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Central vascular cannulation is not a risk-free procedure, especially in pediatric patients. Newborn and infants are small and low-weighted, their vascular structures have high mobility because of tissue laxity and their vessels are superficial and with small diameter. These characteristics, together with the natural anatomical variability and poor collaboration of small children, make this technique more difficult to apply. Therefore, ultrasound imaging is increasingly being used to locate vessels and guide vascular access in this population. Objective (a) To present a model that simulates the vascular system for training ultrasound-guided vascular access in pediatrics patients; (b) to ultrasound-guided vascular cannulation in the model. Results The model consisted of two components: (a) muscular component: avian muscle, (b) vascular component: elastic tube-like structure filled with fluid. 864 ecoguided punctures was realized in the model at different vessel depth and gauge measures were simulated, for two medical operators with different degree of experience. The average depth and diameter of vessel cannulated were 1.16 (0.42) cm and 0.43 (0.1) cm, respectively. The average number of attempts was of 1.22 (0.62). The percentage of visualization of the needle was 74%. The most frequent maneuver used for the correct location, was the modification of the angle of the needle and the relocation of the guidewire in 24% of the cases. The average time for the correct cannulations was 41 (35.8) s. The more frequent complications were the vascular perforation (11.9%) and the correct vascular puncture without possibility of introducing the guidewire (1.2%). The rate of success was 96%. Conclusions The model simulates the anatomy (vascular and muscular structures) of a pediatric patient. It is cheap models, easily reproducible and a useful tool for training in ultrasound-guided puncture and cannulation.

Objetivo: Describir las características epidemiológicas, clínicas y evolutivas de los pacientes pediátricos con traumatismo craneoencefálico grave (TCEG). Material y método: Revisión de los pacientes ingresados en una unidad de medicina intensiva pediátrica (UMIP) con TCEG en el periodo comprendido entre julio de 1983 y diciembre de 2009. Resultados: De los 389 pacientes con traumatismo craneoencefálico (TCE) ingresados en nuestra unidad durante el periodo de estudio, presentaron TCEG 174 (45%). La media de edad de este grupo fue 67±9 meses, con una puntuación media en la escala de Glasgow (GCS) de 5,5±1,8 y una puntuación PRISM media de 10,7±6,7. La etiología más frecuente de los TCEG fueron los accidentes de tráfico (56%), aunque en la última década existe una disminución significativa de su incidencia (el 58,5 frente al 45,3%; p

Objetivo: Describir los factores asociados a la morbilidad y mortalidad de los pacientes pediátricos con traumatismo craneoencefálico grave (TCEG). Material y método: Revisión de los pacientes ingresados en una unidad de medicina intensiva pediátrica (UMIP) con TCEG en el periodo comprendido entre julio de 1983 y diciembre de 2009. Resultados: De los 389 pacientes con TCE ingresados en nuestra unidad durante el periodo de estudio, presentaron TCEG 174 (45%). La edad media de este grupo fue de 67±9 meses, con una puntuación media en la escala de Glasgow (GCS) de 5,5±1,8 y una puntuación PRISM media de 10,6±6,7. El 39% de los pacientes presentaron lesión encefálica difusa (LED) grave en la TAC. Un 79% de los pacientes en los que se monitorizó la presión intracraneal (PIC) presentaron hipertensión intracraneal (HIC). Estos pacientes tuvieron una mayor incidencia de secuelas graves que aquellos que no desarrollaron HIC (66,7 vs 23,1%; p=0,01). Las secuelas de relevancia clínica se encontraron en 59 pacientes (34%), y fueron graves en el 64% de los mismos. La mortalidad de los pacientes con TCEG fue de un 25% y se asoció de forma significativa a una menor puntuación del GCS, a la existencia de hiperglucemia o HIC, a la presencia de midriasis o shock y a la necesidad de ventilación mecánica. La mortalidad de la LED grave fue significativamente más elevada que la LED leve-moderada (87,5 vs 7,2%; p

Objetivo. Valorar la seguridad y efectividad de un protocolo de sedoanalgesia para procedimientos invasivos en pacientes pediátricos. Diseño. Estudio prospectivo observacional. Ámbito. Una unidad de medicina intensiva pediátrica (UMIP) de un hospital de tercer nivel. Pacientes. 110 niños sometidos a procedimientos invasivos bajo sedoanalgesia durante un período de 3 años. Intervenciones. Se aplicó un protocolo de sedoanalgesia para los procedimientos invasivos con: fentanilo (1-2 mcg/kg con dosis máxima de 100 mcg para la primera dosis y 50 mcg para siguientes) y propofol (1-2 mg/kg con dosis máxima de 100 mg para la primera dosis y 50 mg para las siguientes). El objetivo fue alcanzar un grado III-IV en la escala de Ramsay modificada y amnesia del procedimiento. Variables principales. a) Los tiempos hasta: sedoanalgesia, recuperación, duración del procedimiento y estancia en la unidad de Medicina Intensiva Pediátrica; b) dosis medias de los fármacos administrados; c) grado de sedoanalgesia y amnesia y d) efectos adversos. Resultados. Se realizaron 500 sedoanalgesias para 634 procedimientos a 110 niños. La patología más frecuente fue la onco-hematológica (91%), siendo la punción lumbar con tratamiento intratecal el procedimiento más realizado: (48,5%). No recordaron el mismo el 96,8% de los pacientes, consiguiéndose sedoanalgesia óptima en el 93,4%. Estos pacientes, respecto a aquellos con un menor grado de sedoanalgesia, presentaron un descenso de la presión arterial sistólica (88 ± 19 frente a 98 ± 14 mmHg; p < 0,001), de la frecuencia cardíaca (88 ± 17 frente a 91 ± 25 lpm; p < 0,05) y de la frecuencia respiratoria (19 ± 6 frente a 23 ± 11 respiraciones por minuto; p < 0,05). El tiempo medio hasta la sedoanalgesia fue de 4,62 ± 3,69 minutos y el tiempo de estancia en la UMIP fue de 41,8 ± 19 minutos. La incidencia de complicaciones fue del 6,6% (apnea, hipotensión, bradicardia), resolviéndose éstas con ventilación manual y/o expansión de volumen. Conclusiones. El protocolo de sedoanalgesia para procedimientos invasivos consiguió una sedoanalgesia óptima con amnesia del procedimiento en la casi totalidad de los casos. La monitorización y las medidas de estabilización permitieron el control de las complicaciones presentadas. Objective. Apply a sedoanalgesic (SA) protocol for invasive procedures (PI) in pediatric patients and evaluate its effectiveness and safety. Design. Prospective observational study. Scope. Pediatric Intensive Care Unit (PICU) of third level hospital. Patients. A total of 110 children subjected to invasive procedures under sedoanalgesia with propofol and fentanyl. Intervention. Sedoanalgesic protocol for invasive procedure was applied with: fentanyl (1-2 mcg/kg with maximum dose of 100 mcg for first dose and 50 mcg for the next) and propofol (1-2 mg/kg with maximum of 100 mg for first dose and 50 mg for the next). The objective was to reach III-IV sedoanalgesic grade for modified Ramsay scale and amnesia related to invasive procedure. Main endpoints. a) time to sedoanalgesia and recovery, length for invasive procedure and stay in the Pediatric Intensive Care Unit; b) mean dose of drug; c) sedoanalgesic grade and amnesia related to invasive procedure and d) adverse events. Results. Five hundreds SA were made for 634 IP in 110 children. The most common conditions were oncohematologics (91%), the spinal tap for intrathecal treatment was the most frequent IP (48.5%). Most of the patients (96.8%) did not recall the procedure and an optimum SA was obtained in 93.4%. Patients profoundly sedated presented a significant fall of systolic arterial pressure (88 ± 19 vs 98 ± 14 mmHg, p < 0.001) compared to those with minor SA level, as well as heart rate (88 ± 17 vs 91 ± 25 bpm, p < 0.05) and respiratory rate (19 ± 6 vs 23 ± 11 bpm, p < 0.05). Mean time to reach adequate sedation was 4.62 ± 3.69 minutes and stay time in PICU 41.8 ± 19. Complication incidence was 6.6% (apnea, hypotension, bradycardia), these were resolved with manual ventilation and/or volume expansion. Conclusions. SA protocol reached its goal of: a) effectiveness: SA achieved was optimal, with amnesia of the procedure in almost all patients and b) safety: complications were controlled due to monitorization and stabilization measurements.

Noninvasive ventilation (NIV) with conventional therapy improves the outcome of patients with acute respiratory failure due to hypercapnic decompensation of chronic obstructive pulmonary disease (COPD) or acute cardiogenic pulmonary edema (ACPE). This review summarizes the main effects of NIV in these pathologies. In COPD, NIV improves gas exchange and symptoms, reducing the need for endotracheal intubation, hospital mortality and hospital stay compared with conventional oxygen therapy. NIV may also avoid reintubation and may decrease the length of invasive mechanical ventilation. In ACPE, NIV accelerates the remission of symptoms and the normalization of blood gas parameters, reduces the need for endotracheal intubation, and is associated with a trend towards lesser mortality, without increasing the incidence of myocardial infarction. The ventilation modality used in ACPE does not affect the patient prognosis.

To describe the factors associated to morbidity-mortality in pediatric patients with severe head injury (SHI).A review was made of the patients admitted to the Pediatric Intensive Care Unit (PICU) with SHI between July 1983 and December 2009.Of the 389 patients with head injuries, 174 (45%) presented SHI. The mean age of these subjects was 67 (9) months, with a Glasgow Coma Score (GCS) of 5.5 (1.8) and a PRISM score of 10.6 (6.7). Thirty-nine percent of the patients showed diffuse encephalic injury (DEI) in the computed tomography (CT) study. Seventy-nine percent of the patients subjected to intracranial pressure monitoring (ICP) presented intracranial hypertension. These patients had a greater incidence of serious sequelae (66.7 vs. 23.1%; p=0.01). Sequelae of clinical relevance were recorded in 59 patients (34%), and proved serious in 64% of the cases. The mortality rate among the patients with SHI was 24.7%, and mortality was significantly associated with a lower GCS score, hyperglycemia, intracranial hypertension and the presence of mydriasis or shock. The mortality rate associated to severe DEI was significantly higher than in the case of mild-moderate DEI (87.5 vs. 7.2%; p0.001). The independent mortality risk factors in the pediatric patients with SHI were found to be the presence of mydriasis (OR: 31.27), intracranial hypertension (OR: 13.23) and hyperglycemia (OR: 3.10).a) SHI in pediatric patients was associated with high morbidity-mortality; b) intracranial hypertension was associated to the development of serious sequelae; c) independent mortality risk factors were the existence of mydriasis, intracranial hypertension and hyperglycemia.

To describe the epidemiology, clinical manifestations and evolutive characteristics of pediatric patients with severe head injury (SHI).A review was made of the patients admitted to the pediatric intensive care unit (PICU) with SHI between July 1983 and December 2009.Of the 389 patients with head injuries admitted to the PICU during the study period, 174 (45%) presented SHI. The mean age in this group was of 67±9 months, with a Glasgow Coma Score (GCS) of 5.5±1.8 and a PRISM score of 10.7±6.7. The most frequent etiology of SHI was traffic accidents (56%), though these have decreased significantly in the last decade (58.5% vs 45.3%; P.001). Twenty-one percent of the patients required evacuation of the lesions detected by computed tomography (CT), and 39% presented severe diffuse encephalic injury (DEI). Seventy-nine percent of the patients in whom intracranial pressure (ICP) was monitored presented intracranial hypertension. Sequelae of clinical relevance were recorded in 59 patients (39%), and proved serious in 64% of the cases. The mortality rate in this patient series was 24.7%. Intracranial hypertension decreased significantly in the last decade (88% vs 54%; P.05), and clinical recovery has improved (23.3% vs 63.1%; P.001).a) The incidence of traffic accidents has decreased in the last decade in the studied population; b) patients with SHI in which ICP was monitored showed a high incidence of intracranial hypertension; c) morbidity-mortality among pediatric patients with SHI has decreased over the course of the study period.

Apply a sedoanalgesic (SA) protocol for invasive procedures (PI) in pediatric patients and evaluate its effectiveness and safety.Prospective observational study.Pediatric Intensive Care Unit (PICU) of third level hospital.A total of 110 children subjected to invasive procedures under sedoanalgesia with propofol and fentanyl.Sedoanalgesic protocol for invasive procedure was applied with: fentanyl (1-2 mcg/kg with maximum dose of 100 mcg for first dose and 50 mcg for the next) and propofol (1-2 mg/kg with maximum of 100 mg for first dose and 50 mg for the next). The objective was to reach III-IV sedoanalgesic grade for modified Ramsay scale and amnesia related to invasive procedure. MAIN ENDPOINTS: a) time to sedoanalgesia and recovery, length for invasive procedure and stay in the Pediatric Intensive Care Unit; b) mean dose of drug; c) sedoanalgesic grade and amnesia related to invasive procedure and d) adverse events.Five hundreds SA were made for 634 IP in 110 children. The most common conditions were oncohematologics (91%), the spinal tap for intrathecal treatment was the most frequent IP (48.5%). Most of the patients (96.8%) did not recall the procedure and an optimum SA was obtained in 93.4%. Patients profoundly sedated presented a significant fall of systolic arterial pressure (88 +/- 19 vs 98 +/- 14 mmHg, p0.001) compared to those with minor SA level, as well as heart rate (88 +/- 17 vs 91 +/- 25 bpm, p0.05) and respiratory rate (19 +/- 6 vs 23 +/- 11 bpm, p0.05). Mean time to reach adequate sedation was 4.62 +/- 3.69 minutes and stay time in PICU 41.8 +/- 19. Complication incidence was 6.6% (apnea, hypotension, bradycardia), these were resolved with manual ventilation and/or volume expansion.SA protocol reached its goal of: a) effectiveness: SA achieved was optimal, with amnesia of the procedure in almost all patients and b) safety: complications were controlled due to monitorization and stabilization measurements.