Pedro Celiny Ramos Garcia

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.

OBJECTIVE To 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. METHODS A 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. RESULTS Four 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). CONCLUSION Analyzing 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.

Risk factors for extubation failure in mechanically ventilated pediatric patients

Objective: To describe the incidence of extubation failure and its associated risk factors among mechanically ventilated children. Method: Prospective cohort study. Children who were mechanically ventilated for longer than 12 hrs were followed up to 48 hrs after extubation. Cases of upper airway obstruction, accidental extubation, tracheostomy, or death before extubation were excluded. Extubation failure was defined as reintubation within 48 hrs after extubation. Student’s t-test, Mann-Whitney, and chi-squared tests, odds ratio with 95% confidence interval, and multivariate analysis were used for data analysis. Results: Extubation failure rate was 10.5% (13 of 124 patients). Variables associated with extubation failure were age between 1 and 3 mos (odds ratio [OR] = 5.68; 95% confidence interval [CI] = 1.58–20.42), mechanical ventilation >15 days (OR = 6.36; 95% CI = 1.32–30.61), mean oxygenation index (OI) >5 (OR = 4.08; 95% CI = 1.25–13.30), mean airway pressure 24 hrs before extubation lower than 5 cm H2O (OR = 6.03; 95% CI = 1.48–24.60), continuous positive airway pressure (CPAP) (OR = 4.71; 95% CI = 1.34–16.58), dopamine and dobutamine use (OR = 3.71; 95% CI = 1.08–12.78), intravenous sedation >10 days (OR = 6.60; 95% CI = 1.62–26.90), tachypnea and subcostal retractions (relative risk [RR] = 3.68; 95% CI = 1.14–11.93), and inspired fraction of oxygen (Fio2)>0.4 after extubation (RR = 3.63; 95% CI = 1.21–10.88). After multiple logistic regression analysis, age between 1 and 3 mos, mean OI >5, CPAP and mechanical ventilation >15 days remained associated with extubation failure. Conclusion: Extubation failure was more frequent among young infants who received prolonged ventilatory support and intravenous sedation, used CPAP, had impaired lung oxygenation, and required inotropic therapy.

Ferritin levels in children with severe sepsis and septic shock

Aim: To evaluate serum ferritin level in children with severe sepsis and septic shock and its association with mortality.

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.

Prevalence of burnout in pediatric intensivists: an observational comparison with general pediatricians.

Objective: To study the prevalence of burnout in general pediatricians and pediatric intensivists and to evaluate factors that may be associated with this syndrome. Design: Observational cohort study. Setting: Pediatric departments of two hospitals in south Brazil. Patients: Pediatric intensivists working in two regional PICUs and general pediatricians working in the outpatient departments in the same hospitals. Intervention: Two researchers, blinded to the workplace of the physicians, undertook the assessment of burnout using the Maslach Burnout Inventory scale. Burnout was defined as high score in the domains for “emotional exhaustion” or “depersonalization” or a low score in the “professional accomplishment” domain. Measurements and Main Results: The PICU and general pediatrician groups were similar demographically, and each had 35 recruits. Burnout was present in 50% of the study recruits and was more frequent among pediatric intensivists than general pediatricians (71% vs 29%, respectively, p < 0.01). In regard to the individual Maslach Burnout Inventory domains, the average score was higher for emotional exhaustion and depersonalization and lower for professional accomplishment in the PICU group (p < 0.01). A cluster analysis showed that pediatric intensivists were more likely to develop the burnout syndrome involving all Maslach Burnout Inventory domains. The multivariate analysis found that the odds ratio for burnout in pediatric intensivists was 5.7 (95% CI, 1.9–16.7; p < 0.01). Conclusions: Burnout is frequent among pediatric intensivists and characterized by cumulative involvement of emotional exhaustion, depersonalization, and professional accomplishment. Earlier recognition of emotional exhaustion may be important in preventing the development of a complete burnout syndrome. Improvement in workplace characteristics and measures to improve physician resilience are entirely warranted.

End-of-life practices in seven Brazilian pediatric intensive care units.

Objective: To evaluate the incidence of life support limitation and medical practices in the last 48 hrs of life of children in seven Brazilian pediatric intensive care units (PICUs). Design: Cross-sectional multicenter retrospective study based on medical chart review. Setting: Seven PICUs belonging to university and tertiary hospitals located in three Brazilian regions: two in Porto Alegre (southern region), two in São Paulo (southeastern region), and three in Salvador (northeastern region). Patients: Medical records of all children who died in seven PICUs from January 2003 to December 2004. Deaths in the first 24 hrs of admission to the PICU and brain death were excluded. Interventions: Two pediatric intensive care residents from each PICU were trained to fill out a standard protocol (&kgr; = 0.9) to record demographic data and all medical management provided in the last 48 hrs of life (inotropes, sedatives, mechanical ventilation, full resuscitation maneuvers or not). Students t-test, analysis of variance, chi-square test, and relative risk were used for comparison of data. Measurements and Main Results: Five hundred and sixty-one deaths were identified; 97 records were excluded (61 because of brain death and 36 due to <24 hrs in the PICU). Thirty-six medical charts could not be found. Cardiopulmonary resuscitation was performed in 242 children (57%) with a significant difference between the southeastern and northeastern regions (p = .0003). Older age (p = .025) and longer PICU stay (p = .001) were associated with do-not-resuscitate orders. In just 52.5% of the patients with life support limitation, the decision was clearly recorded in the medical chart. No ventilatory support was provided in 14 cases. Inotropic drug infusions were maintained or increased in 66% of patients with do-not-resuscitate orders. Conclusions: The incidence of life support limitation has increased among Brazilian PICUs but with significant regional differences. Do-not-resuscitate orders are still the most common practice, with scarce initiatives for withdrawing or withholding life support measures.

Surfactant Deficiency in Transient Tachypnea of the Newborn

OBJECTIVE To evaluate surfactant production and function in term neonates with transient tachypnea of the newborn (TTN). STUDY DESIGN Samples of gastric aspirates collected within 30 minutes of birth from 42 term newborns with gestational age ≥ 37 weeks (21 patients with TTN and 21 control subjects), delivered via elective cesarean delivery, were analyzed with lamellar body count and stable microbubble test. RESULTS Results of lamellar body counts and stable microbubble tests were significantly lower in the TTN group than in control subjects (P = .004 and .013, respectively). Lamellar body counts were significantly lower in infants with TTN requiring oxygen for ≥ 24 hours after birth than in infants requiring oxygen for < 24 hours (P = .029). When the cutoff point was 48 hours, the stable microbubble count was significantly lower in the group requiring oxygen for ≥ 48 hours than in the group requiring oxygen for < 48 hours (P = .047). CONCLUSIONS Term infants with TTN had low lamellar body counts associated with decreased surfactant function, suggesting that prolonged disease is associated with surfactant abnormalities.

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.

Profile and consequences of children requiring prolonged mechanical ventilation in three Brazilian pediatric intensive care units

Objective: To describe the characteristics of children submitted to prolonged mechanical ventilation (MV), and evaluate their mortality, and associated factors as well as the potential impact at admissions to the pediatric intensive care unit (PICU). Methods: We conducted a retrospective study enrolling all children admitted to three Brazilian PICUs between January 2003 and December 2005 submitted to MV ≥21 days. The three selected PICUs were located in university-affiliated hospitals. From the medical charts were reported anthropometric data, diagnosis, ventilator parameters on the 21st day, length of MV, length of stay in the PICU, specific interventions (e.g., tracheostomy), and outcome. Results: One hundred eighty-four children (190 admissions) were submitted to prolonged MV (2.5% of all admissions to these 3 Brazilian PICUs), with a median age of 6 months. The mortality rate was 48% and the median time on MV was 32 days. Tracheostomy was performed on only 19% of the patients and, on average after 32 days of intubation. Mortality was associated with peak inspiratory pressure >25 cm H2O (odds ratio = 2.3; 1.1–5.1), fraction of inspired oxygen >0.5 (odds ratio = 6.3; 2.2–18.1), and vasoactive drug infusion (odds ratio = 2.6; 1.1–5.9) on the 21st day of MV. Seventy-six children (1% of the all admissions) were dependent on MV without other organ failures were 830 PICU admissions and were potentially prevented. Conclusions: A small group of children admitted to the PICU requires prolonged MV. The elevated mortality rate is associated with higher ventilatory parameters and vasoactive drug support on the 21st day of MV. Stable children requiring prolonged MV in the PICU potentially prevent additional admissions of a large number of acute and unstable patients.