Palliative extubation: five-year experience in a pediatric hospital / Extubação paliativa: experiência de 5 anos em um hospital pediátrico

Abstract Objective: To present the characteristics of pediatric patients with chronic and irreversible diseases submitted to palliative extubation. Method: This is a descriptive analysis of a series of patients admitted to a public pediatric hospital, with chronic and irreversible diseases, permanently dependent on ventilatory support, who underwent palliative extubation between April 2014 and May 2019. The following information was collected from the medical records: demographic data, diagnosis, duration and type of mechanical ventilation; date, time, and place of palliative extubation; medications used; symptoms observed; and hospital outcome. Results: A total of 19 patients with a mean age of 2.2 years were submitted to palliative extubation. 68.4% of extubations were performed in the ICU; 11 patients (57.9%) died in the hospital. The time between mechanical ventilation withdrawal and in-hospital death ranged from 15 minutes to five days. Thirteen patients used an orotracheal tube and the others used tracheostomy. The main symptoms were dyspnea and pain, and the main drugs used to control symptoms were opioids and benzodiazepines. Conclusions: It was not possible to identify predictors of in-hospital death after ventilatory support withdrawal. Palliative extubation requires specialized care, with the presence and availability of a multidisciplinary team with adequate training in symptom control and palliative care.

Resumo Objetivo: Apresentar as características de pacientes pediátricos portadores de doenças crônicas e irreversíveis submetidos a extubação paliativa. Método: Trata-se de análise descritiva de uma série de casos de pacientes internados em hospital público pediátrico, portadores de doenças crônicas e irreversíveis, dependentes de forma permanente de suporte ventilatório e que foram submetidos a extubação paliativa entre abril de 2014 e maio de 2019. Foram coletadas as seguintes informações do prontuário: dados demográficos, diagnóstico, duração e tipo de ventilação mecânica; data, hora e local de realização da extubação paliativa, medicamentos utilizados, sintomas observados e desfecho hospitalar. Resultados: 19 pacientes com idade média de 2,2 anos foram submetidos a extubação paliativa. 68,4% das extubações foram realizadas dentro da UTI, 11 pacientes (57,9%) evoluíram para óbito no hospital. O tempo entre a retirada de ventilação mecânica e o óbito hospitalar variou entre 15 minutos e 5 dias. 13 pacientes usavam tubo orotraqueal e os demais, traqueostomia. Os principais sintomas foram dispneia e dor e as principais drogas utilizadas para o controle dos sintomas foram os analgésicos opioides e benzodiazepínicos. Conclusões: Não foi possível identificar fatores preditores de óbito no hospital após a retirada do suporte ventilatório. A extubação paliativa demanda cuidado especializado com presença e disponibilidade de equipe multiprofissional com formação adequada em controle de sintomas e cuidados paliativos.

Palliative extubation: five-year experience in a pediatric hospital.

OBJECTIVE: To present the characteristics of pediatric patients with chronic and irreversible diseases submitted to palliative extubation. METHOD: This is a descriptive analysis of a series of patients admitted to a public pediatric hospital, with chronic and irreversible diseases, permanently dependent on ventilatory support, who underwent palliative extubation between April 2014 and May 2019. The following information was collected from the medical records: demographic data, diagnosis, duration and type of mechanical ventilation; date, time, and place of palliative extubation; medications used; symptoms observed; and hospital outcome. RESULTS: A total of 19 patients with a mean age of 2.2 years were submitted to palliative extubation. 68.4% of extubations were performed in the ICU; 11 patients (57.9%) died in the hospital. The time between mechanical ventilation withdrawal and in-hospital death ranged from 15minutes to five days. Thirteen patients used an orotracheal tube and the others used tracheostomy. The main symptoms were dyspnea and pain, and the main drugs used to control symptoms were opioids and benzodiazepines. CONCLUSIONS: It was not possible to identify predictors of in-hospital death after ventilatory support withdrawal. Palliative extubation requires specialized care, with the presence and availability of a multidisciplinary team with adequate training in symptom control and palliative care.

Perinatal Yellow Fever: A Case Report.

An outbreak of yellow fever in Brazil made it possible to assess different presentations of disease such as perinatal transmission. A pregnant woman was admitted to hospital with yellow fever symptoms. She was submitted to cesarean section and died due to fulminant hepatitis. On the sixth day, the newborn developed liver failure and died 13 days later. Yellow fever polymerase chain reaction was positive for both.

Factors associated with intracranial hypertension in children and teenagers who suffered severe head injuries.

OBJECTIVE: To analyze factors associated with intracranial hypertension in pediatric patients who suffered severe head injuries. METHODS: Retrospective cohort study, with data collected from September 1998 through August 2003, including patients aged 0 to 16 who suffered severe head injuries, Glasgow score < 9, and submitted to intracranial pressure (ICP) monitoring (n = 132). Intracranial hypertension (IH) was defined as an episode of ICP > 20 mmHg requiring treatment, while refractory IH was ICP over 25 mmHg requiring barbiturates or decompressive craniectomy. Univariate analysis was followed by multivariate analysis; variables were considered significant if p < 0.05. RESULTS: Ages ranged from 2 months to 16 years, median age 9.7 (6.0-2.3) years. Glasgow scores ranged from 3 to 8, median 6 (4-7). Traffic accidents were responsible for 79.5% of events. Monitoring devices were installed, on average, 14 hours after trauma, median time 24 hours. One hundred and three patients (78%) had IH, while 57 (43.2%) had refractory IH. In multivariate analysis, younger age ranges were associated with IH [relative risk = 1.67 (1.03-2.72); p = 0.037], and abnormal postures were associated with refractory IH [relative risk = 2.25 (1.06-4.78)]. The group mortality rate was 51.5%; it was correlated with use of barbiturates in refractory IH and low cerebral perfusion pressure at the intensive care unit. CONCLUSIONS: IH and refractory IH were frequent events in pediatric patients who suffered severe head injuries. The younger the patient, the greater the chance of developing IH. The presence of abnormal postures was found to be a risk factor for refractory IH.

Fatores associados à hipertensão intracraniana em crianças e adolescentes vítimas de traumatismo crânio-encefálico grave / Factors associated with intracranial hypertension in children and teenagers who suffered severe head injuries

Objetivo: Analisar fatores associados à ocorrência de hipertensão intracraniana em pacientes pediátricos vítimas de traumatismo crânio-encefálico (TCE) grave. Métodos: Coorte com coleta retrospectiva do período de 1998 a 2003. Incluídos pacientes entre 0 e 16 anos com TCE, pontuação < 9 na escala de Glasgow e submetidos a monitoração da pressão intracraniana (PIC) (n = 132). A hipertensão intracraniana (HIC) foi definida como episódio de PIC > 20 mmHg com necessidade de tratamento e HIC refratária, acima de 25 mmHg, com necessidade de coma barbitúrico ou craniectomia descompressiva. Foi realizada análise univariada, seguida de multivariada, sendo consideradas significativas as variáveis com p < 0,05. Resultados: A idade variou entres 2 meses e 16 anos, mediana de 9,7 (6,0-2,3) anos. A pontuação de Glasgow foi de 3 a 8, mediana de 6 (4-7). O trânsito respondeu por 79,5 por cento dos eventos. A instalação do monitor ocorreu, em média, 14 h após o trauma, mediana de 24 h. Cento e três pacientes (78 por cento) apresentaram HIC, e 57 (43,2 por cento), HIC refratária. Na análise multivariada, a menor faixa etária foi associada a HIC risco relativo = 1,67 (1,03-2,72); p = 0,037, e a presença de posturas anormais foi associada a HIC refratária risco relativo = 2,25 (1,06-4,78). A mortalidade do grupo foi de 51,5 por cento e foi relacionada a uso de barbitúrico na HIC refratária e a baixa pressão de perfusão encefálica na unidade de terapia intensiva. Conclusões: HIC e HIC refratária foram eventos frequentes em pacientes pediátricos com TCE grave. Quanto menor a idade do paciente, maior a chance de desenvolvimento de HIC. A presença de posturas anormais foi fator associado a maior ocorrência de HIC refratária.

Objective: To analyze factors associated with intracranial hypertension in pediatric patients who suffered severe head injuries. Methods: Retrospective cohort study, with data collected from September 1998 through August 2003, including patients aged 0 to 16 who suffered severe head injuries, Glasgow score < 9, and submitted to intracranial pressure (ICP) monitoring (n = 132). Intracranial hypertension (IH) was defined as an episode of ICP > 20 mmHg requiring treatment, while refractory IH was ICP over 25 mmHg requiring barbiturates or decompressive craniectomy. Univariate analysis was followed by multivariate analysis; variables were considered significant if p < 0.05. Results: Ages ranged from 2 months to 16 years, median age 9.7 (6.0-2.3) years. Glasgow scores ranged from 3 to 8, median 6 (4-7). Traffic accidents were responsible for 79.5 percent of events. Monitoring devices were installed, on average, 14 hours after trauma, median time 24 hours. One hundred and three patients (78 percent) had IH, while 57 (43.2 percent) had refractory IH. In multivariate analysis, younger age ranges were associated with IH relative risk = 1.67 (1.03-2.72); p = 0.037, and abnormal postures were associated with refractory IH relative risk = 2.25 (1.06-4.78). The group mortality rate was 51.5 percent; it was correlated with use of barbiturates in refractory IH and low cerebral perfusion pressure at the intensive care unit. Conclusions: IH and refractory IH were frequent events in pediatric patients who suffered severe head injuries. The younger the patient, the greater the chance of developing IH. The presence of abnormal postures was found to be a risk factor for refractory IH.

Traumatismo cranioencefálico grave em crianças e adolescentes / Severe traumatic braininjury in children and adolescents

JUSTIFICATIVA E OBJETIVOS: Apresentar uma revisão crítica do traumatismo cranioencefálico (TCE) em crianças e adolescentes, enfocando o trauma grave, as taxas e os aspectos relacionados com a mortalidade e as principais medidas terapêuticas. CONTEÚDO: Revisão sistemática dos artigos incluídos no MEDLINE, SciELO e Lilacs, no período compreendido entre 1985 e 2006, utilizando as seguintes palavras-chave: traumatic brain injury, craniocerebral trauma, children e mortality, além dos principais livros-texto sobre o assunto. Foram analisados também os Guidelines of Brain Trauma Foundation de 2000 e 2003, sendo selecionados os principais trabalhos citados. O traumatismo cranioencefálico é uma das principais causas de morte e seqüelas em crianças e adolescentes. As taxas de mortalidade variaram entre 10 por cento e 55 por cento, principalmente em razão dos critérios de seleção utilizados, da gravidade dos pacientes e dos locais onde foram realizados os estudos. Em geral, a mortalidade em crianças foi menor que as descritas em pacientes adultos. Os principais fatores relacionados com a mortalidade em crianças foram a pontuação na escala de coma de Glasgow, a hipotensão arterial, o edema e ingurgitamento cerebral difusos e a baixa pressão de perfusão encefálica. O tratamento do TCE grave visa a correção dos fatores relacionados com a lesão cerebral secundária. CONCLUSÕES: Os fatores relacionados com melhor prognóstico em crianças ainda permanecem inconclusivos, havendo algumas divergências entre os estudos. Grande parte destes fatores é corrigível ou evitável, com reanimação hídrica inicial agressiva, tratamento cirúrgico em tempo hábil, monitorização e cuidados intensivos adequados.

BACKGROUND AND OBJECTIVES: Present a critical review of traumatic brain injury (TBI) in children and adolescents, focusing on severe TBI, the mortality and the factors related with poor outcome. CONTENTS: It was made a systematic review in MEDLINE, SciElo e Lilacs, with the key words: traumatic brain injury, craniocerebral trauma, children and mortality. The most important articles related in the Guidelines of Brain Trauma Foundation (2000 e 2003) were selected too. TBI is one of the most important causes of mortality and morbidity in children and adolescents, and morbidity in children and adolescents. The mortality variation was between 10 percent and 55 percent, depending of the patients select criteria, trauma severity and units where the studies were made. The children mortality was, in general, lower than that found in adults and the most important factors related with an increased mortality were: Glasgow Coma Score, hypotension, cerebral swelling and lower cerebral perfusion press. Severe TBI endpoint treatment is to correct the secondary brain lesions related factors. CONCLUSIONS: The factors related with better outcomes in children with severe TBI are still obscures, despite the large number of studies, large numbers of studies. Many of these factors can be avoided or correct by aggressive fluid resuscitation, surgery treatment, monitoration and adequate intensive care.

[Severe traumatic braininjury in children and adolescents]. / Traumatismo cranioencefálico grave em crianças e adolescentes.

BACKGROUND AND OBJECTIVES: Present a critical review of traumatic brain injury (TBI) in children and adolescents, focusing on severe TBI, the mortality and the factors related with poor outcome. CONTENTS: It was made a systematic review in MEDLINE, SciElo e Lilacs, with the key words: traumatic brain injury, craniocerebral trauma, children and mortality. The most important articles related in the Guidelines of Brain Trauma Foundation (2000 e 2003) were selected too. TBI is one of the most important causes of mortality and morbidity in children and adolescents, and morbidity in children and adolescents. The mortality variation was between 10% and 55%, depending of the patients select criteria, trauma severity and units where the studies were made. The children mortality was, in general, lower than that found in adults and the most important factors related with an increased mortality were: Glasgow Coma Score, hypotension, cerebral swelling and lower cerebral perfusion press. Severe TBI endpoint treatment is to correct the secondary brain lesions related factors. CONCLUSIONS: The factors related with better outcomes in children with severe TBI are still obscures, despite the large number of studies, large numbers of studies. Many of these factors can be avoided or correct by aggressive fluid resuscitation, surgery treatment, monitoration and adequate intensive care.

Neurotuberculose na infância / Neurotuberculosis in childhood

É relatado o caso clínico de uma criança, previamente hígida, que evoluiu com manifestações neurológicas inespecíficas. O diagnóstico obtido, após investigação intervencionista, foi de neurotuberculose. Instituído tratamento preconizado pela Organização Mundial de Saúde (OMS), com boa resposta clínica. O objetivo é alertar os pediatras para inclusão da neurotuberculose no diagnóstico diferencial de doenças infecciosas e lesões expansivas do sistema nervoso central.

Related a clinical case of a child, previously healthy, who evaluated with unespecific neurological manifestations. The diagnosis obtained, after interventionist investigation, was neurotuberculosis. Instituted treatment extoled by OMS, with good clinical response. The goal is advertise pediatrics to add neurotuberculosis to differential diagnosis of infecctious diseases and expansive lesions of central nervous system.