Pediatric Index Of Mortality Score Research Articles

Polyneuropathy in Critically Ill Mechanically Ventilated Children: Experience From a Tertiary Care Hospital in North India*

To determine the prevalence of critical illness polyneuropathy and its risk factors in critically ill children mechanically ventilated for 7 days or more. Observational cohort study. PICU of a tertiary care hospital from North India. Children 1-15 years old admitted in PICU from June 2016 to September 2017, mechanically ventilated for 7 days or more, excluding those with diagnosed neuromuscular disease, stroke, or spinal pathology. Demographic details, diagnosis, treatment details, and anthropometry at admission and enrolment were recorded. Nerve conduction studies were performed after enrolment and repeated a week later, if the child was still in PICU. Medical Research Council scoring for muscle strength was performed in survivors. Risk factors including Pediatric Index of Mortality-2 score, sepsis, multiple organ dysfunction, hypoalbuminemia, use of steroids, neuromuscular-blocking agents, and vasopressors were recorded. Samples for the level of micronutrients (copper, zinc, folate, and vitamin B12) were collected at the time of enrolling the child and at the time of discharge. Thirty-two children were enrolled, of whom 29 had features of critical illness polyneuropathy on evaluation at day 8 of mechanical ventilation (prevalence, 90.6% [95% CI, 80.5-100%]). The polyneuropathy was axonal in 26 (81.2%), mixed in one patient (3.1%), and uncharacterized in two (6.2%). Sepsis and multiple organ dysfunction were present in 31 subjects (96.9%). No risk factors for critical illness polyneuropathy could be identified although the study was not sufficiently powered to do so. The difference between serum micronutrient levels (copper, zinc, folate, and vitamin B12) between patients who developed polyneuropathy, and those who did not, was statistically insignificant. We observed a high prevalence of critical illness polyneuropathy in children in PICU, mechanically ventilated for 7 days or more; almost all of whom had underlying sepsis.

Early Diagnosis and Prognostic Value of Acute Kidney Injury in Critically Ill Patients.

Background and objectives: In hospitalized children, acute kidney injury (AKI) remains to be a frequent and serious condition, associated with increased patient mortality and morbidity. Identifying early biomarkers of AKI and patient groups at the risk of developing AKI is of crucial importance in current clinical practice. Specific human protein urinary neutrophil gelatinase-associated lipocalin (uNGAL) and interleukin 18 (uIL-18) levels have been reported to peak specifically at the early stages of AKI before a rise in serum creatinine (sCr). Therefore, the aim of our study was to determine changes in uNGAL and uIL-18 levels among critically ill children and to identify the patient groups at the highest risk of developing AKI. Materials and methods: This single-center prospective observational study included 107 critically ill children aged from 1 month to 18 years, who were treated in the Pediatric Intensive Care Unit (PICU) of Lithuanian University of Health Sciences Hospital Kauno Klinikos from 1 December 2013, to 30 November 2016. The patients were divided into two groups: those who did not develop AKI (Group 1) and those who developed AKI (Group 2). Results: A total of 68 (63.6%) boys and 39 (36.4%) girls were enrolled in the study. The mean age of the patients was 101.30 ± 75.90 months. The mean length of stay in PICU and hospital was 7.91 ± 11.07 and 31.29 ± 39.09 days, respectively. A total of 32 (29.9%) children developed AKI. Of them, 29 (90.6%) cases of AKI were documented within the first three days from admission to hospital. In all cases, AKI was caused by diseases of non-renal origin. There was a significant association between the uNGAL level and AKI between Groups 1 and 2 both on day 1 (p = 0.04) and day 3 (p = 0.018). Differences in uNGAL normalized to creatinine in the urine (uCr) (uNGAL/uCr) between the groups on days 1 and 3 were also statistically significant (p = 0.007 and p = 0.015, respectively). uNGAL was found to be a good prognostic marker. No significant associations between uIL-18 or Uil-18/uCr and development of AKI were found. However, the uIL-18 level of >69.24 pg/mL during the first 24 h was associated with an eightfold greater risk of AKI progression (OR = 8.33, 95% CI = 1.39–49.87, p = 0.023). The AUC for uIL-18 was 73.4% with a sensitivity of 62.59% and a specificity of 83.3%. Age of <20 months, Pediatric Index of Mortality 2 (PIM2) score of >2.5% on admission to the PICU, multiple organ dysfunction syndrome with dysfunction of three and more organ systems, PICU length of stay more than three days, and length of mechanical ventilation of >five days were associated with a greater risk of developing AKI. Conclusions: Significant risk factors for AKI were age of <20 months, PIM2 score of >2.5% on admission to the PICU, multiple organ dysfunction syndrome with dysfunction of 3 and more organ systems, PICU length of stay of more than three days, and length of mechanical ventilation of > five days. uNGAL was identified as a good prognostic marker of AKI. On admission to PICU, uNGAL should be measured within the first three days in patients at the risk of developing AKI. The uIL-18 level on the first day was found to be as a biomarker predicting the progression of AKI.

Characteristics and Outcomes of Critically Ill Pediatric Patients with Posterior Reversible Encephalopathy Syndrome.

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiologic entity, typically manifesting as reversible neurological symptoms and signs of white matter edema on magnetic resonance imaging. PRES has been widely described in adults. Studies of PRES in children are mostly limited to case series and case controls. Retrospective chart review of patients under 21years with PRES admitted at a tertiary children's hospital from 2011 to 2016. They were compared to controls matched for age and mortality risk using the Pediatric Index of Mortality-2 score. RESULTS: Sixteen cases of PRES were identified in 13 patients (ages 5-17years, 46% male). PRES presented with altered mental status (75%), seizures (77%), headache (31%), and vision changes (23%). In patients who recovered (n = 11), median days to symptom resolution was three (range 1-8). PRES patients had a higher mortality rate (15% vs. 5%, p < 0.05) and higher mean length of stay (13.1 vs. 4.6days) and were more likely to have autoimmune disease (p < 0.05), immunosuppression (p < 0.05), and anemia (p < 0.05). No PRES patients were diagnosed with epilepsy by last known follow-up, and all of whom had been started on an antiepileptic drug were discontinued within 13months. Sepsis was suspected in 53% of PRES patients and 59% of controls (p = 1.00). All PRES patients had stage II hypertension, versus 41% of controls (p < 0.05). Average creatinine in PRES was 2.35mg/dL compared to 0.90mg/dL in controls (p < 0.05). PRES patients had lower serum calcium (p < 0.05). After correcting for albumin, no association between PRES and hypocalcemia remained. PRES patients had a higher length of stay (13.1 vs. 4.6days, p < 0.05) and mortality rate (15% vs. 3%, p < 0.05). Immunosuppression, autoimmune disease, renal insufficiency, anemia, and hypertension are associated with PRES after controlling for mortality risk in critically ill children. There was no association between corrected serum calcium and sepsis with PRES.

Outcomes of Children With Bronchiolitis Treated With High-Flow Nasal Cannula or Noninvasive Positive Pressure Ventilation.

Initial respiratory support with noninvasive positive pressure ventilation or high-flow nasal cannula may prevent the need for invasive mechanical ventilation in PICU patients with bronchiolitis. However, it is not clear whether the initial choice of respiratory support modality influences the need for subsequent invasive mechanical ventilation. The purpose of this study is to compare the rate of subsequent invasive mechanical ventilation after initial support with noninvasive positive pressure ventilation or high-flow nasal cannula in children with bronchiolitis. Analysis of the Virtual Pediatric Systems database. Ninety-two participating PICUs. Children less than 2 years old admitted to a participating PICU between 2009 and 2015 with a diagnosis of bronchiolitis who were prescribed high-flow nasal cannula or noninvasive positive pressure ventilation as the initial respiratory treatment modality. None. Subsequent receipt of invasive mechanical ventilation was the primary outcome. We identified 6,496 subjects with a median age 3.9 months (1.7-9.5 mo). Most (59.7%) were male, and 23.4% had an identified comorbidity. After initial support with noninvasive positive pressure ventilation or high-flow nasal cannula, 12.3% of patients subsequently received invasive mechanical ventilation. Invasive mechanical ventilation was more common in patients initially supported with noninvasive positive pressure ventilation compared with high-flow nasal cannula (20.1% vs 11.0%: p < 0.001). In a multivariate logistic regression model that adjusted for age, weight, race, viral etiology, presence of a comorbid diagnosis, and Pediatric Index of Mortality score, initial support with noninvasive positive pressure ventilation was associated with a higher odds of subsequent invasive mechanical ventilation compared with high-flow nasal cannula (odds ratio, 1.53; 95% CI, 1.24-1.88). In this large, multicenter database study of infants with acute bronchiolitis that received initial respiratory support with high-flow nasal cannula or noninvasive positive pressure ventilation, noninvasive positive pressure ventilation use was associated with higher rates of invasive mechanical ventilation, even after adjusting for demographics, comorbid condition, and severity of illness. A large, prospective, multicenter trial is needed to confirm these findings.

Prognostic scoring systems in pediatric ICUs: Pediatric Risk of Mortality III versus Pediatric Index of Mortality 2

Background Estimations of disease severity and probability of death are important elements in determining the prognosis of patients in pediatric ICU (PICU), and a more accurate prognostic assessment can lead to more appropriate monitoring, proper management, and family counseling. Objective The aim of the study was to compare the performance of the PRISM III (Pediatric Risk of Mortality III) and the PIM2 (Pediatric Index of Mortality 2) scores at PICU and to investigate the relation between scores and mortality. Patients and methods A prospective observational cohort study was conducted at PICU, Menoufia University Hospital, Egypt, during the period of February to October 2017. The study was approved by the Ethical Committee of Menoufia University Hospital. A total of 50 patients were included during the study period. Within the first hour of admission, PIM2 and PRISM III scores were applied. Patients were followed up for outcome, measured in the form of survivors and nonsurvivors. Results A total 50 patients were included, of whom 35 were survivors and 15 were nonsurvivors. Most survivors and nonsurvivors were females, but there was no statistical significant influence on outcome. The area under the receiver operating characteristic curve was 0.937 (0.863–1.000) for PRISM III and 0.870 (0.759–0.99) for PIM2. There was a positive correlation between the two scores on the day of admission. Conclusion Both PRISM III and PIM2 scores have a good discriminatory performance. PRISM III has better discrimination ability on admission in comparison with PIM2.

Abstract P-324: THE PERFORMANCE OF THE PAEDIATRIC INDEX OF MORTALITY (PIM) SCORE IN PRETERM POPULATIONS IN A PAEDIATRIC INTENSIVE CARE UNIT

Aims & Objectives: Paediatric index of mortality (PIM) score is a widely-used severity scoring system used to predict outcomes of patients admitted to paediatric intensive care units, and to monitor the quality of intensive care. In the UK, preterm neonates may be admitted to paediatric intensive care units. The PIM score is calibrated for necrotising enterocolitis but not for prematurity. We hypothesize that PIM score performance will deteriorate with increasing prematurity. Methods There were 1490 admissions to our unit over 10 years (2006–16) with gestational age between 23 and 37 weeks on admission. They were grouped according to gestational age (23–26 weeks N=81, 27–30 weeks N=399, 31–34 weeks N=579, 35–37 weeks N=431) and the standardised mortality ratio (SMR) was calculated for each group (SMR=Observed deaths/Expected deaths). Results The SMRs with 95% confidence intervals for each group are represented in table 1.More deaths than expected occurred amongst the patients admitted with gestational age 31–34 weeks (95% confidence interval 1.07 – 1.73). SMR for the other groups lie within the 95% confidence interval. Conclusions The PIM score may underestimate morality for preterm neonates admitted to a UK PICU with a gestational age of 31–34 weeks. Our analysis does not support the hypothesis that PIM score performs increasingly poorly with increasing prematurity. However, the numbers of patients in each group remains small and the data was taken from a single UK center. Confirming this observation is important in order for ICUs that admit preterm children to confidently use PIM scoring to assess their performance.

Hypoalbuminemia as a marker of adverse outcome in children admitted to pediatric intensive care unit

Background: Research on critically ill adult patients has shown the usefulness of albumin as a predictor of increased morbidity and mortality. There is a paucity of similar data in pediatric age group. Objective: The objective of the study was to know the incidence of hypoalbuminemia in children admitted to pediatric intensive care unit (PICU) and its correlation to disease severity and clinical outcome. Materials and Methods: This was a prospective observational study conducted at the PICU of a tertiary care hospital. Children of age group 1 month – 18 years admitted to the PICU were included in the study. Serum albumin levels were estimated at the time of admission to PICU. Pediatric index of mortality 2 (PIM2) scoring system was used to assess the severity of illness at admission and to calculate the predicted death rate (PDR). The independent sample t-test and Fisher’s exact test were used to compare the albumin levels with PDR and duration of hospital or PICU stay. Mortality risk was computed using Pearson’s Chi-square test. Multivariate regression analysis was performed to evaluate whether hypoalbuminemia is an independent predictor of mortality. Results: Mean serum albumin level in this study was 3.38±0.89 g/dL. The incidence of hypoalbuminemia was 44.1%. The PDR (calculated using PIM2 score) was increased in children with hypoalbuminemia compared with the normal albumin level group (p=0.004). As compared to children with normal albumin levels, children with hypoalbuminemia had longer duration of PICU stay (95% confidence interval (CI) for difference 0.86–3.03; p=0.05), higher need for ventilator support (odds ratio (OR) 4.2, p=0.003) and higher mortality (OR 0.16, p=0.002). The association of serum albumin levels with mortality remained significant even after adjusting for age and PDR by PIM2 score (OR=3.68; 95% CI, 1.76–7.74; p&lt;0.001). Conclusion: Hypoalbuminemia is a significant predictor of mortality and morbidity in critically ill children.

Six-Hour Sepsis Bundle Decreases Mortality: Truth or Illusion - A Prospective Observational Study.

Aim:The aim of the study is to evaluate whether 6-h sepsis bundle component compliance (complete vs. incomplete) decreases mortality in pediatric patients with severe sepsis and septic shock.Methodology:The study was conducted at a tertiary care hospital. Patients aged 1 month–13 years admitted to pediatric intensive care unit with severe sepsis, or septic shock were prospectively enrolled. The clinical data and blood investigations required for sepsis bundle were recorded. Predicted mortality was calculated at admission by the online pediatric index of mortality-2 (PIM-2) score calculator. Patients who fulfilled all the components of 6-h sepsis bundle were taken as compliant while failure to fulfill even a single component rendered them noncompliant. The outcome was recorded as died or discharged.Results:Of 116 patients, 90 (77.59%) had 100% sepsis bundle component compliance and were taken into the compliant group while the rest 26 (22.41%) were noncompliant. Forty out of 90 patients (44.4%) died in compliant group in comparison to 5 out of 26 (19.3%) in noncompliant group, P = 0.020. The pre- and post-interventional lactates were significantly higher in compliant group as compared to the noncompliant group, P < 0.0001 and 0.019, respectively. Rising lactate level parallels increasing predicted mortality by PIM-2 score in compliant group, but this association failed to reach significance in noncompliant group which can be attributed to less number of subjects available in this group.Conclusion:Irrespective of sepsis bundle compliance (complete/incomplete), outcome depends on the severity of illness reflected by high lactate and predicted mortality.

Being Underweight Is an Independent Risk Factor for Poor Outcomes Among Acutely Critically Ill Children.

Malnutrition is associated with impaired immune function; thus, nutrition status assessment is crucial in critical care medicine. We aimed to investigate the impact of being underweight or overweight on major sequelae and mortality among healthy children with an intensive care unit admission. In this retrospective study, 282 patients aged 1 month to 18 years were enrolled on intensive care unit admission between 2011 and 2012. Children were excluded if they had underlying chronic diseases and were transferred to other hospitals or discharged against medical advice. The patients were further categorized into 3 nutrition status groups according to the weight-for-age (W/A) z score. The prevalence rates of being underweight and overweight, based on W/A z scores of ≤-2 and ≥2, were 8.2% and 5.7%, respectively. Patients who were underweight were younger and had a higher rate of mortality, poor outcomes, and longer duration of mechanical ventilation than those with a normal weight. The patients with mortality or major sequelae had significantly higher rates of being underweight, noninfectious diseases and hypotension, and higher Pediatric Index of Mortality 2 (PIM2) score and creatinine level (all P < .01). In multivariate logistic regression interpretation, the W/A z score ≤-2 (95% CI, 2.992-47.508; P < .001) and PIM2 score (95% CI, 1.094-1.413; P = .001) were independent risk factors for a poor outcome. Being underweight and having a PIM2 score on admission were independent risk factors for poor clinical outcomes among critically ill children without underlying diseases.

Characterizing social worker and chaplain interactions with parents of critically ill children with cancer.

e22024 Background: Parents of children with cancer admitted to the pediatric intensive care unit (PICU) often obtain support from social workers and/or chaplains (SWs/Cs). Yet, empirical work describing the roles and activities of SWs/Cs caring for patients in the PICU is lacking. This study examined the roles of SWs/Cs caring for critically ill children with cancer and their families. Methods: Parents of patients with cancer expected to have a PICU stay &gt; 72 hours, ongoing involvement with palliative care, or a pediatric index of mortality score &gt; 4 were invited to participate. These criteria were meant to identify patients with more complicated PICU admissions. The SWs/Cs caring for these families in the PICU were also invited to participate. SWs/Cs audio recorded information about their encounters with parents and patients, specifically, who was present, the kinds of supports provided, and the discussion topics. These recordings were analyzed using content analysis resulting in broad categories describing support provided to the families by SWs/Cs. Results: In total, 3 SWs and 3 Cs submitted recordings about 34 encounters with families of 9 patients. Categories of activities and supports identified from these recordings included: discussing the child’s condition, assessing parent or child coping, assessing the role of faith, discussing communication between parents and the medical team or advocating for the family with the medical team, providing emotional support to patients and families, discussing concerns outside of the hospital (family, financial, work), and providing legal and/or logistical support. SWs/Cs, in general, provided very similar services to families. Conclusions: SWs and Cs caring for PICU patients with cancer and their families have overlapping roles in providing emotional, communication, and logistical support. Future work will identify barriers and facilitators to SWs and Cs providing support to critically ill children with cancer.

Increasing Incidence of Life-threatening Pertussis: A Retrospective Cohort Study in New Zealand.

Pertussis immunization programs aim to prevent severe infant disease. We investigated temporal trends in infant pertussis deaths and pediatric intensive care unit (PICU) admissions and associations of changes in disease detection and vaccines used with death and PICU admission rates. Using national data from New Zealand (NZ), we described infant pertussis deaths and PICU admissions from 1991 to 2013, over which time national immunization coverage at 2 years of age increased from <80% to 92%. In NZ, pertussis became a notifiable disease with polymerase chain reaction (PCR) diagnosis available in 1997 and acellular replaced whole-cell vaccine in 2000. We used Poisson regression to model temporal trends and compared rates in time intervals using rate ratios (RRs) with 95% confidence intervals (CIs). There were 10 pertussis deaths and 159 infant PICU admissions with pertussis from 1991 to 2013. The annual number of infant pertussis PICU admissions increased from 1991 to 2013 (P = 0.02) but the number of pertussis deaths did not (P = 0.09). The risk of PICU admission during infancy with pertussis was increased in the notification/PCR versus the non-notification/PCR era (RR: 1.12; 95% CI: 1.02-1.19) and when acellular replaced whole-cell vaccine (RR: 1.19; 95% CI: 1.06-1.31). Median Pediatric Index of Mortality scores during 2001-2013 were lower than during 1991-1999 (P < 0.001). Infant PICU pertussis admission rates have increased in NZ despite improvements in immunization coverage. Higher rates have occurred since pertussis notification/PCR became available and since acellular replaced whole-cell vaccine. The severity of disease in infants admitted to PICU with pertussis has decreased in recent years.

Using the paediatric index of mortality score to report severity of illness in babies and children retrieved to New South Wales tertiary centres

Using the paediatric index of mortality score to report severity of illness in babies and children retrieved to New South Wales tertiary centres

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

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

PROPER: Development of an Early Pediatric Intensive Care Unit Readmission Risk Prediction Tool.

No risk prediction model is currently available to measure patient's probability for readmission to the pediatric intensive care unit (PICU). This retrospective case-control study was designed to assess the applicability of an adult risk prediction score (Stability and Workload Index for Transfer [SWIFT]) and to create a pediatric version (PRediction Of PICU Early Readmissions [PROPER]). Eighty-six unplanned early (<48 hours) PICU readmissions from January 07, 2007, to June 30, 2014, were compared with 170 random controls. Patient- and disease-specific data and PICU workload factors were compared across the 2 groups. Factors statistically significant on multivariate analysis were included in the creation of the risk prediction model. The SWIFT scores were calculated for cases and controls and compared for validation. Readmitted patients were younger, weighed less, and were more likely to be admitted from the emergency department. There were no differences in gender, race, or admission Pediatric Index of Mortality scores. A higher proportion of patients in the readmission group had a Pediatric Cerebral Performance Category in the moderate to severe disability category. Cases and controls did not differ with respect to staff workload at discharge or discharge day of the week; there was a much higher proportion of patients on supplemental oxygen in the readmission group. Only 2 of 5 categories in the SWIFT model were significantly different, and although the median SWIFT score was significantly higher in the readmissions group, the model discriminated poorly between cases and controls (area under the curve: 0.613). A 7-category PROPER score was created based on a multiple logistic regression model. Sensitivity of this model (score ≥12) for the detection of readmission was 81% with a positive predictive value of 0.50. We have created a preliminary model for predicting patients at risk of early readmissions to the PICU from the hospital floor. The SWIFT score is not applicable for predicting the risk for pediatric population.

Protocolized Treatment Is Associated With Decreased Organ Dysfunction in Pediatric Severe Sepsis.

To determine whether treatment with a protocolized sepsis guideline in the emergency department was associated with a lower burden of organ dysfunction by hospital day 2 compared to nonprotocolized usual care in pediatric patients with severe sepsis. Retrospective cohort study. Tertiary care children's hospital from January 1, 2012, to March 31, 2014. Patients older than 56 days old and younger than 18 years old with international consensus defined severe sepsis and who required PICU admission within 24 hours of emergency department arrival were included. The exposure was the use of a protocolized emergency department sepsis guideline. The primary outcome was complete resolution of organ dysfunction by hospital day 2. One hundred eighty nine subjects were identified during the study period. Of these, 121 (64%) were treated with the protocolized emergency department guideline and 68 were not. There were no significant differences between the groups in age, sex, race, number of comorbid conditions, emergency department triage level, or organ dysfunction on arrival to the emergency department. Patients treated with protocolized emergency department care were more likely to be free of organ dysfunction on hospital day 2 after controlling for sex, comorbid condition, indwelling central venous catheter, Pediatric Index of Mortality-2 score, and timing of antibiotics and IV fluids (adjusted odds ratio, 4.2; 95% CI, 1.7-10.4). Use of a protocolized emergency department sepsis guideline was independently associated with resolution of organ dysfunction by hospital day 2 compared to nonprotocolized usual care. These data indicate that morbidity outcomes in children can be improved with the use of protocolized care.

Vitamin D deficiency and parathyroid response in critically-ill children: Association with illness severity and clinical outcomes

To determine the prevalence of vitamin D deficiency in critically ill children, and to study its association with parathyroid response, severity of illness and clinical outcomes. Prospective observational study. Medical Pediatric Intensive Care Unit of a tertiary care centre of Northern India. 154 children in-patients: August 2011-January 2013. Vitamin D deficient children were (serum 25-hydroxy vitamin D <20 ug/mL) divided into parathyroid-responder [serum parathyroid hormone >65 pg/mL with 25(OH)D<20 ug/mL and/or calcium corrected for albumin <8.5 mg/dL] and non parathyroid-responder. Illness severity was assessed by Pediatric Index of Mortality-2 (PIM-2) score at admission. Biochemical parameters, illness severity scores and clinical outcomes were compared between parathyroid-responders and non-parathyroid-responders. Vitamin D deficiency and hypocalcemia were observed in 125 (83.1%) and 91 (59%) children, respectively at admission. There were no differences in illness severity score at admission, mortality rate and length of stay between vitamin D-deficient children and 19.8% of non-vitamin D-deficient children. Among Vitamin D-deficient children, parathyroid-responders had higher PIM-2 score at admission compared to non-parathyroid-responder [12.8 (7.4,20.6) vs. 6.5 (2.5,12.2), P=0.01]. However, there were no differences in other clinical outcomes between two groups. Critically ill children have high prevalence of vitamin D deficiency. Parathyroid gland response secondary to hypocalcemia or vitamin D defiency is impaired in critical illness.

Is it taking longer to die in paediatric intensive care in England and Wales?

IntroductionAll-cause infant and childhood mortality has decreased in the UK over the last 30 years. Advances in paediatric critical care have increased survival in paediatric intensive care units (PICUs) but...

Impact of Retrieval, Distance Traveled, and Referral Center on Outcomes in Unplanned Admissions to a National PICU.

Centralization of PICUs requires a transport system that delivers patient outcomes equivalent to that of the same institution admissions. Our aim was to evaluate how pediatric critical care retrieval, distance traveled, and referral center level of ICU support impact on outcomes in unplanned admissions. Retrospective cohort study. The national PICU in New Zealand. A total of 5,609 (45% retrieved) unplanned pediatric admissions (< 15 yr) between January 1, 2004, and January 1, 2014. None. Data analyzed included case-mix, source of admission, diagnostic category, Pediatric Index of Mortality score, PICU-specific resource use, distance traveled, transport duration, and referral hospital ICU level. Outcome measures were crude and risk-adjusted PICU mortality and PICU length of stay. Compared with nontransported admissions, retrieved children were younger, more frequently admitted outside normal working hours, had higher predicted mortality (median Pediatric Index of Mortality score, 4.7% vs 1.5%; p < 0.001) and PICU-specific resource use (respiratory support, vasoactive infusions, and renal replacement therapy). The transport cohort had greater crude mortality rates (8.6% vs 5.6%; p < 0.008) and a median of 29 hours longer PICU stay. There was no significant difference in risk-adjusted mortality between the cohorts (observed/expected mortality ratio for retrieved patients, 0.84 vs nontransported patients, 0.91; p = 0.73). Neither distance traveled (median, 135 km), transport duration (median, 4.4 hr), nor the level of ICU at the referral center had a significant effect on risk-adjusted PICU mortality in the retrieved cohort. Children retrieved to the national PICU in New Zealand have greater predicted mortality risk and PICU-specific resource use than nontransported patients. There is no significant difference in risk-adjusted mortality between retrieved and the same institution admissions. Critically ill pediatric patients can be transported long distances by specially trained and equipped transport teams, without an increase in risk-adjusted PICU mortality.

Infectious Etiologies and Patient Outcomes in Pediatric Septic Shock

Septic shock remains an important cause of death and disability in children. Optimal care requires early recognition and treatment. We evaluated a retrospective cohort of children (age <19) treated in our emergency department (ED) for septic shock during 2008-2012 to investigate the association between timing of antibiotic therapy and outcomes. The exposures were (1) receipt of empiric antibiotics in ≤1 hour and (2) receipt of appropriate antibiotics in ≤1 hour. The primary outcome was development of new or progressive multiple system organ dysfunction syndrome (NP-MODS). The secondary outcome was mortality. Among 321 patients admitted to intensive care, 48% (n = 153) received empiric antibiotics in ≤1 hour. These patients were more ill at presentation with significantly greater median pediatric index of mortality 2 (PIM2) scores and were more likely to receive recommended resuscitation in the ED (61% vs 14%); however, rates of NP-MODS (9% vs 12%) and hospital mortality (7% vs 4%) were similar to those treated later. Early, appropriate antibiotics were administered to 33% (n = 67) of patients with identified or suspected bacterial infection. These patients had significantly greater PIM2 scores but similar rates of NP-MODS (15% vs 15%) and hospital mortality (10% vs 6%) to those treated later. Critically ill children with septic shock treated in a children's hospital ED who received antibiotics in ≤1 hour were significantly more severely ill than those treated later, but they did not have increased risk of NP-MODS or death.

Validación del índice pediátrico de mortalidad 2 (PIM2) en Argentina: un estudio prospectivo, multicéntrico, observacional

The Pediatric Index of Mortality 2 (PIM2) is one of the most commonly used scoring systems to predict mortality in patients admitted to pediatric intensive care units (PICU) in Argentina. The objective of this study was to validate the PIM2 score in PICUs participating in the Quality of Care Program promoted by the Argentine Society of Intensive Care. Multicenter, prospective, observational, cross-sectional study. All patients between 1 month and 16 years old admitted to participating PICUs between January 1st, 2009 and December 31st, 2009 were included. The discrimination and calibration of the PIM2 score were assessed in the entire population and in different subgroups (risk of mortality, age, diagnoses on admission). Two thousand, eight hundred and thirty-two patients were included. PIM2 predicted 246 deaths; however, 297 patients died (p < 0.01). The standardized mortality ratio was 1.20 (95% confidence interval [CI]: 1.01-1.43). The area under the ROC curve was 0.84 (95% CI: 0.82-0.86). Statistically significant differences were detected between the observed and the predicted mortality for the entire population and for the different risk intervals (χ2: 71.02, df: 8, p < 0.001). Statistically significant differences were also found between observed and predicted mortality in adolescent patients (37/22, p = 0.03) and in those hospitalized due to respiratory disease (105/81, p = 0.03). The PIM2 score adequately discriminates survivors from non-survivors. However, it underscores the overall risk of death, especially in adolescent patients and those hospitalized due to respiratory disease. It is critical to take such differences into account when interpreting results.