Julio A Farias

Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, San Paulo, São Paulo, Brazil

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Publications (25)65.55 Total impact

  • J.A. Farias · E. Monteverde · R. Poterala · B. Von Dessauer ·
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    ABSTRACT: South America is a continent of uneven economic development, and this is reflected in pediatric intensive care units (PICUs) and the way they practice mechanical ventilation (MV). PICUs in countries which lack financial resources tend to be less technologically advanced, whereas those in wealthier nations can provide their patients with high-technology services and better quality care. In Guatemala, for example, the official data of the Panamerican Health Organization shows a rate of hospital beds per 1,000 inhabitants of 0.6, while in Brazil it is 2.4. As a standard of comparison, the rate in Canada is 3.4 and in the USA it is 3.1 (Organización Panamericana de la Salud. 2008).
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    ABSTRACT: To describe the characteristics and outcomes of mechanical ventilation in pediatric intensive care units during the season of acute lower respiratory infections. Prospective cohort of infants and children receiving mechanical ventilation for at least 12 hrs. Sixty medical-surgical pediatric intensive care units. All consecutive patients admitted to participating pediatric intensive care units during a 28-day period. Of 2,156 patients admitted to pediatric intensive care units, 1185 (55%) received mechanical ventilation for a median of 5 days (interquartile range 2-8). Median age was 7 months (interquartile range 2-25). Main indications for mechanical ventilation were acute respiratory failure in 78% of the patients, altered mental status in 15%, and acute on chronic pulmonary disease in 6%. Median length of stay in the pediatric intensive care units was 10 days (interquartile range 6-18). Overall mortality rate in pediatric intensive care units was 13% (95% confidence interval: 11-15) for the entire population, and 39% (95% confidence interval: 23 - 58) in patients with acute respiratory distress syndrome. Of 1150 attempts at liberation from mechanical ventilation, 62% (95% confidence interval: 60-65) used the spontaneous breathing trial, and 37% (95% confidence interval: 35-40) used gradual reduction of ventilatory support. Noninvasive mechanical ventilation was used initially in 173 patients (15%, 95% confidence interval: 13-17). In the season of acute lower respiratory infections, one of every two children admitted to pediatric intensive care units requires mechanical ventilation. Acute respiratory failure was the most common reason for mechanical ventilation. The spontaneous breathing trial was the most commonly used method for liberation from mechanical ventilation.
    Pediatric Critical Care Medicine 06/2011; 13(2):158-64. DOI:10.1097/PCC.0b013e3182257b82 · 2.34 Impact Factor
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    ABSTRACT: To assess whether the combination of daily evaluation and use of a spontaneous breathing test could shorten the duration of mechanical ventilation as compared with weaning based on our standard of care. Secondary outcome measures included extubation failure rate and the need for noninvasive ventilation. A prospective, randomized controlled trial. Two pediatric intensive care units at university hospitals in Brazil. The trial involved children between 28 days and 15 yrs of age who were receiving mechanical ventilation for at least 24 hrs. Patients were randomly assigned to one of two weaning protocols. In the test group, the children underwent a daily evaluation to check readiness for weaning with a spontaneous breathing test with 10 cm H2O pressure support and a positive end-expiratory pressure of 5 cm H2O for 2 hrs. The spontaneous breathing test was repeated the next day for children who failed it. In the control group, weaning was performed according to standard care procedures. A total of 294 eligible children were randomized, with 155 to the test group and 139 to the control group. The time to extubation was shorter in the test group, where the median mechanical ventilation duration was 3.5 days (95% confidence interval, 3.0 to 4.0) as compared to 4.7 days (95% confidence interval, 4.1 to 5.3) in the control group (p = .0127). This significant reduction in the mechanical ventilation duration for the intervention group was not associated with increased rates of extubation failure or noninvasive ventilation. It represents a 30% reduction in the risk of remaining on mechanical ventilation (hazard ratio: 0.70). A daily evaluation to check readiness for weaning combined with a spontaneous breathing test reduced the mechanical ventilation duration for children on mechanical ventilation for >24 hrs, without increasing the extubation failure rate or the need for noninvasive ventilation.
    Critical care medicine 06/2011; 39(11):2526-33. DOI:10.1097/CCM.0b013e3182257520 · 6.31 Impact Factor
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    Critical Care 06/2011; 15:1-31. DOI:10.1186/cc10193 · 4.48 Impact Factor
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    ABSTRACT: To describe the clinical characteristics and outcome of patients admitted to pediatric intensive care with influenza A (pH1N1) 2009 in Argentina. Retrospective observational study. Thirteen pediatric intensive care units in Argentina. One hundred and forty-two patients with confirmed or suspected influenza A (H1N1). None. We included 142 critically ill patients. The median age was 19 months (range, 2-110 months) with 39% of the patients <24 months of age. Ninety-nine patients (70%) had an underlying disease. Influenza A (pH1N1) 2009 infection was confirmed in 90 patients and the remaining 52 had a positive direct immunofluorescence assay for influenza A. The median length of stay in the pediatric intensive care unit was 12 days (range, 2-52 days). One hundred eighteen patients (83%) received invasive mechanical ventilation and 19 patients were treated with noninvasive ventilation; however, seven of the patients receiving noninvasive ventilation later needed mechanical ventilation. Sixty-eight patients died (47%) with the most frequent cause refractory hypoxemia. Multivariate logistic regression analysis showed that age <24 months (odds ratio, 2.87; 2.35-3.93), asthma (odds ratio, 1.34; 1.20-2.91), and respiratory coinfection with respiratory syncytial virus (odds ratio, 2.92; 1.20-4.10) were associated with higher mortality. As expected, mechanical ventilation and treatment with inotropes were also associated with increased mortality. The mortality of children admitted to the pediatric intensive care unit with 2009 pH1N1 influenza was high (47%) in our population. Age <24 months, asthma, respiratory coinfection, need of mechanical ventilation, and treatment with inotropes were predictors of poorer outcome.
    Pediatric Critical Care Medicine 05/2011; 13(2):e78-83. DOI:10.1097/PCC.0b013e318219266b · 2.34 Impact Factor

  • American Thoracic Society 2011 International Conference, May 13-18, 2011 • Denver Colorado; 05/2011
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    ABSTRACT: To describe the characteristics and risk factors of pediatric patients who receive prolonged mechanical ventilation, defined as ventilatory support for >21 days. Prospective cohort. Four medical-surgical pediatric intensive care units in four university-affiliated hospitals in Argentina. All consecutive patients from 1 month to 15 yrs old admitted to participating pediatric intensive care units from June 1, 2007, to August 31, 2007, who received mechanical ventilation (invasive or noninvasive) for >12 hrs. None. Demographic and physiologic data on admission to the pediatric intensive care units, drugs and events during the study period, and outcomes were prospectively recorded. A total of 256 patients were included. Of these, 23 (9%) required mechanical ventilation for >21 days and were assigned to the prolonged mechanical ventilation group. Patients requiring prolonged mechanical ventilation had higher mortality (43% vs. 21%, p < .05) and longer pediatric intensive care unit stay: 35 days [28-64 days] vs. 10 days [6-14]). There was no difference between the groups in age and gender distribution, reasons for admission, incidence of immunodeficiencies, or Paediatric Index of Mortality 2 score. The only difference at admission was a higher rate of genetic diseases in prolonged mechanical ventilation patients (26% vs. 9%, p < .05). There was a higher incidence of septic shock (87% vs. 34%, p < .01), acute respiratory distress syndrome (43% vs. 20%, p < .01), and ventilator-associated pneumonia (35% vs. 8%, p < .01) and higher utilization of dopamine (78% vs. 42%, p < .01), norepinephrine (61% vs. 15%, p < .01), multiple antibiotics (83% vs. 20%, p < .01), and blood transfusions (52% vs. 14%, p < .01). The proportion of extubation failure was higher in the prolonged mechanical ventilation group with similar rates of unplanned extubations in both groups. Variables remaining significantly associated with prolonged mechanical ventilation after multivariate analysis were treatment with multiple antibiotics, septic shock, ventilator-associated pneumonia, and use of norepinephrine. Patients with prolonged mechanical ventilation have more complications and require more pediatric intensive care unit resources. Mortality in these patients duplicates that from those requiring shorter support.
    Pediatric Critical Care Medicine 04/2011; 12(6):e287-91. DOI:10.1097/PCC.0b013e3182191c0b · 2.34 Impact Factor
  • A. J. Petros · V. Damjanovic · A. Pigna · J. Farias ·
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    ABSTRACT: The incidence of infection is higher in the neonatal period than at any time in life. Neonates, particularly preterm, are extremely susceptible to infection. Low birth weight is the single most important risk factor for infection in neonates. The reasons for this increased susceptibility include immune system immaturity, poor surface defences, lack of colonisation resistance, invasive medical devices and broad-spectrum antibiotic usage. Increased susceptibility to carriage and infection in preterm neonates is the main factor facilitating transmission of potential pathogens and subsequent outbreaks of infection in the neonatal intensive care unit (NICU). Stay in the NICU is substantially longer than in the paediatric ICU (PICU). Outbreaks are more common in the NICU than in the PICU, and higher overall mortality rates of 10% versus 5% support the observation that children in the NICU are more susceptible hosts than children in the PICU. In this chapter, we present data from four randomised controlled trials of selective digestive-tract decontamination in the paediatric population.
    Infection Control in the Intensive Care Unit, 01/2011: pages 289-303; , ISBN: 978-88-470-1600-2
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    ABSTRACT: To determine the epidemiological features, course, and outcomes of critically ill pediatric patients with Influenza A (H1N1) virus. Prospective cohort of children in pediatric intensive care units (PICUs) due to Influenza A (H1N1) virus infection. Seventeen medical-surgical PICUs in tertiary care hospital in Argentina. All consecutive patients admitted to the PICUs with influenza A (H1N1) viral infection from 15 June to 31 July 2009. Of 437 patients with acute lower respiratory infection in PICUs, 147 (34%) were diagnosed with influenza A (H1N1) related to critical illness. The median age of these patients was 10 months (IQR 3-59). Invasive mechanical ventilation was used in 117 (84%) on admission. The rate of acute respiratory distress syndrome (ARDS) was 80% (118 of 147 patients). Initial non-invasive ventilation failed in 19 of 22 attempts (86%). Mortality at 28 days was 39% (n = 57). Chronic complex conditions (CCCs), acute renal dysfunction (ARD) and ratio PaO(2)/FiO(2) at day 3 on MV were independently associated with a higher risk of mortality. The odds ratio (OR) for CCCs was 3.06, (CI 95% 1.36-6.84); OR for ARD, 3.38, (CI 95% 1.45-10.33); OR for PaO(2)/FiO(2), 4 (CI 95% 1.57-9.59). The administration of oseltamivir within 24 h after admission had a protective effect: OR 0.2 (CI 95% 0.07-0.54). In children with ARDS, H1N1 as an etiologic agent confers high mortality, and the presence of CCCs in such patients increases the risk of death.
    Intensive Care Medicine 03/2010; 36(6):1015-22. DOI:10.1007/s00134-010-1853-1 · 7.21 Impact Factor
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    ABSTRACT: Pandemic influenza A H1N1 2009 virus presents a new challenge to health authorities and communities worldwide. In Argentina, the outbreak was at its peak by the end of June 2009, during the southern winter. A systematic analysis of samples from patients with pandemic H1N1 2009 studied in our laboratory (Virology Laboratory, Hospital de Niños R Gutiérrez, Buenos Aires, Argentina) detected two patients presenting intratreatment emergence of the H275Y neuraminidase mutation, which confers resistance to oseltamivir. Complementary DNAs, including the 275 codon, were obtained by reverse transcriptase PCR using viral RNAs extracted from nasopharyngeal or tracheal aspirates. Conventional sequencing and pyrosequencing were performed on each sample. In order to measure the virus susceptibility to oseltamivir, 50% inhibitory concentration determinations were performed by chemiluminescence. Sequential samples of two paediatric patients under oseltamivir treatment were analysed. Pretreatment samples were composed of 100% oseltamivir-sensitive variants. In case 1, the oseltamivir-resistant variant was found 8 days after the beginning of treatment. In case 2, the viral population became resistant on the second day of treatment, with 83% of the viral population bearing the mutation and this reached 100% on the seventh day. We describe the intratreatment emergence of oseltamivir resistance in two paediatric patients. Pyrosequencing allowed us to detect variant mixtures, showing the transition of the viral population from sensitive to resistant.
    Antiviral therapy 01/2010; 15(6):923-7. DOI:10.3851/IMP1635 · 3.02 Impact Factor
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    ABSTRACT: To investigate the relationship between mechanical ventilation and mortality and the practice of mechanical ventilation applied in children admitted to a high-complexity pediatric intensive care unit in the city of São Paulo, Brazil. Prospective cohort study of all consecutive patients admitted to a Brazilian high-complexity PICU who were placed on mechanical ventilation for 24 hours or more, between October 1(st), 2005 and March 31(st), 2006. Of the 241 patients admitted, 86 (35.7%) received mechanical ventilation for 24 hours or more. Of these, 49 met inclusion criteria and were thus eligible to participate in the study. Of the 49 patients studied, 45 had chronic functional status. The median age of participants was 32 months and the median length of mechanical ventilation use was 6.5 days. The major indication for mechanical ventilation was acute respiratory failure, usually associated with severe sepsis / septic shock. Pressure ventilation modes were the standard ones. An overall 10.37% incidence of Acute Respiratory Distress Syndrome was found, in addition to tidal volumes > 8 ml/kg, as well as normo- or hypocapnia. A total of 17 children died. Risk factors for mortality within 28 days of admission were initial inspiratory pressure, pH, PaO2/FiO2 ratio, oxygenation index and also oxygenation index at 48 hours of mechanical ventilation. Initial inspiratory pressure was also a predictor of mechanical ventilation for periods longer than 7 days. Of the admitted children, 35.7% received mechanical ventilation for 24 h or more. Pressure ventilation modes were standard. Of the children studied, 91% had chronic functional status. There was a high incidence of Acute Respiratory Distress Syndrome, but a lung-protective strategy was not fully implemented. Inspiratory pressure at the beginning of mechanical ventilation was a predictor of mortality within 28 days and of a longer course of mechanical ventilation.
    Clinics (São Paulo, Brazil) 12/2009; 64(12):1161-6. DOI:10.1590/S1807-59322009001200005 · 1.19 Impact Factor
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    ABSTRACT: Background: Influenza A/H1N1swl(IFA/H1N1swl) pandemic virus modified the epidemiological pattern of winter season with a high impact on health care system. Objectives: to describe the epidemiology of IFA/H1N1swl infected patients and identify the lethality risk factors. Methods: a prospective cohort study was conducted; we included suspected patients according country case definition, may-august 2009 period. IFA/H1N1swl infection was confirmed by RT-PCR of nasopharyngeal aspirates. Results: 1613 suspected patients were included, 289(18 %) required hospitalization and 120(41.5%) patients were confirmed; of them, 7.5% (9/120) required mechanical ventilator assistance. All the ambulatory school-children presented Influenza like Illness (ILI) with a mild disease. The hospitalization began in 23rdweek with a peak in 25thweek, according the largest IFA/H1N1swl circulation(53%[48/90]of total isolations). In this period RSV was displaced. The median age of confirmed cases was 16 months(1-228), 49%< 1 year, 63% were males; pneumonia was the most frequent clinical presentation(46%); 62% had comorbidities such as recurrent obstructive bronchitis(38%), immunodeficiency (17.2%), malnourish(8.6%) and neurological diseases(5.2%). Nosocomial infection rate was 19%(23/120). The lethality rate was 5.8 %(7/120); all deceased patients presented comorbidities. Risk factors associated with IFA/H1N1swl lethality were: a)Mechanical ventilator assistance RR:27.4 (3.74-230)p<0.01, b)Age> 5 years RR:15.75(1.97-125)p<0.01 c)Complications RR:15.4(1.71-354)P<0.01, d)Nosocomial infection RR:12.22(1.87-99.9)P<0.01. e)Chronic neurological disease RR:8.33(2.05-33.82)p<0.01. Conclusions a)IFA/H1N1swl infection presented an epidemic pattern (peak 25thweek) displacing the RSV. b)Almost two-thirds of hospitalized patients had comorbidities. c)All the deceased patients presented chronic diseases.
    Infectious Diseases Society of America 2009 Annual Meeting; 10/2009
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    ABSTRACT: Antibiotics are the most prescribed drugs in pediatric intensive care units (PICU) with high impact in pathogens resistance and costs. Evaluate prescription patterns and consumption of antibiotics. From July 2006 to January 2007, monthly cross-sectional cuts were done on antibiotics use at the 1st and 7th days of prescription. A monthly antibiotics consumption average was then calculated. Of 81 patients, 41 received antibiotics, of which 34 were treated for at least seven days. INDICATORS: 1. Mean antibiotics / patient: 83 antibiotics were used at the initial empirical treatment (meropenem 18%, vancomycin 16.8%, amikacin 16.8%, cefotaxime 13.2%, ceftazidime 6%, clarithromycin 6%, piperacillin-tazobactam 4.8%, colistin 4.8%). mean: 2 antibiotics/patient. 98 antibiotics were used at the 7th day (vancomycin 17.3%, meropenem 16.3%, amikacin 9.8%, minocycline 9.8%, colistin 9.1%, amphotericin 6.1%, trimethoprim-sulfamethoxazole 4%, ceftazidime 5.1%). Mean: 2.8 antibiotics/patient. 2. Percentage of specimen obtained: Blood culture 100%, tracheal aspirate 68%, catheter culture 54.5% 3. Percentage of patients with positive culture: Pathogens were isolated in 56.1%, of which: Bacteria in 94.3%, Gram negative non fermenting strains, in 60.6%, Enterobacteriaceae in 24.2%, Gram positive cocci in 15% and Fungi in 5.7%. 4. Percentage of adjusted antibiotic scheme: 52%. 5. Percentage of interrupted antibiotics with negative culture: 22.2%. Monthly average of consumption was: meropenem 13.44; vancomycin 10.2; cefotaxime 3.6; ceftriaxone 2.20; piperacillin-tazobactam 7.38, amikacin 2.3. Vancomicyn and carbapenems were the antibiotics of greater use as initial empirical treatment. The initial empirical scheme would have to be adjusted to the microbiological results in order to obtain a more prudent antibiotic use.
    Archivos argentinos de pediatría 11/2008; 106(5):409-15. DOI:10.1590/S0325-00752008000500007 · 0.37 Impact Factor

  • Archivos argentinos de pediatría 10/2008; 106(5):409-415. · 0.37 Impact Factor
  • E Monteverde · P Neira · J Farías ·

    Anales de Pediatría 06/2008; 68(5):529-30. · 0.83 Impact Factor
  • E. Monteverde · P. Neira · J. Farías ·

    Anales de Pediatría 05/2008; 68(5):529-530. DOI:10.1157/13120058 · 0.83 Impact Factor
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    ABSTRACT: Identify factors associated with the survival of pediatric patients who are submitted to mechanical ventilation (MV) for more than 12 hours. International prospective cohort study. It was performed between April 1 and May 31 1999. All patients were followed-up during 28 days or discharge to pediatric intensive care unit (PICU). 36 PICUs from 7 countries. A total of 659 ventilated patients were enrolled but 15 patients were excluded because their vital status was unknown on discharge. Overall in-UCIP mortality rate was 15,6%. Recursive partitioning and logistic regression were used and an outcome model was constructed. The variables significantly associated with mortality were: peak inspiratory pressure (PIP), acute renal failure (ARF), PRISM score and severe hypoxemia (PaO2/FiO2 < 100). The subgroup with best outcome (mortality 7%) included patients who were ventilated with a PIP < 35 cmH2O, without ARF, or PaO2/FiO2 > 100 and PRISM < 27. In patients with a mean PaO2/FiO2 < 100 during MV mortality increased to 26% (OR: 4.4; 95% CI 2.0 to 9.4). Patients with a PRISM score > 27 on admission to PICU had a mortality of 43% (OR: 9.6; 95% CI 4,2 to 25,8). Development of acute renal failure was associated with a mortality of 50% (OR: 12.7; 95% CI 6.3 to 25.7). Finally, the worst outcome (mortality 58%) was for patients with a mean PIP >/= 35 cmH2O (OR 17.3; 95% CI 8.5 to 36.3). In a large cohort of mechanically ventilated pediatric patients we found that severity of illness at admission, high mean PIP, development of acute renal failure and severe hypoxemia over the course of MV were the factors associated with lower survival rate.
    Medicina Intensiva 12/2006; 30(9):425-31. · 1.34 Impact Factor

  • Medicina Intensiva 12/2006; 30(9):425-431. DOI:10.1016/S0210-5691(06)74565-X · 1.34 Impact Factor
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    Julio A Farias · Ezequiel Monteverde ·

    Jornal de Pediatria 10/2006; 82(5):322-4. DOI:10.2223/JPED.1539 · 1.19 Impact Factor
  • Julio A. Farias · Ezequiel Monteverde ·

    Jornal de Pediatria 10/2006; 82(5). DOI:10.1590/S0021-75572006000600003 · 1.19 Impact Factor

Publication Stats

360 Citations
65.55 Total Impact Points


  • 2011
    • Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
      San Paulo, São Paulo, Brazil
  • 2006-2011
    • University of Buenos Aires
      Buenos Aires, Buenos Aires F.D., Argentina
  • 1998-2011
    • Hospital de Niños Ricardo Gutièrrez
      Buenos Aires, Buenos Aires F.D., Argentina