Daniela Arriagada S

Asplenia congénita y purpura fulminans neumocóccico en paciente pediátrico: Reporte de caso con necropsia y revisión del tema

La condicion de asplenia predispone a infecciones invasoras por bacterias capsuladas. Desconocer previamente ese antecedente dificulta y retarda el tratamiento medico. Streptococcus pneumoniae es el agente habitualmente causal de sepsis en estos pacientes. Los individuos asplenicos son particularmente proclives a evolucionar con shock septico y eventual-mente al desarrollo de purpura fulminans, entidad altamente letal. Comunicamos el caso de una paciente con 3 anos de edad y antecedente de cardiopatia y neumonias a repeticion. Ingreso con compromiso sensorial, febril, hipotensa, con purpura y livedo reticularis. En los examenes de laboratorio destacaba la presencia de leucopenia (3.400/ mm3) trombopenia e hipoprotrombinemia (39%). Se inicio ventilacion mecanica, reanimacion con volumen, farmacos vasoactivos y antibioterapia con vancomicina, clindamicina y ceftriaxona. Evoluciono con shock septico refractario y sindrome de disfuncion organica multiple. Al segundo dia de evolucion una ecograna de abdomen comprobo la ausencia de bazo. En el frotis sanguineo se evidenciaron corpusculos de Howell-Jolly. Hemocul-tivo (+) S. pneumoniae resistente a penicilina (serotipo 19F). Un infarto hemorragico cerebral ocasiono su deceso al octavo dia. El estudio necropsico corroboro la asplenia y evidencio necrohemorragia suprarrenal bilateral. La sepsis en un paciente asplenico puede ser de alguna forma prevenible mediante profilaxis antimicrobiana y vacunacion neumococcica. Dado los antecedentes de la paciente la busqueda de asplenia era fundamental.

Botulismo infantil: Comunicación de un caso clínico y revisión de la literatura

Botulism is a rare disease in Chile and of the known clinical presentation, infant botulism is the most common. We report the case of a previously healthy seven month old male infant with a two weeks history of rinorrea, cough, fatigue, constipation and progressive weakness after the consumption of honey. Stool cultures were positive for Clostridium botulinum group 1 type A and electromyography was compatible with the diagnosis. The patient evolved with arterial hypertension, interpreted as secondary to autonomic dysfunction, which responded to calcium channel blockers. Muscle tone improved progressively during the following four weeks. Infant botulism is a potentially fatal disease; diagnosis can be difficult given the broad clinical manifestations. Prevention should focus on education of parents of infants as well as medical personnel.

La microcirculación en el paciente crítico: Parte II: evaluación y microcirculación como objetivo terapéutico

Microcirculation in the critically ill patient. Part II: evaluation and microcirculation as a therapeutic target Severe sepsis and septic shock involve circulatory, inflammatory and metabolic disorders eventually resulting in a disruption of cellular energy. Microcirculatory disturbances are common in septic patients. Direct obser- vation using sidestream dark field (SDF) videomicroscopy has enabled the construction of microcirculatory failure as a clinical concept in the critically ill patients. Many therapeutic interventions routinely used in the treatment of critically ill patients seem to be associated with limited changes in microcirculatory perfusion, irrespective of systemic hemodynamics, given the heterogeneous nature of these changes and the mechanisms potentially involved. (Key words: Microcirculation, endothelium, capillary, sepsis, shock, circulatory failure, organ failure). Rev Chil Pediatr 2013; 84 (2): 194-204

Shock séptico en pediatría I. Enfoque actual en el diagnóstico y tratamiento

Septic shock in pediatrics I. Current approach in diagnosis and therapeutics Septic shock is a major cause of infant mortality worldwide and represents the progressive underlying inflam matory pathway secondary to an infectious disease, which causes acute cardiovascular dysfunction, not necessarily hypotension, tissue dysoxia and eventually cellular and organ failure. Standard resuscitative measures emphasize clinical recognition and early treatment. These interventions are based on early and aggressive resuscitation with intravenous fluids to optimize tissue perfusion, antibiotics, removal of the source of infec tion and the use of vasoactive drugs if necessary. Therapy should be permanently evaluated according to the standardized laboratory and clinical targets. This publication is an update on the epidemiology and pathophysiology of sepsis, operational definitions, current international campaigns and initiatives concerning proposals to decrease the morbidity and mortality of this condition. It also addresses initial therapeutic approaches in the emergency room. The aim of this study is to present the current state of knowledge in the diagnosis and treatment of patients with septic shock especially in the initial phase before admissions to intensive care units. (Key words: Sepsis, septic shock, bacteremia, resuscitation, pediatric emergency). Rev Chil Pediatr 2013; 84 (5): 484-498

Evaluación de la microcirculación sublingual en un paciente en shock séptico

Sublingual microcirculation asessment in a patient with septic shock Introduction: Septic shock involves a complicated network of circulatory, infl ammatory and metabolic disturbances,leading to cellular energetic disruption. Microcirculatory alterations are frequently observed in septic shock, being characteristic the presence of weak microcirculatory units and heterogeneous microcircu- latory fl ow. Clinical case: A female patient, two months of age, with a pulmonary process-originated septic shock is presented. The description of microcirculation alterations at 24, 72 and 120 hrs was performed while the patient underwent therapy. A MicroScan®, (MicroVision Medical, Amsterdam, Holland) was utilised on the sublingual area. The patient received ventilation support, reanimation fl uids, vasoactive drugs and antibiot- ics. The patient presented low proportion of perfused capillary vessels, low ratio of microcirculatory fl ow and a high heterogeneity in fl ow in the fi rst measurement, all of them independant from systemic hemodynamics and disoxia indicators. These severe alterations improved progressively at 72 and 120 hrs of therapy. Discus- sion: Microcirculatory alterations and its time evolution may be a tool for dynamic diagnostic and severity staging assesment in septic shock. Further studies should assess microcirculation as a target for therapeutic intervention (microcirculatory resuscitation), being also of prognostic value for septic shock and severe sepsis in children.

El niño con Síndrome de Down en la Unidad de Cuidados Intensivos

Down syndrome is the most common chromosomal abnormality in newborns, with a high incidence in Chile. This condition presents unique physiological aspects that should be known, which can affect the child during their stay in an Intensive Care Unit, beyond the neonatal period This review is focused on the respiratory, cardiovascular, infectious and neurological disorders. Anesthetic management and postoperative analgesia considerations, weaning from mechanical ventilation, cervical spine instability and prognosis of the critically ill child with Down syndrome are also analyzed. The evaluation of these conditions should be performed when the patient is admitted to the intensive care unit. The purpose of this update is to update the knowledge of the diagnosis and treatment of potential complications of children with Down syndrome during their stay in the unit of critical patient.

La microcirculación en el paciente crítico: Parte I: generalidades y fisiología en el paciente séptico

Microcirculation in the critically ill. Part I: Review and physiology of septic patients Severe sepsis and septic shock involve circulatory, inflammatory and metabolic disorders eventually resulting in a disruption of cellular energy. Microcirculatory disturbances are common in septic patients. Microcir- culation is the primary site of oxygen and nutrients exchange to cells. Direct observation using Sidestream Dark Field (SDF) imaging has allowed direct visualization of microcirculatory failure in critically ill patients. Septic shock is characterized by weak or vulnerable microcirculatory units and heterogeneity of microcircula- tory flow. Multiple mechanisms may contribute to these alterations, including endothelial dysfunction, altered glycocalyx, impaired inter-cell communication and adhesion and rolling of white blood cells and platelets. Many therapeutic interventions routinely used in the treatment of critically ill patients seem to result in limi- ted changes in microcirculatory perfusion, irrespective of systemic hemodynamics, due to the heterogeneous nature of these changes and the potentially involved mechanisms. Therefore, microcirculatory alterations and their presence in states of shock, especially in septic shock, can represent diagnostic and severity stratification tools and may be a target for therapeutic intervention (microcirculatory resuscitation), besides suggesting a prognostic role. (Key words: Microcirculation, endothelium, capillary, sepsis, shock, circulatory failure, organ failure). Rev Chil Pediatr 2013; 84 (1): 83-92