[Assembly and management of helmet-CPAP in infants and children with acute respiratory insufficiency]. / Montaje y manejo del sistema helmet-CPAP en lactantes y niños con insuficiencia respiratoria aguda.

Application of continuous positive airway pressure (CPAP) during respiratory insufficiency through a helmet interface is not well known in the Pediatric practice. The objective of this paper is to describe the necessary elements for it assembly, management and nursing care. The advantages and disadvantages of helmet compared to other interfaces are also discussed.

[Ethics and pediatric cardiopulmonary resuscitation]. / Etica y reanimación cardiopulmonar pediátrica.

Cardiopulmonary resuscitation (CPR) is a medical activity that involves major ethical issues. As in other areas of clinical ethics, CPR decisions must be based on the principles of autonomy, beneficence, nonmaleficence, and justice. The decision-making process is more difficult in emergency situations, and when the patient is a minor, the parents and the child's best interests must be taken into consideration. There are specific situations in which starting CPR is clearly indicated and others in which ceasing resuscitation maneuvers is justified. Do not attempt resuscitation orders must be respected by health staff. Other ethical issues involved in CPR include resuscitation of potential organ donors, learning CPR procedures, research in CPR, and the information given to the parents of children with cardiorespiratory arrest.

[Management of pediatric multiple trauma patients. Perspective of the pediatric intensive care unit]. / Asistencia al paciente politraumatizado. Realidad actual desde la perspectiva de las unidades de cuidados intensivos.

OBJECTIVE: To study the epidemiology and management of pediatric trauma patients as well as the organizational, human and technical resources dedicated to these children from the perspective of the pediatric intensive care unit (PICU). MATERIAL AND METHODS: A standardized data collection form was sent to 43 PICUs in Spain. Items inquired about the existence of training courses, trauma clinical practice guidelines and trauma registers, and which physician was in charge of trauma patients. Data on casuistics, the age of trauma patients, and the availability of human and technical resources, were also recorded. RESULTS: Twenty-four PICUs completed the questionnaire. The PICU physician was responsible for trauma patient care in 66% of the hospitals. No training courses were available in 59% of the hospitals. No trauma register was available in 62% of the hospitals. Trauma patients represented 11% of PICU admissions, and most patients were aged up to 14 years old. An anesthetist was always at the hospital in 100% of the hospitals. A radiologist and traumatologist were always at the hospital in 91%, a neurosurgeon in 66% and a pediatric surgeon in 50%. The remaining surgical and medical specialties were on call. Continuous intracranial pressure monitoring was available in 87% of the PICUs, jugular venous saturation monitoring in 54% and continuous electroencephalogram and transcranial Doppler ultrasound in 50%. Computed tomography and ultrasound were available at all times in all hospitals. Magnetic nuclear resonance and echocardiography were available at all times in 44% of the hospitals, and arteriography in 42%. CONCLUSION: In Spain, the organization of pediatric trauma management is based on pediatric teams under the supervision of a PICU physician. Some hospitals show a lack of technical and human resources. Therefore, the minimum criteria required to consider a hospital as a pediatric trauma center should be established. Trauma training courses are required.

[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.

[Pediatric advanced life support]. / Reanimación cardiopulmonar avanzada en pediatría.

Advanced life support (ALS) includes all the procedures and maneuvers used to restore spontaneous circulation and breathing, thus minimizing brain injury. The fundamental steps of ALS are airway control with adjuncts, ventilation with 100% oxygen, vascular access and fluid and drug administration, and monitoring to diagnose and treat arrhythmias. Airway control can be achieved by means of oropharyngeal airway, endotracheal intubation, and alternative methods (laryngeal mask and cricothyroidotomy). Vascular access can be achieved by the peripheral venous, intraosseous, central venous, and tracheal routes. The most frequent rhythms found in children with cardiorespiratory arrest are nonshockable (asystole, severe bradycardia, pulseless electrical activity, and complete atrioventricular block). In these cases, adrenaline continues to be the essential drug. Currently, low adrenaline doses (0.01 mg/kg IV and 0.1 mg/kg intratracheal administration) are recommended throughout the resuscitation period. Amiodarone (5 mg/kg) is the drug of choice in cases of ventricular fibrillation refractory to electric shock. The treatment sequence for shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia) is one 4 J/kg electric shock, followed by cardiopulmonary resuscitation (chest compressions and ventilation) for 2 minutes with subsequent reassessment of the electrocardiographic rhythm. Adrenaline must be administered immediately before the third electric shock and subsequently every 3-5 minutes. Amiodarone must be administered immediately before the fourth shock.

[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.

[Comparison between 2 groups of nursing professionals on the knowledge of pediatric pain]. / Comparación de los conocimientos sobre dolor infantil en 2 poblaciones de profesionales de enfermería.

OBJECTIVE: To compare infant pain knowledge between a group of nurses who work in a pediatric hospital and one that works in a general hospital. MATERIAL AND METHODS: Descriptive study based on the use of a validated questionnaire for assessing the knowledge and attitudes of nurses about pediatric pain (Pediatric Nurses' Knowledge and Attitude Survey Regarding Pain [PNKAS]). PNKAS questionnaire was distributed to the nursing staff of a pediatric hospital and a general hospital and the results were compared. RESULTS: The average score obtained in the pediatric vs. the general hospital was: mean, 51.7% vs. 47.2%, 95% confidence interval, 47.5 to 56% vs. 43.6 to 50.8% (P=.098). CONCLUSIONS: There were no differences between the scores in the PNKAS questionnaire between nurses working exclusively with children and nurses working with general population. Training on pediatric pain needs to be improved in nurses caring for sick children.

[Severe acute kidney injury in critically ill children: Epidemiology and prognostic factors]. / Daño renal agudo grave en niños críticos: epidemiología y factores pronósticos.

INTRODUCTION: Acute kidney injury (AKI) is a severe complication in critically ill children. The aim of the study was to describe the characteristics of AKI, as well as to analyse the prognostic factors for mortality and renal replacement therapy (RRT) in children admitted to Paediatric Intensive Care Units (PICUs) in Spain. PATIENTS AND METHODS: Prospective observational multicentre study including children from 7 days to 16 years old who were admitted to a PICU. A univariate and multivariate logistic regression analysis of the risk factors for mortality and renal replacement therapy at PICU discharge were performed. RESULTS: A total of 139 cases of AKI were analysed. RRT was necessary in 60.1% of cases. Mortality rate was 32.6%. At PICU discharge RRT was necessary in 15% of survivors. Thrombopenia and low creatinine clearance values were prognostic markers of RRT at PICU discharge. High values of platelets, serum creatinine and weight were associated with higher survival. CONCLUSIONS: Critically ill children with AKI had a high mortality and morbidity rate. Platelet values and creatinine clearance are markers of RRT at PICU discharge, whereas number of platelets, serum creatinine and weight were associated with mortality.

[Comfort and noise level in infants with helmet interface]. / Confort y nivel de ruido en ventilación no invasiva con interfase helmet en lactantes.

OBJECTIVES: To evaluate comfort and noise intensity using the COMFORT scale in infants who receive respiratory support with a helmet interface. PATIENTS AND METHODS: An observational descriptive study was conducted on all infants (1 to 12 months of age) admitted to a PICU from November 1st 2013 to March 31st 2014 and who received non-invasive ventilation with a helmet interface. Tolerance to the interface was assessed by use of the COMFORT scale. The intensity of the noise to which the infants were exposed was measured with a TES1350A HIBOK 412 sound-level meter. Three measurements were made every day. RESULTS: Twenty seven patients with bronchiolitis (median age: 54 days; range: 10 to 256) were included. Median COMFORT score in the first day was 21 points (14 - 28). An increase in patient comfort was found with a gradual decrease in the scores, with a maximum reduction of 22% from the first hours (score of 22) to the fifth day (score of 18). The minimum sound intensity registered was 42dB, and the maximum was 78dB. Background noise intensity was associated with noise intensity in the helmet. No differences were observed in COMFORT score and noise intensity between ventilator devices. CONCLUSIONS: Helmet interface was well tolerated by infants. COMFORT score results are an indicator that infants were comfortable or very comfortable. The measured noise intensity was in the safe range permitted by World Health Organization.

[Risk factors associated with nosocomial bacteremia in low birth weight neonates. Grady Memorial Hospital, Atlanta]. / Factores de riesgo asociados con bacteriemia nosocomial en recién nacidos de bajo peso al nacimiento. Hospital Grady Memorial, Atlanta.

BACKGROUND: Nosocomial bloodstream infections occur frequently in Neonatal Intensive Care Units and are associated with recognized and unrecognized risk factors. Little has been published regarding risk factors for bloodstream infections in low birth weight neonates. OBJECTIVE: To investigate risk factors for bloodstream infection in neonates < 1,500 g admitted at a Neonatal Intensive Care Unit. METHODS: A prospective study was undertaken in low birth weight neonates (< 1,500g) during a 22 months period. Bivariant, and logistic regresion (stepwise procedure) analysis was used to determine the significance association of bloodstream infection and perinatal and nosocomial risk factors. RESULTS: A total of 72 patiens with nosocomial bacteriemia and 147 non bacteriemic patients were studied. Independent risk factors associated with bloodstream infection were birth weight, persistence of umbilical catheter > 7 days and persistence of peripheral arterial catheter > 1 day. CONCLUSIONS: The uses of umbilical catheter > 7 days, peripheral arterial catheter > 1 day and birth weight < 1,500 g were significant determinants of nosocomial bloodstream infection risk. Because of the importance of invasive procedures as a source of nosocomial bloodstream infections, the lines duration needs to be reviewed with the aim of reducing the incidence of blood stream infection.

[Ventilation in special situations. Mechanical ventilation in acute respiratory distress syndrome/acute pulmonary lesion]. / Ventilación en situaciones especiales. Ventilación mecánica en el síndrome de dificultad respiratoria aguda/lesión pulmonar aguda.

Acute respiratory distress syndrome (ARDS), which was first described by Ashbaugh in 1967, consists of acute hypoxemic respiratory failure (PaO2/FiO2< or =200) associated with bilateral infiltrates on the chest radiograph caused by noncardiac diffuse pulmonary edema. Although ARDS is of multiple etiology, pulmonary or extrapulmonary injury can produce systemic inflammatory response that perpetuates lung disturbances once the initial cause has been eliminated. Most patients with ARDS require mechanical ventilation. Currently, the old standard is conventional ventilation optimized to protect against ventilator-associated lung injury. Other mechanical ventilation strategies such as high-frequency oscillatory ventilation, which is also based on alveolar recruitment and adequate lung volume, can be useful alternatives. In this review, the level of evidence for other therapies, such as prone positioning, nitric oxide and prostacyclin inhalation, exogenous surfactant, and extracorporeal vital support techniques are also analyzed.

[Ventilation in special situations. Mechanical ventilation during transportation of pediatric patients]. / Ventilación en situaciones especiales. Ventilación mecánica durante el transporte pediátrico.

Most severe pediatric injuries occur far from regional centres specialized in the definitive care of the critically-ill child. Adequate initial stabilization and an appropriate transport system significantly decrease morbidity and mortality in these patients. In the last few years, technological developments have improved the quality of medical transportation. Mechanical ventilation is one of the elements that has been affected by these advances with portable ventilators and monitoring systems that are increasingly similar to those used in pediatric intensive care units. To prevent complications from developing during transportation, adequate preparation is required consisting of (i) prior stabilization of the patient, (ii) assessment of potential risks and specific needs, (iii) monitoring, (iv) transport preparation, and (v) assessment of vital signs and patient management. Portable ventilators are designed to be used for short periods under difficult conditions (temperature changes, altitude, rain, knocks, etc.). Consequently they should have specific common characteristics: portability, resistance, ease of handling, low electricity and gas consumption, and safety. They should also be easy to set up. Their programming is generally similar to that of conventional ventilators and should be based on the physiologic characteristics of the child according to age and underlying process.

[Acute renal failure in critically-ill children. A preliminary study]. / Insuficiencia renal aguda en niños críticamente enfermos. Estudio preliminar.

OBJECTIVE: To analyze the characteristics of acute renal failure (ARF) in critically-ill children and develop a protocol for a multicenter study. METHODS: A prospective, descriptive study was performed in four pediatric intensive care units (PICU) over 5 months. Epidemiological, clinical and laboratory data from children aged between 7 days and 16 years with ARF were analyzed. Premature neonates were excluded. RESULTS: There were 16 episodes of ARF in 14 patients and 62.5 % were male (mean 6 SD age: 50 +/- 49 months). The incidence of ARF was 2.5 % of PICU patients. The most frequent primary diseases were nephro-urological (50 %) and heart disease (31 %). The main risk factors for ARF were hypovolemia (44 %) and hypotension (37 %). Six patients (37.5 %) developed ARF following surgery (cardiac surgery in four, kidney transplantation in one and urological surgery in one). Furosemide was used in 13 patients (as continuous perfusion in nine), inotropes in nine and renal replacement therapy in 12. Medical complications were found in 94 % and some organic dysfunction was found in 81 %. The length of stay in the PICU was 21 +/- 21 days. The probability of death according to the Pediatric Risk of Mortality was 14 +/- 8 %. Five patients died (36 % of the patients and 31.2 % of ARF episodes). CONCLUSIONS: The incidence of ARF in critically-ill children is low but remains a cause of high mortality and prolonged stay in the PICU. Mortality was caused not by renal failure but by multiple organ failure.

[Pediatric brain death and donation in Asturias]. / Muerte encefálica y donación en población infantil.

BACKGROUND: Brain death is the irreversible cessation of intracranial neurologic function and is considered as the person's death. The objective of this study was to describe the characteristics of pediatric donors in the Hospital Central de Asturias from October 1995 to October 2002. METHODS: We performed a retrospective and descriptive study of the dead children who were potential donors in the pediatric intensive care unit (PICU). RESULTS: Of 43 dead children, 15 (34.9 %) were diagnosed with brain death. In four patients (family refusal in one, sepsis in two and brain tumor in one) there was no donation. In all patients, the diagnosis of brain death was based on clinical examination and electroencephalogram. Doppler ultrasonography and technetium-99m hexamethylpropyleneamineoxamine (Tc-99-HMPAO) scanning was also performed in three and nine patients respectively. The mean age of the donors was 8.1 years (range: 13 months-15 years). The male/female ratio was 3/1. The cause of death was multiple trauma in six children, brain hemorrhage in three, cardiac arrhythmias in three, lightning strike in one, diabetic ketoacidosis in one, septic shock in one and hypovolemic shock in one. The median interval between admission and brain death was 1.4 days (range: 3 hours-12 days). The time of organ support between brain death and donation was 8.4 hours (range: 6-13 hours). The most frequent complications after brain death were central diabetes insipidus in 90.9 % of the patients, hyperglycemia in 54.5 % and hypokalemia in 45.4 %. During support 72.7 % of the patients required inotropic aid. CONCLUSIONS: In our PICU more than one-third of the dead children suffered brain death, and most became donors. The most frequent cause of brain death was multiple trauma. Coordination with the transplant team and the training of medical staff are important to achieve a high percentage of donations.

[Estimation of creatinine clearance by the height/plasma creatinine formula in critically-ill children]. / Estimación del aclaramiento de creatinina por la talla en pacientes críticamente enfermos.

INTRODUCTION: Critically-ill children frequently show impaired renal function, necessitating adjustment of drug dosages. Our objectives were to study estimated creatinine clearance through the correlation between the height/plasma creatinine formula (CrClest) and measured creatinine clearance (CrClms) and to examine whether CrClest over- or underestimates CrClms by analyzing the influence of diagnosis, severity, and the practical consequences. PATIENTS AND METHODS: Seventy-seven patients admitted to the pediatric intensive care unit were included. CrClms was calculated using serum creatinine and creatinine in urine collected over 24 hours. CrClest was estimated using serum creatinine, height, and a constant. The difference between CrClms and CrClest was expressed as a percentage: (CrClms CrClest) x 100/CrClms. Differences of greater than 15 % were considered poor estimates. ResultsThe mean percentage difference was 29.2 (standard error: 39.9). There were no differences among diagnoses in the distribution of significant bias, although the frequency of metabolic diagnoses was high. Incorrect evaluation of CrClest would result in a therapeutic error in 11.69 % of the cases, with overdosage in 10.39 %. The Pediatric Risk of Mortality (PRISM) score was higher (p < 0.05) in patients at risk for overdosage. CONCLUSIONS: CrClest estimation using the height/plasma creatinine formula was not an accurate method in critically ill children. In 10.39 % of patients with more severe illness, the dosage of renally excreted drugs would be too high. The highest risk was found in patients with metabolic and neurological diagnoses.

[Long QT syndrome presented as epilepsy]. / Síndrome de QT largo presentado como epilepsia.

INTRODUCTION: Long QT syndrome is characterised by an alteration in cardiac repolarisation that brings about ventricular arrhythmias. The resulting cerebral hypoxia leads to fainting and convulsions that, in up to 10% of cases, are interpreted as epilepsy. CASE REPORT: We report the case of a patient of paediatric age who was affected by an isolated presentation of congenital long QT syndrome, which had initially been diagnosed as idiopathic epilepsy, and who suffered a sudden loss of consciousness while doing exercise. The initial electrocardiographic monitoring revealed a ventricular tachycardia in torsades de pointes, which was reversed by advanced cardiopulmonary revival manoeuvres. At 12 days after admission, there was an absence of electrical brain activity and brain death resulted. CONCLUSION: The high mortality among symptomatic patients affected by long QT syndrome and the effectiveness of the treatment highlight the importance of a correct diagnosis. A detailed clinical history and an electroencephalogram with a simultaneous electrocardiogram (ECG) recording, together with continuous EEG recording for 24 hours, with the manual evaluation of the corrected QT, would all help in the identification of unsuspected cases. A complete study of the family, including the possible associated mutations, could be a new form of early diagnosis.

[Thrombosis and obstruction associated with central venous lines. Incidence and risk factors]. / Trombosis y obstrucción asociadas a vías venosas centrales. Incidencia y factores de riesgo.

OBJECTIVE: To analyse the incidence of thrombosis and obstruction associated with central venous lines (CVL) inserted in critically ill children, and to determine their risk factors. DESIGN: Prospective observational study in a Pediatric Intensive Care Unit in a University Hospital. MATERIAL AND METHOD: An analysis was made of 825 CVL placed in 546 patients. Age, gender, weight, type of catheter (lines, size, and brand), final location of the catheter, mechanical ventilation, type of sedation and analgesia used, initial failure by the doctor to perform CVL catheterization, number of attempts, CVL indication, admission diagnosis, emergency or scheduled procedure, and delayed mechanical complications (DMC). Risk factors for these complications were determined by a multiple regression analysis. RESULTS: A total of 52 cases of DMC, 42 cases of obstruction, and 10 of thrombosis were registered. Obstruction and thrombosis rates were 4.96 and 1.18 per 100 CVL, respectively. The only risk factor independently linked to obstruction was the duration of the CVL (OR 1.05; 95% CI; 1.00-1.10). The number of lines with thrombosis (OR 4.88; 95% CI; 1.26-18.0), as well as parenteral nutrition (OR 4.17; 95% CI; 1.06-16.31) was statistically significant according to bivariate analysis. However, no risk factors for thrombosis were found in the multivariate analysis. CONCLUSIONS: Obstruction and thrombosis of CVL inserted in a Pediatric Intensive Care Unit are relatively common complications. CVL duration is an independent risk factor for any line obstruction.