[Spontaneous urinary bladder perforation after pediatric cystoplasty]. / Perforación vesical espontánea tras cistoplastia en la infancia.

OBJECTIVE: The spontaneous cystoplasty perforation is a serious and potentially fatal problem if a delay in diagnosis and treatment occurs. We pretend: 1) to look for prevention analyzing the risk factors, 2) to identify the main data of diagnostic suspicion and 3) to evaluate the result of the treatments done. MATERIAL AND METHODS: Out of 30 children with cystoplasty 5 of them have presented 8 perforations (16,6%). Several influential factors, the symptoms, the treatments and the evolution are reviewed. RESULTS: The average time between cystoplasty and the perforation was 8,2 years. A urethral resistance that allows continence, and an insufficient intermittent catheterization, have been the main risk factors. In the 8 episodes there were abdominal pain and distension. The ultrasonography showed intraperitoneal extravasation in 5 episodes, multiple peritoneal cysts in one, and suggestive image of appendicular plastron in another one. The cystography showed intraperitoneal extravasation only in 3 cases. The initial management was conservative in the 7 episodes diagnosed before surgery, and 3 had a good evolution (42,8%); the other 4 needed surgery with good evolution in all cases. Two of 5 patients (40%) presented 3 relapses in an average time of 5 years. The survival is 100%. CONCLUSIONS: 16,6% of patients with cystoplasty of this series had one or more episodes of spontaneous bladder perforation. The more significant risk factors are a high urethral resistance and an inadequate intermittent catheterization. The patients with cystoplasty, and their families, must know this complication, their risk factors and symptoms to prevent it, or to facilitate an early diagnosis.

Perforación vesical espontánea tras cistoplastia en la infancia / Spontaneous urinary bladder perforation after pediatric cystoplasty

Objetivos: La perforación espontánea de una cistoplastia es un problema grave y potencialmente fatal, si no se diagnostica y se trata a tiempo. Se pretende: 1) buscar una prevención analizando los factores de riesgo, 2) identificarlos principales datos de sospecha diagnóstica y 3) valorar el resultado de los tratamientos realizados. Material y Método: De 30 pacientes pediátricos con cistoplastia, 5 presentaron 8 perforaciones (16,6%). Se revisan los diversos factores influyentes, la clínica, los tratamientos y la evolución. Resultados: El tiempo medio transcurrido entre la cistoplastia y la perforación fue 8,2 años. Los principales factores de riesgo han sido una resistencia uretral que permitía continencia, y una insuficiente realización temporal del sondaje intermitente (SI). En los 8 episodios hubo dolor y distensión abdominal. La ecografía mostró líquido libre intraperitoneal en 5, múltiples quistes peritoneales en 1, e imagen sugestiva de plastrón apendicular en otro. La cistografía sólo mostró paso de contraste a la cavidad peritoneal en 3. El tratamiento inicial fue conservador, sin cirugía, en los 7 episodios diagnosticados preoperatoriamente, siendo la evolución favorable en 3(42,8%); los otros 4 necesitaron tratamiento quirúrgico, con buena evolución en todos. De los 5 pacientes, 2 (40%) presentaron 3 recidivas en un tiempo medio de 5 años. La supervivencia es del 100 %.Conclusiones: El 16,6% de los pacientes con cistoplastia de esta serie, ha tenido uno o más episodios de perforación vesical espontánea. Los factores de riesgo más significativos son una resistencia uretral alta y la inadecuada realización del SI. Los pacientes con cistoplastia y sus familias deben conocer esta complicación, sus factores de riesgo y sus síntomas, para prevenirla o facilitar un diagnóstico precoz (AU)

Objective: The spontaneous cystoplasty perforation is a serious and potentially fatal problem if a delay in diagnosis and treatment occurs. We pretend: 1) to look for prevention analyzing the risk factors, 2) to identify the main data of diagnostic suspicion and 3) to evaluate the result of the treatments done. Material and Methods: Out of 30 children with cystoplasty 5 of them have presented 8 perforations (16,6%). Several influential factors, the symptoms, the treatments and the evolution are reviewed. Results: The average time between cystoplasty and the perforation was 8,2 years. A urethral resistance that allows continence, and an insufficient intermittent catheterization, have been the main risk factors. In the 8 episodes there were abdominal pain and distension. The ultrasonography showed intraperitoneal extravasation in 5 episodes, multiple peritoneal cysts in one, and suggestive image of appendicular plastron in another one. The cystography showed intraperitoneal extravasation only in 3 cases. The initial management was conservative in the 7 episodes diagnosed before surgery, and 3 had a good evolution (42,8%); the other 4 needed surgery with good evolution in all cases. Two of 5 patients (40%) presented 3 relapses in an average time of 5 years. The survival is 100%. Conclusions: 16,6% of patients with cystoplasty of this series had one or more episodes of spontaneous bladder perforation. The more significant risk factors are a high urethral resistance and an inadequate intermittent catheterization. The patients with cystoplasty, and their families, must know this complication, their risk factors and symptoms to prevent it, or to facilitate an early diagnosis (AU)

[Adrenal function in children with sepsis and septic shock]. / Función suprarrenal en niños con sepsis y shock séptico.

OBJECTIVES: To assess adrenal function in children with sepsis and septic shock with petechiae and to investigate the possible relationship between adrenal hypofunction, sonographic diagnosis of massive bilateral adrenal hemorrhage, and other factors available early in this disturbance. PATIENTS AND METHODS: Prospective observational study of 24 patients (14 boys, 10 girls), aged 2.9.24 years, admitted to the pediatric intensive care unit with sepsis and septic shock with petechiae during a 1.5-year period. The control group included 26 healthy children (13 boys, 13 girls), aged 8.8.6.4.2 years. Plasma cortisol and adrenocorticotropic hormone (ACTH) were measured by radioimmunoassay and adrenal ultrasonography was performed. RESULTS: Plasma cortisol and ACTH levels were 243.7 ng/ml and 135.0 pg/ml in the patient group and 145.4 ng/ml and 21.1 pg/ml in the control group (p<0.01 in both). Adrenal insufficiency was found in four patients. Children with insufficiency more frequently required noradrenaline than did those with normal adrenal function (4/4 vs 2/20). Necrotic purpura (2/4 vs 2/20), massive adrenal hemorrhage (2/3 vs 1/20), lower platelet count (69.500 vs 212.895/l), lower prothrombin activity (19.0 vs 49.2%), lower fibrinogenemia (51.2 vs 304,4 mg/dl), higher pediatric risk of mortality III (PRISM III) scores (11.7 vs 2.7) and higher mortality rate (3/4 vs 1/20) were found in children with adrenal insufficiency than in those with normal adrenal function. CONCLUSIONS: Plasma cortisol and ACTH levels were increased in children with sepsis and septic shock. Adrenal insufficiency was uncommon. Adrenal insufficiency was associated with severe hemodynamic failure, necrotic purpura, disseminated intravascular coagulopathy, massive bilateral adrenal hemorrhage and high mortality rate.

Función suprarrenal en niños con sepsis y shock séptico / Adrenal function in children with sepsis and septic shock

Objetivos: Estudiar la función suprarrenal en niños con sepsis y shock séptico asociados a petequias. Establecer la relación entre insuficiencia suprarrenal e imagen ecográfica de hemorragia suprarrenal bilateral masiva y otras variables disponibles precozmente. Pacientes y métodos: Estudio prospectivo observacional de 24 pacientes (14 varones) de 2,9 ± 2,4 años ingresados en una unidad de cuidados intensivos pediátricos con sepsis y shock séptico asociados a petequias en un período de 1,5 años. El grupo control incluyó 26 niños sanos (13 varones) de 8,8 ± 4,2 años. Se determinaron el cortisol y la hormona corticotropa (ACTH) mediante radioinmunoanálisis (RIA) en plasma y se realizó ecografía de suprarrenales. Resultados Los valores de cortisol y ACTH fueron 243,7 ng/ml y 135,0 pg/ml en el grupo estudiado y 145,4 ng/ml y 21,1 pg/ml en el control (p<0,01 en ambos). Presentaron insuficiencia suprarrenal 4 pacientes. El grupo de pacientes con insuficiencia frente al grupo con función suprarrenal adecuada se caracterizó por requerir siempre noradrenalina (4/4 frente a 2/20), presentar más frecuentemente exantema necrótico (2/4 frente a 2/20) y hemorragia suprarrenal masiva (2/3 frente a 1/20), cifra inferior de plaquetas (69.500 frente a 212.895/ml), menor actividad de protrombina (19,0 frente a 49,2%), menor fibrinogenemia (51,2 frente a 304,4 mg/dl), mayor puntuación en el sistema PRISM III (11,7 frente a 2,7) y mayor mortalidad (3/4 frente a 1/20). Conclusiones: Los niños con sepsis y shock séptico presentan concentraciones plasmáticas de cortisol y ACTH elevadas. Una escasa proporción presenta insuficiencia suprarrenal. La aparición de insuficiencia suprarrenal se relaciona con presencia de grave afectación hemodinámica, púrpura necrótica, coagulación intravascular diseminada (CID), hemorragia suprarrenal bilateral masiva y alta mortalidad (AU)

Autoembolización espontánea en un niño con priapismo postraumático de alto flujo / Spontaneous self-embolization in a child with postraumatic high flow priapism

Existen dos tipos de priapismo: el venoso o de bajo flujo, que es característicamente doloroso, y el arterial o de alto flujo, indoloro y mucho más raro, especialmente en la infancia. Se expone el caso de un varón de 5 años que 6 días después de sufrir un traumatismo perineal cerrado, presentó un priapismo indoloro, de tipo arterial, con aneurisma y fístula de la arteria dorsal del pene, que se resolvió espontáneamente mediante autoembolización, 11 días después de su inicio. Se hace una revisión bibliográfica de 14 casos de priapismo arterial postraumático en la infancia, no habiendo encontrado ningún otro caso resuelto mediante autoembolización espontánea (AU)

[Spontaneous autoembolization in a child with high-flow post-traumatic priapism]. / Autoembolización espontánea en un niño con priapismo postraumático de alto flujo.

There are two sort of priapism: the venous or low flow priapism, that is usually painful, and the arterial or high flow one, painless and rare, especially in childhood. We present a case of a boy 5 years old, who 6 days after to suffer a perineal closed traumatism, had a painless and arterial priapism, with aneurism and fistula of the dorsal penile arteria, that was resolute spontaneously through self-embolization, 11 days after. We review the bibliography of 14 cases of arterial posttraumatic priapism in childhood, without find any case resolute by spontaneous self-embolization.