Pediatric Intensive Care Unit Mortality Research Articles

59 The Pediatric Alien Study: Incidence and Outcome of the Acute Respiratory Distress Syndrome in Children

IntroductionThe incidence and outcome of the acute respiratory distress syndrome (ARDS) in children is not well known, especially under current ventilatory practices. The goal of this study was to determine...

150 Neurocognitive Development of Children Four Years after Critical Illness and Treatment with Tight Glucose Control: A Randomized, Controlled Trial

Background and aimsThe first large RCT on tight-glucose-control (TGC) to age-adjusted normoglycemia in the pediatric-intensive-care-unit (PICU) (Vlasselaers 2009) revealed that TGC reduced PICU morbidity and mortality as compared with usual-care,...

Oral care with 0.12% chlorhexidine for the prevention of ventilator-associated pneumonia in critically ill children: Randomised, controlled and double blind trial

PurposeTo test the effectiveness of oral care with 0.12% chlorhexidine in decreasing ventilator-associated pneumonia in critically ill children. MethodsProspective, randomised, controlled, double-blind clinical trial performed in a paediatric critical care unit at a university hospital. The sample was composed of 96 mechanically ventilated children randomly allocated to the chlorhexidine group (oral care with a toothbrush and an antiseptic gel twice a day) and the placebo group (oral care with a toothbrush and a non-antiseptic gel twice a day). Microbiological analyses of oropharyngeal and tracheal secretions were performed 24, 48 and 96h after intubation. Chi-square, Fischer's exact and Mann–Whitney tests were applied (p≤0.05). ResultsThe chlorhexidine group was composed of 46 children, and the placebo group consisted of 50 children. Within these samples, 15 (32.6%) children in the chlorhexidine group and 16 (32.0%) children in the placebo group developed ventilator-associated pneumonia (p=0.949). Children in the chlorhexidine group without potentially pathogenic microflora in their oropharynx 24h after mechanical ventilation presented with fewer episodes of ventilator-associated pneumonia (p=0.019). The pathogen colonization profile of children with ventilator-associated pneumonia in the chlorhexidine group included Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa. In the placebo group, Pseudomonas aeruginosa and Escherichia coli were the predominant potentially pathogenic microorganisms. The intervention did not influence paediatric intensive care unit mortality (p=0.425), hospital length of stay (p=0.143), or paediatric intensive care unit length of stay (p=0.177). ConclusionsThe use of 0.12% chlorhexidine did not significantly modify the VAP incidence in a sample of mechanically ventilated children.

Chronic conditions among children admitted to U.S. pediatric intensive care units

To estimate the prevalence of chronic conditions among children admitted to U.S. pediatric intensive care units and to assess whether patients with complex chronic conditions experience pediatric intensive care unit mortality and prolonged length of stay risk beyond that predicted by commonly used severity-of-illness risk-adjustment models. Retrospective cohort analysis of 52,791 pediatric admissions to 54 U.S. pediatric intensive care units that participated in the Virtual Pediatric Intensive Care Unit Systems database in 2008. Hierarchical logistic regression models, clustered by pediatric intensive care unit site, for pediatric intensive care unit mortality and length of stay >15 days. Standardized mortality ratios adjusted for severity-of-illness score alone and with complex chronic conditions. Fifty-three percent of pediatric intensive care unit admissions had complex chronic conditions, and 18.5% had noncomplex chronic conditions. The prevalence of these conditions and their organ system subcategories varied considerably across sites. The majority of complex chronic condition subcategories were associated with significantly greater odds of pediatric intensive care unit mortality (odds ratios 1.25-2.9, all p values < .02) compared to having a noncomplex chronic condition or no chronic condition, after controlling for age, gender, trauma, and severity-of-illness. Only respiratory, gastrointestinal, and rheumatologic/orthopedic/psychiatric complex chronic conditions were not associated with increased odds of pediatric intensive care unit mortality. All subcategories were significantly associated with prolonged length of stay. All noncomplex chronic condition subcategories were either not associated or were negatively associated with pediatric intensive care unit mortality, and most were not associated with prolonged length of stay, compared to having no chronic conditions. Among this group of pediatric intensive care units, adding complex chronic conditions to risk-adjustment models led to greater model accuracy but did not substantially change unit-level standardized mortality ratios. Children with complex chronic conditions were at greater risk for pediatric intensive care unit mortality and prolonged length of stay than those with no chronic conditions, but the magnitude of risk varied across subcategories. Inclusion of complex chronic conditions into models of pediatric intensive care unit mortality improved model accuracy but had little impact on standardized mortality ratios.

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.

Risk factors and outcome of ventilator associated tracheitis (VAT) in pediatric trauma patients

We sought to investigate the risk factors and outcome of Ventilator Associated Tracheitis (VAT) according to the Center for Disease Control (CDC) definition in pediatric trauma patients who were ventilated for ≥48 hr. In a retrospective cohort study, medical records of all pediatric trauma patients admitted to our Pediatric Intensive Care Unit (PICU) between April 2002 and April 2007 were reviewed. Medical records were reviewed for patients' demographics, Trauma Injury Severity Score (TISS), Glasgow Coma Scale (GCS), type of trauma, and other potential risk factors prior to the development of VAT (such as hyperglycemia, rate of re-intubation and tracheotomy, presence of chest tubes and central lines, urinary tract infection, seizures, need for cardiopulmonary resuscitation, use of total parental nutrition, transfusion, use of H(2) blockers, steroids, and pressors/inotropes). Medical records were also reviewed for days of mechanical ventilation, PICU length of stay, and PICU mortality. During the study period, 217 trauma patients were admitted to the PICU, 113 patients met our inclusion criteria and 21.2% (24/113) developed VAT. On average patients with VAT (in comparison to patients without VAT), had a higher TISS score on admission [38.6 ± 16.9 vs. 24.2 ± 10.6; respectively (P < 0.01)], longer days of ventilation and PICU length of stay [11.5 ± 6.2 vs. 3.7 ± 2.3 days (P < 0.001) and 16.4 ± 8.3 vs. 5.4 ± 2.8 days (P < 0.001), respectively]. There was no difference in mortality between the two groups. In a logistic regression model adjusting for possible confounders, the TISS score (adjusted OR 7.53; CI: 2.01-28.14; P = 0.03 and use of pressors/inotropes (adjusted OR 4.64; CI: 1.28-16.86; P = 0.01) were the only independent risk factors associated with VAT. We conclude that the severity of illness and use of pressors/inotropes are associated with VAT in pediatric trauma patients. We also conclude that VAT is associated with an increase in days of mechanical ventilation and PICU length of stay in pediatric trauma patients.

Short‐term and long‐term mortality following pediatric intensive care

The aim of the present study was to examine short-term and long-term mortality following discharge from the pediatric intensive care unit (PICU). This was a prospective observational study. Data collected consisted of demographics, severity scores, procedures, treatment, need for and duration of mechanical ventilation (MV), length of PICU and hospital stay, and mortality at PICU and hospital discharge, at 3 and 6 months and at 1 and 2 years. A total of 300 patients (196 boys and 104 girls), aged 54.26 ± 49.93 months, were included in the study. Median (interquartile range) Pediatric Risk of Mortality (PRISM III-24) score was 7 (3-11) and predicted mortality rate was 11.16%. MV rate was 67.3% (58.3% at admission) for 6.54 ± 14.15 days, and length of PICU and hospital stay was 8.85 ± 23.28 days and 20.69 ± 28.64 days, respectively. Mortality rate at discharge was 9.7% and cumulative mortality rate thereafter was 12.7%, 15.0%, 16.7%, 19.0%, and 19.0% at hospital discharge, 3 months, 6 months, 1 year and 2 years, respectively. Significant risk factors of PICU mortality were inotrope use, PRISM III-24 score >8, MV, arterial and central venous catheterization, nosocomial infection, complications, and cancer. Independent predictors of mortality at discharge were inotrope use and PRISM III-24 score, whereas predictors of mortality at 2 years were comorbidity and cancer. A 2 year follow-up period seems sufficient for a comprehensive mortality analysis of PICU patients. Severity of critical illness is the key factor of short-term mortality, whereas comorbidity is the major determinant of long-term mortality.

Implications of different fluid overload definitions in pediatric stem cell transplant patients requiring continuous renal replacement therapy

In critically ill pediatric patients, fluid overload (FO) >10% has been identified as a threshold for possible interventions, including initiation of continuous renal replacement therapy (CRRT). However, multiple definitions have been reported, and there remains no consensus method for FO calculation. The goal of this study was to compare different methods of FO determination and to assess their relative value in predicting outcomes. This is a retrospective single-center review of 21 pediatric stem cell transplant patients (PSCT) that required CRRT from 2004 to 2009. We compared eight definitions (4 weight-based and 4 fluid-balance based) that varied by baseline weights. Outcome measures were pediatric intensive care unit (PICU) mortality and pediatric logistic organ dysfunction (PELOD) scores. The number of patients identified as having >10% FO varied significantly according to the definition used, from 14 to 48% (p = 0.002). Significant intra-subject variability was observed; the median difference between individual minimum and maximum %FO scores was 11.4% (IQR 6.8, 17.1%). %FO was not significantly associated with PICU mortality, but five of eight FO definitions were predictive of higher subsequent PELOD scores. Our study is one of the first to compare different FO definitions and the impact on predicting outcomes. Our findings suggest that depending on the FO definition used, there is significant variability in the calculated %FO in PSCT patients, and this has important implications for clinical decision-making. Further studies are necessary to determine an optimal FO definition that is clinically relevant and predictive of important outcomes.

Benchmarking, public reporting, and pay-for-performance: A mixed-methods survey of California pediatric intensive care unit medical directors

We sought to assess the attitudes of pediatric intensive care unit medical directors in California regarding the need for, the validity of, and the potential impact of benchmarking, public reporting, and pay-for-performance on pediatric critical care. Cross-sectional survey. Pediatric intensive care units in California. Medical directors of pediatric intensive care units. None. Self-administered questionnaire and a semi-structured phone interview from 16 pediatric intensive care unit medical directors. All data were anonymized before review. Standard methods for identifying and agreeing on themes in transcribed interviews were applied. Seventy-three percent of California pediatric intensive care unit medical directors agree that benchmarking improves patient outcomes but are undecided whether public reporting and pay-for-performance improve healthcare quality. They are wary of the validity of data used to generate these performance measures and are discouraged by the time and costs required to collect data for standard performance outcomes (severity-adjusted pediatric intensive care unit mortality). Leadership opinions appear potentially "dynamic" in multiple domains and across each of the measures assessed. Pediatric intensive care unit medical directors sometimes express contradictory opinions about the merits of shared benchmarking efforts and express concerns across a range of logistic, methodological, and policy issues. These findings raise fundamental questions about how to create clinical performance standards that facilitate quality improvement in the face of a seriously divided constituency. Further, we propose that pediatric intensive care unit medical directors play more active roles in the development, implementation, and communication of shared state-wide data collection.

Los cuidados intensivos pediátricos en Latinoamérica

Objective To describe the practice of pediatric intensive care in Latin America and compare it with two European countries. Design Analysis of data presented by member countries of the Sociedad Latinoamericana de Cuidado Intensivo Pediátrico (SLACIP), Spain and Portugal, in the context of a Symposium of Spanish and Portuguese – speaking pediatric intensivists during the Fifth World Congress on Pediatric Intensive Care. Setting Pediatric intensive care units (PICUs). Participants Pediatric intensivists in representation of each member country of the SLACIP, Spain and Portugal. Interventions None. Variables of interest Each country presented its data on child health, medical facilities for children, pediatric intensive care units, pediatric intensivists, certification procedures, equipment, morbidity, mortality, and issues requiring intervention in each participating country. Results Data from 11 countries was analyzed. Nine countries were from Latin America (Argentina, Colombia, Cuba, Chile, Ecuador, Honduras, México, Dominican Republic and Uruguay), and two from Europe (Spain and Portugal). Data from Bolivia and Guatemala were partially considered. Populational, institutional, and operative differences were identified. Mean PICU mortality was 13.29% in Latin America and 5% in the European countries ( P = 0.005). There was an inverse relationship between mortality and availability of pediatric intensive care units, pediatric intensivists, number of beds, and number of pediatric specialty centers. Financial and logistic limitations, as well as deficiencies in support disciplines, severity of diseases, malnutrition, late admissions, and inadequate initial treatments could be important contributors to mortality at least in some of these countries. Conclusion There are important differences in population, morbidity and mortality in critically ill children among the participating countries. Mortality shows an inverse correlation to the availability of pediatric intensive care units, intensive care beds, pediatric intensivists, and pediatric subspecialty centers.

Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy.

In pediatric intensive care unit (PICU) patients, fluid overload (FO) at initiation of continuous renal replacement therapy (CRRT) has been reported to be an independent risk factor for mortality. Previous studies have calculated FO based on daily fluid balance during ICU admission, which is labor intensive and error prone. We hypothesized that a weight-based definition of FO at CRRT initiation would correlate with the fluid balance method and prove predictive of outcome. This is a retrospective single-center review of PICU patients requiring CRRT from July 2006 through February 2010 (n=113). We compared the degree of FO at CRRT initiation using the standard fluid balance method versus methods based on patient weight changes assessed by both univariate and multivariate analyses. The degree of fluid overload at CRRT initiation was significantly greater in nonsurvivors, irrespective of which method was used. The univariate odds ratio for PICU mortality per 1% increase in FO was 1.056 [95% confidence interval (CI) 1.025, 1.087] by the fluid balance method, 1.044 (95% CI 1.019, 1.069) by the weight-based method using PICU admission weight, and 1.045 (95% CI 1.022, 1.07) by the weight-based method using hospital admission weight. On multivariate analyses, all three methods approached significance in predicting PICU survival. Our findings suggest that weight-based definitions of FO are useful in defining FO at CRRT initiation and are associated with increased mortality in a broad PICU patient population. This study provides evidence for a more practical weight-based definition of FO that can be used at the bedside.

Daily practice of mechanical ventilation in Italian pediatric intensive care units: A prospective survey*

To assess how children requiring endotracheal intubation are mechanically ventilated in Italian pediatric intensive care units (PICUs). A prospective, national, observational, multicenter, 6-month study. Eighteen medical-surgical PICUs. A total of 1943 consecutive children, aged 0-16 yrs, admitted between November 1, 2006 and April 30, 2007. None. Data on cause of respiratory failure, length of mechanical ventilation (MV), mode of ventilation, use of specific interventions were recorded for all children requiring endotracheal intubation for >24 hrs. Children were stratified for age, type of patient, and cause of respiratory failure. A total of 956 (49.2%) patients required MV via an endotracheal tube; 673 (34.6%) were ventilated for >24 hrs. The median length of MV was 4.5 days for all patients. If postoperative patients were excluded, the median time was 5 days. Bronchiolitis (6.7%), pneumonia (6.7%), and upper airway obstruction (5.3%) were the most frequent causes of acute respiratory failure, and altered mental status (9.2%) was the most frequent reason for MV. The overall mortality was 6.7% with highest rates for heart disease (nonoperative), sepsis, and acute respiratory distress syndrome (26.1%, 22.2%, and 16.7% respectively). Length of stay, associated chronic disease, severity score on admission, and PICU mortality were significantly higher in children who received MV (p < .05) than in children who did not. Controlled MV and pressure support ventilation + synchronized intermittent mandatory ventilation were the most frequently used modes of ventilatory assistance during PICU stay. Mechanical ventilation is frequently used in Italian PICUs with almost one child of two requiring endotracheal intubation. Children treated with MV represent a more severe category of patients than children who are breathing spontaneously. Describing the standard care and how MV is performed in children can be useful for future clinical studies.

Acute kidney injury is an independent risk factor for pediatric intensive care unit mortality, longer length of stay and prolonged mechanical ventilation in critically ill children: a two-center retrospective cohort study

IntroductionIn adults, small (< 50%) serum creatinine (SCr) increases predict mortality. It is unclear whether different baseline serum creatinine (bSCr) estimation methods affect findings of acute kidney injury (AKI)-outcome associations. We characterized pediatric AKI, evaluated the effect of bSCr estimation approaches on AKI-outcome associations and evaluated the use of small SCr increases to predict AKI development.MethodsWe conducted a retrospective cohort database study of children (excluding postoperative cardiac or renal transplant patients) admitted to two pediatric intensive care units (PICUs) for at least one night in Montreal, QC, Canada. The AKI definition was based on the Acute Kidney Injury Network staging system, excluding the requirement of SCr increase within 48 hours, which was impossible to evaluate on the basis of our data set. We estimated bSCr two ways: (1) the lowest SCr level in the three months before admission or the average age- and gender-based norms (the standard method) or (2) by using average norms in all patients. Outcomes were PICU mortality and length of stay as well as required mechanical ventilation. We used multiple logistic regression analysis to evaluate AKI risk factors and the association between AKI and mortality. We used multiple linear regression analysis to evaluate the effect of AKI on other outcomes. We calculated diagnostic characteristics for early SCr increase (< 50%) to predict AKI development.ResultsOf 2,106 admissions (mean age ± SD = 5.0 ± 5.5 years; 47% female), 377 patients (17.9%) developed AKI (using the standard bSCr method) during PICU admission. Higher Pediatric Risk of Mortality score, required mechanical ventilation, documented infection and having a bSCr measurement were independent predictors of AKI development. AKI was associated with increased mortality (adjusted odds ratio (OR) = 3.7, 95% confidence interval (95% CI) = 2.1 to 6.4, using the standard bSCr method; OR = 4.5, 95% CI = 2.6 to 7.9, using normative bSCr values in all patients). AKI was independently associated with longer PICU stay and required mechanical ventilation. In children with no admission AKI, the initial percentage SCr increase predicted AKI development (area under the curve = 0.67, 95% CI = 0.60 to 0.74).ConclusionsAKI is associated with increased mortality and morbidity in critically ill children, regardless of the bSCr used. Paying attention to small early SCr increases may contribute to early AKI diagnosis in conjunction with other new AKI biomarkers.

Severe head injury in children: intensive care unit activity and mortality in England and Wales

Objective: To explore the relationship between volume of paediatric intensive care unit (PICU) head injury (HI) admissions, specialist paediatric neurosurgical PICU practice, and mortality in England and Wales.Methods: Analysis of HI cases (age <16 years) from the Paediatric Intensive Care Audit Network national cohort of sequential PICU admissions in 27 units in England and Wales, in the 5 years 2004–2008. Risk-adjusted mortality using the Paediatric Index of Mortality (PIM) model was compared between PICUs aggregated into quartile groups, first to fourth based on descending number of HI admissions/year: highest volume, medium–higher volume, medium–lower volume, and lowest volume. The effect of category of PICU interventions – observation only, mechanical ventilation (MV) only, and intracranial pressure (ICP) monitoring – on outcome was also examined. Observations were reported in relation to specialist paediatric neurosurgical PICU practice.Results: There were 2575 admissions following acute HI (4.4% of non-cardiac surgery PICU admissions in England and Wales). PICU mortality was 9.3%. Units in the fourth-quartile (lowest volume) group did not have significant specialist paediatric neurosurgical activity on the PICU; the other groups did. Overall, there was no effect of HI admissions by individual PICU on risk-adjusted mortality. However, there were significant effects for both intensive care intervention category (p<0.001) and HI admissions by grouping (p<0.005). Funnel plots and control charts using the PIM model showed a hierarchy in increasing performance from lowest volume (group IV), to medium–higher volume (group II), to highest volume (group I), to medium–lower volume (group III) sectors of the health care system.Conclusions: The health care system in England and Wales for critically ill HI children requiring PICU admission performs as expected in relation to the PIM model. However, the lowest-volume sector, comprising 14 PICUs with little or no paediatric neurosurgical activity on the unit, exhibits worse than expected outcome, particularly in those undergoing ICP monitoring. The best outcomes are seen in units in the mid-volume sector. These data do not support the hypothesis that there is a simple relationship between PICU volume and performance.

Glucose variability and survival in critically ill children: Allostasis or harm?*

To assess whether individual blood glucose variability in critically ill children is associated with increased mortality and to define the temporal patterns of blood glucose variability during critical illness in children. Retrospective cohort study. A 20-bed pediatric intensive care unit in a children's hospital. Patients aged 0-20 yrs and with at least 12 blood glucose measurements taken within the first 72 hrs of pediatric intensive care unit admission. None. A total of 101 eligible patients had 3,144 measured blood glucose concentrations with 16% mortality. Nonsurvivors had higher median blood glucose concentrations (129 mg/dL vs. 118 mg/dL, p < .01), more hyperglycemia (blood glucose >200 mg/dL) (88% vs. 59%, p < .05), and more hypoglycemia (blood glucose <60 mg/dL) (56% vs. 15%, p < .01) than survivors. The mean blood glucose range (257 mg/dL vs. 185 mg/dL, p < .01) and the blood glucose variability (63 mg/dL vs. 45 mg/dL, p = .02) were greater in nonsurvivors compared with survivors. Blood glucose variability tertiles were proportionately associated with increasing mortality: 6% vs. 15% vs. 27% (p = .07). Compared with survivors, daily blood glucose variability was significantly higher in nonsurvivors during the first 48 hrs of admission and after 1 wk of admission. After controlling for confounders, individual blood glucose variability was associated with higher pediatric intensive care unit mortality for each mg/dL of blood glucose concentration (adjusted odds ratio, 1.03; 95% confidence interval, 1.01-1.05). Glucose variability is common in critically ill children and is associated with increased mortality. Whereas early alterations in blood glucose may represent allostasis, later fluctuations in blood glucose may represent an alteration of autoregulation with resulting higher mortality. Control of variability may need to be incorporated into glycemic control regimens.

Three decades of pediatric intensive care: Who was admitted, what happened in intensive care, and what happened afterward*

To describe the characteristics of children admitted to intensive care in 1982, 1995, and 2005-2006, and their long-term outcome. Pediatric intensive care unit in a university-affiliated children's hospital. Information for 2005-2006 admissions was obtained from pediatric intensive care unit database, and long-term outcome was ascertained through telephone interviews. Results were compared to previous cohorts from 1982 and 1995. A total of 4010 children were admitted on 5250 occasions. Readmissions increased from 11% for 1982 to 31% in 2005 to 2006 (p < .001). In 2005-2006, fewer children were admitted after accidents (p < .001), or with croup (p < .001), or epiglottitis (p = .01), and 8% were treated with noninvasive ventilation compared to none in 1982 (p < .0001). Among children aged > or =1 month, pediatric intensive care unit length of stay remained constant. The risk of death predicted by the Pediatric Index of Mortality (PIM) remained constant (approximately 6%) between 1995 and 2005-2006.The proportion that died in the pediatric intensive care unit fell from 11.0% in 1982 to 4.8% in 2005-2006 (p < .001). Among children aged >/=1 month, proportion admitted with a preexisting moderate or severe disability was similar: 12.0% in 1982 and 14.6% in 2005-2006 (p = .11), but the proportion with a moderate or severe disability at follow-up increased from 8.4% in 1982 to 17.9% in 2005-2006 (p < .001). The proportion of children aged > or =1 month who either died in the pediatric intensive care unit or survived with disability did not improve: it was 19.4% in 1982 and 22.7% in 2005-2006. Over the last three decades, the length of stay in the pediatric intensive care unit and the severity of illness have not changed, but there has been a substantial reduction in pediatric intensive care unit mortality. However, the proportion of survivors with moderate or severe disability increased significantly. Some children who would have been allowed to die in 1982 and 1995 were kept alive in 2005-2006, but survived with disability. This trend has important implications for our patients and their families, and for the community as a whole.

Critical illness in children with influenza A/pH1N1 2009 infection in Canada*

To describe characteristics, treatment, and outcomes of critically ill children with influenza A/pandemic influenza A virus (pH1N1) infection in Canada. An observational study of critically ill children with influenza A/pH1N1 infection in pediatric intensive care units (PICUs). Nine Canadian PICUs. A total of 57 patients admitted to PICUs between April 16, 2009 and August 15, 2009. None. Characteristics of critically ill children with influenza A/pH1N1 infection were recorded. Confirmed intensive care unit cases were compared with a national surveillance database containing all hospitalized pediatric patients with influenza A/pH1N1 infection. Risk factors were assessed with a Cox proportional hazard model. The PICU cohort and national surveillance data were compared, using chi-square tests. Fifty-seven children were admitted to the PICU for community-acquired influenza A/pH1N1 infection. One or more chronic comorbid illnesses were observed in 70.2% of patients, and 24.6% of patients were aboriginal. Mechanical ventilation was used in 68% of children, 20 children (35.1%) had acute lung injury on the first day of admission, and the median duration of ventilation was 6 days (range, 0-67 days). The PICU mortality rate was 7% (4 of 57 patients). When compared with nonintensive care unit hospitalized children, PICU children were more likely to have a chronic medical condition (relative risk, 1.73); aboriginal ethnicity was not a risk factor of intensive care unit admission. During the first outbreak of influenza A/pH1N1 infection, when the population was naïve to this novel virus, severe illness was common among children with underlying chronic conditions and aboriginal children. Influenza A/pH1N1-related critical illness in children was associated with severe hypoxemic respiratory failure and prolonged mechanical ventilation. However, this higher rate and severity of respiratory illness did not result in an increased mortality when compared with seasonal influenza.

Does Asbestos Exposure (Asbestosis) Cause (Clinical) Airway Obstruction (Small Airway Disease)?

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CMV pneumonia in HIV‐infected ventilated infants

The contributing role of cytomegalovirus (CMV) in infants treated for Pneumocystis jiroveci pneumonia (PJP) is unknown. High dose steroids used in the treatment of PJP may further immunocompromise these infants contributing to the development of CMV pneumonia. The aim of this study was to determine the role of CMV pneumonia in infants being ventilated for suspected PJP. In this prospective study HIV infected infants being treated with trimethoprim-sulfamethoxazole (TMP/SMX) and ventilated for suspected PJP were included if they had not responded to treatment. Open lung biopsy was performed if there was no improvement in ventilatory requirements. Twenty-five HIV positive infants with a mean age of 3.3 months were included. Lung biopsy was performed in 17 (68%) and post-mortem lung tissue was obtained in 8 (32%). After evaluation of the histology, immunohistochemistry, and viral cultures from lung tissue, the most likely causes of pneumonia were: CMV and PJP dual infection 36% (n = 9), CMV pneumonia 36% (n = 9), and PJP 24% (n = 6). The pp65 test for CMV antigen was falsely negative in 24%. The mean blood CD4 count was 287/microl. There was an association between the CD4 lymphocyte status and the final diagnosis, with the CMV and PJP group (CD4 110/microl) having the lowest CD4 status (P = 0.0128). Pediatric Intensive Care Unit (PICU) mortality was 72% (n = 18) and in hospital mortality 88%. Of the ventilated infants failing to respond to treatment, 72% had histologically confirmed CMV pneumonia, probably accounting for the high mortality in this cohort. The incidence of CMV disease in HIV infected infants being ventilated for severe pneumonia warrants that ganciclovir is used empirically until CMV disease is excluded. The role of lung biopsy in these circumstances needs to be researched.

Impact of early warning on paediatric intensive care

Aims To evaluate the impact of an early warning system and paediatric emergency team training on unplanned admissions to paediatric intensive care unit (PICU). Methods An early warning system, which asks staff to respond to breaches of physiological criteria, was introduced to a paediatric teaching hospital. This was accompanied by a change in role of the resuscitation team to an “early response team”, reinforced by weekly 2-hourly simulation team training. The multidisciplinary training focuses on identifying deteriorating patients, communication within the team, and early escalation to consultant staff. A prospective audit covering the year before and after this intervention was conducted. Results The number of unplanned admissions to PICU increased from 90 to 115, reflecting a similar increase of activity within the hospital. The year before introduction, the resuscitation team was called 11 times, in contrast to 36 involvements of the early response team the year after. The average time from breach of early warning criteria to first response (defined as: nursing intervention including increased observations, medical review, transfer to higher dependency unit) was reduced from 4.6 to 1.1 h. The proportion of deteriorating patients seen by a consultant, from the time of breach to PICU admission, increased from 49% to 82%. The time from breach to PICU admission fell from 21 to 10 h. Level of sickness at the time of admission to PICU was reduced by 24% (PIM1)/13% (PIM2). Length of PICU stay fell from an average 6.9 to 5.0 days, with the absolute number of bed days reducing by 10%. The number of deaths fell from 12 to 4. Conclusion The authors observed major changes in the management of deteriorating paediatric inpatients: the response within the hospital was faster, involved more senior staff and lead to earlier PICU admission. This also applied when the paediatric emergency team was not called. Subsequently, predicted and actual PICU mortality and length of stay was reduced. This suggests that weekly team training, a local innovation to support early warning implementation, influences the judgement of key decision makers in the care of deteriorating patients both within the team and as individuals.