Background: In premature infants with preterm prolonged rupture of membranes, death after birth is often due to persistent pulmonary hyper-tension. Patients: Aerosolized iloprost was used to treat pulmonary hypertension due to prolonged preterm rupture of fetal membranes (7-56 days) in four extremely low-birthweight neonates (23-25 weeks’ gestation, weight 448-645 g) under spontaneous breathing supported by nasal continuous positive airway pressure. Method: Inhalation dose was 2 μg/kg b.w. and between 44 and 65 inhalations were performed in each patient starting within the first hour of life over a total of several days. Single inhalations lasted 5 min and were not repeated until 60 min had elapsed. Results: After the first inhalation, the PaO₂/FiO₂ mean ratio increased from 65 (range 35-114) to 194 (148-250) mmHg and oxygenation requirements decreased within the next 7 days. Echocardiography similarly showed reduction in pulmonary resistance. We observed no severe side effects on blood pressure or prolonged bleeding time during inhalation. Conclusions: Iloprost inhalation might therefore be an additional treatment for improving oxygenation in cases of persistent pulmonary hypertension in extremely low-birthweight infants under spontaneous breathing. Further randomized clinical studies are required to establish the role of iloprost in this setting. Hintergrund: Bei sehr kleinen Frühgeborenen mit langem vorzeitigen Blasensprung ist die Mortalität, bedingt durch einen pulmonalen Hypertonus, erhöht. Patienten: Iloprost wurde bei vier sehr kleinen Frühgeborenen (23-25 Schwangerschaftswoche, Geburtsgewicht 448-645 g) mit langem vorzeitigen Blasensprung (7-56 Tage) unter nasaler CPAP-unterstützter Spontanatmung inhalativ appliziert. Methode: Die einzelne Inhalationsdosis betrug 2 μg/kg KG und wurde über 5 Minuten vernebelt. Die erste Inhalation startete innerhalb der ersten Lebensstunde. Weitere Inhalationen wurden erst nach Ablauf von 60 Minuten wiederholt. Insgesamt wurden über einen Zeitraum von 7 Tagen zwischen 44 und 65 Inhalationen je Patient durchgeführt. Ergebnisse: Nach der ersten Inhalation stieg der PaO₂/FiO₂- Wert von 65 mmHg (35-114) auf 194 mmHg (148-250) an. Der Sauerstoffbedarf fiel über einen Zeitraum von 7 Tagen ab. Parallel durchgeführte Echokardiographien zeigten einen Abfall des pulmonalen Widerstandes. Schwere Nebenwirkungen wie arterielle Hypotonie oder verlängerte Blutungszeiten wurden während den Inhalationen nicht beobachtet. Schlussfolgerung: Iloprost-Inhalationen scheinen als zusätzliche therapeutische Maßnahme zur Senkung des Sauerstoffbedarfs bei sehr kleinen Frühgeborenen mit persistierendem pulmonalen Hypertonus unter CPAP-unterstützter Spontanatmung geeignet. Kontrolliert-randomisierte klinische Studien sind erforderlich, um den Gebrauch von Iloprost in diesen speziellen Krankheitsbilden zu untersuchen.

The aim of this retrospective analysis was to provide information on how infections with respiratory syncytial virus (RSV) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) differ in symptoms, clinical course, outcome, and utilization of hospital care. We investigated 748 polymerase chain reaction results from symptomatic children aged 0–4 years in Cologne, Germany. One hundred sixty-nine patients tested positive for RSV (22.6%) and 24 children for SARS-CoV-2 (3.2%). Symptomatic patients with RSV infection were hospitalized significantly longer. RSV-positive patients needed oxygen supplementation significantly more often as well as high-flow therapy. With regard to care efforts, RSV-infected patients put higher pressure on the hospital and utilized more hospital resources.

Objectives: The Pediatric Emergency Ruler (PaedER) is a height-based drug dose recommendation tool that was reported to reduce life-threatening medication errors by 90%. The PaedER was introduced into the Cologne Emergency Medical Service (EMS) in 2008 along with educational measures, publications, and lectures for pediatric drug safety. We reviewed the impact of these continuously ongoing measures on medication errors after 10 years. Methods: The PaedER was introduced and distributed to all 14 emergency ambulances and 2 helicopters staffed with emergency physicians in the city of Cologne in November 2008. Electronic records and medical protocols of the Cologne EMS over two 20-month periods from March 2007 to October 2008 and March 2018 to October 2019 data sets were retrieved. The administered doses of either intravenous, intraosseous, intranasal, or buccal fentanyl, midazolam, ketamine, or epinephrine were recorded. Primary outcome measure was the rate of severe drug dosing errors with a deviation from the recommended dose of greater than 300%. Results: A total of 59 and 443 drug administrations were analyzed for 2007/08 and 2018/19, respectively. The overall rate of drug dosing errors decreased from 22.0% to 9.9% (P = 0.014; relative risk reduction, 55%). Four of 5 severe dosing errors for epinephrine were avoided (P < 0.021; relative risk reduction, 78%). Documentation of patient’s weight increased from 3.2% in 2007/08 to 30.5% in 2018/19 (P < 0.001). Conclusions: The distribution of the PaedER combined by educational measures significantly reduced the rates of life-threatening medication errors in a large EMS. Those results should motivate further initiatives on pediatric drug safety in prehospital emergency care.

Long-term intravenous sedation may present problems due to dependence and side effects. Medical records of children who were administered isoflurane were reviewed. 15 patients (9 boys, 6 girls) with a mean age of 11.8 month (+2.4) were analysed. Analgesia and sedation was given in mean 9.7+1.1 days before commencing inhalation using a modified application device (AnaConDa^©). Administration was given over a period of 7.2+1.4 days. Depth of sedation was monitored by using Comfort- and Hartwig-scores. Observations included continuous monitoring of heart-rate, pulse oxymetry, blood pressure and cerebral tissue oxygenation. Within 4 h post administration of isoflurane a satisfactory increase in the depth of sedation was seen and kept till extubation. 6/15 patients received tracheostomies during the observation period. None of the patients observed suffered life-critical events of the modi­fied application of isoflurane proceeded without complications. Ketamine and clonidine infusion rates were significantly reduced (p<0.005) as well as the use and overall infusion rate of midazolam, γ-hydroxy butyrate, fentanyl and morphine (p<0.05). Isoflurane inhalation may provide an additional option for long-term sedation in a specific group of critically ill infants but neurodegenerative toxic effects will have to be taken into account when using volatile anesthetics at any time during infancy. Eine lang andauernde intravenöse Sedierung kann durch Abhängigkeit und Nebenwirkungen erheblich erschwert sein. Alle medizinischen Daten von Kindern, die Isofluran erhalten haben, 15 Patienten (9 Jungen, 6 Mädchen) mit einem mittleren Alter von 11,8 Monaten (+ 2,4), wurden ausgewertet. Vor Beginn der Inhalation mittels eines modifizierten Applikationsgerätes (AnaConDa^©) wurden Analgetika und Sedativa im Mittel 9,7+1,1 Tage gegeben. Die Inhalation da­uerte im Mittel 7,2+1,4 Tage an. Die Sedierungstiefe wurde anhand des Comfort- und des Hartwig-Scores gemessen. Die weitere Beobachtung beinhaltete Herzfrequenz, Pulsoxymetrie, Blutdruck und zerebrale Gewebsoxygenierung. Innerhalb von 4 Stunden nach Beginn der Isofluran-Inhalation wurde eine zufriedenstellende Sedierungstiefe erreicht und bis zur Extubation gehalten. 6/15 Patienten erhielten im Verlauf der Beobachtungszeit ein Tracheostoma. Bei keinem Patienten wurden lebensgefährliche Komplikationen beobachtet. Die technische Durchführung verlief komplikationslos. Sowohl die Ketamin- und Clonidin- Infusionsraten wurden signifikant (p<0,005) reduziert als auch die Gesamtinfusionsmengen von Midazolam, γ-Hydroxy­butyrat, Fentanyl und Morphin (p<0,05). Die Isofluran-Inhalation ist möglicherweise eine ergänzende Option für die Langzeitsedierung kritisch kranker Kinder. Dabei müssen toxisch-neurodegenerative Effekte bei der Verwendung volatiler Anästhetika in jedem Kindesalter berücksichtigt werden.