Evaluación de un dispositivo de CPAP sin respirador en lainsuficiencia respiratoria aguda en pediatría / Evaluation of a continuous positive airway pressure system without a ventilator to treat acute respiratory failure in children

OBJETIVO: La CPAP en ventilación no invasiva es utilizadaampliamente en el paciente pediátrico con insuficienciarespiratoria aguda. Sin embargo la escasez deinterfases específicas, respiradores adecuados y la escasatolerancia de la técnica en estos pacientes pueden hacerfracasar su aplicación. El objetivo de este estudio fueanalizar la eficacia de un sistema de CPAP formado porun circuito respiratorio de Mapleson modificado, durantela IRA en pediatría.MATERIAL Y MÉTODOS: Estudio prospectivo observacionalrealizado en niños con insuficiencia respiratoriaaguda con indicación de ventilación no invasiva. LaCPAP se aplicó mediante un circuito respiratorio MaplesonD provisto de un manómetro y un tubo nasofaríngeocomo interfase. Se recogieron previo al tratamiento y 2horas después, frecuencia cardiaca, frecuencia respiratoria,fracción inspirada de oxígeno, presión arterial deoxígeno, de dióxido de carbono y pulsioximetría.RESULTADOS: Se incluyeron 16 pacientes de edadmedia 3,8 años durante un periodo de 18 meses. Observamosuna disminución PaCO2 desde 66,8±18,08 mmHga 46,48±5,9 mmHg tras CPAP (p=0,16) y un aumento enla relación PaO2/FiO2 de 201±111 a 262±115 mm Hg trasCPAP (p=0,30). La FC descendió de 156±22 a 127±18l/min (p=0,05) y la FR de 53±15 a 33±13 resp/min(p<0,05). No se registraron complicaciones graves y latolerancia fue adecuada. La técnica se consideró exitosaen 12 pacientes (75%).CONCLUSIONES: La aplicación de CPAP sin respiradormediante circuito Mapleson D puede ser utilizado comoventilación no invasiva en pacientes pediátricos con insuficienciarespiratoria aguda con elevada tasa de éxito (AU)

OBJETIVE: Noninvasive continuous positive airwaypressure (CPAP) is widely used in pediatric patients withacute respiratory failure. However, the lack of specificinterfaces and appropriate ventilators and poor tolerance ofthe technique by these patients can lead to failure of theapplication. The aim of this study was to analyze the efficacyof a CPAP system using a modified Mapleson breathingcircuit during acute respiratory failure in pediatric patients.MATERIAL AND METHODS: We performed a prospectiveobservational study in children with acute respiratoryfailure in whom noninvasive ventilation was indicated.CPAP was applied through a Mapleson D circuit fittedwith a manometer and a nasopharyngeal tube as theinterface. Heart rate, respiratory rate, inspired oxygenfraction (FiO2), PaO2, PaCO2, and pulse oximetry weremeasured before treatment and after 2 hours of treatment.RESULTS: Sixteen patients with a mean age of 3.8 yearswere studied for a period of 18 months. We observed amean (SD) change in PaCO2 from 66.8 (18.08) mm Hg to46.48 (5.9) mm Hg after CPAP (P=.16) and a mean changein the PaO2/FiO2 ratio from 201 (111) to 262 (115) afterCPAP (P=.30). The mean heart rate fell from 156 (22)beats/min to 127 (18) beats/min (P=.05) and the meanrespiratory rate from 53 (15) breaths/min to 33 (13)breaths/min (P<.05). No severe complications wererecorded and tolerance was satisfactory. The techniquewas considered a success in 12 patients (75%).CONCLUSIONS: CPAP without a ventilator, through aMapleson D circuit, can be used with a high success rateto provide noninvasive ventilation for pediatric patientswith acute respiratory failure (AU)

Thoracic epidural anesthesia decreases C-reactive protein levels in patients undergoing elective coronary artery bypass graft surgery with cardiopulmonary bypass.

BACKGROUND: Coronary artery bypass graft surgery with cardiopulmonary bypass induces a systemic inflammatory response. However, when thoracic epidural anaesthesia is administered as part of a combined anesthetic technique, the stress response associated with the cardiopulmonary bypass (CPB) may be attenuated. METHODS: Twenty-two patients undergoing elective coronary artery bypass graft surgery were randomized to receive either balanced general anesthesia with 7-20 microg/kg fentanyl (GA group) or combined anesthesia with 3-6 microg/kg fentanyl and an epidural bolus of 0.33% bupivacaine followed by a continuous perfusion of 0.175% bupivacaine, which was continued up to 48 hours after surgery (TEA group). The hemodynamic levels, troponin I, C-reactive protein (CRP), fibrinogen, leukocyte and platelet counts were recorded preoperatively, and 5 h, 16 h, 24 h, and 36 h after termination of the cardiopulmonary bypass. The time to tracheal extubation and cardiopulmonary complication rate were measured postoperatively. Data were analyzed with the Student's t and Mann Whitney tests, as appropriate. Differences were considered significant at P<0.05. RESULTS: All parameters significantly increased following CPB. The increase in CRP levels were lower in the TEA group at 16 hours (P=0.048). The increase of fibrinogen levels were lower in the TEA group at 24 hours (P=0.047). No differences were found in troponin levels between groups during the study. No significant differences were observed in extubation times (GA group 750+/-144 min; TEA group 702+/-451 min). CONCLUSION: Thoracic epidural anaesthesia, as a part of a combined anesthetic technique, attenuated the inflammatory response (CRP and fibrinogen levels) to cardiac surgery with cardiopulmonary bypass. However, this effect was not reflected in a decrease of troponin I levels, reduced incidence of complications, or in an earlier extubation time.

[Evaluation of a continuous positive airway pressure system without a ventilator to treat acute respiratory failure in children]. / Evaluación de un dispositivo de CPAP sin respirador en la insuficiencia respiratoria aguda en pediatría.

OBJECTIVE: Noninvasive continuous positive airway pressure (CPAP) is widely used in pediatric patients with acute respiratory failure. However, the lack of specific interfaces and appropriate ventilators and poor tolerance of the technique by these patients can lead to failure of the application. The aim of this study was to analyze the efficacy of a CPAP system using a modified Mapleson breathing circuit during acute respiratory failure in pediatric patients. MATERIAL AND METHODS: We performed a prospective observational study in children with acute respiratory failure in whom noninvasive ventilation was indicated. CPAP was applied through a Mapleson D circuit fitted with a manometer and a nasopharyngeal tube as the interface. Heart rate, respiratory rate, inspired oxygen fraction (FiO2), PaO2, PaCO2, and pulse oximetry were measured before treatment and after 2 hours of treatment. RESULTS: Sixteen patients with a mean age of 3.8 years were studied for a period of 18 months. We observed a mean (SD) change in PaCO2 from 66.8 (18.08) mm Hg to 46.48 (5.9) mm Hg after CPAP (P=.16) and a mean change in the PaO2/FiO2 ratio from 201 (111) to 262 (115) after CPAP (P=.30). The mean heart rate fell from 156 (22) beats/min to 127 (18) beats/min (P=.05) and the mean respiratory rate from 53 (15) breaths/min to 33 (13) breaths/min (P<.05). No severe complications were recorded and tolerance was satisfactory. The technique was considered a success in 12 patients (75%). CONCLUSIONS: CPAP without a ventilator, through a Mapleson D circuit, can be used with a high success rate to provide noninvasive ventilation for pediatric patients with acute respiratory failure.

Modificar el ayuno preoperatorio puede modular la respuesta de estrés postquirúrgico / A change in preoperative fasting can modulate postoperative stress response

No disponible

Lesiones neurológicas durante la circulación extracorpórea: fisiopatología, monitorización y protección neurológica / Neurological lesions during extracorporeal circulation: physiopathology, monitoring and neurological protection

La incidencia de lesiones neurológicas graves tras la cirugía cardíaca se ha establecido en un 6,1 per cent: un 3,1 per cent de lesiones focales y un 3 per cent de lesiones difusas. Parece que su causa es multifactorial. Se ha conjeturado que ciertos factores preoperatorios, como la presencia de hipertensión, diabetes insulinodependiente, la edad avanzada y la presencia de enfermedad cerebrovascular previa, se asociarían con la aparición de estas lesiones. Sin embargo, también se relaciona con factores intraoperatorios: el tipo de manejo ácido-base, el flujo sistémico durante la circulación extracorpórea (CEC), la presión de perfusión cerebral, el hematócrito durante la CEC, la duración de ésta, el control de las glucemias y la liberación de mediadores inflamatorios. Aunque se han utilizado diversos métodos de protección neurológica durante la CEC, ninguno ha demostrado evitar completamente la aparición de estas lesiones. Habitualmente se emplea la hipotermia, la prevención del desprendimiento de placas de ateroma con ecocardiografía, la prevención de microembolismos con filtros y la hemodilución. Últimamente se han ensayado diversos fármacos con resultados dispares (AU)