Guía de recomendaciones para el manejo de pacientes pediátricos con enfermedad severa por SARS-CoV-2 / Recommendations guide for the management of pediatric patients with severe SARS-CoV-2

Resumen: La aparición del SARS-CoV-2 a partir de diciembre de 2019 y su rápida expansión en el mundo alcanzando el estatus de Pandemia, se ha convertido en un gran desafío para los equipos de salud. Aunque la evidencia de la infección en niños aún es escasa comparada a la de los adultos, se ha hecho evidente que a nivel de la población pediátrica, la mayor parte de las veces la infección es asintomática o de curso leve, sin embargo no todos los pacientes tienen esta evolución, lo que ha motivado la discusión en los equipos de Cuidados Criticos Pediátricos respecto a cómo enfrentar estos pacientes con enfermedad grave. Este consenso es fruto del trabajo de la Rama de Cuidados Intensivos Pe diátricos de la Sociedad Chilena de Pediatría, recogiendo la evidencia disponible al momento de la revisión más la opinión de expertos nacionales en Cuidados Intensivos Pediátricos. El propósito de estas recomendaciones, es ofrecer a los equipos que atienden a pacientes críticos pediátricos, una guía para el diagnóstico y tratamiento de pacientes que evolucionen con COVID 19 grave, que puedan ser aplicadas en todas las UPC Pediátricas de nuestro país, haciendo especial énfasis en aquellas medidas que han demostrado mayor efectividad a nivel de estudios diagnósticos, tratamiento y cuidados del personal de salud.

Abstract: The appearance of SARS-CoV-2 from December 2019 and its rapid expansion in the world reaching Pandemic status, has become a great challenge for health teams. Although the evidence of infection in children is still scarce compared to that of adults, it has become evident that at the pediatric po pulation level, most of the time the infection is asymptomatic or mild, but not all the patients have this evolution, which has motivated the discussion in the Pediatric Critical Care teams regarding how to face these patients with a more serious disease. This consensus is the result of the work of the Pediatric Intensive Care Branch of the Chilean Society of Pediatrics, collecting the evidence available at the time of the review plus the opinion of national experts in Pediatric Intensive Care. The purpose of these recommendations is to offer teams that care for critically ill pediatric patients a guide for the diagnosis and treatment of patients who evolve with severe COVID 19, which can be applied in all Pediatric UPCs in our country, with special emphasis in those measures that have shown greater effectiveness at the level of diagnostic studies, treatment and care of health personnel.

Effectiveness of Two Targeted Temperature Management Methods After Pediatric Postcardiac Arrest: A Multicenter International Study.

OBJECTIVES: It is currently recommended that after return of spontaneous circulation following cardiac arrest, fever should be prevented using TTM through a servo-controlled system. This technology is not yet available in many global settings, where manual physical measures without servo-control is the only option. Our aim was to compare feasibility, safety and quality assurance of servo-controlled system versus no servo-controlled system cooling, TTM protocols for cooling, maintenance and rewarming following return of spontaneous circulation after cardiac arrest in children. DESIGN: Prospective, multicenter, nonrandomized, study. SETTING: PICUs of 20 hospitals in South America, Spain, and Italy, 2012-2014. PATIENTS: Under 18 years old with a cardiac arrest longer than 2 minutes, in coma and surviving to PICU admission requiring mechanical ventilation were included. METHODS: TTM to 32-34°C was performed by prospectively designed protocol across 20 centers, with either servo-controlled system or no servo-controlled system methods, depending on servo-controlled system availability. We analyzed clinical data, cardiac arrest, temperature, mechanical ventilation duration, length of hospitalization, complications, survival, and neurologic outcomes at 6 months. PRIMARY OUTCOME: feasibility, safety and quality assurance of the cooling technique and secondary outcome: survival and Pediatric Cerebral Performance Category at 6 months. MEASUREMENTS AND MAIN RESULTS: Seventy patients were recruited, 51 of 70 TTM (72.8%) with servo-controlled system. TTM induction, maintenance, and rewarming were feasible in both groups. Servo-controlled system was more effective than no servo-controlled system in maintaining TTM (69 vs 60%; p = 0.004). Servo-controlled system had fewer temperatures above 38.1°C during the 5 days of TTM (0.1% vs 2.9%; p < 0.001). No differences in mortality, complications, length of mechanical ventilation and of stay, or neurologic sequelae were found between the two groups. CONCLUSIONS: TTM protocol (for cooling, maintenance and rewarming) following return of spontaneous circulation after cardiac arrest in children was feasible and safe with both servo-controlled system and no servo-controlled system techniques. Achieving, maintaining, and rewarming within protocol targets were more effective with servo-controlled system versus no servo-controlled system techniques.

Therapeutic Drug Monitoring of Vancomycin in Pediatric Patients With Extracorporeal Membrane Oxygenation Support.

OBJECTIVES: Determine pharmacokinetic (PK) parameters and optimal dosage of vancomycin for children on extracorporeal membrane oxygenation (ECMO). METHODS: Retrospective PK study of vancomycin in pediatric patients on ECMO who received IV vancomycin 40 to 60 mg/kg/day every 6 hours. Patients were analyzed according to the presence of acute kidney injury (AKI) and requirement of renal replacement therapy (RRT). RESULTS: Data from 40 children, with a median age of 2.7 years of age (1 month to 14 years) were evaluated. Thirty-two patients (80%) received vancomycin. Vancomycin therapeutic drug monitoring was performed in 29 patients. The subgroup without AKI or RRT were 15. With initial doses, vancomycin trough levels were within therapeutic range in 53% of patients. After dose change, 93% of patients achieved therapeutic levels. The adjusted dose was 40 (34-60) mg/kg/day every 6 hours. Estimated PK parameters were clearance (CL) 1.67 (1-1.67) mL/kg/min; volume of distribution (Vd) 0.73 (0.7-0.9) L/kg; and half-life (t½) 6.2 (4.9-8.06) hours. In the AKI subgroup, 11 patients, the initial median dose was 40 (30-45) mg/kg/day every 8 (6-12) hours. Trough concentrations of vancomycin were within therapeutic range in 27% of patients. After dose modifications, 63% of patients achieved target trough concentration. The final adjusted dose was 20 mg/kg/day (15-30) every 12 (12-24) hours. Estimated PK parameters were Vd 1.16 (0.68-1.6) L/kg; CL 0.83 (0.38-1) mL/kg/min; and a t½ of 23.6 (16.2-31) hours. CONCLUSIONS: In patients without AKI or RRT, Vd of vancomycin was similar and CL was lower compared to pediatric critically ill patients without ECMO. Treatment could be started at 40 mg/kg/day every 6 hours. In patients with AKI, the use of lower doses should be used.

[Viral respiratory co-infections in pediatric patients admitted for acute respiratory infection and their impact on clinical severity]. / Co-infección viral respiratoria en niños hospitalizados por infección respiratoria aguda y su impacto en la gravedad clínica.

INTRODUCTION: Respiratory viruses are the leading cause of acute respiratory tract infection (ARI) in children. It has been reported that viral respiratory co-infection could be associated with severe clinical course. OBJECTIVES: To describe the frequency of viral co-infection in children admitted for AlRI and evaluate whether this co-infection was associated with more severe clinical course. PATIENTS AND METHODS: Prospective, descriptive study in pediatric patients who were hospitalized for ARI, with molecular detection of at least 1 respiratory virus in nasopharyngeal sample studied by PCR-Microarray for 17 respiratory viruses. RESULTS: 110 out of 147 patients with detection of > 1 respiratory virus were included. Viral co-infection was detected in 41/110 (37%). 22/110 children (20%) were classified as moderate to severe clinical course and 88/110 (80%) were classified as mild clinical course. In the group of moderate to severe clinical course, viral respiratory co-infection was detected in 6/22 (27.3%), compared to 35/88 (39.8 %) in the mild clinical course group. No statistically significant difference was found regarding the presence of co-infection between groups (p = 0.33). CONCLUSIONS: We detected high rates of viral co-infection in children with ARI. It was not possible to demonstrate that viral co-infections were related with severe clinical course in hospitalized children.

Co-infección viral respiratoria en niños hospitalizados por infección respiratoria aguda y su impacto en la gravedad clínica / Viral respiratory co-infections in pediatric patients admitted for acute respiratory infection and their impact on clinical severity

Introduction: Respiratory viruses are the leading cause of acute respiratory tract infection (ARI) in children. It has been reported that viral respiratory co-infection could be associated with severe clinical course. Objectives: To describe the frequency of viral co-infection in children admitted for AlRI and evaluate whether this co-infection was associated with more severe clinical course. Patients and Methods: Prospective, descriptive study in pediatric patients who were hospitalized for ARI, with molecular detection of at least 1 respiratory virus in nasopharyngeal sample studied by PCR-Microarray for 17 respiratory viruses. Results: 110 out of 147 patients with detection of > 1 respiratory virus were included. Viral co-infection was detected in 41/110 (37%). 22/110 children (20%) were classified as moderate to severe clinical course and 88/110 (80%) were classified as mild clinical course. In the group of moderate to severe clinical course, viral respiratory co-infection was detected in 6/22 (27.3%), compared to 35/88 (39.8 %) in the mild clinical course group. No statistically significant difference was found regarding the presence of co-infection between groups (p = 0.33). Conclusions: We detected high rates of viral co-infection in children with ARI. It was not possible to demonstrate that viral co-infections were related with severe clinical course in hospitalized children.

Introducción: Los virus respiratorios son la principal causa de infección aguda del tracto respiratorio (IRA) en pediatría. Se ha descrito que la co-infección viral podría relacionarse con infecciones virales respiratorias de curso más grave. Objetivo: Describir la frecuencia de co-infección viral en niños hospitalizados por IRA y determinar si esta co-infección se relacionó con una evolución clínica más grave. Pacientes y Métodos: Estudio descriptivo, prospectivo, en pacientes pediátricos hospitalizados por IRA entre junio y agosto 2010, que tuvieron detección molecular de al menos un virus respiratorio en muestra nasofaríngea estudiada por RPC-microarreglo para 17 virus respiratorios. Resultados: Se incluyeron 110 de 147 pacientes con detección de > 1 virus respiratorio. Se detectó co-infección viral en 41/110 (37%). En cuanto a evolución clínica, 22/110 niños (20%) se clasificaron como evolución moderada a grave (MG) y 88/110 (80%) se clasificaron como evolución leve (L). En el grupo MG se detectó co-infección viral respiratoria en 6/22 (27,3%), mientras que en el grupo L se detectó co-infección en 35/88 (39,8%). No se encontró diferencia significativa en relación a la presencia de co-infección entre ambos grupos (p = 0,33). Conclusión: Se demostró la presencia de co-infección viral en un alto porcentaje de niños con IRA. No fue posible demostrar que la presencia de coinfección viral tenga relación con una evolución clínica más grave en estos niños hospitalizados.

[Pneumoparotitis or pneumoparotid: a differential diagnosis to consider]. / Neumoparotiditis o neumoparótida en el niño: un diagnóstico diferencial a considerar.

Childhood parotid swelling has a number of differential diagnosis mostly of inflammatory origin. Pneumoparotitis is an uncommon cause of parotid inflammation. It is caused by an excessive increase of intraoral pressure and secondary passage of air into the Stensen or Stenon duct and its glandular branches. Diagnostic clues can usually be obtained by a directed anamnesis. Ultrasonography (US) and computed tomography are essential diagnostic tools for this condition that has a benign course with spontaneous resolution in most cases. We present four cases of pneumoparotitis diagnosed by US in children 5 to 13 years of age. One of the cases occurred after the child chewed gum and made bubbles for a prolonged time-period and the other three after inflating baloons, making bubbles inside a pool and after playing the flute. All cases resolved spontaneously after two days. We suggest to consider pneumoparotitis in the differential diagnosis of parotid swelling in children.

First Pediatric Intensive Care Congress in Chile.

OBJECTIVE: To summarize the First Chilean Congress on Pediatric Critical Care Medicine. DATA SOURCE/EXTRACTION: Program schedule, presentations, abstracts. STUDY SELECTION: Descriptive summary of the congress. CONCLUSIONS: The Chilean Society of Pediatric Critical Care organized the First Pediatric Intensive Care Congress in Chile, having a registration of 217 delegates. All the pediatric intensive care units of the country had a representative in the Congress either as a delegate or a faculty member, which provided an excellent opportunity for interactions between them. The international faculty addressed state-of-the-art issues, with a charge of highlighting basic science relevant to clinical practice, which motivated long interactive question-and-answer sessions with the audience. Strong evidence was presented by Chilean faculty debaters who discussed controversial topics, making these sessions very attractive. An entire day was scheduled with a simultaneous nursing session. More than 80 intensive care nurses benefited from a very interactive day with five symposia and short oral presentations. A randomized multi-institutional research protocol studying reintubation rate using three methods for weaning from mechanical ventilation was discussed during the meeting. Thirteen units committed to participate. Twenty-three posters were displayed in the congress. Posters describing the activity of pediatric intensive care units were also presented. The mean for intensive care unit beds was 6.8 and for intermediate care beds was 7.1. Annual admissions showed a mean of 640 patients, and mortality rate ranged from 4.1% to 12%, with a mean of 6.7%

Trends in nutritional status and stature among school-age children in Chile.

OBJECTIVE: We studied the prevalence of weight excess and short stature among school-age children in Chile over the past decade. METHODS: We designed a descriptive cross-sectional, school-based study to analyze nutritional and stature trends in prepubertal and pubertal boys and girls from 1986 to 1998. RESULTS: Between 1986 and 1998, we detected significant increases in obesity risk (body mass index between the 85th and 95th percentiles): from 8.3% to 19.6% in prepubertal males, from 5.4% to 14.6% in pubertal males, from 10.2% to 16.2% in prepubertal females, and from 9.7% to 24.9% in pubertal females. Obesity (body mass index > 95th percentile) increased significantly, from 4.3% to 29.5% in prepubertal males, from 1.6% to 14.6% in pubertal, from 4.7% to 24.0% in prepubertal females, and from 2.3% to 17.6% in pubertal females. During this same period, the prevalences of short stature (height for age below the 10th percentile) decreased from 40.9% to 12.0% in prepubertal males, from 44.2% to 20.4% in pubertal males, from 29.8% to 12.7% in prepubertal females, and from 41.1% to 25.8% in pubertal females. CONCLUSIONS: Chile represents a special model of fast changes in nutritional and growth trends due to social and political interventions and economic development. The significance of these findings in the health of Chilean adults and the urgency to implement measures to prevent further increases in obesity and simultaneously decrease the prevalence of short stature are discussed.

Mineralizacion osea en pacientes con insuficiencia hepática / Bone mineralization in patients with hepatic insuficiency

La insuficiencia hepática (IH) crónica altera la mineralización ósea (MO) de acuerdo a la etiología de la IH, debido a los problemas nutricionales agregados y por el tratamiento post transplante con inmunosupresores y glucocorticoides. El objetivo del presente estudio fue conocer la mineralización ósea en niños con insuficiencia hepática secundaria a atresia de vías biliares y la dinámica ósea. La mineralización ósea se determinó en columna lumbar (L2-L4) mediante un densitómetro Lunar radiológico y la dinámica ósea a través la medición de osteocalcina en el suero y piridinolinas en la orina. El rango de edad de los pacientes estudiados fue de 7 meses a 14 a¤os. El porcentaje de adecuación del IMC fue de 102.1 ( 6.7 y el puntaje z de talla/edad fue de -0.53(1.06. La densidad mineral ósea (DMO) en L2-L4 z =-2.48 (1.23, la osteocalcina sérica de 44.1(13.9 8/8 casos disminuidos, la excreción de calcio urinaria 3.8 (3.3 aumentada en 5/8 casos y D-piridinolinas urinarias 39.9 (25.0, en todos los casos por sobre los valores de población sana. Se concluye que los pacientes con IH, previo al trasplante presentan precozmente un déficit de DMO, con un recambio óseo con menores índices de formación y mayores de resorción. Esta situación es susceptible de ir deteriorándose aun mas con el uso de corticoides después del transplante, lo que deberá prevenirse con mediadas nutricionales, aumento de la actividad física y un adecuado manejo de su tratamiento farmacológico.

Experiencia clínica con ceftriaxona en el tratamiento de infecciones severas en pediatría / Clinical experience with ceftriaxone in the treatment of acute infections in pediatrics

Entre 1982 y 1986 se evaluó la eficacia y tolerancia de Ceftriaxona (CFX) en 67 casos de infecciones sistémicas en niños; 49 meningitis, 10 ventriculitis y 8 septicemias neonatales, con dosis de 100 mg/kg/día cada 12 o 24 hrs. Se observó curación bacteriológica con erradicación precoz del agente causal en 62 pacientes (92,5 por ciento) con un 68,7 por ciento de curación clínica y 31,3 por ciento de mejoría. La terapia fracasó en 1 paciente con ventriculitis en que no se retiró la prótesis colonizada, en un recién nacido de pretérmino con septicemia y en 3 pacientes con meningitis: un caso de infección por S. pneumoniiae, una meningo-ventriculitis neonatal por enterobacter hafniae y una infección intrahospitalaria por K. pneumoniae multirresistente. La CIM 90 de CFX frente a H. influenzae, S. pneumoniae, Streptococcus grupo B fue <0,04 ug/mlñ y los títulos inhibitorios de LCR en casos de meningitis fluctuaron entre 1/8 y 1/1024. Ceftriaxona demostró excelente eficacia clínica y bacteriológica con buena tolerancia y ventajas prácticas al administrarse 1 ó 2 veces al día

Daño neurológico central y compromiso isquémico local secundario a inyección de penicilina benzatina / Central neurologic demage and local ischemic compromise secondary to injection of benzathine penicillin

Un lactante menor de 7 meses de edad, a consecuencia de la inyección intraarterial inadvertida de penicilina benzatina en la región glútea, la que fue indicada por un diagnóstico de faringitis, sufrió compromiso neurológico central y lesione isquémicas con necrosis glútea y pérdida de un ortejo. La frecuencia de casos similares reportados ha aumentado en la literatura. Este tipo de complicación se observa casi exclusivamente en niños menores de 3 años y ocurre a pesar de emplear una técnica correcta de punción. Ante la falta de tratamiento satisfactorio, el mejor manejo de este tipo de accidentes es la prevención, mediante la racionalización del uso de estos preparados, prescribiéndolos sólo cuando su empleo está plenamente justificado

Hipoglicemia neonatal por hipersinsulinismo y nesidioblastosis / Neonatal hypoglycemia due to hyperinsulinism and nesidioblastosis

Se analizan 9 casos de hiperinsulinismo. Los síntomas se iniciaron entre 3 y 48 horas de vida, siendo los más frecuentes: cianosis, temblores y convulsiones. En los 9 pacientes se efectuó pancreatectomía subtotal entre 75 y 95%, debido a la imposibilidad de controlar las cifras de glicemia con aportes elevados de glucosa. Dos fueron reintervenidos, extrayéndose el remanente de tejido pancreático. Sólo uno de éstos requirió insulina por 4 días, y el otro enzimas pancreáticas por un mes. Los hallazgos histológicos mostraron hiperplasia de células beta y nesidioblastosis. Fallecieron 2 pacientes por complicaciones sépticas. La evolución neurológica muestra RDSM severo en 2 casos, y en los restantes RDSM leve o normal. Se señala la importancia de un diagnóstico precoz, tratamiento adecuado y oportuno para evitar las secuelas neurológicas. No debe postergarse el tratamiento quirúrgico si persiste la hipoglicemia con el manejo médico

[Clinical analysis and evaluation of various hematologic and metabolic constants with the use of monthly microdoses of parenteral contraceptives]. / Análisis clínico y valoración de algunas constantes hematologicas y metabólicas con el uso de un anticonceptivo parenteral mensual en microdósis.

PIP: 75 women of proven fertility were treated as a contraceptive measure with an injection of 75 mg. of duhydroxyprogesterone acetophenide, and of 5 mg. of estradiol enanthate. Doses were half of what regularly used, and were injected between the 7th and the 9th day of the cycle. Total number of cycles studied was 859. Most important side effects of the treatment was headache in 28.3% of patients, spotting in 15.5%, and emotional instability in 10.5%. Metabolic and hematologic data were unchanged, and vaginal cytology was negative. There were no pregnancies. It must be remembered that, in every contraceptive treatment, lower doses are always preferable when equally effective. (Summary in ENG).^ieng