Papers by Jesús López-herce
Resuscitation, 2015
Abstracts / Resuscitation 96S (2015) 5-42 used to score team performance and procedural skills be... more Abstracts / Resuscitation 96S (2015) 5-42 used to score team performance and procedural skills before and after educational debriefings; improvement >10% was considered clinically significant. Our institutional review board approved the study. All providers and parents were provided written information and could opt-out at any time. Two experienced facilitators led the three-phased debriefings: In the descriptive phase the providers briefly described the event without any emotional comments. In the analysing phase short sequences of the video focusing on both technical skills, guideline adherence, and non-technical skills were demonstrated. Finally, providers summarized learning points and future application of knowledge.
Critical care (London, England), 2006
Refractory septic shock has dismal prognosis despite aggressive therapy. The purpose of the prese... more Refractory septic shock has dismal prognosis despite aggressive therapy. The purpose of the present study is to report the effects of terlipressin (TP) as a rescue treatment in children with catecholamine refractory hypotensive septic shock. We prospectively registered the children with severe septic shock and hypotension resistant to standard intensive care, including a high dose of catecholamines, who received compassionate therapy with TP in nine pediatric intensive care units in Spain, over a 12-month period. The TP dose was 0.02 mg/kg every four hours. Sixteen children (age range, 1 month-13 years) were included. The cause of sepsis was meningococcal in eight cases, Staphylococcus aureus in two cases, and unknown in six cases. At inclusion the median (range) Pediatric Logistic Organ Dysfunction score was 23.5 (12-52) and the median (range) Pediatric Risk of Mortality score was 24.5 (16-43). All children had been treated with a combination of at least two catecholamines at high ...
Critical Care, 2010
Introduction Continuous renal replacement therapy (CRRT) frequently gives rise to complications i... more Introduction Continuous renal replacement therapy (CRRT) frequently gives rise to complications in critically ill children. However, no studies have analyzed these complications prospectively. The purpose of this study was to analyze the complications of CRRT in children and to study the associated risk factors.
BMC Endocrine Disorders, 2014
Background: To study hormonal changes associated with severe hyperglycemia in critically ill chil... more Background: To study hormonal changes associated with severe hyperglycemia in critically ill children and the relationship with prognosis and length of stay in intensive care.
Resuscitation, 2012
Purpose: Incorrect resuscitation after hypovolemic shock is a major contributor to preventable pe... more Purpose: Incorrect resuscitation after hypovolemic shock is a major contributor to preventable pediatric death. Several studies have demonstrated that small volumes of hypertonic or hypertonic-hyperoncotic saline can be an effective initial resuscitation solution. However, there are no pediatric studies to recommend their use. The aim of this study is to determine if in an infant animal model of hemorrhagic shock, the use of hypertonic fluids, as opposed to isotonic crystalloids, would improve global hemodynamic and perfusion parameters. Methods: Experimental, randomized animal study including thirty-four 2-to-3-month-old piglets. 30 min after controlled 30 mL kg −1 bleed, pigs were randomized to receive either normal saline (NS) 30 mL kg −1 (n = 11), 3% hypertonic saline (HS) 15 mL kg −1 (n = 12), or 5% albumin plus 3% hypertonic saline (AHS) 15 mL kg −1 (n = 11). Results: High baseline heart rate (HR) and low mean arterial pressure (MAP), cardiac index (CI), brain tissue oxygenation index (bTOI), and lactate were recorded 30 min after volume withdrawal, with no significant differences between groups. Thirty minutes after volume replacement there were no significant differences between groups for HR (NS, 188 ± 14; HS, 184 ± 14; AHS, 151 ± 14 bpm); MAP (NS, 80 ± 7; HS, 86 ± 7; AHS, 87 ± 7 mmHg); CI (NS, 4.1 ± 0.4; HS, 3.9 ± 0.4; AHS, 5.1 ± 0.4 mL min −1 m −2 ); lactate (NS, 2.8 ± 0.7; HS, 2.3 ± 0.6; AHS, 2.4 ± 0.6 mmol L −1 ); bTOI (NS, 43.9 ± 2.2; HS, 40.1 ± 2.5; AHS, 46.1 ± 2.3%).
Resuscitation, 2012
Aim: Bioreactance is a new non-invasive method for cardiac output measurement (NICOM). There are ... more Aim: Bioreactance is a new non-invasive method for cardiac output measurement (NICOM). There are no studies that have analysed the utility of this technique in a pediatric animal model of hemorrhagic shock. Methods: A prospective study was performed using 9 immature Maryland pigs weighing 9 to 12 kg was performed. A Swan-Ganz catheter, a PiCCO catheter and 4 dual surface electrodes were placed at the four corners of the anterior thoracic body surface. Shock was induced by withdrawing a blood volume of 30 mL/kg, and then after, 30 mL/kg of Normal saline was administered. Seven simultaneous measurements of cardiac index (CI) were made by pulmonary artery thermodilution (PATD), Femoral artery thermodilution (FATD), and NICOM before, during, and after hypovolaemia and during and after volume expansion. Results: The mean difference (bias) of differences (limits of agreement) between PATD and FATD was 0.84 (−1.87-3.51) L/min/1.77 m 2 , between PATD and NICOM was 1.95 (−1.79-5.69) L/min/1.77 m 2 , and between FATD and NICOM was 1.06 (−1.40-3.52) L/min/1.77 m 2 . A moderate correlation was found between PATD and FATD (r = 0.43; P = 0.01), but no correlation was found between bioreactance and either PATD or FATD. Hypovolemia and volume expansion produced important significant differences in CI as measured by PATD and FATD, while the changes with bioreactance were small and non significant. Conclusions: PATD and FATD measurements showed similar responses to hypovolemic shock and volume expansion. Bioreactance persistently underestimates the CI and is not significantly altered by either inducing hemorrhagic shock, or later, through volume expansion. Bioreactance is not a suitable method for monitoring the CI in pediatric hemorrhagic shock.
Background: The 2010 guidelines recommend chest compressions (CPR) for cardio pulmonary resuscita... more Background: The 2010 guidelines recommend chest compressions (CPR) for cardio pulmonary resuscitation be performed at the rate of more than 100 times per minute. However, there is little evidence on the optimal tempo of chest compressions obtained from people and that takes into consideration rescuers' fatigue.
The Journal of Thoracic and Cardiovascular Surgery, 2013
The objective was to study the clinical course of children requiring continuous renal replacement... more The objective was to study the clinical course of children requiring continuous renal replacement therapy (CRRT) after cardiac surgery and to analyze the factors associated with mortality. A prospective observational study was performed that included all children requiring CRRT after cardiac surgery, comparing these patients with other critically ill children requiring CRRT. Univariate and multivariate analyses were performed to determine the influence of each factor on mortality. Eighty-one (4.9%) of 1650 children undergoing cardiac surgery required CRRT; 65 of them (80.2%) presented multiorgan failure. Children starting CRRT after cardiac surgery had lower mean arterial pressure and lower urea and creatinine levels, and were more likely to require mechanical ventilation than other children on CRRT. The incidence of complications was similar. Cardiac surgery increased the probability of requiring CRRT for more than 14 days. Mortality was 43% in children receiving CRRT after cardiac surgery and 29% in other children (P = .05). Factors associated with mortality in the univariate analysis were age less than 12 months, weight less than 10 kg, higher Pediatric Risk of Mortality Score, hypotension, lower urea and creatinine on starting CRRT, and use of hemofiltration. In the multivariate analysis, the only factor associated with mortality was hypotension on starting CRRT (hazard ratio, 4.01; 95% confidence interval, 1.2-13.4; P = .024). Although only a small percentage of children undergoing cardiac surgery required CRRT, mortality in these patients was high. Hypotension at the time of starting the technique was the only factor associated with a higher mortality.
Respiratory care, 2011
BACKGROUND: The mechanism of high-flow oxygen therapy and the pressures reached in the airway hav... more BACKGROUND: The mechanism of high-flow oxygen therapy and the pressures reached in the airway have not been defined. We hypothesize that flow would generate continuous positive pressure is low, and that elevated flow rates in this model could produce moderate pressures. The objective of this study is to analyze the pressure generated by a high-flow oxygen therapy system in an experimental model of the pediatric airway. METHODS: An experimental in vitro study was performed. A high-flow oxygen therapy system was connected to three types of interface (nasal cannulae, nasal mask, and face mask) and applied to two types of pediatric manikin (infant and neonatal). The pressures generated in the circuit, in the airway, and in the pharynx were measured at different flow rates (5, 10, 15, and 20 L/min). The experiment was conducted with and without a leak (mouth sealed and unsealed). Linear regression analyses were performed for each set of measurements. RESULTS: The pressures generated with...
Resuscitation, 2010
ObjectivesIt is possible that the exportation of North American and European models has hindered ... more ObjectivesIt is possible that the exportation of North American and European models has hindered the creation of a structured cardiopulmonary resuscitation (CPR) training programme in developing countries. The objective of this paper is to describe the design and present the results of a European paediatric and neonatal CPR training programme adapted to Honduras.
Intensive Care Medicine, 2010
Objective: To study the clinical course in children requiring continuous renal replacement therap... more Objective: To study the clinical course in children requiring continuous renal replacement therapy (CRRT) and to analyse factors associated with mortality. Design: Prospective observational study. Setting: Paediatric intensive care department of a tertiary university hospital. Patients: Critically ill children with CRRT were included in the study. Intervention: Continuous renal replacement therapy. Measurements and results: Univariate and multivariate analyses were performed to analyse the influence of each factor on mortality. The ability of the PRISM, PIM II and PELOD severity of illness scores to predict mortality was tested using receiver-operating characteristic curve statistics. A total of 174 children aged between 1 month and 22 years were treated with CRRT. Mortality was 35.6%, and multiorgan failure and haemodynamic disturbances were the principal causes of death. Mortality was higher in children less than 12 months of age (44.7%; P = 0.037) and in patients with a diagnosis of sepsis (44.1%; P = 0.001). Haemodynamic disturbances at the time of starting CRRT (hypotension or need for adrenaline [0.6 lg/kg/min) and the presence of multiorgan failure were the factors associated with an increased risk of mortality. The PRISM scale was the severity score with the best predictive capacity, although all three scales underestimated the actual mortality. Conclusions: Mortality in children who require CRRT is high. Haemodynamic disturbances and the presence of multiorgan failure at the time of starting the technique are the factors associated with a higher mortality. The clinical severity scores underestimate mortality in children requiring CRRT.
Pediatric Cardiology, 2014
We evaluated two pressure-recording analytical method (PRAM) software versions (v.1 and v.2) to m... more We evaluated two pressure-recording analytical method (PRAM) software versions (v.1 and v.2) to measure cardiac index (CI) in hemodynamically stable critically ill children and investigate factors that influence PRAM values. The working hypothesis was that PRAM CI measurements would stay within normal limits in hemodynamically stable patients. Ninety-five CI PRAM measurements were analyzed in 47 patients aged 1-168 months. Mean CI was 4.1 ± 1.4 L/min/m 2 (range 2.0-7.0). CI was outside limits defined as normal (3-5 L/min/m 2 ) in 53.7 % of measurements (47.8 % with software v.1 and 69.2 % with software v.2, p = 0.062). Moreover, 14.7 % of measurements were below 2.5 L/min/m 2 , and 13.6 % were above 6 L/min/m 2 . CI was significantly lower in patients with a clearly visible dicrotic notch than in those without (3.7 vs. 4.6 L/min/m 2 , p = 0.004) and in children with a radial arterial catheter (3.5 L/min/m 2 ) than in those with a brachial (4.4 L/min/m 2 , p = 0.021) or femoral catheter (4.7 L/min/m 2 , p = 0.005). By contrast, CI was significantly higher in children under 12 months (4.2 vs. 3.6 L/min/m 2 , p = 0.034) and weighing under 10 kg (4.2 vs. 3.6 L/min/m 2 , p = 0.026). No significant differences were observed between cardiac surgery patients and the rest of children. A high percentage of CI measurements registered by PRAM were outside normal limits in hemodynamically stable, critically ill children. CI measured by PRAM may be influenced by the age, weight, location of catheter, and presence of a dicrotic notch.
ABSTRACT Introduction and objectivesTo study the clinical course of children requiring continuous... more ABSTRACT Introduction and objectivesTo study the clinical course of children requiring continuous renal replacement therapy after cardiac surgery and to analyze factors associated with mortality.MethodsA prospective observational study was performed that included children requiring continuous renal replacement therapy after cardiac surgery. Univariate and multivariate analyses were performed to determine the influence of each factor on mortality. We compared these patients with other critically ill children requiring continuous renal replacement therapy.ResultsOf 1650 children undergoing cardiac surgery, 81 (4.9%) required continuous renal replacement therapy, 65 of whom (80.2%) presented multiple organ failure. The children who started continuous renal replacement therapy after cardiac surgery had lower mean arterial pressure, lower urea and creatinine levels, and higher mortality (43%) than the other children on continuous renal replacement therapy (29%) (P = .05). Factors associated with mortality in the univariate analysis were age less than 12 months, weight under 10 kg, higher pediatric risk of mortality score, hypotension, lower urea and creatinine levels when starting continuous renal replacement therapy, and the use of hemofiltration. In the multivariate analysis, hypotension when starting continuous renal replacement therapy, pediatric risk of mortality scores equal to or greater than 21, and hemofiltration were associated with mortality.Conclusions Although only a small percentage of children undergoing cardiac surgery required continuous renal replacement therapy, mortality among these patients was high. Hypotension and severity of illness when starting the technique and hemofiltration were factors associated with higher mortality.Full English text available from: www.revespcardiol.org
Critical Care, 2014
Introduction: Most studies have analyzed pre-arrest and resuscitation factors associated with mor... more Introduction: Most studies have analyzed pre-arrest and resuscitation factors associated with mortality after cardiac arrest (CA) in children, but many patients that reach return of spontaneous circulation die within the next days or weeks. The objective of our study was to analyze post-return of spontaneous circulation factors associated with in-hospital mortality after cardiac arrest in children. Methods: A prospective multicenter, multinational, observational study in 48 hospitals from 12 countries was performed. A total of 502 children aged between 1 month and 18 years with in-hospital cardiac arrest were analyzed. The primary endpoint was survival to hospital discharge. Univariate and multivariate logistic regression analyses were performed to assess the influence of each post-return of spontaneous circulation factor on mortality. Results: Return of spontaneous circulation was achieved in 69.5% of patients; 39.2% survived to hospital discharge and 88.9% of survivors had good neurological outcome. In the univariate analysis, post-return of spontaneous circulation factors related with mortality were pH, base deficit, lactic acid, bicarbonate, FiO2, need for inotropic support, inotropic index, dose of dopamine and dobutamine at 1 hour and at 24 hours after return of spontaneous circulation as well as Pediatric Intensive Care Unit and total hospital length of stay. In the multivariate analysis factors associated with mortality at 1 hour after return of spontaneous circulation were PaCO 2 < 30 mmHg and >50 mmHg, inotropic index >14 and lactic acid >5 mmol/L. Factors associated with mortality at 24 hours after return of spontaneous circulation were PaCO 2 > 50 mmHg, inotropic index >14 and FiO 2 ≥ 0.80. Conclusions: Secondary in-hospital mortality among the initial survivors of CA is high. Hypoventilation, hyperventilation, FiO 2 ≥ 0.80, the need for high doses of inotropic support, and high levels of lactic acid were the most important post-return of spontaneous circulation factors associated with in-hospital mortality in children in our population.
Resuscitation, 2012
Arterial hyperoxia after resuscitation has been associated with increased mortality in adults. Th... more Arterial hyperoxia after resuscitation has been associated with increased mortality in adults. The aim of this study was to test the hypothesis that post-resuscitation hyperoxia and hypocapnia are associated with increased mortality after resuscitation in pediatric patients. We performed a prospective observational multicenter hospital-based study including 223 children aged between 1 month and 18 years who achieved return of spontaneous circulation after in-hospital cardiac arrest and for whom arterial blood gas analysis data were available. After return of spontaneous circulation, 8.5% of patients had hyperoxia (defined as PaO(2)&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;300 mm Hg) and 26.5% hypoxia (defined as PaO(2)&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;60 mm Hg). No statistical differences in mortality were observed when patients with hyperoxia (52.6%), hypoxia (42.4%), or normoxia (40.7%) (p=0.61). Hypocapnia (defined as PaCO(2)&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;30 mm Hg) was observed in 13.5% of patients and hypercapnia (defined as PaCO(2)&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;50 mm Hg) in 27.6%. Patients with hypercapnia or hypocapnia had significantly higher mortality (59.0% and 50.0%, respectively) than patients with normocapnia (33.1%) (p=0.002). At 24h after return of spontaneous circulation, neither PaO(2) nor PaCO(2) values were associated with mortality. Multiple logistic regression analysis showed that hypercapnia (OR, 3.27; 95% CI, 1.62-6.61; p=0.001) and hypocapnia (OR, 2.71; 95% CI, 1.04-7.05; p=0.04) after return of spontaneous circulation were significant mortality factors. In children resuscitated from cardiac arrest, hyperoxemia after return of spontaneous circulation or 24h later was not associated with mortality. On the other hand, hypercapnia and hypocapnia were associated with higher mortality than normocapnia.
Resuscitation, 2014
The aim of the study was to analyze the mortality and neurological outcome factors of in-pediatri... more The aim of the study was to analyze the mortality and neurological outcome factors of in-pediatric intensive care unit (in-PICU) cardiac arrest (CA) in a multicenter international study. It was a prospective observational multicenter study in Latin-American countries, Spain, Portugal, and Italy. A total of 250 children aged from 1 month to 18 years who suffered in-PICU CA were studied. Countries and patient-related variables, arrest life, support-related variables, procedures, and clinical and neurological status at hospital discharge according to the Pediatric Cerebral Performance Category (PCPC) scale were registered. The primary endpoint was survival at hospital discharge and neurological outcome at the same time was the secondary endpoint. Univariate and multivariate logistic regression analyses were performed. Return of spontaneous circulation maintained longer than 20 min was achieved in 172 patients (69.1%) and 101 (40.4%) survived to hospital discharge. In the univariate ana...
Pediatric Emergency Care, 2015
Objectives: The objective of this study was to analyze the characteristic and the prognostic fact... more Objectives: The objective of this study was to analyze the characteristic and the prognostic factors of in-hospital pediatric cardiac arrest (CA) in a public hospital Honduras.
Critical Care, 2006
Introduction Shockable rhythms are rare in pediatric cardiac arrest and the results of defibrilla... more Introduction Shockable rhythms are rare in pediatric cardiac arrest and the results of defibrillation are uncertain. The objective of this study was to analyze the results of cardiopulmonary resuscitation that included defibrillation in children.
Intensive Care Medicine, 2010
Purpose: The objective of this study was to compare the efficacy of terlipressin versus adrenalin... more Purpose: The objective of this study was to compare the efficacy of terlipressin versus adrenaline in an experimental infant animal model of asphyxial cardiac arrest (ACA). Design: Prospective randomised animal study. Setting: Laboratory research department of a university hospital. Methods: Seventy-one, 2-monthold, mechanically ventilated piglets were investigated. ACA was induced by removal of mechanical ventilation. Resuscitation was performed by means of manual external chest compressions and mechanical ventilation (CC ? V). After 3 min of CC ? V, return of spontaneous circulation (ROSC) was observed in 11 animals. The 60 piglets without ROSC were then randomised to the four study groups: adrenaline standard dose (Asd): 0.01 mg/kg/3 min; adrenaline high dose (Ahd): first dose (0.01 mg/kg) and subsequent doses (0.1 mg/kg/3 min); terlipressin (T): 20 lg/kg/6 min; and adrenaline standard dose plus terlipressin (Asd ? T). Measurements and results: The relationship between haemodynamic (heart rate, blood pressure, ECG rhythm, cardiac index), respiratory (end-tidal CO 2 , blood gas analysis) and tissue perfusion (gastric intramucosal pH, central, cerebral and renal saturation) parameters and ROSC was analysed. ROSC was achieved in three piglets treated with Asd (20%), four treated with Ahd (26.7%), one treated with T (6.7%) and seven treated with Asd ? T (46.7%) (P = 0.099). ROSC was achieved in 43.1% of animals with pulseless electrical activity, 30.4% with asystole and none with ventricular fibrillation (P = 0.0001). Conclusion: In this infant animal model of cardiac arrest, there was a non-significant trend towards better outcome when terlipressin was combined with adrenaline compared with the use of adrenaline or terlipressin alone.
Pediatric Critical Care Medicine, 2010
Pediatric cardiac arrest unresponsive to advanced life support and several adrenaline doses has a... more Pediatric cardiac arrest unresponsive to advanced life support and several adrenaline doses has a very poor prognosis. Alternative vasopressors could improve the results of resuscitation in such cases. We report our experience with the compassionate administration of terlipressin in children who suffered in-pediatric intensive care unit cardiac arrest and did not respond to immediate advanced life support and at least three epinephrine doses. Prospective multicenter registry. Three pediatric intensive care units at university-affiliated tertiary care children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospitals. Five pediatric patients, aged 5 mos to 12 yrs, with in-pediatric intensive care unit cardiac arrest unresponsive to advanced life support that included at least three epinephrine doses. Addition of terlipressin (10-20 microg/kg intravenous, up to two doses) to standard cardiopulmonary resuscitation. Sustained return of spontaneous circulation was achieved in four cases, two of them were declared dead 6 and 12 hrs later, and the remaining two survived without cardiopulmonary procedures-related sequelae and with good neurologic condition. Terlipressin might contribute to obtain sustained return of spontaneous circulation in children with refractory in-hospital cardiac arrest. A randomized controlled clinical trial should be conducted to investigate the optimal drug treatment in pediatric cardiac arrest.
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Papers by Jesús López-herce