Andréa M. G. Cordeiro

Availability of pediatric and neonatal intensive care units in the city of São Paulo

OBJECTIVE To describe the health care service provided in pediatric intensive care units in the city of São Paulo, by identifying and describing the units and analyzing their geographic distribution. METHODS A descriptive cross-sectional study was carried out during a two-year period (August 2000 to July 2002). Data were collected through questionnaires answered by medical directors of each pediatric and neonatal intensive care unit. RESULTS São Paulo is served by 107 pediatric and neonatal intensive care units, of which 85 (79.4%) completed and returned the questionnaire. We found a very unequal distribution of units as there were more units in places with the least pediatric population. Regarding to pediatric intensive care units specialization, 7% were pediatric, 41.2% were neonatal and 51.7% were mixed (pediatric and neonatal). Regarding hospital funds, 15.3% were associated with philanthropic institutions, 37.6% were private and 47% were public. A total of 1,067 beds were identified, of which 969 were active. The ratio bed/patient aged 0-14 was 1/2,728, varying from 1/604 at health districts-I to 1/6,812 at health districts-III. The units reported an average of 11.7 beds (2 to 60). The neonatal intensive care unit had a median of 16.9 beds per unit and pediatric intensive care units a median of 8.5 beds/unit. CONCLUSION In São Paulo, we found an uneven distribution of pediatric and neonatal intensive care units among the health districts. There was also an uneven distribution between public and private units, and neonatal and pediatric ones. The current report is the first step in the effort to improve the quality of medical assistance in pediatric and neonatal intensive care units in São Paulo.

Incidência e características endoscópicas de lesões das vias aéreas associadas à intubação traqueal em crianças

OBJECTIVES: describe the incidence and endoscopic characteristics of airway injuries in children submitted to intubation. METHODS: during a two-year period (october/1999-october/2001) we conducted a prospective study in which all patients that required intubation, excluding those who deceased before extubation and newborns (NB) weighing less than 1.250g, were submitted to airway endoscopy at extubation. The endoscopic findings were classified as minor, moderate or severe. Descriptions were made through proportions and medians, comparisons were done through chi-square for proportions. RESULTS: we studied 61 NB and 154 children. In 89.8%, 55 NB and 138 children (P=0.89), it was detected at least one lesion in a total of 507. Patients with minor lesions were 54.8% (IC95%:48.1-61.5), those with moderate were 24.2% (IC95%:18.5-30.0) and severe injury occurred in 10.7% (IC95%:6.6-14.8). Lesions at the glottis (48.1% of lesions) and subglottis (35.1%) presented the highest incidence. Erosions had the highest incidence in both age groups (P=0.88). Vocal folds edema was the main moderate lesion in both groups (P=0.96), followed by ulcerations (P=0.92). Fibrous nodules at vocal folds and adhesions were the main severe injuries in both groups (P=0.12). Subglottic stenosis was detected in 2.8% of the patients without difference between groups (P=0.35). CONCLUSIONS: we observed a high incidence of airway injury, without statistical significant difference between age groups in regard to the incidence and characteristics of the injuries. Minor injury was detected in the majority of the population. Lesions were mainly noticed at the glottis and were characterized by erosions, edema and ulcerations.

Comparison between an upper airway obstruction score and airway endoscopy to detect airway injury associated with endotracheal intubation in children

OBJECTIVE To compare an upper airway obstruction score vs. airway endoscopy to detect moderate or severe airway injury associated with endotracheal intubation in children. METHODS Prospective study. Airway endoscopy and clinical evaluation were performed after extubation. Airway injuries identified on endoscopy or according to the upper airway obstruction score were classified as minor, moderate or severe. The obstruction score was assessed in terms of sensitivity, specificity, positive and negative predictive values and likelihood ratio to detect moderate or severe injuries. RESULTS Among 215 patient, endoscopy was normal in 10.2%. Minor lesions were diagnosed in 54.9% of the patients, followed by moderate (24.2%) and severe (10.7%) lesions. In 163 patients with upper airway obstruction, the score classified injuries as minor in 23.3%, moderate in 41.4% and severe in 11.2%. A score > or = 4 had a sensitivity of 73.3% (95% CI: 67.4-79.2) to detect moderate or severe injuries and a specificity of 58.6% (95% CI: 52.0-65.2) to exclude patients without moderate or severe lesions. The positive predictive value of a score > or = 4 was 48.7% (95% CI: 42.0-55.4). In patients with a score < or = 3 the chance of not presenting moderate or severe injuries was 80.4% (95% CI: 75.1-85.7). The probability of a patient with moderate or severe injuries to present a score > or = 4 was 73.3% compared to patients without those injuries (41.4%) (1.8 fold higher). CONCLUSIONS The score reliably ruled out moderate or severe airway injury in patients with minor upper airway distress. On the other hand, scores > or = 4 presented a low specificity. Clinical evaluation can be useful to rule out patients with minor airway injuries.

Eficácia e segurança do uso inalatório da adrenalina-L na laringite pós-intubação utilizada em associação com a dexametasona

OBJECTIVE: to assess the efficacy and safety of the use of nebulized L-epinephrine associated with dexamethasone in postintubation laryngitis. METHOD: We carried out a prospective, randomized, double-blind, placebo controlled study with two cohorts of patients with postintubation laryngitis graded 3 to 6 by Downes-Raphaelly score during two years. Our population was divided into two groups: A and B; both groups received intravenous dexamethasone and two doses of nebulized saline; however, only group B received L-epinephrine. The efficacy was assessed by Downes-Raphaelly score. The side effects of L-epinephrine were evaluated according to the occurrence of cardiac arrhythmia, increased blood pressure, and average heart rate of group B in comparison to group A. RESULTS: Twenty-two patients were included in group A (average score = 4.8) and 19 in group B (average score = 5.2). During treatment, 3 patients in group A presented a score of 8 and were reintubated. This group also showed higher mean clinical scores than group B during the first two hours of the protocol; these results were not statistically significant. No side effects were observed due to epinephrine. The gas blood measurements were adequate in both groups, but better in the control group. CONCLUSIONS: We did not observe increased efficacy for the treatment of postintubation laryngitis when nebulized L-epinephrine was used simultaneously with intravenous dexamethasone. Some indicators, however, did present a favorable trend when combined therapy was used and should be submitted to further evaluation.

Contribuição da biópsia pulmonar a céu aberto na avaliação de pneumopatias difusas e agudas em unidade de terapia intensiva pediátrica

Introducao:: Os dados clinico-laboratoriais convencionais raramente fornecem o diagnostico empneumopatias difusas. O objetivo deste estudo foi avaliar o papel da biopsia pulmonar a ceu aberto noque se refere ao seu potencial diagnostico, ao impacto dos resultados sobre a conduta clinica e aincidencia de complicacoes do procedimento. Material e metodos: Material e metodos: No periodo de janeiro/1987 ajaneiro/1997, 29 biopsias pulmonares foram realizadas em criancas com pneumopatias difusas, eminsuficiencia respiratoria aguda, sem etiologia e sem resposta a terapeutica empirica previa. Foramexcluidos os recem-nascidos, criancas com pneumopatias cronicas previas e criancas comcoagulopatia ou choque intrataveis. Todas as biopsias foram realizadas atraves de microtoracotomia nopulmao mais acometido ao exame radiologico. O fragmento de tecido pulmonar foi analisado pormeio de culturas e de exames de microscopia otica, eletronica e imunofluorescencia. Resultados: Resultados: Oprocessamento do material da biopsia forneceu pelo menos um diagnostico histopatologico em todasas criancas estudadas (100%) e em 20 (68,9%) obteve-se um diagnostico etiologico. Os principaisdiagnosticos histopatologicos foram: pneumonite intersticial nao especifica com fibrose variavel em 18casos; bronquiolite em oito casos e hipertensao pulmonar em tres casos. Nos diagnosticos etiologicos,os principais agentes foram: citomegalovirus em seis criancas; Pneumocystis carinii em tres;adenovirus em tres e infeccao pelo virus respiratorio sincicial em tres casos. Os resultados gerarammudancas no tratamento em 20 casos (68,9%). As principais alteracoes de conduta foram aintroducao de corticoterapia em 14 pacientes e a revisao da antibioticoterapia em seis. Sete casos(24,1%) apresentaram complicacoes, que foram resolvidas, e nenhum obito foi relacionado aoprocedimento. Conclusao:Conclusao: Conclui-se que a biopsia pulmonar a ceu aberto e um procedimento que,mesmo invasivo, deve ser considerado na avaliacao de criancas com pneumopatias difusas graves, semetiologia definida, sem resposta a terapeutica previamente instituida e em insuficiencia respiratoria.

Therapeutic of septic children with purpuric presentation with two antibiotic schedules

OBJECTIVE: The authors evaluate the therapeutic efficacy of two antibiotic schedules, ceftriaxone alone and the combined use of ampicillin and chloramphenicol, in the treatment of septic children with purpuric presentation.METHODS: A randomized open clinical trial was conducted including septic children with purpuric presentation treated at a pediatric intensive care unit from April 1988 to June 1992. All cases with systemic purpura standing for less than a week were included in one of two groups, except for those recently hospitalized or with previous hemorrhagic disturbs. Patients in group A received ampicillin and chloramphenicol and those in group B were given ceftriaxone. Quantitative parameters were adopted to compare the efficacy of the two antibiotic schedules: sensitivity of bacteria isolated at blood and liquor cultures, complications, therapeutic procedures, period of hospitalization, and sequelae.RESULTS: 19 cases were included in the group A and 16 in group B, both homogenous on clinical-laboratorial aspects. The parameters evaluated did not show different efficacy between the two antimicrobial schedules tested, except for the number of complications observed during hospitalization, which was higher among the children that received ampicillin and chloramphenicol. The overall mortality for the patients treated was 13.8%, excluded the undernourished. CONCLUSIONS: The authors verify similar clinical therapeutic efficacy with the combined use of ampicillin and chloramphenicol or ceftriaxone, as observed previously. It must be pointed that the number of complications detected during hospitalization were higher in the group that received the combined antibiotic schedule. Low mortality in the present study may be attributed to the early diagnosis and therapeutic measures adopted at the pediatric intensive care unit.