Abstract Objective: To investigate the role of Complex Chronic Conditions (CCCs) on the outcomes of pediatric patients with refractory septic shock, as well as the accuracy of PELOD-2 and Vasoactive Inotropic Score (VIS) to predict mortality in this specific population. Methods: This is a single-center, retrospective cohort study. All patients diagnosed with septic shock requiring vasoactive drugs admitted to a 13-bed PICU in southern Brazil, between January 2016 and July 2018, were included. Clinical and demographic characteristics, presence of CCCs and VIS, and PELOD-2 scores were accessed by reviewing electronic medical records. The main outcome was considered PICU mortality. Results: 218 patients with septic shock requiring vasoactive drugs were identified in the 30-month period and 72% of them had at least one CCC. Overall mortality was 22%. Comparing to patients without previous comorbidities, those with CCCs had a higher mortality (26.7% vs 9.8%; OR = 3.4 [1.3–8.4]) and longer hospital length of stay (29.3 vs 14.8; OR 2.39 [1.1–5.3]). Among the subgroups of CCCs, “Malignancy” was particularly associated with mortality (OR = 2.3 [1.0–5.1]). VIS and PELOD-2 scores in 24 and 48 hours were associated with mortality and a PELOD-2 in 48 hours > 8 had the best performance in predicting mortality in patients with CCC (AUROC = 0.89). Conclusion: Patients with CCCs accounted for the majority of those admitted to the PICU with septic shock and related to poor outcomes. The high prevalence of hospitalizations, use of resources, and significant mortality determine that patients with CCCs should be considered a priority in the healthcare system.

SUMMARY OBJECTIVE: This study aimed to assess the clonidine infusion rate in the first 6 h, as maintenance dose (first 24 h), and in the pre-extubation period (last 24 h), as well as the cumulative dose of other sedatives and the hemodynamic response. METHODS: This is a retrospective cohort study. RESULTS: Children up to the age of 2 years who were admitted to the pediatric intensive care unit of a tertiary referral hospital in the south region of Brazil, between January 2017 and December 2018, were submitted to mechanical ventilation, and received continuous clonidine infusions were included in the study. The initial, maintenance, and pre-extubation doses of clonidine; the vasoactive-inotropic score; heart rate; and systolic and diastolic blood pressure of the study participants were assessed. A total of 66 patients with a median age of 4 months who were receiving clonidine infusions were included. The main indications for mechanical ventilation were acute viral bronchiolitis (56%) and pneumonia associated with acute respiratory distress syndrome (15%). The median of clonidine infusion in the first 6 h (66 patients) was 0.53 μg/kg/h (IQR 0.49–0.88), followed by 0.85 μg/kg/h (IQR 0.53–1.03) during maintenance (57 patients) and 0.63 μg/kg/h (IQR 0.54–1.01) during extubation period (42 patients) (p=0.03). No differences were observed in the doses regarding the indication for mechanical ventilation. Clonidine infusion was not associated with hemodynamic changes and showed no differences when associated with adjuvants. CONCLUSION: Clonidine demonstrated to be a well-tolerated sedation option in pediatric patients submitted to mechanical ventilation, without relevant influence in hemodynamic variables.

Abstract Objective: To determine the prevalence of life support limitation (LSL) in patients who died after at least 24 h 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 24 h 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 donot-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.

Abstract 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 48 h and lactate and leukocytes within 24 h 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 (> 135 ng/mL), lactate (> 1.7 mmol/L), and CRP (> 6.7 mg/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.

Resumo Objetivo Revisar os principais aspectos da definição, diagnóstico e manejo do paciente pediátrico com sepse e choque séptico. Fontes de dados Uma pesquisa nas plataformas de dados Medline e Embase foi feita. Os artigos foram escolhidos segundo interesse dos autores, priorizaram-se as publicações dos últimos 5 anos. Síntese dos dados A sepse continua a ser uma causa importante de mortalidade em pacientes pediátricos. A variabilidade de apresentação clínica dificulta uma definição precisa em pediatria. A estabilização da via aérea com adequada oxigenação, e ventilação se necessário, ressuscitação volêmica inicial, administração de antibióticos e suporte cardiovascular são a base do tratamento da sepse. Em cenários de poucos recursos, deve-se atentar para os riscos de sobrecarga hídrica na administração de fluidos. A administração de drogas vasoativas, como adrenalina ou noradrenalina, se faz necessária na ausência da resposta ao volume na primeira hora. O seguimento do tratamento do choque deve seguir alvos como restauração dos sinais vitais e clínicos de choque e controle do foco de infecção. Recomenda-se a avaliação multimodal, com auxílio da ecografia à beira-leito para manejo após as primeiras horas. No choque refratário, deve-se atentar para situações como tamponamento cardíaco, hipotireoidismo, insuficiência adrenal, catástrofe abdominal e foco de infecção não controlado. Conclusões Implantação de protocolos e avançadas tecnologias propiciou uma redução da mortalidade da sepse. Em cenários de poucos recursos, as boas práticas, como reconhecimento precoce da sepse, administração de antibióticos e cuidadosa infusão de fluidos, são os pilares do manejo da sepse.

Abstract 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.

Resumo Objetivo Analisar a precisão do estridor em comparação com o exame endoscópico no diagnóstico de estenose subglótica pós-intubação em crianças. Método Foram incluídas neste estudo de coorte prospectivo crianças que necessitaram de intubação endotraqueal por mais de 24 horas. Elas foram monitoradas diariamente e submetidas à nasofibrolaringoscopia flexível após a extubação. As crianças com anomalias moderadas foram submetidas a outro exame sete a 10 dias depois. Caso as lesões persistissem ou os sintomas evoluíssem, a laringoscopia era realizada com anestesia geral. Os pacientes foram avaliados diariamente quanto ao estridor após a extubação. Resultados Participaram 187 crianças. A incidência de estridor após a intubação foi de 44,38%. O estridor apresentou uma sensibilidade de 77,78% (intervalo de confiança de 95% [IC]: 51,9-92,6) e especificidade de 59,18% (IC: 51,3-66,6) na detecção de SGS. O valor preditivo positivo foi de 16,87% (IC: 9,8-27,1) e o valor preditivo negativo (VPN) foi de 96,15% (IC: 89,9-98,8). O estridor que persistiu por mais de 72 horas ou que começou 72 horas após a extubação teve uma sensibilidade de 66,67% (IC: 41,2-85,6), especificidade de 89,1% (IC: 83,1-93,2), valor preditivo positivo de 40,0% (IC: 23,2-59,3) e valor preditivo negativo de 96,07% (IC: 91,3-98,4). A área sob a curva de característica de operação do receptor (ROC) foi de 0,78 (IC: 0,65-0,91). Conclusões A ausência de estridor foi adequada para descartar a estenose subglótica pós-intubação. A especificidade desse critério melhorou quando o estridor perdurou por mais de 72 horas ou começou mais de 72 horas após a extubação. Assim, a endoscopia com anestesia geral pode ser utilizada para confirmar a estenose subglótica somente em pacientes que desenvolveram ou continuaram com estridor por mais de 72 horas após a extubação.

Abstract Objective To assess the accuracy of stridor in comparison to endoscopic examination for diagnosis of pediatric post-intubation subglottic stenosis. Method Children who required endotracheal intubation for >24 h were included in this prospective cohort study. Children were monitored daily and underwent flexible fiberoptic laryngoscopy after extubation. Those with moderate-to-severe abnormalities underwent another examination 7-10 days later. If lesions persisted or symptoms developed, laryngoscopy under general anesthesia was performed. Patients were assessed daily for stridor after extubation. Results A total of 187 children were included. The incidence of post-extubation stridor was 44.38%. Stridor had a sensitivity of 77.78% (95% confidence interval [95% CI]: 51.9-92.6) and specificity of 59.18% (95% CI: 51.3-66.6) in detecting subglottic stenosis. The positive predictive value was 16.87% (95% CI: 9.8-27.1), and the negative predictive value was 96.15% (95% CI: 89.9-98.8). Stridor persisting longer than 72 h or starting more than 72 h post-extubation had a sensitivity of 66.67% (95% CI: 41.2-85.6), specificity of 89.1% (95% CI: 83.1-93.2), positive predictive value of 40.0% (95% CI: 23.2-59.3), and negative predictive value of 96.07% (95% CI: 91.3-98.4). The area under the receiver operating characteristic (ROC) curve was 0.78 (95% CI: 0.65-0.91). Conclusions Absence of stridor was appropriate to rule out post-intubation subglottic stenosis. The specificity of this criterion improved when stridor persisted longer than 72 h or started more than 72 h post-extubation. Thus, endoscopy under general anesthesia can be used to confirm subglottic stenosis only in patients who develop or persist with stridor for more than 72 h following extubation.

RESUMO Objetivo: Analisar as características e a evolução de crianças internadas por queimaduras em unidade de terapia intensiva de trauma pediátrico para atendimento de queimados. Métodos: Estudo observacional, por meio da análise retrospectiva de crianças (< 16 anos) admitidas na unidade de terapia intensiva de trauma pediátrico vítimas de queimaduras, entre janeiro de 2013 e dezembro de 2015. Foram analisadas variáveis sociodemográficas e clínicas: agente causal, superfície corporal queimada, presença de lesão inalatória, tempo de internação hospitalar e mortalidade. Resultados: Foram avaliados 140 pacientes, sendo 61,8% do sexo masculino, com mediana da idade de 24 meses e mortalidade geral de 5%. A principal causa de queimadura foi escaldamento (51,4%), seguida de acidente com fogo (38,6%) e choque elétrico (6,4%). Ventilação mecânica foi utilizada em 20,7% dos casos. Lesão inalatória associada apresentou risco relativo de 6,1 (3,5 - 10,7) para necessidade de suporte ventilatório e risco relativo para mortalidade de 14,1 (2,9 - 68,3) quando comparados aos pacientes sem esta lesão associada. Houve significativa associação entre a superfície queimada e a mortalidade (p < 0,002), atingindo 80% nos pacientes com mais de 50% de área queimada. Os pacientes que evoluíram ao óbito apresentaram Tobiasen's Abbreviated Burn Severity Index significativamente maior que os sobreviventes (9,6 ± 2,2 versus 4,4 ± 1,1; p < 0,001). Tobiasen's Abbreviated Burn Severity Index ≥ 7 representou risco relativo para morte de 68,4 (IC95% 9,1 - 513,5). Conclusão: As queimaduras por escaldamento são bastante frequentes e estão associadas à alta morbidade. A mortalidade está associada à superfície corporal queimada e à presença de lesão inalatória. Ênfase especial deve ser dada aos acidentes por fogo, reforçando o diagnóstico e o tratamento adequados da lesão inalatória.

ABSTRACT Objective: To analyze the characteristics and outcomes of children hospitalized for burns in a pediatric trauma intensive care unit for burn patients. Methods: An observational study was conducted through the retrospective analysis of children (< 16 years) admitted to the pediatric trauma intensive care unit for burn victims between January 2013 and December 2015. Sociodemographic and clinical variables were analyzed including the causal agent, burned body surface, presence of inhalation injury, length of hospital stay and mortality. Results: The study analyzed a sum of 140 patients; 61.8% were male, with a median age of 24 months and an overall mortality of 5%. The main cause of burns was scalding (51.4%), followed by accidents involving fire (38.6%) and electric shock (6.4%). Mechanical ventilation was used in 20.7% of the cases. Associated inhalation injury presented a relative risk of 6.1 (3.5 - 10.7) of needing ventilatory support and a relative risk of mortality of 14.1 (2.9 - 68.3) compared to patients without this associated injury. A significant connection was found between burned body surface and mortality (p < 0.002), reaching 80% in patients with a burned area greater than 50%. Patients who died had a significantly higher Tobiasen Abbreviated Burn Severity Index than survivors (9.6 ± 2.2 versus 4.4 ± 1.1; p < 0.001). A Tobiasen Abbreviated Burn Severity Index ≥ 7 represented a relative risk of death of 68.4 (95%CI 9.1 - 513.5). Conclusion: Scalding burns are quite frequent and are associated with high morbidity. Mortality is associated with the amount of burned body surface and the presence of inhalation injury. Special emphasis should be given to accidents involving fire, reinforcing proper diagnosis and treatment of inhalation injury.

RESUMO Objetivo: Traduzir e adaptar transculturalmente para o português do Brasil o instrumento Pediatric Confusion Assessment Method for the Intensive Care Unit para detecção de delirium em unidades de terapia intensiva pediátrica, incluindo algoritmo e instruções. Métodos: Utilizou-se a abordagem universalista para tradução e adaptação transcultural de instrumentos de aferição em saúde. Um grupo de especialistas em terapia intensiva pediátrica avaliou as equivalências conceitual e de itens. Em seguida, a avaliação da equivalência semântica consistiu de tradução do inglês para o português por dois tradutores independentes; conciliação em uma única versão; retradução por um nativo de língua inglesa; e consenso de seis especialistas quanto à compreensão de linguagem e de conteúdo, por meio de respostas do tipo Likert e Índice de Validade de Conteúdo. Finalmente, avaliou-se a equivalência operacional, aplicando-se um pré-teste em 30 pacientes. Resultados: A retradução foi aprovada pelos autores originais. As medianas das respostas do consenso variaram de boa a excelente, exceto na característica "início agudo" das instruções. Itens com Índice de Validade de Conteúdo baixo, relativos às características "início agudo" e "pensamento desorganizado", foram adaptados. No pré-teste, a expressão "acene com a cabeça" foi modificada para "balance a cabeça", para melhor compreensão. Não houve necessidade de outros ajustes, resultando na versão final para o português do Brasil. Conclusão: A versão brasileira do Pediatric Confusion Assessment Method for the Intensive Care Unit foi obtida segundo as recomendações internacionais, podendo ser utilizada no Brasil para o diagnóstico de delirium em crianças graves com 5 anos de idade ou mais, sem atraso de desenvolvimento cognitivo.

ABSTRACT 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.

RESUMO Entre as principais causas de morte em nosso meio, situam-se acidentes automobilísticos, afogamento e queimaduras acidentais. O estrangulamento é uma injúria potencialmente fatal, além de importante causa de homicídio e suicídio em adultos e adolescentes. Em crianças, sua ocorrência é usualmente acidental. No entanto, nos últimos anos, vários casos de estrangulamento acidental em crianças ao redor do mundo têm sido reportados. Paciente masculino de 2 anos de idade foi vítima de estrangulamento em vidro do carro. Admitido na unidade de terapia intensiva pediátrica com Escala de Coma de Glasgow de 8, piora progressiva da disfunção respiratória e torpor. Paciente apresentou quadro de Síndrome da Angústia Respiratória Aguda, edema agudo de pulmão e choque. Foi manejado com ventilação mecânica protetora, drogas vosoativas e antibioticoterapia. Recebeu alta da unidade de terapia intensiva sem sequelas neurológicas ou pulmonares. Após 12 dias de internação, teve hospitalar alta para casa em ótimo estado. A incidência de estrangulamento por vidro de automóvel é rara, mas de alta morbimortalidade, devido ao mecanismo de asfixia ocasionado. Felizmente, os automóveis mais modernos dispõem de dispositivos que interrompem o fechamento automático dos vidros se for encontrada alguma resistência. No entanto, visto a gravidade das complicações de pacientes vítimas de estrangulamento, é significativamente relevante o manejo intensivo neuroventilatório e hemodinâmico das patologias envolvidas, para redução da morbimortalidade, assim como é necessário implementar novas campanhas para educação dos pais e cuidadores das crianças, visando evitar acidentes facilmente preveníveis e otimizar os mecanismos de segurança nos automóveis com vidros elétricos.

ABSTRACT Among the main causes of death in our country are car accidents, drowning and accidental burns. Strangulation is a potentially fatal injury and an important cause of homicide and suicide among adults and adolescents. In children, its occurrence is usually accidental. However, in recent years, several cases of accidental strangulation in children around the world have been reported. A 2-year-old male patient was strangled in a car window. The patient was admitted to the pediatric intensive care unit with a Glasgow Coma Scale score of 8 and presented with progressive worsening of respiratory dysfunction and torpor. The patient also presented acute respiratory distress syndrome, acute pulmonary edema and shock. He was managed with protective mechanical ventilation, vasoactive drugs and antibiotic therapy. He was discharged from the intensive care unit without neurological or pulmonary sequelae. After 12 days of hospitalization, he was discharged from the hospital, and his state was very good. The incidence of automobile window strangulation is rare but of high morbidity and mortality due to the resulting choking mechanism. Fortunately, newer cars have devices that stop the automatic closing of the windows if resistance is encountered. However, considering the severity of complications strangulated patients experience, the intensive neuro-ventilatory and hemodynamic management of the pathologies involved is important to reduce morbidity and mortality, as is the need to implement new campaigns for the education of parents and caregivers of children, aiming to avoid easily preventable accidents and to optimize safety mechanisms in cars with electric windows.

RESUMO Objetivo: Estimar a carga de trabalho e dimensionar a equipe de enfermagem utilizando as escalas TISS-28 e NEMS em uma unidade de terapia intensiva pediátrica. Métodos: Estudo prospectivo observacional com abordagem quantitativa, realizado na unidade de terapia intensiva pediátrica de um hospital universitário, no período de 1o de janeiro de 2009 a 31 de dezembro de 2009. Foram incluídas todas as crianças que permaneceram internadas por mais de 8 horas, com duração de internação de 4 horas em caso de óbito. Foram coletados os dados clínicos, e determinados o Paediatric Index of Mortality 2 e as escalas TISS-28 e NEMS. O TISS-28 e o NEMS foram convertidos em horas de trabalho da equipe de enfermagem, e o dimensionamento seguiu os parâmetros do Conselho Federal de Enfermagem. A correlação de Pearson e o modelo de Bland-Altman foram utilizados para verificar a associação e a concordância entre os instrumentos. Resultados: Foram incluídas 459 crianças, totalizando 3.409 observações. As médias do TISS-28 e do NEMS foram 20,8±8 e 25,2±8,7 pontos, respectivamente. A carga de trabalho de enfermagem foi de 11 horas pelo TISS-28 e 13,3 horas pelo NEMS. A estimativa do número de profissionais pelo TISS-28 e NEMS foi de 29,6 e 35,8 profissionais, respectivamente. O TISS-28 e o NEMS apresentaram correlação e concordância adequadas. Conclusão: O tempo despendido nas atividades de enfermagem e o dimensionamento da equipe refletido pelo NEMS foram significativamente maiores quando comparados ao TISS-28.

ABSTRACT 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.

RESUMO Os pacientes admitidos em uma unidade de terapia intensiva estão sujeitos à sobrecarga fluídica acumulada e recebem volume endovenoso pela ressuscitação agressiva, preconizada nas recomendações de tratamento do choque séptico, além de outras fontes de líquidos relacionadas às medicações e ao suporte nutricional. A estratégia liberal de oferta hídrica tem sido associada a maiores morbidade e mortalidade. Apesar de haver poucos estudos prospectivos pediátricos, novas estratégias estão sendo propostas. Esta revisão não sistemática discute a fisiopatologia da sobrecarga fluídica, suas consequências e as estratégias terapêuticas disponíveis. Durante a síndrome da resposta inflamatória sistêmica, o glicocálice endotelial é danificado, favorecendo o extravasamento fluídico, traduzido em edema intersticial. O extravasamento para o terceiro espaço se traduz em maior tempo de ventilação mecânica, maior necessidade de terapia de substituição renal e mais tempo de internação na unidade de terapia intensiva e no hospital, entre outros. A monitorização hemodinâmica adequada, bem como a infusão cautelosa de fluídos, pode minimizar estes danos. Uma vez instalada a sobrecarga fluídica acumulada, o tratamento com o uso crônico de diuréticos de alça pode levar a uma resistência ao uso destas medicações. A utilização precoce de vasopressores (norepinefrina) para melhora do débito cardíaco e perfusão renal, a associação de diuréticos e uso da aminofilina para indução de diurese, e a utilização de protocolos de sedação e mobilização precoce são algumas estratégias que podem reduzir morbimortalidade na unidade de terapia intensiva.

ABSTRACT Patients admitted to an intensive care unit are prone to cumulated fluid overload and receive intravenous volumes through the aggressive resuscitation recommended for septic shock treatment, as well as other fluid sources related to medications and nutritional support. The liberal liquid supply strategy has been associated with higher morbidity and mortality. Although there are few prospective pediatric studies, new strategies are being proposed. This non-systematic review discusses the pathophysiology of fluid overload, its consequences, and the available therapeutic strategies. During systemic inflammatory response syndrome, the endothelial glycocalyx is damaged, favoring fluid extravasation and resulting in interstitial edema. Extravasation to the third space results in longer mechanical ventilation, a greater need for renal replacement therapy, and longer intensive care unit and hospital stays, among other changes. Proper hemodynamic monitoring, as well as cautious infusion of fluids, can minimize these damages. Once cumulative fluid overload is established, treatment with long-term use of loop diuretics may lead to resistance to these medications. Strategies that can reduce intensive care unit morbidity and mortality include the early use of vasopressors (norepinephrine) to improve cardiac output and renal perfusion, the use of a combination of diuretics and aminophylline to induce diuresis, and the use of sedation and early mobilization protocols.