Blanca Toledo

Sevoflurane Therapy for Severe Refractory Bronchospasm in Children

Objectives: To describe the effect of inhaled sevoflurane in the treatment of severe refractory bronchospasm in children. Design: Retrospective case series. Setting: Two PICUs of tertiary general university hospitals in Spain. Patients: Ten patients ranging from 5 months to 14 years old with severe bronchospasm and acute respiratory failure requiring tracheal intubation and mechanical ventilation and treated with sevoflurane from 2008 to 2015. Intervention: Inhaled sevoflurane therapy was initiated after failure of conventional medical management and mechanical ventilation. In two patients, sevoflurane was administered through a Servo 900C ventilator (Maquet, Bridgewater, NJ) equipped with a vaporizer and in the other eight patients via the Anesthetic Conserving Device (AnaConDa; Sedana medical, Uppsala, Sweden) with a critical care ventilator. Measurements and Main Results: Inhaled sevoflurane resulted in statistically significant decreases of PaCO2 of 34.2 torr (95% CI, 8.3–60), peak inspiratory pressure of 14.3 cm H2O (95% CI, 8.6–19.9), and improvement in pH of 0.17 (0.346–0.002) within 6 hours of administration. Only one patient presented hypotension responsive to volume administration at the beginning of the treatment. All patients could be extubated within a median time of 120 hours (interquartile range, 46–216). Conclusions: Inhaled sevoflurane therapy decreases the levels of PaCO2 and peak inspiratory pressure values, and it may be considered as a rescue therapy in patients with life-threatening bronchospasm refractory to conventional therapy.

Evolución a largo plazo de los niños tratados con técnicas de depuración extrarrenal continua

INTRODUCTION The objective of this study is to analyze long-term outcomes and kidney function in children requiring continuous renal replacement therapy (CRRT) after an acute kidney injury episode. PATIENTS AND METHODS A retrospective observational study was performed using a prospective database of 128 patients who required CRRT admitted to the pediatric intensive care unit between years 2006 and 2012. The subsequent outcomes were assessed in those surviving at hospital discharge. RESULTS Of the 128 children who required RRT in the pediatric intensive care unit, 71 survived at hospital discharge (54.4%), of whom 66 (92.9%) were followed up. Three patients had chronic renal failure prior to admission to the NICU. Of the 63 remaining patients, 6 had prolonged or relapses of renal function disturbances, but only one patient with atypical Hemolytic Uremic Syndrome developed end-stage renal failure. The rest had normal kidney function at the last check-up. CONCLUSIONS Most of surviving children that required CRRT have a positive outcome later on, presenting low mortality rates and recovery of kidney function in the medium term.

Acetazolamide Therapy for Metabolic Alkalosis in Pediatric Intensive Care Patients

Objective: Patients in PICUs frequently present hypochloremic metabolic alkalosis secondary to loop diuretic treatment, especially those undergoing cardiac surgery. This study evaluates the effectiveness of acetazolamide therapy for metabolic alkalosis in PICU patients. Design: Retrospective, observational study. Setting: A tertiary care children’s hospital PICU. Patients: Children receiving at least a 2-day course of enteral acetazolamide. Interventions: None. Measurements and Main Results: Demographic variables, diuretic treatment and doses of acetazolamide, urine output, serum electrolytes, urea and creatinine, acid-base excess, pH, and use of mechanical ventilation during treatment were collected. Patients were studied according to their pathology (postoperative cardiac surgery, decompensated heart failure, or respiratory disease). A total of 78 episodes in 58 patients were identified: 48 were carried out in cardiac postoperative patients, 22 in decompensated heart failure, and eight in respiratory patients. All patients received loop diuretics. A decrease in pH and PCO2 in the first 72 hours, a decrease in serum HCO3– (mean, 4.65 ± 4.83; p < 0.001), and an increase in anion gap values were observed. Urine output increased in cardiac postoperative patients (4.5 ± 2.2 vs 5.1 ± 2.0; p = 0.020), whereas diuretic treatment was reduced in cardiac patients. There was no significant difference in serum electrolytes, blood urea, creatinine, nor chloride after the administration of acetazolamide from baseline. Acetazolamide treatment was well tolerated in all patients. Conclusions: Acetazolamide decreases serum HCO3– and PCO2 in PICU cardiac patients with metabolic alkalosis secondary to diuretic therapy. Cardiac postoperative patients present a significant increase in urine output after acetazolamide treatment.

Cisplatin-Induced Non-Oliguric Acute Kidney Injury in a Pediatric Experimental Animal Model in Piglets

Objective To design an experimental pediatric animal model of acute kidney injury induced by cisplatin. Methods Prospective comparative observational animal study in two different phases. Acute kidney injury was induced using three different doses of cisplatin (2, 3 and 5 mg/kg). The development of nephrotoxicity was assessed 2 to 4 days after cisplatin administration by estimating biochemical parameters, diuresis and renal morphology. Analytical values and renal morphology were compared between 15 piglets treated with cisplatin 3 mg/kg and 15 control piglets in the second phase of the study. Results 41 piglets were studied. The dose of 3 mg/kg administered 48 hours before the experience induced a significant increase in serum creatinine and urea without an increase in potassium levels. Piglets treated with cisplatin 3 mg/kg had significantly higher values of creatinine, urea, phosphate and amylase, less diuresis and lower values of potassium, sodium and bicarbonate than control piglets. Histological findings showed evidence of a dose-dependent increase in renal damage. Conclusions a dose of 3 mg/kg of cisplatin induces a significant alteration in renal function 48 hours after its administration, so it can be used as a pediatric animal model of non-oliguric acute kidney injury.

Comparison between manual and mechanical chest compressions during resuscitation in a pediatric animal model of asphyxial cardiac arrest

Aims Chest compressions (CC) during cardiopulmonary resuscitation are not sufficiently effective in many circumstances. Mechanical CC could be more effective than manual CC, but there are no studies comparing both techniques in children. The objective of this study was to compare the effectiveness of manual and mechanical chest compressions with Thumper device in a pediatric cardiac arrest animal model. Material and methods An experimental model of asphyxial cardiac arrest (CA) in 50 piglets (mean weight 9.6 kg) was used. Animals were randomized to receive either manual CC or mechanical CC using a pediatric piston chest compressions device (Life-Stat®, Michigan Instruments). Mean arterial pressure (MAP), arterial blood gases and end-tidal CO2 (etCO2) values were measured at 3, 9, 18 and 24 minutes after the beginning of resuscitation. Results There were no significant differences in MAP, DAP, arterial blood gases and etCO2 between chest compression techniques during CPR. Survival rate was higher in the manual CC (15 of 30 = 50%) than in the mechanical CC group (3 of 20 = 15%) p = 0.016. In the mechanical CC group there was a non significant higher incidence of haemorrhage through the endotracheal tube (45% vs 20%, p = 0.114). Conclusions In a pediatric animal model of cardiac arrest, mechanical piston chest compressions produced lower survival rates than manual chest compressions, without any differences in hemodynamic and respiratory parameters.

PS-240 Developing A Toxic Paediatric Animal Model Of Non-oliguric Acute Renal Injury With Cisplatin

Introduction Developing a non-oliguric paediatric animal model of acuterenal injury (AKI) could be useful to study the evolution of diuresis after treatments. Cisplatin causes a dose-dependant poliuric renal failure in humans. A dose of 5 mg/kg has been used in rats to produced AKI but there are no studies in pigs. Objectives To define the target dose of Cisplatin that develops anon-oliguric toxic acute kidney injury in piglets. Methods A prospective experimental study was performed in 8 piglets (mean 10 kg). Three different intravenous doses of Cisplatin (2, 3 and5 mg/kg) and two different periods of time between administration and evaluation (2 and 4 days) were studied. Urine and blood samples were collected. Results Results are presented in Table 1. A dose of 2 mg/kg did not produce important alteration of renal function at any given time. A very severe oliguric AKI with extremely high hyperkalemia was observed four days after a 3 mg/kg dose and 3 days after a 5 mg/kd dose. A dose of 3 mg/kg administrated 48 h before produced an important AKI without severe hyperkalemia. Abstract PS-240 Table 1 Cisplatin dose mg/kg Days after inyection Initial diuresis (ml/h) Creatinine (mg/dL) Urea (mg/dL) Sodium (mmol/L) Potasium (mmol/L) Phosphate (mg/dL) 2 4 - 1.0 46 140 4.3 - 2 4 31 0.9 45 138 4.5 6.8 3 2 20 3.6 174 138 4.6 13.5 3 2 22 1.5 142 135 3.4 15 3 2 38 4.2 209 132 5.9 16 3 2 30 3.8 189 137 4.2 15.8 3 4 7 9.5 518 137 8.7 20.3 5 3 1 5.5 409 120 10.4 14.8 Conclusions A dose of 3 mg/kgof intravenous cisplatin producednon-oliguric AKI after 48 h in piglets. This dose and interval can be used for toxic paediatric animal models of AKI.

PO-0264 Constipation Treatment Protocol In Critically Ill Children

Backgrounds and aims Constipation in critically ill patients is associated with severity of illness. There are no clinical guidelines in critically ill children. The aim of this study is to review the results with our treatment protocol. Methods Prospective observational study including children admitted to the PICU >3 days. Constipation was defined as ≥4 days with no stools. Constipation was treated with saline rectal enemas or polyethylene glycol + ions (PEGI). PEGI was prepared mixing one paediatric packet (6.9 g) with 20 ml of water. Initial dose was 1–2 ml/kg/8 h and after intestinal transit was observed, it was diminished to 0,5–1 ml/kg/24 h. Adult preparation form (13,8 g) in 40 ml of water was used in children >25 kg. Clinical and demographic data were recorded. Results 68/150 patients (45.3%), median age 38.5 months (IQR 8.5–82.5) had constipation. Rectal enemas were administered to 15 patients (19.2%). It was useful (stool produced within the next two hours) in 50% of them. 47 patients (60.2%) were treated with PEGI obtaining stool production in the next 48 h in 60.3% of them. Median (IQR) dose of PGEI was 0.9 (0.6–1.3 g/kg/day). Median (IQR) time to first stool production after PEGI was 1 (0–2 days). Diarrhoea was the most frequent side effect observed in 4 patients with PEGI. Conclusions Constipation in critically ill children is a very common problem. Our treatment protocol seems to be useful and secure. More studies are necessary to evaluate treatment efficacy and security and to develop clinical guidelines.

O-070 Haemodynamic Impact Of The Connection Of Continuous Renal Replacement Therapy In Critically Ill Children

Background Continuous Renal Replacement Therapies (CRRT) are the treatment of choice for critically ill children with Acute Renal Injury. Hypotension after starting CRRT is frequent but there are no studies that have analysed their incidence and importance. Patients and methods A prospective, observational study was performed including critically ill children treated with CRRT between October 2009 and December 2013. Hemodynamic data and connection characteristics were collected before, during and 60 min after CRRT circuit connection. Hypotension with the connection was defined as a decrease in mean arterial pressure >20% from baseline and/or intravenous fluid expansion and/or if increase in vasopressors was required. Results 161 connections in 36 children (median age 18.8 months) were analysed. 28 patients (77.8%) were in the postoperative period of cardiac surgery, 94% on mechanical ventilation and 86.1% with vasopressors. The circuit prime was discarded in 8.7% of connections, the heparinised prime was infused in 18% and the circuit was previously primed witha colloid (albumin in 77.5%) or crystalloid without heparine in 73.3%. Hypotension occurred in 49.7% of connections with a median of 5 min after the beginning. In 38.5% of the connections fluid expansion was required and in 12.4% vasopressors were increased. There was no hypotension relation to age or weight. Previous priming of the circuit reduced the frequency of hypotension to 44.6% vs. 71.4% (p = 0.004). Conclusions Hypotension after CRRT connection is very frequent in critically ill children. Priming the circuit improves hemodynamic tolerance of the connection.