Description of a Swine Infant Model of Volume-Controlled Hemorrhagic Shock.

Hemorrhagic shock is a leading cause of morbidity and mortality in pediatric patients. Interpretation of the clinical indicators validated in adults to guide resuscitation and comparison between different therapies is difficult in children due to the inherent heterogeneity of this population. As a result, compared to adults, appropriate management of pediatric hemorrhagic shock is still not well established. In addition, the scarcity of pediatric patients with hemorrhagic shock precludes the development of clinically relevant studies. For this reason, an experimental pediatric animal model is necessary to study the effects of hemorrhage in children as well as their response to different therapies. We present an infant animal model of volume-controlled hemorrhagic shock in anesthetized young pigs. Hemorrhage is induced by withdrawing a previously calculated blood volume, and the pig is subsequently monitored and resuscitated with different therapies. Here, we describe a precise and highly reproducible model of hemorrhagic shock in immature swine. The model yields hemodynamic data that characterizes compensatory mechanisms that are activated in response to severe hemorrhage.

Microcirculatory Changes in Pediatric Patients During Congenital Heart Defect Corrective Surgery.

A prospective, observational single-center study was carried out. Pediatric patients undergoing congenital heart defect surgery were evaluated before, during, and after surgery. At each time point, sublingual microcirculation and clinical parameters were assessed, along with analytical variables. Twenty-four patients were included. All microcirculatory parameters worsened during cardiopulmonary bypass and returned to baseline values after surgery (p ≤ 0.001). In the intraoperative evaluation, body temperature correlated with perfused small vessel density (p = 0.014), proportion of perfused small vessels (p < 0.001), small vessel microvascular flow index (p = 0.003), and small vessel heterogeneity index (p < 0.002). Patients with cyanotic disease exhibited higher small vessel density (p < 0.008) and higher density of perfused small vessels (p < 0.022) at baseline, and a lower microvascular flow index (p = 0.022) and higher heterogeneity (p = 0.026) in the intraoperative phase. Children with congenital heart disease exhibited decreased vascular density and microvascular blood flow and increased heterogeneity during cardiopulmonary bypass. All these parameters returned to baseline values after surgery.

Hemodynamic disturbances and oliguria during continuous kidney replacement therapy in critically ill children.

BACKGROUND: About 1.5% of patients admitted to the Pediatric Intensive Care Unit (PICU) will require continuous kidney replacement therapy (CKRT)/renal replacement therapy (CRRT). Mortality of these patients ranges from 30 to 60%. CKRT-related hypotension (CKRT-RHI) can occur in 19-45% of patients. Oliguria after onset of CKRT is also common, but to date has not been addressed directly in the scientific literature. METHODS: A prospective observational study was conducted to define factors involved in the hemodynamic changes that take place during the first hours of CKRT, and their relationship with urinary output. RESULTS: Twenty-five patients who were admitted to a single-center PICU requiring CKRT between January 1, 2014, and December 31, 2018, were included, of whom 56.3% developed CKRT-RHI. This drop in blood pressure was transient and rapidly restored to baseline, and significantly improved after the third hour of CKRT, as core temperature and heart rate decreased. Urine output significantly decreased after starting CKRT, and 72% of patients were oliguric after 6 h of therapy. Duration of CKRT was significantly longer in patients presenting with oliguria than in non-oliguric patients (28.7 vs. 7.9 days, p = 0.013). CONCLUSIONS: The initiation of CKRT caused hemodynamic instability immediately after initial connection in most patients, but had a beneficial effect on the patient's hemodynamic status after 3 h of therapy, presumably owing to decreases in body temperature and heart rate. Urine output significantly decreased in all patients and was not related to negative fluid balance, patient's hemodynamic status, CKRT settings, or kidney function parameters.

Nutrición en niños tratados con técnicas de depuración extrarrenal continua / Nutrition in children with continuous renal replacement therapy

INTRODUCCIÓN: El objetivo de este estudio ha sido analizar el estado de nutrición, la alimentación y las complicaciones digestivas de los niños que precisan técnicas de depuración extrarrenal continua (TDEC). MATERIAL Y MÉTODOS: Estudio retrospectivo realizado sobre una base de datos prospectiva de los niños tratados con TDEC entre 2013 y 2017. Se analizaron las características de los pacientes, la técnica de depuración, el tipo de nutrición, el aporte calórico y proteico, las complicaciones digestivas y la evolución clínica. RESULTADOS: Sesenta y cinco niños (61,5% varones) fueron tratados con TDEC y 24 (37%) precisaron soporte con oxigenación con membrana extracorpórea. Un 27,7% tenían un peso inferior al percentil 3 y un 48,4% una talla inferior al percentil 3. Al inicio de la TDEC 31 niños (47,7%) recibían nutrición enteral y 52 (80%) al final de la misma. La nutrición enteral fue por sonda transpilórica en el 76% de los casos. La mediana de aporte calórico fue de 63 kcal/kg/día y la del aporte proteico de 1,6 g/kg/día. Cuarenta y ocho pacientes (73,8%) presentaron complicaciones digestivas: 29 (44,6%) distensión gástrica o restos gástricos excesivos, 22 (33,8%) estreñimiento, 8 (12,3%) vómitos y 4 (6,1%) diarrea. Un paciente con oxigenación con membrana extracorpórea presentó isquemia intestinal. En 3 pacientes (4,6%) se tuvo que suspender la nutrición enteral por complicaciones. No existió relación entre las complicaciones y el tipo de alimentación o la asistencia en oxigenación con membrana extracorpórea. CONCLUSIONES: Un elevado porcentaje de niños tratados con TDEC presentan malnutrición, pero la mayoría pueden ser alimentados con nutrición enteral. Aunque el porcentaje de complicaciones digestivas es elevado, en pocos pacientes se tiene que suspender la nutrición enteral

INTRODUCTION: The aim of this study was to analyse the nutritional state, diet and gastrointestinal complications of children that require continuous renal replacement therapy (CRRT). MATERIAL AND METHODS: A retrospective analysis of a database, which included the information about patients who required CRRT between the years 2013 and 2017. Data were collected on the replacement technique, type of nutrition, calorie and protein intake, gastrointestinal complications, and clinical course. RESULTS: A total of 65 children (61.5% male) were treated with CRRT, and 24 patients (37%) also needed ECMO support. Just over one-quarter (27.7%) of patients had a weight less than P3, and 48.4% of them a height less than P3. At the beginning of the technique, 31 children (47.7%) received enteral nutrition, at the end, there were 52 patients receiving enteral nutrition (80%). The transpyloric tube was used to provide nutrition in 76% of the cases. The median caloric intake was 63kcal/kg/day, and the protein intake was 1.6g/kg/day. There were gastrointestinal difficulties during the process in 48 patients (73.8%), with 29 (44.6%) patients being diagnosed with gastric distension or excessive gastric remains, 22 (33.8%) with constipation, 8 (12.3%) with vomiting, and 4 (6.1%) diarrhoea. One patient treated with ECMO presented with intestinal ischaemia. Enteral nutrition was cancelled in 3 patients (4.6%) due to the complications. There was no relationship between complications and type of diet or ECMO assistance. CONCLUSIONS: A high percentage of children treated with CRRT showed undernutrition but they had adequate tolerance to the enteral nutrition. Although the gastrointestinal complications percentage was high in few subjects, these complications are the reason why enteral nutrition was stopped

[Nutrition in children with continuous renal replacement therapy]. / Nutrición en niños tratados con técnicas de depuración extrarrenal continua.

INTRODUCTION: The aim of this study was to analyse the nutritional state, diet and gastrointestinal complications of children that require continuous renal replacement therapy (CRRT). MATERIAL AND METHODS: A retrospective analysis of a database, which included the information about patients who required CRRT between the years 2013 and 2017. Data were collected on the replacement technique, type of nutrition, calorie and protein intake, gastrointestinal complications, and clinical course. RESULTS: A total of 65 children (61.5% male) were treated with CRRT, and 24 patients (37%) also needed ECMO support. Just over one-quarter (27.7%) of patients had a weight less than P3, and 48.4% of them a height less than P3. At the beginning of the technique, 31 children (47.7%) received enteral nutrition, at the end, there were 52 patients receiving enteral nutrition (80%). The transpyloric tube was used to provide nutrition in 76% of the cases. The median caloric intake was 63kcal/kg/day, and the protein intake was 1.6g/kg/day. There were gastrointestinal difficulties during the process in 48 patients (73.8%), with 29 (44.6%) patients being diagnosed with gastric distension or excessive gastric remains, 22 (33.8%) with constipation, 8 (12.3%) with vomiting, and 4 (6.1%) diarrhoea. One patient treated with ECMO presented with intestinal ischaemia. Enteral nutrition was cancelled in 3 patients (4.6%) due to the complications. There was no relationship between complications and type of diet or ECMO assistance. CONCLUSIONS: A high percentage of children treated with CRRT showed undernutrition but they had adequate tolerance to the enteral nutrition. Although the gastrointestinal complications percentage was high in few subjects, these complications are the reason why enteral nutrition was stopped.

Hemodynamic Effects of Connection to Continuous Renal Replacement Therapy in a Pediatric Animal Model.

To assess the hemodynamic effects of connection to continuous renal replacement therapy (CRRT) in a pediatric experimental animal model. Prospective experimental study was performed using piglets between 2 and 3 months of age and 9-11 kg. CRRT with a PrismaflexR monitor and HF20 filter (surface of 0.2 m2 ) was started after monitoring and anesthetic induction with an initial blood flow at 20 mL/min with 10 mL/min increases every minute until the goal flow of 5 mL/kg/min was achieved. Heart rate, blood pressure, central venous pressure, cardiac index, and renal blood flow were registered at baseline, 5, 15, 30, 60, 120, 180, 240, and 360 min. IBM SPSS Statistics 20.0 package was used for analysis. A P value of <0.05 was considered statistically significant. Thirty-four piglets were studied. Blood pressure, cardiac output, and systemic vascular resistance significantly decreased 5-min after CRRT connection (mean arterial pressure from 85.5 to 70.8 mm Hg, P < 0.001, cardiac index from 3.6 to 3.3 L/min/m2 P = 0.024, and systemic vascular resistance index from 1759 to 1607 dyn.s/cm5 P = 0.012). No significant changes were found in renal blood flow or central venous pressure. All parameters gradually increased at 15 and 30 min after connection but complete recovery was never achieved. Connection to CRRT produces a significant decrease in arterial pressure, cardiac index, and peripheral vascular resistances in hemodynamically stable piglets.

Non-invasive mechanical ventilation after heart surgery in children.

BACKGROUND: The purpose of the study was to analyze the characteristics and evolution of non-invasive mechanical ventilation (NIV) in the postoperative period of heart surgery in children. METHODS: Retrospective observational study including all children requiring NIV after heart surgery in a single center pediatric intensive care unit (PICU) between 2001 and 2012. Demographic characteristics, ventilation parameters and outcomes were registered, comparing the first 6 years of the study with the last 6 years. RESULTS: 935 children required invasive or non-invasive mechanical ventilation, of which 200 (21.4) received NIV. The median duration of NIV was 3 days. Mortality rate was 3.9%. The use of NIV increased from 13.2% in the first period to 29.2% in the second period (p <0.001). Continuous positive airway pressure (CPAP) was the most common modality of NIV (65.5%). The use of bilevel positive airway pressure mode (BIPAP) increased from 15% in the first period to 42.9% in the second period (p < 0.001). The nasopharyngeal tube was the most common interface (66%), but the use of nasal cannula increased from 3.3 to 41.4% in the second period (p < 0.001). NIV failed in 15% of patients. The mortality rate did not change, the duration of NIV decreased and the PICU length of stay increased throughout the study. CONCLUSIONS: NIV is increasingly being used in the postoperative period of heart surgery in our center with an 85% success rate and is associated with a lesser need for invasive mechanical ventilation. CPAP was the most common modality and the "nasopharyngeal tube" was the most common interface in our study although, in the latter years, the use of BIPAP and nasal cannula has increased significantly.

Diffuse persistent pulmonary interstitial emphysema secondary to mechanical ventilation in bronchiolitis.

BACKGROUND: Persistent interstitial pulmonary emphysema (PIE) is a rare disease and it is even more uncommon in full-term infants, like our patient. When conservative management is not successful, surgical treatment should be considered. In our case, ECMO support was iniciated to keep the patient ventilated in order to allow the lung to heal using lung protection strategies. CASE PRESENTATION: We report an 18-day-old male infant with bronchiolitis that required mechanical ventilation with high positive airway pressures due to severe respiratory insufficiency. Chest X-rays and computed tomography scan revealed a severely hyperinflated left lung with extensive destructive changes and multiple small bullae. These findings were consistent with diffuse persistent interstitial emphysema (PIE), probably due to mechanical ventilation. The patient required high frequency oscillatory ventilation, inotropic support and continuous renal replacement therapy. He eventually suffered a cardiac arrest that required cardiopulmonary resuscitation and ECMO during 5 days with progressive clinical improvement and normalization of the X-ray. CONCLUSION: We present a patient with diffuse persistent interstitial emphysema who, despite an unfavorable evolution with different mechanical ventilation strategies, had a good response after ECMO assistance.

Pharmacological interaction between valproic acid and carbapenem: what about levels in pediatrics?

UNLABELLED: Valproic acid (VPA) is the most commonly used antiepileptic drug in pediatric patients, but its major drawback is its multiple pharmacological interactions. OBJECTIVE: To study children who had been simultaneously treated with carbapenems and valproic acid, considering drug levels, pharmacological interactions and clinical follow-up. MATERIAL AND METHODS: Retrospective study of children who simultaneously received treatment with VPA and carbapenems between January 2003 and December 2011. Demographic variables, indication of treatment, dose, VPA plasma levels, interactions, clinical manifestations and medical management were analyzed. RESULTS: 28 children with concomitant treatment with both drugs were included in the study. 64.3% were males. 78.6% of the interactions were observed in the Intensive Care Unit. 60.7% of children had been previously treated VPA and its major indication were generalized seizures. Basal plasma levels of VPA were recorded in 53% and at 24 h after admittance in 60%. "40% of basal VPA levels were below therapeutic range prior to the administration of carbapenem. After the introduction of carbapenem 88% of level determinations were below therapeutic range". 54.5% of the patients that were chronically receiving VPA and had good control of epilepsy before admission had seizures during the coadministration. One patient that was on VPA before admission but with bad control of epilepsy worsened, and one patient that acutely received VPA did not achieve seizure freedom. In these cases it was necessary to either increase VPA dose or change to a different antiepileptic drug. CONCLUSIONS: Little is known about the mechanism of pharmacologic interactions between carbapenems and VPA, but it leads to a reduction in plasma levels that may cause a loss of seizure control, so simultaneous use of both drugs should be avoided when possible. If not, VPA levels should be monitored.

Prevention and treatment of intraluminal catheter thrombosis in children hospitalised in a paediatric intensive care unit.

AIM: The aim of the study was to develop and implement a protocol for the prevention and treatment of catheter related intraluminal thrombosis in a paediatric intensive care unit METHODS: A computerised search was carried out on MEDLINE, through PubMed, using the medical subject heading 'central venous catheter', 'central venous access device', 'central venous line' associated with 'occlusion', 'obstruction', 'catheter-related thrombosis', 'critically ill patients' and 'thrombolytic therapy'. References of reviewed articles were also searched for relevant titles as well as non-randomised controlled trials and series of cases when no information of higher level of evidence was available. RESULTS: With the information gathered, a protocol for the prevention and treatment of catheter related intraluminal thrombosis was elaborated and those recommendations that best suit our environment were included. They were agreed upon by a broad panel of professionals working in the Pediatric Intensive Care Unit and the Pharmacy Department. CONCLUSIONS: Due to the variety of options available for the pharmacotherapeutic management of intraluminal catheter thrombosis, one measure to improve the quality of the therapy and to diminish the variability in the prescription could be the implementation of a protocol as described in this paper.