Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Spanish Society of Pediatric Intensive Care (SECIP) consensus recommendations for ECMO transport.

The evolution of extracorporeal membrane oxygenation treatment and the transport of patients receiving this treatment has changed dramatically in the last decade unevenly in different regions. The creation of specialized referral centers has been shown to improve outcomes. For all these reasons, it has been necessary to create networks of specialized teams and the number of secondary transports of patients with this treatment is increasing. In order to improve the quality of treatment and offer a guide to the services involved in these transports, the critical transport working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Spanish Society of Pediatric Intensive Care (SECIP) have carried out a joint effort to prepare these recommendations, focused on the following aspects: indications, reference center systems, means of transport, characteristics and equipment, human teams, training and clinical safety.

Safe intravenous administration in pediatrics: A 5-year Pediatric Intensive Care Unit experience with smart pumps. / Administración segura de medicamentos intravenosos en pediatría: 5 años de experiencia de una Unidad de Cuidados Intensivos Pediátricos con bombas de infusión inteligentes.

OBJECTIVES: To estimate the impact of smart pump implementation in a pediatric intensive care unit in terms of number and type of administration errors intercepted. DESIGN: Observational, prospective study carried out from January 2010 to March 2015 with syringe and great volumen infusion pumps available in the hospital. SETTING: A tertiary level hospital pediatric intensive care unit. PARTICIPANTS: Infusions delivered with infusion pumps in all pediatric intensive care unit patients. INTERVENTIONS: Design of a drug library with safety limits for all intravenous drugs prescribed. MAIN VARIABLES: Users' compliance with drug library as well as number and type of errors prevented were analyzed. RESULTS: Two hundred and eighty-three errors were intercepted during 62 months of study. A high risk drug was involved in 58% of prevented errors, such as adrenergic agonists and antagonists, sedatives, analgesics, neuromuscular blockers, opioids, potassium and insulin. Users' average compliance with the safety software was 84%. CONCLUSIONS: Smart pumps implementation has proven effective in intercepting high risk drugs programming errors. These results might be exportable to other critical care units, involving pediatric or adult patients. Interdisciplinary colaboration is key to succeed in this process.

[Paediatric training for developing clinical activities]. / Formación pediátrica para el desarrollo de actividades clínicas.

The general training received by pharmacists in Hospital Pharmacy enables them to analyse and implement improvements in the prescription, dispensing and administration of medications. This may lead to an increase in the overall safety of the use of drugs. The main goal of the paediatric pharmacist is to improve patient care by greater attention to the individual via validation of medical prescriptions and pharmaceutical follow-up, leading to safe, effective and efficient pharmacotherapy. This is a multidisciplinary review by the Pharmacy Department and Paediatric Intensive Care Unit. The objectives were to analyse the role of a resident pharmacist in PICU to identify improvements to promote rational drug use, and to design a teaching program for paediatric pharmacists that may serve as a reference for other centres.

[Evaluation of a paediatric critical care training program for residents in paediatrics]. / Evaluación de un programa de formación en cuidados intensivos pediátricos para residentes de pediatría.

OBJECTIVE: To evaluate a training program in paediatric critical care for residents in paediatrics. METHODS: Description of a paediatric critical care training program for residents in paediatrics. To evaluate the results of the program an initial, and final written test, an evaluation by the physician responsible for the program, a self-evaluation by the residents, and a written survey on the quality of the training program, were performed. RESULTS: From April 1998 to August 2009, 156 residents were included in the training program. All residents showed an improvement between the initial and final written test; initial score (5.6+/-1.2), final score (8.6+/-0.7) (P<0.001). Only 14.1% of the residents answered at least 70 % of the questions correctly in the initial test, compared with 96.6 % in the final test (P<0.001). The score in final test was significantly higher than the self-evaluation by the residents (6.7+/-1.2) and the evaluation by the tutor (6.9+/-0.9) (P<0.001). There were no differences between the practical self-evaluation by the residents (6.2+/-1.0) and the practical evaluation by the tutor (6.7+/-0.9). Residents considered the training program as adequate: theoretical education (8.5+/-0.8), resident handbook (9+/-0.9), practical training (8.3+/-1.0), investigation (7.6+/-2.0) and human relationship (9.2+/-0.9). CONCLUSIONS: This training program is an useful educational method for training paediatric intensive care residents. The evaluation of the training program is essential to improve the education in paediatric residents.

[Prognostic factors for bronchiolitis complications in a pediatric intensive care unit]. / Factores pronósticos de evolución complicada en la bronquiolitis que requiere ingreso en cuidados intensivos pediátricos.

OBJECTIVE: To analyse the prognostic factors for complications in children with bronchiolitis admitted to a pediatric intensive care unit (PICU). PATIENTS AND METHOD: A retrospective study was performed on children with bronchiolitis admitted into a PICU between 2000 and 2006. Univariate and multivariate analysis were performed to study the prognostic factors of complications, mechanical ventilation requirements, mortality and PICU stays of more than 15 days. RESULTS: A total of 110 patients were studied, of whom 72 (65.5%) had high risk factors: prematurity (39.1%), cardiac disease (38.2%) and bronchopulmonary dysplasia (16.3%). A total of 82.7% of patients had complications; 26% need invasive mechanical ventilation and the mortality was 3.6%, and 16.4% stayed in PICU for more than 15 days. Factors associated with mechanical ventilation were the clinical Wood-Downes score and heart disease. A weight less than 5 kg was associated with complications; heart disease and invasive mechanical ventilation were associated with a longer PICU stay; prematurity and mechanical ventilation were associated with mortality. CONCLUSIONS: Children with bronchiolitis admitted into the PICU had a high frequency of complications, often needed mechanical ventilation and had long stays in the PICU, but the mortality is low. The best prognostic factors on admission into the PICU were the acute respiratory insufficiency score, the presence of heart disease and were premature at birth.

[Early extubation with caudal morphine after pediatric heart surgery]. / Extubación precoz con morfina caudal tras cirugía cardíaca pediátrica.

OBJECTIVES: To analyze the viability of immediate extubation of children after corrective surgery for congenital heart defects with extracorporeal membrane oxygenation using an anesthetic technique involving caudal morphine, and to study the effect on length of stay in the pediatric intensive care unit (PICU) or elsewhere in the hospital. MATERIAL AND METHODS: Twenty-nine ASA I-II patients without coagulation alterations undergoing surgery to correct simple heart defects were selected for extubation after surgery. Anesthesia was provided with with sevoflurane, midazolam, rocuronium, fentanil (maximum dose 10 micrograms/Kg) and a bolus of caudal morphine (50-60 micrograms/Kg) after anesthetic induction. Patient characteristics, type of surgery, times of extracorporeal circulation and of ischemia, arterial blood gases upon arrival in the PICU, postoperative complications and quality of analgesia were the variables analyzed. We also compared length of stay in the PICU and hospital for the study group and for a historical control group of 23 patients who had no received caudal morphine or been selected for early extubation. RESULTS: All patients were extubated satisfactorily in the operating room. None required reintubation or reoperation. Postoperative pain was controlled with metamizol alone for 79.3%. No episodes of respiratory depression or neurological complications were observed. PICU and hospital stays were significantly shorter in the study group than in the control group. CONCLUSIONS: Of patients undergoing simple corrective heart surgery with extracorporeal membrane oxygenation immediate extubation did not increase postoperative morbimortality and shortened the hospital stay. A single dose of caudal morphine provided optimum conditions for extubation and good control of postoperative pain. Strict measures must be taken, however, to avoid postpuncture bleeding.

[Nitric oxide treatment in children: clinical course, toxicity and factors influencing its effects]. / Tratamiento con óxido nítrico en niños: evolución clínica, toxicidad y factores que influyen en la respuesta.

OBJECTIVE: The purpose of this study was to analyze the clinical evolution, acute toxicity and factors which influence the response to nitric oxide treatment in children. PATIENTS AND METHODS: We studied prospectively 25 children, 14 boys and 11 girls, between 15 days and 16 years of age. Seventeen patients were diagnosed with ARDS and 8 with PHT. All patients presented hypoxemia and/or PHT refractory to conventional therapy and were treated with inhaled NO (1.5 to 45 ppm) between 45 minutes to 47 days. We studied the secondary effects, morbidity and mortality, and analyzed the relationship between NO effects and age, sex, diagnosis, infection, previous PaO2/FiO2 ratio, previous oxygenation index and previous mean pulmonary arterial pressure (mPAP)/mean systemic arterial pressure (mSAP). RESULTS: The effect of NO was maintained during the time of administration without tachyphylaxis. There were no secondary effects of NO administration. NO2 was always < 2 ppm and metahemoglobinemia was below 3.5%. There was no relationship between the effect of NO and the rest of the factors analyzed. Twelve patients (48%) survived, 9 of the children with ARDS (53%) and 3 of the children with PHT (38%). Eleven of the 21 patients who improved with NO treatment survived (52%), as did 1 of the 4 patients who did not improve (25%). CONCLUSIONS: Prolonged administration of inhaled NO at low concentrations maintains the improvement of oxygenation and pulmonary hypertension without acute secondary effects. We have not found factors that could predict the clinical response to NO.