[Cost-effectiveness analysis high flow oxygen therapy in the treatment of SARS-CoV-2 pneumonia]. / Coste-efectividad de la oxigenoterapia de alto flujo en el tratamiento de la neumonía por SARS-CoV-2.

INTRODUCTION: high-oxygen nasal cannulas in patients with respiratory failure secondary to SARS-CoV-2 pneumonia have not been studied from a cost-effectiveness point of view. METHODS: Retrospective analysis of patients who had entered the COVID-area of an intensive medicine service in a third reference hospital, between March-December 2020. An effectiveness cost analysis was carried out comparing 2therapeutic decisions: the experimental strategy was defined as a mixed strategy consisting of the initial application of high flow nasal oxygen (HFNO) and application of VMI only to HFNO failures. The optimal rational decision was defined as maximizing expected profit, and economic efficiency was assessed by calculating the Incremental Cost-Effectiveness Ratio (ICER) for years of life gained. RESULTS: Of the 185 patients tested, 101 (55%) received invasive mechanical ventilation immediately and 84 (45%) were treated with HFNO at the outset. In the cost-effectiveness analysis, comparing both therapeutic strategies, the probability that the experimental strategy would be more effective was 0.974, reaching statistical significance: Difference in average proportions -0.113; 95% CI:-0.018 to -0.208. This corresponds to an NNT of 9 patients. The optimal decision was HFNO's strategy followed by VMI in HFNO failures. This option had an RCEI of 5582 euros per year of life gained. CONCLUSIONS: It is important to establish in the future reliable markers in the use of HFNO so that this therapy improves its cost-effective benefits.

[Assembly and management of helmet-CPAP in infants and children with acute respiratory insufficiency]. / Montaje y manejo del sistema helmet-CPAP en lactantes y niños con insuficiencia respiratoria aguda.

Application of continuous positive airway pressure (CPAP) during respiratory insufficiency through a helmet interface is not well known in the Pediatric practice. The objective of this paper is to describe the necessary elements for it assembly, management and nursing care. The advantages and disadvantages of helmet compared to other interfaces are also discussed.

OLA strategy for ARDS: Its effect on mortality depends on achieved recruitment (PaO2/FiO2) and mechanical power. Systematic review and meta-analysis with meta-regression.

OBJECTIVE: The "Open Lung Approach" (OLA), that includes high levels of positive end-expiratory pressure coupled with limited tidal volumes, is considered optimal for adult patients with ARDS. However, many previous meta-analyses have shown only marginal benefits of OLA on mortality but with statistical heterogeneity. It is crucial to identify the most likely moderators of this effect. To determine the effect of OLA strategy on mortality of ventilated ARDS patients. We hypothesized that the degree of recruitment achieved in the control group (PaO2/FiO2 ratio on day 3 of ventilation), and the difference in Mechanical Power (MP) or Driving Pressure (DP) between experimental and control groups will be the most likely sources of heterogeneity. DESIGN: A Systematic Review and Meta-analysis was performed according to PRISMA statement and registered in PROSPERO database. We searched only for randomized controlled trials (RCTs). GRADE guidelines were used for rating the quality of evidence. Publication bias was assessed. For the Meta-analysis, we used a Random Effects Model. Sources of heterogeneity were explored with Meta-Regression, using a priori proposed set of possible moderators. For model comparison, Akaike's Information Criterion with the finite sample correction (AICc) was used. SETTING: Not applicable. PATIENTS: Fourteen RCTs were included in the study. INTERVENTIONS: Not applicable. MAIN VARIABLES OF INTEREST: Not applicable. RESULTS: Evidence of publication bias was detected, and quality of evidence was downgraded. Pooled analysis did not show a significant difference in the 28-day mortality between OLA strategy and control groups. Overall risk of bias was low. The analysis detected statistical heterogeneity. The two "best" explicative meta-regression models were those that used control PaO2/FiO2 on day 3 and difference in MP between experimental and control groups. The DP and MP models were highly correlated. CONCLUSIONS: There is no clear benefit of OLA strategy on mortality of ARDS patients, with significant heterogeneity among RCTs. Mortality effect of OLA is mediated by lung recruitment and mechanical power.

OLA strategy for ARDS: Its effect on mortality depends on achieved recruitment (PaO2/FiO2) and mechanical power. Systematic review and meta-analysis with meta-regression.

OBJECTIVE: The "Open Lung Approach" (OLA), that includes high levels of positive end-expiratory pressure coupled with limited tidal volumes, is considered optimal for adult patients with ARDS. However, many previous meta-analyses have shown only marginal benefits of OLA on mortality but with statistical heterogeneity. It is crucial to identify the most likely moderators of this effect. To determine the effect of OLA strategy on mortality of ventilated ARDS patients. We hypothesized that the degree of recruitment achieved in the control group (PaO2/FiO2 ratio on day 3 of ventilation), and the difference in Mechanical Power (MP) or Driving Pressure (DP) between experimental and control groups will be the most likely sources of heterogeneity. DESIGN: A Systematic Review and Meta-analysis was performed according to PRISMA statement and registered in PROSPERO database. We searched only for randomized controlled trials (RCTs). GRADE guidelines were used for rating the quality of evidence. Publication bias was assessed. For the Meta-analysis, we used a Random Effects Model. Sources of heterogeneity were explored with Meta-Regression, using a priori proposed set of possible moderators. For model comparison, Akaike's Information Criterion with the finite sample correction (AICc) was used. SETTING: Not applicable. PATIENTS: Fourteen RCTs were included in the study. INTERVENTIONS: Not applicable. MAIN VARIABLES OF INTEREST: Not applicable. RESULTS: Evidence of publication bias was detected, and quality of evidence was downgraded. Pooled analysis did not show a significant difference in the 28-day mortality between OLA strategy and control groups. Overall risk of bias was low. The analysis detected statistical heterogeneity. The two "best" explicative meta-regression models were those that used control PaO2/FiO2 on day 3 and difference in MP between experimental and control groups. The DP and MP models were highly correlated. CONCLUSIONS: There is no clear benefit of OLA strategy on mortality of ARDS patients, with significant heterogeneity among RCTs. Mortality effect of OLA is mediated by lung recruitment and mechanical power.

[Boussignac continuous positive airway pressure device during inter-hospital transportation in infants aged less than three months]. / Dispositivo de presión positiva continua en la vía aérea de Boussignac durante el transporte interhospitalario en lactantes menores de tres meses.

BACKGROUND: The present study aims to evaluate the safety and effectiveness of the Boussignac continuous positive airway pressure device (CPAPB) when used during the transportation of infants under three months of age with bronchiolitis. METHODS: Transversal analytical observational study of four years duration. Data was collected on 25 infants who needed inter-hospital transportation to the reference Paediatric Intensive Care Unit (PICU), with CPAPB and Helmet interface. The epidemiological characteristics of the transportation and evolution in the PICU were registered, as well as the cardiorespiratory gastronomic parameters prior to transfer and on arrival at the PICU. RESULTS: The median level of continuous airway pressure (CPAP) used during the transfer was 7 cm H2O (6-7.25). No patient required endotracheal intubation during transportation, while one patient required this during the first six hours of admission in the PICU. The following cardiorespiratory parameters presented a statistically significant improvement on arrival at the PICU: modified Wood-Downes score [8.40 (2.1) vs 5.29 (1.68)], respiratory frequency [60.72 (12.73) vs 47.28 (10.31)], cardiac frequency [167.28 (22.60) vs 154.48 (24.83)] and oxygen saturation [92.08 (5.63) vs 97.64 (2.27)]. CONCLUSIONS: Application of CPAPB proved to be a safe method of respiratory support in infants under three months of age. Its use during transportation brought an improvement in cardiorespiratory parameters.

[Prognostic indexes of mortality in pediatric intensive care units]. / Indices pronósticos de mortalidad en cuidados intensivos pediátricos.

OBJECTIVE: To assess the validity of the Pediatric Risk of Mortality score (PRISM), the Pediatric Index of Mortality (PIM) and the PIM 2 in two Spanish pediatric intensive care units. PATIENTS AND METHODS: We prospectively studied 241 critically ill children consecutively admitted over a 6-month period. The overall performance of the scoring systems was assessed by the Standardized Mortality Ratio (SMR), comparing observed deaths with expected deaths by each index. Discrimination (the ability of the model to distinguish between patients who live and those who die) was quantified by calculating the area under the receiver operating characteristic (ROC) curve. Calibration (the accuracy of mortality risk predictions) was calculated with the Hosmer-Lemeshow goodness-of-fit test, in which statistical calibration is evidenced by p > 0.05. RESULTS: The mortality rate was 4.1 %. PRISM overestimated mortality (SMR = 0.44). Discrimination was better for PRISM and PIM 2 than for PIM (areas under ROC curves: 0.883, 0.871, and 0.800 respectively), with no significant differences. Finally, calibration was acceptable for PIM 2 (x2 (8) = 4.8730, p 0.8461) and for PIM (x2 (8) = 8.0876, p 0.5174), but no statistical calibration was found for PRISM (x2 (8) = 15.0281, p 0.0133). CONCLUSIONS: PIM and PIM 2 showed better discrimination and calibration than PRISM in a heterogeneous group of children in Spanish critical care units. However, these results should be confirmed in a larger study.

[Noninvasive ventilation in a pediatric intensive care unit]. / Aplicación de ventilación no invasiva en una unidad de cuidados intensivos pediátricos.

OBJECTIVE: To describe our experience of noninvasive positive-pressure ventilation (NIPPV). PATIENTS AND METHODS: We performed a retrospective study of all patients who underwent NIPPV in our unit over an 18-month period. To assess the effectiveness of NIPPV, respiratory rate, heart rate, inspired oxygen, and arterial blood gases PaO2 and PaCO2 were evaluated before and 2 hours after initiating NIPPV. RESULTS: Twenty-three patients with a mean age of 36.7 months underwent a total of 24 NIPPV trials. Indications for NIPPV were: hypoxemic acute respiratory failure (14 trials), hypercapnic acute respiratory failure (four trials), and postextubation respiratory failure (six trials). Conventional ventilators were used in 10 trials and specific noninvasive ventilators were used in 14. The main interfaces used were buconasal mask in patients older than 1 year, and pharyngeal prong in infants aged less than 1 year. In all groups, significant decreases in respiratory distress, defined as a reduction in tachypnea (45 +/- 16 breaths/min pre-treatment vs. 34 +/- 12 breaths/min post-treatment; p = 0.001), and tachycardia (148 +/- 27 beats/min pre-treatment vs. 122 +/- 22 beats/min (after or post) post-treatment; p < 0.001) were observed after initiation of NIPPV. The oxygenation index PaO2/FiO2 also improved (190 +/- 109 pre-treatment vs. 260 +/- 118 post-treatment; p = 0.010). Five patients (20.8 %) required intubation and conventional mechanical ventilation after NIPPV, of which three were aged less than 6 months. CONCLUSIONS: NIPPV should be considered as a ventilatory support option in the treatment of acute respiratory failure in selected children.

[Importance of initial management in severe pediatric trauma]. / Importancia de la evaluación inicial en los traumatismos graves en la infancia.

INTRODUCTION: Trauma is the most frequent cause of mortality in childhood and adolescence and causes almost 25% of admissions in Pediatric Intensive Care Units (PICU). We have evaluated the initial assesment of the severely injured children admitted in our PICU (pre-hospital care). MATERIAL AND METHODS: We reviewed the children younger than 16 years admitted in our PICU between January 1996 and December 2002. Prehospital caretakers, transportation after initial evaluation and therapeutic management were analized, using Pediatric Trauma Score (PTS) and Pediatric Risk of Mortality Score (PRISM) as predictors of injury severity and mortality, respectively. RESULTS: We treated 152 traumatized children in this period, 106 males and 46 females, with a mean age of 7.5 +/- 4.3 years. 116 patients received inmediate medical care with a mean PTS significatively greater than non-medical group (12 children). Non-medical caretakers treated 8.1% of severe trauma (PTS<8). Specialized transporter was inadequated in 7.1% of severe traumatized children. Gastric and vesical tube and spinal inmobilization were accomplished in 50%, specially in children with low PTS and high PRISM. We found a great variability in fluid and drugs administration. CONCLUSIONS: Although there has been a good evolution in treatment of pediatric trauma, in order to diminish morbidity and mortality it is necessary to identify and correct deficiencies in management, specially during the "golden hour", and train pre-hospital caretakers in pediatric trauma management.

[Acute renal failure in critically-ill children. A preliminary study]. / Insuficiencia renal aguda en niños críticamente enfermos. Estudio preliminar.

OBJECTIVE: To analyze the characteristics of acute renal failure (ARF) in critically-ill children and develop a protocol for a multicenter study. METHODS: A prospective, descriptive study was performed in four pediatric intensive care units (PICU) over 5 months. Epidemiological, clinical and laboratory data from children aged between 7 days and 16 years with ARF were analyzed. Premature neonates were excluded. RESULTS: There were 16 episodes of ARF in 14 patients and 62.5 % were male (mean 6 SD age: 50 +/- 49 months). The incidence of ARF was 2.5 % of PICU patients. The most frequent primary diseases were nephro-urological (50 %) and heart disease (31 %). The main risk factors for ARF were hypovolemia (44 %) and hypotension (37 %). Six patients (37.5 %) developed ARF following surgery (cardiac surgery in four, kidney transplantation in one and urological surgery in one). Furosemide was used in 13 patients (as continuous perfusion in nine), inotropes in nine and renal replacement therapy in 12. Medical complications were found in 94 % and some organic dysfunction was found in 81 %. The length of stay in the PICU was 21 +/- 21 days. The probability of death according to the Pediatric Risk of Mortality was 14 +/- 8 %. Five patients died (36 % of the patients and 31.2 % of ARF episodes). CONCLUSIONS: The incidence of ARF in critically-ill children is low but remains a cause of high mortality and prolonged stay in the PICU. Mortality was caused not by renal failure but by multiple organ failure.

[Estimation of creatinine clearance by the height/plasma creatinine formula in critically-ill children]. / Estimación del aclaramiento de creatinina por la talla en pacientes críticamente enfermos.

INTRODUCTION: Critically-ill children frequently show impaired renal function, necessitating adjustment of drug dosages. Our objectives were to study estimated creatinine clearance through the correlation between the height/plasma creatinine formula (CrClest) and measured creatinine clearance (CrClms) and to examine whether CrClest over- or underestimates CrClms by analyzing the influence of diagnosis, severity, and the practical consequences. PATIENTS AND METHODS: Seventy-seven patients admitted to the pediatric intensive care unit were included. CrClms was calculated using serum creatinine and creatinine in urine collected over 24 hours. CrClest was estimated using serum creatinine, height, and a constant. The difference between CrClms and CrClest was expressed as a percentage: (CrClms CrClest) x 100/CrClms. Differences of greater than 15 % were considered poor estimates. ResultsThe mean percentage difference was 29.2 (standard error: 39.9). There were no differences among diagnoses in the distribution of significant bias, although the frequency of metabolic diagnoses was high. Incorrect evaluation of CrClest would result in a therapeutic error in 11.69 % of the cases, with overdosage in 10.39 %. The Pediatric Risk of Mortality (PRISM) score was higher (p < 0.05) in patients at risk for overdosage. CONCLUSIONS: CrClest estimation using the height/plasma creatinine formula was not an accurate method in critically ill children. In 10.39 % of patients with more severe illness, the dosage of renally excreted drugs would be too high. The highest risk was found in patients with metabolic and neurological diagnoses.

[Pediatric brain death and donation in Asturias]. / Muerte encefálica y donación en población infantil.

BACKGROUND: Brain death is the irreversible cessation of intracranial neurologic function and is considered as the person's death. The objective of this study was to describe the characteristics of pediatric donors in the Hospital Central de Asturias from October 1995 to October 2002. METHODS: We performed a retrospective and descriptive study of the dead children who were potential donors in the pediatric intensive care unit (PICU). RESULTS: Of 43 dead children, 15 (34.9 %) were diagnosed with brain death. In four patients (family refusal in one, sepsis in two and brain tumor in one) there was no donation. In all patients, the diagnosis of brain death was based on clinical examination and electroencephalogram. Doppler ultrasonography and technetium-99m hexamethylpropyleneamineoxamine (Tc-99-HMPAO) scanning was also performed in three and nine patients respectively. The mean age of the donors was 8.1 years (range: 13 months-15 years). The male/female ratio was 3/1. The cause of death was multiple trauma in six children, brain hemorrhage in three, cardiac arrhythmias in three, lightning strike in one, diabetic ketoacidosis in one, septic shock in one and hypovolemic shock in one. The median interval between admission and brain death was 1.4 days (range: 3 hours-12 days). The time of organ support between brain death and donation was 8.4 hours (range: 6-13 hours). The most frequent complications after brain death were central diabetes insipidus in 90.9 % of the patients, hyperglycemia in 54.5 % and hypokalemia in 45.4 %. During support 72.7 % of the patients required inotropic aid. CONCLUSIONS: In our PICU more than one-third of the dead children suffered brain death, and most became donors. The most frequent cause of brain death was multiple trauma. Coordination with the transplant team and the training of medical staff are important to achieve a high percentage of donations.

[Long QT syndrome presented as epilepsy]. / Síndrome de QT largo presentado como epilepsia.

INTRODUCTION: Long QT syndrome is characterised by an alteration in cardiac repolarisation that brings about ventricular arrhythmias. The resulting cerebral hypoxia leads to fainting and convulsions that, in up to 10% of cases, are interpreted as epilepsy. CASE REPORT: We report the case of a patient of paediatric age who was affected by an isolated presentation of congenital long QT syndrome, which had initially been diagnosed as idiopathic epilepsy, and who suffered a sudden loss of consciousness while doing exercise. The initial electrocardiographic monitoring revealed a ventricular tachycardia in torsades de pointes, which was reversed by advanced cardiopulmonary revival manoeuvres. At 12 days after admission, there was an absence of electrical brain activity and brain death resulted. CONCLUSION: The high mortality among symptomatic patients affected by long QT syndrome and the effectiveness of the treatment highlight the importance of a correct diagnosis. A detailed clinical history and an electroencephalogram with a simultaneous electrocardiogram (ECG) recording, together with continuous EEG recording for 24 hours, with the manual evaluation of the corrected QT, would all help in the identification of unsuspected cases. A complete study of the family, including the possible associated mutations, could be a new form of early diagnosis.