Physical rehabilitation in Brazilian pediatric intensive care units: a multicenter point prevalence study

OBJECTIVE

To determine the prevalence and factors associated with the physical rehabilitation of critically ill children in Brazilian pediatric intensive care units.

METHODS

A 2-day, cross-sectional, multicenter point prevalence study comprising 27 pediatric intensive care units (out of 738) was conducted in Brazil in April and June 2019. This Brazilian study was part of a large multinational study called Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU). The primary outcome was the prevalence of mobility provided by physical therapy or occupational therapy. Clinical data on patient mobility, potential mobility safety events, and mobilization barriers were prospectively collected in patients admitted for ≥ 72 hours.

RESULTS

Children under the age of 3 years comprised 68% of the patient population. The prevalence of therapist-provided mobility was 74%, or 277 out of the 375 patient-days. Out-of-bed mobility was most positively associated with family presence (adjusted odds ratios 3.31;95%CI 1.70 - 6.43) and most negatively associated with arterial lines (adjusted odds ratios 0.16; 95%CI 0.05 - 0.57). Barriers to mobilization were reported on 27% of patient-days, the most common being lack of physician order (n = 18). Potential safety events occurred in 3% of all mobilization events.

CONCLUSION

Therapist-provided mobility in Brazilian pediatric intensive care units is frequent. Family presence was high and positively associated with out-of-bed mobility. The presence of physiotherapists 24 hours a day in Brazilian pediatric intensive care units may have a substantial impact on the mobilization of critically ill children.

Development of a prognostic model for pediatric acute liver failure in a Brazilian center

OBJECTIVE

Pediatric acute liver failure (PALF) is a heterogeneous, rare, and severe condition, which outcome is survival due to liver spontaneous recovery or death. The patients who do not recover may be allocated to liver transplantation, which is the standard treatment. This study aimed to build a prognostic model to support the clinical decision to indicate liver transplantation for patients with PALF in a Brazilian center.

METHODS

The authors retrospectively analyzed the clinical variables of 120 patients in the liver transplantation program of the 'Children's Institute of the University of São Paulo, Brazil. The authors conducted a univariate analysis of variables associated with survival in PALF. Logistic multivariate analysis was performed to find a prognostic model for the outcome of patients with pediatric acute liver failure.

RESULTS

Risk factors were analyzed using univariate analysis. Two prognostic models were built using multiple logistic regression, which resulted in 2 models: model 1(INR/ALT) and model 2 (INR/Total bilirubin). Both models showed a high sensitivity (97.9%/96.9%), good positive predictive value (89.5%/90.4%), and accuracy (88.4%/88.5%), respectively. The receiver operating characteristic was calculated for both models, and the area under the curve was 0.87 for model 1 and 0.88 for model 2. The Hosmer-Lemeshow test showed that model 1 was good.

CONCLUSION

The authors built a prognostic model for PALF using INR and ALT that can contribute to the clinical decision to allocate patients to liver transplantation.

Tracheostomy practices in children on mechanical ventilation: a systematic review and meta-analysis

OBJECTIVE

To evaluate current practices of tracheostomy in children regarding the ideal timing of tracheostomy placement, complications, indications, mortality, and success in decannulation.

SOURCE OF DATA

The authors searched PubMed, Embase, Cochrane Library, Google Scholar, and complemented by manual search. The guidelines of PRISMA and MOOSE were applied. The quality of the included studies was evaluated with the Newcastle-Ottawa Scale. Information extracted included patients' characteristics, outcomes, time to tracheostomy, and associated complications. Odds ratios (ORs) with 95% CIs were computed using the Mantel-Haenszel method.

SYNTHESIS OF DATA

Sixty-six articles were included in the qualitative analysis, and 8 were included in the meta-analysis about timing for tracheostomy placement. The risk ratio for "death in hospital outcome" did not show any benefit from performing a tracheostomy before or after 14 days of mechanical ventilation (p = 0.49). The early tracheostomy before 14 days had a great impact on the days of mechanical ventilation (-26 days in mean difference, p < 0.00001). The authors also found a great reduction in hospital length of stay (-31.4 days, p < 0.008). For the days in PICU, the mean reduction was of 14.7 days (p < 0.007).

CONCLUSIONS

The meta-analysis suggests that tracheostomy performed in the first 14 days of ventilation can reduce the time spent on the ventilator, and the length of stay in the hospital, with no effect on mortality. The decision to perform a tracheostomy early or late may be more dependent on the baseline disease than on the time spent on ventilation .

Extracorporeal membrane oxygenation for respiratory failure in children: the years before and after the 2009 H1N1 pandemic

OBJECTIVE

To evaluate whether there was any impact on the number of pediatric extracorporeal membrane oxygenation runs and survival rates in the years subsequent to the 2009 pandemic.

METHODS

We studied two different periods of extracorporeal membrane oxygenation support for respiratory failure in children by analyzing datasets from the Extracorporeal Life Support Organization. Autoregressive integrated moving average models were constructed to estimate the effect of the pandemic. The year 2009 was the year of intervention (the H1N1 epidemic) in an interrupted time series model. Data collected from 2001 - 2010 were considered preintervention, and data collected from 2010 - 2017 were considered postintervention.

RESULTS

There was an increase in survival rates in the period 2010 - 2017 compared to 2001 - 2010 (p < 0.0001), with a significant improvement in survival when extracorporeal membrane oxygenation was performed for acute respiratory failure due to viral pneumonia. The autoregressive integrated moving average model shows an increase of 23 extracorporeal membrane oxygenation runs per year, prior to the point of the level effect (2009). In terms of survival, the preslope shows that there was no significant increase in survival rates before 2009 (p = 0.41), but the level effect was nearly significant after two years (p = 0.05), with a 6% increase in survival. In four years, there was an 8% (p = 0.03) increase in survival, and six years after 2009, there was up to a 10% (p = 0.026) increase in survival.

CONCLUSION

In the years following 2009, there was a significant, global incremental increase in the extracorporeal membrane oxygenation survival rates for all runs, mainly due to improvements in the technology and treatment protocols for acute respiratory failure related to viral pneumonia and other respiratory conditions.

The Impact of the Novel Coronavirus on Brazilian PICUs

OBJECTIVES

To study the impact of the coronavirus disease 2019 pandemic, considering the physical distancing and schools closing, on the characteristics of admission and epidemiology on Brazilian PICUs.

DESIGN

Observational, multicenter, time series analysis, of electronic medical records from 15 PICU in Brazil. Data consisted of all March, April, and May PICU admissions from 2017 to 2020.

SETTING

Fifteen private PICUs in Brazil.

PATIENTS

Pediatric patients admitted to the PICU from March to May since 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The period from March 11, 2020, to March 17, 2020, was considered the "intervention point" studied, corresponding to the suspension of school activities and the beginning of physical distancing in Brazil. During the pandemic period studied, there were 28 cases of coronavirus disease 2019 (one death). The mean age was higher (p = 0.000), the length of stay was shorter (p = 0.000), but mortality rates were similar among the periods (p = 0.36). The model estimated a reduction of 1,483 PICU admissions from March 2020 to May 2020. At the end of May, there was an estimated drop of -146.6 bronchiolitis admissions (95% CI, -242.8 to -50.3; p = 0.016); -71 asthma admissions (95% CI, -93.6 to -48.63; p = 0.000); and -59 community-acquired pneumonia admissions (95% CI, -74.7 to -43.3; p = 0.000) per period. The model showed no effect of the "intervention" (physical distancing) on hospitalization rates for epilepsy, diarrhea, sepsis, bacterial meningitis, or surgery when analyzed individually. When assessed together, the model estimated a reduction of 73.6 admissions (95% IC, -132 to -15.2; p = 0.43).

CONCLUSIONS

The coronavirus disease 2019 pandemic strongly affected Brazilian PICUs, reducing admissions, length of stay, and the epidemiological profile. The measures to oppose the coronavirus disease 2019 pandemic may have prevented thousands of PICU hospitalizations across the country.

High-flow nasal cannula as a post-extubation respiratory support strategy in preterm infants: a systematic review and meta-analysis

OBJECTIVE

Perform a systematic review and meta-analysis to assess the effectiveness and complications caused by the use of the high-flow nasal cannula in relation to the post-extubation continuous positive airway pressure system in preterm newborns.

DATA SOURCES

The searches were performed from January 2013 to December 2018 in the PubMed and Embase databases, as well as a manual search on the internet.

DATA SYNTHESIS

Two reviewers independently conducted the search, and a third reviewer resolved questions that arose. Ninety-eight articles from the chosen sources were evaluated, and 66 were discarded because they did not meet the inclusion criteria (inadequate topic, age range, or design, in addition to the duplicates). Fifteen articles were read in full, and five more were discarded due to inadequacy to the topic or design. There were ten articles left for systematic review and four for meta-analysis. The study showed non-inferiority in terms of therapeutic failure of the high-flow nasal cannula in relation to continuous positive airway pressure after extubation of preterm newborns. In the meta-analysis, nasal trauma was significantly lower in patients submitted to the high-flow nasal cannula compared to those using continuous positive airway pressure (p<0.00001).

CONCLUSION

The high-flow nasal cannula is not inferior to continuous positive airway pressure for post-extubation respiratory support in preterm newborns with a gestational age of 32 weeks or less and greater than 28 weeks, in addition to resulting in less nasal trauma.

MANAGEMENT OF ACUTE RESPIRATORY DISTRESS SYNDROME IN A CHILD WITH ADENOVIRUS PNEUMONIA: CASE REPORT AND LITERATURE REVIEW

OBJECTIVE

To report the case of a child who developed acute respiratory distress syndrome (ARDS) from a pulmonary infection by adenovirus.

CASE DESCRIPTION

A female patient aged 2 years and 6 months, weighting 10,295 grams developed fever, productive cough and vomiting, later on progressing to ARDS despite initial therapy in accordance with the institutional protocol for ARDS treatment. The child evolved to refractory hypoxemia and hypercapnia, requiring high parameters of mechanical pulmonary ventilation and use of vasoactive agents. In the treatment escalation, the patient received steroids, inhaled nitric oxide (iNO), was submitted to the prone position, started oscillatory high-frequency ventilation (HFOV) and extracorporeal membrane oxygenation (ECMO) was indicated due to severe refractory hypoxemia. During this time, the patient's clinical response was favorable to HFOV, improving oxygenation index and hypercapnia, allowing the reduction of vasoactive medications and mechanical ventilation parameters, and then the indication of ECMO was suspended. The patient was discharged after 26 days of hospital stay without respiratory or neurological sequelae.

COMMENTS

Adenovirus infections occur mainly in infants and children under 5 years of age and represent 2 to 5% of respiratory diseases among pediatric patients. Although most children with adenovirus develop a mild upper respiratory tract disease, more severe cases can occur. ARDS is a serious pulmonary inflammatory process with alveolar damage and hypoxemic respiratory failure; Adenovirus pneumonia in children may manifest as severe pulmonary morbidity and respiratory failure that may require prolonged mechanical ventilation. Exclusive pulmonary recruitment and HFOV are advantageous therapeutic options.

MALIGNANT HYPERTHERMIA IN A CHILD AFTER MAGNETIC RESONANCE IMAGING: A CASE REPORT

Objective:

To report on a case of malignant hyperthermia in a child after a magnetic resonance imaging of the skull was performed using sevoflurane anesthesia.

Case description:

A 3-year-old boy admitted to the pediatric intensive care unit after presenting clinical and laboratory findings consistent with unspecified viral meningoencephalitis. While the patient was sedated, a magnetic resonance imaging of the skul was performed using propofol followed by the administration of sevoflurane through a laryngeal mask in order to continue anesthesia. Approximately three hours after the start of the procedure, the patient presented persistent tachycardia, tachypnea, generalized muscular stiffness and hyperthermia. With a diagnostic hypothesis of malignant hyperthermia, dantrolene was then administered, which immediately induced muscle stiffness, tachycardia, tachypnea and reduced body temperature.

Comments:

Malignant hyperthermia is a rare pharmacogenetic syndrome characterized by a severe hypermetabolic reaction after the administration of halogenated inhalational anesthetics or depolarizing muscle relaxants such as succinylcholine, or both. Although it is a potentially fatal disease, the rapid administration of continued doses dantrolene has drastically reduced the morbidity and mortality of the disease.

Practices related to assessment of sedation, analgesia and delirium among critical care pediatricians in Brazil

Objective

To understand the use of tools, protocols and comfort measures related to sedation/analgesia, and to screen the occurrence of delirium in pediatric intensive care units.

Methods

A survey with 14 questions was distributed by e-mail to Brazilian critical care pediatricians. Eight questions addressed physician and hospital demographics, and six inquired practices to assess sedation, analgesia, and delirium in pediatric intensive care units.

Results

Of 373 questionnaires sent, 61 were answered (16.3%). The majority of physicians were practicing in the Southeast region (57.2%). Of these, 46.5% worked at public hospitals, 28.6% of which under direct state administration. Of respondents, 57.1% used formal protocols for sedation and analgesia, and the Ramsay scale was the most frequently employed (52.5%). Delirium screening scores were not used by 48.2% of physicians. The Cornell Assessment of Pediatric Delirium was the score most often used (23.2%). The majority (85.7%) of physicians did not practice daily sedation interruption, and only 23.2% used non-pharmacological measures for patient comfort frequently, with varied participation of parents in the process.

Conclusion

This study highlights the heterogeneity of practices for assessment of sedation/analgesia and lack of detection of delirium among critical care pediatricians in Brazil.

Fulminant acute hepatitis in pediatrics in Latin America and the Caribbean

SUMMARY OBJECTIVE: The objective of this review was to investigate the epidemiology of Fulminant Acute Hepatitis in Latin America and the Caribbean and identify possible measures aimed at a better understanding and improvement of patient support. METHODS: We used 3 different researchers to investigate the topic of Fulminant Acute Hepatitis in pediatrics in papers published by Latin American and Caribbean authors in the PubMed and SciELO databases from 2000 to 2016. RESULTS: We found 2,879 articles in the databases searched. After selecting and excluding articles according to the study protocol, 68 remaining studies were obtained for analysis. A total of 1,265 cases of acute fulminant hepatitis were detected, with a predominance of females (42.9%), followed by males (39.4%), with no description of sex in 17.7% of the cases. The main cause was viral hepatitis, representing 45.1% of the cases. The hepatitis A virus was responsible for 34.7% of the total cases and 76.9% of the infectious causes. Of the total number of patients, 26.9% were described as idiopathic, and 11.5% had no cause. CONCLUSION: The preventable causes of Fulminant Acute Hepatitis include hepatitis viruses - primarily the hepatitis A virus - and poisoning. Active vaccination, basic sanitation, and public awareness can reduce the number of patients and, consequently, the costs of liver transplantation due to these causes.

Evaluation of the use of electronic medical record systems in Brazilian intensive care units

OBJECTIVE

To examine the prevalence of the use of electronic medical record systems in Brazilian intensive care units and the perceptions of intensive care physicians regarding the contribution of electronic medical record systems toward improving safety and quality in clinical practice.

METHODS

Using an online questionnaire, physicians working in Brazilian intensive care units answered questions about the use of electronic medical record systems in the hospitals in which they worked. They were asked about the types of electronic medical record systems used and their levels of satisfaction with these systems in terms of improving quality and safety.

RESULTS

Of the 4,772 invitations sent, 204 physicians responded to the questionnaire. Most used electronic medical record and prescription systems (92.6%), worked in private hospitals (43.1%), worked in general adult intensive care units (66.7%) and used Private System A (39.2%); most systems had been used for between 2 and 4 years (25.5%). Furthermore, the majority (84.6%) believed that the electronic system provided better quality than a paper system, and 76.7% believed that electronic systems provided greater safety than paper systems.

CONCLUSION

Electronic medical record systems seem to be widely used by the Brazilian intensive care physicians who responded to the questionnaire and, according to the data, seem to provide greater quality and safety than do paper records.

SÍNDROME POSTERIOR DO TRONCO CEREBRAL E O USO DE VENTILAÇÃO ASSISTIDA AJUSTADA NEURALMENTE (NAVA) EM LACTENTE

Objective:

To report a rare case of dorsal brainstem syndrome in an infant after hypoxic-ischemic episode due to severe sepsis and the use of neurally adjusted ventilatory assist (NAVA) to aid in diagnosis and in the removal of mechanical ventilation.

Case description:

A 2-month-old male infant, previously healthy, presented with severe sepsis that evolved to dorsal brainstem syndrome, which usually occurs after hypoxic-ischemic injury in neonates and infants, and is related to very specific magnetic resonance images. Due to neurological lesions, thei nfant remained in mechanical ventilation. A NAVA module was installed to keep track of phrenic nerve conduction to the diaphragm, having successfully showed neural conduction and helped removing mechanical ventilation.

Comments:

Dorsal brainstem syndrome is a rare condition that should be considered after hypoxic-ischemic episode in infants.

Anaphylaxis Knowledge Among Pediatric Intensivists in Brazil: A Multicenter Survey

OBJECTIVE

To assess the knowledge and practice preferences of anaphylaxis treatment among pediatric intensivists in 5 Brazilian pediatric intensive care unit (PICU) settings.

STUDY DESIGN

The cohort was a cross-sectional sample from 5 PICUs; a 7-question survey was personally applied to participants regarding their professional clinical experience and the first-line drug choices when treating an anaphylaxis episode.

RESULTS

Of 43 participant physicians, the majority (83.8%) correctly identified epinephrine as the treatment of choice for anaphylaxis, yet only 41.9% chooses the intramuscular route of administration.

CONCLUSION

This study shows that the knowledge of anaphylaxis treatment is deficient among pediatric intensivists in Brazil. The dissemination of recent World Allergy Organization guidelines on anaphylaxis should be encouraged.

Spontaneous intracranial hemorrhage in children: report of a hemophilia patient who survived due to a brain cyst

We report the case of a 2-year-old child who survived an acute episode of severe spontaneous intracranial hemorrhage with clinical and radiological signs of intracranial hypertension and transtentorial herniation. The patient underwent emergency surgery to drain the hematoma, and a catheter was inserted to monitor intracranial pressure. In the initial computed tomography analysis performed prior to hematoma drainage, a brain cyst was evident contralateral to the hematoma, which, based on the analysis by the care team, possibly helped to avoid a worse outcome because the cyst accommodated the brain after the massive hemorrhage. After the investigation, the patient was determined to have previously undiagnosed hemophilia A. The patient underwent treatment in intensive care, which included the control of intracranial pressure, factor VIII replacement and discharge without signs of neurological impairment.