Health professionals' perceptions about the decision-making process in the care of pediatric patients. / Percepção de profissionais de saúde sobre o processo de tomada de decisão na assistência a pacientes pediátricos.

OBJECTIVE: To evaluate the perceptions of physicians, nurses and nursing technicians of their participation in the decision-making process surrounding life support limitation in terminally ill pediatric patients, with comparisons by professional category. METHODS: A cross-sectional study was conducted in the pediatric intensive care unit of a tertiary public university hospital with the participation of physicians, nurses and nursing technicians. The MacArthur Admission Experience Survey Voice Scale was used to assess and quantify the perceptions of professionals who assisted 17 pediatric patients with life support limitation within 24 hours after the outcome of each patient was determined. All professionals working in the unit (n = 117) who were potentially eligible for the study received a free and informed consent form prior to the occurrence of the cases studied. RESULTS: Study participants included 25/40 (62.5%) physicians, 10/17 (58.8%) nurses and 41/60 (68.3%) nursing technicians, representing 65% of the eligible professionals identified. The questionnaire return rate was higher for physicians than technicians (p = 0.0258). A perceived lack of voice was reported in all three professional categories at varying rates that were lower for physicians than for nurses and nursing technicians (p < 0.00001); there was no difference between the latter (p = 0.7016). In the three professional categories studied, three subscale items were reported. For two of the three statements, there were significant differences between physicians and nurses (p = 0.004) and between physicians and nursing technicians (p = 0.001). For one of the statements, there was no difference among the three professional categories. CONCLUSION: Respondents perceived a lack of voice in the decision-making process at varying rates across the three categories of studied professionals who assisted terminally ill pediatric patients with life support limitation, with physicians expressing lowered rates of perceived coercion.

Percepção de profissionais de saúde sobre o processo de tomada de decisão na assistência a pacientes pediátricos / Health professionals' perceptions about the decision-making process in the care of pediatric patients

RESUMO Objetivo: Avaliar as percepções de médicos, enfermeiros e técnicos de enfermagem sobre sua participação no processo de tomada de decisão de limitação de suporte de vida, em pacientes pediátricos terminais, comparando por categoria profissional. Métodos: Estudo transversal realizado em unidade de terapia intensiva pediátrica de hospital público universitário, terciário, com a participação de médicos, enfermeiros e técnicos de enfermagem. Foi usada a Escala de Voz da MacArthur Admission Experience Survey para avaliar e quantificar a percepção dos profissionais que assistiram 17 pacientes pediátricos em limitação de suporte de vida, nas primeiras 24 horas após o desfecho de cada paciente. Todos os profissionais que atuavam na unidade (n=117), potencialmente elegíveis para a pesquisa, receberam o Termo de Consentimento Livre e Esclarecido previamente à ocorrência dos casos. Resultados: Participaram 25/40 (62,5%) médicos, 10/17 (58,8%) enfermeiros e 41/60 (68,3%) técnicos de enfermagem, representando 65% dos profissionais elegíveis. A taxa de devolução dos questionários pelos médicos foi maior que a dos técnicos (p = 0,0258). Houve registro de percepção de falta de voz nas três categorias profissionais, em taxas variáveis, porém menos percebida pelos médicos do que pelos enfermeiros e técnicos (p < 0,00001); entre estes últimos, não houve diferença (p = 0,7016). Nas três categorias profissionais, foram assinalados os três itens que compõem a subescala. Em duas das três afirmativas, houve diferença significativa entre médicos e enfermeiros (p = 0,004), e entre médicos e técnicos (p = 0,001). Em uma das afirmativas, não houve diferença entre as três categorias profissionais. Conclusão: Houve percepção de falta de voz no processo de tomada de decisão, em taxas variáveis, nas três categorias de profissionais que assistiram pacientes pediátricos terminais em limitação de suporte de vida, sendo os médicos os que expressaram menor percepção de coerção.

ABSTRACT Objective: To evaluate the perceptions of physicians, nurses and nursing technicians of their participation in the decision-making process surrounding life support limitation in terminally ill pediatric patients, with comparisons by professional category. Methods: A cross-sectional study was conducted in the pediatric intensive care unit of a tertiary public university hospital with the participation of physicians, nurses and nursing technicians. The MacArthur Admission Experience Survey Voice Scale was used to assess and quantify the perceptions of professionals who assisted 17 pediatric patients with life support limitation within 24 hours after the outcome of each patient was determined. All professionals working in the unit (n = 117) who were potentially eligible for the study received a free and informed consent form prior to the occurrence of the cases studied. Results: Study participants included 25/40 (62.5%) physicians, 10/17 (58.8%) nurses and 41/60 (68.3%) nursing technicians, representing 65% of the eligible professionals identified. The questionnaire return rate was higher for physicians than technicians (p = 0.0258). A perceived lack of voice was reported in all three professional categories at varying rates that were lower for physicians than for nurses and nursing technicians (p < 0.00001); there was no difference between the latter (p = 0.7016). In the three professional categories studied, three subscale items were reported. For two of the three statements, there were significant differences between physicians and nurses (p = 0.004) and between physicians and nursing technicians (p = 0.001). For one of the statements, there was no difference among the three professional categories. Conclusion: Respondents perceived a lack of voice in the decision-making process at varying rates across the three categories of studied professionals who assisted terminally ill pediatric patients with life support limitation, with physicians expressing lowered rates of perceived coercion.

Admission source and mortality in a pediatric intensive care unit.

BACKGROUND AND AIMS: Studies carried out in different countries have shown that source of patient admission in Intensive Care Units (ICUs) is associated to death. Patients admitted from wards show a greater ICU mortality. The aim of the present study was to investigate the association between admission source and outcome in a Pediatric Intensive Care Unit (PICU). MATERIALS AND METHODS: We studied all PICU admissions that took place between January 2002 and December 2005 in a tertiary hospital in Brazil. The major outcome studied was death while in the PICU. The independent variable analyzed was admission source, defined either as pediatric emergency room (PER), wards, operating room (OR) of the same hospital or other sources. RESULTS: A total of 1823 admissions were studied. The overall expected mortality based on the Pediatric Index of Mortality 2 was 6.5% and the observed mortality was 10.3%. In adjusted analysis, the mortality was doubled in patients admitted from wards when compared with the PER patients. CONCLUSIONS: Observed mortality rates were higher in patients admitted from wards within the same hospital, even after adjustment.

Evidence of safety of chloral hydrate for prolonged sedation in PICU in a tertiary teaching hospital in southern Brazil.

OBJECTIVE: To evaluate the utilization of chloral hydrate (CH) for sedation in pediatric intensive care and the incidence of adverse drug reactions. METHODS: This was a cohort study including patients with prescription of chloral hydrate hospitalized in the pediatric intensive care unit (PICU) of a university-affiliated, general, tertiary teaching hospital. Data were collected from a spreadsheet for daily monitoring, and clinical events registered in the patient records were analyzed to evaluate the causality of suspected adverse drug reactions (ADR), applying the Naranjo algorithm. RESULTS: Three hundred forty-three patients who had been prescribed CH were studied. Ages ranged from 0 to 18 years, and 63% were male. The most frequent cause for PICU admission was bronchiolitis (77.6%), and 58.6% required mechanical ventilation. In 92.7% of cases, CH was indicated to control agitation and in 7.3% for procedural sedation. The median time of CH use was 6 days. The incidence of suspected ADR was 22.7% ± 2.3. Oxygen desaturation was the most frequent adverse event (64.6%), followed by hypotension. Specific treatment was required in 60.9% of the events. Chloral hydrate as cause for suspected ADR was classified as probable in 39 events (35.5%) and as possible in 70 (63.6%), and no event was classified as definite. In the multivariate analysis, only mechanical ventilation was predictive of ADR to CH. CONCLUSIONS: The study described the clinical practice of sedation with CH in the PICU setting of a tertiary teaching hospital in southern Brazil. Data suggest that CH is an alternative for prolonged sedation in PICU

Validação de escalas de sedação em crianças submetidas à ventilação mecânica internadas em uma unidade de terapia intensiva pediátrica terciária / Validation of sedation scores in mechanically ventilated children admitted to a tertiary pediatric intensive care unit

OBJETIVOS: O uso de escalas de sedação é fundamental em unidades de terapia intensiva pediátrica. A escala Comfort-Behavior é validada para avaliação de crianças, contudo, é um instrumento extenso. A escala de avaliação da atividade motora está validada para adultos, é mais simples do que a anterior e possível de ser usada em crianças. Nenhuma dessas escalas está validada na língua portuguesa. O objetivo primário deste estudo foi validar as duas escalas traduzidas para o português em crianças submetidas à ventilação mecânica. Os objetivos secundários foram avaliar o nível de sedação dos pacientes em ventilação mecânica de unidades de terapia intensiva pediátrica terciária e comparar o desempenho das duas escalas nesta população. MÉTODOS: Após a tradução para o português, as escalas foram aplicadas em 26 pacientes por dois médicos, simultaneamente. Obteve-se um total de 116 observações por escala. RESULTADOS: O coeficiente de correlação intraclasse foi 0,90 (IC95 por cento 0,85 - 0,93) para a escala Comfort-Behavior e 0,94 (IC 95 por cento 0,92 - 0,96) para a avaliação da atividade motora. O alfa de Crombach para o observador A ao aplicar a escala Comfort-Behvior foi 0,81 e para o observador B, 0,92. O coeficiente de Spearman para o observador A foi 0,86 e para o observador B, 0,91. As aplicações das escalas revelaram pacientes bastante sedados, atingindo pontuações baixas em ambas. CONCLUSÕES: A validação das escalas Comfort-Behavior e avaliação da atividade motora para o português foi realizada com sucesso. Ambas foram adequadas para emprego em crianças em ventilação mecânica. Nas aplicações avaliadas, o nível de sedação observado na unidade estudada foi alto.

OBJECTIVES: Sedation scores are important tools for use in pediatric intensive care units. The Comfort-Behavior scale is a valid method for the assessment of children although it is considered an extensive scale. The motor activity assessment scale is validated for an adult population. We considered it simpler then the one above and suitable for application in children. None of these scores had been translated into Portuguese. Our objective was to apply both scales in Portuguese to a pediatric population under mechanical ventilation. Secondary objectives were to evaluate the sedation level of children on mechanical ventilation in tertiary pediatric intensive care units and to compare the Comfort- Behavior and motor activity assessment scales in this population. METHODS: After translating the scales into Portuguese, both were simultaneously applied to 26 patients by 2 pediatricians. Each scale was applied 116 times in total. RESULTS: The intraclass correlation coefficient was 0.90 (0.85 - 0.93 CI 95 percent) for the Comfort-Behavior and 0.94 (0.92 - 0.96 CI 95 percent) for the motor activity assessment scale. When applying the Comfort-Behavior scale, the Crombach's alpha was 0.81 for observer A and 0.92 for observer B. The Spearman coefficient was 0.86 for observer A and 0.91 for observer B. These patients were found to be deeply sedated, showing low values in both scales. CONCLUSIONS: The scales were successfully translated into Portuguese and both were adequate to assess pain and sedation in the pediatric population under mechanical ventilation. Sedation level was high in this sample of applications.

Validation of sedation scores in mechanically ventilated children admitted to a tertiary pediatric intensive care unit. / Validação de escalas de sedação em crianças submetidas à ventilação mecânica internadas em uma unidade de terapia intensiva pediátrica terciária.

OBJECTIVES: Sedation scores are important tools for use in pediatric intensive care units. The Comfort-Behavior scale is a valid method for the assessment of children although it is considered an extensive scale. The motor activity assessment scale is validated for an adult population. We considered it simpler then the one above and suitable for application in children. None of these scores had been translated into Portuguese. Our objective was to apply both scales in Portuguese to a pediatric population under mechanical ventilation. Secondary objectives were to evaluate the sedation level of children on mechanical ventilation in tertiary pediatric intensive care units and to compare the Comfort- Behavior and motor activity assessment scales in this population. METHODS: After translating the scales into Portuguese, both were simultaneously applied to 26 patients by 2 pediatricians. Each scale was applied 116 times in total. RESULTS: The intraclass correlation coefficient was 0.90 (0.85 - 0.93 CI 95%) for the Comfort-Behavior and 0.94 (0.92 - 0.96 CI 95%) for the motor activity assessment scale. When applying the Comfort-Behavior scale, the Crombach's alpha was 0.81 for observer A and 0.92 for observer B. The Spearman coefficient was 0.86 for observer A and 0.91 for observer B. These patients were found to be deeply sedated, showing low values in both scales. CONCLUSIONS: The scales were successfully translated into Portuguese and both were adequate to assess pain and sedation in the pediatric population under mechanical ventilation. Sedation level was high in this sample of applications.

Retrospective study of the survival of patients who underwent cardiopulmonary resuscitation in an intensive care unit.

OBJECTIVE: To evaluate clinical and evolutive characteristics of patients admitted in an intensive care unit after cardiopulmonary resuscitation, identifying prognostic survival factors. METHODS: A retrospective study of 136 patients admitted between 1995 and 1999 to an intensive care unit, evaluating clinical conditions, mechanisms and causes of cardiopulmonary arrest, and their relation to hospital mortality. RESULTS: A 76% mortality rate independent of age and sex was observed. Asystole was the most frequent mechanism of death, and seen in isolation pulmonary arrest was the least frequent. Cardiac failure, need for mechanical ventilation, cirrhosis and previous stroke were clinically significant (p < 0.01) death factors. CONCLUSION: Prognostic factors supplement the doctor's decision as to whether or not a patient will benefit from cardiopulmonary resuscitation.

Estudo retrospectivo de sobrevida de pacientes submetidos à reanimaçäo cardiorrespiratória em unidade de tratamento intensivo / Retrospective study of the survival of patients who underwent cardiopulmonary resuscitation in an intensive care unit

OBJECTIVE: To evaluate clinical and evolutive characteristics of patients admitted in an intensive care unit after cardiopulmonary resuscitation, identifying prognostic survival factors.METHODS: A retrospective study of 136 patients admitted between 1995 and 1999 to an intensive care unit, evaluating clinical conditions, mechanisms and causes of cardiopulmonary arrest, and their relation to hospital mortality.RESULTS: A 76 percent mortality rate independent of age and sex was observed. Asystole was the most frequent mechanism of death, and seen in isolation pulmonary arrest was the least frequent. Cardiac failure, need for mechanical ventilation, cirrhosis and previous stroke were clinically significant (p<0.01) death factors.CONCLUSION: Prognostic factors supplement the doctor's decision as to whether or not a patient will benefit from cardiopulmonary resuscitation

Febre aguda sem sinais de localização em crianças menores de 36 meses de idade / Acute fever without source in infants and children less than 36 months of age

Objetivo: O objetivo deste artigo é ralizar uma revisão atualizada sobre febre aguda em crianças menores de 36 meses sem sinais de localização e discutir aspectos práticos de diagnóstico e manejo. Metodologia: Foram revisados artigos de literatura específica da área, apresentado-se tema de forma prática e relatando-se as recomendações dos autores. Resultados: Crianças febris são responsáveis por uma proporção importante de visitas aos ambulatórios pediátricos, sendo a maioria menor que 3 anos de idade. Ao primeiro exame, pode não haver diferença na aparência clínica de uma criança com uma doença viral, bacteremia oculta com infeccção bacteriana grave. Os autores apresentam recomendações e os protocolos citados na literatura para auxiliar os médicos no manejo dos lactentes e crianças com febre aguda sem sinal de localização. Conclusão: Emboram existam vários protocolos de avaliação manejo do lactente febril, nenhum esquema diagnóstico e terapêutico é ótimo para todos os pacientes. Os pediatras podem individualizar seu manejo desses pacientes, conforme sua experiência ou interpretação das recomedações da literatura