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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Female patient aged 7 years&#44; postoperative from thoracic surgery&#44; extubated&#44; with the drains removed 4<span class="elsevierStyleHsp" style=""></span>hours ago&#44; presents with respiratory distress and need for increased oxygen&#46; Auscultation reveals some hypoventilation in the right hemithorax and percussion proves inconclusive&#46; Thoracic ultrasound is immediately performed by the doctor on call&#44; obtaining the diagnosis of pneumothorax in less than a minute without the need for further radiological examination&#46; This is so-called &#8220;bedside&#8221;&#44; &#8220;clinical&#8221; or &#8220;focused&#8221; ultrasound&#44; which is an extension of the physical examination of the patient&#44; performed by the treating doctor at the place where the problem arises&#44; seeking an urgent dichotomous &#40;yes&#47;no&#41; answer and greater assurance when faced with a diagnostic or procedural requirement&#46; It offers assurance&#44; by minimising possible complications from procedures as well as avoiding radiation&#44; efficacy&#44; by facilitating management focused on the patient&#39;s specific needs&#44; fairness&#44; because it is a resource available at any time of day or night and in almost any healthcare centre&#44; immediacy&#44; by not delaying diagnosis and treatment&#44; and efficiency&#44; because all the advantages mentioned are achieved at minimal cost after the initial investment&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Its use in paediatrics is less common than that described in the adult population and it is routinely implemented more often in urgent than in critical care areas&#46; A survey conducted in 2015 by the Ultrasound Working Group of the Sociedad Espa&#241;ola de Cuidados Intensivos Pedi&#225;tricos &#40;SECIP&#58; Spanish Paediatric Intensive Care Society&#41; found that 65&#37; of Paediatric Intensive Care Units &#40;PICUs&#41; used it&#44; but only for a few applications&#46; This underuse may be due to the scarcity of publications and evidence in this particular population&#44; but since we know that the differences in image acquisition and interpretation are minimal and that it is harmless when correctly used&#44; this should not be an impediment to implementing it&#59; and the fact is that as regards the applicability of clinical ultrasound to critically ill children it really can be said that the child is the adult writ small&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">There is evidence in children of the benefit of clinical ultrasound for vascular access cannulation&#44; reducing the number of attempts and complications in cannulation of the internal jugular vein and even achieving lower figures in femoral and subclavian access as well&#44; but always using it in real time &#40;ultrasound-guided puncture&#41;&#46; Subclavian or brachiocephalic vein cannulation from the supraclavicular region is a possibility increasingly used in paediatrics and neonatology with promising results&#44; though it requires a certain amount of experience&#46; Correct estimation of ventricular function&#44; pericardial effusion and possible tamponade&#44; and also intravascular volume status&#44; in conjunction with examination of the inferior vena cava&#44; has been shown to be viable after a brief period of training&#46; During cardiopulmonary resuscitation&#44; and especially in the case of pulseless electrical activity&#44; it can be useful in diagnosing the possible causes &#40;hypovolaemia&#44; pneumothorax&#44; tamponade&#44; pulmonary thromboembolism&#41; provided&#44; it does not interfere with chest compressions&#46; Thoracic ultrasound is very useful in the diagnosis and management of pneumothorax&#44; pleural effusion&#44; pulmonary consolidations&#44; acute respiratory distress syndrome and acute pulmonary oedema&#44; where&#44; moreover&#44; it produces quantification of the artefacts&#44; and is related to intrapulmonary extravascular fluid and pulmonary artery wedge pressure&#46; It also makes it possible to verify various degrees of lung aeration&#44; helping to monitor progress and response to various treatments&#44; such as diuretics and haemodiafiltration or increasing the pressures in the respirator&#44; and estimating probabilities of success during a trial extubation or on initiating non-invasive ventilation&#46; In patients with multiple trauma the FAST &#40;Focused Assessment Sonography for Trauma&#41; protocol is very specific for detecting free fluid and quite sensitive in the case of intra-abdominal lesions requiring intervention or transfusion&#46; In addition&#44; it provides a means of alerting to the presence of intracranial hypertension in patients with traumatic brain injury&#44; both by using pulsed Doppler and colour &#40;duplex&#41; to assess the behaviour of cerebral flows in the arteries and by measuring optic nerve sheath diameter&#46; It can also help in checking for correct endotracheal tube and vascular access placement&#44; visualising the pupillary light reflex&#44; fractures&#44; ascites&#44; diaphragm movement&#44; performance of paracentesis&#44; thoracocentesis and lumbar puncture&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Bedside ultrasound really comes into its own in carrying out protocols that seek to determine the causes of various types of conditions by using the various applications mentioned in a systematic and integrated way&#44; such as RUSH &#40;Rapid Ultrasound for Shock and Hypotension&#41; for shock&#44; BLUE &#40;Bedside Lung Ultrasound in Emergency&#41; for respiratory distress&#44; FEEL &#40;Focused Echo Evaluation in Life support&#41; for cardiorespiratory arrest&#44; and others&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The usefulness of bedside ultrasound in PICUs is reflected in the possibility of modifying or confirming the diagnosis at the moment when the need arises&#44; with the consequent optimisation of medical management and reduction in performing other diagnostic tests and consulting other specialists&#44; as well as a reduction in complications resulting from certain procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; ultrasound also has its drawbacks&#44; and the most important of these is the risk that misinterpretation may lead to faulty patient management&#44; which is linked to the experience of the examiner&#46; To minimise this risk we must ensure that proper training is given through implementation programmes&#44; designed not only for new intensive care specialists but also for those who are unfamiliar with the technique&#46; The training objectives must be based on recommendations from existing experts on bedside ultrasound in adult critical patients<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> and in paediatric emergencies&#44; given the current lack of such experts in paediatric intensive care&#44; but at the same time these recommendations must be adapted to the particular needs of each hospital&#44; depending on the type of patients it treats&#46; Implementation programmes must begin with a phase of training in the technique&#44; seeking to teach skills not only in acquiring images but also interpreting them and incorporating them into the care process&#44; and in addition&#44; the minimum knowledge an intensive care specialist has to achieve must also be determined&#46; Being too ambitious with certain kinds of examination&#44; trying to obtain measurements or images that are the province of cardiologists or radiologists&#44; may over-complicate the technique and demotivate clinicians from learning and subsequently using it&#44; as well as increasing the likelihood of erroneous interpretations&#46; Training should ideally be followed by a phase of practice supervised by expert staff&#44; until the person is qualified to make clinical decisions&#46; This period can vary widely according to whether the applications require a greater or lesser number of supervised examinations&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In view of the clear benefit this technique offers for paediatric critical patients&#44; and in order to assist in the dissemination and implementation of this new tool&#44; as well as providing unified definitions&#44; protocols for its use and standardised minimum training&#44; the Ultrasound Working Group &#40;Grupo de Trabajo de Ecograf&#237;a&#41; was set up in 2015 at the SECIP National Conference held in Toledo&#46; It is a platform seeking to promote correct use of bedside ultrasound and improve the current evidence through studies such as RECANVA&#44; on vascular access cannulation in children admitted to Intensive Care Units &#40;ICUs&#41;&#44; which is already underway&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Ultrasound in critical patients is changing our day-to-day work&#46; It is not just another machine to add to the range of PICU equipment but functions as an extension of our own senses&#44; enabling us to see inside the patient autonomously and immediately&#44; offering the possibility of greater diagnostic precision&#44; a way of monitoring the response to certain treatments and greater security in procedures&#46; Knowing not only all its possibilities and how to use them but also&#44; and above all&#44; its limitations will enable us to obtain the maximum benefit from a technique which undoubtedly improves the day-to-day management of our patients&#46;</p></span>"
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Editorial
Bedside ultrasound in the critically ill paediatric patient
Ecografía a pie de cama en el niño crítico
Luis Renter Valdovinosa,
Corresponding author
lrentervaldovinos@gmail.com

Corresponding author.
, Ignacio Oulego Errozb, in representation and members of the Working Group of the Spanish Ultrasound Society of Pediatric Intensive Care
a Unidad de Cuidados Intensivos Pediátricos, Servicio de Medicina Pediátrica, Parc Taulí Sabadell, Hospital Universitario, Sabadell, Barcelona, Spain
b Unidad de Cuidados Intensivos Pediátricos, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Female patient aged 7 years&#44; postoperative from thoracic surgery&#44; extubated&#44; with the drains removed 4<span class="elsevierStyleHsp" style=""></span>hours ago&#44; presents with respiratory distress and need for increased oxygen&#46; Auscultation reveals some hypoventilation in the right hemithorax and percussion proves inconclusive&#46; Thoracic ultrasound is immediately performed by the doctor on call&#44; obtaining the diagnosis of pneumothorax in less than a minute without the need for further radiological examination&#46; This is so-called &#8220;bedside&#8221;&#44; &#8220;clinical&#8221; or &#8220;focused&#8221; ultrasound&#44; which is an extension of the physical examination of the patient&#44; performed by the treating doctor at the place where the problem arises&#44; seeking an urgent dichotomous &#40;yes&#47;no&#41; answer and greater assurance when faced with a diagnostic or procedural requirement&#46; It offers assurance&#44; by minimising possible complications from procedures as well as avoiding radiation&#44; efficacy&#44; by facilitating management focused on the patient&#39;s specific needs&#44; fairness&#44; because it is a resource available at any time of day or night and in almost any healthcare centre&#44; immediacy&#44; by not delaying diagnosis and treatment&#44; and efficiency&#44; because all the advantages mentioned are achieved at minimal cost after the initial investment&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Its use in paediatrics is less common than that described in the adult population and it is routinely implemented more often in urgent than in critical care areas&#46; A survey conducted in 2015 by the Ultrasound Working Group of the Sociedad Espa&#241;ola de Cuidados Intensivos Pedi&#225;tricos &#40;SECIP&#58; Spanish Paediatric Intensive Care Society&#41; found that 65&#37; of Paediatric Intensive Care Units &#40;PICUs&#41; used it&#44; but only for a few applications&#46; This underuse may be due to the scarcity of publications and evidence in this particular population&#44; but since we know that the differences in image acquisition and interpretation are minimal and that it is harmless when correctly used&#44; this should not be an impediment to implementing it&#59; and the fact is that as regards the applicability of clinical ultrasound to critically ill children it really can be said that the child is the adult writ small&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">There is evidence in children of the benefit of clinical ultrasound for vascular access cannulation&#44; reducing the number of attempts and complications in cannulation of the internal jugular vein and even achieving lower figures in femoral and subclavian access as well&#44; but always using it in real time &#40;ultrasound-guided puncture&#41;&#46; Subclavian or brachiocephalic vein cannulation from the supraclavicular region is a possibility increasingly used in paediatrics and neonatology with promising results&#44; though it requires a certain amount of experience&#46; Correct estimation of ventricular function&#44; pericardial effusion and possible tamponade&#44; and also intravascular volume status&#44; in conjunction with examination of the inferior vena cava&#44; has been shown to be viable after a brief period of training&#46; During cardiopulmonary resuscitation&#44; and especially in the case of pulseless electrical activity&#44; it can be useful in diagnosing the possible causes &#40;hypovolaemia&#44; pneumothorax&#44; tamponade&#44; pulmonary thromboembolism&#41; provided&#44; it does not interfere with chest compressions&#46; Thoracic ultrasound is very useful in the diagnosis and management of pneumothorax&#44; pleural effusion&#44; pulmonary consolidations&#44; acute respiratory distress syndrome and acute pulmonary oedema&#44; where&#44; moreover&#44; it produces quantification of the artefacts&#44; and is related to intrapulmonary extravascular fluid and pulmonary artery wedge pressure&#46; It also makes it possible to verify various degrees of lung aeration&#44; helping to monitor progress and response to various treatments&#44; such as diuretics and haemodiafiltration or increasing the pressures in the respirator&#44; and estimating probabilities of success during a trial extubation or on initiating non-invasive ventilation&#46; In patients with multiple trauma the FAST &#40;Focused Assessment Sonography for Trauma&#41; protocol is very specific for detecting free fluid and quite sensitive in the case of intra-abdominal lesions requiring intervention or transfusion&#46; In addition&#44; it provides a means of alerting to the presence of intracranial hypertension in patients with traumatic brain injury&#44; both by using pulsed Doppler and colour &#40;duplex&#41; to assess the behaviour of cerebral flows in the arteries and by measuring optic nerve sheath diameter&#46; It can also help in checking for correct endotracheal tube and vascular access placement&#44; visualising the pupillary light reflex&#44; fractures&#44; ascites&#44; diaphragm movement&#44; performance of paracentesis&#44; thoracocentesis and lumbar puncture&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Bedside ultrasound really comes into its own in carrying out protocols that seek to determine the causes of various types of conditions by using the various applications mentioned in a systematic and integrated way&#44; such as RUSH &#40;Rapid Ultrasound for Shock and Hypotension&#41; for shock&#44; BLUE &#40;Bedside Lung Ultrasound in Emergency&#41; for respiratory distress&#44; FEEL &#40;Focused Echo Evaluation in Life support&#41; for cardiorespiratory arrest&#44; and others&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The usefulness of bedside ultrasound in PICUs is reflected in the possibility of modifying or confirming the diagnosis at the moment when the need arises&#44; with the consequent optimisation of medical management and reduction in performing other diagnostic tests and consulting other specialists&#44; as well as a reduction in complications resulting from certain procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; ultrasound also has its drawbacks&#44; and the most important of these is the risk that misinterpretation may lead to faulty patient management&#44; which is linked to the experience of the examiner&#46; To minimise this risk we must ensure that proper training is given through implementation programmes&#44; designed not only for new intensive care specialists but also for those who are unfamiliar with the technique&#46; The training objectives must be based on recommendations from existing experts on bedside ultrasound in adult critical patients<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> and in paediatric emergencies&#44; given the current lack of such experts in paediatric intensive care&#44; but at the same time these recommendations must be adapted to the particular needs of each hospital&#44; depending on the type of patients it treats&#46; Implementation programmes must begin with a phase of training in the technique&#44; seeking to teach skills not only in acquiring images but also interpreting them and incorporating them into the care process&#44; and in addition&#44; the minimum knowledge an intensive care specialist has to achieve must also be determined&#46; Being too ambitious with certain kinds of examination&#44; trying to obtain measurements or images that are the province of cardiologists or radiologists&#44; may over-complicate the technique and demotivate clinicians from learning and subsequently using it&#44; as well as increasing the likelihood of erroneous interpretations&#46; Training should ideally be followed by a phase of practice supervised by expert staff&#44; until the person is qualified to make clinical decisions&#46; This period can vary widely according to whether the applications require a greater or lesser number of supervised examinations&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In view of the clear benefit this technique offers for paediatric critical patients&#44; and in order to assist in the dissemination and implementation of this new tool&#44; as well as providing unified definitions&#44; protocols for its use and standardised minimum training&#44; the Ultrasound Working Group &#40;Grupo de Trabajo de Ecograf&#237;a&#41; was set up in 2015 at the SECIP National Conference held in Toledo&#46; It is a platform seeking to promote correct use of bedside ultrasound and improve the current evidence through studies such as RECANVA&#44; on vascular access cannulation in children admitted to Intensive Care Units &#40;ICUs&#41;&#44; which is already underway&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Ultrasound in critical patients is changing our day-to-day work&#46; It is not just another machine to add to the range of PICU equipment but functions as an extension of our own senses&#44; enabling us to see inside the patient autonomously and immediately&#44; offering the possibility of greater diagnostic precision&#44; a way of monitoring the response to certain treatments and greater security in procedures&#46; Knowing not only all its possibilities and how to use them but also&#44; and above all&#44; its limitations will enable us to obtain the maximum benefit from a technique which undoubtedly improves the day-to-day management of our patients&#46;</p></span>"
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ISSN: 23412879
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Anales de Pediatría (English Edition)