Factors associated with survival and neurologic outcome after in-hospital cardiac arrest in children: A cohort study.

Aim: In-hospital paediatric cardiopulmonary resuscitation (CPR) survival has been improving in high-income countries. This study aimed to analyse factors associated with survival and neurological outcome after paediatric CPR in a middle-income country. Methods: This observational study of in-hospital cardiac arrest using Utstein-style registry included patients <18 years old submitted to CPR between 2015 and 2020, at a high-complexity hospital. Outcomes were survival and neurological status assessed using Paediatric Cerebral Performance Categories score at prearrest, discharge, and after 180 days. Results: Of 323 patients who underwent CPR, 108 (33.4%) survived to discharge and 93 (28.8%) after 180 days. In multivariable analysis, lower survival at discharge was associated with liver disease (OR 0.060, CI 0.007-0.510, p = 0.010); vasoactive drug infusion before cardiac arrest (OR 0.145, CI 0.065-0.325, p < 0.001); shock as the immediate cause (OR 0.183, CI 0.069-0.486, p = 0.001); resuscitation > 30 min (OR 0.070, CI 0.014-0.344, p = 0.001); and bicarbonate administration during CPR (OR 0.318, CI 0.130-0.780, p = 0.01). The same factors remained associated with lower survival after 180 days. Neurological outcome was analysed in the 93 survivors after 180 days following CPR. Prearrest neurological dysfunction was observed in 31.4%, and neurological prognosis was favourable in 79.7% at discharge and similar after 180 days. Conclusion: In-hospital paediatric cardiac arrest patients with complex chronic conditions had lower survival associated with liver disease, shock as cause of cardiac arrest, vasoactive drug infusion before cardiac arrest, bicarbonate administration during CPR, and prolonged resuscitation. Most survivors had favourable neurological outcome.

Changing the view: impact of simulation-based mastery learning in pediatric tracheal intubation with videolaryngoscopy

Abstract Objective: To determine the effect of a training program using simulation-based mastery learning on the performance of residents in pediatric intubations with videolaryngoscopy. Method: Retrospective cohort study carried out in a tertiary pediatric hospital between July 2016 and June 2018 evaluating a database that included the performance of residents before and after training, as well as the outcome of tracheal intubations. A total of 59 pediatric residents were evaluated in the pre-training with a skills' checklist in the scenario with an intubation simulator; subsequently, they were trained individually using a simulator and deliberate practice in the department itself. After training, the residents were expected to have a minimum passing grade (90/100) in a simulated scenario. The success of the first attempted intubation, use of videolaryngoscopy, and complications in patients older than 1 year of age during the study period were also recorded in clinical practice. Results: Before training, the mean grade was 77.5/100 (SD 15.2), with only 23.7% (14/59) of residents reaching the minimum passing grade of 90/100. After training, 100% of the residents reached the grade, with an average of 94.9/100 (SD 3.2), p < 0.01, with only 5.1% (3/59) needing more practice time than that initially allocated. The success rate in the first attempt at intubation in the emergency department with videolaryngoscopy was 77.8% (21/27). The rate of adverse events associated with intubations was 26% (7/27), representing a serious event. Conclusions: Simulation-based mastery learning increased residents' skills related to intubation and allowed safe tracheal intubations with video laryngoscopy.

Changing the view: impact of simulation-based mastery learning in pediatric tracheal intubation with videolaryngoscopy.

OBJECTIVE: To determine the effect of a training program using simulation-based mastery learning on the performance of residents in pediatric intubations with videolaryngoscopy. METHOD: Retrospective cohort study carried out in a tertiary pediatric hospital between July 2016 and June 2018 evaluating a database that included the performance of residents before and after training, as well as the outcome of tracheal intubations. A total of 59 pediatric residents were evaluated in the pre-training with a skills' checklist in the scenario with an intubation simulator; subsequently, they were trained individually using a simulator and deliberate practice in the department itself. After training, the residents were expected to have a minimum passing grade (90/100) in a simulated scenario. The success of the first attempted intubation, use of videolaryngoscopy, and complications in patients older than 1year of age during the study period were also recorded in clinical practice. RESULTS: Before training, the mean grade was 77.5/100 (SD 15.2), with only 23.7% (14/59) of residents reaching the minimum passing grade of 90/100. After training, 100% of the residents reached the grade, with an average of 94.9/100 (SD 3.2), p<0.01, with only 5.1% (3/59) needing more practice time than that initially allocated. The success rate in the first attempt at intubation in the emergency department with videolaryngoscopy was 77.8% (21/27). The rate of adverse events associated with intubations was 26% (7/27), representing a serious event. CONCLUSIONS: Simulation-based mastery learning increased residents' skills related to intubation and allowed safe tracheal intubations with video laryngoscopy.

Evaluation of rapid sequence intubation in the pediatric emergency department.

OBJECTIVES: To describe the experience of the emergency department of a pediatric hospital with rapid sequence intubation (RSI) and to identify the factors associated with successful intubation. METHODS: This prospective, observational, cross-sectional study conducted from July 2005 to December 2007 consisted of collection of data regarding tracheal intubations performed at the emergency department of Instituto da Criança of Hospital das Clínicas, School of Medicine, Universidade de São Paulo. Successful tracheal intubations were the ones performed at the first attempt. RESULTS: One-hundred and seventeen tracheal intubations were performed; 80% of them were RSIs; 79% of patients had underlying diseases; acute respiratory failure was the cause of tracheal intubation in 40%; success rate was 39%; second-year pediatric resident physicians were responsible for 74% of tracheal intubations; positive pressure ventilation was performed in 74% of procedures, with less frequent use among patients who were successfully intubated (p = 0.002). Midazolam was the sedative used in 80% of procedures, and rocuronium was the neuromuscular blocker in 100%; complications of RSI were described in 80% of intubations, with decreased oxygen saturation being reported in 47% and lower decrease in those patients successfully intubated (p < 0.001); difficulties related to tracheal intubation were less frequent in the successful procedures (p < 0.001). CONCLUSION: RSI is the method of choice for tracheal intubations performed in the emergency department (80%). In spite of the low success rate (39%) in the present study, RSI has proven to be a safe method, with a low incidence of severe complications. The success of tracheal intubation using RSI seems to be directly related to the preparation of the procedure and the health professional's experience. Thus, we conclude that further training of resident physicians and health professionals working in the emergency department is required.

Avaliação da sequência rápida de intubação em pronto-socorro pediátrico / Evaluation of rapid sequence intubation in the pediatric emergency department

OBJETIVOS: Descrever a experiência do pronto-socorro de um hospital pediátrico com a sequência rápida de intubação e detectar os fatores associados ao sucesso. MÉTODOS: Estudo prospectivo transversal observacional de julho de 2005 a dezembro de 2007, de coleta de dados das intubações traqueais realizadas no pronto-socorro do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Foi considerada intubação traqueal com sucesso aquela realizada na primeira tentativa. RESULTADOS: Foram realizadas 117 intubações traqueais, 80 por cento sob sequência rápida de intubação; 79 por cento eram portadores de doenças de base; a insuficiência respiratória aguda foi a causa da intubação traqueal em 40 por cento; a taxa de sucesso foi de 39 por cento; o residente de pediatria do segundo ano foi o responsável por 74 por cento das intubações traqueais; foi realizada ventilação com pressão positiva em 74 por cento dos procedimentos, sendo menor a sua utilização entre os pacientes que foram intubados com sucesso (p = 0,002). Midazolam foi o sedativo utilizado em 80 por cento dos procedimentos, e rocurônio foi o bloqueador neuromuscular em 100 por cento; complicações decorrentes da sequência rápida de intubação foram descritas em 80 por cento, sendo a queda da saturação de oxigênio relatada em 47 por cento e menor nos pacientes intubados com sucesso (p < 0,001); dificuldades relativas à intubação traqueal foram menos relatadas nos procedimentos com sucesso (p < 0,001). CONCLUSÃO: A sequência rápida de intubação foi o método de escolha nas intubações traqueais realizadas no pronto-socorro (80 por cento) e demonstrou ser um método seguro e com baixa incidência de complicações graves, apesar de ter apresentado baixa taxa de sucesso (39 por cento) neste estudo. O sucesso da intubação traqueal com sequência rápida de intubação parece estar diretamente relacionado ao preparo adequado do procedimento e experiência do profissional, podendo-se concluir que é necessário maior treinamento dos residentes e dos assistentes envolvidos no atendimento de emergência.

OBJECTIVES: To describe the experience of the emergency department of a pediatric hospital with rapid sequence intubation (RSI) and to identify the factors associated with successful intubation. METHODS: This prospective, observational, cross-sectional study conducted from July 2005 to December 2007 consisted of collection of data regarding tracheal intubations performed at the emergency department of Instituto da Criança of Hospital das Clínicas, School of Medicine, Universidade de São Paulo. Successful tracheal intubations were the ones performed at the first attempt. RESULTS: One-hundred and seventeen tracheal intubations were performed; 80 percent of them were RSIs; 79 percent of patients had underlying diseases; acute respiratory failure was the cause of tracheal intubation in 40 percent; success rate was 39 percent; second-year pediatric resident physicians were responsible for 74 percent of tracheal intubations; positive pressure ventilation was performed in 74 percent of procedures, with less frequent use among patients who were successfully intubated (p = 0.002). Midazolam was the sedative used in 80 percent of procedures, and rocuronium was the neuromuscular blocker in 100 percent; complications of RSI were described in 80 percent of intubations, with decreased oxygen saturation being reported in 47 percent and lower decrease in those patients successfully intubated (p < 0.001); difficulties related to tracheal intubation were less frequent in the successful procedures (p < 0.001). CONCLUSION: RSI is the method of choice for tracheal intubations performed in the emergency department (80 percent). In spite of the low success rate (39 percent) in the present study, RSI has proven to be a safe method, with a low incidence of severe complications. The success of tracheal intubation using RSI seems to be directly related to the preparation of the procedure and the health professional's experience. Thus, we conclude that further training of resident physicians and health professionals working in the emergency department is required.

A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest.

BACKGROUND: When efforts to resuscitate a child after cardiac arrest are unsuccessful despite the administration of an initial dose of epinephrine, it is unclear whether the next dose of epinephrine (i.e., the rescue dose) should be the same (standard) dose or a higher dose. METHODS: We performed a prospective, randomized, double-blind trial to compare high-dose epinephrine (0.1 mg per kilogram of body weight) with standard-dose epinephrine (0.01 mg per kilogram) as rescue therapy for in-hospital cardiac arrest in children after failure of an initial, standard dose of epinephrine. The trial included 68 children, and Utstein-style reporting guidelines were used. The primary outcome measure was survival 24 hours after the arrest. RESULTS: The rate of survival at 24 hours was lower in the group assigned to a high dose of epinephrine as rescue therapy than in the group assigned to a standard dose: 1 of the 34 patients in the high-dose group survived for 24 hours, as compared with 7 of the 34 patients in the standard-dose group (unadjusted odds ratio for death with the high dose, 8.6; 97.5 percent confidence interval, 1.0 to 397.0; P=0.05). After adjustment by multiple logistic-regression analysis for differences in the groups at the time of arrest, the high-dose group tended to have a lower 24-hour survival rate (odds ratio for death, 7.9; 97.5 percent confidence interval, 0.9 to 72.5; P=0.08). The two treatment groups did not differ significantly in terms of the rate of return of spontaneous circulation (which occurred in 20 patients in the high-dose group and 21 of those in the standard-dose group; odds ratio, 1.1; 97.5 percent confidence interval, 0.4 to 3.0). None of the patients in the high-dose group, as compared with four of those in the standard-dose group, survived to hospital discharge. Among the 30 patients whose cardiac arrest was precipitated by asphyxia, none of the 12 who were assigned to high-dose epinephrine were alive at 24 hours, as compared with 7 of the 18 who were assigned to a standard dose (P=0.02). CONCLUSIONS: We did not find any benefit of high-dose epinephrine rescue therapy for in-hospital cardiac arrest in children after failure of an initial standard dose of epinephrine. The data suggest that high-dose therapy may be worse than standard-dose therapy.

A prospective investigation into the epidemiology of in-hospital pediatric cardiopulmonary resuscitation using the international Utstein reporting style.

OBJECTIVE: Data regarding pediatric in-hospital cardiopulmonary resuscitation (CPR) have been limited because of retrospective study designs, small sample sizes, and inconsistent definitions of cardiac arrest and CPR. The purpose of this study was to prospectively describe and evaluate pediatric in-hospital CPR with the international consensus-derived epidemiologic definitions from the Utstein guidelines. METHODS: All 129 in-hospital CPRs during 12 months at a 122-bed university children's hospital in Sao Paulo, Brazil, were described and evaluated using Utstein reporting guidelines. These guidelines include standardized descriptions of hospital variables, patient variables, arrest/event variables, and outcome variables. CPR was defined as chest compressions and assisted ventilation provided because of cardiac arrest or because of severe bradycardia with poor perfusion. Outcome variables included sustained return of spontaneous circulation, 24-hour survival, 30-day survival, 1-year survival, and neurologic status of survivors by the Pediatric Cerebral Performance Category Scale. RESULTS: Of the 6024 children admitted to the hospital, 176 (3%) had an episode that met the criteria for provision of CPR and 129 (2%) received CPR, 86 for clinical cardiac arrest and 43 for bradycardia with poor perfusion. Most of the children (71%) had preexisting chronic diseases. The most common precipitating causes were respiratory failure (61%) and shock (29%). The initial cardiac rhythm was asystole in 71 children (55%), pulseless electrical activity in 12 (9%), ventricular fibrillation in 1, and bradycardia with pulses and poor perfusion in 43 (33%). Eighty-three children (64%) attained sustained return of spontaneous circulation (>20 minutes), 43 (33%) were alive at 24 hours, 24 (19%) were alive at 30 days, and 19 (15%) were alive at 1 year. Although many factors correlated with 24-hour survival, multivariate logistic regression analysis revealed independent association of 24-hour survival with respiratory failure as the precipitating cause (odds ratio [OR]: 4.92; 95% confidence interval [CI]: 1.73-14.0), bradycardia with pulses as the initial event (OR: 2.68; 95% CI: 1.01-7.1), and shorter duration of CPR (OR: 0.92; 95% CI: 0.89-0.96 for each elapsed minute). Similarly, 30-day survival was independently associated with respiratory failure as the precipitating cause and shorter duration of CPR. Thirty-day survival decreased by 5% with each elapsed minute of CPR. Nineteen (91%) of the 21 survivors to hospital discharge and 16 (83%) of the 19 1-year survivors had no demonstrable long-term change in neurologic function from their pre-CPR status. CONCLUSIONS: During this study, CPR was uncommon but not rare. Respiratory failure was the most common precipitating cause, followed by shock. Preexisting chronic diseases were prevalent among these children. Asystole was the most common initial cardiac rhythm, and bradycardia with pulses and poor perfusion was the second most common. Ventricular fibrillation was rare, but children with acute cardiac diseases, such as cardiac surgery and acute cardiomyopathies, were not admitted to this children's hospital. CPR was effective: nearly two thirds of these children were initially successfully resuscitated, and one third were alive at 24 hours compared with imminent death without CPR and advanced life support. Nevertheless, survival progressively decreased over time, generally as a result of the underlying disease process. One-year survival was 15%. Importantly, most of these survivors had no demonstrable change in gross neurologic function from their pre-CPR status.

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

Suporte avançado de vida em pediatria / Pediatric advanced life support

A parada cardíaca em crianças é consequência de problemas respiratórios ou circulatórios e a parada cardíaca primária é evento raro nessa faixa etária diferentemente do adulto. Sendo assim, em geral observam-se em crianças, várias doenças e lesöes traumáticas que desencadeiam falência respiratória ou circulatória, com consequente hipoxemia e acidose progressivas que levam à parada cardíaca em assistolia. A prevençäo da parada cardiorrespiratória é essencial na faixa etária pediátrica, o que impöe o emprego imediato de terapias adequadas a cada doença. A monitorizaçäo dos parâmetros clínicos - frequência respiratória, frequência cardíaca, coloraçäo das mucosas e perfusäo periférica - é obrigatória em todas as crianças que apresentem algum risco mesmo que mínimo, de desenvolver insuficiência respiratória ou circulatória. Na suspeita de parada cardiorrespiratória, a equipe médica deve agir de forma rápida e eficiente. Suporte básico de vida tem papel fundamental em pediatria, devendo-se dar ênfase à abertura de vias aéreas e ventilaçäo, já que as principais causas de falência cardiopulmonar säo respiratórias. Para administrar-se medicamentos e fluidos durante a ressuscitaçäo cardiopulmonar, a pulçäo intra-óssea é muito últil e deve ser preferida à canulaçäo de veias centrais., Embora ainda haja controvérsias, doses altas de adrenalina näo recomendadas após a primeira dose a cada 3 a 5 minutos.

Monitorizaçäo das concentraçöes séricas da vancomicina em crianças com infecçöes por bactérias multiresistentes / Monitorization of blood levels of vancomycin in children with multi-resistant bacterial infections

As propriedades farmacocinéticas da vancomicina säo mais conhecidas em adultos e sabe-se que vários fatores a influenciam, principalmente a idade. Por esse motivo foram estudadas as concentraçöes séricas no pico e no vale de 22 crianças que receberam vancomicina para o tratamento de infecçäo cuja bactéria suspeita ou confirmada era o estafilococo multi-resistente. As doses utilizadas, assim como o preparo e a administraçäo seguiram as normas recomendadas. O estudo foi realizado na fase de equilíbrio e as dosagens foram feitas por imunofluorescência polarizada. As concentraçöes séricas no pico variaram entre 23 e 99mcg/ml, sendo que somente 8 casos (36 por cento) estiveram entre 30 e 40mcg/ml. As concentraçöes séricas no vale variaram entre 4 e 26mcg/ml, sendo que 10 casos (45 por cento) encontravam-se entre 5 e 10mcg/ml. Essas observaçöes confirmaram a imprevisibilidade das concentraçöes séricas a partir da dose recomendada e säo indicativas da necessidade da monitorizaçäo sérica para cada caso.

Abscesso de músculo psoas em crianças / Psoas muscular abcess in children

Os sintomas de abscesso de músculo psoas em crianças säo inespecíficos, e o diagnóstico diferencial se faz principalmente dentre as doenças que compöem a síndrome do quadril doloroso na infância, sendo necessário métodos de imagem para confirmaçäo diagnóstica. Durante o primeiro semestre de 1995, foram atendidas 48.550 crianças no Pronto Socorro do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de Säo Paulo, sendo que quatro crianças tiveram o diagnóstico de abcesso de músculo psoas (2 do sexo feminino e 2 do sexo masculino). A idade variou de 1 a 12 anos. Todas apresentavam quadro clínico de longa duraçäo e sintomas inespecíficos, sendo o diagnóstico confirmado por ultra-som e/ou tomografia abdominal. Em 3 delas, foi isolado o Staphylococcus aureus como agente etiológico. Os dados observados säo semelhantes aos da literatura.