Simulador de Técnicas de Depuração Extra-Renal/Hemofiltração: Uso da Simulação para Treino no Manuseamento deste Dispositivo

Introdução: A simulação possibilita o ensino e treino de técnicas de suporte de vida complexas sem riscos para o doente. Até ao momento, as únicas opções de treino no manuseamento de terapêuticas de depuração extra-renal contínua (TDEC) eram a aprendizagem directa em doentes submetidos a esta técnica ou mediante observação dos efeitos da manipulação do circuito não conectado ao doente. Por este motivo foi elaborado um simulador de TDEC, usado em cursos de simulação realizados para treino de equipas de cuidados intensivos pediátricos (UCIP). Objectivos: Analisar a performance e utilidade de um novo simulador que possibilita o controlo externo do dispositivo de TDEC, simulando "in situ" cenários que mimetizam condições de doentes tratados com TDEC. Métodos: Foi criado um dispositivo que, uma vez conectado ao aparelho de TDEC, permite o controlo em tempo real de todas as pressões de hemofiltração, de acordo com as condições clínicas e acções dos participantes. Foram simulados diversos cenários e complicações possíveis em doentes submetidos a estas técnicas e avaliada a performance deste dispositivo "in vitro". A satisfação dos participantes foi avaliada mediante a aplicação de um inquérito. Resultados: Foram realizados 4 cursos de TDEC de Maio de 2009 a Março de 2012. Incluídos 60 participantes, todos com experiência clínica prévia em UCIP. Realizados 32 cenários, abrangendo complicações relacionados com o cateter, coagulação dos filtros e ajuste inadequado dos parâmetros de hemofiltração. Nos cenários simulados, o dispositivo simulador permitiu, em tempo real, mudanças simples e rápidas nas pressões do monitor de TDEC e em resposta às atitudes tomadas pelos participantes para a sua resolução. Não foram registadas intercorrências relacionadas com disfunção do dispositivo. Os participantes consideraram-no muito útil como ferramenta de aprendizagem activa, permitindo uma gestão realista das condições clínicas simuladas, com potencial impacto sobre a sua futura prática diária. Os instrutores consideraram-no fácil de manusear e realista. Conclusões: Este simulador permite uma simulação mais fidedigna dos cenários de TDEC, resolvendo o problema da interferência do instrutor no cenário simulado. Este poderia melhorar as capacidades dos simuladores de alta fidelidade disponíveis e utilizar-se como uma ferramenta docente na formação de profissionais de saúde

Nutritional status and clinical outcome of children on continuous renal replacement therapy: a prospective observational study

BACKGROUND: No studies on continuous renal replacement therapy (CRRT) have analyzed nutritional status in children. The objective of this study was to assess the association between mortality and nutritional status of children receiving CRRT. METHODS: Prospective observational study to analyze the nutritional status of children receiving CRRT and its association with mortality. The variables recorded were age, weight, sex, diagnosis, albumin, creatinine, urea, uric acid, severity of illness scores, CRRT-related complications, duration of admission to the pediatric intensive care unit, and mortality. RESULTS: The sample comprised 174 critically ill children on CRRT. The median weight of the patients was 10 kg, 35% were under percentile (P) 3, and 56% had a weight/P50 ratio of less than 0.85. Only two patients were above P95. The mean age for patients under P3 was significantly lower than that of the other patients (p = 0.03). The incidence of weight under P3 was greater in younger children (p = 0.007) and in cardiac patients and in those who had previous chronic renal insufficiency (p = 0.047). The mortality analysis did not include patients with pre-existing renal disease. Mortality was 38.9%. Mortality for patients with weight < P3 was greater than that of children with weight > P3 (51% vs 33%; p = 0.037). In the univariate and multivariate logistic regression analyses, the only factor associated with mortality was protein-energy wasting (malnutrition) (OR, 2.11; 95% CI, 1.067-4.173; p = 0.032). CONCLUSIONS: The frequency of protein-energy wasting in children who require CRRT is high, and the frequency of obesity is low. Protein-energy wasting is more frequent in children with previous end-stage renal disease and heart disease. Underweight children present a higher mortality rate than patients with normal body weight

Continuous propofol perfusion in critically ill children

Objetivo: Describir la sedación con perfusión continua de propofol en ni˜nos en estado crítico. Dise˜no: Estudio observacional descriptivo retrospectivo. Ámbito: Unidad de cuidados intensivos pediátricos. Pacientes: Pacientes que requirieron sedoanalgesia entre el 1 de octubre de 2009 y el 30 de septiembre de 2010. Intervenciones: Ninguna. Variables recogidas: Demográficas, clínicas, de laboratorio, diagnóstico, tratamiento, complicaciones y evolución de cada paciente. Se analizaron los posibles efectos adversos asociados a la administración de propofol, comparando el grupo de pacientes a los que se les administró con el resto de los ni˜nos críticos. Resultados: Recibieron propofol en perfusión continua 71 de los 222 pacientes recogidos (32%). Los fármacos sedoanalgésicos más utilizados fueron el midazolam, seguido del fentanilo y del propofol. La dosis media de propofol fue de 2,1 mg/kg/h [desviación estándar (DE) 1,3, rango: 0,5-6)] y la duración media de 6,7 días (DE 8,5; rango: 0,5-40). La edad media fue de 45,8 meses (mediana 24; rango intercuartil: 7-65), siendo el 52% varones. Ningún paciente presentó síndrome de infusión por propofol ni otros efectos adversos graves. Los pacientes tratados con propofol presentaron con mayor frecuencia algunas alteraciones analíticas que el resto, pero no se demostró relación causa efecto con la administración del fármaco. No existieron diferencias significativas en los niveles de lactato ni en la incidencia de infecciones entre ambos grupos. Conclusión: el propofol a una dosis de 1 a 4 mg/kg/h puede utilizarse como un fármaco alternativo para la sedación de mantenimiento en los ni˜nos críticamente enfermos. Sin embargo son necesarios más estudios que valoren su eficacia y seguridad.Q3Q3Artículo original410-415Objective: To describe sedation with continuous perfusion of propofol in critically ill children. Design: A retrospective, descriptive observational study was carried out. Setting: A pediatric intensive care unit. Patients: Pediatric patients requiring sedoanalgesia between October 1, 2009 and September 30, 2010. Interventions: None. Data collected: Demographic, clinical and laboratory test variables, diagnosis, treatment, complications and evolution in each patient. In addition, the potential adverse effects associated with propofol administration were analyzed. Results: Midazolam, fentanyl and propofol were the most commonly used sedative and analgesic drugs. Seventy-one out of 222 patients (32%) received propofol in continuous infusion. The average dose was 2.1 mg/kg/h (SD 1.3, range: 0.5 to 6), and the average duration of treatment was of 6.7 days (SD 8.5 range 0.5---40). Fifty-two percent were males, and the mean patient age was 45.8 months (median: 24; interquartile range: 7-65). No patient developed propofol infusion syndrome or other serious drug-related adverse effects. Patients treated with propofol showed more abnormal laboratory test findings, although no relationship to drug administration could be demonstrated. There were no significant differences in lactate level or in the incidence of infection in either group. Conclusions: Propofol at a dose of 1 to 4 mg/kg/h is a safe alternative for sustained sedation in critically ill children. However, further studies are needed to assess its effects and safety profile

Postpyloric enteral nutrition in the critically ill child with shock: a prospective observational study

<p>Abstract</p> <p>Background</p> <p>Tolerance to enteral nutrition in the critically ill child with shock has not been studied. The purpose of the study was to analyze the characteristics of enteral nutrition and its tolerance in the critically ill child with shock and to compare this with non-shocked patients.</p> <p>Methods</p> <p>A prospective, observational study was performed including critically ill children with shock who received postpyloric enteral nutrition (PEN). The type of nutrition used, its duration, tolerance, and gastrointestinal complications were assessed. The 65 children with shock who received PEN were compared with 461 non-shocked critically ill children who received PEN.</p> <p>Results</p> <p>Sixty-five critically ill children with shock, aged between 21 days and 22 years, received PEN. 75.4% of patients with shock received PEN exclusively. The mean duration of the PEN was 25.2 days and the maximum calorie intake was 79.4 kcal/kg/day. Twenty patients with shock (30.7%) presented gastrointestinal complications, 10 (15.4%) abdominal distension and/or excessive gastric residue, 13 (20%) diarrhoea, 1 necrotising enterocolitis, and 1 duodenal perforation due to the postpyloric tube. The frequency of gastrointestinal complications was significantly higher than in the other 461 critically ill children (9.1%). PEN was suspended due to gastrointestinal complications in 6 patients with shock (9.2%). There were 18 deaths among the patients with shock and PEN (27.7%). In only one patient was the death related to complications of the nutrition.</p> <p>Conclusion</p> <p>Although most critically ill children with shock can tolerate postpyloric enteral nutrition, the incidence of gastrointestinal complications is higher in this group of patients than in other critically ill children.</p

Empty Urbanism: the bursting of the Spanish housing bubble

The depth of the Spanish housing crisis manifests itself in the collapse of construction activity and in the amount of housing and land stocks. The geography of the crisis shows its widespread nature, and the intensity of the previous bubble explains spatial differences. Resulting from this collapse are some problematic areas of 'empty urbanism'. An enormous land bubble, emerging from the peculiar Spanish urban development model, was a key factor in the impacts - caused by the crisis - on the territory and land-use plans. The crisis has demonstrated the unsustainability of this and the urgency of change in the existing land-use plans

Predicting non-invasive ventilation failure in children from the SpO₂/FiO₂ (SF) ratio

PURPOSE: Our objective was to assess whether SpO₂/FiO₂ (SF) ratio could be a useful NIV outcome predictor in children with acute respiratory failure (ARF) and tried to develop a predictive model of NIV failure. METHODS: Prospective, observational, multicenter study. Episodes of ARF-fulfilling inclusion criteria from 15 January 2010 to 14 January 2011 were treated with NIV according to a pre-established protocol. Clinical variables were collected at baseline and at 1, 2, 6, 12 and 24 h. Failure criterion was the need for endotracheal intubation. Failures were considered as "early" if occurring ≤6 h after NIV initiation, "intermediate" if occurring between 6 and 24 h, and "late" if occurring after 24 h. Variables with a p < 0.1 in univariate analysis corrected by age were included in multivariate analysis. Models were calculated based on multivariate analysis. RESULTS: During the study period, 390 episodes were included. NIV success rate was 81.3 %. Among ARF causes, failure occurred most frequently in ARDS episodes. The failure predictive model for the whole sample included SF ratio at 1 h, age and PRISM III-24 (area under the curve AUC of 0.755). For early NIV failures, SF ratio at 1 h was the only variable within model (AUC 0.748). The analysis of intermediate NIV failures identified 3 variables independently linked to NIV outcome: PRISM III-24, RR decrease at 6 h, and SF ratio at 6 h (AUC 0.895). No model was identified for late NIV failure. CONCLUSIONS: SF ratio is a reliable predictor of early NIV failure in children

Efektivitas implementasi pendidikan karakter berbasis layanan bimbingan klasikal dengan pendekatan experiential learning untuk meningkatkan karakter disiplin manajemen waktu (studi pra eksperimen pada siswa kelas VIII D SMP N 3 Purwantoro, Wonogiri tahun ajaran 2015/2016)

<p>(*) Significant difference (p < 0.05) from baseline, same group. (‡) p < 0.05 from hemorrhage, same group. (#) p < 0.05 from group NS.</p