Time Course of Mechanical Ventilation Driving Pressure Levels in Pediatric Acute Respiratory Distress Syndrome: Outcomes in a Prospective, Multicenter Cohort Study From Colombia, 2018-2022.

OBJECTIVES: High driving pressure (DP, ratio of tidal volume (Vt) over respiratory system compliance) is a risk for poor outcomes in patients with pediatric acute respiratory distress syndrome (PARDS). We therefore assessed the time course in level of DP (i.e., 24, 48, and 72 hr) after starting mechanical ventilation (MV), and its association with 28-day mortality. DESIGN: Multicenter, prospective study conducted between February 2018 and December 2022. SETTING: Twelve tertiary care PICUs in Colombia. PATIENTS: One hundred eighty-four intubated children with moderate to severe PARDS. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The median (interquartile range [IQR]) age of the PARDS cohort was 11 (IQR 3-24) months. A total of 129 of 184 patients (70.2%) had a pulmonary etiology leading to PARDS, and 31 of 184 patients (16.8%) died. In the first 24 hours after admission, the plateau pressure in the nonsurvivor group, compared with the survivor group, differed (28.24 [IQR 24.14-32.11] vs. 23.18 [IQR 20.72-27.13] cm H2O, p < 0.01). Of note, children with a Vt less than 8 mL/kg of ideal body weight had lower adjusted odds ratio (aOR [95% CI]) of 28-day mortality (aOR 0.69, [95% CI, 0.55-0.87]; p = 0.02). However, we failed to identify an association between DP level and the oxygenation index (aOR 0.58; 95% CI, 0.21-1.58) at each of time point. In a diagnostic exploratory analysis, we found that DP greater than 15 cm H2O at 72 hours was an explanatory variable for mortality, with area under the receiver operating characteristic curve of 0.83 (95% CI, 0.74-0.89); there was also increased hazard for death with hazard ratio 2.5 (95% CI, 1.07-5.92). DP greater than 15 cm H2O at 72 hours was also associated with longer duration of MV (10 [IQR 7-14] vs. 7 [IQR 5-10] d; p = 0.02). CONCLUSIONS: In children with moderate to severe PARDS, a DP greater than 15 cm H2O at 72 hours after the initiation of MV is associated with greater odds of 28-day mortality and a longer duration of MV. DP should be considered a variable worth monitoring during protective ventilation for PARDS.

Factors associated with prolonged mechanical ventilation in children with pulmonary failure: Cohort study from the LARed Network registry.

OBJECTIVES: To identify factors associated with prolonged mechanical ventilation (pMV) in pediatric patients in pediatric intensive care units (PICUs). DESIGN: Secondary analysis of a prospective cohort. SETTING: PICUs in centers that are part of the LARed Network between April 2017 and January 2022. PARTICIPANTS: Pediatric patients on mechanical ventilation (IMV) due to respiratory causes. We defined IMV time greater than the 75th percentile of the global cohort. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Demographic data, diagnoses, severity scores, therapies, complications, length of stay, morbidity, and mortality. RESULTS: 1698 children with MV of 8±7 days were included, and pIMV was defined as 9 days. Factors related to admission were age under 6 months (OR 1.61, 95% CI 1.17-2.22), bronchopulmonary dysplasia (OR 3.71, 95% CI 1.87-7.36), and fungal infections (OR 6.66, 95% CI 1.87-23.74), while patients with asthma had a lower risk of pIMV (OR 0.30, 95% CI 0.12-0.78). Regarding evolution and length of stay in the PICU, it was related to ventilation-associated pneumonia (OR 4.27, 95% CI 1.79-10.20), need for tracheostomy (OR 2.91, 95% CI 1.89-4.48), transfusions (OR 2.94, 95% CI 2.18-3.96), neuromuscular blockade (OR 2.08, 95% CI 1.48-2.93), high-frequency ventilation (OR 2.91, 95% CI 1.89-4.48), and longer PICU stay (OR 1.13, 95% CI 1.10-1.16). In addition, mean airway pressure greater than 13cmH2O was associated with pIMV (OR 1.57, 95% CI 1.12-2.21). CONCLUSIONS: Factors related to IMV duration greater than 9 days in pediatric patients in PICUs were identified in terms of admission, evolution, and length of stay.

[Central venous catheter-related complications in critically ill children]. / Complicaciones relacionadas con catéteres venosos centrales en niños críticamente enfermos.

OBJECTIVE: Placing central venous catheters is essential when managing critically ill children. This paper was thus aimed at identifying the major complications involved in this and determining the incidence of mechanical and infection-related complications associated with central venous catheterization in critically ill children. MATERIAL AND METHODS: A descriptive study was undertaken between October 2011 and March 2012 of all new central venous catheters inserted in critically ill children. The definition of central venous catheter infection was based on CDC criteria. RESULTS: During the study period 200 central venous catheters were placed, 51 % in male patients, mostly infants; 71 % required mechanical ventilation and 56.5 % medication for hemodynamic support. Respiratory tract infections were the leading diagnosis on admission in 33 % of the cases. Complications were reported in 8.5 % of the children (52 % of these being due to mechanical complication and 48 % to infection). Mechanical complication incidence was 4.5% and eight central venous catheters fulfilled CDC criteria for central line associated blood stream infection (4 % incidence, i.e. 5 per 1,000 catheter/day rate). CONCLUSIONS: Despite some complications arising from its use, central venous catheter placement is a safe procedure. Mechanical and infection incidence associated with central venous catheter placement should be known, not only because it differs from that regarding adult patients but also because this can help to establish preventative measures for reducing such complications and improving the care of critically ill children.

Perfusion pediatrica / Pediatric perfusion

La incidencia de enfermedad cardíaca congénita es de 8 por ciento por cada 1000 nacidos vivos. El 90 por ciento son CIV, CÍA, Ductus, estenosis pulmonar y coartación aórtica. En algunos es indispensable el uso de la Circulación Extracorpórea para su corrección quirúrgica (1). En la Clínica San Rafael, 159 pacientes han sido intervenidos entre enero de 1996 y octubre de 2000, 83 niños y 76 niñas, en edades entre los 9 días y los 17 años, con una media de 6 años. Los tipos de corrección fueron: cierre de ductus arteriosos persistente, cierre de comunicaciones inter-auriculares (CIA), cierre de comunicaciones inter-ventriculares (CIV), coartación aórtica, fístula sistémico pulmonar, Fallot, cambio válvula mitral, cambio válvula aórtica, plastia válvula aórtica, plastia válvula tricúspide, plastia válvula pulmonar, canal aurículo-ventricular, doble salida de ventrículo derecho, transposición de grandes vasos, drenaje venoso anómalo, tumor del ventrículo izquierdo. En todos los pacientes se aplicó el protocolo establecido en nuestra Institución, siendo el perfusionista quien seleccionó el oxigenador, el circuito, las cánulas, el hemoconcentrador pediátrico y la purga. La experiencia adquirida en la Clínica San Rafael ha permitido realizar intervenciones de cardiopatías complejas con buenos resultados. La Técnica de Perfusión, es muy importante en el resultado de la intervención, haciendo que ésta sea segura y fiable

Concordancia entre observadores en la determinación de la edad gestacional por medio de la prueba de Ballard

Entre el 1 de diciembre de 1989 y el 28 de febrero de 1990 se estudiaron 50 recién nacidos. El peso promedio al nacimientofue de 2814 gr, SD 653 g y la edad gestacional varió entre 30 y 47 semanas, con un promedio de 38.3 semanas y SD de 3.0 semanas. Dos pediatras y dos residentes de primer año evaluaron cada recien nacido con respecto a la edad gestacional por el método descrito por Ballard en 1979. La variable principal fue la edad gestacional y la correlación entre las variables se calculó por el método Kappa. El estudio mostró una gran variabilidad entre los observadores haciendo clínicamente inútil la prueba. Estos resultados merecen una posterior evaluación en nuevos estudios