Marcelo Barciela Brandão

Analysis of 52 patients with head trauma assisted at pediatric Intensive Care Unit: considerations about intracranial pressure monitoring

OBJECTIVES Analysis of 52 pediatric patients with head trauma assisted at Intensive Care Unit; to present considerations about epidemiologic factors of trauma, clinical presentation, tomografic aspects, hemodynamic changes and treatment options of intracranial hypertension; to present considerations about the intracranial pressure (ICP) monitoring. METHOD Retrospective study involving 52 patients with head trauma and 17 patients submitted to a ICP monitoring. RESULTS We found a male predominance, mean age 7.75 years-old, main cause was run over (38.5%); 21.2% patients presentd arterial hypotension; 67.3% were considered severe head trauma. According to Marshall tomografic grading we had 19.2% type I, 65.4% type II, 3.8% type III, 3.8% type IV and 7.7% type V. Seizures occurred in 25% children ICP monitoring was made in 32.7% of all patients. Mortality rate was 11.5%. In 58% the maximum ICP level occured at the second day of trauma. CONCLUSION Prognosis was related to severity of trauma, arterial hypotension, Marshalls tomografic gradind III and IV and ICP high values. The ICP monitoring was considered useful to allow the identification and treatment of intracranial hypertension.

O óbito em crianças com diarréia aguda e choque em UTI

BACKGROUND: Describe clinical and epidemiological characteristics of pediatric patients diagnosed with acute diarrhea and shock, admitted to the pediatric intensive care unit, in order to compare the evolution of clinical data between the survival and non-survival groups, thereby identifying the risk factors of death. METHODS: In the Pediatric Intensive Care Unit of the Clinical Hospital at the State University of Campinas (UNICAMP), a non-controlled, descriptive and retrospective study was carried out from February 1994 to January 1998 The epidemiological and clinical/evolution data were analyzed and the groups of those who survived (56) and did not survive (15) were compared. For continuous variables, the Chi-Square test was used and for categorical variables, the Fishers Exact test, for values lower than five. RESULTS: Seventy one children aged from 0.4 to 13.9 months were admitted, 15 of them died (21.2%). Low birth weight was found in 18.1% and the mean breast-feeding time was 1.1 months. The average length of stay was 5.6 days. 52/71 children needed mechanical ventilation, use of vasoactive drugs and sodium bicarbonate was necessary in 23/71 and 15/71, respectively. 93% of children were given antibiotics. The use of sodium bicarbonate, vasoactive drugs and mechanical ventilation showed an association with risk of death, but only vasoactive drugs (OR=18.56) and an age less than 3 months (OR=0.10) showed a statistically significant difference in multivariate analysis. CONCLUSIONS: Acute diarrhea and shock occurred mainly in children under 3 months of age with a severe clinical/laboratorial condition. During clinical evolution, the high risk of death was related to the use of vasoactive drugs, a support therapy used in critical patients.

Sala de emergência em pediatria: casuística de um hospital universitário

AbStRAct Objective : Describe the clinical course of pediatric patients treated at a pediatric emergency room in a university hospital. Methods : This retrospective descriptive study was conducted between January 1 st and December 31 st , 2004. Data retrieved were: demographical and clinical characacteristics, diagnostic hy-potheses, need of tracheal intubation, deaths, transfers and need of hospitalization of children between zero and 14 years old. Patients were divided in four groups: no deaths; deaths 24 hours; transfers to other hospitals after initial care. Results : 203 children were treated: 59.1% boys; mean age of 3.4 years; 65% previously healthy. The most common diag-nosis was respiratory failure (31.1%). Of the 22 deaths, 3.5% took place during the first 24 hours and 7.4% after this; 172 children (84.7%) were discharged after a mean hospital length of stay of 19.2 days. Nine children (4.4%) were transferred to other hospitals. Among the 203 children, 50 children (24.6%) were intubated after admission and 86 children (42.4%) had to be admitted to a pediatric intensive care unit.

Ultrasound guidance for internal jugular vein cannulation in PICU: a randomised controlled trial

Objective We investigated whether ultrasound guidance was advantageous over the anatomical landmark technique when performed by inexperienced paediatricians. Design Randomised controlled trial. Setting A paediatric intensive care unit of a teaching hospital. Patients 80 children (aged 28 days to <14 years). Interventions Internal jugular vein cannulation with ultrasound guidance in real time or the anatomical landmark technique. Main outcome measures Success rate, success rate on the first attempt, success rate within three attempts, puncture time, number of attempts required for success and occurrence of complications. Results We found a higher success rate in the ultrasound guidance than in the control group (95% vs 61%, respectively; p<0.001; relative risk (RR)=0.64, 95% CI (CI) 0.50 to 0.83). Success on the first attempt was seen in 95% and 34% of venous punctures in the US guidance and control groups, respectively (p<0.001; RR=0.35, 95% CI 0.23 to 0.54). Fewer than three attempts were required to achieve success in 95% of patients in the US guidance group but only 44% in the control group (p<0.001; RR=0.46, 95% CI 0.32 to 0.66). Haematomas, inadvertent arterial punctures, the number of attempts and the puncture time were all significantly lower in the ultrasound guidance than in the control group (p<0.015 for all). Conclusions Critically ill children may benefit from the ultrasound guidance for internal jugular cannulation, even when the procedure is performed by operators with limited experience. Trial registration number RBR-4t35tk.

Ultrasound Guidance for Pediatric Central Venous Catheterization: A Meta-analysis

We systematically searched the literature to investigate the effects of ultrasound guidance on clinical outcomes in pediatric patients undergoing central venous catheterization. BrightcoveDefaultPlayer10.1542/6138655993001PEDS-VA_2018-1719 Video Abstract CONTEXT: Central venous catheterization is routinely required in patients who are critically ill, and it carries an associated morbidity. In pediatric patients, the procedures can be difficult and challenging, predominantly because of their anatomic characteristics. OBJECTIVE: To determine whether ultrasound-guided techniques are associated with a reduced incidence of failures and complications when compared with the anatomic landmark technique. DATA SOURCES: We conducted a systematic search of PubMed and Embase. STUDY SELECTION: We included randomized controlled trials and nonrandomized studies in which researchers compare ultrasound guidance with the anatomic landmark technique in children who underwent central venous catheterization. DATA EXTRACTION: Study characteristics, sample sizes, participant characteristics, settings, descriptions of the ultrasound technique, puncture sites, and outcomes were analyzed. Pooled analyses were performed by using random-effects models. RESULTS: A total of 23 studies (3995 procedures) were included. Meta-analysis revealed that ultrasound guidance significantly reduced the risk of cannulation failure (odds ratio = 0.27; 95% confidence interval: 0.17–0.43), with significant heterogeneity seen among the studies. Ultrasound guidance also significantly reduced the incidence of arterial punctures (odds ratio = 0.34; 95% confidence interval: 0.21–0.55), without significant heterogeneity seen among the studies. Similar results were observed for femoral and internal jugular veins. LIMITATIONS: Potential publication bias for cannulation failure and arterial puncture was detected among the studies. However, no publication bias was observed when analyzing only the subgroup of randomized clinical trials. CONCLUSIONS: Ultrasound-guided techniques are associated with a reduced incidence of failures and inadvertent arterial punctures in pediatric central venous catheterization when compared with the anatomic landmark technique.

Association between single nucleotide polymorphisms in TLR4, TLR2, TLR9, VDR, NOS2 and CCL5 genes with acute viral bronchiolitis

Abstract Background Acute viral bronchiolitis is the leading cause of hospitalization among infants during the first year of life. Most infants hospitalized for bronchiolitis do not present risk factors and are otherwise healthy. Our objective was to determine the genetic features associated with the risk and a severe course of bronchiolitis. Methods We prospectively evaluated 181 infants with severe bronchiolitis admitted at three hospitals over a 2-year period, who required oxygen therapy. The control group consisted of 536 healthy adults. Patients were evaluated for the presence of comorbidities (premature birth, chronic respiratory disease, and congenital heart disease), underwent nasopharyngeal aspirate testing for virus detection by multiplex-PCR, and SNPs identification in immune response genes. Patient outcomes were assessed. Results We observed association between SNP rs2107538*CCL5 and bronchiolitis caused by respiratory syncytial virus(RSV) and RSV-subtype-A, and between rs1060826*NOS2 and bronchiolitis caused by rhinovirus. SNPs rs4986790*TLR4, rs1898830*TLR2, and rs2228570*VDR were associated with progression to death. SNP rs7656411*TLR2 was associated with length of oxygen use; SNPs rs352162*TLR9, rs187084*TLR9, and rs2280788*CCL5 were associated with requirement for intensive care unit admission; while SNPs rs1927911*TLR4, rs352162*TLR9, and rs2107538*CCL5 were associated with the need for mechanical ventilation. Conclusions Our findings provide some evidence that SNPs in CCL5 and NOS2 are associated with presence of bronchiolitis and SNPs in TLR4, TLR2, TLR9, VDR and CCL5 are associated with severity of bronchiolitis.

First Clinical Consensus and National Recommendations on Tracheostomized Children of the Brazilian Academy of Pediatric Otorhinolaryngology (ABOPe) and Brazilian Society of Pediatrics (SBP)

INTRODUCTION Tracheostomy is a procedure that can be performed in any age group, including children under 1year of age. Unfortunately health professionals in Brazil have great difficulty dealing with this condition due to the lack of standard care orientation. OBJECTIVE This clinical consensus by Academia Brasileira de Otorrinolaringologia Pediátrica (ABOPe) and Sociedade Brasileira de Pediatria (SBP) aims to generate national recommendations on the care concerning tracheostomized children. METHODS A group of experts experienced in pediatric tracheostomy (otorhinolaryngologists, intensive care pediatricians, endoscopists, and pediatric pulmonologists) were selected, taking into account the different regions of Brazil and following inclusion and exclusion criteria. RESULTS The results generated from this document were based on the agreement of the majority of participants regarding the indications, type of cannula, surgical techniques, care, and general guidelines and decannulation. CONCLUSION These guidelines can be used as directives for a wide range of health professionals across the country that deal with tracheostomized children.

Diagnóstico pouco frequente de dor abdominal em unidade de emergência infantil

Descricao do caso: Escolar de nove anos procurou pronto-socorro infantil com queixa de dor abdominal subita e palidez. Nao apresentava outros sintomas ou sinais ao exame fisico alem de mucosas descoradas e hemograma com nivel baixo de hemoglobina. Durante a observacao intra-hospitalar, apresentou episodio de melena. Foi realizada endoscopia digestiva alta, sendo observadas gastrite erosiva de antro e ulcera duodenal, com Helicobacter pylori positivo. O paciente foi tratado com esquema triplice (inibidor de bomba de protons e dois antimicrobianos) por uma semana e, posteriormente, acompanhado ambulatorialmente. Comentarios: O caso em questao descreve uma doenca rara em unidade de emergencia pediatrica. O paciente referia dor abdominal e observou-se palidez confirmada por baixo nivel de hemoglobina, que se manteve nos exa- mes subsequentes durante a observacao no pronto-socorro infantil, dificultando o diagnostico de sangramento ativo. Porem, a presenca de melena na evolucao facilitou e pro- piciou a conducao do caso para se chegar a hipotese de sangramento digestivo alto. Realizada endoscopia digestiva alta, que confirmou o diagnostico de gastrite erosiva de ABSTRACT