Development and validation of a clinical score for early diagnosis of constipation in critically ill children.

Constipation affects almost 50% of critically ill pediatric patients and is related to their morbidity and mortality. However, little attention is paid to it and it is diagnosed late and when there are already complications. The objective of this study is to develop and validate a score to identify critically ill children with high risk of constipation 48 h after admission. A single center two phase-study was carried out; the first one (retrospective observational study) to develop the score and the second one to validate it in another prospective observational study. Children between 15 days of life and 18 years old admitted to the PICU for more than 3 days were included. Demographic and clinical data during the first 48 h after PICU admission were collected. Univariate and multivariate analysis and ROC curves were used to develop and validate the score. Data from 145 patients (62.8% boys) with a mean age of 34.9 ± 7.3 months were used to develop the score. Independent factors identified to develop the score were: weight > 7 kg, admission to PICU after surgery, need of vasoconstrictors, doses of fentanyl ≥ 2 mcg/kg/h, and initiation of enteral nutrition later than 48 h after admission. Two cut-off values were identified to set low constipation risk (< 5.7 points) and high constipation risk (> 6.2 points). This score was validated in 124 patients showing a sensibility of 63.2%, specificity of 95.5% and a positive/negative predictive values (P/NPV) of 100% and 82.1% respectively to identify constipated patients. This is the first score to identify high constipation risk in critically ill children. This score is easy to apply, and internal validation has shown a PPV of 100%.

Changes in hemodynamics, renal blood flow and urine output during continuous renal replacement therapies.

Continuous renal replacement therapies (CRRT) affect hemodynamics and urine output. Some theories suggest a reduced renal blood flow as the cause of the decreased urine output, but the exact mechanisms remain unclear. A prospective experimental study was carried out in 32 piglets (2-3 months old) in order to compare the impact of CRRT on hemodynamics, renal perfusion, urine output and renal function in healthy animals and in those with non-oliguric acute kidney injury (AKI). CRRT was started according to our clinical protocol, with an initial blood flow of 20 ml/min, with 10 ml/min increases every minute until a goal flow of 5 ml/kg/min. Heart rate, blood pressure, central venous pressure, cardiac output, renal blood flow and urine output were registered at baseline and during the first 6 h of CRRT. Blood and urine samples were drawn at baseline and after 2 and 6 h of therapy. Blood pressure, cardiac index and urine output significantly decreased after starting CRRT in all piglets. Renal blood flow, however, steadily increased throughout the study. Cisplatin piglets had lower cardiac index, higher vascular resistance, lower renal blood flow and lower urine output than control piglets. Plasma levels of ADH and urine levels of aquaporin-2 were lower, whereas kidney injury biomarkers were higher in the cisplatin group of piglets. According to our findings, a reduced renal blood flow doesn't seem to be the cause of the decrease in urine output after starting CRRT.

Resultados tras implantación de un protocolo de sedoanalgesia para procedimientos en ámbito hospitalario / Results after implementation of a sedoanalgesia protocol for procedures in hospital environment

INTRODUCCIÓN: Se analiza la efectividad y seguridad de un protocolo específico de sedoanalgesia para procedimien tos, y evalúa la satisfacción del personal sanitario con cada procedimiento. PACIENTES Y MÉTODO: Estudio prospectivo de un protocolo de sedoanalgesia para procedimientos en ámbito hospitalario en menores de 18 años, con una estrategia individualizada según la situación basal del paciente, el tipo de procedimiento y la experiencia del pediatra responsable de la sedación. Se registraron las variables: diagnóstico que motiva el procedimiento, tipo de procedimiento, datos antropométri cos, alergias, medicación, estado ASA y enfermedad de base, tiempo de ayuno, auscultación pul monar, temperatura, saturación de oxígeno, frecuencia respiratoria, frecuencia cardiaca, tensión arterial, lugar de sedación, tipo de fármaco, dosis, tipo de vía, escala de sedación Ramsay, duración de la sedación, tipo y tratamiento de efectos adversos, presencia de familiares durante todo el pro cedimiento y satisfacción del paciente. RESULTADOS: Se realizaron 279 sedaciones. Los fármacos más usados fueron óxido nitroso (62,7%) y midazolam (16,5%); las vías de administración más utili zadas fueron la inhalada (62,4%) y la intravenosa (15,8%). La satisfacción fue alta para el pediatra (92,5%), el enfermero (94,3%), los familiares (96,8%) y los pacientes (93,6%), con una buena correlación entre ellos, y fue significativamente menor al usar midazolam y las vías nasal y bucal. La tasa de efectos adversos fue del 3,2%, y ninguno fue grave. CONCLUSIONES: La implementación de un protocolo específico de sedoanalgesia para procedimientos en el ámbito hospitalario consigue una alta efectividad y seguridad, además de un alto nivel de satisfacción, tanto en familiares como en personal sanitario.

INTRODUCTION: We analyze the effectiveness and safety of a specific analgosedation protocol for procedures, and eva luate the satisfaction of the health personnel with each procedure. PATIENTS AND METHOD: Prospective study of an analgosedation protocol for hospital procedures in children under 18 years of age, with an individualized strategy based on the patient's baseline situation, the type of procedure and the experience of the pediatrician responsible for the sedation. The following variables were recorded: diagnosis motivating the procedure, type of procedure, anthropometric data, allergies, medication, ASA status and baseline disease, fasting time, lung auscultation, temperature, oxygen saturation, res piratory rate, heart rate, blood pressure, sedation location, type of drug, dose, route of administra tion, Ramsay sedation scale, duration of sedation, type and treatment of adverse effects, presence of family members throughout the procedure, and patient satisfaction. RESULTS: 279 sedations were performed. The most commonly used drugs were nitrous oxide (62.7%) and midazolam (16.5%); the most commonly used routes of administration were the inhaled one (62.4%) and the intravenous one (15.8%). The satisfaction was high for the pediatrician (92.5%), the nurse (94.3%), the family (96.8%), and patients (93.6%), with a good correlation between them, and it was significantly lower when using midazolam and the nasal and oral routes. The adverse effects rate was 3.2%, and none was severe. CONCLUSIONS: The implementation of a specific analgosedation protocol for procedures in the hospital environment achieves high levels of effectiveness and safety, as well as a high level of satisfaction, both in family members and in health personnel.

Utilidad pronóstica de las puntuaciones de fallo multiorgánico y del índice inotrópico en el postoperatorio de trasplante cardiaco en niños / Prognostic utility of the multiorgan failure scores and inotropic index in the postoperative of cardiac transplantation in children

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Complicaciones hematológicas en niños tratados con oxigenación por membrana extracorpórea / Hematological complications in children subjected to extracorporeal membrane oxygenation

Objetivos: Analizar las complicaciones hematológicas y las necesidades transfusionales en niños tratados con oxigenación por membrana extracorpórea (ECMO). Diseño: Estudio retrospectivo. Ámbito: Unidad de cuidados intensivos pediátricos. Pacientes: Niños menores de 18 años tratados con ECMO entre septiembre de 2006 y noviembre de 2015. Intervenciones: Ninguna. Variables de interés: Características clínicas, de la ECMO, anticoagulación, parámetros hematológicos y de coagulación, transfusiones y evolución clínica. Resultados: Se estudiaron 100 pacientes con una mediana de edad de 11 meses. Presentaron sangrado 76; el mediastino fue la localización más frecuente; 39 precisaron revisión quirúrgica. En los primeros 3 días de ECMO, el 97% de los pacientes precisaron transfusión de hematíes (34,4 ml/kg al día), el 94% plaquetas (21,1ml/kg al día) y el 90% plasma (26,6ml/kg al día). Los pacientes posquirúrgicos, con imposibilidad de salida de la circulación extracorpórea, los que presentaron sangrado al inicio de la ECMO, los que precisaron revisión quirúrgica y los que tuvieron canulación transtorácica requirieron mayor volumen de transfusiones. Se produjeron tromboembolias en 14 pacientes y hemólisis en 33. La mortalidad de los niños que presentaron sangrado al inicio de ECMO (57,6%) fue significativamente mayor que la del resto (37,5%) (p = 0,048). Conclusiones: Los niños tratados con ECMO presentan una elevada incidencia de sangrado y precisan un gran volumen de transfusiones. El postoperatorio de cirugía, el sangrado al inicio de la ECMO, la necesidad de revisión quirúrgica, la imposibilidad de salida de la circulación extracorpórea y la canulación transtorácica se asocian a un mayor volumen de transfusiones. Los niños que sangraron al inicio de la ECMO presentaron mayor mortalidad

Objectives: To analyze the hematological complications and need for transfusions in children receiving extracorporeal life support (ECLS). Design: A retrospective study was carried out. Setting: A pediatric intensive care unit. Patients: Children under 18 years of age subjected to ECLS between September 2006 and November 2015. Interventions: None. Variables of interest: Patient and ECLS characteristics, anticoagulation, hematological and coagulation parameters, transfusions and clinical course. Results: A total of 100 patients (94 with heart disease) with a median age of 11 months were studied. Seventy-six patients presented bleeding. The most frequent bleeding point was the mediastinum and 39 patients required revision surgery. In the first 3days, 97% of the patients required blood transfusion (34.4ml/kg per day), 94% platelets (21.1ml/kg per day) and 90% plasma (26.6ml/kg per day). Patients who were in the postoperative period, those who were bleeding at the start of ECLS, those requiring revision surgery, those who could not suspend extracorporeal circulation, and those subjected to transthoracic cannulation required a greater volume of transfusions than the rest of the patients. Thromboembolism occurred in 14 patients and hemolysis in 33 patients. Mortality among the children who were bleeding at the start of ECLS (57.6%) was significantly higher than in the rest of the patients (37.5%) (P=.048). Conclusions: Children subjected to ECLS present high blood product needs. The main factors related to transfusions were the postoperative period, bleeding at the start of ECLS, revision surgery, transthoracic cannulation, and the impossibility of suspending extracorporeal circulation. Children with bleeding suffered greater mortality than the rest of the patients

Results after implementation of a sedoanalgesia protocol for procedures in hospital environment. / Resultados tras implantación de un protocolo de sedoanalgesia para procedimientos en ámbito hospitalario.

INTRODUCTION: We analyze the effectiveness and safety of a specific analgosedation protocol for procedures, and eva luate the satisfaction of the health personnel with each procedure. PATIENTS AND METHOD: Prospective study of an analgosedation protocol for hospital procedures in children under 18 years of age, with an individualized strategy based on the patient's baseline situation, the type of procedure and the experience of the pediatrician responsible for the sedation. The following variables were recorded: diagnosis motivating the procedure, type of procedure, anthropometric data, allergies, medication, ASA status and baseline disease, fasting time, lung auscultation, temperature, oxygen saturation, res piratory rate, heart rate, blood pressure, sedation location, type of drug, dose, route of administra tion, Ramsay sedation scale, duration of sedation, type and treatment of adverse effects, presence of family members throughout the procedure, and patient satisfaction. RESULTS: 279 sedations were performed. The most commonly used drugs were nitrous oxide (62.7%) and midazolam (16.5%); the most commonly used routes of administration were the inhaled one (62.4%) and the intravenous one (15.8%). The satisfaction was high for the pediatrician (92.5%), the nurse (94.3%), the family (96.8%), and patients (93.6%), with a good correlation between them, and it was significantly lower when using midazolam and the nasal and oral routes. The adverse effects rate was 3.2%, and none was severe. CONCLUSIONS: The implementation of a specific analgosedation protocol for procedures in the hospital environment achieves high levels of effectiveness and safety, as well as a high level of satisfaction, both in family members and in health personnel.

Hematological complications in children subjected to extracorporeal membrane oxygenation. / Complicaciones hematológicas en niños tratados con oxigenación por membrana extracorpórea.

OBJECTIVES: To analyze the hematological complications and need for transfusions in children receiving extracorporeal life support (ECLS). DESIGN: A retrospective study was carried out. SETTING: A pediatric intensive care unit. PATIENTS: Children under 18 years of age subjected to ECLS between September 2006 and November 2015. INTERVENTIONS: None. VARIABLES OF INTEREST: Patient and ECLS characteristics, anticoagulation, hematological and coagulation parameters, transfusions and clinical course. RESULTS: A total of 100 patients (94 with heart disease) with a median age of 11 months were studied. Seventy-six patients presented bleeding. The most frequent bleeding point was the mediastinum and 39 patients required revision surgery. In the first 3days, 97% of the patients required blood transfusion (34.4ml/kg per day), 94% platelets (21.1ml/kg per day) and 90% plasma (26.6ml/kg per day). Patients who were in the postoperative period, those who were bleeding at the start of ECLS, those requiring revision surgery, those who could not suspend extracorporeal circulation, and those subjected to transthoracic cannulation required a greater volume of transfusions than the rest of the patients. Thromboembolism occurred in 14 patients and hemolysis in 33 patients. Mortality among the children who were bleeding at the start of ECLS (57.6%) was significantly higher than in the rest of the patients (37.5%) (P=.048). CONCLUSIONS: Children subjected to ECLS present high blood product needs. The main factors related to transfusions were the postoperative period, bleeding at the start of ECLS, revision surgery, transthoracic cannulation, and the impossibility of suspending extracorporeal circulation. Children with bleeding suffered greater mortality than the rest of the patients.

Criterios de ingreso y alta y organización de los cuidados intensivos pediátricos / Guidelines of admission, discharge and organization of the pediatric intensive care

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Tools for the Individualized Therapy of Teicoplanin for Neonates and Children.

The aim of this study was to develop a population pharmacokinetic (PK) model for teicoplanin across childhood age ranges to be used as Bayesian prior information in the software constructed for individualized therapy. We developed a nonparametric population model fitted to PK data from neonates, infants, and older children. We then implemented this model in the BestDose multiple-model Bayesian adaptive control algorithm to show its clinical utility. It was used to predict the dosages required to achieve optimal teicoplanin predose targets (15 mg/liter) from day 3 of therapy. We performed individual simulations for an infant and a child from the original population, who provided early first dosing interval concentration-time data. An allometric model that used weight as a measure of size and that also incorporated renal function using the estimated glomerular filtration rate (eGFR), or the ratio of postnatal age (PNA) to serum creatinine concentration (SCr) for infants <3 months old, best described the data. The median population PK parameters were as follows: elimination rate constant (Ke) = 0.03 · (wt/70)-0.25 · Renal (h-1); V = 19.5 · (wt/70) (liters); Renal = eGFR0.07 (ml/min/1.73 m2), or Renal = PNA/SCr (µmol/liter). Increased teicoplanin dosages and alternative administration techniques (extended infusions and fractionated multiple dosing) were required in order to achieve the targets safely by day 3 in simulated cases. The software was able to predict individual measured concentrations and the dosages and administration techniques required to achieve the desired target concentrations early in therapy. Prospective evaluation is now needed in order to ensure that this individualized teicoplanin therapy approach is applicable in the clinical setting. (This study has been registered in the European Union Clinical Trials Register under EudraCT no. 2012-005738-12.).

Controversias en RCP Básica Pediátrica tras las nuevas recomendaciones del 2015 / No disponible

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Is Hydrogen Breath Test with Lactulose Feasible for Measuring Gastrocecal Transit in Critically Ill Children? Pilot Study about Modification of the Technique.

Introduction. Gastrocecal transit time (GCTT) can be measured by exhaled hydrogen after lactulose intake (lactulose-eH2 test). The objectives were to assess whether it is possible to carry out this test in critically ill children with and without mechanical ventilation (MV) and to analyze whether the results are consistent with clinical findings. Methods. Patients admitted to the Pediatric Intensive Care Unit (PICU) for more than 3 days were included. Those with gastrointestinal disease prior to admission were excluded. A modified technique to obtain eH2 from the ventilator tubes was performed. Results. Sixteen patients (37.5% boys) with a median age of 19 (5-86.5) months were included. Five patients (31.2%) were breathing spontaneously but lactulose-eH2 test could not be performed while it could be performed successfully in the 11 patients with MV. Seven patients (63.3%) did not show an eH2 peak. The other 4 showed a median time of 130 min (78.7-278.7 min) from lactulose intake to a 10 ppm eH2 peak. Children with an eH2 peak had intestinal movements earlier [6.5 (1.5-38.5) versus 44 (24-72) hours p = 0.545]. Conclusion. Although the designed adaption is useful for collecting breath samples, lactulose-eH2 test may not be useful for measuring GCTT in critically ill children.

Servicio de Cuidados Intensivos Pediátricos del Hospital General Universitario Gregorio Marañón / Pediatric Intensive Care Department of the Hospital Materno Infantil Gregorio Marañón

La Unidad de Cuidados Intensivos Pediátricos (UCIP) es el servicio del Hospital General Universitario Gregorio Marañón (HGUGM), que cuenta con un equipo de profesionales sanitarios específicamente preparados, con experiencia y dedicación completa, que cumple con los requisitos funcionales, estructurales y organizativos suficientes para garantizar la atención de los niños cuya enfermedad pueda comprometer su vida o de aquellos que precisen recuperación tras haber sido sometidos a una cirugía mayor. En este artículo se describe la estructura y la distribución de espacios de la Unidad, la organización asistencial, la cartera de servicios, la actividad asistencial, docente e investigadora, las perspectivas de futuro y la cooperación internacional (AU)

The pediatric intensive care unit of the University Hospital Gregorio Marañón meets all the functional, structural and organizational requirements to ensure the optimal management of critical care pediatric patients affected of life threatening diseases and of those that need stabilization after major surgery procedures. The unit is ruled by experienced and highly specialized staff in a full time dedication basis. This article describes the structure and space distribution of the unit, the organization of the healthcare activities, the education and research programs and the portfolio of healthcare specialties attended. The future objectives and the international cooperation issues are also discussed (AU)

Daño renal agudo grave en niños críticos: epidemiología y factores pronósticos / Severe acute kidney injury in critically ill children: Epidemiology and prognostic factors

INTRODUCCIÓN: El daño renal agudo (DRA) es una complicación grave en niños críticos. El objetivo de este estudio fue describir las características de esta patología en las Unidades de Cuidados Intensivos Pediátricos (UCIP) españolas e identificar factores de riesgo asociados con la mortalidad y la necesidad de depuración extrarrenal al alta. PACIENTES Y MÉTODOS: Estudio prospectivo observacional multicéntrico que incluyó niños de 7 días a 16 años de edad con DRA ingresados en UCIP. Se realizó un estudio univariante y multivariante de los factores de riesgo asociados con la mortalidad y necesidad de depuración extrarrenal al alta. RESULTADOS: Se analizaron 139 casos de DRA. En el 60,1% de los casos fue necesaria la utilización de alguna técnica de depuración. La mortalidad durante el ingreso fue del 32,4% y el 15,1% de los supervivientes necesitaban diálisis al alta de la UCIP. En el estudio de regresión logística multivariante la trombocitopenia y los valores bajos de aclaramiento de creatinina fueron factores pronósticos que predijeron la necesidad de diálisis al alta. Ajustando por peso, las cifras elevadas de plaquetas y creatinina se relacionaron con una mayor supervivencia. CONCLUSIONES: Los niños críticamente enfermos con DRA presentan una morbimortalidad elevada. La cifra de plaquetas y el aclaramiento de creatinina son marcadores de necesidad de diálisis al alta de la UCIP y la cifra de plaquetas, la creatinina sérica y el peso, marcadores de supervivencia

INTRODUCTION: Acute kidney injury (AKI) is a severe complication in critically ill children. The aim of the study was to describe the characteristics of AKI, as well as to analyse the prognostic factors for mortality and renal replacement therapy (RRT) in children admitted to Paediatric Intensive Care Units (PICUs) in Spain. PATIENTS AND METHODS: Prospective observational multicentre study including children from 7 days to 16 years old who were admitted to a PICU. A univariate and multivariate logistic regression analysis of the risk factors for mortality and renal replacement therapy at PICU discharge were performed. RESULTS: A total of 139 cases of AKI were analysed. RRT was necessary in 60.1% of cases. Mortality rate was 32.6%. At PICU discharge RRT was necessary in 15% of survivors. Thrombopenia and low creatinine clearance values were prognostic markers of RRT at PICU discharge. High values of platelets, serum creatinine and weight were associated with higher survival. CONCLUSIONS: Critically ill children with AKI had a high mortality and morbidity rate. Platelet values and creatinine clearance are markers of RRT at PICU discharge, whereas number of platelets, serum creatinine and weight were associated with mortality

Evolución a largo plazo de los niños tratados con técnicas de depuración extrarrenal continua / Long-term outcomes of children treated with continuous renal replacement therapy

INTRODUCCIÓN: El objetivo de este estudio fue analizar la evolución a largo plazo y la función renal de los niños que han requerido técnicas de depuración extrarrenal continua (TDEC) tras un daño renal agudo. PACIENTES Y MÉTODOS: Se realizó un estudio observacional retrospectivo sobre una base de datos prospectiva en 128 pacientes que requirieron TDEC durante su ingreso en la Unidad de Cuidados Intensivos Pediátrica (UCIP) durante los años 2006 a 2012. Se analizó la evolución de los pacientes que sobrevivieron al alta de la UCIP. RESULTADOS: Setenta y uno de los 128 niños tratados con TDEC, un 54,4%, sobrevivió al alta y se realizó el seguimiento en 66 de ellos (92,9%). Tres pacientes presentaban insuficiencia renal crónica previa al ingreso en UCIP. De los 63 pacientes restantes, 6 presentaron alteración de la función renal prolongada o recaídas, pero solo un paciente con un síndrome hemolítico-urémico atípico quedó en insuficiencia renal terminal, presentando el resto una función renal normal en la última revisión. CONCLUSIONES: La mayoría de los niños que precisan TDEC y que sobreviven al episodio agudo presentan una buena evolución posterior con baja mortalidad y recuperación de la función renal a medio plazo

INTRODUCTION: The objective of this study is to analyze long-term outcomes and kidney function in children requiring continuous renal replacement therapy (CRRT) after an acute kidney injury episode. PATIENTS AND METHODS: A retrospective observational study was performed using a prospective database of 128 patients who required CRRT admitted to the pediatric intensive care unit between years 2006 and 2012. The subsequent outcomes were assessed in those surviving at hospital discharge. RESULTS: Of the 128 children who required RRT in the pediatric intensive care unit, 71 survived at hospital discharge (54.4%), of whom 66 (92.9%) were followed up. Three patients had chronic renal failure prior to admission to the NICU. Of the 63 remaining patients, 6 had prolonged or relapses of renal function disturbances, but only one patient with atypical Hemolytic Uremic Syndrome developed end-stage renal failure. The rest had normal kidney function at the last check-up. CONCLUSIONS: Most of surviving children that required CRRT have a positive outcome later on, presenting low mortality rates and recovery of kidney function in the medium term