Paulo Cesar Koch Nogueira

Malnutrition as an independent predictor of clinical outcome in critically ill children

OBJECTIVE To determine the nutritional status of a cohort of children admitted to a pediatric intensive care unit (ICU) and to assess the effect of malnutrition as an independent risk factor affecting outcome in this patient group. METHODS In a prospective cohort study, 385 children admitted to the ICU of a teaching hospital over a 2-y period were assessed for nutritional status at admission and clinical outcome. The outcome variables were 30-d mortality, length of ICU stay, and length of mechanical ventilation. Potential exposure variables were gender, age, diagnosis (clinical versus surgical), septic shock, malnutrition, and scores on the Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction. Nutritional status was determined using z scores of weight for age, height for age, and body mass index, based on the World Health Organization child growth standards. Patients with z score < -2 of anthropometric indexes were considered malnourished. RESULTS 175 patients (45.5%) were malnourished on admission. Sixteen patients of the malnourished group (9.14%) and 25 patients (11.9%) of the non-malnourished group died. Malnutrition was associated with greater length of mechanical ventilation and length of ICU stay, but not with mortality on univariate analysis. Malnutrition was associated with greater length of ventilation on the multiple logistic regression model (OR 1.76, 95%; CI 1.08-2.88; P = 0.024). CONCLUSION Malnutrition is common among children admitted to an ICU. This factor was not a predictor of mortality but showed independent association with length of mechanical ventilation.

Pressão arterial elevada em escolares de Santos: relação com a obesidade

OBJECTIVE: The escalating prevalence of obesity has led to an increase in the blood pressure of children and adolescents. This works aims to assess the relation between blood pressure and obesity in school children of Santos. METHODS: We performed a cross-sectional study in two phases. In a first screening we measured blood pressure and performed anthropometric evaluation of 7.440 children (9.0 ± 1.1 years, 3891 or 52% of girls). Then a sample, including 1.713 children (9.7 ± 1.1 years, 826 or 48% of girls), among those who presented with blood pressure equal to or above the 90 percentile in the screening phase was selected and visited again for new blood pressure and anthropometric measurements. In both phases of the study we considered as high blood pressure those values equal to or higher than the 95 percentile for the gender and stature of each individual. RESULTS: In the screening phase 1.123/7.440 (15%) of children presented high blood pressure; obese children presented an increased frequency of high blood pressure (OR = 3.7 95% CI=3.2 4.3). In the second phase 43/1.713 (2.7%) presented high blood pressure; obese children again presented an increased frequency of high blood pressure (OR = 1.5 95% CI=1.2 1.8). Moreover we observed a progressive rise of systolic blood pressure parallel to the BMI at all intervals of BMI and not only in obese children. CONCLUSION: Our work reinforces data in literature suggesting increased risk of high blood pressure among obese children. Increase in blood pressure may be cumulative with BMI rise, not only in obese children.

Adesão à técnica de lavagem de mãos em Unidade de Terapia Intensiva Neonatal

OBJECTIVE:To evaluate the hand washing technique employed by health professionals and visitors of patients treated in a Neonatal Intensive Care Unit (NICU). METHODS: A prospective observational study was performed in the NICU of a teaching hospital in Santos, Sao Paulo, Brazil. The evaluation was made during seven months, with mornings and afternoons observations. Data were collected by two medical students. Observed people were not informed of the objective of the research. Two approaches were used to compare the hand washing technique: a) analysis by intention to treat, considering individuals who did not wash their hands as using an inadequate technique and b) by protocol analysis, considering only those who washed their hands. The chi-square or Fishers exact tests were used to compare the groups and p<0.05 was adopted in all tests to reject the null hypothesis. RESULTS: 43 observations were performed, which lasted about 30 minutes each, being 20 in the morning and 23 in the afternoon. We observed six physicians (14%), 26 nurses (60%), three (7%) laboratory and X-ray technicians and eight (19%) relatives of patients. Among these, 24 (55.8%) washed their hands before entering the unit. The procedure was adopted more frequently during the morning (75%) than in the afternoon (39%). The correct technique was never adopted by any observed category. CONCLUSIONS: Hand washing techniques are rarely followed in hospitals and, therefore, educational programs to increase the compliance with health professionals are urgent.

Oral vitamin intake in children receiving long-term dialysis

OBJECTIVE To evaluate dietary and oral supplement vitamin intake in children submitted to dialysis (peritoneal dialysis and hemodialysis). DESIGN Prospective clinical trial in a 12-month follow-up period. SETTING Children with end-stage renal disease (ESRD) who attended the pediatric nephrology clinic of Universidade Federal de São Paulo-Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, Brazil. PATIENTS Thirty children (18 girls, 23 in peritoneal dialysis, 7 in hemodialysis) with age 9.3 +/- 7.4 years. INTERVENTION METHODOLOGY: Six successive assessments of both anthropometric indexes and 3-day dietary diaries in children receiving a daily dose of oral water-soluble vitamin supplement. MAIN OUTCOME MEASURES Anthropometric indexes (weight/age [W/A], height/age [H/A], midarm muscle area/age [MAMA/A], and fat area/age [FA/A]) and dietary adequacy-% recommended dietary allowance (RDA) (computerized nutritional analysis from 3-day dietary intake diary). RESULTS Anthropometric indexes analysis showed that 53% of children were <-2.0 standard deviation score (SDS) of W/A, 63% were <-2.0 SDS of H/A, and 43.3% were <-1.65 SDS of MAMA/A, suggesting growth deficit and low muscle wasted. Total caloric intake was lower than 100% of RDA in 90% of children. Dietary intake of water-soluble vitamins was <100% of RDA in the majority of children, as follows: vitamin C (24/30), B1 (28/30), B2 (22/30), B3 (27/30), B6 (26/30), B12 (1/30), pantothenic acid (24/30), and folic acid (9/30). The combined dietary and vitamin supplement intake resulted in excessive oral intake for almost all the vitamins. CONCLUSION Dietary intake of water-soluble vitamins is lower than the RDA in the majority of children with ESRD; supplementation is necessary to reach the RDA. The use of the available vitamin supplement resulted in vitamin intakes that exceeded the RDA for almost all of the vitamins. However, we do not know if these intakes exceeded the childrens requirements, nor whether they had any clinically significant harmful effects.

Estresse ocupacional e suas repercussões na qualidade de vida de médicos e enfermeiros intensivistas pediátricos e neonatais

OBJETIVO: Investigar as relacoes entre trabalho e qualidade de vida de medicos e enfermeiros em unidades de terapia intensiva pediatrica e neonatal. METODOS: Estudo transversal com 37 medicos e 20 enfermeiros. O Job Content Questionnarie (JCQ), Effort-Reward Imbalance (ERI) e World Health Organization Quality of Life (WHOQOL-100) foram utilizados. A correlacao foi estimada atraves do coeficiente de correlacao de Spearman. RESULTADOS: O esforco e inversamente correlacionado com os dominios: fisico, psicologico, nivel de independencia, meio ambiente (p<0,01) e relacao social (p<0,05). A recompensa e inversamente correlacionada com os dominios psicologico (p<0,05) e nivel de independencia (p<0,01). Controle sobre o trabalho e diretamente correlacionado com o dominio fisico (p<0,05). A demanda psicologica e inversamente correlacionada com os dominios fisico (p<0,05), psicologico (p<0,01) e nivel de independencia (p<0,05). A demanda fisica e inversamente correlacionada com os dominios fisico, nivel de independencia, meio ambiente (p<0,01) e psicologico (p<0,05) . Inseguranca no trabalho e inversamente correlacionada com os dominios psicologico, nivel de independencia (p<0,05) e meio ambiente (p<0,01). Suporte do supervisor e diretamente correlacionado com nivel de independencia (p<0,05). CONCLUSAO: Medicos e enfermeiros apresentaram altos esforcos, demandas psicologicas, fisicas e inseguranca no trabalho que repercutem na qualidade de vida.

Ionized hypocalcemia is an early event and is associated with organ dysfunction in children admitted to the intensive care unit

PURPOSE The purpose was to determine the frequency and risk factors of ionized hypocalcemia and to evaluate this disturbance as a predictor of mortality in a pediatric intensive care unit (ICU). MATERIALS AND METHODS In a prospective cohort study, 337 children admitted consecutively to an ICU were monitored regarding serum ionized calcium concentrations during the first 10 days of admission. The following variables were analyzed as independent of hypocalcemia: age; malnutrition; sepsis; Pediatric Index of Mortality 2; first 3 days organ dysfunction score (Pediatric Logistic Organ Dysfunction); and use of steroids, furosemide, and anticonvulsants. Hypocalcemia was defined as a serum ionized calcium concentration less than 1.15 mmol/L. RESULTS The rate of hypocalcemia was 77.15%. In a multivariate model, higher Pediatric Logistic Organ Dysfunction scores during the first 3 days of ICU stay were independently associated with hypocalcemia (odds ratio, 2.24; 95% confidence interval, 1.23-4.07; P=.008). Medications associated with hypocalcemia were furosemide (dose≥2 mg/[kg d]) and methylprednisolone (dose≥2 mg/[kg d]). No significant association was found between hypocalcemia and 10-day mortality. CONCLUSIONS Ionized hypocalcemia is common during the ICU stay, particularly in the first 3 days of admission. This disturbance was not found to be a predictor of mortality, but it is independently associated with more severe organ dysfunction.

Prevalência de pressão arterial elevada em crianças e adolescentes do ensino fundamental

OBJETIVO: Verificar la prevalencia de presion arterial elevada en ninos y adolescentes y su asociacion con indicadores antropometricos. METODOS: Estudio transversal incluyendo a estudiantes de tres instituciones de ensenanza de Botucatu (Sao Paulo, Brasil). Las variables evaluadas fueron: presion arterial (PA) (obtenida en tres ocasiones distintas), peso, estatura, indice de masa corporal (IMC), circunferencia braquial, circunferencia abdominal (CA), pliegues cutaneos tricipital y subescapular. La PA fue verificada por metodo auscultatorio, siendo posteriormente clasificada como pre-hipertension (PH) e hipertension arterial (HAS) para los valores entre los percentiles 90 y 95 y superior al percentil 95, respectivamente. Los datos antropometricos fueron comparados, conforme al sexo, por la prueba t de Student. La correlacion de Pearson fue utilizada para verificar la variacion de las PA sistolica (PAS) y diastolica (PAD) segun datos antropometricos. La variacion del escore Z de la PA segun percentil de IMC fue evaluada por el analisis de variancia seguida por la prueba de Tukey. RESULTADOS: Se evaluaron 903 ninos (51,7% ninos), con edad de 9,3±2,5 anos para ambos sexos. La prevalencia de PH fue de 9,1% y de HAS fue de 2,9%. Hubo correlacion positiva significativa entre los niveles presoricos elevados (PAS/PAD > percentil 90) y las variables antropometricas, con valores mayores para peso (r=0,53 y r=0,45, p<0,05, respectivamente) y CA (r=0,50 y r=0,38, p<0,05, respectivamente). CONCLUSIONES: La prevalencia de niveles presoricos elevados en esta casuistica fue compatible con otros estudios brasilenos e internacionales, correlacionandose positivamente con indicadores antropometricos elevados, lo que senaliza la influencia del exceso de peso en la PA ya en la infancia.

What are the factors that influence the attainment of satisfactory energy intake in pediatric intensive care unit patients receiving enteral or parenteral nutrition

OBJECTIVE Children admitted to the intensive care unit (ICU) are at risk of inadequate energy intake. Although studies have identified factors contributing to an inadequate energy supply in critically ill children, they did not take into consideration the length of time during which patients received their estimated energy requirements after having achieved a satisfactory energy intake. This study aimed to identify factors associated with the non-attainment of estimated energy requirements and consider the time this energy intake is maintained. METHODS This was a prospective study involving 207 children hospitalized in the ICU who were receiving enteral and/or parenteral nutrition. The outcome variable studied was whether 90% of the estimated basal metabolic rate was maintained for at least half of the ICU stay (satisfactory energy intake). The exposure variables for outcome were gender, age, diagnosis, use of vasopressors, malnutrition, route of nutritional support, and Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction scores. RESULTS Satisfactory energy intake was attained by 20.8% of the patients, within a mean time of 5.07 ± 2.48 d. In a multivariable analysis, a diagnosis of heart disease (odds ratio 3.62, 95% confidence interval 1.03-12.68, P = 0.045) increased the risk of insufficient energy intake, whereas malnutrition (odds ratio 0.43, 95% confidence interval 0.20-0.92, P = 0.030) and the use of parenteral nutrition (odds ratio 0.34, 95% confidence interval 0.15-0.77, P = 0.001) were protective factors against this outcome. CONCLUSION A satisfactory energy intake was reached by a small proportion of patients during their ICU stay. Heart disease was an independent risk factor for the non-attainment of satisfactory energy intake, whereas malnutrition and the use of parenteral nutrition were protective factors against this outcome.

Prevalência estimada da doença renal crônica terminal em crianças no Estado de São Paulo

OBJECTIVE: To estimate the prevalence of pediatric end-stage renal disease and evaluate demographics and renal disease characteristics in state of Sao Paulo over the year 2008. METHODS: Observational, descriptive, and cross-sectional study based on a population sample with subjects < 18 years. The data collecting assumed three forms: 1. A questionnaire for dialysis units; 2. Search in the Transplant Center to determine the number and characteristics of patients who had been in a transplant waiting list over the study period; 3. Search in the database of patients registered at the Latin American Collaborative Registry of Pediatric Kidney Transplantation. RESULTS: Data from 301 patients aged 9.0 ± 5.8, including 140 girls (46.5%), resulting in an estimate prevalence of 23.4 cases per million age-related population (pmarp). The age group most frequently found was 10 to 15 years (32.2%), and urinary tract malformation was the most usual known etiology (24.9%). Most children underwent kidney transplantation (62.1%) and among subjects on dialysis, hemodialysis was predominant (71.2%). The Sistema Unico de Saude - Unified National Health System - (SUS) provided the financial support for treatments. CONCLUSION: The prevalence of 23.4 cases pmarp found by the authors is lower than that reported in Western world. We believe data were underestimated in the present study, as few dialysis units returned the completed questionnaire. This potential bias does not invalidate the exploratory character of results. Further mechanisms for retrospective and earlier data collecting on pediatric chronic renal disease (CRD) are needed so that the burden of this serious health condition can be appropriately sized up.

Estimated prevalence of childhood end-stage renal disease in the state of São Paulo

OBJECTIVE To estimate the prevalence of pediatric end-stage renal disease and evaluate demographics and renal disease characteristics in state of São Paulo over the year 2008. METHODS Observational, descriptive, and cross-sectional study based on a population sample with subjects < 18 years. The data collecting assumed three forms: 1. A questionnaire for dialysis units; 2. Search in the Transplant Center to determine the number and characteristics of patients who had been in a transplant waiting list over the study period; 3. Search in the database of patients registered at the Latin American Collaborative Registry of Pediatric Kidney Transplantation. RESULTS Data from 301 patients aged 9.0 ± 5.8, including 140 girls (46.5%), resulting in an estimate prevalence of 23.4 cases per million age-related population (pmarp). The age group most frequently found was 10 to 15 years (32.2%), and urinary tract malformation was the most usual known etiology (24.9%). Most children underwent kidney transplantation (62.1%) and among subjects on dialysis, hemodialysis was predominant (71.2%). The Sistema Único de Saúde - Unified National Health System - (SUS) provided the financial support for treatments. CONCLUSION The prevalence of 23.4 cases pmarp found by the authors is lower than that reported in Western world. We believe data were underestimated in the present study, as few dialysis units returned the completed questionnaire. This potential bias does not invalidate the exploratory character of results. Further mechanisms for retrospective and earlier data collecting on pediatric chronic renal disease (CRD) are needed so that the burden of this serious health condition can be appropriately sized up.