[Pediatric shock--pathophysiology, diagnosis and treatment]. / Das Kind im Schock--Pathophysiologie, Früherkennung und Therapie.

Shock remains a significant cause of morbidity and potential mortality in the pediatric population. It is defined as a impaired perfusion with a too high oxygen demand in comparison to oxygen delivery. The cause of hypoxia may be found in a hypovolemic condition due to hemorrhage or loss of gastro-intestinal fluids, a disorder in volume distribution or a cardiac dysfunction. Less frequent are patients with an obstruction in the outflow tract of the heart or disorders in binding oxygen to hemoglobin. Hypoxia leads to lactat-acidosis with the clinical signs of tachypnoea, tachycardia and restlessness. It is of greatest importance to recognize the ongoing dysfunction early, in spite of mechanism of compensation with a high cardiac output, warm periphery and dry skin (warm shock). Is there no adequate therapy decompensation will occur with vasoconstriction, cold periphery and low cardiac output. This will lead to multiple organ dysfunction syndrome with neurological, renal, further cardiac, pulmonary and metabolic disorders. If this point of no return is reached, cell death will continue to occur and the patient will die. Early and aggressive volume therapy is indicated, filling the cardiac system with crystalloids or colloids. Later on under clinical conditions inotropic drugs will improve cardiac output and oxygen delivery. Only by recognizing these patients as early as possible we will be able to reduce morbidity and mortality of this potentially dangerous syndrome.

[Changes in the epidemiology of the acute respiratory distress syndrome (ARDS) in children]. / Cambios en la epidemiología del síndrome de dificultad respiratoria aguda (SDRA) en niños.

OBJECTIVE: Our aim was to analyze, in a retrospective study, changes in acute respiratory distress syndrome (ARDS) within the same pediatric intensive care unit by using the same diagnostic criteria as published in 1982. PATIENTS AND METHODS: Fifteen patients (mean age 5.1 years, range 16 days-15 years) admitted between 1988 and 1994 fulfilling our former criteria for ARDS were included in the study. RESULTS: The incidence of ARDS after the age of 7 days was 0.45% of all admissions between the age of 1 week and 16 years vs 1.79% in the former series of patients (p < 0.001). Thus, the yearly rate of ARDS decreased from 5.7 to 2.1 cases per year. Six patients suffered a chronic underlying disease vs none in 1982 (p < 0.01). Triggering of ARDS by infection/inflammation was present in 14/15 patients vs 7/20 in the first series (p < 0.001). Except for the nadir PaO2/FiO2 ratio (54 mmHg vs 97 mmHg, p < 0.01), and duration of FiO2 > or = 0.5 (204 h vs 39 h, p < 0.01) there was no statistically significant difference with regard to respiratory data. Incidence of multiple organ/system failure and numbers of failing organs/systems remained unchanged. Eight of 15 patients died in the actual series vs 8/20 in 1982 (not significant). CONCLUSIONS: Compared to our former data, the incidence of ARDS has decreased. Although the number of patients with severe chronic disease has increased, mortality remains statistically unchanged. Infection/inflammation is currently the predominant event triggering ARDS. Judging by the PaO2/FiO2 ratio and duration of FiO2 > or = 0.5, pulmonary involvement is more severe. The number of failing organs/systems remains nearly twice as frequent in non-survivors compared to survivors.

[Heart arrest: septic and hypovolemic shock--intraosseous infusion technique]. / Herzstillstand: septischer und hypovolämischer Schock--intraossäre Infusionstechnik.

Cardiorespiratory arrests in infants are most often caused by generalized hypoxia. This leads to the well-known fact that the outcome of arrests in the pediatric age group is poor. On the other hand we have the chance to recognize the ongoing hypoxia at early stages. Prevention of this dangerous situation is the aim of treatment. Clinical manifestations of shock states in children differ considerably from those seen in adult patients. Causes and treatment of hypovolemic and septic shock and the technique of intraosseous puncture and infusion are described in detail.

Respiratory syncytial virus triggered adult respiratory distress syndrome in infants: a report of two cases.

Two infants with severe respiratory syncytial virus infection which resulted eventually in classical adult respiratory distress syndrome (ARDS) are presented. Both infants had severe apneic spells, necessitating intubation and mechanical ventilation (MV). Chest radiographs changed after a few days after institution of MV from initial bronchopneumonia like pattern to severe ARDS. Assessment of respiratory system mechanics (single breath occlusion technique) revealed severe restrictive disease in both cases. The first patient recovered with residual restrictive changes determined during a follow-up 2.5 months later, whereas the second infant died because of ARDS, pulmonary interstitial emphysema and hypoxemic hypoxia.