Lara de Araújo Torreão

End-of-life practices in seven Brazilian pediatric intensive care units.

Objective: To evaluate the incidence of life support limitation and medical practices in the last 48 hrs of life of children in seven Brazilian pediatric intensive care units (PICUs). Design: Cross-sectional multicenter retrospective study based on medical chart review. Setting: Seven PICUs belonging to university and tertiary hospitals located in three Brazilian regions: two in Porto Alegre (southern region), two in São Paulo (southeastern region), and three in Salvador (northeastern region). Patients: Medical records of all children who died in seven PICUs from January 2003 to December 2004. Deaths in the first 24 hrs of admission to the PICU and brain death were excluded. Interventions: Two pediatric intensive care residents from each PICU were trained to fill out a standard protocol (&kgr; = 0.9) to record demographic data and all medical management provided in the last 48 hrs of life (inotropes, sedatives, mechanical ventilation, full resuscitation maneuvers or not). Students t-test, analysis of variance, chi-square test, and relative risk were used for comparison of data. Measurements and Main Results: Five hundred and sixty-one deaths were identified; 97 records were excluded (61 because of brain death and 36 due to <24 hrs in the PICU). Thirty-six medical charts could not be found. Cardiopulmonary resuscitation was performed in 242 children (57%) with a significant difference between the southeastern and northeastern regions (p = .0003). Older age (p = .025) and longer PICU stay (p = .001) were associated with do-not-resuscitate orders. In just 52.5% of the patients with life support limitation, the decision was clearly recorded in the medical chart. No ventilatory support was provided in 14 cases. Inotropic drug infusions were maintained or increased in 66% of patients with do-not-resuscitate orders. Conclusions: The incidence of life support limitation has increased among Brazilian PICUs but with significant regional differences. Do-not-resuscitate orders are still the most common practice, with scarce initiatives for withdrawing or withholding life support measures.

Brain death: medical management in seven Brazilian pediatric intensive care units

OBJECTIVE To assess the incidence of brain death (BD) and its medical management and adopted protocols after its diagnosis in seven pediatric intensive care units (PICUs) located in three Brazilian regions. METHODS A cross-sectional and multicenter study was conducted, based on the retrospective review of medical records regarding all deaths that occurred between January 2003 and December 2004 in seven Brazilian PICUs of tertiary hospitals located in Porto Alegre (two), São Paulo (two) and Salvador (three). Two pediatric intensive care residents from each hospital were previously trained and filled out a standard protocol for the investigation of demographic data, cause of death, diagnosis of BD, related protocols and subsequent medical management. RESULTS A total of 525 death patients were identified and 61 (11.6%) were defined as BD. The incidence of BD was different (p = 0.015) across the seven PICUs, but with no difference across the three regions. Intracranial hemorrhage was the most frequent cause of BD (31.1%). In 80% of the cases the diagnosis of BD was confirmed by complementary exams (south = 100%, southeast = 68% and northeast = 72%; p = 0.02). The interval between the diagnosis of BD and the withdrawal of life support was different (p < 0.01) across the three regions, being faster (p = 0.04) in the south (1.8+/-1.9 h) than in the southeast (28.6+/-43.2 h) and than in the northeast (15.5+/-17.1 h). Only six (9.8%) children with BD were organ donors. CONCLUSION Although a Brazilian law defining the criteria for the determination of BD has been in place since 1997, we verified that it is not followed as strictly as it should be. Consequently, unnecessary life support is offered to deceased individuals, and there is a discrete involvement of PICUs in organ donation.

Cardiopulmonary resuscitation: discrepancy between the actual cardiopulmonary resuscitation and the documentation in the medical record

OBJECTIVES: To describe the characteristics of the patients not resuscitated in a university affiliated pediatric hospital. To characterize the data registered in the chart regarding the resuscitation and evaluate ethical and legal aspects of CPR (cardiopulmonary resuscitation). METHODS: Retrospective study of 176 deaths that occurred in a one year time period. The chart was reviewed and compared to information received directly from the physician that participated in the patientacute;s resuscitation. Ethical and legal aspects involved in resuscitation efforts were discussed. RESULTS: During the study period 176 deaths occurred. 47 (26.7%) patients did not receive CPR as reported directly by the physician in charge of the patient when the dead occurred. Two patients were excluded, because the chart could not be found. Prior to their death, 64.4% (29/45) received mechanical ventilatory support and 48.5% (33/45) received inotropic support. 60% (27/45) of the deaths occurred in the intensive care unit. The most common diagnoses at admission were sepsis in 28% (13/45) and pneumonia with respiratory failure in 27% (12/45). The most common underlying medical conditions were malignancies in 28.8% (13/45). Of these 45 patients, the medical record about CPR was available in 40 charts. It was documented that 11/40 (27.5%) were declared dead without resuscitation efforts and in 29/40 (72.5%) the medical record stated that CPR was performed without improvement in vital signs. CONCLUSION: There was a discrepancy between the actual cardiopulmonary resuscitation efforts and the documentation of cardiopulmonary resuscitation in the medical record. This behavior may be due to fear of possible legal consequences of not performing cardiopulmonary resuscitation. However, in patients with very poor prognosis it may be ethically justified to withhold CPR.

Ventilação não invasiva em crianças com insuficiência respiratória aguda – uma revisão sistemática

RESUMO Objetivo: Avaliar o papel da ventilacao nao invasiva no tratamento de criancas com insuficiencia respiratoria aguda. Metodos: Revisao sistematica da literatura sobre ventilacao nao invasiva nas bases MEDLINE, LILACS, EMBASE e Cochrane, alem de referencias de artigos. Os desfechos avaliados foram resposta sobre a oxigenacao e ventilacao sanguinea, e a sobrevida dos pacientes. Resultados: Foram encontrados 120 estudos sobre ventilacao nao invasiva ate Maio de 2010. Destes, apenas 19 eram sobre ventilacao nao invasiva em criancas. Ja ha ensaios [...]

Noninvasive ventilation for acute respiratory failure in children - a systematic review.

OBJECTIVE To assess the role of noninvasive ventilation in the treatment of children with acute respiratory failure. METHODS A systematic review of literature on noninvasive ventilation in MEDLINE, LILACS, EMBASE, and Cochrane databases, besides references in articles. The outcomes evaluated were responses in blood oxygenation and ventilation, and patient survival. RESULTS A total of 120 studies on noninvasive ventilation were found as of May, 2010. Of these, only 19 were about noninvasive ventilation in children. On the other hand, there are prospective and cohort clinical trials leading to a level II quality of evidence concerning the use of noninvasive ventilation in children. CONCLUSION There is scientific evidence for proposing the use of noninvasive ventilation, with a B-II degree of recommendation.