Pediatric Logistic Organ Dysfunction Score Research Articles

The Platelet-to-lymphocyte ratio, PELOD-2 score, and mortality rate in pediatric sepsis

Background Sepsis is life-threatening organ dysfunction caused by a regulated immune response to infection. Sepsis remains the most common cause of death in infants and children worldwide. The Pediatric Logistic Organ Dysfunction (PELOD-2) score, one of the most widely used scoring systems in pediatric sepsis patients, has been shown to be accurate in predicting mortality. The platelet-to-lymphocyte ratio (PLR) is a new clinical indicator of inflammation in a variety of diseases including sepsis.
 Objective To investigate the relationship between PLR, PELOD-2 score, and clinical outcomes in pediatric patients with sepsis.
 Methods This retrospective cohort study was conducted in the Pediatric Intensive Care Unit (PICU), Prof R.D. Kandou Hospital, Manado, North Sulawesi, from February to August 2020. Subjects’ PELOD-2 score and PLR were recorded once within the first 24 hours of PICU admission. We analyzed patients’ PELOD-2 score, PLR, and mortality rate, with 95% confidence interval (CI) for each value.
 Results Of 96 children with sepsis admitted to the PICU during the study period, 87 patients (46 boys; 52.9%) met the inclusion criteria. In total, 50 (57.47%) patients were non-survivors. Mean PLR values among survivors [77.54 (SD 50.08)] was significantly lower compared to the values among non-survivors [157.13 (SD 67.38)]; as well as the PELOD-2 score in the survivors group [12 (SD 1.32)] was significantly lower than its value in the non-survivors [14.65 (SD 2.09)]. Spearman’s analysis showed a moderately positive correlation between PLR and PELOD-2 score (r=0.444; 95%CI 0.44 to 1; P<0.01). Biserial point correlation analysis revealed a significant association between PLR and mortality rate (rpb=0.566; P<0.0001),with elevated PLR related to an increased risk of mortality.
 Conclusion There are positive correlations between PLR, PELOD-2 score, and mortality rate in pediatric patients with sepsis. Higher PLR and PELOD-2 score are associated with higher mortality.

Role of soluble triggering receptor expressed in myeloid cells-1 in distinguishing SIRS, sepsis, and septic shock in the pediatric intensive care unit

BackgroundResearch into new markers has been intensified for early diagnosis, prognosis, and differentiation of SIRS, sepsis, and septic shock in recent years. This study aimed to investigate the role of soluble triggering receptor expressed in myeloid cells-1 (sTREM-1) and interleukin (IL)-6 in distinguishing between systemic inflammatory response syndrome (SIRS), sepsis, and septic shock in pediatric intensive care unit (PICU) patients. MethodsBetween June 2014 and July 2015, 90 consecutive patients who were treated in the PICU were included in this prospective observational study. Patients were divided into four groups: control (n = 23), SIRS (n = 22), sepsis (n = 23), and septic shock (n = 22). All patients were evaluated for white blood cell (WBC), serum C-reactive protein (CRP), procalcitonin (PCT), IL-6, and sTREM-1 levels at 0, 24, and 72 h of admission. The prognostic evaluations were made using the Pediatric Risk of Mortality III (PRISM III) and Pediatric Logistic Organ Dysfunction (PELOD) scores. Patients were evaluated in terms of age, gender, prognosis, pathogen growth in culture, PRISM III and PELOD score, WBC, CRP, PCT, IL-6, and sTREM-1 levels and a comparison was made between groups. ResultsThere was no significant difference between all groups in terms of the 0-, 24-, and 72-h sTREM-1 values (p = 0.761, p = 0.360, and p = 0.822, respectively). CRP and PCT values did not differ between the septic shock, sepsis, and SIRS groups at 0, 24, and 72 h. In the septic shock group, the 0-h IL-6 value was significantly higher than that of the SIRS group (p = 0.025). The 24-h IL-6 value in the septic shock group was significantly higher than the values of the sepsis and SIRS groups (p = 0.048 and p = 0.043, respectively). No significant difference was detected between the septic shock, sepsis, and SIRS groups in terms of IL-6 values at 72 h. ConclusionsTREM-1 is not useful for the diagnosis of infection and for distinguishing between sepsis, septic shock, and SIRS since it does not offer a clear diagnostic value for PICU patients, unlike other reliable markers such as WBC, CRP, and PCT. Elevated IL-6 levels may indicate septic shock in PICU patients. More research on sTREM-1 is needed in this setting.

Validation of the vasoactive-inotropic score in predicting pediatric septic shock mortality: A retrospective cohort study.

Introduction:Mortality in pediatric septic shock remains very high. Vasoactive-inotropic score (VIS) is widely used to predict prognosis in patients with heart disease. It is a simple method that was initially used as a predictor of morbidity and mortality in postoperative patients with congenital heart diseases. Previous reports showed that high VIS score was associated with high mortality in pediatric sepsis. However, its discriminative value remains unclear. We aim to explore the discriminative value of VIS in predicting mortality in pediatric septic shock patients.Methods:We conducted a retrospective cohort study on medical records of septic shock patients who received care in the pediatric intensive care unit (PICU). We screened medical records of pediatric patients which were diagnosed with septic shock and admitted to the PICU and received vasoactive/inotropic score for more than 8 h. Other supporting examination results were recorded, such as organ function evaluation for calculation of Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score. The outcome of patients was recorded. The receiver operating curve was constructed to calculate the area under the curve (AUC), sensitivity, and specificity of each cutoff point.Results:We obtained the optimum cutoff point of VIS > 11 with 78.87% sensitivity and 72.22% specificity. AUC positive was 0.779 (P < 0.001); predictive value and negative predictive value were 91.80% and 46.43%, respectively.Conclusion:VIS > 11 has a good ability to predict mortality in children with septic shock.

Predictors of Failure of Noninvasive Ventilation in Critically Ill Children.

Noninvasive ventilation (NIV) is a common modality employed to treat acute respiratory failure. Most data guiding its use is extrapolated from adult studies. We sought to identify clinical predictors associated with failure of NIV, defined as requiring intubation. This single-center retrospective observational study included children admitted to pediatric intensive care unit (PICU) between July 2014 and June 2016 treated with NIV, excluding postextubation. A total of 148 patients was included. Twenty-seven (18%) failed NIV. There was no difference between the two groups with regard to age, gender, comorbidities, or etiology of acute respiratory failure. Those that failed had higher admission pediatric risk of mortality ( p = 0.01) and pediatric logistic organ dysfunction ( p = 0.002) scores and higher fraction of inspired oxygen (FiO 2 ; p = 0.009) at NIV initiation. Failure was associated with lack of improvement in tachypnea. At 6 hours of NIV, the failure group had worsening tachypnea with a median increase in respiratory rate of 8%, while the success group had a median reduction of 18% ( p = 0.06). Multivariable Cox's proportional hazard models revealed FiO 2 at initiation and worsening respiratory rate at 1- and 6-hour significant risks for failure of NIV. Failure was associated with a significantly longer PICU length of stay (success [2.8 days interquartile range (IQR): 1.7, 5.5] vs. failure [10.6 days IQR: 5.6, 13.2], p < 0.001). NIV can be successfully employed to treat acute respiratory failure in pediatric patients. There should be heightened concern for NIV failure in hypoxemic patients whose tachypnea is unresponsive to NIV. A trend toward improvement should be closely monitored.

A Machine Learning Classifier Improves Mortality Prediction Compared With Pediatric Logistic Organ Dysfunction-2 Score: Model Development and Validation.

To determine whether machine learning algorithms can better predict PICU mortality than the Pediatric Logistic Organ Dysfunction-2 score. Retrospective study. Quaternary care medical-surgical PICU. All patients admitted to the PICU from 2013 to 2019. None. We investigated the performance of various machine learning algorithms using the same variables used to calculate the Pediatric Logistic Organ Dysfunction-2 score to predict PICU mortality. We used 10,194 patient records from 2013 to 2017 for training and 4,043 patient records from 2018 to 2019 as a holdout validation cohort. Mortality rate was 3.0% in the training cohort and 3.4% in the validation cohort. The best performing algorithm was a random forest model (area under the receiver operating characteristic curve, 0.867 [95% CI, 0.863-0.895]; area under the precision-recall curve, 0.327 [95% CI, 0.246-0.414]; F1, 0.396 [95% CI, 0.321-0.468]) and significantly outperformed the Pediatric Logistic Organ Dysfunction-2 score (area under the receiver operating characteristic curve, 0.761 [95% CI, 0.713-0.810]; area under the precision-recall curve (0.239 [95% CI, 0.165-0.316]; F1, 0.284 [95% CI, 0.209-0.360]), although this difference was reduced after retraining the Pediatric Logistic Organ Dysfunction-2 logistic regression model at the study institution. The random forest model also showed better calibration than the Pediatric Logistic Organ Dysfunction-2 score, and calibration of the random forest model remained superior to the retrained Pediatric Logistic Organ Dysfunction-2 model. A machine learning model achieved better performance than a logistic regression-based score for predicting ICU mortality. Better estimation of mortality risk can improve our ability to adjust for severity of illness in future studies, although external validation is required before this method can be widely deployed.

Fibrinolytic Impairment and Mortality in Pediatric Septic Shock: A Single-Center Prospective Observational Study.

Fibrinolytic shutdown is associated with poor prognosis in adult sepsis, but data in the pediatric population are sparse. This study aimed to identify the association between impaired fibrinolysis and mortality in pediatric septic shock. A prospective, observational study conducted between August 2019 and August 2020. PICU at a pediatric tertiary hospital in Hanoi, Vietnam. Fifty-six pediatric patients who met septic shock criteria were enrolled. None. Conventional coagulation tests and rotational thromboelastometry were performed at diagnosis. The fibrinolytic activity on extrinsic pathway thromboelastometry was negatively correlated with the Vasoactive-Inotropic Score at 24 hours post-PICU admission, peak lactate level during the first 24 hours, Pediatric Logistic Organ Dysfunction-2 score, and Pediatric Risk of Mortality-III score (all p < 0.05). Compared with patients with nonovert disseminated intravascular coagulation, dysfunction of less than two organs, and who survived, patients with overt disseminated intravascular coagulation, dysfunction of greater than two organs, and who died showed significantly lower fibrinolytic activity, represented by significantly higher lysis indexes (%) and lower maximum lysis (%) (all p < 0.05). The threshold values for prediction of mortality were lysis index 60 minutes greater than 97.5 (area under the curve = 0.86; sensitivity = 73%; specificity = 90%), maximum lysis less than 6.5 (area under the curve = 0.83; sensitivity = 73%; specificity = 87%), and lysis index 45 minutes greater than 99.5 (area under the curve = 0.83; sensitivity = 73%; specificity = 85%). Hypofibrinolysis was associated with prolonged PICU length of stay in survivors and with early mortality in nonsurvivors. Fibrinolytic shutdown in pediatric septic shock is associated with an increase in disease severity and mortality. This highlights the need for further investigations regarding whether fibrinolytic therapy improved the outcome of pediatric septic shock.

Efficacy and safety of plasma hemodiafiltration (PHDF) in pediatric patients with multiple organ dysfunction syndrome with shock and DIC: a preliminary study

BackgroundMultiple organ dysfunction syndrome is the leading cause of death in pediatric intensive care units and can be very critical when combined with shock and disseminated intravascular coagulation (DIC). Currently, there is no effective treatment. We developed a new hemodiafiltration (HDF) method called plasma HDF (PHDF) that uses fresh frozen plasma as replacement fluid and investigated the safety and efficacy of this treatment.MethodsWe enrolled critically ill children with (1) a Pediatric Logistic Organ Dysfunction 2 (PELOD-2) score ≥ 14, (2) a Japanese Ministry of Health and Welfare (JMHW) DIC score ≥ 7, (3) a vasoactive inotropic score (VIS) ≥ 10, and (4) a serum total protein concentration ≤ 5.0 g/dL. PHDF was performed for 5 h and then switched to continuous HDF. The primary endpoint was the 28-day mortality rate. Secondary endpoints included assessment of vital signs, blood test data, and fluid balance from PHDF start to day 7.ResultsNine patients (four males and five females) between 3 days and 40 months of age, weighing 2.1–13 kg, met the inclusion criteria. Although the median PMR was 0.94 (0.71–0.96), the 28-day mortality rate was 22.2% (2/9). One hour after the start of PHDF, there was an increase in mean arterial pressure and central venous pressure and a decrease in heart rate; by day 7, there was a significant decrease in the PELOD-2 score, the JMHW DIC score, and the VIS. Hypoproteinemia also improved the day after PHDF. Water balance was able to remain negative after day 2.ConclusionsPHDF was found to be effective in the treatment of DIC and circulatory failure by supplementing coagulation and antithrombotic factors as well as by raising colloid osmotic pressure to increase circulating blood volume. PHDF has been shown to be a safe and useful treatment for critically ill children and has the potential to improve 28-day survival.

Tracheostomy before 14 Days: Is It Associated with Better Outcomes in Pediatric Patients on Prolonged Mechanical Ventilation?

IntroductionWith the advancement of pediatric critical care services across India, many children require prolonged mechanical ventilation (MV), and tracheostomy is recommended to them. However, many pediatric intensivists have concerns regarding the safety, feasibility, and outcome of tracheostomy.We aimed to analyze clinical characteristics, indication, duration, and outcome of tracheostomized children with respect to timing of tracheostomy.Materials and methodsWe conducted a retrospective study from the hospital clinical database of consecutive patients below 12 years who had undergone tracheostomy after admission into the pediatric intensive care unit (PICU) for prolonged ventilation (≥96 hours) from January 2015 to December 2019. The study was approved by the Institutional Ethics Committee. Patients were divided into two groups: tracheostomies done within 14 days of MV (early tracheostomy) and patients with tracheostomies performed after 14 days (late tracheostomy). Patients’ age, sex, indications, complications, decannulation rate, length of MV, PICU, and hospital stay were analyzed.ResultsOf the 1,425 patients on invasive MV, 87 (6.1%) patients required tracheostomy after a mean 13.37 days of MV. The most common indication was encephalopathy 32 (36.7%) followed by acute respiratory distress syndrome 20 (22.9%). Factors like higher pediatric logistic organ dysfunction score, vasoactive inotrop score, incidence of pretracheostomy ventilator-associated pneumonia, and difficulty in obtaining parental consent were associated with late tracheostomy. The early tracheostomy group had a higher decannulation rate (odds ratio, 5.17; p, 0.01) and weaning rate (odds ratio, 5.94; p, 0.032). The late tracheostomy group needed a longer duration of MV, PICU, and hospital stay. Complications of tracheostomy were less in the early tracheostomy patients (odds ratio, 2.95; p, 0.03).ConclusionEarly tracheostomy was associated with lower complications, higher successful weaning rates, and less utilization of intensive care facilities in patients receiving prolonged MV.Clinical significanceIn the context of scarcity of data on the timing of tracheostomy in children with prolonged ventilation (≥96 hours) the study shows that early (<14 days) tracheostomy is associated with a better outcome.How to cite this articleSarkar M, Roychowdhoury S, Bhakta S, Raut S, Nandi M. Tracheostomy before 14 Days: Is It Associated with Better Outcomes in Pediatric Patients on Prolonged Mechanical Ventilation? Indian J Crit Care Med 2021;25(4):435–440.

P0148 / #1909: COMPARISON OF SCORING SYSTEMS IN TERTIARY PEDIATRIC INTENSIVE CARE UNIT

Aims & Objectives: To compare the scoring systems in tertiary pediatric intensive care unit (PICU) in Turkey. Methods: Patients, admitted to the PICU from November 2018 to October 2019, were included. Demographic findings, lactate levels and the or pediatric risk of mortality (PRISM) 3, PRISM 4, pSOFA (pediatric sequential organ failure assessment), pediatric index of mortality 2 (PIM2), PELOD-2 (pediatric logistic organ dysfunction-2) in the first 24 hours at admission were recorded. Results: 326 patients (159 girls and 167 boys; mean age 55.5 months; IQR 1-213) were included and the mortality rate was 10.4%. Mean PRISM 3 score (3.2± 0.4 vs. 30.7 ± 6.0), PRISM 4 score (1.04 ± 0.08 vs. 12.2±4), pSOFA score (1.30 ± 0.11 vs. 7.02 ± 0.84), PIM2 score (2.83 ± 0.35/ vs. 26.6 ± 6.1) and PELOD-2 score (0.67 ± 0.18 vs. 22.4 ± 6.5) were higher among patients who died than the survivors (p<0.001, p<0.01, p<0.001, p<0.001 and p<0.01; respectively). Although all scoring systems were higher in patients who died; pSOFA had higher sensitivity comparing the other scoring systems, while lower specificity. Conclusions: The maximum pSOFA score in the first 24 hours at admission had better performance than other scoring systems for PICU mortality without classifying different disease groups. It would be useful to evaluate scoring systems in different disease groups and larger patient series.

Vasoactive-inotropic Score for Early Detection and Mortality Prediction of Sepsis in Children

BACKGROUND: Early detection and treatment of sepsis can prevent septic shock and reduce mortality rate. Troponin can become a prognostic factor in sepsis. However, not all health facilities are equipped to assess troponin levels. Vasoactive-inotropic score (VIS) is a simpler and more accessible method to describe hemodynamic status. The aim of this study was to assess the suitability of VIS score as early prognosis and mortality predictor of sepsisMETHODS: A retrospective study was conducted to determine the correlation between VIS and troponin levels for sepsis cases in Pediatric Intensive Care Unity (PICU) Haji Adam Malik Hospital, Medan from January 2018 to December 2019. VIS score at 48 hours, maximum VIS score, pediatric logistic organ dysfunction-2 (PELOD-2) score, cardiac troponin levels at 48 hours were taken from medical records.RESULTS: There were 54 samples analyzed. VIS scores were positively correlated (p&lt;0.001) to troponin T and troponin I levels at 48 hours (r=0.670 and r=0.606, respectively). VIS at 48 hours and maximum VIS were related to mortality (p=0.001 and p&lt;0.001, respectively). VIS score at 48 hours could be used as a predictive factor for mortality (area under the curve (AUC): 79.7%, p&lt;0.001) with a cut-off point at 11 (74.4% sensitivity and 80% specificity). High VIS at 48 hours indicated poor outcomes of sepsis in children with odd ratio (OR) value: 1.99 (95% confidence interval (CI): 1.25-3.19).CONCLUSION: Vasoactive-inotropic score was suitable as an alternative to cardiac troponin T and troponin I levels at 48 hours to early detect myocardial dysfunctions and mortality in children.KEYWORDS: troponin, vasoactive-inotropic score, sepsis, children, mortality

Pediatric Multi-Organ Dysfunction Syndrome: Analysis by an Untargeted "Shotgun" Lipidomic Approach Reveals Low-Abundance Plasma Phospholipids and Dynamic Recovery over 8-Day Period, a Single-Center Observational Study.

Lipids are molecules involved in metabolism and inflammation. This study investigates the plasma lipidome for markers of severity and nutritional status in critically ill children. Children with multi-organ dysfunction syndrome (MODS) (n = 24) are analyzed at three time-points and cross-referenced to sedation controls (n = 4) for a total of N = 28. Eight of the patients with MODS, needed veno-arterial extracorporeal membrane oxygenation (VA ECMO) support to survive. Blood plasma lipid profiles are quantified by nano-electrospray (nESI), direct infusion high resolution/accurate mass spectrometry (MS), and tandem mass spectrometry (MS/MS), and compared to nutritional profiles and pediatric logistic organ dysfunction (PELOD) scores. Our results show that PELOD scores were not significantly different between MODS and ECMO cases across time-points (p = 0.66). Lipid profiling provides stratification between sedation controls and all MODS patients for total lysophosphatidylserine (lysoPS) (p-value = 0.004), total phosphatidylserine (PS) (p-value = 0.015), and total ether-linked phosphatidylethanolamine (ether-PE) (p-value = 0.03) after adjusting for sex and age. Nutrition intake over time did not correlate with changes in lipid profiles, as measured by caloric and protein intake. Lipid measurement in the intensive care environment shows dynamic changes over an 8-day pediatric intensive care unit (PICU) course, suggesting novel metabolic indicators for defining critically ill children.

Delayed Administration of Antibiotics Beyond the First Hour of Recognition Is Associated with Increased Mortality Rates in Children with Sepsis/Severe Sepsis and Septic Shock

To compare the risk of mortality and other clinical outcomes in children with sepsis, severe sepsis, or septic shock who received antibiotics within the first hour of recognition (early antibiotics group) with those who received antibiotics after the first hour (delayed antibiotics group). In this prospective cohort study, we enrolled children <17years of age presenting to the pediatric emergency and diagnosed with sepsis or septic shock without prior antibiotic therapy. Primary outcome was mortality and the secondary outcomes were day 1 Pediatric Logistic Organ Dysfunction score, ventilator-free days, and hospital-free days. These outcomes were compared between the early and the delayed antibiotic groups. The reference point for defining early and delayed antibiotic groups was time 0, which was measured from the time the patient was diagnosed to have sepsis, severe sepsis, or septic shock to the time of administration of the first dose of antibiotics. About three-fourths (77%) of the 441 children enrolled had septic shock. A total of 241 (55%) and 200 (45%) children were in the delayed and early antibiotic groups, respectively. Children in the delayed group had significantly higher odds of mortality than those in the early group (29% vs 20%; aOR 1.83; 95% CI, 1.14-2.92; P=.01). The time to shock reversal was significantly shorter, and the ventilator-free days and hospital-free days were significantly greater, in the early antibiotic group. There was no difference between the groups with regard to any of the other clinical outcomes. Delayed administration of antibiotics beyond 1hour of recognition was associated with higher mortality rates in children with sepsis, severe sepsis, and septic shock. Antibiotics should be administered within the first hour, along with other resuscitative measures, in these children.

Relationship between Procalcitonin and C-Reactive Protein on Pelod Score in Pediatric Surgery Sepsis Patients at Dr Soetomo General Hospital Surabaya

The incidence of sepsis in the world was estimated around 1.8 million cases / year , whereas 25-38% ofthem requiring treatment in intensive care unit , with mortality of 1,400 cases / day . In Indonesia, child’smortality rate due to sepsis is still very high, around 50% -70%, and if accompanied with septic shock andmultiple organs dysfunction, the rate is increased (80%) . One of the scoring system that can describe theseverity degree of multiple organs dysfunction in children is PELOD (Pediatric Logistic Organ Dysfunction)score. But this assessment is time consuming, because many parameters that have to be calculated. One ofthe ways to shorten the time is by using diagnostic markers such as procalcitonin (PCT) and C-ReactiveProtein (CRP).Method: The research is a study of analytic observational to determine the relationship between PELODscore with a value of procalcitonin and CRP in patients of children with sepsis and determine the cutoff pointof procalcitonin and CRP can be associated with incidence of septic shock. Research carried out for threemonths started in January 2020 until April 2020. Patients who meet the criteria for inclusion and exclusionrequested approval. Laboratory blood tests were done from day 1-3 of the sepsis.Results: In the study it was obtained the result that the age of majority is in the category of 5-10 years thatas many as 11 patients (36.7%). In the category of the type of sex the most are men - men that 19 patients(63.3%) and patients mostly great suffering sepsis that 23 patients (76.7%). Analysis between CRP withPELOD Score by using the chi-square test , the obtained results that there is a relationship that significantbetween CRP with PELOD Sc ore on a day to 1-3 with a value of p value of each 0,001 ( p &lt; 0,05) ; 0.002( p &lt; 0.05) ; 0.004 ( p &lt; 0.05), which means that there is significant relationship between CRP with PELODScore . Analysis between PCT with PELOD Score by using the chi-square test , the obtained results thatthere is a relationship that significant between PCT with PELOD Score on a day to 1-3 with a value ofp value respectively 0.005 ( p &lt; 0,05) ; 0.001 ( p&gt; 0.05) ; 0.016 ( p&gt; 0.05), which means that there is arelationship which is significantly meaningful between PCT with PELOD Score. In research it obtained thevalue of the boundary between the groups of patients with sepsis with shock, sepsis is Pelod score value of29 is the boundary between groups of sepsis and shock, sepsis, CRP value of 88 is the boundary betweengroups of sepsis and shock, sepsis, PCT value 9 is the boundary between groups of sepsis and shock sepsis .Conclusion: There is a significant relationship between the PCT with PELOD Score and significantrelationship between the CRP with PELOD Score.

Life-Threatening Hemoptysis in a Pediatric Referral Center.

Hemoptysis is uncommon in children, even among the critically ill, with a paucity of epidemiological data to inform clinical decision-making. We describe hemoptysis-associated ICU admissions, including those who were critically ill at hemoptysis onset or who became critically ill as a result of hemoptysis, and identify predictors of mortality. Retrospective cohort study. Demographics, hemoptysis location, and management were collected. Pediatric Logistic Organ Dysfunction-2 score within 24 hours of hemoptysis described illness severity. Primary outcome was inhospital mortality. Quaternary pediatric referral center between July 1, 2010, and June 30, 2017. Medical/surgical (PICU), cardiac ICU, and term neonatal ICU admissions with hemoptysis during or within 24 hours of ICU admission. No intervention. There were 326 hemoptysis-associated ICU admissions in 300 patients. Most common diagnoses were cardiac (46%), infection (15%), bronchiectasis (10%), and neoplasm (7%). Demographics, interventions, and outcomes differed by diagnostic category. Overall, 79 patients (26%) died inhospital and 109 (36%) had died during follow-up (survivor mean 2.8 ± 1.9 yr). Neoplasm, bronchiectasis, renal dysfunction, inhospital hemoptysis onset, and higher Pediatric Logistic Organ Dysfunction-2 score were independent risk factors for inhospital mortality (p < 0.02). Pharmacotherapy (32%), blood products (29%), computerized tomography angiography (26%), bronchoscopy (44%), and cardiac catheterization (36%) were common. Targeted surgical interventions were rare. Of survivors, 15% were discharged with new respiratory support. Of the deaths, 93 (85%) occurred within 12 months of admission. For patients surviving 12 months, 5-year survival was 87% (95% CI, 78-92) and mortality risk remained only for those with neoplasm (log-rank p = 0.001). We observed high inhospital mortality from hemoptysis-associated ICU admissions. Mortality was independently associated with hemoptysis onset location, underlying diagnosis, and severity of critical illness at event. Additional mortality was observed in the 12-month posthospital discharge. Future directions include further characterization of this vulnerable population and management recommendations for life-threatening pediatric hemoptysis incorporating underlying disease pathophysiology.

Can serum ferritin be employed as prognostic marker of pediatric septic shock and severe sepsis?

Introduction: Serum ferritin has emerged as an independent marker predicting the outcome of critically ill patients. The cutoff value of ferritin in predicting mortality in septic children is not well established. Objective: The aim is to determine the cutoff value of ferritin which is, best predictive of mortality in patients with age from 1 month to 12 years with a diagnosis of septic shock or severe sepsis and to evaluate correlation with PRISM III score, and Pediatric Logistic Organ Dysfunction score (PELODS). Materials and Methods: A prospective observational study was conducted over a period of 2 years at pediatric intensive care unit (PICU) in children with age from 1 month to 12 years with septic shock or severe sepsis and PICU stay &gt;24 h. Children with autoimmune diseases, primary hemophagocytic lymphohistiocytosis, blood transfusion in the past 4 months, known malignancies and immunosuppressive treatment were excluded. PRISM-III and PELODS were assessed to predict the risk of mortality and severity of disease. The highest value of ferritin was taken to draw area under the curve using receiver operating characteristic curve and determine cutoff value. Results: Out of 176 children of septic shock or severe sepsis, 132 were included in the study. Mortality rate was 22.7% (n = 30). PRISM III and PELODS-2 were significantly high in nonsurvivors (P ≤ 0.001 and 0.006, respectively). The cutoff value of ferritin at 2375 ng/dl had sensitivity 96.7% and specificity 88% to predict mortality. Ferritin level was positively correlated to the PRISM III and PELODS, correlation coefficient 0.447 and 0.601, respectively. Conclusion: Serum ferritin values ≥2375 ng/mL in children with septic shock, and severe sepsis was significantly associated with mortality. Its performance had a good correlation with PRISM III and PELODS.

Evaluation of perfusion index in pediatric trauma patients.

The aim of this study is to investigate the effectiveness of perfusion index (PI) measured by non-invasive pulse oximetry in the evaluation of pediatric trauma patients and to show its correlation with pediatric trauma score (PTS). Patients hospitalized in the pediatric intensive care unit due to trauma were examined between March 2017 and March 2018. Characteristic variables of the patients, Pediatric Index of Mortality 2 score, Pediatric Logistic Organ Dysfunction score, PTS, type of trauma, number of systems affected by trauma, mechanical ventilation, transfusion, hemoglobin, lactate, PI at admission, length of ICU stay, and prognosis were recorded. Ninety-one pediatric trauma patients were included in the study. The majority of the patients were male (64.8%), with a mean age of 99.47±71.27 months, the most common cause of trauma was an out of-vehicle traffic accident. There was a positive correlation between PI and PTS (p<0.05). In patients with PTS TS ≤8, the mean PI was 0.89, the standard deviation was 0.35; however, the mean PI was 1.77, the standard deviation was 0.95 in the group with PTS >8, and it was statistically significant (p=0.000). PI can be used for non-invasive and rapid assessment of unstable patients separately or in combination with PTS in pediatric trauma patients.

Prevalence and outcomes of sepsis in children admitted to public and private hospitals in Latin America: a multicenter observational study.

ObjectiveTo report the prevalence and outcomes of sepsis in children admitted to public and private hospitals.MethodsPost hoc analysis of the Latin American Pediatric Sepsis Study (LAPSES) data, a cohort study that analyzed the prevalence and outcomes of sepsis in critically ill children with sepsis on admission at 21 pediatric intensive care units in five Latin American countries.ResultsOf the 464 sepsis patients, 369 (79.5%) were admitted to public hospitals and 95 (20.5%) to private hospitals. Compared to those admitted to private hospitals, sepsis patients admitted to public hospitals did not differ in age, sex, immunization status, hospital length of stay or type of admission but had higher rates of septic shock, higher Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality 2 (PIM 2), and Pediatric Logistic Organ Dysfunction (PELOD) scores, and higher rates of underlying diseases and maternal illiteracy. The proportion of patients admitted from pediatric wards and sepsis-related mortality were higher in public hospitals. Multivariate analysis did not show any correlation between mortality and the type of hospital, but mortality was associated with greater severity on pediatric intensive care unit admission in patients from public hospitals.ConclusionIn this sample of critically ill children from five countries in Latin America, the prevalence of septic shock within the first 24 hours at admission and sepsis-related mortality were higher in public hospitals than in private hospitals. Higher sepsis-related mortality in children admitted to public pediatric intensive care units was associated with greater severity on pediatric intensive care unit admission but not with the type of hospital. New studies will be necessary to elucidate the causes of the higher prevalence and mortality of pediatric sepsis in public hospitals.

Serum Ferritin Predicts Neither Organ Dysfunction Nor Mortality in Pediatric Sepsis Due to Tropical Infections.

Objective: To evaluate serial ferritin levels measured in the initial 72 h of admission as a biomarker for new and progressive multi organ dysfunction syndrome (NPMODS) and mortality (unfavorable outcomes) in critically ill children with sepsis due to tropical infections.Material and Methods: In this prospective observational study from a tertiary care teaching hospital in India, children 3 month to 12 years with a diagnosis of acute febrile illness and any two features suggesting tropical infections [cytopenia (platelet count <1,00,000/cu.mm, total leucocyte count <4,000/cu.mm), hepatomegaly and/or splenomegaly, lymphadenopathy, systemic signs (rash, edema), respiratory distress, and encephalopathy not accounted by localized infection] were eligible for inclusion. Children with known or suspected disorder of iron metabolism were excluded. Primary outcome was to determine the association of serial ferritin levels with mortality and NPMODS. Secondary outcomes included estimation of the prevalence of hyperferritinemia and comparison of risk prediction scores with serial ferritin measurement in predicting unfavorable outcomes.Measurements and Main Results: In the 202 children enrolled, diagnosis could be established in 133 (65.8%) children. Scrub typhus and dengue were the most common infections. Median (IQR) ferritin measured at admission (n = 183) and on day 3 (n = 120) of hospital stay were 798 (378, 3,205) μg/L and 429 (213,680) μg/L, respectively. Majority (n = 180, 89.1%) had MODS at admission defined as per International pediatric sepsis consensus conference. NPMODS occurred in 47 (23.3%) children of whom 37 (18.3%) died. Children with three or less organ dysfunctions had lower mortality. Neither admission ferritin values nor the percentage change over 72 h was different between children with favorable and unfavorable outcomes. Pediatric Risk of Mortality (PRISM-III) and daily Pediatric Logistic Organ Dysfunction score (dPELOD2 score) were significantly different in those with unfavorable outcomes. Admission ferritin levels and percentage change in 72 h had poor discriminatory power for mortality with AUC of 0.53 (0.53, 0.67) and 0.50 (0.50, 0.64), respectively. dPELOD2 had the best discriminatory power for mortality with AUC of 0.89 (0.89, 0.95).Conclusions: Serial ferritin estimation predicted neither organ dysfunction nor mortality in pediatric sepsis with tropical infections. dPELOD-2 and PRISM-III predicted unfavorable outcomes better than ferritin. The current diagnostic criteria for MODS overestimated organ dysfunctions in tropical infections and hence may need modification with further validation in this epidemiological cohort.

Gene expression signatures identify paediatric patients with multiple organ dysfunction who require advanced life support in the intensive care unit.

BackgroundMultiple organ dysfunction syndrome (MODS) occurs in the setting of a variety of pathologies including infection and trauma. Some patients decompensate and require Veno-Arterial extra corporeal membrane oxygenation (ECMO) as a palliating manoeuvre for recovery of cardiopulmonary function. The molecular mechanisms driving progression from MODS to cardiopulmonary collapse remain incompletely understood, and no biomarkers have been defined to identify those MODS patients at highest risk for progression to requiring ECMO support.MethodsWhole blood RNA-seq profiling was performed for 23 MODS patients at three time points during their ICU stay (at diagnosis of MODS, 72 hours after, and 8 days later), as well as four healthy controls undergoing routine sedation. Of the 23 MODS patients, six required ECMO support (ECMO patients). The predictive power of conventional demographic and clinical features was quantified for differentiating the MODS and ECMO patients. We then compared the performance of markers derived from transcriptomic profiling including [1] transcriptomically imputed leukocyte subtype distribution, [2] relevant published gene signatures and [3] a novel differential gene expression signature computed from our data set. The predictive power of our novel gene expression signature was then validated using independently published datasets.FindingNone of the five demographic characteristics and 14 clinical features, including The Paediatric Logistic Organ Dysfunction (PELOD) score, could predict deterioration of MODS to ECMO at baseline. From previously published sepsis signatures, only the signatures positively associated with patient's mortality could differentiate ECMO patients from MODS patients, when applied to our transcriptomic dataset (P-value ranges from 0.01 to 0.04, Student's test). Deconvolution of bulk RNA-Seq samples suggested that lower neutrophil counts were associated with increased risk of progression from MODS to ECMO (P-value = 0.03, logistic regression, OR=2.82 [95% CI 0.63 - 12.45]). A total of 30 genes were differentially expressed between ECMO and MODS patients at baseline (log2 fold change ≥ 1 or ≤ -1 with false discovery rate ≤ 0.01). These genes are involved in protein maintenance and epigenetic-related processes. Further univariate analysis of these 30 genes suggested a signature of seven DE genes associated with ECMO (OR > 3.0, P-value ≤ 0.05, logistic regression). Notably, this contains a set of histone marker genes, including H1F0, HIST2H3C, HIST1H2AI, HIST1H4, HIST1H2BL and HIST1H1B, that were highly expressed in ECMO. A risk score derived from expression of these genes differentiated ECMO and MODS patients in our dataset (AUC = 0.91, 95% CI 0.79-1.00, P-value = 7e-04, logistic regression) as well as validation dataset (AUC= 0.73, 95% CI 0.53-0.93, P-value = 2e-02, logistic regression).InterpretationThis study demonstrates that transcriptomic features can serve as indicators of severity that could be superior to traditional methods of ascertaining acuity in MODS patients. Analysis of expression of signatures identified in this study could help clinicians in the diagnosis and prognostication of MODS patients after arrival to the Hospital.

Pediatric SOFA score for detecting sepsis in children

Background The pediatric logistic organ dysfunction-2 (PELOD-2) score is recommended by the Indonesian Pediatric Society Emergency and Intensive Care Working Group as an indicator of life-threatening organ dysfunction for sepsis in children. However, The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) recommended the Sequential (Sepsis-related) Organ Failure Assessment (SOFA) score in determining life-threatening organ dysfunction, which has not been adjusted for pediatric patients.&#x0D; Objective To assess the accuracy of the pediatric SOFA score in diagnosing sepsis in children admitted to the pediatric intensive care unit (PICU) at Mohammad Hoesin Hospital, Palembang, South Sumatera.&#x0D; Methods The study was conducted in children with organ dysfunction caused by infection admitted in PICU, from April to December 2019. Subjects were included by consecutive sampling, according to the following inclusion criteria: all patients aged 1 month to 18 years who met organ dysfunction and two SIRS criteria, with infection according to the 2005 PSCC criteria. Laboratory tests performed included complete blood count (CBC), blood gas analysis, measurement of C-reactive protein (CRP), liver and kidney function tests. In all patients, pSOFA and PELOD-2 scores were calculated within 24 hours of admission. We compared the accuracy of pSOFA score to PELOD-2 score ≥ 11. &#x0D; Results Of 108 subjects, there were 59 males and 49 females, with median age 11 (range 1-193) months. We compared the accuracy of pSOFA score to PELOD-2 score ≥ 11 and obtained a sensitivity of 93.3% and a specificity of 79.5%, for pSOFA cut-off score ≥ 8. Pediatric SOFA score cutoff ≥ 8 was determined by receiver operating curve (ROC). The area under the curve (AUC) for pediatric SOFA score was 93.9% (95%CI 89.7 to 98.0%).&#x0D; Conclusion Pediatric SOFA score ≥ 8 is the optimal cut-off for predicting life-threatening organ dysfunction in pediatric sepsis. Multicenter revalidation is needed to find the most optimal cut-off point for general use in Indonesia.