Um retrato de UTI Pediátricas em um recorte transversal durante a pandemia de COVID-19: uma avaliação de estrutura das unidades / A cross-sectional Portrait of Pediatric ICUs during the COVI-19 pandemic: an assessment of the structure of the units

O interesse da presente Dissertação surgiu com o intuito de avaliar as Unidades de Terapia Intensiva Pediátricas no aspecto de estrutura do serviço. O inquérito do estudo foi colhido de 01/07/2020 a 31/10/2020 através de um questionário autopreenchido pelos 29 médicos responsáveis técnicos e pelos 1084 profissionais de saúde atuantes nas unidades. O objetivo primário da Dissertação foi avaliar a adequabilidade de aspectos estruturais de 29 Unidades de Terapia Intensiva Pediátricas de sete estados no Brasil à regulamentação normativa que já estava vigente no país antes da pandemia, e às normativas e demandas impostas durante a pandemia. Foram analisados seletos indicadores de estrutura (recursos humanos, protocolos, estrutura física, orientações e rotinas na pandemia, educação continuada e treinamento, e recursos materiais). Na análise de indicadores para verificação de adequação à normativa regulamentadora, avaliou-se que na dimensão de recursos humanos e protocolos ao menos um terço das unidades não cumpriam requisitos previstos em norma. Em recursos humanos, as menores proporções observadas foram para a categoria de técnicos de enfermagem, médicos diaristas e fisioterapeutas (65.5%, 69.1%, 82.7%). Para protocolos clínicos, há 55.2% de unidades que têm protocolos de sepse, sedação e dor instalados e vigentes. Apesar de já haver essa defasagem em questões estruturais, quando se analisou a adequação para as normativas e demandas da pandemia, verificou-se que a resposta das unidades nas diferentes dimensões de estrutura analisadas foi em geral melhor ou semelhante ao observado em estudos feitos na mesma época na América Latina. Foram entrevistados 1084 profissionais de saúde e 60% tiveram disponibilidade de Equipamentos de Proteção Individual (EPI) para assistência em procedimentos geradores de aerossol. As unidades com financiamento privado obtiveram maiores proporções de adequação em recursos humanos para algumas categorias profissionais durante a pandemia como para médicos intensivistas (44.8% x 17.2%; p<0.01). Também houve diferença significativa em recursos materiais, como para assistência em procedimentos geradores de aerossol (31.3% x 28.8%; p=0.02). A categoria profissional que teve mais inadequação à normativa para disponibilidade de EPI foi a de técnicos de enfermagem (14.4% x 11.3%; p<0.01). O que se observou, portanto, foi que nos aspectos avaliados a situação pré-pandemia era razoável, mas já com espaços para melhorias, e durante a crise sanitária houve uma resposta comparável a resultados encontrados em outros estudos na região. Porém, se tivesse havido uma gestão mais eficiente com deslocamento adequado de recursos, é provável que a reação tivesse sido melhor. (AU)

The interest of this dissertation arose to evaluate Pediatric Intensive Care Units (PICU) in terms of service structure. The study survey was collected from 07/01/2020 to 10/31/2020 through a self-completed questionnaire by the 29 technical responsible physicians and 1084 health professionals working in the unit. The primary objective was to describe and evaluate the suitability of structural aspects of 29 Pediatric Intensive Care Units from seven states in Brazil to the normative regulation that was already in course in Brazil before the pandemic, and to the norms and demands imposed during the pandemic. It is proposed to analyze structure indicators (human resources, protocols, physical structure, guidelines and routines in the pandemic, continuing education and training, and material resources). In the analysis of indicators for verification of adequacy to the regulatory norms, it was evaluated that in the dimension of human resources and protocols, at least one third of the units did not fulfill requirements foressen in the norm. In human resources, the lowest proportions observed were for the category of nursing technicians, diarist doctors and physiotherapists (65.5%, 69.1%, 82.7%). For protocols and routines, there are 55.2% of units that have sepsis sedation and pain protocols installed and current. Despite this lag, already existing, when the suitability for the pandemic's regulations and demands was analyzed, it was found that the response of the units in the different structural dimensions analyzed was generally better or similar to that observed in studies carried out at that period in Latin America. There were 1084 health professionals interviewed and 60% had personal protective Equipment (PPE) available for assistance in aerosol- generating procedures. Units with private funding had higher proportions of adequacy in human resources for some professional categories during the pandemic such as intensive care physicians (44.8% x 17.2%; p<0.01), and material resources, such as assistance in aerosol-generating procedures (31.3% x 28.8%; p=0.02). The professional category that had the most inadequacy to the regulations for the availability for of PPE (personal protective equipment) was that of nursing technicians (14.4% x 11.3%; p<0.01). What was observed, therefore, was that in the aspects evaluated, the pre-pandemic situation was reasonable, but already with room for improvement, and during the health crisis there was a response comparable to results found in other studies in the region. However, if there had been more efficient management with adequate allocation of resources, it is likely that the reaction would have been better. (AU)

Factores de riesgo asociados a infecciones por Acinetobacter baumannii en una unidad de cuidados intensivos pediátricos / Risk factors associated to Acinetobacter baumannii in a PICU

El Acinetobacter baumannii (Ab) es un germen nosocomial, multiresistente, afecta especialmente a pacientes críticamente enfermos, contribuyendo en la mortalidad; su impacto en nuestro medio es desconocido. Objetivos: el presente estudio pretende determinar la incidencia de infección por Ab y los principales factores de riesgo asociados. Métodos: se realizó un estudio observacional, de tipo caso y control en 257 niños internados en la UTIP del Hospital del Niño Manuel Ascencio Villarroel. Resultados: encontrándose 4 brotes a lo largo del año y una incidencia de 7,8/100 internados; el germen fue aislado en superficies inanimadas, no así en el personal. Se evidenciaron los siguientes factores de riesgo tras 10 días de exposición: Días de internación en UTIP (OR=10,09; p=0,000), uso de ventilador mecánico (OR=15,75; p=0,000), intubación endotraqueal (OR=17,09; p=0,000), catéter urinario (OR=11,9; p=0,000), catéter venoso central (OR=12,9; p=0,000), catéter venoso periférico (OR=14,2; p=0,000), sonda naso u orogástrico (OR=13; p=0,000). La mortalidad observada no varía significativamente de la mortalidad general. Conclusiones: concluimos que el Ab es el principal agente bacteriano nosocomial en la UTIP, la estancia prolongada en el servicio, y los días de invasividad aumentan el riesgo de adquirir este germen; se requieren medidas de control de los brotes para disminuir su incidencia.

Acinetobacter baumannii (Ab) is a nosocomial, multiresistent pathogen, affecting especially critically ill patients, leading to mortality; is unknown its impact in our hospital. Objectives: this study pretends to determinate infection incidence of Ab and its risk factors associated. Methods: it was performed an observational, case and control study, in 257 children admitted to Manuel Ascencio Villarroel Children Hospital; we found 4 spreads in a year, the incidence was 7,8/100 of admitted patients. Ab was isolated in environmental cultures, but was not found in personal cultures. Results: we found following risk factors after 10 days exposure: PICU days internship (OR=10,09; p=0,000), mechanical ventilation (OR=15,75; p=0,000), endothacheal tube (OR=17,09; p=0,000), urinary catheter (OR=11,9; p=0,000), central venous catheter (OR=12,9; p=0,000), peripherical venous catheter (OR=14,2; p=0,000), oro or nasogastric catheter (OR=13; p=0,000); mortality found associated to Ab was similar to the found in the control group Conclusions: we concluded that Ab is the most frequent pathogen isolated in our PICU, prolonged stay and invasive methods increase risk to be infected by this pathogen; control measures are necessary to decrease its incidence.

Candidemia en las unidades de cuidados intensivos neonatal y pediatría del Hospital "Dr. Domingo Luciani": Incidencia y susceptibilidad antifúngica (2006-2009) / Cadidemia in neonatal and pediatric intensive care unit of "Dr. Domingo Luciani" Hospital: Incidence and antifungal susceptibility ()2006-2009

La incidencia de candidemia en la Unidad de Terapia Intensiva Neonatal (UTIN) y Pediátrica (UTIP) ha aumentado significativamente en las últimas décadas y se observa un cambio en la distribución de especies del género Candida, siendo cada vez más frecuente el aislamiento de especies no albicans. En paralelo, se ha registrado un aumento considerable de cepas que han desarrollado resistencia secundaria a los antifúngicos. Se planteó como objetivo determinar la frecuencia de candidemia y susceptibilidad a los antifúngicos de Candida spp en la UTIN y UTIP del Hospital "Dr. Domingo Luciani" (HDL) en el período enero 2006 a diciembre 2009. Se realizó un estudio descriptivo/retrospectivo de corte transversal donde se revisaron los archivos de micología obteniéndose 86 registros de hemocultivos, 35 de los cuales fueron enfrentados a su historia médica correspondiente para el estudio de los factores asociados a candidemia. Para el manejo de los datos se usó el software Excel, y para el análisis estadístico se evaluaron las variables por medidas de tendencia central. Los cultivos positivos representaron el 43% (35/86) y Candida no albicans (28/35) se aisló en el 80% de los casos. La frecuencia de las especies aisladas fue: Candida parapsilosis 23/35 (66 %), Candida albicans 7/35 (20%), Candida tropicalis 3/35 (9%) y Candida guillermondii 2/35 (6%).Todas las especies fueron sensibles a fluconazol (FZ) y voriconazol (VZ), a excepción de una cepa de C. parapsilosis que resultó resistente a FZ (4%) y SDD a VZ (4%). De todos los factores estudiados, se evidenció una asociación entre el uso de catéter venoso central (CVC), nutrición parenteral total (NPT), ventilación mecánica asistida (VMA) y presencia de candidemia, encontrándose estos como los principales factores asociados a candidemia en nuestra serie. Se concluye que existe un predominio de las especies no albicans, siendo C. parapsilosis la más frecuente en sangre.

The incidence of candidemia in Neonatal Intensive Care Unit (NICU) and Pediatric Intensive Care Unit (PICU) has increased significantly in recent decades and there is a change in the distribution of Candida species, becoming more frequent isolation of non- albicans species. In parallel, there has been a significant increase in strains that have developed secondary resistance to antifungal agents. It was our objective to determine the frequency of candidemia and antifungal susceptibility of Candida spp in the NICU and PICU of the Hospital "Dr. Domingo Luciani" (HDL) in the period January 2006 to December 2009. We designed a descriptive / retrospective cross-sectional study, the mycology laboratory files were reviewed and 86 blood cultures records were obtained, 35 of whom were opposed to its medical history in order to study risk factors associated with candidemia. For data management Excel software was used, and statistical analysis variables were assessed by measures of central tendency. Positive cultures represented 43% (35/86) and non-albicans Candida (28/35) was isolated in 80% of cases. The frequency of the isolated species was: Candida parapsilosis 23/35 (66%), Candida albicans 7/35 (20%), Candida tropicalis 3/35 (9%) and Candida guillermondii 2/35 (6%). All species were susceptible to fluconazole (FZ) and voriconazole (VZ), except for one strain of C. parapsilosis which were resistant to FZ (4%) and SDD to VZ (4%). Of all variables we studied, it showed an association between the uses of central venous catheter (CVC), total parenteral nutrition (TPN), attended mechanical ventilation ( AMV) and presence of candidemia, been these the main factors associated with c andidemia in our serie. We conclude that there is a prevalence of non-albicans species and C. parapsilosis was found as the most common isolated from blood-culture