Pediatric Intensive Care Unit Mortality Research Articles

Paediatric cancer patients with severe sepsis or septic shock at the PICU with positive microbiological results do worse than those with negative results: a retrospective cohort study

PurposeInfections are a leading cause of mortality and morbidity in paediatric cancer patients. The aim of this study was to determine whether positive or negative microbiological results impact the clinical outcomes of sepsis in paediatric cancer patients admitted to the paediatric intensive care unit (PICU).MethodsWe performed a retrospective observational single-centre cohort study between 1 January 2018 and 31 December 2020 in the Netherlands. All paediatric cancer patients aged 0 to 18 years admitted to PICU due to severe sepsis or septic shock were included.ResultsWe identified 73 PICU admissions in 58 unique patients. Forty-nine of the 73 PICU admissions (67.1%) had positive blood and/or bronchoalveolar lavage microbiological results. Patients with positive results had a higher Paediatric Logistic Organ Dysfunction-2 (PELOD-2) score at PICU admission compared to patients with negative results (median (IQR), 7 (6–9) vs 6 (4–8), p = 0.04). Mortality in PICU among patients with positive results was significantly higher when compared to patients with negative results, 18% versus 0% respectively (p = 0.03). In addition, patients with positive results had significantly less ventilator-free days at day 28 compared to patients with negative results, median (IQR) 26 (19–28) versus 28 (27–28) respectively (p = 0.01).ConclusionsMicrobiologically confirmed infections (bacterial, viral, or fungal) in paediatric cancer patients with sepsis are associated with higher mortality in PICU and a higher need for PICU resources. Large-scale (multicentre) studies in paediatric oncologic patients are required to confirm these results.

Serum anion gap versus lactate clearance as mortality predictors in critically ill children

Introduction: Mortality prediction is important for optimal resource allocation in the paediatric intensive care unit (PICU). Objectives: To estimate the predictive value of serum corrected anion gap (cAG) and lactate clearance for predicting mortality in PICU. Method: We conducted a prospective study of children admitted to the PICU of a tertiary hospital. PRISM III and IV score, cAG and lactate clearance were done in all patients, and the predictive value was calculated for mortality. Results: The mortality in the study group was 12%. The cAG was significantly lower in survivors than in non-survivors (p <0.001). The lactate levels at 6 hours (AUC 0.898) had the best mortality prediction, followed by admission lactate (AUC 0.804) and cAG (AUC 0.742). However, the lactate clearance did not show good predictive value. Conclusions: The cAG is an excellent mortality predictor in a low-resource setting.

Mortality in Patients with Leukemia and Lymphoma Urgently Admitted to the PICU: Secondary Analysis of Data from a Cluster Randomized Controlled Trial

AbstractObjectives were to describe the severity of illness in patients with leukemia or lymphoma urgently admitted to pediatric intensive care and explores the risk factors for mortality. A secondary analysis was performed of prospectively collected data from a cluster-randomized controlled trial in 21 children's hospitals from 2011 to 2015. Eligible patients were urgently admitted to intensive care and had a diagnosis of leukemia or lymphoma. Associations with intensive care mortality (primary outcome) were determined with multivariable generalized estimating equation with a logit link, accounting for clustering by site. Associations with time to intensive care mortality (secondary outcome) were determined with multivariable proportional hazards models. A total of 109 patients were included, age 115 (interquartile range [IQR] 42, 168) months and intensive care length of stay was 3 (IQR 2, 6) days. During the first hour in intensive care 36 (33%) were ventilated, and during intensive care 45 (41.3%) had at least 1 technology day. Day 1 Pediatric Logistic Organ Dysfunction (PELOD) score was ≥ 20 in 37 (33.9%), Pediatric Index of Mortality 2 mortality risk was > 10% in 35 (32.1%), and Children's Resuscitation Intensity Scale (RISC) was ≥ 3 (late admission to intensive care) in 32 (31.7%). Intensive care mortality was 20/109 (18.3%); with intensive care stay ≥ 20 days mortality was 51%. Previous urgent pediatric intensive care unit (PICU) admission, mechanical ventilation, and day 1 PELOD score were associated with higher PICU mortality. Mechanical ventilation, day 1 PELOD score, and late admission to the PICU (RISC ≥ 2) were associated with time to death. Patients with leukemia and lymphoma urgently admitted to intensive care had mortality of 18.3%, an improvement from historical cohorts. Risk factors were not accurate enough to make individual patient care decisions.

Design and rationale of the Post-Intensive Care Syndrome – paediatrics (PICS-p) Longitudinal Cohort Study

IntroductionAs paediatric intensive care unit (PICU) mortality declines, there is growing recognition of the morbidity experienced by children surviving critical illness and their families. A comprehensive understanding of the adverse...

Fresh Frozen Plasma Versus Solvent Detergent Plasma for Cardiopulmonary Bypass Priming in Neonates and Infants Undergoing Cardiac Surgery: A Retrospective Cohort Study

ObjectiveCompared with Fresh Frozen Plasma (FFP), Omniplasma has been attributed to an increased coagulation potential and an increased fibrinolytic potential. This study aimed to compare Omniplasma and FFP used for cardiopulmonary bypass (CPB) priming regarding the incidence of post-operative thrombotic-or haemorrhagic complications and outcome in paediatric patients undergoing cardiac surgery. DesignA retrospective observational cohort study SettingThis single-center study was performed in the University Medical Center Groningen ParticipantAll paediatric patients up to 10 kg undergoing cardiac surgery with CPB. InterventionsProcedures where FFP was used for CPB priming were compared with those where Omniplasma was used. Measurements and main resultsThe primary outcome parameter was a composite endpoint consisting of 1) Paediatric Intensive Care Unit (PICU) mortality, 2) thromboembolic complications, and 3) haemorrhagic complications during PICU stay. We included 143 procedures in the analyses, 90 (63%) in the FFP- and 53 (37%) in the Omniplasma-group. The occurrence of the combined primary endpoint (FFP 20% vs omniplasma 11%, p=0.18 and its components did not differ between the used CPB priming agent). Omniplasma for CPB priming was associated with decreased Unfractionated Heparin administration per kg bodyweight (585 IU vs 510 IU, p=0.03), a higher pre- and post-operative Activated Clotting Time (ACT) discrepancy (90% vs 94%, p=0.03), a lower post-operative ACT value (125 seconds vs 118 seconds, p=0.01), and less Red Blood Cell transfusion per kilogram bodyweight (78 ml vs. 55 ml, p=0.02). However, none of the variables differed statistically significant in the multivariate logistic regression analyses. ConclusionsWe did not find an association between the used plasma for CPB priming and thromboembolic, haemorrhagic complication, and death in neonates and infants undergoing cardiac surgery. Omniplasma seems to be safe to use in this population.

Role of Blood Lactate Clearance in Predicting Outcomes among Septic Patients Admitted to the PICU: A Prospective Cohort Study

Introduction: A crucial metric for evaluating the effectiveness of microcirculation in septic shock is serum lactate. Lactate clearance within the first 24 hours of admission has predictive value for death in Paediatric Intensive Care Unit (PICU) admissions. Higher mortality was observed in septic patients who were unable to clear elevated admission lactate. Aim: To determine the admission lactate level and to investigate whether failure to clear elevated lactate in septic patients can prognosticate high PICU mortality. Materials and Methods: This prospective cohort study was conducted from August 2021 to July 2022 at PICU, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India. A total of 75 children, aged two months to 18 years, admitted to the PICU for sepsis or septic shock, were enrolled in the study. The authors measured blood lactate at Intensive Care Unit (ICU) admission, at 6, 12, and 24 hours. Lactate clearance was calculated, and its association with mortality after 24 hours of PICU stay was measured using the Chi-square test. Results: Out of the total, 55 survived, comprising 31 males (41.3%) and 44 females (58.7%). When comparing admission blood lactate to lactate clearance >10% at 6, 12, and 24 hours, there was no correlation between the two variables and mortality in PICU patients with sepsis. Conclusion: Lactate clearance in the first 24 hours of PICU stay was recommended as a parameter associated with the mortality rate among septic patients. However, the authors did not find any correlation.

ADAMTS13 in pediatric sepsis: a prognostic biomarker with potential therapeutic implications

BackgroundGrowing evidence implicates a pro-thrombotic state, caused by ADAMTS13 deficiency, in sepsis-associated organ dysfunction, but pediatric data is limited. Our purpose was to evaluate association of ADAMTS13 with prognosis of pediatric sepsis.ResultsThis was prospective observational study, conducted on 70 children with sepsis and 18 healthy controls. Patients were classified upon Pediatric Intensive Care Unit (PICU) admission into sepsis, severe sepsis, and septic shock groups. Serum ADAMTS13 was measured within 24 h of admission. The primary outcome was all-cause PICU mortality. ADAMTS13 was lower among patients than controls [median and interquartile range (IQR): 1.30 (0.88–3.13ng/mL) vs. 6.00 (5.55–6.50 ng/mL); p < 0.001]. ADAMTS13 was lower in both severe sepsis and septic shock than sepsis [median (IQR): 0.90 (0.80–1.75 ng/mL); 1.0 ng/ml (0.90–1.20); and 2.80 (1.00–3.85ng/mL), p = 0.026 and 0.006 respectively]. ADAMTS13 was lower among non-survivors compared with survivors [median (IQR): 0.9 (0.80–1.18 ng/mL) vs. 2.45 (0.98–3.50 ng/mL); p < 0.001]. ADAMTS13 had area under Receiver Operating Characteristic Curve (AUC) of 0.77 for mortality prediction. Lower ADAMTS13 level was associated with mechanical ventilation; vasoactive medications; acute respiratory distress syndrome; and multiple organ dysfunction syndrome. ADAMTS13 correlated with pediatric Sequential Organ Failure Assessment (pSOFA) score (rs = -0.46, p < 0.001); vasoactive infusion days ((rs = -0.48, p < 0.001); and vasoactive-inotropic score on day1 (rs = -0.43, p < 0.001) and day2 ((rs = -0.41; p < 0.001).ConclusionIn pediatric sepsis, lower ADAMTS13 level is a risk factor for organ dysfunction and mortality, lending theoretical foundations to therapeutic interventions aiming at reversing the pro-thrombotic state in sepsis.

Hemodynamic and Homeostasis Changes after Continuous Renal Replacement Therapy in Septic Shock Children at Vietnam National Children’s Hospital

Objectives: This study aims to describe changes in hemodynamics and homeostasis after continuous renal replacement therapy (CRRT) in septic shock children without acute kidney injury. Methods: An observational study was conducted in the pediatric intensive care unit (PICU) at Vietnam National Children’s Hospital from January 2018 to June 2022. Children aged under 18 years old with septic shock and without acute kidney injury who required CRRT were analyzed on demographic factors, baseline clinical and laboratory results, changes in hemodynamics and homeostasis at 6 hours, 12 hours, 24 hours, 48 hours, 72 hours, 4 days and 5 days after CRRT initiation. Results: A total of 125 children (male, 57.6%) were enrolled in the study. The median age was 11.5 months (IQR: 5 – 29). Overall PICU mortality rate at day 28 was 40.8%. Among survivors, there was a statistically significant improvement in heart rate, mean blood pressure, vasoactive inotropic score (VIS), and pH at all mentioned periods after CRRT initiation. Lactatemia statistically significantly decreased after 24 hours of CRRT initiation (p &lt; 0.05). Among non-survivors, there was a statistically significant improvement in heart rate at all the periods and in mean blood pressure at 6 hours and 12 hours, while there was no improvement in VIS, pH, and lactatemia. Conclusion: CRRT played an important role in stabilizing hemodynamics and homeostasis in septic shock children without acute kidney injury.&#x0D; &#x0D; &#x0D; &#x0D;

Associations Between Core Temperature Disorders and Outcomes of Pediatric Intensive Care Unit Patients.

The few studies of associations between fever and outcomes in pediatric intensive care unit (PICU) patients have conflicting findings. Associations between hypothermia and patient outcomes have not been studied. To investigate the incidence and characteristics of fever and hypothermia and their associations with adverse outcomes among PICU patients. Patients consecutively admitted to 2 PICUs in a 2-year period were prospectively studied. Core temperature was mainly measured by rectal or axillary thermometry. Fever and hypothermia were defined as core temperatures of greater than 38.0 °C and less than 36.0 °C, respectively. Prolonged mechanical ventilation, prolonged PICU stay, and PICU mortality were the adverse patient outcomes studied. Associations between patient outcomes and core temperature disorders were evaluated with univariate comparisons and multivariate analyses. Of 545 patients enrolled, fever occurred in 299 (54.9%) and hypothermia occurred in 161 (29.5%). Both temperature disorders were independently associated with prolonged mechanical ventilation and prolonged PICU stay (P < .001) but not with PICU mortality. Late onset of fever (P < .001) and hypothermia (P = .009) were independently associated with prolonged mechanical ventilation, fever magnitude and duration (both P < .001) were independently associated with prolonged PICU stay, and fever magnitude (P < .001) and infectious cause of hypothermia (P= .01) were independently associated with higher PICU mortality. These findings provide evidence that the manifestation and characteristics of fever and hypothermia are independent predictors of adverse outcomes in PICU patients.

The outcome of high-frequency oscillatory ventilation in pediatric patients with acute respiratory distress syndrome in an intensive care unit.

In adults with acute respiratory distress syndrome (ARDS), high-frequency oscillatory ventilation (HFOV) has been associated with higher mortality rates. Therefore, its use in children with ARDS is still controversial. Evaluate the overall mortality of HFOV in children with ARDS and explore mortality-related risk factors; compare the outcome of using HFOV post-endotracheal intubation early (≤24 hours) versus late (≤24 hours). Retrospective (medical record review) SETTING: Pediatric intensive care unit in a tertiary care center in Saudi Arabia. Data were collected from medical records of all pediatric patients with ARDS aged one week to 14 years, who were admitted to the pediatric intensive care unit (PICU) from January 2016-June 2019 and who required HFOV. PICU mortality. 135 ARDS patients including 74 females (54.8%), and 61 males (45.2%), with a median age (interquar-tile range) of 35 (72) months. The overall mortality rate was 60.0% (81/135), and most died in the first 28 days in the PICU (91.3%, 74/8). Of non-survivors, 75.3% (61/81) were immunocompromised, and 24.7% (20/81) were immuno-competent patients, 52 (64.2%) received inotropic support, 40 (49.4%) had a bone-marrow transplant (BMT) before HFOV initiation. Although the prone position was used in 20.7% (28/135) to improve the survival rate post-HFOV ventilation, only 28.6% (8/28) survived. In addition, altered code status or chemotherapy reported a significant association with mortality (P<.05). Interestingly, early HFOV initiation (≤24 hours) did not seem to have a high impact on survival compared to late initiation (>24 hours); (57.4% vs. 42.6%, P=.721). Immunocompromised and oncology patients, including post-BMT, reported poorer outcomes, and neither the prone position nor early use of HFOV improved outcomes. However, it is recommended to replicate the study in a larger cohort to generalize the results. Retrospective single-center study.

Characteristics, Outcomes and Bed Utilization of 15-to-18-Year-Old Adolescents in a Pediatric Intensive Care Unit in Thailand

Objective: There is a trend toward expanding pediatric age range. At the borderline age of 15-18 years, the characteristics of patients requiring intensive care admission in low- and middle-income countries are unknown. Our institution recently changed the cut-off age for pediatric care from 15 to 18 years. The objective of this study was to determine the characteristics, outcomes and bed utilization of patients aged 15-18 years admitted to pediatric intensive care unit (PICU) after this change. Materials and Methods: This is an observational study at a tertiary medical PICU. Patients aged 15-18 years admitted to PICU in 2019-2020 were eligible. Medical records were reviewed. Results: There were 1030 PICU admissions from all age groups. Fifty-two patients aged 15-18 years were admitted, with a total of 68 admissions. Eighty-seven percent had chronic conditions. The most common acute conditions were septic shock and infection, the most common chronic conditions were systemic lupus erythematosus (SLE) and hematologic malignancies. Forty-seven percent required mechanical ventilation, 36% required vasoactive medications and 27% required continuous renal replacement therapy. PICU mortality rate in patients aged 15-18 years old was significantly higher than that in the younger age group (13.24% vs 3.64%, p = 0.002). Hospital mortality rate was 22%. Conclusion: Patients aged 15-18 years requiring PICU admission had high prevalence of chronic conditions and high mortality risk. Special attention should be given to the care of this group. The most common acute conditions were septic shock and infection. The most common chronic conditions were SLE and hematologic malignancies.

Prognostic factors for multi-organ dysfunction in pediatric oncology patients admitted to the pediatric intensive care unit.

Pediatric oncology patients who require admission to the pediatric intensive care unit (PICU) have worse outcomes compared to their non-cancer peers. Although multi-organ dysfunction (MOD) plays a pivotal role in PICU mortality and morbidity, risk factors for MOD have not yet been identified. We aimed to identify risk factors at PICU admission for new or progressive MOD (NPMOD) during the first week of PICU stay. This retrospective cohort study included all pediatric oncology patients aged 0 to 18 years admitted to the PICU between June 2018 and June 2021. We used the recently published PODIUM criteria for defining multi-organ dysfunction and estimated the association between covariates at PICU baseline and the outcome NPMOD using a multivariable logistic regression model, with PICU admission as unit of study. To study the predictive performance, the model was internally validated by using bootstrap. A total of 761 PICU admissions of 571 patients were included. NPMOD was present in 154 PICU admissions (20%). Patients with NPMOD had a high mortality compared to patients without NPMOD, 14% and 1.0% respectively. Hemato-oncological diagnosis, number of failing organs and unplanned admission were independent risk factors for NPMOD. The prognostic model had an overall good discrimination and calibration. The risk factors at PICU admission for NPMOD may help to identify patients who may benefit from closer monitoring and early interventions. When applying the PODIUM criteria, we found some opportunities for fine-tuning these criteria for pediatric oncology patients, that need to be validated in future studies.

Prognostic factors of sepsis in children with acute leukemia admitted to the pediatric intensive care unit.

To analyze the prognostic factors of sepsis in children with acute leukemia admitted to the pediatric intensive care unit (PICU) and to compare the efficacy of different scoring systems for predicting the outcome of children. Patients with an acute leukemia diagnosis admitted to a tertiary care university hospital PICU due to sepsis during chemotherapy between May 2015 and August 2022 were retrospectively analyzed through an electronic medical record system. During this period, 693 children with acute leukemia initially diagnosed were admitted to the center, and 155 (22.3%) of them were transferred to PICU due to deterioration of the disease during treatment. Total 109 (70.3%) patients were transferred to PICU due to sepsis. Here, 17 patients was excluded (prior treatment from another hospital; referring from other hospitals; discontinued treatment; incomplete medical record). Of the 92 patients studied, the mortality rate was 35.9%. Multivariate analysis revealed that remission status, lactate level, invasive mechanical ventilation (IMV), and inotropic support within 48hours after PICU transfer were independent risk factors for PICU mortality. The pediatric sequential organ failure assessment (PSOFA) score had the greatest predictive validity for hospital mortality (area under the receiver operating characteristic curve [AUROC]: 0.83, 95% confidence intervals [CI]: 0.74-0.92), followed by the pediatric early warning score (PEWS) (0.82, 0.73-0.91) and pediatric critical illness score (PCIS) (0.79, 0.69-0.88). The mortality rate among children with acute leukemia complicated with sepsis is high after being transferred to the PICU. Various scoring systems can be used to monitor the clinical status of patients, identify sepsis early, detect critical illness, and determine the optimal time for transfer to the PICU for supportive treatment, thereby improving the prognosis of these patients.

Association of Extubation Failure Rates With High-Flow Nasal Cannula, Continuous Positive Airway Pressure, and Bilevel Positive Airway Pressure vs Conventional Oxygen Therapy in Infants and Young Children

Extubation failure (EF) has been associated with worse outcomes in critically ill children. The relative efficacy of different modes of noninvasive respiratory support (NRS) to prevent EF is unknown. To study the reported relative efficacy of different modes of NRS (high-flow nasal cannula [HFNC], continuous positive airway pressure [CPAP], and bilevel positive airway pressure [BiPAP]) compared to conventional oxygen therapy (COT). MEDLINE, Embase, and CINAHL Complete through May 2022. Randomized clinical trials that enrolled critically ill children receiving invasive mechanical ventilation for more than 24 hours and compared the efficacy of different modes of postextubation NRS. Random-effects models were fit using a bayesian network meta-analysis framework. Between-group comparisons were estimated using odds ratios (ORs) or mean differences with 95% credible intervals (CrIs). Treatment rankings were assessed by rank probabilities and the surface under the cumulative rank curve (SUCRA). The primary outcome was EF (reintubation within 48 to 72 hours). Secondary outcomes were treatment failure (TF, reintubation plus NRS escalation or crossover to another NRS mode), pediatric intensive care unit (PICU) mortality, PICU and hospital length of stay, abdominal distension, and nasal injury. A total of 11 615 citations were screened, and 9 randomized clinical trials with a total of 1421 participants were included. Both CPAP and HFNC were found to be more effective than COT in reducing EF and TF (CPAP: OR for EF, 0.43; 95% CrI, 0.17-1.0 and OR for TF 0.27, 95% CrI 0.11-0.57 and HFNC: OR for EF, 0.64; 95% CrI, 0.24-1.0 and OR for TF, 0.34; 95% CrI, 0.16- 0.65). CPAP had the highest likelihood of being the best intervention for both EF (SUCRA, 0.83) and TF (SUCRA, 0.91). Although not statistically significant, BiPAP was likely to be better than COT for preventing both EF and TF. Compared to COT, CPAP and BiPAP were reported as showing a modest increase (approximately 3%) in nasal injury and abdominal distension. The studies included in this systematic review and network meta-analysis found that compared with COT, EF and TF rates were lower with modest increases in abdominal distension and nasal injury. Of the modes evaluated, CPAP was associated with the lowest rates of EF and TF.

Sepsis Prognostic Scores Accuracy in Predicting Adverse Outcomes in Children With Sepsis Admitted to the Pediatric Intensive Care Unit From the Emergency Department: A 10-Year Single-Center Experience.

To compare the performance of several prognostic scores calculated in the first 24 hours of admission (day 1) in predicting mortality and morbidity among critically ill children with sepsis presenting to the pediatric emergency department (PED) and then admitted to the pediatric intensive care unit (PICU). Single-center, retrospective cohort study in children with a diagnosis of sepsis visiting the PED and then admitted to the PICU from January 1, 2010 to December 31, 2019. Sepsis organ dysfunction scores-pediatric Sequential Organ Failure Assessment (pSOFA) (Schlapbach, Matics, Shime), quickSOFA, quickSOFA-L, Pediatric Logistic Organ Dysfunction (PELOD)-2, quickPELOD-2, and Pediatric Multiple Organ Dysfunction score-were calculated during the first 24 hours of admission (day 1) and their performance compared with systemic inflammatory response syndrome (SIRS) and severe sepsis-International Consensus Conference on Pediatric Sepsis(ICCPS)-derived criteria-using the area under the receiver operating characteristic curve. Primary outcome was PICU mortality. Secondary outcomes were: a composite of death and new disability (ie, change from baseline Pediatric Overall Performance Category score ≥1); prolonged PICU length of stay (>5 d); prolonged invasive mechanical ventilation (MV) (>3 d). Among 60 patients with sepsis, 4 (6.7%) died, 7 (11.7%) developed new disability, 26 (43.3%) experienced prolonged length of stay, and 21 (35%) prolonged invasive MV. The prognostic ability in mortality discrimination was significantly higher for organ dysfunction scores, with PELOD-2 showing the best performance (area under the receiver operating characteristic curve, 0.924; 95% confidence interval, 0.837-1.000), significantly better than SIRS 3 criteria (0.924 vs 0.509, P = 0.009), SIRS 4 criteria (0.924 vs 0.509, P < 0.001), and severe sepsis (0.924 vs 0.527, P < 0.001). Among secondary outcomes, PELOD-2 performed significantly better than SIRS criteria and severe sepsis to predict prolonged duration of invasive MV, whereas better than severe sepsis to predict "poor outcome" (mortality or new disability). Day 1 organ dysfunction scores performed better in predicting mortality and morbidity outcomes than ICCPS-derived criteria. The PELOD-2 was the organ dysfunction score with the best performance for all outcomes.

The outcome of acute kidney injury substages based on urinary cystatin C in critically ill children

BackgroundThe concept of acute kidney injury (AKI) substages has been recommended to better phenotype AKI and identify high-risk patient groups and therefore improve the diagnostic accuracy of AKI. However, there remains a gap between the recommendation and the clinical application. The study aimed to explore the incidence of AKI substages based on a sensitive AKI biomarker of urinary cystatin C (uCysC), and to determine whether AKI substages were relevant with respect to outcome in critically ill children.ResultsThe multicenter cohort study enrolled 793 children in pediatric intensive care unit (PICU) of four tertiary hospitals in China. Children were classified as non-AKI, sub-AKI and AKI substages A and B according to uCysC level at PICU admission. Sub-AKI was defined by admission uCysC level ≥ 1.26 mg/g uCr in children not meeting the KDIGO criteria of AKI. In children who fulfilled KDIGO criteria, those with uCysC < 1.26 was defined as AKI substage A, and with ≥ 1.26 defined as AKI substage B. The associations of AKI substages with 30-day PICU mortality were assessed. 15.6% (124/793) of patients met the definition of sub-AKI. Of 180 (22.7%) patients with AKI, 90 (50%) had uCysC-positive AKI substage B and were more likely to have classical AKI stage 3, compared to substage A. Compared to non-AKI, sub-AKI and AKI substages A and B were risk factors significantly associated with mortality, and the association of sub-AKI (adjusted hazard ratio HR = 2.42) and AKI substage B (adjusted HR = 2.83) with mortality remained significant after adjustment for confounders. Moreover, AKI substage B had increased risks of death as compared with sub-AKI (HR = 3.10) and AKI substage A (HR = 3.19).ConclusionsSub-AKI defined/based on uCysC occurred in 20.2% of patients without AKI and was associated with a risk of death close to patients with AKI substage A. Urinary CysC-positive AKI substage B occurred in 50% of AKI patients and was more likely to have classical AKI stage 3 and was associated with the highest risk of mortality.

Validation of a Clinical Tool to Predict Neurological Outcomes in Critically Ill Children-A Prospective Observational Study.

To evaluate the performance of the empiric tool by Gupta et al. in predicting neurological outcomes in children admitted to the pediatric intensive care unit (PICU) and to evaluate the association of biomarkers S100B and NSE with neurological outcomes. This prospective observational study was conducted in 163 critically ill children aged 2 mo to 17 y admitted to the PICU from June 2020 to July 2021. The authors used the prediction tool developed by Gupta et al.; the tool was applied at admission and at PICU discharge/death. Samples for NSE and S100B were collected at admission and discharge. The performance of the new tool was assessed through discrimination and calibration. Risk factors for "unfavorable outcomes" (decline in PCPC score by > 1) were evaluated by multivariate analysis. The PICU mortality was 28% (n = 45). When the tool developed by Gupta et al. was used at the time of admission, favorable neurological outcomes were predicted for 69% (112) children. The area under the curve for the new tool at admission was 0.72 and at discharge/death it was 0.99, and the calibration was excellent at both time points. Independent factors associated with unfavorable neurological outcomes were higher PCPC scores and organ failure. As the number of samples processed for NSE and S100B was less, statistical analysis was not attempted. The new tool by Gupta et al. has good discrimination, calibration, sensitivity, and specificity and can be used as a prediction tool. NSE and S100B are promising biomarkers and need further evaluation.

Performance of Brazilian Pediatric Risk of Severity Model for Illness (Brprism) Compared to Pediatric Index of Mortality and Pediatric Risk of Mortality 2

Introduction: The best prognosis score with which to evaluate high-risk patients upon admission into pediatric intensive care is not well established in resource-limited settings. The objective of study was to formulate a risk-of-illness severity model for pediatric mortality to be applied upon PICU admission in resource-limited settings. Methods: Our study was designed to develop an illness severity index and a prognostic model for critically ill children. A prospective, observational multicenter pilot study, performed between February 1995 and October 1999, evaluated the variables, methodology and statistical techniques for the development of a model. A single-center prospective cohort study, performed between November 1999 and October 2004, collected information from consecutive admissions into the Pediatric Intensive Care Unit (PICU) at a high-complexity university, teaching, and reference hospital in São Paulo, Brazil. Results: In the pilot study, 1,459 patients (a PICU mortality rate of 16%) were included, and in the second study, 1,033 patients (a PICU mortality rate of 13.9% and a hospital mortality rate of 6.9% after PICU discharge) were included. We used multivariable regression to determine two probabilistic models; the first addressed survival and the overall probability of death (hospital plus PICU deaths), and the second was conditional (i.e., PICU death). An illness severity index stratified these probabilities into three risk strata: low-, medium- and high-risk patients. In the final step, the new death probabilities were estimated using a Bayesian adjustment. Conclusions: The model estimates three probabilities (survival, death in the PICU and death in the hospital after PICU discharge) stratified into three risk categories. To the best of our knowledge, this is the first study using a Bayesian adjustment to determine a prognosis and illness severity, and it should enable us to make therapeutic adjustments and provide appropriate counseling for high-risk patients in resource-limited settings.

Prognostic Conversations Between Parents and Physicians in the Pediatric Intensive Care Unit.

Up to 80% of pediatric intensive care unit (PICU) patients experience new morbidities upon discharge. Patients and families rely on clear communication to prepare for post-PICU morbidities. Surveys were given at PICU discharge to parents and attending physicians of patients who developed multi-organ dysfunction within 24 hours of PICU admission and whose parents completed an initial survey 5 to 10 days after PICU admission. Participants were asked about prognostic conversations regarding PICU mortality; patient post-PICU physical, cognitive, and psychological morbidities; and parent post-PICU psychological morbidities. Parents also indicated whether they wanted more prognostic information. Forty-nine parents and 20 PICU attending physicians completed surveys for 49 patients. Thirty parent (61%) and 29 physician (59%) surveys reported participating in any prognostic conversations. Concordance between parents and physicians about prognostic conversations was slight (κ = 0.19). Parent (n = 22; 45%) and physician (n = 23; 47%) surveys most commonly reported prognostic conversations about post-PICU physical morbidities. Parents less commonly reported conversations about post-PICU cognitive morbidities (n = 10; 20%). According to parents, bedside nurses and physicians provided most prognostic information; social workers (54%) most commonly discussed parent psychological morbidities. Twenty-six parents (53%) requested more prognostic information. Most parents and physicians reported having prognostic conversations, primarily about post-PICU physical morbidities. More than half of parents wanted more information about potential post-PICU morbidities. More research is needed to understand how and when medical professionals should have prognostic conversations with parents.

Comparative Analysis of Intensive Care Prognosis Scoring Systems and Acute Kidney Injury Scores (AKIN and pRIFLE) in Critically Ill Children

A total of 716 children, whose serum creatinine levels were within the normal limits at the time of admission to the PICU between January 2018 and December 2020, were included. Along with the demographic and clinical variables, AKIN and pRIFLE classifications were recorded at the most advanced stage of AKI. Along with the PIM-2, PRISM III, and PELOD-2 scores, the highest value of the pSOFA score was recorded. According to the pRIFLE and AKIN classifications, 62 (8.7%) patients developed kidney injury, which had a statistically significant effect on mortality. The occurrence of renal injury was found to be statistically strongly and significantly correlated with high PRISM III, PELOD-2, and pSOFA scores. When the stages of kidney injury according to the AKIN criteria were compared with the PRISM III, PELOD 2, and pSOFA scores, a significant difference was found between the patients who did not develop AKI and those who developed stage 1, stage 2, and stage 3 kidney injury. For the PRISM III, PELOD 2, and pSOFA scores, there were no significant differences between the stages according to the AKIN criteria. A substantial difference was discovered between the patients who did not develop AKI and those who were in the risk, injury, and failure plus loss stages according to the pRIFLE criteria. According to the PIM-2 ratio and pRIFLE criteria, there was a statistically significant difference between patients in the injury and failure plus loss stages and those who did not develop AKI. Our study is the first pediatric study to show a substantial correlation between the variables associated with the PICU scoring modalities in critically ill children with AKI. Identifying the risk factors for the development of AKI and planning antimicrobial regimens for patients with favorable prognoses at the time of PICU admission could lower mortality rates.