Teaching Chest Ultrasound in an Experimental Porcine Model.

OBJECTIVE: The objective of this study was to evaluate the efficacy of a short hands-on chest ultrasound course to detect normal lung pattern, pneumothorax (PTX), and pleural effusion (PE) in a porcine animal model. METHODS: Thirty-six trainees with no previous experience in chest ultrasound participated in the study. A 1.5-hour training course covering both theory and practice was developed. All static and dynamic signs of the normal lung parenchyma, PTX, and PE were analyzed. Four pigs were used. Approval by the local institutional animal care was obtained. An 8F drainage catheter was inserted into the pleural cavity under general anesthesia for injection of air or saline solution. A Vivid Q ultrasound with a 12L-RS linear probe was used. A baseline preintervention evaluation and 2 postintervention evaluations (one after theoretical class and the other after additional training with the animal model) were made. Sensitivity and specificity with the 95% confidence interval for recognition of the 3 patterns were analyzed, and results were compared with those obtained in the preintervention evaluation. RESULTS: All normal lung signs were detected, as these were signs of PE and PTX. Participants were able to diagnose a normal pattern (sensitivity, 100% [90%-100%]; specificity, 90% [84%-95%]), PE (sensitivity, 89% [75%-95%]; specificity, 95% [89%-98%]), and PTX (sensitivity, 82% [72%-89%]; specificity, 97% [90%-99%]) after 30 minutes of class and normal pattern (sensitivity, 95% [85%-98%]; specificity, 95% [85%-98%]), PE (sensitivity, 100% [88%-100%]; specificity, 98% [94%-99%]), and PTX (sensitivity, 90% [73%-96%]; specificity, 98% [92%-99%]) in the animal model. CONCLUSIONS: The porcine model is useful for ultrasound examination of the lung parenchyma and detection of pleural disease. Its use in the experimental laboratory is a major refinement that enables trainees to identify acute pulmonary complications.

Supraventricular tachycardia in children from the perspective of a specialised between-hospital transport team.

AIMS: The aim of this study is to establish the incidence of supraventricular tachycardia (SVT) as a main reason for between-hospital transfer in children, as well as to describe the clinical presentation, prognosis and treatment, risk factors presenting with haemodynamic compromise, and to propose a specific management protocol for the transport. METHODS: A retrospective observational study was conducted on all patients with supraventricular tachycardia transferred by the Hospital Vall d'Hebron Sistema de Emergencias Médicas Pediátricas (SEM-P) between January 2005 and June 2017. RESULTS: During the study period, 67 (0.9%) patients (out of a total number of 7348 transfers) suffered from SVT. The median age was 57 days (2 h-18 years old). There was clinical evidence of cardiogenic shock on admission in 14 (20.9%) patients. Age ≤1 year was the only independent risk factor associated with presenting with cardiogenic shock on admission, with an OR of 10.2 (95% CI: 1.2-89.9; p = 0.004). The majority of patients could be treated appropriately by the local hospital team, except for oral intubation and cardioversion that were performed mainly by the transport team on arrival at the local hospital. Median stabilisation time was 35 min (9-169), and median total transport time was 30 min (9-165). CONCLUSIONS: Only 0.9% of transport cases are due to SVT, but this can be highly demanding as patients can be critically ill. Age ≤1 year was the only independent risk factor associated with presenting with cardiogenic shock on admission. Coordination between the local and the transport teams is crucial for a good clinical outcome.

[Supraventricular tachycardia in children from the perspective of a specialised between-hospital transport team]. / Taquicardia paroxística supraventricular desde la perspectiva del transporte interhospitalario.

AIMS: The aim of this study is to establish the incidence of supraventricular tachycardia (SVT) as a main reason for between-hospital transfer in children, as well as to describe the clinical presentation, prognosis and treatment, risk factors presenting with haemodynamic compromise, and to propose a specific management protocol for the transport. METHODS: A retrospective observational study was conducted on all patients with supraventricular tachycardia transferred by the Hospital Vall d'Hebron Sistema de Emergencias Médicas Pediátricas (SEM-P) between January 2005 and June 2017. RESULTS: During the study period, 67 (0.9%) patients (out of a total number of 7348 transfers) suffered from SVT. The median age was 57 days (2 hours-18 years old). There was clinical evidence of cardiogenic shock on admission in 14 (20.9%) patients. Age ≤ 1 year was the only independent risk factor associated with presenting with cardiogenic shock on admission, with an OR of 10.2 (95% CI: 1.2-89.9; P=.004). The majority of patients could be treated appropriately by the local hospital team, except for oral intubation and cardioversion that were performed mainly by the transport team on arrival at the local hospital. Median stabilisation time was 35minutes (9-169), and median total transport time was 30minutes (9-165). CONCLUSIONS: Only 0.9% of transport cases are due to SVT, but this can be highly demanding as patients can be critically ill. Age ≤ 1 year was the only independent risk factor associated with presenting with cardiogenic shock on admission. Coordination between the local and the transport teams is crucial for a good clinical outcome.

A Case of Persistent Air Leak Managed by Selective Left Main Bronchus Intubation in an Infant with Pulmonary Tuberculosis.

BACKGROUND Persistent air leak, or persistent pneumothorax, is defined as a pneumothorax that persists beyond the first week, or air leak through a chest drain for more than 48 hours. The most common findings in pediatric pulmonary tuberculosis are parenchymal disease and mediastinal lymphadenopathy, but airway obstruction can cause emphysema and pneumothorax. A case is presented of persistent air leak in a 3-month-old infant with pulmonary tuberculosis that was managed by selective left main bronchus intubation. CASE REPORT A 3-month-old boy presented with respiratory distress and fever. Imaging findings suggested pulmonary tuberculosis, and first-line anti-tuberculous treatment was initiated with isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE). He was discharged home after eight days, but was admitted four days later with respiratory distress. Chest X-rays showed a tension pneumothorax that required drainage and chest computed tomography (CT) showed right lung emphysema. Bronchoscopy found extrinsic obstruction of both main bronchi. Chest drains continued to leak air leak after 48 h. Right middle and lower lobectomy and drainage of multiple lymph nodes resulted in significant improvement. He developed pneumonia and acute respiratory distress syndrome, which prevented mechanical ventilation. The left main bronchus was selectively intubated to allow the air leak to heal and to ventilate the lung. He was extubated 10 days later and recovered completely. CONCLUSIONS This case highlights that when medical management of persistent air leak associated with tuberculosis is not effective, surgery, active ventilation, and selective main bronchus intubation should be considered.

[Point-of-care ultrasound: Is it time to include it in the paediatric specialist training program?] / Ecografía a pie de cama: ¿es el momento de incluirla en la formación del pediatra?

Point-of-care ultrasound (POCUS) has become an essential tool for clinical practice in recent years. It should be considered as an extension of the standard physical examination, which complements and enriches it without substituting it. POCUS enables the physician to answer specific clinical questions about the diagnosis, to understand better the pathophysiological context, to orientate the treatment, and to perform invasive procedures more safely. Despite its current use in many centres, and in most paediatric sub-specialties, there are currently no specific recommendations addressing educational aims in the different training areas, as well as methodology practice and the certification process in paediatrics. These ingredients are essential for POCUS implementation in daily practice, with a quality guarantee in terms of efficiency and safety. Several POCUS experts in different paediatric medicine environments performed a non-systematic review addressing the main paediatric POCUS applications in paediatrics. The lack of educational programs in POCUS in Spain is also discussed, and the experience in the United States of America in this topic is provided. Considering the current situation of POCUS in paediatrics, we strongly believe that it is urgent to establish evidence-based recommendations for POCUS training that should be the base to develop educational programs and to include POCUS in the paediatric residency training.

Ultrasound-guided or landmark techniques for central venous catheter placement in critically ill children.

PURPOSE: To assess whether ultrasound guidance improves central venous catheter placement outcomes compared to the landmark technique in critically ill children. METHODS: A prospective multicentre observational study was carried out in 26 paediatric intensive care units over 6 months. Children 0-18 years old who received a temporary central venous catheter, inserted using either ultrasound or landmark techniques, were eligible. The primary outcome was the first-attempt success rate. Secondary outcomes included overall placement success, number of puncture attempts, number of procedures requiring multiple punctures (> 3 punctures), number of procedures requiring punctures at more than one vein site and immediate mechanical complications. To account for potential confounding factors, we used propensity scores. Our primary analysis was based on 1:1 propensity score matching. The association between cannulation technique and outcomes in the matched cohort was estimated using generalized estimating equations and mixed-effects models to account for patient-level and hospital-level confounders. RESULTS: Five hundred central venous catheter-placement procedures involving 354 patients were included. Ultrasound was used for 323 procedures, and the landmark technique was used for 177. Two hundred and sixty-six procedures were matched (133 in the ultrasound group and 133 in the landmark group). Ultrasound was associated with an increase in the first-attempt success rate [46.6 vs. 30%, odds ratio 2.09 (1.26-3.46); p < 0.001], a reduced number of puncture attempts [2 (1-3) vs. 2 (1-4), B coefficient - 0.51 (95% confidence interval - 1.01 to - 0.03), p = 0.035], and fewer overall mechanical complications [12 vs. 22.5%, odds ratio 0.47 (95% confidence interval 0.24-0.91), p = 0.025] in the matched cohort. The number of puncture attempts was the main factor associated with overall complications. CONCLUSIONS: Compared with the landmark technique, ultrasound guidance was associated with an increased first-attempt success rate, a reduced number of puncture attempts, and fewer complications during central venous catheter placement in critically ill children.

[Point-of-care ultrasound in Spanish paediatric intensive care units]. / Ecografía en el punto de cuidado en las unidades de cuidados intensivos pediátricos españolas.

INTRODUCTION: Point-of-care (bedside) ultrasound is being increasingly used by paediatricians who treat critically ill children. The aim of this study is to describe its availability, use, and specific training in Paediatric Intensive Care Units in Spain. MATERIAL AND METHODS: A descriptive, cross-sectional, multicentre study was performed using an online survey. RESULTS: Of a total of 51 PICUs identified in our country, 64.7% responded to the survey. Just over half (53.1%) have their own ultrasound machine, 25% share it, with other units with the usual location in the PICU, and 21.9% share it, but it is usually located outside the PICU. Ultrasound machine availability was not related to size, care complexity, or number PICU admissions. The ultrasound was used daily in 35% of the units, and was associated with location of the machine in the PICU (P=.026), the existence of a transplant program (P=.009), availability of ECMO (P=.006), and number of admissions (P=.015). 45.5% of PICUs has less than 50% of the medical staff specifically trained in bedside ultrasound, and 18.2% have all their medical staff trained. The presence of more than 50% of medical staff trained was associated with a higher rate of daily use (P=.033), and with specific use to evaluate cardiac function (P=.033), intravascular volume estimation (P=.004), or the presence of intra-abdominal collections (P=.021). CONCLUSIONS: Bedside ultrasound is frequently available in Spanish PICUs. Specific training is still variable, but it should serve to enhance its implementation.