Pediatric Risk Of Mortality Score Research Articles

The performance of pediatric risk of mortality score in pediatric patients with severe hand, foot and mouth disease

Objective To comment the severity of severe hand, foot and mouth disease(HFMD) by pediatric risk of mortality score(PRISM), and assess the performance of PRISM in predicting mortality or complication probability in HFMD. Methods Four hundred and twenty-four severe HFMD pediatric patients were recruited in the study from 1th Jan 2010 to 31th June 2013.Information on the outcome and the variables required to calculate PRISM score were collected.The logistic regression model developed in the learning sample was evaluated in the test sample by calculating the area under the receiver operating characteristic(ROC) curve to assess discrimination pneumorrhagia and death.Calibration across deciles of risk was evaluated using the Hosmer-Lemeshow goodness-of-fit χ2 test. Results The area under the ROC curve were 0.87(95%CI 0.80~0.94)for PRISM in predicting pneumorrhagia probability.The area under the ROC curve were 0.87(95%CI 0.80~0.95)for PRISM in predicting mortality probability.The PRISM in observed and expected pneumorrhagia did not demonstrate good calibration at ten mortality risk intervals(χ2=36.66, P<0.001). The PRISM in observed and expected mortality did not demonstrate good calibration at ten mortality risk intervals(χ2=41.11, P<0.001). Conclusion The PRISM score is demonstrated good discrimination of pneumorrhagia and death in HFMD pediatric patients, but the performance of calibration is not good. Key words: Pediatric risk of mortality score; Severe hand, foot and mouth disease; Receiver operating characteristic; Hosmer-Lemeshow goodness-of-fit χ2 test

Pattern of neurological dysfunctions in pediatric intensive care unit.

The aim of this retrospective study is to evaluate the burden, characterize the demographics and visualize the final outcome of the critical neurological cases admitted to a tertiary pediatric intensive care unit in Cairo University Children Hospital. Data of 139 pediatric critical care patients admitted with neurological dysfunction were reviewed, retrospectively. Patients with critical neurological illness represented 30% of the total admissions (n = 139). Coma patients (n = 115, 83%) were divided into structural/intrinsic coma (n = 54, 47%) and metabolic/toxic (n = 61, 53%). Patients with neuromuscular disorders comprised 17% (24/139) of the cohort. Patients with toxic/metabolic coma had higher Pediatric Risk of Mortality scores, higher inotrope scores, more organ system failures, a higher percentage of pre admission cardiac arrests and higher frequency of septic shock diagnosis. Predictors of death in the whole group included (a) Number of organ failure: patients with three or more organ systems failure were 3.1 times more liable to die (b) Glasgow Coma Scale (GCS): cases with GCS score less than eight were 4.2 times more prone to die, (c) Those who developed acute lung injury in less than 14 days of mechanical ventilation were 10.7 times more prone to die than those who had not. Patients with toxic/metabolic coma required more intensive support giving into consideration that advanced sepsis and presence of a family member with drug addiction played a big role as an underlying cause. National programs for implementation of sepsis goal directed therapy and health awareness about the hazards of accidental drug intake are of supreme importance. Predictive factors for death in coma patients on admission were low GCS score, presence of multiple organ system failure and acute lung injury.

Nutritional assessment in a pediatric intensive care unit

Objective To assess nutritional status of critically ill children, and to investigate the correlation of nutritional status with illness severity and clinical outcomes, so as to provide a theoretical basis for rational nutrition support of critically ill children. Methods All patients hospitalized in the pediatric intensive care unit of Beijing Children' s Hospital from November, 2010 to January 2011 were enrolled and studied prospectively. We collected anthropometric parameters (body length/height, body weight, head circumference, etc) for nutritional assessment, as well as their clinical data such as underlying diseases, pediatric risk of mortality scores (PRISM) , length of hospital stay and mechanical ventilation duration. Results In 196 cases , the prevalence of malnutrition was 21.9% (43/196). Malnutrition group had greater PRISM scores, higher mechanical ventilation rate and a lower 28-day survival rate than normal nutritional status group (allP <0.05). Conclusions The prevalence of malnutrition on admission to the PICU was high and poor nutritional status indicated greater illness severity and adverse clinical outcomes Key words: Critical illness; Malnutrition; Anthropometry; Nutritional status; Pediatric critical illness score; Pediatric risk of mortality scores; Severity of diseases; Clinical outcomes.

The prevalance of and factors associated with intra-abdominal hypertension on admission Day in critically Ill pediatric patients: A multicenter study

PurposeTo investigate admission prevalence of intraabdominal hypertension (IAH) and to determine clinical and laboratory characteristics on admission day associated with IAH in critically ill pediatric patients. Materials and MethodsOne hundred thirty newly admitted critically ill pediatric patients were included. Intra-abdominal pressure (IAP) was measured 4 times (every 6 hours) with the bladder pressure method. Data included the demographics, diagnostic category, pediatric logistic organ dysfunction score and pediatric risk of mortality score II, clinical concomitant factors, and conditions potentially associated with increased intra-abdominal pressure. ResultsSeventy patients (56.1%) had a normal IAP (≤10 mmHg, mean IAP [mmHg] 7.18 ± 1.85), while 60 patients (43.9%) had IAP >10 mmHg (mean IAP [mmHg] 15.46 ± 5.21). Hypothermia frequency, lactate levels, number of patients with oligo-anuria, and mechanical ventilation requirement were higher among patients with IAH compared to patients without IAH (both, P< .05). Hypothermia (OR, 3.899; 95% CI, 1.305-11.655; P< .03) and lactate levels (OR, 1.283 for each mmol/L increase; 95% CI, 1.138-1.447; P< .001) were only significantly associated with IAH. ConclusionsIntra-abdominal hypertension seems to affect nearly half of newly admitted critically ill pediatric patients. Lactate level and the presence of hypothermia seem to be the independent predictors of the presence of IAH.

The performance of pediatric risk of mortality in inter-hospital transport of critically ill pediatric patients

Objective To assess the performance of pediatric risk of mortality (PRISM) in predicting mortality probability in inter-hospital transport of critically ill pediatric patients by a perspective study. Methods Four hundred and twelve pediatric patients with inter-hospital transportations were recruited in the study from 1th August 2012 to 31th May 2013. The information on demographic characteristics, the reasons for inter-hospital transport, the category of disease and the severity of illness was collected. Information on age, sex, diagnosis, length of stay in PICU, the outcome and the variables required to calculate PRISM score were collected. The logistic regression model developed in the learning sample was evaluated in the test sample by calculating the area under the receiver operating characteristic plot (Az ROC) to assess discrimination between death and survival. Calibration across deciles of risk was evaluated using the Hosmer-Lemeshow goodness-of-fit χ2 test. Results Among 412 inter-hospital transport of critically ill pediatric patients, the majority of patients (89.08%, 367/412) were neonates and infants, and above two thirds of the children were suffering from respiratory diseases (172 cases), and miscellaneous diseases (169 cases). Forty-five (10.92%) inter-hospital transport of critically ill pediatric patients died at the time of hospitalization. The area under the receiver-operating characteristic curve was 0.829 (95%confidence intervals 0.768~0.890) for PRISM. The Hosmer-Lemeshow test gave a chi-square of 8.75 (P=0.364) for PRISM. Conclusion The PRISM score is demonstrated good discrimination and calibration in predicting death probability of inter-hospital transport of critically ill pediatric patients. Key words: Inter-hospital transport; Critically ill pediatric patients; Pediatric risk of mortality

Clinical and molecular characteristics of invasive community-acquired Staphylococcus aureus infections in Chinese children.

BackgroundThis study aims to investigate the clinical features of invasive community-acquired Staphylococcus aureus (CA-SA) infection in Chinese children and analyze its molecular features.MethodsClinical data and invasive CA-SA isolates were prospectively collected. Pediatric risk of mortality (PRISM) score was used for disease severity measurement. Molecular typing was then performed, followed by expression analysis for virulence genes.ResultsAmong 163 invasive CA-SA infection cases, 71 (43.6%) were methicillin-resistant SA (MRSA) infections and 92 (56.4%) were methicillin-susceptible SA (MSSA). A total of 105 (64.4%) children were younger than 1 year old, and 79.7% (129/163) were under 3 years age. Thirteen kinds of diseases were observed, in which bacteremia and pneumonia accounted for 65.6% (107/163) and 52.8% (86/163), respectively. A total of 112 (68.1%) patients had two or more infective sites simultaneously, and four cases (2.5%) died. CA-MSSA more frequently caused multi-sites infections, bacteremia, and musculoskeletal infection than MRSA. A total of 25 sequence types (STs) were detected. MRSA mainly comprised ST59 (49/71, 69%), whereas the most frequent clonotypes were ST88 (15/92, 16.3%), ST25 (13/92, 14.1%), ST7 (13/92, 14.1%), ST2155 (12/92, 13%), and ST188 (9/92, 9.8%) for MSSA. Seven STs were common to both MSSA and MRSA groups. No differences in clinical presentation or PRISM score were found between the two groups or among different ST. The expression levels of the four known virulence genes varied among the six main ST clones.ConclusionsInvasive CA-SA infections were characterized by high incidence and multi-site infections in young children in China. The clinical manifestations of CA-MSSA were more frequently associated with multi-site infections, bacteremia and musculoskeletal infection than those of CA-MRSA. Isolated genotypes may be relevant to the expressions of virulence genes, but not to clinical manifestations.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-014-0582-4) contains supplementary material, which is available to authorized users.

Validity of pediatric risk of mortality score in prediction of mortality in North Indian pediatric intensive care unit

Background: The pediatric risk of mortality (PRISM) score allows assessment of the severity of illness and mortality risk adjustment in heterogeneous groups of the patients in an objective manner. It has been developed and validated mostly at pediatric intensive care unit (PICUs) of developed countries with very few reports from India. Objectives: This study was planned to evaluate the usefulness of the PRISM score and to correlate it with the mortality in patients admitted to PICU of a northern Indian PICU. Material and Methods: A prospective, observational study was conducted between January 2012 and June 2013, during which a totalof 150 consecutive cases were enrolled for the study. PRISM score was calculated within 24 h of their admission and receiver operating characteristic (ROC) curve was used to establishing the validity of the PRISM score for predicting the mortality. Results: Overall mortality was 12.5%, and the PRISM score for survivors versus non-survivors was 7.5878 ± 5.032 versus 20.63 ± 3.41, respectively. No difference was seen between the observed and expected value of mortality calculated from PRISM score (Z = 0.467-1.521, p = 0.291– 0.64), thereby establishing the validity of the PRISM score in predicting the mortality in our PICU (ROC curve - area under the curve 0.934). The observed and expected values of the mortality were more comparable for lower PRISM scores (0-15) and a PRISM score of 13.5 has the highest sensitivity and specificity. Conclusion: We concluded that PRISM score is a valid parameter to predict the mortality among the ICU patients in Indian set ups.

PO-0041 Is Echocardiography An Essential Tool In Mechanically Ventilated Critically Ill Children: Where Do We Stand In Training Of Paediatric Intensivists To Perform Bedside Echocardiography?

<h3>Objective</h3> To determine the indication and need for echocardiographic assessment according to clinical severity of patients and therapeutic interventions performed after echocardiographic evaluation in critically ill children. <h3>Design</h3> Prospective observational study. <h3>Setting</h3> 14-bed, tertiary care Paediatric Intensive Care Unit (PICU). <h3>Methods</h3> The PICU is a multidisciplinary referral centre. A total of 140 children; 75 mechanically ventilated (MV) and 65 spontaneously breathing (SB) who were admitted to our unit consecutively from March to August 2013 were included into the study. The indication for echocardiography and therapeutic interventions performed after cardiology consultation were recorded. For the estimation of severity of disease the paediatric risk of mortality score (PRISM) III was determined. The correlation between Prism III score and the need for echocardiographic evaluations were analysed. <h3>Results</h3> Ages of all patients were between 45 days to 18 years. The male-female ratio was 1.33. Echocardiography was indicated in 88% (n = 66) of MV and%46.2 (n = 30) of SB patients. In 35.4% (n = 34) of patients who underwent echocardiographic evaluation no definitive change occured in treatment strategy while in 64.6% (n = 62) of patients decisive/supplemental information was obtained. Echocardiographic evaluation was necessary in MV children (p &lt; 0.001) when compared with SB group and there was a positive correlation between Prism III score and the need for echocardiographic evaluation. <h3>Conclusion</h3> Echocardiographic evaluation is essential in mechanically ventilated children and the need for echocardiographic assesment increases according to clinical severity of patients. Basic training for intensivists in this technique is challenging and needs to be developed and supported in critically ill children.

Use of therapeutic plasma exchange in children with thrombocytopenia-associated multiple organ failure in the Turkish thrombocytopenia-associated multiple organ failure network.

Thrombocytopenia-associated multiple organ failure can lead to high mortality in critically ill children, possibly related to consequences of thrombotic microangiopathy. Plasma exchange therapy may improve thrombotic microangiopathy. The purpose of this observational cohort study is to describe whether there is an association between use of plasma exchange therapy and outcome in the Turkish thrombocytopenia-associated multiple organ failure network. We performed a retrospective cohort analysis in patients with thrombocytopenia-associated multiple organ failure at three different PICUs comparing those who received plasma exchange (+) plus standard therapies with those who did not receive plasma exchange (-) and only received standard therapies. Among 42 of the enrolled patients with thrombocytopenia-associated multiple organ failure, all had a primary or secondary sepsis diagnosis. Fifteen received plasma exchange therapy (PE [+] group) and 27 received standard medical treatment without plasma exchange (PE [-] group). The mean age was 17.69 months (8.24-54.22) in the PE (+) group and 13.46 months (6.47-20.55) in the PE (-) group. Age (p = 0.232), gender (p = 0.206), thrombocyte count (p = 0.09), Organ Failure Index score (p = 0.111), and pediatric logistic organ dysfunction score (p = 0.177) at admission were not statistically different between groups. The overall 28-day mortality was higher in the PE (-) group (70.37%) compared with the PE (+) group (26.67%) (univariate p = 0.006; multivariate controlling for pediatric logistic organ dysfunction, Organ Failure Index, Pediatric Risk of Mortality scores, and neurological failure p = 0.048). Length of stay was increased in the PE (+) group (p = 0.004). The positive association found between use of plasma exchange therapy and improved survival supports the potential of this therapy in Turkish children with thrombocytopenia-associated multiple organ failure. The positive, although less so, associated treatment effect observed after controlling for illness severity provides further rationale for performing a randomized controlled trial in the pediatric Turkish thrombocytopenia-associated multiple organ failure network. Sample size calculations call for a 100-patient trial with a pre hoc interim analysis after enrollment of 50 patients with thrombocytopenia-associated multiple organ failure.

Predictors of Mortality in Mechanically Ventilated Critical Pertussis in a low Income Country.

BackgroundCritical pertussis is characterized by severe respiratory failure, important leukocytosis, pulmonary hypertension, septic shock and encephalopathy.AimTo describe the clinical course of critical pertussis, and identify predictors of death at the time of presentation for medical care.MethodologyRetrospective study conducted in children’s hospital Tunisian PICU between 01 January and 31 October 2013. Patients with critical pertussis confirmed by RT-PCR and requiring mechanical ventilation were included. Predictors of death were studied.ResultsA total of 17 patients was studied. Median age was 50 days. Mortality was 23%. Predictors risk of mortality were : high PRISM score (Pediatric Risk of Mortality Score) (p=0,007), shock (p=0,002), tachycardia (p=0,005), seizures (p=0,006), altered mental status (p=0,006), elevated WBC count (p=0,003) and hemodynamic support (p=0022). However, the difference did not reach statistical significance in comorbidity, pneumoniae, high pulmonary hypertension or exchange transfusion. Concomitant viral or bacterial co-infection was not related to poor outcome.ConclusionYoung infants are at high risk to have critical pertussis. Despite advances in life support and the treatment of organ failure in childhood critical illness, critical pertussis remains difficult to treat.

Clonidine in the sedation of mechanically ventilated children: A pilot randomized trial

PurposeClonidine is often used as a sedative in critically ill children, but its effectiveness has not been evaluated in a large, rigorous randomized controlled trial. Our objectives in this pilot trial were to assess the feasibility of a larger trial with respect to (1) effective screening, (2) recruitment, (3) timely drug administration, and (4) protocol adherence. Materials and methodsThis is a randomized, blinded, placebo-controlled pilot trial. Mechanically ventilated children received enteral clonidine 5 μg/kg or placebo every 6 hours; additional sedatives were at the discretion of attending physicians. ResultsWe enrolled 50 children. The median interquartile range (IQR) age was 2.5 (0.7-5.2) years, and Pediatric Risk of Mortality score on pediatric intensive care unit admission was 12 (8-15). In terms of feasibility outcomes, 90 (87%) of 104 eligible patients were approached for consent, and on average, 1.7 children were enrolled per month. Thirty-five (70%) were enrolled within 1 day of becoming eligible (mean, 1.2 days). Thereafter, 94% of doses were administered by protocol. Clinical outcomes and adverse effects were not significantly different between the groups. ConclusionsThis pilot trial demonstrated feasibility of a larger randomized controlled trial. Some important challenges emerged, allowing refinement of the study protocol and enrolment estimates. We recommend that future trials capitalize on the experience gained and use these results to design a larger trial focusing on clinically important outcomes.

Therapeutic Role of Anakinra, an Interleukin-1 Receptor Antagonist, in the Management of Secondary Hemophagocytic Lymphohistiocytosis/Sepsis/Multiple Organ Dysfunction/Macrophage Activating Syndrome in Critically Ill Children*

Secondary hemophagocytic lymphohistiocytosis, macrophage activating syndrome, and sepsis share the same inflammatory phenotype leading often to multiple organ dysfunction syndrome needing intensive care. The goal of this article is to describe our experience with anakinra (Kineret), a recombinant interleukin-1 receptor antagonist, in decreasing the systemic inflammation. Retrospective case series. The PICU at the Helen DeVos Children's Hospital (Grand Rapids, MI). The records of eight critically ill children presumed to have secondary hemophagocytic lymphohistiocytosis at our institution between January 1, 2011, and July 31, 2012, were reviewed. All of the patients were treated with anakinra (Kineret) and in some cases systemic corticosteroids as first-line therapy for secondary hemophagocytic lymphohistiocytosis. Patients had a median age of 14 years and a median Pediatric Risk of Mortality score of 11.5. Four were previously healthy and four had underlying diseases that could have made them susceptible to secondary hemophagocytic lymphohistiocytosis. Indications for PICU transfer were respiratory distress 50% (4 of 8), cardiovascular instability 37.5% (3 of 8), and chest pain (1 of 8). Five of the patients (62.5%) were mechanically ventilated and 62.5% (5 of 8) received vasoactive infusions. Inflammatory markers were assessed linearly at the start of therapy and 7 days later. Baseline C-reactive protein was 206 ± 50 mg/L (mean ± SEM) at the start of anakinra and decreased by 67.1% to 68 ± 36 mg/L (p = 0.03). Ferritin decreased by 63.8% to 3,210 ± 1,178 ng/mL (p = 0.30), and fibrinogen decreased by 42% to 158 ± 41 mg/dL (p = 0.03). Absolute neutrophil count (p = 0.38) and absolute lymphocyte count (p = 0.69) did not change significantly. No infections were attributed to anakinra therapy. One patient died long after treatment with anakinra while receiving pre-hematopoietic stem cell transplant chemotherapy. Anakinra could represent a promising therapeutic approach in these life-threatening disorders that are likely underdiagnosed and often difficult to treat.

ABSTRACT 753

Background and aims: The PRISM score (Pediatric Risk of Mortality Score) is an objective measurement of 14 physiological variables which reflect the severity of illness. Aims: Aiming to assess significance of the PRISM score in the prediction of the outcome in newly established PICU at Tripoli-Libya. Methods: Prospectively and randomly selective study. This study involved 139 patients selected randomly from the period of May 2006 till May 2007, 122 of them survived and 17 died (12.2% mortality). Results: The PRISM score showed strong correlation with the outcome in terms of survival (p<0.01), and there was no significant difference between predicted and observed mortality rate at different PRISM scores especially at lower scores. The ROC curve plotted showed good results with an area of 70% under the curve. The age showed no predictive power for the outcome (p>0.6), and the predicted/observed mortality rates were nearly the same of neonates and older patients.The other study variables name, sex and diagnosis showed no significance to the outcome and were early excluded from the study. Conclusions: The study concluded that the PRISM score is suitable scoring system for the prediction of the mortality and survival rates in EL-KHADRA PICU provided the currant circumstances, services and experience.

Evaluation of endocrine function in children admitted to pediatric intensive care unit

Although studied widely in adulthood, little is known about endocrinological disorders during critical illnesses in childhood. The aims of this study were to define the endocrinological changes in patients admitted to pediatric intensive care unit (PICU) and to identify their effects on prognosis. Forty patients with a mean age of 5.1 years admitted to PICU were enrolled in the study. Blood samples were taken at admission and at 24 and 48 h to measure cortisol, adrenocorticotropic hormone (ACTH), prolactin, growth hormone (GH), GH binding protein (GHBP), insulin-like growth factor-binding protein-3 (IGFBP-3) and interleukin-6 (IL-6). The severity of the patient's condition was assessed using pediatric risk of mortality (PRISM) and pediatric logistic organ dysfunction (PELOD) scores. PRISM and PELOD scores were significantly higher in non-survivors. Cortisol, ACTH, prolactin, GH, GHBP, IGFBP-3 and IL-6 were not significantly different between the survivors and non-survivors. There was a negative correlation between baseline IGFBP-3 and PRISM scores. A positive correlation was seen between cortisol level at 24 h and PRISM score. On multivariate linear regression analysis, PRISM score was best explained by ACTH and cortisol at 24 h. A positive weak correlation was detected between IL-6 at 24 h and PELOD scores. Although there was no difference between survivors and non-survivors regarding the studied endocrine parameters, there were associations between cortisol, ACTH, IL-6 and IGFBP-3 and risk assessment scores, and, given that these scores correlated with mortality, these parameters might be useful as prognostic factors.

Clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock from Rohtak, Haryana: A prospective observational study.

Background:Information regarding early predictive factors for mortality and morbidity in sepsis is limited from developing countries.Methods:A prospective observational study was conducted to determine the clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock. Children aged 1 month to 14 years admitted to a tertiary care pediatric intensive care unit (PICU) with a diagnosis of sepsis, severe sepsis, or septic shock were enrolled in the study. Hemodynamic and laboratory parameters which discriminate survivors from nonsurvivors were evaluated.Results:A total of 50 patients (30 [60%] males) were enrolled in the study, of whom 21 (42%) were discharged (survivors) and rest 29 (58%) expired (nonsurvivor). Median (interquartile range) age of enrolled patients were 18 (6, 60) months. Mortality was not significantly predicted individually by any factor including age (odds ratio [OR] [95% confidence interval [CI]]: 0.96 [0.91-1.01], P = 0.17), duration of PICU stay (OR [95% CI]: 1.18 [0.99-1.25], P = 0.054), time lag to PICU transfer (OR [95% CI]: 1.02 [0.93-1.12], P = 0.63), Pediatric Risk of Mortality (PRISM) score at admission (OR [95% CI]: 0.71 [0.47-1.04], P = 0.07) and number of organ dysfunction (OR [95% CI]: 0.03 [0.01-1.53], P = 0.08).Conclusion:Mortality among children with sepsis, severe sepsis, and septic shock were not predicted by any individual factors including the time lag to PICU transfer, duration of PICU stay, presence of multiorgan dysfunction, and PRISM score at admission.

Hypoalbuminemia in critically sick children.

Context:There is a paucity of data evaluating serum albumin levels and outcome of critically ill-children admitted to intensive care unit (ICU).Aims:The aim was to study frequency of hypoalbuminemia and examine association between hypoalbuminemia and outcome in critically ill-children.Settings and Design:Retrospective review of medical records of 435 patients admitted to 12 bedded pediatric ICU (PICU).Materials and Methods:Patients with hypoalbuminemia on admission or any time during PICU stay were compared with normoalbuminemic patients for demographic and clinical profile. Effect of albumin infusion was also examined. Odds ratio and 95% confidence interval were calculated using SPSS 16.Results:Hypoalbuminemia was present on admission in 21% (92 of 435) patients that increased to 34% at the end of 1st week and to 37% (164 of 435) during rest of the stay in PICU. Hypoalbuminemic patients had higher Pediatric Risk of Mortality scores (12.9 vs. 7.5, P < 0.001) and prolonged PICU stay (13.8 vs. 6.7 days, P < 0.001); higher likelihood of respiratory failure requiring mechanical ventilaton (84.8% vs. 28.8%, P < 0.001), prolonged ventilatory support, progression to multiorgan dysfunction syndrome (87.8% vs. 16.2%) and risk of mortality (25.6% vs. 17.7%). Though, the survivors among recipients of albumin infusion had significantly higher increase in serum albumin level (0.76 g/dL, standard deviation [SD] 0.54) compared with nonsurvivors (0.46 g/dL, SD 0.44; P = 0.016), albumin infusion did not reduce the risk of mortality.Conclusions:Hypoalbuminemia is a significant indicator of mortality and morbidity in critically sick children. More studies are needed to define role of albumin infusion in treatment of such patients.

Aluminum phosphide (celphos) poisoning in children: A 5-year experience in a tertiary care hospital from northern India

Background:Aluminum phosphide (ALP) (celphos) is an agricultural pesticide commonly implicated in poisoning. Literature pertaining to the clinical manifestations and treatment outcome of its poisoning among children is limited.Materials and Methods:A retrospective chart review was conducted of the medical records of 30 children aged less than 14 years admitted to pediatric intensive care unit (PICU) of a tertiary care hospital in northern India. Demographic, clinical, and laboratory parameters were recorded. The outcome was categorized into “survivors” and “nonsurvivors.”Results:The Mean (SD) age of the enrolled children [19 males (63.3%)] was 8.55 (3.07) years. Among the 30 children, 14 (46.67%) were nonsurvivors and the rest 16 (53.33%) were survivors. Nonsurvivors had ingested significantly higher doses of ALP (P < 0.001), and showed higher time lag to PICU transfer (P 0.031), presence of abnormal radiological findings on chest skiagram (P = 0.007), and a higher Pediatric Risk of Mortality (PRISM) III score (P < 0.001) at admission. Use of magnesium sulfate was associated significantly with survival [odds ratio (OR) (95% CI): 0.11 (0.02-0.66); P 0.016].Conclusion:The present study highlights that survival among children with ALP poisoning is predicted by dose of ALP ingestion, time lag to medical attention, and higher PRISM score at admission. Use of magnesium sulfate could be associated with better survival among them.

Pulmonary matrix metalloproteinase-9 activity in mechanically ventilated children with respiratory syncytial virus

Respiratory syncytial virus (RSV) infection is a potent stimulus for airway epithelial expression of matrix metalloproteinase (MMP)-9. MMP-9 activity in vivo is a predictor of disease severity in children with RSV-induced respiratory failure. Human airway epithelial cells were infected with RSV A2 strain and analysed for MMP-9 and tissue inhibitor of metalloproteinase (TIMP)-1 (a natural inhibitor of MMP-9) release. In addition, endotracheal samples from children with RSV-RF and controls (non-RSV pneumonia and nonlung disease controls) were analysed for MMP-9, TIMP-1, human neutrophil elastase and myeloperoxidase activity. RSV infection of airway epithelia was sufficient to rapidly induce MMP-9 transcription and protein release. Pulmonary MMP-9 activity peaked at 48 h in infants with RSV-induced respiratory failure. In the RSV group, MMP-9 activity and MMP-9/TIMP-1 ratio imbalance predicted higher oxygen requirement and worse paediatric risk of mortality scores. The highest levels of human neutrophil elastase and myeloperoxidase activity were measured in the RSV cohort; however, unlike MMP-9, these neutrophil markers failed to predict disease severity. These results support the hypothesis that RSV is a potent stimulus for MMP-9 expression and release from human airway epithelium, and that MMP-9 is an important biomarker of disease severity in mechanically ventilated children with RSV lung infection.

The Relationship of Fluid Administration to Outcome in the Pediatric Calfactant in Acute Respiratory Distress Syndrome Trial*

Adult studies have demonstrated the relationship between fluid overload and poor outcomes in acute lung injury/acute respiratory distress syndrome. The approach of pediatric intensivists to fluid management in acute lung injury/acute respiratory distress syndrome and its effect on outcomes is less clear. In a post hoc analysis of our Calfactant in Acute Respiratory Distress Syndrome trial, we examined the relationship of fluid balance to in-hospital outcomes in subjects with acute lung injury/acute respiratory distress syndrome. Calfactant in Acute Respiratory Distress Syndrome was a masked randomized controlled trial of calfactant surfactant versus placebo in pediatric patients with acute lung injury/acute respiratory distress syndrome due to direct lung injury. Caregivers were encouraged to follow a conservative fluid management guideline based on the adult Fluid and Catheter Treatment Trial. Daily fluid balance was collected for the first 7 days after trial enrollment and correlated with clinical outcomes. Children admitted to PICUs with acute lung injury/acute respiratory distress syndrome from 24 children's hospitals in six different countries. Post hoc analysis of daily fluid balance in subjects from the Pediatric Calfactant in Acute Respiratory Distress Syndrome trial. Despite the conservative fluid guideline, fluid management was more consistent with a "liberal" approach. On average, study subjects accumulated 1.96 ± 4.2 L/m over the first 7 days of the trial. Subjects who died accumulated on average 8.7 ± 9.5 L/m versus 1.2 ± 2.4 L/m in survivors. Increasing fluid accumulation was associated with fewer ventilator-free days and worsening oxygenation. Multivariable regression models that included age, gender, Pediatric Risk of Mortality score, initial oxygen saturation index and PaO2/FIO2 ratio, injury category, and treatment arm failed to account for the differences in fluid management. Pediatric intensivists generally follow a "liberal" approach to fluid management in children with acute lung injury/acute respiratory distress syndrome. Illness severity or oxygenation disturbance did not explain differences in fluid accumulation but such accumulation was associated with worsening oxygenation, a longer ventilator course, and increased mortality. A more conservative approach to fluid management may improve outcomes in children with acute lung injury/acute respiratory distress syndrome.

Continuous renal replacement therapy in children after cardiac surgery

The objective was to study the clinical course of children requiring continuous renal replacement therapy (CRRT) after cardiac surgery and to analyze the factors associated with mortality. A prospective observational study was performed that included all children requiring CRRT after cardiac surgery, comparing these patients with other critically ill children requiring CRRT. Univariate and multivariate analyses were performed to determine the influence of each factor on mortality. Eighty-one (4.9%) of 1650 children undergoing cardiac surgery required CRRT; 65 of them (80.2%) presented multiorgan failure. Children starting CRRT after cardiac surgery had lower mean arterial pressure and lower urea and creatinine levels, and were more likely to require mechanical ventilation than other children on CRRT. The incidence of complications was similar. Cardiac surgery increased the probability of requiring CRRT for more than 14 days. Mortality was 43% in children receiving CRRT after cardiac surgery and 29% in other children (P = .05). Factors associated with mortality in the univariate analysis were age less than 12 months, weight less than 10 kg, higher Pediatric Risk of Mortality Score, hypotension, lower urea and creatinine on starting CRRT, and use of hemofiltration. In the multivariate analysis, the only factor associated with mortality was hypotension on starting CRRT (hazard ratio, 4.01; 95% confidence interval, 1.2-13.4; P = .024). Although only a small percentage of children undergoing cardiac surgery required CRRT, mortality in these patients was high. Hypotension at the time of starting the technique was the only factor associated with a higher mortality.