Objectives: It is currently recommended that after return of spontaneous circulation following cardiac arrest, fever should be prevented using TTM through a servo-controlled system. This technology is not yet available in many global settings, where manual physical measures without servo-control is the only option. Our aim was to compare feasibility, safety and quality assurance of servo-controlled system versus no servo-controlled system cooling, TTM protocols for cooling, maintenance and rewarming following return of spontaneous circulation after cardiac arrest in children. Design: Prospective, multicenter, nonrandomized, study. Setting: PICUs of 20 hospitals in South America, Spain, and Italy, 2012–2014. Patients: Under 18 years old with a cardiac arrest longer than 2 minutes, in coma and surviving to PICU admission requiring mechanical ventilation were included. Methods: TTM to 32–34°C was performed by prospectively designed protocol across 20 centers, with either servo-controlled system or no servo-controlled system methods, depending on servo-controlled system availability. We analyzed clinical data, cardiac arrest, temperature, mechanical ventilation duration, length of hospitalization, complications, survival, and neurologic outcomes at 6 months. Primary outcome: feasibility, safety and quality assurance of the cooling technique and secondary outcome: survival and Pediatric Cerebral Performance Category at 6 months. Measurements and Main Results: Seventy patients were recruited, 51 of 70 TTM (72.8%) with servo-controlled system. TTM induction, maintenance, and rewarming were feasible in both groups. Servo-controlled system was more effective than no servo-controlled system in maintaining TTM (69 vs 60%; p = 0.004). Servo-controlled system had fewer temperatures above 38.1°C during the 5 days of TTM (0.1% vs 2.9%; p < 0.001). No differences in mortality, complications, length of mechanical ventilation and of stay, or neurologic sequelae were found between the two groups. Conclusions: TTM protocol (for cooling, maintenance and rewarming) following return of spontaneous circulation after cardiac arrest in children was feasible and safe with both servo-controlled system and no servo-controlled system techniques. Achieving, maintaining, and rewarming within protocol targets were more effective with servo-controlled system versus no servo-controlled system techniques.

OBJECTIVE:To characterize the practices of nutritional support in Latin American and Spanish PICUs.DESIGN:Survey with a questionnaire sent to Latin American Society of Pediatric Intensive Care members.SETTING:PICUs of participant hospitals.PATIENTS:Critically ill children between 1 month and 18 years old.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Forty-seven surveys from 17 countries were analyzed. Sixty-seven percent of PICUs were from university-affiliated hospitals, with a median of 380 admissions/yr. Sixty-eight percent and 48.9% had a nutritional support team and nutritional support protocol, respectively. Seventy-five percent completed nutritional evaluations, with 34.2% at admission. PICUs with high-volume admissions were likely to have a nutritional support team (p < 0.005), and university-affiliated hospitals showed a trend of having a nutritional support team (p = 0.056). Measured, estimated, and ideal weights were used in 75%, 14.6%, and 10.4%, respectively. Energy requirements were calculated using Holliday & Segar and Schofield equations in 90% of the PICUs; 43% used correction factors. Only three PICUs had indirect calorimetry. At day 3 of initiation of nutritional support, 57.3% of PICUs provided at least 50% of the calculated energy requirement, and 91.5% at day 5. Protein needs were estimated according to American Society for Parenteral and Enteral Nutrition and European Society for Clinical Nutrition and Metabolism/European Society for Paediatric Gastroenterology Hepatology and Nutrition guidelines in 55.3% and 40.4%, respectively. Enteral nutrition was the preferred feeding method, initiated in 97.7% at 48 hours. The feeding route was gastric (82.9%), by bolus (42.5%) or continuous (57.4%). Monitoring methods included gastric residual measurement in 55.3%. Enteral nutrition was discontinued in 82.8% when gastric residual was 50% of the volume. Prokinetics were used in 68%. More than half of PICUs used parenteral nutrition, with 95.8% of them within 72 hours. Parenteral nutrition was administered by central vein in 93.6%. Undernourished children received parenteral nutrition sooner, whether or not enteral nutrition intolerance was present. When enteral nutrition was not tolerated beyond 72 hours, parenteral nutrition was started in 57.4%. Parenteral nutrition was initiated when enteral nutrition delivered less than 50% in 97%.CONCLUSIONS:Nutritional practices are heterogeneous in Latin American PICUs, but the majority use nutritional support strategies consistent with international guidelines.

Introduction:  The aim of this study is to calculate the theoretical frequency of potential drug interactions (PDI) and their characteristics in the therapeutic plan of hospitalized patients in a Pediatric Intensive Care Unit (PICU).  Patients and Methods:  An observational study was conducted which analyzed PICU prescriptions between September and November 2011. The inclusion criteria included to be hospitalized in a PICU, requirements of at least 3 drugs, except those topically applied, either gender, no age limit, no hospital stay required. The Micromedex ® 2.0 program was used to detect and classify PDI.  Results:  Of 223 patients, 100 met inclusion criteria, 610 prescriptions were analyzed and 815 drugs were prescribed. 1,240 PDI were detected in 44 patients; 12 patients received more than 10 drugs each, presenting 1,162 PDI (93.7% of total PDI). 8 patients were hospitalized for more than 10 days, presenting 1,035 PDI (83.5% of total PDI). According to PDI theoretical severity, 37.5% were high, 51.7% moderate, 6.7% low and 4.1% contraindicated. The therapeutic group most involved was antimicrobials (17.6%) and the most frequently involved individual drugs were chloral hydrate (15.9%), midazolam (14.1%) and vecuronium (13.4%).  Conclusion:  PDI were more frequent in patients associated with major polypharmacy and longer hospital stay.

Para muchos la primera reanimacion boca-boca descrita en la historia de la humanidad aparece en el libro segundo de los Reyes de la Biblia, donde se relata la reanimacion de un nino Sunamita por parte del profeta Eliseo, fechada aproximadamente alrededor del ano 700 A.C. “El profeta se subio a la cama y se acosto sobre el nino colocando su boca, ojos y sus manos contra las del nino y estrechando su cuerpo contra el suyo y lo hizo mas de una vez, y el nino fue adquiriendo color y estornudo 7 veces.” Hubo de pasar muchisimo tiempo en la his-toria de la humanidad, antes de que los prime-ros ejemplos de unidades de cuidados intensi-vos (UCI) en el mundo aparecieran. Recien en 1854 durante la guerra de Crimea en la que In-glaterra, Francia y Turquia declararon la gue-rra a Rusia, aparece la experiencia de Florence Nightingale y mas de 38 voluntarios capacita-dos por ella, que se dedicaron a atender a los soldados heridos en una unidad de pacientes graves disenada por esta enfermera y escritora, logrando bajar la mortalidad desde un 40% a tan solo un 2%.Posteriormente, en EE.UU., Walter Edward Dandy, quien fuera un pionero de las opera-ciones neuroquirurgicas, observo la necesidad de controlar el despertar de la anestesia en los pacientes quirurgicos, lo que lo motivo a im-pulsar la creacion de salas adyacentes a los pa-bellones quirurgicos, denominadas “recovery rooms”. Fundo asi la primera UCI de recupera-cion de anestesia de la que se tenga referencia, en el hospital John Hopkins en Baltimore en 1920.El desarrollo consecuente de estas unidades estuvo asociado al avance paralelo de la ciru-gia y la anestesiologia, que experimentaban grandes progresos en los campos de la cardio-cirugia e intervenciones de torax. No fue sino hasta la decada de los 50 en que se produje-ron las epidemias de poliomielitis que se vio un desarrollo aparte de estas unidades para la atencion de pacientes con insuficiencia respira-toria, y que tratados en ventiladores a presion negativa intermitente dentro de un recipiente metalico (pulmon de acero) presentaban una mortalidad cercana al 90%. Fue asi como en 1952, el Dr. Bjorn Ibsen, un anestesista danes, decidio tratar estos pacientes con traqueotomia infralaringea y Ventilacion a Presion Positiva manual con bolsa de resucitacion. Con este nuevo metodo, se logro un descenso de la mor-talidad al 45%. Al mismo tiempo, Ibsen pudo objetivar los beneficios de tener en forma per-manente un area especifica dotada de personal entrenado y multidisciplinario para el manejo adecuado de los pacientes criticos. De esta for-ma logro establecer la primera UCI general en el Hospital Kommune (Copenhagen) en 1954. Cabe destacar que el “personal entrenado” al que recurrio inicialmente el Dr. Ibsen, fueron estudiantes de medicina y monjas, quienes ad-

Acute liver failure (ALF) due to Epstein Barr Virus (EBV) is rare in immunocompetent patients. The role of steroids in this case is not well defined and remains controversial. Case report: 7 years old female presenting with unspecific respiratory symptoms for 2 weeks, fever, lymphadenopathy, jaundice and dark brown urine. Total bilirubin: 9 and direct: 6.3, alkaline phosphatases: 523; AST: 7.527, ALT: 6.537; Prothrombin (PT): 17%, INR: 4.7; ammonium 510 and glucose 33. Abdominal ultrasound: normal liver and splenomegaly. Monotest Positive. She was transferred to a liver transplant centre (LT). Lab results at admission: PT 21%, bilirubin 9.8, AST 2717, ALT 3.716 and ammonium 177. EEG with diffuse and slowing conductivity consistent with encephalopathy. Positive IgM EBV, other aetiologies were ruled out. She was activated for LT due to ALF and while in waiting list methylprednisolone was administered for 5 days. She evolved with normalization of liver tests and clinical improvement. Conclusion: In this case the use of steroids was associated with a rapid and favourable clinical and laboratory response without negative side effects. As in other presentations of serious infection by EBV, should consider the use of steroids in ALF due to EBV.

La falla hepatica fulminante (FHF) debida a Virus Epstein Barr (VEB) es poco frecuente en inmunocompetentes. La utilidad de los esteroides en este cuadro no ha sido definida y permanece muy controversial. Objetivo: Reportar el caso de una paciente con mononucleosis infecciosa por VEB que presenta FHF y es tratada con corticoides. Caso clinico: Escolar con cuadro de 2 sem de sintomas respiratorios altos, fiebre, adenopatias, con ictericia y orina oscura. Bilirrubina total: 9; B. Directa: 6,3; Fosfatasas Alcalinas: 523; GOT: 7.527; GPT: 6.537; Protrombina (PT): 17%; INR: 4,7; Amonio 510 y glicemia 33. Ecografia abdominal higado normal y esplenomegalia. Monotest Positivo. Se transfirio a centro de trasplante hepatico (TH). Laboratorio de ingreso PT 21%; bilirrubina en 9,8; GOT 2717; GPT 3716 y amonio 177. EEG con enlentecimiento difuso compatible con encefalopatia grado 1. IgM VEB positiva, descartandose otras etiologias. Se activo para TH por FHF y mientras se administro Metilprednisolona por 5 dias. Evoluciono con normalizacion de las pruebas hepaticas y mejoria clinica. Conclusion: En este caso el uso de esteroides se asocio a una rapida y favorable respuesta tanto clinica como de laboratorio sin presentar efectos secundarios negativos. Al igual que en otras presentaciones de infeccion grave por VEB, debiera considerarse el uso de esteroides en FHF por VEB.

Rational Use of Corticoids in a Patient with Septic ShockIntroduction: Septic shock (SS) is a significant cause of mortality in NICUs.Objective: Review current knowledge on Hypothalamic-Pituitary-Adrenal Axis (HPA) and the scientific support for the use of glucocorticoids in the use of this clinical picture.We know that The patient's ability to evolve into improvement or worsening depends upon the ability of the HPA axis to develop and sustain an adequate response to the stress provoked by SS.In some patients, due to many reasons, the prolongation of SS leads to a deficit of cortisol that results in functional acute adrenal insufficiency.Cortisol levels do not respond to ACTH stimulation test.There is no consensus among authors as to what is a normal concentration of cortisol during stress, or even if it is correlated with death among children with SS.The American College of Critical Care Medicine guidelines for SS in Pediatrics and Neonatology have made some recommendations for use of hydrocortisone.

Acute liver failure in children. Experience of a liver transplant centerBackground: Acute liver failure (ALF) in childhood is defined as biochemical evidence of liver injury, absence of known chronic liver disease and coagulopathy not corrected by vitamin K administration, with INR greater than 1.5 if the patient has encephalopathy or greater than 2.0 if the patient does not have encephalopathy.Objective: Report the experience of a single liver transplant center (LT) in the treatment of 8 children with ALF and review the literature.Method: Retrospective review of clinical charts of patients with ALF.Results: The median age was 8 years-old (range 0-11), three females.Five patients underwent LT.Two patients died, one of them LT.The etiologies were 4 undetermined, 1 autoimmune, 1 Wilson Disease, 1 Parvovirus and 1 chronic graft rejection.All grafts were from cadaver donor, 3 of them reduced.Two out of five patients with encephalopathy grade III-IV died.The one year survival rate was 75%.Conclusions: Children with ALF should be treated in experienced centers with facilities for liver transplant.Transplantation should be offered only if the underlying disease is treatable by liver replacement and if transplant prognosis is better than that of the underlying disease.

Background: Acute liver failure (ALF) in childhood is defined as biochemical evidence of liver injury, absence of known chronic liver disease and coagulopathy not corrected by vitamin K administration, with INR greater than 1.5 if the patient has encephalopathy or greater than 2.0 if the patient does not have encephalopathy. Objective: Report the experience of a single liver transplant center (LT) in the treatment of 8 children with ALF and review the literature. Method: Retrospective review of clinical charts of patients with ALF. Results: The median age was 8 years-old (range 0-11), three females. Five patients underwent LT. Two patients died, one of them LT. The etiologies were 4 undetermined, 1 autoimmune, 1 Wilson Disease, 1 Parvovirus and 1 chronic graft rejection. All grafts were from cadaver donor, 3 of them reduced. two out of five patients with encephalopathy grade III-IV died. The one year survival rate was 75%. Conclusions: Children with ALF should be treated in experienced centers with facilities for liver transplant. Transplantation should be offered only if the underlying disease is treatable by liver replacement and if transplant prognosis is better than that of the underlying disease.

BACKGROUND:Sirolimus (SRL) is an immunosuppressive drug increasingly used in children undergoing solid organ transplantation. SRL does not cause glucose intolerance, hypertension, nephrotoxicity or neurotoxicity offering significant potential advantages over calceneurin inhibitors (CM).AIM:To report five children treated with SRL.MATERIAL AND METHODS:A retrospective review of four children undergoing orthotopic liver transplantation (OLT) and one undergoing renal transplantation with recurrent acute rejection (RAR), chronic rejection (CR) or toxicity due to CM, treated with SRL between June 2001 and November 2006.RESULTS:As primary immunosuppressive therapy, all patients received 3 drugs: CM (Tacrolimus (FK) or Cyclosporine), mycophenolate mofetil and steroids. Mean age at treatment with SRL was 98 months. Children undergoing OLT had a late introduction of SRL (mean time after OLT: 37 months), and mean follow-up was 24 months. In this group rescue indications of SRL were RAR in one, CR in one, thrombotic thrombocytopenic purpura (TTP) in one, food allergy in one and other CM toxicity in three. Only one did not experience adverse events due to SRL, but no one required discontinuation of SRL. There were remissions of RAR, CR, TTP and food allergy. The patient with RT was switched from FK to SRL at day 18th after RT, but he had severe neutropenia that led to discontinuation of SRL.CONCLUSIONS:SRL may be useful in pediatric solid organ transplant recipients suffering from RAR, CR, TTP, food allergy and CM toxicity. Careful attention should be directed to detect side effects and avoid severe complications.

Traumatic brain injury (TBI) is one of the most frequent causes of mortality in childhood. The treatment of patients with severe TBI is directed to prevention, early detection and treatment of secondary injuries due to extra and/or intracranial etiologies. Brain ischemia is a central cause of brain damage and its prevention has become a primary goal for intensivists. New techniques have developed to detect brain ischemia directly bedside the patient, through the monitoring of oxygen tissue pressure (P ti O 2 ). Our objective is to report 2 pediatric patients with severe TBI and P ti O 2 monitoring, in order to ilustrate the possibility that offers this technique in early detection of brain ischemia and review the current literature. We analyzed the clinical records of the patients with coma Glasgow score below 8. The intracranial pressure and P ti O 2 monitoring was made through a catheter implanted in the encephalic matter. The device allowed early detection of secondary injuries and an optimal therapeutic approach in the patients, both with good outcome at discharge. The P ti O 2 monitoring showed high safety and reliability.

Background: In 2001, dutch researchers reported a new virus able to cause high and low acute respiratory infection (ARI) in children. It belongs to the Paramyxoviridae family and constitutes the first human pathogen in the genus Metapneumovirus: human Metapneumovirus (hMPV). Objective: Report a retrospective review of 4 infants with hMPV low ARI with severe respiratory failure, admitted in Pediatric Intensive Care Unit between November 2005 and September 2006 and review the literature. Patients and Methods: Common respiratory virus and Bordetella pertussis were ruled out. Polymerase chain reaction was performed to detect the fusion protein(f)of hMPV and Adenovirus cellular culture. Results: All 4 cases had obstructive bronchial syndrome (OBS), 3 required invasive mechanical ventilation and 2 cases presented spontaneous pneumotorax. Co-infection with Adenovirus was detected in 2 cases. Bacterial cultures were negative. No patients died. Conclusion: hMPV must be suspected in infants with severe acute respiratory failure. The co-infection with Adenovirus must be ruled out.

Massive acute hydrothorax (MAH) is a severe and unusual noninfectious complication of peritoneal dialysis (PD). It can lead to acute respiratory failure and may diminish the effectiveness of the dialytic therapy. Many therapeutic strategies for this complication are employed, ranging from conservative methods like reduction of the volume of the dialysate and the transitory interruption of the PD, to more aggressive therapies as the closure of diaphragmatic defects by videothoracoscopy with or without pleurodesis. Herein, we report a two years old girl that developed acute renal failure due to an hemolytic uremic syndrome. She underwent PD and developed MAH PD was temporarily ceased and continuous veno-venous hemofiltration, was started. After 8 days, PD was resumed uneventfully. The temporary interruption of the PD was an effective measure to avoid the recurrence of the MAH.

Massive acute hydrothorax secondary to peritoneal dialysis in a hemolytic uremic syndrome. Report of one caseMassive acute hydrothorax (MAH) is a severe and unusual noninfectious complication of peritoneal dialysis (PD).It can lead to acute respiratory failure and may diminish the effectiveness of the dialytic therapy.Many therapeutic strategies for this complication are employed, ranging from conservative methods like reduction of the volume of the dialysate and the transitory interruption of the PD, to more aggressive therapies as the closure of diaphragmatic defects by videothoracoscopy with or without pleurodesis.Herein, we report a two years old girl that developed acute renal failure due to an hemolytic uremic syndrome.She underwent PD and developed MAH.PD was temporarily ceased and continuous veno-venous hemofiltration was started.After 8 days, PD was resumed uneventfully.The temporary interruption of the PD was an effective measure to avoid the recurrence of the MAH (Rev Méd Chile 2006; 134: 91-4).

Introduccion: La infeccion por parvovirus humano B19 (PHB 19) produce un amplio rango de enfermedades que van desde eritema infeccioso en ninos hasta artritis aguda en adultos. Algunos estudios sugieren un rol patogenico del PHB 19 en el desarrollo de la hepatitis aguda (HA) y falla hepatica fulminante (FHF) en ninos y adultos. La Anemia aplastica (AA) es una complicacion reconocida de la HA y FHF por PHB 19. Objetivo: Reportar un caso de FHF por infeccion por PHB 19 y revisar la literatura. Caso clinico: Nina de 7 anos de edad con HA que en una semana desarrollo FHF con serologia IgM anti-PHB 19 positiva. Otras causas virales, autoinmunes, metabolicas o toxicas fueron descartadas. Fue sometida a trasplante hepatico ortotopico (THO) y un ano despues no ha presentado complicaciones. Conclusiones: El PHB 19 puede causar HA y FHF, su oportuno diagnostico y tratamiento, que en el caso de la FHF incluye el THO puede resultar en un pronostico favorable