Ignacio Oulego-Erroz

Continuous Terlipressin Infusion as Rescue Treatment in a Case Series of Children with Refractory Septic Shock

Background: Despite intensive therapy, refractory pediatric septic shock has a high rate of morbidity and mortality. Additional treatments are needed to improve outcomes in such cases. Objective: To report the clinical effects of continuous terlipressin infusion as rescue treatment for children with septic shock refractory to high catecholamine doses. Methods: Sixteen episodes of catecholamine-resistant septic shock were recorded in 15 children (aged from newborn to 15 years) who received compassionate rescue treatment with terlipressin at 6 pediatric intensive care units. Terlipressin treatment consisted of a loading dose (20 μg/kg) followed by continuous infusion at a rate of 4–20 μg/kg/h. Terlipressin was titrated at increases of 1 μg/kg/h to maintain mean arterial pressure (MAP) in normal range for age and to reduce catecholamine dosage. The main outcome was survival of the episode. Secondary outcomes included hemodynamic effects, ischemia, and terlipressin-related adverse events. Results: Terlipressin increased median MAP from 48 (range 42–63) to 68 (45–115) mm Hg 30 minutes after terlipressin administration (p < 0.01). MAP was subsequently sustained, which allowed for the reduction of norepinephrine infusion from 2 μg/kg/min (1–4) at baseline to 1.5 μg/kg/min (0.4–4) at 1 hour, 1.3 μg/kg/min (0–8) at 4 hours, 1 μg/kg/min (0–2) at 12 hours, 0.45 μg/kg/min (0–1.4) at 24 hours, and 0 μg/kg/min (0–0.6) at 48 hours (p < 0.05 vs baseline in all cases). In 8 (50%) of the 16 septic shock episodes the patients survived, 7 (44%) without sequelae. One patient survived with sequelae (minor amputation and mild cutaneous ischemia). Eight patients had signs of ischemia at admission; terlipressin induced reversible ischemia in another 4 patients. Meningococcal infection, prior ischemia, and MAP were risk factors for mortality. Conclusions: Continuous terlipressin infusion may improve hemodynamics and survival in some children with refractory septic shock. Terlipressin could contribute to tissue ischemia.

Ascending aorta elasticity in children with isolated bicuspid aortic valve

BACKGROUND Aortic dilation is common in children with bicuspid aortic valve (BAV) but aortic complications are infrequent. The aim of this study was to investigate elastic properties of the ascending aorta (AAo) and its relation to AAo size in children with isolated BAV without significant valve dysfunction. METHODS 24 children with isolated BAV and 24 healthy controls with tricuspid aortic valve (TAV) matched by gender, age and body surface area (BSA) were studied. Aortic strain (AS), aortic distensibility (DIS) and aortic stiffness index (SI) were derived from M-mode echocardiography at the AAo together with cuff blood pressure recordings. BAV children with dilated AAo (z score ≥ 2) and non dilated (z score<2) were compared. RESULTS BAV children had larger aortas than controls at the sinuses of Valsalva, sinotubular junction and AAo (p<0.05). AS was lower in BAV than in controls (10.15 ± 4.93 vs 16.93 ± 5.17 p=0.000), DIS was lower in BAV than in controls (8.51 ± 3.90 vs 14.37 ± 4.20 p=0.000) and SI was higher in BAV than in controls (7.19 ± 4.45 vs 4.05 ± 2.33 p=0.04). There were no significant differences in AS, DIS and SI between children with dilated and non-dilated AAo. AS, DIS and SI were not related to BSA, age or AAo size. CONCLUSIONS AAo elasticity assessed by transthoracic echocardiography is impaired in BAV children without significant valve dysfunction compared to TAV children. Impaired elasticity seems to be independent from aortic dilation. Measuring aortic elasticity may help to identify children at greater risk for complications as adults.

A popular song improves CPR compression rate and skill retention by schoolchildren: a manikin trial.

As part of the strategy to increase bystander CPR, training choolchildren has been recommended because of their ability o learn and retain knowledge and skills.1–3 We hypothesized hat a popular song (an inexpensive and widely available trainng method) with a beat fitting recommended chest compression CC) rate would improve the acquisition and retention of this skill n schoolchildren. We performed a parallel manikin study in 59 ntrained schoolchildren (aged 13–14 years) randomized into two roups: “Macarena song” (34 children) and “Silent or control” (25 hildren). All children received 1 h of BLS training emphasizing coninuous CC. “Macarena song” was trained to make CC with the audio uidance of the song “Macarena” by Los del Río (103 beats per inute). The control group was trained in a traditional way. After hat, all the participants were asked to make continuous CC durng 2 min, first in silence and then with the audio guidance of the ong “Macarena”. The test was repeated one month later. At that oment, the “Song” group was told to perform continuous CC durng 2 min, thinking on “Macarena” song (so trying to follow the hythm mentally) whereas control group performed CC with the arget of 100 per minute, without additional advice. After a 20-min est period, all subjects listened to “Macarena” and then performed nother 2 min of CC but now thinking on the “Macarena” song to ollow the rhythm. In both groups a 10% deviation from the taret was considered acceptable (target: 180–226 CC in 2 min; that s 100 ± 10 per minute for control group and 103 ± 10 per minute or song group) (see Fig. 1). The Macarena group performed significantly less CC than conrol group when tested in silence. Most participants performed lmost perfect rate when listening to Macarena. Macarena song mproved the percentage of participants achieving the CC rate taret along the study (Table 1; Fig. 2). A song that is easily remembered by young people could be a ood audio guidance for CC provided it has a suitable rhythm for C. Many people have notice the potential usefulness of songs to uide CC and it is apparently being introduced, without additional ssessment, in many BLS courses around the world. We have choen the song “Macarena” by Los del Río, because it has a continuous hythm (no change in rhythm pattern or pauses) and it is a funny nd well-known song. Our results indicate that this audio guidance s effective to help schoolchildren to achieve the CC rate target. Our esults, although limited to short term skill retention, show that a ong could also serve to improve skill retention. “Rolling refreshers” s a novel and effective approach for retraining of health providers n psychomotor skills.4 We suggest that a comparable program ith song audio guidance could be effective for schoolchildren and hould be challenged. We have only assessed one of the compo-

Is ultrasound a feasible tool to verify endotracheal tube position in neonates

Tracheal intubation (TI) is a common procedure in neonatal ntensive care unit. Esophageal intubation may occur depending n operator’s experience and clinical setting (e.g. during resusitation) with significant morbidity. Clinical signs alone are not eliable to confirm endotracheal tube (ETT) position and a secndary method is needed. Capnography is mostly used. However, it s not 100% accurate and may yield false negative results in case of ow pulmonary blood flow during cardiopulmonary arrest1. Chest adiography is usually performed after TI to discard misplacement f ETT, mainly right mainstem intubation (RMI). Ultrasound is an lternative and complementary method that may permit both verfication of TI and ETT insertion depth2,3. We checked ETT position with ultrasound and capnography uring 10 intubations in 7 newborns. Patient’s weight and gesational age ranged from 530 to 3150 gram and 24–40 weeks espectively. All patient were intubated for respiratory distress nd were in a stable hemodynamic condition. A 8 Hz microconvex robe was placed in the longitudinal (L) and transversal (T) planes bove the supraesternal notch during insertion of ETT. TI was onfirmed if ETT was clearly identified within the trachea immeiately posterior to anterior tracheal wall in L and a characteristic omet tail artefact arising from ETT surface was seen in T4 (Fig. 1). fter intubation, the patient was bagged and the ultrasound probe as placed in the thorax to check the presence of lung sliding ign (LSS). A bilateral LSS indicates correct TI while unilateral right SS indicates RMI. After intubation radiography was performed.

Verification of endotracheal tube placement using ultrasound during emergent intubation of a preterm infant.

Endotracheal tube (ET) verification in newborns is usually chieved primarily by direct visualization of the ET passing through he vocal cords by direct laryngoscopy. This is the preferred ethod by most experienced neonatologists. However, there is vidence indicating that incidental oesophageal intubation is freuent leading to potential serious harm for the baby so a secondary erification method may be necessary.1 As clinical signs such as uscultation alone may be inaccurate in the preterm, an end tidal arbon dioxide (ETCO2) detector is usually recommended. Howver, in the setting of low or absent pulmonary blood flow such as uring resuscitation or severe hypotension capnography may yield alse negative results.2 Ultrasound is an alternative and compleentary method for ET verification shown to be at least as rapid nd accurate as capnography for emergent intubation in children nd adults.3,4 Here we communicate its use in a very low birth eight preterm infant and illustrate the technique. A 31 week estation and 1.410 g 5-days old female baby was being treated or severe sepsis and necrotizing enterocolitis in our NICU. He as on high ventilatory support (Peak pressure 27 mmHg, PEEP mmHg, FiO2 60%) because of respiratory failure needing surfacant replacement. He suffered an accidental extubation with rapid oss of lung recruitment, severe desaturation (Sat 70%), bradycardia nd hypotension that did not respond to bag mask ventilation. She as reintubated with a 2.5 mm uncuffed tube without improveent (Sat 75%). Capnography was not readily available and we ecided to check ET location by ultrasound. We used an 8-Hz icroconvex transducer in the longitudinal and transversal plane bove the suprasternal notch. We were able to clearly see the T within the trachea immediately posterior to tracheal anterior ings (Fig. 1). We then added a PEEP valve to the bag and venilated the baby with an increasing level of PEEP (max. 8 mmHg) xygen saturation slowly raised in two minutes and the baby tabilized. Ultrasound may be useful to verify ET during emergent intubaion of preterm babies. The most important technical issue is the use f a small sized transducer suitable for the preterm’s neck. A secorial or microconvex high frequency transducer may be optimal. ransducer should be placed 1–2 cm above the suprasternal notch cricotiroid membrane) in the longitudinal and transversal planes. ongitudinal plane may be more useful as we can see echogenic nterior tracheal rings with the ET lying just beneath them as two chogenic lines. With minimal caudal angulation of the transducer oward the suprasternal notch we may be able to identify the ET ip (Fig. 1). Ultrasound is an alternative and adjunct method to verfy ET that in neither case substitutes direct laryngoscopy or

Comparison of ultrasound guided brachiocephalic and internal jugular vein cannulation in critically ill children

PURPOSE To determine whether ultrasound (US)-guided longitudinal in-plane supraclavicular cannulation of the brachiocephalic vein (BCV) improves cannulation success rates compared to transverse out-of-plane internal jugular vein (IJV) cannulation in urgent insertion of temporary central venous catheters (CVC) in critically ill children. MATERIALS AND METHODS Prospective open pilot (non-randomized) comparative study carried out in a pediatric intensive care unit (PICU) of a university-affiliated hospital. Newborns and children aged 0 to 14 years admitted to the PICU in whom an urgent CVC was clinically indicated and was inserted in the IJV or BCV by US guidance were eligible. First-attempt success rate, overall success rate, number of puncture attempts, and cannulation time were compared between IJV and BCV techniques. RESULTS Forty-six procedures (24 IJV and 22 BCV) in 38 patients were included. Full-sample median (range) age and weight were 13 (0.6-160) months and 9.5 (0.94-50) kg. No significant differences between IJV and BCV groups were observed for sex, age, weight, admission diagnosis, intra-procedural mechanical ventilation and sedation protocol. First attempt success rate was higher in the BCV than the IJV group (73 vs 37.5%, P= .017). Overall success rate was slightly higher in the BCV group (95 vs 83%, P = nonsignificant). Median (range) number of cannulation attempts [1 (1-3) vs 2 (1-4)] and cannulation time [66 (25-300) vs 170 (40-500) seconds] were significantly lower in the BCV group (P< .05). Patients weight was inversely related to the number of cannulation attempts (Pearson coefficient -0.537, P= .007) and cannulation time (Pearson coefficient -0.495, P= .014) in the IJV but not in the BCV group. No major complications were observed. CONCLUSIONS Ultrasound-guided supraclavicular in-plane BCV cannulation improved first attempt CVC cannulation success rates and reduced puncture attempts and cannulation time compared to US-guided out-of-plane IJV in critically ill children. A large randomized clinical trial is warranted to confirm our results.

Is Tracheal Intubation Possible During Pediatric Cardiopulmonary Resuscitation Without Interruption of Chest Compressions? A Simulation Study

Quick and safe airway management is essential during peaiatric cardiopulmonary resuscitation (CPR); tracheal intubation TI) is considered the definitive method for airway control during dvanced CPR.1 Current guidelines recommend performing chest ompressions as continuously as possible, avoiding interruptions, ven during other resuscitation procedures like TI.2 However, few ata support the ability to simultaneously perform these proceures fulfilling the recommended limit time (less than 30 s).3 A randomized crossover trial study was performed to test the bility of paediatric residents to intubate the trachea of manikins y means of standard direct laringoscopy during continuous chest ompressions (CCC). The Megacode Baby® and Megacode Junior® rainer manikins (Laerdal España, Madrid) were chosen. These anikins are representative of an infant 3 to 9 months old and 5 to years old child, respectively. Twenty-three residents who were rained to intubate child and infant manikins were eligible. They ere asked to perform TI in manikins assisted by standard laringocopes (Miller and Macintosh) according to age, while a colleague elivered CCC. Chest compressions were performed by a pediatriian trained on quality CPR, with the two thumb-encircling hands echnique in the infant and the one hand technique in the child anikin.4 The sequence of manikin intubation was randomized. Primary endpoints were the rate of successful placement of the ube in the trachea and the duration of the TI in seconds. Total intuation time (TTI) was defined as the time since the operator picked p the laryngoscope until the tube was deemed to be correctly ositioned (by means of observation of clear thorax rising when nsufflation with bag was done). To assess the subjective opinion bout the difficulty of the procedure, participants were asked to rate t on a visual analogue scale (VAS) with a score from 0 (extremely asy) to 10 (extremely difficult). Quantitative data are presented as edian an interquartile range (IQR). In the infant scenario, the median (IQR) TTI was 28.2 20.4–34.4) s. Seven of 23 participants required more than 30 s o perform TI, two of them requiring more than 45 s and one, ore than 1 min. In the child scenario, the median (IQR) TTI was 0.2 (18.6–25.1) s. In three of 23 cases, the time required was longer han 30 s, one of them requiring more than 45 s, and another one, ore than 1 min. Median (IQR) VAS score was 4 (2–6) in the infant cenario and 3 (0–6) in the child scenario (Table 1). In simulated infant and child CPR scenarios, most of paediatric esidents were able to intubate the trachea during CCC, validating t least “in vitro” the feasibility of the new guidelines. However, ome of the participants failed to achieve TI in less than 30 s in uch conditions (7 of 23 with the infant manikin and 3 of 23 with he child one). Our results suggest that, at least in infants, specific

Out-of-hospital pediatric cardiorespiratory arrest in Galicia: impact of the 2005 resuscitation guidelines.

Introduction: Pediatric out-of-hospital cardiorespiratory arrest (CRA) is a rare event but has a high mortality and morbidity among survivors. In 2005, an international consensus on science and treatment recommendations has been released, with the aim of improving the assistance of patients who had and, eventually, increasing survival without neurologic sequelae. Our objective was to assess the impact of the 2005 guidelines on the initial prehospital assistance of children with out-of-hospital CRA in a community with scattered population. Methods: This is a prospective observational study following the Utstein-style guidelines of pediatric CRA in 2 periods: group 1 (pre-2005), from July 2002 to February 2005 (32 months); and group 2 (post-2005), from January 2007 to December 2008 (24 months). Patients aged from 0 months to 16 years who had an out-of-hospital respiratory or cardiac arrest were included in the study. Results: There were 31 patients (84% cardiac) who had CRA in group 1 and 21 patients (62% cardiac) who had CRA in group 2 (P = 0.073). Both groups were comparable in age, sex, CRA cause, place of CRA incident, management of airway, fluid administrations, and defibrillation attempts. A significant increment in the number of bystander cardiopulmonary resuscitation (CPR) was observed in group 2 (13 [62%] vs 7 [29%], P = 0.004). The intraosseous access was more frequently used in the post-2005 group (8 [38%] vs 5 [16%], P = 0.021). In group 2, a higher percentage of patients received more than 1 adrenaline dose (95% vs 61%, P = 0.006), were treated with bicarbonate (7 [33%] vs 3 [10%], P = 0.045), and were not treated with atropine (5 [24%] vs 17 [55%], P = 0.020). Survival to hospital admission, sustained return of spontaneous circulation, and survival to hospital discharge were comparable in both groups. Conclusions: In cases of pediatric out-of-hospital CRA in a community with scattered population, after the introduction of the 2005 international CPR recommendations, there was an increase in bystander CPR and changes in immediate treatment were detected. However, these changes did not result in a significant outcome improvement.

N-terminal-probrain natriuretic peptide as a biomarker of moderate to severe bronchopulmonary dysplasia in preterm infants: A prospective observational study

N‐terminal‐probrain natriuretic peptide (NT‐proBNP) is a marker of hemodynamically significant patent ductus arteriosus (HsPDA) in preterm infants. In this study, we assessed whether NT‐proBNP levels could predict the risk of moderate to severe bronchopulmonary dysplasia (BPD) and/or death.

Test de elevación pasiva de las piernas y respuesta a líquidos en un niño politraumatizado

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