Vomitos en Pediatrìa

Dr. Douglas Umbría douglasumbria@hotmail.com [SALUD_LORETO] <SALUD_LORETO@yahoogroups.com>

Para:Ciberpeds,Pediatras Yahoo Chiquinquira,Salud Loreto,Pediatria Peru

8 jul a las 8:28

Vomitos en Pediatrìa

Vomiting in Children.

Shields, T.M et al.

Pediatrics in review. 2018; 39(7): 342 – 358

El vómito es un síntoma muy común en el niño y motivo frecuente en nuestra consulta. 

Se define como la expulsión forzada del contenido gástrico a través de la boca y / o nariz.

Puede presentarse en cualquier enfermedad y en cualquier momento de su evolución. 

Su importancia es variable, puede ser desde un síntoma acompañante de una enfermedad hasta un síntoma fundamental.

Hay 4 vías fisiológicas principales que pueden desencadenar el reflejo emético: toxinas mecánicas, transmitidas por la sangre, el movimiento y los desencadenantes emocionales.

Cada vía se desencadena por diferentes sistemas de órganos e involucra diferentes neurotransmisores.

Encontrar una etiología puede ser un reto porque los vómitos pueden implicar una

variedad de diferentes sistemas de órganos en el cuerpo.

En pediatría existen múltiples patologías que cursan con vómitos; las causas infecciosas son las más frecuentes (GEA, infecciones respiratorias, otitis, neumonías, infecciones del tracto urinario, sepsis, meningitis).

Los vómitos relacionados con patología quirúrgica generalmente se asocian a dolor abdominal.

La invaginación es la causa más frecuente de obstrucción intestinal entre los 3 meses y los 3 años.

El establecimiento de un diagnóstico diferencial para el vómito debe tener en cuenta tanto la edad del niño como las características temporales de su vómito.

El vómito difiere del reflujo gastroesofágico (GER) y la regurgitación ya que en estas dos últimas condiciones no hay expulsión de contenido duodenales.

Tambien difieren de la rumiación, ya en esta los pacientes se auto promueven para regurgitar de manera electiva, y con frecuencia mastican y tragan sus alimentos regurgitados nuevamente. 

El tratamiento farmacológico no está indicado de forma rutinaria. 

Podemos emplear ondansetrón para garantizar la tolerancia oral en los niños con gastroenteritis aguda, este medicamento (a una dosis de i.v. a 0,15 mg/kg máximo 8 mg y v.o. a 2 mg para 8-15 kg, 4 mg para 15-30 kg y 8 > 30 kg) ha demostrado ser capaz de disminuir el número de vómitos en niños esta patología así como el número de ingresos y reconsultas en los servicios de urgencias, con mínimos efectos secundarios (diarrea leve), siendo un fármaco seguro.

Comparto interesante revisión sobre la fisiopatología, causas diagnóstico y tratamiento en Pediatrìa en el siguiente link:

https://drive.google.com/file/d/1RxLbZojKdHTa9ByTx3nGfoWTl97qKfL3/view?usp=sharing

Neuroprotección farmacológica / Pharmacological neuroprotection

Julio 5, 2018. No. 3132

PDF Un metaanálisis de neuroprotección farmacológica en cirugía no cardíaca: enfoque en estatinas, lidocaína, ketamina y sulfato de magnesio. A meta-analysis of pharmacological neuroprotection in noncardiac surgery: focus on statins, lidocaine, ketamine, and magnesium sulfate. Zeng ZW1, Zhang YN, Lin WX, Zhang WQ, Luo R. Author information Eur Rev Med Pharmacol Sci. 2018 Mar;22(6):1798-1811. doi: 10.26355/eurrev_201803_14599. Abstract OBJECTIVE: Non-cardiac surgery is associated with perioperative cerebral complications (delirium, postoperative cognition dysfunction, stroke). While rare, these complications can lead to disabilities and deaths. Information is ambiguous as to whether pharmacological preoperative treatment exerts neuroprotection. We wished to systematically assess potential modulation by statins, lidocaine, ketamine or magnesium sulfate of the relative risk of cerebral complications in noncardiac surgery. Selection of these pharmacological agents was based on their known neuroprotective abilities. PATIENTS AND METHODS: By searching Medline, EMBASE and Cochrane databases, we identified 4 suitable publications that collectively enrolled 1358 patients (intent-to-treat population), of which 679 patients were treated preoperatively with statins (404 patients on atorvastatin and 275 on rosuvastatin) and 679 patients with preoperative placebo. The reported cerebral outcome was stroke, assessed either within 30 days (4 publications) or 6 months (2 publications) after surgery. RESULTS: Episodes of stroke within 30 days and 6 months postoperatively were observed in several publications, enabling aggregate analyses. No modulation by statins of the relative risk of stroke at 30 days was observed (risk ratio 1.59, 95% confidence interval 0.08-30.97; p = 0.76). At 6 months, statins showed an insignificant trend toward neuroprotection (risk ratio 0.33, 95% confidence interval 0.05-2.10; p = 0.24). CONCLUSIONS: The available clinical data are still scarce. Our analyses indicate no protective effects by statins against perioperative stroke but some favorable trends toward delayed stroke. Further randomized trials are needed to unequivocally assess the neuroprotective potential of current pharmacological agents in non-cardiac surgery. PDF Congresos Médicos por Especialidades en todo Mundo Medical Congresses by Specialties around the World Información / Information Ver Programa Curso Regional de Sur Sureste de Medicina del Dolor y Cuidados Paliativos Agosto 24-25. Oaxaca, México Informacion / Information Información / Information Events of the California Society of Anesthesiologists Información / Information Safe Anaesthesia Worldwide Delivering safe anaesthesia to the world's poorest people Informes / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

UCI / ICU

Julio 2, 2018. No. 3129

Novela en PDF El papel del ultrasonido en la atención crítica prehospitalaria: una revisión sistemática. The role of point of care ultrasound in prehospital critical care: a systematic review. Bøtker MT1,2, Jacobsen L3,4, Rudolph SS5,6, Knudsen L7. Author information Scand J Trauma Resusc Emerg Med. 2018 Jun 26;26(1):51. doi: 10.1186/s13049-018-0518-x. Abstract BACKGROUND: In 2011, the role of Point of Care Ultrasound (POCUS) was defined as one of the top five research priorities in physician-provided prehospital critical care and future research topics were proposed; the feasibility of prehospital POCUS, changes in patient management induced by POCUS and education of providers. This systematic review aimed to assess these three topics by including studies examining all kinds of prehospital patients undergoing all kinds of prehospital POCUS examinations and studies examining any kind of POCUS education in prehospital critical care providers. METHODS AND RESULTS: By a systematic literature search in MEDLINE, EMBASE, and Cochrane databases, we identified and screened titles and abstracts of 3264 studies published from 2012 to 2017. Of these, 65 studies were read in full-text for assessment of eligibility and 27 studies were ultimately included and assessed for quality by SIGN-50 checklists. No studies compared patient outcome with and without prehospital POCUS. Four studies of acceptable quality demonstrated feasibility and changes in patient management in trauma. Two studies of acceptable quality demonstrated feasibility and changes in patient management in breathing difficulties. Four studies of acceptable quality demonstrated feasibility, outcome prediction and changes in patient management in cardiac arrest, but also that POCUS may prolong pauses in compressions. Two studies of acceptable quality demonstrated that short (few hours) teaching sessions are sufficient for obtaining simple interpretation skills, but not image acquisition skills. Three studies of acceptable quality demonstrated that longer one- or two-day courses including hands-on training are sufficient for learning simple, but not advanced, image acquisition skills. Three studies of acceptable quality demonstrated that systematic educational programs including supervised examinations are sufficient for learning advanced image acquisition skills in healthy volunteers, but that more than 50 clinical examinations are required for expertise in a clinical setting. CONCLUSION: Prehospital POCUS is feasible and changes patient management in trauma, breathing difficulties and cardiac arrest, but it is unknown if this improves outcome. Expertise in POCUS requires extensive training by a combination of theory, hands-on training and a substantial amount of clinical examinations - a large part of these needs to be supervised. KEYWORDS: Cardiac arrest; Critical care; Dyspnea; Education; Point of care; Prehospital; Systematic review; Trauma; Ultrasound PDF Antiepiléticos en el paciente grave Antiepileptic drugs in critically ill patients. Farrokh S1, Tahsili-Fahadan P2,3, Ritzl EK2,4, Lewin JJ 3rd5, Mirski MA5. Author information Crit Care. 2018 Jun 7;22(1):153. doi: 10.1186/s13054-018-2066-1. Abstract BACKGROUND: The incidence of seizures in intensive care units ranges from 3.3% to 34%. It is therefore often necessary to initiate or continue anticonvulsant drugs in this setting. When a new anticonvulsant is initiated, drug factors, such as onset of action and side effects, and patient factors, such as age, renal, and hepatic function, should be taken into account. It is important to note that the altered physiology of critically ill patients as well as pharmacological and nonpharmacological interventions such as renal replacement therapy, extracorporeal membrane oxygenation, and target temperature management may lead to therapeutic failure or toxicity. This may be even more challenging with the availability of newer antiepileptics where the evidence for their use in critically ill patients is limited. MAIN BODY: This article reviews the pharmacokinetics and pharmacodynamics of antiepileptics as well as application of these principles when dosing antiepileptics and monitoring serum levels in critically ill patients. The selection of the most appropriate anticonvulsant to treat seizure and status epileptics as well as the prophylactic use of these agents in this setting are also discussed. Drug-drug interactions and the effect of nonpharmacological interventions such as renal replacement therapy, plasma exchange, and extracorporeal membrane oxygenation on anticonvulsant removal are also included. CONCLUSION: Optimal management of antiepileptic drugs in the intensive care unit is challenging given altered physiology, polypharmacy, and nonpharmacological interventions, and requires a multidisciplinary approach where appropriate and timely assessment, diagnosis, treatment, and monitoring plans are in place. KEYWORDS: Antiepileptic drugs; Critical care; Drug-drug Interaction; Pharmacodynamics; Pharmacokinetics; Seizure PDF Biomarcadores en falla renal inducida por sepsis Biomarkers of Sepsis-Induced Acute Kidney Injury. Wang K1, Xie S1, Xiao K1, Yan P1, He W2, Xie L1. Author information Biomed Res Int. 2018 Apr 24;2018:6937947. doi: 10.1155/2018/6937947. eCollection 2018. Abstract Sepsis, an infection-induced systemic disease, leads to pathological, physiological, and biochemical abnormalities in the body. Organ dysfunction is caused by a dysregulated host response to infection during sepsis which is a major contributing factor to acute kidney injury (AKI) and the mortality rate for sepsis doubles due to coincidence of AKI. Sepsis-induced AKI is strongly associated with increased mortality and other adverse outcomes. More timely diagnosis would allow for earlier intervention and could improve patient outcomes. Sepsis-induced AKI is characterized by a distinct pathophysiology compared with other diseases and may also have unique patterns of plasma and urinary biomarkers. This concise review summarizes properties and perspectives of the biomarkers for their individual clinical utilization. PDF Ver programa Información / Information Congresos Médicos por Especialidades en todo Mundo Medical Congresses by Specialties around the World Información / Information Events of the California Society of Anesthesiologists Información / Information Safe Anaesthesia Worldwide Delivering safe anaesthesia to the world's poorest people Informes / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org

Bloqueos neuroaxiales con ultrasonido / Ultrasound guided central neuraxial block

Junio 29, 2018. No. 3126

Sonoanatomía relevante para los bloqueos neuroaxiales centrales guiados por ecografía a través del abordaje paramediano en la región lumbar. Sonoanatomy relevant for ultrasound-guided central neuraxial blocks via the paramedian approach in the lumbar region. Karmakar MK1, Li X, Kwok WH, Ho AM, Ngan Kee WD. Author information Br J Radiol. 2012 Jul;85(1015):e262-9. doi: 10.1259/bjr/93508121. Epub 2011 Oct 18. Abstract OBJECTIVES: The use of ultrasound to guide peripheral nerve blocks is now a well-established technique in regional anaesthesia. However, despite reports of ultrasound guided epidural access via the paramedian approach, there are limited data on the use of ultrasound for centralneuraxial blocks, which may be due to a poor understanding of spinal sonoanatomy. The aim of this study was to define the sonoanatomy of the lumbar spine relevant for central neuraxial blocks via the paramedian approach. METHODS: The sonoanatomy of the lumbar spine relevant for central neuraxial blocks via the paramedian approach was defined using a "water-based spine phantom", young volunteers and anatomical slices rendered from the Visible Human Project data set. RESULTS: The water-based spine phantom was a simple model to study the sonoanatomy of the osseous elements of the lumbar spine. Each osseous element of the lumbar spine, in the spine phantom, produced a "signature pattern" on the paramedian sagittal scans, which was comparable to its sonographic appearance in vivo. In the volunteers, despite the narrow acoustic window, the ultrasound visibility of the neuraxial structures at the L3/L4 and L4/L5 lumbar intervertebral spaces was good, and we were able to delineate the sonoanatomy relevant for ultrasound-guided central neuraxial blocks via the paramedian approach. CONCLUSION: Using a simple water-based spine phantom, volunteer scans and anatomical slices from the Visible Human Project (cadaver) we have described the sonoanatomy relevant for ultrasound-guided central neuraxial blocks via the paramedian approach in the lumbar region. PDF Ultrasonido para bloqueos neuroaxiales Ultrasound for Central Neuraxial Blockade Kyle R. Kirkham, Ki Jinn Chin Curr Anesthesiol Rep (2013) 3:242-249 Abstract The evidence base supporting the role of ultrasound to assist the performance of neuraxial anesthesia has become increasingly strong over the last decade. In both the lumbar and thoracic spine, ultrasound has been shown to optimize technical performance, improve patient outcomes, and potentially reduce harm. Specifically, ultrasound aids in identification of intervertebral levels, estimation of depth to epidural and intrathecal spaces, and localization of important landmarks including the midline and interlaminar space. These characteristics can facilitate both planning and performance of neuraxial blockade by reducing the required number of needle insertions and redirections, minimizing the risk of traumatic needle placements, and improving block effectiveness after epidural placement. This report details the evidence supporting each of these outcomes and also discusses the current understanding of both learning and teaching the skill of neuraxial ultrasonography. Keywords Ultrasound Epidural anesthesia Spinal anesthesia PDF Guía con ultrasonido para bloqueos neuroaxiales Ultrasound guided central neuraxial block Samina Ismail Anaesth Pain & Intensive Care 2015;19(3):361-365 ABSTRACT Central neuraxial blocks (CNB) are the preferred blocks in the practice of regional anesthesia. Palpation of the anatomical landmarks is used for the identification of the space, which is not always the best method when CNB is performed in overweight patients or patients having atypical spines like scoliosis. Ultrasound (US) has recently been utilized to facilitate CNB. However, CNB US can be difficult, because the structures need to be visualized by US are surrounded by bones, which do not allow ultrasound rays to pass through. Therefore in order to allow deeper penetration, the ultrasound probe used for CNB is a curved probe of low frequency of 2-5 mHz, as it allows deeper penetration at the expense of image resolution. There are two scanning planes; transverse and longitudinal which supplements each other. US for CNB helps in determining the intercristal line, exact intervertebral level, midline, ideal point of insertion, distance to ligamentum flavum and needle trajectory. US for CNB has improved patient safety by decreasing the number of attempts, chances of dural puncture and damage to conus medullaris. It has also improved patient satisfaction and has proved to be an ideal learning tool for the trainees. Key words: Regional Anesthesia; Spinal Injections; Spinal Puncture; Anesthesia, Spinal; Anesthesia, Epidural; Anesthesia, Conduction; Ultrasonography Citation: Ismail S. Ultrasound Guided Central Neuraxial Block. PDF Ver programa Información / Information Congresos Médicos por Especialidades en todo Mundo Medical Congresses by Specialties around the World Información / Information Events of the California Society of Anesthesiologists Información / Information Safe Anaesthesia Worldwide Delivering safe anaesthesia to the world's poorest people Informes / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org