Adherence to Pediatric Sepsis Treatment Recommendations at Emergency Departments: A Multicenter Study in Latin America.

OBJECTIVE: Sepsis is one of the most urgent health care issues worldwide. Guidelines for early identification and treatment are essential to decrease sepsis-related mortality. Our aim was to collect data on the epidemiology of pediatric septic shock (PSS) from the emergency department (PED) and to assess adherence to recommendations for its management in the first hour. METHODS: A multicenter, prospective, cross-sectional study was conducted evaluating children with PSS seen at the PED of 10 tertiary-care centers in Latin America. Adherence to guidelines was evaluated. RESULTS: We included 219 patients (median age, 3.7 years); 43% had comorbidities, 31% risk factors for developing sepsis, 74% clinical signs of "cold shock," and 13% of "warm shock," 22% had hypotension on admission. Consciousness was impaired in 55%. A peripheral line was used as initial access in 78% (median placement time, 10 minutes). Fluid and antibiotics infusion was achieved within a median time of 30 minutes (interquartile range [IQR], 20-60 minutes) and 40 minutes (IQR, 20-60 minutes), respectively; 40% responded inadequately to fluids requiring vasoactive drugs (median time at initiation, 60 minutes; IQR, 30-135 minutes). Delay to vasoactive drug infusion was significantly longer when a central line was placed compared to a peripheral line (median time, 133 minutes [59-278 minutes] vs 42 minutes [30-70 minutes], respectively [ P < 0.001]). Adherence to all treatment goals was achieved in 13%. Mortality was 10%. An association between mortality and hypotension on admission was found (26.1% with hypotension vs 4.9% without; P < 0.001). CONCLUSIONS: We found poor adherence to the international recommendations for the treatment of PSS in the first hour at the PED in third-level hospitals in Latin America.

OBJECTIVE: Sepsis is one of the most urgent health care issues worldwide. Guidelines for early identification and treatment are essential to decrease sepsis-related mortality. Our aim was to collect data on the epidemiology of pediatric septic shock (PSS) from the emergency department (PED) and to assess adherence to recommendations for its management in the first hour. METHODS: A multicenter, prospective, cross-sectional study was conducted evaluating children with PSS seen at the PED of 10 tertiary-care centers in Latin America. Adherence to guidelines was evaluated. RESULTS: We included 219 patients (median age, 3.7 years); 43% had comorbidities, 31% risk factors for developing sepsis, 74% clinical signs of "cold shock," and 13% of "warm shock," 22% had hypotension on admission. Consciousness was impaired in 55%. A peripheral line was used as initial access in 78% (median placement time, 10 minutes). Fluid and antibiotics infusion was achieved within a median time of 30 minutes (interquartile range [IQR], 20­60 minutes) and 40 minutes (IQR, 20­60 minutes), respectively; 40% responded inadequately to fluids requiring vasoactive drugs (median time at initiation, 60 minutes; IQR, 30­135 minutes). Delay to vasoactive drug infusion was significantly longer when a central line was placed compared to a peripheral line (median time, 133 minutes [59­278 minutes] vs 42 minutes [30­70 minutes], respectively [ P < 0.001]). Adherence to all treatment goals was achieved in 13%. Mortality was 10%. An association between mortality and hypotension on admission was found (26.1% with hypotension vs 4.9% without; P < 0.001). CONCLUSIONS: We found poor adherence to the international recommendations for the treatment of PSS in the first hour at the PED in third-level hospitals in Latin America.

Decision-Making Process for the Implementation of the Child Therapeutic Support Limitation Plan: Nurses' Experiences.

Aim: To present nurses' experience in the decision-making process for implementing a therapeutic support limitation plan in the PICU. Method: Qualitative exploratory research was conducted through semi-structured interviews with 25 intensive care nurses from January to June 2019. The textual corpus was then submitted for content analysis. Results: Two categories emerged: the nurse and decision-making process of the TSLP and ambivalence of the participating nurse's feelings in implementing the TSLP. These categories are interrelated in that the decision-making process mobilizes the ambivalence of the participating nurses' feelings. Final considerations and implications for practice: The starting point of communication between the health teams consists of acquiring information about the concerned child's end-of-life care plan with no prospect of cure and with some form of therapeutic limit admitted to the PICU. Therefore, this study helps to map possible research gaps on the topic and mobilize researchers to build educational materials, protocols, and tools for comprehensive care that can be used by nurses when faced with ethical dilemma, such as decision-making through TSLP.

Empirical evaluation of an architectural technical debt index in the context of the Apache and ONAP ecosystems.

Background: Architectural Technical Debt (ATD) in a software-intensive system denotes architectural design choices which, while being suitable or even optimal when adopted, lower the maintainability and evolvability of the system in the long term, hindering future development activities. Despite the growing research interest in ATD, how to gain an informative and encompassing viewpoint of the ATD present in a software-intensive system is still an open problem. Objective: In this study, we evaluate ATDx, a data-driven approach providing an overview of the ATD present in a software-intensive system. The approach, based on the analysis of a software portfolio, calculates severity levels of architectural rule violations via a clustering algorithm, and aggregates results into different ATD dimensions. Method: To evaluate ATDx, we implement an instance of the approach based on SonarQube, and run the analysis on the Apache and ONAP ecosystems. The analysis results are then shared with the portfolio contributors, who are invited to participate in an online survey designed to evaluate the representativeness and actionability of the approach. Results: The survey results confirm the representativeness of the ATDx, in terms of both the ATDx analysis results and the used architectural technical debt dimensions. Results also showed the actionability of the approach, although to a lower extent when compared to the ATDx representativeness, with usage scenarios including refactoring, code review, communication, and ATD evolution analysis. Conclusions: With ATDx, we strive for the establishment of a sound, comprehensive, and intuitive architectural view of the ATD identifiable via source code analysis. The collected results are promising, and display both the representativeness and actionability of the approach. As future work, we plan to consolidate the approach via further empirical experimentation, by considering other development contexts (e.g., proprietary portfolios and other source code analysis tools), and enhancing the ATDx report capabilities.

Risk factors for severe COVID-19 infection in Brazilian children.

The aim of this study was to describe the epidemiological characteristics and clinical outcome of children hospitalized with COVID-19 and identify the risk factors for severe disease. All hospital admissions of pediatric patients between March and December 2020 in the southern region of Brazil were reviewed and the patients positive for RT-PCR for SARS-CoV-2 were identified. This region encompasses a population of over 2.8 million children and adolescents. Data were extracted from a national database that includes all cases of severe acute respiratory syndrome requiring hospitalization in Brazil. A total of 288 hospitalizations (51.3% female) with a median age of 3 years (interquartile range 0-12 years) were identified. Of these, 38.9% had chronic medical conditions, 55.6% required some form of supplementary oxygen, and 30.2% were admitted to an intensive care unit. There were 17 deaths (5.9%) related to COVID-19. Age less than 30 days was significantly associated with increased odds of critical illness (OR 9.52, 95% CI 3.01-30.08), as well as the presence of one chronic condition (OR 5.08 95%CI 2.78-9.33) or two or more chronic conditions (OR 6.60, 95% CI 3.17-13.74). Conclusion: Age under 30 days old and presence of chronic conditions were strongly associated with unfavorable outcomes in Brazilian children with SARS-CoV-2 infection. These findings could help local public health authorities to develop specific policies to protect this more vulnerable group of children.

Use of magnesium sulfate in continuous infusion in patients with severe acute asthma, in a pediatric emergency room.

INTRODUCTION: Asthma is a chronic disease, of high prevalence, with important morbidity and that can lead to death in childhood. The use of intravenous magnesium sulfate has been indicated in cases refractory to the initial management with inhaled bronchodilators and corticosteroids. OBJECTIVE: To evaluate the use of magnesium sulfate in continuous infusion (50 mg/kg/h in 4 h) in children with severe acute asthma in a pediatric emergency room. LOCATION: Ten-bed general pediatric emergency room, university hospital, tertiary, in southern Brazil. PATIENTS: All children over 2 years old with severe acute asthma refractory to the initial treatment who received a continuous infusion of magnesium sulfate at a dose of 50 mg/kg/h in 4 h, from April 2017 to October 2019. CONCLUSION: Based on this study, the use of continuous intravenous magnesium sulfate proved to be well tolerated, leading to improved respiratory status, and can be considered as a satisfactory adjunctive therapy in the management of severe acute asthma.

Impact of A/H1N1 influenza in children at a Brazilian University Hospital.

BACKGROUND: A/H1N1 influenza is a viral disease that affects a significant part of the population mainly in winter, leading to increased number of medical consultations, hospitalizations and consequently care spending in emergency. METHODS: This is a case-series retrospective study, involving patients admitted to a tertiary hospital in southern Brazil in 2016 with a clinical diagnosis of acute respiratory infection of the influenza type and laboratory confirmation of influenza A/H1N1. RESULTS: 64 patients were included, mostly male, median age of 48.3 months. Chronic underlying diseases were found in 73% of the patients, and these patients evolved to the most unfavorable outcome. About vaccination, of the 57 patients with an age range for vaccination, only 28% had complete vaccination coverage. The main clinical manifestations found in the included patients were fever, cough, intercostal indrawing, wheezing, tachypnea and pulmonary crackles. These patients were mainly followed-up with laboratory tests and chest X-ray. Consolidation was evident in 43% of patients followed by interstitial infiltrate in 33%. A five-day course of neuraminidase inhibitor was prescribed for all patients, as recommended by the WHO, but due to the complications, 73% of the patients required antibiotic therapy, and 61% oxygen therapy. The majority of patients had a favorable outcome, but 11 required intensive care and one died. CONCLUSIONS: A/H1N1 influenza persists as an important public health problem, mainly due to high morbidity and hospitalization rates. It is important to identify patients with A/H1N1 influenza and clinical situations with higher risk of complications. Through this study, it is possible to analyze the characteristics of pediatric patients with A/H1N1 influenza and mainly to emphasize assistance of populations with comorbidities, since they present higher rates of complications and death.

Impact of A/H1N1 influenza in children at a Brazilian University Hospital

ABSTRACT Background A/H1N1 influenza is a viral disease that affects a significant part of the population mainly in winter, leading to increased number of medical consultations, hospitalizations and consequently care spending in emergency. Methods This is a case-series retrospective study, involving patients admitted to a tertiary hospital in southern Brazil in 2016 with a clinical diagnosis of acute respiratory infection of the influenza type and laboratory confirmation of influenza A/H1N1. Results 64 patients were included, mostly male, median age of 48.3 months. Chronic underlying diseases were found in 73% of the patients, and these patients evolved to the most unfavorable outcome. About vaccination, of the 57 patients with an age range for vaccination, only 28% had complete vaccination coverage. The main clinical manifestations found in the included patients were fever, cough, intercostal indrawing, wheezing, tachypnea and pulmonary crackles. These patients were mainly followed-up with laboratory tests and chest X-ray. Consolidation was evident in 43% of patients followed by interstitial infiltrate in 33%. A five-day course of neuraminidase inhibitor was prescribed for all patients, as recommended by the WHO, but due to the complications, 73% of the patients required antibiotic therapy, and 61% oxygen therapy. The majority of patients had a favorable outcome, but 11 required intensive care and one died. Conclusions A/H1N1 influenza persists as an important public health problem, mainly due to high morbidity and hospitalization rates. It is important to identify patients with A/H1N1 influenza and clinical situations with higher risk of complications. Through this study, it is possible to analyze the characteristics of pediatric patients with A/H1N1 influenza and mainly to emphasize assistance of populations with comorbidities, since they present higher rates of complications and death.

Pediatric emergency in Brazil: the consolidation of an area in the pediatric field.

OBJECTIVE: The aim of this study was to present a review on the evolution, development, and consolidation of the pediatric emergency abroad and in Brazil, as well as to discuss the residency program in this key area for pediatricians. DATA SOURCES: This was a narrative review, in which the authors used pre-selected documents utilized as the minimum requirements for the Residency Program in Pediatric Emergency Medicine and articles selected by interest for the theme development, at the SciELO and Medline databases, between 2000 and 2017. DATA SYNTHESIS: The historical antecedents and the initial evolution of pediatric emergency in Brazil, as well as several challenges were described, regarding the organization, the size, the training of professionals, and also the regulation of the professional practice in this new specialty. Additionally, a new pediatric emergency residency program to be implemented in Brazil is described. CONCLUSIONS: Pediatric emergency training will be a powerful stimulus to attract talented individuals, to establish them in this key area of medicine, where they can exercise their leadership by promoting care qualification, research, and teaching, as well as acting decisively in their management.

Pediatric emergency in Brazil: the consolidation of an area in the pediatric field / Emergência pediátrica no Brasil: a consolidação da área de atuação para o pediatra

Abstract Objective: The aim of this study was to present a review on the evolution, development, and consolidation of the pediatric emergency abroad and in Brazil, as well as to discuss the residency program in this key area for pediatricians. Data sources: This was a narrative review, in which the authors used pre-selected documents utilized as the minimum requirements for the Residency Program in Pediatric Emergency Medicine and articles selected by interest for the theme development, at the SciELO and Medline databases, between 2000 and 2017. Data synthesis: The historical antecedents and the initial evolution of pediatric emergency in Brazil, as well as several challenges were described, regarding the organization, the size, the training of professionals, and also the regulation of the professional practice in this new specialty. Additionally, a new pediatric emergency residency program to be implemented in Brazil is described. Conclusions: Pediatric emergency training will be a powerful stimulus to attract talented individuals, to establish them in this key area of medicine, where they can exercise their leadership by promoting care qualification, research, and teaching, as well as acting decisively in their management.

Resumo Objetivo: Apresentar uma revisão sobre a evolução, o desenvolvimento e a consolidação da emergência pediátrica no exterior e no Brasil, assim como discutir o programa de residência nessa importante área de atuação para o pediatra. Fontes dos dados: Revisão do tipo narrativa, em que os autores usaram documentos pré-selecionados empregados nos requisitos mínimos para o programa em Residência de Medicina de Emergência Pediátrica e para artigos selecionados por interesse para desenvolvimento do tema usaram as bases de dados SciELO e Medline entre 2000 e 2017. Síntese dos dados: Foram descritos os antecedentes históricos e a evolução inicial da emergência pediátrica no Brasil e diversos desafios, na organização, no dimensionamento, na formação de profissionais e, também, na regulamentação do exercício profissional dessa nova especialidade. Também se descreve um novo programa de residência em emergência pediátrica a ser implantado no Brasil Conclusões: A formação em emergência pediátrica será um poderoso estímulo para atrair indivíduos talentosos, fixá-los nessa importante área da medicina, na qual poderão exercer sua liderança e promover qualificação na assistência, na pesquisa e no ensino, assim como atuar decisivamente no seu gerenciamento.

Símbolo e/ou representação: um mapeamento metapsicológico / Símbolo y/o representación: un mapeo metapsicológico / Symbol and/or representation: a metapsychological mapping

Os autores discutem os conceitos de representação e simbolização inseridos em seus contextos metapsicológicos. Assim, exploram os modelos psicanalíticos freudiano, kleiniano e bioniano, respectivamente, buscando compreender a origem lógica desses conceitos, contrastá-los, ver seus desenvolvimentos e discutir as implicações teóricas, clínicas e técnicas. No âmbito freudiano, apoiam-se em Freud, Garcia-Roza, Laplanche e Pontalis, Green e Botella e Botella; no campo kleiniano utilizam Klein, Jones, Ferenczi, Susan Isaacs; e, finalmente, na esfera bioniana, Meltzer, Bion, Ogden e Ferro. Por fim, descrevem algumas de suas repercussões na clínica e técnica psicanalíticas

The authors discuss the concepts of representation and symbolization inserted in their metapsychological contexts. This way, they explore the freudian, kleinian and bionion psychoanalytic model respectively, searching to understand the logic origin of these concepts, as well as contrast them, observe their development and discuss the clinical, theoretical and technical implication. In the freudian scope, the authors rely on Freud, Garcia-Roza, Laplanche e Pontalis, Green and Botella & Botella; in the kleinian field, they make use of Klein, Jones, Ferenczi, Susan Isaacs; and finally, in the bionion perspective, Meltzer, Bion, Ogden and Ferro. Lastly, it is described some of their repercussion in the psychoanalytic clinic and Technique

Los autores discuten los conceptos de representación y simbolización insertados en sus contextos metapsicológicos. Así exploran los modelos psicoanalíticos freudiano, kleiniano y bioniano, respectivamente, buscando comprender el origen lógico de estos conceptos, contrastarlos, ver sus desarrollos y discutir las implicaciones teóricas, clínicas y técnicas. En el ámbito freudiano se apoyan en Freud, García-Roza, Laplanche y Pontalis, Green y Botella y Botella; en el campo kleiniano utilizan a Klein, Jones, Ferenczi, SusanIsaacs; y, finalmente, en la esfera bioniana, Meltzer, Bion, Ogden y Ferro. Por último, describen algunas de sus representaciones en la clínica y en la técnica psicoanalítica

Parents' perspectives on the deaths of their children in two Brazilian paediatric intensive care units.

OBJECTIVES: To evaluate the quality of care offered to terminally ill children and their families in the last days of life in two Brazilian Paediatric Intensive Care Units (PICUs) from the parents' perspectives. METHODS: This was a qualitative, exploratory study. Parents of a child who had died in one of the PICUs 6-12 months previously were invited to take part in two interviews: a private meeting with the PICU assistant physician who cared for their child, to discuss and review any outstanding issues related to the diagnosis, treatment, and prognosis, and a recorded interview with a researcher who was not involved in the child's treatment. Data from the interviews with the researcher were posteriorly grouped in categories according to recurrent terms. RESULTS: Six categories emerged, three of which are reported here. The quality of communication was low; the medical staff frequently used technical terms, limiting understanding. Parental participation in the decision-making process was scarce; decisions were based on the medical perspective. Finally, families reported uncompassionate attitudes from the medical staff and excessive technology in the final moments surrounding the child's death, although nurses were highly involved with palliative care measures and demonstrated sympathetic and supportive postures. CONCLUSION: The interviews uncovered deficiencies in the care provided to parents in the PICUs, indicating a need for changes in practice.

"O lado bom da vida": um olhar psicanalítico / Silver Linings Playbook - a psychoanalytical view

Trata-se de uma resenha do filme "O lado bom da vida", avaliado pela visão da psicanálise.

Nurses' participation in the end-of-life process in two paediatric intensive care units in Brazil.

The aim of this study was to evaluate the medical and nursing care provided to children in the last 24 hours of life in two Brazilian paediatric intensive care units and analyse the nurses' participation in the decision-making process for life support limitation (LSL). The study was based on an analysis of the patients' medical charts, looking at the medical and nursing care provided in the last 24 hours of life during a 6-month period in the two units, and on semi-structured interviews with 20 nurses to evaluate their participation in LSL decisions. The children were classified into two groups: those who were to receive full cardiopulmonary resuscitation (CPR) and a non-CPR group. A total of 34 deaths occurred during the study period. Of these, 17 (50%) were children that had been in the non-CPR group; there were only 10 recorded LSL plans in their medical charts. In the interviews, only 30% of the nurses mentioned active participation in LSL decisions. In conclusion, the paediatric intensive care nurses in these two Brazilian units did not participate much in LSL decisions, and the care offered in the last hours of life to children with terminal and irreversible illness was not primarily directed toward comfort and alleviating suffering.

II Fórum do "Grupo de Estudos do Fim da Vida do Cone Sul": definições, recomendações e ações integradas para cuidados paliativos na unidade de terapia intensiva de adultos e pediátrica / II Forum of the "End of Life Study Group of the Southern Cone of America": palliative care definitions, recommendations and integrated actions for intensive care and pediatric intensive care units

Cuidado paliativo é uma forma de abordagem que visa a melhoria da qualidade de vida de pacientes e seus familiares que enfrentam doenças ameaçadoras à vida, através da prevenção, da identificação e do tratamento precoces dos sintomas de sofrimento físico, psíquico, espiritual e social. Todo paciente criticamente enfermo deve receber cuidados paliativos desde a internação, o que torna de primordial importância a educação e o treinamento dos intensivistas para a implantação destes cuidados nas unidades de terapia intensiva, tanto para atendimento de adultos como pediátrico. Em continuidade aos planos da Câmara Técnica de Terminalidade e Cuidados Paliativos da Associação de Medicina Intensiva Brasileira e, levando em consideração o conceito previamente apontado, foi realizado em outubro de 2010, durante o Congresso Brasileiro de Terapia Intensiva, o IIºForum do "Grupo de Estudos do Fim da Vida do Cone Sul", com o objetivo de elaborar recomendações pertinentes aos cuidados paliativos a serem prestados aos pacientes críticamente enfermos.

Palliative care is aimed to improve the quality of life of both patients and their family members during the course of life-threatening diseases through the prevention, early identification and treatment of the symptoms of physical, psychological, spiritual and social suffering. Palliative care should be provided to every critically ill patient; this requirement renders the training of intensive care practitioners and education initiatives fundamental. Continuing the Technical Council on End of Life and Palliative Care of the Brazilian Association of Intensive Medicine activities and considering previously established concepts, the II Forum of the End of Life Study Group of the Southern Cone of America was conducted in October 2010. The forum aimed to develop palliative care recommendations for critically ill patients.

Dilemas e dificuldades envolvendo decisões de final de vida e oferta de cuidados paliativos em pediatria / Dilemmas and difficulties involving end-of-life decisions and palliative care in children

O objetivo deste artigo é discutir os principais dilemas e dificuldades nas decisões de final de vida de crianças com doença irreversível em fase terminal, assim como, propor uma sequência racional para a instituição de cuidados paliativos nesse grupo pediátrico. Foi realizada busca na base de dados Medline e Lilacs dos artigos publicados nos últimos anos tendo como palavras chaves "final de vida", "cuidados paliativos", "morte" e "doença terminal". Foram selecionados os mais relevantes e aqueles envolvendo crianças, os quais foram analisados em conjunto com publicações prévias dos próprios autores sobre o assunto. O atual código de ética médica brasileiro (2010) é analisado em relação às práticas de final de vida e cuidados paliativos ofertados a pacientes com doença fase terminal e irreversível. A falta de conhecimento e treinamento aliado a receios legais são os principais motivos para que as decisões de final de vida em crianças com doença em fase terminal sejam centradas na opinião médica e com escassa participação da família. O atual código de ética médica dá pleno suporte para essas decisões desde que tomadas de forma consensual com participação da família. O diálogo franco com familiares em relação ao diagnóstico, prognóstico, terapêutica e cuidados paliativos devem ser estabelecidos gradualmente, para definir a melhor estratégia que atenda às necessidades da criança em fase final de vida. O tratamento centrado no bem estar da criança com pleno envolvimento da família é a base para o sucesso do tratamento paliativo em crianças em final de vida.

This review discusses the main dilemmas and difficulties related to end-of-life decision's in children with terminal and irreversible diseases and propose a rational sequence for delivering palliative care to this patients' group. The Medline and Lilacs databases were searched using the terms 'end of life', 'palliative care', 'death' and 'terminal disease' for articles published in recent years. The most relevant articles and those enrolling pediatric patients were selected and compared to previous authors' studies in this field. The current Brazilian Medical Ethics Code (2010) was analyzed regarding end-oflife practices and palliative care for terminal patients. Lack of knowledge, insufficient specific training, and legal concerns are the main reasons why end-of-life decisions in terminal children are based on medical opinion with scarce family participation. The current Brazilian Medical Ethics Code (2010) fully supports end-of-life decisions made consensually with active family participation. Honest dialogue with the family regarding diagnostic, prognostic, therapeutic and palliative care measures should be established gradually to identify the best strategy to meet the child's end-of-life needs. Treatment focused on the child's welfare combined with the family's participation is the basis for successful palliative care of children with terminal diseases.

II Forum of the "End of Life Study Group of the Southern Cone of America": palliative care definitions, recommendations and integrated actions for intensive care and pediatric intensive care units. / II Fórum do "Grupo de Estudos do Fim da Vida do Cone Sul": definições, recomendações e ações integradas para cuidados paliativos na unidade de terapia intensiva de adultos e pediátrica.

Palliative care is aimed to improve the quality of life of both patients and their family members during the course of life-threatening diseases through the prevention, early identification and treatment of the symptoms of physical, psychological, spiritual and social suffering. Palliative care should be provided to every critically ill patient; this requirement renders the training of intensive care practitioners and education initiatives fundamental. Continuing the Technical Council on End of Life and Palliative Care of the Brazilian Association of Intensive Medicine activities and considering previously established concepts, the II Forum of the End of Life Study Group of the Southern Cone of America was conducted in October 2010. The forum aimed to develop palliative care recommendations for critically ill patients.

Dilemmas and difficulties involving end-of-life decisions and palliative care in children. / Dilemas e dificuldades envolvendo decisões de final de vida e oferta de cuidados paliativos em pediatria.

This review discusses the main dilemmas and difficulties related to end-of-life decision's in children with terminal and irreversible diseases and propose a rational sequence for delivering palliative care to this patients' group. The Medline and Lilacs databases were searched using the terms 'end of life', 'palliative care', 'death' and 'terminal disease' for articles published in recent years. The most relevant articles and those enrolling pediatric patients were selected and compared to previous authors' studies in this field. The current Brazilian Medical Ethics Code (2010) was analyzed regarding end-oflife practices and palliative care for terminal patients. Lack of knowledge, insufficient specific training, and legal concerns are the main reasons why end-of-life decisions in terminal children are based on medical opinion with scarce family participation. The current Brazilian Medical Ethics Code (2010) fully supports end-of-life decisions made consensually with active family participation. Honest dialogue with the family regarding diagnostic, prognostic, therapeutic and palliative care measures should be established gradually to identify the best strategy to meet the child's end-of-life needs. Treatment focused on the child's welfare combined with the family's participation is the basis for successful palliative care of children with terminal diseases.

Percepção dos profissionais sobre o tratamento no fim da vida, nas unidades de terapia intensiva da Argentina, Brasil e Uruguai / Perceptions about end of life treatment in Argentina, Brazil and Uruguay intensive care units

OBJETIVO: Avaliar as condutas tomadas nas Unidades de Terapia Intensiva (UTI) com os pacientes críticos terminais. MÉTODOS: Os membros do grupo de estudo do final da vida das sociedades Argentina, Brasileira e Uruguaia de Terapia Intensiva elaboraram um questionário no qual constavam avaliações demográficas sobre os participantes, sobre as instituições em que os mesmos trabalhavam e decisões sobre limite de esforço terapêutico (LET). Neste estudo de corte transversal os membros da equipe multiprofissional das sociedades responderam o questionário durante eventos científicos e, via on line. As variáveis foram analisadas através do teste qui-quadrado sendo considerado significativa p<0,05. RESULTADOS: Participaram do estudo 420 profissionais. No Brasil as UTI tinham mais leitos, foi mais rara a permissão irrestrita de visitas, os profissionais eram mais jovens, trabalhavam a menos tempo na UTI e houve maior participação de não médicos. Três visitas/dia foi o número mais frequente nos três países. Os fatores que mais influíram nas decisões de LET foram prognóstico da doença, co-morbidades e futilidade terapêutica. Nos três países mais de 90 por cento dos participantes já havia decidido por LET. Reanimação cardiorrespiratória, administração de drogas vaso-ativas, métodos dialíticos e nutrição parenteral foram as terapias mais suspensas/recusadas nos três países. Houve diferença significativa quanto à suspensão da ventilação mecânica, mais frequente na Argentina, seguida do Uruguai. Analgesia e sedação foram as terapias menos suspensas nos três países. Definições legais e éticas foram apontadas como as principais barreiras para a tomada de decisão. CONCLUSÃO: Decisões de LET são frequentemente utilizados entre os profissionais que atuam nas UTI dos três países. Existe uma tendência da ação de LET mais pró-ativa na Argentina, e uma maior equidade na distribuição das decisões no Uruguai. Essa diferença parece estar relacionada às diferenças...

ABSTRACT OBJECTIVE: To evaluate end-of-life procedures in intensive care units. METHODS: A questionnaire was prepared by the End-of-Life Study Group of the Argentinean, Brazilian and Uruguayan Intensive Care societies, collecting data on the participants’ demographics, institutions and limit therapeutic effort (LTE) decision making process. During this cross sectional study, the societies’ multidisciplinary teams members completed the questionnaire either during scientific meetings or online. The variables were analyzed with the Chi-square test, with a p<0.05 significance level. RESULTS: 420 professionals completed the questionnaire. The Brazilian units had more beds, unrestricted visit was less frequent, their professionals were younger and worked more recently in intensive care units, and more non-medical professionals completed the questionnaire. Three visits daily was the more usual number of visits for the three countries. The most influencing LTE factors were prognosis, co-morbidities, and therapeutic futility. In the three countries, more than 90 percent of the completers had already made LTE decisions. Cardiopulmonary resuscitation, vasoactive drugs administration, dialysis and parenteral nutrition were the most suspended/refused therapies in the three countries. Suspension of mechanic ventilation was more frequent in Argentina, followed by Uruguay. Sedation and analgesia were the less suspended therapies in the three countries. Legal definement and ethical issues were mentioned as the main barriers for the LTE decision making process. CONCLUSION: LTE decisions are frequent among the professionals working in the three countries’ intensive care units. We found a more proactive LTE decision making trend In Argentina, and more equity for decisions distribution in Uruguay. This difference appears to be related to the participants’ different ages, experiences, professional types and genders.

Evaluating end of life practices in ten Brazilian paediatric and adult intensive care units.

OBJECTIVE: To evaluate the modes of death and treatment offered in the last 24 h of life to patients dying in 10 Brazilian intensive care units (ICUs) over a period of 2 years. DESIGN AND SETTING: Cross-sectional, multicentre, retrospective study based on medical chart review. The medical records of all patients that died in seven paediatric and three adult ICUs belonging to university and tertiary hospitals over a period of 2 years were included. Deaths in the first 24 h of admission to the ICU and brain death were excluded. INTERVENTION: Two intensive care fellows of each ICU were trained in fulfilling a standard protocol (kappa=0.9) to record demographic data and all medical management provided in the last 48 h of life. The Student t test, Mann-Whitney U test, chi(2) test and RR were used for data comparison. MEASUREMENTS AND MAIN RESULTS: 1053 medical charts were included (59.4% adult patients). Life support limitation was more frequent in the adult group (86% vs 43.5%; p<0.001). A 'do not resuscitate' order was the most common life support limitation in both groups (75% and 66%), whereas withholding/withdrawing were more frequent in the paediatric group (33.9% vs 24.9%; p=0.02). The life support limitation was rarely reported in the medical chart in both groups (52.6% and 33.7%) with scarce family involvement in the decision making process (23.0% vs 8.7%; p<0.001). CONCLUSION: Life support limitation decision making in Brazilian ICUs is predominantly centred on the medical perspective with scarce participation of the family, and consequently several non-coherent medical interventions are observed in patients with life support limitation.