PELOD-2 Score Research Articles

PELOD-2 Score Mortality Prediction Ability in Children with Multiple Organ Dysfunction

This study evaluates PELOD-2 score mortality prediction ability in children with multiple organ dysfunction. The descriptive cross-sectional study was carried out on 110 children with Multiple Organ Dysfunction at the Pediatric intensive care unit in Vietnam National Children’s Hospital from 1st January 2015 to 31th June 2016. The study results show that the average PELOD-2 score was high (8.8 ± 3.85 points); the PELOD-2 score of the mortality group was significantly higher than the survivor group with 7.07 ± 2.37 and 10.43 ± 4,28, respectively; mortality rate was directly proportional to PELOD-2 score; the PELOD-2 score could separate the mortality group from the survivor group with the area under the ROC curve of 0.76 and the cut-point PELOD-2 score of 8.5. If children with multiple organ dysfunction had over 10 points of PELOD-2 score, their mortality prediction value was nearly the same as the actual mortality rate. The study concludes that PELOD-2 score was significantly correlated with associated multiple organ dysfunction syndrome and useful in predicting mortality.
 Keywords: Multiple organ dysfunction, PELOD-2 score.
 References
 [1] B. Goldstein, B. Giroir, A. Randolph, International Pediatric Sepsis Consensus Conference: Definitions for Sepsis and Organ Dysfunction in Pediatrics. Pediatric Critical Care Medicine, Vol. 6, 2005, pp. 2-8.[2] J. D. Wilkinson et al., Mortality Associated with Multiple Organ System Failure and Sepsis in Pediatric Intensive Care Unit, The Journal of Pediatrics, Vol. 111, 1987, pp. 324-328[3] J. A. Tantaleán et al., Multiple Organ Dysfunction Syndrome in Children, Pediatric Critical Care Medicine, Vol. 4, 2003, pp. 181-185[4] T. K. Hao, Clinical Characteristics and Prognostic Value of PELOD Score in Pediatric Population With Multi-Organ Dysfunction, 11th Pediatric National Conference, 2014 (in Vietnamese).[5] S. Leteurtre et al., PELOD-2: An Update of the Pediatric Logistic Organ Dysfunction Score, Critical Care Medicine, Vol. 41, 2013, pp. 1761-1773.[6] J. P. Gonçalves et al., Performance of PRISM III and PELOD-2 Scores in A Pediatric Intensive Care Unit, European Journal of Pediatrics, Vol. 174, 2016, pp. 1305-1310.[7] T. K. Hao, Evaluation of PMODS Score in Patients with Multi-organ Dysfunction Syndrome at A Pediatric Intensive Care Unit, Journal of Practical Medicine, Vol. 805, 2012 (in Vietnamese).

The Platelet-to-lymphocyte ratio, PELOD-2 score, and mortality rate in pediatric sepsis

Background Sepsis is life-threatening organ dysfunction caused by a regulated immune response to infection. Sepsis remains the most common cause of death in infants and children worldwide. The Pediatric Logistic Organ Dysfunction (PELOD-2) score, one of the most widely used scoring systems in pediatric sepsis patients, has been shown to be accurate in predicting mortality. The platelet-to-lymphocyte ratio (PLR) is a new clinical indicator of inflammation in a variety of diseases including sepsis.
 Objective To investigate the relationship between PLR, PELOD-2 score, and clinical outcomes in pediatric patients with sepsis.
 Methods This retrospective cohort study was conducted in the Pediatric Intensive Care Unit (PICU), Prof R.D. Kandou Hospital, Manado, North Sulawesi, from February to August 2020. Subjects’ PELOD-2 score and PLR were recorded once within the first 24 hours of PICU admission. We analyzed patients’ PELOD-2 score, PLR, and mortality rate, with 95% confidence interval (CI) for each value.
 Results Of 96 children with sepsis admitted to the PICU during the study period, 87 patients (46 boys; 52.9%) met the inclusion criteria. In total, 50 (57.47%) patients were non-survivors. Mean PLR values among survivors [77.54 (SD 50.08)] was significantly lower compared to the values among non-survivors [157.13 (SD 67.38)]; as well as the PELOD-2 score in the survivors group [12 (SD 1.32)] was significantly lower than its value in the non-survivors [14.65 (SD 2.09)]. Spearman’s analysis showed a moderately positive correlation between PLR and PELOD-2 score (r=0.444; 95%CI 0.44 to 1; P<0.01). Biserial point correlation analysis revealed a significant association between PLR and mortality rate (rpb=0.566; P<0.0001),with elevated PLR related to an increased risk of mortality.
 Conclusion There are positive correlations between PLR, PELOD-2 score, and mortality rate in pediatric patients with sepsis. Higher PLR and PELOD-2 score are associated with higher mortality.

Adverse events after low titer group O whole blood versus component product transfusion in pediatric trauma patients: A propensity-matched cohort study.

Low titer group O whole blood (LTOWB) is used as the initial resuscitative fluid in an increasing number of pediatric trauma and massive bleeding transfusion protocols. There is little data on adverse events following its transfusion in pediatric trauma patients. Blood bank records were queried for pediatric recipients of at least one unit of red blood cells (RBCs) (component group) or LTOWB (LTOWB group) within 24 h of admission between May 2013 and August 2020. Subjects with early death (<72 h) were excluded. Propensity-score matching of LTOWB and component groups was performed. Adverse events were recorded, including transfusion reaction, thromboembolism, acute kidney injury, sepsis, and organ failure based on PELOD-2 score, along with hospital and ICU length of stay (LOS) and ventilator days. Thirty-six LTOWB recipients were matched to 36 conventional component recipients. Subjects were 52% male, with blunt injury mechanism (82%), median (IQR) injury severity score=27 (21-35), and 26% in-hospital mortality. The groups were well matched in terms of demographics and injury characteristics. There were no clinically or statistically significant differences in adverse outcomes including reported transfusion reaction, organ failure, acute kidney injury, sepsis/bacteremia, and venous thromboembolism. Hospital LOS, ventilator days, mortality, and functional disability at discharge were also not significantly different. The LTOWB group had significantly shorter ICU LOS compared to the component group. LTOWB transfusion did not increase the risk of adverse events in children. However, larger studies are required to confirm these results.

P0654 / #2072: PREDICTORS OF MORTALITY IN CRITICAL ILL SEPSIS CHILDREN IN 5 YEARS: INDONESIAN EXPERIENCE

Aims & Objectives: Pediatric sepsis in Indonesia had different outcomes with small sample size. Unfortunately, many hospitals had limitations to perform PELOD-2 score at admission because limited resources and lack of facilities. These problems make patients referred late to the hospital with severe condition. The objective of this study is to determine the risk factors of mortality by clinical manifestation and sepsis biomarkers. Methods: This study is retrospective study with consecutive sampling, by aged 1 month-18 years admitted to ER or PICU Cipto Mangunkusumo Hospital Jakarta during January 2015-May 2020. We divided subjects into two groups survivors and non-surviviors. Clinical manifestations (consciousness, respiratory rate, blood pressure, capillary refill time, and temperature), sepsis biomarker (leukocytes, neutrophils count, C-reactive protein/CRP, and procalcitonin) was documented. We performed external validation of PELOD-2 score and analyze using multivariable logistic regression to determine predictors of mortality. Results: We identified 225 septics patients with 65% of mortality. In this study 56% had respiratory infection, 31% on mechanical ventilation, 59% with hypotension and 51% was used inotropes. The non-survivors had cut-off 8 for PELOD-2 score with sensitivity 73,42%, specificity 82,19% and AUC 66%. Bivariate analysis showed decrease of consciousness (p=0,001), tachypnea (p=0,030), hypotension (p=0,001), CRT>2’’ (p=0,080) and biomarkers showed neutrophils (p=0,153) and CRP ≥ 5 mg/L (p=0,155). Multivariable logistic regression analysis determined predictors of mortality in sepsis children were hypotension (OR=4,294), neutrophilia (OR=3,102) and CRP ≥ 5 mg/L (OR= 2,789). Conclusions: PELOD-2 score ≥ 8 was found correlated with high mortality. However in limited resource setting, the predictors of mortality were hypotension, neutrophilia and CRP ≥ 5.

O027 / #587: THE EPIDEMIOLOGY OF PEDIATRIC SEPSIS IN BRAZILIAN INTENSIVE CARE UNITS (THE SEPSIS PREVALENCE ASSESSMENT DATABASE IN PEDIATRIC POPULATION, SPREAD-PED): AN OBSERVATIONAL STUDY

Aims & Objectives: To evaluate the prevalence of severe sepsis and septic shock in pediatric intensive care units (PICUs) in Brazil, in-hospital mortality and its associated factors and to estimate national incidence of pediatric ICU-treated sepsis. Methods: We did a point-prevalence study with follow-up of patients with sepsis in a nationally-representative random sample of PICU stratified by geographical region and hospital main source of income. We followed patients until hospital discharge censored at 60 days. We assessed mortality prognostic factors using random-effects regression models. Results: On study day, 144 (39.5%) of 365 randomly selected PICUs provided data on 1,120 patients, of whom 280 had severe sepsis or septic shock (prevalence: 25.0 septic patients per 100 ICU beds [95% confidence interval (CI): 21.6 – 28.8]. The PICU sepsis incidence was 2.85 per 100 patient-days, mortality was 19.6%. Age≤2 years-old, incomplete vaccination status, PELOD-2 score at sepsis diagnosis and healthcare-associated infection were independently associated with higher mortality. The projected incidence of ICU-treated severe sepsis per year is 67.9 per 100,000 population (95%CI: 55.9 – 82.4), which yields about 38,552 cases annually, of whom 7,556 die in hospital. Conclusions: In a representative sample of pediatric Brazilian ICUs, sepsis prevalence, population-based incidence of pediatric ICU treated-sepsis and in-hospital mortality were high. The major factors associated with a higher hospital mortality were younger age, inadequate vaccination status, presence of healthcare-associated infection and severity of illness.

Modifying the PELOD-2 score to predict mortality in critically ill patients

Background The PELOD-2 score, which has been widely used to predict multiple organ dysfunction, may be used to predict mortality. Nevertheless, blood gas analyses (BGA) and lactate measurements required for the PELOD-2 cannot be performed in most limited resource settings.&#x0D; Objective To evaluate the performance of modified PELOD-2, without BGA and lactate, to predict mortality in critically ill children. &#x0D; Methods This retrospective cohort study in critically ill children admitted to the pediatric intensive care unit (PICU), Dr. Sardjito Hospital, Yogyakarta, was undertaken from January to December 2018. The modifications to the PELOD-2 score were PELOD-2A (without BGA), PELOD-2B (without lactate), and PELOD-2C (without BGA and lactate). The modified PELOD-2 scores were evaluated using receiver operating characteristic (ROC) curve for discrimination, and Hosmer-Lemeshow goodness-of-fit test for calibration.&#x0D; Results Of 130 subjects, 68 (52.3%) died. A PELOD-2 score cut-off of 6.5 and modified PELOD-2A, 2B, and 2C had sensitivities for predicting mortality of 73.5%, 67.7%, 70.6%, and 63.2%, respectively, and specificities of 75.8%, 77.4%, 77.4%, and 79%, respectively. The area under curve (AUC) of the PELOD-2 score was 78.3 (95%CI 70.5 to 86.2). The AUCs of the modified PELOD-2 scores ranged from 76.8 (95%CI 68.7 to 84.9) to 77.9 (95% CI 69.9 to 85.8). The positive predictive values of PELOD-2 and modified PELOD-2A, 2B, 2C were 76.9%, 76.7%, 77.4% and 76.8%, respectively. The Hosmer-Lemeshow goodness-of-fit test showed good calibration for PELOD-2 (x2=8.74; P=0.27) and modified PELOD-2A (x2=4.91; P=0.67).&#x0D; Conclusion The PELOD-2A, modified without BGA, can still predict mortality well in critically ill PICU patients when using a cut-off score ≥ 6.5.

Correlation between syndecan-1 level and PELOD-2 score and mortality in pediatric sepsis.

Objective:To analyze the correlation between glycocalyx disruption measured via the serum syndecan-1 level and organ dysfunctions assessed by the PELOD-2 score and to evaluate its association with mortality in pediatric sepsis.Methods:We performed a prospective observational study in a tertiary public hospital. Sixty-eight pediatric patients diagnosed with sepsis according to International Pediatric Sepsis Consensus Conference criteria were consecutively recruited. We performed measurements of day 1 and day 5 serum syndecan-1 levels and PELOD-2 score components. Patients were followed up to 28 days following sepsis diagnosis.Results:Overall, the syndecan-1 level was increased in all subjects, with a significantly higher level among septic shock patients (p = 0.01). The day 1 syndecan-1 level was positively correlated with the day 1 PELOD-2 score with a correlation coefficient of 0.35 (p = 0.003). Changes in syndecan-1 were positively correlated with changes in the PELOD-2 score, with a correlation coefficient of 0.499 (p < 0.001) during the first five days. Using the cutoff point of day 1 syndecan-1 ≥ 430ng/mL, organ dysfunction (PELOD-2 score of ≥ 8) could be predicted with an AUC of 74.3%, sensitivity of 78.6%, and specificity of 68.5% (p = 0.001).Conclusion:The day 1 syndecan-1 level was correlated with the day 1 PELOD-2 score but not 28-day mortality. Organ dysfunction (PELOD-2 ≥ 8) could be predicted by the syndecan-1 level in the first 24 hours of sepsis, suggesting its significant pathophysiological involvement in sepsis-associated organ dysfunction.

Assessment of PELOD-2 and PIM-3 scores of children coming from the war in Syria

ObjectivesSince the civil war in Syria began, millions of Syrians have left the country and been forced to migrate to other countries. Turkey is the country with the most refugees hosting 3.6 million refugees. This study aimed to compare the PIM-3 score, PELOD-2 score, PELOD-2 predicted death rate (PDR), mortality rates, demographic data, and outcomes of patients admitted to pediatric intensive care units between refugee children living in Turkey, pediatric patients brought directly from the border by the emergency services, and the general Turkish population. MethodsThis was a retrospective study performed between February 2018 and February 2019 at Hatay State Hospital, very close to the Syrian border. The study included 158 patients. Patients were divided into three groups: Turkish citizens, those living in Turkey as refugees, and those brought from the border. ResultsOf the patients, 57 were Turkish citizens, 33 were refugees, and 68 were brought from the border. For patients, the mean PIM-3 score was 25.62±27.70, the PELOD-2 score was 8.03±4.72, and PELOD2-PDR was 16.07±23.45. The median scores for PIM-3, PELOD-2, and PELOD2-PDR of patients brought from the Syrian border were higher compared with Turkish citizens and refugees. There was no significant difference between refugees and Turkish citizens. Of the patients, 27 died, with the distribution being 15% Turkish citizens, 26% refugees, and 59% brought from the border. The mortality of patients transported from the border was statistically significant (P=0.03). ConclusionWe consider that the source of the difference between patients brought from the border and those living in Turkey may be associated with the continuing war beyond our borders and children experiencing insufficient care conditions. In conclusion, it is not just weapons that cause death in war, and children unfortunately suffer because of this situation.

Sequential Organ Failure Assessment Score As a Predictor of Outcome in Sepsis in Pediatric Intensive Care Unit.

Sequential organ failure assessment (SOFA) score is used as a predictor of outcome of sepsis in the pediatric intensive care unit. The aim of the study is to determine the application of SOFA scores as a predictor of outcome in children admitted to the pediatric intensive care unit with a diagnosis of sepsis. The design involved is prospective observational study. The study took place at the multidisciplinary pediatric intensive care unit (PICU), tertiary care hospital, South India. The patients included are children, aged 1 month to 18 years admitted with a diagnosis of sepsis (suspected/proven) to a single center PICU in India from November 2017 to November 2019. Data collected included the demographic, clinical, laboratory, and outcome-related variables. Severity of illness scores was calculated to include SOFA score day 1 (SF1) and day 3 (SF3) using a pediatric version (pediatric SOFA score or pSOFA) with age-adjusted cutoff variables for organ dysfunction, pediatric risk of mortality III (PRISM III; within 24 hours of admission), and pediatric logistic organ dysfunction-2 or PELOD-2 (days 1, 3, and 5). A total of 240 patients were admitted to the PICU with septic shock during the study period. The overall mortality rate was 42 of 240 patients (17.5%). The majority (59%) required mechanical ventilation, while only 19% required renal replacement therapy. The PRISM III, PELOD-2, and pSOFA scores correlated well with mortality. All three severity of illness scores were higher among nonsurvivors as compared with survivors ( p < 0.001). pSOFA scores on both day 1 (area under the curve or AUC 0.84) and day 3 (AUC 0.87) demonstrated significantly higher discriminative power for in-hospital mortality as compared with PRISM III (AUC, 0.7), and PELOD-2 (day 1, [AUC, 0.73]), and PELOD-2 (day 3, [AUC, 0.81]). Utilizing a cutoff SOFA score of >8, the relative risk of prolonged duration of mechanical ventilation, requirement for vasoactive infusions (vasoactive infusion score), and PICU length of stay were all significantly increased ( p < 0.05), on both days 1 and 3. On multiple logistic regression, adjusted odds ratio of mortality was elevated at 8.65 (95% CI: 3.48-21.52) on day 1 and 16.77 (95% confidence interval or CI: 4.7-59.89) on day 3 ( p < 0.001) utilizing the same SOFA score cutoff of 8. A positive association was found between the delta SOFA ([Δ] SOFA) from day 1 to day 3 (SF1-SF3) and in-hospital mortality (chi-square for linear trend, p < 0.001). Subjects with a ΔSOFA of ≥2 points had an exponential mortality rate to 50%. Similar association was-observed between ΔSOFA of ≥2 and-longer duration of inotropic support ( p = 0.0006) with correlation co-efficient 0.2 (95% CI: 0.15-0.35; p = 0.01). Among children admitted to the PICU with septic shock, SOFA scores on both days 1 and 3, have a greater discriminative power for predicting in-hospital mortality than either PRISM III score (within 24 hours of admission) or PELOD-2 score (days 1 and 3). An increase in ΔSOFA of >2 adds additional prognostic accuracy in determining not only mortality risk but also duration of inotropic support as well.

Validation of PELOD-2 score as a predictor of life-threatening organ dysfunction in pediatric sepsis

Background The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction due to immune dysregulation against infection. It recommends the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score to evaluate life-threatening organ dysfunction. But the SOFA tool has not been adjusted for pediatric patients. The Indonesian Pediatrics Society (IPS) uses the same sepsis definition and recommends using the PELOD-2 score as an indicator of life-threatening organ dysfunction in children. &#x0D; Objective To evaluate the validity of the PELOD-2 score for predicting life-threatening organ dysfunction in pediatric sepsis.&#x0D; Methods A prospective cohort study was conducted in children with sepsis who were admitted to the PICU. Subjects were taken consecutively with inclusion criteria of 1 month-18 years of age, with organ dysfunction, having two or more symptoms of systemic inflammatory response syndrome (SIRS), and suspected or proven infection. PELOD-2 score, with and without lactate result, of each subject were plotted to receiver operating characteristic (ROC) curve, then we determined the most optimal cut off point to predict the life-threathneing organ dysfunction in pediatric sepsis based on the sensitivity and specificity of each score.&#x0D; Results Sixty-six patients were analyzed, with 40 males and 26 females aged 2 to 183 months (median 11 months). Twenty patients died while in the PICU. A PELOD-2 score (with lactate) cut-off ≥ 7 was determined by ROC curve, with sensitivity of 80% and specificity of 78%. The area under the curve (AUC) of PELOD-2 score (with lactate) was 84.8% (95%CI 74.7 to 95.9%). A PELOD-2 score (without lactate) ≥ 7 was the most optimum cut off based on its Youden index, it haD 70% of sensitivity and 80% of specificity.&#x0D; Conclusion PELOD-2 score ≥ 7 , with or without lactate component is the optimal cut-off for predicting life-threatening organ dysfunction in pediatric sepsis.

The Usefulness of C-Reactive Protein, Procalcitonin, and PELOD-2 Score as a Predictive Factor of Mortality in Sepsis

BACKGROUND: Sepsis in children is a significant cause of morbidity and mortality in the pediatric intensive care unit (PICU). Assessment of pediatric sepsis using serial Pediatric Logistic Organ Dysfunction (PELOD)-2 score can be used as a prognostic factor. The use of biomarkers of sepsis is also used for diagnosis and predicting outcomes. Many studies have suggested that C-reactive protein (CRP) and procalcitonin (PCT) can be used to predict mortality.METHODS: A prospective cohort study was conducted to evaluate CRP, PCT, PELOD-2 score and its combination as a predictive factor of mortality in sepsis. All patients admitted to PICU Haji Adam Malik General Hospital, Medan, from April to November 2019 with suspected sepsis were included in this study. Blood examination and PELOD-2 scores were examined in the first 24 hours.RESULTS: A total of 79 children were included with a mortality rate 55.7%. The CRP, PCT, and PELOD-2 score were higher in nonsurvivor (2.8 (0.5-22.4) mg/dL; 9.36 (0.13-79.8) ng/mL; 9 (3-21), respectively). In multivariate logistic regression analysis, neither CRP nor PCT values could be independent predictors of mortality. The PELOD-2 score can be an independent predictor for mortality at a cut-off score of 7 (OR: 3.47 (95% CI: 1.68-7.19)). The combination of PELOD-2 and CRP scores as predictors of mortality showed lower values than PELOD-2 and PCT scores (0.80 vs. 0.95). The combination of all parameters only adds 1% of the predicted mortality value.CONCLUSION: PELOD-2 score with PCT value are recommended to predict mortality children with sepsis.KEYWORDS: sepsis, mortality, C-reactive protein, procalcitonin, PELOD-2 score

Triiodothyronin (T3) as a parameter of mortality in sepsis patients in the PICU

Background Thyroid hormone stimulates the regulation of β-adrenergic receptors in order to increase the inotropic effect of the heart myocardium. Euthyroid sick syndrome is a disorder of non-metabolic thyroid function, which is characterized by a decrease in triiodothyronine (T3) levels in patients with non-thyroid systemic disease, such as sepsis. Low serum T3 hormone level is a potentially high-risk factor for mortality from sepsis. &#x0D; Objective To assess for a relationship between decreased serum T3 levels and mortality in pediatric sepsis patients admitted in the PICU.&#x0D; Methods This study used a nested case-control design. The subjects were children aged 1 month-18 years who were diagnosed with sepsis in the pediatric intensive care unit at Sanglah Hospital, Denpasar, Bali, from September 2017 to January 2019.&#x0D; Results A total of 90 children were included, of whom 44 died and 46 survived. Median age was 10.5 (IQR 44) months in subjects who died and 9 (IQR 50) months in those who survived. The majority of subjects in both groups had well-nourished nutritional status. Bivariate analysis revealed that significantly more subjects who died had low serum T3 (≤1 ng/dL), PELOD-2 score ≥5, than subjects who survived. Multivariate analysis revealed that serum T3 £1 ng/dL (OR 55.1; 95%CI 9 to 334.8; P&lt;0.001) and PELOD-2 score ³5 (OR 6.5; 95%CI 1.6 to 26.7; P=0.01) were significant risk factors for sepsis mortality. &#x0D; Conclusion Low serum T3 level and high PELOD-2 score are risk factors for death in sepsis.

Performance of the Pediatric Sequential Organ Failure Assessment Score in Assessing the Prognosis of Children with Sepsis in A PICU of A Developing Country: A Single-Center Retrospective Observational Study

Background: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis 3) was based on the sequential organ failure assessment (SOFA) score. Matics and Sanchez-Pinto contrived a SOFA score designed specifically for pediatric patients (pSOFA) to evaluate the prognosis of children with sepsis according to the degree of organ dysfunction. Objectives: The aim of our study was to evaluate the predictive validity of the pSOFA for in-hospital mortality in children with sepsis in a pediatric intensive care unit (PICU) of a developing country. Methods: This was a single-center retrospective observational study. The data of 516 children diagnosed with sepsis according to the 2005 International Pediatric Sepsis Consensus Conference was retrospectively analyzed. The patients were divided into survivor group and non-survivor group according to the clinical outcome of 28 days after admission. The variables of pSOFA score, PELOD-2 score and P-MODS were collected and scored. Receiver operating characteristic (ROC) curve was plotted; the efficiency of the pSOFA score for predicting death was evaluated by the area under ROC curve (AUC). Results: ROC curve analysis showed that the AUCs of the pSOFA score, PELOD-2 score and P-MODS predicting the prognosis of children with sepsis in a PICU of a developing country were 0.937, 0.916, and 0.761, respectively (all P < 0.05). Conclusions: The pSOFA score is effective and has the ability to assess the prognosis of children with sepsis in a PICU of a developing country.

Day-1 PELOD-2 and day-1 “quick” PELOD-2 scores in children with sepsis in the PICU

ObjectivesThis study aimed to evaluate the predictive validity of the day-1 PELOD-2 and day-1 “quick” PELOD-2 (qPELOD-2) scores for in-hospital mortality in children with sepsis in a pediatric intensive care unit (PICU) of a developing country. MethodsThe data of 516 children diagnosed as sepsis were retrospectively analyzed. The children were divided into survival group and non-survival group, according to the clinical outcome 28 days after admission. Day-1 PELOD-2, day-1 qPELOD-2, pediatric SOFA (pSOFA), and P-MODS were collected and scored. Receiver operating characteristic (ROC) curves were plotted, and the efficiency of the day-1 PELOD-2, day-1 qPELOD-2 score, pSOFA, and P-MODS for predicting death were evaluated by the area under the ROC curve (AUC). ResultsThe day-1 PELOD-2 score, day-1 qPELOD-2 score, pSOFA, and P-MODS in the non-survivor group were significantly higher than those in the survivor group. ROC curve analysis showed that the AUCs of the day-1 PELOD-2 score, day-1 qPELOD-2 score, pSOFA, and P-MODS for predicting the prognosis of children with sepsis in the PICU were 0.916, 0.802, 0.937, and 0.761, respectively (all p < 0.05). ConclusionsBoth the day-1 PELOD-2 score and day-1 qPELOD-2 score were effective and able to assess the prognosis of children with sepsis in a PICU of a developing country. Additionally, the day-1 PELOD-2 score was superior to the day-1 qPELOD-2 score. Further studies are needed to verify the usefulness of the day-1 qPELOD-2 score, particularly outside of the PICU.

Fluid overload and length of mechanical ventilation in pediatric sepsis

Background Children with sepsis often experience hemodynamic failure and would benefit from fluid resuscitation. On the other hand, critically ill children with sepsis have a higher risk of fluid accumulation due to increased capillary hydrostatic pressure and permeability. Therefore, fluid overload may result in higher morbidity and mortality during pediatric intensive care unit (PICU) hospitalization.&#x0D; Objective To evaluate the correlation between fluid overload and the length of mechanical ventilation in children with sepsis admitted to the PICU.&#x0D; Methods Our retrospective cohort study included children aged 1 month-18 years with sepsis who were admitted to the PICU between January 2013 and June 2018 and mechanically-ventilated. Secondary data was extracted from subjects’ medical records. Data analyses used were independent T-test and survival analysis.&#x0D; Results Of 444 children admitted to the PICU, 166 initially met the inclusion criteria. Of those, 17 children were excluded due to congenital heart disease. Subjects’ median age was 19 months and median PELOD-2 score was 8. Eighteen children (12.1%) had positive fluid balance in the first 48 hours. Median mechanical ventilation duration was 5 days. Fluid overload was significantly correlated with length of mechanical ventilation (P=0.01) and PICU mortality (RR=2.06; 95%CI 2.56 to 166; P=0.001). Neither length of PICU stay nor extubation failure were significantly correlated to fluid overload.&#x0D; Conclusion Fluid overload was significantly correlated with length of mechanical ventilation and may be a predictor of mortality in children with sepsis in the PICU.

Fluid balance after continuous renal replacement therapy initiation and outcome in paediatric multiple organ failure.

Patients with multiple organ failure (MOF) often receive large amounts of resuscitation fluid, making them at high risk of fluid overload (FO). Our main objective was to investigate if the ability to achieve a negative fluid balance during the first 3 continuous renal replacement therapy (CRRT) days was associated with mortality in children with MOF. Retrospective cohort study in a tertiary multidisciplinary academic paediatric hospital. The study included 63 patients (age 0-18 years) with 3 or more failing organs receiving CRRT due to acute kidney injury and/or fluid overload. The median age was 4 months, and PICU mortality was 29%. Survivors had significantly lower degree of FO at CRRT initiation, (median 15% (Interquartile range 9-22)) than non-survivors (24% (17%-37%), P=0.002). On PICU admission, PIM-3 score was significantly higher in non-survivors (P=0.01), but at CRRT initiation there was no difference in PELOD-2 score (P=0.98). Mortality in patients achieving a cumulative net negative fluid balance during the first 3 days after CRRT initiation was 12%, compared to 86% in those not achieving this (P<0.0001). In multivariate analysis, the inability to achieve a net negative fluid balance during 3 days after CRRT initiation (P<0.0001) and FO>20% at CRRT initiation (P=0.0019) remained associated with mortality. Our results suggest that early fluid removal is associated with improved patient outcome in critically ill children receiving CRRT, and that prompt measures should be taken to prevent fluid overload in critical illness. These results need to be verified in further, prospective studies.

Abstract P-215: PIPERACILLIN PHARMACOKINETICS AND DOSING REGIMEN OPTIMIZATION IN CRITICALLY ILL CHILDREN WITH NORMAL AND AUGMENTED RENAL CLEARANCE

Aims & Objectives: Our objectives were to build a pediatric population pharmacokinetic model for Piperacillin, in order to optimize individual dosing regimen. Methods All children admitted in pediatric intensive care unit and receiving intermittent Piperacillin infusions were included. Piperacillin was quantified by high performance liquid chromatography. Pharmacokinetics were described using the non-linear mixed effect modelling software MONOLIX. Monte Carlo simulations were used to optimize dosing regimen, in order to maintain plasma concentration above the minimum inhibitory concentration (16 mg.L-1 for Pseudomonas aeruginosa) throughout the dosing interval (100% fT>MIC). Results We included 50 children with a median (range) post natal age of 27.2 (1.1–222.9) months, median (range) body weight of 11.9 (2.7–50) kg, median (range) PELOD-2 score of 4 (0–16) and median (range) estimated creatinine clearance of 142 (29–675) mL.min-1.m-2. A one compartment model with first-order elimination adequately described the data. Median (range) values for clearance and volume of distribution were respectively 3 (0.71–10) L.h-1 and 3.8 (0.72–25.8) L. Body weight (allometric relationship), estimated creatinine clearance and PELOD-2 severity score were the covariates explaining the estimated between subject variability. To reach the target and according to the simulated dosing regimens, children with acute kidney injury should receive intermittent infusion every 6 hours, administered on 30 minutes. Those with augmented renal clearance should receive a continuous infusion. Conclusions To reach the target, standard intermittent Piperacillin dosing regimen in critically ill children is not appropriate. In addition to body weight, dosing regimens should take into account the creatinine clearance. Continuous infusion is adequate for children with augmented renal clearance.

Acute gut injury: prevalence and impact on outcome in critically ill children

Objectives: Primary: To estimate prevalence of acute gut injury (AGI) in critically ill children during first week. Secondary: To estimate impact of AGI on mortality in critically ill children. Material and Methods: Current study is a part of larger prospective cohort study which includes all children aged between 1 month to 18 years admitted to pediatric intensive care unit. Current study analyzed children admitted during December 2017 to April 2018. Children with chronic gastrointestinal symptoms were excluded. European Society of Intensive Care Medicine classification was used to classify for AGI into four categories. Clinical details and outcome parameters were recorded. Results: Thirty-one children were included in the analysis. Median (IQR) age of the children was 32.5 (7.5-96) months; 32% of patients were male. Thirteen (42%) children died. Prevalence of AGI, gut dysfunction (AGI≥2), and gut failure (AGI≥3) was 64.5%, 41.9% and 22.6% respectively. Mortality was significantly increased in patients with AGI, gut dysfunction and gut failure (18% vs 82%, p = 0.047; 22.5% vs 77.8%, p= 0.009 and 29.1% vs 70.9%, p=0.008 respectively). Area under curve of receiver operating curve (AUC-ROC) for prediction of mortality of worst AGI and worst PELOD-2 score in first week were not significantly different (76.4 % and 81.3% respectively, p=0.67). Conclusion: Acute gut injury and gut dysfunction are significant among critically ill children and are associated with increased mortality. With new objective AGI classification, gut dysfunction should be included as measure of organ dysfunction among pediatric organ dysfunction scores.

The Effect of Diagnostic Blood Loss on Anemia and Transfusion Among Postoperative Patients With Congenital Heart Disease in a Pediatric Intensive Care Unit

PurposeTo evaluate whether diagnostic blood loss can lead to anemia and consequent blood transfusion among postoperative patients with congenital heart disease (CHD) in the pediatric intensive care unit (PICU). Design and MethodsThis prospective observational study was conducted in a university-affiliated tertiary hospital between January and August 2016. CHD patients aged <12years, undergoing cardiac surgery, with a PICU stay >48h were included (n=205). Multivariate logistic regression analyses were used to determine the effect of diagnostic blood loss on anemia and transfusion. ResultsThe mean daily phlebotomy volume was 5.40±1.94mL/d during the PICU stay (adjusted for body weight, 0.63±0.36mL/kg/d). Daily volume/kg was associated with cyanotic CHD, Pediatric Risk of Mortality III score, and Pediatric Logistic Organ Dysfunction (PELOD)-2 score. In total, 101 (49.3%) patients presented with new or more severe anemia after admission to PICU, which was not associated with phlebotomy volume. Forty-one (20.0%) children received one or more RBC transfusions during their PICU stay. Multivariate analysis indicated that PELOD-2 score>5, new or more severe anemia, and daily volume/kg of phlebotomy >0.63mL/kg/d were significantly associated with transfusion after 48h of admission to PICU. ConclusionsOur findings indicate that diagnostic blood loss is not related to postoperative anemia in children with CHD; however, this factor does correlate with blood transfusion, since it somewhat reflects the severity of illness. Practice ImplicationsStrategies should be applied to reduce diagnostic blood loss, as appropriate.

Performance of the PEdiatric Logistic Organ Dysfunction-2 score in critically ill children requiring plasma transfusions.

Background Organ dysfunction scores, based on physiological parameters, have been created to describe organ failure. In a general pediatric intensive care unit (PICU) population, the PEdiatric Logistic Organ Dysfunction-2 score (PELOD-2) score had both a good discrimination and calibration, allowing to describe the clinical outcome of critically ill children throughout their stay. This score is increasingly used in clinical trials in specific subpopulation. Our objective was to assess the performance of the PELOD-2 score in a subpopulation of critically ill children requiring plasma transfusions.Methods This was an ancillary study of a prospective observational study on plasma transfusions over a 6-week period, in 101 PICUs in 21 countries. All critically ill children who received at least one plasma transfusion during the observation period were included. PELOD-2 scores were measured on days 1, 2, 5, 8, and 12 after plasma transfusion. Performance of the score was assessed by the determination of the discrimination (area under the ROC curve: AUC) and the calibration (Hosmer–Lemeshow test).ResultsFour hundred and forty-three patients were enrolled in the study (median age and weight: 1 year and 9.1 kg, respectively). Observed mortality rate was 26.9 % (119/443). For PELOD-2 on day 1, the AUC was 0.76 (95 % CI 0.71–0.81) and the Hosmer–Lemeshow test was p = 0.76. The serial evaluation of the changes in the daily PELOD-2 scores from day 1 demonstrated a significant association with death, adjusted for the PELOD-2 score on day 1.ConclusionsIn a subpopulation of critically ill children requiring plasma transfusion, the PELOD-2 score has a lower but acceptable discrimination than in an entire population. This score should therefore be used cautiously in this specific subpopulation.