Conocimientos sobre ética asistencial de los residentes de pediatría / Knowledge of health care ethics in paediatric residents

INTRODUCCIÓN: La enseñanza de la bioética se ha incorporado a los planes de estudio de medicina y al programa para médicos residentes. Sin embargo, la transmisión de conocimientos basados en la práctica clínica habitualmente no se realiza de una manera bien estructurada. OBJETIVO: Valorar los conocimientos de ética de los residentes de pediatría españoles y analizar su relación con la formación recibida durante la licenciatura y el periodo de residencia. MATERIAL Y MÉTODOS: Se diseñó una encuesta con 20 preguntas tipo test destinada a evaluar conocimientos éticos básicos con repercusión sobre la clínica. Se valoraron la formación recibida durante el pregrado y la residencia, y los principales conflictos éticos afrontados. RESULTADOS: Se obtuvieron 210 encuestas remitidas desde 20 hospitales: 47 correspondientes a (R1), 49 a (R2), 57 a (R3) y 57 a (R4). La media de respuestas correctas fue de 16,8. No hubo diferencias entre los residentes de distinto año ni entre los que manifestaron haber recibido o no formación específica. Se contabilizaron más fallos en preguntas relacionadas con el consentimiento informado, ley de autonomía del paciente, los principios implicados en la calidad de vida, la sistemática del análisis de casos y la dimensión de la justicia distributiva. CONCLUSIONES: La limitación del esfuerzo terapéutico se ha identificado como el principal problema ético en la práctica clínica. Gran parte de los conocimientos sobre ética se adquieren en el pregrado y varían poco durante la residencia, lo que hace necesarios mayores esfuerzos organizativos y docentes durante este periodo

INTRODUCTION: Bioethics has been recently incorporated in to the educational programs of both medical students and medical residents as part of their curriculum. However, its training based on clinical practice is not well structured. OBJECTIVE: To evaluate the knowledge of bioethics in Spanish paediatric residents, and to analyse how this relates to the medical education during graduate and post-graduate training. MATERIAL AND METHODS: A questionnaire with 20 multiple choice questions was designed to evaluate the knowledge in basic ethics with potential implications in clinical practice. We evaluated the education received during graduate and post-graduate training, and the main ethical conflicts faced. RESULTS: A total of 210 completed questionnaires were received from medical residents in paediatrics from 20 different Spanish hospitals, of whom 47 of these were first year residents (R1), 49 were second year residents (R2), 57 were third year residents (R3), and the remaining 57 were final year residents (R4). The mean number of correct answers was 16.8 out of 20. No differences were found between residents in different years of training, nor were there any differences between the group that had received specific training in bioethics versus those who had not. Residents were more likely to give wrong answers related with informed consent, the law on the freedom of the patient, principles of quality of life, the case analysis system, and the dimension of distributive justice. CONCLUSIONS: Limitation of therapeutic efforts was identified as the main ethical problem faced in clinical practice by Spanish residents in paediatrics. Most of the knowledge of bioethics is acquired during graduate training, and improved very little throughout the period of medical residence. Our results suggest that efforts are required in organising and structuring the education in bioethics during the training of residents in paediatrics

[Knowledge of health care ethics in paediatric residents]. / Conocimientos sobre ética asistencial de los residentes de pediatría.

INTRODUCTION: Bioethics has been recently incorporated in to the educational programs of both medical students and medical residents as part of their curriculum. However, its training based on clinical practice is not well structured. OBJECTIVE: To evaluate the knowledge of bioethics in Spanish paediatric residents, and to analyse how this relates to the medical education during graduate and post-graduate training. MATERIAL AND METHODS: A questionnaire with 20 multiple choice questions was designed to evaluate the knowledge in basic ethics with potential implications in clinical practice. We evaluated the education received during graduate and post-graduate training, and the main ethical conflicts faced. RESULTS: A total of 210 completed questionnaires were received from medical residents in paediatrics from 20 different Spanish hospitals, of whom 47 of these were first year residents (R1), 49 were second year residents (R2), 57 were third year residents (R3), and the remaining 57 were final year residents (R4). The mean number of correct answers was 16.8 out of 20. No differences were found between residents in different years of training, nor were there any differences between the group that had received specific training in bioethics versus those who had not. Residents were more likely to give wrong answers related with informed consent, the law on the freedom of the patient, principles of quality of life, the case analysis system, and the dimension of distributive justice. CONCLUSIONS: Limitation of therapeutic efforts was identified as the main ethical problem faced in clinical practice by Spanish residents in paediatrics. Most of the knowledge of bioethics is acquired during graduate training, and improved very little throughout the period of medical residence. Our results suggest that efforts are required in organising and structuring the education in bioethics during the training of residents in paediatrics.

[Glossary of bioethic terms and expressions frequently used in pediatric intensive care practice]. / Glosario de términos y expresiones frecuentes de bioética en la práctica de cuidados intensivos pediátricos.

Ethical issues are of increasing interest in current medicine, and pediatrics is no exception. In critical care, the relevance of these considerations becomes even greater. Commonly used expressions in bioethics, frequently lead to terminological confusion and misunderstandings, as reported by several publications, revealing a lack of clear concepts in many cases. As an attempt to clarify or facilitate the comprehension of the most relevant terms in this field, the Spanish Society of Pediatric Intensive Care has prepared a Glossary of the most commonly used terms and expressions.

Glosario de términos y expresiones frecuentes de bioética en la práctica de cuidados intensivos pediátricos / Glossary of bioethic terms and expressions frequently used in pediatric intensive care practice

Las cuestiones éticas tienen un interés creciente en la medicina actual, y la pediatría no es una excepción. En la medicina intensiva, la relevancia de estas consideraciones es aún mayor. Un problema frecuente, que se ha puesto de manifiesto en diversos trabajos, es la confusión terminológica en las diversas expresiones de uso común en bioética, lo que probablemente se traduce en muchos casos en una falta de claridad conceptual. En un intento de aportar algo de claridad y de facilitar la comprensión de los conceptos y las ideas relevantes en bioética, el Grupo de Ética de la Sociedad Española de Cuidados Intensivos Pediátricos ha elaborado este glosario de términos y expresiones frecuentes en bioética. Todos los miembros del grupo somos intensivistas pediátricos en activo, por lo que, en la selección y definición de estos términos, hemos tenido en cuenta la problemática ética que se plantea en nuestra actividad asistencial diaria, aunque, por supuesto, ha sido fundamental el análisis y la reflexión sobre las ideas y opiniones expuestas en diferentes obras de los autores más relevantes (AU)

Ethical issues are of increasing interest in current medicine, and pediatrics is no exception. In critical care, the relevance of these considerations becomes even greater. Commonly used expressions in bioethics, frequently lead to terminological confusion and misunderstandings, as reported by several publications, revealing a lack of clear concepts in many cases. As an attempt to clarify or facilitate the comprehension of the most relevant terms in this field, the Spanish Society of Pediatric Intensive Care has prepared a Glossary of the most commonly used terms and expressions (AU)

[Ethical attitudes in Spanish pediatric critical care units]. / Encuesta de ética en las unidades de cuidados intensivos pediátricos españolas.

OBJECTIVES: To assess physicians' awareness and experience of ethical problems that arise when dealing with critically ill children in pediatric intensive care units (PICUs). MATERIAL AND METHODS: Questionnaires containing 20 questions about ethical dilemmas and attitudes related to the care of children admitted to PICUs were mailed to 43 PICUs in Spain. RESULTS: Ninety-five responses corresponding to 24 residents and 71 attending physicians were received from 21 PICUs. The occurrence of ethical dilemmas in the PICU was recognized by 96.8 % of the respondents. The most frequent method of solving these problems was through medical consensus (80 %), while family participation in the decision making process was highly variable. A total of 95.8 % of respondents stated that decisions to limit therapy were made in their PICU, although only one third of these decisions were written in the medical record. The most frequent form of therapeutic limitation was the do not resuscitate order. One third (32.6 %) of participants considered there were ethical differences between withdrawal and withholding of treatment. Attending physicians had greater experience of therapeutic limitation than did residents, but their opinions on the subject were similar. CONCLUSIONS: Ethical dilemmas are common in the PICU. In this setting, decisions about limitation of therapy are frequent, although many physicians admit to not being clear on this issue or on other aspects of clinical ethics. Family members' participation in the decision making process is insufficient in Spanish PICUs.

Encuesta de ética en las unidades de cuidados intensivos pediátricos españolas / Ethical attitudes in spanish pediatric critical care units

Objetivos Evaluar la percepción y experiencia que tienen los médicos que trabajan en las unidades de cuidados intensivos pediátricos (UCIP) acerca de los problemas éticos que se generan en la atención al niño crítico. Material y métodos Se enviaron encuestas a las 43 UCIP existentes en nuestro país, con 20 cuestiones relacionadas con los objetivos del trabajo. Resultados Se obtuvieron 95 encuestas contestadas por médicos (24 residentes y 71 médicos de plantilla) de 21 UCIP. El 96,8 % reconocieron que en su UCIP se presentaban problemas de ética asistencial. El consenso médico es el procedimiento más frecuente para resolver estos problemas (80 %), mientras que la participación familiar en la toma de decisiones es muy variable. El 95,8 % refieren que en su UCIP se toman decisiones de limitación terapéutica, aunque sólo un tercio de los casos se hacen constar en la historia clínica. La decisión de no reanimar es la forma más frecuente de limitación. El 32,6 % consideraron que existían diferencias éticas entre no instaurar o retirar un determinado tratamiento. La experiencia práctica en limitación terapéutica es mayor entre los médicos de plantilla que entre los residentes, aunque sus opiniones al respecto son muy similares. Conclusiones La problemática ética asistencial es común en las UCIP. En este entorno, las decisiones de limitación terapéutica son frecuentes aunque muchos médicos reconocen no tener las ideas claras sobre este y otros aspectos de ética clínica. La participación familiar en la toma de decisiones es insuficiente en nuestro medio

Objectives To asses physicians' awareness and experience of ethical problems that arise when dealing with critically ill children in pediatric intensive care units (PICUs). Material and methods Questionnaires containing 20 questions about ethical dilemmas and attitudes related to the care of children admitted to PICUs were mailed to 43 PICUs in Spain. Results Ninety-five responses corresponding to 24 residents and 71 attending physicians were received from 21 PICUs. The occurrence of ethical dilemmas in the PICU was recognized by 96.8 % of the respondents. The most frequent method of solving these problems was through medical consensus (80 %), while family participation in the decision making process was highly variable. A total of 95.8 % of respondents stated that decisions to limit therapy were made in their PICU, although only one third of these decisions were written in the medical record. The most frequent form of therapeutic limitation was the do not resuscitate order. One third (32.6 %) of participants considered there were ethical differences between withdrawal and withholding of treatment. Attending physicians had greater experience of therapeutic limitation than did residents, but their opinions on the subject were similar. Conclusions Ethical dilemmas are common in the PICU. In this setting, decisions about limitation of therapy are frequent, although many physicians admit to not being clear on this issue or on other aspects of clinical ethics. Family members' participation in the decision making process is insufficient in Spanish PICUs

[Neonatal chylothorax and conservative treatment]. / Quilotórax neonatal y tratamiento conservador.

Four cases of chylothorax are reported. Three cases were congenital and the fourth was secondary to surgical repair of esophageal atresia. Of the three cases of congenital chylothorax, two were diagnosed prenatally. In all three patients with congenital chylothorax, the clinical course was favorable and pleural effusion was resolved in 19-80 days. Treatment consisted of pleural taps when respiratory function was compromised, parenteral nutrition, and respiratory support as required. Enteral nutrition was started with a formula containing medium-chain triglycerides while some effusion remained. Weight gain during this period was slow. Follow-up oscillated between 12 months and 6 years with no recurrences. The case of postsurgical chylothorax appeared several days after the intervention. Pleural effusion increased to 705 ml/day and the patient received no enteral nutrition. The patient died from intestinal complications and multiorgan failure 8 days after the onset of chylothorax. The etiology and clinical features of this condition, as well as the short- and long-term outcome with conservative treatment, are reviewed.

Quilotórax neonatal y tratamiento conservador / Neonatal chylothorax and conservative treatment

Se presentan 4 casos de quilotórax neonatal; en 3 casos se trataba de quilotórax congénito y el cuarto fue posquirúrgico tras la corrección de atresia de esófago. De los 3 quilotórax congénitos, dos fueron diagnosticados prenatalmente. Los 3 casos evolucionaron de manera favorable y el derrame desapareció en 19-80 días. Todos fueron tratados con punciones pleurales cuando había compromiso respiratorio, soporte respiratorio según necesidad y nutrición parenteral. La nutrición enteral se inició con una fórmula con triglicéridos de cadena media (MCT), cuando aún persistía algo de derrame. La ganancia ponderal durante este período fue lenta. El seguimiento ha oscilado entre 6 años y 12 meses, no observándose recidivas. El caso de quilotórax posquirúrgico apareció varios días después de la intervención con un volumen de drenaje pleural creciente hasta de 705 ml/día sin estar recibiendo nutrición enteral. La evolución fue mala y el paciente falleció con un cuadro de sufrimiento intestinal y fallo multiorgánico 8 días después del inicio del quilotórax. Se revisa la etiología, clínica y evolución con tratamiento conservador a corto y largo plazo (AU)

[Prospective study of infective complications in newborns with fine silicone catheters used for parenteral nutrition infusion]. / Estudio prospectivo de las complicaciones infecciosas en recién nacidos con catéteres de silicona finos utilizados para infusión de nutrición parenteral.

OBJECTIVE: Percutaneous silastic central venous catheters have contributed to improve the care of neonates. They are quite safe; however, sometimes complications occur, with infections being the most frequent. A prospective study was undertaken in our NICU to know the rate of catheter-related sepsis, the influence of the duration of catheterization, the predominant portal of entry and the microorganisms isolated. PATIENTS AND METHODS: Fifty-two catheters were analyzed. Cultures were obtained once a week by aspiration from the catheter hub, the luer-lock connection and parenteral nutrition solution directly from the bag. If sepsis was suspected, blood cultures were obtained from a different vein. The tip was cultured after catheter withdrawal by the semiquantitative technique of Maki. RESULTS: Nineteen catheters (36.5%), 19 luer-lock connections (21.3%) and 7 parenteral nutrition solutions were colonized. We found a significant increase of the rate of colonization after the catheter had been in place 3 weeks or more (p < 0.05). Coagulase negative Staphylococcus was isolated in 75.7% of the samples. The rate of catheter related sepsis was 15.4% (7/8 caused by coagulase negative Staphylococcus). CONCLUSIONS: Catheter related sepsis may be more frequent than expected it colonization of the catheter were analyzed systematically. Screening catheter colonization allows an earlier diagnosis of pathogens if sepsis develops. Finally, we believe that the use of sterile techniques to handle the catheter and connections will further decrease catheter related infections.

Parenteral nutrition infused by epicutaneous catheter: pulmonary complication.

We present three preterm infants with pulmonary complications due to central venous silicone catheters malpositioned in the left or right pulmonary artery. One infant developed an arterial-bronchial fistula. The other two infants had pneumonitis without evidence of vessel perforation. The course of these complications was good after the catheter was withdrawn into the superior vena cava.