ABSTRACT
OBJECTIVE: To report the prevalence and outcomes of sepsis in children admitted to public and private hospitals. METHODS: Post hoc analysis of the Latin American Pediatric Sepsis Study (LAPSES) data, a cohort study that analyzed the prevalence and outcomes of sepsis in critically ill children with sepsis on admission at 21 pediatric intensive care units in five Latin American countries. RESULTS: Of the 464 sepsis patients, 369 (79.5%) were admitted to public hospitals and 95 (20.5%) to private hospitals. Compared to those admitted to private hospitals, sepsis patients admitted to public hospitals did not differ in age, sex, immunization status, hospital length of stay or type of admission but had higher rates of septic shock, higher Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality 2 (PIM 2), and Pediatric Logistic Organ Dysfunction (PELOD) scores, and higher rates of underlying diseases and maternal illiteracy. The proportion of patients admitted from pediatric wards and sepsis-related mortality were higher in public hospitals. Multivariate analysis did not show any correlation between mortality and the type of hospital, but mortality was associated with greater severity on pediatric intensive care unit admission in patients from public hospitals. CONCLUSION: In this sample of critically ill children from five countries in Latin America, the prevalence of septic shock within the first 24 hours at admission and sepsis-related mortality were higher in public hospitals than in private hospitals. Higher sepsis-related mortality in children admitted to public pediatric intensive care units was associated with greater severity on pediatric intensive care unit admission but not with the type of hospital. New studies will be necessary to elucidate the causes of the higher prevalence and mortality of pediatric sepsis in public hospitals.
OBJETIVO: Relatar a prevalência e os desfechos da sepse em crianças admitidas em hospitais públicos e privados na América Latina. MÉTODOS: Análise post-hoc dos dados do Latin American Pediatric Sepsis Study (LAPSES), um estudo de coorte que avaliou a prevalência e os desfechos da sepse em crianças admitidas em 21 unidades de terapia intensiva pediátricas de cinco países latino-americanos. RESULTADOS: Dentre os 464 pacientes com sepse, 369 (79,5%) foram admitidos em hospitais públicos e 95 (20,5%) em privados. Em comparação com os admitidos em hospitais privados, os pacientes com sepse admitidos em hospitais públicos não diferiram em termos de idade, sexo, condição de imunização, tempo de permanência no hospital ou tipo de admissão, porém tiveram incidência mais alta de choque séptico, escores Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality 2 (PIM 2) e Pediatric Logistic Organ Dysfunction (PELOD) mais altos e taxas mais elevadas de doenças de base e analfabetismo materno. A proporção entre pacientes admitidos a partir de enfermarias pediátricas e mortalidade relacionada à sepse foi mais alta nos hospitais públicos. A análise multivariada não mostrou qualquer correlação entre mortalidade e tipo de hospital, porém, nos hospitais públicos, a mortalidade se associou com níveis mais altos de gravidade no momento da admissão à unidade de terapia intensiva. CONCLUSÃO: Nesta amostra de crianças admitidas em condições críticas em cinco países latino-americanos, a prevalência de choque séptico nas primeiras 24 horas da admissão e a mortalidade relacionada à sepse foram mais elevadas em hospitais públicos do que nos privados. A mortalidade relacionada à sepse mais elevada em crianças admitidas em unidades de terapia intensiva pediátrica de hospitais públicos se associou com maior gravidade por ocasião da admissão à unidade de terapia intensiva, porém não com o tipo de hospital. São necessários novos estudos para elucidar as causas da maior prevalência e mortalidade de sepse pediátrica em hospitais públicos.
Subject(s)
Sepsis , Child , Cohort Studies , Hospital Mortality , Hospitals, Private , Humans , Intensive Care Units, Pediatric , Latin America/epidemiology , Prevalence , Sepsis/epidemiologyABSTRACT
We report a case of Influenza B infection and Kawasaki disease in an adolescent, diagnosed during the COVID-19 pandemic. An asthmatic female adolescent presented with fever and flu-like symptoms for 7 days and was admitted with acute respiratory failure requiring mechanical ventilation. She progressed with hemodynamic instability responsive to vasoactive drugs. Antibiotic therapy and support measures were introduced, showing progressive hemodynamics and respiratory improvement, however with persistent fever and increased inflammatory markers. During the hospitalization, she developed bilateral non-purulent conjunctivitis, hand and feet desquamation, strawberry tongue, and cervical adenopathy, and was diagnosed with Kawasaki disease. She was prescribed intravenous immunoglobulin and, due to the refractory clinical conditions, corticosteroid therapy was added; 24 hours later, the patient was afebrile. No coronary changes were found. A full viral panel including COVID-19 C-reactive protein and serology could only isolate the Influenza B virus. During the hospitalization, she was diagnosed with pulmonary thromboembolism; coagulopathies were investigated, and she was diagnosed with heterozygous factor V Leiden mutation. There is a potential association between Kawasaki disease and infection with Influenza B or with other viruses such as coronavirus. Therefore, this association should be considered in pediatric patients, adolescents included, with prolonged febrile conditions.
Apresentação de um caso de infecção por Influenza B e doença de Kawasaki em adolescente ocorrido durante a pandemia da COVID-19. Adolescente asmática evoluiu com febre e síndrome gripal por 7 dias e deu entrada com quadro de insuficiência respiratória aguda, necessitando de intubação orotraqueal. Evoluiu também com instabilidade hemodinâmica respondedora ao uso de droga vasoativa. Foram introduzidas antibioticoterapia e medidas de suporte. Apresentou melhora hemodinâmica e respiratória progressiva, porém mantinha febre e alteração de provas inflamatórias. Durante internação, evoluiu com conjuntivite não purulenta bilateral, descamação de mão e pés, língua em framboesa e linfonodomegalia cervical, recebendo diagnóstico de doença de Kawasaki. Recebeu gamaglobulina e, por conta de quadro clínico refratário, foi administrado também corticoide, evoluindo afebril 24 horas após. Não apresentou alterações coronarianas. O único agente isolado foi Influenza B, mesmo realizando painel viral e investigação para COVID-19 com reação em cadeia da polimerase e sorologia. Durante internação, apresentou tromboembolismo pulmonar, e, em investigação de coagulopatias, foi diagnosticada com mutação em heterozigose de fator V de Leiden. Há uma potencial associação entre doença de Kawasaki e infecção por Influenza B ou outros vírus, como o coronavírus e, por isso, esses diagnósticos devem ser investigados nos pacientes pediátricos, incluindo adolescentes, com quadros febris prolongados.
Subject(s)
COVID-19 , Influenza, Human/diagnosis , Mucocutaneous Lymph Node Syndrome/diagnosis , Respiratory Insufficiency/diagnosis , Adolescent , Female , Hospitalization , Humans , Influenza B virus/isolation & purification , Influenza, Human/therapy , Mucocutaneous Lymph Node Syndrome/complications , Respiration, Artificial , Respiratory Insufficiency/etiologyABSTRACT
RESUMO Apresentação de um caso de infecção por Influenza B e doença de Kawasaki em adolescente ocorrido durante a pandemia da COVID-19. Adolescente asmática evoluiu com febre e síndrome gripal por 7 dias e deu entrada com quadro de insuficiência respiratória aguda, necessitando de intubação orotraqueal. Evoluiu também com instabilidade hemodinâmica respondedora ao uso de droga vasoativa. Foram introduzidas antibioticoterapia e medidas de suporte. Apresentou melhora hemodinâmica e respiratória progressiva, porém mantinha febre e alteração de provas inflamatórias. Durante internação, evoluiu com conjuntivite não purulenta bilateral, descamação de mão e pés, língua em framboesa e linfonodomegalia cervical, recebendo diagnóstico de doença de Kawasaki. Recebeu gamaglobulina e, por conta de quadro clínico refratário, foi administrado também corticoide, evoluindo afebril 24 horas após. Não apresentou alterações coronarianas. O único agente isolado foi Influenza B, mesmo realizando painel viral e investigação para COVID-19 com reação em cadeia da polimerase e sorologia. Durante internação, apresentou tromboembolismo pulmonar, e, em investigação de coagulopatias, foi diagnosticada com mutação em heterozigose de fator V de Leiden. Há uma potencial associação entre doença de Kawasaki e infecção por Influenza B ou outros vírus, como o coronavírus e, por isso, esses diagnósticos devem ser investigados nos pacientes pediátricos, incluindo adolescentes, com quadros febris prolongados.
ABSTRACT We report a case of Influenza B infection and Kawasaki disease in an adolescent, diagnosed during the COVID-19 pandemic. An asthmatic female adolescent presented with fever and flu-like symptoms for 7 days and was admitted with acute respiratory failure requiring mechanical ventilation. She progressed with hemodynamic instability responsive to vasoactive drugs. Antibiotic therapy and support measures were introduced, showing progressive hemodynamics and respiratory improvement, however with persistent fever and increased inflammatory markers. During the hospitalization, she developed bilateral non-purulent conjunctivitis, hand and feet desquamation, strawberry tongue, and cervical adenopathy, and was diagnosed with Kawasaki disease. She was prescribed intravenous immunoglobulin and, due to the refractory clinical conditions, corticosteroid therapy was added; 24 hours later, the patient was afebrile. No coronary changes were found. A full viral panel including COVID-19 C-reactive protein and serology could only isolate the Influenza B virus. During the hospitalization, she was diagnosed with pulmonary thromboembolism; coagulopathies were investigated, and she was diagnosed with heterozygous factor V Leiden mutation. There is a potential association between Kawasaki disease and infection with Influenza B or with other viruses such as coronavirus. Therefore, this association should be considered in pediatric patients, adolescents included, with prolonged febrile conditions.
Subject(s)
Humans , Female , Adolescent , Respiratory Insufficiency/diagnosis , Influenza, Human/diagnosis , COVID-19 , Mucocutaneous Lymph Node Syndrome/diagnosis , Influenza B virus/isolation & purification , Respiration, Artificial , Respiratory Insufficiency/etiology , Influenza, Human/therapy , Hospitalization , Mucocutaneous Lymph Node Syndrome/complicationsABSTRACT
OBJECTIVES: To report the prevalence of sepsis within the first 24 hours at admission and the PICU sepsis-related mortality among critically ill children admitted to PICU in South America. DESIGN: A prospective multicenter cohort study. SETTING: Twenty-one PICU, located in five South America countries. PATIENTS: All children from 29 days to 17 years old admitted to the participating PICU between June 2011 and September 2011. Clinical, demographic, and laboratory data were registered within the first 24 hours at admission. Outcomes were registered upon PICU discharge or death. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 1,090 patients included in this study, 464 had sepsis. The prevalence of sepsis, severe sepsis, and septic shock were 42.6%, 25.9%, and 19.8%, respectively. The median age of sepsis patients was 11.6 months (interquartile range, 3.2-48.7) and 43% had one or more prior chronic condition. The prevalence of sepsis was higher in infants (50.4%) and lower in adolescents (1.9%). Sepsis-related mortality was 14.2% and was consistently higher with increased disease severity: 4.4% for sepsis, 12.3% for severe sepsis, and 23.1% for septic shock. Twenty-five percent of deaths occurred within the first 24 hours at PICU admission. Multivariate analysis showed that higher Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores, the presence of two or more chronic conditions, and admission from pediatric wards were independently associated with death. CONCLUSIONS: We observed high prevalence of sepsis and sepsis-related mortality among this sample of children admitted to PICU in South America. Mortality was associated with greater severity of illness at admission and potentially associated with late PICU referral.
Subject(s)
Intensive Care Units, Pediatric , Sepsis/epidemiology , Adolescent , Child , Child, Preschool , Developing Countries , Female , Humans , Infant , Infant, Newborn , Male , Multivariate Analysis , Prevalence , Prognosis , Prospective Studies , Risk Factors , Sepsis/diagnosis , Sepsis/etiology , Sepsis/mortality , Severity of Illness Index , South America/epidemiologyABSTRACT
Hemophagocytic lymphohistiocytosis or hemophagocytic syndrome is represented by an uncontrolled inflammatory response characterized by marked histiocyte activation and a cytokine storm. The entity may present a primary or genetic type, and the secondary type is usually triggered by infectious diseases of any kind, autoimmune disease, or neoplasia. This entity, although well described and with definite diagnostic criteria, still remains misdiagnosed because of the overlap presentation with other inflammatory processes. The authors present the case of a 13-year-old girl who was submitted to an appendicectomy complicated with a pericolic abscess, which required a second operation in order to be drained surgically. During the postoperative period of this second surgical procedure, the patient remained febrile, developing cytopenias, and multiple organ failure. Unfortunately, she died despite the efforts of the intensive care staff. The autopsy findings were characteristic of hemophagocytic syndrome. The authors report the case to call attention to this diagnosis whenever unexpected outcomes of infections are experienced.
ABSTRACT
OBJECTIVES: The primary outcome was to compare the effects of dopamine or epinephrine in severe sepsis on 28-day mortality; secondary outcomes were the rate of healthcare-associated infection, the need for other vasoactive drugs, and the multiple organ dysfunction score. DESIGN: Double-blind, prospective, randomized controlled trial from February 1, 2009, to July 31, 2013. SETTING: PICU, Hospital Universitário da Universidade de São Paulo, Brazil. PATIENTS: Consecutive children who are 1 month to 15 years old and met the clinical criteria for fluid-refractory septic shock. Exclusions were receiving vasoactive drug(s) prior to hospital admission, having known cardiac disease, having already participated in the trial during the same hospital stay, refusing to participate, or having do-not-resuscitate orders. INTERVENTIONS: Patients were randomly assigned to receive either dopamine (5-10 µg/kg/min) or epinephrine (0.1-0.3 µg/kg/min) through a peripheral or intraosseous line. Patients not reaching predefined stabilization criteria after the maximum dose were classified as treatment failure, at which point the attending physician gradually stopped the study drug and started another catecholamine. MEASUREMENTS AND MAIN RESULTS: Physiologic and laboratory data were recorded. Baseline characteristics were described as proportions and mean (± SD) and compared using appropriate statistical tests. Multiple regression analysis was performed, and statistical significance was defined as a p value of less than 0.05. Baseline characteristics and therapeutic interventions for the 120 children enrolled (63, dopamine; 57, epinephrine) were similar. There were 17 deaths (14.2%): 13 (20.6%) in the dopamine group and four (7%) in the epinephrine group (p=0.033). Dopamine was associated with death (odds ratio, 6.5; 95% CI, 1.1-37.8; p=0.037) and healthcare-associated infection (odds ratio, 67.7; 95% CI, 5.0-910.8; p=0.001). The use of epinephrine was associated with a survival odds ratio of 6.49. CONCLUSIONS: Dopamine was associated with an increased risk of death and healthcare-associated infection. Early administration of peripheral or intraosseous epinephrine was associated with increased survival in this population. Limitations should be observed while interpreting these results.
Subject(s)
Dopamine/therapeutic use , Epinephrine/therapeutic use , Hospital Mortality/trends , Shock, Septic/drug therapy , Vasoconstrictor Agents/therapeutic use , Adolescent , Age Factors , Brazil , Child , Child, Preschool , Critical Illness/therapy , Dopamine/adverse effects , Double-Blind Method , Epinephrine/adverse effects , Female , Follow-Up Studies , Hospitals, University , Humans , Infant , Intensive Care Units, Pediatric , Length of Stay , Linear Models , Male , Multivariate Analysis , Prospective Studies , Risk Assessment , Severity of Illness Index , Sex Factors , Shock, Septic/diagnosis , Shock, Septic/mortality , Statistics, Nonparametric , Survival Rate , Treatment Outcome , Vasoconstrictor Agents/adverse effectsABSTRACT
OBJECTIVES: To assess whether the combination of daily evaluation and use of a spontaneous breathing test could shorten the duration of mechanical ventilation as compared with weaning based on our standard of care. Secondary outcome measures included extubation failure rate and the need for noninvasive ventilation. DESIGN: A prospective, randomized controlled trial. SETTING: Two pediatric intensive care units at university hospitals in Brazil. PATIENTS: The trial involved children between 28 days and 15 yrs of age who were receiving mechanical ventilation for at least 24 hrs. INTERVENTIONS: Patients were randomly assigned to one of two weaning protocols. In the test group, the children underwent a daily evaluation to check readiness for weaning with a spontaneous breathing test with 10 cm H2O pressure support and a positive end-expiratory pressure of 5 cm H2O for 2 hrs. The spontaneous breathing test was repeated the next day for children who failed it. In the control group, weaning was performed according to standard care procedures. MEASUREMENTS AND MAIN RESULTS: A total of 294 eligible children were randomized, with 155 to the test group and 139 to the control group. The time to extubation was shorter in the test group, where the median mechanical ventilation duration was 3.5 days (95% confidence interval, 3.0 to 4.0) as compared to 4.7 days (95% confidence interval, 4.1 to 5.3) in the control group (p = .0127). This significant reduction in the mechanical ventilation duration for the intervention group was not associated with increased rates of extubation failure or noninvasive ventilation. It represents a 30% reduction in the risk of remaining on mechanical ventilation (hazard ratio: 0.70). CONCLUSIONS: A daily evaluation to check readiness for weaning combined with a spontaneous breathing test reduced the mechanical ventilation duration for children on mechanical ventilation for >24 hrs, without increasing the extubation failure rate or the need for noninvasive ventilation.
Subject(s)
Intensive Care Units, Pediatric , Ventilator Weaning/methods , Adolescent , Child , Child, Preschool , Female , Hospitals, University , Humans , Infant , Male , Prospective Studies , Respiratory Function TestsABSTRACT
Respiratory syncytial virus (RSV) bronchiolitis is the leading cause of lower respiratory tract infection, and the most frequent reason for hospitalization among infants throughout the world. In addition to the acute consequences of the disease, RSV bronchiolitis in early childhood is related to further development of recurrent wheezing and asthma. Despite the medical and economic burden of the disease, therapeutic options are limited to supportive measures, and mechanical ventilation in severe cases. Growing evidence suggests an important role of changes in pulmonary surfactant content and composition in the pathogenesis of severe RSV bronchiolitis. Besides the well-known importance of pulmonary surfactant in maintenance of pulmonary homeostasis and lung mechanics, the surfactant proteins SP-A and SP-D are essential components of the pulmonary innate immune system. Deficiencies of such proteins, which develop in severe RSV bronchiolitis, may be related to impairment in viral clearance, and exacerbated inflammatory response. A comprehensive understanding of the role of the pulmonary surfactant in the pathogenesis of the disease may help the development of new treatment strategies. We conducted a review of the literature to analyze the evidences of pulmonary surfactant changes in the pathogenesis of severe RSV bronchiolitis, its relation to the inflammatory and immune response, and the possible role of pulmonary surfactant replacement in the treatment of the disease.
Subject(s)
Bronchiolitis/immunology , Pulmonary Surfactants/immunology , Respiratory Syncytial Virus Infections/immunology , Animals , Humans , Lung/immunology , Pulmonary Surfactant-Associated Protein A/immunology , Pulmonary Surfactant-Associated Protein D/immunologySubject(s)
Antithrombin III/metabolism , Protein C/metabolism , Sepsis/physiopathology , Antithrombin III/analysis , Blood Coagulation/physiology , Clinical Trials as Topic , Enterocolitis, Necrotizing/epidemiology , Enterocolitis, Necrotizing/etiology , Enterocolitis, Necrotizing/prevention & control , Humans , Infant, Newborn , Intracranial Hemorrhages/epidemiology , Intracranial Hemorrhages/etiology , Intracranial Hemorrhages/prevention & control , Protein C/analysis , Protein S/analysis , Protein S/metabolism , Risk Assessment , Sepsis/complications , Severity of Illness Index , Thromboembolism/prevention & controlABSTRACT
Objetivo: Estudo realizado a partir da revisão deprontuários de pacientes internados na Unidade deTerapia Intensiva Pediátrica do Hospital Universitárioda Universidade de São Paulo, no período dedezembro de 2001 a dezembro de 2004, descreveoito casos de choque séptico refratário a catecolaminas.Método: Observou-se que predominou perfilhemodinâmico, baseado em informações obtidasdo cateter de artéria pulmonar (CAP). Resultados:Houve elevado índice cardíaco e baixa resistênciavascular sistêmica. Conclusão: Os achados desseestudo diferem da descrição de Ceneviva et al.Novos estudos necessitam ser realizados visandoesclarecer o perfil hemodinâmico de crianças comchoque séptico refratário a volume e catecolaminase definir o papel da monitorização com CAP nesses casos.
Objectives: Study done from the revision of charts ofhospitalized patients from the Pediatric Intensive CareUnit of Hospital of the University of São Paulo, in periodof December 2001 to December 2004, describes 8 casesof catecholamine-resistant septic shock. Methods: It wasobserved that the predominant hemodynamic profile, basedon information obtained from pulmonary artery catheter(PAC). Results: There was high cardiac index and lowsystemic vascular resistance. Conclusion: It was differentfrom description of Ceneviva et al. New studies must beundertaken to clarify the hemodynamic profile of childrenwith volume and catecholamine-resistant septic shock andto define the role of PAC monitoring in these cases.
Subject(s)
Humans , Male , Female , Infant, Newborn , Infant , Child, Preschool , Child , Adolescent , Pulmonary Artery/surgery , Catecholamines , Catheterization, Swan-Ganz , Shock, Septic , HemodynamicsSubject(s)
Critical Care , Pediatrics , Practice Guidelines as Topic , Shock, Septic/diagnosis , Shock, Septic/therapy , Child , Child, Preschool , Humans , Infant , Infant, NewbornABSTRACT
Mycoplasma pneumoniae is an important causative agent of respiratory infection in childhood. Although the infection caused by M. pneumoniae is classically described as benign, severe and life-threatening pulmonary and extrapulmonary complications can occur. This study describes the first case of septic shock related to M. pneumoniae in a child with necrotizing pneumonitis, severe encephalitis, and multiple organs involvement, with a favorable outcome after lobectomy and systemic corticosteroids.
Subject(s)
Meningoencephalitis/microbiology , Mycoplasma pneumoniae/isolation & purification , Pneumonia, Mycoplasma/microbiology , Shock, Septic/microbiology , Anti-Bacterial Agents/therapeutic use , Child , Drug Therapy, Combination , Glucocorticoids/therapeutic use , Humans , Immunoenzyme Techniques , Magnetic Resonance Imaging , Male , Meningoencephalitis/diagnosis , Meningoencephalitis/drug therapy , Pneumonectomy , Pneumonia, Mycoplasma/diagnosis , Pneumonia, Mycoplasma/drug therapy , Pneumonia, Mycoplasma/surgery , Shock, Septic/diagnosis , Shock, Septic/drug therapy , Spinal Puncture , Tomography, X-Ray ComputedSubject(s)
Humans , Male , Female , Infant, Newborn , Infant , Child , Pediatrics , Critical Care/methodsABSTRACT
OBJECTIVE: To evaluate the incidence of life support limitation and medical practices in the last 48 hrs of life of children in seven Brazilian pediatric intensive care units (PICUs). DESIGN: Cross-sectional multicenter retrospective study based on medical chart review. SETTING: Seven PICUs belonging to university and tertiary hospitals located in three Brazilian regions: two in Porto Alegre (southern region), two in São Paulo (southeastern region), and three in Salvador (northeastern region). PATIENTS: Medical records of all children who died in seven PICUs from January 2003 to December 2004. Deaths in the first 24 hrs of admission to the PICU and brain death were excluded. INTERVENTIONS: Two pediatric intensive care residents from each PICU were trained to fill out a standard protocol (kappa = 0.9) to record demographic data and all medical management provided in the last 48 hrs of life (inotropes, sedatives, mechanical ventilation, full resuscitation maneuvers or not). Student's t-test, analysis of variance, chi-square test, and relative risk were used for comparison of data. MEASUREMENTS AND MAIN RESULTS: Five hundred and sixty-one deaths were identified; 97 records were excluded (61 because of brain death and 36 due to <24 hrs in the PICU). Thirty-six medical charts could not be found. Cardiopulmonary resuscitation was performed in 242 children (57%) with a significant difference between the southeastern and northeastern regions (p = .0003). Older age (p = .025) and longer PICU stay (p = .001) were associated with do-not-resuscitate orders. In just 52.5% of the patients with life support limitation, the decision was clearly recorded in the medical chart. No ventilatory support was provided in 14 cases. Inotropic drug infusions were maintained or increased in 66% of patients with do-not-resuscitate orders. CONCLUSIONS: The incidence of life support limitation has increased among Brazilian PICUs but with significant regional differences. Do-not-resuscitate orders are still the most common practice, with scarce initiatives for withdrawing or withholding life support measures.