Pediatric Overall Performance Category Research Articles

Survival and neurobehavioral outcomes following out-of-hospital cardiac arrest in pediatric patients with pre-existing morbidity: An analysis of the THAPCA out-of-hospital arrest data

AimPre-arrest morbidity in adults who suffer out-of-hospital cardiac arrest (OHCA) is associated with increased mortality and poorer neurologic outcomes. The objective of this study was to determine if a similar association is seen in pediatric patients. MethodsWe performed a secondary analysis of data from the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial. Study sites included 36 pediatric intensive care units across the United States and Canada. The study enrolled children between the ages of 48 hours and 18 years following an OHCA between September 1, 2009 and December 31, 2012. For our analysis, patients with (N = 151) and without (N = 142) pre-arrest comorbidities were evaluated to assess morbidity, survival, and neurologic function following OHCA. ResultsNo significant difference in 28-day survival was seen between groups. Dependence on technology and neurobehavioral outcomes were assessed among survivors using the Vineland Adaptive Behavior Scales-Second Edition (VABS-II), Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC). Children with pre-existing comorbidities maintained worse neurobehavioral function at twelve months, evidenced by poorer scores on POPC (p = 0.016), PCPC (p = 0.044), and VABS-II (p = 0.020). They were more likely to have a tracheostomy at hospital discharge (p = 0.034), require supplemental oxygen at three months (p = 0.039) and twelve months (p = 0.034), and be mechanically ventilated at twelve months (p = 0.041). ConclusionsThere was no difference in survival to 28 days following OHCA in children with pre-existing comorbidity compared to previously healthy children. The group with pre-existing comorbidity was more reliant on technology following arrest and exhibited worse neurobehavioral outcomes.

Increased rates of invasive bacterial disease in late 2022.

Invasive bacterial disease is associated with significant morbidity and mortality. In winter 2022, there was an apparent increased rate of invasive bacterial disease compared to preceding years.Cross-site retrospective analysis of the three Children's Health Ireland (CHI) hospitals looking at children admitted between 1st October 2022-31st December 2022 (Q4) with community-acquired invasive bacterial disease, defined as an abscess in a normally sterile site in the head, neck and chest or isolation or PCR detection of Streptococcus pneumoniae, Neisseria meningitidis, Streptococcus pyogenes (Group A streptococcus) or Haemophilus influenzae from a normally sterile site. Case numbers were compared to Q4 in each of 2018-2021.Eighty-two children met the case definition in Q4 2022 vs 97 (Q4 2018-2021). In 2022, 42/82 (51%) were female, median age 3.75years (1.5-8.25years). Only 2 (2%) were immunosuppressed and 2 others (2%) had underlying neurodisability. Fifty (61%) were admitted on second or subsequent presentation to a healthcare setting. Fifty-six (68%) had an abscess in a sterile site. Bloodstream infection (positive blood culture or PCR: 24 (29%)) was the most common site of infection, followed by neck 22 (27%) and intracranial 12 (15%). Group A streptococcus (GAS) 27 (33%) was the most common organism isolated. Seven cases (9%) died in 2022 compared to 2 patients (2%) from 2018 to 2021 (p < 0.05). More children had Paediatric Overall Performance Category (POPC) scores > 1 in 2022 than 2018-2021 (p = 0.003). Conclusion: Invasive bacterial diseases increased in Q4 2022 with higher morbidity and mortality than in the preceding 4years. Group A streptococcal infection was the most significant organism in 2022. What is known: • Invasive bacterial disease is the leading cause of childhood mortality globally. • There was an increase in cases of invasive Group A streptococcus infections reported in many countries (including Ireland) during the winter of 2022/23. What is new: • Head, neck and chest abscesses increased in Q4 of 2022 compared to the previous 4years combined. • Invasive bacterial infections in Q4 of 2022 were associated with higher rates of mortality (9%), paediatric intensive care unit (PICU) admission (24%) and requirement for surgical drainage or intervention (67%) than in the preceding years.

Long-Term Functional Outcome Following Neurosurgical Intervention for Suspected Abusive Head Trauma

BackgroundThe purpose of this study was to evaluate the long-term functional and neurodevelopmental outcomes in pediatric patients who underwent neurosurgical intervention following suspected abusive head trauma (AHT). MethodsWe performed a single-center retrospective review (January 1, 2007, to December 31, 2019) of patients aged less than three years who had intracranial injury suspicious for AHT and received a neurosurgical procedure. Long-term functional outcome was measured using the Pediatric Cerebral Performance Category (PCPC), Pediatric Overall Performance Category (POPC), and the Mullen Scales of Early Learning (MSEL). ResultsSeventy-seven patients were identified; 53 survived to discharge and had at least one-year follow-up. To examine long-term functional outcome, PCPC at the last available visit was examined and found to be 1 or 2 (normal to mild disability) for 64% of patients and 3 or 4 (moderate to severe disability) for 36%. The last available MSEL composite score for neurodevelopmental assessment also demonstrated that 13% of patients scored in the “average” range, 17% in the “below average” range, and 70% in the “very low” range. There was no statistical difference in the last available PCPC or POPC score or the last available MSEL score for patients who received a craniotomy when compared with those who received an intracranial shunt. ConclusionsFor patients with AHT who survived to discharge, functional improvements over time were noted in both patients who received craniotomy or who simply required shunt placement. These results suggest that, for patients who survive to discharge, operative management of AHT can lead to reasonable long-term functional outcomes.

Different dosages of methylprednisolone therapy for acute necrotizing encephalopathy of childhood: a 6-year multicenter retrospective study.

Different dosages of methylprednisolone therapy for acute necrotizing encephalopathy of childhood: a 6-year multicenter retrospective study.

Tradução e adaptação transcultural da pediatric cerebral performance category (PCPC) e da pediatric overall performance category (POPC) para o português brasileiro

To translate and culturally adapt the scales Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC) to the Brazilian population. Two English language proficient professionals independently translated the original version of the scales into Brazilian Portuguese. After consensus, it was generated a translated version of each scale. These were back translated into English by two native English translators. A new consensus process resulted in an English version of each scale, which were compared with the originals and approved by the author. A committee of experts with clinical and academic experience in intensive care checked the validity of the content and produced the pre-final versions of the scales, which were tested by 25 professionals from a Pediatric Intensive Care Unit. An audit was conducted to verify the consistency of the methodological process. The pre-final versions were approved by 96% of the Brazilian professionals. No significant changes were made to the content of the instrument; however, it was identified the need of a guide with instructions on how to use the scales. The process of translation and cross-cultural adaptation of the scales was completed and resulted in PCPC-BR and POPC-BR scales.

969: FACTORS AFFECTING DISCHARGE TIMING AFTER INITIAL TRACHEOSTOMY PLACEMENT IN CHILDREN

Introduction: Variability in timing of initial tracheostomy has been described in pediatric patients. However, variability in timing from tracheostomy to PICU discharge has not been described, nor have factors that affect discharge timing have been identified. There are factors beyond the degree of critical illness which affect discharge from PICU, such as rehabilitation facilities, availability of a technology dependent unit within the hospital, and social resources to care for complex technology dependent patients. Methods: The Virtual PICU Systems database was used to analyze a multicenter sample of 2365 patients who received an initial tracheostomy during the PICU stay. Quantile regression was used to identify factors related to timing of discharge following the tracheostomy. Results: The median PICU length of stay (PLOS) after tracheostomy was 10.8d (7.0 – 21.1), which was longer than that predicted by the PRISM3 score (6 days, p< 0.001). Patients admitted with higher PIM2 and PRISM3 s had longer PLOS (p< 0.001 and 0.021). Compared to neonates, children < 2yrs had a significant shorter LOS (-6.8d, p=0.043) and all age groups >2yrs had a significantly shorter LOS (-10d, all p< 0.008). There were no differences in LOS by race or sex. A healthier baseline Pediatric Overall Performance Category (POPC) and a larger POPC change at baseline to discharge were inversely associated with PLOS (p=0.015 and 0.017, respectively). Patients hospitalized for cardiac indications had longer LOS, while those with primary immune or heme/onc diagnoses had shorter PLOS (all p< 0.01). Having a foreign payer was associated with a shorter PLOS (-4d, p=0.001). Conclusions: In patients who received initial tracheostomy, there was variability in the timing from tracheostomy to PICU discharge. These patients had a longer PLOS than predicted by their degree of critical illness. This presents a potential for more efficient, cost-effective care for patients who are medically appropriate for PICU discharge but require complex care coordination. At a conservative estimate of $2500 difference from PICU to a step-down charge per day, would represent nearly a $25 million in potential cost savings in this patient group if actual LOS was the same as PRISM3 predicted LOS.

Early Neurologic Complications and Long-term Neurologic Outcomes of Extracorporeal Membrane Oxygenation Performed in Children.

We aimed at evaluating acute neurologic complications (ANC) and clinical outcome at a 2-year follow-up in children after extracorporeal membrane oxygenation (ECMO). We conducted a single-center, retrospective review of our patient cohort aged between 1 month and 18 years at the time of ECMO support (between June 2014 to January 2017). Outcome analysis included ANC and their clinical consequences.The Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) were used for neurologic assessment performed at discharge from the hospital and at 2nd year follow-up. There were 35 children who required ECMO. The median ECMO time was 9 days (range 2-32 days). Decannulation from ECMO was achieved in 68.6% of patients, and overall, 42.8% survived (15 patients), The incidence of ANC in the surviving patients was 40% (6 children). ANC were intracranial hemorrhage, seizures, cerebral infarction, which occurred in one, two and three of the 15 surviving patients respectively (6.6, 13.3 and 20%). A higher rate of organ failure was related to death (p=0.043), whereas duration on ECMO was a risk factor for the development of ANC (p<0.05). At hospital discharge, the 14 patients evaluated had normal development or -mild disability in 73.2%, and at the 2-year follow-up, 93.4% had these scores. Children who receive ECMO have a risk to develop ANC, which was related to the length of ECMO treatment, while survival was related to less organ failure, Long-term neurological outcome was good in our patient cohort.

Vasoactive-Inotropic Score and Vasoactive-Ventilation-Renal Score as Outcome Predictors for Children on Extracorporeal Membrane Oxygenation.

We aimed to determine the association of vasoactive-inotropic score (VIS) and vasoactive-ventilation-renal (VVR) score with in-hospital mortality and functional outcomes at discharge of children who receive ECMO. A sub-analysis of the multicenter, prospectively collected data by the Collaborative Pediatric Critical Care Research Network (CPCCRN) for Bleeding and Thrombosis on ECMO (BATE database) was conducted. Of the 514 patients who received ECMO across eight centers from December 2012 to February 2016, 421 were included in the analysis. Patients > 18 years of age, patients placed on ECMO directly from cardiopulmonary bypass or as an exit procedure, or patients with an invalid or missing VIS score were excluded. Higher VIS (OR = 1.008, 95% CI: 1.002–1.014, p = 0.011) and VVR (OR: 1.006, 95% CI: 1.001–1.012, p = 0.023) were associated with increased mortality. VIS was associated with worse Pediatric Cerebral Performance Category (PCPC) (OR = 1.027, 95% CI: 1.010–1.044, p = 0.002) and Pediatric Overall Performance Category (POPC) score (OR = 1.023, 95% CI: 1.009–1.038, p = 0.002) at discharge. No association was found between VIS or VVR and Functional Status Score (FSS) at discharge. Using multivariable analyses, controlling for ECMO mode, ECMO location, ECMO indication, primary diagnosis, and chronic diagnosis, extremely high VIS and VVR were still associated with increased mortality.

P0502 / #2098: IMPACT OF THE CORONAVIRUS (COVID-19) PANDEMIC ON CARE AND REHABILITATION OF CHILDREN WHO SURVIVED EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO).

AIMS & OBJECTIVES: To identify indirect impact of COVID-19 pandemic on rehabilitation of paediatric ECMO survivors. METHODS: ECMO-survivors who were 6-12 months post-discharge between Feb-August2020 were prospectively followed up via newly set-up secure videocall clinics between June-August 2020 by biprofessional team (physiotherapist and ECMO physician) using visual inspection,PEDICAT (Paediatric Evaluation of Disability Inventory- Computer Adaptive Test) neurodevelopmental questionnaire and parental PHQ-9(Patient Health questionnaire-9) for depression plus GAD-7(General Anxiety Disorder-7)questionnaires. Impact of pandemic on planned follow-up and investigations, neurodevelopment, psychology of carers, readmissions/delayed presentations was observed. RESULTS: 10 ECMO survivors (median age 25months) were reviewed between February2020 to August2020. 6(60%) children had not received any face-to-face or virtual physiotherapy therapy input for >3 months due to cancellation of non-essential services during COVID-19 pandemic. They remain on the waiting list to receive intensive physiotherapy despite ease of lockdown in June. 7(70%) children have not had planned audiology assessment,4 children have not had neurology review nor neuro-imaging as planned. 4 children continued to show moderate neurodevelopment delay, with no improvement of paediatric overall performance category (POPC) since hospital discharge. 2 parents scored high for post-traumatic anxiety/stress, prompting clinical psychology referral.No children had delayed presentation for acute illnesses. 2 children had a drop in acute admissions since lockdown. CONCLUSIONS: Setting up virtual ECMO follow-up clinics enabled us to identify crucial follow-up care delayed by COVID-19 pandemic and bring it up-to-date.Children with narrow timeframes of neuroplasticity were disadvantaged due to cancellation/postponement of non-essential services. It would be prudent to plan for post-discharge care delivery in advance of a second wave.

Utility of the END-IT Score to Predict the outcome of Childhood Status Epilepticus: A Retrospective Cohort Study.

Introduction:Scoring systems to predict outcomes in pediatric status epilepticus (SE) are limited. We sought to assess usefulness of the END-IT score in pediatric SE.Methodology:We conducted a retrospective study at a tertiary hospital in New Delhi, India. Children aged 1 month–18 years who presented with seizure for ≥5 min/actively convulsing to emergency were enrolled. END-IT score was calculated and correlated with outcome at discharge using Pediatric Overall Performance Category (POPC) scale, in-hospital mortality, and progression to refractory and super-refractory SE (SRSE).Results:We enrolled 140 children (mean age 5.8 years; 67.1% males). Seven children died and 15 had unfavorable outcomes. The predictive accuracy of END-IT at a cutoff of > 2: for unfavorable outcome (POPC score ≥3) was: sensitivity 0.73 (95% CI: 0.45–0.92), specificity 0.94 (95% CI: 0.89–0.98), PPV 0.61 (95% CI: 0.36–0.83), NPV 0.97 (95% CI: 0.92–0.99), positive likelihood ratio (13.09), F1 score (0.666); for death: sensitivity 0.86 (95% CI: 0.42–0.99), specificity 0.91 (95% CI: 0.85–0.95), PPV 0.33 (95% CI: 0.13–0.59), NPV 0.99 (95% CI: 0.96–1.00), F1 score (0.48); for RSE: sensitivity 0.80 (95%CI: 0.28–0.99), specificity 0.90 (95% CI: 0.83–0.94), PPV 0.22 (95% CI: 0.06–0.48) NPV 0.99 (95% CI: 0.96–1.00), F1 score (0.35); for SRSE: sensitivity 0.67 (95% CI: 0.22–0.96) specificity 0.75 (95% CI: 0.66–0.82), PPV 0.22 (95% CI: 0.06–0.48) NPV 0.98 (95% CI: 0.94–0.99), F1 score (0.33).Conclusion:We demonstrate utility of the END-IT score to predict short-term outcomes as well as progression to refractory and SRSE for the first time among children with SE.

Clinical Profile and Short-term Outcome of Pediatric Status Epilepticus at a Tertiary-care Center in Northern India

To assess clinical profile and short term treatment outcomes of pediatric status epilepticus (SE) at a tertiary-care center in northern India. Prospective cohort study enrolled children aged 1 month to 18 years presenting with SE to the emergency department. Enrolled children (109) were treated as per hospital protocols. Clinical features during hospitalization were noted. Pediatric overall performance category (POPC) scale was used for classification of outcome at the time of discharge. Acute symptomatic etiology was identified in 66 (60.6%) cases (CNS infections were predominant). Previous diagnosis of epilepsy was found in 32 (29.4%) children; and benzodiazepine responsive SE were seen in 65 (59.6%) children. Predictors of unfavorable outcome were acute symptomatic etiology (adjusted OR 4.50; 95% CI 1.49, 13.62) and no treatment administered prior to hospital (adjusted OR 3.97; 95% CI 1.06, 14.81). Acute symptomatic etiology, mainly acute CNS infections, is the leading cause of SE in this region. Early and pre-hospital management with benzodiazepines may improve SE outcome.

Status Epilepticus in Pediatric patients Severity Score (STEPSS): A clinical score to predict the outcome of status epilepticus in children- a prospective cohort study

PurposeIn adults, the Status Epilepticus Severity Score (STESS), a clinical score, has been shown to be a good predictor of outcome and treatment response. We devised a pediatric modification of this score: the Status Epilepticus in Pediatric patients Severity Score (STEPSS) and evaluated it in children with status epilepticus. MethodsIn this prospective study, children aged 1 month to 18 years presenting with seizure duration ≥ 5 min or actively convulsing to the emergency room were enrolled. STEPSS score was calculated at the time of admission. Outcomes included death, the Pediatric Overall Performance Category (POPC) at discharge and treatment response. The diagnostic utility of the STEPSS score to predict unfavourable outcome was evaluated. ResultsOne-hundred and forty children (mean age 5.8 years) were enrolled. Seven children died and overall 15 children had an unfavourable outcome. The predictive accuracy of STEPSS at a cut-off of >3: for unfavourable outcome (POPC score ≥ 3) - sensitivity (0.93 [95% CI: 68, 99.8]), specificity (0.81 [95% CI: 0.73, 0.87]), PPV (0.37 [95% CI: 0.22, 0.54]), NPV (0.99 [95% CI: 0.95–1.0]), positive likelihood ratio (4.86), F1 score (0.530); for death - sensitivity (0.86 [95% CI: 0.42, 0.99]), specificity (0.76 [95% CI: 0.68-0.83]), PPV (0.16 [95% CI: 0.06, 0.31]), NPV (0.99 [95% CI: 0.95, 1.0]), F1 score (0.270). ConclusionsThe STEPSS, a simple bedside clinical score, was found to be useful to predict the outcome and treatment response in children with status epilepticus.

Five-year survival, performance, and neurodevelopmental outcome following cardiopulmonary resuscitation after pediatric cardiac surgery, preliminary investigation in a single-center experience

Background and aimChildren who suffer cardiopulmonary arrest (CPA) after cardiac surgery frequently survive with return of spontaneous circulation. However, their neurodevelopmental outcomes and performance are still unclear. The aim of this study is to evaluate the midterm neurodevelopmental outcome and overall performance of children who survived CPA following cardiac surgery. Materials and methodsIn this cohort study, we followed-up children who received cardiopulmonary resuscitation (CPR) post cardiac surgery during 2012–2013. We assessed their 5-year survival, functional, and neurodevelopmental outcomes using two performance scales: Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC). Both scales ranged from 1 for normal to 6 for brain death/death. We compared CPR group with a matching group (1:1) that had similar characteristics and conditions but no CPR. ResultsOut of 758 postoperative cardiac children, 15 (2%) children had 19 episodes of CPA. Their median age was 10 months (0.5–168). Survival rates were 12/15 (80%) on hospital discharge and 10/15 (66%) after 5 years. Among 12 survivors, two patients (17%) scored 6, one (8%) scored 4, five (42%) scored 2, and four (33%) scored 1 on both PCPC and POPC. The median PCPC and POPC scores were [2, (interquartile range: 1–6) and 1, (interquartile range: 1–3, p = 0.018] for CPR and matching group, respectively. Regression analysis identifies duration of CPR, number of CPR session, and late-occurring CPA as risk factors for poor outcome. ConclusionTwo-thirds of children requiring CPR post cardiac surgery survived after 5 years. Their neurodevelopmental and functional evaluation demonstrated worse outcome in comparison with their matching cases. CPR duration, number of CPA events, and late CPA were risk factors for poor outcome. Rehabilitation and special education programs might be needed for these groups of children with special needs.

Long-term mortality and functional outcome after prolonged paediatric intensive care unit stay.

We performed a retrospective, observational study of patients who had spent > 14days in the paediatric intensive care unit (PICU) of our hospital from 2011 to 2013. Specifically, long-term mortality, functional outcome, and PICU resource occupancy were examined. All prolonged-stay patients in our study were < 15years of age. Favourable outcomes were defined as a Pediatric Overall Performance Category (POPC) score of 1-2, and unfavourable outcomes as a POPC score of 3-6 or death. During the study period, there were 1082 PICU admissions involving 805 patients, 111 (13.8%) of whom had one or more prolonged PICU stays. Among these patients, 100 (90%) survived to PICU discharge and 92 (83%) survived to hospital discharge. At the 3-year follow-up, the survival rate was 75% (77/102; nine patients were lost to follow-up) and the favourable outcome rate was 43% (44/102) (57% among survivors). Prolonged PICU-stay patients accounted for 50.5% of the PICU patient-days. Extremely prolonged stays (≥ 28days) correlate with low favourable outcome rates (P = 0.03), but did not correlate with mortality rates (P = 0.16).Conclusion: Although prolonged PICU-stay patients utilized many PICU resources, most survived at least 3years, and > 50% of the survivors had a favourable functional outcome (POPC score). What is Known: • The number of patients with prolonged paediatric intensive care unit (PICU) stays is increasing. • These patients utilize many resources and are at high risk for mortality and disabilities. What is New: • Although prolonged-stay patients accounted for 50% of PICU patient-days, their 3-year survival rate and favourable functional outcome rate (based on Pediatric Overall Performance Category scores) were relatively high. • Extremely prolonged stays (≥ 28days) correlate with low favourable functional outcomes but not with mortality.

Burden of caregiving after a child’s in-hospital cardiac arrest

ObjectiveTo describe caregiver burden among those whose children survive in-hospital cardiac arrest and have high risk of neurologic disability, and explore factors associated with burden during the first year post-arrest. MethodsThe study is a secondary analysis of the Therapeutic Hypothermia after Paediatric Cardiac Arrest In-Hospital (THAPCA-IH) trial. 329 children who had an in-hospital cardiac arrest, chest compressions for >2 min, and mechanical ventilation after return of circulation were recruited to THAPCA-IH. Of these, 155 survived to one year, and caregivers of 138 were assessed for burden. Caregiver burden was assessed at baseline, and 3 and 12 months post-arrest using the Infant Toddler Quality of Life Questionnaire for children <5 years old and the Child Health Questionnaire for children >5 years. Child functioning was assessed using the Vineland Adaptive Behaviour Scales Second Edition (VABS-II), the Paediatric Overall Performance Category (POPC) and Paediatric Cerebral Performance Category (PCPC) scales, and caregiver perception of global functioning. ResultsOf 138 children, 77 (55.8%) were male, 77 (55.8%) were white, and 109 (79.0%) were <5 years old at the time of arrest. Caregiver burden was greater than reference norms at all time points. Worse POPC, PCPC and VABS-II scores at 3 months post-arrest were associated with greater caregiver burden at 12 months. Worse global functioning at 3 months was associated with greater burden at 12 months for children <5 years. ConclusionsCaregiver burden is substantial during the first year after paediatric in-hospital cardiac arrest, and associated with the extent of the child’s neurobehavioural dysfunction.

Toward a comprehensive assessment of functional outcomes in pediatric patients with brain arteriovenous malformations: the Pediatric Quality of Life Inventory.

OBJECTIVE Brain arteriovenous malformations (bAVMs) are rare in pediatric patients but represent the most common cause of hemorrhagic stroke in this population. Pediatric patients demonstrate superior outcomes in comparison with adult patients with similar lesions and presentations. Most studies of clinical outcomes of pediatric bAVMs use the modified Rankin Scale (mRS), despite a lack of validation in pediatric patients. METHODS The authors interviewed the parents of 26 pediatric patients who underwent multimodality bAVM treatment and administered the Pediatric Quality of Life Inventory (PedsQL)-a well-validated tool for pediatric outcomes that quantifies performance in a physical, emotional, social, and school domains. They also reviewed clinical information from the patients' medical charts. Statistical analysis was performed using a log-transformed t-test, the Mann-Whitney exact test, the Kruskal-Wallis test, and Spearman correlation. In addition, the literature was reviewed for prior reports of clinical outcome of pediatric cases of bAVM. RESULTS The average PedsQL health-related quality of life score was 71 ± 24, with an average age at diagnosis of 12.5 years and an average follow-up period of 6.8 years. Seventeen patients (65%) presented with hemorrhage and 4 (15%) with seizures. PedsQL scores correlated strongly and at a statistically significant level (p < 0.001) with mRS, Pediatric Overall Performance Category (POPC), Pediatric Cerebral Performance Category (PCPC), and Glasgow Outcome Scale scores. Multivariate modeling validated special education, corrective devices, and cure status as significant predictors of PedsQL scores. Statistically significant risk factors for undergoing placement of a ventriculoperitoneal shunt included lower Glasgow Coma Scale motor scores on admission (p = 0.042), cerebellar location (p = 0.046), and nidus volume (p = 0.017). Neither treatment modality nor location statistically affected clinical outcomes at follow-up. CONCLUSIONS There have been few studies of long-term clinical outcomes of bAVM in pediatric patients, and previously published studies have used conventional metrics that have been validated in the adult population, such as the mRS. Although these metrics can serve as reasonable surrogates, an accurate understanding of overall health-related quality of life is contingent on utilizing validated toolsets, such as the PedsQL.

Paediatric community-acquired septic shock: results from the REPEM network study

Introduction and purpose of the studyWith this study we aimed to describe a “true world” picture of severe paediatric ‘community-acquired’ septic shock and establish the feasibility of a future prospective trial on early goal-directed therapy in children. During a 6-month to 1-year retrospective screening period in 16 emergency departments (ED) in 12 different countries, all children with severe sepsis and signs of decreased perfusion were included.ResultsA 270,461 paediatric ED consultations were screened, and 176 cases were identified. Significant comorbidity was present in 35.8 % of these cases. Intensive care admission was deemed necessary in 65.7 %, mechanical ventilation in 25.9 % and vasoactive medications in 42.9 %. The median amount of fluid given in the first 6 h was 30 ml/kg. The overall mortality in this sample was 4.5 %. Only 1.2 % of the survivors showed a substantial decrease in Paediatric Overall Performance Category (POPC). ‘Severe’ outcome (death or a decrease ≥2 in POPC) was significantly related (p < 0.01) to: any desaturation below 90 %, the amount of fluid given in the first 6 h, the need for and length of mechanical ventilation or vasoactive support, the use of dobutamine and a higher lactate or lower base excess but not to any variables of predisposition, infection or host response (as in the PIRO (Predisposition, Infection, Response, Organ dysfunction) concept).ConclusionThe outcome in our sample was very good. Many children received treatment early in their disease course, so avoiding subsequent intensive care. While certain variables predispose children to become septic and shocked, in our sample, only measures of organ dysfunction and concomitant treatment proved to be significantly related with outcome. We argue why future studies should rather be large multinational prospective observational trials and not necessarily randomised controlled trials.

Presentations and Outcomes of Children With Intraventricular Hemorrhages After Blunt Head Trauma

To describe the clinical presentations and outcomes of children with intraventricular hemorrhages (IVHs) after blunt head trauma (BHT). Subanalysis of a large, prospective, observational cohort study performed from June 1, 2004, through September 31, 2006. Twenty-five emergency departments participating in the Pediatric Emergency Care Applied Research Network. Patients Children presenting with IVH after BHT. Exposure Blunt head trauma. Clinical presentations and outcomes, including the Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) scores at hospital discharge. Of 15 907 patients evaluated with computed tomography, 1156 (7.3%) had intracranial injuries. Forty-three of the 1156 (3.7%; 95% CI, 2.7%-5.0%) had nonisolated IVHs (ie, with intracranial injuries on computed tomography), and 10 of 1156 (0.9%; 95% CI, 0.4%-1.6%) had isolated IVHs. Only 4 of 43 (9.3%) of those with nonisolated IVHs had Glasgow Coma Scale (GCS) scores of 14 to 15, and all 10 (100.0%) with isolated IVHs had GCS scores of 15. No patients with isolated IVHs required neurosurgery or died. One patient had moderate overall disability (by the POPC score), and no patient had moderate or severe disability at discharge (by the PCPC score). Of the 43 patients with nonisolated IVHs, however, 16 (37.2%) died and 18 (41.9%) required neurosurgery. In 27 patients (62.8%), injuries ranged from moderate overall disability to brain death by the POPC score. Children with nonisolated IVHs after BHT typically present with GCS scores of less than 14, frequently require neurosurgery, and have high mortality rates. In contrast, those with isolated IVHs typically present with normal mental status and are at low risk for acute adverse events and poor outcomes.

P20.5 Functional outcome of children with severe brain injuries

Background Injury is an important factor in childhood morbidity and mortality, with road traffic injuries (RTA) taking the lead. Due to anatomic characteristics, the head is the most frequent site of severe injury in children. The outcome of patients in PICU is significantly dependent on the severity of brain lesion. Aim The aim of this study was to evaluate the functional outcome of patients with injuries treated in pediatric intensive care unit (PICU), with respect to the two important data: the leading injured body region and mechanism of injury. Methods In the period of 2008 to 2009 the data was obtained prospectively and outcome was assessed according to Pediatric Overall Performance Category (POPC) scale for 118 patients in PICU of the University Hospital of Split. Functional performance of patients was assessed as the baseline, pre-admission score (bPOPC) and the discharge functional score (dPOPC) was evaluated before transfer of patients from PICU. Results Head (63.5%) was the most common affected anatomic region, followed by abdomen (15.2%) and limbs (11.0%). The RTA was the leading cause of childhood injury (68%). Deterioration of functional morbidity (ΛP) was worse in children injured in RTA (0.0063) and it was significantly worse children with head injuries (0.0451). Conclusion The outcome expressed with POPC scale is primarily based on neurological functioning. The results of this study point to the importance of prevention of severe brain injury, which is associated with poor long-term outcome of injured children.

Pediatric patients with poor neurological status and arteriovenous malformation hemorrhage: an outcome analysis

In general, patients who present with low Glasgow Coma Scale (GCS) scores and/or fixed and dilated pupils are not expected to do well following arteriovenous malformation (AVM) hemorrhage. However, there is a sense among neurosurgeons that pediatric patients may make a better recovery than adults following such an event. There have been few studies focusing on the outcome of pediatric patients with poor neurological status following AVM hemorrhage. The purpose of this study was to characterize functional outcome in pediatric patients with severe disability after AVM hemorrhage. This was a retrospective analysis of clinical presentation and outcome in 15 patients seen at the authors' pediatric hospital presenting with low GCS scores (defined as GCS ≤ 8) following AVM hemorrhage. Initial GCS scores ranged from 3 to 6, and 11 of 14 patients had fixed pupils on clinical examination (data were not available in 1 patient). Eight of 15 patients suffered primarily a lobar hemorrhage, 3 suffered primarily infratentorial bleeding, 2 suffered primarily hemorrhages of the basal ganglia, and 2 suffered intraventricular hemorrhage. The overall mortality rate was 20% (3 of 15 patients). The clinical outcome of survivors was defined by the Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC) scores at follow-up. One year after AVM hemorrhage, 7 (58%) of the 12 surviving patients showed normal or mild disability (PCPC Score 1 or 2), whereas 5 (42%) of 12 patients had moderate or severe disability (PCPC Score 3 or 4). No patients were in a coma or vegetative state, and 11 (92%) of the 12 patients were functioning independently (POPC Score 1, 2, or 3) 1 year after AVM hemorrhage. All patients were functionally independent by last follow-up, with 8 patients (67%) in the normal or mild disability PCPC category, and 4 in the moderate category (PCPC Score 3). All 12 survivors made a meaningful recovery and went on to live independent lives. Pediatric patients suffering AVM hemorrhage have a good outcome and are able to function independently, despite a poor neurological state initially.