Effects of serum sodium and chloride levels in the outcome of critically ill pediatric patients in the post-operative period of liver transplantation.

BACKGROUND: Sodium and chloride disturbances have attracted increasing attention in recent years. Many pathophysiological effects are associated with hyperchloremia, including reduction in mean arterial pressure and acute renal disease. Pediatric patients undergoing liver transplantation are at risk of developing various electrolyte and biochemical abnormalities, with an impact on their postoperative outcomes. OBJECTIVE: To analyze the impacts of serum sodium and chloride levels on prognosis of Pediatric Liver Transplant receptors. METHODS: This was a retrospective analytical observational study performed in a single transplant reference center in Sao Paulo, Brazil. Included patients were pediatric patients who underwent liver transplantation between January 2015 and July 2019. Statistical regression analysis and General Estimating Equations analysis were performed to evaluate the impacts of sodium and chloride disturbances on the development of acute renal failure and mortality. RESULTS: A total of 143 patients were included in this study. The main diagnosis was Biliary Atresia (62.9%). Twenty-seven patients died (18.9%), and graft dysfunction was the main cause of death (29.6%). The only variable individually associated with 28-days mortality was PIM-3 score (HR 1.59, CI 95% 1.165-2.177, p = 0.004). Forty-one patients (28.6%) developed moderate or severe AKI. PIM-3 score (OR 3.052, 95% CI 1.56-5.97, p = 0.001), hypernatremia (OR 3.49, 95% CI 1.32-9.23, p = 0.012), and hyponatremia (OR 4.24, 95% CI 1.52-11.85, p = 0.006) were independently associated with the development of moderate/severe AKI. CONCLUSIONS: In pediatric patients after liver transplantation, PIM-3 score, and abnormal serum sodium levels were correlated with AKI development.

Major discrepancy between clinical diagnosis of death and anatomopathological findings in adolescents with chronic diseases during 18-years.

OBJECTIVES: To evaluate the inconsistency between clinical diagnosis of death and autopsy findings in adolescents with chronic diseases. METHODS: A cross-sectional study including a sample of adolescents' autopsies who died in a pediatric and adolescent tertiary hospital over 18 consecutive years. During this period, there were n = 2912 deaths, and n = 581/2912(20%) occurred in adolescents. Of these, n = 85/581(15%) underwent autopsies and were analyzed. Further results were divided into two groups: Goldman classes I or II (high disagreement between main clinical diagnosis of death and anatomopathological findings, n = 26) and Goldman classes III, IV or V (low or no disagreement between these two parameters, n = 59). RESULTS: Median age at death (13.5 [10‒19] vs. 13 [10‒19] years, p = 0.495) and disease duration (22 [0‒164] vs. 20 [0‒200] months, p = 0.931), and frequencies for males (58% vs. 44%, p = 0.247) were similar between class I/II vs. class III/IV/V. The frequency of pneumonia (73% vs. 48%, p = 0.029), pulmonary abscess (12% vs. 0%, p = 0.026), as well as isolation of yeast (27% vs. 5%, p = 0.008), and virus (15% vs. 2%, p = 0.029) identified in the autopsy, were significantly higher in adolescents with Goldman class I/II compared to those with Goldman class III/IV/V. In contrast, cerebral edema was significantly lower in adolescents of the first group (4% vs. 25%, p = 0.018). CONCLUSION: This study showed that 30% of the adolescents with chronic diseases had major discrepancies between clinical diagnosis of death and autopsy findings. Pneumonia, pulmonary abscess, as well as isolation of yeast and virus were more frequently identified at autopsy findings in the groups with major discrepancies.

Major discrepancy between clinical diagnosis of death and anatomopathological findings in adolescents with chronic diseases during 18-years

Abstract Objectives: To evaluate the inconsistency between clinical diagnosis of death and autopsy findings in adolescents with chronic diseases. Methods: A cross-sectional study including a sample of adolescents' autopsies who died in a pediatric and adolescent tertiary hospital over 18 consecutive years. During this period, there were n = 2912 deaths, and n = 581/2912(20%) occurred in adolescents. Of these, n = 85/581(15%) underwent autopsies and were analyzed. Further results were divided into two groups: Goldman classes I or II (high disagreement between main clinical diagnosis of death and anatomopathological findings, n = 26) and Goldman classes III, IV or V (low or no disagreement between these two parameters, n = 59). Results: Median age at death (13.5 [10‒19] vs. 13 [10‒19] years, p = 0.495) and disease duration (22 [0‒164] vs. 20 [0‒200] months, p = 0.931), and frequencies for males (58% vs. 44%, p = 0.247) were similar between class I/II vs. class III/IV/V. The frequency of pneumonia (73% vs. 48%, p = 0.029), pulmonary abscess (12% vs. 0%, p = 0.026), as well as isolation of yeast (27% vs. 5%, p = 0.008), and virus (15% vs. 2%, p = 0.029) identified in the autopsy, were significantly higher in adolescents with Goldman class I/II compared to those with Goldman class III/IV/V. In contrast, cerebral edema was significantly lower in adolescents of the first group (4% vs. 25%, p = 0.018). Conclusion: This study showed that 30% of the adolescents with chronic diseases had major discrepancies between clinical diagnosis of death and autopsy findings. Pneumonia, pulmonary abscess, as well as isolation of yeast and virus were more frequently identified at autopsy findings in the groups with major discrepancies.

Limits of therapeutic intervention in a tertiary neonatal intensive care unit in patients with major congenital anomalies in Brazil.

AIM: Major congenital anomalies are an important cause of death in the neonatal intensive care unit (NICU). Therapeutic interventions and the suspension of those already in place often raise ethical dilemmas in neonatal care. METHODS: We analysed treatments-such as ventilatory support, vasoactive drugs, antibiotics, sedation/or analgesia, central venous access and other invasive procedures-offered up to 48 h before death to all newborns with major congenital anomalies over a 3-year period in a NICU in Brazil. We also gathered information contained in medical records concerning conversations with the families and decisions to limit therapeutic interventions. RESULTS: We enrolled 74 newborns who were hospitalised from 1 January 2015 to 31 December 2017. A total of 81.1% had central venous access, 74.3% were on ventilatory support, 56.8% received antibiotics and 43.2% used some sedative/analgesic drugs in their final moments. Conversations were registered in medical records in 76% of cases, and 46% of the families chose therapeutic intervention limits. Those who chose to limit therapeutic interventions asked for less exposure to vasoactive drugs (P = 0.003) and antibiotics (P = 0.003), as well as fewer invasive procedures (P = 0.046). There was no change in ventilatory support (P = 0.66), and palliative extubation was not performed for any patient. CONCLUSIONS: The therapeutic intervention was mainly characterised by maintenance of the current treatment when a terminal situation was identified with no introduction of new treatments that could increase suffering. The families' approach proved to be essential for making difficult decisions in the NICU.

Association between ventilatory settings and pneumothorax in extremely preterm neonates.

OBJECTIVES: Pneumothorax is a catastrophic event associated with high morbidity and mortality, and it is relatively common in neonates. This study aimed to investigate the association between ventilatory parameters and the risk of developing pneumothorax in extremely low birth weight neonates. METHODS: This single-center retrospective cohort study analyzed 257 extremely low birth weight neonates admitted to a neonatal intensive care unit between January 2012 and December 2017. A comparison was carried out to evaluate the highest value of positive end-expiratory pressure (PEEP), peak inspiratory pressure (PIP), and driving pressure (DP) in the first 7 days of life between neonates who developed pneumothorax and those who did not. The primary outcome was pneumothorax with chest drainage necessity in the first 7 days of life. A matched control group was created in order to adjust for cofounders associated with pneumothorax (CRIB II score, birth weight, and gestational age). RESULTS: There was no statistically significant difference in PEEP, PIP, and DP values in the first 7 days of life between extremely low birth weight neonates who had pneumothorax with chest drainage necessity and those who did not have pneumothorax, even after adjusting for potential cofounders. CONCLUSIONS: Pressure-related ventilatory settings in mechanically ventilated extremely low birth weight neonates are not associated with a higher risk of pneumothorax in the first 7 days of life.

Association between ventilatory settings and pneumothorax in extremely preterm neonates

OBJECTIVES: Pneumothorax is a catastrophic event associated with high morbidity and mortality, and it is relatively common in neonates. This study aimed to investigate the association between ventilatory parameters and the risk of developing pneumothorax in extremely low birth weight neonates. METHODS: This single-center retrospective cohort study analyzed 257 extremely low birth weight neonates admitted to a neonatal intensive care unit between January 2012 and December 2017. A comparison was carried out to evaluate the highest value of positive end-expiratory pressure (PEEP), peak inspiratory pressure (PIP), and driving pressure (DP) in the first 7 days of life between neonates who developed pneumothorax and those who did not. The primary outcome was pneumothorax with chest drainage necessity in the first 7 days of life. A matched control group was created in order to adjust for cofounders associated with pneumothorax (CRIB II score, birth weight, and gestational age). RESULTS: There was no statistically significant difference in PEEP, PIP, and DP values in the first 7 days of life between extremely low birth weight neonates who had pneumothorax with chest drainage necessity and those who did not have pneumothorax, even after adjusting for potential cofounders. CONCLUSIONS: Pressure-related ventilatory settings in mechanically ventilated extremely low birth weight neonates are not associated with a higher risk of pneumothorax in the first 7 days of life.

Differences among Severe Cases of Sars-CoV-2, Influenza, and Other Respiratory Viral Infections in Pediatric Patients: Symptoms, Outcomes and Preexisting Comorbidities.

OBJECTIVES: Previous studies focusing on pediatric patients hospitalized with severe coronavirus disease 2019 (COVID-19) have been limited to small case series. We aimed to evaluate the characteristics of a large population of pediatric patients with severe COVID-19 and compare them with patients with severe cases of influenza and other respiratory viruses (ORV). METHODS: We performed a cross-sectional study of Brazilian data from the National Epidemiological Surveillance Information System, gathered from January 1st to July 14th, 2020. The sample included 4,784 patients (2,570 with confirmed COVID-19, 659 with influenza, 1,555 with ORV). Outcome measures included clinical features, preexisting comorbidities, pediatric intensive care unit admissions, need for ventilatory support, and death. RESULTS: Compared with the influenza and ORV groups, the COVID-19 group had a higher proportion of newborns and adolescents, as well as lower frequencies of fever, cough, dyspnea, respiratory distress, and desaturation. Although use of invasive ventilatory support was similar among groups, death rate was highest for COVID-19 (15.2% vs. 4.5% vs. 3.2%, p<0.001), with death risk more than three times the other groups (adjusted OR=3.7 [95% CI 2.5-5.6]). The presence of two or more comorbidities further increased this risk (OR=4.8 [95% CI 3.5-6.6]). Preexisting comorbidities were reported in 986 patients with severe COVID-19 (38%). Mortality rate among COVID-19 patients was significantly higher for almost all comorbidities reported. CONCLUSION: Severe COVID-19 had a higher mortality rate than other viral respiratory illnesses, despite the lower frequency of fever, cough, dyspnea, respiratory distress, and desaturation. Death risk was strongly associated with preexisting comorbidities.

Point-of-care lung ultrasound imaging in pediatric COVID-19.

BACKGROUND: There has been limited data regarding the usefulness of lung ultrasound (US) in children with COVID-19. OBJECTIVE: To describe lung US imaging findings and aeration score of 34 children with COVID-19. METHODS: This study included 0-16-year-old patients with confirmed COVID-19, who were admitted between April 19 and June 18, 2020 in two hospitals in the city of Sao Paulo, Brazil. Lung US was performed as part of the routine evaluation by a skilled Pediatric Emergency physician. Clinical and laboratory data were collected and severity classifications were done according to an available clinical definition. The lung US findings were described for each lung field and a validated ultrasound lung aeration score was calculated. Data obtained was correlated with clinical information and other imaging modalities available for each case. RESULTS: Thirty-four confirmed COVID-19 patients had a lung US performed during this period. Eighteen (18/34) had abnormalities on the lung US, but eight of them (8/18) had a normal chest radiograph. Ultrasound lung aeration score medians for severe/critical, moderate, and mild disease were 17.5 (2-30), 4 (range 0-14), 0 (range 0-15), respectively (p = 0.001). Twelve patients (12/34) also had a chest computed tomography (CT) performed; both the findings and topography of lung compromise on the CT were consistent with the information obtained by lung US. CONCLUSION: Point-of-care lung US may have a key role in assessing lung injury in children with COVID-19.

Association between fluid creep and infection in burned children: A cohort study.

INTRODUCTION: Aggressive fluid resuscitation has been extensively discussed after the establishment of fluid creep phenomenon as a morbidity and mortality factor in burn children. Sepsis is currently the leading cause of death in survivors of burn shock. OBJECTIVES: To evaluate the association between fluid creep and infection in burn children exposed to two different fluid resuscitation strategies with the use of albumin. METHODS: A cohort of 46 burn children with 15-45% of body surface area (BSA) admitted up to 12 h after the incident were evaluated. Patients from early albumin group (n = 23) received 5% albumin between 8 and 12 h from injury and patients from delayed albumin group (n = 23) received 5% albumin after 24 h. Outcomes analysed were development of fluid creep, length of stay in the hospital, number of surgery procedures and infection until hospital discharge. RESULTS: Compared to the delayed group, patients that received early albumin had a shorter length of stay in the hospital (p = 0.007), less fluid creep (4.3% × 56.5%) (p < 0.001), less skin graft procedure (47.8% × 78.3%) (p = 0.032) and less debridement (73.9% × 100%) (p = 0.022). Both length of stay in the hospital and fluid creep arising were associated with infection (p < 0.05). CONCLUSION: Fluid creep, surgery procedures and length of stay in hospital parameters showed better results in burn children treated with early albumin. Fluid creep and length of stay in the hospital were associated with infection, providing a negative prognosis.

Differences among severe cases of SARS-COV-2, influenza, and other respiratory viral infections inpediatric patients: symptoms, outcomes and preexisting comorbidities

OBJECTIVES: Previous studies focusing on pediatric patients hospitalized with severe coronavirus disease 2019 (COVID-19) have been limited to small case series. We aimed to evaluate the characteristics of a large population of pediatric patients with severe COVID-19 and compare them with patients with severe cases of influenza and other respiratory viruses (ORV). METHODS: We performed a cross-sectional study of Brazilian data from the National Epidemiological Surveillance Information System, gathered from January 1st to July 14th, 2020. The sample included 4,784 patients (2,570 with confirmed COVID-19, 659 with influenza, 1,555 with ORV). Outcome measures included clinical features, preexisting comorbidities, pediatric intensive care unit admissions, need for ventilatory support, and death. RESULTS: Compared with the influenza and ORV groups, the COVID-19 group had a higher proportion of newborns and adolescents, as well as lower frequencies of fever, cough, dyspnea, respiratory distress, and desaturation. Although use of invasive ventilatory support was similar among groups, death rate was highest for COVID-19 (15.2% vs. 4.5% vs. 3.2%, p<0.001), with death risk more than three times the other groups (adjusted OR=3.7 [95% CI 2.5-5.6]). The presence of two or more comorbidities further increased this risk (OR=4.8 [95% CI 3.5-6.6]). Preexisting comorbidities were reported in 986 patients with severe COVID-19 (38%). Mortality rate among COVID-19 patients was significantly higher for almost all comorbidities reported. CONCLUSION: Severe COVID-19 had a higher mortality rate than other viral respiratory illnesses, despite the lower frequency of fever, cough, dyspnea, respiratory distress, and desaturation. Death risk was strongly associated with preexisting comorbidities.

Mortality in adolescents and young adults with chronic diseases during 16 years: a study in a Latin American tertiary hospital / Mortalidade entre adolescentes e adultos jovens com doenças crônicas durante 16 anos: estudo em um hospital terciário da América Latina

ABSTRACT Objectives: To evaluate mortality in adolescents and young adult patients with chronic diseases followed in a Latin American tertiary hospital. Methods: A cross-sectional retrospective study was performed in a tertiary/academic hospital in the state of São Paulo, Brazil. Death occurred in 529/2850 (18.5%) adolescents and young adult patients with chronic diseases, and 25/529 (4.7%) were excluded due to incomplete medical charts. Therefore, 504 deaths were evaluated. Results: Deaths occurred in 316/504 (63%) of early adolescent patients and in 188/504 (37%) of late adolescent/young adult patients. Further comparisons between early adolescents (n = 316) and late adolescent/young adult patients (n = 188) with pediatric chronic diseases at the last hospitalization showed that the median disease duration (22.0 [0-173] vs. 43.0 [0-227] months, p < 0.001) was significantly lower in early adolescents vs. late adolescent/young adult patients. The median number of previous hospitalizations was significantly lower in the former group (4.0 [1-45] vs. 6.0 [1-52], p < 0.001), whereas the last hospitalization in intensive care unit was significantly higher (60% vs. 47%, p = 0.003). Regarding supportive measures, palliative care was significantly lower in the younger group compared to the older group (33% vs. 43%, p = 0.02). The frequencies of renal replacement therapy (22% vs. 13%, p = 0.02), vasoactive agents (65% vs. 54%, p = 0.01), and transfusion of blood products (75% vs. 66%, p = 0.03) were significantly higher in the younger group. The five most important etiologies of pediatric chronic diseases were: neoplasias (54.2%), hepatic diseases/transplantation (10%), human immunodeficiency virus (5.9%), and childhood-onset systemic lupus erythematosus and juvenile idiopathic arthritis (4.9%). Autopsy was performed in 58/504 (11%), and discordance between clinical and postmortem diagnoses was evidenced in 24/58 (41.3%). Conclusions: Almost 20% of deaths occurred in adolescents and young adults with distinct supportive care and severe disease patterns. Discordance between clinical diagnosis and autopsy was frequently observed.

RESUMO Objetivos: Avaliar a mortalidade entre adolescentes e pacientes adultos jovens com doenças crônicas acompanhados em um hospital terciário na América Latina. Métodos: Foi feito um estudo retrospectivo transversal em um hospital terciário/universitário no Estado de São Paulo, Brasil. Houve mortalidade de 529/2.850(18,5%) pacientes adolescentes e adultos jovens com doenças crônicas, porém 25/529(4,7%) foram excluídos devido a prontuários médicos incompletos. Portanto, foram avaliados 504 óbitos. Resultados: Ocorrem 316/504(63%) óbitos entre pacientes no início da adolescência e 188/504(37%) pacientes no fim da adolescência/adultos jovens. As comparações adicionais entre os pacientes no início da adolescência (n = 316) e no fim da adolescência/pacientes jovens (n = 188) com doenças crônicas pediátricas na última internação mostraram que a duração média da doença [22,0 (0-173) em comparação com 43,0 (0-227) meses, p < 0,001], foi significativamente menor nos pacientes no início da adolescência em comparação com os pacientes no fim da adolescência/adultos jovens. O número médio de internação anterior foi significativamente menor no primeiro grupo [4,0 (1-45) em comparação com 6,0 (1-52), p < 0,001], ao passo que a última internação na unidade de terapia intensiva foi significativamente maior (60% em comparação com 47%, p = 0,003). Com relação a medidas de suporte, o cuidado paliativo foi significativamente menor no grupo de pacientes no início da adolescência em comparação com o grupo de pacientes no fim da adolescência (33% em comparação com 43%, p = 0,02). As frequências de terapia de substituição renal (22% em comparação com 13%, p = 0,02), agentes vasoativos (65% em comparação com 54%, p = 0,01) e transfusão de hemoderivados (75% em comparação com 66%, p = 0,03) foram significativamente maiores no primeiro grupo. As cinco etiologias mais importantes de doenças crônicas pediátricas foram: neoplasias (54,2%), doenças hepáticas/transplante (10%), vírus da imunodeficiência humana (5,9%), lúpus eritematoso sistêmico de início na infância e artrite idiopática juvenil (4,9%). Foi feita autópsia em 58/504 (11%) e a discordância entre os diagnósticos clínico e pós-morte foi comprovada em 24/58 (41,3%). Conclusões: Quase 20% dos óbitos ocorreram em adolescentes e adultos jovens com diferentes padrões de cuidados de suporte e doenças graves. A discordância entre o diagnóstico clínico e a necropsia foi frequentemente observada.

Admission hypothermia, neonatal morbidity, and mortality: evaluation of a multicenter cohort of very low birth weight preterm infants according to relative performance of the center.

This prospective cohort study aimed to assess the association of admission hypothermia (AH) with death and/or major neonatal morbidities among very low birth weight (VLBW) preterm infants based on the relative performance of 20 centers of the Brazilian Network of Neonatal Research. This is a retrospective analysis of prospectively collected data using the database registry of the Brazilian Network on Neonatal Research. Center performance was defined by the relative mortality rate using conditional inference trees. A total of 4356 inborn singleton VLBW preterm infants born between January 2013 and December 2016 without malformations were included in this study. The centers were divided into two groups: G1 (with lower mortality rate) and G2 (with higher mortality rate). Crude and adjusted relative risks (RR) and 95% confidence intervals (95%CI) were estimated by simple and multiple log-binomial regression models. An AH rate of 53.7% (19.8-93.3%) was significantly associated with early neonatal death in G1 (adjusted RR 1.41, 95% CI 1.09-1.84) and G2 (adjusted RR 1.29, 95%CI 1.01-1.65) and with in-hospital death in G1 (adjusted RR 1.29, 95%CI 1.07-1.58). AH was significantly associated with a lower frequency of necrotizing enterocolitis (adjusted RR 0.58, 95%CI 38-0.88) in G2.Conclusion: AH significantly associated with early neonatal death regardless of the hospital performance. In G2, an unexpected protective association between AH and necrotizing enterocolitis was found, whereas the other morbidities assessed were not significantly associated with AH. What is Known: • Admission hypothermia is associated with early neonatal death. • The association of admission hypothermia with major neonatal morbidities has not been fully established. What is New: • Admission hypothermia was significantly associated with early neonatal and in-hospital death in centers with the lowest relative mortality rates. • Admission hypothermia was not associated with major neonatal morbidities and with in-hospital death but was found to be a protective factor against necrotizing colitis in centers with the highest relative mortality rates.

Mortality in adolescents and young adults with chronic diseases during 16 years: a study in a Latin American tertiary hospital.

OBJECTIVES: To evaluate mortality in adolescents and young adult patients with chronic diseases followed in a Latin American tertiary hospital. METHODS: A cross-sectional retrospective study was performed in a tertiary/academic hospital in the state of São Paulo, Brazil. Death occurred in 529/2850 (18.5%) adolescents and young adult patients with chronic diseases, and 25/529 (4.7%) were excluded due to incomplete medical charts. Therefore, 504 deaths were evaluated. RESULTS: Deaths occurred in 316/504 (63%) of early adolescent patients and in 188/504 (37%) of late adolescent/young adult patients. Further comparisons between early adolescents (n=316) and late adolescent/young adult patients (n=188) with pediatric chronic diseases at the last hospitalization showed that the median disease duration (22.0 [0-173] vs. 43.0 [0-227] months, p<0.001) was significantly lower in early adolescents vs. late adolescent/young adult patients. The median number of previous hospitalizations was significantly lower in the former group (4.0 [1-45] vs. 6.0 [1-52], p<0.001), whereas the last hospitalization in intensive care unit was significantly higher (60% vs. 47%, p=0.003). Regarding supportive measures, palliative care was significantly lower in the younger group compared to the older group (33% vs. 43%, p=0.02). The frequencies of renal replacement therapy (22% vs. 13%, p=0.02), vasoactive agents (65% vs. 54%, p=0.01), and transfusion of blood products (75% vs. 66%, p=0.03) were significantly higher in the younger group. The five most important etiologies of pediatric chronic diseases were: neoplasias (54.2%), hepatic diseases/transplantation (10%), human immunodeficiency virus (5.9%), and childhood-onset systemic lupus erythematosus and juvenile idiopathic arthritis (4.9%). Autopsy was performed in 58/504 (11%), and discordance between clinical and postmortem diagnoses was evidenced in 24/58 (41.3%). CONCLUSIONS: Almost 20% of deaths occurred in adolescents and young adults with distinct supportive care and severe disease patterns. Discordance between clinical diagnosis and autopsy was frequently observed.

Opioid tapering and weaning protocols in pediatric critical care units: a systematic review.

OBJECTIVE: Opioid abstinence syndrome is common in the pediatric intensive care environment because sedation is often needed during the children's treatment. There is no specific guideline regarding the management of these patients; and lately, methadone is an important drug for the prevention of abstinence symptoms during the weaning of opioids. This study gathers the available research to establish the initial dose of methadone, the rate of taper and tools to recognize this syndrome and act promptly. METHODS: A systematic review was made from data of four different databases. Forty-nine articles of observational and experimental studies were selected based on the inclusion criteria (critical pediatric patients in acute use of opioids) and exclusion criteria (previous chronic use of opioids, other medications). The data regarding specific themes were separated in sections: initial dose of methadone, use of protocols in clinical practice, abstinence scales and adjuvant drugs. RESULTS: The articles showed a great heterogeneity of ways to calculate the initial dose of methadone. The pediatric intensive care units of the study had different weaning protocols, with a lower incidence of abstinence when a pre-defined sequence of tapering was used. The Withdrawal Assessment Tool - 1 was the most used scale for tapering the opioids, with good sensitivity and specificity for signs and symptoms. CONCLUSION: There is still little evidence of other medications that can help prevent the abstinence syndrome of opioids. This study tries to promote a better practice during opioid weaning.

Pediatric chronic patients at outpatient clinics: a study in a Latin American University Hospital / Pacientes pediátricos crônicos em clínicas ambulatoriais: estudo em um hospital universitário da América Latina

Abstract Objective: To describe the characteristics of children and adolescentes with chronic diseases of outpatient clinics at a tertiary university hospital. Methods: A cross-sectional study was performed with 16,237 patients with chronic diseases followed-up in one year. The data were collected through the electronic system, according to the number of physician appointments in 23 pediatric specialties. Patients were divided in two groups: children (0-9 years) and adolescents (10-19 years). Early (10-14 years) and late (15-19 years) adolescent groups were also analyzed. Results: Of the total sample, 56% were children and 46% were adolescents. The frequencies of following pediatric specialties were significantly higher in adolescents when compared with children: cardiology, endocrinology, hematology, nephrology/renal transplantation, neurology, nutrology, oncology, palliative and pain care, psychiatry, and rheumatology (p < 0.05). The frequencies of emergency service visits (30% vs. 17%, p < 0.001), hospitalizations (23% vs. 11%, p < 0.001), intensive care unit admissions (6% vs. 2%, p < 0.001), and deaths (1% vs. 0.6%, p = 0.002) were significantly lower in adolescents than in children. However, the number of physician appointments (≥13) per patient was also higher in the adolescent group (5% vs. 6%, p = 0.018). Further analysis comparison between early and late adolescents revealed that the first group had significantly more physician appointments (35% vs. 32%, p = 0.025), and required more than two pediatric specialties (22% vs. 21%, p = 0.047). Likewise, the frequencies of emergency service visits (19% vs. 14%, p < 0.001) and hospitalizations (12% vs. 10%, p = 0.035) were higher in early adolescents. Conclusions: This study evaluated a large population in a Latin American hospital and suggested that early adolescents with chronic diseases required many appointments, multiple specialties and hospital admissions.

Resumo Objetivo: Descrever características de crianças e adolescentes com doenças crônicas de clínicas ambulatoriais em um hospital universitário terciário. Métodos: Um estudo transversal foi realizado com 16.237 pacientes com doenças crônicas acompanhados em um ano. Os dados foram coletados por meio de dados do sistema eletrônico de acordo com o número de consultas médicas em 23 especialidades pediátricas. Os pacientes foram divididos em dois grupos: crianças (0-9 anos) e adolescentes (10-19 anos). Também foram analisados grupos de jovens adolescentes (10-14 anos) e adolescentes mais velhos (15-19 anos). Resultados: 54% eram crianças e 46% eram adolescentes. As frequências das seguintes especialidades pediátricas foram significativamente maiores em adolescentes em comparação a crianças: cardiologia, endocrinologia, hematologia, nefrologia/transplante renal, neurologia, nutrologia, oncologia, cuidados paliativos e cuidado da dor, psiquiatria e reumatologia (p < 0,05). As frequências de visitas a serviços de emergência (30%, em comparação a 17%, p < 0,001), internações (23%, em comparação a 11%, p < 0,001), internações em unidade de terapia intensiva (6%, em comparação a 2%, p < 0,001) e óbitos (1%, em comparação a 0,6%, p = 0,002) foram significativamente menores em adolescentes do que em crianças. Contudo, o número de consultas médicas (≥ 13) por paciente (também) foi maior em grupos de adolescentes (5%, em comparação a 6%, p = 0,018). A comparação de análises adicionais entre jovens adolescentes e adolescentes mais velhos revelou que o primeiro grupo apresentou um número significativamente maior de consultas médicas (35%, em comparação a 32%, p = 0,025) e precisou de mais de duas especialidades pediátricas (22%, em comparação a 21%, p = 0,047). Da mesma forma, as frequências de visitas a serviços de emergência (19%, em comparação a 14%, p < 0,001) e internações (12%, em comparação a 10%, p = 0,035) foram maiores em jovens adolescentes. Conclusões: Este estudo avaliou uma grande população em um hospital da América Latina e sugeriu que jovens adolescentes com doenças crônicas precisaram de muitas consultas, diversas especialidades e internações hospitalares.

Opioid tapering and weaning protocols in pediatric critical care units: a systematic review

SUMMARY OBJECTIVE: Opioid abstinence syndrome is common in the pediatric intensive care environment because sedation is often needed during the children's treatment. There is no specific guideline regarding the management of these patients; and lately, methadone is an important drug for the prevention of abstinence symptoms during the weaning of opioids. This study gathers the available research to establish the initial dose of methadone, the rate of taper and tools to recognize this syndrome and act promptly. METHODS: A systematic review was made from data of four different databases. Forty-nine articles of observational and experimental studies were selected based on the inclusion criteria (critical pediatric patients in acute use of opioids) and exclusion criteria (previous chronic use of opioids, other medications). The data regarding specific themes were separated in sections: initial dose of methadone, use of protocols in clinical practice, abstinence scales and adjuvant drugs. RESULTS: The articles showed a great heterogeneity of ways to calculate the initial dose of methadone. The pediatric intensive care units of the study had different weaning protocols, with a lower incidence of abstinence when a pre-defined sequence of tapering was used. The Withdrawal Assessment Tool - 1 was the most used scale for tapering the opioids, with good sensitivity and specificity for signs and symptoms. CONCLUSION: There is still little evidence of other medications that can help prevent the abstinence syndrome of opioids. This study tries to promote a better practice during opioid weaning.

RESUMO OBJETIVO: A síndrome de abstinência de opioides é comum no ambiente de terapia intensiva pediátrica porque a sedação é frequentemente necessária durante o tratamento das crianças. Não existe uma diretriz específica sobre o manejo desse paciente e, ultimamente, a metadona tem sido uma droga importante para a prevenção dos sintomas de abstinência durante o desmame dos opioides. Este estudo reúne as pesquisas disponíveis para estabelecer a dose inicial de metadona, taxa de redução e ferramentas para reconhecer essa síndrome e agir prontamente. MÉTODOS: Uma revisão sistemática foi feita a partir de dados de quatro diferentes bases de dados. Quarenta e nove artigos, de estudos observacionais e experimentais, foram selecionados com base nos critérios de inclusão (pacientes críticos pediátricos em uso de opioides agudamente) e critérios de exclusão (uso crônico prévio de opioides, outros medicamentos). Os dados referentes a temas específicos foram separados em seções: dose inicial de metadona, uso de protocolos na prática clínica, escalas de abstinência e drogas adjuvantes. RESULTADOS: Os artigos mostraram uma grande heterogeneidade de formas de calcular a dose inicial de metadona. As unidades de terapia intensiva pediátrica do estudo apresentaram diferentes protocolos de desmame, com menor incidência de abstinência quando foi utilizada uma sequência predefinida de redução gradual. A Ferramenta de Avaliação de Retirada - 1 foi a escala mais utilizada durante a redução dos opioides, com boa sensibilidade e especificidade para sinais e sintomas. CONCLUSÃO: Ainda há poucas evidências de outros medicamentos que possam ajudar a prevenir a síndrome de abstinência dos opioides. Este estudo tenta promover uma prática melhor durante o desmame dos opioides.

Changes in lipid metabolism in pediatric patients with severe sepsis and septic shock.

OBJECTIVES: Limited knowledge exists regarding the lipid profiles of critically ill pediatric patients with systemic inflammatory response syndrome. The aim of this study was to evaluate the relationship between the intensity of the inflammatory response and changes in the lipid profiles of critically ill pediatric patients admitted to a pediatric intensive care unit (PICU) with severe sepsis/septic shock. METHODS: This was a prospective and observational study at a 15-bed PICU at a public university hospital. We analyzed the lipid profiles of 40 patients with severe sepsis/septic shock admitted to the PICU on the first and seventh days of hospitalization. C-reactive protein was used as a marker for systemic inflammation. Forty-two pediatric patients seen in the emergency department and without systemic inflammatory response syndrome were used to provide control values. RESULTS: On day 1 of admission to the PICU, the patients had significantly lower levels of total cholesterol (TC), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) as well as higher concentrations of triacylglycerols compared with the control group. There was a significant increase in the TC, HDL, LDL, and apolipoprotein levels from day 1 to day 7 of the study. CONCLUSIONS: During severe sepsis/septic shock, we found lower serum levels of lipoproteins and apolipoproteins, and these were negatively correlated with C-reactive protein. As the inflammatory response improved, the levels of TC, HDL, LDL, and apolipoproteins increased, suggesting a direct relationship between changes in the lipid profiles and inflammation.

Pediatric chronic patients at outpatient clinics: a study in a Latin American University Hospital.

OBJECTIVE: To describe the characteristics of children and adolescentes with chronic diseases of outpatient clinics at a tertiary university hospital. METHODS: A cross-sectional study was performed with 16,237 patients with chronic diseases followed-up in one year. The data were collected through the electronic system, according to the number of physician appointments in 23 pediatric specialties. Patients were divided in two groups: children (0-9 years) and adolescents (10-19 years). Early (10-14 years) and late (15-19 years) adolescent groups were also analyzed. RESULTS: Of the total sample, 56% were children and 46% were adolescents. The frequencies of following pediatric specialties were significantly higher in adolescents when compared with children: cardiology, endocrinology, hematology, nephrology/renal transplantation, neurology, nutrology, oncology, palliative and pain care, psychiatry, and rheumatology (p<0.05). The frequencies of emergency service visits (30% vs. 17%, p<0.001), hospitalizations (23% vs. 11%, p<0.001), intensive care unit admissions (6% vs. 2%, p<0.001), and deaths (1% vs. 0.6%, p=0.002) were significantly lower in adolescents than in children. However, the number of physician appointments (≥13) per patient was also higher in the adolescent group (5% vs. 6%, p=0.018). Further analysis comparison between early and late adolescents revealed that the first group had significantly more physician appointments (35% vs. 32%, p=0.025), and required more than two pediatric specialties (22% vs. 21%, p=0.047). Likewise, the frequencies of emergency service visits (19% vs. 14%, p<0.001) and hospitalizations (12% vs. 10%, p=0.035) were higher in early adolescents. CONCLUSIONS: This study evaluated a large population in a Latin American hospital and suggested that early adolescents with chronic diseases required many appointments, multiple specialties and hospital admissions.