Physical rehabilitation in Brazilian pediatric intensive care units: a multicenter point prevalence study.

OBJECTIVE: To determine the prevalence and factors associated with the physical rehabilitation of critically ill children in Brazilian pediatric intensive care units. METHODS: A 2-day, cross-sectional, multicenter point prevalence study comprising 27 pediatric intensive care units (out of 738) was conducted in Brazil in April and June 2019. This Brazilian study was part of a large multinational study called Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU). The primary outcome was the prevalence of mobility provided by physical therapy or occupational therapy. Clinical data on patient mobility, potential mobility safety events, and mobilization barriers were prospectively collected in patients admitted for ≥ 72 hours. RESULTS: Children under the age of 3 years comprised 68% of the patient population. The prevalence of therapist-provided mobility was 74%, or 277 out of the 375 patient-days. Out-of-bed mobility was most positively associated with family presence (adjusted odds ratios 3.31;95%CI 1.70 - 6.43) and most negatively associated with arterial lines (adjusted odds ratios 0.16; 95%CI 0.05 - 0.57). Barriers to mobilization were reported on 27% of patient-days, the most common being lack of physician order (n = 18). Potential safety events occurred in 3% of all mobilization events. CONCLUSION: Therapist-provided mobility in Brazilian pediatric intensive care units is frequent. Family presence was high and positively associated with out-of-bed mobility. The presence of physiotherapists 24 hours a day in Brazilian pediatric intensive care units may have a substantial impact on the mobilization of critically ill children.

Physical rehabilitation in Brazilian pediatric intensive care units: a multicenter point prevalence study / Reabilitação física em unidades de terapia intensiva pediátrica brasileiras: um estudo multicêntrico de prevalência pontual

ABSTRACT Objective: To determine the prevalence and factors associated with the physical rehabilitation of critically ill children in Brazilian pediatric intensive care units. Methods: A 2-day, cross-sectional, multicenter point prevalence study comprising 27 pediatric intensive care units (out of 738) was conducted in Brazil in April and June 2019. This Brazilian study was part of a large multinational study called Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU). The primary outcome was the prevalence of mobility provided by physical therapy or occupational therapy. Clinical data on patient mobility, potential mobility safety events, and mobilization barriers were prospectively collected in patients admitted for ≥ 72 hours. Results: Children under the age of 3 years comprised 68% of the patient population. The prevalence of therapist-provided mobility was 74%, or 277 out of the 375 patient-days. Out-of-bed mobility was most positively associated with family presence (adjusted odds ratios 3.31;95%CI 1.70 - 6.43) and most negatively associated with arterial lines (adjusted odds ratios 0.16; 95%CI 0.05 - 0.57). Barriers to mobilization were reported on 27% of patient-days, the most common being lack of physician order (n = 18). Potential safety events occurred in 3% of all mobilization events. Conclusion: Therapist-provided mobility in Brazilian pediatric intensive care units is frequent. Family presence was high and positively associated with out-of-bed mobility. The presence of physiotherapists 24 hours a day in Brazilian pediatric intensive care units may have a substantial impact on the mobilization of critically ill children.

RESUMO Objetivo: Determinar a prevalência e os fatores associados à reabilitação física de crianças em estado grave em unidades de terapia intensiva pediátrica brasileiras. Métodos: Realizou-se um estudo de prevalência pontual multicêntrico, transversal, de 2 dias, abrangendo 27 unidades de terapia intensiva pediátrica (do total de 738) no Brasil em abril e junho de 2019. Este estudo brasileiro fez parte de um grande estudo multinacional chamado Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU). O desfecho primário foi a prevalência de mobilidade proporcionada pela fisioterapia ou pela terapia ocupacional. Foram coletados prospectivamente dados clínicos sobre a mobilidade do paciente, possíveis eventos de segurança de mobilidade e barreiras de mobilização em pacientes admitidos por ≥ 72 horas. Resultados: As crianças com idade inferior a 3 anos eram 68% da população de pacientes. A prevalência de mobilidade fornecida pelo terapeuta foi de 74%, ou 277 dos 375 pacientes-dia. A mobilidade para fora do leito foi mais positivamente associada à presença de familiares (razão de chance ajustada de 3,31; IC95% 1,70 - 6,43) e mais negativamente associada às linhas arteriais (razão de chance ajustada de 0,16; IC95% 0,05 - 0,57). Foram relatadas barreiras à mobilização em 27% dos pacientes-dia, sendo a mais comum a falta de prescrição médica (n = 18). Registaram-se eventuais eventos de segurança em 3% de todos os eventos de mobilização. Conclusão: A mobilidade proporcionada pelo terapeuta nas unidades de terapia intensiva pediátrica brasileiras é frequente. A presença de familiares foi alta e positivamente associada à mobilidade para fora do leito. A presença de fisioterapeutas 24 horas por dia nas unidades de terapia intensiva pediátrica brasileiras pode exercer papel importante na mobilização de crianças em estado grave.

Epidemiology and treatment of sepsis at a public pediatric emergency department.

OBJECTIVE: To describe the clinical characteristics and treatment of children with sepsis, severe sepsis, and septic shock at a pediatric emergency department of a public hospital. METHODS: A retrospective, observational study. The medical records of patients included in the hospital Pediatric Sepsis Protocol and patients with discharge ICD-10 A41.9 (sepsis, unspecified), R57 (shock) and A39 (meningococcal meningitis) were evaluated. RESULTS: A total of 399 patients were included. The prevalence of sepsis, severe sepsis, and septic shock at the emergency room were 0.41%, 0.14% and 0.014%, respectively. The median age was 21.5 months for sepsis, 12 months for severe sepsis, and 20.5 months for septic shock. Sepsis, severe sepsis, and septic shock were more often associated with respiratory diseases. The Respiratory Syncytial Virus was the most common agent. The median time to antibiotic and fluid administration was 3 hours in patients with sepsis and severe sepsis. In patients with septic shock, the median times to administer antibiotics, fluid and vasoactive drugs were 2 hours, 2.5 hours and 6 hours, respectively. The median length of hospital stay for patients with sepsis, severe sepsis and septic shock were 3 days, 4 days and 1 day, respectively. The overall mortality was 2%. CONCLUSION: Sepsis had a low prevalence. Early diagnosis and recognition are a challenge for the emergency care pediatrician, the first place of admission.

Epidemiology and treatment of sepsis at a public pediatric emergency department

ABSTRACT Objective To describe the clinical characteristics and treatment of children with sepsis, severe sepsis, and septic shock at a pediatric emergency department of a public hospital. Methods A retrospective, observational study. The medical records of patients included in the hospital Pediatric Sepsis Protocol and patients with discharge ICD-10 A41.9 (sepsis, unspecified), R57 (shock) and A39 (meningococcal meningitis) were evaluated. Results A total of 399 patients were included. The prevalence of sepsis, severe sepsis, and septic shock at the emergency room were 0.41%, 0.14% and 0.014%, respectively. The median age was 21.5 months for sepsis, 12 months for severe sepsis, and 20.5 months for septic shock. Sepsis, severe sepsis, and septic shock were more often associated with respiratory diseases. The Respiratory Syncytial Virus was the most common agent. The median time to antibiotic and fluid administration was 3 hours in patients with sepsis and severe sepsis. In patients with septic shock, the median times to administer antibiotics, fluid and vasoactive drugs were 2 hours, 2.5 hours and 6 hours, respectively. The median length of hospital stay for patients with sepsis, severe sepsis and septic shock were 3 days, 4 days and 1 day, respectively. The overall mortality was 2%. Conclusion Sepsis had a low prevalence. Early diagnosis and recognition are a challenge for the emergency care pediatrician, the first place of admission.

Barriers and Proposed Solutions to a Successful Implementation of Pediatric Sepsis Protocols.

The implementation of managed protocols contributes to a systematized approach to the patient and continuous evaluation of results, focusing on improving clinical practice, early diagnosis, treatment, and outcomes. Advantages to the adoption of a pediatric sepsis recognition and treatment protocol include: a reduction in time to start fluid and antibiotic administration, decreased kidney dysfunction and organ dysfunction, reduction in length of stay, and even a decrease on mortality. Barriers are: absence of a written protocol, parental knowledge, early diagnosis by healthcare professionals, venous access, availability of antimicrobials and vasoactive drugs, conditions of work, engagement of healthcare professionals. There are challenges in low-middle-income countries (LMIC). The causes of sepsis and resources differ from high-income countries. Viral agent such as dengue, malaria are common in LMIC and initial approach differ from bacterial infections. Some authors found increased or no impact in mortality or increased length of stay associated with the implementation of the SCC sepsis bundle which reinforces the importance of adapting it to most frequent diseases, disposable resources, and characteristics of healthcare professionals. Conclusions: (1) be simple; (2) be precise; (3) education; (5) improve communication; (5) work as a team; (6) share and celebrate results.

A Pediatric Sepsis Protocol Reduced Mortality and Dysfunctions in a Brazilian Public Hospital.

Introduction: Few studies in the literature discuss the benefits of compliance with sepsis bundles in hospitals in low- and middle-income countries, where resources are limited and mortality is high. Methods: This is a retrospective cohort study conducted at a public hospital in a low-income region in Brazil. We evaluated whether completion of a sepsis bundle is associated with reduced in-hospital mortality for sepsis, severe sepsis, and septic shock, as well as prevention of septic shock and organ dysfunction. Bundle compliance required the completion of three items: (1) obtaining blood count and culture, arterial or venous blood gases, and arterial or venous lactate levels; (2) antibiotic infusion within the first hour of diagnosis; and (3) infusion of 10-20 ml/kg saline solution within the first hour of diagnosis. Results: A total of 548 children with sepsis, severe sepsis, or septic shock who were treated at the emergency room from February 2008 to August of 2016 were included in the study. Of those, 371 patients were included in the protocol group and had a lower median length of stay (3 days vs. 11 days; p < 0.001), fewer organ dysfunctions during hospitalization (0 vs. 2, p < 0.001), and a lower probability of developing septic shock. According to a propensity score analysis, mortality was lower during the post-implementation period [2.75 vs. 15.4% (RR 95%IC 0.13 (0.06, 0.27); p < 0.001)]. Conclusions: A simple and low-cost protocol was feasible and yielded good results at a general hospital in a low-income region in Brazil. Protocol use resulted in decreased mortality and progression of dysfunctions and was associated with a reduced probability of developing septic shock.

Vomiting in newborns as a result of a duodenal membrane: two case reports.

Vomiting episodes in newborns are extremely common and often attributed to gastroesophageal reflux. The symptoms of vomiting, however, may be caused by other complications. In this report, we present two cases of a 1-month-old male and a 2-month-old female, both presenting vomiting episodes that led to malnutrition. Some pediatricians often attribute the diagnosis of gastroesophageal reflux to newborns that are vomiting; however, there is a portion of the population that has other causes that lead to similar symptoms. The pediatrician should be alert to the clinical signs of weight loss, dehydration and malnutrition to investigate other causes of vomiting.

Vomiting in newborns as a result of a duodenal membrane: two case reports / Episódios de vômitos em recém-nascidos como consequência de membrana duodenal: relatos de dois casos

ABSTRACT Vomiting episodes in newborns are extremely common and often attributed to gastroesophageal reflux. The symptoms of vomiting, however, may be caused by other complications. In this report, we present two cases of a 1-month-old male and a 2-month-old female, both presenting vomiting episodes that led to malnutrition. Some pediatricians often attribute the diagnosis of gastroesophageal reflux to newborns that are vomiting; however, there is a portion of the population that has other causes that lead to similar symptoms. The pediatrician should be alert to the clinical signs of weight loss, dehydration and malnutrition to investigate other causes of vomiting.

RESUMO Episódios de vômito em recém-nascidos são extremamente comuns e frequentemente atribuídos a refluxo gastresofágico. Os sintomas de vômito, no entanto, podem ser causados por outras complicações. Neste relato, apresentamos dois casos: um lactente masculino, com 1 mês de idade, e um feminino, com 2 meses, ambos apresentando episódios de vômitos que levaram à desnutrição. Alguns pediatras costumam atribuir o diagnóstico de refluxo gastresofágico a recém-nascidos que estão vomitando; mas parcela da população tem outras causas que levam a sintomas semelhantes. O pediatra deve estar atento aos sinais clínicos de perda de peso, desidratação e desnutrição, para investigar outras causas de vômitos.

Colloids for the Initial Management of Severe Sepsis and Septic Shock in Pediatric Patients: A Systematic Review.

AIM: The goal of this study was to perform a systematic review of the literature assessing the use of colloids for the initial treatment of severe sepsis and septic shock in pediatric patients. DESIGN: The PICO [Patient, Intervention, Comparison, Outcome] method was used for the selection of studies, and the Cochrane Bias Tool was used to analyze the quality of the selected studies. DATA SEARCH: Relevant studies were sought using the following databases: EMBASE (1980 to March 2014), PubMed (1970 to March 2014), Cochrane (1980 to March 2014), Web of Science, and Scopus. Searches used the following key words: isotonic solution, crystalloid, saline solution, colloid, resuscitation, fluid therapy, sepsis and septic shock, starch, and gelatin. The filters children and clinical trial were used when possible. REVIEW METHOD: Study selection was performed by 1 examiner. The selected articles were analyzed by 2 examiners who validated the articles according to the Cochrane Bias Tool. Discrepancies were resolved by consensus or by a third examiner. RESULT: A total of 110 articles were selected based on the key words. Of these, 99 were excluded because they assessed postoperative follow-up, burn cases, cardiac surgery, or nutritional therapy or were review articles, guidelines, or editorials. One study was included after an analysis of previous reviews. A total of 12 articles were selected for analysis because they were reports of clinical trials conducted with prospective cohorts and they analyzed the use of crystalloids and colloids or colloids only in the initial treatment of severe sepsis or septic shock in children and adolescents. The total number of patients was 4375, and they ranged in age from 2 months to 15 years, with most patients between 5 and 15 years. Five studies assessed patients diagnosed with malaria, 5 assessed patients with dengue shock syndrome, 1 studied febrile diseases, and 1 examined the progression of patients with septic shock caused by various causes. CONCLUSIONS: The studies analyzed did not find evidence to suggest that the use of colloids is superior to crystalloids. In some studies, the fluid volume needed to achieve initial stabilization was smaller in the group given colloids. Crystalloids are the preferred therapeutic option because of their effectiveness, low cost, and wide availability. Colloids may be the first choice in cases of malaria when the central nervous system is affected.

Accident involving a 2-year-old child and Lonomia obliqua venom: clinical and coagulation abnormalities.

Poisons of caterpillars have different effects on inflammatory and coagulation systems. This is a case report of a 2-year-old child that accidentally came in contact with several caterpillars of the species Lonomia obliqua. At first, the patient's exams presented abnormal coagulation and decreased fibrinogen, but the patient did not evolve to active bleeding or acute renal failure. The patient received antilonomic serum 15h after the accident and the treatment was repeated after another 12h due to persistent alterations shown by the coagulation exams. The venom of L. obliqua has several substances that act on the coagulation and inflammatory systems. The event is characterized by a hemorrhagic syndrome with decreases in fibrinogen. L. obliqua Stuart-factor activator (Losac) and L. obliqua prothrombin activator protease (Lopap) are components that act with procoagulatory effects. The pro-inflammatory action occurs due to metalloproteases, hyaluronidases and other substances with inflammatory activity. Studies on caterpillar venom can give new perspectives on the treatment of cancer and other diseases that cause dysfunction of the extra-cellular matrix.

Accident involving a 2-year-old child and Lonomia obliqua venom: clinical and coagulation abnormalities

Poisons of caterpillars have different effects on inflammatory and coagulation systems. This is a case report of a 2-year-old child that accidentally came in contact with several caterpillars of the species Lonomia obliqua. At first, the patient's exams presented abnormal coagulation and decreased fibrinogen, but the patient did not evolve to active bleeding or acute renal failure. The patient received antilonomic serum 15 h after the accident and the treatment was repeated after another 12 h due to persistent alterations shown by the coagulation exams. The venom of L. obliqua has several substances that act on the coagulation and inflammatory systems. The event is characterized by a hemorrhagic syndrome with decreases in fibrinogen. L. obliqua Stuart-factor activator (Losac) and L. obliqua prothrombin activator protease (Lopap) are components that act with procoagulatory effects. The pro-inflammatory action occurs due to metalloproteases, hyaluronidases and other substances with inflammatory activity. Studies on caterpillar venom can give new perspectives on the treatment of cancer and other diseases that cause dysfunction of the extra-cellular matrix...