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OBJECTIVE: To evaluate demographic characteristics, mechanical-ventilation parameters, blood gas values, and ventilatory indexes as predictors of extubation failure in infants with severe acute bronchiolitis. METHODS: We conducted a prospective observational study from March 2004 to September 2005 with consecutive infants (ages 1-12 months) with severe acute bronchiolitis and considered ready to be extubated. We calculated mean airway pressure and oxygenation index. Before extubation we measured respiratory rate, tidal volume, rapid shallow breathing index, maximal inspiratory pressure, and load/force balance. Arterial blood gases were measured 1 hour before extubation. Extubation was classified as a failure if the infant needed re-intubation within 48 hours. RESULTS: Extubation failure occurred in 6 (15%) of the 40 extubated infants. The respective median (and interquartile range) age, weight, and days of mechanical ventilation for the extubation-failure and extubation-success groups were: age 5 (3- 8) months versus 4 (4-6) months (P = .87), weight 4 (3-5) kg versus 6 (5-7) kg (P < .001), and mechanical ventilation days 8 (6-23) d versus 6 (5-12) d (P = .52). There were no significant differences in arterial blood gas values or mechanical-ventilation parameters between the extubation-success and extubation-failure groups. There were statistically significant differences between the extubation-failure and extubation-success groups for 2 risk factors, weight < 4 kg and tidal volume < 4 mL/kg, when those risk factors had a large area under the curve of the receiver operating characteristic. Variables that had a large area under the curve were minute volume < 0.8 mL/kg/min and maximal inspiratory pressure < 50 cm H2O. Variables that had a small area under the curve were load/force balance > 5 and rapid shallow breathing index > 6.7. CONCLUSIONS: In infants with severe acute bronchiolitis the extubation process is complex because of the combined features of this disease. Pediatric studies have not definitely determined predictive factors, weaning protocols, or ventilatory predictive indexes of extubation failure risk in infants with severe acute bronchiolitis. Lower minute volume and lower maximal inspiratory pressure had large areas under the curve of the receiver operating characteristic for extubation-failure risk in infants with severe acute bronchiolitis. [ABSTRACT FROM AUTHOR]

Objective: To verify the performance of the Net Promoter Score (NPS) as a tool to assess parental satisfaction in pediatric intensive care units (PICUs)., Methods: The authors conducted an observational cross-sectional multicenter study in the PICUs of 5 hospitals in Brazil. Eligible participants were all parents or legal guardians of PICU-admitted children, aged 18 years or over. The NPS was administered together with the EMpowerment of PArents in THe Intensive Care (EMPATHIC-30), used as the gold standard, and a sociodemographic questionnaire. For analysis, the results were dichotomized into values greater than or equal to the median of the tests. The associations between the 2 tools were evaluated and the distribution of their results was compared., Results: The parents or legal guardians of 78 PICU-admitted children were interviewed. Of the respondents, 85% were women and 62% were in a private hospital. The median NPS was 10 (IQR, 10-10), and the median EMPATHIC-30 score was 5.7 (IQR, 5.4-5.9). Compared with the gold standard, the NPS had a sensitivity of 100% at all cutoff points, except at cutoff 10, where the sensitivity was slightly lower (97.5%). As for specificity, NPS performance was poorer, with values ranging from 0% (NPS ≥ 5) to 47.4% (NPS = 10)., Conclusions: NPS proved to be a sensitive tool to assess parental satisfaction, but with poor ability to identify dissatisfied users in the sample., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2023. Published by Elsevier Editora Ltda.)

Objectives: To describe pulmonary resistance in children undergoing invasive mechanical ventilation (MV) for different causes., Design: A cross-sectional study., Setting: Two PICUs in the South region of Brazil., Patients: Children 1 month to 15 years old undergoing MV for more than 24 hours were included. We recorded ventilator variables and measured pulmonary mechanics (inspiratory and expiratory resistance, auto positive end-expiratory pressure [PEEP], and dynamic and static compliance) in the first 48 hours of MV., Interventions: Measurements of the respiratory mechanics variables during neuromuscular blockade., Measurements and Main Results: A total of 113 children were included, 5 months (median [interquartile range (IQR) [2.0-21.5 mo]) old, and median (IQR) weight 6.5 kg (4.5-11.0 kg), with 60% male. Median (IQR) peak inspiratory pressure (PIP) was 30 cm H 2 O (26-35 cm H 2 O), and median (IQR) PEEP was 5 cm H 2 O (5-7 cm H 2 O). The median (IQR) duration of MV was 7 days (5-9 d), and mortality was nine of 113 (8%). The median (IQR) inspiratory and expiratory resistances were 94.0 cm H 2 O/L/s (52.5-155.5 cm H 2 O/L/s) and 117 cm H 2 O/L/s (71-162 cm H 2 O/L/s), with negative association with weight and age (Spearman -0.850). When we assess weight, in smaller children (&lt; 10 kg) had increased pulmonary resistance, with mean values over 100 mH 2 O/L/s, which were higher than larger children ( p &lt; 0.001)., Conclusions: Increased pulmonary resistance is prevalent in the pediatric population undergoing invasive MV. Especially in children less than 1 year old, this variable should be considered when defining a ventilatory strategy., (Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objective: The proportion of children with complex chronic conditions is increasing in PICUs around the world. We determined the prevalence and functional status of children with complex chronic conditions in Brazilian PICUs during the COVID-19 pandemic., Methods: The authors conducted a point prevalence cross-sectional study among fifteen Brazilian PICUs during the COVID-19 pandemic. The authors enrolled all children admitted to the participating PICUs with complex chronic conditions on three different days, four weeks apart, starting on April 4 th , 2020. The authors recorded the patient's characteristics and functional status at admission and discharge days., Results: During the 3 study days from March to June 2020, the authors enrolled 248 patients admitted to the 15 PICUs; 148 had CCC (prevalence of 59.7%). Patients had a median of 1 acute diagnosis and 2 chronic diagnoses. The use of resources/devices was extensive. The main mode of respiratory support was conventional mechanical ventilation. Most patients had a peripherally inserted central catheter (63.1%), followed by a central venous line (52.5%), and 33.3% had gastrostomy or/and tracheostomy. The functional status score was significantly better at discharge compared to admission day due to the respiratory status improvement., Conclusions: The prevalence of children with CCC admitted to the Brazilian PICUs represented 59.7% of patients during the COVID-19 pandemic. The functional status of these children improved during hospitalization, mainly due to the respiratory component., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2021 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.)

During the COVID-19 pandemic, hospitals around the world were forced to reorganize their processes in an attempt to contain the spread of the virus while still providing adequate care to patients. In the Pediatric Intensive Care Unit (PICU) setting, changes in family visitation protocols and restrictions on parent chaperones during hospitalization, as well as other changes, interfered with care. Based on a narrative review of the literature, supported by the authors' observations in practice, we aimed to describe the impact of the pandemic on patient and family-centered care (PFCC) in the PICU environment, especially regarding the presence of family members, family support, and communication with patients and their families, as well as the effects of changes in these practices on the mental health of those involved. In this context, several strategies were used to sustain PFCC, and, despite many challenges, attempts were made to achieve the bare-minimum goals of humanized care for patients, families, and providers alike., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Lessa, Bitercourt, Crestani, Andrade, Costa and Garcia.)

Objective: To verify the parents' satisfaction in relation to the care provided to their child admitted to the pediatric intensive care unit and associated clinical factors., Method: Exploratory, cross-sectional study, with a total of 84 parents, in a private hospital in Sao Paulo, Brazil. Data collection took place from March 2019 to January 2020, in the post-discharge period. Data were analyzed using descriptive statistics and Spearman's Correlation Coefficient., Results: Mean satisfaction was high (5.75) (SD=0.35). There was no correlation between parents' satisfaction and length of hospital stay, severity and illness., Conclusion: Parents showed high levels of satisfaction with the care received in pediatric intensive care, regardless of disease classification, length of hospital stay or severity. Greater satisfaction was observed in the domains of professional attitude, care and cure, information and parents' participation.

Objective: To determine the prevalence of life support limitation (LSL) in patients who died after at least 24h of a pediatric intensive care unit (PICU) stay, parent participation and to describe how this type of care is delivered., Methods: Retrospective cohort study in a tertiary PICU at a university hospital in Brazil. All patients aged 1 month to 18 years who died were eligible for inclusion. The exclusion criteria were those brain death and death within 24h of admission., Results: 53 patients were included in the study. The prevalence of a LSL report was 45.3%. Out of 24 patients with a report of LSL on their medical records only 1 did not have a do-not-resuscitate order. Half of the patients with a report of LSL had life support withdrawn. The length of their PICU stay, age, presence of parents at the time of death, and severity on admission, calculated by the Pediatric Index of Mortality 2, were higher in patients with a report of LSL. Compared with other historical cohorts, there was a clear increase in the prevalence of LSL and, most importantly, a change in how limitations are carried out, with a high prevalence of parental participation and an increase in withdrawal of life support., Conclusions: LSLs were associated with older and more severely ill patients, with a high prevalence of family participation in this process. The historical comparison showed an increase in LSL and in the withdrawal of life support., (Copyright © 2020 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.)

Objective: To compare the nursing workload using the Nursing Activities Score (NAS), Therapeutic Intervention Scoring System-28 (TISS-28) and Nine Equivalents of Nursing Manpower Use Score (NEMS) instruments in children admitted to a Pediatric Intensive Care Unit in a university hospital., Method: A prospective cohort study performed in a Pediatric Intensive Care Unit, with a sample formed of all children hospitalized during the study period. Nursing workload was evaluated using the TISS-28, NEMS and NAS instruments, and further divided into two groups: Group 1 forming a category of basic activities items and Group 2 forming a category of other support and intervention activities., Results: The sample consisted of 490 Pediatric Intensive Care Unit admissions, totaling 4617 observations. NAS presented the best estimate of total working hours. TISS-28 and NEMS showed better agreement and the results showed strong correlations between NAS and TISS-28 and between NEMS and TISS-28. In Group 1 (basic activities), NAS(1) and TISS-28(1) showed moderate correlation, in Group 2 (specialized activities) the three instruments showed strong correlations., Conclusion: NAS stood out in the evaluation of nursing workload and showed good correlation and agreement with the TISS-28.

Objectives: To conduct the Brazilian translation, cross-cultural adaptation, validation, and reliability testing of the EMpowerment of PArents in THe Intensive Care (EMPATHIC-30)., Design: Prospective study., Setting: PICU of a tertiary-care teaching hospital., Patients: Parents (n = 141) completed the translated EMPATHIC-30 questionnaire 72 hours after their child's PICU discharge., Interventions: None., Measurements and Main Results: The translation and cultural adaptation were performed in accordance with the principles of good practice for the translation and cultural adaptation process for patient-reported outcomes measures. Sentences were adapted according to the Brazilian syntax. Total content validity coefficient was above the established average (> 0.8). Reliability was evaluated with the coefficients McDonald omega and Cronbach alpha. The lowest Cronbach alpha found was 0.47 (CI 95%, 0.35-0.59) in the organization domain, where the lowest response rate was also concentrated. The values of the other domains were as follows: 0.64 (95% CI, 0.55-0.73) for information, 0.77 (95% CI, 0.71-0.83) for care and treatment, 0.72 (95% CI, 0.66-0.78) for parent participation, and 0.72 (95% CI, 0.65-0.79) for professional attitudes. The total internal consistency independent of the domain was 0.90 (CI 95%, 0.88-0.92). With regard to McDonald Omega, values were identified: 0.68 (95% CI, 0.49-0.88) for information, 0.73 (95% CI, 0.61-0.85) for care and treatment, 0.85 (95% CI, 0.47-0.80) for parent participation, 0.85 (95% CI, 0.76-0.93), and 0.72 (95% CI, 0.58-0.86) for professional attitudes., Conclusions: EMPATHIC-30 has been translated and culturally adapted for the Brazilian population. Validation demonstrated an above-average total content validity coefficient, confirming the instrument content validity. A sufficient reliability was observed in both analyzed coefficients. The results support the use of the Brazilian version of EMPATHIC-30 for the evaluation of parents' satisfaction of children admitted to the PICU., Competing Interests: Dr. Garcia received Scientific Productivity Grants from the Brazilian National Council for Scientific and Technological Development. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objective: To evaluate the prognostic performance of the Pediatric Index of Mortality 2 (PIM2), ferritin, lactate, C-reactive protein (CRP), and leukocytes, alone and in combination, in pediatric patients with sepsis admitted to the pediatric intensive care unit (PICU)., Methods: A retrospective study was conducted in a PICU in Brazil. All patients aged 6 months to 18 years admitted with a diagnosis of sepsis were eligible for inclusion. Those with ferritin and C-reactive protein measured within 48h and lactate and leukocytes within 24h of admission were included in the prognostic performance analysis., Results: Of 350 eligible patients with sepsis, 294 had undergone all measurements required for analysis and were included in the study. PIM2, ferritin, lactate, and CRP had good discriminatory power for mortality, with PIM2 and ferritin being superior to CRP. The cutoff values for PIM2 (> 14%), ferritin (> 135ng/mL), lactate (> 1.7mmol/L), and CRP (> 6.7mg/mL) were associated with mortality. The combination of ferritin, lactate, and CRP had a positive predictive value of 43% for mortality, similar to that of PIM2 alone (38.6%). The combined use of the three biomarkers plus PIM2 increased the positive predictive value to 76% and accuracy to 0.945., Conclusions: PIM2, ferritin, lactate, and CRP alone showed good prognostic performance for mortality in pediatric patients older than 6 months with sepsis. When combined, they were able to predict death in three-fourths of the patients with sepsis. Total leukocyte count was not useful as a prognostic marker., (Copyright © 2020 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.)

Background: Because of its high prevalence and negative impact on quality of life and longevity, overweight in childhood and adolescence is a major public health concern. The objective of the present study was to determine whether excess weight is associated with clinical outcomes in critically ill children and adolescents admitted to the pediatric intensive care unit (PICU)., Method: This retrospective cohort study was performed with children and adolescents admitted to a PICU over 3 years. Nutrition status was classified based on the body mass index z-score for age, following World Health Organization (WHO) criteria. The following outcomes were assessed: mortality, need for mechanical ventilation, length of admission, and multiple organ dysfunction syndrome., Results: Of 1468 patients admitted during the study period, 1407 were included in the study: 956 (68.0%) had adequate weight, 228 (16.2%) were overweight, and 223 (15.8%) were underweight. Associations were detected between most variables and all nutrition categories (underweight, adequate weight, and overweight). In the descriptive analysis, mortality was more prevalent in nutrition status extremes (extremely underweight or overweight). An independent association between nutrition status and mortality was not detected in any category., Conclusion: Nutrition status was not independently associated with poor outcomes. However, overweight should be considered a potential risk factor for adverse clinical outcomes in PICU admissions., (© 2020 American Society for Parenteral and Enteral Nutrition.)

Objective: To evaluate the use of cerebrospinal fluid (CSF) ferritin levels in the diagnosis of purulent meningitis (PM)., Method: We studied 81 children between 28 days and 12 years of age who presented with clinical suspicion of meningitis to the emergency department. CSF ferritin levels were measured and compared between diagnostic groups (PM, aseptic meningitis (AM) and no meningitis)., Results: The median age was 24 (IQR 8-69) months. There were 32 patients with AM (39%), 23 with PM (28%) and 26 with no meningitis (32%). Median CSF ferritin was 4.2 ng/mL (IQR 3.0-6.5), 52.9 ng/mL (IQR 30.7-103 ng/mL) and 2.4 ng/mL (IQR 2-4), respectively. CSF ferritin was higher in children with PM compared with AM (p<0.001) or no meningitis (p<0.001). There was no difference between AM and no meningitis., Conclusion: CSF ferritin may be a useful biomarker to discriminate PM in children with clinical symptoms of this disease., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To assess the prevalence, mortality and risk factors associated with the birth of very low birth weight preterm infants over a period of 33 years., Methods: Four cross-sectional studies were analyzed, using data from perinatal interviews of birth cohorts in the city of Pelotas collected in 1982, 1993, 2004, and 2015. Based on perinatal questionnaires, anthropometric measurements of newborns and death certificates were analyzed to obtain the prevalence rate, neonatal mortality, and risk factors (maternal age, income and type of delivery) for very low birth weight., Results: A total of 19,625 newborns were included in the study. In the years 1982, 1993, 2004, and 2015, there were, respectively, 5909, 5232, 4226, and 4258 births. The prevalence of very low birth weight was, respectively, 1.1% (n=64), 0.9% (n=46), 1.4% (n=61), and 1.3% (n=54). There was no statistical evidence of an increasing trend over time (p=0.11). Among the risk factors, family income in the three poorest quintiles was associated with prevalence rates that were approximately twice as high as in the richest quintile (p=0.003). Mortality per 1000 live births for neonates weighing <1500g decreased from 688 to 259 per thousand from 1982 to 2015 (p<0.001), but still represented 61% of neonatal deaths in the latter year., Conclusion: Although mortality in very low birth weight decreased by more than 60% in recent years, this group still contributes with more than half of neonatal deaths. Low family income remains an important risk factor in this scenario., (Copyright © 2018 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.)

Objectives: To evaluate serum ferritin measured within 48 hours of admission as a prognostic marker and examine the association with unfavorable outcomes in a population of pediatric patients with sepsis and high prevalence of iron deficiency anemia in which this biomarker is routinely measured., Design: Retrospective cohort study., Setting: PICU of a tertiary care teaching hospital in a middle-income country in South America., Patients: All patients 6 months to 18 years old (n = 350) admitted with a diagnosis of sepsis, suspected or proven, were eligible for inclusion. Exclusion criteria were length of PICU stay less than 8 hours and inherited or acquired disorder of iron metabolism that could interfere with serum ferritin levels., Interventions: None., Measurements and Main Results: Three-hundred twelve patients had their ferritin levels measured within 48 hours, and only 38 did not. The prevalence of iron deficiency anemia (hemoglobin < 11 g/dL and mean corpuscular volume < 80 fl was 40.3%. The median of the highest serum ferritin level within 48 hours was 150.5 ng/mL (interquartile range, 82.25-362 ng/mL), being associated with mortality (p < 0.001; Exp(B), 5.170; 95% CI, 2.619-10.205). A 10-fold increase in ferritin level was associated with a five-fold increase in mortality. There was a monotonic increase in mortality with increasing ferritin levels (p < 0.05). Regarding the discriminatory power of ferritin for mortality, the area under the receiver operating characteristic curve was 0.787 (95% CI, 0.737-0.83; p < 0.0001)., Conclusions: Serum ferritin at lower thresholds predicts mortality in children with sepsis admitted to the ICU in a middle-income country with high prevalence of iron deficiency anemia.

Objective: Review the main aspects of the definition, diagnosis, and management of pediatric patients with sepsis and septic shock., Source of Data: A search was carried out in the MEDLINE and Embase databases. The articles were chosen according to the authors' interest, prioritizing those published in the last five years., Synthesis of Data: Sepsis remains a major cause of mortality in pediatric patients. The variability of clinical presentations makes it difficult to attain a precise definition in pediatrics. Airway stabilization with adequate oxygenation and ventilation if necessary, initial volume resuscitation, antibiotic administration, and cardiovascular support are the basis of sepsis treatment. In resource-poor settings, attention should be paid to the risks of fluid overload when administrating fluids. Administration of vasoactive drugs such as epinephrine or norepinephrine is necessary in the absence of volume response within the first hour. Follow-up of shock treatment should adhere to targets such as restoring vital and clinical signs of shock and controlling the focus of infection. A multimodal evaluation with bedside ultrasound for management after the first hours is recommended. In refractory shock, attention should be given to situations such as cardiac tamponade, hypothyroidism, adrenal insufficiency, abdominal catastrophe, and focus of uncontrolled infection., Conclusions: The implementation of protocols and advanced technologies have reduced sepsis mortality. In resource-poor settings, good practices such as early sepsis identification, antibiotic administration, and careful fluid infusion are the cornerstones of sepsis management., (Copyright © 2019 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.)

Objective: To verify the association between prone position, increased diuresis, and decreased cumulative fluid balance in critically ill pediatric patients who underwent mechanical ventilation (MV) for pulmonary causes and describe adverse events related to the use of the position., Methods: This is a retrospective observational study. Patients aged between 1 month and 12 years who underwent MV for pulmonary causes, between January 2013 and December 2015, were selected and divided between those who were put on prone position (PG) and those who were not (CG) during the hospitalization at the Pediatric Intensive Care Unit (PICU). Data were analyzed longitudinally from D1 to D4., Results: A total of 77 patients (PG = 37 and CG = 40) were analyzed. The general characteristics of both groups were similar. In the comparison between the groups, there was no increase in diuresis or decrease in cumulative fluid balance in the prone group. In the longitudinal analysis of D1 to D4, we saw that the PG presented higher diuresis (p = 0.034) and a lower cumulative fluid balance (p = 0.001) in D2. Regarding the use of diuretics, there was greater use of furosemide (P <0.001) and spironolactone (P = 0.04) in the PG. There was no increase in adverse events during the use of the prone position., Conclusion: The prone position was not associated with increased diuresis or decreased cumulative fluid balance in critically ill pediatric patients who underwent to MV for pulmonary causes.

Objective: The stable microbubble test on gastric aspirate and on amniotic fluid has been used for the diagnosis of respiratory distress syndrome in the newborn. However, no study has performed this test on oral aspirates from premature infants. The objective of this study was to evaluate the performance of the stable microbubble test on oral aspirates from preterm newborns to predict respiratory distress syndrome., Method: This study included infants with gestational age <34 weeks. Oral fluids were obtained immediately after birth and gastric fluids were collected within the first 30 minutes of life. The samples were frozen and tested within 72 hours., Results: The sample was composed of paired aspirates from 64 newborns, who were divided into two groups: respiratory distress syndrome group (n=21) and control group (n=43). The median (interquartile range) of the stable microbubble count in the oral samples of infants with respiratory distress syndrome was significantly lower than that of infants who did not develop respiratory symptoms: respiratory distress syndrome group=12 (8-22) stable microbubbles/mm 2 ; control group=100 (48-230)microbubbles/mm 2 (p<0.001). The correlation between microbubble count in gastric and oral aspirates was 0.90 (95% confidence interval=0.85-0.95; p<0.001). Considering a cut-off point of 25microbubbles/mm 2 , the sensitivity and the specificity of the stable microbubble test were 81.4% and 85.7%, respectively., Conclusion: The study suggests that the stable microbubble test performed on oral aspirate is a reliable alternative to that performed on gastric fluid for the prediction of respiratory distress syndrome in the newborn., (Copyright © 2018 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.)

Objective: To compare the prevalence of malnutrition during two time periods in a pediatric intensive care unit., Methods: This was a retrospective cross-sectional study of patients admitted to the pediatric intensive care unit of a university hospital during two one-year periods with an interval of four years between them. Nutritional evaluation was conducted based on weight and height measured at admission. The body mass index-for-age was the parameter chosen to evaluate nutritional status, as classified according to the World Health Organization, according to age group., Results: The total sample size was 881 (406 in the contemporary sample and 475 in the historical sample). There was a significant reduction in malnutrition in the contemporary sample (p = 0.03). Malnourishment in patients in the historical sample was significantly associated with mortality and length of stay, while malnourishment in patients in the contemporary sample was not associated with worse outcomes., Conclusion: There was a significant reduction in malnutrition among patients in the same pediatric intensive care unit when comparing the two time periods. Our findings of a change in nutritional profile in critically ill patients corroborate the nutritional status data of children and adolescents worldwide.

Objective: To undertake the translation and cross-cultural adaption into Brazilian Portuguese of the Pediatric Confusion Assessment Method for the Intensive Care Unit for the detection of delirium in pediatric intensive care units, including the algorithm and instructions., Methods: A universalist approach for the translation and cross-cultural adaptation of health measurement instruments was used. A group of pediatric critical care specialists assessed conceptual and item equivalences. Semantic equivalence was evaluated by means of a translation from English to Portuguese by two independent translators; reconciliation into a single version; back-translation by a native English speaker; and consensus among six experts with respect to language and content understanding by means of Likert scale responses and the Content Validity Index. Finally, operational equivalence was assessed by applying a pre-test to 30 patients., Results: The back-translation was approved by the original authors. The medians of the expert consensus responses varied between good and excellent, except for the feature "acute onset" of the instructions. Items with a low Content Validity Index for the features "acute onset" and "disorganized thinking" were adapted. In the pre-test, the expression "signal with your head" was modified into "nod your head" for better understanding. No further adjustments were necessary, resulting in the final version for Brazilian Portuguese., Conclusion: The Brazilian version of the Pediatric Confusion Assessment Method for the Intensive Care Unit was generated in agreement with the international recommendations and can be used in Brazil for the diagnosis of delirium in critically ill children 5 years of age or above and with no developmental cognitive disabilities.

Objective: The aim of this study was to present a review on the evolution, development, and consolidation of the pediatric emergency abroad and in Brazil, as well as to discuss the residency program in this key area for pediatricians., Data Sources: This was a narrative review, in which the authors used pre-selected documents utilized as the minimum requirements for the Residency Program in Pediatric Emergency Medicine and articles selected by interest for the theme development, at the SciELO and Medline databases, between 2000 and 2017., Data Synthesis: The historical antecedents and the initial evolution of pediatric emergency in Brazil, as well as several challenges were described, regarding the organization, the size, the training of professionals, and also the regulation of the professional practice in this new specialty. Additionally, a new pediatric emergency residency program to be implemented in Brazil is described., Conclusions: Pediatric emergency training will be a powerful stimulus to attract talented individuals, to establish them in this key area of medicine, where they can exercise their leadership by promoting care qualification, research, and teaching, as well as acting decisively in their management., (Copyright © 2017 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.)

Objective: To estimate the workload and size the nursing team using the scales TISS-28 and NEMS in a pediatric intensive care unit., Methods: An observational prospective study with a quantitative approach was conducted at the pediatric intensive care unit of a university hospital from Jan 1st, 2009 to Dec 31st, 2009. All children who remained hospitalized for more than 8 hours were included, with length of stay of 4 hours in case of death. Clinical data were collected and the Paediatric Index of Mortality 2 and the scores TISS-28 and NEMS were determined. The TISS-28 and NEMS were converted into working hours of the nursing team and sizing complied with the parameters of the Brazilian Federal Nursing Council. Pearson's correlation and the Bland-Altman model were used to verify the association and agreement between the instruments., Results: A total of 459 children were included, totaling 3,409 observations. The average values for the TISS-28 and NEMS were 20.8±8 and 25.2±8.7 points, respectively. The nursing workload was 11 hours by TISS-28 and 13.3 hours by NEMS. The estimated number of professionals by TISS-28 and NEMS was 29.6 and 35.8 professionals, respectively. The TISS-28 and NEMS showed adequate correlation and agreement., Conclusion: Time spent in nursing activities and team sizing reflected by the NEMS were significantly greater when compared to the TISS-28.

Objective: The aim of this study was to verify the association of echocardiogram, ferritin, C-reactive protein, and leukocyte count with unfavorable outcomes in pediatric sepsis., Methods: A prospective cohort study was carried out from March to December 2014, with pediatric critical care patients aged between 28 days and 18 years. Inclusion criteria were diagnosis of sepsis, need for mechanical ventilation for more than 48h, and vasoactive drugs. Serum levels of C-reactive protein, ferritin, and leukocyte count were collected on the first day (D0), 24h (D1), and 72h (D3) after recruitment. Patients underwent transthoracic echocardiography to determine the ejection fraction of the left ventricle on D1 and D3. The outcomes measured were length of hospital stay and in the pediatric intensive care unit, mechanical ventilation duration, free hours of VM, duration of use of inotropic agents, maximum inotropic score, and mortality., Results: Twenty patients completed the study. Patients with elevated ferritin levels on D0 had also fewer ventilator-free hours (p=0.046) and higher maximum inotropic score (p=0.009). Patients with cardiac dysfunction by echocardiogram on D1 had longer hospital stay (p=0.047), pediatric intensive care unit stay (p=0.020), duration of mechanical ventilation (p=0.011), maximum inotropic score (p=0.001), and fewer ventilator-free hours (p=0.020)., Conclusion: Cardiac dysfunction by echocardiography and serum ferritin value was significantly associated with unfavorable outcomes in pediatric patients with sepsis., (Copyright © 2017 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.)