Indicadores de calidad de Cuidados Intensivos Pediátricos en España (estudio QuaCIP) / Indicators of the quality of Pediatric Intensive Care in Spain (QuaCIP Study)

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Parkour: una nueva causa de lesiones internas graves / Parkour: a new cause of serious internal injury

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Trombosis y obstrucción asociadas a vías venosas centrales. Incidencia y factores de riesgo / Thrombosis and obstruction associated with central venous lines. Incidence and risk factors

Objetivo: Analizar la incidencia de trombosis y obstrucción asociada a las vías centrales implantadas a niños críticamente enfermos y la determinación de sus factores de riesgo. Diseño: Estudio prospectivo observacional, desarrollado en una unidad de cuidados intensivos pediátrica de un hospital universitario. Material y método: Se analizaron 825 catéteres venosos centrales (CVC) insertados en 546 pacientes. Se recogieron la edad, el sexo, el peso, el tipo de catéter (luces, tamaño, marca), la localización final del catéter, la existencia de ventilación mecánica, el tipo de sedación y analgesia utilizado, el médico que realizó la técnica, el fallo inicial del residente con posterior canalización por el adjunto, el número de intentos, la indicación, la enfermedad de base, el diagnóstico de ingreso, el tipo de cateterización (urgente, programada o recanalización) y las complicaciones mecánicas tardías (CMT). Se determinaron los factores de riesgo para estas complicaciones mediante un análisis de regresión múltiple. Resultados: Se registraron 52 CMT (6,14%), 42 obstrucciones y 10 trombosis. Las tasas de obstrucción y trombosis fueron de 4,96 y 1,18 por cada 100 CVC, respectivamente. El único factor de riesgo asociado de forma independiente a la obstrucción fue el tiempo de duración del CVC (OR = 1,05, IC del 95%, 1,00-1,10). Respecto a la trombosis, tanto el número de luces (OR = 4,88, IC del 95%, 1,26-18,90) como la nutrición parenteral (OR = 4,17, IC del 95%, 1,06-16,31) alcanzaron significación estadística en el análisis bivariante. Sin embargo, no se objetivaron factores de riesgo para trombosis en el análisis multivariante. Conclusiones: La obstrucción y la trombosis de los CVC insertados en una unidad de cuidados intensivos pediátrica de un hospital universitario son relativamente frecuentes. El tiempo de duración de la vía central es un factor de riesgo independiente para la obstrucción de alguna de sus luces (AU)

Objective: To analyse the incidence of thrombosis and obstruction associated with central venous lines (CVL) inserted in critically ill children, and to determine their risk factors. Design: Prospective observational study in a Pediatric Intensive Care Unit in a University Hospital. Material and method: An analysis was made of 825 CVL placed in 546 patients. Age, gender, weight, type of catheter (lines, size, and brand), final location of the catheter, mechanical ventilation, type of sedation and analgesia used, initial failure by the doctor to perform CVL catheterization, number of attempts, CVL indication, admission diagnosis, emergency or scheduled procedure, and delayed mechanical complications (DMC). Risk factors for these complications were determined by a multiple regression analysis. Results: A total of 52 cases of DMC, 42 cases of obstruction, and 10 of thrombosis were registered. Obstruction and thrombosis rates were 4.96 and 1.18 per 100 CVL, respectively. The only risk factor independently linked to obstruction was the duration of the CVL (OR 1.05; 95% CI; 1.00-1.10). The number of lines with thrombosis (OR 4.88; 95% CI; 1.26-18.0), as well as parenteral nutrition (OR 4.17; 95% CI; 1.06-16.31) was statistically significant according to bivariate analysis. However, no risk factors for thrombosis were found in the multivariate analysis. Conclusions: Obstruction and thrombosis of CVL inserted in a Pediatric Intensive Care Unit are relatively common complications. CVL duration is an independent risk factor for any line obstruction (AU)

[Thrombosis and obstruction associated with central venous lines. Incidence and risk factors]. / Trombosis y obstrucción asociadas a vías venosas centrales. Incidencia y factores de riesgo.

OBJECTIVE: To analyse the incidence of thrombosis and obstruction associated with central venous lines (CVL) inserted in critically ill children, and to determine their risk factors. DESIGN: Prospective observational study in a Pediatric Intensive Care Unit in a University Hospital. MATERIAL AND METHOD: An analysis was made of 825 CVL placed in 546 patients. Age, gender, weight, type of catheter (lines, size, and brand), final location of the catheter, mechanical ventilation, type of sedation and analgesia used, initial failure by the doctor to perform CVL catheterization, number of attempts, CVL indication, admission diagnosis, emergency or scheduled procedure, and delayed mechanical complications (DMC). Risk factors for these complications were determined by a multiple regression analysis. RESULTS: A total of 52 cases of DMC, 42 cases of obstruction, and 10 of thrombosis were registered. Obstruction and thrombosis rates were 4.96 and 1.18 per 100 CVL, respectively. The only risk factor independently linked to obstruction was the duration of the CVL (OR 1.05; 95% CI; 1.00-1.10). The number of lines with thrombosis (OR 4.88; 95% CI; 1.26-18.0), as well as parenteral nutrition (OR 4.17; 95% CI; 1.06-16.31) was statistically significant according to bivariate analysis. However, no risk factors for thrombosis were found in the multivariate analysis. CONCLUSIONS: Obstruction and thrombosis of CVL inserted in a Pediatric Intensive Care Unit are relatively common complications. CVL duration is an independent risk factor for any line obstruction.

Maltrato físico grave con ingreso en Cuidados Intensivos Pediátricos / Severe physical abuse with admission to Pediatric Intensive Care Unit

Introducción. El maltrato infantil es un problema de salud pública. Varios estudios han señalado que este diagnóstico se incrementa de forma alarmante. El objetivo de este estudio es describir la forma de presentación de los casos de maltrato físico infantil que precisaron ingreso en una Unidad de Cuidados Intensivos Pediátricos (UCIP).Métodos. studio descriptivo retrospectivo (1995-2011). Se incluyeron los casos de maltrato físico grave que precisaron ingreso en la UCIP. Se analizaron datos epidemiológicos, clínicos, resultados de las pruebas complementarias y tipos de tratamientos requeridos. Resultados. Se analizaron ocho casos con una mediana de edad de 7 meses. El síntoma guía principal fue neurológico. Los hallazgos patológicos más frecuentes encontrados en las pruebas complementarias fueron hematomas subdurales (6 pacientes), hemorragias retinianas (4 pacientes), sufrimiento cerebral difuso (3 pacientes), fractura craneal (3 pacientes), fracturas óseas en otras localizaciones (2 pacientes). Finalmente, un paciente falleció y dos presentaron secuelas neurológicas graves. Conclusión. La clínica de los malos tratos físicos puede interpretarse erróneamente como una enfermedad neurológica. Es importante considerar este diagnóstico para identificar precozmente casos de maltrato y realizar las pruebas complementarias necesarias. El riesgo de secuelas graves o muerte es elevado, por lo que el diagnóstico precoz es fundamental (AU)

Introduction. Child abuse is a problem of public health. Several reports have demonstrated an increasing tendency for this problem. The objective of this study is to describe cases of severe child abuse admitted to paediatric intensive care unit (PICU).Methods. It is a retrospective study (1995-2011) in which patients diagnosed with physical child abuse admitted to PICU were included. Epidemiological and clinical findings, diagnostic procedures and therapy were analyzed. Results. Eight patients were included with a median age of 7 months. The most frequent sign was neurological. The more frequent injuries associated were subdural haematoma (6 patients), retinal haemorrhages (4 patients), severe abnormality in electroencephalogram (3 patients), skull fracture (3 patients), other fractures (2 patients). Finally, there was one death and two cases of severe neurological damage. Conclusion.C hild abuse can be falsely diagnosed as a neurological disease. Pediatricians should be aware of this pathology in order to identify cases of abuse as soon as possible. The relevance of early diagnosis is based on the fact that an early intervention could prevent severe sequelae or death (AU)

Neurotoxicidad subaguda letal por metotrexato intratecal / Intrathecal methotrexate induced lethal subacute neurotoxicity

El metotrexato es un inhibidor de la dihidrofolato reductasa ampliamente utilizado en el tratamiento de la leucemia, el linfoma y otros tumores sólidos en pacientes pediátricos. Se ha descrito que puede producir neurotoxicidad por mecanismos aún no bien aclarados. La toxicidad neurológica puede ser aguda, subaguda o crónica, según el tiempo de manifestación tras la administración del fármaco. La clínica suele ser reversible, pero ocasionalmente causa la muerte del paciente o importantes secuelas, por lo que conviene vigilar a los pacientes en riesgo. La resonancia magnética nuclear es útil en el diagnóstico, mostrando alteraciones en la difusión de manera precoz. Se han ensayado tratamientos farmacológicos pero ninguno ha demostrado su eficacia actualmente. Presentamos el caso de un adolescente de 15 años de edad con leucemia linfoblástica aguda tipo B que se encontraba en remisión completa y sin infiltración del sistema nervioso central tras la terapia de inducción y consolidación. Después de la administración de metotrexato intratecal desarrolla neurotoxicidad subaguda grave, con deterioro neurológico progresivo hasta un estado de coma persistente con graves alteraciones en la resonancia magnética y el trazado electroencefalográfico. La clínica no mejora con ningún tratamiento. El paciente falleció tras realizarse limitación del esfuerzo terapéutico de acuerdo con la familia (AU)

Methotrexate inhibits dihydrofolate reductase and it is widely used in the treatment of leukemia, lymphoma and other tumors in paediatric patients. There has been described that can produce neurotoxicity for still not well clarified mechanisms. Neurological toxicity can be acute, subacute or chronic, according to the time of manifestation after the administration of the drug. Neurological symptoms often are reversible, but occasionally methotrexate can produce the death of the patient or cause important sequels. For this reason is important to monitor patients in risk. Magnetic resonance imaging is very useful in diagnosis, showing alterations in diffusion-weighted imaging of a precocious way. Several pharmacological treatments have been proved but none of them have demonstrated its efficiency until now. We present the case of a 15-year-old boy diagnosed of acuteB-cell lymphoblastic leukemia in complete remission and without central nervous system leukemic involment postinduction and consolidation therapy. After the administration of intrathecal methotrexate he develops severe subacute neurotoxicity. Neurological symptoms were deteriorating progressively up to a persistent coma with serious alterations in magnetic resonance imaging and electroencephalogram pattern. Clinic did not improve with any treatment. The patient died after limitation of therapeutic effort of agreement by the family (AU)

Cinética de la proteína C reactiva y la procalcitonina en el postoperatorio de cirugía cardíaca en niños / Kinetics of C-reactive protein and procalcitonin after paediatric cardiac surgery

Introducción y objetivos: En el postoperatorio de la cirugía cardíaca se produce una respuesta inflamatoria sistémica que dificulta la identificación de complicaciones. El objetivo fue estudiar el comportamiento de la proteína C reactiva (PCR) y la procalcitonina (PCT), valorando su relación con la gravedad y analizando su utilidad para detectar complicaciones. Métodos: Se estudió prospectivamente a 59 niños intervenidos mediante cirugía cardíaca abierta. Se determinaron la PCR y la PCT al ingreso en una unidad de cuidados intensivos pediátricos, a las 24, a las 48 y a las 72h. Se analizó la relación de la PCR y la PCT con la gravedad clínica valorada mediante las escalas Pediatric Risk Mortality y Therapeutic Intervention Scoring System, y el desarrollo de complicaciones (infecciosas y hemodinámicas). Resultados: La PCR y la PCT aumentaron en las primeras 24h, disminuyendo progresivamente en los 2 días posteriores. La PCR no se relacionó con la gravedad ni con la aparición de complicaciones. La PCT tras la cirugía, a las 24 y a las 48h presentó una moderada correlación con el Pediatric Risk Mortality (r=0,548; 0,434 y 0,446, respectivamente) y una baja con el Therapeutic Intervention Scoring System. Se obtuvieron unos puntos de corte para la PCT>0,17ng/ml (sensibilidad del 73,3%, especificidad del 72,2%) al ingreso y >1,98ng/ml (sensibilidad del 57,1%, especificidad del 87%) a las 48h para detectar complicaciones. No existieron diferencias en la PCR ni en la PCT entre los pacientes con complicaciones infecciosas y hemodinámicas. Conclusiones: En el postoperatorio de la cirugía cardíaca pediátrica la PCR no se correlaciona con la gravedad ni con la presencia de complicaciones. La PCT se correlaciona con la gravedad y puede detectar complicaciones posquirúrgicas (AU)

Introduction and objectives: The systemic inflammatory response syndrome developed after cardiac surgery impedes the detection of complications. The aim of our study was to examine the behaviour of C-reactive protein (CRP) and procalcitonin (PCT), as well as to evaluate its relationship with severity and to analyse its usefulness in the identification of complications. Methods: A total of 59 children who underwent cardiac surgery with cardiopulmonary bypass were prospectively studied. CRP and PCT were determined after surgery and at 24, 48 and 72 hours. The relationships between both parameters and the clinical severity were analysed (evaluated with PRISM and TISS scoring systems), as well as with the incidence of complications (infectious and haemodynamics). Results: Serum concentrations of CRP and PCT increased in the first 24 hours after surgery, with a gradual decrease over the following days. There was no association between CRP and severity or development of complications. A moderate correlation was observed between PCT after surgery, at 24 and 48 hours, and PRISM (r=0.548; 0.434 and 0.446) and a low correlation between PCT and TISS. When studying the identification of complications, we obtained cut-off values of PCT>0.17ng/ml (Ss 73.3%; Sp 72.2%) and PCT>1.98ng/ml (Ss 57.1%; Sp 87%) immediately and 48 hours after surgery. No differences were found in CPR and PCT levels among patients with infectious and haemodynamics complications. Conclusions: CPR does not correlate with the severity or the incidence of complications after paediatric cardiac surgery. PCT correlates with clinical severity and may be able to detect post-surgical complications (AU)

Simulador de pulmón / Lung simulator

Introducción: Uno de los principales problemas en el desarrollo de docencia sobre ventilación mecánica es la falta de modelos de pulmón sencillos, baratos y fácilmente reproducibles. Objetivo: Presentar un nuevo modelo de simulador de pulmón. Material: El simulador de pulmón presenta 2 partes diferenciadas: A) Sistema de resistencia: simula la vía aérea del aparato respiratorio. Formado por 3 o 5 válvulas de bola que permiten el aumento de resistencias y la simulación de fugas. B) Sistema de distensibilidad: reproduce las características de pulmón y caja torácica. Está formado por 3 partes: 1 o 2 cámaras de distensión (pulmón de prueba comercial), mecanismo de conexión al sistema de resistencia y pinza de limitación de distensibilidad. El simulador permite un montaje simple o doble dependiendo de que se incorpore uno o 2 pulmones al sistema de resistencia permitiendo variar el volumen corriente entre 10–500ml. Conclusiones: Presentamos un modelo de simulador de pulmón barato, de fácil montaje y desmontaje, transportable, de uso simple y que permite reproducir patrones restrictivos, obstructivos y presencia de fugas (AU)

Introduction: One of the main limitations to running mechanical ventilation courses is the lack of cheap, interactive, and easily reproducible lung simulators. Objective: Presentation of a new lung simulator. Material: Lung simulator consisting of two different parts: A) Resistance system: simulates respiratory airway. It is made up of 3 or 5 ball valves that allow for the simulation of resistance increase and air leaks. B) Compliance system: it reproduces lungs and rib cage characteristics. It is made up of three parts: 1 or 2 expandable chambers (a commercial test lung), a connection system to the resistance mechanism, and a distensibility limiting clamp. The simulator allows for a single or double assembly depending on the inclusion of one or two lungs to the resistance system, allowing the tidal volume to be adjusted from 10 to 500ml. Conclusions: We present an easily assembled lung simulator for teaching purposes that is cheap, reproducible and interactive, allowing for simulation of patterns of restriction, obstruction, and presence of air leaks (AU)

[Kinetics of C-reactive protein and procalcitonin after paediatric cardiac surgery]. / Cinética de la proteína C reactiva y la procalcitonina en el postoperatorio de cirugía cardíaca en niños.

INTRODUCTION AND OBJECTIVES: The systemic inflammatory response syndrome developed after cardiac surgery impedes the detection of complications. The aim of our study was to examine the behaviour of C-reactive protein (CRP) and procalcitonin (PCT), as well as to evaluate its relationship with severity and to analyse its usefulness in the identification of complications. METHODS: A total of 59 children who underwent cardiac surgery with cardiopulmonary bypass were prospectively studied. CRP and PCT were determined after surgery and at 24, 48 and 72 hours. The relationships between both parameters and the clinical severity were analysed (evaluated with PRISM and TISS scoring systems), as well as with the incidence of complications (infectious and haemodynamics). RESULTS: Serum concentrations of CRP and PCT increased in the first 24 hours after surgery, with a gradual decrease over the following days. There was no association between CRP and severity or development of complications. A moderate correlation was observed between PCT after surgery, at 24 and 48 hours, and PRISM (r=0.548; 0.434 and 0.446) and a low correlation between PCT and TISS. When studying the identification of complications, we obtained cut-off values of PCT>0.17ng/ml (Ss 73.3%; Sp 72.2%) and PCT>1.98ng/ml (Ss 57.1%; Sp 87%) immediately and 48 hours after surgery. No differences were found in CPR and PCT levels among patients with infectious and haemodynamics complications. CONCLUSIONS: CPR does not correlate with the severity or the incidence of complications after paediatric cardiac surgery. PCT correlates with clinical severity and may be able to detect post-surgical complications.

Traumatismo abdominal / Abdominal traumatism

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Sedación y analgesia en el politraumatismo pediátrico / Sedation and analgesics in pediatric polytraumatism

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Inmovilización y movilización del niño politraumatizado / No disponible

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Síndrome de shock hemorrágico y encefalopatía (I) / Haemorrhagic shock syndrome and encephalopathy (I)

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Transporte en Asturias: pacientes, patologías y recursos de traslado / Transportation in Asturias: patients, disease and transfer resources

Introducción: Las necesidades de transporte sanitario varían en cada región. En Asturias nunca se ha realizado un estudio sobre transporte. Objetivos: Descubrir las características de los traslados en Asturias. Pacientes y métodos; Estudio descriptivo prospectivo de todos los transportes secundarios realizados en Asturias entre julio de 2003 y junio de 2004. Resultados: Se registraron 798 indicaciones de traslado (89,9% urgentes). La edad media era 61,4 meses. El 74,7 % se trasladaron desde Urgencias. El motivo más frecuente fue la consulta a Cirugía Infantil (35,0%). En los hospitales de destino un 14,9% fueron ingresados en unidades de cuidados intensivos. Un 28,6% fueron dados de alta desde Urgencias. La patología más frecuente fue la quirúrgica (36,4%). Se trasladaron 266 pacientes en ambulancia convencional, 113 en UVI móvil (UVIm), uno en helicóptero y el resto en vehículo privado o desconocido. A menor edad, mayor era el porcentaje de transportes en UVIm y menor en vehículo propio (p<0,001). De los 380 traslados realizados en vehículo sanitario, un 70% llevaban personal sanitario, un 30% con médico. Conclusiones: Los traslados secundarios fueron frecuentes en Asturias. La patología más frecuente fue la quirúrgica. Un importante porcentaje no precisaron ingreso. La mayoría se trasladaron en vehículos particulares. Casi un tercio de los transportes en vehículo sanitario fueron realizados por médicos. Los pacientes derivados para UCI supusieron un importante porcentaje (AU)

Introduction: Medical transportation need vary depending on the local characteristics. There are no previous studies on paediatric transportation in Asturias in a one-year period. Patients and methods: Prospective study of all the interhospital transports performed in a one-year period (july 2003 to june 2004) in Asturias. Results: Seven hundred and ninety eight transports were recorded (89,9% were considered urgent). Mean age of the patients was 61.4 months. Transfer was indicated when the patient was at the Emergency Department in 74,7%. The most frequent reason for the transfer was consulation with a paediatric surgeon (35%). Fourteen percent of the patients were admitted to an Intensive Care Unit upon arrival at the receiving hospital. Twentyeight percent of the patients were discharged after the transfer. Surgical conditions were the most frequent diagnosis in the children transferred. The transport was performed by conventional ambulance in 266 cases, by Mobile Intensive Care Unit (MICU) in 113, by helicopter in one case and by private or not recorded vehicle in the remaining. The younger the age, the greater the likelihood of MICU transport and the lower the likelihood of being transported by means of a private vehicle (p<0.001). Among the 380 transfers using a medical vehicle, health staff was present in 70%. A physician was present in 30% of the transfers done by ambulance. Conclusions: Paediatric transports are frequent in Asturias. Surgical conditions were the most frequent reason for the transfer. A significant number of the transferred patients did not need to be admitted to the receiving hospital. Most patients were transported by means of a private vehicle. Physicians were part of the transport team in almost one third of the cases in which a medical vehicle was used. Patients referred to an intensive care unit account for an important number of the transportations performed (AU)

Evaluación y tratamiento del shock traumático / Managing of the airway in the polytraumatized child

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Manejo inicial del politraumatismo pediátrico (III). Traumatismo de columna, pelvis y extremidades / Monographic series: initial treatment of pediatric polytraumatism (III). Traumatism of the spinal cord, pelvis and limbs

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