Ricardo Garcia Branco

Boston Children's Hospital, Boston, Massachusetts, United States

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Publications (48)306.65 Total impact

  • Ricardo Garcia Branco · Pedro Celiny Ramos Garcia · Robert Charles Tasker
    Pediatric Critical Care Medicine 06/2015; 16(5):489-90. DOI:10.1097/PCC.0000000000000421 · 2.34 Impact Factor
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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 · 2.34 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 · 1.34 Impact Factor
  • Article: ABSTRACT 85
    Pediatric Critical Care Medicine 05/2014; 15:24. DOI:10.1097/01.pcc.0000448814.49901.0a · 2.34 Impact Factor
  • Pediatric Critical Care Medicine 05/2014; 15:118. DOI:10.1097/01.pcc.0000449246.38360.d6 · 2.34 Impact Factor
  • Pediatric Critical Care Medicine 05/2014; 15:97. DOI:10.1097/01.pcc.0000449148.52166.92 · 2.34 Impact Factor
  • Pediatric Critical Care Medicine 05/2014; 15:56. DOI:10.1097/01.pcc.0000448962.77648.b4 · 2.34 Impact Factor
  • Ricardo Garcia Branco · Pedro Celiny Ramos Garcia · Jefferson P. Piva
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    ABSTRACT: Objective: the aim of this chapter was review the response of the Thyroid and Grown Hormones (GH) in children with severe acute diseases. Data Source: using the terms Thyroid hormone and grown hormone crossed with sepsis, stress and children the searched the Medline data basis and selected the English, Spanish and Portuguese articles (originals and review articles) published in the last years. Main results: Stress and critical illness induce changes in circulating hormone levels. Thyroid hormones increase beta adrenergic receptor affinity and responsiveness to catecholamines. During critical illness, children often develop alterations in thyroid hormone concentrations. A low-T3 state develops with preserved serum T4 levels. In prolonged or more severe critical illnesses, serum T4 levels also became reduced (lowT3-T4 state), increasing mortality rate, length of MV and cathecolamine resistance. In the early phase of critical illness, GH level is elevated, with alteration in pulsatility. Low IGF-I levels are a predictive marker of mortality in critical illness. Non-survivors present significantly lower IGF-I levels than survivors, and IGF-I levels correlate inversely with severity of illness. Conclusion: Thyroid and growth hormone play a major role in the regulatory process related to stress response in acute ill children. The correct diagnosis and early treatment might influence positively the outcome.
    Pediatric Critical Care Medicine, 01/2014: pages 119-126; , ISBN: 978-1-4471-6415-9
  • Ricardo G Branco · Robert C Tasker
    Pediatric Critical Care Medicine 10/2013; 14(8):819-820. DOI:10.1097/PCC.0b013e3182a54c61 · 2.34 Impact Factor
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    Ricardo G Branco · Pedro Celiny R Garcia · Robert C Tasker
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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 · 55.87 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 · 1.67 Impact Factor
  • Ricardo Garcia Branco · Duncan John Macrae
    Pediatric Critical Care Medicine 03/2011; 12(2):229-30. DOI:10.1097/PCC.0b013e318202f5ca · 2.34 Impact Factor
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    ABSTRACT: Background and aims: Burnout Syndrome is a response to chronic occupational stress that may affect to many professional categories. It leads to low quality professional care, poor doctorpatient relationship, decreased ability to express empathy and increased medical errors. We aimed to estimate the prevalence of Burnout Syndrome among pediatric intensivistsand compare to a group of general pediatricians.Methods: a case control study was conducted, selecting the pediatric intensivists working on duty in two regional and referral Brazilian PICU(PICU group) whereas an equal number of general pediatricians working with outpatients in the same hospitals were included as the control group(GPA group). Two blind researchers evaluated the both groups using the Portuguese version of the MBIMaslach Burnout Inventory scale. The protocol was approved by the PUCRS Ethics Committee.Results: 35 cases and 35 controls were evaluated. No demographic differences between the groups were observed. Burnout was present in 71% of the PICU group and in 29% of the GPA group(p< 0.01). The average score for all dimensions were higher for the emotional exhaustion(EE) and depersonalization(DE), and lower for professional accomplishment(PA) in the PICU group (P=0.0003). The multivariate analysis demonstrated that working in a PICU has independently associated with Burnout with an odds ratio 5.7(CI95%;1.9-16.7) when compared to general pediatrician.Conclusions: Burnout among pediatric intensivists is frequent and characteristically manifested by high levels of EE and DE and low levels of PA suggesting low quality of life, emotional suffering and professional dissatisfaction.
    Pediatric Research 11/2010; 68:564-564. DOI:10.1203/00006450-201011001-01138 · 2.31 Impact Factor
  • Ricardo Garcia Branco · Robert Charles Tasker
    Pediatric Critical Care Medicine 11/2010; 11(6):755-7. DOI:10.1097/PCC.0b013e3181f4d606 · 2.34 Impact Factor
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    ABSTRACT: Background and method: ACTH stimulation test is used for the diagnosis of adrenal insufficiency in sepsis, but the optimal dosage of ACTH is still debatable. We, therefore, compared the efficacy of low (1μg/1.73m2) and standard (250µg/1.73m2) dosages of ACTH in identifying adrenal insufficiency in children with septic shock.Method: We evaluated 25 children admitted to PICU with catecholamine-dependent septic shock. Upon recruitment, a blood sample was collected for baseline cortisol determination. After an intravenous administration of low dose ACTH another blood sample was collected in 30 minutes for determination of cortisol response. Four hours after, a second intravenous ACTH stimulation test was performed, now using standard dose. Children were followed until PICU discharge.Results: The mean baseline cortisol was 773±421nmol/L. Baseline cortisol was not different between survivors and non-survivors (724±443 vs 795±241, p=0.16). Mean peak cortisol after low dose ACTH stimulation was 1157±451nmol/L, with mean change from baseline of 458nmol/L. Both mean peak cortisol (1160±445nmol/L) and mean change from baseline (746±458nmol/L) were higher after standard dose ACTH stimulation (p=0.045 and p< 0.01, respectively). There was a good correlation between peak cortisol after low and standard dose ACTH stimulation tests (r2=0.58). Out of the 25 children in the study, 7(28%) had AI. All of these children could be identified using the low dose ACTH stimulation test, but only 3(43%) could be identified using the standard dose ACTH stimulation test (p = 0.01) alone.Conclusion: Low dose ACTH for adrenal stimulation identifies more children with AI when compared with the standard dose test.
    Pediatric Research 11/2010; 68:267-267. DOI:10.1203/00006450-201011001-00522 · 2.31 Impact Factor
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    ABSTRACT: Background/aims: Neuroimmunoendocrine and metabolic dysfunctions are present in critical illness. We investigated whether insulin could reverse or limit these changes.
    Pediatric Research 11/2010; 68:33-33. DOI:10.1203/00006450-201011001-00059 · 2.31 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 · 2.34 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 · 1.94 Impact Factor
  • Branco RG · Tasker RC
    Current Treatment Options in Neurology 09/2010; 12(3):464. · 1.94 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 · 2.34 Impact Factor

Publication Stats

328 Citations
306.65 Total Impact Points


  • 2013–2015
    • Boston Children's Hospital
      Boston, Massachusetts, United States
  • 2014
    • Cambridge University Hospitals NHS Foundation Trust
      Cambridge, England, United Kingdom
  • 2011
    • Royal Brompton and Harefield NHS Foundation Trust
      Harefield, England, United Kingdom
  • 2005–2010
    • University of Cambridge
      • Department of Paediatrics
      Cambridge, ENG, United Kingdom
    • Papworth Hospital NHS Foundation Trust
      Papworth, England, 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