Inhaled magnesium versus inhaled salbutamol in rescue treatment for moderate and severe asthma exacerbations in pediatric patients

OBJECTIVE

To compare the effectiveness of inhaled Magnesium Sulfate associated with Salbutamol versus Inhaled Salbutamol alone in patients with moderate and severe asthma exacerbations.

METHOD

Clinical, prospective and randomized study with patients between 3 and 14 years of age divided into two groups: one to receive inhaled salbutamol associated with magnesium sulfate (GSM), the other to receive inhaled salbutamol alone (GS). The sample consisted of 40 patients, 20 patients in each group. Severity was classified using the modified Wood-Downes score, with values between 4 and 7 classified as moderate and 8 or more classified as severe.

RESULTS

Post-inhalation scores decreased both in patients who received salbutamol and magnesium and in those who received salbutamol alone, with no statistically significant difference between the groups.

CONCLUSIONS

Despite the benefits when administered intravenously, inhalation of the drug alone or in combination did not reduce the severity of the exacerbation.

The epidemiology of sepsis in paediatric intensive care units in Brazil (the Sepsis PREvalence Assessment Database in Pediatric population, SPREAD PED): an observational study

BACKGROUND

Data on the prevalence and mortality of paediatric sepsis in resource-poor settings are scarce. We aimed to assess the prevalence and in-hospital mortality of severe sepsis and septic shock treated in paediatric intensive care units (PICUs) in Brazil, and risk factors for mortality.

METHODS

We performed a nationwide, 1-day, prospective point prevalence study with follow-up of patients with severe sepsis and septic shock, using a stratified random sample of all PICUs in Brazil. Patients were enrolled at each participating PICU on a single day between March 25 and 29, 2019. All patients occupying a bed at the PICU on the study day (either admitted previously or on that day) were included if they were aged 28 days to 18 years and met the criteria for severe sepsis or septic shock at any time during hospitalisation. Patients were followed up until hospital discharge or death, censored at 60 days. Risk factors for mortality were assessed using a Poisson regression model. We used prevalence to generate national estimates.

FINDINGS

Of 241 PICUs invited to participate, 144 PICUs (capacity of 1242 beds) included patients in the study. On the day of the study, 1122 children were admitted to the participating PICUs, of whom 280 met the criteria for severe sepsis or septic shock during hospitalisation, resulting in a prevalence of 25·0% (95% CI 21·6-28·8), with a mortality rate of 19·8% (15·4-25·2; 50 of 252 patients with complete clinical data). Increased risk of mortality was associated with higher Pediatric Sequential Organ Failure Assessment score (relative risk per point increase 1·21, 95% CI 1·14-1·29, p<0·0001), unknown vaccination status (2·57, 1·26-5·24; p=0·011), incomplete vaccination status (2·16, 1·19-3·92; p=0·012), health care-associated infection (2·12, 1·23-3·64, p=0·0073), and compliance with antibiotics (2·38, 1·46-3·86, p=0·0007). The estimated incidence of PICU-treated sepsis was 74·6 cases per 100 000 paediatric population (95% CI 61·5-90·5), which translates to 42 374 cases per year (34 940-51 443) in Brazil, with an estimated mortality of 8305 (6848-10 083).

INTERPRETATION

In this representative sample of PICUs in a middle-income country, the prevalences of severe sepsis or septic shock and in-hospital mortality were high. Modifiable factors, such as incomplete vaccination and health care-associated infections, were associated with greater risk of in-hospital mortality.

FUNDING

Fundação de Amparo à Pesquisa do Estado de São Paulo and Conselho Nacional de Desenvolvimento Científico e Tecnológico.

TRANSLATION

For the Portuguese translation of the abstract see Supplementary Materials section.

Use of Dexamethasone to Prevent Extubation Failure in Pediatric Intensive Care Unit: A Randomized Controlled Clinical Trial

Extubation failure is a common event in intensive care units. Corticosteroids are effective in preventing failure in adults, but no consensus has been reached on this matter in pediatrics. We assessed the efficacy of intravenous dexamethasone in mechanically ventilated children and adolescents for more than 48 hours, with at least one risk factor for failure. Extubations were scheduled 24 hours in advance when possible, and patients were randomly assigned into two groups: one group received a loading dose followed by up to four doses of dexamethasone, and the other group received no corticosteroids. Need for reintubation and length of stay in the pediatric intensive care unit were similar in both groups, and frequency of reintubation was 12.9%.

Diagnosis and treatment of streptococcal toxic shock syndrome in the pediatric intensive care unit: case report

Among the infections caused by Streptococcus β hemolyticus from the Lancefield serogroup A, toxic shock syndrome is perhaps the most severe, and its mortality rate is high. Its clinical similarity to other forms of shock, especially septic shock, can often confuse the evaluator and interfere with the selection of the most appropriate therapy. This report aims to inform readers of the need to add this syndrome as a differential diagnosis in cases of shock, especially those with no well-defined clinical manifestations. For this purpose, we present the case of an infant with common flu-like symptoms who progressed rapidly with a rash, a reduced level of consciousness and clinical and laboratory signs of shock that required intensive support. In addition to cultures indicating the etiological agent, the appearance of exanthema and necrotizing fasciitis led to the diagnosis. However, less than 50% of cases present classic clinical signs of this entity. Penicillins combined with aminoglycosides are still the therapy of choice and are supported by a high level of evidence. Despite the severity of this patient's presentation, the progression was satisfactory.

Comparison between conventional protective mechanical ventilation and high-frequency oscillatory ventilation associated with the prone position

Objective

To compare the effects of high-frequency oscillatory ventilation and conventional protective mechanical ventilation associated with the prone position on oxygenation, histology and pulmonary oxidative damage in an experimental model of acute lung injury.

Methods

Forty-five rabbits with tracheostomy and vascular access were underwent mechanical ventilation. Acute lung injury was induced by tracheal infusion of warm saline. Three experimental groups were formed: healthy animals + conventional protective mechanical ventilation, supine position (Control Group; n = 15); animals with acute lung injury + conventional protective mechanical ventilation, prone position (CMVG; n = 15); and animals with acute lung injury + high-frequency oscillatory ventilation, prone position (HFOG; n = 15). Ten minutes after the beginning of the specific ventilation of each group, arterial gasometry was collected, with this timepoint being called time zero, after which the animal was placed in prone position and remained in this position for 4 hours. Oxidative stress was evaluated by the total antioxidant performance assay. Pulmonary tissue injury was determined by histopathological score. The level of significance was 5%.

Results

Both groups with acute lung injury showed worsening of oxygenation after induction of injury compared with the Control Group. After 4 hours, there was a significant improvement in oxygenation in the HFOG group compared with CMVG. Analysis of total antioxidant performance in plasma showed greater protection in HFOG. HFOG had a lower histopathological lesion score in lung tissue than CMVG.

Conclusion

High-frequency oscillatory ventilation, associated with prone position, improves oxygenation and attenuates oxidative damage and histopathological lung injury compared with conventional protective mechanical ventilation.

Interleukin-12 in children with sepsis and septic shock

OBJECTIVE

To examine the behavior of interleukin-12 and verify whether it can be used to differentiate septic conditions in children.

METHODS

Septic children aged between 28 days and 14 years, prospectively enrolled from 01/2004 to 12/2005, were divided into sepsis (SG; n=47) and septic shock (SSG; n=43) groups. Interleukin-12 levels were measured at admission (T0) and 12 hours later (T12). Disease severity was assessed by the PRISM score.

RESULTS

Interleukin-12 levels did not differentiate children with sepsis from those with septic shock at admission [SSG: 0.24 (0-226.4)=SG: 1.23 (0-511.6); p=0.135)] and T12 [SG: 6.11 (0-230.5)=SSG: 1.32 (0-61.0); p=0.1239)]. Comparing time points, no significant difference was observed in the SG [SG, T0: 1.23 (0-511.6)=T12: 6.11 (0-230.5); p=0.075]. In SSG however, interleukin-12 increased from T0 to T12 (SSG, T0: 0.24 (0-226.4)<T12: 1.32 (0-61.0); p=0.018]. The mean percentage agreement between the clinical diagnosis and laboratory findings was 59.7% and 58.5% for the SG and SSG, respectively, with no significant difference between groups and time points (p>0.05). There was no correlation between onterleukin-12 levels at admission and the PRISM score for either group.

CONCLUSION

Interleukin-12 levels cannot differentiate between septic conditions and are not related to disease severity at admission. In septic shock patients, interleukin-12 increases with time.

Antibiotic treatment schemes for very severe community-acquired pneumonia in children: a randomized clinical study

OBJECTIVE

To compare clinical response to initial empiric treatment with oxacillin plus ceftriaxone and amoxicillin plus clavulanic acid in hospitalized children diagnosed with very severe community-acquired pneumonia (CAP).

METHODS

A prospective randomized clinical study was conducted among children 2 months to 5 years old with a diagnosis of very severe CAP in the pediatric ward of São Paulo State University Hospital in Botucatu, São Paulo, Brazil, from April 2007 to May 2008. Patients were randomly divided into two groups by type of treatment: an oxacillin/ceftriaxone group (OCG, n = 48) and an amoxicillin/clavulanic acid group (ACG, n = 56). Analyzed outcomes were: time to clinical improvement (fever and tachypnea), time on oxygen therapy, length of stay in hospital, need to widen antimicrobial spectrum, and complications (including pleural effusion).

RESULTS

The two groups did not differ statistically for age, sex, symptom duration before admission, or previous antibiotic treatment. Time to improve tachypnea was less among ACG patients than OCG patients (4.8 ± 2.2 versus 5.8 ± 2.4 days respectively; P = 0.028), as was length of hospital stay (11.0 ± 6.2 versus 14.4 ± 4.5 days respectively; P = 0.002). There were no statistically significant differences between the two groups for fever improvement time, time on oxygen therapy, need to widen antimicrobial spectrum, or frequency of pleural effusion.

CONCLUSIONS

Both treatment plans are effective in treating very severe CAP in 2-month-to 5-year-old hospitalized children. The only analyzed outcome that favored amoxicillin/clavulanic acid treatment was time required to improve tachypnea.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT01166932.

High-frequency oscillatory ventilation in pediatrics and neonatology

This article intends to review literature on high frequency oscillatory ventilation and describe its main clinical applications for children and neonates. Articles from the last 15 years were selected using MedLine and SciElo databases. The following key words were used: high frequency oscillatory ventilation, mechanical ventilation, acute respiratory distress syndrome, children, and new-born. The review describes high frequency oscillatory ventilation in children with acute respiratory distress syndrome, air leak syndrome, and obstructive lung disease. Respiratory distress syndrome, bronchopulmonary dysplasia, intracranial hemorrhage, periventricular leukomalacia, and air leak syndrome were reviewed in neonates. Transition from conventional mechanical ventilation to high frequency ventilation and its adjustments relating to oxygenation, CO2 elimination, chest radiography, suctioning, sedatives and use of neuromuscular blocking agents were described. Weaning and complications were also reported. For children, high frequency oscillatory ventilation is a therapeutic option, particularly in acute respiratory distress syndrome, and should be used as early as possible. It may be also useful in the air leak syndrome and obstructive pulmonary disease. Evidence that, in neonates, high frequency oscillatory ventilation is superior to conventional mechanical ventilation is lacking. However there is evidence that better results are only achieved with this ventilatory mode to manage the air leak syndrome.

[Inhaled nitric oxide for children with acute respiratory distress syndrome]

BACKGROUND AND OBJECTIVE

The objective of this study was to review the literature on inhaled nitric oxide to children with acute respiratory distress syndrome.

CONTENTS

A review of literature and selection of the most important publications on inhaled nitric oxide, using the MedLine and Cochrane Systematic Review Databases. This review was organized as follows: introduction; metabolism and biological effects; clinical applications; dosage, gas administration and weaning process; warnings and side-effects. Inhaled nitric oxide use was described in acute respiratory distress syndrome.

CONCLUSIONS

Inhaled nitric oxide as the first vasodilator to produce selective pulmonary vasodilation has beneficial effects on gas exchange and ventilation, improving outcome in children with severe hypoxia. It is safe when administered in intensive care units under strict surveillance and monitoring. Further studies should be concentrated on early treatment, when acute respiratory distress syndrome is potentially reversible.

[Red blood cell transfusion in children admitted in a pediatric intensive care unit]

BACKGROUND AND OBJECTIVES

Indications of red blood cell transfusion in critically ill children are not very well determined. This study aims to describe red blood cells transfusion practice at the PICU of UNESP-Botucatu Medical School.

METHODS

Retrospective observational study of all patients who received transfusion during 2003.

RESULTS

Seventy five patients received transfusion and 105 indications were recorded. 53.3% of the patients were less than one year of age. Increased respiratory rate (75.2%), paleness (65.7%), and hypotension (51.4%) were the alterations more frequently recorded, before transfusion. Also, metabolic acidosis (68.08%) e and hipoxemia (63.8%) were very frequently observed. From 93 hemoglobin (Hb) values recorded, 54 (58.1%) varied from 7 to 10 g/dL and from 90 records of hematocrit (Ht) 66 (73.3%) varied from 21% to 30%. The main indications of the transfusion were anemia, in 75 children (71.4%), and active bleeding in 26 (24.7%). The mean value of Hb before transfusion was 7.82 ± 2.82 g/dL. Seven transfusions were indicated for patients with Hb levels higher than 10 g/dL (postoperative heart surgery and septic patients).

CONCLUSIONS

red blood cells transfusion is carefully prescribed at the PICU by using restrictive indications (Hb between 7 and 10 g/dL). Not always is possible to find out records of the Hb levels immediately before transfusion. Hence, a protocol to better prescribe red blood cell transfusion at the PICU was adopted.

Curvas de percentis de valores normais de medidas ecocardiográficas em crianças eutróficas procedentes da região centro-sul do Estado de São Paulo

OBJECTIVE

To asses the values of echocardiographic measurements in normal children without cardiopathy and to build percentile curves, relating them to the body surface (BS, m(2)).

METHODS

We analyzed M-mode echocardiographic measurements for children between one and 144 months of age. We assessed right ventricular diastolic diameter (RVDd, mm) and left ventricular diastolic diameter (LVDd, mm), LV systolic diameter (LVSd, mm), right ventricular outflow tract diameter (RVOT, mm), aortic diameter (AoD, mm) and left atrial diameter (LAD, mm); left ventricular ejection fraction (LVEF, %); percentage of variation of left ventricular diameter (deltaLV, %); interventricular septum diastolic thickness (IVSDT, mm) and LV posterior wall diastolic thickness (PWDT, mm); left ventricular mass (LVM, g) and LV mass index (LVMI, g/m(2)).

RESULTS

At the end of the study, 595 children (326 male) were assessed. The values of echocardiographic measurements showed a good correlation with BS and allowed the constructing of percentile curves (3%, 25%, 50%, 75% and 97%). Statistically significant differences between the genders were evidenced for the following variables: LVSd, LVDd, RVOT, AoD, LVM and LVMI, and the highest values were observed in male children.

CONCLUSION

The percentile curves of the values obtained can be used as a reference to assess children with suspicion of cardiopathy or to follow-up on those with diagnosed cardiopathy or under treatment with potentially cardiotoxic drugs.

Food restriction induces in vivo ventricular dysfunction in spontaneously hypertensive rats without impairment of in vitro myocardial contractility

Cardiac structures, function, and myocardial contractility are affected by food restriction (FR). There are few experiments associating undernutrition with hypertension. The aim of the present study was to analyze the effects of FR on the cardiac response to hypertension in a genetic model of hypertension, the spontaneously hypertensive rat (SHR). Five-month-old SHR were fed a control or a calorie-restricted diet for 90 days. Global left ventricle (LV) systolic function was evaluated in vivo by transthoracic echocardiogram and myocardial contractility and diastolic function were assessed in vitro in an isovolumetrically beating isolated heart (Langendorff preparation). FR reduced LV systolic function (control (mean +/- SD): 58.9 +/- 8.2; FR: 50.8 +/- 4.8%, N = 14, P < 0.05). Myocardial contractility was preserved when assessed by the +dP/dt (control: 3493 +/- 379; FR: 3555 +/- 211 mmHg/s, P > 0.05), and developed pressure (in vitro) at diastolic pressure of zero (control: 152 +/- 16; FR: 149 +/- 15 mmHg, N = 9, P > 0.05) and 25 mmHg (control: 155 +/- 9; FR: 150 +/- 10 mmHg, N = 9, P > 0.05). FR also induced eccentric ventricular remodeling, and reduced myocardial elasticity (control: 10.9 +/- 1.6; FR: 9.2 +/- 0.9%, N = 9, P < 0.05) and LV compliance (control: 82.6 +/- 16.5; FR: 68.2 +/- 9.1%, N = 9, P < 0.05). We conclude that FR causes systolic ventricular dysfunction without in vitro change in myocardial contractility and diastolic dysfunction probably due to a reduction in myocardial elasticity.

Early administration of inhaled nitric oxide to children with acute respiratory distress syndrome and its effects on oxygenation and ventilator settings: prospective preliminary report of ten patients

AIM

To establish a protocol for the early introduction of inhaled nitric oxide (iNO) therapy in children with acute respiratory distress syndrome (ARDS) and to assess its acute and sustained effects on oxygenation and ventilator settings.

PATIENTS AND METHODS

Ten children with ARDS, aged 1 to 132 months (median, 11 months), with arterial saturation of oxygen <88% while receiving a fraction of inspired oxygen (FiO2) >or=0.6 and a positive end-expiratory pressure of >or=10 cm H2O were included in the study. The acute response to iNO was assessed in a 4-hour dose-response test, and positive response was defined as an increase in the PaO2/FiO2 ratio of 10 mm Hg above baseline values. Conventional therapy was not changed during the test. In the following days, patients who had shown positive response continued to receive the lowest iNO dose. Hemodynamics, PaO2/FiO2, oxygenation index, gas exchange, and methemoglobin levels were obtained when needed. Inhaled nitric oxide withdrawal followed predetermined rules.

RESULTS

At the end of the 4-hour test, all the children showed significant improvement in the PaO2/FiO2 ratio (63.6%) and the oxygenation index (44.9%) compared with the baseline values. Prolonged treatment was associated with improvement in oxygenation, so that FiO2 and peak inspiratory pressure could be quickly and significantly reduced. No toxicity from methemoglobin or nitrogen dioxide was observed.

CONCLUSION

Administration of iNO to children is safe. iNO causes rapid and sustained improvement in oxygenation without adverse effects. Ventilator settings can safely be reduced during iNO treatment.

[Idiopathic pulmonary hemosiderosis: case report]

OBJECTIVE: To alert pediatricians about the possibillity of childhood Idiopathic Pulmonary Hemosiderosis, in cases of anemia associated with chronic lung disease. METHODS: This article documents a case of Idiopathic Pulmonary Hemosiderosis in a 6 year-old child, with histopathological documentation, and reviews it against published literature. RESULTS: A 6 year-old child with history of anemia and lung disease characterized by wheezing, recurrent pneumonia and digital clubbing was admitted to the hospital for investigation, where he suffered sudden respiratory failure and hemoptysis.He was submitted to a lung biopsy which showed a histopathological diagnosis compatible with pulmonary hemosiderosis. Therapy with high doses of corticosteroids was initiated with a good early response. After two and a half months of therapy he had a new bleeding episode, culminating in death. CONCLUSIONS: Idiopathic Pulmonary Hemosiderosis should be included as a possible diagnosis of children with anemia and chronic lung disease. This case is a good example.

Influence of the elevation of the left ventricular diastolic pressure on the values of the first temporal derivative of the ventricular pressure (dP/dt)

PURPOSE

To assess the effects of the elevation of the left-ventricular end-diastolic pressure (LVEDP) on the value of the 1st temporal derivative of the ventricular pressure (dP/dt).

METHODS

Nineteen anesthetized dogs were studied. The dogs were mechanically ventilated and underwent thoracotomy with parasympathetic nervous system block. The LVEDP was controlled with the use of a perfusion circuit connected to the left atrium and adjusted to the height of a reservoir. The elevation of the LVEDP was achieved by a sudden increase in the height of a reservoir filled with blood. Continuous recordings of the electrocardiogram, the aortic and ventricular pressures and the dP/dt were performed.

RESULTS

Elevation of the LVEDP did not result in any variation of the heart rate (167 +/- 16.0 bpm, before the procedure; 167 +/- 15.5 bpm, after the procedure). All the other variables assessed, including systolic blood pressure (128 +/- 18.3 mmHg and 150 +/- 21.5 mmHg), diastolic blood pressure (98 +/- 16.9 mmHg and 115 +/- 19.8 mmHg), LVEDP (5.5 +/- 2.49 and 9.3 +/- 3.60 mmHg), and dP/dt (4,855 +/- 1,082 mmHg/s and 5,149 +/- 1,242 mmHg/s) showed significant increases following the expansion of the ventricular cavity. Although the elevation of the dP/dt was statistically significant, 6 dogs curiously showed a decrease in the values of dP/dt.

CONCLUSION

Sudden elevation of the LVEDP resulted in increased values of dP/dt; however, in some dogs, this response was not uniform.

The rate of force generation by the myocardium is not influenced by afterload

The influence of afterload on the rate of force generation by the myocardium was investigated using two types of preparations: the in situ dog heart (dP/dt) and isolated papillary muscle of rats (dT/dt). Thirteen anesthetized, mechanically ventilated and thoracotomized dogs were submitted to pharmacological autonomic blockade (3.0 mg/kg oxprenolol plus 0.5 mg/kg atropine). A reservoir connected to the left atrium permitted the control of left ventricular end-diastolic pressure (LVEDP). A mechanical constriction of the descending thoracic aorta allowed to increase the systolic pressure in two steps of 20 mmHg (conditions H1 and H2) above control values (condition C). After arterial pressure elevations (systolic pressure C: 119 +/- 8.1; H1: 142 +/- 7.9; H2: 166 +/- 7.7 mmHg; P < 0.01), there were no significant differences in heart rate (C: 125 +/- 13.9; H1: 125 +/- 13.5; H2: 123 +/- 14.1 bpm; P > 0.05) or LVEDP (C: 6.2 +/- 2.48; H1: 6.3 +/- 2.43; H2: 6.1 +/- 2.51 mmHg; P > 0.05). The values of dP/dt did not change after each elevation of arterial pressure (C: 3,068 +/- 1,057; H1: 3,112 +/- 996; H2: 3,086 +/- 980 mmHg/s; P > 0.05). In isolated rat papillary muscle, an afterload corresponding to 50% and 75% of the maximal developed tension did not alter the values of the maximum rate of tension development (100%: 78 +/- 13; 75%: 80 +/- 13; 50%: 79 +/- 11 g mm-2 s-1, P > 0.05). The results show that the rise in afterload per se does not cause changes in dP/dt or dT/dt.

[Influence of sustained increases of arterial pressure on left ventricular dP/dt when the left ventricular diastolic pressure is kept constant]

PURPOSE

To evaluate the influence of sustained elevations of arterial pressure on dP/dt values, while the left ventricular end diastolic pressure was kept constant.

METHODS

Thirteen anesthetized dogs, mechanically ventilated and submitted to thoracotomy and pharmacological autonomic block (atropine-0.5 mg/kg i.v. + oxprenolol-3 mg/kg i.v.) were studied. The arterial pressure elevation was obtained by mechanical constriction of the descending thoracic aorta. Analyses were made in control (C) situation and after two successive increments of arterial pressure, sustained for 10 min, called hypertension 1 (H1) and hypertension 2 (H2), respectively. The end diastolic left ventricular pressure was kept constant by utilization of a perfusion system connected to the left atria.

RESULTS

Heart rate did not change (C: 125 +/- 13.9 bpm; H1: 125 +/- 13.5 bpm; H2: 123 +/- 14.1 bpm; p > 0.05); the LVSP increased (C: 119 +/- 8.1 mmHg; H1: 142 +/- 7.9 mmHg; H2: 166 +/- 7.7 mmHg; p < 0.01); the AoDP increased (C: 89 +/- 11.6 mmHg; H1: 99 +/- 9.5 mmHg; H2: 120 +/- 11.8 mmHg; p < 0.01); the LVEDP (C: 6.2 +/- 2.48 mmHg; H1: 6.3 +/- 2.43 mmHg; H2:6.1 +/- 2.51 mmHg; p > 0.05) and the dP/dt (C: 3068 +/- 1057.1 mmHg/s; H1: 3112 +/- 995.7 mmHg/s; H2: 3086 +/- 979.5 mmHg/s; p > 0.05) did not change.

CONCLUSION

dP/dt values are not influenced by a sustained elevation of arterial pressure, when the end diastolic left ventricular pressure is kept constant.