Paulo Roberto Einloft

Evolution of the medical practices and modes of death on pediatric intensive care units in southern Brazil

Objectives: To study the possible change on mode of deaths, medical decision practices, and family participation on decisions for limiting life-sustaining treatments (L-LST) over a period of 13 yrs in three pediatric intensive care units (PICUs) located in southern Brazil. Methods: A cross-sectional study based on a retrospective chart review (1988 and 1998) and on prospective data collection (from May 1999 to May 2000). Setting: Three PICUs in Porto Alegre, southern Brazilian region. Patients: Children who died in those PICUs during the years of 1988, 1998, and between May 1999 and May 2000. Results: The 3 PICUs admitted 6,233 children during the study period with a mortality rate of 9.2% (575 deaths), and 509 (88.5%) medical charts were evaluated in this study. Full measures for life support (F-CPR) were recognized in 374 (73.5%) children before dying, brain death (BD) was diagnosed in 43 (8.4%), and 92 (18.1%) underwent some limitation of life support treatment (L-LST) There were 140 (27.5%) deaths within the first 24 hrs of admission and 128 of them (91.4%) received F-CPR, whereas just 11 (7.9%) patients underwent L-LST. The average length of stay for the death group submitted to F-CPR was lower (3 days) than the L-LST group (8.5 days; p < .05). The rate of F-CPR before death decreased significantly between 1988 (89.1%) and 1999/2000 (60.8%), whereas the L-LST rose in this period from 6.2% to 31.3%. These changes were not uniform among the three PICUs, with different rates of L-LST (p < .05). The families were involved in the decision-making process for L-LST in 35.9% of the cases, increasing from 12.5% in 1988 to 48.6% in 1999/2000. The L-LST plans were recorded in the medical charts in 76.1% of the deaths, increasing from 50.0% in 1988 to 95.9% in 1999/2000. Conclusion: We observed that the modes of deaths in southern Brazilian PICUs changed over the last 13 yrs, with an increment in L-LST. However, this change was not uniform among the studied PICUs and did not reach the levels described in countries of the Northern Hemisphere. Family participation in the L-LST decision-making process has increased over time, but it is still far behind what is observed in other parts of the world.

Comparison of two prognostic scores (PRISM and PIM) at a pediatric intensive care unit.

OBJECTIVEnTo compare the performance of the PRISM (Pediatric Risk of Mortality) and the PIM (Pediatric Index of Mortality) scores at a general pediatric intensive care unit, investigating the relation between observed mortality and survival and predicted mortality and survival.nnnMETHODSnA contemporary cohort study undertaken between 1 June 1999 and 31 May 2000 at the Pontifícia Universidade Católica do Rio Grande do Sul, Hospital São Lucas pediatric intensive care unit. The inclusion criteria and the PRISM and PIM calculations were performed as set out in the original articles and using the formulae as published. Statistical analysis for model evaluation employed the Flora z test, Hosmer-Lemeshow goodness-of-fit test, ROC curve (receiver operating characteristic) and Spearmans correlation tests. The study was approved by the institutions Ethics Committee.nnnRESULTSnFour hundred and ninety-eight patients were admitted to the pediatric intensive care unit, 77 of whom presented exclusion criteria. Thirty-three (7.83%) of the 421 patients studied died and 388 patients were discharged. Estimated mortality by PRISM was 30.84 (7.22%) with a standardized mortality rate of 1.07 (0.74-1.50), z = -0.45 and by PIM this was 26.13 (6.21%) with a standardized mortality rate of 1.26 (0.87-1.77), z = -1.14. The Hosmer-Lemeshow test gave a chi-square of 9.23 (p = 0.100) for PRISM and 27.986 (p < 0.001) for PIM. The area under the ROC curve was 0.870 (0.810-0.930) for PRISM and 0.845 (0.769-0.920) for PIM. The Spearman test returned r = 0.65 (p < 0.001).nnnCONCLUSIONnAnalyzing the tests we can observe that, although the PIM test was less well calibrated overall, both PRISM and PIM offer a good capacity for discriminating between survivors and moribund patients. They are tools with comparable performance at the prognostic evaluation of the pediatric patients admitted to our unit.

Adrenal response in children with septic shock

ObjectiveTo describe the serum cortisol profile and evaluate the adrenal response in children with septic shock, and determine the influence of these factors on the outcome and mortality in this group.MethodsBetween May and November 2003, 22 children with septic shock admitted to two pediatric intensive care units in southern Brazil were followed. Adrenal function was evaluated based on the levels of cortisol measured on the occasion of the diagnosis of septic shock and on the response of serum cortisol 30u202fmin after the administration of intravenous corticotrophin (0.5u202fμg/1.73u202fm2). Adrenal insufficiency was defined as axa0baseline serum cortisol below 690u202fnmol/l and/or axa0cortisol response to corticotrophin less than 250u202fnmol/l.ResultsAdrenal insufficiency was detected in 17 patients (77.3%). All patients who died had baseline cortisol higher than 690u202fnmol/l. Axa0cortisol response to corticotrophin less than 250u202fnmol/l was associated with axa060% mortality (RRu202f=u202f7.2, 1.03–50.28). Regression analysis showed that the combination of baseline cortisol higher than 690u202fnmol/l and axa0cortisol response to corticotrophin less than 250u202fnmol/l were associated with mortality after correction for gender and PRISM.ConclusionsAdrenal insufficiency is axa0frequent finding in children with septic shock. The low-dose corticotrophin stimulation test seems to be an important tool to distinguish between axa0normal cortisol response to stress and evidence of adrenal failure. Mortality was significantly higher in children that failed to respond to axa0corticotrophin stimulation test.

Perfil epidemiológico de dezesseis anos de uma unidade de terapia intensiva pediátrica

OBJETIVO: Revisar e descrever os dados epidemiologicos dos pacientes admitidos em uma unidade de terapia pediatrica brasileira (UTIP) e compara-los aos aspectos clinicos associados aos indices de gravidade e mortalidade. Descrever as caracteristicas desses pacientes, incluindo os dados demograficos, prevalencia de doencas, indices de mortalidade e fatores associados. METODOS: Os dados foram coletados retrospectivamente de todos os pacientes admitidos na UTIP de um hospital universitario entre 1978 e 1994. Os dados foram expressos em percentagens e comparados pelo teste qui-quadrado, calculando-se o risco relativo (RR) com um intervalo de confianca de 95%, considerando-se um p<0,05. RESULTADOS: Foram selecionados 13.101 pacientes - em sua maioria meninos (58,4%) - com doenca clinica (73,1%), menores de 12 meses de idade (40,4%) e eutroficos (69,5%). O indice geral de mortalidade foi de 7,4%. Os pacientes menores de 12 meses de idade mostraram um RR de 1,86 (CI 1,65-2,10; p<0,0001), enquanto que a desnutricao mostrou um RR de 2,98 (IC 2,64-3,36; p<0,0001). CONCLUSOES: O levantamento epidemiologico mostrou que a mortalidade e maior entre desnutridos e menores de 12 meses de idade. A sepse foi a principal causa de morte.

A sedação e analgesia de crianças submetidas à ventilação mecânica estariam sendo superestimadas

Abstract Objective: to describe the pattern of analgesic and sedativeinfusions in children submitted to mechanical ventilation in a regionalpediatric intensive care unit during a 12-month period. To comparethe use of these drugs among clinical and surgical patients, as wellevaluate the influence of the length of use on the average daily dosesand on the incidence of abstinence syndrome.Methods: this cohort study was performed from April 2001 toMarch 2002, involving children (1 month old to 15 years old)submitted to the mechanical ventilation with a tracheal tube for aperiod longer than 12 hours and who were successfully extubated(dead patients and those who required reintubation were excludedfrom the study). A team of professionals not involved with thepatient’s assistance performed a daily collection of all data up to the28 th day under mechanical ventilation (maximum length of followup for those who remain longer under mechanical ventilation). Themain outcome was the infusion doses of morphine, fentanyl, ketamineand midazolam administered at 12 AM (considering this dose as theaverage dose for that day). The diagnosis of abstinence syndromewas based on the chart revision (recorded diagnosis or based on thespecific antagonist treatment used) and in an interview with theassistant physician on the following days after the extubation. Thisstudy was approved by the Ethics and Scientific Committee of theHSL-PUCRS.

Evolução e característica de lactantes com bronquiolite viral aguda submetidos à ventilação mecânica em uma unidade de terapia intensiva pediátrica brasileira

Objective: To describe the characteristics and the outcome of infants with acute viral bronchiolitis submitted to mechanical ventilation. Methods: We performed a retrospective study enrolling all infants (less than 12 months old) admitted with the diagnosis of acute viral bronchiolitis and submitted to mechanical ventilation in an university affiliated Brazilian pediatric intensive care unit between March, 2004 and September, 2006 (3 consecutives winters). The mechanical ventilation parameters’ employed on 1st, 2nd, 3rd, 7th day and before extubation were evaluated as well as the evolution (mortality rate, presence of acute respiratory distress syndrome and the prevalence of complications). The groups were compared using the Student t test, the MannWhitney U test and the Chi-square test. Results: Fifty-nine infants were included (3.8 ± 2.7 months old, 59% male), with 9.0 ± 9.4 days on mechanical ventilation. Prior mechanical ventilation, non invasive ventilation was instituted in 71% of children. Anemia was observed in 78% of the sample. In 51 infants (86.5%) the lower airway obstructive pattern was maintained up to tracheal extubation with a nil mortality and low prevalence of pneumothorax (7.8%). Acute respiratory distress syndrome occurred in 8 infants (13.5%), with higher mortality and a higher prevalence of pneumothorax (62.5%). Conclusions: The declining mortality in acute viral bronchiolitis is observed even in non developed regions, involving children with high rates of anemia and premature labor. The low mortality is associated with the maintenance of the lower airway obstructive pattern during the period on mechanical ventilation. The development of acute respiratory distress syndrome is associated with increased mortality and higher prevalence of complications, representing the actual challenge in the management of children with severe acute viral bronchiolitis.

Hemodynamic and metabolic effects of vasopressin infusion in children with shock

OBJECTIVEnVasopressin is a neuropeptide hormone which has been used clinically for more than 50 years and plays a major role in circulatory homeostasis and in the regulation of serum osmolality. Recent work has emphasized its role in the treatment of septic shock. This paper reviews the physiology of this neurohormone and the available evidence in favor of its use as a vasodilator for children in shock.nnnSOURCESnMEDLINE, using the terms vasopressin, vasodilation, shock and septic shock, plus synonyms and related terms. Classic publications on the topic were also reviewed and selected depending on their relevance to the study objectives.nnnSUMMARY OF THE FINDINGSnVasopressin is synthesized in the neurohypophysis and released in response to a decrease in plasma volume or an increase in serum osmolality. The action of vasopressin is mediated by the activation of oxytocin receptors and of several G protein-coupled receptors, which are classified according to their location and intracellular transmission routes as V1 receptors (or V1b), V2 and V3 receptors (or V1b). The main role of vasopressin is to induce vasoconstriction. However, in certain organs, it can also induce selective vasodilation. Several clinical studies in adults and children have reported that the effects of vasopressin for the treatment of vasodilatory septic shock, due to a variety of causes, are both beneficial and safe.nnnCONCLUSIONSnThe evidence is restricted. Most studies are retrospective and include a small number of patients. Nevertheless, there is significant experience concerning the use of vasopressin in Pediatrics. Vasopressin has a beneficial clinical effect in children and can be indicated in the treatment of refractory vasodilatory shock, after adequate volume resuscitation and when high doses of other vasopressors are not effective.

Efeito a curto prazo da posição prona na oxigenação de crianças em ventilação mecânica

OBJETIVOS: analisar o efeito a curto prazo da posicao prona na oxigenacao de pacientes pediatricos com hipoxemia severa e submetidos a ventilacao mecânica. MATERIAL E METODOS: ensaio clinico prospectivo, nao randomizado, sendo cada paciente o seu proprio controle, realizado no periodo de julho de 1998 a julho de 1999. Incluidas todas as criancas com diagnostico de insuficiencia respiratoria aguda, em ventilacao mecânica, com pressao inspiratoria positiva (PIP) maior ou igual a 30cm H2O e fracao de oxigenio inspirada (FiO2) maior ou igual a 0,5, que apresentassem PaO2/FiO2 menor ou igual a 200. Os pacientes foram mantidos duas horas na posicao prona, retornando, a seguir, a posicao supina. Avaliou-se a oxigenacao, atraves da PaO2/FiO2, na posicao supina (1 hora antes da mudanca de posicao), com 1 hora de posicao prona e 1 hora apos retornar a posicao supina. Considerou-se responsivo todo o paciente que apresentasse um aumento de, no minimo, 20 na PaO2/FiO2. Os resultados foram comparados atraves do teste t student, Friedman, Qui-quadrado, exato de Fisher e intervalo de confianca (IC). RESULTADOS: participaram do estudo 18 criancas (10 masculinos) com idade media de 11,5 (±11,5) meses e com uma PaO2/FiO2 inicial 96,06 (±41,78). Apos 1 hora em posicao prona, observamos que 5/18 (27,7%) pacientes apresentaram uma melhora na PaO2/FiO2 acima de 20 (teste exato de Fisher, P=0,045). Seis pacientes apresentavam predominantemente diminuicao da complacencia pulmonar (4 com sindrome da angustia respiratoria aguda) e 12 com aumento da resistencia pulmonar (6 com bronquiolite). Nao observamos diferenca entre esses grupos no que se refere a idade, sexo, tempo de ventilacao previa a mudanca de posicao, pressao inspiratoria positiva, fracao de oxigenio inspirada, grau de hipoxemia e evolucao. CONCLUSAO: o uso da posicao prona durante a ventilacao mecânica de criancas severamente hipoxemicas pode promover uma significativa melhora da PaO2/FiO2 a partir da 1o hora.

Norepinephrine infusion increases urine output in children under sedative and analgesic infusion

OBJECTIVEnTo evaluate the effects of early norepinephrine (NE) infusion in children submitted to mechanical ventilation (MV) requiring continuous sedative and analgesic infusion.nnnMETHODSnDouble-blinded, randomized, placebo-controlled trial enrolling children (1 month to 12 years of age) admitted to a Brazilian PICU and expected to require MV and continuous sedative and analgesic drug infusions for at least five days. Children were randomized to receive either norepinephrine (NE) (0.15 mcg/kg/min) or normal saline infusion, started in the first 24 hours of MV, and maintained for 72 hours. We compared hemodynamic variables, fluid intake, renal function and urine output between groups.nnnRESULTSnForty children were equally allocated to the NE or placebo groups, with no differences in baseline characteristics, laboratorial findings, PRISM II score, length of MV, or mortality between groups. The average norepinephrine infusion was 0.143 mcg/kg/min. The NE group showed higher urine output (p = 0.016) and continuous increment in the mean arterial pressure compared to the baseline (p = 0.043). There were no differences in the remaining hemodynamic variables, fluid requirements, or furosemide administration.nnnCONCLUSIONnEarly norepinephrine infusion in children submitted to MV improves mean arterial pressure and increases urine output. These effects were attributed to reversion of vasoplegia induced by the sedative and analgesic drugs.

Supplemented vs. unsupplemented human milk on bone mineralization in very low birth weight preterm infants: a randomized clinical trial

SummaryVery low birth weight preterm newborns weighing less than 1500xa0g were randomized to receive human milk supplemented with FM 85® or not. They have similar bone mineral content (BMC) at baseline, but, at the end of study, BMC was increasingly higher in the FM 85® group.IntroductionThe purpose of this study is to evaluate the effectiveness of a human milk supplement (FM 85®; Nestlé, Vevey, Switzerland) developed for the purpose of improving nutrition, including bone mineralization, in very low birth weight preterm newborns.MethodsPreterm infants weighing less than 1500xa0g at birth admitted to the neonatal intensive care unit of a university hospital were studied. During hospitalization, they were fed at least 50xa0% of human milk. Newborns with ≥20xa0days of age were randomly assigned to the intervention group (nu2009=u200919) to receive human milk supplemented with FM 85® or to a control group (nu2009=u200919) to receive human milk only. Anthropometric measurements, whole-body bone densitometry (DXA), and biochemical tests were performed at study entry and at the end of the study (shortly before discharge when the infant had reached 2000xa0g).ResultsThere were no start- or end-of-study differences between the two groups, except for daily increase in length (pu2009=u20090.010). At baseline, both groups had similar BMC: 5.49u2009±u20093.65 vs. 4.34u2009±u20092.98xa0g (pu2009=u20090.39) for the intervention and control group, respectively. However, at the end of the study, BMC was higher in the intervention group: 10.3u2009±u20094.71 vs. 6.19u2009±u20093.23xa0g (pu2009=u20090.003). The mean increase in BMC during the observation period was 4.90u2009±u20094.46xa0g for the intervention group and 1.86u2009±u20093.17xa0g for the control group (pu2009=u20090.020). Serum alkaline phosphatase levels were higher in the control group (720u2009±u2009465 vs. 391u2009±u2009177xa0IU/L; pu2009=u20090.007).ConclusionsOur data suggest that supplementation of human milk with FM 85® leads to improved bone mineralization in very low birth weight preterm newborns.