Santiago Mencía

Circuit life span in critically ill children on continuous renal replacement treatment: a prospective observational evaluation study.

IntroductionOne of the greatest problems with continuous renal replacement therapy (CRRT) is early coagulation of the filters. Few studies have monitored circuit function prospectively. The purpose of this study was to determine the variables associated with circuit life in critically ill children with CRRT.MethodsA prospective observational study was performed in 122 children treated with CRRT in a pediatric intensive care unit from 1996 to 2006. Patient and filter characteristics were analyzed to determine their influence on circuit life. Data were collected on 540 filters in 122 patients and an analysis was performed of the 365 filters (67.6%) that were changed due to circuit coagulation.ResultsThe median circuit life was 31 hours (range 1 to 293 hours). A univariate and multivariate logistic regression study was performed to assess the influence of each one of the factors on circuit life span. No significant differences in filter life were found according to age, weight, diagnoses, pump, site of venous access, blood flow rate, ultrafiltration rate, inotropic drug support, or patient outcome. The mean circuit life span was longer when the heparin dose was greater than 20 U/kg per hour (39 versus 29.1 hours; P = 0.008), with hemodiafiltration compared with hemofiltration (34 versus 22.7 hours; P = 0.001), with filters with surface areas of 0.4 to 0.9 m2 (38.2 versus 26.1 hours; P = 0.01), and with a catheter size of 6.5 French or greater (33.0 versus 25.0 hours; P = 0.04). In the multivariate analysis, hemodiafiltration, heparin dose of greater than 20 U/kg per hour, filter surface area of 0.4 m2 or greater, and initial creatinine of less than 2 mg/dL were associated with a filter life of more than 24 and 48 hours. Total effluent rate of greater than 35 mL/kg per hour was associated only with a filter life of more than 24 hours.ConclusionCircuit life span in CRRT in children is short but may be increased by the use of hemodiafiltration, higher heparin doses, and filters with a high surface area.

Enteral Nutrition in the Critically Ill Child: Comparison of Standard and Protein-Enriched Diets

OBJECTIVE To compare a standard diet and a protein-enriched diet in critically ill children. STUDY DESIGN In this prospective randomized controlled trial in critically ill children, all patients received enteral nutrition exclusively and were randomly assigned to a standard diet or a protein-enriched diet (1.1 g protein/100 mL of feeding formula). Blood and urine tests, nitrogen balance assessment, and energy expenditure testing by indirect calorimetry were performed before the beginning of the nutrition regimen and at 24 hours, 72 hours, and 5 days after initiation. Demographic data and pediatric mortality risk scores were recorded. RESULTS Fifty-one children were randomized, and 41 completed the study. Of these, 21 patients received standard formula and 20 received a protein-enriched formula. There were no between-group differences in terms age, sex, diagnosis, or mortality risk scores. There was a greater positive trend in levels of prealbumin, transferrin, retinol-binding protein, and total protein in the protein-enriched diet group. These differences were significant only for retinol-binding protein. The positive nitrogen balance trend was also higher in the protein-enriched diet group; however, this difference did not reach statistical significance. No adverse effects or hyperproteinemia were detected in the protein-enriched diet group. CONCLUSIONS The standard diet provides insufficient protein delivery to critically ill children. Enteral protein supplementation is safe and can improve some biochemical parameters of protein metabolism.

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.

Postpyloric enteral nutrition in the critically ill child with shock: a prospective observational study

BackgroundTolerance to enteral nutrition in the critically ill child with shock has not been studied. The purpose of the study was to analyze the characteristics of enteral nutrition and its tolerance in the critically ill child with shock and to compare this with non-shocked patients.MethodsA prospective, observational study was performed including critically ill children with shock who received postpyloric enteral nutrition (PEN). The type of nutrition used, its duration, tolerance, and gastrointestinal complications were assessed. The 65 children with shock who received PEN were compared with 461 non-shocked critically ill children who received PEN.ResultsSixty-five critically ill children with shock, aged between 21 days and 22 years, received PEN. 75.4% of patients with shock received PEN exclusively. The mean duration of the PEN was 25.2 days and the maximum calorie intake was 79.4 kcal/kg/day. Twenty patients with shock (30.7%) presented gastrointestinal complications, 10 (15.4%) abdominal distension and/or excessive gastric residue, 13 (20%) diarrhoea, 1 necrotising enterocolitis, and 1 duodenal perforation due to the postpyloric tube. The frequency of gastrointestinal complications was significantly higher than in the other 461 critically ill children (9.1%). PEN was suspended due to gastrointestinal complications in 6 patients with shock (9.2%). There were 18 deaths among the patients with shock and PEN (27.7%). In only one patient was the death related to complications of the nutrition.ConclusionAlthough most critically ill children with shock can tolerate postpyloric enteral nutrition, the incidence of gastrointestinal complications is higher in this group of patients than in other critically ill children.

Transpyloric enteral nutrition in the critically ill child with renal failure

ObjectiveTo study the efficacy and tolerance of transpyloric enteral nutrition (TEN) in the critically ill child with acute renal failure (ARF).DesignProspective observational study.SettingPaediatric intensive care unit.PatientsCritically ill children with ARF who received TEN were included in the study. They were compared with the remaining 473 critically ill children receiving TEN in this period. Tolerance of nutrition and gastrointestinal complications were assessed.InterventionTranspyloric enteral nutrition.Measurements and resultsFifty-three critically ill children with ARF aged between 3 days and 17 years received TEN. Children with ARF more frequently received parenteral nutrition before TEN (56.6%) than the other patients (17.5%). The incidence of shock, hepatic alterations and mortality was significantly higher in patients with ARF than in the remaining children. In children with ARF the mean duration of the TEN was 16.5 ± 27.3 days and the maximum caloric intake was 77 ± 26.7 kcal/kg/day. Thirteen patients (24.5%) presented gastrointestinal complications, 9 (17%) abdominal distension and/or excessive gastric residue, 5 (9.4%) diarrhoea, 1 necrotising enterocolitis and 1 duodenal perforation. The frequency of gastrointestinal complications was significantly higher in children with ARF. TEN was definitive suspended in five patients due to gastrointestinal complications. Four of these patients were treated with continuous renal replacement therapy. Thirty percent of patients died during TEN. In only one patient was the death related to complications of the nutrition.ConclusionsCritically ill children with ARF tolerate TEN, although the incidence of gastrointestinal complications is higher than in other critically ill children.

Relationship between energy expenditure, nutritional status and clinical severity before starting enteral nutrition in critically ill children

The objective of the present study was to investigate the relationship between energy expenditure (EE), biochemical and anthropometric nutritional status and severity scales in critically ill children. We performed a prospective observational study in forty-six critically ill children. The following variables were recorded before starting nutrition: age, sex, diagnosis, weight, height, risk of mortality according to the Paediatric Risk Score of Mortality (PRISM), the Revised Paediatric Index of Mortality (PIM2) and the Paediatric Logistic Organ Dysfunction (PELOD) scales, laboratory parameters (albumin, total proteins, prealbumin, transferrin, retinol-binding protein, cholesterol and TAG, and nitrogen balance) and EE measured by indirect calorimetry. The results showed that there was no relationship between EE and clinical severity evaluated using the PRISM, PIM2 and PELOD scales or with the anthropometric nutritional status or biochemical alterations. Finally, it was concluded that neither nutritional status nor clinical severity is related to EE. Therefore, EE must be measured individually in each critically ill child using indirect calorimetry.

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.

Responsiveness to stimuli of bispectral index, middle latency auditory evoked potentials and clinical scales in critically ill children

We performed simultaneous recordings of Bispectral Index (BIS) and middle latency auditory evoked potentials. We also recorded two clinical scales, the Modified Ramsay scale and the COMFORT scale. Heart rate and blood pressure were measured once a day, for a maximum of 5 days, in 81 critically ill children. Changes with tactile, auditory, and painful stimuli were analysed. All the stimuli significantly increased the BIS value, the painful stimulus having the greatest effect. The painful stimulus was the only one that altered the middle latency auditory evoked potentials. Although the responses of the clinical scales to stimuli were statistically significant, they were of little clinical relevance. None of the stimuli used significantly altered the heart rate or blood pressure. We conclude that tactile, auditory and painful stimuli produced changes of little relevance in the clinical scales, BIS or middle latency auditory evoked potentials. We found the BIS was the most sensitive method and the painful stimulus had the greatest effect.

Bispectral index and middle latency auditory evoked potentials in children younger than two-years-old.

BACKGROUND:We analyzed the values of the bispectral index (BIS) and midlatency auditory evoked potentials (MLAEP) and their correlation with the modified Ramsay score (RS) during wakefulness and natural sleep in healthy children without pharmacological sedation. METHODS:Fifty-three healthy children younger than 2-yr-old were studied. Children were evaluated simultaneously using the modified RS, the BIS, and MLAEPs. Each patient was studied only once. The correlation and agreement were studied. The correlation among the three methods was determined using the Spearman Rank Correlation test and the agreement among the methods was assessed using by Cohen’s Kappa test. RESULTS:There was a moderate-to-good correlation (r) among the three methods (P = 0.01): BIS and MLAEP (r = 0.574), BIS and RS (r = −0.504), and MLAEP and RS (r = −0.624). However, the level of agreement (&kgr;) was only poor to fair: BIS and MLAEP (&kgr; = 0.392), BIS and RS (&kgr; = 0.270), and MLAEP and RS (&kgr; = 0.409). All the correlations were lower in children between 1 and 6 mo-of-age. When the children were asleep (RS: 3–5), the BIS values were higher in children younger than 1 mo-of-age than in children older than 6 mo-of-age (P after Bonferroni correction = 0.028). CONCLUSIONS:The BIS, MLAEP, and RS have a good correlation in children younger than 2 yr not receiving pharmacological sedation, though the level of agreement was poor.

Assessment of the Level of Sedation in Children After Cardiac Surgery

BACKGROUND There is no reference method for the evaluation of the level of sedation in children after cardiac surgery. The utility of the bispectral index and middle latency auditory evoked potentials has not been evaluated. METHODS The bispectral index, middle latency auditory evoked potentials, Ramsay scale, and COMFORT scale were used for assessment of the level of sedation in critically ill children after cardiac surgery and other surgical procedures. The measurements with these four methods were recorded simultaneously once a day for five days. The level of sedation was categorized in two levels, moderate or deep, according to the values obtained from each method. Correlations and agreements among the methods and the best bispectral index and middle latency auditory evoked potential values that discriminated between the two levels of sedation were calculated. RESULTS Thirty-two children after cardiac surgery were included in the study, together with eighteen children after other surgical procedures who formed the control group. In each group, the correlation and agreement between the four methods varied between moderate and good. In the cardiac surgery patients, when the level of sedation was determined by the Ramsay scale, the best values of bispectral index and middle latency auditory evoked potentials that discriminated between the two levels of sedation were 63.5 and 37.5, respectively, and these values predicted the level of sedation correctly in 84.4% of the patients with each method. CONCLUSIONS Bispectral index and middle latency auditory evoked potentials could be useful to assess the level of sedation in children after cardiac surgery.