Factores pronósticos de evolución complicada en la bronquiolitis que requiere ingreso en cuidados intensivos pediátricos

ObjectiveTo analyse the prognostic factors for complications in children with bronchiolitis admitted to a pediatric intensive care unit (PICU).Patients and methodA 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.ResultsA 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.ConclusionsChildren 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.     

Canalización arterial ecoguiada o por palpación del pulso en la unidad de cuidados intensivos

IntroductionUltrasound (US) guidance increases the success rate and decreases complications during central venous catheterisation (CVC). The benefits of US guidance in arterial catheterisation are less clear. The aim of this study is to compare the outcomes of US-guided arterial catheterisation with the traditional landmark (LM) technique in critically ill children.MethodsA prospective multicentre study was carried out in 18 Paediatric Intensive Care units in Spain during a 6-months period. Ultrasound guided and landmark techniques were compared in terms of cannulation technical success and immediate mechanical complications.ResultsA total of 161 procedures were performed on 128 patients (78 procedures in the US group and 83 in the LM groups). The median (interquartile range) age and weight of the cohort was 11 months (2-52), and 10 kg (4-17), respectively. More than half (59.6%) were male. US was used mainly in big (number of beds 11 [8-16] vs 6 [4-10], p < 0,001) and high complexity intensive care units (cardiac surgery program 76.9% vs. 25.6%, P < .001) as well as in smaller children [weight 5.7 kg (3.8-13) vs 11.5 kg (4.9-22.7), P < .001]. Almost half (49.7%) of the procedures were performed by an inexperienced operator (paediatric resident, or staff with less than 5 years of clinical experience in the PICU), and only 24.4% had performed more than 50 US-guided vascular access procedures before the study. There were no significant differences between US and LM techniques in terms of first-attempt success (35.8% vs 33.7%, P = .773), overall success (75.6% vs 71.1%, P = .514), number of puncture attempts [2 (1-4) vs 2 (1-3), P = .667] and complications (16.6% vs 25.6%, P = .243). Adjustment by potential confounders using multivariate regression models did not modify these results. Subgroup analyses showed that US outperformed LM technique in terms of overall success (83.7% vs 62.7%, P = .036) and complications (10,8% vs 32.5%, P = .020) only when procedures where performed by less-experienced operators.ConclusionsIn this prospective observational multicentre study, US did not improve arterial cannulation outcomes compared to the traditional LM technique in critically ill children. US-guided arterial cannulation may offer advantages when cannulation is performed by inexperienced operators.     

Respuesta a la suspensión de azatioprina en pacientes con enfermedad de Crohn en terapia combinada con infliximab

BackgroundThe use of immunomodulatory agents has changed the management of inflammatory bowel disease. Immunosuppressive drugs (mainly thiopurines) and biological treatments (mainly monoclonal antibodies against TNFα) are currently most frequently and earlier used. The recent report of new cases of the rare and almost always fatal hepatosplenic T-cell lymphoma in young patients on combined therapy with azathioprine/6-mercaptopurine and infliximab suggests that the optimal strategies for reducing increased risk of side-effects need to be urgently assessed.Patients and methodWe report the effects of stopping immunosupressants in four Crohn's disease patients previously treated with azathioprine and infliximab for 6–12 months as combined therapy. The appearance of infusion reactions due to immunogenicity and the loss of efficacy of infliximab are evaluated.ResultsNo adverse events attributable to immunosuppression cessation or changes in infliximab efficacy have been noted during a 6-month evaluation period.ConclusionsStopping immunosuppressant therapy in Crohn's patients with a previous good response to combination therapy (azathioprine and infliximab) does not result in an increased risk of adverse events or loss of infliximab efficacy. Our results must be confirmed in larger and longer studies. Until the pathogenic role of this combined therapy in the incidence of hepatosplenic T-cell lymphoma is clearly defined, we consider that monotherapy with infliximab after a period on combined treatment is a safe and effective strategy.     

Estado actual y utilidad de la autopsia clínica en una unidad de cuidados intensivos pediátricos

BackgroundsThe autopsy is a diagnostic tool in decline over the last few decades. Our purpose is to describe the autopsy rates, the relationship between clinical and post-mortem diagnosis to evaluate the current overall usefulness of the autopsy.Patients and methodsRetrospective review of all cases in which clinical autopsy was performed between January 2004 and December 2009 in a paediatric intensive care unit (PICU) of a tertiary care hospital.ResultsOf 154 deaths in the PICU during the study period, 23 autopsies were performed (rate 14.9%). Autopsy rates decreased over the study period; from 26% in 2004 to 11% in 2009. There was a complete correlation (class V) in seven patients (29.1%). Some missed minor diagnosis (class IV) were found in four patients. Five patients had class III discrepancies, and four had class II discrepancies. Major diagnoses were missed in three (17.4%) patients, with a potencial adverse impact on survival and that could have changed management in life (Class IA). In three cases (13%) the autopsy results led to parents having genetic counselling.ConclusionsThe autopsy rate in our country is low when compared to other developed countries. The fact that in 69.6% of cases the autopsy revealed new findings related with the illness that caused or contributed to death shows that the reasons for performing the autopsy are still valid.     

Evaluación de las intubaciones endotraqueales en una unidad de cuidados intensivos pediátricos

IntroductionTracheal intubation is a frequent procedure in paediatric intensive care units that carries a risk of complications that can increase morbidity and mortality.Patients and methodsProspective, longitudinal, observational study in patients intubated in a level iii paediatric intensive care unit between January and December 2020. We analysed the risk factors associated with failed intubation and adverse events.ResultsThe analysis included 48 intubations. The most frequent indication for intubation was hypoxaemic respiratory failure (25%). The first attempt was successful in 60.4% of intubations, without differences between procedures performed by staff physicians and resident physicians (62.5 vs. 56.3%; P = .759). Difficulty in bag-mask ventilation was associated with failed intubation in the first attempt (P = .028). Adverse events occurred in 12.5% of intubations, and severe events in 8.3%, including one case of cardiac arrest, 2 cases of severe hypotension and one of oesophageal intubation with delayed recognition. None of the patients died. Making multiple attempts was significantly associated with adverse events (P < .002). Systematic preparation of the procedure with cognitive aids and role allocation was independently associated with a lower incidence of adverse events.ConclusionsIn critically ill children, first-attempt intubation failure is common and associated with difficulty in bag-mask ventilation. A significant percentage of intubations may result in serious adverse events. The implementation of intubation protocols could decrease the incidence of adverse events.     

Función renal basal en pediatría: correlación de métodos que dependen de la recogida de orina de 24 h con otros más sencillos que no requieren orina minutada

IntroductionIn daily clinical practice a quick, easy and accessible method is needed to adequately assess renal function. The objectives of this study were: 1. To quantify the relationship and concordance of the glomerular filtration rate (GF) calculated by the clearance of creatinine in 24 h urine (CCr) and the original and modified Schwartz equation (SE); and 2. To correlate urine elimination of substances that depends on the volume of excreted urine in a unit of time with other parameters that are calculated measuring the concentration of these substances in blood and urine.Material and methodsThe study included 401 healthy children with ages between 3 to 14 years (187 male and 214 female). The analysis between the variables was carried out using Pearson's correlation coefficient and the intraclass correlation coefficient (ICC).ResultsThe correlation between values of CCr and the original SE (non-standardised creatinine measurement) was r = 0.58 (P < 0.001) and the concordance, ICC = 0.74. The correlation between CCr values and the modified SE (standardised creatinine measurement) was r = 0.68 (P < .001), and the concordance ICC = 0.78. There was a very significant correlation between the elimination of sodium in a 24 h urine (mEq/kg/24 h) and the Na-Fractional-Excretion (EFNa): r = 0.8 (P < .001). There was a correlation between the potassium elimination in 24 h (mEq/kg/24 h) and EFK: r = 0.85 (P < .001). Between volume/min/1.73 m² and the urine volume percent of GF was: r = 0.88 (P < .001).ConclusionsThese equations provide valuable information of the state of the basal renal function without having to use a timed urine.     

Atención prehospitalaria urgente de los pacientes pediátricos expuestos a tóxicos: características epidemiológico-clínicas y evaluación de la calidad asistencial

ObjectiveTo describe the characteristics of paediatric patients with suspected poisoning treated by advanced life support (ALS) units, and to evaluate quality indicators (QI) for the prehospital emergency care of these patients.MethodA one-year observational study of patients under 18 years of age exposed to poisoning and treated by an ALS unit of the Medical Emergency System in Catalonia. Severe clinical criteria were defined, with 8 QI being evaluated for prehospital emergency care of poisoned paediatric patients.ResultsThe study included a total of 254 patients, with a median age of 14 years-old (p25-75 = 7-16), with intentional poisoning in 50.8% of cases. The most frequently involved toxic agent was carbon monoxide (CO) (33.8%). Poisoning was found in 48.8% of those patients, being serious in 16.5%. Intentionally (OR 5.1; 95% CI: 1.9-13.8) and knowledge of the time of exposure (OD 3.1; 95% CI: 1.3-7.3) were independent risk factors associated with the appearance of severe clinical symptoms. Five QI did not reach the quality standard and included, availability of specific clinical guidelines, activated charcoal administration in selected patients, oxygen therapy administration at maximum possible concentration in carbon monoxide poisoning, electrocardiographic assessment in patients exposed to cardiotoxic substances, and recording of the minimum data set.ConclusionsPaediatric patients attended by ALS units showed specific characteristics, highlighting the involvement of CO and adolescents with voluntary poisoning. The QI assessment was useful to detect weak points in the quality of care of these patients and to develop strategies for improvement.     

Características epidemiológicas y clínicas de los lactantes hospitalizados por infecciones por parechovirus humanos. Estudio prospectivo en España

Introduction

Human parechovirus (HPeV) is one of the recently described picornaviridae viruses that have been associated with fever of unknown origin (FUO), clinical sepsis, gastroenteritis, meningitis, or encephalitis in very young infants. The aim of this study is to describe the epidemiology and clinical features of these viruses.

La monitorización proactiva de niveles de anti-TNF mejora el seguimiento de los pacientes pediátricos con enfermedad de Crohn

Introduction and aimsThe incidence of paediatric inflammatory bowel disease has increased in recent decades. The aim of the present study was to evaluate the role of proactive and serial monitoring of tumour necrosis factor (TNF) inhibitor levels to maintain clinical remission and mucosal healing in the followup of paediatric patients with Crohn disease (CD).MethodProspective study that included all patients diagnosed with CD and treated with adalimumab or infliximab between May 2015 and November 2020 who underwent serial and proactive monitoring of TNF inhibitor levels.ResultsThe study included 30 patients, 21 male (70%). The mean age at diagnosis was 11.3 years (SD, 2.0), the mean age at initiation of TNF inhibitors was 12.6 years (SD, 1.9) with a mean duration of follow-up of 27.1 ± 9.1 months. Clinical remission was defined as a weighted Pediatric Crohn's Disease Activity Index (wPCDAI) of less than 12.5 and mucosal healing as a Mucosal Inflammation Non-invasive Index (MINI) of less than 8. During the follow-up, patients were in clinical remission in 87.1% of the visits, presented with mild disease in 11.4% and with moderate disease in 1.5%, and mucosal healing was assumed in 83% of the visits. The rates of clinical remission and mucosal healing at 1, 2, and 3 years of follow-up were 83.3%, 95.8%, 92.8%, and 86.7%, 87.5% and 85.7%, respectively.ConclusionsProactive and serial monitoring of serum TNF inhibitor levels may make it possible for patients to maintain clinical remission and mucosal healing in the maintenance phase, with individualised optimization of the required dosage and minimization of secondary loss of response.