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

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

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

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

Lipid profile of cerebrospinal fluid in multiple sclerosis patients: a potential tool for diagnosis.

Multiple sclerosis (MS) is a complex multifactorial neuropathology. Although its etiology remains unclear, it has been demonstrated that the immune system attacks myelin, leading to demyelination and axonal damage. The involvement of lipids as one of the main components of myelin sheaths in MS and other demyelinating diseases has been postulated. However, it is still a matter of debate whether specific alteration patterns exist over the disease course. Here, using a lipidomic approach, we demonstrated that, at the time of diagnosis, the cerebrospinal fluid of MS patients presented differences in 155 lipid species, 47 of which were identified. An initial hierarchical clusterization was used to classify MS patients based on the presence of 25 lipids. When a supervised method was applied in order to refine this classification, a lipidomic signature was obtained. This signature was composed of 15 molecules belonging to five different lipid families including fatty acids (FAs). An FA-targeted approach revealed differences in two members of this family: 18:3n3 and 20:0 (arachidic acid). These results reveal a CSF lipidomic signature in MS patients at the time of diagnosis that might be considered as a potential diagnostic tool.

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

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

Assessment of pain in critically ill children. Is cutaneous conductance a reliable tool?

PURPOSE: The purpose of this study is to assess the usefulness and accuracy of skin conductance (SC) as a tool to evaluate the level of sedation and pain in pediatric critical patients during painful procedures and to compare it with hemodynamic variables, clinical scales, and bispectral index (BIS). MATERIALS AND METHODS: This is a prospective observational study in 61 critical children undergoing invasive procedures. Hemodynamic data (heart rate and arterial blood pressure), clinical scales punctuation (Ramsay, COMFORT, and numeric rating pain scales), BIS, and the number of fluctuations of SC per second were collected before, during, and at the end of the procedure. RESULTS: The mean age of the patients was 42.9 (range, 1 month to 16 years). Seventy-two point six percent were postcardiac surgery patients. Nonmuscle-relaxed patients showed a moderate increase in heart rate (P = .02), numeric rating pain scales (P = .03), and Ramsay scale (P = .002). The number of fluctuations of SC per second increased significantly during the procedure (basal, 0.1; maneuver, 0.2; P = .015), but it never reached the level considered as pain or stress nor did it precede clinical scales or BIS. None of the variables studied showed a significant change during the procedure in muscle-relaxed patients. CONCLUSIONS: Skin conductance was not found to be more sensitive or faster than clinical scales for the assessment of pain or stress in critical children undergoing painful procedures. Skin conductance was not useful in muscle-relaxed children.

Evaluación de los cursos de simulación médica avanzada para la formación de los médicos residentes de pediatría en situaciones de emergencia / Evaluation of advanced medical simulation courses for training of paediatric residents in emergency situations

Objetivo: Analizar la utilidad de un curso de simulación en emergencias pediátricas dentro de un nuevo programa de formación de los residentes de pediatría. Métodos: Se diseñó un curso de simulación avanzada con casos prácticos de emergencias pediátricas. Se realizó una evaluación práctica, puntuándose en cada caso clínico de 1 a 5 los siguientes apartados: organización y coordinación del trabajo en equipo, órdenes médicas, monitorización, exploración, tratamientos por aparatos, interpretación pruebas complementarias, información a los padres y evaluación global. Se compararon los resultados según el año de residencia de los participantes. Se evaluó la satisfacción de los alumnos con el curso mediante una encuesta. Resultados: Se realizaron 6 cursos de simulación con 55 residentes, el 29% de segundo año (R2), el 47% R3 y el 23% R4. La puntuación global de los alumnos fue de 3,4 rango intercuartil (RI) 3,2-3,7. La mayor puntuación la obtuvieron en la monitorización inicial (mediana: 4, RI: 4-4,3) y en la exploración inicial (mediana: 4, RI: 3,4-4,2) y la peor en la información a los familiares (mediana: 3, RI: 2,3-3,4). No existieron diferencias significativas en las puntuaciones finales de los residentes según su año de residencia. Los alumnos consideraron muy positivos los cursos, destacando su realismo y utilidad práctica. Conclusiones: Debería considerarse la inclusión de cursos de simulación avanzada en emergencias pediátricas en el programa de formación de los residentes de pediatría, ya que son un método educativo útil y bien valorado por los alumnos(AU)

Objective: To analyse the usefulness of simulation courses in paediatric emergencies in a new training program for paediatrics residents. Methods: An advanced simulation course with practical cases of paediatric emergencies was designed. Assessment of each clinical case was rated from 1 to 5 in the following sections: organization and coordination of team work, physician orders, monitoring, clinical examination, treatments, interpretation of laboratory tests, parent information, and global evaluation. The results were compared by year of residency of the participants. Student satisfaction with the course was assessed through a survey. Results: There were six courses of simulation with 55 residents, of whom 29% were second-year residents (R2), 47% third year (R3), and 23% fourth year (R4). The median global score was 3.4 (IR: 3.2 to 3.7). The highest score was the initial monitoring (median: 4; IR: 4 to 4.3) and the initial medical examination (median: 4; IR: 3.4 to 4.2). The worst aspect was the information to the parents (median: 3; IR: 2.3 to 3.4). There were no significant differences in the global score according to the year of residency. The residents felt very positive about simulation courses, emphasizing the realism and practicality. Conclusions: The inclusion of advanced simulation courses in paediatric emergencies in the training program of paediatric residents is a useful educational method, and is appreciated by residents(AU)

Efectos hemodinámicos del omeprazol por vía intravenosa en niños en estado crítico / Hemodynamic effects of intravenous omeprazole in critically ill children

Introducción: Los pacientes críticos frecuentemente presentan inestabilidad hemodinámica que puede verse empeorada por la administración de algunos fármacos. El omeprazol es un fármaco muy empleado en la profilaxis de la hemorragia digestiva en estos pacientes, pero se desconocen sus efectos cardiovasculares. El objetivo fue estudiar los cambios hemodinámicos producidos por la administración de omeprazol por vía intravenosa en niños críticos y analizar si existen diferencias entre 2 dosis diferentes de omeprazol. Material y métodos: Se realizó un estudio prospectivo observacional aleatorizado, que incluyó niños críticos entre un mes y 14 años de edad, que precisaban profilaxis de hemorragia digestiva. La muestra aleatoria fue de 37 pacientes de los cuales, 19 recibieron omeprazol por vía intravenosa 0,5mg/kg cada 12 h y 18 omeprazol por vía intravenosa 1mg/kg cada 12 h. La dosis correspondiente se administró en 20 min mediante bomba de infusión continua. Se recogieron la frecuencia cardiaca, presión arterial sistólica, media y diastólica, presión venosa central y el electrocardiograma basal, a los 15, 30, 60 y 120min de la infusión. Resultados: La edad media fue de 27,7±33,3 meses. Todos los pacientes recibieron dopamina y 14, adrenalina. No se produjeron modificaciones significativas en ninguna de las variables estudiadas. Ningún paciente precisó modificación del tratamiento inotrópico. No se objetivaron diferencias entre las 2 dosis de omeprazol. Conclusiones: El omeprazol por vía intravenosa es un fármaco hemodinámicamente seguro en niños críticos, a cualquiera de las 2 dosis utilizadas(AU)

Introduction: Critical patients usually have hemodynamic disturbances which may become worse by the administration of some drugs. Omeprazole is a drug used in the prophylaxis of the gastrointestinal bleeding in these patients, but its cardiovascular effects are unknown. The objective was to study the hemodynamic changes produced by intravenous omeprazole in critically ill children and to find out if there are differences between two different doses of omeprazole. Material and methods: A randomized prospective observational study was performed on 37 critically ill children aged from 1 month to 14 years of age who required prophylaxis for gastrointestinal bleeding. Of these, 19 received intravenous omeprazole 0.5mg/kg every 12hours, and 18 received intravenous omeprazole 1mg/kg every 12hours. Intravenous omeprazole was administered in 20minutes by continuous infusion pump. Heart rate, systolic, diastolic and mean arterial blood pressure, central venous pressure and ECG were recorded at baseline, and at 15, 30, 60 and 120minutes of the infusion. Results: There were no significant changes in the electrocardiogram, heart rate, blood pressure and central venous pressure. No patients required inotropic therapy modification. There were no differences between the two doses of omeprazole. Conclusions: Intravenous omeprazole administration of 0.5mg/kg and 1mg/kg is a hemodynamically safe drug in critically ill children(AU)

[Hemodynamic effects of intravenous omeprazole in critically ill children]. / Efectos hemodinámicos del omeprazol por vía intravenosa en niños en estado crítico.

INTRODUCTION: Critical patients usually have hemodynamic disturbances which may become worse by the administration of some drugs. Omeprazole is a drug used in the prophylaxis of the gastrointestinal bleeding in these patients, but its cardiovascular effects are unknown. The objective was to study the hemodynamic changes produced by intravenous omeprazole in critically ill children and to find out if there are differences between two different doses of omeprazole. MATERIAL AND METHODS: A randomized prospective observational study was performed on 37 critically ill children aged from 1 month to 14 years of age who required prophylaxis for gastrointestinal bleeding. Of these, 19 received intravenous omeprazole 0.5mg/kg every 12 hours, and 18 received intravenous omeprazole 1mg/kg every 12 hours. Intravenous omeprazole was administered in 20 minutes by continuous infusion pump. Heart rate, systolic, diastolic and mean arterial blood pressure, central venous pressure and ECG were recorded at baseline, and at 15, 30, 60 and 120 minutes of the infusion. RESULTS: There were no significant changes in the electrocardiogram, heart rate, blood pressure and central venous pressure. No patients required inotropic therapy modification. There were no differences between the two doses of omeprazole. CONCLUSIONS: Intravenous omeprazole administration of 0.5mg/kg and 1mg/kg is a hemodynamically safe drug in critically ill children.

[Evaluation of advanced medical simulation courses for training of paediatric residents in emergency situations]. / Evaluación de los cursos de simulación médica avanzada para la formación de los médicos residentes de pediatría en situaciones de emergencia.

OBJECTIVE: To analyse the usefulness of simulation courses in paediatric emergencies in a new training program for paediatrics residents. METHODS: An advanced simulation course with practical cases of paediatric emergencies was designed. Assessment of each clinical case was rated from 1 to 5 in the following sections: organization and coordination of team work, physician orders, monitoring, clinical examination, treatments, interpretation of laboratory tests, parent information, and global evaluation. The results were compared by year of residency of the participants. Student satisfaction with the course was assessed through a survey. RESULTS: There were six courses of simulation with 55 residents, of whom 29% were second-year residents (R2), 47% third year (R3), and 23% fourth year (R4). The median global score was 3.4 (IR: 3.2 to 3.7). The highest score was the initial monitoring (median: 4; IR: 4 to 4.3) and the initial medical examination (median: 4; IR: 3.4 to 4.2). The worst aspect was the information to the parents (median: 3; IR: 2.3 to 3.4). There were no significant differences in the global score according to the year of residency. The residents felt very positive about simulation courses, emphasizing the realism and practicality. CONCLUSIONS: The inclusion of advanced simulation courses in paediatric emergencies in the training program of paediatric residents is a useful educational method, and is appreciated by residents.

[Use of laser Doppler to assess peripheral tissue perfusion in critically ill children]. / Evaluación de la perfusión tisular periférica mediante láser Doppler en niños en estado crítico.

OBJECTIVE: To analyze skin tissue perfusion at different sites in critically ill children. PATIENTS AND METHODS: A prospective observational study was performed on 41 critically ill children with a median age of 12 months and weight of 8.2 kg. Skin tissue flow was measured in each patient using laser Doppler consecutively in the foot, forearm, thigh and hypochondrium, and its association with demographic and hemodynamic variables, as well as lactate and inotropic index, was analyzed. RESULTS: A total of 144 tissue flow measurements were made, with a median flow of 3.2±2.2 ml/min/100 g tissue. There was a moderate correlation between the tissue flow measured in central locations, abdomen-arm (r(2): 0.574, P=.001), abdomen-thigh (r(2): 0.423, P=.002) and thigh-arm (r(2): 0.703, P<.000), but not with the peripheral measurements (sole of the foot). The limits of agreement, measured between the different locations, were wide (range 6.1 to -2.5 ml/min/100g). There was a slight-moderate correlation between the flow in the sole of the foot with weight (-0.355, P=.039), age (-0.343, P=.044), peripheral temperature (0.503, P=.017) and inotropic index (-0.443, P=.008). CONCLUSIONS: Tissue flow in the foot correlates with weight, age, peripheral temperature and inotropic index. Further studies are needed to analyze its usefulness in assessing peripheral perfusion in situations of shock.

Medición del volumen corriente en ventilación de alta frecuencia / Measuring tidal volume during paediatric oscillatory and jet high-frequency ventilation

Objetivo: Valorar si un espirómetro puede medir el volumen corriente en ventilación de alta frecuencia oscilatoria (VAFO) y por jet (VAFJ) y analizar el efecto de los cambios en los parámetros del respirador. Métodos: Se realizó un estudio con pulmones de prueba pediátricos y en cerdos. Para la VAFO se utilizó el respirador Sensormedics 3100BR y para la VAFJ el respirador Paravent PateR. La medición del volumen corriente (VC) se realizó con un espirómetro D-Fend. Se realizaron cambios en la frecuencia, amplitud y presión media en la vía aérea (PMVA), registrándose los cambios en el VC y las presiones. Resultados: El espirómetro midió el VC en los pulmones de prueba y en los cerdos, pero no pudo medir VC menores de 8 ml, cuando la amplitud era mayor de 55 cmH2O o la PMVA mayor de 30 cmH2O. En la VAFO existió una correlación entre la amplitud y el VC y en la VAFJ entre la presión y el VC. En ambos respiradores existió una correlación negativa entre la frecuencia y el VC. Conclusiones: El espirómetro D-Fend puede medir el volumen corriente durante la VAFO y la VAFJ, pero no es capaz de medir VC menores de 8 o cuando se utilizan amplitudes o presiones elevadas (AU)

Objective: To as certain whether a spirometer can measure tidal volume (TV) during high frequency oscillatory ventilation (HFOV) and high frequency jet ventilation (HFJV), and to analyse the effect of changes in ventilator settings. Methods: The study was performed with paediatric porcine lung models submitted to HFOV with a Sensormedics 3100 ventilator and HFJV with a Paravent Pate R ventilator connected to a D-Fend spirometer. Programmed frequency, amplitude, and mean airway pressure (MAP) were changed in the ventilator, and TV and pressures were recorded using the spirometer. Results: The spirometer measured TV in the paediatric lung models and piglets, but could not measure TV less than 8 ml, when the pressure amplitude was higher than 55 cmH2O or the MAP was higher than 30 cmH2O. With HFOV there was a correlation between amplitude and tidal volume, and a positive correlation between pressure and TV with HFJV. With both respirators there was a negative correlation between frequency and TV. Conclusions: The D-Fend spirometer can measure tidal volume and pressure during HFOV and HFJV. However, it does not work with volumes lower than 8 ml, and high amplitude or mean airway pressure (AU)

[Measuring tidal volume during paediatric oscillatory and jet high-frequency ventilation]. / Medición del volumen corriente en ventilación de alta frecuencia.

OBJECTIVE: To ascertain whether a spirometer can measure tidal volume (TV) during high frequency oscillatory ventilation (HFOV) and high frequency jet ventilation (HFJV), and to analyse the effect of changes in ventilator settings. METHODS: The study was performed with paediatric porcine lung models submitted to HFOV with a Sensormedics 3100 ventilator and HFJV with a Paravent Pat(e)(R) ventilator connected to a D-Fend spirometer. Programmed frequency, amplitude, and mean airway pressure (MAP) were changed in the ventilator, and TV and pressures were recorded using the spirometer. RESULTS: The spirometer measured TV in the paediatric lung models and piglets, but could not measure TV less than 8 ml, when the pressure amplitude was higher than 55 cmH(2)O or the MAP was higher than 30 cmH(2)O. With HFOV there was a correlation between amplitude and tidal volume, and a positive correlation between pressure and TV with HFJV. With both respirators there was a negative correlation between frequency and TV. CONCLUSIONS: The D-Fend spirometer can measure tidal volume and pressure during HFOV and HFJV. However, it does not work with volumes lower than 8 ml, and high amplitude or mean airway pressure.