Pediatric Risk Of Mortality Research Articles

PRISM score as a predictor of mortality among pediatric intensive care units.

Background: The pediatric risk of mortality (PRISM) score predicts mortality in the pediatric intensive care unit (PICU). This study aimed to evaluate the application of PRISM score as a predictor of mortality in intensive care units of a tertiary hospital.
 Methodology: A descriptive cross-sectional study of one year was conducted within the Department of Pediatrics at Ziauddin University and Hospital, located in Karachi, Pakistan. The total number of 263 admitted neonates and children up to the age of 12 years were included. Patients more than 12 years of age admitted in wards and plane for any surgery were excluded from the study; the PRISM score tool was used to collect the data of the neonates and children.
 Results: The mean PRISM score was high among non-survivors (15.3 ± 7.2) as compared to survivors (12.7 ± 9.2) (p=0.023). The predictability of the PRISM score regarding pediatric mortality was shown by the area under the curve (AUC) i.e., 0.636.
 Conclusion: The PRISM score found a significant difference between survival and death groups. Therefore the implication of the PRISM score can be needed in PICU to reduce the mortality rate.

Clinical and Laboratory Findings of 12 Children with Invasive Meningococcal Disease in Pediatric Intensive Care Unit

Introduction Invasive meningococcal disease (IMD) is a serious infectious disease requiring stay in a pediatric intensive care unit (PICU) that continues to be associated with high morbidity and mortality rates. Prompt recognition, early antibiotic therapy, and aggressive supportive therapies can reduce mortality. We aimed to assess the clinical and laboratory characteristics of children with IMD. Patients and Methods. We retrospectively evaluated the medical records of 12 children with IMD requiring PICU stay between January 2018 and July 2019. Results We followed up 12 patients (five girls and seven boys, 5–168 months of age, and four below one year of age) with IMD (nine patients have meningococcemia with meningitis, and three patients have meningococcemia) in PICU. All children were previously healthy and have not received meningococcal vaccines. Their pediatric risk of mortality (PRISM) scores varies between 5 and 37, four of the patients required mechanical ventilation, and the predicted mortality was 39% at admission. Seven patients had catecholamine refractory septic shock and disseminated intravascular coagulation (DIC). Three of the patients required extracorporeal treatment. The predominant serogroup is Men B (5/12). The mortality rate was 16.6% with early use of antibiotics, fluids, and other interventions. Conclusion Mortality related to IMD is higher among children with severe meningococcemia despite early interventions in PICU. Routine use of meningococcal vaccines during childhood would be a better strategy for controlling IMD in both developing and developed countries.

Derivation and Validation of the Critical Bronchiolitis Score for the PICU.

To derive and internally validate a bronchiolitis-specific illness severity score (the Critical Bronchiolitis Score) that out-performs mortality-based illness severity scores (e.g., Pediatric Risk of Mortality) in measuring expected duration of respiratory support and PICU length of stay for critically ill children with bronchiolitis. Retrospective database study using the Virtual Pediatric Systems (VPS, LLC; Los Angeles, CA) database. One-hundred twenty-eight North-American PICUs. Fourteen-thousand four-hundred seven children less than 2 years old admitted to a contributing PICU with primary diagnosis of bronchiolitis and use of ICU-level respiratory support (defined as high-flow nasal cannula, noninvasive ventilation, invasive mechanical ventilation, or negative pressure ventilation) at 12 hours after PICU admission. Patient-level variables available at 12 hours from PICU admission, duration of ICU-level respiratory support, and PICU length of stay data were extracted for analysis. After randomly dividing the cohort into derivation and validation groups, patient-level variables that were significantly associated with the study outcomes were selected in a stepwise backward fashion for inclusion in the final score. Score performance in the validation cohort was assessed using root mean squared error and mean absolute error, and performance was compared with that of existing PICU illness severity scores. Twelve commonly available patient-level variables were included in the Critical Bronchiolitis Score. Outcomes calculated with the score were similar to actual outcomes in the validation cohort. The Critical Bronchiolitis Score demonstrated a statistically significantly stronger association with duration of ICU-level respiratory support and PICU length of stay than mortality-based scores as measured by root mean squared error and mean absolute error. The Critical Bronchiolitis Score performed better than PICU mortality-based scores in measuring expected duration of ICU-level respiratory support and ICU length of stay. This score may have utility to enrich interventional trials and adjust for illness severity in observational studies in this very common PICU condition.

Introducing a Radiography-based Score in Children With Acute Respiratory Failure: A Cross-sectional Study.

Respiratory failure (RF) is one of the most common reasons for hospitalization in pediatric intensive care units (PICU). We propose a radiography-based severity score for the assessment of children with RF and investigate the possible associations with severity indices and outcome. Children with acute RF admitted in PICU were enrolled. Disease severity scores [Pediatric Risk of Mortality (PRISM) and Pediatric Logistic Organ Dysfunction (PELOD)], the ratio of partial pressure arterial oxygen and fraction of inspired oxygen (PaO2/FiO2) ratios, duration of ventilator support (DVS), length of PICU and hospital stay (LOS), and outcome were recorded. A 5-point radiography score that considered potential radiographic findings was derived through stepwise multivariable logistic regression analysis, and validated. Radiographs upon PICU admission and on the worst RF day (maximum respiratory support and worst oxygenation/ventilation parameters) were blindly reviewed and independently scored by 2 radiologists and 2 clinicians, following training. We enrolled 104 children [median age 2.7 (interquartile range, 0.5 to 9.6) y, 65.4% boys]. Overall, 163 radiographs (PICU admission: 86, worst RF day: 77) were assessed. Radiography scores correlated positively with predicted mortality (PELOD, PRISM), DVS, LOS (all P<0.001) and inversely with PaO2/FiO2 (P<0.001). Scores differed among diagnostic categories (P<0.05); patients with acute respiratory distress syndrome, air-leaks, drowning, and pneumonia scored the highest (P<0.005). Radiography scoring trends indicating deterioration were associated with prolonged DVS, PICU, and hospital LOS (P<0.001). Agreement between all raters was good (κ=0.7, P<0.001). This novel radiography score for children with RF, associated with clinical severity scores, mortality risk, duration of ventilatory support, and hospitalization, follows a simple structured approach and can be readily utilized by radiologists and pediatricians as a bedside tool for stratification of disease severity and prognosis.

P0148 / #1909: COMPARISON OF SCORING SYSTEMS IN TERTIARY PEDIATRIC INTENSIVE CARE UNIT

Aims & Objectives: To compare the scoring systems in tertiary pediatric intensive care unit (PICU) in Turkey. Methods: Patients, admitted to the PICU from November 2018 to October 2019, were included. Demographic findings, lactate levels and the or pediatric risk of mortality (PRISM) 3, PRISM 4, pSOFA (pediatric sequential organ failure assessment), pediatric index of mortality 2 (PIM2), PELOD-2 (pediatric logistic organ dysfunction-2) in the first 24 hours at admission were recorded. Results: 326 patients (159 girls and 167 boys; mean age 55.5 months; IQR 1-213) were included and the mortality rate was 10.4%. Mean PRISM 3 score (3.2± 0.4 vs. 30.7 ± 6.0), PRISM 4 score (1.04 ± 0.08 vs. 12.2±4), pSOFA score (1.30 ± 0.11 vs. 7.02 ± 0.84), PIM2 score (2.83 ± 0.35/ vs. 26.6 ± 6.1) and PELOD-2 score (0.67 ± 0.18 vs. 22.4 ± 6.5) were higher among patients who died than the survivors (p<0.001, p<0.01, p<0.001, p<0.001 and p<0.01; respectively). Although all scoring systems were higher in patients who died; pSOFA had higher sensitivity comparing the other scoring systems, while lower specificity. Conclusions: The maximum pSOFA score in the first 24 hours at admission had better performance than other scoring systems for PICU mortality without classifying different disease groups. It would be useful to evaluate scoring systems in different disease groups and larger patient series.

Comparison of PICU Cost and Severity-Adjusted Cost Between Patients With SIRS-Defined Sepsis and Those With Age-Adapted SOFA-Defined Sepsis.

Background: The 2005 International Pediatric Sepsis Consensus definition is considered to lack specificity and may lead to the admission of low-risk patients to the pediatric intensive care unit (PICU). The aim of this study was to compare the PICU cost and the severity-adjusted cost between patients with sepsis defined by the 2005 International Pediatric Sepsis Consensus and those diagnosed using the age-adapted Sepsis-3 criteria.Methods: Septic children identified by the 2005 Consensus were screened for enrollment. The enrolled children were stratified into two subgroups using the age-adapted Sepsis 3.0 definition. A comparison was made between the subgroups of sepsis 3.0-defined children and non-sepsis 3.0-defined septic children. The Severity Adjusted ICU Cost (SAIC) was used to evaluate the case-mixed severity-adjusted costs of the study population. Coefficients in linear regression analyses in subgroups were calculated for presenting variation of PICU costs for every unit change of PRISM score.Results: A total of 397 children were enrolled. The PICU length of stay was longer in the sepsis 3.0 group than in the non-sepsis 3.0 group [median (IQR), 9.0 (5.0, 15.0) vs. 6.0 (3.0, 9.0); P < 0.001]. Pediatric risk of mortality (PRISM) scores and mortality were significantly higher in sepsis 3.0-defined septic patients. The total costs and daily costs in the PICU were both significantly lower in the non-sepsis 3.0 group (P < 0.001). The severity-adjusted ICU cost in the non-sepsis 3.0 group was lower than that in the sepsis 3.0 group [median (IQR), 7,125 (3,588, 11,134) vs. 9,364 (5,680, 15,876); P = 0.001]. There was no significant difference among the regression coefficients.Conclusions: The 2005 International Pediatric Sepsis Consensus definition does not lead to more PICU costs after considering illness severity.Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03598127.

Effects of continuous venovenous hemofiltration on vancomycin trough concentrations in critically ill children.

BackgroundVancomycin trough concentrations are associated with clinical outcomes and drug adverse effects. This study investigates the effects of continuous venovenous hemofiltration (CVVH) on vancomycin trough concentrations in critically ill children with a vancomycin dosage of 40–60 mg/kg/day.MethodsChildren with steady-state vancomycin trough concentrations admitted to the pediatric intensive care unit (PICU) between January 2016 and December 2019 were retrospectively enrolled. Patients were divided into CVVH and non-CVVH groups according to treatment differences and renal function. Vancomycin trough concentrations were then compared between the groups, and risk factors for supratherapeutic trough concentrations (>20 mg/L) were analyzed with logistic regression.ResultsOf the 119 patients included, 35 were enrolled in the CVVH group and 84 in the non-CVVH group. Median vancomycin trough concentrations were significantly higher in the CVVH group than those in the non-CVVH group [14.9 (IQR =9.6–19.6) vs. 9.3 (IQR =7.0–13.4), P<0.001] and the proportion of therapeutic trough concentrations (10–20 mg/L) was similar between CVVH and non-CVVH groups (54.3% vs. 39.3%, P=0.133). However, CVVH therapy patients had a significantly higher proportion of supratherapeutic trough concentrations (20.0% vs. 1.2%, P=0.001) compared to the non-CVVH group. Multivariate analysis demonstrated that the Pediatric Risk of Mortality (PRISM) III score ≥28 (OR =13.7; 95% CI, 1.4–137.0; P=0.026] was an independent risk factor for supratherapeutic trough concentrations in critically ill patients.ConclusionsCVVH therapy affects vancomycin trough concentrations and is associated with supratherapeutic concentrations with a 40–60 mg/kg/day vancomycin dosage. PRISM III scores ≥28 may serve as an independent risk factor for supratherapeutic trough concentrations in children receiving CVVH therapy.

Coronavirus disease in children: A multicentre study from the Kingdom of Saudi Arabia

BackgroundThe COVID-19 global pandemic caused by severe acute respiratory syndrome coronavirus 2 infection, warranted attention for whether it has unique manifestations in children. Children tend to develop less severe disease with a small percentage present with clinical manifestations of paediatric multisystem inflammatory syndrome and have poor prognosis. We studied the characteristics of COVID-19 in children requiring hospitalisation in the Kingdom of Saudi Arabia and assessed the clinical presentation and the risk factors for mortality, morbidity, and paediatric intensive care (PICU) admission. MethodsWe conducted a retrospective analysis of COVID-19 patients under 15 years hospitalised at three tertiary academic hospitals between 1 March and 30 June 2020. ResultsEighty-eight children were enrolled (>20% were infants). Seven (8%) were in critical condition and required PICU admission, and 4 (4.5%) died of which 3 met the full diagnostic criteria of multi-system inflammatory syndrome and had a high Paediatric Risk of Mortality (PRISM) score at the time of admission. The initial polymerase chain reaction (PCR) test result was positive for COVID-19 in most patients (97.7%), and the remaining two patients had positive result in the repeated confirmatory test. In a subset of patients (20 subjects), repeated PCR testing was performed until conversion to negative result, and the average duration for conversion was 8 (95% CI: 5.2–10.5) days Children requiring PICU admission presented with signs of respiratory distress, dehydration, and heart failure. Most had fever (71.4%) and tonsillitis; 61.4% were discharged within 7 days of hospitalisation. Risk factors for mortality included skin rash, hypotension, hypoxia, signs of heart failure, chest radiograph suggestive of acute respiratory distress syndrome, anaemia, leucocytosis, hypernatraemia, abnormal liver enzymes, and high troponin I, and risk factors for prolonged hospitalisation (>7 days) included the presence of comorbidities, leucopaenia, hyponatraemia, and elevated C-reactive protein. ConclusionsThe majority of hospitalised children had a brief febrile illness and made a full recovery, but a minority had severe disease.

Performance of PRISM III and PIM 2 scores in a cancer pediatric intensive care unit.

ObjectiveTo assess the performance of Pediatric Risk of Mortality (PRISM) III and Pediatric Index of Mortality (PIM) 2 scores in the pediatric intensive care unit.MethodsA retrospective cohort study. Data were retrospectively collected from medical records of all patients admitted to the pediatric intensive care unit of a cancer hospital from January 2017 to June 2018.ResultsThe mean PRISM III score was 15, and PIM 2, 24%. From the 338 studied patients, 62 (18.34%) died. The PRISM III estimated mortality was 79.52 patients (23.52%) and for PIM 2 80.19 patients (23.72%), corresponding to a standardized mortality ratio (95% confidence interval: 0.78 for PRISM II and 0.77 for PIM 2). The Hosmer-Lemeshow chi-square test was 11.56, 8df, 0.975 for PRISM II and 0.48, 8df, p = 0.999 for PIM 2. The area under the Receiver Operating Characteristic curve was 0.71 for PRISM III and 0.76 for PIM 2.ConclusionBoth scores overestimated mortality and have shown a regular ability to discriminate between survivors and non-survivors. Models should be developed to quantify the severity of cancer pediatric patients in Pediatric Intensive Care Units and to predict the mortality risk accounting for their peculiarities.

Correlation between Stable Hyperglycemia and Mortality in Children Admitted to the Pediatric Intensive Care Unit of Imam Hossein Hospital.

Background:Stress-induced hyperglycemia is an important issue among pediatrics admitted in the pediatric intensive care unit (PICU). Former studies have declared that hyperglycemia has a high prevalence rate and could increase the risks of mortality among pediatrics. Here, we aimed to investigate the prevalence rate of hyperglycemia and its effects on mortality among pediatrics in the PICU of the hospital.Materials and Methods:This cross-sectional study was performed in 2018–2019 on 88 patients admitted in PICU. Data regarding blood sugar (BS) and other clinical and laboratory parameters were collected. Hyperglycemia was accounted for as BS of >126 mg/dl. Hyperglycemia was divided into: mild (126 <BS <150), moderate (150 <BS <200) and severe (BS >200). The pediatric risk of mortality (PRISM) score was also calculated for each patient during the first 24 h.Results:Thirty patients (34.1%) had persistent hyperglycemia and 58 patients (65.9%) had normal glycemic indexes. Eleven patients (12.5%) had mild, 9 patients (10.2%) had moderate, and 10 patients (11.4%) had severe hyperglycemia. The prevalence of mortality was 5.7% among hyperglycemic patients and 6.8% among normal glycemic pediatrics. There were no statistically significant differences regarding mortality rate (P = 0.499). The mean PRISM score for normal glycemic patients was 7.03 ± 5.18 and for patients with hyperglycemia was 7.36 ± 6.37.Conclusion:Hyperglycemia has no significant effects on mortality and PRISM score of pediatrics in PICU, despite of the previous studies. The frequency of hyperglycemia was also 5.7% among the patients admitted in PICU.

Accuracy of pediatric risk of mortality (PRISM) III score in predicting mortality outcomes in a pediatric intensive care unit in Srinagar

Accuracy of pediatric risk of mortality (PRISM) III score in predicting mortality outcomes in a pediatric intensive care unit in Srinagar

Prevalence and outcomes of sepsis in children admitted to public and private hospitals in Latin America: a multicenter observational study.

ObjectiveTo report the prevalence and outcomes of sepsis in children admitted to public and private hospitals.MethodsPost hoc analysis of the Latin American Pediatric Sepsis Study (LAPSES) data, a cohort study that analyzed the prevalence and outcomes of sepsis in critically ill children with sepsis on admission at 21 pediatric intensive care units in five Latin American countries.ResultsOf the 464 sepsis patients, 369 (79.5%) were admitted to public hospitals and 95 (20.5%) to private hospitals. Compared to those admitted to private hospitals, sepsis patients admitted to public hospitals did not differ in age, sex, immunization status, hospital length of stay or type of admission but had higher rates of septic shock, higher Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality 2 (PIM 2), and Pediatric Logistic Organ Dysfunction (PELOD) scores, and higher rates of underlying diseases and maternal illiteracy. The proportion of patients admitted from pediatric wards and sepsis-related mortality were higher in public hospitals. Multivariate analysis did not show any correlation between mortality and the type of hospital, but mortality was associated with greater severity on pediatric intensive care unit admission in patients from public hospitals.ConclusionIn this sample of critically ill children from five countries in Latin America, the prevalence of septic shock within the first 24 hours at admission and sepsis-related mortality were higher in public hospitals than in private hospitals. Higher sepsis-related mortality in children admitted to public pediatric intensive care units was associated with greater severity on pediatric intensive care unit admission but not with the type of hospital. New studies will be necessary to elucidate the causes of the higher prevalence and mortality of pediatric sepsis in public hospitals.

Serum Ferritin Predicts Neither Organ Dysfunction Nor Mortality in Pediatric Sepsis Due to Tropical Infections.

Objective: To evaluate serial ferritin levels measured in the initial 72 h of admission as a biomarker for new and progressive multi organ dysfunction syndrome (NPMODS) and mortality (unfavorable outcomes) in critically ill children with sepsis due to tropical infections.Material and Methods: In this prospective observational study from a tertiary care teaching hospital in India, children 3 month to 12 years with a diagnosis of acute febrile illness and any two features suggesting tropical infections [cytopenia (platelet count <1,00,000/cu.mm, total leucocyte count <4,000/cu.mm), hepatomegaly and/or splenomegaly, lymphadenopathy, systemic signs (rash, edema), respiratory distress, and encephalopathy not accounted by localized infection] were eligible for inclusion. Children with known or suspected disorder of iron metabolism were excluded. Primary outcome was to determine the association of serial ferritin levels with mortality and NPMODS. Secondary outcomes included estimation of the prevalence of hyperferritinemia and comparison of risk prediction scores with serial ferritin measurement in predicting unfavorable outcomes.Measurements and Main Results: In the 202 children enrolled, diagnosis could be established in 133 (65.8%) children. Scrub typhus and dengue were the most common infections. Median (IQR) ferritin measured at admission (n = 183) and on day 3 (n = 120) of hospital stay were 798 (378, 3,205) μg/L and 429 (213,680) μg/L, respectively. Majority (n = 180, 89.1%) had MODS at admission defined as per International pediatric sepsis consensus conference. NPMODS occurred in 47 (23.3%) children of whom 37 (18.3%) died. Children with three or less organ dysfunctions had lower mortality. Neither admission ferritin values nor the percentage change over 72 h was different between children with favorable and unfavorable outcomes. Pediatric Risk of Mortality (PRISM-III) and daily Pediatric Logistic Organ Dysfunction score (dPELOD2 score) were significantly different in those with unfavorable outcomes. Admission ferritin levels and percentage change in 72 h had poor discriminatory power for mortality with AUC of 0.53 (0.53, 0.67) and 0.50 (0.50, 0.64), respectively. dPELOD2 had the best discriminatory power for mortality with AUC of 0.89 (0.89, 0.95).Conclusions: Serial ferritin estimation predicted neither organ dysfunction nor mortality in pediatric sepsis with tropical infections. dPELOD-2 and PRISM-III predicted unfavorable outcomes better than ferritin. The current diagnostic criteria for MODS overestimated organ dysfunctions in tropical infections and hence may need modification with further validation in this epidemiological cohort.

Predictive Factors of Influenza Outcome in Pediatric Patients by Pediatric Risk of Mortality (PRISM) III

Background Influenza viral infections lead to a wide range of respiratory diseases which have an annual pattern and are responsible for significant morbidity and mortality among children. It was found that influenza among children has significant rates of mortality and morbidity. We aimed to evaluate the diagnostic value of Pediatric Risk of Mortality (PRISM) III scoring system in children with influenza for clinical outcomes of patients. Materials and Methods In this cross-sectional study, 50 children referred to the Children's Hospital of Tabriz (Iran) with flu symptoms who were admitted to the ward or pediatric intensive care unit (PICU) were evaluated through the PRISM III model. Results In this study, 50 children (48% female and 52% male) with a mean age range of 70.28 ±22.46 months with the flu were studied. The mean PICU of patients’ hospitalization was 34.2 ±36.5 days and the mortality rate was 16%. There was no statistically significant relationship between patient mortality and the variables of age, gender, length of hospitalization in PICU and the length of general hospitalization (p <0.05). However, only a statistically significant inverse relationship was observed between blood urea nitrogen (BUN) level and patient mortality among other variables evaluated in the PRISM III model (p = 0.016). In addition, there was a statistically significant relationship between PRISM III model score and mortality in the studied patients (p = 0.002). Conclusion In the present study, considering the cut-off point 14, the sensitivity and specificity of the PRISM III model in estimating the mortality of children with influenza are equal to 87.5% and 85.7%, respectively; so the PRISM III model had excellent diagnostic and estimation power.

Electrocardiometry for Hemodynamic Categorization and Assessment of Fluid Responsiveness in Pediatric Septic Shock: A Pilot Observational Study.

AimTo evaluate the utility of noninvasive electrocardiometry (ICON®) for hemodynamic categorization and assessment of fluid responsiveness in pediatric septic shock.Materials and methodsPilot prospective observational study in a 12-bedded tertiary pediatric intensive care unit (PICU) in children aged between 2 months and 16 years with unresolved septic shock after a 20 mL/kg fluid bolus. Those with cardiac index (CI) <3.3 L/min/m2 and systemic vascular resistance index (SVRI) >1600 dyn sec/cm5/m2 were classified as vasoconstrictive shock–electrocardiometry (VCEC) and those with CI >5.5 L/min/m2 and SVRI <1000 dyn sec/cm5/m2 as vasodilated shock–electrocardiometry (VDEC). Fluid responsiveness was defined as a 10% increase in CI with a 20 mL/kg fluid bolus. Sepsis-induced myocardial dysfunction (SMD) was diagnosed on echocardiography. Outcomes studied included clinical shock resolution, length of PICU stay, and mortality.ResultsThirty children were enrolled over 6 months with a median (interquartile range) age and pediatric risk of mortality (PRISM) III score of 87(21,108) months and 6.75(1.5,8.25), respectively; 14(46.6%) were boys and 4(13.3%) died. Clinically, 19(63.3%) children had cold shock and 11(36.7%) had warm shock; however, 16(53.3%) children had VDEC (including five with clinical cold shock) and 14(46.7%) had VCEC using electrocardiometry. Fluid responsiveness was seen in 16(53.3%) children, 10 in the VCEC group and 6 in the VDEC group. In the VCEC group, the responders had a significant rise in CI and a fall in SVRI, while the responders in the VDEC group had a significant rise in CI and SVRI. Fluid responders, compared to nonresponders, had a significantly higher stroke volume variation (SVV) before fluid bolus (24.1 ± 5.2% vs. 18.2 ± 3.5%, p < 0.001) and a higher reduction in SVV after fluid bolus (10.0 ± 2.8% vs. 6.0 ± 4.5%, p = 0.006), higher lactate clearance (p = 0.03) and lower vasoactive-inotropic score (p = 0.04) at 6 hours, higher percentage of clinical shock resolution at 6 (p = 0.01) and 12 hours (p = 0.01), and lesser mortality (p = 0.002). Five (16.6%) children with VCEC had SMD and were less fluid responsive (p = 0.04) with higher mortality (p = 0.01) compared to those without SMD.Conclusions and clinical significanceContinuous, noninvasive hemodynamic monitoring using electrocardiometry permits hemodynamic categorization and assessment of fluid responsiveness in pediatric septic shock. This may provide real-time guidance for optimal interventions, and thus, improve the outcomes.How to cite this articleRao SS, Reddy M, Lalitha AV, Ghosh S. Electrocardiometry for Hemodynamic Categorization and Assessment of Fluid Responsiveness in Pediatric Septic Shock: A Pilot Observational Study. Indian J Crit Care Med 2021;25(2):185–192.

Value of Thrombomodulin as a Marker for Sepsis in Critically Ill Children.

Pediatric sepsis is altered organ function in critically ill children and a main etiology of mortality for children. Therefore, the authors aimed to assess the role of serum thrombomodulin as valuable biomarker in the diagnosis and prognosis of sepsis in acutely ill pediatrics in the intensive unit. This prospective clinical study conducted on 140 acutely ill patients admitted to the Pediatric Intensive Care Unit (PICU) of Menoufia University Hospital and 50 apparently healthy controls from October 2018 through September 2019. All included children were subjected to clinical examination and the Pediatric Risk of Mortality (PRISM) and Pediatric Index of Mortality II (PIM II) scores were calculated. Serum thrombomodulin was measured for both patients and the control group upon admission. The children were followed for a period of 30 d. Serum thrombomodulin level was increased among all the patients and those with systemic inflammatory response syndrome (SIRS), sepsis and severe sepsis compared with controls (p < 0.001). Furthermore, serum thrombomodulin was higher in patients who died than who survived (p =0.005). Thrombomodulin had area under Receiver Operating Characteristic Curve (AUC) =0.915 for predicting sepsis, whereas C-reactive protein had AUC = 0.789. According to the prognosis, thrombomodulin had AUC = 0.711 for predicting mortality whereas PRISM and PIM scores had AUC = (0.918, 0.960) respectively. Serum thrombomodulin is a promising marker for pediatric sepsis. The data showed that serum thrombomodulin had a valuable role in diagnosis of sepsis early in critically ill pediatrics.

Mean core to peripheral temperature difference and mean lactate levels in first 6 hours of hospitalisation as two indicators of prognosis: an observational cohort study

BackgroundTo study mean core to peripheral temperature difference (CPTD) and the mean lactate levels over the first 6 h of admission to hospital, as indicators of prognosis in critically ill children.MethodsA prospective observational study in a tertiary level Pediatrics ICU in Delhi, India. Seventy eight paediatric patients from 1 month to 12 years were studied. Children with physical trauma, post-surgical patients and patients with peripheral vascular disease were excluded. Core temperature (skin over temporal artery) to peripheral temperature (big toe) difference was measured repeatedly every minute over 6 h and mean of temperature difference was calculated. Pediatric Risk of Mortality (PRISM) II, lactate clearance and mean lactate levels during that time were also studied. In-hospital mortality was used as the outcome measure.ResultsMean temperature differenceDuring the first 6 h after admission the mean temperature difference was 9.37 ± 2 °C in those who died and 3.71 ± 2.27 °C in those who survived (p < 0.0001). The area under the receiver operating curve (AUROC) was 0.953 (p < 0.0001). The comparable AUROC of PRISM II was 0.999 (p < 0.0001).Mean LactateMean lactate level in the first 6 h was 7.1 ± 2.02 mg/dl in those who died compared to 2.86 ± 0.87 mg/dl in those who survived (p < 0.0001). The AUROC curve for mean lactate was 0.989 (95% CI = 0.933 to 0.999; p < 0.0001). AUROC for the lactate clearance was 0.682 (p = 0.0214).ConclusionsThe mean core to peripheral temperature difference over the first 6 h is an easy-to-use and non-invasive method that is useful to predict mortality in children admitted to the Pediatric ICU. The mean lactate during the first 6 h of Pediatric ICU admission is a better index of prognosis than the lactate clearance over the same time period. They may be used as components of a scoring system to predict mortality.

Use of a Mortality Prediction Model in Children on Mechanical Ventilation: A 5-Year Experience in a Tertiary University Hospital.

PurposeCurrently, several scoring systems for predicting mortality in severely ill children who require treatment in a pediatric intensive care unit (PICU) have been established. However, despite providing high-quality care, children might develop complications that can cause rapid deterioration in health status and can lead to death. Hence, this study aimed to establish a simple early predictive mortality (SEPM) model with high specificity in identifying severely ill children who would possibly benefit from extensive mechanical ventilation during PICU admission.Patients and MethodsThis is a retrospective longitudinal study that included pediatric patients aged older than two weeks who were on mechanical ventilation and were admitted to the PICU of King Fahd Hospital of the University from January 2015 to December 2019.ResultsIn total, 400 pediatric patients were included in this study. The mortality rate of children on mechanical ventilation was 28.90%, and most deaths were associated with respiratory (n = 124 [31%]), cardiovascular (n = 76 [19%]), and neurological (n = 68 [17%]) causes. The SEPM model was reported to be effective in predicting mortality, with an accuracy, specificity, and sensitivity of 92.5%, 97.31%, and 66.15%, respectively. Moreover, the accuracy, specificity, and sensitivity of the Pediatric Risk of Mortality (PRISM) III score in predicting mortality was 95.25%, 98.51%, and 78.46%, respectively.ConclusionThe SEPM model had a high specificity for mortality prediction. In this model, only six clinical predictors were used, which might be easily obtained in the early period of PICU admission. The ability of the SEPM model and the PRISM III score in predicting mortality in severely ill children was comparable. However, the accuracy of the newly established model in other settings should be validated, and a prospective longitudinal study that considers the effect of the treatment on the model’s predictive ability must be conducted.

Intensive Care Unit-Acquired Weakness in Children: A Prospective Observational Study Using Simplified Serial Electrophysiological Testing (PEDCIMP Study).

BackgroundTo study the incidence and time of onset of intensive care unit—acquired weakness in a prospective cohort of children (2–12 years) by serial simplified electrophysiological assessment (Pediatric Critical Illness Myopathy Polyneuropathy study, PEDCIMP).MethodsA single-center, prospective cohort study (Trial Registry Number: NCT02763709; PEDCIMP2016) was conducted at the pediatric intensive care unit of a tertiary care hospital in North India. A complete electrophysiological evaluation (4 motor nerves and 2 sensory nerves) was performed at baseline in children (2–12 years) admitted to the ICU with a pediatric risk of mortality (PRISM) of > 20 with more than 24-h stay. Following the entry evaluation, a minimal alternate day simplified electrophysiological testing of the unilateral common peroneal nerve and the sural nerve was assessed. A 25% reduction in compound muscle action potential (CMAP) and sensory nerve action potential from baseline was considered significant for ICUAW and was confirmed by complete electrophysiological re-evaluation.ResultsOf the total 481 children assessed for eligibility, 97 were enrolled. The median age of the cohort was 7 years. Sepsis (81%); need for vasoactive support (43%); multiorgan dysfunction (26%) were the common reasons for admission. Of the 433 eligible patient ICU days, 380 electrophysiological observations were done. A significant decrease of > 25% in CMAP of common peroneal nerve was not detected in any of the 380 observations. However, two children unfit for inclusion were diagnosed with ICUAW during the study period.ConclusionsChildren admitted with PRISM > 20 have a very low incidence of intensive care unit—acquired weakness by serial clinical and abbreviated electrophysiological evaluation.Electronic supplementary materialThe online version of this article (10.1007/s12028-020-01123-x) contains supplementary material, which is available to authorized users.

Association Between Vitamin D Deficiency and Duration of Hospital Stay, Pediatric Intensive Care Unit Stay, and Ventilation; Pediatric Risk of Mortality Score; and Rate of Readmission: A Prospective Observational Study.

IntroductionThe study aims to evaluate the association between a deficiency of Vitamin D level with the duration of hospital stay, pediatric intensive care unit (PICU) stay, and ventilation; the pediatric risk of mortality (PRISM) score, and the rate of readmission.Materials and methodsThis prospective observational study was conducted from November 2014 to October 2015, and the study population consisted of children admitted to the pediatric intensive care unit (PICU) in a tertiary care hospital of Puducherry. After measuring vitamin D levels, children were allotted into three categories depending on their serum 25(OH)D levels as the sufficient group (25[OH]D level ≥ 30 ng/mL), insufficient group (25[OH]D level = 20 - 29.9 ng/mL), and deficient group (25[OH]D level < 20 ng/mL). Among these three groups, the duration of hospital stay, PICU stay, and ventilation; the PRISM score, and the rate of readmission were compared.ResultsA total of 522 patients were included in the study. Based on their 25(OH)D level, 222 patients (42.5%) were in the sufficient category, 153 patients (29.3%) were in the deficient category, and 147 patients (28.2%) were in the insufficient category. Vitamin D deficiency state is not statistically significantly associated with the duration of hospital stay (P = .84), duration of PICU stay (P = .69), duration of ventilation (P = .48), PRISM score (P = .63), and rate of readmission (P = .91).ConclusionsLonger hospital stay, prolonged PICU stay, longer duration of ventilation, and higher PRISM III score were independent risk factors for higher mortality in the PICU. However, lower vitamin D levels are not statistically significant to predict mortality among the study population.