PELOD-2 Score Research Articles

The epidemiology of critical respiratory diseases in ex-premature infants in Vietnam: A prospective single-center study.

This study aimed to describe the epidemiology and etiologies of critical respiratory diseases of ex-premature infants (EPIs) admitted to the Pediatric Intensive Care unit (PICU). Infants ≤2 years old with acute respiratory illnesses admitted to PICU of Vietnam National Children's Hospital from November 2019 to April 2021 were enrolled and followed up to hospital discharge. We compared respiratory pathogens, outcomes, and PICU resources utilized between EPIs and term infants. Among EPIs, we described clinical characteristics and evaluated the association between associated factors and mortality. Among 1183 patients, aged ≤2 years were admitted for critical respiratory illnesses, 202 (17.1%) were EPIs. Respiratory viruses were detected in 53.5% and 38.2% among EPIs and term infants, respectively. Compared to term infants, a higher proportion of EPIs required mechanical ventilation (MV) (85.6 vs. 66.5%, p < .005) and vasopressor support (37.6 vs. 10.7%%, p < .005). EPIs had a higher median PICU length of stay (11.0 [IQR: 7; 22] vs. 6.0 days [IQR: 3; 11], p = .09), hospital length of stay (21.5 [IQR: 13; 40] vs. 10.0 days [IQR: 5; 18], p < .005) and case fatality rate (31.3% vs. 22.6%) compared to term infants. Among EPIs, PIM-3 score (adjusted odds ratio [aOR]: 1.51; 95% confidence interval [CI]: 1.30-1.75) and PELOD-2 score at admission (aOR: 1.41; 95% CI: 1.08-1.85) were associated with mortality. EPIs with critical respiratory illnesses constituted a significant population in the PICU, required more PICU support, and had worse clinical outcomes compared to term infants.

The Association of PELOD-2 Score and Nutritional Status of Children Treated in the Pediatric Intensive Care Unit at Prof. Dr. I.G.N.G. Ngoerah Hospital Denpasar, 2020-2022

Background: The Pediatric Logistic Organ Dysfunction (PELOD-2) is used to measure the severity of vital organ dysfunction due to disease or other medical conditions in pediatric patients admitted to the Pediatric Intensive Care Unit (PICU). Nutritional status is a crucial factor affecting the body's ability to fight disease and the risk of complications. The aim was to evaluate the association between PELOD-2 scores and nutritional status in children treated in the PICU of Prof. Dr. I.G.N.G. Ngoerah Hospital Denpasar. Methods: This study employed a retrospective cross-sectional design using medical record data of children aged 1 month to 18 years treated in the PICU of Prof. Dr. I.G.N.G. Ngoerah Hospital Denpasar from January 2020 to December 2022. Data were collected from 428 subjects meeting the inclusion and exclusion criteria. Data analysis was performed using Chi-Square tests and logistic regression. Results: The study results indicated that PELOD-2 scores were significantly associated with poor nutritional status (OR: 1.71; 95% CI: 1.107–2.73), ventilator use (OR: 5.4; 95% CI: 3.336–8.913), and gender, with males being at higher risk (OR: 1.66; 95% CI: 1.042–2.654). Older age was found to be a protective factor against high PELOD-2 scores (ExpB: 0.996; 95% CI: 0.993–1.00). Conclusion: PELOD-2 scores are significantly associated with poor nutritional status, age, ventilator use, and gender in children treated in the PICU.

Evaluation of performance of Indonesian Sepsis National Guidelines (PNPK) 2021 in diagnosing pediatric bacterial sepsis

Background Sepsis remains one of the causes of child morbidity and mortality worldwide. The reference standard diagnosis of sepsis is blood culture, but its false negative is relatively high. Therefore, a validated triage tool is needed for rapid diagnosis. In Indonesia, diagnosis and management of pediatric sepsis are based on Indonesian Sepsis National Guidelines 2021. Objective To evaluate the performance of Indonesian Sepsis National Guidelines 2021 in diagnosing pediatric bacterial sepsis in PICU. Methods This cross-sectional study was conducted in the PICU unit of Dr. Sardjito Hospital, Yogyakarta, using subject’s the medical records. All patients with suspected bacterial infection who were admitted to the PICU, had complete evaluation of PELOD-2 score, and the blood culture results were included in this study. Sepsis was assessed with Indonesian Sepsis National Guidelines 2021. Performance analysis of the guidelines was conducted with SPSS version 25, by assessing sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and likelihood ratio. Results Two hundred subjects were enrolled in this study, of whom 52.5% were males. Most subjects aged under one year (40.5%), and the most common infection was respiratory system (49%). A total of 63.5% were referral cases, with the length of stay in the previous hospital more than 48 hours (69.7%). There were 77% of subjects had antibiotics treatment at the previous hospital. As for outcomes, 63.5% survived and 36.5% died. The positivity rate of blood culture in this study was 19%. Performance evaluation of Sepsis Indonesian Sepsis National Guidelines 2021 revealed sensitivity 28.95%, specificity 87.65%, accuracy 76.5%, positive predictive value 35.48%, negative predictive value 84.02%, positive likelihood ratio 2.34 (95%CI 1.28 to 4.32) and negative likelihood ratio 0.81 (95%CI 0.7 to 0.94). Conclusion Indonesian Sepsis National Guidelines 2021 (PNPK Sepsis 2021) has low sensitivity and high specificity in diagnosing bacterial sepsis.

Validating the performance of organ dysfunction scores in children with infection: A cohort study.

We aimed to validate the performance of six available scoring models for predicting hospital mortality in children with suspected or confirmed infections. This single-center retrospective cohort study included pediatric patients admitted to the PICU for infection. The primary outcome was hospital mortality. The six scores included the age-adapted pSOFA score, SIRS score, PELOD2 score, Sepsis-2 score, qSOFA score, and PMODS. Of the 5,356 children admitted to the PICU, 9.1% (488) died, and 25.1% (1,342) had basic disease with a mortality rate of 12.7% (171); 65.3% (3,499) of the patients were younger than 2 years, and 59.4% (3,183) were male. The discrimination abilities of the pSOFA and PELOD2 scores were superior to those of the other models. The calibration curves of the pSOFA and PELOD2 scores were consistent between the predictions and observations. Elevated lactate levels were a risk factor for mortality. The pSOFA and PELOD2 scores had superior predictive performance for mortality. Given the relative unavailability of items and clinical operability, the pSOFA score should be recommended as an optimal tool for acute organ dysfunction in pediatric sepsis patients. Elevated lactate levels are related to a greater risk of death from infection in children in the PICU.

Neutrophil lymphocyte ratio and severity of acute kidney injury in septic children

Background Acute kidney injury (AKI) in sepsis is associated with an inflammatory process in kidney microcirculation and may increase morbidity and mortality in children. The neutrophil lymphocyte ratio (NLR) is an inflammatory biomarker of the inflammatory process in sepsis.&#x0D; Objective To determine the role of NLR in predicting the severity of AKI and to describe the demographic and laboratory characteristics, as they relate to outcomes of pediatric patients with AKI and sepsis.&#x0D; Methods This cross-sectional study was conducted in the PICU at Dr. Zainoel Abidin General Hospital (RSUDZA), Banda Aceh, Aceh. Medical record data were obtained from critically ill children with sepsis and AKI. Chi-square test was used to compare the proportions of each variable. We also calculated odds ratios to evaluate the AKI severity, PELOD-2 score, and patient outcomes. Spearman's analysis was used to look for a possible correlation between NLR and AKI severity in septic children.&#x0D; Results Seventy-one subjects with sepsis and AKI were included. Subject characteristics were as follows: 63.4% males, 63.4% &lt; 1 year of age, 56.3% with respiratory problems as a primary disease, 38% with AKI injury stage, and 54.9% subjects with PELOD-2 score ?10. There was no significant correlation between AKI severity and mortality (OR 3.04; 95%CI 0.990 to 9.378; P=0.052). Subjects with a PELOD-2 score ?10 had a 47.6 times higher chance of mortality in septic children with AKI compared to those with PELOD-2 scores &lt;10. There was no correlation between NLR and AKI severity (r=0.019; P=0.878).&#x0D; Conclusion There is no correlation between NLR and AKI severity. Sepsis accompanied by AKI may increase the risk of mortality in children. Septic children with more severe AKI tends to be less survive.

Pediatric Profound Dengue Shock Syndrome and Use of Point-of-Care Ultrasound During Mechanical Ventilation to Guide Treatment: Single-Center Retrospective Study, 2013-2021.

Profound dengue shock syndrome (DSS) complicated by severe respiratory failure necessitating mechanical ventilation (MV) accounts for high case fatality rates among PICU-admitted patients. A major challenge to management is the assessment of intravascular volume, which can be hampered by severe plasma leakage and the use of MV. Retrospective cohort, from 2013 to 2021. Sixty-seven children with profound DSS supported by MV, some of whom underwent bedside point-of-care ultrasound (POCUS) for assessment and monitoring of hemodynamics and fluid administration. PICU of the tertiary Children's Hospital No. 2 in Vietnam. None. We analyzed data clinical and laboratory data during PICU stay. In particular, during use of MV (i.e., at times 0-, 6-, and 24-hr after commencement) and fluid resuscitation. The primary study outcome was 28-day in-hospital mortality, and the secondary outcomes were associations with changes in hemodynamics, blood lactate, and vasoactive-inotrope score (VIS). Patients had a median age of 7 years (interquartile range, 4-9). Use of POCUS during fluid management (39/67), as opposed to not using (28/67), was associated with lower mortality (6/39 [15%] vs. 18/28 [64%]; difference 49 % [95% CI, 28-70%], p < 0.001). Use of POCUS was associated with lower odds of death (adjusted odds ratio 0.17 [95% CI, 0.04-0.76], p = 0.02). The utilization of POCUS, versus not, was associated with greater use of resuscitation fluid, and reductions in VIS and pediatric logistic organ dysfunction (PELOD-2) score at 24 hours after MV and PICU discharge. In our experience of pediatric patients with profound DSS and undergoing MV (2013-2021), POCUS use was associated with lower odds of death, a higher volume of resuscitation fluid, and improvements in the blood lactate levels, VIS, and PELOD-2 score.

Correlation Between Free Triiodothyronine (FT3) with PELOD-2 Score and PICU Length of Stay in Critically Ill Pediatric

Background: Thyroid function disorders, particularly reduced FT3 levels, are frequently observed in critically ill patients. FT3 plays a crucial role in metabolic regulation during critical illness. The extent of the decrease in FT3 levels directly corresponds to the severity of the disease, as indicated by the PELOD-2 score, and indirectly influences the length of stay in the Pediatric Intensive Care Unit (PICU). This study aims to examine the relationship between free triiodothyronine (FT3) levels and both the PELOD-2 score and the length of stay in critically ill pediatric patients. Methods: Cross-sectional study was conducted at Dr. M Djamil Hospital's Pediatric Intensive Care Unit (PICU) from June to September 2022. The study included critically ill pediatric patients who accept the informed consent and were well-nourished, while individuals with a history of thyroid disease, those using exogenous/thyroid hormone/antithyroid drugs, individuals with chronic diseases, and those with Down's syndrome were excluded. The levels of FT3 and PELOD-2 scores were measured within 48 hours of admission, while the length of stay was obtained from medical records. Data analysis was performed using the SPSS program, utilizing the Spearman correlation test. Result: Thirty subjects were included in the study. The mortality rate was 30%. The median FT3 level was 1.5 pg/mL. FT3 levels were low in 26 of 30 samples. There was a significant negative correlation (p = 0,001) between FT3 levels and PELOD-2 scores with moderate value (r = -0.567) and no significant correlation between FT3 levels and PICU length of stay. Conclusion: The lower FT3 level measured, the higher PELOD-2 score found in critically ill children. Keywords: FT3, PELOD-2 score, length of stay, critically ill pediatric

Utility of paediatric logistic organ dysfunction score in predicting mortality in children admitted to PICU at a tertiary care centre

Background: Critically ill children are typically characterized by multiple organ dysfunctions. The use of Paediatric logistic organ dysfunction-2 (PELOD-2) scoring systems has recently been replicated in the paediatric population for morbidity and mortality predictions. Objective of the study was to study the PELOD 2 score in predicting mortality in paediatric intensive care unit within 1 hour of admission. Methods: This was prospective observational study conducted at S Nijalingappa Medical College and Hanagal Shri Kumareshwar Hospital, Bagalkot for period of 16 months. Children aged from 1 month to 14 years admitted to PICU were included in the study and patients whose parents refuse to give consent, age less than 1 month or more than 14 years, those discharged against medical advice were excluded from the study. Venous blood sample were collected within one hour of admission and were analyzed for serum creatinine, serum lactate, total leukocyte count and platelet count and arterial blood sample were collected and paO2 and paCO2 were analysed. Results: Total sample size of study was 80, out of which 52 patients had PELOD 2 score of (&lt;4), 14 patients had score of (5-9), 11 patients had score of (10-14) and 3 patients had score &gt;15.Among total 80 patients 66 survived and 14 died (17.5%). Of the 14 deaths, 3 patients had PELOD 2 score of &gt;15 and 9 had score of 10-14. Pelod-2 score &gt;9 had requirement of mechanical ventilation in 68.4%. Conclusions: Higher the PELOD-2 score on day 1of admission has higher the mortality.

Hypophosphatemia in infants with severe bronchiolitis and association with length of mechanical ventilation.

Electrolyte disorders occurs frequently in children with bronchiolitis. The aim of the present study was to describe the frequency of hypophosphatemia and to evaluate its association with length of mechanical ventilation in infants admitted to a pediatric intensive care unit (PICU) with bronchiolitis. This retrospective cohort study included infants aged between 7 days and 3 months admitted to a PICU between September 2018 and March 2020 and diagnosed with severe acute bronchiolitis requiring respiratory support. Infants with a chronic condition that could potentially be a confounding factor were excluded. The primary outcome was the frequency of hypophosphatemia (<1.55 mmol/L); the secondary outcomes were the frequency of hypophosphatemia during the PICU stay, and the association with length of mechanical ventilation (LOMV). Among the 319 infants admitted 178 had at least one phosphatemia value and were included in the study. The frequency of hypophosphatemia was 41% at PICU admission (61/148) and 46% during the PICU stay (80/172). The median [IQR] LOMV was significantly longer in children with hypophosphatemia at admission (109 [65-195] hvs. 67 [43-128] h, p = 0.007), and in multivariable linear regression lower phosphatemia at admission was associated with longer LOMV (p < 0.001) after controlling for severity (PELOD2 score) and weight. Hypophosphatemia was frequent in infants with severe bronchiolitis admitted to a PICU and was associated with a longer LOMV.

Noninvasive Ventilation for Pediatric Acute Respiratory Distress Syndrome: Experience From the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Prospective Cohort Study.

The worldwide practice and impact of noninvasive ventilation (NIV) in pediatric acute respiratory distress syndrome (PARDS) is unknown. We sought to describe NIV use and associated clinical outcomes in PARDS. Planned ancillary study to the 2016/2017 prospective Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study. One hundred five international PICUs. Patients with newly diagnosed PARDS admitted during 10 study weeks. None. Children were categorized by their respiratory support at PARDS diagnosis into NIV or invasive mechanical ventilation (IMV) groups. Of 708 subjects with PARDS, 160 patients (23%) received NIV at PARDS diagnosis (NIV group). NIV failure rate (defined as tracheal intubation or death) was 84 of 160 patients (53%). Higher nonrespiratory pediatric logistic organ dysfunction (PELOD-2) score, Pa o2 /F io2 was less than 100 at PARDS diagnosis, immunosuppression, and male sex were independently associated with NIV failure. NIV failure was 100% among patients with nonrespiratory PELOD-2 score greater than 2, Pa o2 /F io2 less than 100, and immunosuppression all present. Among patients with Pa o2 /F io2 greater than 100, children in the NIV group had shorter total duration of NIV and IMV, than the IMV at initial diagnosis group. We failed to identify associations between NIV use and PICU survival in a multivariable Cox regression analysis (hazard ratio 1.04 [95% CI, 0.61-1.80]) or mortality in a propensity score matched analysis ( p = 0.369). Use of NIV at PARDS diagnosis was associated with shorter exposure to IMV in children with mild to moderate hypoxemia. Even though risk of NIV failure was high in some children, we failed to identify greater hazard of mortality in these patients.

The Role of Blood Purification by HA330 as Adjunctive Treatment in Children with Septic Shock

Introduction: Despite advances in supportive care for critically ill patients, sepsis remains an important cause of death worldwide in the PICU. One of the hallmarks of sepsis is hyperinflammation due to the excessive release of inflammatory mediators. Recently, new therapeutic approaches, such as immune modulation and blood purification, have been tried to improve outcomes in patients with septic shock. Methods: This study is a prospective observational study composed of children with septic shock and the PELOD-2 score ≥10 or the PRISM-3 score ≥15. All received 2–4 h of HA330 treatment on 2 consecutive days, used as adjunctive therapy. The effectiveness of HA330 hemoperfusion was evaluated by improving the PELOD-2 and PRISM-3 scores, the vasoactive inotropic score (VIS), and inflammatory markers from baseline to 72 h after the use of HA330 hemoperfusion. Results: Twelve patients hospitalized in the PICU and diagnosed with septic shock between July 2021 and May 2022 were included in this study and received hemoperfusion with HA330. The average PELOD-2 and PRISM-3 scores decreased significantly from 9.5 (IQR: 6.5–13.0) at baseline to 2.0 (IQR: 0–6.5) at 72 h (p = 0.002) and from 16.5 (IQR: 15.0–20.5) at baseline to 5.5 (IQR: 2.0–9.5) at 72 h (p = 0.002), respectively. The VIS decreased significantly from baseline to 72 h (p = 0.003). IL-6, procalcitonin, and lactate levels also decreased significantly from baseline to 72 h (p = 0.005, 0.03, and 0.03, respectively). Two of 12 patients expired due to their underlying condition (2/12, 16.7%). Device-related adverse events did not occur in this study. Conclusions: Our observational case series suggests a possible role for HA330 hemoperfusion as an adjunctive treatment of refractory septic shock in children with high severity scores in the context of rapid improvement in organ dysfunction, without serious adverse effects.

The clinical and biomarker approach to predict sepsis mortality in pediatric patients

Background Sepsis is a leading cause of pediatric morbidity and mortality. The prevalence of sepsis mortality in Indonesia varies between 22.5 to 52%.&#x0D; Objective To identify the clinical criteria for predicting sepsis mortality and evaluate the performance of the PELOD-2 score.&#x0D; Methods This retrospective cohort study included pediatric patients admitted to the emergency department or pediatric intensive care unit (PICU) of Cipto Mangunkusumo Hospital, Jakarta, Indonesia, from January 2015 to May 2020. Demographic characteristics (age and sex), clinical manifestations [nutritional status, presence of shock, need for intubation, source of infection, inotrope use, mean arterial pressure, pulse rate, respiratory rate, and Glasgow Coma Scale (GCS) score], laboratory [leukocyte, platelet, neutrophil, and lymphocyte counts, neutrophil-to-lymphocyte count ratio (NLCR), procalcitonin, C-reactive protein (CRP), and lactate profile], PELOD-2 score, and mortality data were recorded as outcomes.&#x0D; Results We analyzed data from 241 sepsis subjects. The overall mortality rate was 65%. Shock [OR 3.2 (95%CI 1.80 to -5.55, P&lt;0.001)], GCS &lt;9 [OR 2.4 (95%CI 1.30 to 4.23, P=0.005)], inotrope use [OR 3.1 (95%CI 1.74 to 5.5, P&lt;0.001)], CRP &gt;33.5 mg/L [OR 2.5 (95%CI 1.14 to 5.35, P=0.02)], and lactate level &gt;2.85 [OR 2.1 (95%CI 1.02 to 4.56, P=0.04)] were considered significant predictors of mortality. A PELOD-2 cut-off score of &gt;8 had optimal sensitivity (81.2%) and specificity (72.9%) to predict mortality, with an OR of 11.6 (95%CI 5.72 to 23.5, P&lt;0.001).&#x0D; Conclusion Shock, GCS score, inotrope use, CRP, and lactate level can serve as clinical biomarkers to predict mortality in pediatric sepsis. A PELOD-2 score of &gt;8 can predict mortality with reasonably good sensitivity and specificity.

Perioperative Nutritional Status and Organ Dysfunction Following Surgery for Congenital Heart Disease.

Children with congenital heart disease (CHD) are at risk of malnutrition; however, there is limited information regarding the impact of nutritional status on organ dysfunction and outcomes after surgery for CHD. The study aim was to assess the association between malnutrition, organ dysfunction, and outcomes after surgery for CHD. Retrospective cohort study of patients aged 30days to 18years admitted to the cardiac intensive care unit (CICU) following cardiac surgery. Nutritional status (malnutrition defined as weight for age z-score < -2) and validated organ dysfunction scores (pSOFA and PELOD-2) on CICU days 1 and 3 were collected. The cohort included 967 patients with a median age of 2.8years (IQR 0.46, 7.12) and hospital survival of 98.86%. The prevalence of malnutrition was 18.5% (n = 179). By multivariable logistic regression analysis including age, malnutrition, cardiopulmonary bypass time, and duration of mechanical ventilation; High STAT category (OR 7.51 [1.03-54], p = 0.0462) and PSOFA score > 5day 1 (OR 1.84 [1.25-2.72], p = 0.0021) were associated with mortality; in a similar model including the same variables; High STAT category (OR 9.12 [1.33-62], p = 0.0243) and PELOD-2 score > 5day 1 (OR 1.75 [1.10-2.77], p = 0.0175) were associated with mortality. Malnutrition was associated with persistent or worsening organ dysfunction by pSOFA (p < 0.05) and PELOD-2 (p < 0.01) on day 3. Malnutrition was present in infants and children undergoing surgery for congenital heart disease. Organ dysfunction and high surgical risk were associated with mortality. Malnutrition was not associated with mortality but was associated with postoperative organ dysfunction.

Red Cell Distribution Width on First Day Intensive Care Unit Admission in Paediatrics.

Red distribution width (RDW) has recently been acclaimed as prognostic marker for mortality in critically-ill patients. However, this claim is still unclear and reports are still inadequate for the association between RDW and mortality in critically-ill paediatric patients. This research assessed the correlation between RDW within 24 hours of PICU (paediatric intensive care unit) admission and PELOD-2 score. A cross-sectional study was carried out involving 59 pediatric patients admitted to the PICU Haji Adam Malik Hospital, Medan, Indonesia, from May to July 2019. The association between RDW and PELOD-2 score was assessed by using Spearman correlation test. The RDW level of paediatric patients in the PICU on the first 24 hours was elevated (median 14.7%, range 11.4-31.2%). The median of PELOD-2 score assessment was 8 (range 2-21). There was no significant correlation between RDW and PELOD-2 in this research (r=0.187, p=0.156).

609: NEPHROTOXIC MEDICATIONS AND THEIR ASSOCIATION WITH ACUTE KIDNEY INJURY IN CRITICALLY ILL CHILDREN

Introduction: The incidence of developing acute kidney injury (AKI) in the pediatric intensive care unit (PICU) is estimated to be 26% (Kaddourah, 2017). Nephrotoxic medications are a modifiable risk factor associated with AKI in non-critically ill children & neonates (Moffett, 2011 & Stoops, 2019). The primary objective of this study is to evaluate the association between the number of nephrotoxic medications and the risk of developing AKI in critically ill children. Methods: This is a single center retrospective cohort study of critically ill children admitted to a tertiary care PICU. Inclusion criteria was patients age 0-21 years admitted for >24 hours. Exclusion criteria was history of chronic kidney disease or if expired within 24 hours of admission. We considered the same list of medications used in previous studies to be nephrotoxic, NSAIDs, certain antibiotics, and chemotherapy agents. AKI was defined by Kidney Disease: Improving Global Outcomes (KDIGO) criteria including serum creatinine increase by ≥0.3, >1.5 times baseline, or urine output < 0.5 mL/kg/hr for ≥12 hours. Severe AKI was defined as Stage 2 & 3 AKI. Exposure to the number of nephrotoxic medications and development of AKI was analyzed. Results: 60 patients were analyzed. Median age was 6.55 (1.12-12.71) years and mostly male (55%). Median LOS was 3 (2-5) days. Majority had a respiratory illness as primary diagnosis (31%). Median PELOD2 score was 3.5 (2-7). Incidence of AKI was 40%. 46% of patients who developed AKI did not have any nephrotoxic medications administered. 42% of patients with AKI were administered 1 nephrotoxic medication. 12% of patients with AKI had exposure to ≥2 medications. Amongst all patients with AKI, 88% had severe AKI. The most common medications administered were ibuprofen (22%) and vancomycin (17%). Exposure to the number of nephrotoxic medications and development of AKI was assessed with Fisher’s Exact test. There was no statistical significance with the number of nephrotoxic medications and the development of AKI (p=0.962). Correlation analysis revealed an increased rate of AKI with PICU LOS ≥5 days (p=0.029). Conclusions: There was no statistically significant association between the number of nephrotoxic medications and the development of AKI. Patients with longer LOS had a higher risk of developing AKI.

Analysis of predictors of mortality and clinical outcomes of different subphenotypes for moderate-to-severe pediatric acute respiratory distress syndrome: A prospective single-center study.

This study aimed to observe the prognosis of patients with moderate-to-severe pediatric acute respiratory distress syndrome (PARDS) admitted to the Pediatric Intensive Care Unit (PICU) as a function of underlying conditions and available treatment strategies, and to investigate the risk factors for death and the outcomes of different clinical subphenotypes. Patients were divided into non-survivors and survivors according to the prognosis 28 days after the diagnosis. The risk factors for death and the predictive value of relevant factors for mortality were analyzed. Latent class analysis was used to identify different clinical subphenotypes. A total of 213 patients with moderate-to-severe PARDS were enrolled, of which 98 (46.0%) died. Higher PELOD2 scores (OR = 1.082, 95% CI 1.004-1.166, p < 0.05), greater organ failure (OR = 1.617, 95% CI 1.130-2.313, p < 0.05), sepsis (OR = 4.234, 95% CI 1.773-10.111, p < 0.05), any comorbidity (OR = 3.437, 95% CI 1.489-7.936, p < 0.05), and higher infiltration area grade (IAG) (OR = 1.980, 95% CI 1.028-3.813, p < 0.05) were associated with higher mortality. The combination of these five indicators had the largest area under the curve (sensitivity 89.79%, specificity 94.78%). Patients were classified into higher-risk and lower-risk phenotype group according to the latent class analysis. Compared to the lower-risk phenotype, more patients with higher-risk phenotype suffered from sepsis (24.40% vs. 12.20%, p < 0.05), inherited metabolic diseases (45.80% vs. 25.60%, p < 0.05), positive respiratory pathogens (48.10% vs. 26.80%, p < 0.05), and higher IAG (p < 0.05); they also had significantly higher PIM3 and PELOD2 scores (p < 0.05), with an extremely high mortality rate (61.1% vs. 22.0%, p < 0.05). Moderate-to-severe PARDS has high morbidity and mortality in PICU; a higher PELOD2 score, greater organ failure, sepsis, any comorbidity, and higher IAG were risk factors for death, and the combination of these five indicators had the greatest value in predicting prognosis. More patients with sepsis, positive respiratory pathogens, higher PIM3 and PELOD2 scores, and higher IAG were in higher-risk phenotype group, which had worse outcomes. Clear classification facilitates targeted treatment and prognosis determination.

Polymyxin B Hemoperfusion in Pediatric Septic Shock: Single-Center Observational Case Series.

OBJECTIVES:To evaluate the use of direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) as adjunctive therapy during pediatric patients with septic shock.DESIGN:Prospective observational study.SETTING:Nine-bed PICUs at university referral hospital.PATIENTS:Children (30 d to 15 yr) with septic shock and Pediatric Logistic Organ Dysfunction (PELOD)-2 score greater than or equal to 10 or Pediatric Risk of Mortality (PRISM) 3 score greater than or equal to 15, who were also receiving at least one inotrope.INTERVENTION:Patients received 2–4 hour treatment with PMX-DHP 20R column on 2 consecutive days.MEASUREMENTS AND MAIN RESULTS:We enrolled six children aged 21–167 months old (median, 99-mo old), with a body weight of 10–50 kg (median, 28 kg). All six patients had both PELOD-2 greater than or equal to 10 and PRISM-3 greater than or equal to 15, required invasive mechanical ventilation, and received standard treatment for septic shock before enrollment. We observed significant improvement in PELOD-2 score from baseline to 72 hours after the start of PMX-DHP (mean [95% CI] from 14.3 [12.2–16.5] to 6.0 [0.3–11.7]; p = 0.006). The vasoactive inotropic score (VIS) and lactate concentration also significantly decreased from baseline to 72 hours (VIS, 60 mmol/L [25–95 mmol/L] to 4.0 mmol/L [44.1–12 mmol/L]; p = 0.003; lactate, 2.4 mmol/L [1.0–3.8 mmol/L] to 1.0 mmol/L [0.5–1.5 mmol/L]; p = 0.01). Five of six patients survived. There was no device-related adverse event in these patients.CONCLUSIONS:In this case series of treatment with PMX-DHP as adjunctive therapy in children with refractory septic shock and high baseline severity, we have shown that patient recruitment is feasible. We have also found that clinical hemodynamic and severity of illness scores at 72 hours may be potential end points for testing in future randomized controlled trials.

Epidemiology and outcomes of septic shock in children with complex chronic conditions in a developing country PICU

ObjectiveTo investigate the role of Complex Chronic Conditions (CCCs) on the outcomes of pediatric patients with refractory septic shock, as well as the accuracy of PELOD-2 and Vasoactive Inotropic Score (VIS) to predict mortality in this specific population. MethodsThis is a single-center, retrospective cohort study. All patients diagnosed with septic shock requiring vasoactive drugs admitted to a 13-bed PICU in southern Brazil, between January 2016 and July 2018, were included. Clinical and demographic characteristics, presence of CCCs and VIS, and PELOD-2 scores were accessed by reviewing electronic medical records. The main outcome was considered PICU mortality. Results218 patients with septic shock requiring vasoactive drugs were identified in the 30-month period and 72% of them had at least one CCC. Overall mortality was 22%. Comparing to patients without previous comorbidities, those with CCCs had a higher mortality (26.7% vs 9.8%; OR = 3.4 [1.3–8.4]) and longer hospital length of stay (29.3 vs 14.8; OR 2.39 [1.1- 5.3]). Among the subgroups of CCCs, “Malignancy” was particularly associated with mortality (OR = 2.3 [1.0–5.1]). VIS and PELOD-2 scores in 24 and 48 hours were associated with mortality and a PELOD-2 in 48 hours > 8 had the best performance in predicting mortality in patients with CCC (AUROC = 0.89). ConclusionPatients with CCCs accounted for the majority of those admitted to the PICU with septic shock and related to poor outcomes. The high prevalence of hospitalizations, use of resources, and significant mortality determine that patients with CCCs should be considered a priority in the healthcare system.

Inadequate Oxygen Delivery Dose and Major Adverse Events in Critically Ill Children With Sepsis.

The inadequate oxygen delivery (IDo2) index is used to estimate the probability that a patient is experiencing inadequate systemic delivery of oxygen. Its utility in the care of critically ill children with sepsis is unknown. To evaluate the relationship between IDo2 dose and major adverse events, illness severity metrics, and outcomes among critically ill children with sepsis. Clinical and IDo2 data were retrospectively collected from the records of 102 critically ill children with sepsis, weighing >2 kg, without preexisting cardiac dysfunction. Descriptive, nonparametric, odds ratio, and correlational statistics were used for data analysis. Inadequate oxygen delivery doses were significantly higher in patients who experienced major adverse events (n = 13) than in those who did not (n = 89) during the time intervals of 0 to 12 hours (P < .001), 12 to 24 hours (P = .01), 0 to 24 hours (P < .001), 0 to 36 hours (P < .001), and 0 to 48 hours (P < .001). Patients with an IDo2 dose at 0 to 12 hours at or above the 80th percentile had the highest odds of a major adverse event (odds ratio, 23.6; 95% CI, 5.6-99.4). Significant correlations were observed between IDo2 dose at 0 to 12 hours and day 2 maximum vasoactive inotropic score (ρ = 0.27, P = .006), day 1 Pediatric Logistic Organ Dysfunction (PELOD-2) score (ρ = 0.41, P < .001), day 2 PELOD-2 score (ρ = 0.44, P < .001), intensive care unit length of stay (ρ = 0.35, P < .001), days receiving invasive ventilation (ρ = 0.42, P < .001), and age (ρ = -0.47, P < .001). Routine IDo2 monitoring may identify critically ill children with sepsis who are at the highest risk of adverse events and poor outcomes.

Factors Associated with Pediatric In-Hospital Recurrent Cardiac Arrest

AbstractThe objective of this article was to identify demographic and clinical factors associated with early recurrent arrest (RA; &lt;48 hours) and late RA (≥48 hours) among pediatric inpatients following an initial in-hospital cardiac arrest. A retrospective cohort study of inpatients was performed in a free-standing academic quaternary care children's hospital. All inpatients were &lt;18 years old with a cardiac arrest event requiring ≥1 minute of cardiopulmonary resuscitation with the return of spontaneous circulation sustained for ≥20 minutes at Seattle Children's Hospital from February 1, 2012, to September 18, 2019. Of the 237 included patients, 20 (8%) patients had an early RA and 30 (13%) had a late RA. Older age and severe prearrest acidosis were associated with a higher risk of early RA, odds ratios (OR) = 1.2 (95% confidence interval [CI]: 1.1–1.3) per additional year and 4.6 (95% CI: 1.2–18.1), respectively. Prearrest organ dysfunction was also associated with a higher risk of early RA with an OR of 3.3 (95% CI: 1.1–9.4) for respiratory dysfunction, OR = 1.4 (95% CI: 1.1–1.9) for each additional dysfunctional organ system, and OR = 1.1 (95% CI: 1–1.2) for every one-point increase in PELOD2 score. The neonatal illness category was associated with a lower risk of late RA, OR 0.3 (95% CI: 0.1–0.97), and severe postarrest acidosis was associated with a higher risk of late RA, OR = 4.2 (95% CI: 1.1–15). Several demographic and clinical factors offer some ability to identify children who sustain a recurrent cardiac arrest, offering a potential opportunity for intervention to prevent early recurrent arrest.