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1.
Pediatr Emerg Care ; 38(9): e1496-e1502, 2022 Sep 01.
Artigo em Espanhol, Inglês | MEDLINE | ID: mdl-35802481

RESUMO

OBJECTIVE: Sepsis is one of the most urgent health care issues worldwide. Guidelines for early identification and treatment are essential to decrease sepsis-related mortality. Our aim was to collect data on the epidemiology of pediatric septic shock (PSS) from the emergency department (PED) and to assess adherence to recommendations for its management in the first hour. METHODS: A multicenter, prospective, cross-sectional study was conducted evaluating children with PSS seen at the PED of 10 tertiary-care centers in Latin America. Adherence to guidelines was evaluated. RESULTS: We included 219 patients (median age, 3.7 years); 43% had comorbidities, 31% risk factors for developing sepsis, 74% clinical signs of "cold shock," and 13% of "warm shock," 22% had hypotension on admission. Consciousness was impaired in 55%. A peripheral line was used as initial access in 78% (median placement time, 10 minutes). Fluid and antibiotics infusion was achieved within a median time of 30 minutes (interquartile range [IQR], 20-60 minutes) and 40 minutes (IQR, 20-60 minutes), respectively; 40% responded inadequately to fluids requiring vasoactive drugs (median time at initiation, 60 minutes; IQR, 30-135 minutes). Delay to vasoactive drug infusion was significantly longer when a central line was placed compared to a peripheral line (median time, 133 minutes [59-278 minutes] vs 42 minutes [30-70 minutes], respectively [ P < 0.001]). Adherence to all treatment goals was achieved in 13%. Mortality was 10%. An association between mortality and hypotension on admission was found (26.1% with hypotension vs 4.9% without; P < 0.001). CONCLUSIONS: We found poor adherence to the international recommendations for the treatment of PSS in the first hour at the PED in third-level hospitals in Latin America.


OBJECTIVE: Sepsis is one of the most urgent health care issues worldwide. Guidelines for early identification and treatment are essential to decrease sepsis-related mortality. Our aim was to collect data on the epidemiology of pediatric septic shock (PSS) from the emergency department (PED) and to assess adherence to recommendations for its management in the first hour. METHODS: A multicenter, prospective, cross-sectional study was conducted evaluating children with PSS seen at the PED of 10 tertiary-care centers in Latin America. Adherence to guidelines was evaluated. RESULTS: We included 219 patients (median age, 3.7 years); 43% had comorbidities, 31% risk factors for developing sepsis, 74% clinical signs of "cold shock," and 13% of "warm shock," 22% had hypotension on admission. Consciousness was impaired in 55%. A peripheral line was used as initial access in 78% (median placement time, 10 minutes). Fluid and antibiotics infusion was achieved within a median time of 30 minutes (interquartile range [IQR], 20­60 minutes) and 40 minutes (IQR, 20­60 minutes), respectively; 40% responded inadequately to fluids requiring vasoactive drugs (median time at initiation, 60 minutes; IQR, 30­135 minutes). Delay to vasoactive drug infusion was significantly longer when a central line was placed compared to a peripheral line (median time, 133 minutes [59­278 minutes] vs 42 minutes [30­70 minutes], respectively [ P < 0.001]). Adherence to all treatment goals was achieved in 13%. Mortality was 10%. An association between mortality and hypotension on admission was found (26.1% with hypotension vs 4.9% without; P < 0.001). CONCLUSIONS: We found poor adherence to the international recommendations for the treatment of PSS in the first hour at the PED in third-level hospitals in Latin America.


Assuntos
Hipotensão , Sepse , Choque Séptico , Criança , Pré-Escolar , Estudos Transversais , Serviço Hospitalar de Emergência , Humanos , América Latina/epidemiologia , Estudos Prospectivos , Sepse/diagnóstico , Sepse/tratamento farmacológico , Sepse/epidemiologia , Choque Séptico/diagnóstico , Choque Séptico/epidemiologia , Choque Séptico/terapia
2.
Int J Palliat Nurs ; 19(10): 495-502, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24162280

RESUMO

OBJECTIVES: To evaluate the quality of care offered to terminally ill children and their families in the last days of life in two Brazilian Paediatric Intensive Care Units (PICUs) from the parents' perspectives. METHODS: This was a qualitative, exploratory study. Parents of a child who had died in one of the PICUs 6-12 months previously were invited to take part in two interviews: a private meeting with the PICU assistant physician who cared for their child, to discuss and review any outstanding issues related to the diagnosis, treatment, and prognosis, and a recorded interview with a researcher who was not involved in the child's treatment. Data from the interviews with the researcher were posteriorly grouped in categories according to recurrent terms. RESULTS: Six categories emerged, three of which are reported here. The quality of communication was low; the medical staff frequently used technical terms, limiting understanding. Parental participation in the decision-making process was scarce; decisions were based on the medical perspective. Finally, families reported uncompassionate attitudes from the medical staff and excessive technology in the final moments surrounding the child's death, although nurses were highly involved with palliative care measures and demonstrated sympathetic and supportive postures. CONCLUSION: The interviews uncovered deficiencies in the care provided to parents in the PICUs, indicating a need for changes in practice.


Assuntos
Atitude Frente a Morte , Unidades de Terapia Intensiva Pediátrica/organização & administração , Pais/psicologia , Relações Profissional-Família , Qualidade da Assistência à Saúde/organização & administração , Assistência Terminal/organização & administração , Adulto , Atitude do Pessoal de Saúde , Brasil , Criança , Pré-Escolar , Comunicação , Tomada de Decisões , Feminino , Humanos , Lactente , Masculino
3.
PeerJ Comput Sci ; 8: e833, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35494860

RESUMO

Background: Architectural Technical Debt (ATD) in a software-intensive system denotes architectural design choices which, while being suitable or even optimal when adopted, lower the maintainability and evolvability of the system in the long term, hindering future development activities. Despite the growing research interest in ATD, how to gain an informative and encompassing viewpoint of the ATD present in a software-intensive system is still an open problem. Objective: In this study, we evaluate ATDx, a data-driven approach providing an overview of the ATD present in a software-intensive system. The approach, based on the analysis of a software portfolio, calculates severity levels of architectural rule violations via a clustering algorithm, and aggregates results into different ATD dimensions. Method: To evaluate ATDx, we implement an instance of the approach based on SonarQube, and run the analysis on the Apache and ONAP ecosystems. The analysis results are then shared with the portfolio contributors, who are invited to participate in an online survey designed to evaluate the representativeness and actionability of the approach. Results: The survey results confirm the representativeness of the ATDx, in terms of both the ATDx analysis results and the used architectural technical debt dimensions. Results also showed the actionability of the approach, although to a lower extent when compared to the ATDx representativeness, with usage scenarios including refactoring, code review, communication, and ATD evolution analysis. Conclusions: With ATDx, we strive for the establishment of a sound, comprehensive, and intuitive architectural view of the ATD identifiable via source code analysis. The collected results are promising, and display both the representativeness and actionability of the approach. As future work, we plan to consolidate the approach via further empirical experimentation, by considering other development contexts (e.g., proprietary portfolios and other source code analysis tools), and enhancing the ATDx report capabilities.

4.
Inquiry ; 59: 469580221100777, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35538400

RESUMO

Aim: To present nurses' experience in the decision-making process for implementing a therapeutic support limitation plan in the PICU. Method: Qualitative exploratory research was conducted through semi-structured interviews with 25 intensive care nurses from January to June 2019. The textual corpus was then submitted for content analysis. Results: Two categories emerged: the nurse and decision-making process of the TSLP and ambivalence of the participating nurse's feelings in implementing the TSLP. These categories are interrelated in that the decision-making process mobilizes the ambivalence of the participating nurses' feelings. Final considerations and implications for practice: The starting point of communication between the health teams consists of acquiring information about the concerned child's end-of-life care plan with no prospect of cure and with some form of therapeutic limit admitted to the PICU. Therefore, this study helps to map possible research gaps on the topic and mobilize researchers to build educational materials, protocols, and tools for comprehensive care that can be used by nurses when faced with ethical dilemma, such as decision-making through TSLP.


Assuntos
Enfermeiras e Enfermeiros , Assistência Terminal , Criança , Comunicação , Tomada de Decisões , Humanos , Pesquisa Qualitativa
5.
J Immunol ; 183(1): 718-31, 2009 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-19535630

RESUMO

Immune mediators associated with human tuberculosis (TB) remain poorly defined. This study quantified levels of lung immune mediator gene expression at the time of diagnosis and during anti-TB treatment using cells obtained by induced sputum. Upon comparison to patients with other infectious lung diseases and volunteers, active pulmonary TB cases expressed significantly higher levels of mediators that counteract Th1-type and innate immunity. Despite the concomitant heightened levels of Th1-type mediators, immune activation may be rendered ineffectual by high levels of intracellular (SOCS and IRAK-M) and extracellular (IL-10 and TGF-betaRII, IL-1Rn, and IDO) immune suppressive mediators. These modulators are a direct response to Mycobacterium tuberculosis as, by day 30 of anti-TB treatment, many suppressive factors declined to that of controls whereas most Th1-type and innate immune mediators rose above pretreatment levels. Challenge of human immune cells with M. tuberculosis in vitro up-regulated these immune modulators as well. The observed low levels of NO synthase-2 produced by alveolar macrophages at TB diagnosis, along with the heightened amounts of suppressive mediators, support the conclusion that M. tuberculosis actively promotes down-modulatory mediators to counteract Th1-type and innate immunity as an immunopathological strategy. Our data highlight the potential application of immune mediators as surrogate markers for TB diagnosis or treatment response.


Assuntos
Regulação para Baixo/imunologia , Pulmão/imunologia , Pulmão/patologia , Células Th1/imunologia , Células Th1/patologia , Tuberculose Pulmonar/imunologia , Tuberculose Pulmonar/patologia , Adulto , Líquido da Lavagem Broncoalveolar/citologia , Líquido da Lavagem Broncoalveolar/imunologia , Líquido da Lavagem Broncoalveolar/microbiologia , Células Cultivadas , Regulação para Baixo/genética , Feminino , Regulação da Expressão Gênica/imunologia , Humanos , Mediadores da Inflamação/antagonistas & inibidores , Mediadores da Inflamação/metabolismo , Pulmão/metabolismo , Masculino , Pessoa de Meia-Idade , Escarro/imunologia , Escarro/microbiologia , Células Th1/microbiologia , Tuberculose Pulmonar/genética , Adulto Jovem
6.
Int J Palliat Nurs ; 17(6): 264, 267-70, 2011 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-21727883

RESUMO

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


Assuntos
Planejamento Antecipado de Cuidados , Cuidados para Prolongar a Vida , Padrões de Prática em Enfermagem , Assistência Terminal , Adolescente , Brasil , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Pediátrica , Masculino , Relações Médico-Enfermeiro , Estudos Prospectivos
7.
Braz J Infect Dis ; 25(6): 101650, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34774486

RESUMO

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.


Assuntos
COVID-19 , Adolescente , Brasil/epidemiologia , Criança , Pré-Escolar , Feminino , Hospitalização , Humanos , Lactente , Recém-Nascido , Masculino , Fatores de Risco , SARS-CoV-2
8.
Pediatr Pulmonol ; 56(7): 1924-1930, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33831259

RESUMO

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.


Assuntos
Asma , Sulfato de Magnésio , Doença Aguda , Asma/tratamento farmacológico , Broncodilatadores/uso terapêutico , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Humanos , Sulfato de Magnésio/uso terapêutico
9.
J Med Ethics ; 36(6): 344-8, 2010 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-20439333

RESUMO

OBJECTIVE: To evaluate the modes of death and treatment offered in the last 24 h of life to patients dying in 10 Brazilian intensive care units (ICUs) over a period of 2 years. DESIGN AND SETTING: Cross-sectional, multicentre, retrospective study based on medical chart review. The medical records of all patients that died in seven paediatric and three adult ICUs belonging to university and tertiary hospitals over a period of 2 years were included. Deaths in the first 24 h of admission to the ICU and brain death were excluded. INTERVENTION: Two intensive care fellows of each ICU were trained in fulfilling a standard protocol (kappa=0.9) to record demographic data and all medical management provided in the last 48 h of life. The Student t test, Mann-Whitney U test, chi(2) test and RR were used for data comparison. MEASUREMENTS AND MAIN RESULTS: 1053 medical charts were included (59.4% adult patients). Life support limitation was more frequent in the adult group (86% vs 43.5%; p<0.001). A 'do not resuscitate' order was the most common life support limitation in both groups (75% and 66%), whereas withholding/withdrawing were more frequent in the paediatric group (33.9% vs 24.9%; p=0.02). The life support limitation was rarely reported in the medical chart in both groups (52.6% and 33.7%) with scarce family involvement in the decision making process (23.0% vs 8.7%; p<0.001). CONCLUSION: Life support limitation decision making in Brazilian ICUs is predominantly centred on the medical perspective with scarce participation of the family, and consequently several non-coherent medical interventions are observed in patients with life support limitation.


Assuntos
Unidades de Terapia Intensiva , Cuidados para Prolongar a Vida/métodos , Assistência Terminal/métodos , Adulto , Idoso , Brasil , Criança , Pré-Escolar , Estudos Transversais , Tomada de Decisões , Feminino , Hospitais Universitários , Humanos , Unidades de Terapia Intensiva Pediátrica , Tempo de Internação , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Suspensão de Tratamento/estatística & dados numéricos
10.
Pediatr Crit Care Med ; 10(3): 375-80, 2009 May.
Artigo em Inglês | MEDLINE | ID: mdl-19325502

RESUMO

OBJECTIVE: To describe the characteristics of children submitted to prolonged mechanical ventilation (MV), and evaluate their mortality, and associated factors as well as the potential impact at admissions to the pediatric intensive care unit (PICU). METHODS: We conducted a retrospective study enrolling all children admitted to three Brazilian PICUs between January 2003 and December 2005 submitted to MV > or =21 days. The three selected PICUs were located in university-affiliated hospitals. From the medical charts were reported anthropometric data, diagnosis, ventilator parameters on the 21st day, length of MV, length of stay in the PICU, specific interventions (e.g., tracheostomy), and outcome. RESULTS: One hundred eighty-four children (190 admissions) were submitted to prolonged MV (2.5% of all admissions to these 3 Brazilian PICUs), with a median age of 6 months. The mortality rate was 48% and the median time on MV was 32 days. Tracheostomy was performed on only 19% of the patients and, on average after 32 days of intubation. Mortality was associated with peak inspiratory pressure >25 cm H2O (odds ratio = 2.3; 1.1-5.1), fraction of inspired oxygen >0.5 (odds ratio = 6.3; 2.2-18.1), and vasoactive drug infusion (odds ratio = 2.6; 1.1-5.9) on the 21st day of MV. Seventy-six children (1% of the all admissions) were dependent on MV without other organ failures were 830 PICU admissions and were potentially prevented. CONCLUSIONS: A small group of children admitted to the PICU requires prolonged MV. The elevated mortality rate is associated with higher ventilatory parameters and vasoactive drug support on the 21st day of MV. Stable children requiring prolonged MV in the PICU potentially prevent additional admissions of a large number of acute and unstable patients.


Assuntos
Unidades de Terapia Intensiva Pediátrica , Respiração Artificial/mortalidade , Brasil/epidemiologia , Criança , Feminino , Humanos , Lactente , Masculino , Admissão do Paciente , Prognóstico , Estudos Retrospectivos , Fatores de Tempo
11.
Pediatr Crit Care Med ; 9(1): 26-31, 2008 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-18477910

RESUMO

OBJECTIVE: To evaluate the incidence of life support limitation and medical practices in the last 48 hrs of life of children in seven Brazilian pediatric intensive care units (PICUs). DESIGN: Cross-sectional multicenter retrospective study based on medical chart review. SETTING: Seven PICUs belonging to university and tertiary hospitals located in three Brazilian regions: two in Porto Alegre (southern region), two in São Paulo (southeastern region), and three in Salvador (northeastern region). PATIENTS: Medical records of all children who died in seven PICUs from January 2003 to December 2004. Deaths in the first 24 hrs of admission to the PICU and brain death were excluded. INTERVENTIONS: Two pediatric intensive care residents from each PICU were trained to fill out a standard protocol (kappa = 0.9) to record demographic data and all medical management provided in the last 48 hrs of life (inotropes, sedatives, mechanical ventilation, full resuscitation maneuvers or not). Student's t-test, analysis of variance, chi-square test, and relative risk were used for comparison of data. MEASUREMENTS AND MAIN RESULTS: Five hundred and sixty-one deaths were identified; 97 records were excluded (61 because of brain death and 36 due to <24 hrs in the PICU). Thirty-six medical charts could not be found. Cardiopulmonary resuscitation was performed in 242 children (57%) with a significant difference between the southeastern and northeastern regions (p = .0003). Older age (p = .025) and longer PICU stay (p = .001) were associated with do-not-resuscitate orders. In just 52.5% of the patients with life support limitation, the decision was clearly recorded in the medical chart. No ventilatory support was provided in 14 cases. Inotropic drug infusions were maintained or increased in 66% of patients with do-not-resuscitate orders. CONCLUSIONS: The incidence of life support limitation has increased among Brazilian PICUs but with significant regional differences. Do-not-resuscitate orders are still the most common practice, with scarce initiatives for withdrawing or withholding life support measures.


Assuntos
Unidades de Terapia Intensiva Pediátrica , Cuidados para Prolongar a Vida/estatística & dados numéricos , Padrões de Prática Médica , Assistência Terminal/métodos , Brasil/epidemiologia , Criança , Pré-Escolar , Estudos Transversais , Feminino , Mortalidade Hospitalar , Humanos , Lactente , Masculino , Estudos Retrospectivos
12.
Braz J Infect Dis ; 22(3): 219-223, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29879425

RESUMO

BACKGROUND: A/H1N1 influenza is a viral disease that affects a significant part of the population mainly in winter, leading to increased number of medical consultations, hospitalizations and consequently care spending in emergency. METHODS: This is a case-series retrospective study, involving patients admitted to a tertiary hospital in southern Brazil in 2016 with a clinical diagnosis of acute respiratory infection of the influenza type and laboratory confirmation of influenza A/H1N1. RESULTS: 64 patients were included, mostly male, median age of 48.3 months. Chronic underlying diseases were found in 73% of the patients, and these patients evolved to the most unfavorable outcome. About vaccination, of the 57 patients with an age range for vaccination, only 28% had complete vaccination coverage. The main clinical manifestations found in the included patients were fever, cough, intercostal indrawing, wheezing, tachypnea and pulmonary crackles. These patients were mainly followed-up with laboratory tests and chest X-ray. Consolidation was evident in 43% of patients followed by interstitial infiltrate in 33%. A five-day course of neuraminidase inhibitor was prescribed for all patients, as recommended by the WHO, but due to the complications, 73% of the patients required antibiotic therapy, and 61% oxygen therapy. The majority of patients had a favorable outcome, but 11 required intensive care and one died. CONCLUSIONS: A/H1N1 influenza persists as an important public health problem, mainly due to high morbidity and hospitalization rates. It is important to identify patients with A/H1N1 influenza and clinical situations with higher risk of complications. Through this study, it is possible to analyze the characteristics of pediatric patients with A/H1N1 influenza and mainly to emphasize assistance of populations with comorbidities, since they present higher rates of complications and death.


Assuntos
Hospitais Universitários/estatística & dados numéricos , Vírus da Influenza A Subtipo H1N1 , Influenza Humana/epidemiologia , Adolescente , Brasil/epidemiologia , Criança , Pré-Escolar , Comorbidade , Feminino , Febre/epidemiologia , Humanos , Lactente , Influenza Humana/patologia , Influenza Humana/terapia , Tempo de Internação , Masculino , Estudos Retrospectivos , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Fatores de Risco , Taquipneia/epidemiologia , Fatores de Tempo
14.
J Pediatr (Rio J) ; 83(2 Suppl): S109-16, 2007 May.
Artigo em Inglês | MEDLINE | ID: mdl-17530135

RESUMO

OBJECTIVE: To analyze the medical practices and the end-of-life care provided to children admitted to pediatric intensive care units in different parts of the globe. SOURCES: Articles on end-of-life care published during the last 20 years were selected from the PubMed, MEDLINE and LILACS databases, with emphasis on studies of death in pediatric intensive care units in Brazil, Latin America, Europe and North America, using the following keywords: death, bioethics, pediatric intensive care, cardiopulmonary resuscitation and life support limitation. SUMMARY OF THE FINDINGS: Publications on life support limitation (LSL) are concentrated in North America and Europe. In North American pediatric intensive care units there is a greater incidence of LSL (approximately 60%) than in Europe or Latin America (30-40%). These differences appear to be related to cultural, religious, legal and economic factors. Over the last decade, LSL in Brazilian pediatric intensive care units has increased from 6 to 40%, with do not resuscitate orders as the most common method. Also of note is the low level of family participation in the decision-making process. A recent resolution adopted by the Federal Medical Council (Conselho Federal de Medicina) regulated LSL in our country, demystifying a certain apprehension of a legal nature. The authors present a proposal for a protocol to be followed in these cases. CONCLUSIONS: The adoption of LSL with children in the final phases of irreversible diseases has ethical, moral and legal support. In Brazil, these measures are still being adopted in a timid manner, demanding a change in behavior, especially in the involvement of families in the decision-making process.


Assuntos
Cuidados para Prolongar a Vida , Assistência Terminal/ética , Brasil , Criança , Protocolos Clínicos , Ética Médica , Humanos , Unidades de Terapia Intensiva Pediátrica , Internacionalidade , Cuidados para Prolongar a Vida/ética , Cuidados para Prolongar a Vida/normas , Cuidados Paliativos , Padrões de Prática Médica , Ordens quanto à Conduta (Ética Médica) , Assistência Terminal/normas , Suspensão de Tratamento/ética
15.
J Pediatr (Rio J) ; 83(2): 133-40, 2007.
Artigo em Inglês | MEDLINE | ID: mdl-17327930

RESUMO

OBJECTIVE: To assess the incidence of brain death (BD) and its medical management and adopted protocols after its diagnosis in seven pediatric intensive care units (PICUs) located in three Brazilian regions. METHODS: A cross-sectional and multicenter study was conducted, based on the retrospective review of medical records regarding all deaths that occurred between January 2003 and December 2004 in seven Brazilian PICUs of tertiary hospitals located in Porto Alegre (two), São Paulo (two) and Salvador (three). Two pediatric intensive care residents from each hospital were previously trained and filled out a standard protocol for the investigation of demographic data, cause of death, diagnosis of BD, related protocols and subsequent medical management. RESULTS: A total of 525 death patients were identified and 61 (11.6%) were defined as BD. The incidence of BD was different (p = 0.015) across the seven PICUs, but with no difference across the three regions. Intracranial hemorrhage was the most frequent cause of BD (31.1%). In 80% of the cases the diagnosis of BD was confirmed by complementary exams (south = 100%, southeast = 68% and northeast = 72%; p = 0.02). The interval between the diagnosis of BD and the withdrawal of life support was different (p < 0.01) across the three regions, being faster (p = 0.04) in the south (1.8+/-1.9 h) than in the southeast (28.6+/-43.2 h) and than in the northeast (15.5+/-17.1 h). Only six (9.8%) children with BD were organ donors. CONCLUSION: Although a Brazilian law defining the criteria for the determination of BD has been in place since 1997, we verified that it is not followed as strictly as it should be. Consequently, unnecessary life support is offered to deceased individuals, and there is a discrete involvement of PICUs in organ donation.


Assuntos
Morte Encefálica/diagnóstico , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Padrões de Prática Médica/ética , Doadores de Tecidos/estatística & dados numéricos , Obtenção de Tecidos e Órgãos , Brasil/epidemiologia , Causas de Morte , Criança , Estudos Transversais , Humanos , Incidência , Estudos Retrospectivos
16.
J Pediatr (Rio J) ; 93 Suppl 1: 68-74, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28869808

RESUMO

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


Assuntos
Medicina de Emergência/educação , Internato e Residência , Pediatria/educação , Prática Profissional , Brasil , Humanos
17.
Pediatr Crit Care Med ; 6(3): 258-63, 2005 May.
Artigo em Inglês | MEDLINE | ID: mdl-15857521

RESUMO

OBJECTIVES: To study the possible change on mode of deaths, medical decision practices, and family participation on decisions for limiting life-sustaining treatments (L-LST) over a period of 13 yrs in three pediatric intensive care units (PICUs) located in southern Brazil. METHODS: A cross-sectional study based on a retrospective chart review (1988 and 1998) and on prospective data collection (from May 1999 to May 2000). SETTING: Three PICUs in Porto Alegre, southern Brazilian region. PATIENTS: Children who died in those PICUs during the years of 1988, 1998, and between May 1999 and May 2000. RESULTS: The 3 PICUs admitted 6,233 children during the study period with a mortality rate of 9.2% (575 deaths), and 509 (88.5%) medical charts were evaluated in this study. Full measures for life support (F-CPR) were recognized in 374 (73.5%) children before dying, brain death (BD) was diagnosed in 43 (8.4%), and 92 (18.1%) underwent some limitation of life support treatment (L-LST) There were 140 (27.5%) deaths within the first 24 hrs of admission and 128 of them (91.4%) received F-CPR, whereas just 11 (7.9%) patients underwent L-LST. The average length of stay for the death group submitted to F-CPR was lower (3 days) than the L-LST group (8.5 days; p < .05). The rate of F-CPR before death decreased significantly between 1988 (89.1%) and 1999/2000 (60.8%), whereas the L-LST rose in this period from 6.2% to 31.3%. These changes were not uniform among the three PICUs, with different rates of L-LST (p < .05). The families were involved in the decision-making process for L-LST in 35.9% of the cases, increasing from 12.5% in 1988 to 48.6% in 1999/2000. The L-LST plans were recorded in the medical charts in 76.1% of the deaths, increasing from 50.0% in 1988 to 95.9% in 1999/2000. CONCLUSION: We observed that the modes of deaths in southern Brazilian PICUs changed over the last 13 yrs, with an increment in L-LST. However, this change was not uniform among the studied PICUs and did not reach the levels described in countries of the Northern Hemisphere. Family participation in the L-LST decision-making process has increased over time, but it is still far behind what is observed in other parts of the world.


Assuntos
Estado Terminal/mortalidade , Tomada de Decisões , Unidades de Terapia Intensiva Pediátrica/organização & administração , Padrões de Prática Médica/tendências , Assistência Terminal/tendências , Brasil/epidemiologia , Reanimação Cardiopulmonar , Pré-Escolar , Estudos Transversais , Feminino , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica/tendências , Tempo de Internação , Cuidados para Prolongar a Vida/tendências , Masculino , Planejamento de Assistência ao Paciente/tendências , Ordens quanto à Conduta (Ética Médica) , Suspensão de Tratamento/tendências
18.
J Pediatr (Rio J) ; 81(2): 111-7, 2005.
Artigo em Português | MEDLINE | ID: mdl-15858671

RESUMO

OBJECTIVES: To describe causes of death and factors involved in the decision-making process related to life support limitation at three university-affiliated pediatric intensive care units in the south of Brazil. METHODS: A retrospective study was conducted, based on a review of the medical records of all deaths occurring during 2002 at three pediatric intensive care units in Porto Alegre. Three previously trained pediatric fellows from each service performed the study. Data were assessed relating to general case characteristics, causes of death (failed cardiopulmonary resuscitation, brain death, do-not-resuscitate orders, withholding or withdrawing life-sustaining treatment -- the last three modes were classified as the life support limitation group), length of stay in hospital, end-of-life plans and the participation of patients families and Ethics Committees. The Student t test, Mann Whitney, chi-square, odds ratio and multivariate analyses were used for comparisons. RESULTS: Close to 53.3% of fatal cases had received full cardiopulmonary resuscitation. The incidence of life support limitation was 36%, with statistical differences (p = 0.014) between the three hospitals (25 versus 54.3 and 45.5%, respectively). The most frequent form of life support limitation was a do-not-resuscitate order (70%). Life support limitation was associated with the presence of chronic disease (odds ratio = 8.2; 95%CI 3.2-21.3) and length stay in the pediatric intensive care unit (odds ratio = 4.4; 95%CI 1.6-11.8). The rate of involvement of families and Ethics Committees in the decision-making process was lesser than 10%. CONCLUSIONS: Cardiopulmonary resuscitation is offered more frequently than is observed in northern countries. In contrast, life support limitation is offered through do-not-resuscitate orders. These findings and the low participation of the families in the decision-making process reflect the difficulties to be overcome by those professionals who are responsible for handling critically ill children in southern Brazil.


Assuntos
Morte , Unidades de Terapia Intensiva Pediátrica , Cuidados para Prolongar a Vida , Assistência Terminal , Brasil , Reanimação Cardiopulmonar , Criança , Pré-Escolar , Métodos Epidemiológicos , Ética Médica , Feminino , Humanos , Cuidados para Prolongar a Vida/ética , Masculino , Relações Profissional-Família , Ordens quanto à Conduta (Ética Médica) , Assistência Terminal/ética
19.
J Pediatr (Rio J) ; 79 Suppl 2: S223-30, 2003 Nov.
Artigo em Português | MEDLINE | ID: mdl-14647719

RESUMO

OBJECTIVE: To review the current strategies for use of sedatives and analgesics in emergency rooms and intensive care units. SOURCE OF DATA: Original data from our emergency rooms and intensive care units; Medline literature review focused on sedatives and analgesic drugs; textbooks. SUMMARY OF THE FINDINGS: Despite the advances in understanding pain in children, in many critical care units the misguided treatment of pain and anxiety still results in significant morbidity. Difficulties in communication, invasive procedures and the belief that children do not have sufficient neurologic development to process noxious sensations are still a challenge in intensive care units. CONCLUSIONS: The last decade was marked by significant advances in understanding pediatric pain. Treating intensive care unit-related pain and anxiety has clear benefits which may influence the course of disease.


Assuntos
Analgésicos/uso terapêutico , Ansiedade/tratamento farmacológico , Cuidados Críticos , Hipnóticos e Sedativos/uso terapêutico , Dor/tratamento farmacológico , Criança , Tratamento de Emergência , Humanos
20.
Braz. j. infect. dis ; 22(3): 219-223, May-June 2018. tab, graf
Artigo em Inglês | LILACS | ID: biblio-974210

RESUMO

ABSTRACT Background A/H1N1 influenza is a viral disease that affects a significant part of the population mainly in winter, leading to increased number of medical consultations, hospitalizations and consequently care spending in emergency. Methods This is a case-series retrospective study, involving patients admitted to a tertiary hospital in southern Brazil in 2016 with a clinical diagnosis of acute respiratory infection of the influenza type and laboratory confirmation of influenza A/H1N1. Results 64 patients were included, mostly male, median age of 48.3 months. Chronic underlying diseases were found in 73% of the patients, and these patients evolved to the most unfavorable outcome. About vaccination, of the 57 patients with an age range for vaccination, only 28% had complete vaccination coverage. The main clinical manifestations found in the included patients were fever, cough, intercostal indrawing, wheezing, tachypnea and pulmonary crackles. These patients were mainly followed-up with laboratory tests and chest X-ray. Consolidation was evident in 43% of patients followed by interstitial infiltrate in 33%. A five-day course of neuraminidase inhibitor was prescribed for all patients, as recommended by the WHO, but due to the complications, 73% of the patients required antibiotic therapy, and 61% oxygen therapy. The majority of patients had a favorable outcome, but 11 required intensive care and one died. Conclusions A/H1N1 influenza persists as an important public health problem, mainly due to high morbidity and hospitalization rates. It is important to identify patients with A/H1N1 influenza and clinical situations with higher risk of complications. Through this study, it is possible to analyze the characteristics of pediatric patients with A/H1N1 influenza and mainly to emphasize assistance of populations with comorbidities, since they present higher rates of complications and death.


Assuntos
Humanos , Masculino , Feminino , Lactente , Pré-Escolar , Criança , Adolescente , Influenza Humana/epidemiologia , Vírus da Influenza A Subtipo H1N1 , Hospitais Universitários/estatística & dados numéricos , Fatores de Tempo , Brasil/epidemiologia , Comorbidade , Estudos Retrospectivos , Fatores de Risco , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Influenza Humana/patologia , Influenza Humana/terapia , Febre/epidemiologia , Taquipneia/epidemiologia , Tempo de Internação
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