Pediatric Logistic Organ Dysfunction Research Articles

Fluid Removal in Children on Continuous Renal Replacement Therapy Improves Organ Dysfunction Score

AbstractThe objective is to assess impact of fluid removal on improvement in organ function in children who received continuous renal replacement therapy (CRRT) for management of acute kidney injury and/or fluid overload (FO). A retrospective review of eligible patients admitted to a tertiary level intensive care unit over a 3-year period was performed. Improvement in nonrenal organ function, the primary outcome, was defined as decrease in nonrenal component of Pediatric Logistic Organ Dysfunction (PELOD) score on day 3 of CRRT. The cohort was categorized into Group 1 (improvement) and Group 2 (no improvement or worsening) in nonrenal PELOD score. Multivariable logistic regression analysis was performed to identify independent predictors. A higher PELOD score at CRRT initiation (odds ratio [OR]: 1.11, 95% confidence interval [CI]: 1.05, 1.18, p < 0.001), belonging to infant-age group (OR: 4.53, 95% CI: 4.40, 5.13, p = 0.02) and greater fluid removal during initial 3 days of CRRT (OR: 1.05, 95% CI: 1.01, 1.10, p = 0.01) were associated with an improvement in nonrenal PELOD score at day 3 of CRRT. FO at CRRT initiation (OR: 0.66, 95% CI: 0.46, 0.93, p = 0.02) and having an underlying oncologic diagnosis (OR: 0.28, 95% CI: 0.09, 0.85, p = 0.03) were associated with worsening of nonrenal PELOD score at day 3 of CRRT. Careful consideration of certain modifiable patient and/or fluid removal kinetic factors may have an impact on outcomes.

Annexin A2 Loss After Cardiopulmonary Bypass and Development of Acute Postoperative Respiratory Dysfunction in Children.

In a prospective, observational study conducted over a 1-year period in children undergoing cardiac surgery requiring CPB, we analyzed A2 expression in peripheral blood mononuclear cells at different time points. We then assessed the relationship of A2 expression with organ function at each time point in the early postoperative period. Twenty-three-bed mixed PICU in a tertiary academic center. Patients 1 month to 18 years old undergoing cardiac surgery requiring CPB. We analyzed A2 expression in 22 enrolled subjects (n = 9, 1-23 mo old; n = 13, 2-18 yr old) and found a proteolysis-mediated decline in intact A2 immediately after bypass (p = 0.0009), reaching a median of 4% of baseline at 6 hours after bypass (p < 0.0001), and recovery by postoperative day 1. The degree of A2 depletion immediately after bypass in 1-23-month-olds correlated strongly with the extent of organ dysfunction, as measured by PICU admission Vasoactive-Ventilation-Renal (p = 0.004) and PEdiatric Logistic Organ Dysfunction-2 (p = 0.039) scores on postoperative day 1. A2 depletion immediately after bypass also correlated with more protracted requirement for both respiratory support (p = 0.007) and invasive ventilation (p = 0.013) in the 1-23-month-olds. The degree of depletion of A2 following CPB correlates with more severe organ dysfunction, especially acute respiratory compromise in children under 2 years. These findings suggest that loss of A2 may contribute to pulmonary microvascular leak in young children following CPB.

Application of a gene modular approach for clinical phenotype genotype association and sepsis prediction using machine learning in meningococcal sepsis

Sepsis is a major global health concern causing high morbidity and mortality rates. Our study utilized a Meningococcal Septic Shock (MSS) temporal dataset to investigate the correlation between gene expression (GE) changes and clinical features. The research used Weighted Gene Co-expression Network Analysis (WGCNA) to establish links between gene expression and clinical parameters in infants admitted to the Pediatric Critical Care Unit with MSS. Additionally, various machine learning (ML) algorithms, including Support Vector Machine (SVM), Naive Bayes, K-Nearest Neighbors (KNN), Decision Tree, Random Forest, and Artificial Neural Network (ANN) were implemented to predict sepsis survival. The findings revealed a transition in gene function pathways from nuclear to cytoplasmic to extracellular, corresponding with Pediatric Logistic Organ Dysfunction score (PELOD) readings at 0, 24, and 48 h. ANN was the most accurate of the six ML models applied for survival prediction. This study successfully correlated PELOD with transcriptomic data, mapping enriched GE modules in acute sepsis. By integrating network analysis methods to identify key gene modules and using machine learning for sepsis prognosis, this study offers valuable insights for precision-based treatment strategies in future research. The observed temporal-spatial pattern of cellular recovery in sepsis could prove useful in guiding clinical management and therapeutic interventions.

Application of organ dysfunction assessment scores following pediatric lung transplantation.

Organ dysfunction (OD) after lung transplantation can reflect preoperative organ failure, intraoperative acute organ damage and post-operative complications. We assessed two OD scoring systems, both the PEdiatric Logistic Organ Dysfunction (PELOD) and the pediatric Sequential Organ Failure Assessment (pSOFA) scores, in recognizing risk factors for morbidity as well as recipients with prolonged post-transplant morbidity. Medical records of recipients from January 2009 to March 2016 were reviewed. PELOD and pSOFA scores were calculated on post-transplant days 1-3. Risk factors assessed included cystic fibrosis (CF), prolonged surgical time and worst primary graft dysfunction (PGD) score amongst others. Patients were classified into three groups based on their initial scores (group A) and subsequent trends either uptrending (group B) or downtrending (group C). Morbidity outcomes were compared between these groups. Total 98 patients were enrolled aged 0-20 years. Risk factors for higher pSOFA scores ≥ 5 on day 1 included non-CF diagnosis and worst PGD scores (p=.0006 and p=.03, respectively). Kruskal Wallis analysis comparing pSOFA group A versus B versus C scores showed significantly prolonged ventilatory days (median 1vs. 4vs. 2, p=.0028) and ICU days (median 4vs. 10vs. 6, p=.007). Similarly, PELOD group A versus B versus C scores showed significantly prolonged ventilatory days (1vs. 5vs. 2, p=<.0001). Implementing pSOFA scores bedside is a more effective tool compared to PELOD in identifying risk factors for worsened OD post-lung transplant and can be valuable in providing direction on morbidity outcomes in the ICU.

Triage Policies at U.S. Hospitals with Pediatric Intensive Care Units

Objectives To characterize the prevalence and content of pediatric triage policies. Methods We surveyed and solicited policies from U.S. hospitals with pediatric intensive care units. Policies were analyzed using qualitative methods and coded by 2 investigators. Results Thirty-four of 120 institutions (28%) responded. Twenty-five (74%) were freestanding children’s hospitals and 9 (26%) were hospitals within a hospital. Nine (26%) had approved policies, 9 (26%) had draft policies, 5 (14%) were developing policies, and 7 (20%) did not have policies. Nineteen (68%) institutions shared their approved or draft policy. Eight (42%) of those policies included neonates. The polices identified 0 to 5 (median 2) factors to prioritize patients. The most common factors were short- (17, 90%) and long- (14, 74%) term predicted mortality. Pediatric scoring systems included Pediatric Logistic Organ Dysfunction-2 (12, 63%) and Score for Neonatal Acute Physiology and Perinatal Extensions-II (4, 21%). Thirteen (68%) policies described a formal algorithm. The most common tiebreakers were random/lottery (10, 71%) and life cycles (9, 64%). The majority (15, 79%) of policies specified the roles of triage team members and 13 (68%) precluded those participating in patient care from making triage decisions. Conclusions While many institutions still do not have pediatric triage policies, there appears to be a trend among those with policies to utilize a formal algorithm that focuses on short- and long-term predicted mortality and that incorporates age-appropriate scoring systems. Additional work is needed to expand access to pediatric-specific policies, to validate scoring systems, and to address health disparities.

627: EPIDEMIOLOGY OF SEVERE PEDIATRIC PNEUMONIA IN ASIA: A PROSPECTIVE MULTINATIONAL OBSERVATIONAL STUDY

Introduction: Severe pneumonia is a common indication for admission to the pediatric intensive care unit (PICU) and a leading cause of morbidity and mortality. The lack of epidemiology and outcome data from Asia is a barrier to improving outcomes of severe pneumonia in the region. Methods: This is a prospective multicenter cohort study carried out from April 2019 to April 2022. Fifteen PICUs participated in this study under the Pediatric Acute & Critical Care Medicine Asian Network. Epidemiological, microbiological and outcome data were collected up to hospital discharge. Univariate logistic regression analysis were conducted to explore the association between potential risk factors and severe outcomes [acute respiratory distress syndrome (ARDS) and PICU mortality]. Multivariable analysis was performed withforward stepwise logistic regression adjusted for sites and COVID-19 pandemic including variables with p< 0.05 in univariate model. Results: There were 786 children with severe pneumonia in PICU with mean (standard deviation) age 2.8 (3.9) years. 384/786 (48.9%) had comorbidities; 126/786 (16.0%) had a history of prematurity (gestational age < 37 weeks). Admission Pediatric Index of Mortality 3 (PIM3) and Pediatric Logistic Organ Dysfunction 2 (PELOD2) score were 16.2 (22.9) and 4.1(4.6). A sole viral or bacterial pathogen was identified in 179/786 (22.4%) and 165/786 (21.0%). Co-infections occurred in 114/786 (14.5%) patients. ARDS and mortality occurred in 156/786 (20.1%) and 70/786(8.9%) patients. In the multivariable model, risk factors for ARDS included PIM3 [adjusted odds ratio (aOR) [95% confidence interval (CI)] of 1.02 (1.01, 1.03)], PELOD2 [aOR 1.08 (95%CI 1.02, 1.13)] and involvement of 4 quadrants on chest-x-ray, [aOR 2.69 (95%CI 1.39, 5.18)]. Risk factors for mortality included PIM 3 [aOR 1.03 (95%CI 1.01, 1.04)], involvement of 4 quadrants on chest-x-ray [aOR 2.72 (95%CI 1.10, 6.73)], bacterial [aOR 2.61 (95%CI 1.00, 6.82)], fungus or mycobacterium [aOR 12.30 (95%CI 1.45, 104.57)] and co-infections [aOR 2.72 (95%CI 1.10, 10.35)]. Conclusions: The rate of ARDS and mortality in severe pneumonia admitted to PICU in Asia was high. Risk factors for poor outcomes were admission severity scores, generalized X-ray involvement and identification of bacteria, fungus/mycobacteria or co-infections.

619: THE IMPACT OF NEIGHBORHOOD FACTORS ON PATIENT DISEASE SEVERITY ON PRESENTATION TO THE PICU

Introduction: Health disparities yield worse health outcomes for critically ill patients. Neighborhoods capture social and physical attributes experienced by residents. Increasingly, neighborhood-level geographic variations in health disparities have been reported. Individuals are commonly clustered into neighborhoods based on socioeconomic status. The impact of sociodemographic factors on outcomes for PICU patients is understudied. Few studies delve into the specific neighborhood characteristics affecting disease severity on PICU admission. To address this gap, we conducted a retrospective study exploring the association between geography and disease severity on PICU presentation, with sociodemographic neighborhood data and clinical data as additional predictors. We anticipate patients with higher disease severity will be clustered in low opportunity neighborhoods. Methods: Electronic medical record patient data were collected for non-elective admissions to the PICU from Jan 2013 to Dec 2019. The peak Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score for the first 72 hours of admission was calculated for each encounter. Addresses were geocoded into census tracts. The Childhood Opportunity Index (COI), Social Vulnerability Index (SVI), and Neighborhood Disorder Index (NDI) were matched to each census tract. We report descriptive analyses, Spearman correlation coefficients for continuous variables, and Kruskal-Wallis test results for categorical variables. Results: There were 8497 unique patient encounters for 5874 distinct patients. Data were skewed right with a PELOD-2 score mean of 3.2 and median of 3.0. There was no correlation between the SVI (p=0.129), COI (p=0.957) or NDI (p=0.363) and peak PELOD-2 score. There was a correlation between age (rho 0.102, p< 0.001) and number of comorbidities (rho 0.373, p< 0.001) and peak PELOD-2 scores. There was a difference between median PELOD-2 scores for varying races and insurance types (p< 0.001). Conclusions: There was no association between neighborhood resources and peak PELOD-2 scores; however, there was a difference in mean PELOD-2 scores across varying races and insurance types. This indicates a need for more analyses to evaluate the association between neighborhood indices and peak PELOD-2 scores when accounting for other sociodemographic variables.

Mortality Assesment of Pediatric Septic Patients Through Pediatric Sofa+Anion Gap and Pelod-2 Scores

Highlight: Sepsis and septic shock cause morbidity and mortality in pediatric patients. The accuracy of pediatric sequential organ failure assessment and anion gap (pSOFA+AG) was compared with AG and pediatric logistic organ dysfunction-2 (AG+PELOD-2). The mortality assessment of pediatric septic patients showed that pSOFA was more sensitive than PELOD-2, while pSOFA+AG was not more sensitive than PELOD-2. Abstract: Sepsis and septic shock are some of the causes of morbidity and mortality (50-60%) in pediatric patients treated in intensive care rooms. This study aimed to compare the accuracy of pediatric Sequential Organ Failure Assessment (pSOFA) score combined with anion gap (AG) score to Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score in the assessment of mortality in pediatric septic patients at the Resuscitation Room of Dr. Soetomo Geeneral Academic Hospital, Surabaya, Indonesia. This was a retrospective observational cohort study using pediatric sepsis diagnosis guidelines based on the 2016 Pediatric Sepsis Consensus and medical records between January-December 2018. All data of patients aged 1 month to 16 years with suspected infection at the Resuscitation Room were collected based on predisposing infections, signs of infection, and warning signs. Organ dysfunction was assessed by calculating the pSOFA+AG scores, PELOD-2 scores, and corrected anion gap (cAG) in the first 24 hours. Sepsis mortality was assessed by comparing the results of the pSOFA, pSOFA+AG, and PELOD-2. The results showed 94.9% sensitivity and 70.0% specificity (p&lt;0.0001) in the pSOFA, 89.9% sensitivity and 71.3% specificity (p&lt;0.0001) in the PELOD-2, 79.7% sensitivity and 65% specificity (p&lt;0.0001) in the AG, 79.7% sensitivity and 73.8% specificity (p&lt;0.0001) in the cAG, and 79.3% sensitivity (p&lt;0.0001) in the pSOFA+AG. In conclusion, pSOFA was more sensitive than PELOD-2, while the use of pSOFA+AG was not more sensitive than PELOD-2 in assessing the mortality of pediatric septic patients.

Comparing Pediatric Index of Mortality 3, Pediatric Logistic Organ Dysfunction 2 (PELOD-2), and Modified PELOD-2 scores for Mortality Prognosis in Vietnamese Children with Multiple Organ Dysfunction Syndrome

Objective: To evaluate the performance of three scores, the Pediatric Index of Mortality 3 (PIM-3), the Pediatric Logistic Organ Dysfunction 2 (PELOD-2), and the modified PELOD-2 scores, in predicting mortality in multiple organ dysfunction syndrome (MODS) children in Vietnam.Material and Methods: This cross-sectional study of MODS children admitted to the pediatric intensive care unit (PICU) of a central children’s hospital in the Mekong Delta, Vietnam, was undertaken from April 2019 to June 2021. All three scores were evaluated using receiver operating characteristic (ROC) curves for discrimination and the Hosmer-Lemeshow goodness-of-fit test for calibration.Results: Of eighty-four subjects, the median age was 24.5 months and the overall mortality rate was 63.1%. ROC curve analysis showed that the area under the curve of PIM-3, PELOD-2, and modified PELOD-2 for predicting the death of MODS children were 0.77, 0.89, and 0.89, respectively. With individual cut-offs, the PIM-3, PELOD-2, and modified PELOD-2 scores had sensitivities for predicting mortality of 81.1%, 79.2%, and 81.1%, respectively, and specificities of 61.3%, 87.1%, and 80.6%, respectively. All three scores performed well in the Hosmer-Lemeshow goodness-of-fit test, indicating high calibration between predicted and observed mortalities (PIM-3: χ²=4.36, p-value=0.823; PELOD-2: χ²=4.837, p-value=0.775; modified PELOD-2: χ²=6.082, p-value=0.638).Conclusion: The PELOD-2 and modified PELOD-2 scores showed a better mortality prognosis than the PIM-3 score. Compared to the PELOD-2, the modified PELOD-2 with fewer parameters can still predict mortality well in Vietnamese children with MODS when using a cut-off score ≥9.

Multisystem Inflammatory Syndrome in Children Presenting as Acute Appendicitis

Background The majority of multisystemic inflammatory syndrome in children (MIS-C) patients presented with gastrointestinal symptoms. To draw attention to association of MIS-C and acute appendicitis, we reported a number of patients presented with localized symptoms as appendicitis but later diagnosed as MIS-C. The main goal of this study was to point out that localized presentation of MIS-C, and the secondary outcome was to compare 2 different treatment modalities of MIS-C. Methods The patients admitted to intensive care units of 2 tertiary hospitals, with diagnosis of MIS-C and accompanying clinically or radiologically suspected or confirmed appendicitis, were included. Data were retrospectively analyzed. The patients were examined in 2 groups as intravenous immunoglobulin (IVIG)-only and combined therapy. The combined therapy was defined as at least 2 immunomodulatory treatments of which included IVIG, steroid, Anakinra, and plasmapheresis. Results Between June 2020 and December 2020, 9 patients were enrolled in the study. The mean age was 8.7 ± 3.4 years. All patients had delayed diagnosis because of investigations focusing on abdominal pathologies such as appendicitis. Four patients had typical ultrasonographic findings of appendicitis and 2 were complicated with perforation. All patients had cardiovascular compromise accompanying at least 1 more organ dysfunction. In the IVIG only group, the median lymphocyte count was 480 cells/mm3 and the median levels of ferritin, C-reactive protein (CRP), procalcitonin, and interleukin 6 were 955 pg/mL, 17.4 mg/dL, 33.9 ng/mL, and 136.3 pg/mL, respectively. In the combined therapy group, the median lymphocyte count was 1200 cells/mm3 and the median levels of ferritin, CRP, procalcitonin, and interleukin 6 were 1650 pg/mL, 28 mg/dL, 47.8 ng/mL, and 56.7 pg/mL, respectively. The median pediatric risk of mortality 3 and pediatric logistic organ dysfunction scores of the combined therapy group were higher than IVIG-only group. The IVIG-only patients were more lymphopenic at presentation (P = 0.014), while ferritin, CRP, and procalcitonin levels of combined therapy group were higher than IVIG-only group (P = 0.376, P = 0.181, and P = 0.346, respectively). The mean length of stay in pediatric intensive care unit of combined therapy group was shorter than IVIG-only group. Conclusions Multisystemic inflammatory syndrome in children should be kept in mind in the differential diagnosis of patients with localized gastrointestinal symptoms, such as acute appendicitis. Early diagnosis and proper treatment of MIS-C may have a critical role in the patient's outcome.

Vascular Reactivity Index and PELOD-2 as a mortality predictor in paediatric septic shock: a single-centre retrospective study

BackgroundThe mortality rate for children with septic shock is stil quite high in low-income and middle-income countries (31.7%). One of the most widely used scoring systems to assess mortality in...

Development of a model for early differentiation of adenovirus pneumonia from Mycoplasma pneumoniae pneumonia.

Adenovirus pneumonia (AVP) and Mycoplasma pneumoniae pneumonia (MPP) have similar clinical manifestations such as a high prevalence of lung consolidation, making the differential diagnosis difficult before the etiology is reported. This study aimed to compare AVP and MPP, and to build a predictive model to differentiate them early. We selected 198 cases of AVP and 876 cases of MPP. Clinical manifestations, computed tomography (CT) features, and biomarkers were compared. A logistic regression model was built to predict AVP. The area under the curve (AUC) of the receiver-operating characteristic was calculated to evaluate the discriminant ability of the prediction model. Patients in the AVP group were mainly infants and toddlers, while the MPP group had more pre-school age children. The rate of hypoxemia and severe pneumonia was 3- and 11-times higher, respectively, in the AVP group than in the MPP group (5.6% vs. 1.8%, 27.8% vs. 2.5%, P<0.01). The proportion of patients with a Pediatric Logistic Organ Dysfunction-2 score ≥2 was 10 times higher in the AVP group than in the MPP group (17.4% vs. 1.7%, P<0.01). Bilateral pneumonia was present in 90.2% of the AVP group. Biomarkers, such as interleukin (IL)-2 receptor, IL-10 and lactic dehydrogenase (LDH), were considerably higher in the AVP group than in the MPP group (P<0.01). The predictive model included eight variables, namely: age, severe pneumonia, bilateral pneumonia, ground-glass attenuation, consolidation, atelectasis, C-reactive protein, and LDH. The AUC was 86.6%. Compared with MPP, AVP affects younger children, presents a more severe respiratory tract involvement, results in a larger range of lung lesions, and is associated with higher inflammatory biomarkers. Our predictive model includes a combination of clinical features, imaging findings, and biomarkers. It may help pediatricians in the early differentiation of AVP from MPP.

Multiple Organ Dysfunction Syndrome and Pediatric Logistic Organ Dysfunction-2 Score in Pediatric Cerebral Malaria.

Malaria resulted in an estimated 627,000 deaths in 2020, the majority of which occurred in children under 5 years of age. Cerebral malaria (CM) is a severe manifestation of the disease with case fatality rates of up to 40%. Autopsies in children with CM have demonstrated sequestration of Plasmodium falciparum parasites in the brain as well as multiple other organs. Thus, multiple organ dysfunction syndrome (MODS) may be present in pediatric patients with CM, but its frequency and association with mortality have not been evaluated. This is a retrospective study of data collected prospectively from children with CM admitted in Blantyre, Malawi. Physical examination findings and laboratory values necessary to calculate a Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score, a validated method that quantifies organ dysfunction in critically ill children, were abstracted. A total of 145 patients were included. Mortality was 15% (n = 22). Ten patients (7%) had single organ dysfunction, 36 (25%) had two organs involved, 68 (47%) had dysfunction of three organs, and 31 (21%) patients had four organs affected. Beyond neurologic dysfunction, other organ systems involved included hematologic (77%), renal (61%), cardiovascular (44%), and respiratory (1%). The median PELOD-2 score on admission was 4 (interquartile range [IQR] = 3-6) in survivors and 6.5 (IQR = 5-10) in the nonsurvivors (P < 0.0001). Admission PELOD-2 score predicted mortality with an area under the curve of 0.75. MODS is widespread in pediatric patients with CM. Objectively identifying children with MODS, and therefore at an increased risk of mortality, may allow for the allocation of limited resources.

Correlation of Syndecan-1 Level and Fluid Overload in Children with Sepsis

Background: Fluid resuscitation is one of the basic principles for managing sepsis, but excessive fluid causes the shedding of the endothelial glycocalyx (syndecan-1) and can cause capillary leakage and tissue edema. This study aimed to determine the correlation between the syndecan-1 level and fluid overload in children with sepsis. Materials and Methods: This was an analytic, cross-sectional study conducted in a pediatric intensive care unit. A total of 49 children aged 0–18 participated in this study. Factors investigated were age, gender, nutritional status, the site of infection, organ dysfunction, the severity of sepsis, outcome, blood culture, procalcitonin level, and Pediatric Logistic Organ Dysfunction-2 score. The syndecan-1 level was measured by examining the subject’s blood serum. Statistical analysis was done using the Spearman correlation test. Results: Forty-nine sepsis children aged 0–18 were enrolled, with a median age of 12 months. The respiration system was the most common site of infection, and dysfunction of the respiration system was the most common found in the subjects. The median of fluid overload was 8.3%, and the median of procalcitonin and syndecan levels was 17 ng/mL (interquartile range [IQR] = 1.97–64.03 ng/mL) and 372 ng/mL (IQR = 223.5–1389 ng/mL), respectively. The Spearman’s correlation test found a moderate correlation between syndecan-1 and fluid overload (r = 0.469, P = 0.001). Conclusion: The plasma concentrations of syndecan-1, a marker of endothelial glycocalyx shedding, were moderately correlated with the fluid overload in patients with sepsis, indicating the link between the fluid overload and the shedding of the glycocalyx.

Comparison of high flow oxygen therapy versus noninvasive mechanical ventilation for successful weaning from invasive ventilation in children: An observational study.

Post-extubation respiratory failure is associated with a poor prognosis due to increased ventilator-associated pneumonia, and longer length of stay in the ICU and hospital. In this study, we aimed to evaluate the efficacy of high-flow nasal cannula (HFNC) and noninvasive mechanical ventilation (NIMV) on extubation success in children. A total of 48 patients, aged between 1 month and 18 years, who were weaned to either NIMV or HFNC were included. Patients who had tracheostomy or were not weaned and underwent unplanned extubation were excluded. Age, gender, anthropometric parameters, Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores, oxygenation index, mechanical ventilation length of stay (LOS), HFNC/NIMV LOS, Modified Downes-Silverman score (MDS), and venous blood gas parameters, pediatric intensive care unit (PICU) LOS were recorded. 24 patients were extubated to NIMV, and 24 patients to HFNC. HFNC LOS and NIMV LOS were similar (P = .621). The failure rates at the 48th hour of HFNC and NIMV were 33% (n = 8), and 33% respectively (n = 8) (P = 1.0). PICU LOS and mortality rate was also similar (P = .06, P = .312 respectively). MDS decreased significantly in both groups (P < .001, P = .02 respectively). Changes in blood gas parameters and MDS within the first 48-hour of device application were similar between the 2 groups. HFNC is not inferior to NIMV in patients with extubation difficulty or those expected to have such difficulty in terms of treatment success, PICU LOS, and mortality. Therefore, HFNC appears to be a weaning technique alternative to NIMV after extubation.

Balanced Crystalloids versus Normal Saline in Children with Critical Asthma.

There is little known about the impact of maintenance fluid choice in children with critical asthma on clinical outcomes. Our primary study objectives were to determine the differences in the serum chloride and bicarbonate levels based on the receipt of 0.9% saline or a balanced solution. The secondary study objectives included differences in acute kidney injury (AKI) and intensive care unit (ICU)/hospital length of stay (LOS). In this retrospective cohort study, we included 1166 patients admitted to a quaternary children’s hospital with critical asthma between 2017 and 2019. The patients were stratified based on if they received 0.9% saline or a balanced solution (Lactated Ringer’s or Plasma-lyte) for maintenance therapy. The study outcomes were determined using independent sample t-tests, multivariable logistic regression, and negative binomial regression. The patients who received 0.9% saline maintenance therapy had a significantly higher increase in their serum chloride levels when compared to those who received balanced solutions (0.9% saline: +4 mMol/L, balanced: +2 mMol/L, p = 0.002). There was no difference in the decrease in the serum bicarbonate levels (0.9% saline: −0.4 mMol/L, balanced: −0.5 mMol/L, p = 0.830). After controlling for age, race, sex, and the Pediatric Logistic Organ Dysfunction (PELOD-2) score, there was no association between the type of fluid received and the development of AKI (OR 0.87, 95% CI: 0.46–1.63, p = 0.678). Additionally, there was no association between the type of fluid and hospital or ICU LOS. Thus, despite higher serum chloride levels in the patients that received 0.9% saline, the choice of fluid therapy did not have an impact on the serum bicarbonate values, the development of AKI or hospital and ICU LOS, suggesting there is little difference between 0.9% saline and balanced solutions as maintenance therapy in children with critical asthma.

Oxygenation Severity Categories and Long-Term Quality of Life among Children who Survive Septic Shock

Abstract Objectives This study aimed to test whether early oxygenation failure severity categories (absent/mild/moderate/severe) were associated with health-related quality of life (HRQL) deterioration among children who survived sepsis-related acute respiratory failure. Methods We performed a secondary analysis of a study of community-acquired pediatric septic shock, Life After Pediatric Sepsis Evaluation. The primary outcome was an adjusted decline in HRQL ≥ 25% below baseline as assessed 3 months following admission. Logistic regression models were built to test the association of early oxygenation failure including covariates of age and nonrespiratory Pediatric Logistic Organ Dysfunction-2 score. Secondarily, we tested if there was an adjusted decline in HRQL at 6 and 12 months and functional status at 28 days. Results We identified 291 children who survived to discharge and underwent invasive ventilation. Of those, that 21% (61/291) had mild oxygenation failure, 20% (58/291) had moderate, and 17% (50/291) had severe oxygenation failure. Fifteen percent of children exhibited a decline in HRQL of at least 25% from their baseline at the 3-month follow-up time point. We did not identify an association between the adjusted severity of oxygenation failure and decline in HRQL ≥ 25% at 3-, 6-, or 12-month follow-up. Children with oxygenation failure were more likely to exhibit a decline in functional status from baseline to hospital discharge, but results were similar across severity categories. Conclusion Our findings that children of all oxygenation categories are at risk of HRQL decline suggest that those with mild lung injury should not be excluded from comprehensive follow-up, but more work is needed to identify those at the highest risk.

Evaluation of Critically Ill Paediatric Patients in the Adult ICU

Background: Critically ill paediatric patient (CIPP) care may be required in the adult intensive care unit (aICU) of hospitals in cases where there is no paediatric intensive care unit (pICU) or when the pICU bed capacity is insufficient. Objectives: This is a retrospective evaluation of CIPPs who were accommodated in aICUs over the last 10 years to determine the type of hospital admission, indications for hospitalization, presence of comorbidities, treatments, causes of mortality, and effects of these parameters on mortality. Methods: We retrospectively analysed the medical records of 600 patients aged 28 days to 17 years who had been cared for at least 24 hours in aICUs between 2011 and 2021. Results: The average age of the CIPPs ((252 female (42%), 348 male (58%)) was 6 (7.4 ± 5.4) years. The mortality rate was 14.7%, and trauma (31.8%) was the most common cause of mortality, followed by respiratory diseases and septic shock. The independent risk factors found to be associated with mortality were as follows: Lower age, admission to ICUs from emergency departments of hospitals, higher Pediatric Risk of Mortality III and Pediatric Logistic Organ Dysfunction II scores, duration of hospital stay and of mechanical ventilation, vasopressor/inotropic agent requirement in the first 24 hours, higher total transfusion requirement, presence of nosocomial infection, thrombocytopenia, and lower haemoglobin level. Conclusions: It is important to achieve the best results and better outcomes for CIPPs in pICUs. However, a significant proportion of CIPPs currently hospitalized in aICUs are admitted with trauma. A close follow-up of mortality scores and clinical parameters in the early period of CIPP care in the aICU is critical as some mortality risk factors are preventable.

Pediatric acute liver failure: An experience of a pediatric intensive care unit from resource limited settings.

IntroductionPediatric acute liver failure is a rare and serious disease. Though liver transplantation is considered as the established treatment option for patients who are unlikely to recover with medical management, however, with the advancement of medical care there has been an increase in spontaneous regeneration of liver, obviating the need for liver transplantation. We identified the etiologies, outcome and prognostic factors of acute liver failure and the validity of the existing liver transplantation criteria to predict the outcome of pediatric acute liver failure.Materials and methodsThis was a retrospective study done from January 2014 to December 2019 in a tertiary pediatric critical care unit in South India. All children aged between 1 month to 18 years admitted with acute liver failure were enrolled.ResultsOf 125 children with acute liver failure, the main etiologies were infections (32%), indeterminate (23%), paracetamol toxicity (21%), metabolic (13%) and others (11%). Dengue was the most common infection (55%). The median pediatric logistic organ dysfunction score at admission was 12 (4–27). Of 125 patients, 63.2% (n = 79) had spontaneous regeneration which was higher in paracetamol induced (92.3%) compared to non-paracetamol induced acute liver failure (55.5%). Only two patients underwent liver transplantation and 35% died. Peak alanine transaminase and use of inotropes significantly predicted the outcome of disease. Of 38 children meeting King's College Hospital criteria for liver transplantation, 57.9% had spontaneous regeneration and 36.8% died. Of 74 children meeting INR > 4 criteria, 54% (n = 40) had spontaneous regeneration and 43.2% died. INR >4 criteria was more sensitive than King's College Hospital criteria for predicting the need for liver transplantation.ConclusionPediatric acute liver failure is caused by varied etiologies and infections were the commonest cause. Despite having a seriously ill cohort of patients, medical management resulted in spontaneous regeneration in the majority of children with acute liver failure. The use of inotropes, advanced hepatic encephalopathy, and peak alanine transaminase were predictors of poor outcome in children with acute liver failure and these patients could be considered for liver transplantation as available. Therefore, we may need to develop better predictors of pediatric acute liver failure in resource limited settings.

P50 implies adverse clinical outcomes in pediatric acute respiratory distress syndrome by reflecting extrapulmonary organ dysfunction

Hypoxemia and multiple organ dysfunction are significant contributors to mortality in patients with pediatric acute respiratory distress syndrome (PARDS). P50, the oxygen tension at which hemoglobin is 50% saturated, is a measure of hemoglobin-oxygen affinity, and its alteration might have implications for tissue hypoxia and organ dysfunction. The purpose of this single-center, retrospective study was to evaluate P50 levels in PARDS and to determine the association between P50 and clinical outcomes. The study included 212 children diagnosed with PARDS according to the Pediatric Acute Lung Injury Consensus Conference definition who required invasive mechanical ventilation and had arterial blood gas results of hemoglobin oxygen saturation < 97% at the time of diagnosis. P50 levels were calculated using Doyle’s method, and organ dysfunction was assessed using the Pediatric Logistic Organ Dysfunction-2 score. Most patients exhibited more than one dysfunctional extrapulmonary organ at PARDS onset. P50 increased with increasing PARDS severity (mild (26.6 [24.9–29.6]), moderate (26.8 [25.0–29.5]), and severe PARDS (29.1 [26.1–32.4] mmHg; P = 0.025). Moreover, P50 demonstrated a significant positive association with extrapulmonary organ dysfunction score (β = 0.158, P = 0.007) and risk of mortality (adjusted hazard ratio, 1.056; 95% confidence interval, 1.015–1.098; P = 0.007), irrespective of initial PARDS severity. The relationship between P50 and mortality was largely mediated by extrapulmonary organ dysfunction. A high P50 value at the time of PARDS diagnosis may be associated with mortality via dysfunctional extrapulmonary organs. Future studies should consider P50 as a potential candidate index for risk stratification of PARDS patients.