RESUMO Objetivo: Embora a necropsia seja considerada o exame padrão-ouro de diagnóstico, observa-se declínio em sua realização, enquanto cresce o número de eventos adversos na saúde, dos quais 17% são erros diagnósticos. O estudo objetivou estimar a prevalência do erro de diagnóstico, com base no diagnóstico anatomopatológico, em uma Unidade de Terapia Intensiva Pediátrica (UTIP). Métodos: Estudo de corte transversal, retrospectivo, de 31pacientes que foram a óbito entre 2004 e 2014. Os diagnósticos foram comparados para verificar se houve concordância de diagnóstico principal (CDP) e diagnóstico da causa da morte (DCM), classificados de acordo com os critérios de Goldman. Resultados: De 3.117 pacientes, 263 foram a óbito. Em 38 casos foi realizada autopsia (14,4%) e 31 foram incluídos no estudo. Observou-se decréscimo de 67% no número de autopsias em dez anos. Concordância absoluta entre os diagnósticos (classe V) foi observada em 18 casos (58,0%) e discordância (classe I), em 11 (35,4%). Observou-se maior dificuldade no diagnóstico de doenças agudas e de evolução fatal rápida, como as miocardites. Sete pacientes foram admitidos em estado geral grave, indo a óbito nas primeiras 24 horas de internação. Conclusões: A necropsia não só permite a identificação de erros diagnósticos, como também a oportunidade de se aprender com o erro. Os resultados enfatizam a importância desse exame para a elucidação diagnóstica e a construção de uma base de informações sobre os principais diagnósticos envolvidos em pacientes que evoluem rapidamente para o óbito em UTIP, aumentando o grau de suspeição pela equipe da Unidade.

ABSTRACT Objective: Although autopsy is deemed the gold standard for diagnosis, its performance has been decreasing while adverse events have been increasing, of which 17% consist in diagnostic errors. The purpose of this study was to estimate the prevalence of diagnostic errors based on anatomopathological diagnosis in a Pediatric Intensive Care Unit (PICU). Methods: This is a cross-sectional, retrospective study on 31patients who died between 2004 and 2014. Diagnoses were compared in order to assess whether there was agreement between clinical major diagnosis (CMD) and the cause of death as described in the autopsy record (CDAR), which were classified according to the Goldman Criteria. Results: Of 3,117 patients, 263 died (8.4%). Autopsy was conducted in 38 cases (14.4%), and 31 were included in the study. Therewas a 67% decrease in the number of autopsies over the last 10years. Absolute agreement between the diagnoses (class V) was observed in 18 cases (58.0%), and disagreement (class I), in 11 (35.4%). Therewas greater difficulty in diagnosing acute diseases and diseases of rapid fatal evolution such as myocarditis. Sevenpatients were admitted in critical health conditions and died within the first 24 hours of hospitalization. Conclusions: Autopsy not only enables to identify diagnostic errors, but also provides the opportunity to learn from mistakes. The results emphasize the relevance of the autopsy examination for diagnostic elucidation and the creation of an information database concerning the main diagnoses of patients who rapidly progress to death in PICU, increasing the index of clinical suspicion of the team working at this unit.

This study was designed to investigate the effect of early weaning and concentrate supplementation on performance and metabolic profile of lambs in four production systems on pasture: suckling lambs not supplemented until slaughter; suckling lambs supplemented with concentrate in creep feeding until slaughter; early weaned lambs not supplemented until slaughter; early weaned lambs supplemented with concentrate until slaughter. Performance was assessed by average daily gain (ADG) and body condition score (BCS) measurements. Metabolic profile was delineated by measuring serum albumin, urea, creatinine, cholesterol, glucose and aspartate aminotransferase. Weaning reduced ADG by 92 g/d and the ADG for weaned and suckling lambs were 113 g/d and 205 g/d, respectively. Supplementation increased ADG by 117 g/d and the ADG was 99 g/d for non-supplemented and 216 g/d for supplemented lambs. Body weight and BCS at the end of trial were lower in weaned and non-supplemented animals (20.7 kg and 1.5 points), and higher in those on creep feeding (35.3 kg and 3.3 points). Weaning decreased serum levels of albumin, cholesterol and aspartate aminotransferase. Supplementation increased serum albumin and decreased serum aspartate aminotransferase. Serum urea was not affected by weaning or supplementation and remained high during the trial. Serum creatinine and glucose were lower in weaned and non-supplemented lambs. Early weaning generates unsuitable metabolic profile and low performance and may not be recommended as single strategy to produce lambs on pasture. Concentrate supplementation has similar response to suckling on the performance and metabolic profile of animals, and may be considered an efficient strategy to improve the nutritional status of early weaned lambs.

OBJETIVO: descrever as complicações maternas decorrentes dos procedimentos endoscópicos terapêuticos em Medicina fetal, realizados em um centro universitário no Brasil. MÉTODOS: estudo observacional retrospectivo que incluiu gestantes atendidas no período de Abril de 2007 a Maio de 2010. Esses casos foram submetidos aos seguintes procedimentos: ablação vascular placentária com laser (AVPL) por síndrome de transfusão feto-fetal (STFF) grave; oclusão traqueal fetal (OTF) e retirada de balão traqueal por via endoscópica por hérnia diafragmática congênita (HDC) grave e AVPL, com ou sem cauterização bipolar do cordão umbilical, por síndrome da perfusão arterial reversa (SPAR) em gêmeo acárdico. As principais variáveis descritas para cada condição clínica/tipo de cirurgia foram as complicações maternas e a sobrevida (alta do berçário) do neonato/lactente. RESULTADOS: cinquenta e seis gestantes foram submetidas a 70 procedimentos: STFF grave (34 pacientes; 34 cirurgias); HDC grave (16 pacientes; 30 cirurgias) e SPAR (6 pacientes; 6 cirurgias). Entre as 34 gestantes tratadas com AVPL por STFF, duas (2/34=5,9%) apresentaram perda de líquido amniótico para a cavidade peritoneal e sete (7/34=20,6%) tiveram abortamento após os procedimentos. A sobrevida de pelo menos um gêmeo foi de 64,7% (22/34). Entre as 30 intervenções realizadas para HDC, houve perda de líquido amniótico para a cavidade peritoneal materna em um caso (1/30=3,3%) e rotura prematura pré-termo de membranas após três (3/30=30%) fetoscopias para retirada do balão traqueal. A sobrevida com alta do berçário foi de 43,8% (7/16). Entre os seis casos de SPAR, houve sangramento materno para a cavidade peritoneal após uma cirurgia (1/6=16,7%) e a sobrevida com alta do berçário foi de 50% (3/6). CONCLUSÕES: em concordância com os dados disponíveis na literatura, em nosso centro, os benefícios relacionados às intervenções endoscópicas terapêuticas em casos de STFF, HDC e SPAR parecem superar os riscos de complicações maternas que, raramente, foram consideradas graves.

PURPOSE: to describe the maternal complications due to therapeutic endoscopic procedures in fetal Medicine performed at an university center in Brazil. METHODS: retrospective observational study including patients treated from April 2007 to May 2010 who underwent laser ablation of placental vessels (LAPV) for severe twin-twin transfusion syndrome (TTTS); fetal tracheal occlusion (FETO) and endoscopic removal of tracheal balloon in cases of severe congenital diaphragmatic hernia (CDH); LAPV with or without bipolar coagulation of the umbilical cord in cases of twin reversed arterial perfusion (TRAP) sequence. The main variables described for each disease/type of surgery were maternal complications and neonatal survival (discharge from nursery). RESULTS: fifty-six patients underwent 70 procedures: Severe TTTS (34 patients; 34 surgeries); severe CDH (16 patients; 30 surgeries), and TRAP sequence (6 patients; 6 surgeries). Among 34 women who underwent LAPV for TTTS, two (2/34=5.9%) experienced amniotic fluid leakage to the peritoneal cavity and seven (7/34=20.6%) miscarried after the procedure. Survival of at least one twin was 64.7% (22/34). Among 30 interventions performed in cases of CDH, there was amniotic fluid leakage into the maternal peritoneal cavity in one patient (1/30=3.3%) and premature preterm rupture of membranes after three (3/30=30%) fetoscopies for removal of the tracheal balloon. Infant survival with discharge from nursery was 43.8% (7/16). Among six cases of TRAP sequence, there was bleeding into the peritoneal cavity after surgery in one patient (1/6=16.7%) and neonatal survival with discharge from nursery was 50% (3/6). CONCLUSIONS: in agreement with the available data in literature, at our center, the benefits related to therapeutic endoscopic interventions for TTTS, CDH and TRAP sequence seem to overcome the risks of maternal complications, which were rarely considered severe.