Ricardo Garcia Branco

Cambridge University Hospitals NHS Foundation Trust, Cambridge, England, United Kingdom

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Publications (46)277.11 Total impact

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    ABSTRACT: Objective: To study the prevalence of burnout in general pediatricians and pediatric intensivists and to evaluate factors that may be associated with this syndrome. Design: Observational cohort study. Setting: Pediatric departments of two hospitals in south Brazil. Patients: Pediatric intensivists working in two regional PICUs and general pediatricians working in the outpatient departments in the same hospitals. Intervention: Two researchers, blinded to the workplace of the physicians, undertook the assessment of burnout using the Maslach Burnout Inventory scale. Burnout was defined as high score in the domains for "emotional exhaustion" or "depersonalization" or a low score in the "professional accomplishment" domain. Measurements and Main Results: The PICU and general pediatrician groups were similar demographically, and each had 35 recruits. Burnout was present in 50% of the study recruits and was more frequent among pediatric intensivists than general pediatricians (71% vs 29%, respectively, p < 0.01). In regard to the individual Maslach Burnout Inventory domains, the average score was higher for emotional exhaustion and depersonalization and lower for professional accomplishment in the PICU group (p < 0.01). A cluster analysis showed that pediatric intensivists were more likely to develop the burnout syndrome involving all Maslach Burnout Inventory domains. The multivariate analysis found that the odds ratio for burnout in pediatric intensivists was 5.7 (95% CI, 1.9-16.7; p < 0.01). Conclusions: Burnout is frequent among pediatric intensivists and characterized by cumulative involvement of emotional exhaustion, depersonalization, and professional accomplishment. Earlier recognition of emotional exhaustion may be important in preventing the development of a complete burnout syndrome. Improvement in workplace characteristics and measures to improve physician resilience are entirely warranted.
    Pediatric Critical Care Medicine 07/2014; 15(8). DOI:10.1097/PCC.0000000000000218 · 2.33 Impact Factor
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    ABSTRACT: Objetivo Comparar la eficacia de midazolam intramuscular (MDZ-IM) con la de diazepam intravenoso (DZP-IV) para convulsiones en niños. Diseño Ensayo clínico aleatorizado. Ámbito Servicio de Urgencias Pediátricas. Pacientes Niños de entre 2 meses y 14 años internados con convulsiones. Intervención Los pacientes fueron aleatorizados para recibir DZP-IV o MDZ-IM. Mediciones principales Tiempo hasta el inicio del tratamiento (minutos), tiempo entre la administración del medicamento y el cese de la convulsión (minutos), tiempo hasta el cese de la convulsión (minutos), y tasa de fallo del tratamiento. El tratamiento fue considerado exitoso cuando las convulsiones cesaron en los 5 min tras la administración del medicamento. Resultados Completaron el estudio 32 niños (16 por grupo). No fue posible obtener acceso intravenoso en 4 pacientes (25%) del grupo DZP-IV. El tiempo entre la internación y el tratamiento fue menor en el grupo MDZ-IM (2,8 vs. 7,4 min; p < 0,001), así como el tiempo hasta el cese de la convulsión (7,3 vs. 10,6 min; p = 0,006). En 2 niños de cada grupo (12,5%), las convulsiones continuaron después de 10 min de tratamiento. No hubo diferencias entre los grupos en los parámetros fisiológicos o eventos adversos (p = 0,171); un niño (6,3%) del grupo MDZ-IM presentó hipotensión, y 5 del grupo DZP-IV (31%) presentaron hiperactividad o vómitos. Conclusión Dada su eficacia, facilidad y velocidad de administración, MDZ-IM es una excelente opción para el tratamiento de convulsiones infantiles, posibilitando un tratamiento precoz y reduciendo la duración de la convulsión. No hubo diferencias en las complicaciones al aplicar MDZ-IM o DZP-IV.
    Medicina Intensiva 06/2014; 39(3). DOI:10.1016/j.medin.2014.04.003 · 1.24 Impact Factor
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    Pediatric Critical Care Medicine 01/2014; 15:24. DOI:10.1097/01.pcc.0000448814.49901.0a · 2.33 Impact Factor
  • Pediatric Critical Care Medicine 01/2014; 15:118. DOI:10.1097/01.pcc.0000449246.38360.d6 · 2.33 Impact Factor
  • Pediatric Critical Care Medicine 01/2014; 15:97. DOI:10.1097/01.pcc.0000449148.52166.92 · 2.33 Impact Factor
  • Pediatric Critical Care Medicine 01/2014; 15:56. DOI:10.1097/01.pcc.0000448962.77648.b4 · 2.33 Impact Factor
  • Ricardo G Branco, Robert C Tasker
    Pediatric Critical Care Medicine 10/2013; 14(8):819-820. DOI:10.1097/PCC.0b013e3182a54c61 · 2.33 Impact Factor
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    ABSTRACT: To the Editor: Skjerven and colleagues (June 13 issue)(1) reported that inhaled racemic adrenaline is not more effective than inhaled saline in infants with acute bronchiolitis. Inhaled therapies are used frequently to treat children with bronchiolitis,(2) despite the lack of evidence from clinical trials and recommendations against their use.(3) The American Academy of Pediatrics recommendations for bronchiolitis state, A carefully monitored trial of -adrenergic or -adrenergic medication is an option. Inhaled bronchodilators should be continued only if there is a documented positive clinical response to the trial using an objective means of evaluation.(3) We wonder whether the authors could identify ...
    New England Journal of Medicine 09/2013; 369(11):1075-6. DOI:10.1056/NEJMc1308964#SA1 · 54.42 Impact Factor
  • Ricardo G Branco, Carlo L Acerini, Robert C Tasker
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    ABSTRACT: Carbohydrate metabolism is essential for survival and a constant supply of carbohydrate provides the substrate for the metabolic pathways that fuel cell activity. Under normal circumstances a complex neuroendocrine mechanism maintains glucose level within an optimal range. Shortage of carbohydrate (i.e., hypoglycaemia) is a severe threat to homeostasis and triggers the stress response. Indeed, hypoglycaemia is recognised as a 'gold standard' stressor for the activation of the neuroendocrine system (e.g., the insulin tolerance test)(1,2). When blood glucose concentrations drop to potentially harmful levels, neuroendocrine counter-regulatory changes promote resistance to glucose uptake in peripheral tissues and stimulates glycogenolysis in the liver, tailoring cell and tissue metabolic supply according to the body's need. This article is protected by copyright. All rights reserved.
    Acta Paediatrica 08/2013; 102(12). DOI:10.1111/apa.12402 · 1.84 Impact Factor
  • Ricardo Garcia Branco, Duncan John Macrae
    Pediatric Critical Care Medicine 03/2011; 12(2):229-30. DOI:10.1097/PCC.0b013e318202f5ca · 2.33 Impact Factor
  • Pediatric Research 11/2010; 68:564-564. DOI:10.1203/00006450-201011001-01138 · 2.84 Impact Factor
  • Ricardo Garcia Branco, Robert Charles Tasker
    Pediatric Critical Care Medicine 11/2010; 11(6):755-7. DOI:10.1097/PCC.0b013e3181f4d606 · 2.33 Impact Factor
  • Pediatric Research 11/2010; 68:267-267. DOI:10.1203/00006450-201011001-00522 · 2.84 Impact Factor
  • Pediatric Research 11/2010; 68:33-33. DOI:10.1203/00006450-201011001-00059 · 2.84 Impact Factor
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    ABSTRACT: To evaluate the feasibility and safe operationalization of a pediatric glycemic control protocol in the setting of a general pediatric intensive care unit in a developing country. Prospective, observational cohort study carried out over 12 months. Fourteen-bed pediatric intensive care unit in Brazil. Children requiring mechanical ventilation with at least one organ system dysfunction were included. Glucose was monitored and insulin used for persistent hyperglycemia (glucose >140 mg/dL [7.8 mmol/L] for at least two observations separated by at least a 1-hr interval), with a target glucose during insulin use of 60-140 mg/dL (3.3-7.8 mmol/L). Out of 410 admissions, 144 children met the criteria for applying the protocol. One hundred fourteen of 144 (79%) children had at least one peak glucose level that was hyperglycemic, but only 44 (31%) children required insulin. Insulin infusion was most frequently started on day 1 (61%), with a glucose level at the time of 229 ± 79 mg/dL (12.7 ± 4.4 mmol/L). The mean glucose level after 6 hrs of insulin was 172 ± 87 mg/dL (9.6 ± 4.8 mmol/L), and the time to achieve the target glucose range was 9.5 (2-20) hrs (median [interquartile range]). The overall duration of insulin was 24.5 (10-48) hrs, and the average dose required was 0.06 ± 0.03 U/kg/hr. In the whole series, the peak glucose level was 202 ± 93 mg/dL (11.2 ± 5.2 mmol/L), with no difference between survivors and nonsurvivors. There was no difference in mortality when different glucose bands were considered and no association between glucose level and mortality. The overall rate of hypoglycemia (glucose <40 mg/dL [2.2 mmol/L]) was 8.3%, and it was more common in those receiving insulin (20% vs. 3%, p < .05). Hyperglycemia is frequent in critically ill children managed in a pediatric intensive care unit in a developing country. Using a glycemic control protocol, one-third of these children required insulin, but attendants should be aware of a significant risk of hypoglycemia in this setting. Based on these data, a trial to detect a 20% relative reduction in mortality (power 90%, p = .05) associated with insulin in a similar population would need to screen >10,000 patients.
    Pediatric Critical Care Medicine 10/2010; 12(3):265-70. DOI:10.1097/PCC.0b013e3181f52847 · 2.33 Impact Factor
  • Ricardo G Branco, Robert C Tasker
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    ABSTRACT: OPINION STATEMENT: Meningococcal meningitis (MM) is the most common presentation of meningococcal disease and an important cause of morbidity and mortality worldwide. When MM is associated with shock, early recognition and treatment of shock is essential. No investigation should delay starting antibiotics once the diagnosis is suspected. Corticosteroids can be started at the same time as the antibiotics or just before, but this is not a specific recommendation for MM. Low-dose steroids should be used in meningococcal disease with refractory shock. Altered blood flow, cerebral edema, and raised intracranial pressure are problems that should be considered in all patients with MM and decreased consciousness level. When mechanical ventilation is required, the target carbon dioxide level is 4.0 to 4.5 kPa, with avoidance of hypocapnia. Seizures, although not frequent, can occur in MM and require prompt treatment. Other treatments, such as mannitol and activated protein C, should be avoided. Potential new treatments requiring further investigation include neuroprotection with hypothermia or glycerol.
    Current Treatment Options in Neurology 09/2010; 12(5):464-74. DOI:10.1007/s11940-010-0086-5 · 2.18 Impact Factor
  • Branco RG, Tasker RC
    Current Treatment Options in Neurology 09/2010; 12(3):464. · 2.18 Impact Factor
  • Ricardo G Branco, Arjun Chavan, Robert C Tasker
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    ABSTRACT: To evaluate continuous subcutaneous glucose monitoring in pediatric critical illness. Prospective evaluation. Mixed university pediatric intensive care unit. Children aged 1 mo to 16 yrs requiring mechanical ventilation with at least two organ system failures. None. Blood samples obtained from an arterial line, measurements using point-of-care glucometer, and laboratory analysis were compared with continuous subcutaneous glucose monitoring. Fourteen patients yielded 11,880 continuous subcutaneous glucose monitoring measurements; 436 glucometer levels and 34 laboratory levels had mean time-paired glucose values of 108 +/- 29 mg/dL and 110 +/- 25 mg/dL, respectively. Mean continuous subcutaneous glucose monitoring glucose was 101 +/- 31 mg/dL for samples paired with glucometer and 95 +/- 40 mg/dL for samples paired with laboratory tests. Continuous subcutaneous glucose monitoring measurements correlated with glucometer (r = 0.44) and laboratory testing (r = 0.48). Mean absolute differences between continuous subcutaneous glucose monitoring measurement and glucometer and laboratory values were 18 +/- 16 mg/dL and 25 +/- 20 mg/dL, respectively. Clarke error grid analysis found 69% of the measurements to be in zone A (clinically accurate), 29% in zone B (benign errors), and 2% in zone D (failure to detect errors). The mean absolute relative difference between the continuous subcutaneous glucose monitoring measurement and glucometer and laboratory measurements were 17% and 23%, respectively. Bland-Altman analysis showed good agreement between continuous subcutaneous glucose monitoring and the other methods of glucose measurement. However, in the lower range (< or =74 mg/dL) 39% of the continuous subcutaneous glucose monitoring readings had a difference >15 mg/dL. On multiple regressions, only glucometer glucose values, continuous subcutaneous glucose monitoring levels, and base deficit were associated with the mean absolute relative difference. The performance of continuous subcutaneous glucose monitoring against point-of-care glucometer and laboratory measurements may be considered "good" using statistical definitions (Bland-Altman and Clarke error grid analysis). However, there are important limitations in children with large base deficit, being actively cooled, and with glucose in the lower range, which may limit its application.
    Pediatric Critical Care Medicine 11/2009; 11(3):415-9. DOI:10.1097/PCC.0b013e3181c59144 · 2.33 Impact Factor
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    ABSTRACT: External validation of the paediatric logistic organ dysfunction (PELOD) score in two paediatric intensive care units (PICU) in South America. Prospective observational cohort study including all PICU admissions from July 2003 to December 2004 in Porto Alegre, Brazil, and from January 2004 to December 2004 in Buenos Aires, Argentina. The data collected included demographic variables, diagnosis, need for mechanical ventilation, length of PICU stay and mortality, and the 12 variables in the PELOD score. For each PELOD score variable, the worst daily value and the worst value of the whole PICU stay were used for the daily PELOD (dPELOD) and PELOD scores, respectively. A total of 1,476 admissions (51.3% from Argentina and 48.7% from Brazil) were analysed. Observed and predicted mortality were, respectively, 4.7% and 6.6%, with a standardized mortality ratio of 0.72. The score showed excellent discrimination capacity, with an area under the receiver operator characteristic (ROC) curve of 0.93 (0.88-0.98). The dPELOD score on days 1-5 also showed good discrimination capacities, with areas under the ROC curve >0.85. However, PELOD and dPELOD scores showed poor calibration with the Hosmer-Lemeshow test (chi-square 72.3, p < 0.001). This poor calibration was explained by a deficiency in the PELOD score where it fails to identify two risk intervals; 3.1-16.2% and 40-80%. The PELOD score is reproducible, has excellent discrimination, but over-predicts mortality and has poor calibration. Although the lack of calibration may not invalidate the score, the PELOD score is a discontinuous variable and we advise careful consideration when using it as a surrogate endpoint in clinical trials.
    European Journal of Intensive Care Medicine 05/2009; 36(1):116-22. DOI:10.1007/s00134-009-1489-1 · 5.54 Impact Factor
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    ABSTRACT: To assess the safety of low-dose vasopressin infusion in critically ill children requiring prolonged mechanical ventilation (MV) at risk of developing sedation/analgesia-related hypotension. Randomized pilot safety study in children expected to require MV for at least 3 days. Children received either vasopressin (0.0005 U/kg/min) or sodium chloride (0.9%) infusion for a period of 48 h. Haemodynamic variables, urine output and serum electrolytes were closely monitored and analyzed. Twelve children in each group had similar baseline characteristics. Vasopressin infusion was associated with an 8 mmol/L fall in serum sodium concentration (p < 0.01) and with higher incidence of hyponatraemia (8 vs. 66%, p < 0.01). In normotensive children, low-dose vasopressin also induced a reversible decrease in urine output, and acutely increased blood pressure (p < 0.01). After stopping the vasopressin there was rebound hypotension (p < 0.01). Low-dose vasopressin infusion in haemodynamically stable, but critically ill, children is associated with reduction in urine output and decreased serum sodium level, yielding a high incidence of hyponatraemia. We conclude that these effects limit further study of prophylactic vasopressin for sedation-related hypotension in a randomized controlled trial.
    European Journal of Intensive Care Medicine 02/2009; 35(2):355-9. DOI:10.1007/s00134-008-1392-1 · 5.54 Impact Factor

Publication Stats

302 Citations
277.11 Total Impact Points


  • 2014
    • Cambridge University Hospitals NHS Foundation Trust
      Cambridge, England, United Kingdom
  • 2013
    • Boston Children's Hospital
      Boston, Massachusetts, United States
  • 2011
    • Royal Brompton and Harefield NHS Foundation Trust
      Harefield, England, United Kingdom
  • 2005–2010
    • University of Cambridge
      • Department of Paediatrics
      Cambridge, ENG, United Kingdom
  • 2003–2010
    • Pontifícia Universidade Católica do Rio Grande do Sul
      • Department of Pediatrics
      Pôrto de São Francisco dos Casaes, Rio Grande do Sul, Brazil