Hidratación en el síndrome urémico hemolítico / Hydration in hemolytic uremic syndrome

El síndrome urémico hemolítico asociado a diarrea es precedido por una gastroenteritis por Escherichia coli productora de toxina Shiga. Se recomiendan medidas de sostén, especialmente, la restricción hídrica para evitar la sobrecarga cardiopulmonar. Sin embargo, la expansión de volumen con líquidos isotónicos, en el período prodrómico o síndrome urémico hemolítico establecido, es segura y eficaz, reduce los requerimientos de diálisis, los días de internación y de terapia intensiva, los eventos neurológicos y la hiponatremia.Por ello, se propone, bajo supervisión nefrológica y/o garantizando el acceso a un centro de alta complejidad a corto plazo, hidratar a todo paciente sin signos de sobrecarga cardiopulmonar, independientemente de su función renal, con expansión inicial de volumen. Luego, si se logra una diuresis adecuada, no dializarlo (excepto que presente un trastorno metabólico/electrolítico intratable médicamente) y continuar la hidratación con una solución isotónica de dextrosa al 5 % para una adecuada hidratación y diuresis.

Diarrhea-associated hemolytic uremic syndrome is preceded by gastroenteritis due to Shiga toxin-producing Escherichia coli. Support measures are recommended, specifically, fluid restriction to avoid cardiopulmonary overload. However, in the prodromal period or with established hemolytic uremic syndrome, volume expansion with isotonic fluids is safe and effective, and reduces the need for dialysis, the length of hospital and intensive care stay, neurological events, and hyponatremia.Therefore, when nephrological monitoring is available and/or short-term access to a tertiary care hospital is guaranteed, it is suggested to hydrate patients with no signs of cardiopulmonary overload, regardless of their renal function, with initial volume expansion. Afterwards, if an adequate urine output is achieved, the patient should not be dialyzed (except if they have a medically intractable metabolic/electrolyte disorder) and hydration should be continued with an isotonic solution containing 5 % dextrose for adequate hydration and urine output.

Hydration in hemolytic uremic syndrome. / Hidratación en el síndrome urémico hemolítico.

Diarrhea-associated hemolytic uremic syndrome is preceded by gastroenteritis due to Shiga toxin-producing Escherichia coli. Support measures are recommended, specifically, fluid restriction to avoid cardiopulmonary overload. However, in the prodromal period or with established hemolytic uremic syndrome, volume expansion with isotonic fluids is safe and effective, and reduces the need for dialysis, the length of hospital and intensive care stay, neurological events, and hyponatremia. Therefore, when nephrological monitoring is available and/or short-term access to a tertiary care hospital is guaranteed, it is suggested to hydrate patients with no signs of cardiopulmonary overload, regardless of their renal function, with initial volume expansion. Afterwards, if an adequate urine output is achieved, the patient should not be dialyzed (except if they have a medically intractable metabolic/electrolyte disorder) and hydration should be continued with an isotonic solution containing 5 % dextrose for adequate hydration and urine output.

Fluid restriction versus volume expansion in children with diarrhea-associated HUS: a retrospective observational study.

BACKGROUND: Fifty percent of patients with typical diarrhea-associated hemolytic uremic syndrome (D+HUS) require kidney replacement therapy (KRT). In these patients, dehydration worsens disease prognosis. We evaluated dialysis requirement, presence of seizures, and mortality rate among patients diagnosed with D+HUS treated with volume expansion (VE) versus fluid restriction (FR). METHODS: Thirty-five patients with D+HUS were enrolled; 16 received VE and 19 were historical patients who received conventional FR. RESULTS: Upon admission or during treatment, neither group presented evidence of fluid overload. The VE group received higher volumes of saline (VE 27 ml/kg [10-30] over a 3-h period vs. FR 0 ml), had higher urine output after 12 h (VE vs. FR: OR 6.2 [1.2-41.6], P = 0.03), and required less dialysis (VE 2 [12.5%, CI 95% 0-29] vs. FR 9 [47.4%, CI 95% 24-70], P = 0.035). The VE group had an absolute risk reduction of 0.34 (CI 95% 0.07-0.63); hence, three patients treated with VE were required to avoid one KRT. VE also corrected initial hyponatremia and maintained serum sodium within normal ranges. No statistical differences were observed regarding number of patients with seizures (P = 0.08) or mortality (P = 1.0). CONCLUSIONS: VE markedly reduces the number of patients requiring KRT and keeps serum sodium within a normal range. We propose to initially hydrate every patient with D+HUS and without signs of fluid overload, with 10 ml/kg/h 0.9% saline solution IV, over a 3-h period. Afterwards, if urine output is ≥ 0.5 ml/kg/h, it is recommended to not dialyze and continue IV hydration schedule with isotonic (D5) saline solution, according to their needs.

[Hyperglycemia in the pediatric emergency. Not everything is diabetes]. / Hiperglucemia en la urgencia pediatrica. No todo es diabetes.

Hyperglycemia is a rare finding in pediatric emergency. Hyperglycemia as pediatric emergency presentation (blood glucose>126 mg/dl), may correspond to a diabetes mellitus type 1, the finding of a casual hyperglycemia in an obese patient and type 2 diabetes, hyperglycemia without decompensation of the monogenic diabetes or stress hyperglycemia. The latter are often not ketosis, limited to acute illness and usually do not develop diabetes at follow-up. We found only 2.9% of patients (8/270 children) with stress hyperglycemia who developed diabetes mellitus at follow-up. The use of insulin in the most severe cases improves the evolution and decreases morbidity. There is an overlap of intermediate states in the presentation of hyperglycemia requiring specialist help to unravel the underlying state in the follow-up.

Hiperglucemia en la urgencia pediatrica. No todo es diabetes / Hyperglycemia in the pediatric emergency. Not everything is diabetes

La hiperglucemia es un hallazgo poco frecuente en la urgencia pediátrica. La hiperglucemia, glucemia ≥ 126 mg/dl, puede corresponder a un cuadro de diabetes mellitus tipo 1; el hallazgo de una hiperglucemia casual en un paciente obeso y con diabetes tipo 2; la hiperglucemia sin descompensación de una diabetes monogénica o ser una hiperglucemia por estrés. Estas últimas suelen ser no cetósicas, limitadas a la enfermedad aguda y, generalmente, no desarrollan diabetes en el seguimiento posterior. En un análisis, hayamos solo un 2,9% de casos (8/270 niños) con hiperglucemia por estrés que desarrollaron diabetes mellitus en el seguimiento posterior. El uso de insulina en los casos más graves mejora la evolución y disminuye la morbimortalidad. Existe una superposición de cuadros intermedios en la presentación de la hiperglucemia, que requiere el auxilio del especialista para desentrañar el cuadro subyacente en el seguimiento posterior.

Hyperglycemia is a rare finding in pediatric emergency. Hyperglycemia as pediatric emergency presentation (blood glucose ≥ 126 mg/dl), may correspond to a diabetes mellitus type 1, the finding of a casual hyperglycemia in an obese patient and type 2 diabetes, hyperglycemia without decompensation of the monogenic diabetes or stress hyperglycemia. The latter are often not ketosis, limited to acute illness and usually do not develop diabetes at follow-up. We found only 2.9% of patients (8/270 children) with stress hyperglycemia who developed diabetes mellitus at follow-up. The use of insulin in the most severe cases improves the evolution and decreases morbidity. There is an overlap of intermediate states in the presentation of hyperglycemia requiring specialist help to unravel the underlying state in the follow-up.

Malrotación intestinal con vólvulo, asociada a hiperglucemia grave por estrés / Intestinal malrotation with volvulus associated with severe stress hyperglycemia

Se presenta un niño de 2 años internado con diagnóstico de debut diabético, con glucemia de 500 mg% al ingreso, sin cetosis ni acidosis metabólica. Presenta también vómitos biliosos y amarronados, con deposiciones sanguinolentas. Se opera con diagnóstico presuntivo de obstrucción intestinal aguda, hallándose vólvulo intestinal secundario a malrotación intestinal congénita. Luego de la cirugía normaliza la glucemia. Se asume el cuadro como hiperglucemia sin cetosis, de característica graves, por estrés, secundaria a vólvulo por malrotación intestinal. Esta asociación, aún no ha sido descripta.

A 2-year-old boy was admitted with diagnosis of diabetes debut, with blood glucose of 500 mg% on admission, without ketosis or metabolic acidosis. He also presented bilious vomiting and brownish bloody stools. He was operated with a presumptive diagnosis of acute intestinal obstruction. The fnal diagnosis was volvulus, secondary to congenital malrotation. After surgery, he normalized blood sugar levels. The clinical setting was assumed as hyperglycemia without ketosis, with characteristic of severity caused by stress, secondary to volvulus in malrotation. This association has not yet been described.

[Intestinal malrotation with volvulus associated with severe stress hyperglycemia]. / Malrotación intestinal con vólvulo, asociada a hiperglucemia grave por estrés.

A 2-year-old boy was admitted with diagnosis of diabetes debut, with blood glucose of 500 mg% on admission, without ketosis or metabolic acidosis. He also presented bilious vomiting and brownish bloody stools. He was operated with a presumptive diagnosis of acute intestinal obstruction. The final diagnosis was volvulus, secondary to congenital malrotation. After surgery, he normalized blood sugar levels. The clinical setting was assumed as hyperglycemia without ketosis, with characteristic of severity caused by stress, secondary to volvulus in malrotation. This association has not yet been described.

Validation and development of a clinical prediction rule in clinically suspected community-acquired pneumonia.

OBJECTIVES: To develop a mathematical model to predict the probability of having community-acquired pneumonia and to evaluate an already developed prediction rule that has not been validated in a clinical scenario. METHODS: Children who presented with fever and had presumptive clinical diagnosis of pneumonia were evaluated in 4 institutions of different complexity during 1 year. The variables assessed were sex, age, respiratory rate, days with fever, maximum body temperature, presence of tachypnea, cough, chest pain, intercostal retraction, nasal flaring, abdominal pain, vomiting, grunting, rales, decreased breath sounds, wheezing, fatigue, loss of appetite, loss of sleep, and season of the year. The chest radiographs were photographed and then interpreted by 2 pediatric radiologists. RESULTS: A total of 257 children were evaluated: 179 (69%) had clinical and radiological diagnosis of community-acquired pneumonia, and 78 (30%) had no radiological confirmation. A total of 96 photographs were recorded, and in 64 of the cases, there was agreement in the diagnosis between the evaluating pediatrician and the radiologists (kappa index = 0.68).With the calculated probabilities, it was possible to build a receiving operating characteristic curve and, based on the estimated coefficients we calculated, a value associated to the probability of having pneumonia. CONCLUSIONS: We developed a model including 5 variables of high level of sensitivity for the diagnosis of pneumonia. To use it, it would be useful to apply the appropriate software. In addition, we validated a clinical prediction rule of 4 variables that proved to have 93.8% sensitivity to diagnose pneumonia in children with a fever and localized rales, or decreased breath sounds, or tachypnea, or any combination of these 4 variables.

[Macklin effect in pediatric spontaneous pneumomediastinum]. / Efecto Macklin en el neumomediastino espontáneo pediátrico.

Pneumomediastinum is defined as the presence of air in the mediastinum, and may be secondary to trauma or spontaneous. We present the case of a four-year old patient with a spontaneous pneumomediastinum secondary to a violent cough episode, presumably due to a simple cold. The presence of cervical pain, swelling and crepitus warned the pediatrician, who ordered the patient admission. Diagnosis was confirmed by chest and neck plane x-rays. The disorder had a short duration and favorable outcome with no specific treatment aside from symptomatic. CT scan performed at admission revealed an air migration through the perivasculobronchial sheath towards the mediastinum, the so-called "Macklin effect". This is the first description of this entity in pediatrics.

Efecto Macklin en el neumomediastino espontáneo pediátrico / Macklin effect in pediatric spontaneous pneumomediastinum

Observamos un caso de neumomediastino espontáneo, o seasin traumatismo o iatrogenia en su fisiopatología, secundario a un acceso de tos, presumiblemente un simple catarro, en un niño de cuatro años. La presencia de dolor, tumoración cervicaly crepitación a la palpación alertó al pediatra. Se confirmó por radiografías de tórax y cuello. El cuadro fue de cortaevolución y sólo requirió tratamiento sintomático. En la TAC realizada al ingreso se observó el aire migrando por las vainas perivasculobronquiales rumbo al mediastino, por primera vezen pediatría (efecto Macklin).

Estudio multicéntrico de la urgencia pediátrica / An assessment of consultation and health care in pediatric emergency services. A multicentric study

Introducción. Realizamos una descripción de las características clínicas y epidemiológicas de la consultaespontánea en servicios de urgencia pediátricos.Población, materiales y métodos. Este trabajo tieneun diseño descriptivo prospectivo. Durante losmeses de abril, agosto y noviembre del año 2003 yfebrero del 2004, en forma multicéntrica y al azar, sellevó a cabo un protocolo semanal en las guardiaspediátricas de ocho hospitales. Cada uno de losautores registraron diez pacientes menores de 18años que consultaron en forma consecutiva y espontánea.Resultados. Se evaluaron 1.435 pacientes. La edadmedia fue de 4,55 años y el 68,9 por ciento fueron menoresde 6 años. El 17,6 por ciento tenían enfermedad de base, la más frecuente fue la patología broncobstructiva(59,1 por ciento). El motivo principal de consulta (75,8 por ciento)fue fiebre, trauma, dificultad respiratoria, erupción, otalgia, síntomas de resfrío, diarrea y vómitos.En el 34,4 por ciento se pidieron exámenes complementariosy se realizaron en el 15,2 por ciento interconsultascon otras especialidades. El 83,9 por ciento de los diagnósticos fueron: 1) catarro de vías aéreas superiores (16,5 por ciento); 2) crisis asmáticas y bronquiolitis (15,5 por ciento); 3) trauma (11,2 por ciento); 4) gastroenteritis (8,6 por ciento); 5) faringitis (7,9 por ciento); 6) otitis (7,4 por ciento); 7) erupción (6,7 por ciento); 8) neumonía (4,5 por ciento) y 9) fiebresin foco (2,7 por ciento). Los casos de trauma, oxicaciones y catarro de vías aéreas superiores tuvieron más incidencia en los hospitales generales. Cinco pacientes concurrieron a la guardia con riesgo demuerte: cuatro con diagnóstico de apnea (1/286) yuno en paro cardiorrespiratorio (1/1.435).Conclusiones. La mayor parte de los pacientes eranlactantes o preescolares. El principal motivo deconsulta fue fiebre. Las interconsultas se concentraronen pocas especialidades.

Acute renal failure in typical Kawasaki disease.

Few cases of Kawasaki disease with acute renal failure have been described and only three articles report histological findings. We present an 8-year-old boy with typical Kawasaki disease and acute renal failure who did not require dialysis and had a complete recovery. Pathological findings in percutaneous biopsy included tubulointerstitial nephropathy with mild mesangial expansion, without vessel involvement or deposits in basal membrane. These findings were similar to those previously reported. We also detected apoptotic bodies in tubules.

Estudio clínico, serológico y epidemiológico de la rubéola en Buenos Aires / Clinical, serological and epidemiological study of rubella in Buenos Aires

Introducción.El objetivo del presente estudio fue determinar los patrones epidemiológicos y morfológicos de la rubéola.Material y Métodos.Entre abril de 1995 y abril de 1996 se atendieron 625 niños en el consultorio de enfermedades exantemáticas del Hospital de Niños"Ricardo Gutierrez"En aquellos pacientes con criterios clínicis de rubéola se obtuvo una muestra de sangre para la búsqueda de anticuerpos antirubéola por enzomoinmunoensayo de captura de IgM(Abott).Resultados.de los 625 pacientes con exantema,261(41,7 por ciento)tuvieron diagnóstico de rubéola por criterios clínicos.En 217 se obtuvo una muestra de sangrre para la búsqueda de anticuerpos IgM antirrubéola por enzinoinmunoensayo:de éstos,179(82,4 por ciento)fueron positivos.En los niños rubéola confirmada por serología se encontró incidencia estacional,con un mayor número de casos en primavera.La media de edad fue de 6,17 años(rango 2,5 meses-18 años)y menos del 3 por ciento de los casos se presentaron en lactantes.En el 92 por ciento de los casos el exantema fue universal,con progresión cefalocaudal en el 81 por ciento de los pacientes.Se encontraron adenopatías en el 92 por ciento,fiebre en el 48 por ciento y compromiso articular en el 13 por ciento.La medida de la duración de exantema fue de 3,91 días(1,5-10 días)Conclusiones.1)La rubéola fue la causa más frecuente de enfermedad exantemática.2)Se encontró una alta relación entre el diagnóstico clínico de rubéola y la serología