Servicio de Cuidados Intensivos Pediátricos del Hospital General Universitario Gregorio Marañón / Pediatric Intensive Care Department of the Hospital Materno Infantil Gregorio Marañón

La Unidad de Cuidados Intensivos Pediátricos (UCIP) es el servicio del Hospital General Universitario Gregorio Marañón (HGUGM), que cuenta con un equipo de profesionales sanitarios específicamente preparados, con experiencia y dedicación completa, que cumple con los requisitos funcionales, estructurales y organizativos suficientes para garantizar la atención de los niños cuya enfermedad pueda comprometer su vida o de aquellos que precisen recuperación tras haber sido sometidos a una cirugía mayor. En este artículo se describe la estructura y la distribución de espacios de la Unidad, la organización asistencial, la cartera de servicios, la actividad asistencial, docente e investigadora, las perspectivas de futuro y la cooperación internacional (AU)

The pediatric intensive care unit of the University Hospital Gregorio Marañón meets all the functional, structural and organizational requirements to ensure the optimal management of critical care pediatric patients affected of life threatening diseases and of those that need stabilization after major surgery procedures. The unit is ruled by experienced and highly specialized staff in a full time dedication basis. This article describes the structure and space distribution of the unit, the organization of the healthcare activities, the education and research programs and the portfolio of healthcare specialties attended. The future objectives and the international cooperation issues are also discussed (AU)

Conservative surgical treatment for toxic megacolon due to Clostridium difficile infection in a transplanted pediatric patient.

Severe disease caused by Clostridium difficile is frequently encountered in transplant recipients and carries a high mortality. Numerous studies have been published on this subject in the adult population, but few in the pediatric setting. A 4-year-old boy who had undergone heart transplant 20 months earlier was admitted to the pediatric intensive care unit after humoral rejection. Seven days after admission, he developed septic shock, abdominal distension, and paralytic ileus without diarrhea. Pseudomembranous colitis due to C. difficile was confirmed by microbiological and radiological studies. Despite treatment with rectal vancomycin and intravenous metronidazole, the patient did not improve and required decompressive laparotomy; because of the poor subsequent clinical course, terminal ileostomy and cecostomy were performed in a second operation. Recovery was satisfactory, and surgical reconstruction of intestinal tract was performed 3 months later without complications. Although early surgery with total colectomy is indicated, when there is a poor response to medical treatment in cases of C. difficile toxic megacolon, the case we present responded favorably to a conservative surgical approach that enabled intestinal integrity to be restored 3 months later. In the pediatric population, less aggressive therapeutic options should be considered, as they have benefits on the subsequent quality of life of the patient.

Impact on knowledge and practice of an intervention to control catheter infection in the ICU.

Information on the impact of care bundles has been mainly acquired in adult intensive care units (ICUs). However, specific data for educational programs are scarce. Our objective was to analyze the impact of an educational program on the knowledge and prevention of catheter-related bloodstream infection (CRBSI) in two pediatric intensive care units (P-ICUs). A prospective study was carried out at a large teaching institution in Madrid, Spain. Healthcare workers' (HCWs) knowledge of guidelines for the prevention of CRBSI was assessed before and after the educational program using a questionnaire covering 12 issues. A 20-min program was offered to all HCWs on each ICU shift. The incidence density of CRBSI was assessed before, during, and after the educational program. A total of 174 questionnaires were completed by HCWs from both the neonatal ICU (N-ICU) and the P-ICU before the intervention and 54 were completed after the intervention (120 participants were not present during this period). The incidence density of CRBSI before, during, and after the intervention was 6.2, 5.2, and 9.3 in the N-ICU and 2.2, 3.1, and 2.9 in the P-ICU (p > 0.05). A single 20-min educational intervention on the prevention of CRBSI significantly improved HCWs' knowledge, but was not enough to reduce the incidence density of CRBSI.

Guidelines for preventing catheter infection: assessment of knowledge and practice among paediatric and neonatal intensive care healthcare workers.

We analysed knowledge of and adherence to guidelines for the prevention of catheter-related infection (CRI) among Spanish healthcare workers (HCWs) from paediatric and neonatal intensive care units by distributing 357 questionnaires to 31 Spanish hospitals. The overall mean scores for individual knowledge and daily practice were 5.61 and 5.78, respectively. Our results reveal room for improvement in Spanish HCWs' knowledge of prevention of CRI. Continuing education programmes and implementation of care bundles must be introduced to improve prevention and management of CRI.

Programa de control y seguimiento de ventilación no invasiva domiciliaria en pacientes pediátricos. Unidad multidisciplinar / Non invasive home control and follow –up program in pediatric patients. A multidisciplinary Unit

La ventilación mecánica no invasiva constituye una nueva modalidad de terapia de soporte respiratorio en la que no se precisa invadir, mediante traqueostomía o intubación endotraqueal, la vía aérea. Se utiliza en pacientes con fallo respiratorio agudo o crónico como alternativa menos agresiva a la ventilación mecánica convencional, buscando evitar las complicaciones asociadas a la intubación endotraqueal y mejorar la calidad de vida del enfermo. Durante los últimos 5-10 años se ha generalizado su uso, debido en gran parte a los avances médicos y tecnológicos que han contribuido al aumento de supervivencia del paciente crítico, al mejor diagnóstico y conocimiento de enfermedades que cursan con aumento de resistencias de la vía aérea superior o con hipoventilación central o periférica así como al desarrollo de nuevos aparatos de fácil manejo adaptados al tratamiento domiciliario. La creación de un programa de control y seguimiento de ventilación no invasiva domiciliaria en pacientes pediátricos va a producir mejoras psicosociales para el paciente y su familia y beneficios económicos para el sistema de salud. En esta revisión nos vamos a referir al tratamiento ambulatorio y domiciliario de niños con insuficiencia respiratoria crónica y a la necesidad de creación de unidades especializadas multidisciplinares de intervención en este tipo de enfermos (AU)

Non-invasive mechanical ventilation is a new respiratory support therapy modality in which it is not necessary to invade the airway with tracheostomy or endotracheal intubation. It is used in patients with acute or chronic respiratory failure as a less aggressive alternative to conventional mechanical ventilation, seeking to avoid the complications associated to endotracheal intubation and to improve the patient´s quality of life. During the last 5-10 years, its use has become generalized, largely due to the medical and technological advances that have contributed to the increased survival of the critical patients, to the better diagnosis and knowledge of diseases that occur with increased resistances of the upper airway or with central and/or peripheral hypoventilation and to the development of new easily used apparatus adapted to home treatment. The creation of a control and follow-up program of non-invasive home ventilation in pediatric patients will produce psychosocial and economic benefits for the health care system. In this review, we are going to mention the out-patient and home treatment of children with chronic respiratory failure and the need to create specialized multidisciplinary intervention units in this type of patient (AU)

Hepatic dysfunction after cardiac surgery in children.

OBJECTIVE: The objective of this study was to analyze the incidence and significance of hepatic dysfunction after cardiac surgery in children. DESIGN: Prospective, observational study. SETTING: Pediatric intensive care unit of a university hospital. PATIENTS: The study consisted of 232 children ranging in age from newborn to 17 years with no history of liver disease. MEASUREMENTS AND MAIN RESULTS: Aspartate aminotransferase (AST), alanine aminotransferase (ALT), gammaglutamyltranspeptidase (GGT), alkaline phosphatase, total and conjugated bilirubin, blood glucose, urea, creatinine, and coagulation studies were determined at admission, at 24 and 48 hrs, and at 7 days. Hepatic dysfunction was taken as an ALT of > 100 IU/L or a moderate or high hepatic score. The statistical study included bivariate analysis and multivariate logistic regression to study the risk factors for hepatic dysfunction. Twenty-one patients (9%) showed an ALT > 100 IU/L, and 29.3% had a moderate or high hepatic score. A relationship was found between hepatic dysfunction and the type of cardiopathy (D-transposition of the great arteries and coarctation of the aorta), shock, the administration of dopamine or epinephrine, renal insufficiency, the presence of pulmonary changes (pulmonary edema, atelectasis, pulmonary hypertension, hypoxemia), hematologic disturbances (prothrombin time, kaolin-cephalin time, fibrinogen, and platelets), and the need for a greater number of transfusions of packed cells, plasma, and platelets. Compared with 7.6% of the rest of the patients (p <.001), 38% of patients with an ALT > 100 IU/L died. The hepatic score of those patients who died was 4.2 (2.3)-higher than that of the survivors at 1.5 (1.8), (p <.001). Shock and renal insufficiency were the factors most significantly related to the development of hepatic dysfunction. CONCLUSIONS: Hepatic dysfunction is an uncommon complication in children after cardiac surgery. This complication is related mainly to hemodynamic disturbances and renal insufficiency and is an indicator of poor prognosis.

Surfactant treatment for acute respiratory distress syndrome.

OBJECTIVE: To determine prospectively the efficacy of surfactant in acute respiratory distress syndrome. STUDY DESIGN: Twenty patients, 1 month to 16 years of age, diagnosed with an acute pulmonary disease with severe hypoxaemia (PaO2/FiO2 < 100) (13 with systemic or pulmonary disease and seven with cardiac disease) were treated with one to six doses of 50-200 mg/kg of porcine surfactant administered directly into the trachea. The surfactant was considered to be effective when the PaO2/FiO2 improved by > 20%. RESULTS: After initial surfactant administration the PaO2/FiO2 increased significantly in patients with systemic or pulmonary disease from 68 to 111, and the oxygenation index (OI) diminished significantly from 36.9 to 27.1. The PaO2/FiO2 and OI did not improve in children with cardiac disease. The improvement of the patients who survived was greater than that of those who died. CONCLUSIONS: Surfactant moderately improves oxygenation in some children with severe acute respiratory distress syndrome secondary to pulmonary or systemic disease.

Transpyloric enteral feeding in critically ill children.

BACKGROUND: Nutrition is important in childhood because the child has a lower energy reserve than the adult and a higher demand for calories because of ongoing growth. In this study, the utility of transpyloric enteral feeding (TEF) in critically ill children was evaluated. METHODS: A prospective, descriptive study was made in a pediatric intensive care unit of a tertiary pediatric center of 41 critically ill children, 30 after surgical procedures and 11 with nonsurgical illness, aged 8 days to 12 years, who received transpyloric enteral feeding with 8- or 10-Fr weighted feeding tubes. Analysis was made of tolerance and complications (vomiting, abdominal distension, excessive gastric residual, diarrhea, and pulmonary aspiration) of TEF. RESULTS: The mean duration of TEF was 19.5 +/- 26.8 days (range, 1-120 days). The administration of sedative agents or inotropic drugs did not alter toleration of TEF. Eight of 12 patients treated with continuous infusion of vecuronium tolerated TEF without complications. Eleven gastrointestinal complications occurred in 10 patients, abdominal distension and excessive gastric residual in 7 (17%), and diarrhea in 4 (9.7%). In 7 patients gastrointestinal complications improved, with decreasing use or transitory interruption of TEF, but in 4 patients (9.7%), TEF had to be withdrawn. Gastrointestinal complications were more frequent in postsurgical than in nonsurgical patients (p < 0.001). No patients suffered from pulmonary aspiration, and the incidence of pulmonary infection and hepatic dysfunction diminished during TEF. CONCLUSIONS: Transpyloric enteral feeding is a good method of nutritional support in critically ill children and can be used in patients treated with neuromuscular blocking agents. The frequency and severity of complications and the risks of pulmonary infection and hepatic dysfunction related to TEF are low.

Pediatric basic and advanced life support courses: first experience in Spain.

OBJECTIVE: to evaluate the efficiency of the first experience in pediatric basic and advanced life support courses in Spain. MATERIAL AND METHODS: we have given two pediatric basic life support (PBLS) courses of 8 h each to 52 school teachers and ambulance drivers, and 10 30-h pediatric advanced life support (PALS) courses to 276 health professionals, 62 nurses and 214 physicians (80 pediatricians, 57 pediatric, anesthesiology and intensive care medicine residents, 10 general physicians and 52 emergency physicians). We developed the courses according to the guidelines for pediatric life support from the European Resuscitation Council. We performed an initial and final theoretical written test, continuous practical evaluation and a written survey about the quality of the course. RESULTS: on PBLS courses, only 12% of practitioners answered at least 80% of the questions in the initial theory test correctly, compared with 77% in the final test (P < 0.001). All the students acquired skills in basic pediatric resuscitation. In the PALS courses, only 30% of practitioners answered at least 75% of the questions in the initial test correctly (35% of physicians and 12% of nurses, P < 0.01); this percentage increased to 95.6% in the final test (96% of physicians and 93.5% of nurses, P < 0.05). Of students, 95% acquired skills in advanced pediatric resuscitation. All students and teachers considered the theoretical and practical formation received adequate. CONCLUSIONS: basic and advanced pediatric life support courses are a useful educational method for the general population, health professionals, physicians and nurses in theoretical and practical pediatric resuscitation.

Facial nerve paralysis following pediatric cardiac surgery.

A newborn female diagnosed with transposition of the great vessels with restrictive ventricular septal defect presented left facial peripheral nerve paralysis following anatomical surgery correction (arterial switch) by cardiopulmonary bypass. We have not found any causal factor either in the anesthesia or postoperative period. The electromyogram presented signs of peripheral nerve impairment, and the cerebral echography and electroencephalogram were normal. The facial nerve paralysis was almost recovered seven weeks after surgery. This is the first pediatric patient reported with peripheral facial nerve paralysis after cardiac surgery.

Factors affecting survival in young alpacas (Lama pacos).

Factors affecting survival of young from birth to weaning (7 mo) in alpacas (Lama pacos) were evaluated in data collected at the Estacion Experimental de Camelidos Sudamericanos La Raya in the Altiplano region of Peru. Age of dam effects on survival rate were curvilinear; survival rate increased from approximately 78% for offspring of 3-yr-old dams to about 91% for those from 9- to 11-yr-old dams, then declined to about 85% for 15-yr-old dams. Weight of dam measured 2 mo prior to parturition was associated negatively with survival of the young (b = -.7%/kg). Alpaca born early in the season of birth had a higher survival rate than those born late; the regression of survival on birth date was -.2%/d. Survival rates were curvilinearly related with birth weight and were highest at weights of 9 to 11 kg (90%) and lowest at weights of 4 to 5 kg (20% to 40%). The estimated heritabilities of survival and birth weight were .10 +/- .17 and .34 +/- .23, weight was -.18 +/- .82; the corresponding environmental and phenotypic correlations were positive (.37 and .26, respectively).