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1.
Pediatr Crit Care Med ; 15(7): e300-5, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24901801

RESUMO

OBJECTIVES: High-volume hemofiltration has shown beneficial effects in severe sepsis and multiple organ failure, improving hemodynamics and fluid balance. Recent studies suggest that acute liver failure shares many pathophysiologic similarities with sepsis. Therefore, we assessed the systemic effects of high-volume hemofiltration in children with acute liver failure. DESIGN: Retrospective observational cohort study. PATIENTS: Twenty-two children. SETTING: Forty-two-bed multidisciplinary pediatric and neonatal ICUs in a tertiary university hospital. INTERVENTION: We evaluated high-volume hemofiltration therapy as part of standard management of 22 children admitted in our unit for acute liver failure. Fifteen patients had fulminant hepatic failure, three had acute-on-chronic liver disease, and four had primary nonfunction. High-volume hemofiltration was initiated in patients requiring emergency liver transplantation and when hepatic encephalopathy grade higher than 2 and/or hemodynamic instability requiring vasopressors occurred. High-volume hemofiltration was defined by a flow of ultrafiltrate of more than 80 mL/kg/hr. Clinical and biological variables were assessed before and 24 and 48 hours after initiation of high-volume hemofiltration therapy. MEASUREMENTS AND MAIN RESULTS: High-volume hemofiltration was initiated with a median grade III of hepatic encephalopathy. The median flow of ultrafiltrate was 119 mL/kg/hr (range, 80-384). After 24 hours of high-volume hemofiltration treatment, we observed an increase in mean arterial pressure (p = 0.0002) and a decrease in serum creatinine (p = 0.0002). In half of the patients, the encephalopathy grade decreased. After 48 hours of treatment, mean arterial pressure (p = 0.0005), grade of hepatic encephalopathy (p = 0.04), and serum creatinine (p = 0.0002) improved. Overall mortality was 45.4% (n = 10). Emergency liver transplantation was performed in eight children. Five patients spontaneously recovered liver function. CONCLUSIONS: High-volume hemofiltration therapy significantly improves hemodynamic stability and neurological status in children with acute liver failure awaiting for emergency liver transplantation.


Assuntos
Cuidados Críticos , Hemofiltração , Falência Hepática Aguda/terapia , Adolescente , Fatores Etários , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Falência Hepática Aguda/complicações , Falência Hepática Aguda/mortalidade , Transplante de Fígado , Masculino , Seleção de Pacientes , Estudos Retrospectivos , Resultado do Tratamento
3.
Intensive Care Med ; 40(1): 84-91, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24158409

RESUMO

PURPOSE: Severe bronchiolitis is the leading cause of admission to the pediatric intensive care unit (PICU). Nasal continuous positive airway pressure (nCPAP) has become the primary respiratory support, replacing invasive mechanical ventilation (MV). Our objective was to evaluate the economic and clinical consequences following implementation of this respiratory strategy in our unit. METHODS: This was a retrospective cohort analysis of 525 infants with bronchiolitis requiring respiratory support and successively treated during two distinct periods with invasive MV between 1996 and 2000, P1 (n = 193) and nCPAP between 2006 and 2010, P2 (n = 332). Costs were estimated using the hospital cost billing reports. RESULTS: Patients' baseline characteristics were similar between the two periods. P2 is associated with a significant decrease in the length of ventilation (LOV) (4.1 ± 3.5 versus 6.9 ± 4.6 days, p < 0.001), PICU length of stay (LOS) (6.2 ± 4.6 versus 9.7 ± 5.5 days, p < 0.001) and hospital LOS. nCPAP was independently associated with a shorter duration of ventilatory support than MV (hazard ratio 1.8, 95% CI 1.5-2.2, p < 0.001). nCPAP was also associated with a significant decrease in ventilation-associated complications, and less invasive management. The mean cost of acute viral bronchiolitis-related PICU hospitalizations was significantly decreased, from 17,451 to 11,205 € (p < 0.001). Implementation of nCPAP led to a reduction of the total annual cost of acute viral bronchiolitis hospitalizations of 715,000 €. CONCLUSION: nCPAP in severe bronchiolitis is associated with a significant improvement in patient management as shown by the reduction in invasive care, LOV, PICU LOS, hospital LOS, and economic burden.


Assuntos
Bronquiolite/terapia , Pressão Positiva Contínua nas Vias Aéreas/métodos , Avaliação de Processos e Resultados (Cuidados de Saúde)/estatística & dados numéricos , Doença Aguda , Bronquiolite/economia , Pressão Positiva Contínua nas Vias Aéreas/efeitos adversos , Pressão Positiva Contínua nas Vias Aéreas/economia , Análise Custo-Benefício , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica/economia , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Estimativa de Kaplan-Meier , Tempo de Internação/economia , Avaliação de Processos e Resultados (Cuidados de Saúde)/economia , Respiração Artificial/efeitos adversos , Respiração Artificial/economia , Respiração Artificial/métodos , Estudos Retrospectivos , Fatores de Tempo
4.
Expert Rev Gastroenterol Hepatol ; 7(7): 629-41, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24070154

RESUMO

Pediatric liver transplantation (LT) is one of the most successful solid organ transplants with long-term survival more than 80%. Many aspects have contributed to improve survival, especially advancements in pre-, peri- and post-transplant management. The development of new surgical techniques, such as split-LT and the introduction of living related LT, has extended LT to small infants. Progress in the last 30 years has also been characterized by the introduction of calcineurin inhibitors. One problem remains the lack of donors. Donation after cardiac death offers a new possibility to increase the pool of potential donors. In children with acute liver failure, increasing interest has centered on the possibility of providing temporary liver support based on extracorporeal devices or hepatocyte transplantation. Similarly, hepatocyte transplantation offers new perspective in children with metabolic failure. As long-term survival increases, attention has now focused on the quality of life achieved by children undergoing LT.


Assuntos
Falência Hepática/cirurgia , Transplante de Fígado/tendências , Adolescente , Fatores Etários , Criança , Pré-Escolar , Oxigenação por Membrana Extracorpórea/tendências , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto , Hepatócitos/transplante , Humanos , Imunossupressores/uso terapêutico , Lactente , Recém-Nascido , Falência Hepática/diagnóstico , Falência Hepática/mortalidade , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Fatores de Risco , Fatores de Tempo , Doadores de Tecidos/provisão & distribução , Resultado do Tratamento , Listas de Espera
6.
Intensive Care Med ; 37(11): 1881-7, 2011 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-21965096

RESUMO

PURPOSE: To determine how decisions to forgo life support are made in European pediatric intensive care units (PICUs). METHODS: A multicenter, prospective study, the Eurydice II study, among 45 PICUs: 20 in France, 21 in Northern/Western (N/W) European countries, and 4 in Eastern/Central (E/C) Europe. Data were collected between November 2009 and April 2010 through a questionnaire. RESULTS: The decision to forgo life-sustaining treatment was made in 166 (40.6%) out of 409 deceased children (median 42.9%, France 38.2%, N/W European countries 60.0%, E/C European countries 0%; P < 0.001). In the E/C group, more patients died after cardiopulmonary resuscitation (CPR) failure than after forgoing life support (P < 0.001). In all PICUs, caregivers discussed the decision during a formal meeting, after which the medical staff made the final decision. The decision was often documented in the medical record (median 100%). The majority of the parents were informed of the final decision and were at the bedside during their child's death (median 100%). Decision to forgo life-sustaining treatment occurred in 40.6% of children, compared with 33% in Eurydice I. A high percentage of parents from France were now informed about the meeting and its conclusion as compared with Eurydice I (median 100%). CONCLUSIONS: The results of this study and comparison with the Eurydice I study (2002) show a trend towards standardization of end-of-life practices across N/W European countries and France in the past decade.


Assuntos
Tomada de Decisões , Unidades de Terapia Intensiva Pediátrica , Cuidados para Prolongar a Vida , Suspensão de Tratamento/estatística & dados numéricos , Pré-Escolar , Europa (Continente) , Feminino , França , Pesquisas sobre Serviços de Saúde , Humanos , Masculino , Estudos Prospectivos , Inquéritos e Questionários , Assistência Terminal/tendências
7.
Intensive Care Med ; 37(12): 2002-7, 2011 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-21993811

RESUMO

PURPOSE: To determine the optimal level of nasal continuous positive airway pressure (nCPAP) in infants with severe hypercapnic viral bronchiolitis as assessed by the maximal unloading of the respiratory muscles and improvement of breathing pattern and gas exchange. METHODS: A prospective physiological study in a tertiary paediatric intensive care unit (PICU). Breathing pattern, gas exchange, intrinsic end expiratory pressure (PEEPi) and respiratory muscle effort were measured in ten infants with severe hypercapnic viral bronchiolitis during spontaneous breathing (SB) and three increasing levels of nCPAP. RESULTS: During SB, median PEEPi was 6 cmH(2)O (range 3.9-9.2 cmH(2)O), median respiratory rate was 78 breaths/min (range 41-96), median inspiratory time/total duty cycle (T (i)/T (tot)) was 0.45 (range 0.40-0.48) and transcutaneous carbon dioxide pressure (P (tc)CO(2)) was 61.5 mmHg (range 50-78). In all the infants, an nCPAP level of 7 cmH(2)O was associated with the greatest reduction in respiratory effort with a mean reduction in oesophageal and diaphragmatic pressure swings of 48 and 46%, respectively, and of the oesophageal and diaphragmatic pressure time product of 49 and 56%, respectively. During nCPAP, median respiratory rate decreased to 56 breaths/min (range 39-108, p < 0.05), median T (i)/T (tot) decreased to 0.40 (range 0.34-0.44, p < 0.50) and P (tc)CO(2) decreased to 49 mmHg (range 35-65, p < 0.05). Only one infant with associated bacterial pneumonia required intubation and all the infants were discharged alive from the PICU after a median stay of 5.5 (range 3-27 days). CONCLUSION: In infants with hypercapnic respiratory failure due to acute viral bronchiolitis, an nCPAP level of 7 cmH(2)O is associated with the greatest unloading of the respiratory muscles and improvement of breathing pattern, as well as a favourable short-term clinical outcome.


Assuntos
Bronquiolite Viral/fisiopatologia , Bronquiolite Viral/terapia , Pressão Positiva Contínua nas Vias Aéreas/métodos , Hipercapnia/fisiopatologia , Nariz , Feminino , França , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica , Masculino , Estudos Prospectivos , Troca Gasosa Pulmonar/fisiologia , Respiração , Infecções por Vírus Respiratório Sincicial/fisiopatologia , Infecções por Vírus Respiratório Sincicial/terapia , Vírus Sinciciais Respiratórios , Índice de Gravidade de Doença
8.
Expert Rev Gastroenterol Hepatol ; 5(6): 717-29, 2011 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-22017699

RESUMO

Acute liver failure (ALF) is a rare but devastating syndrome. ALF in children differs from that observed in adults in both the etiologic spectrum and the clinical picture. Specific therapy to promote liver recovery is often not available and the underlying cause of the liver failure is often not determined. Management requires a multidisciplinary approach and should focus on preventing or treating complications and arranging for early referral to a transplant center. Although liver transplantation has increased the chance of survival, children who have ALF still face an increased risk of death, both while on the waiting list and after emergency liver transplantation. This article will review the current knowledge of the epidemiology, pathobiology and treatment of ALF in neonates, infants and children, and discuss some recent controversies.


Assuntos
Falência Hepática Aguda/etiologia , Falência Hepática Aguda/cirurgia , Transplante de Fígado , Adolescente , Edema Encefálico/prevenção & controle , Criança , Pré-Escolar , Encefalopatia Hepática/prevenção & controle , Humanos , Incidência , Lactente , Recém-Nascido , Falência Hepática Aguda/epidemiologia
9.
Pediatr Crit Care Med ; 12(5): 494-503, 2011 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-21897156

RESUMO

BACKGROUND: According to World Health Organization estimates, sepsis accounts for 60%-80% of lost lives per year in childhood. Measures appropriate for resource-scarce and resource-abundant settings alike can reduce sepsis deaths. In this regard, the World Federation of Pediatric Intensive Care and Critical Care Societies Board of Directors announces the Global Pediatric Sepsis Initiative, a quality improvement program designed to improve quality of care for children with sepsis. OBJECTIVES: To announce the global sepsis initiative; to justify some of the bundles that are included; and to show some preliminary data and encourage participation. METHODS: The Global Pediatric Sepsis Initiative is developed as a Web-based education, demonstration, and pyramid bundles/checklist tool (http://www.pediatricsepsis.org or http://www.wfpiccs.org). Four health resource categories are included. Category A involves a nonindustrialized setting with mortality rate <5 yrs and >30 of 1,000 children. Category B involves a nonindustrialized setting with mortality rate <5 yrs and <30 of 1,000 children. Category C involves a developing industrialized nation. In category D, developed industrialized nation are determined and separate accompanying administrative and clinical parameters bundles or checklist quality improvement recommendations are provided, requiring greater resources and tasks as resource allocation increased from groups A to D, respectively. RESULTS: In the vanguard phase, data for 361 children (category A, n = 34; category B, n = 12; category C, n = 84; category D, n = 231) were successfully entered, and quality-assurance reports were sent to the 23 participating international centers. Analysis of bundles for categories C and D showed that reduction in mortality was associated with compliance with the resuscitation (odds ratio, 0.369; 95% confidence interval, 0.188-0.724; p < .0004) and intensive care unit management (odds ratio, 0.277; 95% confidence interval, 0.096-0.80) bundles. CONCLUSIONS: The World Federation of Pediatric Intensive Care and Critical Care Societies Global Pediatric Sepsis Initiative is online. Success in reducing pediatric mortality and morbidity, evaluated yearly as a measure of global child health care quality improvement, requires ongoing active recruitment of international participant centers. Please join us at http://www.pediatricsepsis.org or http://www.wfpiccs.org.


Assuntos
Saúde Global , Unidades de Terapia Intensiva Pediátrica , Sepse , Sociedades , Adolescente , Antibacterianos/uso terapêutico , Criança , Mortalidade da Criança/tendências , Pré-Escolar , Comportamento Cooperativo , Cuidados Críticos , Países Desenvolvidos , Humanos , Lactente , Avaliação de Resultados (Cuidados de Saúde) , Desenvolvimento de Programas
13.
Clin Res Hepatol Gastroenterol ; 35(6-7): 430-7, 2011 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-21531191

RESUMO

The management of children with acute liver failure mandates a multidisciplinary approach and intense monitoring. In recent years, considerable progress has been made in developing specific and supportive medical measures, but clinical studies have mainly concerned adult patients. There are no specific medical therapies, except for a few metabolic diseases presenting with acute liver failure. Liver transplantation still remains the only definitive therapy in most instances. Recent clinical studies suggest that hepatocyte transplantation may be useful for bridging patients to liver transplantation, for providing metabolic support during liver failure and for replacing liver transplantation in certain metabolic liver diseases.


Assuntos
Falência Hepática Aguda/etiologia , Falência Hepática Aguda/terapia , Criança , Colestase/complicações , Contraindicações , Nutrição Enteral , Circulação Extracorpórea , Galactosemias/complicações , Insuficiência Cardíaca/prevenção & controle , Hemocromatose/complicações , Hemorragia/etiologia , Hemorragia/terapia , Encefalopatia Hepática/etiologia , Hepatite Autoimune/complicações , Degeneração Hepatolenticular/complicações , Humanos , Hipoglicemia/etiologia , Hipertensão Intracraniana/prevenção & controle , Icterícia/etiologia , Falência Hepática Aguda/diagnóstico , Testes de Função Hepática , Transplante de Fígado , Fígado Artificial , Erros Inatos do Metabolismo/complicações , Insuficiência Renal/prevenção & controle , Insuficiência Respiratória/prevenção & controle , Erros Inatos do Metabolismo de Esteroides , Tirosinemias/complicações
14.
J Pediatr ; 158(1): 142-8, 148.e1, 2011 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-20846672

RESUMO

OBJECTIVE: To better describe the natural history, mode of inheritance, and the epidemiological and clinical features of isolated congenital asplenia, a rare and poorly understood primary immunodeficiency. STUDY DESIGN: A French national retrospective survey was conducted in hospital pediatric departments. A definitive diagnosis of ICA was based on the presence of Howell-Jolly bodies, a lack of detectable spleen, and no detectable cardiovascular malformation. RESULTS: The study included 20 patients (12 males and 8 females) from 10 kindreds neither related to each other nor consanguineous. The diagnosis of ICA was certain in 13 cases (65%) and probable in 7 cases (35%). Ten index cases led to diagnosis of 10 additional cases in relatives. Five cases were sporadic and 15 were familial, suggesting autosomal dominant inheritance. Median age was 12 months at first infection (range, 2-516 months), 11 months at diagnosis of asplenia (range, 0-510 months), and 9.9 years at last follow-up (range, 0.7-52 years). Fifteen patients sustained 18 episodes of invasive bacterial infection, caused mainly by Streptococcus pneumoniae (61%). Outcomes were poor, with 9 patients (45%) dying from fulminant infection. CONCLUSIONS: ICA is more common than was previously thought, with an autosomal dominant inheritance in at least some kindreds. Relatives of cases of ICA should be evaluated for ICA, as should children and young adults with invasive infection.


Assuntos
Baço/anormalidades , Adolescente , Adulto , Criança , Pré-Escolar , Anormalidades Congênitas/diagnóstico , Anormalidades Congênitas/epidemiologia , Anormalidades Congênitas/genética , Feminino , França/epidemiologia , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Linhagem , Estudos Retrospectivos , Adulto Jovem
15.
Pediatr Crit Care Med ; 11(3): 385-9, 2010 May.
Artigo em Inglês | MEDLINE | ID: mdl-20101195

RESUMO

OBJECTIVES: To investigate the detection of hepatitis A virus ribonucleic acid in patients with acute liver failure and to assess if the results have any clinical implications for the evolution of acute liver failure in children. Hepatitis A infection, a vaccine-preventable disease, is an important cause of acute liver failure in children in Argentina. Universal vaccination in 1-yr-old children was implemented in June 2005. DESIGN: Observational study in which patients were divided into Group 1 consisting of positive hepatitis A virus ribonucleic acid and Group 2 consisting of negative hepatitis A virus ribonucleic acid. SETTING: Pediatric intensive care unit in National Pediatric Hospital "Dr. J. P. Garrahan," Buenos Aires, Argentina. PATIENTS: Thirty-three patients with the diagnosis of acute liver failure secondary to hepatitis A virus infection and admitted to the Garrahan Pediatric Hospital between September 2003 and September 2005 were enrolled in the study. Twenty of these children were admitted to the pediatric intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Samples for total ribonucleic acid detection and genotyping were obtained from serum and/or stools on admission. We found positive hepatitis A virus ribonucleic acid in 13 patients and negative hepatitis A virus ribonucleic acid in 20 patients. The following clinical variables were evaluated: time of evolution, hospital stay, admission to the pediatric intensive care unit, pediatric intensive care unit stay, time on mechanical ventilation, criteria for orthotopic liver transplantation, and mortality. Characterization of the isolates did not reveal differences related to genotype; all cases were IA. No statistical significance was found as to the variables. However, positive hepatitis A virus ribonucleic acid showed lower percentages of pediatric intensive care unit admissions, criteria for orthotopic liver transplantation, number of orthotopic liver transplantation, and mortality than the group of patients with negative hepatitis A virus ribonucleic acid. CONCLUSIONS: Hepatitis A virus genotyping studies did not show any particularities, all cases were IA and, thus, apparent associations between genotype and the clinical presentation of acute liver failure could not be found.


Assuntos
Genótipo , Vírus da Hepatite A/genética , Vírus da Hepatite A/isolamento & purificação , Hepatite A/diagnóstico , Falência Hepática Aguda/etiologia , RNA/sangue , Adolescente , Argentina/epidemiologia , Criança , Pré-Escolar , Fezes/virologia , Feminino , Hepatite A/epidemiologia , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica , Falência Hepática Aguda/virologia , Masculino , Observação
16.
Pediatr Crit Care Med ; 10(5): 597-600, 2009 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-19451845

RESUMO

The World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS) is an international body that brings together international expertise, experience, and influence to improve the outcomes of children suffering from life-threatening illness and injury. Its mission is educational, scientific, and charitable in nature. WFPICCS is committed to a global environment, in which all children have access to intensive and critical care of the highest standard. It exists to find ways of improving the care of critically ill children throughout the world, and making that knowledge available to those who care for such children. As in an ideal world all children should have access to state of the art critical care services, this is unlikely to happen anytime soon. Faced with this reality, the member societies of the WFPICCS will strive to develop the best model and provide the best care for critically ill and injured children worldwide. The challenge is to find the appropriate role that we need to (and can effectively) play in decreasing both unnecessary death and suffering for children. Clearly, we cannot achieve these goals on our own, hence WFPICCS visualizes close cooperation and collaboration with other agencies offering care to critically ill or injured children such as the World Health Organization, World Federation of Societies of Intensive and Critical Care Medicine, International Pediatric Associations, and regional organizations and programs to achieve our objectives. We feel that this document while imperfect is a good starting point and hope that it will stimulate more discussion to guide the agenda of the federation for years to come.


Assuntos
Cuidados Críticos/organização & administração , Saúde Global , Objetivos Organizacionais , Pediatria/organização & administração , Humanos , Cooperação Internacional , Sociedades Médicas
17.
J Neurosurg Pediatr ; 3(1): 66-9, 2009 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-19119908

RESUMO

OBJECT: In this study, the authors investigated the clinical efficacy of decompressive craniectomy treatments for nontraumatic intracranial hypertension in children. METHODS: Seven patients with nontraumatic refractory high intracranial pressure (ICP) were enrolled in the study between 1995 and 2005; there were 2 boys and 5 girls with a mean age of 9 years (range 4-14). Decompressive craniectomy was performed in all patients after standard medical therapy had proven insufficient and ICP remained > 50 mm Hg. All patients had a Glasgow Coma Scale score < 8 at admission and a mean Pediatric Risk of Mortality Scale score of 20 (range 10-27). RESULTS: One patient died of persistent high ICP and circulatory failure 48 hours after surgery. Six months later, according to their Glasgow Outcome Scale scores, 3 patients had adequate recoveries, 2 patients recovered with moderate disabilities, and 1 patient had severe disabilities. According to the Pediatric Overall Performance Category Scale, 4 patients received a score of 2 (mild disability), 1 a score of 3 (moderate disability), and 1 a score of 4 (severe disability). Five patients returned to school and normal life. CONCLUSIONS: The authors found decompressive craniectomy to be an effective and lifesaving technique in children. This procedure should be included in the arsenal of treatments for nontraumatic intracranial hypertension.


Assuntos
Craniotomia/métodos , Descompressão Cirúrgica/métodos , Hipertensão Intracraniana/cirurgia , Neuronavegação/métodos , Adolescente , Criança , Pré-Escolar , Avaliação da Deficiência , Feminino , Escala de Resultado de Glasgow , Humanos , Unidades de Terapia Intensiva Pediátrica , Hipertensão Intracraniana/etiologia , Masculino , Exame Neurológico , Complicações Pós-Operatórias/diagnóstico , Resultado do Tratamento
18.
Pediatr Crit Care Med ; 9(6): 560-6, 2008 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-18838925

RESUMO

OBJECTIVE: To examine intercontinental differences in end-of-life practices in pediatric intensive care units. DESIGN: An international survey. The on-line questionnaire consisted of two case scenarios with five questions each. The scenarios described the management of children in pediatric intensive care units and the questions dealt with the decision-making process and the modalities of forgoing life support. SETTING: The participants at the 5th World Congress on Pediatric Critical Care Medicine organized by the World Federation of Pediatric Intensive and Critical Care Societies (June 2007, Geneva, Switzerland) were invited to participate. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Six hundred sixty seven complete questionnaires were received from 71 countries, which were grouped into six continents: Europe (52.7%), North America (17.9%) and South America (9.5%), Asia (7.6%), Australia (6%), and Middle East (4.3%). In both scenarios, physicians played the major role in decision making in all of the continents. However, parents from North America, Australia, the Middle East, and Asia seem to be more involved in the decision-making process, compared with those from Europe and South America. In cases of septic shock, caregivers from Europe and South America are more prone to forego life support despite parents' wishes. In North America and Australia, parents' presence during cardiopulmonary resuscitation is usually accepted (89.7% and 92.3%, respectively), whereas their presence is less accepted in Asia (54%) and Europe (54.8%), or much less accepted in South America (25.8%) and the Middle East (7.1%). In both scenarios, the option to withhold rather than withdraw life supports was more commonly chosen among all continents, except South America, where the withdrawal of life support was more often proposed (51.6% vs. 45.2%). CONCLUSIONS: This study confirms that important intercontinental differences exist toward end-of-life issues in pediatric intensive care. Although the legal and ethical situation is rapidly evolving, a certain degree of paternalism seems to persist among European and South-American caregivers. This study suggests that ethical principles depend on the cultural roots of countries or continents, emphasizing the need to foster dialogue on end-of-life issues around the world to learn from each other and improve end-of-life care in pediatric intensive care units.


Assuntos
Atitude do Pessoal de Saúde , Saúde Global , Unidades de Terapia Intensiva Pediátrica , Assistência Terminal , Coleta de Dados , Humanos
19.
Intensive Care Med ; 34(12): 2248-55, 2008 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-18712350

RESUMO

INTRODUCTION: A prospective physiological study was performed in 12 paediatric patients with acute moderate hypercapnic respiratory insufficiency to assess the ability of noninvasive positive pressure ventilation (NPPV) to unload the respiratory muscles and improve gas exchange. MATERIALS AND METHODS: Breathing pattern, gas exchange, and inspiratory muscle effort were measured during spontaneous breathing and NPPV. RESULTS: NPPV was associated with a significant improvement in breathing pattern, gas exchange and respiratory muscle output. Tidal volume and minute ventilation increased by 33 and 17%, and oesophageal and diaphragmatic pressure time product decreased by 49 and 56%, respectively. This improvement in alveolar ventilation translated into a reduction in mean partial pressure in carbon dioxide from 48 to 40 mmHg (P = 0.01) and in respiratory rate from 48 to 41 breaths/min (P = 0.01). No difference between a clinical setting and a physiological setting of NPPV was observed. In conclusion, this study shows that NPPV is able to unload the respiratory muscles and improve clinical outcome in young patients admitted to the paediatric intensive care unit for acute moderate hypercapnic respiratory insufficiency.


Assuntos
Respiração com Pressão Positiva , Insuficiência Respiratória/terapia , Adolescente , Gasometria , Criança , Pré-Escolar , Pressão Positiva Contínua nas Vias Aéreas , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Respiração
20.
Pediatr Clin North Am ; 55(3): 791-804, xiii, 2008 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-18501766

RESUMO

Most deaths in the pediatric intensive care unit occur after a decision to withhold or withdraw life-sustaining treatments. The management of children at the end of life can be divided into three steps. The first concerns the decision-making process. The second concerns the actions taken once a decision has been made to forego life-sustaining treatments. The third regards the evaluation of the decision and its implementation. The mission of pediatric intensive care has expanded to provide the best possible care to dying children and their families. Improving the quality of care received by dying children remains an ongoing challenge for every pediatric intensive care unit team member.


Assuntos
Parada Cardíaca/terapia , Unidades de Terapia Intensiva Pediátrica/normas , Cuidados para Prolongar a Vida/normas , Avaliação de Resultados (Cuidados de Saúde)/métodos , Criança , Tomada de Decisões , Humanos , Cuidados para Prolongar a Vida/métodos
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