Browsing by Author "Donoso, Alejandro"
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Item Angiotensin-converting enzyme insertion/deletion polymorphism is associated with severe hypoxemia in pediatric ARDS(Springer, 2012) Cruces, Pablo; Puga, Alonso; Erranz, Benjamín; Donoso, Alejandro; Carvajal, Cristobal; Wilhelm, Jan; Repetto, GabrielaPURPOSE: The D allele of the insertion/deletion (I/D) polymorphism of a 287-bp sequence in the angiotensin-converting enzyme (ACE) gene has been associated with an increased activity of this enzyme. Its role in susceptibility to acute respiratory distress syndrome (ARDS) has not been well defined. We hypothesized that ACE I/D genotype in pediatrics is associated with ARDS and plasma levels of angiotensin II. METHODS: Prospective case-control study in patients under 15 years of age from a mixed Chilean population. Sixty patients with ARDS and 60 controls were included. Association between ACE genotype and ARDS was evaluated as the primary outcome; mortality and severe hypoxemia were examined as secondary outcomes. Plasma angiotensin-II concentration was measured by immunoassay at admission. RESULTS: Frequency of ACE I/D genotype was similar in ARDS and control groups (p = 0.18). In the ARDS group, severe hypoxemia was less frequent in D allele carriers (p < 0.05). Plasma angiotensin-II levels were associated with genotype in the ARDS group, but not controls, being higher in D allele carriers (p = 0.016). CONCLUSION: These data do not support the association between ACE I/D genotype and ARDS, although severe hypoxemia was less frequent in D allele carriers. ACE I/D polymorphism modified angiotensin-II levels in pediatric ARDS, but its pathogenic role is not well understood and needs to be addressed in future studies.Item Botulismo infantil. Comunicación de un caso clínico y revisión de la literatura(Sociedad Chilena de Infectología, 2009) Arriagada, Daniela; Wilhelm, Jan; Donoso, AlejandroEl botulismo es un trastorno poco frecuente en nuestro país. De las formas conocidas, el botulismo infantil da cuenta de la mayoría de los casos. Comunicamos el caso clínico de un paciente de siete meses, sexo masculino, sin antecedentes mórbidos. Historia de dos semanas de coriza, tos y decaimiento. Tras la ingesta de miel presentó exacerbación de la sinto-matología respiratoria, constipación y debilidad muscular progresiva. Se analizó muestra de heces resultando positiva para Clostridium botulinum grupo I tipo A. El estudio electromiográñco fue compatible con el diagnóstico. Presentó hipertensión arterial, atribuyéndose a disfunción autonómica, con buena respuesta a bloqueadores de los canales de calcio. Recuperó progresivamente el tono muscular. En un control ambulatorio se apreciaba importante regresión de la sinto-matología. El botulismo infantil es una enfermedad potencialmente letal de no tratarse oportunamente y de difícil diagnóstico, ya que su presentación es similar a otros cuadros clínicos. Es necesario educar a padres y personal médico sobre las medidas de prevención para los lactantes bajo doce meses de edad.Item 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, PabloIntroducción: 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.Item Coqueluche grave: Estado del arte(Sociedad Medica de Santiago, 2012) Donoso, Alejandro; Arriagada, Daniela; Cruces, Pablo; Diaz, FrancoPertussis is a contagious disease that has reappeard in the recent years as a public health problem in our country. The clinical presentation has changed especially in the main risk group, children under one year old, evolving in occasions to a highly lethal course called malignant or severe Pertussis. The present review discusses the epidemiology and the mechanisms of pathogenicity, and also describes the risk factors, clinical features and pathophysiology of this particular form. The current evidence and effectiveness of new treatments are described, and a treatment algorithm is proposed.Item 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, PabloBACKGROUND: 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.Item 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, PabloBackground: 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.Item 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, PabloEn 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.Item Evaluación de la microcirculación sublingual en un paciente en shock séptico(2012) Donoso, Alejandro; Arriagada, Daniela; Cruces, Pablo; Abarca, Juan; Díaz, FrancoIntroducción: 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.Item Falla multiorgánica asociada a hipertermia en una lactante con síndrome de Prader-Willi. caso clínico(Sociedad Argentina de Pediatría, 2013) Donoso, Alejandro; Arriagada, Daniela; Campbell, Stephanie; Cruces, PabloHeat stroke is a medical emergency characterized primarily by an elevated core temperature associated with a systemic inflammatory response, which causes multiple organ dysfunction in which encephalopathy predominates. If it is not early treated has high mortality. The Prader-Willi syndrome is a multisystem genetic disorder secondary to an abnormality in long arm chromosome 15 (15q11-q13), characterized by neonatal central hypotonia, developmental delay, hypogonadism, hyperphagia and obesity. These patients are susceptible to developing thermoregulatory problems. We report the case of a 5-month-old infant, in whom a diagnosis of Prader-Willi syndrome was established in the course of a febrile episode without known focus, who developed multiorganic failure and rhabdomyolysis secondary to hyperthermia.Item Fístula nefrobronquial en paciente pediátrico. Caso clínico(Sociedad Argentina de Pediatría, 2014) Arriagada, Daniela; Donoso, Alejandro; Cruces, Pablo; Verdugo, JaimeNephrobronchial fistula is a rare complication of kidney infections, usually occurring in adult patients with xanthogranulomatous pyelonephritis and very occasionally in children. We reported a 12-year-old girl, with a history of myelomeningocele and recurrent urinary tract infection, who presented with a four-week fever, cough and dyspnea, developing septic shock and presenting flood of airway by pus which caused cardiac arrest. A diagnosis of left perirenal extensive collection was established by abdominal computed tomography (CT). The patient first had antibiotic therapy and percutaneous drainage was performed draining pus and air. Thoracic and abdominal CT scan was performed corroborating transdiaphragmatic fistula. Total nephrectomy was performed. The patient showed gradual improvement after surgery and total regression of symptoms. Pathologic examination concluded chronic pyelonephritis. This case report illustrates a rare complication in children, the importance of early diagnosis of urinary tract infection in patients with comorbidities and of exhibiting a high index of suspicion to a potentially lethal complication.Item 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, PabloBACKGROUND: 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.Item 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, FrancoRecent 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.Item Neonatal meningococcal disease(2011) Donoso, Alejandro; Fuentes Fuhrmann, C.; Arriagada, DanielaItem Respiratory and hemodynamic effects of a stepwise lung recruitment maneuver in pediatric ARDS: a feasibility study(John Wiley & Sons, 2013) Cruces, Pablo; Donoso, Alejandro; Valenzuela, Jorge; Díaz, FrancoBACKGROUND: Little is known about the efficacy and safety of recruitment maneuvers (RMs) in pediatric patients with acute respiratory distress syndrome (ARDS). We therefore assessed the effects on gas exchange and lung mechanics and the possible detrimental effects of a sequential lung RMs and decremental positive end-expiratory pressure (PEEP) titration in pediatric ARDS patients. METHODS: We enrolled patients <15 years of age with ARDS, progressive hypoxemia, <72 hr of mechanical ventilation, and hemodynamic stability. A step-wise RM and decremental PEEP trial were performed. Safety was evaluated as the occurrence of hypotension and low pulse oxymeter oxygen saturation during the maneuver and development of airleaks after. Efficacy was evaluated as changes in lung compliance (Cdyn ) and gas exchange 1, 12, and 24 hr after the RM. RESULTS: We included 25 patients, of median age 5 (1-16) months, median weight 7.0 (4.1-9.2) kg, median PaO2 /FIO2 117 (96-139), and median Cdyn 0.48 (0.41-0.68) ml/cmH2 O/kg at baseline. Thirty RM were performed, with all completed successfully. No airleaks developed. Mild hypotension was detected during four procedures. Following RM, Cdyn , and PaO2 /FIO2 increased significantly (P < 0.01 each), without changes in PaCO2 (P = 0.4). A >25% improvement in lung function (Cdyn or PaO2 /FIO2 ) was observed after 90% of the RM procedures. Gas exchange worsening over the next 24 hr resulted in HFOV use in 36% of patients, while the remaining subjects sustained improvements in oxygenation at 12 and 24 hr. The 28-day mortality rate was 16%. CONCLUSIONS: Sequential RMs were safe and well tolerated in hemodynamically stable children with ARDS. RMs and a decremental PEEP trial may improve lung function in pediatric patients with ARDS and severe hypoxemia.Item Ruptura gástrica idiopática en niño preescolar. Informe de un caso(Sociedad Argentina de Pediatría, 2012) Donoso, Alejandro; Arriagada, Daniela; Cruces, Pablo; Diaz, FrancoIdiopathic gastric rupture is rare in children. Most of them occur in newborn. The authors report the case of a 2-year-old female toddler with no significant medical records. Clinical picture began 48 h before with abdominal pain, nausea and vomiting. She was admitted to the Emergency Room in poor general condition, with abdominal distension and rebound tenderness. Laparotomy was performed immediately show-ing multiple perforations in the posterior wall of the stomach. Partial gastrectomy was performed. Afterwards, she was admitted to ICU in shock. She received mechanical ventilation, intravenous fluid administration (260 ml/kg in 12 h), vasoactive support and antibacterial therapy (cefotaxime and metronidazole). Laboratory showed leukopenia and thrombocytopenia. Etiological study was entirely negative for toxic and drug consumption. Collagen disease was ruled out and serum level of gastrin was normal. Her post operative course was characterized by persistent fever caused by left subphrenic collection (positive culture for Candida galabrata). Peritoneal lavage via laparotomy and percutaneous drainage of the residual collections were performed. She completed 3 weeks of antibacterial and antifungal therapies with adequate outcome. Her follow-up in 12 months was uneventful.Item Septic shock in ICU: Update in hemodynamic monitoring(2013) Arriagada, Daniela; Donoso, Alejandro; Cruces, Pablo; Díaz, FrancoIn recent decades, new and important concepts have emerged for the diagnosis and management of the pediatric patient with septic shock, although the basic principles have remained similar over time. Attending physicians in the pediatric intensive care unit (PICU) must be fully aware of these concepts in order to improve patient care in the critical care unit. Hemodynamic monitoring is a tool that not only allows detection of the source of hemodynamic instability but also guides treatment and assesses its effectiveness. Fluid loading is considered the fi rst step in the resuscitation of hemodynamically unstable patients. Nevertheless, clinical determination of the intravascular volume can be extremely diffi cult in a critically ill patient. Studies performed have demonstrated that cardiac fi lling pressures are unable to predict fl uid responsiveness. Dynamic tests of volume responsiveness use the change in stroke volume during mechanical ventilation assessing the patients’ Frank-Starling curve. Through fl uid challenge the clinician can assess whether the patient has a preload reserve that can be used to increase the stroke volume. In this review we updated the available information on basic and functional hemodynamic monitoring.Item Shock séptico en la Unidad de Cuidados Intensivos. Terapéutica avanzada, inmunoparálisis y genómica. Estado del arte(Sociedad Argentina de Pediatría, 2014) Arriagada, Daniela; Donoso, Alejandro; Cruces, Pablo; Díaz, FrancoNew and important concepts have emerged for the advanced management of the child with septic shock in the recent decades. Attending physicians in the Pediatric intensive care unit must be fully aware of them to improve patient care in the critical care unit. It should be considered the use of immune therapy only in selected groups of patients. Continuous renal replacement therapies are well tolerated and their early use prevents deleterious fluid overload. Removal of inflammatory mediators by using high volume hemofiltration may play a role in hyperdynamic septic patients. The use of plasmapheresis is recommended in patients with thrombocytopenia-associated multiple organ failure. Extracorporeal support use should be considered in those with refractory septic shock despite goals directed therapy. The immunoparalysis has been associated with nosocomial infections and late mortality. The information from genetic markers may allow early intervention and preventive genomics-based medicine.Item Shock séptico en pediatría I. Enfoque actual en el diagnóstico y tratamiento(2013) Donoso, Alejandro; Arriagada, Daniela; Cruces, Pablo; Díaz, FrancoEl shock séptico es una de las principales causas de mortalidad infantil a nivel mundial y representa una compleja y progresiva vía inflamatoria secundaria a una enfermedad infecciosa, la cual origina disfunción cardiovascular aguda, no necesariamente hipotensión arterial, condicionando disoxia tisular y eventualmente falla celular y orgánica. Los paquetes de medidas de resucitación propuestos enfatizan el reconocimiento clínico y un tratamiento precoz. Estas intervenciones se basan en la pronta y agresiva resucitación con fluidos intravenosos para una adecuada perfusión tisular, administración de antibióticos, remoción del foco infeccioso y el uso de drogas vasoactivas en caso de ser necesario. La terapia debe evaluarse permanentemente según la normalización de metas clínicas y de laboratorio. En la presente publicación se actualiza el conocimiento de las características epidemiológicas y fisiopatológicas de la sepsis, una puesta al día en definiciones operacionales, campañas internacionales y referentes a las iniciativas propuestas para disminuir su morbimortalidad. Se aborda el enfoque terapéutico inicial en el servicio de urgencia. El objetivo de este artículo es dar a conocer el estado actual del conocimiento en el diagnóstico y tratamiento del paciente con shock séptico especialmente en su fase inicial previo al ingreso a UCI.Item Shock séptico en pediatría II. Enfoque actual en el diagnóstico y tratamiento(2013) Donoso, Alejandro; Arriagada, Daniela; Cruces, Pablo; Díaz, FrancoAunque los principios básicos para el diagnóstico y los pilares terapéuticos del niño con shock séptico se mantienen en el tiempo, es innegable que en las últimas décadas se han incorporado nuevos y trascendentes conceptos, siendo importante que el médico tratante en el Servicio de Urgencia tenga conocimiento a cabalidad de ellos. En la segunda parte de esta actualización se discuten las similitudes y diferencias entre la población infantil y adulta, la utilidad de las metas de reanimación metabólicas, como también el enfoque terapéutico inicial en el paciente séptico. Los conceptos más importantes revisados se refieren a las diferencias entre el niño y adulto con shock séptico, especialmente en la fisiopatología, clínica y tratamiento. Se recalca la importancia de expansión de la volemia y el uso de drogas vasoactivas si no hay respuesta a fluidos de reanimación. El manejo terapéutico debe estar orientado a la búsqueda de la normalización de metas macrohemodinámicas y de perfusión sistémica. Se deben evitar los errores más frecuentes de observar en el tratamiento inicial del paciente séptico. Esta entidad presenta una elevada incidencia y mortalidad, por lo cual el manejo precoz y agresivo es de máxima importancia en pediatría.Item Shock séptico en unidad de cuidados intensivos. Enfoque actual en el tratamiento(Sociedad Chilena de Pediatría. Publicado por Elsevier España, S.L.U., 2015) Arriagada, Daniela; Donoso, Alejandro; Cruces, Pablo; Díaz, FrancoEssential therapeutic principles in children with septic shock persist over time, although some new concepts have been recently incorporated, and fully awareness of pediatricians and intensivists is essential. Fluid resuscitation is a fundamental intervention, but the kind of ideal fluid has not been established yet, as each of these interventions has specific limitations and there is no evidence supportive of the superiority of one type of fluid. Should septic shock persists despite adequate fluid resuscitation, the use of inotropic medication and/or vasopressors is indicated. New vasoactive drugs can be used in refractory septic shock caused by vasopressors, and the use of hydrocortisone should be considered in children with suspected adrenal insufficiency, as it reduces the need for vasopressors. The indications for red blood cells transfusion or the optimal level of glycemia are still controversial, with no consensus on the threshold value for the use of these blood products or the initiation of insulin administration, respectively. Likewise, the use of high-volume hemofiltration is a controversial issue and further study is needed on the routine recommendation in the course of septic shock. Nutritional support is crucial, as malnutrition is a serious complication that should be properly prevented and treated. The aim of this paper is to provide update on the most recent advances as concerns the treatment of septic shock in the pediatric population.