Pediatric Index Of Mortality Research Articles

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Introduction: Children with chronic conditions exhibit an increased rate of severe acute illnesses requiring pediatric critical care. Some of these children receive mechanical ventilation; however, the subcategory of chronic conditions requiring mechanical ventilation and associated with mortality risk in children remains unclear. Hypothesis: The objective of this study was to delineate the risk of PICU mortality and prolonged duration of mechanical ventilation and PICU stay in children with chronic conditions requiring mechanical ventilation in the PICU. Methods: A retrospective cohort study was conducted in a 10-bed PICU in a tertiary children’s hospital in Japan. We reviewed all intubation cases in the PICU between April 2008 and July 2012. We recorded age, sex, Pediatric Index of Mortality 2 (PIM2) scores, main reason for admission, history of chronic conditions, duration of mechanical ventilation, duration of PICU stay, and mortality throughout the study period. Results: During the study period, 351 children underwent mechanical ventilation, of which 10.0% exhibited more than two chronic conditions, 40.4 % exhibited one chronic condition, and 49.6 % exhibited no chronic condition. Children with chronic conditions were not associated with mortality or prolonged duration of PICU stay. Of the various chronic subcategories, the subcategory of hematological/oncological chronic conditions was associated with significantly greater odds of PICU mortality [odds ratios, 4.77; 1.18–12.5); p < 0.01] and significantly longer duration of mechanical ventilation (p = 0.021) compared with non-hematological/oncological chronic conditions. There was no difference in PIM2 scores between the two groups (p = 0.251). Respiratory, cardiac, central nervous, gastrointestinal, and other chronic conditions were not associated with increased odds of PICU mortality and duration of mechanical ventilation. Conclusions: Children with one or more than two chronic conditions are not at a greater risk for PICU mortality and prolonged duration of PICU stay compared with children with no chronic condition. PIM2 scores were not increased in either group; however, hematological/oncological chronic conditions were associated with an adverse outcome.

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Introduction: Our aim was to evaluate the association between time and day of admission to a pediatric intensive care unit (PICU) and patient outcomes. Hypothesis: Patient outcomes are not associated with the time (day shift vs. night shift) or the day (weekday vs. weekend) of admission to the PICU. Methods: We conducted a retrospective cohort study of all children admitted to our PICU from January 2005 to Jan 2009. Admissions were divided into three groups: weekday admissions (Mon-Fri) from 7AM-7PM (Group 1), weekday admissions from 7PM-7AM (Group 2) and all weekend admissions on Saturdays and Sundays (Group 3). We extracted de-linked data from the hospital VPS database relating to age, gender, Pediatric Index of Mortality 2 Risk of Mortality (PIM2ROM), length of PICU stay and mortality. Descriptive data is presented as mean for parametric data or median for non-parametric data and as percentages for categorical data. Kruskal-Wallis one-way analysis of variance is used to assess the differences in the means of the three groups. Binary data (mortality and gender) is analyzed using Chi-square test. A p value <0.05 is considered significant. Results: Out of a total 5718 admissions to the PICU 2230 (39%) were in Group 1, 2242 (39%) were in Group 2 and 1246 (22%) were in Group 3. Males and females were 56.2% and 43.8% with no difference among the groups. The median ages of patients in the three groups were 65.1, 6.8 and 47.9 months respectively with younger patients being admitted on the weekends (p=0.01). Overall mortality rate was 1.97% with rates of 2.1%, 1.6% and 2.4% in the three groups respectively (p=0.22). The median lengths of stay were 1.86, 1.72 and 1.9 respectively. The median PIM2ROM was 0.011, 0.01 and 0.0099 respectively. There was no statistical difference in gender distribution, mortality, length of stay or PIM2ROM between the three groups. Conclusions: Age of patients admitted tended to be lower on the weekends. Admission to a PICU during weekends or at night was not found to be associated with an increased mortality or length of stay.

Inflammatory cytokine measurement quickly discriminates gram-negative from gram-positive bacteremia in pediatric hematology/oncology patients with septic shock

We performed a prospective study to evaluate the ability of inflammatory cytokines in discriminating gram-negative from gram-positive bacteremia in septic shock. During the study period, the serum inflammatory cytokine levels were measured at the onset of septic shock by flow cytometry in pediatric hematology/oncology patients with septic shock. One hundred episodes of septic shock were enrolled. Of 97 episodes of monomicrobial infection, 73.2 % were caused by gram-negative bacteremia and 26.8 % by gram-positive bacteremia. Interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-α were closely related to the pediatric index of mortality 2 (PIM2) score and mortality. However, although the PIM2 score and mortality were comparable, the IL-6, IL-10, and TNF-α levels were significantly higher in patients with gram-negative bacteremia (GNB) than those with gram-positive bacteremia (median levels, pg/mL: IL-6: 784.1 vs. 254.4, P = 0.001; IL-10: 192.2 vs. 19.7, P < 0.001; TNF-α: 4.2 vs. 2.0, P < 0.001). Of the three cytokines, IL-10 was the most useful biomarker for GNB prediction in the derivation cohort and a cutoff value of 50 pg/mL showed a sensitivity of 70.8 % and a specificity of 80.0 %, with a positive predictive value of 89.5 %. When this cutoff value was applied to the validation cohort, the sensitivity, specificity, and positive predictive value were 80.9, 75.0, and 90.5 %, respectively. Flow cytometry-based inflammatory cytokine measurement is a helpful adjuvant approach for early and quick discrimination of gram-negative from gram-positive bacteremia in pediatric hematology/oncology patients with septic shock which might be useful for evaluating the severity of shock and the selection and/or timely withdrawal or switch of antibiotics.

The relationship between blood lactate concentration, the Paediatric Index of Mortality 2 (PIM2) and mortality in paediatric intensive care

Blood lactate concentration predicts mortality in neonates, infants, children and adults, with evidence that it has better predictive power than other markers of acid-base status such as absolute base excess or pH. To investigate whether blood lactate concentration on admission predicts mortality in paediatric intensive care and if its addition can improve the performance of the Paediatric Index of Mortality2 (PIM2) mortality prediction score. Retrospective cohort study in one 20-bed UK paediatric intensive care unit (PICU) using data from the PICU clinical and blood gas analyser databases between 2006 and 2010. Only cases with a blood lactate concentration measured at the same time as the PIM2 variables were included. Logistic regression was used to assess if blood lactate concentration predicted mortality independently of PIM2, adjusting for potential confounders, and if it could replace absolute base excess in the PIM2 model. There were 155 deaths amongst 2,380 admissions (6.5%). Admission lactate in non-survivors was higher than in survivors (mean [standard deviation, SD]) 6.6 [5.6] versus 3.0 [2.5]mmol/l, had a positive association with mortality [adjusted odds ratio (OR) for death per unit (mmol/l)] increase 1.11 [95% confidence interval (CI) 1.06-1.16; p<0.001] and significantly improved the model fit of PIM2 when it replaced absolute base excess (p<0.001). PICU admission blood lactate concentration predicts mortality independently of PIM2. Given the limitations of this study, a prospective multi-centre evaluation is required to establish whether it should be added to the PIM2 model with or without replacement of base excess.

825 Hypoalbuminemia is Independently Associated with Morbidity and Mortality in Critically ill Children

Background and AimAlthough hypoalbuminemia has been recognized as a marker of poor outcome in adult patients, this association has not been demonstrated in a general population of pediatric critically ill...

Long-term quality of life of patients treated in paediatric intensive care unit

The changes in long-term quality of life (QOL) of children treated in paediatric intensive care unit (PICU) were investigated in relation to their QOL before critical illness together with the influence of underlying chronic health condition and severity of illness estimated by Paediatric Index of Mortality 2 on the long-term outcome. This study included 189 children treated in PICU and 179 children from outpatient clinics as controls. QOL was evaluated according to the Royal Alexandra Hospital for Children Measure of Function (RAHC MOF). The long-term QOL in 70 % of children treated in PICU was good, although there was a significant diminution of QOL in children treated in PICU in comparison with their preadmission scores and with the children from outpatient clinics who served as controls (p < 0.001). Severity of illness had a significant impact on children's QOL (p = 0.016) 6 months after treatment in PICU. Twenty-four months after discharge, the RAHC MOF score was still decreased in 19 % of children treated in PICU, and in significantly more patients with a chronic health condition (CHC) treated in PICU, than in their peers from outpatient clinics (p = 0.029). Reduced QOL was significantly more frequent in children with neurodevelopmental disability than in children without CHC 24 months after discharge from PICU (p = 0.013). Acute illness has a significant impact both on children with and without CHC after treatment in PICU 6 months after discharge. Twenty-four months after discharge, comorbidity was identified as the decisive factor for diminished QOL in children after PICU treatment.

What are the factors that influence the attainment of satisfactory energy intake in pediatric intensive care unit patients receiving enteral or parenteral nutrition?

ObjectiveChildren admitted to the intensive care unit (ICU) are at risk of inadequate energy intake. Although studies have identified factors contributing to an inadequate energy supply in critically ill children, they did not take into consideration the length of time during which patients received their estimated energy requirements after having achieved a satisfactory energy intake. This study aimed to identify factors associated with the non-attainment of estimated energy requirements and consider the time this energy intake is maintained. MethodsThis was a prospective study involving 207 children hospitalized in the ICU who were receiving enteral and/or parenteral nutrition. The outcome variable studied was whether 90% of the estimated basal metabolic rate was maintained for at least half of the ICU stay (satisfactory energy intake). The exposure variables for outcome were gender, age, diagnosis, use of vasopressors, malnutrition, route of nutritional support, and Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction scores. ResultsSatisfactory energy intake was attained by 20.8% of the patients, within a mean time of 5.07 ± 2.48 d. In a multivariable analysis, a diagnosis of heart disease (odds ratio 3.62, 95% confidence interval 1.03–12.68, P = 0.045) increased the risk of insufficient energy intake, whereas malnutrition (odds ratio 0.43, 95% confidence interval 0.20–0.92, P = 0.030) and the use of parenteral nutrition (odds ratio 0.34, 95% confidence interval 0.15–0.77, P = 0.001) were protective factors against this outcome. ConclusionA satisfactory energy intake was reached by a small proportion of patients during their ICU stay. Heart disease was an independent risk factor for the non-attainment of satisfactory energy intake, whereas malnutrition and the use of parenteral nutrition were protective factors against this outcome.

Tracheostomy in children admitted to paediatric intensive care

PurposeTracheostomy is a common intervention for adults admitted to intensive care; many are performed early and most are percutaneous. Our study aimed to elucidate current practice and indications for children...

Predicting PICU patient survival prognosis: Pediatric Logistic Organ Dysfunction vs Pediatric Index of Mortality scores

Background Determining prognosis of patients using scoringsystems have been done in many pediatric intensive care units(PICU). The scoring systems frequently used are pediatric logisticorgan dy sfunction (PELOD), pediatric index of mortality (PIM)and pediatric risk of mortality (PRISM).Objective To compare the performance of PELOD and PIM scoresin predicting the prognosis of survival vs death in PICU patients.Methods A prognostic test in this prospective, cohort study wasconducted in the PICU of the Kariadi General Hospital, Semarang.PELOD and PIM calculations were performed using formulae frompreviously published articles. Statistical analyses included receiveroperating curve (ROC) characteristics to describe discriminationcapacity, sensitivity, specificity, positive predictive value, negativepredictive value and accuracy.Results Thirty-three patients fulfilling the inclusion criteria wereenrolled in the study. PELOD score for area under the ROCwas 0.87 (95% CI 0.73 to 1.0; P=0.003), while that for PIMwas 0.65 (95% CI 0.39 to 0.90; P=0.2). PELOD scores showedsensitivity 85.7% (95% CI 59.8 to 100), specificity 84.6% (95%CI 70.7 to 98.5), positive predictive value 60.0% (95% CI 29.6to 90.4) negative predictive value 95.6% (95% CI 87.3 to 100)and accuracy 84.8%. PIM scores showed sensitivity 85.7% (95%CI 59.8 to 100), specificity 50.0% (95% CI 30.8 to 69.2), positivepredictive value 31.6% (95% CI 10,7 to 52.5), negative predictivevalue 92.9% (95% CI 79.4 to 100) and accuracy 57.6%.Conclusion PELOD scoring had better specificity, positive predictivevalue, negative predictive value, accuracy and discrimination capacitythan PIM scoring for predicting the survival prognosis of patients inthe PICU. [Paediatr Indones. 2012;52:165-9].

Relationship Between Arterial Partial Oxygen Pressure After Resuscitation From Cardiac Arrest and Mortality in Children

Observational studies in adults have shown a worse outcome associated with hyperoxia after resuscitation from cardiac arrest. Extrapolating from adult data, current pediatric resuscitation guidelines recommend avoiding hyperoxia. We investigated the relationship between arterial partial oxygen pressure and survival in patients admitted to the pediatric intensive care unit (PICU) after cardiac arrest. We conducted a retrospective cohort study using the Pediatric Intensive Care Audit Network (PICANet) database between 2003 and 2010 (n=122,521). Patients aged <16 years with documented cardiac arrest preceding PICU admission and arterial blood gas analysis taken within 1 hour of PICU admission were included. The primary outcome measure was death within the PICU. The relationship between postarrest oxygen status and outcome was modeled with logistic regression, with nonlinearities explored via multivariable fractional polynomials. Covariates included age, sex, ethnicity, congenital heart disease, out-of-hospital arrest, year, Pediatric Index of Mortality-2 (PIM2) mortality risk, and organ supportive therapies. Of 1875 patients, 735 (39%) died in PICU. Based on the first arterial gas, 207 patients (11%) had hyperoxia (Pa(O)(2) ≥300 mm Hg) and 448 (24%) had hypoxia (Pa(O)(2) <60 mm Hg). We found a significant nonlinear relationship between Pa(O)(2) and PICU mortality. After covariate adjustment, risk of death increased sharply with increasing hypoxia (odds ratio, 1.92; 95% confidence interval, 1.80-2.21 at Pa(O)(2) of 23 mm Hg). There was also an association with increasing hyperoxia, although not as dramatic as that for hypoxia (odds ratio, 1.25; 95% confidence interval, 1.17-1.37 at 600 mm Hg). We observed an increasing mortality risk with advancing age, which was more pronounced in the presence of congenital heart disease. Both severe hypoxia and, to a lesser extent, hyperoxia are associated with an increased risk of death after PICU admission after cardiac arrest.

Patterns of post-traumatic stress symptoms in families after paediatric intensive care

To establish longitudinal rates of post-traumatic stress in a cohort of child-parent pairs; to determine associations with poorer outcome. This was a prospective longitudinal cohort study set in a 21-bed unit. In total 66 consecutive admissions aged 7-17 years were screened with one parent at 3 and 12 months post-discharge. Measures used were the Children's Revised Impact of Event Scale (CRIES-8) and the SPAN (short form of Davidson Trauma Scale). In total 29 (44 %) child-parent pairs contained at least one member who scored above cut-off 12 months after discharge, with scores increasing over time for 18 parents and 26 children. At 3 months, 28 (42 %) parents and 20 (32 %) children scored above cut-off; at 12 months the rates were 18 (27 %) parents and 17 (26 %) children. Parents scoring above cut-off at 12 months were more likely to have had a child admitted non-electively (100 % vs. 77 %, p = 0.028); had higher 3-month anxiety scores (11.5 vs. 4.5, p = 0.001) and their children had higher post-traumatic stress scores at 3 months (14 vs. 8, p = 0.017). Children who scored above cut-off at 12 months had higher 3-month post-traumatic stress scores (18 vs. 7, p = 0.001) and higher Paediatric Index of Mortality (PIM) scores on admission (10 vs. 4, p = 0.037). The findings that (a) nearly half of families were still experiencing significant symptoms of post-traumatic stress 12 months after discharge; (b) their distress was predicted more by subjective than by objective factors and (c) many experienced delayed reactions, indicate the need for longer-term monitoring and more support for families in this situation.

International comparison of the performance of the paediatric index of mortality (PIM) 2 score in two national data sets

To test the performance of PIM2 in French-speaking (FS) paediatric intensive care units (PICUs) and its relative performance when recalibrated using data from FS and Great Britain (GB) PICUs of different size. Consecutive admissions to 15 FS (n = 5,602) and 31 GB PICUs (n = 20,693) from June 2006 to October 2007 were included. The recalibrated PIM2 were applied to PICUs of different size within the FS and GB PICUs and between the two groups. PICU size was defined using number of admissions/month. Discrimination and calibration were evaluated using the area under the ROC curve (AUC) and the goodness-of-fit test, respectively. Logistic regression, funnel plots and standardized W scores were performed in the two groups and between different PICU sizes. In FS PICUs, the original PIM2 had good discrimination (AUC = 0.85) and moderate calibration (p = 0.07). The recalibrated PIM2 scores had good calibration in FS (p = 0.33) and moderate calibration in GB (p = 0.06). Calibration was poor when the recalibrated FS PIM2 was applied to GB (p = 0.02) but good when the GB recalibration was applied to the FS (p = 0.36). Using the original PIM2 coefficients, calibration was poor in large units in both groups but improved following recalibration. There were no effects of PICU size on risk-adjusted mortality in GB and a significant effect in the FS PICUs with a minimum risk-adjusted mortality at about 35 admissions/month. The PIM2 score was valid in the FS population. The recalibration based on GB data could be applied to FS PICUs. Such recalibration may facilitate comparisons between countries.

Atención del paciente crítico pediátrico en una UCI de adultos. Utilidad del índice PIM

ObjectivesAn analysis is made of the characteristics of patients younger than 14 years treated in an adult ICU (AICU), to determine the procedures and techniques required by such patients, and to evaluate the use of the Pediatric Index of Mortality (PIM) in stratifying severity. DesignA retrospective observational study was carried out. SettingAn AICU of a second level hospital. PatientsWe studied 130 patients aged from 1 month to 14 years (average age 6.1±4 years) treated in the AICU from January 1997 to December 2010. Variables of interestClinical-demographic parameters, diagnosis, clinical procedures, PIM score, length of stay, transfer to pediatric ICU (PICU), and mortality. Classification by destination (AICU, PICU) and outcome (alive, dead). PIM and assessment of the diagnostic performance curve (ROC) for mortality. ResultsThe average age of the patients was 6.1±4 years. Most common diagnoses: trauma (26.9%) and sepsis (22.3%). Main procedures: mechanical ventilation (58.5%), central venous line (74.6%) and vasoactive drugs (20%). A total of 64.6% were transferred to PICU, and the overall mortality was 13%. Patients who stayed in the AICU were older (8.2±4 vs 5.5±4 years, p<0.001), had low morbidity, and their stay was short (44.5±38hours). The PIM score was significantly higher in the patients who died (60±20 AICU, 38±30 PICU) than in those who survived (4±1 AICU, 9±1 PICU) (p<0.001). ROC curve with AUC=0.91 (95%CI: 0.85 to 0.98). ConclusionsThe PIM score can stratify severity and identify patients at an increased risk of death. Critical child care in the AICU requires the presence of adequate materials and the continuous learning of procedures adapted to pediatric patients in order to ensure adequate care.

Obesity Is Not Associated With Increased Mortality and Morbidity in Critically Ill Children

To evaluate the effect of obesity on mortality, length of mechanical ventilation, and length of stay (LOS) in critically ill children. Retrospective cohort study in 2- to 18-year-olds, admitted to the pediatric intensive care unit (PICU) at the Children's Hospital of Wisconsin from 2005-2009 who required invasive ventilation. Weight z score was used to categorize patients as normal (-1.89 to 1.04), overweight (1.05-1.65), obese (1.66-2.33), and severely obese (>2.33). Underweight patients were excluded. Age, gender, admission type, Pediatric Index of Mortality 2 score, operative status, trauma status, admission Pediatric Outcome Performance Category, and diagnosis categories were also collected. The outcomes were mortality, total ventilator days, and PICU LOS. Univariate analysis was used to compare the groups, and multivariate logistic regression was used to compare mortality. Total ventilation days and LOS were modeled with linear regression. In total, 1030 patients were included in the study, with 753 normal weight, 137 overweight, 76 obese, and 64 severely obese. The risk-adjusted mortality rates in overweight (odds ratio [OR], 1.06; 95% confidence interval [CI], 0.62-1.82), obese (OR, 0.68; 95% CI, 0.31-1.48), and severely obese patients (OR, 1.02; 95% CI, 0.45-2.34) were not significantly different compared with the normal-weight group. Total ventilation days (P = .9628) and PICU LOS (P = .8431) were not significantly different between the groups after adjusting for risk factors. Critically ill overweight, obese, and severely obese children who require invasive mechanical ventilation have similar mortality, length of stay in the PICU, and ventilator days as compared with normal-weight children.

Effect of race on the timing of the Glenn and Fontan procedures for single-ventricle congenital heart disease*

Disparities in health care have been documented between different racial groups in the United States. We hypothesize that there will be racial variance in the timing of the Glenn and Fontan procedures for children with single-ventricle physiology. We performed a retrospective review of a national pediatric intensive care unit database (Virtual PICU Performance System, LLC). Children with hypoplastic left heart syndrome, tricuspid atresia, and common ventricle, admitted from January 2006 to July 2008, were included. Data included race, weight, age, medical length of stay, Paediatric Index of Mortality 2 score, and survival. None. There were 423 patients from 29 hospitals. The study population was 7.6% black, 13.0% Hispanic, 59.8% white, 9.2% "other," and 11.6% had missing racial/ethnic information. Diagnoses included 255 patients with hypoplastic left heart syndrome, 91 with tricuspid atresia, and 77 with common ventricle. The median age for the Glenn procedure (n = 205) was 5.5 months (interquartile range, 4.6-7.0 months) and 39.7 months (interquartile range, 32.4-50.6 months) for the Fontan procedure (n = 218). There was no difference between the median age at the time of the Glenn or Fontan procedures between the different racial/ethnic groups (p = .65 and p = .16, respectively). The medical length of intensive care unit stay for patients receiving the Glenn and Fontan procedures was 3.7 days (interquartile range, 1.9-6.1 days) and 3.7 days (interquartile range, 1.9-6.8 days), respectively. There were no differences in medical length of intensive care unit stay for the Glenn procedure between the different racial/ethnic groups (p = .21). Hispanic patients had a longer medical length of intensive care unit stay (6.3 days; interquartile range, 3.1-9.9 days) than white patients (2.9 days; interquartile range, 1.8-5.3 days) for the Fontan procedure (p = .008). The timing of single-ventricle palliative procedures was not affected by race/ethnicity.

Validation of pediatric index of mortality 2 (PIM2) in a single pediatric intensive care unit in Japan

The Pediatric Index of Mortality 2 (PIM2), one of the key mortality prediction models for children in intensive care units, has not been validated in Japan. The purpose of this study was to validate the performance of PIM2 in a population of patients admitted to one pediatric intensive care unit (PICU) in Japan. This was a prospective cohort study involving consecutive patients admitted to the largest multidisciplinary PICU in Japan between 1 January 2008 and 31 December 2010. There were no interventions. A total of 2,536 patients were included in this study of whom 67 (2.6%) died. Discrimination between survival and death assessed by the area under the receiver operating characteristic curve was 0.92 [95% confidence interval (CI) 0.89-0.96]. Calibration across the five risk intervals according to the Hosmer-Lemeshow goodness-of-fit test showed a chi-square value of 4.8 (df = 5, p = 0.44). The standardized mortality ratio for the whole population was 0.77 (95% CI 0.59-0.96). At the largest PICU center in Japan, the PIM2 was found to have excellent discriminatory power and good calibration, although it over-predicted deaths. Based on these results, PIM2 can be used as a good prediction model for pediatric mortality, which is a tool used to assess the overall quality of care in a PICU.

Change in Ratio of Observed-to-Expected Deaths in Pediatric Patients after Implementing a Closed Policy in an Adult ICU That Admits Children

Backgrounds. We examined the effect on the prognosis of critically ill pediatric patients after a closed ICU policy was implemented into an adult ICU that admitted children. Materials and Methods. We assessed the Pediatric Index of Mortality 2 (PIM2) score of pediatric patients (≤15 y.o.) admitted to the ICU from 2001 to 2009. In our teaching hospital, the department for intensive care was established in January 2004. Since then, for critical care patients, we have followed a closed ICU policy with full-time intensivists. We subsequently compared PIM2 scores and the ratio of observed-to-expected deaths (O/E ratio) for three three-year periods: 2001–2003 (before closed policy), 2004–2006, and 2007–2009. Results. Data was collected from 532 pediatric patients. While the PIM2 score statistically significantly increased from 0.066 ± 0.130 for 2001–2003 to 0.114 ± 0.239 for 2004–2006 and 0.086 ± 0.147 for 2007–2009, the O/E ratio decreased from 1.49 for 2001–2003 to 0.82 for 2004–2006 and remained at 0.82 for 2007–2009. Conclusion. The O/E ratio for critically ill pediatric patients improved after the establishment of a closed policy in an adult ICU that admitted children.

Admission source and mortality in a pediatric intensive care unit

Background and Aims:Studies carried out in different countries have shown that source of patient admission in Intensive Care Units (ICUs) is associated to death. Patients admitted from wards show a greater ICU mortality. The aim of the present study was to investigate the association between admission source and outcome in a Pediatric Intensive Care Unit (PICU).Materials and Methods:We studied all PICU admissions that took place between January 2002 and December 2005 in a tertiary hospital in Brazil. The major outcome studied was death while in the PICU. The independent variable analyzed was admission source, defined either as pediatric emergency room (PER), wards, operating room (OR) of the same hospital or other sources.Results:A total of 1823 admissions were studied. The overall expected mortality based on the Pediatric Index of Mortality 2 was 6.5% and the observed mortality was 10.3%. In adjusted analysis, the mortality was doubled in patients admitted from wards when compared with the PER patients.Conclusions:Observed mortality rates were higher in patients admitted from wards within the same hospital, even after adjustment.

Induced mild hypothermia in children

The objective of this study was to measure outcomes and to determine the safety and effectiveness of mild induced hypothermia in children after traumatic and posthypoxic brain injury. Methods. Forty patients, following traumatic or posthypoxic brain injury, were involved in the study. Mean age was 10.7 ± 0.8 years. Median GCS (Glasgow Coma Scale) was 6.0 (4-7) and mean PIM2 (Pediatric Index of Mortality) 14.6 ± 3.8 %. Results. GOS (Glasgow Outcome Scale) of 5 was assigned for 15 (37.5%) patients, GOS 4 for 14 (35.0%), GOS 3 for 7 (17.5%) and GOS 2 for 4 (10%) patients. The average GOS in patients after severe head trauma was 3.6 ± 0.9 points and in patients with posthypoxic brain injury 5 points, (p < 0.05). No life threatening complications occurred. Conclusion. Mild induced hypothermia can be safely used in pediatric patents after severe traumatic or posthypoxic brain injury. This method may be of benefit while improving outcomes in children.

Incidence and risk factors associated with venous thrombotic events in pediatric intensive care unit patients*

To evaluate the incidence and risk factors associated with venous thromboembolism (VTE) in children admitted to pediatric intensive care units (PICUs). Prospective observational study. Eleven tertiary care PICUs in the United States. Children who were admitted to PICUs and had radiographically confirmed VTE over a rolling 6-month period were enrolled in the study. Demographic, patient-related, and outcomes data were collected and compared with all children admitted during the same period. None. : Sixty-six symptomatic VTE were documented in sixty-two patients among 6653 patients admitted to 11 PICUs. Thirteen (19.7%) of the thrombi were present on admission. The incidence rate was 0.74% (range, 0-2.7% per PICU) with a point prevalence of 0.93%. Doppler ultrasound was most frequently used to diagnose or confirm a suspected VTE. Variables associated with unadjusted risk for VTE include: younger age (3.8 months for patients with VTE vs. 51 months for non-VTE patients, p < .001), cardiac diagnosis (41% in VTE cases vs. 15% in non-VTE, p < .001), pre-/post-operative status (63% in VTE cases vs. 40% in non-VTE, p = .001), presence of central venous catheter (88% in VTE case vs. 17% in non-VTE, p < .001), or mechanical ventilation (85% in VTE cases vs. 30% non-VTE, p < .001). Multivariate analysis showed increased risk of VTE with CVC (odds ratio 6.9; confidence interval 2.7-17.5) and mechanical ventilation (odds ratio 2.8; confidence interval 0.98-7.93). Children with VTE were sicker (Pediatric Index of Mortality 2 score risk of mortality of 3.0% vs. 0.9%; p<0.0001), stayed longer in the ICU (21.2 days vs. 1.6 days; p < .0001) and had increased mortality (10.2% vs. 2.6; p < .0001). Children admitted to the PICU have an increased risk of VTE. The presence of a CVC is the strongest risk factor for VTE in this PICU population. Children with VTE were younger, sicker, stayed longer in PICU, and had a higher mortality rate.