Pediatric Logistic Organ Dysfunction Research Articles

Platelet Profile as Prognostic Factor in Critically ill Children

BACKGROUND: Previous studies showed that platelet profile may reflect the platelet function better than the platelet count itself, but the study on its use as a prognostic indicator in critically ill children is still limited.
 AIM: We analyzed the association between platelet profile such as platelet count, plateletcrit (PCT), mean platelet volume (MPV), and platelet distribution width (PDW) and mortality, also its correlation with pediatric logistic organ dysfunction-2 (PELOD-2) score in critically ill children admitted to the pediatric intensive care unit (PICU).
 METHODS: A prospective cohort study was conducted in PICU Haji Adam Malik General Hospital, Medan. Assessment of platelet profile (platelet count, PCT, MPV, and PDW) and PELOD score on the 1st and 3rd day of PICU admission were performed.
 RESULTS: Eighty-three subjects were recruited in this study, 44 were boy with a median age of 6 (1–17) years old. The septic patient was 43 subjects (51.8%). Platelet count on the 1st day (p = 0.024) and PDW on the 3rd day (p = 0.018) of PICU admission was significantly associated with mortality. There was no correlation between platelet profile and PELOD-2 score on day 1 and 3. However, the difference between MPV on days 1 and 3 (ΔMPV) significantly correlated with the change of PELOD-2 score (r = 0,647, p < 0.0001).
 CONCLUSION: Platelet count on 1st day and PDW on the 3rd day had a significant association with mortality but no correlation between platelet profile and PELOD-2 score.

The effect of thiaminepyrophosphate levels on mortality and morbidity ın patients with stress hyperglycemia

Background: The aim of this study is to evaluate the thiamine pyrophosphate deficiency and effects on critical illness hyperglycemia in pediatric intensive care. Materials-Methods: 126 critically ill children included to the study which applied to Erciyes University Faculty of Medicine, Department of Pediatric Intensive Care Unit (ICU). Age, sex, diagnosis and presence of malnutrition in admission to ICU; Pediatric risk of Mortality III (PRISM III) and Pediatric Logistic Organ Dysfunction (PELOD) scores; mechanical ventilation and length of stay in ICU was evaluated. Blood glucose, thiamine pyrophosphate, cortisol, insulin, C-peptide, HbA1c level, serum lactate in blood gas were analyzed at the time of application. Results: The patients grouped based on blood glucose levels, the group whose glucose level in blood is more than 150 mg/dl (n:75); PRISM and PELOD scores were high, mechanical ventilation and length of stay in intensive care were longer, thiamine pyrophosphate levels were lower (p<0.001, p=0.005, p=0.008, p<0.001, p<0.01). In case of blood glucose >150 mg/dl (n:51) and thiamine pyrophosphate <180 nmol/l is together; mortality increases 3.342-fold and the case was statistically significant (p=0.014). The group whose glucose level in blood is more than 150 mg/dl respectively, insulin, c-peptide and cortisol levels found high and the findings were statistically significant (p<0.001, p=0.005, p=0.040). Conclusion: Stress hyperglycemia is a common situation seen in critically ill patients as a cause of worse clinical outcomes. Identification of stress hyperglycemia due to thiamine deficiency is difficult but it will shed light on the treatment of critically ill children.

Sequential Organ Failure Assessment Score As a Predictor of Outcome in Sepsis in Pediatric Intensive Care Unit.

Sequential organ failure assessment (SOFA) score is used as a predictor of outcome of sepsis in the pediatric intensive care unit. The aim of the study is to determine the application of SOFA scores as a predictor of outcome in children admitted to the pediatric intensive care unit with a diagnosis of sepsis. The design involved is prospective observational study. The study took place at the multidisciplinary pediatric intensive care unit (PICU), tertiary care hospital, South India. The patients included are children, aged 1 month to 18 years admitted with a diagnosis of sepsis (suspected/proven) to a single center PICU in India from November 2017 to November 2019. Data collected included the demographic, clinical, laboratory, and outcome-related variables. Severity of illness scores was calculated to include SOFA score day 1 (SF1) and day 3 (SF3) using a pediatric version (pediatric SOFA score or pSOFA) with age-adjusted cutoff variables for organ dysfunction, pediatric risk of mortality III (PRISM III; within 24 hours of admission), and pediatric logistic organ dysfunction-2 or PELOD-2 (days 1, 3, and 5). A total of 240 patients were admitted to the PICU with septic shock during the study period. The overall mortality rate was 42 of 240 patients (17.5%). The majority (59%) required mechanical ventilation, while only 19% required renal replacement therapy. The PRISM III, PELOD-2, and pSOFA scores correlated well with mortality. All three severity of illness scores were higher among nonsurvivors as compared with survivors ( p < 0.001). pSOFA scores on both day 1 (area under the curve or AUC 0.84) and day 3 (AUC 0.87) demonstrated significantly higher discriminative power for in-hospital mortality as compared with PRISM III (AUC, 0.7), and PELOD-2 (day 1, [AUC, 0.73]), and PELOD-2 (day 3, [AUC, 0.81]). Utilizing a cutoff SOFA score of >8, the relative risk of prolonged duration of mechanical ventilation, requirement for vasoactive infusions (vasoactive infusion score), and PICU length of stay were all significantly increased ( p < 0.05), on both days 1 and 3. On multiple logistic regression, adjusted odds ratio of mortality was elevated at 8.65 (95% CI: 3.48-21.52) on day 1 and 16.77 (95% confidence interval or CI: 4.7-59.89) on day 3 ( p < 0.001) utilizing the same SOFA score cutoff of 8. A positive association was found between the delta SOFA ([Δ] SOFA) from day 1 to day 3 (SF1-SF3) and in-hospital mortality (chi-square for linear trend, p < 0.001). Subjects with a ΔSOFA of ≥2 points had an exponential mortality rate to 50%. Similar association was-observed between ΔSOFA of ≥2 and-longer duration of inotropic support ( p = 0.0006) with correlation co-efficient 0.2 (95% CI: 0.15-0.35; p = 0.01). Among children admitted to the PICU with septic shock, SOFA scores on both days 1 and 3, have a greater discriminative power for predicting in-hospital mortality than either PRISM III score (within 24 hours of admission) or PELOD-2 score (days 1 and 3). An increase in ΔSOFA of >2 adds additional prognostic accuracy in determining not only mortality risk but also duration of inotropic support as well.

The Role of Therapeutic Plasma Exchange in the Treatment of Childhood Intoxication: A Single-Center Experience.

Therapeutic plasma exchange is used to treat neurologic, hematological, renal, and autoimmune diseases with a known or suspected etiopathogenesis. However, there is incomplete understanding of the use of therapeutic plasma exchange in pediatric cases of intoxication. This study investigated 5 years of experience with therapeutic plasma exchange to treat intoxication cases. A retrospective, case series, single-center study. PICU of Baskent University, Dr. Turgut Noyan Teaching, and Medical Research Center Hospital in Adana, Turkey. Fourteen patients diagnosed with intoxication who underwent therapeutic plasma exchange between January 2013 and January 2018. None. Data pertaining to 14 patients, including their medical history (exposure to drugs/toxicants), demographics, initial presentation, and severity of clinical symptoms (requirement of mechanical ventilation, Glasgow Coma Scale score, and the pediatric severity of illness score [Pediatric Logistic Organ Dysfunction] were retrospectively reviewed. The most common indication for therapeutic plasma exchange was multiple drug intoxication, followed by amitriptyline, Amanita phalloides mushroom, carbamazepine, mercury, verapamil, and botulism. All patients underwent therapeutic plasma exchange and two patients underwent hemodialysis before therapeutic plasma exchange. There was no mortality or complications related to the therapeutic plasma exchange procedure. Clinical improvement was observed after therapeutic plasma exchange in 13 of the 14 patients; one patient with verapamil intoxication died. Therapeutic plasma exchange appears to be safe and effective for treating pediatric cases of intoxication, including multidrug and amitriptyline intoxication, and is associated with significant recovery in the majority of severely affected patients. Treatment of intoxication with therapeutic plasma exchange should be guided primarily by the properties of the causative toxic substances/drugs, and consideration of patient age, the severity of clinical symptoms, Pediatric Logistic Organ Dysfunction score and response to initial supportive and antidotal treatment.

The Usefulness of C-Reactive Protein, Procalcitonin, and PELOD-2 Score as a Predictive Factor of Mortality in Sepsis

BACKGROUND: Sepsis in children is a significant cause of morbidity and mortality in the pediatric intensive care unit (PICU). Assessment of pediatric sepsis using serial Pediatric Logistic Organ Dysfunction (PELOD)-2 score can be used as a prognostic factor. The use of biomarkers of sepsis is also used for diagnosis and predicting outcomes. Many studies have suggested that C-reactive protein (CRP) and procalcitonin (PCT) can be used to predict mortality.METHODS: A prospective cohort study was conducted to evaluate CRP, PCT, PELOD-2 score and its combination as a predictive factor of mortality in sepsis. All patients admitted to PICU Haji Adam Malik General Hospital, Medan, from April to November 2019 with suspected sepsis were included in this study. Blood examination and PELOD-2 scores were examined in the first 24 hours.RESULTS: A total of 79 children were included with a mortality rate 55.7%. The CRP, PCT, and PELOD-2 score were higher in nonsurvivor (2.8 (0.5-22.4) mg/dL; 9.36 (0.13-79.8) ng/mL; 9 (3-21), respectively). In multivariate logistic regression analysis, neither CRP nor PCT values could be independent predictors of mortality. The PELOD-2 score can be an independent predictor for mortality at a cut-off score of 7 (OR: 3.47 (95% CI: 1.68-7.19)). The combination of PELOD-2 and CRP scores as predictors of mortality showed lower values than PELOD-2 and PCT scores (0.80 vs. 0.95). The combination of all parameters only adds 1% of the predicted mortality value.CONCLUSION: PELOD-2 score with PCT value are recommended to predict mortality children with sepsis.KEYWORDS: sepsis, mortality, C-reactive protein, procalcitonin, PELOD-2 score

Prediction of Acquired Morbidity Using Illness Severity Indices in Pediatric Intensive Care Patients.

To assess the ability of two illness severity scores, Pediatric Logistic Organ Dysfunction Score 2 and Pediatric Index of Mortality 3, in predicting PICU-acquired morbidity. Retrospective chart review conducted from April 2015 to March 2016. Single-center study in a multidisciplinary PICU in a tertiary pediatric hospital in Singapore. The study included all index admissions of patients 0-18 years old to the PICU during the study period. None. Three outcomes were assessed at hospital discharge: mortality, survival with new morbidity defined as an increase in the Functional Status Scale score of greater than or equal to 3 points from baseline, and survival without morbidity. Of 577 consecutive admissions, 95 were excluded: 82 readmissions, 10 patients greater than or equal to 18 years old, two patients with missing baseline data, and one transferred to another PICU. Of 482 patients, there were 37 hospital deaths (7.7%) and 39 (8.1%) with acquired new morbidity. Median admission Pediatric Logistic Organ Dysfunction Score 2 and Pediatric Index of Mortality 3 scores differed among the three outcome groups. In addition, differences were found in emergency admission and neurologic diagnosis rates, PICU mechanical ventilation usage rates, and PICU length of stay. The highest proportion of neurologic diagnoses was observed in the new morbidity group. The final model simultaneously predicted risks of mortality, survival with new morbidity and survival without morbidity using admission Pediatric Logistic Organ Dysfunction Score 2 score, admission type, neurologic diagnosis, and preexisting chronic disease. Pediatric Logistic Organ Dysfunction Score 2 was superior to Pediatric Index of Mortality 3 in predicting risks of mortality and new morbidity, as indicated by volume under surface values of 0.483 and 0.362, respectively. Risk of mortality, survival with new morbidity, and survival without morbidity can be predicted simultaneously using admission Pediatric Logistic Organ Dysfunction Score 2, admission type, admission diagnosis, and preexisting chronic disease. Future independent studies will be required to validate the proposed model before clinical implementation.

Characteristics and Clinical Outcomes of Prolonged Continuous Renal Replacement Therapy in Critically Ill Pediatric Patients.

Paralleling improved outcomes in critically ill patients, survival for pediatric acute kidney injury has improved. Continuous renal replacement therapy is the preferred modality to optimize fluid and electrolyte management as well as nutritional support for children developing acute kidney injury in the PICU. However, some patients remain too fragile for transition to intermittent renal replacement therapies and require continuous renal replacement therapy for a prolonged period. Characteristics of this cohort and factors impacting outcomes are not well known. We aimed to describe the characteristics of pediatric patients requiring prolonged continuous renal replacement therapy and evaluate the factors impacting hospital survival. Retrospective chart review. Tertiary PICU. Children requiring prolonged continuous renal replacement therapy. Prolonged continuous renal replacement therapy was defined as continuous renal replacement therapy dependence greater than or equal to 28 days. Primary outcome was hospital mortality. None. From 2013 to 2016, 344 patients received continuous renal replacement therapy, 36 (10%) received continuous renal replacement therapy for greater than or equal to 28 days. Seventeen patients (47%) were female. Overall mortality was 44% (16/36); 69% (11/16) of nonsurvivors died of sepsis. Pediatric Logistic Organ Dysfunction score was significantly higher in nonsurvivors. Mortality rate was significantly higher in patients who were neutropenic at continuous renal replacement therapy start. Neutropenia (defined as absolute neutrophil count < 1,500/mm) at continuous renal replacement therapy start was the only independent predictor of mortality. One in four survivors did not recover renal function and remained dialysis dependent. Prolonged continuous renal replacement therapy patients are at high risk of nonrecovery of renal function and require close monitoring. The majority of nonsurvivors in the study group died from sepsis. Neutropenia at continuous renal replacement therapy initiation was associated with increased risk of mortality. Progression of underlying disease process could explain the higher death rate in patients with neutropenia; however, inadequate treatment of infectious complications could be another explanation to explore further in future studies.

Nosocomial Infection Following Severe Traumatic Injury in Children.

Nosocomial infection is a common source of morbidity in critically injured children including those with traumatic brain injury. Risk factors for nosocomial infection in this population, however, are poorly understood. We hypothesized that critically ill pediatric trauma patients with traumatic brain injury would demonstrate higher rates of nosocomial infection than those without traumatic brain injury. Retrospective case-control study. PICU, single institution. Patients under 18 years old who were admitted to the PICU for at least 48 hours following a traumatic injury were included. Patients were admitted between September 2008 and December 2015. Patients with the following injury types were excluded: thermal injury, drowning, hanging/strangulation, acute hypoxic ischemic encephalopathy, or nonaccidental trauma. Data collected included demographics, injury information, hospital and PICU length of stay, vital signs, laboratory data, insertion and removal dates for invasive devices, surgeries performed, transfusions of blood products, and microbiology culture results. Initial Pediatric Risk of Mortality III and Pediatric Logistic Organ Dysfunction-2 scores were determined. Patients were classified as having: 1) an isolated traumatic brain injury, 2) a traumatic injury without traumatic brain injury, or 3) polytrauma with traumatic brain injury. None. Two hundred three patients were included in the analyses, and 27 patients developed a nosocomial infection. Patients with polytrauma with traumatic brain injury demonstrated a significantly higher infection rate (30%) than patients with isolated traumatic brain injury (6%) or traumatic injury without traumatic brain injury (9%) (p < 0.001). This increased rate of nosocomial infection was noted on univariate analysis, on multivariable analysis, and after adjusting for other risk factors. In this single-center, retrospective analysis of critically ill pediatric trauma patients, nosocomial infections were more frequently observed in patients admitted following polytrauma with traumatic brain injury than in patients with isolated traumatic brain injury or trauma without traumatic brain injury.

Evaluation of Pediatric Risk of Mortality Score III (PISM III) and Pediatric Logistic Organ Dysfunction (PELOD) Scores in pediatric intensive care unit

Amaç: Bu çalışmanın amacı çocuk yoğun bakım ünitesine yatırılan hastaların Pediatric Risk of Mortality Score III(PRISM III) ve Pediatric Logistic Organ Dysfunction(PELOD) skorları ile hastaların karakteristik özelliklerinin kıyaslanması ve bu skorların eksitus ve hayatta kalma oranlarını göstermedeki başarısını araştırmaktır. Yöntem: Mart 2017-Mart 2018 tarihleri arasında çocuk yoğun bakım ünitesine yatırılan toplam 372 hasta çalışmaya alınmıştır. Hastaların cinsiyeti, yaşı, yatış nedeni, altta yatan hastalık, cerrahi olup olmaması, PRISM III, PELOD skorları, ilk 24 saatte mekanik ventilatör izlemi, ilk 24 saat içinde transfüze edilip edilmemesi, yatış hemogram değerleri ve hastanın eksitus olup olmaması sonuçları kaydedildi. Bulgular: Hastaların 188’i kız (%50.5), 184‘ü erkek (%49.5) ti. Yaş ortalamaları 48 (12-144) ay olarak hesaplanmıştır. %92.2 si servise devir veya taburcu edilirken %7.8 i eksitus olmuştu. PRISM III ve PELOD değerleri eksitus olan hastalarda anlamlı derecede yüksek (p&amp;lt;0.001) iken medyan değeri PRISM III ve PELOD için eksitus olan hastalarda 12 olarak saptanmıştır. Ortalama yoğun bakım yatış süresi bu süreçte 4 (3-9) gün olup altta yatan hastalığı olanlarda ortalama 5 (3-12) gün olarak hesaplanmıştır. PRISM III ün spesifitesi %67.35 iken sensitivitesi %89.66, PELOD içinse spesifite %93.86, sensitivite %51.7 saptandı. Sonuç; PRISM III skoru mortaliteyi, PELOD skoru morbidiyeti tahmin etmede güçlü skorlardır. PRISM III ve PELOD skorları çocuk yoğun bakım ünitelerinde mortalite ve morbiditeyi öngörmede kullanılabilir.

Prediction of Pediatric Critical Care Resource Utilization for Disaster Triage.

Pediatric protocols to guide allocation of limited resources during a disaster lack data to validate their use. The 2011 Pediatric Emergency Mass Critical Care Task Force recommended that expected duration of critical care be incorporated into resource allocation algorithms. We aimed to determine whether currently available pediatric illness severity scores can predict duration of critical care resource use. Retrospective cohort study. Seattle Children's Hospital. PICU patients admitted 2016-2018 for greater than or equal to 12 hours (n = 3,206). None. We developed logistic and linear regression models in two-thirds of the cohort to predict need for and duration of PICU resources based on Pediatric Risk of Mortality-III, Pediatric Index of Mortality-3, and serial Pediatric Logistic Organ Dysfunction-2 scores. We tested the predictive accuracy of the models with the highest area under the receiver operating characteristic curve (need for each resource) and R (duration of use) in a validation cohort of the remaining one of three of the sample and among patients admitted during one-third of the sample and among patients admitted during surges of respiratory illness. Pediatric Logistic Organ Dysfunction score calculated 12 hours postadmission had higher predictive accuracy than either Pediatric Risk of Mortality or Pediatric Index of Mortality scores. Models incorporating 12-hour Pediatric Logistic Organ Dysfunction score, age, Pediatric Overall Performance Category, Pediatric Cerebral Performance Category, chronic mechanical ventilation, and postoperative status had an area under the receiver operating characteristic curve = 0.8831 for need for any PICU resource (positive predictive value 80.2%, negative predictive value 85.9%) and area under the receiver operating characteristic curve = 0.9157 for mechanical ventilation (positive predictive value 85.7%, negative predictive value 89.2%) within 7 days of admission. Models accurately predicted greater than or equal to 24 hours of any resource use for 78.9% of patients and greater than or equal to 24 hours of ventilation for 83.1%. Model fit and accuracy improved for prediction of resource use within 3 days of admission, and was lower for noninvasive positive pressure ventilation, vasoactive infusions, continuous renal replacement therapy, extracorporeal membrane oxygenation, and length of stay. A model incorporating 12-hour Pediatric Logistic Organ Dysfunction score performed well in estimating how long patients may require PICU resources, especially mechanical ventilation. A pediatric disaster triage algorithm that includes both likelihood for survival and for requiring critical care resources could minimize subjectivity in resource allocation decision-making.

Predicting Mortality in Children With Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study.

Pediatric acute respiratory distress syndrome is heterogeneous, with a paucity of risk stratification tools to assist with trial design. We aimed to develop and validate mortality prediction models for patients with pediatric acute respiratory distress syndrome. Leveraging additional data collection from a preplanned ancillary study (Version 1) of the multinational Pediatric Acute Respiratory Distress syndrome Incidence and Epidemiology study, we identified predictors of mortality. Separate models were built for the entire Version 1 cohort, for the cohort excluding neurologic deaths, for intubated subjects, and for intubated subjects excluding neurologic deaths. Models were externally validated in a cohort of intubated pediatric acute respiratory distress syndrome patients from the Children's Hospital of Philadelphia. The derivation cohort represented 100 centers worldwide; the validation cohort was from Children's Hospital of Philadelphia. There were 624 and 640 subjects in the derivation and validation cohorts, respectively. None. The model for the full cohort included immunocompromised status, Pediatric Logistic Organ Dysfunction 2 score, day 0 vasopressor-inotrope score and fluid balance, and PaO2/FIO2 6 hours after pediatric acute respiratory distress syndrome onset. This model had good discrimination (area under the receiver operating characteristic curve 0.82), calibration, and internal validation. Models excluding neurologic deaths, for intubated subjects, and for intubated subjects excluding neurologic deaths also demonstrated good discrimination (all area under the receiver operating characteristic curve ≥ 0.84) and calibration. In the validation cohort, models for intubated pediatric acute respiratory distress syndrome (including and excluding neurologic deaths) had excellent discrimination (both area under the receiver operating characteristic curve ≥ 0.85), but poor calibration. After revision, the model for all intubated subjects remained miscalibrated, whereas the model excluding neurologic deaths showed perfect calibration. Mortality models also stratified ventilator-free days at 28 days in both derivation and validation cohorts. We describe predictive models for mortality in pediatric acute respiratory distress syndrome using readily available variables from day 0 of pediatric acute respiratory distress syndrome which outperform severity of illness scores and which demonstrate utility for composite outcomes such as ventilator-free days. Models can assist with risk stratification for clinical trials.

Effect of 3 pediatric scores of critical illness in prognostic evaluation of children with sepsis in intensive care units

Objective To investigate the effect of 3 pediatric scores of critical illness including Pediatric Critical Illness Score (PCIS), Pediatric Logistic Organ Dysfunction Score 2 (PELOD-2), and Pediatric Multiple Organ Dysfunction Score (P-MODS) in estimating the prognosis of illness in children with sepsis in pediatric intensive care unit (PICU). Methods The data of 516 pediatric patients diagnosed as sepsis in PICU of Affiliated Hospital of Guangdong Medical University from June 2016 to June 2018 were retrospectively analyzed, and they were divided into survival group and death group according to the clinical outcome on the 28th day after admission.Then, the receiver operating characteristic (ROC) curve was plotted, and the efficiency of PCIS, PELOD-2 and P-MODS for predicting death was evaluated by the area under ROC curve (AUC). Results There were 488 pediatric patients survived, while 28 cases died during hospitalization.Compared with the survival group, the death group had a significantly lower PCIS score [86(82, 88) scores vs.89(84, 92)scores], and significantly higher PELOD-2 and P-MODS scores[PELOD-2: 6.5(4.0, 8.0) scores vs.0 (0, 2.0) scores, P-MODS: 3(2, 6) scores vs.1(1, 2) scores], and the differences were significant(Z=3 259.500, 14.228, 4.688, all P<0.05). ROC curve analysis showed that the AUCs of PCIS, PELOD-2 and P-MODS for predicting prognosis of pediatric patients with sepsis in PICU were 0.761, 0.916 and 0.761, respectively(Z=6.127, 14.228, 4.688, all P<0.05). Conclusions PCIS, PELOD-2 and P-MODS are effective and have good ability to assess the prognosis of pediatric patients with sepsis in the PICU.It seems that PELOD-2 is the most effective. Key words: Pediatric scores of critical illness; Pediatric intensive care unit; Sepsis; Prognostic evaluation

Comparison of the Automated Pediatric Logistic Organ Dysfunction-2 Versus Manual Pediatric Logistic Organ Dysfunction-2 Score for Critically Ill Children.

The Pediatric Logistic Organ Dysfunction-2 is a validated score that quantifies organ dysfunction severity and requires complex data collection that is time-consuming and subject to errors. We hypothesized that a computer algorithm that automatically collects and calculates the Pediatric Logistic Organ Dysfunction-2 (aPELOD-2) score would be valid, fast and at least as accurate as a manual approach (mPELOD-2). Retrospective cohort study. Single center tertiary medical and surgical pediatric critical care unit (Sainte-Justine Hospital, Montreal, Canada). Critically ill children participating in four clinical studies between January 2013 and August 2018, a period during which mPELOD-2 data were manually collected. None. The aPELOD-2 was calculated for all consecutive admissions between 2013 and 2018 (n = 5,279) and had a good survival discrimination with an area under the receiver operating characteristic curve of 0.84 (95% CI, 0.81-0.88). We also collected data from four single-center studies in which mPELOD-2 was calculated (n = 796, 57% medical, 43% surgical) and compared these measurements to those of the aPELOD-2. For those patients, median age was 15 months (interquartile range, 3-73 mo), median ICU stay was 5 days (interquartile range, 3-9 d), mortality was 3.9% (n = 28). The intraclass correlation coefficient between mPELOD-2 and aPELOD-2 was 0.75 (95% CI, 0.73-0.77). The Bland-Altman showed a bias of 1.9 (95% CI, 1.7-2) and limits of agreement of -3.1 (95% CI, -3.4 to -2.8) to 6.8 (95% CI, 6.5-7.2). The highest agreement (Cohen's Kappa) of the Pediatric Logistic Organ Dysfunction-2 components was noted for lactate level (0.88), invasive ventilation (0.86), and creatinine level (0.82) and the lowest for the Glasgow Coma Scale (0.52). The proportion of patients with multiple organ dysfunction syndrome was higher for aPELOD-2 (78%) than mPELOD-2 (72%; p = 0.002). The aPELOD-2 had a better survival discrimination (area under the receiver operating characteristic curve, 0.81; 95% CI, 0.72-0.90) over mPELOD-2 (area under the receiver operating characteristic curve, 0.70; 95% CI, 0.59-0.82; p = 0.01). We successfully created a freely available automatic algorithm to calculate the Pediatric Logistic Organ Dysfunction-2 score that is less labor intensive and has better survival discrimination than the manual calculation. Use of an automated system could greatly facilitate integration of the Pediatric Logistic Organ Dysfunction-2 score at the bedside and within clinical decision support systems.

A randomized controlled trial of high parenteral protein feeding in septic children: the role of tumor necrosis factor-alpha-308 polymorphism

BACKGROUND Septic children cause high protein degradation and inadequate nutritional intake would worsen the outcomes. In addition, there are conflicting results of association between tumor necrosis factor-α (TNFA)-308 polymorphism and poorer outcomes. This study was aimed to investigate the impact of high protein feeding in septic children and to examine the role of the TNFA-308 polymorphism in outcome of sepsis.&#x0D; METHODS In this randomized controlled trial, septic children were randomly assigned to receive either high protein feeding (amino acid of 4 g/kg of body weight [kgBW]/day) or standard nutrient (amino acid of 2 g/kgBW/day) for three days in the pediatric intensive care unit of four hospitals in Indonesia. The patient’s enrollment was done between April 2016 and May 2017. The primary outcome was the pediatric logistic organ dysfunction (PELOD) score. TNFA-308 polymorphism was investigated using restriction fragment length polymorphism method in both groups. PELOD score was analyzed as mean differences and gene polymorphism was analyzed with mortality in a subgroup.&#x0D; RESULTS There were 40 children in each group. PELOD score on day-1 (22.4 versus 20.5, p = 0.429), day-2 (20.5 versus 19.8, p = 0.815), and day-3 (18.8 versus 19.8, p = 0.772) were not lower in high protein feeding compared to standard feeding. TNFA-308 polymorphism had no role in mortality of both groups (high protein, p = 0.426; standard, p = 0.456).&#x0D; CONCLUSIONS From this study, researchers concluded that a high protein intervention did not significantly decrease the PELOD score, length of stay, and duration of ventilator use in both groups.

Early Enteral Nutrition Is Associated With Improved Clinical Outcomes in Critically Ill Children: A Secondary Analysis of Nutrition Support in the Heart and Lung Failure-Pediatric Insulin Titration Trial.

The impact of early enteral nutrition on clinical outcomes in critically ill children has not been adequately described. We hypothesized that early enteral nutrition is associated with improved clinical outcomes in critically ill children. Secondary analysis of the Heart and Lung Failure-Pediatric Insulin Titration randomized controlled trial. Thirty-five PICUs. Critically ill children with hyperglycemia requiring inotropic support and/or invasive mechanical ventilation who were enrolled for at least 48 hours with complete nutrition data. Subjects received nutrition via guidelines that emphasized enteral nutrition and were classified into early enteral nutrition (enteral nutrition within 48 hr of study randomization) and no early enteral nutrition (enteral nutrition after 48 hr of study randomization, or no enteral nutrition at any time). Of 608 eligible subjects, 331 (54%) received early enteral nutrition. Both early enteral nutrition and no early enteral nutrition groups had similar daily caloric intake over the first 8 study days (median, 36 vs 36 kcal/kg/d; p = 0.93). After controlling for age, body mass index z scores, primary reason for ICU admission, severity of illness, and mean Vasopressor-Inotrope Score at the time of randomization, and adjusting for site, early enteral nutrition was associated with lower 90-day hospital mortality (8% vs 17%; p = 0.007), more ICU-free days (median, 20 vs 17 d; p = 0.02), more hospital-free days (median, 8 vs 0 d; p = 0.003), more ventilator-free days (median, 21 vs 19 d; p = 0.003), and less organ dysfunction (median maximum Pediatric Logistic Organ Dysfunction, 11 vs 12; p < 0.001). In critically ill children with hyperglycemia requiring inotropic support and/or mechanical ventilation, early enteral nutrition was independently associated with better clinical outcomes.

Critical Illness Factors Associated With Long-Term Mortality and Health-Related Quality of Life Morbidity Following Community-Acquired Pediatric Septic Shock.

A companion article reports the trajectory of long-term mortality and significant health-related quality of life disability among children encountering septic shock. In this article, the investigators examine critical illness factors associated with these adverse outcomes. Prospective, cohort-outcome study, conducted 2013-2017. Twelve United States academic PICUs. Critically ill children, 1 month to 18 years, with community-acquired septic shock requiring vasoactive-inotropic support. Illness severity, organ dysfunction, and resource utilization data were collected during PICU admission. Change from baseline health-related quality of life at the month 3 follow-up was assessed by parent proxy-report employing the Pediatric Quality of Life Inventory or the Stein-Jessop Functional Status Scale. In univariable modeling, critical illness variables associated with death and/or persistent, serious health-related quality of life deterioration were candidates for multivariable modeling using Bayesian information criterion. The most clinically relevant multivariable models were selected among models with near-optimal statistical fit. Three months following septic shock, 346 of 389 subjects (88.9%) were alive and 43 of 389 had died (11.1%); 203 of 389 (52.2%) had completed paired health-related quality of life surveys. Pediatric Risk of Mortality, cumulative Pediatric Logistic Organ Dysfunction scores, PICU and hospital durations of stay, maximum and cumulative vasoactive-inotropic scores, duration of mechanical ventilation, need for renal replacement therapy, extracorporeal life support or cardiopulmonary resuscitation, and appearance of pathologic neurologic signs were associated with adverse outcomes in univariable models. In multivariable regression analysis (odds ratio [95% CI]), summation of daily Pediatric Logistic Organ Dysfunction scores, 1.01/per point (1.01-1.02), p < 0.001; highest vasoactive-inotropic score, 1.02/per point (1.00-1.04), p = 0.003; and any acute pathologic neurologic sign/event, 5.04 (2.15-12.01), p < 0.001 were independently associated with death or persistent, serious deterioration of health-related quality of life at month 3. Biologically plausible factors related to sepsis-associated critical illness organ dysfunction and its treatment were associated with poor outcomes at month 3 follow-up among children encountering septic shock.

Trajectory of Mortality and Health-Related Quality of Life Morbidity Following Community-Acquired Pediatric Septic Shock.

In-hospital pediatric sepsis mortality has decreased substantially, but long-term mortality and morbidity among children initially surviving sepsis, is unknown. Accordingly, the Life After Pediatric Sepsis Evaluation investigation was conducted to describe the trajectory of mortality and health-related quality of life morbidity for children encountering community-acquired septic shock. Prospective, cohort-outcome study, conducted 2013-2017. Twelve academic PICUs in the United States. Critically ill children, 1 month to 18 years, with community-acquired septic shock requiring vasoactive-inotropic support. Demographic, infection, illness severity, organ dysfunction, and resource utilization data were collected daily during PICU admission. Serial parent proxy-report health-related quality of life assessments were obtained at baseline, 7 days, and 1, 3, 6, and 12 months following PICU admission utilizing the Pediatric Quality of Life Inventory or Stein-Jessop Functional Status Scale. Among 389 children enrolled, mean age was 7.4 ± 5.8 years; 46% were female; 18% were immunocompromised; and 51% demonstrated chronic comorbidities. Baseline Pediatric Overall Performance Category was normal in 38%. Median (Q1-Q3) Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores at PICU admission were 11.0 (6.0-17.0) and 9.0 (6.0-11.0); durations of vasoactive-inotropic and mechanical ventilation support were 3.0 days (2.0-6.0 d) and 8.0 days (5.0-14.0 d); and durations of PICU and hospital stay were 9.4 days (5.6-15.4 d) and 15.7 days (9.2-26.0 d). At 1, 3, 6, and 12 months following PICU admission for the septic shock event, 8%, 11%, 12%, and 13% of patients had died, while 50%, 37%, 30%, and 35% of surviving patients had not regained their baseline health-related quality of life. This investigation provides the first longitudinal description of long-term mortality and clinically relevant, health-related quality of life morbidity among children encountering community-acquired septic shock. Although in-hospital mortality was 9%, 35% of survivors demonstrated significant, health-related quality of life deterioration from baseline that persisted at least 1 year following hospitalization for septic shock.

Calcium, Magnesium and phosphate deficiency and their Effect on Clinical outcome in Critically Ill child

Critical illness may trigger an acute phase response which is associated with several metabolic derangements. These include hypocalcaemia, hypophosphatemia and hypomagnesaemia. To determine the incidence and associated risk factors of hypocalcaemia, hypomagnesaemia and hypophosphatemia that develop in critically ill children and their effect on their clinical outcome. 50 child enrolled in our study aged from 1month to 6 years admitted in pediatric intensive care unit in Benha University Hospital. Levels of serum calcium, magnesium and phosphate were measured during admission. The following variables were analyzed: age, gender, diagnosis on admission, clinical severity score on admission OFI (Organ Failure Index) and daily scores PELOD (Pediatric Logistic Organ Dysfunction), length of hospital stay and outcome were analyzed. Out of 50 patients, the frequency of Calcium deficiency was (64%), magnesium deficiency (46%), and phosphate deficiency (57%) on admission. There was negative correlation between calcium level and PELOD (P=0.048), OFI (P=0.001) and period of hospitalization (P=0.002). Patients with hypomagnesaemia on admission had higher PELOD score (P=0.008), higher OFI (P=0.008),prolonged period of hospitalization(P=0.038) and was associated with hypokalemia (P<0.05). Hypophosphatemia was associated with higher PELOD score (P=0.019) and increased period of hospitalization (P=0.012). Mortality rate increased in patients with hypocalcaemia (P=0.022) and also in patients with hypomagnesaemia (P=0.006). Deficiency of calcium, magnesium and phosphate were common among critically ill children and affected clinical outcome of patient.

Hemodynamic effects of intravenous paracetamol in critically ill children with septic shock on inotropic support

BackgroundTreatment with intravenous paracetamol may impair hemodynamics in critically ill adults. Few data are available in children. The aim of this study was to investigate the frequency, extent, and risk factors of hypotension following intravenous paracetamol administration in children with septic shock on inotropic support.MethodsWe retrospectively reviewed the electronic medical charts of all children aged 1 month to 18 years with septic shock who were treated with intravenous paracetamol while on inotropic support at the critical care unit of a tertiary pediatric medical center in 2013–2018. Data were collected on patient demographics, underlying disease, Pediatric Logistic Organ Dysfunction (PELOD) score, hemodynamic parameters before and up to 120 min after paracetamol administration, and need for inotropic support or intravenous fluid bolus. The main outcome measures were a change in blood pressure, hypotension, and hypotension requiring intervention.ResultsThe cohort included 45 children of mean age 8.9 ± 5.1 years. The mean inotropic support score was 12.1 ± 9.5. A total of 105 doses of paracetamol were administered. The lowest mean systolic pressure (108 ± 15 mmHg) was recorded at 60 min (p = 0.002). Systolic blood pressure decreased at 30, 60, 90, and 120 min after delivery of 50, 67, 61, and 59 drug doses, respectively. There were 5 events of systolic hypotension (decrease of 1 to 16 mmHg below systolic blood pressure hypotensive value). Mean arterial pressure decreased by ≥ 15% in 8 drug doses at 30 min (7.6%, mean − 19 ± 4 mmHg), 18 doses at 60 min (17.1%, mean − 20 ± 7 mmHg), 16 doses at 90 min (15.2%, mean − 20 ± 5 mmHg), and 17 doses at 120 min (16.2%, mean − 19 ± 5 mmHg). Mean arterial hypotension occurred at the respective time points in 2, 13, 10, and 9 drug doses. After 12 drug doses (11.4%), patients required an inotropic dose increment or fluid bolus.ConclusionsHypotensive events are not uncommon in critically ill children on inotropic support treated with intravenous paracetamol, and physicians should be alert to their occurrence and the need for intervention.

Examining 1:1 vs. 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision.

Blood transfusions following major burn injury are common due to operative losses, blood sampling, and burn physiology. While massive transfusion improves outcomes in adult trauma patients, literature examining its effect in critically ill children is limited. The study purpose was to prospectively compare outcomes of major pediatric burns receiving a 1:1 vs. 4:1 packed red blood cell to fresh frozen plasma transfusion strategy during massive burn excision. Children with >20% total body surface area burns were randomized to a 1:1 or 4:1 packed red blood cell/fresh frozen plasma transfusion ratio during burn excision. Parameters examined include patient demographics, burn size, pediatric risk of mortality (PRISM) scores, pediatric logistic organ dysfunction scores, laboratory values, total blood products transfused, and the presence of blood stream infections or pneumonia. A total of 68 children who met inclusion criteria were randomized into two groups (n = 34). Mean age, PRISM scores, estimated blood loss (600 ml (400-1175 ml) vs. 600 ml (300-1150 ml), P = 0.68), ventilator days (5 vs. 9, P = 0.47), and length of stay (57 vs. 60 days, P = 0.24) had no difference. No differences in frequency of blood stream infection (20 vs. 18, P = 0.46) or pneumonia events (68 vs. 116, P = 0.08) were noted. On multivariate analysis, only total body surface area burn size, inhalation injury, and PRISM scores (P < 0.05) were significantly associated with infections.