Impact of sustained neuromuscular blockade on outcome of mechanically ventilated children.

BACKGROUND: Neuromuscular blocking agents (NMBA) are commonly administered to critically ill children in pediatric intensive care units (PICU) in the USA and Europe. Although NMBA are frequently used in PICU patients, their role in the PICU setting has not yet been clearly defined. The aim of this study was to describe the sustained administration of NMBA and its impact on outcome of PICU patients. METHODS: A 3-year retrospective cohort study was conducted to compare mechanically-ventilated patients who received NMBA for at least 12 h with patients who did not (control group). RESULTS: A total of 317 consecutive patients were ventilated over 3473 days. Patients were similar in age, weight and severity scores. Thirty-four children (10.7%) received NMBA. Compared with controls, the neuromuscular blockade (NMB) group had a longer duration of mechanical ventilation (13.7 vs 5.5 days, P= 0.000), longer PICU stay (20 vs 11 days, P= 0.000) and increased occurrence of ventilator-associated pneumonia (6.6 vs 4.1/1000 ventilator days, P= 0.010). The NMB use was not associated with higher mortality (8.8% vs 17.6%, P= 0.287) or longer hospital stay (30.5 vs 23 days, P= 0.117). CONCLUSION: Although the use of NMBA was not associated with greater mortality, we found that sustained use of NMBA is associated with prolonged mechanical ventilation, longer PICU stay and higher incidence of ventilator-associated pneumonia when compared with controls. Larger studies are necessary to confirm these findings.

Hypophosphatemia in critically ill children: prevalence and associated risk factors.

BACKGROUND: Hypophosphatemia is a disorder with potential complications and is often unrecognized in critically ill patients. AIMS: To identify the prevalence of hypophosphatemia and risk factors associated to this disorder in critically ill children. METHODS: In a prospective cohort study, 82 children admitted consecutively to a pediatric intensive care unit (ICU) were monitored regarding phosphorus serum levels during the first 10 days of admission. The following variables were analyzed as independent for hypophosphatemia: age, gender, diagnosis at admission, malnutrition, phosphorus intake, clinical severity score at admission (pediatric index of mortality 2) and daily scores (Pediatric Logistic Organ Dysfunction), sepsis, use of dopamine, furosemide and steroids, starvation period, and refeeding. Children with a z score of less than -2 of expected weight for age or body mass index (National Center for Health Statistics, 2000) were considered malnourished. Variables significantly associated with hypophosphatemia by bivariate analysis (p < 0.1) were included in a multiple logistic regression model. RESULTS: The rate of hypophosphatemia was 61% during the first 10 days of pediatric ICU stay, and 12 patients developed hypophosphatemia during the study period. Malnutrition was present in 39.1% of patients, and the sera phosphorus concentration was significantly lower in malnourished than in well-nourished children (2.6 +/- 0.7 mg/dL vs. 3.5 +/- 0.8 mg/dL, p = 0.01). The multiple logistic regression model indicated the diagnosis of acute respiratory disease (odds ratio: 3.22; confidence interval: 1.03-10.1; p = 0.04), use of dopamine (odds ratio: 8.65; confidence interval: 1.58-47.3; p = 0.01), and malnutrition (odds ratio: 3.96; confidence interval: 1.19-13.3; p = 0.02) as independent risk factors for hypophosphatemia. None of the other potential risk factors discriminated for hypophosphatemia. CONCLUSIONS: Hypophosphatemia was common in the first 10 days of ICU hospitalization and was associated with the diagnosis of respiratory disease, use of dopamine, and malnutrition. These factors should be taken into account during clinical follow up of critically ill children, especially when these conditions are found together.

[Plasma vitamin A levels in deprived children with pneumonia during the acute phase and after recovery]. / Níveis plasmáticos de vitamina A em crianças carentes com pneumonia na fase aguda e após recuperação.

OBJECTIVE: The aim of this study was to examine the plasma retinol of children in the acute phase of pneumonia and after recovery and to investigate the association between plasma levels of retinol after recovery with socioeconomic variables, nutritional status and severity of pneumonia. METHODS: A prospective cohort study which included 40 low-income hospitalized children with pneumonia, aged 6 months to 5 years. We evaluated: plasma retinol level during the acute phase and after recovery, years of schooling of the head of the family, per capita income, birth weight, nutritional status, hemoglobin levels and severity of pneumonia. RESULTS: Mean plasma retinol levels were significantly higher after recovery than during the acute phase of infection (1.4+/-0.6 vs. 1.7+/-0.6 micromol/l, p = 0.03). The frequency of inadequate plasma retinol levels (< 1.05 micromol/l) was 32.5 and 17.5% for the acute phase and after recovery, respectively. There were no statistically significant associations between plasma retinol deficiency and the clinical and epidemiological variables studied. More severe pneumonia was observed in 30/40 (75%) of the patients. There was no statistically significant association between plasma retinol inadequacy after recovery and severity of pneumonia (4/30 - 13.3% vs. 3/10 - 30.0%, p = 0.34). CONCLUSION: Serum retinol levels were significantly higher after recovery than during the acute phase of pneumonia. There was no statistically significant association between the deficiency of serum retinol and the clinical and epidemiological variables studied.