Pediatric Risk Of Mortality Research Articles

A multicenter retrospective study on clinical features and pathogenic composition of septic shock in children

Objective: To investigate the clinical features, pathogen composition, and prognosis of septic shock in pediatric intensive care units (PICU) in China. Methods: Multi-center retrospective cohort study. A retrospective analysis was conducted on the clinical data of children with septic shock from 10 hospitals in China between January 2018 and December 2021. The clinical features, pathogen composition, and outcomes were collected. Patients were categorized into malignant tumor and non-malignant tumor groups, as well as survival and mortality groups. T test, Mann Whitney U test or Chi square test were used respectively for comparing clinical characteristics and prognosis between 2 groups. Multiple Logistic regression was used to identify risk factors for mortality. Results: A total of 1 247 children with septic shock were included, with 748 males (59.9%) and the age of 3.1 (0.9, 8.8) years. The in-patient mortality rate was 23.2% (289 cases). The overall pathogen positive rate was 68.2% (851 cases), with 1 229 pathogens identified. Bacterial accounted for 61.4% (754 strains) and virus for 24.8% (305 strains). Among all bacterium, Gram negative bacteria constituted 64.2% (484 strains), with Pseudomonas aeruginosa and Enterobacter being the most common; Gram positive bacteria comprised 35.8% (270 strains), primarily Streptococcus and Staphylococcus species. Influenza virus (86 strains (28.2%)), Epstein-Barr virus (53 strains (17.4%)), and respiratory syncytial virus (46 strains (17.1%)) were the top three viruses. Children with malignant tumors were older and had higher pediatric risk of mortality (PRISM) Ⅲ score, paediatric sequential organ failure assessment (pSOFA) score (7.9 (4.3, 11.8) vs. 2.3 (0.8, 7.5) years old, 22 (16, 26) vs. 16 (10, 24) points, 10 (5, 14) vs. 8 (4, 12) points, Z=11.32, 0.87, 4.00, all P<0.05), and higher pathogen positive rate, and in-hospital mortality (77.7% (240/309) vs. 65.1% (611/938), 29.7% (92/309) vs. 21.0% (197/938), χ2=16.84, 10.04, both P<0.05) compared to the non-tumor group. In the death group, the score of PRISM Ⅲ, pSOFA (16 (22, 29) vs. 14 (10, 20) points, 8 (12, 15) vs. 6 (3, 9) points, Z=4.92, 11.88, both P<0.05) were all higher, and presence of neoplastic disease, positive rate of pathogen and proportion of invasive mechanical ventilation in death group were also all higher than those in survival group (29.7% (87/289) vs. 23.2% (222/958), 77.8% (225/289) vs. 65.4% (626/958), 73.7% (213/289) vs. 50.6% (485/958), χ2=5.72, 16.03, 49.98, all P<0.05). Multiple Logistic regression showed that PRISM Ⅲ, pSOFA, and malignant tumor were the independent risk factors for mortality (OR=1.04, 1.09, 0.67, 95%CI 1.01-1.05, 1.04-1.12, 0.47-0.94, all P<0.05). Conclusions: Bacterial infection are predominant in pediatric septic shock, but viral infection are also significant. Children with malignancies are more severe and resource consumptive. The overall mortality rate for pediatric septic shock remains high, and mortality are associated with malignant tumor, PRISM Ⅲ and pSOFA scores.

Risk factors and outcome of ventilator associated pneumonia in children aged 1 month to 12 years admitted in paediatric intensive care unit of a tertiary care hospital in Northern India

Background: Ventilator-associated pneumonia (VAP) is pneumonia that occurs after the patient has been on mechanical ventilation for more than 48 hours. There is a paucity of literature depicting the severity of VAP in the North Indian population. The current study was taken up to study the risk factors and outcomes of ventilator-associated pneumonia in children aged 1 month-12 years admitted in pediatric intensive care unit (PICU). Methods: A prospective observational study was conducted in the department of pediatrics, VMMC and Safdarjung Hospital, New Delhi for 18 months. The children aged 1 month to 12 years who were mechanically ventilated in the PICU for more than 48 hours were included in the study. Demographic details, nutritional status, and underlying primary diagnosis were recorded along with details about the duration of hospital stay, ventilator days and reintubation, clinical pulmonary infection score (CPIS), and paediatric risk of mortality (PRISM) score. Results: A significant positive correlation was seen between PRISM score with duration of ventilator and hospital stay. A higher PRISM III score was found to have a significant association with the development of VAP in the patients. Duration of ventilator stay and duration of hospital stay were the major risk factors for the incidence of VAP. Conclusions: The major risk factors that contributed to the development of VAP were the duration of ventilator stay and hospital stay. PRISM III score was found as a useful tool in predicting the development of VAP in the patients. Further larger prospective and multicentric studies are required to evaluate the risk factors and outcome of VAP.

Multisystemic Inflammatory Syndrome in Children (MIS-C) With COVID-19 and Kidney Involvement: Poor Outcomes in a Case Series.

Multisystemic inflammatory syndrome (Mis-C) has emerged in May 2020 as a serious complication of coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). A total of 6 children presented to tertiary care hospitals with Mis-C, of which 5 (83%) have died during hospitalization. All included patients presented with respiratory symptoms (ranged from mild to severe acute respiratory distress syndrome) and gastrointestinal symptoms. Most of the patients are known to have medical illnesses. Pediatric Risk of Mortality (PRISM) IV score ranged from 3 to 87. All patients developed acidosis and varying stages of acute kidney injury and electrolyte disturbances. All were treated for coagulopathy, thrombocytopenia, bacterial infections as well as antiviral medications (either ritonavir or lopinavir). Most patients had chest X-ray changes either unilateral or bilateral lung changes. Multisystemic inflammatory syndrome is a rare, yet serious complication of SARS-CoV2 infection in children. Multisystem involvement should be anticipated and promptly treated.

Daily Sedation Interruption vs Continuous Sedation in Pediatric Patients Receiving Mechanical Ventilation

The effectiveness of daily sedation interruption (DSI, defined as temporary interruption of sedation) has yet to be demonstrated in critically ill pediatric patients. To compare the clinical outcomes of DSI vs continuous intravenous (IV) sedation in patients receiving invasive mechanical ventilation (MV) support in the pediatric intensive care unit (PICU). A systematic search for studies was conducted using predefined keywords and Medical Subject Headings in 5 major databases (PubMed, Embase, Web of Science, CINAHL [Cumulated Index to Nursing and Allied Health Literature], and Cochrane Central Register of Controlled Trials) from database inception to October 31, 2023. Retrospective and prospective observational studies, randomized clinical trials (RCTs), and systematic reviews were assessed for inclusion. Studies were eligible if they compared DSI to continuous IV sedation in patients aged 18 years or younger requiring MV in the PICU. Study characteristics, including the types of sedation, sedation protocols, and clinical outcomes, were extracted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was followed. A random-effects model was used to pool results from articles for the meta-analysis. The primary outcomes of interest were duration of MV and length of PICU stay. Secondary outcomes included total sedative dose requirement, adverse events (eg, complications associated with MV, withdrawal, and delirium), and mortality. A total of 6 RCTs with 2810 pediatric patients (1569 males [55.8%]; mean age, 26.5 [95% CI, 15.0-37.9] months) were included in the final analysis; patients had a mean PRISM (Pediatric Risk of Mortality) score of 13.68 (95% CI, 10.75-16.61). Compared with continuous IV sedation, DSI was associated with a reduction in length of PICU stay (5 studies, n = 2770; mean difference [MD], -1.45 [95% CI, -2.75 to -0.15] days; P = .03]. There was no difference in MV duration (5 studies, n = 2750; MD, -0.93 [95% CI, -1.89 to 0.04] days; P = .06), total doses of midazolam (3 studies, n = 191; MD, -1.66 [95% CI, -3.95 to 0.63] mg/kg) and morphine used (2 studies, n = 189; MD, -2.63 [95% CI, -7.01 to 1.75] mg/kg), or adverse events (risk ratio [RR], 1.03 [95% CI, 0.74-1.42]; P = .88). There was no difference in mortality between patients exposed vs not exposed to DSI (RR, 0.89 [95% CI, 0.55-1.46]; P = .65). This systematic review and meta-analysis found that use of DSI in pediatric patients was associated with reduced length of PICU stay with no increase in adverse events. Further research is needed to ascertain whether this strategy is associated with improved neurodevelopmental outcomes in PICU survivors.

Infant feeding and criticality in children.

Data support the protective effects of human breast milk (HBM) feeding in acute illness but little is known about the impact of HBM feeding on the criticality of infants. To explore the relationship between early HBM feeding and severity of illness and recovery in critically ill children requiring intubation and mechanical ventilation for acute respiratory failure (ARF). Prospective cohort study of mothers of patients aged 1-36 months who participated in the acute and follow-up phases of the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial. Participants completed a survey describing HBM dose fed during their infant's first month of life. Of 138 patients, 70 (51%) received exclusive HBM feedings (90%-100% total feeds) and 68 (49%) did not. We found no group differences in severity of illness on paediatric intensive care unit (PICU) admission or severity of paediatric acute respiratory distress syndrome (PARDS) within the first 24-48 h of intubation/mechanical ventilation (Pediatric Risk of Mortality [PRISM] III-12 score median: 5 vs. 5, p = .88; moderate/severe PARDS: 53% vs. 54%, p = .63). While median time to recovery from ARF was reduced by 1 day in patients who received exclusive HBM feedings, the difference between groups was not statistically significant (median 1.5 vs. 2.6 days, hazard ratio 1.40 [95% confidence interval, 0.99-1.97], p = .06). Human breast milk dose was not associated with severity of illness on PICU admission in children requiring mechanical ventilation for ARF. Data support the protective effects of HBM during acute illness and data from this study support a clinically important reduction in time to recovery of ARF. Paediatric nurses should continue to champion HBM feeding to advance improvements in infant health.

Comparison Between Mortality Scoring Systems in Pediatric Intensive Care Unit Reliability and Effectiveness

Purpose: In pediatric intensive care unit (PICU), high mortality risk is a significant issue. Risk adjustment tools are in place for early estimation of mortality risk. Pediatric Risk of Mortality(PRISM), Pediatric Index of Mortality(PIM), Pediatric Logistic Organ Dysfunction(PELOD) and Pediatric Sequential Organ Failure Assessment(PSOFA) are commonly used. The aim of this study was to evaluate the predictive performance of mortality using PRISM III, PIM3, PELOD-2, and PSOFA. Materials and Methods: This retrospective single-center study analysed patients aged between 1month-18years who were treated in PICU for various diseases between April and December2021. Their electronic records were retrospectively examined for demographic characteristics, medical and clinical expectations, and morbidity/mortality. Results: The study included 300 patients with a hospitalization period of 56.73±105.95 days. At the end of the study, 56(18.7%) patients had died.All scoring systems and mortality correlations were statistically significant(p

Practical quality improvement changes for a low-resourced pediatric unit.

This work describes a sustainable and replicable initiative to optimize multi-disciplinary care and uptake of clinical best practices for patients in a pediatric intensive care unit in Low/Middle Income Countries and to understand the various factors that may play a role in the reduction in child mortality seen after implementation of the Quality Improvement Initiative. This was a longitudinal assessment of a quality improvement program with the primary outcome of intubated pediatric patient mortality. The program was assessed 36 months following implementation of the quality improvement intervention using a t-test with linear regression to control for co-variates. An Impact Pathway model was developed to describe potential pathways for improvement, and context was added with an exploratory analysis of adoption of the intervention and locally initiated interventions. 147 patients were included in the sustainability cohort. Comparing the initial post-implementation cohort to the sustainability cohort, the overall PICU unexpected extubations per 100 days mechanical ventilation decreased significantly from baseline (6.98) to the first year post intervention (3.52; p < 0.008) but plateaued without further significant decrease in the final cohort (3.0; p = 0.73), whereas the mortality decreased from 22.4 (std 0.42) to 9.5% (std 0.29): p value: 0.002 (confidence intervals: 0.05;0.21). The regression model that examined age, sex, diagnosis and severity of illness (via aggregate Pediatric Risk of Mortality (PRISM) scores between epochs) yielded an adjusted R-squared (adjusting for the number of predictors) value of 0.046, indicating that approximately 4.6% of the variance in mortality was explained by the predictors included in the model. The overall significance of the regression model was supported by an F-statistic of 3.198 (p = 0.00828). age, weight, diagnosis, and severity of illness. 15 new and locally driven quality practices were observed in the PICU compared to the initial post-implementation time period. The Impact Pathway model suggested multiple unique potential pathways connecting the improved patient outcomes with the intervention components. Sustained improvements were seen in the care of intubated pediatric patients. While some of this improvement may be attributable to the intervention, it appears likely that the change is multifactorial, as evidenced by a significant number of new quality improvement projects initiated by the local clinical team. Although currently limited by available data, the use of Driver Diagram and Impact Pathway models demonstrates several proposed causal pathways and holds potential for further elucidating the complex dynamics underlying such improvements.

Social Determinants of Health and Health-Related Quality of Life Following Pediatric Septic Shock: Secondary Analysis of the Life After Pediatric Sepsis Evaluation Dataset, 2014-2017.

Social determinants of health (SDOH) are associated with disparities in disease severity and in-hospital outcomes among critically ill children. It is unknown whether SDOH are associated with later outcomes. We evaluated associations between SDOH measures and mortality, new functional morbidity, and health-related quality of life (HRQL) decline among children surviving septic shock. Secondary analysis of the Life After Pediatric Sepsis Evaluation (LAPSE) prospective cohort study was conducted between 2014 and 2017. Twelve academic U.S. PICUs were involved in the study. Children younger than 18 years with community-acquired septic shock were involved in the study. None. We assessed associations between race, ethnicity, income, education, marital status, insurance, language, and home U.S. postal code with day 28 mortality, new functional morbidity at discharge per day 28, and HRQL decline using logistic regression. Of 389 patients, 32% ( n = 98) of families had household income less than $50,000 per year. Median Pediatric Risk of Mortality (PRISM) score was 11 (interquartile range 6, 17). We found that English language and Area Deprivation Index less than 50th percentile were associated with higher PRISM scores. Mortality was 6.7% ( n = 26), new functional morbidity occurred in 21.8% ( n = 78) of patients, and HRQL decline by greater than 10% occurred in 31.0% of patients ( n = 63). We failed to identify any association between SDOH measures and mortality, new functional morbidity, or HRQL decline. We are unable to exclude the possibility that annual household income greater than or equal to $50,000 was associated with up to 81% lesser odds of mortality and, in survivors, more than three-fold greater odds of HRQL decline by greater than 10%. In this secondary analysis of the 2014-2017 LAPSE dataset, we failed to identify any association between SDOH measures and in-hospital or postdischarge outcomes following pediatric septic shock. This finding may be reflective of the high illness severity and single disease (sepsis) of the cohort, with contribution of clinical factors to functional and HRQL outcomes predominating over prehospital and posthospital SDOH factors.

Evaluation of the impact of trained pediatric intensivists on patient management in intensive care unit: An uncontrolled before-after study

It is known that the presence of a pediatric intensivist in the pediatric intensive care unit (PICU) improves the quality of patient care and treatment. In this study, it was aimed to determine the differences in the quality of patient care between the period when a pediatric intensivist is actively working and the period when he/she is not actively working. This is a retrospective cohort observational study conducted in Batman Training and Research Hospital. Children aged 1 month to 18 years old admitted to the PICU between October 2020 and March 2021 were enrolled in the study. The 6-month period without an intensivist was compared with the period when the patients were treated by a pediatric intensivist. Demographic data and mortality of the group were recorded and compared between groups. There was no statistically significant difference between the groups in terms of number, gender, and age. The mean Pediatric Risk of Mortality (PRISM) score and Pediatric Death Rate (PDR) were higher in group 2, and these differentiations were statistically significant (0.39 ± 0.18vs 4.57 ± 2.36, p&lt;0.001; 1.08 ± 0.15 vs 2,05 ± 1.25, p&lt;0.001). Although mortality was statistically higher in group 2, there were no invasive procedures like mechanical ventilatory support, dialysis, and central venous catheter applications in group 1. The ratio of patient acceptance from other hospitals was higher in group 2 (p&lt;0.001). In intensive care units under the management of intensivists, clinical follow-up of critical and risky patients can be performed on-site. This protects from transfer difficulties. Invasive interventions can be performed on patients with less risk, and yet mortality is below average. Pediatric intensive care units should be managed by pediatric intensivists and their numbers should be increased.

Comparison of diagnostic criteria for sepsis-associated acute kidney injury in the pediatric intensive care unit: a retrospective cohort study.

pRIFLE (Pediatric Risk, Injury, Failure, Loss, End Stage Renal Disease), KDIGO (Kidney Disease Improving Global Outcomes) and pROCK (Pediatric Reference Change Value Optimized for AKI) are diagnostic criteria used for acute kidney injury (AKI) incidence evaluation. The aim of this study was to explore the diagnostic consistency, incidence and mortality rate, clinical signs, and influencing factors of renal injury related to sepsis in children diagnosed by three different AKI diagnostic criteria, and then evaluate which one was more valuable. A retrospective analysis was performed on the clinical data of children with severe sepsis. The patients were diagnosed and staged according to the 2007 pRIFLE standard, the 2012 KDIGO standard, and the 2018 pROCK standard. The clinical characteristics and prognosis of children with different stages of sepsis were compared between the three diagnostic standards. A total of 62 patients with sepsis were included. Blood stream infection is common (11 cases, 17.74%). According to pRIFLE, KDIGO, and pROCK standards, the incidence of sepsis-associated AKI (SA-AKI) was 74.2%, 67.7%, and 56.5%, respectively. The pRIFLE had the highest diagnostic rate of early detection of SA-AKI. There was no statistical difference in SA-AKI incidence or staging consistency between the pRIFLE and KDIGO groups (κ=0.0671; κ>0.60); the consistency of SA-AKI diagnoses across the three standards was good (all P values <0.05), and pROCK demonstrated a higher specificity. A high Pediatric Risk of Mortality (PRISM) score and high procalcitonin level were independent risk factors. Shock and renal replacement therapy were independent risk factors for SA-AKI death. Death from admission to 28 days after admission was used as an endpoint to draw a survival graph, which revealed that the AKI group had a significantly higher risk of death than did the non-AKI group. The consistency of diagnosing SA-AKI across the three classification criteria was similar, and mortality rate increased with increased SA-AKI staging. The pRIFLE criteria were more sensitive in the early detection of SA-AKI, while the pROCK had higher specificity. There was no significant difference between the pRIFLE and KDIGO in terms of incidence, diagnosis, or staging of SA-AKI.

Utility of Metagenomic Next-Generation Sequencing for Diagnosis of Infectious Diseases in Critically Ill Immunocompromised Pediatric Patients.

Infections cause high rates of illness and death in children worldwide. However, studies on the clinical value of metagenomic next-generation sequencing (mNGS) for immunocompromised children are still limited. From June 2021 to December 2023, 119 samples were collected at Pediatric Intensive Care Unit (PICU) of a single-center pediatric hospital and classified into two groups based on their immune states. We compared the diagnostic performance of mNGS and conventional microbiological test (CMT) for pathogen identification, and assessed the clinical impacts of mNGS. Among the 119 samples, 48 (40.34%) belonged to the immunocompromised children. mNGS had a higher positivity rate than CMT (76.47% vs 55.46%, P = 0.0006). The positive percent agreement (PPA) of mNGS for immunocompromised children was higher compared to immunocompetent children (95.24% vs 77.78%). The most common pathogens for immunocompromised patients were gram-negative bacteria and herpesvirus. However, immunocompetent children showed a higher detection rate for gram-positive bacteria and respiratory viruses. Furthermore, the proportions of the positive impact of mNGS results were significantly higher in immunocompromised patients compared to immunocompetent patients for both diagnosis (91.67% vs 57.75%) and treatment (95.83% vs 64.79%) (P < 0.0001). Immunocompromised state, length of hospital stays, times stay in ICU, Pediatric Risk of Mortality (PRISM) score, neutrophil percentage (NEUT%) and the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) were considered independent factors for poor prognosis in critically ill pediatric patients. In patients from PICU, mNGS had a greater clinical significance in immunocompromised children compared to immunocompetent children. mNGS technology is an important auxiliary method for achieving accurate diagnosis and treatment of critically ill pediatric patients.

Study on red blood cell distribution width in children with severe Mycoplasma pneumoniae pneumonia.

Background: This study aimed to investigate the clinical value of the red blood cell distribution width (RDW) in severe Mycoplasma pneumoniae pneumonia (MPP). Methods: A total of 185 children with diagnosed severe MPP were included. The patients' case records and laboratory examination data were analyzed retrospectively. The children were grouped into quartiles based on RDW. Results: Univariate analysis revealed that RDW was significantly correlated with the Pediatric Risk of Mortality (PRISM) III score, Sepsis-Related Organ Failure Assessment score, incidence of invasive intubation and 30-day in-hospital mortality. After adjustment for the severity of illness, multivariate analysis revealed that the PRISM III score and RDW were factors independently associated with 30-day in-hospital mortality. Conclusion: This study revealed that RDW could be correlated with the long-term prognosis and severity of severe MPP.

Burden of Respiratory Disease in Pediatric Intensive Care Unit: Experience from a PICU of a Tertiary Care Center in Pakistan.

We aimed to determine the burden of respiratory disease by examining clinical profiles and associated predictors of morbidity and mortality of patients admitted to a Pediatric Intensive Care Unit (PICU) in Pakistan, a resource limited country. We also stratified the respiratory diseases as defined by the Pediatric Advanced Life Support (PALS) Classification. A retrospective study was conducted on children aged 1 month to 18 years who were diagnosed with respiratory illness at the PICU in a tertiary hospital in Karachi, Pakistan. Demographics, essential clinical details including immunization status, and the outcome in terms of mortality or survival were recorded. Predictors of mortality and morbidity including prolonged intubation and mechanical ventilation in the PICU were analyzed using the chi-square test or Fischer's exact test as appropriate. 279 (63.8% male; median age 9 months, IQR 4-36 months) patients were evaluated of which 44.2% were malnourished and 23.3% were incompletely immunized. The median length of stay in the PICU was 3 days (IQR 2-5 days). Pneumonia was the principal diagnosis in 170 patients (62%) and accounted for most deaths. 76/279 (27.2%) were ventilated, and 67/279(24.0%) needed inotropic support. A high Pediatric Risk of Mortality (PRISM) III score, pneumothorax, and lower airway disease were significantly associated with ventilation support. The mortality rate of patients was 14.3%. Predictors of mortality were a high PRISM III score (OR 1.179; 95% CI 1.024-1.358, P=0.022) and a positive blood culture (OR 4.305; 95% CI 1.062-17.448, P=0.041). Pneumonia is a significant contributor of respiratory diseases in the PICU in Pakistan and is the leading cause of morbidity and mortality. A high PRISM III score, pneumothorax, and lower airway disease were predictors for ventilation support. A high PRISM III score and a positive blood culture were predictors of patient mortality in our study.

Paediatric Risk of Mortality (PRISM) III Score and Serum Lactate Levels as Predictor of Outcome in Children Admitted to the Paediatric Intensive Care Unit

Objective − To evaluate prognostic indicators of mortality in children admitted to the Paediatric Intensive Care Unit (PICU) and to correlate blood lactate levels with Pediatric Risk of Mortality (PRISM) III scores.Methods − A cross sectional study was conducted between March 2021 and October 2022 in the PICU of the P S Govindasamy (PSG) Institute of Medical Sciences and Research. On the basis of the laboratory and clinical parameters, the PRISM III score was calculated at admission. Lactate levels were measured at admission and 24 hours after admission.Results − The study included 107 patients of whom the majority (54.2%) were female. The median patient age was 3 years and the median duration of PICU stay was 4 days. Among the hospitalized patients, 90.7% were survivors, with female patients having an 8.8-fold higher risk of mortality compared to males (P=0.05). The serum lactate value in survivors (2.95 mmol/L) was much lower in comparison to non-survivors (3.11 mmol/L). The PRISM III value measured at the time of admission in survivors (8) was low when compared to non-survivors (16.50). The area under the curve (AUC) for PRISM III was 0.884 compared to lactate levels (0.831).Conclusion − A significant positive correlation was seen between the PRISM III score and lactate levels. The study indicates that monitoring patients admitted to the PICU in relation to their PRISM III score and lactate levels can improve their overall prognosis and facilitate early resuscitation.

A prospective cohort study of severe sepsis-induced dyslipidemia and changes in D-dimer levels in children: do they affect the prognosis?

BackgroundThe dyslipidemia and changes in D-dimer values that occur in children with severe sepsis remain unidentified.ObjectiveThe current research aimed to explore the relationship between D-dimer and lipid profile values, including total cholesterol (TC), lipoproteins, apolipoprotein A-V (Apo A-5), triglycerides (TG), and in-hospital nonsurvival in children with severe sepsis or septic shock in pediatric intensive care.Study designThe study design is as follows: prospective cohort study.ParticipantsChildren with severe sepsis or septic shock who were admitted to the intensive care unit of a university pediatric hospital.InterventionVital signs, sepsis assessment, pediatric sequential organ failure assessment (PSOFA) score, high-density lipoprotein (HDL), Apo A-5, TG, low-density lipoprotein (LDL), TC, D-dimer, mortality outcome, and pediatric risk of mortality (PRISM) III score were evaluated.OutcomesThe primary outcome was in-hospital nonsurvival.ResultsThe nonsurvivors had significantly higher D-dimer levels than the survivors, with a significant cutoff level of 0.87 μg/mL (AUC: 0.85, sensitivity: 93.3%, PVN: 90.6%, accuracy: 79.0%, PVP: 72.5%, and specificity: 64.7%). D-dimer was inversely correlated with WBC count and positively correlated with patient age, PRISM III score, PSOFA score, and INR. However, nonsurvivors had higher TG levels and lower TC, HDL, LDL, and Apo A-5 levels than survivors, but this variation was insignificant. Apo A-5 levels were inversely correlated with HDL and positively correlated with TG levels.ConclusionsThis study suggests that D-dimer is a promising biomarker for severe sepsis in children, with a mortality cutoff level of 0.87 μg/mL. However, lipid profiles are not predictors of sepsis-related mortality.

Cortisol levels associated with mortality in children with critical illness: a systematic review

Background Critically ill patients, including those with sepsis, have increased cortisol levels due to activation of the hypothalamic-pituitary-adrenal (HPA) axis or critical illness-related corticosteroid insufficiency (CIRCI).&#x0D; Objective To evaluate for a possible association between cortisol levels and mortality from sepsis in pediatric patients by systematic review of the literature.&#x0D; Methods A systematic review was conducted on studies involving critically ill children, including those with sepsis. We included studies published between 2011-2020 analyzing data on cortisol levels (total serum cortisol, serum-free cortisol, salivary cortisol, real-time free cortisol, basal serum cortisol and post-adrenocorticotropin hormone (ACTH) stimulation test, or basal salivary cortisol and post-ACTH stimulation test), the predictive score for mortality (Pediatric Logistic Organ Dysfunction/PELOD), Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality (PIM), Vasotropic Inotropic Score (VIS), or Pediatric Critical Illness Score (PCIS)], mortality (non-survivor percentage), and CIRCI percentage as an outcome in patients with critical illness, sepsis, and septic shock.&#x0D; Results Twenty-one observational studies were included in our systematic review, with a total of 2,212 subjects, 916 of whom had sepsis. Nineteen studies indicated a positive association between elevated cortisol levels and mortality in critically ill children, but 2 studies stated that there was no association with the CIRCI percentage of 32.3 and 84.3% respectively. The mortality percentage of critically ill patients with elevated cortisol levels and sepsis were 25.81 (2.7-60)% and 35.31 (6-60)%, respectively. The percentages of CIRCI in critically ill and sepsis patients were 21.91 (0-84.3)% and 21.35 (0-84.3)%, respectively.&#x0D; Conclusion Cortisol levels may increase or decrease in critically ill children. Elevated cortisol levels are associated with mortality in septic children. The effect of CIRCI on mortality in critically ill children cannot be concluded.

Abstract 102: Early Bolus Epinephrine Administration During Pediatric Cardiopulmonary Resuscitation for Bradycardia With Poor Perfusion

Introduction: Though epinephrine is recommended during CPR for children with bradycardia with poor perfusion, a registry study identified an association between epinephrine administration and worse outcomes. Our objective was to use granular data from the ICU-RESUScitation (ICU-RESUS) trial, including markers of illness severity not available in registries, to further investigate epinephrine use in this population. We hypothesized that when controlling for patient characteristics, early epinephrine administration would be associated with superior outcomes in children receiving CPR for bradycardia with poor perfusion. Methods: Prespecified secondary analysis of ICU-RESUS, a multicenter cluster randomized trial of pediatric (&lt;19 years) IHCA in 18 PICUs. Index events (October 2016 to March 2021) lasting 2 minutes with an initial rhythm of bradycardia with poor perfusion were included. Early administration of bolus epinephrine (first 2 minutes of CPR) was chosen as the exposure since pulselessness during CPR for bradycardia with poor perfusion develops at a median of 3 minutes. The association between early epinephrine and outcomes was evaluated with Poisson multivariable regression controlling for a priori pre-arrest characteristics including Pediatric Risk of Mortality (PRISM) score and vasoactive inotropic score (VIS). Results: Of 452 patients, 322 (71.2%) received early epinephrine. The early epinephrine group had higher PRISM and VIS and more frequently received calcium and sodium bicarbonate. On univariate analysis, the early epinephrine group had lower, but not statistically significantly, rates of survival to discharge (174/322 [54%] vs 82/130 [63%], p=0.093) and survival with favorable neurologic outcome (164/322 [51%] vs 75/130 [58%], p=0.212). In multivariable analysis, early epinephrine was not associated with survival to discharge (RR 0.97, 95% CI 0.82, 1.14) or survival with favorable neurologic outcome (RR 0.99, 95% CI 0.82, 1.18). Conclusion: In this cohort of pediatric IHCA with an initial rhythm of bradycardia with poor perfusion, early bolus epinephrine was not associated with outcomes when controlling for illness severity. Further work should focus on which patients with this rhythm benefit from epinephrine.

Predictive Value of PRISM-4, PIM-3, CRP, Albumin, CRP/Albumin Ratio and Lactate in Critically Ill Children.

The accurate prediction of the prognosis for critically ill children is crucial, with the Pediatric Index of Mortality (PIM) and Pediatric Risk of Mortality (PRISM) being extensively utilized for this purpose. Albumin, C-reactive protein (CRP), and lactate levels, which are indicative of inflammation and circulatory status in critically ill children, have not been incorporated into existing scoring systems. This retrospective cohort study evaluated the association between biological markers and the clinical outcomes in children with critical illnesses. PRISM-4 and PIM-3 death probability (DP), albumin, lactate, CRP, and CRP/albumin ratio were recorded upon admission. The accuracy of the indexes in predicting mortality were assessed by calculating the area under the curve (AUC). There were 942 patients included and the 28-day mortality rate was 7.9%. The AUC for PRISM-4, PIM-3, CRP, CRP/albumin ratio, albumin, and lactate were 0.923, 0.896, 0.798, 0.795, 0.751, 0.728, respectively. The findings in the subgroup analysis of septic patients were similar to those found in the overall population. Although CRP, CRP/albumin ratio, albumin, and lactate levels are all linked to mortality in children, CRP and the CRP/albumin ratio have lower predictive values than albumin and lactate. Incorporation of albumin and lactate into scoring systems will improve predictability.

Comparison of PRISM IV and PIM III prognostic scores as mortality indicators among paediatric intensive care unit patients &amp;nbsp;

Introduction: Identifying prognosis of patients admitted in the paediatric intensive care unit (PICU) is of paramount importance to better allocate medical resources, reduce patient-doctor conflict and for overall better patient care. Many scoring systems have been formulated to accomplish this task including paediatric risk of mortality (PRISM) IV and paediatric index of mortality (PIM) III.Objectives: To compare PRISM IV and PIM III as prognostic scoring tools in the PICU of a tertiary healthcare centreMethod: This prospective observational study was conducted in the PICU, Dhiraj hospital, SBKS MI&amp;RC, Gujarat, India, from March 2021 to September 2022. It included all patients from age 1 month to 18 years who were admitted in the PICU for &gt;24 hours and gave consent for this study. They were thoroughly examined and investigations were done within the first hour of admission as per standard guidelines and their PRISM IV and PIM III scores were calculated and data were analysed.Results: A total of 74 patients was enrolled in this study. Whilst 43 (58.1%) patients were discharged, 18 (24.3%)] were discharged against medical advice(DAMA) moribund, 4 were DAMA (non-moribund) and 9 (12.2%) died. Receiver Operating Characteristic (ROC) curves were made for both PRISM IV and PIM III scores. Discriminatory powers of PIM III (AUC 0.725; 95% CI: 0.609 to 0.823) and PRISM IV (AUC 0.8; 95% CI: 0.691 to 0.884) were acceptable. Whilst PRISM IV was the better predictor of mortality at cut off point of &gt;4 with area under curve of 0.8 for correctly predicting mortality, this difference was not statistically significant (p value=0.354). Multivariate logistic regression analysis showed that the duration of stay(days) and PRISM IV value &gt;4 were significant independent risk factors of mortality after adjusting for confounding factors.Conclusions: Both PRISM IV and PIM III were good prognostic scoring tools in the PICU of the tertiary healthcare centre. Multivariate logistic regression analysis showed that the duration of stay(days) and PRISM IV value &gt;4 were significant independent risk factors of mortality after adjusting for confounding factors.

Impact of the COVID-19 pandemic on diabetic ketoacidosis management in the pediatric intensive care unit.

Diabetic ketoacidosis (DKA) is a common endocrine emergency in pediatric patients. Early presentation to health facilities, diagnosis, and good management in the pediatric intensive care unit (PICU) are crucial for better outcomes in children with DKA. This was a single-center, retrospective cohort study conducted between February 2015 and January 2022. Patients with DKA were divided into two groups according to pandemic status and diabetes diagnosis. The study enrolled 59 patients, and their mean age was 11±5 years. Forty (68%) had newly diagnosed type 1 diabetes mellitus (T1DM), and 61% received follow-up in the pre-pandemic period. Blood glucose, blood ketone, potassium, phosphorus, and creatinine levels were significantly higher in the new-onset T1DM group compared with the previously diagnosed group (P=0.01, P=0.02, P<0.001, P=0.01, and P=0.08, respectively). In patients with newly diagnosed T1DM, length of PICU stays were longer than in those with previously diagnosed T1DM (28.5±8.9 vs. 17.3±6.7 hours, P<0.001). The pandemic group was compared with pre-pandemic group, there was a statistically significant difference in laboratory parameters of pH, HCO3, and lactate and also Pediatric Risk of Mortality (PRISM) III score. All patients survived, and there were no neurologic sequelae. Patients admitted during the pandemic period were admitted with more severe DKA and had higher PRISM III scores. During the pandemic period, there was an increase in the incidence of DKA in the participating center compared to that before the pandemic.