Black oil sunflower seed ingestion associated with renal azotemia, gastroesophageal ulceration, and a high mortality rate in four alpacas and two llamas.

CASE DESCRIPTION: 4 alpacas and 2 llamas (11 months to 11 years old) from 2 properties were examined for lethargy (6/6), salivation and regurgitation (4/6), and recumbency (3/6). Signs developed approximately 48 to 72 hours after accidental access to black oil sunflower seeds. CLINICAL FINDINGS: 3 alpacas died suddenly prior to treatment and were necropsied. One llama survived, and 1 alpaca and 1 llama died after days of medical treatment. All 3 treated animals had systemic inflammatory signs including tachycardia, fever, and hematologic changes. Biochemical anomalies included azotemia, hyperglycemia, hyponatremia, hypochloremia, and hypoalbuminemia. Necropsy identified numerous sunflower seeds in the gastrointestinal tract of all 5 animals that died, with pulmonary congestion (5/5 animals), mild centrilobular vacuolar hepatic degeneration (4/5), and erosions of the esophagus (3/5) and first (3/5) and third (1/5) compartments of the forestomach. Renal tubular necrosis was found in the 2 animals that died on day 4 of treatment. TREATMENT AND OUTCOME: One llama responded successfully to intensive medical management including supplemented IV fluid therapy, oral and partial parenteral nutrition, and administration of antimicrobials, furosemide, and insulin and was clinically normal with plasma biochemical analysis values within reference range 12 weeks later. Vitamin D, oxalates, heavy metals, and mycotoxins were excluded as the cause of clinical signs on the basis of screening of uneaten seeds and tissue samples and gastric content from the treated llama that died. CLINICAL RELEVANCE: Inadvertent large volume black oil sunflower seed ingestion resulted in a high mortality rate in camelids. A specific toxic principle was not identified. Feeding this product to camelids is not recommended to avoid the risk of accidental overingestion and subsequent disease.

Respiratory and pharmacological management in severe acute bronchiolitis: Were clinical guidelines not written for critical care?

PURPOSE: The treatment applied for children admitted to the pediatric intensive care unit (PICU) for severe acute bronchiolitis may differ from general recommendations. The first objective of our study was to describe the treatments offered to these children in a Spanish tertiary PICU. The second objective was to analyse the changes in management derived from the publication of the American Academy of Pediatrics (AAP) bronchiolitis guideline in 2014. METHODS: This was a retrospective-prospective observational study conducted during two epidemic waves (2014-2015 and 2015-2016). The AAP guidelines were distributed and taught to PICU staff between both epidemic waves. RESULTS: A total of 138 children were enrolled (78 male). In the first period, 78 children were enrolled. The median age was 1.8 months (IQR 1.1-3.6). There were no differences between the management in the two periods, except for the use of high-flow oxygen therapy (HFOT); its use increased in the second period. Overall, 83% of patients received non-invasive ventilation or HFOT. Children older than 12 months received HFOT exclusively. In comparison, continuous positive airway pressure and bi-level positive airway pressure were used less during the period 2015-2016 (P=0.036). Regarding pharmacological therapy, 70% of patients received antibiotics, 23% steroids, 33% salbutamol, 31% adrenaline, and 7% hypertonic saline. The mortality rate was zero. CONCLUSIONS: Our PICU did not follow the AAP recommendations. There were no differences between the two periods, except in the use of HFOT. All children older than 12 months received HFOT exclusively. The rate of using invasive mechanical ventilation was also low.

Accuracy of CD64 expression on neutrophils and monocytes in bacterial infection diagnosis at pediatric intensive care admission.

The CD64 receptor has been described as an interesting bacterial infection biomarker. Its expression has not been studied in previously healthy children admitted to pediatric critical care unit (PICU). Our objective was firstly to describe the CD64 expression and secondly study its diagnostic accuracy to discriminate bacterial versus viral infection in this children. We made a prospective double-blind observational study (March 2016-February 2018). A flow cytometry (FC) was done from peripheral blood at PICU admission. We studied the percentage of CD64+ neutrophils and the CD64 mean fluorescence intensity (MFI) on neutrophils (nCD64) and monocytes (mCD64). Statistical analyses were performed with non-parametric tests (p < 0.05). Twenty children in the bacterial infection group (BIG) and 25 in the viral infection group (VIG). Children in BIG showed higher values of CD64+ neutrophils (p = 0.000), nCD64 (p = 0.001), and mCD64 (p = 0.003). In addition, CD64+ neutrophils and nCD64 expression have positive correlation with procalcitonin and C reactive protein. The nCD64 area under the curve (AUC) was 0.83 (p = 0.000). The %CD64+ neutrophils showed an AUC of 0.828 (p = 0.000). The mCD64 AUC was 0.83 (p = 0.003). The nCD64 and %CD64+ neutrophils also showed higher combined values of sensitivity (74%) and specificity (90%) than all classical biomarkers.In our series CD64 expression allows to discriminate between bacterial and viral infection at PICU admission. Future studies should confirm this and be focused in the study of CD64 correlation with clinical data and its utility as an evolution biomarker in critical care children.

C. albicans, C. parapsilosis and C. tropicalis invasive infections in the PICU: clinical features, prognosis and mortality.

Candida albicans remains the most common agent associated with invasive Candida infection (ICI), but with increasing number of non-albicans species. An epidemiological, observational study exploring host criteria, clinical characteristics and mortality of ICI was performed in 24 pediatric intensive care units (PICU) in Spain. Patients were analyzed in global and distributed by infecting species (for groups with ≥ 15 patients). A total of 125 ICI were included: 47 by C. albicans, 37 by C. parapsilosis, 19 by C. tropicalis, 4 C. glabrata, and 18 others. Up to 66% of ICI by C. albicans and 75.7% by C. parapsilosis occurred in children ≤ 24 months, while the percentage of children >60 months was higher in ICI by C. tropicalis. Bloodstream infection was most common among C. tropicalis (78.9%) or C. parapsilosis (83.8%) ICI, but urinary infections were almost as common as bloodstream infections among C. albicans ICI (31.9% and 38.3%, respectively). Fever refractory to antimicrobials was the most frequent host criterion (46.4% patients), but with equal frequency than prolonged neutropenia in C. tropicalis ICI. Thrombopenia was more frequent (p<0.05) in C. parapsilosis (60.7%) or C. tropicalis (66.7%) ICI than in C. albicans ICI (26.5%). Uremia was more frequent (p<0.05) in C. albicans (78.3%) or C. tropicalis (73.3%) than in C. parapsilosis ICI (40.7%). Multiple organ failure and heart insufficiency was higher in C. tropicalis ICI. Short duration (≤ 7 days) of PICU stay was more frequent in C. albicans ICI. Mortality rates were: 8.5% (C. albicans ICI), 13.5% (C. parapsilosis ICI) and 23.3% (C. tropicalis ICI). ICI by different Candida species showed different clinical profiles and mortality, making essential identification at species level.

Ventilación mecánica domiciliaria en niños: estudio multicéntrico español / Domiciliary mechanical ventilation in children: a spanish multicentre study

Introducción: La ventilación mecánica domiciliaria (VMD) es una técnica cada vez más frecuente en el niño. Existen pocos estudios que hayan analizado las características y necesidades de los niños sometidos a esta técnica. Material y métodos: Estudio descriptivo observacional transversal multicéntrico de pacientes entre un mes y 16 años dependientes de ventilación mecánica domiciliaria. Resultados: Se estudiaron 163 pacientes de 17 hospitales españoles con una edad media de 7,6 años. La causa más frecuente de VMD fueron los trastornos neuromusculares. El inicio de la VMD fue a una edad media de 4,6 años. Un 71,3% recibieron ventilación no invasiva. Los pacientes con ventilación invasiva tenían menor edad, menor edad de inicio de la VMD y mayor tiempo de uso diario. El 80,9% precisaban VM solo durante el sueño, y un 11,7% durante todo el día. Únicamente un 3,4% de los pacientes tiene asistencia sanitaria externa como ayuda a la familia. Un 48,2% es controlado en consultas específicas de VMD o consultas multidisciplinares. Un 72,1% de los pacientes está escolarizado (recibiendo enseñanza adaptada un 42,3%). Solo un 47,8% de los pacientes escolarizados cuentan con cuidadores específicos en su centro escolar. Conclusiones: La VMD en niños se utiliza en un grupo muy heterogéneo de pacientes iniciándose en un importante porcentaje en los primeros 3 años de vida. A pesar de que un significativo porcentaje de pacientes tiene una gran dependencia de la VMD pocas familias cuentan con ayudas específicas tanto a nivel escolar como en el domicilio, y el seguimiento sanitario es heterogéneo y poco coordinado(AU)

Introduction: Domiciliary mechanical ventilation (DMV) use is increasing in children. Few studies have analysed the characteristics of patients using this technique. Materials and methods: An observational, descriptive, transversal, multicentre study was conducted on patients between 1 month and 16 years of age dependent on domiciliary mechanical ventilation. Results: A total of 163 patients with a median age of 7.6 years from 17 Spanish hospitals were studied. The main reasons for DMV were neuromuscular disorders. The median age at beginning of DMV was 4.6 years. Almost three-quarters (71.3%) received non-invasive ventilation. Patients depending on invasive ventilation were younger, started DMV at an earlier age, and had more hours of mechanical ventilation per day. The large majority (80.9%) used DMV during sleep time only, and 11.7% during the whole day. Only 3.4% of patients had external health assistance. Just under half (48.2%) were being followed up in specific DMV or multidisciplinary clinics. Almost three-quarters (72.1%) of patients attended school (42.3% with adapted schooling). Only 47.8% of school patients had specific caregivers in their schools. Conclusions: DMV in children is used in a very heterogeneous group of patients, and in an important number of patients it is started before the third year of life. Despite there being a significant proportion of patients with a high dependency on DMV, few families receive specific support at home or at school, and health care surveillance is variable and poorly coordinated(AU)

Predicting non-invasive ventilation failure in children from the SpO2/FiO2 (SF) ratio.

PURPOSE: Our objective was to assess whether SpO2/FiO2 (SF) ratio could be a useful NIV outcome predictor in children with acute respiratory failure (ARF) and tried to develop a predictive model of NIV failure. METHODS: Prospective, observational, multicenter study. Episodes of ARF-fulfilling inclusion criteria from 15 January 2010 to 14 January 2011 were treated with NIV according to a pre-established protocol. Clinical variables were collected at baseline and at 1, 2, 6, 12 and 24 h. Failure criterion was the need for endotracheal intubation. Failures were considered as "early" if occurring ≤6 h after NIV initiation, "intermediate" if occurring between 6 and 24 h, and "late" if occurring after 24 h. Variables with a p < 0.1 in univariate analysis corrected by age were included in multivariate analysis. Models were calculated based on multivariate analysis. RESULTS: During the study period, 390 episodes were included. NIV success rate was 81.3 %. Among ARF causes, failure occurred most frequently in ARDS episodes. The failure predictive model for the whole sample included SF ratio at 1 h, age and PRISM III-24 (area under the curve AUC of 0.755). For early NIV failures, SF ratio at 1 h was the only variable within model (AUC 0.748). The analysis of intermediate NIV failures identified 3 variables independently linked to NIV outcome: PRISM III-24, RR decrease at 6 h, and SF ratio at 6 h (AUC 0.895). No model was identified for late NIV failure. CONCLUSIONS: SF ratio is a reliable predictor of early NIV failure in children.

[Domiciliary mechanical ventilation in children: a Spanish multicentre study]. / Ventilación mecánica domiciliaria en niños: estudio multicéntrico español.

INTRODUCTION: Domiciliary mechanical ventilation (DMV) use is increasing in children. Few studies have analysed the characteristics of patients using this technique. MATERIALS AND METHODS: An observational, descriptive, transversal, multicentre study was conducted on patients between 1 month and 16 years of age dependent on domiciliary mechanical ventilation. RESULTS: A total of 163 patients with a median age of 7.6 years from 17 Spanish hospitals were studied. The main reasons for DMV were neuromuscular disorders. The median age at beginning of DMV was 4.6 years. Almost three-quarters (71.3%) received non-invasive ventilation. Patients depending on invasive ventilation were younger, started DMV at an earlier age, and had more hours of mechanical ventilation per day. The large majority (80.9%) used DMV during sleep time only, and 11.7% during the whole day. Only 3.4% of patients had external health assistance. Just under half (48.2%) were being followed up in specific DMV or multidisciplinary clinics. Almost three-quarters (72.1%) of patients attended school (42.3% with adapted schooling). Only 47.8% of school patients had specific caregivers in their schools. CONCLUSIONS: DMV in children is used in a very heterogeneous group of patients, and in an important number of patients it is started before the third year of life. Despite there being a significant proportion of patients with a high dependency on DMV, few families receive specific support at home or at school, and health care surveillance is variable and poorly coordinated.

[Severe bronchiolitis. Changes in epidemiology and respiratory support]. / Bronquiolitis grave. Cambios epidemiológicos y de soporte respiratorio.

INTRODUCTION: Bronchiolitis generates lots of admissions during the cold months in the paediatric intensive care units (PICU). New forms of respiratory support are being used and could improve the care of these patients. OBJECTIVES: To analyse the epidemiological and respiratory support changes of children admitted to the PICU. PATIENTS AND METHODS: An observational, retrospective, descriptive and analytical study of patients with the diagnosis of bronchiolitis admitted to the PICU of a tertiary hospital during the respiratory syncytial virus (RSV) epidemic months between 2005 and 2010. RESULTS: A total of 229 patients were admitted, of whom 83% were infected with RSV. The mean age was 1.48 months, with children under 3 months being the greatest number of admissions (73.3%). December was the month with the highest number of admissions (52%). Mortality was 0.9%. The mean time of stay in the PICU and on respiratory assistance were 4 and 3 days, respectively (no significant differences between the periods studied). Patients with RSV bronchiolitis were younger than the negative RSV (mean 2.61 months and 4.05 months, P=.023). Active respiratory support was required in 73% of cases. The percentage of patients who required active respiratory support increased over the years (Z=3.81, P=.00014), especially high flow nasal oxygen therapy (Z=3.62, P=.00028). An inverse relationship was observed between patient age and length of stay in PICU (Beta=-0.245, P ≤.0001) and days on respiratory support (Beta=-0.167, P=.039). CONCLUSIONS: Most patients admitted to the PICU are less than 3 months old. Mortality was 0.9%. Respiratory support (especially non-invasive mechanical ventilation and high flow nasal oxygen therapy) is used increasingly often. The youngest patients need more days in PICU and more respiratory support.

Bronquiolitis grave. Epidemiología y evolución de 284 pacientes / Severe bronchiolitis. Epidemiology and clinical course of 284 patients

Introducción La bronquiolitis es la causa más frecuente de hospitalización y un motivo frecuente de ingreso en la unidad de cuidados intensivos pediátricos (UCIP) en menores de un año durante los meses de invierno. El objetivo del estudio fue analizar las características y la evolución de los pacientes que precisan ingreso en la UCIP por bronquiolitis. Pacientes y método Estudio descriptivo, observacional, por revisión de historias clínicas entre noviembre de 1994 y marzo de 2006 de todos los pacientes ingresados en la UCIP por bronquiolitis. Resultados Se estudiaron 284 pacientes. La mayoría ingresaron durante los meses de diciembre y enero; el 74 % presentaban infección por el virus respiratorio sincitial. Un 68 % presentó algún factor de riesgo de evolución grave: el más frecuente fue la edad menor de 6 semanas (45 %) seguido del antecedente de prematuridad (30 %). En total 64/284 pacientes (24 %) precisaron ventilación mecánica. La mortalidad fue de 1,8 % y se asoció a la existencia de enfermedad previa (p < 0,001). Condicionaron un mayor riesgo de ventilación mecánica y una estancia en la UCIP más prolongada, la asociación de dos o más factores de riesgo (42/284; 15 %), las pausas de apnea (73/284; 25,7 %) y la imagen de consolidación o atelectasia en la radiografía de tórax al ingreso (157/284; 55 %). Conclusiones La mayoría de los pacientes que ingresan en la UCIP por bronquiolitis grave son lactantes sanos cuyo principal factor de riesgo es la corta edad. La asociación de dos o más factores de riesgo, la presencia de consolidación radiológica y las pausas de apnea al ingreso son los principales determinantes de evolución grave en la UCIP. La mortalidad por bronquiolitis es baja y se asocia a la existencia de enfermedades crónicas previas

Introduction Bronchiolitis is the leading cause of hospital admission and a frequent cause of pediatric intensive care unit (PICU) admission among infants during the winter months. The objective of this study was to analyze the characteristics and clinical course of patients admitted to the PICU for bronchiolitis. Patients and method We performed a descriptive, observational study by clinical chart review of all patients admitted to the PICU for severe bronchiolitis from November 1994 to March 2006. Results A total of 284 patients were included. Most were admitted during December and January and 74 % had respiratory syncytial virus (RSV) infection. At least one risk factor for severe disease was present in 68 % of the patients: the most frequent risk factor was age < 6 weeks (45 %), followed by prematurity (30 %). Mechanical ventilation was required in 64 of the 284 patients (24 %). Mortality was 1.8 % and was associated with chronic pre-existing illness (p < 0.001). The factors associated with a greater risk of mechanical ventilation and a longer PICU stay were the association of two or more risk factors (42/284; 15 %), the presence of apnea (73/284; 25.7 %), and images of pulmonary consolidation or atelectasis on admission chest X-ray (157/284; 55 %). Conclusions Most patients admitted for severe bronchiolitis to the PICU are healthy infants whose principal risk factor is young age. The main predictors of severe clinical course during PICU stay are the association of two or more risk factors, the presence of apnea, and pulmonary consolidation on admission chest X-ray. Bronchiolitis-associated mortality is low and is associated with pre-existing chronic illness

Miastenia gravis juvenil. Una enfermedad olvidada por los pediatras / Juvenile myasthenia gravis. An overlooked disease by pediatricians

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Infectious complications of percutaneous central venous catheterization in pediatric patients: a Spanish multicenter study.

OBJECTIVE: Analysis of infectious complications and risk factors in percutaneous central venous catheters. DESIGN: One-year observational, prospective, multicenter study (1998-1999). SETTING: Twenty Spanish pediatric intensive care units. PATIENTS: Eight hundred thirty-two children aged 0-14 years. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: One thousand ninety-two catheters were analyzed. Seventy-four (6.81%) catheter-related bloodstream infections (CRBSI) were found. The CRBSI rate was 6.4 per 1,000 CVC days (95% CI 5.0-8.0). Risk factors for CRBSI were weight under 8 kg (p < 0.001), cardiac failure (RR 2.69; 95% CI 1.95-4.38; p < 0.001), cancer (RR 1.66; 95% CI 0.97-2.78; p=0.05), silicone catheters (RR 2.82; 95% CI 1.49-5.35; p = 0.006), guidewire exchange catheterization (p=0.002), obstructed catheters (RR 2.67; 95% CI 1.63-4.39; p<0.001), and more than 12 days' indwelling time (RR 5.9; 95% CI 3.63-9.41; p<0.001). Multivariate Cox regression identified lower patient weight (HR 2.4; 95% CI 1.11-5.19; p=0.002), guidewire exchange catheterization (HR 2.2; 95% CI 1.07-4.54; p=0.049) and more than 12 days' indwelling time (HR 1.97; 95% CI 0.89-4.36; p=0.089) as significant independent predictors of CRBSI. Factors which protected against infection were the use of povidone-iodine on hubs (HR 0.42; 95% CI 0.19-0.96; p=0.025) and porous versus impermeable dressing (HR 0.41; 95% CI 0.23-0.74; p=0.004). Two children (0.24%) died from endocarditis following catheter-related sepsis due to Stenotrophomonas maltophilia in one case and P. aeruginosa in the other. CONCLUSIONS: Catheter-related sepsis is associated with lower patient weight and more than 12 days' indwelling time, but not with the insertion site. Cleaning hubs with povidone-iodine protects from infection.

Prognostic value of gastric intramucosal pH in critically ill children.

OBJECTIVE: To determine the association of tonometrically measured gastric intramucosal pH (pHi) to the occurrence of multiple organ dysfunction syndrome (MODS) and death in critically ill children. DESIGN: Prospective, observational study. SETTING: Pediatric intensive care unit (ICU) of a teaching children's hospital. PATIENTS: Fifty-one critically ill children admitted (median age 5.4+/-5 [SD] yrs; range 1 mo to 16 yrs) with the following diagnoses: post major surgery (n=26), sepsis (n=8), multiple trauma (n=5), acute respiratory distress syndrome (n=4), and "miscellaneous" (n=8). INTERVENTIONS: Placement of a tonometric catheter. MEASUREMENTS AND MAIN RESULTS: Pediatric Risk of Mortality (PRISM) score and clinical data were collected on admission and pHi daily during their stay in the pediatric ICU. A sigmoid tonometer was used to determine the pHi. Unconditional logistic regression was used to investigate the prognostic value of pHi. On admission, 26 patients presented with low gastric pHi (< or =7.35) and 17 of them had values of <7.30. The mortality rate in children with pHi <7.30 was 47.1% (95% confidence interval, 26.2 to 69) in contrast with an 11.7% mortality rate (95% confidence interval, 4.6 to 26.6) in children having a pHi of > or =7.30 (p=.015). The pHi and PRISM score on admission were independent predictive factors of death. The risk of mortality is increased when the pHi is low (odds ratio=2.5). However, we did not find the pHi to be a predictor for developing MODS. CONCLUSIONS: Our results show that pHi is an independent predictor of mortality in patients admitted to a pediatric ICU. Although no relationship was observed between the risk of MODS and gastric pHi, the univariate difference of 21% vs. 41% is highly suggestive. The pHi determination is a minimally invasive procedure and well tolerated in children of all ages.