Mental Health and Emotional Disorders During the COVID-19 Pandemics: Prevalence and Extent in PICU Staff.

OBJECTIVES: To assess the prevalence of burnout, anxiety and depression symptoms, and posttraumatic stress disorder (PTSD) in PICU workers in Brazil during the first peak of the COVID-19 pandemic. To compare the results of subgroups stratified by age, gender, professional category, health system, and previous mental health disorders. DESIGN: Multicenter, cross-sectional study using an electronic survey. SETTING: Twenty-nine public and private Brazilian PICUs. SUBJECTS: Multidisciplinary PICU workers. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Self-reported questionnaires were used to measure burnout (Maslach Burnout Inventory), anxiety and depression (Hospital Anxiety and Depression Scale), and PTSD (Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [PCL-5]) in 1,084 respondents. Subjects were mainly young (37.1 ± 8.4 yr old) and females (85%), with a median workload of 50 hours per week. The prevalence of anxiety and depression was 33% and 19%, respectively, whereas PTSD was 13%. The overall median burnout scores were high in the emotional exhaustion and personal accomplishment dimensions (16 [interquartile range (IQR), 8-24] and 40 [IQR, 33-44], respectively) whereas low in the depersonalization one (2 [IQR, 0-5]), suggesting a profile of overextended professionals, with a burnout prevalence of 24%. Professionals reporting prior mental health disorders had higher prevalence of burnout (30% vs 22%; p = 0.02), anxiety (51% vs 29%; p < 0.001), and depression symptoms (32.5% vs 15%; p < 0.001), with superior PCL-5 scores for PTSD ( p < 0.001). Public hospital workers presented more burnout (29% vs 18.6%, p < 0.001) and more PTSD levels (14.8% vs 10%, p = 0.03). Younger professionals were also more burned out ( p < 0.05 in all three dimensions). CONCLUSIONS: The prevalence of mental health disorders in Brazilian PICU workers during the first 2020 peak of COVID-19 was as high as those described in adult ICU workers. Some subgroups, particularly those reporting previous mental disorders and younger professionals, should receive special attention to prevent future crises.

Prevalence and functional status of children with complex chronic conditions in Brazilian PICUs during the COVID-19 pandemic

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.

Prevalence and functional status of children with complex chronic conditions in Brazilian PICUs during the COVID-19 pandemic.

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.

Consenso Abem para o ensino de comunicação nas escolas médicas brasileiras / ABEM consensus for the brazilian medical schools' communication curriculum

Resumo: Introdução: A comunicação é uma competência essencial para o(a) médico(a) e outras categorias profissionais, e deve ser desenvolvida durante sua formação profissional. A elaboração de um projeto de comunicação, incluindo um consenso brasileiro, visou subsidiar as escolas médicas a preparar os estudantes de Medicina para se comunicarem efetivamente com os(as) cidadãos/cidadãs brasileiros(as), de características plurais intra e inter-regionais, pautando-se no profissionalismo e nos princípios do Sistema Único de Saúde (SUS). Objetivo: Este manuscrito apresenta o consenso para o ensino de comunicação nas escolas médicas brasileiras. Método: O consenso foi construído colaborativamente com 276 participantes, experts em comunicação, docentes, profissionais de saúde e discentes, de 126 escolas médicas e cinco instituições de saúde, ao longo de nove encontros presenciais em congressos e de encontros virtuais quinzenais ou mensais. Nos encontros, compartilharam-se as experiências dos participantes e o material bibliográfico, incluindo os consensos internacionais, e apresentou-se o consenso em construção, com discussão em grupos para elencar novos componentes para o consenso brasileiro, seguida por debate com todos para pactuá-los. A versão final foi aprovada em reunião virtual, com convite a todos(as) os(as) participantes em julho de 2021. Após submissão, diversas alterações foram requeridas, o que demandou novos encontros para revisão da versão final do consenso. Resultado: O consenso tem como pressupostos que a comunicação deve ser centrada nas relações, pautada nos princípios do SUS, na participação social e no profissionalismo, e embasada nas Diretrizes Curriculares Nacionais do curso de graduação em Medicina, em referenciais teóricos e nas evidências científicas. São descritos objetivos específicos para desenvolver a competência em comunicação nos estudantes, abrangendo: fundamentos teóricos; busca e avaliação crítica da literatura; elaboração e redação de documentos; comunicação intrapessoal e interpessoal no ambiente acadêmico-científico, na atenção à saúde em diversos contextos clínicos e na gestão em saúde. Recomenda-se a inserção curricular da comunicação do início ao final do curso, integrada a outros conteúdos e áreas de saber. Conclusão: Espera-se que esse consenso contribua para a revisão ou implementação da comunicação nos currículos das escolas médicas brasileiras.

Abstract: Introduction: Communication is an essential competence for the physician and other professional categories, and must be developed their professional training. The creation of a communication project including a Brazilian consensus aimed to subsidize medical schools in preparing medical students to communicate effectively with Brazilian citizens, with plural intra and inter-regional characteristics, based on the professionalism and the Brazilian Unified System (SUS) principles. Objective: The objective of this manuscript is to present the consensus for the teaching of communication in Brazilian medical schools. Method: The consensus was built collaboratively with 276 participants, experts in communication, faculty, health professionals and students from 126 medical schools and five health institutions in face-to-face conference meetings and biweekly or monthly virtual meetings. In the meetings, the participants' experiences and bibliographic material were shared, including international consensuses, and the consensus under construction was presented, with group discussion to list new components for the Brazilian consensus, followed by debate with everyone, to agree on them. The final version was approved in a virtual meeting with invitation to all participants in July 2021. After the submission, several changes were required, which demanded new meetings to review the consensus final version. Result: The consensus is based on assumptions that communication should be relationship-centered, embedded on professionalism, grounded on the SUS principles and social participation, and based on the National Guidelines for the undergraduate medical course, theoretical references and scientific evidence. Specific objectives to develop communication competence in the students are described, covering: theoretical foundations; literature search and its critical evaluation; documents drafting and editing; intrapersonal and interpersonal communication in the academicscientific environment, in health care and in health management; and, communication in diverse clinical contexts. The inclusion of communication in the curriculum is recommended from the beginning to the end of the course, integrated with other contents and areas of knowledge. Conclusion: It is expected that this consensus contributes the review or implementation of communication in Brazilian medical schools' curricula.

Influência da participação de estudantes em ligas acadêmicas na escolha da especialidade para o programa de residência médica da Bahia 2017 / Influence of student participation in academic leagues in the choice of specialty for the Bahia 2017 Medical Residency Program

Introdução: A participação em Ligas Acadêmicas (LAs), hoje, é um importante componente do processo formativo do estudante de Medicina. No entanto, esta participação pode estar propiciando precocemente a escolha da especialidade futura, limitando a atuação e a busca por conhecimento amplo e generalizado. Objetivo: Avaliar a influência da participação em LAs sobre a escolha da especialidade por recém-ingressos no Programa de Residência Médica da Bahia 2017 (PRM/BA/2017). Métodos: Estudo epidemiológico observacional transversal, no qual residentes do PRM/BA/2017, durante matrícula, foram convidados a responder questionário contendo informações sobre a participação em LAs e a escolha da especialização médica. Resultados:Dos 339 entrevistados, 79,8% participaram de LAs. Destes, 45,4% consideraram que a participação em LAs influenciou a escolha da especialidade. A correlação geral entre participação em LAs e escolha de especialidade na mesma área (correlação L-E) atingiu 30,9% e foi encontrada aumentada de maneira significativa no grupo que considerou que a participação em LAs influenciou o processo decisório, que participou da LA durante mais de 3 semestres, que ocupou 3 ou 4 cargos em uma mesma liga, que participou de "Estágios" e que alegou "Afinidade/Curiosidade" como principal motivo para entrada na LA. Das grandes áreas da Medicina, o grupo que optou por Cirurgia Geral apresentou maior correlação L-E (53,1%) e o que optou pela Pediatria menor (12,5%) Conclusões: Apesar de estar presente no processo formativo da maioria dos estudantes, a participação em LAs não pareceu representar a especialização precoce destes. O fator mais associado à correlação L-E foi a percepção de que esta participação influenciou a escolha da especialidade.

Introduction: Participating in Academic Leagues (LAs) nowadays is an important component of the medical student's graduation process. However, this participation may be prematurely promoting specialty choice, limiting the performance and the search for ample and widespread knowledge. Objective: Evaluate the influence of participating in LAs with regards to the choice of specialty by new entrants in the Medical Residency Program of Bahia 2017 (PRM/BA/2017). Methodology: This is an observational cross-sectional epidemiological study in which residents from the PRM/BA/2017, during the enrollment, were invited to respond a questionnaire containing information about the participation in LAs and the choice of medical specialization. Results: 339 individuals were interviewed. 79.8% of interviewed participated in LAs. From those, 45.4% considered that participating in LAs influenced the choice of specialty. The general correlation between participation in LAs and the choice of a specialty at the same area (L-E correlation) reached 30.9%. A higher and significant L-E correlation was found in group that considered participation in LA as a influence in the decision making process, that participated in LA for more than 3 semesters, that occupied 3 or 4 positions at the same league, that participated on "Internship" and that claimed "Affinity/Curiosity" as the main reason for get into LA. Within all the medical specialties, the group that have chosen General Surgery had higher L-E correlation and the one that chose Pediatrics had lower. Conclusions: Despite being present in the training process of most students, participating in LAs did not seem to represent their premature specialization. The most associated factor with the L-E correlation was the perception that this participation influenced the choice of the specialization.

Perfil das internações por causas respiratórias em duas unidades de terapia intensiva pediátricas em Salvador, Bahia / Profile of hospitalizations for respiratory causes in two pediatric intensive care units in Salvador, Bahia / Perfil de hospitalizaciones por causas respiratórias en dos unidades de cuidados intensivos pediátricos en Salvador, Bahía

As doenças respiratórias são associadas a grande morbidade e mortalidade na faixa etária pediátrica e, assim, responsáveis por hospitalizações em Unidades de Terapia Intensiva Pediátricas (UTIPs). O objetivo deste estudo foi descrever as principais causas de admissão por doenças respiratórias e a evolução desses pacientes em duas UTIPs. Tratou-se de estudo descritivo e retrospectivo. Foram coletados dados de todos os pacientes admitidos por doença do trato respiratório, durante o ano de 2011, em duas UTIPs terciárias, da cidade de Salvador, Bahia. Nesse período, foram admitidos 625 pacientes, dos quais 355 (56,8%) tinham doença do trato respiratório. Destes, a maioria foi do sexo masculino (55,2%) e houve predominância de lactentes (55,8%). O tempo de permanência em UTIP esteve entre um e sete dias (75,8%). Pneumonia foi a principal causa de admissão (37,7%), seguida de bronquiolite (18,9%) e asma (12,4%). O uso de ventilação não invasiva foi verificado em 178 pacientes (50,1%) e 86 pacientes (24,2%) necessitaram de ventilação invasiva. Houve 23 óbitos (6,47%). Concluiu- -se que as doenças respiratórias constituem ainda causas importantes de morbimortalidade na infância.

Respiratory diseases are associated to high morbidity and mortality in pediatric patients and so are responsible for hospitalizations in Pediatric Intensive Care Units (PICUs). The objective of this study was to describe the main causes of admission due to respiratory diseases and the evolution of these patients in two PICUs. This was a descriptive and a retrospective study. Data were collected from all patients admitted for respiratory tract disease in two tertiary PICUs, in Salvador-Bahia, during the year 2011. During this period, 625 patients were admitted, of whom 355 (56,8%) had respiratory tract disease. The majority of them was male (55,2%) predominantly infants (55,8%). The length of stay in PICUs range was between one to seven days (75,8%). Pneumonia was the leading cause of admission (37,7%), followed by bronchiolitis (18,9%) and asthma (12,4%). The use of noninvasive ventilation was found in 178 patients (50,1%) and 86 patients (24,2%) required invasive ventilation. In conclusion, respiratory diseases are current important causes of morbidity and mortality in childhood.

Enfermedades respiratorias se asocian con una alta morbilidad y mortalidad en pacientes pediátricos y por lo tanto responsable de las hospitalizaciones en unidades de cuidados intensivos pediátricos (UCIP). El objetivo de este estudio fue describir las principales causas de internamiento por enfermedades respiratorias y la evolución de estos pacientes en dos UCIP. Se trató de un estudio descriptivo y retrospectivo. Se recogieron datos de todos los pacientes internados por enfermedades respiratorias durante el año 2011, en dos UCIP terciarias de Salvador-Bahía. Durante este período, 625 pacientes internados, de los cuales, 355 (56,8%) tenían enfermedad del tracto respiratorio. De ellos, la mayoría fue del sexo masculino (55,2%) y hubo un predominio de lactantes (55,8%). El tiempo de permanencia en la UCIP varió de un a siete días (75,8%). La neumonía es la principal causa de internamiento (37,7%), seguida por bronquiolitis (18,9%) y el asma (12,4%). Se observó el uso de la ventilación no invasiva en 178 pacientes (50,1%) y 86 pacientes (24,2%) requirieron ventilación invasiva. Hubo 23 muertes (6,47%). Las enfermedades respiratorias son causas importantes de morbilidad y mortalidad en la infancia.

Bioética e literatura: relato de experiência do Eixo ético-humanístico FMB-UFBA / Bioética y literatura: relato de experiencia del Eje Ético-humanístico FMB-UFBA / Bioethics and literature: the experience report of Ethical-humanistic axis - FMB-UFBA

O ensino médico brasileiro tem-se transformado para atender às demandas do modelo assistencial em saúde e à implementação do Sistema Único de Saúde, bem como formar profissionais com atuação generalista, capazes de prestar assistência integral e humanizada. A reforma curricular da Faculdade de Medicina da Universidade Federal da Bahia, marco no ensino médico no estado, implantou o Eixo ético-humanístico do primeiro ao oitavo semestre do curso médico. Neste Eixo, diversas ferramentas são utilizadas no ensino da ética médica e bioética, inclusive literatura narrativa. A partir de observação empreendida no período de 2009 a 2012 este trabalho relata a experiência do referido Eixo com o uso dessa forma de literatura para o ensino médico. A literatura pode ser usada como ferramenta para viabilizar o debate sobre questões político-sociais, necessárias à formação do médico, e induzir reflexões sobre o sofrimento humano e as relações humanas imanentes à prática médica.

La educación médica en Brasil ha sido objeto de reforma con el fin de atender a las demandas del modelo de atención de salud y a la implementación del Sistema Único de Salud y de formar médicos generalistas capaces de proporcionar la atención médica integral y humanizada. La reforma curricular de la Facultad de Medicina de la Universidad Federal de Bahía (FMB-UFBA), hito em la educación médica en el Estado, há implementado el Eje Ético-humanístico, desde el primer al octavo semestre del plan de estudios médicos. En dicho Eje, se utilizan diversas herramientas para la estúdio de la ética médica y bioética, incluso literatura narrativa. Desde observación tomada en el período de 2009 a 2012. Este trabajo relata la experiência del referido Eje con el uso de este tipo de literatura para el estúdio médico. La literatura puede ser utilizada como una herramienta que permite el debate sobre los planteamientos políticos y sociales, necesarios a la formación del médico e inducen a las reflexiones acerca del sufrimiento humano y las relaciones humanas inherentes a la práctica médica.

Medical education in Brazil has been reconstructed in order to attend demands of the health care model, the implementation of the Unified Health System and to form generalist physicians that are able to provide humanistic and integral health care. The curricular reform, a turning point in medical education in the Faculty of Medicine, Federal University of Bahia (FMB-UFBA), has implemented its Ethical-humanistic axis, from the first to the eighth semester of medical school curriculum. Many tools are applied in the teaching of medical ethics and bioethics, including the use of literature. This work aims to report the experience of Ethical-humanistic axis of FMB-UFBA in the use of literature in medical education during the period from 2009 to 2012. Literature can be used as a tool that enables the debate on political and social issues, necessary in medical education and allow the reflection on human suffering and human relations inherent to medical practice.

Noninvasive ventilation for acute respiratory failure in children: a systematic review / Ventilação não invasiva em crianças com insuficiência respiratória aguda: uma revisão sistemática

Objective: To evaluate the use of the non-invasive ventilation in the treatment of children with acute respiratory failure. Methods: A systematic review of literature was conducted in MEDLINE, LILACS, EMBASE and Cochrane Library databases and references of articles. Blood oxygenation, ventilation and survival were the outcomes evaluated. Results: Until May 2010, 120 publications related to non-invasive ventilation were found. Only 19 of them were clinical trials focused on the use of non-invasive ventilation in children. There are already prospective clinical trials and cohort studies to support a quality of evidence level II concerning the use of non-invasive ventilation in children. Conclusions: There is moderate evidence to support the non-invasive ventilation use in children, with a B-II grade of recommendation.

Objetivo: Avaliar o papel da ventilação não invasiva no tratamento de crianças com insuficiência respiratória aguda. Métodos: Revisão sistemática da literatura sobre ventilação não invasiva nas bases MEDLINE, LILACS, EMBASE e Cochrane, além de referências de artigos. Os desfechos avaliados foram resposta sobre a oxigenação e ventilação sanguínea, e a sobrevida dos pacientes. Resultados: Foram encontrados 120 estudos sobre ventilação não invasiva até Maio de 2010. Destes, apenas 19 eram sobre ventilação não invasiva em crianças. Já há ensaios clínicos prospectivos e de coorte, levando a uma qualidade de evidência nível II sobre o uso de ventilação não invasiva em crianças. Conclusão: Já há evidência científica para recomendar o uso da ventilação não invasiva, com um grau de recomendação B-II.

Noninvasive ventilation for acute respiratory failure in children - a systematic review.

OBJECTIVE: To assess the role of noninvasive ventilation in the treatment of children with acute respiratory failure. METHODS: A systematic review of literature on noninvasive ventilation in MEDLINE, LILACS, EMBASE, and Cochrane databases, besides references in articles. The outcomes evaluated were responses in blood oxygenation and ventilation, and patient survival. RESULTS: A total of 120 studies on noninvasive ventilation were found as of May, 2010. Of these, only 19 were about noninvasive ventilation in children. On the other hand, there are prospective and cohort clinical trials leading to a level II quality of evidence concerning the use of noninvasive ventilation in children. CONCLUSION: There is scientific evidence for proposing the use of noninvasive ventilation, with a B-II degree of recommendation.

End-of-life practices in seven Brazilian pediatric intensive care units.

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.

Avaliação do conhecimento de estudantes de medicina sobre morte encefálica / Evaluation of medical students knowledge on brain death

JUSTIFICATIVA E OBJETIVOS: Por ser um conceito relativamente novo e pouco divulgado na sociedade, o diagnóstico de morte encefálica (ME) ainda não é bem aceito pela população em geral, inclusive entre médicos e estudantes de Medicina. O objetivo deste estudo foi avaliar o conhecimento de uma amostra de estudantes de Medicina sobre o protocolo diagnóstico de ME. MÉTODO: Estudo descritivo de corte transversal, avaliando acadêmicos de duas faculdades de Medicina de Salvador-BA. Foi distribuído um questionário auto-aplicável composto por questões referentes à conhecimento, técnico e ético, contidos na Resolução nº 1.480/97 do Conselho Federal de Medicina, que dispõe sobre os critérios para caracterização de ME. RESULTADOS: Foram avaliados 115 estudantes. A média de acertos nas 14 questões sobre o conhecimento dos critérios da ME foi de 6,7 ± 1,8; sendo maior entre os estudantes que haviam assistido alguma apresentação sobre ME. A maioria dos estudantes (87,4 por cento) soube identificar os pacientes candidatos ao protocolo de ME. No entanto, apenas 5,2 por cento e 16,1 por cento dos estudantes acertaram, respectivamente, os testes clínicos e complementares que devem ser realizados durante o protocolo. Frente a um paciente não-doador com diagnóstico confirmado de ME, 66,4 por cento referiram que o suporte artificial de vida deve ser suspenso. Apenas 15 por cento dos estudantes entrevistados já avaliaram um paciente com ME, sendo este percentual maior entre os que já haviam realizado estágio em UTI (38,2 por cento versus 5,1 por cento; p < 0,001). CONCLUSÕES: Os resultados deste estudo apontaram para um conhecimento limitado dos estudantes avaliados sobre os critérios para caracterização da ME, principalmente em relação à sua abordagem prática.

BACKGROUND AND OBJECTIVES: Because brain death (BD) is a new concept and little divulged, itÆs not well accepted in general population, including doctors and Medical students. This study aims to evaluate the knowledge of a sample of Medical students on the Brazilian BD diagnosis protocol. METHODS: Descriptive cross-sectional survey that evaluated students from two medical schools in Salvador-BA. We used a questionnaire composed by questions about technical and ethical knowledge contained in the Federal Council of MedicineÆs Resolution nº 1480/97 that establishes the criteria for BD diagnosis. RESULTS: We evaluated 115 Medical students. In 14 questions about the knowledge of BD criteria, the mean of right answers were 6.7 ± 1.8, which were higher among the students that had attended some presentation on BD. Most of the students (87.4 percent) knew how to identify the candidates to the BD diagnosis protocol. However, only 5.2 percent and 16.1 percent of the students answered right, respectively, the clinical and complementary tests that should be accomplished during the diagnosis protocol. Facing a no-donor patient with confirmed diagnosis of BD, 66.4 percent referred that artificial life support should be suspended. Only 15 percent of the interviewed students had already evaluated a patient with BD, being this percentage higher among those who had already frequented ICU (38.2 percent versus 5.1 percent; p < 0.001). CONCLUSIONS: The results of this study showed a limited knowledge of the evaluated students on BD diagnosis criteria, mainly in relation to the practical approach of this condition.

Brain death: medical management in seven Brazilian pediatric intensive care units

OBJETIVO: Avaliar a incidência de morte encefálica (ME), bem como as condutas e protocolos adotados após confirmação diagnóstica em sete unidades de tratamento intensivo pediátrico (UTIP) localizadas em três regiões brasileiras. MÉTODOS: Estudo transversal e multicêntrico baseado na revisão e análise retrospectiva de prontuários de todos os óbitos ocorridos entre janeiro de 2003 e dezembro de 2004 em sete UTIP localizadas em Porto Alegre (duas), São Paulo (duas) e Salvador (três). Dois residentes de cada serviço previamente treinados preencheram protocolo padronizado avaliando dados demográficos, causa do óbito, critérios para diagnóstico de ME e conduta médica adotada. RESULTADOS: Identificamos 525 óbitos, sendo 61 (11,6 por cento) com diagnóstico de ME. A incidência de ME diferiu entre as sete UTIP (24,2 a 4,5 por cento; p = 0,015), porém sem diferença nas três regiões (12, 15 e 7 por cento; p = 0,052). A causa mais freqüente foi hemorragia intracraniana (31,1 por cento). Em 80 por cento dos casos, o diagnóstico clínico de ME foi confirmado por exame complementar (100 por cento na Região Sul, 68 por cento na Sudeste e 72 por cento na Nordeste, p = 0,02). A retirada de suporte vital após diagnóstico de ME diferiu nas três regiões, sendo mais rápida (p = 0,04) no Sul (1,8±1,9 h) que no Sudeste (28,6±43,2 h) e Nordeste (15,5±17,1 h). Apenas seis (9,8 por cento) crianças com ME foram doadoras de órgãos. CONCLUSÃO: Apesar da lei que define critérios para ME existir no Brasil desde 1997, verificamos que ela não é obedecida uniformemente. Conseqüentemente, suporte vital desnecessário é ofertado a indivíduos já mortos, existindo ainda um modesto envolvimento das UTIP com doações de órgãos.

OBJECTIVE: To assess the incidence of brain death (BD) and its medical management and adopted protocols after its diagnosis in seven pediatric intensive care units (PICUs) located in three Brazilian regions. METHODS: A cross-sectional and multicenter study was conducted, based on the retrospective review of medical records regarding all deaths that occurred between January 2003 and December 2004 in seven Brazilian PICUs of tertiary hospitals located in Porto Alegre (two), São Paulo (two) and Salvador (three). Two pediatric intensive care residents from each hospital were previously trained and filled out a standard protocol for the investigation of demographic data, cause of death, diagnosis of BD, related protocols and subsequent medical management. RESULTS: A total of 525 death patients were identified and 61 (11.6 percent) were defined as BD. The incidence of BD was different (p = 0.015) across the seven PICUs, but with no difference across the three regions. Intracranial hemorrhage was the most frequent cause of BD (31.1 percent). In 80 percent of the cases the diagnosis of BD was confirmed by complementary exams (south = 100 percent, southeast = 68 percent and northeast = 72 percent; p = 0.02). The interval between the diagnosis of BD and the withdrawal of life support was different (p < 0.01) across the three regions, being faster (p = 0.04) in the south (1.8±1.9 h) than in the southeast (28.6±43.2 h) and than in the northeast (15.5±17.1 h). Only six (9.8 percent) children with BD were organ donors. CONCLUSION: Although a Brazilian law defining the criteria for the determination of BD has been in place since 1997, we verified that it is not followed as strictly as it should be. Consequently, unnecessary life support is offered to deceased individuals, and there is a discrete involvement of PICUs in organ donation.

Brain death: medical management in seven Brazilian pediatric intensive care units.

OBJECTIVE: To assess the incidence of brain death (BD) and its medical management and adopted protocols after its diagnosis in seven pediatric intensive care units (PICUs) located in three Brazilian regions. METHODS: A cross-sectional and multicenter study was conducted, based on the retrospective review of medical records regarding all deaths that occurred between January 2003 and December 2004 in seven Brazilian PICUs of tertiary hospitals located in Porto Alegre (two), São Paulo (two) and Salvador (three). Two pediatric intensive care residents from each hospital were previously trained and filled out a standard protocol for the investigation of demographic data, cause of death, diagnosis of BD, related protocols and subsequent medical management. RESULTS: A total of 525 death patients were identified and 61 (11.6%) were defined as BD. The incidence of BD was different (p = 0.015) across the seven PICUs, but with no difference across the three regions. Intracranial hemorrhage was the most frequent cause of BD (31.1%). In 80% of the cases the diagnosis of BD was confirmed by complementary exams (south = 100%, southeast = 68% and northeast = 72%; p = 0.02). The interval between the diagnosis of BD and the withdrawal of life support was different (p < 0.01) across the three regions, being faster (p = 0.04) in the south (1.8+/-1.9 h) than in the southeast (28.6+/-43.2 h) and than in the northeast (15.5+/-17.1 h). Only six (9.8%) children with BD were organ donors. CONCLUSION: Although a Brazilian law defining the criteria for the determination of BD has been in place since 1997, we verified that it is not followed as strictly as it should be. Consequently, unnecessary life support is offered to deceased individuals, and there is a discrete involvement of PICUs in organ donation.

[Evaluation of medical students knowledge on brain death]. / Avaliação do conhecimento de estudantes de medicina sobre morte encefálica.

BACKGROUND AND OBJECTIVES: Because brain death (BD) is a new concept and little divulged, it’s not well accepted in general population, including doctors and Medical students. This study aims to evaluate the knowledge of a sample of Medical students on the Brazilian BD diagnosis protocol. METHODS: Descriptive cross-sectional survey that evaluated students from two medical schools in Salvador-BA. We used a questionnaire composed by questions about technical and ethical knowledge contained in the Federal Council of Medicine’s Resolution nº 1480/97 that establishes the criteria for BD diagnosis. RESULTS: We evaluated 115 Medical students. In 14 questions about the knowledge of BD criteria, the mean of right answers were 6.7 ± 1.8, which were higher among the students that had attended some presentation on BD. Most of the students (87.4%) knew how to identify the candidates to the BD diagnosis protocol. However, only 5.2% and 16.1% of the students answered right, respectively, the clinical and complementary tests that should be accomplished during the diagnosis protocol. Facing a no-donor patient with confirmed diagnosis of BD, 66.4% referred that artificial life support should be suspended. Only 15% of the interviewed students had already evaluated a patient with BD, being this percentage higher among those who had already frequented ICU (38.2% versus 5.1%; p < 0.001). CONCLUSIONS: The results of this study showed a limited knowledge of the evaluated students on BD diagnosis criteria, mainly in relation to the practical approach of this condition.

Ethical aspects in the management of the terminally ill patient in the pediatric intensive care unit.

OBJECTIVE: To identify the prevalence of management plans and decision-making processes for terminal care patients in pediatric intensive care units. METHODOLOGY: Evidence-based medicine was done by a systematic review using an electronic data base (LILACS, 1982 through 2000) and (MEDLINE, 1966 through 2000). The key words used are listed and age limits (0 to 18 years) were used. RESULTS: One hundred and eighty two articles were found and after selection according to the exclusion/inclusion criteria and objectives 17 relevant papers were identified. The most common decisions found were do-not-resuscitation orders and withdrawal or withholding life support care. The justifications for these were "imminent death" and "unsatisfatory quality of life". CONCLUSION: Care management was based on ethical principles aiming at improving benefits, avoiding harm, and when possible, respecting the autonomy of the terminally ill patient.

Ethical aspects in the management of the terminally ill patient in the pediatric intensive care unit

OBJETIVO: Identificar a prevalência das condutas e o processo de decisão na abordagem do paciente terminal na UTI pediátrica. METODOLOGIA: Revisão sistemática da literatura. seguindo os critérios da medicina baseada em evidências. nas seguintes bases de dados: LILACS (1982-2000) e MEDLINE (1966-2000). usando os descritores abaixos limitados para a idade (0 a 18 anos). RESULTADOS: Foram selecionados 183 artigos e após análise dos critérios de exclusão / inclusão e os objetivos restaram 17 artigos. As condutas mais prevalentes foram: ordem de não ressuscitar. omissão e/ou suspensão de suporte de vida. As justificativas mais encontradas para tais condutas foram: "morte iminente" e "qualidade de vida insatisfatória". CONCLUSAO: A abordagem tem base nos princípios éticos e visa maximizar o benefício e evitar a distanásia. se possível. respeitando a autonomia do paciente terminal.

Ressuscitação cardiopulmonar: discrepância entre o procedimento de ressuscitação e o registro no prontuário / Cardiopulmonary resuscitation: discrepancy between the actual cardiopulmonary resuscitation and the documentation in the medical record

Objetivo: Descrever as caracteristicas de pacientes não ressuscitados em um hospital-escola pediátrico de nível terciário, caracterizar como foi feito o registro da não ressuscitação no protuário e avaliar os aspectos éticos e legais envolvidos na ressuscitação cardiopulmonar. Método: Foi feito um estudo tipo coorte prospectivo, exploratório e observacional de todas as paradas cardiorrespiratórias (PCR) neste período. Os médicos que atenderam cada PCR foram entrevistados, geralmente nas primeiras 24 pós o evento. Posteriormente foi revisto o prontuário para confrontar a informação referente à ressuscitação cardiopulmonar com o fato registrado no prontuário. São discutidos aspectos ético-legais envolvidos na ressuscitação cardiopulmonar. Resultados: Durante o ano de estudo houve 176 PCRs. Destas 47 (26,7 por cento) não foram ressuscitadas. Foram excluídos 2 casos; na avaliação de 45 pacientes, 64,4 por cento (29/45) estavam em ventilação mecânica e 48,9 por cento (23/45) usavam drogas vasoativas. O óbito ocorreu em 60 por cento (27/45) na UTI. O diagnóstico à admissão mais frequente foi sepse em 28,8 por cento (13/45) e broncopneumonia e insuficiência respiratória em 27 por cento (12/45). a doença de base mais encontrada foi a oncológica com 28,8 por cento (13/45). Foi possível avaliar o registro do óbito prontuários de pacientes não ressuscitados. Em 11 destes 40 (27,5 por cento) a descrição era: "constatado óbito"e nos outros 29 (72,5 por cento) constava: "feitas manobras habituais de ressuscitação sem sucesso". Conclusão: Este trabalho comprovou que o registro inverídico no prontuário em relação aos procedimentos de ressuscitação ocorreu com muita frequência. É injustificavel a discrepância encontrada entre o que foi realizado e o que foi registrado no prontuário. Esta conduta se deve ao receio das consequências legais de uma conduta médica que foi adota em benefício do paciente e é justificável, portanto, do ponto de vista ético

Aspectos éticos e legais na emergência / Ethical and legal aspects at the emergency departament

Objetivo: Discutir aspectos éticos e legais das aaatitudes dos médicos em emergências e pronto-atendimentos baseados em códigos de conduta e estatutos legais vigentes no país. Métodos: Os autores levantam questionamentos a partir de casos clínicos ilustrativos e fazem comentários utilizando o Código de Ética Médica, o Estatuto da Criança e do Adolescente Hospitalizados, além de resoluções do Conselho Federal de Medicina. Resultados: São abordados os direitos da criança enquanto paciente e o direito de informação dos pais; a questão do abuso e maus-tratos domiciliares e o dever do médico como denunciante de tal prática no interesse e proteção da criança; a responsabilidade médica mesmo em condições adversas de trabalho, bem como os cuidados do profissional na transferência de pacientes pra outras instituições; o dilema entre não-adotar e/ou retirar medidas de suporte de vida na emergência e o impedimento de atestar o óbito em situações de morte violenta; o exercício da autonomia e da tomada de decisões do paciente adolescente e os seus limites, incluindo as situações de quebra de confidencialidade. Conclusões: Os comentários apresentados no artigo procuram esclarecer o pediatra no sentido de detectar conflitos éticos e legais no atendimento de emergência, bem como prepará-lo para tomar atitudes que obedeçam os códigos e estatutos vigentes e respeitem os direitos dos pacientes