Ecografía en el paciente hemodinámicamente inestable / Ultrasound in hemodynamically unstable patient

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Formación continuada en Pediatría: de oyentes a protagonistas / Continuing education in Pediatrics: from listeners to main characters

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Utilidad de la ecografía comparada con la capnografía y la radiografía en la intubación traqueal / Usefulness of bedside ultrasound compared to capnography and X-ray for tracheal Intubation

OBJETIVOS: Evaluar la utilidad de la ecografía frente a la capnografía y la radiografía en la intubación traqueal (IT) en niños y neonatos. MATERIAL Y MÉTODOS: Se incluyó a pacientes hemodinámicamente estables intubados en la UCIP y UCIN. Se verificó la posición del tubo endotraqueal (TET) tras cada intubación mediante ecografía traqueal y capnografía. Posteriormente, se comprobó la profundidad del TET por ecografía mediante la visualización de la punta del mismo y el deslizamiento pleural y, posteriormente, con radiografía de tórax. Se cronometraron los tiempos de realización de las técnicas. RESULTADOS: Se incluyó a 31 intubaciones en 26 pacientes (15 en UCIP y 16 en UCIN). No hubo diferencias significativas entre la ecografía y la capnografía ni entre la ecografía y la radiografía en la detección de la IT ni en la comprobación de la profundidad del TET. La sensibilidad y la especificidad de la ecografía comparada con la capnografía y la radiografía fueron del 92 y el 100%, y del 100 y el 75%, respectivamente. La ecografía fue significativamente más lenta que la capnografía (12 [4-16] vs. 6 [3-12] s; p < 0,001) y más rápida que la radiografía (0,22 [0,17-0,40] vs. 20 [17-25] min; p < 0,001). CONCLUSIONES: La ecografía parece tan efectiva como la capnografía, aunque más lenta en la comprobación de la IT. Podría ser de utilidad en situaciones donde la capnografía no sea fiable. La ecografía es tan efectiva y más rápida que la radiografía en la evaluación de la profundidad del TET, por lo que podría disminuir la utilización rutinaria de la radiografía

OBJECTIVES: The aim of this study was to assess the usefulness of bedside ultrasound compared to capnography and X-ray for endotracheal intubation in children and newborns. MATERIALS AND METHODS: Hemodynamically stable children intubated in pedriatric and neonatal intensive care unit were included. Endotracheal tube insertion was checked after every intubation attempt by tracheal ultrasound and capnography simultaneously. The endotracheal tube insertion depth was then checked by assesment of lung sliding by thoracic ultrasound. Thereafter, Chest X-ray was performed and interpreted as usual. Time to perform each technique was recorded. RESULTS: The study included 31 intubations in 26 patients (15 in PICU and 16 in NICU). There were no statistically significant differences between tracheal ultrasound and capnography or between thoracic ultrasound and x-ray in identifying the correct endotracheal intubation and assessment of endotracheal tube insertion depth, respectively. Sensibility and specificity of ultrasound compared to capnography was 92% and 100%, and 100% and 75% compared to X-ray. Ultrasound was significantly slower compared to capnography [12 (4-16) vs 6 (3-12) seconds; P<.001] and significantly quicker compared to X-ray [0.22 (0.17-0.40) vs. 20 (17-25) minutes, P<.001]. CONCLUSIONS: Ultrasound appears to be as effective as capnography, although slower, for identifying endotracheal intubation. Ultrasound may be useful in clinical situations, such as cardiopulmonary resuscitation where capnography is less reliable. Ultrasound is as effective and quicker than X-ray for assessment of endotracheal tube insertion depth, and it may contribute to decrease the routine use of X-ray after tracheal intubation

Hipertiroidismo neonatal e hipertensión pulmonar / Neonatal hyperthyroidism and pulmonary hypertension

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Comparación de la ecografía y la radiografía de tórax para la localización de catéteres venosos centrales / Comparison of bedside ultrasound and chest x-ray for inserting central lines

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[Usefulness of bedside ultrasound compared to capnography and X-ray for tracheal intubation]. / Utilidad de la ecografía comparada con la capnografía y la radiografía en la intubación traqueal.

OBJECTIVES: The aim of this study was to assess the usefulness of bedside ultrasound compared to capnography and X-ray for endotracheal intubation in children and newborns. MATERIALS AND METHODS: Hemodynamically stable children intubated in pedriatric and neonatal intensive care unit were included. Endotracheal tube insertion was checked after every intubation attempt by tracheal ultrasound and capnography simultaneously. The endotracheal tube insertion depth was then checked by assesment of lung sliding by thoracic ultrasound. Thereafter, Chest X-ray was performed and interpreted as usual. Time to perform each technique was recorded. RESULTS: The study included 31 intubations in 26 patients (15 in PICU and 16 in NICU). There were no statistically significant differences between tracheal ultrasound and capnography or between thoracic ultrasound and x-ray in identifying the correct endotracheal intubation and assessment of endotracheal tube insertion depth, respectively. Sensibility and specificity of ultrasound compared to capnography was 92% and 100%, and 100% and 75% compared to X-ray. Ultrasound was significantly slower compared to capnography [12 (4-16) vs 6 (3-12) seconds; P<.001] and significantly quicker compared to X-ray [0.22 (0.17-0.40) vs. 20 (17-25) minutes, P<.001]. CONCLUSIONS: Ultrasound appears to be as effective as capnography, although slower, for identifying endotracheal intubation. Ultrasound may be useful in clinical situations, such as cardiopulmonary resuscitation where capnography is less reliable. Ultrasound is as effective and quicker than X-ray for assessment of endotracheal tube insertion depth, and it may contribute to decrease the routine use of X-ray after tracheal intubation.

Test de elevación pasiva de las piernas y respuesta a líquidos en un niño politraumatizado / Passive leg raising test and fluid responsiveness in a child with multiple injuries

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Dificultad diagnóstica en la enfermedad de Kawasaki incompleta / Diagnostic difficulty in incomplete Kawasaki disease

El manejo de los pacientes con sospecha de enfermedad de Kawasaki incompleta es difícil. La ausencia de marcadores específicos de la enfermedad y la similitud con otros procesos infecciosos mucho más frecuentes pueden conducir a un retraso en el diagnóstico. Es importante mantener un alto índice de sospecha para poder iniciar el tratamiento con inmunoglobulina precozmente y prevenir la afectación coronaria. Las recomendaciones de la Academia Americana de Pediatría y la Asociación Americana del Corazón son una guía útil para mejorar el rendimiento diagnóstico en estos casos. En el siguiente caso clínico exponemos una EK incompleta y se discuten las bases para el diagnóstico (AU)

The management of patients with suspicion of incomplete Kawasaki disease is difficult. The absence of specific markers of the disease and its similarity to other much more frequent infectious processes may lead to a delay in its diagnosis. It is important to maintain a high index of suspicion to be able to initiate immunoglobin treatment early and to prevent coronary involvement. The recommendations of the American Academy of Pediatrics and the American Heart Association are a useful guide to improve the diagnostic yield in these cases. We present an incomplete Kawasaki disease in the following clinical case and discuss the bases for its diagnosis (AU)

Uso de la ecografía en la comprobación de la intubación traquealurgente en Pediatría: experiencia preliminar / Use of ultrasonograph in the verification of urgent tracheal intubation in pediatrics: preliminary experience

Introducción y objetivos. El método estándar para la confirmación de la intubación traqueal es la laringoscopia directa; siendo el método secundario más recomendado la capnografía. Por otro lado, existe un interés creciente en el uso de la ecografía como técnica alternativa y complementaria, con la ventaja añadida de permitir comprobar los movimientos respiratorios, sin embargo, su uso es aún limitado. Exponemos nuestra experiencia preliminar con el uso de la ecografía para este fin, describiendo e ilustrando la técnica en una pequeña serie de pacientes. Material y métodos. Se comprobó la intubación correcta en los planos longitudinal y transversal así como la ausencia de intubación bronquial selectiva mediante ecografía. Posteriormente un segundo investigador revisó y analizó las imágenes obtenidas para evaluar la concordancia entre ambos. Casos clínicos. Fueron incluidas 7 intubaciones en 5 pacientes, sin producirse en ningún caso intubación esofágica. La mediana del tiempo de comprobación fue 63,5 (28- 97,5) segundos. La posición del tubo fue considerada como correcta ecográficamente en 6 de los casos, según el signo del lung sliding y la motilidad diafragmática; sin embargo, por radiografía convencional sólo se consideró correcta en 5. En 27 de las 28 imágenes registradas hubo concordancia entre ambos investigadores. Comentarios. La ecografía parece ser un método alternativo útil y rápido para la confirmación de la intubación traqueal. En comparación con los métodos convencionales se trata de una técnica no invasiva, que permite descartar la intubación selectiva del bronquio derecho de forma rápida y podría contribuir a evitar la realización de radiografías (AU)

Introduction and objectives. Direct laringoscopy is the standard method to confirm proper endotracheal tube placement; capnography represents the second most recommended method. Nowadays, ultrasound is gaining interest as an alternative and complementary technique, which also allows the comprobation of respiratory movements. Unfortunately this use is still limited. This study aimed to show our experience with the use of ultrasound for this purpose, describing and illustrating the technique in a small series of patients. Material and methods. Proper intubation in longitudinal and transverse plane, as well as the absence of selective bronchial intubation was verified by ultrasound. Subsequently the obtained images were reviewed and analyzed by a second researcher to evaluate the correlation between them. Clinical cases. Seven intubations in five patients were included, none of them were esophagical. The average time to verify was 63.5 (28-97.5) seconds. Correct tube position was considered by ultrasound lung sliding and diaphragmatic motility in 6 cases, in contrast with 5 cases by conventional radiography. In 27 of 28 recorded images there was an agreement between both researchers. Comments. Ultrasound appears to be a useful and fast alternative technique to confirm tracheal intubation. Compared with conventional methods it is a noninvasive technique that allows to dismiss selective right bronchial intubation in a fast way and can contribute to avoid excessive use of radiography (AU)

Evaluación sistemática de la actuación de los pediatras ante un caso simulado de taquicardia supraventricular / Systematic assessment of the paediatrician’s performance during simulated supraventricular tachycardia

Objetivo: El presente estudio persigue dos objetivos: a) analizar mediante una lista estructurada de tareas la calidad del manejo clínico en un escenario simulado de la taquicardia supraventricular (TSV) aguda y b) identificar posibles errores y áreas de mejora sobre las que incidir en el entrenamiento. Material y métodos: Se han revisado y valorado de forma sistemática los escenarios simulados de TSV realizados en los cursos de simulación avanzada pediátrica llevados a cabo entre junio2008 y abril 2010. Se programaron en el sistema SimBaby(R) tres escenarios de dificultad creciente: TSV estable (TSV-E), TSV inicialmente estable que progresa a inestable (TSV-EI) y TSV inestable (TSV-I). La evaluación del escenario se basó en una lista de 18 tareas derivadas de las recomendaciones del ILCOR. Resultados: Se analizaron 45 escenarios (15 escenarios de TSV-E, 25 de TSV e-I y 5 de TSVI),en los que participaron 167 pediatras. Se completaron correctamente 328 de 551 (59,5%) tareas posibles. El porcentaje medio (desviación estándar) de tareas correctas por escenario varió en función del caso: 63,4 (16,7) en la TSV-E, 47,8 (20,3) en la TSV-EI y 38,6 (31) en la TSV-I (p = 0,028). No se observaron diferencias significativas entre los pediatras de atención primaria y los de atención hospitalaria. La mayoría de los participantes diagnosticaron correctamente la TSV; sin embargo, se cometieron errores importantes como no identificar la inestabilidad hemodinámica en 20 de 43 (48%) escenarios, dosis incorrectas de adenosina en 18 de 39 (48%) escenarios, la administración inadecuada de adenosina en 23 de 39 (59%) escenarios y no reconocer la indicación de cardioversión inmediata en 15 de 31 (48%) escenarios. Conclusiones: Los pediatras saben identificar una TSV pero precisan mejorar su capacitación para tratarla de forma adecuada. El análisis sistemático de la actuación de los profesionales ante un caso simulado permite detectar tanto sus puntos fuertes como las áreas en las que es preciso reforzar la enseñanza (AU)

Introduction: The aims of this study are to: a) assess the quality in clinical management during a simulated scenario of acute supraventricular tachycardia (SVT) by means of a structured task-based checklist and to b) detect pitfalls and grey areas where reinforcement in training maybe needed. Material and methods: We systematically reviewed SVT simulated scenarios during simulation courses between June 2008 and April 2010. Three scenarios were programmed using SimBaby(R) simulation system, and included stable SVT (S-SVT), stable progressing to unstable SVT (SU-SVT) and unstable SVT (U-SVT). Scenarios were evaluated by means of an 18-task checklist based on ILCOR international recommendations. Results: A total of 45 scenarios were assessed with the participation of 167 paediatricians, including 15 S-SVT, 25 SU-SVT and 5 U-SVT scenarios. Out of a total of 551 possible tasks, 328 (59.5%) were completed correctly. The mean percentage of correct tasks per scenario was 63.4 (16.7) for S-SVT, 47.8 (20.3) for SU-ST and 38.6 (31) for U-SVT (p = 0.028). There were no significant differences between primary care paediatricians and hospital paediatricians. Most of the participants correctly identified non-sinus rhythm as SVT. However, important pitfalls wereobserved, including failure to identify haemodynamic instability in 20 out of 43 (48%) cases, an incorrect dose of adenosine in 18 out of 39 (48%), incorrect adenosine administration in 23 out of 39 (59%), and non-recognition of indication to emergent cardio version in 15 out of 31 (48%).Conclusions: Paediatricians are able to diagnose SVT correctly, but need to improve their skills in treatment. Systematic analysis of clinical performance in a simulated scenario allows the identification of strengths, as well as weak points, where reinforcement is needed(AU)

Persistent cerebral blood flow by transcranial Doppler ultrasonography in an asphyxiated newborn meeting brain death diagnosis: case report and review of the literature.

We want to illustrate the difficulty of establishing a brain death diagnosis in newborn children and how an easy and useful tool, the transcranial Doppler ultrasonography, can leave an unexpected result that complicates the process despite the rest of the diagnostic tests. We describe a 36-week gestation newborn male who was diagnosed of brain death after asphyxiated and offered for donation. After initial stabilization at admission, we established brain death diagnosis by checking and meeting every criterion. The donation process was complicated because of persistent blood flow on transcranial Doppler ultrasonography. Transcranial Doppler ultrasonography is a very useful method to assess cerebral blood flow. However, caution and individualization are needed when interpreting this complementary exam, especially in highly conflictive situations like brain death diagnosis.

[Systematic assessment of the paediatrician's performance during simulated supraventricular tachycardia]. / Evaluación sistemática de la actuación de los pediatras ante un caso simulado de taquicardia supraventricular.

INTRODUCTION: The aims of this study are to: a) assess the quality in clinical management during a simulated scenario of acute supraventricular tachycardia (SVT) by means of a structured task-based checklist and to b) detect pitfalls and grey areas where reinforcement in training may be needed. MATERIAL AND METHODS: We systematically reviewed SVT simulated scenarios during simulation courses between June 2008 and April 2010. Three scenarios were programmed using SimBaby® simulation system, and included stable SVT (S-SVT), stable progressing to unstable SVT (SU-SVT) and unstable SVT (U-SVT). Scenarios were evaluated by means of an 18-task checklist based on ILCOR international recommendations. RESULTS: A total of 45 scenarios were assessed with the participation of 167 paediatricians, including 15 S-SVT, 25 SU-SVT and 5 U-SVT scenarios. Out of a total of 551 possible tasks, 328 (59.5%) were completed correctly. The mean percentage of correct tasks per scenario was 63.4 (16.7) for S-SVT, 47.8 (20.3) for SU-ST and 38.6 (31) for U-SVT (p=0.028). There were no significant differences between primary care paediatricians and hospital paediatricians. Most of the participants correctly identified non-sinus rhythm as SVT. However, important pitfalls were observed, including failure to identify haemodynamic instability in 20 out of 43 (48%) cases, an incorrect dose of adenosine in 18 out of 39 (48%), incorrect adenosine administration in 23 out of 39 (59%), and non-recognition of indication to emergent cardioversion in 15 out of 31 (48%). CONCLUSIONS: Paediatricians are able to diagnose SVT correctly, but need to improve their skills in treatment. Systematic analysis of clinical performance in a simulated scenario allows the identification of strengths, as well as weak points, where reinforcement is needed.

¿Mejora el aporte proteico precoz el crecimiento extrauterino en recién nacidos pretérmino de bajo peso? / Does early parenteral protein intake improve extrauterine growth in low birth weight preterms?

Introducción: El retraso de crecimiento postnatal es frecuente en los recién nacidos pretérmino (RNPT) de bajo peso. La administración precoz de proteínas en su nutrición parece mejorar el crecimiento extrauterino y las comorbilidades asociadas. Evaluamos el impacto sobre el crecimiento posnatal de un nuevo protocolo de nutrición parenteral con aporte precoz de aminoácidos en recién nacidos < 1.500g. Material y métodos: Estudio observacional de casos-controles sobre una muestra de 58 RNPT < 1.500g. El grupo de casos lo formaron 29 RNPT que recibieron al menos 1,5g/kg/día de aminoácidos vía parenteral en las primeras 24h de vida, con aumentos diarios hasta alcanzar al menos 3,5g/kg/día al 3.°-4.° día, comparándose con un grupo control de 29 RNPT en los que el aporte de aminoácidos se inició el 2.°-3.° día de vida a 1g/kg/día, con incrementos menores diariamente. Valoramos la evolución somatométrica de ambos en el primer mes de vida. Resultados: No había diferencias en las características basales (sexo, edad gestacional, parámetros somatométricos) entre ambos grupos. Los RNPT que recibieron proteínas a dosis mayores y más precozmente tuvieron una ganancia de peso significativamente mayor que el grupo control (423±138g vs. 315±142g; p=0,005), presentando también una mayor velocidad de ganancia ponderal diaria (19,4±3,3 vs. 16,5±4,8; p=0,010) y una recuperación más precoz del peso al nacimiento (11,5±3,3 días vs. 14,5±4,5 días; p=0,045). No se observó mayor incidencia de complicaciones. Conclusiones: El aporte precoz de aminoácidos a dosis más altas mejora la ganancia ponderal en RNPT sin observarse un riesgo añadido para el paciente(AU)

Introduction: Extrauterine growth restriction affects most premature newborns. Early and higher parenteral protein intake seems to improve postnatal growth and associated comorbidities. We evaluate the impact of a new parenteral nutrition protocol based on early amino acid administration on postnatal growth in premature infants with a birth weight < 1,500 grams. Material and methods: A case-control study in 58 premature newborns with a birth weight < 1,500 grams. In the case group we included 29 preterm neonates who received at least 1.5g/kg/day parenteral amino acid during the first 24hours after birth, reaching a maximum dose of 3.5g/kg/day on the 3rd-4th day after birth. The control group was formed by 29 preterm neonates for whom protein support began on the 2nd-3rd day after birth with a dose of 1g/kg/day with lower daily increases than the case group. Growth rates and complications were followed until 28 days of life or discharge from NICU. Results: There were no differences between groups in baseline characteristics. Premature newborns who received higher and earlier doses of proteins had a greater weight gain than the control group, and this difference was statistically significant (423±138g vs. 315±142g; P=.005). In addition, they had a higher daily weight gain rate (19.4±3.3 vs. 16.5±4.8; P=.010) and they regained birth weight earlier (11.5±3.3 days vs. 14.5±4.5 days; P=.045). A higher incidence of complications was not observed. Conclusions: Early and higher amino acid administration improves growth rate in premature neonates with no apparent increase in risks for the patient(AU)

Epilepsia versus síncope convulsivo: la cama basculante como herramienta diagnóstica / Epilepsy versus convulsive syncope: tilt table test as a diagnostic tool

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