Donación en asistolia controlada (tipo III de Maastricht) en pediatría / Pediatric donation after controlled cardiac death (Maastricht type III donors)

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La donación en asistolia controlada (tipo III de Maastricht) en pediatría / Pediatric organ donation following controlled circulatory death (Maastrich category III)

La población infantil presenta una mayor morbimortalidad en lista de espera de trasplante y una mayor dificultad para la obtención de donantes pediátricos; la evolución a muerte encefálica es excepcional en este grupo de edad. La donación en asistolia tipo III se determina tras la certificación de la muerte del paciente por criterios circulatorios y respiratorios, tras la decisión previa e independiente de adecuación del esfuerzo terapéutico (AET). Actualmente los resultados parecen apoyar que los órganos de donación en asistolia no tienen una peor supervivencia que los procedentes de una donación tras la muerte encefálica. La aplicación de protocolos de donación en asistolia controlada podría aumentar significativamente el número de donantes y trasplantes, lo que beneficiaría no sólo a la población pediátrica, sino también a la adulta, al aumentar el número de órganos disponibles. Sin embargo, en la edad pediátrica, sobre todo en la etapa neonatal, existen algunas particularidades en este tipo de donación que son objeto de debate; entre ellas, la identificación de pacientes candidatos, la definición de fallecimiento o la subrogación del consentimiento de donación. En este artículo se revisan los aspectos éticos que deben tenerse en cuenta en la aplicación de este tipo de protocolos, tanto en la decisión de realizar una AET como en la información y el consentimiento informado, el manejo y los cuidados paliativos, el proceso de retirada del soporte vital, la certificación de fallecimiento y el soporte familiar (AU)

Children constitute a specific population who face a higher risk of mortality and morbidity while on a transplant waiting list and who encounter greater difficulty in finding suitable organ donors, since progression towards brain death is exceptional in this age group. Maastricht category III organ donation after circulatory determination of death is defined as that which occurs following confirmation of death using circulatory and respiratory criteria in patients who die as a result of the decision to limit therapy, which must have been made previously and independently. Results published in the current literature seem to indicate that survival of organs donated after circulatory death is not lower than that of organs donated after brain death. The establishment of controlled cardiac death organ donation protocols could significantly increase the number of donors and transplants, which would imply a great number of available organs, thus benefitting not only children but also the adult population. There is, however, a number of particular aspects pertaining pediatric and especially neonatal patients which are subject to debate, such as the identification of transplant candidates, the definition of death and the withdrawal of consent for organ donation. In this article, the ethical issues that can arise during the implementation of these protocols are reviewed, including those related to the decision to limit therapy, the way of conveying information and obtaining informed consent, medical management and palliative care, the process of life-support withdrawal, death certification and bereavement support (AU)

Programa multicéntrico para la atención integral del recién nacido con agresión hipóxico-isquémica perinatal (ARAHIP) / Multicenter program for the integrated care of newborns with perinatal hypoxic-ischemic insult (ARAHIP)

INTRODUCCIÓN: El recién nacido con indicadores de potencial evento hipóxico-isquémico perinatal precisa de una atención integral que detecte precozmente si necesita tratamiento con hipotermia y el control de los factores agravantes del da˜no cerebral en las primeras 6 h de vida. PACIENTES Y MÉTODOS: Aplicación de un programa prospectivo de ámbito poblacional que ordena y sistematiza la atención durante las primeras 6 h de vida en los ≥ 35 semanas nacidos con indicadores de agresión hipóxico-isquémica perinatal. El programa involucra 12 hospitales (91.217 m2), 7 de nivel asistencial i-ii y 5 de nivel III. Se establecen 4 protocolos: a) detección del recién nacido con potencial agresión hipóxico-isquémica; b) vigilancia de la repercusión neurológica y en otros órganos; c) control y tratamiento de complicaciones, y d) vigilancia y acciones durante el transporte. RESULTADOS: Entre junio del 2011 y junio del 2013, de 32.325 recién nacidos ≥ 35 semanas, 213 cumplieron criterios de potencial agresión hipóxico-isquémica perinatal (7,4 por 1.000). El 92% siguió la monitorización establecida en el programa; 33 recién nacidos tuvieron encefalopatía hipóxico-isquémica moderada-grave (1 por 1.000) y 31/33 (94%) recibieron tratamiento con hipotermia. CONCLUSIONES: El programa Atención integral al Recién nacido con Agresión Hipóxico-Isquémica Perinatal ha permitido ofrecer atención integral al recién nacido con indicadores de agresión hipóxico-isquémica perinatal. Se han controlado factores comórbidos agravantes de la lesión cerebral y se han detectado aquellos con encefalopatía hipóxico-isquémica moderadagrave, permitiendo iniciar la hipotermia dentro de las primeras 6 h de vida. Programas de ámbito poblacional son cruciales para disminuir la morbimortalidad asociada a la encefalopatía hipóxico-isquémica

INTRODUCTION: Newborns with perinatal indicators of a potential hypoxic-ischemic event require an integrated care in order to control the aggravating factors of brain damage, and the early identification of candidates for hypothermia treatment. PATIENTS AND METHODS: The application of a prospective, populational program that organizes and systematizes medical care during the first 6 hours of life to all newborns over 35 weeks gestational age born with indicators of a perinatal hypoxic-ischemic insult. The program includes 12 hospitals (91,217 m2); two level I centers, five level II centers, and five level III hospitals. The program establishes four protocols: a) detection of the newborn with a potential hypoxic-ischemic insult, b) surveillance of the neurological repercussions and other organ involvement, c) control and treatment of complications, d) procedures and monitoring during transport. RESULTS: From June 2011 to June 2013, 213 of 32325 newborns above 35 weeks gestational age met the criteria of a potential hypoxic-ischemic insult (7.4/1000), with 92% of them being cared for following the program specifications. Moderate-severe hypoxic-ischemic encephalopathy was diagnosed in 33 cases (1/1,000), and 31 out of the 33 received treatment with hypothermia (94%). CONCLUSIONS: The program for the Integrated Care of Newborns with Perinatal Hypoxic-Ischemic Insult has led to providing a comprehensive care to the newborns with a suspected perinatal hypoxic-ischemic insult. Aggravators of brain damage have been controlled, and cases of moderate-severe hypoxic-ischemic encephalopathy have been detected, allowing the start of hypothermia treatment within the first six hours of life. Populational programs are fundamental to reducing the mortality and morbidity of hypoxic-ischemic encephalopathy

[Multicenter program for the integrated care of newborns with perinatal hypoxic-ischemic insult (ARAHIP)]. / Programa multicéntrico para la atención integral del recién nacido con agresión hipóxico-isquémica perinatal (ARAHIP).

INTRODUCTION: Newborns with perinatal indicators of a potential hypoxic-ischemic event require an integrated care in order to control the aggravating factors of brain damage, and the early identification of candidates for hypothermia treatment. PATIENTS AND METHODS: The application of a prospective, populational program that organizes and systematizes medical care during the first 6 hours of life to all newborns over 35 weeks gestational age born with indicators of a perinatal hypoxic-ischemic insult. The program includes 12 hospitals (91,217 m(2)); two level i centers, five level ii centers, and five level iii hospitals. The program establishes four protocols: a) detection of the newborn with a potential hypoxic-ischemic insult, b) surveillance of the neurological repercussions and other organ involvement, c) control and treatment of complications, d) procedures and monitoring during transport. RESULTS: From June 2011 to June 2013, 213 of 32325 newborns above 35 weeks gestational age met the criteria of a potential hypoxic-ischemic insult (7.4/1000), with 92% of them being cared for following the program specifications. Moderate-severe hypoxic-ischemic encephalopathy was diagnosed in 33 cases (1/1,000), and 31 out of the 33 received treatment with hypothermia (94%). CONCLUSIONS: The program for the Integrated Care of Newborns with Perinatal Hypoxic-Ischemic Insult has led to providing a comprehensive care to the newborns with a suspected perinatal hypoxic-ischemic insult. Aggravators of brain damage have been controlled, and cases of moderate-severe hypoxic-ischemic encephalopathy have been detected, allowing the start of hypothermia treatment within the first six hours of life. Populational programs are fundamental to reducing the mortality and morbidity of hypoxic-ischemic encephalopathy.

Morphological and immunohistochemical observations on leiomyoma of the ventral ligament of the oviduct of the hen.

Leiomyomas of the ventral ligament (LVLs) of the oviduct from 2-year-old spent layers were examined. These tumours can be present either as single large masses or as multiple smaller nodules. The most common site of origin of the tumours was the centre of the free margin of the ventral ligament, but some small tumours were observed at the insertion of this ligament into the magnum of the oviduct. Most samples were highly vascular and some blood vessels within the tumours had vacuolation of the smooth muscle cells. These findings suggest that the proliferative processes leading to LVLs may include transformation of the blood vessels of the ventral ligament. Immunohistochemically, the tumour cells expressed vimentin, α-smooth muscle actin, desmin and heavy-caldesmon. These avian leiomyomas have been proposed as a model for similar tumours in other species.

Congenital chylothorax: from foetal life to adolescence.

AIM: To analyse the main prenatal and postnatal features of congenital chylothorax (CC), and the outcome including mid-term follow-up. METHODS: We searched our databases for CC diagnosed between 1990 and 2006. Data of 29 cases were retrieved and analysed. Follow-up until 3 years of age was available for all patients. RESULTS: Most patients were diagnosed prenatally (94%) and most cases were complicated by foetal hydrops (66.7%). The overall survival rate at 3 years was 56%. A significantly poorer outcome was observed when foetal hydrops, preterm birth < 34 weeks, large effusions and/or early-onset pneumothorax were present. An important but not significant improvement in the survival rate was observed through the study period; while in 1990-1998, the survival rate was 41.7%, from 1999 to 2006 it was 66.7% (p = 0.19). In the mid-term follow-up, we did not observe any recurrence of CC and most infants remain asymptomatic. However, 27% of survivors were diagnosed as having asthma in early infancy. CONCLUSION: CC still carries a significant risk of perinatal mortality. However, continuous advances in foetal and neonatal medicine are improving the prognosis of these patients, and nowadays most of them are likely to survive. Beyond the neonatal period, most survivors have an uneventful outcome.