Franco Díaz R

Consecuencias hemodinámicas y respiratorias del síndrome compartimental abdominal en un modelo experimental

Hemodynamic and respiratory alterations in an experimental abdominal compartment syndrome model 2 , p = 0.01) and abdominal perfu- sion pressure by 20% (72.3 ± 3.2 to 57.3 ± 4.0 mmhg, p <0.001) without changes in heart rate, arterial or cen- tral venous pressure. in addition there was an approximately 50% worsening of respiratory system compliance (1.28 ± 0.09 to 0.62 ± 0.04 ml/cmh2O/kg, p = 0.002) associated with a significant increase in intrathoracic pressure and slight decrease in oxygenation. Discussion: in this experimental model, the early development of hemodynamic and pulmonary dysfunction could be observed. a reduction of cardiac output that was not detec - ted by conventional monitoring and a substantial deterioration of lung mechanics, characteristic of restrictive disease, associated with mild alterations in gas exchange were reported.

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.

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

Rol de la evaluación preparticipativa en adolescentes, en el diagnóstico de enfermedades cardiovasculares y prevención de muerte súbita

Promotion of physical activity must be a priority in all modern societies, but there are some persons with medical conditions that can develop serious symptoms associated with sports, that can even be fatal, such as sudden death (SD). Adolescents are the age groups with the higher level of participation in recreation or competitive sports. International studies have demonstrated that approximately 1:250.000 adolescents die during the practice of sports. Of these, 50% had a prodrome 24 hours before the event and 75% had an underlying cardiovascular disease. Therefore, adolescents should be screened for cardiovascular diseases prior to their engagement in sports. This review gives a scientific approach to this issue, usually oversized by mass media. It also analyzes and reports international governmental strategies and practical tools for the clinician that must perform this type of screening.

Caracterización de la ventilación mecánica no invasiva pediátrica hospitalaria

Background: Non-invasive mechanical ventilation (NIMV) has been established in the last decade in many Pediatric ICUs worldwide. However, several questions are still present about the real use of this therapy in our country. Objective: To describe the use of NIV in Chile in 2005. Method: A survey was sent by internet to all 43 Chilean PICU, in order to record some aspects like epidemiology, cause of hospitalization, human and material resources, technical parameters and complications regarding every patient ventilated with NIMV during 2005. Collected data was analyzed considering the overall sample and also separated by geographical regions (13 regions including the Metropolitan) and administrative issue (public or private centers). Results: 21 units answered the survey (49%), mostly (59%) from public hospitals in the Metropolitan Region. 4 centers did not use NIV in that period, all of them from provinces. This therapy was never instituted outside the ICU or High Dependency Unit (HDU). 68% of the units had this therapy since at least 2 years ago. 71% of the units provided NIMV up to 30 patients and 3 units ventilated between 100 and 400 patients in 2005. 71% answered that the average duration of NIV was 2-4 days. The most frequent diagnoses were asthma and pneumonia. The failure rate varied from < 1% to 50%. 55% of the units did not have defined criteria of institution or withdrawal of this ventilatory support and, also, 70% did not have a written guideline. Conclusion: We had a low response rate to the survey. At least 10% of all of the PICUs do not provide NIV in Chile. We found remarkable diversities among the different units regarding the number of treated patients, criteria of institution and withdrawal of NIMV, failure rate and absence of guidelines. The information obtained in this survey should be known and analyzed by health team members in order to ensure a more sensible and rigorous use of the NIMV.

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.

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

Shock cardiogénico causado por implantación anómala de arteria coronaria

Introduccion: Las anomalias de implantacion de las arterias coronarias constituyen menos del 1% de las cardiopatias congenitas. La implantacion anomala de la arteria coronaria izquierda (IAACI) es la mas frecuente y se presenta habitualmente con manifestaciones de isquemia miocardica. Caso clinico: Comunicamos un lactante de 2 meses de edad, sexo masculino, quien ingreso con shock cardiogenico y acidosis metabolica grave. Radiografia de torax con cardiomegalia marcada, ecocardiograma revelo disfuncion sistolica ventricular izquierda grave con FAVI 13%), evidencias de miocardiopatia dilatada y sospecha IAACI (cara posterolateral izquierda tronco arteria pulmonar). Recibio ventilacion mecanica, expansores de volumen, transfusion de hemoderivados, drogas inotropicas, infusion furosemida, hipotermia moderada e infusion de calcio continua. Evoluciono con disfuncion organica con: shock cardiogenico y falla renal no oligurica. Al quinto dia se logra estabilizacion y se somete a resolucion quirurgica, efectuandose transferencia coronaria desde tronco de arteria pulmonar a aorta. Fue dado de alta a su domicilio al mes de ingresado. Control ambulatorio a los tres meses con funcion cardiaca normal. Comentario: IAAC se manifiesta por isquemia miocardica y los sintomas aparecen habitualmente al ocurrir el descenso de la resistencia vascular pulmonar. El resultado a largo plazo es bueno, si se realiza la revascularizacion en forma temprana. Su sospecha y busqueda debe de ser acuciosa, contando con el valioso rol de la evaluacion ecocardiografica, en todo paciente que curse con shock cardiogenico y miocardiopatia dilatada.

Pericarditis purulenta primaria por Streptococcus pneumoniae, a propósito de un caso clínico

Hoy en dia la pericarditis purulenta (PP) es una patologia poco frecuente, pero de pronostico grave. Comunicamos el caso clinico de un paciente de 3 meses, sano previamente. Consulto por palidez, rechazo alimentario y dificultad respiratoria de pocas horas de evolucion. La radiografia de torax demostro cardiomegalia. Evoluciono hacia shock cardiogenico por taponamiento cardiaco. Recibio inicialmente expansores de volumen y drogas vasoactivas. Antibioterapia con vancomicina y ceftriaxona. Ecocar-diograma objetivo derrame pericardico extenso, complementado con TAC que descarto foco infeccioso endotoraxico. Se realizo pericardiocentesis y luego ventana pericardica. Se aislo en hemocultivo Streptococcus pneumoniae, sensible a penicilina. Luego de drenaje quirurgico y control de infeccion presento evolucion favorable. No se encontro sitio infeccioso extrapericardico. Completo tres semanas de tratamiento antibiotico. Estudio inmunologico fue normal. La PP es observada raramente en individuos sanos. La presentacion en este caso fue de horas, por un agente inhabitual y de extrema gravedad. Un diagnostico precoz, en conjunto con un tratamiento medico-quirurgico es fundamental, como la mejor forma de evitar secuelas.