Pediatric Risk Of Mortality Research Articles

Diagnostic Accuracy of a Host Gene Expression Signature That Discriminates Clinical Severe Sepsis Syndrome and Infection-Negative Systemic Inflammation Among Critically Ill Children.

SeptiCyte Lab (Immunexpress, Seattle, WA), a molecular signature measuring the relative expression levels of four host messenger RNAs, was developed to discriminate critically ill adults with infection-positive versus infection-negative systemic inflammation. The objective was to assess the performance of Septicyte Lab in critically ill pediatric patients. Prospective observational study. Pediatric and Cardiac ICUs, Seattle Children's Hospital, Seattle, WA. A cohort of 40 children with clinically overt severe sepsis syndrome and 30 children immediately postcardiopulmonary bypass surgery was recruited. The clinically overt severe sepsis syndrome children had confirmed or highly suspected infection (microbial culture orders, antimicrobial prescription), two or more systemic inflammatory response syndrome criteria (including temperature and leukocyte criteria), and at least cardiovascular ± pulmonary organ dysfunction. None (observational study only). Next-generation RNA sequencing was conducted on PAXgene blood RNA samples, successfully for 35 of 40 (87.5%) of the clinically overt severe sepsis syndrome patients and 29 of 30 (96.7%) of the postcardiopulmonary bypass patients. Forty patient samples (~ 60% of cohort) were reanalyzed by reverse transcription-quantitative polymerase chain reaction, to check for concordance with next-generation sequencing results. Postcardiopulmonary bypass versus clinically overt severe sepsis syndrome descriptors included the following: age, 7.3 ± 5.5 versus 9.0 ± 6.6 years; gender, 41% versus 49% male; Pediatric Risk of Mortality, version III, 7.0 ± 4.6 versus 8.7 ± 6.4; Pediatric Logistic Organ Dysfunction, version II, 5.1 ± 2.2 versus 4.8 ± 2.8. SeptiCyte Lab strongly differentiated postcardiopulmonary bypass and clinically overt severe sepsis syndrome patients by receiver operating characteristic curve analysis, with an area-under-curve value of 0.99 (95% CI, 0.96-1.00). Equivalent performance was found using reverse transcription-quantitative polymerase chain reaction. There was no significant correlation between the score produced by the SeptiCyte Lab test and measures of illness severity, immune compromise, or microbial culture status. SeptiCyte Lab is able to discriminate clearly between clinically well-defined and homogeneous postcardiopulmonary bypass and clinically overt severe sepsis syndrome groups in children. A broader investigation among children with more heterogeneous inflammation-associated diagnoses and care settings is warranted.

Prediction of mortality by pediatric risk of mortality (PRISM III) score in teriary care rural hospital in India

Background: The mortality in pediatric and neonatal critical care units can be predicted using scores. Prediction of mortality using (PRISM III) score in first 24 hours of admission in pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU).Methods: Pediatric cases below 14 years with necessary investigations admitted in PICU and neonates in NICU during the period 1st August 2009 to 31 July 2011. Post-operative and patients with malformations or malignancy were excluded. A prospective observational study carried out at tertiary care rural hospital having 10 bedded well equipped PICU and NICU each. In subjects fulfilling inclusion criteria, PRISM III score which includes 17 variables was calculated within 24 hours of admission. The outcome at discharge was determined as non-survival or survival.Results: With increasing PRISM III score there was increase in mortality. PRISM III score offered a good discriminative power with the areas under the ROC curve > 0.86 (95% CI). Among different variables minimum systolic blood pressure, pupillary reflex, mental status (GCS), acidic pH, total co2, BUN, platelet count and PTT showed very high significant association with the mortality and Pco2, PaO2, temperature, potassium and creatinine showed significant association with mortality. Variables like Heart rate, Glucose, Alkaline pH and WBC count showed no significant association with the mortality.Conclusions: PRISM III score can be effectively used as a reflector of severity of illness.

Morbidity and mortality prediction in pediatric heart surgery: Physiological profiles and surgical complexity

ObjectivesOutcome prediction for pediatric heart surgery has focused on mortality but mortality has been significantly reduced over the past 2 decades. Clinical care practices now emphasize reducing morbidity. Physiology-based profiles assessed by the Pediatric Risk of Mortality (PRISM) score are associated with new significant functional morbidity detected at hospital discharge. Our aims were to assess the relationship between new functional morbidity and surgical risk categories (Risk Adjustment for Congenital Heart Surgery [RACHS] and Society for Thoracic Surgery Congenital Heart Surgery Database Mortality Risk [STAT]), measure the performance of 3-level (intact survival, survival with new functional morbidity, or death) and 2-level (survival or death) PRISM prediction algorithms, and assess whether including RACHS or STAT complexity categories improves the PRISM predictive performance. MethodsPatients (newborn to age 18 years) were randomly selected from 7 sites (December 2011-April 2013). Morbidity (using the Functional Status Scale) and mortality were assessed at hospital discharge. The most recently published PRISM algorithms were tested for goodness of fit, and discrimination with and without the RACHS and STAT complexity categories. ResultsThe mortality rate in the 1550 patients was 3.2%. Significant new functional morbidity rate occurred in 4.8%, increasing from 1.8% to 13.9%, 1.7%, and 12.9% from the lowest to the highest RACHS and STAT categories, respectively. The 3-level and 2-level PRISM models had satisfactory goodness of fit and substantial discriminative ability. Inclusion of RACHS and STAT complexity categories did not improve model performance. ConclusionsBoth mortality and new, functional morbidity are important outcomes associated with surgical complexity and can be predicted using PRISM algorithms. Adding surgical complexity to the physiologic profiles does not improve predictor performance.

Effects of paraoxonase, arylesterase, ceruloplasmin, catalase, and myeloperoxidase activities on prognosis in pediatric patients with sepsis

BackgroundThe present study aimed to investigate the levels of paraoxonase (PON), stimulated paraoxonase (SPON), arylesterase (ARE), ceruloplasmin (CLP), myeloperoxidase (MPO), and catalase (CAT) in pediatric sepsis and to explore their effects on the prognosis of sepsis. MethodsPatients diagnosed with sepsis (n=33) and healthy controls (n=30) were included. PON, SPON, ARE, CLP, MPO, and CAT activities were measured in the sepsis and control groups. Additionally, the parameters were compared between survivors and non-survivors in the sepsis group. The levels of hemoglobin, white blood cell, platelet, lactate, and C-reactive protein were measured in the blood samples drawn from the patients with sepsis at diagnosis, at the 48th hour, and on day 7. The pediatric risk of mortality and pediatric logistic organ dysfunction scores of the patients were used for the estimation of severity of disease. ResultsLower ARE (153.24 vs. 264.32U/L; p<0.001), lower CLP (80.58 vs. 97.98U/L; p=0.032), lower MPO (91.24 vs. 116.55U/L; p=0.023), and higher CAT levels (256.5 vs.145.5kU/L; p=0.003) were determined in the sepsis group as compared to the control group. There was no difference between the groups in terms of PON or SPON levels. No difference was determined between the survivors and non-survivors in terms of any of the parameters. ConclusionsThe present study determined that ARE, CLP, CAT, and MPO levels are different between the pediatric patients with sepsis and healthy controls. ARE level can be a potent biomarker for sepsis in critical patients in intensive care units. Further studies with larger samples are required to demonstrate the value of these parameters as prognostic biomarkers in pediatric sepsis.

Impact of acute kidney injury on long-term mortality and progression to chronic kidney disease among critically ill children.

Objectives:To determine the 2-year outcome of acute kidney injury (AKI) following admission to pediatric critical care units (PICU).Methods:A retrospective cohort study was conducted between January 2012 and December 2013. We followed 131 children admitted to PICU, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia with a diagnosis of AKI, based on pRIFLE (pediatric risk, injury, failure, loss, and end-stage renal disease), for 2 years. During the study period, 46 children died and 38 of survivors completed the follow-up. Factors affecting long-term progression to chronic kidney disease were also evaluated.Results:The 2-year mortality was more than 40%. The main determinant of the 2-year mortality was the pediatric risk of mortality (PRISM) score, which increased the risk of mortality by 6% per each one score (adjusted odds ratio, 1.06: 95% confidence interval: 1.00-1.11). By the end of the 2 years, 33% of survivors had reduction in the glomerular filtration rate and proteinuria, and 73% were hypertensive. Patients with more severe renal impairment at admission, based on the pRIFLE criteria, had higher mortality rate. This association, however, was not independent since it was influenced by baseline disease severity (PRISM score).Conclusion:Large proportion of patients admitted to PICU with AKI either died during the first 2 months of follow-up or developed long-term complications. The severity of AKI, however, was not an independent risk factor for mortality.

Etiologies, outcomes, and prognostic factors of pediatric acute liver failure: A single center’s experience in Turkey

Our aim was to determine the etiologies, outcomes, and prognostic indicators in children with acute liver failure. Ninety-one patients who were followed for pediatric acute liver failure (PALF) over a 15-year period were included. Patients who survived with supportive therapy were designated as Group 1, while those who died or underwent liver transplantation were designated as Group 2. There were 37 (40.6%) patients in Group 1 (spontaneous recovery) and 54 (59.4%) patients in Group 2. Thirty-two patients (35.2%) underwent liver transplantation. Infectious and indeterminate causes were the most common etiologies (33% each). Among the infectious causes, hepatitis A (76%) was the most frequent. Hepatic encephalopathy grade 3-4 on admission and during follow-up and high Pediatric Risk of Mortality (PRISM) and Pediatric End-Stage Liver Disease (PELD) scores within the first 24 h were related with a poor prognosis. Group 2 had a more prolonged prothrombin time, higher international normalized ratio, more prolonged activated partial thromboplastin time (aPTT), and higher levels of total and direct bilirubin, ammonia, and lactate (for all, p<0.01). Infectious and indeterminate cases constituted the most common etiology of PALF, and the etiology was related to the prognosis in our series. Although high PELD and PRISM scores were related to poor prognoses, no sharp thresholds for individual laboratory tests could be elucidated. Liver transplantation was the only curative treatment for patients with poor prognoses and resulted in high survival rates (1-, 5-, and 10-year survival rates of 81.3%, 81.3%, and 75%, respectively) in our study.

Comparison of Severity Scoring Systems in a Pediatric Intensive Care Unit in India: A Single-Center Prospective, Observational Cohort Study.

Objective The aim of this study is to validate Pediatric Risk of Mortality (PRISM) and Pediatric Index of Mortality (PIM) scoring systems in a pediatric intensive care unit (PICU) in India. Design This is a single-center prospective cohort study. Setting This study was conducted at an eight-bed PICU. Methods PRISM- and PIM-based predicted mortality rates were calculated and compared in 120 pediatric patients. Results Estimated mortality using PRISM (5.68%) and PIM (8.84%) was lower than observed (21.7%) mortality. PIM had slightly better power of calibration than PRISM. The discriminatory performance of both models was comparable. Conclusion Both models can be validated with suitable changes according to PICU settings of India.

Pediatric index of mortality 2 scores in pediatric intensive care unit patients

Background Comprehensive care for critically ill children in the pediatric intensive care unit (PICU) is done with the aim of achieving good outcomes. Severe disease in children is characterized by disruption of homeostatic processes, and can be evaluated by mortality scoring methods. There are several mortality scoring methods which can be used to predict mortality in children, the pediatric risk of mortality (PRISM) and pediatric index of mortality (PIM) are the most preferably used among all. The pediatric index of mortality 2(PIM2) is a key mortality prediction model for children receiving treatment in intensive care units, but its use has not been well validated in Indonesia.Objective To evaluate the performance of PIM2 model in PICU patients.Methods This cross-sectional study was conducted on PICU patients at Sanglah Hospital from November 2012 to April 2013. Patients underwent PIM2 scoring during their admission. The predictive ability of PIM2 scoring for patient mortality was analyzed using ROC curve.Results A total of 54 patients were included in this study, of whom 8 (14.8%) died. Discrimination between survival and death was assessed by the area under the receiver operating characteristic curve and found to be 0.81 (95% CI 0.59 to 1.03). Sensitivity was 75 (95%CI 36 to 96)% and specificity was 98 (95%CI 87 to 99)%. The PIM2 cut off value was ≥ -0.99.Conclusion The PIM 2 model has a good discriminatory power and calibration for predicting the mortality of children admitted to PICU and therefore is recommended for routine use in clinical practice. [

Relationship Between Beta Cell Dysfunction and Severity of Disease Among Critically Ill Children: A STROBE-Compliant Prospective Observational Study.

Although beta cell dysfunction has been proved to predict prognosis among humans and animals, its prediction on severity of disease remains unclear among children. The present study was aimed to examine the relationship between beta cell dysfunction and severity of disease among critically ill children.This prospective study included 1146 critically ill children, who were admitted to Pediatric Intensive Care Unit (PICU) of Hunan Children's Hospital from November 2011 to August 2013. Information on characteristics, laboratory tests, and prognostic outcomes was collected. Homeostasis model assessment (HOMA)-β, evaluating beta cell function, was used to divide all participants into 4 groups: HOMA-β = 100% (group I, n = 339), 80% ≤ HOMA-β < 100% (group II, n = 71), 40% ≤ HOMA-β < 80% (group III, n = 293), and HOMA-β < 40% (group IV, n = 443). Severity of disease was assessed using the worst Sequential Organ Failure Assessment (SOFA) score, Pediatric Risk of Mortality (PRISM) III score, incidence of organ damage, septic shock, multiple organ dysfunction syndrome (MODS), mechanical ventilation (MV) and mortality. Logistic regression analysis was used to evaluate the risk of developing poor outcomes among patients in different HOMA-β groups, with group I as the reference group.Among 1146 children, incidence of HOMA-β < 100% was 70.41%. C-peptide and insulin declined with the decrement of HOMA-β (P < 0.01). C-reactive protein and procalcitonin levels, rather than white blood cell, were significantly different among 4 groups (P < 0.01). In addition, the worst SOFA score and the worst PRISMIII score increased with declined HOMA-β. For example, the worst SOFA score in group I, II, III, and IV was 1.55 ± 1.85, 1.71 ± 1.93, 1.92 ± 1.63, and 2.18 ± 1.77, respectively. Furthermore, patients with declined HOMA-β had higher risk of developing septic shock, MODS, MV, and mortality, even after adjusting age, gender, myocardial injury, and lung injury. For instance, compared with group I, the multivariate-adjusted odds ratio (95% confidence interval) for developing septic shock was 2.17 (0.59, 8.02), 2.94 (2.18, 6.46), and 2.76 (1.18, 6.46) among patients in group II, III, and IV, respectively.Beta cell dysfunction reflected the severity of disease among critically ill children. Therefore, assessment of beta cell function is critically important to reduce incidence of adverse events in PICU.

Factors present on admission associated with increased mortality in children admitted to a paediatric intensive care unit (PICU)

Background. The admission of children to an intensive care unit (ICU) necessitates the selection of children who will benefit most from scarce ICU resources. Decisions should be based on objective data available on outcomes related to particular conditions and resource availability. Objective. To determine which sociodemographic factors and paediatric scoring systems can be used on admission to identify patients who would derive the most benefit. Methods. A retrospective review was undertaken of the charts of children admitted to a paediatric ICU (PICU) over a 6-month period. Charts were analysed according to health status, biographical and demographic data, as well as Pediatric Risk of Mortality (PRISM), Pediatric Logistic Organ Dysfunction (PELOD) and Paediatric Index of Mortality 3 (PIM3) scores to determine which factors were associated with an increased mortality risk. Results. Two hundred and two children were admitted during the study period. Ninety-six children were included in the study, 79 files were not found and 27 children were ineligible. The median age was 14 months and the mortality rate was 15.6%. The significant factor associated with mortality was severe malnutrition. In total 88% of required data were available for the calculation of both the PRISM and PELOD scores and 95% for PIM3 score. The PRISM, PELOD and PIM3 standardised mortality ratios were 2.5, 4.8 and 2.9, respectively. P -values for PRISM, PELOD and PIM3 were <0.05. Conclusion. Severe malnutrition is a statistically significant factor in predicting mortality. This possibly reflects the social context in which the children live. PRISM, PELOD and PIM3 underpredict mortality in our setting. A larger sample is required to verify these outcomes and to determine whether other factors play a role.

Soluble Urokinase Plasminogen Activator Receptor: A New Biomarker in the Pediatric Intensive Care Unit.

To evaluate the value of soluble urokinase plasminogen activator receptor (suPAR) in diagnosing sepsis and predicting mortality in critically ill children. In a prospective cohort study, 69 critically ill children admitted into the pediatric intensive care unit (PICU) were randomly enrolled in addition to 15 healthy children as a control group. Clinical examination was performed, including calculation of the Pediatric Risk of Mortality (PRISM) and Pediatric Index of Mortality2 (PIM2). suPAR was measured in patients at admission as well as in the controls. Patients were followed up for 30d. suPAR level was significantly higher among the total patient cohort compared to controls (p < 0.0001). suPAR was also significantly higher among patients with sepsis compared to both controls (p < 0.0001) and patients without sepsis (p < 0.0001). Furthermore, suPAR level was significantly elevated in non-survivors compared to survivors (p 0.008). Receiver operating characteristic curve (ROC curve) analysis revealed an area under the curve (AUC) of 0.80 for suPAR for diagnosis of sepsis while C-reactive protein (CRP) had an AUC of 0.82. Regarding the prognosis, suPAR had an AUC of 0.69 for prediction of mortality, whereas the AUC for PRISM, PIM2, and CRP were 0.82, 0.81, and 0.77 respectively. suPAR has both a diagnostic and a prognostic value for critically ill children. However, it does not seem to be superior to the classic laboratory markers and clinical scoring systems.

Red cell transfusions as an independent risk for mortality in critically ill children.

BackgroundSeverity of illness is an important consideration in making the decision to transfuse as it is the sicker patient that often needs a red cell transfusion. Red blood cell (RBC) transfusions could potentially have direct effects and interact with presenting illness by contributing to pathologies such as multi-organ dysfunction and acute lung injury thus exerting a considerable impact on overall morbidity and mortality. In this study, we examine if transfusion is an independent predictor of mortality, or if outcomes are merely a result of the initial severity as predicted by Pediatric Risk of Mortality (PRISM) III, Pediatric Index of Mortality (PIM2), and day 1 Pediatric Logistic Organ Dysfunction (PELOD) scores.MethodsA single center retrospective study was conducted using data from a prospectively maintained transfusion database and center-specific data at our pediatric ICU between January 2009 and December 2012. Multivariate regression was used to control for the effects of clinical findings, therapy, and severity scores, with mortality as the dependent variable. Likelihood ratios and area under the curve were used to test the fidelity of severity scores by comparing transfused vs. non-transfused patients.ResultsThere were 4975 admissions that met entry criteria. In multivariate analysis, PRISM III scores and serum hemoglobin were significant predictors of transfusion (p < 0.05). Transfused and non-transfused subjects were distinctly disparate, so multivariate regression was used to control for differences. Severity scores, age, volume transfused, and vasoactive agents were significantly associated with mortality whereas hemoglobin was not. A substantial number of transfusions (45 %) occurred in the first 24 h, and patients transfused later (24–48 h) were more likely to die compared to this earlier time point. Likelihood ratio testing revealed statistically significant differences in severity scoring systems to predict mortality in transfused vs. non-transfused patients.ConclusionsThis study suggests that RBC transfusion is an important risk factor that is statistically independent of severity. The timing of transfusions that related strongest to mortality remained outside the purview of severity scoring, as these happened beyond the timing of data collection for most scoring systems.

Oxygen therapy via high flow nasal cannula in pediatric intensive care unit.

The aim of the present study was to assess the efficacy and safety of oxygen therapy via high flow nasal cannula in pediatric patients with acute respiratory failure. Patients who were admitted to pediatric intensive care unit and were administered high flow nasal cannula (HFNC) therapy between January 2015 and January 2016 were enrolled. Arterial blood gas parameters, respiratory rates (RR), heart rates (HR), systolic, db > iastolic, and mean arterial pressures (SBP, DBP, MAP), dyspnea scores, fractional oxygen indices (FiO < sub > 2 < /sub > ), and oxygen saturations (SatO < sub > 2 < /sub > ) were recorded at baseline, 30 minutes, and 12 hours. The study enrolled a total of 50 patients of whom 24 (48%) were female and 26 (52%) were male. Statistically significant reductions occurred in mean HR and RR values at 30 minutes and 12 hours compared to those at 0 minute (p < 0.05). Significant increases were observed in SatO2 values at 30 minutes (p.0.001) and 12 hours (p:0.005) compared to SatO2 value at 0 minute (p < 0.05). Similarly, there occurred significant reductions in mean FiO < sub > 2 < /sub > values at 30 minutes and 12 hours compared to baseline (p < 0.05). Significant reductions occurred in mean dyspnea score at 30 minutes (p:0.001) and 12 hours (p:0.001) compared to that at 0 minute (p < 0.05). pH, PaCO < sub > 2 < /sub > , PaO < sub > 2 < /sub > , SBP, and DBP values at 0 minute, 30 minutes, and 12 hours were not significantly different from one another (p > 0.05). No significant correlations were found between treatment failure and age at admission; mean pediatric index of mortality (PIM II), pediatric risk of mortality (PRISM), pediatric logistic organ dysfunction (PELOD) and pediatric multiple organ dysfunction score (P-MODS); and HR, RR, SatO2, pH, PaCO2, PaO2, SBP, DBP, MAP, FiO2 at baseline (p > 0.05). Therapy was successful in 40 (80%) patients whereas there occurred a need for invasive ventilation in 10 (20%) patients. High flow nasal oxygen therapy can be used for patients with acute severe hypoxemic respiratory failure without concurrent hypercapnia when adequate equipment and monitorization tools exist.

Impact of malnutrition on pediatric risk of mortality score and outcome in Pediatric Intensive Care Unit.

Objectives:This study was done to determine the effect of malnutrition on mortality in Pediatric Intensive Care Unit (PICU) and on the pediatric risk of mortality (PRISM) scoring.Subjects and Methods:This was a prospective study done over 1 year. There were total 400 patients (1 month 14 years), who were divided into cases with weight for age <3rd centile and controls with ≥3rd centile of WHO charts. Cases were subdivided into mild/moderate (61–80% of expected weight for age) and severe malnutrition (<60%).Results:Out of total, 38.5% patients were underweight, and malnutrition was more in infancy, 61/104, i.e. 58.5% (P - 0.003). There was no significant difference in vitals at admission. Cases needed prolonged mechanical ventilation (P - 0.0063) and hospital stay (P - 0.0332) compared to controls. Mean and median PRISM scores were comparable in both the groups, but mortality was significantly higher in severely malnourished (P value 0.027).Conclusion:Severe malnutrition is independently associated with higher mortality even with similar PRISM score. There is need to give an additional score to children with weight for age <60% of expected.

Application of the Berlin definition in children with acute respiratory distress syndrome

Purpose: The revised Berlin definition (BD) showed better predictive validity for mortality in adults with acute respiratory distress syndrome (ARDS). We examined the validity of BD for pediatric ARDS as compared to the American-European Consensus Conference definition (AECCD). Methods: This single-center, retrospective study included 127 patients aged 1 month to 19 years who were admitted to the medical intensive care unit due to acute lung injury (ALI, n=31) or ARDS (n=96) using the AECCD. All patient characteristics and mortality rates were compared between the individual severity groups according to the BD and AECCD. Results: Sixty-four patients (50%) died. Mortality rates increased across the severity groups according to both definitions (26% in mild, 42% in moderate, and 75% in severe by the BD [P<0.001]; 26% in ALI non-ARDS and 58% in ARDS by the AECCD [P=0.002]). The mortality risk increased only for ‘severe ARDS’ (hazard radio for mortality, 2.56; 95% confidence intervals [CI], 1.14-5.78; P=0.023) after adjusting for confounding factors. The BD better predicted mortality, with an integrated area under the receiver operating characteristic curve (iAUC) of 0.651 (95% CI, 0.571-0.725), than the AECCD, with an iAUC of 0.584 (95% CI, 0.523-0.637). The pediatric risk of mortality (PRISM) III and pediatric index of mortality 3 scores were significantly different across BD severity groups, whereas only PRISM III scores were different according to the AECCD. Conclusion: The BD applied to children with ARDS. It could be adopted to severity classifications and predict pediatric ARDS mortality better than the AECCD. (Allergy Asthma Respir Dis 2016:4:257-263)

Receptor for advanced glycation endproducts in pediatric sepsis: a pilot study

Background Sepsis in pediatric patients is still a leading cause of morbidity and mortality. Aim The aim of the study was to determine whether the serum level of receptor for advanced glycation endproducts (RAGEs) can be used as a potential diagnostic and prognostic marker in septic children. Patients and methods A pilot study was conducted on pediatric intensive care unit patients who had clinical evidence of sepsis over a 1-year period. Forty patients were enrolled in the study within the first 24 h after onset of sepsis; they were classified according to 28-day mortality into survivors and nonsurvivors. Complete blood count, erythrocyte sedimentation rate, C-reactive protein, and soluble form of RAGE (sRAGE) were measured. Bacterial cultures from suitable body fluids were prepared. Results There was a significantly higher mean serum sRAGE level among septic patients compared with controls (P=0.001); the level was higher in nonsurvivors compared with survivors (P=0.001). A cutoff value of 1325 pg/ml for serum sRAGE showed a sensitivity of 89.2% and a specificity of 78.3%. There were positive correlations with C-reactive protein and Pediatric Risk of Mortality III, and no correlation with bacterial culture. Multivariate logistic regression analysis showed that sRAGE level and leukocytic count were significant markers in the diagnosis of sepsis (P=0.047 and 0.001, respectively). sRAGE level and Pediatric Risk of Mortality III score were significant parameters in sepsis prognosis (P=0.019 and 0.043, respectively). Conclusion Serum sRAGE can be used as a diagnostic and prognostic marker in pediatric sepsis, especially in those with a negative blood culture.

Timing of antibiotics, volume and vasoactive infusions in children with sepsis: it is all in the timing.

We share the view of van Paridon et al. [1] that robust data on fluid bolus therapy for sepsis resuscitation are needed, and looked with interest to the Alberta Sepsis Network’s recent report to add to our understanding. We note that the authors chose to exclude children who were expected to die <24 hours from presentation. We would be grateful to know how many cases were excluded on this basis. The majority of the hazard from sepsis lies in this period. We recently defined this risk in a similar cohort of children; 55 % of all sepsis deaths (78 % of these being previously healthy children) occurred within the first 24 hours [2]. Resuscitation interventions such as fluid and vasoactive drugs are guided by changes in physiology. Inasmuch as physiological variables are associated with mortality, these interventions are also likely to have an immediate effect on mortality. The authors suggest potential explanations for the 1-year mortality effect seen with aggressive fluid administration: while all are not only plausible but likely, the effect will only be seen if the acute phase is overcome. By excluding children dying early, the authors also reduce the potential to propensity match children receiving similar levels of interventions. Pediatric Risk of Mortality (PRISM) scores control for severity of illness, but information is lost given that the PRISM score utilises categories of haemodynamic variables rather than age-standardised continuous variables [3]. We wonder whether the modest effect size difference would persist with these alterations to the methodology.

A correlation study among scoring systems for assessing the severity of illness in critically ill pediatric patients

Objective To analyse the correlation among pediatric risk of mortality score(PRISM), pediatric index of mortality(PIM), pediatric index of mortality 2(PIM2) and pediatric clinical illness score(PCIS). Methods Eight hundred and fifty-two critically ill children were recruited in the study from 1th Jan 2014 to 31th Jun 2013.Information on age, sex, diagnosis, the outcome and the variables required to calculate PRISM, PIM, PIM2 and PCIS were collected. Results Among 852 critically ill cases enrolled in the study, 518 patients were male and 334 were female, the ratio of male to female was 1.55∶1.The median of age was 6.5(IQR: 2-21) months.Seven hundred and forty-five patients survived at the end of the PICU stay, the rest died(107 patients, 12.56%). The majority of patients were suffering from respiratory diseases, miscellaneous diseases, hematological system diseases, nervous system diseases and congenital heart diseases.The estimated probabilities of death reveal a positive and significant correlation between the PRISM and the PIM, PIM2, with Pearson's correlation coefficient being 0.490(P<0.001) and 0.477(P<0.001), respectively.The correlation coefficient between the PIM and PIM2 was 0.938(P<0.001). The correlation coefficient between the PCIS and PRISM, PIM, PIM2 were -0.208(P<0.001), -0.166(P<0.001) and -0.189(P<0.001), respectively. Conclusion A positive correlation was found among PRISM, PIM and PIM2 scores.A negative correlation was found between PCIS and other three scores(PRISM, PIM and PIM2). The study has demonstrated that lower PCIS can indicate the severity of illness, but the scoring system of PCIS couldn't fully evaluate the severity of illness for critically ill pediatric patients. Key words: Pediatric risk of mortality; Pediatric index of mortality; Pediatric clinical illness score; Correlation study

Early Elevated B-Type Natriuretic Peptide Levels are Associated with Cardiac Dysfunction and Poor Clinical Outcome in Pediatric Septic Patients.

To determine the B-type natriuretic peptide (BNP) level in pediatric septic patients, and to investigate its association with cardiovascular dysfunction and clinical outcome. Pediatric patients with sepsis or septic shock were prospectively enrolled in our pediatric intensive care unit (PICU). On day 1 of admission, plasma BNP levels were measured at the time-point of echocardiography. Myocardial dysfunction was defined as left ventricular fractional shortening (FS) < 30%. Inotropic support was quantified by inotropic scores and disease severity was assessed by Pediatric Risk of Mortality (PRISM) III scores. Therafter, associations between BNP levels and clinical parameters were analyzed. There were 94 patients (mean: 5.6 yr, range: 2 mo-17 yr) that were consecutively enrolled in this study. The median BNP level was 127 pg/ml (range: 5 to 4950 pg/ml). BNP levels were correlated with PRISM III (rho = 0.36, p = 0.001) and C-reactive protein level (r = 0.39, p = 0.001). The median BNP levels were not only higher in patients with septic shock (n = 34) than those with sepsis (n = 58) (213 vs. 54 pg/ml, p = 0.0004), but also higher in patients with myocardial dysfunction (n = 18) than those with preserved myocardial function (n = 66) (765 vs. 65 pg/ml, p < 0.001). We also found that BNP levels correlated negatively with FS (r = -0.56, p < 0.001) and positively with inotropic scores (r = 0.34, p = 0.04). Most importantly, the median BNP levels were higher in non-survivors (n = 13) than survivors (n = 81) (367 vs. 106 pg/ml, p = 0.003). BNP levels are elevated in pediatric septic patients early in the disease course, and increased levels are associated with cardiovascular dysfunction and worse clinical outcome. B-type natriuretic peptide; Cardiac function; Pediatric; Sepsis; Septic shock.

A Importância da Referenciação Precoce na Falência Hepática Aguda Pediátrica

Acute liver failure is a rare disorder associated to high morbidity and mortality despite survival improvement through liver transplantation. The importance of a multidisciplinary approach and early referral to a pediatric liver transplantation center were important conclusions of a national meeting in 2008, from which resulted an actuation consensus. To characterize acute liver failure admissions in a Pediatric Intensive Care Unit of the portuguese pediatric livertransplantation center. To compare results before (A) and after (B) 2008. Observational, retrospective study during a 20 year period (1994-2014). age < 18 years old and acute liver failure (INR ≥ 2 without vitamin K response and hepatocellular necrosis). Children with previous liver disease were excluded. Fifty children were included, with median age of 24.5 months. The most common etiology under 2 years old was metabolic (34.6%) and above that age was infectious (29.2%). Forty six percent were submitted to liver transplantation and 78% of them survived. Overall mortality was 34%. Median referral time was 7 days in period A (n = 35) and 2 days in period B (n = 15; p = 0.006). Pediatric risk of mortality's median was 14.7 in period A and 6.5 in B (p = 0.019). Mortality was 37% vs 26% in periods A and B, respectively (p = 0.474). Overall mortality was similar to the observed in other European centers. Liver transplantation is in fact the most effective therapeutic option. After 2008, there was a reduction in referral time and cases severity on admission; however, mortality has not reduced so far.