Impact of SARS-CoV-2 Infection on the Association Between Laboratory Tests and Severe Outcomes Among Hospitalized Children.

Background: To assist clinicians with identifying children at risk of severe outcomes, we assessed the association between laboratory findings and severe outcomes among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children and determined if SARS-CoV-2 test result status modified the associations. Methods: We conducted a cross-sectional analysis of participants tested for SARS-CoV-2 infection in 41 pediatric emergency departments in 10 countries. Participants were hospitalized, had laboratory testing performed, and completed 14-day follow-up. The primary objective was to assess the associations between laboratory findings and severe outcomes. The secondary objective was to determine if the SARS-CoV-2 test result modified the associations. Results: We included 1817 participants; 522 (28.7%) SARS-CoV-2 test-positive and 1295 (71.3%) test-negative. Seventy-five (14.4%) test-positive and 174 (13.4%) test-negative children experienced severe outcomes. In regression analysis, we found that among SARS-CoV-2-positive children, procalcitonin ≥0.5 ng/mL (adjusted odds ratio [aOR], 9.14; 95% CI, 2.90-28.80), ferritin >500 ng/mL (aOR, 7.95; 95% CI, 1.89-33.44), D-dimer ≥1500 ng/mL (aOR, 4.57; 95% CI, 1.12-18.68), serum glucose ≥120 mg/dL (aOR, 2.01; 95% CI, 1.06-3.81), lymphocyte count <1.0 × 109/L (aOR, 3.21; 95% CI, 1.34-7.69), and platelet count <150 × 109/L (aOR, 2.82; 95% CI, 1.31-6.07) were associated with severe outcomes. Evaluation of the interaction term revealed that a positive SARS-CoV-2 result increased the associations with severe outcomes for elevated procalcitonin, C-reactive protein (CRP), D-dimer, and for reduced lymphocyte and platelet counts. Conclusions: Specific laboratory parameters are associated with severe outcomes in SARS-CoV-2-infected children, and elevated serum procalcitonin, CRP, and D-dimer and low absolute lymphocyte and platelet counts were more strongly associated with severe outcomes in children testing positive compared with those testing negative.

Post-COVID-19 Conditions Among Children 90 Days After SARS-CoV-2 Infection.

Importance: Little is known about the risk factors for, and the risk of, developing post-COVID-19 conditions (PCCs) among children. Objectives: To estimate the proportion of SARS-CoV-2-positive children with PCCs 90 days after a positive test result, to compare this proportion with SARS-CoV-2-negative children, and to assess factors associated with PCCs. Design, Setting, and Participants: This prospective cohort study, conducted in 36 emergency departments (EDs) in 8 countries between March 7, 2020, and January 20, 2021, included 1884 SARS-CoV-2-positive children who completed 90-day follow-up; 1686 of these children were frequency matched by hospitalization status, country, and recruitment date with 1701 SARS-CoV-2-negative controls. Exposure: SARS-CoV-2 detected via nucleic acid testing. Main Outcomes and Measures: Post-COVID-19 conditions, defined as any persistent, new, or recurrent health problems reported in the 90-day follow-up survey. Results: Of 8642 enrolled children, 2368 (27.4%) were SARS-CoV-2 positive, among whom 2365 (99.9%) had index ED visit disposition data available; among the 1884 children (79.7%) who completed follow-up, the median age was 3 years (IQR, 0-10 years) and 994 (52.8%) were boys. A total of 110 SARS-CoV-2-positive children (5.8%; 95% CI, 4.8%-7.0%) reported PCCs, including 44 of 447 children (9.8%; 95% CI, 7.4%-13.0%) hospitalized during the acute illness and 66 of 1437 children (4.6%; 95% CI, 3.6%-5.8%) not hospitalized during the acute illness (difference, 5.3%; 95% CI, 2.5%-8.5%). Among SARS-CoV-2-positive children, the most common symptom was fatigue or weakness (21 [1.1%]). Characteristics associated with reporting at least 1 PCC at 90 days included being hospitalized 48 hours or more compared with no hospitalization (adjusted odds ratio [aOR], 2.67 [95% CI, 1.63-4.38]); having 4 or more symptoms reported at the index ED visit compared with 1 to 3 symptoms (4-6 symptoms: aOR, 2.35 [95% CI, 1.28-4.31]; ≥7 symptoms: aOR, 4.59 [95% CI, 2.50-8.44]); and being 14 years of age or older compared with younger than 1 year (aOR, 2.67 [95% CI, 1.43-4.99]). SARS-CoV-2-positive children were more likely to report PCCs at 90 days compared with those who tested negative, both among those who were not hospitalized (55 of 1295 [4.2%; 95% CI, 3.2%-5.5%] vs 35 of 1321 [2.7%; 95% CI, 1.9%-3.7%]; difference, 1.6% [95% CI, 0.2%-3.0%]) and those who were hospitalized (40 of 391 [10.2%; 95% CI, 7.4%-13.7%] vs 19 of 380 [5.0%; 95% CI, 3.0%-7.7%]; difference, 5.2% [95% CI, 1.5%-9.1%]). In addition, SARS-CoV-2 positivity was associated with reporting PCCs 90 days after the index ED visit (aOR, 1.63 [95% CI, 1.14-2.35]), specifically systemic health problems (eg, fatigue, weakness, fever; aOR, 2.44 [95% CI, 1.19-5.00]). Conclusions and Relevance: In this cohort study, SARS-CoV-2 infection was associated with reporting PCCs at 90 days in children. Guidance and follow-up are particularly necessary for hospitalized children who have numerous acute symptoms and are older.

Outcomes of SARS-CoV-2-Positive Youths Tested in Emergency Departments: The Global PERN-COVID-19 Study.

Importance: Severe outcomes among youths with SARS-CoV-2 infections are poorly characterized. Objective: To estimate the proportion of children with severe outcomes within 14 days of testing positive for SARS-CoV-2 in an emergency department (ED). Design, Setting, and Participants: This prospective cohort study with 14-day follow-up enrolled participants between March 2020 and June 2021. Participants were youths aged younger than 18 years who were tested for SARS-CoV-2 infection at one of 41 EDs across 10 countries including Argentina, Australia, Canada, Costa Rica, Italy, New Zealand, Paraguay, Singapore, Spain, and the United States. Statistical analysis was performed from September to October 2021. Exposures: Acute SARS-CoV-2 infection was determined by nucleic acid (eg, polymerase chain reaction) testing. Main Outcomes and Measures: Severe outcomes, a composite measure defined as intensive interventions during hospitalization (eg, inotropic support, positive pressure ventilation), diagnoses indicating severe organ impairment, or death. Results: Among 3222 enrolled youths who tested positive for SARS-CoV-2 infection, 3221 (>99.9%) had index visit outcome data available, 2007 (62.3%) were from the United States, 1694 (52.6%) were male, and 484 (15.0%) had a self-reported chronic illness; the median (IQR) age was 3 (0-10) years. After 14 days of follow-up, 735 children (22.8% [95% CI, 21.4%-24.3%]) were hospitalized, 107 (3.3% [95% CI, 2.7%-4.0%]) had severe outcomes, and 4 children (0.12% [95% CI, 0.03%-0.32%]) died. Characteristics associated with severe outcomes included being aged 5 to 18 years (age 5 to <10 years vs <1 year: odds ratio [OR], 1.60 [95% CI, 1.09-2.34]; age 10 to <18 years vs <1 year: OR, 2.39 [95% CI 1.38-4.14]), having a self-reported chronic illness (OR, 2.34 [95% CI, 1.59-3.44]), prior episode of pneumonia (OR, 3.15 [95% CI, 1.83-5.42]), symptoms starting 4 to 7 days prior to seeking ED care (vs starting 0-3 days before seeking care: OR, 2.22 [95% CI, 1.29-3.82]), and country (eg, Canada vs US: OR, 0.11 [95% CI, 0.05-0.23]; Costa Rica vs US: OR, 1.76 [95% CI, 1.05-2.96]; Spain vs US: OR, 0.51 [95% CI, 0.27-0.98]). Among a subgroup of 2510 participants discharged home from the ED after initial testing and who had complete follow-up, 50 (2.0%; 95% CI, 1.5%-2.6%) were eventually hospitalized and 12 (0.5%; 95% CI, 0.3%-0.8%) had severe outcomes. Compared with hospitalized SARS-CoV-2-negative youths, the risk of severe outcomes was higher among hospitalized SARS-CoV-2-positive youths (risk difference, 3.9%; 95% CI, 1.1%-6.9%). Conclusions and Relevance: In this study, approximately 3% of SARS-CoV-2-positive youths tested in EDs experienced severe outcomes within 2 weeks of their ED visit. Among children discharged home from the ED, the risk was much lower. Risk factors such as age, underlying chronic illness, and symptom duration may be useful to consider when making clinical care decisions.

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.

Características clínicas de los pacientes pediátricos con COVID-19 en un departamento de emergencia

RESUMEN Introducción: El patrón epidemiológico y clínico reportado de la infección por SARS-CoV2, sigue siendo poco específico en los niños. Objetivo: Describir aspectos epidemiológicos y clínicos de los casos de COVID-19 atendidos en un Departamento de Emergencia Pediátrico entre marzo y septiembre de 2020. Materiales y Métodos: Estudio observacional, descriptivo retrospectivo de serie de casos consecutivos. Se incluyeron pacientes de 0- 18 años en un muestreo no probabilístico. Las variables analizadas fueron los datos demográficos, triangulo de evaluación pediátrica, situación de contacto, síntomas, cuadro clínico, hospitalización, estado nutricional, analítica de laboratorio e imágenes. Los datos fueron analizados en SPSS V21 utilizando estadísticas descriptivas. Resultados: Ingresaron 56 pacientes, el 37,5% menores de 2 años, 32% con comorbilidad y 52 % con un contacto cercano. Se hospitalizó el 51,8%. La mediana de tiempo de hospitalización fue 48 (P25 6- P75 90) horas. El cuadro clínico predominante fue la infección de vías aérea superiores. El 9% presentó un cuadro severo o crítico, y el 5,4% ingresó a terapia intensiva. Hubo 1 fallecido con grave comorbilidad. La PCR se realizó con una mediana de 4 días (min. 0 máx. 10) de inicio de síntomas. Conclusión: Más de un tercio de los pacientes con Covid - 19 fue menor de 2 años y una igual proporción presentó comorbilidad. Los signos y síntomas clínicos fueron principalmente inespecíficos y los complejos sindromáticos variados. La mayoría presentó un cuadro leve, aunque siete niños tuvieron una afección severa. La forma clínica más frecuente fue la afectación de vías aéreas superiores seguido de neumonía y cuadros diarreicos. Un paciente con comorbilidad severa falleció.

ABSTRACT Introduction: The epidemiological and clinical patterns of COVID-19 infection remain unclear, especially among children. Objective: To describe epidemiological and clinical aspects of COVID-19 cases treated in a Pediatric Emergency Department between March and September 2020. Materials and Methods: This was an observational, descriptive and retrospective study of a series of consecutive cases. Patients aged 0-18 years were included in a non-probability sampling. The variables analyzed were: demographic data, pediatric evaluation triangle, contact situation, symptoms, clinical picture, hospitalization, nutritional status, laboratory analysis and images. Data were analyzed in SPSS V21 using descriptive statistics Results: 56 patients were admitted. 37.5% were under 2 years old and 32% had comorbid conditions. 51.8% were hospitalized. The median time of hospitalization was 48 (P25 6- P75 90) hours. The predominant clinical picture was lower airway infection. 9% presented severe or critical symptoms, and 5.4% were admitted to intensive care. There was 1 deceased patient, who had severe comorbidities. The PCR was performed with a median of 4 days (min. 0 max. 10) of symptom onset Conclusion: More than a third of the patients with Covid -19 were under 2 years of age and 32% had a comorbidity. The clinical picture was mild in 70% of the cases, although more than half were hospitalized and 5.4% were admitted to intensive care. The most frequent clinical presentation was upper airway involvement followed by pneumonia. One patient with severe comorbidities died.

Efectividad de la furosemida nebulizada en el tratamiento dela crisis asmática severa en niños / Effectiveness of nebulized furosemide in the treatment of severe asthma attack in children

Introducción: La hiperosmolaridad de las secreciones por las altas concentraciones de iones seha correlacionado con la hiperreactividad bronquial, esto llevó a considerar el uso de la furosemida inhalada como tratamiento adicional enel asma bronquial. Objetivo:Evaluar si la administración de la furosemida nebulizada asociadoal tratamiento convencional del asma severo en pacientes mayores de 5 años disminuye el tiempo de crisis y la permanencia en el Departamento de Emergencia (DE). Metodología:Estudio randomizado controlado de pacientes con exacerbación asmática severa en un DE. Se excluyeronpacientes con comorbilidad. Los sujetos fueron aleatorizados recibiendo en la nebulización, el grupo experimental:furosemida, salbutamol e ipratropio yel grupo control: salbutamol e ipratropio. Y el resto del tratamiento farmacológico fue igual en ambosgrupos. El primer punto de corte fue el descenso del score en más de 2 puntos a las 2 h del tratamiento; los puntos secundarios fueron descenso del score a las 6 h, tiempo de permanencia en el departamento de emergencia e ingreso a UCIP. Resultados: Los grupos experimental (n: 46) y control (n: 36) presentaron características basales similares. La proporción de sujetos con disminución de más de dos puntosen el score a las 2 h de tratamiento y fue de 76% en el experimentalversus el control que fue de 82 % (p = 0,323). La estadía media fue 19,2±10,35 h en el experimental versus 19,7±14,5 h en el control (p = 0,670). Nose encontraron diferencias significativas en el score y puntaje del esfuerzo respiratorio en las mediciones cada 2 horas.Conclusión:La furosemida nebulizada no mejoróde manera significativa los parámetros clínicos ni la estancia en el DEP.

The hyperosmolarity of the secretions due to high ion concentrations has been correlated with bronchial hyperresponsiveness.This led to the consideration of the first uses of inhaled furosemide as an additional treatment for bronchial asthma. Objective: To assess whether the administration of nebulized furosemide as an adjunct medicine associated with conventional treatment ofsevere asthma in patients older than 5 years weighing ≥20 kg decreases the time of crisis and the stay in the Emergency Department (ED). Methodology:Randomized controlled study of patients with severe asthma exacerbation in a PED. Patients with comorbidity were excluded. The subjects were randomized into: Group 1 (Experimental) (n = 46): Furosemide associated with salbutamol and nebulized ipatropium and Group 2 (Control) (n = 36): Nebulization with Salbutamol and Ipratropium. Both groupsreceived the usual pharmacological treatment. The first cut-off point was a decrease in the score by more than 2 points at 2 hafter treatment; secondary points were decrease in score at 6 h, time spent in the emergency department and admission to the PICU. Results:The baselinecharacteristics were similar in both groups. The proportion of subjects with a decrease of more than two points in the score at 2 h of treatment in Group 1 was 76% compared to Group 2, which was 82% (p = 0.323). The mean stay was 19.2 ± 10.35 h inGroup 1vs 19.7 ± 14.5 h in Group (p = 0.670). No significant differences were found in the score and score ofrespiratory effort in measurements every 2 hours. Conclusion:Nebulized furosemide as an adjunct drug in the treatment of severeasthma did not significantly improve the clinical parameters or the stay in the PED.

Fiebre, Tos y Resfrío ¿Qué más tiene? Impacto de la Pandemia por Sars-Cov-2 en la consulta por enfermedades respiratorias en la emergencia pediátrica / Fever, Cough And Cold What Else Do You Have? Impact Of The Sars-Cov-2 Pandemic In The Consultation For Respiratory Diseases In The Pediatric Emergency

Cuando llega el otoño, los profesionales en los servicios de emergencias pediátricas(SEP) se enteran antes que los árboles decidan cambiar las hojas. El aumento en el número de pacientes es tan importante como la repetición de los motivos de consulta y de las explicaciones sobre la futilidad de los ¨tratamientos para los virus¨. Además de los resfríos con y sin fiebre que llevan al SEP al colapso, están los cuadros severos de bronquiolitis, laringitis, crisis asmáticas y neumonías que demandan una atención especializada.

When fall arrives, pediatric emergency services (SEP) professionals know before the trees decide to change their leaves. The increase in the number of patients is as important as the repetition of the reasons for consultation and the explanations about the futility of ¨treatments for viruses¨. In addition to colds with and without fever that lead EPS to collapse, there are severe symptoms of bronchiolitis, laryngitis, asthma attacks and pneumonia that demand specialized care.

Oxigenoterapia por cánula nasal de alto flujo en pacientes con crisis asmática en un departamento de emergencia pediátrica / High flow nasal cannula oxygen therapy in patients with asthmatic crisis in the pediatric emergency department

INTRODUCCIÓN: Pocos estudios son concluyentes sobre la utilidad de la Oxigenoterapia por Cánula Nasal de Alto Flujo (CNAF) en pacientes con crisis asmática. OBJETIVO: Determinar la eficacia de la CNAF en niños mayores de 2 años con crisis asmática severa y moderada que no responde al tratamiento inicial. PACIENTES Y MÉTODO: Ensayo clínico randomizado controlado abierto de pacientes con exacerbación asmática en un Departamento de Emergencia Pediátrica. Se excluyó crisis mediadas por infecciones y comorbilidad. Los pacientes fueron aleatorizados: Grupo 1 CNAF (n: 32) y Grupo 2 Oxigenoterapia Convencional (n: 33). Ambos grupos recibieron el tratamiento farmacológico habitual. El primer punto de corte fue el descenso del PIS en más de 2 puntos a las 2 horas del tratamiento; los puntos secundarios: descenso del PIS a las 6 horas, tiempo de permanencia en la emergencia e ingreso a UCIP. RESULTADOS: Las características basales fueron similares en ambos grupos. La proporción de sujetos con disminución de más de dos puntos en el PIS a las 2 horas de tratamiento Grupo 1: 43,7% IC 95% (28-60) vs Grupo 2: 48,4%; IC 95% (32-64) p 0,447. La estadía media fue 24,8 ± 12,3 horas en el Grupo1 vs 24 ± 14,8 horas en el Grupo2; IC 95% (7,56-5,96) p 0,37. No encontramos diferencias del score y puntaje del esfuerzo respiratorio en mediciones cada 2 horas. Ningún paciente ingresó a cuidados intensivos. CONCLUSIONES: La incorporación de la CNAF al tratamiento de pacientes con crisis asmática no presentó beneficios clínicos ni disminuyó el tiempo de estadía en el DEP.

INTRODUCTION: There are few conclusive studies on the usefulness of High-Flow Nasal Cannula (HFNC) Oxygen Therapy in patients with asthmatic crises. OBJECTIVE: To determine the effectiveness of HFNC in chil dren older than 2 years of age that present severe and moderate asthmatic crises that do not respond to initial treatment. PATIENTS AND METHOD: Open controlled randomized clinical trial of patients with asthma exacerbation in the Pediatric Emergency Department. Infection- and comorbidity-media ted crises were excluded. Subjects were randomized as follows: Group 1 HFNC (n:32) and Group 2 Conventional Oxygen Therapy (n:33). Both groups received the usual pharmacological treatment. The first cut-off point was the decrease of more than 2 points of the PIS after 2 hours of treatment; secondary points were PIS decrease at 6 hours, stay time in the Emergency Room, and PICU admis sion. RESULTS: The patient's baseline characteristics were similar in both groups. The proportion of subjects with more than two points decrease in the PIS after two hours of treatment in Group 1 was 43.7% CI 95% (28-60) vs. Group 2 48.4%; CI 95% (32-64) p 0.447. The mean stay time was 24.8 ± 12.3 hours in Group 1 vs. 24 ± 14.8 hours in Group 2; CI 95% (7.56-5.96) p 0.37. We did not find differences in the respiratory effort score measurements every 2 hours. No patients were admitted to intensive care. CONCLUSIONS: The incorporation of HFNC oxygen therapy in the treatment of patients with asthmatic crises in the Pediatric Emergency Department did not show clinical benefits nor did it diminish the stay time.

Evaluación del manejo avanzado de la vía aérea en un departamento de emergencia pediátrica / Evaluation of advanced airway management in a pediatric emergency department

La intubación endotraqueal (IET) en pacientes críticamente enfermos es un procedimiento de alto riesgo que requiere alta competencia en el manejo de la vía aérea. Es esencial conocer las habilidades de los médicos de emergencia en el manejo avanzado de vías aéreas y de vías aéreas difíciles (VAD). Estudio observacional, descriptivo y prospectivo cuyo objetivo fue describir el manejo avanzado de vías aéreas y VAD en un departamento de emergencia pediátrica. Fueron incluidos 66 pacientes de 0 a 18 años que requirieron intubación endotraqueal entre mayo 2018 a enero 2019. Se evaluó el diagnóstico fisiopatológico, prevalencia de VAD, uso de secuencia de intubación rápida (SIR), herramienta utilizada para la intubación, tiempo de intubación, intentos, operador, y complicaciones. Se estableció como éxito si el paciente era intubado en dos intentos. En el 19,7% de los pacientes se identificó predicción de VAD, se realizó SIR en 64 (96,9%) pacientes. La tasa de éxito fue 77,3% (51/66), en el primer intento 39/66 (59,1%) y en el segundo 12/54 (77,3%). Se requirió cambio de operador en 14 oportunidades. Todos fueron intubados por laringoscopia convencional. El tiempo de intubación osciló entre 2-6 minutos. La media del número de intentos fue 1,8 (± 1,4). Las complicaciones del IET se presentaron en 22 pacientes, siendo la frecuencia de saturación menor a 70% significativamente mayor en los pacientes que requirieron más de dos intentos para la intubación. La identificación de VAD se presentó con relativa frecuencia.

Endotracheal intubation (EIT) in critically ill patients is a high-risk procedure that requires high competence in the management of the airway. It is essential to know the skills of emergency physicians in the advanced management of airways and difficult airways (DA). Observational, descriptive and prospective study with the objective to describe the advanced management of airways and VAD in a pediatric emergency department, that includes patients from 0 to 18 years who required endotracheal intubation between May 2018 and January 2019. The physio pathological diagnosis, prevalence of VAD, use of rapid intubation sequence (SIR), tool used for intubation, intubation time, attempts, operator, and complications were evaluated. It was established as success if the patient was intubated in two attempts. We studied 66 patients between 0.7-192 months of age (median: 7.5 months). In 19.7% of the patients, prediction of VAD was identified; SIR was performed in 64 (96.9%) patients. Success rate was 77.3% (51/66), in the first attempt 39/66 (59.1%) and in the second 12/54 (77.3%). Operator change was required in 14 opportunities. All patients were intubated by conventional laryngoscopy. Intubation time ranged between 2-6 minutes. mean number of attempts was 1.8 (± 1.4). Complications of the EIT were present in 22 patients; frequency of saturation less than 70% was significantly higher in patients who required more than two attempts for intubation. The identification of difficult airway was relatively frequent.

High flow nasal cannula oxygen therapy in patients with asthmatic crisis in the pediatric emergency department. / Oxigenoterapia por cánula nasal de alto flujo en pacientes con crisis asmática en un departamento de emergencia pediátrica.

INTRODUCTION: There are few conclusive studies on the usefulness of High-Flow Nasal Cannula (HFNC) Oxygen Therapy in patients with asthmatic crises. OBJECTIVE: To determine the effectiveness of HFNC in chil dren older than 2 years of age that present severe and moderate asthmatic crises that do not respond to initial treatment. PATIENTS AND METHOD: Open controlled randomized clinical trial of patients with asthma exacerbation in the Pediatric Emergency Department. Infection- and comorbidity-media ted crises were excluded. Subjects were randomized as follows: Group 1 HFNC (n:32) and Group 2 Conventional Oxygen Therapy (n:33). Both groups received the usual pharmacological treatment. The first cut-off point was the decrease of more than 2 points of the PIS after 2 hours of treatment; secondary points were PIS decrease at 6 hours, stay time in the Emergency Room, and PICU admis sion. RESULTS: The patient's baseline characteristics were similar in both groups. The proportion of subjects with more than two points decrease in the PIS after two hours of treatment in Group 1 was 43.7% CI 95% (28-60) vs. Group 2 48.4%; CI 95% (32-64) p 0.447. The mean stay time was 24.8 ± 12.3 hours in Group 1 vs. 24 ± 14.8 hours in Group 2; CI 95% (7.56-5.96) p 0.37. We did not find differences in the respiratory effort score measurements every 2 hours. No patients were admitted to intensive care. CONCLUSIONS: The incorporation of HFNC oxygen therapy in the treatment of patients with asthmatic crises in the Pediatric Emergency Department did not show clinical benefits nor did it diminish the stay time.

Evaluación del manejo avanzado de la vía aérea en un departamento de emergencia pediátrico / Evaluation of advanced airway management in a pediatric emergency department

Introducción: La intubación endotraqueal en pacientes críticamente enfermos es un procedimiento de riesgo que requiere alta competencia en el manejo de la vía aérea. Es esencial conocer las habilidades de los médicos de emergencia pediátrica en el manejo avanzado de vías aéreas y de vías aéreas difíciles. Objetivo: Describir el manejo avanzado de vías aéreas y vías aéreas difíciles en un departamento de emergencia pediátrico. Materiales y Métodos: Estudio observacional, descriptivo y prospectivo en pacientes de 0 a 18 años que requirieron intubación endotraqueal en el periodo comprendido desde el 10 de mayo del 2018 al 31 de mayo del 2019. Se evaluó diagnóstico fisiopatológico, prevalencia de vía aérea difícil, aplicación de secuencia de intubación rápida, herramienta utilizada para la intubación, tiempo de intubación, intentos, operador y complicaciones. Se definió éxito al paciente intubado en dos intentos. Resultados: Se incluyeron 93 pacientes, la mediana de edad fue 10 (0.7-192) meses . En 19 (20,4%) pacientes se identificó predicción de vía aérea difícil, se realizó secuencia de intubación rápida en 91 (97,8%) pacientes. El porcentaje de éxito fue 83,9% (78/93). En el primer intento 59,1% (55/93) y en el segundo 50% (19/38). Se requirió cambio de operador en 19 oportunidades. Todos fueron intubados por laringoscopia convencional. La mediana para el tiempo de intubación fue 3 (2-5.5) minutos. La media del número de intentos fue 1,8 (± 1,3). La complicación observada fue la desaturación de oxígeno en 23 (24,7%) pacientes. Conclusión: La primera causa de intubación según el diagnóstico fisiopatológico fue la falla cardiopulmonar y la identificación de vía aérea difícil se presentó con relativa frecuencia.

Introduction: Endotracheal intubation in critically ill patients is a risky procedure that requires a high level of competence in airway management. It is essential to know the skills of pediatric emergency physicians in the advanced management of airways and difficult airways. Objective: To describe the advanced management of difficult airways and airways in a pediatric emergency department. Materials and Methods: This was an observational, descriptive and prospective study in patients from ages 0 to 18 years who required endotracheal intubation from May 10, 2018 to May 31, 2019. We evaluated pathophysiological diagnosis, prevalence of difficult airway, rapid intubation sequence intubation application, tools used for intubation, intubation time, attempts, operator characteristics and complications. Successful intubation patients was defined as intubation in two attempts. Results: 93 patients were included, the median of age was 10 (0.7-192) months. In 19 (20.4%) patients, difficult airway prediction was identified, rapid intubation sequence was performed in 91 (97.8%) patients. The percentage of success was 83.9% (78/93). In the first attempt 59.1% (55/93) and in the second 50% (19/38). Operator change was required 19 times. All were intubated by conventional laryngoscopy The median for intubation time was 3 (2-5.5) minutes. The average number of attempts was 1.8 (± 1.3). The complication observed was oxygen desaturation in 23 (24.7%) patients. Conclusion: The first cause of intubation according to the diagnosis pathophysiological was cardiopulmonary failure. Difficult airway identification was relatively frequent.

Eficacia del propofol-fentanilo comparada con propofolketamina en procedimientos dolorosos mayores en un Departamento de Emergencia Pediátrica / Efficacy of propofol-fentanyl compared with propofolketamine in significantly painful procedures in a Pediatric Emergency Department

Objetivo: Comparar la eficacia de la combinación propofol - fentanilo (P / F) con propofol - ketamina (P / K) en procedimientos dolorosos mayores en un Departamento de Emergencias Pediátricas (DEP). Diseño: Ensayo aleatorizado, controlado, abierto, con cegamiento del evaluador. Material y Métodos: Se incluyeron pacientes de 6 meses a 18 años, con una clasificación ASA menor o igual a 3, sometidos a sedación y analgesia para la realización de procedimientos dolorosos. Intervenciones: Los sujetos fueron asignados al azar para recibir propofol-fentanilo o propofol-ketamina. Se evaluaron las complicaciones. Las variables fueron: datos demográficos, tipos de procedimientos, tiempo hasta la adecuada sedación y analgesia, dosis adicionales requeridas, tiempo de recuperación y efectos adversos. Resultados: Se analizaron sesenta procedimientos (30 por grupo). No hubo diferencias en la edad, el sexo, el tipo de procedimiento, la duración de la infusión y la duración del procedimiento o el tiempo de recuperación. El tiempo para lograr la sedación (minutos) fue mayor con P / F que con P / K: 2 (1-4 rango intercuartilo) vs. 1 (rango intercuartil a 1-1). El tiempo (minutos) para lograr una analgesia adecuada con P / F fue 2 (1-5 rango intercuartilo) vs. 1 (1-1 ,25 rango intercuartilo). p <0,001. El P / F requirió más dosis adicionales, 80% frente a 43%, p <0,004, y tuvo más efectos secundarios, 46, 6% (intervalo de confianza [IC] del 95%: 70% a 100%) versus 20% (95%). % CI-2% a 59%) p <0,024. La proporción de efectos adversos graves con P/F vs P/K fue: 6% (95% CI-1,8% a 2%) versus 0% (95% CI-0 a 0%) p 0.246. Conclusiones: Concluimos que las combinaciones de Propofol / Fentanilo y Propofol/Ketamina, son eficaces en alcanzar la sedoanalgesia en procedimientos muy dolorosos y cortos. Presentando la primera combinación más efectos secundarios y requiriendo más tiempo y dosis adicionales para lograr los niveles deseados de sedoanalgesia.

Objective: To compare the efficacy of the combination of propofol - fentanyl (P / F) with propofol - ketamine (P / K) in significantly painful procedures in a Pediatric Emergency Department (PED). Design: This was a randomized, controlled, open label trial, with evaluator blinding. Materials and Methods: Patients from 6 months to 18 years were included, with an ASA classification less than or equal to 3, undergoing sedation and analgesia for significantly painful procedures. Interventions: Subjects were randomized to receive propofol-fentanyl or propofol-ketamine. Complications were evaluated. The variables were: demographic data, procedure type, time to adequate sedation and analgesia, additional doses required, recovery time and adverse effects. Results: Sixty procedures were analyzed (30 per group). There were no differences in age, sex, procedure type, duration of infusion, duration of the procedure or recovery time. The time to achieve sedation (minutes) was higher with P / F than with P / K: 2 (1-4 interquartile range) vs. 1 (interquartile range to 1-1). The time (minutes) to achieve adequate analgesia with P / F was 2 (1-5 interquartile range) vs. 1 (1-1, 25 interquartile range). p <0.001. The P / F required more additional doses, 80% vs. 43%, p <0.004, and had more side effects, 46.6% (95% confidence interval [CI]: 70% to 100%) versus 20% (95% CI-2% to 59%), p <0.024. The proportion of serious adverse effects with P / F vs P / K was: 6% (95% CI-1.8% to 2%) versus 0% (95% CI-0 to 0%), p = 0.246. Conclusions: We conclude that the combinations of Propofol / Fentanyl and Propofol / Ketamine are effective in achieving sedoanalgesia in significantly painful and short-duration procedures, with the P / F combination having more side effects and requiring more time and additional doses to achieve the desired levels of sedoanalgesia.

Análisis de las reconsultas en 24 horas en un Departamento de Emergencias Pediátricas durante el período epidémico de infecciones respiratorias / Analysis of repeat visits within 24 hours in a Pediatric Emergency Department during the epidemic period of respiratory infections

Introducción: Conocer las características de las reconsultas en un servicio de urgencia permite realizar intervenciones para mejorar la calidad de la atención. La reconsulta dentro de las 24 hs puede implicar un error en la apreciación de la gravedad o una insatisfacción del usuario respecto al resultado de su consulta inicial. Objetivo: Conocer las características de las Reconsultas dentro de las 24 horas en el Departamento de Emergencias Pediátricas (DEP) durante un período epidémico. Materiales y métodos: Estudio Observacional Descriptivo de corte Transversal Retrospectivo. Se incluyeron pacientes entre 0 a 18 años que reconsultaron dentro de las 24 horas en el DEP de un hospital pediátrico de referencia. Se analizó: edad, sexo, triage, procedencia, motivo de consulta, diagnóstico, hospitalización, intervenciones, exámenes complementarios (laboratorio e imágenes), tiempo de reconsulta. Los datos fueron analizados con SPSSv21. Las variables cualitativas se expresaron como porcentajes, la relación entre variables se realizó mediante la prueba de chi cuadrado de Pearson, las cuantitativas se expresaron como promedios con sus desviaciones estándar. Resultados: En el período de estudio consultaron 28.882 pacientes, 4% (1.169) reconsultaron , todos ingresaron al estudio. La mediana de edad fue de 24 meses (2 - 204), el 59,4% provenían de zonas fuera de la ciudad de San Lorenzo, área de referencia del hospital. El nivel de triage fue en su mayoría III y IV. El tiempo entre la primera consulta y la reconsulta fue de 16±6 horas, los diagnósticos más frecuentes fueron las enfermedades respiratorias: síndrome bronquial obstructivo (SBO) (14%), resfrío (13%), bronquiolitis (13%). Se realizaron intervenciones en 31,2% y exámenes complementarios en 17,4%. El 13,3% (156/1169) de las reconsultas fueron hospitalizadas y requirieron un mayor porcentaje de intervenciones. Conclusión: Aunque entre las reconsultas predominó un nivel de triage de baja prioridad, existió la necesidad de realizar intervenciones. Un grupo de pacientes necesitó ser hospitalizado. La epidemia de enfermedades respiratorias en el mes analizado podría ser un factor contribuyente.

Introduction: Knowing the characteristics of repeat visits to an emergency service allows interventions to improve the quality of care. A repeat visit within 24 hours may imply an error in the assessment of the severity of the condition or user dissatisfaction regarding the result of the initial consultation. Objective: To characterize repeat visits within 24 hours in the Pediatric Emergency Department (PED) during an epidemic period. Materials and methods: This was an observational, retrospective, crosssectional study. Patients aged 0 to 18 years were included, who had repeat visits within 24 hours in the PED of a pediatric referral hospital. The following were analyzed: age, sex, triage, place of origin, reason for consultation, diagnosis, hospitalization, interventions, complementary exams (laboratory and imaging), timing of repeat visit. The data were analyzed with SPSv21. The qualitative variables were expressed as percentages, the relationship between variables was performed using the Pearson chi-square test, the quantitative variables were expressed as averages with their standard deviations. Results: During the study period, 28,882 patients consulted, 4% (1,169) had repeat visits, all of which were included in the study. The median age was 24 months (2 - 204), and 59.4% came from areas outside the city of San Lorenzo, the hospital's reference area. The triage levels were mostly III and IV. The time between the first consultation and the repeat visit was 16 ± 6 hours, the most frequent diagnoses were respiratory diseases: obstructive bronchial syndrome (OBS) (14%), cold (13%), and bronchiolitis (13%). Interventions were carried out in 31.2% and complementary examinations in 17.4%. 13.3% (156/1169) of patients with repeat visits were hospitalized and required a higher number of interventions. Conclusion: Although a low priority triage level predominated among the repeat visits, there was a need to carry out interventions. A group of patients needed to be hospitalized. The epidemic of respiratory diseases ocurring during the study period could be a contributing factor.

Dengue y Bradicardia: caracterización clínica y evolución

Introducción: Las alteraciones de la conducción cardiaca y bradicardia, están descriptos en el Dengue, aunque su fisiopatología no es del todo clara. Objetivo: Describir las características clínicas y evolución de los pacientes con dengue y bradicardia. Metodología: estudio observacional, descriptivo, longitudinalde seguimiento de una cohorte. Fueron incluidos pacientes de 1 mes a 18 años ingresados en el Servicio de Urgencias del Hospital General Pediátrico Niños de Acosta Ñu, con diagnóstico de dengue, que presentaron bradicardia y que hayan tenido seguimiento hasta la desaparición del síntoma. Variables edad, sexo, clasificación del dengue, resultado del electrocardiograma (ECG), radiografía de tórax, inicio de bradicardia, frecuencia cardiaca al egreso, duración de la bradicardia en el seguimiento y días de hospitalización. Los datos fueron analizados en SPSSv 21, utilizando la estadística descriptiva. El protocolo fue aprobado por el Comité de ética. Resultados: En el periodo de estudio se hospitalizaron 310 pacientes con Dengue. El 6,4% (20/310) presentó bradicardia. La edad media fue de 12,7±2,8 años, con predominio del sexo masculino. Algunos pacientes ya tenían bradicardia en el momento del ingreso (9/20), mientras que otros lo presentaron en el curso de la hospitalización (11/20). Hubo un caso de bloqueo AV y los demás presentaron bradicardia sinusal (19/29). La bradicardia persistió al alta en la mayoría de los pacientes (18/20) y se resolvió durante la primera semana de seguimiento. El promedio de días de hospitalización fue 7,1±1,9. Conclusión: La frecuencia de bradicardia fue del 6,4%. La mayoría de los pacientes tenía el diagnóstico de Dengue Grave. Un alto porcentaje continuaba con bradicardia al momento del alta sin manifestaciones clínicas de dengue. En la mayoría de los pacientes se presentó durante la hospitalización y se normalizó durante el seguimiento al alta.

Introduction: Alterations in cardiac conduction and bradycardia are described in Dengue, although its pathophysiology is not entirely clear. Objective: To describe the clinical characteristics and course of patients with dengue and bradycardia. Methodology: This was an observational, descriptive and longitudinal cohort study. We enrolled patients from 1 month to 18 years of age who were admitted to the Emergency Department of the Acosta Ñu Children's General Hospital with a diagnosis of dengue, who presented bradycardia and who had follow-up until the disappearance of the symptom. The variables were age, sex, dengue classification, electrocardiogram (ECG) results, chest x-ray, onset of bradycardia, heart rate at discharge, duration of bradycardia during follow-up and days of hospitalization. Data were analyzed in SPSSv 21, using descriptive statistics. The protocol was approved by the Hospital Ethics Committee. Results: During the study period, 310 patients with Dengue were hospitalized. 6.4% (20/310) had bradycardia. The average age was 12.7 ± 2.8 years, with a predominance of males. Some patients already had bradycardia at the time of admission (9/20), while others developed it during hospitalization (11/20). There was one case of AV block and the others presented sinus bradycardia (19/29). Bradycardia persisted at discharge in most patients (18/20) and resolved during the first week of follow-up. The average number of hospitalization days was 7.1 ± 1.9. Conclusions: The frequency of bradycardia was 6.4%. The majority of patients had a diagnosis of severe dengue. A high percentage of patients continued to have bradycardia at discharge with no other clinical manifestations of dengue. In the majority of patients, bradycardia presented during hospitalization and normalized at their discharge follow-up.

Percepción materna de los signos, síntomas de alarma y creencias populares sobre el cuidado y las enfermedades neonatales en el departamento de emergencias pediátricas

Introducción: La percepción materna de los signos de alarma y las creencias populares influyen en el cuidado de los neonatos. El objetivo del presente trabajo fue describir la percepción materna de los signos de alarma y las creencias culturales relacionadas al cuidado del neonato. Material y Método: Estudio observacional descriptivo prospectivo. Previo consentimiento informado se realizó una entrevista, con preguntas abiertas y cerradas a madres de neonatos con nivel de prioridad de la atención II y III en el Departamento de emergencias pediátricas (DEP). Variables: Edad materna, escolaridad, procedencia, paridad, edad del neonato, antecedente de haber estado hospitalizado, motivo de la consulta, orientaciones sobre los cuidados neonatales, concepto de fiebre, signos de enfermedad grave y las llamadas enfermedades culturales. Los datos fueron procesados en SPSS v21 utilizando estadísticas descriptivas. Resultados: Se encuestó a 100 madres, la mayoría procedente del departamento Central, con estudios secundarios y más de la mitad era primíparas. El 63% definió correctamente la fiebre. Solo el 25% recibió orientación sobre los cuidados del neonato por personal sanitario. El 90% reconoció la fiebre como signo de alarma. El 25 % manifestó creer en las llamadas enfermedades culturales. El 40% de los neonatos usaba ombliguero, y el 51% llevaba una cinta roja atada a la muñeca como medida de protección contra el mal. Conclusiones: La mayoría de las madres tuvo una adecuada percepción de al menos 2 signos de alarma Un cuarto de estas mujeres creía en las enfermedades culturales y más de la mitad de sus neonatos tenía amuletos contra el mal.

Introduction: Maternal understanding of warning signs and symptoms and popular beliefs influence the care of newborns. The objective of this study was to describe the maternal understanding of warning signs and the cultural beliefs related to newborn care. Methods: This was a prospective, descriptive, observational study. After obtaining informed consent, an interview, using open and closed questions was performed with mothers of newborns presenting with priority levels of care II and III in the Pediatric Emergency Department (PED). Variables: Maternal age, education, prove-nance, parity, age of the newborn, history of having been hospitalized, chief complaint, guidance on newborn care, understanding of fever and signs of serious illness and so-called cultural diseases. The data was processed in SPSS v21 using descriptive statistics. Results: 100 mothers were surveyed, most of them from Central Department and with secondary-level education. More than half were primiparous. 63% correctly defined fever. Only 25% received guidance from health personnel re-garding newborn care. 90% recognized fever as a warning sign. 25% said they believe in the so-called cultural diseases. 40% of neonates wore bellybands, and 51% wore a red ribbon tied to the wrist as a protective measure against evil. Conclusions: Most mothers had an adequate understan-ding of at least 2 warning signs. A quarter of these women believed in cultural diseases and more than half of their neonates had amulets against evil.

[The Spanish triage system in the evaluation of neonates in paediatric emergency departments]. / El sistema español de triaje en la evaluación de los neonatos en las urgencias pediátricas.

The triage system in the emergency department classifies patients according to priority levels of care. Neonates are a vulnerable population and require rapid assessment. OBJECTIVE: To correlate the priority levels in newborns seen in the paediatric emergency department with admissions, resource consumption, and service times. PATIENTS AND METHOD: Observational study, using the Andorran triage model (MAT-SET) with ePATV4 software database, in paediatric emergencies. Neonates were classified into 3 levels of care established for them as level I resuscitation, level II emergency, and level iii urgent. The correlation between levels of priority and admission and resource consumption were analysed, as well as the time spent on medical care and stay in the emergency department. RESULTS: The study included 1103 infants. The highest priority level was positively correlated with hospital admission (r = 0.66, P<.005) and resource consumption (r = 0.59, P < .005). The medical care times were 126 ± 203, 119 ± 51, and 33 ± 81 min for levels i, ii, and iii, respectively and the stay in emergency department was 150 ± 203, 131 ± 80, and 55 ± 86 min, respectively for these levels (P < .05). CONCLUSION: The higher level of priority in the care of neonates in the paediatric emergency department was positively correlated with increased need for hospital admission and resource consumption. They also required a longer time for medical care and stay in the emergency department.

El sistema español de triaje en la evaluación de los neonatos en las urgencias pediátricas / The Spanish triage system in the evaluation of neonates in paediatric emergency departments

El triaje en el departamento de urgencias clasifica a los pacientes en niveles según prioridad en la atención. Los neonatos constituyen una población vulnerable y requieren una rápida evaluación. Objetivo: Correlacionar los niveles de prioridad en neonatos que consultan en el departamento de urgencias pediátricas con la hospitalización, consumo de recursos y tiempos de atención. Pacientes y Método: Estudio observacional, utilizando la base de datos del modelo andorrano de triaje (MAT-SET) con el software ePATV4 en las urgencias pediátricas. Se incluyó a neonatos clasificados en los 3 niveles de atención establecida: nivel i resucitación, nivel ii emergencia y nivel iii urgencia. Se analizó la correlación entre los niveles de prioridad, la hospitalización y el consumo de recursos. Además, se analizaron los tiempos de atención médica y estadía en urgencias. Resultados: Se incluyeron 1.103 neonatos. Se encontró que el mayor nivel de prioridad se correlacionó positivamente con la hospitalización (r = 0,66; p < 0,005) y con el consumo de recursos (r = 0,59; p < 0,005). Los tiempos de atención fueron 126 ± 203, 51 ± 119 y 33 ± 81 min para los niveles i, ii, y iii, respectivamente y los de estadía 150 ± 203, 80 ± 131 y 55 ± 86 min, respectivamente para dichos niveles (p < 0,05). Conclusiones: El mayor nivel de prioridad en la atención de los neonatos en la urgencia pediátrica se correlacionó positivamente con una mayor necesidad de hospitalización y consumo de recursos. Además, requirieron mayor tiempo de atención y estadía en la urgencia.

The triage system in the emergency department classifies patients according to priority levels of care. Neonates are a vulnerable population and require rapid assessment. Objective: To correlate the priority levels in newborns seen in the paediatric emergency department with admissions, resource consumption, and service times. Patients and Method: Observational study, using the Andorran triage model (MAT-SET) with ePATV4 software database, in paediatric emergencies. Neonates were classified into 3 levels of care established for them as level I resuscitation, level II emergency, and level iii urgent. The correlation between levels of priority and admission and resource consumption were analysed, as well as the time spent on medical care and stay in the emergency department. Results: The study included 1103 infants. The highest priority level was positively correlated with hospital admission (r = 0.66, P<.005) and resource consumption (r = 0.59, P < .005). The medical care times were 126 ± 203, 119 ± 51, and 33 ± 81 min for levels i, ii, and iii, respectively and the stay in emergency department was 150 ± 203, 131 ± 80, and 55 ± 86 min, respectively for these levels (P < .05). Conclusion: The higher level of priority in the care of neonates in the paediatric emergency department was positively correlated with increased need for hospital admission and resource consumption. They also required a longer time for medical care and stay in the emergency department.