¿Cuáles son los factores predictores de fracaso de ventilación no invasiva más fiables en una unidad de cuidados intensivos pediátricos? / What are the most reliable predictive factors of non-invasive ventilation failure in paediatric intensive care units?

Introducción: La ventilación no invasiva (VNI) se ha convertido en un tratamiento habitual de la insuficiencia respiratoria aguda (IRA). Nuestro objetivo ha sido identificar factores predictores de fracaso de VNI para detectar precozmente a los pacientes en los que no tendrá éxito. Pacientes y métodos: Estudio de cohortes prospectivo que incluyó a todos los pacientes con IRA que recibieron VNI como tratamiento inicial entre 2005 y 2009, en una unidad de cuidados intensivos pediátricos de 14 camas de un hospital universitario de tercer nivel. Se recogieron datos clínicos e información sobre la VNI, previamente a su inicio, a las 2, 8, 12 y 24 horas. La razón entre saturación de hemoglobina y fracción de oxígeno inspirada (S/F) se calculó retrospectivamente. Se definió fallo de VNI como necesidad de intubación o necesidad de rescate con presión binivel (BLPAP). Se realizaron análisis estadísticos univariable y multivariable. Resultados: Un total de n = 282 pacientes recibieron soporte no invasivo, presión continua = 71, BLPAP = 211. El porcentaje de éxito de la muestra global fue 71%. Los pacientes tratados con BLPAP vs. presión continua, aquellos con S/F más elevados a las 2horas (odds ratio 0,991, IC 95%: 0,986-0,996, p = 0,001) y los mayores de 6 meses (hazard ratio 0,375, IC 95% 0,171-0,820, p = 0,014), presentaron menor riesgo de fracaso. Los pacientes con frecuencias cardíacas más altas y mayor presión positiva inspiratoria en vía aérea a las 2horas (odds ratio 1,021, IC 95%: 1,008-1,034, p = 0,001; hazard ratio 1,214, IC 95%: 1,046-1,408, p = 0,011) presentaron mayor riesgo de fracaso. Conclusiones: La edad < 6 meses, S/F, frecuencia cardíaca y presión positiva inspiratoria en la vía aérea a las 2 horas son factores predictores independientes de fracaso de VNI inicial en pacientes con IRA admitidos en una unidad de cuidados intensivos pediátricos

Introduction: Despite there being limited evidence, non-invasive ventilation (NIV) has become a common treatment for acute respiratory failure (ARF). The aim of this study was to identify the predictive factors of NIV failure, in order to enable early detection of patients failing the treatment. Patients and methods: Prospective cohort study was conducted that included all ARF patients that received NIV as the initial treatment between 2005 and 2009 in a fourteen-bed Paediatric Intensive Care Unit (PICU) of a tertiary university hospital. Information was collected about the NIV, as well as clinical data prior to NIV, at 2, 8, 12, and 24hrs. The haemoglobin saturation (SpO2)/fraction of inspired oxygen (FiO2) ratio (S/F) was retrospectively calculated. NIV failure was defined as the need for intubation or requiring rescue with bi-level pressure (BLPAP). Univariate and multivariate statistical analyses were performed. Results: A total of 282 patients received non-invasive support, with 71 receiving Continuous Pressure (CPAP), and 211 with BLPAP treatment. The overall success rate was 71%. Patients receiving BLPAP vs. CPAP, patients with higher S/F ratios at 2 hours (odds ratio [OR] 0.991, 95% CI 0.986-0.996, P = .001], and patients older than 6 months (Hazard ratio [HZ] 0.375, 95% CI 0.171-0.820, P = .014], were also more likely to fail. Patients with higher heart rates (HR) at 2hours (OR 1.021, 95% CI [1.008-1.034], P = .001) and higher inspiratory positive airway pressure (IPAP) at 2hours were more prone to failure (HZ 1.214, 95% CI [1.046-1.408], P = .011). Conclusions: Age below 6 months, S/F ratio, HR, and IPAP at 2 hours are independent predictive factors for initial NIV failure in paediatric patients with ARF admitted to the PICU

[What are the most reliable predictive factors of non-invasive ventilation failure in paediatric intensive care units?] / ¿Cuáles son los factores predictores de fracaso de ventilación no invasiva más fiables en una unidad de cuidados intensivos pediátricos?

INTRODUCTION: Despite there being limited evidence, non-invasive ventilation (NIV) has become a common treatment for acute respiratory failure (ARF). The aim of this study was to identify the predictive factors of NIV failure, in order to enable early detection of patients failing the treatment. PATIENTS AND METHODS: Prospective cohort study was conducted that included all ARF patients that received NIV as the initial treatment between 2005 and 2009 in a fourteen-bed Paediatric Intensive Care Unit (PICU) of a tertiary university hospital. Information was collected about the NIV, as well as clinical data prior to NIV, at 2, 8, 12, and 24hrs. The haemoglobin saturation (SpO2)/fraction of inspired oxygen (FiO2) ratio (S/F) was retrospectively calculated. NIV failure was defined as the need for intubation or requiring rescue with bi-level pressure (BLPAP). Univariate and multivariate statistical analyses were performed. RESULTS: A total of 282 patients received non-invasive support, with 71 receiving Continuous Pressure (CPAP), and 211 with BLPAP treatment. The overall success rate was 71%. Patients receiving BLPAP vs. CPAP, patients with higher S/F ratios at 2hours (odds ratio [OR] 0.991, 95% CI 0.986-0.996, P=.001], and patients older than 6 months (Hazard ratio [HZ] 0.375, 95% CI 0.171-0.820, P=.014], were also more likely to fail. Patients with higher heart rates (HR) at 2hours (OR 1.021, 95% CI [1.008-1.034], P=.001) and higher inspiratory positive airway pressure (IPAP) at 2hours were more prone to failure (HZ 1.214, 95% CI [1.046-1.408], P=.011). CONCLUSIONS: Age below 6 months, S/F ratio, HR, and IPAP at 2hours are independent predictive factors for initial NIV failure in paediatric patients with ARF admitted to the PICU.

Cord blood interleukin-6 as a predictor of early-onset neonatal sepsis.

AIM: To compare diagnostic accuracy in cord blood of interleukin-6 (IL-6) with C-reactive protein (CRP) as predictors of early-onset neonatal sepsis (EOS) in newborns with prenatal risk factors for infection. METHODS: During 12 months, cord blood IL-6 and CRP were measured immediately after birth in neonates with prenatal risk factors of infection. The odds of developing sepsis based on IL-6 and CRP values were calculated using likelihood ratios (LR), and their accuracy as predictors was compared by binary logistic regression. Multivariable logistic regression analyses were performed to identify independent risk factors for sepsis. RESULTS: Ten of 128 neonates (7.8%) were diagnosed with EOS confirmed with positive blood culture in five cases (3.9%). Cord blood IL-6 was a greater predictor of sepsis than CRP [ROC for IL-6 (0.88) vs. CRP (0.70)]. IL-6-positive and IL-6-negative LR [7.14 vs. -0.11] were superior to those calculated for CRP [2.86 vs. -0.51]. Chorioamnionitis and Apgar at 1 min were identified as independent risk factors for EOS. CONCLUSIONS: Cord blood IL-6 showed superior LR than CRP; therefore, it is a better predictor to initiate treatment in neonates with prenatal infectious risk factors immediately after birth.

Sodium concentration in rehydration fluids for children with ketoacidotic diabetes: effect on serum sodium concentration.

OBJECTIVES: To analyze in a retrospective cohort if sodium concentration in the rehydration fluids influence natremia in children with diabetic ketoacidosis (DKA). STUDY DESIGN: Consecutive episodes of diabetic ketoacidosis admitted in a tertiary care referral center from 2000 to 2005. Rehydration was programmed for 48 hours with a 2-bag system. Initial rehydration was performed with isotonic fluids and thereafter with variable tonicity. Analysis of the influence of the different factors on natremia was performed with a multivariate linear regression analysis. RESULTS: Forty-two episodes of DKA were reviewed. Increased sodium content in rehydration fluids behaved as an independent variable, causing a positive tendency of natremia (P < .008). CONCLUSIONS: Sodium concentration in the rehydration fluids behaves as an independent factor that influences positively the trend of the serum concentration of sodium during DKA rehydration. We propose the use of isotonic solutions for rehydration in diabetic ketoacidosis.

Courses on mechanical ventilation in pediatrics: first experience in Spain.

OBJECTIVE: To analyse the initial experience in mechanical ventilation courses held by the Respiratory Group of the Spanish Paediatric Intensive Care Society. MATERIALS AND METHODS: From 2002 to 2006, 15 courses on paediatric mechanical ventilation were held in eight hospitals in Spain, attended by a total of 367 physicians (53.4 % trainees and 46.6 % staff physicians from Paediatrics, Neonatology or Emergency). An initial theoretical written test of 40 questions was completed by participants, followed by short theory classes and practical workshops based on clinical situations, with ventilators and ventilation simulators, with five to seven students per workshop. At the end of the course participants completed a theoretical written test, in which it was considered necessary to answer correctly at least 70% of the questions, a practical evaluation (with assessment grades from 1 to 5) and a written survey about the quality of the course (with assessment grades from 0 to 10). RESULTS: In the initial test, only 20% of students answered 70% of questions correctly, whilst in the final test 93% hit this target, (p < 0.001). In the practical evaluation, 96% of students demonstrated sufficient acquisition of practical skills (grades equal to or greater than 3). In the participant survey, the course methodology was rated at 8.7 +/- 0.5, organisation 8.7 +/- 0.4, teaching staff 9.2 +/- 0.2, theoretical classes 8.7 +/- 0.4 and practical sessions 8.8 +/- 0.3. CONCLUSIONS: Mechanical ventilation courses are a useful educational method for health professionals in theoretical and practical mechanical ventilation.