ECMO cardiaco / Cardiac ECMO

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Cuidados del donante / Care of the donor

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Asistencia inicial al traumatismo pediátrico y reanimación cardiopulmonar / Initial pediatric trauma care and cardiopulmonary resuscitation

Los accidentes son la causa más frecuente de muerte en niños por encima del año de edad. Las causas más importantes de muerte por accidente son los accidentes de tráfico, el ahogamiento, las lesiones intencionadas, las quemaduras y las caídas. La reanimación cardiopulmonar es una parte más del conjunto de acciones de estabilización inicial en un niño con traumatismo. La parada cardiorrespiratoria en los primeros minutos después del accidente, ocurre generalmente por obstrucción de la vía aérea o mala ventilación, pérdida masiva de sangre o lesión cerebral grave, y tiene muy mal pronóstico. La parada en las horas siguientes al traumatismo está generalmente producida por hipoxia, hipovolemia, hipotermia, hipertensión intracraneal o alteraciones hidroelectrolíticas. La primera respuesta ante el traumatismo, tiene tres componentes: proteger (valoración del escenario y establecimiento de medidas de seguridad), alarmar (activación del sistema de emergencias) y socorrer (atención inicial al traumatismo). La atención inicial al traumatismo se divide en reconocimiento primario y secundario. El reconocimiento primario incluye los siguientes pasos secuenciales: A. control cervical, alerta y vía aérea; B: respiración; C: circulación y control de la hemorragia; D: disfunción neurológica, y E: exposición. El reconocimiento secundario consiste en la evaluación del accidentado mediante la anamnesis, exploración física ordenada desde la cabeza a las extremidades y práctica de exámenes complementarios. Durante la atención al traumatismo se pueden precisar algunas maniobras específicas que no suelen ser necesarias en otras situaciones de emergencia como son maniobras de extracción y movilización, control cervical mediante inmovilización cervical bimanual y colocación del collarín cervical y retirada del casco. Si durante la asistencia inicial al traumatismo ocurre una parada cardiorrespiratoria las maniobras de reanimación cardiopulmonar se realizarán de forma inmediata adaptándose a las características específicas del niño traumatizado

Accidents are a frequent cause of death in children older than 1 year. The most frequent causes of death by accident are traffic accidents, drowning, intentional injuries, burns, and falls. Cardiopulmonary resuscitation is one component of the set of actions needed to obtain initial stabilization of a child with serious trauma. In the first few minutes after the accident, cardiorespiratory arrest can occur due to airway obstruction or inadequate ventilation, massive blood loss or severe brain damage; cardiorespiratory arrest in this setting has a dismal outcome. When arrest occurs hours after trauma, it is usually caused by hypoxia, hypovolemia, hypothermia, intracranial hypertension, or electrolyte disturbances. The first response to trauma should include three objectives: to protect (scenario assessment and implementation of safety measures), to alert (activation of the emergency medical system) and to help (initial trauma care). Initial trauma care includes primary and secondary surveys. The primary survey involves several consecutive steps: A. airway and cervical spine stabilization, B. breathing, C. circulation and hemorrhage control, D. neurological dysfunction, and E. exposure. The secondary survey consists of assessment of the victim by means of anamnesis, sequential physical examination (from head to limbs) and complementary investigations. During emergency trauma care, specific procedures such as extrication and mobilization maneuvers, cervical spine control by means of bimanual immobilization, and cervical collar placement or helmet removal. If a cardiorespiratory arrest occurs during initial trauma care, resuscitation maneuvers must be immediately started with the specific adaptations indicated in children with trauma

[Pharmacokinetic interaction between valproic acid and meropenem]. / Interacción farmacocinética entre ácido valproico y meropenem.

Several reports have described a decrease in valproic acid (VPA) serum concentrations when carbapenem therapy is administered. The exact mechanism of this pharmacokinetic interaction is unknown, although several experimental studies have been carried out in animals. Because of these interactions, plasma concentrations of VPA in these patients should be monitored and, whenever possible, VPA or carbapenem therapy should be substituted by other drugs. We describe the cases of two epileptic children who simultaneously received meropenem and VPA. Concentrations of VPA decreased to subtherapeutic levels. We review the various mechanisms for this interaction proposed to date, as well as all reported cases.

Interacción farmacocinética entre ácido valproico y meropenem / Pharmacokinetic interaction between valproic acid and meropenem

Se ha descrito que la administración de antibióticos carbapenémicos puede producir la disminución de las concentraciones plasmáticas de ácido valproico (VPA). El mecanismo por el que se produce esta interacción farmacocinética no está claro, a pesar de los estudios publicados en modelos animales. Dada la interacción, se aconseja la monitorización de concentración y la sustitución, siempre que sea posible, del VPA por otro antiepiléptico o del carbapenem por un antibiótico de otro grupo. Se describen los casos de 2 niños epilépticos que recibieron simultáneamente meropenem y VPA y en los que se observa una disminución de las concentraciones plasmáticas de VPA hasta niveles subterapéuticos. Se recogen los mecanismos propuestos para la interacción y los casos publicados hasta la fecha

Several reports have described a decrease in valproic acid (VPA) serum concentrations when carbapenem therapy is administered. The exact mechanism of this pharmacokinetic interaction is unknown, although several experimental studies have been carried out in animals. Because of these interactions, plasma concentrations of VPA in these patients should be monitored and, whenever possible, VPA or carbapenem therapy should be substituted by other drugs. We describe the cases of two epileptic children who simultaneously received meropenem and VPA. Concentrations of VPA decreased to subtherapeutic levels. We review the various mechanisms for this interaction proposed to date, as well as all reported cases

[Initial pediatric trauma care and cardiopulmonary resuscitation]. / Asistencia inicial al traumatismo pediátrico y reanimación cardiopulmonar.

Accidents are a frequent cause of death in children older than 1 year. The most frequent causes of death by accident are traffic accidents, drowning, intentional injuries, burns, and falls. Cardiopulmonary resuscitation is one component of the set of actions needed to obtain initial stabilization of a child with serious trauma. In the first few minutes after the accident, cardiorespiratory arrest can occur due to airway obstruction or inadequate ventilation, massive blood loss or severe brain damage; cardiorespiratory arrest in this setting has a dismal outcome. When arrest occurs hours after trauma, it is usually caused by hypoxia, hypovolemia, hypothermia, intracranial hypertension, or electrolyte disturbances. The first response to trauma should include three objectives: to protect (scenario assessment and implementation of safety measures), to alert (activation of the emergency medical system) and to help (initial trauma care). Initial trauma care includes primary and secondary surveys. The primary survey involves several consecutive steps: A. airway and cervical spine stabilization, B. breathing, C. circulation and hemorrhage control, D. neurological dysfunction, and E. exposure. The secondary survey consists of assessment of the victim by means of anamnesis, sequential physical examination (from head to limbs) and complementary investigations. During emergency trauma care, specific procedures such as extrication and mobilization maneuvers, cervical spine control by means of bimanual immobilization, and cervical collar placement or helmet removal. If a cardiorespiratory arrest occurs during initial trauma care, resuscitation maneuvers must be immediately started with the specific adaptations indicated in children with trauma.

[Prevalence of mechanical ventilation in pediatric intensive care units in Spain]. / Prevalencia de la ventilación mecánica en las unidades de cuidados intensivos pediátricos en España.

OBJECTIVE: To study the prevalence and characteristics of mechanical ventilation in children admitted to Spanish pediatric intensive care units (PICU). MATERIAL AND METHODS: A prospective, multicenter, observational study was performed using a written questionnaire sent to the 46 PICUs in Spain. Clinical data and mechanical ventilation settings in patients undergoing mechanical ventilation on 19th February 2002 were collected. RESULTS: Thirty-three PICUs participated in the study (27 had patients undergoing mechanical ventilation on the study day). The prevalence of mechanical ventilation was 86 patients (45.5 %). The mean age of patients undergoing mechanical ventilation was 36 months and the median was 8 months. Sixty percent of the patients were boys. The main indications for mechanical ventilation were acute respiratory failure (46.5 %), chronic respiratory failure (10.4 %), coma (11.6 %) and postoperative status (10.5 %). Endotracheal tubes were used in 73.2 % and a tracheostomy tube was used in 23.2 %. The most frequent mechanical ventilation modalities used were synchronized intermittent mandatory ventilation (SIMV) in 43 % and control or assisted-control ventilation in 36 %. In 30 % of the patients the duration of mechanical ventilation was longer than 1 month. From the initiation of mechanical ventilation to the study day, pneumothorax developed in 8.1 % of the patients, accidental extubation occurred in 10.5 % and ventilator-associated pneumonia developed in 17.4 %. CONCLUSIONS: A high percentage of children admitted to the PICU requires mechanical ventilation. The most frequent indication is respiratory failure. The most frequently used modality in children aged less than 1 month is pressure SIMV. In children older than 1 month volume-cycled or pressure-limited ventilation and volume-cycled SMIV are used in similar proportions. The prevalence of prolonged mechanical ventilation and the incidence of ventilator-associated complications are very high.

[Group B Streptococcus late-onset disease presenting as cellulitis-adenitis syndrome]. / Síndrome de celulitis-adenitis por estreptococo del grupo B como presentación de sepsis neonatal tardía.

Cellulitis-adenitis syndrome is a rare clinical manifestation of group B Streptococcus (GBS) late-onset disease. Its significance lies in the fact that local infection may be the only initial sign of systemic infection that is often concurrent with meningitis. Soft tissue involvement (cellulitis-adenitis) can sometimes be the only initial manifestation of GBS infection. We report four cases of GBS cellulitis-adenitis syndrome from different hospitals in Barcelona and Tarragona. We emphasize that early diagnosis and treatment may improve the potentially poor prognosis of these patients, and stress the need to rule out central nervous system involvement by studying cerebrospinal fluid.

Síndrome de celulitis-adenitis por estreptococo del grupo B como presentación de sepsis neonatal tardía / Group B Streptococcus late-onset disease presenting as cellulitis-adenitis syndrome

El síndrome de celulitis-adenitis es una forma de presentación clínica poco frecuente de la sepsis neonatal tardía por estreptococo del grupo B. La principal importancia de esta entidad radica en el hecho que se trata de una manifestación local de un proceso infeccioso sistémico que con frecuencia afecta al sistema nervioso central (SNC). En ocasiones, la afectación de tejidos blandos (adenitis-celulitis) puede ser la única manifestación inicial de la dicha infección. Se presentan 4 casos de esta entidad en diferentes centros hospitalarios de Barcelona y Tarragona, con la intención de remarcar que el diagnóstico y el tratamiento precoces pueden mejorar el pronóstico potencialmente grave de estos pacientes, y se insiste en la necesidad de descartar una posible afectación del SNC mediante estudio del líquido cefalorraquídeo (AU)

[Respiratory function monitoring: curves of pressure, volume and flow]. / Monitorización de la función respiratoria: curvas de presión, volumen, y flujo.

Respiratory function curves are a graphic representation of changes in volume, pressure or flow during the respiratory cycle. These changes can represent changes with respect to time (curves of volume-time, pressure-time and flow-time) or changes in one variable with respect to another (curves of flow-volume and of volume-pressure). Respiratory function curves enable analysis of the physiopathology in a patient, detection of changes in clinical status, optimization of ventilatory strategy, and evaluation of treatment response. They can also be used to facilitate patient comfort, prevent complications and iatrogeny, evaluate the course of weaning from mechanical ventilation, and help to establish a prognosis. In clinical practice these curves can show the presence of air leaks, indicate possible high resistance in the airway, suggest the possibility of trapped air, detect the presence of anomalous expiratory volume, identify the presence of secretions in the airway or water in the circuit, indicate the optimal PEEP, and reveal changes in pulmonary compliance.

Retirada de la asistencia respiratoria / Weaning from mechanical ventilation

La retirada de la VM define el proceso que permite el paso de VM a ventilación espontánea. Se trata de un proceso que puede ocupar una porción significativa de la duración total de la VM y cuyo éxito o fracaso tiene implicaciones de gran trascendencia para el paciente. Para asegurar al máximo su éxito es preciso evaluar minuciosamente al paciente mediante: valoración de los requisitos para la extubación, tanto clínicos como de soporte ventilatorio; realización de una prueba preextubación y la evaluación de los indicadores pronósticos del éxito o fracaso de la extubación. La valoración preextubación pasa generalmente por una prueba de respiración espontánea en tubo en T o bien con CPAP con presión de soporte, sin que ninguno de los dos métodos haya demostrado superioridad sobre el otro. El mejor indicador pronóstico del éxito de la extubación es la valoración clínica del esfuerzo respiratorio del paciente. Por último, una vez llevada a cabo la retirada del soporte ventilatorio puede ser necesario tratar sus complicaciones o, incluso, reinstaurar la VM (AU)

[Mechanical ventilation in pediatrics (III). Weaning, complications and other types of ventilation. Weaning from mechanical ventilation]. / Ventilación mecánica en pediatría (III). Retirada de la ventilación, complicaciones y otros tipos de ventilación. Retirada de la asistencia respiratoria.

Weaning from mechanical ventilation can be defined as the process that allows the transition from mechanical ventilation to spontaneous breathing. This process can account for a significant proportion of total ventilation time and failure to resume spontaneous breathing affects patient outcome. Thus, to ensure maximum success, patient readiness for weaning and extubation should be evaluated through the following steps: the patient must fulfill pre-established clinical and ventilatory support criteria for extubation, the patient should be observed during a breathing trial on minimal or no ventilatory support, and variables used to predict weaning success should indicate a favorable outcome. Breathing trials are usually conducted while the patient breathes spontaneously through a T-tube system or through the ventilator circuit on minimal ventilatory support. Neither of these methods has proved superior to the other. The best prognostic indicator of weaning outcome is clinical assessment of respiratory effort. Once mechanical ventilation is discontinued, it may be necessary to treat post-extubation complications or even to resume ventilatory support.

[End-of-life decision-making in critical care]. / Limitación terapéutica en cuidados intensivos.

Introduction Termination of artificial life-support in critically-ill patients without chance of recovery or with severe damage is frequent in the intensive care unit (UCI). Patients and methodsWe studied the present situation concerning the withdrawal of life support in Spain using data collected over 10 years in referral hospitals with pediatric ICUs. Forty-nine patients were included, of which 43 had chronic diseases.ResultsThe most frequent causes of admission to the pediatric ICU in this type of patiens was respiratory failure followed by cardiovascular surgery. The family seemed to be a key element when taking a decision although in a few cases the medical team acted paternalistically. The most common ways of limiting life-support were withholding or withdrawing some treatments (mainly mechanical ventilation and vasoactive drugs) and implementing do-not-resuscitate orders. Sedation and suitable pain management were widely used in terminal care. After the decision to limit life-support was made, six patients were discharged from the pediatric ICU. ConclusionsAlthough each case should be treated individually, because of the wide variation found in the limitation of life-support, we suggest the need for common guidelines that could help the decision-making process.

[Pediatric trauma life support and cardiopulmonary resuscitation]. / Asistencia inicial al trauma pediátrico y reanimación cardiopulmonar.

Accidents are the most frequent cause of mortality among children older than one year. Thus, the need to proceed to cardiopulmonary resuscitation (CPR) during the early phases of trauma life support (TLS) is always a possibility. Trauma is a special situation in CPR: expected problems (i.e., hemorrhage, pneumo-hemothorax, hypothermia, and difficult intubation and vascular access), specific therapeutic actions (i.e., helmet retrieval and cervical spine immobilization), and exceptions to standard CPR guidelines (i.e., contraindication for the head tilt-chin lift manoeuvre) can arise. Therefore, TLS and CPR interventions must be appropriately integrated. TLS is considered a method (much like CPR). It combines organization and leadership with competent, structured and timely actions. Appropriate intervention within the first few moments ("platinum half-hour" and " golden hour") and first day ("silver day") is essential. As in CPR, two modalities can be distinguished: basic TLS (on the scene, without technical resources) and advanced TLS (with resources). The acronym PAA summarizes basic TLS: Protect-Alert-Aid. The advanced TLS sequence includes the following: primary survey and initial stabilization, secondary survey, triage, transport, and definitive care. The main objective of the primary survey and initial stabilization phase is the identification and treatment of injuries with immediate potential to cause death. CPR in the context of TLS should be adapted to the special features of trauma. Particular attention should be paid to the cervical spine. While not specific for trauma care, the early and generous administration of oxygen should be emphasized.

Asistencia inicial al trauma pediátrico y reanimación cardiopulmonar / Pediatric trauma life support and cardiopulmonary resuscitation

Los accidentes son la causa más frecuente de muerte en niños de más de 1 año. Así, es posible tener que proceder a la reanimación cardiopulmonar (RCP) durante la asistencia inicial al trauma pediátrico (AITP). El trauma constituye una situación especial en cuanto a la RCP: problemas esperables (p. ej., hemorragia, neumo-hemotórax, hipotermia, dificultades para la intubación o el acceso vascular), acciones terapéuticas particulares (p. ej., retirada de casco, colocación de collarín cervical), y excepciones a las recomendaciones generales de reanimación (p. ej., contraindicación de la maniobra frente-mentón).Por ello, es necesario saber integrar AITP y RCP.La AITP es un método de actuación (como la RCP) que combina organización y liderazgo con actuación competente, estructurada y oportuna. La actuación en los primeros momentos ("media hora de platino" y " hora de oro") y durante el primer día ("día de plata") es esencial. Como en la RCP se distinguen dos modalidades: AITP básica (en el escenario, sin recursos materiales) y AITP avanzada (con recursos). La AITP básica se resume en el acrónimo PAS: Proteger-Alertar-Socorrer. La secuencia de AITP avanzada incluye: reconocimiento primario y estabilización inicial, segundo reconocimiento, categorización, transporte y cuidados definitivos. La fase de reconocimiento primario y estabilización inicial tiene por objetivo la identificación y el tratamiento de lesiones de riesgo vital inmediato. La RCP debe adaptarse a las particularidades del trauma antes aludidas. En particular, debe tenerse un cuidado exquisito con la columna cervical. En todo caso, debe enfatizarse que el oxígeno es el medicamento fundamental (AU)