Extracción de oxígeno como predictor de mortalidad en pacientes con ventilación con alta frecuencia / Oxygen extraction as a predictor of mortality in patients on high frequency ventilation

Introducción: La ventilación con alta frecuencia (VAFO) puede reducir el gasto cardíaco. Analizamos su repercusión hemodinámica e identificamos factores pronósticos de mortalidad. Pacientes y métodos: Entre enero del 2003 y diciembre del 2010, incluimos a 48 niños con fallo respiratorio sometidos a VAFO. El diseño del estudio fue prospectivo, observacional y descriptivo. Los criterios de inclusión se basaron en la existencia de hipoxemia. Las variables estudiadas fueron: presiones arterial y venosa central, pH arterial, saturación venosa e índice de extracción de oxígeno; haciéndose determinaciones previas a la VAFO, durante y antes de pasar a convencional. Se identificaron factores pronósticos mediante un análisis bivariante y determinamos un modelo predictivo de mortalidad. Resultados: La edad fue de 21 (4-72) meses. Al ingreso, las escalas de PRISM y Murray fueron de 33 y de 2,8, la PaO2/FiO2 de 61 y el índice de oxigenación de 35. Tras la VAFO, se obtuvo un aumento del pH (p>0,001), de la presión arterial media (p<0,001) y de la saturación venosa, y un descenso de la presión venosa y de la extracción de O2 (p < 0,001). Los factores pronósticos de mortalidad a las 24 h de iniciar la VAFO fueron: FiO2, PaO2/FiO2, índice de oxigenación, shunt, pH, presiones venosa central y arterial media, saturación venosa y extracción de O2. El modelo creado a las 12 h, compuesto por la SvcO2 y el ETO2, fue capaz de pronosticar la muerte con una probabilidad del 92,3%. Conclusiones: La VAFO mejora la hemodinámica. El modelo a las 12 h es el que mejor nos predice la muerte(AU)

Introduction: The high frequency oscillatory ventilation (HFOV) may reduce cardiac output. The haemodynamics were analysed and predictors of mortality identified. Patients and methods: A total of 48 children with respiratory failure undergoing HFOV between January 2003 and December 2010 were included. The study design was prospective, observational, and descriptive. Inclusion criteria were based on the existence of hypoxemia. The variables studied were: arterial and central venous pressure, arterial pH, venous saturation and oxygen extraction ratio, with determinations performed prior to HFOV, during, and before turning to conventional ventilation. Prognostic factors were identified by bivariate analysis and a predictive model of mortality was developed. Results: The mean age was 21 [4 to 72] months. On admission, PRISM scales and Murray were 33 and 2.8, PaO2/FiO2 of 61 and oxygenation index of 35. After HFOV an increase in pH (P<0.001), mean arterial pressure (P<0.001) and venous saturation, and decreased venous pressure and O2 extraction (P<0.001), was obtained. The prognostic factors of mortality at 24hours after starting HFOV were: FiO2, PaO2/FiO2, oxygenation index, shunt, pH, central venous pressure and mean arterial pressure, venous saturation, and O2 extraction. The model developed at 12hours, consisting of EtO2 and SvcO2 was able to predict death with a probability of 92.3%. Conclusions: HFOV improves haemodynamics. The model at 12hours is the best predictor of death(AU)

[Oxygen extraction as a predictor of mortality in patients on high frequency ventilation]. / Extracción de oxígeno como predictor de mortalidad en pacientes con ventilación de alta frecuencia.

INTRODUCTION: The high frequency oscillatory ventilation (HFOV) may reduce cardiac output. The haemodynamics were analysed and predictors of mortality identified. PATIENTS AND METHODS: A total of 48 children with respiratory failure undergoing HFOV between January 2003 and December 2010 were included. The study design was prospective, observational, and descriptive. Inclusion criteria were based on the existence of hypoxemia. The variables studied were: arterial and central venous pressure, arterial pH, venous saturation and oxygen extraction ratio, with determinations performed prior to HFOV, during, and before turning to conventional ventilation. Prognostic factors were identified by bivariate analysis and a predictive model of mortality was developed. RESULTS: The mean age was 21 [4 to 72] months. On admission, PRISM scales and Murray were 33 and 2.8, PaO(2)/FiO(2) of 61 and oxygenation index of 35. After HFOV an increase in pH (P<.001), mean arterial pressure (P<.001) and venous saturation, and decreased venous pressure and O(2) extraction (P<.001), was obtained. The prognostic factors of mortality at 24 hours after starting HFOV were: FiO(2), PaO(2)/FiO(2), oxygenation index, shunt, pH, central venous pressure and mean arterial pressure, venous saturation, and O(2) extraction. The model developed at 12 hours, consisting of EtO(2) and SvcO(2) was able to predict death with a probability of 92.3%. CONCLUSIONS: HFOV improves haemodynamics. The model at 12 hours is the best predictor of death.

[High-frequency oscillatory ventilation. A single-center study]. / Nuestra experiencia con la ventilación de alta frecuencia oscilatoria.

INTRODUCTION: High-frequency oscillatory ventilation is a safe and effective means of delivering mechanical ventilatory support. OBJECTIVE: To evaluate the safety and effectiveness of high-frequency oscillatory ventilation in pediatric patients with acute respiratory failure. PATIENTS AND METHOD: From August 2003 to July 2005, we performed a prospective observational study of 11 children older than 1 month who underwent high-frequency oscillatory ventilation. Pediatric risk of mortality scores (PRISM), Murray lung-injury scores and air leak scores were recorded at baseline before ventilation. The following variables were studied: ventilatory settings (FiO2 and mean airway pressure), gasometric (PaO2, SaO2, PaCO2, pHa, PaO2/FiO2 ratio) and hemodynamic parameters (Partm, PVC), and the oxygenation index. RESULTS: The overall survival rate was 82 %. Significant increases were found in PaO2 (p < 0.05), SaO2 (p < 0.05) and the PaO2/FiO2 ratio (p < 0.05), while mean airway pressure (p < 0.001), oxygenation index (p < 0.001), and FiO2 (p < 0.001) significantly decreased over time. CONCLUSIONS: High-frequency oscillatory ventilation significantly improved oxygenation in children with acute hypoxemic respiratory failure.

Nuestra experiencia con la ventilación de alta frecuencia oscilatoria / High-frequency oscillatory ventilation. A single-center study

Introducción La ventilación de alta frecuencia oscilatoria es una terapéutica válida, que utiliza una estrategia protectora pulmonar. Objetivo Evaluar la utilidad de esta técnica en niños con insuficiencia respiratoria aguda. Pacientes y método Entre agosto de 2003 y julio de 2005 realizamos un estudio prospectivo y observacional de 11 niños mayores de un mes tratados con ventilación de alta frecuencia oscilatoria. Se hizo una valoración de la gravedad, con la escala Pediatric Risk of Mortality (PRISM); del daño pulmonar, con la de Murray, y de la gravedad del barotrauma, con la de escape aéreo. Se estudiaron las siguientes variables: del respirador (fracción inspiratoria de oxígeno [FiO2], presión media en la vía aérea), gasométricas (presión parcial arterial de oxígeno [PaO2], saturación arterial de oxígeno [SaO2], presión parcial arterial de dióxido de carbono [PaCO2], pH arterial [pHa], relación PaO2/FiO2), índice de oxigenación, y hemodinámicas (presión arterial media [PAM], presión venosa central [PVC]). Resultados La supervivencia global fue del 82 %. Nosotros hemos encontrado modificaciones consistentes en un incremento de la PaO2 (p < 0,05), SaO2 (p < 0,05), y relación PaO2/ FiO2 (p < 0,05); así como un descenso de la presión media en la vía aérea (p < 0,001), del índice de oxigenación (p < 0,001) y de la FiO2 (p < 0,001). Conclusiones La ventilación de alta frecuencia oscilatoria ha mejorado la oxigenación en niños con fallo respiratorio agudo hipoxémico

Introduction High-frequency oscillatory ventilation is a safe and effective means of delivering mechanical ventilatory support. Objective To evaluate the safety and effectiveness of high-frequency oscillatory ventilation in pediatric patients with acute respiratory failure. Patients and method From August 2003 to July 2005, we performed a prospective observational study of 11 children older than 1 month who underwent high-frequency oscillatory ventilation. Pediatric risk of mortality scores (PRISM), Murray lung-injury scores and air leak scores were recorded at baseline before ventilation. The following variables were studied: ventilatory settings (FiO2 and mean airway pressure), gasometric (PaO2, SaO2, PaCO2, pHa, PaO2/FiO2 ratio) and hemodynamic parameters (Partm, PVC), and the oxygenation index. Results The overall survival rate was 82 %. Significant increases were found in PaO2 (p < 0.05), SaO2 (p < 0.05) and the PaO2/FiO2 ratio (p < 0.05), while mean airway pressure (p < 0.001), oxygenation index (p < 0.001), and FiO2 (p < 0.001) significantly decreased over time. Conclusions High-frequency oscillatory ventilation significantly improved oxygenation in children with acute hypoxemic respiratory failure

[Utility of procalcitonin, C-reactive protein and leukocyte count in the detection of meningococcal disease during an epidemic cluster]. / Utilidad de la procalcitonina, proteína C reactiva y recuento leucocitario en la detección de enfermedad meningocócica durante un brote epidémico.

OBJECTIVE: To determine the clinical utility of biological markers of the acute phase of bacterial infection (procalcitonin, C-reactive protein and leukocyte count) in invasive meningococcal disease during an epidemic cluster. PATIENTS AND METHODS: Thirty-six patients with feverish syndrome who visited the emergency unit of our hospital within a 6-month period were studied. In all patients, serum procalcitonin and C reactive protein levels and leukocyte count were determined, and blood culture was performed. RESULTS: Invasive meningococcal disease, confirmed by blood culture, was found in seven of the 36 patients studied. The most frequent clinical presentation was a feverish syndrome of less than 24 hours of onset, progressing to sepsis in subsequent hours. Comparison of procalcitonin and C reactive protein concentrations in patients with and without meningococcal disease revealed that procalcitonin and C reactive protein levels greater than 10 ng/ml and 49.95 ng/ml respectively had high sensitivity, specificity and predictive values. Procalcitonin levels < 0.5 ng/ml were useful to easily rule out invasive meningococcal disease. In the case of leukocyte count, no value with clinical significance could be established, although counts were higher in patients with invasive meningococcal disease. CONCLUSIONS: The finding of prolactin levels of < 0.5 ng/ml and/or C-reactive protein levels of < 49.95 ng/ml in children or teenagers with fever of less than 24 hours of onset indicates a low probability of invasive meningococcal disease in epidemic situations.

Utilidad de la procalcitonina, proteína C reactiva y recuento leucocitario en la detección de enfermedad meningocócica durante un brote epidémico / Utility of procalcitonin, c-reactive protein and leukocyte count in the detection of meningococcal disease during an epidemic cluster

Objetivo: Determinar la utilidad clínica de los marcadores biológicos de fase aguda de infección bacteriana (procalcitonina, proteína C reactiva [PCR] y recuento leucocitario) en la enfermedad invasiva meningocócica durante un brote epidémico. Pacientes y métodos: Se estudiaron 36 enfermos con síndrome febril que acudieron al servicio de urgencias de nuestro hospital durante un período de 6 meses. En todos los pacientes se realizaron determinaciones de niveles séricos de procalcitonina, PCR, recuento leucocitario y hemocultivo. Resultados: La enfermedad invasiva meningocócica, confirmada por hemocultivo, apareció en 7 de los 36 enfermos estudiados. La presentación clínica más habitual fue un síndrome febril de menos de 24 h que evolucionó a sepsis en horas posteriores. La comparación de las concentraciones de procalcitonina y PCR en los pacientes con y sin enfermedad meningocócica reveló que para valores de procalcitonina y PCR > 10 y > 49,95 ng/ml, respectivamente, tenían una elevada sensibilidad, especificidad y valores predictivos, aunque valores de procalcitonina inferiores a0,5 ng/ml tenían valor clínico al descartar la enfermedad fácilmente. En el caso del recuento de leucocitos no se pudo determinar un valor adecuado que tuviera significación clínica, aunque los pacientes con infección meningocócica presentaban recuentos más altos. Conclusiones: El hallazgo de niveles de procalcitonina inferiores a0,5 y/o 49,95 ng/ml de PCR en niños y jóvenes con fiebre de menos de 24 h de evolución indica una baja probabilidad de enfermedad invasiva meningocócica en situaciones epidémicas (AU)

Objective: To determine the clinical utility of biological markers of the acute phase of bacterial infection (procalcitonin, C-reactive protein and leukocyte count) in invasive meningococcal disease during an epidemic cluster. Patients and methods: Thirty-six patients with feverish syndrome who visited the emergency unit of our hospital within a 6-month period were studied. In all patients, serum procalcitonin and Creactive protein levels and leukocyte count were determined, and blood culture was performed. Results: Invasive meningococcal disease, confirmed by blood culture, was found in seven of the 36 patients studied. The most frequent clinical presentation was a feverish syndrome of less than 24 hours of onset, progressing to sepsis in subsequent hours. Comparison of procalcitonin and Creactive protein concentrations in patients with and without meningococcal disease revealed that procalcitonin and C reactive protein levels greater than 10 ng/ml and49.95 ng/ml respectively had high sensitivity, specificity and predictive values. Procalcitonin levels < 0.5 ng/ml were useful to easily rule out invasive meningococcal disease. In the case of leukocyte count, no value with clinical significance could be established, although counts were higher in patients with invasive meningococcal disease. Conclusions: The finding of prolactin levels of < 0.5 ng/ml and/orC-reactive protein levels of < 49.95 ng/ml in children or teenagers with fever of less than 24 hours of onset indicates a low probability of invasive meningococcal disease in epidemic situations (AU)

Sepsis y meningitis neumocócica 2001-2003: incidencia, clínica e identificación de serotipos / Pneumococcal sepsis and meningitis, 2001-2003: incidence, clinical features and identification of serotypes

Objetivo: Determinar las tasas de incidencia, características clínicas y serotipos causantes de meningitis y sepsis neumocócica en los últimos años. Material y métodos: Estudio prospectivo de los casos de sepsis y meningitis neumocócica que ingresaron en nuestro hospital entre enero de 2001 y febrero de 2003. Se aisló el germen en cultivo de líquido cefalorraquídeo y/o sangre. Se identificó el serotipo de neumococo en los casos que se produjeron en 2002 y 2003. Se analizan los parámetros epidemiológicos, bacteriológicos y clínicos. Resultados: Se han diagnosticado 14 casos, en 12 niños; dos niños presentaron 2 episodios de meningitis y/o sepsis. La incidencia anual fue de 15,38 casos por cada 100.000 niños menores de 2 años y de 9,16 casos por cada 100.000 niños menores de 5 años de edad. El 67% eran menores de 2 años de edad. Todos los mayores de 2 años presentaban algún factor de riesgo de padecer enfermedad neumocócica invasora. Los serotipos identificados fueron: 6B en cinco casos, 14 en dos y 18C en uno. El 69% de las cepas aisladas presentaba sensibilidad intermedia o resistencia a penicilina y el 54% mostraba resistencia a eritromicina. El 57% de los niños sufrieron complicaciones graves: dos (14%) quedaron con secuelas neurológicas graves y 3 fallecieron (21 %).Conclusiones: Las sepsis y meningitis neumocócicas tienen una alta morbimortalidad. En el último año, hemos observado un aumento importante de su incidencia. Todos los serotipos identificados están incluidos en la vacuna conjugada heptavalente. Actualmente, el método más eficaz para prevenir esta grave enfermedad es el uso generalizado de la vacuna heptavalente

Objective. To determine the incidence, clinical features and serotypes implicated in pneumococcal sepsis and meningitis in recent years. Material and methods. We performed a prospective study of cases of pneumococcal sepsis and meningitis that occurred in our hospital between January, 2001 and February, 2003. Streptococcus pneumoniae was isolated from cerebrospinal fluid and/or blood cultures in all the patients. Serotyping was performed in the cases occurring in 2002 and 2003. The epidemiological, bacteriological and clinical characteristics were studied. Results. Fourteen cases were identified in 12 patients. Two children had recurrent meningitis and/or sepsis. From 0 to 2 years of age, the incidence of pneumococcal meningitis was 15.38 cases per 100,000 population per year, and from 0 to 5 years of age, it was 9.16 cases per 100,000 population per year. Eight patients (67%) were aged less than 2 years. All children older than 2 years had a predisposing disease. The most common serotype was 6B (5 cases). Penicillin-resistant strains were detected in 69% of cases and erythromycin-resistant strains in 54%. Fifty-seven percent of the children developed serious complications. Conclusions. Pneumococcal meningitis and sepsis are common causes of morbidity and mortality. Their incidence increased considerably over the past year. All the serotypes isolated were included in the heptavalent conjugate vaccine. The most effective way to combat these severe infections would be through widespread vaccination with the conjugate pneumococcal vaccine

Sepsis recurrente por Streptococcus pneumoniae en niña con asplenia y déficit de C3 / Recurrent sepsis due to Streptococcus pneumoniae in a girl with asplenia and C3 deficit

Streptococcus pneumoniae puede originar infecciones invasoras: graves en niños, como la meningitis, con una alta morbi-mortalidad. La sepsis con shock séptico y fracaso multiorgánico, de etiología neumocócica, es un cuadro clínico muy poco frecuente. En ocasiones, los factores que predisponen a padecer enfermedad neumocócica invasora no han sido diagnosticados previamente y pueden dar lugar a cuadros clínicos de repetición. Presentamos un caso de sepsis neumocócica recurrente en una niña con asplenia y déficit de 0. Es necesario realizar estudios detallados en los niños que padecen enfermedad invasora grave por neumococo, para detectar esos factores de riesgo. La vacuna conjugada heptavalente es el método más eficaz de prevención de esta grave enfermedad (AU)

[Renal failure as a factor leading to epileptic seizures]. / Insuficiencia renal como factor desencadenante de crisis epilépticas.

OBJECTIVE: To analyze the incidence of convulsive seizures in renal failure by studying the semiological characteristics of the convulsive episodes, their subsequent evolution and the presence of possible sequelae. The relationship between the different potential causes of the seizures and their evolution and treatment was also analyzed. MATERIAL AND METHODS: We retrospectively reviewed the clinical histories of 108 patients admitted to the hospital over a 20-year period with a diagnosis of renal failure: 55 were undergoing predialysis, 42 renal transplantation, 7 peritoneal dialysis and 3 hemodialysis. One patient was excluded for not fulfilling the selection criteria. Computer study of the 18 quantitative and qualitative variables was carried out with the SPSS 9.0.1 program. RESULTS: Of the 107 patients, 16 (14.95 %) had suffered some type of convulsive seizure. None was in the predialysis group. As triggering factors, hydroelectrolyte imbalance was found in eight patients and hypertension was found in four. In the remaining patients the causes were not well-defined. Only three patients with epilepsy prior to renal failure presented sequelae. CONCLUSIONS: Epileptic seizures in renal failure in childhood can be considered as occasional seizures that do not usually become chronic or produce sequelae. Information on the management of seizures in renal failure should be disseminated among professionals treating systemic diseases.