Recomendaciones de consenso sobre el transporte de pacientes en ECMO de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) y la Sociedad Española de Cuidados Intensivos Pediátricos (SECIP) / Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Spanish Society of Pediatric Intensive Care (SECIP) consensus recommendations for ECMO transport

La evolución del tratamiento de oxigenación por membrana extracorpórea (ECMO) y en particular del transporte de los pacientes sometidos a él, ha cambiado de forma significativa en la última década y lo ha hecho de manera desigual en diferentes regiones. Se ha demostrado que la creación de centros de referencia especializados mejora los resultados. Por todo ello ha sido necesario crear redes de equipos especializados y el número de transportes secundarios de pacientes con este tratamiento está en aumento. Con el fin de mejorar la calidad del tratamiento y ofrecer una guía para los servicios que intervienen en estos transportes, los grupos de trabajo de transporte crítico de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) y la Sociedad Española de Cuidados Intensivos Pediátricos (SECIP) han realizado un trabajo conjunto de elaboración de estas recomendaciones, enfocadas a los siguientes aspectos: indicaciones, sistemas de centros de referencia, medios de transporte, características y equipamiento, equipos humanos, formación y seguridad clínica (AU)

The evolution of extracorporeal membrane oxygenation treatment and the transport of patients receiving this treatment has changed dramatically in the last decade unevenly in different regions. The creation of specialized referral centers has been shown to improve outcomes. For all these reasons, it has been necessary to create networks of specialized teams and the number of secondary transports of patients with this treatment is increasing. In order to improve the quality of treatment and offer a guide to the services involved in these transports, the critical transport working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Spanish Society of Pediatric Intensive Care (SECIP) have carried out a joint effort to prepare these recommendations, focused on the following aspects: indications, reference center systems, means of transport, characteristics and equipment, human teams, training and clinical safety (AU)

Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Spanish Society of Pediatric Intensive Care (SECIP) consensus recommendations for ECMO transport.

The evolution of extracorporeal membrane oxygenation treatment and the transport of patients receiving this treatment has changed dramatically in the last decade unevenly in different regions. The creation of specialized referral centers has been shown to improve outcomes. For all these reasons, it has been necessary to create networks of specialized teams and the number of secondary transports of patients with this treatment is increasing. In order to improve the quality of treatment and offer a guide to the services involved in these transports, the critical transport working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Spanish Society of Pediatric Intensive Care (SECIP) have carried out a joint effort to prepare these recommendations, focused on the following aspects: indications, reference center systems, means of transport, characteristics and equipment, human teams, training and clinical safety.

Safe intravenous administration in pediatrics: A 5-year Pediatric Intensive Care Unit experience with smart pumps. / Administración segura de medicamentos intravenosos en pediatría: 5 años de experiencia de una Unidad de Cuidados Intensivos Pediátricos con bombas de infusión inteligentes.

OBJECTIVES: To estimate the impact of smart pump implementation in a pediatric intensive care unit in terms of number and type of administration errors intercepted. DESIGN: Observational, prospective study carried out from January 2010 to March 2015 with syringe and great volumen infusion pumps available in the hospital. SETTING: A tertiary level hospital pediatric intensive care unit. PARTICIPANTS: Infusions delivered with infusion pumps in all pediatric intensive care unit patients. INTERVENTIONS: Design of a drug library with safety limits for all intravenous drugs prescribed. MAIN VARIABLES: Users' compliance with drug library as well as number and type of errors prevented were analyzed. RESULTS: Two hundred and eighty-three errors were intercepted during 62 months of study. A high risk drug was involved in 58% of prevented errors, such as adrenergic agonists and antagonists, sedatives, analgesics, neuromuscular blockers, opioids, potassium and insulin. Users' average compliance with the safety software was 84%. CONCLUSIONS: Smart pumps implementation has proven effective in intercepting high risk drugs programming errors. These results might be exportable to other critical care units, involving pediatric or adult patients. Interdisciplinary colaboration is key to succeed in this process.

Formación pediátrica para el desarrollo de actividades clínicas / Paediatric training for developing clinical activities

Resumen El farmacéutico, por su formación general en el ámbito de la Farmacia Hospitalaria, tiene la capacidad para analizar e implantar mejoras en los circuitos de prescripción, dispensación y administración de medicamentos, lo cual repercute en la mejora de la seguridad global en la utilización de medicamentos. El objetivo principal del farmacéutico pediátrico es mejorar la calidad asistencial del paciente mediante una atención individualizada a través de la validación de las prescripciones médicas y del seguimiento farmacoterapéutico, que permita una farmacoterapia efectiva, segura y eficiente. Esta revisión nace del fruto de una experiencia multidisciplinar entre el Servicio de Farmacia y la Unidad de Cuidados Intensivos Pediátricos, cuyos objetivos fueron analizar el papel del farmacéutico residente en la UCIP para establecer líneas de mejora en sus actividades que potencien el uso racional del medicamento y diseñar un programa docente para el farmacéutico pediátrico que pueda servir como modelo inicial para otros centros (AU)

The general training received by pharmacists in Hospital Pharmacy enables them to analyse and implement improvements in the prescription, dispensing and administration of medications. This may lead to an increase in the overall safety of the use of drugs. The main goal of the paediatric pharmacist is to improve patient care by greater attention to the individual via validation of medical prescriptions and pharmaceutical follow-up, leading to safe, effective and efficient pharmacotherapy. This is a multidisciplinary review by the Pharmacy Department and Paediatric Intensive Care Unit. The objectives were to analyse the role of a resident pharmacist in PICU to identify improvements to promote rational drug use, and to design a teaching program for paediatric pharmacists that may serve as a reference for other centres (AU)

[Paediatric training for developing clinical activities]. / Formación pediátrica para el desarrollo de actividades clínicas.

The general training received by pharmacists in Hospital Pharmacy enables them to analyse and implement improvements in the prescription, dispensing and administration of medications. This may lead to an increase in the overall safety of the use of drugs. The main goal of the paediatric pharmacist is to improve patient care by greater attention to the individual via validation of medical prescriptions and pharmaceutical follow-up, leading to safe, effective and efficient pharmacotherapy. This is a multidisciplinary review by the Pharmacy Department and Paediatric Intensive Care Unit. The objectives were to analyse the role of a resident pharmacist in PICU to identify improvements to promote rational drug use, and to design a teaching program for paediatric pharmacists that may serve as a reference for other centres.

[Evaluation of a paediatric critical care training program for residents in paediatrics]. / Evaluación de un programa de formación en cuidados intensivos pediátricos para residentes de pediatría.

OBJECTIVE: To evaluate a training program in paediatric critical care for residents in paediatrics. METHODS: Description of a paediatric critical care training program for residents in paediatrics. To evaluate the results of the program an initial, and final written test, an evaluation by the physician responsible for the program, a self-evaluation by the residents, and a written survey on the quality of the training program, were performed. RESULTS: From April 1998 to August 2009, 156 residents were included in the training program. All residents showed an improvement between the initial and final written test; initial score (5.6+/-1.2), final score (8.6+/-0.7) (P<0.001). Only 14.1% of the residents answered at least 70 % of the questions correctly in the initial test, compared with 96.6 % in the final test (P<0.001). The score in final test was significantly higher than the self-evaluation by the residents (6.7+/-1.2) and the evaluation by the tutor (6.9+/-0.9) (P<0.001). There were no differences between the practical self-evaluation by the residents (6.2+/-1.0) and the practical evaluation by the tutor (6.7+/-0.9). Residents considered the training program as adequate: theoretical education (8.5+/-0.8), resident handbook (9+/-0.9), practical training (8.3+/-1.0), investigation (7.6+/-2.0) and human relationship (9.2+/-0.9). CONCLUSIONS: This training program is an useful educational method for training paediatric intensive care residents. The evaluation of the training program is essential to improve the education in paediatric residents.

Evaluación de un programa de formación en cuidados intensivos pediátricos para residentes de pediatría / Evaluation of a paediatric critical care training program for residents in paediatrics

Objetivo: Evaluar los resultados de un programa de formación en cuidados intensivos pediátricos para residentes de Pediatría. Métodos: Se diseñó un programa de formación en cuidados intensivos pediátricos para médicos residentes de Pediatría y se evaluaron los resultados con una prueba teórica escrita inicial y final, una evaluación por el médico responsable, una autoevaluación de los residentes y una encuesta escrita sobre la calidad del programa. Resultados: Desde abril del 1998 hasta agosto de 2009, se incluyeron a 156 residentes en el programa de formación. Los residentes mostraron mejoría entre la evaluación teórica inicial (5,6±1,2) y la final (8,6±0,7) (p<0,001). Un 14,1% contestó correctamente al menos el 70 % de las preguntas de la evaluación inicial y un 96,6 % de la final (p<0,001). La puntuación teórica final fue significativamente más alta que la autoevaluación de los residentes (6,7±1,2) y la evaluación de los tutores (6,9±0,9) (p<0,001). No hubo diferencias entre la autoevaluación práctica de los residentes (5,8±1,3) y la evaluación práctica del tutor (6,7±0,9). Los residentes consideraron adecuado el programa formativo: formación teórica (8,5±0,8), manual de residentes (9±0,9), educación práctica (8,3±1,0), investigación (7,6±2,0) y trato humano (9,2±0,9). Conclusiones: El programa descrito es un método educativo útil para la formación teórica y práctica de los residentes de Pediatría en cuidados intensivos. La evaluación del programa de entrenamiento es esencial para mejorar la formación de los residentes de Pediatría (AU)

Objective: To evaluate a training program in paediatric critical care for residents in paediatrics. Methods: Description of a paediatric critical care training program for residents in paediatrics. To evaluate the results of the program an initial, and final written test, an evaluation by the physician responsible for the program, a self-evaluation by the residents, and a written survey on the quality of the training program, were performed. Results: From April 1998 to August 2009, 156 residents were included in the training program. All residents showed an improvement between the initial and final written test; initial score (5.6±1.2), final score (8.6±0.7) (P<0.001). Only 14.1% of the residents answered at least 70 % of the questions correctly in the initial test, compared with 96.6 % in the final test (P<0.001). The score in final test was significantly higher than the self-evaluation by the residents (6.7±1.2) and the evaluation by the tutor (6.9±0.9) (P<0.001). There were no differences between the practical self-evaluation by the residents (6.2±1.0) and the practical evaluation by the tutor (6.7±0.9). Residents considered the training program as adequate: theoretical education (8.5±0.8), resident handbook (9±0.9), practical training (8.3±1.0), investigation (7.6±2.0) and human relationship (9.2±0.9). Conclusions: This training program is an useful educational method for training paediatric intensive care residents. The evaluation of the training program is essential to improve the education in paediatric residents (AU)

[Prognostic factors for bronchiolitis complications in a pediatric intensive care unit]. / Factores pronósticos de evolución complicada en la bronquiolitis que requiere ingreso en cuidados intensivos pediátricos.

OBJECTIVE: To analyse the prognostic factors for complications in children with bronchiolitis admitted to a pediatric intensive care unit (PICU). PATIENTS AND METHOD: A retrospective study was performed on children with bronchiolitis admitted into a PICU between 2000 and 2006. Univariate and multivariate analysis were performed to study the prognostic factors of complications, mechanical ventilation requirements, mortality and PICU stays of more than 15 days. RESULTS: A total of 110 patients were studied, of whom 72 (65.5%) had high risk factors: prematurity (39.1%), cardiac disease (38.2%) and bronchopulmonary dysplasia (16.3%). A total of 82.7% of patients had complications; 26% need invasive mechanical ventilation and the mortality was 3.6%, and 16.4% stayed in PICU for more than 15 days. Factors associated with mechanical ventilation were the clinical Wood-Downes score and heart disease. A weight less than 5 kg was associated with complications; heart disease and invasive mechanical ventilation were associated with a longer PICU stay; prematurity and mechanical ventilation were associated with mortality. CONCLUSIONS: Children with bronchiolitis admitted into the PICU had a high frequency of complications, often needed mechanical ventilation and had long stays in the PICU, but the mortality is low. The best prognostic factors on admission into the PICU were the acute respiratory insufficiency score, the presence of heart disease and were premature at birth.

Factores pronósticos de evolución complicada en la bronquiolitis que requiere ingreso en cuidados intensivos pediátricos / Prognostic factors for bronchiolitis complications in a pediatric intensive care unit

Objetivos: analizar los factores pronósticos de evolución complicada de los niños con bronquiolitis aguda que requieren ingreso en cuidados intensivos pediátricos (UCIP). Pacientes y método: se realizó un estudio observacional retrospectivo de los niños con bronquiolitis ingresados en la UCIP entre 2000 y 2006. Se realizó un estudio univariable y multivariable para analizar los factores pronósticos de aparición de complicaciones, necesidad de ventilación mecánica, mortalidad e ingreso en UCIP mayor de 15 días. Resultados: se estudió a 110 pacientes; 72 (65,5%) tenían antecedentes personales de alto riesgo: prematuridad (39,1%), cardiopatía congénita (38,2%) y displasia broncopulmonar (16,3%). El 82,7% de los pacientes presentó complicaciones, el 26% precisó ventilación mecánica invasiva y el 3,6% murió. En un 16,4% de los pacientes el ingreso en UCIP fue mayor de 15 días. Los factores asociados a evolución complicada fueron el estado de gravedad clínico y la presencia de cardiopatía para la ventilación mecánica invasiva; el peso<5kg para las complicaciones; la cardiopatía y la necesidad de ventilación mecánica invasiva para larga duración de ingreso, y la ventilación mecánica invasiva y el antecedente de prematuridad para la mortalidad. Conclusiones: los niños con bronquiolitis que ingresan en UCIP presentan una elevada tasa de complicaciones, precisan frecuentemente ventilación mecánica, tienen una duración de ingreso prolongada, y su mortalidad es baja. Los factores que mejor predicen el pronóstico son la gravedad de la insuficiencia respiratoria en el momento de ingreso del niño en la UCIP, la presencia de cardiopatía y el antecedente de prematuridad (AU)

Objective: To analyse the prognostic factors for complications in children with bronchiolitis admitted to a pediatric intensive care unit (PICU). Patients and method: A retrospective study was performed on children with bronchiolitis admitted into a PICU between 2000 and 2006. Univariate and multivariate analysis were performed to study the prognostic factors of complications, mechanical ventilation requirements, mortality and PICU stays of more than 15 days. Results: A total of 110 patients were studied, of whom 72 (65.5%) had high risk factors: prematurity (39.1%), cardiac disease (38.2%) and bronchopulmonary dysplasia (16.3%). A total of 82.7% of patients had complications; 26% need invasive mechanical ventilation and the mortality was 3.6%, and 16.4% stayed in PICU for more than 15 days. Factors associated with mechanical ventilation were the clinical Wood-Downes score and heart disease. A weight less than 5kg was associated with complications; heart disease and invasive mechanical ventilation were associated with a longer PICU stay; prematurity and mechanical ventilation were associated with mortality. Conclusions: Children with bronchiolitis admitted into the PICU had a high frequency of complications, often needed mechanical ventilation and had long stays in the PICU, but the mortality is low. The best prognostic factors on admission into the PICU were the acute respiratory insufficiency score, the presence of heart disease and were premature at birth(AU)

[Early extubation with caudal morphine after pediatric heart surgery]. / Extubación precoz con morfina caudal tras cirugía cardíaca pediátrica.

OBJECTIVES: To analyze the viability of immediate extubation of children after corrective surgery for congenital heart defects with extracorporeal membrane oxygenation using an anesthetic technique involving caudal morphine, and to study the effect on length of stay in the pediatric intensive care unit (PICU) or elsewhere in the hospital. MATERIAL AND METHODS: Twenty-nine ASA I-II patients without coagulation alterations undergoing surgery to correct simple heart defects were selected for extubation after surgery. Anesthesia was provided with with sevoflurane, midazolam, rocuronium, fentanil (maximum dose 10 micrograms/Kg) and a bolus of caudal morphine (50-60 micrograms/Kg) after anesthetic induction. Patient characteristics, type of surgery, times of extracorporeal circulation and of ischemia, arterial blood gases upon arrival in the PICU, postoperative complications and quality of analgesia were the variables analyzed. We also compared length of stay in the PICU and hospital for the study group and for a historical control group of 23 patients who had no received caudal morphine or been selected for early extubation. RESULTS: All patients were extubated satisfactorily in the operating room. None required reintubation or reoperation. Postoperative pain was controlled with metamizol alone for 79.3%. No episodes of respiratory depression or neurological complications were observed. PICU and hospital stays were significantly shorter in the study group than in the control group. CONCLUSIONS: Of patients undergoing simple corrective heart surgery with extracorporeal membrane oxygenation immediate extubation did not increase postoperative morbimortality and shortened the hospital stay. A single dose of caudal morphine provided optimum conditions for extubation and good control of postoperative pain. Strict measures must be taken, however, to avoid postpuncture bleeding.

Extubación precoz con morfina caudal tras cirugía cardíacapediátrica / Early exttubation with caudal morphine after pediatric heart surgery

OBJETIVO: Analizar la viabilidad y la influencia en la estancia en la Unidad de Cuidados Intensivos Pediátricos (UCIP) y en el hospital de la extubación inmediata de niños sometidos a corrección de cardiopatías congénitas bajo circulación extracorpórea (CEC) utilizando una técnica anestésica basada en la administración de morfina caudal. MATERIAL Y MÉTODOS: 29 pacientes ASA I-II, sin alteraciones de la coagulación y sometidos a corrección de una cardiopatía simple, fueron seleccionados para ser extubados tras la intervención. La anestesia se realizó con sevoflurano, midazolam, rocuronio, fentanilo (dosis máxima de 10 µg/Kg) y bolo de morfina caudal (50-60 µg/Kg) tras la inducción anestésica. Se analizaron las variables demográficas, tipo de cirugía, tiempo de CEC y de isquemia, gasometría arterial a su llegada a UCIP, complicaciones postoperatorias y grado de analgesia. Asimismo se compararon las estancias en la UCIP y en el hospital con las de un grupo control histórico de 23 pacientes a los que no se administró morfina caudal ni hubo intencionalidad de conseguir su extubación precoz. RESULTADOS: Todos los pacientes fueron extubados satisfactoriamente en quirófano. Ninguno requirió reintubación o reintervención. En el 79,3 por ciento de los casos el dolor se controló sólo con metamizol durante el postoperatorio. No se registraron episodios de depresión respiratoria ni complicaciones neurológicas. La estancia en UCIP y hospitalaria fueron significativamente más bajas que en el grupo control. CONCLUSIONES: La extubación inmediata de pacientes intervenidos por cardiopatía simple bajo CEC no aumentó la morbimortalidad postoperatoria y acortó la estancia hospitalaria. La morfina caudal en dosis única proporcionó unas condiciones óptimas para la extubación y un buen control del dolor postoperatorio, aunque deben extremarse las precauciones para prevenir un sangrado postpunción (AU)

[Nitric oxide treatment in children: clinical course, toxicity and factors influencing its effects]. / Tratamiento con óxido nítrico en niños: evolución clínica, toxicidad y factores que influyen en la respuesta.

OBJECTIVE: The purpose of this study was to analyze the clinical evolution, acute toxicity and factors which influence the response to nitric oxide treatment in children. PATIENTS AND METHODS: We studied prospectively 25 children, 14 boys and 11 girls, between 15 days and 16 years of age. Seventeen patients were diagnosed with ARDS and 8 with PHT. All patients presented hypoxemia and/or PHT refractory to conventional therapy and were treated with inhaled NO (1.5 to 45 ppm) between 45 minutes to 47 days. We studied the secondary effects, morbidity and mortality, and analyzed the relationship between NO effects and age, sex, diagnosis, infection, previous PaO2/FiO2 ratio, previous oxygenation index and previous mean pulmonary arterial pressure (mPAP)/mean systemic arterial pressure (mSAP). RESULTS: The effect of NO was maintained during the time of administration without tachyphylaxis. There were no secondary effects of NO administration. NO2 was always < 2 ppm and metahemoglobinemia was below 3.5%. There was no relationship between the effect of NO and the rest of the factors analyzed. Twelve patients (48%) survived, 9 of the children with ARDS (53%) and 3 of the children with PHT (38%). Eleven of the 21 patients who improved with NO treatment survived (52%), as did 1 of the 4 patients who did not improve (25%). CONCLUSIONS: Prolonged administration of inhaled NO at low concentrations maintains the improvement of oxygenation and pulmonary hypertension without acute secondary effects. We have not found factors that could predict the clinical response to NO.