Amaya Bustinza

Surfactant treatment for acute respiratory distress syndrome

OBJECTIVE To determine prospectively the efficacy of surfactant in acute respiratory distress syndrome. STUDY DESIGN Twenty patients, 1 month to 16 years of age, diagnosed with an acute pulmonary disease with severe hypoxaemia (PaO2/FiO2 < 100) (13 with systemic or pulmonary disease and seven with cardiac disease) were treated with one to six doses of 50–200 mg/kg of porcine surfactant administered directly into the trachea. The surfactant was considered to be effective when the PaO2/FiO2 improved by > 20%. RESULTS After initial surfactant administration the PaO2/FiO2increased significantly in patients with systemic or pulmonary disease from 68 to 111, and the oxygenation index (OI) diminished significantly from 36.9 to 27.1. The PaO2/FiO2 and OI did not improve in children with cardiac disease. The improvement of the patients who survived was greater than that of those who died. CONCLUSIONS Surfactant moderately improves oxygenation in some children with severe acute respiratory distress syndrome secondary to pulmonary or systemic disease.

Transpyloric enteral feeding in critically ill children.

BACKGROUND Nutrition is important in childhood because the child has a lower energy reserve than the adult and a higher demand for calories because of ongoing growth. In this study, the utility of transpyloric enteral feeding (TEF) in critically ill children was evaluated. METHODS A prospective, descriptive study was made in a pediatric intensive care unit of a tertiary pediatric center of 41 critically ill children, 30 after surgical procedures and 11 with nonsurgical illness, aged 8 days to 12 years, who received transpyloric enteral feeding with 8- or 10-Fr weighted feeding tubes. Analysis was made of tolerance and complications (vomiting, abdominal distension, excessive gastric residual, diarrhea, and pulmonary aspiration) of TEF. RESULTS The mean duration of TEF was 19.5 +/- 26.8 days (range, 1-120 days). The administration of sedative agents or inotropic drugs did not alter toleration of TEF. Eight of 12 patients treated with continuous infusion of vecuronium tolerated TEF without complications. Eleven gastrointestinal complications occurred in 10 patients, abdominal distension and excessive gastric residual in 7 (17%), and diarrhea in 4 (9.7%). In 7 patients gastrointestinal complications improved, with decreasing use or transitory interruption of TEF, but in 4 patients (9.7%), TEF had to be withdrawn. Gastrointestinal complications were more frequent in postsurgical than in nonsurgical patients (p < 0.001). No patients suffered from pulmonary aspiration, and the incidence of pulmonary infection and hepatic dysfunction diminished during TEF. CONCLUSIONS Transpyloric enteral feeding is a good method of nutritional support in critically ill children and can be used in patients treated with neuromuscular blocking agents. The frequency and severity of complications and the risks of pulmonary infection and hepatic dysfunction related to TEF are low.

Cardiac output and blood volume parameters using femoral arterial thermodilution

Background:  The pulse‐induced continuous cardiac output (PiCCO) system is a less invasive method than pulmonary thermodilution for the measurement of cardiac output and estimating blood volume parameters. The normal values in children have not been defined. The purpose of the present paper was therefore to evaluate cardiac output and parameters of blood volume using femoral arterial thermodilution in critically ill children.

Pediatric basic and advanced life support courses: first experience in Spain

OBJECTIVE to evaluate the efficiency of the first experience in pediatric basic and advanced life support courses in Spain. MATERIAL AND METHODS we have given two pediatric basic life support (PBLS) courses of 8 h each to 52 school teachers and ambulance drivers, and 10 30-h pediatric advanced life support (PALS) courses to 276 health professionals, 62 nurses and 214 physicians (80 pediatricians, 57 pediatric, anesthesiology and intensive care medicine residents, 10 general physicians and 52 emergency physicians). We developed the courses according to the guidelines for pediatric life support from the European Resuscitation Council. We performed an initial and final theoretical written test, continuous practical evaluation and a written survey about the quality of the course. RESULTS on PBLS courses, only 12% of practitioners answered at least 80% of the questions in the initial theory test correctly, compared with 77% in the final test (P < 0.001). All the students acquired skills in basic pediatric resuscitation. In the PALS courses, only 30% of practitioners answered at least 75% of the questions in the initial test correctly (35% of physicians and 12% of nurses, P < 0.01); this percentage increased to 95.6% in the final test (96% of physicians and 93.5% of nurses, P < 0.05). Of students, 95% acquired skills in advanced pediatric resuscitation. All students and teachers considered the theoretical and practical formation received adequate. CONCLUSIONS basic and advanced pediatric life support courses are a useful educational method for the general population, health professionals, physicians and nurses in theoretical and practical pediatric resuscitation.

Postpyloric enteral nutrition in the critically ill child with shock: a prospective observational study

BackgroundTolerance to enteral nutrition in the critically ill child with shock has not been studied. The purpose of the study was to analyze the characteristics of enteral nutrition and its tolerance in the critically ill child with shock and to compare this with non-shocked patients.MethodsA prospective, observational study was performed including critically ill children with shock who received postpyloric enteral nutrition (PEN). The type of nutrition used, its duration, tolerance, and gastrointestinal complications were assessed. The 65 children with shock who received PEN were compared with 461 non-shocked critically ill children who received PEN.ResultsSixty-five critically ill children with shock, aged between 21 days and 22 years, received PEN. 75.4% of patients with shock received PEN exclusively. The mean duration of the PEN was 25.2 days and the maximum calorie intake was 79.4 kcal/kg/day. Twenty patients with shock (30.7%) presented gastrointestinal complications, 10 (15.4%) abdominal distension and/or excessive gastric residue, 13 (20%) diarrhoea, 1 necrotising enterocolitis, and 1 duodenal perforation due to the postpyloric tube. The frequency of gastrointestinal complications was significantly higher than in the other 461 critically ill children (9.1%). PEN was suspended due to gastrointestinal complications in 6 patients with shock (9.2%). There were 18 deaths among the patients with shock and PEN (27.7%). In only one patient was the death related to complications of the nutrition.ConclusionAlthough most critically ill children with shock can tolerate postpyloric enteral nutrition, the incidence of gastrointestinal complications is higher in this group of patients than in other critically ill children.

Transpyloric enteral nutrition in the critically ill child with renal failure

ObjectiveTo study the efficacy and tolerance of transpyloric enteral nutrition (TEN) in the critically ill child with acute renal failure (ARF).DesignProspective observational study.SettingPaediatric intensive care unit.PatientsCritically ill children with ARF who received TEN were included in the study. They were compared with the remaining 473 critically ill children receiving TEN in this period. Tolerance of nutrition and gastrointestinal complications were assessed.InterventionTranspyloric enteral nutrition.Measurements and resultsFifty-three critically ill children with ARF aged between 3 days and 17 years received TEN. Children with ARF more frequently received parenteral nutrition before TEN (56.6%) than the other patients (17.5%). The incidence of shock, hepatic alterations and mortality was significantly higher in patients with ARF than in the remaining children. In children with ARF the mean duration of the TEN was 16.5 ± 27.3 days and the maximum caloric intake was 77 ± 26.7 kcal/kg/day. Thirteen patients (24.5%) presented gastrointestinal complications, 9 (17%) abdominal distension and/or excessive gastric residue, 5 (9.4%) diarrhoea, 1 necrotising enterocolitis and 1 duodenal perforation. The frequency of gastrointestinal complications was significantly higher in children with ARF. TEN was definitive suspended in five patients due to gastrointestinal complications. Four of these patients were treated with continuous renal replacement therapy. Thirty percent of patients died during TEN. In only one patient was the death related to complications of the nutrition.ConclusionsCritically ill children with ARF tolerate TEN, although the incidence of gastrointestinal complications is higher than in other critically ill children.

Severe ischemia of the lower limb and of the intestine associated with systemic vasoconstrictor therapy and femoral arterial catheterization.

Objective: To report a case of peripheral and intestinal ischemia associated with arterial catheterization and terlipressin treatment in a child. Design: Case report. Setting: Pediatric intensive care unit of a university hospital. Patient: The patient was a 2-month-old female infant with shock refractory to treatment with catecholamines, who received treatment with terlipressin (20 &mgr;g/kg/4 hrs). In order to monitor her cardiac output, the right femoral artery was catheterized with a 4-Fr PiCCO catheter. At 60 hrs, the patient presented progressive ischemia of the right lower limb and intestinal ischemia. The ischemia did not improve despite withdrawal of the catheter and interruption of the terlipressin administration; it progressed to massive intestinal ischemia, and the patient died. Conclusions: Arterial catheterization combined with the administration of vasoconstrictor drugs, particularly vasopressin or terlipressin, can lead to local ischemic complications and severe intestinal ischemia in infants in shock.

Hepatic dysfunction after cardiac surgery in children.

Objective The objective of this study was to analyze the incidence and significance of hepatic dysfunction after cardiac surgery in children. Design Prospective, observational study. Setting Pediatric intensive care unit of a university hospital. Patients The study consisted of 232 children ranging in age from newborn to 17 years with no history of liver disease. Measurements and Main Results Aspartate aminotransferase (AST), alanine aminotransferase (ALT), gammaglutamyltranspeptidase (GGT), alkaline phosphatase, total and conjugated bilirubin, blood glucose, urea, creatinine, and coagulation studies were determined at admission, at 24 and 48 hrs, and at 7 days. Hepatic dysfunction was taken as an ALT of > 100 IU/L or a moderate or high hepatic score. The statistical study included bivariate analysis and multivariate logistic regression to study the risk factors for hepatic dysfunction. Twenty-one patients (9%) showed an ALT > 100 IU/L, and 29.3% had a moderate or high hepatic score. A relationship was found between hepatic dysfunction and the type of cardiopathy (D-transposition of the great arteries and coarctation of the aorta), shock, the administration of dopamine or epinephrine, renal insufficiency, the presence of pulmonary changes (pulmonary edema, atelectasis, pulmonary hypertension, hypoxemia), hematologic disturbances (prothrombin time, kaolin-cephalin time, fibrinogen, and platelets), and the need for a greater number of transfusions of packed cells, plasma, and platelets. Compared with 7.6% of the rest of the patients (p < .001), 38% of patients with an ALT > 100 IU/L died. The hepatic score of those patients who died was 4.2 (2.3)—higher than that of the survivors at 1.5 (1.8), (p < .001). Shock and renal insufficiency were the factors most significantly related to the development of hepatic dysfunction. Conclusions Hepatic dysfunction is an uncommon complication in children after cardiac surgery. This complication is related mainly to hemodynamic disturbances and renal insufficiency and is an indicator of poor prognosis.

Nutritional status and clinical outcome of children on continuous renal replacement therapy: a prospective observational study

BackgroundNo studies on continuous renal replacement therapy (CRRT) have analyzed nutritional status in children. The objective of this study was to assess the association between mortality and nutritional status of children receiving CRRT.MethodsProspective observational study to analyze the nutritional status of children receiving CRRT and its association with mortality. The variables recorded were age, weight, sex, diagnosis, albumin, creatinine, urea, uric acid, severity of illness scores, CRRT-related complications, duration of admission to the pediatric intensive care unit, and mortality.ResultsThe sample comprised 174 critically ill children on CRRT. The median weight of the patients was 10 kg, 35% were under percentile (P) 3, and 56% had a weight/P50 ratio of less than 0.85. Only two patients were above P95. The mean age for patients under P3 was significantly lower than that of the other patients (p = 0.03). The incidence of weight under P3 was greater in younger children (p = 0.007) and in cardiac patients and in those who had previous chronic renal insufficiency (p = 0.047). The mortality analysis did not include patients with pre-existing renal disease. Mortality was 38.9%. Mortality for patients with weight < P3 was greater than that of children with weight > P3 (51% vs 33%; p = 0.037). In the univariate and multivariate logistic regression analyses, the only factor associated with mortality was protein-energy wasting (malnutrition) (OR, 2.11; 95% CI, 1.067-4.173; p = 0.032).ConclusionsThe frequency of protein-energy wasting in children who require CRRT is high, and the frequency of obesity is low. Protein-energy wasting is more frequent in children with previous end-stage renal disease and heart disease. Underweight children present a higher mortality rate than patients with normal body weight.

Nosocomial outbreak of Clostridium difficile-associated disease in a pediatric intensive care unit in Madrid.

Unit in Madrid • Author(s): Amaya Bustinza, MD; Maria José Solana, MD; Belén Padilla, MD; Jesús López‐Herce, MD, PhD; Maria José Santiago, MD; Mercedes Marin, PharmD, PhD Source: Infection Control and Hospital Epidemiology, Vol. 30, No. 2 (February 2009), pp. 199201 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/593958 . Accessed: 16/05/2014 17:40