OBJECTIVES: To assess the prevalence of burnout, anxiety and depression symptoms, and posttraumatic stress disorder (PTSD) in PICU workers in Brazil during the first peak of the COVID-19 pandemic. To compare the results of subgroups stratified by age, gender, professional category, health system, and previous mental health disorders. DESIGN: Multicenter, cross-sectional study using an electronic survey. SETTING: Twenty-nine public and private Brazilian PICUs. SUBJECTS: Multidisciplinary PICU workers. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Self-reported questionnaires were used to measure burnout (Maslach Burnout Inventory), anxiety and depression (Hospital Anxiety and Depression Scale), and PTSD (Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [PCL-5]) in 1,084 respondents. Subjects were mainly young (37.1 ± 8.4 yr old) and females (85%), with a median workload of 50 hours per week. The prevalence of anxiety and depression was 33% and 19%, respectively, whereas PTSD was 13%. The overall median burnout scores were high in the emotional exhaustion and personal accomplishment dimensions (16 [interquartile range (IQR), 8–24] and 40 [IQR, 33–44], respectively) whereas low in the depersonalization one (2 [IQR, 0–5]), suggesting a profile of overextended professionals, with a burnout prevalence of 24%. Professionals reporting prior mental health disorders had higher prevalence of burnout (30% vs 22%; p = 0.02), anxiety (51% vs 29%; p < 0.001), and depression symptoms (32.5% vs 15%; p < 0.001), with superior PCL-5 scores for PTSD ( p < 0.001). Public hospital workers presented more burnout (29% vs 18.6%, p < 0.001) and more PTSD levels (14.8% vs 10%, p = 0.03). Younger professionals were also more burned out ( p < 0.05 in all three dimensions). CONCLUSIONS: The prevalence of mental health disorders in Brazilian PICU workers during the first 2020 peak of COVID-19 was as high as those described in adult ICU workers. Some subgroups, particularly those reporting previous mental disorders and younger professionals, should receive special attention to prevent future crises.

RESUMO OBJETIVO: Avaliar o desempenho dos escores de mortalidade Pediatric Risk of Mortality (PRISM) e Pediatric Index of Mortality 2 (PIM2) na Unidade de Terapia Intensiva Pediátrica (UTIP) Terciária da Fundação Santa Casa de Misericórdia do Pará (FSCMPA). MATERIAIS E MÉTODOS: Estudo de coorte retrospectivo, incluindo pacientes admitidos na UTIP, entre janeiro de 2017 a abril de 2018, com permanência por mais de 8 h. Os critérios de exclusão foram: permanência superior a 90 dias; parada cardiorrespiratória sem estabilidade em 12 h; cuidados paliativos; e morte encefálica. Para calcular os sistemas de escores e desfecho, utilizou-se as variáveis Standardized Mortality Rate (SMR), calibração e discriminação, que foram comparadas pelos testes goodness-of-fit e curvas Receiver Operating Characteristic (ROC), respectivamente. RESULTADOS: Entre as 458 internações, 429 (93,7%) foram incluídas. A mortalidade geral foi de 17,5%, sendo que 64,0% eram menores de 2 anos de idade e 58,7% dos que evoluíram a óbito foram submetidos à ventilação mecânica por período maior que sete dias. A média de probabilidade de morte estimada do PRISM foi 9,85%, enquanto a média do PIM2 foi de 14,2%. O SMR foi de 1,35 (1,26-1,72) para o PRISM e de 1,23 (1,13-1,58) para o PIM2. A área sob a curva ROC foi de 0,89 (IC 95% 0,81-0,91) para o PRISM e 0,87 (IC 95% 0,83-0,91) para o PIM2. CONCLUSÃO: Na UTIP da FSCMPA, o PRISM e o PIM2 tiveram boa calibração e bom poder discriminatório. O SMR foi superior a um.ABSTRACT OBJECTIVE: To evaluate the performance of the Pediatric Risk of Mortality (PRISM) and Pediatric Index of Mortality 2 (PIM2) scores in the Tertiary Pediatric Intensive Care Unit (PICU) of the Fundação Santa Casa de Misericórdia do Pará (FSCMPA). MATERIALS AND METHODS: A retrospective cohort study was conducted with patients hospitalized in PICU for more than 8 h, from January 2017 to April 2018. Exclusion criteria were: stay longer than 90 days; cardiorespiratory arrest without stability in 12 h; palliative care; and brain death. To calculate score and outcome systems, Standardized Mortality Rate (SMR), calibration, and discrimination variables were used and compared by goodness-of-fit and Receiver Operating Characteristic (ROC) curves, respectively. RESULTS: Among the 458 hospitalizations, 429 (93.7%) were included. Overall mortality was 17.5%, with 64.0% under 2 years of age; and 58.7% of those who evolved to death were submitted to mechanical ventilation for more than seven days. The estimated mean probability of death from PRISM was 9.85%, while the mean PIM2 was 14.2%. The SMR was 1.35 (1.26-1.72) for PRISM and 1.23 (1.13-1.58) for PIM2. The area under the ROC curve was 0.89 (95% CI 0.81-0.91) for PRISM and 0.87 (95% CI 0.83-0.91) for PIM2. CONCLUSION: In the FSCMPA PICU, PRISM and PIM2 had good calibration and good discriminatory power. The SMR was greater than one.

This is a multicentre prospective cohort including critically ill children and adolescents, with confirmed critical disease related to SARS-CoV-2, admitted to three tertiary paediatric intensive care units in the Brazilian Amazon, between April 2020 and July 2022. 208 patients were included (median age was 3.5 years). The majority had malnutrition (62%) and comorbidities (60.6%). Mechanical ventilation support, cardiogenic shock and acute respiratory distress syndrome occurred in 47%, 30% and 34.1% of patients, respectively. There were 37 (18%) deaths. A poor outcome of severe COVID-19 and multisystem inflammatory syndrome in children was observed in children and adolescents from the Brazilian Amazon.

Purpose: SARS-CoV-2 infection in children is usually asymptomatic/mild. However, some patients may develop critical forms. Our aim was to evaluate the independent risk factors associated to in-hospital mortality in children with critical disease related to SARS-CoV-2. Methods: This is multicenter prospective cohort included critically ill children (1 month/18 years of age), with confirmed critical disease related to SARS-CoV-2 admitted to three tertiary Pediatric Intensive Care Units (PICU) in Brazilian Amazon, between April 2020/July 2022. Main outcome was in-hospital mortality. The independent risk factors associated with mortality were evaluated with a multivariable Cox proportional regression. Results: 208 patients were assessed. Median age was 33 months and median follow-up was 277 days (range, 2-759). Death occurred in 37 (17.8%) patients with a median follow-up of 7 (4-13) days. Most non-survivors had at least one comorbidity - 34 (91.9%). Substantial clinical features, laboratory and ventilatory parameters were associated with mortality. Independent risk factors for mortality were underweight status (HR= 6.64, p=0.01), vasoactive inotropic score (VIS) > 84 (HR=4.76, p=0.05), acute respiratory distress syndrome (HR=8.63, p=0.02) and erythrocyte sedimentation rate (ESR) >18 mm/hour (HR=3.95, p=0.03). Conclusions: This study of critically ill patients with COVID-19 and MIS-C from the Brazilian Amazon showed a high mortality rate. The risk of death was higher for underweight individuals, those with higher levels of VIS and ESR, presence of ARDS. The majority of deaths occurred within 10 days of hospitalization, highlighting the importance of prompt recognition in regard to these patients.

Background: Some children can develop severe forms of SARS-CoV-2 infection either acutely or later, as represented by multisystemic inflammatory syndrome in children (MIS- C). To identify the risk factors for worse outcomes in hospitalized children and adolescents with severe acute SARS-CoV-2 infection and MIS-C. Methods: This multicenter cohort study included all children and adolescents with confirmed or suspected critical SARS-CoV-2 infection admitted to the PICU between April 2020 and September 2021. The exclusion criteria were incomplete vaccinal status, immunocompromised status, and end-of-life decision. The main variables analyzed were epidemiological, clinical, and laboratory data, and ventilator settings at admission and after 72 h. The patients were divided into three groups (G): confirmed coronavirus disease (COVID-19) with MIS-C criteria (G1), confirmed COVID-19 without MIS-C criteria (G2), and MIS-C criteria without confirmed COVID-19. Results: The median age of the patients was 28 months in G1, with comorbidities in 40 patients (72.7%) (p < 0.0001). The duration of exposure (median 23 days; p = 0.004) and fever were longer in G1 (12 days; p = 0.001). Moreover, invasive mechanical ventilation (IMV) was required in 44 patients (80%, p < 0.0001), and cardiogenic shock occurred in 26 patients (54.2%, p < 0.0001) in G1. Subnutrition was most frequent in G1 in 55 cases (57.3%; p = 0.01). Under nutrition (< 2 SD for weight), longer exposure time (odds ratio [OR]: 2.11; 95% confidence interval [CI]: 1.37–3.25; p = 0.001), IMV time (OR: 2.6; 95% CI: 1.15–5.85; p = 0.03), and length of hospital stay (OR: 10.94; 95% CI: 1.93–63.1; p = 0.007) were associated with critical MIS-C in G1. Conclusions: In the Brazilian Amazon area, specifically in the Pará state, we identified a cluster of more severe forms of pediatric acute or late SARS-CoV-2 infection.

Objectives: To determine blood glucose distribution values; to assess the association of admission serum glucose levels with 28-day mortality to the frequency of invasive mechanical ventilation-free days. Design: Retrospective cohort studySetting: Brazilian Amazon Region. Patients: Population (n = 400) composed of patients admitted to the pediatric intensive care unit, from January 2016 to December 2017. Exclusion criteria were patients with length of stay of <24 hours; diabetes mellitus; suspicion or evidence of inborn errors of metabolism; insulin use; palliative care and brain death. Main outcome measures: The patients were divided into 4 groups: 1) serum glucose <60mg/dL; 2) control group if serum glucose between 60-126 mg/dL; 3) between 127-150mg/dL; or 4) if > 150mg/dL. Results: Serum glucose levels frequency were: <60: 43 (11%); 60-126: 235 (58.7%); 127-150: 51 (13%) and > 150: 71 (18%). Groups 3 and 4 had the highest frequency of external origin, with respectively 24 (47.1%) and 40 (56.3%); the main diagnosis was infection, with 26 (51%) and 50 (70.4%), respectively. Sepsis occurred in 24 (47.1%) and 47 (66.2%) individuals in the groups 3 and 4, respectively, while septic shock was more frequent in the group 4 (46 [4.8%]). Group 2 had predominance of ventilator-associated pneumonia with 11 (36.7%). The estimate of ventilation-free days in group 4 was 2.84 (SD +/- 0.69; 95% CI: 1.5-4.2). Conclusion: Hyperglycemia group had a lower frequency of ventilation-free days and higher 28-day mortality.

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Objectives: To evaluate the risk factors and mortality associated with septic shock and multiple organ dysfunction syndrome (MODS), and to examine associations with unfavorable outcomes among pediatric patients from the Brazilian Amazon. Design: A matched nested case-control, observational, single-center study was conducted between January 1, 2016, and December 31, 2019. Patients: All children admitted to the pediatric intensive care unit (PICU) with sepsis, as defined in the inclusion criteria, were included. Interventions: The selected cases consisted of patients with septic shock with MODS, while the control group consisted of children who were randomly chosen (1:2 ratio) among patients admitted to the PICU, matched for age and sex. Qualified students collected the data while being “blinded” to the research hypotheses. Measurements and Main Results: There was an association between septic shock with MODS and pH, sodium bicarbonate and base excess, hypernatremia, hypocalcemia, and hyperchloremia. In patients with septic shock with or without MODS, hypocalcemia, hyperchloremia, hypomagnesemia, hypokalemia, and hypophosphatemia were associated with mortality. We also observed an association between acute respiratory distress symptoms, elevated anion gap, and hyperlactatemia in patients with septic shock and non-surviving MODS. Infections by gram-negative organisms, changes in coagulation markers, inadequate nutritional status, pulmonar impairment requiring invasive support, and the presence of acute respiratory distress syndrome were associated with an increased risk of septic shock with MODS and mortality. Conclusions: In our study, septic shock with MODS associated with death affected male infants with previous comorbidities, hospitalized for clinical reasons, and coming from other services. The main factors associated with a higher risk of septic shock with MODS in this study were the origin of outside facilities.