Paulo Roberto Antonacci Carvalho

Identificação de medicamentos "não apropriados para crianças" em prescrições de unidade de tratamento intensivo pediátrica

Objective: To assess the extent of use of drugs not appropriate for children in prescriptions issued in a tertiary pediatric intensive care unit (PICU), according to FDA standards. Methods: Observational cross-sectional study. The prescriptions issued to all patients admitted to the PICU at Hospital de Clinicas de Porto Alegre, Brazil, over a six-week period were assessed. Patients’ age, sex, weight, prior disease, reason for admission to the PICU and pediatric index of mortality (PIM) were recorded, as were all drugs prescribed, their indications, presentations, doses, frequencies and means of administration. Adequacy for prescription of drugs in three pediatric age ranges was defined according to USA Food and Drug Administration (FDA) approval classification, based on the USP DI 2001 drug reference database. Results: Data were obtained in the months of July and August 2002, on different days, for six consecutive weeks, based on prescriptions issued to 51 patients in 54 admissions to the PICU. Median patient age was 10.5 months; 61% of patients were male. Two thirds of patients (65%) presented prior disease. 87% of admissions were due to clinical reasons, of which 57% were respiratory complaints. A total of 747 prescription items were registered, with prevalence of 10.5% for nonapproved uses and 49.5% for off-label uses. No statistically significant difference was found in the distribution of prevalence of irregular prescription either by the three age ranges or by level of severity of

Modos de morrer na UTI pediátrica de um hospital terciário

BACKGROUND To determine the prevalence of different modes of death and to identify therapeutic limitations in patients admitted to the Pediatric Intensive Care Unit (PICU) at a teaching hospital. METHODS A retrospective study was carried out. Information was collected from the medical records of patients who died at the PICU of Hospital de Clinicas de Porto Alegre between July 1st, 1996 and June 30th, 1997. Four modes of death were considered: patient not responding to cardiopulmonary resuscitation methods (NRCPR), brain death (BD), withdrawal / withhold life-support measures (W/WLS) and decision not to resuscitate (DNR). For cause of death we employed the criterion of organ failure. RESULTS Out of 61 deaths occurred during the period under analysis, 44 patients were included in the study. Patient age median was 28 months. The cause of death for all patients was multiple organ failure. Twenty-six patients (59%) were classified in group I (NRCPR and BD) and 18 (41%) in group II (W/WLS and DNR). Among patients of group II, 83% had a chronic and/or debilitating disease (p = 0.017; chi(2)). The prevalent reason for patient admission was the need for organ support (55%), both respiratory and cardiovascular. The median for duration of patient stay at the PICU was 5 days and at the hospital was 11 days. There was no statistically significant difference between the two groups in terms of reason for patient admission or duration of PICU/hospital stay. CONCLUSIONS There was a high prevalence of W/WLS and DNR deaths among ICU patients, thus suggesting therapeutic limitation for them. We were unable to evaluate the level of participation by the medical team and by the family in this decision making process.BACKGROUND: To determine the prevalence of different modes of death and to identify therapeutic limitations in patients admitted to the Pediatric Intensive Care Unit (PICU) at a teaching hospital. METHODS: A retrospective study was carried out. Information was collected from the medical records of patients who died at the PICU of Hospital de Clinicas de Porto Alegre between July 1st, 1996 and June 30th, 1997. Four modes of death were considered: patient not responding to cardiopulmonary resuscitation methods (NRCPR), brain death (BD), withdrawal / withhold life-support measures (W/WLS) and decision not to resuscitate (DNR). For cause of death we employed the criterion of organ failure. RESULTS: Out of 61 deaths occurred during the period under analysis, 44 patients were included in the study. Patient age median was 28 months. The cause of death for all patients was multiple organ failure. Twenty-six patients (59%) were classified in group I (NRCPR and BD) and 18 (41%) in group II (W/WLS and DNR). Among patients of group II, 83% had a chronic and/or debilitating disease (p = 0.017; c2). The prevalent reason for patient admission was the need for organ support (55%), both respiratory and cardiovascular. The median for duration of patient stay at the PICU was 5 days and at the hospital was 11 days. There was no statistically significant difference between the two groups in terms of reason for patient admission or duration of PICU/hospital stay. CONCLUSIONS: There was a high prevalence of W/WLS and DNR deaths among ICU patients, thus suggesting therapeutic limitation for them. We were unable to evaluate the level of participation by the medical team and by the family in this decision making process.

Prevalência das síndromes inflamatórias sistêmicas em uma unidade de tratamento intensivo pediátrica terciária

Objective: To assess the prevalence of systemic inflammatory syndromes on admission to a tertiary-care university pediatric intensive care unit (ICU), and relate this to length of hospital stay, risk of death and mortality rate. Methods: Cross-sectional, prospective, observational study, including all patients admitted to the Hospital de ClInicas de Porto Alegre (HCPA) ICU between August 1st 1999 and July 31st 2000. Patient demographic variables were considered together with the risk of mortality on admission, co-morbidities, length of hospital stay and ICU outcome, in addition to variables that characterize the systemic inflammatory syndromes (systemic inflammatory response syndrome, sepsis, severe sepsis and septic shock). Results: We studied 447 admissions of 388 patients; 54% were male, with a median age of 20 months. The prevalence of systemic inflammatory response syndrome (SIRS) was 68%: 2/3 infectious (sepsis, severe sepsis or septic shock) and 1/3 non-infectious. Risk of mortality scores for patients with infectious SIRS were higher than for those with non-infectious SIRS (6.75% [P25=2.25 - P75=21.3] vs. 2.35% [P25=1.1 - P75=6.7]; p=0) and increased according to SIRS severity (2.9; 10.85, 43.9%; p<0.05). The observed mortality was 12% for patients with SIRS and 5.8% for those without SIRS (p=0.057); the observed mortality for infectious SIRS was 14.9% and for non-infectious 6.3% (p=0.041). The period spent in ICU for infectious SIRS was longer than for non-infectious cases: 3 days (P25=2 - P75=7) vs. 2 days (P25=1.5 - P75=4); p=0.006. Conclusions: The prevalence rate of patients with systemic inflammatory response syndrome upon admission to HCPA pediatric intensive care unit was elevated, with a predominance of infectious syndromes, responsible for longer stays, increased risk of mortality and increased mortality of patients during the period evaluated.

Advances in sepsis diagnosis and treatment

OBJETIVO: Apresentar uma revisao critica e atualizada sobre a sepse, principalmente os aspectos diagnosticos e terapeuticos. FONTES DOS DADOS: Pesquisa bibliografica em periodicos indexados em base Medline, tanto de revisao como ensaios clinicos e pesquisa laboratorial. SINTESE DOS DADOS: A Conferencia Internacional sobre Definicao de Sepse ampliou a relacao de possiveis sinais clinicos e laboratoriais de sepse, o que podera permitir a suspeicao e manejo iniciais mais eficazes. Na avaliacao laboratorial, alem da pesquisa do agente infectante, varios marcadores da resposta inflamatoria tais como as citoquinas inflamatorias e a procalcitonina, tem sido identificados, mas ainda sem sensibilidade e especificidade suficientes para diagnostico seguro. Quanto ao tratamento, as intervencoes precoces sobre os disturbios hemodinâmicos continuam sendo primordiais para o desfecho, assim como o uso racional de antimicrobianos. Terapias de remocao de toxinas e de aumento da resposta imune inata ainda nao provaram definitivamente seu valor. O uso de bloqueadores da resposta inflamatoria isolados, em qualquer fase do seu estagio, falhou em reduzir a mortalidade. O corticoide ressurge com resultados animadores, mesmo em pacientes sem insuficiencia adrenal relacionada a sepse. A proteina C ativada (drotrecogina-a), em um grande estudo, mostrou reducao de 6% de mortalidade em uma amostragem selecionada, oferecendo uma possibilidade de melhor prognostico na sepse. CONCLUSOES: Comparativamente aos avancos dos ultimos anos, pouco se obteve com relacao a diminuicao de mortalidade por sepse, pela complexidade das relacoes patogeno-hospedeiro. A regulacao individual de cada reacao do hospedeiro nao mostrou o efeito esperado. Algumas estrategias, ja conhecidas, foram reafirmadas como beneficas, e outras, como o uso de corticoide e a proteina C ativada, estao surgindo como terapias promissoras. As pesquisas apontam para a combinacao de terapias imunomoduladoras como a melhor alternativa para melhorar o desfecho na sepse.

Rotavirus Gastroenteritis in Children in 4 Regions in Brazil: A Hospital-Based Surveillance Study

BACKGROUND Rotavirus is a major cause of gastroenteritis in children. Knowledge of rotavirus genotypes is important for vaccination strategies. METHODS During 2005-2006, rotavirus surveillance studies were conducted in São Paulo, Salvador, Goiânia, and Porto Alegre, Brazil. Stool samples were collected from children <5 years of age who had diarrhea and were screened by the Rotaclone Enzyme Immunoassay for the presence of rotavirus. Confirmed rotavirus-positive samples were characterized for P and G genotypes by reverse-transcriptase polymerase chain reaction. RESULTS A total of 510 stool samples were collected. Of these, 221 (43.3%) were positive for rotavirus. Overall, G9 was the predominant G type, followed by G2, and G1; P[4] and P[8] were the predominant P types. The most frequent G/P genotype combination detected was G2P[4], followed by G9P[8], G9P[4], and G1P[8]. G2P[4] was the predominant type in Goiânia and Salvador; G9P[8] and G1P[8] were predominant in São Paulo and Porto Alegre, respectively. CONCLUSIONS The prevalence, seasonality, and genotype distribution of rotavirus infection varied in different regions in Brazil. With immunization programs, continuous monitoring of rotavirus types is important to detect novel and emerging strains.

Association Between Length of Intubation and Subglottic Stenosis in Children

To investigate the role of the length of intubation and other risk factors in the development of laryngeal lesions in children undergoing endotracheal intubation in an intensive care unit and to determine the incidence of subglottic stenosis (SGS).

The impact of admission to a pediatric intensive care unit assessed by means of global and cognitive performance scales

OBJECTIVE To assess the impact of admission to the pediatric intensive care unit (ICU) at the Hospital de Clínicas de Porto Alegre, RS, Brazil on childrens cognitive and global performance. METHODS An observational, longitudinal study of a sequential sample of critically ill children. The following indicators were used: the Pediatric Index of Mortality (PIM), for severity and risk of death at admission, the Pediatric Cerebral Performance Category (PCPC), for cognitive morbidity and the Pediatric Overall Performance Category (POPC), for global morbidity, at admission and at discharge. Morbidity related to the ICU was measured according to the difference between classifications at discharge and at admission (delta scores). The Kruskal-Wallis test was applied. RESULTS A total of 443 patients were assessed, 54% of whom were male, with a median age of 12 months (IQ 4-45), and a median ICU stay of 4.24 days (IQ 2.4-8). The mortality rate was 6.3%. The median PIM score was 2.36% (IQ 1-7). On admission, 46% of the patients had some degree of cognitive morbidity and 66% had some degree of global morbidity. At discharge there was 60% cognitive morbidity and 86% global morbidity. The assessment of ICU-related morbidity revealed that 25% of the patients had undergone cognitive changes while 41% had undergone global variations, at discharge compared with admission. CONCLUSIONS Although affected by the elevated degree of morbidity at admission, the impact of the ICU stay was more significant in the global than in the cognitive domain. In the same manner, both risk of death at admission and length of stay had a significant effect on the morbidity of severely ill patients.

Admission source and mortality in a pediatric intensive care unit

Background and Aims: Studies carried out in different countries have shown that source of patient admission in Intensive Care Units (ICUs) is associated to death. Patients admitted from wards show a greater ICU mortality. The aim of the present study was to investigate the association between admission source and outcome in a Pediatric Intensive Care Unit (PICU). Materials and Methods: We studied all PICU admissions that took place between January 2002 and December 2005 in a tertiary hospital in Brazil. The major outcome studied was death while in the PICU. The independent variable analyzed was admission source, defined either as pediatric emergency room (PER), wards, operating room (OR) of the same hospital or other sources. Results: A total of 1823 admissions were studied. The overall expected mortality based on the Pediatric Index of Mortality 2 was 6.5% and the observed mortality was 10.3%. In adjusted analysis, the mortality was doubled in patients admitted from wards when compared with the PER patients. Conclusions: Observed mortality rates were higher in patients admitted from wards within the same hospital, even after adjustment.

Impacto da internação em unidade de terapia intensiva pediátrica: avaliação por meio de escalas de desempenho cognitivo e global

OBJECTIVE: To assess the impact of admission to the pediatric intensive care unit (ICU) at the Hospital de Clinicas de Porto Alegre, RS, Brazil on childrens cognitive and global performance. METHODS: An observational, longitudinal study of a sequential sample of critically ill children. The following indicators were used: the Pediatric Index of Mortality (PIM), for severity and risk of death at admission, the Pediatric Cerebral Performance Category (PCPC), for cognitive morbidity and the Pediatric Overall Performance Category (POPC), for global morbidity, at admission and at discharge. Morbidity related to the ICU was measured according to the difference between classifications at discharge and at admission (delta scores). The Kruskal-Wallis test was applied. RESULTS: A total of 443 patients were assessed, 54% of whom were male, with a median age of 12 months (IQ 4-45), and a median ICU stay of 4.24 days (IQ 2.4-8). The mortality rate was 6.3%. The median PIM score was 2.36% (IQ 1-7). On admission, 46% of the patients had some degree of cognitive morbidity and 66% had some degree of global morbidity. At discharge there was 60% cognitive morbidity and 86% global morbidity. The assessment of ICU-related morbidity revealed that 25% of the patients had undergone cognitive changes while 41% had undergone global variations, at discharge compared with admission. CONCLUSIONS: Although affected by the elevated degree of morbidity at admission, the impact of the ICU stay was more significant in the global than in the cognitive domain. In the same manner, both risk of death at admission and length of stay had a significant effect on the morbidity of severely ill patients.

Avaliação do conhecimento de intensivistas sobre morte encefálica

nancial losses, and unavailability of organs for transplants. The intensive care physician plays an essential role in this diagnosis. This study intended to evaluate intensivists’ knowledge concerning brain death. METHODS: Cross-sectional study in 15 intensive care units (ICU) in eight hospitals in the city of Porto Alegre, Brazil. RESULTS: Two hundred forty-six intensivists were interviewed in a consecutive sample between April and December 2005. The prevalence of lack of knowledge regarding the concept was of 17%. Twenty per cent of the interviewees ignored the legal need for complementary confi rmatory tests for their diagnosis. Forty-seven per cent considered themselves