Evaluation of serum cardiac troponin I values in children less than 1 year of age

OBJECTIVE: The objective is to verify the cardiac troponin I values in children less than 1 year of age without clinical cardiac dysfunction. METHODS: The cardiac troponin I values were determined in 99 children less than 1 year of age, including term infants without diseases related to cardiac dysfunction using the specific kit Opus T Troponin I (cTn) (Dade Behring Inc. -Newalk, DE 19714, USA). RESULTS: All children have values of cardiac troponin I less than 0.1 ng/ml. CONCLUSION: We verified that the cardiac troponin I value is less than 0.1 ng/ml in children less than 1 year, including term infants without cardiac dysfunction, when analized by the kit Opus T Troponin I (cTn) test modules.OBJETIVO: Verificar os valores séricos para troponina I cardíaca em crianças abaixo de um ano de idade, sem disfunção cardíaca clínica. MÉTODOS: Os níveis séricos de troponina I cardíaca foram determinados em 99 crianças com idade abaixo de um ano, incluindo-se recém-nascidos a termo, sem doenças relacionadas a comprometimento da função cardíaca identificável clinicamente, por meio do kit específico Opus T Troponin I (cTn) (Dade Behring Inc. - Newalk, DE 19714, USA). RESULTADOS: A dosagem sérica de troponina I cardíaca apresentou, em todos os pacientes, valor menor que 0,1 ng/ml. CONCLUSÃO: Verificamos que o valor da dosagem sérica de troponina I cardíaca é menor do que 0,1 ng/ml para pacientes pediátricos, sem disfunção cardíaca, desde recém-nascidos a termo até um ano de idade, quando realizada por meio do kit Opus T Troponin I (cTn) test modules.Hospital Padre Albino UTI pediátricaUNIFESP-EPM Departamento de PediatriaUNIFESP, EPM, Depto. de PediatriaSciEL

Noise level in a pediatric intensive care unit

OBJECTIVE: The purpose of this study was to verify the noise level at a PICU. METHODS: This prospective observational study was performed in a 10 bed PICU at a teaching hospital located in a densely populated district within the city of São Paulo, Brazil. Sound pressure levels (dBA) were measured 24 hours during a 6-day period. Noise recording equipment was placed in the PICU access corridor, nursing station, two open wards with three and five beds, and in isolation rooms. The resulting curves were analyzed. RESULTS: A basal noise level variation between 60 and 70 dBA was identified, with a maximum level of 120 dBA. The most significant noise levels were recorded during the day and were produced by the staff. CONCLUSION: The basal noise level identified exceeds International Noise Council recommendations. Education regarding the effects of noise on human hearing and its relation to stress is the essential basis for the development of a noise reduction program.OBJETIVO: Verificar o nível de ruídos em uma unidade de cuidados intensivos pediátricos. MÉTODOS: Estudo observacional e prospectivo realizado em uma unidade de cuidados intensivos pediátricos de 10 leitos de um hospital universitário da cidade de São Paulo, Brasil. Os níveis de ruídos foram medidos por meio de equipamento instalado no corredor de acesso à unidade de cuidados intensivos pediátricos, posto de enfermagem, duas salas com três e cinco leitos, bem como nas unidades de isolamento. O equipamento utilizado foi calibrado para registrar a pressão do som em dBA, durante 24 horas, por 6 dias. Os dados foram analisados de acordo com as curvas gráficas registradas pelo equipamento. RESULTADOS: Foi identificado um nível basal de ruídos de 60 a 70 dBA, com pico de 120 dBA. Os níveis mais elevados foram identificados no período diurno, decorrentes da atividade e comunicação dos profissionais. CONCLUSÃO: Os níveis de ruídos identificados excederam as recomendações do International Noise Council, da Organização Mundial da Saúde. A educação sobre os efeitos prejudiciais de ruídos na audição humana e sua relação com o estresse constituem as bases para a implementação de programas de redução de ruídos.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departmento de PediatriaUNIFESP-EPM Departmento de EnfermagemUNIFESP-EPMUNIFESP, EPM, Departmento de PediatriaUNIFESP, EPM Departmento de EnfermagemUNIFESP, EPMSciEL

Post cardiac surgery In children: extubation failure predictor's

BACKGROUND AND OBJECTIVES: It is important to know the risk factors for extubation failure (EF) in children submitted to cardiac surgery in order to avoid inherent events due to reintubation (airways injury, usage of medications, cardiovascular changes) and because of prolonged ventilatory support (pneumonias, reduction of the ventilatory muscles strength). The objective of this study is to evaluate mechanical ventilation (MV) parameters, ventilatory mechanics [rapid shallow breathing index (RSBI), ventilatory muscles force [the maximum inspiratory pressure (MIP), the maximum expiratory pressure (MEP) and the load/force balance (LFB)] and blood gases before and after extubation in pediatric patients undergoing cardiac surgery. METHODS: Prospective (March 2004 to March 2006) observational cross sectional study, enrolling children submitted to cardiac surgery admitted to an university PICU hospital and considered able to be extubated. With the tracheal tube in situ and maintaining the children spontaneously breathing we evaluate: expiratory minute volume (V E), MIP and MEP. We calculated the RSBI [(RR/VT)/Weight)], LFB [15x [(3xMAP)/MIP] + 0.03 x RSBI-5], the mean airway pressure (MAP) [MAP={(PIP-PEEP)x[Ti/(Te+Ti)]}+PEEP] and the oxygenation index (OI) [OI=(FiO2 x MAP/PaO2)x100]. Arterial blood gas was collected one hour before extubation. If after 48 hours there was no need to reintubate the patient the extubation was considered successful (SE). RESULTS: 59 children were included. EF was observed in 19% (11/59). Median (QI25%-75%) for age, weight, MAP, OI, duration of MV after cardiac surgery (DMV) were respectively, 36 (12-82) months, 12 (8-20) kg, 8 (6-9), 2 (2-5), 1 (1-3) days. Median (QI25-75%) of EF in relation to SE for OI, LFB and DMV were respectively 5(3-8) versus 2(2-4), p = 0.005; [8(6-11) versus 5(4-6), p =0.002 and 3(2-5) versus 1(1-2) days, p = 0.026. Mean ± SD of EF in relation to SE for V E, PaO2 and MIP were respectively 1.7 ± 0.82 versus 3 ± 2.7 mL/kg/min, p = 0.003); 64 ± 34 versus 111 ± 50 mmHg, p = 0.002 and 53 ± 18 versus 78 ± 28 cmH2O; p=0.002. Concerning the risk factors for EF: OI > 2 (area under the ROC 0.74, p = 0.017) and LFB > 4 (area under the ROC 0.80, p = 0.002), achieved a sensibility of 100% and specificity of 80%; MIP 2, LFB > 4, DMV > 3 days; V E 2 (área 0,74, p = 0,017) e da RCF > 4 (área 0,80, p = 0,002); 80% de sensibilidade e 60% de especificidade da PiMáx 2, RCF > 4, tempo de VPM > 3 dias, V E < 1,7 mL/kg/min , PaO2 < 64 mmHg e PiMáx < - 53 cmH2O. A MAP, o diagnóstico de base, o IRS e os gases sangüíneos não estiveram relacionados com a falha da extubação.PUC-RSUNIFESP-EPMHospital São PauloPUC-RS Faculdade de MedicinaUFRGSHospital São Lucas Unidade de Terapia Intensiva PediátricaUNIFESP-EPM Faculdade de MedicinaHospital São Paulo Unidade de Cuidados Intensivos PediátricaPronto Socorro Infantil Sabará e Santa CatarinaHospital São Lucas UTIPHospital São Paulo UCIP e Semi-IntensivaHospital São Lucas UTIP Unidade de Terapia Intensiva NeonatalUNIFESP, EPMHospital São PauloUNIFESP, EPM Faculdade de MedicinaHospital São Paulo Unidade de Cuidados Intensivos PediátricaHospital São Paulo UCIP e Semi-IntensivaSciEL

Duration of mechanical ventilation and development of bronchopulmonary dysplasia

OBJECTIVE: Verify the association between duration of mechanical ventilation and development of bronchopulmonary dysplasia in neonates weighting at birth less than 1500g. METHODS: Retrospective study conducted with neonates weighting less than 1500g at birth submitted to mechanical ventilation. Neonates presenting major birth defects, transferred to other services or died before the 28th day of life were excluded from the study. Three groups were analyzed according to duration of mechanical ventilation: 1 to 7 days, 8 to 14 days and more than 15 days. The chance ratio of developing bronchopulmonary dysplasia was calculated for each group. RESULTS: From the 216 clinical histories assessed, 121 met the criteria for inclusion in the study. Mean birth weight and gestational age were 1199.8 g and 31.8 weeks. Of all neonates submitted to mechanical ventilation from 1 to 7 days, 15.5% developed bronchopulmonary dysplasia; from 8 to 14 days 60% and from more than 15 days, 88.2%; chance ratios were equal to 0.16; 11.25 and 16.36, respectively. CONCLUSION: The chance of a neonate weighting less than 1500 g developing bronchopulmonary dysplasia was 11 times higher in those submitted to mechanical ventilation for up to 14 days. This chance was even higher in those ventilated for more than 15 days. That is why the nursing staff assisting high risk patients should consider the possibility of extubating neonates during their first week of life.OBJETIVO: Verificar a associação entre o tempo de uso da ventilação mecânica e o desenvolvimento de displasia broncopulmonar em recém-nascidos com peso de nascimento 15 dias. Foi calculada a razão de chance para o desenvolvimento de displasia broncopulmonar em cada período de utilização da ventilação mecânica. RESULTADOS: Dos 216 prontuários avaliados, 121 preencheram os critérios de inclusão. As médias do peso de nascimento e idade gestacional foram de 1199,8 g e 31,8 semanas. No período de 1 a 7 dias de uso da ventilação mecânica, 15,5% dos recém-nascidos evoluíram com displasia broncopulmonar; no período de 8 a 14 dias, 60%; e no período > 15 dias, 88,2%; com razão de chance de 0,16, 11,25 e 16,36, respectivamente. CONCLUSÃO: A possibilidade de um recém-nascido com peso de nascimento < 1500 g desenvolver displasia broncopulmonar foi 11 vezes maior naqueles que permaneceram em ventilação mecânica por até 14 dias e esta chance aumentou ainda mais nos que foram ventilados por mais de 15 dias, devendo a equipe que presta atendimento ao paciente de alto risco estar empenhada na extubação dos recém-nascidos ainda na primeira semana de vida.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL

Are we doing enough to prevent methicillin-resistant Staphylococcus aureus outbreaks?

Univ São Paulo, São Paulo, BrazilUniversidade Federal de São Paulo, São Paulo, BrazilUniversidade Federal de São Paulo, EPM, São Paulo, BrazilWeb of Scienc

Cardiorespiratory repercussions of the peritoneal dialysis in critically ill children

BACKGROUND AND OBJECTIVES: Peritoneal dialysis (PD) is frequently used to replace glomerular filtration and to control acid-base, electrolyte and fluid disturbances in critically ill children with acute renal failure. However, cardiorespiratory changes can happen during this procedure. The objective of this review is to describe the PD cardio-respiratory repercutions in the pediatric patient and the evidence level of the studies that approach these repercutions. METHODS: Bibliographic revision about PD cardio-respiratory repercutions in the pediatric patient. Medline, Ovid e Lilacs databases were searched for articles from 1990 to 2007 with the following key words in Portuguese, English and Spanish: diálise peritoneal, efeitos hemodinâmicos, complicações respiratórias, complicações cardíacas, Pediatria; peritoneal dialysis, hemodynamic effects, respiratory complications, cardiac complications, Pediatric; peritoneal diálisis, efecto hemodinámico, complicaciones respiratorias, complicaciones cardiacas, Pediatria. The retrieved articles were classified according to Cook et al. 1992. RESULTS: Thirteen articles were retrieved, 8 of them were about cardiorespiratory repercussions and five approached respiratory repercussions of PD. These studies evaluated 178 critically ill patients, from newborns to adolescents. Among the respiratory repercutions during PD the most frequent ones were decrease of the pulmonary compliance and arterial oxygen partial pressure and increase of airway resistance and carbon dioxide partial pressure; after the infusion of PD fluid the studies pointed out an increased arterial oxygen partial pressure/ inspired oxygen fraction relation and diminution of the alveolar-arterial difference and oxygenation index. Increase of the mean arterial pressure, pulmonary artery pressure, right and left atrial pressure and systemic vascular resistance and, reduction of the central venous pressure were the described cardio-circulatory repercutions during PD. CONCLUSIONS: Pulmonary volumes, gas exchange and cardio-circulatory alterations are the most frequent complications during and after PD in the pediatric patient. Therefore critically ill pediatric patients with acute renal failure needing PD should be monitored during and after this procedure to avoid clinical deterioration and to educate the multi-professional team.JUSTIFICATIVA E OBJETIVOS: A diálise peritoneal (DP) é um procedimento freqüentemente indicado para crianças graves com insuficiência renal aguda, sua finalidade é substituir a filtração glomerular e melhorar o controle do equilíbrio hidroeletrolítico e ácido-básico. Entretanto, podem ocorrer alterações cardiorrespiratórias durante o procedimento. Desta forma, o objetivo deste estudo foi descrever as repercussões cardiorrespiratórias da DP em Pediatria e o nível de evidência dos estudos que abordam as repercussões. MÉTODO: Revisão bibliográfica de artigos que abordassem as repercussões cardiorrespiratórias da DP em Pediatria. Pesquisa nos bancos de dados Medline, Ovid e Lilacs, analisando artigos publicados entre 1990 e 2007, com as seguintes palavras-chave, nos idiomas português, inglês e espanhol, respectivamente: diálise peritoneal, efeitos hemodinâmicos, complicações respiratórias, complicações cardíacas, Pediatria; peritoneal dialysis, hemodynamic effects, respiratory complications, cardiac complications, Pediatric; peritoneal diálisis, efecto hemodinámico, complicaciones respiratorias, complicaciones cardiacas, Pediatria. Os artigos encontrados foram classificados em nível de evidências segundo Cook e col. 1992. RESULTADOS: Foram encontrados 13 artigos, sendo que oito deles abordaram as repercussões cardiocirculatórias e cinco abordaram as repercussões no sistema respiratório da DP. Esses estudos avaliaram pacientes na faixa etária de recém-nascidos a adolescentes graves, totalizando 178 crianças. Dentre as complicações respiratórias mais freqüentes durante a DP encontrou-se a redução da complacência pulmonar e da pressão parcial arterial de oxigênio, aumento da resistência das vias aéreas e da pressão parcial arterial de gás carbônico; após a infusão de fluído na DP os estudos demonstraram um aumento da relação entre a pressão parcial e a fração inspirada de oxigênio, diminuição da diferença alvéolo-arterial de oxigênio e do índice de oxigenação. Dentre as complicações cardiocirculatórias, foram descritas que durante a DP ocorreu um aumento da pressão arterial média, pressão de artéria pulmonar, pressão atrial direita e esquerda, redução da pressão venosa central e aumento da resistência vascular sistêmica. CONCLUSÕES: A alteração dos volumes pulmonares, das trocas gasosas e cardiocirculatórias são as repercussões mais freqüentes durante e após a DP em Pediatria. Portanto, as crianças graves com IRA e em DP devem ser monitoradas durante e após este procedimento, para se evitar a piora clínica e para orientação das intervenções multiprofissionais

Value of clinical pulmonary infection score in critically ill children as a surrogate for diagnosis of ventilator-associated pneumonia

Rationale: Although the modified clinical pulmonary infection score (mCPIS) has been endorsed by national organizations, only a very few pediatric studies have assessed it for the diagnosis of ventilator-associated pneumonia (VAP).Methods: Seventy children were prospectively included if they fulfilled the diagnosis criteria for VAP referenced by the Centers for Disease Control and Prevention. the primary outcome was performance of mCPIS calculated on day 1 to accurately identify VAP as defined by microbiological data.Results: the data showed that an mCPIS of 6 or higher had a sensitivity of 94%, specificity of 50%, positive predictive value of 64%, negative predictive value of 90%, a positive likelihood ratio of 1.88, and a negative likelihood ratio of 0.11. the area under the receiver operating characteristic curve was 0.70. A positive posttest result increased the disease probability by 15.4%, whereas a negative test result reduced the probability by 38.6%. Patients with an mCPIS of 6 or higher had longer length of mechanical ventilation and pediatric intensive care unit stay compared with patients with an mCPIS lower than 6.Conclusion: the mCPIS had a clinically acceptable performance, and it can be a helpful screening tool for VAP diagnosis. An mCPIS lower than 6 was highly able in distinguishing patients without VAP. Despite its high sensitivity and negative predictive value of this score, further studies are required to assess the use of mCPIS in guiding therapeutic decisions. (C) 2014 Elsevier Inc. All rights reserved.Hosp Servidor Publ Municipal, Pediat Intens Care Unit, Dept Pediat, BR-01532900 São Paulo, BrazilUniv São Paulo, Pediat Intens Care Unit, São Paulo, BrazilUniv São Paulo, Dept Neonatol, São Paulo, BrazilUniv São Paulo, Childrens Inst, Fac Med Clin Hosp, São Paulo, BrazilUniversidade Federal de São Paulo, Pediat Intens Care Unit, Dept Pediat, São Paulo, BrazilUniversidade Federal de São Paulo, Pediat Intens Care Unit, Dept Pediat, São Paulo, BrazilWeb of Scienc

Functional capacity after pediatric liver transplantation: A pilot study

The prospective cross-sectional study investigated the 6MWT performance in pediatric group of liver transplant recipients (6-17 yr, median post-transplantation time of 22 months) and compared to the normal values obtained in healthy children as well as evaluated the reproducibility of the 6MWT. We analyzed the relationship between walked distance and the 6MWw, distance walked x body weight) with the anthropometric, clinical, and pulmonary functions. in post-transplanted group, the average walked distance was significantly shorter compared with control (687 +/- 80 m vs. 511 +/- 72 m, p < 0.001). the calculated ICC coefficient confirmed the reproducibility among tests. the Pearson correlation revealed that only walked distance in the 6MWT was moderately correlated with tidal volume. Conversely, the 6MWw was significantly correlated with age, weight, height, BMI, FVC, PEF rate, and volume expiratory. According to multiple regression analysis, age, VE and FVC factors explained 80% of the variance in the 6MWw. in conclusion, the pediatric liver transplant recipients' performance in the 6MWT is significantly lower than the values for healthy children of the same age. Notably, the 6MWw may provide relevant information, constituting an additional parameter in the determination of functional capacity.Universidade Federal de São Paulo UNIFESP, Dept Pediat, BR-04304000 São Paulo, BrazilUniv São Paulo, Sch Med, Intens Care Neonatol Childrens Inst, São Paulo, BrazilUniversidade Federal de São Paulo UNIFESP, Dept Pharmacol, BR-04304000 São Paulo, BrazilUniversidade Federal de São Paulo UNIFESP, Dept Surg, Div Pediat Liver Transplantat, BR-04304000 São Paulo, BrazilUniversidade Federal de São Paulo UNIFESP, Dept Pediat, BR-04304000 São Paulo, BrazilUniversidade Federal de São Paulo UNIFESP, Dept Pharmacol, BR-04304000 São Paulo, BrazilUniversidade Federal de São Paulo UNIFESP, Dept Surg, Div Pediat Liver Transplantat, BR-04304000 São Paulo, BrazilWeb of Scienc

Early Empiric Antibiotic Use Is Associated With Delayed Feeding Tolerance in Preterm Infants: A Retrospective Analysis

The causative factors of neonatal feeding intolerance are poorly understood, but potentially related to clinical practices such as empiric antibiotic usage. The objective of this study was to evaluate whether early empiric antibiotic exposure negatively affects preterm infants' enteral feeding tolerance. Data from infants without risk factors for sepsis, 500 to 1499 g birth weight and 24 to 34 weeks gestational age were analyzed. The primary outcomes were the empiric antibiotic exposure effects on the infants' total parenteral nutrition usage duration and prevalence of necrotizing enterocolitis (NEC). Among the 901 infants included, 67 were exposed to early empiric antibiotic. A 50% increase in parenteral nutrition usage duration and a 4-fold greater prevalence of NEC was seen in the early empiric antibiotic-exposed neonates, when compared with control infants (P<0.01). Early empiric antibiotic exposure appears to negatively influence preterm infant feeding tolerance and possibly contributes to NEC.Brazilian Ministry of HealthUniv Sao Paulo, Fac Med Ribeirao Preto, Sao Paulo, BrazilUniv Sao Paulo, Fac Med Sau Paulo, Sao Paulo, BrazilUniv Fed Sao Paulo, Escola Paulista Med, Sao Paulo, BrazilInst Med Integral Prof Fernando Figueira IMIP, Recife, PE, BrazilUniv Fed Maranhao, Hosp Univ, Sao Luis, BrazilUniv Estadual Campinas, Fac Ciencias Med, Sao Paulo, BrazilUNESP, Fac Med Botucatu, Botucatu, SP, BrazilFiocruz MS, Inst Fernandes Figueira, Rio De Janeiro, BrazilPUC Porto Alegre, Fac Med, Porto Alegre, RS, BrazilUniv Fed Rio Grande do Sul, Porto Alegre, RS, BrazilUniv Estado Rio De Janeiro, Rio De Janeiro, BrazilUniv Fed Minas Gerais, Belo Horizonte, MG, BrazilUniv Fed Uberlandia, Uberlandia, MG, BrazilFac Ciencias Med Minas Gerais, Belo Horizonte, MG, BrazilUniv Sao Paulo, Hosp Univ, Sao Paulo, BrazilHosp Estadual Sumare, Sumare, BrazilHosp Geral Pirajussara, Taboao De Serra, BrazilHosp Estadual Diadema, Diadema, BrazilUniv Estadual Londrina, Londrina, BrazilUniv Fed Parana, Curitiba, Parana, BrazilUniv Toronto, Toronto, ON, CanadaUniv Fed Sao Paulo, Escola Paulista Med, Sao Paulo, BrazilBrazilian Ministry of HealthWeb of Scienc