Use of Noninvasive Ventilation in Respiratory Failure After Extubation During Postoperative Care in Pediatrics.

The purpose of this study was to determine the rate of failure of noninvasive ventilation (NIV) after cardiac surgery in pediatric patients with respiratory failure after extubation and to identify predictive success factors. This was a prospective cohort study of pediatric patients diagnosed with congenital heart disease who underwent heart surgery and used NIV. Data were collected from 170 patients with a median age of 2 months. No patient presented cardiorespiratory arrest nor any other complication during the use of NIV. The success rate for the use of NIV was 61.8%. Subjects were divided for analysis into successful and failed NIV groups. Statistical analysis used Chi-square, Mann-Whitney, and Student's t tests, which were performed after univariate and multivariate logistic regression for p < 0.05. In the multivariate analysis, only the minimal pressure gradient (OR 1.45 with p = 0.007), maximum oxygen saturation (OR 0.88 with p = 0.011), and maximum fraction of inspired oxygen (FiO2) (OR 1.16 with p < 0.001) influenced NIV failure. The following variables did not present a statistical difference: extracorporeal circulation time (p = 0.669), pulmonary hypertension (p = 0.254), genetic syndrome (p = 0.342), RACHS-1 score (p = 0.097), age (p = 0.098), invasive mechanical ventilation duration (p = 0.186), and NIV duration (p = 0.804). In conclusion, NIV can be successfully used in children who, after cardiac surgery, develop respiratory failure in the 48 h following extubation. Although the use of higher pressure gradients and higher FiO2 are associated with a greater failure rate for NIV use, it was found to be generally safe.

The impact of daily evaluation and spontaneous breathing test on the duration of pediatric mechanical ventilation: a randomized controlled trial.

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.

Transplante hepático com doador vivo familiar / Liver transplantation from living related donors

Objetivos: Apresentar a experiência com os primeiros 12 transplantes hepáticos com doadores vivos realizados no Hospital Sírio-Libanês de Säo Paulo. Métodos: Foram utilizados como doadores 6 pais e 6 mäes com idade entre 30 e 48 anos. Todos os doadores form submetidos ao termo de consentimento esclarecido, à avaliaçäo clínica, laboratorial e radiológica, e à coleta prévia de sangue para autotransfusäo. A idade dos receptores variou de 7 meses a 10 anos e, o peso, de 6,3 a 34 kg. Seis receptores foram considerados de alto risco devido a complicaçöes da doença hepática avançada e foram submetidos ao transplante em caráter de urgência. Resultados: A mortalidade dos doadores foi nula, e o tempo médio de internaçäo foi de 10 dias. Foram observadas complicaçöes técnicas em 4 receptores, enquanto que, em 7, ocorreram um ou mais episódios de infecçäo bacteriana, viral ou fúngica. Um ou mais episódios de rejeiçäo, comprovados por biópsia, foram diagnosticados em 7 pacientes. A sobrevida dos receptores foi de 67 por cento, sendo 83 por cento nos casos eletivos e 50 por cento nos casos urgentes. O seguimento pós-operatório variou de 8 a 25 meses. Dos 8 sobreviventes, 7 apresentam excelente qualidade de vida e funçäo hepática normal...