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1.
Pediatr Crit Care Med ; 13(2): 158-64, 2012 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-21725275

RESUMEN

OBJECTIVE: To describe the characteristics and outcomes of mechanical ventilation in pediatric intensive care units during the season of acute lower respiratory infections. DESIGN: Prospective cohort of infants and children receiving mechanical ventilation for at least 12 hrs. SETTING: Sixty medical-surgical pediatric intensive care units. PATIENTS: All consecutive patients admitted to participating pediatric intensive care units during a 28-day period. MEASUREMENTS AND MAIN RESULTS: Of 2,156 patients admitted to pediatric intensive care units, 1185 (55%) received mechanical ventilation for a median of 5 days (interquartile range 2-8). Median age was 7 months (interquartile range 2-25). Main indications for mechanical ventilation were acute respiratory failure in 78% of the patients, altered mental status in 15%, and acute on chronic pulmonary disease in 6%. Median length of stay in the pediatric intensive care units was 10 days (interquartile range 6-18). Overall mortality rate in pediatric intensive care units was 13% (95% confidence interval: 11-15) for the entire population, and 39% (95% confidence interval: 23 - 58) in patients with acute respiratory distress syndrome. Of 1150 attempts at liberation from mechanical ventilation, 62% (95% confidence interval: 60-65) used the spontaneous breathing trial, and 37% (95% confidence interval: 35-40) used gradual reduction of ventilatory support. Noninvasive mechanical ventilation was used initially in 173 patients (15%, 95% confidence interval: 13-17). CONCLUSION: In the season of acute lower respiratory infections, one of every two children admitted to pediatric intensive care units requires mechanical ventilation. Acute respiratory failure was the most common reason for mechanical ventilation. The spontaneous breathing trial was the most commonly used method for liberation from mechanical ventilation.


Asunto(s)
Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Respiración Artificial/estadística & datos numéricos , Infecciones del Sistema Respiratorio/terapia , Estaciones del Año , Enfermedad Aguda , Preescolar , Femenino , Mortalidad Hospitalaria , Humanos , Lactante , América Latina/epidemiología , Masculino , Portugal/epidemiología , Estudios Prospectivos , Infecciones del Sistema Respiratorio/mortalidad , España/epidemiología , Resultado del Tratamiento
2.
Pediatrics ; 125(1): e1-8, 2010 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-20008417

RESUMEN

OBJECTIVE: Several studies have evaluated dexamethasone for prevention of hearing loss in childhood bacterial meningitis, but results have varied. We compared dexamethasone and/or glycerol recipients with placebo recipients, and measured hearing at 3 threshold levels. METHODS: Children aged 2 months to 16 years with meningitis were treated with ceftriaxone but were double-blindly randomly assigned to receive adjuvant dexamethasone intravenously, glycerol orally, both agents, or neither agent. We used the Glasgow coma scale to grade the presenting status. The end points were the better ear's ability to detect sounds of >40 dB, >or=60 dB, and >or=80 dB, with these thresholds indicating any, moderate-to-severe, or severe impairment, respectively. All tests were interpreted by an external audiologist. Influence of covariates in the treatment groups was examined by binary logistic regression. RESULTS: Of the 383 children, mostly with meningitis caused by Haemophilus influenzae type b or Streptococcus pneumoniae, 101 received dexamethasone, 95 received dexamethasone and glycerol, 92 received glycerol, and 95 received placebo. Only the presenting condition and young age predicted impairment independently through all threshold levels. Each lowering point in the Glasgow scale increased the risk by 15% to 21% (odds ratio: 1.20, 1.21, and 1.15 [95% confidence interval: 1.06-1.35, 1.07-1.37, and 1.01-1.31]; P = .005, .003, and .039) for any, moderate-to-severe, or severe impairment, respectively. Each increasing month of age decreased the risk by 2% to 6% (P = .0001, .0007, and .041, respectively). Neither dexamethasone nor glycerol prevented hearing loss at these levels regardless of the causative agent or timing of antimicrobial agent. CONCLUSIONS: With bacterial meningitis, the child's presenting status and young age are the most important predictors of hearing impairment. Little relief is obtained from current adjuvant medications.


Asunto(s)
Ceftriaxona/administración & dosificación , Dexametasona/administración & dosificación , Glicerol/administración & dosificación , Pérdida Auditiva/tratamiento farmacológico , Meningitis Bacterianas/complicaciones , Administración Oral , Adolescente , Audiometría , Niño , Preescolar , Intervalos de Confianza , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Esquema de Medicación , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Pérdida Auditiva/etiología , Pérdida Auditiva/prevención & control , Humanos , Lactante , Infusiones Intravenosas , Modelos Logísticos , Masculino , Meningitis Bacterianas/tratamiento farmacológico , Meningitis Bacterianas/microbiología , Meningitis por Haemophilus/complicaciones , Meningitis por Haemophilus/diagnóstico , Meningitis por Haemophilus/tratamiento farmacológico , Meningitis Neumocócica/complicaciones , Meningitis Neumocócica/diagnóstico , Meningitis Neumocócica/tratamiento farmacológico , Oportunidad Relativa , Probabilidad , Estudios Prospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento
3.
Clin Infect Dis ; 46(8): 1248-52, 2008 Apr 15.
Artículo en Inglés | MEDLINE | ID: mdl-18444863

RESUMEN

A post hoc analysis of 654 children with bacterial meningitis showed that the level of consciousness is the most important predictor of death and/or neurological sequelae, more than is etiology per se. This finding emphasizes the need of including a measurement of the presenting status in all studies examining treatment efficacy.


Asunto(s)
Meningitis Bacterianas/mortalidad , Meningitis Bacterianas/patología , Causas de Muerte , Estado de Conciencia , Femenino , Humanos , Lactante , Modelos Logísticos , Masculino , Análisis Multivariante , Pronóstico , Factores de Riesgo
4.
Clin Infect Dis ; 45(10): 1277-86, 2007 Nov 15.
Artículo en Inglés | MEDLINE | ID: mdl-17968821

RESUMEN

BACKGROUND: Despite favorable meta-analyses, no study involving third-generation cephalosporins for the treatment of childhood bacterial meningitis has documented a benefit of adjuvant dexamethasone therapy if the outcomes are examined individually. METHODS: We conducted a prospective, randomized, double-blind trial comparing adjuvant dexamethasone or glycerol with placebo in children aged from 2 months through 16 years in Latin America. Ceftriaxone was administered to all children; children were randomized to also receive dexamethasone intravenously, glycerol orally, both agents, or neither agent. Primary end points were death, severe neurological sequelae, or deafness, with the first 2 end points forming a composite end point. A subgroup analysis for Haemophilus influenzae type b meningitis was undertaken. Intention-to-treat analysis was performed using binary logistic regression models. RESULTS: H. influenzae type b, pneumococci, and meningococci were the main agents found among 654 patients; dexamethasone was given to 166, dexamethasone and glycerol were given to 159, glycerol was given to 166, and placebo was given to 163. No adjuvant therapy significantly affected death or deafness. In contrast, glycerol and dexamethasone plus glycerol reduced severe neurological sequelae, compared with placebo; the odds ratios were 0.31 (95% confidence interval [95% CI], 0.13-0.76; P=.010) and 0.39 (95% CI, 0.17-0.93; P=.033), respectively. For neurological sequelae and death, the odds ratios were 0.44 (95% CI, 0.25-0.76; P=.003) and 0.55 (95% CI, 0.32-0.93; P=.027), respectively. Dexamethasone therapy prevented deafness in patients with H. influenzae type b meningitis only if patients were divided grossly into dexamethasone recipients and nonrecipients and if timing between dexamethasone and ceftriaxone administration was not taken into account (odds ratio, 0.27; 95% CI, 0.09-0.77; P=.014). CONCLUSION: Oral glycerol therapy prevents severe neurological sequelae in patients with childhood meningitis. Safety, availability, low cost, and oral administration also add to its usefulness, especially in resource-limited settings.


Asunto(s)
Antibacterianos/uso terapéutico , Quimioterapia Adyuvante/métodos , Dexametasona/uso terapéutico , Glicerol/uso terapéutico , Meningitis Bacterianas/tratamiento farmacológico , Enfermedades del Sistema Nervioso/prevención & control , Adolescente , Antiinflamatorios/efectos adversos , Antiinflamatorios/uso terapéutico , Ceftriaxona/uso terapéutico , Niño , Preescolar , Sordera/prevención & control , Muerte , Dexametasona/efectos adversos , Método Doble Ciego , Quimioterapia Combinada , Femenino , Glicerol/efectos adversos , Humanos , América Latina , Masculino , Meningitis Bacterianas/complicaciones , Meningitis Bacterianas/microbiología , Meningitis por Haemophilus/complicaciones , Meningitis por Haemophilus/tratamiento farmacológico , Meningitis por Haemophilus/microbiología , Meningitis Meningocócica/complicaciones , Meningitis Meningocócica/tratamiento farmacológico , Meningitis Meningocócica/microbiología , Placebos/administración & dosificación , Estudios Prospectivos , Resultado del Tratamiento
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