Description of a Swine Infant Model of Volume-Controlled Hemorrhagic Shock.

Hemorrhagic shock is a leading cause of morbidity and mortality in pediatric patients. Interpretation of the clinical indicators validated in adults to guide resuscitation and comparison between different therapies is difficult in children due to the inherent heterogeneity of this population. As a result, compared to adults, appropriate management of pediatric hemorrhagic shock is still not well established. In addition, the scarcity of pediatric patients with hemorrhagic shock precludes the development of clinically relevant studies. For this reason, an experimental pediatric animal model is necessary to study the effects of hemorrhage in children as well as their response to different therapies. We present an infant animal model of volume-controlled hemorrhagic shock in anesthetized young pigs. Hemorrhage is induced by withdrawing a previously calculated blood volume, and the pig is subsequently monitored and resuscitated with different therapies. Here, we describe a precise and highly reproducible model of hemorrhagic shock in immature swine. The model yields hemodynamic data that characterizes compensatory mechanisms that are activated in response to severe hemorrhage.

Efecto de tres dietas enterales con diferente contenido en proteínas sobre el metabolismo proteico en lactantes críticamente enfermos: un ensayo clínico aleatorizado / Effect of three enteral diets with different protein contents on protein metabolism in critically ill infants: A randomized controlled trial

Introducción: No se ha establecido cuál es el aporte óptimo para mejorar el metabolismo proteico sin producir efectos adversos en lactantes gravemente enfermos. Nuestro objetivo fue analizar si un mayor aporte proteico a través de la nutrición enteral se relaciona con una mejoría en el balance proteico en lactantes críticamente enfermos. Material y métodos: Se diseñó un estudio multicéntrico, prospectivo, aleatorizado y controlado (diciembre de 2016 a junio de 2019). Se incluyeron lactantes críticamente enfermos con nutrición enteral, asignándose aleatoriamente a tres dietas con diferente contenido proteico: estándar (1,7g/100ml), hiperproteica (2,7g/100ml) e hiperproteica suplementada (5,1g/100ml). Se realizaron análisis de sangre y orina y se calculó el balance nitrogenado en el momento basal y tras 3-5días de nutrición. Se analizó la variación del balance nitrogenado y de las proteínas séricas (proteínas totales, albúmina, transferrina, prealbúmina y proteína ligada al retinol) a lo largo del periodo de estudio. Resultados: Noventa y nueve lactantes (33 por grupo) completaron el estudio. No se encontraron diferencias entre grupos en características demográficas, puntuaciones de gravedad y otros tratamientos recibidos, salvo corticoides, administrados en una mayor proporción de pacientes del tercer grupo. Tuvo lugar un aumento significativo de los niveles de prealbúmina y proteína ligada al retinol en los grupos con nutrición hiperproteica e hiperproteica suplementada. El balance nitrogenado aumentó en todos los grupos, pero este incremento no fue significativo en el grupo de nutrición hiperproteica suplementada. No se encontraron diferencias en cuanto a tolerancia gastrointestinal. Los pacientes con nutrición hiperproteica suplementada presentaron niveles superiores de urea sérica y mayor incidencia de hiperuremia. (AU)

Introduction: The optimal intake to improve protein metabolism without producing adverse effects in seriously ill infants has yet to be established. The aim of our study was to analyse whether an increased protein intake delivered through enteral nutrition would be associated with an improvement in nitrogen balance and serum protein levels in critically ill infants. Material and methods: We conducted a multicentre, prospective randomized controlled trial (December 2016-June 2019). The sample consisted of critically ill infants receiving enteral nutrition assigned randomly to 3 protein content groups: standard diet (1.7g/dL), protein-enriched diet (2.7g/dL) and high protein-enriched diet (5.1g/dL). Blood and urine tests were performed, and we assessed nitrogen balance at baseline and at 3 to 5days of the diet. We analysed variations in nitrogen balance and serum protein levels (total protein, albumin, transferrin, prealbumin, and retinol-binding protein) throughout the study period. Results: Ninety-nine infants (33 per group) completed the study. We did not find any differences were between groups in demographic characteristics, severity scores or prescribed medications, except for corticosteroids, administered in a higher proportion of patients in the third group. We observed significant increases in prealbumin and retinol-binding protein levels in patients receiving the protein-enriched and high protein-enriched diets at 3 to 5days compared to baseline. The nitrogen balance increased in all groups, but the differences were not significant in the high protein-enriched group. There were no differences in gastrointestinal tolerance. Patients fed high protein-enriched formula had higher levels of serum urea, with a higher incidence of hyperuraemia in this group. (AU)

Effect of three enteral diets with different protein contents on protein metabolism in critically ill infants: a randomized controlled trial.

INTRODUCTION: The optimal intake to improve protein metabolism without producing adverse effects in seriously ill infants has yet to be established. The aim of our study was to analyse whether an increased protein intake delivered through enteral nutrition would be associated with an improvement in nitrogen balance and serum protein levels in critically ill infants. METHODS: We conducted a multicentre, prospective randomized controlled trial (December 2016-June 2019). The sample consisted of critically ill infants receiving enteral nutrition assigned randomly to 3 protein content groups: standard diet (1.7 g/dL), protein-enriched diet (2.7 g/dL) and high protein-enriched diet (5.1 g/dL). Blood and urine tests were performed, and we assessed nitrogen balance at baseline and at 3-5 days of the diet. We analysed variations in nitrogen balance and serum protein levels (total protein, albumin, transferrin, prealbumin, and retinol-binding protein) throughout the study period. RESULTS: Ninety-nine infants (33 per group) completed the study. We did not find any differences were between groups in demographic characteristics, severity scores or prescribed medications, except for corticosteroids, administered in a higher proportion of patients in the third group. We observed significant increases in prealbumin and retinol-binding protein levels in patients receiving the protein-enriched and high protein-enriched diets at 3-5 days compared to baseline. The nitrogen balance increased in all groups, but the differences were not significant in the high protein-enriched group. There were no differences in gastrointestinal tolerance. Patients fed high protein-enriched formula had higher levels of serum urea, with a higher incidence of hyperuraemia in this group. CONCLUSION: Enteral administration of higher amounts of protein improves serum protein levels in critically ill children. A protein intake of 2.2 g/kg/day is generally safe and well tolerated, whereas an intake of 3.4 g/kg/day may produce hyperuraemia in some patients.

Microcirculatory Changes in Pediatric Patients During Congenital Heart Defect Corrective Surgery.

A prospective, observational single-center study was carried out. Pediatric patients undergoing congenital heart defect surgery were evaluated before, during, and after surgery. At each time point, sublingual microcirculation and clinical parameters were assessed, along with analytical variables. Twenty-four patients were included. All microcirculatory parameters worsened during cardiopulmonary bypass and returned to baseline values after surgery (p ≤ 0.001). In the intraoperative evaluation, body temperature correlated with perfused small vessel density (p = 0.014), proportion of perfused small vessels (p < 0.001), small vessel microvascular flow index (p = 0.003), and small vessel heterogeneity index (p < 0.002). Patients with cyanotic disease exhibited higher small vessel density (p < 0.008) and higher density of perfused small vessels (p < 0.022) at baseline, and a lower microvascular flow index (p = 0.022) and higher heterogeneity (p = 0.026) in the intraoperative phase. Children with congenital heart disease exhibited decreased vascular density and microvascular blood flow and increased heterogeneity during cardiopulmonary bypass. All these parameters returned to baseline values after surgery.

Importancia y dificultades del voluntariado y cooperación en los estudiantes del grado de medicina / Importance and difficulties of voluntary service and cooperation in medical degree students

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Daño renal agudo secundario a nefritis tubulointersticial aguda por uso de medicamentos. Caso clínico / Acute renal damage secondary to acute tubulointerstitial nephritis drug use. Case report

Resumen Introducción: La nefritis tubulointersticial aguda (NTIA) es infrecuente en la edad pediátrica. Se caracteriza por la infiltración del parénquima renal por células mononucleares y/o polinucleares con afectación secundaria de los túbulos sin lesión glomerular, y puede ser producida por infecciones, enfermedades inmunológicas, fármacos, o ser de origen idiopático. Objetivo: Describir un caso de NTIA secundario a antiinflamatorios no esteroidales (AINE) en un lactante, con énfasis en esta aso ciación para ser considerada por los pediatras. Caso clínico: Lactante de 10 meses, sin antecedentes previos, trasladada a nuestro hospital por daño renal agudo estadio 3, clasificación KDIGO 2012. Los tres días previos recibió tratamiento con amoxicilina e ibuprofeno por otitis media aguda. En la exploración física destacaba leve edema palpebral con presión arterial normal. En la orina presentaba proteinuria no nefrótica con componente tubular, microhematuria y leucocituria. La ecografía renal no mostraba alteraciones. Ante la sospecha de NTIA se cambió el antibiótico a cefotaxima intrave nosa y se suspendió el ibuprofeno realizándose manejo conservador del daño renal agudo. Presentó aumento de la creatinina (4.14 mg/dL) y eosinofilia, siendo el estudio inmunológico negativo. Se trató con metilprednisolona, con normalización de la función renal. Conclusión: La NTIA se puede producir por cualquier medicamento mediante una reacción inmunológica idiosincrásica. Entre los medicamentos responsables se identifican fármacos de uso frecuente en la edad pediátrica, como los AINEs, por lo que se necesita una alta sospecha diagnóstica por parte de los pediatras.

Abstract Introduction: Acute tubulointerstitial nephritis (ATIN) is a rare entity in the pediatric age. It is de fined by the infiltration of the renal parenchyma by mononuclear and/or polynuclear cells with se condary involvement of the tubules, without glomerular injury. It can be triggered by infections or immunological diseases, drugs like NSAIDs or be of idiopathic origin. Objective: To raise awareness among pediatricians about the prescription of NSAIDs, especially to patients of less than a year old, since they can provoke renal damage. Case report: A ten month old child, with no nephrological an tecedents of interest, was transferred to our hospital due to acute renal failure stage 3 KDIGO 2012. The three previous days received treatment with amoxicillin and ibuprofen for acute otitis media. Physical examination revealed mild eyelid edema with normal blood pressure. In the urine analysis, there were non-nephrotic proteinuria with tubular component, microhematuria and leukocyturia. Renal ultrasound showed no abnormalities. ATIN was suspected and so the antibiotic was changed to intravenous cefotaxime and ibuprofen was discontinued, opting for conservative management of acute renal damage. There was an increase in the number of creatinine up to 4.14 mg/dL and eosinophilia, with the immunological study being negative. Treatment with methylprednisolone was initiated, achieving normalization of renal function. Discussion: NTIA can be produced by any me dication through an idiosyncratic immune reaction. Among the responsible drugs, there are ones commonly used in the pediatric age, such as NSAIDs. Therefore, the pediatricians should pay special attention during prescriptions and have a high diagnostic suspicion of this disease.

[Acute renal damage secondary to acute tubulointerstitial nephritis drug use. Case report]. / Daño renal agudo secundario a nefritis tubulointersticial aguda por uso de medicamentos. Caso clínico.

INTRODUCTION: Acute tubulointerstitial nephritis (ATIN) is a rare entity in the pediatric age. It is de fined by the infiltration of the renal parenchyma by mononuclear and/or polynuclear cells with se condary involvement of the tubules, without glomerular injury. It can be triggered by infections or immunological diseases, drugs like NSAIDs or be of idiopathic origin. OBJECTIVE: To raise awareness among pediatricians about the prescription of NSAIDs, especially to patients of less than a year old, since they can provoke renal damage. CASE REPORT: A ten month old child, with no nephrological an tecedents of interest, was transferred to our hospital due to acute renal failure stage 3 KDIGO 2012. The three previous days received treatment with amoxicillin and ibuprofen for acute otitis media. Physical examination revealed mild eyelid edema with normal blood pressure. In the urine analysis, there were non-nephrotic proteinuria with tubular component, microhematuria and leukocyturia. Renal ultrasound showed no abnormalities. ATIN was suspected and so the antibiotic was changed to intravenous cefotaxime and ibuprofen was discontinued, opting for conservative management of acute renal damage. There was an increase in the number of creatinine up to 4.14 mg/dL and eosinophilia, with the immunological study being negative. Treatment with methylprednisolone was initiated, achieving normalization of renal function. DISCUSSION: NTIA can be produced by any me dication through an idiosyncratic immune reaction. Among the responsible drugs, there are ones commonly used in the pediatric age, such as NSAIDs. Therefore, the pediatricians should pay special attention during prescriptions and have a high diagnostic suspicion of this disease.

Diffuse persistent pulmonary interstitial emphysema secondary to mechanical ventilation in bronchiolitis.

BACKGROUND: Persistent interstitial pulmonary emphysema (PIE) is a rare disease and it is even more uncommon in full-term infants, like our patient. When conservative management is not successful, surgical treatment should be considered. In our case, ECMO support was iniciated to keep the patient ventilated in order to allow the lung to heal using lung protection strategies. CASE PRESENTATION: We report an 18-day-old male infant with bronchiolitis that required mechanical ventilation with high positive airway pressures due to severe respiratory insufficiency. Chest X-rays and computed tomography scan revealed a severely hyperinflated left lung with extensive destructive changes and multiple small bullae. These findings were consistent with diffuse persistent interstitial emphysema (PIE), probably due to mechanical ventilation. The patient required high frequency oscillatory ventilation, inotropic support and continuous renal replacement therapy. He eventually suffered a cardiac arrest that required cardiopulmonary resuscitation and ECMO during 5 days with progressive clinical improvement and normalization of the X-ray. CONCLUSION: We present a patient with diffuse persistent interstitial emphysema who, despite an unfavorable evolution with different mechanical ventilation strategies, had a good response after ECMO assistance.

[Risk factors for prolonged mechanical ventilation after cardiac surgery in children]. / Factores de riesgo de la ventilación mecánica prolongada de niños con cirugía cardíaca.

OBJECTIVE: To study the postoperative factors associated with prolonged mechanical ventilation after cardiac surgery in children. DESIGN: Prospective observational study. SETTING: Pediatric intensive care unit (PICU). PATIENTS: 59 children aged between 2 months and 14 years after cardiac surgery. VARIABLES OF INTEREST: We analyzed postoperative parameters associated to mechanical ventilation lasting more than 3 and more than 7 days. We performed a stepwise multiple logistic regression analysis to study the influence of each factor on prolonged mechanical ventilation. RESULTS: Mechanical ventilation lasted more than 3 days in 19 (32%) children and more than 7 days in 12 (20%). Predictive factors at PICU admission and 24 hours after admission associated with mechanical ventilation at 3 and 7 days were age less than 12 months, weight less than 7 kg, extrapulmonary complications (hypotension, arrhythmias, postoperative bleeding, delayed sternal closure, and airway complications), nitric oxide treatment, midazolam perfusion more than 4 microg/kg/min or fentanyl perfusion more than 4 microg/kg/h, and continuous muscle relaxant treatment. In the logistic multiple regression study, weight less than 7 kg and extrapulmonary complications predicted 82.8% of children with mechanical ventilation more than 3 days and 87.9% with mechanical ventilation more than 7 days. CONCLUSIONS: Weight less than 7 kg and extrapulmonary complications are the most important factors associated with prolonged mechanical ventilation after cardiac surgery in children.

Factores de riesgo de la ventilación mecánica prolongada de niños con cirugía cardíaca / Risk factors for prolonged mechanical ventilation after cardiac surgery in children

Objetivo. Estudiar los factores postoperatorios que influyen en la prolongación de la ventilación mecánica en niños sometidos a cirugía cardíaca. Diseño. Estudio prospectivo observacional. Ámbito. Unidad de cuidados intensivos pediátricos (UCIP). Pacientes. Cincuenta y nueve niños de edades entre 2 meses y 14 años sometidos a cirugía cardíaca. Variables de interés. Se estudiaron los factores postoperatorios que se relacionaron con la duración de ventilación mecánica > 3 y > 7 días. Se realizó un estudio de regresión logística multivariable paso a paso para analizar la influencia de cada factor en la ventilación mecánica prolongada. Resultados. Precisaron ventilación mecánica más de 3 días 19 (32%) niños y más de 7 días, 12 (20%). Los factores al ingreso y a las 24 h en la UCIP que se relacionaron con una duración de la ventilación > 3 y > 7 días fueron la edad < 12 meses, el peso < 7 kg, la presencia de complicaciones extrapulmonares (hipotensión, arritmias, sangrado postoperatorio, tórax abierto y alteraciones de la vía aérea), la necesidad de administrar óxido nítrico, la sedación con midazolam > 4 μg/kg/min o fentanilo > 4 μg/kg/h y la relajación muscular. En el estudio de regresión logística, el peso < 7 kg más la presencia de complicaciones extrapulmonares al ingreso en la UCIP predijeron el 82,8% de los niños con ventilación mecánica > 3 días y el 87,9%, > 7 días. Conclusiones. El peso < 7 kg y la presencia de complicaciones extrapulmonares son los factores más importantes de los relacionados con la necesidad de ventilación mecánica prolongada en el postoperatorio de cirugía cardíaca en niños

Objective. To study the postoperative factors associated with prolonged mechanical ventilation after cardiac surgery in children. Design. Prospective observational study. Setting. Pediatric intensive care unit (PICU). Patients. 59 children aged between 2 months and 14 years after cardiac surgery. Variables of interest. We analyzed postoperative parameters associated to mechanical ventilation lasting more than 3 and more than 7 days. We performed a step wise multiple logistic regression analysis to study the influence of each factor on prolonged mechanical ventilation. Results. Mechanical ventilation lasted morethan 3 days in 19 (32%) children and more than 7days in 12 (20%). Predictive factors at PICU admission and 24 hours after admission associated with mechanical ventilation at 3 and 7 days were age less than 12 months, weight less than 7 kg, extrapulmonary complications (hypotension, arrhythmias, postoperative bleeding, delayed sternal closure, and airway complications), nitric oxidetreatment, midazolam perfusion more than 4 g/kg/min or fentanyl perfusion more than 4 g/kg/h, and continuous muscle relaxant treatment. In the logistic multiple regression study, weight less than 7 kg and extrapulmonary complications predicted 82.8% of children with mechanical ventilation more than 3 days and 87.9% with mechanical ventilation more than 7 days. Conclusions. Weight less than 7 kg and extrapulmonary complications are the most important factors associated with prolonged mechanical ventilation after cardiac surgery in children