International Consensus Criteria for Pediatric Sepsis and Septic Shock.

Importance: Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, but it excluded children. Objective: To update and evaluate criteria for sepsis and septic shock in children. Evidence Review: The Society of Critical Care Medicine (SCCM) convened a task force of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents. Using evidence from an international survey, systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million electronic health record encounters from 10 sites on 4 continents, a modified Delphi consensus process was employed to develop criteria. Findings: Based on survey data, most pediatric clinicians used sepsis to refer to infection with life-threatening organ dysfunction, which differed from prior pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant term, severe sepsis. The SCCM task force recommends that sepsis in children be identified by a Phoenix Sepsis Score of at least 2 points in children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. Children with a Phoenix Sepsis Score of at least 2 points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than 8 times that of children with suspected infection not meeting these criteria. Mortality was higher in children who had organ dysfunction in at least 1 of 4-respiratory, cardiovascular, coagulation, and/or neurological-organ systems that was not the primary site of infection. Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point in the Phoenix Sepsis Score, which included severe hypotension for age, blood lactate exceeding 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively. Conclusions and Relevance: The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force using a large international database and survey, systematic review and meta-analysis, and modified Delphi consensus approach. A Phoenix Sepsis Score of at least 2 identified potentially life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiological assessment, and research in pediatric sepsis and septic shock around the world.

Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock.

Importance: The Society of Critical Care Medicine Pediatric Sepsis Definition Task Force sought to develop and validate new clinical criteria for pediatric sepsis and septic shock using measures of organ dysfunction through a data-driven approach. Objective: To derive and validate novel criteria for pediatric sepsis and septic shock across differently resourced settings. Design, Setting, and Participants: Multicenter, international, retrospective cohort study in 10 health systems in the US, Colombia, Bangladesh, China, and Kenya, 3 of which were used as external validation sites. Data were collected from emergency and inpatient encounters for children (aged <18 years) from 2010 to 2019: 3 049 699 in the development (including derivation and internal validation) set and 581 317 in the external validation set. Exposure: Stacked regression models to predict mortality in children with suspected infection were derived and validated using the best-performing organ dysfunction subscores from 8 existing scores. The final model was then translated into an integer-based score used to establish binary criteria for sepsis and septic shock. Main Outcomes and Measures: The primary outcome for all analyses was in-hospital mortality. Model- and integer-based score performance measures included the area under the precision recall curve (AUPRC; primary) and area under the receiver operating characteristic curve (AUROC; secondary). For binary criteria, primary performance measures were positive predictive value and sensitivity. Results: Among the 172 984 children with suspected infection in the first 24 hours (development set; 1.2% mortality), a 4-organ-system model performed best. The integer version of that model, the Phoenix Sepsis Score, had AUPRCs of 0.23 to 0.38 (95% CI range, 0.20-0.39) and AUROCs of 0.71 to 0.92 (95% CI range, 0.70-0.92) to predict mortality in the validation sets. Using a Phoenix Sepsis Score of 2 points or higher in children with suspected infection as criteria for sepsis and sepsis plus 1 or more cardiovascular point as criteria for septic shock resulted in a higher positive predictive value and higher or similar sensitivity compared with the 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria across differently resourced settings. Conclusions and Relevance: The novel Phoenix sepsis criteria, which were derived and validated using data from higher- and lower-resource settings, had improved performance for the diagnosis of pediatric sepsis and septic shock compared with the existing IPSCC criteria.

Factores asociados a ventilación mecánica prolongada en niños con fallo respiratorio de causa pulmonar: Estudio de cohortes del registro de LARed Network / Factors associated with prolonged mechanical ventilation in children with pulmonary failure: Cohort study from the LARed Network registry

Objetivos Identificar los factores asociados con la ventilación mecánica prolongada (pVMI) en pacientes pediátricos en la unidad de cuidados intensivos pediátricos (UCIP). Diseño Análisis secundario de una cohorte prospectiva. Ámbito UCIP en los centros que integran LARed Network entre abril del 2017 y enero del 2022. Participantes Pacientes pediátricos en ventilación mecánica (VMI) debido a causas respiratorias. Definimos pVMI como eventos con tiempo VMI mayor al percentil 75 global. Intervenciones Ninguna.Variables de interés principales Datos demográficos, diagnósticos, puntajes de gravedad, terapias, complicaciones, estancias y morbimortalidad. Resultados Se incluyó a 1.698 niños con VMI de 8 ± 7 días y se definió pVMI en 9 días. Los factores relacionados al ingreso fueron la edad menor de 6 meses (OR 1,61, IC del 95%, 1,17-2,22), la displasia broncopulmonar (OR 3,71, IC del 95%, 1,87-7,36) y las infecciones fúngicas (OR 6,66, IC del 95%, 1,87-23,74), mientras que los pacientes con asma tuvieron menor riesgo de pVMI (OR 0,30, IC del 95%, 0,12-0,78). En cuanto a la evolución y la estancia en UCIP, se relacionó a neumonía asociada a la ventilación mecánica (OR 4,27, IC del 95%, 1,79-10,20), necesidad de traqueostomía (OR 2,91, IC del 95%, 1,89-4,48), transfusiones (OR 2,94, IC del 95%, 2,18-3,96), bloqueo neuromuscular (OR 2,08, IC del 95%, 1,48-2,93) y ventilación de alta frecuencia (OR 2,91, IC del 95%, 1,89-4,48) y una mayor estadía en UCIP (OR 1,13, IC del 95%, 1,10-1,16). Además, la presión media aérea mayor a 13cmH2O se asoció a pVMI (OR 1,57, IC del 95%, 1,12-2,21). Conclusiones Se identificaron factores relacionados con VMI de duración mayor a 9 días en pacientes pediátricos en UCIP en cuanto a ingreso, evolución y estancia. (AU)

Objectives To identify factors associated with prolonged mechanical ventilation (pMV) in pediatric patients in pediatric intensive care units (PICUs). Design Secondary analysis of a prospective cohort.SettingPICUs in centers that are part of the LARed Network between April 2017 and January 2022. Participants Pediatric patients on mechanical ventilation (IMV) due to respiratory causes. We defined IMV time greater than the 75th percentile of the global cohort. Interventions None.Main variables of interestDemographic data, diagnoses, severity scores, therapies, complications, length of stay, morbidity, and mortality. Results One thousand 6hundred and ninety 8children with MV of 8±7 days were included, and pIMV was defined as 9 days. Factors related to admission were age under 6 months (OR 1.61, 95% CI 1.17–2.22), bronchopulmonary dysplasia (OR 3.71, 95% CI 1.87–7.36), and fungal infections (OR 6.66, 95% CI 1.87–23.74), while patients with asthma had a lower risk of pIMV (OR 0.30, 95% CI 0.12–0.78). Regarding evolution and length of stay in the PICU, it was related to ventilation-associated pneumonia (OR 4.27, 95% CI 1.79–10.20), need for tracheostomy (OR 2.91, 95% CI 1.89–4.48), transfusions (OR 2.94, 95% CI 2.18–3.96), neuromuscular blockade (OR 2.08, 95% CI 1.48–2.93), high-frequency ventilation (OR 2.91, 95% CI 1.89–4.48), and longer PICU stay (OR 1.13, 95% CI 1.10–1.16). In addition, mean airway pressure greater than 13cmH2O was associated with pIMV (OR 1.57, 95% CI 1.12–2.21). Conclusions Factors related to IMV duration greater than 9 days in pediatric patients in PICUs were identified in terms of admission, evolution, and length of stay. (AU)

Factors associated with prolonged mechanical ventilation in children with pulmonary failure: Cohort study from the LARed Network registry.

OBJECTIVES: To identify factors associated with prolonged mechanical ventilation (pMV) in pediatric patients in pediatric intensive care units (PICUs). DESIGN: Secondary analysis of a prospective cohort. SETTING: PICUs in centers that are part of the LARed Network between April 2017 and January 2022. PARTICIPANTS: Pediatric patients on mechanical ventilation (IMV) due to respiratory causes. We defined IMV time greater than the 75th percentile of the global cohort. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Demographic data, diagnoses, severity scores, therapies, complications, length of stay, morbidity, and mortality. RESULTS: 1698 children with MV of 8±7 days were included, and pIMV was defined as 9 days. Factors related to admission were age under 6 months (OR 1.61, 95% CI 1.17-2.22), bronchopulmonary dysplasia (OR 3.71, 95% CI 1.87-7.36), and fungal infections (OR 6.66, 95% CI 1.87-23.74), while patients with asthma had a lower risk of pIMV (OR 0.30, 95% CI 0.12-0.78). Regarding evolution and length of stay in the PICU, it was related to ventilation-associated pneumonia (OR 4.27, 95% CI 1.79-10.20), need for tracheostomy (OR 2.91, 95% CI 1.89-4.48), transfusions (OR 2.94, 95% CI 2.18-3.96), neuromuscular blockade (OR 2.08, 95% CI 1.48-2.93), high-frequency ventilation (OR 2.91, 95% CI 1.89-4.48), and longer PICU stay (OR 1.13, 95% CI 1.10-1.16). In addition, mean airway pressure greater than 13cmH2O was associated with pIMV (OR 1.57, 95% CI 1.12-2.21). CONCLUSIONS: Factors related to IMV duration greater than 9 days in pediatric patients in PICUs were identified in terms of admission, evolution, and length of stay.

Clinical decision support tools for paediatric sepsis in resource-poor settings: an international qualitative study.

OBJECTIVE: New paediatric sepsis criteria are being developed by an international task force. However, it remains unknown what type of clinical decision support (CDS) tools will be most useful for dissemination of those criteria in resource-poor settings. We sought to design effective CDS tools by identifying the paediatric sepsis-related decisional needs of multidisciplinary clinicians and health system administrators in resource-poor settings. DESIGN: Semistructured qualitative focus groups and interviews with 35 clinicians (8 nurses, 27 physicians) and 5 administrators at health systems that regularly provide care for children with sepsis, April-May 2022. SETTING: Health systems in Africa, Asia and Latin America, where sepsis has a large impact on child health and healthcare resources may be limited. PARTICIPANTS: Participants had a mean age of 45 years, a mean of 15 years of experience, and were 45% female. RESULTS: Emergent themes were related to the decisional needs of clinicians caring for children with sepsis and to the needs of health system administrators as they make decisions about which CDS tools to implement. Themes included variation across regions and institutions in infectious aetiologies of sepsis and available clinical resources, the need for CDS tools to be flexible and customisable in order for implementation to be successful, and proposed features and format of an ideal paediatric sepsis CDS tool. CONCLUSION: Findings from this study will directly contribute to the design and implementation of CDS tools to increase the uptake and impact of the new paediatric sepsis criteria in resource-poor settings.

Challenges and health-care priorities for reducing the burden of paediatric sepsis in Latin America: a call to action.

Sepsis is a worldwide public health problem due to its high incidence and accompanying mortality, morbidity, and financial burden. It is a major cause of admission to paediatric intensive care units; despite advances in the diagnosis and treatment, both incidence and mortality are high in low-income and middle-income countries. There are several barriers in addressing the enormous burden of paediatric sepsis in these countries, which include: lack of data of incidence and mortality; unfamiliarity of sepsis by the lay public, leading to failure to seek care early, and by health professionals, leading to failure to treat emergently; and insufficient government funding for sepsis care programmes leading to inadequate staffing, material, and financial resources, and therefore, poor health systems. Socioeconomic inequalities, such as inequity and marked variation in income and education, high rates of malnutrition, high percentage of young population, and health systems that do not meet the population's demands also represent barriers in the care of children with sepsis in Latin America. In this Viewpoint, we draw attention to the problem of paediatric sepsis in Latin America and call for action to reduce the disease burden by proposing some solutions.

Latin American Consensus on the Management of Sepsis in Children: Sociedad Latinoamericana de Cuidados Intensivos Pediátricos [Latin American Pediatric Intensive Care Society] (SLACIP) Task Force: Executive Summary.

Objective: The aim of this study was to develop evidence-based recommendations for the diagnosis and treatment of sepsis in children in low- and middle-income countries (LMICs), more specifically in Latin America. Design: A panel was formed consisting of 27 experts with experience in the treatment of pediatric sepsis and two methodologists working in Latin American countries. The experts were organized into 10 nominal groups, each coordinated by a member. Methods: A formal consensus was formed based on the modified Delphi method, combining the opinions of nominal groups of experts with the interpretation of available scientific evidence, in a systematic process of consolidating a body of recommendations. The systematic search was performed by a specialized librarian and included specific algorithms for the Cochrane Specialized Register, PubMed, Lilacs, and Scopus, as well as for OpenGrey databases for grey literature. The GRADEpro GDT guide was used to classify each of the selected articles. Special emphasis was placed on search engines that included original research conducted in LMICs. Studies in English, Spanish, and Portuguese were covered. Through virtual meetings held between February 2020 and February 2021, the entire group of experts reviewed the recommendations and suggestions. Result: At the end of the 12 months of work, the consensus provided 62 recommendations for the diagnosis and treatment of pediatric sepsis in LMICs. Overall, 60 were strong recommendations, although 56 of these had a low level of evidence. Conclusions: These are the first consensus recommendations for the diagnosis and management of pediatric sepsis focused on LMICs, more specifically in Latin American countries. The consensus shows that, in these regions, where the burden of pediatric sepsis is greater than in high-income countries, there is little high-level evidence. Despite the limitations, this consensus is an important step forward for the diagnosis and treatment of pediatric sepsis in Latin America.

Comparison of Interleukin-6 Plasma Concentration in Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Pediatric Sepsis.

Importance: Multisystem Inflammatory Syndrome in Children (MIS-C) associated with SARS-CoV-2 infection is thought to be driven by a post-viral dysregulated immune response, where interleukin 6 (IL-6) might have a central role. In this setting, IL-6 inhibitors are prescribed as immunomodulation in cases refractory to standard therapy. Objective: To compare plasma IL-6 concentration between critically ill children with MIS-C and sepsis. Design: A retrospective cohort study from previously collected data. Setting: Individual patient data were gathered from three different international datasets. Participants: Critically ill children between 1 month-old and 18 years old, with an IL-6 level measured within 48 h of admission to intensive care. Septic patients were diagnosed according to Surviving Sepsis Campaign definition and MIS-C cases by CDC criteria. We excluded children with immunodeficiency or immunosuppressive therapy. Exposure: None. Main Outcome(s) and Measure(s): The primary outcome was IL-6 plasma concentration in MIS-C and sepsis group at admission to the intensive care unit. We described demographics, inflammatory biomarkers, and clinical outcomes for both groups. A subgroup analysis for shock in each group was done. Results: We analyzed 66 patients with MIS-C and 44 patients with sepsis. MIS-C cases were older [96 (48, 144) vs. 20 (5, 132) months old, p < 0.01], but no differences in sex (41 vs. 43% female, p = 0.8) compared to septic group. Mechanical ventilation use was 48.5 vs. 93% (p < 0.001), vasoactive drug use 79 vs. 66% (p = 0.13), and mortality 4.6 vs. 34.1% (p < 0.01) in MIS-C group compared to sepsis. IL-6 was 156 (36, 579) ng/dl in MIS-C and 1,432 (122, 6,886) ng/dl in sepsis (p < 0.01), while no significant differences were observed in procalcitonin (PCT) and c-reactive protein (CRP). 52/66 (78.8%) patients had shock in MIS-C group, and 29/44 (65.9%) had septic shock in sepsis group. Septic shock had a significantly higher plasma IL-6 concentration than the three other sub-groups. Differences in IL-6, CRP, and PCT were not statistically different between MIS-C with and without shock. Conclusions and Relevance: IL-6 plasma concentration was elevated in critically ill MIS-C patients but at levels much lower than those of sepsis. Furthermore, IL-6 levels don't discriminate between MIS-C cases with and without shock. These results lead us to question the role of IL-6 in the pathobiology of MIS-C, its diagnosis, clinical outcomes, and, more importantly, the off-label use of IL-6 inhibitors for these cases.

Mortality and clinical characteristics of multisystem inflammatory syndrome in children (MIS-C) associated with covid-19 in critically ill patients: an observational multicenter study (MISCO study).

BACKGROUND: The clinical presentation and severity of Multisystem Inflammatory Syndrome in Children associated with COVID-19 (MIS-C) is widespread and presents a very low mortality rate in high-income countries. This research describes the clinical characteristics of MIS-C in critically ill children in middle-income countries and the factors associated with the rate of mortality and patients with critical outcomes. METHODS: An observational cohort study was conducted in 14 pediatric intensive care units (PICUs) in Colombia between April 01, 2020, and January 31, 2021. Patient age ranged between one month and 18 years, and each patient met the requirements set forth by the World Health Organization (WHO) for MIS-C. RESULTS: There were seventy-eight children in this study. The median age was seven years (IQR 1-11), 18 % (14/78) were under one year old, and 56 % were male. 35 % of patients (29/78) were obese or overweight. The PICU stay per individual was six days (IQR 4-7), and 100 % had a fever upon arrival to the clinic lasting at least five days (IQR 3.7-6). 70 % (55/78) of patients had diarrhea, and 87 % (68/78) had shock or systolic myocardial dysfunction (78 %). Coronary aneurysms were found in 35 % (27/78) of cases, and pericardial effusion was found in 36 %. When compared to existing data in high-income countries, there was a higher mortality rate observed (9 % vs. 1.8 %; p=0.001). When assessing the group of patients that did not survive, a higher frequency of ferritin levels was found, above 500 ngr/mL (100 % vs. 45 %; p=0.012), as well as more cardiovascular complications (100 % vs. 54 %; p = 0.019) when compared to the group that survived. The main treatments received were immunoglobulin (91 %), vasoactive support (76 %), steroids (70.5 %) and antiplatelets (44 %). CONCLUSIONS: Multisystem Inflammatory Syndrome in Children due to SARS-CoV-2 in critically ill children living in a middle-income country has some clinical, laboratory, and echocardiographic characteristics similar to those described in high-income countries. The observed inflammatory response and cardiovascular involvement were conditions that, added to the later presentation, may explain the higher mortality seen in these children.

Challenges of implementing the Paediatric Surviving Sepsis Campaign International Guidelines 2020 in resource-limited settings: A real-world view beyond the academia.

The Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-associated Organ Dysfunction in Children was released in 2020 and is intended for use in all global settings that care for children with sepsis. However, practitioners managing children with sep sis in resource-limited settings (RLS) face several challenges and disease patterns not experienced by those in resource-rich settings. Based upon our collective experience from RLS, we aimed to reflect on the difficulties of implementing the international guidelines. We believe there is an urgent need for more evidence from RLS on feasible, efficacious approaches to the management of sepsis and septic shock that could be included in future context-specific guidelines.

Pediatric Inflammatory Multisystem Syndrome Associated With SARS-CoV-2: A Case Series Quantitative Systematic Review.

ABSTRACT: Pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (PIMS-TS) is infrequent, but children might present as a life-threatening disease. In a systematic quantitative review, we analyzed 11 studies of PIMS-TS, including 468 children reported before July 1, 2020. We found a myriad of clinical features, but we were able to describe common characteristics: previously healthy school-aged children, persistent fever and gastrointestinal symptoms, lymphopenia, and high inflammatory markers. Clinical syndromes such as myocarditis and Kawasaki disease were present in only one third of cases each one. Pediatric intensive care unit admission was frequent, although length of stay was less than 1 week, and mortality was low. Most patients received immunoglobulin or steroids, although the level of evidence for that treatment is low. The PIMS-ST was recently described, and the detailed quantitative pooled data will increase clinicians' awareness, improve diagnosis, and promptly start treatment. This analysis also highlights the necessity of future collaborative studies, given the heterogeneous nature of the PIMS-TS.

Reduced PICU respiratory admissions during COVID-19.

BACKGROUND: The COVID-19 pandemic reached the Southern Hemisphere in the autumn of 2020, thus coinciding with its expected annual viral respiratory season. The potential impact of national strategies aimed at mitigating COVID-19 during the pandemic on the incidence of other critical viral lower respiratory tract infections (LRTIs) in children is unknown. METHODS: We analysed admission data for LRTIs from 22 paediatric intensive care units (PICUs) in four countries, part of a large international Latin American registry of children with acute respiratory failure (Red Colaborativa Pediátrica de Latinoamérica [LARed Network]). RESULTS: Between January and August, there were 83% fewer PICU admissions for LRTIs in 2020 compared to the 2018/2019 average over the same period. Similar decreases were noted for PICU admissions due to respiratory syncytial virus and influenza (92% and 78%, respectively). CONCLUSION: We observed a striking reduction in PICU admissions due to viral LRTIs over winter, during the COVID-19 pandemic in South America.

Therapeutic variability in infants admitted to Latin-American pediatric intensive units due to acute bronchiolitis. / Variabilidad terapéutica en lactantes con bronquiolitis hospitalizados en unidades de cuidados intensivos latinoamericanas.

The objective of this study was to describe the management of infants with acute bronchiolitis admit ted to 20 pediatric intensive care units (PICU) members of LARed in 5 Latin American countries. Pa tients and Method: Retrospective, multicenter, observational study of data from the Latin American Registry of Acute Pediatric Respiratory Failure. We included children under 2 years of age admitted to the PICU due to community-based acute bronchiolitis between May and September 2017. Demo graphic and clinical data, respiratory support, therapies used, and clinical results were collected. A subgroup analysis was carried out according to geographical location (Atlantic v/s Pacific), type of insurance (Public v/s Private), and Academic v/s non-Academic centers. Results: 1,155 patients were included in the registry which present acute respiratory failure and 6 were excluded due to the lack of information in their record form. Out of the 1,147 patients, 908 were under 2 years of age, and out of those, 467 (51.4%) were diagnosed with acute bronchiolitis, which was the main cause of admission to the PICU due to acute respiratory failure. The demographic and severity characteristics among the centers were similar. The most frequent maximum ventilatory support was the high-flow nasal can nula (47%), followed by non-invasive ventilation (26%) and invasive mechanical ventilation (17%), with a wide coefficient of variation (CV) between centers. There was a great dispersion in the use of treatments, where the use of bronchodilators, antibiotics, and corticosteroids, representing a CV up to 400%. There were significant differences in subgroup analysis regarding respiratory support and treatments used. One patient of this cohort passed away. Conclusion: we detected wide variability in respiratory support and treatments among Latin American PICUs. This variability was not explained by demographic or clinical differences. The heterogeneity of treatments should encourage collabora tive initiatives to reduce the gap between scientific evidence and practice.

Variabilidad terapéutica en lactantes con bronquiolitis hospitalizados en unidades de cuidados intensivos latinoamericanas / Therapeutic variability in infants admitted to Latin-American pediatric intensive units due to acute bronchiolitis

Resumen: Objetivo: describir las terapias utilizadas en lactantes con bronquiolitis aguda admitidos en 20 Uni dades de Cuidados Intensivos (UCI) pediátricos miembros de LARed en 5 países latinoamerica nos. Pacientes y Método: Estudio observacional retrospectivo, multicéntrico, de datos del Registro Latinoamericano de Falla Respiratoria Aguda Pediátrica. Se incluyeron niños menores de 2 años ingresados a UCI pediátrica por bronquiolitis aguda comunitaria entre mayo-septiembre 2017. Se recolectaron datos demográficos, clínicos, soporte respiratorio, terapias utilizadas y resultados clí nicos. Se realizó análisis de subgrupos según ubicación geográfica, tipo financiación y presencia de academia. Resultados: Ingresaron al registro 1155 pacientes con falla respiratoria aguda. Seis casos fueron excluidos por no tener formulario completo. De los 1147 pacientes, 908 eran menores de 2 años. De ellos, 467 tuvieron diagnóstico de bronquiolitis aguda, correspondiendo a la principal causa de ingreso a UCI pediátrica por falla respiratoria aguda (51,4%). Las características demográficas y de gravedad entre los centros fueron similares. El soporte máximo respiratorio más frecuente fue cánula nasal de alto flujo (47%), seguido por ventilación mecánica no invasiva (26%) y ventilación mecánica invasiva (17%), con un coeficiente de variación (CV) amplio entre los centros. Hubo una gran dispersión en uso de terapias, siendo frecuente el uso de broncodilatadores, antibióticos y corticoides, con CV hasta 400%. El análisis de subgrupos mostró diferencias significativas en soporte respiratorio y tratamientos utilizados. Un paciente falleció en esta cohorte. Conclusión: Detectamos gran variabilidad en el soporte respiratorio y tratamientos entre UCI pediátricas latinoamericanas. Esta variabilidad no es explicada por disparidades demográficas ni clínicas. Esta heterogeneidad de tratamientos debería promover iniciativas colaborativas para disminuir la brecha entre la evidencia científica y la práctica asistencial.

Abstract: The objective of this study was to describe the management of infants with acute bronchiolitis admit ted to 20 pediatric intensive care units (PICU) members of LARed in 5 Latin American countries. Pa tients and Method: Retrospective, multicenter, observational study of data from the Latin American Registry of Acute Pediatric Respiratory Failure. We included children under 2 years of age admitted to the PICU due to community-based acute bronchiolitis between May and September 2017. Demo graphic and clinical data, respiratory support, therapies used, and clinical results were collected. A subgroup analysis was carried out according to geographical location (Atlantic v/s Pacific), type of insurance (Public v/s Private), and Academic v/s non-Academic centers. Results: 1,155 patients were included in the registry which present acute respiratory failure and 6 were excluded due to the lack of information in their record form. Out of the 1,147 patients, 908 were under 2 years of age, and out of those, 467 (51.4%) were diagnosed with acute bronchiolitis, which was the main cause of admission to the PICU due to acute respiratory failure. The demographic and severity characteristics among the centers were similar. The most frequent maximum ventilatory support was the high-flow nasal can nula (47%), followed by non-invasive ventilation (26%) and invasive mechanical ventilation (17%), with a wide coefficient of variation (CV) between centers. There was a great dispersion in the use of treatments, where the use of bronchodilators, antibiotics, and corticosteroids, representing a CV up to 400%. There were significant differences in subgroup analysis regarding respiratory support and treatments used. One patient of this cohort passed away. Conclusion: we detected wide variability in respiratory support and treatments among Latin American PICUs. This variability was not explained by demographic or clinical differences. The heterogeneity of treatments should encourage collabora tive initiatives to reduce the gap between scientific evidence and practice.

Obstrucción intestinal por semillas de Vasconcellea: reporte de tres casos y revisión de la literatura / Intestinal obstruction due to Vasconcellea seeds: Report of three cases and literature review / Obstrução intestinal por sementes de Vasconcellea: reporte de três casos e revisão da literatura

Vasconcellea spp., es una especie de papaya andina que crece en las áreas rurales cerca a Medellín, Colombia. Debido al agradable y dulce sabor de sus frutos, con frecuencia los niños ingieren accidentalmente sus semillas. Luego de la ingestión, las semillas se engranan en la luz del colon y obstruyen la salida de la materia fecal, lo que causa dolor y distensión abdominal, y favorece la translocación bacteriana. El diagnóstico se basa en la historia clínica y el tacto rectal. El tratamiento depende del grado de afectación local y sistémica e incluye la desimpactación del contenido rectal bajo anestesia general y lavados del colon con solución salina al 0,9%. En los casos más graves se ha requerido colostomía derivativa. En la literatura médica no existen reportes de obstrucción intestinal por semillas de Vasconcellea, posiblemente porque se han confundido con las del género Carica. En este artículo se describen tres casos tratados en servicios pediátricos de Medellín en los años 2012 y 2013; observamos que es una entidad poco sospechada, lo que lleva a un diagnóstico tardío con posibles consecuencias catastróficas. Es importante educar a la población para prevenir la ingestión de las semillas.

Vasconcellea spp., is a species of Andean papaya commonly cultivated in rural communities close to Medellín, Colombia. Due to the pleasant and sweet flavor of its fruits, children frequently ingest its seeds accidentally. After ingestion, the seeds are engaged in the colonic lumen and block the exit of stools, causing pain and bloating, and promoting bacterial translocation. Diagnosis is based on clinical history and rectal examination. Treatment depends on the degree of local and systemic involvement and includes disimpaction of rectal contents under general anesthesia and colonic washes with 0.9% saline solution. In severe cases derivative colostomy has been required. In the literature there are no reports of intestinal obstruction due to Vasconcellea seeds, possibly because it has been mistaken for seeds of the genus Carica. In this article, three cases treated at pediatric services in Medellín, Colombia, in 2012 and 2013 are described. We note that this is a rarely suspected disease, leading to late diagnosis and potential catastrophic consequences. It is important to educate people to prevent the ingestion of the seeds.

Vasconcellea spp., é uma espécie de mamão papaia andino que cresce nas áreas rurais perto a Medellín, Colômbia. Devido ao agradável e doce sabor de seus frutos, com frequência as crianças ingerem acidentalmente suas sementes. Depois da ingestão, as sementes se engrenam na luz do cólon e obstruem a saída da matéria fecal, o que causa dor e distensão abdominal, e favorece a translocação bacteriana. O diagnóstico se baseia na história clínica e o tato retal. O tratamento depende do grau de afetação local e sistémica e inclui a desimpactação do conteúdo retal sob anestesia geral e lavagens do cólon com solução salina a 0,9%. Nos casos mais graves foi necessário colostomia derivativa. Na literatura médica não existem reportes de obstrução intestinal por sementes de Vasconcellea, possivelmente porque se confundiram com as do gênero Carica. Neste artigo se descrevem três casos tratados em serviços pediátricos de Medellín nos anos 2012 e 2013; observamos que é uma entidade pouco suspeitada, o que leva a um diagnóstico tardio com possíveis consequências catastróficas. É importante educar à população para prevenir a ingestão das sementes.

Epidemiología de la sepsis en pediatría: primer estudio colombiano multicéntrico / Epidemiology of sepsis in pediatrics: first colombiam multicenter survey

En el año 2002 la campaña Sobreviviendo a la Sepsis estableció algunos lineamientos para disminuir la elevada mortalidad en el mundo por la sepsis. Entre estos lineamientos se encuentra la recomendación para reconocer que la sepsis es una enfermedad que causa probablemente muchas muertes y un alto costo de atención en las unidades de cuidado intensivo pediátrico. Conocer sobre el comportamiento de este padecimiento probablemente sea el primer paso para poder impactarla. En el mundo hay pocos estudios de la epidemiología de la sepsis en niños y, en Colombia, menos aun. Quizá el estudio realizado en Estados Unidos en los años noventa sea de los más representativos. En Latinoamérica, especialmente en Brasil. Se han desarrollado también algunos estudios sobre la epidemiología de la enfermedad. Los autores se proponen iniciar un estudio multicéntrico sobre la epidemiología de la sepsis pediátrica en Colombia, por lo que se ha diseñado una página en Internet www.sepsisencolombia.com. para la recolección de los datos y la actualización permanentemente a la comunidad científica local en este tema.

In 2002, the Surviving sepsis campaign defined a strategy that aimed to reduce the high mortality due to sepsis. One point of this strategy was a recommendation to recognize that the sepsis is an important cause of deaths and high economic costs in the pediatric intensive care units. Knowledge of the disease is the first step to impact it. There are few studies of the sepsis epidemiology in the world children, and even less in Colombia. Maybe, the most important study in this field was developed in the United States in the nineties. In Latin-America there are others studies, especially in Brazil, but none in Colombia. The authors pretend to do a multicenter study about the epidemiology of the pediatric sepsis in Colombia. A web site has been designed to collect data and to give up-to-date information to the local scientific community about this topic: www.sepsisencolombia.com.