Francisco Bruno

Evolution of the medical practices and modes of death on pediatric intensive care units in southern Brazil

Objectives: To study the possible change on mode of deaths, medical decision practices, and family participation on decisions for limiting life-sustaining treatments (L-LST) over a period of 13 yrs in three pediatric intensive care units (PICUs) located in southern Brazil. Methods: A cross-sectional study based on a retrospective chart review (1988 and 1998) and on prospective data collection (from May 1999 to May 2000). Setting: Three PICUs in Porto Alegre, southern Brazilian region. Patients: Children who died in those PICUs during the years of 1988, 1998, and between May 1999 and May 2000. Results: The 3 PICUs admitted 6,233 children during the study period with a mortality rate of 9.2% (575 deaths), and 509 (88.5%) medical charts were evaluated in this study. Full measures for life support (F-CPR) were recognized in 374 (73.5%) children before dying, brain death (BD) was diagnosed in 43 (8.4%), and 92 (18.1%) underwent some limitation of life support treatment (L-LST) There were 140 (27.5%) deaths within the first 24 hrs of admission and 128 of them (91.4%) received F-CPR, whereas just 11 (7.9%) patients underwent L-LST. The average length of stay for the death group submitted to F-CPR was lower (3 days) than the L-LST group (8.5 days; p < .05). The rate of F-CPR before death decreased significantly between 1988 (89.1%) and 1999/2000 (60.8%), whereas the L-LST rose in this period from 6.2% to 31.3%. These changes were not uniform among the three PICUs, with different rates of L-LST (p < .05). The families were involved in the decision-making process for L-LST in 35.9% of the cases, increasing from 12.5% in 1988 to 48.6% in 1999/2000. The L-LST plans were recorded in the medical charts in 76.1% of the deaths, increasing from 50.0% in 1988 to 95.9% in 1999/2000. Conclusion: We observed that the modes of deaths in southern Brazilian PICUs changed over the last 13 yrs, with an increment in L-LST. However, this change was not uniform among the studied PICUs and did not reach the levels described in countries of the Northern Hemisphere. Family participation in the L-LST decision-making process has increased over time, but it is still far behind what is observed in other parts of the world.

Comparison of two prognostic scores (PRISM and PIM) at a pediatric intensive care unit.

OBJECTIVE To compare the performance of the PRISM (Pediatric Risk of Mortality) and the PIM (Pediatric Index of Mortality) scores at a general pediatric intensive care unit, investigating the relation between observed mortality and survival and predicted mortality and survival. METHODS A contemporary cohort study undertaken between 1 June 1999 and 31 May 2000 at the Pontifícia Universidade Católica do Rio Grande do Sul, Hospital São Lucas pediatric intensive care unit. The inclusion criteria and the PRISM and PIM calculations were performed as set out in the original articles and using the formulae as published. Statistical analysis for model evaluation employed the Flora z test, Hosmer-Lemeshow goodness-of-fit test, ROC curve (receiver operating characteristic) and Spearmans correlation tests. The study was approved by the institutions Ethics Committee. RESULTS Four hundred and ninety-eight patients were admitted to the pediatric intensive care unit, 77 of whom presented exclusion criteria. Thirty-three (7.83%) of the 421 patients studied died and 388 patients were discharged. Estimated mortality by PRISM was 30.84 (7.22%) with a standardized mortality rate of 1.07 (0.74-1.50), z = -0.45 and by PIM this was 26.13 (6.21%) with a standardized mortality rate of 1.26 (0.87-1.77), z = -1.14. The Hosmer-Lemeshow test gave a chi-square of 9.23 (p = 0.100) for PRISM and 27.986 (p < 0.001) for PIM. The area under the ROC curve was 0.870 (0.810-0.930) for PRISM and 0.845 (0.769-0.920) for PIM. The Spearman test returned r = 0.65 (p < 0.001). CONCLUSION Analyzing the tests we can observe that, although the PIM test was less well calibrated overall, both PRISM and PIM offer a good capacity for discriminating between survivors and moribund patients. They are tools with comparable performance at the prognostic evaluation of the pediatric patients admitted to our unit.

Perfil epidemiológico de dezesseis anos de uma unidade de terapia intensiva pediátrica

OBJETIVO: Revisar e descrever os dados epidemiologicos dos pacientes admitidos em uma unidade de terapia pediatrica brasileira (UTIP) e compara-los aos aspectos clinicos associados aos indices de gravidade e mortalidade. Descrever as caracteristicas desses pacientes, incluindo os dados demograficos, prevalencia de doencas, indices de mortalidade e fatores associados. METODOS: Os dados foram coletados retrospectivamente de todos os pacientes admitidos na UTIP de um hospital universitario entre 1978 e 1994. Os dados foram expressos em percentagens e comparados pelo teste qui-quadrado, calculando-se o risco relativo (RR) com um intervalo de confianca de 95%, considerando-se um p<0,05. RESULTADOS: Foram selecionados 13.101 pacientes - em sua maioria meninos (58,4%) - com doenca clinica (73,1%), menores de 12 meses de idade (40,4%) e eutroficos (69,5%). O indice geral de mortalidade foi de 7,4%. Os pacientes menores de 12 meses de idade mostraram um RR de 1,86 (CI 1,65-2,10; p<0,0001), enquanto que a desnutricao mostrou um RR de 2,98 (IC 2,64-3,36; p<0,0001). CONCLUSOES: O levantamento epidemiologico mostrou que a mortalidade e maior entre desnutridos e menores de 12 meses de idade. A sepse foi a principal causa de morte.

A sedação e analgesia de crianças submetidas à ventilação mecânica estariam sendo superestimadas

Abstract Objective: to describe the pattern of analgesic and sedativeinfusions in children submitted to mechanical ventilation in a regionalpediatric intensive care unit during a 12-month period. To comparethe use of these drugs among clinical and surgical patients, as wellevaluate the influence of the length of use on the average daily dosesand on the incidence of abstinence syndrome.Methods: this cohort study was performed from April 2001 toMarch 2002, involving children (1 month old to 15 years old)submitted to the mechanical ventilation with a tracheal tube for aperiod longer than 12 hours and who were successfully extubated(dead patients and those who required reintubation were excludedfrom the study). A team of professionals not involved with thepatient’s assistance performed a daily collection of all data up to the28 th day under mechanical ventilation (maximum length of followup for those who remain longer under mechanical ventilation). Themain outcome was the infusion doses of morphine, fentanyl, ketamineand midazolam administered at 12 AM (considering this dose as theaverage dose for that day). The diagnosis of abstinence syndromewas based on the chart revision (recorded diagnosis or based on thespecific antagonist treatment used) and in an interview with theassistant physician on the following days after the extubation. Thisstudy was approved by the Ethics and Scientific Committee of theHSL-PUCRS.

Intramuscular midazolam versus intravenous diazepam for treatment of seizures in the pediatric emergency department: A randomized clinical trial☆

AIM To compare the therapeutic efficacy of intramuscular midazolam (MDZ-IM) with that of intravenous diazepam (DZP-IV) for seizures in children. DESIGN Randomized clinical trial. SETTING Pediatric emergency department. PATIENTS Children aged 2 months to 14 years admitted to the study facility with seizures. INTERVENTION Patients were randomized to receive DZP-IV or MDZ-IM. MAIN MEASUREMENTS Groups were compared with respect to time to treatment start (min), time from drug administration to seizure cessation (min), time to seizure cessation (min), and rate of treatment failure. Treatment was considered successful when seizure cessation was achieved within 5min of drug administration. RESULTS Overall, 32 children (16 per group) completed the study. Intravenous access could not be obtained within 5min in four patients (25%) in the DZP-IV group. Time from admission to active treatment and time to seizure cessation was shorter in the MDZ-IM group (2.8 versus 7.4min; p<0.001 and 7.3 versus 10.6min; p=0.006, respectively). In two children per group (12.5%), seizures continued after 10min of treatment, and additional medications were required. There were no between-group differences in physiological parameters or adverse events (p=0.171); one child (6.3%) developed hypotension in the MDZ-IM group and five (31%) developed hyperactivity or vomiting in the DZP-IV group. CONCLUSION Given its efficacy and ease and speed of administration, intramuscular midazolam is an excellent option for treatment of childhood seizures, enabling earlier treatment and shortening overall seizure duration. There were no differences in complications when applying MDZ-IM or DZP-IV.

Rapid airway access

OBJECTIVE: To review the steps involved in safe airway management in critically ill children. SOURCES OF DATA: Review of articles selected through Medline until April 2003 using the following key words: intubation, children, sedation. SUMMARY OF THE FINDINGS: Airway compromise is rare, but whenever it occurs, the situation depends on professionals trained to carry out safe, early, and rapid airway management, with no harm to the patient. The method currently advocated for airway management is rapid sequence intubation, which requires preparation, sedation and neuromuscular block. We observed that it is not possible to apply one single intubation protocol to all cases, since the selection of the most adequate procedure depends on indication and patient conditions. We defined the drug doses most commonly used in our setting, since little is know so far about the real effect of sedatives and analgesics. In most situations, the association of an opioid (fentanyl at 5-10 µg/kg) with a sedative (midazolam at 0.5 mg/kg) and a neuromuscular blocking agent are sufficient for tracheal intubation. CONCLUSIONS: Training, knowledge, and skill in airway management are of fundamental importance for pediatric intensive caregivers and are vital for the adequate treatment of critically ill children. We present an objective and dynamic text aimed at offering a theoretical basis for the generation of new protocols, to be implemented according to the strengths and difficulties of each service.

Efeito a curto prazo da posição prona na oxigenação de crianças em ventilação mecânica

OBJETIVOS: analisar o efeito a curto prazo da posicao prona na oxigenacao de pacientes pediatricos com hipoxemia severa e submetidos a ventilacao mecânica. MATERIAL E METODOS: ensaio clinico prospectivo, nao randomizado, sendo cada paciente o seu proprio controle, realizado no periodo de julho de 1998 a julho de 1999. Incluidas todas as criancas com diagnostico de insuficiencia respiratoria aguda, em ventilacao mecânica, com pressao inspiratoria positiva (PIP) maior ou igual a 30cm H2O e fracao de oxigenio inspirada (FiO2) maior ou igual a 0,5, que apresentassem PaO2/FiO2 menor ou igual a 200. Os pacientes foram mantidos duas horas na posicao prona, retornando, a seguir, a posicao supina. Avaliou-se a oxigenacao, atraves da PaO2/FiO2, na posicao supina (1 hora antes da mudanca de posicao), com 1 hora de posicao prona e 1 hora apos retornar a posicao supina. Considerou-se responsivo todo o paciente que apresentasse um aumento de, no minimo, 20 na PaO2/FiO2. Os resultados foram comparados atraves do teste t student, Friedman, Qui-quadrado, exato de Fisher e intervalo de confianca (IC). RESULTADOS: participaram do estudo 18 criancas (10 masculinos) com idade media de 11,5 (±11,5) meses e com uma PaO2/FiO2 inicial 96,06 (±41,78). Apos 1 hora em posicao prona, observamos que 5/18 (27,7%) pacientes apresentaram uma melhora na PaO2/FiO2 acima de 20 (teste exato de Fisher, P=0,045). Seis pacientes apresentavam predominantemente diminuicao da complacencia pulmonar (4 com sindrome da angustia respiratoria aguda) e 12 com aumento da resistencia pulmonar (6 com bronquiolite). Nao observamos diferenca entre esses grupos no que se refere a idade, sexo, tempo de ventilacao previa a mudanca de posicao, pressao inspiratoria positiva, fracao de oxigenio inspirada, grau de hipoxemia e evolucao. CONCLUSAO: o uso da posicao prona durante a ventilacao mecânica de criancas severamente hipoxemicas pode promover uma significativa melhora da PaO2/FiO2 a partir da 1o hora.

Norepinephrine infusion increases urine output in children under sedative and analgesic infusion

OBJECTIVE To evaluate the effects of early norepinephrine (NE) infusion in children submitted to mechanical ventilation (MV) requiring continuous sedative and analgesic infusion. METHODS Double-blinded, randomized, placebo-controlled trial enrolling children (1 month to 12 years of age) admitted to a Brazilian PICU and expected to require MV and continuous sedative and analgesic drug infusions for at least five days. Children were randomized to receive either norepinephrine (NE) (0.15 mcg/kg/min) or normal saline infusion, started in the first 24 hours of MV, and maintained for 72 hours. We compared hemodynamic variables, fluid intake, renal function and urine output between groups. RESULTS Forty children were equally allocated to the NE or placebo groups, with no differences in baseline characteristics, laboratorial findings, PRISM II score, length of MV, or mortality between groups. The average norepinephrine infusion was 0.143 mcg/kg/min. The NE group showed higher urine output (p = 0.016) and continuous increment in the mean arterial pressure compared to the baseline (p = 0.043). There were no differences in the remaining hemodynamic variables, fluid requirements, or furosemide administration. CONCLUSION Early norepinephrine infusion in children submitted to MV improves mean arterial pressure and increases urine output. These effects were attributed to reversion of vasoplegia induced by the sedative and analgesic drugs.

Cardiac dysfunction and ferritin as early markers of severity in pediatric sepsis

OBJECTIVE The aim of this study was to verify the association of echocardiogram, ferritin, C-reactive protein, and leukocyte count with unfavorable outcomes in pediatric sepsis. METHODS A prospective cohort study was carried out from March to December 2014, with pediatric critical care patients aged between 28 days and 18 years. Inclusion criteria were diagnosis of sepsis, need for mechanical ventilation for more than 48h, and vasoactive drugs. Serum levels of C-reactive protein, ferritin, and leukocyte count were collected on the first day (D0), 24h (D1), and 72h (D3) after recruitment. Patients underwent transthoracic echocardiography to determine the ejection fraction of the left ventricle on D1 and D3. The outcomes measured were length of hospital stay and in the pediatric intensive care unit, mechanical ventilation duration, free hours of VM, duration of use of inotropic agents, maximum inotropic score, and mortality. RESULTS Twenty patients completed the study. Patients with elevated ferritin levels on D0 had also fewer ventilator-free hours (p=0.046) and higher maximum inotropic score (p=0.009). Patients with cardiac dysfunction by echocardiogram on D1 had longer hospital stay (p=0.047), pediatric intensive care unit stay (p=0.020), duration of mechanical ventilation (p=0.011), maximum inotropic score (p=0.001), and fewer ventilator-free hours (p=0.020). CONCLUSION Cardiac dysfunction by echocardiography and serum ferritin value was significantly associated with unfavorable outcomes in pediatric patients with sepsis.

Uso de surfactante exógeno no tratamento da bronquiolite viral grave: relato de caso

OBJECTIVE: to describe the possible clinical and laboratory effects of exogenous surfactant instillation into the tracheal tube of a child with severe acute bronchiolitis undergoing mechanical ventilation. CASE REPORT: a 2-month-old girl with clinical diagnosis of acute viral bronchiolitis underwent mechanical ventilation. She required high positive inspiratory peak pressure (35 to 45 cmH2O) and high inspiratory fraction of oxygen (FiO2 = 0.9), but showed no clinical response or improvement in the arterial blood gas analysis. An exogenous surfactant (Exosurf®, Glaxo - 50 mg/kg) was used to facilitate the use of a less aggressive ventilatory strategy. RESULTS: four hours after surfactant administration, it was possible to reduce the positive peak inspiratory pressure (PIP) from 35 to 30 cmH2O, and FiO2 from 0.9 to 0.6; and to increase the positive end-expiratory pressure (PEEP) from 6 to 9 cmH2O. During this period the paO2/FiO2 ratio increased from 120 to 266. At the end of 24 hours, FiO2 could be reduced to 0.4. DISCUSSION: surfactant inactivation may be a decisive factor in the unfavorable evolution of some severe cases of acute bronchiolitis. The tracheal instillation of exogenous surfactant, in these cases, allows us to adopt less aggressive ventilatory strategies, and promotes rapid clinical responses.OBJECTIVE: To describe the possible clinical and laboratory effects of exogenous surfactant instillation into the tracheal tube of a child with severe acute bronchiolitis undergoing mechanical ventilation. CASE REPORT: a 2-month-old girl with clinical diagnosis of acute viral bronchiolitis underwent mechanical ventilation. She required high positive inspiratory peak pressure (35 to 45 cmH(2)O) and high inspiratory fraction of oxygen (FiO(2) = 0.9), but showed no clinical response or improvement in the arterial blood gas analysis. An exogenous surfactant (Exosurf(R), Glaxo - 50 mg/kg) was used to facilitate the use of a less aggressive ventilatory strategy. RESULTS: Four hours after surfactant administration, it was possible to reduce the positive peak inspiratory pressure (PIP) from 35 to 30 cmH(2)O, and FiO(2) from 0.9 to 0.6; and to increase the positive end-expiratory pressure (PEEP) from 6 to 9 cmH(2)O. During this period the paO(2)/FiO(2) ratio increased from 120 to 266. At the end of 24 hours, FiO(2) could be reduced to 0.4. DISCUSSION: Surfactant inactivation may be a decisive factor in the unfavorable evolution of some severe cases of acute bronchiolitis. The tracheal instillation of exogenous surfactant, in these cases, allows us to adopt less aggressive ventilatory strategies, and promotes rapid clinical responses.