Andréa Maria Cordeiro Ventura

ACCM/PALS haemodynamic support guidelines for paediatric septic shock: an outcomes comparison with and without monitoring central venous oxygen saturation

IntroductionThe ACCM/PALS guidelines address early correction of paediatric septic shock using conventional measures. In the evolution of these recommendations, indirect measures of the balance between systemic oxygen delivery and demands using central venous or superior vena cava oxygen saturation (ScvO2u202f≥u202f70%) in axa0goal-directed approach have been added. However, while these additional goal-directed endpoints are based on evidence-based adult studies, the extrapolation to the paediatric patient remains unvalidated.ObjectiveThe purpose of this study was to compare treatment according to ACCM/PALS guidelines, performed with and without ScvO2 goal-directed therapy, on the morbidity and mortality rate of children with severe sepsis and septic shock.Design, participants and interventionsChildren and adolescents with severe sepsis or fluid-refractory septic shock were randomly assigned to ACCM/PALS with or without ScvO2 goal-directed resuscitation.MeasurementsTwenty-eight-day mortality was the primary endpoint.ResultsOf the 102 enrolled patients, 51 received ACCM/PALS with ScvO2 goal-directed therapy and 51 received ACCM/PALS without ScvO2 goal-directed therapy. ScvO2 goal-directed therapy resulted in less mortality (28-day mortality 11.8% vs. 39.2%, pu202f=u202f0.002), and fewer new organ dysfunctions (pu202f=u202f0.03). ScvO2 goal-directed therapy resulted in more crystalloid (28 (20–40) vs. 5 (0–20)u202fml/kg, pu202f<u202f0.0001), blood transfusion (45.1% vs. 15.7%, pu202f=u202f0.002) and inotropic (29.4% vs. 7.8%, pu202f=u202f0.01) support in the first 6u202fh.ConclusionsThis study supports the current ACCM/PALS guidelines. Goal-directed therapy using the endpoint of axa0ScvO2u202f≥u202f70% has axa0significant and additive impact on the outcome of children and adolescents with septic shock.

Enteral Nutrition Protocols for Critically Ill Patients Are They Necessary

OBJECTIVEnNutrition therapy protocols seek to correlate current scientific knowledge with clinical practice by converting evidence-based efficacy data into clinical effectiveness. Implementing nutrition therapy protocols should be justified by their impact on clinical outcomes. Thus, our objective was to analyze studies that verified the effect of implementing protocols for enteral nutrition (EN) in critically ill patients who are mechanically ventilated. We investigated initiation of nutrition therapy, time until nutrition requirements are met, optimization of protein and energy intake, duration of mechanical ventilation, length of hospital and intensive care unit stay, mortality, and adherence to protocols.nnnMETHODSnWe reviewed studies of human adults published over a 14-year period in English, Portuguese, French, or Spanish and available in MEDLINE, LILACS, EMBASE, and CINAHL databases. Reference lists of the most relevant articles were also searched. The Medical Subject Heading (MeSH) terms searched were (enteral nutrition) subheading (therapy) AND (critical care) OR (critical illness) OR (intensive care). Terms were searched for in both the title and abstract.nnnRESULTSnNineteen studies were included. Nutrition therapy was optimized after the implementation of nutrition protocols in all studies. However, the impact on clinical outcomes was modest.nnnCONCLUSIONSnOur analysis of previously published studies indicates that implementing a nutrition therapy protocol can lead to optimization of various aspects of nutrition practice. Further studies that take into consideration local facilitating (as well as hindering) factors may reveal the impact of strategic EN protocols on clinical outcomes.

Evaluation of the dead space to tidal volume ratio as a predictor of extubation failure.

OBJECTIVEnThe objective of this study was to evaluate the ratio of dead space to tidal volume (VD/VT) as a predictor of extubation failure of children from mechanical ventilation.nnnMETHODSnFrom September 2001 to January 2003 we studied a cohort consisting of all children (1 day-15 years) submitted to mechanical ventilation at a pediatric intensive care unit who were extubated and for whom pre-extubation ventilometry data were available, including the VD/VT ratio. Extubation success was defined as no need for any type of ventilatory support, invasive or otherwise, within 48 hours. Patients who tolerated extubation, with or without noninvasive support, were defined as success-R and compared with those who were reintubated. Statistic analysis was based on a VD/VT cutoff point of 0.65.nnnRESULTSnDuring the study period 250 children received mechanical ventilation at the pediatric intensive care unit. Eighty-six of these children comprised the study sample. Twenty-one children (24.4%) met the criteria for extubation failure, with 11 (12.8%) of these requiring non-invasive support and 10 (11.6%) reintubation. Their mean age was 16.8 (+/-30.1) months (median = 5.5 months). The mean VD/VT ratio for all cases was 0.62 (+/-0.18). Mean VD/VT ratios for patients with successful and failed extubations were 0.62 (+/-0.17) and 0.65 (+/-0.21) (p = 0.472), respectively. Logistic regression failed to reveal any statistically significant correlation between VD/VT ratio and success or failure of extubation (p = 0.8458), even for patients who were reintubated (p = 0.5576).nnnCONCLUSIONSnIn a pediatric population receiving mechanical ventilation due to a variety of etiologies, the VD/VT ratio was unable to predict the populations at risk of extubation failure or of reintubation.

Avaliação da relação entre espaço morto e volume corrente como índice preditivo de falha de extubação

OBJETIVO: O objetivo do estudo foi avaliar a relacao entre espaco morto e volume corrente (VD/VT) como preditivo de falha na extubacao de criancas sob ventilacao mecânica. METODOS: Entre setembro de 2001 e janeiro de 2003, realizamos uma coorte, na qual foram incluidas todas as criancas (1 dia-15 anos) submetidas a ventilacao mecânica na unidade de terapia intensiva pediatrica em que foi possivel realizar a extubacao e a ventilometria pre-extubacao com a medida do indice VD/VT. Considerou-se falha na extubacao a necessidade de reinstituicao de algum tipo de assistencia ventilatoria, invasiva ou nao, em um periodo de 48 horas. Para a analise dos pacientes que foram reintubados, definiu-se como sucesso-R a nao reintubacao. Para as analises estatisticas, utilizou-se um corte do VD/VT de 0,65. RESULTADOS: No periodo estudado, 250 criancas receberam ventilacao mecânica na unidade de terapia intensiva pediatrica. Destas, 86 compuseram a amostra estudada. Vinte e uma criancas (24,4%) preencheram o criterio de falha de extubacao, com 11 (12,8%) utilizando suporte nao-invasivo e 10 (11,6%) reintubadas. A idade media foi de 16,8 (±30,1) meses, e a mediana, de 5,5 meses. A media do indice VD/VT de todos os casos foi de 0,62 (±0,18). As medias do indice VD/VT para os pacientes que tiveram a extubacao bem sucedida e para os que falharam foram, respectivamente, 0,62 (±0,17) e 0,65 (±0,21) (p = 0,472). Na regressao logistica, o indice VD/VT nao apresentou correlacao estatisticamente significativa com o sucesso ou nao da extubacao (p = 0,8458), nem para aqueles que foram reintubados (p = 0,5576). CONCLUSOES: Em uma populacao pediatrica submetida a ventilacao mecânica, por etiologias variadas, o indice VD/VT nao possibilitou predizer qual a populacao de risco para falha de extubacao ou reintubacao.

Epidemiology of Sepsis in Children Admitted to Picus in South America

Objectives: To report the prevalence of sepsis within the first 24 hours at admission and the PICU sepsis-related mortality among critically ill children admitted to PICU in South America. Design: A prospective multicenter cohort study. Setting: Twenty-one PICU, located in five South America countries. Patients: All children from 29 days to 17 years old admitted to the participating PICU between June 2011 and September 2011. Clinical, demographic, and laboratory data were registered within the first 24 hours at admission. Outcomes were registered upon PICU discharge or death. Interventions: None. Measurements and Main Results: Of the 1,090 patients included in this study, 464 had sepsis. The prevalence of sepsis, severe sepsis, and septic shock were 42.6%, 25.9%, and 19.8%, respectively. The median age of sepsis patients was 11.6 months (interquartile range, 3.2–48.7) and 43% had one or more prior chronic condition. The prevalence of sepsis was higher in infants (50.4%) and lower in adolescents (1.9%). Sepsis-related mortality was 14.2% and was consistently higher with increased disease severity: 4.4% for sepsis, 12.3% for severe sepsis, and 23.1% for septic shock. Twenty-five percent of deaths occurred within the first 24 hours at PICU admission. Multivariate analysis showed that higher Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores, the presence of two or more chronic conditions, and admission from pediatric wards were independently associated with death. Conclusions: We observed high prevalence of sepsis and sepsis-related mortality among this sample of children admitted to PICU in South America. Mortality was associated with greater severity of illness at admission and potentially associated with late PICU referral.

Ruptura traumática de via aérea em criança: um desafio diagnóstico

OBJETIVO: Relatar um caso de ruptura da via aerea em crianca vitima de trauma toracico decorrente de queda do tanque de lavar roupas. DESCRICAO: Relato de caso descritivo. O paciente pre-escolar de 34 meses, do sexo masculino foi atendido na unidade de terapia intensiva pediatrica de Hospital Universitario. Foram realizados os seguintes procedimentos: radiografia simples e tomografia de torax, endoscopia respiratoria, toracotomia, antibioticoterapia, ventilacao mecânica. A radiografia simples de torax, tomografia computadorizada de torax e endoscopia respiratoria foram necessarias para definir o diagnostico de ruptura traumatica da via aerea associada a contusao pulmonar, pneumotorax, pneumomediastino e enfisema subcutâneo. O paciente foi submetido a toracotomia para reparacao de lesao quase completa de bronquio principal esquerdo. Antibioticoterapia de largo espectro e suporte ventilatorio contribuiram para resolucao do caso sem sequelas a medio prazo. COMENTARIOS: Na vigencia de trauma toracico em crianca, a busca diagnostica por lesoes incomuns, mas potencialmente letais, como a ruptura da via aerea, deve ser incessante, particularmente naqueles pacientes com fortes evidencias clinicas. A complementacao diagnostica deve ser otimizada com a radiografia simples de torax, a tomografia de torax e o exame endoscopico que estabelece o diagnostico definitivo.