Eliana de Andrade Trotta

Identificação de medicamentos "não apropriados para crianças" em prescrições de unidade de tratamento intensivo pediátrica

Objective: To assess the extent of use of drugs not appropriate for children in prescriptions issued in a tertiary pediatric intensive care unit (PICU), according to FDA standards. Methods: Observational cross-sectional study. The prescriptions issued to all patients admitted to the PICU at Hospital de Clinicas de Porto Alegre, Brazil, over a six-week period were assessed. Patients’ age, sex, weight, prior disease, reason for admission to the PICU and pediatric index of mortality (PIM) were recorded, as were all drugs prescribed, their indications, presentations, doses, frequencies and means of administration. Adequacy for prescription of drugs in three pediatric age ranges was defined according to USA Food and Drug Administration (FDA) approval classification, based on the USP DI 2001 drug reference database. Results: Data were obtained in the months of July and August 2002, on different days, for six consecutive weeks, based on prescriptions issued to 51 patients in 54 admissions to the PICU. Median patient age was 10.5 months; 61% of patients were male. Two thirds of patients (65%) presented prior disease. 87% of admissions were due to clinical reasons, of which 57% were respiratory complaints. A total of 747 prescription items were registered, with prevalence of 10.5% for nonapproved uses and 49.5% for off-label uses. No statistically significant difference was found in the distribution of prevalence of irregular prescription either by the three age ranges or by level of severity of

Prevalência das síndromes inflamatórias sistêmicas em uma unidade de tratamento intensivo pediátrica terciária

Objective: To assess the prevalence of systemic inflammatory syndromes on admission to a tertiary-care university pediatric intensive care unit (ICU), and relate this to length of hospital stay, risk of death and mortality rate. Methods: Cross-sectional, prospective, observational study, including all patients admitted to the Hospital de ClInicas de Porto Alegre (HCPA) ICU between August 1st 1999 and July 31st 2000. Patient demographic variables were considered together with the risk of mortality on admission, co-morbidities, length of hospital stay and ICU outcome, in addition to variables that characterize the systemic inflammatory syndromes (systemic inflammatory response syndrome, sepsis, severe sepsis and septic shock). Results: We studied 447 admissions of 388 patients; 54% were male, with a median age of 20 months. The prevalence of systemic inflammatory response syndrome (SIRS) was 68%: 2/3 infectious (sepsis, severe sepsis or septic shock) and 1/3 non-infectious. Risk of mortality scores for patients with infectious SIRS were higher than for those with non-infectious SIRS (6.75% [P25=2.25 - P75=21.3] vs. 2.35% [P25=1.1 - P75=6.7]; p=0) and increased according to SIRS severity (2.9; 10.85, 43.9%; p<0.05). The observed mortality was 12% for patients with SIRS and 5.8% for those without SIRS (p=0.057); the observed mortality for infectious SIRS was 14.9% and for non-infectious 6.3% (p=0.041). The period spent in ICU for infectious SIRS was longer than for non-infectious cases: 3 days (P25=2 - P75=7) vs. 2 days (P25=1.5 - P75=4); p=0.006. Conclusions: The prevalence rate of patients with systemic inflammatory response syndrome upon admission to HCPA pediatric intensive care unit was elevated, with a predominance of infectious syndromes, responsible for longer stays, increased risk of mortality and increased mortality of patients during the period evaluated.

Advances in sepsis diagnosis and treatment

OBJETIVO: Apresentar uma revisao critica e atualizada sobre a sepse, principalmente os aspectos diagnosticos e terapeuticos. FONTES DOS DADOS: Pesquisa bibliografica em periodicos indexados em base Medline, tanto de revisao como ensaios clinicos e pesquisa laboratorial. SINTESE DOS DADOS: A Conferencia Internacional sobre Definicao de Sepse ampliou a relacao de possiveis sinais clinicos e laboratoriais de sepse, o que podera permitir a suspeicao e manejo iniciais mais eficazes. Na avaliacao laboratorial, alem da pesquisa do agente infectante, varios marcadores da resposta inflamatoria tais como as citoquinas inflamatorias e a procalcitonina, tem sido identificados, mas ainda sem sensibilidade e especificidade suficientes para diagnostico seguro. Quanto ao tratamento, as intervencoes precoces sobre os disturbios hemodinâmicos continuam sendo primordiais para o desfecho, assim como o uso racional de antimicrobianos. Terapias de remocao de toxinas e de aumento da resposta imune inata ainda nao provaram definitivamente seu valor. O uso de bloqueadores da resposta inflamatoria isolados, em qualquer fase do seu estagio, falhou em reduzir a mortalidade. O corticoide ressurge com resultados animadores, mesmo em pacientes sem insuficiencia adrenal relacionada a sepse. A proteina C ativada (drotrecogina-a), em um grande estudo, mostrou reducao de 6% de mortalidade em uma amostragem selecionada, oferecendo uma possibilidade de melhor prognostico na sepse. CONCLUSOES: Comparativamente aos avancos dos ultimos anos, pouco se obteve com relacao a diminuicao de mortalidade por sepse, pela complexidade das relacoes patogeno-hospedeiro. A regulacao individual de cada reacao do hospedeiro nao mostrou o efeito esperado. Algumas estrategias, ja conhecidas, foram reafirmadas como beneficas, e outras, como o uso de corticoide e a proteina C ativada, estao surgindo como terapias promissoras. As pesquisas apontam para a combinacao de terapias imunomoduladoras como a melhor alternativa para melhorar o desfecho na sepse.

The impact of admission to a pediatric intensive care unit assessed by means of global and cognitive performance scales

OBJECTIVE To assess the impact of admission to the pediatric intensive care unit (ICU) at the Hospital de Clínicas de Porto Alegre, RS, Brazil on childrens cognitive and global performance. METHODS An observational, longitudinal study of a sequential sample of critically ill children. The following indicators were used: the Pediatric Index of Mortality (PIM), for severity and risk of death at admission, the Pediatric Cerebral Performance Category (PCPC), for cognitive morbidity and the Pediatric Overall Performance Category (POPC), for global morbidity, at admission and at discharge. Morbidity related to the ICU was measured according to the difference between classifications at discharge and at admission (delta scores). The Kruskal-Wallis test was applied. RESULTS A total of 443 patients were assessed, 54% of whom were male, with a median age of 12 months (IQ 4-45), and a median ICU stay of 4.24 days (IQ 2.4-8). The mortality rate was 6.3%. The median PIM score was 2.36% (IQ 1-7). On admission, 46% of the patients had some degree of cognitive morbidity and 66% had some degree of global morbidity. At discharge there was 60% cognitive morbidity and 86% global morbidity. The assessment of ICU-related morbidity revealed that 25% of the patients had undergone cognitive changes while 41% had undergone global variations, at discharge compared with admission. CONCLUSIONS Although affected by the elevated degree of morbidity at admission, the impact of the ICU stay was more significant in the global than in the cognitive domain. In the same manner, both risk of death at admission and length of stay had a significant effect on the morbidity of severely ill patients.

Admission source and mortality in a pediatric intensive care unit

Background and Aims: Studies carried out in different countries have shown that source of patient admission in Intensive Care Units (ICUs) is associated to death. Patients admitted from wards show a greater ICU mortality. The aim of the present study was to investigate the association between admission source and outcome in a Pediatric Intensive Care Unit (PICU). Materials and Methods: We studied all PICU admissions that took place between January 2002 and December 2005 in a tertiary hospital in Brazil. The major outcome studied was death while in the PICU. The independent variable analyzed was admission source, defined either as pediatric emergency room (PER), wards, operating room (OR) of the same hospital or other sources. Results: A total of 1823 admissions were studied. The overall expected mortality based on the Pediatric Index of Mortality 2 was 6.5% and the observed mortality was 10.3%. In adjusted analysis, the mortality was doubled in patients admitted from wards when compared with the PER patients. Conclusions: Observed mortality rates were higher in patients admitted from wards within the same hospital, even after adjustment.

Impacto da internação em unidade de terapia intensiva pediátrica: avaliação por meio de escalas de desempenho cognitivo e global

OBJECTIVE: To assess the impact of admission to the pediatric intensive care unit (ICU) at the Hospital de Clinicas de Porto Alegre, RS, Brazil on childrens cognitive and global performance. METHODS: An observational, longitudinal study of a sequential sample of critically ill children. The following indicators were used: the Pediatric Index of Mortality (PIM), for severity and risk of death at admission, the Pediatric Cerebral Performance Category (PCPC), for cognitive morbidity and the Pediatric Overall Performance Category (POPC), for global morbidity, at admission and at discharge. Morbidity related to the ICU was measured according to the difference between classifications at discharge and at admission (delta scores). The Kruskal-Wallis test was applied. RESULTS: A total of 443 patients were assessed, 54% of whom were male, with a median age of 12 months (IQ 4-45), and a median ICU stay of 4.24 days (IQ 2.4-8). The mortality rate was 6.3%. The median PIM score was 2.36% (IQ 1-7). On admission, 46% of the patients had some degree of cognitive morbidity and 66% had some degree of global morbidity. At discharge there was 60% cognitive morbidity and 86% global morbidity. The assessment of ICU-related morbidity revealed that 25% of the patients had undergone cognitive changes while 41% had undergone global variations, at discharge compared with admission. CONCLUSIONS: Although affected by the elevated degree of morbidity at admission, the impact of the ICU stay was more significant in the global than in the cognitive domain. In the same manner, both risk of death at admission and length of stay had a significant effect on the morbidity of severely ill patients.

Validação de escalas de sedação em crianças submetidas à ventilação mecânica internadas em uma unidade de terapia intensiva pediátrica terciária

OBJETIVOS: O uso de escalas de sedacao e fundamental em unidades de terapia intensiva pediatrica. A escala Comfort-Behavior e validada para avaliacao de criancas, contudo, e um instrumento extenso. A escala de avaliacao da atividade motora esta validada para adultos, e mais simples do que a anterior e possivel de ser usada em criancas. Nenhuma dessas escalas esta validada na lingua portuguesa. O objetivo primario deste estudo foi validar as duas escalas traduzidas para o portugues em criancas submetidas a ventilacao mecânica. Os objetivos secundarios foram avaliar o nivel de sedacao dos pacientes em ventilacao mecânica de unidades de terapia intensiva pediatrica terciaria e comparar o desempenho das duas escalas nesta populacao. METODOS: Apos a traducao para o portugues, as escalas foram aplicadas em 26 pacientes por dois medicos, simultaneamente. Obteve-se um total de 116 observacoes por escala. RESULTADOS: O coeficiente de correlacao intraclasse foi 0,90 (IC95% 0,85 - 0,93) para a escala Comfort-Behavior e 0,94 (IC 95% 0,92 - 0,96) para a avaliacao da atividade motora. O alfa de Crombach para o observador A ao aplicar a escala Comfort-Behvior foi 0,81 e para o observador B, 0,92. O coeficiente de Spearman para o observador A foi 0,86 e para o observador B, 0,91. As aplicacoes das escalas revelaram pacientes bastante sedados, atingindo pontuacoes baixas em ambas. CONCLUSOES: A validacao das escalas Comfort-Behavior e avaliacao da atividade motora para o portugues foi realizada com sucesso. Ambas foram adequadas para emprego em criancas em ventilacao mecânica. Nas aplicacoes avaliadas, o nivel de sedacao observado na unidade estudada foi alto.

Retrospective Study of the Survival of Patients who Underwent Cardiopulmonary Resuscitation in an Intensive Care Unit

OBJECTIVE To evaluate clinical and evolutive characteristics of patients admitted in an intensive care unit after cardiopulmonary resuscitation, identifying prognostic survival factors. METHODS A retrospective study of 136 patients admitted between 1995 and 1999 to an intensive care unit, evaluating clinical conditions, mechanisms and causes of cardiopulmonary arrest, and their relation to hospital mortality. RESULTS A 76% mortality rate independent of age and sex was observed. Asystole was the most frequent mechanism of death, and seen in isolation pulmonary arrest was the least frequent. Cardiac failure, need for mechanical ventilation, cirrhosis and previous stroke were clinically significant (p < 0.01) death factors. CONCLUSION Prognostic factors supplement the doctors decision as to whether or not a patient will benefit from cardiopulmonary resuscitation.

Acid and Weakly Acidic Gastroesophageal Reflux and Pepsin Isoforms (A and C) in Tracheal Secretions of Critically Ill Children

BACKGROUND Gastroesophageal reflux (GER) and pulmonary aspiration are frequent in patients in the ICU. The presence of pepsin in airways seems to be the link between them. However, pepsin isoforms A (gastric specific) and C (pneumocyte potentially derived) need to be distinguished. This study aimed to evaluate GER patterns and to determine the presence of pepsin A and C in tracheal secretions of critically ill children receiving mechanical ventilation. METHODS All patients underwent combined multichannel intraluminal impedance-pH (MII-pH) monitoring. Tracheal secretion samples were collected to determine the presence of pepsin. Pepsin A and C were evaluated by Western blot. MII-pH parameters analyzed were number of total GER episodes (NGER); acid, weakly acidic, and weakly alkaline GER episodes; and proximal and distal GER episodes. RESULTS Thirty-four patients (median age, 4 months; range, 1-174 months) were included. MII-pH monitoring detected 2,172 GER episodes (77.0% were weakly acidic; 71.7% were proximal). The median NGER episodes per patient was 59.5 (25th-75th percentile, 20.3-85.3). Weakly acidic GER episodes per patient were significantly more frequent than acid GER episodes per patient (median [25th-75th percentile], 43.5 [20.3-68.3] vs 1.0 [0-13.8], respectively; P < .001). Only three patients had an altered acid reflux index (44.9%, 12.7%, and 13.6%) while not taking antacid drugs. Pepsin A was found in 100% of samples and pepsin C in 76.5%. CONCLUSIONS The majority of GER episodes of children in the ICU were proximal and weakly acidic. All patients had aspiration of gastric contents as detected by pepsin A in tracheal fluid. A specific pepsin assay should be performed to establish gastropulmonary aspiration because pepsin C was found in > 70% of samples.

Health professionals' perceptions about the decision-making process in the care of pediatric patients

Objective To evaluate the perceptions of physicians, nurses and nursing technicians of their participation in the decision-making process surrounding life support limitation in terminally ill pediatric patients, with comparisons by professional category. Methods A cross-sectional study was conducted in the pediatric intensive care unit of a tertiary public university hospital with the participation of physicians, nurses and nursing technicians. The MacArthur Admission Experience Survey Voice Scale was used to assess and quantify the perceptions of professionals who assisted 17 pediatric patients with life support limitation within 24 hours after the outcome of each patient was determined. All professionals working in the unit (n = 117) who were potentially eligible for the study received a free and informed consent form prior to the occurrence of the cases studied. Results Study participants included 25/40 (62.5%) physicians, 10/17 (58.8%) nurses and 41/60 (68.3%) nursing technicians, representing 65% of the eligible professionals identified. The questionnaire return rate was higher for physicians than technicians (p = 0.0258). A perceived lack of voice was reported in all three professional categories at varying rates that were lower for physicians than for nurses and nursing technicians (p < 0.00001); there was no difference between the latter (p = 0.7016). In the three professional categories studied, three subscale items were reported. For two of the three statements, there were significant differences between physicians and nurses (p = 0.004) and between physicians and nursing technicians (p = 0.001). For one of the statements, there was no difference among the three professional categories. Conclusion Respondents perceived a lack of voice in the decision-making process at varying rates across the three categories of studied professionals who assisted terminally ill pediatric patients with life support limitation, with physicians expressing lowered rates of perceived coercion.