PICU Mortality Research Articles

Abstract P-615: POST-EXTUBATION USE OF NON-INVASIVE VENTILATION IN CHILDREN- A RANDOMIZED CONTROLLED TRIAL

Aims & Objectives: The present investigation was to study the effect of elective use NIV on reintubation, length of stay (LOS) in PICU and hospital and mortality after extubation. Methods Over 12 months all patients on invasive mechanical ventilation (IMV) for >48 hrs were enrolled after successful weaning. Patients were randomized immediately before extubation to receive NIV or O2 therapy. All cases were monitored for increased work of breathing and blood gases were obtained at 2, 6 and 24 hours post extubation. Results 97 patients were randomized, 46 received NIV (BIPAP mode, Drager Evita) and 51 received O2 by simple mask. SpO2 was maintained>92%. The primary disease, PRISM scores at 12 (8.4 ± 7.2 vs 8.9 ± 6.9, p value 0.6) and 24 (9.3 ± 8 vs 8.8 ± 7, p value 0.9) hrs and duration of MV prior to extubation (4.5 ± 3.7 vs 4.3 ± 3.4 days, p value 0.7) were not significantly different in two study groups. Out of 97 patients, 19 (19.7%) patients were re-intubated within 48 hours of extubation, 13(25%) patients belonged to O2 group and 6(13%) were in NIV group (p value- 0.12). The post extubation durations of PICU (4.18 ± 2.9 vs 3.67 ± 2.5 days, p value 0.4) and hospital stay (18 ± 9 vs 17.2 ± 12.3 days, p value 0.3) were not significantly different in two study groups. There were two deaths, one in each study group. Conclusions NIV did not show benefits over oxygen therapy in immediate post extubation state in children.

Abstract PD-015: BALANCED SALT SOLUTION VERSUS NORMAL SALINE IN RESUSCITATION OF PEDIATRIC SEPSIS: A RANDOMIZED CONTROL TRIAL

Aims & Objectives: Rationale Pediatric sepsis is the leading cause of PICU admissions and mortality. Current evidences in resuscitation of adult sepsis pointed to the importance of types of crystalloid and fluid-related complication on resuscitation outcomes, but evidences are lacking in pediatric populations. Objectives To compare the outcomes of pediatric sepsis resuscitation with different types of crystalloid fluid. Methods We randomly assigned the participants into 3 groups to received NSS, RLS or Sterofundin as bolus fluid therapy. Other standard of cares were continued with primary care physicians’ judgment. Data were analysed using SPSS version 22. Results 31 patients were included into the study. Median age 33 mo. (IQR 21 – 60), PELODS-II score at 5 pts. (IQR 1 – 7), PRISM-III score at 5 pts. (IQR 2 – 9 pts.). Median dose of resuscitation fluid was 30 mL/kg (IQR 20 – 40). Baseline demographic data were not significantly different between 3 groups. After resuscitation, acid-base status parameters and fluid-related complications were not significantly different among groups. Subgroup analysis of patients received bolus fluid ≥ 30 mL/kg showed significant better lactate clearance after 24 hrs. in RLS group (p-value 0.046). Mortality, ventilator days, PICU & hospital LOS were not different between groups. Conclusions Resuscitation of pediatric sepsis with RLS when dosing ≥ 30 mL/kg, comparing with NSS, resulted in significant better lactate clearance at 24 hrs. after resuscitation. Balanced salt solution were not associated with significantly different rate of fluid-related complications.

Long-term Mortality After Acute Kidney Injury in the Pediatric ICU.

(1) To evaluate the association between acute kidney injury (AKI) in the PICU and long-term mortality and (2) to determine the extent to which adding the urine output (UO)-defined AKI alters the association. A 2-center retrospective cohort study of children (≤18 years old) admitted to the PICU between 2003 and 2005 for noncardiac surgery, with follow-up until 2010. Patients with end stage renal disease, no provincial health insurance number, who died during hospitalization, or could not be linked to administrative data were excluded. One hospitalization per patient was included. AKI was defined by using serum creatinine criteria and/or UO criteria. Mortality was ascertained by using administrative data. Cox regression analysis was performed to evaluate the association between AKI and long-term mortality. The study population included 2041 patients (55.7% male, mean admission age 6.5 ± 5.8 years). Of 2041 hospital survivors, 9 (0.4%) died within 30 days, 51 (2.5%) died within 1 year, and 118 (5.8%) died within 5 to 7 years postdischarge. AKI was independently associated with 5- to 7-year mortality (adjusted hazard ratio [95% confidence interval]: 3.10 [1.46-6.57] and 3.38 [1.63-7.02], respectively). Including UO did not strengthen the association. AKI is associated with 5- to 7-year mortality. Because this is an observational study we cannot determine if AKI is causative of mortality or of the pathophysiology. However, patients with AKI represent a high-risk group. It is reasonable that these patients be considered for targeted follow-up until future researchers better elucidate these relationships.

PRISM Score as predictor of mortality in PICU

Background: Since decades there has been growth in pediatric critical care hence there is a need to have a standard way of assessing severity of illness and the risk of mortality. PRISM score is based on the physiological derangement by disease process which is determined within 24 hrs of admission and includes 14 variables including clinical and laboratory measures. The score has been found to have good assessment of the risk of mortality Aims: to determine the relationship between mortality & different PRISM scores. The present study aims at PICU admissions with sample size of 100.Methodology: An observational prospective study was carried out at a tertiary care center in Moradabad Uttar Pradesh targeting children aged 1 month to 12 years in PICU. A thorough and focused clinical examination was done and blood samples were drawn within 24 hrs of admission to assess the PRISM score variables.Results: A total of 100 children between 6months to 12 years with a median of 10 months were enrolled into the study between the months of January 2018 and march 2018. 90% deaths were noted with score more than 39 as compared to 35% with PRISM score of 20-29. Conclusion- there is increased in number of deaths score with increasing PRISM score.

Clinical profile and outcomes of children with Hemophagocytic Lymphohistiocytosis (HLH) in the PICU of a tertiary care children’s hospital

Background : Hemophagocytic Lymphohistiocytosis (HLH) is a life-threatening syndrome of immune dysregulation leading to excessive cytokine production and multi-organ dysfunction. The Incidence of HLH varies between 1 per 5,000 to 1 per 1,00,000 in different studies. Diagnosis of HLH requires high suspicion as severe sepsis with organ dysfunction is a close differential. Differentiation of primary & secondary HLH is also difficult. Early recognition is very important for the timely institution of the treatment Methods : We conducted a retrospective analysis of children admitted to the PICU between January 2007 to July 2017 who were diagnosed to have HLH using HLH-2004 criteria. Demographic, clinical & laboratory parameters, treatment details & outcomes were recorded. Outcomes of secondary HLH treated with cytotoxic chemotherapy were compared with those treated with immuno-modulatory therapy alone. Results : Out of 6678 children admitted to the PICU during the study period, 47 were diagnosed with HLH. Ten children had primary HLH and 37 had secondary HLH. Forty two (89%) children had fever, 40 (85%) splenomegaly, 43 (91%) bicytopenia, 45 (95%) hyperferritinemia, 41 (87%) hemophagocytosis in the bone marrow, 44 (93%) low fibrinogen levels and 32 (68%) had high triglyceride levels. Among those with primary HLH, 6 were familial and 4 were immunodeficiency related. Mutation analysis by next generation sequencing was positive in 2 children with familial HLH. In our analysis, the different aetiologies for secondary HLH were Dengue (12 patients), Epstein Barr Virus (6 patients), Scrub typhus, Staphylococcus aureus, Sphingomonas, Typhoid and Adenovirus (each 1 patient) and the rest (14 patients) had culture negative sepsis. The overall PICU mortality rate was 55.3%. Mortality rate of primary HLH was 80% when compared to 48.6% in secondary HLH. In children with secondary HLH, 14 were treated with corticosteroids & Intravenous Immune Globulin (IVIG) only (immune-modulatory therapy group) and the remaining 27 children received Steroids, Etoposide, Cyclosporine +/- IVIG (Cytotoxic chemotherapy group). Mortality was higher in children with secondary HLH who received cytotoxic chemotherapy (52%) when compared to immunomodulatory therapy (28%) alone. Conclusion : The incidence of HLH in this population of critically ill children (7/1000) is higher than those reported elsewhere. Secondary HLH was more common than primary. Outcomes of secondary HLH were better in those treated with Immunomodulatory therapy alone.

The Relationship Between Remoteness and Outcomes in Critically Ill Children.

A significant number of children live in remote geographic areas without direct access to tertiary care PICU. Our objective was to explore the relationship between remoteness and outcomes of critically ill children in Canada. Retrospective cohort study of patients admitted to the PICU from February 1, 2015, to January 31, 2016. Pediatric tertiary care PICU in Canada. All children admitted to PICU during the study period. None MEASUREMENTS AND MAIN RESULTS:: Four hundred fifty-five unique PICU admissions were included. One hundred sixty-nine patients were transported from another center of whom 28 lived in remote areas. For transported patients, remoteness (hazard ratio, 2.76, p < 0.001; hazard ratio, 2.22, p = 0.006), admission Pediatric Risk of Mortality (hazard ratio, 1.11; p = 0.001; hazard ratio, 1.05, p = 0.016), and transport by a noncritical care trained team (hazard ratio, 0.61, p = 0.021; hazard ratio, 0.66, p = 0.045) were associated with increased PICU and hospital lengths of stay, respectively. PICU mortality increased with duration of transport (odds ratio, 1.46; 95% CI, 1.09-1.97; p = 0.012). The odds of a remote-area patient being refused admission during the winter were significantly higher (odds ratio, 8.2; 95% CI, 3.0-22.3; p < 0.001) than a patient not requiring transport. Admission Pediatric Risk of Mortality score (4, interquartile range, 1-8 vs 2, interquartile range, 0-5; p = 0.001) and mortality rate (7.1%, 12/169 vs 0%, 0/286; p < 0.001) were significantly higher for transported than for nontransported patients. Remoteness was associated with increased PICU and hospital length of stay, and duration of transport was associated with higher admission Pediatric Risk of Mortality (PRISM) scores and mortality rates. Patients requiring transport had a significantly higher PICU mortality rate than those presenting directly to a tertiary care center. Further studies are needed to explore potential policy and healthcare resource implications of these findings.

Risk Stratification in Pediatric Acute Respiratory Distress Syndrome: A Multicenter Observational Study.

The Pediatric Acute Lung Injury Consensus Conference developed a pediatric specific definition for acute respiratory distress syndrome (PARDS). In this definition, severity of lung disease is stratified into mild, moderate, and severe groups. We aim to describe the epidemiology of patients with PARDS across Asia and evaluate whether the Pediatric Acute Lung Injury Consensus Conference risk stratification accurately predicts outcome in PARDS. A multicenter, retrospective, descriptive cohort study. Ten multidisciplinary PICUs in Asia. All mechanically ventilated children meeting the Pediatric Acute Lung Injury Consensus Conference criteria for PARDS between 2009 and 2015. None. Data on epidemiology, ventilation, adjunct therapies, and clinical outcomes were collected. Patients were followed for 100 days post diagnosis of PARDS. A total of 373 patients were included. There were 89 (23.9%), 149 (39.9%), and 135 (36.2%) patients with mild, moderate, and severe PARDS, respectively. The most common risk factor for PARDS was pneumonia/lower respiratory tract infection (309 [82.8%]). Higher category of severity of PARDS was associated with lower ventilator-free days (22 [17-25], 16 [0-23], 6 [0-19]; p < 0.001 for mild, moderate, and severe, respectively) and PICU free days (19 [11-24], 15 [0-22], 5 [0-20]; p < 0.001 for mild, moderate, and severe, respectively). Overall PICU mortality for PARDS was 113 of 373 (30.3%), and 100-day mortality was 126 of 317 (39.7%). After adjusting for site, presence of comorbidities and severity of illness in the multivariate Cox proportional hazard regression model, patients with moderate (hazard ratio, 1.88 [95% CI, 1.03-3.45]; p = 0.039) and severe PARDS (hazard ratio, 3.18 [95% CI, 1.68, 6.02]; p < 0.001) had higher risk of mortality compared with those with mild PARDS. Mortality from PARDS is high in Asia. The Pediatric Acute Lung Injury Consensus Conference definition of PARDS is a useful tool for risk stratification.

Time of Admission to the PICU and Mortality.

To evaluate for any association between time of admission to the PICU and mortality. Retrospective cohort study of admissions to PICUs in the Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database from 2009 to 2014. One hundred and twenty-nine PICUs in the United States. Patients less than 18 years old admitted to participating PICUs; excluding those post cardiac bypass. None. A total of 391,779 admissions were included with an observed PICU mortality of 2.31%. Overall mortality was highest for patients admitted from 07:00 to 07:59 (3.32%) and lowest for patients admitted from 14:00 to 14:59 (1.99%). The highest mortality on weekdays occurred for admissions from 08:00 to 08:59 (3.30%) and on weekends for admissions from 09:00 to 09:59 (4.66%). In multivariable regression, admission during the morning 06:00-09:59 and midday 10:00-13:59 were independently associated with PICU death when compared with the afternoon time period 14:00-17:59 (morning odds ratio, 1.15; 95% CI, 1.04-1.26; p = 0.006 and midday odds ratio, 1.09; 95% CI; 1.01-1.18; p = 0.03). When separated into weekday versus weekend admissions, only morning admissions were associated with increased odds of death on weekdays (odds ratio, 1.13; 95% CI, 1.01-1.27; p = 0.03), whereas weekend admissions during the morning (odds ratio, 1.33; 95% CI, 1.14-1.55; p = 0.004), midday (odds ratio, 1.27; 95% CI, 1.11-1.45; p = 0.0006), and afternoon (odds ratio, 1.17; 95% CI, 1.03-1.32; p = 0.01) were associated with increased risk of death when compared with weekday afternoons. Admission to the PICU during the morning period from 06:00 to 09:59 on weekdays and admission throughout the day on weekends (06:00-17:59) were independently associated with PICU death as compared to admission during weekday afternoons. Potential contributing factors deserving further study include handoffs of care, rounds, delays related to resource availability, or unrecognized patient deterioration prior to transfer.

Can the Pediatric Logistic Organ Dysfunction-2 Score on Day 1 Be Used in Clinical Criteria for Sepsis in Children?

A recent task force has proposed the use of Sequential Organ Failure Assessment in clinical criteria for sepsis in adults. We sought to evaluate the predictive validity for PICU mortality of the Pediatric Logistic Organ Dysfunction-2 and of the "quick" Pediatric Logistic Organ Dysfunction-2 scores on day 1 in children with suspected infection. Secondary analysis of the database used for the development and validation of the Pediatric Logistic Organ Dysfunction-2. Nine university-affiliated PICUs in Europe. Only children with hypotension-low systolic blood pressure or low mean blood pressure using age-adapted cutoffs-and lactatemia greater than 2 mmol/L were considered in shock. We developed the quick Pediatric Logistic Organ Dysfunction-2 score on day 1 including tachycardia, hypotension, and altered mentation (Glasgow < 11): one point for each variable (range, 0-3). Outcome was mortality at PICU discharge. Discrimination (Area under receiver operating characteristic curve-95% CI) and calibration (goodness of fit test) of the scores were studied. This study included 862 children with suspected infection (median age: 12.3 mo; mortality: n = 60 [7.0%]). Area under the curve of the Pediatric Logistic Organ Dysfunction-2 score on day 1 was 0.91 (0.86-0.96) in children with suspected infection, 0.88 (0.79-0.96) in those with low systolic blood pressure and hyperlactatemia, and 0.91 (0.85-0.97) in those with low mean blood pressure and hyperlactatemia; calibration p value was 0.03, 0.36, and 0.49, respectively. A Pediatric Logistic Organ Dysfunction-2 score on day 1 greater than or equal to 8 reflected an overall risk of mortality greater than or equal to 9.3% in children with suspected infection. Area under the curve of the quick Pediatric Logistic Organ Dysfunction-2 score on day 1 was 0.82 (0.76-0.87) with systolic blood pressure or mean blood pressure; calibration p value was 0.89 and 0.72, respectively. A score greater than or equal to 2 reflected a mortality risk greater than or equal to 19.8% with systolic blood pressure and greater than or equal to 15.9% with mean blood pressure. Among children admitted to PICU with suspected infection, Pediatric Logistic Organ Dysfunction-2 score on day 1 was highly predictive of PICU mortality suggesting its use to standardize definitions and diagnostic criteria of pediatric sepsis. Further studies are needed to determine the usefulness of the quick Pediatric Logistic Organ Dysfunction-2 score on day 1 outside of the PICU.

Repeated Critical Illness and Unplanned Readmissions Within 1 Year to PICUs.

To determine the occurrence rate of unplanned readmissions to PICUs within 1 year and examine risk factors associated with repeated readmission. Retrospective cohort analysis. Seventy-six North American PICUs that participated in the Virtual Pediatric Systems, LLC (VPS, LLC, Los Angeles, CA). Ninety-three thousand three hundred seventy-nine PICU patients discharged between 2009 and 2010. None. Index admissions and unplanned readmissions were characterized and their outcomes compared. Time-to-event analyses were performed to examine factors associated with readmission within 1 year. Eleven percent (10,233) of patients had 15,625 unplanned readmissions within 1 year to the same PICU; 3.4% had two or more readmissions. Readmissions had significantly higher PICU mortality and longer PICU length of stay, compared with index admissions (4.0% vs 2.5% and 2.5 vs 1.6 d; all p < 0.001). Median time to readmission was 30 days for all readmissions, 3.5 days for readmissions during the same hospitalization, and 66 days for different hospitalizations. Having more complex chronic conditions was associated with earlier readmission (adjusted hazard ratio, 2.9 for one complex chronic condition; hazard ratio, 4.8 for two complex chronic conditions; hazard ratio, 9.6 for three or more complex chronic conditions; all p < 0.001 compared no complex chronic condition). Most specific complex chronic condition conferred a greater risk of readmission, and some had considerably higher risk than others. Unplanned readmissions occurred in a sizable minority of PICU patients. Patients with complex chronic conditions and particular conditions were at much higher risk for readmission.

A Case-Control Analysis of Postoperative Fluid Balance and Mortality After Pediatric Cardiac Surgery.

A positive fluid balance after cardiac surgery may be associated with poor outcomes; however, previous studies looking at this association have been limited by the number of deaths in the study population. Our primary aim was to determine the relationship between postoperative cumulative fluid balance and mortality in cardiac surgical patients. Secondary aims were to study the association between fluid balance and duration of mechanical ventilation, intensive care and hospital length of stay. Case-control study. A 30-bed multidisciplinary PICU. All patients admitted to the PICU following cardiac surgery from 2010 to 2014. Deaths during PICU admission following cardiac surgery (cases) were matched 1:3 with children who survived to PICU discharge (controls) using the following criteria: age at surgery (within a 20% age range), Risk Adjusted Congenital Heart Surgery (RACHS-1) category, and year of admission. Of 1,996 eligible children, 46 died (2.3%) of whom 45 (98%) were successfully matched. Cumulative fluid balance on days 2 and 7 was not associated with PICU mortality. On multivariable analysis, factors associated with mortality were cardiopulmonary bypass time (per 10-min increase, odds ratio [95% CI], 1.06 [1.00-1.12]; p = 0.03), extracorporeal membrane oxygenation requirement within 3 days (46.6 [9.47-230.11]; p < 0.001), peak serum chloride (mmol/L) in the first 48 hours (1.12 [1.01-1.23]), and time to start peritoneal dialysis after surgery (in comparison to no peritoneal dialysis, odds ratio [95% CI] in those started on early peritoneal dialysis was 1.07 [0.33-3.41]; p = 0.90 and in late peritoneal dialysis 3.65 [1.21-10.99]; p = 0.02). Children with cumulative fluid balance greater than or equal to 5% by day 2 spent longer on mechanical ventilation (median [interquartile range], 211 hr [97-539] vs 93 hr [34-225]; p <0.001), in PICU (11 d [8-26] vs 6 [3-13]; p < 0.001) and in hospital (22 d [13-39] vs 14 d [8-30]; p = 0.001). Early fluid overload is not associated with mortality. However, it is associated with increased duration of mechanical ventilation and PICU length of stay. Early peritoneal dialysis commencement (compared with late peritoneal dialysis) after surgery was associated with decreased mortality.

Outcomes for Children Receiving Noninvasive Ventilation as the First-Line Mode of Mechanical Ventilation at Intensive Care Admission: A Propensity Score-Matched Cohort Study*

To compare outcomes of children receiving noninvasive ventilation with those receiving invasive ventilation as first-line mode of mechanical ventilation following unplanned intensive care admission. Propensity score-matched cohort study analyzing data prospectively collected by the Pediatric Intensive Care Audit Network over 8 years (2007-2014). Thirty-one PICUs in the United Kingdom and Ireland; twenty-one of whom submitted Pediatric Critical Care Minimum Dataset data for the entire study period. Children consecutively admitted to study PICUs. Planned admissions following surgery, unplanned admissions from other hospitals, those on chronic ventilation, and those who did not receive mechanical ventilation on the day of PICU admission were excluded. Use of noninvasive ventilation, rather than invasive ventilation, as the first-line mode of mechanical ventilation. PICU mortality, length of ventilation, length of PICU stay, and ventilator-free days at day 28. During the study period, there were 151,128 PICU admissions. A total of 15,144 admissions (10%) were eligible for analysis once predefined exclusion criteria were applied: 4,804 (31.7%) received "noninvasive ventilation first," whereas 10,221 (67.5%) received "invasive ventilation first"; 119 (0.8%) admissions could not be classified. Admitting PICU site explained 6.5% of the variation in first-line mechanical ventilation group (95% CI, 2.0-19.0%). In propensity score-matched analyses, receiving noninvasive ventilation first was associated with a significant reduction in mortality by 3.1% (95% CI, 1.7-4.6%), length of ventilation by 1.6 days (95% CI, 1.0-2.3), and length of PICU stay by 2.1 days (95% CI, 1.3-3.0), as well as an increase in ventilator-free days at day 28 by 3.7 days (95% CI, 3.1-4.3). Use of noninvasive ventilation as first-line mode of mechanical ventilation in critically ill children admitted to PICU in an unplanned fashion may be associated with significant clinical benefits. Further high-quality evidence regarding optimal patient selection and timing of initiation of noninvasive ventilation could lead to less variability in clinical care between institutions and improved patient outcomes.

Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes.

Tracheal intubation in PICUs is a common procedure often associated with adverse events. The aim of this study is to evaluate the association between immediate events such as tracheal intubation associated events or desaturation and ICU outcomes: length of stay, duration of mechanical ventilation, and mortality. Prospective cohort study with 35 PICUs using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from January 2013 to June 2015. Desaturation defined as Spo2 less than 80%. PICUs participating in NEAR4KIDS. All patients less than18 years of age undergoing primary tracheal intubations with ICU outcome data were analyzed. Five thousand five hundred four tracheal intubation encounters with median 108 (interquartile range, 58-229) tracheal intubations per site. At least one tracheal intubation associated event was reported in 892 (16%), with 364 (6.6%) severe tracheal intubation associated events. Infants had a higher frequency of tracheal intubation associated event or desaturation than older patients (48% infants vs 34% for 1-7 yr and 18% for 8-17 yr). In univariate analysis, the occurrence of tracheal intubation associated event or desaturation was associated with a longer mechanical ventilation (5 vs 3 d; p < 0.001) and longer PICU stay (14 vs 11 d; p < 0.001) but not with PICU mortality. The occurrence of severe tracheal intubation associated events was associated with longer mechanical ventilation (5 vs 4 d; p < 0.003), longer PICU stay (15 vs 12 d; p < 0.035), and PICU mortality (19.9% vs 9.6%; p < 0.0001). In multivariable analyses, the occurrence of tracheal intubation associated event or desaturation was significantly associated with longer mechanical ventilation (+12%; 95% CI, 4-21%; p = 0.004), and severe tracheal intubation associated events were independently associated with increased PICU mortality (OR = 1.80; 95% CI, 1.24-2.60; p = 0.002), after adjusted for patient confounders. Adverse tracheal intubation associated events and desaturations are common and associated with longer mechanical ventilation in critically ill children. Severe tracheal intubation associated events are associated with higher ICU mortality. Potential interventions to decrease tracheal intubation associated events and oxygen desaturation, such as tracheal intubation checklist, use of apneic oxygenation, and video laryngoscopy, may need to be considered to improve ICU outcomes.

Pediatric Acute Respiratory Distress Syndrome in Pediatric Allogeneic Hematopoietic Stem Cell Transplants: A Multicenter Study.

Immunodeficiency is both a preexisting condition and a risk factor for mortality in pediatric acute respiratory distress syndrome. We describe a series of pediatric allogeneic hematopoietic stem cell transplant patients with pediatric acute respiratory distress syndrome based on the recent Pediatric Acute Lung Injury Consensus Conference guidelines with the objective to better define survival of this population. Secondary analysis of a retrospective database. Twelve U.S. pediatric centers. Pediatric allogeneic hematopoietic stem cell transplant recipients requiring mechanical ventilation. None. During the first week of mechanical ventilation, patients were categorized as: no pediatric acute respiratory distress syndrome or mild, moderate, or severe pediatric acute respiratory distress syndrome based on oxygenation index or oxygen saturation index. Univariable logistic regression evaluated the association between pediatric acute respiratory distress syndrome and PICU mortality. A total of 91.5% of the 211 patients met criteria for pediatric acute respiratory distress syndrome using the Pediatric Acute Lung Injury Consensus Conference definition: 61.1% were severe, 27.5% moderate, and 11.4% mild. Overall survival was 39.3%. Survival decreased with worsening pediatric acute respiratory distress syndrome: no pediatric acute respiratory distress syndrome 66.7%, mild 63.6%, odds ratio = 1.1 (95% CI, 0.3-4.2; p = 0.84), moderate 52.8%, odds ratio = 1.8 (95% CI, 0.6-5.5; p = 0.31), and severe 24.6%, odds ratio = 6.1 (95% CI, 2.1-17.8; p < 0.001). Nonsurvivors were more likely to have multiple consecutive days at moderate and severe pediatric acute respiratory distress syndrome (p < 0.001). Moderate and severe patients had longer PICU length of stay (p = 0.01) and longer mechanical ventilation course (p = 0.02) when compared with those with mild or no pediatric acute respiratory distress syndrome. Nonsurvivors had a higher median maximum oxygenation index than survivors at 28.6 (interquartile range, 15.5-49.9) versus 15.0 (interquartile range, 8.4-29.6) (p < 0.0001). In this multicenter cohort, the majority of pediatric allogeneic hematopoietic stem cell transplant patients with respiratory failure met oxygenation criteria for pediatric acute respiratory distress syndrome based on the Pediatric Acute Lung Injury Consensus Conference definition within the first week of invasive mechanical ventilation. Length of invasive mechanical ventilation, length of PICU stay, and mortality increased as the severity of pediatric acute respiratory distress syndrome worsened.

Pao 2/Fio 2 Ratio Derived From the Spo 2/Fio 2 Ratio to Improve Mortality Prediction Using the Pediatric Index of Mortality-3 Score in Transported Intensive Care Admissions*

To derive a relationship between the SpO2/FIO2 ratio and PaO2/FIO2 ratio across the entire range of SpO2 values (0-100%) and to evaluate whether mortality prediction using the Pediatric Index of Mortality-3 can be improved by the use of PaO2/FIO2 values derived from SpO2/FIO2. Retrospective analysis of prospectively collected data. A regional PICU transport service. Children transported to a PICU. None. The relationship between SpO2/FIO2 and PaO2/FIO2 across the entire range of SpO2 values was first studied using several mathematical models in a derivation cohort (n = 1,235) and then validated in a separate cohort (n = 306). The best SpO2/FIO2-PaO2/FIO2 relationship was chosen according to the ability to detect respiratory failure (PaO2/FIO2 ≤ 200). The discrimination of the original Pediatric Index of Mortality-3 score and a derived Pediatric Index of Mortality-3 score (where SpO2/FIO2-derived PaO2/FIO2 values were used in place of missing PaO2/FIO2 values) were compared in a different cohort (n = 1,205). The best SpO2/FIO2-PaO2/FIO2 relationship in 1,703 SpO2/FIO2-to-PaO2/FIO2 data pairs was a linear regression equation of ln[PF] regressed on ln[SF]. This equation identified children with a PaO2/FIO2 less than or equal to 200 with a specificity of 73% and sensitivity of 61% in children with SpO2 less than 97% (92% and 33%, respectively, when SpO2 ≥ 97%) in the validation cohort. PaO2/FIO2 derived from SpO2/FIO2 (derived PaO2/FIO2) was better at predicting PICU mortality (area under receiver operating characteristic curve, 0.64; 95% CI, 0.55-0.73) compared with the original PaO2/FIO2 (area under receiver operating characteristic curve, 0.54; 95% CI, 0.49-0.59; p = 0.02). However, there was no difference in the original and derived Pediatric Index of Mortality-3 scores and their discriminatory ability for mortality. SpO2-based metrics perform no worse than arterial blood gas-based metrics in mortality prediction models. Future Pediatric Index of Mortality score versions may be improved by the inclusion of risk factors based on oxygen saturation values, especially in settings where PaO2 values are missing in a significant proportion of cases.

The Impact of Chronic Health Conditions on Length of Stay and Mortality in a General PICU.

Each year approximately 20,000 children are admitted to PICUs across the United Kingdom. It is highlighted in several international studies that 40-70% of children admitted to PICUs have at least one chronic health condition that leads to increased length of stay and higher mortality rates. The prevalence of chronic health conditions in children admitted to U.K. PICUs is unknown. The purpose of this study was to use existing clinical data to explore the prevalence and impact of chronic health conditions on length of stay and mortality in a tertiary U.K. PICU. Single-centre retrospective observational cohort study. Single, tertiary referral PICU. One thousand one hundred ninety-seven children 0-18 years old admitted between March 1, 2009, and February 28, 2013. None. Data were derived from the unit's data submitted to the Paediatric Intensive Care Audit Network, the U.K. national PICU dataset. Data included demographics, diagnosis, Pediatric Index of Mortality-2 score, PICU interventions, PICU outcomes, chronic health condition etiologies, admission, and discharge dates and times. In total, 554 of 1,197 (46.3%) had at least one chronic health condition. Of 554, 371 patients (67.1%) presented with a single chronic health condition, 126 (22.6%) with two chronic health conditions, and 57 (10.3%) with at least three chronic health conditions to a maximum of four chronic health conditions. There was a statistically significant difference in length of stay in those with a chronic health condition compared with those without (medians, 4 vs 3 d [interquartile range, 1-7 d]; Mann-Whitney U test, p < 0.001). The length of stay also increased significantly according to the number of chronic health conditions (Kruskal-Wallis test, p < 0.001). Mortality was significantly different between those with and without chronic health conditions (8.8% vs 5.4%; chi-square test, p = 0.024). Having two or at least three chronic health conditions significantly increased mortality compared with no chronic health conditions (odds ratio, 2.3 [CI, 1.2-4.55]; p = 0.013 and 2.95 [CI, 1.28-6.8]; p = 0.011), respectively. The increasing number of chronic healthcare conditions is associated with length of stay and mortality.

The prevalence of hyperglycemia in critically ill children admitted in PICU

Background: Stress hyperglycemia is mainly due to increased gluconeogenesis and glycogenolysis & insulin resistance. Longer duration of hyperglycemia during hospital stay is known to have adverse outcome. Aim of Study: To study the prevalence of hyperglycemia and its association with PICU mortality and morbidity in terms of duration of PICU stay. Design: Prospective Observational study. Method: All critically ill children belonging to age group of 1 month to 14 years, admitted in PICU from 1st May 2011 to 15th September 2011 over a period of four and a half months. Children were followed throughout their hospital stay and outcome in terms of mortality and duration of PICU stay were noted. Blood glucose levels weredone every 3 hourly during the first 48 hours of PICU admission. Highest blood glucose level in the first 48 hours was defined as the peak glucose level. The mean of glucose values of first 24 and first 48 hours were calculated. Result: Prevalence of hyperglycemia was 58%. Mortality rate was higher in the hyperglycemic patients (56%) as compared to normoglycemics (14%) and overall mortality (36%). The p value for difference in the mean of peak RBS and 24 hours mean RBS of the non-survivors and survivors was <0.005 and hence significant. Statistical Analysis: Independent student t test used for analysis. Conclusion: Hyperglycemia during first 24 hours of PICU admission was associated with higher mortality rate and longer duration of PICU stay.

Nutritional support for critically ill children.

Nutritional support in the critically ill child has not been well investigated and is a controversial topic within paediatric intensive care. There are no clear guidelines as to the best form or timing of nutrition in critically ill infants and children. This is an update of a review that was originally published in 2009. . The objective of this review was to assess the impact of enteral and parenteral nutrition given in the first week of illness on clinically important outcomes in critically ill children. There were two primary hypotheses:1. the mortality rate of critically ill children fed enterally or parenterally is different to that of children who are given no nutrition;2. the mortality rate of critically ill children fed enterally is different to that of children fed parenterally.We planned to conduct subgroup analyses, pending available data, to examine whether the treatment effect was altered by:a. age (infants less than one year versus children greater than or equal to one year old);b. type of patient (medical, where purpose of admission to intensive care unit (ICU) is for medical illness (without surgical intervention immediately prior to admission), versus surgical, where purpose of admission to ICU is for postoperative care or care after trauma).We also proposed the following secondary hypotheses (a priori), pending other clinical trials becoming available, to examine nutrition more distinctly:3. the mortality rate is different in children who are given enteral nutrition alone versus enteral and parenteral combined;4. the mortality rate is different in children who are given both enteral feeds and parenteral nutrition versus no nutrition. In this updated review we searched: the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2); Ovid MEDLINE (1966 to February 2016); Ovid EMBASE (1988 to February 2016); OVID Evidence-Based Medicine Reviews; ISI Web of Science - Science Citation Index Expanded (1965 to February 2016); WebSPIRS Biological Abstracts (1969 to February 2016); and WebSPIRS CAB Abstracts (1972 to February 2016). We also searched trial registries, reviewed reference lists of all potentially relevant studies, handsearched relevant conference proceedings, and contacted experts in the area and manufacturers of enteral and parenteral nutrition products. We did not limit the search by language or publication status. We included studies if they were randomized controlled trials; involved paediatric patients, aged one day to 18 years of age, who were cared for in a paediatric intensive care unit setting (PICU) and had received nutrition within the first seven days of admission; and reported data for at least one of the pre-specified outcomes (30-day or PICU mortality; length of stay in PICU or hospital; number of ventilator days; and morbid complications, such as nosocomial infections). We excluded studies if they only reported nutritional outcomes, quality of life assessments, or economic implications. Furthermore, we did not address other areas of paediatric nutrition, such as immunonutrition and different routes of delivering enteral nutrition, in this review. Two authors independently screened the searches, applied the inclusion criteria, and performed 'Risk of bias' assessments. We resolved discrepancies through discussion and consensus. One author extracted data and a second checked data for accuracy and completeness. We graded the evidence based on the following domains: study limitations, consistency of effect, imprecision, indirectness, and publication bias. We identified only one trial as relevant. Seventy-seven children in intensive care with burns involving more than 25% of the total body surface area were randomized to either enteral nutrition within 24 hours or after at least 48 hours. No statistically significant differences were observed for mortality, sepsis, ventilator days, length of stay, unexpected adverse events, resting energy expenditure, nitrogen balance, or albumin levels. We assessed the trial as having unclear risk of bias. We consider the quality of the evidence to be very low due to there being only one small trial. In the most recent search update we identified a protocol for a relevant randomized controlled trial examining the impact of withholding early parenteral nutrition completing enteral nutrition in pediatric critically ill patients; no results have been published. There was only one randomized trial relevant to the review question. Research is urgently needed to identify best practices regarding the timing and forms of nutrition for critically ill infants and children.

Validation of a Pediatric Early Warning Score in Hospitalized Pediatric Oncology and Hematopoietic Stem Cell Transplant Patients.

To evaluate the correlation of a Pediatric Early Warning Score with unplanned transfer to the PICU in hospitalized oncology and hematopoietic stem cell transplant patients. We performed a retrospective matched case-control study, comparing the highest documented Pediatric Early Warning Score within 24 hours prior to unplanned PICU transfers in hospitalized pediatric oncology and hematopoietic stem cell transplant patients between September 2011 and December 2013. Controls were patients who remained on the inpatient unit and were matched 2:1 using age, condition (oncology vs hematopoietic stem cell transplant), and length of hospital stay. Pediatric Early Warning Scores were documented by nursing staff at least every 4 hours as part of routine care. Need for transfer was determined by a PICU physician called to evaluate the patient. A large tertiary/quaternary free-standing academic children's hospital. One hundred ten hospitalized pediatric oncology patients (42 oncology, 68 hematopoietic stem cell transplant) requiring unplanned PICU transfer and 220 matched controls. None. Using the highest score in the 24 hours prior to transfer for cases and a matched time period for controls, the Pediatric Early Warning Score was highly correlated with the need for PICU transfer overall (area under the receiver operating characteristic = 0.96), and in the oncology and hematopoietic stem cell transplant groups individually (area under the receiver operating characteristic = 0.95 and 0.96, respectively). The difference in Pediatric Early Warning Score results between the cases and controls was noted as early as 24 hours prior to PICU admission. Seventeen patients died (15.4%). Patients with higher Pediatric Early Warning Scores prior to transfer had increased PICU mortality (p = 0.028) and length of stay (p = 0.004). We demonstrate that our institution's Pediatric Early Warning Score is highly correlated with the need for unplanned PICU transfer in hospitalized oncology and hematopoietic stem cell transplant patients. Furthermore, we found an association between higher scores and PICU mortality. This is the first validation of a Pediatric Early Warning Score specific to the pediatric oncology and hematopoietic stem cell transplant populations, and supports the use of Pediatric Early Warning Scores as a method of early identification of clinical deterioration in this high-risk population.

Obesity and Mortality Risk in Critically Ill Children.

Childhood obesity is epidemic and may be associated with PICU mortality. Using a large multicenter PICU database, we investigated the association between obesity and PICU mortality, adjusting for initial severity of illness. We further investigated whether height- and weight-based classifications of obesity compared with a weight-based classification alone alter the mortality distribution. This retrospective analysis used prospectively collected data from the Virtual PICU Systems database. Height, weight, age, and gender were used to calculate z score groups based on Centers for Disease Control and Prevention and World Health Organization growth curves. A random effects mixed logistic regression model was used to evaluate the association between obesity and PICU mortality, controlling for hospital, initial severity of illness, and comorbidities. A total of 127,607 patients were included; the mortality rate was 2.48%. Being overweight was independently associated with increased PICU mortality after controlling for severity of illness with the Pediatric Index of Mortality 2 score and preexisting comorbidities. Mortality had a U-shaped distribution when classified according to weight-for-age or weight-for-height/BMI. When classifying patients using weight-for-age without respect to height, the nadir of the mortality curve was shifted, potentially falsely implying a benefit to mild obesity. Risk-adjusted PICU mortality significantly increases as weight-for-height/BMI increases into the overweight and obese ranges. We believe that height data are necessary to correctly classify body habitus; without such information, a protective benefit from mild obesity may be incorrectly concluded.