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Biomedical subjects

Jefferson Pedro Piva

Publications and source records attributed to Jefferson Pedro Piva.

12 recordsLinked to original sources
PubMed2005

The burden of paediatric intensive care: a South American perspective.

Paediatric intensive care is a relatively new medical specialty that has shown a marked growing up around the world over the last three decades. The limits and the development of this new specialty are not uniform from country to country. Original articles relating to paediatric intensive care and some South American data bases of health care were evaluated and relevant results were selected. Using these data, we describe the main characteristics of paediatric intensive care in South America and discuss some associated factors (e.g. economic aspects, health systems, ethical aspects) that could interfere with the quality and extent of care. A strong relationship between the financial stability of each region and the complexity and quality of paediatric intensive care was seen. A better coverage and more sophisticated paediatric intensive care units (PICUs) are concentrated in the more developed countries (Brazil, Chile and Argentina). Compared to the northern hemisphere, children admitted to the South American PICUs have higher mortality and higher rates of intervention (mechanical ventilation and indwelling catheters). Medical paternalism has a strong influence in the decision-making process offered to terminally ill patients. This phenomenon increases the length of stay, reduces the number of available beds and increases costs. In conclusion, during the last 20 years PICUs have developed and increased their coverage in South America. However, the most sophisticated and well equipped PICUs are preferentially located in the more developed areas whereas those areas with higher infant mortality rates have few PICU beds. Improvements in the economical stability, regional health organisation as well as the rationale for PICU localisation are some of the important goals to be reached in the near future.

Child↗
PubMed2005

Evolution of the medical practices and modes of death on pediatric intensive care units in southern Brazil.

OBJECTIVES: To study the possible change on mode of deaths, medical decision practices, and family participation on decisions for limiting life-sustaining treatments (L-LST) over a period of 13 yrs in three pediatric intensive care units (PICUs) located in southern Brazil. METHODS: A cross-sectional study based on a retrospective chart review (1988 and 1998) and on prospective data collection (from May 1999 to May 2000). SETTING: Three PICUs in Porto Alegre, southern Brazilian region. PATIENTS: Children who died in those PICUs during the years of 1988, 1998, and between May 1999 and May 2000. RESULTS: The 3 PICUs admitted 6,233 children during the study period with a mortality rate of 9.2% (575 deaths), and 509 (88.5%) medical charts were evaluated in this study. Full measures for life support (F-CPR) were recognized in 374 (73.5%) children before dying, brain death (BD) was diagnosed in 43 (8.4%), and 92 (18.1%) underwent some limitation of life support treatment (L-LST) There were 140 (27.5%) deaths within the first 24 hrs of admission and 128 of them (91.4%) received F-CPR, whereas just 11 (7.9%) patients underwent L-LST. The average length of stay for the death group submitted to F-CPR was lower (3 days) than the L-LST group (8.5 days; p < .05). The rate of F-CPR before death decreased significantly between 1988 (89.1%) and 1999/2000 (60.8%), whereas the L-LST rose in this period from 6.2% to 31.3%. These changes were not uniform among the three PICUs, with different rates of L-LST (p < .05). The families were involved in the decision-making process for L-LST in 35.9% of the cases, increasing from 12.5% in 1988 to 48.6% in 1999/2000. The L-LST plans were recorded in the medical charts in 76.1% of the deaths, increasing from 50.0% in 1988 to 95.9% in 1999/2000. CONCLUSION: We observed that the modes of deaths in southern Brazilian PICUs changed over the last 13 yrs, with an increment in L-LST. However, this change was not uniform among the studied PICUs and did not reach the levels described in countries of the Northern Hemisphere. Family participation in the L-LST decision-making process has increased over time, but it is still far behind what is observed in other parts of the world.

Brazil↗
PubMed2003

[Adrenal insufficiency in children with septic shock].

OBJECTIVE: To review the criteria for diagnosing and treating adrenal insufficiency in patients with septic shock. SOURCE OF DATA: Articles published in Brazilian and foreign journals selected through these publicationś websites and Medline, as well as references cited in key articles. SUMMARY OF THE FINDINGS: The literature reports a range betwen 17 and 54% for the finding of adrenal insufficiency in patients with septic shock. There is no consensus for diagnosing adrenal insufficiency in patients suffering from critical diseases, particularly in patients with septic shock. The presence of volume-refractory and catecholamine-resistant septic shock suggests this condition, while basal cortisol under 25 micro g/dl is a diagnostic criterion indicating adrenal insufficiency. The adrenal stimulation test is a useful resource for identifying patients with relative adrenal insufficiency. Our testing option for adrenal stimulation in children is the use of corticotropin in low doses (0.5 micro g/1,73 m(2)). An increase of less than 9 micro g/dl in the value of postcorticotropin-stimulated cortisol suggests the presence of occult (relative) adrenal insufficiency. In patients with septic shock presenting adrenal insufficiency, either suspected or confirmed, the administration of hydrocortisone in shock or stress doses can be vital for a favorable clinical outcome. CONCLUSIONS: The existing data, although controversial, already provides a basis to determine when to begin hormone replacement therapy, the serum level of cortisol accepted as adequate, and the choice of corticotropin doses for performing the adrenal stimulation test and diagnosing occult or relative adrenal insufficiency in patients with septic shock.

Adrenal Cortex Function Tests↗
PubMed2003

[Analgesia and sedation in emergency situations and in the pediatric intensive care unit].

OBJECTIVE: To review the current strategies for use of sedatives and analgesics in emergency rooms and intensive care units. SOURCE OF DATA: Original data from our emergency rooms and intensive care units; Medline literature review focused on sedatives and analgesic drugs; textbooks. SUMMARY OF THE FINDINGS: Despite the advances in understanding pain in children, in many critical care units the misguided treatment of pain and anxiety still results in significant morbidity. Difficulties in communication, invasive procedures and the belief that children do not have sufficient neurologic development to process noxious sensations are still a challenge in intensive care units. CONCLUSIONS: The last decade was marked by significant advances in understanding pediatric pain. Treating intensive care unit-related pain and anxiety has clear benefits which may influence the course of disease.

Analgesics↗
PubMed2002

[A sixteen-year epidemiological profile of a pediatric intensive care unit, Brazil].

OBJECTIVE: To review epidemiological data from patients admitted to a Pediatric Intensive Care Unit (PICU), Brazil, and to compare them to medical aspects associated to disease severity and mortality. Also, to profile these patients, including demographic data, disease prevalence, mortality rates and associated factors. METHODS: Retrospective data were collected from all patients admitted in a PICU of a university hospital between 1978 and 1994. Data were presented as percentages and compared using Chi-square, and calculating the relative risk (RR) with a 95% confidence interval, p<0.05. RESULTS: Of 13, 101 patients selected, most of them were boys (58.4%), younger than 12 months of age (40.4%), well-nourished (69.5%), and with clinical disease (73.1%). The general mortality rate was 7.4%. Patients aged less than 12 months showed a RR of 1.86 (CI 1.65 - 2.10; p<0.0001), while the RR of malnutrition was 2.98 (CI 2.64 - 3.36; p<0.0001). CONCLUSIONS: The epidemiological survey showed that the mortality is higher in malnourished children younger than 12 months of age. Sepsis was the most main cause of death.

Age Factors↗
PubMedDate not supplied

[Controversies in the pharmacological management of acute asthma in children].

OBJECTIVE: To present a review of controversial issues related to the pharmacological management of the treatment of acute asthma in children. SOURCES: Articles published in national and international scientific journals. Data were selected from Lilacs and Medline databases. SUMMARY OF THE FINDINGS: The article was organized into topics, presenting aspects on which there is consensus regarding the pharmacological treatment of asthma in children. Issues related to the use of metered dose inhaler versus nebulizers, the role of beta2-adrenergic drugs administered intravenously as well as the role of methylxanthine and magnesium sulfate are approached critically. CONCLUSIONS: Inhaled beta2-agonist drugs combined with corticosteroids remain the treatment of choice for acute episodes of asthma in children. Either nebulizers or metered dose inhalers connected to spacers are efficient for the relief of acute symptoms. Patients who are refractory to conventional treatment and develop severe acute asthma should receive beta2-agonist drugs intravenously, provided they are properly monitored. Methylxanthine and magnesium sulfate should be considered a second choice for selected patients.

English Abstract↗
PubMedDate not supplied

[Sedation and analgesia in children submitted to mechanical ventilation could be overestimated?].

OBJECTIVE: To describe the pattern of analgesic and sedative infusions in children submitted to mechanical ventilation in a regional pediatric intensive care unit during a 12-month period. To compare the use of these drugs among clinical and surgical patients, as well evaluate the influence of the length of use on the average daily doses and on the incidence of abstinence syndrome. METHODS: This cohort study was performed from April 2001 to March 2002, involving children (1 month old to 15 years old) submitted to the mechanical ventilation through a tracheal tube for a period longer than 12 hours and who were successfully extubated (dead patients and those who required reintubation were excluded from the study). A team of professionals not involved with the patient's assistance performed a daily collection of all data up to the 28th day under mechanical ventilation (maximum length of follow up for those who remain longer under mechanical ventilation). The main outcome was the infusion doses of morphine, fentanyl, ketamine and midazolam administered at 12 AM (considering this dose as the average dose for that day). The diagnosis of abstinence syndrome was based on the chart revision (recorded diagnosis or based on the specific antagonist treatment used) and in an interview with the assistant physician on the following days after the extubation. This study was approved by the Ethics and Scientific Committee of the HSL-PUCRS. RESULTS: 127 children were eligible for this study, but only 124 patients were analyzed (16.0 +/- 29-5 months old; 58% male; 92 defined as clinical patients and 32 as surgical patients). An average of 1.7 sedative-analgesic infusion per patient a day was used in the whole group (without difference between clinical and surgical groups). Morphine and fentanyl were the most common drugs infused in both groups (fentanyl was preferred for the clinical group and morphine for the surgical group). The mean length of infusion was different (p<0.01) between clinical and surgical patients (6.8 and 3.9 days, respectively). After the 7th day, there was a significant increase in the fentanyl and midazolam doses (p<0.01), as well as a higher incidence of abstinence syndrome in the clinical group (p<0.01). CONCLUSION: This study evaluated the daily practice in a regional PICU, and it demonstrated that analgesic and sedative infusions in children submitted to mechanical ventilation are used according to an uncontrolled pattern (average 1.7 drugs/patient/day) and those classified as clinical patients used these drugs for longer periods, what could explain the higher prevalence of abstinence syndrome in this group.

Analgesics↗
PubMedDate not supplied

[Assessment of intubation procedures at reference pediatric and neonatal intensive care units].

OBJECTIVE: To describe intubation procedures in two pediatric and two neonatal intensive care units in the city of Porto Alegre. METHODS: Cross-sectional study divided into a retrospective and a prospective phase. All intubations performed in these units during a 6-month period were considered. Data were collected by interviewing the physician responsible for the procedure and reviewing the patients' charts, including drugs administered, sedation status, number of attempts, difficulties and complications during the procedure. Data were analyzed using the t test and the Mann-Whitney test for continuous variables and the chi-square test for categorical variables, considering a p < 0.05. RESULTS: Sedatives were administered in 89.5% of the 134 pediatric procedures and 24% of the 116 neonatal procedures (p < 0.001). Muscle relaxants were prescribed for 3% of the children and 0.9% of the neonates. Only 53.7% of the children and 31.9% of the neonates were considered as adequately relaxed. The children who were inadequately relaxed had more intubations attempts (2.4-/+1.3 vs 1.7-/+1.2 p = 0.001), became more hypoxemic (20.9 vs 5.5% p = 0.015) and were more difficult to intubate (54.8 vs 25% p < 0.001). There were more urgent cases and more intubations attempts (2-/+1.2 vs 1.5-/+0.9 p = 0.036) among the inadequately relaxed neonates. Difficulties and complications occurred in 38.8 and 28.3% of the pediatric cases and 29 and 12% of the neonatal cases, respectively. CONCLUSIONS: There was no established routine for intubation procedures in the units studied, and the use of muscle relaxants was not usual. The absence of adequate muscle relaxation is associated with more intubation attempts, difficulties and hypoxemia during the intubation procedure.

Adolescent↗
PubMedDate not supplied

[Comparison of two prognostic scores (PRISM and PIM) at a pediatric intensive care unit].

OBJECTIVE: To compare the performance of the PRISM (Pediatric Risk of Mortality) and the PIM (Pediatric Index of Mortality) scores at a general pediatric intensive care unit, investigating the relation between observed mortality and survival and predicted mortality and survival. METHODS: A contemporary cohort study undertaken between 1 June 1999 and 31 May 2000 at the Pontifícia Universidade Católica do Rio Grande do Sul, Hospital São Lucas pediatric intensive care unit. The inclusion criteria and the PRISM and PIM calculations were performed as set out in the original articles and using the formulae as published. Statistical analysis for model evaluation employed the Flora z test, Hosmer-Lemeshow goodness-of-fit test, ROC curve (receiver operating characteristic) and Spearman's correlation tests. The study was approved by the institution's Ethics Committee. RESULTS: Four hundred and ninety-eight patients were admitted to the pediatric intensive care unit, 77 of whom presented exclusion criteria. Thirty-three (7.83%) of the 421 patients studied died and 388 patients were discharged. Estimated mortality by PRISM was 30.84 (7.22%) with a standardized mortality rate of 1.07 (0.74-1.50), z = -0.45 and by PIM this was 26.13 (6.21%) with a standardized mortality rate of 1.26 (0.87-1.77), z = -1.14. The Hosmer-Lemeshow test gave a chi-square of 9.23 (p = 0.100) for PRISM and 27.986 (p < 0.001) for PIM. The area under the ROC curve was 0.870 (0.810-0.930) for PRISM and 0.845 (0.769-0.920) for PIM. The Spearman test returned r = 0.65 (p < 0.001). CONCLUSION: Analyzing the tests we can observe that, although the PIM test was less well calibrated overall, both PRISM and PIM offer a good capacity for discriminating between survivors and moribund patients. They are tools with comparable performance at the prognostic evaluation of the pediatric patients admitted to our unit.

Child↗