Association of endotracheal tube repositioning and acute laryngeal lesions during mechanical ventilation in children.

The objective of this study is to determine the incidence of post-extubation acute laryngeal lesions in a pediatric intensive care unit (PICU) and potential risk factors. Children, aged 28 days to 5 years, admitted to the PICU who required endotracheal intubation for at least 24 h were enrolled. Exclusion criteria were a previous intubation, history of laryngeal disease, current or past tracheostomy, the presence of craniofacial malformations and patients considered on palliative care. All patients underwent flexible fiber-optic laryngoscopy (FFL) not later than 8 h after extubation. A blinded researcher identified and classified laryngeal lesions based on recorded media. 231 children were enrolled between November 2005 and December 2015. At FFL examination, 102 children (44.15%) presented moderate to severe laryngeal lesions. On a multivariable analysis, we found that for each additional day with repositioning of the endotracheal tube, there was an increase of 7.3% (RR 95% CI 1.012-1.137; P = 0.018) on the baseline risk of developing moderate to severe acute laryngeal lesions. Furthermore, for each additional dose of sedation per day of intubation, there was also an increase of 3.5% on the same baseline risk (RR 95% CI 1.001-1.070; P = 0.041). The amount of tube repositioning episodes and the need for extra doses of sedation (as a proxy for possible agitation) were found to be associated with acute laryngeal lesions. Adequate sedation and minimized tube repositioning should be pursued to possibly prevent the development of post-extubation airway compromise.

The experience of families in face of the finiteness of their children in the process of adopting palliative care.

OBJECTIVE: To reveal the experience of family members after learning their child would adopt palliative care. METHOD: Phenomenological research on Heidegger's perspective. The participants were eleven family members of children who were recommended palliative care in the Pediatric Intensive Care Unit from a university hospital in southern Brazil. The statements were obtained in a semi-structured interview, from January to November/2017, and submitted to Heidegger's theoretical-philosophical analysis. Research approved by the institution's Ethical Committee. RESULTS: The communication of palliative care triggers the perception of the child's existencial facticity in the Family, revealing reactions explained in the thematic dimensions: "Coping with the finiteness of the child when confronted with the proposal of adopting palliative care" and "The need for compassionate and attentive care". FINAL CONSIDERATIONS: Phenomenology allows us to understand the parent's existential purpose. An understanding perspective can help interdisciplinary teams to communicate the adoption of palliative care in a sensitive and ethical way, focusing on the best interest of the child.

Effects of critical illness on the functional status of children with a history of prematurity. / Efeitos da doença crítica no status funcional de crianças com histórico de prematuridade.

OBJECTIVE: To evaluate the effects of critical illness on the functional status of children aged zero to 4 years with or without a history of prematurity after discharge from the pediatric intensive care unit. METHODS: This was a secondary cross-sectional study nested in an observational cohort of survivors from a pediatric intensive care unit. Functional assessment was performed using the Functional Status Scale within 48 hours after discharge from the pediatric intensive care unit. RESULTS: A total of 126 patients participated in the study, 75 of whom were premature, and 51 of whom were born at term. Comparing the baseline and functional status at pediatric intensive care unit discharge, both groups showed significant differences (p < 0.001). Preterm patients exhibited greater functional decline at discharge from the pediatric intensive care unit (61%). Among patients born at term, there was a significant correlation between the Pediatric Index of Mortality, duration of sedation, duration of mechanical ventilation and length of hospital stay with the functional outcomes (p = 0.05). CONCLUSION: Most patients showed a functional decline at discharge from the pediatric intensive care unit. Although preterm patients had a greater functional decline at discharge, sedation and mechanical ventilation duration influenced functional status among patients born at term.

OBJETIVO: Avaliar os efeitos da doença crítica no status funcional de crianças de zero a 4 anos com e sem histórico de prematuridade após a alta da unidade de terapia intensiva pediátrica. MÉTODOS: Estudo transversal secundário aninhado a uma coorte de caráter observacional de sobreviventes de uma unidade de terapia intensiva pediátrica. A avaliação funcional aconteceu por meio da Functional Status Scale no período de até 48 horas após a alta da unidade de terapia intensiva pediátrica. RESULTADOS: Participaram do estudo 126 pacientes, sendo 75 prematuros e 51 nascidos a termo. Na comparação entre o status funcional basal e o status funcional da alta da unidade de terapia intensiva pediátrica, ambos os grupos apresentaram diferenças significativas (p < 0,001). Na alta da unidade de terapia intensiva pediátrica, as alterações funcionais aumentaram significativamente em ambos os grupos (p < 0,001). Os pacientes prematuros apresentaram maior declínio funcional na alta da unidade de terapia intensiva pediátrica (61%). Nos pacientes nascidos a termo, houve correlação significativa entre Pediatric Index of Mortality, tempo de sedação, tempo de ventilação mecânica e tempo de internação com os desfechos funcionais (p = 0,05). CONCLUSÃO: A maior parte dos pacientes estudados apresentou declínio funcional na alta da unidade de terapia intensiva pediátrica. Apesar de os pacientes prematuros apresentarem maior declínio funcional na alta, os pacientes nascidos a termo apresentaram influência do tempo de sedação e do tempo de uso de ventilação mecânica nos seus status funcionais.

Use of magnesium sulfate in continuous infusion in patients with severe acute asthma, in a pediatric emergency room.

INTRODUCTION: Asthma is a chronic disease, of high prevalence, with important morbidity and that can lead to death in childhood. The use of intravenous magnesium sulfate has been indicated in cases refractory to the initial management with inhaled bronchodilators and corticosteroids. OBJECTIVE: To evaluate the use of magnesium sulfate in continuous infusion (50 mg/kg/h in 4 h) in children with severe acute asthma in a pediatric emergency room. LOCATION: Ten-bed general pediatric emergency room, university hospital, tertiary, in southern Brazil. PATIENTS: All children over 2 years old with severe acute asthma refractory to the initial treatment who received a continuous infusion of magnesium sulfate at a dose of 50 mg/kg/h in 4 h, from April 2017 to October 2019. CONCLUSION: Based on this study, the use of continuous intravenous magnesium sulfate proved to be well tolerated, leading to improved respiratory status, and can be considered as a satisfactory adjunctive therapy in the management of severe acute asthma.

Rotavirus gastroenteritis in children in 4 regions in Brazil: a hospital-based surveillance study.

BACKGROUND: Rotavirus is a major cause of gastroenteritis in children. Knowledge of rotavirus genotypes is important for vaccination strategies. METHODS: During 2005-2006, rotavirus surveillance studies were conducted in São Paulo, Salvador, Goiânia, and Porto Alegre, Brazil. Stool samples were collected from children <5 years of age who had diarrhea and were screened by the Rotaclone Enzyme Immunoassay for the presence of rotavirus. Confirmed rotavirus-positive samples were characterized for P and G genotypes by reverse-transcriptase polymerase chain reaction. RESULTS: A total of 510 stool samples were collected. Of these, 221 (43.3%) were positive for rotavirus. Overall, G9 was the predominant G type, followed by G2, and G1; P[4] and P[8] were the predominant P types. The most frequent G/P genotype combination detected was G2P[4], followed by G9P[8], G9P[4], and G1P[8]. G2P[4] was the predominant type in Goiânia and Salvador; G9P[8] and G1P[8] were predominant in São Paulo and Porto Alegre, respectively. CONCLUSIONS: The prevalence, seasonality, and genotype distribution of rotavirus infection varied in different regions in Brazil. With immunization programs, continuous monitoring of rotavirus types is important to detect novel and emerging strains.

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.

Evidence of safety of chloral hydrate for prolonged sedation in PICU in a tertiary teaching hospital in southern Brazil.

OBJECTIVE: To evaluate the utilization of chloral hydrate (CH) for sedation in pediatric intensive care and the incidence of adverse drug reactions. METHODS: This was a cohort study including patients with prescription of chloral hydrate hospitalized in the pediatric intensive care unit (PICU) of a university-affiliated, general, tertiary teaching hospital. Data were collected from a spreadsheet for daily monitoring, and clinical events registered in the patient records were analyzed to evaluate the causality of suspected adverse drug reactions (ADR), applying the Naranjo algorithm. RESULTS: Three hundred forty-three patients who had been prescribed CH were studied. Ages ranged from 0 to 18 years, and 63% were male. The most frequent cause for PICU admission was bronchiolitis (77.6%), and 58.6% required mechanical ventilation. In 92.7% of cases, CH was indicated to control agitation and in 7.3% for procedural sedation. The median time of CH use was 6 days. The incidence of suspected ADR was 22.7% ± 2.3. Oxygen desaturation was the most frequent adverse event (64.6%), followed by hypotension. Specific treatment was required in 60.9% of the events. Chloral hydrate as cause for suspected ADR was classified as probable in 39 events (35.5%) and as possible in 70 (63.6%), and no event was classified as definite. In the multivariate analysis, only mechanical ventilation was predictive of ADR to CH. CONCLUSIONS: The study described the clinical practice of sedation with CH in the PICU setting of a tertiary teaching hospital in southern Brazil. Data suggest that CH is an alternative for prolonged sedation in PICU

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.

Flexible fiber-optic laryngoscopy in the first hours after extubation for the evaluation of laryngeal lesions due to intubation in the pediatric intensive care unit.

OBJECTIVE: To evaluate the feasibility and safety of using fiber-optic laryngoscopy in the first hours after extubation for the early diagnosis of laryngeal lesions in infants and children in the pediatric intensive care unit and describe the findings of such approach. METHODS: Patients 0-4 years old who had undergone endotracheal intubation for longer than 24h were included in the study. Exclusion criteria were history of laryngeal symptoms, current intubation or tracheostomy, craniofacial malformations, or a poor prognosis according to the medical team responsible for the patient. Exams were performed in the pediatric intensive care unit in the first 8h after extubation; the patient was at the bedside and did not receive sedation. The fiber-optic laryngoscope was used to obtain images of the larynx. Minor complications were: saturation decrease not below 85% and rapid recovery, and minor nasal bleeding. Severe complications were: bradycardia and laryngospasm that required intervention. Images were evaluated by a blinded examiner, and findings were classified as mild and unspecific (edema and hyperemia), or specific, such as laryngomalacia and glottic granulation and subglottic ulceration and granulation. Results were expressed as means and standard deviations when the variable had a normal distribution, and as median and interquartile ranges for asymmetric data. RESULTS: Forty-one patients, mean age 2.7 months (interquartile range 1.5-6.1), were included in the study. Fiber-optic laryngoscopy was performed between 40 min and 8h after extubation, and mean time was 4.9h (standard deviation=2.4h). Mean exam duration was 4.16 min (2.41-7.12 min; standard deviation=1 min). One patient (2.4%) had mild desaturation, a minor complication. No other complications were found. Thirty-five patients were available to 6-month follow-up and subglottic stenosis was found in 11.4%. CONCLUSIONS: Fiber-optic laryngoscopy may be safely performed in the first hours after extubation, with few minor complications. It does not take long, but provides accurate information about the conditions of the supraglottic and glottic larynx. The subglottic region can also be visualized in most patients. This easily performed exam seems to be useful for the diagnosis of pediatric patients with acute laryngeal lesions due to intubation.

Efeitos da doença crítica no status funcional de crianças com histórico de prematuridade / Effects of critical illness on the functional status of children with a history of prematurity

RESUMO Objetivo: Avaliar os efeitos da doença crítica no status funcional de crianças de zero a 4 anos com e sem histórico de prematuridade após a alta da unidade de terapia intensiva pediátrica. Métodos: Estudo transversal secundário aninhado a uma coorte de caráter observacional de sobreviventes de uma unidade de terapia intensiva pediátrica. A avaliação funcional aconteceu por meio da Functional Status Scale no período de até 48 horas após a alta da unidade de terapia intensiva pediátrica. Resultados: Participaram do estudo 126 pacientes, sendo 75 prematuros e 51 nascidos a termo. Na comparação entre o status funcional basal e o status funcional da alta da unidade de terapia intensiva pediátrica, ambos os grupos apresentaram diferenças significativas (p < 0,001). Na alta da unidade de terapia intensiva pediátrica, as alterações funcionais aumentaram significativamente em ambos os grupos (p < 0,001). Os pacientes prematuros apresentaram maior declínio funcional na alta da unidade de terapia intensiva pediátrica (61%). Nos pacientes nascidos a termo, houve correlação significativa entre Pediatric Index of Mortality, tempo de sedação, tempo de ventilação mecânica e tempo de internação com os desfechos funcionais (p = 0,05). Conclusão: A maior parte dos pacientes estudados apresentou declínio funcional na alta da unidade de terapia intensiva pediátrica. Apesar de os pacientes prematuros apresentarem maior declínio funcional na alta, os pacientes nascidos a termo apresentaram influência do tempo de sedação e do tempo de uso de ventilação mecânica nos seus status funcionais.

ABSTRACT Objective: To evaluate the effects of critical illness on the functional status of children aged zero to 4 years with or without a history of prematurity after discharge from the pediatric intensive care unit. Methods: This was a secondary cross-sectional study nested in an observational cohort of survivors from a pediatric intensive care unit. Functional assessment was performed using the Functional Status Scale within 48 hours after discharge from the pediatric intensive care unit. Results: A total of 126 patients participated in the study, 75 of whom were premature, and 51 of whom were born at term. Comparing the baseline and functional status at pediatric intensive care unit discharge, both groups showed significant differences (p < 0.001). Preterm patients exhibited greater functional decline at discharge from the pediatric intensive care unit (61%). Among patients born at term, there was a significant correlation between the Pediatric Index of Mortality, duration of sedation, duration of mechanical ventilation and length of hospital stay with the functional outcomes (p = 0.05). Conclusion: Most patients showed a functional decline at discharge from the pediatric intensive care unit. Although preterm patients had a greater functional decline at discharge, sedation and mechanical ventilation duration influenced functional status among patients born at term.

Undersedation is a risk factor for the development of subglottic stenosis in intubated children.

OBJECTIVE: To analyze the level of sedation in intubated children as a risk factor for the development of subglottic stenosis. METHODS: All patients between 30 days and 5 years of age who required endotracheal intubation in the pediatric intensive care unit between 2013 and 2014 were included in this prospective study. They were monitored daily and COMFORT-B scores were obtained. Flexible fiber-optic laryngoscopy was performed within eight hours of extubation, and repeated seven to ten days later if the first examination showed moderate to severe laryngeal injuries. If these lesions persisted and/or if the child developed symptoms in the follow-up period, microlaryngoscopy under general anesthesia was performed to evaluate for subglottic stenosis. RESULTS: The study included 36 children. Incidence of subglottic stenosis was 11.1%. Children with subglottic stenosis had a higher percentage of COMFORT-B scores between 23 and 30 (undersedated) than those who did not develop subglottic stenosis (15.8% vs. 3.65%, p=0.004). CONCLUSION: Children who developed subglottic stenosis were less sedated than children who did not develop subglottic stenosis.

The experience of families in face of the finiteness of their children in the process of adopting palliative care / Experiencias familiares ante la finitud del niño en el proceso de adopción de cuidados paliativos / Vivências de familiares diante da finitude da criança no processo de adoção de cuidados paliativos

ABSTRACT Objective: To reveal the experience of family members after learning their child would adopt palliative care. Method: Phenomenological research on Heidegger's perspective. The participants were eleven family members of children who were recommended palliative care in the Pediatric Intensive Care Unit from a university hospital in southern Brazil. The statements were obtained in a semi-structured interview, from January to November/2017, and submitted to Heidegger's theoretical-philosophical analysis. Research approved by the institution's Ethical Committee. Results: The communication of palliative care triggers the perception of the child's existencial facticity in the Family, revealing reactions explained in the thematic dimensions: "Coping with the finiteness of the child when confronted with the proposal of adopting palliative care" and "The need for compassionate and attentive care". Final considerations: Phenomenology allows us to understand the parent's existential purpose. An understanding perspective can help interdisciplinary teams to communicate the adoption of palliative care in a sensitive and ethical way, focusing on the best interest of the child.

RESUMEN Objetivo: Revelar la experiencia de familiares después de descubrir que sus niños serían sometidos a paliativos del niño. Método: Investigación fenomenológica em la perspectiva de Heidegger. Participaron once familiares de niños internados en Unidad de Cuidados Intensivos Pediátricos de hospital universitario del sur de Brasil con indicación de cuidados paliativos. Los discursos fueron obtenidos en entrevista semiestructurada, de enero a noviembre/2017, y sometidos al análisis teórico-filosófico Heideggeriano. Investigación aprobada por el Comité de Ética de la institución. Resultados: La comunicación de cuidados paliativos dispara la percepción de la facticidad existencial del niño en la Familia, revelando reacciones explicadas en las dimensiones temáticas: Enfrentando la finitud del niño frente a propuesta de cuidados paliativos y La necesidad de cuidado compasivo y solícito. Consideraciones finales: La fenomenología permite comprender el propósito existencial de los padres. La perspectiva integral puede ayudar el equipo a comunicar la adopción de cuidados paliativos, de una manera sensible y ética, centrándose en el interés superior del niño.

RESUMO Objetivo: Desvelar a vivência de familiares após notícia da adoção de cuidados paliativos para a criança. Método: Pesquisa fenomenológica na perspectiva de Heidegger. Participaram onze familiares de crianças na Unidade de Terapia Intensiva Pediátrica de hospital universitário do sul do Brasil com indicação de cuidados paliativos. Os depoimentos foram obtidos em entrevista semi-estruturada, de janeiro a novembro/2017, submetidos à análise teórico-filosófica de Heidegger. Pesquisa aprovada pelo Comitê de Ética da instituição. Resultados: A comunicação de cuidados paliativos desencadeia no familiar a percepção da facticidade existencial da criança, descortinando reações explicitadas nas dimensões temáticas: Enfrentando a finitude da criança diante da proposta de cuidados paliativos e Necessidade de cuidado compassivo e solícito. Considerações finais: A fenomenologia permitiu compreender o familiar em seu propósito existencial. A perspectiva compreensiva pode auxiliar a equipe interdisciplinar na comunicação da decisão de cuidados paliativos, de modo sensível e ético, focalizando o melhor interesse da criança.

Characteristics and progression of children with acute viral bronchiolitis subjected to mechanical ventilation.

OBJECTIVE: To analyze the characteristics of children with acute viral bronchiolitis subjected to mechanical ventilation for three consecutive years and to correlate their progression with mechanical ventilation parameters and fluid balance. METHODS: Longitudinal study of a series of infants (< one year old) subjected to mechanical ventilation for acute viral bronchitis from January 2012 to September 2014 in the pediatric intensive care unit. The children's clinical records were reviewed, and their anthropometric data, mechanical ventilation parameters, fluid balance, clinical progression, and major complications were recorded. RESULTS: Sixty-six infants (3.0 ± 2.0 months old and with an average weight of 4.7 ± 1.4kg) were included, of whom 62% were boys; a virus was identified in 86%. The average duration of mechanical ventilation was 6.5 ± 2.9 days, and the average length of stay in the pediatric intensive care unit was 9.1 ± 3.5 days; the mortality rate was 1.5% (1/66). The peak inspiratory pressure remained at 30cmH2O during the first four days of mechanical ventilation and then decreased before extubation (25 cmH2O; p < 0.05). Pneumothorax occurred in 10% of the sample and extubation failure in 9%, which was due to upper airway obstruction in half of the cases. The cumulative fluid balance on mechanical ventilation day four was 402 ± 254mL, which corresponds to an increase of 9.0 ± 5.9% in body weight. Thirty-seven patients (56%) exhibited a weight gain of 10% or more, which was not significantly associated with the ventilation parameters on mechanical ventilation day four, extubation failure, duration of mechanical ventilation or length of stay in the pediatric intensive care unit. CONCLUSION: The rate of mechanical ventilation for acute viral bronchiolitis remains constant, being associated with low mortality, few adverse effects, and positive cumulative fluid balance during the first days. Better fluid control might reduce the duration of mechanical ventilation.

Health professionals' perceptions about the decision-making process in the care of pediatric patients. / Percepção de profissionais de saúde sobre o processo de tomada de decisão na assistência a pacientes pediátricos.

OBJECTIVE: To evaluate the perceptions of physicians, nurses and nursing technicians of their participation in the decision-making process surrounding life support limitation in terminally ill pediatric patients, with comparisons by professional category. METHODS: A cross-sectional study was conducted in the pediatric intensive care unit of a tertiary public university hospital with the participation of physicians, nurses and nursing technicians. The MacArthur Admission Experience Survey Voice Scale was used to assess and quantify the perceptions of professionals who assisted 17 pediatric patients with life support limitation within 24 hours after the outcome of each patient was determined. All professionals working in the unit (n = 117) who were potentially eligible for the study received a free and informed consent form prior to the occurrence of the cases studied. RESULTS: Study participants included 25/40 (62.5%) physicians, 10/17 (58.8%) nurses and 41/60 (68.3%) nursing technicians, representing 65% of the eligible professionals identified. The questionnaire return rate was higher for physicians than technicians (p = 0.0258). A perceived lack of voice was reported in all three professional categories at varying rates that were lower for physicians than for nurses and nursing technicians (p < 0.00001); there was no difference between the latter (p = 0.7016). In the three professional categories studied, three subscale items were reported. For two of the three statements, there were significant differences between physicians and nurses (p = 0.004) and between physicians and nursing technicians (p = 0.001). For one of the statements, there was no difference among the three professional categories. CONCLUSION: Respondents perceived a lack of voice in the decision-making process at varying rates across the three categories of studied professionals who assisted terminally ill pediatric patients with life support limitation, with physicians expressing lowered rates of perceived coercion.

Incidence and endoscopic characteristics of acute laryngeal lesions in children undergoing endotracheal intubation.

INTRODUCTION: Acute laryngeal lesions after intubation appear to be precursors of chronic lesions. OBJECTIVE: To describe the incidence and type of acute laryngeal lesions after extubation in a pediatric intensive care unit (PICU). METHODS: A cohort study involving children from birth to <5 years, submitted to intubation for more than 24h in the PICU of an university hospital. In the first eight hours after extubation, a flexible fiberoptic laryngoscopy (FFL) was performed at the bedside. Those with moderate to severe abnormalities underwent a second examination seven to ten days later. RESULTS: 177 patients were included, with a median age of 2.46 months. The mean intubation time was 8.19 days. Seventy-three (41.2%) patients had moderate or severe alterations at the FFL, with the remaining showing only minor alterations or normal results. During follow-up, 16 children from the group with moderate to severe lesions developed subglottic stenosis. One patient from the normal FFL group had subglottic stenosis, resulting in an incidence of 9.6% of chronic lesions. CONCLUSION: Most children in the study developed mild acute laryngeal lesions caused by endotracheal intubation, which improved in a few days after extubation.

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.

Association between length of intubation and subglottic stenosis in children.

OBJECTIVES/HYPOTHESIS: To investigate the role of the length of intubation and other risk factors in the development of laryngeal lesions in children undergoing endotracheal intubation in an intensive care unit and to determine the incidence of subglottic stenosis (SGS). STUDY DESIGN: Prospective study. METHODS: Children aged from birth to <5 years admitted to the Pediatric Intensive Care Unit of Hospital de Clinicas de Porto Alegre who required endotracheal intubation for more than 24 hours were eligible. Children underwent flexible fiber-optic laryngoscopy (FFL) after extubation. Those who presented moderate to severe abnormalities in this first examination underwent another FFL between 7 and 10 days. If lesions persisted or symptoms developed, regardless of initial findings, laryngoscopy under general anesthesia was performed. RESULTS: We followed 142 children. In the first FFL, 58 children (40.8%) had moderate to severe laryngeal lesions. During follow-up, 16 children developed SGS, representing an incidence of 11.3% (95% confidence interval, 7.1-17.5). Multivariate analysis showed that for every 5 additional days of intubation, there was a 50.3% increase in the risk of developing SGS, and for each additional sedation doses/day, there was a 12% increase in the same outcome. CONCLUSIONS: In this first prospective research protocol in children, we found a higher incidence of SGS than in most previous studies. The length of intubation and the need for additional sedation doses appear to be key factors for the development of SGS during endotracheal intubation.

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

RESUMO Entre as principais causas de morte em nosso meio, situam-se acidentes automobilísticos, afogamento e queimaduras acidentais. O estrangulamento é uma injúria potencialmente fatal, além de importante causa de homicídio e suicídio em adultos e adolescentes. Em crianças, sua ocorrência é usualmente acidental. No entanto, nos últimos anos, vários casos de estrangulamento acidental em crianças ao redor do mundo têm sido reportados. Paciente masculino de 2 anos de idade foi vítima de estrangulamento em vidro do carro. Admitido na unidade de terapia intensiva pediátrica com Escala de Coma de Glasgow de 8, piora progressiva da disfunção respiratória e torpor. Paciente apresentou quadro de Síndrome da Angústia Respiratória Aguda, edema agudo de pulmão e choque. Foi manejado com ventilação mecânica protetora, drogas vosoativas e antibioticoterapia. Recebeu alta da unidade de terapia intensiva sem sequelas neurológicas ou pulmonares. Após 12 dias de internação, teve hospitalar alta para casa em ótimo estado. A incidência de estrangulamento por vidro de automóvel é rara, mas de alta morbimortalidade, devido ao mecanismo de asfixia ocasionado. Felizmente, os automóveis mais modernos dispõem de dispositivos que interrompem o fechamento automático dos vidros se for encontrada alguma resistência. No entanto, visto a gravidade das complicações de pacientes vítimas de estrangulamento, é significativamente relevante o manejo intensivo neuroventilatório e hemodinâmico das patologias envolvidas, para redução da morbimortalidade, assim como é necessário implementar novas campanhas para educação dos pais e cuidadores das crianças, visando evitar acidentes facilmente preveníveis e otimizar os mecanismos de segurança nos automóveis com vidros elétricos.

ABSTRACT 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.

A comparison of gradual sedation levels using the Comfort-B scale and bispectral index in children on mechanical ventilation in the pediatric intensive care unit.

OBJECTIVE: Compare the scores resulting from the Comfort-B scale with the bispectral index in children in an intensive care unit. METHODS: Eleven children between the ages of 1 month and 16 years requiring mechanical ventilation and sedation were simultaneously classified based on the bispectral index and the Comfort-B scale. Their behavior was recorded using digital photography, and the record was later evaluated by three independent evaluators. Agreement tests (Bland-Altman and Kappa) were then performed. The correlation between the two methods (Pearson correlation) was tested. RESULTS: In total, 35 observations were performed on 11 patients. Based on the Kappa coefficient, the agreement among evaluators ranged from 0.56 to 0.75 (p<0.001). There was a positive and consistent association between the bispectral index and the Comfort-B scale [r=0.424 (p=0.011) to r=0.498 (p=0.002)]. CONCLUSION: Due to the strong correlation between the independent evaluators and the consistent correlation between the two methods, the results suggest that the Comfort-B scale is reproducible and useful in classifying the level of sedation in children requiring mechanical ventilation.

Admission source and mortality in a pediatric intensive care unit.

BACKGROUND AND AIMS: Studies carried out in different countries have shown that source of patient admission in Intensive Care Units (ICUs) is associated to death. Patients admitted from wards show a greater ICU mortality. The aim of the present study was to investigate the association between admission source and outcome in a Pediatric Intensive Care Unit (PICU). MATERIALS AND METHODS: We studied all PICU admissions that took place between January 2002 and December 2005 in a tertiary hospital in Brazil. The major outcome studied was death while in the PICU. The independent variable analyzed was admission source, defined either as pediatric emergency room (PER), wards, operating room (OR) of the same hospital or other sources. RESULTS: A total of 1823 admissions were studied. The overall expected mortality based on the Pediatric Index of Mortality 2 was 6.5% and the observed mortality was 10.3%. In adjusted analysis, the mortality was doubled in patients admitted from wards when compared with the PER patients. CONCLUSIONS: Observed mortality rates were higher in patients admitted from wards within the same hospital, even after adjustment.