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Introducción: En los últimos años destaca en la literatura especializada una preocupación reciente sobre las cuestiones referentes al cuidado del paciente en fase terminal dentro de la unidad de cuidados intensivos pediátrica (UCIP), prestando especial atención a la unidad familia/paciente, comunicación y muerte digna. Objetivo: Evaluar a través de la revisión bibliográfica, la experiencia y el desarrollo de los cuidados al final de la vida dentro de las UCIP, determinando qué tipo de estudios se han realizado, qué temas se han tratado y cuál ha sido la evolución en los últimos años. Material y métodos: Revisión de la literatura médica en Medline y la base de datos National Library of Medicine Gateway, utilizando las palabras claves extraídas del MeSH: "end of life", "pediatric intensive care", "critical care", "palliative care", "death", "compassionate care". El año límite inferior de la búsqueda fue 1990. Los idiomas seleccionados fueron inglés y castellano. Los criterios de inclusión fueron la relación con el tema objeto de estudio, excluyéndose aquellos artículos que no tenían abstract. Se obtuvieron trabajos adicionales a través de las referencias bibliográficas de los artículos seleccionados. Resultados: De la búsqueda inicial se obtuvieron un total de 81 artículos de los que se seleccionaron 43 por sus referencias al cuidado al final de la vida en UCI, de los cuáles 18 hacían especial referencia a la UCIP. Más de la mitad (62 %) fueron revisiones del tema y el resto, estudios de tipo descriptivo u observacional. El número de publicaciones es creciente a partir del año 1995. La mayoría de los trabajos (85 %) han sido realizados en Estados Unidos y Canadá, y se han encontrado tres referencias en España. Conclusiones: En los últimos años se han llevado a cabo varios estudios que muestran cada vez mayor sensibilización acerca de cuestiones sobre la limitación del esfuerzo terapéutico y la necesidad de mejorar los cuidados médicos y de bienestar al final de la vida en el entorno de la UCIP

Introduction: In the last few years, there has been growing concern in the literature about issues related to end-of-life care in pediatric intensive care units (PICUs), with special attention on the family/patient unit, communication, and a dignified death. Objective: To evaluate the experience and development of end-of-life care in PICUs through a literature review, by determining the type of studies that have been performed, their topics, the issues discussed, and their development in the last few years. Material and methods: Review of the medical literature in Medline and the database of the National Library of Medicine Gateway, using the key words from MeSH: "end of life", "pediatric intensive care", "critical care", "palliative care", "death", and "compassionate care". The earliest year of the search was 1990. The languages selected were English and Spanish. Inclusion criteria were the relationship with the topic to be studied, excluding articles with no abstract. Additional searches were made of references in selected articles. Results: Eighty-one articles were retrieved from the initial search. Of these, 43 were selected as the most relevant investigations in end-of-life care in ICUs and 18 placed special emphasis on the PICU. More than half of the articles (62 %) were reviews and the remaining articles were descriptive or observational studies. The number of publications increased after 1995. Most of the studies were performed in the USA or Canada and only three studies were performed in Spain. Conclusions: In the last few years, several studies have been performed that reveal increasing concern about limits to therapeutic intervention and the need to improve end-of-life care in the PICU setting

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INTRODUCTION: In the last few years, there has been growing concern in the literature about issues related to end-of-life care in pediatric intensive care units (PICUs), with special attention on the family/patient unit, communication, and a dignified death. OBJECTIVE: To evaluate the experience and development of end-of-life care in PICUs through a literature review, by determining the type of studies that have been performed, their topics, the issues discussed, and their development in the last few years. MATERIAL AND METHODS: Review of the medical literature in Medline and the database of the National Library of Medicine Gateway, using the key words from MeSH: "end of life", "pediatric intensive care", "critical care", "palliative care", "death", and "compassionate care". The earliest year of the search was 1990. The languages selected were English and Spanish. Inclusion criteria were the relationship with the topic to be studied, excluding articles with no abstract. Additional searches were made of references in selected articles. RESULTS: Eighty-one articles were retrieved from the initial search. Of these, 43 were selected as the most relevant investigations in end-of-life care in ICUs and 18 placed special emphasis on the PICU. More than half of the articles (62 %) were reviews and the remaining articles were descriptive or observational studies. The number of publications increased after 1995. Most of the studies were performed in the USA or Canada and only three studies were performed in Spain. CONCLUSIONS: In the last few years, several studies have been performed that reveal increasing concern about limits to therapeutic intervention and the need to improve end-of-life care in the PICU setting.

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We analyze 13 children between 1 and 3 years old (mean: 24.6 +/- 6.5 months), who were diagnosed (by direct or radiological examination) of epiglottitis. Seven were male. All of them had fever and respiratory distress. Six blood cultures (46%) were positive for Hemophilus Influenzae, and in 5 cases were resistant to beta-lactamases. Diagnose was made by radiology (70%) or by direct examination (30%). Five patients were not intubated (38%), with a favorable outcome. One died after a cardiorespiratory arrest due to self-extubation. We describe in this study our experience in the conservative treatment of epiglotitis, although initial nasotracheal intubation is the safest method for the management of this entity.

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We analyzed 8 cases of meningococcal septic shock diagnosed in a three year period. The age varied from 20 months to 10 years (mean: 4.8 years). Two patients died. Every child was monitored with a Swan-Ganz catheter 5 F or 7F, placed on by puncture of internal jugular or subclavicular veins. Of this hemodynamic study, we can conclude that in septic shock, there is a myocardial depression, that persist for several days, and improves with dopamine and dobutamine. In addition to this, in sepsis exists a pulmonary hypertension that makes worse the prognosis.

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We study the renal function in meningococcal sepsis in other to get prognostic data in disease evolution. We include 116 patients of whom we take data of anamnesis; physical examination; blood, urine and cerebrospinal fluid biochemical and microbiologic studies and TISS and APS score. We analyze qualitative and quantitative data of renal function statistical and we compare with another prognostic data of disease. We find that renal failure in meningococcal sepsis gets worse the prognostic of the disease.

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We report the occurrence of familial erythrophagocytic lymphohistiocytosis disease in a child who had greater involvement of the brain than of visceral organs. The diagnosis was made during life, allowing us to carry out biological, histological and immunological studies. The natural Killer activity was abolished in this patient. The combination chemotherapy--including systemic administration of VP 16-213, steroids and intrathecal methotrexate--, failed to stem the rapid course of the disease.

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There are no reports analyzing the results of pediatric intensive care in Europe. We evaluated quantitatively the severity of illness and the amount of care required for 714 consecutively admitted patients. We used simultaneously the Clinical Classification System (CCS) the Acute Physiology Score (APS) and the Therapeutic Intervention Scoring System (TISS). Overall mortality at 1 month was 15%. The mortality rate was higher for CCS Class IV patients (32.3%) than for CCS III (4.5%) and CCS II (3.2%). The difference was significant between CCS IV and CCS III and II respectively (p less than 0.001) but no difference was observed between CCS III and CCS II. The patients were also classified among 7 major organ system failures: cardio vascular, respiratory, neurologic, gastro intestinal, renal, metabolic, hematologic. Three of them were primarily involved: respiratory (44.9%) cardio-vascular (20.7%), neurologic (18.8%). Among these 3 groups the highest mortality was observed in cardio-vascular patients (p less than 0.01 v.s. respiratory, p less than 0.05 v.s. neurologic). The death rate was 22% among the 264 neonates, 9.7% among the 247 infants (p less than 0.01) and 12.6% among the 198 children. APS and TISS scores increased significantly with the CCS classes.(ABSTRACT TRUNCATED AT 250 WORDS)

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IV catecholamines are a very important therapy in the Pediatric ICU. Their application is very discussed, principally in the pediatric age, where effects, beginning by a remembrance of its physiology (endogenous production, storing, destruction, with an explanation of the adrenergic system, according with Ahlquist). Pharmacologic activity and clinical characteristics of their application and basic requirements for its IV use (monitorization, exact dosification, permeable venous way) are revised. Authors analyse independently the three catecholamines of more common use: isoproterenol, dopamine and dobutamine, discussing systematically its' actions on three levels: a) heart; b) systemic circulation, and c) pulmonary circulation. They discuss their indications, contraindications, risks and precaution in their use and dosification concluding that the more common catecholamines are dopamine and dobutamine, being the last one more recommended in the future, by its' more selective effects on the heart. Isoproterenol has very specific indications, in acute phases and during short periods of time. Adrenaline and noradrenaline are also considered. Finally, association of different drugs looking for improvement of positive effects and reduction of negative ones is mentioned.

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Clinical, hemodynamic and pathologic findings of three patients with total anomalous pulmonary venous drainage to the portal vein system are presented. Some of the findings are emphasized because of its rarity in previous reports. These are: 1) Cyanosis was mild. 2) There was some obstruction of the foramen ovale, besides the obstruction at the portal system level. In two patients gastrointestinal bleeding and analitical evidence of renal failure, were found, both findings not previously reported to our knowledge.

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Experience on the treatment of 85 ventricular fibrillation in 20 children by transthoracic electric shock with continuous electrical current is studied. Initially an energy level of 2 W./sec./Kg., was used and obtained 95% of effectivity. 50% of patients were dead because they did not recover effective cardiac rhythm, in spite of the effectivity of desfibrillation. Authors evaluate the importance of correction of metabolic disturbances and hipoxemia as predisposing factors of ventricular fibrillation and success of treatment. They think that energy level of 2 W./sec./Kg., is efficient. Effectivity of therapy depends, mainly, on rapidity and training of the pediatric intensive care team.

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A case of renal vein and inferior cava thrombosis in a previously catheterized infant with cyanotic congenital heart disease is reported. The different origins of R.V.T. in newborns and infants are briefly discussed. The different factors that favour the beginning of thrombotic process (cyanotic heart disease diabetic mother, etc.) are also emphasized. Some considerations are made on the danger inherent to the use of intravascular catheters.

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