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THE CYTOKINES AND LACTIC ACID ARE PRODUCED DURING MSOF FROM THE INVOLVED ORGANS LONG AFTER THE ONSET OF SEPSIS E. Douzinas, A. Kotanidou, D. Sionis, D. Sfyras, F. Tsidemiadou, C.

USEFULNESS OF NOSOCOMIAL INFECTION AS A PREDICTOR OF INTRA-HOSPITAL MORTALITY IN ICU PATIENTS X.Sarmiento(**),E.Mesellos( $5 ), C.Boque(*), M.Bodi(*), F.Berrachina(* ). JJ.Guardlola(* ) ------------------------------------------------Nosocomial Infection is a frequent occurrence In all the ICUs and seems to worsen the prognosis of patients. Severity of Disease Indices that predict mortality have been used to predict the rise of Nosocomial Infection but there are no studies to ascertain the role of Nosocomial Infection In addition to severity Indices as a predictor of mortality. We have carried out such a study in two polivalent ICUs during the last three months of 1991. Data were collected in a prospective fashion. On admission to the unit the following Indices were determined In all patients: 11PM. APACHE-II.SAPS,OSF and Glasgow Coma Score. Patients were examined daily seeking to Identify the presence of Nosocbmtal Infection. 1988 CDC definitions for Nosocomial Infections were used. The main end-point of the study was Intro-hospital mortality. The study group consisted of 223 patients. We used logistic regression analysis to evaluate the Independent importance of the following prognostic variables for intro-hospital mortality: MPM. SAPS, APACHE-I1, APACHE original version, OSF. Glasgow Come Score, and presence or ebscence of Nosocomial Infection during the patient's stay In the ICU. Our results showed that Nosocomial Infection added prognostic information to the association of MPM 4 OSF. Also the association of high MPM (>0.30). OSF>2 and the presence of any Nosocomlel Infection during the ICU stay selected the subgroup of patients with the highest risk of intro- hospital mortality ( 755). The predictive value of this set of variables was higher (hen that of the other severity Indices used either Independently or In combination. We conclude that the presence or absence of Nosocomial Infection is a powerful predictor of Intrahospllal mortality when added to MPM • OSF

Roussos The cytokines has been shown to be released shortly after the onset of septic shock and to return to base values some hours later (Hess DG Surg Gynecol Obstet 166:147 1988, Michie HR N Engl J Med 318:1481 1988). Currently, the two main cytokins i.e. 11 -1 and TNF is regarded to play an important role in the acute inflammatory reaction resulting in the pathogenesis of primary tissue injury that preceeds the manifestation of MSOF (Tracey KJ Science 234:470 1986). As the values of these two cytokins are normal during the course of MSOF, it is not well known whether their production has ceased or they are still produced but rapidly eliminated. The latter may be due to the rapid excretion or to cell internalisation on the effector sites. To substantiate this aspect we proceeded as follows: Eight patients fullfilling the criteria of MSOF (Cerra F New Horizons 1;1989) were selected, 3 with primary manifestation of pulmonary involvement (ARDS) and 5 with hepatic (hyperbilirubineamia in the absence of extrahepatic bile duct obstruction). A Swan-Ganz catheter was inserted in pulmonary artery and another in hepatic veins 10,j2.5 days after the acute phase of sepsis. Blood was withdrawn with the inflated baloon in wedge position from both sites and at the same time from a peripheral vein. The levels of TNF, II-1a and lactic acid was measured in all specimens i.e. pulmonary artery blood (PAB), hepatic vein blood (HVB) and peripheral vein blood (PVB) using the ELISA method. The average levels of lactic acid in the patients suffering notably from hepatic involvement were 611±6 (HVB), 1.42±0.41 (PAB) and 428j: 4 mmol /I (PVB). The values for the patients with ARDS were 2.09±0.66, 2.51±0.72 and 2.110.3 mmol/I respectively. The average levels of II-1 were 33,62±18.52pg/mI(HVB), 28.75±1.21 pg/mI(PAB) and 28.62±14.96 pg/mt (PVB) while those of TNF were in the normal range. In conclusion from these preliminary data, it appears that in patients with MSOF the involved organs continue to function under anaerobic conditions long after the acute phase of sepsis. More importantly despite of what is accepted up to now, it appears from these data that the involved organs (liver, lung) continue producing II -1 long after the original onset of sepsis. Department of Critical Care Evangelismos Hospital 45, 1psilantou str. Athens 11521, Greece

* DEPARTMENT OF INTENSIVE CARE HOSPITAL JOAN XXIII, TARRAGONA (SPAIN) •* DEPARTMENT OF INTENSIVE CARE. IIOSPITAL GERMANS TRIAS P UJ OL . BADALONA (SPAIN)

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DEVELOPMENT OF A DECISION SUPPORT SYSTEM IN A PEDIATRIC INTENSIVE CARE UNIT. THE "LATIDO"

EARLY SOMATOSENSORY (ESEP) AND BRAINSTEM AUDITORY (BAEP) EVOKED POTENTIALS IN ACUTE HEPATIC ENCEPHALOPATHY

RESEARCH PROJECT. X. Pastor, J. Jaurrsgulzar, A. Palomeque, C. Sierra. Intensive care of patients is closely related to the time factor. This is more important in pediatric patients after open heart surgery. Unfortunately there is not enough number of high level human experts in the domain available over 24 hours each day to take care of them. It is also difficult to design a complete research protocol without the aid of an automated system for data collection. By that reason we are developing a computerized prototype based on artificial intelligence techniques. The system is composed of three microcomputers running in collaboration. One acts as a Clinical Agent and has the most complete knowledge about the domain where it is working. The other two are devoted to capture biological signals and to process them. The monitorization equipment is based on conventional hemodynamic and respiratory monitors and ventilators that are connected with the computer by an analog interface. The capture application, called the Capture and Processing-module, is build upon the Labwiew application and the filtered signal is stored with data about the patient and monitorization settings. The main task of that agent is the validation of the biological parameters according technical and contextual informations and configure the capture protocol. The interpretation module runs in other microcomputer and can receive and send information with the other two modules.lts main task is the analysis of data coming from de Capture and Processing module and determines the physiological status and emergency situations. The clinical agent has structured knowledge about the domain of congenital malformations of the heart and their physiological derangements as well as the management during the postoperative period. The two last modules are been builded in LISP language because it is easier to represent the medical knowledge and establish the complex mechanisms of inference who are characterized by several aspects like: fuzziness, nonmonotony, temporal reasoning, functional reasoning, etc.. *Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Clinic University of Barcelona. Villarroel, 170. 08036 BARCELONA. SPAIN

ADVANTAGE FOR PROGNOSIS. M.L Sonnet, D.Floret, D.Perrot, D.Stamm. ESEP and BAEP were recorded in 6 infants (3 males, 3 females, age : 7±5.7 years) hospitalized in Pediatric Intensive Care Unit for acute hepatic failure (1 viral hepatitis B, 1 viral hepatitis A, 2 viral hepatitis non A-non B, 1 Reye's syndrome, 1 Wilson's disease) with hepatic encephalopathy (4 had grade 4, 1 grade 3, and 1 grade 2 encephalopathy). ESEP were elicited by stimulation of the median nerve and lemniscal pathway recorded from the scalp by cephalic and extra-cephalic reference electrodes (opposite the primary sensitive area). Several parameters (morphology, amplitude, presence or absence) of cortical ESEP (N20-P25) and hypothalamic potential P14 were studied and compared to those of normal infants. BAEP were recorded by ear stimulation with alternating clicks. The auditory pathway response was recorded from the scalp. 3 distinctive peaks were examined (cochlear nerve peak 1, protuberance peak Ill, inferior or mesencephalic colliculus peak V) Conduction times (I-V and III-V) and ratio of amplitude peaks I / V were studied. The alterations of latencies were interpreted taking thiopental administration into account. 4 children exhibited normal cortical ESEP and BAEP); 3 awoke without sequelae (2 received liver transplant : one deceased because of pulmonary complications). In one infant, BAEP were normal and cortical ESEP abolished ten days before death (intracranial hypertension by cerebral oedema).in one other infant, BAEP were normal and cortical ESEP asymmetric ( unilateral ESEP suppression by cortical oedema) : he died (intracranial hypertension). Intracranial hypertension by cerebral oedema often leads to death in acute hepatic failure. Evoked potentials appeared to be reliable for evaluating severity level and reversability of cortical-subcor ical (ESEP) and brainstem (BAEP) alterations. When cortical ESEP are abolished at two successive recordings (without regeneration after treatment of cerebral oedema), prognosis is poor with lack of recovery of cognitive functions due to irreversible cortical lesions : in these cases, argument may be made against liver transplantation. Electroencephalography-Evoked Potentials and Pediatric Intensive Care Units. HBpital Edouard HERRIOT, 69437 LYON Cedex 03, FRANCE.

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HAEMODYNAMIC EFFECTS OF INTRAVENOUS BOLUS OF CALCIUM CHLORIDE IN CHILDREN IN THE PERIOPERATIVE PERIOD FOLLOWING CARDIAC SURGERY. LA Murdoch, A Mitchell, S Parsons, S A Qureshi. Calcium chloride (CaCl2) is often administered to patients in the perioperative period in the belief that it will increase blood pressure and cardiac index (CI). This study examines the response to btilus administration of CaCl2 in 12 children studied between April and December 1990 following cardiac surgery. All children had baseline ionised calcium (ICa) levels measured. Baseline heart rate (HR), mean arterial pressure (MAP) and central venous pressure (CVP) were recorded. Cl was measured by thermodilution using a pulmonary artery flotation catheter and taken as the mean of three measurements. SVRI was calculated from the standard formula SVRI= MAP-CVP /Cl. Each child then received a bolus of 0.lml /Kg of 10% CaCl2 given over 5 mins. Repeat measurements of CI, ICa and SVRI together with the recordings of HR, MAP and CVP were made at 20 and 40 mins after the administration of CaC12. No changes in ventilatory or inotropic support were made during the course of the study. Statistical analysis of the data was by paired and unpaired Students t-tests with modification using the Bonferroni equation. Data shown as mean ± S.E.M unless stated. The children were seperated into Groups A and B depending on their baseline ICa levels. Group A (n=6) had ionised hypocalaemia ICa < 1.1 mmols/l (mean ± S.D of 0.87 ± 0.1) and Group B (n=6) had ionised normocalcaemia ICa > 1.1 mmols/I (mean ± S. D of 1.18 ± 0.04). There were no other significant differences between the two groups when analysed for age, weight, baseline arterial pH, HR, MAP, CI and SVRI or response to the bolus of CaC12 at 20 or 40 rains. Therefore for the purposes of this study they were analysed as a whole. For

ANTITHROMBIN III REPLACEMENT IN PRETERM INFANTS R. Brangenberg, M. Bodensohn, U. Bürger

(n= 12) the baseline lCa rose from 1.03 ± 0.05 to 1.18 ± 0.04 mmols/s

(p<0.00001) at 20 and 1.18 ± 0.04 mmols/l (p<0.00001) at 40 mins respectively. The MAP rose on average by 8.2 ± 2.2% (p<0.01) at 20 and 2.9 ± 2.2%(p <0.7) at 40 mins. Cl however fell on average by 10.5 ± 2.5% at 20 (p< 0.007) and 7.5 ±1.5% (p<0.o1)at 40 rains. This was reflected by an increase in SVRI of 17.6 ± 5% (p<0.05) at 20 and 10.5 ± 4% at 40 reins. (p<0.09). Bolus administration of CaC12 has similar effects in children with

ionised hypocalaemia and ionised normocalaemia. Although CaCl2 produces a significant rise in MAP at 20 mins it occurs as the result of an increasing afterload with a concominant fall in Cl. Therefore administration of CaC12 may be harmful haemodynamically.

In preterm infants the actzvityy of AT III, the main inhibitor of thrombin, ist lowered in dependence of gestational age. These infants-are prone to consumption coagulopathy caused by complications like. sepsis or ADS. Babies with lower levels of AT III have been shown to have worse outcome than neonates with levels appropriate for gestational age, including higher mortality and increased incidence of intracranial hemorrhage. In our study we wanted to show the effect of early AT III substitution on coagulation parameters and on complications especially intracranial hemorrhage (IC H) and R DS. 108 preterm infants at a gestational age of 25 - 34 weeks (mean 29 weeks, birthweight 600 - 2170 g, mean: 1285 g) received AT III concentrate 100 - 200 u/kg on the day of birth and the following days only in case of a new decrease. AT III activity on the day of birth (20 - 72 %, mean: 40 %, n = 24) was lower than described for term infants. After substitution AT III activity showed a significant (p = 0.001) increase on day 1 (16 - 170 %, mean: 90 %). No significant decrease was seen between day 1 and day 5 - 9 (39 - 125 %, mean 77 %). Although only 10 infants were treated with surfactant the duration of ventilation was short with 0 - 34 days (mean: 3.75 days, n = 108).

rO patients developed

bronchopulm onary dysplasia, 24 retinopathy of prematurity (grade II: n = 1, grade Ill n = 1). The incidence of severe intracranial hemorrhage grade 11(3/108), grade III (4/108) and grade IV (0/108) was low. By inhibiting the progression of consumption coagulopathy AT III substitution seems to reduce complications like intracranial hemorrhage and severe ADS with long term ventilation. Department of Pediatrics, Kreiskrankenhaus Traunstein, 8220 Traunstein, FRG

Department of Paediatric Cardiology, Guy's Hospital, St Thomas's St, London SEI 9RT England.

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CONTINUOUS VENOVENOUS HAEMOFILTRATION IN NEWBORN INFANTS J FI Reeves, W W Butt

GASTRIC LESIONS AND ACID PRODUCTION IN NEWBORNS IN NEONATAL INTENSIVE CARE UNIT

Continuous arteriovenous haemofiltration (CAVH) is the technique most ftequently used as renal support in newborn infants but it has the disadvantages of limited blood flows, poor solute clearance, short filter life and the potential for deleterious haemodynamic effects. Continuous venovenous haemofiltration (CVVH) addresses these shortcomings. Between April 1989 and October 1991, 17 infants were treated with filtration in the Intensive Care Unit of the Royal Children's Hospital, Melbourne, Australia. The median body weight was 3.3kg (range 2.5-4) and the median age was 7 days (2-72). The indication for filtration was acute renal failure (9), sepsis (4), inborn errors of metabolism (3) and fluid overload (1). Four techniques were used: CVVH (16), CAVH (2), continuous venovenous plasmafiltration (CWP 1) and continuous arteriovenous plasmafiltration (CAVP 1). Filtration was usually performed through a double lumen catheter (6.5F, model DLK4006, Vas-cath Inc, Toronto, Canada) inserted into the femoral vein. A customised filtration circuit (model PXRCM501A, Gambro, Melbourne, Australia) was used which enabled the inclusion of a heat exchanger in line. The circuit was connected to either a Renaflo HF250 (Renal Systems, Minneapolis, USA), Gambro PF1000 or Gambro FH22 filter and blood pumped by a Gambro Blood Pump MPM10. Filter performance: Using blood flows of 25-40 ml/min we were able to achieve filtrate flow of up to 600m1/hr (clearance of 30m1/min/m 2 , J Pediatr 1991;118:879). The median duration of filtration was 46hr (range 4.5-260hr) and the median filter life was 35hr (4.5-260). Complications include one episode of superior vans caval thrombosis (due to the placement of an excessively large cannula, 11 Fr, in the internal jugular vein) and one episode of line-related sepsis. Rapid onset of hypothermia occurred at higher flows in the first few Infants despite wrapping the circuit with aluminium foil and warming the replacement fluids. This was corrected by the inclusion of an in-line ECMO heat exchanger (ECMOtherm, SciMed Life Systems, Minneapolis, USA). Electrolyte abnormalities (hypophosphataemia and hyperlactaemia) were seen when commercial replacement solutions were employed so the replacement fluid for haemofiltration is now made up in-house to the following concentrations (mmol/L): Na 135, K 3, Ca 1.5, Mg 0.7, HCO3 25, PO4 1, Cl 100, dextrose 0.3% and acetate to balance.

A-L.Kuusela, T.Ruuska, A.Karikoski-Leo, V.Lautamatt'

Intensive Care Unit, Royal Children's Hospital, Parkville 3052, Australia

Infants treated in neonatal intensive care have been prospectively screened for gastric lesions by performing gastroscopy and for acid production by 24-hour pH-monitoring. Gastroscopy was done with Olympus XGIF-5.2 gastroscope and pH-monitoring was done with Syntetics Digitrapper pH-monitoring set. The procedures were performed during the first week of life The birth weight ranged from 560g to 418Og and gestational weeks from 23 to 41 weeks. A total of 69 infants have been studied with gastroscopy and pH-monitoring has been done to 37 of them. Only six of them were symptomatic. Gastric lesions - ulcer, erosions, gastritis - were seen in 81% either histologically or macroscopically. 13 of the smallest infants treated with mechanical ventilator had histologically acute erosive gastritis with cystic glands. Even the small preterm infants had gastric pH below four, which shows their capacity to produce acid. Ranitidine treatment was given to symptomatic infants or those with severe macroscopic findings. During ranitidine treatment gastric pH stays over six constantly. In control gastroscopies all ranitidine treated lesions were healing. We conclude that gastric lesions are very common in infants with high stress in neonatal intensive care. Acid plays also an important role in formation of gastritis and ulcer disease even in small infants in intensive care units. Depatment of Pediatrics, Tampere University Hospital, Tampere Teiskontie 35 Box 607 SF-33101 Tampere, Finland