Short report - Usefulness of point-of-care ultrasound in pediatric SARS-CoV-2 infection.

SARS-CoV-2 infection in children is uncommon compared to adult population. However, some children required hospital and/or PICU admission. The aim of this short communication is to share our experience with Point-of-Care Ultrasound (POCUS) when managing these patients. Remarkably, all cases presented pleural and pericardial effusions, detected by POCUS, despite showing an adequate urinary output and prior to receiving any kind of fluid resuscitation. Effusions have been described as rare among SARS-CoV-2 infection in adult population. By performing portable chest X-Ray they would have gone unnoticed in our patients. Other POCUS findings consisted of all types of consolidations and coalescent B-line patterns. POCUS was also performed in order to optimize PEEP, checking adequate endotracheal intubation positioning (avoiding the risk of contagiousness related to auscultation in this framework), and to assess volemia status, cardiac performance, and brain neuro-monitoring. There was not cross-infection. In pediatric SARS-CoV-19 effusions are frequent but easily unnoticed unless lung and echo POCUS are performed.

Infecciones osteoarticulares en niños. Revisión de la casuística entre 1997 y 2007 en un hospital General / Osteoarticular infections in children. Review of the casuistic between 1997 and 2007 in a general Hospital

Las infecciones osteoarticulares son más frecuentes en niños que en adultos y causan morbilidad y secuelas a largo plazo importantes. Hemos realizado un estudio retrospectivo de los casos de infección ósteo-articular (IOA) (artritis séptica, osteomielitis aguda o ambas) diagnosticados en nuestro hospital entre 1997 y 2007. Se diagnosticaron 16 niños con IOA, 7 (43%) en los últimos 2 años. Feuron artritis séptica (AS) 9 (56%), uno con afectación ósea asociada, y 7 (44%) osteomielitis aguda (OA). Entre los niños con AS la edad osciló entre 13 y 150 meses (mediana, 33). Las articulaciones más afectadas fueron la rodilla y el tobillo. Se documentaron microbiológicamente 3 casos (33%), (S. aureus, S. pneumoniae y P. aeruginosa). Los días totales de antibioterapia oscilaron entre 18 y 40 (media, 30). Entre los niños con OA, la edad varió entre 16 y 168 meses (mediana, 92). La localización más frecuente fue la tibia. Se documentaron microbiológicamente 4 casos (57%). Todos fueron S. aureus. La duración de la antibioterapia varió entre 24 y 53 días (media, 35). Las infecciones osteoartículares siguen siendo frecuentes, con una aumento progresivo en la incidencia. La principal etiología sigue siendo el S. aureus, por lo que la cobertura antibiótica empírica debe dirigirse contra este microorganismo (AU)

Bone and joint infections are more frequent in children tan in adults and cause orbidity and important long-term sequels. A retrospective analysis of all the diagnosed cases of bone and/or joint between 1997 and 2007 was performed. 16 children were diagnosed of bone and/or infection, 7 (43%) in the last 2 years. Septic arthritis (SA) was found in 9 patients (56%), one of them with bone extension, and acute osteomyelitis (AO) in 7 (44%). Children with SA had ages between 13 and 150 months (median 33). The most frequently affected joints were the knee and the ankle. We documented microbiologically 3 cases (33%), (s. aureus, s. pneumonia and P. aeruginosa). The days of antibiotic therapy ranged between 18 and 40 (mean 30), and those of intravenous therapy between 8 and 24 (mean 13). The age of children diagnosed of AO ranged between 16 and 168 months (median 92). The most frequent location was the tibia. In 2 occasions, surgical drainage was performed. The microbiologic diagnosis was made in 4 cases (57%). All of them were S. aureus. The day of antibiotic therapy ranged between 24 and 53 days (mean 35), our of which between 7 and 46 days (mean 14) was made intravenous. Bone and joint infections are still frequent. The incidence seems to increase in the last years. S. aureus in the main responsible agent, so the empirical antibiotic treatment should be directed against this microorganism (AU)

Encefalopatía tras sedación prolongada con midazolam / Encephalopathy after prolonged sedation with midazolam

La analgesia y la sedación son terapias necesarias para el manejo adecuado del niño críticamente enfermo. El midazolam es una benzodiacepina, ampliamente utilizada en las Unidades de Cuidados Intensivos Pediátricos, a pesar de que su uso continuado produce tolerancia y dependencia. Tras su retirada puede aparecer síndrome de abstinencia y están descritas otras alteraciones neurológicas no claramente relacionadas con la deprivación del mismo. Presentamos el caso de una niña que, tras las retirada de sedación prolongada con midazolam y fentanilo, presentó un cuadro de desconexión de medio, hipertonía generalizada, movimientos estereotipados faciales, automatismos orales, ausencia de fijación de la mirada y de movimientos intencionales, estrabismo y, posiblemente, alucinaciones. La paciente no tuvo síntomas típicos de síndrome de abstinencia y se descartaron otras causas de encefalopatía. Las alteraciones se resolvieron espontáneamente en 3 semanas por lo que la sintomatología se atribuyó a un efecto adverso relacionado con la administración prolongada de midazolam

Analgesia and sedation are essential parts of the management of teh critically ill child. Midazolam is a widely used benzodiazepine in the Pediatric Intensive Care Units, but its use produces tolerance and dependence. After its discontinuation, abstinence syndrome can appear and also there are reported other neurological abnormalities not clearly related with the withdrawal. We report the case of a girl that after discontinuation of prolonged sedation with midazolam and fentanyl showed diminished level of consciousness generalized hipertony, facial grimacing, poor visual tracking, absence of coordinated movements, strabismus and possibly hallucinations. The patient did not present symptoms or signs suggesting withdrawal syndrome. Other causes of encephalopathy were ruled out. All abnormalities were spontaneously resolved in 3 weeks, and were attributed to an adverse effect of prolonged midazolam infusion

Hipernatremia como causa de corea y rabdomiólisis / Hypernatremia as cause of chorea and rhabdomyolysis

La hipernatremia severa asocia un estado de hiperosmolaridad que puede producir rabdomiólisis y consecuentemente desencadenar un fracaso renal agudo. La aparición de corea transitoria es una rara complicación de la hipernatremia. Presentamos un caso de un lactante de nueve meses con hipernatremia por una intoxicación salina que presentó rabdomiólisis con fracaso renal agudo y corea transitoria (AU)

[Techniques and complementary techniques. Complementary treatments: nitric oxide, prone positioning and surfactant]. / Técnicas y tratamientos complementarios. Tratamientos complementarios: óxido nítrico, posición en prono y surfactante.

The management of hypoxic respiratory failure is based on oxygen delivery and ventilatory support with lung-protective ventilation strategies. Better understanding of acute lung injury have led to new therapeutic approaches that can modify the outcome of these patients. These adjunctive oxygenation strategies include inhaled nitric oxide and surfactant delivery, and the use of prone positioning. Nitric oxide is a selective pulmonary vasodilator that when inhaled, improves oxygenation in clinical situations such as persistent pulmonary hypertension of the newborn, pulmonary hypertension associated with congenital heart disease, and acute respiratory distress syndrome (ARDS). When applied early in ARDS, prone positioning improves distribution of ventilation and reduces the intrapulmonary shunt. The surfactant has dramatically decreased mortality caused by hyaline membrane disease in premature newborns, although the results have been less successful in ARDS. Greater experience is required to determine whether the combination of these treatments will improve the prognosis of these patients.

Hipernatremia grave por administración accidental de sal común / Fatal hypernatremia due to exogenous salt intake

La hipernatremia es una alteración electrolítica común, aunque rara vez se debe a un exceso absoluto de sodio. La hipernatremia grave debida a ingestión de sal común, bien de forma accidental o bien como forma de maltrato infantil, es una entidad infrecuente pero que conlleva una alta mortalidad, así como dificultades para conseguir un tratamiento terapéutico óptimo. Apesar de ser fácilmente reconocible mediante las pruebas de laboratorio, la determinación de su etiología es con frecuencia muy difícil de establecer. Es importante tener presente que, incluso una ingesta sorprendentemente pequeña de sal puede provocar una hipernatremia aguda grave con desenlace fatal. Se describen 2casos de intoxicación salina grave en 2niñas de 20y 7meses de edad, respectivamente, cuya primera manifestación fue hipernatremia grave y convulsiones tras la ingesta accidental de sal común. En el caso1, la administración inadvertida de sal común, en lugar de azúcar, a dos yogures provocó una hipernatremia aguda y estado convulsivo. En el caso2, un error en la preparación de la solución de rehidratación oral (agua saturada con sal) originó un cuadro de convulsiones, coagulopatía de consumo y trombosis del seno venoso longitudinal. Ambos casos fallecieron con el diagnóstico de muerte encefálica (AU)

[Low grade disseminated astrocytoma in childhood]. / Astrocitomas de bajo grado diseminados en la infancia.

INTRODUCTION: Leptomeningeal dissemination is a common event in some kinds of cerebral tumours, but in low-grade astrocytomas who classically have been conferred a benign course. However, multifocal affectation is described each time more frequently in these group of tumours. CLINIC CASES: We present three patients aged respectively 8 and 10 months and 10 years, who were diagnosed of low-grade astrocytoma with multicentric spread. They were treated with systemic chemotherapy and controlled with MRI. At the end of the treatment an important reduction in tumours' size was observed in the three cases. DISCUSSION: Biological behaviour of low-grade astrocytoma as been reviewed in last years. By one side, it has been seen that certain histological characteristics are associated with an aggressive behaviour: on the other hand, long-term evolution of these tumours can be complicated with tumoral recurrence, malignization and leptomeningeal dissemination. This last one is observed each time more frequently since the use of MRI in the diagnose of cerebral tumours has become routine. From the therapeutic point of view, chemotherapy represents an effective choice for these patients' management, when surgery is not possible and radiotherapy not advisable, allowing in many cases to stop tumoral growth and sometimes to reduce it's size strongly.

[Allogenic bone marrow transplantation in Wiskott-Aldrich syndrome]. / Trasplante de medula ósea alogénico en el síndrome de Wiskott-Aldrich.

Two males of 3 and 3 1/2 years of age with the Wiskott-Aldrich syndrome who underwent bone marrow transplantation from an HLA compatible brother following conditioning treatment with busulphan and cyclophosphamide are described. In both patients the taking of the graft was proven by study of blood subgroups and correction of the immunodeficiency, normalization of platelet number and function and disappearance of cutaneous eczema were seen. At 3 and 1 year respectively of the transplantation the patients showed no evidence of graft versus host disease and no severe infections or hemorrhagic episodes have seen.

[Allogeneic bone marrow transplantation in children with acute lymphoblastic leukemia]. / Trasplante de medula ósea alogénico en niños con leucemia linfoblástica aguda.

PURPOSE: Long disease-free survival can be achieved with chemotherapy in over 50% of children with acute lymphoblastic leukaemia (ALL). However, those children suffering relapse or presenting with poor-risk features at diagnosis have scarce possibility of doing well with conventional chemotherapy. Bone marrow transplantation (BMT) is a good choice in such cases. MATERIAL AND METHODS: Between July 1985 and January 1992, twenty-four children with ALL underwent BMT in the Service of Pediatrics of the Hospital Ramón y Cajal. In seven patient with poor-risk criteria at diagnosis BMT was performed in the first complete remission (CR) and in seventeen cases it was performed after the second CR. The conditioning for transplantation consisted of cyclophosphamide plus total body irradiation in 21 patients and cyclophosphamide plus busulphan in 3 others. RESULTS: Fifteen patients persist in CR with post-transplant follow-up of 3 to 73 months (median, 31 months). Five patients died due to complications of the transplantation techniques, and four others died upon leukaemic relapse. The probability of disease-free survival for all cases is 61%, a plateau being reached at 13 months (83% and 52% for BMT in first or second CR, respectively). CONCLUSIONS: These findings confirm the efficacy of BMT in the treatment of children with ALL in second CR, or in first CR when there are very poor risk criteria at diagnosis.

[Bone marrow transplantation in malignant diseases in childhood using reverse isolation technics: evaluation of results]. / Trasplante de médula ósea en enfermedades malignas en la edad pediátrica con aislamiento inverso convencional: valoración de resultados.

Between July 1985 and March 1990, 31 pediatric patients with neoplastic diseases underwent bone marrow transplantation (22 allogenic and 9 autologous). Routine reverse isolation techniques with sterilization of the gastrointestinal tract were used in all cases. Of these patients, 55% had fever and 32% had a documented infection. In allogenic bone marrow transplants, 23% developed graft-versus-host disease, grade I-IV. The incidence of infection and graft-versus-host disease compares favorably with other published reports from centers utilizing laminar air flow rooms during bone marrow transplantation. This suggest that standard reverse isolation techniques may be used without increasing the morbidity and mortality in these patients.