Continuous clonidine infusion: an alternative for children on mechanical ventilation.

OBJECTIVE: This study aimed to assess the clonidine infusion rate in the first 6 h, as maintenance dose (first 24 h), and in the pre-extubation period (last 24 h), as well as the cumulative dose of other sedatives and the hemodynamic response. METHODS: This is a retrospective cohort study. RESULTS: Children up to the age of 2 years who were admitted to the pediatric intensive care unit of a tertiary referral hospital in the south region of Brazil, between January 2017 and December 2018, were submitted to mechanical ventilation, and received continuous clonidine infusions were included in the study. The initial, maintenance, and pre-extubation doses of clonidine; the vasoactive-inotropic score; heart rate; and systolic and diastolic blood pressure of the study participants were assessed. A total of 66 patients with a median age of 4 months who were receiving clonidine infusions were included. The main indications for mechanical ventilation were acute viral bronchiolitis (56%) and pneumonia associated with acute respiratory distress syndrome (15%). The median of clonidine infusion in the first 6 h (66 patients) was 0.53 µg/kg/h (IQR 0.49-0.88), followed by 0.85 µg/kg/h (IQR 0.53-1.03) during maintenance (57 patients) and 0.63 µg/kg/h (IQR 0.54-1.01) during extubation period (42 patients) (p=0.03). No differences were observed in the doses regarding the indication for mechanical ventilation. Clonidine infusion was not associated with hemodynamic changes and showed no differences when associated with adjuvants. CONCLUSION: Clonidine demonstrated to be a well-tolerated sedation option in pediatric patients submitted to mechanical ventilation, without relevant influence in hemodynamic variables.

Continuous clonidine infusion: an alternative for children on mechanical ventilation

SUMMARY OBJECTIVE: This study aimed to assess the clonidine infusion rate in the first 6 h, as maintenance dose (first 24 h), and in the pre-extubation period (last 24 h), as well as the cumulative dose of other sedatives and the hemodynamic response. METHODS: This is a retrospective cohort study. RESULTS: Children up to the age of 2 years who were admitted to the pediatric intensive care unit of a tertiary referral hospital in the south region of Brazil, between January 2017 and December 2018, were submitted to mechanical ventilation, and received continuous clonidine infusions were included in the study. The initial, maintenance, and pre-extubation doses of clonidine; the vasoactive-inotropic score; heart rate; and systolic and diastolic blood pressure of the study participants were assessed. A total of 66 patients with a median age of 4 months who were receiving clonidine infusions were included. The main indications for mechanical ventilation were acute viral bronchiolitis (56%) and pneumonia associated with acute respiratory distress syndrome (15%). The median of clonidine infusion in the first 6 h (66 patients) was 0.53 μg/kg/h (IQR 0.49-0.88), followed by 0.85 μg/kg/h (IQR 0.53-1.03) during maintenance (57 patients) and 0.63 μg/kg/h (IQR 0.54-1.01) during extubation period (42 patients) (p=0.03). No differences were observed in the doses regarding the indication for mechanical ventilation. Clonidine infusion was not associated with hemodynamic changes and showed no differences when associated with adjuvants. CONCLUSION: Clonidine demonstrated to be a well-tolerated sedation option in pediatric patients submitted to mechanical ventilation, without relevant influence in hemodynamic variables.

International Survey on Determinants of Antibiotic Duration and Discontinuation in Pediatric Critically Ill Patients.

OBJECTIVES: We hypothesized that antibiotic use in PICUs is based on criteria not always supported by evidence. We aimed to describe determinants of empiric antibiotic use in PICUs in eight different countries. DESIGN: Cross-sectional survey. SETTING: PICUs in Canada, the United States, France, Italy, Saudi Arabia, Japan, Thailand, and Brazil. SUBJECTS: Pediatric intensivists. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used literature review and focus groups to develop the survey and its clinical scenarios (pneumonia, septic shock, meningitis, and intra-abdominal infections) in which cultures were unreliable due to antibiotic pretreatment. Data analyses included descriptive statistics and linear regression with bootstrapped SEs. Overall response rate was 39% (482/1,251), with individual country response rates ranging from 25% to 76%. Respondents in all countries prolonged antibiotic duration based on patient characteristics, disease severity, pathogens, and radiologic findings (from a median increase of 1.8 d [95% CI, 0.5-4.0 d] to 9.5 d [95% CI, 8.5-10.5 d]). Younger age, severe disease, and ventilator-associated pneumonia prolonged antibiotic treatment duration despite a lack of evidence for such practices. No variables were reported to shorten treatment duration for all countries. Importantly, more than 39% of respondents would use greater than or equal to 7 days of antibiotics for patients with a positive viral polymerase chain reaction test in all scenarios, except in France for pneumonia (29%), septic shock (13%), and meningitis (6%). The use of elevated levels of inflammatory markers to prolong antibiotic treatment duration varied among different countries. CONCLUSIONS: Antibiotic-related decisions are complex and may be influenced by cultural and contextual factors. Evidence-based criteria are necessary to guide antibiotic duration and ensure the rational use of antibiotics in PICUs.

Early fluid overload was associated with prolonged mechanical ventilation and more aggressive parameters in critically ill paediatric patients.

AIM: We evaluated the influence of early fluid overload on critically ill children admitted to a paediatric intensive care unit by examining mechanical ventilation (MV), mortality, length of stay and renal replacement therapy. METHODS: This retrospective cohort study covered January 2015 to December 2016 and focused on all episodes of MV support that exceeded 24 hours. The fluid overload percentage (FO%) was calculated daily for the first 72 hours and we estimated its effect on outcomes. RESULTS: We included 186 MV episodes in 154 patients. The median age was 13.8 months, with an interquartile range (IQR) of 3.8-34.0 months, and the mortality rate was 12.4%. The median FO% in the first 72 hours was 8.0% (IQR 3.6%-11.2%). An FO% of ≥10% was associated with higher ventilatory parameters, namely peak inspiratory pressure (P = .023) and positive end expiratory pressure (P = .003), and renal replacement therapy (P = .02) and higher mortality (8.8% vs 19.7%). In a multivariate Cox regression model, FO ≥ 10% at 72 hours was independently associated with longer MV support, but not mortality (P = .001). CONCLUSION: In a heterogeneous paediatric population given MV, an early cumulative FO of ≥10% was associated with more aggressive ventilatory parameters and prolonged length of MV, but not mortality.

Evolution of the medical practices and modes of death on pediatric intensive care units in southern Brazil.

OBJECTIVES: To study the possible change on mode of deaths, medical decision practices, and family participation on decisions for limiting life-sustaining treatments (L-LST) over a period of 13 yrs in three pediatric intensive care units (PICUs) located in southern Brazil. METHODS: A cross-sectional study based on a retrospective chart review (1988 and 1998) and on prospective data collection (from May 1999 to May 2000). SETTING: Three PICUs in Porto Alegre, southern Brazilian region. PATIENTS: Children who died in those PICUs during the years of 1988, 1998, and between May 1999 and May 2000. RESULTS: The 3 PICUs admitted 6,233 children during the study period with a mortality rate of 9.2% (575 deaths), and 509 (88.5%) medical charts were evaluated in this study. Full measures for life support (F-CPR) were recognized in 374 (73.5%) children before dying, brain death (BD) was diagnosed in 43 (8.4%), and 92 (18.1%) underwent some limitation of life support treatment (L-LST) There were 140 (27.5%) deaths within the first 24 hrs of admission and 128 of them (91.4%) received F-CPR, whereas just 11 (7.9%) patients underwent L-LST. The average length of stay for the death group submitted to F-CPR was lower (3 days) than the L-LST group (8.5 days; p < .05). The rate of F-CPR before death decreased significantly between 1988 (89.1%) and 1999/2000 (60.8%), whereas the L-LST rose in this period from 6.2% to 31.3%. These changes were not uniform among the three PICUs, with different rates of L-LST (p < .05). The families were involved in the decision-making process for L-LST in 35.9% of the cases, increasing from 12.5% in 1988 to 48.6% in 1999/2000. The L-LST plans were recorded in the medical charts in 76.1% of the deaths, increasing from 50.0% in 1988 to 95.9% in 1999/2000. CONCLUSION: We observed that the modes of deaths in southern Brazilian PICUs changed over the last 13 yrs, with an increment in L-LST. However, this change was not uniform among the studied PICUs and did not reach the levels described in countries of the Northern Hemisphere. Family participation in the L-LST decision-making process has increased over time, but it is still far behind what is observed in other parts of the world.

Risk factors for extubation failure in mechanically ventilated pediatric patients.

OBJECTIVE: To describe the incidence of extubation failure and its associated risk factors among mechanically ventilated children. METHOD: Prospective cohort study. Children who were mechanically ventilated for longer than 12 hrs were followed up to 48 hrs after extubation. Cases of upper airway obstruction, accidental extubation, tracheostomy, or death before extubation were excluded. Extubation failure was defined as reintubation within 48 hrs after extubation. Student's t -test, Mann-Whitney, and chi-squared tests, odds ratio with 95% confidence interval, and multivariate analysis were used for data analysis. RESULTS: Extubation failure rate was 10.5% (13 of 124 patients). Variables associated with extubation failure were age between 1 and 3 mos (odds ratio [OR] = 5.68; 95% confidence interval [CI] = 1.58-20.42), mechanical ventilation >15 days (OR = 6.36; 95% CI = 1.32-30.61), mean oxygenation index (OI) >5 (OR = 4.08; 95% CI = 1.25-13.30), mean airway pressure 24 hrs before extubation lower than 5 cm H(2)O (OR = 6.03; 95% CI = 1.48-24.60), continuous positive airway pressure (CPAP) (OR = 4.71; 95% CI = 1.34-16.58), dopamine and dobutamine use (OR = 3.71; 95% CI = 1.08-12.78), intravenous sedation >10 days (OR = 6.60; 95% CI = 1.62-26.90), tachypnea and subcostal retractions (relative risk [RR] = 3.68; 95% CI = 1.14-11.93), and inspired fraction of oxygen (Fio(2)) > 0.4 after extubation (RR = 3.63; 95% CI = 1.21-10.88). After multiple logistic regression analysis, age between 1 and 3 mos, mean OI > 5, CPAP and mechanical ventilation >15 days remained associated with extubation failure. CONCLUSION: Extubation failure was more frequent among young infants who received prolonged ventilatory support and intravenous sedation, used CPAP, had impaired lung oxygenation, and required inotropic therapy.

[Sedation and analgesia in children submitted to mechanical ventilation could be overestimated?]. / A sedação e analgesia de crianças submetidas à ventilação mecânica estariam sendo superestimadas?

OBJECTIVE: To describe the pattern of analgesic and sedative infusions in children submitted to mechanical ventilation in a regional pediatric intensive care unit during a 12-month period. To compare the use of these drugs among clinical and surgical patients, as well evaluate the influence of the length of use on the average daily doses and on the incidence of abstinence syndrome. METHODS: This cohort study was performed from April 2001 to March 2002, involving children (1 month old to 15 years old) submitted to the mechanical ventilation through a tracheal tube for a period longer than 12 hours and who were successfully extubated (dead patients and those who required reintubation were excluded from the study). A team of professionals not involved with the patient's assistance performed a daily collection of all data up to the 28th day under mechanical ventilation (maximum length of follow up for those who remain longer under mechanical ventilation). The main outcome was the infusion doses of morphine, fentanyl, ketamine and midazolam administered at 12 AM (considering this dose as the average dose for that day). The diagnosis of abstinence syndrome was based on the chart revision (recorded diagnosis or based on the specific antagonist treatment used) and in an interview with the assistant physician on the following days after the extubation. This study was approved by the Ethics and Scientific Committee of the HSL-PUCRS. RESULTS: 127 children were eligible for this study, but only 124 patients were analyzed (16.0 +/- 29-5 months old; 58% male; 92 defined as clinical patients and 32 as surgical patients). An average of 1.7 sedative-analgesic infusion per patient a day was used in the whole group (without difference between clinical and surgical groups). Morphine and fentanyl were the most common drugs infused in both groups (fentanyl was preferred for the clinical group and morphine for the surgical group). The mean length of infusion was different (p<0.01) between clinical and surgical patients (6.8 and 3.9 days, respectively). After the 7th day, there was a significant increase in the fentanyl and midazolam doses (p<0.01), as well as a higher incidence of abstinence syndrome in the clinical group (p<0.01). CONCLUSION: This study evaluated the daily practice in a regional PICU, and it demonstrated that analgesic and sedative infusions in children submitted to mechanical ventilation are used according to an uncontrolled pattern (average 1.7 drugs/patient/day) and those classified as clinical patients used these drugs for longer periods, what could explain the higher prevalence of abstinence syndrome in this group.

A sedaçäo e analgesia de crianças submetidas à ventilaçäo mecânica estariam sendo superestimadas? / Sedation and analgesia in children submitted to mechanical ventilation could be overestimated?

OBJETIVO: descrever o perfil de uso de analgésicos e sedativos em crianças submetidas à ventilaçäo mecânica, internadas em uma UTI pediátrica de referência, em um período de 12 meses, avaliando o tempo de uso dessas drogas, as doses diárias utilizadas e a incidência de síndrome de abstinência. MÉTODOS: estudo de coorte prospectivo (abril de 2001 a março de 2002), envolvendo crianças em ventilaçäo mecânica (via tubo traqueal) por um período superior a 12 horas, com idade entre 30 dias e 15 anos, que tivessem sucesso no processo de extubaçäo (excluídos os óbitos ou aqueles que necessitassem reintubaçäo). Uma equipe näo envolvida com a assistência coletava os dados diariamente, até o 28º dia de ventilaçäo mecânica (tempo máximo de seguimento para aqueles que eventualmente permanecessem um tempo superior a 28 dias em ventilaçäo artificial), sendo o principal desfecho a dose, infundida às 12h da manhä, de morfina, fentanil, quetamina e midazolam (assumindo esta como a dose média naquele dia para cada uma destas drogas). O diagnóstico de síndrome de abstinência foi definido através de pesquisa no prontuário (registro do diagnóstico ou tomada de medidas terapêuticas neste sentido) e por entrevista com o médico assistente de cada paciente, realizada nos dias subseqüentes à extubaçäo. A pesquisa foi aprovada pelo Comitê de Ética e Pesquisa do HSL-PUCRS. RESULTADOS: dos 127 pacientes elegíveis para este estudo, obtivemos dados de 124 pacientes (16,0+29,5 meses, 58 por cento meninos; 92 definidos como clínicos e 32 como cirúrgicos). Cada criança utilizou uma média de 1,7 sedativos-analgésicos em infusäo por dia (sem diferença entre pacientes clínicos e cirúrgicos). Os opióides (morfina e fentanil) foram as drogas mais utilizadas em ambos grupos (fentanil o preferido entre os clínicos, e a morfina entre os cirúrgicos, p<0,001). O tempo médio de uso diferiu significativamente (p<0,01) entre os clínicos e cirúrgicos (6,8 contra 3,9 dias), observando-se também que, a partir de 7 dias de uso, houve um aumento significativo (p<0,01) nas doses de fentanil e midazolam; assim como uma maior prevalência de abstinência (42 por cento) no grupo de pacientes clínicos (p<0,01). CONCLUSÕES: neste estudo que avaliou a prática diária de uma UTI brasileira de referência...

Cuidados com o recém-nascido normal / Care of the normal newborn

O nascimento, por ser um momento de transição, é cercado por uma série de cuidados dirigidos ao preparo de um ambiente favorável ao recém-nascido(RN). Acompanhar o comportamento do feto logo antes do nascimento, o comportamento do RN logo após o parto e o seguimento dos primeiros minutos de vida até a alta hospitalar constituem uma estratégia simples, adequada e eficaz na avaliação da trajetória do bebê na sua adaptação à vida extra-uterina. Neste módulo de ensino serão abordados os cuidados com o RN normal em vários aspectos, desde o período anteparto imediato até a alta hospitalar