Preditores, padrão de desmame e desfecho em longo prazo de pacientes com ventilação mecânica prolongada em unidade de terapia intensiva no norte da Índia / Predictors and pattern of weaning and long-term outcome of patients with prolonged mechanical ventilation at an acute intensive care unit in North India

RESUMO Objetivo: Examinar as características clínicas, o padrão de desmame e o desfecho de pacientes que necessitaram de ventilação mecânica por tempo prolongado em uma unidade de terapia intensiva em um país com recursos financeiros limitados. Métodos: Estudo prospectivo observacional em centro único, realizado na Índia, no qual todos os pacientes adultos que necessitaram de ventilação mecânica prolongada foram acompanhados quanto a duração e padrão do desmame, e à sobrevivência, tanto por ocasião da alta da unidade de terapia intensiva quanto após 12 meses. A definição de ventilação mecânica prolongada adotada foi a do consenso da National Association for Medical Direction of Respiratory Care. Resultados: Durante o período de 1 ano, 49 pacientes com média de idade de 49,7 anos receberam ventilação mecânica prolongada; 63% deles eram do sexo masculino e 84% tinham uma enfermidade de natureza clínica. As medianas dos escores APACHE II e SOFA quando da admissão foram, respectivamente, 17 e 9. O tempo mediano de ventilação foi 37 dias. A razão mais comum para início da ventilação foi insuficiência respiratória secundária à sepse (67%). O desmame foi iniciado em 39 (79,5%) pacientes, com sucesso em 34 deles (87%). A duração mediana do desmame foi de 14 (9,5 - 19) dias, e o tempo mediano de permanência na unidade de terapia intensiva foi 39 (32 - 58,5) dias. A duração do suporte com vasopressores e a necessidade de hemodiálise foram preditores independentes significantes de insucesso no desmame. No acompanhamento após 12 meses, 65% dos pacientes sobreviveram. Conclusão: Mais de um quarto dos pacientes com ventilação invasiva na unidade de terapia intensiva necessitaram de ventilação mecânica prolongada. Os desmames foram bem-sucedido em dois terços dos pacientes, e a maioria deles sobreviveu até o acompanhamento após 12 meses.

ABSTRACT Objective: This study aimed to examine the clinical characteristics, weaning pattern, and outcome of patients requiring prolonged mechanical ventilation in acute intensive care unit settings in a resource-limited country. Methods: This was a prospective single-center observational study in India, where all adult patients requiring prolonged ventilation were followed for weaning duration and pattern and for survival at both intensive care unit discharge and at 12 months. The definition of prolonged mechanical ventilation used was that of the National Association for Medical Direction of Respiratory Care. Results: During the one-year period, 49 patients with a mean age of 49.7 years had prolonged ventilation; 63% were male, and 84% had a medical illness. The median APACHE II and SOFA scores on admission were 17 and 9, respectively. The median number of ventilation days was 37. The most common reason for starting ventilation was respiratory failure secondary to sepsis (67%). Weaning was initiated in 39 (79.5%) patients, with success in 34 (87%). The median weaning duration was 14 (9.5 - 19) days, and the median length of intensive care unit stay was 39 (32 - 58.5) days. Duration of vasopressor support and need for hemodialysis were significant independent predictors of unsuccessful ventilator liberation. At the 12-month follow-up, 65% had survived. Conclusion: In acute intensive care units, more than one-fourth of patients with invasive ventilation required prolonged ventilation. Successful weaning was achieved in two-thirds of patients, and most survived at the 12-month follow-up.

Treating Hyperglycemia in the Critically Ill Child: Is there Enough Evidence.

Need and purpose of review: Hyperglycemia is prevalent among critically ill pediatric patients. Previously thought to be an adaptive response to stress, hyperglycemia is now recognized to be associated with an adverse outcome. Correction of such hyperglycemia with insulin infusion has been shown to improve outcome but carries risk of hypoglycemia. This review addresses these issues related to treatment of hyperglycemia. Methods: A Pubmed search was performed using the search strategy: (hyperglycemia OR blood glucose OR insulin therapy) AND (critical illness OR critical care OR intensive care unit). Randomized controlled trials, clinical trials, metaanalysis and observational studies (adult and pediatric) published in the last 10 years were included. Conclusion: Blood sugar monitoring and correction of hyperglycemia while caring for critically ill children is crucial. A modest blood glucose target of <150 mg/dL is appropriate. Providing adequate nutrition along with training of the nursing personnel would prevent any adverse effect such as hypoglycemia.

Continuous hypertonic saline for acute liver failure.

Acute liver failure (ALF) is a clinical condition with high mortality. The most common cause of death in ALF is cerebral edema. We present a 12-year-old boy with hepatitis A-related acute liver failure in grade IV hepatic encephalopathy successfully managed in the ICU using continuous hypertonic saline as the preferred osmotherapy.

Staphylococcal sepsis presenting as pulmonary embolism.

Deep vein thrombosis in children is rare and is often secondary to a predisposing condition. Staphylococcal sepsis following furunculosis and complicated by deep vein thrombosis and septic pulmonary emboli in a fourteen-yr-old boy is presented. He was managed successfully with antibiotics and anticoagulation.

Neonatal arrhythmias.

OBJECTIVE: Neonatal arrhythmias are not uncommon; however, they rarely cause hemodynamic compromise. This paper aims to study the etiology, spectrum and outcome of neonates with arrhythmias who presented to a pediatric department. METHODS: All neonates, either inborn or brought to the pediatric emergency with rhythm disorders, between August 1999 to August 2002, were included prospectively. Evaluation including a search for secondary causes of rhythm disorder and a chest X-ray, standard 12-lead electrocardiography and echocardiography in all. The management required in each and the outcomes were noted. RESULTS: Nine neonates were identified, of which 4 were inborn. Tachycardia was seen in 8 neonates and bradycardia in only one. Three neonates had an antenatal onset of arrhythmias; in the rest it was postnatal in onset. Five neonates had a secondary rhythm disorder, secondary to metabolic derangements in 4 and a cardiac mass in 1. Five had ventricular arrhythmias and 5 had hemodynamic compromise due to the arrhythmia. The outcome was poor in 4 and was related to the underlying illness. CONCLUSION: Tachyarrhythmia is more common than bradyarrhythmia in the neonate. Arrhythmias secondary to various metabolic causes are more common than primary rhythm disorders.

Approach to a child with a heart murmur.

The vast majority of children with heart murmurs have an 'innocent' murmur. Differentiation of such murmurs from those due to structural cardiac disease, so called 'pathological' murmurs, is largely clinical. Pediatricians are capable of differentiating one from the other, provided a detailed evaluation is done. This article outlines the salient features of innocent murmurs that help us recognize them clinically.

Persistent coagulopathy in snake bite.

Bleeding diathesis is a cardinal feature of viperine bite, which has been thought to last not more than 24 hours. There is scarcity of literature about prolonged bleeding disorder in snake envenomation. Various explanations suggested in the literature include-temporary decrease in antivenin levels, rapid elimination of antivenin from circulation or continuous release of unneutralised venom from the envenomated site. Two children with prolonged coagulopathy lasting for more than a week, correction of which required more than 300 ml of antisnake venom are reported here.

Hypokalemic respiratory paralysis in Bartter's syndrome.

Life threatening hypokalemia can be a mode of presentation in renal salt wasting (Group-1) patients of Bartter's syndrome causing hypokalemic respiratory paralysis. Treatment on an emergent basis is required. In the long run, such patients may require higher doses of supplementary potassium and potassium sparing diuretics.