Mortality In Pediatric Intensive Care Research Articles

Increase in pediatric intensive care mortality after the Coronavirus pandemic.

Increase in pediatric intensive care mortality after the Coronavirus pandemic.

Association between pediatric intensive care mortality and mechanical ventilation settings during extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome.

The main objective of this study was to describe the current mechanical ventilation (MV) settings during extracorporeal membrane oxygenation (ECMO) for pediatric acute respiratory distress syndrome (P-ARDS) in six European centers. This is a retrospective observational cohort study performed in six European centers from January 2009 to December 2019. Children > 1month to 18years supported with ECMO for refractory P-ARDS were included. Collected data were as follows: patients' pre-ECMO medical condition, pre-ECMO adjunctive therapies for P-ARDS, pre-ECMO and during ECMO MV settings on day (D) 1, D3, D7, and D14 of ECMO, use of adjunctive therapies during ECMO, duration of ECMO, pediatric intensive care unit length of stay, and survival. A total of 255 patients with P-ARDS were included. The multivariate analysis showed that PEEP on D1 (OR = 1.13, 95% CI [1.03-1.24], p = 0.01); D3 (OR = 1.17, 95% CI [1.06-1.29], p = 0.001); and D14 (OR = 1.21, 95% CI [1.05-1.43], p = 0.02) and DP on D7 were significantly associated with higher odds of mortality (OR = 0.82, 95% CI [0.71-0.92], p = 0.001). Moreover, DP on D1 above 15 cmH2O (OR 2.23, 95% CI (1.09-4.71), p = 0.03) and native lung FiO2 above 60% on D14 (OR 10.36, 95% CI (1.51-116.15), p = 0.03) were significantly associated with higher odds of mortality. Conclusion: MV settings during ECMO for P-ARDS varied among centers; however, use of high PEEP levels during ECMO was associated with higher odds of mortality as well as a DP above 15 cmH2O and a native lung FiO2 above 60% on D14 of ECMO. What is Known: • Invasive ventilation settings are well defined for pediatric acute respiratory distress syndrome; however, once the children required an extracorporeal respiratory support, there is no recommendation how to set the mechanical ventilator. • Impact of invasive ventilator during extracorporeal respiratory support ad only been during the first days of this support but the effects of these settings later in the assistance are not described. What is New: • It seems to be essential to early decrease FiO2 on native lung once the ECMO flow allows an efficient oxygenation. • Tight control to limit the driving pressure at 15 cmH20 during ECMO run seems to be associated with better survival rate.

Bacteriological Profile of Health Care Associated Infection and Antibiotic Resistance Pattern of Isolates at Picu in a Tertiary Care Hospital

Background: Healthcare Associated Infections (HAIs) are a major cause of morbidity and mortality inPediatric intensive care units (PICUs). The aim was to determine bacteriological profile of HAI and toestablish an antibiogram of isolates in our PICU.Materials and Method: This was a retrospective study conducted at the Department of Pediatrics (PediatricIntensive Care Unit) of AIIMS, Jodhpur. Data was collected over 2 years from January 2017 to December2018. Among the114 culture positive isolates, 50% (57/114) were gram negative and 22.8% (26/114) weregram positive organisms. Culture positivity for fungal growth was 14 % (17/114) and rest 12.2% (14/114)were contaminants. The most common isolate in gram negative organism was Acinetobacter baumannii andin gram positive organism most common isolates were Enterococcus. Most commonly detected HAI typeswere ventilator associated pneumonia (VAP) - 34% (20/59). All gram negative organisms were resistant tocarbepenems except Pseudomonas (100% sensitivity). Among gram positive organisms, methicillin resistantstaphylococcus aureus (MRSA) was 100% sensitive to gentamicin, amikacin, vancomycin and linezolid.Conclusion: The retrospective study showed that both gram positive and negative bacteria as well as fungalorganisms are responsible for HAIs. Most of the strains were multi drug resistant.

A deep learning model for real-time mortality prediction in critically ill children

BackgroundThe rapid development in big data analytics and the data-rich environment of intensive care units together provide unprecedented opportunities for medical breakthroughs in the field of critical care. We developed and validated a machine learning-based model, the Pediatric Risk of Mortality Prediction Tool (PROMPT), for real-time prediction of all-cause mortality in pediatric intensive care units.MethodsUtilizing two separate retrospective observational cohorts, we conducted model development and validation using a machine learning algorithm with a convolutional neural network. The development cohort comprised 1445 pediatric patients with 1977 medical encounters admitted to intensive care units from January 2011 to December 2017 at Severance Hospital (Seoul, Korea). The validation cohort included 278 patients with 364 medical encounters admitted to the pediatric intensive care unit from January 2016 to November 2017 at Samsung Medical Center.ResultsUsing seven vital signs, along with patient age and body weight on intensive care unit admission, PROMPT achieved an area under the receiver operating characteristic curve in the range of 0.89–0.97 for mortality prediction 6 to 60 h prior to death. Our results demonstrated that PROMPT provided high sensitivity with specificity and outperformed the conventional severity scoring system, the Pediatric Index of Mortality, in predictive ability. Model performance was indistinguishable between the development and validation cohorts.ConclusionsPROMPT is a deep model-based, data-driven early warning score tool that can predict mortality in critically ill children and may be useful for the timely identification of deteriorating patients.

Admission Hyperoxia Is a Risk Factor for Mortality in Pediatric Intensive Care.

To determine whether the association between hyperoxia and increased risk-adjusted mortality in adult intensive care patients is also observed in a pediatric intensive care population. Single-center retrospective analysis of admissions to ICU over a 5-year period commencing January 1, 2012, examining the relationship between PaO2 measured within the first hour of admission and risk-adjusted mortality. Standardized mortality rates were calculated using the Pediatric Index of Mortality-3, and patients were grouped into 50 mm Hg (6.67 kPa) PaO2 bands to assess the relationship between initial PaO2 and risk-adjusted mortality. Tertiary PICU with 17 beds and 1,100 annual admissions located in metropolitan Sydney, Australia. A total of 1,447 patients 0-18 years old with PaO2 recorded at admission to the ICU. None. There were 5,176 patients admitted to the ICU during the study period and 1,447 (28%) with PaO2 recorded at admission. A U-shaped relationship between raw mortality and admission PaO2 was observed, with lowest mortality (2.3% and 2.6%, respectively) observed in the 101-150 (13.5-20.0 kPa) and 151-200 mm Hg (20.1-26.7 kPa) bands and the highest mortality observed in patients with PaO2 less than 50 mm Hg (6.67 kPa) with mortality of 5.3%, or greater than 350 mm Hg (46.7 kPa) with mortality of 18.2%. Hyperoxia at admission was associated with an increase in risk-adjusted mortality, with polynomial regression indicating a strong correlation between PaO2 band and risk-adjusted outcome (r = 0.845). When included in a multivariate model that included the Pediatric Index of Mortality-3 variables, the odds ratio for hyperoxia (defined as PaO2 > 250 mm Hg [33.3 kPa]) predicting death was 2.66 (p = 0.047). In this single-center study, hyperoxia at admission to the PICU was highly correlated with increased risk-adjusted mortality. Further investigation of these observations in a large multicenter cohort is warranted.

Admission hyperoxia is a risk factor for mortality in pediatric intensive care

目的 了解成人ICU中高氧血症和风险校正病死率升高之间的关系是否也见于PICU。 设计 单中心回顾性分析自2012年1月1日起5年间ICU住院患儿入院1 h内所测PaO2和风险校正病死率的关系。采用儿童死亡指数(pediatric index of mortality，PIM-3)计算标准化病死率(standardized mortality rates，SMR)。患儿按50 mmHg(6.67 kPa，1 mmHg＝0.133 kPa) PaO2分组以评估初始PaO2与风险校正病死率间的关系。场所 位于澳大利亚悉尼，拥有17个床位且年收治患儿1 100例的三级PICU。1 447例于PICU入院时记录PaO2的0～18岁患儿。 对象 1 447例于PICU入院时记录PaO2的0～18岁患儿。 干预措施 无 测量方法及主要结果 研究期间PICU入院患儿5 176例，其中1 447例(28%)具有入院PaO2记录。未校正病死率与入院PaO2 U型相关，101～150 mmHg (13.5～20.0 kPa)及151～200 mmHg(20.1～26.7 kPa)时病死率最低(分别为2.3%及2.6%)，PaO2 350 mmHg(46.7 kPa)时病死率最高(分别为5.3%及18.2%)。入院时高氧血症与风险校正病死率升高有关，多因素回归显示PaO2区间与风险校正预后显著相关(r＝0.845)。包括PIM-3的多因素模型显示高氧血症(定义为PaO2>250 mmHg，333 kPa)预测死亡优势比为2.66(P＝0.047)。 结论 本单中心研究显示PICU入院高氧血症与风险校正病死率升高显著相关。需要在大规模多中心群体中进一步调查研究这一关系。

Prognostic value of rise in neutrophil to lymphocyte ratio and platelet to lymphocyte ratio in predicting the mortality in pediatric intensive care

Objective: To assess the prognostic value of rise in NLR and PLR in pediatric intensive care as markers of mortality. Materials and methods: A retrospective study based on 2 year data from HIMS and G-HEALTH data systems of AJ Institute of Medical Science, of all patients admitted to PICU after excluding those in whom all the study parameters were not retrievable. NLR and PLR ratios were determined and compared to PELOD 2 using SPSS version 17.0 Results: The demographic data was matched, the median NLR rise was 0.175 (IQR 1.714) while for PLR rise was 4.623 (IQR 85.533). PELOD 2 predicted mortality in 72.2% of the patients, while NLR increase predicted in 64.11% and PLR increase in 77.77%. A decreasing trend in NLR and PLR were both closely related to lesser length of stay in hospital and better survival. Conclusion: The study gives an insight into the fact that simple and inexpensive markers such as rise in NLR and PLR helps in predicting the mortality in the pediatric intensive care which is comparable to PELOD scoring.

Admission Plasma Troponin I Is Associated With Mortality in Pediatric Intensive Care.

Assessment of whether admission plasma troponin I level is associated with mortality or requirement for vasoactive drugs in pediatric intensive care. Retrospective cohort study. Single centre, tertiary referral general PICU, without a cardiac surgical program. Three hundred and nineteen patients 0-18 years old in two cohorts. Cohort 1 was admitted between January 2009 and September 2012 and the cohort 2 between April 2014 and April 2015. None. Plasma troponin I was measured in patients in cohort 1 only if the attending physician ordered the test due to clinical concern regarding myocardial injury. The second cohort had plasma troponin I routinely measured at admission. The primary outcome was death during PICU admission, and the secondary outcome was maximum inotrope requirement during PICU stay, measured by Vasoactive Inotrope Score. Plasma troponin I was a discriminator for mortality in both cohorts (area under the receiver-operating characteristic curve of 0.73 and 0.86 in cohorts 1 and 2, respectively). In an adjusted analysis using Cox regression, accounting for Pediatric Index of Mortality 2 risk of mortality and age, elevated plasma troponin I was significantly associated with death in both cohorts (hazard ratio, 4.99; p = 0.033; hazard ratio, 10.5; p = 0.026 in cohorts 1 and 2, respectively). Elevated plasma troponin I was only associated with increased Vasoactive Inotrope Score following multivariate analysis in the cohort 2. Detectable plasma troponin I at admission to PICU is independently associated with death. The utility of troponin I as a stratification biomarker requires further evaluation.

Role of extracellular histones in sepsis

Sepsis is a common desease with a high mortality in pediatric intensive care unit.The pathogenesis of sepsis remains unclear.Recent studies have found that extracellular histones play an important role in the incidence of sepsis.This review provides new ideas for the diagnosis and treatment of sepsis. Key words: Extracellular histones; Sepsis; Inflammation; Coagulation

The Use and Evaluation of Pediatric Index of Mortality and Pediatric Risk of Mortality in Pediatric Intensive Care

The Use and Evaluation of Pediatric Index of Mortality and Pediatric Risk of Mortality in Pediatric Intensive Care

Effects of Out-of-Hours and Winter Admissions and Number of Patients per Unit on Mortality in Pediatric Intensive Care

To investigate the effect of out-of-hours and winter admissions, and unit size on risk adjusted mortality in pediatric intensive care. A national pediatric intensive care clinical audit provided data on over 86000 admissions to 29 pediatric intensive care units (2006-2011). Multivariate logistic regression modeled risk adjusted mortality prior to discharge with out-of-hours (night, weekend, public holiday) admissions, admissions per unit, winter admission, and potential confounders, overall and separately for emergency and planned admissions. Nearly one-half (47.1%) of admissions were out-of-hours (n = 40948) and 79.2% of those were emergencies. Mortality for all out-of-hours admissions was raised (OR 1.1; 95% CI 1.02-1.2; P = .013), accounted for by planned admissions (OR 1.99; 95% CI 1.67-2.37; P < .001) compared with a reduced risk for emergency admissions (OR 0.93; 95% CI 0.86-1.1; P = .07). Winter admissions were associated with increased risk. Unit size did not affect mortality. A child admitted to pediatric intensive care as an out-of-hours emergency is not at increased risk of dying compared with a weekday daytime admission, indicating pediatric intensive care units provide consistent quality of care around the clock. Excess mortality in planned out-of-hours admissions may be explained by admissions following complex operations where risk-adjustment models underestimate the true probability of mortality. In winter, a time of seasonally high bed occupancy, there was an increased mortality risk, an effect which requires further investigation. Despite the different characteristics of small units, the absence of any effect of unit size on mortality suggests that number of admissions per unit does not influence standards of care.

Extremes of weight centile are associated with increased risk of mortality in pediatric intensive care

IntroductionAlthough numerous studies have linked extremes of weight with poor outcome in adult intensive care patients, the effect of weight on intensive care outcome has not previously been reported in the pediatric population. The aim of this study was to investigate the relationship between admission weight centile and risk-adjusted mortality in pediatric intensive care patients.MethodsData were collected on 6337 consecutively admitted patients over an 8.5 year period in a 15 bed pediatric intensive care unit (ICU) located in a university-affiliated tertiary referral children's hospital. A weight centile variable was entered into a multivariate logistic regression model that included all other pediatric index of mortality (PIM-2) variables, in order to determine whether weight centile was an independent risk factor for mortality.ResultsWeight centile was associated with mortality in both univariate and multivariate analysis, with the lowest mortality being associated with weights on the 75th centile and increasing symmetrically around this nadir. A transformed weight centile variable (absolute value of weight centile-75) was independently associated with mortality (odds ratio 1.02, P = 0.000) when entered into a multivariate logistic regression model that included the PIM-2 variables.ConclusionsIn this single-center cohort, weight centile was an independent risk factor for mortality in the ICU, with mortality increasing for patients at either end of the weight spectrum. These observations suggest that the accuracy of mortality prediction algorithms may be improved by inclusion of weight centile in the models. A prospective multicenter study should be undertaken to confirm our findings.

Glucose control, organ failure, and mortality in pediatric intensive care*

In ventilated children, to determine the prevalence of hyperglycemia, establish whether it is associated with organ failure, and document glycemic control practices in Australasian pediatric intensive care units (PICUs). Prospective inception cohort study. All nine specialist PICUs in Australia and New Zealand. Children ventilated > 12 hrs excluding those with diabetic ketoacidosis, on home ventilation, undergoing active cardiopulmonary resuscitation on admission, or with do-not-resuscitate orders. None. All blood glucose measurements for up to 14 days, clinical and laboratory values needed to calculate Paediatric Logistic Organ Dysfunction (PELOD) scores, and insulin use were recorded in 409 patients. Fifty percent of glucose measurements were > 6.1 mmol/L, with 89% of patients having peak values > 6.1 mmol/L. The median time to peak blood glucose was 7 hrs. Hyperglycemia was defined by area under the glucose-time curve > 6.1 mmol/L above the sample median. Thirteen percent of hyperglycemic subjects died vs. 3% of nonhyperglycemic subjects. There was an independent association between hyperglycemia and a PELOD score > or = 10 (odds ratio 3.41, 95% confidence interval 1.91-6.10) and death (odds ratio 3.31, 95% confidence interval 1.26-7.7). Early hyperglycemia, defined using only glucose data in the first 48 hrs, was also associated with these outcomes but not with PELOD > or = 10 after day 2 or with worsening PELOD after day 1. Five percent of patients received insulin. Hyperglycemia is common in PICUs, occurs early, and is independently associated with organ failure and death. However, early hyperglycemia is not associated with later or worsening organ failure. Australasian PICUs seldom use insulin.

After-hours admissions are not associated with increased risk-adjusted mortality in pediatric intensive care

To examine the influence of time of admission on risk-adjusted mortality and length of stay for nonelective patients admitted to a pediatric intensive care unit (ICU) without 24-h per day in-house intensivist coverage. Data analyzed came from a comprehensive, prospectively collected ICU database. A 12-bed pediatric ICU located in a university-affiliated tertiary referral children's hospital. Subjects consisted of 4,456 consecutive nonelective patients admitted over a 10-year period (1997-2006). None. Patients were categorized according to time of admission to the ICU as either in-hours (0800-1800 Monday-Friday and 0800-1200 on weekends), when an intensivist is present in the ICU, or after-hours (all other times), when intensivists attend only on an as-needed basis. Multivariate logistic regression was used to assess the effect of time of admission on outcome after adjustment for severity of illness using the Paediatric Index of Mortality (PIM). Patients admitted after hours had a lower risk-adjusted mortality than those admitted during normal working hours, with an odds ratio for death of 0.712 (95% confidence interval 0.518-0.980, p = 0.037). Length of stay was also significantly shorter for patients admitted after hours (44.05h vs. 50.0h, p = 0.001). A lack of in-house intensivist presence is not associated with any increase in mortality or length of stay for patients admitted to our pediatric ICU; on the contrary, after-hours admission in this cohort was associated with a decreased risk-adjusted mortality and a shorter length of stay.