Pediatric Index Of Mortality Research Articles

Efficacy and Safety of Prolonged Magnesium Sulfate Infusions in Children With Refractory Status Asthmaticus.

ObjectivesThere is a paucity of data on the use of intravenous magnesium sulfate infusion in children with refractory status asthmaticus. The purpose of this study was to evaluate the efficacy and safety of prolonged magnesium sulfate infusion as an advanced therapy.MethodsThis is a single center retrospective study of children admitted to our pediatric intensive care unit (PICU) with status asthmaticus requiring continuous albuterol. Treatment group included patients receiving magnesium for ≥4 h and control group included those on other therapies only. Patients were matched 1:4 based on age, sex, obesity, pediatric index of mortality III and pediatric risk of mortality III scores. Primary outcomes included PICU length of stay (LOS) and mechanical ventilation (MV) requirement. Secondary outcomes included mortality, extracorporeal membrane oxygenation (ECMO) requirement, analyses of factors associated with PICU LOS and MV requirement and safety of magnesium infusion. Logistic and linear regressions were employed to determine factors associated with MV requirement and PICU LOS, respectively.ResultsTreatment and control groups included 27 and 108 patients, respectively. Median initial infusion rate was 15 mg/kg/hour, with median duration of 28 h. There was no difference in the MV requirement between the treatment and control groups [7 (25.9%) vs. 20 patients (18.5%), p = 0.39]. Median PICU LOS and ECMO use were significantly higher in treatment vs. control group [(3.63 vs. 1.09 days, p < 0.01) and (11.1 vs. 0%, p < 0.01), respectively]. No mortality difference was noted. On regression analysis, patients receiving ketamine and higher prednisone equivalent dosing had higher odds of MV requirement [OR 19.29 (95% CI 5.40–68.88), p < 0.01 and 1.099 (95% CI 1.03–1.17), p < 0.01, respectively]. Each mg/kg increase in prednisone equivalent dosing corresponded to an increase in PICU LOS by 0.13 days (95% CI 0.096–0.160, p < 0.01). Magnesium infusions were not associated with lower MV requirement or lower PICU LOS after controlling for covariates. Fourteen (51.9%) patients in the treatment group had an adverse event, hypotension being the most common.ConclusionMagnesium sulfate infusions were not associated with MV requirement, PICU LOS or mortality.

Acute kidney injury in COVID-19 pediatric patients in North America: Analysis of the virtual pediatric systems data.

Despite extensive research into acute kidney injury (AKI) in adults, research into the epidemiology, associated risk factors, treatment, and mortality of AKI in pediatric COVID-19 patients is understudied. Advancing understanding of this disease is crucial to further developing treatment and preventative care strategies to reduce morbidity and mortality. This is a retrospective analysis of 2,546 COVID-19 pediatric patients (age ≤ 21 years) who were admitted the ICU in North America. Analysis of the Virtual Pediatric Systems (VPS) COVID-19 database was conducted between January 1, 2020, and June 30, 2021. Out of a total of 2,546 COVID positive pediatric patients, 10.8% (n = 274) were diagnosed with AKI. Significantly higher continuous and categorical outcomes in the AKI subset compared to the non-AKI cohort included: length of stay at the hospital (LOS) [9.04 (5.11-16.66) vs. 5.09 (2.58-9.94) days], Pediatric Index of Mortality (PIM) 2 probability of death [1.20 (0.86-3.83) vs. 0.96 (0.79-1.72)], PIM 3 probability of death [0.98 (0.72-2.93) vs. 0.78 (0.69-1.26)], mortality [crude OR (95% CI): 5.01 (2.89-8.70)], airway and respiratory support [1.63 (1.27-2.10)], cardio-respiratory support [3.57 (1.55-8.23)], kidney support [12.52 (5.30-29.58)], and vascular access [4.84 (3.70-6.32)]. This is one of the first large scale studies to analyze AKI among pediatric COVID-19 patients admitted to the ICU in North America. Although the course of the COVID-19 virus appears milder in the pediatric population, renal complications may result, increasing the risk of disease complication and mortality.

Multisystem Inflammatory Syndrome in Children and Acute Kidney Injury: Retrospective Study of Five Italian PICUs.

Multisystem inflammatory syndrome in children (MIS-C) manifests with heart dysfunction and respiratory failure some weeks after a severe acute respiratory syndrome coronavirus disease 2 infection. The aim of our study was to explore the prevalence, severity, timing, and duration of acute kidney injury (AKI) in MIS-C patients. Furthermore, we evaluated which clinical variables and outcomes are associated with AKI. Multicenter retrospective study. Five tertiary hospital PICUs in Italy. Data were collected in the first 7 days of PICU admission and renal function was followed throughout the hospital stay. Patients less than 18 years old admitted to the PICU for greater than 24 hours with MIS-C. None. We collected the following data, including: demographic information, inflammatory biomarkers, lactate levels, Pa o2 /F io2 , ejection fraction, N-terminal pro-B-type natriuretic peptide (NT-proBNP), renal function (serum creatinine, urinary output, fluid balance, and percentage fluid accumulation), Vasoactive-Inotropic Score (VIS), pediatric Sequential Organ Failure Assessment (pSOFA), and Pediatric Index of Mortality 3. AKI was diagnosed in eight of 38 patients (21%) and severe AKI was present in four of eight patients. In all cases, AKI was present at PICU admission and its median (interquartile range) duration was 3.5 days (1.5-5.7 d). We did not identify differences between AKI and no-AKI patients when not making correction for multiple comparisons, for example, in weight, ejection fraction, pSOFA, Pa o2 /F io2 , and lactates. We failed to identify any difference in these groups in urine output and fluid balance. Exploratory analyses of serial data between no-AKI and AKI patients showed significant differences on lymphocyte count, NT-proBNP value, ejection fraction, pSOFA, Pa o2 /F io2 , and VIS. In this multicenter Italian PICU experience, MIS-C is associated with AKI in one-in-five cases. In general, AKI is characterized by an associated reduction in glomerular filtration rate with a self-limiting time course.

Internal validation and evaluation of the predictive performance of models based on the PRISM-3 (Pediatric Risk of Mortality) and PIM-3 (Pediatric Index of Mortality) scoring systems for predicting mortality in Pediatric Intensive Care Units (PICUs)

PurposeThe study was aimed to assess the prognostic power The Pediatric Risk of Mortality-3 (PRISM-3) and the Pediatric Index of Mortality-3 (PIM-3) to predict in-hospital mortality in a sample of patients admitted to the PICUs.Design and methodsThe study was performed to include all children younger than 18 years of age admitted to receive critical care in two hospitals, Mashhad, northeast of Iran from December 2017 to November 2018. The predictive performance was quantified in terms of the overall performance by measuring the Brier Score (BS) and standardized mortality ratio (SMR), discrimination by assessing the AUC, and calibration by applying the Hosmer-Lemeshow test.ResultsA total of 2446 patients with the median age of 4.2 months (56% male) were included in the study. The PICU and in-hospital mortality were 12.4 and 16.14%, respectively. The BS of the PRISM-3 and PIM-3 was 0.088 and 0.093 for PICU mortality and 0.108 and 0.113 for in-hospital mortality. For the entire sample, the SMR of the PRISM-3 and PIM-3 were 1.34 and 1.37 for PICU mortality and 1.73 and 1.78 for in-hospital mortality, respectively. The PRISM-3 demonstrated significantly higher discrimination power in comparison with the PIM-3 (AUC = 0.829 vs 0.745) for in-hospital mortality. (AUC = 0.779 vs 0.739) for in-hospital mortality. The HL test revealed poor calibration for both models in both outcomes.ConclusionsThe performance measures of PRISM-3 were better than PIM-3 in both PICU and in-hospital mortality. However, further recalibration and modification studies are required to improve the predictive power to a clinically acceptable level before daily clinical use.Practice implicationsThe calibration of the PRISM-3 model is more satisfactory than PIM-3, however both models have fair discrimination power.

Mortality and Factors Related in Pediatric Intensive Care Unit Patients Treated with Vancomycin

Abstract There is limited information available regarding clinical outcome and rate of mortality in relation to invasive methicillin-resistant Staphylococcus aureus (MRSA) infection in pediatric intensive care unit (PICU) patients treated with vancomycin in this tertiary hospital in northern Thailand. Therapeutic drug monitoring (TDM) is recommended vancomycin prescription; however, it is important to investigate the outcome of this monitoring in PICU patients. This study aims to evaluate the mortality and factors related to these in PICU patients treated with vancomycin. A retrospective study was conducted in PICU patients given vancomycin from April 2018 to April 2019. The following variables were included: age, sex, underlying disease, diagnosis, length of stay (LOS) in PICU, Pediatric Index of Mortality 2 (PIM 2) score, mechanical ventilator use, renal replacement therapy (RRT), laboratory data, vancomycin dose, trough serum vancomycin concentration (Ctrough) and mortality rate. One hundred and sixty pediatric patients were enrolled into the study (median age 12 months, range 2-180 months, 69.4% male). Ctrough of vancomycin (10–20 mg/L) was recorded in 32.5% (n = 52) of cases. Septic shock was the most common diagnosis (49.3%) and the mortality rate was 39.4%. Results indicated that children who had a vancomycin Ctrough outside the therapeutic range, mechanical ventilator use and RRT use were statistically significantly associated with higher mortality rate (adjusted OR 3.29, 95% CI, 1.41-7.69; P &lt;0.05), (adjusted OR 6.22, 95% CI, 1.67-23.16; P &lt; 0.05) and (adjusted OR 10.41, 95% CI, 2.62-41.37; P &lt; 0.05). These factors were related to mortality and further studies are needed to determine if this outcome can be improved. Keywords: Vancomycin, Vancomycin trough concentration, Pediatric patients, Intensive care, Mortality, Factors related to mortality

Analysis of Fluid Balance as Predictor of Length of Assisted Mechanical Ventilation in Children Admitted to Pediatric Intensive Care Unit (PICU).

Background Ventilator-associated lung injury (VALI) is a devastating complication of assisted mechanical ventilation (AMV) and is one of the root causes of prolonged AMV. Many strategies were made to decrease the effect of the same. This study is conducted to determine the association of prolonged AMV with fluid balance and pediatric index of mortality 2 (PIM2) score. Methods This prospective observational study was carried out in a PICU of a tertiary care centre over a period of 12 months. Patient's fluid balance was calculated by tabulating fluid input-output over initial 48 hours of AMV. The PIM2 score on admission was documented. The association between qualitative variables was assessed by a chi-square test. Comparison of quantitative data measured between cases with duration of AMV ≥ 7 days and <7 days was done using the Mann–Whitney U test. Correlation between quantitative data was done by using the Pearson product moment correlation. Results Out of 40 patients, 27 patients who had ≥15% positive fluid balance required prolonged mechanical ventilation. Similarly, 27 patients with PIM2 score ≥ 5 required prolonged AMV. On applying the Pearson chi-square test, we found a significant association between positive fluid balance and prolonged mechanical ventilation (P value = 2.25 × 10−7 (<0.05)). Likewise, a statistically significant association was found between PIM2 score and prolonged ventilation (P value = 1.19 × 10−5 (<0.05)). Conclusion There is a significant association of prolonged AMV with positive fluid balance (>15%) and PIM2 score (>5). By strict maintenance of fluid balance with appropriate intervention, the length of AMV and PICU stay can be decreased.

Predicting the Risk of Mortality in Children using a Fuzzy-Probabilistic Hybrid Model.

Introduction The mortality risk in children admitted to Pediatric Intensive Care Units (PICU) is usually estimated by means of validated scales, which only include objective data among their items. Human perceptions may also add relevant information to prognosticate the risk of death, and the tool to use this subjective data is fuzzy logic. The objective of our study was to develop a mathematical model to predict mortality risk based on the subjective perception of PICU staff and to evaluate its accuracy compared to validated scales. Methods A prospective observational study in two PICUs (one in Spain and another in Latvia) was performed. Children were consecutively included regardless of the cause of admission along a two-year period. A fuzzy set program was developed for the PICU staff to record the subjective assessment of the patients' mortality risk expressed through a short range and a long range, both between 0% and 100%. Pediatric Index of Mortality 2 (PIM2) and Therapeutic Intervention Scoring System 28 (TISS28) were also prospectively calculated for each patient. Subjective and objective predictions were compared using the logistic regression analysis. To assess the prognostication ability of the models a stratified B-random K-fold cross-validation was performed. Results Five hundred ninety-nine patients were included, 308 in Spain (293 survivors, 15 nonsurvivors) and 291 in Latvia (282 survivors, 9 nonsurvivors). The best logistic classification model for subjective information was the one based on MID (midpoint of the short range), whereas objective information was the one based on PIM2. Mortality estimation performance was 86.3% for PIM2, 92.6% for MID, and the combination of MID and PIM2 reached 96.4%. Conclusions Subjective assessment was as useful as validated scales to estimate the risk of mortality. A hybrid model including fuzzy information and probabilistic scales (PIM2) seems to increase the accuracy of prognosticating mortality in PICU.

Assessment of left and right ventricular Tei indices in critically ill children with septic shock

BackgroundChildren with septic shock are subjected to global myocardial dysfunction. Myocardial performance (Tei) index has been used to detect the combined systolic and diastolic ventricular function in adult and neonatal sepsis. ObjectivesAssessment of left and right ventricular Tei indices in critically ill children with septic shock treated with inotropes and/or vasoactive agents. MethodsNinety children with septic shock and 90 controls were examined by conventional echocardiography. Cardiac chamber dimensions, ejection fraction, cardiac index, left and right ventricular Tei indices were measured. Severity of sepsis was detected using Pediatric index of mortality 2 score. ResultsPatients had significantly lower mean values of left ventricular internal diameter in diastole and left atrial diameter when compared to controls (p < 0.05). Patients and non-survivors had significantly higher mean values of left and right ventricular Tei indices when compared to controls and survivors respectively (p < 0.05). Mean values of ejection fraction and cardiac index were significantly lower in patients when compared to their controls (p < 0.001). Pediatric index of mortality 2 score correlated positively with the left ventricular Tei index (r = 0.334, p < 0.001), right ventricular Tei index (r = 0.544, p < 0.001) and negatively with the left ventricular internal diameter in diastole (r = − 0.224, p < 0.03). ConclusionPediatric sepsis is associated with global myocardial dysfunction. Tei index is a rapid simple parameter that can be used for the evaluation of myocardial dysfunction in children with septic shock. Pediatric index of mortality 2 score correlated positively with Tei indices, hence we recommend they could be used for grading of sepsis severity in the future.

Noninvasive Respiratory Support during Pediatric Critical Care Transport: A Retrospective Cohort Study

AbstractNoninvasive respiratory support (NRS) including high flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP) is increasingly used for children with respiratory failure requiring interhospital transport by pediatric critical care transport (PCCT) teams. In this retrospective observational study of children receiving NRS on transport between January 1st, 2017 and December 31st, 2019 by a single PCCT service in England, we describe a cohort of children, looking at patient characteristics, journey logistics, adverse events, and failure of NRS (as defined by emergency intubation on transport or within 24 hours of arriving on the pediatric intensive care unit), and to attempt to identify risk factors that were associated with NRS failure. A total of 3,504 patients were transported during the study period. Three hundred and seventeen (9%) received NRS. Median age was 4.9 months (IQR: 1.0–18.2); median weight was 5.1 kg (IQR: 3.1–13). The primary diagnostic category was cardiorespiratory in 244/317 (77%) patients. Comorbidities were recorded in 189/317 (59.6%) patients. Median Pediatric Index of Mortality-3 (PIM3) score was 0.024 (IQR: 0.012–0.045). Median stabilization time was 80 minutes while median patient journey time was 40 minutes. Nineteen adverse events were described (clinical deterioration, equipment failure/interface issues) affecting 6% of transports. The incidence of NRS failure was 6.6%. No risk factors associated with NRS failure were identified. We concluded that NRS can be considered safe during pediatric transport for children with a wide range of diagnoses and varying clinical severity, with a low rate of adverse events and need for intubation on transport or on the PICU.

Comparison of PRISM III and PIM II Score in Predicting Mortality in Paediatric Intensive Care Unit: An Observational Study

Introduction: Prognostic scores play a vital role in predicting the outcome of children admitted in Paediatric Intensive Care Unit (PICU) thereby reducing the mortality. For paediatric populations Paediatric Risk of Mortality (PRISM) and Paediatric Index of Mortality (PIM) are the principal scores. As limited PICU beds are available in many tertiary care centres, PRISM score helps in predicting mortality risk and admission to PICU. Aim: To compare PRISM III and PIM II in predicting the mortality in sick children in a PICU and their relation between observed and predicted mortality. Materials and Methods: This was a prospective observational study, conducted in Chengalpattu Medical College Hospital, Chennai, Tamil Nadu, India, from July 2018 to June 2019 that enrolled 102 children who were admitted to PICU. At first hour of admission, PIM score was assessed and at 24 hours of admission PRISM score was assessed and the mortality was predicted. Children were followed-up until discharge or death, and the predicted mortality was compared with actual mortality and validation of scores was done using Statistical Package for the Social Sciences (SPSS) version 16. Results: Mean age of the population was 37.6 months, and majority of the children were aged less than 12 months. Male children were predominant (52%). Major system involvement was respiratory system 38 (37.3%) and mortality was 18 (17.6%). The mean score for death in PRISM and PIM were 11.8 and 19.9, respectively. The mean score for survival in PRISM and PIM were 4.4 and 9, respectively. Total PRISM and PIM score was lower in children who survived and mortality has been observed with higher scores. On comparison PRISM score was better to predict the mortality than PIM. The Area Under Curve (AUC) and sensitivity for PRISM score were 0.881 with 95% CI (0.769 to 0.992) and 94.44% respectively versus the AUC and sensitivity for PIM score were 0.768 with CI (0.628 to 0.908) and 61.11%, respectively. Using logistic regression, risk of mortality was analysed and found that increase in one score has 0.62 times the increased risk of death in PRISM score and thus it predicts the mortality better. Conclusion: The PRISM score was better than PIM score for risk stratification and to optimise available limited resources. Both scores underestimate the predicted mortality in comparison to observed mortality

Nonthyroidal illness syndrome as marker of severity in pediatric high dependency units: A single-center prospective cross-sectional observation study from Brazil

Background: Limited data is available in children with nonthyroidal illness syndrome (NTIS) and its association with prognosis in acute illness. This study was conducted to compare thyroid function as marker of severity with pediatric risk of mortality (PRISM) and pediatric index of mortality (PIM) in pediatric high dependency unit (PHDU).Subjects and Methods: This was a prospective, cross-sectional observational study of 225 patients, aged 1–14 years with respiratory symptoms, admitted to a PHDU in a secondary care hospital in Brazil. PRISM-IV and PIM-2 scores were calculated and serum thyroid-stimulating hormone (TSH), free T4, T3, and T4 levels were measured on admission. The presence of NTIS was considered in patients with total T3 below reference values, which may be associated with normal or low levels of total T4.Results: The mean age of the study population was 52.9 ± 35.9 months; Male-to-female ratio is was 1.2. All patients had normal free T4 levels. In 65.9% of cases, TSH remained within normal limits, while 34.1% were below the reference range for age. The prevalence of NTIS was 45.8%. Total T3 was normal in 54.2% and total T4 was normal in 90.2% of cases. Low total T3 with normal total T4 was found in 36% of patients while both total T3 and T4 were low in 9.8% of cases. Lower PRISM IV scores (P = 0.0014) and lower PIM-2 scores (P < 0.0001) were significantly correlated with absence of NTIS.Conclusions: Patients without evidence of NTIS have lower disease severity scores and a better prognosis.

Scoring Systems for Organ Dysfunction and Multiple Organ Dysfunction: The PODIUM Consensus Conference.

Multiple scores exist to characterize organ dysfunction in children. To review the literature on multiple organ dysfunction (MOD) scoring systems to estimate severity of illness and to characterize the performance characteristics of currently used scoring tools and clinical assessments for organ dysfunction in critically ill children. Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020. Studies were included if they evaluated critically ill children with MOD, evaluated the performance characteristics of scoring tools for MOD, and assessed outcomes related to mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. Data were abstracted into a standard data extraction form by a task force member. Of 1152 unique abstracts screened, 156 full text studies were assessed including a total of 54 eligible studies. The most commonly reported scores were the Pediatric Logistic Organ Dysfunction Score (PELOD), pediatric Sequential Organ Failure Assessment score (pSOFA), Pediatric Index of Mortality (PIM), PRISM, and counts of organ dysfunction using the International Pediatric Sepsis Definition Consensus Conference. Cut-offs for specific organ dysfunction criteria, diagnostic elements included, and use of counts versus weighting varied substantially. While scores demonstrated an increase in mortality associated with the severity and number of organ dysfunctions, the performance ranged widely. The multitude of scores on organ dysfunction to assess severity of illness indicates a need for unified and data-driven organ dysfunction criteria, derived and validated in large, heterogenous international databases of critically ill children.

939. Predicting Attributable Mortality in Pediatric Patients with Cancer Admitted to the Intensive Care Unit for Suspected Infection

Abstract Background Infection and sepsis are important contributors to mortality in children with cancer. Although pediatric risk prediction scores have improved identification of children at high risk of death in the PICU, the value of these tests in immunocompromised children is unknown. Methods In this IRB-approved retrospective study performed at St. Jude Children’s Research Hospital, we evaluated the performance of 4 pediatric risk scores, the Pediatric Risk of Mortality (PRISM), Pediatric Sequential Organ Failure Assessment (pSOFA), Quick Sequential Organ Failure Assessment (qSOFA) scores (using data available at 1, 6, 12 and 24 hours) and the Paediatric Index of Mortality 3 (PIM-3) score (at 1 hour), to predict attributable mortality (death ≤ 60 days without organ dysfunction recovery). Inclusion criteria: Age &amp;lt; 24 years, active cancer therapy (other than bone marrow transplantation), and admission to PICU between 2013 and 2019 with suspected infection (collection of a blood culture and initiation of antibiotic therapy). Scores were calculated using the worst value obtained for each variable. Score distributions were compared by the Mann-Whitney U test, and optimal cutoffs selected by maximizing Youden’s index. An unadjusted p-value &amp;lt; 0.05 was considered statistically significant. Results Of 202 episodes of PICU admission for suspected infection in 168 participants, there were 12 attributable (6%) and 4 unrelated (2%) deaths. Demographic and cancer-related characteristics were not associated with mortality (Table 1). Of the 4 prediction scores, only the PRISM score at 24 hours was associated with mortality (P = 0.012; Table 2). For PRISM score ≥ 18, sensitivity was 58.3%, specificity was 81.6%, positive predictive value was 16.7%, and negative predictive value was 96.9% for attributable mortality. Table 1. Risk factors for attributable mortality in pediatric patients with cancer admitted to the intensive care unit with suspected infection. Table 2. Association between risk prediction scores and attributable mortality in pediatric patients with cancer admitted to the intensive care unit with suspected infection. Conclusion In children with cancer admitted to PICU with suspected infection, early pediatric risk prediction scores did not predict mortality. The PRISM score calculated at 24 hours did predict mortality but was relatively insensitive. Further research is needed to develop a risk score for immunocompromised children and to validate the 24 hour PRISM score in this population. Disclosures Joshua Wolf, MBBS, PhD, FRACP, Karius Inc. (Research Grant or Support) Joshua Wolf, MBBS, PhD, FRACP, Nothing to disclose

Pediatric Simplified Acute Physiology Score II: Establishment of a New, Repeatable Pediatric Mortality Risk Assessment Score.

Objectives: In critical care it is crucial to appropriately assess the risk of mortality for each patient. This is especially relevant in pediatrics, with its need for accurate and repeatable scoring. Aim of this study was to evaluate an age-adapted version of the expanded Simplified Acute Physiology Score II; (p-SAPS II), a repeatable, newly-designed scoring system compared to established scores (Pediatric Sequential Organ Failure Assessment Score/pSOFA, Pediatric Logistic Organ Dysfunction Score-2/PELOD-2 and Pediatric Index of Mortality 3/PIM3).Design: This retrospective cohort pilot study included data collected from patients admitted to the Pediatric Intensive Care Unit (PICU) at the Medical University of Vienna between July 2017 through December 2018.Patients: 231 admissions were included, comprising neonates (gestational age of ≥ 37 weeks) and patients up to 18 years of age with a PICU stay longer than 48 h.Main Outcomes: Mortality risk prediction and discrimination between survivors and non-survivors were the main outcomes of this study. The primary statistical methods for evaluating the performance of each score were the area under the receiver operating characteristic curve (AUROC) and goodness-of-fit test.Results: Highest AUROC curve was calculated for p-SAPS II (AUC = 0.86; 95% CI: 0.77–0.96; p < 0.001). This was significantly higher than the AUROCs of PELOD-2/pSOFA but not of PIM3. However, in a logistic regression model including p-SAPS II and PIM3 as covariates, p-SAPS II had a significant effect on the accuracy of prediction (p = 0.003). Nevertheless, according to the goodness-of-fit test for p-SAPS II and PIM3, p-SAPS II overestimated the number of deaths, whereas PIM3 showed acceptable estimations. Repeatability testing showed increasing AUROC values for p-SAPS II throughout the clinical stay (0.96 at day 28) but still no significant difference to PIM 3. The prediction accuracy, although improved over the days and even exceeded PIM 3.Conclusions: The newly-created p-SAPS II performed better than the established PIM3 in terms of discriminating between survivors and non-survivors. Furthermore, p-SAPS II can be assessed repeatably throughout a patient's PICU stay what improves mortality prediction. However, there is still a need to optimize calibration of the score to accurately predict mortality sooner throughout the clinical stay.

Fluid overload in children with pediatric acute respiratory distress syndrome: A retrospective cohort study.

To assess the association of cumulative fluid overload (FO) up to 14 days from the diagnosis of pediatric acute respiratory syndrome (PARDS) with pediatric intensive care unit (PICU) mortality, 28-day mechanical ventilation free days (VFD), and 28-day intensive care unit free days (IFD). We hypothesized that fluid overload, even beyond the acute period, would be associated with increased morbidity and mortality. We conducted a retrospective cohort study of PARDS patients admitted to PICU from 2009 to 2015. For repeated admissions, we considered the admission with the highest oxygenation index (OI). Daily FO (%) was calculated as (intake - output)/weight at PICU admission × 100. Peak cumulative FO (CFO) was the highest CFO from the diagnosis of PARDS to Day 14 or to PICU discharge or mortality, whichever was earliest. Rate to peak CFO was the peak CFO divided by the number of days to reach that highest CFO. The association of FO with mortality, VFD and IFD were analyzed with logistic and linear regression models, with the following covariates: Pediatric Index of Mortality 2 score, PARDS severity, and the presence of acute kidney injury (AKI). There were 165 patients included in this study, with a mortality rate of 45.5% (75/165), median age 3.2 years (interquartile range [IQR] 0.7-9.9) and OI 15.8 (IQR 9.5-27.9). Seventy-three (44.2%) patients had severe PARDS and 64 (38.8%) had AKI. AKI (aOR [adjusted odds ratio] 3.19, 95% CI [confidence interval] 1.43-7.09, p = 0.004) and rate to peak cumulative FO (aOR 1.23, 95% CI 1.07-1.42, p = 0.004) were associated with mortality. AKI and peak cumulative FO were associated with decreased VFD and IFD. The rate to peak CFO over the first 14 days of PARDS was associated with mortality and peak CFO was associated with decreased VFD and IFD.

Criteria for Pediatric Sepsis-A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce.

To determine the associations of demographic, clinical, laboratory, organ dysfunction, and illness severity variable values with: 1) sepsis, severe sepsis, or septic shock in children with infection and 2) multiple organ dysfunction or death in children with sepsis, severe sepsis, or septic shock. MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020. Case-control studies, cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years with suspected or confirmed infection, which included the terms "sepsis," "septicemia," or "septic shock" in the title or abstract. Study characteristics, patient demographics, clinical signs or interventions, laboratory values, organ dysfunction measures, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed. One hundred and six studies met eligibility criteria of which 81 were included in the meta-analysis. Sixteen studies (9,629 patients) provided data for the sepsis, severe sepsis, or septic shock outcome and 71 studies (154,674 patients) for the mortality outcome. In children with infection, decreased level of consciousness and higher Pediatric Risk of Mortality scores were associated with sepsis/severe sepsis. In children with sepsis/severe sepsis/septic shock, chronic conditions, oncologic diagnosis, use of vasoactive/inotropic agents, mechanical ventilation, serum lactate, platelet count, fibrinogen, procalcitonin, multi-organ dysfunction syndrome, Pediatric Logistic Organ Dysfunction score, Pediatric Index of Mortality-3, and Pediatric Risk of Mortality score each demonstrated significant and consistent associations with mortality. Pooled mortality rates varied among high-, upper middle-, and lower middle-income countries for patients with sepsis, severe sepsis, and septic shock (p < 0.0001). Strong associations of several markers of organ dysfunction with the outcomes of interest among infected and septic children support their inclusion in the data validation phase of the Pediatric Sepsis Definition Taskforce.

Evaluation of Severity of Illness Scores in the Pediatric ECMO Population.

Though commonly used for adjustment of risk, severity of illness and mortality risk prediction scores, based on the first 24 h of intensive care unit (ICU) admission, have not been validated in the pediatric extracorporeal membrane oxygenation (ECMO) population. We aimed to determine the association of Pediatric Index of Mortality 2 (PIM2), Pediatric Risk of Mortality Score III (PRISM III) and Pediatric Logistic Organ Dysfunction (PELOD) scores with mortality in pediatric patients on ECMO. This was a retrospective cohort study of children ≤18 years of age included in the Pediatric ECMO Outcomes Registry (PEDECOR) from 2014 to 2018. Logistic regression and Receiver Operating Characteristics (ROC) curves were used to calculate the area under the curve (AUC) to evaluate association of mortality with the scores. Of the 655 cases, 289 (44.1%) did not survive until hospital discharge. AUCs for PIM2, PRISM III, and PELOD predicting mortality were 0.52, 0.52, and 0.51 respectively. PIM2, PRISM III, and PELOD scores are not associated with odds of mortality for pediatric patients receiving ECMO. These scores for a general pediatric ICU population should not be used for prognostication or risk stratification of a select population such as ECMO patients.

Pulmonary hypertension among children with in-hospital cardiac arrest: A multicenter study

AimsTo determine the prevalence of pulmonary hypertension (PH) among children with in-hospital cardiac arrest (IHCA) and its association with survival. MethodsChildren (<18 years) admitted to ICUs participating in the Virtual Pediatric Systems multicenter registry between January 2011 and December 2017 who had an IHCA during their hospitalization were included. Patients were classified by whether they had a documented diagnosis of PH at the time of IHCA. Clinical characteristics were compared between patients with and without PH. After propensity score matching, conditional logistic regression within the matched cohort determined the association between PH and survival to hospital discharge. ResultsOf 18,575 children with IHCA during the study period, 1,590 (8.6%) had a pre-arrest diagnosis of PH. Patients with PH were more likely to be 29 days to 2 years of age, female, Black/African American, and American Indian/Alaskan Native, and to be treated in a cardiac ICU or mixed PICU/cardiac ICU. At ICU admission, PH patients had a lower probability of death as determined by the Pediatric Index of Mortality 2 (PIM-2) score. Patients with PH were more likely to be receiving inhaled nitric oxide (13.0% vs. 2.1%; p < 0.001). Propensity score matching successfully matched 1,302 PH patients with 3,604 non-PH patients. Patients with PH were less likely to survive to hospital discharge (aOR 0.83; 95% CI: 0.72–0.95; p = 0.01) than non-PH patients. ConclusionsIn this large multicenter study, 8.6% of children with IHCA had pre-existing documented PH. These children were less likely to survive to hospital discharge than those without PH.

Comparison of urine albumin creatinine ratio with the pediatric index of mortality 2 score for prediction of pediatric intensive care unit outcomes

BackgroundPredicting morbidity and mortality in a pediatric intensive care unit (PICU) is of extreme importance to make precise decisions for better outcomes.AimWe compared the urine albumin creatinine ratio (ACR) with the established PICU score, pediatric index of mortality 2 (PIM 2) for predicting PICU outcomes.MethodsThis cross-sectional study enrolled 67 patients admitted to PICU with systemic inflammatory response syndrome. Urine ACR was estimated on admission, and PIM 2 score was calculated. ACR was compared with PIM 2 for PICU outcome measures: the need for inotropes, development of multiple organ dysfunction syndrome (MODS), duration of PICU stay, and survival.ResultsMicroalbuminuria was found in 77.6% of patients with a median ACR of 80 mg/g. ACR showed a significant association with the need for inotropes (p < 0.001), MODS (p = 0.001), and significant correlation to PICU stay (p 0.001, rho = 0.361). The area under the receiver operating characteristic curve for ACR (0.798) was comparable to that of PIM 2 (0.896). The cutoff value of ACR derived to predict mortality was 110 mg/g. The study subjects were divided into 2 groups: below cutoff and above the cutoff. Outcome variables, inotrope use, MODS, mortality, and PICU stay compared between these subgroups, were statistically significant.ConclusionACR is a good predictor of PICU outcomes and is comparable to PIM 2 for mortality prediction.

Hypophosphatemia in critically ill pediatric patients receiving enteral and oral nutrition.

Hypophosphatemia(HP) is related to several comorbidities in pediatric intensive care units (PICUs). This study aimed to evaluate the incidence of HP in severely ill pediatric patients receiving oral and/or enteral nutrition. The secondary objectives were to investigate the association between HP and the inflammatory state, PICU length of stay, severity, mortality, nutrition status, and protein, energy, calcium, vitamin D, and phosphate intake. A prospective, observational cohort study was conducted in a PICU of a quaternary hospital. Participants aged between 28 days and 14 years were included. Anthropometric and laboratory assessments were performed ≤72 h after PICU admission and repeated after 7 days for three consecutive times. Energy, protein, calcium, phosphate, and vitamin D intake per day of hospitalization were recorded individually. The Pediatric Index of Mortality 2 (PIM2) was used to determine each patient's severity score. A total of 103 participants were included in the study. Hypophosphatemic events ranged from 27.2% to 37.5% among the assessments. HP was associated with high C-reactive protein levels (P = .012) and lower energy adequacy (P = .037). Serum phosphorus was inversely correlated (weak correlation) with PIM2 (P = .017). HP is common in critically ill pediatric patients, even when they are not receiving parenteral nutrition. It is necessary to monitor serum phosphorus levels and consider the possibility of early replacement, especially in patients showing high levels of inflammation. In addition to inflammation itself, low energy intake and illness severity were related to HP.