Review of electrical impedance tomography in the pediatric patient.

Electrical impedance tomography (EIT) is a new method of monitoring non-invasive mechanical ventilation, at the bedside and useful in critically ill patients. It allows lung monitoring of ventilation and perfusion, obtaining images that provide information on lung function. It is based on the physical principle of impedanciometry or the body's ability to conduct an electrical current. Various studies have shown its usefulness both in adults and in pediatrics in respiratory distress syndrome, pneumonia and atelectasis in addition to pulmonary thromboembolism and pulmonary hypertension by also providing information on pulmonary perfusion, and may be very useful in perioperative medicine; especially in pediatrics avoiding repetitive imaging tests with ionizing radiation.

Original and minimally invasive approach to a left-lung refractory atelectasis after reparation of an aortic recoarctation in a lactant: Selective endobronchial CPAP.

Atelectasis is one of the most common respiratory complications in pediatric patients after open-heart surgery, and may lead to weaning failure and increased morbidity. We report the use of an original, minimally invasive approach to refractory left lung atelectasis after repair of an aortic coarctation in a 2 month-old infant, in which a CPAP system connected to a flexible endobronchial tube resolved the atelectasis.

Valoración y tratamiento perioperatorio de los pacientes con síndromes arritmogénicos refractarios a tratamiento médico: a propósito de un caso clínico / Perioperative management of patients with arrhythmogenic syndromes refractory to medical treatment: A clinical case report

Las cardiopatías familiares relacionadas con la muerte súbita son un grupo de enfermedades cardiovasculares (miocardiopatías, canalopatías, enfermedades aórticas…) que requieren familiaridad del anestesiólogo con el tratamiento perioperatorio de los trastornos hemodinámicos complejos, así como con el tratamiento quirúrgico de los mismos1. Presentamos el caso de un varón de 12 años diagnosticado de miocardiopatía hipertrófica no obstructiva, tras una parada cardiorrespiratoria, al que se le practicó una simpatectomía izquierda guiada por videotoracoscopia por síncopes frecuentes, a pesar de tratamiento farmacológico e implantación de un desfibrilador automático implantable. Siempre que se produzca un síncope arrítmico en el contexto de enfermedades cardiacas familiares, la denervación cardiaca izquierda debe considerarse como el siguiente paso en el plan de tratamiento2.(AU)

Family heart diseases related to sudden death are a group of cardiovascular diseases (cardiomyopathies, channelopathies, aortic diseases...) that require familiarity of the anesthesiologist with the perioperative treatment of complex hemodynamic disorders, as well as their surgical treatment1. We present the case of a 12-year-old man diagnosed with non-obstructive hypertrophic cardiomyopathy, after cardiorespiratory arrest, who underwent video-guided thoracoscopy-guided left sympathectomy for frequent syncope, despite pharmacological treatment and implantation of an implantable automatic defibrillator. Whenever arrhythmic syncope occurs in the setting of familial heart disease, left heart denervation should be considered as the next step in the treatment plan2.(AU)

Perioperative management of patients with arrhythmogenic syndromes refractory to medical treatment: A clinical case report.

Family heart diseases related to sudden death are a group of cardiovascular diseases (cardiomyopathies, channelopathies, aortic diseases …) that require familiarity of the anesthesiologist with the perioperative treatment of complex hemodynamic disorders, as well as their surgical treatment.1 We present the case of a 12-year-old man diagnosed with non-obstructive hypertrophic cardiomyopathy (MHNO), after cardiorespiratory arrest (PCR), who underwent video-guided thoracoscopy-guided left sympathectomy (VATS) for frequent syncope, despite pharmacological treatment and implantation of an implantable automatic defibrillator (ICD). Whenever arrhythmic syncope occurs in the setting of familial heart disease, left heart denervation should be considered as the next step in the treatment plan.2.

Perioperative management of patients with arrhythmogenic syndromes refractory to medical treatment: A clinical case report. / Valoración y tratamiento perioperatorio de los pacientes con síndromes arritmogénicos refractarios a tratamiento médico: a propósito de un caso clínico.

Family heart diseases related to sudden death are a group of cardiovascular diseases (cardiomyopathies, channelopathies, aortic diseases...) that require familiarity of the anesthesiologist with the perioperative treatment of complex hemodynamic disorders, as well as their surgical treatment1. We present the case of a 12-year-old man diagnosed with non-obstructive hypertrophic cardiomyopathy, after cardiorespiratory arrest, who underwent video-guided thoracoscopy-guided left sympathectomy for frequent syncope, despite pharmacological treatment and implantation of an implantable automatic defibrillator. Whenever arrhythmic syncope occurs in the setting of familial heart disease, left heart denervation should be considered as the next step in the treatment plan2.

Monitorización de la oximetría cerebral en el manejo de la hipoxemia severa asociada a la transposición de grandes arterias mediante atrioseptostomía con balón / Cerebral oximetry monitoring in the management of severe hypoxaemia associated with transposition of the great arteries with balloon atrial septostomy

La transposición de las grandes arterias (D-TGA) es una de las cardiopatías congénitas más comunes que requieren una intervención quirúrgica en la etapa neonatal. En neonatos muy afectados por una D-TGA, la hipoxemia, la acidemia y la insuficiencia cardiaca congestiva secundaria se mejora a menudo con una atrioseptostomía con balón (ASB). Los métodos actuales empleados para evaluar el aporte y el consumo de oxígeno tisular, con frecuencia no son específicos. La espectroscopia cercana al infrarrojo o near infrared spectroscopy (NIRS) permite una medición continua no invasiva de la oxigenación tisular, reflejando el estado de la perfusión tisular en tiempo real. Debido a que se sabe poco sobre el efecto directo de la ASB en el cerebro neonatal y en la oxigenación cerebral de los mismos, nosotros medimos la eficacia de la ASB en 2 pacientes con D-TGA utilizando el NIRS antes y después de la ASB. Concluimos que la ASB mejora la saturación cerebral de oxígeno en neonatos con D-TGA

Transposition of the great arteries (D-TGA) is one of the most common congenital heart diseases requiring neonatal surgical intervention. In the desperately ill neonate with TGA and the resultant hypoxaemia, acidemia, and congestive heart failure, improvement is often obtained with balloon atrial septostomy (BAS). Current methods employed to evaluate oxygen delivery and tissue consumption are frequently nonspecific. Near infrared spectroscopy (NIRS) allows a continuous non-invasive measurement of tissue oxygenation which reflects perfusion status in real time. Because little is known about the direct effect of BAS on the neonatal brain and on cerebral oxygenation, we measured the effectiveness of BAS in two patients with D-TGA using NIRS before and after BAS. We concluded BAS improves cerebral oxygen saturation in neonates with D-TGA

Parada cardíaca relacionada con la anestesia en el síndrome Williams-Beuren / Cardiac arrest related to anaesthesia in Williams-Beuren syndrome

El síndrome de Williams-Beuren es la manifestación clínica de una alteración genética congénita en el gen de la elastina, entre otros. Existen antecedentes de parada cardíaca refractaria a maniobras de resucitación en contexto anestésico. Es alta la incidencia de isquemia miocárdica durante la inducción anestésica, pero existen pacientes que, sin esta causa, también presentan eventos cardíacos muy graves. Quedan cuestiones aún por resolver. La descripción de casos permitirá definir factores fisiopatológicos comunes y disminuir la morbimortalidad. Presentamos el caso de un niño de 3 años con parada cardíaca en la inducción anestésica, rescatado con asistencia circulatoria con membrana de oxigenación extracorpórea e hipotermia inducida como protección cerebral

Williams-Beuren syndrome is the clinical manifestation of a congenital genetic disorder in the elastin gene, among others. There is a history of cardiac arrest refractory to resuscitation manoeuvres in anaesthesia. The incidence of myocardial ischaemia is high during anaesthetic induction, but there are patients who do not have this condition yet also have had very serious cardiac events, and issues that are still to be resolved. Case descriptions will enable the common pathophysiological factors to be defined, and decrease morbidity and mortality. We report the case of a 3-year-old boy with cardiac arrest at induction, rescued with circulatory assistance with extracorporeal membrane oxygenation and hypothermia induced for cerebral protection

Importancia de la monitorización bilateral de la oxigenación cerebral: caso clínico de asimetría durante el bypass cardiopulmonar secundaria a infarto cerebral previo / The importance of bilateral monitoring of cerebral oxygenation (NIRS): Clinical case of asymmetry during cardiopulmonary bypass secondary to previous cerebral infarction

La oximetría cerebral «near infrared spectroscopy»(NIRS) determina la oxigenación tisular cerebral. Describimos el caso clínico de un niño de 12 meses de edad con hemiparesia derecha secundaria a infarto de arteria cerebral media izquierda hacía 8 meses. El niño fue sometido a una ampliación del tracto de salida del ventrículo derecho por estenosis pulmonar mediante bypass cardiopulmonar. En periodos del bypass cardiopulmonar se detectan asimetrías NIRS entre ambos hemisferios cerebrales con descensos críticos en hemisferio derecho lo que indica estados de perfusión y consumo de oxígeno diferentes entre los 2 hemisferios. La utilización de neuromonitorización multimodal NIRS-BIS permitió actuar sobre la presión de perfusión y profundidad anestésica para equilibrar la balanza entre el aporte y el consumo de oxígeno cerebral. No se detectó daño neurológico sobreañadido en el postoperatorio. Consideramos necesaria la monitorización NIRS bilateral para detectar asimetrías entre los 2 hemisferios, que aunque no se manifiesten en el registro basal, pueden surgir en el periodo intraoperatorio, permitiendo detectar y tratar la isquemia-hipoxia cerebral en el hemisferio sano, que provocaría un daño neurológico sobreañadido (AU)

Cerebral oximetry based on near infrared spectroscopy (NIRS) technology is used to determine cerebral tissue oxygenation. We hereby present the clinical case of a 12-month old child with right hemiparesis secondary to prior left middle cerebral artery stroke 8 months ago. The child underwent surgical enlargement of the right ventricular outflow tract (RVOT) with cardiopulmonary bypass. During cardiopulmonary bypass, asymmetric NIRS results were detected between both hemispheres. The utilization of multimodal neuromonitoring (NIRS-BIS) allowed acting on both perfusion pressure and anesthetic depth to balance out the supply and demand of cerebral oxygen consumption. No new neurological sequelae were observed postoperatively. We consider bilateral NIRS monitoring necessary in order to detect asymmetries between cerebral hemispheres. Although asymmetries were not present at baseline, they can arise intraoperatively and its monitoring thus allows the detection and treatment of cerebral ischemia-hypoxia in the healthy hemisphere, which if undetected and untreated would lead to additional neurological damage (AU)

Cerebral oximetry monitoring in the management of severe hypoxaemia associated with transposition of the great arteries with balloon atrial septostomy. / Monitorización de la oximetría cerebral en el manejo de la hipoxemia severa asociada a la transposición de grandes arterias mediante atrioseptostomía con balón.

Transposition of the great arteries (D-TGA) is one of the most common congenital heart diseases requiring neonatal surgical intervention. In the desperately ill neonate with TGA and the resultant hypoxaemia, acidemia, and congestive heart failure, improvement is often obtained with balloon atrial septostomy (BAS). Current methods employed to evaluate oxygen delivery and tissue consumption are frequently nonspecific. Near infrared spectroscopy (NIRS) allows a continuous non-invasive measurement of tissue oxygenation which reflects perfusion status in real time. Because little is known about the direct effect of BAS on the neonatal brain and on cerebral oxygenation, we measured the effectiveness of BAS in two patients with D-TGA using NIRS before and after BAS. We concluded BAS improves cerebral oxygen saturation in neonates with D-TGA.

Cardiac arrest related to anaesthesia in Williams-Beuren syndrome. / Parada cardíaca relacionada con la anestesia en el síndrome Williams-Beuren.

Williams-Beuren syndrome is the clinical manifestation of a congenital genetic disorder in the elastin gene, among others. There is a history of cardiac arrest refractory to resuscitation manoeuvres in anaesthesia. The incidence of myocardial ischaemia is high during anaesthetic induction, but there are patients who do not have this condition yet also have had very serious cardiac events, and issues that are still to be resolved. Case descriptions will enable the common pathophysiological factors to be defined, and decrease morbidity and mortality. We report the case of a 3-year-old boy with cardiac arrest at induction, rescued with circulatory assistance with extracorporeal membrane oxygenation and hypothermia induced for cerebral protection.

The importance of bilateral monitoring of cerebral oxygenation (NIRS): Clinical case of asymmetry during cardiopulmonary bypass secondary to previous cerebral infarction. / Importancia de la monitorización bilateral de la oxigenación cerebral: caso clínico de asimetría durante el bypass cardiopulmonar secundaria a infarto cerebral previo.

Cerebral oximetry based on near infrared spectroscopy (NIRS) technology is used to determine cerebral tissue oxygenation. We hereby present the clinical case of a 12-month old child with right hemiparesis secondary to prior left middle cerebral artery stroke 8 months ago. The child underwent surgical enlargement of the right ventricular outflow tract (RVOT) with cardiopulmonary bypass. During cardiopulmonary bypass, asymmetric NIRS results were detected between both hemispheres. The utilization of multimodal neuromonitoring (NIRS-BIS) allowed acting on both perfusion pressure and anesthetic depth to balance out the supply and demand of cerebral oxygen consumption. No new neurological sequelae were observed postoperatively. We consider bilateral NIRS monitoring necessary in order to detect asymmetries between cerebral hemispheres. Although asymmetries were not present at baseline, they can arise intraoperatively and its monitoring thus allows the detection and treatment of cerebral ischemia-hypoxia in the healthy hemisphere, which if undetected and untreated would lead to additional neurological damage.

Parada cardiaca relacionada con la anestesia en pediatría. Registro en un hospital infantil terciario / Anesthesia-related cardiac arrest in children. Data from a tertiary referral hospital registry

Objetivos. El objetivo del presente estudio es analizar las paradas cardiacas relacionadas con la anestesia en un hospital infantil terciario, con el fin de identificar factores de riesgo que permitan establecer oportunidades de mejora. Métodos. Estudio retrospectivo de 5 años, sobre las paradas cardiacas relacionadas con la anestesia que ocurrieron en pacientes pediátricos. Se incluyeron todos los procedimientos anestésicos urgentes y electivos realizados por anestesiólogos. Los datos obtenidos incluyeron características del paciente, del procedimiento, la causa probable y la evolución de la parada cardiaca. Se calculó la odds ratio mediante análisis univariante para determinar los factores clínicos asociados a la parada y a la mortalidad. Resultados. Se registraron un total de 15 paradas cardiacas relacionadas con la anestesia en 43.391 procedimientos anestésicos (3,4 por 10.000), con incidencia en niños ASA I-II frente ASA ≥ III de 0,28 y 19,27 por 10.000, respectivamente. Los principales factores de riesgo fueron niños con estado físico ASA ≥ III (p < 0,001), menores de un mes (p < 0,001), menores de un año (p < 0,001), procedimientos urgentes (p < 0,01), procedimientos cardiológicos (p < 0,001) y procedimientos del laboratorio de hemodinamia (p < 0,05). Las principales causas del paro cardiaco fueron cardiovasculares (53,3%), debidas principalmente a hipovolemia, seguidas de causas respiratorias (20%) y por efectos adversos de la medicación (20%). La incidencia de mortalidad y lesión neurológica secundaria a la parada en las primeras 24 h fue de 0,92 y 1,38 por 10.000, respectivamente. La mortalidad en los primeros 3 meses fue de 1,6 por 10.000. Las principales causas de mortalidad fueron ASA ≥ III, edad menor de un año, hipertensión arterial pulmonar, paradas en áreas alejadas del área quirúrgica, duración de la reanimación cardiopulmonar mayor de 20 min y cuando no se aplicó hipotermia tras la parada. Conclusión. Los principales factores de riesgo para la parada cardiaca fueron ASA ≥ III, edad menor de un año, procedimientos urgentes, cardiológicos y los realizados en el laboratorio de hemodinamia. La causa principal de la parada fue cardiovascular, debida principalmente a hipovolemia. Todos los pacientes que fallecieron o tuvieron lesión neurológica eran ASA ≥ III. La hipertensión arterial pulmonar conlleva riesgo de mortalidad relacionada con la anestesia (AU)

[Anesthesia-related cardiac arrest in children. Data from a tertiary referral hospital registry]. / Parada cardiaca relacionada con la anestesia en pediatría. Registro en un hospital infantil terciario.

OBJECTIVES: The aim of this study is to analyze the cardiac arrests related to anesthesia in a tertiary children's hospital, in order to identify risk factors that would lead to opportunities for improvement. METHODS: A 5-year retrospective study was conducted on anesthesia related cardiac arrest occurring in pediatric patients. All urgent and elective anesthetic procedures performed by anesthesiologists were included. Data collected included patient characteristics, the procedure, the probable cause, and outcome of the cardiac arrest. Odds ratio was calculated by univariate analysis to determine the clinical factors associated with cardiac arrest and mortality. RESULTS: There were a total of 15 cardiac arrests related to anesthesia in 43,391 anesthetic procedures (3.4 per 10,000), with an incidence in children with ASA I-II versus ASA≥III of 0.28 and 19.27 per 10,000, respectively. The main risk factors were children ASA≥III (P<.001), less than one month old (P<.001), less than one year old (P<.001), emergency procedures (P<.01), cardiac procedures (P<.001) and procedures performed in the catheterization laboratory (P<.05). The main causes of cardiac arrest were cardiovascular (53.3%), mainly due to hypovolemia, and cardiovascular depression associated with induction of anesthesia, followed by respiratory causes (20%), and medication causes (20%). The incidence of mortality and neurological injury within the first 24h after the cardiac arrest was 0.92 and 1.38 per 10,000, respectively. The mortality in the first 3 months was 1.6 per 10,000. The main causes of death were ASA≥III, age under one year, pulmonary arterial hypertension, cardiac arrest in areas remote from the surgery area, a duration of cardiopulmonary resuscitation over 20min, and when hypothermia was not applied after cardiac arrest. CONCLUSION: The main risk factors for cardiac arrest were ASA≥III, age under one year, emergency procedures, cardiology procedures and procedures performed in the catheterization laboratory. The main cause of the cardiac arrest was due mainly to cardiovascular hypovolemia. All patients who died or had neurological injury were ASA≥III. Pulmonary arterial hypertension is a risk of anesthesia-related mortality.

[Inhaled anesthesia through a device for noninvasive continuous positive airway pressure ventilation for upper digestive endoscopy in pediatric patients]. / Anestesia inhalatoria mediante un dispositivo de ventilación no invasiva tipo "CPAP sin respirador" para endoscopia digestiva alta en pacientes pediátricos.

OBJECTIVE: The demand for sedation for pediatric diagnostic procedures performed outside operating rooms has increased considerably, but the ideal method to choose has been the subject of debate. The aim of this study was to assess the efficacy of using a device for continuous positive airway pressure, connected to a Mapleson D circuit and a nasopharyngeal tube as the interface, in order to ventilate and administer sevoflurane for upper digestive tract endoscopy in children. MATERIAL AND METHODS: Prospective cohort study of children undergoing upper digestive tract endoscopy. We recorded epidemiologic variables, heart rate, mean arterial pressure, arterial oxygen saturation and procedure-related adverse events before, during and 10 minutes after the procedure. Time spent in the recovery room was also recorded. The endoscopist asked the patients about their level of satisfaction and whether they had noticed any irritating smell or gas smell. RESULTS: Data was collected on 29 patients (17 boys, 12 girls) with a mean (SD) age of 4.2 (3.9) years. The mean duration of endoscopy was 15 (7) minutes. Arterial oxygen saturation below 92% during the procedure did not occur and the endoscopic exploration was completed satisfactorily with this technique in 28 patients (96%). All were discharged from the recovery room within 30 minutes. The endoscopist reported that the technique was considered satisfactory in all cases, although 2 children noted an anesthetic "gas" smell. CONCLUSIONS: A modified Mapleson D circuit and nasopharyngeal tube can be used effectively as an interface for noninvasive ventilation and administration of sevoflurane during upper digestive endoscopy in pediatric patients.

Anestesia inhalatoria mediante un dispositivo de ventilación no invasiva tipo “CPAP sin respirador” para endoscopia digestiva alta en pacientes pediátricos / Inhaled anesthesia through a device for noninvasive continuous positive airway pressure ventilation for upper digestive endoscopy in pediatric patients

OBJETIVO: La demanda de sedación para procedimientosdiagnósticos realizados en áreas alejadas delquirófano ha aumentado considerablemente en pediatría.La técnica de elección continúa siendo objeto dedebate. El objetivo de este estudio fue valorar la eficaciade un dispositivo de CPAP formado por un circuito deMapleson D y un tubo nasofaríngeo como interfase,como técnica de ventilación, junto a la administración desevoflurano, en endoscopias digestivas altas en niños.MATERIAL Y MÉTODOS: Estudio prospectivo de cohortesde niños sometidos a endoscopia digestiva alta. Serecogieron datos epidemiológicos, frecuencia cardiaca,presión arterial media, saturación arterial de oxígeno,así como los efectos secundarios atribuibles antes,durante y 10 minutos después del procedimiento. Tambiénel tiempo de estancia en la sala de despertar. Se preguntópor el grado de satisfacción y percepción de olorirritante o a gas por el endoscopista.RESULTADOS: Se recogieron los datos de 29 pacientes(17 niños y 12 niñas), con una edad promedio de4,2 ± 3,9 años. La duración media de la prueba fue de15 ± 7 min. No se detectaron saturaciones arteriales deoxígeno inferiores a 92% durante los procedimientos,considerándose la técnica satisfactoria en 28 casos(96%). Todos los pacientes fueron dados de alta a los 30minutos de finalización del proceso. En todos los casos elendoscopista consideró adecuada la técnica y en 2 casosrefirió haber percibido “olor a gas” anestésico.CONCLUSIONES: La utilización de un circuito deMapleson D modificado y un tubo nasofaríngeo a modode interfase puede ser utilizada eficazmente como soporteventilatorio no invasivo, junto a la administración desevoflurano, durante la endoscopia digestiva alta enpacientes pediátricos(AU)

OBJETIVE: The demand for sedation for pediatricdiagnostic procedures performed outside operatingrooms has increased considerably, but the ideal methodto choose has been the subject of debate. The aim of thisstudy was to assess the efficacy of using a device forcontinuous positive airway pressure, connected to aMapleson D circuit and a nasopharyngeal tube as theinterface, in order to ventilate and administersevoflurane for upper digestive tract endoscopy inchildren.MATERIAL AND METHODS: Prospective cohort study ofchildren undergoing upper digestive tract endoscopy.We recorded epidemiologic variables, heart rate, meanarterial pressure, arterial oxygen saturation andprocedure-related adverse events before, during and 10minutes after the procedure. Time spent in the recoveryroom was also recorded. The endoscopist asked thepatients about their level of satisfaction and whetherthey had noticed any irritating smell or gas smell.RESULTS: Data was collected on 29 patients (17 boys,12 girls) with a mean (SD) age of 4.2 (3.9) years. Themean duration of endoscopy was 15 (7) minutes. Arterialoxygen saturation below 92% during the procedure didnot occur and the endoscopic exploration was completedsatisfactorily with this technique in 28 patients (96%).All were discharged from the recovery room within 30minutes. The endoscopist reported that the techniquewas considered satisfactory in all cases, although 2children noted an anesthetic "gas” smell. CONCLUSIONS: A modified Mapleson D circuit andnasopharyngeal tube can be used effectively as aninterface for noninvasive ventilation and administrationof sevoflurane during upper digestive endoscopy inpediatric patients(AU)

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Evaluación de un dispositivo de CPAP sin respirador en lainsuficiencia respiratoria aguda en pediatría / Evaluation of a continuous positive airway pressure system without a ventilator to treat acute respiratory failure in children

OBJETIVO: La CPAP en ventilación no invasiva es utilizadaampliamente en el paciente pediátrico con insuficienciarespiratoria aguda. Sin embargo la escasez deinterfases específicas, respiradores adecuados y la escasatolerancia de la técnica en estos pacientes pueden hacerfracasar su aplicación. El objetivo de este estudio fueanalizar la eficacia de un sistema de CPAP formado porun circuito respiratorio de Mapleson modificado, durantela IRA en pediatría.MATERIAL Y MÉTODOS: Estudio prospectivo observacionalrealizado en niños con insuficiencia respiratoriaaguda con indicación de ventilación no invasiva. LaCPAP se aplicó mediante un circuito respiratorio MaplesonD provisto de un manómetro y un tubo nasofaríngeocomo interfase. Se recogieron previo al tratamiento y 2horas después, frecuencia cardiaca, frecuencia respiratoria,fracción inspirada de oxígeno, presión arterial deoxígeno, de dióxido de carbono y pulsioximetría.RESULTADOS: Se incluyeron 16 pacientes de edadmedia 3,8 años durante un periodo de 18 meses. Observamosuna disminución PaCO2 desde 66,8±18,08 mmHga 46,48±5,9 mmHg tras CPAP (p=0,16) y un aumento enla relación PaO2/FiO2 de 201±111 a 262±115 mm Hg trasCPAP (p=0,30). La FC descendió de 156±22 a 127±18l/min (p=0,05) y la FR de 53±15 a 33±13 resp/min(p<0,05). No se registraron complicaciones graves y latolerancia fue adecuada. La técnica se consideró exitosaen 12 pacientes (75%).CONCLUSIONES: La aplicación de CPAP sin respiradormediante circuito Mapleson D puede ser utilizado comoventilación no invasiva en pacientes pediátricos con insuficienciarespiratoria aguda con elevada tasa de éxito (AU)

OBJETIVE: Noninvasive continuous positive airwaypressure (CPAP) is widely used in pediatric patients withacute respiratory failure. However, the lack of specificinterfaces and appropriate ventilators and poor tolerance ofthe technique by these patients can lead to failure of theapplication. The aim of this study was to analyze the efficacyof a CPAP system using a modified Mapleson breathingcircuit during acute respiratory failure in pediatric patients.MATERIAL AND METHODS: We performed a prospectiveobservational study in children with acute respiratoryfailure in whom noninvasive ventilation was indicated.CPAP was applied through a Mapleson D circuit fittedwith a manometer and a nasopharyngeal tube as theinterface. Heart rate, respiratory rate, inspired oxygenfraction (FiO2), PaO2, PaCO2, and pulse oximetry weremeasured before treatment and after 2 hours of treatment.RESULTS: Sixteen patients with a mean age of 3.8 yearswere studied for a period of 18 months. We observed amean (SD) change in PaCO2 from 66.8 (18.08) mm Hg to46.48 (5.9) mm Hg after CPAP (P=.16) and a mean changein the PaO2/FiO2 ratio from 201 (111) to 262 (115) afterCPAP (P=.30). The mean heart rate fell from 156 (22)beats/min to 127 (18) beats/min (P=.05) and the meanrespiratory rate from 53 (15) breaths/min to 33 (13)breaths/min (P<.05). No severe complications wererecorded and tolerance was satisfactory. The techniquewas considered a success in 12 patients (75%).CONCLUSIONS: CPAP without a ventilator, through aMapleson D circuit, can be used with a high success rateto provide noninvasive ventilation for pediatric patientswith acute respiratory failure (AU)

Fluidoterapia perioperatoria en pediatría: estado actual / Perioperative fluid management in paediatrics: current status

La fluidoterapia perioperatoria es un tema controvertido en el paciente pediátrico. La pauta más extendida se basa en conceptos de hace más de 50 años, que proponían reponer las necesidades de agua y electrolitos en base al peso y utilizando fluidos glucosados hipotónicos. Evidencias científicas actuales sugieren que esta práctica puede condicionar lesiones iatrogénicas graves. Este riesgo se incrementa por alteraciones fisiológicas que ocurren en el periodo perioperatorio, como son la secreción inadecuada de hormona antidiurética y la tendencia a la hiperglucemia, secundarias al estrés quirúrgico. De hecho, la sustitución de fluidos hipotónicos por isotónicos, la restricción de la cantidad de fluidos administrados y también la utilización de fluidos con menor porcentaje de glucosa parecen mejorar el pronóstico postquirúrgico. El objetivo del trabajo es alertar sobre la incidencia y riesgosde las alteraciones hidroelectrolíticas perioperatorias y demostrar que su etiología está relacionada con el aporte inadecuado de fluidos (AU)

Perioperative fluid management in paediatrics has been the focus of considerable controversy. The current standard of care is based in concepts described more than 50 years ago, which recommend to administer hypotonic solutions to satisfy electrolyte and water requirements. Recent scientific evidences highlight the risk of iatrogenic lesions with this practice. Physiological changes that occur in the perioperative setting, such as inappropriate secretion of antidiuretic hormone and the tendency to hyperglycaemia, secondary to surgical stress response, further increase this risk. On the contrary, the use of isotonic in favour of hypotonic fluids, the restriction of the volume infused and the use of low dextrose concentration solutions seem to improve postoperative prognosis. It is our intent to alert physicians that water and electrolyte disturbances are extremely common in the perioperative period. Furthermore, these derangements have potential risks and are most often related to inadequate infusion of fluids (AU)

[Anesthetic induction with nitrous-oxide-free sevoflurane in pediatric patients]. / Inducción anestésica con sevoflurano libre de óxido nitroso en pediatría.

OBJECTIVE: To evaluate the pediatric use of inhaled nitrous oxide (N2O)-free induction with sevoflurane for the purpose of protecting staff from exposure to workplace air pollution. PATIENTS AND METHODS: Prospective, randomized trial in ASA class 1-2 children in whom a tidal breathing technique was used for anesthetic induction in a variety of surgical procedures. Patients were allocated to 2 groups. The sevo-N2O group inhaled 8% sevoflurane in a 60/40% mixture of oxygen and N2O. The sevo-air group received 8% sevoflurane in a mixture of oxygen and air (inspired oxygen fraction, 40%). We recorded mean arterial pressure (MAP), heart rate, oxygen saturation by pulse oximetry (SpO2), limb response to venous puncture, alveolar concentration of sevoflurane, and incidence of adverse events. RESULTS: Twenty-two patients were assigned to each group. The vein was catheterized in all patients without a pain reflex in the limb, and there were no statistically significant differences in MAP, heart rate, SpO2, or incidence of adverse events. Mean (SD) alveolar concentration of sevoflurane, however, differed between the 2 groups: 53% (0.51%) in the sevo-N2O group and 4.91% (0.41%) in the sevo-air group (P = .028). CONCLUSIONS: N2O-free anesthetic induction by tidal breathing of 8% sevoflurane provides similar anesthetic conditions (efficacy, safety, and rapid onset) without a higher incidence of adverse events. The use of N2O can therefore be avoided.