[Fibrinolytic treatment with tissue plasminogen activator in a thrombosed modified Blalock-Taussig shunt]. / Tratamiento fibrinolítico con activador tisular de plasminógeno de una fístula modificada de Blalock-Taussig trombosada.

Thrombolytic therapy of a systemic pulmonary fistula is a rare method of treatment in newborns with thrombosed systemic-pulmonary shunt. We report the case of a newborn girl with a complex congenital heart defect. On the ninth day of life a modified right Blalock-Taussig shunt was performed. The ductus arteriosus was not ligated. Six days later the baby developed severe hypoxemia. The results of echocardiography and cardiac catheterization showed a total thrombosis of the fistula and complete absence of flow throughout the shunt. After insertion of an arterial catheter into the proximal end of the shunt we started fibrinolytic treatment with recombinant tissue plasminogen activator (r-TPA) in continuous infusion. After 14 hours of treatment we confirmed by angiography complete clot dissolution. The baby left the hospital in good condition when she was 23 days old. In the follow-up (4th month of life) the shunt is still permeable. Thrombolytic therapy with r-TPA locally applied in case of acute thrombosis of a systemic-pulmonary shunt appears to be a good therapeutic option avoiding the risks of a new surgical procedure.

[Surgical cryoablation in a child with malignant ventricular tachycardia refractory to drugs and radiofrequency ablation]. / Crioablación quirúrgica en un niño con taquicardia ventricular maligna refractaria a fármacos y a ablación por radiofrecuencia.

A ten-months-old child with incessant monomorphic ventricular tachycardia is presented. Tachyarrhythmia is refractory to antiarrhythmic drugs and refractory to endocardial radiofrequency current ablation. Epicardial cryoablation of arrhythmogenic area without artificial circulation resulted in the abrupt termination of tachycardia. No tachyarrhythmias were inducible postoperatively. The reduction of ventricular rate by surgical cryoablation does produces resolution of the arrhythmia-induced cardiomyopathy.

[Evaluation of the surgical correction in complete atrioventricular channels]. / Evaluación de la corrección quirúrgica en los canales auriculoventriculares completos.

We review our experience of surgical correction in atrioventricular canals between 1979 and 1991. 81 patients, ranging in ages from 5 to 109 months (with an average of 33 months) and weight from 4 to 25 kg (with an average of 9 kg), underwent primary repair. Another cardiac anomalies associated were ruled out, except patency of the arterial ductus. 33 patients (46%) presented the complete form of atrioventricular canals, 27 (33%) the partial form and 17 (21%) the transitional form. 55 patients (68%) of the sample had Down's syndrome. Regarding the cases with the complete form they were frequently associated to Down's syndrome. Thus, 89% of the cases of complete form had Down's syndrome. All operations for complete form cases used a two-patch technique and physiological reconstruction of the left atrioventricular valve. No patient underwent pulmonary artery banding or was discharged from surgery correction due to pulmonary pressure or resistance. The average age of the children with complete form was 19.5 months (11 months from 1986). The main hemodynamic parameters were mean pulmonary arterial pressure of 57 +/- 12 mmHg, pulmonary-systemic pressure relation of 0.87 +/- 0.12 and total pulmonary resistance of 6.3 +/- 4.0 U/m2. The hospital mortality was 32% in the complete form, comparable to samples of similar characteristics. We related this mortality with the hemodynamic profile at the time of surgical correction, compatible with pulmonary vascular obstructive disease, with the elevated percentage of Down's syndrome and with the delay in the surgical operation age.

[Pressure support ventilation]. / Modalidades de soporte.

Assisted mechanical ventilation is highly useful in clinical practice and allows good interaction between the patient and ventilator. The major uses of this mode are to reduce the work of breathing in patients with intact spontaneous breathing and to provide additional support during weaning from mechanical ventilation, especially when this has been prolonged.

[Protein C concentrate in the treatment of severe sepsis in the pediatric setting]. / Concentrado de proteína C en el tratamiento de la sepsis grave en pediatría.

Patients with severe sepsis develop acquired protein C deficiency, and the extent of such deficiency and negative clinical outcomes correlate. Replacing this protein may help prevent such a condition. Two protein C types are commercially available - concentrated and activated proteins. None is registered for the treatment of severe sepsis in the pediatric setting. Experience with protein C in this group of conditions is limited. Appropriate clinical trials are required to establish effectiveness and safety, and to elucidate the role of either protein C type in the management of this condition in the pediatric setting. This paper discusses experience with the use of protein C concentrate as an adjuvant treatment in addition to conventional therapy in three children with severe sepsis at a Pediatric Intensive Care Unit. In all 3 cases of our study, high levels of protein C correlated to coagulation parameter normalization and reduced dimer D levels. Two out of three had a favorable outcome following treatment, whereas the third patient died as a result of septic shock and multiple organ dysfunction.

[Meningococcal disease. new prevention strategies]. / Enfermedad meningocócica: nuevas estrategias de prevención.

Because conjugate C meningococcal vaccines represent a significant advance in the prevention of meningococcal disease, currently accepted recommendations on vaccination should be revised. The health authorities are responsible for carrying out national surveillance programs and for evaluating the need for vaccination programs. These programs should target all groups at risk for this disease and should confer adequate and lasting protection in vaccinated children.

[Fever and petechial exanthema in children]. / Fiebre y exantema petequial en niños.

In an attempt to determine clinical and analytical predictive parameters of a possible grave disease, we have carried out a retrospective study of 172 children admitted to our hospital with fever and petechiae as initial symptoms. The ages ranged between 1 month and 10 years. Even though we have not found a clinical symptom or analysis sufficiently sensitive as to predict all grave diseases, the general clinical state of the child associated with either a high or low white cell count and an abnormal coagulation study should be alert signals for a serious infectious disease. On the contrary, if the clinical and analytical parameters are within normal limits the risk of a grave disease is low. We emphasize the high incidence of meningococcal disease (26%).

[Pneumococcal meningitis: epidemiological, clinical and bacteriological characteristics]. / Meningitis neumocócica: características epidemiológicas, clínicas y bacteriológicas.

OBJECTIVE: To analyze the epidemiological and clinical features of pneumococcal meningitis. PATIENTS AND METHODS: We performed a retrospective study of 53 cases of pneumococcal meningitis that occurred in 47 pediatric patients in our hospital between 1977 and 2000. Four children had recurrent meningitis. In all patients Streptococcus pneumoniae was isolated from cerebrospinal fluid culture. The epidemiological, bacteriological and clinical characteristics were studied. RESULTS: Pneumococcal meningitis represented 6 % of bacterial meningitis in our environment with 2-3 cases registered per year. Seventy-two percent of cases occurred in winter and spring. The age of affected children was between 1 month and 13 years. Sixty-five percent of children older than 2 years had a predisposing disease. Penicillin-resistant strains were detected in 1990 and cefotaxime-resistant strains were isolated in 1994. Seven children (13 %) had severe neurological sequels and two (4 %) died. CONCLUSIONS: Pneumococcal meningitis produces higher morbidity and mortality than other types of bacterial meningitis. The disease usually affects children younger than 2 years and older children with a predisposing disease. In the last few years, the importance of pneumococcal meningitis has increased due to the lower incidence of other types of bacterial meningitis. Because of beta-lactam resistant strains, initial empirical treatment should include vancomycin. The above data suggest the advisability of the generalized use of heptavalent pneumococcal conjugate vaccine in the pediatric population in our environment.

[Macrophage activation syndrome: a diagnostic challenge]. / Síndrome de activación del macrófago: un reto diagnóstico.

Macrophage activation syndrome, or hemophagocytic syndrome, is a rare disease with high morbidity and mortality. It is a disorder of the mononuclear phagocyte system. Two forms have been described; primary or familial hemophagocytic lymphohistiocytosis and secondary or sporadic hemophagocytic syndrome. Diagnosis of macrophage activation syndrome poses a real challenge for the pediatrician and in many cases is only made at autopsy. We describe two patients with hemophagocytic syndrome associated with parvovirus B19 and Epstein-Barr virus infection.

[Acute respiratory infections in pediatric intensive care units. A multicenter prospective study]. / Infecciones respiratorias agudas en unidades de cuidados intensivos pediátricos. Estudio prospectivo multicéntrico.

OBJECTIVE: The purpose of this study was to know the etiology, clinical background, treatment an evolution of severe infectious diseases in children admitted to Pediatric Intensive Care Units (PICUs). PATIENTS AND METHODS: A multicenter prospective study was carried out. Children with respiratory infections admitted to 10 PICUs throughout Spain between May 1994 and April 1995 were included in a long term survey. The nosocomial infections were not included. Student's t and Wilcoxon tests were used for quantitative variables and Chi square with Yates correction and Fisher's test for the qualitative variables. RESULTS: One hundred twenty-two patients with acute respiratory infections were studied. The mean value on Downes score at admittance was 5.2 +/- 2.3. Diagnosis were allocated as follows: 47 bronchopneumonia (38.5%), 40 bronchiolitis (33%), 15 epiglotitis (12%), 14 laryngitis (11.5%) and "others" 6 (5%). Etiologic agents were identified in 69 cases (56.5%), with respiratory syncytial virus being the most frequently isolated agent (35 cases, 51%), followed by Hemophilus influenzae in 13 cases (19%). The mean PICU stay was 5.8 +/- 7.9 days (1-67 days). Of these cases, 112 (92%) recovered completely and 9 (7%) died (8 with bronchopneumonia and 1 with epiglotitis). A significant association could be seen between the increase in mortality and the variables Downes' score and diagnosis of bronchopneumonia. CONCLUSIONS: The most frequent respiratory infections in the PICU were pneumonia and bronchopneumonia. Viral etiology, with a frequency of 54%, was the main cause of respiratory infection. Bacterial etiology represented 46% of the total cases, with Hemophilus influenzae as the most frequent etiologic agent.