Particularidades del síndrome de dificultad respiratoria aguda en edades pediátricas / Particularities of the acute respiratory distress syndrome at pediatric ages

Desde las primeras descripciones del síndrome de dificultad respiratoria aguda los pediatras intensivistas reconocieron que posee particularidades que la hacen diferente en la población pediátrica. El objetivo de este trabajo es divulgar la definición específica en el modelo infantil, aunque existen similitudes en la fisiopatología del síndrome de dificultad respiratoria en adultos y niños. Se revisaron los conceptos vigentes sobre el síndrome de dificultad respiratoria aguda desde su descripción, a través de los diferentes consensos (desde el de 1994 hasta el de 2015) y se señalaron las recomendaciones en el tratamiento y seguimiento de esta entidad. Los tópicos que se trataron fueron: concepto; prevalencia y epidemiología; fisiopatología, severidad y enfermedades asociadas; soporte ventilatorio; tratamientos secundarios específicos sobre el pulmón; tratamientos concomitantes; monitoreo general y pulmonar; soporte ventilatorio no invasivo; terapia extracorpórea y el seguimiento a largo plazo. Las recomendaciones propuestas en la última conferencia de consenso para el tratamiento del síndrome de dificultad respiratoria en edades pediátricas permiten optimizar el tratamiento e identificar necesidades futuras de investigación del tema.

Since the first descriptions of the acute respiratory distress syndrome, the intensive service pediatrician admitted that it has some particularities that make it different in the pediatric population. The objective of this paper was to explain the specific definition in the infant model despite the similarities in the physiopathology of this syndrome in adults and children. The current concepts about the acute respiratory distress syndrome from its first description through the various consensuses about it (1994 to 2915) were reviewed, and the recommendations in terms of treatment and follow-up were also pointed out. The addressed topics were concept, prevalence and epidemiology, physiopathology, severity and associated diseases; ventilatory support, specific secondary treatments for the lung, concomitant treatments, general and pulmonary monitoring, non-invasive ventilatory support, extracorporeal therapy and long-term follow-up. The recommendations for the treatment of the respiratory distress syndrome at pediatric ages suggested by the last consensus conference allow optimizing the treatment and identifying future requirements for research on this subject.

Particularidades del síndrome de dificultad respiratoria aguda en edades pediátricas / Particularities of the acute respiratory distress syndrome at pediatric ages

Desde las primeras descripciones del síndrome de dificultad respiratoria aguda los pediatras intensivistas reconocieron que posee particularidades que la hacen diferente en la población pediátrica. El objetivo de este trabajo es divulgar la definición específica en el modelo infantil, aunque existen similitudes en la fisiopatología del síndrome de dificultad respiratoria en adultos y niños. Se revisaron los conceptos vigentes sobre el síndrome de dificultad respiratoria aguda desde su descripción, a través de los diferentes consensos (desde el de 1994 hasta el de 2015) y se señalaron las recomendaciones en el tratamiento y seguimiento de esta entidad. Los tópicos que se trataron fueron: concepto; prevalencia y epidemiología; fisiopatología, severidad y enfermedades asociadas; soporte ventilatorio; tratamientos secundarios específicos sobre el pulmón; tratamientos concomitantes; monitoreo general y pulmonar; soporte ventilatorio no invasivo; terapia extracorpórea y el seguimiento a largo plazo. Las recomendaciones propuestas en la última conferencia de consenso para el tratamiento del síndrome de dificultad respiratoria en edades pediátricas permiten optimizar el tratamiento e identificar necesidades futuras de investigación del tema(AU)

Since the first descriptions of the acute respiratory distress syndrome, the intensive service pediatrician admitted that it has some particularities that make it different in the pediatric population. The objective of this paper was to explain the specific definition in the infant model despite the similarities in the physiopathology of this syndrome in adults and children. The current concepts about the acute respiratory distress syndrome from its first description through the various consensuses about it (1994 to 2915) were reviewed, and the recommendations in terms of treatment and follow-up were also pointed out. The addressed topics were concept, prevalence and epidemiology, physiopathology, severity and associated diseases; ventilatory support, specific secondary treatments for the lung, concomitant treatments, general and pulmonary monitoring, non-invasive ventilatory support, extracorporeal therapy and long-term follow-up. The recommendations for the treatment of the respiratory distress syndrome at pediatric ages suggested by the last consensus conference allow optimizing the treatment and identifying future requirements for research on this subject(AU)

Predicted versus measured energy expenditure by continuous, online indirect calorimetry in ventilated, critically ill children during the early postinjury period.

OBJECTIVE: Compare the energy expenditure, predicted by anthropometric equations, with that measured by continuous on-line indirect calorimetry in ventilated, critically ill children during the early postinjury period. DESIGN: Prospective, clinical study. SETTING: Pediatric intensive care unit of a pediatric university hospital. PATIENTS: A total of 43 ventilated, critically ill children during the first 6 hrs after injury. INTERVENTIONS: An indirect calorimeter was used to continuously measure the energy expenditure for 24 hrs. MEASUREMENTS AND MAIN RESULTS: Clinical data collected were age, gender, actual and ideal weight, height, and body surface. Nutritional status was assessed by Waterlow and Shukla Index. Severity of illness was determined by Pediatric Risk of Mortality, Physiologic Stability Index, and Therapeutic Intervention Scoring System. Energy expenditure was measured (MEE) by continuous on-line indirect calorimetry for 24 hrs. Predicted Energy Expenditure (PEE) was calculated using the Harris-Benedict, Caldwell-Kennedy, Schofield, Food and Agriculture/World Health Organization/United Nation Union, Maffeis, Fleisch, Kleiber, Dreyer, and Hunter equations, using the actual and ideal weight. MEE and PEE were compared using paired Student's t-test, linear correlation (r), intraclass correlation coefficient (pI), and the Bland-Altman method. Mean MEE resulted in 674 +/- 384 kcal/day. Most of the predictive equations overestimated MEE in ventilated, critically ill children during the early postinjury period. MEE and PEE differed significantly (p<.05) except when the Caldwell-Kennedy and the Fleisch equations were used. r2 ranged from 0.78 to 0.81 (p<.05), and pI was excellent (>.75) for the Caldwell-Kennedy, Schofield, Food and Agriculture/World Health Organization/United Nation Union, Fleisch, and Kleiber equations. The Bland-Altman method showed poor accuracy; the Caldwell-Kennedy equation was the best predictor of energy expenditure (bias, 38 kcal/day; precision, +/- 179 kcal/day). The accuracy in the medical group was higher (pI range,.71-.94) than in surgical patients (pI range,.18-.75). CONCLUSIONS: Predictive equations do not accurately predict energy expenditure in ventilated, critically ill children during the early postinjury period; if available, indirect calorimetry must be performed.

Soluciones utilizadas en el tratamiento de la hipovolemia

Se realizó una actualización sobre el uso de las sustancias más utilizadas en el reemplazo de volumen. Se plantea que la controversia entre el uso de cristaloides/coloides aún mantiene vigencia, aunque se trata de hallar la sustancia ideal que restablezca la volemia de forma adecuada, con el mínimo de reacciones adversas y costo. Dentro de los coloides se enfatizó en las desventajas del uso de la albúmina y su sustitución por otros expansores de volumen de tipo coloide, donde se encuentran las gelatinas y los almidones. Otro tipo de sustancias transportadoras de oxígeno están en fase de ensayo clínico, como son los fluorocarbonos y las hemoglobinas sintéticas, sin que se haya encontrado superioridad de tipo terapéutico.

An updating on the most used substances in volume therapy is made. It is stated that the controversy aroused by the use of crystalloids/colloids is still standing, although efforts are made to find the ideal substance to reestablish volemia in an appropiate way with the minimum of adverse reactions and cost. As regards colloids, emphasis is made on the disadvantages of the use of albumin and its substitution by other colloid volume expanders, such as gelatins and starches. Other types of oxygen transporting substances as fluorocarbons and synthetic haemoglobins are under clinical assay. No therapeutic superiority has been found yet.