Neurological repercussions of changes in cerebral blood flow in neonates undergoing cardiovascular surgery.

INTRODUCTION: Surgery for congenital heart disease can generate cerebral perfusion-associated alterations with neurological repercussions. OBJECTIVE: To analyze the relationship of peri-surgical cerebrovascular resistance index (RI) with mediate neurological functions after congenital heart disease surgery. METHOD: Prospective cohort study of 34 neonates in whom basilar artery RI, serum oxygen, carbon dioxide and lactate levels were determined before and after palliative or corrective procedures. We related pre-surgical RI with post-surgical ability to initiate the enteral route or to restore unassisted spontaneous breathing. RESULTS: Three groups were formed: 79 neonates with high RI (> 0.73), 73 with normal RI (0.63 to 0.73) and eight with low RI (< 0.63). In the former group, high RI persisted in the postoperative period, with persistent hyperlactatemia and hypoxia; in 86 %, the enteral route could not be initiated, and neither could assisted ventilation be withdrawn. In the second group, RI remained within normal values. In the third group, although RI, serum lactate and arterial oxygen pressure tended to normalize, 71 % had severe neurological damage. CONCLUSIONS: RI changes were common, although neurological damage appears to occur more commonly when RI remains high, possibly associated with low cerebral blood flow.

INTRODUCCIÓN: La cirugía de cardiopatías congénitas puede generar alteraciones perfusorias cerebrales con repercusión neurológica. OBJETIVO: Analizar la relación del índice de resistencia (IR) vascular cerebral periquirúrgico con funciones neurológicas mediatas posteriores a cirugía de cardiopatía congénita. MÉTODO: Estudio de cohorte prospectivo de 34 neonatos en quienes se determinó IR de la arteria basilar, niveles séricos de oxígeno, dióxido de carbono y lactato, antes y después de procedimientos paliativos o correctivos. Relacionamos el IR prequirúrgico con la capacidad posquirúrgica para iniciar la vía enteral o restablecer la respiración espontánea no asistida. RESULTADOS: Se integraron tres grupos: 79 neonatos con IR alto > 0.73, 73 con IR normal de 0.63 a 0.73 y ocho con IR bajo < 0.63. En los primeros persistió IR elevado en el posquirúrgico, con hiperlactatemia e hipoxia persistentes; en 86 % no se logró iniciar la vía enteral ni retirar la ventilación asistida. En los segundos, el IR se mantuvo en valores normales. En los terceros, si bien el IR, el lactato sérico y la presión arterial de oxígeno tendieron a normalizarse, 71 % presentó daño neurológico grave. CONCLUSIONES: Los cambios en el IR fueron frecuentes, aunque el daño neurológico parece presentarse más cuando el IR se mantiene alto, posiblemente asociado con flujos cerebrales bajos.

Repercusión neurológica por cambios en el flujo sanguíneo cerebral en neonatos sometidos a cirugía cardiovascular / Neurological repercussions of changes in cerebral blood flow in neonates undergoing cardiovascular surgery

Resumen Introducción: La cirugía de cardiopatías congénitas puede generar alteraciones perfusorias cerebrales con repercusión neurológica. Objetivo: Analizar la relación del índice de resistencia (IR) vascular cerebral periquirúrgico con funciones neurológicas mediatas posteriores a cirugía de cardiopatía congénita. Método: Estudio de cohorte prospectivo de 34 neonatos en quienes se determinó IR de la arteria basilar, niveles séricos de oxígeno, dióxido de carbono y lactato, antes y después de procedimientos paliativos o correctivos. Relacionamos el IR prequirúrgico con la capacidad posquirúrgica para iniciar la vía enteral o restablecer la respiración espontánea no asistida. Resultados: Se integraron tres grupos: 17 neonatos con IR alto > 0.73, cinco con IR normal de 0.63 a 0.73 y seis con IR bajo < 0.63. En los primeros persistió IR alto en el posquirúrgico, con hiperlactatemia e hipoxia persistentes; en 86 % no se logró iniciar la vía enteral ni retirar la ventilación asistida. En los segundos, el IR se mantuvo en valores normales. En los terceros, si bien el IR, el lactato sérico y la presión arterial de oxígeno tendieron a normalizarse, 71 % presentó daño neurológico grave. Conclusiones: Los cambios en el IR fueron frecuentes, aunque el daño neurológico parece presentarse más cuando el IR se mantiene alto, posiblemente asociado a flujos cerebrales bajos.

Abstract Introduction: Surgery for congenital heart disease can generate cerebral perfusion-associated alterations with neurological repercussions. Objective: To analyze the relationship of peri-surgical cerebrovascular resistance index (RI) with mediate neurological functions after congenital heart disease surgery. Method: Prospective cohort study of 34 neonates in whom basilar artery RI, serum oxygen, carbon dioxide and lactate levels were determined before and after palliative or corrective procedures. We related pre-surgical RI with post-surgical ability to initiate the enteral route or to restore unassisted spontaneous breathing. Results: Three groups were formed: 17 neonates with high RI (> 0.73), five with normal RI (0.63-0.73) and six with low RI (< 0.63). In the former group, high RI persisted in the postoperative period, with persistent hyperlactatemia and hypoxia; in 86%, the enteral route could not be initiated, and neither could assisted ventilation be withdrawn. In the second group, IR remained within normal values. In the third group, although RI, serum lactate and arterial oxygen pressure tended to normalize, 71% had severe neurological damage. Conclusions: RI changes were common, although neurological damage appears to occur more commonly when RI remains high, possibly associated with low cerebral blood flow.

Risk Factors for Central Line-Associated Bloodstream Infection in Critically Ill Neonates.

OBJECTIVE: To identify independent risk factors to develop a central line- associated bloodstream infection (CLABSI) in critically ill neonates with major underlying diseases. METHODS: A nested case-control study was conducted in a neonatal intensive care unit (NICU). Patients with a central venous catheter (CVC) were included. Cases were neonates who developed a CLABSI and controls were patients without CLABSI. Variables included: perinatal history, characteristics of the catheter, installation and catheter use, surgical interventions, and hospital stay. Odds ratio (OR) and 95% confidence intervals (CI) were calculated. X2, Fisher exact, and Mann-Whitney U tests were used when appropriate. Variables with a p value ≤0.10 in the univariate analysis were introduced in a non-conditional logistic regression model. RESULTS: Seventy four cases and 105 controls were analyzed. Univariate risk factors were: any surgery, abdominal surgery, length of hospitalization (≥14 d), double-lumen CVC, surgical cut-down technique, complications, CVC placement in internal jugular vein, dressing type, blood transfusions, parenteral nutrition, and number of CVC manipulations (>200). In the logistic regression analysis, independent risk factors with a p value <0.05 were: double-lumen catheter (OR 5.8, 95% CI 1.2-30), length of hospitalization ≥14 d (OR 4.6, 95% CI 1.8-11.4), abdominal surgery (OR 2.7, 95% CI 1.2-6.2) and blood transfusions (OR 2.5, 95% CI 1.2-5.3). CONCLUSIONS: One risk factor was related to the catheter itself. Management of underlying diseases in specialized NICU contributes to a greater extent to the development of a central line-associated bloodstream infection.

Risk Factors for Intracardiac Thrombosis in the Right Atrium and Superior Vena Cava in Critically Ill Neonates who Required the Installation of a Central Venous Catheter.

BACKGROUND: Central venous catheter (CVC) installation is essential for the treatment of critically ill neonates; however, it is associated with the development of neonatal intracardiac thrombosis, which is a complication that is associated with a poor prognosis. We aimed to identify specific risk factors for the development of intracardiac thrombosis in the right atrium (RA) and superior vena cava (SVC) related to the use of CVC in critically ill neonates. METHODS: A case-control study was conducted at the tertiary referral neonatal intensive care unit of the Pediatric Hospital Siglo XXI in Mexico City, Mexico from 2008 to 2013. The included cases (n = 43) were de novo patients with intracardiac thrombosis in the RA and SVC diagnosed by echocardiography. The controls (n = 43) were neonates without intracardiac thrombosis or thrombosis at other sites. A logistic regression analysis was conducted, and odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. RESULTS: The independent risk factors for intracardiac thrombosis in the RA and SVC were the surgical cut-down insertion technique (OR = 2.98; 95% CI: 1.18-9.10), a maternal history of gestational diabetes/diabetes mellitus (OR = 10.64; 95% CI: 1.13-121.41), Staphylococcus epidermidis infection (OR = 7.09; 95% CI: 1.09-45.92), and CVC placement in the SVC (OR = 5.77; 95% CI: 1.10-30.18). CONCLUSION: This study allowed us to identify several contributing factors to the development of intracardiac thrombosis in the RA and SVC related to the installation of a CVC in a subgroup of critically ill neonates. Multicenter and well-designed studies with a larger number of patients could help validate our findings and/or identify other risk factors that were not identified in the present study.

Limitantes para la lactancia materna del recién nacido pretérmino hospitalizado / Limitations for breastfeeding newborn preterm hospitalized

Resumen:

Introducción: en el recién nacido hospitalizado se incrementa el riesgo de complicaciones e infecciones nosocomiales relacionadas con la hospitalización y el compromiso inmunológico, en esta condición la lactancia materna exclusiva puede ayudar disminuir la morbimortalidad durante este período.

Objetivo: describir las causas que limitan la lactancia materna del recién nacido pretérmino hospitalizado en una unidad de cuidados intensivos neonatales.

Metodología: estudio descriptivo, se aplicó un instrumento estructurado con cinco secciones, la 1 y 2 con datos generales y antecedentes patológicos de la madre-hijo; las secciones 3, 4 y 5 abordan aspectos de información y prácticas sobre lactancia materna y solicitud de leche; se realizó una entrevista cara a cara a 36 madres de 36 recién nacidos hospitalizados. Se utilizó estadística descriptiva. Resultados: el 52.8 % de los recién nacidos fueron prematuros y con alimentación el 50 % de ellos. En 68 % de los casos la principal limitante para la lactancia fue la información deficiente en la conservación y traslado de la leche materna al hospital.

Conclusiones: la deficiente información de las madres sobre la conservación y traslado de la leche materna está relacionado con la no extracción de leche, se recomienda el fortalecimiento de las estrategias de educación a las madres del recién nacido hospitalizado, para la extracción y conservación de la leche, así como de los beneficios que aporta al sistema inmunológico.

Abstract:

Introduction: Hospital newborn complications and the risk of nosocomial infections related to hospitalization and increases immunocompromised, in this condition of exclusive breastfeeding can help reduce morbidity and mortality this critical period.

Objective: To describe the causes that limit breastfeeding newborn hospitalized in the Neonatal Intensive Care Unit.

Methodology: Descriptive study, a structured instrument with five sections, the 1 and 2 with general data and medical history of the mother-son was applied; Sections 3, 4 and 5 information, aspects of the practice of breastfeeding and milk demand; We face to face 36 to 36 mothers of newborns hospitalized interview was conducted. For data analysis Descriptive statistics were used. Results: 52.8% of newborns are premature and supply 50% of them; the average maternal age was 27 years, engaged in household 83.3% and 52.7% higher average education. In 68% of cases the main constraint to breastfeeding was poor reporting on conservation and transfer of breast milk to the hospital, the low milk 20%, 8% and fatigue work 4%.

Conclusions: Poor mother's information on the conservation and transfer of breast milk is related to the non-extraction of milk, strengthening education strategies is recommended to mothers of newborn hospitalized for extraction and conservation Milk and on the benefits to immune support.

[Research in pediatrics]. / Investigación en pediatría.

In the interest of encouraging the promotion of research done by physicians of the Instituto Mexicano del Seguro Social, in this supplement we publish articles written by residents of different specialties related to critical themes on pediatrics. These residents are guided by affiliated physicians from the Hospital de Pediatría del Centro Médico Nacional Siglo XXI.

Con el objetivo de fomentar la difusión de investigaciones que son producto de las tesis de los médicos del Instituto Mexicano del Seguro Social, en el presente suplemento se publican artículos escritos por residentes de diferentes especialidades relacionadas con temas prioritarios de la pediatría. Estos residentes son dirigidos por médicos adscritos del Hospital de Pediatría del Centro Médico Nacional Siglo XXI.

[Reliability and validity of an instrument to evaluate integral clinical competence in medical residents]. / Confiabilidad y validez de un instrumento de evaluación de la competencia clínica integral de médicos residentes.

BACKGROUND: The evaluation of clinical competence in medical residents is a complex procedure. Teachers need reliable and valid instruments to evaluate objectively the, clinical competence. The aim of this study was to determine the reliability and validity of an instrument designed to evaluate the clinical competence of medical residents. METHODS: We designed an instrument taking into consideration every part of the clinical method, and three different levels of competence were determined for each one. The instrument was examined with regards to the clarity, pertinence and sufficiency of each clinical indicator by five expert pediatricians. The instrument was finally constituted by 11 indicators. Each resident was evaluated independently by three pediatricians. RESULTS: A total of 651 measurements were done in 234 residents. The instrument distinguished between extreme groups, had a value of Cronbach's alpha of 0.778 and the factorial analysis set apart two factors: clinical competence and complementary competences. No statistical differences were found between evaluators neither in global evaluation or in each indicator. CONCLUSIONS: The instrument here proposed is valid and reliable. It may be used in formative evaluation of medical residents in clinical specialization programs.

Introducción: la evaluación de la competencia clínica de un residente es un proceso complejo. Los profesores requieren de instrumentos confiables y válidos para evaluar objetivamente la competencia clínica. El objetivo fue evaluar la confiabilidad y validez de un instrumento (IECC) diseñado para evaluar la competencia clínica integral de los médicos residentes. Métodos: se diseñó un instrumento a partir de los diferentes pasos del método clínico, y se determinaron tres niveles de competencia para cada uno. El instrumento fue revisado respecto a su claridad, pertinencia y la suficiencia de sus indicadores planteados por cinco médicos pediatras expertos. Cada residente fue evaluado independientemente por tres médicos. Resultados: se obtuvieron en total 651 mediciones en 234 residentes. El instrumento discriminó entre grupos extremos. Se obtuvo un valor de alfa de Cronbach de 0.778 y el análisis factorial distinguió dos factores: competencia clínica y competencias complementarias. No se encontraron diferencias entre evaluadores en las calificaciones globales ni en cada uno de los indicadores. Conclusión: el instrumento propuesto es válido y confiable. Se propone como una herramienta más en la evaluación formativa de los médicos residentes de especialidades clínicas.