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Browsing by Author "Díaz, Franco"

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A physiological approach to understand the role of respiratory effort in the progression of lung injury in SARS-CoV-2 infection
(2020) Cruces, Pablo; Retamal, Jaime; Hurtado, Daniel E.; Erranz, Benjamín; Iturrieta, Pablo; González, Carlos; Díaz, Franco
Deterioration of lung function during the first week of COVID-19 has been observed when patients remain with insufficient respiratory support. Patient self-inflicted lung injury (P-SILI) is theorized as the responsible, but there is not robust experimental and clinical data to support it. Given the limited understanding of P-SILI, we describe the physiological basis of P-SILI and we show experimental data to comprehend the role of regional strain and heterogeneity in lung injury due to increased work of breathing. In addition, we discuss the current approach to respiratory support for COVID-19 under this point of view
Characteristics of Medically Transported Critically Ill Children with Respiratory Failure in Latin America: Implications for Outcomes
(2021) Serra, Jesus; Díaz, Franco; Cruces, Pablo; Carvajal, Cristobal; Nuñez, Maria; Donoso, A.; Bravo, J A; Carbonell, M.; Courtie, C.; Fernández. A.; Martínez, L.; Martínez, J.; Menta, S.; Pedrozo, Luis; Wegner, A.; Monteverde, Nicolas; Jaramillo, Juan; Jabornisky, Roberto; González, Sebastián; Kudchadkar, Sapna; Vásquez, Pablo; On behalf of LARed Network
Several challenges exist for referral and transport of critically ill children in resource-limited regions such as Latin America; however, little is known about factors associated with clinical outcomes. Thus, we aimed to describe the characteristics of critically ill children in Latin America transferred to pediatric intensive care units for acute respiratory failure to identify risk factors for mortality. We analyzed data from 2,692 patients admitted to 28 centers in the Pediatric Collaborative Network of Latin America Acute Respiratory Failure Registry. Among patients referred from another facility (773, 28%), nonurban transports were independently associated with mortality (adjusted odds ratio = 9.4; 95% confidence interval: 2.4-36.3).
Clasificación PIRO en sepsis grave y shock séptico pediátrico: Nuevo modelo de estratificación y su utilidad en pronóstico
(Sociedad Chilena de Infectología, 2010) Arriagada, Daniela; Díaz, Franco; Donoso, Alejandro; Cruces, Pablo
Introducción: La compresión de la sepsis como un proceso dinámico, resultado de la interacción entre hospedero y agente infeccioso, ha llevado al sistema de estratificación "PIRO" (P) Predisposición, (I) Injuria/ Infección, (R) Respuesta y (O) disfunción de Órganos, clasificación orientada a predecir la muerte en pacientes con sepsis, a ganar adeptos. Sin embargo, faltan estudios clínicos que lo validen. Objetivo: Evaluar la certeza de la clasificación "PIRO" en sepsis grave y shock séptico para predecir mortalidad. Pacientes y Método: Estudio retrospectivo efectuado en una UCI pediátrica de 13 camas durante 24 meses (enero 2006 a diciembre 2007). Uno de los cuatro autores registró las características demográficas, clínicas y microbiológicas de la totalidad de pacientes ingresados con diagnóstico de sepsis grave y shock séptico, agrupándolos según sobrevida. Fueron clasificadas estas variables según sistema PIRO Se evaluó la asociación de estas variables con la mortalidad. Resultados: 42 pacientes, edad 11 meses (3,2-58) y mortalidad 19%. Las variables asociadas a mortalidad fueron: (P) antecedente de patología crónica (OR: 7; IC95% 0,95-51) e inmunodeficiencia (6,2; 1,1-35,2); (R) leucopenia (9; 1,96-41,72); (O) disfunción de 3 o más órganos (6,1; 1,22-31). Ninguna de las variables (I) se asoció a mortalidad. Conclusiones: El sistema "PIRO" es un modelo en desarrollo para una clasificación individual, de fácil aplicación. Permite reconocer factores asociados a un resultado fatal, en la presente casuística dado por inmunodeficiencia, leucopenia y fallo de tres o más sistemas. Es importante realizar estudios transversales para definir una etapificación PIRO consensuada y luego validarla prospectivamente.
Consecuencias hemodinámicas y respiratorias del síndrome compartimental abdominal en un modelo experimental
(2012) Díaz, Franco; Donso, Alejandro; Carvajal, Cristóbal; Salomón, Tatiana; Torres, María Fernanda; Erranz, Benjamín; Cruces, Pablo
Introducción: El síndrome compartimental abdominal (SCA) es una entidad grave, de escaso reporte en población pediátrica por una inadecuada alerta y reconocimiento. Puede ser originado por causas médicas y quirúrgicas, presentando una elevada mortalidad. Objetivo: Determinar la magnitud de las consecuencias hemodinámicas y respiratorias iniciales desencadenadas por la inducción de un SCA en un modelo experimental. Método: Doce cerdos anestesiados (4,8 ± 0,1 kg). El SCA fue inducido con instilación de solución coloide en cavidad peritoneal para obtener una presión intra-abdominal (PIA) de 25 ± 5 mmHg. En condiciones basales y posterior a inducción del SCA se realizó monitorización hemodinámica convencional y termodilución transpulmonar. Paralelamente se midió gasometría arterial y análisis de mecánica pulmonar. Resultados: Hubo una reducción del gasto cardíaco en 16% (5,19 ± 0,33 a 4,34 ± 0,28 l/min/m2, p = 0,01) y de la presión de perfusión abdominal en 20% (72,3 ± 3,2 a 57,3 ± 4,0 mmHg, p < 0,001) sin cambios en frecuencia cardiaca, presión arterial y venosa central. Además ocurrió un deterioro de la compliance del sistema respiratorio cercana al 50% (1,28 ± 0,09 a 0,62 ± 0,04 ml/cmH2O/kg, p = 0,002) asociado a un incremento significativo en las presiones intratorácicas y disminución leve de la oxigenación. Discusión: En este modelo experimental se pudo apreciar el desarrollo temprano de disfunción hemodinámica y pulmonar. Se evidenció una reducción de gasto cardiaco no detectado por la monitorización convencional y un deterioro substancial de la mecánica pulmonar, propia de una enfermedad restrictiva, asociado a alteraciones leves del intercambio gaseoso. Creemos que es fundamental monitorizar la PIA en pacientes predispuestos a desarrollar un SCA, más aún ante empeoramiento de disfunciones orgánicas dado que la hipotensión e hipoxemia grave son signos tardíos de esta complicación.
Decreased lung compliance increases preload dynamic tests in a pediatric acute lung injury model
(Sociedad Chilena de Pediatría. Publicado por Elsevier España, S.L.U., 2015) Erranz, Benjamín; Díaz, Franco; Donoso, Alejandro; Salomón, Tatiana; Carvajal, Cristóbal; Torres, María Fernanda; Cruces, Pablo
BACKGROUND: Preload dynamic tests, pulse pressure variation (PPV) and stroke volume variation (SVV) have emerged as powerful tools to predict response to fluid administration. The influence of factors other than preload in dynamic preload test is currently poorly understood in pediatrics. The aim of our study was to assess the effect of tidal volume (VT) on PPV and SVV in the context of normal and reduced lung compliance in a piglet model. MATERIAL AND METHOD: Twenty large-white piglets (5.2±0.4kg) were anesthetized, paralyzed and monitored with pulse contour analysis. PPV and SVV were recorded during mechanical ventilation with a VT of 6 and 12mL/kg (low and high VT, respectively), both before and after tracheal instillation of polysorbate 20. RESULTS: Before acute lung injury (ALI) induction, modifications of VT did not significantly change PPV and SVV readings. After ALI, PPV and SVV were significantly greater during ventilation with a high VT compared to a low VT (PPV increased from 8.9±1.2 to 12.4±1.1%, and SVV from 8.5±1.0 to 12.7±1.2%, both P<0.01). CONCLUSIONS: This study found that a high VT and reduced lung compliance due to ALI increase preload dynamic tests, with a greater influence of the latter. In subjects with ALI, lung compliance should be considered when interpreting the preload dynamic tests.
Diferencia veno-arterial de dióxido de carbono como predictor de gasto cardiaco disminuido en modelo pediátrico experimental
(Sociedad Medica de Santiago, 2012) Díaz, Franco; Donoso, Alejandro; Carvajal, Cristóbal; Salomón, Tatiana; Torres, María; Erranz, Benjamín; Cruces, Pablo
Background: Cardiac output (CO) measurement is not a standard of care for critically ill children, but it can be estimated by indirect methods such as veno-arterial pCO2 difference (ΔVACO2). Aim: To determine the correlation between CO and ΔVACO2 and evaluate the usefulness of ΔVACO2 in the diagnosis of low CO in an experimental pediatric model. Materials and Methods: Thirty piglets weighing 4.8 ± 0.35 kg were anesthetized and monitored with transpulmonary thermodilution. Lung injury was induced with tracheal instillation of Tween 20®. Serial measurements of central venous and arterial blood gases, as well as CO, were obtained at baseline, 1, 2 and 4 h after lung injury induction. Low cardiac output (LCO) was defined as CO lower than 2.5 Llminlm2. Results: There was an inverse correlation between CO and ΔVACO2 (r = -0.36, p < 0.01). ΔVACO2 was 14 ± 8 mmHg in LCO state and 8 ± 6 mmHg when this condition was not present (p < 0.01). Area under the receiver operating characteristic (ROC) curves of ΔVACO2 and LCO state was 0.78 (0.68-0.86). The best cut-point was 8.9 mmHg to determine LCO with a sensibility 0.78, specificity 0.7, positive predictive value 0.27 and negative predictive value 0.96. Conclusions: In this model there was an inverse correlation between ΔVACO2 and CO. The best cutoff value to discard LCO was ΔVACO2 of 8.9 mmHg, indicating that under this value the presence of LCO is very unlikely.
Driving Pressure and Normalized Energy Transmission Calculations in Mechanically Ventilated Children Without Lung Disease and Pediatric Acute Respiratory Distress Syndrome
(2021) Díaz, Franco; González-Dambrauskass, Sebastián; Cristiani, Federico; Casanova, Daniel R.; Cruces, Pablo
OBJECTIVES: To compare the new tools to evaluate the energy dissipated to the lung parenchyma in mechanically ventilated children with and without lung injury. We compared their discrimination capability between both groups when indexed by ideal body weight and driving pressure. DESIGN: Post hoc analysis of individual patient data from two previously published studies describing pulmonary mechanics. SETTING: Two academic hospitals in Latin-America. PATIENTS: Mechanically ventilated patients younger than 15 years old were included. We analyzed two groups, 30 children under general anesthesia (ANESTH group) and 38 children with pediatric acute respiratory distress syndrome. INTERVENTIONS: Respiratory mechanics were measured after intubation in all patients. MEASUREMENTS AND MAIN RESULTS: Mechanical power and derived variables of the equation of motion (dynamic power, driving power, and mechanical energy) were computed and then indexed by ideal body weight. Driving pressure was higher in pediatric acute respiratory distress syndrome group compared with ANESTH group. Receiver operator curve analysis showed that driving pressure had the best discrimination capability compared with all derived variables of the equation of motion indexed by ideal body weight. The same results were observed when the subgroup of patients weighs less than 15kg. There was no difference in unindexed mechanical power between groups. CONCLUSIONS: Driving pressure is the variable that better discriminates pediatric acute respiratory distress syndrome from nonpediatric acute respiratory distress syndrome in children than the calculations derived from the equation of motion, even when indexed by ideal body weight. Unindexed mechanical power was useless to differentiate against both groups. Future studies should determine the threshold for variables of the energy dissipated by the lungs and their association with clinical outcomes.
Estimated impact of maternal vaccination on global paediatric influenzarelated in-hospital mortality: A retrospective case series
(2021) Lowensteyn, Yvette N.; Nairb, Harish; Nunes, Marta C.; Roessel, Ichelle van; Vernooij, Femke S.; Willemsen, Joukje; Mazur, Natalie I.; Bont, Louis J.; FLU GOLD study group; Díaz, Franco
Background Influenza virus infection is an important cause of under-five mortality. Maternal vaccination protects children younger than 3 months of age from influenza infection. However, it is unknown to what extent paediatric influenza-related mortality may be prevented by a maternal vaccine since global age-stratified mortality data are lacking. Methods We invited clinicians and researchers to share clinical and demographic characteristics from children younger than 5 years who died with laboratory-confirmed influenza infection between January 1, 1995 and March 31, 2020. We evaluated the potential impact of maternal vaccination by estimating the number of children younger than 3 months with in-hospital influenza-related death using published global mortality estimates. Findings We included 314 children from 31 countries. Comorbidities were present in 166 (53%) children and 41 (13%) children were born prematurely. Median age at death was 8·6 (IQR 4·5–16·6), 11·5 (IQR 4·3–24·0), and 15·5 (IQR 7·4–27·0) months for children from low- and lower-middle-income countries (LMICs), upper-middle-income countries (UMICs), and high-income countries (HICs), respectively. The proportion of children younger than 3 months at time of death was 17% in LMICs, 12% in UMICs, and 7% in HICs. We estimated that 3339 annual influenza-related in-hospital deaths occur in the first 3 months of life globally. Interpretation In our study, less than 20% of children is younger than 3 months at time of influenza-related death. Although maternal influenza vaccination may impact maternal and infant influenza disease burden, additional immunisation strategies are needed to prevent global influenza-related childhood mortality. The missing data, global coverage, and data quality in this study should be taken into consideration for further interpretation of the results.
Estrategias ventilatorias ante el niño con síndrome de distress respiratorio agudo e hipoxemia grave
(Academia Nacional de Medicina de México, A.C, 2015) Donoso, Alejandro; Arriagada, Daniela; Díaz, Franco; Cruces, Pablo
En esta revisión se recogen los conceptos fundamentales del uso de ventilación mecánica (VM) en niños con síndrome de distress respiratorio agudo (SDRA) e hipoxemia refractaria. Se discuten conceptos de VM protectora y potencial de reclutamiento (PR), y se examinan las opciones ventilatorias y/o maniobras destinadas a optimizar el tejido pulmonar no aireado –maniobra de reclutamiento alveolar (MRA), titulación de la presión positiva al final de la espiración (PEEP), ventilación de alta frecuencia oscilatoria (VAFO) y ventilación con liberación de presión de la vía aérea (APRV)– u orientadas a corregir la alteración ventilación/perfusión (V/Q) –uso de decúbito prono–, y como única medida farmacológica se discute el uso de relajantes neuromusculares. En la práctica, el concepto de VM protectora implica efectuar un ajuste individualizado de la PEEP y del volumen corriente (VT). El uso de maniobras de reclutamiento alveolar y titulación decreciente de la PEEP puede mejorar la función pulmonar en pacientes con SDRA. Ante escenarios de fracaso de VM se debe considerar el inicio precoz de la VAFO. El posicionamiento en prono de forma temprana y prolongada puede mejorar el intercambio gaseoso, en espera de un mejor control de la causa que motivó la VM.
Evaluación de la microcirculación sublingual en un paciente en shock séptico
(2012) Donoso, Alejandro; Arriagada, Daniela; Cruces, Pablo; Abarca, Juan; Díaz, Franco
Introducción: El shock séptico involucra una compleja red de alteraciones circulatorias, infl amatorias y metabólicas que conducen a una disrupción energética celular. En el shock séptico se observan frecuentemente alteraciones microcirculatorias, siendo característico la existencia de unidades microcirculatorias débiles y un fl ujo microcirculatorio heterogéneo. Caso clínico: Se presenta una paciente de dos meses de edad con shock séptico de foco pulmonar, en la que realizamos una descripción de las alteraciones microcirculatorias a las 24, 72 y 120 h durante su tratamiento. Se utilizó MicroScan®, (MicroVision Medical, Amsterdam, Holanda) en el área sublingual. La paciente recibió soporte ventilatorio, fl uidos de reanimación, drogas vasoactivas y antibióticos. En la medición inicial la paciente presentaba una baja proporción de capilares perfundidos, un bajo índice de flujo microcirculatorio y una alta heterogeneidad de fl ujo, todas ellas con independencia de la hemodinamia sistémica e indicadores de disoxia. Estas alteraciones graves mejoraron progresivamente a las 72 y 120 h de tratamiento. Discusión: Las alteraciones microcirculatorias y su evolución temporal pueden ser una herramienta diagnóstica dinámica y de estratifi cación de gravedad en estados de shock séptico. En estudios futuros la microcirculación deberá ser evaluada como un objetivo de intervención terapéutica (resucitación microcirculatoria) presentando a su vez un rol pronóstico en el shock séptico y sepsis grave en niños.
Implementation of preemptive fluid strategy as a bundle to prevent fluid overload in children with acute respiratory distress syndrome and sepsis
(2018) Díaz, Franco; Nuñez, María José; Pino, Pablo; Erranz, Benjamín; Cruces, Pablo
Background Fluid overload (FO) is associated with unfavorable outcomes in critically ill children. Clinicians are encouraged to avoid FO; however, strategies to avoid FO are not well-described in pediatrics. Our aim was to implement a bundle strategy to prevent FO in children with sepsis and pARDS and to compare the outcomes with a historical cohort. Methods A quality improvement initiative, known as preemptive fluid strategy (PFS) was implemented to prevent early FO, in a 12-bed general PICU. Infants on mechanical ventilation (MV) fulfilling pARDS and sepsis criteria were prospectively recruited. For comparison, data from a historical cohort from 2015, with the same inclusion and exclusion criteria, was retrospectively reviewed. The PFS bundle consisted of 1. maintenance of intravenous fluids (MIVF) at 50% of requirements; 2. drug volume reduction; 3. dynamic monitoring of preload markers to determine the need for fluid bolus administration; 4. early use of diuretics; and 5. early initiation of enteral feeds. The historical cohort treatment, the standard fluid strategy (SFS), were based on physician preferences. Peak fluid overload (PFO) was the primary outcome. PFO was defined as the highest FO during the first 72 h. FO was calculated as (cumulative fluid input – cumulative output)/kg*100. Fluid input/output were registered every 12 h for 72 h. Results Thirty-seven patients were included in the PFS group (54% male, 6 mo (IQR 2,11)) and 39 with SFS (64%male, 3 mo (IQR1,7)). PFO was lower in PFS (6.31% [IQR4.4–10]) compared to SFS (12% [IQR8.4–15.8]). FO was lower in PFS compared to CFS as early as 12 h after admission [2.4(1.4,3.7) v/s 4.3(1.5,5.5), p < 0.01] and maintained during the study. These differences were due to less fluid input (MIVF and fluid boluses). There were no differences in the renal function test. PRBC requirements were lower during the first 24 h in the PFS (5%) compared to SFS (28%, p < 0.05). MV duration was 81 h (58,98) in PFS and 118 h (85154) in SFS(p < 0.05). PICU LOS in PFS was 5 (4, 7) and in SFS was 8 (6, 10) days. Conclusion Implementation of a bundle to prevent FO in children on MV with pARDS and sepsis resulted in less PFO. We observed a decrease in MV duration and PICU LOS. Future studies are needed to address if PFS might have a positive impact on health outcomes.
Influence of tidal volume on pulse pressure variation and stroke volume variation during experimental intra-abdominal hypertension
(BioMed Central Ltd., 2015) Díaz, Franco; Erranz, Benjamín; Donoso, Alejandro; Salomón, Tatiana; Cruces, Pablo
BACKGROUND: Pulse pressure variation (PPV) and stroke volume variation (SVV) are frequently used to assess fluid responsiveness in critically ill patients on mechanical ventilation (MV). There are many factors, in addition to preload that influence the magnitude of these cyclic variations. We sought to investigate the effect of tidal volume (V(T)) on PPV and SVV, and prediction of fluid responsiveness in a model of intra-abdominal hypertension (IAH). METHODS: Twelve anesthetized and mechanically ventilated piglets on continuous pulse contour cardiac output monitoring. Hypovolemia was ruled out with 2 consecutive fluid boluses after instrumentation. IAH was induced by intraperitoneal instillation of colloid solution with a goal of reducing respiratory system compliance by 50 %. Subjects were classified as fluid responders if stroke volume increased >15 % after each fluid challenge. SVV and PPV were recorded with tidal volumes (VT) of 6, 12 and 18 ml/kg before IAH after IAH induction and after a fluid challenge during IAH. RESULTS: V(T) influenced PPV and SVV at baseline and during IAH, being significantly larger with higher V(T). These differences were attenuated after fluid administration in both conditions. After IAH induction, there was a significant increase in SVV with the three-tested V(T), but the magnitude of that change was larger with high V(T): with 6 ml/kg from 3 % (3, 4) to 5 % (4, 6.25) (p = 0.05), with 12 ml/kg from 5 % (4, 6) to 11 % (8.75, 17) (p = 0.02) and 18 ml/kg from 5 % (4,7.5) to 15 % (8.75, 19.5) (p = 0.02). Similarly, PPV increased with all the tested VT after IAH induction, being this increase larger with high VT: with 6 ml/kg from 3 % (2, 4.25) to 6 % (4.75, 7) (p = 0.05), with 12 ml/kg from 5 % (4, 6) to 13.5 % (10.25, 15.5) (p = 0.02) and 18 ml/kg from 7 % (5.5, 8.5) to 24 % (13.5, 30.25) (p = 0.02). One third of subjects responded to fluid administration after IAH, but neither SVV nor PPV were able to identify the fluid responders with the tested V(T). CONCLUSION: IAH induction in non-hypovolemic subjects significantly increased SVV and PPV with the three tested V(T), but the magnitude of that change was higher with larger V(T). This observation reveals the dependence of functional hemodynamic markers on intrathoracic as well intra-abdominal pressures, in addition to volemic status. Also, PPV and SVV were unable to predict fluid responsiveness after IAH induction. Future studies should take into consideration these findings when exploring relationships between dynamic preload indicators and fluid responsiveness during IAH.
Latin American Consensus on the Management of Sepsis in Children: Sociedad Latinoamericana de Cuidados Intensivos Pediátricos [Latin American Pediatric Intensive Care Society] (SLACIP) Task Force: Executive Summary
(2021) Fernández-Sarmiento, Jaime; De Souza, Daniela Carla; Martinez, Anacaona; Nieto, Victor; López-Herce, Jesús; Soares Lanziotti, Vanessa; Arias López, María Del Pilar; Brunow De Carvalho, Werther; Oliveira, Claudio F.; Jaramillo-Bustamante, Juan Camilo; Díaz, Franco; Yock-Corrales, Adriana; Ruvinsky, Silvina; Munaico, Manuel; Pavlicich, Viviana; Iramain, Ricardo; Márquez, Marta Patricia; González, Gustavo; Yunge, Mauricio; Tonial, Cristian; Cruces, Pablo; Palacio, Gladys; Grela, Carolina; Slöcker-Barrio, Maria; Campos-Miño, Santiago; González-Dambrauskas, Sebastian; Sánchez-Pinto, Nelson L.; Celiny García, Pedro; Jabornisky, Roberto
Mechanical power in pediatric acute respiratory distress syndrome: a PARDIE study
(2022) Bhalla, Anoopindar; Klein, Margaret; Alapont, Vicent; Guillaume, Emeriaud; Emeriaud, Guillaume; Kneyber, Martin; Medina, Alberto; Cruces, Pablo; Takeuchi, Muneyuki; Maddux, Aline; Mourani, Peter; Camilo, Cristina; Díaz, Franco; White, Benjamin; Yehya, Nadir; Pappachan, John; Di Nardo, Matteo; Shein, Steven; Newth, Christopher; Khemani, Robinder; Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network
Background: Mechanical power is a composite variable for energy transmitted to the respiratory system over time that may better capture risk for ventilator-induced lung injury than individual ventilator management components. We sought to evaluate if mechanical ventilation management with a high mechanical power is associated with fewer ventilator-free days (VFD) in children with pediatric acute respiratory distress syndrome (PARDS).
Mild hypothermia attenuates lung edema and plasma interleukin-1 beta in a rat mechanical ventilation-induced lung injury model
(2011) Cruces, Pablo; Ronco, Ricardo; Erranz, Benjamín; Conget, Paulette; Carvajal, Cristóbal; Donoso, Alejandro; Díaz, Franco
Recent data suggest that deep hypothermia has protective effects on experimental induced lung injury. It is not well known if these effects persist with mild hypothermia. The authors hypothesized that mild hypothermia may attenuate lung injury and decrease local and systemic proinflammatory cytokines in a rat model of injurious mechanical ventilation (MV). Twelve Sprague-Dawley male adult rats were anesthetized, intubated, and randomly allocated to normothermia group (37 degrees C) (NT) or mild hypothermia group (34 degrees C) (MH). After 2 hours of deleterious MV (peak inspiratory pressure [PIP] 40 cm H2O, zero end-expiratory pressure [ZEEP], and inspiratory fraction of oxygen [Fio(2)] 100%), arterial blood gases, lung gravimetry, and histological study were obtained. Protein content, interleukin (IL)-1 beta, and tumor necrosis factor (TNF)-alpha were measured in plasma and bronchoalveolar lavage (BAL) fluid. Subjects that underwent MH had a significant lower wet-to-dry lung weight ratio (8.32 +/- 0.28 vs. 10.8 +/- 0.49, P = .01), IL-1 beta plasma concentration (0.6 +/- 0.6 vs. 10.27 +/- 2.80 pg/mL, P = .0048) and Paco(2). There were no differences in terms of Pao(2), histological injury, or BAL protein content. In this model of injurious mechanical ventilation, subjects treated with mild hypothermia had less lung edema and lower plasma IL-1 beta. Some of known beneficial effects of deep hypothermia can be obtained with mild hypothermia.
Ninguém sozinho é melhor do que todos juntos: o papel das redes na terapia intensiva pediátrica
(2019) González, Sebastián; Juan, Jaramillo; Díaz, Franco
A doença crítica é um evento raro em pediatria. Crow et al. demonstraram recentemente o quanto é incomum que uma criança seja admitida à unidade de terapia intensiva (UTI) pediátrica. Embora, do ponto de vista populacional, seja infrequente, condições comuns na UTI pediátrica, como sepse, representam uma ameaça internacional, e atualmente persistem importantes disparidades em termos de desfechos nas condições em que há limitação de recursos. Crianças hospitalizadas em UTIs pediátricas têm características singulares, diagnósticos heterogêneos e ampla variedade de idades. Mais ainda, muitos obstáculos práticos, como substancial variedade de processos de cuidados proporcionados por diferentes sistemas de saúde (diferenças organizacionais entre os hospitais, baixo acesso a serviços de cuidados domiciliares, baixa disponibilidade de leitos, e assim por diante), podem coexistir e tornar difícil a obtenção de amostras de tamanho representativo em pesquisas relacionadas à UTI pediátrica. Em geral, uma única UTI pediátrica não dispõe de volume suficiente de pacientes para obter informações significativas a respeito de um grupo homogêneo específico de crianças e, assim, obter pesquisa de boa qualidade. Assim, a variabilidade entre diferentes provedores, em termos de práticas clínicas comuns, é ampla, o que pode ser um importante fator para o mau uso de intervenções terapêuticas e diagnósticas, assim como um obstáculo para melhoria dos desfechos obtidos. Felizmente, nestes últimos anos, muitos esforços coletivos têm sido envidados para levar adiante o campo de pesquisa em UTI pediátrica, por meio do uso do modelo de redes. O presente artigo oferece breve visão das redes de pesquisa, com foco especial nas redes colaborativas.
La pandemia COVID-19 como oportunidad de reflexión en Educación en Ciencias de la Salud
(2020) Millán, Teresa; Heresi, Carolina; Díaz, Franco; Weisstaub, Gerardo; Vargas, Nelson A.
Pediatric Critical Care and COVID19
(2020) González-Dambrauskas, Sebastián; Vásquez-Hoyos, Pablo; Camporesi, Anna; Díaz, Franco; Piñeres-Olave, Byron Enrique; Fernández-Sarmiento, Jaime; Gertz, Shira; Harwayne-Gidansky, Ilana; Pietroboni, Pietro; Shein, Steven L.; Urbano, Javier; Wegner, Adriana; Zemanate, Eliana; Karsies, Todd
Pediatric inflammatory multisystem syndrome associated with SARS-CoV-2: a case series quantitative systematic review
(2021) Bustos B., Raúl; Jaramillo-Bustamante, Juan Camilo; Vásquez-Hoyos, Pablo; Cruces, Pablo; Díaz, Franco
Pediatric inflammatory multisystem syndrome associated with SARS-CoV-2 (PIMS-TS) is infrequent, but children might present as a life-threatening disease. In a systematic quantitative review, we analyzed 11 studies PIMS-TS, including 468 children reported before Jul 1st. We found a myriad of clinical features, but we were able to describe common characteristics: previously healthy school-aged children, persistent fever and gastrointestinal symptoms, lymphopenia, and high inflammatory markers. Clinical syndromes like myocarditis and Kawasaki disease were present in only one-third of cases each one. PICU admission was frequent, although LOS was less than one week, and mortality was low. Most patients received immunoglobulin or steroids, although the level of evidence for that treatment is low. PIMS-ST was recently described, and the detailed quantitative pooled data will increase clinicians' awareness, improve diagnosis, and promptly start treatment. This analysis also highlights the necessity of future collaboratives studies, given the heterogeneous nature of PIMS-TS.
Positive end-expiratory pressure improves elastic working pressure in anesthetized children
(2018) Cruces, Pablo; González-Dambrauskas, Sebastián; Cristiani, Federico; Martínez, Javier; Henderson, Ronnie; Erranz, Benjamín; Díaz, Franco
Background Positive end-expiratory pressure (PEEP) has been demonstrated to decrease ventilator-induced lung injury in patients under mechanical ventilation (MV) for acute respiratory failure. Recently, some studies have proposed some beneficial effects of PEEP in ventilated patients without lung injury. The influence of PEEP on respiratory mechanics in children is not well known. Our aim was to determine the effects on respiratory mechanics of setting PEEP at 5 cmH2O in anesthetized healthy children. Methods Patients younger than 15 years old without history of lung injury scheduled for elective surgery gave informed consent and were enrolled in the study. After usual care for general anesthesia, patients were placed on volume controlled MV. Two sets of respiratory mechanics studies were performed using inspiratory and expiratory breath hold, with PEEP 0 and 5 cmH2O. The maximum inspiratory and expiratory flow (QI and QE) as well as peak inspiratory pressure (PIP), plateau pressure (PPL) and total PEEP (tPEEP) were measured. Respiratory system compliance (CRS), inspiratory and expiratory resistances (RawI and RawE) and time constants (KTI and KTE) were calculated. Data were expressed as median and interquartile range (IQR). Wilcoxon sign test and Spearman’s analysis were used. Significance was set at P < 0.05. Results We included 30 patients, median age 39 (15–61.3) months old, 60% male. When PEEP increased, PIP increased from 12 (11,14) to 15.5 (14,18), and CRS increased from 0.9 (0.9,1.2) to 1.2 (0.9,1.4) mL·kg− 1·cmH2O− 1; additionally, when PEEP increased, driving pressure decreased from 6.8 (5.9,8.1) to 5.8 (4.7,7.1) cmH2O, and QE decreased from 13.8 (11.8,18.7) to 11.7 (9.1,13.5) L·min− 1 (all P < 0.01). There were no significant changes in resistance and QI. Conclusions Analysis of respiratory mechanics in anesthetized healthy children shows that PEEP at 5 cmH2O places the respiratory system in a better position in the P/V curve. A better understanding of lung mechanics may lead to changes in the traditional ventilatory approach, limiting injury associated with MV.

Browsing by Author "Díaz, Franco"

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