Withdrawal syndrome in the pediatric intensive care unit. Incidence and risk factors.

OBJECTIVE: To determine the incidence of withdrawal syndrome after prolonged infusion of fentanyl and midazolam in children, and the associated risk factors. DESIGN: Historic or retrospective cohort study. SETTING: Pediatric Intensive Care Unit in an academic center. PATIENTS: Forty-eight pediatric patients who received sedation and analgesia only with fentanyl and midazolam through continuous infusion for at least 48 hours. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Collected data included demographic and clinical parameters, dose and duration of sedation received, and incidence, severity and treatment of withdrawal syndrome. RESULTS: Fifty percent of the patients developed withdrawal syndrome. There were significant differences between the patients who developed withdrawal syndrome and those who did not, in terms of the duration of infusion and the cumulative doses of both drugs. A cumulative fentanyl dose of 0.48 mg/kg, a cumulative midazolam dose of 40 mg/kg, and a duration of infusion of both drugs of 5.75 days were risk factors for the development of withdrawal syndrome. Most children developed mild or moderate disease, beginning about 12-36 hours after weaning from infusion. Methadone was used in most cases for treating withdrawal. CONCLUSIONS: There is a high incidence of withdrawal syndrome in children following the continuous infusion of midazolam and fentanyl. The duration of infusion of both drugs and higher cumulative doses are associated with the development of withdrawal syndrome.

[Determinants of uremia elevation in the first days of life in premature infants born before 30 weeks of gestation]. / Factores determinantes de la elevación de la uremia en los primeros días de vida en recién nacidos con menos de 30 semanas de gestación.

OBJECTIVE: To identify the determinants associated with uremia elevation in the first days of life in extremely premature infants. METHODS: We performed a prospective cohort study in a cohort of neonates born at less than 30 weeks of gestation. RESULTS: Forty-eight preterm infants were included, of which 10 died. The mean fluid administration was 55, 72, 88 and 124 mL/kg on the first, second, third and seventh days of life. Amino acid doses were low in the first two days of life and were unrelated to uremia elevation. Thirty-one percent of the infants presented hypernatremia. Uremia was measured in 31 infants between the fifth and tenth days of life and 12 infants (38.7 %) had uremia values of 100 mg/dL or higher, without creatinine elevation. All of these infants were born at less than 27 weeks of gestation, weighed less than 850 grams at birth, and showed greater weight loss (19.2 % vs. 13.8 %; p 5 0.037) and higher natremia (150.2 mEq/L vs. 146.6 mEq/L; p 5 0.023). The use of furosemide increased the risk of elevated uremia (relative risk: 2.54; 95 % confidence interval: 1.05 6.14). CONCLUSIONS: Total uremia of 100 mg/dL or higher was associated with dehydration, greater weight loss, higher natremia, furosemide use, lower gestational age, and lower birth weight.

[Chronic multifocal osteomyelitis]. / Osteomielitis crónica múltiple.

The cases of three female Guinean children are described. Bloods tests were nonspecific, showing a moderately high globular sedimentation rate. The patients received combined therapy with systemic antibiotic therapy (including local gentamicin administration in two of the three patients) and surgery. One patient returned to Guinea and was lost to follow-up. The second patient showed severe sequelae and the third patient had a favorable outcome. In recent years, the prevalence of chronic osteomyelitis in Africa has increased. Most patients have multiple bone involvement and multiple etiology. Blood cultures are negative in 40 % of patients and severe radiologic abnormalities, most commonly fractures, are frequent. A successful therapeutic regimen must be based on antibiotic and surgical treatment.

[Validation of the transcutaneous carbon dioxide tension measurements in critical paediatric patients]. / Validación de la medición transcutánea de la presión parcial de dióxido de carbono en el paciente crítico pediátrico.

OBJECTIVE: To estimate the accuracy of the transcutaneous carbon dioxide tension measurement (PtCO(2)) compared to the measurement of the arterial carbon dioxide tension (PaCO(2)). MATERIAL AND METHODS: An analytical, longitudinal, prospective and observational study, of a dynamic cohort taken from the in-patients of a Paediatric Intensive Care Unit (PICU). The PtCO(2) was measured with the SenTec AG analyzer, and the sensor was applied with the specific Multi-Site Attachment Ring. PtCO(2) and PaCO(2) were recorded at the same time. The statistical significance of the association between paired measurements was evaluated with the Snedecor's F test, the Pearson's r(2) correlation coefficient and the Interclass Correlation Coefficient (ICC). The degree of agreement was evaluated with the Bland & Altman method. The consistency of the results was evaluated with the ANalysis Of the VAriance (ANOVA). RESULTS: One hundred and six paired measurements, PtCO(2) and PaCO(2), from twelve patients, were compared. The means of the PaCO(2) and PtCO(2) were 51.0+/-13mmHg and 50.1+/-14mmHg, respectively; r(2)=0.87 (p<0.001), ICC=0.96, (95% CI: 0.94-0.97). The Bland-Altman analysis showed a mean difference of-0.9mmHg (95% CI:-2.0 to 0.2mmHg). The correlation was better in cases with no respiratory disease, with low respiratory assistance, with PaCO(2)>50mmHg and with the sensor applied on the forehead. The results were consistent. No side effects derived from the use of the ring were observed. CONCLUSION: The correlation between PtCO(2) and PaCO(2) is excellent and stable. The ring sensor was safe and easy to use.