[Prognostic indexes of mortality in pediatric intensive care units]. / Indices pronósticos de mortalidad en cuidados intensivos pediátricos.

OBJECTIVE: To assess the validity of the Pediatric Risk of Mortality score (PRISM), the Pediatric Index of Mortality (PIM) and the PIM 2 in two Spanish pediatric intensive care units. PATIENTS AND METHODS: We prospectively studied 241 critically ill children consecutively admitted over a 6-month period. The overall performance of the scoring systems was assessed by the Standardized Mortality Ratio (SMR), comparing observed deaths with expected deaths by each index. Discrimination (the ability of the model to distinguish between patients who live and those who die) was quantified by calculating the area under the receiver operating characteristic (ROC) curve. Calibration (the accuracy of mortality risk predictions) was calculated with the Hosmer-Lemeshow goodness-of-fit test, in which statistical calibration is evidenced by p > 0.05. RESULTS: The mortality rate was 4.1 %. PRISM overestimated mortality (SMR = 0.44). Discrimination was better for PRISM and PIM 2 than for PIM (areas under ROC curves: 0.883, 0.871, and 0.800 respectively), with no significant differences. Finally, calibration was acceptable for PIM 2 (x2 (8) = 4.8730, p 0.8461) and for PIM (x2 (8) = 8.0876, p 0.5174), but no statistical calibration was found for PRISM (x2 (8) = 15.0281, p 0.0133). CONCLUSIONS: PIM and PIM 2 showed better discrimination and calibration than PRISM in a heterogeneous group of children in Spanish critical care units. However, these results should be confirmed in a larger study.

[Noninvasive ventilation in a pediatric intensive care unit]. / Aplicación de ventilación no invasiva en una unidad de cuidados intensivos pediátricos.

OBJECTIVE: To describe our experience of noninvasive positive-pressure ventilation (NIPPV). PATIENTS AND METHODS: We performed a retrospective study of all patients who underwent NIPPV in our unit over an 18-month period. To assess the effectiveness of NIPPV, respiratory rate, heart rate, inspired oxygen, and arterial blood gases PaO2 and PaCO2 were evaluated before and 2 hours after initiating NIPPV. RESULTS: Twenty-three patients with a mean age of 36.7 months underwent a total of 24 NIPPV trials. Indications for NIPPV were: hypoxemic acute respiratory failure (14 trials), hypercapnic acute respiratory failure (four trials), and postextubation respiratory failure (six trials). Conventional ventilators were used in 10 trials and specific noninvasive ventilators were used in 14. The main interfaces used were buconasal mask in patients older than 1 year, and pharyngeal prong in infants aged less than 1 year. In all groups, significant decreases in respiratory distress, defined as a reduction in tachypnea (45 +/- 16 breaths/min pre-treatment vs. 34 +/- 12 breaths/min post-treatment; p = 0.001), and tachycardia (148 +/- 27 beats/min pre-treatment vs. 122 +/- 22 beats/min (after or post) post-treatment; p < 0.001) were observed after initiation of NIPPV. The oxygenation index PaO2/FiO2 also improved (190 +/- 109 pre-treatment vs. 260 +/- 118 post-treatment; p = 0.010). Five patients (20.8 %) required intubation and conventional mechanical ventilation after NIPPV, of which three were aged less than 6 months. CONCLUSIONS: NIPPV should be considered as a ventilatory support option in the treatment of acute respiratory failure in selected children.

[Importance of initial management in severe pediatric trauma]. / Importancia de la evaluación inicial en los traumatismos graves en la infancia.

INTRODUCTION: Trauma is the most frequent cause of mortality in childhood and adolescence and causes almost 25% of admissions in Pediatric Intensive Care Units (PICU). We have evaluated the initial assesment of the severely injured children admitted in our PICU (pre-hospital care). MATERIAL AND METHODS: We reviewed the children younger than 16 years admitted in our PICU between January 1996 and December 2002. Prehospital caretakers, transportation after initial evaluation and therapeutic management were analized, using Pediatric Trauma Score (PTS) and Pediatric Risk of Mortality Score (PRISM) as predictors of injury severity and mortality, respectively. RESULTS: We treated 152 traumatized children in this period, 106 males and 46 females, with a mean age of 7.5 +/- 4.3 years. 116 patients received inmediate medical care with a mean PTS significatively greater than non-medical group (12 children). Non-medical caretakers treated 8.1% of severe trauma (PTS<8). Specialized transporter was inadequated in 7.1% of severe traumatized children. Gastric and vesical tube and spinal inmobilization were accomplished in 50%, specially in children with low PTS and high PRISM. We found a great variability in fluid and drugs administration. CONCLUSIONS: Although there has been a good evolution in treatment of pediatric trauma, in order to diminish morbidity and mortality it is necessary to identify and correct deficiencies in management, specially during the "golden hour", and train pre-hospital caretakers in pediatric trauma management.

[Neonatal visits to a pediatric emergency service]. / Atención a neonatos en una unidad de urgencias pediátricas.

OBJECTIVE: To determine the profile of neonatal visits to a pediatric emergency service and to compare this profile with that of other pediatric age groups. METHOD: We retrospectively reviewed the reports of all neonates who presented to the pediatric emergency service in 2000. Patients transferred from other hospitals were excluded. Age, sex, time of presentation, source of referral, presenting complaint, investigations, final diagnosis and hospitalization were analyzed. RESULTS: Three hundred and nine neonatal visits were identified. The mean age was 14.3 days and 57.3 % were male. Demand was greatest during evening and night shifts and on Sundays. The most common presenting complaints were irritability/crying (19.1 %), constipation (11.7 %) and jaundice (8.7 %). The most frequent diagnoses were infantile colic (16.8 %), constipation (9.7 %) and jaundice (8.7 %). No morbid processes were found in 12.0 % of the patients and complementary investigations were not required in 68.3 %. Fifty-one neonates (16.5 %) were admitted, mainly due to jaundice (9 patients) and sepsis (8 patients). Patients referred by physicians (29 patients, 9.4 %), especially those referred by pediatricians, were admitted and required investigations more often than self-referred patients. The admission rate was higher in neonates than in other pediatric age groups. CONCLUSIONS: Most neonatal utilization of emergency services is due to trivial problems that could be solved in primary care. Appropriate training is required to avoid unnecessary tests without overlooking potentially serious conditions.

[Care of critically-ill children in Asturias (Spain): characteristics and effectiveness]. / Asistencia a los niños críticamente enfermos en Asturias: características y efectividad.

OBJECTIVE: To describe the work performed in the Pediatric Intensive Care Unit of the Hospital Central de Asturias (Spain) in its first 5 years and to assess the effectiveness of the care provided. METHODS: A prospective study of the characteristics of critically-ill children admitted from 1996 to 2000 was performed. Effectiveness was defined as the ratio of observed to expected mortality, determined by pediatric risk of mortality (PRISM) score calculated 24 hours after admission. RESULTS: The median age of critically-ill children was 38 months and the mean length of stay was 6.8 days. Forty percent of the patients were transferred from other hospitals in Asturias and Leon. The most frequent causes of admission were respiratory, neurological and infectious diseases, and trauma. Overall mortality was 4.3 %. Over the years the severity of the patients increased with a consequent rise in mean length of stay, use of central venous access and mechanical ventilation. Forty-two percent of deaths were expected. The effectiveness of care was high among high-risk patients, among those with respiratory and metabolic diseases and in the postoperative period but was low among patients with hematologic and gastrointestinal diseases. Effectiveness increased over time. CONCLUSIONS: Studies analyzing pediatric intensive care units are useful for assessing and improving the effectiveness of care in these centers.

[Deletion 11q23 --> qter (Jacobsen Syndrome) associated with duodenal atresia and annular pancreas]. / Deleción terminal del 11q (síndrome de Jacobsen) asociada a atresia duodenal con páncreas anular.

Jacobsen syndrome is a rare chromosomal disorder due to terminal 11q deletion. Prominent features are growth and psychomotor retardation, trigonocephaly and a characteristic facial dysmorphism, but many different abnormalities have been reported. We present the case of a preterm male. Prenatal ultrasonography was suspicious for duodenal atresia. At birth, the boy presented the craniofacial features typical of Jacobsen syndrome, together with diffusely spread petechiae and talipes equinovarus. Hemogram revealed pancytopenia. Ultrasound examination showed left renal agenesis and confirmed the duodenal atresia. Cerebral computed tomography scan, electroencephalogram and cardiac studies showed no abnormalities. Annular pancreas was found during surgery to correct the duodenal atresia. The karyotype was 46,XY,del(11)(q23.2 --> qter), which confirmed Jacobsen syndrome.A wide spectrum of clinical features is described in Jacobsen syndrome, with phenotype-karyotype correlation. This is the first report of duodenal atresia and annular pancreas.