Latin American Consensus on the Management of Sepsis in Children: Sociedad Latinoamericana de Cuidados Intensivos Pediátricos [Latin American Pediatric Intensive Care Society] (SLACIP) Task Force: Executive Summary.

Objective: The aim of this study was to develop evidence-based recommendations for the diagnosis and treatment of sepsis in children in low- and middle-income countries (LMICs), more specifically in Latin America. Design: A panel was formed consisting of 27 experts with experience in the treatment of pediatric sepsis and two methodologists working in Latin American countries. The experts were organized into 10 nominal groups, each coordinated by a member. Methods: A formal consensus was formed based on the modified Delphi method, combining the opinions of nominal groups of experts with the interpretation of available scientific evidence, in a systematic process of consolidating a body of recommendations. The systematic search was performed by a specialized librarian and included specific algorithms for the Cochrane Specialized Register, PubMed, Lilacs, and Scopus, as well as for OpenGrey databases for grey literature. The GRADEpro GDT guide was used to classify each of the selected articles. Special emphasis was placed on search engines that included original research conducted in LMICs. Studies in English, Spanish, and Portuguese were covered. Through virtual meetings held between February 2020 and February 2021, the entire group of experts reviewed the recommendations and suggestions. Result: At the end of the 12 months of work, the consensus provided 62 recommendations for the diagnosis and treatment of pediatric sepsis in LMICs. Overall, 60 were strong recommendations, although 56 of these had a low level of evidence. Conclusions: These are the first consensus recommendations for the diagnosis and management of pediatric sepsis focused on LMICs, more specifically in Latin American countries. The consensus shows that, in these regions, where the burden of pediatric sepsis is greater than in high-income countries, there is little high-level evidence. Despite the limitations, this consensus is an important step forward for the diagnosis and treatment of pediatric sepsis in Latin America.

Consensus of the Respiratory Committee of the Latin American Society for Pediatric Intensive Care: Management of pediatric SARS-CoV-2. (SLACIP): COVID-19 Pediatric / Consenso del Comité Respiratorio Sociedad Latinoamericana Terapia Intensiva Pediátrica: Manejo SARS-CoV-2 pediátrico. (SLACIP): COVID-19 Pediátrico

Introduction The COVID-19 pandemic generated many controversies in the management of critically ill pediatric patients. The main ones were about ventilatory support, phenotypic differences between adults and children, and acute and subacute clinical forms. For this reason, the Respiratory Committee (RC) of the Latin American Society of Pediatric Intensive Care (SLACIP) generated a document to summarize the recommendations with the best evidence. The objective of these recommendations is to provide an update on issues related to pediatric COVID-19. Methods and Materials The Respiratory Committee created a group composed of 19 pediatric kinesiologists/physiotherapists and intensivists from 8 Latin American countries and defined on 3/27/20 the 15 most relevant topics, assigning 3 referents and 2 reviewers for each. The manuscripts went through 4 stages until their final version. The complete document was freely distributed on 22/05/20 and updated twice (07/08/20 and 02/09/21). For the current version there were 3 special collaborators. Result The material consists of a complete 94-page document and an executive summary. The topics included are case definition, epidemiology, clinical classification, subacute inflammatory syndrome, personal protective equipment, aerosolization situations (intubation, extubation, suctioning, sampling, filter replacement, cardiopulmonary resuscitation, early mobilization), high flow cannula support, invasive, non-invasive and high frequency mechanical ventilation, pharmacological treatment, laboratory and imaging. Conclusion The purpose of this document is to serve as a guide for nurses, kinesiologists/physiotherapists and physicians in the management of critically ill pediatric patients with COVID-19.

Introducción La pandemia por COVID-19 generó muchas controversias en el manejo de los pacientes pediátricos críticos. Las principales fueron sobre el soporte ventilatorio, las diferencias fenotípicas entre adultos y niños y las formas clínicas aguda y subaguda.Por esa razón el Comité Respiratorio (CR) de la Sociedad Latinoamericana de Cuidados Intensivos Pediátricos (SLACIP) generó un documento para resumir las recomendaciones con mayor evidencia. El objetivo de estas recomendaciones es brindar una actualización de temas relacionados a COVID-19 pediátrico.Métodos y Materiales El Comité Respiratorio creó un grupo compuesto por 19 kinesiólogos/fisioterapeutas y médicos intensivistas pediátricos de 8 países de Latinoamérica y definió el 27/03/20 los 15 temas más relevantes, asignando 3 referentes y 2 revisores por cada uno. Los manuscritos pasaron por 4 etapas hasta su versión final. El documento completo se distribuyó libremente el 22/05/20, actualizándose en dos oportunidades (07/08/20 y el 02/09/21). Para la versión actual se contó con 3 colaboradores especiales.Resultado El material se compone de un documento completo de 94 páginas y un resumen ejecutivo. Los temas incluidos son definición de caso, epidemiología, clasificación clínica, síndrome inflamatorio subagudo, equipos de protección personal, situaciones de aerosolización (intubación, extubación, aspiración, toma de muestras, recambio de filtros, reanimación cardiopulmonar, movilización temprana), soporte con cánula de alto flujo, ventilación mecánica invasiva, no invasiva y de alta frecuencia, tratamiento farmacológico, laboratorio e imágenes.Conclusión La elaboración de este documento ha tenido como fin servir de guía para enfermeros, kinesiólogos/fisioterapeutas y médicos en el manejo de pacientes pediátricos en estado crítico por COVID-19.

Effectiveness of Two Targeted Temperature Management Methods After Pediatric Postcardiac Arrest: A Multicenter International Study.

OBJECTIVES: It is currently recommended that after return of spontaneous circulation following cardiac arrest, fever should be prevented using TTM through a servo-controlled system. This technology is not yet available in many global settings, where manual physical measures without servo-control is the only option. Our aim was to compare feasibility, safety and quality assurance of servo-controlled system versus no servo-controlled system cooling, TTM protocols for cooling, maintenance and rewarming following return of spontaneous circulation after cardiac arrest in children. DESIGN: Prospective, multicenter, nonrandomized, study. SETTING: PICUs of 20 hospitals in South America, Spain, and Italy, 2012-2014. PATIENTS: Under 18 years old with a cardiac arrest longer than 2 minutes, in coma and surviving to PICU admission requiring mechanical ventilation were included. METHODS: TTM to 32-34°C was performed by prospectively designed protocol across 20 centers, with either servo-controlled system or no servo-controlled system methods, depending on servo-controlled system availability. We analyzed clinical data, cardiac arrest, temperature, mechanical ventilation duration, length of hospitalization, complications, survival, and neurologic outcomes at 6 months. PRIMARY OUTCOME: feasibility, safety and quality assurance of the cooling technique and secondary outcome: survival and Pediatric Cerebral Performance Category at 6 months. MEASUREMENTS AND MAIN RESULTS: Seventy patients were recruited, 51 of 70 TTM (72.8%) with servo-controlled system. TTM induction, maintenance, and rewarming were feasible in both groups. Servo-controlled system was more effective than no servo-controlled system in maintaining TTM (69 vs 60%; p = 0.004). Servo-controlled system had fewer temperatures above 38.1°C during the 5 days of TTM (0.1% vs 2.9%; p < 0.001). No differences in mortality, complications, length of mechanical ventilation and of stay, or neurologic sequelae were found between the two groups. CONCLUSIONS: TTM protocol (for cooling, maintenance and rewarming) following return of spontaneous circulation after cardiac arrest in children was feasible and safe with both servo-controlled system and no servo-controlled system techniques. Achieving, maintaining, and rewarming within protocol targets were more effective with servo-controlled system versus no servo-controlled system techniques.

A prospective, randomized, controlled trial of noninvasive ventilation in pediatric acute respiratory failure.

OUTCOMES: To compare the benefits of noninvasive ventilation (NIV) plus standard therapy vs. standard therapy alone in children with acute respiratory failure; assess method effectiveness in improving gas exchange and vital signs; and assess method safety. DESIGN: Prospective, randomized, controlled study. SITE: Two pediatric intensive care units in Santiago, Chile, at Clínica Santa María and Clínica Dávila, respectively. PATIENTS AND METHODS: Fifty patients with acute respiratory failure admitted to pediatric intensive care units were recruited; 25 patients were randomly allocated to noninvasive inspiratory positive airway pressure and expiratory positive airway pressure plus standard therapy (study group); the remaining 25 were given standard therapy (control group). Both groups were comparable in demographic terms. INTERVENTIONS AND MEASUREMENTS: The study group received NIV under inspiratory positive airway pressure ranging between 12 cm and 18 cm H2O and expiratory positive airway pressure between 6 cm and 12 cm H2O. Vital signs (cardiac and respiratory frequency), Po2, Pco2, pH, and Po2/Fio2 were recorded at the start and 1, 6, 12, 24, and 48 hrs into the study. RESULTS: Heart rate and respiratory rate improved significantly with NIV. Heart rate and respiratory rate were significantly lower after 1 hr of treatment compared with admission (p = 0.0009 and p = 0.004, respectively). The trend continued over time, heart rate being significantly lower than control after the first hour and heart rate after 6 hrs. With NIV, Po2/Fio2 improved significantly from the first hour. The endotracheal intubation was significantly lower (28%) in the NIV group than in the control group (60%; p = 0.045). CONCLUSIONS: NIV improves hypoxemia and the signs and symptoms of acute respiratory failure. NIV seems to afford these patients protection from endotracheal intubation.

First Pediatric Intensive Care Congress in Chile.

OBJECTIVE: To summarize the First Chilean Congress on Pediatric Critical Care Medicine. DATA SOURCE/EXTRACTION: Program schedule, presentations, abstracts. STUDY SELECTION: Descriptive summary of the congress. CONCLUSIONS: The Chilean Society of Pediatric Critical Care organized the First Pediatric Intensive Care Congress in Chile, having a registration of 217 delegates. All the pediatric intensive care units of the country had a representative in the Congress either as a delegate or a faculty member, which provided an excellent opportunity for interactions between them. The international faculty addressed state-of-the-art issues, with a charge of highlighting basic science relevant to clinical practice, which motivated long interactive question-and-answer sessions with the audience. Strong evidence was presented by Chilean faculty debaters who discussed controversial topics, making these sessions very attractive. An entire day was scheduled with a simultaneous nursing session. More than 80 intensive care nurses benefited from a very interactive day with five symposia and short oral presentations. A randomized multi-institutional research protocol studying reintubation rate using three methods for weaning from mechanical ventilation was discussed during the meeting. Thirteen units committed to participate. Twenty-three posters were displayed in the congress. Posters describing the activity of pediatric intensive care units were also presented. The mean for intensive care unit beds was 6.8 and for intermediate care beds was 7.1. Annual admissions showed a mean of 640 patients, and mortality rate ranged from 4.1% to 12%, with a mean of 6.7%

Potencia máxima de los músculos inspiratorios / Maximal power of the inspiratory muscles

Con el propósito de investigar la relación fuerza-velocidad de contracción de los músculos inspiratorios en individuos normales, estudiamos 22 sujetos (13 hombres y 9 mujeres, de 20 a 48 años de edad) durante esfuerzos máximos con cargas inspiratorias crecientes que se lograron agregando pesos a una válvula inspiratoria. Con cada carga se calculó la potencia multiplicando la presión en la boca por el flujo inspiratorio. En cada individuo se observó una disminución gradual del flujo inspiratorio al aumentar las cargas inspiratorias. Al aumentar la carga en todos los sujetos se observó un incremento progresivo de la potencia, que luego disminuyó una vez alcanzado su valor máximo. La máxima potencia se alcanzó con presiones de 66,3 + 13,7% (DE) de la Plmax y fue de 511 ñ 196 cm H2O x L x s -1 en los hombres y de 251 ñ 77 cm H2O x L x s -1 en las mujeres (p < 0,01). En 8 de los individuos la prueba se repitió entre una y tres semanas después, y se observó una buena reproducibilidad (r = 0,98). Los resultados confirman que la máxima potencia muscular inspiratoria se puede medir fácilmente y que ella se alcanza con valores submáximos de presión y flujo. En consecuencia, este índice debería ser poco dependiente de la colaboración del sujeto, por lo que podría ser útil en la evaluación clínica de la función muscular inspiratoria

Resistencia a la fatiga de los músculos inspiratorios: comparación de dos métodos de medición / Inspiratory muscle endurance: comparison of 2 methods for measuring

Con el propósito de establecer si la medición de la presión inspiratoria máxima sostenible (PIMS) es un método útil para evaluar la tolerancia a la fatiga de los músculos inspiratorios, en 8 sujetos normales comparamos este método con la ventilación máxima sostenible (VMS), que es ampliamente utilizada para evaluar este aspecto de la función muscular inspiratoria. La VMS alcanzó un promedio de 88.4 ñ 28 L min -1 correspondiente a un 61 ñ 11,4% (DS) de la ventilación máxima voluntaria teórica; la PIMS fue de 94 ñ 33 cm H2O lo que correspondió a un 73 ñ 12,7% de la presión inspiratoria máxima. La carga máxima sostenible fue de 387 ñ 149 g. Se observó una correlación significativa entre PIMS y VMS (r = 0.71 p < 0.05) y entre PIMS y carga máxima sostenible (r = 0.92 p < 0.001). La relación entre esta última y la VMS no alcanzó significación estadística (r = 0.62). La duración de la medición de VMS fluctuó entre 40 y 60 minutos y la medición de la PIMS entre 15 y 20 minutos. La correlación significativa entre las dos pruebas sugiere que PIMS es un método útil para medir la resistencia a la fatiga con la ventaja de su mayor simplicidad y corta duración