Introduction:The Full Outline of UnResponsiveness -FOUR scale has been previously validated to assess impaired consciousness in the adult population. The aim of this study is the translation into Portuguese and validation of the FOUR scale in the pediatric population. The study also compares the FOUR scale and Glasgow coma scale score ratings and the clinical outcome of patients hospitalized in Pediatric Intensive Care Units. Material and Methods:This study prospectively rated patients admitted to the Pediatric Intensive Care Units with impaired consciousness during one year. Both scales were applied daily to patients by three types of examiners: intensivists, residents and nurses, from the moment of admission until clinical discharge. Neurological sequelae was evaluated using the King's Outcome Scale for Childhood Head Injury -KOSCHI. Results: Twenty seven patients between one and 17 years of age were included. Both scales are reliable and inter-rater reliability was greater for the FOUR score. Glasgow coma scale showed a minimum score in eight evaluations, whereas the FOUR scale obtained the minimum score in only two of these evaluations. In both scales there was a strong association between the admission score and the patient's outcome (area under curve FOUR = 0.939, versus Glasgow coma scale = 0.925). Discussion: The FOUR scale provides more neurological information than Glasgow coma scale in patients with impaired consciousness and has prognostic interest. Conclusion:The FOUR scale can be applied in patients admitted with impaired consciousness in Pediatric Intensive Care Units. We think that a multicenter study would be very beneficial for confirming and generalizing these results.
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Criança do sexo feminino, 5 anos de idade, sem antecedentes pré-natais, perinatais e pós-natais relevantes, foi observada por febre e tosse produtiva persistente. No exame físico destacava-se o murmúrio vesicular diminuído no terço inferior do hemitórax direito, faces anterior e posterior. Estudo analítico sem leucocitose e proteína C reativa de 46 mg/L. Radiografia torácica com imagem de hipotransparência basal direita com aspeto heterogéneo e apagamento do ângulo costofrénico direito ( Fig. 1), o que justificou a realização de ecografia torácica, que revelou derrame mínimo livre no fundo de saco pleural direito com espessura máxima de 6 mm e parênquima arejado na base do pulmão, sem outras alterações visíveis. Foi decidida realização de tomografia computorizada torácica para esclarecimento dos achados imagiológicos, nomeadamente eventual presença de alguma malformação estrutural parenquimatosa ou vascular, que mostrou áreas de condensação no lobo inferior direito compatíveis com alterações infeciosas, com pequena área de condensação na língula e algumas imagens quísticas visíveis, com ausência de derrame pleural (Fig. 2). No internamento foi realizada pesquisa de Mycoplasma pneumoniae por reação em cadeia da polimerase, que foi positiva. Apesar de negado contacto com pessoas com diagnóstico de tuberculose, foi realizada prova de Mantoux que foi anérgica às 72 horas. A doente cumpriu sete dias de antibioterapia endovenosa com ampicilina e clindamicina, com evolução favorável, tendo sido orientada para cirurgia pediátrica. Posteriormente foi repetida a tomografia computorizada torácica, que revelou imagens quísticas no segmento apical do lobo inferior direito (Fig. 3). Por se tratar de uma provável malformação pulmonar congénita com apresentação por pneumonia atípica, foi decidida lobectomia inferior direita por toracoscopia, que decorreu sem intercorrências. A doente ficou internada nas 24 horas seguintes à cirurgia na unidade de cuidados intensivos pediátrica, sempre em ventilação espontânea, com dreno torácico direito em drenagem livre sero-hemática até ao terceiro dia de internamento, altura em que teve alta sob terapêutica com amoxicilina e ácido clavulânico.O estudo histológico revelou quistos (dimensões < 2 cm) dispersos no parênquima pulmonar, revestidos por epitélio cilíndrico ciliado do tipo respiratório, sem artéria acompanhante, confirmando o diagnóstico de malformação pulmonar congénita tipo II. Atualmente mantém-se assintomática. A malformação pulmonar congénita, anteriormente designada malformação adenomatoide pulmonar quística (MAPQ), descrita pela primeira vez por Stoek em 1897, é uma entidade clínica rara, caracterizada por uma anomalia da maturação pulmonar, resultando na formação de quistos de conteúdo gasoso ou líquido,
Objective: Dornase alfa (rhDNase) reduces the viscosity of purulent sputum in the lungs. The use in patients with cystic fibrosis (CF) is proven. However, the evidence of its applicability to other conditions is limited. This study aims to present the authors’ experience with the use of rhDNase in non-CF patients admitted to the Pediatric Intensive Care Unit (PICU). At the study center, rhDNase was used during flexible bronchoscopies in 24 cases, of which 20 (83%) had atelectasis and seven (29%) were admitted to PICU. Four patients (57%) were on invasive mechanical ventilation (MV). Case description: Two cases of daily rhDNase administration at PICU are presented: patient A was an 8-year-old boy admitted with septic shock and acute respiratory distress syndrome (ARDS). The patient required mechanical ventilation with aggressive settings and experienced several clinical complications. On D50, he started rhDNase treatment with an improvement in FiO2, PaCO2 and PaO2/FiO2 ratio according to radiologic findings. He was extubated on D23 of treatment. Patient B was a 17-month-old girl admitted with a convulsive status epilepticus who experienced respiratory complications (infectious and barotrauma) with ARDS, requiring aggressive ventilation. She initiated rhDNase treatment on D60. During the treatment an improvement in FiO2, PaO2/FiO2 ratio and a tendency of PaCO2 decrease were found. She had radiological improvement. No complications were described. Comments: RhDNase may be a helpful and safe tool to use in PICU prolonged intubated patients with ventilator-induced lung injury. Further studies are needed to assess and propose valid indications.
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