Oral ketamine for radiotherapy in children with cancer

Children coming for radiotherapy under sedation usually get repeated injections, which cause distress to both the child and the parents. A prospective study was conducted to evaluate the efficacy of oral ketamine for sedation for radiotherapy (RT) in children with cancer. Ten children who received 49 sittings of RT were given 8–15 mg/kg body weight of oral ketamine. The onset time, recovery time, efficacy of sedation and incidence of abnormal movements were compared with another group of 8 children, who received intramuscular ketamine in the dose of 6 mg/kg for a total of 28 sittings of RT. Onset time and recovery time were significantly longer in oral ketamine group as compared to the intramuscular group (p<0.001). Limb movements in patients receiving oral ketamine necessitated further supplement of sedation and interruption of RT. These drawbacks discourage use of oral ketamine as a good sedative for radiotherapy treatment in paediatric oncology patients.     

Propofol and Propofol–Ketamine in Pediatric Patients Undergoing Cardiac Catheterization

We investigated the effects of propofol and propofol–ketamine on hemodynamics, sedation level, and recovery period in pediatric patients undergoing cardiac catheterization. We performed a prospective, randomized, double-blind study. The study included 60 American Society of Anesthesiologists physical status II or III (age range, 1 month–13 years) undergoing cardiac catheterization for evaluation of congenital heart disease. Propofol and ketamine were prepared in 5% glucose solution to a final concentration of 5 and 1 mg/ml, respectively; similar injectors containing 5% glucose solution only were prepared. Fentanyl (1 μg/kg) and propofol (1.5 mg/kg) were given to both groups. Then, group 1 received 0.5 ml/kg of 5% glucose and group 2 0.5 ml/kg of ketamine solution by an anesthesiologist who was unaware of the groups of patients. Local anesthesia with 1% lidocaine was administered before intervention in all patients. The noninvasively measured mean arterial pressure, heart rate, respiratory rate, and peripheral oxygen saturation were recorded at the baseline, following drug administration, at 3, 5, 10, 15, 20, and 30 minutes and then at 15-minute intervals until the end of the procedure. Additional drug and fentanyl requirements to maintain a sedation level of 4 or 5 were recorded. After the procedure, the time to a Steward recovery score of 6 and adverse effects in the first 24 hours were recorded. The number of patients with more than a 20% decrease in mean arterial pressure was 11 in group 1 and 3 in group 2 (p < 0.05). The number of patients who experienced more than a 20% decrease in heart rate was 12 in group 1 and 5 in group 2 (p = 0.054). Ten patients in group 1 and 3 patients in group 2 required additional fentanyl doses (p = 0.057). The number of additional propofol doses was lower in group 2 (p < 0.05). Propofol combined with low-dose ketamine preserves mean arterial pressure better without affecting the recovery and thus is a good option in pediatric patients undergoing cardiac catheterization.     

Intramuscular midazolam vs intravenous diazepam for acute seizures

Objective : To determine effectiveness of intramuscular midazolam to control acute seizures in children as compared to intravenous diazepam.Methods: 115 children in the age group of 1 month to 12 years who presented with acute convulsions were enrolled in the study. Patients who already had an intravenous access present were treated intravenous diazepam. Patients without an IV access at the time of convulsions were randomised into 2 groups and treated with either intramuscular midazolam or intravenous diazepam for control of seizures. Time interval from administration of drug to cessation of seizures was compared. Effectiveness of IM midazolam in various age groups, types of convulsions and etiology of convulsions was analyzed. Side effects of both drugs were evaluated.Results: the mean interval to cessation of convulsions with IM midazolam was 97.22 seconds whereas in diazepam group without prior IV access it was 250.35 seconds and in diazepam group with prior IV access it was 119.4 seconds. IM midazolam acted faster in all age groups and in patients with febrile convulsions, which was statistically significant. IM midazolam was equally effective in various types of convulsions be it GTC or focal convulsions. 7 patients (10.8%) had thrombophlebitis associated with IV diazepam administration whereas none of the patients in the midazolam group had any side effects, which was statistically significant.Conclusion: IM midazolam is an effective agent for controlling acute convulsions in children especially in children with febrile convulsions. It has relatively no side effects as compared to Intravenous diazepam and can be used as a first line agent for treatment of acute convulsions in patients with difficult intravenous access.     

Oral iron is sufficient for erythropoietin treatment of very low birth-weight infants

The aim of this study was to compare two different doses and means of administration of iron in recombinant human erythropoietin (rHuEPO)-treated very low birth-weight (VLBW) infants. VLBW infants (n = 41) were randomized to one of three groups. Fourteen infants were treated with rHuEPO (300 IU/kg three times a week s.c.) and oral iron (ferrofumarate, 6 mg of iron/kg per day). Another 14 infants received the same erythropoietin dose and intramuscular iron (ferroxypolymaltose, once 12 mg of iron/kg weekly). Thirteen infants were treated with the same dose of intramuscular iron but did not receive rHuEPO. After the 3-week study period, haemoglobin concentrations and reticulocyte counts were similar in the rHuEPO-treated groups and both were higher than in the group not receiving rHuEPO (P < 0.001). In both rHuEPO-treated groups the transferrin receptor concentration increased from 6.8–7.2 mg/l to 10.5–11.3 mg/l. Conclusion In erythropoietin-treated very low birth weight infants the iron need for erythropoiesis can be met by oral administration of iron. Received: 17 November 1997 and in revised form: 6 March 1998 / Accepted: 30 April 1998     

Superior vena cava syndrome

Objective : In order to study the clinical profile of children presenting with superior vena cava syndrome (SVCS), case records of all children presenting with SVCS over a 10-year period were retrospectively analyzed.Methods :Twenty one children (20 males and 1 female) with a median age of 10.0 years (range 5.0 to 12.0 years) were detected to have an underlying hematological malignancy.T-cell acute lymphoblastic leukemia accounted for a major share (57%) in the underlying etiology; 33% of the subjects had non-Hodgkin’s lymphoma (T-cell lymphoblastic lymphoma).Result : No Patient required radiotherapy or urgent thoracotomy. Among survivors (n=11), who were alive and well at the time of writing this report, the median follow-up was 6.5 years, (range 0.5–9.6 years). T-cell ALL and lymphoblastic lymphoma are common underlying causes of SVCS in Indian children.Conclusion : The value of diagnostic interventions performed under local anaesthesia and prebiopsy corticosteroids usage was found to be reassuring since long-term survival without disease is achievable.     

Prediction of extubation failure in preterm neonates

The aim of this study was to compare the results of lung function measurements made before and after extubation and ventilator settings recorded immediately prior to extubation with regard to their ability to predict extubation success in mechanically ventilated, prematurely born infants. Immediately after extubation all infants were nursed in an appropriate amount of humidified oxygen bled into a headbox. Functional residual capacity, spontaneous tidal volume and compliance of the respiratory system were measured both within 4 h before and within 24 h after extubation. The peak inspiratory pressure and inspired oxygen concentration immediately prior to extubation were recorded. The results were related to extubation failure: requirement for continuous positive airways pressure or re-ventilation within 48 h of extubation. A total of 30 infants, median gestational age 29 weeks (range 25–33 weeks) were studied at a median postnatal age of 3 days (range 1–6 days). Extubation failed in ten infants, who differed significantly from the rest of the cohort with regard to their post extubation functional residual capacity (FRC) (median 23, range 15.6–28.7 ml/kg versus 28.6, range 18.1–39.2 ml/kg, P < 0.01) and their requirement for a higher inspired oxygen concentration post extubation (median 0.30, range 0.21–0.40 versus 0.22, range 0.21–0.36, P < 0.05). An FRC of less than 26 ml/kg post extubation had the highest positive predictive value in predicting extubation failure. Conclusion A low lung volume performed best in predicting extubation failure when compared to the results of other lung function measurements and commonly used `clinical' indices, i.e. ventilator settings. A low gestational age, however, was a better predictor of extubation failure than a low lung volume. Received: 1 November 1998 / Accepted: 16 April 1999     

Abnormal insulin response to glucose following treatment for Wilms' tumor in childhood

To determine whether β-cell function could be impaired by the treatment for Wilms' tumour (WT) in childhood, we investigated the insulin secretion of 44 survivors of WT (22 males) with a median off-treatment follow up of 8.3 years (range 1–19.8). All patients had an intravenous glucose tolerance test (IVGTT) (0.5 gm/kg, max 25 g) to determine the first-phase insulin response (FPIR) (sum of the 1- and 3-min insulin concentrations). Median age at the time of the study was 12.7 years (range 4.2–22.7). Eight subjects (7 males) had a FPIR value below the 3rd percentile, and 7 (3 males) above the 97th centile. Among the 22 patients who received radiotherapy, 7 (6 males) showed a FPIR  < 3rd percentile versus only 1 (a male) of the 22 patients who received no radiation (31.8% vs 4.5%; P < 0.05). Analysis of variance showed that the time elapsed since therapy had a significant role on the development of low FPIR only in males. The 7 patients with an insulin release > 97th percentile did not show any significant difference compared to subjects with lower insulin values for weight, age at diagnosis, sex, time elapsed since treatment, radiotherapy and chemotherapy protocol. Conclusion An impaired insulin response is evident in some patients treated for WT in childhood, mainly in male patients who received abdominal radiotherapy and were examined a longer time after therapy. We hypothesize that this decreased insulin release is related to damage due to radiotherapy and therefore a careful follow up is recommended in adulthood in these patients. Received: 15 May 1996 / Accepted: 24 September 1996     

Propofol versus midazolam/ketamine for procedural sedation in pediatric oncology

Different pharmacologic agents have been used for sedation in children undergoing invasive procedures. The authors prospectively compared the efficacy, the occurrence of adverse effects, cardiovascular parameters, oxygen saturation and induction, and recovery time in propofol with or without morphine versus midazolam/ketamine sedation for procedural sedation in children with malignancies and hematologic disorders. Fifty children received either propofol with or without morphine or ketamine/midazolam sedation for invasive procedures. Intravenous sedation consisted of 0.1 mg midazolam/kg and 1.0 mg ketamine/kg or 2 mg propofol/kg with or without 0.1 mg morphine/kg. Incremental dosages of ketamine or propofol were given, if necessary, to achieve or to maintain adequate sedation levels. Systolic and diastolic blood pressure, heart rate, oxygen saturation, time to induce sedation, recovery time, and adverse effects were recorded. All invasive procedures were successfully completed, with satisfactory sedation levels in all 25 patients in the propofol group and 23 of the 25 patients in the ketamine group. In 14 of the 25 procedures in the propofol group and 4 of the 25 procedures in the ketamine group, sedation was associated with side effects, the most common being oxygen desaturation. There was a significant increase in diastolic blood pressure after ketamine medication and a significant decrease in systolic and diastolic blood pressure and heart rate in the propofol group. Induction and recovery times in the propofol group were significantly shorter. Both regimens for procedural sedation are efficacious in achieving satisfactory sedation levels for invasive procedures. Propofol offers a quicker onset of sedation and a faster, smoother recovery but is associated with a higher rate of side effects. Considering the substantial rate of adverse effects, these procedural sedations should be performed only by physicians trained in advanced airway management and life support.     

Use of intramuscular ketamine for endoscopy sedation in children

OBJECTIVE: To report the experience of the use of intramuscular (IM) ketamine for endoscopy sedation in children. METHODOLOGY: Children over 6 months of age scheduled for elective endoscopy - esophagogastroduodenoscopy (EGD), bronchoscopy and nasopharyngolaryngoscopy (NPL) were enrolled for (2 mg/kg to 3 mg/kg) intramuscular ketamine sedation. A repeated dose of 2 mg/kg intramuscular ketamine was administered to those who failed the first sedation. Alternative sedation (intravenous midazolam and fentanyl) was given to children who failed ketamine sedation twice. Sedation was regarded as successful if the procedure was completed by endoscopist with a single dose of ketamine. RESULTS: Sixty children were enrolled for the study. Overall success rate in our patients was 78.3%. Failure rate in infants was 50%, i.e. 4 out of 8. For children aged 1-7, the failure rate was 32%. Failure rate dropped markedly to 6.7% for those older than 7 years of age, and it showed significant difference when compared with the other two groups. Two cases of laryngospasm were experienced in the present study. CONCLUSION: Intramuscular ketamine is an effective medication for sedation in endoscopy undertaken in children over age 7 years, but it should be avoided with children under age 7 because of the high failure rate.     

Efficacy and safety of intravenous midazolam and ketamine as sedation for therapeutic and diagnostic procedures in children

OBJECTIVE: We have used the combination of midazolam, a short-acting benzodiazepine, and ketamine, a "dissociative anesthetic," to provide conscious sedation for invasive or lengthy procedures. METHODS: A total of 350 procedures (74 lumbar punctures, 97 bone marrow aspirations or biopsies, 84 radiotherapy sessions, and 95 imaging studies) were performed on 68 children, 4 months to 17 years of age, in both inpatient and ambulatory settings. All patients had an intravenous line in place and were monitored for heart rate and O2 saturation by pulse oximetry for the duration of the procedure and recovery time. Blood pressure was monitored periodically (every 5 to 30 minutes). Oxygen and suction equipment was available during the procedure. In addition to the individual performing the procedure, a second staff member trained in airway management (eg, physician, nurse practitioner, or registered nurse) was present to monitor vital signs and respiratory status. Patients were sedated initially with midazolam (0.05 to 0.1 mg/kg intravenously; maximum single dose of 2 mg, maximum total dose of 4 mg), followed by ketamine (1 to 2 mg/kg intravenously). During lengthy procedures, additional doses of ketamine (0.5 to 1 mg/kg) were given as necessary. Effectiveness of the sedation, recovery time, and adverse events associated with the sedative regimen were documented. RESULTS: All patients were effectively sedated with this regimen. Four patients experienced transient decrease in O2 saturation (<85%) requiring temporary interruption of the procedure and oxygen by blow-by; the procedure was subsequently completed without incident in each case. Two patients experienced significant agitation during recovery from sedation. This side effect resolved spontaneously after 5 to 10 minutes in one patient and was effectively treated with diphenhydramine hydrochloride in the other. Twenty-four lumbar punctures were associated with transient decrease in O2 saturation (88% to 92%), which improved by relief of neck flexion and/or blow-by oxygen. No hypotension, bradycardia, or respiratory depression requiring respiratory support or reversal of sedation was noted. Anesthesia recovery time ranged from <15 minutes to 120 minutes with >70% of patients recovering within 30 minutes. Most patients demonstrated an increase in oral secretions requiring occasional suctioning. Transient sleep disturbances were reported in only two patients. CONCLUSIONS: This sedative regimen of intravenous midazolam and ketamine was found to be safe and effective. Its use has greatly reduced patient and parent anxiety for diagnostic and therapeutic procedures.     

Drumstick leaves as source of vitamin A in ICDS-SFP

Objective : This pilot study is about to assess the feasibility and acceptability of introducing dehydrated drumstick leaves, (DDL) (Moringa oleifera), as a source of vitamin A, into the salty recipes provided by the supplementary food (SF) component of the Integrated Child Development Scheme (ICDS) along with nutrition communication (NC).Methods : An integrated approach was adapted in this study which included comprehensive training sessions for the staff of the ICDS and Non-government organization (NGO) involved in the SF preparations. Prior to the acceptability trials, data were elicited on the socio-economic profile and knowledge about vitamin A, from 60 children of 1–5 year of age attending two anganwadi centres of the ICDS.Result : From these, 40 children attending one anganwadi were supplemented with pre-tested DDL incorporated recipes (5–7g DDI/100 g product) along with NC for one month. Spot observations and organoleptic evaluation results indicated high compliance of the DDL-recipes by the children. The results also indicated that the recipes were highly acceptable to the ICDS authorities as well as the NGO staff.Conclusion : The pilot study indicated that integration of NC along with the introduction of unconventional DDL, into the ICDS-SF, was feasible and can be endeavoured for a longer duration in the existing national programmes.     

Efficacy and safety of a mixture of ketamine, midazolam and atropine for procedural sedation in paediatric oncology: a randomised study of oral versus intramuscular route

Aim:   To evaluate the efficacy and safety of a mixture of ketamine, midazolam and atropine given orally by comparing the same mixture given through the intramuscular route in children with malignancy undergoing minor invasive procedures.
Methods:   Sixty children, aged between 1 and 10 years, scheduled to undergo minor procedures were randomised into two groups to receive a mixture of ketamine (6 mg/kg), midazolam (0.05 mg/kg) and atropine (0.02 mg/kg) intramuscularly (Group 1) or ketamine (10 mg/kg), midazolam (0.2 mg/kg) and atropine (0.05 mg/kg) orally (Group 2). Sedation score, observer-rated visual analogue scale for pain were noted by an observer blinded to the route of drug administration.
Results:   Optimum sedation was present in all children in both groups after drug administration, with Group 1 being more deeply sedated than Group 2 at the start of the procedure. Supplementation with intravenous ketamine was required in four children in Group 1 and eight children in Group 2 ( P  = 0.33). The mean (±SD) observer-rated visual analogue scale for pain during the procedure was 8.33 (±15.99) and 9.33 (±16.39) in Group 1 and Group 2, respectively ( P  = 0.892). One patient in Group 1 had vomiting after the procedure. There were no differences in proportion of patients with hallucinations and nystagmus in both groups.
Conclusions:   A mixture of ketamine, midazolam and atropine given orally provides sedation and analgesia similar to that produced by the same drugs given intramuscularly. It offers advantage over the intramuscular route as it is painless and can be given for minor paediatric oncology procedures with appropriate monitoring.     

Silastic catheters for home antibiotic therapy in patients with cystic fibrosis

Repeated 14-day courses of intravenous antibiotic therapy for patients with cystic fibrosis (CF), who have been colonized with Pseudomonas aeruginosa (PA), is one currently accepted treatment. Conventional intravenous cannulas for antibiotic delivery often have a short line life leading to frequent venipunctures. Therefore we used silastic catheters as a peripheral venous access. Silastic catheters (15 cm, 0.6 mm diameter) were inserted 10 cm into a cubital vein in 15 patients with CF (age 5–32 years) for 20 antibiotic courses. After the antibiotic infusion the catheter was flushed with 200 U heparin (2 ml Vetren). In all patients the antibiotic therapy was delivered as a home therapy. In 15 antibiotic courses the silastic catheter could be continuously used for 14 days. One patient with methicillin resistant Staphylococcus aureus received antibiotic therapy for 54 consecutive days using the same silastic catheter. The catheter had to be removed in four courses: once because of thrombophlebitis with local inflammation, once because of burning pain during infusion and occlusion twice. In one case the patient removed his catheter because of technical problems. No other serious side effects occurred. Ten patients had previously received intravenous antibiotics at least once. The median line life of the last used conventional peripheral cannula of all patients was 4 days versus 14 days with the use of the silastic catheter (P < 0.005). All patients preferred the silastic catheter to other venous access. Conclusion Because of the long line life and easy handling, silastic catheters may be an alternative venous access to perform home antibiotic therapy in patients with CF. Received: 9 May 1996 / Accepted: 24 September 1996     

Ketamine and midazolam for invasive procedures in children with malignancy: a comparison of routes of intravenous, oral, and rectal administration

We investigated the efficacy of a combination of ketamine and midazolam, comparing intravenous, oral, and rectal administrations for invasive procedures in children with malignancy. Seventy-three children under 5 years of age, who were scheduled for invasive procedure, were assigned to one of three groups: IV group (n = 25), ketamine 1 mg/kg and midazolam 0.05-0.1 mg/kg were given intravenously; PO group (n = 24), ketamine 3 mg/kg and midazolam 0.5 mg/kg were given orally; and PR group (n = 24), ketamine 3 mg/kg and midazolam 0.5 mg/kg given rectally. Vital signs including blood pressure, pulse rate, respiratory rate, and oxygen saturation were monitored, and patients were observed for side-effects. Optimal sedation (drowsy and asleep) was provided in 78 per cent of all patients and no statistical difference was observed among the three groups. No severe complications were observed in all groups. Recovery time from sedation was significantly longer in the intravenous group (>120 min in two patients). Hallucination was noted in three (12 per cent) patients given intravenous medication, but not in those given oral or rectal medications. It is concluded that intravenous, oral, and rectal midazolam/ketamine are equally effective for invasive procedures in children with malignancy. The use of intravenous ketamine/midazolam may produce prolonged sedation and psychedelic effects in children. These adverse effects may alter the child's comfort and parental satisfaction.     

Simplified Pulmonary Vasodilatory Testing in the Cardiac Catheterization Laboratory with Nasal Cannula Nitric Oxide

In patients with pulmonary hypertension, pulmonary vasodilator testing with inhaled nitric oxide (NO) during cardiac catheterization provides valuable data for defining future care plans. Previously, the use of delivery systems for spontaneously breathing individuals required a tight-fitting seal by face mask and an approved delivery and dilution device. We hypothesized that a simplified delivery system using nasal cannula could be utilized to effectively deliver NO during cardiac catheterization. We developed a simple delivery system to deliver through a nasal cannula a concentration of NO at 50 ppm at the nares along with supplemental oxygen (O₂) via face tent. We prospectively employed this system for 10-minute intervals on 11 patients (age range, 7 months to 41 years) with pulmonary hypertension undergoing scheduled cardiac catheterization. Mean pulmonary artery pressure (PA_p) decreased from 62 mmHg (range, 38–99) at room air testing to 45 mmHg (range, 36–91) with the addition of NO plus O₂ (p = 0.014). Pulmonary vascular resistance (PVR) decreased from 11.6 U · m² (range, 4.5–43.4) to 6.3 U · m² (range, 2.0–34.2) (p = 0.001). A response of 20% or more reduction in PVR was seen in all 11 patients. The initial ratio of pulmonary to systemic vascular resistance (R_p:R_s) was 0.49 (range, 0.25–3.5) and decreased to 0.35 (range 0.1–2.6) (p = 0.002). No adverse side effects were noted. We found this NO delivery system to be a simple and effective method of pulmonary vasodilatory testing that may have wide applicability in the cardiac catheterization laboratory.     

Conventional ventilation in neonates : Experience from Saudi Arabia

Objective. To study the clinical profile and immediate outcome of inborn neonates receiving intermittent positive pressure ventilation (IPPV) at the neonatal intensive care unit of Civil Hospital, Khamis Mushayt, Saudi Arabia, a level II nursery.Methods : 78 liveborn neonates who had received IPPV over a 20 months period from January 1999 to August 2000 were reviewed from their charts and nursery registers. The indications for IPPV and the immediate outcome including complications were studied with respect to various weight groups (1 kg or less, >1–1.25 kg, >1.25–1.5, >1.5–2 kg and >2 kg) and gestation groups (28 weeks or less, 29–32 weeks, 33–36 weeks and full term).Result : Hyaline Membrane disease (n=31, 39.7%) and perinatal asphyxia (n=29, 37.2%) were the major indications for IPPV. 67.9% (53 of the 78) ventilated neonates survived. The chances for survival showed a statistically significant increase with increasing birthweight (P = 0.0006) and with increasing gestational age (P = 0.002). (80%) (44 of 55) of neonates weighing more than 1.25 kg survivedvs 39.1% (9 of 23) of those 1.25 kg or less, P=0.0011. Similarly, 79.3% (46 of 58) of neonates of 29 or more weeks of gestation survivedvs 35% (7 of 20) of those 28 weeks or less, P = 0.0007. The complications seen in the study group included blood culture positive sepsis (n=7), pulmonary hemorrhage (n=6), air leak syndromes (n=4), endotracheal tube related problems (n=5), chronic lung disease (n=3) and retinopathy of prematurity (n=2).Conclusion : Gestational age of less than 28 weeks and birth weight less than 1.25 kg can be recommended as the cut off weight and gestation criteria forin utero transfer in this centre and upgradation of existing facilities are urgently called for to improve the survival rates further.     

Blood transfusion

To study the relationship between blood transfusion, iron load and retinopathy of prematurity (ROP), we performed a prospective observational cohort study in a level III neonatal intensive care unit. During a 24-month period, data on the volume of blood transfused during the first 6 weeks of life and on the incidence of ROP were collected in all surviving very low birth weight infants (n = 114 median birth weight␣1130␣g, range 520–1500 g). Associations between these data and values for serum iron, transferrin and ferritin measured at weekly intervals were analysed in a nested case-control design by logistic regression. There was a significant association between the volume of blood transfused and the incidence of ROP. After adjustment for gestational age at birth, duration of oxygen therapy FiO₂> 0.3) and duration of mechanical ventilation, the relative risk of developing ROP was 6.4 (95% CI 1.2–33.4) for infants who had received 16–45 ml/kg, and 12.3 (1.6–92.5) for those who had received more than 45 ml/kg of blood (reference, 0–15 ml/kg). In contrast, there was no independent relationship between ROP and any of the parameters on iron metabolism analysed. Conclusion This study confirms the role of blood transfusions as an independent risk factor for ROP. This relationship, however, does not appear to be mediated via an increased iron load. Received: 5 September 1996 and in revised form: 17 October 1996 / Accepted: 26 October 1996     

Intramuscular antibiotic treatment of urinary tract infection

Objective: This study had been carried out to investigate the effects of intramuscular daily single dose antibiotic treatment during five days in the outpatient clinics in children having lower UTI and to observe the effects to the disease course in infants and toddlers.Methodology: 36 children (12 boys) at the ages of between 5–68 months were enrolled into the study. Regarding the antibiogram suitability, single dose ceftriaxon or amikacin is prescribed to the patients for five days.Result: In the urine culturesE. Coli was most commonly isolated. There was correlation between leukocytosis and insufficient weight gain (p< 0.05). A correlation was also noted between recurrence of the disease and urinary tract abnormalities detected on the ultrasonography (p< 0.05). Reenfection were detected in 1 of the infants and in 2 of the older children. There was no correlation between the recurrence and the therapy given.Conclusion: We consider that five-day intramuscular antibiotic therapy could be effective in the treatment of lower UTI and it can be recommended as a safe treatment modality in patients representing unwillingness to come to follow-up visits     

Use of Ketofol for procedural sedation and analgesia in children with hematological diseases

Background: The aim of this study was to evaluate the effectiveness and safety of intravenous ketamine–propofol admixture (“ketofol”) in the same syringe for procedural sedation and analgesia in children undergoing bone marrow aspiration. Methods: This was a prospective, observational pilot study. Patients aged between 4 and 12 years requiring sedation for bone marrow aspiration were included. Ketofol (1 : 1 mixture of ketamine 10 mg/mL and propofol 10 mg/mL) was given intravenously in 0.5 mg/kg aliquots each with a 1‐min interval and titrated to reach sedation levels of 3 or 4 (Ramsay score). The primary outcome was patient satisfaction with the degree of sedation. Secondary outcomes included injection pain, total sedation time, recovery time, hemodynamic and respiratory parameters, and adverse events. Results: A total of 20 patients were enrolled in the study. The median total dose of ketofol administered was 1.25 mg/kg each of propofol and ketamine (95%CI 0.77–2 mg/kg). The median score on the visual analog scale was 0 (extremely comfortable) (0–1.5; 95%CI 0.2–2.2). Median recovery time was 23 min (20.5–28 min; 95%CI 17.1–51.2). The incidence of injection pain was 2/20. Two patients had transient diplopia and one child reported dreams. No patients had hypotension, vomiting or required airway intervention. Conclusion: Ketofol provided effective sedation, which was reflected in the high degree of satisfaction recorded by children requiring procedural sedation and analgesia for bone marrow aspiration. We also observed rapid recovery and no clinically significant complications. A large number of patients is required to evaluate and validate these findings.     

Intravenous immunoglobulins in severe Guillian-Barre syndrome in childhood

Objective : This is a retrospective analysis of 25 children with severe Guillaln-Barre syndrome admitted to our PICU.Method : All children were treated with intravenous immunoglobulins (IVIG) in a dose of 2 g/kg body weight over 2–5 days in addition to supportive and respiratory care. Seventeen children were elective admissions to the PICU whereas 8 children were transferred from other hospitals in a critical condition. Five of 8 of the late referrals died as compared to none of the elective admissions.Result : All 8 of the late referrals required mechanical ventilation as against 3 of the 17 elective admissions. Mean duration of PICU stay in the late referrals was 27 days as compared to 15 days in the elective admissions.Conclusion : The authors concur with previously published reports, that early use of IVIG could reduce the mortality and the need for intubation and mechanical ventilation.