Low vitamin C concentrations and prognosis in critically ill children

Undernutrition at PICU Admission Is Predictor of 60-Day Mortality and PICU Length of Stay in Critically Ill Children

Near-Fatal Asthma: An Ounce of Prevention May be Worth More than a Pound of Cure

Dear Editor, Hypophosphataemia, which is frequent in critically ill adults [1], may induce myocardial dysfunction [2]. Hypophosphataemia was recently reported in two-thirds of children in a Brazilian paediatric intensive care unit (PICU) [3], with malnutrition as the main risk factor [4]. No studies have assessed prevalence of hypophosphataemia at PICU admission in countries where malnutrition is exceedingly rare. We reviewed the medical records of all patients admitted to our PICU in Paris, France, from January 2007 to April 2009. We collected causes of admission; sex; age; weight; PRISM III score and predicted risk of mortality; calcaemia; phosphataemia; C-reactive protein (CRP); use of steroids, diuretics, and catecholamines; times on mechanical ventilation and in the PICU; and deaths. Hypophosphataemia was defined as phosphate B1.15 mmol/L [5]. The Z-score for weight was used as a marker of overall nutritional status, because stature and brachial circumference were rarely collected at admission. Data were described as median (inter-quartile range) or percentage and compared using Wilcoxon, Mann–Whitney, or v test. Factors associated with hypophosphataemia (p \ 0.10) on univariate analysis were entered into a multivariable model using a multipleimputation method to include missing data, and odds ratios with 95% confidence intervals were computed. Mortality was compared using Wilcoxon–Mann–Whitney test. All calculations were performed using SAS v9.1 software (SAS Institute Inc., Cary, NC, USA). Of the 1,537 PICU stays, 613 stays had phosphataemia measured at admission. These patients were older [24 (4;95) months versus 14 (2;57) months; p = 0.001] and had higher risk of mortality [2.2% (1.0%;5.9%) versus 1.9% (0.8%;3.7%); p \ 0.0001] than children without phosphataemia measurements. The results showed hypophosphataemia for 128 stays, including severe hypophosphataemia (\0.6 mmol/L) for 6 stays (Table 1). On univariate analysis, factors significantly associated with hypophosphataemia at admission were CRP [100 mg/L [2.74 (1.74;4.31), p \ 0.0001], PRISM [4 [1.55 (1.00;2.38), p = 0.05], steroids [2.32 (1.38;3.92), p = 0.002], female gender [1.41 (0.95;2.08), p = 0.09], postoperative period [0.60 (0.34;1.07), p = 0.08] and hypocalcaemia [1.56 (1.00;2.43), p = 0.05]. On multivariable analysis, only CRP [100 mg/L [2.86 (1.79;4.59), p \ 0.0001] and PRISM [4 [1.61 (1.03;2.51), p = 0.03] remained significant. Hypophosphataemia at admission had no effect on mechanical ventilation duration (p = 0.40), PICU length of stay (p = 0.91) or mortality (p = 0.82). In this large sample, one-fifth of patients had hypophosphataemia at PICU admission. We employed a similar threshold to define hypophosphataemia as has been used in recent studies [3, 4]. Weight Z-score

Background and aimUndernutrition (UN) may negatively impact clinical outcomes for hospitalized patients. The relationship between UN status at pediatric intensive care unit (PICU) admission and clinical outcomes is still not well-reported. This systematic meta-analysis review evaluated the impact of UN at admission to PICU on clinical outcomes, including mortality incidence, length of stay (LOS), and the need for and length of time on mechanical ventilation (MV).MethodsA search was conducted using relevant and multi-medical databases from inception until January 2022. We considered studies that examined the link between UN at PICU admission and clinical outcomes in patients aged 18 years or younger. Pooled risk difference estimates for the PICU outcomes were calculated using a random-effects model.ResultThere were a total of 10,638 patients included in 17 observational studies; 8,044 (75.61%) and 2,594 (24.38%) patients, respectively, were normal-nourished (NN) and undernourished (UN). In comparison to NN patients, UN patients had a slightly higher risk of mortality (RD = 0.02, P = 0.05), MV usage (RD = 0.05, P = 0.02), and PICU LOS (RD = 0.07, P = 0.007). While the duration of MV was significantly longer in UN than in NN (RD = 0.13, P < 0.0001). Sensitivity analysis of UN classification cohorts with a z-score < -2 or in the 5%, patetints age up to 18 years, and mixed diagnose for PICU admission demonstrated a 6-fold increase in the probability of PICU LOS in UN patients compared to NN patients (RD = 0.06, 95% CI = 0.01, 0.12). UN patients have a higher risk of MV usage RD = 0.07, 95% CI = 0.00, 0.14) in studies involving cohorts with a mixed primary diagnosis for PICU admission.ConclusionIn PICU, UN is linked to mortality incidence, longer PICU stay, MV usage, and duration on MV. The primary diagnosis for PICU admission may also influence clinical outcomes. Determining the prevalence of UN in hospitalized patients, as well as the subgroups of patients diagnosed at the time of admission, requires more research. This may help explain the relationship between nutritional status and clinical outcomes in PICU patients.

Background. Prematurity is a major risk factor for paediatric morbidity and mortality. Rehospitalisation with paediatric intensive care unit (PICU) admission constitutes significant morbidity; however, the extent of this problem in South Africa (SA) is not known. Objective. To describe the outcomes, clinical course and characteristics of premature and ex-premature infants admitted to a SA PICU, and to determine predictors of mortality. Methods. This prospective observational study analysed unplanned PICU admissions of infants in the first six months of life, over a six-month period. The primary outcome was mortality. Data were analysed using standard descriptive and inferential statistics. Results. Included in the study were 29 infants (65% male; median (interquartile range) birthweight and gestational age 1 715 (1 130 - 2 340) g and 32 (29 - 34) weeks, respectively) in 33 admissions. Five (17.2%) infants died in the PICU. Apnoea (39.4%), respiratory failure (24.2%) and shock (24.2%) were the most common reasons for PICU admission, secondary to pneumonia (33.3%), sepsis (27.3%) and meningitis (12.1%); 72.4% of infants were mechanically ventilated; and 48.3% received blood transfusions. Higher revised paediatric index of mortality score ( p =0.03), inotrope use ( p <0.0001), longer duration of mechanical ventilation ( p =0.03), and cardiac arrest in the PICU ( p <0.0001) were associated with mortality on univariate analysis with no independent predictors of mortality. Conclusion. Infections leading to apnoea, respiratory failure and shock are common indications for PICU readmission in premature infants. Mechanical ventilation and blood transfusion were frequently required.

In this issue of the Journal of Pediatric Gastroenterology and Nutrition, Goday et al (1) report on the outcomes of children with acute pancreatitis discharged from the Pediatric Intensive Care Units (PICU) using a multicenter database, Virtual PICU Systems (VPS)LLC. They found that mortality from acute pancreatitis was rare compared to the adult series. Recent studies estimate the annual incidence of pediatric acute pancreatitis similar to the rates reported in adults (2). Most children with acute pancreatitis have a mild course (3, 4). In a subset of patients, the disease becomes severe with the emergence of local and systemic complications (i.e. peripancreatic fluid collections, single or multiple organ failure) (5). Adults who develop persistent organ failure and/or infected pancreatic necrosis are at increased risk of death from acute pancreatitis (35-50%) (6). The overall outcomes are better in children compared to adults: the death rate from acute pancreatitis is less than 10% in children and associated with severe disease and presence of systemic complications (3, 4, 7). In children, the etiologies of acute pancreatitis are diverse. Biliary/obstructive factors, medications and multisystem diseases are the main causes of acute pancreatitis in the pediatric age group (3, 4, 8). Goday et al (1) focused their questions on the outcome of children admitted to PICU with acute pancreatitis, utilizing VPS. VPS is a clinical database with over 110 hospital members who collect information from all PICU admissions, including demographics, discharge diagnoses (primary and secondary), interventions, severity of illness scores and mortality data. The authors used two severity of illness scores: Pediatric Index of Mortality-2 (PIM2, based on data obtained at the time of PICU admission) and PRISM III scores (based on data obtained during the first 24 hours of PICU admission). Other outcome measures included PICU length of stay, incidence and duration of mechanical ventilation and mortality rate. Of the 360,612 PICU discharges over a 4 year-period, they analyzed 2,076 patients with the diagnosis of acute pancreatitis. In 331 patients, acute pancreatitis was the primary diagnosis; in 1,695 patients, acute pancreatitis was a secondary diagnosis (other diagnoses were also present). The authors found a low mortality rate in children who were admitted to PICU with acute pancreatitis as the primary diagnosis (0.3%, only 1 patient died) compared to children with secondary acute pancreatitis (6.8%). Children with primary acute pancreatitis had lower PIM2 and PRISM III scores, shorter PICU stays and fewer days of mechanical ventilation compared to the secondary acute pancreatitis group. The data from this large cohort of patients confirm the findings in other single-center pediatric studies that reported similar mortality rates that were mostly related to multisystem disease rather than acute pancreatitis alone (3, 4). Whether it was a primary or secondary diagnosis, the mortality rate from acute pancreatitis in children is much lower compared to the adult population. There are limitations in our understanding of pediatric pancreatitis and the reasons why the mortality rate is lower in children compared to adults. Goday et al (1) were not able to study whether this striking difference is due to fewer cases of severe acute pancreatitis in children. They were not able to assess the etiologies of acute pancreatitis nor evaluate for the presence of complications and disease severity. It is also not known whether patients with acute pancreatitis were diagnosed using well-established criteria (9) or they were all uniformly in critical condition to be admitted to the PICU at all centers. It is possible that the diagnosis of acute pancreatitis was missed or inaccurate. The database did also not allow the authors to determine whether acute pancreatitis was present upon admission or developed during the course of PICU stay. Nevertheless, the study analyzes a large group of children admitted to PICU and reports that acute pancreatitis possibly has a different course in children with lower mortality rates compared to adults. The authors found that the weight z scores were much higher in patients with primary acute pancreatitis compared to the secondary acute pancreatitis group. Therefore, the obesity did not seem to correlate with disease mortality as observed in adults (10). However, it is not known whether obesity is associated with disease severity in pediatric acute pancreatitis. Large pediatric inpatient databases are useful in understanding relatively rare diseases by defining demographics, assessing for comorbidities, identifying disease burden and evaluating national trends. Goday et al (1) followed a strategy similar to a recent study that utilized the Healthcare Cost and Utilization Projects Kids' Inpatient Database (HCUP-KID) to demonstrate an increased incidence and disease burden of pediatric acute pancreatitis (7). The data are not collected prospectively or with the study question in mind, therefore may not be suitable for a thorough analysis. Future studies should include a multicenter, prospective design to analyze the epidemiology and severity of acute pancreatitis, its outcomes and disease predictors in children.

Introduction: The pediatric index of mortality (PIM) 3 is one of several severity scoring systems used for predicting the outcome of patients admitted to pediatric intensive care units (PICUs) based on data collected within the first hour of admission. It avoids potential bias from the effects of treatment after admission and offers practical utility in assigning children to clinical trials soon after PICU admission. PIM 3 is an updated version of PIM 2 for predicting mortality in the PICU. It provides an international standard based on a large contemporary dataset for the comparison of risk-adjusted mortality among children admitted to intensive care. Objective: The aim was to evaluate the performance of the PIM 3 score in predicting mortality in a tertiary care PICU. Materials and Methods: This was a cohort observational study conducted at a tertiary care PICU from January 2016 to October 2018. All patients between 1 month and 15 years of age who were admitted in the PICU in Latifa Hospital were included. PIM 3 scoring was done for all the patients. All data were extracted from the computerized ICU registry database. Scores were calculated using the PIM 3 calculator application. Data were entered into Microsoft Excel 2013 and analyzed using SPSS v24.0. We analyzed the association between PIM 3 score and mortality. The performance of PIM 3 score was assessed by calibration and discrimination. Calibration evaluated PIM 3 at different risks of mortality and was assessed by standardized mortality ratio (SMR) and Pearson’s χ² goodness-of-fit test. SMR was calculated to a mean probability of death and the ratio of observed-to-expected death rates. Discrimination evaluated how well PIM distinguished between patients who survived and died and was assessed using the area under the curve (AUC) with a 95% confidence interval (CI) from the receiver-operating characteristics plot. Results: A total of 583 patients were included in the study, 46 of whom (7.9%) died. The overall SMR was 0.53. SMR was 0.33 and 0.72 in the p < 14.3% and p > 14.3% group, respectively. The expected mortality rate based on PIM 3 score was 9.2 and 37.5% in the p < 14.3% and p > 14.3% group, respectively. Conclusion: The PIM 3 was used to predict mortality in PICU patients in Latifa Hospital, Dubai. The overall accumulated expected mortality was 87.081 (5%) compared to the observed mortality of 46 (7.9%) and SMR of 0.53. PIM 3 had acceptable discrimination ability with an AUC of 0.78 (95% CI 0.69–0.87).

Despite advances in hematopoietic stem cell transplantation (HSCT), a considerable number of pediatric HSCT patients develops post-transplant complications requiring admission to the pediatric intensive care unit (PICU). The objective of this study was to evaluate clinical findings, PICU supportive therapy and outcome as well as predictive factors for 6-months survival after discharge of HSCT patients from PICU. This retrospective single-center analysis investigated patient characteristics, microbiological findings, reasons for admission and death of 54 cases accounting for 94 admissions to the PICU of the University Children's Hospital Tuebingen from 2002 to 2017. We compared clinical characteristics between children with and without 6-months survival after discharge from PICU following HSCT. Finally, we assessed the potential prognostic value of the oncological Pediatric Risk of Mortality Score (O-PRISM), the Pediatric Sequential Organ Failure Assessment Score (pSOFA) and the pRIFLE Criteria for Acute Kidney Injury for 6-months survival using Generalized Estimating Equations (GEE) and Receiver Operating Characteristic curves. Respiratory insufficiency, gastroenterological problems and sepsis were the most common reasons for PICU admission. Out of 54 patients, 38 (70%) died during or after their last PICU admission, 30% survived for at least six months. When considering only first PICU admissions, we could not determine prognostic factors for 6-months mortality. In contrast, under consideration of all PICU admissions in the GEE model, ventilation (p=0.03) and dialysis (p=0.007) were prognostic factors for 6-months mortality. Furthermore, pSOFA (p=0.04) and O-PRISM (p=0.02) were independent risk factors for 6-months mortality considering all PICU admissions. Admission of HSCT patients to PICU is still associated with poor outcome and 69% of patients died within 6 months. Need for respiratory support and dialysis are associated with poor outcome. Prediction of 6-months survival is difficult, especially during a first PICU admission. However, on subsequent PICU admissions pSOFA and O-PRISM scores might be useful to predict mortality. These scores should be prospectively evaluated in further studies to verify whether they can identify pediatric HSCT recipients profiting most from transferal to the PICU.

Objective: To explore the relationship between volume of paediatric intensive care unit (PICU) head injury (HI) admissions, specialist paediatric neurosurgical PICU practice, and mortality in England and Wales.Methods: Analysis of HI cases (age <16 years) from the Paediatric Intensive Care Audit Network national cohort of sequential PICU admissions in 27 units in England and Wales, in the 5 years 2004–2008. Risk-adjusted mortality using the Paediatric Index of Mortality (PIM) model was compared between PICUs aggregated into quartile groups, first to fourth based on descending number of HI admissions/year: highest volume, medium–higher volume, medium–lower volume, and lowest volume. The effect of category of PICU interventions – observation only, mechanical ventilation (MV) only, and intracranial pressure (ICP) monitoring – on outcome was also examined. Observations were reported in relation to specialist paediatric neurosurgical PICU practice.Results: There were 2575 admissions following acute HI (4.4% of non-cardiac surgery PICU admissions in England and Wales). PICU mortality was 9.3%. Units in the fourth-quartile (lowest volume) group did not have significant specialist paediatric neurosurgical activity on the PICU; the other groups did. Overall, there was no effect of HI admissions by individual PICU on risk-adjusted mortality. However, there were significant effects for both intensive care intervention category (p<0.001) and HI admissions by grouping (p<0.005). Funnel plots and control charts using the PIM model showed a hierarchy in increasing performance from lowest volume (group IV), to medium–higher volume (group II), to highest volume (group I), to medium–lower volume (group III) sectors of the health care system.Conclusions: The health care system in England and Wales for critically ill HI children requiring PICU admission performs as expected in relation to the PIM model. However, the lowest-volume sector, comprising 14 PICUs with little or no paediatric neurosurgical activity on the unit, exhibits worse than expected outcome, particularly in those undergoing ICP monitoring. The best outcomes are seen in units in the mid-volume sector. These data do not support the hypothesis that there is a simple relationship between PICU volume and performance.

BackgroundThis study aimed to describe the characteristics and outcomes of children and adolescents with autoimmune inflammatory rheumatic diseases (AIIRD) who were admitted to the pediatric intensive care unit (PICU). The accuracy of the Pediatric Risk of Mortality (PRISM) III and Pediatric Index of Mortality (PIM) 3 scores to predict the mortality were investigated.MethodsThis was a retrospective cohort study. Children and adolescents with AIIRD aged ≤ 18 years who were admitted to the PICU at the largest university-based referral center in Thailand during July 2011 to June 2021 were included.ResultsThere were 122 PICU admissions from 74 patients; mean age of 12.0 ± 4.3 years, 74.3% female. Majority of AIIRD were systemic lupus erythematosus (SLE) (83.8%), followed by systemic juvenile idiopathic arthritis (5.4%), juvenile dermatomyositis (JDM) (2.7%) and microscopic polyangiitis (2.7%). The main cause of admission was combined infection and disease flare (29.5%). Pneumonia was the main site of infection. Acinetobacter baumanii was the most common causative agent. Macrophage activation syndrome occurred in 8 (6.5%) admissions. The mortality rate of PICU admissions was 14.8% from 18 deaths; 17 with SLE and 1 with JDM. Mechanical ventilation (aOR 24.07, 95%CI:1.33-434.91, P= 0.031), pneumothorax (aOR 24.08, 95%CI:1.76-328.86, P = 0.017 and thrombocytopenia (aOR 8.34, 95%CI:1.31–53.73, P = 0.025) were associated with mortality. The risk of mortality rate as predicted by the PRISM III score increased with a score ≥ 9. For the PIM 3 score, the risk of mortality increased if the score ≥ 3. The area under the ROC curve for the PRISM III and PIM 3 scores was 0.741 (95%CI: 0.633–0.849), P = 0.001 and 0.804 (95%CI: 0.685–0.924), P < 0.001, respectively. The model calibration using the Hosmer-Lemeshow goodness of fit test demonstrated a chi-square of 4.335, P = 0.826 for PRISM III and 7.987, P = 0.435 for PIM 3.ConclusionSLE was the main AIIRD that required admission to the PICU. Mechanical ventilation, pneumothorax and thrombocytopenia were associated with mortality in pediatric patients with AIIRD. The PRISM III and PIM 3 scores demonstrated good calibration, while the PIM 3 score provided better discrimination ability in the prediction of mortality for pediatric AIIRD.

careful selection of the appropriate mode of feeding and monitoring the success of the feeding strategy. The use of specific nutrients, which possess a drug-like effect on the immune or inflammatory state during critical illness, continues to be an exciting area of investigation. The lack of systematic research and clinical trials on various aspects of nutrition support in the PICU is striking and makes it challenging to compile evidence based practice guidelines. There is an urgent need to conduct well-designed, multicenter trials in this area of clinical practice. The extrapolation of data from adult critical care literature is not desirable and many of the interventions proposed in adults will have to undergo systematic examination and careful study in critically ill children prior to their application in this population. In the following sections, we will discuss some of the key aspects of nutrition support therapy in the PICU; examine the literature and provide best practice guidelines based on evidence from PICU patients, where available. While some PICU popu lations include neonates, A.S.P.E.N. Clinical Guidelines for neonates will be published as a separate series.

Health-Related Quality of Life (HRQoL) after Pediatric Intensive Care Unit (PICU) admission is considered a valuable outcome measure. Yet, data on HRQoL after PICU admission are scarce and often collected in heterogeneous patient groups. The current study aimed to evaluate HRQoL in children with bronchiolitis 6 months after PICU admission, which represents a homogenous patient group. This study was conducted at the Radboud University Medical Centre in the Netherlands. Children admitted to the PICU between November 2019 and April 2020 were eligible. HRQoL was assessed with the “TNO-AZL Preschool children Quality of Life” (TAPQOL) questionnaire and compared to Dutch normative data. Lower scores represent worse HRQoL. HRQoL was assessed in 34 children (response rate 81%), mean age at assessment was 7.6 months (SD 2.5 months), and median length of stay was 5 days (range 1–17). Parents reported significant lower scores on stomach problems (p < 0.001; d = 0.8) and lung problems (p < 0.001; d = 1.2) and significant higher scores on appetite (p < 0.001; d = 0.6) and problem behavior (p < 0.001; d = 0.5) compared to normative data. Effect sizes were moderate to large.Conclusion: Significant differences in several HRQoL domains were found after PICU admission for bronchiolitis compared to normative data. Whereas the domains lung and stomach problems showed significantly impaired scores, most domains revealed HRQoL levels comparable with healthy peers. This study may contribute to the optimization of HRQoL PICU outcomes by highlighting specific HRQoL domains to focus on at admission and during follow-up.What is Known:• With the decline in PICU mortality, HRQoL became an important outcome measure. Yet, the currently limited number of studies on HRQoL outcomes often involve heterogeneous patient groups.• Bronchiolitis is one of the most frequent reasons for PICU admission, and although a significant part of children admitted for bronchiolitis has a medical history, compared with other reasons for PICU admission, this patient group is relatively homogeneous in terms of age, disease course, and treatment.What is New:• In the present study, six months after PICU admission for bronchiolitis, children scored differently on multiple HRQoL domains compared to healthy peers.• Significantly impaired HRQoL scores were reported on lung and stomach problems in comparison to normative data.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00431-022-04700-8.

Association between admission body mass index and outcomes in critically ill children: A systematic review and meta-analysis

Simple SummarySurvival of children with Wilms tumor is excellent. However, treatment-related complications may occur, requiring treatment at the pediatric intensive care unit (PICU). The aim of our retrospective study was to assess the frequency, clinical characteristics, and outcome of 175 children with Wilms tumor requiring treatment at the PICU in the Netherlands. Thirty-three patients (almost 20%) required unplanned PICU admission during their disease course. Younger age at diagnosis, intensive chemotherapy regimens, and bilateral tumor surgery were risk factors for these unplanned PICU admissions. Three children required renal replacement therapy, two of which continued dialysis after PICU discharge. Two children died during their PICU stay. During follow up, hypertension and renal dysfunction were frequently observed, which justifies special attention for kidney function and blood pressure monitoring during and after treatment of these children.Survival rates are excellent for children with Wilms tumor (WT), yet tumor and treatment-related complications may require pediatric intensive care unit (PICU) admission. We assessed the frequency, clinical characteristics, and outcome of children with WT requiring PICU admissions in a multicenter, retrospective study in the Netherlands. Admission reasons of unplanned PICU admissions were described in relation to treatment phase. Unplanned PICU admissions were compared to a control group of no or planned PICU admissions, with regard to patient characteristics and short and long term outcomes. In a multicenter cohort of 175 children with an underlying WT, 50 unplanned PICU admissions were registered in 33 patients. Reasons for admission were diverse and varied per treatment phase. Younger age at diagnosis, intensive chemotherapy regimens, and bilateral tumor surgery were observed in children with unplanned PICU admission versus the other WT patients. Three children required renal replacement therapy, two of which continued dialysis after PICU discharge (both with bilateral disease). Two children died during their PICU stay. During follow-up, hypertension and chronic kidney disease (18.2 vs. 4.2% and 15.2 vs. 0.7%) were more frequently observed in unplanned PICU admitted patients compared to the other patients. No significant differences in cardiac morbidity, relapse, or progression were observed. Almost 20% of children with WT required unplanned PICU admission, with young age and treatment intensity as potential risk factors. Hypertension and renal impairment were frequently observed in these patients, warranting special attention at presentation and during treatment and follow-up.

Fluid administration is essential in patients undergoing hematopoietic stem cell transplant (HSCT). Admission to pediatric intensive care unit (PICU) is required for 11-29% of pediatric HSCT recipients and is associated with high mortality. The objective of this study was to determine if a positive fluid balance acquired during the HSCT procedure is a risk factor for PICU admission. The medical records of 87 consecutive children who underwent a first HSCT were reviewed retrospectively for the following periods: from admission for HSCT to PICU admission for the first group (PICU group), and from admission for HSCT to hospital discharge for the second group (non-PICU group). Fluid balance was determined on the basis of weight gain (WG) and fluid overload (FO). PICU group consisted of 19 patients (21.8%). Among these, 13 (68.4%) developed>or=10% WG prior to PICU admission compared with 15 (22.1%) in the non-PICU group (p<0.001). Thirteen patients (68.4%) developed>or=10% FO prior to PICU admission compared with 31 (45.6%) in the non-PICU group (p=0.075). Following multivariate analysis, >or=10% WG (p=0.018) and cardiac dysfunction on admission for HSCT (p=0.036) remained independent risk factors for PICU admission. Smaller children (p=0.033) and patients with a twofold increase in serum creatinine (p=0.026) were at risk of developing>or=10% WG. This study shows that WG is a risk factor for PICU admission in pediatric HSCT recipients. Further research is needed to better understand the pathophysiology of WG in these patients and to determine the impact of WG prevention on PICU admission.