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Introdution: The application of palliative care on children with terminal cancer faces several obstacles by reason of complex symptomatological management. Objectives: This case report aims to describe the experience of the Paediatric Cancer Center in HIAS (Hospital Infantil Albert Sabin) in cases that required palliative sedation, and the elaboration of protocol for indication, practice, and special care in sedation. Methods: We elaborated and applied a sedation algorithm to symptom management for palliative sedation in children age 2 to 17. The symptoms were categorized into visceral or psychiatric pathways. Best practice in sedation was addressed with prioritization of individual care, treatment variability, symptom relieve, and planned sedation to intended pain control. Results: Some individuals presented persistence of symptoms, although the use of benzodiazepines and opioids were satisfactory in most patients. The mean hospitalization time was extensive and the period between the beginning of palliative care and death was highly variable (2 to 15 days). Conclusions: Our algorithm was useful to establish an effective and safe measure to guide pediatric sedation and palliative care. The palliative care should be planned with qualified health professionals in the area to enhance its efficiency in relieving physical and physicological symptoms. Introdução: a instituição de cuidados paliativos em crianças portadoras de câncer terminal enfrenta vários percalços, principalmente em casos de dificuldade no controle sintomatológico da doença. Objetivos: este estudo descreve a experiência do serviço do Centro Pediátrico de Câncer (CPC) do Hospital Infantil Albert Sabin (HIAS) em casos de aplicação de sedação paliativa e na elaboração de protocolos de indicação, prática e cuidados especiais. Métodos: elaborado e aplicado algoritmo de sedação paliativa para controle sintomatológico em crianças e adolescentes de 2 a 17 anos. Os sintomas foram classificados em vias viscerais ou psiquiátricas. Também foram abordadas boas condutas em sedação para individualização e variedade de tratamentos, alívio de sintoma refratário e bom controle álgico. Resultados: encontrou-se persistência dos sintomas em alguns indivíduos, mas a terapêutica com benzodiazepínicos e opioides mostrou-se satisfatória com o algoritmo utilizado. O tempo médio de internação foi longo e o período desde o início dos cuidados paliativos ao óbito foi altamente variável (2 a 15 dias). Conclusão: o algoritmo foi útil em estabelecer meios efetivos e seguros de guiar a sedação pediátrica. Os cuidados paliativos devem ser pensados em conjunto com profissionais qualificados na área de modo que envolva o alívio dos sintomas físicos e mentais do paciente.

Hemophagocytic syndrome or hemophagocytic lymphohistiocytosis (HLH) is an infrequent and underdiagnosed condition caused by an overactive immune response, resulting in blood cells phagocytosis. After kidney transplantation (KTx), HLH is usually secondary (or reactive) to infectious and neoplastic processes and has a high mortality rate. No effective treatment is available for this condition. Usual procedures include detecting and treating the pathology triggering the immune system dysregulation, other than administration of intravenous human immunoglobulin (IVIG) and high doses of steroids, and plasmapheresis. The best protocol for maintenance immunosuppressive therapy is also unknown. This article presents two cases of post-KTx reactive HLH that underwent adjuvant IVIG treatment and obtained good clinical results. Despite the high morbidity and mortality associated with reactive HLH after KTx, the early and precise diagnosis and the administration of IVIG therapy along with the treatment of the triggering disease, was an effective strategy to control HLH.

Background Preoperative anxiety and distress can produce significant psychological impacts on children undergoing oncologic care or investigation. Adjuvant therapy is used for pain management in children; however, pre-analgesia options are restricted because they can cause undesirable outcomes. Objectives Our study aimed to investigate the use of gabapentin in procedural sedation as adjuvant therapy in children undergoing oncologic treatment. Methods We performed a double-blinded, randomized, clinical trial at Albert Sabin Infant's Hospital in Fortaleza, Brazil. Children aged 1 - 6 years who had myelogram or lumbar puncture (associated or not with intrathecal chemotherapy) received placebo or gabapentin syrups (15 mg/kg and 30 mg/kg) one to two hours before the procedure. Preoperative anxiety was evaluated by the Yale preoperative anxiety scale modified (m-YPAS scale). The pediatric anesthesia emergence delirium (PAED) and children and infants postoperative pain scale (CHIPP) scales were used for emergence delirium and pain intensity measurement, respectively. Results We evaluated 135 patients. We observed that the gabapentin groups presented lower m-YPAS scores than the placebo group at separation and induction times. Postoperatively, the gabapentin groups had lower PAED and CHIPP scores than the placebo group; however, only had PAED scores clinical relevance. No significant differences were found between the gabapentin groups. Furthermore, children with less than three prior similar procedures were more likely to benefit from gabapentin. Postoperative vomiting was prevented by 30 mg/kg gabapentin. Conclusions Although gabapentin has little preoperative effects, it ameliorates anxiety before induction, improves anesthetic induction, and reduces the occurrence of emergence delirium and postoperative vomiting up to eight hours after the procedure. Thus, we indicate gabapentin as adjuvant therapy for procedural sedation.

Background There are meta-analyzes in adults demonstrating the benefits of using gabapentin to improve postoperative pain in orthopedic surgeries. In pediatrics, it has never been studied. Objectives The aim of this study was to evaluate the use of gabapentin 10 mg/kg, orally, in postoperative analgesia, hemodynamic stability and its pre/postoperative anxiolytic effect in children subjected to unilateral inferior limb surgery. Methods We performed a double-blinded, randomized study. 84 patients in Albert Sabin Children's Hospital were selected for elective surgery that were divided into 2 groups: gabapentin group, who received gabapentin 1 to 2 hours before the procedure and the control group. Both groups were submitted to the same general anesthesia protocol with 0.125% bupivacaine femoral and sciatic block. Patients received scheduled dipyrone and morphine was used as the rescue analgesic up to 2/2 h. Postoperative pain was assessed using a scale appropriate for age (CRIES, CHIPPS or Wong-Baker face scale). We registered hemodynamic parameters, analgesic consumption and pre/postoperative anxiolytics. Results A decrease in pain intensity in the 4th and 8th postoperative hours was observed in gabapentin group, both groups had the same opioid consumption. Children in the gabapentin group had an odds ratio of 25.6 for preoperative sedation and gabapentin promoted reduction of postoperative agitation. During orotracheal intubation the gabapentin group exhibited attenuation of the hemodynamic response. Conclusions Gabapentin was superior to placebo in reducing postoperative pain. Children who received gabapentin were more sedated in the operating room, less agitated in the postoperative period and the autonomic response to intubation was reduced.