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Background: To understand critical paediatric coronavirus disease 2019 (COVID-19) and evaluate factors associated with mortality in children from high and low-middle income countries. Methods: Prospective, observational study of critically ill children hospitalised for COVID-19 in 18 countries throughout North America, Latin America, and Europe between April 1 and December 31, 2020. Associations with mortality were evaluated using logistic regression. Findings: 557 patients (median age, 8 years; 24% <2 years) were enrolled from 55 sites (63% Latin American). Half had comorbidities. Invasive (41%) or non-invasive (20%) ventilation and vasopressors (56%) were the most common support modalities. Hospital mortality was 10% and higher in children <2 years old (15%; odds ratio 1·94, 95%CI 1·08-3·49). Most who died had pulmonary disease. When adjusted for age, sex, region, and illness severity, mortality-associated factors included cardiac (aOR 2·89; 95%CI 1·2-6·94) or pulmonary comorbidities (aOR 4·43; 95%CI 1·70-11·5), admission hypoxemia (aOR 2·44; 95%CI 1·30-4·57), and lower respiratory symptoms (aOR 2·96; 95%CI 1·57-5·59). MIS-C (aOR 0·25; 95%CI 0·1-0·61) and receiving methylprednisolone (aOR 0·5; 95%CI 0·25-0·99), IVIG (aOR 0·32; 95%CI 0·16-0·62), or anticoagulation (aOR 0·49; 95%CI 0·25-0·95) were associated with lower mortality although these associations might be limited to children >2 years old. Interpretation: We identified factors associated with COVID-19 mortality in critically ill children from both high and low-middle income countries, including higher mortality with younger age and COVID-related pulmonary disease but lower mortality in MIS-C. Further research is needed on optimal treatments for younger children and respiratory failure in paediatric COVID-19. Funding: None.
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New diagnoses of leukaemia and other malignancies are recently being made in paediatric patients with COVID-19. The rates of mortality and morbidity in some of these children are expected to be higher. In new cases, concurrent diagnosis can be difficult because multisystemic inflammatory syndrome (MIS-C) and malignancies have similar clinical presentations. We present the case of a preteenage child where the diagnosis of leukaemia was complicated and delayed by a multisystem involvement and an inconclusive bone marrow study. Clinical teams managing children with COVID-19 and MIS-C should suspect leukaemia and other malignancies when the clinical course is complicated and bone marrow suppression is persistent. Prompt diagnosis will allow start of treatment on time, minimising complications.
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COVID-19 , Leucemia-Linfoma Linfoblástico de Células Precursoras , Síndrome do Desconforto Respiratório , Insuficiência Respiratória , COVID-19/complicações , Criança , Humanos , Leucemia-Linfoma Linfoblástico de Células Precursoras/complicações , Leucemia-Linfoma Linfoblástico de Células Precursoras/diagnóstico , Síndrome de Resposta Inflamatória Sistêmica/diagnósticoRESUMO
Current therapies frequently used for refractory septic shock include hydrocortisone, vasopressin, extracorporeal membrane oxygenation (ECMO) support, inodilators, levosimendan and methylene blue. The evidence for these treatments is very limited. We present a case of a 5-year-old patient with refractory septic shock, secondary to Listeria monocytogenes meningitis. She presented with status epilepticus and developed septic shock. Shock persisted despite multiple high-dose vasoactive medications. ECMO support was not available. The medical team decided to use methylene blue to revert the vasoplegia, with excellent results. Shortly after the administration, vasopressors were weaned off and the high lactate cleared. She developed severe neurological sequelae due to brain haemorrhage secondary to the Listeria meningitis. The evidence supporting methylene blue for refractory septic shock in paediatric patients is limited. This case represents the effectiveness of this therapy without secondary effects.
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Oxigenação por Membrana Extracorpórea , Listeriose , Choque Séptico , Criança , Pré-Escolar , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Humanos , Listeriose/complicações , Listeriose/tratamento farmacológico , Azul de Metileno/uso terapêutico , Choque Séptico/complicações , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêuticoRESUMO
INTRODUCTION: The objective of the study was to analyse the correlation between extracorporeal life support (ECLS) and aortic cross-clamp times and optic nerve sheath diameter (ONSD). PATIENTS AND METHODS: Study in a cohort of patients aged 0-15 years that underwent ECLS for cardiac surgery after obtention of signed informed consent. We calculated a sample size of 23 participants. First, we obtained 3 vertical and 3 horizontal measurements of the ONSD for each eye and calculated the mean of both eyes for each measurement to be used in the analysis. The measurements were made at admission and at 6 and 24â¯h post surgery. We retrieved the ECLS time and the aortic cross-clamp time were from the operative report. RESULTS: We analysed data for 23 participants, 52.2% female, with a median age of 14 months. The median ECLS time was 60â¯min; the median aortic cross-clamp time was 32â¯min. The median baseline ONSD was 3.1â¯mm. ONSD values had increased a median of 0.015â¯mm at 6â¯h post surgery (Pâ¯=â¯.03). We found a positive correlation between ECLS time and ONSD values (râ¯=â¯0.476, Pâ¯<â¯0,05). The ONSD values returned to baseline by 24â¯h post surgery. None of the patients developed signs or symptoms of increased intracranial pressure. CONCLUSION: Our study found a correlation between ECLS time and ONSD at 24â¯h post surgery. We found variations in the ONSD even in patients without signs or symptoms of increased ICP. Further research is required to identify the factors related to these variations.
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Oxigenação por Membrana Extracorpórea , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Pressão Intracraniana/fisiologia , Masculino , Nervo Óptico/diagnóstico por imagem , Estudos Prospectivos , UltrassonografiaRESUMO
SARS-CoV-2 infection in children with primary immunodeficiency disease (PID) and its complications have not yet been well described, the course of COVID-19 can range from mild illness to death. We aim to report the case of a child with a PID who develop a severe and persistent pulmonary COVID-19 infection. We present chronologically his clinical course, tests, interventions and radiological findings showing his irregular evolution and poor response to infection. This case highlights the need to accurately monitor the immune response in these cases to try to stop the progression of the damage.
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COVID-19 , Doenças da Imunodeficiência Primária , Criança , Família , Humanos , Pulmão/diagnóstico por imagem , SARS-CoV-2RESUMO
AIM: Studies assessing the association between admission time to paediatric intensive care unit (PICU) and mortality are sparse with conflicting results. We aimed to evaluate the impact of time of admission on PICU mortality within 48 h after admission. METHODS: This was a single-centre prospective cohort. We collected data from all consecutive children aged 1 month to 16 years over 10 years. RESULTS: We included a total of 1368 admissions, with a PICU mortality of 6.6%. Compared with daytime admissions, the overall mortality rate (5.3% vs. 8.5%, P = 0.026) and the mortality within 48 h after admission were higher for those admitted during night-time (2% vs. 4.2%, P = 0.021). There were no differences between mortality rates and the day of admission (weekend admissions vs. weekday admissions). The adjusted odds of death within 48 h after admission was 2.5 (95% confidence interval = 1.22-5.24, P = 0.012) for patients admitted at night-time. A secondary analysis assessing trends in mortality rates during admission showed that the last 5 years of study were more responsible for the chances of death within 48 h (odds ratio = 7.6, 95% confidence interval = 1.91-30.17, P = 0.0039). CONCLUSION: Admission to the PICU during night shifts was strongly associated with death compared to daytime admissions. A time analysis of the moment of admission is necessary as a metric of quality of care to identify the interruption or improvement in the continuity of care. Further studies are needed to assess the modified contributing factors.
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Unidades de Terapia Intensiva Pediátrica , Admissão do Paciente , Criança , Estudos de Coortes , Mortalidade Hospitalar , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Fatores de TempoRESUMO
BACKGROUND: Persistent inflammation, immunosuppression and catabolism syndrome (PICS) has been described in critically ill adults and may contribute to unfavourable outcomes. The present study aimed to describe and characterise PICS in critically ill children (PICS-ped) and to verify its association with clinical outcomes. METHODS: A prospective longitudinal study was conducted in a paediatric intensive care unit (PICU) with children aged between 3 months and 15 years. PICS-ped, based on adult definition, was described. PICS-ped was defined as PICU length of stay >14 days; C-reactive protein > 10.0 mg L-1 ; lymphocytes <25%; and any reduction of mid-upper arm circumference Z-score. Clinical, demographic, nutritional status, nutrition therapy parameters and clinical outcomes were assessed. Statistical analysis comprised Mann-Whitney and Fisher's chi-squared tests, as well as logistic and Cox regression. P < 0.05 was considered statistically significant. RESULTS: In total, 153 children were included, with a median age of 51.7 months (interquartile range 15.6-123.4 months), and 60.8% male. The mortality rate was 10.5%. The prevalence of PICS-ped was 4.6%. Days using vasoactive drugs and days using antibiotics were associated with PICS-ped. PICS-ped was associated with mortality in crude (odds ratio = 6.67; P = 0.013) and adjusted analysis (odds ratio = 7.14; P = 0.017). PICS-ped was also associated with PICU and hospital length of stay, as well as duration of mechanical ventilation. Similar results were found in a subset of critically ill children who required mechanical ventilation for more than 48 h. CONCLUSIONS: Children with PICS-ped required antibiotics or vasoactive drugs for a longer period. PICS-ped was associated with poor clinical outcomes in critically ill children. More studies are needed to properly define PICS-ped for this population.
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Estado Terminal , Terapia de Imunossupressão , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Inflamação , Tempo de Internação , Estudos Longitudinais , Masculino , Estudos ProspectivosRESUMO
AIM: To describe nurse and physician perspectives on enabling factors that promote sustainability of high flow use in resource-limited settings. BACKGROUND: Over 650 000 children died from respiratory infections in 2016 globally. Many deaths could be prevented with access to advanced paediatric respiratory support, but sustainability of technology in resource-limited settings remains challenging. INTRODUCTION: Local providers have expertise related to site-specific barriers to sustainability. Engaging local providers during implementation can identify strategies to promote ongoing technology use beyond initial deployment. METHODS: This qualitative descriptive study was conducted five focus groups with nineteen nurses and seven individual interviews with physicians in a Peruvian paediatric intensive care unit. Data were analysed using a realist thematic approach. RESULTS: Providers described five important factors for high flow sustainability: (i) Applying high flow to a broader patient population, including use outside the paediatric intensive care unit to increase opportunities for practice; (ii) Establishing a multidisciplinary approach to high flow management at all hours; (iii) Willingness of nurses and physicians to adopt standardization; (iv) Ongoing high flow leadership; (v) Transparency of high flow impact, including frequent reporting of clinical outcomes of high flow patients. DISCUSSION: Local providers described strategies to overcome barriers to sustainability of high flow in their clinical setting, many of which are generalizable to implementation projects in other resource-limited settings. CONCLUSION AND POLICY IMPLICATIONS: These findings provide nursing, administrative leaders and policymakers with strategies to promote sustainability of new technology in resource-limited settings, including development of guidelines for appropriate clinical use, change management support, leadership development and clinical outcome reporting procedures. Administrative support and oversight are paramount to foster successful implementation in these settings.
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Pessoal de Saúde/psicologia , Unidades de Terapia Intensiva Pediátrica/organização & administração , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Fluxo de Trabalho , Adulto , Atitude do Pessoal de Saúde , Feminino , Saúde Global , Política de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Peru , Pesquisa QualitativaRESUMO
Bronchopulmonary dysplasia (BPD) is occasionally associated with tracheobronchomalacia, and it is this combination that can lead to serious outcomes. The most severe cases require tracheostomies, ventilatory support and eventually even tracheal stents or surgery. Ventilation in patients with tracheomalacia is complicated without a good patient-ventilator synchrony; the neurally adjusted ventilatory assist (NAVA) mode is potentially beneficial in these cases. This case report presents a patient affected by BPD and severe tracheobronchomalacia who was tracheostomised and ventilated 24 hours a day and who suffered from episodes of airway collapse despite using the NAVA mode. It was necessary to increase the positive end-expiratory pressure to 20 cmH2O (the PEEP-20 manoeuvre) for several minutes during an episode; this allowed the trachea to remain open and allowed us to optimise the patient's ventilation. This strategy has previously been described in a patient with tracheomalacia, reducing the frequency and need for sedation in the following episodes.
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Displasia Broncopulmonar/terapia , Respiração com Pressão Positiva , Traqueobroncomalácia/terapia , Traqueostomia , Desmame do Respirador , Humanos , LactenteRESUMO
Antibiotic consumption (AC) is a key component of antimicrobial stewardship programs to recognize local patterns of antibiotic use. Our aim was to measure AC in neonatal units, including neonatal (NICU)/paediatric (PICU) intensive care units in different countries. We conducted a multicenter, retrospective, cohort study in three NICUs, one neonatal ward, and three PICUs with a total of 84 beds. Global and individual AC in days of therapy (DOT) and DOT per 1000 patient-days were assessed. During the study period, 2567 patients were admitted, corresponding to 4961 patient-days in neonatal units and 9243 patient-days in PICUs. Multidrug-resistant Gram-negative bacteria and methicillin-resistant Staphylococcus aureus were more frequent in Brazil than in Germany. Average AC was 386.5 and 1335.5 DOT/1000PD in German and Brazilian neonatal units, respectively. Aminopenicillins plus 3rd generation cephalosporins were the most commonly prescribed antibiotics in German neonatal units, while aminopenicillins plus aminoglycosides were the class most commonly used in Brazilian NICU. Average AC was 888.1 and 1440.7 DOT/1000PD in German and Brazilian PICUs, respectively. Antipseudomonal penicillins were most commonly used in the German PICU, and glycopeptides were the most frequently prescribed in Brazilian PICUs. Carbapenems represented 2.3-14% of total DOTs in German neonatal units and 4% in the Brazilian NICU and 13.0% in the German PICU and 6-12.2% in Brazilian PICUs. We concluded that different patterns of most commonly prescribed antibiotics were observed in neonatal units and PICUs in these two countries, probably related to different local patterns of antibiotic resistance, with a higher antibiotic consumption in Brazilian study units.
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Antibacterianos/uso terapêutico , Gestão de Antimicrobianos/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos , Unidades de Terapia Intensiva Neonatal , Unidades de Terapia Intensiva Pediátrica , Centros Médicos Acadêmicos/estatística & dados numéricos , Adolescente , Antibacterianos/administração & dosagem , Brasil , Criança , Pré-Escolar , Farmacorresistência Bacteriana Múltipla , Feminino , Alemanha , Bactérias Gram-Negativas/efeitos dos fármacos , Humanos , Lactente , Recém-Nascido , Masculino , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Estudos RetrospectivosRESUMO
OBJECTIVE: To identify determinants and outcomes associated with infection in paediatric systemic lupus erythematosus (SLE) patients at admission and during hospitalization in intensive care units (ICUs). PATIENTS AND METHODS: A retrospective cohort study of paediatric SLE patients admitted to two ICUs was conducted. Frequency and risk factors of infection as well as mortality were studied. RESULTS: Seventy-three infection episodes amongst 55 patients were analysed. The median age was 14.4 years (IQR 12.5-16). The median SLEDAI was 16 (IQR 12-20). Twenty-nine episodes were documented at admission; the CRP was higher in these patients (6.58 versus 1.04 mg/dl, p<0.001) than in non-infected patients, even after multivariate adjustment (OR 8.6, 95% CI = 2.1-34.8, p = 0.003). Twenty-five (34.7%) episodes occurred during hospitalization. Lupus activity (OR 1.14, 95% CI = 1.01-1.27, p = 0.029), cyclophosphamide (OR 17.9, 95% CI = 2-156, p = 0.009) and mechanical ventilation (OR 16, 95% CI = 2.1-122, p = 0.008) were associated with infection. Ten episodes (14%) led to death. Admission to the ICU due to infection was strongly associated with mortality (90% versus 31.8%, OR 19.4, 95% CI = 2.3-163, p = 0.006). CONCLUSION: In paediatric lupus patients admitted to the ICU, elevated CRP should alert clinicians to possible infection. During hospitalization, SLE activity and cyclophosphamide were associated with infection. Infection at admission to the ICU was strongly associated with mortality.
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Hospitalização/estatística & dados numéricos , Infecções/epidemiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Lúpus Eritematoso Sistêmico/complicações , Adolescente , Estudos de Coortes , Ciclofosfamida/administração & dosagem , Feminino , Humanos , Imunossupressores/administração & dosagem , Infecções/etiologia , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Lúpus Eritematoso Sistêmico/fisiopatologia , Masculino , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
Resumen: Objetivo: cuantificar el uso de sedoanalgesia en niños críticamente enfermos con asistencia ventilatoria mecánica (AVM) en la Unidad de Cuidados Intensivos (UCIN) del Centro Hospitalario Pereira Rossell (CHPR). Metodología: estudio observacional descriptivo y prospectivo realizado entre los meses de mayo a setiembre de 2017. Se incluyeron pacientes ingresados a UCIN que requirieron AVM y sedoanalgesia o mioparalización. Se registraron las siguientes variables: sexo, edad, peso, diagnóstico al ingreso. En relación con la sedación y analgesia se registraron dosis indicadas y recibidas de cada fármaco y las dosis acumulativas. Se las comparó con un estudio realizado en 2012 en UCIN. Resultados: se incluyeron 37 pacientes. El promedio de días de AVM fue de 3,7. La causa más frecuente de AVM fue patología respiratoria (n=34). Se observó discordancia entre dosis indicada y dosis recibida tanto de opiáceos, benzodiacepinas y paralizantes musculares, pero en menor medida que lo registrado en el año 2012. Las dosis acumulativas de midazolam, fentanyl y atracurio disminuyeron respecto al año 2012. Conclusión: se observó una disminución de las dosis promedio utilizadas de cada fármaco, de la duración de la AVM y una menor incidencia de síndrome de abstinencia. Las causas de esta observación pueden ser multifactoriales.
Summary: Objective: to quantify benzodiazepines and opioids dosages used in critically ill children under invasive mechanical ventilation (IMV) hospitalized in a Paediatric Intensive Care Unit (PICU). Methodology: an observational study was carried out from May to September 2017. It included children who under IMV hospitalized in a PICU and who were treated with benzodiazepines, opioids and/or neuromuscular blockers. These children key clinical features were recorded. Cumulative doses of benzodiazepines, opioids and neuromuscular blockers were recorded. Results were compared with the data obtained in a previous experience in the same PICU in 2012. Results: 37 children were included. IMV average duration of was 3.7 days. Cumulative doses and treatment duration of midazolam, fentanyl and atracurium decreased from 2012 to 2017. There were differences between the doses prescribed and the doses actually received in both periods. Conclusion: cumulative doses of benzodiazepines, opioids and neuromuscular blockers decreased in the 2012-2017 period.
Resumo: Objetivo: quantificar o uso da sedação e analgesia em crianças criticamente doentes com Assistência de Ventilação Mecânica (MAV) na Unidade de Terapia Intensiva (UTIN) do Centro Hospitalar Pediátrico Pereira Rossell (CHPR). Metodologia: estudo observacional descritivo e prospectivo realizado de maio a setembro de 2017. Incluíram-se pacientes internados em UTIN que necessitaram de MAV e sedação e analgesia e / ou bloqueadores neuromusculares. Registraram-se as seguintes variáveis: sexo, idade, peso, diagnóstico no momento da admissão. Foram registradas as doses indicadas e recebidas de cada droga de sedação e analgesia, assim como as doses cumulativas. Os resultados foram comparados com um estudo realizado em 2012 na UTIN. Resultados: incluíram-se 37 pacientes. O tempo médio de AVM foi de 3,7 dias. A causa mais frequente de MAV foi doença respiratória (n = 34). Observou-se dissonância entre a dose indicada e a dose recebida dos opiáceos, benzodiazepínicos e agentes paralisantes musculares, mas em grau menor do que o registrado em 2012. As doses cumulativas de midazolam, fentanil e atracúrio diminuíram em relação a 2012. Conclusão: observamos uma diminuição nas doses médias de cada droga utilizada, na duração da MAV e uma menor incidência de síndrome de abstinência. Esta observação pode ter causas multifatoriais.
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OBJECTIVES: To evaluate the advantages and disadvantages of using different standard concentration infusions for high-alert inotropic and vasoactive drugs in paediatric intensive care units (ICUs). METHODS: Retrospective data analysis was performed on drug prescriptions for patients in paediatric ICUs. A matrix was developed based on optimal concentration recommendations for each drug, taking into consideration solution stability and patient safety. Hypothetical volumes were calculated for three standard solutions (high concentration - HC, low concentration - LC and fluid restriction - FR) and compared to the actual administered volumes to evaluate the impact of the volumes of each standard solution for varying weight ranges in paediatric care. Finally, a risk assessment of the standard infusions was conducted using the NPSA 20 tool along with an assessment of the pharmacoeconomic impact. KEY FINDINGS: The results suggest the need for at least two standard concentrations for each of the studied drugs in order to attend to the different weight ranges and clinical conditions of paediatric patients in intensive care. CONCLUSIONS: High concentration is ideal for patients up to 20 kg. For patients over 20 kg, FR is recommended, while LC should only be used in specific situations. Modifying the hospital pharmacotherapy system to include standard solutions is safer and reduces the risks of adverse effects. The pharmacoeconomic analysis did not show any impact on costs, although a reduction in adverse effects should be considered.
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Cardiotônicos/administração & dosagem , Unidades de Terapia Intensiva Pediátrica , Segurança do Paciente/normas , Vasoconstritores/administração & dosagem , Vasodilatadores/administração & dosagem , Criança , Pré-Escolar , Dobutamina/administração & dosagem , Dopamina/administração & dosagem , Epinefrina/administração & dosagem , Humanos , Lactente , Recém-Nascido , Infusões Intravenosas/normas , Concentração Máxima Permitida , Milrinona/administração & dosagem , Estudos Retrospectivos , Medição de RiscoRESUMO
BACKGROUND: Hand hygiene is considered the single most effective means of reducing healthcare-associated infections, but improving and sustaining hand hygiene compliance remains a great challenge. OBJECTIVES: To compare hand hygiene compliance before and after interventions to promote adherence in a paediatric intensive care unit (PICU) and to identify predictors of intention to perform the behaviour "hand hygiene during patient care in the PICU". METHODS: A before and after study was conducted in three phases. Based on the World Health Organization guideline for hand hygiene compliance monitoring, 1261 hand hygiene opportunities were directly observed during routine patient care by two observers simultaneously, in a nine-bed PICU in Brazil, before and after infrastructure and educational interventions. To identify predictors of healthcare professionals' intention to perform the behaviour hand hygiene during patient care, a data collection instrument was designed based on the Theory of Planned Behaviour. Statistical analyses were undertaken using Chi-square test or the Fisher's exact test and regression analysis. A significance level of 5% (p < 0.05) was applied to all analyses. RESULTS: The hand hygiene compliance rate increased significantly from 27.3% in the "pre-intervention phase" to 33.1% in "phase 1-post-intervention," to 37.0% in "phase 2-post-intervention" (p = .010). Perceived social pressure (p = .026) was a determinant factor of intention to perform the behaviour. CONCLUSIONS: Hand hygiene compliance raised significantly after infrastructure, educational, and performance feedback interventions. However, despite the significant effect of the implemented interventions, the overall hand hygiene compliance rate was low. Perceived social pressure characterised a determinant factor of intention to perform the behaviour "hand hygiene during patient care in the PICU", reinforcing the need for behaviour determinants analysis when designing promotional interventions.
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Infecção Hospitalar/prevenção & controle , Fidelidade a Diretrizes , Higiene das Mãos , Pessoal de Saúde , Controle de Infecções/métodos , Unidades de Terapia Intensiva Pediátrica , Adulto , Brasil , Cuidados Críticos , HumanosRESUMO
The death of a child in the Paediatric Intensive Care Unit (PICU) is difficult, the loss generates feelings of sadness and pain; this study highlights the different coping strategies used by nurses to manage this situation and find the strength to provide care at the end of life. OBJECTIVE: Explore the strategies used by nurses in the PICU in coping with death. METHODS: Study conducted in the city of Manizales, Colombia, during the months of October, November and December. A qualitative, hermeneutical phenomenological approach was used. The method of intentional sampling for the selection of participating nurses (n=10) working in PICU, in-depth interviews were conducted for the construction of the information and the data were analyzed according to the procedures proposed by Cohen, Kahn and Steeves. RESULTS: Nurses use coping strategies focused on emotions: they inhibit their feelings towards the patient and their family; they use communication and prayer with the patient, as well as accompaniment to alleviate the suffering of the family. CONCLUSION: UCIP nurses develop coping strategies for end-of-life care using spiritual resources and communication with the family who require ongoing support, reflecting on death and accompanying the child in its transcendence.
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Adaptação Psicológica , Atitude Frente a Morte , Recursos Humanos de Enfermagem Hospitalar/psicologia , Adulto , Criança , Feminino , Humanos , Unidades de Terapia Intensiva Pediátrica , MasculinoRESUMO
Background Problems related to pharmacotherapy are common in patients admitted to the paediatric intensive care unit (PICU) and are associated with increased healthcare costs. Data on the impact of clinical pharmacist interventions to prevent pharmacotherapy-related problems and to minimize costs in the PICU are limited. Objectives To evaluate the number and type of clinical pharmacist interventions in the PICU and to determine cost savings associated with them. Setting a ten bed PICU of a tertiary-care university hospital in Brazil. Method This was a prospective, observational study conducted over 1-year. The Failure Mode and Effects Analysis (FMEA) tool was applied at the beginning of the study to assess drug-related risks in the PICU and to guide clinical pharmacist interventions. Main outcome measure Number and type of clinical pharmacist interventions and healthcare-related costs. Results One hundred sixty-two children were followed-up by the clinical pharmacist and 1586 prescriptions were evaluated; pharmacotherapy-related problems were identified in 12.4% of them. Sixteen of 75 failure modes identified by FMEA were potentially reduced by the clinical pharmacist interventions. There were 197 interventions with a cost saving of R$ 15,118.73 (US$ 4828.00). Clinical pharmacist interventions were related to drug interaction and therapeutic monitoring (34.5%), drug selection (22.3%), dosing and frequency (16.8%), prescription (13.2%) and administration (13.2%). Ninety-seven per cent of the clinical pharmacist interventions were accepted by the medical team. The interventions with larger cost savings were related to administration (39%). Conclusion The clinical pharmacist interventions minimized the risks of pharmacotherapy-related problems and contributed to the reduction of costs associated with medical prescription.
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Custos de Cuidados de Saúde/estatística & dados numéricos , Unidades de Terapia Intensiva Pediátrica/economia , Erros de Medicação/economia , Erros de Medicação/prevenção & controle , Serviço de Farmácia Hospitalar/economia , Serviço de Farmácia Hospitalar/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos ProspectivosRESUMO
AIM: Identification of critically ill children upon presentation to the emergency department (ED) is challenging, especially when resources are limited. The objective of this study was to identify ED risk factors associated with serious clinical deterioration (SCD) during hospitalisation in a resource-limited setting. METHODS: A retrospective case-control study of children less than 18 years of age presenting to the ED in a large, freestanding children's hospital in Peru was performed. Cases had SCD during the first 7 days of hospitalisation whereas controls did not. Information collected during initial ED evaluation was used to identify risk factors for SCD. RESULTS: A total of 120 cases and 974 controls were included. In univariate analysis, young age, residence outside Lima, evaluation at another facility prior to ED presentation, congenital malformations, abnormal neurologic baseline, co-morbidities and a prior paediatric intensive care unit admission were associated with SCD. In multivariate analysis, age < 12 months, residence outside Lima and evaluation at another facility prior to ED presentation remained associated with SCD. In addition, comatose neurological status, hypoxaemia, tachycardia, tachypnoea and temperature were also associated with SCD. CONCLUSIONS: Many risk factors for SCD during hospitalisation can be identified upon presentation to the ED. Using these factors to adjust monitoring during and after the ED stay has the potential to decrease SCD events. Further studies are needed to determine whether this holds true in other resource-limited settings.
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Deterioração Clínica , Serviço Hospitalar de Emergência/organização & administração , Hospitais Pediátricos/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Adolescente , Análise de Variância , Estudos de Casos e Controles , Criança , Pré-Escolar , Países em Desenvolvimento , Feminino , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Lactente , Masculino , Análise Multivariada , Avaliação das Necessidades , Peru , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do TratamentoRESUMO
At present, there are growing rates of psychiatric symptoms among some occupational categories, with emphasis on health professionals who work in hospitals. This study aimed to identify the occurrence of mental health problems (anxiety and depression) among 92 nursing workers in a paediatric cardiac intensive care unit. This is an exploratory, cross-sectional study, with a quantitative approach. The research was conducted in a public university hospital specialising in cardiology, pneumology, and thoracic and cardiac surgery. The data were collected between June and July of 2012 through socio-demographic and Self-Reporting Questionnaire (SRQ-20) instruments. The analysis of the results revealed the occurrence of mental health problems in 45% (41) of the workers. There was the prevalence of tension, nervousness and worry symptoms, followed by headache. Findings highlight the need for protective measures towards the mental health of workers who assist children with serious heart disease.
Assuntos
Cardiopatias Congênitas/enfermagem , Unidades de Terapia Intensiva Pediátrica , Transtornos Mentais/epidemiologia , Recursos Humanos de Enfermagem Hospitalar/psicologia , Adulto , Ansiedade/epidemiologia , Brasil/epidemiologia , Estudos Transversais , Depressão/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Inquéritos e QuestionáriosRESUMO
PURPOSE: Central line-associated bloodstream infection (CLABSI) is an important cause of complications in paediatric intensive care units (PICUs). Peripherally inserted central catheters (PICCs) could be an alternative to central venous catheters (CVCs) and the effect of PICCs compared with CVCs on CLABSI prevention is unknown in PICUs. Therefore, we aimed to evaluate whether PICCs were associated with a protective effect for CLABSI when compared to CVCs in critically ill children. METHODS: We have carried out a retrospective multicentre study in four PICUs in São Paulo, Brazil. We included patients aged 0-14 years, who needed a CVC or PICC during a PICU stay from January 2013 to December 2015. Our primary endpoint was CLABSI up to 30 days after catheter placement. We defined CLABSI based on the Center for Disease Control and Prevention's National Healthcare Safety Networks (NHSN) 2015 surveillance definitions. To account for potential confounders, we used propensity scores with inverse probability weighting. RESULTS: A total of 1660 devices (922 PICCs and 738 CVCs) in 1255 children were included. The overall CLABSI incidence was 2.28 (95% CI 1.70-3.07)/1000 catheter-days. After covariate adjustment using propensity scores, CVCs were associated with higher risk of CLABSI (adjHR 2.20, 95% CI 1.05-4.61; p = 0.037) compared with PICCs. In a sensitivity analysis, CVCs remained associated with higher risk of CLABSI (adjHR 2.18, 95% CI 1.02-4.64; p = 0.044) after adding place of insertion and use of parenteral nutrition to the model as a time-dependent variable. CONCLUSIONS: PICC should be an alternative to CVC in the paediatric intensive care setting for CLABSI prevention.
Assuntos
Infecções Relacionadas a Cateter/prevenção & controle , Cateterismo Venoso Central/efeitos adversos , Cateterismo Periférico/efeitos adversos , Cateteres Venosos Centrais/efeitos adversos , Adolescente , Bacteriemia/epidemiologia , Bacteriemia/prevenção & controle , Infecções Relacionadas a Cateter/epidemiologia , Cateterismo Venoso Central/métodos , Cateterismo Periférico/métodos , Cateterismo Periférico/estatística & dados numéricos , Cateteres Venosos Centrais/estatística & dados numéricos , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Pediátrica , Masculino , Pontuação de Propensão , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Fatores de TempoRESUMO
Introducción: La vitamina D posee múltiples acciones sobre el organismo: es necesaria para la salud ósea, la función cardiovascular y del sistema inmune. En adultos críticos, el déficit de vitamina D (DVD) es frecuente y se ha asociado a sepsis y a desenlaces clínicos desfavorables. Objetivos: Determinar la prevalencia del DVD y establecer su asociación con desenlaces clínicos relevantes en niños ingresados a una Unidad de Cuidados Intensivos Pediátricos (UCIP) en Concepción, región del centro-sur de Chile. Pacientes y método: Estudio de cohorte prospectivo observacional en 90 niños. Los niveles plasmáticos de vitamina D fueron medidos al ingreso en la UCIP. Se analizaron características demográficas, escalas de gravedad (PRISM, PELOD, VIS) y desenlaces clínicos. El déficit de 25OHD se definió como niveles < 20 ng/mL. Se determinó la asociación entre el DVD y desenlaces relevantes mediante el cálculo del riesgo relativo (RR). Resultados: El valor promedio (DE) de la vitamina D en toda la cohorte fue de 22,8 (1,0) ng/mL. La prevalencia del DVD fue del 43,3%. El DVD se asoció significativamente con el uso de fármacos vasoactivos (RR 1,6; IC 95%: 1,2-2,3; p < 0,01), ventilación mecánica (RR 2,2; IC 95%: 1,2-3,9; p < 0,01), shock séptico (RR 1,9; IC 95%: 1,3-2,9; p < 0,001) y necesidad de fluidos de reanimación > 40 ml/kg en las primeras 24 h (RR 1,5; IC 95%: 1,1-2,1; p < 0,05). Conclusiones: En este estudio, el DVD al ingreso en UCIP fue prevalente en pacientes pediátricos críticos y se asoció a desenlaces clínicos adversos. Se requieren más ensayos para determinar si la restauración rápida de los niveles de vitamina D permitiría mejorar los desenlaces clínicos en niños críticamente enfermos.
Introduction: Vitamin D is essential for bone health, as well as for cardiovascular and immune function. In critically ill adults vitamin D deficiency (VDD) is common, and is associated with sepsis and higher critical illness severity. Objectives: To establish the prevalence of VDD and its association with clinically relevant outcomes in children admitted to a Paediatric Intensive Care Unit (PICU) in Concepcion, Chile. Patients and method: Prospective observational cohort study in 90 consecutive children admitted to the PICU in a university general hospital. Blood was collected on admission to PICU and analysed for 25-OH-D levels. Severity of illness and vasopressor use were assessed using PRISM, PELOD, and vasoactive-inotropic score (VIS) score. VDD was defined as a serum 25-OH-D level < 20 ng/ml. Relative risks (RR) were calculated to determine the association between VDD and relevant clinical outcomes. Results: Mean (SD) serum vitamin D (25-OH-D) level in the cohort was 22.8 (1.0) ng/ml. The prevalence of VDD was 43.3%. VDD was associated with vasopressors use (RR 1.6; 95%CI: 1.2-2.3; P<.01), mechanical ventilation (RR 2.2; 95%CI: 1.2-3.9, P<.01), septic shock (RR 1.9; 95%CI: 1.3-2.9, P<.001), and fluid bolus > 40 ml/kg in the first 24 h of admission (RR 1.5; 95%CI: 1.1-2.1, P<.05). Conclusions: In this study, VDD at PICU admission was prevalent in critically ill children and was associated with adverse clinical outcomes. Further studies are needed to assess the potential benefit of optimizing vitamin D status in the PICU.