Characteristics and management of patients with SARS-CoV2 infection admitted to pediatric intensive care units: Data analysis of the Spanish national multicenter registry.

INTRODUCTION: The purpose of this study is to describe the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) disease characteristics and management in children admitted to the pediatric intensive care units (PICU). METHODS: The present study was based on a national multicentric prospective registry including PICU patients with SARS-CoV2 infection or symptoms of multisystem inflammatory syndrome in children (MIS-C). RESULTS: A total of 298 patients were admitted to 41 different Spanish PICUs. A total of 76% of them were previously healthy. The most frequent manifestation was MIS-C (69.8%). On admission, 59.4% of patients did not have respiratory distress, and only 17.4% needed conventional mechanical ventilation (MV). The need for MV was associated with age (incidence rate ratios [IRR] 1.21, p < .012), pediatric sequential organ failure assessment score (p-SOFA) Score (IRR 1.12, p = .001), and need for transfusion (IRR 4.5, p < .004) in MIS-C patients, and with vasoactive drug use (IRR 2.73, p = .022) and the diagnosis of acute respiratory distress syndrome (IRR 2.83, p = .018) in patients admitted for other reasons. During the first day of admission, 56% of patients met shock criteria and 50.7% needed vasoactive drugs. In MIS-C patients, their use was associated with higher p-SOFA score (IRR 1.06, p < .001) and with the diagnosis of shock (IRR 5.78, p < .001). In patients without MIS-C, it was associated with higher p-SOFA score (IRR 1.05, p = .022). The mortality rate was 3%, being lower in MIS-C patients compared to patients admitted for other reasons (0.5% vs. 9.4%, p < .001). It was also lower in previously healthy patients compared to patients with previous comorbidities (0.9% vs. 9.7%, p < .001). CONCLUSIONS: Severe SARS-CoV2 infection is uncommon in the pediatric population. In our series, respiratory distress was rare, being MIS-C the most frequent cause of PICU admission related to SARS-CoV2. In most cases, the course of the disease was mild except in children with previous diseases.

Efecto de tres dietas enterales con diferente contenido en proteínas sobre el metabolismo proteico en lactantes críticamente enfermos: un ensayo clínico aleatorizado / Effect of three enteral diets with different protein contents on protein metabolism in critically ill infants: A randomized controlled trial

Introducción: No se ha establecido cuál es el aporte óptimo para mejorar el metabolismo proteico sin producir efectos adversos en lactantes gravemente enfermos. Nuestro objetivo fue analizar si un mayor aporte proteico a través de la nutrición enteral se relaciona con una mejoría en el balance proteico en lactantes críticamente enfermos. Material y métodos: Se diseñó un estudio multicéntrico, prospectivo, aleatorizado y controlado (diciembre de 2016 a junio de 2019). Se incluyeron lactantes críticamente enfermos con nutrición enteral, asignándose aleatoriamente a tres dietas con diferente contenido proteico: estándar (1,7g/100ml), hiperproteica (2,7g/100ml) e hiperproteica suplementada (5,1g/100ml). Se realizaron análisis de sangre y orina y se calculó el balance nitrogenado en el momento basal y tras 3-5días de nutrición. Se analizó la variación del balance nitrogenado y de las proteínas séricas (proteínas totales, albúmina, transferrina, prealbúmina y proteína ligada al retinol) a lo largo del periodo de estudio. Resultados: Noventa y nueve lactantes (33 por grupo) completaron el estudio. No se encontraron diferencias entre grupos en características demográficas, puntuaciones de gravedad y otros tratamientos recibidos, salvo corticoides, administrados en una mayor proporción de pacientes del tercer grupo. Tuvo lugar un aumento significativo de los niveles de prealbúmina y proteína ligada al retinol en los grupos con nutrición hiperproteica e hiperproteica suplementada. El balance nitrogenado aumentó en todos los grupos, pero este incremento no fue significativo en el grupo de nutrición hiperproteica suplementada. No se encontraron diferencias en cuanto a tolerancia gastrointestinal. Los pacientes con nutrición hiperproteica suplementada presentaron niveles superiores de urea sérica y mayor incidencia de hiperuremia. (AU)

Introduction: The optimal intake to improve protein metabolism without producing adverse effects in seriously ill infants has yet to be established. The aim of our study was to analyse whether an increased protein intake delivered through enteral nutrition would be associated with an improvement in nitrogen balance and serum protein levels in critically ill infants. Material and methods: We conducted a multicentre, prospective randomized controlled trial (December 2016-June 2019). The sample consisted of critically ill infants receiving enteral nutrition assigned randomly to 3 protein content groups: standard diet (1.7g/dL), protein-enriched diet (2.7g/dL) and high protein-enriched diet (5.1g/dL). Blood and urine tests were performed, and we assessed nitrogen balance at baseline and at 3 to 5days of the diet. We analysed variations in nitrogen balance and serum protein levels (total protein, albumin, transferrin, prealbumin, and retinol-binding protein) throughout the study period. Results: Ninety-nine infants (33 per group) completed the study. We did not find any differences were between groups in demographic characteristics, severity scores or prescribed medications, except for corticosteroids, administered in a higher proportion of patients in the third group. We observed significant increases in prealbumin and retinol-binding protein levels in patients receiving the protein-enriched and high protein-enriched diets at 3 to 5days compared to baseline. The nitrogen balance increased in all groups, but the differences were not significant in the high protein-enriched group. There were no differences in gastrointestinal tolerance. Patients fed high protein-enriched formula had higher levels of serum urea, with a higher incidence of hyperuraemia in this group. (AU)

Effect of three enteral diets with different protein contents on protein metabolism in critically ill infants: a randomized controlled trial.

INTRODUCTION: The optimal intake to improve protein metabolism without producing adverse effects in seriously ill infants has yet to be established. The aim of our study was to analyse whether an increased protein intake delivered through enteral nutrition would be associated with an improvement in nitrogen balance and serum protein levels in critically ill infants. METHODS: We conducted a multicentre, prospective randomized controlled trial (December 2016-June 2019). The sample consisted of critically ill infants receiving enteral nutrition assigned randomly to 3 protein content groups: standard diet (1.7 g/dL), protein-enriched diet (2.7 g/dL) and high protein-enriched diet (5.1 g/dL). Blood and urine tests were performed, and we assessed nitrogen balance at baseline and at 3-5 days of the diet. We analysed variations in nitrogen balance and serum protein levels (total protein, albumin, transferrin, prealbumin, and retinol-binding protein) throughout the study period. RESULTS: Ninety-nine infants (33 per group) completed the study. We did not find any differences were between groups in demographic characteristics, severity scores or prescribed medications, except for corticosteroids, administered in a higher proportion of patients in the third group. We observed significant increases in prealbumin and retinol-binding protein levels in patients receiving the protein-enriched and high protein-enriched diets at 3-5 days compared to baseline. The nitrogen balance increased in all groups, but the differences were not significant in the high protein-enriched group. There were no differences in gastrointestinal tolerance. Patients fed high protein-enriched formula had higher levels of serum urea, with a higher incidence of hyperuraemia in this group. CONCLUSION: Enteral administration of higher amounts of protein improves serum protein levels in critically ill children. A protein intake of 2.2 g/kg/day is generally safe and well tolerated, whereas an intake of 3.4 g/kg/day may produce hyperuraemia in some patients.

Formación en reanimación cardiopulmonar pediátrica en los grados de Medicina y Enfermería en las universidades españolas / Training in pediatric cardiopulmonary resuscitation in the Medicine and Nursing degrees in Spanish universities

Objetivos: Conocer la docencia en reanimación cardiopulmonar (RCP) pediátrica en las universidades españolas.Material y métodos.Se envió una encuesta a los responsables de pediatría de las universidades españolas.Resultados.Se recibieron 35 respuestas de Medicina y 18 de Enfermería. Existió una gran diversidad en la docencia de la RCP y su duración. En muchos casos, la duración de la formación en RCP es insuficiente.Conclusiones.Es necesario establecer unos requisitos de formación obligatoria en RCP pediátrica para los grados de Medicina y Enfermería. (AU)

Aims: To analyse the education in pediatric cardiopulmonary resuscitation (CPR) in the universities in Spain.Material and methods.A survey was sent to those responsible for Pediatrics at the Spanish universities.Results.35 responses from Medicine and 18 from Nursing were received). There was a great diversity in CPR teaching and duration. In many cases, the duration of the training is insufficient.Conclusions.It is necessary to establish mandatory training requirements in pediatric CPR for Medicine and Nursing degrees. (AU)

A Dynamic Approach for Early Risk Prediction of Gram-Negative Bloodstream Infection and Systemic Inflammatory Response Syndrome in Febrile Pediatric Hemato-Oncology Patients.

Background: The aim of this study was to evaluate the usefulness of C-Reactive Protein (CRP), Procalcitonin (PCT), and Interleukine 6 (IL6) biomarkers in predicting the existence of high-risk episodes (HRE) during the first 24 h of fever in pediatric cancer patients. HRE were defined as the presence of Gram-negative bloodstream infections or Systemic Inflammatory Response Syndrome. Methods: The study included 103 consecutive fever episodes in 44 hemato-oncological pediatric patients, from whom samples for biomarkers were taken upon initial evaluation (CRP-1, PCT-1 and IL6-1) and then between 12 and 24 h afterward (CRP-2, PCT-2 and IL6-2). Results: An IL6-1 value higher than 164 pg/mL showed an area under the curve (AUC) of 0.890 (0.791−0.989) and OR of 48.68 (7.92−951.42, p < 0.001) to detect HRE in multivariate analysis. A PCT-1 higher than 0.32 ng/mL showed an AUC of 0.805 (0.700−0.910) and OR of 4.55 (0.90−27.84, p = 0.076). A PCT-2 higher than 0.94 ng/mL showed an AUC of 0.836 (0.725−0.947) and OR of 13.01 (1.82−149.13, p = 0.018), and an increase in CRP between the first and second sample (CRP-2vs1) higher than 291% also showed an AUC of 0.785 (0.655−0.915) and OR of 31.09 (4.87−355.33, p = 0.001). Conclusions: IL6-1, PCT-2, and CRP-2vs1 showed a strong and independent correlation with HREs in pediatric cancer patients. CRP variations over the first 24 h provide an improvement in predictive models that are especially useful if IL-6 and PCT are not available.

Multicenter randomized clinical trial comparing dexamethasone versus placebo in preventing upper airway obstruction after extubation in critically ill children.

To analyze the effectiveness of dexamethasone in preventing upper airway obstruction (UAO) symptoms after extubation and the need of reintubation in critically ill children. Multicenter, prospective, double-blind, randomized, phase IV clinical trial involving five pediatric intensive care units. Children between 1 month and 16 years-of-age intubated for more than 48 h were included. Patients were randomized to receive placebo or dexamethasone 0.25 mg/kg every 6 h, 6-to-12 h prior to extubation (four doses). 48 h follow-up was carried out after extubation. Severity of UAO symptoms (Taussig score, stridor) and reintubation requirement were compared. 147 patients were randomized (10 were excluded), 70 patients received dexamethasone and 67 placebo. No global differences were found in the presence of stridor or moderate-to-severe UAO symptoms (Taussig ≥ 5), but Taussig ≥ 5 was less frequent in patients less than 2 years-of-age treated with steroids (p = 0.014). Median Taussig score was lower in the dexamethasone group 1 h after extubation, p < 0.001. 27 patients required reintubation, 9 due to UAO: 3 (4.3%) in the dexamethasone group and 6 (8.9%) in the placebo group, p = 0.319. In those intubated > 5 days, reintubation due to UAO was higher in the placebo group (2.4% vs. 14.3, p = 0.052). Nebulized epinephrine and budesonide were required more frequently in the placebo group in the first 2 h (p = 0.041) and 1 h (p = 0.02) after extubation, respectively. No relevant side effects were observed. Dexamethasone prior to extubation did not significantly reduce moderate-severe UAO symptoms, except for patients under 2-years of age. Dexamethasone could decrease Taussig score and the need of rescue therapies, as well as reintubation rates in those intubated for more than 5 days.

Biomarkers and Fever in Children with Cancer: Kinetics and Levels According to Final Diagnosis.

We investigated the kinetics of CRP, PCT, IL-6 and MR-proADM in a cohort of consecutive febrile patients with cancer in order to test the hypothesis that higher plasma concentrations and the absence of a rapid decrease in peak values would be associated with disease severity. (1) Method: A prospective descriptive and analytical study of patients with cancer and fever (≤18 years of age) at a University Hospital was carried out between January 2018 and December 2019. Information collected: sex, age, diagnosis, date and symptoms at diagnosis and medical history. The episodes were classified into three groups: bacterial infection, non-bacterial infection and systemic inflammatory response syndrome (SIRS). (2) Results: One hundred and thirty-four episodes were included. Bacterial infection criteria were met in 38 episodes. Biomarkers were measured at four different points: baseline, at 12-24 h, at 25-48 h and at 49-72 h. All the biomarkers evaluated decreased after the peak level was reached. IL-6 and MR-proADM showed a trend towards higher levels in the SIRS group although this rise was statistically significant only for IL-6 (p < 0.005). Bacterial infections more frequently presented values of PCT above the cut-off point (>0.5 ng/mL) at 12-24 h. (3) Conclusion: In our experience, IL-6 kinetics is faster than PCT kinetics and both are faster than CRP in patients with fever and cancer who present a good outcome. Patients with a good evolution show a rapid increase and decrease of PCT and particularly of IL-6 levels.

Anales de Pediatría: otra etapa cumplida / Anales de Pediatría: Another milestone achieved

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Informe anual de los editores de Anales de Pediatría / Annual report of Anales de Pediatría editors

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Informe anual de los editores de Anales de Pediatría / The Anales de Pediatría editors annual report

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