Pediatric Disseminated Lemierre Syndrome in 2 Infants: Not Too Young for an Ancient Disease.

The Lemierre syndrome is characterized by an oropharyngeal infection, thrombosis of the internal jugular vein, and multiple septic metastases. Fusobacterium necrophorum is a common cause of it. The incidence is 0.6 to 2.3 cases per million with a mortality rate of 4% to 18%. Its fast evolution and the possibility of severe complications require a high index of suspicion for its diagnosis. We present 2 infants with Lemierre syndrome. The younger case, a 6-month-old infant, was fully recovered. In the other side, and despite an aggressive therapy, an 18-month-old infant developed cerebral palsy. We also provide a short literature review with a focus on clinical presentation and differential diagnosis in order to initiate an early and adequate therapy.

Early postoperative complications of intracranial tumors in children.

BACKGROUND: The aim of this study was to describe the complications experienced by patients after central nervous system tumor resection during pediatric intensive care Unit (PICU) admission. Our attempt was to assess the association between epidemiological, clinical data and tumor characteristics prior to surgery and presence of postoperative complications. METHODS: We design an observational, descriptive and retrospective study by review of medical records. Patients aged 0-18 years, admitted to the PICU of our hospital, after surgery for tumor resection in the central nervous system. RESULTS: We collected a total of 145 postoperative. At PICU, 48.3% of the patients (70/145) had some type of postoperative complication. It they were, in order of frequency: a new neurological deficit at discharge (29%, 42/145), pneumocephalus (21%, 30/145), electrolyte disturbances (17.9%, 26), infection (16.6%, 24), anemia (8.3%, 12), seizures (7.6%, 11), endocrine disorders (7.6%, 11), intracranial hypertension (5.5%, 8) and stroke (7, 4.8%). One patient died. There was no difference in overall complication and the tumor site. However, supratentorial tumors had less need for MV (73% vs. 92%, P=0.002, OR 2.7 [1.2-6.1]), shorter duration for MV (11 hours vs. 48 hours, P=0.02), lower frequency of neurological deficit (22% vs. 37%, P=0.004, OR 1.4 [1-2.1]) and cerebrospinal fluid fistula (1% vs. 13%, P=0.004, OR 2.1 [1.6- 2.8]). They were more frequent seizures (13% vs. 2%, P=0.024, OR 1.8 [1.4-2.3]), central diabetes insipidus (17% vs. 0%, P<0.001, OR 4.3 [1.6-11.7]) and endocrine disruption (14% vs. 0%, P=0.001, OR 2 [1.7-2.4]). CONCLUSIONS: The intracranial tumors surgery requires monitoring in intensive care because the risk of postoperative complications is high. The tumor location is related to the occurrence of some of these complications.

Respiratory Failure in Children With Hemato-oncological Diseases Admitted to the PICU: A Single-center Experience.

Respiratory failure (RF) is a main cause of pediatric intensive care unit (PICU) admission in children with hemato-oncological diseases. We present a retrospective chart review of children admitted to our PICU because of RF (January 2006 to December 2010). The aims of this study are the following: (1) to describe the demographical and clinical characteristics and respiratory management of these children; and (2) to identify the factors associated with mechanical ventilation (MV) and mortality. A total of 69 patients, encompassing 88 episodes, were included (55/88 cases were hypoxemic RF). The first respiratory support at PICU admission was, in decreasing order of frequency, high-flow oxygen nasal cannula (HFNC; 50/88), noninvasive ventilation (NIV; 13/88), and oxygen nasal cannula (16/88). MV was necessary in 47/88 episodes, 38/47 after another respiratory support. In 18/28 children with initial NIV, MV was required later. MV was associated with O-PRISM score, NIV requirement, suspected respiratory infection, and days of PICU treatment. Patients without MV showed an increased survival rate (P=0.001). In summary, the hypoxemic RF was the main cause of PICU admission, and HFNC or NIV was almost always the first respiratory support. The use of MV was associated with a higher mortality rate. The utility of precocious HFNC or NIV should be investigated in larger clinical studies.

Serum sRAGE as a potential biomarker for pediatric bronchiolitis: a pilot study.

PURPOSE: Traditional inflammatory biomarkers are insufficient for the evaluation of bronchiolitis severity. Recent investigations have shown that the receptor for advanced glycation end product (RAGE) and its soluble isoforms (sRAGE) play a critical role in the pathogenesis of lung injury. Main objective was to assess the serum levels of sRAGE of children with severe bronchiolitis admitted to the pediatric intensive care unit (PICU). Secondary objective was to study sRAGE correlation with the evolution and traditional biomarkers. METHODS: Prospective, observational and descriptive study, 43 healthy controls and 37 patients (December 2011-February 2012) were enrolled. sRAGE levels were assessed and compared. In patients, the relation between sRAGE levels and clinical evolution, respiratory assistance, white blood cell count, absolute neutrophils count, serum C-reactive protein, and serum procalcitonin was analyzed. RESULTS: A statistical difference was found in the mean value of sRAGE at PICU admission between patients and controls (1,215.7 ± 535 vs 849 ± 579 pg/ml). Also a significant inverse correlation was found between sRAGE and the Wood-Downes Score at admission (p = 0.02). CONCLUSIONS: Serum sRAGE could be elevated in children with bronchiolitis. Larger clinical studies are necessary to elucidate its role as a bronchiolitis inflammatory and/or lung injury biomarker.

Effects of local administration of allogenic adipose tissue-derived mesenchymal stem cells on functional recovery in experimental traumatic brain injury.

OBJECTIVE: Traumatic brain injury (TBI) is the leading cause of mortality and morbidity in paediatric patients after the first year of life. The aim of this study was to evaluate effects of locally administered allogeneic mesenchymal stem cells (MSC), in the acute period after a TBI. METHODOLOGY: MSC were isolated from peritoneal fat of healthy rats, expanded in vitro and labelled with the green fluorescent protein. Rats were placed in one of three experimental groups: (1) CONTROL: TBI, (2) IP-CONTROL: TBI + local saline and (3) IP-Treat: TBI + 2 × 10(5) MSC 24 hours after receiving a moderate, unilateral, controlled cortical impact. Motor and cognitive behavioural tests were performed to evaluate functional recovery. Histological examination and immunohistochemistry were used to identify cell distribution. MAIN RESULTS: Improved performance was found on motor tests in the MSC-treated group compared to control groups. MSC were found in the perilesional area and their number decreased with time after transplantation. MSC treatment increased the cell density in the hippocampus (CA3 pyramidal cells and granule cells in the dentate gyrus) and enhanced neurogenesis in this area. CONCLUSION: MSC cell therapy resulted in better recovery of motor function compared with the control group. This cellular therapy might be considered for patients suffering from TBI.

Management of unstable pediatric hemato-oncology patient: results of a Web-based survey to pediatric oncologists in Spain.

UNLABELLED: The current management and monitoring of unstable pediatric hemato-oncology patient (UPHOP) in the oncology ward is not well defined. To evaluate this concept, an anonymous Web-based survey was sent to the 150 Spanish pediatric oncologists registered in the Spanish Society of Pediatric Hemato-Oncology. The response rate was 57 %, with the following main results: Pediatric intensive consulting was available for 97 %, and it was made in case of UPHOP by 37 % of oncologists, up to 65 % if hemodynamic instability. In case of inotropic support initiation, 32 % of respondents never consulted the intensivist. Dopamine is first chosen inotropic; 28 % of surveyed considered there is no limit in its dosage or it is superior to 20 µg/kg/min before an intensivist consulting. Pediatric intensive care admission was considered necessary in case of fever with hemodynamic instability by 15 % of respondents. Respiratory monitoring was mainly done by clinical signs (67 %). In case of respiratory insufficiency, the noninvasive respiratory support by high-flow ventilation with nasal cannula was applied by 57 % in the oncology ward. In case of acute kidney injury, diuretics were generally the initial therapy. The anticonvulsive drugs most frequently applied were valproic acid (93 %), diazepam (88 %), and phenytoin (81 %). CONCLUSION: A consensus should be achieved among oncologists and intensivists. The creation and training of rapid response teams could be useful to improve the UPHOP management.

C-reactive protein and procalcitonin are predictors of the severity of acute appendicitis in children.

OBJECTIVE: The aim of this study was to evaluate the use of procalcitonin (PCT) and C-reactive protein (CRP) on admission as predictors of the severity of appendicitis in children. METHODS: We prospectively studied 111 consecutive patients admitted with a diagnosis of acute appendicitis between July 2009 and February 2010 and recorded the following variables: age, sex, time since diagnosis, laboratory data, complications (abscess, intestinal obstruction), presence of hemodynamic instability, mortality, length of stay, and need for admission to the pediatric intensive care unit. Patients were divided into 2 groups according to the diagnosis confirmed during surgery (group 1, appendicitis; group 2, localized or generalized peritonitis). RESULTS: Group 1 comprised 69 patients, and group 2 comprised 42 patients. Procalcitonin and CRP values were significantly lower in group 1 than in group 2 (0.15 vs 4.95 ng/mL [P < 0.001] and 3 vs 14.3 mg/dL [P < 0.001]). For a diagnosis of peritonitis, a PCT cutoff of 0.18 ng/mL gave a sensitivity of 97%, specificity of 80%, positive predictive value of 72%, and negative predictive value of 89.3%. The equivalent values for a CRP cutoff of 3 mg/dL were 95%, 74%, 68%, and 96.2%. Complications and the need for admission to the pediatric intensive care unit were more common in patients with peritonitis. CONCLUSIONS: On admission, CRP and PCT predict the outcome of pediatric patients with appendicitis. Children with CRP greater than 3 mg/dL and/or PCT greater than 0.18 ng/mL have a greater risk of complications; thus, intervention should be early, and patients should be monitored closely.

Decompressive craniectomy in 14 children with severe head injury: clinical results with long-term follow-up and review of the literature.

BACKGROUND: Decompressive craniectomy (DC) is a controversial therapeutic measure used in patients with intractable intracranial hypertension after severe head injury. This study describes the morbidity and mortality of DC in 14 children with a mean follow-up of 3.2 years. We review published evidence from the past 10 years on the indications for DC in pediatric brain trauma. We also examine timing, surgical technique, and the results of this procedure. METHOD: We retrospectively reviewed patients who underwent DC from 2002 to 2010. Clinical data were collected at admission, as were data on the indication for craniectomy, timing, and surgical technique. Perioperative intracranial pressure (ICP), complications of craniectomy, and Glasgow Outcome Scale score at 2 years were recorded as outcome variables. RESULTS: Fourteen craniectomies were performed. The median presenting Glasgow Coma Scale score was 6.5 (range, 4-15). Ten patients were presented with anisocoria. In 13 patients, craniectomy initially decreased ICP to <25 mm Hg. Two patients (14%) had a poor prognosis on admission and died. The most frequent complications were hygroma (8 patients) and infections (3 patients). The mean Glasgow Outcome Scale score at the 2-year follow-up visit was 4.4 (range, 4-5). Behavioral and psychiatric abnormalities and poor academic performance were frequent (82%). CONCLUSIONS: DC reduces ICP in pediatric patients with traumatic brain injury. The mortality rate is low and long-term prognosis in survivors is good. Complications related to surgery are frequent. Wide craniectomy with duraplasty seems to be the most common technique. Defining the most appropriate indications and timing for DC in pediatric patients should be the objective of future prospective studies.

Usefulness of pneumococcal antigen detection in pleural effusion for the rapid diagnosis of infection by Streptococcus pneumoniae.

Pleural effusion is increasingly reported in children. Standard culture of blood or pleural fluid is frequently negative and molecular diagnosis by polymerase chain reaction is not available in all hospitals. The Binax NOW Streptococcus pneumoniae Antigen test (Binax, Portland, USA) is a rapid immunochromatographic test (ICT) for the detection of the C polysaccharide antigen. We evaluated the Binax NOW test on the pleural fluid of 73 children hospitalized with pleural effusion over a period of 4 years. In our sample, the sensitivity and specificity of ICT were high (88% and 71%, respectively), with a positive predictive value of 96%. Detection of the pneumococcal antigen in pleural fluid by ICT is easy and quick, and enables us to identify the pneumococcal origin of the effusion, thus, making the treatment of complicated pneumonia suitably and early.

Retrospective Study in Children With Necrotizing Pneumonia: Nine Years of Intensive Care Experience.

BACKGROUND: Although necrotizing pneumonia (NN) is one of the most feared complications of community-acquired pneumonia, data in pediatric patients are scarce. The objective of this article is to describe children admitted to pediatric intensive care unit (PICU) because of NN. METHODS: Retrospective-prospective observational study in children admitted with NN to PICU (from January 1, 2010, to December 31, 2018). The data collected included information on disease epidemiology, PICU management, respiratory assistance and disease evolution. RESULTS: Fifty-one children were included, 42 of 51 had received 7-valent or 13-valent pneumococcal vaccine. Median age was 3.2 years (1.9-4.2), 15 of 51 had signs of sepsis at admission. Forty-nine patients presented pleural effusion with drainage in 46. The most common respiratory support modality was high-flow oxygen nasal cannula (17/51). Computed tomography was the gold standard for diagnosis. Etiologic diagnosis was obtained in 34 of 51, and pneumococcus was isolated in 29 of 34. In all of these cases, initial detection was made by capsular antigen in pleural fluid. Children with pneumococcal NN had fewer days of evolution prior to PICU admission (P = 0.041). Cefotaxime with clindamycin was used in 49 of 51. Surgery was necessary in 3 of 51 patients. After PICU discharge, only 5 of 51 were readmitted. There were deaths. CONCLUSIONS: In our study, the NN was mainly observed in children around 3 years old. The main causal agent was pneumococcus. The evolution towards NN appeared to be faster than in case of other etiologies. Surgery management was unusual. All children required prolonged admissions but had a full clinical recovery.

Impact of 13-valent pneumococcal conjugate vaccination on invasive pneumococcal disease in children under 15 years old in Madrid, Spain, 2007 to 2016: The HERACLES clinical surveillance study.

Streptococcus pneumoniae is a major cause of morbidity and mortality worldwide. Using the data from the HERACLES clinical surveillance study (2007-2016), we describe the population impact of the 13-valent pneumococcal conjugate vaccine (PVC13) on invasive pneumococcal disease (IPD) in children <15 years of age in the Community of Madrid, Spain. After six years of the inclusion of PCV13 in the vaccination calendar (2010-2016), and despite changes in the Regional Immunization Programme that limited its availability, the net benefit incidence rate (IR) of IPD fell by 70.1% (IRR 0.3 [95% CI: 0.22-0.4]; p ≤ 0.001), mainly due to a significant reduction (91%) in the PCV13 serotypes (IRR 0.09 [95% CI: 0.05-0.16], p ≤ 0.001). Furthermore, no significant changes were detected in the IR of IPD caused by non-PCV13 serotypes. The IRs of the aggressive, resistant and most prevalent serotype in the analysed population, the 19A serotype, dramatically decreased from the beginning to the end of the study (98%) [IRR 0.03 (95% CI: 0.00-0.19), p ≤ 0.001], to its almost total disappearance. Remarkably, this reduction led to a pronounced decline in the percentage of cefotaxime-resistant isolates and the incidence of meningitis cases. Assessment of the clinical impact revealed a reduction in the number of all clinical presentations of IPD, confirming the effectiveness of the PCV13. Finally, PCV13 detected by PCR is predicted to have a stronger impact than the one based on culture methods, which can overlook more than 20% of cases of IPD, mainly pleural empyemas.

Decline in pneumococcal meningitis in Spain after introduction of the heptavalent pneumococcal conjugate vaccine.

All patients < or =14 years old with a diagnosis of pneumococcal meningitis (n = 160) were included (2001, 2004-2006). Incidence per 100,000 child <5 years old varied from 6.14 in 2001 to 2.83 in 2006 (54% of reduction, P < 0.01). There was a significant correlation (R2 = 0.9506) with PCV7 distribution increase. No significant changes in the incidence by nonvaccine serotypes were found when comparing 2001 and 2006. The case fatality rate was 7.5%.

Circulating soluble RAGE and cell surface RAGE on peripheral blood mononuclear cells in healthy children.

BACKGROUND: The receptor for advanced glycation end products (RAGE) has a critical role in the pathogenesis of inflammation. In healthy children, its basal expression on the peripheral blood mononuclear cell (PBMC) and the basal circulating soluble RAGE (sRAGE) levels are unknown. The aim of this study was to describe both. METHODS: This is a monocentric, observational and descriptive study of samples obtained from healthy children. The RAGE expression on PBMC was analyzed using flow cytometry. The sRAGE values were determined with a specific sandwich enzyme-linked immunosorbent assay (ELISA) kit, later the relation between cellular RAGE and sRAGE was described. RESULTS: Forty-three children were included. The median sRAGE level was 849.0±579.0 pg/mL. The RAGE mean fluorescence intensity (MFI) was 1382±506 in monocytes and 792±506 in lymphocytes. There were no differences between genders. A negative correlation was found between sRAGE and RAGE MFI in lymphocytes (r=-0.3; p=0.04). CONCLUSIONS: We describe for the first time the RAGE surface levels on PBMC in children. It showed a negative correlation with sRAGE. The sRAGE circulating level is lower than the sRAGE level described in adult population or non-healthy children. Our findings should be confirmed in order to apply them as reference values for future investigations.

CD64 on monocytes and granulocytes in severe acute bronchiolitis: Pilot study on its usefulness as a bacterial infection biomarker.

The CD64 receptor has been described as a biomarker of bacterial infection. We speculated that CD64 surface expression on monocytes and granulocytes of children with severe acute bronchiolitis (SAB) could be altered in cases of probable bacterial infection (PBI) determined using classical biomarkers (procalcitonin and C-reactive protein, leukocyte count, and radiographic findings). A prospective observational pilot study was conducted from October 2015 to February 2016 in children admitted for pediatric critical care. A blood sample was taken in the first 24 hours of admission, and CD64 was measured by flow cytometry. The values obtained were analyzed and correlated with traditional biomarkers of PBI. Thirty-two children were included; a correlation was found between CD64 expression and the PBI criteria. CD64 surface expression was higher in children with PBI (area under the receiver operating characteristic curve of 0.73; P = 0.042) and the percentage of CD64+ granulocytes was higher in children with PBI. This is the first study to describe CD64 surface expression on monocytes and granulocytes in SAB, finding CD64 values to be higher in children with PBI. Larger clinical studies are needed to elucidate the real accuracy of CD64 as a biomarker of bacterial infection.

Infectious complications of percutaneous central venous catheterization in pediatric patients: a Spanish multicenter study.

OBJECTIVE: Analysis of infectious complications and risk factors in percutaneous central venous catheters. DESIGN: One-year observational, prospective, multicenter study (1998-1999). SETTING: Twenty Spanish pediatric intensive care units. PATIENTS: Eight hundred thirty-two children aged 0-14 years. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: One thousand ninety-two catheters were analyzed. Seventy-four (6.81%) catheter-related bloodstream infections (CRBSI) were found. The CRBSI rate was 6.4 per 1,000 CVC days (95% CI 5.0-8.0). Risk factors for CRBSI were weight under 8 kg (p < 0.001), cardiac failure (RR 2.69; 95% CI 1.95-4.38; p < 0.001), cancer (RR 1.66; 95% CI 0.97-2.78; p=0.05), silicone catheters (RR 2.82; 95% CI 1.49-5.35; p = 0.006), guidewire exchange catheterization (p=0.002), obstructed catheters (RR 2.67; 95% CI 1.63-4.39; p<0.001), and more than 12 days' indwelling time (RR 5.9; 95% CI 3.63-9.41; p<0.001). Multivariate Cox regression identified lower patient weight (HR 2.4; 95% CI 1.11-5.19; p=0.002), guidewire exchange catheterization (HR 2.2; 95% CI 1.07-4.54; p=0.049) and more than 12 days' indwelling time (HR 1.97; 95% CI 0.89-4.36; p=0.089) as significant independent predictors of CRBSI. Factors which protected against infection were the use of povidone-iodine on hubs (HR 0.42; 95% CI 0.19-0.96; p=0.025) and porous versus impermeable dressing (HR 0.41; 95% CI 0.23-0.74; p=0.004). Two children (0.24%) died from endocarditis following catheter-related sepsis due to Stenotrophomonas maltophilia in one case and P. aeruginosa in the other. CONCLUSIONS: Catheter-related sepsis is associated with lower patient weight and more than 12 days' indwelling time, but not with the insertion site. Cleaning hubs with povidone-iodine protects from infection.

Effect of the different 13-valent pneumococcal conjugate vaccination uptakes on the invasive pneumococcal disease in children: Analysis of a hospital-based and population-based surveillance study in Madrid, Spain, 2007-2015.

In the Community of Madrid, the 13-valent pneumococcal conjugate vaccine (PCV13) replaced the 7-valent (PCV7) in the fully government-funded Regional Immunization Program (RIP) in May, 2010, but was later excluded in May, 2012, and included again in January, 2015. These unique changes allowed us to assess the impact of the different pneumococcal vaccination policies on PCV13 uptake in infants and on the incidence rate (IR) of invasive pneumococcal disease (IPD) in children <15 years old. In this prospective, active, surveillance study, we estimated PCV13 uptakes, IR and incidence rate ratios (IRR) for total IPD and for IPD caused by PCV13- and non-PCV13 serotypes in children <15 years, stratified by age, in four periods with different vaccination policies: fully government-funded PCV7 vaccination, fully government-funded PCV13, mixed public/private funding and only private funding. Vaccine uptakes reached 95% in periods with public-funded pneumococcal vaccination, but fell to 67% in the private funding period. Overall, IR of IPD decreased by 68% (p<0.001) in 2014-15, due to 93% reduction in the IR of PCV13-type IPD (p<0.001) without significant changes in non-PCV13-type IPD. A fully government-funded PCV13 vaccination program lead to high vaccine uptake and dramatic reductions in both overall and PCV13-type IPD IR. When this program was switched to private PCV13 vaccination, there was a fall in vaccine coverage and stagnation in the decline of PCV13-type IPD with data suggesting a weakening of herd immunity.

Impact of 13-valent pneumococcal conjugate vaccine on pneumococcal meningitis in children.

OBJECTIVES: To evaluate the impact of 13-valent pneumococcal conjugate vaccine on pneumococcal meningitis in children. METHODS: Children younger than 15years of age attending 27 hospitals in the Region of Madrid with confirmed pneumococcal meningitis were identified in a prospective surveillance study, from 2007 to 2015. Clinical data, neurological sequelae, pneumococcal vaccination status, serotyping and antibiotic susceptibility were recorded. RESULTS: One hundred and four cases of pneumococcal meningitis were identified, 63 during the period of routine 7-valent pneumococcal conjugate vaccine immunisation (May 2007-April 2010) and 41 during the period of 13-valent pneumococcal conjugate vaccine immunisation (May 2010-April 2015). When both periods were compared, a 62% (95% CI: 45-75%) decrease in the incidence of pneumococcal meningitis was observed, from 2.19 cases per 100,000 inhabitants in the PCV7 period to 0.81 per 100,000 inhabitants in the PCV13 period (p=0.0001), mainly due to an 83% (95% CI: 30-96%) reduction in cases caused by serotype 19A. Isolates not susceptible to cefotaxime (MIC>0.5µg/L) decreased from 27% to 8%, (p=0.02). Mean patient ages rose from 28.7months to 38.5months (p<0.05). Case fatality rate across both periods was 5%. An unfavourable outcome (death or neurological sequelae) occurred in 27% of patients, while the rate was similar in both periods. There was no increase in meningitis caused by pneumococcal serotypes not included in 13-valent pneumococcal conjugate vaccine throughout the years of the study. CONCLUSIONS: Immunisation with 13-valent pneumococcal conjugate vaccine has reduced the rate of pneumococcal meningitis in children less than 15years, with a near-elimination of cefotaxime-resistant isolates, but morbidity has remained unchanged. A shift of pneumococcal meningitis towards slightly higher age groups was also observed.

Cerebral salt wasting syndrome in children with acute central nervous system injury.

The purpose of this investigation was to describe the causes, clinical pattern, and treatment of cerebral salt wasting syndrome in children with acute central nervous system injury. This retrospective study focused on patients120 mEq/L), and volume depletion. Fourteen patients were identified with cerebral salt wasting syndrome, 12 after a neurosurgical procedure (8 brain tumor, 4 hydrocephalus) and 2 after severe brain trauma. In 11 patients the cerebral salt wasting syndrome was diagnosed during the first 48 hours of admission. Prevalence of cerebral salt wasting syndrome in neurosurgical children was 11.3/1000 surgical procedures. The minimum sodium was 122+/-7 mEq/L, the maximum urine osmolarity 644+/-59 mOsm/kgH2O. The maximum sodium supply was 1 mEq/kg/h (range, 0.1-2.4). The mean duration of cerebral salt wasting syndrome was 6+/-5 days (range 1-9). In conclusion, cerebral salt wasting syndrome can complicate the postoperative course of children with brain injury; it is frequently present after surgery for brain tumors and hydrocephalus and in patients with severe head trauma. Close monitoring of salt and fluid balance is essential to prevent severe neurologic and hemodynamic complications.

[Critically ill pediatric hemato-oncology patient: What we do is what we should do?]. / Paciente crítico oncohematológico, ¿hacemos lo que deberíamos hacer?

OBJECTIVE: Primary objective, to describe the management and monitorization of critically ill pediatric hemato-oncology patient (CIPHO) in the Spanish pediatric intensive care units (PICU). Secondary objective, through a literature review, to identify possible areas of improvement. MATERIAL AND METHODS: Observational transversal descriptive study. An anonymous web-based survey was sent to 324 Spanish pediatric intensivists from April 2011 to May 2011. None of them were pediatric residents. RESULTS: The survey was answered by 105 intensivists, 59/105 always agreed their treatment with the oncologist. In case of hemodynamic instability, non-invasive blood pressure monitoring is always done by 85/105 and almost always optimized by intra-arterial measuring (85/105) and central venous pressure (70/105). If respiratory failure the use of non-invasive ventilation (NIPPV) is always (36/105) or frequently (60/105) established prior to conventional mechanical ventilation. To replace or withdraw non-invasive ventilation only 44/96 of the respondents to this question use a clinical protocol. Before the instauration of conventional mechanical ventilation the oncological prognosis is considered by 72/105. In case of acute oliguric renal failure the renal replacement techniques are widely used (74/105). The withdrawal of sustaining life support is frequently discussed (75/103) and agreed with the oncologist (91/103) and caregivers (81/103). CONCLUSIONS: In our study, despite there is not a defined standard-of-care, the respondents showed similar therapeutics and monitorization choices. The use of NIPPV as first respiratory assistance is extended. Prospective, observational and multicenter studies should be developed to establish the results of this management in this population.

Pediatric ARDS: effect of supine-prone postural changes on oxygenation.

OBJECTIVE: To determine the effect of repeated prone positioning (supine-prone/prone-supine) on oxygenation in children suffering from ARDS. DESIGN: Single-center prospective case series. SETTING: University pediatric ICU. PATIENTS: Consecutive pediatric patients with severe ARDS (PaO(2)/FiO(2) <200, Murray score >2.5). INTERVENTIONS: Patients were treated as soon as possible with supine-prone/prone-supine positioning every 8 h until clinical improvement or death occurred. MEASUREMENTS AND RESULTS: Twenty-three patients who had ARDS (0.5-months to 12.6-years-old), were placed in the prone position within 56+/-109 h after the diagnosis of ARDS. Prone-supine/supine-prone postural changes were repeated every 8 h for 9.7+/-5.5 days. Changes in PaO(2)/FiO(2) ratio during supine-prone and prone-supine positioning were evaluated. A positive change was defined as an increase of 15% of baseline value. The patient was classified as a responder when the mean increase in the prone position was greater than 15%. There were 18 responders and five non-responders. The responders showed an increase in PaO(2)/FiO(2) ratio of 22%, from 91+/-33 to 112+/-43 (P <0.001), when they were placed from the supine to the prone position. Their PaO(2)/FiO(2) ratio dropped from 109+/- 37 to 94 +/-36, P = 0.011, when changed from the prone to supine position. The overall mortality rate in this series was 48% (11 patients), which was higher in the non-responders (80%) than in the responders (39%), although this difference was not statistically significant (P = 0.95). CONCLUSIONS: The prone position improves oxygenation in a significant proportion of children with ARDS. Although no statistically significant difference was found for the mortality rate, it was higher for the non-responders (80%) vs the responders (39%).