Franco Díaz

Coqueluche grave: Estado del arte

La coqueluche (tos ferina) es una enfermedad infecto-contagiosa, que ha resurgido en los ultimos anos como problema de salud publica en nuestro pais. La presentacion clinica no ha cambiado, siendo los lactantes bajo un ano el principal grupo de riesgo, evolucionando, en ocasiones hacia un cuadro altamente letal denominada coqueluche maligna o grave. En la presente revision se discute su epidemiologia, mecanismos de patogenicidad como tambien se describen los factores de riesgo, caracteristicas clinicas de esta evolucion y su fisiopatologia. Se presenta la evidencia actual, utilidad de nuevos tratamientos y una propuesta de algoritmo terapeutico.

Respiratory and hemodynamic effects of a stepwise lung recruitment maneuver in pediatric ARDS: A feasibility study

Little is known about the efficacy and safety of recruitment maneuvers (RMs) in pediatric patients with acute respiratory distress syndrome (ARDS). We therefore assessed the effects on gas exchange and lung mechanics and the possible detrimental effects of a sequential lung RMs and decremental positive end‐expiratory pressure (PEEP) titration in pediatric ARDS patients.

Mild hypothermia attenuates lung edema and plasma interleukin-1β in a rat mechanical ventilation-induced lung injury model

ABSTRACT Recent data suggest that deep hypothermia has protective effects on experimental induced lung injury. It is not well known if these effects persist with mild hypothermia. The authors hypothesized that mild hypothermia may attenuate lung injury and decrease local and systemic proinflammatory cytokines in a rat model of injurious mechanical ventilation (MV). Twelve Sprague-Dawley male adult rats were anesthetized, intubated, and randomly allocated to normothermia group (37°C) (NT) or mild hypothermia group (34°C) (MH). After 2 hours of deleterious MV (peak inspiratory pressure [PIP] 40 cm H2O, zero end-expiratory pressure [ZEEP], and inspiratory fraction of oxygen [Fio2] 100%), arterial blood gases, lung gravimetry, and histological study were obtained. Protein content, interleukin (IL)-1β, and tumor necrosis factor (TNF)-α were measured in plasma and bronchoalveolar lavage (BAL) fluid. Subjects that underwent MH had a significant lower wet-to-dry lung weight ratio (8.32 ± 0.28 vs. 10.8 ± 0.49, P = .01), IL-1β plasma concentration (0.6 ± 0.6 vs. 10.27 ± 2.80 pg/mL, P = .0048) and Paco2. There were no differences in terms of Pao2, histological injury, or BAL protein content. In this model of injurious mechanical ventilation, subjects treated with mild hypothermia had less lung edema and lower plasma IL-1β. Some of known beneficial effects of deep hypothermia can be obtained with mild hypothermia.

Central Venous Lines Are a Risk Factor for Chylothorax in Infants After Cardiac Surgery

Objective: Chylothorax complicates congenital heart disease (CHD) surgery and may be associated with significant morbidity. Etiology of chylothorax is multifactorial, and it has been associated with deep venous thrombosis and obstruction from central venous lines (CVLs) in patients without CHD. We sought to determine whether CVL insertion site was associated with the occurrence of chylothorax in infants after cardiac surgery. Design: Retrospective cohort of patients less than one year of age who underwent CHD surgery requiring cardiopulmonary bypass from 2008 to 2012. Chylothorax was identified by clinical diagnosis and/or laboratory findings (milky effusion, fluid with >100 mg/dL of triglycerides and/or >80% of lymphocytes). Central venous lines insertion site was verified by reviewing procedure notes and chest x-rays. Internal jugular (IJ), subclavian vein, and femoral vein (FV) CVLs were used during the study period. Results: Three hundred and ninety-two patients were included (mean age 97 days, mean weight 4.5 kg). Sixty-two (15.8%) of these patients developed chylothorax after surgery. Patients with chylothorax had longer bypass time (P = .02), longer cross-clamp time (P = .03), higher RACHS-1 category (P = .03), and more frequent upper body CVLs (IJ or subclavian vein; P = .03). There was no significant association with age, gender, preoperative weight, and height. Multivariate analysis showed patients with a CVL in the upper body (IJ or subclavian vein) were almost two times more likely to develop a chylothorax than patients who had FV CVL, (odds ratio = 1.9, 95% confidence interval = 1.05-5.60; P = .044). Conclusion: Postoperative chylothorax is associated with line insertion in the upper body (subclavian vein and IJ). Avoidance of CVLs in these locations may decrease its incidence.

Surfactant deactivation in a pediatric model induces hypovolemia and fluid shift to the extravascular lung compartment.

Surfactant deficiency is the pivotal abnormality in Neonatal and Acute Respiratory Distress Syndrome. Surfactant deactivation can produce hypoxemia, loss of lung compliance, and pulmonary edema, but its circulatory consequences are less understood.

Mild hypothermia increases pulmonary anti-inflammatory response during protective mechanical ventilation in a piglet model of acute lung injury

The effects of mild hypothermia (HT) on acute lung injury (ALI) are unknown in species with metabolic rate similar to that of humans, receiving protective mechanical ventilation (MV). We hypothesized that mild hypothermia would attenuate pulmonary and systemic inflammatory responses in piglets with ALI managed with a protective MV.

Fluid overload and outcomes in critically ill children: A single center prospective cohort study

Objective: To prospectively evaluate the association between fluid overload (FO) and clinical outcomes, mortality, mechanical ventilation (MV), and duration and length of stay in a pediatric intensive care unit (PICU). Methods: Over a 12‐month period, patients who were on MV for > 24 h or vasoactive support were prospectively included. Demographic and clinical data were recorded. Daily FO was calculated as [(fluid in − fluid out) / admission weight] × 100%. Multivariate stepwise logistic regression analysis was used to determine predictors of survival. Results: 224 patients were included; median age was 3.3 (IQR 0.7, 9.9) years, mortality was 15.6%. The median peak FO (PFO) was 12.5% (IQR 5, 25), PFO > 10% was present in 55.8% of patients, and PFO > 20% was present in 33%. The PFO in non‐survivors was 17.8% (IQR 8, 30) and 11% (IQR 4, 23) in survivors (p = 0.028). A survival analysis showed no association between PFO and mortality. A multivariate analysis identified vasoactive support, > 3 organ failures and acute kidney injury (AKI) but not FO as independent risk factors for mortality. FO was associated with MV duration and PICU length of stay. Conclusion: FO is frequent in a general PICU population, but PFO is not an independent risk factor for mortality. Future studies of FO should focus on patients with AKI and multiorgan failure for better classification of severity and potential interventions. HighlightsFluid overload is frequent in critically ill children.Non‐survivors had higher peak fluid overload than survivors in this general PICU cohort.Fluid overload is not independently associated with mortality.Fluid overload is associated with significant morbidity, like duration of mechanical ventilation.

Sífilis congénita: presentación como shock séptico después del período neonatal

El espectro clinico de la sifilis congenita varia desde la infeccion asintomatica a una sepsis fulminante. Comunicamos el caso de un recien nacido de sexo femenino, de 27 dias de edad, sano, sin antecedentes maternos, con adecuado control obstetrico y screening prenatal negativo. Consulto por fiebre y lesiones cutaneas de 24 h de evolucion. Ingreso a unidad de cuidados intensivos con compromiso sensorial, hiporeactividad, con lesiones descamativas eritematosas peribucales, palmo-plantares y hepato-esplenomegalia. En los examenes de laboratorio destaco la presencia de anemia, leucocitosis, trombo-citopenia y PCR elevada. Evoluciono con shock septico, hipoalbuminemia y acidosis metabolica. Se diagnostico sifilis congenita por VDRL con titulos 1:128 y VDRL en LCR con titulos 1:8; el VDRL materno fue 1:32. Completo terapia con penicilina G i.v. por tres semanas con adecuada respuesta clinica y de laboratorio. La sifilis congenita puede no ser diagnosticada al momento del nacimiento, por ende se debe tener un alto indice de sospecha, considerando los posibles errores en la serologia prenatal y las variadas formas de presentacion clinica, incluida la sepsis neonatal, durante el primer mes de vida.Clinical spectrum of congenital syphilis ranges from asymptomatic infection to fulminant sepsis. Treponema pallidum is acquired crossing the placenta from the mother to the fetus during maternal spirochetemia or through direct contact of the child with an infected lesion at delivery. We report a 27 days-old previously healthy girl diagnosed with congenital syphilis. Her mother had an unremarkable previous history, adequate obstetric care and negative prenatal screening test for syphilis. The patient was brought to the ER due to development of skin lesions and fever in the last 24 h. She was admitted to pediatric ICU lethargic and poorly responsive, with hepa-tosplenomegaly and perioral, palmoplantar erythematous desquamative scaly lesions. Laboratory data revealed anemia, leukocytosis, thrombocytopenia and C-reactive protein of 183 mg/l. Soon after admission she developed septic shock with leukocytosis up to 45,800/mm3 and exacerbation of thrombocytopenia, hypoalbuminemia and metabolic acidosis. Congenital syphilis was diagnosed at the second day of admission with VDRL titers of 1:128 in serum and 1:8 in cerebrospinal fluid. Maternal serum VDRL was positive with titers of 1:32. The patient was treated with penicillin for three weeks with adequate clinical and laboratory response. Congenital syphilis is a life threatening infection, but cannot always be diagnosed at birth. Health care workers must be aware of the difficulties in obtaining a definitive diagnosis and must have a high index of suspicion, considering the possible errors of prenatal serology and the diverse possible clinical presentations, including neonatal sepsis during the first month of life.

Decreased lung compliance increases preload dynamic tests in a pediatric acute lung injury model

BACKGROUND Preload dynamic tests, pulse pressure variation (PPV) and stroke volume variation (SVV) have emerged as powerful tools to predict response to fluid administration. The influence of factors other than preload in dynamic preload test is currently poorly understood in pediatrics. The aim of our study was to assess the effect of tidal volume (VT) on PPV and SVV in the context of normal and reduced lung compliance in a piglet model. MATERIAL AND METHOD Twenty large-white piglets (5.2±0.4kg) were anesthetized, paralyzed and monitored with pulse contour analysis. PPV and SVV were recorded during mechanical ventilation with a VT of 6 and 12mL/kg (low and high VT, respectively), both before and after tracheal instillation of polysorbate 20. RESULTS Before acute lung injury (ALI) induction, modifications of VT did not significantly change PPV and SVV readings. After ALI, PPV and SVV were significantly greater during ventilation with a high VT compared to a low VT (PPV increased from 8.9±1.2 to 12.4±1.1%, and SVV from 8.5±1.0 to 12.7±1.2%, both P<0.01). CONCLUSIONS This study found that a high VT and reduced lung compliance due to ALI increase preload dynamic tests, with a greater influence of the latter. In subjects with ALI, lung compliance should be considered when interpreting the preload dynamic tests.

Tetania severa por uso de enemas fosfatados, reporte de caso

Phosphate enemas are frequently used in the treatment of constipation. Errors in dosage and administration can lead to severe complications. OBJECTIVE To report a case of severe toxicity of phosphate enemas in a child with no risk factors. CASE 2 years old female, with functional constipation, was brought to emergency department because abdominal pain. She was diagnosed with fecal impaction and received half a bottle of Fleet Adult® (Laboratorio Synthon, Chile) two times, with no clinical resolution, deciding to start proctoclisis in pediatric ward. Soon after admission, she presented painful tetany, but alert and oriented. Patient was transferred to PICU where severe hyperphosphatemia and secondary hypocalcemia were confirmed. Her treatment included electrolyte correction; removal of residual phosphate enema and hyperhydration. Tetany resolved over 2 hours after admission and no other complications. Proctoclisis was performed and patient was discharged three days after admission with pharmacological management of constipation. CONCLUSION Phosphate enemas may cause serious complications in children with no risk factors. Errors in dosage, administration and removal of the enema are causes of toxicity in this group. Pediatricians and health personnel must be aware of risks and signs of toxicity of phosphate enema.