Critical Care News

Volume 3, Number 2

January, 1996

Critical Care News
is the official quarterly newsletter of the Section on Critical Care Medicine of the
American Academy of Pediatrics.

Questions or comments should be addressed to the editors,
Brahm Goldstein, MD, Otwell Timmons, MD, and/or Kristan Outwater, MD

• 1996 AAP Abstracts
• AAP Research Grant Applications
• Career Achievement Award
• 1995 Fall AAP Meeting Summary
• 1995 Best Abstracts Listing
• Acute Pulmonary Hemorrhage:
  • Call the CDC
• Suggestions & Comments
• Call for 1996 Distinguished Career
• Award Nominations (enclosed)

1996 AAP Abstracts to be Published in Pediatrics

This will greatly enhance the scientific integrity of AAP national meetings, increase the number and quality of abstract submissions, and provide dissemination of critical care education and research to a wide pediatric audience.

This will also mean that there will be no extensions of the April 1st deadline for abstract submissions. Abstract forms will be mailed to members of the Section in 1996. Submissions should be sent to Brahm Goldstein.

New Investigator Research Grant Applications Available

New Investigator Research Award

The purpose of the American Academy of Pediatrics Section on Critical Care Medicine New Investigator Research Award is to promote understanding of critical illness and injury in children through clinical and/or laboratory research. The grant will provide support for a research project to an individual who has demonstrated aptitude for clinical or basic science during his or her pediatric critical care fellowship or during the first two years of post-fellowship experience as a junior faculty member in an academic setting.

Dan Notterman, MD, FAAP, FCCM will be Chair of the subcommittee reviewing grant applications. The award will be judged on the following criteria: scientific merit, clarity of the presentation, likelihood of productivity by the investigator, evidence of appropriate academic environment by the sponsor, and, relevance to critical care.

Grant applications are available from:

Jacqueline Bucko

AAP Sections Manager

Div. of Sections

141 Northwest Point Blvd.

PO Box 927

Elk Grove Village, IL

60009-0927

Tel: 1-800-433-9016 ext. 6759

Distinguished Career Award in Pediatric Critical Care:
Call for Nominations

Please take a few minutes to write in your nomination for the 1996 award. The nominee should exhibit the qualities commensurate with a career achievement award in the and have distinguished himself/herself in the areas of clinical care, teaching, and research.

Based upon the mailed responses, the Award Subcommittee (Drs. Goldstein, Lorie Frankel, David Jaimovich, and Daniel Notterman) will choose the top three nominees. The final award winner will be decided by the SectionUs Executive Committee. The award will be presented at the 1996 Section meeting in Boston, MA.

Update from The AAP Section on Critical Care Executive Meeting

Full details will be published in the March newsletter.

Executive Committee Membership

Abstract Winners from the 1995 Fall Meeting

Acute Pulmonary Hemorrhage in Infants:
A call for reports to the CDC

The CDC requests reports of acute pulmonary hemorrhage in infants. If you have seen any infants with acute pulmonary hemorrhage, please alert the CDC immediately. A study to determine the cause of acute pulmonary hemorrhage is beginning, prompted by a cluster of cases of this rare disease that occurred in Cleveland last year. During January 1993-November 1994, eight cases of acute pulmonary hemorrhage/ hemosiderosis were diagnosed among infants at Rainbow Babies and ChildrenUs Hospital in Cleveland. In comparison, during 1983-1993, a total of three cases of pulmonary hemosiderosis were diagnosed among infants and children at this hospital.

For each of the eight infants (mean age: 10.3 weeks; range: 4 weeks-16 weeks), onset of hemoptysis was associated with pallor and an abrupt cessation in crying; fever was not reported for any of the infants. Other reported symptoms on admission included limpness, lethargy, and grunting. At the time of initial evaluation at the hospital, seven infants required admission to the pediatric intensive care unit because of hemoptysis and respiratory distress.

All eight infants were black, and seven were male. The median age of their mothers was 20 years (range: 15-29 years). Seven of the pregnancies and deliveries occurred without complications; one infant born at 27 weeks' gestation and weighing 2 lb., 2 oz (950 g) had complications of severe prematurity. All infants lived within a 6-mile radius of the hospital. No infants were breast fed; before admission, all were fed cow's-milk-based formula.

Laboratory findings on admission included a normal white blood cell count (median=13.8 cells/mm3) and features consistent with a normocytic, normochromic anemia characteristic of acute blood loss with a mean hematocrit of 27.1% (normal: 36.0%-47.0%) and a mean hemoglobin of 9.1 g/dL (normal: 10.0-15.0 g/dL). Red blood cell morphology was suggestive of a microangiopathic process: microscopic examination indicated that five of the eight infants had mild to moderate (1+ to 2+) hemolysis characterized by the presence of microcytes, burr cells, spherocytes, and bizarre fragments. Based on guaiac testing, occult blood was present in the stool of three infants. Results of coagulation studies included normal prothrombin and partial thromboplastin time for all infants.

Chest radiographs of all infants showed diffuse, bilateral infiltrates consistent with pulmonary hemorrhage. In six infants, the mean serum magnesium level was 2.1 mg/dL (normal: 1.4-1.9 mg/dL).

Cultures of blood, urine, and bronchoalveolar lavage from seven infants were negative for bacterial, mycotic, and viral pathogens. Cultures of bronchoalveolar lavage from one infant grew Bacillus sp. Hemosiderin-laden macrophages--indicating continued pulmonary hemorrhage- -were detected in each of the seven infants who underwent bronchoscopy more than 2 weeks after the acute hemorrhage. No other site of bleeding (i.e., gastrointestinal or nasopharyngeal) was identified during endoscopic evaluation. Immunoglobulin G levels to cow's milk proteins were above normal (>20 U/mL) in five of seven infants.

Five infants required mechanical ventilation for an average of 5 days. All infants survived the first hospitalization and were discharged in stable condition without evidence of hemoptysis after a median length of stay of 10 days (range: 2-35 days). In five infants, acute hemoptysis necessitating readmission recurred within 1 day to 6 months of discharge. One death--attributed to severe hypoxic encephalopathy secondary to recurring pulmonary hemorrhage--occurred in a 9-week-old full-term infant.

The eight cases of acute pulmonary hemorrhage/ hemosiderosis described exceed the number expected at this hospital during a 2-year period. Massive acute pulmonary hemorrhage occurs rarely in infants; it usually is attributed to cardiac or vascular malformations, infectious processes, immune vasculitides, trauma, or known milk protein allergies. Cases for which the etiology is undetermined traditionally have been classified as idiopathic pulmonary hemosiderosis (IPH) and account for less than 5% of all cases of pulmonary hemorrhage during infancy.

The pathologic mechanism for IPH in children is unknown. Recent histomorphologic techniques suggest that the initial histopathologic damage occurs at the alveolar epithelial surface. IPH has been associated with circulating antibodies to cow's milk protein; however, this association has not been consistently reproduced. In addition, some reports have described familial occurrences of pulmonary hemosiderosis, suggesting a possible genetic vulnerability to a toxicant.

To identify additional cases of acute pulmonary hemorrhage/hemosiderosis, the CDC has established the following provisional surveillance case definition: hemoptysis in an infant aged less than 1 year not attributed to cardiac or vascular malformations, infectious processes, or trauma. A case report form is available from CDC.

Pediatricians are asked to report possible cases through state health departments to Dr. Ruth Etzel.

SUGGESTIONS & COMMENTS:

Brahm Goldstein, MD, FAAP, FCCM
Chief, Division of Pediatric Critical Care
Oregon Health Sciences University
3181 SW Sam Jackson Park Road
Portland, OR 97201 (PED)
Tel 503-494-1544 Fax 503-494-4953
goldsteb@ohsu.edu

Kristan Outwater, MD, FAAP, FCCM (Chairperson)
Pediatric Intensive Care Unit
St. Lukes Health Care Assoc.
700 Cooper Ave.
Saginaw, MI 48602
Tel 517-793-6373 Fax 517-793-7649

Otwell Timmons, MD, FAAP
PO Box 32861
Charlotte, NC 28232-2861
Tel 704-355-7815 Fax 704-355-3116
otimmons@med.unc.edu

The success and utility of this newsletter is dependent upon input from Section members. Ideas for articles, job listings, and notices of upcoming events related to Pediatric Critical Care are welcome.

Other issues of Critical Care News Available

• July, 1996
• September, 1996
• January, 1997
• March, 1997
• September, 1997
• January, 1998
• July, 1998
• October, 1998
• January, 1999
• September, 1999