Extubation failure after cardiac surgery in children with Down syndrome.

Extubation failure (EF) after cardiac surgery is associated with poorer outcomes. Approximately 50% of children with Down syndrome (DS) have congenital heart disease. Our primary aim was to describe the frequency of EF and identify risk factors for its occurrence in a population of patients with DS after cardiac surgery. Secondary aims were to describe complications, length of hospital stay, and mortality rates. This report was a retrospective case-control study and was carried out in a national reference congenital heart disease repair center of Chile. This study includes all infants 0-12 months old with DS who were admitted to pediatric intensive care unit after cardiac surgery between January 2010 and November 2020. Patients with EF (cases) were matched 1:1 with children who did not fail their extubation (controls) using the following criteria: age at surgery, sex, and type of congenital heart disease. Overall, 27/226 (11.3%) failed their first extubation. In the first analysis, before matching of cases and controls was made, we found association between EF and younger age (3.8 months vs 5 months; p = 0.003) and presence of coarctation of the aorta (p = 0.005). In the case-control univariate analysis, we found association between an increased cardiothoracic ratio (CTR) (p = 0.03; OR 5 (95% CI 1.6-16.7) for a CTR > 0.59) and marked hypotonia (27% vs 0%; p = 0.01) with the risk of EF. No differences were found in ventilatory management. CONCLUSIONS: In pediatric patients with DS, EF after cardiac surgery is associated with younger age, presence of aortic coarctation, higher CTR reflecting the degree of cardiomegaly and hypotonia. Recognition of these factors may be helpful when planning extubation for these patients. WHAT IS KNOWN: • Extubation failure after cardiac surgery is associated with higher morbidity and mortality rates. Some studies report higher rates of extubation failure in patients with Down syndrome. WHAT IS NEW: • In children with Down syndrome, extubation failure after cardiac surgery is associated with younger age, presence of aortic coarctation, higher CTR reflecting cardiomegaly and severe hypotonia.

[Monitoring of anticoagulant treatment with Unfractionated Heparin in pediatrics]. / Monitoreo del tratamiento anticoagulante con Heparina no Fraccionada en pediatría.

Unfractionated heparin (UFH) is the most widely used anticoagulant in hospitalized patients. The therapeutic range (TR) was defined in adults according to the prolongation of the activated Partial Thromboplastin Time (aPTT). However, the recommendation is to maintain a therapeutic range with anti-factor Xa assay (antiFXa). As this technique is more complex to perform and less available, it is recommended to make local correlation curves of aPTT with antiFXa. OBJECTIVE: to determine the correlation between the values of aPTT and antiFXa in patients treated with UFH. PATIENTS AND METHOD: 52 patients between 2 days to 14 years of age hospitalized in the Pediatric Critical Patient Unit were recruited. They received treatment with UFH in continuous infusion for at least 24 hours. aPTT and antiFXa tests were performed according to the moment of anticoagulation. To evaluate the concordance of the levels of aPTT with those of antiFXa, the Kappa statistical coefficient of Landis and Koch was used. RESULTS: 105 samples were collected from 52 patients. The overall concordance was 0.452 (moderate correlation). In patients aged < 1 month (n = 40), a considerable correlation was evident (r = 0.617); in those from 1 month to < 6 months (n = 18) and 6 months - < 12 months with aPTT < 120 seconds (n = 11), also showed a considerable correlation (r = 0.636 and 0.615, respec tively), while in those aged > 12 months (n = 37) with aPTT < 120 seconds, a moderate correlation was evident (r = 0.454). CONCLUSION: In our population, there is a moderate correlation between the values of aPTT and antiFXa.

[Pediatric tracheostomy: Ten year experience in an Intensive Care Unit]. / Traqueostomía en niños: Experiencia de 10 años en una Unidad de Cuidados Intensivos Pediátricos.

INTRODUCTION: Pediatric tracheostomy indications have changed over the last 30 years, from acute and transient pro cedures secondary to airway obstruction to programmed tracheostomies indicated due to the need for chronic use of mechanical ventilation (MV). OBJECTIVE: To describe indications and morbidity associated with pediatric tracheostomies during a ten-year period. PATIENTS AND METHODS: Descrip tive study. Clinical records review of discharged patients (< 15 years old) tracheostomized during their hospital stay between 2005 and 2015. Demographic and clinical variables were evaluated before and after tracheostomy, stay in intensive care unit, age at the time of the tracheostomy, indication of tracheostomy, early complications (< 7 days), late complications (> 7 days), and mortality. RESULTS: 59 children with tracheostomy were analyzed, 36 (59%) tracheostomies were performed in children under 6 months, and 39 (60%) in males. 23 (39%) had a confirmed or under study genopathy and 25 (42%) had congenital heart disease. The main indications for tracheostomy were 58% secondary to airway disease and 42% due to chronic use of MV. Within the airway disease group, subglottic steno sis, vocal cord paralysis, and tracheobronchomalacia were the principal reasons for indication, and in the group of chronic use of MV, the main causes were bronchopulmonary dysplasia and chronic lung disease. We did not find tracheostomy-related mortality. 89% of the patients were discharged with tracheostomy and 59% with chronic use of MV. The probability of being discharged with a tracheos tomy was higher in younger patients while the chronic use of MV at discharge was higher in patients with a greater number of extubation failures before tracheostomy. CONCLUSION: Tracheostomy is a safe procedure in children, where the predominant causes of indication are airway disease and the need for chronic use of MV. Most children with tracheostomies are discharged with tracheostomy and chronic use of MV. Younger children, those with difficult weaning, confirmed or suspected ge nopathy, or special health needs are at greater risk of needing tracheostomy and chronic use of MV.

Clinical profile of children with diabetic ketoacidosis in fifteen years of management in a Critical Care Unit. / Perfil clínico de niños con cetoacidosis diabética en una Unidad de Paciente Crítico.

INTRODUCTION: Diabetic ketoacidosis (DKA) is the main cause of morbidity and mortality in children with type 1 diabetes mellitus (T1DM) due to clinical and biochemical alterations associated, cerebral edema as one of the most critical because of the high mortality rates and long-term neurological se quelae. OBJECTIVE: To analyze the clinical characteristics and complications of patients with DKA ad mitted to a pediatric intensive care unit. PATIENTS AND METHODS: Retrospective study of DKA patients treated at the Hospital Clínico, Pontificia Universidad Católica de Chile (UPCPUC) between 2000 and 2015. Demographic characteristics, clinical manifestations, biochemical alterations, treatment, complications, and prognosis were assessed. Patients with T1DM onset were compared with those patients already diagnosed with diabetes, analyzing variables according to distribution. RESULTS: 46 DKA events were identified, 67% of them were the first episode of DKA. 66% of patients already diagnosed with diabetes were admitted due to poor adherence to treatment. The main symptoms described were: 63% polydipsia, 56% polyuria, 48% vomiting, 39% weight loss and 35% abdominal pain, and mean blood sugar levels of 522 mg/dL, pH 7.17, and plasma osmolality of 305 mOsm/L. 89% of patients received insulin infusion, and 37% presented hypokalemia. No episodes of cerebral edema or deaths were registered. CONCLUSIONS: Most of the DKA admissions were due to T1DM onset. In the group of patients already diagnosed with diabetes, the poor adherence to treatment was the main cause of decompensation. There were no serious complications or deaths associated with DKA management during the studied period. Early diagnosis and proper and standardized treatment contributed to reducing morbidity and mortality in children with DKA.

Perfil clínico de niños con cetoacidosis diabética en una unidad de paciente crítico / Clinical profile of children with diabetic ketoacidosis in a critical care unit

INTRODUCCIÓN: La cetoacidosis (CAD) es la principal causa de morbimortalidad en niños con diabetes mellitus tipo 1 (DM1) debido a las alteraciones bioquímicas asociadas, siendo el más temido el edema cerebral, con altas tasas de mortalidad y secuelas neurológicas a largo plazo. OBJETIVO: caracterizar el perfil clínico y las complicaciones de pacientes con CAD ingresados en una unidad de paciente crítico pediátrico. PACIENTES Y MÉTODO: Revisión retrospectiva de pacientes con CAD atendidos en el Hospital Clínico de la Pontificia Universidad Católica de Chile (UPCPUC) entre los años 2000 y 2015. Se evaluaron características demográficas, manifestaciones clínicas, alteraciones bioquímicas, tratamiento, complicaciones y pronóstico. Se compararon pacientes con debut de DM1 versus diabéticos conocidos, analizándose variables según distribución. RESULTADOS: Se identificaron 46 episodios de CAD. El 67% de éstos correspondió a un debut de DM1. El 66% de los diabéticos conocidos ingresaron por mala adherencia al tratamiento. Los principales síntomas de presentación fueron: 63% polidipsia, 56% poliuria, 48% vómitos, 39% pérdida de peso y 35% dolor abdominal, con medias de Glicemia 522 mg/dL, pH 7,17 y osmolaridad plasmática 305 mOsm/L. El 89% recibió insulina en infusión. El 37% presentó hipokalemia. No se registraron episodios de edema cerebral ni muertes. CONCLUSIONES: La mayoría de los ingresos por CAD correspondió a debut de DM1. En el grupo de diabéticos conocidos, la mala adherencia al tratamiento fue la principal causa de descompensación. No se presentaron complicaciones graves ni muertes asociadas al manejo de la CAD durante el período estudiado. El diagnóstico precoz y el tratamiento adecuado y estandarizado pudieran contribuir a reducir la morbilidad y mortalidad en niños con CAD.

INTRODUCTION: Diabetic ketoacidosis (DKA) is the main cause of morbidity and mortality in children with type 1 diabetes mellitus (T1DM) due to clinical and biochemical alterations associated, cerebral edema as one of the most critical because of the high mortality rates and long-term neurological se quelae. OBJECTIVE: To analyze the clinical characteristics and complications of patients with DKA ad mitted to a pediatric intensive care unit. PATIENTS AND METHODS: Retrospective study of DKA patients treated at the Hospital Clínico, Pontificia Universidad Católica de Chile (UPCPUC) between 2000 and 2015. Demographic characteristics, clinical manifestations, biochemical alterations, treatment, complications, and prognosis were assessed. Patients with T1DM onset were compared with those patients already diagnosed with diabetes, analyzing variables according to distribution. RESULTS: 46 DKA events were identified, 67% of them were the first episode of DKA. 66% of patients already diagnosed with diabetes were admitted due to poor adherence to treatment. The main symptoms described were: 63% polydipsia, 56% polyuria, 48% vomiting, 39% weight loss and 35% abdominal pain, and mean blood sugar levels of 522 mg/dL, pH 7.17, and plasma osmolality of 305 mOsm/L. 89% of patients received insulin infusion, and 37% presented hypokalemia. No episodes of cerebral edema or deaths were registered. CONCLUSIONS: Most of the DKA admissions were due to T1DM onset. In the group of patients already diagnosed with diabetes, the poor adherence to treatment was the main cause of decompensation. There were no serious complications or deaths associated with DKA management during the studied period. Early diagnosis and proper and standardized treatment contributed to reducing morbidity and mortality in children with DKA.

Histiocitosis: reporte de un caso / Histiocytosis: case report

La histiocitosis de células de Langerhans se describió desde el siglo XIX. Su origen y patogénesis se basan actualmente en tres eventos: clonalidad comprobada, un proceso reactivo a una infección viral, una proliferación y daño mediados por citocinas. El diagnóstico es histopatológico con la demostración de gránulos de Birbeck o la positividad para CD1a. Afecta a pacientes de cualquier edad y se manifiesta como una lesión osteolítica única o hasta como una enfermedad sistémica. El tratamiento es la resección quirúrgica, la radioterapia o la quimioterapia. El pronóstico varía de acuerdo a la presentación clínica.

Langerhans’s cell histiocytosis was first described in the XIX century. Its origin and pathogenesis are based mainly on 3 events: clonal proliferation, a cytokines – mediated reactive process secondary to a viral infection. Diagnosis is based on histopathologic studies by the presence of Birbeck granules or CD1a positivity. Langerhans’ cell histiocytosis affects patients of any age; it may present as a single osteolitic lesion or as a systemic disease. Treatment is based on surgical resection, radiotherapy or chemotherapy. Outcome varies on the clinical presentation of the disease.

Perfil de morbilidad anual de menores de 6 años consultantes / Morbidity profile in children younger than 6 years old

La magnitud y características de la morbilidad atendida en los consultorios de atención primaria proporciona información de gran utilidad para orientar acciones de prevención y curación de los usuarios del sistema nacional de servicios de salud. Con el objetivo de actualizar la estructura de la morbilidad infantil y obtener nuevos índices de atención se cuantificaron los episodios y las consultas por morbilidad, y se describieron los diagnósticos y se muestran las diferencias por mes para el total de niños y por año de edad. Se tomó una muestra aleatoria sistemática mensual, representativa por edad y sexo, hasta completar 468 menores de 6 años, consultantes en el consultorio Dr. José Symon Ojeda del Servicio de Salud Metropolitano Norte, y se realizó seguimiento a cada niño, durante un año. El 53 por ciento son varones; la frecuencia de niños por edad disminuye de 29,1 por ciento menores de 1 año a 8,2 por ciento a los 5 años. Se registraron 2,498 episodios de morbilidad que originaron 3,122 consultas. El 86,5 por ciento de los diagnósticos se concentró en tres grupos de causas: 67,1 por ciento afecciones respiratorias (25,9 por ciento enfermedad respiratoria aguda (ERA) alta y 41,2 por ciento ERA baja). 10,2 por ciento infecciones y parasitarias y 9,2 por ciento del sistema nervioso y órganos de los sentidos; enfermedades de la piel, digestivas y accidentes contribuyen con algo más de 2 por ciento cada uno, los demás grupos muestran importancia relativa inferior a 2 por ciento. Los diagnósticos específicos más frecuentes son bronquitis aguda (17,3 por ciento), bronquitis obstructiva (16,9 por ciento), neumopatías (6,2 por ciento), otitis media aguda (6,4 por ciento), amigdalitis y diarrea aguda (5 por ciento cada uno), dermatitis, conjuntivitis y traumatismos, 2 por ciento cada uno. Algunos diagnósticos son significativamente más frecuentes en primavera y verano (p<0,05), es el caso de diarrea aguda, enfermedades de la piel y conjuntivitis. Las afecciones respiratorias, ya sea en total, separadas en altas y bajas o desagregadas en diagnóticos específicos, son significativamente más frecuentes entre abril y agosto, pero no muestran diferencias significativas por sexo ni edad