Artur Figueiredo Delgado

Hospital malnutrition and inflammatory response in critically ill children and adolescents admitted to a tertiary intensive care unit

UNLABELLED Critical illness has a major impact on the nutritional status of both children and adults. A retrospective study was conducted to evaluate the incidence of hospital malnutrition at a pediatric tertiary intensive care unit (PICU). Serum concentrations of IL-6 in subgroups of well-nourished and malnourished patients were also evaluated in an attempt to identify those with a potential nutritional risk. METHODS A total of 1077 patients were enrolled. Nutritional status was evaluated by Z-score (weight for age). We compared mortality, sepsis incidence, and length of hospital stay for nourished and malnourished patients. We had a subgroup of 15 patients with severe malnutrition (MN) and another with 14 well-nourished patients (WN). Cytokine IL-6 determinations were performed by enzyme-linked immunosorbent assay. RESULTS 53% of patients were classified with moderate or severe malnutrition. Similar amounts of C- reactive protein (CRP) were observed in WN and MN patients. Both groups were able to increase IL-6 concentrations in response to inflammatory systemic response and the levels followed a similar evolution during the study. However, the mean values of serum IL-6 were significantly different between WN and MN patients across time, throughout the study (p = 0.043). DISCUSSION a considerable proportion of malnourished patients need specialized nutritional therapy during an intensive care unit (ICU) stay. Malnutrition in children remains largely unrecognized by healthcare workers on admission. CONCLUSIONS The incidence of malnutrition was very high. Malnourished patients maintain the capacity to release inflammatory markers such as CRP and IL-6, which can be considered favorable for combating infections On the other hand, this capacity might also have a significant impact on nutritional status during hospitalization.

The impact of daily evaluation and spontaneous breathing test on the duration of pediatric mechanical ventilation: a randomized controlled trial.

Objectives:To assess whether the combination of daily evaluation and use of a spontaneous breathing test could shorten the duration of mechanical ventilation as compared with weaning based on our standard of care. Secondary outcome measures included extubation failure rate and the need for noninvasive ventilation. Design:A prospective, randomized controlled trial. Setting:Two pediatric intensive care units at university hospitals in Brazil. Patients:The trial involved children between 28 days and 15 yrs of age who were receiving mechanical ventilation for at least 24 hrs. Interventions:Patients were randomly assigned to one of two weaning protocols. In the test group, the children underwent a daily evaluation to check readiness for weaning with a spontaneous breathing test with 10 cm H2O pressure support and a positive end-expiratory pressure of 5 cm H2O for 2 hrs. The spontaneous breathing test was repeated the next day for children who failed it. In the control group, weaning was performed according to standard care procedures. Measurements and Main Results:A total of 294 eligible children were randomized, with 155 to the test group and 139 to the control group. The time to extubation was shorter in the test group, where the median mechanical ventilation duration was 3.5 days (95% confidence interval, 3.0 to 4.0) as compared to 4.7 days (95% confidence interval, 4.1 to 5.3) in the control group (p = .0127). This significant reduction in the mechanical ventilation duration for the intervention group was not associated with increased rates of extubation failure or noninvasive ventilation. It represents a 30% reduction in the risk of remaining on mechanical ventilation (hazard ratio: 0.70). Conclusions:A daily evaluation to check readiness for weaning combined with a spontaneous breathing test reduced the mechanical ventilation duration for children on mechanical ventilation for >24 hrs, without increasing the extubation failure rate or the need for noninvasive ventilation.

Application of the pediatric risk of mortality (PRISM) score and determination of mortality risk factors in a tertiary pediatric intensive care unit

INTRODUCTION: To establish disease severity at admission can be performed by way of the mortality prognostic. Nowadays the prognostic scores make part of quality control and research. The Pediatric Risk of Mortality (PRISM) is one of the scores used in the pediatric intensive care units. OBJECTIVES: The purpose of this study is the utilization of the PRISM and determination of mortality risk factors in a tertiary pediatric intensive care unit. METHODS : Retrospective cohort study, in a period of one year, at a general tertiary pediatric intensive care unit. The pediatric risk of mortality scores corresponding to the first 24 hours of hospitalization were recorded; additional data were collected to characterize the study population. RESULTS: 359 patients were included; the variables that were found to be risk factors for death were multiple organ dysfunction syndrome on admission, mechanical ventilation, use of vasoactive drugs, hospital‐acquired infection, parenteral nutrition and duration of hospitalization (p < 0,0001). Fifty‐four patients (15%) died; median pediatric risk of mortality score was significantly lower in patients who survived (p = 0,0001). The ROC curve yielded a value of 0.76 (CI 95% 0,69–0,83) and the calibration was shown to be adequate. DISCUSSION: It is imperative for pediatric intensive care units to implement strict quality controls to identify groups at risk of death and to ensure the adequacy of treatment. Although some authors have shown that the PRISM score overestimates mortality and that it is not appropriate in specific pediatric populations, in this study pediatric risk of mortality showed satisfactory discriminatory performance in differentiating between survivors and non‐survivors. CONCLUSIONS: The pediatric risk of mortality score showed adequate discriminatory capacity and thus constitutes a useful tool for the assessment of prognosis for pediatric patients admitted to a tertiary pediatric intensive care units.

Nutrition Therapy in a Pediatric Intensive Care Unit Indications, Monitoring, and Complications

BACKGROUND Nutrition therapy (NT) is essential for the care of critically ill children. Inadequate feeding leads to malnutrition and may increase the patients risk of morbidity and mortality. The aim of this study was to describe the NT used in a tertiary pediatric intensive care unit (PICU). METHODS The authors evaluated NT administered to 90 consecutive patients who were hospitalized for 7 days in the PICU of Instituto da Criança, Hospital das Clínicas, Universidade de São Paulo, Brazil. NT was established according to the protocol provided by the institutions NT team. NT provided a balance of fluids and nutrients and was monitored with a weekly anthropometric nutrition assessment and an evaluation of complications. RESULTS NT was initiated, on average, within 72 hours of hospitalization. Most children (80%) received enteral nutrition (EN) therapy; of these, 35% were fed orally and the rest via nasogastric or postpyloric tube. There were gastrointestinal complications in patients (5%) who needed a postpyloric tube. Parenteral nutrition (PN) was used in only 10% of the cases, and the remaining 10% received mixed NT (EN + PN). The average calorie and protein intake was 82 kcal/kg and 2.7 g/kg per day. Arm circumference and triceps skinfold thickness decreased. CONCLUSIONS The use of EN was prevalent in the tertiary PICU, and few clinical complications occurred. There was no statistically significant change in most anthropometric indicators evaluated during hospitalization, which suggests that NT probably helped patients maintain their nutrition status.

Challenges of nutritional assessment in pediatric ICU.

Purpose of reviewThe nutritional assessment of children in the pediatric ICU is unique in view of the metabolic changes of the underlying disease. This review addresses the use and limitations of anthropometry and laboratorial and body composition markers in the diagnosis of the nutritional status of such patients. Recent findingsThe presence of inflammatory activity leads to body composition changes (lean mass reduction) and undernutrition. Nutritional assessment in pediatric ICU must prioritize anthropometric and laboratory markers that can differentiate body composition to detect specific macronutrient and micronutrient deficiencies and assessment of the inflammatory activity. SummaryNutritional assessment is one of the main aspects of the pediatric intensive care patient and is the most important tool to avoid hospital undernutrition. There is currently no gold standard for nutritional assessment in the pediatric ICU. The results of anthropometric and laboratory markers must be jointly analyzed, but individually interpreted according to disease and metabolic changes, in order to reach a correct diagnosis of the nutritional status and to plan and monitor the nutritional treatment.

Nutritional follow-up of critically ill infants receiving short term parenteral nutrition

Few studies have tried to characterize the efficacy of parenteral support of critically ill infants during short period of intensive care. We studied seventeen infants during five days of total parenteral hyperalimentation. Subsequently, according to the clinical conditions, the patients received nutritional support by parenteral, enteral route or both up to the 10th day. Evaluations were performed on the 1st, 5th, and 10th days. These included: clinical data (food intake and anthropometric measurements), haematological data (lymphocyte count), biochemical tests (albumin, transferrin, fibronectin, prealbumin, retinol-binding protein) and hormone assays (cortisol, insulin, glucagon). Anthropometric measurements revealed no significant difference between the first and second evaluations. Serum albumin and transferrin did not change significantly, but mean values of fibronectin (8.9 to 16 mg/dL), prealbumin (7.7 to 18 mg/dL), and retinol-binding protein (2.4 to 3. 7 mg/dL) increased significantly (p < 0.05) from the 1st to the 10th day. The hormonal study showed no difference for insulin, glucagon, and cortisol when the three evaluations were compared. The mean value of the glucose/insulin ratio was of 25.7 in the 1st day and 15. 5 in the 5th day, revealing a transitory supression of this hormone. Cortisol showed values above normal in the beginning of the study. We conclude that the anthropometric parameters were not useful due to the short time of the study; serum proteins, fibronectin, prealbumin, and retinol-binding protein were very sensitive indicators of nutritional status, and an elevated glucose/insulin ratio, associated with a slight tendency for increased cortisol levels suggest hypercatabolic state. The critically ill patient can benefit from an early metabolic support.

Miocardite fulminante associada ao vírus influenza H1N1: relato de caso e revisão de literatura

A case of fulminant myocarditis associated with the H1N1 influenza virus. This case report describes the patients clinical course and emphasizes the importance of bedside echocardiography as an aid in the early diagnosis and management of children with severe myocardial dysfunction. It also discusses aspects relevant to the treatment and prognosis of fulminant myocarditis. The patient was a female, 4 years and 8 months old, previously healthy and with a history of flu symptoms in the past two weeks. The patient was admitted to the emergency room with signs of hemodynamic instability, requiring ventilatory support and vasoactive drugs. The laboratory tests, chest X-ray and echocardiogram suggested the presence of myocarditis. The test for H1N1 in nasopharyngeal secretions was positive. The patient evolved to refractory cardiogenic shock despite the clinical measures applied and died 48 hours after admission to the intensive care unit. The H1N1 influenza virus is an etiological agent associated with acute myocarditis, but there are few reported cases of fulminant myocarditis caused by the H1N1 virus. The identification of signs and symptoms suggestive of fulminant progression should be immediate, and bedside echocardiography is a useful tool for the early detection of myocardial dysfunction and for therapeutic guidance. The use of immunosuppressive therapy and antiviral therapy in acute myocarditis of viral etiology is controversial; hence, the treatment is based on hemodynamic and ventilatory support. The use of hemodynamic support by extracorporeal membrane oxygenation emerges as a promising treatment.Caso de miocardite fulminante asso- ciada ao virus influenza H1N1, em que foi descrita a evolucao clinica do paciente e enfatizada a importância do ecocardio- grama a beira do leito como auxilio no diagnostico precoce e manejo de crian- cas com disfuncao miocardica grave, alem de terem sido discutidos aspectos relevantes relacionados a terapeutica e ao prognostico da miocardite fulminante. Trata-se de paciente do sexo feminino, 4 anos e 8 meses, previamente higida, com historia de quadro gripal ha 2 semanas. Admitida no pronto-socorro com sinais de instabilidade hemodinâmica, neces- sitando de suporte ventilatorio e drogas vasoativas. Exames laboratoriais, radio- grafia de torax e ecocardiograma suges - tivos de miocardite. Pesquisa positiva para H1N1 em secrecao de nasofaringe. Evoluiu com choque cardiogenico re- fratario a despeito das medidas clinicas,

Dual candidemia detected by nested polymerase chain reaction in two critically ill children

The use of improved microbiological procedures associated with molecular techniques has increased the identification of Candida bloodstream infections, even if the isolation of more than one species by culture methods remains uncommon. We report the cases of two children presenting with severe gastrointestinal disorders and other risk factors that contribute to Candida infections. In the first patient, C. albicans DNA was initially detected by a nested-amplification and C. tropicalis was found later during hospitalization, while blood cultures were persistently negative. In the second child, there was amplification of C. albicans and C. glabrata DNA in the same samples, but blood cultures yielded only C. albicans. Both patients received antifungal therapy but had unfavorable outcomes. These two cases illustrate that PCR was more successful than culture methods in detecting Candida in the bloodstream of high risk children, and was also able to detect the presence of more than one species in the same patient that might impact therapy when the fungi are resistant to azole compounds.

O impacto da introdução precoce de terapia nutricional enteral na redução da morbimortalidade na terapia intensiva pediátrica: uma revisão sistemática

OBJECTIVE To assess the impact of early introduction of enteral nutrition therapy in reducing morbidity and mortality in pediatric intensive care unit. METHODS Search in the literature of the last 10 years, in English and the target population of individuals aged 1 month to 18 years admitted to pediatric intensive care units in the databases PubMed, Lilacs and Embase using the keywords: Critical Care, Nutritional Support and Nutrition Disorders or Malnutrition. RESULTS Despite advances in the quality of clinical care, the prevalence of malnutrition in hospitalized children remains unchanged in the last 20 years (15-30%) and has implications for the time of admission, course of illness and morbidity. Malnutrition is common and is often poorly recognized and therefore, untreated. Nutritional therapy is an essential part in the treatment of pediatric patients who have severely ill hypercatabolic state protein, which can be minimized with an effective nutritional treatment plan. In this study, we reviewed publications which have shown that there is still a paucity of randomized and controlled studies with good statistical treatment in relation to enteral nutritional therapy with outcomes related to morbidity and mortality. The current guidelines for nutritional therapy in these patients are largely based on expert opinion and data extrapolated from adult studies and studies in healthy children. CONCLUSION The scientific evidence on the use of enteral nutrition therapy in improving the development of critically ill pediatric patients is still scarce and further studies are needed focusing on it, and better guidelines must be formulated.

Importance of the use of protocols for the management of analgesia and sedation in pediatric intensive care unit

Introduction: Analgesia and sedation are essential elements in patient care in the intensive care unit (ICU), in order to promote the control of pain, anxiety and agitation, prevent the loss of devices, accidental extubation, and improve the synchrony of the patient with mechanical ventilation. However, excess of these medications leads to rise in morbidity and mortality. The ideal management will depend on the adoption of clinical and pharmacological measures, guided by scales and protocols. Objective: Literature review on the main aspects of analgesia and sedation, abstinence syndrome, and delirium in the pediatric intensive care unit, in order to show the importance of the use of protocols on the management of critically ill patients. Method: Articles published in the past 16 years on PubMed, Lilacs, and the Cochrane Library, with the terms analgesia, sedation, abstinence syndrome, mild sedation, daily interruption, and intensive care unit. Results: Seventy-six articles considered relevant were selected to describe the importance of using a protocol of sedation and analgesia. They recommended mild sedation and the use of assessment scales, daily interruptions, and spontaneous breathing test. These measures shorten the time of mechanical ventilation, as well as length of hospital stay, and help to control abstinence and delirium, without increasing the risk of morbidity and morbidity. Conclusion: Despite the lack of controlled and randomized clinical trials in the pediatric setting, the use of protocols, optimizing mild sedation, leads to decreased morbidity.