Vânia Euzébio de Aguiar

Use of Ketofol for procedural sedation and analgesia in children with hematological diseases

Background:  The aim of this study was to evaluate the effectiveness and safety of intravenous ketamine–propofol admixture (“ketofol”) in the same syringe for procedural sedation and analgesia in children undergoing bone marrow aspiration.

Unplanned Extubation in the Neonatal ICU: A Systematic Review, Critical Appraisal, and Evidence-Based Recommendations

OBJECTIVE: To update the state of knowledge on unplanned extubations (UEs) in neonatal ICUs. This review focuses on the following topics: incidence, risk factors, reintubation after UE, outcomes, and prevention. METHODS: The MEDLINE, EMBASE, CINAHL, Scielo, Lilacs, and Cochrane databases were searched for relevant publications from January 1, 1950, through January 30, 2012. Fifteen articles were selected for data abstraction. The search strategy included the following key words: “unplanned extubation,” “accidental extubation,” “self extubation,” “unintentional extubation,” “unexpected extubation,” “inadvertent extubation,” “unintended extubation,” “spontaneous extubation,” “treatment interference,” and “airway accident.” Study quality was assessed using the Newcastle-Ottawa scale. Grades of recommendation were assessed according to the Oxford Centre for Evidence-Based Medicines levels of evidence system. Studies with Newcastle-Ottawa scale score ≥ 5 that included appropriate statistical analysis were deemed of high methodological quality. RESULTS: The overall mean Newcastle-Ottawa scale score was 3.5. UE rates ranged from 0.14 to 5.3 UEs/100 intubation days, or 1% to 80.8%. Risk factors included restlessness/agitation (13–89%), poor fixation of endotracheal tube (8.5–31%), tube manipulation at the time of UE (17–30%), and performance of a patient procedure at bedside (27.5–51%). One study showed that every day on mechanical ventilation increased the UE risk 3% (relative risk 1.03, P < .001). The association between birth weight/gestational age and UE is controversial. Reintubation rates ranged from 8.3% to 100%. There is still a gap of information about strategies addressed to reduce the incidence of UE. The best method of endotracheal tube securement remains a controversial issue. CONCLUSIONS: Despite numerous publications on UE, there are few studies assessing preventive strategies for adverse events and there is a lack of randomized clinical trials. Recommendations are proposed based on the current available literature.

Value of Repeat Cranial Computed Tomography in Pediatric Patients Sustaining Moderate to Severe Traumatic Brain Injury

BACKGROUND Repeat head computed tomography (CT) is standard practice for traumatic brain injury (TBI) at many centers. The few studies available in children remain unclear over the value of repeat CT within 24 hours to 48 hours of lesion in such patients. The purpose of the present study was to assess the value of repeat cranial CT in children presenting moderate or severe TBI. METHODS A retrospective study performed within a pediatric intensive care unit between January 2000 and December 2006. All patients with moderate and severe TBI who survived the first 24 hours after admission were included. Clinical data collected included age, lesion mechanism, time between first and second CTs, disease severity score at admission, and Glasgow Coma Scale (GCS) both at admission and day of repeat CT. RESULTS A total of 63 children were assessed whose mean age was 72 months (48-112). The time between the first and the second CT scans averaged 25.78 hours +/- 13.75 hours (range, 6-48 hours). The reasons for ordering repeat CT scans were divided as follows: follow-up (78%), neurologic deterioration (20.4%), and increased intracranial pressure (1.6%). The change on the follow-up CT scan was compared with the GCS score. The GCS score was improved in 66.6% of patients, remained the same in 15.9%, and worsened in 17.5%. The appearance on the CT scans was better, the same or worse in 41.3%, 34.9%, and 23.8% of patients, respectively. There was a significant association between GCS and changes in findings on repeat CT (OR = 34.5, confidence interval [5.98-199.04], p = 0.000009). The positive and negative predictive values were 82% and 89%, respectively. One patient with a worsened GCS required surgical intervention based on the repeat CT scan. CONCLUSION An unchanged or improving neurologic examination in children sustaining moderate or severe TBI who are appropriately monitored may be adequate to exclude the possibility of neurosurgical intervention and, hence, repeat head CT scan.

Impact of sustained neuromuscular blockade on outcome of mechanically ventilated children

Background:  Neuromuscular blocking agents (NMBA) are commonly administered to critically ill children in pediatric intensive care units (PICU) in the USA and Europe. Although NMBA are frequently used in PICU patients, their role in the PICU setting has not yet been clearly defined. The aim of this study was to describe the sustained administration of NMBA and its impact on outcome of PICU patients.

Procedural sedation for insertion of central venous catheters in children: comparison of midazolam/fentanyl with midazolam/ketamine

Background:  There is a lack of studies evaluating procedural sedation for insertion of central venous catheters (CVC) in pediatric patients in emergency departments or pediatric intensive care units (PICU). This study was designed to evaluate whether there is a difference in the total sedation time for CVC insertion in nonintubated children receiving two sedation regimens.

Assessing Outcome in Interhospital Infant Transport: The Transport Risk Index of Physiologic Stability Score at Admission

OBJECTIVE To evaluate the performance of the Transport Risk Index of Physiologic Stability (TRIPS) score at admission for early mortality prediction. METHODS The study included all consecutive outborn infants admitted to a single neonatal intensive care unit (NICU) over a 3-year period. The data collected included demographic variables, 7-day NICU mortality, and severe (≥ grade 3) intraventricular hemorrhage (IVH), TRIPS score at admission, and Score for Neonatal Acute Physiology II (SNAP-II) and SNAP-Perinatal Extension-II (SNAPPE-II) scores. RESULTS A total of 175 neonates were enrolled. TRIPS at admission discriminated 7-day mortality from survival with a receiver operating characteristic (ROC) area of 0.80, and predictive performance of TRIPS for severe IVH showed a ROC area of 0.67. The TRIPS had good calibration for all strata (p = 0.49). For gestational age (GA) >32 weeks, the area under the curve (AUC) for TRIPS was 0.71, whereas the AUC for GA ≤32 weeks was 0.99 for 7-day mortality. Predictive performance of TRIPS for 7-day mortality was similar to that of SNAP-II and SNAPPE-II. CONCLUSION TRIPS score at admission had a good performance to discriminate high-risk patients for 7-day mortality, mainly infants with GA ≤32 weeks. TRIPS might be a useful triage tool if applied at the time of first contact with a transport service.

Pediatric surgeon vs general surgeon: Does subspecialty training affect the outcome of appendicitis?

The absence of pediatric surgeons in many centers results in restriction of patient access to pediatric subspecialty care. The aim of this study was to compare the outcomes of children treated for appendicitis by pediatric surgeons (PS) and by general surgeons (GS).

Value of clinical pulmonary infection score in critically ill children as a surrogate for diagnosis of ventilator-associated pneumonia☆

RATIONALE Although the modified clinical pulmonary infection score (mCPIS) has been endorsed by national organizations, only a very few pediatric studies have assessed it for the diagnosis of ventilator-associated pneumonia (VAP). METHODS Seventy children were prospectively included if they fulfilled the diagnosis criteria for VAP referenced by the Centers for Disease Control and Prevention. The primary outcome was performance of mCPIS calculated on day 1 to accurately identify VAP as defined by microbiological data. RESULTS The data showed that an mCPIS of 6 or higher had a sensitivity of 94%, specificity of 50%, positive predictive value of 64%, negative predictive value of 90%, a positive likelihood ratio of 1.88, and a negative likelihood ratio of 0.11. The area under the receiver operating characteristic curve was 0.70. A positive posttest result increased the disease probability by 15.4%, whereas a negative test result reduced the probability by 38.6%. Patients with an mCPIS of 6 or higher had longer length of mechanical ventilation and pediatric intensive care unit stay compared with patients with an mCPIS lower than 6. CONCLUSION The mCPIS had a clinically acceptable performance, and it can be a helpful screening tool for VAP diagnosis. An mCPIS lower than 6 was highly able in distinguishing patients without VAP. Despite its high sensitivity and negative predictive value of this score, further studies are required to assess the use of mCPIS in guiding therapeutic decisions.

The product of platelet and neutrophil counts (PN product) at presentation as a predictor of outcome in children with meningococcal disease

Abstract Background: Despite improvement in the treatment of Neisseria meningitidis infection, meningococcal diseases (MD) are still an important cause of morbidity and mortality around the world. This study assessed the performance of the product of platelet and neutrophil counts (PN product) at the time of presentation to hospital as a predictor of outcome in children with MD. Methods: Retrospective evaluation of children with clinical MD admitted to two paediatric intensive care units in Brazil. Results: Seventy-two children aged 2–156 months were studied. Overall mortality was 19.7%. The PN product, the Glasgow Meningococcal Septicaemia Prognostic Score and the Paediatric Risk of Mortality score discriminated between survivors and non-survivors. A PN ≤ 113 had a sensitivity of 28.6% (95% CI 8.6–58.1), specificity of 96.6% (95% CI 88.1–99.5) and positive and negative predictive values of 66.7% and 84.8%. The area under the receiver operating characteristic curve was 0.85 (95% CI 0.74–0.92). Conclusion: The PN product had a lower performance than reported in previous studies from a developed country. The PN product, however, is a good indicator of mortality in MD but needs to be validated for the population to which it is being applied.

How the modified Clinical Pulmonary Infection Score can identify treatment failure and avoid overusing antibiotics in ventilator-associated pneumonia.

Although the modified Clinical Pulmonary Infection Score (CPIS) has been used to guide treatment decisions in adults with ventilator‐associated pneumonia (VAP), paediatric studies are lacking. We assessed a modified CPIS tool to define VAP resolution and identify treatment failure at an early stage.