RESUMO
Importance: Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, but it excluded children. Objective: To update and evaluate criteria for sepsis and septic shock in children. Evidence Review: The Society of Critical Care Medicine (SCCM) convened a task force of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents. Using evidence from an international survey, systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million electronic health record encounters from 10 sites on 4 continents, a modified Delphi consensus process was employed to develop criteria. Findings: Based on survey data, most pediatric clinicians used sepsis to refer to infection with life-threatening organ dysfunction, which differed from prior pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant term, severe sepsis. The SCCM task force recommends that sepsis in children be identified by a Phoenix Sepsis Score of at least 2 points in children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. Children with a Phoenix Sepsis Score of at least 2 points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than 8 times that of children with suspected infection not meeting these criteria. Mortality was higher in children who had organ dysfunction in at least 1 of 4-respiratory, cardiovascular, coagulation, and/or neurological-organ systems that was not the primary site of infection. Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point in the Phoenix Sepsis Score, which included severe hypotension for age, blood lactate exceeding 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively. Conclusions and Relevance: The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force using a large international database and survey, systematic review and meta-analysis, and modified Delphi consensus approach. A Phoenix Sepsis Score of at least 2 identified potentially life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiological assessment, and research in pediatric sepsis and septic shock around the world.
Assuntos
Sepse , Choque Séptico , Humanos , Criança , Choque Séptico/mortalidade , Insuficiência de Múltiplos Órgãos/diagnóstico , Insuficiência de Múltiplos Órgãos/etiologia , Consenso , Sepse/mortalidade , Síndrome de Resposta Inflamatória Sistêmica/diagnóstico , Escores de Disfunção OrgânicaRESUMO
Importance: The Society of Critical Care Medicine Pediatric Sepsis Definition Task Force sought to develop and validate new clinical criteria for pediatric sepsis and septic shock using measures of organ dysfunction through a data-driven approach. Objective: To derive and validate novel criteria for pediatric sepsis and septic shock across differently resourced settings. Design, Setting, and Participants: Multicenter, international, retrospective cohort study in 10 health systems in the US, Colombia, Bangladesh, China, and Kenya, 3 of which were used as external validation sites. Data were collected from emergency and inpatient encounters for children (aged <18 years) from 2010 to 2019: 3â¯049â¯699 in the development (including derivation and internal validation) set and 581â¯317 in the external validation set. Exposure: Stacked regression models to predict mortality in children with suspected infection were derived and validated using the best-performing organ dysfunction subscores from 8 existing scores. The final model was then translated into an integer-based score used to establish binary criteria for sepsis and septic shock. Main Outcomes and Measures: The primary outcome for all analyses was in-hospital mortality. Model- and integer-based score performance measures included the area under the precision recall curve (AUPRC; primary) and area under the receiver operating characteristic curve (AUROC; secondary). For binary criteria, primary performance measures were positive predictive value and sensitivity. Results: Among the 172â¯984 children with suspected infection in the first 24 hours (development set; 1.2% mortality), a 4-organ-system model performed best. The integer version of that model, the Phoenix Sepsis Score, had AUPRCs of 0.23 to 0.38 (95% CI range, 0.20-0.39) and AUROCs of 0.71 to 0.92 (95% CI range, 0.70-0.92) to predict mortality in the validation sets. Using a Phoenix Sepsis Score of 2 points or higher in children with suspected infection as criteria for sepsis and sepsis plus 1 or more cardiovascular point as criteria for septic shock resulted in a higher positive predictive value and higher or similar sensitivity compared with the 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria across differently resourced settings. Conclusions and Relevance: The novel Phoenix sepsis criteria, which were derived and validated using data from higher- and lower-resource settings, had improved performance for the diagnosis of pediatric sepsis and septic shock compared with the existing IPSCC criteria.
Assuntos
Sepse , Choque Séptico , Humanos , Criança , Choque Séptico/mortalidade , Insuficiência de Múltiplos Órgãos , Estudos Retrospectivos , Escores de Disfunção Orgânica , Sepse/complicações , Mortalidade HospitalarRESUMO
Background: Fluids are often administered for various purposes, such as resuscitation, replacement, maintenance, nutrition, or drug infusion. However, its use is not without risks. Critically ill patients are highly susceptible to fluid accumulation (FA), which is associated with poor outcomes, including organ dysfunction, prolonged mechanical ventilation, extended hospital stays, and increased mortality. This study aimed to assess the association between FA and poor outcomes in critically ill children. Methods: In this systematic review and meta-analysis, we searched PubMed, Embase, ClinicalTrials.gov, and Cochrane Library databases from inception to May 2024. Relevant publications were searched using the following terms: child, children, infant, infants, pediatric, pediatrics, critically ill children, critical illness, critical care, intensive care, pediatric intensive care, pediatric intensive care unit, fluid balance, fluid overload, fluid accumulation, fluid therapy, edema, respiratory failure, respiratory insufficiency, pulmonary edema, mechanical ventilation, hemodynamic instability, shock, sepsis, acute renal failure, acute kidney failure, acute kidney injury, renal replacement therapy, dialysis, mortality. Paediatric studies were considered eligible if they assessed the effect of FA on the outcomes of interest. The main outcome was all-cause mortality. Pooled analyses were performed by using random-effects models. This review was registered on PROSPERO (CRD42023432879). Findings: A total of 120 studies (44,682 children) were included. Thirty-five FA definitions were identified. In general, FA was significantly associated with increased mortality (odds ratio [OR] 4.36; 95% confidence interval [CI] 3.53-5.38), acute kidney injury (OR 1.98; 95% CI 1.60-2.44), prolonged mechanical ventilation (weighted mean difference [WMD] 38.1 h, 95% CI 19.35-56.84), and longer stay in the intensive care unit (WMD 2.29 days; 95% CI 1.19-3.38). The percentage of FA was lower in survivors when compared to non-survivors (WMD -4.95 [95% CI, -6.03 to -3.87]). When considering only studies that controlled for potential confounding variables, the pooled analysis revealed 6% increased odds of mortality associated with each 1% increase in the percentage of FA (adjusted OR = 1.06 [95% CI, 1.04-1.09). Interpretation: FA is significantly associated with poorer outcomes in critically ill children. Thus, clinicians should closely monitor fluid balance, especially when new-onset or worsening organ dysfunction occurs in oedematous patients, indicating potential FA syndrome. Future research should explore interventions like restrictive fluid therapy or de-resuscitation methods. Meanwhile, preventive measures should be prioritized to mitigate FA until further evidence is available. Funding: None.
RESUMO
Abstract Introduction Vancomycin is widely prescribed to treat or prevent Gram-positive infections in pediatric liver transplant recipients. The objective of this prospective cohort study is to describe vancomycin pharmacokinetics and to evaluate the therapeutic target attainment after initial dose regimen. Materials and methods Patients with previous renal injury were excluded. Vancomycin therapy started with 40‒60 mg/kg/day. The pharmacokinetic parameters were assessed using two steady-state blood samples and the first-order kinetic equations. Therapeutic target was defined as vancomycin 24-hour Area Under the Curve/Minimum Inhibitory Concentration (AUC/MIC) ≥ 400 and < 600. Results Sixteen patients were included. The found vancomycin clearance, half-life, and volume of distribution were, respectively: 2.1 (1.3‒2.8) mL/kg/min, 3.3 (2.7‒4.4) hours, and 0.7 (0.5‒0.9) L/kg. With the initial dose, only 6 (37 %) patients reached the therapeutic target against Gram-positive pathogens with MIC 1 mg/L. After individual dose adjustments, all patients reached the target. The correlation between trough levels and AUC was low (R2= 0.5). Conclusions Pediatric patients with preserved renal function after liver transplantation have an increased volume of distribution for vancomycin, and most patients present subtherapeutic levels after the standard initial dosing regimen. With the vancomycin AUC-guided monitoring and dosing, it is possible to improve therapeutic target attainment.
RESUMO
ABSTRACT Objective: To assess Brazilian pediatric intensivists' general knowledge of extracorporeal membrane oxygenation, including evidence for its use, the national funding model, indications, and complications. Methods: This was a multicenter cross-sectional survey including 45 Brazilian pediatric intensive care units. A convenience sample of 654 intensivists was surveyed regarding their knowledge on managing patients on extracorporeal membrane oxygenation, its indications, complications, funding, and literature evidence. Results: The survey addressed questions regarding the knowledge and experience of pediatric intensivists with extracorporeal membrane oxygenation, including two clinical cases and 6 optional questions about the management of patients on extracorporeal membrane oxygenation. Of the 45 invited centers, 42 (91%) participated in the study, and 412 of 654 (63%) pediatric intensivists responded to the survey. Most pediatric intensive care units were from the Southeast region of Brazil (59.5%), and private/for-profit hospitals represented 28.6% of the participating centers. The average age of respondents was 41.4 (standard deviation 9.1) years, and the majority (77%) were women. Only 12.4% of respondents had taken an extracorporeal membrane oxygenation course. Only 19% of surveyed hospitals have an extracorporeal membrane oxygenation program, and only 27% of intensivists reported having already managed patients on extracorporeal membrane oxygenation. Specific extracorporeal membrane oxygenation management questions were responded to by only 64 physicians (15.5%), who had a fair/good correct response rate (median 63.4%; range 32.8% to 91.9%). Conclusion: Most Brazilian pediatric intensivists demonstrated limited knowledge regarding extracorporeal membrane oxygenation, including its indications and complications. Extracorporeal membrane oxygenation is not yet widely available in Brazil, with few intensivists prepared to manage patients on extracorporeal membrane oxygenation and even fewer intensivists recognizing when to refer patients to extracorporeal membrane oxygenation centers.
RESUMO Objetivo: Avaliar os conhecimentos gerais dos intensivistas pediátricos brasileiros sobre oxigenação por membrana extracorpórea, incluindo evidências de uso, modelo de custeio nacional, indicações e complicações. Métodos: Este estudo foi um inquérito transversal multicêntrico que incluiu 45 unidades de terapia intensiva pediátrica brasileiras. Realizou-se inquérito de conveniência com 654 intensivistas quanto aos seus conhecimentos sobre manejo de pacientes em oxigenação por membrana extracorpórea, suas indicações, complicações, custeio e evidências bibliográficas. Resultados: O inquérito abordou questões relativas aos conhecimentos e à experiência dos intensivistas pediátricos sobre oxigenação por membrana extracorpórea, incluindo dois casos clínicos e seis questões facultativas sobre o manejo de pacientes em oxigenação por membrana extracorpórea. Dos 45 centros convidados, 42 (91%) participaram do estudo, e 412 (63%) dos 654 intensivistas pediátricos responderam ao inquérito. A maioria das unidades de terapia intensiva pediátrica eram da Região Sudeste do Brasil (59,5%), e os hospitais privados com fins lucrativos representavam 28,6% dos centros participantes. A média de idade dos respondentes era de 41,4 (desvio-padrão de 9,1) anos, e a maioria (77%) era mulher. Apenas 12,4% dos respondentes tinham formação em oxigenação por membrana extracorpórea. Dos hospitais pesquisados, apenas 19% tinham um programa de oxigenação por membrana extracorpórea, e apenas 27% dos intensivistas declararam já ter manejado pacientes em oxigenação por membrana extracorpórea. Apenas 64 médicos (15,5%) responderam a questões específicas sobre o manejo de oxigenação por membrana extracorpórea (mediana 63,4%; oscilando entre 32,8% e 91,9%). Conclusão: A maioria dos intensivistas pediátricos brasileiros demonstrou conhecimentos limitados de oxigenação por membrana extracorpórea, incluindo suas indicações e complicações. A oxigenação por membrana extracorpórea ainda não está amplamente disponível no Brasil, com poucos intensivistas preparados para o manejo de pacientes em oxigenação por membrana extracorpórea e ainda menos intensivistas capazes de reconhecer quando devem encaminhar pacientes para centros de oxigenação por membrana extracorpórea.
RESUMO
ABSTRACT Objective To describe the clinical characteristics and treatment of children with sepsis, severe sepsis, and septic shock at a pediatric emergency department of a public hospital. Methods A retrospective, observational study. The medical records of patients included in the hospital Pediatric Sepsis Protocol and patients with discharge ICD-10 A41.9 (sepsis, unspecified), R57 (shock) and A39 (meningococcal meningitis) were evaluated. Results A total of 399 patients were included. The prevalence of sepsis, severe sepsis, and septic shock at the emergency room were 0.41%, 0.14% and 0.014%, respectively. The median age was 21.5 months for sepsis, 12 months for severe sepsis, and 20.5 months for septic shock. Sepsis, severe sepsis, and septic shock were more often associated with respiratory diseases. The Respiratory Syncytial Virus was the most common agent. The median time to antibiotic and fluid administration was 3 hours in patients with sepsis and severe sepsis. In patients with septic shock, the median times to administer antibiotics, fluid and vasoactive drugs were 2 hours, 2.5 hours and 6 hours, respectively. The median length of hospital stay for patients with sepsis, severe sepsis and septic shock were 3 days, 4 days and 1 day, respectively. The overall mortality was 2%. Conclusion Sepsis had a low prevalence. Early diagnosis and recognition are a challenge for the emergency care pediatrician, the first place of admission.
Assuntos
Humanos , Lactente , Criança , Choque Séptico/diagnóstico , Choque Séptico/terapia , Choque Séptico/epidemiologia , Sepse/diagnóstico , Sepse/terapia , Sepse/epidemiologia , Estudos Retrospectivos , Serviço Hospitalar de Emergência , Tempo de InternaçãoRESUMO
RESUMO Objetivo: Avaliar a probabilidade de atingir o alvo pela razão entre a área sob a curva e a concentração inibitória mínima de vancomicina em pacientes pediátricos após o esquema de dose empírica e demonstrar a aplicabilidade desse método para o monitoramento da vancomicina. Metódos: Foi realizado um estudo de coorte retrospectivo que incluiu pacientes pediátricos com função renal normal internados entre janeiro e dezembro de 2020. O modelo de um compartimento com cinética de primeira ordem foi utilizado para estimar os parâmetros farmacocinéticos, e a área sob a curva foi calculada pela regra do trapézio. O alvo terapêutico foi definido como a razão entre a área sob a curva e a concentração inibitória mínima ≥ 400 e < 600. O teste do qui-quadrado foi aplicado para comparar a probabilidade de atingir o alvo nos grupos etários, enquanto os parâmetros farmacocinéticos foram comparados pelo teste de Kruskal-Wallis com o teste de Dunn para análises post hoc. Consideraram-se significativos os valores de p < 0,05. Resultados: Foram analisados, no total, 42 pares de níveis de vancomicina de 17 pacientes inscritos neste estudo. Após a dose diária empírica de vancomicina, o alvo terapêutico foi atingido em cinco (29%) pacientes; quatro pacientes (24%) apresentavam razão entre a área sob a curva inicial supraterapêutica e o valor de concentração inibitória mínima (> 600mg.h/L) e oito (47%) tinham valores subterapêuticos (< 400mg.h/L). Os patógenos mais identificados foram Staphylococcus spp. (n = 7). Os níveis de vale e as áreas sob a curva mostraram valores moderados de correlação (R2 = 0,73). Um (6%) paciente apresentou lesão renal aguda. Conclusão: A maioria dos pacientes não atingiu o alvo terapêutico com esquema de dose empírica de vancomicina, e a implementação de dosagem baseada na área sob a curva usando duas medições de amostra permitiu ajustes de dose em tempo real com base nos parâmetros farmacocinéticos dos indivíduos.
ABSTRACT Objective: To assess the percentage of vancomycin area under the curve/minimum inhibitory concentration target attainment in pediatric patients after the empirical dose regimen and to demonstrate the applicability of this method for vancomycin monitoring. Methods: A retrospective cohort study was performed including pediatric patients with normal renal function admitted between January 2020 and December 2020. The one-compartment model with first-order kinetics was used to estimate the pharmacokinetic parameters, and the area under the curve was calculated by the trapezoidal rule. The therapeutic target was defined as area under the curve/minimum inhibitory concentration ≥ 400 and < 600. The Chi-squared test was applied to compare the percentage of target attainment over age groups, while the pharmacokinetic parameters were compared by the Kruskal-Wallis test with Dunn's test for post hoc analyses. We considered significant p-values < 0.05. Results: In total, 42 pairs of vancomycin levels were analyzed from 17 patients enrolled in this study. After empirical vancomycin daily dosing, the therapeutic target was achieved in five (29%) patients; four patients (24%) had a supratherapeutic initial area under the curve/minimum inhibitory concentration value (> 600mg.h/L), and eight (47%) patients had subtherapeutic values (< 400mg.h/L). The most identified pathogens were Staphylococcus spp. (n = 7). Trough levels and areas under the curve showed moderate correlation values (R2 = 0.73). Acute kidney injury occurred in one (6%) patient. Conclusion: Most patients did not reach the therapeutic target with a vancomycin empirical dose regimen, and the implementation of area under the curve-based dosing using two sample measurements allowed for real-time dose adjustments based on individuals' pharmacokinetic parameters.
RESUMO
RESUMO Objetivo: Relatar a prevalência e os desfechos da sepse em crianças admitidas em hospitais públicos e privados na América Latina. Métodos: Análise post-hoc dos dados do Latin American Pediatric Sepsis Study (LAPSES), um estudo de coorte que avaliou a prevalência e os desfechos da sepse em crianças admitidas em 21 unidades de terapia intensiva pediátricas de cinco países latino-americanos. Resultados: Dentre os 464 pacientes com sepse, 369 (79,5%) foram admitidos em hospitais públicos e 95 (20,5%) em privados. Em comparação com os admitidos em hospitais privados, os pacientes com sepse admitidos em hospitais públicos não diferiram em termos de idade, sexo, condição de imunização, tempo de permanência no hospital ou tipo de admissão, porém tiveram incidência mais alta de choque séptico, escores Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality 2 (PIM 2) e Pediatric Logistic Organ Dysfunction (PELOD) mais altos e taxas mais elevadas de doenças de base e analfabetismo materno. A proporção entre pacientes admitidos a partir de enfermarias pediátricas e mortalidade relacionada à sepse foi mais alta nos hospitais públicos. A análise multivariada não mostrou qualquer correlação entre mortalidade e tipo de hospital, porém, nos hospitais públicos, a mortalidade se associou com níveis mais altos de gravidade no momento da admissão à unidade de terapia intensiva. Conclusão: Nesta amostra de crianças admitidas em condições críticas em cinco países latino-americanos, a prevalência de choque séptico nas primeiras 24 horas da admissão e a mortalidade relacionada à sepse foram mais elevadas em hospitais públicos do que nos privados. A mortalidade relacionada à sepse mais elevada em crianças admitidas em unidades de terapia intensiva pediátrica de hospitais públicos se associou com maior gravidade por ocasião da admissão à unidade de terapia intensiva, porém não com o tipo de hospital. São necessários novos estudos para elucidar as causas da maior prevalência e mortalidade de sepse pediátrica em hospitais públicos.
ABSTRACT Objective: To report the prevalence and outcomes of sepsis in children admitted to public and private hospitals. Methods: Post hoc analysis of the Latin American Pediatric Sepsis Study (LAPSES) data, a cohort study that analyzed the prevalence and outcomes of sepsis in critically ill children with sepsis on admission at 21 pediatric intensive care units in five Latin American countries. Results: Of the 464 sepsis patients, 369 (79.5%) were admitted to public hospitals and 95 (20.5%) to private hospitals. Compared to those admitted to private hospitals, sepsis patients admitted to public hospitals did not differ in age, sex, immunization status, hospital length of stay or type of admission but had higher rates of septic shock, higher Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality 2 (PIM 2), and Pediatric Logistic Organ Dysfunction (PELOD) scores, and higher rates of underlying diseases and maternal illiteracy. The proportion of patients admitted from pediatric wards and sepsis-related mortality were higher in public hospitals. Multivariate analysis did not show any correlation between mortality and the type of hospital, but mortality was associated with greater severity on pediatric intensive care unit admission in patients from public hospitals. Conclusion: In this sample of critically ill children from five countries in Latin America, the prevalence of septic shock within the first 24 hours at admission and sepsis-related mortality were higher in public hospitals than in private hospitals. Higher sepsis-related mortality in children admitted to public pediatric intensive care units was associated with greater severity on pediatric intensive care unit admission but not with the type of hospital. New studies will be necessary to elucidate the causes of the higher prevalence and mortality of pediatric sepsis in public hospitals.
Assuntos
Humanos , Criança , Sepse/epidemiologia , Unidades de Terapia Intensiva Pediátrica , Prevalência , Estudos de Coortes , Hospitais Privados , Mortalidade Hospitalar , América Latina/epidemiologiaRESUMO
Abstract Objective: To describe the clinical characteristics of children and adolescents admitted to intensive care with confirmed COVID-19. Method: Prospective, multicenter, observational study, in 19 pediatric intensive care units. Patients aged 1 month to 19 years admitted consecutively (March-May 2020) were included. Demographic, clinical-epidemiological features, treatment, and outcomes were collected. Subgroups were compared according to comorbidities, age < 1 year, and need for invasive mechanical ventilation. A multivariable logistic regression model was used for predictors of severity. Results: Seventy-nine patients were included (ten with multisystemic inflammatory syndrome). Median age 4 years; 54% male (multisystemic inflammatory syndrome, 80%); 41% had comorbidities (multisystemic inflammatory syndrome, 20%). Fever (76%), cough (51%), and tachypnea (50%) were common in both groups. Severe symptoms, gastrointestinal symptoms, and higher inflammatory markers were more frequent in multisystemic inflammatory syndrome. Interstitial lung infiltrates were common in both groups, but pleural effusion was more prevalent in the multisystemic inflammatory syndrome group (43% vs. 14%). Invasive mechanical ventilation was used in 18% (median 7.5 days); antibiotics, oseltamivir, and corticosteroids were used in 76%, 43%, and 23%, respectively, but not hydroxychloroquine. The median pediatric intensive care unit length-of-stay was five days; there were two deaths (3%) in the non- multisystemic inflammatory syndrome group. Patients with comorbidities were older and comorbidities were independently associated with the need for invasive mechanical ventilation (OR 5.5; 95% CI, 1.43-21.12; p = 0.01). Conclusions: In Brazilian pediatric intensive care units, COVID-19 had low mortality, age less than 1 year was not associated with a worse prognosis, and patients with multisystemic inflammatory syndrome had more severe symptoms, higher inflammatory biomarkers, and a greater predominance of males, but only comorbidities and chronic diseases were independent predictors of severity.
Resumo Objetivo: Descrever as características clínicas de crianças e adolescentes internados em unidade de terapia intensiva com COVID-19 confirmada. Método: Estudo prospectivo, multicêntrico, observacional, em 19 unidades de terapia intensiva pediátrica. Foram incluídos pacientes entre um mês e 19 anos, admitidos consecutivamente (março a maio de 2020). As características demográficas, clínico-epidemiológicas, o tratamento e os resultados foram coletados. Os subgrupos foram comparados de acordo com as comorbidades, idade < 1 ano e necessidade de ventilação mecânica invasiva. Um modelo de regressão logística multivariável foi utilizado para preditores de gravidade. Resultados: Setenta e nove pacientes foram incluídos (10 com síndrome inflamatória multi-ssistêmica). Mediana de idade, quatro anos; 54% eram do sexo masculino (síndrome inflamatória multissistêmica, 80%); 41% tinham comorbidades (síndrome inflamatória multissistêmica, 20%). Febre (76%), tosse (51%) e taquipneia (50%) foram comuns nos dois grupos. Sintomas graves egastrointestinais e marcadores inflamatórios mais elevados foram mais frequentes na presença de síndrome inflamatória multissistêmica. Infiltrados intersticiais pulmonares foram comuns em ambos os grupos, mas o derrame pleural foi mais prevalente no grupo com síndrome inflamatória multissistêmica (43% vs. 14%). A ventilação mecânica invasiva foi utilizada em 18% (mediana 7,5 dias); antibióticos, oseltamivir e corticosteroides foram utilizados em 76%, 43% e 23%, respectivamente, mas não a hidroxicloroquina. A mediana do tempo de permanência na unidade de terapia intensiva pediátrica foi de 5 dias; duas mortes ocorreram (3%) no grupo não- síndrome inflamatória multissistêmica. Os pacientes com comorbidades eram mais velhos, e as comorbidades foram independentemente associadas à necessidade de ventilação mecânica invasiva(OR 5,5; IC95%, 1,43-21,12; P 0,01). Conclusões: Nas unidades de terapia intensiva pediátrica brasileiras, a COVID-19 apresentou baixa mortalidade, a idade inferior a um ano não foi associada a um pior prognóstico, os pacientes com síndrome inflamatória multissistêmica apresentaram sintomas mais graves, biomarcadores inflamatórios mais elevados e uma grande predominância no sexo masculino, mas apenas a presença de comorbidades e doenças crônicas foi um preditor independente de gravidade.
Assuntos
Humanos , Masculino , Feminino , Recém-Nascido , Lactente , Pré-Escolar , Criança , Adolescente , Pneumonia Viral/terapia , Respiração Artificial/métodos , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Infecções por Coronavirus/terapia , Síndrome de Resposta Inflamatória Sistêmica , Pandemias , Pneumonia Viral/epidemiologia , Brasil , Estudos Prospectivos , Infecções por Coronavirus/epidemiologia , Betacoronavirus , SARS-CoV-2 , COVID-19 , Hospitalização , Tempo de Internação/estatística & dados numéricosAssuntos
Humanos , Criança , Sepse/terapia , Sepse/epidemiologia , Países em Desenvolvimento , RendaRESUMO
A sepse, ou resposta inflamatória do organismo à infecção, é uma das principais doenças da infância, consome parcela substancial dos recursos financeiros das unidades de terapia intensiva, sendo causa comum de óbito em crianças. Essa doença é considerada um problema de saúde pública em expansão, negligenciada por muitos setores da sociedade. Objetivo: Descrever a prevalência e mortalidade por sepse em crianças admitidas em Unidades de Terapia Intensiva Pediátrica (UTIP) da América Latina. Desenho: Estudo prospectivo, multicêntrico, observacional. Ambiente: Vinte e uma UTIPs de cinco países da América Latina. Pacientes: Todas as crianças com idades entre 29 dias e 17 anos admitidas nas UTIPs participantes no período de 1 de junho a 30 de setembro de 2011. Características clínicas, demográficas e dados laboratoriais das primeiras 24 horas de internação na UTIP foram registrados. As crianças foram acompanhadas até a alta da UTIP ou óbito. Sepse foi definida de acordo com a International Pediatric Sepsis Consensus Conference (2005). Intervenções: Nenhuma. Resultados: Dos 1090 pacientes incluídos, 464 preenchiam os critérios de sepse. A prevalência de sepse, sepse grave e choque séptico foi de 42,6%, 25,9% e 19,8%, respectivamente. A mediana de idade dos pacientes com sepse foi de 11,6 meses (IQR: 3,2 - 48,7), 43% tinham uma ou mais doenças crônicas. A prevalência de sepse foi maior nas crianças menores de 1 ano de idade e caiu drasticamente nos adolescentes (50,4 vs 1,9%; p < 0,001). A mortalidade global por sepse foi de 14,2% e foi consistentemente maior com o aumento da gravidade da doença: 4,4% para sepse, 12,3% para sepse grave e 23,1% para choque séptico. Vinte e cinco por cento dos óbitos ocorreram durante as primeiras 24 horas de internação na UTIP. A análise multivariada demonstrou que os escores PRISM (OR 1,06, IC 95% 1,02 - 1,11; p= 0,005) e PELOD (OR 1,06, IC 95% 1,02 - 1,11; p= 0,001), a presença de duas ou mais doenças crônicas...
Sepsis, or the systemic inflammatory response to infection, is a major childhood disease, wastes a substantial amount of the intensive care units' financial resources and is a common cause of death in children. The disease is considered a growing public health problem, often overlooked by several sections of our community. Objective: To report the sepsis-related prevalence and mortality among critically ill children admitted to Pediatric Intensive Care Units (PICUs) in Latin America. Design: A prospective, multicenter cohort study. Setting: Twenty-one PICUs, located in five Latin America countries. Patients: All children from 29 days to 17 years old admitted to the participating PICUs from June to September, 2011. Clinical, demographic and laboratory data were registered within the first 24 hours of admission. Outcomes were registered at PICU discharge or death. Sepsis was defined according to the International Pediatric Sepsis Consensus Conference (2005). Results: Among 1090 included patients, 464 had sepsis. The prevalence of sepsis, severe sepsis and septic shock was 42.6%, 25.9% and 19.8%, respectively. The median age of sepsis patients was 11.6 months (IQR 3.2-48.7), 43% of whom had one or more prior chronic conditions. The prevalence of sepsis was higher in children under 1 year and very low in adolescents (50.4 vs 1.9%, p= 0.001). Sepsis-related mortality was 14.2% and was consistently higher with increasing sepsis severity: 4.4% for sepsis, 12.3% for severe sepsis and 23.1% for septic shock. Twenty-five percent of the deaths occurred within the first 24 hours of admission. Multivariate analysis showed that PRISM (OR 1.06, 95% CI 1.02 - 1.11, p= 0.005) and PELOD scores (OR 1.06, 95% CI 1.02 - 1.11, p= 0.001), the presence of two or more chronic conditions (OR 2.74, 95% CI 1.40 - 5.36, p= 0.003) and admission from pediatric wards (OR 2.44, 95% CI 1.19 - 5.01, p= 0.015) were independently associated with...
Assuntos
Humanos , Recém-Nascido , Lactente , Pré-Escolar , Criança , Adolescente , Criança , Epidemiologia , Unidades de Terapia Intensiva Pediátrica , Mortalidade , Prevalência , Sepse , América LatinaRESUMO
Objetivo: Estudo realizado a partir da revisão deprontuários de pacientes internados na Unidade deTerapia Intensiva Pediátrica do Hospital Universitárioda Universidade de São Paulo, no período dedezembro de 2001 a dezembro de 2004, descreveoito casos de choque séptico refratário a catecolaminas.Método: Observou-se que predominou perfilhemodinâmico, baseado em informações obtidasdo cateter de artéria pulmonar (CAP). Resultados:Houve elevado índice cardíaco e baixa resistênciavascular sistêmica. Conclusão: Os achados desseestudo diferem da descrição de Ceneviva et al.Novos estudos necessitam ser realizados visandoesclarecer o perfil hemodinâmico de crianças comchoque séptico refratário a volume e catecolaminase definir o papel da monitorização com CAP nesses casos.
Objectives: Study done from the revision of charts ofhospitalized patients from the Pediatric Intensive CareUnit of Hospital of the University of São Paulo, in periodof December 2001 to December 2004, describes 8 casesof catecholamine-resistant septic shock. Methods: It wasobserved that the predominant hemodynamic profile, basedon information obtained from pulmonary artery catheter(PAC). Results: There was high cardiac index and lowsystemic vascular resistance. Conclusion: It was differentfrom description of Ceneviva et al. New studies must beundertaken to clarify the hemodynamic profile of childrenwith volume and catecholamine-resistant septic shock andto define the role of PAC monitoring in these cases.