RESUMO
OBJECTIVE: To improve understanding of the causes of morbidity and mortality among critically ill children in the countries studied. DESIGN: Survey of hospital records between 1992 and 1994. SETTING: Six pediatric intensive care units (ICUs) (four ICUs in Mexico City and two ICUs in Ecuador). PATIENTS: Consecutive patients (n = 1,061) admitted to the units studied. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The mortality rate for low-risk patients (pediatric Risk of Mortality [PRISM] score of < or = 10, n = 701) was more than four times the rate predicted by the PRISM score (8.1% vs. 1.8%, p < .001), with an additional 11.3% of this group incurring major morbidity. The mortality rate for moderate-risk patients (PRISM scores of 11 to 20, n = 232) was more than twice predicted (28% vs. 12%, p < .001). For low-risk patients, death was significantly associated with tracheal intubation, central venous cannulation, pneumonia, age of < 2 months, use of more than two antibiotics, and nonsurgical diagnosis (after controlling for PRISM score). Central venous cannulation and tracheal intubation in the lower-risk groups were performed more commonly in units in Mexico than in one comparison unit in the United States (p < .001). CONCLUSIONS: For six pediatric ICUs in Mexico and Ecuador, mortality was significantly higher than predicted among lower-risk patients. Tracheal intubation, central catheters, pneumonia, sepsis, and nonsurgical status were associated with poor outcome for low-risk groups. We speculate that reducing the use of invasive central catheters and endotracheal intubation for lower-risk patients, coupled with improved infection control, could lower mortality rates in the population studied.
Assuntos
Estado Terminal/terapia , Mortalidade Hospitalar , Unidades de Terapia Intensiva Pediátrica/normas , Avaliação de Resultados em Cuidados de Saúde , Índice de Gravidade de Doença , Pré-Escolar , Cuidados Críticos , Estado Terminal/mortalidade , Equador , Humanos , Lactente , México , Razão de Chances , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de RiscoRESUMO
To determine the prevalence and clinical consequences of hypocalcemia in pediatric intensive care unit patients, we prospectively studied calcium homeostasis in 145 of these patients. The total serum calcium concentration was measured in all patients. The serum ionized calcium concentration was measured in blood samples collected from those 71 (49%) patients who had low total serum calcium values (less than 8.5 mg/dl (2.12 mmol/L). Of the 71 patients, 26 (36.6%) had ionized hypocalcemia. Therefore the prevalence of ionized hypocalcemia was at least 17.9% (26/145). Death occurred in 8 (31%) of 26 patients with ionized hypocalcemia versus 3 (2.5%) of 119 patients with normocalcemia (p less than 0.0001). However, the severity of illness score was higher (p less than 0.05) in the children with ionized hypocalcemia than in normocalcemic children (mean Therapeutic Intervention Scoring System score 33 +/- 17 vs 22 +/- 11, respectively). More of the children with ionized hypocalcemia had sepsis (p = 0.0299) and they required the administration of vasopressor agents more often (p = 0.0002) than their normocalcemic counterparts. Of the 26 patients with ionized hypocalcemia, 17 (65.4%) had biochemical evidence of either absolute or relative hypoparathyroidism, determined by means of an immunoradiometric assay that measures only biologically active parathyroid hormone. We conclude the following: (1) ionized hypocalcemia is common in severely ill children. (2) Patients with ionized hypocalcemia have a higher mortality rate than those with normocalcemia; however, because the former are more severely ill, no causality is apparent or suggested. (3) Functional hypoparathyroidism may occur in critically ill children.
Assuntos
Hipocalcemia/epidemiologia , Adolescente , Adulto , Fatores Etários , Cálcio/sangue , Criança , Pré-Escolar , Estudos Transversais , Humanos , Hipocalcemia/etiologia , Hipoparatireoidismo/etiologia , Lactente , Recém-Nascido , Infecções/complicações , Unidades de Terapia Intensiva Pediátrica , Hormônio Paratireóideo/sangue , Prognóstico , Estudos Prospectivos , Vasoconstritores/uso terapêuticoAssuntos
Dentição/anormalidades , Intubação Intratraqueal/efeitos adversos , Respiração com Pressão Positiva/efeitos adversos , Anormalidades Dentárias/etiologia , Amelogênese Imperfeita/etiologia , Criança , Pré-Escolar , Seguimentos , Humanos , Lactente , Recém-Nascido , Doenças do Recém-Nascido/terapiaRESUMO
Percutaneous catheterization of the radial artery appears to be a simple and safe alternative to catheterization of the umbilical artery for monitoring critically ill neonates. This avoids the serious and potentially fatal complications associated with use of the umbilical arterial catheter, and it is also applicable to monitoring of neonates in whom the umbilical artery is no longer patent. We observed no serious sequelae in cannulation of the radial artery and think that the technique should be used more widely.