Conocimientos sobre ética asistencial de los residentes de pediatría / Knowledge of health care ethics in paediatric residents

INTRODUCCIÓN: La enseñanza de la bioética se ha incorporado a los planes de estudio de medicina y al programa para médicos residentes. Sin embargo, la transmisión de conocimientos basados en la práctica clínica habitualmente no se realiza de una manera bien estructurada. OBJETIVO: Valorar los conocimientos de ética de los residentes de pediatría españoles y analizar su relación con la formación recibida durante la licenciatura y el periodo de residencia. MATERIAL Y MÉTODOS: Se diseñó una encuesta con 20 preguntas tipo test destinada a evaluar conocimientos éticos básicos con repercusión sobre la clínica. Se valoraron la formación recibida durante el pregrado y la residencia, y los principales conflictos éticos afrontados. RESULTADOS: Se obtuvieron 210 encuestas remitidas desde 20 hospitales: 47 correspondientes a (R1), 49 a (R2), 57 a (R3) y 57 a (R4). La media de respuestas correctas fue de 16,8. No hubo diferencias entre los residentes de distinto año ni entre los que manifestaron haber recibido o no formación específica. Se contabilizaron más fallos en preguntas relacionadas con el consentimiento informado, ley de autonomía del paciente, los principios implicados en la calidad de vida, la sistemática del análisis de casos y la dimensión de la justicia distributiva. CONCLUSIONES: La limitación del esfuerzo terapéutico se ha identificado como el principal problema ético en la práctica clínica. Gran parte de los conocimientos sobre ética se adquieren en el pregrado y varían poco durante la residencia, lo que hace necesarios mayores esfuerzos organizativos y docentes durante este periodo

INTRODUCTION: Bioethics has been recently incorporated in to the educational programs of both medical students and medical residents as part of their curriculum. However, its training based on clinical practice is not well structured. OBJECTIVE: To evaluate the knowledge of bioethics in Spanish paediatric residents, and to analyse how this relates to the medical education during graduate and post-graduate training. MATERIAL AND METHODS: A questionnaire with 20 multiple choice questions was designed to evaluate the knowledge in basic ethics with potential implications in clinical practice. We evaluated the education received during graduate and post-graduate training, and the main ethical conflicts faced. RESULTS: A total of 210 completed questionnaires were received from medical residents in paediatrics from 20 different Spanish hospitals, of whom 47 of these were first year residents (R1), 49 were second year residents (R2), 57 were third year residents (R3), and the remaining 57 were final year residents (R4). The mean number of correct answers was 16.8 out of 20. No differences were found between residents in different years of training, nor were there any differences between the group that had received specific training in bioethics versus those who had not. Residents were more likely to give wrong answers related with informed consent, the law on the freedom of the patient, principles of quality of life, the case analysis system, and the dimension of distributive justice. CONCLUSIONS: Limitation of therapeutic efforts was identified as the main ethical problem faced in clinical practice by Spanish residents in paediatrics. Most of the knowledge of bioethics is acquired during graduate training, and improved very little throughout the period of medical residence. Our results suggest that efforts are required in organising and structuring the education in bioethics during the training of residents in paediatrics

[Knowledge of health care ethics in paediatric residents]. / Conocimientos sobre ética asistencial de los residentes de pediatría.

INTRODUCTION: Bioethics has been recently incorporated in to the educational programs of both medical students and medical residents as part of their curriculum. However, its training based on clinical practice is not well structured. OBJECTIVE: To evaluate the knowledge of bioethics in Spanish paediatric residents, and to analyse how this relates to the medical education during graduate and post-graduate training. MATERIAL AND METHODS: A questionnaire with 20 multiple choice questions was designed to evaluate the knowledge in basic ethics with potential implications in clinical practice. We evaluated the education received during graduate and post-graduate training, and the main ethical conflicts faced. RESULTS: A total of 210 completed questionnaires were received from medical residents in paediatrics from 20 different Spanish hospitals, of whom 47 of these were first year residents (R1), 49 were second year residents (R2), 57 were third year residents (R3), and the remaining 57 were final year residents (R4). The mean number of correct answers was 16.8 out of 20. No differences were found between residents in different years of training, nor were there any differences between the group that had received specific training in bioethics versus those who had not. Residents were more likely to give wrong answers related with informed consent, the law on the freedom of the patient, principles of quality of life, the case analysis system, and the dimension of distributive justice. CONCLUSIONS: Limitation of therapeutic efforts was identified as the main ethical problem faced in clinical practice by Spanish residents in paediatrics. Most of the knowledge of bioethics is acquired during graduate training, and improved very little throughout the period of medical residence. Our results suggest that efforts are required in organising and structuring the education in bioethics during the training of residents in paediatrics.

Infección nosocomial del tracto urinario en niños críticos / Nosocomial urinary tract infection in critical pediatric patients

Objetivos: Determinar la densidad de incidencia, etiología y factores de riesgo de la infección de orina nosocomial (ITUn) en una UCIP de segundo nivel. Diseño: Estudio prospectivo descriptivo durante un periodo de 1 año que incluyó a 104 pacientes ingresados durante más de 48 h en nuestra UCIP. Se recogieron urocultivos diarios a los pacientes con sonda vesical hasta su retirada y cada 48 h a los no sondados hasta el alta. Ámbito: Unidad de cuidados intensivos pediátricos de segundo nivel. Pacientes: Se incluyó a todos los pacientes que ingresaron por más de 48 h en el año 2009. Se excluyó a los menores de 15 días y a los que presentaban una infección de orina o pielonefritisal ingreso o antes de las 48 h tras su ingreso. Resultados: Seis pacientes presentaron una ITUn (el 5,8% de los ingresos), con una densidad de incidencia de 5/1.000 pacientes/día y de 12,19/1.000 días de sonda. Se identificaron 4casos por Escherichia coli (uno, multirresistente) y 2 por Candida albicans. Los niños con ITUn tuvieron significativamente más antecedentes personales y mayor estancia que los niños sin infección y, aunque sin significación estadística, menor edad y mayor número de días con sonda. Conclusiones: Nuestra densidad de incidencia de infección de orina asociada a dispositivo es superior a la publicada; esto puede deberse, entre otras causas, a las características de los pacientes atendidos y al método exhaustivo empleado para su detección (AU)

Objective: To determine the incidence, etiology and risk factors of nosocomial urinary tractinfections (nUTI) in a second level Pediatric Intensive Care Unit (PICU).Patients and methods: A prospective study of 104 patients admitted to the PICU with a length of stay of more than 48 hours was carried out over a one year period (January to December2009) to study the incidence and risk factors of nUTI. Urine samples were collected and cultured in all patients admitted for more than 48 hours to our PICU. Those needing indwelling urinary catheters had urine samples collected upon admission and every 24 hours until catheterretrieval, while those who did not need catheters had samples collected upon admission and every 48 hours until discharge from the PICU. Results: Six patients (5.8% of those admitted) were diagnosed of nUTI, with an incidence density of 5/1000 patients/day and 12.2/1000 catheterization days. Four of these were caused byE. coli (including a multiresistant strain), and two by C. albicans. Patients suffering nUTIs had significantly more relevant medical antecedents and a longer period of admittance than patients without nUTI. A statistically non significant tendency towards increased infection risk was also found in younger patients and in those who needed an indwelling catheter for longer periods. Conclusions: We found a higher incidence density of catheter associated nUTI than in other reports. This at least partially could be due to the characteristics of our patients, and to the exhaustive methodology used for detection (AU)

[Severe iatrogenic airway obstruction due to lingual lymphangioma]. / Obstruction iatrogène sévère de la voie aérienne par un lymphangiome lingual.

Lymphangioma of the tongue is a rare and benign tumour involving congenital and cystic abnormalities derived from lymphatic vessels. Treatment modalities include surgery and a large number of different intralesional injections of sclerosing agents. Presently, OK-432 (Picibanil(®)) is the preferred sclerosant and when administered intralesionally will result in inflammation, sclerosis, and cicatricial contraction of the lesion. We report a case of microcystic lymphangioma of the tongue in a 5-year-old boy treated with an intralesional injection of OK-432. In the immediate postoperative period, the patient suffered severe diffuse swelling, progressive upper airway obstruction with inspiratory stridor, and respiratory distress requiring emergency fiberoptic nasotracheal intubation. Although OK-432 injections are found to be safe and effective as a first line of treatment for lymphangiomas, local swelling with potentially life-threatening airway compromise should be anticipated, especially when treating lesions near the upper airway.

[Nosocomial urinary tract infection in critical pediatric patients]. / Infección nosocomial del tracto urinario en niños críticos.

OBJECTIVE: To determine the incidence, etiology and risk factors of nosocomial urinary tract infections (nUTI) in a second level Pediatric Intensive Care Unit (PICU). PATIENTS AND METHODS: A prospective study of 104 patients admitted to the PICU with a length of stay of more than 48 hours was carried out over a one year period (January to December 2009) to study the incidence and risk factors of nUTI. Urine samples were collected and cultured in all patients admitted for more than 48 hours to our PICU. Those needing indwelling urinary catheters had urine samples collected upon admission and every 24 hours until catheter retrieval, while those who did not need catheters had samples collected upon admission and every 48 hours until discharge from the PICU. RESULTS: Six patients (5.8% of those admitted) were diagnosed of nUTI, with an incidence density of 5/1000 patients/day and 12.2/1000 catheterization days. Four of these were caused by E. coli (including a multiresistant strain), and two by C. albicans. Patients suffering nUTIs had significantly more relevant medical antecedents and a longer period of admittance than patients without nUTI. A statistically nonsignificant tendency towards increased infection risk was also found in younger patients and in those who needed an indwelling catheter for longer periods. CONCLUSIONS: We found a higher incidence density of catheter associated nUTI than in other reports. This at least partially could be due to the characteristics of our patients, and to the exhaustive methodology used for detection.

Síndrome de Lemierre. La enfermedad olvidada / Lemierre syndrome. The forgotten disease

El síndrome de Lemierre es una entidad clínica caracterizada por una infección orofaríngea aguda que origina una tromboflebitis de la vena yugular interna, así como embolismos sépticos múltiples que afectan preferentemente al pulmón. Describimos el caso de una niña de 13 años de edad, que ingresa en nuestra unidad por presentar una neumonía cavitada y tromboflebitis de la vena yugular interna tras haber sufrido una infección orofaríngea. En los hemocultivos iniciales se identificó un Fusobacterium necrophorum. Se inició tratamiento con heparina de bajo peso molecular y antibióticos intravenosos durante 4 semanas, tras las cuales la paciente fue dada de alta completamente asintomática. El síndrome de Lemierre es actualmente una enfermedad rara debido al uso generalizado de antibióticos; no obstante es importante tenerla en consideración y mantener un alto índice de sospecha diagnóstica, ya que un tratamiento precoz es esencial para una evolución satisfactoria

Lemierre syndrome is a clinical entity characterized by an acute oropharyngeal infection that causes thrombophlebitis of the internal jugular vein and multiple septic embolisms that preferentially affect the lung. We describe the case of a 13 year old girl who was admitted to our unit due to cavitated pneumonia and thrombophlebitis of the internal jugular vein after having suffered an oropharyngeal infection. Fusobacterium necrophorum was identified in the initial blood cultures. Treatment was initiated with low weight molecular heparin and intravenous antibiotics for four weeks, after which the patient was discharged completely asymptomatic.Lemierre syndrome is presently a rare disease due to the generalized use of antibiotics. However, it is important to remember it and maintain a high index of diagnostic suspicion since early treatment is essential for a satisfactory evolution

Sepsis meningocócica y leishmaniasis visceral. Una coinfección infrecuente / Meningococcal sepsis and visceral leishmaniasis. An infrequent coinfection

El diagnóstico de infección por Leishmania es con frecuencia difícil de realizar, ya que la presentación clínica puede ser incompleta en casos de coinfección. Describimos el caso de un niño de 6 años de edad que presentó una sepsis meningocócica grave al mismo tiempo que una coinfección no sospechada por Leishmania. No había antecedentes de inmunodepresión previos a este episodio y la serología para el virus de la inmunodeficiencia humana (VIH) fue negativa. Un aspirado de médula ósea, en la segunda semana, confirmó el diagnóstico de leishmaniasis. Aunque la infección concomitante de estos 2 microorganismos pudo empeorar el curso de la enfermedad, la evolución fue satisfactoria. Este caso sugiere la necesidad de considerar la presencia de patógenos no usuales cuando hay fiebre persistente tras una sepsis meningocócica y, por tanto, de realizar una investigación microbiológica exhaustiva (AU)

Uso de isoflurano inhalado en el status asmático en el niño / Status asthmaticus in children. Use of inhaled isoflurane

Presentamos el caso de un niño de nueve años de edad en status asmático sometido a ventilación mecánica que no respondió a tratamiento combinado de salbutamol, aminofilina y ketamina en infusión continua además de esteroides, anticolinérgicos y sulfato de magnesio en bolos a dosis elevadas. Solamente la administración inhalada de isoflurano al 1 por ciento a través del tubo endotraqueal durante tres días, consiguió la resolución del broncoespasmo en este caso de status asmático crítico. La administración de anestésicos inhalados puede ser vital en casos de status asmático que son refractarios a las opciones terapéuticas máximas. (AU)

[Assessment of 200 critically ill transferred children at a pediatric intensive care unit]. / Valoración de 200 traslados de niños críticos en una Unidad de Cuidados Intensivos Pediátricos.

BACKGROUND: Pediatric intensive care units have developed as treatment areas with a concentration of specialized equipment and personnel. Critically ill children often need to be moved to and from these critical care areas for diagnostic or therapeutic procedures. Such transport may pose additional risk to the critically ill patient. PATIENTS AND METHODS: In order to assess the problems encountered in our transport process, a prospective study was performed. A questionnaire was undertaken to evaluate the transport of critically ill children hospitalized in the Pediatric Intensive Care Unit of the Hospital Universitario Puerta del Mar from Cádiz over an eleven month period. RESULTS: Two hundred children transported were evaluated. Forty-seven (23.5%) were interhospital transported patients and one hundred fifty-three (76.5%) were intrahospital transported patients. The most common type of intrahospital transport involves transfers between the operating room and the intensive care unit (73 patients, 36.5%). Deterioration in respiratory, cardiovascular and other physiological systems was registered in twenty-two patients (11%). One hundred four equipment-related mishaps were noted in eighty-six patients (43%) during the transport process. Dislodgement of intravenous catheters, loss of oxygen supply, endotracheal tube problems and equipment malfunction were the most common mishaps noted. CONCLUSIONS: Our results would suggest that more training regarding the transport of the critically ill child are needed in our area.

Magill forceps: a vital forceps.

Foreign body aspiration is not an uncommon problem in infants and toddlers, and should be considered as a serious and sometimes fatal condition. We report three cases of foreign body aspiration which were located below the vocal cords, causing a nearly complete airway obstruction with severe respiratory distress. In all cases they were successfully removed in the emergency department using a laryngoscope and Magill forceps. It is important for physicians who take care of children in emergency department to know the management of these life-threatening situations. Knowledge of pediatric advanced life support measures with airway management and proper training in laryngoscope and Magill forceps management can save lives in many children.

[The treatment of the Guillain-Barré syndrome in childhood by plasmapheresis]. / Tratamiento del síndrome de Guillain Barré en la infancia mediante plasmaféresis.

We have performed 18 plasmapheresis [correction of plasma exchange] sessions in a group of 5 patients diagnosed as having Guillain-Barré Syndrome. These patients were diagnosed according to clinical, analytical and electromyographic criteria. In three patients we observed an obvious clinical improvement during the treatment. In one of the patients there was no appreciable evolution. This patient suffered from acute lymphocytic leukemia. We were unable to evaluate the remaining patient since this child underwent posthypoxic encephalopathy secondary to cardiac arrest. On the basis of the results obtained, we advocate the treatment of this polyneuropathy by plasmapheresis [correction of plasma exchange].