Avaliacao do uso da mistura de helio e oxigenio no estudo da ventilacao de criancas com doenca pulmonar obstrutiva cronica

Objetivo: estudar a distribuição do radioaerossol 99m-Tc-DTPA quando o Heliox é utilizado como veículo de nebulização na cintilografia pulmonar ventilatória de crianças e adolescentes com diagnóstico de doença pulmonar obstrutiva crônica. Tipo de estudo: ensaio clínico randomizado e controlado. Material e métodos: entre março de 1996 e setembro de 1998, foram incluídos neste estudo todas as crianças e adolescentes, entre 5 e 18 anos, em acompanhamento pela Unidade de Pneumologia Pediátrica do Hospital de Clínicas de Porto Alegre (HCPA), com diagnóstico de doença pulmonar obstrutiva crônica e que necessitassem realizar cintilografia pulmonar ventilatória. Concomitante ao estudo cintilográfico foi realizado o estudo da função pulmonar (espirometria). Neste estudo, foi definido como obstrução ao fluxo aéreo quando os pacientes apresentassem um Coeficiente Expiratório Forçado no 1° segundo (CEF1) inferior a 0,75, e um índice no Fluxo Expiratório Forçado a 75% sobre a Capacidade Vital Forçada (FEF15/ CVF) inferior a 0,25. Os pacientes foram alocados de forma aleatória em dois grupos: Heliox (Hélio 80% e Oxigênio 20%), ou Oxigênio, de acordo com veículo utilizado na nebulização do radioaerossol 99mTc-DTPA na cintilografia pulmonar ventilatória. Os resultados da cintilografia foram expressos através do slope, ou inclinação da curva de aquisição cumulativa de radioatividade pulmonar, e pela concentração cumulativa máxima de radioatividade obtida nos campos pulmonares. Foi determinado, ainda, por difração de raios laser, o tamanho médio das partículas de 99mTcDTPA geradas quando se utilizou Heliox e Oxigênio como veículos da nebulização. Os grupos foram comparados entre si, elegendo-se como di ferença significativa um valor de "p" inferior a 0,05. As variáveis contínuas foram expressas através das médias e desviospadrão (±DP), e comparadas através do teste T de Student. As variáveis categóricas foram expressas em percentagem (%) ou sob a forma descritiva e comparadas pelo teste Quiquadrado, usando a correção de Yates ou teste exato de Fischer, quando necessário. Resultados: foram alocados dez pacientes em cada grupo, não havendo diferença entre eles no que se refere à distribuição de sexo, diagnósticos etiológicos e presença de desnutrição. As médias de peso, altura, superfície corpórea, assim como os resultados da espirometria nos grupos Heliox e Oxigênio, também não apresentaram diferenças estatisticamente significativas (p>0,05). Dos 20 pacientes participantes do estudo, dez apresentavam na espirometria uma redução do CEF1 e do FEF15/ CVF, definidos como tendo obstrução ao fluxo aéreo. Destes, 6 estavam no grupo do Heliox, e 4 no grupo do Oxigênio. O grupo Heliox apresentou uma média dos slopes de 5.039 (±1.652), que foi significativamente maior (p=0,018) que a média dos slopes do grupo do Oxigênio (3.410 ± 1.1 00). Os pacientes do grupo Heliox com redução do CEF 1 e do FEF1sl CVF apresentaram uma concentração cumulativa de radiação nos campos pulmonares (2.755.891 ±.80 1.859 contagens) significativamente maior (p0.05). Of the 20 patients included in the study, 10 had reduction in the CEF1 and in the FEF75/ CVF index ofthe pulmonary function study, and were classified as having airway obstruction flow. Six ofthem were in the Heliox group and 4 in the Oxygen group. The mean slope in the Heliox group was 5,039 (±.1,652), with a significant difference (p=0.018) when compared to the mean slope ofthe Oxygen group (3,410 ±1,100). The patients with reduction at the CEF1 and FEF75/ CVF index in the Heliox group obtained a mean cumulative radiation in the lung fields of 2,755,891 ±801,859 counts, and showed a significant difference (p<0.05) when compared to the patients of the same group without reduction at the CEF 1 and FEF1sl CVF index (1,598,075 ±675,310 counts). The patients with reduction at the CEF, and FEF1sl CVF index in the Heliox group obtained a mean slope of 5.697 ±1.365, and showed a significant difference (p=0.017) when compared to the mean slope ofthe patients with reduction at the CEF1 and FEF75/ CVF index in the Oxygen group (3,467 ±651). The patients of the Oxygen group with and without airway obstruction flow in the pulmonary function study did not show any difference when they were compared on the basis of either the means of the slopes (p=0.903) or the means ofthe cumulative radiation in the lung fields (p=0.960). The patients o f the Heliox group and Oxygen group without airway obstruction flow at the pulmonary function study did not show any statistical difference when the were compared on the basis of either the means of the slopes (p= 0.507) or the means of the cumulative radiation in the lung fields (p=O. 795). The mean diameter of the parti eles o f 99mTc- DTP A generated when Heliox was used at a flow of 10 liters by minute as a vehicle of the scintigraphic study was 2.13 (±0.62J..L), with a statistical difference (p=0.004) when compared with the mean diameter o f the parti eles generated when Oxygen was used as a vehicle (0,88 ±0,99 J.l). Conclusions: When Heliox was used as a vehicle of radioaresol of 99mTc-DTP~ in the Scintigraphic study of children and adolescents with chronic obstructive lung disease, it showed a better distribution o f the 99mTc-DTPA and in the radiation activity into the lungs than that obtained when Oxygen was used. The benefits of Heliox over Oxygen in the capacity of inhaling parti eles are more evident in the presence of lower airway obstruction flow. When Oxygen and Heliox were used as a vehicle to inhale radioactive particles in patients without airway obstruction we could not demonstrate any difference in the distribution and in the radiation activity into the lungs. The mean diameters ofthe particles o f 99mTc-DTPA generated by Heliox and Oxygen showed a significant difference. In spite of this, the mean diameters observed in both groups were included in the recornmended range (between I and 5 u). Therefore, the observed differences between the particles generated by both gases could notjustify the effects ofHeliox demonstrated in this study

Choque séptico em pediatria : o estado da arte

Objective Review the main aspects of the definition, diagnosis, and management of pediatric patients with sepsis and septic shock. Source of data A search was carried out in the MEDLINE and Embase databases. The articles were chosen according to the authors' interest, prioritizing those published in the last five years. Synthesis of data Sepsis remains a major cause of mortality in pediatric patients. The variability of clinical presentations makes it difficult to attain a precise definition in pediatrics. Airway stabilization with adequate oxygenation and ventilation if necessary, initial volume resuscitation, antibiotic administration, and cardiovascular support are the basis of sepsis treatment. In resource-poor settings, attention should be paid to the risks of fluid overload when administrating fluids. Administration of vasoactive drugs such as epinephrine or norepinephrine is necessary in the absence of volume response within the first hour. Follow-up of shock treatment should adhere to targets such as restoring vital and clinical signs of shock and controlling the focus of infection. A multimodal evaluation with bedside ultrasound for management after the first hours is recommended. In refractory shock, attention should be given to situations such as cardiac tamponade, hypothyroidism, adrenal insufficiency, abdominal catastrophe, and focus of uncontrolled infection. Conclusions The implementation of protocols and advanced technologies have reduced sepsis mortality. In resource-poor settings, good practices such as early sepsis identification, antibiotic administration, and careful fluid infusion are the cornerstones of sepsis management.Objetivo Revisar os principais aspectos da definição, diagnóstico e manejo do paciente pediátrico com sepse e choque séptico. Fontes de dados Uma pesquisa nas plataformas de dados Medline e Embase foi feita. Os artigos foram escolhidos segundo interesse dos autores, priorizaram-se as publicações dos últimos 5 anos. Síntese dos dados A sepse continua a ser uma causa importante de mortalidade em pacientes pediátricos. A variabilidade de apresentação clínica dificulta uma definição precisa em pediatria. A estabilização da via aérea com adequada oxigenação, e ventilação se necessário, ressuscitação volêmica inicial, administração de antibióticos e suporte cardiovascular são a base do tratamento da sepse. Em cenários de poucos recursos, deve-se atentar para os riscos de sobrecarga hídrica na administração de fluidos. A administração de drogas vasoativas como adrenalina ou noradrenalina, se faz necessária na ausência da resposta ao volume na primeira hora. O seguimento do tratamento do choque deve seguir alvos como restauração dos sinais vitais e clínicos de choque e controle do foco de infecção. Recomenda-se a avaliação multimodal, com auxílio da ecografia à beira-leito para manejo após as primeiras horas. No choque refratário, deve-se atentar para situações como tamponamento cardíaco, hipotireoidismo, insuficiência adrenal, catástrofe abdominal e foco de infecção não controlado. Conclusões Implantação de protocolos e avançadas tecnologias propiciou uma redução da mortalidade da sepse. Em cenários de poucos recursos, as boas práticas, como reconhecimento precoce da sepse, administração de antibióticos e cuidadosa infusão de fluidos, são os pilares do manejo da sepse

Two-thumb technique is superior to two- finger technique in cardiopulmonary resuscitation of simulated out-of- hospital cardiac arrest in infants

BACKGROUND: To compare the 2-finger and 2-thumb chest compression techniques on infant manikins in an out-of- hospital setting regarding efficiency of compressions, ventilation, and rescuer pain and fatigue. METHODS AND RESULTS: In a randomized crossover design, 78 medical students performed 2 minutes of cardiopulmonary resuscitation with mouth-to- nose ventilation at a 30:2 rate on a Resusci Baby QCPR infant manikin (Laerdal, Stavanger, Norway), using a barrier device and the 2-finger and 2-thumb compression techniques. Frequency and depth of chest compressions, proper hand position, complete chest recoil at each compression, hands-off time, tidal volume, and number of ventilations were evaluated through manikin-embedded SkillReporting software. After the interventions, standard Likert questionnaires and analog scales for pain and fatigue were applied. The variables were compared by a paired t-test or Wilcoxon test as suitable. Seventy-eight students participated in the study and performed 156 complete interventions. The 2-thumb technique resulted in a greater depth of chest compressions (42 versus 39.7 mm; P<0.01), and a higher percentage of chest compressions with adequate depth (89.5% versus 77%; P<0.01). There were no differences in ventilatory parameters or hands-off time between techniques. Pain and fatigue scores were higher for the 2-finger technique (5.2 versus 1.8 and 3.8 versus 2.6, respectively; P<0.01). CONCLUSIONS: In a simulation of out-of- hospital, single-rescuer infant cardiopulmonary resuscitation, the 2-thumb technique achieves better quality of chest compressions without interfering with ventilation and causes less rescuer pain and fatigue

Da Conferência Internacional de Sepse em Pediatria 2005 ao Consenso Sepsis-3

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Airway resistance and respiratory compliance in children with acute viral bronchiolitis requiring mechanical ventilation support

Background: Acute viral bronchiolitis (AVB) is a very frequent disease that affects the lower airways of young children increasing the inspiratory and expiratory resistance in variable degree as well as reducing the pulmonary compliance. It would be desirable to know whether these variables are associated with the outcome. Objectives: To evaluate the respiratory mechanics in infants with AVB requiring mechanical ventilation (MV) support and to evaluate if respiratory mechanics predict outcomes in children with AVB supported on MV. To evaluate the respiratory mechanics in infants with AVB submitted to MV. Materials and methods: A prospective observational study was conducted in two pediatric intensive care units (PICUs) between February 2016 and March 2017. Included were infants (1 month to 1 year old) admitted with AVB and requiring MV for >48 hours. Auto-PEEP, dynamic compliance (Cdyn), static compliance (Cstat), expiratory resistance (ExRes), and inspiratory resistance (InRes) were evaluated once daily on the second and third day of MV. Results: A total of 64 infants (median age of 2.8 months and a mean weight of 4.8 ± 1.7 kg) were evaluated. A mean positive inspiratory pressure (PIP) of 31.5 ± 5.2 cmH2O, positive end-expiratory pressure (PEEP) of 5.5 ± 1.4 cmH2O, resulting in a mean airway pressure (MAP) of 12.5 ± 2.2 cmH2O and delta pressure of 22.5 ± 4.4 cmH2O without difference between the two hospitals. Measurements of respiratory mechanics showed high values of InRes and ExRes (median 142 [IQ25–75 106–180] cmH2O/L/s and 158 [IQ25–75 130–195.3] cmH2O/L/s, respectively), accompanied by decreased Cdyn and Cstat (0.46 ± 0.19 and 0.81 ± 0.25 mL/kg/cmH2O, respectively). None of the variables was associated with mortality, length of MV, or length of PICU stay. Conclusion: Infants with AVB requiring MV support present very high InRes and ExRes values. These findings might be the reason for the aggressive ventilatory parameters, especially PIP, required to ventilate this group of children with lower airway obstruction. Clinical significance: Monitoring respiratory mechanics could represent a useful tool to guide the ventilatory strategy to be adopted in patients with AVB

Epidemiology and outcomes of septic shock in children with complex chronic conditions in a developing country PICU

Objective To investigate the role of Complex Chronic Conditions (CCCs) on the outcomes of pediatric patients with refractory septic shock, as well as the accuracy of PELOD-2 and Vasoactive Inotropic Score (VIS) to predict mortality in this specific population. Methods This is a single-center, retrospective cohort study. All patients diagnosed with septic shock requiring vasoactive drugs admitted to a 13-bed PICU in southern Brazil, between January 2016 and July 2018, were included. Clinical and demographic characteristics, presence of CCCs and VIS, and PELOD-2 scores were accessed by reviewing electronic medical records. The main outcome was considered PICU mortality. Results 218 patients with septic shock requiring vasoactive drugs were identified in the 30-month period and 72% of them had at least one CCC. Overall mortality was 22%. Comparing to patients without previous comorbidities, those with CCCs had a higher mortality (26.7% vs 9.8%; OR = 3.4 [1.3–8.4]) and longer hospital length of stay (29.3 vs 14.8; OR 2.39 [1.1- 5.3]). Among the subgroups of CCCs, “Malignancy” was particularly associated with mortality (OR = 2.3 [1.0–5.1]). VIS and PELOD-2 scores in 24 and 48 hours were associated with mortality and a PELOD-2 in 48 hours > 8 had the best performance in predicting mortality in patients with CCC (AUROC = 0.89). Conclusion Patients with CCCs accounted for the majority of those admitted to the PICU with septic shock and related to poor outcomes. The high prevalence of hospitalizations, use of resources, and significant mortality determine that patients with CCCs should be considered a priority in the healthcare system

Estrangulamento acidental em crianças por fechamento automático de vidro de carro

Among the main causes of death in our country are car accidents, drowning and accidental burns. Strangulation is a potentially fatal injury and an important cause of homicide and suicide among adults and adolescents. In children, its occurrence is usually accidental. However, in recent years, several cases of accidental strangulation in children around the world have been reported. A 2-year-old male patient was strangled in a car window. The patient was admitted to the pediatric intensive care unit with a Glasgow Coma Scale score of 8 and presented with progressive worsening of respiratory dysfunction and torpor. The patient also presented acute respiratory distress syndrome, acute pulmonary edema and shock. He was managed with protective mechanical ventilation, vasoactive drugs and antibiotic therapy. He was discharged from the intensive care unit without neurological or pulmonary sequelae. After 12 days of hospitalization, he was discharged from the hospital, and his state was very good. The incidence of automobile window strangulation is rare but of high morbidity and mortality due to the resulting choking mechanism. Fortunately, newer cars have devices that stop the automatic closing of the windows if resistance is encountered. However, considering the severity of complications strangulated patients experience, the intensive neuro-ventilatory and hemodynamic management of the pathologies involved is important to reduce morbidity and mortality, as is the need to implement new campaigns for the education of parents and caregivers of children, aiming to avoid easily preventable accidents and to optimize safety mechanisms in cars with electric windows

Avaliação do procedimento de intubação traqueal em unidades de referência de terapia intensiva pediátricas e neonatais

OBJETIVO: Descrever a taxa de sucesso e os fenômenos associados ao procedimento de intubação traqueal em duas unidades de terapia intensiva neonatais e duas pediátricas de Porto Alegre. MÉTODOS: Estudo transversal, com etapas retrospectiva e prospectiva, em que foram avaliadas todas as intubações ocorridas durante 6 meses em quatro unidades selecionadas. Realizou-se revisão padronizada de prontuários e entrevista com os médicos responsáveis, para caracterizar o procedimento de intubação. Utilizou-se o teste t para variáveis contínuas com distribuição normal, Mann-Whitney para distribuição assimétrica e o qui-quadrado para variáveis categóricas, com p OBJECTIVE: To describe intubation procedures in two pediatric and two neonatal intensive care units in the city of Porto Alegre. METHODS: Cross-sectional study divided into a retrospective and a prospective phase. All intubations performed in these units during a 6-month period were considered. Data were collected by interviewing the physician responsible for the procedure and reviewing the patients' charts, including drugs administered, sedation status, number of attempts, difficulties and complications during the procedure. Data were analyzed using the t test and the Mann-Whitney test for continuous variables and chi-square test for categorical variables, considering a p < 0.05. RESULTS: Sedatives were administered in 89.5% of the 134 pediatric procedures and 24% of the 116 neonatal procedures (p < 0.001). Muscle relaxants were prescribed for 3% of the children and 0.9% of the neonates. Only 53.7% of the children and 31.9% of the neonates were considered as adequately relaxed. The children who were inadequately relaxed had more intubations attempts (2.4&plusmn;1.3 vs 1.7&plusmn;1.2 p = 0.001), became more hypoxemic (20.9 vs 5.5% p = 0.015) and were more difficult to intubate (54.8 vs 25% p < 0.001). There were more urgent cases and more intubations attempts (2&plusmn;1.2 vs 1.5&plusmn;0.9 p = 0.036) among the inadequately relaxed neonates. Difficulties and complications occurred in 38.8 and 28.3% of the pediatric cases and 29 and 12% of the neonatal cases, respectively. CONCLUSIONS: There was no established routine for intubation procedures in the units studied, and the use of muscle relaxants was not usual. The absence of adequate muscle relaxation is associated with more intubation attempts, difficulties and hypoxemia during the intubation procedure

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