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)

Predicción del índice PaO2/FiO2 a partir del índice SpO2/FiO2 ajustado por la medición transcutánea de CO2 en niños críticamente enfermos / Prediction of PaO2/FiO2 ratio from SpO2/FiO2 ratio adjusted by transcutaneous CO2 measurement in critically ill children

Objetivo: Evaluar si la inclusión de la medición transcutánea de CO2 (PtcCO2) mejora el modelo de predicción del índice presión arterial de oxígeno/ fracción inspirada de oxígeno [PaO2/FiO2 (P/F)] a partir del índice saturación de oxígeno/FiO2 [SpO2/FiO2 (S/F)]. Métodos: Análisis retrospectivo de datos gasométricos correspondientes a niños críticamente enfermos. Se incluyen PaO2, SpO2, FiO2 y PtcCO2 de 40 muestras en 8 pacientes. Se calculó un modelo de regresión lineal múltiple para predecir el índice P/F a partir del índice S/F y la PtcCO2. Con la fórmula obtenida se obtuvieron los valores de índice S/F correspondientes con los valores de índice P/F de 200 y 300 para distintos niveles de PtcCO2. Se determinaron las curvas de características operador receptor para los valores corte del índice P/F (200 y 300). Resultados: El modelo de regresión lineal fue: P/F=37,277+(1,072×S/F) – (1,567×PtcCO2); p<0,0001; R2=0,469. Con esta ecuación, para una PtcCO2 de 40 mmHg, valores de índice P/F de 200 y 300 correspondieron respectivamente a valores de índice S/F de 295,1 y 426,5. Un índice P/F calculado menor de 256,7 equivaldría a un índice P/F real menor de 200 (sensibilidad 84,6%; especificidad 85,2%) y un índice P/F calculado menor de 297,6 equivaldría a un índice P/F real menor de 300 (sensibilidad 89,7%; especificidad 82%). Conclusión: La PtcCO2 modifica la predicción del índice P/F a partir del índice S/F. Son necesarios estudios prospectivos que validen en una muestra más amplia los resultados encontrados en este estudio (AU)

Objective: To evaluate if the inclusion of the transcutaneous CO2 tension measurement (PtcCO2) can improve partial pressure of oxygen/ fraction of inspired oxygen ratio [PaO2/FiO2 (P/F)] prediction from pulse oximetry saturation/FiO2 ratio [SpO2/FiO2 (S/F)]. Methods: Retrospective analysis of blood gas data from critically ill children. PaO2, SpO2, FiO2 and PtcCO2 from 40 samples in 8 patients were analysed. A multiple linear regression model was performed to predict P/F ratio from S/F ratio and PtcCO2. Using the equation obtained, S/F ratio values were calculated for P/F ratios of 200 and 300 and different levels of PtcCO2. Receiver Operator Characteristic (ROC) curves were made to analyse the diagnostic values of P/F ratio (200 and 300). Results: The linear regression model was: P/F=37.277+(1.072×S/F) – (1.567×PtcCO2); P<0.0001; R2=0.469. Using the equation, for a PtcCO2 value of 40 mmHg, P/F ratios of 200 and 300 corresponded to S/F ratios of 295.1 and 426.5, respectively. Computed P/F ratio less than 256.7 had 84.6% sensitivity and 85.2% specificity for the diagnosis of P/F ratio less than 200. Computed P/F ratio less than 297.6 had 89.7% sensitivity and 82% specificity for the diagnosis of P/F ratio less than 300. Conclusion: PtcCO2 has a significant influence on the prediction of P/F ratio from S/F ratio. Prospective studies with more patients are needed to validate these results (AU)

[Prediction of PaO2/FiO2 ratio from SpO2/FiO2 ratio adjusted by transcutaneous CO2 measurement in critically ill children]. / Predicción del índice PaO2/FiO2 a partir del índice SpO2/FiO2 ajustado por la medición transcutánea de CO2 en niños críticamente enfermos.

OBJECTIVE: To evaluate if the inclusion of the transcutaneous CO(2) tension measurement (PtcCO(2)) can improve partial pressure of oxygen/ fraction of inspired oxygen ratio [PaO(2)/FiO(2) (P/F)] prediction from pulse oximetry saturation/FiO(2) ratio [SpO(2)/FiO(2) (S/F)]. METHODS: Retrospective analysis of blood gas data from critically ill children. PaO(2), SpO(2), FiO(2) and PtcCO(2) from 40 samples in 8 patients were analysed. A multiple linear regression model was performed to predict P/F ratio from S/F ratio and PtcCO(2). Using the equation obtained, S/F ratio values were calculated for P/F ratios of 200 and 300 and different levels of PtcCO2. Receiver Operator Characteristic (ROC) curves were made to analyse the diagnostic values of P/F ratio (200 and 300). RESULTS: The linear regression model was: P/F=37.277+(1.072×S/F) - (1.567×PtcCO2); P<.0001; R(2)=0.469. Using the equation, for a PtcCO(2) value of 40 mmHg, P/F ratios of 200 and 300 corresponded to S/F ratios of 295.1 and 426.5, respectively. Computed P/F ratio less than 256.7 had 84.6% sensitivity and 85.2% specificity for the diagnosis of P/F ratio less than 200. Computed P/F ratio less than 297.6 had 89.7% sensitivity and 82% specificity for the diagnosis of P/F ratio less than 300. CONCLUSION: PtcCO(2) has a significant influence on the prediction of P/F ratio from S/F ratio. Prospective studies with more patients are needed to validate these results.

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)

Massive lower gastrointestinal haemorrhage, successfully treated with corticosteroids, as main symptom of Schönlein-Henoch purpura.

Schönlein-Henoch purpura is a small vessel disease that affects mainly skin and kidney, although several gastrointestinal symptoms may occur including abdominal pain, intussusception, perforation or bleeding. Massive lower gastrointestinal haemorrhage is rare and even more as the main symptom of the disease. We present a case of a 2-year-old boy with Schönlein-Henoch purpura who developed a massive lower gastrointestinal bleeding requiring blood transfusion. In this patient both Schönlein-Henoch purpura and gastrointestinal haemorrhage were successfully treated with intravenous methylprednisolone, avoiding surgical intervention. Physicians need to have a high index of suspicion when evaluating these patients, even more when dermatologic signs are scarce. Glucocorticosteroid therapy may be effective when treating severe gastrointestinal symptoms.

Hematoma subdural subagudo asociado a quiste aracnoideo / No disponible

No disponible

Manejo inicial del politraumatismo pediátrico (III). Situaciones especiales en el paciente politraumatizado / Monographic series: initial treatment of pediatric polytraumatism (III). Special situations in the polytraumatized patient

No disponible

Categorización y triage del niño politraumatizado / Categorization and triage of the polytraumatized child

No disponible

Traumatismo torácico / Thoracic traumatism

No disponible

Segunda evaluación del niño politraumatizado / Second evaluation of polytraumatized child

No disponible

Manejo de la vía aérea en el niño politraumatizado / Evaluation and treatment of traumatic shock

No disponible

Carro de paradas pediátrico en los hospitales / Pediatric resuscitation trolley in the hospitals

No disponible

[Noninvasive ventilation in a pediatric intensive care unit]. / Aplicación de ventilación no invasiva en una unidad de cuidados intensivos pediátricos.

OBJECTIVE: To describe our experience of noninvasive positive-pressure ventilation (NIPPV). PATIENTS AND METHODS: We performed a retrospective study of all patients who underwent NIPPV in our unit over an 18-month period. To assess the effectiveness of NIPPV, respiratory rate, heart rate, inspired oxygen, and arterial blood gases PaO2 and PaCO2 were evaluated before and 2 hours after initiating NIPPV. RESULTS: Twenty-three patients with a mean age of 36.7 months underwent a total of 24 NIPPV trials. Indications for NIPPV were: hypoxemic acute respiratory failure (14 trials), hypercapnic acute respiratory failure (four trials), and postextubation respiratory failure (six trials). Conventional ventilators were used in 10 trials and specific noninvasive ventilators were used in 14. The main interfaces used were buconasal mask in patients older than 1 year, and pharyngeal prong in infants aged less than 1 year. In all groups, significant decreases in respiratory distress, defined as a reduction in tachypnea (45 +/- 16 breaths/min pre-treatment vs. 34 +/- 12 breaths/min post-treatment; p = 0.001), and tachycardia (148 +/- 27 beats/min pre-treatment vs. 122 +/- 22 beats/min (after or post) post-treatment; p < 0.001) were observed after initiation of NIPPV. The oxygenation index PaO2/FiO2 also improved (190 +/- 109 pre-treatment vs. 260 +/- 118 post-treatment; p = 0.010). Five patients (20.8 %) required intubation and conventional mechanical ventilation after NIPPV, of which three were aged less than 6 months. CONCLUSIONS: NIPPV should be considered as a ventilatory support option in the treatment of acute respiratory failure in selected children.

Aplicación de ventilación no invasiva en una unidad de cuidados intensivos pediátricos / Noninvasive ventilation in a pediatric intensive care unit

Objetivo: Describir nuestra experiencia con la aplicación de ventilación no invasiva (VNI). Pacientes y métodos: Estudio retrospectivo, durante 18 meses, de los pacientes críticamente enfermos en los que se empleó VNI. Para valorar su eficacia se registraron la frecuencia cardíaca, frecuencia respiratoria, fracción inspiratoria de oxígeno (FiO2), presión parcial arterial de oxígeno (PaO2) y de dióxido de carbono (PaCO2) antes y 2 h después del inicio de la VNI. Resultados: La VNI se utilizó en 24 ocasiones sobre 23 pacientes con edad media de 36,7 meses. En 14 casos se indicó por insuficiencia respiratoria hipoxémica, en cuatro por insuficiencia respiratoria hipercápnica y en seis por insuficiencia respiratoria postextubación. Se utilizaron respiradores convencionales en 10 casos y respiradores específicos de VNI en 14 casos. Como interfases se utilizaron principalmente la prótesis faríngea en pacientes menores de un año y la mascarilla buconasal en los mayores de un año. En todos los grupos se observó una disminución de la dificultad respiratoria definida por una disminución de la taquipnea(45 +/- 16 resp./min pretratamiento frente a 34 +/- 12resp./min postratamiento; p = 0,001) y la taquicardia(148 +/- 27 lat./min pretratamiento frente a 122 +/- 22 lat./min postratamiento; p < 0,001) tras el inicio de la VNI. También se observó una mejoría significativa del cociente PaO2/FiO2 (190 +/- 109 pretratamiento frente a 260 +/- 118postratamiento; p = 0,010). Cinco pacientes (20,8%) precisaron intubación y ventilación mecánica convencional tras la VNI. De ellos, tres tenían menos de 6 meses. Conclusiones: La VNI puede ser una alternativa a la ventilación mecánica convencional en determinados pacientes con insuficiencia respiratoria aguda

Objective: To describe our experience of noninvasive positive pressure ventilation (NIPPV).Patients and methods We performed a retrospective study of all patients who underwent NIPPV in our unit over an 18-month period. To assess the effectiveness of NIPPV, respiratory rate, heart rate, inspired oxygen, and arterial blood gases PaO2 andPaCO2 were evaluated before and 2 hours after initiating NIPPV. Results: Twenty-three patients with a mean age of 36.7 month sunder went a total of 24 NIPPV trials. Indications for NIPPV were: hypoxemic acute respiratory failure (14 trials), hypercapnicacute respiratory failure (four trials), and postextubationrespiratory failure (six trials). Conventional ventilators were used in 10 trials and specific noninvasive ventilators were used in 14. The main interfaces used were buconasal mask in patients older than 1 year, and pharyngeal prong in infants aged less than 1 year. In all groups, significant decreases in respiratory distress, defined as a reduction in tachypnea (45 +/- 16 breaths/min pre-treatments. 34 +/- 12 breaths/min post-treatment; p = 0,001),and tachycardia (148 +/- 27 beats/min pre-treatment vs.122 +/- 22 beats/min (after or post) post-treatment; p < 0,001) were observed after initiation of NIPPV. The oxygenation index PaO2/FiO2 also improved (190 +/- 109 pre-treatment vs. 260 +/- 118 post-treatment; p = 0,010).Five patients (20.8 %) required intubation and conventional mechanical ventilation after NIPPV, of which three were aged less than 6 months. Conclusions NIPPV should be considered as a ventilatory support option in the treatment of acute respiratory failure in selected children

Hepatomegalia y hemangiomas cutáneos / Hepatomegaly and cutaneous hemangiomas

No disponible

[Use of peripherally inserted multilumen catheters as an alternative to central venous access]. / Utilización de catéteres multilumen de acceso periférico como alternativa a las vías centrales.

BACKGROUND: In the last decade alternatives to central venous lines in critically ill children have been developed. Multilumen catheters have classically been used through central venous access but there are no reports on their use as peripherally inserted central lines. PATIENTS AND METHODS: We performed a retrospective study of patients admitted to the pediatric intensive care unit in the previous 3 years who underwent catheterization with peripherally inserted central venous lines. The catheters were four French, double-lumen and 30-cm long. RESULTS: Twenty-two catheters were used in 22 children (mean age: 8.3 years; range 1.7-13.8). The catheters remained in place for a mean of 7.2 days. Ninety percent of the catheters were placed in antecubital veins. The catheters were used to administer antibiotics (59 %), other drugs (81 %), total parenteral nutrition (50 %) and blood (9 %). Central venous pressure monitoring was performed in eight patients. Complications were found in five patients (22 %): three cases of phlebitis, one catheter occlusion and one infection at the site of insertion. No significant differences were found in the complication rate between peripherally inserted catheters and 298 central venous catheters inserted in our unit in the same time period. CONCLUSIONS: Peripherally inserted multilumen catheters may be an alternative in the management of critically-ill pediatric patients.

Utilización de catéteres multilumen de acceso periférico como alternativa a las vías centrales / Use of peripherally inserted multilumen catheters as an alternative to central venous access

Antecedentes: En la última década han aparecido alternativas a las vías centrales en niños graves. Los catéteres multilumen se utilizan clásicamente mediante canalización venosa central, no existiendo experiencia en su uso como vía central de acceso periférico (VCAP). Pacientes y métodos: Estudio retrospectivo de los pacientes ingresados en cuidados intensivos pediátricos en los últimos 3 años en los que fue colocada una VCAP utilizando un catéter de 4 F, 2 luces y 30 cm. Resultados: Se incluyeron 22 VCAP canalizadas en 22 niños (edad media, 8,35 años; límites, 1,7-13,8). La duración media fue 7,2 días. El 90% se canalizó en venas antecubitales. Se utilizaron para administrar antibióticos (59%), otros fármacos (81%), nutrición parenteral (50%) y transfusiones (9%). En 8 pacientes se monitorizó la presión venosa central. Se observaron complicaciones en 5 pacientes (22%): tres flebitis, una obstrucción y una infección de la puerta de entrada del catéter. No hubo diferencias significativas respecto a las complicaciones encontradas en 298 vías centrales canalizadas en la unidad durante el mismo período de tiempo. Comentarios: Los catéteres multilumen colocados como VCAP constituyen una alternativa en el tratamiento del paciente crítico (AU)