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ABSTRACT: OBJECTIVE: The aim of this study was to determine the incidence, characteristics, related factors, and clinical implications of gastroesophageal reflux (GER) in critically ill children using esophageal pH monitoring and multichannel intraluminal impedance. METHODS: A prospective observational clinical study was performed including 36 non-enterally fed critically ill children with mechanical ventilation, aged 1 mo to 7 y, in the first 48 h after admission in the pediatric intensive care unit (PICU). Esophageal pH monitoring and multichannel intraluminal impedance were used. RESULTS: Multichannel intraluminal impedance detected 352 episodes of GER (20.1% acid, 53.8% weak acid, 26% alkaline), whereas pH monitoring detected 171 episodes (100% acid). There were no differences in the type of reflux according to age and no differences in the number or type of reflux according to the administration of inotropic or sedatives drugs or the duration of mechanical ventilation. Patients treated with vecuronium had fewer episodes of GER than those without muscle relaxant drugs. CONCLUSIONS: The incidence of GER in non-enterally fed critically ill children with mechanical ventilation is high in the first 48 h after admission to the PICU. Multichannel intraluminal impedance is more sensitive than pH monitoring for establishing the diagnosis of GER because the refluxate is alkaline or weak acid in the majority of episodes. Patients who received muscle relaxants had a lower frequency of GER.
Nutrition 02/2013; · 3.03 Impact Factor
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ABSTRACT: PURPOSE: To analyze prognostic factors associated with in-hospital cardiac arrest (CA) in children. METHODS: A prospective, multicenter, multinational, observational study was performed on pediatric in-hospital CA in 12 countries and included 502 children between 1 month and 18 years. The primary endpoint was survival at hospital discharge. Univariate and multivariate logistic regression analyses were performed to assess the influence of each factor on mortality. RESULTS: Return of spontaneous circulation was achieved in 69.5 % of patients; 39.2 % survived to hospital discharge and 88.9 % of survivors had good neurological outcome. The pre-arrest factors related to mortality were lower Human Development Index [odds ratio (OR) 2.32, 95 % confidence interval (CI) 1.28-4.21], oncohematologic disease (OR 3.33, 95 % CI 1.60-6.98), and treatment with inotropic drugs at the time of CA (OR 2.35, 95 % CI 1.55-3.56). CA and resuscitation factors related to mortality were CA due to neurological disease (OR 5.19, 95 % CI 1.49-18.73) and duration of cardiopulmonary resuscitation greater than 10 min (OR 4.00, 95 % CI 1.49-18.73). Factors related to survival were CA occurring in the pediatric intensive care unit (PICU) (OR 0.38, 95 % CI 0.16-0.86) and shockable rhythm (OR 0.26, 95 % CI 0.09-0.73). CONCLUSIONS: In-hospital CA in children has a low survival but most of the survivors have a good neurological outcome. Some prognostic risk factors cannot be modified, making it important to focus efforts on improving hospital organization to care for children at risk of CA in the PICU and, in particular, in other hospital areas.
European Journal of Intensive Care Medicine 11/2012; · 5.17 Impact Factor
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ABSTRACT: OBJECTIVE: To compare the effect of 2 doses of intravenous omeprazole on gastric pH, gastrointestinal bleeding, and adverse effects in critically ill children. STUDY DESIGN: We undertook a prospective randomized clinical trial in critically ill children at risk of gastrointestinal bleeding. The effect of 2 intravenous omeprazole regimens (0.5 or 1 mg/kg every 12 hours) on the gastric pH and incidence of gastrointestinal hemorrhage was compared. The efficacy criteria were a gastric pH >4 and the absence of clinically significant gastrointestinal bleeding. RESULTS: Forty patients, 20 in each treatment group, were studied. Overall, the gastric pH was greater than 4 for 57.8% of the time, with no difference between the doses (P = .66). The percentage of time with a gastric pH > 4 increased during the study (47.8% between 0 and 24 hours vs 76% between 24 and 48 hours, P = .001); the greater dose showed a greater increase in the percentage of time with a pH > 4: between hours 24 and 48 of the study, the gastric pH was greater than 4 for 84.5% of the time with the 1 mg/kg dose and for 65.5% of the time with the 0.5 mg/kg dose (P = .036). Plasma omeprazole levels were greater with 1 mg/kg dose, but no correlation was found between omeprazole plasma levels and gastric pH. No toxic adverse effects were detected, and there was no clinically significant bleeding. CONCLUSION: Neither of the 2 omeprazole regimens achieved adequate alkalinization of the gastric pH during the first 24 hours. Between 24 and 48 hours, the 1 mg/kg dose maintained the gastric pH greater than 4 for a greater percentage of the time.
The Journal of pediatrics 11/2012; · 4.02 Impact Factor
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ABSTRACT: PURPOSE: Arterial hyperoxia after resuscitation has been associated with increased mortality in adults. The aim of this study was to test the hypothesis that post-resuscitation hyperoxia and hypocapnia are associated with increased mortality after resuscitation in pediatric patients. METHODS: We performed a prospective observational multicenter hospital-based study including 223 children aged between 1 month and 18 years who achieved return of spontaneous circulation after in-hospital cardiac arrest and for whom arterial blood gas analysis data were available. RESULTS: After return of spontaneous circulation, 8.5% of patients had hyperoxia (defined as PaO(2)>300mmHg) and 26.5% hypoxia (defined as PaO(2)<60mmHg). No statistical differences in mortality were observed when patients with hyperoxia (52.6%), hypoxia (42.4%), or normoxia (40.7%) (p=0.61). Hypocapnia (defined as PaCO(2)<30mmHg) was observed in 13.5% of patients and hypercapnia (defined as PaCO(2)>50mmHg) in 27.6%. Patients with hypercapnia or hypocapnia had significantly higher mortality (59.0% and 50.0%, respectively) than patients with normocapnia (33.1%) (p=0.002). At 24h after return of spontaneous circulation, neither PaO(2) nor PaCO(2) values were associated with mortality. Multiple logistic regression analysis showed that hypercapnia (OR, 3.27; 95% CI, 1.62-6.61; p=0.001) and hypocapnia (OR, 2.71; 95% CI, 1.04-7.05; p=0.04) after return of spontaneous circulation were significant mortality factors. CONCLUSIONS: In children resuscitated from cardiac arrest, hyperoxemia after return of spontaneous circulation or 24h later was not associated with mortality. On the other hand, hypercapnia and hypocapnia were associated with higher mortality than normocapnia.
Resuscitation 07/2012; · 3.60 Impact Factor
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Critical care medicine 05/2012; 40(5):1646-7. · 6.37 Impact Factor
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ABSTRACT: INTRODUCTION AND OBJECTIVES: To study the clinical course of children requiring continuous renal replacement therapy after cardiac surgery and to analyze factors associated with mortality. METHODS: A prospective observational study was performed that included children requiring continuous renal replacement therapy after cardiac surgery. Univariate and multivariate analyses were performed to determine the influence of each factor on mortality. We compared these patients with other critically ill children requiring continuous renal replacement therapy. RESULTS: Of 1650 children undergoing cardiac surgery, 81 (4.9%) required continuous renal replacement therapy, 65 of whom (80.2%) presented multiple organ failure. The children who started continuous renal replacement therapy after cardiac surgery had lower mean arterial pressure, lower urea and creatinine levels, and higher mortality (43%) than the other children on continuous renal replacement therapy (29%) (P=.05). Factors associated with mortality in the univariate analysis were age less than 12 months, weight under 10 kg, higher pediatric risk of mortality score, hypotension, lower urea and creatinine levels when starting continuous renal replacement therapy, and the use of hemofiltration. In the multivariate analysis, hypotension when starting continuous renal replacement therapy, pediatric risk of mortality scores equal to or greater than 21, and hemofiltration were associated with mortality. CONCLUSIONS: Although only a small percentage of children undergoing cardiac surgery required continuous renal replacement therapy, mortality among these patients was high. Hypotension and severity of illness when starting the technique and hemofiltration were factors associated with higher mortality. Full English text available from: www.revespcardiol.org.
Revista Espa de Cardiologia 04/2012; 65(9):795-800. · 2.53 Impact Factor
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ABSTRACT: Incorrect resuscitation after hypovolemic shock is a major contributor to preventable pediatric death. Several studies have demonstrated that small volumes of hypertonic or hypertonic-hyperoncotic saline can be an effective initial resuscitation solution. However, there are no pediatric studies to recommend their use. The aim of this study is to determine if in an infant animal model of hemorrhagic shock, the use of hypertonic fluids, as opposed to isotonic crystalloids, would improve global hemodynamic and perfusion parameters.
Experimental, randomized animal study including thirty-four 2-to-3-month-old piglets. 30 min after controlled 30 mL kg(-1) bleed, pigs were randomized to receive either normal saline (NS) 30 mL kg(-1) (n=11), 3% hypertonic saline (HS) 15 mL kg(-1) (n=12), or 5% albumin plus 3% hypertonic saline (AHS) 15 mL kg(-1) (n=11).
High baseline heart rate (HR) and low mean arterial pressure (MAP), cardiac index (CI), brain tissue oxygenation index (bTOI), and lactate were recorded 30 min after volume withdrawal, with no significant differences between groups. Thirty minutes after volume replacement there were no significant differences between groups for HR (NS, 188±14; HS, 184±14; AHS, 151±14 bpm); MAP (NS, 80±7; HS, 86±7; AHS, 87±7 mmHg); CI (NS, 4.1±0.4; HS, 3.9±0.4; AHS, 5.1±0.4 mL min(-1)m(-2)); lactate (NS, 2.8±0.7; HS, 2.3±0.6; AHS, 2.4±0.6 mmol L(-1)); bTOI (NS, 43.9±2.2; HS, 40.1±2.5; AHS, 46.1±2.3%).
In this model of hypovolemic shock, hypertonic fluids achieved similar end-points as twice the volume of NS. Animals treated with albumin plus hypertonic saline presented prolonged increase in blood volume parameters and recovery of the oxygen debt.
Resuscitation 03/2012; 83(9):1159-65. · 3.60 Impact Factor
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ABSTRACT: A gastric pH below 4 increases the risk of gastrointestinal hemorrhage in critically ill patients. The pH can be monitored intermittently by testing the gastric aspirate using pH paper or continuously using a pH-meter (often in combination with multichannel intraluminal impedance). The objective of this study was to compare these two methods of pH measurement.
An observational, prospective study was conducted in critically ill children between 1 month and 14 years with at least two risk factors for gastrointestinal hemorrhage. Gastric pH was measured continuously by a multichannel pH-meter tube and every 2 h using pH paper on aspirates of gastric juice.
A total of 471 gastric pH measurements were analyzed. The mean gastric pH measured by the pH-meter was 4.3±2.5 and that by pH paper was 3.9±2.2. The gastric pH was above 4 in 49.6% of the measurements taken on the basis of the gastric aspirate and in 49.8% of the pH-meter readings. The correlation between the two methods was moderate (0.59; P<0.001) but the concordance was low (0.54). The concordance with regard to determining a gastric pH above or below 4 was 77%.
pH paper is a simple and inexpensive method that can be useful for initial patient monitoring, but it should not be used as a substitute for monitoring by pH-meter in patients in whom strict control of the gastric pH is required.
European journal of gastroenterology & hepatology 01/2012; 24(1):33-6. · 1.66 Impact Factor
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ABSTRACT: The mechanism of high-flow oxygen therapy and the pressures reached in the airway have not been defined. We hypothesized that the flow would generate a low continuous positive pressure, and that elevated flow rates in this model could produce moderate pressures. The objective of this study was to analyze the pressure generated by a high-flow oxygen therapy system in an experimental model of the pediatric airway.
An experimental in vitro study was performed. A high-flow oxygen therapy system was connected to 3 types of interface (nasal cannulae, nasal mask, and oronasal mask) and applied to 2 types of pediatric manikin (infant and neonatal). The pressures generated in the circuit, in the airway, and in the pharynx were measured at different flow rates (5, 10, 15, and 20 L/min). The experiment was conducted with and without a leak (mouth sealed and unsealed). Linear regression analyses were performed for each set of measurements.
The pressures generated with the different interfaces were very similar. The maximum pressure recorded was 4 cm H(2)O with a flow of 20 L/min via nasal cannulae or nasal mask. When the mouth of the manikin was held open, the pressures reached in the airway and pharynxes were undetectable. Linear regression analyses showed a similar linear relationship between flow and pressures measured in the pharynx (pressure = -0.375 + 0.138 × flow) and in the airway (pressure = -0.375 + 0.158 × flow) with the closed mouth condition.
According to our hypothesis, high-flow oxygen therapy systems produced a low-level CPAP in an experimental pediatric model, even with the use of very high flow rates. Linear regression analyses showed similar linear relationships between flow and pressures measured in the pharynx and in the airway. This finding suggests that, at least in part, the effects may be due to other mechanisms.
Respiratory care 12/2011; 57(5):721-6. · 2.01 Impact Factor
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Artificial Organs 12/2011; 35(12):1194. · 2.00 Impact Factor
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ABSTRACT: The objective of this study is to describe and analyse the initial experience in paediatric acute renal replacement therapy (ARRT) education by means of specific courses.
Three paediatric ARRT courses were run. The course programme included initial and final multiple-choice question (MCQ) exams, short lectures, practical workshops [in vitro peritoneal dialysis (PD) and continuous renal replacement therapy (CRRT) machines skill stations, real-time PD and CRRT in paediatric animal models and paediatric CRRT advanced simulation scenarios based on real cases) and an anonymous survey on the perceived value of the course (score from 0: very bad to 10: perfect). Number of students per workshop was six to eight. Continuous assessment of participants' performance was done.
In the initial MCQ, only 11% of students answered correctly at least 70% of questions, while in the final test, 90.5% hit this target (P < 0.001). In the performance assessments, all of the students demonstrated sufficient acquisition of practical skills. In the perceived value survey, the course methodology was rated at 9.3, organization 9.9, teaching staff 9.6, lectures 9 and practical sessions 9.1.
Specifically designed CRRT and PD courses are adequate for teaching the theoretical aspects and training these procedures. The combination of laboratory, training with animals and advanced simulation scenarios might have a synergistic effect on learning.
Nephrology Dialysis Transplantation 09/2011; 27(5):1807-11. · 3.40 Impact Factor
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ABSTRACT: Constipation is a common complication in critically ill children and it is occasionally resistant to the drugs typically used in treatment. Neostigmine has been used in some cases of refractory constipation in critically ill adults. There is no reference to its use in critically ill children. We describe 3 cases of refractory constipation in critically ill children treated with intravenous neostigmine by continuous infusion. Two patients responded well. There were no adverse effects. We conclude that continuous intravenous neostigmine can be effective in critically ill children with refractory constipation. Further studies are necessary to determine the dose and safety of the treatment.
Journal of pediatric gastroenterology and nutrition 08/2011; 53(2):224-6. · 2.18 Impact Factor
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ABSTRACT: Bioreactance is a new non-invasive method for cardiac output measurement (NICOM). There are no studies that have analysed the utility of this technique in a pediatric animal model of hemorrhagic shock.
A prospective study was performed using 9 immature Maryland pigs weighing 9 to 12 kg was performed. A Swan-Ganz catheter, a PiCCO catheter and 4 dual surface electrodes were placed at the four corners of the anterior thoracic body surface. Shock was induced by withdrawing a blood volume of 30 mL/kg, and then after, 30 mL/kg of Normal saline was administered. Seven simultaneous measurements of cardiac index (CI) were made by pulmonary artery thermodilution (PATD), Femoral artery thermodilution (FATD), and NICOM before, during, and after hypovolaemia and during and after volume expansion.
The mean difference (bias) of differences (limits of agreement) between PATD and FATD was 0.84 (-1.87-3.51)L/min/1.77 m(2), between PATD and NICOM was 1.95 (-1.79-5.69)L/min/1.77 m(2), and between FATD and NICOM was 1.06 (-1.40-3.52)L/min/1.77 m(2). A moderate correlation was found between PATD and FATD (r=0.43; P=0.01), but no correlation was found between bioreactance and either PATD or FATD. Hypovolemia and volume expansion produced important significant differences in CI as measured by PATD and FATD, while the changes with bioreactance were small and non significant.
PATD and FATD measurements showed similar responses to hypovolemic shock and volume expansion. Bioreactance persistently underestimates the CI and is not significantly altered by either inducing hemorrhagic shock, or later, through volume expansion. Bioreactance is not a suitable method for monitoring the CI in pediatric hemorrhagic shock.
Resuscitation 07/2011; 83(1):125-9. · 3.60 Impact Factor
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Resuscitation 03/2011; 82(6):780; author reply 780-1. · 3.60 Impact Factor
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ABSTRACT: The objective of the present study was to investigate the relationship between energy expenditure (EE), biochemical and anthropometric nutritional status and severity scales in critically ill children. We performed a prospective observational study in forty-six critically ill children. The following variables were recorded before starting nutrition: age, sex, diagnosis, weight, height, risk of mortality according to the Paediatric Risk Score of Mortality (PRISM), the Revised Paediatric Index of Mortality (PIM2) and the Paediatric Logistic Organ Dysfunction (PELOD) scales, laboratory parameters (albumin, total proteins, prealbumin, transferrin, retinol-binding protein, cholesterol and TAG, and nitrogen balance) and EE measured by indirect calorimetry. The results showed that there was no relationship between EE and clinical severity evaluated using the PRISM, PIM2 and PELOD scales or with the anthropometric nutritional status or biochemical alterations. Finally, it was concluded that neither nutritional status nor clinical severity is related to EE. Therefore, EE must be measured individually in each critically ill child using indirect calorimetry.
The British journal of nutrition 03/2011; 105(5):731-7. · 3.45 Impact Factor
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ABSTRACT: To analyze the correlations between hemodynamic, oxygenation and tissue perfusion values in an infant animal model of asphyctic cardiac arrest (ACA).
A prospective observational animal study was performed in seventy one, two month-old piglets. CA was induced by removal of mechanical ventilation and was followed by advanced life support after at least 10 min. Correlations between hemodynamic [heart rate (HR), mean arterial pressure (MAP), cardiac index (CI), stroke volume index (SVI) and intrathoracic blood index (ITBI) measured by PiCCO method], blood gas values (arterial and central venous saturation), and tissue perfusion values [intramucosal gastric pH (pHi), and tissue oxygenation (cerebral and renal saturation)] were analyzed during asphyxia, resuscitation and after return of spontaneous circulation (ROSC).
Among global hemodynamic parameters, the only moderate significant correlation observed was between CI and ITBI (r = .551). Among tissue oxygenation/perfusion values, a moderate to good significant correlation (r = .460-.763) between arterial oxygen saturation, central venous, renal and cerebral oxygen saturation was observed. Lactic acid, potassium (K) and pHi were correlated (r = .561-.639), but no correlation was found between them and tissue oxygenation parameters. Global hemodynamic parameters (CI, HR, MAP) did not correlate with renal and cerebral saturations and tissue perfusion parameters.
During ACA and after ROSC global hemodynamic parameters do not correlate with oxygenation and tissue perfusion values. Additional studies which assess the potential usefulness of tissue oxygenation/perfusion parameters during cardiac arrest and ROSC are needed.
Resuscitation 03/2011; 82(6):755-9. · 3.60 Impact Factor
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ABSTRACT: To compare a standard diet and a protein-enriched diet in critically ill children.
In this prospective randomized controlled trial in critically ill children, all patients received enteral nutrition exclusively and were randomly assigned to a standard diet or a protein-enriched diet (1.1 g protein/100 mL of feeding formula). Blood and urine tests, nitrogen balance assessment, and energy expenditure testing by indirect calorimetry were performed before the beginning of the nutrition regimen and at 24 hours, 72 hours, and 5 days after initiation. Demographic data and pediatric mortality risk scores were recorded.
Fifty-one children were randomized, and 41 completed the study. Of these, 21 patients received standard formula and 20 received a protein-enriched formula. There were no between-group differences in terms age, sex, diagnosis, or mortality risk scores. There was a greater positive trend in levels of prealbumin, transferrin, retinol-binding protein, and total protein in the protein-enriched diet group. These differences were significant only for retinol-binding protein. The positive nitrogen balance trend was also higher in the protein-enriched diet group; however, this difference did not reach statistical significance. No adverse effects or hyperproteinemia were detected in the protein-enriched diet group.
The standard diet provides insufficient protein delivery to critically ill children. Enteral protein supplementation is safe and can improve some biochemical parameters of protein metabolism.
The Journal of pediatrics 03/2011; 159(1):27-32.e1. · 4.02 Impact Factor
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ABSTRACT: The objective of this study was to evaluate a new bioreactance method for noninvasive cardiac output (CO) measurement (NICOM) in children. Ten patients between 1 and 144 months of age and with no hemodynamic disturbances were studied. Using bioreactance, heart rate (HR), mean arterial pressure (MAP), and cardiac index (CI) measurements were made every 6-8 h. CI was 2.4 ± 1.03 l/min/1.73 m(2) (range 1-4.9 l/min/1.73 m(2)); There were significant correlations between CI and age (r = 0.50, P = 0.003), weight (r = 0.66, P < 0.001), and MAP (r = 0.369, P = 0.037). Significant differences in CI (P < 0.001) were detected between children weighing <10 kg (1.9 ± 0.73 l/min/1.73 m(2); range 1-3.2), 10-20 kg (2.07 ± 0.7 l/min/1.73 m(2); range 1-3.6), and >20 kg (3.7 ± 0.8 l/min/1.73 m(2); range 2.4-4.9). We conclude that the CI measured by bioreactance in children varies with the age and weight of the patients and is lower than the normal range in a large percentage of measurements. These data suggest that this method is not useful for evaluating CI in small children.
Pediatric Cardiology 02/2011; 32(4):469-72. · 1.30 Impact Factor
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ABSTRACT: The incidence of hypophosphatemia is high in critically ill children on continuous renal replacement therapy (CRRT) and the addition of phosphate supplements to the replacement and dialysis fluids reduces the frequency of hypophosphatemia. The objective of this study was to determine the in vitro stability of the CRRT solutions after phosphate addition. Three different concentrations of phosphate, 2.5, 4.6 and 7.7 mg/dL, in the replacement and dialysis fluids were analyzed. The pH, glucose, total calcium, phosphate, and magnesium were determined before adding the phosphate and at 2, 24, and 48 h after its addition. The bags were macroscopically observed for possible precipitation. After addition of the phosphate, its concentration remained stable and there were no significant changes in the concentrations of the other components. There were no visible signs of precipitation up to 48 h. The addition of phosphate to the CRRT fluids at concentrations of up to 7.7 mg/dL does not cause problems with precipitation or instability of the mixture.
Therapeutic apheresis and dialysis: official peer-reviewed journal of the International Society for Apheresis, the Japanese Society for Apheresis, the Japanese Society for Dialysis Therapy 02/2011; 15(1):75-80. · 1.39 Impact Factor
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ABSTRACT: Study the influence of hypotonic (HT) and isotonic (IT) maintenance fluids in the incidence of dysnatraemias in critically ill children.
Prospective, randomized study conducted in three paediatric intensive care units (PICU). One hundred and twenty-five children requiring maintenance fluid therapy were included: 62 received HT fluids (50-70 mmol/L tonicity) and 63 IT fluids (156 mmol/L tonicity). Age, weight, cause of admission, sodium and fluid intake, and diuresis were collected. Blood electrolytes were measured on admission, 12 and 24 h later.
Blood sodium levels at 12 h were 133.7±2.7 mmol/L in HT group vs. 136.8±3.5 mmol/L in IT group (p=0.001). Adjusted for age, weight and sodium level at PICU admission, the blood sodium values of patients receiving HT fluids decrease by 3.22 mmol/L (CI: 4.29/2.15)(p=0.000). Adjusted for age, weight and hyponatraemia incidence at admission, patients receiving HT fluids increased the risk of hyponatraemia by 5.8-fold (CI: 2.4-14.0) during the study period (p=0.000).
Hypotonic maintenance fluids increase the incidence of hyponatraemia because they decrease blood sodium levels in normonatraemic patients. IT maintenance fluids do not increase the incidence of dysnatraemias and should be considered as the standard maintenance fluids.
Acta Paediatrica 02/2011; 100(8):1138-43. · 2.07 Impact Factor
