Ramón Moral

Transpyloric enteral feeding in critically ill children.

BACKGROUND Nutrition is important in childhood because the child has a lower energy reserve than the adult and a higher demand for calories because of ongoing growth. In this study, the utility of transpyloric enteral feeding (TEF) in critically ill children was evaluated. METHODS A prospective, descriptive study was made in a pediatric intensive care unit of a tertiary pediatric center of 41 critically ill children, 30 after surgical procedures and 11 with nonsurgical illness, aged 8 days to 12 years, who received transpyloric enteral feeding with 8- or 10-Fr weighted feeding tubes. Analysis was made of tolerance and complications (vomiting, abdominal distension, excessive gastric residual, diarrhea, and pulmonary aspiration) of TEF. RESULTS The mean duration of TEF was 19.5 +/- 26.8 days (range, 1-120 days). The administration of sedative agents or inotropic drugs did not alter toleration of TEF. Eight of 12 patients treated with continuous infusion of vecuronium tolerated TEF without complications. Eleven gastrointestinal complications occurred in 10 patients, abdominal distension and excessive gastric residual in 7 (17%), and diarrhea in 4 (9.7%). In 7 patients gastrointestinal complications improved, with decreasing use or transitory interruption of TEF, but in 4 patients (9.7%), TEF had to be withdrawn. Gastrointestinal complications were more frequent in postsurgical than in nonsurgical patients (p < 0.001). No patients suffered from pulmonary aspiration, and the incidence of pulmonary infection and hepatic dysfunction diminished during TEF. CONCLUSIONS Transpyloric enteral feeding is a good method of nutritional support in critically ill children and can be used in patients treated with neuromuscular blocking agents. The frequency and severity of complications and the risks of pulmonary infection and hepatic dysfunction related to TEF are low.

Cardiac output and blood volume parameters using femoral arterial thermodilution

Background:  The pulse‐induced continuous cardiac output (PiCCO) system is a less invasive method than pulmonary thermodilution for the measurement of cardiac output and estimating blood volume parameters. The normal values in children have not been defined. The purpose of the present paper was therefore to evaluate cardiac output and parameters of blood volume using femoral arterial thermodilution in critically ill children.

Pediatric basic and advanced life support courses: first experience in Spain

OBJECTIVE to evaluate the efficiency of the first experience in pediatric basic and advanced life support courses in Spain. MATERIAL AND METHODS we have given two pediatric basic life support (PBLS) courses of 8 h each to 52 school teachers and ambulance drivers, and 10 30-h pediatric advanced life support (PALS) courses to 276 health professionals, 62 nurses and 214 physicians (80 pediatricians, 57 pediatric, anesthesiology and intensive care medicine residents, 10 general physicians and 52 emergency physicians). We developed the courses according to the guidelines for pediatric life support from the European Resuscitation Council. We performed an initial and final theoretical written test, continuous practical evaluation and a written survey about the quality of the course. RESULTS on PBLS courses, only 12% of practitioners answered at least 80% of the questions in the initial theory test correctly, compared with 77% in the final test (P < 0.001). All the students acquired skills in basic pediatric resuscitation. In the PALS courses, only 30% of practitioners answered at least 75% of the questions in the initial test correctly (35% of physicians and 12% of nurses, P < 0.01); this percentage increased to 95.6% in the final test (96% of physicians and 93.5% of nurses, P < 0.05). Of students, 95% acquired skills in advanced pediatric resuscitation. All students and teachers considered the theoretical and practical formation received adequate. CONCLUSIONS basic and advanced pediatric life support courses are a useful educational method for the general population, health professionals, physicians and nurses in theoretical and practical pediatric resuscitation.

A paediatric cardiopulmonary resuscitation training project in Honduras

OBJECTIVES It is possible that the exportation of North American and European models has hindered the creation of a structured cardiopulmonary resuscitation (CPR) training programme in developing countries. The objective of this paper is to describe the design and present the results of a European paediatric and neonatal CPR training programme adapted to Honduras. MATERIALS AND METHODS A paediatric CPR training project was set up in Honduras with the instructional and scientific support of the Spanish Group for Paediatric and Neonatal CPR. The programme was divided into four phases: CPR training and preparation of instructors; training for instructors; supervised teaching; and independent teaching. RESULTS During the first phase, 24 Honduran doctors from paediatric intensive care, paediatric emergency and anaesthesiology departments attended the paediatric CPR course and 16 of them the course for preparation as instructors. The Honduran Paediatric and Neonatal CPR Group was formed. In the second phase, workshops were given by Honduran instructors and four of them attended a CPR course in Spain as trainee instructors. In the third phase, a CPR course was given in Honduras by the Honduran instructors, supervised by the Spanish team. In the final phase of independent teaching, eight courses were given, providing 177 students with training in CPR. CONCLUSIONS The training of independent paediatric CPR groups with the collaboration and scientific assessment of an expert group could be a suitable model on which to base paediatric CPR training in Latin American developing countries.

Nutritional status and clinical outcome of children on continuous renal replacement therapy: a prospective observational study

BackgroundNo studies on continuous renal replacement therapy (CRRT) have analyzed nutritional status in children. The objective of this study was to assess the association between mortality and nutritional status of children receiving CRRT.MethodsProspective observational study to analyze the nutritional status of children receiving CRRT and its association with mortality. The variables recorded were age, weight, sex, diagnosis, albumin, creatinine, urea, uric acid, severity of illness scores, CRRT-related complications, duration of admission to the pediatric intensive care unit, and mortality.ResultsThe sample comprised 174 critically ill children on CRRT. The median weight of the patients was 10 kg, 35% were under percentile (P) 3, and 56% had a weight/P50 ratio of less than 0.85. Only two patients were above P95. The mean age for patients under P3 was significantly lower than that of the other patients (p = 0.03). The incidence of weight under P3 was greater in younger children (p = 0.007) and in cardiac patients and in those who had previous chronic renal insufficiency (p = 0.047). The mortality analysis did not include patients with pre-existing renal disease. Mortality was 38.9%. Mortality for patients with weight < P3 was greater than that of children with weight > P3 (51% vs 33%; p = 0.037). In the univariate and multivariate logistic regression analyses, the only factor associated with mortality was protein-energy wasting (malnutrition) (OR, 2.11; 95% CI, 1.067-4.173; p = 0.032).ConclusionsThe frequency of protein-energy wasting in children who require CRRT is high, and the frequency of obesity is low. Protein-energy wasting is more frequent in children with previous end-stage renal disease and heart disease. Underweight children present a higher mortality rate than patients with normal body weight.

Continuous venovenous renal replacement therapy using a conventional infusion pump.

To evaluate continuous venovenous hemofiltration and hemodiafiltration with a conventional infusion pump in a pediatric sized animal model. Fourteen Maryland pigs weighing 8 to 13 kg were used. A conventional infusion pump (IVAC 571), with a flow of 900 ml/h and a pediatric hemofilter of 0.22 m2 were used. Ringer’s solution was used for both the dialysate and the replacement fluid. Each experiment included 1 hour of hemofiltration and 1 hour of hemodiafiltration. Heart rate, arterial blood pressure, pH, Na, K, Cl, and hematocrit were measured every 30 minutes. Mean ultrafiltrate flow was 249.7 ± 100.3 ml/hr, 240.5 ± 109.5 ml/hr with hemofiltration and 271 ± 101.1 ml/hr with hemodiafiltration, the differences not being significant. No significant changes were seen in heart rate, blood pressure, hematocrit, electrolytes, or pH. Pressure in the circuit rose from 107.7 ± 70.3 mm Hg at the beginning of the experiment to 234.2 ± 118.1 mm Hg after 2 hours (p < 0.05). The technique was well tolerated by all the pigs. Continuous venovenous hemofiltration and hemodiafiltration with a conventional infusion pump is a possible alternative to conventional methods of extrarenal replacement therapy in neonates and infants.

Description and evaluation of a training programme in pediatric intensive care for pediatric residents

Abstract Objective. To evaluate the efficacy of a training program in pediatric intensive care for pediatric residents. Design. A prospective observational study. Setting. A pediatric intensive care unit. Interventions and measurements. A training program for residents in pediatrics. We performed an initial and final written theoretical test, an evaluation by the physician responsible for the program, a self-assessment by the residents, and a written survey on the quality of the training program. Results. Fifty-three pediatric residents were included in the training program. All residents showed improvement between the initial and final written theoretical tests [initial score 4.8±1.2, final score 8.3±0.8, p<0.001]. Only 7.5% of the residents answered correctly at least 70% of the questions in the initial theoretical test, compared with 94.1% in the final test [p<0.001]. The score in the final theoretical test, 8.3±0.8, was significantly higher than the residents’ self-evaluation, 6.7±0.9, and the evaluat...