[Recommendations on cardiopulmonary resuscitation in patients with suspected or confirmed SARS-CoV-2 infection (COVID-19). Executive summary]. / Recomendaciones sobre reanimación cardiopulmonar en pacientes con sospecha o infección confirmada por SARS-CoV-2 (COVID-19). Resumen ejecutivo.

The SARS-CoV-2 pandemic has created new scenarios that require modifications to the usual cardiopulmonary resuscitation protocols. The current clinical guidelines on the management of cardiorespiratory arrest do not include recommendations for situations that apply to this context. Therefore, the National Cardiopulmonary Resuscitation Plan of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), in collaboration with the Spanish Group of Pediatric and Neonatal CPR and with the Teaching Life Support in Primary Care program of the Spanish Society of Family and Community Medicine (SEMFyC), have written these recommendations, which are divided into 5 parts that address the main aspects for each healthcare setting. This article consists of an executive summary of them.

Pediatric and neonatal transport in Spain, Portugal and Latin America. / Transporte pediátrico y neonatal en España, Portugal y Latinoamérica.

OBJECTIVE: To study the organization of inter-hospital transport of pediatric and neonatal patients in Spain, Portugal and Latin America. DESIGN: An observational study was performed. An on-line survey was sent by email including questions about characteristics of national, regional and local health transport systems, vehicles, material, and composition of the transport team and their training. SETTING: Hospital pediatric healthcare professionals treating children in Spain, Portugal and Latin America RESULTS: A total of 117 surveys from 15 countries were analyzed. Of them, 55 (47%) come from 15 regions of Spain and the rest from Portugal and 13 Latin American countries. The inter-hospital transport of pediatric patients is unified only in the Spanish regions of Baleares and Cataluña and in Portugal. Chile has a mixed unified transport system for pediatric and adult patients. Only 51.4% of responders have an educational program for the transport personnel, and only in 36.4% of them the educational program is specific for pediatric patients. In Spain and Portugal the transport is executed mostly by public entities, while in Latin America public and private systems coexist. Specific pediatric equipment is more frequent in the transport teams in the Iberian Peninsula than in Latin American teams. The specific pediatric transport training is less frequent for teams in Latin America than on Spain and Portugal. CONCLUSIONS: There is a great variation in the organization of children transport in each country and region. Most of countries and cities do not have unified and specific teams of pediatric transport, with pediatric qualified personnel and specific material.

[Evolution of non-invasive ventilation in acute bronchiolitis]. / Evolución de la ventilación mecánica no invasiva en la bronquiolitis.

OBJECTIVES: The aim of the study was to analyse the evolution, over a12-year period, of the use of non-invasive (NIV) and invasive ventilation (IV) in children admitted to a Paediatric Intensive Care Unit (PICU) due to acute bronchiolitis. PATIENTS AND METHODS: A retrospective observational study was performed including all children who were admitted to the PICU requiring NIV or IV between 2001 and 2012. Demographic characteristics, ventilation assistance and clinical outcome were analysed. A comparison was made between the first six years and the last 6 years of the study. RESULTS: A total of 196 children were included; 30.1% of the subjects required IV and 93.3% required NIV. The median duration of IV was 9.5 days and NIV duration was 3 days. The median PICU length of stay was 7 days, and 2% of the patients died. The use of NIV increased from 79.4% in first period to 100% in the second period (P<.0001) and IV use decreased from 46% in first period to 22.6% in the last 6 years (P<.0001). Continuous positive airway pressure and nasopharyngeal tube were the most frequently used modality and interface, although the use of bi-level non-invasive ventilation (P<.001) and of nasal cannulas significantly increased (P<.0001) in the second period, and the PICU length of stay was shorter (P=.011). CONCLUSION: The increasing use of NIV in bronchiolitis in our PICU during the last 12 years was associated with a decrease in the use of IV and length of stay in the PICU.

Morbimortality associated to acute kidney injury in patients admitted to pediatric intensive care units.

AIM: To describe the morbimortality associated to the development of acute kidney injury (AKI) defined by the pediatric adaptation of the RIFLE criteria in a Pediatric Intensive Care Unit (PICU). DESIGN: A retrospective cohort study was carried out. SETTING: Children admitted to a PICU in a tertiary care hospital. Patients or participants A total of 320 children admitted to a tertiary care hospital PICU during the year 2011. Neonates and renal transplant patients were excluded. Primary endpoints AKI was defined and classified according to the pediatric adaptation to the RIFLE criteria. PICU and hospital stays, use of mechanical ventilation and mortality were used to evaluate morbimortality. RESULTS: A total of 315 children met the inclusion criteria, with a median age of 19 months (range 6-72). Of these patients, 128 presented AKI (73 reached the Risk category and 55 reached the Injury and Failure categories). Children with AKI presented a longer PICU stay (6.0 [4.0-12.5] vs. 3.5 [2.0-7.0] days) and hospital stay (17 [10-32] vs. 10 [7-15] days), and a greater need for mechanical ventilation (61.7 vs. 36.9%). The development of AKI was an independent factor of morbidity, associated with a longer PICU and hospital stay, and with a need for longer mechanical ventilation, with a proportional relationship between increasing morbidity and the severity of AKI. CONCLUSION: The development of AKI in critically ill children is associated with increased morbimortality, which is proportional to the severity of renal injury.

[Domiciliary mechanical ventilation in children: a Spanish multicentre study]. / Ventilación mecánica domiciliaria en niños: estudio multicéntrico español.

INTRODUCTION: Domiciliary mechanical ventilation (DMV) use is increasing in children. Few studies have analysed the characteristics of patients using this technique. MATERIALS AND METHODS: An observational, descriptive, transversal, multicentre study was conducted on patients between 1 month and 16 years of age dependent on domiciliary mechanical ventilation. RESULTS: A total of 163 patients with a median age of 7.6 years from 17 Spanish hospitals were studied. The main reasons for DMV were neuromuscular disorders. The median age at beginning of DMV was 4.6 years. Almost three-quarters (71.3%) received non-invasive ventilation. Patients depending on invasive ventilation were younger, started DMV at an earlier age, and had more hours of mechanical ventilation per day. The large majority (80.9%) used DMV during sleep time only, and 11.7% during the whole day. Only 3.4% of patients had external health assistance. Just under half (48.2%) were being followed up in specific DMV or multidisciplinary clinics. Almost three-quarters (72.1%) of patients attended school (42.3% with adapted schooling). Only 47.8% of school patients had specific caregivers in their schools. CONCLUSIONS: DMV in children is used in a very heterogeneous group of patients, and in an important number of patients it is started before the third year of life. Despite there being a significant proportion of patients with a high dependency on DMV, few families receive specific support at home or at school, and health care surveillance is variable and poorly coordinated.

[Prolonged stay in pediatric intensive care units: mortality and healthcare resource consumption]. / Ingreso prolongado en la unidad de cuidados intensivos pediátricos: mortalidad y consumo de recursos asistenciales.

OBJECTIVE: To analyze mortality and resource consumption in patients with long stays in pediatric intensive care units (PICUs). DESIGN: A retrospective, descriptive case series study. SCOPE: Medical-surgical PICU in a third level hospital. PATIENTS: Data were collected from patients with a stay of 28 days or more in PICU between 2006 and 2010. Of the 2118 patients assisted in this period, 83 (3.9%) required prolonged stay. STUDY VARIABLES: Morbidity-mortality and resource consumption among patients with prolonged stay in the PICU. RESULTS: Mortality was higher in patients with a long stay (22.9%) than in the rest of patients (2%) (p<0.001). In 52.6% of these patients, death occurred after withdrawal of treatment or after not starting resuscitation measures. Patients with prolonged stay showed a high incidence of nosocomial infection (96.3%) and an important consumption of healthcare resources (97.6% required conventional mechanical ventilation, 90.2% required transfusion of blood products, 86.7% required intravenous vasoactive drugs and 22.9% required extracorporeal membrane oxygenation [ECMO]). CONCLUSIONS: Critical children with prolonged stay in the PICU show important morbidity and mortality, and an important consumption of healthcare resources. The adoption of specific measures permitting early identification of patients at risk of prolonged stay is needed in order to adapt therapeutic measures and available resources, and to improve treatment efficiency.

[Use of high-flow nasal cannula for non-invasive ventilation in children]. / Utilización de cánulas nasales de alto flujo para la ventilación no invasiva en niños.

OBJECTIVE: To analyse the efficacy and tolerance of non-invasive mechanical ventilation (NIMV) via high-flow oxygen therapy nasal cannulae in children after withdrawal of mechanical ventilation and/or with moderate respiratory insufficiency. PATIENTS AND METHODS: A prospective observational clinical study including 34 children between 9 months and 17 years treated with NIMV via high-flow oxygen therapy nasal cannulae. The following variables were analysed: age, sex, respiratory rate, heart rate, oxygen saturation, blood gases, clinical improvement, tolerance, onset of complications and treatment failure. RESULTS: NIMV was used in 13 children after withdrawal of mechanical ventilation and in 21 with respiratory failure. A high percentage (82.3%) of patients improved clinically and/or allowed the mechanical ventilation to be withdrawn, but there were no significant changes in respiratory rate, heart rate, pH, pCO(2) or saturation. NIMV was not effective in 6 patients (17.6%) and required change to a nasal or buconasal mask (5 patients) or intubation (1 patient). Two patients (5.9%) required change of interface to a nasal or buconasal mask, one had nasal erosion, and another, although improved clinically, showed excessive leakage. The duration of treatment was 48 hours (range 1 to 312 hours). CONCLUSIONS: Non-invasive mechanical ventilation via high-flow oxygen therapy nasal cannulae is effective and well tolerated in a high percentage of children after withdrawal of mechanical ventilation or with moderate respiratory insufficiency.

[Kinetics of C-reactive protein and procalcitonin after paediatric cardiac surgery]. / Cinética de la proteína C reactiva y la procalcitonina en el postoperatorio de cirugía cardíaca en niños.

INTRODUCTION AND OBJECTIVES: The systemic inflammatory response syndrome developed after cardiac surgery impedes the detection of complications. The aim of our study was to examine the behaviour of C-reactive protein (CRP) and procalcitonin (PCT), as well as to evaluate its relationship with severity and to analyse its usefulness in the identification of complications. METHODS: A total of 59 children who underwent cardiac surgery with cardiopulmonary bypass were prospectively studied. CRP and PCT were determined after surgery and at 24, 48 and 72 hours. The relationships between both parameters and the clinical severity were analysed (evaluated with PRISM and TISS scoring systems), as well as with the incidence of complications (infectious and haemodynamics). RESULTS: Serum concentrations of CRP and PCT increased in the first 24 hours after surgery, with a gradual decrease over the following days. There was no association between CRP and severity or development of complications. A moderate correlation was observed between PCT after surgery, at 24 and 48 hours, and PRISM (r=0.548; 0.434 and 0.446) and a low correlation between PCT and TISS. When studying the identification of complications, we obtained cut-off values of PCT>0.17ng/ml (Ss 73.3%; Sp 72.2%) and PCT>1.98ng/ml (Ss 57.1%; Sp 87%) immediately and 48 hours after surgery. No differences were found in CPR and PCT levels among patients with infectious and haemodynamics complications. CONCLUSIONS: CPR does not correlate with the severity or the incidence of complications after paediatric cardiac surgery. PCT correlates with clinical severity and may be able to detect post-surgical complications.

[Evaluation of a paediatric critical care training program for residents in paediatrics]. / Evaluación de un programa de formación en cuidados intensivos pediátricos para residentes de pediatría.

OBJECTIVE: To evaluate a training program in paediatric critical care for residents in paediatrics. METHODS: Description of a paediatric critical care training program for residents in paediatrics. To evaluate the results of the program an initial, and final written test, an evaluation by the physician responsible for the program, a self-evaluation by the residents, and a written survey on the quality of the training program, were performed. RESULTS: From April 1998 to August 2009, 156 residents were included in the training program. All residents showed an improvement between the initial and final written test; initial score (5.6+/-1.2), final score (8.6+/-0.7) (P<0.001). Only 14.1% of the residents answered at least 70 % of the questions correctly in the initial test, compared with 96.6 % in the final test (P<0.001). The score in final test was significantly higher than the self-evaluation by the residents (6.7+/-1.2) and the evaluation by the tutor (6.9+/-0.9) (P<0.001). There were no differences between the practical self-evaluation by the residents (6.2+/-1.0) and the practical evaluation by the tutor (6.7+/-0.9). Residents considered the training program as adequate: theoretical education (8.5+/-0.8), resident handbook (9+/-0.9), practical training (8.3+/-1.0), investigation (7.6+/-2.0) and human relationship (9.2+/-0.9). CONCLUSIONS: This training program is an useful educational method for training paediatric intensive care residents. The evaluation of the training program is essential to improve the education in paediatric residents.

[Prognostic factors for bronchiolitis complications in a pediatric intensive care unit]. / Factores pronósticos de evolución complicada en la bronquiolitis que requiere ingreso en cuidados intensivos pediátricos.

OBJECTIVE: To analyse the prognostic factors for complications in children with bronchiolitis admitted to a pediatric intensive care unit (PICU). PATIENTS AND METHOD: A retrospective study was performed on children with bronchiolitis admitted into a PICU between 2000 and 2006. Univariate and multivariate analysis were performed to study the prognostic factors of complications, mechanical ventilation requirements, mortality and PICU stays of more than 15 days. RESULTS: A total of 110 patients were studied, of whom 72 (65.5%) had high risk factors: prematurity (39.1%), cardiac disease (38.2%) and bronchopulmonary dysplasia (16.3%). A total of 82.7% of patients had complications; 26% need invasive mechanical ventilation and the mortality was 3.6%, and 16.4% stayed in PICU for more than 15 days. Factors associated with mechanical ventilation were the clinical Wood-Downes score and heart disease. A weight less than 5 kg was associated with complications; heart disease and invasive mechanical ventilation were associated with a longer PICU stay; prematurity and mechanical ventilation were associated with mortality. CONCLUSIONS: Children with bronchiolitis admitted into the PICU had a high frequency of complications, often needed mechanical ventilation and had long stays in the PICU, but the mortality is low. The best prognostic factors on admission into the PICU were the acute respiratory insufficiency score, the presence of heart disease and were premature at birth.

[The effect of helium on ventilator parameters: in vitro study with a Servoi ventilator]. / Efecto del helio sobre los parámetros de los respiradores en ventilación mecánica: estudio in vitro con el respirador Servoi.

OBJECTIVE: To analyze the changes in respiratory parameters in a Servoi ventilator with heliox. MATERIAL AND METHODS: In vitro study with a Servoi (Maquet) ventilator in volume controlled (VC), pressure controlled (PC) and volume control regulated by pressure (VCPR) modes connected to an artificial lung. A heliox tank with a fixed concentration of helium 70 % and oxygen 30 % was connected to the air inlet of the ventilator. The ventilator was set in VC mode with tidal volumes of 30, 50, 100, 250 and 500 ml; in PC mode with pressure of 20 and 30 cmH(2)O and in VCPR mode with tidal volume of 150 ml. In each case FiO(2) of 21, 30, 40, 50, 60, 70, 80, 90 and 100 % was used. The FiO(2), inspired and expired tidal volume and inspiratory pressure measured by the ventilator and a pitot spirometer (Datex_S5) were compared. RESULTS: In VC and VCPR modes the increase in helium produced a progressive decrease in the pressure needed to administrate the set volume. Heliox also produced a decrease in the tidal volume measured by the spirometer and the tidal expired volume measured by the respirator. In PC mode, heliox produced a progressive increase in the inspired tidal volume, increasing the differences between inspired and expired tidal volumes. CONCLUSIONS: Heliox used with Servoi ventilator produces a decrease in inspiratory pressures in VC and VCPR modes, and an increase in inspiratory tidal volume in PC mode. In all modes heliox reduced the expired tidal volume measured by the ventilator and the spirometer. These changes should be borne in mind if heliox is used with this ventilator.

[Experience with high-flow nasal cannula oxygen therapy in children]. / Experiencia con la oxigenoterapia de alto flujo en cánulas nasales en niños.

OBJECTIVE: To analyze the efficacy of a high-flow oxygen therapy system in children with moderate respiratory failure and/or high oxygen requirements. PATIENTS AND METHODS: We performed a prospective, observational clinical study of patients treated with a high-flow oxygen therapy system via nasal cannulae. The following variables were analyzed: clinical severity score, respiratory rate, heart rate, clinical improvement, oxygen saturation, blood gases, complications, and the need for ventilation after starting the treatment. RESULTS: Eighteen treatments were studied in 16 patients (two girls and 14 boys) aged between 2 and 156 months. With the high-flow oxygen therapy system, respiratory rate slightly decreased from 34.5 bpm to 32.2 bpm (p<0.04) and O2 saturation increased from 90.2% to 93.5% (p<0.02). Fourteen patients showed a clinical improvement and/or tolerated the change from the previous respiratory assistance. The duration of treatment was 3 days (range: 6 hours to 25 days). Mild complications (initial irritability and excessive humidity) were observed in two patients, but treatment interruption was not required. No secondary respiratory tract infections were observed. The system was withdrawn in four patients, due to lack of improvement in two patients, deterioration after initial improvement in one patient, and failure of the system's temperature regulation in one patient. CONCLUSIONS: The high-flow oxygen therapy system is effective in a large percentage of children with high oxygen requirements and/or moderate respiratory failure.

[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.

[Material for the pediatric resuscitation trolley]. / Material del carro de reanimación cardiopulmonar pediátrica.

Cardiorespiratory arrest and the need for cardiopulmonary resuscitation can occur anywhere, both in the out-of-hospital and in-hospital settings. Therefore, all healthcare centers (hospitals, primary care facilities, out-of-hospital emergency services) must be prepared to initiate life support procedures in children and to treat other life-threatening emergencies. To achieve this objective, adequate material including a full crash cart or resuscitation trolley is essential and must be available in all healthcare centers. Specific items contained in the trolley can vary according to the characteristics of the facility and the most probable type of resuscitation needed (for example, neonatal resuscitation). At least one resuscitation trolley must be available in primary care centers, pediatric intensive care units, emergency departments, out-of-hospital emergency services, and pediatric wards. The trolley must be located in an easily accessible site and must contain only indispensable material. It is essential to include instruments in several sizes, covering children of all ages, as well as enough spare instruments and medications that could be required during resuscitation. The material must be checked periodically and all the staff (physicians, nurses, and auxiliary personnel) must be familiar with the trolley's contents and the location of all material and drugs.