Randomized controlled trial comparing nasal intermittent positive pressure ventilation and nasal continuous positive airway pressure in premature infants after tracheal extubation.

OBJECTIVE:: To analyze the frequency of extubation failure in premature infants using conventional mechanical ventilation (MV) after extubation in groups subjected to nasal intermittent positive pressure ventilation (nIPPV) and continuous positive airway pressure (nCPAP). METHOD:: Seventy-two premature infants with respiratory failure were studied, with a gestational age (GA) ≤ 36 weeks and birth weight (BW) > 750 g, who required tracheal intubation and mechanical ventilation. The study was controlled and randomized in order to ensure that the members of the groups used in the research were chosen at random. Randomization was performed at the time of extubation using sealed envelopes. Extubation failure was defined as the need for re-intubation and mechanical ventilation during the first 72 hours after extubation. RESULTS:: Among the 36 premature infants randomized to nIPPV, six (16.6%) presented extubation failure in comparison to 11 (30.5%) of the 36 premature infants randomized to nCPAP. There was no statistical difference between the two study groups regarding BW, GA, classification of the premature infant, and MV time. The main cause of extubation failure was the occurrence of apnea. Gastrointestinal and neurological complications did not occur in the premature infants participating in the study. CONCLUSION:: We found that, despite the extubation failure of the group of premature infants submitted to nIPPV being numerically smaller than in premature infants submitted to nCPAP, there was no statistically significant difference between the two modes of ventilatory support after extubation.

Randomized controlled trial comparing nasal intermittent positive pressure ventilation and nasal continuous positive airway pressure in premature infants after tracheal extubation / Estudo controlado e randomizado entre uso de ventilação positiva intermitente e pressão positiva contínua em vias aéreas em recém-nascidos prematuros após a extubação traqueal

Summary Objective: To analyze the frequency of extubation failure in premature infants using conventional mechanical ventilation (MV) after extubation in groups subjected to nasal intermittent positive pressure ventilation (nIPPV) and continuous positive airway pressure (nCPAP). Method: Seventy-two premature infants with respiratory failure were studied, with a gestational age (GA) ≤ 36 weeks and birth weight (BW) > 750 g, who required tracheal intubation and mechanical ventilation. The study was controlled and randomized in order to ensure that the members of the groups used in the research were chosen at random. Randomization was performed at the time of extubation using sealed envelopes. Extubation failure was defined as the need for re-intubation and mechanical ventilation during the first 72 hours after extubation. Results: Among the 36 premature infants randomized to nIPPV, six (16.6%) presented extubation failure in comparison to 11 (30.5%) of the 36 premature infants randomized to nCPAP. There was no statistical difference between the two study groups regarding BW, GA, classification of the premature infant, and MV time. The main cause of extubation failure was the occurrence of apnea. Gastrointestinal and neurological complications did not occur in the premature infants participating in the study. Conclusion: We found that, despite the extubation failure of the group of premature infants submitted to nIPPV being numerically smaller than in premature infants submitted to nCPAP, there was no statistically significant difference between the two modes of ventilatory support after extubation.

Resumo Objetivo: analisar a frequência de falha da extubação em recém-nascidos pré-termo (RNPT) em uso de ventilação mecânica (VM) convencional após a extubação traqueal nos grupos submetidos à ventilação por pressão positiva intermitente por via nasal (nIPPV) e pressão positiva contínua em vias aéreas (nCPAP). Método: foram estudados 72 RNPT portadores de insuficiência respiratória, com idade gestacional (IG) ≤ 36 semanas e peso de nascimento (PN) > 750 g, que necessitaram de entubação traqueal e ventilação mecânica. O estudo foi controlado e randomizado a fim de garantir a aleatoriedade na escolha dos integrantes dos grupos. A randomização foi realizada no momento da extubação por meio de envelopes selados. Falha da extubação foi definida como necessidade de reentubação e ventilação mecânica durante as primeiras 72 horas após a extubação. Resultados: entre os 36 RN randomizados para nIPPV, seis (16,6%) apresentaram falha de extubação em comparação a 11 (30,5%) dos 36 RN randomizados para nCPAP. Não houve diferença estatística entre os dois grupos de estudo em relação a PN, IG, classificação do RN e tempo de VM. A principal causa de falha da extubação foi a ocorrência de apneia. Complicações gastrointestinais e neurológicas não ocorreram nos RNPT participantes do estudo. Conclusão: constatamos que no grupo dos RNPT submetidos à nIPPV, apesar da falha da extubação ser numericamente menor que nos RNPT submetidos à nCPAP, não houve diferença estatisticamente significante entre os dois modos de suporte ventilatório após a extubação.

Hospital malnutrition and inflammatory response in critically ill children and adolescents admitted to a tertiary intensive care unit.

UNLABELLED: Critical illness has a major impact on the nutritional status of both children and adults. A retrospective study was conducted to evaluate the incidence of hospital malnutrition at a pediatric tertiary intensive care unit (PICU). Serum concentrations of IL-6 in subgroups of well-nourished and malnourished patients were also evaluated in an attempt to identify those with a potential nutritional risk. METHODS: A total of 1077 patients were enrolled. Nutritional status was evaluated by Z-score (weight for age). We compared mortality, sepsis incidence, and length of hospital stay for nourished and malnourished patients. We had a subgroup of 15 patients with severe malnutrition (MN) and another with 14 well-nourished patients (WN). Cytokine IL-6 determinations were performed by enzyme-linked immunosorbent assay. RESULTS: 53% of patients were classified with moderate or severe malnutrition. Similar amounts of C- reactive protein (CRP) were observed in WN and MN patients. Both groups were able to increase IL-6 concentrations in response to inflammatory systemic response and the levels followed a similar evolution during the study. However, the mean values of serum IL-6 were significantly different between WN and MN patients across time, throughout the study (p = 0.043). DISCUSSION: a considerable proportion of malnourished patients need specialized nutritional therapy during an intensive care unit (ICU) stay. Malnutrition in children remains largely unrecognized by healthcare workers on admission. CONCLUSIONS: The incidence of malnutrition was very high. Malnourished patients maintain the capacity to release inflammatory markers such as CRP and IL-6, which can be considered favorable for combating infections On the other hand, this capacity might also have a significant impact on nutritional status during hospitalization.

Hospital malnutrition and inflammatory response in critically ill children and adolescents admitted to a tertiary intensive care unit

Critical illness has a major impact on the nutritional status of both children and adults. A retrospective study was conducted to evaluate the incidence of hospital malnutrition at a pediatric tertiary intensive care unit (PICU). Serum concentrations of IL-6 in subgroups of well-nourished and malnourished patients were also evaluated in an attempt to identify those with a potential nutritional risk. METHODS: A total of 1077 patients were enrolled. Nutritional status was evaluated by Z-score (weight for age). We compared mortality, sepsis incidence, and length of hospital stay for nourished and malnourished patients. We had a subgroup of 15 patients with severe malnutrition (MN) and another with 14 well-nourished patients (WN). Cytokine IL-6 determinations were performed by enzyme-linked immunosorbent assay. RESULTS: 53 percent of patients were classified with moderate or severe malnutrition. Similar amounts of C- reactive protein (CRP) were observed in WN and MN patients. Both groups were able to increase IL-6 concentrations in response to inflammatory systemic response and the levels followed a similar evolution during the study. However, the mean values of serum IL-6 were significantly different between WN and MN patients across time, throughout the study (p = 0.043). DISCUSSION: a considerable proportion of malnourished patients need specialized nutritional therapy during an intensive care unit (ICU) stay. Malnutrition in children remains largely unrecognized by healthcare workers on admission. CONCLUSIONS: The incidence of malnutrition was very high. Malnourished patients maintain the capacity to release inflammatory markers such as CRP and IL-6, which can be considered favorable for combating infections On the other hand, this capacity might also have a significant impact on nutritional status during hospitalization.

Análise comparativa da freqüência de prematuridade e baixo peso entre filhos de mães adolescentes e adultas / Comparative analysis of prematurity and low birth weight between newborns of adolescent and adult mothers

A gravidez na adolescência é um problema de saúde pública por ser considerada uma gravidez de alto risco. A incidência de prematuridade e de baixo peso ao nascer entre filhos de mães adolescentes varia dependendo da região e pais estudado. OBJETIVO: realizar uma análise comparativa da freqüência de prematuridade e baixo peso entre filhos de mães adolescentes e adultas. MÉTODO: estudo prospectivo comparativo de uma série de casos no qual foram incluídos 132 mães e seus recém nascidos (51 mães adolescente e 81 mães adultas) internados em dois hospitais públicos da cidade de São Paulo, no período de junho de 2005 a maio de 2006. Em relação às mães foram analisadas as seguintes variáveis: idade, raça, escolaridade, ocupação, número de gestações e de abortos, pré-natal (número de consultas), antecedentes mórbidos antes e durante o pré-natal, tipo de parto e uso de drogas lícitas e ilícitas. Em relação aos recém-nascidos foram analisados: Boletim de Apgar, sexo, peso de nascimento, idade gestacional, adequação nutricional e aleitamento materno. RESULTADOS: A gravidez na adolescência esteve relacionada com nascimentos de crianças prematuras (16-31.4% no grupo de mães adolescentes e 7-8.65% no grupo de mães adultas, p=0.01), e esta relação não foi observada com o baixo peso ao nascer (14-27.5% no grupo adolescente e 16-19.8% no grupo de mães adultas, p=0.17). Não houve diferenças significantes em relação aos outros parâmetros. CONCLUSÕES: a assistência pré-natal pareceu diminuir a freqüência de baixo peso ao nascer em filhos de mães adolescentes. Não houve interferência na freqüência da prematuridade(AU)

Adolescent pregnancy is a high-risk gestation and the incidence of prematurity and low birth weight in adolescent mothers' newborns is different in each region and country. OBJECTIVE: to carry out a comparative analysis of prematurity and low birth weight frequency between newborns of adolescent and adult mothers. METHODS: this is a prospective study that investigated 132 mothers and their children (51 adolescent mothers and 81 adult mothers) that were hospitalized in two public hospitals in the city of S„o Paulo from June, 2005 to May, 2006. The following data were compared: mothers - age, race, school level, occupation, number of gestations and abortions, prenatal follow-up (number of medical visits), type of delivery and use of drugs. For the neonates: Apgar Score, gender, gestational age, birth weight, nutritional classification and breastfeeding. RESULTS: pregnancy in adolescence was statistically associated with premature births (16-31.4 percent in the adolescent group and 7-8.65 percent in the adult group, p=0.01) but not with low birth weight (14-27.5 percent in the adolescent group and 16-19.8 percent in the adult group, p=0.17). There were no significant differences in relation to the other parameters. CONCLUSIONS: we observed that an adequate prenatal follow-up seemed to reduce the low birth weight frequency in newborns of adolescent mothers but not the frequency of prematurity.(AU)

Choque refratário e óbito após intoxicação por sulfato ferroso / Refractory shock and death by iron poisoning

OBJETIVO: Descrever um caso de intoxicação por ferro em uma criança após ingestão acidental de sulfato ferroso. DESCRIÇÃO DO CASO: Lactente de 11 meses de idade admitida após ingestão acidental de sulfato ferroso (dose desconhecida); apresentava diarréia, desidratação grave e torpor. Inicialmente, foram adotadas medidas para estabilização hemodinâmica, suporte ventilatório e terapia vasopressora. A dosagem de ferro sérico era de 259μmol/L, sendo iniciado desferoxamina. Apesar do tratamento, manteve quadro de instabilidade hemodinâmica, sem melhora após associação de adrenalina. Evoluiu para óbito 50 horas após admissão no hospital por choque refratário. COMENTÁRIOS: O sulfato ferroso é uma medicação amplamente utilizada em nosso meio e de fácil acesso às crianças nos domicílios. No caso descrito, apesar do diagnóstico precoce e dos cuidados prestados prontamente, não foi possível evitar grave evolução para choque refratário e óbito. Portanto, é importante prevenir a intoxicação e conhecer a evolução de uma intoxicação por ferro, uma vez que o tratamento nem sempre evita a má evolução.

OBJECTIVE: To present a case of a child with iron intoxication due to an accidental ingestion of ferrous sulfate. CASE DESCRIPTION: An eleven-month-old child was admitted to the hospital after an accidental ingestion of ferrous sulfate, presenting diarrhea, severe dehydration and drowsiness. Initially, therapies for hemodynamic stabilization, ventilatory support and vasopressor drugs were adopted. Laboratory test revealed high serum iron level (259μmol/L) and deferoxamine administration was started. Despite treatment, the child persisted with hemodynamic instability, without improvement after epinephrine infusion and died 50 hours after admission, due to refractory shock. COMMENTS: The ferrous sulfate is widely used and easily accessible for children in their homes. In this case report, despite prompt diagnosis and early institution of adequate treatment, it was not possible to avoid the development of refractory shock and death. Therefore, it is important to avoid intoxication as well as to improve medical knowledge about the pathophysiology of iron intoxication, acknowledging that treatment not always avoids a poor outcome.

Análise comparativa da freqüência de prematuridade e baixo peso entre filhos de mães adolescentes e adultas / Comparative analysis of prematurity and low birth weight between newborns of adolescent and adult mothers

A gravidez na adolescência é um problema de saúde pública por ser considerada uma gravidez de alto risco. A incidência de prematuridade e de baixo peso ao nascer entre filhos de mães adolescentes varia dependendo da região e pais estudado. Objetivo: realizar uma análise comparativa da freqüência de prematuridade e baixo peso entre filhos de mães adolescentes e adultas. Método: estudo prospectivo comparativo de uma série de casos no qual foram incluídos 132 mães e seus recém nascidos (51 mães adolescente e 81 mães adultas) internados em dois hospitais públicos da cidade de São Paulo, no período de junho de 2005 a maio de 2006. Em relação às mães foram analisadas as seguintes variáveis: idade, raça, escolaridade, ocupação, número de gestações e de abortos, pré-natal (número de consultas), antecedentes mórbidos antes e durante o pré-natal, tipo de parto e uso de drogas lícitas e ilícitas. Em relação aos recém-nascidos foram analisados: Boletim de Apgar, sexo, peso de nascimento, idade gestacional, adequação nutricional e aleitamento materno. Resultados: A gravidez na adolescência esteve relacionada com nascimentos de crianças prematuras (16-31.4 por cento no grupo de mães adolescentes e 7-8.65 por cento no grupo de mães adultas, p= 0.01), e esta relação não foi observada com o baixo peso ao nascer (14-27.5 por cento no grupo adolescente e 16-19.8 por cento no grupo de mães adultas, p= 0.17). Não houve diferenças significantes em relação aos outros parâmetros. Conclusões: a assistência pré-natal pareceu diminuir a freqüência de baixo peso ao nascer em filhos de mães adolescentes. Não houve interferência na freqüência da prematuridade.

Neonatal sepsis and meningitis caused by Neisseria meningitidis: a case report.

OBJECTIVE: To report a full-term newborn infant that developed a sepsis associated to meningitis caused by Neisseria meningitidis serogroup C on the 14th day of life. CASE DESCRIPTION: The patient was a term female infant, born to a mother with Systemic Lupus Erythematosus, with birth weight of 2,610 g, Apgar Score 1, 4 and 8, who needed mechanical ventilation for 24 hours. On the 7th day of life, the neonate was discharged from the hospital with good overall condition. On the 15th day of life, the newborn infant presented fever and respiratory failure. The cerebrospinal fluid showed 1042 cells/mm3, with neutrophilic predominance, protein of 435 mg/dL, and glucose < 10 mg/dL. The blood and the cerebrospinal fluid cultures were positive for Neisseria meningitidis serogroup C. The neonate was hospitalized, needing mechanical ventilation and vasoactive drugs, and received 21 days of crystalline penicillin. After hospital discharge, there were no signs of neurological sequels and the infant was able to be breastfed. The case report presents a unique situation: an uncommon etiology of neonatal meningitis and favorable evolution, despite neurological sequels reported in the literature. This report emphasizes the need to prevent the premature exposure of newborn infants to pathological agents, especially if they presented birth injuries and/or are preterm, due to their lack of immunological capacity.

Neonatal sepsis and meningitis caused by Neisseria meningitidis: a case report

OBJECTIVE: To report a full-term newborn infant that developed a sepsis associated to meningitis caused by Neisseria meningitidis serogroup C on the 14th day of life. CASE DESCRIPTION: The patient was a term female infant, born to a mother with Systemic Lupus Erythematosus, with birth weight of 2,610g, Apgar Score 1, 4 and 8, who needed mechanical ventilation for 24 hours. On the 7th day of life, the neonate was discharged from the hospital with good overall condition. On the 15th day of life, the newborn infant presented fever and respiratory failure. The cerebrospinal fluid showed 1042 cells/mm³, with neutrophilic predominance, protein of 435 mg/dL, and glucose < 10 mg/dL. The blood and the cerebrospinal fluid cultures were positive for Neisseria meningitidis serogroup C. The neonate was hospitalized, needing mechanical ventilation and vasoactive drugs, and received 21 days of crystalline penicillin. After hospital discharge, there were no signs of neurological sequels and the infant was able to be breastfed. The case report presents a unique situation: an uncommon etiology of neonatal meningitis and favorable evolution, despite neurological sequels reported in the literature. This report emphasizes the need to prevent the premature exposure of newborn infants to pathological agents, especially if they presented birth injuries and/or are preterm, due to their lack of immunological capacity.

OBJETIVO: Relatar o caso de um recém-nascido de termo que apresentou no 14° dia de vida sepse associada à meningite, cujo agente etiológico foi a Neisseria meningitidis sorotipo C. DESCRIÇÃO DO CASO: recém-nascido de termo, cuja mãe é portadora de lupus eritematoso sistêmico, feminino, peso de nascimento de 2610g, Escala de Apgar 1, 4 e 8, sendo intubado e ventilado por 24 horas. Recebeu alta no 7° dia de vida em boas condições. No 15° dia de vida apresentou febre e desconforto respiratório. O líquido cefalorraquidiano mostrou 1042 células/mm³, com predomínio de neutrófilos, proteinorraquia de 435 mg/dL e glicorraquia < 10 mg/dL; a bacterioscopia revelou a presença de diplococos. Foi internado na Terapia Intensiva Neonatal, necessitou de ventilação mecânica e de drogas vasoativas. A hemocultura e a cultura do líquido cefalorraquidiano foram positivas para Neisseria meningitidis C. O recém-nascido foi tratado por 21 dias com penicilina cristalina. Recebeu alta hospitalar em boas condições, em aleitamento materno exclusivo e sem seqüelas neurológicas. O caso descrito apresenta como peculiaridades: etiologia incomum de meningite neonatal e evolução favorável, apesar dos relatos em literatura mostrarem seqüelas neurológicas. Destaca-se ainda, a necessidade de enfatizar a não exposição precoce do recém-nascido, especialmente se tiver tido agravos ao nascimento ou for prematuro, devido à sua inexperiência imunológica.

[Effects of recombinant human erythropoietin in preterm newborns with infectious diseases]. / Efeitos da eritropoetina recombinante humana em recém-nascidos pré-termo com doenças infecciosas.

OBJECTIVE: To study the effects of recombinant human erythropoietin (rHuEpo) in preterm newborns (PTNs) with serious infectious diseases. METHODS: A not randomized case-control study was carried out in 34 preterm newborns with diagnosis of serious infectious pathologies, gestational age up to 35 weeks, birth weight less than 1500 g and clinical stability. Newborns selected for treatment with rHuEpo received 400 U/kg erythropoietin ss, subcutaneously twice a week. Oral iron supplementation was initiated when the levels of serum ferritin were lower than 60 mcg/l. The study was continued for six weeks or until the patient was discharged from the hospital. Erythropoiesis, granulopoiesis, thrombocytopoiesis, the need for transfusions and the occurrence of new episodes of infectious disease were analyzed. RESULTS: In the treated group there was a significant increase in the number of reticulocytes, although there was no statistically significant difference between the groups with regard to the number or volume of transfusions. There was no significant difference in neutrophils and platelet values. CONCLUSION: The use of rHuEpo, 800 U/kg/week, in PTNs with infectious diseases was effective in inducing erythropoiesis, without significant changes in the number of neutrophils or platelets. This strategy, and the accurate control of the blood collected for laboratory exams, may be beneficial for prevention of the anemia in PTNs with serious infectious diseases.

Lesões de pele do tipo acrodermatite enteropática em duas crianças com doença da urina de xarope do bordo / Acrodermatitis enteropathica-like eruption in two children with maple syrup urine disease

Lesões cutâneas semelhantes à acrodermatite enteropática têm sido descritas em pacientes com algumas doenças metabólicas tratadas com dietas hipoprotéicas. Esses pacientes geralmente apresentam baixos níveis séricos de alguns aminoácidos, especialmente da isoleucina. Descrevemos dois pacientes que evoluíram com lesões semelhantes às da acrodermatite enteropática durante o tratamento da doença da urina do xarope de bordo , sem deficiência do zinco. A suplementação da isoleucina determinou rápida melhora das lesões dermatológicas.

Acrodermatitis enteropathica-like cutaneous lesions have been reported in patients with some metabolic disorders that are treated with a low-protein diet. These patients usually have low blood levels of some amino acids, especially isoleucine. We describe two patients who evolved with eruptions resembling acrodermatitis enteropathica while undergoing treatment for maple syrup urine disease, without zinc deficiency. Isoleucine supplementation led to a prompt improvement of the skin disorder.

Efeitos da eritropoetina recombinante humana em recém-nascidos pré-termo com doenças infecciosas / Effects of recombinant human erythropoietin in preterm newborns with infectious diseases

OBJETIVO: Analisar os efeitos da eritropoetina recombinante humana (rHuEpo) em recém-nascidos pré-termo com doenças infecciosas graves. MÉTODOS: Foi realizado um estudo controlado, não randomizado, em 34 recém-nascidos com diagnóstico de patologias infecciosas graves, peso de nascimento igual ou inferior a 1500 g, idade gestacional inferior a 35 semanas e estabilidade clínica. Os recém-nascidos designados para o tratamento com rHuEpo receberam a eritropoetina ß na dose de 400 UI/kg, duas vezes por semana, por via subcutânea. A suplementação oral com ferro foi iniciada quando os níveis de ferritina sérica foram inferiores a 60 mcg/L. O estudo foi realizado durante seis semanas ou até a alta hospitalar do paciente. Foram avaliados a eritropoese, o número de transfusões, o número de neutrófilos, a contagem de plaquetas e os episódios de novas infecções durante o tratamento com o hormônio. RESULTADOS: Houve aumento significativo do número de reticulócitos no grupo tratado; entretanto, não houve impacto sobre o número ou volume de transfusões. Não foram observadas alterações no número de neutrófilos ou plaquetas. CONCLUSÃO: O uso de rHuEpo em RNPT com doenças infecciosas, na dose de 800 UI/Kg/semana, foi efetivo para induzir eritropoese, sem ocorrerem alterações significativas sobre o número de neutrófilos ou plaquetas. Essa estratégia, associada ao controle rigoroso do volume de sangue retirado para exames, poderá ser benéfica na prevenção da anemia em RNPT com infecção grave.

OBJECTIVE: To study the effects of recombinant human erythropoietin (rHuEpo) in preterm newborns (PTNs) with serious infectious diseases. METHODS: A not randomized case-control study was carried out in 34 preterm newborns with diagnosis of serious infectious pathologies, gestational age up to 35 weeks, birth weight less than 1500 g and clinical stability. Newborns selected for treatment with rHuEpo received 400 U/kg erythropoietin ß, subcutaneously twice a week. Oral iron supplementation was initiated when the levels of serum ferritin were lower than 60 mcg/l. The study was continued for six weeks or until the patient was discharged from the hospital. Erythropoiesis, granulopoiesis, thrombocytopoiesis, the need for transfusions and the occurrence of new episodes of infectious disease were analyzed. RESULTS: In the treated group there was a significant increase in the number of reticulocytes, although there was no statistically significant difference between the groups with regard to the number or volume of transfusions. There was no significant difference in neutrophils and platelet values. CONCLUSION: The use of rHuEpo, 800 U/kg/week, in PTNs with infectious diseases was effective in inducing erythropoiesis, without significant changes in the number of neutrophils or platelets. This strategy, and the accurate control of the blood collected for laboratory exams, may be beneficial for prevention of the anemia in PTNs with serious infectious diseases.

Avaliação da relação entre espaço morto e volume corrente como índice preditivo de falha de extubação / Evaluation of the dead space to tidal volume ratio as a predictor of extubation failure

OBJETIVO: O objetivo do estudo foi avaliar a relação entre espaço morto e volume corrente (VD/VT) como preditivo de falha na extubação de crianças sob ventilação mecânica. MÉTODOS: Entre setembro de 2001 e janeiro de 2003, realizamos uma coorte, na qual foram incluídas todas as crianças (1 dia-15 anos) submetidas a ventilação mecânica na unidade de terapia intensiva pediátrica em que foi possível realizar a extubação e a ventilometria pré-extubação com a medida do índice VD/VT. Considerou-se falha na extubação a necessidade de reinstituição de algum tipo de assistência ventilatória, invasiva ou não, em um período de 48 horas. Para a análise dos pacientes que foram reintubados, definiu-se como sucesso-R a não reintubação. Para as análises estatísticas, utilizou-se um corte do VD/VT de 0,65. RESULTADOS: No período estudado, 250 crianças receberam ventilação mecânica na unidade de terapia intensiva pediátrica. Destas, 86 compuseram a amostra estudada. Vinte e uma crianças (24,4 por cento) preencheram o critério de falha de extubação, com 11 (12,8 por cento) utilizando suporte não-invasivo e 10 (11,6 por cento) reintubadas. A idade média foi de 16,8 (±30,1) meses, e a mediana, de 5,5 meses. A média do índice VD/VT de todos os casos foi de 0,62 (±0,18). As médias do índice VD/VT para os pacientes que tiveram a extubação bem sucedida e para os que falharam foram, respectivamente, 0,62 (±0,17) e 0,65 (±0,21) (p = 0,472). Na regressão logística, o índice VD/VT não apresentou correlação estatisticamente significativa com o sucesso ou não da extubação (p = 0,8458), nem para aqueles que foram reintubados (p = 0,5576). CONCLUSÕES: Em uma população pediátrica submetida a ventilação mecânica, por etiologias variadas, o índice VD/VT não possibilitou predizer qual a população de risco para falha de extubação ou reintubação.

OBJECTIVE: The objective of this study was to evaluate the ratio of dead space to tidal volume (VD/VT) as a predictor of extubation failure of children from mechanical ventilation. METHODS: From September 2001 to January 2003 we studied a cohort consisting of all children (1 day-15 years) submitted to mechanical ventilation at a pediatric intensive care unit who were extubated and for whom pre-extubation ventilometry data were available, including the VD/VT ratio. Extubation success was defined as no need for any type of ventilatory support, invasive or otherwise, within 48 hours. Patients who tolerated extubation, with or without noninvasive support, were defined as success-R and compared with those who were reintubated. Statistic analysis was based on a VD/VT cutoff point of 0.65. RESULTS:During the study period 250 children received mechanical ventilation at the pediatric intensive care unit. Eighty-six of these children comprised the study sample. Twenty-one children (24.4 percent) met the criteria for extubation failure, with 11 (12.8 percent) of these requiring non-invasive support and 10 (11.6 percent) reintubation. Their mean age was 16.8 (±30.1) months (median = 5.5 months). The mean VD/VT ratio for all cases was 0.62 (±0.18). Mean VD/VT ratios for patients with successful and failed extubations were 0.62 (±0.17) and 0.65 (±0.21) (p = 0.472), respectively. Logistic regression failed to reveal any statistically significant correlation between VD/VT ratio and success or failure of extubation (p = 0.8458), even for patients who were reintubated (p = 0.5576). CONCLUSIONS: In a pediatric population receiving mechanical ventilation due to a variety of etiologies, the VD/VT ratio was unable to predict the populations at risk of extubation failure or of reintubation.

Evaluation of the dead space to tidal volume ratio as a predictor of extubation failure.

OBJECTIVE: The objective of this study was to evaluate the ratio of dead space to tidal volume (VD/VT) as a predictor of extubation failure of children from mechanical ventilation. METHODS: From September 2001 to January 2003 we studied a cohort consisting of all children (1 day-15 years) submitted to mechanical ventilation at a pediatric intensive care unit who were extubated and for whom pre-extubation ventilometry data were available, including the VD/VT ratio. Extubation success was defined as no need for any type of ventilatory support, invasive or otherwise, within 48 hours. Patients who tolerated extubation, with or without noninvasive support, were defined as success-R and compared with those who were reintubated. Statistic analysis was based on a VD/VT cutoff point of 0.65. RESULTS: During the study period 250 children received mechanical ventilation at the pediatric intensive care unit. Eighty-six of these children comprised the study sample. Twenty-one children (24.4%) met the criteria for extubation failure, with 11 (12.8%) of these requiring non-invasive support and 10 (11.6%) reintubation. Their mean age was 16.8 (+/-30.1) months (median = 5.5 months). The mean VD/VT ratio for all cases was 0.62 (+/-0.18). Mean VD/VT ratios for patients with successful and failed extubations were 0.62 (+/-0.17) and 0.65 (+/-0.21) (p = 0.472), respectively. Logistic regression failed to reveal any statistically significant correlation between VD/VT ratio and success or failure of extubation (p = 0.8458), even for patients who were reintubated (p = 0.5576). CONCLUSIONS: In a pediatric population receiving mechanical ventilation due to a variety of etiologies, the VD/VT ratio was unable to predict the populations at risk of extubation failure or of reintubation.

Enterococo resistente à vancomicina em UTI pediátrica: descrição de um caso e revisão da literatura / Vancomycin-resistant enterococci in Pediatric Intensive Care Unit: case and literature review

Objetivo: relatar caso pediátrico de infecção por enterococo resistente à vancomicina (VRE), discutir fatores de risco relacionados ao surgimento destes agentes, medidas profiláticas para p´revenção e transmissão de cepas multirresistentes com a racionalização do uso de antinicrobianos e educação da equipe. Relato de caso: criança de 10 anos com teratoma imaturo e antecedente de internações pregressas em unidade de terapia intensiva e quimioterapia. A biopsia demonstrou tratar-se de teratoma maduro. Paciente foi submetida à ressecção parcial do tumor, com abordagem intestinal e realização de ileostomia, havendo necessidade de nova internação em UTI. Necessitou de várias reabordagens cirúsrgicas, evoluindo com infecção intra-abdominal e choque séptico. No período, utilizou antibiotocterapia de largo espectro. Na terceira cirurgia, isolou-se Enrerococcus faecium em líquido ascítico. A criança faleceu um dia após esta intervenção. Comentários: a infecção por VRE pode ser atribuída à flora endógena do paciente, ao contato direto ou indireto, por meio das mãos dos profissionais de saúde,ou por ambiente contaminado.

Estado imunológico e mecanismos de defesa anti-infecciosa do recém-nascido pré-termo

O texto apresenta uma revisão bibliográfica dos trabalhos publicados nos sobre o estado imunológico do recém-nascido prematuro e seus mecanismos de defesa antiinfecciosa. Arquivo em PDF. Requer o Adobe Acrobat Reader

Immunologic factors in human milk: the effects of gestational age and pasteurization.

This study compared concentrations of total protein, lysozyme, and immunoglobulins (IgA, IgG, IgM) in samples of colostrum (n=101) obtained from mothers of infants<32 weeks, 32 to 36(6) 7 weeks, and >or=37 weeks gestational age, both before and after pasteurization. Total protein was measured by refraction index, lysozyme by the lysoplate method, and immunoglobulins through the radial immunodiffusion technique. The total protein concentration was greater in colostrum of the <32 weeks and 32 to 36(6) 7 weeks categories compared to full-term (P<.001), while concentrations of lysozyme and IgM were similar. IgA concentrations were higher in the <32 weeks group compared to the full-term and similar to the 32 to 36(6) 7 weeks group (P<.05). The IgG was higher in the <32 weeks category compared to 32 to 36(6) 7 weeks, and both were similar to the full-term (P<.05). Pasteurization significantly decreased all of the factors analyzed.

[Clinical and laboratory evolution of children born to HIV positive mothers]. / Evolução clínica e laboratorial de recém-nascidos de mães HIV positivas.

UNLABELLED: The vertical transmission of HIV (Human Immunodeficiency Virus) has become the main target of prophylactic Zidovudina (AZT) therapy during gestation, parturition as well as for the newborn. BACKGROUND: To characterize the clinical and laboratory evolution of HIV exposed children. METHODS: Prospective study of 64 HIV exposed children, classified into two groups. Group A, made up of 23 pairs of mothers and newborns, who did not receive AZT; Group B, made up of 41 pairs, who received AZT at some stage of prophylaxis. RESULTS: The average maternal age was 26.8 years, the use of illicit drugs occurred in 17.2% of the pregnant women, twenty (31.3%) of the women had diseases. Between the groups there were no significant differences related to prenatal frequency of maternal illnesses, birth body dimensions and growth sequence. Both study groups presented with similar lymphocyte and blood counts. On the average, seroreversion took place at 16 months. Vertical transmission occurred in 6 children (9.3%), none of the children in the subgroup who received prophylaxis during all phases were infected. CONCLUSIONS: The prophylactic therapy with AZT during all the periods recommended and the long term follow-up of the HIV exposed children constitute one of the best strategies for prevention of the acquired immunodeficiency syndrome (AIDS) in infants.

A importância do primeiro retorno pós-alta de recém-nascidos de baixo risco / The importance of the first visit to the outpatient pediatric clinic after discharge of low-risk full term newborn infants

Objetivos: analisar a importância de um ambulatório de retorno de recém-nascidos (RN) de baixo risco em relação à detecção e controle de intercorrências precoces, evolução ponderal, manutenção de aleitamento materno e ao cumprimento das orientações fornecidas na alta. Método: análise retrospectiva, incluindo todos os RN de baixo risco admitidos no berçário anexo à maternidade do HC-FM-USP, no período de 1º de janeiro de 2001 a 31 de março de 2003, que compareceram ao retorno ambulatorial pós-data. Os RN foram dividos em doi grupos: G1 - retorno < 14 dias, e G2 - retorno > 14 dias. Os grupos foram comparados entre si quanto às características do RN ao nascimento, à evolução na inidade neonatal e qunato às condições clínicas no retorno ambulatorial. Resultados: No G1 observou-se maior taxa de aleitamento materno, maior número de casos de icterícia e de patologia de coto umbilical. No G2 encontravam-se os RN que apresentaram maior tempo médio de internação, na maioria das vezes, por necessidade de fototerapia. O uso de fototerapia durante a internação relacionou-se à manutenção de icterícia no retorno (p = 0,0508). Todos os RN foram vacinados contra hepatite B e realizou-se triagem neonatal para hipotireoidismo e fenilcetonúria na inidade neonatal. Conclusões: o retorno ambulatorial em até 14 dias foi mais efetivo para a detecção de intercorrências precoces, reforço ao aleitamento materno e avaliação das orientações recebidas na alta. Os autores recomendam retorno ambulatorial para todos os RN de baixo risco durante a primeira semana de vida, a fim de melhorar a evolução dos mesmos pós-alta.