Diagnóstico e conduta de sepse em crianças de hospital de referência de 2016 e 2017 / Diagnosis and management of sepsis in children from a referral hospital in 2016 and 2017

A sepse é definida pela presença de disfunção orgânica ameaçadora à vida secundária a resposta desregulada do organismo a determinada infecção(SINGER et al,2016). Atualmente, os critérios para seu diagnóstico, estabelecidos no Sepse-3(2016) e Sepse-4(2017), dependem da pontuação de dois ou mais pontos no escore SOFA (Sequential Organ Failure Assessment), que leva em consideração os quadros respiratórios, coagulativo, hepático, cardiovascular, renal e do sistema nervoso central do paciente. Esses quadros são avaliados através de marcadores clínicos e laboratoriais, respectivamente o coeficiente entre a pressão parcial de oxigênio (PaO2) sobre a fração inspirada de oxigênio (FiO2), contagem de plaquetas, bilirrubina, creatinina ou débito urinário e escala de coma de Glasgow (SINGER et al,2016).Nos neonatos os parâmetros são diferentes devido a suas diferenças fisiológicas, nesses casos o diagnóstico é dado pela presença de taquipneia, taquicardia, instabilidade térmica,hipotensão na ausência de desidratação e alterações nas contagens de glóbulos brancos(BIBI et al, 2012). Apesar desses critérios não serem completamente aceitos na comunidade científica(CARNEIRO;GOMES;POVOA,2017), seu uso na prática hospitalar parece apresentar maiores benefícios na acurácia diagnóstica quando comparados aos critérios antecessores (BESEN et al,2016) razão pela qual será o critério adotado nesta pesquisa.Em relação ao choque séptico, trata-se de uma evolução do quadro, na qual anormalidades graves circulatórias, celulares e metabólicas estão associadas com maior risco de mortalidade(MARTIN, 2016), sendo seu diagnóstico em crianças problemático pois o choque em si tende a ocorrer muito antes do início da hipotensão, sendo esta indicativa de choque descompensado. Assim,o choque séptico deve ser caracterizado prioritariamente pela taquicardia (que pode estar ausente em pacientes com hipotermia) com redução da perfusão periférica ou oligúria (GOLDSTEIN; GIROIR;RANDOLPH, 2005).No atendimento clínico deve-se atentar aos sinais de complicações da sepse, como: presença de delirium e alterações nos reflexos, pois podem acusar comprometimento neurológico, o tempo de preenchimento vascular, indicativo de choque séptico, e manchas brancas na pele, que pode ser preditivo de choque séptico, pois indica hipoperfusão (POSTELNICU; EVANS, 2017).Achados clínicos presentes na sepse podem contemplar petéquias e púrpuras, quando houver instabilidade hemodinâmica, febre, tosse, e hipoxemia em casos de leucocitose e infiltrados pulmonares, ou abdome distendido timpânico com febre e leucocitose, associado a perfuração intestinal (GOLDSTEIN; GIROIR; RANDOLPH, 2005).Para a confirmação da sepse deve-se fazer a hemocultura, porém devido à necessidade de uma ação rápida pode-se utilizar outros exames complementares que ajudam a confirmar a sepse como:hemograma completo com contagem de plaquetas, PCR, procalcitonina e citocinas (EDWARDS;BAKER, 2004).O hemograma é utilizado para avaliar quantidade de linfócitos e neutrófilos, entretanto o hemograma é mais útil para excluir a possibilidade de sepse do que para confirmar a mesma (POLIN, 2012).O PCR encontra-se aumentado em reações inflamatórias como a sepse, é um exame altamente sensível porém pouco específico, os níveis de PCR podem ser utilizados para acompanhar a eficiência da terapia antibiótica (MUKHERJEE et al., 2015).A procalcitonina é liberada em resposta a toxinas bacterianas, diversos estudos mostraram que ela pode ser utilizada para detectar infecções bacterianas graves em crianças febris (MANIACI et al., 2008),As taxas de mortalidade por sepse são influenciadas por diversos fatores, tais como o quadro clínico na admissão, o agente etiológico envolvido na doença, presença ou não de choque séptico,presença ou não de disfunção de mais de dois órgãos e a presença de comorbidade. Dos fatores de risco para óbito por sepse destaca-se a presença de complicações durante a internação e envolvimento de dois ou mais órgãos pela infecção, isto demonstra a importância de uma terapêutica precoce no prognóstico do paciente aplicando antibióticos de forma empírica tomando como base as bactérias de maior prevalência na região (PEDRO; MORCILLO; BARACAT, 2015).Portanto, pretende-se avaliar as condições de admissão e desfecho de internamento das crianças com sepse, analisando a influência de fatores como a forma de diagnóstico, o tempo de permanência hospitalar,a admissão em UTI e tratamento empregado no prognóstico do paciente visando estabelecer fatores que contribuíram e prejudicaram a evolução do paciente séptico

Tempo de permanência de crianças diagnosticadas com sepse em UTI e estudo dos dispositivos usados nesses pacientes. / Length of stay of children diagnosed with sepsis in ICU and study of the devices used in these patients.

A sepse é definida pela presença de disfunção orgânica ameaçadora à vida secundária a resposta desregulada do organismo a determinada infecção. Caso não haja um tratamento adequado da sepse inicialmente pode haver evolução para choque séptico. Pacientes com sepse geralmente requerem internação na unidade de terapia intensiva (UTI). Através desse estudo conclui-se que o óbito causado por sepse bem como a taxa de incidência da doença pode ocorrer em pacientes mais jovens. Além de 100% dos óbitos terem ocorrido no grupo de recém-nascidos, a incidência da doença é drasticamente mais prevalente em crianças mais jovens: 67% dos pacientes eram recém nascidos e apenas 31% era lactente e 1% era pré-escolar

Cannabis Medicinal no gerenciamento do TDAH: desafios enfrentados

INTRODUCTION: Attention deficit hyperactivity disorder is a disease characterized by lack of concentration, hyperactivity and impulsivity and disorganization. Treated through medication therapy and psychotherapy. OBJECTIVES: Address the challenges faced by patients with ADHD who use cannabis. METHODS: Integrative review, carried out based on the guiding question: "What are the main challenges faced by medicinal cannabis in people with Attention Deficit Hyperactivity Disorder?", through articles in Portuguese and English, published between 2018 and 2023, originating from the MEDLINE, HomeoIndex, IBECS databases. Data collection took place in September 2023 RESULTS: The sample consisted of 7 articles, which denoted two nuclei: Self-medication and related difficulties in individuals diagnosed with ADHD; Medicinal Cannabis and challenges faced. CONCLUSION: It is understood that there is a lack of research related to the subject addressed, which is why many patients resort to the use of cannabis, which is why early identification of the disease is necessary, in order to be able to treat it in the best possible way. way, with proven scientific methods.INTRODUÇÃO: O Transtorno de déficit de atenção e hiperatividade é uma doença caracterizada pela falta de concentração, hiperatividade e impulsividade e desorganização. Tratada por meio de terapia medicamento e psicoterapia. OBJETIVOS: Abordar os desafios enfrentados em pacientes com TDAH que fazem uso do cannabis. MÉTODOS: Revisão integrativa, realizada com base na pergunta norteadora: "Quais os principais desafios enfrentados do cannabis medicinal em pessoas com Transtorno de Déficit de Atenção e Hiperatividade?”, através de artigos em língua portuguesa e inglesa, publicados no período de 2018 a 2023, originados das bases de dados MEDLINE, HomeoIndex, IBECS. Realizou-se a coleta de dados em setembro de 2023 RESULTADOS: A amostra foi constituída por 7 artigos, que denotaram dois núcleos: Automedicação e dificuldades relacionadas em indivíduos diagnosticados com TDAH; Cannabis Medicinal e desafios enfrentados. CONCLUSÃO: Entende-se que, há escassez de pesquisas relacionadas ao assunto abordado, por isso muitos pacientes recorrem ao uso da cannabis, por isso faz-se necessário uma identificação precoce da doença, para assim poder tratá-la da melhor maneira, com métodos científicos comprovados

Patients with Crohn's disease have longer post-operative in-hospital stay than patients with colon cancer but no difference in complications' rate

BACKGROUNDRight hemicolectomy or ileocecal resection are used to treat benign conditions like Crohn's disease (CD) and malignant ones like colon cancer (CC).AIMTo investigate differences in pre- and peri-operative factors and their impact on post-operative outcome in patients with CC and CD.METHODSThis is a sub-group analysis of the European Society of Coloproctology's prospective, multi-centre snapshot audit. Adult patients with CC and CD undergoing right hemicolectomy or ileocecal resection were included. Primary outcome measure was 30-d post-operative complications. Secondary outcome measures were post-operative length of stay (LOS) at and readmission.RESULTSThree hundred and seventy-five patients with CD and 2,515 patients with CC were included. Patients with CD were younger (median = 37 years for CD and 71 years for CC (P < 0.01), had lower American Society of Anesthesiology score (ASA) grade (P < 0.01) and less comorbidity (P < 0.01), but were more likely to be current smokers (P < 0.01). Patients with CD were more frequently operated on by colorectal surgeons (P < 0.01) and frequently underwent ileocecal resection (P < 0.01) with higher rate of de-functioning/primary stoma construction (P < 0.01). Thirty-day post-operative mortality occurred exclusively in the CC group (66/2515, 2.3%). In multivariate analyses, the risk of post-operative complications was similar in the two groups (OR 0.80, 95%CI: 0.54-1.17; P = 0.25). Patients with CD had a significantly longer LOS (Geometric mean 0.87, 95%CI: 0.79-0.95; P < 0.01). There was no difference in re-admission rates. The audit did not collect data on post-operative enhanced recovery protocols that are implemented in the different participating centers.CONCLUSIONPatients with CD were younger, with lower ASA grade, less comorbidity, operated on by experienced surgeons and underwent less radical resection but had a longer LOS than patients with CC although complication's rate was not different between the two groups

NEOTROPICAL CARNIVORES: a data set on carnivore distribution in the Neotropics

Mammalian carnivores are considered a key group in maintaining ecological health and can indicate potential ecological integrity in landscapes where they occur. Carnivores also hold high conservation value and their habitat requirements can guide management and conservation plans. The order Carnivora has 84 species from 8 families in the Neotropical region: Canidae; Felidae; Mephitidae; Mustelidae; Otariidae; Phocidae; Procyonidae; and Ursidae. Herein, we include published and unpublished data on native terrestrial Neotropical carnivores (Canidae; Felidae; Mephitidae; Mustelidae; Procyonidae; and Ursidae). NEOTROPICAL CARNIVORES is a publicly available data set that includes 99,605 data entries from 35,511 unique georeferenced coordinates. Detection/non-detection and quantitative data were obtained from 1818 to 2018 by researchers, governmental agencies, non-governmental organizations, and private consultants. Data were collected using several methods including camera trapping, museum collections, roadkill, line transect, and opportunistic records. Literature (peer-reviewed and grey literature) from Portuguese, Spanish and English were incorporated in this compilation. Most of the data set consists of detection data entries (n = 79,343; 79.7%) but also includes non-detection data (n = 20,262; 20.3%). Of those, 43.3% also include count data (n = 43,151). The information available in NEOTROPICAL CARNIVORES will contribute to macroecological, ecological, and conservation questions in multiple spatio-temporal perspectives. As carnivores play key roles in trophic interactions, a better understanding of their distribution and habitat requirements are essential to establish conservation management plans and safeguard the future ecological health of Neotropical ecosystems. Our data paper, combined with other large-scale data sets, has great potential to clarify species distribution and related ecological processes within the Neotropics. There are no copyright restrictions and no restriction for using data from this data paper, as long as the data paper is cited as the source of the information used. We also request that users inform us of how they intend to use the data

The impact of stapling technique and surgeon specialism on anastomotic failure after right?sided colorectal resection: an international multicentre, prospective audit

Aim There is little evidence to support choice of technique and configuration for stapled anastomoses after right hemicolectomy and ileocaecal resection. This study aimed to determine the relationship between stapling technique and anastomotic failure. Method Any unit performing gastrointestinal surgery was invited to contribute data on consecutive adult patients undergoing right hemicolectomy or ileocolic resection to this prospective, observational, international, multicentre study. Patients undergoing stapled, side?to?side ileocolic anastomoses were identified and multilevel, multivariable logistic regression analyses were performed to explore factors associated with anastomotic leak. Results One thousand three hundred and forty?seven patients were included from 200 centres in 32 countries. The overall anastomotic leak rate was 8.3%. Upon multivariate analysis there was no difference in leak rate with use of a cutting stapler for apical closure compared with a noncutting stapler (8.4% vs 8.0%, OR 0.91, 95% CI 0.54–1.53, P = 0.72). Oversewing of the apical staple line, whether in the cutting group (7.9% vs 9.7%, OR 0.87, 95% CI 0.52–1.46, P = 0.60) or noncutting group (8.9% vs 5.7%, OR 1.40, 95% CI 0.46–4.23, P = 0.55) also conferred no benefit in terms of reducing leak rates. Surgeons reporting to be general surgeons had a significantly higher leak rate than those reporting to be colorectal surgeons (12.1% vs 7.3%, OR 1.65, 95% CI 1.04–2.64, P = 0.04). Conclusion This study did not identify any difference in anastomotic leak rates according to the type of stapling device used to close the apical aspect. In addition, oversewing of the anastomotic staple lines appears to confer no benefit in terms of reducing leak rates. Although general surgeons operated on patients with more high?risk characteristics than colorectal surgeons, a higher leak rate for general surgeons which remained after risk adjustment needs further exploration

Relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit

Aim: The anastomosis technique used following right-sided colonic resection is widely variable and may affect patient outcome. This study aimed to assess the association between leak and anastomosis technique (stapled vs handsewn). Method: This was a prospective, multicentre, international audit including patients undergoing elective or emergency right hemicolectomy or ileo-caecal resection operations over a 2-month period in early 2015. The primary outcome measure was the presence of anastomotic leak within 30\ua0days of surgery, determined using a prespecified definition. Mixed effects logistic regression models were used to assess the association between leak and anastomosis method, adjusting for patient, disease and operative cofactors, with centre included as a random-effect variable. Results: This study included 3208 patients, of whom 78.4% (n\ua0=\ua02515) underwent surgery for malignancy and 11.7% (n\ua0=\ua0375) underwent surgery for Crohn's disease. An anastomosis was performed in 94.8% (n\ua0=\ua03041) of patients, which was handsewn in 38.9% (n\ua0=\ua01183) and stapled in 61.1% (n\ua0=\ua01858). Patients undergoing handsewn anastomosis were more likely to be emergency admissions (20.5% handsewn vs 12.9% stapled) and to undergo open surgery (54.7% handsewn vs 36.6% stapled). The overall anastomotic leak rate was 8.1% (245/3041), which was similar following handsewn (7.4%) and stapled (8.5%) techniques (P\ua0=\ua00.3). After adjustment for cofactors, the odds of a leak were higher for stapled anastomosis (adjusted OR\ua0=\ua01.43; 95% CI: 1.04\u20131.95; P\ua0=\ua00.03). Conclusion: Despite being used in lower-risk patients, stapled anastomosis was associated with an increased anastomotic leak rate in this observational study. Further research is needed to define patient groups in whom a stapled anastomosis is safe

The relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit.

BACKGROUND: Anastomosis technique following right sided colonic resection is widely variable and may affect patient outcomes. This study aimed to assess the association between leak and anastomosis technique (stapled versus handsewn) METHODS: This was a prospective, multicentre, international audit including patients undergoing elective or emergency right hemicolectomy or ileo-caecal resection operations over a two-month period in early 2015. The primary outcome measure was the presence of anastomotic leak within 30 days of surgery, using a pre-specified definition. Mixed effects logistic regression models were used to assess the association between leak and anastomosis method, adjusting for patient, disease and operative cofactors, with centre included as a random effect variable. RESULTS: This study included 3208 patients, of whom 78.4% (n=2515) underwent surgery for malignancy and 11.7% (n=375) for Crohn's disease. An anastomosis was performed in 94.8% (n=3041) of patients, which was handsewn in 38.9% (n=1183) and stapled in 61.1% (n=1858) cases. Patients undergoing handsewn anastomosis were more likely to be emergency admissions (20.5% handsewn versus 12.9% stapled) and to undergo open surgery (54.7% versus 36.6%). The overall anastomotic leak rate was 8.1% (245/3041), which was similar following handsewn (7.4%) and stapled (8.5%) techniques (p=0.3). After adjustment for cofactors, the odds of a leak were higher for stapled anastomosis (adjusted odds ratio 1.43, 95% confidence interval 1.04-1.95, p=0.03). DISCUSSION: Despite being used in lower risk patients, stapled anastomosis was associated with an increased anastomotic leak rate in this observational study. Further research is needed to define patient groups in whom a stapled anastomosis is safe. This article is protected by copyright. All rights reserve

Predictors for anastomotic leak, postoperative complications, and mortality after right colectomy for cancer: Results from an international snapshot audit

Background: A right hemicolectomy is among the most commonly performed operations for colon cancer, but modern high-quality, multination data addressing the morbidity and mortality rates are lacking. Objective: This study reports the morbidity and mortality rates for right-sided colon cancer and identifies predictors for unfavorable short-term outcome after right hemicolectomy. Design: This was a snapshot observational prospective study. Setting: The study was conducted as a multicenter international study. Patients: The 2015 European Society of Coloproctology snapshot study was a prospective multicenter international series that included all patients undergoing elective or emergency right hemicolectomy or ileocecal resection over a 2-month period in early 2015. This is a subanalysis of the colon cancer cohort of patients. Main Outcome Measures: Predictors for anastomotic leak and 30-day postoperative morbidity and mortality were assessed using multivariable mixed-effect logistic regression models after variables selection with the Lasso method. Results: Of the 2515 included patients, an anastomosis was performed in 97.2% (n = 2444), handsewn in 38.5% (n = 940) and stapled in 61.5% (n = 1504) cases. The overall anastomotic leak rate was 7.4% (180/2444), 30-day morbidity was 38.0% (n = 956), and mortality was 2.6% (n = 66). Patients with anastomotic leak had a significantly increased mortality rate (10.6% vs 1.6% no-leak patients; p 65 0.001). At multivariable analysis the following variables were associated with anastomotic leak: longer duration of surgery (OR = 1.007 per min; p = 0.0037), open approach (OR = 1.9; p = 0.0037), and stapled anastomosis (OR = 1.5; p = 0.041). Limitations: This is an observational study, and therefore selection bias could be present. For this reason, a multivariable logistic regression model was performed, trying to correct possible confounding factors. Conclusions: Anastomotic leak after oncologic right hemicolectomy is a frequent complication, and it is associated with increased mortality. The key contributing surgical factors for anastomotic leak were anastomotic technique, surgical approach, and duration of surgery

Risk factors for unfavourable postoperative outcome in patients with Crohn's disease undergoing right hemicolectomy or ileocaecal resection. An international audit by ESCP and S-ECCO

Aim: Patient- and disease-related factors, as well as operation technique, all have the potential to impact on postoperative outcome in Crohn's disease. The available evidence is based on small series and often displays conflicting results. The aim was to investigate the effect of preoperative and intra-operative risk factors on 30-day postoperative outcome in patients undergoing surgery for Crohn's disease. Method: This was an international prospective snapshot audit including consecutive patients undergoing right hemicolectomy or ileocaecal resection. The study analysed a subset of patients who underwent surgery for Crohn's disease. The primary outcome measure was the overall Clavien\u2013Dindo postoperative complication rate. The key secondary outcomes were anastomotic leak, reoperation, surgical site infection and length of stay in hospital. Multivariable binary logistic regression analyses were used to produce odds ratios and 95% confidence intervals. Results: In all, 375 resections in 375 patients were included. The median age was 37 and 57.1% were women. In multivariate analyses, postoperative complications were associated with preoperative parenteral nutrition (OR 2.36, 95% CI 1.10\u20134.97), urgent/expedited surgical intervention (OR 2.00, 95% CI 1.13\u20133.55) and unplanned intra-operative adverse events (OR 2.30, 95% CI 1.20\u20134.45). The postoperative length of stay in hospital was prolonged in patients who received preoperative parenteral nutrition (OR 31, 95% CI 1.08\u20131.61) and those who had urgent/expedited operations (OR 1.21, 95% CI 1.07\u20131.37). Conclusion: Preoperative parenteral nutritional support, urgent/expedited operation and unplanned intra-operative adverse events were associated with unfavourable postoperative outcome. Enhanced preoperative optimization and improved planning of operation pathways and timings may improve outcomes for patients