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OBJECTIVE: To describe the epidemiology, clinical characteristics and outcomes of children with cytomegalovirus (CMV) active infection in the pediatric intensive care unit (PICU) and to investigate risk factors for mortality. METHODS: This was a retrospective cohort study of patients who had CMV DNA detected in blood samples and/or tracheal aspirates by polymerase chain reaction (PCR) during stay at 2 PICUs of a university hospital. Suspected cases without etiological confirmation and patients with laboratory-confirmed CMV infection before PICU admission were excluded. RESULTS: Demographic, clinical and outcome data were collected from medical records. From January 1, 2012, to December 31, 2019, 4748 children were admitted to the PICUs. Thirty-five (0.74%; 95% CI 0.51%-1.02%) had laboratory-confirmed CMV active infection; 71.4% were immunocompromised and 11 (31.4%) died. Patients who died were older than those who survived (median age 65 vs. 5.5 months, respectively; P = 0.048), and they received antiviral therapy for a shorter time (median 12 vs. 23 days, respectively; P = 0.001). The main causa mortis was septic shock (82%) and in most deceased patients (73%) the last CMV PCR before death was positive. PELOD score >6 was a risk factor for death (RR 2.96; 95% CI 1.07-8.21). Viral load in blood had a poor ability for the prediction of death (area under the receiver operating characteristic curve 0.62; 95% CI 0.37-0.84). CONCLUSIONS: The incidence of CMV active infection during PICU stay was 0.74% in an upper-middle income country with a high CMV seroprevalence. PELOD score higher than 6 was a risk factor for death. No association was observed between CMV viral load and mortality.
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Infecções por Citomegalovirus , Citomegalovirus , Humanos , Criança , Idoso , Estudos Retrospectivos , Estado Terminal , Estudos Soroepidemiológicos , Infecções por Citomegalovirus/epidemiologiaRESUMO
OBJECTIVES: To investigate the impact of complex chronic conditions on the use of healthcare resources and hospitalization costs in a pediatric ward of a public tertiary referral university hospital in Brazil. METHODS: This is a longitudinal study with retrospective data collection. Overall, three one-year periods, separated by five-year intervals (2006, 2011, and 2016), were evaluated. Hospital costs were calculated in three systematic samples of 100 patients each, consisting of patients with and without complex chronic conditions in proportion to their participation in the studied year. RESULTS: Over the studied period, the hospital received 2,372 admissions from 2,172 patients. The proportion of hospitalized patients with complex chronic conditions increased from 13.3% in 2006 to 16.9% in 2016 as a result of a greater proportion of neurologically impaired children, which rose from 6.6% to 11.6% of the total number of patients in the same period. Patients' complexity also progressively increased, which greatly impacted the use of healthcare resources and costs, increasing by 11.6% from 2006 (R$1,300,879.20) to 2011 (R$1,452,359.71) and 9.4% from 2011 to 2016 (R$1,589,457.95). CONCLUSIONS: Hospitalizations of pediatric patients with complex chronic conditions increased from 2006 to 2016 in a Brazilian tertiary referral university hospital, associated with an important impact on hospital costs. Policies to reduce these costs in Brazil are greatly needed.
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Custos Hospitalares , Criança , Humanos , Centros de Atenção Terciária , Estudos Retrospectivos , Estudos Longitudinais , Brasil , Doença CrônicaRESUMO
Abstract Objective The proportion of children with complex chronic conditions is increasing in PICUs around the world. We determined the prevalence and functional status of children with complex chronic conditions in Brazilian PICUs during the COVID-19 pandemic. Methods The authors conducted a point prevalence cross-sectional study among fifteen Brazilian PICUs during the COVID-19 pandemic. The authors enrolled all children admitted to the participating PICUs with complex chronic conditions on three different days, four weeks apart, starting on April 4th, 2020. The authors recorded the patient's characteristics and functional status at admission and discharge days. Results During the 3 study days from March to June 2020, the authors enrolled 248 patients admitted to the 15 PICUs; 148 had CCC (prevalence of 59.7%). Patients had a median of 1 acute diagnosis and 2 chronic diagnoses. The use of resources/devices was extensive. The main mode of respiratory support was conventional mechanical ventilation. Most patients had a peripherally inserted central catheter (63.1%), followed by a central venous line (52.5%), and 33.3% had gastrostomy or/and tracheostomy. The functional status score was significantly better at discharge compared to admission day due to the respiratory status improvement. Conclusions The prevalence of children with CCC admitted to the Brazilian PICUs represented 59.7% of patients during the COVID-19 pandemic. The functional status of these children improved during hospitalization, mainly due to the respiratory component.
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BACKGROUND: We investigated the association of nutritional risk and inflammatory marker level with length of stay (LOS) in children and adolescents hospitalized for COVID-19 infection in two pediatric teaching hospitals in a developing country. METHODS: This was a cross-sectional analytical retrospective study performed in two pediatric hospitals. We included the data from all children and adolescents who were hospitalized with a SARS-CoV-2 infection between March and December 2020. Demographic, anthropometric, clinical, and laboratory data were extracted from electronic medical records. Nutritional risk was assessed according to the STRONGkids tool within 24 hours of admission and was categorized into two levels: ≥4 (high risk) and <4 (moderate or low risk). Means or medians were compared between nutritional risk groups using the t test and Mann-Whitney U test, respectively. The association of nutritional risk and inflammatory markers with LOS was estimated using the Kaplan-Meier method and log-rank test. Cox proportional-hazard and linear regression models were performed, and adjusted for sex, age, and respiratory symptoms. RESULTS: From a total of 73 patients, 20 (27.4%) had a STRONGkids score ≥4 at admission, which was associated with a longer LOS even after adjusting (ß = 12.30; 1.74-22.9 95% CI; P = 0.023). The same association was observed between LOS and all laboratory markers except for D-dimer. CONCLUSION: Among children and adolescents with COVID-19, a STRONGkids score ≥4 at admission, lower values of albumin, lymphocytes, and hemoglobin, and higher CRP values were associated with longer LOS.
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COVID-19 , Desnutrição , Adolescente , COVID-19/epidemiologia , Criança , Estudos Transversais , Hospitalização , Humanos , Tempo de Internação , Desnutrição/diagnóstico , Avaliação Nutricional , Estado Nutricional , Estudos Retrospectivos , SARS-CoV-2RESUMO
OBJECTIVE: The proportion of children with complex chronic conditions is increasing in PICUs around the world. We determined the prevalence and functional status of children with complex chronic conditions in Brazilian PICUs during the COVID-19 pandemic. METHODS: The authors conducted a point prevalence cross-sectional study among fifteen Brazilian PICUs during the COVID-19 pandemic. The authors enrolled all children admitted to the participating PICUs with complex chronic conditions on three different days, four weeks apart, starting on April 4th, 2020. The authors recorded the patient's characteristics and functional status at admission and discharge days. RESULTS: During the 3 study days from March to June 2020, the authors enrolled 248 patients admitted to the 15 PICUs; 148 had CCC (prevalence of 59.7%). Patients had a median of 1 acute diagnosis and 2 chronic diagnoses. The use of resources/devices was extensive. The main mode of respiratory support was conventional mechanical ventilation. Most patients had a peripherally inserted central catheter (63.1%), followed by a central venous line (52.5%), and 33.3% had gastrostomy or/and tracheostomy. The functional status score was significantly better at discharge compared to admission day due to the respiratory status improvement. CONCLUSIONS: The prevalence of children with CCC admitted to the Brazilian PICUs represented 59.7% of patients during the COVID-19 pandemic. The functional status of these children improved during hospitalization, mainly due to the respiratory component.
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COVID-19 , Brasil/epidemiologia , COVID-19/epidemiologia , Criança , Doença Crônica , Estudos Transversais , Estado Funcional , Humanos , Unidades de Terapia Intensiva Pediátrica , Pandemias , PrevalênciaRESUMO
ABSTRACT OBJECTIVES To investigate the impact of complex chronic conditions on the use of healthcare resources and hospitalization costs in a pediatric ward of a public tertiary referral university hospital in Brazil. METHODS This is a longitudinal study with retrospective data collection. Overall, three one-year periods, separated by five-year intervals (2006, 2011, and 2016), were evaluated. Hospital costs were calculated in three systematic samples of 100 patients each, consisting of patients with and without complex chronic conditions in proportion to their participation in the studied year. RESULTS Over the studied period, the hospital received 2,372 admissions from 2,172 patients. The proportion of hospitalized patients with complex chronic conditions increased from 13.3% in 2006 to 16.9% in 2016 as a result of a greater proportion of neurologically impaired children, which rose from 6.6% to 11.6% of the total number of patients in the same period. Patients' complexity also progressively increased, which greatly impacted the use of healthcare resources and costs, increasing by 11.6% from 2006 (R$1,300,879.20) to 2011 (R$1,452,359.71) and 9.4% from 2011 to 2016 (R$1,589,457.95). CONCLUSIONS Hospitalizations of pediatric patients with complex chronic conditions increased from 2006 to 2016 in a Brazilian tertiary referral university hospital, associated with an important impact on hospital costs. Policies to reduce these costs in Brazil are greatly needed.
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Humanos , Masculino , Feminino , Lactente , Pré-Escolar , Criança , Atenção Terciária à Saúde/tendências , Criança , Doença Crônica , Hospitalização/economiaRESUMO
Coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), became a pandemic in March 2020, affecting millions of people worldwide. However, COVID-19 in pediatric patients represents 1-5% of all cases, and the risk for developing severe disease and critical illness is much lower in children with COVID-19 than in adults. Multisystem inflammatory syndrome in children (MIS-C), a possible complication of COVID-19, has been described as a hyperinflammatory condition with multiorgan involvement similar to that in Kawasaki disease or toxic shock syndrome in children with evidence of SARS-CoV-2 infection. This review presents an update on the diagnostic methods for COVID-19, including reverse-transcriptase polymerase chain reaction (RT-PCR) tests, serology tests, and imaging, and summarizes the current recommendations for the management of the disease. Particular emphasis is placed on respiratory support, which includes noninvasive ventilation and invasive mechanical ventilation strategies according to lung compliance and pattern of lung injury. Pharmacological treatment, including pathogen-targeted drugs and host-directed therapies, has been addressed. The diagnostic criteria and management of MIS-C are also summarized.
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Tratamento Farmacológico da COVID-19 , COVID-19 , Síndrome de Resposta Inflamatória Sistêmica , COVID-19/terapia , Criança , Humanos , Pandemias , SARS-CoV-2 , Síndrome de Resposta Inflamatória Sistêmica/terapiaRESUMO
This review aims to verify the main epidemiologic, clinical, laboratory-related, and therapeutic aspects of coronavirus disease 2019 (COVID-19) in critically ill pediatric patients. An extensive review of the medical literature on COVID-19 was performed, mainly focusing on the critical care of pediatric patients, considering expert opinions and recent reports related to this new disease. Experts from a large Brazilian public university analyzed all recently published material to produce a report aiming to standardize the care of critically ill children and adolescents. The report emphasizes on the clinical presentations of the disease and ventilatory support in pediatric patients with COVID-19. It establishes a flowchart to guide health practitioners on triaging critical cases. COVID-19 is essentially an unknown clinical condition for the majority of pediatric intensive care professionals. Guidelines developed by experts can help all practitioners standardize their attitudes and improve the treatment of COVID-19.
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Betacoronavirus , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , COVID-19 , Teste para COVID-19 , Criança , Técnicas de Laboratório Clínico , Infecções por Coronavirus/metabolismo , Estado Terminal , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pandemias , Respiração com Pressão Positiva/métodos , Reação em Cadeia da Polimerase Via Transcriptase Reversa , SARS-CoV-2 , Síndrome Respiratória Aguda Grave/diagnóstico , Síndrome Respiratória Aguda Grave/terapia , Índice de Gravidade de Doença , Fatores de TempoRESUMO
BACKGROUND: Mechanisms influencing severity of acute lower respiratory infection (ALRI) in children are not established. We aimed to assess the role of inflammatory markers and respiratory viruses in ALRI severity. METHODS: Concentrations of interleukin(IL)-33, soluble suppression of tumorigenicity (sST)2, IL-1ß, tumor necrosis factor α, IL-4, IL-6 and IL- 8 and types of respiratory viruses were evaluated in children at the first and fifth days after hospital admission. Disease severity was defined as need for mechanical ventilation. RESULTS: Seventy-nine children <5 years-old were included; 33(41.8%) received mechanical ventilation. No associations between virus type, viral load or co-detections and severity of disease were observed. Detection of IL-33 and sST2 in nasopharyngeal aspirates (NPA) on admission were associated with higher risk for mechanical ventilation (RR = 2.89 and RR = 4.57, respectively). IL-6 and IL-8 concentrations were higher on Day 5 in mechanically ventilated children. IL-6 NPA concentrations decreased from Day 1 to Day 5 in children who did not receive mechanical ventilation. Increase in sST2 NPA concentrations from Day 1 to Day 5 was associated with longer hospital length of stay (p < 0.01). CONCLUSIONS: An exacerbated local activation of the IL-33/ST2 axis and persistently high sST2 concentrations over time were associated with severity of viral ALRI in children.
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Proteína 1 Semelhante a Receptor de Interleucina-1/metabolismo , Interleucina-33/metabolismo , Infecções por Vírus Respiratório Sincicial/metabolismo , Infecções por Vírus Respiratório Sincicial/patologia , Infecções Respiratórias/metabolismo , Infecções Respiratórias/patologia , Biomarcadores/metabolismo , Pré-Escolar , Feminino , Hospitalização , Humanos , Interleucina-6/metabolismo , Interleucina-8/metabolismo , Masculino , Estudos Prospectivos , Índice de Gravidade de DoençaRESUMO
Coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), became a pandemic in March 2020, affecting millions of people worldwide. However, COVID-19 in pediatric patients represents 1-5% of all cases, and the risk for developing severe disease and critical illness is much lower in children with COVID-19 than in adults. Multisystem inflammatory syndrome in children (MIS-C), a possible complication of COVID-19, has been described as a hyperinflammatory condition with multiorgan involvement similar to that in Kawasaki disease or toxic shock syndrome in children with evidence of SARS-CoV-2 infection. This review presents an update on the diagnostic methods for COVID-19, including reverse-transcriptase polymerase chain reaction (RT-PCR) tests, serology tests, and imaging, and summarizes the current recommendations for the management of the disease. Particular emphasis is placed on respiratory support, which includes noninvasive ventilation and invasive mechanical ventilation strategies according to lung compliance and pattern of lung injury. Pharmacological treatment, including pathogen-targeted drugs and host-directed therapies, has been addressed. The diagnostic criteria and management of MIS-C are also summarized.
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Humanos , Criança , Adulto , Pneumonia Viral/epidemiologia , Coronavirus , Betacoronavirus , COVID-19 , Síndrome de Resposta Inflamatória Sistêmica , Pandemias , SARS-CoV-2RESUMO
This review aims to verify the main epidemiologic, clinical, laboratory-related, and therapeutic aspects of coronavirus disease 2019 (COVID-19) in critically ill pediatric patients. An extensive review of the medical literature on COVID-19 was performed, mainly focusing on the critical care of pediatric patients, considering expert opinions and recent reports related to this new disease. Experts from a large Brazilian public university analyzed all recently published material to produce a report aiming to standardize the care of critically ill children and adolescents. The report emphasizes on the clinical presentations of the disease and ventilatory support in pediatric patients with COVID-19. It establishes a flowchart to guide health practitioners on triaging critical cases. COVID-19 is essentially an unknown clinical condition for the majority of pediatric intensive care professionals. Guidelines developed by experts can help all practitioners standardize their attitudes and improve the treatment of COVID-19.
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Humanos , Masculino , Feminino , Criança , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Betacoronavirus , Fatores de Tempo , Índice de Gravidade de Doença , Respiração com Pressão Positiva/métodos , Estado Terminal , Infecções por Coronavirus/metabolismo , Técnicas de Laboratório Clínico , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Síndrome Respiratória Aguda Grave/diagnóstico , Síndrome Respiratória Aguda Grave/terapia , Diagnóstico Diferencial , Pandemias , Teste para COVID-19 , SARS-CoV-2 , COVID-19RESUMO
BACKGROUND: Methylene blue (MB) has been advocated for the treatment of shock refractory to standard measures. MB is proposed to increase blood pressure in shock by interfering with guanylate cyclase and nitric oxide synthase (NOS) activity. Several studies have evaluated the vasoconstrictive and positive inotropic effects of MB in septic shock patients. However, there is a paucity of studies involving trauma patients. CASE REPORT: A 4-year-old boy was hit by a truck while riding his bicycle and was treated with fluid resuscitation at the emergency department and then taken to the operating room for damage-control surgery. He had liver, diaphragm, rectal, and thoracic injuries. At the pediatric intensive care unit (PICU), he remained hypotensive despite volume, dopamine, epinephrine, and norepinephrine infusion. A dose of 0.5 mg/kg of i.v. MB was administered. During the next 2 h after MB administration, we were able to wean him off norepinephrine, and doses of epinephrine and dopamine were reduced. Ultimately, he was discharged from the PICU 13 days later in good condition. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Trauma patients who have experienced bleeding and survived the initial insult are still at risk of dying from continuing systemic hypoperfusion and the resultant multiple organ dysfunctions. Use of a low dose of MB as an adjuvant to treat shock might improve survival of these patients.
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Azul de Metileno/farmacologia , Choque Hemorrágico/tratamento farmacológico , Pressão Sanguínea/efeitos dos fármacos , Pressão Sanguínea/fisiologia , Pré-Escolar , Humanos , Hipotensão/tratamento farmacológico , Unidades de Terapia Intensiva Pediátrica/organização & administração , Masculino , Azul de Metileno/farmacocinética , Azul de Metileno/uso terapêutico , Ferimentos e Lesões/tratamento farmacológicoRESUMO
RESUMO Introdução: a Simulação é uma técnica de ensino que vem ganhando grande aceitação para o ensino de habilidades e comportamento profissional em diversas áreas. Para contornar as limitações impostas pelo elevado custo dos materiais envolvidos e da necessidade de capacitação específica, as instituições de ensino superior (IES) têm implantado laboratórios específicos. A FMRP-USP completou recentemente a instalação de seu Laboratório de Simulação (LabSim) com os objetivos de: 1) Centralizar, facilitar, capacitar e coordenar as atividades didáticas que envolvam Simulação para os cursos oferecidos pela FMRP-USP; 2) Promover autoaprendizado entre alunos de graduação para consolidação e complementação do conteúdo fornecido em cursos regulares; 3) Desenvolver iniciativas inovadoras de capacitação e pesquisa em Simulação em Saúde. Objetivos: descrever o processo de implantação do LabSim para preservar a história da FMRP-USP; analisar este processo para traçar novas metas para seu desenvolvimento contínuo. Metodologia: o processo de desenvolvimento e fomento do LabSim é descrito em função cronológica, destacando-se as motivações para as decisões tomadas. Trata-se de estudo descritivo, embasado no resgate documental pertinente da FMRP-USP. Resultados: 1) A simulação é uma metodologia de ensino e não o simples uso de tecnologia, sendo necessário o investimento em capacitação de pessoal além da incorporação de tecnologia. 2) A estrutura física é um componente importante para explorar a metodologia em sua totalidade. Deve-se considerar os princípios de Flexibilidade, Aproveitamento de Espaço, Gerenciamento de fluxo, Conectividade e Imersão. Também deve ser considerada a realização de "benchmarking", avaliando as soluções de outros laboratórios para que possam ser contextualizadas à realidade da IES. 3) Deve-se individualizar a aquisição de novos equipamentos com base nas disciplinas que já utilizam a metodologia e a aquisição deve estar vinculada com capacitação. 4) Um dos potenciais dos simuladores atuais é o autoaprendizado, que pode maximizar o tempo de exposição e individualizar o "feedback". Conclusões: o LabSim da FMRP-USP deve ainda concretizar algumas de suas metas como a capacitação docente, o fortalecimento da inclusão de disciplinas da FMRP-USP buscando atuação multidisciplinar de acordo com as normas da Comissão de Graduação, o desenvolvimento de pesquisas na área de simulação e a projeção nacional e internacional do laboratório através de processos de acreditação. No entanto, frente às conquistas expostas, a implantação do LabSim é uma experiência exitosa e se encontra em franca evolução. (AU)
Introduction: simulation is a technique that has gained great acceptance for teaching skills and professional behavior in several areas. To overcome the limitations imposed by the high cost of the materials involved and the need for specific training, higher education institutions have implemented dedicated laboratories. Ribeirao Preto Medical School of University of Sao Paulo (RPMS-USP) has recently installed its Simulation Lab (LabSim) with the following goals: 1) To centralize, facilitate, train and coordinate didactic activities involving Simulation; 2) To promote self-directed learning among undergraduate students; 3) To develop research in Simulation in Healthcare. Objectives: to describe the process of LabSim implementation to preserve the RPMS-USP history; to analyze this process to outline new goals for its continued development. This is a descriptive study, based on revised historical documents. Methodology: the process of LabSim development is described in chronological order, highlighting the motivations for the decisions made. Results: 1) Simulation is a teaching methodology and not the simple use of technology, being necessary the training of personnel besides the incorporation of technology. 2) The physical structure is an important component to explore the methodology in its entirety. One should consider the principles of Flexibility, Space Utilization, Flow Management, Connectivity and Immersion. Consider Benchmarking to evaluate the solutions of other laboratories so you can contextualize them into your reality. 3) Individualize the addition of new simulator according to the disciplines that already use the methodology and link this acquisition with personnel training. 4) The self-learning potential of new simulators can maximize the exposure time and individualize the feedback. Conclusions: the RPMS-USP's LabSim future goals include teacher training, strengthening the inclusion of disciplines, seeking multidisciplinary action in accordance with the standards of the Undergraduate Committee, the development of research in the field of Simulation and the national and international projection of the laboratory through accreditation processes. Nevertheless, based on the evidence provided, the implementation of the LabSim is a very successful and evolving experience.(AU)
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Educação Médica , Simulação de Paciente , Treinamento por SimulaçãoRESUMO
: Cerebrovascular events associated with marijuana use have been reported previously. This association is plausible, but not well-established yet. A 14-year-old girl, long-term heavy cannabis user, presented with generalized tonic-clonic seizures and decreased level of consciousness a few hours after smoking cannabis. Brain magnetic resonance imaging showed multiple areas of acute, subacute and chronic ischemic lesions in the left frontal lobe, basal ganglia, and corpus callosum. History of other illicit drug use and other known causes of stroke were ruled out. Cannabis might cause stroke through direct effects on the cerebral blood circulation, orthostatic hypotension, vasculitis, vasospasm, and atrial fibrillation. Long-term daily use of marijuana in young people may cause serious damage to the cerebrovascular system.
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Cannabis/efeitos adversos , Infarto Cerebral/induzido quimicamente , Infarto Cerebral/diagnóstico por imagem , Fumar Maconha/efeitos adversos , Convulsões/induzido quimicamente , Adolescente , Feminino , HumanosRESUMO
We aimed to investigate the clinicopathological features of pertussis in children admitted to a tertiary-care university hospital in Brazil.This was a retrospective cohort study of all pediatric hospital admissions with pertussis from January 1, 2008 to December 31, 2014. We also reported the autopsy findings in children who died.Fifty-five patients admitted to the hospital over the study period had laboratorial confirmation of Bordetella pertussis infection, 17 (30.9%) needed pediatric intensive care unit (PICU) admission and 6 (10.9%) died. All patients who died were younger than 60 days old and unvaccinated for pertussis; 50% of them had coinfection with respiratory syncytial virus. Leukocyte count ≥40,000/mm at hospital admission was an independent risk factor for PICU admission. Mean heart rate during hospitalization ≥160âbpm was an independent risk factor for death. A cut-off point of 41,200âleukocytes/mm at hospital admission had sensitivity of 64.7% and specificity of 89.5% to predict PICU admission (area under the curve 0.75) and sensitivity of 100% and specificity of 81.6% to predict death (area under the curve 0.93). Autopsy showed medial thickening of small pulmonary arteries in 80% of patients who had pulmonary hypertension; intravascular aggregates of leukocytes or pulmonary thrombosis were not observed. Immunohistochemical staining of tissue samples obtained at autopsy identified B pertussis and respiratory syncytial virus in pulmonary and extra-pulmonary sites.Marked leukocytosis at presentation was associated with morbidity and mortality in children hospitalized with pertussis. Implementation of preventive strategies is crucial to diminish the incidence of the disease, especially in young unimmunized infants.
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Coqueluche/mortalidade , Autopsia , Brasil/epidemiologia , Feminino , Hospitalização , Hospitais Pediátricos , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Pediátrica , Contagem de Leucócitos , Masculino , Estudos Retrospectivos , Fatores de Risco , Coqueluche/epidemiologiaRESUMO
OBJECTIVES: To test the tolerance and safety of an alveolar recruitment manoeuvre performed in the immediate postoperative period of corrective open heart surgery in children with congenital heart disease associated with excessive pulmonary blood flow and pulmonary arterial hypertension due to left-to-right shunt. METHODS: Ten infants aged 1-24 months with congenital heart disease associated with excessive pulmonary blood flow and pulmonary artery hypertension (mean pulmonary artery pressure ≥ 25 mmHg) were evaluated. The alveolar recruitment manoeuvre was performed in the operating theatre right after skin closure, and consisted of three successive stages of 30 s each, intercalated by a 1-min interval of baseline ventilation. Positive end-expiratory pressure was set to 10 cmH2O in the first stage and to 15 cmH2O in the two last ones, while the peak inspiratory pressure was kept at to 30 cmH2O in the first stage and at 35 cmH2O in the latter ones. Haemodynamic and respiratory variables were recorded. RESULTS: There was a slight but significant increase in mean pulmonary artery pressure from baseline to Stage 3 (P = 0.0009), as well as between Stages 1 and 2 (P = 0.0001), and 1 and 3 (P = 0.001), with no significant difference between Stages 2 and 3 (P = 0.06). Upon completion of the third stage, there were significant increases in arterial haemoglobin saturation as measured by pulse oximetry (P = 0.0009), arterial blood partial pressure of oxygen (P = 0.04), venous blood oxygen saturation of haemoglobin (P = 0.03) and arterial oxygen partial pressure over inspired oxygen fraction ratio (P = 0.04). A significant reduction in arterial blood partial pressure of carbon dioxide (P = 0.01) and in end tidal carbon dioxide also occurred (P = 0.009). The manoeuvre was well tolerated and besides a slight and transitory elevation in mean pulmonary artery, no other adverse haemodynamic or ventilatory effect was elicited. CONCLUSIONS: The alveolar recruitment manoeuvre seemed to be safe and well tolerated immediately after open heart surgery in infants liable to pulmonary hypertensive crises.
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Pressão Arterial , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Cardiopatias Congênitas/cirurgia , Hipertensão Pulmonar/etiologia , Respiração com Pressão Positiva/métodos , Alvéolos Pulmonares/fisiopatologia , Artéria Pulmonar/fisiopatologia , Circulação Pulmonar , Dióxido de Carbono/sangue , Pré-Escolar , Feminino , Cardiopatias Congênitas/complicações , Cardiopatias Congênitas/fisiopatologia , Humanos , Hipertensão Pulmonar/sangue , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/fisiopatologia , Lactente , Masculino , Oxigênio/sangue , Pressão Parcial , Projetos Piloto , Respiração com Pressão Positiva/efeitos adversos , Estudos Prospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: To investigate whether the development of hypokalemia in patients with diabetic ketoacidosis (DKA) treated in the pediatric critical care unit (PCCU) could be caused by increased potassium (K(+)) excretion and its association with insulin treatment. STUDY DESIGN: In this prospective observational study of patients with DKA admitted to the PCCU, blood and timed urine samples were collected for measurement of sodium (Na(+)), K(+), and creatinine concentrations and for calculations of Na(+) and K(+) balances. K(+) excretion rate was expressed as urine K(+)-to-creatinine ratio and fractional excretion of K(+). RESULTS: Of 31 patients, 25 (81%) developed hypokalemia (plasma K(+) concentration <3.5 mmol/L) in the PCCU at a median time of 24 hours after therapy began. At nadir plasma K(+) concentration, urine K(+)-to-creatinine ratio and fractional excretion of K(+) were greater in patients who developed hypokalemia compared with those without hypokalemia (19.8 vs 6.7, P = .04; and 31.3% vs 9.4%, P = .004, respectively). Patients in the hypokalemia group received a continuous infusion of intravenous insulin for a longer time (36.5 vs 20 hours, P = .015) and greater amount of Na(+) (19.4 vs 12.8 mmol/kg, P = .02). At peak kaliuresis, insulin dose was higher in the hypokalemia group (median 0.07, range 0-0.24 vs median 0.025, range 0-0.05 IU/kg; P = .01), and there was a significant correlation between K(+) and Na(+) excretion (r = 0.67, P < .0001). CONCLUSIONS: Hypokalemia was a delayed complication of DKA treatment in the PCCU, associated with high K(+) and Na(+) excretion rates and a prolonged infusion of high doses of insulin.
Assuntos
Cetoacidose Diabética/tratamento farmacológico , Hipopotassemia/etiologia , Insulina/efeitos adversos , Adolescente , Aldosterona/farmacologia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Insulina/farmacologia , Insulina/uso terapêutico , Masculino , Estudos ProspectivosRESUMO
Este texto apresenta uma abordagem clínica dos distúrbios do equilíbrio ácido-base. A interpretaçãoapropriada do estado ácido-base requer o conhecimento do quadro clínico integrado aos resultadoslaboratoriais. O valor do pH determina o distúrbio primário: acidose metabólica ou respiratória, se o pHfor menor que 7,40; alcalose metabólica ou respiratória, se o pH for maior que 7,40. Se o ânion gap formaior que 20 mEq/L, há acidose metabólica, independente dos valores do pH ou da concentraçãoplasmática de bicarbonato. A ausência da resposta compensatória esperada a determinado distúrbioprimário indica a presença de um distúrbio misto.
This paper presents a clinical approach to disorders of acid-base balance. A proper interpretation of theacid-base status requires knowledge of the clinical setting integrated with laboratory results. The pHvalue determines the primary disorder: metabolic or respiratory acidosis, if the pH is less than 7.40;metabolic or respiratory alkalosis, if the pH is greater than 7.40. If the anion gap is greater than 20 mEq/L, a metabolic acidosis is present regardless of the pH value or plasma bicarbonate concentration.Absence of the expected compensatory response to a primary disorder indicates the presence of amixed disorder.
Assuntos
Humanos , Masculino , Feminino , Acidose , Alcalose , Cetose , Equilíbrio Ácido-BaseRESUMO
Este texto aborda a avaliação inicial e o manejo sistematizado da criança vítima de trauma, assim comoas particularidades da ressuscitação no trauma crânio-encefálico.
This paper discusses the initial assessment and systematic management of the pediatric trauma victim,as well as the peculiarities of resuscitation of head injured children.
Assuntos
Humanos , Masculino , Feminino , Criança , Traumatismo Múltiplo/diagnóstico , Traumatismo Múltiplo/terapia , Traumatismos Craniocerebrais/terapiaRESUMO
Este texto apresenta uma revisão da definição, classificação, fisiopatologia e tratamento inicial dos diversos tipos de choque na criança. O reconhecimento precoce e o tratamento agressivo do choque em tempo oportuno são essenciais à prevenção da parada cardiorrespiratória e à melhora do desfecho
This paper presents a review of the definition, classification, pathophysiology and initial management of the different types of shock in children. Early recognition and aggressive treatment of shock in a timely manner are essential to the prevention of cardiopulmonary arrest and out come improvement.