for gestation (SGA baby). She was noted to have neonatal hyperbilirubinemia in the immediate neonatal period. Weight gain remained poor in spite of adequate feeding and supplementation. Persistent abdominal distension was noted, and was administered anti-flatulence drugs for the same and no improvement was noted. X-ray done showed gaseous distension. Tests for hypothyroidism and for Hirsch sprung disease were normal. Baby noted to have persistent vomiting; ultrasonography done was normal. After 1 month she developed cold clammy extremities with thread pulse, poor urine output, persistent vomiting with significantly distended abdomen. Investigations revealed E-coli positive UTI for which started on appropriate antibiotics. However the condition of the baby deteriorated and baby developed metabolic acidosis which was initially attributed to resistant E-coli sepsis. On further investigating, elevated level of alpha fetoprotein (AFP) was noted. The other reports revealed significant coagulopathy and the algorithmic work up revealed tyrosinemia. Tyrosinemia type I should be differentiated from other causes of hepatitis and hepatic failure in infants. Background: Albumin binds to bilirubin in the intravascular space and decreases the level of unbound bilirubin. During BET (blood exchange transfusion), as bilirubin levels fall, bilirubin moves from extravascular to intravascular space due to equilibration between two spaces and is available for removal by exchange. Thus, if albumin level could be increased in the intravascular space, the efficacy of BET may be improved. Background: Vascular dysfunction, accelerated thickening of arterial intima, and changes in ventricular functions contribute to increased cardiovascular morbidity in type 1 diabetes mellitus.

To investigate the changes of the arteries and myocardium and its relation to early biomarkers of inflammation hsCRP, CD146, vitamin C and D 3 in children with diabetes.

Methods: 30 children with T1DM (11.1 ± 3.8 years) and 30 healthy controls were included with matchable sex and age. Levels of hsCRP and CD146, vitamin C, D 3 , HbA1c were measured. QTc interval, left ventricular (LV) functions brachial artery flow-mediated dilation (FMD) responses and carotid intima-media thickness (IMT) were assessed .

Results: Children with diabetes had significantly lower E velocity (P \ 0.001), decreased E/A ratio (P \ 0.001), increased early DcT (P \ 0.001), and prolonged IVRT (P \ 0.001) compared with controls. Significant lower FMD response (P \ 0.001) and increased IMT (P \ 0.001) in cases compared with controls. A significant positive correlation between increased QTc interval and low FMD and increased IMT (P \ 0.001). A significant correlation between LV diastolic dysfunction and increased CEC event (P \ 0.04) and level of hsCRP (P.001. Increased carotid IMT and low FMD were higher in patients in the lowest tertile of vitamin C than in those in the highest tertile (P \ 0.001 and P = 0.014, respectively). Conclusion: Children with DM rarely have insight on the significance of DM, and their diet is difficult to control. Early regular evaluation of patients with diabetes for alterations in vascular endothelial dysfunction may help in early detection and prevention. Vitamin C supplementation may improve the prognosis. Nutritional management influences immediate survival as well as subsequent growth and development of low birth weight (LBW) and very low birth weight (VLBW) infants. Preterm infant formula (PTF) is used when there is an inadequate supply of mother's milk or mother is unable to breastfeed and donor breast milk is unavailable.

Objectives and methods: The purpose of this prospective multicenter study was to evaluate short-term effects on nutritional status (auxological and biochemical parameters) in a population of 97 preterm infants with a birth weight between 500 and 2,000 g, and a gestational age of 25-34 weeks postmenstrual age, who received a new preterm infant formula when comparing with 75 fortified human milk fed infants.

Results: No significant differences were observed between FHM and formula fed infants in terms of growth, feeding tolerance and biochemical prophiles.

Conclusions: We conclude that Nutribèn Pre is a valid, effective and safe alternative for the nutrition of preterm infants. The tested thyroid hormones, by using highly sensitive and specific RIA test, in serum from the umbilical cord in the newborn which suffer during birth (N = 66), showed the following: the perinatal factors evaluated through a lower Apgar score do not change the thyroid function in newborn in relation to the control group. Only under conditions of prenatal infections with various postnatal development we determined a state of ''low T3'' for sick newborn in relation to the healthy. The basic characteristic of the changes in thyroid status in newborn with severe non-thyroidal illness (N = 32), with a positive outcome, in relation to the control group (N = 28), is a result state of ''low T3-T4'' with significantly reduced free fraction of FT3 and FT4 (p \ 0.001), increased fractions of rT3 (0.001 \ p \ 0.05), and without changes in TBG and TSH. A statistical comparison of the mean values (t test) of the sick with positive outcome in a relation to the decreased showed an even larger depression of the active thyroid hormone in the decreased, especially of T4 (p \ 0.001), but also of TSH (p \ 0.01), in spite of the decreased values of thyroid hormones. This certainly shows an inefficient feedback mechanism in critically sick before death. It is evident that a relationship exists between the degree of illness and depression of the active thyroid hormones, especially T4 as a predictor of possible mortality. Objective: In this study we propose to highlight the impact of gestational diabetes on the risk of prematurity, respiratory distress syndrome and major complications of prematurity.

Methods: This retrospective study is based on analysis of data collected from Philanthropya Hospital-Department of Neonatology, during January 2012-March 2013. The followed parameters in preterm infants included: gestational age, birth weight, maternal age, multiple births, prenatal therapy with steroids, postnatal stabilizing, metabolic status: glucose, serum calcium in the newborn.

Results: Data analysis revealed the importance of monitoring metabolic status (glycosylated hemoglobin, serum glucose) in mothers at risk of premature birth, so that from 2,172 infants born in this period, 185 were premature. A number of 10 children at term and 25 preterm were born from mothers with gestational diabetes or pregestaţional, neonatal complication rate was similar: hypoglycemia, hypocalcemia, RDS, hyperbilirubinemia, metabolic seizures. Conclusion: Study regarding the problems of 25 preterm and 10 term babies born from diabetic mothers, indicate that prematurity is the only significant factor influencing the outcome. A direct relationship has been demonstrated between prematurity and increased incidence of metabolic disorders, respiratory distress syndrome and hyperbilirubinemia in these infants, however, with proper prenatal care, neonates of diabetic mothers do not seem to represent a hight risk to develop major complications of prematurity compared to neonates from non diabetic mothers. Systolic arterial pressure values in the 99th percentile were paired with BMI values above the 96th percentile in 18.2 % of cases. Both blood pressure components increase significantly with age. Diastolic arterial pressure indirectly correlates with blood sugar levels. Male subjects were found to be most exposed to systolic blood pressure values in the 95th percentile (32.2 % males vs. 22.9 % females). According to their relative weight in metabolic syndrome diagnosis, the clinical criteria considered were: triglycerides above the 95th percentile, blood pressure above the 95th percentile, blood sugar levels above 100 mg/dL. Conclusions: Cardiovascular risk factors seem to aggregate in metabolic syndrome sufferers. The second most important metabolic syndrome marker in children, HBP, increases significantly with age. Aim: Hyperglycaemia is common in very low birth weight premature neonates and associated with increased risk of intraventricular haemorrhage, increased mortality and morbidity. However, available data about the effects of sever hyperglycemia on developing brain seems to be limited in the early life. Therefore, we evaluated the effects of moderate and severe hyperglycemia on developing rat brain. Method: Thirty newborn Sprague-Dawley rats were randomly divided into three groups as control, mild hyperglycemia (30 % dextrose) and severe hyperglycemia (50 % dextrose) . Pups in the hyperglycemia groups were administered subcutaneous sterile dextrose solution at a dose of 4 ml/ kg daily from the 2nd day to the 11th day of life. Blood glucose levels were measured every day in all study groups by Glucostix Ò . Rat brain tissues were removed at the end of the study. Histopathological and immunohistochemical (TUNEL and caspase) examinations were performed. Results: Weight of the brain tissues in rats with hyperglycemia groups were significantly lower than the control group (P \ 0.05).

Weight of the brain tissues in rats with moderate hyperglycemia were lower than severe hyperglycemia (P \ 0.05). In the histopathologic and immunochemical evaluation, severity of brain damage and apoptosis were significantly higher in the severe hyperglycemia group, especially at the level of the hippocampus (P \ 0.05). Conclusion: In this study, particularly brain damaging effects of severe hyperglycemia were obviously seen in the developing brains of the pups. It might infer that severe hyperglycemia can damage the developing brain especially in preterm infants.

Neuro Critical Care (573) Introduction: NACA, a novel anti-oxidant, has indicated some promising results regarding organ protection after hypoxia. Patients and methods: Study design: Fifty-four newborn piglets, age 12-36 h, were included. Blood pressure, EEG and ECG were measured continuously. Randomised parallel-group design; one control group (n = 6) and 4 experimental groups (n = 12). Piglets were exposed to global hypoxia (BE -15 or -20 mmol/l, i.e. moderate/severe asphyxia) with or without NACA-treatment. Observed for 9.5 h. Statistics: The statistical analysis was performed by using SPSS. An independent samples t test was used, a p value \ 0.05 was considered significant.

Results: In piglets exposed to moderate asphyxia and treatment with NACA the mean rise in MABP was significantly lower, 26 ± 10 (±SD) from end hypoxia to 37 ± 7 after 30 min reoxygenation (deltaMABP = 11 ± 5.7),than for the group not exposed to NACA; MABP 34 ± 22 at end hypoxia and 54 ± 25 after 30 min reoxygenation (deltaMABP = 20 ± 8), p \ 0.01).

Significant difference between piglets exposed to severe asphyxia and treatment with NACA; MABP 33 ± 17 from end hypoxia to 38 ± 10 after 30 min reoxygenation (deltaMABP = 5 ± 12), and the group without NACA; MABP31 ± 22 at end hypoxia and 48 ± 25 after 30 min reoxygenation (deltaMABP = 17 ± 8), (p \ 0.01).

There were no differences in heart rate, pCO 2 , pO 2 , BE, temperature, pH, Lactate or cleaved Caspase 3, between the groups treated with or without NACA. Conclusion: The pigs in the NACA-groups had a slower rise of blood pressure after hypoxia. Whether this reflects an effect of NACA or underlying compensatory mechanisms is unknown. Further studies will address possible neuroprotective effects of NACA treatment following birth.

Nursing Science Group ( Anorectal malformations comprise a wide spectrum of diseases, which can affect boys and girls, and involve the distal anus and rectum as well as the urinary and genital tracts. In routine ultrasounds of a 29-year-old primigravida woman at 36 weeks, Anorectal malformation was identified. At 38 weeks gestation, an appropriate-for-gestational-age, 1,940 g, male was delivered by elective cesarean section at a tertiary level center. Associated malformations such as cardiac or genitourinary abnormalities were identified. Postnatal management included maintenance of feeding, fluids and electrolytes, stoma care, prevention of hypothermia, prevention of sepsis, and maintenance of cardiorespiratory stability. A primary or staged closure approach was used to repair the defect. Primary nurse was in a position to address the ongoing fears and concerns of these parents using a multidisciplinary and individualized approach. Although the initial instability of the infant temporarily precluded holding him, for example, primary nurse encouraged parents to hold their infant as soon as stability was achieved. The nurse promoted her inclusion in infant care needs such as stoma care. Regular family meetings with members of the multidisciplinary team provided parents an opportunity to ask questions and had their fears and concerned addressed. This case study has provided a guide of nursing care of the infant with an anorectal malformation and a guide for postnatal, and postoperative management. Nurses can be pivotal in meeting the needs of infants and families as they confront the challenges of recovery from this congenital anomaly. Background: With the new ESPNIC section structure to promote professional development it is timely to establish a European S194 Intensive Care Med (2013) 39 (Suppl 1):S1-S200

Total serum bilirubin in covered group, during the first 48 h of treatment, significantly were declined than control group (P value = 0.003). The cover around the phototherapy devices not only did not increase the side effects of phototherapy, but also had a positive impact in reducing duration of Jaundice (P value \ 0.0001) and duration of hospitalization (P value \ 0.0001).

The study results showed that using white plastic cover around the phototherapy unit can increase the therapeutic effect of phototherapy. In all cases hyperbilirubinemia lasted more than 14 days. Newborns with prolonged neonatal hyperbilirubinemia were divided into following groups: newborns with prolonged neonatal hyperbilirubinemia 31, 37 % newborns from anamnez perinatal infection of intrauterine origin were examined but bacteriologically not confirmed, 22 % newborns with cerebral ischemia and 10 % newborns born from mothers with hypothyroidism. Identification of the level of procalcitonin in plasma or serum was holded in the way of immuno chromatographical method. At the end of observation it was fixed, the value of PCT-test of newborns of prolonged neonatal hyperbilirubinemia in all studied groups 38.15 ± 1.07 week at age of 14 and more days of life made up 50 out of 100 children.5 ng/ ml and were not dependant from gestational, postnatal age. In four children the value of PCT-test in 14-18 days of life estimated 0.5 ng/ml. Out of them one of child, born from a mothers with complicated history and with factors of risk developing bacterial infection, in the 4th day of life PCT-test composed 2 ng/ml. In the dynamics of neonatal period it was not observed bacterial infection, and the level of PCT-test in the 6th day of life decreased up to 0.5 ng/ml. The level of procalcitonin plasma allows to present definite amount of characteristics defining hidden inflammatory process of newborns with prolonged neonatal hyperbilirubinemia in different background. The value of PCT-test in plasma or serum more than 0.5 ng/ml shows the amount hidden inflammatory process in children with prolonged neonatal hyperbilirubinemia.

Hospital Infection Control, The Org. of Teaching Hospitals Institute, Alexandria, Egypt

Introduction: It is unrealistic to hope for a germ free NICU, but it is possible to reduce the likelihood of hygiene. The NICU hygiene is affected drastically by the medical staff and the internal environment. This study will describe some of interactions between the laboratory and the improper housekeeping procedures.

Methods: The present study was conducted in NICU Damanhour Teaching Hospital. Where the cleanliness and sanitation was evaluated by bacteriological examination of the umbilical stump and the internal environment of the wards represented by floor, air, baby balance, baby heater, air condition device and baby care units.

The study revealed the failure of the routine housekeeping process. The study suggested three categories to control and prevent NICU Nosocomial infections. Also suggested a new technical for cleaning and sanitation of baby incubators by using stabilized hydrogen peroxide instead of formaline gas or other toxic disinfectants this process takes 45 min only instead of 48 h in case of formaline so we can save more lives by our limited no. of incubators, also this technical succeeded 100 % in removing all pathogenic microorganism.

The study revealed failure of routine housekeeping process, and suggests three methods to control and prevent NICU nosocomial infections, it also proposed a new technique, for cleaning Wards and baby incubators, and decreased the motility and morbidity rates among neonates.

Pharmacology ( Objectives: Alcohol consumption is an important epidemiological problem among the adolescents affecting their health and social life. Perceptions regarding the social implications and level of health risks with alcohol consumption were assessed among school students in Ajman, UAE. Materials and methods: A sample of 411 school students was surveyed on their perceptions of social implications and health related risks with alcohol consumption. A pre-tested, close-ended, selfadministered questionnaire was filled in after consenting. The data was analyzed using SPSS version 19; Chi square test was applied to determine association between variables. Results: Male students constituted 55.7 % of the total and the age ranged between 15 and 17 years. 'Alcohol consumption is harmful', was indicated by 91.2 %. Moderate-severe level of health with alcohol consumption was attributed by 91.7 %. Majority of the female students reported moderate-severe health risk with alcohol consumption than the males (96.3 and 87.7 %; p \ 0.01). 81.3 %believed alcohol consumption is associated with social problems. The common perceived social implications were frequent quarrel or arguments, accidents, problems with police, parents, friends, and poor academic performance. Female students highly perceived 'decline in academic performance, problems with parents and friends, and accidents as major social implications with alcohol consumption (p \ 0.05).There was no association between student's age, parents' qualification with level of alcohol related-health risks attributed.

was reached on these two tools, similarly to what has been done for BD in adults.

Results: 221 infants with ARDS coming from 7 European PICU were enrolled. Study algorithm is shown in Fig. 1 .

Mortality (p = 0.04), composite outcome ECMO/mortality (p = 0.009), survival time (p = 0.002) and PICU stay (p = 0.002) were different across the BD severity classes, while they were similar using the old ARDS definition. ROC analysis shows better productivity using BD than the old definition (for mortality AUC 0.6; p = 0.04; for ECMO/mortality: 0.62; p = 0.013). Illustrative radiographs and ARDS risk factors were blindly evaluated by some Respiratory Section members: there was a significant concordance between raters (for radiographs ICC = 0.6; p \ 0.008; for risk factors: ICC = 0.919; p \ 0.001).

Conclusions: BD is suitable and reliable for infants. We developed a consensus about clinical tools to use BD at the bedside. Objectives: Nasal obstruction is one of the main symptoms in chronic rhino sinusitis. The aim of the study is evaluation of nasal obstruction by acoustic rhinometry (AR) in children with chronic rhino sinusitis.

Methods: The study included 101 patients (2-15 years old) and 60 healthy children (control group). The children of the first group received a conservative treatment (anti-bacterial and vessel-constrictive treatment). Children of the second group received a conservative treatment, including the daily nasal lavage with antiseptic solution. We have investigated the nasal permeability by means of AR, using the rhino-meter RHIN 2000.

Results: In children with chronic rhino sinusitis, before the decongestion, the volume of the nasal cavity V is decreased, compared to the one of healthy children (group I: 2 69 + 0.164; group II: 2.89 + 0.260; healthy children-3.77 + 0.301). Also, we are attesting a decrease of the MCA, especially of the MCA 2. The examination of children after the decongestion demonstrates the increase of the volume data and of MCA; while in children with rhino sinusitis these parameters, anyway, do not reach the values of healthy children. The evaluation of the dynamics of modification of AR data on the 5th and on the 10th day of treatment shows the occurrence of the authentic differences between the corresponding indicators in children of group I and group II.

Conclusions: The mini-invasive nature, the simplicity and rapidness of the AR have a special value while applying this method in children. Neurally Adjusted Ventilatory Assist (NAVA) is a ventilation mode which uses electrical activity of a diaphragm to control ventilation. NAVA may be used both as an invasive and non-invasive ventilation and it helps to provide ventilation suited to a patient's needs and to wean a patient from mechanical ventilation gradually, in the way controlled by the patient himself. The authors present eight preterm infants ventilated using invasive and noninvasive NAVA. The mean corrected gestational age was 28 weeks (minimum 25, maximum 31) and the mean birth weight was 1,162 g (minimum 740 g, maximum 1,500 g). Four neonates were diagnosed with congenital infection. Six preterm infants were successfully ventilated and weaned using NAVA and NIV NAVA and in two cases ventilation mode had to be changed because of multiple central apneas. NAVA may be a useful ventilatory tool that helps to achieve gradual transition from invasive mechanical ventilation, through non-invasive ventilatory support to spontaneous breathing. Objectives: Compare end-tidal CO 2 (ETCO 2 ) with arterial CO 2 (PaCO 2 ) measurement during high frequency percussive ventilation (HFPV) in newborn infants and to assess the validity of ETCO 2 measurement in guiding the ventilation strategy.

The results of blood gas measurements corresponding ETCO 2 measurements were recorded. A correlation coefficient between ETCO 2 and PaCO 2 was calculated and a Bland Altmann graph was generated to assess the level of agreement. Significance was defined for two-tailed values of p \ 0.05. Analyses were performed in separate groups according to endotracheal tube (ETT) size 2.0-2.5-3.0 and 3.5 mm.

Results: 380 end-tidal and arterial CO 2 pairs were analyzed from 22 ventilated neonates. The correlation coefficient between ETCO 2 and PaCO 2 varied depending on the ETT size from 0.59 for size 2.0 mm to 0.64 for size 3.5 mm. The ETCO 2 value was lower than the corresponding PaCO 2 value in 52.6 % of the cases. The mean bias was -11.81 mmHg for all the ETT size, this was statistically significantly different from zero (p \ 0,001). The mean bias for each ETT size varied from -17.73 for tube size 2.0 mm, -13.29 for size 2.5 mm, -9.89 for size 3.0 mm and -7.36 for tube size 3.5 mm. During the study period we observed, a clear relation in the trends over time between ETCO 2 and PaCO 2 .

Conclusions: Despite the moderately strong correlation between ETCO 2 and PaCO 2 , the use of capnography could improve the observation of the ventilated premature infant and was able to detect low and high CO 2 warning levels, and thus, reduce adverse effects of mechanical ventilation. Despite compelling evidence showing that therapeutic hypothermia (TH) improves outcome in neonatal hypoxic-ischaemic encephalopathy and in adults after ventricular fibrillation, there are lacking evidence in paediatric patients with return of spontaneous circulation (ROSC) after cardiac arrest (CA). This prospective study aims to assess efficacy and safety of TH after paediatric CA.

This study was conducted in post-ROSC patients admitted to our PICU from January 2012 to April 2013. According to our protocol, using a servo-controlled cooling device, target temperature (32°-34°C) was gained quickly and maintained with minor fluctuations (0.2-0.5°C/h) for 24/36 h. Nine patients were included, mean age was 14 months (IQR 1.6-177). RCP duration was 34 ± 17 min and the gap between RCP and the start of hypothermia was 3.7 ± 1.6 h. Length of mechanical ventilation was 96 h (IQR 72-276), PICU stay was 10 days . VIS score was 11.3 ± 8.8. Five patients survived with Glasgow Outcome Scale 2.4 ± 1.4. A significant inverse correlation was found between survival and VIS 24 (r -0.74, p 0.024) and PRISM-III 24 (r -0.72, p 0.023). At 3 months follow-up, Paediatric Cerebral Performance Category score was B2 in four patients. Due to lacking evidence and protocols, TH after paediatric CA is not widely used. This study supports TH in children with ROSC but further studies are needed. Conclusions: Over the last 10 years there has been a marked increase in the overall activity of PETS. However, the proportion of children referred for critical illness requiring invasive mechanical ventilation and/or circulatory support has not changed suggesting that the increased activity is not due to a change in referral patterns. . Median PICU-stay was 4.5 days (IQR 2-13) for entire PICU population and 13 days (IQR 8-26) for ventilated patients. Correlation between BA and PICU-stay was demonstrated (r = 0.64, p = 0.0004). Patients requiring PICU stay [7 days, correlation was found between PICU-stay and MV need (r = 0.98, p = 0.0001). Seven patients showed evidence of ALI/ARDS and five underwent severe sepsis/ septic shock. Patients admitted to burn unit had median age 22 months (IQR 15-31), median stay 6 days (IQR 3-11), median BA 6.75 % (IQR 4-13). Despite children represented 25 % of total burned patients in recent literature, few data are available on intensive care of children with severe burns, but a worse outcome was suggested for children admitted to adult facilities. This 2-years experience illustrates potential advantages of a cooperation between a burn unit and a tertiary referral PICU in the management of infants with severe burns. Introduction: Cardiac arrest is a clinical event that can occur suddenly, often without premonitory signs. Outcome of CPR is dependent on many factors, the site of event, quality of CPR, whether the event was witnessed, time to basic life support, time to advanced life support and initial rhythm. Purpose: To determine the outcome of cardiopulmonary resuscitation in PICU and factors associated with unfavorable outcome. Methods: retrospective study of children with cardiac arrest and required CPR in PICU over a period from January to December 2010. Two outcome variables were measured (ROSC) and survival to discharge from PICU. Results: 700 PICU admission, a total of 172 (24.6 %) patients developed cardiac arrest that required CPR. ROSC was achieved in 78 cases (45.3 %), 25 patients (14.5 %) survived to discharge and 94 patients (54.7 %) did not respond to resuscitations. Success and survival were significantly higher in cases resuscitated for B20 min than [20 min (100 and 33.3 % vs. 32.4 and 10.1 % respectively). Success and survival were better for mechanical ventilation than those were not (48.1 and 17.8 % vs. 37.2 and 4.7 % respectively). Defibrillation was successful in 10 cases (25 %) and survival was in 1 case (0.5 %) and out of survivors 80 % had good neurological outcome. Conclusion: The frequency of cardiac arrest needed CPR was recorded in 24.6 %. Improving the quality of CPR is an important factor to improve the outcome by implementing training programs. Studies using neurophysiolological methods to predict the neurological outcome are needed.

Patients without previous intubation during admission or those with palliative indication for NIV were excluded. Patients were analyzed separately as rescue NIV (r-NIV): NIV used after extubation if respiratory failure reappeared, or elective NIV (e-NIV): NIV used immediately after extubation to prevent respiratory failure. Patient's demographic data, underlying disease, physiologic data (including SpO 2 /FiO 2 ratio (SF)) previous, at 2, 8, 12 and 24 h were collected. NIV failure, defined as need for intubation, was the primary outcome. Descriptive, Uni-and Multivariate statistic analysis (Cox Regression) was performed to identify predictive factor for NIV failure. Results: The sample consists of 316 patients. 113 r-NIV and 203 e-NIV. 203 were male (64.5 %). r-NIV patients, median age was 12 months

Conclusion: Lower SF ratio values at 2 h and age are predictive factors of NIV failure in post-extubation patients

Peri-induction'' complications

NWTS (RRT) role

Methods: Retrospective data from retrieval forms in infants intubated in DGH between 1st

Methods: Retrospective study conducted on critically ill children admitted in PICU, with severe sepsis, severe acute dehydration, and deceased by MultiOrgan Dysfunction Syndrome. The acid-base status (including lactate) assessment was made at entry, 6, 12, 24, 48, 72 h. Severe hyperlactatemia was defined as levels [5 mmol/l. Results: Study was conducted on 23 deaths occurred between

1) did not predict poor outcome. Conclusions: The acid-base status remains a serious prognostic marker, and lactate level a highly indicator of survival in critically ill children, even more the level exceeds 5 mmol/l and lactate clearance is very poor. References: Fall P, Szerlip H (2005) From sour milk to septic shock

Methods: Retrospective review of medical records of children supported with VAD at our institution. Data: median and range unless stated otherwise. Results: From

%); congenital heart disease (n = 3; 21.4 %); restrictive cardiomyopathy (n = 2; 14.2 %)

Seven patients (50 %) received ECMO before VAD

Device: Excor-Berlin Heart Ò (EBH) (n = 10; 66.6 %), univentricular

Ò (LEV) (n = 5; 30 %), univentricular (n = 3; 60 %), biventricular (n = 2; 40 %)

EBH 26 days

Complications: non CNS bleeding (n = 8incidence of sepsis, in neonate treated for suspected sepsis, is low. Purpose: To evaluate the effect of procalcitonin PCT in neonatal sepsis diagnose versus other laboratory test (CRP)

Results: 73 newborns were randomly assigned wither to the standard group (n = 34) or the PCT group (n = 39). The two groups were similar for baseline demographics, risk factors for EOS, gestational age, birth weight, Apgar score 1 and 5 min, and early conventional laboratory findings. PCT show to be more sensitive related to other markers, sensitivity was 90.9 % and NPV 96.15 %. vs CRP sensitivity 54.54 % and NPV 75 %. On average, PCTguided decision-making resulted in a shortening of 40 h of antibiotic therapy in GA [ 34 weeks newborn. No difference found in antibiotics treatment in neonates with sepsis in two groups. Clinical outcome was better in study group related to secondary sepsis episode

Aims: To establish research priorities for PICU and NICU nursing across Europe. Methods: A 3-round electronic Delphi approach was performed in 2012-2013. Questionnaires were developed separately for PICU and NICU nursing experts groups and were translated into seven different languages. Results: The PICU eDelphi

%) completed all three rounds

In the NICU eDelphi, eight priority research domains were identified in order of priority these are: Pain and Stress, Family Centred Care, Clinical Nursing Care Practices, Quality and Safety, Ethics, Respiratory & Ventilation, Infection and Inflammation and Professional Issues. Conclusions: The results provide input for a roadmap for future ESPNIC nursing research actions to improve clinical practice and patient care

But clinical uses of these studies are restricted. We aimed that detection of the Doppler velocity features of the hepatic veins (HV) and hepatic portal vein (HPV) in diagnosing and follow-up of the NEC. Enrolled subjects divided two groups as NEC+ and NEC-. Group NEC+ was consisted of 24 preterms with suspected/diagnosed with NEC. Group NEC-was consisted of 25 matched healthy preterms. Daily serial Doppler examinations were performed within the 24 h after the onset of the NEC' clinical findings and continued until the initial day of the feeding

During NEC course, in recovered patients these measurements increased day by day. Cut-off level of the RoBF for NEC diagnosing was detected as 0.66. During NEC management mean RoBF level was detected as 0.77 ± 0.17 at the initial day of the feeding. Doppler velocity of the HPV and HVs, and their ratio via liver should be use for diagnosing NEC. Daily measurements of the PBF and RoBF in newborns suspected/diagnosed with NEC may be beneficial for NEC following and decide to when their start to feeding. 577 -LATE BREAKERS EFFECT OF LOW-DOSE ORAL ERYTHROMYCIN ON MILK TOLERANCE

The Netherlands Background: European Society for Intensive Care Medicine has recently issued a new ARDS definition through international consensus and empirical evaluation. The so called ''Berlin definition'' (BD) has some intrinsic characteristics that could make it suitable for the early pediatric age. Methods: We designed a collaborative project within the ESPNIC Respiratory Section to merge dataset of several PICU to evaluate BD on large population of infants with ARDS. Then, illustrative vignettes have been created to help interpreting chest X-rays

Paediatric Anaesthetics, 2 North West and North Wales Retrieval Service(NWTS), Royal Manchester Children's Hospital NHS Trust, Manchester, 3 Paediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, 4 Paediatric Intensive Care Unit, Royal Manchester Children's Hospital NHS Trust, Manchester, UK Background: NWTS is a regional retrieval team (RRT)commissioned for stabilisation, retrieval of sick children to PICU in Northwest England and Wales. There is paucity of data on emergency intubation of critically ill infants. Aims: To Highlight:Background: Elective caesarean section before 39 weeks has been associated with a higher incidence of iatrogenic respiratory distress and pneumothorax in term newborn babies, probably because of a higher respiratory morbidity and the need of resuscitation. These factors have not been systematically evaluated in our patients. Objective: To know whether the gestational age, type of delivery, and intensity of resuscitation, are associated with an increment in the incidence of pneumothorax in term neonates. Patients and methods: Full term neonates born in our maternity from January 2006 to December 2010 were studied, together with the type of delivery (Vaginal, Forceps or Caesarean Section). Advanced CPR was defined as the need of bag and mask intermittent ventilation, intubation, chest compression and/or administration of medication. The diagnosis of pneumothorax was clinical and radiological in all cases. Results: 32,238 full term new-borns were included. Type of delivery: Vaginal 76.1 %, C-Section 12.4 %, and Forceps 11.5 %. The incidence of pneumothorax was 0.316 %. It was significantly higher in C-Section (0.85 %), than Forceps (0.59 %) or non-instrumental Vaginal deliveries (0.19 %) (p = 0.000); in infants C40 weeks GA (0.37 %) than B39 weeks GA (0.24 %) (p = 0.033); and in advanced CPR (4.29 %) compared to basic CPR (0.18 %) (p = 0.000). Conclusions: A GA C40 weeks, C-Section or Forceps delivery, and advanced CPR were significantly associated with a higher incidence of pneumothorax in full term newborn babies. We did not observe any increase of pneumothorax among neonates born through elective C-Section before 39 weeks of gestation. Background: Heat loss after delivery could interfere with adaptation due to metabolic and hemodynamic derangements. Associated perinatal factors and its relation with morbidity and mortality during the neonatal period have not been systematically studied in our unit. Objectives: To know the temperature of VLBW infants on admission to our NICU, and to determine the associated perinatal variables, and the association of temperature with morbidity and mortality. Patients and methods: Infants born in our maternity from January 2006 to November 2012, birth weights 401-1,499 g and/or \30 weeks GA, were included. Bivariate associations between antepartum/birth variables and admission temperature, and between this and selected morbidities and mortality were examined, followed by multivariable linear or logistic regressions to detect independent associations. Results: 635 infants were included. Mean (±SD) BW and GA were 1,137.6 ± 257.6 g, and 29.48 ± 2.82 weeks, respectively. Mean admission temperature was 35.8 ± 0.6°C (range 33.0-37.8°C). Proportion on infants with T a \36°C: 44.4 %. Independently associated perinatal variables were chorioamnionitis, birth weight, vaginal

Background: Urinary neutrophil gelatinase-associated lipocalin (uNGAL) is a promising biomarker to monitor acute kidney injury (AKI). However, after pediatric transplantation the pattern of uNGAL levels is not known in the early post-transplant period. We aimed to describe the pattern of uNGAL levels in this population in a pilot study. Method: We evaluated daily uNGAL levels up to 14 days in 10 kidney (KT) and 12 liver transplant recipients (LT) receiving tacrolimus. uNGAL cut-offs of 2.2 and 135 ng/ml were used, as previously found in healthy children (\2.2 ng/ml) and children at risk for AKI ([135 ng/ml) .Results: In KT recipients, the median uNGAL level was 14.9 (IQR: 29.6) ng/ml. Sixty-two of the uGNAL measurements (92.5 %) were above 2.2 ng/ml and three (4.5 %) in two patients were above 135 ng/ ml. All KT patients had an uNGAL [2.2 ng/ml at least once during the first 14 days after transplantation. In LT recipients, the median uNGAL level was 13.6 (IQR: 21.9) ng/ml. 90 % of all uNGAL measurements were above 2.2 ng/ml. Seven uNGAL measurements (7 %) in two LT patients were higher than 135 ng/ml. No relation was found between high uNGAL levels and AKI. Conclusion: This is the first study in pediatric transplant recipients reporting uNGAL levels up to 14 days post-transplantation. Although, most uNGAL levels were not suggestive for AKI, they were higher than reported in healthy children, suggestive of subclinical renal function. We suggest uNGAL to be investigated as an early biomarker for subtle renal function loss. Objectives: In the PICU, midazolam is regularly administered orally in the absence of IV access. The lack of information on maturation of intestinal CYP3A, the drug metabolizing enzyme which is involved in oral absorption of midazolam, hampers adequate dosing of oral midazolam in children. The aim of this study was to investigate CYP3A mediated oral bioavailability (F) and clearance (CL) of oral midazolam across the pediatric age range. Methods: Pharmacokinetic (PK) data were obtained from a combined dataset of 7 previously reported studies in 52 preterm infants (26-37 weeks, PNA 2-13 days), 305 children (3 month-18 years) and 20 adults, who received IV and/or PO midazolam. Population PK modeling was performed using NONMEM v6.2, and the influence of PNA, bodyweight (BW), and study population was investigated. Results: Midazolam F was negatively influenced by BW in an allometric function and decreased from 67 % (29-100 %) in a preterm neonate (0.77) kg to 17 % (7-27 %) in an adult (70 kg). BW influenced midazolam CL in a previously introduced allometric function with a BW dependent exponent (BDE), gradually changing from 0.82 in a preterm neonate (0.77 kg) to 0.28 in an adult (70 kg). Conclusions: Midazolam F decreases from preterm neonates to adults, leading to higher systemic availability of midazolam concentrations in preterm neonates (67 %) compared to older children or adults (17 %). This information may aid to design dosing guidelines for oral CYP3A substrates in children, which take into account maturation in CYP3A mediated drug metabolism.

Objective: To compare neonatal respiratory outcomes by method of delivery in a large diverse cohort in China. Methods: 52 hospitals from 23 provinces of China were enrolled in this prospective study from May 1st 2010 to December 31st 2011. A standardized database was established in each hospital and all the data were transferred to Children's Hospital of Fudan University simultaneously. Birth complicated by known congenital anomalies was excluded. Associations between method of delivery and neonatal respiratory morbidities were estimated using logistic regression. Results: Total 100,308 neonates were identified. The overall cesarean delivery rate was 46.68 % (range between 11.49 and 73.79 %). The proportion of elective cesarean delivery among all cesarean delivery was 84.41 %. Comparing to vaginal delivery, cesarean delivery was associated with increased morbidities of RDS (1.19 vs. 0.72 %, p \ 0.0001, , TTN (1.11 vs. 0.29 %, p \ 0.0001, ) and respiratory failure (0.28 vs. 0.13 %, p \ 0.0001, 95 %CI 1.576-2.835). The risk of TTN had no relationship with labor (1.08 vs. 1.12 %, p = 0.772, OR = 0.965, 95 %CI 0.759-1.228). The overall lengths of hospitalization between vaginal and cesarean deliveries were 4.8 ± 4.0 days and 6.0 ± 4.4 days (p \ 0.0001, 95 %CI -1.31 * -1.18) respectively. Three was no significant difference in mortality. Conclusions: The overall cesarean delivery rate nationwide was much higher than the appropriate rate. The respiratory morbidities were higher in cesarean delivery newborns, especially that of TTN with subsequent higher hospitalization rate. Objectives: Main goal of our study was to assess importance of prone position and ventilation mode (conventional and HFOV) application sequence on the histopathological image of lung tissue damage in experimental model of ARDS. Methods: We enrolled total of 34 experimental models (piglets). Group 1 (control group) had conventional ventilation mode in supine position; group 2 (PP) had conventional ventilation mode with the circulation of prone position (6 h) and supine position (6 h); group 3 (HFOV) had HFOV ventilation mode in supine position during the whole experiment; group 4 (HFOV + PP) had HFOV ventilation mode in supine position for initial 6 h, afterwards the circulation of prone position and supine position was established; group 5 (PP + HFOV) had conventional ventilation mode with the circulation of prone and supine position and after 6 h model was switched to HFOV ventilation. We collected four lung tissue samples from each piglet-bilaterally from dorsocaudal (dependent, D) lung segments and bilaterally from ventrorostral (non-dependent, ND) lung segments. Detected changes in lung tissue were scored in extensity (e, 0-3) and intensity (i, 0-4). Results: We found no significant differences in all studied parameters between all groups. Moreover, there was also no difference in intensity and extensity of changes in dependent and non-dependent lung segments. Introduction: The kidney is the most damaged organ in asphyxiated infants. Renal vasoconstriction due to adenosine metabolite may lead to a fall in glomerular filtration rate (GFR). This study was designed to determine whether aminophylline an adenosine receptor antagonist, could prevent or ameliorate kidney dysfunction in neonates with perinatal asphyxia. Materials and methods: Forty term neonates with perinatal asphyxia were randomized to study (n = 19) and control group (n = 21) who received a intravenously a single dose of aminophylline (5 mg/kg) or an equal volume of placebo (5 % dextrose in water) during the first 3 h of life, respectively. Daily urine output, 24 h fluid intake, weight and serum creating were recorded during the first 5 days of life.

Results: The incidence of severe kidney dysfunction was not significantly different between two groups. Two infants in treatment group and three in placebo group; p = 0.23, plasma creatinine (pcr) levels were increased in both groups in the 2nd day and reached the maximum in the 3rd day. Then it gradually decreased the fourth and 5th days of life. There was no significant difference in pcr or GFR between study and placebo group in these 5 days (p [ 0.05). However, urinary output/input ratio was in the aminophylline group in the first 3 days of life. Conclusion: Prophylactic administration of Aminophylline in asphyxiated neonates could not change the process of failure in patients but could increase urinary output in first days of life. Background: Milk intolerance due to gastrointestinal dysmotility is a common problem in preterm infants. Erythromycin have prokinetic effect on gastrointestinal motility. The purpose of this study was to assess the effectiveness of low-dose oral erythromycin as prophylaxis in preterm infants on milk tolerance. Methods: This clinical trial was conducted on 70 preterm infants with a gestational age between 28 to 34 weeks who were admitted to the neonatal intensive care unit of Imam Reza (AS) hospital in Kermanshah, Iran. Thirty-five infants in the control group were received breast milk alone and 35 infants in treatment group received 2.5 mg/ kg every 6 h oral erythromycin for 10 days in addition to breast milk. The time taken to reach full enteral feeding, duration of hospitalization, daily vomiting episodes and residual volume of gastric lavage were compared between the two groups.

Results: There was no significant differences between the two groups regard to the sex distribution, birth weight, gestational age and age feeds offered. Did not Significant difference between the two groups in the time to reach full enteral feeding (P = 0.058). The number episodes of gastric residue was significantly higher in the control group than in the treatment group (5.11 ± 2.92 versus 2.23 ± 1.88, P 0.003).No infant in the two groups developed necrotizing enterocolitis, cardiac arrhythmias, and hypertrophic pyloric stenosis. Conclusion: Prophylactic use of low-dose oral erythromycin in preterm infants does not reduce time to reach full enteral feeding. Objective: Jaundice is a common problem in neonatal period. Phototherapy is the most common treatment for neonatal jaundice. The purpose of this study was to determine the effect of adding white plastic cover around the phototherapy unit on hyperbilirubinemia in full term neonates with jaundice. Methods: In this randomized controlled trial, over 12 months (Oct 2009 -Oct 2010 , 182 term neonates with uncomplicated jaundice, admitted at neonatal unit of Imam Reza Hospital (AS) in Kermanshah province of Iran, were selected. They were randomized in two groups. Control group received conventional phototherapy without cover around the apparatus and covered group received conventional phototherapy with plastic cover around the unit. After enrolment, total serum bilirubin was measured every 12 h at two groups. Phototherapy was continued until the total serum bilirubin decreased to 12.5 mg/dl or lesser.

Results: There were no significant differences between two groups for gestational age, birth weight, postnatal age, weight (at admission time), serum level of hemoglobin, hematocrit and reticulocyte count.Conclusion: Majority of the students was aware of the negative impact of alcohol use on health and social life. Media and schools can play integral role in imparting awareness regarding the social implications and health effects of alcohol consumption. Background and aims: A large number of children receive medication containing valproic acid (VPA) or carbamazepine (CBZ). The purpose of this study is to assess the vulnerability of the paediatric population to the known side effects of these types of anticonvulsants.

The study was conducted on a group of 48 children below 18 years of age, under medication with VPA and/or CBZ as active substances. Haematological and biochemical investigations were performed. Results: One-third of subjects (11/VPA, 4/CBZ) were found to have anaemia, while 8 patients had clotting abnormalities (7/VPA, 2/CBZ). More than a half of the study lot showed sodium and chloride ion imbalances, resulting in 22 cases of induced acidosis (16/VPA, 6/CBZ). BUN/creatinine ratios were also high for many of the children: 23/VPA, 4/CBZ, as were liver enzyme levels, for 8 children. In seven of the investigated subjects (5/VPA, 2/CBZ), ammonium ions were present in excess, suggesting an increased NH 4 + production to compensate for metabolic acidosis-a theory upheld by statistical correlation (p = 0.022). It can be assumed that an increase in ammonium ion concentration could be considered a warning signal for severe upcoming impairment of renal and hepatic functions. Conclusions: Anticonvulsant therapy needs to be carefully monitored, especially in children, who are more susceptible to homeostasis changes associated with anaemia, clotting disorders and impaired hydro electrolyte and hepatic balances.Respiratory Failure (585-588)

Objectives: The Victorian Paediatric Emergency Transport Service (PETS) provides advice on management and performs retrieval of critically ill children throughout Victoria, Tasmania and Southern New South Wales. This study aimed to evaluate changes in referrals and retrievals over the past 10 years. Methods: Data was extracted from the PETS database for 2002-2011, inclusive. Severity of illness was categorised by the level of organ-support required during retrieval and the data obtained analysed for proportions and trends over time (z-test). Results: There were 7,281 referrals to PETS resulting in 6,377 transfers (88 %) of which 3,338 (46 %) were performed by the PETS team, 35 % by air. There was a highly significant increase in the number of referrals and PETS transfers per year (p \ 0.01). There was a small but significant increase in the proportion of referrals from regional hospitals and children transferred with non-invasive ventilation (p \ 0.01). The rate of PETS referrals is significantly higher in Legend: I in hospital, O out-of-hospital, CPR cardiopulmonary resuscitation, TH therapeutic hypothermia, MV mechanical ventilation, VIS vasopressor intropic score, GOS Glasgow outcome scale, POPC pediatric overall performance category scale