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Ingelse SA, Geukers VG, Dijsselhof ME, Lemson J, Bem RA, van Woensel JB. Less Is More?-A Feasibility Study of Fluid Strategy in Critically Ill Children With Acute Respiratory Tract Infection. Front Pediatr 2019; 7:496. [PMID: 31921715 PMCID: PMC6915071 DOI: 10.3389/fped.2019.00496] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 11/15/2019] [Indexed: 12/25/2022] Open
Abstract
Background: Fluid overload is common in critically ill children and is associated with adverse outcome. Therefore, restricting fluid intake may be beneficial. This study aims to study the feasibility of a randomized controlled trial (RCT) comparing a conservative to a standard, more liberal, strategy of fluid management in mechanically ventilated pediatric patients with acute respiratory tract infection (ARTI). Methods: This is a feasibility study in a single, tertiary referral pediatric intensive care unit (PICU). Twenty-three children receiving mechanical ventilation for ARTI, without ongoing hemodynamic support, admitted to the PICU of the Emma Children's Hospital/Amsterdam UMC between 2016 and 2018 were included. Patients were randomized to a conservative (<70% of normal intake) or standard (>85% of normal intake) fluid strategy, which was kept throughout the period of mechanical ventilation. Results: Primary endpoints were adherence to fluid strategy and safety parameters such as calorie and protein intake. Secondary outcomes were cumulative fluid intake (CFI) and cumulative fluid balance (CFB) on day 3. In the conservative group, in 75% of the mechanical ventilation days patients achieved their target fluid intake. Median [25th-75th percentiles] calorie intake over all mechanical ventilation days was 67.9 [51.5-74.0] kcal/kg/day in the conservative vs. 67.2 [58.0-75.2] kcal/kg/day in the standard group (p = 0.878). Protein intake was 1.6 [1.3-1.8] gr protein/kg in the conservative and 1.5 [1.2-1.7] gr protein/kg in the standard group (p = 0.598). No adverse effects on hemodynamics or electrolyte imbalances were noted. Mean (±SD) CFI on day 3 was 262.3 (±58.9) ml/kg in the conservative group vs. 360.5 (±52.6) ml/kg in the standard fluid group (p < 0.001), which did not result in a lower CFB. Conclusions: A conservative fluid strategy in mechanically ventilated children with ARTI seems feasible, without limiting metabolic needs. However, in our study a conservative fluid strategy surprisingly did not reduce the degree of fluid overload. This study aids the design and sample size calculation of a future larger multicenter RCT, in which we need to redefine the target fluid strategy, possibly by even further fluid restriction and early initiation of active diuresis. Clinical Trial Registration: ClinicalTrials.gov, identifier: NCT02989051.
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Affiliation(s)
- Sarah A Ingelse
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Vincent G Geukers
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Monique E Dijsselhof
- Department of Dietetics, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - Joris Lemson
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - Reinout A Bem
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Job B van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Jaeger B, Abeling NG, Salomons GS, Struys EA, Simas-Mendes M, Geukers VG, Poll-The BT. Pyridoxine responsive epilepsy caused by a novel homozygous PNPO mutation. Mol Genet Metab Rep 2016; 6:60-3. [PMID: 27014579 PMCID: PMC4789384 DOI: 10.1016/j.ymgmr.2016.01.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 01/26/2016] [Accepted: 01/26/2016] [Indexed: 12/20/2022] Open
Abstract
We report a patient with anti-epileptic treatment refractory neonatal seizures responsive to pyridoxine. Biochemical analysis revealed normal markers for antiquitin deficiency and also mutation analysis of the ALDH7A1 (Antiquitin) gene was negative. Mutation analysis of the PNPO gene revealed a novel, homozygous, presumed pathogenic mutation (c.481C > T; p.(Arg161Cys)). Measurements of B6 vitamers in a CSF sample after pyridoxine administration revealed elevated pyridoxamine as the only metabolic marker for PNPO deficiency. With pyridoxine monotherapy the patient is seizure free and neurodevelopmental outcome at the age of 14 months is normal.
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Affiliation(s)
- B Jaeger
- Department of Pediatric Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - N G Abeling
- Laboratory of Genetic Metabolic Diseases, Academic Medical Center, Amsterdam, The Netherlands
| | - G S Salomons
- Department of Clinical Chemistry, Metabolic Unit, VU University Medical Center, Amsterdam, The Netherlands
| | - E A Struys
- Department of Clinical Chemistry, Metabolic Unit, VU University Medical Center, Amsterdam, The Netherlands
| | - M Simas-Mendes
- Department of Clinical Chemistry, Metabolic Unit, VU University Medical Center, Amsterdam, The Netherlands
| | - V G Geukers
- Pediatric Intensive Care Department, Academic Medical Center, Amsterdam, The Netherlands
| | - B T Poll-The
- Department of Pediatric Neurology, Academic Medical Center, Amsterdam, The Netherlands
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Geukers VG, Dijsselhof ME, Jansen NJG, Breur JMPJ, van Harskamp D, Schierbeek H, van Goudoever JB, Bos AP, Sauerwein HP. The effect of short-term high versus normal protein intake on whole-body protein synthesis and balance in children following cardiac surgery: a randomized double-blind controlled clinical trial. Nutr J 2015. [PMID: 26215396 PMCID: PMC4517637 DOI: 10.1186/s12937-015-0061-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Infants undergoing cardiac surgery are at risk of a negative protein balance, due to increased proteolysis in response to surgery and the cardiopulmonary bypass circuit, and limited intake. The aim of the study was to quantify the effect on protein kinetics of a short-term high-protein (HP) diet in infants following cardiac surgery. Methods In a prospective, double-blinded, randomized trial we compared the effects of a HP (5 g · kg−1 · d−1) versus normal protein (NP, 2 g · kg−1 · d−1) enteral diet on protein kinetics in children <24 months, on day 2 following surgical repair of congenital heart disease. Valine kinetics and fractional albumin synthesis rate (FSRalb) were measured with mass spectrometry using [1-13C]valine infusion. The Mann–Whitney U test was used to investigate differences between group medians. Additionally, the Hodges-Lehmann procedure was used to create a confidence interval with a point estimate of median differences between groups. Results Twenty-eight children (median age 9 months, median weight 7 kg) participated in the study, of whom in only 20 subjects isotopic data could be used for final calculations. Due to underpowering of our study, we could not draw conclusions on the primary outcome parameters. We observed valine synthesis rate of 2.73 (range: 0.94 to 3.36) and 2.26 (1.85 to 2.73) μmol · kg−1 · min−1 in the HP and NP diet, respectively. The net valine balance was 0.54 (−0.73 to 1.75) and 0.24 (−0.20 to 0.63) μmol · kg−1 · min−1 in the HP and NP group. Between groups, there was no difference in FSRalb. We observed increased oxidation and BUN in the HP diet, compared to the NP diet, as a plausible explanation of the metabolic fate of surplus protein. Conclusions It is plausible that the surplus protein in the HP group has caused the increase of valine oxidation and ureagenesis, compared to the NP group. Because too few patients had completed the study, we were unable to draw conclusions on the effect of a HP diet on protein synthesis and balance. We present our results as new hypothesis generating data. Trial registration Dutch Trial Register NTR2334.
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Affiliation(s)
- Vincent G Geukers
- Pediatric Intensive Care Department H8-190, Emma Children's Hospital (EKZ), Academic Medical Center (AMC), Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands. .,Department of Pediatrics, EKZ, AMC, Amsterdam, The Netherlands.
| | | | - Nicolaas J G Jansen
- Pediatric Intensive Care Department, Wilhelmina Children's Hospital (WKZ), University Medical Center Utrecht (UMCUtrecht), Lundlaan 6, 3584, EA, Utrecht, The Netherlands.
| | | | | | - Henk Schierbeek
- Department of Pediatrics, EKZ, AMC, Amsterdam, The Netherlands.
| | - Johannes B van Goudoever
- Department of Pediatrics, EKZ, AMC, Amsterdam, The Netherlands. .,Department of Pediatrics, VU University Medical Center, Boelelaan 1117, 1081, HV, Amsterdam, The Netherlands.
| | - Albert P Bos
- Pediatric Intensive Care Department H8-190, Emma Children's Hospital (EKZ), Academic Medical Center (AMC), Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands. .,Department of Pediatrics, EKZ, AMC, Amsterdam, The Netherlands.
| | - Hans P Sauerwein
- Department of Endocrinology and Metabolism (emeritus), AMC, Amsterdam, The Netherlands.
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Leijssen LGJ, Linthorst GE, Geukers VG, Ploem MCC. [The 'interesting case' and patient privacy: handling patient data in medical education]. Ned Tijdschr Geneeskd 2015; 159:A9458. [PMID: 26469735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The use of patient histories has become an essential part of medical education. Patient histories are important for the relevance, effectiveness and appeal of medical education. The sharing of patient-related information in education and further training is expected to increase in the coming years. The sharing of patient information with colleagues, students or other interested parties can conflict with the rules protecting patient privacy. The most important rule in this context is that it is the patients who decide whether their cases can be shown to others for educational purposes. Patient consent is not required if the data or images used have been fully anonymized. If the information can be traced to the patient, consent is required, preferably documented in writing. The teaching physician is responsible for the storage, protection and destruction of patient data and for controlling access to information.
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Abstract
The authors report a case of a gunshot wound to the brain in a 2.5-year-old girl. To treat the uncontrollably elevated intracranial pressure, the patient underwent bilateral decompressive craniectomy and experimental open-wound treatment. She recovered to a good functional level.
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Affiliation(s)
- Pepijn van den Munckhof
- Neurosurgical Center Amsterdam, Academic Medical Center, Room H2-241, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Geukers VG, de Neef M, Dijsselhof ME, Sauerwein HP, Bos AP. Effect of a nurse-driven feeding algorithm and the institution of a nutritional support team on energy and macronutrient intake in critically ill children. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.eclnm.2011.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Geukers VG, Li Z, Ackermans MT, Bos AP, Jinfeng L, Sauerwein HP. High-carbohydrate/low-protein-induced hyperinsulinemia does not improve protein balance in children after cardiac surgery. Nutrition 2012; 28:644-50. [PMID: 22261573 DOI: 10.1016/j.nut.2011.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 07/03/2011] [Accepted: 09/27/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE In pediatric cardiac surgery, fluid-restricted low-protein (LoProt) diets account for cumulative protein deficits with increased morbidity. In this setting, we aimed to inhibit proteolysis by a high-carbohydrate (HiCarb)-intake-induced hyperinsulinemia and improve protein balance. METHODS The effect of a HiCarb/LoProt (glucose 10 mg · kg(-1) · min(-1)/protein 0.7 g · kg(-1) · d(-1)) versus a normal-carbohydrate (NormCarb)/LoProt (glucose 7.5 mg · kg(-1) · min(-1)/protein 0.3 g · kg(-1) · d(-1)) enteral diet on whole-body protein breakdown and balance was compared in a prospective, randomized, single-blinded trial in 24 children after cardiac surgery. On the second postoperative day, plasma insulin and amino acid concentrations, protein breakdown (endogenous rate of appearance of valine), protein synthesis (non-oxidative disposal of valine), protein balance, and the rate of appearance of urea were measured by using an isotopic infusion of [1-(13)C]valine and [(15)N(2)]urea. RESULTS The HiCarb/LoProt diet led to a serum insulin concentration that was three times higher than the NormCarb/LoProt diet (596 pmol/L, 80-1833, and 198 pmol/L, 76-1292, respectively, P = 0.02), without differences in plasma glucose concentrations. There were no differences in plasma amino acid concentrations, non-oxidative disposal of valine, and endogenous rate of appearance of valine between the groups, with a negative valine balance in the two groups (-0.65 μmol · kg(-1) · min(-1), -1.91 to 0.01, and -0.58 μmol · kg(-1) · min(-1), -2.32 to -0.07, respectively, P = 0.71). The serum cortisol concentration in the HiCarb/LoProt group was lower compared with the NormCarb/LoProt group (204 nmol/L, 50-544, and 532 nmol/L, 108-930, respectively, P = 0.02). CONCLUSION In children with fluid restriction after cardiac surgery, a HiCarb/LoProt diet compared with a NormCarb/LoProt diet stimulates insulin secretion but does not inhibit proteolysis further and therefore cannot be advocated for this purpose.
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Affiliation(s)
- Vincent G Geukers
- Pediatric Intensive Care Department, Emma Children's Hospital/Academic Medical Center, Amsterdam, Netherlands.
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Geukers VG, Veenhoven RH, Schouten-van Meeteren AY, Bruin MC, de Haas M. [Neutropenia due to antibodies against Type III Fc receptors on neutrophil granulocytes: 3 children with different clinical courses]. Ned Tijdschr Geneeskd 1998; 142:362-4. [PMID: 9562743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Three children (girls) suffered from neutropenia mediated by anti-neutrophil IgG-Fc receptor type III (Fc gamma RIII) antibodies. The first patient (newborn) had asymptomatic and transient neutropenia caused by maternal Fc gamma RIII iso-antibodies. The second patient (6 months), whose neutropenia was diagnosed as a 'benign neutropenia of childhood' caused by transient anti-NAI autoantibodies, suffered from mild bacterial infections. The third patient (12 years) suffered from serious infections. The anti-Fc gamma RIII autoantibodies showed neither anti-NA1 nor anti-NA2 specificity. She also developed autoimmune thyroiditis (Graves' disease). Both the duration of the neutropenia and the seriousness of the bacterial infection were variable in our patient group. The first two patients both made spontaneous recoveries, while the third patient depended ultimately on granulocyte-colony stimulating factor (G-CSF).
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Affiliation(s)
- V G Geukers
- Spaarne Ziekenhuis, afd. Kindergeneeskunde, Haarlem
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