The Relevance of Airway Resistance in Children Requiring Mechanical Ventilatory Support.

OBJECTIVES: To describe pulmonary resistance in children undergoing invasive mechanical ventilation (MV) for different causes. DESIGN: A cross-sectional study. SETTING: Two PICUs in the South region of Brazil. PATIENTS: Children 1 month to 15 years old undergoing MV for more than 24 hours were included. We recorded ventilator variables and measured pulmonary mechanics (inspiratory and expiratory resistance, auto positive end-expiratory pressure [PEEP], and dynamic and static compliance) in the first 48 hours of MV. INTERVENTIONS: Measurements of the respiratory mechanics variables during neuromuscular blockade. MEASUREMENTS AND MAIN RESULTS: A total of 113 children were included, 5 months (median [interquartile range (IQR) [2.0-21.5 mo]) old, and median (IQR) weight 6.5 kg (4.5-11.0 kg), with 60% male. Median (IQR) peak inspiratory pressure (PIP) was 30 cm H 2 O (26-35 cm H 2 O), and median (IQR) PEEP was 5 cm H 2 O (5-7 cm H 2 O). The median (IQR) duration of MV was 7 days (5-9 d), and mortality was nine of 113 (8%). The median (IQR) inspiratory and expiratory resistances were 94.0 cm H 2 O/L/s (52.5-155.5 cm H 2 O/L/s) and 117 cm H 2 O/L/s (71-162 cm H 2 O/L/s), with negative association with weight and age (Spearman -0.850). When we assess weight, in smaller children (< 10 kg) had increased pulmonary resistance, with mean values over 100 mH 2 O/L/s, which were higher than larger children ( p < 0.001). CONCLUSIONS: Increased pulmonary resistance is prevalent in the pediatric population undergoing invasive MV. Especially in children less than 1 year old, this variable should be considered when defining a ventilatory strategy.

Brazilian Translation, Cross-Cultural Adaptation, Validity, and Reliability of the EMpowerment of PArents in THe Intensive Care 30 (EMPATHIC-30) Questionnaire to Measure Parental Satisfaction in PICUs.

OBJECTIVES: To conduct the Brazilian translation, cross-cultural adaptation, validation, and reliability testing of the EMpowerment of PArents in THe Intensive Care (EMPATHIC-30). DESIGN: Prospective study. SETTING: PICU of a tertiary-care teaching hospital. PATIENTS: Parents (n = 141) completed the translated EMPATHIC-30 questionnaire 72 hours after their child's PICU discharge. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The translation and cultural adaptation were performed in accordance with the principles of good practice for the translation and cultural adaptation process for patient-reported outcomes measures. Sentences were adapted according to the Brazilian syntax. Total content validity coefficient was above the established average (> 0.8). Reliability was evaluated with the coefficients McDonald omega and Cronbach alpha. The lowest Cronbach alpha found was 0.47 (CI 95%, 0.35-0.59) in the organization domain, where the lowest response rate was also concentrated. The values of the other domains were as follows: 0.64 (95% CI, 0.55-0.73) for information, 0.77 (95% CI, 0.71-0.83) for care and treatment, 0.72 (95% CI, 0.66-0.78) for parent participation, and 0.72 (95% CI, 0.65-0.79) for professional attitudes. The total internal consistency independent of the domain was 0.90 (CI 95%, 0.88-0.92). With regard to McDonald Omega, values were identified: 0.68 (95% CI, 0.49-0.88) for information, 0.73 (95% CI, 0.61-0.85) for care and treatment, 0.85 (95% CI, 0.47-0.80) for parent participation, 0.85 (95% CI, 0.76-0.93), and 0.72 (95% CI, 0.58-0.86) for professional attitudes. CONCLUSIONS: EMPATHIC-30 has been translated and culturally adapted for the Brazilian population. Validation demonstrated an above-average total content validity coefficient, confirming the instrument content validity. A sufficient reliability was observed in both analyzed coefficients. The results support the use of the Brazilian version of EMPATHIC-30 for the evaluation of parents' satisfaction of children admitted to the PICU.

Prevalence, mortality and risk factors associated with very low birth weight preterm infants: an analysis of 33 years / Prevalência, mortalidade e fatores de risco associados ao prematuro de muito baixo peso ao nascer: uma análise de 33 anos

Abstract Objective: To assess the prevalence, mortality and risk factors associated with the birth of very low birth weight preterm infants over a period of 33 years. Methods: Four cross-sectional studies were analyzed, using data from perinatal interviews of birth cohorts in the city of Pelotas collected in 1982, 1993, 2004, and 2015. Based on perinatal questionnaires, anthropometric measurements of newborns and death certificates were analyzed to obtain the prevalence rate, neonatal mortality, and risk factors (maternal age, income and type of delivery) for very low birth weight. Results: A total of 19,625 newborns were included in the study. In the years 1982, 1993, 2004, and 2015, there were, respectively, 5909, 5232, 4226, and 4258 births. The prevalence of very low birth weight was, respectively, 1.1% (n = 64), 0.9% (n = 46), 1.4% (n = 61), and 1.3% (n = 54). There was no statistical evidence of an increasing trend over time (p = 0.11). Among the risk factors, family income in the three poorest quintiles was associated with prevalence rates that were approximately twice as high as in the richest quintile (p = 0.003). Mortality per 1000 live births for neonates weighing <1500 g decreased from 688 to 259 per thousand from 1982 to 2015 (p < 0.001), but still represented 61% of neonatal deaths in the latter year. Conclusion: Although mortality in very low birth weight decreased by more than 60% in recent years, this group still contributes with more than half of neonatal deaths. Low family income remains an important risk factor in this scenario.

Resumo Objetivo: Verificar a prevalência, mortalidade e fatores de risco associados aos nascimentos de prematuros de muito baixo peso ao nascer (MBPN) ao longo de 33 anos. Métodos: Série de quatro estudos transversais com o uso de dados das entrevistas perinatais das coortes de nascimento da cidade de Pelotas coletados em 1982, 1993, 2004 e 2015. A partir de questionários perinatais, medidas antropométricas dos recém-nascidos e certidões de óbito, foram analisadas a prevalência, a mortalidade neonatal e os fatores de risco (idade materna, renda e tipo de parto) para prematuros de muito baixo peso ao nascer. Resultados: Foram incluídos no estudo 19.625 recém-nascidos. Em 1982, 1993, 2004 e 2015 ocorreram, respectivamente, 5.909, 5.232, 4.226 e 4.258 nascimentos. A prevalência de prematuros de muito baixo peso ao nascer naqueles anos foi, respectivamente, de 1,1% (n = 64), 0,9% (n = 46), 1,4% (n = 61) e 1,3% (n = 54). A tendência de aumento durante o período não alcançou significância estatística (p = 0,11). Entre os fatores de risco, a renda familiar nos três quintis mais pobres esteve associada a prevalências cerca de duas vezes mais altas do que no quintil mais rico (p = 0,003). A mortalidade por 1.000 nascidos vivos para os neonatos com peso < 1500 g caiu de 688 para 259 por mil ao longo dos anos (p < 0,001), mas ainda representa 61% dos óbitos neonatais em 2015. Conclusão: Embora a mortalidade nos prematuros de muito baixo peso ao nascer tenha diminuído em mais de 60% nos últimos anos, esse grupo ainda contribui com mais da metade dos óbitos neonatais. A baixa renda familiar continua a ser fator de risco importante nesse cenário.

Prediction of Poor Outcomes for Septic Children According to Ferritin Levels in a Middle-Income Setting.

OBJECTIVES: To evaluate serum ferritin measured within 48 hours of admission as a prognostic marker and examine the association with unfavorable outcomes in a population of pediatric patients with sepsis and high prevalence of iron deficiency anemia in which this biomarker is routinely measured. DESIGN: Retrospective cohort study. SETTING: PICU of a tertiary care teaching hospital in a middle-income country in South America. PATIENTS: All patients 6 months to 18 years old (n = 350) admitted with a diagnosis of sepsis, suspected or proven, were eligible for inclusion. Exclusion criteria were length of PICU stay less than 8 hours and inherited or acquired disorder of iron metabolism that could interfere with serum ferritin levels. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three-hundred twelve patients had their ferritin levels measured within 48 hours, and only 38 did not. The prevalence of iron deficiency anemia (hemoglobin < 11 g/dL and mean corpuscular volume < 80 fl was 40.3%. The median of the highest serum ferritin level within 48 hours was 150.5 ng/mL (interquartile range, 82.25-362 ng/mL), being associated with mortality (p < 0.001; Exp(B), 5.170; 95% CI, 2.619-10.205). A 10-fold increase in ferritin level was associated with a five-fold increase in mortality. There was a monotonic increase in mortality with increasing ferritin levels (p < 0.05). Regarding the discriminatory power of ferritin for mortality, the area under the receiver operating characteristic curve was 0.787 (95% CI, 0.737-0.83; p < 0.0001). CONCLUSIONS: Serum ferritin at lower thresholds predicts mortality in children with sepsis admitted to the ICU in a middle-income country with high prevalence of iron deficiency anemia.

Prevalence, mortality and risk factors associated with very low birth weight preterm infants: an analysis of 33 years.

OBJECTIVE: To assess the prevalence, mortality and risk factors associated with the birth of very low birth weight preterm infants over a period of 33 years. METHODS: Four cross-sectional studies were analyzed, using data from perinatal interviews of birth cohorts in the city of Pelotas collected in 1982, 1993, 2004, and 2015. Based on perinatal questionnaires, anthropometric measurements of newborns and death certificates were analyzed to obtain the prevalence rate, neonatal mortality, and risk factors (maternal age, income and type of delivery) for very low birth weight. RESULTS: A total of 19,625 newborns were included in the study. In the years 1982, 1993, 2004, and 2015, there were, respectively, 5909, 5232, 4226, and 4258 births. The prevalence of very low birth weight was, respectively, 1.1% (n=64), 0.9% (n=46), 1.4% (n=61), and 1.3% (n=54). There was no statistical evidence of an increasing trend over time (p=0.11). Among the risk factors, family income in the three poorest quintiles was associated with prevalence rates that were approximately twice as high as in the richest quintile (p=0.003). Mortality per 1000 live births for neonates weighing <1500g decreased from 688 to 259 per thousand from 1982 to 2015 (p<0.001), but still represented 61% of neonatal deaths in the latter year. CONCLUSION: Although mortality in very low birth weight decreased by more than 60% in recent years, this group still contributes with more than half of neonatal deaths. Low family income remains an important risk factor in this scenario.

Fluid balance in pediatric patients in prone position: a pragmatic study.

OBJECTIVE: To verify the association between prone position, increased diuresis, and decreased cumulative fluid balance in critically ill pediatric patients who underwent mechanical ventilation (MV) for pulmonary causes and describe adverse events related to the use of the position. METHODS: This is a retrospective observational study. Patients aged between 1 month and 12 years who underwent MV for pulmonary causes, between January 2013 and December 2015, were selected and divided between those who were put on prone position (PG) and those who were not (CG) during the hospitalization at the Pediatric Intensive Care Unit (PICU). Data were analyzed longitudinally from D1 to D4. RESULTS: A total of 77 patients (PG = 37 and CG = 40) were analyzed. The general characteristics of both groups were similar. In the comparison between the groups, there was no increase in diuresis or decrease in cumulative fluid balance in the prone group. In the longitudinal analysis of D1 to D4, we saw that the PG presented higher diuresis (p = 0.034) and a lower cumulative fluid balance (p = 0.001) in D2. Regarding the use of diuretics, there was greater use of furosemide (P <0.001) and spironolactone (P = 0.04) in the PG. There was no increase in adverse events during the use of the prone position. CONCLUSION: The prone position was not associated with increased diuresis or decreased cumulative fluid balance in critically ill pediatric patients who underwent to MV for pulmonary causes.

Fluid balance in pediatric patients in prone position: a pragmatic study

SUMMARY OBJECTIVE: To verify the association between prone position, increased diuresis, and decreased cumulative fluid balance in critically ill pediatric patients who underwent mechanical ventilation (MV) for pulmonary causes and describe adverse events related to the use of the position. METHODS: This is a retrospective observational study. Patients aged between 1 month and 12 years who underwent MV for pulmonary causes, between January 2013 and December 2015, were selected and divided between those who were put on prone position (PG) and those who were not (CG) during the hospitalization at the Pediatric Intensive Care Unit (PICU). Data were analyzed longitudinally from D1 to D4. RESULTS: A total of 77 patients (PG = 37 and CG = 40) were analyzed. The general characteristics of both groups were similar. In the comparison between the groups, there was no increase in diuresis or decrease in cumulative fluid balance in the prone group. In the longitudinal analysis of D1 to D4, we saw that the PG presented higher diuresis (p = 0.034) and a lower cumulative fluid balance (p = 0.001) in D2. Regarding the use of diuretics, there was greater use of furosemide (P <0.001) and spironolactone (P = 0.04) in the PG. There was no increase in adverse events during the use of the prone position. CONCLUSION: The prone position was not associated with increased diuresis or decreased cumulative fluid balance in critically ill pediatric patients who underwent to MV for pulmonary causes.

RESUMO OBJETIVO: Verificar a associação entre posição prona, aumento da diurese e diminuição do balanço hídrico em pacientes pediátricos criticamente enfermos e submetidos à ventilação mecânica (VM) por causa pulmonar, além de descrever eventuais intercorrências relacionadas à aplicação dessa posição. MÉTODOS: Estudo observacional retrospectivo. Pacientes submetidos à VM por causa pulmonar, com idade entre 1 mês e 12 anos no período entre janeiro de 2013 e dezembro de 2015, foram selecionados e divididos entre os que receberam posição prona (GP) e os que não receberam (GC) durante a internação na Unidade de Terapia Intensiva Pediátrica (Utip). Os dados foram analisados longitudinalmente de D1 a D4. RESULTADOS: Foram analisados77 pacientes (GP=37 e GC=40). Em termos de características gerais, os grupos foram semelhantes entre si. Na comparação entre os grupos, não houve aumento da diurese ou diminuição do balanço hídrico cumulativo no grupo prona. Na análise longitudinal de D1 a D4, evidenciou-se que o GP apresentou maior diurese (p=0,034) e menor balanço hídrico cumulativo (p = 0,001) no D2. Com relação ao uso de diuréticos, houve maior uso de furosemida (P<0,001) e de espironolactona (P=0,04) no GP. Não houve aumento de eventos adversos durante a utilização da posição prona. CONCLUSÃO: A posição prona não demonstrou associação com aumento da diurese ou diminuição de balanço hídrico cumulativo em pacientes críticos pediátricos submetidos à VM por causa pulmonar.

Pediatric emergency in Brazil: the consolidation of an area in the pediatric field.

OBJECTIVE: The aim of this study was to present a review on the evolution, development, and consolidation of the pediatric emergency abroad and in Brazil, as well as to discuss the residency program in this key area for pediatricians. DATA SOURCES: This was a narrative review, in which the authors used pre-selected documents utilized as the minimum requirements for the Residency Program in Pediatric Emergency Medicine and articles selected by interest for the theme development, at the SciELO and Medline databases, between 2000 and 2017. DATA SYNTHESIS: The historical antecedents and the initial evolution of pediatric emergency in Brazil, as well as several challenges were described, regarding the organization, the size, the training of professionals, and also the regulation of the professional practice in this new specialty. Additionally, a new pediatric emergency residency program to be implemented in Brazil is described. CONCLUSIONS: Pediatric emergency training will be a powerful stimulus to attract talented individuals, to establish them in this key area of medicine, where they can exercise their leadership by promoting care qualification, research, and teaching, as well as acting decisively in their management.

Cardiac dysfunction and ferritin as early markers of severity in pediatric sepsis / Disfunção cardíaca e a ferritina como marcadores precoces de gravidade na sepse pediátrica

Abstract Objective: The aim of this study was to verify the association of echocardiogram, ferritin, C-reactive protein, and leukocyte count with unfavorable outcomes in pediatric sepsis. Methods: A prospective cohort study was carried out from March to December 2014, with pediatric critical care patients aged between 28 days and 18 years. Inclusion criteria were diagnosis of sepsis, need for mechanical ventilation for more than 48 h, and vasoactive drugs. Serum levels of C-reactive protein, ferritin, and leukocyte count were collected on the first day (D0), 24 h (D1), and 72 h (D3) after recruitment. Patients underwent transthoracic echocardiography to determine the ejection fraction of the left ventricle on D1 and D3. The outcomes measured were length of hospital stay and in the pediatric intensive care unit, mechanical ventilation duration, free hours of VM, duration of use of inotropic agents, maximum inotropic score, and mortality. Results: Twenty patients completed the study. Patients with elevated ferritin levels on D0 had also fewer ventilator-free hours (p = 0.046) and higher maximum inotropic score (p = 0.009). Patients with cardiac dysfunction by echocardiogram on D1 had longer hospital stay (p = 0.047), pediatric intensive care unit stay (p = 0.020), duration of mechanical ventilation (p = 0.011), maximum inotropic score (p = 0.001), and fewer ventilator-free hours (p = 0.020). Conclusion: Cardiac dysfunction by echocardiography and serum ferritin value was significantly associated with unfavorable outcomes in pediatric patients with sepsis.

Resumo Objetivo: Verificar a associação do ecocardiograma, da ferritina, da proteína C reativa (PCR) e da contagem de leucócitos com desfechos desfavoráveis na sepse pediátrica. Métodos: Estudo de coorte prospectivo, de março a dezembro de 2014, com pacientes críticos pediátricos entre 28 dias e 18 anos. Critérios de inclusão foram diagnóstico de sepse, necessidade de ventilação mecânica (VM) por mais de 48 horas e uso de drogas vasoativas. Avaliaram‐se os níveis séricos PCR, ferritina, contagem de leucócitos, no recrutamento (D0), 24 horas (D1) e 72 horas (D3) após o recrutamento. No D1 e no D3 todos os pacientes foram submetidos a ecocardiograma transtorácico para determinação da Fração de Ejeção (FE) do ventrículo esquerdo. Os desfechos avaliados foram tempo de internação hospitalar e na Unidade de Terapia Intensiva Pediátrica (UTIP); duração da VM; horas livres de VM; duração do uso de inotrópicos; escore de inotrópicos máximo e mortalidade. Resultados: Vinte pacientes completaram o estudo. Ferritina elevada no D0 associou‐se com menor tempo livre de ventilação (p = 0,046) e maior escore de inotrópicos máximo (p = 0,009). A disfunção cardíaca pelo ecocardiograma no D1 relacionou‐se com maior tempo de internação hospitalar (p = 0,047), de UTIP (p = 0,020), VM total (p = 0,011), escore de inotrópicos máximo (p = 0,001) e menor tempo livre de VM (p = 0,020). Conclusão: A disfunção cardíaca pelo ecocardiograma e o valor de ferritina sérica associaram‐se significativamente com desfechos desfavoráveis nos pacientes pediátricos com sepse.

Cardiac dysfunction and ferritin as early markers of severity in pediatric sepsis.

OBJECTIVE: The aim of this study was to verify the association of echocardiogram, ferritin, C-reactive protein, and leukocyte count with unfavorable outcomes in pediatric sepsis. METHODS: A prospective cohort study was carried out from March to December 2014, with pediatric critical care patients aged between 28 days and 18 years. Inclusion criteria were diagnosis of sepsis, need for mechanical ventilation for more than 48h, and vasoactive drugs. Serum levels of C-reactive protein, ferritin, and leukocyte count were collected on the first day (D0), 24h (D1), and 72h (D3) after recruitment. Patients underwent transthoracic echocardiography to determine the ejection fraction of the left ventricle on D1 and D3. The outcomes measured were length of hospital stay and in the pediatric intensive care unit, mechanical ventilation duration, free hours of VM, duration of use of inotropic agents, maximum inotropic score, and mortality. RESULTS: Twenty patients completed the study. Patients with elevated ferritin levels on D0 had also fewer ventilator-free hours (p=0.046) and higher maximum inotropic score (p=0.009). Patients with cardiac dysfunction by echocardiogram on D1 had longer hospital stay (p=0.047), pediatric intensive care unit stay (p=0.020), duration of mechanical ventilation (p=0.011), maximum inotropic score (p=0.001), and fewer ventilator-free hours (p=0.020). CONCLUSION: Cardiac dysfunction by echocardiography and serum ferritin value was significantly associated with unfavorable outcomes in pediatric patients with sepsis.

Pilot Mechanistic Study of Insulin Modulation of Somatotrophic Hormones, Inflammation, and Lipid Metabolism During Critical Illness in Children.

OBJECTIVES: To evaluate the mechanism of insulin modulation on somatotrophic response, inflammation, and lipid metabolism in critically ill children. DESIGN: Open-label randomized mechanistic study. SETTING: Two-center, tertiary PICU study. PATIENTS: Thirty critically ill children between 1 month and 14 years old, requiring mechanical ventilation and with evidence of two or more organ system failures. INTERVENTIONS: Randomized physiologic design of hyperinsulinemic-euglycemic clamp using continuous insulin infusion at 0.1 U/kg/hr versus conventional management. MEASUREMENTS AND MAIN RESULTS: Thirteen children underwent hyperinsulinemic-euglycemic clamp. Blood samples for somatotrophic, inflammatory, and metabolic evaluation were obtained before randomization, and 24 and 72 hours later. A growth hormone oscillation profile was obtained during the first night. There was no difference between groups at baseline. Growth hormone resistance, increased proinflammatory cytokines, and increased lipolysis with low lipoprotein levels were present in all patients. Hyperinsulinemic-euglycemic clamp did not affect growth hormone, insulin-like growth factor-1 or insulin-like growth factor binding protein-3 levels. By day 2, insulin reduced insulin-like growth factor binding protein-1 levels. Tumor necrosis factor-α and interleukin-1ß were similar in both groups, whereas interleukin-6 levels reduced over time only in children receiving hyperinsulinemic-euglycemic clamp. Hyperinsulinemic-euglycemic clamp also decreased free fatty acid levels, which was accompanied by increased low-density lipoprotein cholesterol and relative increase in high-density lipoprotein levels. Total cholesterol and triglycerides were unchanged. CONCLUSIONS: Insulin does not reverse most of the somatotrophic changes induced by the stress of critical illness. Rather, it may improve lipid metabolism and down-regulate some markers of the inflammatory response.

Pediatric emergency in Brazil: the consolidation of an area in the pediatric field / Emergência pediátrica no Brasil: a consolidação da área de atuação para o pediatra

Abstract Objective: The aim of this study was to present a review on the evolution, development, and consolidation of the pediatric emergency abroad and in Brazil, as well as to discuss the residency program in this key area for pediatricians. Data sources: This was a narrative review, in which the authors used pre-selected documents utilized as the minimum requirements for the Residency Program in Pediatric Emergency Medicine and articles selected by interest for the theme development, at the SciELO and Medline databases, between 2000 and 2017. Data synthesis: The historical antecedents and the initial evolution of pediatric emergency in Brazil, as well as several challenges were described, regarding the organization, the size, the training of professionals, and also the regulation of the professional practice in this new specialty. Additionally, a new pediatric emergency residency program to be implemented in Brazil is described. Conclusions: Pediatric emergency training will be a powerful stimulus to attract talented individuals, to establish them in this key area of medicine, where they can exercise their leadership by promoting care qualification, research, and teaching, as well as acting decisively in their management.

Resumo Objetivo: Apresentar uma revisão sobre a evolução, o desenvolvimento e a consolidação da emergência pediátrica no exterior e no Brasil, assim como discutir o programa de residência nessa importante área de atuação para o pediatra. Fontes dos dados: Revisão do tipo narrativa, em que os autores usaram documentos pré-selecionados empregados nos requisitos mínimos para o programa em Residência de Medicina de Emergência Pediátrica e para artigos selecionados por interesse para desenvolvimento do tema usaram as bases de dados SciELO e Medline entre 2000 e 2017. Síntese dos dados: Foram descritos os antecedentes históricos e a evolução inicial da emergência pediátrica no Brasil e diversos desafios, na organização, no dimensionamento, na formação de profissionais e, também, na regulamentação do exercício profissional dessa nova especialidade. Também se descreve um novo programa de residência em emergência pediátrica a ser implantado no Brasil Conclusões: A formação em emergência pediátrica será um poderoso estímulo para atrair indivíduos talentosos, fixá-los nessa importante área da medicina, na qual poderão exercer sua liderança e promover qualificação na assistência, na pesquisa e no ensino, assim como atuar decisivamente no seu gerenciamento.

Association between nutritional status and outcomes in critically-ill pediatric patients – a systematic review / Relação do estado nutricional com desfechos em pacientes pediátricos críticos - Revisão sistemática

Abstract Objectives: To systematically review the evidence about the impact of nutritional status in critically-ill pediatric patients on the following outcomes during hospitalization in pediatric intensive care units: length of hospital stay, need for mechanical ventilation, and mortality. Data source: The search was carried out in the following databases: Lilacs (Latin American and Caribbean Health Sciences), MEDLINE (National Library of Medicine United States) and Embase (Elsevier Database). No filters were selected. Results: A total of seven relevant articles about the subject were included. The publication period was between 1982 and 2012. All articles assessed the nutritional status of patients on admission at pediatric intensive care units and correlated it to at least one assessed outcome. A methodological quality questionnaire created by the authors was applied, which was based on some references and the researchers’ experience. All included studies met the quality criteria, but only four met all the items. Conclusion: The studies included in this review suggest that nutritional depletion is associated with worse outcomes in pediatric intensive care units. However, studies are scarce and those existing show no methodological homogeneity, especially regarding nutritional status assessment and classification methods. Contemporary and well-designed studies are needed in order to properly assess the association between children's nutritional status and its impact on outcomes of these patients.

Resumo Objetivos: Revisar, de forma sistemática, as evidências acerca do impacto do estado nutricional de pacientes pediátricos críticos sobre os seguintes desfechos durante a internação em unidades de terapia intensiva pediátrica: tempo de internação, necessidade de ventilação mecânica e mortalidade. Fonte de dados: A busca foi feita nas seguintes bases de dados: Lilacs (Literatura Latino‐Americana e do Caribe em Ciências da Saúde), Medline (National Library of Medicine, Estados Unidos) e Embase (Elsevier Base de Dados). Não houve seleção de filtros. Resultados: Foram incluídos sete artigos relevantes sobre o tema. O período de publicação variou entre 1982 e 2012. Todos avaliam o estado nutricional de pacientes no momento da internação em terapia intensiva pediátrica e se relacionam com pelo menos um desfecho estudado. Foi aplicado um questionário de qualidade metodológica criado pelos autores. Ele foi baseado em algumas referências e na experiência dos pesquisadores. Todos os estudos incluídos alcançaram os critérios de qualidade, porém apenas quatro atenderam a todos os itens. Conclusão: Os estudos incluídos nesta revisão sugerem que a depleção do estado nutricional está relacionada com piores desfechos em terapia intensiva pediátrica. Porém os estudos são escassos e os existentes não têm uniformidade metodológica, em especial nos métodos de avaliação e classificação do estado nutricional. São necessários estudos atuais e bem delineados com o objetivo de avaliar adequadamente essa relação entre o estado nutricional de crianças e sua repercussão nos desfechos desses pacientes.

Association between nutritional status and outcomes in critically-ill pediatric patients - a systematic review.

OBJECTIVES: To systematically review the evidence about the impact of nutritional status in critically-ill pediatric patients on the following outcomes during hospitalization in pediatric intensive care units: length of hospital stay, need for mechanical ventilation, and mortality. DATA SOURCE: The search was carried out in the following databases: Lilacs (Latin American and Caribbean Health Sciences), MEDLINE (National Library of Medicine United States) and Embase (Elsevier Database). No filters were selected. RESULTS: A total of seven relevant articles about the subject were included. The publication period was between 1982 and 2012. All articles assessed the nutritional status of patients on admission at pediatric intensive care units and correlated it to at least one assessed outcome. A methodological quality questionnaire created by the authors was applied, which was based on some references and the researchers' experience. All included studies met the quality criteria, but only four met all the items. CONCLUSION: The studies included in this review suggest that nutritional depletion is associated with worse outcomes in pediatric intensive care units. However, studies are scarce and those existing show no methodological homogeneity, especially regarding nutritional status assessment and classification methods. Contemporary and well-designed studies are needed in order to properly assess the association between children's nutritional status and its impact on outcomes of these patients.

Nurses' participation in the end-of-life process in two paediatric intensive care units in Brazil.

The aim of this study was to evaluate the medical and nursing care provided to children in the last 24 hours of life in two Brazilian paediatric intensive care units and analyse the nurses' participation in the decision-making process for life support limitation (LSL). The study was based on an analysis of the patients' medical charts, looking at the medical and nursing care provided in the last 24 hours of life during a 6-month period in the two units, and on semi-structured interviews with 20 nurses to evaluate their participation in LSL decisions. The children were classified into two groups: those who were to receive full cardiopulmonary resuscitation (CPR) and a non-CPR group. A total of 34 deaths occurred during the study period. Of these, 17 (50%) were children that had been in the non-CPR group; there were only 10 recorded LSL plans in their medical charts. In the interviews, only 30% of the nurses mentioned active participation in LSL decisions. In conclusion, the paediatric intensive care nurses in these two Brazilian units did not participate much in LSL decisions, and the care offered in the last hours of life to children with terminal and irreversible illness was not primarily directed toward comfort and alleviating suffering.