A poor and delayed anti-SARS-CoV2 IgG response is associated to severe COVID-19 in children.

BACKGROUND: Most children and youth develop mild or asymptomatic disease during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, a very small number of patients suffer severe Coronavirus induced disease 2019 (COVID-19). The reasons underlying these different outcomes remain unknown. METHODS: We analyzed three different cohorts: children with acute infection (n=550), convalescent children (n=138), and MIS-C (multisystem inflammatory syndrome in children, n=42). IgG and IgM antibodies to the spike protein of SARS-CoV-2, serum-neutralizing activity, plasma cytokine levels, and the frequency of circulating Follicular T helper cells (cTfh) and plasmablasts were analyzed by conventional methods. FINDINGS: Fifty-eight percent of the children in the acute phase of infection had no detectable antibodies at the time of sampling while a seronegative status was found in 25% and 12% of convalescent and MIS-C children, respectively. When children in the acute phase of the infection were stratified according disease severity, we found that contrasting with the response of children with asymptomatic, mild and moderate disease, children with severe COVID-19 did not develop any detectable response. A defective antibody response was also observed in the convalescent cohort for children with severe disease at the time of admission. This poor antibody response was associated to both, a low frequency of cTfh and a high plasma concentration of inflammatory cytokines. INTERPRETATION: A weak and delayed kinetic of antibody response to SARS-CoV-2 together with a systemic pro-inflammatory profile characterize pediatric severe COVID-19. Because comorbidities are highly prevalent in children with severe COVID-19, further studies are needed to clarify their contribution in the weak antibody response observed in severe disease. FUNDING: National Agency for Scientific and Technological Promotion from Argentina (IP-COVID-19-0277 and PMO-BID-PICT2018-2548).

Blood neutrophils from children with COVID-19 exhibit both inflammatory and anti-inflammatory markers.

BACKGROUND: Perhaps reflecting that children with COVID-19 rarely exhibit severe respiratory symptoms and often remain asymptomatic, little attention has been paid to explore the immune response in pediatric COVID-19. Here, we analyzed the phenotype and function of circulating neutrophils from children with COVID-19. METHODS: An observational study including 182 children with COVID-19, 21 children with multisystem inflammatory syndrome (MIS-C), and 40 healthy children was performed in Buenos Aires, Argentina. Neutrophil phenotype was analyzed by flow cytometry in blood samples. Cytokine production, plasma levels of IgG antibodies directed to the spike protein of SARS-CoV-2 and citrullinated histone H3 were measured by ELISA. Cell-free DNA was quantified by fluorometry. FINDINGS: Compared with healthy controls, neutrophils from children with COVID-19 showed a lower expression of CD11b, CD66b, and L-selectin but a higher expression of the activation markers HLA-DR, CD64 and PECAM-1 and the inhibitory receptors LAIR-1 and PD-L1. No differences in the production of cytokines and NETs were observed. Interestingly, the expression of CD64 in neutrophils and the serum concentration of IgG antibodies directed to the spike protein of SARS-CoV-2 distinguished asymptomatic from mild and moderate COVID-19. INTERPRETATION: Acute lung injury is a prominent feature of severe COVID-19 in adults. A low expression of adhesion molecules together with a high expression of inhibitory receptors in neutrophils from children with COVID-19 might prevent tissue infiltration by neutrophils preserving lung function. FUNDING: This study was supported by the Ministry of Science and Technology (National Agency for Scientific and Technological Promotion, IP-COVID-19-0277 and PMO BID PICT 2018-2548), and University of Buenos Aires from Argentina (20020170100573BA).

Ensayo clínico aleatorizado sobre la administración de una solución de mantenimiento intravenosa hipotónica comparada contra una isotónica en pacientes pediátricos críticos / Hypotonic versus isotonic maintenance fluids in critically ill pediatric patients: a randomized control trial

Introducción. Las soluciones hipotónicas se han vinculado a la producción de hiponatremia iatrogénica. Objetivos. Evaluar las variaciones en el sodio sérico (NaS) tras la administración de una solución de mantenimiento intravenosa isotónica (NaCl al 0,9% en dextrosa al 5%) en comparación con una solución de mantenimiento hipotónica (NaCl al 0,45% en dextrosa al 5%). Material y métodos. Ensayo clínico aleatorizado, doble ciego y controlado. Se enrolaron pacientes pediátricos con una estadía esperada en la unidad de cuidados intensivos mayor de 24 horas, NaS normal y líquidos intravenosos > 80% de los líquidos totales de mantenimiento. La concentración sérica de Na se midió antes de colocar la solución de mantenimiento y al reducir la administración de ésta a < 80% del total del aporte. Resultados. Se incorporaron 63 pacientes, que fueron asignados en forma aleatoria a recibir una solución de mantenimiento hipotónica (n= 32) o isotónica (n= 31). Las características basales fueron similares en ambos grupos. No hubo diferencias con respecto a la cantidad de solución administrada (grupo hipotónico 865 ± 853 ml; grupo isotónico 778 ± 649 ml, p= 0,654) o el tiempo de infusión (grupo hipotónico: 24 ± 10,8 horas; grupo isotónico: 27,6 ± 12,8 horas, p= 0,231). Se encontró una diferencia en el NaS luego de la administración de las soluciones de mantenimiento (grupo hipotónico: 137,8 ± 4,3 mmol/L; grupo isotónico: 140,0 ± 4,1 mmol/L, p=0,04). Ninguna de las dos soluciones de mantenimiento aumentó el riesgo de hiponatremia (Na < 135 mmol/L) o de hipernatremia (Na > 145 mmol/L). Conclusiones. Ambas soluciones de mantenimiento, en 24 horas de infusión, no aumentaron el riesgo de producir hiponatremia iatrogénica.

Introduction: Hypotonic fluids have been associated with the development of iatrogenic hyponatremia. Objectives. To assess variations in serum sodium (sNa) following the intravenous administration of isotonic maintenance fluids (0.9% NaCl/5% dextrose) compared to hypotonic maintenance fluids (0.45% NaCl/5% dextrose). Material and Methods. Randomized, controlled, double-blind clinical trial. Pediatric patients with an expected length of stay in the intensive care unit of more than 24 hours were enrolled, with normal serum Na, and IV fluids >80% of total maintenance fluids. Serum Na level was measured before administering maintenance fluids and when reducing the administration to <80% of total fluids. Results. The study included 63 patients who were randomly assigned to receive hypotonic (n= 32) or isotonic (n= 31) maintenance fluids. Baseline characteristics were similar inboth groups. There were no differences in terms of volume of fluid administered (hypotonic group: 865 ± 853 mL; isotonic group: 778 ± 649 mL; p=0.654) or infusion duration (hypotonic group: 24 ± 10.8 hours; isotonic group: 27.6 ± 12.8 hours; p= 0.231). A difference was found in the serum Na following the administration of maintenance fluids (hypotonic group: 137.8 ± 4.3 mmol/L; isotonic group: 140.0 ±4.1 mmol/L, p= 0.04). None of these two maintenance fluids increased the risk of hyponatremia (Na <135 mmol/L) or hypernatremia (Na >145 mmol/L). Conclusions. Neither hypotonic nor isotonic maintenance fluids increased the risk of developing iatrogenic hyponatremia with the 24 hour infusion.

Impact of a quality improvement intervention on the incidence of unplanned extubations in a Pediatric Intensive Care Unit.

INTRODUCTION: An unplanned extubation (UEX) is a frequent and preventable adverse event of mechanical ventilation. OBJECTIVES: To fnd out the causes of unplanned extubation and assess the use of a quality improvement intervention to reduce this event rate. POPULATION: Patients with invasive mechanical ventilation for more than 12 hours over the period from May 1st 2010 and April 30th 2011 in a Pediatric Intensive Care Unit (PICU). DESIGN: Uncontrolled, before and after study. A quality improvement intervention was used over the period between November 2010 and April 2011, which included training PICU staff, establishing standards to fx the endotracheal tube and control its fxation. RESULTS: There were 395 patients admitted to the PICU, 262 (66%) were on mechanical ventilation for more than 12 hours. A total of 27 patients had 30 UEX events: 22 during the period between May and October 2010, and 8 during the period between November 2010 and April 2011. The most common causes of UEX were incorrect fxation of the endotracheal tube (n= 11) and the use of a procedure of care (n= 11). Patients with UEX required additional days on mechanical ventilation: 7 (3-15.5) versus 5 (2-8) days; p= 0.077 and hospitalization: 9.5 (5-19) versus 7 (4-10) days; p= 0.049. During the implementation of the quality improvement intervention, the mean incidence of UEX decreased from 2.30 (95% CI: 1.12-3.49) to 0.86 (95% CI: 0.27-1.44) per 100 days of mechanical ventilation (p= 0.037). CONCLUSIONS: The most common causes of UEX were the incorrect fxation of the endotracheal tube and the use of a procedure of care. The implementation of a quality improvement intervention reduced the incidence of UEX.

Impact of a quality improvement intervention on the incidence of unplanned extubations in a Pediatric Intensive Care Unit / Impacto de una intervención de mejora de calidad sobre la incidencia de extubaciones no planeadas en una unidad de cuidados intensivos pediátricos

Introduction. An unplanned extubation (UEX) is a frequent and preventable adverse event of mechanical ventilation. Objectives. To fnd out the causes of unplanned extubation and assess the use of a quality improvement intervention to reduce this event rate. Population. Patients with invasive mechanical ventilation for more than 12 hours over the period from May 1st 2010 and April 30th 2011 in a Pediatric Intensive Care Unit (PICU). Design. Uncontrolled, before and after study. A quality improvement intervention was used over the period between November 2010 and April 2011, which included training PICU staff, establishing standards to fx the endotracheal tube and control its fxation. Results. There were 395 patients admitted to the PICU, 262 (66%) were on mechanical ventilation for more than 12 hours. A total of 27 patients had 30 UEX events: 22 during the period between May and October 2010, and 8 during the period between November 2010 and April 2011. The most common causes of UEX were incorrect fxation of the endotracheal tube (n= 11) and the use of a procedure of care (n= 11). Patients with UEX required additional days on mechanical ventilation: 7 (3-15.5) versus 5 (2-8) days; p= 0.077 and hospitalization: 9.5 (5-19) versus 7 (4-10) days; p= 0.049. During the implementation of the quality improvement intervention, the mean incidence of UEX decreased from 2.30 (95% CI: 1.12-3.49) to 0.86 (95% CI: 0.27-1.44) per 100 days of mechanical ventilation (p= 0.037). Conclusions. The most common causes of UEX were the incorrect fxation of the endotracheal tube and the use of a procedure of care. The implementation of a quality improvement intervention reduced the incidence of UEX.(AU)

Introducción. Las extubaciones no planeadas (ENP) son eventos adversos frecuentes y prevenibles de la ventilación mecánica. Objetivos. Conocer las causas de las extubaciones no planeadas y evaluar la utilidad de la aplicación de una intervención de mejora de la calidad para disminuir ese evento. Población. Pacientes con ventilación mecánica invasiva durante más de 12 horas durante el período comprendido entre el 1 de mayo del 2010 y el 30 de abril del 2011 en una unidad de cuidados intensivos pediátricos (UCIP). Diseño. Estudio antes-después no controlado. Se aplicó una intervención de mejora de calidad en el período noviembre de 2010-abril de 2011 que incluyó capacitación del personal de la UCIP, estandarización de la fjación del tubo endotraqueal y control de la fjación. Resultados. Ingresaron en la UCIP 395 pacientes, 262 (66%) recibieron ventilación mecánica durante más de 12 horas. Presentaron 30 episodios de ENP 27 pacientes: 22 durante el período mayo a octubre de 2010, y 8 durante el período noviembre de 2010-abril de 2011. Las causas más frecuentes fueron la incorrecta fjación del tubo endotraqueal (n= 11) y la realización de un procedimiento de atención y cuidado (n= 11). Los pacientes que la presentaron requirieron más días de ventilación mecánica: 7 (3 a 15,5) contra 5 (2 a 8) días; p= 0,077 y de internación: 9,5 (5 a 19) contra 7 (4 a 10) días; p= 0,049. Durante la intervención de mejora de la calidad la incidencia media de ENP disminuyó de 2,30 (IC 95% 1,12 a 3,49) a 0,86 (IC 95% 0,27 a 1,44) por 100 días de ventilación mecánica (p= 0,037). Conclusiones. Las causas más frecuentes de ENP fueron la incorrecta fjación del tubo endotraqueal y la realización de procedimientos de atención y cuidado. La implementación de una intervención de mejora de la calidad disminuyó la incidencia de ENP.(AU)

Impact of a quality improvement intervention on the incidence of unplanned extubations in a Pediatric Intensive Care Unit / Impacto de una intervención de mejora de calidad sobre la incidencia de extubaciones no planeadas en una unidad de cuidados intensivos pediátricos

Introduction. An unplanned extubation (UEX) is a frequent and preventable adverse event of mechanical ventilation. Objectives. To fnd out the causes of unplanned extubation and assess the use of a quality improvement intervention to reduce this event rate. Population. Patients with invasive mechanical ventilation for more than 12 hours over the period from May 1st 2010 and April 30th 2011 in a Pediatric Intensive Care Unit (PICU). Design. Uncontrolled, before and after study. A quality improvement intervention was used over the period between November 2010 and April 2011, which included training PICU staff, establishing standards to fx the endotracheal tube and control its fxation. Results. There were 395 patients admitted to the PICU, 262 (66%) were on mechanical ventilation for more than 12 hours. A total of 27 patients had 30 UEX events: 22 during the period between May and October 2010, and 8 during the period between November 2010 and April 2011. The most common causes of UEX were incorrect fxation of the endotracheal tube (n= 11) and the use of a procedure of care (n= 11). Patients with UEX required additional days on mechanical ventilation: 7 (3-15.5) versus 5 (2-8) days; p= 0.077 and hospitalization: 9.5 (5-19) versus 7 (4-10) days; p= 0.049. During the implementation of the quality improvement intervention, the mean incidence of UEX decreased from 2.30 (95% CI: 1.12-3.49) to 0.86 (95% CI: 0.27-1.44) per 100 days of mechanical ventilation (p= 0.037). Conclusions. The most common causes of UEX were the incorrect fxation of the endotracheal tube and the use of a procedure of care. The implementation of a quality improvement intervention reduced the incidence of UEX.

Introducción. Las extubaciones no planeadas (ENP) son eventos adversos frecuentes y prevenibles de la ventilación mecánica. Objetivos. Conocer las causas de las extubaciones no planeadas y evaluar la utilidad de la aplicación de una intervención de mejora de la calidad para disminuir ese evento. Población. Pacientes con ventilación mecánica invasiva durante más de 12 horas durante el período comprendido entre el 1 de mayo del 2010 y el 30 de abril del 2011 en una unidad de cuidados intensivos pediátricos (UCIP). Diseño. Estudio antes-después no controlado. Se aplicó una intervención de mejora de calidad en el período noviembre de 2010-abril de 2011 que incluyó capacitación del personal de la UCIP, estandarización de la fjación del tubo endotraqueal y control de la fjación. Resultados. Ingresaron en la UCIP 395 pacientes, 262 (66%) recibieron ventilación mecánica durante más de 12 horas. Presentaron 30 episodios de ENP 27 pacientes: 22 durante el período mayo a octubre de 2010, y 8 durante el período noviembre de 2010-abril de 2011. Las causas más frecuentes fueron la incorrecta fjación del tubo endotraqueal (n= 11) y la realización de un procedimiento de atención y cuidado (n= 11). Los pacientes que la presentaron requirieron más días de ventilación mecánica: 7 (3 a 15,5) contra 5 (2 a 8) días; p= 0,077 y de internación: 9,5 (5 a 19) contra 7 (4 a 10) días; p= 0,049. Durante la intervención de mejora de la calidad la incidencia media de ENP disminuyó de 2,30 (IC 95% 1,12 a 3,49) a 0,86 (IC 95% 0,27 a 1,44) por 100 días de ventilación mecánica (p= 0,037). Conclusiones. Las causas más frecuentes de ENP fueron la incorrecta fjación del tubo endotraqueal y la realización de procedimientos de atención y cuidado. La implementación de una intervención de mejora de la calidad disminuyó la incidencia de ENP.

Hypotonic versus isotonic maintenance fluids in critically ill pediatric patients: a randomized controlled trial.

INTRODUCTION: Hypotonic fluids have been associated with the development of iatrogenic hyponatremia. OBJECTIVES: To assess variations in serum sodium (sNa) following the intravenous administration of isotonic maintenance fluids (0.9% NaCl/5% dextrose) compared to hypotonic maintenance fluids (0.45% NaCl/5% dextrose). MATERIAL AND METHODS: Randomized, controlled, double-blind clinical trial. Pediatric patients with an expected length of stay in the intensive care unit of more than 24 hours were enrolled, with normal serum Na, and IV fluids >80% of total maintenance fluids. Serum Na level was measured before administering maintenance fluids and when reducing the administration to <80% of total fluids. RESULTS: The study included 63 patients who were randomly assigned to receive hypotonic (n= 32) or isotonic (n= 31) maintenance fluids. Baseline characteristics were similar in both groups. There were no differences in terms of volume of fluid administered (hypotonic group: 865 ± 853 mL; isotonic group: 778 ± 649 mL; p= 0.654) or infusion duration (hypotonic group: 24 ± 10.8 hours; isotonic group: 27.6 ± 12.8 hours; p= 0.231). A difference was found in the serum Na following the administration of maintenance fluids (hypotonic group: 137.8 ± 4.3 mmol/L; isotonic group: 140.0 ± 4.1 mmol/L, p= 0.04). None of these two maintenance fluids increased the risk of hyponatremia (Na 145 mmol/L). CONCLUSIONS: Neither hypotonic nor isotonic maintenance fluids increased the risk of developing iatrogenic hyponatremia with the 24 hour infusion.

Hypotonic versus isotonic maintenance fluids in critically ill pediatric patients: a randomized controlled trial / Hypotonic versus isotonic maintenance fluids in critically ill pediatric patients: a randomized controlled trial.

INTRODUCTION: Hypotonic fluids have been associated with the development of iatrogenic hyponatremia. OBJECTIVES: To assess variations in serum sodium (sNa) following the intravenous administration of isotonic maintenance fluids (0.9

dextrose) compared to hypotonic maintenance fluids (0.45

dextrose). MATERIAL AND METHODS: Randomized, controlled, double-blind clinical trial. Pediatric patients with an expected length of stay in the intensive care unit of more than 24 hours were enrolled, with normal serum Na, and IV fluids >80

of total maintenance fluids. Serum Na level was measured before administering maintenance fluids and when reducing the administration to <80

of total fluids. RESULTS: The study included 63 patients who were randomly assigned to receive hypotonic (n= 32) or isotonic (n= 31) maintenance fluids. Baseline characteristics were similar in both groups. There were no differences in terms of volume of fluid administered (hypotonic group: 865 ± 853 mL; isotonic group: 778 ± 649 mL; p= 0.654) or infusion duration (hypotonic group: 24 ± 10.8 hours; isotonic group: 27.6 ± 12.8 hours; p= 0.231). A difference was found in the serum Na following the administration of maintenance fluids (hypotonic group: 137.8 ± 4.3 mmol/L; isotonic group: 140.0 ± 4.1 mmol/L, p= 0.04). None of these two maintenance fluids increased the risk of hyponatremia (Na 145 mmol/L). CONCLUSIONS: Neither hypotonic nor isotonic maintenance fluids increased the risk of developing iatrogenic hyponatremia with the 24 hour infusion.

Ensayo clínico aleatorizado sobre la administración de una solución de mantenimiento intravenosa hipotónica comparada contra una isotónica en pacientes pediátricos críticos: a randomized control trial / Hypotonic versus isotonic maintenance fuids in critically ill pediatric patients

Introducción. Las soluciones hipotónicas se han vinculado a la producción de hiponatremia iatrogénica. Objetivos. Evaluar las variaciones en el sodio sérico (NaS) tras la administración de una solución de mantenimiento intravenosa isotónica (NaCl al 0,9% en dextrosa al 5%) en comparación con una solución de mantenimiento hipotónica (NaCl al 0,45% en dextrosa al 5%). Material y métodos. Ensayo clínico aleatorizado, doble ciego y controlado. Se enrolaron pacientes pediátricos con una estadía esperada en la unidad de cuidados intensivos mayor de 24 horas, NaS normal y líquidos intravenosos > 80% de los líquidos totales de mantenimiento. La concentración sérica de Na se midió antes de colocar la solución de mantenimiento y al reducir la administración de ésta a < 80% del total del aporte. Resultados. Se incorporaron 63 pacientes, que fueron asignados en forma aleatoria a recibir una solución de mantenimiento hipotónica (n= 32) o isotónica (n= 31). Las características basales fueron similares en ambos grupos. No hubo diferencias con respecto a la cantidad de solución administrada (grupo hipotónico 865 ± 853 ml; grupo isotónico 778 ± 649 ml, p= 0,654) o el tiempo de infusión (grupo hipotónico: 24 ± 10,8 horas; grupo isotónico: 27,6 ± 12,8 horas, p= 0,231). Se encontró una diferencia en el NaS luego de la administración de las soluciones de mantenimiento (grupo hipotónico: 137,8 ± 4,3 mmol/L; grupo isotónico: 140,0 ± 4,1 mmol/L, p= 0,04). Ninguna de las dos soluciones de mantenimiento aumentó el riesgo de hiponatremia (Na 145 mmol/L). Conclusiones. Ambas soluciones de mantenimiento, en 24 horas de infusión, no aumentaron el riesgo de producir hiponatremia iatrogénica.(AU)

Introduction. Hypotonic fluids have been associated with the development of iatrogenic hyponatremia. Objectives. To assess variations in serum sodium (sNa) following the intravenous administration of isotonic maintenance fuids (0.9% NaCl/5% dextrose) compared to hypotonic maintenance fuids (0.45% NaCl/5% dextrose). Material and Methods. Randomized, controlled, double-blind clinical trial. Pediatric patients with an expected length of stay in the intensive care unit of more than 24 hours were enrolled, with normal serum Na, and IV fuids >80% of total maintenance fuids. Serum Na level was measured before administering maintenance fuids and when reducing the administration to <80% of total fuids. Results. The study included 63 patients who were randomly assigned to receive hypotonic (n= 32) or isotonic (n= 31) maintenance fuids. Baseline characteristics were similar in both groups. There were no differences in terms of volume of fuid administered (hypotonic group: 865 ± 853 mL; isotonic group: 778 ± 649 mL; p= 0.654) or infusion duration (hypotonic group: 24 ± 10.8 hours; isotonic group: 27.6 ± 12.8 hours; p= 0.231). A difference was found in the serum Na following the administration of maintenance fuids (hypotonic group: 137.8 ± 4.3 mmol/L; isotonic group: 140.0 ± 4.1 mmol/L, p= 0.04). None of these two maintenance fuids increased the risk of hyponatremia (Na 145 mmol/L). Conclusions. Neither hypotonic nor isotonic maintenance fluids increased the risk of developing iatrogenic hyponatremia with the 24 hour infusion.(AU)

Ensayo clínico aleatorizado sobre la administración de una solución de mantenimiento intravenosa hipotónica comparada contra una isotónica en pacientes pediátricos críticos: a randomized control trial / Hypotonic versus isotonic maintenance fuids in critically ill pediatric patients

Introducción. Las soluciones hipotónicas se han vinculado a la producción de hiponatremia iatrogénica. Objetivos. Evaluar las variaciones en el sodio sérico (NaS) tras la administración de una solución de mantenimiento intravenosa isotónica (NaCl al 0,9% en dextrosa al 5%) en comparación con una solución de mantenimiento hipotónica (NaCl al 0,45% en dextrosa al 5%). Material y métodos. Ensayo clínico aleatorizado, doble ciego y controlado. Se enrolaron pacientes pediátricos con una estadía esperada en la unidad de cuidados intensivos mayor de 24 horas, NaS normal y líquidos intravenosos > 80% de los líquidos totales de mantenimiento. La concentración sérica de Na se midió antes de colocar la solución de mantenimiento y al reducir la administración de ésta a < 80% del total del aporte. Resultados. Se incorporaron 63 pacientes, que fueron asignados en forma aleatoria a recibir una solución de mantenimiento hipotónica (n= 32) o isotónica (n= 31). Las características basales fueron similares en ambos grupos. No hubo diferencias con respecto a la cantidad de solución administrada (grupo hipotónico 865 ± 853 ml; grupo isotónico 778 ± 649 ml, p= 0,654) o el tiempo de infusión (grupo hipotónico: 24 ± 10,8 horas; grupo isotónico: 27,6 ± 12,8 horas, p= 0,231). Se encontró una diferencia en el NaS luego de la administración de las soluciones de mantenimiento (grupo hipotónico: 137,8 ± 4,3 mmol/L; grupo isotónico: 140,0 ± 4,1 mmol/L, p= 0,04). Ninguna de las dos soluciones de mantenimiento aumentó el riesgo de hiponatremia (Na 145 mmol/L). Conclusiones. Ambas soluciones de mantenimiento, en 24 horas de infusión, no aumentaron el riesgo de producir hiponatremia iatrogénica.

Introduction. Hypotonic fluids have been associated with the development of iatrogenic hyponatremia. Objectives. To assess variations in serum sodium (sNa) following the intravenous administration of isotonic maintenance fuids (0.9% NaCl/5% dextrose) compared to hypotonic maintenance fuids (0.45% NaCl/5% dextrose). Material and Methods. Randomized, controlled, double-blind clinical trial. Pediatric patients with an expected length of stay in the intensive care unit of more than 24 hours were enrolled, with normal serum Na, and IV fuids >80% of total maintenance fuids. Serum Na level was measured before administering maintenance fuids and when reducing the administration to <80% of total fuids. Results. The study included 63 patients who were randomly assigned to receive hypotonic (n= 32) or isotonic (n= 31) maintenance fuids. Baseline characteristics were similar in both groups. There were no differences in terms of volume of fuid administered (hypotonic group: 865 ± 853 mL; isotonic group: 778 ± 649 mL; p= 0.654) or infusion duration (hypotonic group: 24 ± 10.8 hours; isotonic group: 27.6 ± 12.8 hours; p= 0.231). A difference was found in the serum Na following the administration of maintenance fuids (hypotonic group: 137.8 ± 4.3 mmol/L; isotonic group: 140.0 ± 4.1 mmol/L, p= 0.04). None of these two maintenance fuids increased the risk of hyponatremia (Na 145 mmol/L). Conclusions. Neither hypotonic nor isotonic maintenance fluids increased the risk of developing iatrogenic hyponatremia with the 24 hour infusion.

Hypotonic versus isotonic maintenance fluids in critically ill pediatric patients: a randomized controlled trial. / Hypotonic versus isotonic maintenance fluids in critically ill pediatric patients: a randomized controlled trial.

INTRODUCTION: Hypotonic fluids have been associated with the development of iatrogenic hyponatremia. OBJECTIVES: To assess variations in serum sodium (sNa) following the intravenous administration of isotonic maintenance fluids (0.9

NaCl/5

dextrose) compared to hypotonic maintenance fluids (0.45

NaCl/5

dextrose). MATERIAL AND METHODS: Randomized, controlled, double-blind clinical trial. Pediatric patients with an expected length of stay in the intensive care unit of more than 24 hours were enrolled, with normal serum Na, and IV fluids >80

of total maintenance fluids. Serum Na level was measured before administering maintenance fluids and when reducing the administration to <80

of total fluids. RESULTS: The study included 63 patients who were randomly assigned to receive hypotonic (n= 32) or isotonic (n= 31) maintenance fluids. Baseline characteristics were similar in both groups. There were no differences in terms of volume of fluid administered (hypotonic group: 865 ± 853 mL; isotonic group: 778 ± 649 mL; p= 0.654) or infusion duration (hypotonic group: 24 ± 10.8 hours; isotonic group: 27.6 ± 12.8 hours; p= 0.231). A difference was found in the serum Na following the administration of maintenance fluids (hypotonic group: 137.8 ± 4.3 mmol/L; isotonic group: 140.0 ± 4.1 mmol/L, p= 0.04). None of these two maintenance fluids increased the risk of hyponatremia (Na 145 mmol/L). CONCLUSIONS: Neither hypotonic nor isotonic maintenance fluids increased the risk of developing iatrogenic hyponatremia with the 24 hour infusion.

Impact of a quality improvement intervention on the incidence of unplanned extubations in a Pediatric Intensive Care Unit. / Impact of a quality improvement intervention on the incidence of unplanned extubations in a Pediatric Intensive Care Unit.

INTRODUCTION: An unplanned extubation (UEX) is a frequent and preventable adverse event of mechanical ventilation. OBJECTIVES: To fnd out the causes of unplanned extubation and assess the use of a quality improvement intervention to reduce this event rate. POPULATION: Patients with invasive mechanical ventilation for more than 12 hours over the period from May 1st 2010 and April 30th 2011 in a Pediatric Intensive Care Unit (PICU). DESIGN: Uncontrolled, before and after study. A quality improvement intervention was used over the period between November 2010 and April 2011, which included training PICU staff, establishing standards to fx the endotracheal tube and control its fxation. RESULTS: There were 395 patients admitted to the PICU, 262 (66

) were on mechanical ventilation for more than 12 hours. A total of 27 patients had 30 UEX events: 22 during the period between May and October 2010, and 8 during the period between November 2010 and April 2011. The most common causes of UEX were incorrect fxation of the endotracheal tube (n= 11) and the use of a procedure of care (n= 11). Patients with UEX required additional days on mechanical ventilation: 7 (3-15.5) versus 5 (2-8) days; p= 0.077 and hospitalization: 9.5 (5-19) versus 7 (4-10) days; p= 0.049. During the implementation of the quality improvement intervention, the mean incidence of UEX decreased from 2.30 (95

CI: 1.12-3.49) to 0.86 (95

CI: 0.27-1.44) per 100 days of mechanical ventilation (p= 0.037). CONCLUSIONS: The most common causes of UEX were the incorrect fxation of the endotracheal tube and the use of a procedure of care. The implementation of a quality improvement intervention reduced the incidence of UEX.