Paulo Sérgio Lucas da Silva

Hospital Estadual Centra

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Marcelo Cunio Machado Fonseca

Universidade Federal de São Paulo

Vânia Euzébio de Aguiar

Hospital do Servidor Público Municipal

Werther Brunow de Carvalho

Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

Maria Eunice Reis

Hospital Infantil Joana de Gusmão

Thais Suelotto Machado Fonseca

Faculdade de Ciências Médicas da Santa Casa de São Paulo

Henrique Monteiro Neto

Hospital Israelita Albert Einstein

Jaques Waisberg

Hospital do Servidor Público Estadual

Daniela Farah

Universidade Federal de São Paulo

Simone Iglesias

Universidade Federal de São Paulo

Emerson Yukio Kubo

Hospital Estadual Centra

Cooperative Institutions

Universidade Federal de São Paulo

Hospital do Servidor Público Municipal

Universidade de São Paulo

Hospital Estadual Centra

Hospital São Paulo

Faculdade de Medicina do ABC

Hospital do Servidor Público Estadual

Dr. Euryclides Hospital de Jesus Zerbini

Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

Fundação de Apoio à Universidade Federal de São Paulo

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Opioid and Benzodiazepine Withdrawal Syndrome in PICU Patients

Journal of Addiction Medicine (2016)

Paulo Sérgio Lucas da Silva Maria Eunice Reis Thais Suelotto Machado Fonseca Marcelo Cunio Machado Fonseca

Although iatrogenic withdrawal syndrome (IWS) has been recognized in patients exposed to opioids and benzodiazepines, very few studies have used a validated tool for diagnosis and assessment of IWS in critically ill children. We sought to determine IWS rate, risk factors, and outcomes of IWS patients.Prospective observational study conducted in a pediatric intensive care unit. A total of 137 patients (31 with IWS and 106 with no IWS) received a continuous infusion of fentanyl and midazolam for 3 or more days. The Sophia Observation withdrawal Symptoms scale was repeatedly applied when children were weaned off sedation/analgesia.The overall incidence of IWS was 22.6%. Of the 31 IWS patients, 6 showed IWS with less than 5 days sedation or analgesia. Logistic regression showed that the median peak dose of midazolam was associated with IWS development (odds ratio 1.4). Receiver-operating curve showed a cut-off value of 0.35 mg/kg/h for midazolam peak dose (sensitivity 96.7%, specificity 51%, positive predictive value 36.6%, and negative predictive value 98.2%), with area under the curve of 0.80. IWS patients had a longer time on mechanical ventilation, prolonged pediatric intensive care unit, and hospital stays, and required prolonged period to have drugs discontinued.Although length of sedation/analgesia for at least5 days has been widely proposed for monitoring IWS, our data suggest that initiating monitoring after 3 sedation days is highly recommended. In addition, patients requiring infusion rates of midazolam above 0.35 mg/kg/h should be considered at high risk for IWS.

10.1097/adm.0000000000000197

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Citations (42)

How the modified Clinical Pulmonary Infection Score can identify treatment failure and avoid overusing antibiotics in ventilator‐associated pneumonia

Acta Paediatrica (2014)

Paulo Sérgio Lucas da Silva Vânia Euzébio de Aguiar Marcelo Cunio Machado Fonseca

Although the modified Clinical Pulmonary Infection Score (CPIS) has been used to guide treatment decisions in adults with ventilator-associated pneumonia (VAP), paediatric studies are lacking. We assessed a modified CPIS tool to define VAP resolution and identify treatment failure at an early stage.We identified 70 mechanically ventilated children with VAP according to the Center for Disease Control criteria. Modified CPIS was initially measured at VAP onset and then three and five days afterwards. Children were defined as low risk or high risk based on a cut-off score of six.There were 50 high-risk and 20 low-risk patients. Culture results were positive in 64% of the high-risk patients and just 10% of the low-risk patients. Patients on adequate therapy significantly improved their CPIS scores by day three, regardless of the likelihood of VAP. A lack of score improvement demonstrated sensitivity of 100% and specificity of 83% when it came to detecting treatment failure. The area under the receiver operating curve was 0.92.Serial modified CPIS measurements showed that low-risk patients with negative cultures at day three should be considered for a short course of antibiotics. In contrast, high-risk patients with no score improvement were potentially failing their treatment.

Ventilator-associated Pneumonia

10.1111/apa.12710

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Citations (2)

Use of fentanyl and midazolam in mechanically ventilated children—Does the method of infusion matter?

Journal of Critical Care (2015)

Paulo Sérgio Lucas da Silva Maria Eunice Reis Vânia Euzébio de Aguiar Marcelo Cunio Machado Fonseca

Midazolam

10.1016/j.jcrc.2015.12.003

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Predicting Reintubation After Unplanned Extubations in Children: Art or Science?

Journal of Intensive Care Medicine (2016)

Paulo Sérgio Lucas da Silva Maria Eunice Reis Thais Suelotto Machado Fonseca Marcelo Cunio Machado Fonseca

Reintubation following unplanned extubation (UE) is often required and associated with increased morbidity; however, knowledge of risk factors leading to reintubation and subsequent outcomes in children is still lacking. We sought to determine the incidence, risk factors, and outcomes related to reintubation after UEs.All mechanically ventilated children were prospectively tracked for UEs over a 7-year period in a pediatric intensive care unit. For each UE event, data associated with reintubation within 24 hours and outcomes were collected.Of 757 intubated patients, 87 UE occurred out of 11 335 intubation days (0.76 UE/100 intubation days), with 57 (65%) requiring reintubation. Most of the UEs that did not require reintubation were already weaning ventilator settings prior to UE (73%). Univariate analysis showed that younger children (<1 year) required reintubation more frequently after an UE. Patients experiencing UE during weaning experienced significantly fewer reintubations, whereas 90% of patients with full mechanical ventilation support required reintubation. Logistic regression revealed that requirement of full ventilator support (odds ratio: 37.5) and a COMFORT score <26 (odds ratio: 5.5) were associated with UE failure. There were no differences between reintubated and nonreintubated patients regarding the length of hospital stay, ventilator-associated pneumonia rate, need for tracheostomy, and mortality. Cardiovascular and respiratory complications were seen in 33% of the reintubations.The rate of reintubation is high in children experiencing UE. Requirement of full ventilator support and a COMFORT score <26 are associated with reintubation. Prospective research is required to better understand the reintubation decisions and needs.

Intermittent mandatory ventilation

Ventilator-associated Pneumonia

10.1177/0885066616675130

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Successful treatment of vancomycin-resistant enterococcus ventriculitis in a child

The Brazilian Journal of Infectious Diseases (2007)

Paulo Sérgio Lucas da Silva Henrique Monteiro Neto Lílian Márcia Sejas

Enterococci are an uncommon cause of CNS infection. A 20 month-old boy, diagnosed with hydrocephalus with ventriculoperitoneal shunt and history of lengthy hospitalization and use of wide spectrum antibiotics, was admitted to the pediatric intensive care unit diagnosed with ventriculitis. On the 14th day of empirical antibiotic therapy (vancomycin and meropenem) the child presented fever while the CSF sample culture evidenced vancomycin-resistant Enterococcus faecium. The patient received intravenous linezolid achieving cerebrospinal fluid sterilization. Conclusion: Intravenous linezolid appears to be a safe and effective therapy for vancomycin-resistant enterococcus ventriculoperitoneal shunt infection.

Ventriculitis

Vancomycin-resistant Enterococcus

Gram-positive bacterial infections

10.1590/s1413-86702007000200027

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Risk Factors and Outcomes of Unplanned PICU Postoperative Admissions

Pediatric Critical Care Medicine (2013)

Paulo Sérgio Lucas da Silva Vânia Euzébio de Aguiar Marcelo Cunio Machado Fonseca

Background: Although unplanned postoperative admission to PICUs (unplanned intensive care admission [UIA]) is uncommon, it might be associated with increased costs, morbidity, and mortality. However, detailed knowledge of risk factors and outcomes after UIA in children is still lacking. Objectives: To determine prevalence, risk factors, and outcomes of UIA patients compared with non-UIA patients. Design: Case–control study. Setting: A tertiary university–affiliated hospital. Patients: All postoperative children admitted to the PICU were monitored for UIA. About 28 cases and 88 controls were included. Interventions: none. Measurements and Main Results: The overall prevalence of UIA was 2.6%. About 28 patients (24.1%) of 116 had unplanned admission. Multiple logistic regression revealed that factors predicting UIA were airway abnormality (odds ratio 16.2, 95% confidence interval 2.65–99.6), anesthetic factors (odds ratio 5.8, 95% confidence interval 1.06–32.2), and hypoxia intraoperative (odds ratio 7.4, 95% confidence interval 1.21–46.24). Procedures on abdomen, emergency surgery, combined anesthesia, and occurrence of intraoperative adverse events were also risk factors for an UIA. Patients with UIA had longer duration of mechanical ventilation than non-UIA patients (4.5 vs. 2 days, p = 0.01), but there were no differences in length of PICU and hospital stays. Preventable adverse events were detected in 25% of UIA children. Conclusions: Airway abnormality, anesthetic factors, and hypoxia intraoperative were risk factors associated with UIA. Although preventable events contribute significantly to unplanned PICU admissions, they constitute a room of opportunity in quality improvement programs.

10.1097/pcc.0b013e3182720fab

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Citations (17)

Unplanned Endotracheal Extubations in the Intensive Care Unit

Anesthesia & Analgesia (2012)

Paulo Sérgio Lucas da Silva Marcelo Cunio Machado Fonseca

In this study, we updated the state of knowledge on unplanned tracheal extubations in the intensive care unit. We focused on the following topics: incidence, risk factors, reintubation after unplanned extubation, outcomes, and prevention. Based on this review, recommendations were made for preventing unplanned extubations.Electronic databases were searched for relevant publications from January 1, 1950 through June 30, 2011 on the MEDLINE, EMBASE, CINAHL, SciELO, LILACS, and Cochrane systems. Fifty articles were eligible for data abstraction. Study quality was assessed using the Newcastle-Ottawa Scale. Grades of recommendation were assessed according to the Oxford Centre for Evidence-Based Medicine.Unplanned extubations occur at a rate of 0.1 to 3.6 events per 100 intubation days. Risk factors associated with unplanned extubations included male gender (odds ratio [OR] 4.8), APACHE score ≥17 (OR 9.0), chronic obstructive pulmonary disease, restlessness/agitation (OR 3.3-30.6), lower sedation level (OR 2.0-5.4), higher consciousness level (OR 1.4-2.0), and use of physical restraints (OR 3.1). Reintubation rates ranged from 1.8% to 88% of unplanned extubations. Thirteen studies assessed preventive measures for avoiding unplanned extubations. These studies focused on data collection tools, standardization of procedures, staff education, staff surveillance, and identification and management of high-risk patients. These studies reported reductions in unplanned extubation rate from 22% to 53%. The best methods of securing the endotracheal tube and use of physical restraints remain controversial issues.Despite numerous publications on unplanned extubation, few studies assess preventive strategies for adverse events, and few clinical trials have assessed unplanned extubations. Recommendations are proposed based on the currently available literature.

CINAHL

10.1213/ane.0b013e31824b0296

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Citations (132)

Nebulized 0.5, 2.5 and 5 ml l-epinephrine for post-extubation stridor in children: a prospective, randomized, double-blind clinical trial

Intensive Care Medicine (2011)

Paulo Sérgio Lucas da Silva Marcelo Cunio Machado Fonseca Simone Iglesias Emílio Lopes Vânia Euzébio de Aguiar

Vital signs

Croup

10.1007/s00134-011-2408-9

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Citations (22)

Revisiting unplanned extubation in the pediatric intensive care unit: What's new?

Heart & Lung (2017)

Paulo Sérgio Lucas da Silva Daniela Farah Marcelo Cunio Machado Fonseca

10.1016/j.hrtlng.2017.08.006

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Citations (20)

Pediatric surgeon vs general surgeon: Does subspecialty training affect the outcome of appendicitis?

Pediatrics International (2013)

Paulo Sérgio Lucas da Silva Vânia Euzébio de Aguiar Jaques Waisberg

The absence of pediatric surgeons in many centers results in restriction of patient access to pediatric subspecialty care. The aim of this study was to compare the outcomes of children treated for appendicitis by pediatric surgeons (PS) and by general surgeons (GS).This was a retrospective review of the charts of all consecutive patients <16 years old who underwent appendectomy during 2 years The primary outcome measure was the overall rate of complications. Secondary outcome measures included length of hospital stay (LOS), symptom duration, time from emergency department diagnosis to surgery, and readmission rate within 30 days.A total of 94 patients (PS group, n = 66; GS group, n = 28) were included. PS patients were younger. For patients with complicated appendicitis, complications were significantly more prevalent in the GS group (57% vs 15%; P = 0.0001). Median LOS was not significantly different between the two groups for complicated appendicitis, but patients with non-complicated appendicitis had a significant longer LOS when treated by PS (3.74 ± 1.5 vs 2.57 ± 1.21 days; P = 0.0041). Patients in the PS group had a prolonged use of antibiotics (2 vs 4 days; P = 0.001), and longer LOS (3 vs 4 days; P = 0.0018).Overall complication rates were similar between PS and GS. Complications were significantly more prevalent in patients with complicated appendicitis who were treated by GS.

Subspecialty

10.1111/ped.12208

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Citations (20)