Werther Brunow de Carvalho

Nosocomial infection in a pediatric intensive care unit in a developing country

OBJECTIVEnDetermine the rate and outcome of nosocomial infection (NI) in pediatric intensive care unit patients in a developing country.nnnDESIGNnProspective cohort study using the Centers for Disease Control and Prevention definitions to diagnose nosocomial infection and NNISS (National Nosocomial Infection Surveillance System) methodology.nnnSETTINGnSão Paulo Hospital - Universidade Federal de São Paulo - Brazil, a 700-bed teaching hospital with an 8-bed pediatric intensive care unit.nnnPARTICIPANTSnAll 515 children consecutively admitted to the pediatric intensive care unit from April 1996 to October 1997.nnnRESULTSnThe NI incidence was 18.3% and the mean infection rate per 1,000 patient days was 46.1; the ventilator-associated pneumonia rate was 18.7 per 1,000 ventilator days; the central line-associated bloodstream infection rate was 10.2 per 1,000 central line days; and the urinary tract catheter-associated infection rate was 1.8 per 1,000 catheter days. Pneumonia was the most common NI (31.6%), followed by bloodstream infections (17.3%), and surgical site infection (17.3%). Gram-negative bacterias were the most common pathogens identified in the NIs (54.8%), followed by Gram-positive bacterias (23.8%), and yeasts.nnnCONCLUSIONnPneumonia was the most common type of NI. A high incidence of ventilator-associated pneumonia and central line-associated bloodstream infections was found, whereas the urinary tract catheter-associated infection rate was low. Gram-negative bacterias were the most common etiologic agents identified in the unit, and yeasts were frequently found. Pediatric patients have characteristics of their own, with major differences when compared to the adult population.

Enteral nutrition in critically ill children: are prescription and delivery according to their energy requirements?

BACKGROUNDnThe purpose of this study was to compare the differences between prescribed and delivered energy among critically ill children and to identify the factors that impede the optimal delivery of enteral nutrition in the first 5 days of nutrition support.nnnMETHODSnIn a prospective cohort study, we evaluated 55 critically ill children aged 8.2 ± 11.4 months (0-162.3 months), who were fed for ≥2 days through a gastric or postpyloric tube. The patients were followed from admission until day 10 of enteral nutrition. Prescribed and delivered energy were recorded daily and compared with each other and with the estimated basal metabolic rate (BMR). The Paediatric Index of Mortality 2 (PIM 2) was used to estimate illness severity.nnnRESULTSnThe ratio of delivered:required energy was <90% in 55.7% of the enteral nutrition days. Low prescription was the main reason for not achieving the energy goal in the first 5 days of enteral nutrition. Discrepancies between prescribed and delivered: energy were attributable to interruptions in feeding caused by clinical instability, airway management, radiologic and surgical procedures, and accidental feeding tube removal. The other factors associated with the delivery of less than required energy were PIM 2 ≥15%, gastrointestinal complications, dialysis, and use of α-adrenergic vasoactive drugs. The latter was the only variable in multivariate analysis that was associated with not ultimately achieving energy goal.nnnCONCLUSIONSnThe prescription and delivery of energy were not adequate in >50% of enteral nutrition days. The gap between the effective administration and energy requirements can be explained by both underprescription and underdelivery. Administration of vasoactive drugs was the only variable independently associated with a low energy supply.

Fatores que tornam estressante o trabalho de médicos e enfermeiros em terapia intensiva pediátrica e neonatal: estudo de revisão bibliográfica

OBJETIVOS: Revisao de literatura sobre estresse ocupacional e sindrome de burnout em medicos e enfermeiros que trabalham em unidade de terapia intensiva pediatrica e neonatal. METODOS: Os artigos foram identificados a partir das bases de dados MedLine, LILACS e SciElo, usando as palavras-chave estresse, burnout, medicos, enfermagem, unidade de terapia intensiva, unidade de cuidados intensivos pediatricos e unidades de cuidados intensivos neonatais. O periodo pesquisado foi de 1990 a 2007. RESULTADOS: Medicos e enfermeiros que trabalham em unidade de terapia intensiva pediatrica e neonatal sao candidatos a apresentarem estresse, alteracoes psicologicas e sindrome de Burnout. Pesquisas sobre o tema identificaram alteracoes importantes que acometem medicos e enfermeiros intensivistas: sobrecarga de trabalho, burnout, desejo de abandonar o trabalho e niveis elevados de cortisol entre outros fatores. CONCLUSOES: Os profissionais que trabalham em unidade de terapia intensiva pediatrica e neonatal , pela especificidade do seu trabalho, estao expostos ao risco do estresse ocupacional e, consequentemente ao Burnout. Estes dados sugerem a necessidade de serem feitas pesquisas, com o objetivo de desenvolver medidas preventivas e modelos de intervencao.

Noise level in a pediatric intensive care unit

OBJECTIVEnThe purpose of this study was to verify the noise level at a PICU.nnnMETHODSnThis prospective observational study was performed in a 10 bed PICU at a teaching hospital located in a densely populated district within the city of São Paulo, Brazil. Sound pressure levels (dBA) were measured 24 hours during a 6-day period. Noise recording equipment was placed in the PICU access corridor, nursing station, two open wards with three and five beds, and in isolation rooms. The resulting curves were analyzed.nnnRESULTSnA basal noise level variation between 60 and 70 dBA was identified, with a maximum level of 120 dBA. The most significant noise levels were recorded during the day and were produced by the staff.nnnCONCLUSIONnThe basal noise level identified exceeds International Noise Council recommendations. Education regarding the effects of noise on human hearing and its relation to stress is the essential basis for the development of a noise reduction program.

Nível de ruídos em uma unidade de cuidados intensivos pediátricos

OBJETIVO: Verificar o nivel de ruidos em uma unidade de cuidados intensivos pediatricos. METODOS: Estudo observacional e prospectivo realizado em uma unidade de cuidados intensivos pediatricos de 10 leitos de um hospital universitario da cidade de Sao Paulo, Brasil. Os niveis de ruidos foram medidos por meio de equipamento instalado no corredor de acesso a unidade de cuidados intensivos pediatricos, posto de enfermagem, duas salas com tres e cinco leitos, bem como nas unidades de isolamento. O equipamento utilizado foi calibrado para registrar a pressao do som em dBA, durante 24 horas, por 6 dias. Os dados foram analisados de acordo com as curvas graficas registradas pelo equipamento. RESULTADOS: Foi identificado um nivel basal de ruidos de 60 a 70 dBA, com pico de 120 dBA. Os niveis mais elevados foram identificados no periodo diurno, decorrentes da atividade e comunicacao dos profissionais. CONCLUSAO: Os niveis de ruidos identificados excederam as recomendacoes do International Noise Council, da Organizacao Mundial da Saude. A educacao sobre os efeitos prejudiciais de ruidos na audicao humana e sua relacao com o estresse constituem as bases para a implementacao de programas de reducao de ruidos.

Availability of pediatric and neonatal intensive care units in the city of São Paulo

OBJECTIVEnTo describe the health care service provided in pediatric intensive care units in the city of São Paulo, by identifying and describing the units and analyzing their geographic distribution.nnnMETHODSnA descriptive cross-sectional study was carried out during a two-year period (August 2000 to July 2002). Data were collected through questionnaires answered by medical directors of each pediatric and neonatal intensive care unit.nnnRESULTSnSão Paulo is served by 107 pediatric and neonatal intensive care units, of which 85 (79.4%) completed and returned the questionnaire. We found a very unequal distribution of units as there were more units in places with the least pediatric population. Regarding to pediatric intensive care units specialization, 7% were pediatric, 41.2% were neonatal and 51.7% were mixed (pediatric and neonatal). Regarding hospital funds, 15.3% were associated with philanthropic institutions, 37.6% were private and 47% were public. A total of 1,067 beds were identified, of which 969 were active. The ratio bed/patient aged 0-14 was 1/2,728, varying from 1/604 at health districts-I to 1/6,812 at health districts-III. The units reported an average of 11.7 beds (2 to 60). The neonatal intensive care unit had a median of 16.9 beds per unit and pediatric intensive care units a median of 8.5 beds/unit.nnnCONCLUSIONnIn São Paulo, we found an uneven distribution of pediatric and neonatal intensive care units among the health districts. There was also an uneven distribution between public and private units, and neonatal and pediatric ones. The current report is the first step in the effort to improve the quality of medical assistance in pediatric and neonatal intensive care units in São Paulo.

Comparison between the Comfort and Hartwig sedation scales in pediatric patients undergoing mechanical lung ventilation

CONTEXTnA high number of hospitalized children do not receive adequate sedation due to inadequate evaluation and use of such agents. With the increase in knowledge of sedation and analgesia in recent years, concern has also risen, such that it is now not acceptable that incorrect evaluations of the state of childrens pain and anxiety are made.nnnOBJECTIVEnA comparison between the Comfort and Hartwig sedation scales in pediatric patients undergoing mechanical lung ventilation.nnnDESIGNnProspective cohort study.nnnSETTINGnA pediatric intensive care unit with three beds at an urban teaching hospital.nnnPATIENTSnThirty simultaneous and independent observations were conducted by specialists on 18 patients studied.nnnDIAGNOSTIC TESTnComfort and Hartwig scales were applied, after 3 minutes of observation.nnnMAIN MEASUREMENTSnAgreement rate (kappa).nnnRESULTSnOn the Comfort scale, the averages for adequately sedated, insufficiently sedated, and over-sedated were 20.28 (SD 2.78), 27.5 (SD 0.70), and 15.1 (SD 1.10), respectively, whereas on the Hartwig scale, the averages for adequately sedated, insufficiently sedated, and over-sedated were 16.35 (SD 0.77), 20.85 (SD 1.57), and 13.0 (SD 0.89), respectively. The observed agreement rate was 63% (p = 0.006) and the expected agreement rate was 44% with a Kappa coefficient of 0.345238 (z = 2.49).nnnCONCLUSIONSnIn our study there was no statistically significant difference whether the more complex Comfort scale was applied (8 physiological and behavioral parameters) or the less complex Hartwig scale (5 behavioral parameters) was applied to assess the sedation of mechanically ventilated pediatric patients.

Tempo de ventilação mecânica e desenvolvimento de displasia broncopulmonar

OBJECTIVE: Verify the association between duration of mechanical ventilation and development of bronchopulmonary dysplasia in neonates weighting at birth less than 1500g. METHODS: Retrospective study conducted with neonates weighting less than 1500g at birth submitted to mechanical ventilation. Neonates presenting major birth defects, transferred to other services or died before the 28th day of life were excluded from the study. Three groups were analyzed according to duration of mechanical ventilation: 1 to 7 days, 8 to 14 days and more than 15 days. The chance ratio of developing bronchopulmonary dysplasia was calculated for each group. RESULTS: From the 216 clinical histories assessed, 121 met the criteria for inclusion in the study. Mean birth weight and gestational age were 1199.8 g and 31.8 weeks. Of all neonates submitted to mechanical ventilation from 1 to 7 days, 15.5% developed bronchopulmonary dysplasia; from 8 to 14 days 60% and from more than 15 days, 88.2%; chance ratios were equal to 0.16; 11.25 and 16.36, respectively. CONCLUSION: The chance of a neonate weighting less than 1500 g developing bronchopulmonary dysplasia was 11 times higher in those submitted to mechanical ventilation for up to 14 days. This chance was even higher in those ventilated for more than 15 days. That is why the nursing staff assisting high risk patients should consider the possibility of extubating neonates during their first week of life.

Hypophosphatemia in critically ill children

The purpose of this paper is to review clinical studies on hypophosphatemia in pediatric intensive care unit patients with a view to verifying prevalence and risk factors associated with this disorder. We searched the computerized bibliographic databases Medline, Embase, Cochrane Library, and LILACS to identify eligible studies. Search terms included critically ill, pediatric intensive care, trauma, sepsis, infectious diseases, malnutrition, inflammatory response, surgery, starvation, respiratory failure, diuretic, steroid, antiacid therapy, mechanical ventilation. The search period covered those clinical trials published from January 1990 to January 2004. Studies concerning endocrinological disorders, genetic syndromes, rickets, renal diseases, anorexia nervosa, alcohol abuse, and prematurity were not included in this review. Out of 27 studies retrieved, only 8 involved pediatric patients, and most of these were case reports. One clinical trial and one retrospective study were identified. The prevalence of hypophosphatemia exceeded 50%. The commonly associated factors in most patients with hypophosphatemia were refeeding syndrome, malnutrition, sepsis, trauma, and diuretic and steroid therapy. Given the high prevalence, clinical manifestations, and multiple risk factors, the early identification of this disorder in critically ill children is crucial for adequate replacement therapy and also to avoid complications.

Bronquiolite aguda, uma revisão atualizada

Acute bronchiolitis (AB) is a frequent cause of hospitalization among children and its main etiological agent is respiratory syncytial virus (RSV). It occurs epidemically during autumn and winter. Some populations of children such as premature newborns, infants with congenital heart disease and those with chronic lung disease, immunocompromised, undernourished, among others, present increased morbidity and mortality risk. The virus multiplies in epithelial ciliated cells while inflammation and cellular debris cause obstruction of the airways, hyperinflation, atelectasis, and wheezing and gas exchange imbalance. Definitive evidence still does not exist about treatment of this disease, Treatment includes oxygen therapy, hydration, inhaled beta-2 agonists, racemic epinephrine, recombinant DNase and respirotherapy, among others. Prophylactic measures include administration of monoclonal antibodies. The majority of children with AB, independent of disease severity, recover without sequels. The natural course of this disease usually varies, from seven to ten days ,however some children may not recover for weeks.