Síndrome de apnea obstructiva del sueño con repercusión sistémica. A propósito de un caso / Obstructive sleep apnea syndrome with systemic repercussion. Case report

Presentamos el caso de un niño de 4 años que ingresa en la unidad de cuidados intensivos pediátricos (UCIP) por mal estado general, dificultad respiratoria severa con débil esfuerzo y ronquido inspiratorio. La auscultación cardiopulmonar muestra hipoventilación y ritmo de galope, tiene hepatomegalia y, desde el punto de vista neurológico, presenta disminución del nivel de conciencia (Glasgow 6/15). En las pruebas complementarias, se observa un daño hipóxico-isquémico generalizado(creatinina sérica de 1,8 mg/dL; GOT de 23.730 UI/L y GPT de 5.771 UI/L; actividad de protrombina del 31% y troponina de1,73 ng/mL). La radiografía de tórax muestra una discreta cardiomegalia y la ecocardiografía hipertensión pulmonar. En la eco-Doppler abdominal se observa una severa hiperecogenicidad cortical renal y hepatomegalia. En el electroencefalograma hay signos de afectación cerebral generalizada, y en la tomografía computarizada (TC) craneal aparecen dos áreas cerebrales sugestivas de infartos isquémicos e hipertrofia adenoidea. A los pocos días del ingreso, se realiza una adenoamigdalectomía. En el momento del alta, los parámetros analíticos son normales, y en la ecocardiografía no se observa hipertensión pulmonar (AU)

We present a case report of a four year old child who is admittedat the PICU due to general bad condition, serious respiratorydifficulty with low effort and inspiratory snoring. The cardiopulmonarauscultation shows hypoventilation and gallop rhythm.He also shows hepatomegaly and awareness reduction at aneurological level (Glasgow 6/15). The complementary testsshow a generalized hypoxic-ischemic injury (serum creatinine of1.8 mg/dL; GOT of 23,730 IUI/L and GPT of 5,771 IU/L; prothrombinactivity 31% and troponin 1.73 ng/mL). Thorax X-rayshows cardiomegaly and the echocardiography pulmonary hypertension.The abdominal echo-doppler shows a serious renalcortical hyperechogenicity and hepatomegaly. At the electroencephalographthere are some signs of generalized cerebraldamage and in the cranial scan there are two cerebral areasthat suggest ischemic infarctions and adenoid hypertrophy. Atonsillectomy is performed some days after admission. At thedischarge, the analytical parameters are normal and there is nopulmonary hypertension (PHT) in the echocardiography (AU)

[Parental perception of PICU end-of-life care and areas of improvement]. / Percepción subjetiva de los padres sobre los cuidados al final de la vida en una UCIP y cómo mejorarlos.

INTRODUCTION: We developed a study to investigate how end-of-life care is delivered in our PICU. It was based on questionnaires. Questionnaires are incomplete tools to study perceptions. Knowing this, information was completed by interviewing some parents. OBJECTIVE: To know in depth the parental perception on potential improvements relating to end of life care in the PICU. METHODS: Long and probing interviews with parents of deceased children. Answers were analyzed through content analysis (qualitative methodology). RESULTS: Eleven parents and/or mothers agreed to meet for an interview. They mentioned that end-of-life care may be improved in the following areas: information and communication, attention to families, death and after-death time, Unit organization, children care during admittance, and empathy from the staff. CONCLUSIONS: It is possible to obtain information about end-of-life care by asking parents. Content analysis provides us with useful knowledge to face child death and improve care. The main areas to improve are related with family-centered care.

Percepción subjetiva de los padres sobre los cuidados al final de la vida en una UCIP y cómo mejorarlos / Parental perception of PICU end-of-life care and areas of improvement

Introducción: Se llevó a cabo un estudio para examinar la idoneidad de los cuidados al final de la vida proporcionados en una unidad de cuidados intensivos pediátricos (UCIP), basado principalmente en cuestionarios. Los cuestionarios son una herramienta incompleta para estudiar percepciones y vivencias. Por ello, se complementó la información haciendo entrevistas largas a algunos padres. Objetivos: Conocer en profundidad la percepción de los padres sobre cómo mejorar los cuidados al final de la vida en la UCIP. Métodos: Entrevistas largas con padres de niños fallecidos en la UCIP. Análisis del contenido de las entrevistas (metodología cualitativa). Resultados: Accedieron a una entrevista 11 padres y/o madres. Refirieron que la atención al final de la vida podría mejorar en los siguientes aspectos: información y comunicación, atención a los familiares, los momentos del fallecimiento e inmediatos a éste, la estructura y funcionamiento de la unidad, cuidados del niño durante el ingreso y actitud de empatía por parte del personal. Conclusiones: Es posible obtener información de cómo se llevan a cabo los cuidados al final de la vida preguntando a los padres. El análisis del contenido de sus respuestas nos aporta un conocimiento útil para afrontar el fallecimiento de los niños. Los ámbitos fundamentales de mejora se refieren a la atención a las familias

Introduction: We developed a study to investigate how end-of-life care is delivered in our PICU. It was based on questionnaires. Questionnaires are incomplete tools to study perceptions. Knowing this, information was completed by interviewing some parents. Objective: To know in depth the parental perception on potential improvements relating to end of life care in the PICU. Methods: Long and probing interviews with parents of deceased children. Answers were analyzed through content analysis (qualitative methodology). Results: Eleven parents and/or mothers agreed to meet for an interview. They mentioned that end-of-life care may be improved in the following areas: information and communication, attention to families, death and after-death time, Unit organization, children care during admittance, and empathy from the staff. Conclusions: It is possible to obtain information about end-of-life care by asking parents. Content analysis provides us with useful knowledge to face child death and improve care. The main areas to improve are related with family-centered care

[Pneumococcal conjugate vaccine failure in HIV-infected child. Clinical case]. / Fallo de la vacuna antineumocócica conjugada en un niño VIH positivo. A propósito de un caso.

Despite appropriate antimicrobial therapy and vaccination, invasive pneumococcal infections remain associated with significant mortality, especially in selected high-risk groups (asplenic, humoral immunity deficient patients, etc.). We present a 13-year-old caucasian boy with HIV infection (vertical transmission). He received treatment with highly-active antiretroviral therapy (amprenavir, lamivudine and zidovudine) and vaccination with 23-valent vaccine (6 years old) and 7-valent pneumococcal conjugate vaccine (10 years old). His CD4 count and his viral load at these times were 2,063/microl and 13461 cop/ml, when he was 6 years old and 1,315/microl and 32400 cop/ml when he was 10 years old, respectively. The latest CD4 count (1,000/microl) and his viral load (3800 cop/ml) confirmed satisfactory control of the disease. He was referred to our emergency department presenting with fever, head and stomach-ache and vomiting. In the following hours his condition continued to deteriorate and depressed level of consciousness and meningismus were observed. Streptococcus pneumoniae, serotype 18 C, was detected in blood and cerebrospinal fluid cultures. Despite appropriate treatment with antibiotics (cefotaxime and vancomycin) and anti-oedema medications, brain-death was confirmed 24 hours after his admittance.

Fallo de la vacuna antineumocócica conjugada en un niño VIH positivo. A propósito de un caso / Pneumococcal conjugate vaccine failure in HIV-infected child

La infección neumocócica sigue asociada con una importante mortalidad, especialmente en grupos de riesgo (esplenectomizados, déficit de la inmunidad humoral, etc.) a pesar de vacunas y antibióticos adecuados. Presentamos a un niño de 13 años VIH positivo por transmisión vertical tratado con triple terapia (amprenavir, lamivudina y zidovudina). Fue vacunado con vacuna 23-valente a los 6 años y conjugada heptavalente a los 10 años de edad. El recuento de células CD4 y su carga viral a los 6 años eran de 2.063/μl y 13.461 copias/ml, respectivamente. A los 10 años el recuento de CD4 y su carga viral eran de 1.315/μl y 32.400 copias/ml, respectivamente. El último recuento de CD4 (1.000/μl) y la carga viral (3.800 copias/ml) confirmaban un buen control de la enfermedad 15 días antes del ingreso. Acude a urgencias por fiebre, dolor abdominal y vómitos. Hay un progresivo deterioro del nivel de conciencia y signos meníngeos. En el hemocultivo y en el cultivo de LCR crece Streptococcus pneumoniae serotipo 18C, y es tratado con cefotaxima y vancomicina, así como medidas antiedema cerebral, pero evoluciona a muerte cerebral en 24 h (AU)

Despite appropriate antimicrobial therapy and vaccination, invasive pneumococcal infections remain associated with significant mortality, especially in selected high-risk groups (asplenic, humoral immunity deficient patients, etc.). We present a 13-year-old caucasian boy with HIV infection (vertical transmission). He received treatment with highly-active antiretroviral therapy (amprenavir, lamivudine and zidovudine) and vaccination with 23-valent vaccine (6 years old) and 7-valent pneumococcal conjugate vaccine (10 years old). His CD4 count and his viral load at these times were 2,063/μl and 13461 cop/ml, when he was 6 years old and 1,315/μl and 32400 cop/ml when he was 10 years old, respectively. The latest CD4 count (1,000/μl) and his viral load (3800 cop/ml) confirmed satisfactory control of the disease. He was referred to our emergency department presenting with fever, head and stomach-ache and vomiting. In the following hours his condition continued to deteriorate and depressed level of consciousness and meningismus were observed. Streptococcus pneumoniae, serotype 18 C, was detected in blood and cerebrospinal fluid cultures. Despite appropriate treatment with antibiotics (cefotaxime and vancomycin) and anti-oedema medications, brain-death was confirmed 24 hours after his admittance (AU)

[End-of-life care in a Spanish Pediatric Intensive Care Unit: staff and parental evaluation]. / Cuidados al final de la vida en una unidad de cuidados intensivos pediátricos: evaluación por parte del personal y de los padres.

OBJECTIVES: To evaluate end-of-life care in a Paediatric Intensive Care Unit (PICU). METHODS: Retrospective study developed in a PICU. SUBJECTS: 41 workers from the PICU and parents of 26 deceased children (from 2001 to 2005). A questionnaire was designed to investigate end-of-life care. RESULTS: An age < 1-year old and a chronic or congenital disease correlated with a perceived lack of consistency in information. Nearly 38 % parents were with their children at the time of death; 64 % of all parents consider this "positive", and 13 % consider it "negative". Forty per cent of staff stated that it is "positive" for parents to be by the side of their child at the time of death, and 52 % do not know. Seventy-three per cent of staff, but only 29 % of parents want further professional psychological support for parents. Twenty per cent of children died following withdrawal of life support. The most important factors for this decision were the possibility of survival and quality of life. The majority (73 %) of caregivers express the view that often, this decision should be taken earlier. CONCLUSIONS: Analysis of staff opinions underlines the importance of the way news is communicated, the timing of withdrawal of life support, and the need for psychological support. Parents emphasized the role of the family during time spent in a PICU and during the last moments.

Cuidados al final de la vida en una unidad de cuidados intensivos pediátricos: evaluación por parte del personal y de los padres / End-of-life care in a Spanish Pediatric Intensive Care Unit: staff and Parental Evaluation

Objetivos: Evaluar los cuidados al final de la vida en una unidad de cuidados intensivos pediátricos (UCIP). Métodos: Estudio retrospectivo desarrollado en una UCIP. Los sujetos fueron 41 trabajadores de la UCIP y los padres de 26 niños fallecidos entre 2001 y 2005. Se diseñó un cuestionario para evaluar los cuidados al final de la vida proporcionados en este período. Resultados: La edad inferior a 1 año y las enfermedades crónicas o congénitas son las variables que se correlacionaron con una mayor percepción de incoherencia en la información. Cerca del 38 % de los padres estuvieron junto a sus hijos en el momento del fallecimiento; el 64 % de ellos consideran estar presentes algo positivo, y el 13 %, algo negativo. El 40 % del personal declaró que es positivo para los padres estar al lado de sus hijos en el momento del fallecimiento, y el 52 % no sabía si era positivo o negativo. El 73 % del personal, pero sólo el 29 % de los padres, desearía apoyo psicológico profesional para los padres. El 20 % de los niños fallecieron tras la retirada del soporte vital. Los factores más importantes para esta decisión fueron la posibilidad de supervivencia y la calidad de vida. La mayoría de los sanitarios expresaron que, a menudo, esta decisión debería haber sido tomada antes. Conclusiones: El análisis del personal subraya la importancia del cómo las noticias son comunicadas, del momento de retirada del soporte vital y la necesidad del apoyo psicológico. Los padres enfatizan más el papel de la familia en la UCIP y durante los últimos momentos (AU)

Objectives: To evaluate end-of-life care in a Paediatric Intensive Care Unit (PICU). Methods: Retrospective study developed in a PICU. Subjects: 41 workers from the PICU and parents of 26 deceased children (from 2001 to 2005). A questionnaire was designed to investigate end-of-life care. Results: An age < 1-year old and a chronic or congenital disease correlated with a perceived lack of consistency in information. Nearly 38 % parents were with their children at the time of death; 64 % of all parents consider this "positive", and 13 % consider it "negative". Forty per cent of staff stated that it is "positive" for parents to be by the side of their child at the time of death, and 52 % do not know. Seventy-three per cent of staff, but only 29 % of parents want further professional psychological support for parents. Twenty per cent of children died following withdrawal of life support. The most important factors for this decision were the possibility of survival and quality of life. The majority (73 %) of caregivers express the view that often, this decision should be taken earlier. Conclusions: Analysis of staff opinions underlines the importance of the way news is communicated, the timing of withdrawal of life support, and the need for psychological support. Parents emphasized the role of the family during time spent in a PICU and during the last moments (AU)

[Evaluation of energy expenditure in children. Physiological and clinical implications and measurement methods]. / Valoración del gasto energético en los niños. Implicaciones fisiológicas y clínicas. Métodos de medición.

The present article reviews the importance of the study of energy metabolism and its methods of assessment in children. Classically, energy requirements have been assessed by predictive equations based on anthropometric data. However, there are several physiologic and pathogenic states that may cause discrepancies between estimated and real values and consequently direct measurements of energy expenditure should be used. The gold standard to assess total energy expenditure during prolonged periods is the doubly labeled water method, which is mainly used for research studies. The best approach for resting energy expenditure determination in the clinical setting is indirect calorimetry. However, this method does not provide data on energy consumption under free-living conditions and its use in some critical care patients is restricted by technical limitations. Several other approaches to assess activity have been developed, based on heart rate, body temperature measurements, motion sensors and combined methods.

Valoración del gasto energético en los niños. Implicaciones fisiológicas y clínicas. Métodos de medición / Evaluation of energy expenditure in children. Physiological and clinical implications and measurement methods

Se revisa en este artículo la importancia del estudio del metabolismo energético y sus métodos de valoración en los niños. Clásicamente se han utilizado ecuaciones antropométricas para la predicción de los requerimientos energéticos, pero en muchos estados fisiológicos y patológicos existen discrepancias entre los valores estimados y los reales, por lo que deben emplearse mediciones directas del consumo energético. El método del agua doblemente marcada es el patrón oro para la medición del gasto energético total en períodos prolongados; se utiliza preferentemente en investigación. La calorimetría indirecta se considera el patrón de referencia para la determinación del gasto energético en reposo en la práctica clínica, si bien no ofrece datos del consumo energético en condiciones reales de vida y presenta limitaciones técnicas que impiden su uso en algunos pacientes críticos. Se analizan otros métodos que intentan solventar los problemas de medición, basados en datos de frecuencia cardíaca, temperatura, sensores de movimiento y métodos combinados (AU)

The present article reviews the importance of the study of energy metabolism and its methods of assessment in children. Classically, energy requirements have been assessed by predictive equations based on anthropometric data. However, there are several physiologic and pathogenic states that may cause discrepancies between estimated and real values and consequently direct measurements of energy expenditure should be used. The gold standard to assess total energy expenditure during prolonged periods is the doubly labeled water method, which is mainly used for research studies. The best approach for resting energy expenditure determination in the clinical setting is indirect calorimetry. However, this method does not provide data on energy consumption under free-living conditions and its use in some critical care patients is restricted by technical limitations. Several other approaches to assess activity have been developed, based on heart rate, body temperature measurements, motion sensors and combined methods (AU)

[Pyroglutamic acidemia associated with acetaminophen]. / Acidosis piroglutámica asociada a paracetamol.

We report a case of pyroglutamic acidemia probably related to acetaminophen administration. A 16-month boy recovering from hemolytic uremic syndrome abruptly developed unexplained high anion gap metabolic acidosis requiring hemodialysis. Septic shock, lactic acidosis and salicylate intoxication were ruled out. Betahydroxybutyrate and acetoacetate levels were within the normal range. No osmolarity gap or high amino acid levels were found. Urine and blood pyroglutamic acid levels were 392 mmol/mol creatinine (reference range: 9-55) and 9.8 mmol/L (reference range<0.16), respectively. The patient was receiving acetaminophen. We conclude that pyroglutamic acidosis should be considered in patients receiving acetaminophen who abruptly develop high anion gap metabolic acidosis not attributable to more common causes.

Acidosis piroglutámica asociada a paracetamol / Pyroglutamic acidemia associated with acetaminophen

El objetivo del manuscrito es comentar un caso de acidosis piroglutámica probablemente relacionada con la administración de paracetamol. Un niño de 16 meses en fase de recuperación de un síndrome hemolítico urémico desarrolló bruscamente acidosis metabólica con anión gap aumentado que precisó hemodiálisis. El paciente no presentaba signos sugerentes de sepsis y la acidosis láctica y la intoxicación por salicilatos se descartaron. Las concentraciones de betahidroxibutirato, acetoacetato, aminoácidos séricos y el osmol gap fueron normales. La determinación urinaria y sérica de ácido piroglutámico fue patológica: 392 mmol/mol creatinina (rango de referencia: 9-55) y 9,8 mmol/l (referencia < 0,16), respectivamente. El paciente estaba recibiendo paracetamol. La acidosis piroglutámica se debe descartar en el paciente que esté recibiendo paracetamol y desarrolle de forma brusca acidosis metabólica con anión gap aumentado sin otra causa precipitante

We report a case of pyroglutamic acidemia probably related to acetaminophen administration. A 16-month boy recovering from hemolytic uremic syndrome abruptly developed unexplained high anion gap metabolic acidosis requiring hemodialysis. Septic shock, lactic acidosis and salicylate intoxication were ruled out. Betahydroxybutyrate and acetoacetate levels were within the normal range. No osmolarity gap or high amino acid levels were found. Urine and blood pyroglutamic acid levels were 392 mmol/mol creatinine (reference range: 9-55) and 9.8 mmol/L (reference range < 0.16), respectively. The patient was receiving acetaminophen. We conclude that pyroglutamic acidosis should be considered in patients receiving acetaminophen who abruptly develop high anion gap metabolic acidosis not attributable to more common causes

Actuación en urgencias ante una crisis convulsiva en niños / Emergency actuation in convulsive seizures in children

La Crisis Convulsiva (CC) es un frecuente motivo de consulta pediátrica en urgencias que representa una situación de riesgo inmediato o potencial. La valoración y el tratamiento inicial del paciente en fase aguda tiene como objetivos el mantenimiento de la vía aérea, asegurar oxigenación, ventilación y circulación adecuadas. Simultáneamente se intenta suprimir la actividad convulsiva, prevenir las recurrencias e identificar y tratar la causa. En el paciente pediátrico es esencial considerar el origen metabólico (hipoglucemia, alteraciones iónicas y metabolopatías). Se describe un algoritmo de tratamiento inicial que incluye la administración de diazepam inicialmente rectal, seguido de intravenoso. Excepto en neonato y lactante pequeño, como fármaco de segunda línea se propone el uso de Valproato IV, si no existen contraindicaciones o el paciente estaba ya utilizando éste, empleando difenilhidantoína en caso de fallo de éste. El uso de midazolam por diversas vías puede ser una alternativa útil, frente a tiopental en pacientes con crisis rebeldes que no han respondido a tratamientos previos. Se analiza la presencia de CC en el contexto de fiebre, que obliga a diferenciar entre procesos benignos propios de la edad pediátrica como las crisis convulsivas febriles típicas y las crisis febriles atípicas, éstas con mayor posibilidad de estar relacionados con procesos patológicos. Se describen las características de ambas y se propone un algoritmo para orientar su manejo adecuado en la urgencia pediátrica. Las crisis comiciales en pacientes afebriles representan un problema diferente y en pediatría se relacionan generalmente con desajustes de la medicación en pacientes con antecedentes previos o con procesos de origen epiléptico que efectúan su comienzo. Sin embargo, en estos pacientes es imprescindible descartar la presencia de intoxicación y lesiones estructurales mediante una cuidadosa exploración y pruebas de imagen inmediatas o diferidas según los casos

Convulsive seizures (CS) are a frequent cause of paediatric emergency consultation comporting an immediate or potential risk situation. The initial assessment and management of the patient in the acute phase aims at maintaining airway permeability and ensuring adequate oxygenation, ventilation and circulation/perfusion. A simultaneous aim is the suppression of the convulsive activity, the prevention of recurrences and the identification and treatment of the cause. In the case of the paediatric patient it is essential to consider a possible metabolic origin (hypoglycaemia, ion derangements and metabolic diseases). We here describe an algorithm for initial management which encompasses diazepam administration (initially per rectum, then intravenously). With the exception of neonates and young infants, i.v. valproate is proposed as second-line therapy if no contraindications exist or the patient was already using this therapy, with diphenylhydantoin in case of valproate failure. Midazolam (through various administration routes) might represent a useful alternative, as opposed to thiopental in patients with refractory seizures not responding to previous therapies. The presence of CS in the context of fever is analysed, as this particular constellation demands differentiation between benign processes associated to paediatric ages (such as typical and atypical febrile seizures, the latter having a greater probability of being associated to pathologic conditions). The characteristic features of both are described and an algorithm is proposed for guiding their adequate management in paediatric emergency conditions. Epileptic seizures in non-febrile patients represent a different problem and, in the paediatric setting, they are usually related to medication maladjustments in patients with a previous history of epileptic processes, or to debuting epileptic processes. However, in these patients, it is a must to rule out the presence of intoxication and/or structural lesions through a careful and cornprehensive clinical examination and imaging procedures (immediate or deferred according to the particular case)

Síndrome de Guillain-Barré después de trasplante hepático pediátrico / Guillain-Barré syndrome after pediatric liver transplantation

La presentación de un síndrome de Guillain-Barré en el postoperatorio inmediato de un trasplante de órganos sólidos en niños es un hecho infrecuente. La patogenia de estos casos se ha explicado generalmente por la presencia de infección por alguno de los agentes tradicionalmente implicados en la aparición del síndrome (citomegalovirus, Campylobacter jejuni).Presentamos un caso de síndrome de Guillain-Barré en un receptor de trasplante hepático, en el que no se encontró ninguno de los factores descritos habitualmente como inductores del mismo, y revisamos los aspectos etiopatogénicos y clinicoterapéuticos de este síndrome (AU)

[Battered baby syndrome. Report of a case with severe sequelae]. / Síndrome del niño zarandeado. Presentación de un caso con graves secuelas.

OBJECTIVE: To present a case with shaken-baby syndrome after having seizures and respiratory problems. CLINICAL CASE: A previously normal child of 7 months of age presented an acute picture of status epilepticus with respiratory problems and periods of apnea. He was studied with electroencephalography, computerized tomography, magnetic resonance (MR) imaging and spectroscopic-MR. The child showed the presence of small subdural and epidural hematomas in both frontal regions 24 hours after the onset of the problem. The follow-up with MR studies revealed voluminous subdural bilateral hygroma that increased the size along the following six months, despite treatment with bilateral subdural-peritoneal shunt, and the patient showed infantile spasms. At 8 years of age, the patient shows severe mental retardation with autistic behavior and blindness, though he is able to walk without help and he has not seizures. The subdural hygroma decreased the size, but MR shows severe cortico-subcortical atrophy of both parieto-occipital regions. Spectroscopic MR study discloses severe neuronal lost and gliosis. CONCLUSIONS: The shaken-baby syndrome causes severe encephalopathy and vision problems, blindness in many cases, after showing voluminous subdural and/or epidural hematomas which lead to a severe neuronal lost and gliosis. Shaken-baby syndrome is not always associated with skull fracture nor is necessarily related with battered-child syndrome.

Síndrome del niño zarandeado.Presentación de un caso con graves secuelas / Battered baby syndrome. Report of a case with severe sequelae

Objetivo. Presentar el caso de un niño con `síndrome de niño zarandeado' tras sufrir crisis convulsivas y paradas respiratorias. Caso clínico. Un niño de 7 meses, previamente normal, presentó de forma espontánea un cuadro convulsivo que evolucionó a estado epiléptico y paradas respiratorias con fases de apnea. Fue estudiado con electroencefalografía, tomografía computarizada, resonancia magnética (RM) y RM espectroscópica. A las 24 horas el niño mostraba una discreta colección subdural y extradural frontal bilateral. El seguimiento con RM mostró, al cabo de un mes, voluminosa colección subdural bilateral que aumentó de tamaño durante los seis meses siguientes, pese a tener endoprótesis subdural-peritoneal bilateral, y la presencia de síndrome de West. Posteriormente, el paciente experimentó una leve mejoría, pero continúa con encefalopatía y pérdida de visión (ceguera casi completa) muy graves, y con gran atrofia cerebral córticosubcortical predominantemente de las regiones parietoccipitales. La RM espectroscópica reveló gran pérdida neuronal y gliosis. Conclusiones. El `síndrome del niño zarandeado' es un cuadro que cursa con encefalopatía y pérdida de visión muy graves tras provocar hematomas subdurales y/o extradurales, que conducen a importante pérdida neuronal y gliosis cerebral. No siempre existe fractura craneal ni se observa maltrato en el `síndrome del niño zarandeado' (AU)

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[Fisher's index as indicator of severity and its course in the postoperative period following liver transplantation in children]. / Indice de Fisher como indicador de gravedad y su evolución en el postoperatorio inmediato del trasplante hepático en niños.

OBJECTIVES: To study the evolution of Fisher index during the early postoperative period after liver transplantation in children. PATIENTS AND METHODS: We have studied 32 liver transplants performed on 26 pediatric patients, during the first week of the post-operative period. In all cases the BCAA/AAA quotient was determined before transplant, at the time of PICU admission, and on days 1, 2, 3, 4, 5, 6 and 7 after transplant. RESULTS: Compared to control group values, the Fisher index for these patients is significantly lower at pre-transplant (p < 0,0001), upon admission (p < 0,001), and days 1 (p < 0,0001), 2 (p < 0,0001) and 3 (p < 0, 0001). Comparison between non-survivors and survivors shows a significant reduction in the first group on the index in days 1 (p < 0,02), 3 (p < 0,02), 4 (p < 0,005), 5 (p < 0,002), 6 (p < 0,03) and 7 (p < 0,01) of post-transplant. CONCLUSIONS: The evolution of the Fisher index can be useful as an indication of the severity of the condition of these kinds of patients, which would help to establish more aggressive treatment to improve prognosis.

[Effectiveness of hemodynamic treatment guided by gastric intramucosal pH monitoring]. / Eficacia del tratamiento hemodinámico guiado por el pH intramucoso gástricoen niños críticamente enfermos.

OBJECTIVE: To determine whether gastric intramucosal pH can be used as an indicator for the treatment of critically ill children. METHODS: A protocol for hemodynamic treatment was tested in 34 critically ill children (medical and surgical patients). Endpoint was considered as normalization of gastric intramucosal pH. Hemodynamic complications were compared with another group of critically ill patients who received conventional treatment. RESULTS: Treatment designed to improve tissue oxygenation (hemodynamic stabilization, volume expansion, and dobutamine perfusion) raised pHi values from 7.25 +/- 0.04 to 7.32 +/- 0.13 (p = 0.014). Seventy-three percent of the children with pHi < 7.30 presented hemodynamic complications. These findings were compared with the results obtained in a control group of 30 critically-ill children given conventional treatment in the pediatric intensive care unit. In this group, 93.8% of the children with a pHi < 7.30 developed hemodynamic complications. CONCLUSIONS: We conclude that gastric intramucosal pHi can be useful as an indicator for the hemodynamic treatment of critically ill children.

Índice de fisher como indicador de gravedad y su evolución en el postoperatorio inmediato del trasplante hepático en niños / Fisher's index as an indicator of severity and its evolution in the postoperative period following liver transplantation in children

OBJETIVO: Estudiar la evolución del índice de Fisher y su utilidad como indicador de gravedad, durante el postoperatorio inmediato de pacientes pediátricos sometidos a un trasplante de hígado. PACIENTES Y MÉTODOS: El estudio comprende 32 trasplantes de hígado realizados en 26 niños. En todos los casos el índice BCAA/AAA fue determinado antes del trasplante, al ingreso postrasplante y los días 1, 2, 3, 4, 5, 6 y 7 después del trasplante. RESULTADOS: Comparado con el grupo control, el índice de Fisher de los pacientes fue significativamente más bajo en el pretrasplante (p < 0,0001), al ingreso (p < 0,001) y los días 1 (p < 0,0001), 2 (p < 0,0001) y 3 (p < 0,0001). Al comparar el grupo de pacientes vivos con el grupo de pacientes fallecidos, se evidencia una disminución significativa en el grupo de pacientes fallecidos los días 1 (p < 0,02), 3 (p < 0,02), 4 (p < 0,005), 5 (p < 0,002), 6 (p < 0,03) y 7 (p < 0,01). CONCLUSIÓN: La evolución del índice de Fisher puede servir como parámetro indicador de gravedad en pacientes pediátricos sometidos a un trasplante de hígado, lo que permitiría establecer un tratamiento más intensivo que pudiera mejorar el pronóstico de estos enfermos (AU)