Does the maternal-fetal transmission of SARS-CoV-2 occur during pregnancy?

BACKGROUND AND OBJETIVE: On January 7th, 2020, a new coronavirus, SARS-CoV-2, was identified, as responsible for a new human disease: COVID-19. Given its recent appearance, our current knowledge about the possible influence that this disease can exert on pregnancy is very limited. One of the unknowns to be solved is whether there is a vertical transmission of the infection during pregnancy. PATIENTS AND METHODS: Using the Real-time Polymerase Chain Reaction techniques for SARS-CoV-2 nucleic acids, the possible presence of this germ in vaginal discharge and amniotic fluid was investigated in four pregnant Caucasian patients affected by mild acute symptoms of COVID-19 during the second trimester of pregnancy. RESULTS: There is no laboratory evidence to suggest a possible passage of SARS-CoV-2 from the infected mother to the amniotic fluid. CONCLUSIONS: It is necessary to expand the investigation of COVID-19 cases diagnosed during pregnancy to clarify the real influence that SARS-CoV-2 has on pregnant women and their offspring, as well as those factors that modulate the disease.

Does the maternal-fetal transmission of SARS-CoV-2 occur during pregnancy? / ¿Existe transmisión materno-fetal del SARS-CoV-2 durante la gestación?

BACKGROUND AND OBJECTIVE: On January 7th, 2020, a new coronavirus, SARS-CoV-2, was identified, as responsible for a new human disease: COVID-19. Given its recent appearance, our current knowledge about the possible influence that this disease can exert on pregnancy is very limited. One of the unknowns to be solved is whether there is a vertical transmission of the infection during pregnancy. PATIENTS AND METHODS: Using the Real-time Polymerase Chain Reaction techniques for SARS-CoV-2 nucleic acids, the possible presence of this germ in vaginal discharge and amniotic fluid was investigated in four pregnant Caucasian patients affected by mild acute symptoms of COVID-19 during the second trimester of pregnancy. RESULTS: There is no laboratory evidence to suggest a possible passage of SARS-CoV-2 from the infected mother to the amniotic fluid. CONCLUSIONS: It is necessary to expand the investigation of COVID-19 cases diagnosed during pregnancy to clarify the real influence that SARS-CoV-2 has on pregnant women and their offspring, as well as those factors that modulate the disease.

[Is there an appropriate bispectral index for upper gastrointestinal endoscopy in spontaneous breathing in the pediatric patient?]. / ¿Existe un valor de índice biespectral adecuado para endoscopias digestivas altas en respiración espontánea en el paciente pediátrico?

OBJECTIVE: The bispectral index (BIS) values that predict appropriate anesthetic level to perform an upper gastrointestinal endoscopy in spontaneous breathing are not well established in Pediatrics. The objective of this study is to determine whether it is possible to find an appropriate, less profound, BIS level in the pediatric patient that would enable an upper gastrointestinal endoscopy (UGE) to be performed in spontaneous breathing without causing gag reflex or motor response. MATERIAL AND METHOD: A prospective study was designed and included 61 patients from 12-167 months old, and an ASAI-II who needed a diagnostic UGE. The study was conducted from October 2011 to March 2013. INTERVENTION: UGE performed with an anesthetic protocol using propofol. The vital signs measured were heart and respiratory rate, pulse oximetry, non-invasive blood pressure. The sedation level score (Ramsay scale) and BIS values were also measured. The first attempt was performed at BIS level 60-69, and this was not feasible, then the anesthetic was deepened and a second attempt made at BIS level 50-59. If this was still not possible a deeper anesthetic level was then achieved and a third attempt made at BIS level 45-49. Variables of interest were: effective BIS level (eBIS), BIS level at which UGE was performed without gag reflex or motor response; propofol total dose (mgkg(-1)), induction time (time from onset of sedation to effective start of UGE). A logistic regression analysis was performed to obtain an equation to estimate the possibility of UGE success. RESULTS: The distribution of the patient was: male 40%, female 60%, with 11 (18%) patients under 36 months. The statistical values are expressed as mean and standard deviation, with following results; age (months): 95.9±45.86; weight (kg): 30.5±14.68; effective BIS: 56.41±4.63; induction time (minutes): 11.07±2.69; total propofol dose (per kg): 4.86±1.21. An additional intra-procedure propofol bolus was given in 38 patients (62%), with 7/38 of them (18%) due to movement, and 31/38 (82%) due to BIS level increase. No statistical differences were found in effective BIS level between older and younger patients. CONCLUSIONS: According to the results, BIS levels below 59 predict UGE success, with 72.13% sensitivity and 88.06% specificity in the pediatric population studied.

[Neurogenic stunned myocardium in Pediatrics. A case report]. / Aturdimiento miocárdico neurogénico en Pediatría. A propósito de un caso.

Neurogenic stunned myocardium is an unusual clinical entity. It mimics an acute coronary syndrome with electrocardiographic abnormalities, cardiac dysfunction and elevated cardiac enzymes with absence of obstructive coronary disease. It may occur after a neurosurgical procedure. A case is presented of neurogenic stunned myocardium occurring in a child after removal of a posterior fossa medulloblastoma. The patient developed nodal tachycardia with hemodynamic impairment. The clinical course was satisfactory due to antiarrhythmic therapy, with biochemical, echocardiographic, and clinical improvement within a week.

[Usefulness of monitoring anaesthesia with the bispectral index in upper gastrointestinal endoscopies with spontaneous breathing]. / Utilidad de la monitorización anestésica con el índice biespectral en endoscopias digestivas altas en respiración espontánea.

INTRODUCTION: The objective of this investigation is to determine whether bispectral index (BIS®) monitoring during intravenous anaesthesia with spontaneous breathing for upper gastrointestinal endoscopy (UGE) in a pediatric population is useful for: a) decreasing the amount of drug, b) decreasing the time for awakening, and c) improving patient safety. PATIENTS AND METHOD: A quasi-experimental case-control prospective study was conducted in the setting of a second level hospital pediatric intensive care unit. PATIENTS: Children aged 1-13 years. CASE: ASA I patient who needed a diagnostic UGE; eligible, 36, participants, 30. CONTROL: historical cohort of patients who needed UGE (years 2008-2010): 50 patients. INTERVENTION: UGE performed with anaesthetic protocol, vital signs monitoring, sedation level (Ramsay scale) and BIS monitoring. VARIABLES OF INTEREST: propofol total dose (mg/kg), induction time, time in performing the UGE, awakening time (min); initial BIS (iBIS), and BIS during the UGE; adverse effects. RESULTS: There were no significant differences in sex, age or weight between case (B) and control (C) population. No significant differences in total propofol doses: (B 4.9 ± 1.4 mg/kg; C 5.2 ± 1.6 mg/kg, P=.492), awakening time (B 12.2 ± 4.6 min; C 12.8 ± 4.4 min, P=.402), time for execution of UGE (B 9.5 ± 4.8 min; C 11.3 ± 6.5 min, P=.335) and induction time (B 11.1 ± 2.6 min; C 10.1 ± 4.2 min, P=.059), iBIS 55.4 ± 6.9. There were no significant differences in adverse effects: 2 patients suffered from mild desaturation in the control group. CONCLUSIONS: BIS monitoring for diagnostic UGE in spontaneous breathing in a pediatric population is feasible, but does not appear to decrease awakening time or the amount of propofol needed. Furthermore, there was no statistically significant decrease in the number of adverse effects.

[Safety and efficacy of continuous infusion propofol for diagnostic upper gastrointestinal endscopy in spontaneous breathing]. / Seguridad y eficacia del propofol en perfusión continua para la realización de endoscopias digestivas altas diagnósticas en respiración espontánea.

INTRODUCTION: Invasive procedures (IP) are an important reason for admision to PICU. Paediatric patients need a special anaesthetic approach and deep sedation is frequently required. The objective was to evaluate the safety and efficacy of continuous infusion propofol to achieve sedation for diagnostic upper gastrointestinal endoscopy (UGE) in spontaneous breathing. PATIENTS AND METHODS: Prospective observational study. SCOPE: Secondary hospital Paediatric Intensive Care Unit. Period of study September 2009 to May 2010. PATIENTS: Children subjected to diagnostic UGE. INTERVENTION: sedation-analgesia protocol with: fentanyl (1 ug/kg for first dose and 0.5 ug/kg for the next one), propofol (1-2 mg/kg for first dose and continuous infusion at 3-4 mg/kg/h, if needed, subsequent doses at 0.5-1 mg/kg and increasing infusion from 1 mg/kg/h up to 6 mg/kg/h maximum). The objective was to reach 5-6 grade for modified Ramsay scale and amnesia related to UGE. Main endpoints: a) dose of drugs, b) time to sedoanalgesia, recovery and length for the procedure, c) sedoanalgesis grade and amnesia related to procedure and d) adverse effects. RESULTS: Expressed as median and interquartile range; 31 sedoanalgesias were performed on 31 children for UGE. Indications for UGE were suspected coeliac disease (84%) or dyspeptic syndrome (16%). Mean age was 8 (2-11) years. Propofol total dose 5 (3.8-6.2) mg/kg. Propofol infusion rate 4 (3.8-4.5) mg/kg/h. Fentanyl dose 1 (1-1) µg/kg. Induction time 6 (5-9) minutes, procedural time 15 (10-25) minutes and recovery/awake time 10 (9-14) minutes. Adverse effects observed consisted of 1 patient vomiting. UGE was successfully achieved in 100%. Amnesia was achieved in all of the 21 patients older than 4 years. CONCLUSIONS: Continuous propofol infusion seems to be both effective and safe to achieve sedation for diagnostic upper gastrointestinal endoscopy in spontaneously breathing.

[Adequacy of acute peritoneal dialysis in pediatric patients]. / Adecuación de diálisis peritoneal aguda en Unidad de Cuidados Intensivos Pediátrica.

Acute peritoneal dialysis (APD) is still a useful tool in the critical pediatric patient. Acute kidney failure due to septic shock often requires invasive depuration procedures and although hemofiltration is very effective, not all pediatric Intensive Care Units have the equipment necessary to establish it. Pediatric APD is generally initiated with short dwell times, every hour exchanges and 10-20 ml/kg filling volumes. We present the evolution of two critical patients with kidney failure on APD who benefited from the measurement of dialysate-to-plasma (D/P) ratios for creatinine and urea, and dialysate-to-solution ratio for glucose (Dt/Do) to optimize APD prescription.

[Utility of inhaled nitric oxide in patient with acute respiratory distress syndrome and un-operated Fallot's tetralogy]. / Utilidad del óxido nítrico inhalado en paciente con síndrome de distrés respiratorio agudo y tetralogía de Fallot no intervenida.

Utility of inhaled nitric oxide in the treatment of acute respiratory distress syndrome (ARDS) with pulmonary hypertension (PHT) is controversial and there are few studies in the literature that evaluate its effects during prolonged administration. We analyze the case of a 45 day old male patient with un-operated Fallot's tetralogy who developed ARDS and PHT with non-cardiac cause, that required prolonged mechanical ventilation (30 days) and administration of inhaled nitric oxide (INO). Before the INO, the oxygenation index was 19, and at a few minutes of its application it decreased to 15. The patient developed a dependence on INO, tolerating its gradual weaning. Administration could be interrupted at 27 days on onset. We did not observe toxic effects during the administration of INO.

[Sildenafil in the treatment of pulmonary hypertension]. / Sildenafilo en el tratamiento de la hipertensión pulmonar.

Pulmonary hypertension (PHT) is a rare entity that is difficult to treat. Prognosis is poor. Sildenafil, a selective inhibitor of type 5 phosphodiesterase, has been proposed among the many treatments available for primary and secondary pulmonary hypertension. We report our experience with an infant with pulmonary hypertension due to congenital mitral stenosis and persistent ductus arteriosus, who developed congestive cardiac failure with persistent PHT despite surgical correction. Conventional treatment was unsuccessful and the patient was treated with sildenafil. The clinical course was satisfactory, allowing extubation and withdrawal of vasoactive drugs; pulmonary and left atrial pressure decreased and the patient was discharged. She is currently being treated on an outpatient basis with oral sildenafil and shows satisfactory hemodynamic status. We review alternatives to conventional treatments for pulmonary hypertension with special reference to pediatrics.