Manoel de Carvalho

Erro médico em pacientes hospitalizados

Objetivo: o presente artigo tem por objetivo revisar a literatura e discutir a questao do erro medico em pacientes hospitalizados, enfocando sua conceituacao, incidencia, fatores predisponentes e mecanismos de prevencao. Aborda, em especial, erros e eventos adversos com drogas envolvendo recem-nascidos e pacientes pediatricos. Metodos: revisao bibliografica utilizando banco de dados Medline, selecionando-se aqueles com informacoes atuais e relevantes. Resultados:mesmo assumindo que a notificacao do erro medico nao ocorre em um grande numero de eventos, e importante notar que sua incidencia e muito maior do que julgamos. So nos EUA, cerca de um milhao de pacientes por ano sao vitimas de erros medicos e eventos adversos com drogas. Segundo recente metanalise, esta e, hoje, a quarta causa de morte nos EUA. Em unidades de terapia intensiva neonatal e pediatrica, nas quais e grande a complexidade e a frequencia de procedimentos, a ocorrencia de erros e maior. Estima-se que quinze por cento das internacoes em unidades de terapia intensiva neonatal sejam acompanhadas de erro medico. A maioria destes erros acontece durante o periodo noturno, e envolve administracao incorreta de droga (35%) e erro na interpretacao da prescricao (26%). Fatores ambientais (barulho, calor), psicologicos (tedio, ansiedade, estresse) e fisiologicos (fadiga, sono) contribuem para a ocorrencia de erros. Recente estudo revela que apos um plantao de 24 horas, sem dormir, o desempenho psicomotor de um profissional de saude e semelhante ao de um individuo legalmente bebado (nivel serico alcoolico maior ou igual a 0,08%)! Conclusoes: mesmo em profissionais conscientes, erros sao acompanhantes inevitaveis da condicao humana. A prevencao de erros deve basear-se na busca de causas reais, que geralmente incluem erros no sistema de organizacao e implementacao do servico. Erros devem ser aceitos como evidencia de falha no sistema, e encarados como oportunidade de revisao do processo e aprimoramento da assistencia prestada ao paciente.

Variables associated with extra uterine growth restriction in very low birth weight infants

OBJECTIVES To determine the rate of extrauterine growth restriction in very low birth weight infants and to evaluate the influence of perinatal variables, clinical practices, and neonatal morbidities on this outcome. METHODS A longitudinal study was performed in four neonatal units in the city of Rio de Janeiro. 570 very low birth weight infants were analyzed. The study included perinatal variables, variables related to clinical practices, and incident morbidities in these preterm infants. Extrauterine growth restriction was defined using z-scores for weight or head circumference ≤ -2 for corrected age. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) and R software. RESULTS This study comprised 570 infants, of which 49% were males, and 33% were small for gestational age (SGA). The mean weight and head circumference at birth were 1,113 ± 267 g and 27 ± 2 cm, respectively. The mean z-scores of birth weight and weight at discharge were -0.96 ± 0.78 and -1.54 ± 0.75, respectively; for head circumference, the mean z-scores at birth and at discharge were -0.63 ± 1.18 and -0.45 ± 0.94, respectively. The rate of extrauterine growth restriction considering the weight was 26% (149/570) and considering the head circumference, 5% (29/570). SGA was the variable with the greatest impact on both growth restriction for weight (PR = 4.33) and for head circumference (PR = 2.11) in adjusted analyses. CONCLUSION extrauterine growth restriction was high in the population, especially for SGA newborns and those with neonatal morbidities.

Medication errors in a neonatal intensive care unit

OBJECTIVE To determine the incidence and type of medical errors in a newborn intensive care unit and the relationship between the error and the patients clinical status. METHODS We reviewed the medical charts, during the first 7 days of hospitalization, of all high-risk newborn infants admitted for a period of 3 months. RESULTS Seventy-three patients were admitted during the study period. Their mean birth weight was 2,140 g (640-5,020 g) and mean gestational age was 34 weeks (25-40 weeks). Of 73 medical charts analyzed, 40 (55%) had one or more errors. A total of 365 days of hospitalization was analyzed and 95 medical errors were detected (one error per 3.9 days of hospitalization). The most frequent error was associated with medication use (84.2%). Use of therapeutic procedures (drugs, phototherapy, etc.) without proper prescription in the patients chart (commission error) accounted for 7.4% of the errors, and incidence of omission errors was 8.4%. Incidence of medical errors was significantly higher in newborn infants with lower gestational age. CONCLUSIONS Incidence of errors in the care of high-risk newborn infants is elevated. Strategies to improve education of health professionals involved in the care and development of local culture by disseminating clear, accessible algorithms to guide behavior when errors occur must be encouraged.

Efficacy of new microprocessed phototherapy system with five high intensity light emitting diodes (Super LED)

Objectives: To evaluate the efficacy of a microprocessed phototherapy (PT) system with five high intensity light emitting diodes (Super LED) for the treatment of neonatal hyperbilirubinemia of premature infants.

Avaliação da eficácia clínica de uma nova modalidade de fototerapia utilizando diodos emissores de luz

OBJECTIVES: To evaluate the efficacy of a microprocessed phototherapy (PT) system with five high intensity light emitting diodes (Super LED) for the treatment of neonatal hyperbilirubinemia of premature infants. METHODS: Randomized clinical trial using Super LED phototherapy in the study group and twin halogen spotlight phototherapy in the control group. A stratified blocked randomization, based on birth weight, was performed. The duration of phototherapy and the rate of decrease of total serum bilirubin (TSB) concentration in the first 24 hours of treatment were the main outcome measures. RESULTS: We studied 88 infants, 44 in the Super LED group and 44 in the halogen spotlight PT group. The demographic characteristics of the patients in both groups were similar. Infants in the Super LED group had a similar mean initial serum bilirubin level (10.1±2.4 mg%) to those receiving halogen spotlight treatment (10.9±2.0 mg%). After 24 hours of treatment, the decrease in total serum bilirubin levels was significantly greater in the Super LED group (27.9 vs. 10.7%, p< 0.01) and duration of phototherapy was significantly shorter in this group (36.8 h vs. 63.8 h, p < 0.01). After 24 hours of treatment, a significantly greater number of patients receiving Super LED phototherapy had reached serum bilirubin concentrations low enough to allow withdrawal of treatment (23 vs. 10, p < 0.01). CONCLUSIONS: Our results demonstrate that the efficacy of Super LED phototherapy for treating hyperbilirubinemia in premature infants was significantly better than halogen phototherapy.

O uso da fototerapia em recém-nascidos: avaliação da prática clínica

OBJECTIVES: to describe the use of phototherapy in the day to day clinical practice by healthcare professionals of public maternity hospitals in the city of Rio de Janeiro. METHODS: heads of healthcare departments, doctors and nurses of 17 public maternity hospitals were interviewed on issues related to phototherapy management in their services. RESULTS: eighty nine healthcare professionals were interviewed. Seventy four per cent of the doctors noted there was a written guideline for neonatal jaundice management in their departments but with a great variation of responses related to the medical conduct adopted, including among professionals working in the same unit, 74% of doctors prescribed prophylactic phototherapy and 64% said they increased fluid intake during treatment. Distance placed between the newborn and the irradiance source varied from 20 to 70 cms. Half of the respondents noted the lack of guidelines to verify irradiation during phototherapy. A marked variation of bilirubin serum levels were used for phototherapy and exchange blood transfusion indications. CONCLUSIONS: our findings suggest the lack of consensus among healthcare professionals related to the use of phototherapy and that some of the routinely adopted practices could impair treatment efficacy.

Cardiac troponin T and illness severity in the very-low-birth-weight infant.

Introduction. Respiratory distress are very common in Very-low-birth-weight (VLBW) infants and Myocardial injury may play a role in the disease outcome. Cardiac troponin T (cTnT) is the most useful marker of injury in adult population, but has not been extensively studied in this population. Aim. To study the role of cTnT in VLBW infants and its association with clinical outcomes. Methods. All VLBW infants admitted to our NICU were included in the study. Echocardiography and blood samples for cTnT determination were collected at 24 and 48 hours of life, and values >0.1 ng/mL were considered CTnT-positive values. Results. A total of 116 neonates had their blood samples collected. The median cTnT concentration within 24 hours was 0.191 (0.1–0.79) ng/mL and within 48 hours was 0.293 (0.1–1.0) ng/mL. A logistic regression analysis showed that PDA, low GA, and use of dopamine were independently associated with positive cTnT and abnormal Dopplerfluxometry and diuretics use had protective effects and was independently associated with troponin values. Conclusion. We observed a high prevalence of positivecTnT values in VLBW infants associated with illness severity. Our findings suggest that cTnT may be a useful and early marker of myocardial injury in VLBW infants.

Ultrasound-guided brain abscess aspiration in neonates.

Four cases of brain abscess in neonates are described, diagnosed by ultrasonography and CT. All abscesses were confirmed surgically. One patient was operated on 5 weeks after diagnosis because of initial parental refusal. The etiology in all cases was meningitis superimposed on an hypoxic-ischemic insult. Two cases had a single abscess while the other two had multiple lesions. All cases were operated on with intraoperative ultrasound examination through the fontanelle. The case with delayed aspiration showed complete evolution from localized cerebritis to complete capsule formation with mass effect. One abscess was sterile, and in the others grew Klebsiella pneumoniae and Enterobacter aerogenes. The microorganism initially isolated from the lumbar CSF was also found in the abscess. Even after sterilization of the lumbar CSF, all abscesses were still present. Ultrasound examination and CT are compared.

High-intensity phototherapy for the treatment of severe nonhaemolytic neonatal hyperbilirubinemia

Aim:  To describe the clinical approach to term and near‐term newborn infants with severe hyperbilirubinaemia and to analyse the effect of high‐intensity phototherapy on total serum bilirubin (TSB) levels.

Eventos adversos associados à exsanguíneotransfusão na doença hemolítica perinatal: experiência de dez anos

Objective: To determine the incidence of adverse events associated with exchange-transfusions performed during the past ten years and to evaluate if there is association between the severity of patient’s clinical condition before the procedure and the incidence of adverse events. Methods: All infants admitted to treat hemolytic disease secondary to Rhesus Alloimunoization in the Neonatal Intensive Care Unit were enrolled in the study. Patients were divided into two groups: Group 1, neonates admitted solely for asymptomatic hyperbilirubinemia before the exchange transfusion; Group 2, neonates with other medical conditions besides the hemolytic jaundice. Incidence of adverse events was determined, as well as the relative risk of each adverse event. Results: 300 newborn infants with Rh hemolytic jaundice were studied. A total of 143 patients underwent 207 exchange transfusions. The rate of increase in the serum bilirubin levels (>0,5mg/dL/hour) was the main indication for exchange transfusion. Adverse events occurred in 22.7% of the cases and the mortality rate was 0.7%. The majority of adverse events were asymptomatic, and low platelet count was the most frequent one. The incidence of serious adverse events (bradycardia or heart arrhythmias and thrombocytopenia) was 2.1 times higher in Group 2 than in Group 1 (RR: 2.1; CI: 95% 1.3-3.4). There was one death during the study period associated to the procedure. Conclusions: Although exchange transfusion is a frequent procedure for treating severe neonatal hyperbilirubinemia, the incidence of adverse events is high, especially if patients’ clinical condition is unstable before the procedure.