Mortality in patients with severe COVID-19 who underwent tracheostomy due to prolonged mechanical ventilation / Mortalidad en pacientes con COVID-19 grave sometidos a traqueostomía por ventilación mecánica prolongada

BACKGROUND: The usefulness of tracheostomy has been questioned in patients with COVID-19 and prolonged invasive mechanical ventilation (IMV). AIM: To compare the 90-day mortality rate of patients who underwent a tracheostomy due prolonged IMV with those that did not receive this procedure. MATERIAL AND METHODS: We studied a historical cohort of 92 patients with COVID-19 and prolonged IMV (> 10 days). The primary outcome was the 90-day mortality rate. Secondary outcomes included days on IMV, hospital/intensive care unit (ICU) length of stay, frequency of nosocomial infections, and thrombotic complications demonstrated by images. A logistic regression was performed to adjust the effect of tracheostomy by SOFA score and days on IMV. RESULTS: Forty six patients aged 54 to 66 years (72% males) underwent tracheostomy. They had a median of two comorbidities, and received the procedure after a median of 20.5 days on IMV (interquartile range: 17-26). 90-day mortality was lower in patients who were tracheostomized than in the control group (6.5% vs. 32.6%, p-value < 0.01). However, after controlling for confounding factors, no differences were found in mortality between both groups (relative risk = 0.303, p-value = 0.233). Healthcare-associated infections and hospital/ICU length of stay were higher in patients with tracheostomy than in controls. Thrombotic complications occurred in 42.4% of the patients, without differences between both groups. No cases of COVID-19 were registered in the healthcare personnel who performed tracheostomies. CONCLUSIONS: In patients with COVID-19 undergoing prolonged IMV, performing a tracheostomy is not associated with excess mortality, and it is a safe procedure for healthcare personnel.

ANTECEDENTES: La utilidad de la traqueostomía en pacientes COVID-19 sometidos a ventilación mecánica invasiva (VMI) prolongada ha sido cuestionada. OBJETIVO: Comparar la mortalidad a 90 días en estos pacientes, con y sin traqueostomía. MATERIAL Y MÉTODOS: Estudiamos una cohorte histórica de 92 pacientes COVID-19 con VMI prolongada (>10 días). El desenlace prima-rio fue mortalidad a 90 días. Se consideraron desenlaces secundarios los días en VMI, estadía hospitalaria/UCI, frecuencia de infecciones nosocomiales, y eventos trombóticos. Mediante regresión logística se ajustó el efecto de la traqueostomía en la mortalidad, por SOFA y días de VMI. RESULTADOS: Cuarenta y seis pacientes de 54 a 66 años (72% hombres) fueron traqueostomizados. Ellos tenían una mediana de dos comorbilidades, y recibieron el procedimiento luego de una mediana de 20,5 días en VMI (rango intercuartílico: 17-26). En el análisis crudo, la mortalidad a 90 días fue menor en los pacientes con traqueostomía que en el grupo control (6,5% vs. 32,6%; p < 0,001). No obstante, luego de controlar por factores de confusión, no se encontraron diferencias en mortalidad (riesgo relativo 0,303; p = 0,233). Las infecciones asociadas a la atención de salud y la estadía en hospital/UCI fueron mayores en los pacientes traqueostomizados que en los controles. Los eventos trombóticos ocurrieron en el 42,4% de los pacientes, sin diferencias entre grupos. No hubo casos de COVID-19 en el personal de salud que realizó las traqueostomías. CONCLUSIONES: En pacientes con COVID-19 sometidos a VMI prolongada, la realización de una traqueostomía no se asocia a un exceso de mortalidad, y es un procedimiento seguro para el personal sanitario.

Mortality in patients with severe COVID-19 who underwent tracheostomy due to prolonged mechanical ventilation.

BACKGROUND: The usefulness of tracheostomy has been questioned in patients with COVID-19 and prolonged invasive mechanical ventilation (IMV). AIM: To compare the 90-day mortality rate of patients who underwent a tracheostomy due prolonged IMV with those that did not receive this procedure. MATERIAL AND METHODS: We studied a historical cohort of 92 patients with COVID-19 and prolonged IMV (> 10 days). The primary outcome was the 90-day mortality rate. Secondary outcomes included days on IMV, hospital/intensive care unit (ICU) length of stay, frequency of nosocomial infections, and thrombotic complications demonstrated by images. A logistic regression was performed to adjust the effect of tracheostomy by SOFA score and days on IMV. RESULTS: Forty six patients aged 54 to 66 years (72% males) underwent tracheostomy. They had a median of two comorbidities, and received the procedure after a median of 20.5 days on IMV (interquartile range: 17-26). 90-day mortality was lower in patients who were tracheostomized than in the control group (6.5% vs. 32.6%, p-value < 0.01). However, after controlling for confounding factors, no differences were found in mortality between both groups (relative risk = 0.303, p-value = 0.233). Healthcare-associated infections and hospital/ICU length of stay were higher in patients with tracheostomy than in controls. Thrombotic complications occurred in 42.4% of the patients, without differences between both groups. No cases of COVID-19 were registered in the healthcare personnel who performed tracheostomies. CONCLUSIONS: In patients with COVID-19 undergoing prolonged IMV, performing a tracheostomy is not associated with excess mortality, and it is a safe procedure for healthcare personnel.

[Herpes Zoster Ophthalmicus presenting as acute headache]. / Debut de herpes zóster oftálmico como cefalea intensa.

Herpes Zoster (HZ) is rare in childhood and is defined as the reactivation of the latent varicella-zoster virus in patients who have previously been infected with varicella. When the virus affects the ophthal mic nerve it is called herpes zoster ophthalmicus (HZO) and it can produce, among other symptoms, acute headache, so it must be considered as a differential diagnosis. OBJECTIVE: To describe a clinical case of HZO in a pediatric patient and to recognize its clinical manifestations and their importance in the differential diagnosis of acute headache in children. CLINICAL CASE: Immunocompetent 11-year- old girl, vaccinated according to the recommended immunization schedule, excluding chickenpox vaccine due to past infection, presented to the emergency department (ED) with a 5-day long uni lateral headache. After 36 hours of hospitalization, she presented vesicular cutaneous lesions in her forehead, left upper eyelid, and nose. Positive fluorescein stain dendritic corneal lesions were iden tified in the ophthalmic exam. Antiviral systemic and topic therapy were set, obtaining an initial good response, but later she presented complications such as postherpetic neuralgia one month after hospital discharge and several postherpetic neuralgia episodes despite treatment with gabapentin in addition to two herpes zoster ophthalmicus relapses with acute keratouveitis one year after the initial episode. CONCLUSION: It is essential to include HZO in the differential diagnosis of acute headache, especially when presented unilaterally and/or with ocular symptoms, regardless of the presence of cutaneous lesions, and even more so in patients with history of chickenpox infection. Those patients who were vaccinated against this disease in their childhood will benefit from at least partial protection against HZO.

Problemas diagnósticos de la intoxicación por cianuro derivada de la ingesta de almendras amargas / Difficulties in the diagnosis of cyanide poisoning following consumption of bitter almonds

Los casos de intoxicación por ingesta de cianuro en niños son raros. La almendra amarga contiene amigdalina y se descompone tras su ingesta, produciendo ácido cianhídrico que bloquea el uso celular del oxígeno, lo que ocasiona afectación de órganos diana. Presentamos un caso de sospecha de intoxicación por cianuro en un niño de 3 años tras ingesta de almendras amargas. El diagnóstico de sospecha se estableció con base en la clínica gastrointestinal y neurológica y en el hallazgo gasométrico de acidosis metabólica con hiperlactacidemia y anión GAP aumentado, lo cual es muy específico de esta entidad. No se pudieron determinar los niveles de cianuro en ningún laboratorio habitual de España, tampoco en el Instituto Toxicológico Nacional y Ciencias Forenses sin disponer de orden judicial. Ante la clínica inespecífica y las dificultades para determinar la concentración de cianuro en sangre, debe ofrecerse tratamiento precoz y antídoto específico ante la sospecha de intoxicación por cianuro (AU)

Cyanide poisoning in children is rare. Bitter almonds contain amygdalin, and hydrolysis of this compound following ingestion yields hydrocyanic acid, which inhibits cellular oxygen use and therefore causes target organ damage. We present a case of suspected cyanide poisoning in a child aged 3 years after the ingestion of bitter almonds. The diagnosis was based on the gastrointestinal and neurological symptoms and the detection of metabolic acidosis with hyperlacticaemia and a high anion gap, which are highly specific for this type of poisoning. Blood cyanide levels could not be measured in any clinical laboratory in Spain, and it was also not possible to do it in the National Institute of Toxicology and Forensic Sciences without a court order. Given the non-specific symptoms and the difficulty of measuring the concentration of cyanide in blood, treatment should be initiated early with administration of specific antidote if cyanide poisoning is suspected. (AU)

[Actions that should not be taken with a paediatric patient who has been exposed to a potentially toxic substance]. / Acciones que no hay que hacer ante un paciente que ha contactado con un posible tóxico.

OBJECTIVE: To show the preparation process by the Poisoning Working Group of the Spanish Society of Paediatric Emergencies (GTI-SEUP), of the list of things «not to do¼ for a paediatric patient who has been exposed to a potentially toxic substance. METHOD: The preparation process of the list was carried out in three phases. First: «Brainstorming¼ that was open to all members of the GTI-SEUP. Second: Recommendations were selected by following modified-Delphi methodology. All participants were asked to rate the proposals (from 1 = strongly disagree to 9 = strongly agree). Those with an average score greater than 8 were accepted (provided that at least two-thirds of the participants had given them a score ≥ 7), and a second consultation was made for the recommendations with an average score between 6 and 8. Third: Writing and creating a consensus of the final document was done. RESULT: A total of 11 proposals were initially obtained. Thirty-two of the 57 GTI-SEUP participants completed the scoring questionnaire. In the first consultation, seven «not to do¼ recommendations were accepted, and four obtained a doubtful average score (between 6 and 8). After the second consultation, the list was made up of eight recommendations. Two refer to general management, four to gastrointestinal decontamination techniques, and two to the administration of antidotes. CONCLUSION: The list of actions that should not be taken with a child that has been exposed to a possible poison is a consensus tool, within the GTI-SEUP, to promote improvement in the quality of care offered to these patients. This improvement is based on avoiding unnecessary measures, which can sometimes be harmful to the child.

Impacto de la normativa autonómica para la prevención de accidentes pirotécnicos / Impact of regional laws on firework accident prevention

No disponible

Granuloma de Majocchi / Majocchi granuloma

No disponible

Otoemisiones en los niños tratados con gentamicina de un hospital comarcal / Otoacoustic emissions in children treated with gentamicin in a secondary hospital

INTRODUCCIÓN: Las recomendaciones de la Comisión Nacional para la Detección Precoz de la Hipoacusia (CODEPEH) aconsejan re-valorar la audición de aquellos niños que hayan sufrido algún evento potencialmente dañino para la audición como es la utilización de antibióticos ototóxicos como la gentamicina. Las otoemisiones evocadas son un buen método de evaluación de la integridad de la función coclear. MATERIAL Y MÉTODO: Se presenta un estudio prospectivo que incluye a 92 niños, sin otros factores de riesgo auditivo, en los que se pautó tratamiento con gentamicina intravenosa por riesgo séptico/sepsis o infección urinaria y en los que se realizaron otoemisiones seriadas: al ingreso, al finalizar el tratamiento y al mes del alta (si estaban alteradas). RESULTADOS: Ningún sujeto presentó otoemisiones alteradas al final del seguimiento. CONCLUSIÓN: La gentamicina parece un antibiótico seguro en tratamientos con una duración < 10 días y a las dosis descritas. Las otoemisiones son un método barato, rápido, incruento y fiable para comprobar la posible ototoxicidad por gentamicina. Su realización podría ahorrar la determinación de niveles del fármaco

INTRODUCTION: The National Commission for the Early Detection of Hearing Loss (CODEPEH) recommends the re-evaluation of hearing in children who have suffered any potentially harmful event, such as the prescription of ototoxic antibiotics such as gentamicin. The evoked otoacoustic emissions (EOAE) are a good method for assessing the integrity of cochlear functionality. MATERIAL AND METHOD: A prospective study is presented, including 92 children who were treated with intravenous gentamicin for septic risk/sepsis or urinary tract infection. The children underwent serial EOAE: on admission, at the end of treatment and one month later (if altered on discharge). RESULTS: In the end, none of the subjects were affected by the treatment. CONCLUSION: Gentamicin appears to be a safe antibiotic in treatments lasting < 10 days and at the doses described. EOAE are an inexpensive, fast, non-invasive and reliable method to check for gentamicin ototoxicity. This could save in the determination of drug levels

Otoacoustic emissions in children treated with gentamicin in a secondary hospital. / Otoemisiones en los niños tratados con gentamicina de un hospital comarcal.

INTRODUCTION: The National Commission for the Early Detection of Hearing Loss (CODEPEH) recommends the re-evaluation of hearing in children who have suffered any potentially harmful event, such as the prescription of ototoxic antibiotics such as gentamicin. The evoked otoacoustic emissions (EOAE) are a good method for assessing the integrity of cochlear functionality. MATERIAL AND METHOD: A prospective study is presented, including 92 children who were treated with intravenous gentamicin for septic risk/sepsis or urinary tract infection. The children underwent serial EOAE: on admission, at the end of treatment and one month later (if altered on discharge). RESULTS: In the end, none of the subjects were affected by the treatment. CONCLUSION: Gentamicin appears to be a safe antibiotic in treatments lasting <10days and at the doses described. EOAE are an inexpensive, fast, non-invasive and reliable method to check for gentamicin ototoxicity. This could save in the determination of drug levels.