[Experience in COVID-19 in hospitalized patients in pediatric critical units during pandemic period]. / Experiencia en COVID-19 en pacientes hospitalizados en unidades de paciente crítico pediátrico durante el periodo pandémico.

OBJECTIVES: To characterize the COVID-19 disease profile in Chilean children hospitalized in pediatric intensive care units (PICU) and to evaluate risk factors associated with severe COVID-19. PATIENTS AND METHOD: A multicenter prospective cohort study with patients 0-18 years of age with confirmed SARS-CoV-2 hospitalized in PICU. Clinical, laboratory, imaging, and therapeutic variables were recorded. We compared "mild/moderate COVID-19" with ''severe COVID-19" using median with interquartile range (IQR), Mann-Whitney U test, two-tailed Fisher's test, and forward binary multivariate analysis to adjust variables for "severe COVID-19". A p < 0.05 was considered significant. RESULTS: From 16 PICUs, 219 patients were recruited, 55.3% were male, with a median age of 86 months (IQR: 13.5-156). The most frequent comorbidities were obesity and respiratory diseases. Overall mortality was 3.6%. "Severe COVID-19" (26.5%) showed more leukopenia, lymphopenia, increased inflammatory parameters, and altered organ function (p < 0.05). It also developed more sepsis/shock, ARDS, and organ dysfunction, requiring more hemodynamic, anti-inflammatory, anticoagulation, and antibiotic therapy, with a longer stay in the PICU/hospital (p < 0.05), and 13.8% of mortality. Risk factors associated with "severe COVID-19" were shock on admission to the PICU [aOR 28.44 (95%CI 10.45-77.4)], obesity [aOR 3.55 (95%CI 1.3-9.6)], consolidation [aOR 3.1 (95%CI 1.1 -8.7)], atelectasis [aOR: 8.7 (95%CI 1.17-64.3)], stress dose of corticosteroids [aOR 7.7 (95%CI 1.9-30.6)], early antibiotic therapy [aOR: 12.02 (95%CI 1.11-130.02)], acquired/congenital immunodeficiency [aOR: 19.2 (95%CI: 1.19-321)], and oncological pathology [aOR 10.7 (95%CI 2.14-47.8)]. CONCLUSION: In this Chilean pediatric cohort, most patients with COVID-19 admitted to de PICU were male, of school age, with associated comorbidity. Risk factors for developing severe COVID-19 were the presence of comorbidities such as acquired/congenital immunodeficiency, oncological pathology, and obesity, in addition to shock on admission and consolidations on X-rays.

[Childhood and COVID-19: The indirect effects of the COVID-19 pandemic on the well-being of children and adolescents]. / Infancia y COVID-19: Los efectos indirectos de la pandemia COVID-19 en el bienestar de niños, niñas y adolescentes.

The impact of the COVID-19 pandemic has been overlooked in children and adolescents since many of the negative effects have been the result of containment and mitigation measures and will only be quantifiable in the medium and long term. Although the global response has been successful in reducing the lethality of the disease, the harmful effect on vulnerable populations, such as children and adolescents, is enormous and has been classified as catastrophic by international organizations. The pandemic has deeply affected the physical and mental health of children and adolescents, but also silently its negative effects extend across many areas such as schooling, familiar economy, child labor and food security. The third year of the pandemic is an opportunity to include the multidimen sional well-being of children and adolescents as a cornerstone of society's response to a global crisis, whether health, economic or political.

Variability in care for children with severe acute asthma in Latin America.

BACKGROUND: Care variability for children with severe acute asthma has been well documented in high-income countries, yet data from low- and middle-income regions are lacking. We sought to characterize the magnitude of practice variability in the care of Latin American children to identify opportunities for standardization of care. METHODS: A cross-sectional study performed through a retrospective analysis of contemporaneously collected data of children with severe acute asthma admitted to a center contributing to the LARed Network registry between May 2017 and May 2019. Centers were grouped by geographic location: Atlantic (AT), South Pacific (SP), and North Central (NC). RESULTS: Among 434 children, most received care in hospitals in the AT group (54% [235/434]), followed by the NC (23% [101/434]) and SP (23% [98/434]) groups. The majority of children in the AT (92% [215/235]) and SP (91% [89/98]) groups received nebulized salbutamol/albuterol, while metered-dose inhalers were preferred in the NC group (72% [73/101]). There was a wide variation in the use of antibiotics: AT (57% [135/235]), SP (48% [47/98]), and NC (14% [14/101]). The same was true for ipratropium bromide: AT (67% [157/235]), SP (90% [88/98]), and NC (17% [17/101]), and aminophylline: AT (57% [135/235]), NC (5% [5/101]), and SP (0% [0/98]). High-flow nasal cannula was the preferred respiratory support modality in the AT (60% [141/235]) and NC (40% [40/101]) groups, while bilevel positive airway pressure (BiPAP) use was more common in the SP group (80% [78/98]). CONCLUSION: We identified significant variability in care for severe acute asthma. Our findings will help to inform the design of future studies, quality improvement initiatives, and development of practice guidelines within Latin America.

Admisiones por bronquiolitis en 13 unidades de cuidados intensivos pediátricos del Uruguay: ¿es igual en Montevideo que en el interior? / Bronchiolitis admissions in 13 pediatric intensive care units in Uruguay: is it the same in Montevideo (capital city) and the provinces? / Internações por bronquiolite em 13 unidades de terapia intensiva pediátrica do Uruguai: são iguais em Montevidéu e no Interior do país?

Resumen: Objetivos: describir las características clínicas y epidemiológicas de niños admitidos por bronquiolitis en 13 unidades de cuidados intensivos pediátricos (UCIP) del Uruguay y comparar los resultados asistenciales finales entre UCIP de Montevideo (UM) y del interior del país (UI). Material y método: estudio observacional retrospectivo multicéntrico de los registros ingresados a base de datos prospectiva de LARed Network. Se incluyeron niños mayores de 1 mes y menores de 2 años admitidos en el período 1 de mayo de 2017 y 30 de abril de 2019 con diagnóstico de bronquiolitis comunitaria. Se analizaron datos demográficos, clínicos, así como intervenciones y desenlaces al alta. Resultados: se analizaron 666 casos. No se detectaron diferencias significativas de comorbilidades ni en el soporte respiratorio al ingreso. En UI los pacientes fueron derivados con más frecuencia desde otro hospital. La distancia y tiempo medio, así como el porcentaje de traslados mayor de 50 km, fue también mayor. En UI los pacientes tuvieron mayor gravedad clínica y gasométrica al ingreso. El perfil radiológico y etiológico fue similar. Virus respiratorio sincicial (VRS) aislado > 50%. La indicación global de corticoides superó el 25% y el de broncodilatadores el 85%. La prescripción de antibióticos y adrenalina nebulizada fue mayor en UI. La cánula nasal de alto flujo (CNAF) fue globalmente el método de soporte respiratorio más utilizado, aunque se observó un mayor uso de ventilación mecánica invasiva (VMI) y CPAP en UI (47% vs 28% en UM). No hubo diferencias en el número de complicaciones por VMI o ventilación no invasiva, ni en el uso de terapias de rescate. Tampoco se notaron diferencias significativas en la duración de la estadía en UCIP, ni en la mortalidad absoluta y ajustada, y hubo un solo caso de nueva morbilidad. Conclusiones: los niños admitidos en UI tuvieron mayor gravedad al ingreso y más factores de riesgo relacionados con mal pronóstico en el traslado, recibiendo más antibióticos y soporte invasivo que aquellos ingresados en UM. El CNAF fue el tipo de soporte respiratorio más utilizado en el país. Se detectó alto porcentaje de prescripción de terapias no recomendadas, como broncodilatadores y corticoides. La mortalidad y complicaciones fueron bajas, así como la generación de morbilidad residual.

Summary: Objectives: to describe the clinical and epidemiological characteristics of children admitted for bronchiolitis in 13 Pediatric Intensive Care Units (UCIP) in Uruguay and compare the final care outcomes between Montevideo (UM) and Interior of the country (IU). Method: multicenter, retrospective, observational study of data entered in the LARed Network prospective database. Children over 1 month and younger than 2 years admitted between May 1, 2017 and April 30, 2019 with a diagnosis of Community Bronchiolitis were included in the study. Demographic and clinical data were analyzed, as well as interventions and discharge outcomes. Results: 666 cases were analyzed. No significant differences in comorbidity and respiratory support were detected at admission. In IU patients were referred more frequently from another hospital. The distance and average time, as well as the percentage of transfers greater than 50 km, was also higher. In IU, patients had greater clinical and gasometrical severity at admission. The radiological and etiological profile was similar (VRS at > 50%). The overall indication of corticosteroids exceeded 25% and that of bronchodilators exceeded 85%. The prescription for antibiotics and nebulized adrenaline was higher in IU. The high flow nasal cannula (HFNC) was globally the most widely used respiratory support method, although increased use of invasive mechanical ventilation (IMV) and CPAP in IU (43% vs 28% in UM) was observed. There were no differences in the number of complications from IVF or non-invasive ventilation, nor in the use of rescue therapies. There were also no significant differences in the length of stay at UCIP or in absolute and adjusted mortality and there was only one case of new morbidity. Conclusions: children admitted to IU had higher severity scores and more transfer-related risk factors, received more antibiotics and invasive support. HFNC was the most widely used type of respiratory support in the country. A high prescription of non-recommended therapies such as bronchodilators and corticosteroids was detected. Mortality and complications were low, as were the generation of new morbidity.

Resumo: Objetivos: descrever as características clínicas e epidemiológicas de crianças internadas por bronquiolite em 13 Unidades de Terapia Intensiva Pediátrica (UTIP) do Uruguai e comparar os resultados finais do atendimento entre UTIP de Montevidéu (UM) e do Interior do país (IU). Material e métodos: estudo observacional retrospectivo multicêntrico dos dados inseridos no banco de dados prospectivo da Rede LARed. Foram incluídas crianças maiores de 1 mês e menores de 2 anos internadas no período de 1º de maio de 2017 a 30 de abril de 2019 com diagnóstico de bronquiolite comunitária. Dados demográficos e clínicos, bem como intervenções e desfechos na alta, foram analisados. Resultados: foram analisados 666 casos. Não foram detectadas diferenças significativas nas comorbidades ou no suporte respiratório na admissão. No IU, os pacientes foram encaminhados com maior frequência a outro hospital. A distância e o tempo médios, assim como o percentual de transferências superiores a 50 km, também foram maiores. No IU, os pacientes apresentaram maior gravidade clínica e gasométrica na admissão. O perfil radiológico e etiológico foi semelhante. O vírus sincicial respiratório (RSV) foi isolado em > 50%. A indicação global de corticosteroides ultrapassou 25% e a de broncodilatadores 85%. A prescrição de antibióticos e adrenalina nebulizada foi maior no IU. A cânula nasal de alto fluxo (CNAF) foi o método de suporte respiratório mais utilizado, embora tenha sido observado um maior uso de ventilação mecânica invasiva (VMI) e CPAP no IU (47% vs 28% em UM). Não houve diferenças no número de complicações devido à VMI ou Ventilação Não Invasiva, ou no uso de terapias de resgate. Também não foram observadas diferenças significativas no tempo de internação na UTIP ou na mortalidade absoluta e ajustada, havendo apenas um caso de nova morbidade. Conclusões: as crianças admitidas no IU apresentaram maior gravidade na admissão e mais fatores de risco relacionados ao mau prognóstico na transferência, recebendo mais antibióticos e suporte invasivo do que as internadas em UM. O CNAF foi o tipo de suporte respiratório mais utilizado no país. Detectou-se alto percentual de prescrição de terapias não recomendadas, como broncodilatadores e corticosteroides. A mortalidade e as complicações foram baixas, assim como a geração de morbidade residual.

Recommendations for the initial management of multisystem inflammatory syndrome temporally related to COVID-19, in children and adolescents. / Recomendaciones para el manejo inicial del síndrome inflamatorio multisistémico relacionado temporalmente con COVID-19, en niños y adolescentes.

Multisystem inflammatory syndrome temporally related to COVID-19 in children and adolescents is a clinical presentation of SARS-CoV-2 infection. It shares some features with Kawasaki disease, toxic shock, sepsis, macrophage activation syndrome, and myocarditis. Few publications have addressed its initial management, which is similar to that proposed for septic shock. This review analyzes such approach based on the characteristics typical of multisystem inflammatory syndrome related to COVID-19 in accordance with the paradigm of an "institutional practice guideline" and suggests therapeutic approach strategies, including early detection, stabilization, referral, specific treatment, and process analysis.

El síndrome inflamatorio multisistémico en niños y adolescentes temporalmente relacionado con COVID-19 es una presentación clínica de la infección por SARS-CoV-2. Comparte algunas características con la enfermedad de Kawasaki, el shock tóxico, la sepsis, el síndrome de activación macrofágica y la miocarditis. Son escasas las publicaciones que abordan su manejo inicial, que tiene semejanzas con el propuesto para el shock séptico. Esta revisión analiza dicho abordaje basado en las características propias del síndrome inflamatorio multisistémico relacionado con COVID-19, de acuerdo con el paradigma de construcción de una "guía de práctica institucional", y sugiere estrategias de aproximación terapéutica, que incluyen detección temprana, estabilización, referencia, tratamiento específico y análisis de procesos.

Reduced PICU respiratory admissions during COVID-19.

BACKGROUND: The COVID-19 pandemic reached the Southern Hemisphere in the autumn of 2020, thus coinciding with its expected annual viral respiratory season. The potential impact of national strategies aimed at mitigating COVID-19 during the pandemic on the incidence of other critical viral lower respiratory tract infections (LRTIs) in children is unknown. METHODS: We analysed admission data for LRTIs from 22 paediatric intensive care units (PICUs) in four countries, part of a large international Latin American registry of children with acute respiratory failure (Red Colaborativa Pediátrica de Latinoamérica [LARed Network]). RESULTS: Between January and August, there were 83% fewer PICU admissions for LRTIs in 2020 compared to the 2018/2019 average over the same period. Similar decreases were noted for PICU admissions due to respiratory syncytial virus and influenza (92% and 78%, respectively). CONCLUSION: We observed a striking reduction in PICU admissions due to viral LRTIs over winter, during the COVID-19 pandemic in South America.

Guía de recomendaciones para el manejo de pacientes pediátricos con enfermedad severa por SARS-CoV-2 / Recommendations guide for the management of pediatric patients with severe SARS-CoV-2

Resumen: La aparición del SARS-CoV-2 a partir de diciembre de 2019 y su rápida expansión en el mundo alcanzando el estatus de Pandemia, se ha convertido en un gran desafío para los equipos de salud. Aunque la evidencia de la infección en niños aún es escasa comparada a la de los adultos, se ha hecho evidente que a nivel de la población pediátrica, la mayor parte de las veces la infección es asintomática o de curso leve, sin embargo no todos los pacientes tienen esta evolución, lo que ha motivado la discusión en los equipos de Cuidados Criticos Pediátricos respecto a cómo enfrentar estos pacientes con enfermedad grave. Este consenso es fruto del trabajo de la Rama de Cuidados Intensivos Pe diátricos de la Sociedad Chilena de Pediatría, recogiendo la evidencia disponible al momento de la revisión más la opinión de expertos nacionales en Cuidados Intensivos Pediátricos. El propósito de estas recomendaciones, es ofrecer a los equipos que atienden a pacientes críticos pediátricos, una guía para el diagnóstico y tratamiento de pacientes que evolucionen con COVID 19 grave, que puedan ser aplicadas en todas las UPC Pediátricas de nuestro país, haciendo especial énfasis en aquellas medidas que han demostrado mayor efectividad a nivel de estudios diagnósticos, tratamiento y cuidados del personal de salud.

Abstract: The appearance of SARS-CoV-2 from December 2019 and its rapid expansion in the world reaching Pandemic status, has become a great challenge for health teams. Although the evidence of infection in children is still scarce compared to that of adults, it has become evident that at the pediatric po pulation level, most of the time the infection is asymptomatic or mild, but not all the patients have this evolution, which has motivated the discussion in the Pediatric Critical Care teams regarding how to face these patients with a more serious disease. This consensus is the result of the work of the Pediatric Intensive Care Branch of the Chilean Society of Pediatrics, collecting the evidence available at the time of the review plus the opinion of national experts in Pediatric Intensive Care. The purpose of these recommendations is to offer teams that care for critically ill pediatric patients a guide for the diagnosis and treatment of patients who evolve with severe COVID 19, which can be applied in all Pediatric UPCs in our country, with special emphasis in those measures that have shown greater effectiveness at the level of diagnostic studies, treatment and care of health personnel.

Protecting children from iatrogenic harm during COVID19 pandemic.

Critical care management of patients with COVID-19 has been influenced by a mixture of public, media and societal pressure, as well as clinical and anecdotal observations from many prominent researchers and key opinion leaders. These factors may have affected the principles of evidence-based medicine and encouraged the widespread use of non-tested pharmacological and aggressive respiratory support therapies, even in intensive care units (ICUs). The COVID-19 pandemic has predominantly affected adult populations, while children appear to be relatively spared of severe disease. Notwithstanding, paediatric intensive care (PICU) clinicians may already have been influenced by changes in practices of adult ICUs, and these changes may pose unintended consequences to the vulnerable population in the PICU. In this article, we analyse several potential iatrogenic causes of the detrimental effects of the current pandemic to children and highlight the risks underlying a sudden change of clinical practice.

Ruptura gástrica idiopática en niño preescolar: informe de un caso / Idiopathic gastric rupture in toddler: case report

La ruptura gástrica idiopática es una patología muy poco frecuenteen niños. La gran mayoría de los casos ocurre en el período neonatal. Comunicamos el caso de una paciente preescolar de 2 años, sexo femenino, sin antecedentes mórbidos. Consultócon antecedente de 48 h de dolor abdominal, náuseas y vómitos.Ingresó al servicio de urgencia en malas condiciones generales, con un abdomen distendido y signos de irritación peritoneal. Se realizó laparotomía exploradora de emergencia que reveló ruptura gástrica en pared posterior ocasionada por múltiples perforaciones. Se efectuó gastrectomía parcial. Ingresó a UCIen shock. Recibió asistencia ventilatoria mecánica, reanimación con fluidos (260 ml/kg en 12 h), fármacos vasoactivos y tratamiento antibiótico con cefotaxima-metronidazol. El laboratorio evidenció leucopenia y trombopenia. El estudio etiológico fue negativo para ingesta de tóxicos y medicamentos. Se descartócolagenopatía y su gastrinemia fue normal. Su postoperatorio se caracterizó por persistencia de fiebre originada porcolección subfrénica izquierda (cultivo positivo para Candida galabrata). Se realizó limpieza quirúrgica mediante laparotomía y drenaje percutáneo de las colecciones residuales. Completótres semanas de terapia antibiótica y antifúngica con evolución satisfactoria. El control ambulatorio de la paciente a los 12 meses fue normal.(AU)

Ruptura gástrica idiopática en niño preescolar: informe de un caso / Idiopathic gastric rupture in toddler: case report

La ruptura gástrica idiopática es una patología muy poco frecuenteen niños. La gran mayoría de los casos ocurre en el período neonatal. Comunicamos el caso de una paciente preescolar de 2 años, sexo femenino, sin antecedentes mórbidos. Consultócon antecedente de 48 h de dolor abdominal, náuseas y vómitos.Ingresó al servicio de urgencia en malas condiciones generales, con un abdomen distendido y signos de irritación peritoneal. Se realizó laparotomía exploradora de emergencia que reveló ruptura gástrica en pared posterior ocasionada por múltiples perforaciones. Se efectuó gastrectomía parcial. Ingresó a UCIen shock. Recibió asistencia ventilatoria mecánica, reanimación con fluidos (260 ml/kg en 12 h), fármacos vasoactivos y tratamiento antibiótico con cefotaxima-metronidazol. El laboratorio evidenció leucopenia y trombopenia. El estudio etiológico fue negativo para ingesta de tóxicos y medicamentos. Se descartócolagenopatía y su gastrinemia fue normal. Su postoperatorio se caracterizó por persistencia de fiebre originada porcolección subfrénica izquierda (cultivo positivo para Candida galabrata). Se realizó limpieza quirúrgica mediante laparotomía y drenaje percutáneo de las colecciones residuales. Completótres semanas de terapia antibiótica y antifúngica con evolución satisfactoria. El control ambulatorio de la paciente a los 12 meses fue normal.

Ruptura gástrica idiopática en niño preescolar: informe de un caso / Idiopathic gastric rupture in toddler: case report

La ruptura gástrica idiopática es una patología muy poco frecuenteen niños. La gran mayoría de los casos ocurre en el período neonatal. Comunicamos el caso de una paciente preescolar de 2 años, sexo femenino, sin antecedentes mórbidos. Consultócon antecedente de 48 h de dolor abdominal, náuseas y vómitos.Ingresó al servicio de urgencia en malas condiciones generales, con un abdomen distendido y signos de irritación peritoneal. Se realizó laparotomía exploradora de emergencia que reveló ruptura gástrica en pared posterior ocasionada por múltiples perforaciones. Se efectuó gastrectomía parcial. Ingresó a UCIen shock. Recibió asistencia ventilatoria mecánica, reanimación con fluidos (260 ml/kg en 12 h), fármacos vasoactivos y tratamiento antibiótico con cefotaxima-metronidazol. El laboratorio evidenció leucopenia y trombopenia. El estudio etiológico fue negativo para ingesta de tóxicos y medicamentos. Se descartócolagenopatía y su gastrinemia fue normal. Su postoperatorio se caracterizó por persistencia de fiebre originada porcolección subfrénica izquierda (cultivo positivo para Candida galabrata). Se realizó limpieza quirúrgica mediante laparotomía y drenaje percutáneo de las colecciones residuales. Completótres semanas de terapia antibiótica y antifúngica con evolución satisfactoria. El control ambulatorio de la paciente a los 12 meses fue normal.(AU)

[Idiopathic gastric rupture in toddler: case report]. / Ruptura gástrica idiopática en niño preescolar: informe de un caso.

Idiopathic gastric rupture is rare in children. Most of them occur in newborn. The authors report the case of a 2-year-old female toddler with no significant medical records. Clinical picture began 48 h before with abdominal pain, nausea and vomiting. She was admitted to the Emergency Room in poor general condition, with abdominal distension and rebound tenderness. Laparotomy was performed immediately show-ing multiple perforations in the posterior wall of the stomach. Partial gastrectomy was performed. Afterwards, she was admitted to ICU in shock. She received mechanical ventilation, intravenous fluid administration (260 ml/kg in 12 h), vasoactive support and antibacterial therapy (cefotaxime and metronidazole). Laboratory showed leukopenia and thrombocytopenia. Etiological study was entirely negative for toxic and drug consumption. Collagen disease was ruled out and serum level of gastrin was normal. Her post operative course was characterized by persistent fever caused by left subphrenic collection (positive culture for Candida galabrata). Peritoneal lavage via laparotomy and percutaneous drainage of the residual collections were performed. She completed 3 weeks of antibacterial and antifungal therapies with adequate outcome. Her follow-up in 12 months was uneventful.