Hipotensión arterial postoperatoria: el enemigo inadvertido / Postoperative arterial hypotension: The unnoticed enemy

La hipotensión postoperatoria es un problema de salud frecuentemente subestimado, asociado a una elevada morbimortalidad y a un mayor uso de recursos sanitarios. También plantea importantes retos clínicos, tecnológicos y humanos para la asistencia sanitaria. Al tratarse de un factor de riesgo modificable y evitable, este documento pretende aumentar su visibilidad, definiendo su impacto clínico y los retos tecnológicos que conlleva la optimización de su manejo, teniendo en cuenta aspectos clínico-tecnológicos, humanísticos y económicos.(AU)

Postoperative hypotension is a frequently underestimated health problem associated with high morbidity and mortality and increased use of health care resources. It also poses significant clinical, technological, and human challenges for healthcare. As it is a modifiable and avoidable risk factor, this document aims to increase its visibility, defining its clinical impact and the technological challenges involved in optimizing its management, taking clinical-technological, humanistic, and economic aspects into account.(AU)

Revisión crítica de las recomendaciones sobre fluidoterapia perioperatoria y monitorización hemodinámica de Recuperación intensificada en cirugía del adulto (RICA): Declaración de posición del Grupo de Trabajo de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasia, Medicina transfusional y Fluidoterapia (SHTF) de la Sociedad Española de Anestesiología y Reanimación (SEDAR) / A critical review of the Perioperative Fluid Therapy and Hemodynamic Monitoring recommendations of the Enhanced Recovery of the Adult Pathway (RICA): A position statement of the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR)

En un esfuerzo por estandarizar el manejo perioperatorio y mejorar los resultados posoperatorios de los pacientes adultos sometidos a cirugía, el Ministerio de Sanidad, a través del Grupo Español de Rehabilitación Multimodal (GERM) y el Instituto Aragonés de Ciencias de la Salud, en colaboración con diversas sociedades científicas españolas, y sobre la base de la evidencia disponible, publicó en 2021 la guía Recuperación intensificada en cirugía del adulto (RICA). Dicho documento incluye 12 medidas perioperatorias relacionadas con la fluidoterapia y la monitorización hemodinámica. La administración de fluidos y la monitorización hemodinámica no son sencillas, pero están directamente relacionadas con los resultados de los pacientes. El Subcomité de Fluidoterapia y monitorización hemodinámica de la Sección de Hemostasia, Medicina transfusional y Fluidoterapia (SHTF) de la Sociedad Española de Anestesiología y Reanimación (SEDAR) ha analizado dichas recomendaciones, concluyendo que deberían ser revisadas, ya que no siguen la metodología adecuada. (AU)

In an effort to standardize perioperative management and improve postoperative outcomes of adult patients undergoing surgery, the Ministry of Health, through the Spanish Multimodal Rehabilitation Group (GERM), and the Aragonese Institute of Health Sciences, in collaboration with multiple Spanish scientific societies and based on the available evidence, published in 2021 the Spanish Intensified Adult Recovery (RICA) guideline. This document includes 12 perioperative measures related to fluid therapy and hemodynamic monitoring. Fluid administration and hemodynamic monitoring are not straightforward but are directly related to postoperative patient outcomes. The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR) has reviewed these recommendations and concluded that they should be revised as they do not follow an adequate methodology. (AU)

A critical review of the perioperative fluid therapy and hemodynamic monitoring recommendations of the Enhanced Recovery of the Adult Pathway (RICA): A position statement of the fluid therapy and hemodynamic monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR).

In an effort to standardize perioperative management and improve postoperative outcomes of adult patients undergoing surgery, the Ministry of Health, through the Spanish Multimodal Rehabilitation Group (GERM), and the Aragonese Institute of Health Sciences, in collaboration with multiple Spanish scientific societies and based on the available evidence, published in 2021 the Spanish Intensified Adult Recovery (RICA) guideline. This document includes 12 perioperative measures related to fluid therapy and hemodynamic monitoring. Fluid administration and hemodynamic monitoring are not straightforward but are directly related to postoperative patient outcomes. The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR) has reviewed these recommendations and concluded that they should be revised as they do not follow an adequate methodology.

Postoperative arterial hypotension: the unnoticed enemy.

Postoperative hypotension is a frequently underestimated health problem associated with high morbidity and mortality and increased use of health care resources. It also poses significant clinical, technological, and human challenges for healthcare. As it is a modifiable and avoidable risk factor, this document aims to increase its visibility, defining its clinical impact and the technological challenges involved in optimizing its management, taking clinical-technological, humanistic, and economic aspects into account.

No todo son malos tratos: pensando en un diagnóstico alternativo / Not always it’s a child abuse: thinking of an alternative diagnosis

Introducción: Los pediatras estamos muy concienciados sobre nuestro papel en el diagnóstico del maltrato, ya que si éste no se diagnostica y denuncia a tiempo, puede traer graves consecuencias en los niños, tanto físicas como psíquicas. Sin embargo, como médicos, también podemos incurrir en diagnósticos erróneos de maltrato, con la importancia que esta falsa afirmación supone desde el punto de vista legal y familiar. Material y métodos: Revisamos las historias de cuatro pacientes con patologías diversas que fueron diagnosticados inicialmente de maltrato. En todos ellos se encontró una causa médica que explicaba sus patologías y descartaba nuestra hipótesis inicial de maltrato. Conclusiones: Como pediatras, debemos estar alerta sobre los signos y síntomas que pueden hacernos pensar en maltrato. Sin embargo, también debemos conocer las patologías que pueden parecer efectos de un maltrato, y siempre debemos pensar en los posibles diagnósticos diferenciales cuando se nos plantea un posible caso de maltrato (AU)

Backgrounds: Paediatricians are concerned about our role in diagnosis of child abuse, due to the terrible consequences, both physical and psychological, that children can suffer if it’s not diagnosed and reported on time. However, as doctors, we can fall into misdiagnosis, with the importance of this wrong statement means legally and in their families. Material and methods: We have reviewed four medical records with different diseases. All of them were initially diagnosed of child abuse, but in all we found a medical cause that explained their diseases and child abuse could be ruled out. Conclusions: As paediatricians, we must be alert about signs and symptoms that might make us think about child abuse. However, we also must know diseases that can simulate child abuse and we must consider an alternative diagnoses always than we were thinking about the possibility of physical or sexual child abuse (AU)

Depresión del segmento ST durante la taquicardia supraventricular. ¿Se debe a la isquemia? / ST-segment depression during paroxysmal supraventricular tachycardia, is ischemia involved?

La aparición de alteraciones significativas de la repolarización durante episodios de taquicardia supraventricular no es un hecho infrecuente. A menudo, estos episodios cursan con dolor torácico, lo que puede hacer pensar en una enfermedad coronaria. Se presenta el caso de un paciente de 9 años de edad, tratado en nuestro centro por un episodio de taquicardia supraventricular y dolor torácico, con posterior depresión del segmento ST que no se normalizó hasta horas después del episodio. Se realiza una revisión de las taquicardias paroxísticas supraventriculares por vía accesoria y se discute el valor diagnóstico y la etiología de las alteraciones de la repolarización durante las taquicardias supraventriculares (AU)

Repolarization abnormalities during supraventricular tachycardias are not unusual. They are frequently accompanied by chest pain, this may lead to a false diagnosis of coronary ischemia. We present a 9-year-old child with an episode of supraventricular tachycardia, chest pain and pronounced ST-segment depression treated in our hospital. A review about paroxysmal atrioventricular re-entrant tachycardia is presented. Diagnostic value and aetiology of repolarization abnormalities during supraventricular tachycardias are discussed (AU)

Obstrucción urinaria por cálculo uretral / Urinary obstruction by urethral calculus

La litiasis renal es una patología típica del adulto, y menos frecuente en la edad pediátrica, por lo que no siempre se piensa en ella. Presentamos el caso de un niño de 3 años de edad con un cálculo uretral, previamente diagnosticado de infección de orina, que acudió al servicio de urgencias con síntomas de obstrucción urinaria, provocados por la expulsión en ese momento del cálculo (AU)

Urolithiasis is a typically adult disease, infrequent in the paediatric age, so we rarely think about it. We present the case of a 3 years old child with a urethral lithiasis, previously diagnosed of urinary infection, who presented with symptoms of urinary obstruction, caused by the expulsion of a urethral stone at that moment (AU)

Úlceras de Lipschütz: a propósito de dos nuevos casos / Lipschütz’s ulcers: two new cases report

Presentamos los casos de dos niñas de 13 y 11 años de edad, previamente sanas, que consultaron en nuestro servicio de urgencias pediátricas por presentar úlceras dolorosas genitales agudas que aparecieron en el contexto de un proceso febril. Las exploraciones complementarias descartaron tanto una enfermedad venérea como el resto de causas habituales de úlceras genitales. En ambos casos las lesiones desaparecieron en un periodo de 2 semanas sin secuelas(AU)

We present the cases of two girls, 13 and 11 aged respectively, who had previously been healthy, that consulted in our pediatric emergency because of painful acute genital ulcers that appeared in the context of a febrile process. The complementary examinations ruled out both veneral disease and the other usual causes of genital ulcerations. In both cases, the lesions disappeared in a period of two weeks without sequelae(AU)

Lactante con edema pulmonary postobstructivo tras retirada de cuerpo extraño en la vía aérea / Infant with post-obstructive pulmonary edema after removal of foreign body in the airway

Los niños con obstrucción aguda o crónica de la vía aérea tienen riesgo de desarrollar edema agudo de pulmón postoobstructivo (EPP) tras la desobstrucción de la vía aérea. Es importante conocer esta patología, habitualmente confundida con patologías más frecuentes como neumonía o broncoespasmo, para realizar un diagnóstico y tratamiento precoces. Presentamos a continuación el caso de un lactante de 7 meses que presentó EPP tras la desobstrucción de la vía aérea provocada por n tapón de plástico (AU)

Children with either acute or chronic upper airway obstruction are at risk of developing post obstructive pulmonary oedema (POPE). It´s important to know about this pathology, often misdiagnosed as brochoespasm or pneumonia, in order to make a correct diagnoses and treatment. We describe a case of a 7-month infant who developed POPE after the relief of an upper airway obstruction caused by a plastic bottle cap (AU)

[Anesthetic management of a boy with sialidosis]. / Manejo anestésico de un paciente con sialidosis.

Sialidosis is an autosomal recessive disease caused by neuraminidase deficiency, which causes material rich in sialic acid to accumulate in various tissues and organs, leading to morphological and functional changes. Mainly the osteoarticular, cardiorespiratory, and central nervous systems are affected. We report the case of a 14-year-old boy diagnosed with sialidosis type 2 who was proposed for spinal column arthrodesis to treat severe thoracolumbar scoliosis. Physical examination revealed pectus carinatum; facial deformity and macroglossia; hypertelorism and frontal bossing; short neck; atlantoaxial subluxation; severe arthrogryposis of elbows, knees and wrists, coxa valga, and club foot. Relevant medical history included moderately severe aortic valve insufficiency and myoclonic epilepsy. Surgery was performed under balanced anesthesia. Awakening was delayed and the patient was transferred to the intensive care unit under mechanical ventilation. Anesthetic problems that can present in patients with such deformities include difficult airway, complicated management of associated cardiopathy, and difficult weaning from mechanical ventilation.

Manejo anestésico de un paciente con sialidosis / Anesthetic management of a boy with sialidosis

La sialidosis es una enfermedad autosómica recesivacausada por el déficit del enzima neuraminidasa. Dichodéficit provoca un acúmulo de material rico en ácido siálicoen diversos tejidos y órganos de la economía, ocasionandoalteraciones morfológicas y funcionales en losmismos. Afecta principalmente al sistema osteoarticular,cardiorrespiratorio y sistema nervioso central (SNC).Presentamos el caso clínico de un varón de 14 añosdiagnosticado de sialidosis tipo II, propuesto para artrodesisde columna vertebral por escoliosis toracolumbarsevera. A la exploración física presentaba deformidadtorácica en quilla, facies dismórfica con macroglosia,hipertelorismo y frente olímpica, cuello corto, subluxaciónatloaxoidea y artrogriposis severa con flexo decodos, rodillas, muñecas, coxa valga y pies equinos.Como antecedentes personales destacaba la existencia deinsuficiencia aórtica moderada y epilepsia mioclónica.Fue intervenido bajo anestesia general balanceada presentandoretraso en el despertar y precisando traslado ala unidad de cuidados intensivos con ventilación mecánica.Los problemas anestésicos que pueden presentar estospacientes comprenden la existencia de una vía aérea difícil,el manejo de las cardiopatías asociadas y las dificultadesen la desconexión de la ventilación mecánica

Sialidosis is an autosomal recessive disease caused byneuraminidase deficiency, which causes material rich insialic acid to accumulate in various tissues and organs,leading to morphological and functional changes.Mainly the osteoarticular, cardiorespiratory, and centralnervous systems are affected.We report the case of a 14-year-old boy diagnosed withsialidosis type 2 who was proposed for spinal columnarthrodesis to treat severe thoracolumbar scoliosis. Physicalexamination revealed pectus carinatum; facial deformityand macroglossia; hypertelorism and frontal bossing;short neck; atlantoaxial subluxation; severe arthrogryposisof elbows, knees and wrists, coxa valga, andclub foot. Relevant medical history included moderatelysevere aortic valve insufficiency and myoclonic epilepsy.Surgery was performed under balanced anesthesia. Awakeningwas delayed and the patient was transferred to theintensive care unit under mechanical ventilation.Anesthetic problems that can present in patients withsuch deformities include difficult airway, complicatedmanagement of associated cardiopathy, and difficultweaning from mechanical ventilation

[Antipyretic effectiveness of ibuprofen and paracetamol]. / Eficacia de ibuprofeno y paracetamol como antitérmicos.

OBJECTIVE: To compare the antipyretic effectiveness of ibuprofen and paracetamol and to evaluate the possible influence of patients' sex, weight, height and underlying disease on effectiveness. PATIENTS AND METHODS: A total of 166 children with fever, defined as a temperature equal to or above 38 degrees C, were enrolled. Of these, 80 were given paracetamol at a dose of 15 mg per kg and 86 were given 7 mg of ibuprofen per kg. Temperature was recorded at 60, 120,180 and 240 minutes after drug administration. Data were statistically analyzed, including analysis of paired data. RESULTS: Ninety percent of the children became afebrile at some time during the study with both paracetamol and ibuprofen. Seventy-four percent of the patients remained afebrile 4 hours after drug administration. The mean temperatures obtained with ibuprofen versus paracetamol were 37.66 +/- 0.73 vs 37.8 +/- 0.65, p = 0.22 one hour after drug administration; 37.09 +/- 0.83 vs 37.29 +/- 0.71, p = 0.14 two hours after drug administration; 37.12 +/- 1.05 vs 37.28 +/- 0.87, p = 0.64 three hours after drug administration; and 37.40 +/- 1.12 vs 37.46 +/- 1.00, p = 0.72 four hours after drug administration. The maximum rate of temperature decrease was achieved during the first 60 minutes after drug administration (-1.32 +- 0.83 with ibuprofen vs -1.09 +/- 0.77 with paracetamol, p = 0.10). In children aged between 5 and 12 years, ibuprofen achieved significantly lower temperatures than paracetamol (38.00 +/- 0.65 vs 37.45 +/- 0.43, p = 0.02 at 1 hour; 36.71 +/- 0.66 vs 37.60 +/- 0.93, p = 0.01 at 2 hours; 36.80 +/- 0.79 vs 37.67 +/- 1.12, p = 0.03 at 3 hours). Analysis by weight, height or underlying disease revealed no significant differences. CONCLUSIONS: Both ibuprofen and paracetamol proved to be successful in reducing temperature. The effectiveness of ibuprofen and paracetamol was similar, except in children aged more than 5 years old, in whom ibuprofen was more effective. Weight, sex and underlying disease had no influence on effectiveness.

Eficacia de ibuprofeno y paracetamol como antitérmicos / Antipyretic effectiveness of ibuprofen and paracetamol

Objetivo: El objetivo del estudio es analizar comparativamente la eficacia de ibuprofeno y paracetamol, y evaluar la posible repercusión sobre la misma de sexo, peso, talla y enfermedad subyacente. Pacientes y métodos: Se recogieron los datos de filiación de 166 niños con temperatura axilar igual o superior a 38 °C. Se administraron 15 mg/kg de paracetamol a 80 de ellos y 7 mg/kg de ibuprofeno a 86. Se recogió después la temperatura que presentaban a los 60, 120, 180 y 240 min de su administración. Con estos datos se realizó un análisis estadístico, incluyendo un análisis de datos apareados. Resultados: Ibuprofeno y paracetamol consiguieron dejar afebriles en algún momento del estudio al 90 % de los niños. El 74% de los pacientes permanecieron afebriles 4 h después de administrarlos. En la muestra global, las temperaturas obtenidas con ibuprofeno frente a paracetamol fueron: 37,66 +/- 0,73 frente a 37,80 +/- 0,65 (p = 0,22) a la hora de su administración; 37,09 +/- 0,83 frente a 37,29 +/- 0,71 a las 2 h; 37,12 +/- 1,05 frente a 37,28 +/- 0,87 (p = 0,64) a las 3 h; 37,40 +/- 1,12 frente a 37,46 +/- 1,00 (p = 0,72) a las 4 h. La máxima velocidad de descenso se alcanzó durante los primeros 60 min (–1,32 +/- 0,83 para ibuprofeno frente a –1,09 +/- 0,77 con paracetamol; p = 0,10). En cuanto al factor edad, en los niños de edad comprendida entre 5 y 12 años se lograron temperaturas significativamente menores con ibuprofeno que con paracetamol (38,00 +/- 0,65 frente a 37,45 +/- 0,43 [p = 0,02] en la primera hora; 36,71 +/- 0,66 frente a 37,60 +/- 0,93 [p = 0,01] en la segunda hora; 36,80 +/- 0,79 frente a 37,67 +/- 1,12 [p = 0,03] en la tercera hora). El análisis de datos en función del peso, sexo y enfermedad no mostró diferencias significativas. Conclusiones: Ibuprofeno y paracetamol demostraron ser efectivos a la hora de descender la temperatura. Ambos fármacos mostraron una eficacia antitérmica similar, salvo en los niños mayores de 5 años, donde se demostró mayor eficacia con ibuprofeno. Peso, sexo y enfermedad de base no determinaron diferencias de eficacia

Objective: To compare the antipyretic effectiveness of ibuprofen and paracetamol and to evaluate the possible influence of patients’ sex, weight, height and underlying disease on effectiveness. Patients and methods: A total of 166 children with fever, defined as a temperature equal to or above 38 °C, were enrolled. Of these, 80 were given paracetamol at a dose of 15 mg per kg and 86 were given 7 mg of ibuprofen per kg. Temperature was recorded at 60, 120,180 and 240 minutes after drug administration. Data were statistically analyzed, including analysis of paired data. Results: Ninety percent of the children became afebrile at some time during the study with both paracetamol and ibuprofen. Seventy-four percent of the patients remained afebrile 4 hours after drug administration. The mean temperatures obtained with ibuprofen versus paracetamol were 37.66 +/- 0.73 vs 37.8 +/- 0.65, p = 0.22 one hour after drug administration; 37.09 +/- 0.83 vs 37.29 +/- 0.71, p = 0.14 two hours after drug administration; 37.12 +/- 1.05 vs 37.28 +/- 0.87, p = 0.64 three hours after drug administration; and 37.40 = 1.12 vs 37.46 +/- 1.00, p = 0.72 four hours after drug administration. The maximum rate of temperature decrease was achieved during the first 60 minutes after drug administration (–1.32 +/- 0.83 with ibuprofen vs –1.09 +/- 0.77 with paracetamol, p = 0.10). In children aged between 5 and 12 years, ibuprofen achieved significantly lower temperatures than paracetamol (38.00 +/- 0.65 vs 37.45 +/- 0.43, p = 0.02 at 1 hour; 36.71 +/- 0.66 vs 37.60 +/- 0.93, p = 0.01 at 2 hours; 36.80 +/- 0.79 vs 37.67 +/- 1.12, p = 0.03 at 3 hours). Analysis by weight, height or underlying disease revealed no significant differences. Conclusions: Both ibuprofen and paracetamol proved to be successful in reducing temperature. The effectiveness of ibuprofen and paracetamol was similar, except in children aged more than 5 years old, in whom ibuprofen was more effective. Weight, sex and underlying disease had no influence on effectiveness