Publications by authors named "Tiago Henrique de Souza"

9 Publications

  • Page 1 of 1

Hypophosphatemia in critically ill pediatric patients receiving enteral and oral nutrition.

JPEN J Parenter Enteral Nutr 2021 Jul 21. Epub 2021 Jul 21.

Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil.

Background: Hypophosphatemia(HP) is related to several comorbidities in pediatric intensive care units (PICUs). This study aimed to evaluate the incidence of HP in severely ill pediatric patients receiving oral and/or enteral nutrition. The secondary objectives were to investigate the association between HP and the inflammatory state, PICU length of stay, severity, mortality, nutrition status, and protein, energy, calcium, vitamin D, and phosphate intake.

Methods: A prospective, observational cohort study was conducted in a PICU of a quaternary hospital. Participants aged between 28 days and 14 years were included. Anthropometric and laboratory assessments were performed ≤72 h after PICU admission and repeated after 7 days for three consecutive times. Energy, protein, calcium, phosphate, and vitamin D intake per day of hospitalization were recorded individually. The Pediatric Index of Mortality 2 (PIM2) was used to determine each patient's severity score.

Results: A total of 103 participants were included in the study. Hypophosphatemic events ranged from 27.2% to 37.5% among the assessments. HP was associated with high C-reactive protein levels (P = .012) and lower energy adequacy (P = .037). Serum phosphorus was inversely correlated (weak correlation) with PIM2 (P = .017).

Conclusion: HP is common in critically ill pediatric patients, even when they are not receiving parenteral nutrition. It is necessary to monitor serum phosphorus levels and consider the possibility of early replacement, especially in patients showing high levels of inflammation. In addition to inflammation itself, low energy intake and illness severity were related to HP.
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July 2021

Extubation in the pediatric intensive care unit: predictive methods. An integrative literature review.

Rev Bras Ter Intensiva 2021 Apr-Jun;33(2):304-311

Universidade Estadual de Campinas - Campinas (SP), Brasil.

For extubation in pediatric patients, the evaluation of readiness is strongly recommended. However, a device or practice that is superior to clinical judgment has not yet been accurately determined. Thus, it is important to conduct a review on the techniques of choice in clinical practice to predict extubation failure in pediatric patients. Based on a search in the PubMed®, Biblioteca Virtual em Saúde, Cochrane Library and Scopus databases, we conducted a survey of the predictive variables of extubation failure most commonly used in clinical practice in pediatric patients. Of the eight predictors described, the three most commonly used were the spontaneous breathing test, the rapid shallow breathing index and maximum inspiratory pressure. Although the disparity of the data presented in the studies prevented statistical treatment, it was still possible to describe and analyze the performance of these tests.
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November 2021

Hemodynamic effects of increased intra-abdominal pressure in critically ill children.

J Pediatr (Rio J) 2021 Sep-Oct;97(5):564-570. Epub 2020 Dec 21.

Universidade Estadual de Campinas (UNICAMP), Hospital das Clínicas, Departamento de Pediatria, Unidade de Terapia Intensiva Pediátrica, Campinas, SP, Brazil. Electronic address:

Objective: To evaluate the influence of intra-abdominal pressure on the cardiac index (CI) at different intra-abdominal hypertension grades achieved when performing an abdominal compression maneuver (ACM). Evaluating the effectiveness of the ACM in distending the left internal jugular vein (LIJV).

Methods: Prospective observational study conducted in the PICU of a quaternary care teaching hospital. Participants underwent the ACM and the IAP was measured with an indwelling urinary catheter. At each IAH grade reached during the ACM, the CI was measured by transthoracic echocardiography and the LIJV cross-sectional area (CSA) was determined by ultrasonography.

Results: Twenty-four children were included (median age and weight of 3.5 months and 6.37kg, respectively). The median CI observed at baseline and during IAH grades I, II, III, and IV were 3.65L/min/m (IQR 3.12-4.03), 3.38L/min/m (IQR 3.04-3.73), 3.16L/min/m (IQR 2.70-3.53), 2.89L/min/m (IQR 2.38-3.22), and 2.42L/min/m (IQR 1.91-2.79), respectively. A 25% increase in the LIJV CSA area was achieved in 14 participants (58%) during the ACM.

Conclusion: The ACM significantly increases IAP, causing severe reversible impairment in the cardiovascular system and is effective in distending the LIJV in just over half of the subjects. Even low levels of HIA can result in significant cardiac dysfunction in children. Therefore, health professionals should be aware of the negative hemodynamic repercussions caused by the increased IAP.
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October 2021

COVID-19 and Children: Many Questions Yet To Be Answered.

Ann Acad Med Singap 2020 08;49(8):527-529

Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore.

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August 2020

Protein intake deficiency in critically ill children with respiratory insufficiency: A call to action?

Clin Nutr ESPEN 2020 06 17;37:69-74. Epub 2020 Apr 17.

University of Campinas, Unicamp, School of Medical Sciences, 126 Tessália Vieira de Camargo St., Cidade Universitária "Zeferino Vaz", Campinas, SP, 13083-887, Brazil; São Leopoldo Mandic College of Medicine and Dentistry, 13 Dr. José Rocha Junqueira St., Swift, Campinas, SP, 13045-755, Brazil. Electronic address:

Background & Aims: Adequate energy-protein intake is associated with improved clinical outcomes in critically ill children. The aim of this study was to evaluate the time of enteral nutrition (EN) onset and the energy-protein intake in critically ill pediatric patients admitted with respiratory insufficiency.

Methods: A single-center prospective cohort study, including children and adolescents, aged from 1 month to 14 years. All patients had been diagnosed with respiratory insufficiency and were exclusively enterally fed and had been admitted to a Pediatric Intensive Care Unit (PICU) of a public quaternary hospital in southeastern Brazil. Demographic, clinical, and nutritional therapy characteristics were recorded. Early EN (EEN) was considered when EN was initiated within the first 48 h of PICU admission.

Results: Seventy-one patients were included in this study, 64.79% were male with a median age of 6 months (2; 13) and a median PICU length of stay of 13.00 days (6.75; 23.00). PICU mortality was 4.23% and 78.87% of patients were under mechanical ventilation within the first 48 h of PICU admission with a median time of mechanical ventilation of 10 days (6.00; 16.50). The median energy adequacy was 74.97% (50.29; 93.94) and the median protein adequacy was 56.12% (40.72; 69.81). Only 7.25% of the patients achieved protein adequacy. Nutritional variables were compared between groups: EEN and late EN (LEN). EEN was utilized in 69.01% of patients who had increased energy (41.80 [34.07; 51.17] versus 23.60 [11.22; 35.17] kcal/kg/day; p < 0.0001) and protein intake (0.94 [0.78, 1.16] versus 0.53 [0.30, 0.79] g/kg/day, p < 0.0001) and better nutritional adequacies (p < 0.0001).

Conclusions: Patients who received EEN had increased energy-protein delivery and adequacies. However, protein inadequacy occurred throughout in all patients within this sample, regardless the onset of EN.
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June 2020

Lung ultrasound in children with pneumonia: interoperator agreement on specific thoracic regions.

Eur J Pediatr 2019 Sep 16;178(9):1369-1377. Epub 2019 Jul 16.

Pediatric Intensive Care Unit, Department of Pediatrics, State University of Campinas (UNICAMP), 1000, Hermantino Coelho St., Campinas, SP, 13087-500, Brazil.

The objective of this study was to evaluate the interoperator agreement of lung ultrasonography (LUS) on specific thoracic regions in children diagnosed with pneumonia and to compare the findings of the LUS with the chest X-ray. Participants admitted to the ward or PICU underwent LUS examinations performed by an expert and a novice operator. A total of 261 thoracic regions in 23 patients were evaluated. Median age and weight of participants were 30 months and 11.6 kg, respectively. A substantial overall agreement between operators was found for normal lung tissue (κ = 0.615, 95% confidence interval (95% CI) = 0.516-0.715) and for consolidations (κ = 0.635, 95% CI = 0.532-0.738). For B-lines, a moderate agreement was observed (κ = 0.573, 95% CI = 0.475-0.671). An almost perfect agreement was found for pleural effusion (κ = 0.868, 95% CI = 0.754-0.982). The diagnosis of consolidations by LUS showed a high sensitivity (93% for both operators) but a low specificity (14% for expert and 25% for novice operator). While intubated patients presented significantly more consolidations, nonintubated patients presented more normal ultrasound patterns.Conclusion: Even when performed by operators with very distinct degrees of experience, LUS had a good interoperator reliability for detecting sonographic patterns on specific thoracic regions. What is Known: • Lung ultrasound is feasible, safe, and highly accurate for the diagnosis of pneumonia in children; however, it does not allow global visualization of the thorax in a single moment as in chest X-rays, and, similar to the stethoscope, partial thorax assessments must be performed sequentially. What is New: • This is the first study evaluating the agreement of LUS on specific thoracic regions between operators with distinct degrees of experience performing the sonograms. • There is a good agreement between an expert operator and a novice operator who underwent a brief theoretical-practical training program on LUS.
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September 2019

Ultrasound Guidance for Pediatric Central Venous Catheterization: A Meta-analysis.

Pediatrics 2018 11;142(5)

Division of Pediatric Critical Care, Department of Pediatrics, University of Campinas, Campinas, São Paulo, Brazil; and.

: media-1vid110.1542/5828324804001PEDS-VA_2018-1719 CONTEXT: Central venous catheterization is routinely required in patients who are critically ill, and it carries an associated morbidity. In pediatric patients, the procedures can be difficult and challenging, predominantly because of their anatomic characteristics.

Objective: To determine whether ultrasound-guided techniques are associated with a reduced incidence of failures and complications when compared with the anatomic landmark technique.

Data Sources: We conducted a systematic search of PubMed and Embase.

Study Selection: We included randomized controlled trials and nonrandomized studies in which researchers compare ultrasound guidance with the anatomic landmark technique in children who underwent central venous catheterization.

Data Extraction: Study characteristics, sample sizes, participant characteristics, settings, descriptions of the ultrasound technique, puncture sites, and outcomes were analyzed. Pooled analyses were performed by using random-effects models.

Results: A total of 23 studies (3995 procedures) were included. Meta-analysis revealed that ultrasound guidance significantly reduced the risk of cannulation failure (odds ratio = 0.27; 95% confidence interval: 0.17-0.43), with significant heterogeneity seen among the studies. Ultrasound guidance also significantly reduced the incidence of arterial punctures (odds ratio = 0.34; 95% confidence interval: 0.21-0.55), without significant heterogeneity seen among the studies. Similar results were observed for femoral and internal jugular veins.

Limitations: Potential publication bias for cannulation failure and arterial puncture was detected among the studies. However, no publication bias was observed when analyzing only the subgroup of randomized clinical trials.

Conclusions: Ultrasound-guided techniques are associated with a reduced incidence of failures and inadvertent arterial punctures in pediatric central venous catheterization when compared with the anatomic landmark technique.
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November 2018


Rev Paul Pediatr 2019 Jan-Mar;37(1):126-129. Epub 2018 Aug 30.

Universidade Estadual de Campinas, Campinas, SP, Brasil.

Objective: To report a rare case of a child with invasive pneumococcal disease that presented meningitis associated with pericarditis.

Case Description: This report describes the unfavorable clinical course of a previously healthy 6-months-old female infant who initially presented symptoms of fever and respiratory problems. A chest X-ray revealed an increased cardiac area with no radiographic changes in the lungs. After identifying a pericardial effusion, the patient experienced seizures and went into coma. Pneumonia was excluded as a possibility during the clinical investigation. However, Streptococcus pneumoniae was identified in the cerebrospinal fluid and blood cultures. An initial neurological examination showed that the patient was brain dead, which was then later confirmed according to protocol.

Comments: Purulent pericarditis has become a rare complication of invasive pneumococcal disease since the advent of antibiotic therapy. Patients with extensive pneumonia are primarily predisposed and, even with early and adequate treatment, are prone to high mortality rates. The association of pneumococcal meningitis and pericarditis is uncommon, and therefore difficult to diagnose. As such, diagnostic suspicion must be high in order to institute early treatment and increase survival.
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August 2019

Ultrasound guidance for internal jugular vein cannulation in PICU: a randomised controlled trial.

Arch Dis Child 2018 10 4;103(10):952-956. Epub 2018 Apr 4.

Deparment of Pediatrics, University of Campinas (UNICAMP), Campinas, Brazil.

Objective: We investigated whether ultrasound guidance was advantageous over the anatomical landmark technique when performed by inexperienced paediatricians.

Design: Randomised controlled trial.

Setting: A paediatric intensive care unit of a teaching hospital.

Patients: 80 children (aged 28 days to <14 years).

Interventions: Internal jugular vein cannulation with ultrasound guidance in real time or the anatomical landmark technique.

Main Outcome Measures: Success rate, success rate on the first attempt, success rate within three attempts, puncture time, number of attempts required for success and occurrence of complications.

Results: We found a higher success rate in the ultrasound guidance than in the control group (95% vs 61%, respectively; p<0.001; relative risk (RR)=0.64, 95% CI (CI) 0.50 to 0.83). Success on the first attempt was seen in 95% and 34% of venous punctures in the US guidance and control groups, respectively (p<0.001; RR=0.35, 95% CI 0.23 to 0.54). Fewer than three attempts were required to achieve success in 95% of patients in the US guidance group but only 44% in the control group (p<0.001; RR=0.46, 95% CI 0.32 to 0.66). Haematomas, inadvertent arterial punctures, the number of attempts and the puncture time were all significantly lower in the ultrasound guidance than in the control group (p<0.015 for all).

Conclusions: Critically ill children may benefit from the ultrasound guidance for internal jugular cannulation, even when the procedure is performed by operators with limited experience.

Trial Registration Number: RBR-4t35tk.
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October 2018