SARS-CoV-2 en Pediatría: abordaje de la transmisión, fisiopatología ehipótesis de presentación clínica / Sars-cov-2 in pediatrics: transmission approach, pathophysiology and clinical presentation hypothesis

La pandemia de COVID-19 causada por el síndrome respiratorio agudo severo coronavirus 2 (SARS-CoV-2) es una infección producida por inhalación de gotas o contacto directo con superficies infectadas. Los síntomas clínicos son similares a cualquier infección viral respiratoria aguda; la enfermedad suele ser más leve en los niños. El objetivo fue describir el abordaje de la transmisión, la fisiopatología y las manifestaciones clínicas del SARS-CoV-2 en población pediátrica. Se realizó una revisión bibliográfica en bases de datos académicas PubMed, LILACS, OVID-MEDLINE usando términos DECS-LILACS, aplicando filtros de búsqueda y se seleccionaron textos científicos e información relevante para la investigación. Los resultados evidencian una menor incidencia, prevalencia, hospitalizaciones e ingreso a unidades de cuidados intensivos. Es necesario corroborar las hipótesis planteadas para fortalecer estos conocimientos y determinar las características que predominan en la lesión pulmonar por infección de SARS-CoV-2 en Pediatría.(UA)

The COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an infection caused by inhalation of droplets or direct contact with infected surfaces. The clinical symptoms are similar to any acute respiratory viral infection; the disease is usually milder in children. The objective was to describe the transmission approach, pathophysiology and clinical manifestations of SARS-CoV-2 in the pediatric population. A bibliographic review was carried out in PubMed, LILACS, OVID-MEDLINE academic databases using DECS-LILACS terms, applying search filters and scientific texts and relevant information for the research were selected. The results show a lower incidence, prevalence, hospitalizations and admission to intensive care units. It is necessary to corroborate the hypotheses proposed to strengthen this knowledge and determine the characteristics that predominate in pulmonary injury due to SARS-CoV-2 infection in pediatrics.(AU)

Organ dysfunction syndrome and mitochondrial adaptation in the septic patient. / Síndrome de disfunción de órganos y adaptación mitocondrial en el paciente séptico.

The ability to maintain an adequate energy balance and to respond and adapt to environmental stress at the cellular level are cornerstones for the survival and evolution of organisms. Therefore, in the presence of various factors, a cellular protection response is triggered by activation of mitochondrial function-dependent signaling. However, this essential reaction for individual cell survival can be detrimental to organ function (maladaptation), transforming the close balance between the two into the pathogenetic axis of organ dysfunction and eventual recovery in septic patients. Macrocirculatory and microcirculatory disruption undoubtedly contributes to organ dysfunction in the early stage of septic shock, while intrinsic metabolic-bioenergetic failure (cytopathic hypoxia) perpetuates inadequate cellular function. Therefore, mitochondrial dysfunction is a key process in the induction of multiple organ dysfunction syndrome in the septic patient. This syndrome can be considered as a complex hypometabolic adaptive phenomenon in the face of excessive and prolonged inflammatory stimulus to achieve regulation of energy homeostasis and preservation of organ function. In the future, there should be a transition from the current consensus therapeutic options, which are limited to control of the infectious focus, hemodynamic and life support, to metabolic resuscitation based on the molecular and genetic alterations triggered by the infection.

Piedra angular para la sobrevida y la evolución de los organismos es su capacidad de mantener un adecuado balance energético, así como también que las células respondan y se adapten al estrés ambiental. Por ello, ante la presencia de diversos factores se origina una respuesta de protección celular mediante la activación de señalización dependiente de la función mitocondrial. Sin embargo, esta reacción, esencial para la supervivencia individual de las células, puede ser perjudicial para la función orgánica (adaptación inadecuada), transformando el estrecho equilibrio entre ambas en el eje patogénico de la disfunción orgánica y su eventual recuperación en el paciente séptico. Las alteraciones macrocirculatorias y microcirculatorias contribuyen, indudablemente, a la disfunción orgánica en la etapa precoz del choque séptico, mientras que la falla metabólica-bioenergética intrínseca (hipoxia citopática) perpetúa una función celular inadecuada. Por lo tanto, la disfunción mitocondrial es un proceso clave en la inducción del síndrome de disfunción multiorgánica en el paciente séptico. Este síndrome puede considerarse como un complejo fenómeno adaptativo hipometabólico ante un estímulo inflamatorio excesivo y prolongado, para lograr la regulación de la homeostasis energética y la preservación de la función de los órganos. En el futuro, debería producirse una transición entre las opciones terapéuticas actuales consensuadas, que se limitan al control del foco infeccioso y el soporte hemodinámico y vital, hacia una reanimación metabólica basada en las alteraciones moleculares y genéticas desencadenadas por la infección.

Coagulopatía por SARS-CoV-2 / SARS-COV-2 COAGULOPATHY

En diciembre de 2019 se descubrió un nuevo coronavirus, asociado a pacientes que sufrían un cuadro de neumonía en Hubei provincia de China, desde ese momento se estudia las características del virus, como también de la patología que produce. En los pacientes graves, se observó un estado proinflamatorio y procoagulante que provocó la disfunción multiorgánica, y, en muchos de ellos, la muerte. El objetivo de este trabajo consiste en describir la fisiopatología de la coagulopatía que esta infección, sorprendentemente, provoca. Es importante remarcar la relación que existe entre los estados inflamatorios y la cascada de la coagulación, cuyas disfunciones ocurren en situaciones de gravedad, como es la sepsis. El SARS-CoV-2 entrara a la célula mediante el receptor de la enzima convertidora de angiotensinógeno. En los estadios avanzados o críticos de la enfermedad, el estímulo hiperinflamatorio y el ambiente protrombótico provocarán un daño multiorgánico. El enfoque de los pacientes en estadios avanzados o críticos debe ser de soporte vital, junto a una terapia anticoagulante completa

In December 2019, a new coronavirus, SARS-CoV-2, was discovered in patients suffering from pneumonia. In critically ill patients, a proinflammatory and procoagulant state was observed: this led to multiorgan dysfunction, and, in many patients, to death. The objective of this work is to describe the pathophysiology of coagulopathy that this infection, surprisingly, causes. It is important to highlight the cross-talk between inflammation and coagulation in serious situations, such as sepsis. SARS-CoV-2 will enter the cell via the angiotensinogen converting enzyme receptor. In the advanced or critical stages of the disease, the hyperinflammatory stimulus and the prothrombotic environment will cause multi-organ damage. The approach of patients in advanced or critical stages should be life support, together with full anticoagulant therapy.

Is mortality in elderly septic patients as high as expected? Long-term mortality in a surgical sample cohort.

PURPOSE: To determine the differences in short- and long-term mortality in elderly septic patients with multiorgan dysfunction syndrome and establish the factors related to non-survival. MATERIALS AND METHODS: A retrospective cohort study was made of 206 patients over 65 years of age with septic and septic shock criteria admitted to the ICU of Rio Hortega Hospital between January 2011 and February 2017. Study variables were obtained from electronic database records. RESULTS: A total of 206 patients were included, divided into three groups of age (65-74, 75-85, >85 years). There were no significant differences in mortality according to age group after 28 days, 90 days or one year (28.6%, 32.1% and 45.2% in the 65-74 years age group; 32.5%, 38.6% and 45.8% in the 75-85 years age group, 41%, 48.7% and 56.4% in the >85 years age group). The factors related to mortality were: chronic heart failure, non-haematological cancer, liver dysfunction and central nervous system dysfunction. CONCLUSIONS: The results indicate that there is no significant difference in mortality among the different age groups. About 50% of the elderly patients survive a septic process. There is a close relationship between the number of affected organs and days of dysfunction, the use of interventional techniques and long-term mortality.

Sepsis en pediatría: nuevos conceptos / Sepsis in pediatrics: New concepts

La sepsis es una de las principales causas de mortalidad en adultos y en niños. El impacto es negativo en la salud de la población, y los gastos generados en el sistema de salud se los calcula en varios miles de millones de dólares. La muerte infantil a nivel mundial representa por décadas una compleja y progresiva enfermedad inflamatoria secundaria a un agente infeccioso, la cual origina disoxia tisular y eventualmente falla celular y orgánica, sin necesariamente pasar por hipotensión en etapas tempranas sino en etapas tardías de enfermedad. En la presente publicación se actualiza las definiciones realizadas a partir del Tercer Consenso de Definiciones de Sepsis y Choque Séptico y las Campañas Internacionales Sobreviviendo a la Sepsis, tomando como referencia un mejor entendimiento de la patobiología de la enfermedad. Se aborda la necesidad de usar un puntaje de disfunción de órganos en niños para valorar y predecir la mortalidad de una mejor manera y realizar ensayos clínicos. El objetivo de este artículo es dar a conocer el estado actual del conocimiento en la parte operacional de definiciones y la sugerencia de adaptar los conceptos a las guías clínicas nacionales.

Sepsis is one of the leading causes of mortality in adults and children. It has a negative impact on the population's health, and the expenses for the healthcare system are estimated at several billion dollars. Worldwide, infant death has represented for decades a complex and progressive inflammatory disease secondary to an infectious agent, which causes tissue dysoxia and eventually cell and organ failure, without necessarily going through hypotension in the early stages but in later stages of the disease. This review updates the definitions from the Third Consensus on Definitions of Sepsis and Septic Shock and the International Surviving Campaigns, which provide us a better understanding of the pathobiology of the disease. It elaborates on the need to use a score of organ dysfunction in children for better appraisal and prediction of mortality, and to conduct clinical trials. The objective of this article is to present the current status of knowledge of the operational definitions and to suggest the adaptation of the concepts in the national clinical guidelines.

Comparative study of bacterial translocation control with nitric oxide donors and COX2 inhibitor.

OBJECTIVE AND DESIGN: To evaluate the beneficial effects of exogenous NO and an inhibitor of the COX2, and their action levels in a model of SIRS/bacterial translocation (BT) induced by Zymosan A(®). MATERIAL AND METHODS: Ninety Wistar rats were submitted to different treatments, and after 12h and 24h they were anaesthetized in order to collect blood, mesenteric lymph nodes, and kidney for subsequent biochemical analyses and microbiological examinations. TREATMENTS: A nitric oxide donor, Molsidomine(®), was compared with a COX2 inhibitor, Celecoxib(®). METHODS: Zymosan A(®) was administered to Wistar rats. The animals were divided into 6 groups: one group for survival study, Group (1) No manipulation (BASAL); Group (2) vehicle of Zymosan A(®) given intraperitoneally (SHAM); Group I (control), with Zymosan A(®) (0.6g/kg) intraperitoneally; Group II (Molsidomine), with Molsidomine(®) (4mg/kg) through the penis dorsal vein, 30min prior to administration of the Zy(®) (0.6g/kg); Group III (Celecoxib), with Celecoxib(®) (400mg/kg) orally through a stomach tube, 6h prior to administration of the Zy (0.6g/kg). DETERMINATIONS: The parameters survival, bacterial translocation, renal function, neutrophil accumulation, oxygen free radicals (OFR), detoxifying enzymes, and cytokines were measured at different times after Zymosan administration. RESULTS: The model established induced a mortality rate of 100% and generated BT and systemic inflammatory response syndrome (SIRS) in all samples. It also significantly increased all variables, with p<.001 for MPO and all pro-inflammatory cytokines, and p<.01 for all OFR. Treatment with Molsidomine reduced mortality to 0%, decreased BT, MPO, pro-inflammatory cytokines and OFR (p<.001) significantly and increased IL-10 and IL-6 production. Moreover, the Celecoxib(®) showed a lower capacity for SIRS regulation. CONCLUSIONS: The exogenous administration of NO prevented BT and controlled SIRS. Therefore these results suggest that Molsidomine could be used as a therapeutic strategy to protect against BT.

Predictive scoring systems in multiorgan failure: A cohort study.

OBJECTIVE: An evaluation is made of the hospital mortality predicting capacity of the main predictive scoring systems. DESIGN: A 2-year retrospective cohort study was carried out. SETTING: A third level ICU with surgical and medical patients. PATIENTS: All patients with multiorgan failure during the first day in the ICU. MAIN VARIABLES: APACHE II and IV, SAPS II and III, MPM II and hospital mortality. RESULTS: A total of 568 patients were included. Mortality rate: 39.8% (226 patients). Discrimination (area under the ROC curve; 95% CI): APACHE IV (0.805; 0.751-0.858), SAPS II (0.755; 0.697-0.814), MPM II (0.748; 0.688-0.809), SAPS III (0.737; 0.675-0.799) and APACHE II (0.699; 0.633-0.765). MPM II showed the best calibration, followed by SAPS III. APACHE II, SAPS II and APACHE IV showed very poor calibration. Standard mortality ratio (95% CI): APACHE IV 1.9 (1.78-2.02); APACHE II 1.1 (1.07-1.13); SAPS III 1.1 (1.06-1.14); SAPS II 1.03 (1.01-1.05); MPM 0.9 (0.86-0.94). CONCLUSIONS: APACHE IV showed the best discrimination, with poor calibration. MPM II showed good discrimination and the best calibration. SAPS II, in turn, showed the second best discrimination, with poor calibration. The APACHE II calibration and discrimination values currently disadvise its use. SAPS III showed good calibration with modest discrimination. Future studies at regional or national level and in certain critically ill populations are needed.

Limitation of life-sustaining treatment in patients with prolonged admission to the ICU. Current situation in Spain as seen from the EPIPUSE Study.

OBJECTIVE: Limitation of life-sustaining treatment (LLST) is a recommended practice in certain circumstances. Limitation practices are varied, and their application differs from one center to another. The present study evaluates the current situation of LLST practices in patients with prolonged admission to the ICU who suffer worsening of their condition. DESIGN: A prospective, observational cohort study was carried out. SETTING: Seventy-five Spanish ICUs. PATIENTS: A total of 589 patients suffering 777 complications or adverse events with organ function impairment after day 7 of admission, during a three-month recruitment period. MAIN VARIABLES OF INTEREST: The timing of limitation, the subject proposing LLST, the degree of agreement within the team, the influence of LLST upon the doctor-patient-family relationship, and the way in which LLST is implemented. RESULTS: LLST was proposed in 34.3% of the patients presenting prolonged admission to the ICU with severe complications. The incidence was higher in patients with moderate to severe lung disease, cancer, immunosuppressive treatment or dependence for basic activities of daily living. LLST was finally implemented in 97% of the cases in which it was proposed. The decision within the medical team was unanimous in 87.9% of the cases. The doctor-patient-family relationship usually does not change or even improves in this situation. CONCLUSION: LLST in ICUs is usually carried out under unanimous decision of the medical team, is performed more frequently in patients with severe comorbidity, and usually does not have a negative impact upon the relationship with the patients and their families.

Síndrome de respuesta inflamatoria sistémica y disfunción orgánica en urgencias pediátricas / Association between systemic inflammatory response and organ dysfunction in paediatric emergencies

En las salas de Emergencias Pediátricas la gravedad o el riesgo de fallecer es un hecho de especial importancia. La gravedad de una enfermedad es difícil de definir, para esto, se han desarrollado escalas de riesgo de muerte. Para optimizar la preparación del departamento de emergencia en el manejo de niños con enfermedades graves necesitamos conocer las características del paciente y su enfermedad. Objetivo: Evaluar relación entre síndrome de respuesta inflamatoria sistémica y disfunción orgánica en niños Metodología: Cohorte prospectiva. Niños con enfermedad aguda grave, admitidos en forma consecutiva al departamento de urgencias, evaluación de variables clínicas y fisiológicas. Análisis del efecto de variables sobre el riesgo de disfunción orgánica múltiple o mortalidad Resultados: Riesgo de enfermedad aguda grave, 70/105 niños <12 años; edad mediana 0,9 (0,3-3,9) años; síndrome de disfunción orgánica múltiple, 14 (24,1%) de 58; tasa de mortalidad observada 6,9%. Riesgo de muerte en niños con disfunción multiorgánica 3/14 (21,4%) contra 1(2,3%) de 44 niños sin disfunción multiorgánica (RR 9,4; χ2 6,1; p 0,04) Conclusión: En niños con enfermedad aguda grave el riesgo de muerte esta positivamente asociado con el riesgo de disfunción orgánica múltiple.

In pediatric emergency rooms, the risk of dying is a fact of particular importance. The severity of a disease is difficult to define, for this reason, risk of death scales have been developed. To optimize the preparation of emergency departments in the management of children with serious diseases we need to know the characteristics of the patient and his illness. Goal: To assess the relationship between systemic inflammatory response syndrome and organ dysfunction in children Methodology: Prospective cohort. Children with serious acute illness, admitted consecutively to the Emergency Department, evaluation of clinical and physiological variables. Analysis of the effect of variables on the risk of mortality and multiple organ dysfunction Results: Serious risk of acute illness, 70/105 children < 12 years; age median 0.9 (0, 3-3, 9) years; multiple organ dysfunction syndrome, 14 (24.1%) 58; rate 6.9% observed mortality. Risk of death in children with dysfunction multi-organ 3/14 (21.4%) against 1(2,3%) of 44 children without multiple organ dysfunction (RR 9.4; ) χ2 ( 6.1; p 0.04) Conclusion: In children with acute and severe illnesses, the risk of death is positively associated with the risk of multiple organ dysfunction.

[The influence of symbiotics in multi-organ failure: randomised trial]. / Influencia de los simbióticos en la disfunción multiorgánica: ensayo aleatorizado.

BACKGROUND AND OBJECTIVE: To assess whether the administration of symbiotic preparations in patients with multi-organ failure (MOF) diminishes the evolution of the failure, the inflammatory response generated, the colonization pattern and the Intensive Care Unit (ICU) infectious illness. PATIENTS AND METHOD: Randomized and controlled trial. All patients with MOF were included. Neutropenia and acute pancreatitis patients were excluded. A symbiotic (Simbiotic Drink) was administered via enteral feeding during the first 7 days. Variables of interest were: Sequential Organ Failure Assessment (SOFA) score evolution, systemic concentrations of lactate, fibrinogen and D-dimer; skin and mucosa colonization and infectious disease register. RESULTS: Eighty-nine patients were included; 46 in the symbiotic group (SG) and 43 in the control group (CG). There were 68.5% males, with a median age of 69 years. There were no significant differences in the patients' fundamental characteristics (medical history, age, reason for admission, severity scores), nor in the length of ICU stay or in mortality. Comparing the SG with the CG, there were lower lactate levels on the second day, more fibrinogen levels on the days 5 and 7, and lower D-dimer levels on the day 7. Eight hundred and ninety-five cultures were performed for colonization assessment, with isolation of 528 microorganisms. No differences in microbiological resistance were found; there were more colonization in the SG by Candida in mucous membranes after the third day; this situation resolved after stopping symbiotic administration. Twenty-two patients suffered an infectious disease in ICU, 14 in SG (42.4%) and 19 in CG (57.6%). Although no differences were found in the microbiological pattern, there was a predominance of Candida spp. over other microorganisms (4 vs. 0 cases). CONCLUSIONS: The symbiotic preparation Simbiotic Drink, administered in MOF, results in differences to improve the early lactate levels and late fibrinogen/D-dimer levels as well as mucosa colonization by Candida. There were no differences in the ICU evolution.

[Analysis of organ failure and mortality in sepsis due to secondary peritonitis]. / Análisis de la insuficiencia de órganos y mortalidad en la sepsis por peritonitis secundaria.

OBJECTIVES: To identify the organs most susceptible to develop multiorgan dysfunction syndrome (MODS) in patients with sepsis due to secondary peritonitis, and to determine the outcome and mortality predicting utility of the SOFA (Sequential Organ Failure Assessment) system. DESIGN: A prospective, observational cohort study was made. SETTING: The resuscitation unit of a third-level university hospital. PATIENTS: A prospective, observational cohort study was made of 102 patients with sepsis of abdominal origin and failure of at least one organ related to the infection. The demographic characteristics were documented, along with the abdominal origin of sepsis, mortality after 28 days, and the daily SOFA score. RESULTS: The mortality rate after 28 days was 55%. A total of 53% of the patients presented failure of two or more organs on the first day of admission. The mean daily SOFA score was significantly higher among the patients that died after day 4 of admission. The variables showing a statistically significant correlation to increased mortality were: MODS (P=.000), central nervous system failure (P=.000) and SOFA score on day 4 of admission (P=.012). The area under the ROC curve showed the mortality predicting capacity of the SOFA score on day 4 of admission to be 0.703 (95%CI 0.538-0.853; P=.026). The maximum discriminating capacity was recorded for MODS, with an area under the ROC curve of 0.776 (95%CI 0.678-0.874; P=.000). CONCLUSIONS: Organ failure outcome as predicted by the SOFA score showed high precision - the mean SOFA score on day 4 of admission being a good mortality predictor. MODS was the main cause of death, while central nervous system, renal and respiratory failure were identified as the mortality risk factors.

Validación de dos escalas de valor pronóstico en niños que ingresan a UCI / Validation of two prediction value scores in children admitted to the intensive care unit

Las escalas PIM (Índice de Mortalidad Pediátrica) y PELOD (Índice Pediátrico de Disfunción Orgánica) son sistemas de evaluación que permiten la estimación de la severidad de la enfermedad y el ajuste del riesgo de mortalidad en grupos heterogéneos de pacientes. El objetivo del presente trabajo fue el de validar las escalas PIM y PELOD en una Unidad de Cuidados Intensivos pediátrica (UCIP). Metodología. Fueron incluidos 97 niños con edad menor o igual a 12 años; las variables estudiadas fueron la mortalidad o sobrevida durante la estancia en UCI. PIM incluye 7 variables medidas durante la primera hora de admisión a UCI; PELOD incluye disfunción de seis sistemas orgánicos en 12 variables. Para estimar discriminación, se utilizó el área bajo la curva de rendimiento diagnóstico, y para evaluar calibración, la bondad de ajuste de Hosmer-Lemeshow. Resultados. Edad media 4,0 años (rango intercuartil 1,0-8,1); estancia 6,0 días; (rango 3,0 a 17,0); las principales causas de ingreso a UCIP fueron accidentes 30, sepsis 19, neurológicas 14. Desarrollaron disfunción orgánica múltiple 58 (59,8%) de 97. La mortalidad observada fue de 17,5%. La predicción de riesgo de mortalidad por PIM fue significativamente más alta en no sobrevivientes (0,48±0,35) que sobrevivientes (0,18±0,23; t test 3,40 p<0,003); calibración (p=0,025) y discriminación (área bajo la curva = 0,79 ± 0,057; p<0,001) de PIM fue buena. Conclusión: PIM es una medida válida de predicción de riesgo de mortalidad en UCIP en nuestro medio

The Pediatric Index of Mortality (PIM) and Pediatric Logistic Organ Dysfunction (PLOD) scale are scoring systems that allow assessment of the severity of illness and mortality risk adjustment in heterogeneous groups of patients. The aim of this study was to validate the accuracy and reliability of PIM and PELOD scoring in a pediatric Intensive Care Unit (ICU) Methods: 97 children under 12 years of age were included. Survival and mortality during the stay in the ICU were studied. PIM scale includes 7 parameters measured during the first hour of admission to the ICU; PELOD includes dysfunction of 6 organs and systems in 12 variables. The area under the curve was used to assess discrimination and calibration was assessed with the Hosmer-Lemeshow goodness of fit test. Results: The median patient age was 4,0 years (inter-quartile range 1,0-8,1), median length of stay was 6 days (range 3-17). Main causes for admission to the ICU were accidents 30, sepsis 19, neurological 14. Fifty eight patients (59,8%) developed multiple organic dysfunction. Observed mortality was 17,5%. Prediction of risk of mortality with PIM was significantly higher in non survivors (0,48 ± 0,35) than in survivors (0,18 ± 0,23); t test 3,40 p<0,003; calibration (p=0,025) and discrimination (area under the curve = 0,79±0,057; p<0,001) for PIM was good. Conclusions: PIM is a valid prediction index for mortality risk in pediatric ICU in our hospitals

Insuficiencia hepática fulminante debida a golpe de calor

Presentamos un caso de "golpe de calor" (GC) grave complicado de insuficiencia hepática fulminante, admitido a la UCI del Instituto Médico la Floresta (IMLF). Se trataba de una paciente de 14 años de edad que se encontraba realizando ejercicios de montañismo en San Juan de los Morros (Venezuela), en un día de mucho calor y humedad. La paciente presentó en forma brusca un cuadro de convulsiones tónico-clónicas generalizadas e hipertermia, seguido de coma profundo. Durante los días siguientes fue desarrollando falla multiorgánica progresiva caracterizada por insuficiencia renal aguda, coagulación intravascular diseminada (CID) e insuficiencia hepática fulminante (IHF). El tratamiento consistió en asistencia ventilatoria mecánica, corticoesteroides y nutrición enteral. La paciente sobrevivió y recuperó las funciónes hepática, renal, y neurológica después de 3 semanas. Hasta ahora solo han sido reportados 3 casos de IHF secundaria a GC. Este caso ilustra que a pesar de la gravedad de la IHF con falla multiorgánica, la paciente sobrevivió con solo las medidas de soporte vital actualmente disponibles en las UCI.

We present a case of a young female patient, admitted to our ICU with a heat stroke (HS) while she was practicing trekking in San Juan de Los Morros (Venezuela) during a hot day with high humidity. The patient had generalized convulsions and hyperthermia followed by coma. During the following days she presented multiple organ failure, including renal failure, disseminated intravascular coagulation (DIC), and fulminant hepatic failure (FHF). The treatment consisted of mechanical ventilatory assistance, corticosteroids, enteral nutrition and other vital supporting measures in the ICU. Up to now there have been published only three cases of FHF following exertional HS. The patient survived and recovered normal hepatic, renal and neurological function after 3 weeks of conservative treatment. This case of FHF demonstrates that in spite of the severity of the FHF and multiple organ failure, the patient survived only with the supporting measures currently available in the ICU.