Epidemiology and outcomes of septic shock in children with complex chronic conditions in a developing country PICU

Abstract Objective: To investigate the role of Complex Chronic Conditions (CCCs) on the outcomes of pediatric patients with refractory septic shock, as well as the accuracy of PELOD-2 and Vasoactive Inotropic Score (VIS) to predict mortality in this specific population. Methods: This is a single-center, retrospective cohort study. All patients diagnosed with septic shock requiring vasoactive drugs admitted to a 13-bed PICU in southern Brazil, between January 2016 and July 2018, were included. Clinical and demographic characteristics, presence of CCCs and VIS, and PELOD-2 scores were accessed by reviewing electronic medical records. The main outcome was considered PICU mortality. Results: 218 patients with septic shock requiring vasoactive drugs were identified in the 30-month period and 72% of them had at least one CCC. Overall mortality was 22%. Comparing to patients without previous comorbidities, those with CCCs had a higher mortality (26.7% vs 9.8%; OR = 3.4 [1.3-8.4]) and longer hospital length of stay (29.3 vs 14.8; OR 2.39 [1.1-5.3]). Among the subgroups of CCCs, "Malignancy" was particularly associated with mortality (OR = 2.3 [1.0-5.1]). VIS and PELOD-2 scores in 24 and 48 hours were associated with mortality and a PELOD-2 in 48 hours > 8 had the best performance in predicting mortality in patients with CCC (AUROC = 0.89). Conclusion: Patients with CCCs accounted for the majority of those admitted to the PICU with septic shock and related to poor outcomes. The high prevalence of hospitalizations, use of resources, and significant mortality determine that patients with CCCs should be considered a priority in the healthcare system.

Continuous clonidine infusion: an alternative for children on mechanical ventilation.

OBJECTIVE: This study aimed to assess the clonidine infusion rate in the first 6 h, as maintenance dose (first 24 h), and in the pre-extubation period (last 24 h), as well as the cumulative dose of other sedatives and the hemodynamic response. METHODS: This is a retrospective cohort study. RESULTS: Children up to the age of 2 years who were admitted to the pediatric intensive care unit of a tertiary referral hospital in the south region of Brazil, between January 2017 and December 2018, were submitted to mechanical ventilation, and received continuous clonidine infusions were included in the study. The initial, maintenance, and pre-extubation doses of clonidine; the vasoactive-inotropic score; heart rate; and systolic and diastolic blood pressure of the study participants were assessed. A total of 66 patients with a median age of 4 months who were receiving clonidine infusions were included. The main indications for mechanical ventilation were acute viral bronchiolitis (56%) and pneumonia associated with acute respiratory distress syndrome (15%). The median of clonidine infusion in the first 6 h (66 patients) was 0.53 µg/kg/h (IQR 0.49-0.88), followed by 0.85 µg/kg/h (IQR 0.53-1.03) during maintenance (57 patients) and 0.63 µg/kg/h (IQR 0.54-1.01) during extubation period (42 patients) (p=0.03). No differences were observed in the doses regarding the indication for mechanical ventilation. Clonidine infusion was not associated with hemodynamic changes and showed no differences when associated with adjuvants. CONCLUSION: Clonidine demonstrated to be a well-tolerated sedation option in pediatric patients submitted to mechanical ventilation, without relevant influence in hemodynamic variables.

Continuous clonidine infusion: an alternative for children on mechanical ventilation

SUMMARY OBJECTIVE: This study aimed to assess the clonidine infusion rate in the first 6 h, as maintenance dose (first 24 h), and in the pre-extubation period (last 24 h), as well as the cumulative dose of other sedatives and the hemodynamic response. METHODS: This is a retrospective cohort study. RESULTS: Children up to the age of 2 years who were admitted to the pediatric intensive care unit of a tertiary referral hospital in the south region of Brazil, between January 2017 and December 2018, were submitted to mechanical ventilation, and received continuous clonidine infusions were included in the study. The initial, maintenance, and pre-extubation doses of clonidine; the vasoactive-inotropic score; heart rate; and systolic and diastolic blood pressure of the study participants were assessed. A total of 66 patients with a median age of 4 months who were receiving clonidine infusions were included. The main indications for mechanical ventilation were acute viral bronchiolitis (56%) and pneumonia associated with acute respiratory distress syndrome (15%). The median of clonidine infusion in the first 6 h (66 patients) was 0.53 μg/kg/h (IQR 0.49-0.88), followed by 0.85 μg/kg/h (IQR 0.53-1.03) during maintenance (57 patients) and 0.63 μg/kg/h (IQR 0.54-1.01) during extubation period (42 patients) (p=0.03). No differences were observed in the doses regarding the indication for mechanical ventilation. Clonidine infusion was not associated with hemodynamic changes and showed no differences when associated with adjuvants. CONCLUSION: Clonidine demonstrated to be a well-tolerated sedation option in pediatric patients submitted to mechanical ventilation, without relevant influence in hemodynamic variables.

Epidemiology and outcomes of septic shock in children with complex chronic conditions in a developing country PICU.

OBJECTIVE: To investigate the role of Complex Chronic Conditions (CCCs) on the outcomes of pediatric patients with refractory septic shock, as well as the accuracy of PELOD-2 and Vasoactive Inotropic Score (VIS) to predict mortality in this specific population. METHODS: This is a single-center, retrospective cohort study. All patients diagnosed with septic shock requiring vasoactive drugs admitted to a 13-bed PICU in southern Brazil, between January 2016 and July 2018, were included. Clinical and demographic characteristics, presence of CCCs and VIS, and PELOD-2 scores were accessed by reviewing electronic medical records. The main outcome was considered PICU mortality. RESULTS: 218 patients with septic shock requiring vasoactive drugs were identified in the 30-month period and 72% of them had at least one CCC. Overall mortality was 22%. Comparing to patients without previous comorbidities, those with CCCs had a higher mortality (26.7% vs 9.8%; OR = 3.4 [1.3-8.4]) and longer hospital length of stay (29.3 vs 14.8; OR 2.39 [1.1- 5.3]). Among the subgroups of CCCs, "Malignancy" was particularly associated with mortality (OR = 2.3 [1.0-5.1]). VIS and PELOD-2 scores in 24 and 48 hours were associated with mortality and a PELOD-2 in 48 hours > 8 had the best performance in predicting mortality in patients with CCC (AUROC = 0.89). CONCLUSION: Patients with CCCs accounted for the majority of those admitted to the PICU with septic shock and related to poor outcomes. The high prevalence of hospitalizations, use of resources, and significant mortality determine that patients with CCCs should be considered a priority in the healthcare system.

Risk factors for severe COVID-19 infection in Brazilian children.

The aim of this study was to describe the epidemiological characteristics and clinical outcome of children hospitalized with COVID-19 and identify the risk factors for severe disease. All hospital admissions of pediatric patients between March and December 2020 in the southern region of Brazil were reviewed and the patients positive for RT-PCR for SARS-CoV-2 were identified. This region encompasses a population of over 2.8 million children and adolescents. Data were extracted from a national database that includes all cases of severe acute respiratory syndrome requiring hospitalization in Brazil. A total of 288 hospitalizations (51.3% female) with a median age of 3 years (interquartile range 0-12 years) were identified. Of these, 38.9% had chronic medical conditions, 55.6% required some form of supplementary oxygen, and 30.2% were admitted to an intensive care unit. There were 17 deaths (5.9%) related to COVID-19. Age less than 30 days was significantly associated with increased odds of critical illness (OR 9.52, 95% CI 3.01-30.08), as well as the presence of one chronic condition (OR 5.08 95%CI 2.78-9.33) or two or more chronic conditions (OR 6.60, 95% CI 3.17-13.74). Conclusion: Age under 30 days old and presence of chronic conditions were strongly associated with unfavorable outcomes in Brazilian children with SARS-CoV-2 infection. These findings could help local public health authorities to develop specific policies to protect this more vulnerable group of children.

Two-Thumb Technique Is Superior to Two-Finger Technique in Cardiopulmonary Resuscitation of Simulated Out-of-Hospital Cardiac Arrest in Infants.

Background To compare the 2-finger and 2-thumb chest compression techniques on infant manikins in an out-of-hospital setting regarding efficiency of compressions, ventilation, and rescuer pain and fatigue. Methods and Results In a randomized crossover design, 78 medical students performed 2 minutes of cardiopulmonary resuscitation with mouth-to-nose ventilation at a 30:2 rate on a Resusci Baby QCPR infant manikin (Laerdal, Stavanger, Norway), using a barrier device and the 2-finger and 2-thumb compression techniques. Frequency and depth of chest compressions, proper hand position, complete chest recoil at each compression, hands-off time, tidal volume, and number of ventilations were evaluated through manikin-embedded SkillReporting software. After the interventions, standard Likert questionnaires and analog scales for pain and fatigue were applied. The variables were compared by a paired t-test or Wilcoxon test as suitable. Seventy-eight students participated in the study and performed 156 complete interventions. The 2-thumb technique resulted in a greater depth of chest compressions (42 versus 39.7 mm; P<0.01), and a higher percentage of chest compressions with adequate depth (89.5% versus 77%; P<0.01). There were no differences in ventilatory parameters or hands-off time between techniques. Pain and fatigue scores were higher for the 2-finger technique (5.2 versus 1.8 and 3.8 versus 2.6, respectively; P<0.01). Conclusions In a simulation of out-of-hospital, single-rescuer infant cardiopulmonary resuscitation, the 2-thumb technique achieves better quality of chest compressions without interfering with ventilation and causes less rescuer pain and fatigue.

End-of-life practices in patients admitted to pediatric intensive care units in Brazil: A retrospective study

Abstract Objective: To determine the prevalence of life support limitation (LSL) in patients who died after at least 24 h of a pediatric intensive care unit (PICU) stay, parent participation and to describe how this type of care is delivered. Methods: Retrospective cohort study in a tertiary PICU at a university hospital in Brazil. All patients aged 1 month to 18 years who died were eligible for inclusion. The exclusion criteria were those brain death and death within 24 h of admission. Results: 53 patients were included in the study. The prevalence of a LSL report was 45.3%. Out of 24 patients with a report of LSL on their medical records only 1 did not have a donot-resuscitate order. Half of the patients with a report of LSL had life support withdrawn. The length of their PICU stay, age, presence of parents at the time of death, and severity on admission, calculated by the Pediatric Index of Mortality 2, were higher in patients with a report of LSL. Compared with other historical cohorts, there was a clear increase in the prevalence of LSL and, most importantly, a change in how limitations are carried out, with a high prevalence of parental participation and an increase in withdrawal of life support. Conclusions: LSLs were associated with older and more severely ill patients, with a high prevalence of family participation in this process. The historical comparison showed an increase in LSL and in the withdrawal of life support.

Performance of prognostic markers in pediatric sepsis.

OBJECTIVE: To evaluate the prognostic performance of the Pediatric Index of Mortality 2 (PIM2), ferritin, lactate, C-reactive protein (CRP), and leukocytes, alone and in combination, in pediatric patients with sepsis admitted to the pediatric intensive care unit (PICU). METHODS: A retrospective study was conducted in a PICU in Brazil. All patients aged 6 months to 18 years admitted with a diagnosis of sepsis were eligible for inclusion. Those with ferritin and C-reactive protein measured within 48h and lactate and leukocytes within 24h of admission were included in the prognostic performance analysis. RESULTS: Of 350 eligible patients with sepsis, 294 had undergone all measurements required for analysis and were included in the study. PIM2, ferritin, lactate, and CRP had good discriminatory power for mortality, with PIM2 and ferritin being superior to CRP. The cutoff values for PIM2 (> 14%), ferritin (> 135ng/mL), lactate (> 1.7mmol/L), and CRP (> 6.7mg/mL) were associated with mortality. The combination of ferritin, lactate, and CRP had a positive predictive value of 43% for mortality, similar to that of PIM2 alone (38.6%). The combined use of the three biomarkers plus PIM2 increased the positive predictive value to 76% and accuracy to 0.945. CONCLUSIONS: PIM2, ferritin, lactate, and CRP alone showed good prognostic performance for mortality in pediatric patients older than 6 months with sepsis. When combined, they were able to predict death in three-fourths of the patients with sepsis. Total leukocyte count was not useful as a prognostic marker.

End-of-life practices in patients admitted to pediatric intensive care units in Brazil: A retrospective study.

OBJECTIVE: To determine the prevalence of life support limitation (LSL) in patients who died after at least 24h of a pediatric intensive care unit (PICU) stay, parent participation and to describe how this type of care is delivered. METHODS: Retrospective cohort study in a tertiary PICU at a university hospital in Brazil. All patients aged 1 month to 18 years who died were eligible for inclusion. The exclusion criteria were those brain death and death within 24h of admission. RESULTS: 53 patients were included in the study. The prevalence of a LSL report was 45.3%. Out of 24 patients with a report of LSL on their medical records only 1 did not have a do-not-resuscitate order. Half of the patients with a report of LSL had life support withdrawn. The length of their PICU stay, age, presence of parents at the time of death, and severity on admission, calculated by the Pediatric Index of Mortality 2, were higher in patients with a report of LSL. Compared with other historical cohorts, there was a clear increase in the prevalence of LSL and, most importantly, a change in how limitations are carried out, with a high prevalence of parental participation and an increase in withdrawal of life support. CONCLUSIONS: LSLs were associated with older and more severely ill patients, with a high prevalence of family participation in this process. The historical comparison showed an increase in LSL and in the withdrawal of life support.

Septic shock in pediatrics: the state-of-the-art / Choque séptico em pediatria: o estado da arte

Abstract Objective Review the main aspects of the definition, diagnosis, and management of pediatric patients with sepsis and septic shock. Source of data A search was carried out in the MEDLINE and Embase databases. The articles were chosen according to the authors' interest, prioritizing those published in the last five years. Synthesis of data Sepsis remains a major cause of mortality in pediatric patients. The variability of clinical presentations makes it difficult to attain a precise definition in pediatrics. Airway stabilization with adequate oxygenation and ventilation if necessary, initial volume resuscitation, antibiotic administration, and cardiovascular support are the basis of sepsis treatment. In resource-poor settings, attention should be paid to the risks of fluid overload when administrating fluids. Administration of vasoactive drugs such as epinephrine or norepinephrine is necessary in the absence of volume response within the first hour. Follow-up of shock treatment should adhere to targets such as restoring vital and clinical signs of shock and controlling the focus of infection. A multimodal evaluation with bedside ultrasound for management after the first hours is recommended. In refractory shock, attention should be given to situations such as cardiac tamponade, hypothyroidism, adrenal insufficiency, abdominal catastrophe, and focus of uncontrolled infection. Conclusions The implementation of protocols and advanced technologies have reduced sepsis mortality. In resource-poor settings, good practices such as early sepsis identification, antibiotic administration, and careful fluid infusion are the cornerstones of sepsis management.

Resumo Objetivo Revisar os principais aspectos da definição, diagnóstico e manejo do paciente pediátrico com sepse e choque séptico. Fontes de dados Uma pesquisa nas plataformas de dados Medline e Embase foi feita. Os artigos foram escolhidos segundo interesse dos autores, priorizaram-se as publicações dos últimos 5 anos. Síntese dos dados A sepse continua a ser uma causa importante de mortalidade em pacientes pediátricos. A variabilidade de apresentação clínica dificulta uma definição precisa em pediatria. A estabilização da via aérea com adequada oxigenação, e ventilação se necessário, ressuscitação volêmica inicial, administração de antibióticos e suporte cardiovascular são a base do tratamento da sepse. Em cenários de poucos recursos, deve-se atentar para os riscos de sobrecarga hídrica na administração de fluidos. A administração de drogas vasoativas, como adrenalina ou noradrenalina, se faz necessária na ausência da resposta ao volume na primeira hora. O seguimento do tratamento do choque deve seguir alvos como restauração dos sinais vitais e clínicos de choque e controle do foco de infecção. Recomenda-se a avaliação multimodal, com auxílio da ecografia à beira-leito para manejo após as primeiras horas. No choque refratário, deve-se atentar para situações como tamponamento cardíaco, hipotireoidismo, insuficiência adrenal, catástrofe abdominal e foco de infecção não controlado. Conclusões Implantação de protocolos e avançadas tecnologias propiciou uma redução da mortalidade da sepse. Em cenários de poucos recursos, as boas práticas, como reconhecimento precoce da sepse, administração de antibióticos e cuidadosa infusão de fluidos, são os pilares do manejo da sepse.

Accuracy of stridor-based diagnosis of post-intubation subglottic stenosis in pediatric patients / Precisão do diagnóstico de estenose subglótica pós-intubação com base em estridorem pacientes pediátricos

Abstract Objective To assess the accuracy of stridor in comparison to endoscopic examination for diagnosis of pediatric post-intubation subglottic stenosis. Method Children who required endotracheal intubation for >24 h were included in this prospective cohort study. Children were monitored daily and underwent flexible fiberoptic laryngoscopy after extubation. Those with moderate-to-severe abnormalities underwent another examination 7-10 days later. If lesions persisted or symptoms developed, laryngoscopy under general anesthesia was performed. Patients were assessed daily for stridor after extubation. Results A total of 187 children were included. The incidence of post-extubation stridor was 44.38%. Stridor had a sensitivity of 77.78% (95% confidence interval [95% CI]: 51.9-92.6) and specificity of 59.18% (95% CI: 51.3-66.6) in detecting subglottic stenosis. The positive predictive value was 16.87% (95% CI: 9.8-27.1), and the negative predictive value was 96.15% (95% CI: 89.9-98.8). Stridor persisting longer than 72 h or starting more than 72 h post-extubation had a sensitivity of 66.67% (95% CI: 41.2-85.6), specificity of 89.1% (95% CI: 83.1-93.2), positive predictive value of 40.0% (95% CI: 23.2-59.3), and negative predictive value of 96.07% (95% CI: 91.3-98.4). The area under the receiver operating characteristic (ROC) curve was 0.78 (95% CI: 0.65-0.91). Conclusions Absence of stridor was appropriate to rule out post-intubation subglottic stenosis. The specificity of this criterion improved when stridor persisted longer than 72 h or started more than 72 h post-extubation. Thus, endoscopy under general anesthesia can be used to confirm subglottic stenosis only in patients who develop or persist with stridor for more than 72 h following extubation.

Resumo Objetivo Analisar a precisão do estridor em comparação com o exame endoscópico no diagnóstico de estenose subglótica pós-intubação em crianças. Método Foram incluídas neste estudo de coorte prospectivo crianças que necessitaram de intubação endotraqueal por mais de 24 horas. Elas foram monitoradas diariamente e submetidas à nasofibrolaringoscopia flexível após a extubação. As crianças com anomalias moderadas foram submetidas a outro exame sete a 10 dias depois. Caso as lesões persistissem ou os sintomas evoluíssem, a laringoscopia era realizada com anestesia geral. Os pacientes foram avaliados diariamente quanto ao estridor após a extubação. Resultados Participaram 187 crianças. A incidência de estridor após a intubação foi de 44,38%. O estridor apresentou uma sensibilidade de 77,78% (intervalo de confiança de 95% [IC]: 51,9-92,6) e especificidade de 59,18% (IC: 51,3-66,6) na detecção de SGS. O valor preditivo positivo foi de 16,87% (IC: 9,8-27,1) e o valor preditivo negativo (VPN) foi de 96,15% (IC: 89,9-98,8). O estridor que persistiu por mais de 72 horas ou que começou 72 horas após a extubação teve uma sensibilidade de 66,67% (IC: 41,2-85,6), especificidade de 89,1% (IC: 83,1-93,2), valor preditivo positivo de 40,0% (IC: 23,2-59,3) e valor preditivo negativo de 96,07% (IC: 91,3-98,4). A área sob a curva de característica de operação do receptor (ROC) foi de 0,78 (IC: 0,65-0,91). Conclusões A ausência de estridor foi adequada para descartar a estenose subglótica pós-intubação. A especificidade desse critério melhorou quando o estridor perdurou por mais de 72 horas ou começou mais de 72 horas após a extubação. Assim, a endoscopia com anestesia geral pode ser utilizada para confirmar a estenose subglótica somente em pacientes que desenvolveram ou continuaram com estridor por mais de 72 horas após a extubação.

Accuracy of stridor-based diagnosis of post-intubation subglottic stenosis in pediatric patients.

OBJECTIVE: To assess the accuracy of stridor in comparison to endoscopic examination for diagnosis of pediatric post-intubation subglottic stenosis. METHOD: Children who required endotracheal intubation for >24h were included in this prospective cohort study. Children were monitored daily and underwent flexible fiberoptic laryngoscopy after extubation. Those with moderate-to-severe abnormalities underwent another examination 7-10 days later. If lesions persisted or symptoms developed, laryngoscopy under general anesthesia was performed. Patients were assessed daily for stridor after extubation. RESULTS: A total of 187 children were included. The incidence of post-extubation stridor was 44.38%. Stridor had a sensitivity of 77.78% (95% confidence interval [95% CI]: 51.9-92.6) and specificity of 59.18% (95% CI: 51.3-66.6) in detecting subglottic stenosis. The positive predictive value was 16.87% (95% CI: 9.8-27.1), and the negative predictive value was 96.15% (95% CI: 89.9-98.8). Stridor persisting longer than 72h or starting more than 72h post-extubation had a sensitivity of 66.67% (95% CI: 41.2-85.6), specificity of 89.1% (95% CI: 83.1-93.2), positive predictive value of 40.0% (95% CI: 23.2-59.3), and negative predictive value of 96.07% (95% CI: 91.3-98.4). The area under the receiver operating characteristic (ROC) curve was 0.78 (95% CI: 0.65-0.91). CONCLUSIONS: Absence of stridor was appropriate to rule out post-intubation subglottic stenosis. The specificity of this criterion improved when stridor persisted longer than 72h or started more than 72h post-extubation. Thus, endoscopy under general anesthesia can be used to confirm subglottic stenosis only in patients who develop or persist with stridor for more than 72h following extubation.

Septic shock in pediatrics: the state-of-the-art.

OBJECTIVE: Review the main aspects of the definition, diagnosis, and management of pediatric patients with sepsis and septic shock. SOURCE OF DATA: A search was carried out in the MEDLINE and Embase databases. The articles were chosen according to the authors' interest, prioritizing those published in the last five years. SYNTHESIS OF DATA: Sepsis remains a major cause of mortality in pediatric patients. The variability of clinical presentations makes it difficult to attain a precise definition in pediatrics. Airway stabilization with adequate oxygenation and ventilation if necessary, initial volume resuscitation, antibiotic administration, and cardiovascular support are the basis of sepsis treatment. In resource-poor settings, attention should be paid to the risks of fluid overload when administrating fluids. Administration of vasoactive drugs such as epinephrine or norepinephrine is necessary in the absence of volume response within the first hour. Follow-up of shock treatment should adhere to targets such as restoring vital and clinical signs of shock and controlling the focus of infection. A multimodal evaluation with bedside ultrasound for management after the first hours is recommended. In refractory shock, attention should be given to situations such as cardiac tamponade, hypothyroidism, adrenal insufficiency, abdominal catastrophe, and focus of uncontrolled infection. CONCLUSIONS: The implementation of protocols and advanced technologies have reduced sepsis mortality. In resource-poor settings, good practices such as early sepsis identification, antibiotic administration, and careful fluid infusion are the cornerstones of sepsis management.

Characteristics and outcome of burned children admitted to a pediatric intensive care unit. / Características e evolução de pacientes queimados admitidos em unidade de terapia intensiva pediátrica.

OBJECTIVE: To analyze the characteristics and outcomes of children hospitalized for burns in a pediatric trauma intensive care unit for burn patients. METHODS: An observational study was conducted through the retrospective analysis of children (< 16 years) admitted to the pediatric trauma intensive care unit for burn victims between January 2013 and December 2015. Sociodemographic and clinical variables were analyzed including the causal agent, burned body surface, presence of inhalation injury, length of hospital stay and mortality. RESULTS: The study analyzed a sum of 140 patients; 61.8% were male, with a median age of 24 months and an overall mortality of 5%. The main cause of burns was scalding (51.4%), followed by accidents involving fire (38.6%) and electric shock (6.4%). Mechanical ventilation was used in 20.7% of the cases. Associated inhalation injury presented a relative risk of 6.1 (3.5 - 10.7) of needing ventilatory support and a relative risk of mortality of 14.1 (2.9 - 68.3) compared to patients without this associated injury. A significant connection was found between burned body surface and mortality (p < 0.002), reaching 80% in patients with a burned area greater than 50%. Patients who died had a significantly higher Tobiasen Abbreviated Burn Severity Index than survivors (9.6 ± 2.2 versus 4.4 ± 1.1; p < 0.001). A Tobiasen Abbreviated Burn Severity Index ≥ 7 represented a relative risk of death of 68.4 (95%CI 9.1 - 513.5). CONCLUSION: Scalding burns are quite frequent and are associated with high morbidity. Mortality is associated with the amount of burned body surface and the presence of inhalation injury. Special emphasis should be given to accidents involving fire, reinforcing proper diagnosis and treatment of inhalation injury.

OBJETIVO: Analisar as características e a evolução de crianças internadas por queimaduras em unidade de terapia intensiva de trauma pediátrico para atendimento de queimados. MÉTODOS: Estudo observacional, por meio da análise retrospectiva de crianças (< 16 anos) admitidas na unidade de terapia intensiva de trauma pediátrico vítimas de queimaduras, entre janeiro de 2013 e dezembro de 2015. Foram analisadas variáveis sociodemográficas e clínicas: agente causal, superfície corporal queimada, presença de lesão inalatória, tempo de internação hospitalar e mortalidade. RESULTADOS: Foram avaliados 140 pacientes, sendo 61,8% do sexo masculino, com mediana da idade de 24 meses e mortalidade geral de 5%. A principal causa de queimadura foi escaldamento (51,4%), seguida de acidente com fogo (38,6%) e choque elétrico (6,4%). Ventilação mecânica foi utilizada em 20,7% dos casos. Lesão inalatória associada apresentou risco relativo de 6,1 (3,5 - 10,7) para necessidade de suporte ventilatório e risco relativo para mortalidade de 14,1 (2,9 - 68,3) quando comparados aos pacientes sem esta lesão associada. Houve significativa associação entre a superfície queimada e a mortalidade (p < 0,002), atingindo 80% nos pacientes com mais de 50% de área queimada. Os pacientes que evoluíram ao óbito apresentaram Tobiasen's Abbreviated Burn Severity Index significativamente maior que os sobreviventes (9,6 ± 2,2 versus 4,4 ± 1,1; p < 0,001). Tobiasen's Abbreviated Burn Severity Index ≥ 7 representou risco relativo para morte de 68,4 (IC95% 9,1 - 513,5). CONCLUSÃO: As queimaduras por escaldamento são bastante frequentes e estão associadas à alta morbidade. A mortalidade está associada à superfície corporal queimada e à presença de lesão inalatória. Ênfase especial deve ser dada aos acidentes por fogo, reforçando o diagnóstico e o tratamento adequados da lesão inalatória.

Características e evolução de pacientes queimados admitidos em unidade de terapia intensiva pediátrica / Characteristics and outcome of burned children admitted to a pediatric intensive care unit

RESUMO Objetivo: Analisar as características e a evolução de crianças internadas por queimaduras em unidade de terapia intensiva de trauma pediátrico para atendimento de queimados. Métodos: Estudo observacional, por meio da análise retrospectiva de crianças (< 16 anos) admitidas na unidade de terapia intensiva de trauma pediátrico vítimas de queimaduras, entre janeiro de 2013 e dezembro de 2015. Foram analisadas variáveis sociodemográficas e clínicas: agente causal, superfície corporal queimada, presença de lesão inalatória, tempo de internação hospitalar e mortalidade. Resultados: Foram avaliados 140 pacientes, sendo 61,8% do sexo masculino, com mediana da idade de 24 meses e mortalidade geral de 5%. A principal causa de queimadura foi escaldamento (51,4%), seguida de acidente com fogo (38,6%) e choque elétrico (6,4%). Ventilação mecânica foi utilizada em 20,7% dos casos. Lesão inalatória associada apresentou risco relativo de 6,1 (3,5 - 10,7) para necessidade de suporte ventilatório e risco relativo para mortalidade de 14,1 (2,9 - 68,3) quando comparados aos pacientes sem esta lesão associada. Houve significativa associação entre a superfície queimada e a mortalidade (p < 0,002), atingindo 80% nos pacientes com mais de 50% de área queimada. Os pacientes que evoluíram ao óbito apresentaram Tobiasen's Abbreviated Burn Severity Index significativamente maior que os sobreviventes (9,6 ± 2,2 versus 4,4 ± 1,1; p < 0,001). Tobiasen's Abbreviated Burn Severity Index ≥ 7 representou risco relativo para morte de 68,4 (IC95% 9,1 - 513,5). Conclusão: As queimaduras por escaldamento são bastante frequentes e estão associadas à alta morbidade. A mortalidade está associada à superfície corporal queimada e à presença de lesão inalatória. Ênfase especial deve ser dada aos acidentes por fogo, reforçando o diagnóstico e o tratamento adequados da lesão inalatória.

ABSTRACT Objective: To analyze the characteristics and outcomes of children hospitalized for burns in a pediatric trauma intensive care unit for burn patients. Methods: An observational study was conducted through the retrospective analysis of children (< 16 years) admitted to the pediatric trauma intensive care unit for burn victims between January 2013 and December 2015. Sociodemographic and clinical variables were analyzed including the causal agent, burned body surface, presence of inhalation injury, length of hospital stay and mortality. Results: The study analyzed a sum of 140 patients; 61.8% were male, with a median age of 24 months and an overall mortality of 5%. The main cause of burns was scalding (51.4%), followed by accidents involving fire (38.6%) and electric shock (6.4%). Mechanical ventilation was used in 20.7% of the cases. Associated inhalation injury presented a relative risk of 6.1 (3.5 - 10.7) of needing ventilatory support and a relative risk of mortality of 14.1 (2.9 - 68.3) compared to patients without this associated injury. A significant connection was found between burned body surface and mortality (p < 0.002), reaching 80% in patients with a burned area greater than 50%. Patients who died had a significantly higher Tobiasen Abbreviated Burn Severity Index than survivors (9.6 ± 2.2 versus 4.4 ± 1.1; p < 0.001). A Tobiasen Abbreviated Burn Severity Index ≥ 7 represented a relative risk of death of 68.4 (95%CI 9.1 - 513.5). Conclusion: Scalding burns are quite frequent and are associated with high morbidity. Mortality is associated with the amount of burned body surface and the presence of inhalation injury. Special emphasis should be given to accidents involving fire, reinforcing proper diagnosis and treatment of inhalation injury.

Accidental strangulation in children by the automatic closing of a car window. / Estrangulamento acidental em crianças por fechamento automático de vidro de carro.

Among the main causes of death in our country are car accidents, drowning and accidental burns. Strangulation is a potentially fatal injury and an important cause of homicide and suicide among adults and adolescents. In children, its occurrence is usually accidental. However, in recent years, several cases of accidental strangulation in children around the world have been reported. A 2-year-old male patient was strangled in a car window. The patient was admitted to the pediatric intensive care unit with a Glasgow Coma Scale score of 8 and presented with progressive worsening of respiratory dysfunction and torpor. The patient also presented acute respiratory distress syndrome, acute pulmonary edema and shock. He was managed with protective mechanical ventilation, vasoactive drugs and antibiotic therapy. He was discharged from the intensive care unit without neurological or pulmonary sequelae. After 12 days of hospitalization, he was discharged from the hospital, and his state was very good. The incidence of automobile window strangulation is rare but of high morbidity and mortality due to the resulting choking mechanism. Fortunately, newer cars have devices that stop the automatic closing of the windows if resistance is encountered. However, considering the severity of complications strangulated patients experience, the intensive neuro-ventilatory and hemodynamic management of the pathologies involved is important to reduce morbidity and mortality, as is the need to implement new campaigns for the education of parents and caregivers of children, aiming to avoid easily preventable accidents and to optimize safety mechanisms in cars with electric windows.

Translation and cross-cultural adaptation of the Pediatric Confusion Assessment Method for the Intensive Care Unit into Brazilian Portuguese for the detection of delirium in pediatric intensive care units. / Tradução e adaptação transcultural para o Brasil do Pediatric Confusion Assessment Method for the Intensive Care Unit para detecção de delirium em unidades de terapia intensiva pediátrica.

OBJECTIVE: To undertake the translation and cross-cultural adaption into Brazilian Portuguese of the Pediatric Confusion Assessment Method for the Intensive Care Unit for the detection of delirium in pediatric intensive care units, including the algorithm and instructions. METHODS: A universalist approach for the translation and cross-cultural adaptation of health measurement instruments was used. A group of pediatric critical care specialists assessed conceptual and item equivalences. Semantic equivalence was evaluated by means of a translation from English to Portuguese by two independent translators; reconciliation into a single version; back-translation by a native English speaker; and consensus among six experts with respect to language and content understanding by means of Likert scale responses and the Content Validity Index. Finally, operational equivalence was assessed by applying a pre-test to 30 patients. RESULTS: The back-translation was approved by the original authors. The medians of the expert consensus responses varied between good and excellent, except for the feature "acute onset" of the instructions. Items with a low Content Validity Index for the features "acute onset" and "disorganized thinking" were adapted. In the pre-test, the expression "signal with your head" was modified into "nod your head" for better understanding. No further adjustments were necessary, resulting in the final version for Brazilian Portuguese. CONCLUSION: The Brazilian version of the Pediatric Confusion Assessment Method for the Intensive Care Unit was generated in agreement with the international recommendations and can be used in Brazil for the diagnosis of delirium in critically ill children 5 years of age or above and with no developmental cognitive disabilities.