Feasibility and Short-Term Outcomes in Liver-First Approach: A Spanish Snapshot Study (the RENACI Project).

(1) Background: The liver-first approach may be indicated for colorectal cancer patients with synchronous liver metastases to whom preoperative chemotherapy opens a potential window in which liver resection may be undertaken. This study aims to present the data of feasibility and short-term outcomes in the liver-first approach. (2) Methods: A prospective observational study was performed in Spanish hospitals that had a medium/high-volume of HPB surgeries from 1 June 2019 to 31 August 2020. (3) Results: In total, 40 hospitals participated, including a total of 2288 hepatectomies, 1350 for colorectal liver metastases, 150 of them (11.1%) using the liver-first approach, 63 (42.0%) in hospitals performing <50 hepatectomies/year. The proportion of patients as ASA III was significantly higher in centers performing ≥50 hepatectomies/year (difference: 18.9%; p = 0.0213). In 81.1% of the cases, the primary tumor was in the rectum or sigmoid colon. In total, 40% of the patients underwent major hepatectomies. The surgical approach was open surgery in 87 (58.0%) patients. Resection margins were R0 in 78.5% of the patients. In total, 40 (26.7%) patients had complications after the liver resection and 36 (27.3%) had complications after the primary resection. One-hundred and thirty-two (89.3%) patients completed the therapeutic regime. (4) Conclusions: There were no differences in the surgical outcomes between the centers performing <50 and ≥50 hepatectomies/year. Further analysis evaluating factors associated with clinical outcomes and determining the best candidates for this approach will be subsequently conducted.

Nanomedicine for the Treatment of Viral Diseases: Smaller Solution to Bigger Problems.

The continuous evolution of new viruses poses a danger to world health. Rampant outbreaks may advance to pandemic level, often straining financial and medical resources to breaking point. While vaccination remains the gold standard to prevent viral illnesses, these are mostly prophylactic and offer minimal assistance to those who have already developed viral illnesses. Moreover, the timeline to vaccine development and testing can be extensive, leading to a lapse in controlling the spread of viral infection during pandemics. Antiviral therapeutics can provide a temporary fix to tide over the time lag when vaccines are not available during the commencement of a disease outburst. At times, these medications can have negative side effects that outweigh the benefits, and they are not always effective against newly emerging virus strains. Several limitations with conventional antiviral therapies may be addressed by nanotechnology. By using nano delivery vehicles, for instance, the pharmacokinetic profile of antiviral medications can be significantly improved while decreasing systemic toxicity. The virucidal or virus-neutralizing qualities of other special nanomaterials can be exploited. This review focuses on the recent advancements in nanomedicine against RNA viruses, including nano-vaccines and nano-herbal therapeutics.

Circadian-Coupled Genes Expression and Regulation in HIV-Associated Chronic Obstructive Pulmonary Disease (COPD) and Lung Comorbidities.

People living with HIV (PLWH) have an elevated risk of chronic obstructive pulmonary disease (COPD) and are at a higher risk of asthma and worse outcomes. Even though the combination of antiretroviral therapy (cART) has significantly improved the life expectancy of HIV-infected patients, it still shows a higher incidence of COPD in patients as young as 40 years old. Circadian rhythms are endogenous 24 h oscillations that regulate physiological processes, including immune responses. Additionally, they play a significant role in health and diseases by regulating viral replication and its corresponding immune responses. Circadian genes play an essential role in lung pathology, especially in PLWH. The dysregulation of core clock and clock output genes plays an important role in chronic inflammation and aberrant peripheral circadian rhythmicity, particularly in PLWH. In this review, we explained the mechanism underlying circadian clock dysregulation in HIV and its effects on the development and progression of COPD. Furthermore, we discussed potential therapeutic approaches to reset the peripheral molecular clocks and mitigate airway inflammation.

Doppler ultrasound in the assessment of renal perfusion before and during continuous kidney replacement therapy in the pediatric intensive care unit.

BACKGROUND: This study aimed to assess observer variability and describe renal resistive index (RRI) and pulsatility index (PI) before and after onset of continuous kidney replacement therapy (CKRT). A secondary objective was to correlate Doppler ultrasound findings with those from direct measurement of renal blood flow (RBF). METHODS: This is a prospective observational study in hemodynamically stable Maryland piglets with and without acute kidney injury (AKI) and in hemodynamically unstable critically ill children requiring CKRT. Doppler-based RRI and PI were assessed for each subject. Measurements were made by two different operators (pediatric intensivists) before and after CKRT onset. RESULTS: Observer variability assessment in the measurement of RRI and PI rendered a moderate correlation for both RRI (ICC 0.65, IQR 0.51-0.76) and PI (ICC 0.63, IQR 0.47-0.75). RRI and PI showed no correlation with RBF or urine output. Baseline RRI and PI were normal in control piglets [RRI 0.68 (SD 0.02), PI 1.25 (SD 0.09)] and those with AKI [RRI 0.68 (SD 0.03), PI 1.20 (SD 0.13)]. Baseline RRI and PI were elevated in critically ill children (RRI 0.85, PI 2.0). PI and RRI did not change with CKRT in any study group. CONCLUSIONS: Observer variability between inexperienced pediatric intensivists was comparable with that between senior and junior operators. Doppler-based calculations did not correlate with invasive measurements of RBF. RRI and PI were normal in hemodynamically stable piglets with and without AKI. RRI and PI were high in hemodynamically unstable patients requiring CKRT. RRI and PI did not change after CKRT onset, despite changes in hemodynamic status. A higher resolution version of the Graphical abstract is available as Supplementary information.

Hemodynamic disturbances and oliguria during continuous kidney replacement therapy in critically ill children.

BACKGROUND: About 1.5% of patients admitted to the Pediatric Intensive Care Unit (PICU) will require continuous kidney replacement therapy (CKRT)/renal replacement therapy (CRRT). Mortality of these patients ranges from 30 to 60%. CKRT-related hypotension (CKRT-RHI) can occur in 19-45% of patients. Oliguria after onset of CKRT is also common, but to date has not been addressed directly in the scientific literature. METHODS: A prospective observational study was conducted to define factors involved in the hemodynamic changes that take place during the first hours of CKRT, and their relationship with urinary output. RESULTS: Twenty-five patients who were admitted to a single-center PICU requiring CKRT between January 1, 2014, and December 31, 2018, were included, of whom 56.3% developed CKRT-RHI. This drop in blood pressure was transient and rapidly restored to baseline, and significantly improved after the third hour of CKRT, as core temperature and heart rate decreased. Urine output significantly decreased after starting CKRT, and 72% of patients were oliguric after 6 h of therapy. Duration of CKRT was significantly longer in patients presenting with oliguria than in non-oliguric patients (28.7 vs. 7.9 days, p = 0.013). CONCLUSIONS: The initiation of CKRT caused hemodynamic instability immediately after initial connection in most patients, but had a beneficial effect on the patient's hemodynamic status after 3 h of therapy, presumably owing to decreases in body temperature and heart rate. Urine output significantly decreased in all patients and was not related to negative fluid balance, patient's hemodynamic status, CKRT settings, or kidney function parameters.

Infection in critically ill pediatric patients on continuous renal replacement therapy.

INTRODUCTION: Continuous renal replacement therapies (CRRT) are frequently used in critically ill children and may increase the risk of infection. However, the incidence, characteristics and prognosis of infection in critically ill children on CRRT have not been studied. METHODS: Data from a prospective, single-center register of critically ill children treated with CRRT was analyzed. RESULTS: 55 children (40% under 1 year of age) were treated with CRRT between June 2008 and January 2012; 43 patients (78.2%) presented 1 or more infections. The most common condition of patients requiring CRRT was heart disease (69%). Infection occurred a median of 11 days after the initiation of CRRT (IQ range: 4 to 21 days). A total of 21 patients (48.8 %) developed 1 infection, 7 (16.2%) developed 2 infections and 15 (34.9%) developed 3 or more infections. The most frequent infection was catheter-related bacteremia, with no differences in catheter location. CRRT duration longer than 4.5 days was the only risk factor for infection. Patients with infection had a longer length of stay (LOS) in the Pediatric Intensive Care Unit (PICU) than patients without it (37.8 vs. 17.6, p = 0.019), but there were no differences in mortality (30.2% vs. 33.3%; p = 0.84). CONCLUSIONS: Infection rate is high in critically ill children treated with CRRT. More than 4 days of CRRT increases the risk of infection. Infection in these patients entails a longer stay in the PICU but did not increase mortality.

Nutritional status and clinical outcome of children on continuous renal replacement therapy: a prospective observational study.

BACKGROUND: No studies on continuous renal replacement therapy (CRRT) have analyzed nutritional status in children. The objective of this study was to assess the association between mortality and nutritional status of children receiving CRRT. METHODS: Prospective observational study to analyze the nutritional status of children receiving CRRT and its association with mortality. The variables recorded were age, weight, sex, diagnosis, albumin, creatinine, urea, uric acid, severity of illness scores, CRRT-related complications, duration of admission to the pediatric intensive care unit, and mortality. RESULTS: The sample comprised 174 critically ill children on CRRT. The median weight of the patients was 10 kg, 35% were under percentile (P) 3, and 56% had a weight/P50 ratio of less than 0.85. Only two patients were above P95. The mean age for patients under P3 was significantly lower than that of the other patients (p = 0.03). The incidence of weight under P3 was greater in younger children (p = 0.007) and in cardiac patients and in those who had previous chronic renal insufficiency (p = 0.047). The mortality analysis did not include patients with pre-existing renal disease. Mortality was 38.9%. Mortality for patients with weight < P3 was greater than that of children with weight > P3 (51% vs 33%; p = 0.037). In the univariate and multivariate logistic regression analyses, the only factor associated with mortality was protein-energy wasting (malnutrition) (OR, 2.11; 95% CI, 1.067-4.173; p = 0.032). CONCLUSIONS: The frequency of protein-energy wasting in children who require CRRT is high, and the frequency of obesity is low. Protein-energy wasting is more frequent in children with previous end-stage renal disease and heart disease. Underweight children present a higher mortality rate than patients with normal body weight.

Evolución y factores de riesgo de mortalidad en niños sometidos a cirugía cardiaca que requieren técnicas de depuración extrarrenal continua / Evolution and mortality risk factors in children with continuous renal replacement therapy after cardiac surgery

Introducción y objetivos. El objetivo fue estudiar la evolución de los niños que requieren técnicas de depuración extrarrenal continua tras la cirugía cardiaca y analizar los factores asociados con la mortalidad. Métodos. Estudio prospectivo observacional. Se incluyó a los niños que requirieron técnicas de depuración extrarrenal continua tras la cirugía cardiaca. Se realizaron análisis univariable y multivariable para estudiar la influencia de cada factor en la mortalidad. Resultados. De los 1.650 niños sometidos a cirugía cardiaca, 81 (4,9%) requirieron técnicas de depuración extrarrenal. Los niños que precisaron técnicas de depuración extrarrenal tras la cirugía cardiaca presentaban una presión arterial media y unos valores de urea y creatinina más bajos, y su mortalidad fue mayor (43%) que la del resto de los niños (29%) (p=0,05). En el estudio univariable, los factores asociados con mortalidad fueron: edad < 12 meses, peso < 10 kg, hipotensión, puntuación elevada de riesgo de mortalidad infantil y valores bajos de creatinina al inicio de la técnica. En el estudio multivariable, la hipotensión en el momento del inicio de las técnicas de depuración extrarrenal continua, una puntuación puntuación elevada de riesgo de mortalidad infantil ≥ 21 y la hemofiltración fueron los factores asociados con la mortalidad. Conclusiones. Aunque sólo un pequeño porcentaje de los niños sometidos a cirugía cardiaca precisan técnicas de depuración extrarrenal continua, su mortalidad es elevada. La hipotensión y la gravedad clínica al inicio de la técnica de depuración y la hemofiltración como técnica de depuración fueron los factores asociados con la mortalidad (AU)

Introduction and objectives. To study the clinical course of children requiring continuous renal replacement therapy after cardiac surgery and to analyze factors associated with mortality. Methods. A prospective observational study was performed that included children requiring continuous renal replacement therapy after cardiac surgery. Univariate and multivariate analyses were performed to determine the influence of each factor on mortality. We compared these patients with other critically ill children requiring continuous renal replacement therapy. Results. Of 1650 children undergoing cardiac surgery, 81 (4.9%) required continuous renal replacement therapy, 65 of whom (80.2%) presented multiple organ failure. The children who started continuous renal replacement therapy after cardiac surgery had lower mean arterial pressure, lower urea and creatinine levels, and higher mortality (43%) than the other children on continuous renal replacement therapy (29%) (P=.05). Factors associated with mortality in the univariate analysis were age less than 12 months, weight under 10 kg, higher pediatric risk of mortality score, hypotension, lower urea and creatinine levels when starting continuous renal replacement therapy, and the use of hemofiltration. In the multivariate analysis, hypotension when starting continuous renal replacement therapy, pediatric risk of mortality scores equal to or greaterer than 21, and hemofiltration were associated with mortality. Conclusions. Although only a small percentage of children undergoing cardiac surgery required continuous renal replacement therapy, mortality among these patients was high. Hypotension and severity of illness when starting the technique and hemofiltration were factors associated with higher mortality (AU)

Evolution and mortality risk factors in children with continuous renal replacement therapy after cardiac surgery.

INTRODUCTION AND OBJECTIVES: To study the clinical course of children requiring continuous renal replacement therapy after cardiac surgery and to analyze factors associated with mortality. METHODS: A prospective observational study was performed that included children requiring continuous renal replacement therapy after cardiac surgery. Univariate and multivariate analyses were performed to determine the influence of each factor on mortality. We compared these patients with other critically ill children requiring continuous renal replacement therapy. RESULTS: Of 1650 children undergoing cardiac surgery, 81 (4.9%) required continuous renal replacement therapy, 65 of whom (80.2%) presented multiple organ failure. The children who started continuous renal replacement therapy after cardiac surgery had lower mean arterial pressure, lower urea and creatinine levels, and higher mortality (43%) than the other children on continuous renal replacement therapy (29%) (P=.05). Factors associated with mortality in the univariate analysis were age less than 12 months, weight under 10 kg, higher pediatric risk of mortality score, hypotension, lower urea and creatinine levels when starting continuous renal replacement therapy, and the use of hemofiltration. In the multivariate analysis, hypotension when starting continuous renal replacement therapy, pediatric risk of mortality scores equal to or greater than 21, and hemofiltration were associated with mortality. CONCLUSIONS: Although only a small percentage of children undergoing cardiac surgery required continuous renal replacement therapy, mortality among these patients was high. Hypotension and severity of illness when starting the technique and hemofiltration were factors associated with higher mortality.

Clinical course and mortality risk factors in critically ill children requiring continuous renal replacement therapy.

OBJECTIVE: To study the clinical course in children requiring continuous renal replacement therapy (CRRT) and to analyse factors associated with mortality. DESIGN: Prospective observational study. SETTING: Paediatric intensive care department of a tertiary university hospital. PATIENTS: Critically ill children with CRRT were included in the study. INTERVENTION: Continuous renal replacement therapy. MEASUREMENTS AND RESULTS: Univariate and multivariate analyses were performed to analyse the influence of each factor on mortality. The ability of the PRISM, PIM II and PELOD severity of illness scores to predict mortality was tested using receiver-operating characteristic curve statistics. A total of 174 children aged between 1 month and 22 years were treated with CRRT. Mortality was 35.6%, and multiorgan failure and haemodynamic disturbances were the principal causes of death. Mortality was higher in children less than 12 months of age (44.7%; P = 0.037) and in patients with a diagnosis of sepsis (44.1%; P = 0.001). Haemodynamic disturbances at the time of starting CRRT (hypotension or need for adrenaline >0.6 microg/kg/min) and the presence of multiorgan failure were the factors associated with an increased risk of mortality. The PRISM scale was the severity score with the best predictive capacity, although all three scales underestimated the actual mortality. CONCLUSIONS: Mortality in children who require CRRT is high. Haemodynamic disturbances and the presence of multiorgan failure at the time of starting the technique are the factors associated with a higher mortality. The clinical severity scores underestimate mortality in children requiring CRRT.

Clinical course of children requiring prolonged continuous renal replacement therapy.

A prospective observational study was performed to analyze the clinical course of critically ill children who require continuous renal replacement therapy (CRRT). Variables associated with prolonged CRRT were analyzed. Of the 174 children treated with CRRT, 32 (18.3%) required CRRT for >14 days and 20 (11.5%) for >21 days. Prolonged CRRT was more common in patients with heart disease and those requiring mechanical ventilation, hemodiafiltration, and higher doses of heparin. The same factors were found when patients with CRRT for >14 days and 21 days were studied. Overall mortality rate was 35.6%; it was slightly higher in patients on prolonged CRRT (43.7% with CRRT > 14 days and 45% with CRRT >21 days), though the differences were not statistically significant. We conclude that there were no differences in the pre-CRRT clinical characteristics, severity of illness, and renal function in critically ill children requiring prolonged CRRT. Prolonged CRRT was more frequently required by patients with heart disease and those on mechanical ventilation. Patients with prolonged CRRT required more frequent hemodiafiltration and higher doses of heparin. Mortality was slightly higher in children with longer CRRT, though this difference did not reach statistical significance.

Complications of continuous renal replacement therapy in critically ill children: a prospective observational evaluation study.

INTRODUCTION: Continuous renal replacement therapy (CRRT) frequently gives rise to complications in critically ill children. However, no studies have analyzed these complications prospectively. The purpose of this study was to analyze the complications of CRRT in children and to study the associated risk factors. METHODS: A prospective, single-centre, observational study was performed in all critically ill children treated using CRRT in order to determine the incidence of complications related to the technique (problems of catheterization, hypotension at the time of connection to the CRRT, hemorrhage, electrolyte disturbances) and their relationship with patient characteristics, clinical severity, need for vasoactive drugs and mechanical ventilation, and the characteristics of the filtration techniques. RESULTS: Of 174 children treated with CRRT, 13 (7.4%) presented problems of venous catheterization; this complication was significantly more common in children under 12 months of age and in those weighing less than 10 kg. Hypotension on connection to CRRT was detected in 53 patients (30.4%). Hypotension was not associated with any patient or CRRT characteristics. Clinically significant hemorrhage occurred in 18 patients (10.3%); this complication was not related to any of the variables studied. The sodium, chloride, and phosphate levels fell during the first 72 hours of CRRT; the changes in electrolyte levels during the course of treatment were not found to be related to any of the variables analyzed, nor were they associated with mortality. CONCLUSIONS: CRRT-related complications are common in children and some are potentially serious. The most common are hypotension at the time of connection and electrolyte disturbances. Strict control and continuous monitoring of the technique are therefore necessary in children on CRRT.

The use of continuous renal replacement therapy in series with extracorporeal membrane oxygenation.

A large percentage of patients on extracorporeal membrane oxygenation (ECMO) require continuous renal replacement therapy (CRRT) usually performed through a different venous access or by introducing a filter into the ECMO circuit. Here, we evaluated the efficacy and safety of including a CRRT machine in the circuit by connecting its inlet line after the centrifugal pump and its outlet line before the oxygenator. We tested the function of the combined system initially in a closed circuit, followed by an experimental animal study, and, finally, in a clinical trial with six children. Both machines functioned adequately and there were no significant changes in the pressures of the ECMO circuit after the introduction of the CRRT device, thus achieving the preset negative balances and normalization of the serum urea and creatinine concentrations. The mean life of the filters was about 138 h, and only one filter needed changing due to clotting. Our study shows that the introduction of a CRRT device into the ECMO circuit is a safe and effective technique that improves fluid balance, increases filter life, and does not cause complications. For these reasons, this may be a good method for performing CRRT in patients on ECMO.

Circuit life span in critically ill children on continuous renal replacement treatment: a prospective observational evaluation study.

INTRODUCTION: One of the greatest problems with continuous renal replacement therapy (CRRT) is early coagulation of the filters. Few studies have monitored circuit function prospectively. The purpose of this study was to determine the variables associated with circuit life in critically ill children with CRRT. METHODS: A prospective observational study was performed in 122 children treated with CRRT in a pediatric intensive care unit from 1996 to 2006. Patient and filter characteristics were analyzed to determine their influence on circuit life. Data were collected on 540 filters in 122 patients and an analysis was performed of the 365 filters (67.6%) that were changed due to circuit coagulation. RESULTS: The median circuit life was 31 hours (range 1 to 293 hours). A univariate and multivariate logistic regression study was performed to assess the influence of each one of the factors on circuit life span. No significant differences in filter life were found according to age, weight, diagnoses, pump, site of venous access, blood flow rate, ultrafiltration rate, inotropic drug support, or patient outcome. The mean circuit life span was longer when the heparin dose was greater than 20 U/kg per hour (39 versus 29.1 hours; P = 0.008), with hemodiafiltration compared with hemofiltration (34 versus 22.7 hours; P = 0.001), with filters with surface areas of 0.4 to 0.9 m2 (38.2 versus 26.1 hours; P = 0.01), and with a catheter size of 6.5 French or greater (33.0 versus 25.0 hours; P = 0.04). In the multivariate analysis, hemodiafiltration, heparin dose of greater than 20 U/kg per hour, filter surface area of 0.4 m2 or greater, and initial creatinine of less than 2 mg/dL were associated with a filter life of more than 24 and 48 hours. Total effluent rate of greater than 35 mL/kg per hour was associated only with a filter life of more than 24 hours. CONCLUSION: Circuit life span in CRRT in children is short but may be increased by the use of hemodiafiltration, higher heparin doses, and filters with a high surface area.

An Integrative Approach to Burnout in Secondary School Teachers: Examining the Role of Student Disruptive Behaviour and Disciplinary Issues

The aim of this paper is to examine from an integrative approach to what extent occupational stressors when in combination with other variables that have accredited their explicative value in accounting for teacher distress in other domains (personal, psychosocial and outside the occupational sphere) contribute to predicting and/or explaining the different components of burnout. The sample consists in 1386 secondary education teachers. The statistical results obtained confirm for all dimensions in the syndrome the explanatory role of occupational stressors related with student disruptive behaviours/attitudes and disciplinary issues (conflict management and lack of support/consensus). The remaining variables in the study (Type A pattern, optimism, hardiness, friend and family support, life events) also contribute to accounting for burnout, albeit to a lesser extent than occupational factors. Results not only confirm the suitability of the selected variables but also the necessity to design integration studies in which, besides another type of determinants, to include variables from the occupational domain. In other words, our findings suggest that student disruptive behaviour, the difficulties experienced by teachers in managing conflict and the lack support/consensus as regards disciplinary actions are ‘necessary’ ingredients if we are to successfully predict burnout in secondary school teachers (AU)

Este artículo examina, desde un acercamiento integrador, en qué medida los estresores laborales, cuando se incluyen conjuntamente con otras variables con probada capacidad explicativa del malestar docente pertenecientes a otros ámbitos (personal, psicosocial y extralaboral), contribuyen a predecir y/o explicar las distintas facetas del burnout. La muestra está formada por 1386 profesores de Enseñanza Secundaria. Los resultados confirman, para todas las dimensiones del síndrome, el protagonismo explicativo de los estresores laborables relacionados con las conductas y/o actitudes problemáticas de los alumnos y las cuestiones disciplinarias (manejo de conflictos y falta de apoyo/consenso). Las restantes variables incluidas (patrón Tipo A, optimismo, personalidad resistente, apoyo familia y amigos, eventos vitales) también contribuyen a dar cuenta del desgaste laboral, aunque en menor medida que los factores laborales. Los resultados no sólo confirman la idoneidad de las variables seleccionadas, sino también la necesidad de diseñar estudios integradores en los que, además de otro tipo de determinantes, se incorporen variables del ámbito laboral. Nuestros hallazgos indican que las conductas y/o actitudes problemáticas de los alumnos, las dificultades de los profesores en el manejo del conflicto y la falta de apoyo/consenso en cuestiones disciplinarias, parecen ingredientes “necesarios” si queremos predecir satisfactoriamente el burnout de los docentes de secundaria (AU)

Postpyloric enteral nutrition in the critically ill child with shock: a prospective observational study.

BACKGROUND: Tolerance to enteral nutrition in the critically ill child with shock has not been studied. The purpose of the study was to analyze the characteristics of enteral nutrition and its tolerance in the critically ill child with shock and to compare this with non-shocked patients. METHODS: A prospective, observational study was performed including critically ill children with shock who received postpyloric enteral nutrition (PEN). The type of nutrition used, its duration, tolerance, and gastrointestinal complications were assessed. The 65 children with shock who received PEN were compared with 461 non-shocked critically ill children who received PEN. RESULTS: Sixty-five critically ill children with shock, aged between 21 days and 22 years, received PEN. 75.4% of patients with shock received PEN exclusively. The mean duration of the PEN was 25.2 days and the maximum calorie intake was 79.4 kcal/kg/day. Twenty patients with shock (30.7%) presented gastrointestinal complications, 10 (15.4%) abdominal distension and/or excessive gastric residue, 13 (20%) diarrhoea, 1 necrotising enterocolitis, and 1 duodenal perforation due to the postpyloric tube. The frequency of gastrointestinal complications was significantly higher than in the other 461 critically ill children (9.1%). PEN was suspended due to gastrointestinal complications in 6 patients with shock (9.2%). There were 18 deaths among the patients with shock and PEN (27.7%). In only one patient was the death related to complications of the nutrition. CONCLUSION: Although most critically ill children with shock can tolerate postpyloric enteral nutrition, the incidence of gastrointestinal complications is higher in this group of patients than in other critically ill children.