Claudio Flauzino de Oliveira

Time-and Fluid-Sensitive Resuscitation for Hemodynamic Support of Children in Septic Shock : Barriers to the Implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a Pediatric Intensive Care Unit in a Developing World

Objectives: To analyze mortality rates of children with severe sepsis and septic shock in relation to time-sensitive fluid resuscitation and treatments received and to define barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support guidelines in a pediatric intensive care unit in a developing country. Methods: Retrospective chart review and prospective analysis of septic shock treatment in a pediatric intensive care unit of a tertiary care teaching hospital. Ninety patients with severe sepsis or septic shock admitted between July 2002 and June 2003 were included in this study. Results: Of the 90 patients, 83% had septic shock and 17% had severe sepsis; 80 patients had preexisting severe chronic diseases. Patients with septic shock who received less than a 20-mL/kg dose of resuscitation fluid in the first hour of treatment had a mortality rate of 73%, whereas patients who received more than a 40-mL/kg dose in the first hour of treatment had a mortality rate of 33% (P < 0.05). Patients treated less than 30 minutes after diagnosis of severe sepsis and septic shock had a significantly lower mortality rate (40%) than patients treated more than 60 minutes after diagnosis (P < 0.05). Controlling for the risk of mortality, early fluid resuscitation was associated with a 3-fold reduction in the odds of death (odds ratio, 0.33; 95% confidence interval, 0.13-0.85). The most important barriers to achieve adequate severe sepsis and septic shock treatment were lack of adequate vascular access, lack of recognition of early shock, shortage of health care providers, and nonuse of goals and treatment protocols. Conclusions: The mortality rate was higher for children older than 2 years, for those who received less than 40 mL/kg in the first hour, and for those whose treatment was not initiated in the first 30 minutes after the diagnosis of septic shock. The acknowledgment of existing barriers to a timely fluid administration and the establishment of objectives to overcome these barriers may lead to a more successful implementation of the American College of Critical Care Medicine guidelines and reduced mortality rates for children with septic shock in the developing world.

Complications of tracheobronchial foreign body aspiration in children: report of 5 cases and review of the literature

Foreign body aspiration (FBA) is one of leading causes of death in children, especially among those younger than 3 years of age. The inhalation of a foreign body may cause a wide variety of symptoms, and early diagnosis is highly associated with the successful removal of the inhaled foreign material. Despite the great advances in endoscopic procedures and anesthesia, a large number of difficulties and complications still result from foreign body aspiration. We describe 5 cases of serious acute complications following aspiration of foreign bodies that became lodged in the tracheobronchial tree, including pneumomediastinum, pneumothorax, total atelectasis, foreign body dislodgment, and need for thoracotomy in children admitted into our intensive care unit in 1999 and 2000; these were all situations that could have been prevented with early recognition and prompt therapeutic intervention.

Prognóstico da hipoglicemia hiperinsulinêmica persistente da infância: uma revisão sistemática

Objective: To describe the prognosis of persistent hyperinsulinemic hypoglycemia of infancy, submitted or not to pancreatectomy. Data sources: Databases Medline and Ovid were searched for studies published in the last ten years with the expression “hyperinsulinemic hypoglycemia”. Manuscripts about the prognosis of patients with persistent hyperinsulinemic hypoglycemia of infancy (zero to ten years) were analyzed, in order to do a systematic review. Data synthesis: Two hundred sixty-nine publications were identified, and 13 had information about the prognosis of the persistent hyperinsulinemic hypoglycemia of infancy, including eight studies of patients submitted to pancreatectomy. The main factor associated with the prognosis was the neurological status. In the analyzed studies, the incidence of neurological development delay varied from 10 to 70%, depending on the sample and on the age of onset. Among children submitted to pancreatectomy in order to treat the hypoglycemia, the main factors that influenced prognosis were the characteristics and the extension of the pancreatic injury. Focal injuries caused significantly less complications that the diffuse injuries. The incidence of diabetes mellitus after a partial or subtotal pancreatectomy varied from 25 to 100%, depending on the patients evaluated in each study. Conclusions: The timing of symptoms onset influen ces directly the severity of the neurological status and the prognosis. In the patients submitted to pancreatectomy, the characteristics of the pancreatic injury determine the extent of the consequences.

Choque refratário e óbito após intoxicação por sulfato ferroso

OBJECTIVE: To present a case of a child with iron intoxication due to an accidental ingestion of ferrous sulfate. CASE DESCRIPTION: An eleven-month-old child was admitted to the hospital after an accidental ingestion of ferrous sulfate, presenting diarrhea, severe dehydration and drowsiness. Initially, therapies for hemodynamic stabilization, ventilatory support and vasopressor drugs were adopted. Laboratory test revealed high serum iron level (259μmol/L) and deferoxamine administration was started. Despite treatment, the child persisted with hemodynamic instability, without improvement after epinephrine infusion and died 50 hours after admission, due to refractory shock. COMMENTS: The ferrous sulfate is widely used and easily accessible for children in their homes. In this case report, despite prompt diagnosis and early institution of adequate treatment, it was not possible to avoid the development of refractory shock and death. Therefore, it is important to avoid intoxication as well as to improve medical knowledge about the pathophysiology of iron intoxication, acknowledging that treatment not always avoids a poor outcome.