Diagnóstico del delirium en pediatría: una tarea ardua pero imprescindible / The diagnosis of delirium in pediatric intensive care: A burdensome yet essential task

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El niño con enfermedad por virus Ébola: un nuevo reto para el intensivista pediátrico / The child with Ebola virus disease: a new challenger of the pediatric intensive care physician

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Spinal surgery in the univentricular heart--is it viable?

INTRODUCTION: The management of patients with Fontan physiology who undergo scoliosis surgery is difficult. The purpose of this article was to describe our experience in the management of patients with Fontan circulation undergoing spinal surgery for correction of scoliosis. MATERIALS AND METHODS: This was a retrospective study including patients with Fontan physiology who underwent spinal orthopaedic surgery. Anaesthetic management, post-operative complications, paediatric intensive care unit and total hospital stay, and the need for blood transfusions were analysed. RESULTS: We identified eight children with Fontan physiology who had undergone spinal surgery from 2000 to 2010. All patients were receiving cardiac medications at the time of spinal surgery. The mean age at surgery was 14.8 years (range 12-21). In all, three patients needed inotropic support with dopamine (3, 5, and 8 µg/kg/min), which was started during surgery. During the immediate post-operative period, one patient died because of hypovolaemic shock caused by massive bleeding and dysrythmia. Mean blood loss during the post-operative period was 22.2 cc/kg (7.8-44.6). Surgical drainages were maintained for a mean time of 3 days (range 1-7). The mean hospital stay was 9.2 days (range 6-19). Pleural effusions developed in two patients. On follow-up, one patient presented with thoracic pseudarthrosis and another with a serohaematoma of the surgical wound. CONCLUSIONS: Spinal surgery in patients with Fontan circulation is a high-risk operation. These patients must be managed by a specialised team.

Nuevas estrategias de monitorización hemodinámica con el monitor PiCCO / New strategies of hemodynamic monitoring using the PiCCO monitor

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Insuficiencia respiratoria aguda en el niño / Acute respiratory failure in the child

La insuficiencia respiratoria, hipoxia con o sin hipercapnia, es un síndrome frecuente en niños. Su diagnóstico y tratamiento es más sencillo cuando se conoce la fisiopatología. Los procesos implicados en la oxigenación tisular y en la eliminación de dióxido de carbono son la ventilación, la perfusión y la difusión. Alteraciones en cualquiera de estos procesos pueden desencadenar insuficiencia respiratoria. Las manifestaciones clínicas de la insuficiencia respiratoria son muy variadas y la morbi-mortalidad en niños ha disminuido con el desarrollo de nuevas técnicas ventiladoras, tratamientos farmacológicos adyuvantes y ECMO (AU)

Respiratory failure, hypoxia with or without hipercapnia, is common in infants and children. The knowledge of the underlying abnormal physiology facilitates the diagnosis and therapy. A variety of processes including ventilation, perfusion and diffusion are involved in tissue oxygenation and carbon dioxide removal. Abnormalities in any of these mechanisms can lead to respiratory failure. The spectrum of clinical findings I highly variable. Efforts to decrease morbidity and mortality have fuelled investigations into innovative methods of ventilation, ventilation techniques, pharmacotherapeutic adjuncts and extracorporeal life support modalities (AU)

Aneurisma congénito del ductus arterioso: a propósito de un caso con revisión de la literatura / Congenital aneurisma of a patent ductos arterious: a case report

Presentamos un caso de aneurisma congénito del ductus arteriosos con insuficiencia cardiaca neonatal e imagen de masa paracardíaca izquierda en la radiografía de tórax, diagnosticado mediante ecocardiografía y confirmado con angiografía. La paciente fue intervenida sin complicaciones, realizándose exéresis del aneurisma y cierre del ductus. En la evolución se diagnosticó de síndrome de Beals-Hetch. Tras seis años de seguimiento, la paciente está asintomática y con normalidad cardiovascular determinada por ecocardiografía (AU)

We report a case of aneurysm of the ductus arteriosus present with heart failure in the neonatal period. The chest x-ray showed an enlarged heart together with a left paracardiac mass. The echocardiogram showed an aneurysmatic patent ductus arteriosus, confirmed by angiography. The condition was successfully corrected by surgery without complications. In the follow-up a Beals-Hetch syndrome was diagnosed. After 6 years of follow-up, the patient remains symptoms free with normal echocardiographic data (AU)

[Early postoperative complications of thoracoscopy versus thoracotomy in pediatric idiopathic scoliosis]. / Estudio comparativo de las complicaciones postoperatorias inmediatas de la toracoscopia frente a la toracotomía en la escoliosis idiopática infantil.

INTRODUCTION: Thoracoscopic surgery has been used for anterior release, discectomy, and fusion in severe scoliosis or kyphosis. The indications of thoracoscopy for the treatment of pediatric spinal deformity are similar to those of thoracotomy-based spinal surgery. OBJECTIVE: We designed a comparative study to observe the immediate complications in the postoperative period after thoracoscopy or thoracotomy for scoliosis in the pediatric population. MATERIAL AND METHODS: The postsurgical complications of 63 interventions for idiopathic scoliosis over a 10-year period were analyzed. Conventional thoracotomy was used in 37 interventions (59 %) and thoracoscopy was used in 26 (41 %). RESULTS: In patients treated with the thoracolumbar endoscopic procedure, oral nutrition was resumed earlier, the mean length of hospital stay was lower, and debit drainage or requirement of surgical drainage were lower. CONCLUSIONS: Fewer immediate postsurgical complications were observed in scoliosis surgery when thoracoscopy was used.

Estudio comparativo de las complicaciones postoperatorias inmediatas de la toracoscopia frente a la toracotomía en la escoliosis idiopática infantil / Early postoperative complications of thoracoscopy versus thoracotomy in pediatric idiopathic scoliosis

Introducción La toracoscopia es una técnica quirúrgica que se utiliza en cirugía anterior, discectomía y fusión vertebral en pacientes con escoliosis o cifosis graves. Las indicaciones de la toracoscopia para el tratamiento de la deformidad espinal son similares a las de la toracotomía. Objetivo Nos planteamos el estudio comparativo de las complicaciones postoperatorias inmediatas de la toracoscopia frente a la toracotomía en escoliosis infantil. Material y métodos Se analizó, en un período de 10 años, el postoperatorio de 63 intervenciones quirúrgicas de escoliosis idiopática, de las cuales 37 (59 %) se realizaron mediante toracotomía convencional y 26 (41 %) mediante abordaje endoscópico toracolumbar. Resultados En el grupo de pacientes a los que se les practicó un abordaje endoscópico toracolumbar la tolerancia oral fue más precoz y el tiempo de estancia media, así como el débito y requerimiento de los drenajes quirúrgicos fue menor. Conclusiones Las complicaciones de la cirugía de escoliosis en el postoperatorio inmediato son menores cuando la técnica quirúrgica empleada es la toracoscopia

Introduction Thoracoscopic surgery has been used for anterior release, discectomy, and fusion in severe scoliosis or kyphosis. The indications of thoracoscopy for the treatment of pediatric spinal deformity are similar to those of thoracotomy-based spinal surgery. Objective We designed a comparative study to observe the immediate complications in the postoperative period after thoracoscopy or thoracotomy for scoliosis in the pediatric population. Material and methods The postsurgical complications of 63 interventions for idiopathic scoliosis over a 10-year period were analyzed. Conventional thoracotomy was used in 37 interventions (59 %) and thoracoscopy was used in 26 (41 %). Results In patients treated with the thoracolumbar endoscopic procedure, oral nutrition was resumed earlier, the mean length of hospital stay was lower, and debit drainage or requirement of surgical drainage were lower. Conclusions Fewer immediate postsurgical complications were observed in scoliosis surgery when thoracoscopy was used

Encefalopatía tras sedación prolongada con midazolam / Encephalopathy after prolonged sedation with midazolam

La analgesia y la sedación son terapias necesarias para el manejo adecuado del niño críticamente enfermo. El midazolam es una benzodiacepina, ampliamente utilizada en las Unidades de Cuidados Intensivos Pediátricos, a pesar de que su uso continuado produce tolerancia y dependencia. Tras su retirada puede aparecer síndrome de abstinencia y están descritas otras alteraciones neurológicas no claramente relacionadas con la deprivación del mismo. Presentamos el caso de una niña que, tras las retirada de sedación prolongada con midazolam y fentanilo, presentó un cuadro de desconexión de medio, hipertonía generalizada, movimientos estereotipados faciales, automatismos orales, ausencia de fijación de la mirada y de movimientos intencionales, estrabismo y, posiblemente, alucinaciones. La paciente no tuvo síntomas típicos de síndrome de abstinencia y se descartaron otras causas de encefalopatía. Las alteraciones se resolvieron espontáneamente en 3 semanas por lo que la sintomatología se atribuyó a un efecto adverso relacionado con la administración prolongada de midazolam

Analgesia and sedation are essential parts of the management of teh critically ill child. Midazolam is a widely used benzodiazepine in the Pediatric Intensive Care Units, but its use produces tolerance and dependence. After its discontinuation, abstinence syndrome can appear and also there are reported other neurological abnormalities not clearly related with the withdrawal. We report the case of a girl that after discontinuation of prolonged sedation with midazolam and fentanyl showed diminished level of consciousness generalized hipertony, facial grimacing, poor visual tracking, absence of coordinated movements, strabismus and possibly hallucinations. The patient did not present symptoms or signs suggesting withdrawal syndrome. Other causes of encephalopathy were ruled out. All abnormalities were spontaneously resolved in 3 weeks, and were attributed to an adverse effect of prolonged midazolam infusion

[Early postoperative complications after scoliosis surgery]. / Complicaciones médicas precoces en el postoperatorio de cirugía de escoliosis.

Several medical complications can occur after scoliosis surgery in children and adolescents. New surgical techniques have allowed greater degrees of scoliosis correction but have also increased the possibility of postsurgical deficit due to their greater aggressivity. We analyzed the early postsurgical complications of scoliosis surgery in a pediatric intensive care unit over a 10-year period. Seventy-six surgical procedures were performed. Of these, no complications occurred in 55 (73%). Chest X-ray revealed pulmonary atelectasia in 8 patients (10%) and pleural effusion in 7 patients (9%). Symptoms and signs of infection related to surgery were observed in only 6 children (8%). The absence of severe medical complications may be related to new surgical techniques and an experienced team.

Complicaciones médicas precoces en el postoperatorio de cirugía de escoliosis / Early postoperative complications after scoliosis surgery

Diversas complicaciones médicas pueden ocurrir tras la cirugía de columna. Las técnicas quirúrgicas actuales han permitido mayor grado de corrección de la escoliosis, pero al mismo tiempo ha aumentado la posibilidad de déficit postoperatorio debido a su mayor agresividad. Se analizaron las complicaciones precoces en el postoperatorio de cirugía de escoliosis en una unidad de cuidados intensivos a lo largo de 10 años. Se realizaron 76 intervenciones quirúrgicas, de las cuales en 55 (73 %) no hubo ningún tipo de complicaciones. En 8 pacientes (10 %) se observó en la radiografía de tórax una atelectasia pulmonar, siete (9 %) desarrollaron derrames pleurales y únicamente en 6 niños (8 %) se pudo constatar síntomas y signos infecciosos relacionados con la intervención quirúrgica. La ausencia de complicaciones médicas graves se debió, posiblemente, a la asociación de nuevas técnicas con un equipo experimentado

Several medical complications can occur after scoliosis surgery in children and adolescents. New surgical techniques have allowed greater degrees of scoliosis correction but have also increased the possibility of postsurgical deficit due to their greater aggressivity. We analyzed the early postsurgical complications of scoliosis surgery in a pediatric intensive care unit over a 10-year period. Seventy-six surgical procedures were performed. Of these, no complications occurred in 55 (73 %). Chest X-ray revealed pulmonary atelectasia in 8 patients (10 %) and pleural effusion in 7 patients (9 %). Symptoms and signs of infection related to surgery were observed in only 6 children (8 %). The absence of severe medical complications may be related to new surgical techniques and an experienced team

[Ventilation in special situations. Mechanical ventilation in congenital cardiopathies and pulmonary hypertension]. / Ventilación en situaciones especiales. Ventilación mecánica en cardiopatías congénitas e hipertensión pulmonar.

The cardiovascular and respiratory systems act as a functional unit. Mechanical ventilation modifies pulmonary volumes, which generates changes in autonomic nervous system reactivity and provokes tachy- or brady-cardia (depending on the tidal volume used). Mechanical ventilation also decreases cardiac filling volumes (pre-load) and alters pulmonary vascular resistances. In addition, intrathoracic pressures are enlarged, which usually produces a decrease in right atrium filling and an increase in right ventricle afterload. If coronary flow is impaired, myocardial contractility is reduced. However, if cardiac failure is present, mechanical ventilation is especially beneficial because it corrects hypoxia and respiratory acidosis, decreases the work of breathing, and improves stroke volume. Mechanical ventilation in congenital heart diseases is indicated either as lifesaving support or as physiopathological treatment to modify the ratio between pulmonary and systemic flow. As a general rule, if excessive pulmonary blood flow is present, the aim of respiratory support is to increase pulmonary vascular resistance by using high levels of airway pressure and even by delivering FiO2<21%. When there is low pulmonary flow, the lowest possible intrathoracic pressures should be used, especially in cases of pulmonary hypertension, which will also require high FiO2. However, mechanical ventilation has adverse effects and consequently it must be stopped as early as possible, once the child is stable and requires minimal cardiopulmonary support. Weaning can even be performed in the operating room, when the surgical procedure is finished. When this is not possible, weaning should be performed in the pediatric intensive care unit. Because there are no criteria for successful withdrawal of mechanical support in congenital heart disease, general pediatric criteria should be used.