Dexmedetomidina y analgesia perioperatoria en niños / Dexmedetomidine and perioperative analgesia in children

La dexmedetomidina (DEX) es un agente anestésico que mimetiza el sueño profundo natural y produce una mínima depresión cardiorrespiratoria, convirtiéndose en una opción muy valiosa en el manejo de un paciente tan exigente como es el pediátrico. El objetivo principal de esta mini revisión fue centrarse en el papel de la DEX como analgésico en el período perioperatorio de niños sometidos a anestesia. Se realizó una búsqueda bibliográfica, entre 2010 y 2021, en Google, Pubmed, Embase y Cochrane Library. Se repasaron diferentes aspectos como su farmacología, efectividad, seguridad y la evidencia más reciente sobre su uso clínico como analgésico en anestesia pediátrica. Igualmente se incluyó una estimación de coste del tratamiento analgésico perioperatorio con DEX.(AU)

Dexmedetomidine (DEX) is an anaesthetic agent that mimics natural deep sleep and produces minimal cardiorespiratory depression. As such, it is a very valuable option in the management of such a challenging population as paediatric patients. The main objective of this mini review was to evaluate the role of DEX as a perioperative analgesic in children receiving anaesthesia. We searched Google, Pubmed, Embase and the Cochrane Library for articles published between 2010 and 2021, and reviewed various of aspects of DEX, such as pharmacology, effectiveness, safety, and the most recent evidence on its clinical use as an analgesic in paediatric anaesthesia. We also include a cost estimate of perioperative analgesia with DEX.(AU)

Dexmedetomidine and perioperative analgesia in children.

Dexmedetomidine (DEX) is an anaesthetic agent that mimics natural deep sleep and produces minimal cardiorespiratory depression. As such, it is a very valuable option in the management of such a challenging population as paediatric patients. The main objective of this mini review was to evaluate the role of DEX as a perioperative analgesic in children receiving anaesthesia. We searched Google, Pubmed, Embase and the Cochrane Library for articles published between 2010 and 2021, and reviewed various of aspects of DEX, such as pharmacology, effectiveness, safety, and the most recent evidence on its clinical use as an analgesic in paediatric anaesthesia. We also include a cost estimate of perioperative analgesia with DEX.

Dexmedetomidine & perioperative analgesia in children. / Dexmedetomidina & analgesia perioperatoria en niños.

Dexmedetomidine (DEX) is an anaesthetic agent that mimics natural deep sleep and produces minimal cardiorespiratory depression. As such, it is a very valuable option in the management of such a challenging population as paediatric patients. The main objective of this mini review was to evaluate the role of DEX as a perioperative analgesic in children receiving anaesthesia. We searched Google, Pubmed, Embase and the Cochrane Library for articles published between 2010 and 2021, and reviewed various of aspects of DEX, such as pharmacology, effectiveness, safety, and the most recent evidence on its clinical use as an analgesic in paediatric anaesthesia. We also include a cost estimate of perioperative analgesia with DEX.

«Safety First¼: Design of an anesthetic checklist in pediatrics. / «Safety First¼: diseño de un checklist anestésico en pediatría.

INTRODUCTION: Quality improvement in health care entails the design of reliable processes which prevent and mitigate medical errors. Checklists are cognitive tools which reduce such errors. The primary objective of this study was to design an anesthetic checklist in Pediatrics to be implemented in our hospital. METHODS: Delphi technique was used, with 3 rounds of questionnaire surveys: a generic questionnaire to obtain dimensions and items; and 2 specific ones to score individual items and obtain an overall rating for the checklist (median), and to measure the level of consensus (relative interquartile range) and internal reliability (Wilcoxon signed-rank test). RESULTS: Final version of the checklist obtained a high overall score (Med 9) with a very high consensus (RIR 5%). Internal consensus was reached on all items (RIR ≤ 30%). Wilcoxon signed-rank test found no statistically significant differences, demonstrating reliability or consistency of responses between consecutive rounds. CONCLUSION: The Anesthetic checklist in Pediatrics has been methodically designed for implementation and use in our hospital.

A pilot study into the use of Continuous Venous Hyperfiltration to manage patients in a critical state with dysregulated inflammation. / Estudio piloto sobre el uso de la Hiperfiltración Venosa Continua para el manejo de pacientes en estado crítico con inflamación desregulada.

INTRODUCTION: Haemofiltration paradigms used to manage critically ill patients with a dysregulated inflammatory response (DIR) assess kidney function to monitor its onset, adaptation, and completion. A Continuous Venous Hyperfiltration (CONVEHY) protocol is presented, in which a non-specific adsorption membrane (AN69-ST-Heparin Grafted) is used with citrate as an anticoagulant and substitution fluid. CONVEHY uses tools readily available to achieve kidney related and non-related objectives, and it is guided by the monitoring of pathophysiological responses. OBJECTIVES: To compare the response to an AN69-ST-HG membrane when heparin (He, n=5: Standard protocol) or citrate (Ci, n=6: CONVEHY protocol) was used to evaluate whether a larger study into the benefits of this protocol would be feasible. MATERIALS AND METHODS: In a retrospective pilot study, the benefits of the CONVEHY protocol to manage patients with a DIR in a surgical critical care unit (CCUs) were assessed by evaluating the SOFA (Sequential Organ Failure Assessment) (He 11 ± 2.35; Ci 11 ± 3.63: p=0.54) and APACHE II (He 28.60 ± 9.40; Ci 24 ± 8.46: p=0.93) scores. RESULTS: Nights in hospital (He 35.2 ± 16.3 nights; Ci 9 ± 2.53: p=0.004), hospital admission after discharge from the CCUs (He 40.25 ± 21.82; Ci 13.2 ± 4.09: p=0.063), patients hospitalised >20 days (He 80%; Ci 0%: p=0.048), days requiring mechanical ventilation (He 16 ± 5.66; Ci 4 ± 1.72: p=0.004), and the predicted (55.39 ± 26.13%) versus real mortality in both groups (9.1%: p=0.004). CONCLUSIONS: The CONVEHY protocol improves the clinical responses of patients with DIR, highlighting the potential value of performing larger and confirmatory studies.

Early blood pressure alterations are associated with pro-inflammatory markers in type 1 diabetes mellitus.

The aim of this study was to evaluate the relationship between early blood pressure (BP) changes (detected using ambulatory BP monitoring; ABPM) with different markers of inflammation and endothelial dysfunction in patients with type 1 diabetes mellitus (T1DM). The study design was observational cross-sectional in 85 T1DM patients, clinically normotensive and with normo-albuminuria. We analyzed the relationships between ABPM-measured BP alterations over 24 h with the inflammatory cytokines (interleukin-6 (IL-6), tumor necrosis factor-α and vascular endothelial growth factor (VEGF)) and the markers of endothelial damage (vascular adhesion molecule, intercellular adhesion molecule and plasminogen activator inhibitor-1 (PAI)). Despite being recorded as normotensive, 27 (31.8%) subjects presented with an average of pathological BP. VEGF levels were significantly elevated in the patients with an altered mean diurnal values compared with normotensives (112.33 (72.87-213.53) pg ml-1 vs 71.03 (37.71-107.92) pg ml-1; P=0.007). Further, VEGF levels correlated significantly with the parameters of diurnal BP and of 24 h values. IL-6 concentration was a risk factor in the patients with hypertension (OR=1.406; P=0.027). There were no modifications in the levels of markers of endothelial damage. Summarizing, there is an increase in pro-inflammatory cytokines, but not the endothelial adhesion molecules, in early stages of arterial hypertension in patients with T1DM.

[Central blockades in Pediatrics: A review of current literature]. / Bloqueos centrales en Pediatría: una revisión de la literatura actual.

Pediatric neuraxial anesthesia is an effective tool that can be used as a supplement or alternative to general anesthesia. However, there have always been doubts about its usefulness and risk-benefit ratio. The purpose of this review is to describe the current role of central blockades in pediatric patients, upgrade practical and safety aspects, and review the latest technological advances applied to this procedure.

Postpartum development of endothelial dysfunction and oxidative stress markers in women with previous gestational diabetes mellitus.

BACKGROUND: Relationships between adhesion molecules (AM), oxidative stress, gestational diabetes mellitus (GDM) and future development of type 2 diabetes mellitus are unclear. AIM: We investigated AM and oxidant/antioxidant markers in women with previous history of GDM. SUBJECTS AND METHODS: Postpartum women with GDM (cases; n = 41) and healthy women (controls; n = 21) had clinical and laboratory variables measured, including indicators of vascular damage (ICAM-1, VCAM-1 and E-selectin), oxidative stress (LPO, GSH and GST) and antioxidant markers (catalase, SOD, GPX and TAC). RESULTS: Previous GDM versus control women presented higher body mass index: 27.4 ± 5.6 versus 23.9 ± 3.6 (p = 0.013); waist circumference: 85.2 ± 12.9 versus 77.5 ± 9.0 (p = 0.017); MetS (WHO definition): 14.6 versus 0 % (p = 0.012); MetS (NCEP-ATPIII definition): 22 versus 0 % (p = 0.002); low HDL: 36.6 versus 9.5 % (p = 0.024); fasting glucose (mmol/L): 5.4 ± 0.6 versus 4.9 ± 0.2 (p < 0.001); glucose 120 min (mg/dL): 105.0 ± 30.2 versus 85.1 ± 14.2 (p = 0.007); fasting insulin (µU/mL): 13.4 ± 8.1 versus 8.4 ± 4.3 (p = 0.004); HOMA index: 3.3 ± 2.3 versus 1.8 ± 1.0 (p = 0.002); HbA1c (%/mmol/mol): 5.4 ± 0.2 versus 5.2 ± 0.2/36 ± 1.4 versus 33 ± 1.4 (p = 0.021); uric acid (mg/dL): 4.1 ± 1 versus 3.5 ± 0.6 (p = 0.009); catalase (nmol/min/mL): 38.7 ± 15.6 versus 28.9 ± 11.1 (p = 0.013). There were no significant differences in hypertension prevalence, lipid fractions, albumin/creatinine ratio and AM. CONCLUSIONS: Women with previous GDM have high catalase levels which correlate positively with glucose intolerance, indicating the potential effect of oxidative stress on postpartum dysglycemic status.

[Knowledge of health care ethics in paediatric residents]. / Conocimientos sobre ética asistencial de los residentes de pediatría.

INTRODUCTION: Bioethics has been recently incorporated in to the educational programs of both medical students and medical residents as part of their curriculum. However, its training based on clinical practice is not well structured. OBJECTIVE: To evaluate the knowledge of bioethics in Spanish paediatric residents, and to analyse how this relates to the medical education during graduate and post-graduate training. MATERIAL AND METHODS: A questionnaire with 20 multiple choice questions was designed to evaluate the knowledge in basic ethics with potential implications in clinical practice. We evaluated the education received during graduate and post-graduate training, and the main ethical conflicts faced. RESULTS: A total of 210 completed questionnaires were received from medical residents in paediatrics from 20 different Spanish hospitals, of whom 47 of these were first year residents (R1), 49 were second year residents (R2), 57 were third year residents (R3), and the remaining 57 were final year residents (R4). The mean number of correct answers was 16.8 out of 20. No differences were found between residents in different years of training, nor were there any differences between the group that had received specific training in bioethics versus those who had not. Residents were more likely to give wrong answers related with informed consent, the law on the freedom of the patient, principles of quality of life, the case analysis system, and the dimension of distributive justice. CONCLUSIONS: Limitation of therapeutic efforts was identified as the main ethical problem faced in clinical practice by Spanish residents in paediatrics. Most of the knowledge of bioethics is acquired during graduate training, and improved very little throughout the period of medical residence. Our results suggest that efforts are required in organising and structuring the education in bioethics during the training of residents in paediatrics.

Cefalea postpunción dural tras herniotomía inguinal pediátrica / No disponible

No disponible

Infección nosocomial del tracto urinario en niños críticos / Nosocomial urinary tract infection in critical pediatric patients

Objetivos: Determinar la densidad de incidencia, etiología y factores de riesgo de la infección de orina nosocomial (ITUn) en una UCIP de segundo nivel. Diseño: Estudio prospectivo descriptivo durante un periodo de 1 año que incluyó a 104 pacientes ingresados durante más de 48 h en nuestra UCIP. Se recogieron urocultivos diarios a los pacientes con sonda vesical hasta su retirada y cada 48 h a los no sondados hasta el alta. Ámbito: Unidad de cuidados intensivos pediátricos de segundo nivel. Pacientes: Se incluyó a todos los pacientes que ingresaron por más de 48 h en el año 2009. Se excluyó a los menores de 15 días y a los que presentaban una infección de orina o pielonefritisal ingreso o antes de las 48 h tras su ingreso. Resultados: Seis pacientes presentaron una ITUn (el 5,8% de los ingresos), con una densidad de incidencia de 5/1.000 pacientes/día y de 12,19/1.000 días de sonda. Se identificaron 4casos por Escherichia coli (uno, multirresistente) y 2 por Candida albicans. Los niños con ITUn tuvieron significativamente más antecedentes personales y mayor estancia que los niños sin infección y, aunque sin significación estadística, menor edad y mayor número de días con sonda. Conclusiones: Nuestra densidad de incidencia de infección de orina asociada a dispositivo es superior a la publicada; esto puede deberse, entre otras causas, a las características de los pacientes atendidos y al método exhaustivo empleado para su detección (AU)

Objective: To determine the incidence, etiology and risk factors of nosocomial urinary tractinfections (nUTI) in a second level Pediatric Intensive Care Unit (PICU).Patients and methods: A prospective study of 104 patients admitted to the PICU with a length of stay of more than 48 hours was carried out over a one year period (January to December2009) to study the incidence and risk factors of nUTI. Urine samples were collected and cultured in all patients admitted for more than 48 hours to our PICU. Those needing indwelling urinary catheters had urine samples collected upon admission and every 24 hours until catheterretrieval, while those who did not need catheters had samples collected upon admission and every 48 hours until discharge from the PICU. Results: Six patients (5.8% of those admitted) were diagnosed of nUTI, with an incidence density of 5/1000 patients/day and 12.2/1000 catheterization days. Four of these were caused byE. coli (including a multiresistant strain), and two by C. albicans. Patients suffering nUTIs had significantly more relevant medical antecedents and a longer period of admittance than patients without nUTI. A statistically non significant tendency towards increased infection risk was also found in younger patients and in those who needed an indwelling catheter for longer periods. Conclusions: We found a higher incidence density of catheter associated nUTI than in other reports. This at least partially could be due to the characteristics of our patients, and to the exhaustive methodology used for detection (AU)

[Nosocomial urinary tract infection in critical pediatric patients]. / Infección nosocomial del tracto urinario en niños críticos.

OBJECTIVE: To determine the incidence, etiology and risk factors of nosocomial urinary tract infections (nUTI) in a second level Pediatric Intensive Care Unit (PICU). PATIENTS AND METHODS: A prospective study of 104 patients admitted to the PICU with a length of stay of more than 48 hours was carried out over a one year period (January to December 2009) to study the incidence and risk factors of nUTI. Urine samples were collected and cultured in all patients admitted for more than 48 hours to our PICU. Those needing indwelling urinary catheters had urine samples collected upon admission and every 24 hours until catheter retrieval, while those who did not need catheters had samples collected upon admission and every 48 hours until discharge from the PICU. RESULTS: Six patients (5.8% of those admitted) were diagnosed of nUTI, with an incidence density of 5/1000 patients/day and 12.2/1000 catheterization days. Four of these were caused by E. coli (including a multiresistant strain), and two by C. albicans. Patients suffering nUTIs had significantly more relevant medical antecedents and a longer period of admittance than patients without nUTI. A statistically nonsignificant tendency towards increased infection risk was also found in younger patients and in those who needed an indwelling catheter for longer periods. CONCLUSIONS: We found a higher incidence density of catheter associated nUTI than in other reports. This at least partially could be due to the characteristics of our patients, and to the exhaustive methodology used for detection.

Benefits of continuous subcutaneous insulin infusion in type 1 diabetes previously treated with multiple daily injections with once-daily glargine and pre-meal analogues.

BACKGROUND/AIMS: There is insufficient information about the use of continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI) using long-acting insulin analogs in relation to possible metabolic consequences and, as well, on the grade of patient satisfaction. The aim of the study was to evaluate the usefulness of CSII treatment in patients with type 1 diabetes in achieving glycemic objectives using continuous glucose monitoring system (CGMS) and in improving patient's satisfaction with treatment. METHODS: We have studied 45 type 1 diabetic patients treated with MDI with once-daily glargine and pre-meal rapid-acting insulin analogues, and 20 patients who commenced CSII because they had not achieved a good glycemic control. RESULTS: With CSII, there were significant reductions in insulin requirements (0.75+/-0.21 vs. 0.64+/-0.21 UI/kg/day; p=0.001), HbA (1c) (7.99+/-0.76 vs. 7.19+/-0.51%; p=0.001) and hypoglycemic episodes (4.60+/-1.82 vs. 3.05+/-1.88 events/patient/week; p=0.031) and improved patient satisfaction with treatment. CSII reduced hyperglycemic episodes in 04:00-08 h period (131.65+/-113.49 vs. 69.70+/-101.52 min; p=0.049), 24 h period area-under-the-curve (AUC) (4521.60+/-3689.23 vs. 3000.36+/-493.96 mmol/L x min; p=0.025) and AUC before dinner (217.36+/-181.46 vs. 136.22+/-202.88 mmol/L x min; p=0.048). CONCLUSIONS: In selected patients with poor metabolic control with once-daily glargine and pre-meal rapid-acting insulin analogues, CSII is a good alternative since it reduces hypoglycemic episodes and insulin requirement and improves glycemic control and patient's satisfaction.

[Ultrasonographic and power Doppler appearance of locoregional metastases from cutaneous melanoma]. / Aspecto ecográfico y en power doppler de las metástasis macroscópicas locorregionales del melanoma cutáneo.

OBJECTIVE: To describe the morphological and vascular ultrasound findings of cutaneous melanoma locoregional metastasis, both in lymph nodes and in superficial soft tissues. To see if detection of these findings allows a sure diagnosis. MATERIALS AND METHODS: The morphological aspects of melanoma metastasis were evaluated with high-resolution ultrasound, and vascularisation by power color, by means the malignancy criteria previously described. RESULTS: 71 loco-regional metastasis were found, in 32 patients: 15 lymph node metastases (21.2%) and 56 soft tissues metastases (78.8%). All of them were histologic confirmation. In 19 cases metastasis were not detected by clinical evaluation. The lymph node metastasis had: low echogenicity (100%) with heterogeneous texture (66.7%); absence of echogenic hilus (93.3%); a ratio between longitudinal and transverse diameters<2 in most cases (86.2%); and peripheral or mixed vascularisation (86.6%). A statistic signification (p=0.049) was proved between L/T ratio and vascularisation type. Soft tissues metastases presented: a maximal diameter between 3-27 mm (mean: 6.91); oval or round shape, sometimes lobulate; well-defined margins (100%); low echogenicity (100%); heterogeneous texture (64.3%); and they showed vascularisation even in the smallest lesions (<5 mm). A statistic signification (p=0.006) was proved between the size and the vascularisation degree. CONCLUSION: US findings allow a suspicion diagnosis of melanoma locoregional metastasis even when metastasis was not detected in physical exam.

Aspecto ecográfico y en power doppler de las metástasis macroscópicas locorregionales del melanoma cutáneo / Ultrasonographic and power Doppler appearance of locoregional metastases from cutaneous melanoma

Objetivo. Describir las características ecográficas morfológicas y vasculares de las metástasis locorregionales del melanoma cutáneo, tanto ganglionares como en tejidos superficiales; observar si el reconocimiento ecográfico de estas lesiones permite el diagnóstico con alto grado de certeza. Material y métodos. Se valoró el aspecto morfológico en ecografía de alta resolución y la vascularización mediante power color, de las metástasis locorregionales de melanoma, aplicando los criterios de malignidad propios de estas lesiones, descritos en la literatura. Resultados. Se encontraron 71 metástasis locorregionales en 32 pacientes, 15 metástasis ganglionares (21,2%) y 56 metástasis de partes blandas (78,8%), que se confirmaron anatomopatológicamente. En 19 casos no fueron sospechadas clínicamente. Las metástasis ganglionares presentaron ecogenicidad baja (100%) con textura heterogénea (66,7%), ausencia de hilio ecogénico (93,3%), una relación entre el diámetro longitudinal y transverso < 2 (86,6%) y vascularización periférica o mixta (86,6%). Se demostró una relación estadística significativa (p = 0,049) entre el L/T ratio y el tipo de vascularización. Las metástasis de partes blandas presentaron un diámetro máximo entre 3-27 mm (media: 6,91), forma ovalada o redondeada, a veces lobulada, márgenes bien definidos (100%), ecogenicidad baja (100%), textura heterogénea (64,3%) y presencia de vascularización (100%), incluso en las lesiones más pequeñas (< 5 mm). Se demostró una relación estadística significativa (p = 0,006) entre el tamaño y el grado de vascularización. Conclusión. Las características ecográficas permiten el diagnóstico de sospecha de las metástasis locorregionales del melanoma cutáneo, incluso en aquéllas que no pueden ser sospechadas clínicamente

Objetive. To describe the morphological and vascular ultrasound findings of cutaneous melanoma locoregional metastasis, both in lymph nodes and in superficial soft tissues. To see if detection of these findings allows a sure diagnosis. Materials and methods. The morphological aspects of melanoma metastasis were evaluated with high-resolution ultrasound, and vascularisation by power color, by means the malignancy criteria previously described. Results. 71 loco-regional metastasis were found, in 32 patients: 15 lymph node metastases (21,2%) and 56 soft tissues metastases (78,8%). All of them were histologyc confirmation. In 19 cases metastasis were not detected by clinical evaluation. The lymph node metastasis had: low echogenicity (100%) with heterogeneous texture (66,7%); absence of echogenic hilus (93,3%); a ratio between longitudinal andtransverse diameters < 2 in most cases (86,2%); and peripheral or mixed vascularisation (86,6%). A statistic signification (p = 0,049) was proved between L/T ratio and vascularisation type. Soft tissues metastases presented: a maximal diameter between 3-27 mm (mean: 6,91); oval or round shape, sometimes lobulate; well-defined margins (100%); low echogenicity(100%); heterogeneous texture (64,3%); and they showedvascularisation even in the smallest lesions (< 5 mm). A statisticsignification (p = 0,006) was proved between the sizeand the vascularisation degree.Conclusion. US findings allow a suspicion diagnosis ofmelanoma locoregional metastasis even when metastasiswas not detected in physical exam (AU)