[Ultrasound-guided cannulation or by pulse palpation in the intensive care unit]. / Canalización arterial ecoguiada o por palpación del pulso en la unidad de cuidados intensivos.

INTRODUCTION: Ultrasound (US) guidance increases the success rate and decreases complications during central venous catheterisation (CVC). The benefits of US guidance in arterial catheterisation are less clear. The aim of this study is to compare the outcomes of US-guided arterial catheterisation with the traditional landmark (LM) technique in critically ill children. METHODS: A prospective multicentre study was carried out in 18 Paediatric Intensive Care units in Spain during a 6-months period. Ultrasound guided and landmark techniques were compared in terms of cannulation technical success and immediate mechanical complications. RESULTS: A total of 161 procedures were performed on 128 patients (78 procedures in the US group and 83 in the LM groups). The median (interquartile range) age and weight of the cohort was 11months (2-52), and 10kg (4-17), respectively. More than half (59.6%) were male. US was used mainly in big (number of beds 11 [8-16] vs 6 [4-10], p < 0,001) and high complexity intensive care units (cardiac surgery program 76.9% vs. 25.6%, P<.001) as well as in smaller children [weight 5.7kg (3.8-13) vs 11.5kg (4.9-22.7), P<.001]. Almost half (49.7%) of the procedures were performed by an inexperienced operator (paediatric resident, or staff with less than 5years of clinical experience in the PICU), and only 24.4% had performed more than 50 US-guided vascular access procedures before the study. There were no significant differences between US and LM techniques in terms of first-attempt success (35.8% vs 33.7%, P=.773), overall success (75.6% vs 71.1%, P=.514), number of puncture attempts [2 (1-4) vs 2 (1-3), P=.667] and complications (16.6% vs 25.6%, P=.243). Adjustment by potential confounders using multivariate regression models did not modify these results. Subgroup analyses showed that US outperformed LM technique in terms of overall success (83.7% vs 62.7%, P=.036) and complications (10,8% vs 32.5%, P=.020) only when procedures where performed by less-experienced operators. CONCLUSIONS: In this prospective observational multicentre study, US did not improve arterial cannulation outcomes compared to the traditional LM technique in critically ill children. US-guided arterial cannulation may offer advantages when cannulation is performed by inexperienced operators.

Infecciones durante oxigenación de membrana extracorpórea / Experience with infections in the use of extracorporeal membrane oxygenation

OBJETIVO: Identificar factores de riesgo asociados con el desarrollo de infecciones nosocomiales en pacientes pediátricos asistidos con oxigenación por membrana extracorpórea (ECMO). PACIENTES Y MÉTODOS: Se han revisado de forma retrospectiva los pacientes que han recibido asistencia en ECMO de enero de 2011 a diciembre de 2014. Se han recogido datos demográficos, sobre la asistencia y sobre las infecciones que aparecen durante dicha asistencia. RESULTADOS: En este periodo hubo 50 asistencias en ECMO. Veinte pacientes tuvieron 23 episodios de infección, de los que 16 fueron bacteriemias, siendo el microorganismo más frecuente el estafilococo coagulasa negativo (habiendo 2 casos de candidemia). En cuanto a los grupos de edad, el lugar y el tipo de canulación, la presencia de coagulopatía grave y la realización de intervenciones quirúrgicas durante la asistencia, ninguno de estos factores resultó un factor de riesgo de infección estadísticamente significativo. La duración media de soporte en ECMO fue significativamente mayor en los pacientes que tuvieron alguna infección (8,91 vs. 5,96 días; p = 0,039). No hubo diferencias significativas en cuanto a la estancia en la Unidad de Cuidados Intensivos Pediátricos ni en cuanto a la supervivencia. CONCLUSIONES: La incidencia de infección durante ECMO es muy alta y los pacientes que tienen una infección están asistidos un tiempo significativamente mayor, por lo que se deben instaurar medidas para prevenir la aparición de estas infecciones e intentar minimizar el tiempo de asistencia en ECMO

OBJECTIVE: To identify risk factors associated with infectious complications acquired by paediatric patients during extracorporeal life support (ECLS). PATIENTS AND METHODS: Patients under ECLS from January 2011 to December 2014 have been retrospectively reviewed and data on demographics, care and infectious complications were collected. RESULTS: There were 50 ECLS assistances in the study period, of which 20 patients had 23 infectious complications: 16 were bloodstream infections, with coagulase negative staphylococci being the predominant isolate (there were 2 cases of candidaemia). Age, site of cannulation procedure, cannulation site, severe coagulopathy, and surgical interventions during assistance were analysed as risk factors for infectious complications, but no significant differences were found. ECLS duration was significantly longer in patients with infectious complications (8.91 vs 5.91 days; P=.039). There were no significant differences as regards Paediatric Intensive Care Unit (PICU) stay, or in survival. CONCLUSIONS: Infectious complications during ECLS are very common, and ECLS duration is significantly longer in patients with infections. Measures should be put in place to prevent infectious complications and reduce time on ECLS

Ultrasound-guided or landmark techniques for central venous catheter placement in critically ill children.

PURPOSE: To assess whether ultrasound guidance improves central venous catheter placement outcomes compared to the landmark technique in critically ill children. METHODS: A prospective multicentre observational study was carried out in 26 paediatric intensive care units over 6 months. Children 0-18 years old who received a temporary central venous catheter, inserted using either ultrasound or landmark techniques, were eligible. The primary outcome was the first-attempt success rate. Secondary outcomes included overall placement success, number of puncture attempts, number of procedures requiring multiple punctures (> 3 punctures), number of procedures requiring punctures at more than one vein site and immediate mechanical complications. To account for potential confounding factors, we used propensity scores. Our primary analysis was based on 1:1 propensity score matching. The association between cannulation technique and outcomes in the matched cohort was estimated using generalized estimating equations and mixed-effects models to account for patient-level and hospital-level confounders. RESULTS: Five hundred central venous catheter-placement procedures involving 354 patients were included. Ultrasound was used for 323 procedures, and the landmark technique was used for 177. Two hundred and sixty-six procedures were matched (133 in the ultrasound group and 133 in the landmark group). Ultrasound was associated with an increase in the first-attempt success rate [46.6 vs. 30%, odds ratio 2.09 (1.26-3.46); p < 0.001], a reduced number of puncture attempts [2 (1-3) vs. 2 (1-4), B coefficient - 0.51 (95% confidence interval - 1.01 to - 0.03), p = 0.035], and fewer overall mechanical complications [12 vs. 22.5%, odds ratio 0.47 (95% confidence interval 0.24-0.91), p = 0.025] in the matched cohort. The number of puncture attempts was the main factor associated with overall complications. CONCLUSIONS: Compared with the landmark technique, ultrasound guidance was associated with an increased first-attempt success rate, a reduced number of puncture attempts, and fewer complications during central venous catheter placement in critically ill children.

[Experience with infections in the use of extracorporeal membrane oxygenation]. / Infecciones durante oxigenación de membrana extracorpórea.

OBJECTIVE: To identify risk factors associated with infectious complications acquired by paediatric patients during extracorporeal life support (ECLS). PATIENTS AND METHODS: Patients under ECLS from January 2011 to December 2014 have been retrospectively reviewed and data on demographics, care and infectious complications were collected. RESULTS: There were 50 ECLS assistances in the study period, of which 20 patients had 23 infectious complications: 16 were bloodstream infections, with coagulase negative staphylococci being the predominant isolate (there were 2 cases of candidaemia). Age, site of cannulation procedure, cannulation site, severe coagulopathy, and surgical interventions during assistance were analysed as risk factors for infectious complications, but no significant differences were found. ECLS duration was significantly longer in patients with infectious complications (8.91 vs 5.91 days; P=.039). There were no significant differences as regards Paediatric Intensive Care Unit (PICU) stay, or in survival. CONCLUSIONS: Infectious complications during ECLS are very common, and ECLS duration is significantly longer in patients with infections. Measures should be put in place to prevent infectious complications and reduce time on ECLS.

[Spanish patients with central hypoventilation syndrome included in the European Registry. The 2015 data]. / Pacientes españoles con síndrome de hipoventilación central incluidos en el Registro europeo. Datos del 2015.

INTRODUCTION: Congenital Central Hypoventilation Syndrome (CCHS) is a very rare genetic disease. In 2012 the European Central Hypoventilation Syndrome (EuCHS) Consortium created an online patient registry in order to improve care. AIM: To determine the characteristics and outcomes of Spanish patients with CCHS, and detect clinical areas for improvement. MATERIALS AND METHOD: An assessment was made on the data from Spanish patients in the European Registry, updated on December 2015. RESULTS: The Registry contained 38 patients, born between 1987 and 2013, in 18 hospitals. Thirteen (34.2%) were older than 18 years. Three patients had died. Genetic analysis identified PHOX2B mutations in 32 (86.5%) out of 37 patients assessed. The 20/25, 20/26 and 20/27 polyalanine repeat mutations (PARMs) represented 84.3% of all mutations. Longer PARMs had more, as well as more severe, autonomic dysfunctions. Eye diseases were present in 47%, with 16% having Hirschsprung disease, 13% with hypoglycaemia, and 5% with tumours. Thirty patients (79%) required ventilation from the neonatal period onwards, and 8 (21%) later on in life (late onset/presentation). Eight children (21%) were using mask ventilation at the first home discharge. Five of them were infants with neonatal onset, two of them, both having a severe mutation, were switched to tracheostomy after cardiorespiratory arrest at home. Approximately one-third (34.3%) of patients were de-cannulated and switched to mask ventilation at a mean age of 13.7 years. Educational reinforcement was required in 29.4% of children attending school. CONCLUSION: The implementation of the EuCHS Registry in Spain has identified some relevant issues for optimising healthcare, such as the importance of genetic study for diagnosis and assessment of severity, the high frequency of eye disease and educational reinforcement, as well as some limitations in ventilatory techniques.

Cuidados al final de la vida en la unidad de cuidados intensivos pediátricos. Empleo de técnicas de investigación cualitativa para el análisis del afrontamiento de la muerte y situaciones críticas / End-of-life care in the pediatric intensive care unit. Use of qualitative research techniques for analyzing coping with death and critical situations

Fundamento: En la última década, se aprecia un creciente interés por los aspectos más humanos de la enfermedad que se traduce en un acercamiento a la familia y a su sufrimiento. Objetivo: Conocer en profundidad la experiencia de los profesionales y de los padres de niños ingresados en la unidad de cuidados intensivos pediátricos (UCIP). Material y métodos: Se organizaron grupos focales (GF) de padres de hijos fallecidos o con secuelas graves ingresados en la UCIP los años 1999-2002. Asimismo, se desarrollaron reuniones de GF de profesionales. Se revisó desde el ingreso hasta la muerte y el seguimiento del duelo. Se recogieron las inquietudes y las necesidades expresadas por el personal sanitario. Resultados: Se contactó con 133 familias (40% de hijos fallecidos y 60% de hijos con secuelas), de los que acudieron un 75% y un 44%, respectivamente. Las madres acudieron más (61%) en el caso de fallecidos, y las parejas (51%), en el caso de niños con secuelas. Asimismo, se organizaron GF con 22 personas (5 médicos, 11 enfermeras y 5 auxiliares de enfermería). Se recogieron los principales problemas, discrepancias y soluciones. Se instauraron medidas de mejora acordes con la información recibida. Conclusiones: La aplicación de GF ha permitido el acercamiento a las necesidades y problemas más importantes de los padres de niños que ingresan en la UCIP, así como de los profesionales. Esta información ha facilitado la implantación de medidas de mejora de una forma realista y ajustada a estas necesidades

Background: In the last 10 years, there has been increasing concern for a more human approach to illness, which has led to a better understanding of families and their suffering. Objective: To gain greater insight into the experience of the parents of children admitted to the PICU and of the health workers in these units. Material and methods: Focus groups (FG) composed of parents with children who had died or who were having serious sequels were organized in the PICU from 1999-2002. Likewise, FG meetings with health professionals were set up. The period from admission to death and support for grieving families were reviewed. At the same time, the concerns and needs mentioned by health professionals were collected. Results: A total of 133 families were contacted by surface mail (40% had children who had died and 60% had children with sequels who survived); of these, 75% of the families in the first group and 44% of those in the second group attended the FG. Attendance by mothers (61%) was more frequent in the case of death, and attendance by couples (51%) was more frequent in children with sequels. Focus groups were organized with 22 health professionals (five physicians, 11 nurses and five nurses' aids). The main problems, discrepancies and solutions identified by the distinct groups were recorded. Improvement measures were implemented according to the available information. Conclusions: The use of FG allowed us to approach to the most important needs and problems of parents with children admitted to the PICU, as well as those of the heath workers in the unit. This information allowed improvement measures adjusted to these needs to be implemented in a realistic manner