Medical practices during the last 48 hours of life in children admitted to seven Brazilian Pediatric intensive care units

Introduction

During the last decades life support limitation (LSL) practices have been offered more frequently in Latin American pediatric intensive care units (PICUs). We hypothesize that, depending on the Brazilian region, the incidence of LSL and the medical management may differ.

Objective

To evaluate the incidence of LSL practices and the medical management during the last 48 hours of life of children admitted to seven PICUs located in regions of Brazil.

Methods

A multicenter, observational and retrospective chart review study. The medical chart of all deaths occurring between January 2003 and December 2004 in seven Brazilian PICUs located in Porto Alegre (two), Sao Paulo (two) and Salvador (three) were evaluated. Two pediatric intensive care residents of each service filled a standard protocol searching for: demographic data, mode of death (full reanimation, nonreanimation orders or withdrawn treatment) and medical management during the last 48 hours of life. Student's t test, analysis of variance, chi-square test and relative risk were used for comparing the data.

Results

There were 561 deaths, 36 being excluded that died with less than 24 hours, 61 with brain death and 36 missing charts. Full cardiopulmonary reanimation was offered to 56.5%, with differences between the northeast and southeast regions (P < 0.001). Higher age (P = 0.02) and long length of PICU stay were associated with nonreanimation orders. The plan for LSL was recorded in a clear manner in just 52.7%. No respiratory support was observed in 14 dying children. For 66% patients with do-not-resuscitate orders the inotrope drugs were maintained or increased in the last 48 hours.

Conclusion

The incidence of LSV has increased among the Brazilian PICUs with a difference between the regions. The nonreanimation order is still the most common practice with scarce initiative for withdrawn life support.