PRISM Score Research Articles

Abstract 14066: O -GlcNAc Levels Stimulation is a New Potential Therapeutic Strategy at the Early Phase of Septic Shock in the Young

Background: We have shown that increase in O -GlcNAc levels, a post-translational modification involved in the stress response, at the early phase of septic shock in adult (84 days old rats) is a potential new therapeutic strategy. Most studies focus in adults while the population most affected by septic shock, young children, is rarely studied. Considering that O- GlcNAc levels are higher in the young, the impact of O- GlcNAc on septic shock in the young should be tested. Purpose: Evaluate if O- GlcNAc stimulation could improve sepsis outcomes in young. Methods: Endotoxemic shock was induced in 28 days old rats with an i.v. injection of saline (CTRL, n=10) or LPS (O111:B4, 20mg.kg -1 - LPS, n=9). 1 hour after LPS rats were randomly assigned to no therapy (LPS), fluidotherapy (saline, 10ml.kg -1 - LPS+R, n=10) ± NButGT (10 mg.kg -1 - NButGT, n=11) to increase O- GlcNAc levels. 2 hours later, physiological functions and markers of severity were measured and used in adapted Pediatric RISk of Mortality score (PRISM score). The impact of treatment on survival was evaluated on n=16 per group. Mass spectrometry (MS) study was performed to identify O -GlcNAcylated proteins. Results: LPS induce a shock (mean arterial pressure (MAP): CTRL: 67.2 ± 1.9; LPS: 50.7 ± 2.1; mmHg; p<0.05), alter biological parameters (lactates: CTRL: 3.92 ± 0.26; LPS: 6.42 ± 0.45; mmol.l -1 ; pH: CTRL: 7.27 ± 0.02; LPS: 7.15 ± 0.02; p<0.05), PRISM score (p<0.05) and is associated with multi organs dysfunction (troponin T: CTRL: 19.7 ± 4.0; LPS: 45.4 ± 11.4; ng.l -1 ; creatinine: CTRL: 15.9 ± 1.5; LPS: 25.3 ± 2.6; μmol.l -1 ; p<0.05). LPS+R has no beneficial effect while NButGT improves MAP (p<0.05), PRISM score (p<0.05) and the median survival (NButGT: 36.0; LPS+R: 13.65; hours; p<0.001) compared to LPS+R treatment. MS highlight important variations of O- GlcNAcylation particularly that of mitochondrial proteins. Conclusions: Despite higher O- GlcNAc levels, we demonstrate that O- GlcNAc stimulation is also a potential new therapeutic strategy for septic shock in young. Our results show that it is the difference between the basal levels and the post-stimulation levels which induces a protection against sepsis. Proteins identify by MS will need to be specifically studied to decipher their impact in septic shock.

Abnormal Metaphase Cytogenetics Adds to Currently Known Risk-Factors for Venous Thromboembolism in Multiple Myeloma: Derivation of the PRISM score

Background: Prevention and management of venous thromboembolic events [VTE] is an important component of supportive care in newly diagnosed multiple myeloma [MM], especially in the era of immunomodulatory drugs [IMiDs]. Recently, two validated risk assessment models [RAMs], SAVED and IMPEDE-VTE, were developed to identify patients at high risk of VTE. However, these models have following limitations: (1) Patients were not uniformly treated in the era of contemporary MM therapy (2) Disease-specific variables were not available in the databases from which these scores were derived. Our primary aim was to develop a simple predictive model for VTE in MM using patient-specific, disease-specific, and treatment-specific variables. Our secondary aim was to assess the impact of VTE on overall survival [OS]. Methods: All consecutive patients with newly diagnosed MM treated at Cleveland Clinic from 1/1/2008 to 12/31/2018 were included in our analysis. The primary objective was to identify baseline variables associated with VTE within 12 months of treatment initiation. Candidate variables included those in IMWG, SAVED, and IMPEDE-VTE models as well as additional risk-factors from literature review in MM and cancer-associated VTE. Stepwise selection with variable entry criterion of p<0.20 and a variable retention criterion of p<0.05 was used to identify significant factors on multivariable analysis [MVA]. RAM was developed by subtracting 1 from the hazard ratio of a potential variable, rounding to the nearest 0.5, and multiplying by 2 to obtain a whole number. The impact of VTE on OS was assessed with landmark analysis. Results: A total of 934 patients with newly diagnosed MM and available data on VTE occurrence were considered for inclusion. We excluded patients with VTE within 6 months before starting therapy [n=5] and patients on therapeutic anticoagulation or receiving >1 prophylactic regimen [n=146], resulting in a total of 783 patients for model development. The most common induction regimen was bortezomib [V]-lenalidomide [R]-dexamethasone [VRD; 41%], followed by VD [22%], RD [20%], V-cyclophosphamide-dexamethasone [VCD; 11%], and others [7%]. Median age at treatment initiation was 63 years [range, 22-91], 55% were males, and 20% were Blacks. ISS stage III disease was present in 32%, high-risk FISH in 23%, abnormal metaphase cytogenetics in 18%, and serum creatinine >2 mg/dl in 19% of patients. Notably, 76% had received a dexamethasone dose of 120-160 mg/cycle, with only 5.9% started on a higher dose [>160 mg/cycle]. The most common thromboprophylaxis agent was aspirin [60%], followed by low molecular weight heparin [LMWH; 3.8%]; 37% of patients received no thromboprophylaxis. Erythropoietin and intravenous immunoglobulin were used in 2.9% and 1.2% of patients respectively. Median time to VTE from treatment initiation was 3.2 months. Cumulative incidence of VTE at 6 and 12 months was 8.2% [95% CI, 6.6-10.1] and 11.5% [95% CI, 9.5-13.6] respectively. Factors significantly associated with development of VTE on MVA were combined to develop the PRISM score [Table 1]: Prior VTE history [HR 5.06; 8 points], Black Race [HR 1.71; 1 point], IMiD use [HR 2.17; 2 points], Surgery within 3 months [HR 3.44; 5 points], and abnormal Metaphase cytogenetics [HR 2.10; 2 points]. The theoretical score range is 0-18, with a HR of 1.28 per 1-point increase in score [c-statistic 0.62]. Internal bootstrap validation including 1,000 samples showed a c-statistic of 0.62 [IQR, 0.60-0.64]. Using three risk groups by recursive partitioning analysis, 17.8%, 74%, and 8.1% belonged to low [0], intermediate [1-6], and high-risk [>6] groups respectively. The 12-month cumulative incidence of VTE in the 3 respective groups were 2.7%, 10.8%, and 36.5% [Figure 1]. Occurrence of VTE in the first 12 months was not associated with worse OS on landmark analysis at 3, 6, 9, and 12 months. Conclusion: We have developed and internally validated a RAM for VTE in MM in the context of contemporary MM therapy including disease-specific variables. Studies of external validation and comparison with existing RAMs are warranted. The PRISM Score could be used to identify high-risk patients for thromboprophylaxis. Figure Disclosures Valent: Amgen Inc.: Other: Teaching, Speakers Bureau; Takeda Pharmaceuticals: Other: Teaching, Speakers Bureau; Celgene: Other: Teaching, Speakers Bureau. Khouri:Sanofi Genzyme: Other: Advisory Board. Anwer:Incyte, Seattle Genetics, Acetylon Pharmaceuticals, AbbVie Pharma, Astellas Pharma, Celegene, Millennium Pharmaceuticals.: Honoraria, Research Funding, Speakers Bureau. Khorana:Pharmacyclics: Honoraria; Pfizer: Honoraria; Sanofi: Honoraria; Medscape: Honoraria; Leo Pharma: Honoraria; Seattle Genetics: Honoraria; Pharmacyte: Honoraria; Leap: Research Funding; Bayer: Honoraria; Janssen: Honoraria; Merck: Research Funding; Array: Other: Research funding (to institution); BMS: Honoraria, Research Funding.

Impact of the development of acute kidney injury on patients admitted to the pediatric intensive care unit

ObjectiveTo identify the risk factors for the development of acute kidney injury and for short and long‐term mortality of patients with acute kidney injury after admission to the Pediatric Intensive Care Unit. Materials and methodsRetrospective analysis of patients admitted to the Pediatric Intensive Care Unit from January 2004 to December 2008. Acute kidney injury was defined by the KDIGO criterion. Risk factors for acute kidney injury, in‐hospital, and long‐term mortality were obtained through multivariate logistic regression analysis. Long‐term mortality (up to 2011) was obtained by searching the institution's database and by telephone contact with patients’ family members. ResultsA total of 434 patients were evaluated and the incidence of acute kidney injury was 64%. Most acute kidney injury episodes (78%) occurred within the first 24 hours after admission to the Pediatric Intensive Care Unit. The risk factors for the development of acute kidney injury were: low volume of diuresis, younger age, mechanical ventilation, vasoactive drugs, diuretics, and amphotericin. Lower weight, positive fluid balance, acute kidney injury, dopamine use and mechanical ventilation were independent risk factors for in‐hospital mortality. Long‐term mortality was 17.8%. Systolic blood pressure, PRISM score, low volume of diuresis, and mechanical ventilation were independent risk factors associated with long‐term mortality after admission to the Pediatric Intensive Care Unit. ConclusionAcute kidney injury was a frequent, early event, and was associated with in‐hospital mortality and long‐term mortality after admission to the Pediatric Intensive Care Unit.

The effect of thiaminepyrophosphate levels on mortality and morbidity ın patients with stress hyperglycemia

Background: The aim of this study is to evaluate the thiamine pyrophosphate deficiency and effects on critical illness hyperglycemia in pediatric intensive care. Materials-Methods: 126 critically ill children included to the study which applied to Erciyes University Faculty of Medicine, Department of Pediatric Intensive Care Unit (ICU). Age, sex, diagnosis and presence of malnutrition in admission to ICU; Pediatric risk of Mortality III (PRISM III) and Pediatric Logistic Organ Dysfunction (PELOD) scores; mechanical ventilation and length of stay in ICU was evaluated. Blood glucose, thiamine pyrophosphate, cortisol, insulin, C-peptide, HbA1c level, serum lactate in blood gas were analyzed at the time of application. Results: The patients grouped based on blood glucose levels, the group whose glucose level in blood is more than 150 mg/dl (n:75); PRISM and PELOD scores were high, mechanical ventilation and length of stay in intensive care were longer, thiamine pyrophosphate levels were lower (p<0.001, p=0.005, p=0.008, p<0.001, p<0.01). In case of blood glucose >150 mg/dl (n:51) and thiamine pyrophosphate <180 nmol/l is together; mortality increases 3.342-fold and the case was statistically significant (p=0.014). The group whose glucose level in blood is more than 150 mg/dl respectively, insulin, c-peptide and cortisol levels found high and the findings were statistically significant (p<0.001, p=0.005, p=0.040). Conclusion: Stress hyperglycemia is a common situation seen in critically ill patients as a cause of worse clinical outcomes. Identification of stress hyperglycemia due to thiamine deficiency is difficult but it will shed light on the treatment of critically ill children.

Association of Urinary Albumin:Creatinine Ratio with Outcome of Children with Sepsis.

ABSTRACTObjectiveThe aim of the study was to investigate the association of urinary albumin:creatinine ratio (ACR) with regard to the outcome of sepsis patients and to study the trends of ACR with severity of disease, organ dysfunction, microcirculation status, the use of inotrope, and mechanical ventilation use, and length of pediatric intensive care unit (PICU) stay.Materials and methodsIn the prospective observational study, the patients with varying categories of sepsis admitted in the PICU with stay >24 hours were enrolled consecutively. Urine samples were collected at the time of admission (ACR1), 12 hours (ACR2), and 24 hours (ACR3).ResultsOne hundred and thirty-eight patients including 56 cases of sepsis, 31 of severe sepsis, 22 of septic shock, and 29 of multiorgan dysfunction syndrome (MODS) cases were analyzed. There were 29 (21%) deaths. ACR (median, IQR) was significantly higher in nonsurvivors [ACR1 198.9 (111.2–329.4) vs 124.5 (59.37–294.5), p 0.03], [ACR2 213.8 (112.5–350) vs 117.8 (62.6–211.9) p 0.008], [ACR3 231.8 (99.9–441.2 vs 114.4 (44.1–240.3), p 0.005]. The ACR is increased progressively with the increasing severity of sepsis (p < 0.001). The performance of ACR operative characteristics was compared with that of PRISM and PELOD scores. In deceased, ACR was significantly correlated with blood pH, lactate, and base deficit. A cutoff value of ACR 102.7 mg/g had sensitivity 86.2%, specificity 40.4%, positive predictive value 27.8%, and negative predictive value 91.7%. The use of inotropes, mechanical ventilation (>48 hours), and mortality was significantly higher in patients with ACR >102 mg/g. The probability of death varied from 17.6 to 19% in the first 24 hours of admission. ACR was significantly cheaper as compared to PRISM score and PELOD score estimations.ConclusionUrinary ACR, a cost-effective tool, correlates with the severity of sepsis and associated morbidity and mortality in children.How to cite this articleSachdev A, Raheja K, Gupta N, Chugh P. Association of Urinary Albumin:Creatinine Ratio with Outcome of Children with Sepsis. Indian J Crit Care Med 2020;24(6):465–472.

A unique population in today’s paediatric intensive care unit: immigrant children presenting with infectious diseases

IntroductionDespite similar disease severity scores; we found a higher crude death rate in the group of immigrant children compared to the group of native children in a paediatric intensive care unit. Our study aimed to compare descriptive data and standardised mortality ratios (SMR) in order to analyse differences in mortality. Material and MethodsWe conducted a retrospective study comparing demographic characteristics, diagnostic data, disease severity scores and mortality in immigrant children of Syrian descent and children of Turkish descent. We included data for the medical and surgical patients admitted in 1 year. The sample included 1283 patients. ResultsWe compared the age and sex distribution, presence of underlying disease, frequency of community-acquired infectious diseases, length of say, PRISM scores, SMR and crude death rates in the 2 groups.There were 1077 patients in the Turkish group and 206 patients in the immigrant group. The proportion of patients with underlying disease was greater in the Turkish group (42% vs 37.4%). The proportion of patients with a community-acquired infectious disease as the presenting complaint was similar in both groups (52.9% vs 47.4%). The mortality in patients with infectious disease was higher in the immigrant group (19.3% vs 9.8%). There was not significant difference in the mean PRISM score between the 2 groups. We found a higher mortality in the immigrant group (16% vs 11%). The standardised mortality ratio was 0.32 in the total sample, group; 0.4 in the immigrant group and 0.24 in the Turkish group. ConclusionsIn our study, we found an association between community-acquired infectious disease and increased mortality in the immigrant group. The underlying mechanism for this increase remains to be explained and further research is required to determine whether parameters related to infection should be added to this severity score for its use in this specific population.

The patient demographics, radiographic index and surgical invasiveness for mechanical failure (PRISM) model established for adult spinal deformity surgery

Mechanical failure (MF) following adult spinal deformity (ASD) surgery is a severe complication and often requires revision surgery. Predicting a patient’s risk of MF is difficult, despite several potential risk factors that have been reported. The purpose of this study was to establish risk stratification model for predicting the MF based on demographic, and radiographic data. This is a multicenter retrospective review of the risk stratification for MF and included 321 surgically treated ASD patients (55 ± 19 yr, female: 91%). The analyzed variables were recorded for at least 2 yr and included age, gender, BMI, BMD, smoking status, frailty, fusion level, revision surgery, PSO, LIF, previous surgery, spinal alignment, GAP score, Schwab-SRS type, and rod materials. Multivariate logistic regression analyses were performed to identify the independent risk factors for MF. Each risk factor was assigned a value based on its regression coefficient, and the values of all risk factors were summed to obtain the PRISM score (range 0–12). We used an 8:2 ratio to split the data into a training and a testing cohort to establish and validate the model. MF developed in 41% (n = 104) of the training subjects. Multivariate analysis revealed that BMI, BMD, PT, and frailty were independent risk factors for MF (BMI: OR 1.7 [1.0–2.9], BMD: OR 3.8 [1.9–7.7], PT: OR 2.6 [1.8–3.9], frailty: OR 1.9 [1.1–3.2]). The MF rate increased with and correlated well with the risk grade as shown by ROC curve (AUC of 0.81 [95% CI 0.76–0.86]). The discriminative ability of the score in the testing cohort was also good (AUC of 0.86 ([95% CI 0.77–0.95]). We successfully developed an MF-predicting model from individual baseline parameters. This model can predict a patient’s risk of MF and will help surgeons adjust treatment strategies to mitigate the risk of MF.

Plasma lactate can improve the accuracy of the Pediatric Sequential Organ Failure Assessment Score for prediction of mortality in critically ill children: A pilot study

BackgroundPlasma lactate has been used to predict the prognosis of critically ill children, but mortality risk scores appear to be more appealing, particularly in resource-limited countries. ObjectiveTo assess the prognostic utility of lactate compared with the pediatric Sequential Organ Failure Assessment (pSOFA) score among the general pediatric intensive care unit (PICU) population. MethodsThis was a prospective observational study including 78 children admitted to a tertiary-level PICU. Plasma lactate was measured upon admission and repeated 24h later. pSOFA score, Pediatric Risk of Mortality, and Pediatric Index of Mortality-2 (PIM2) were calculated. The primary outcome was 30-day mortality. ResultsIn total, 47.4% of patients had hyperlactatemia at admission. Among these, 20.5% had persistent hyperlactatemia. No significant difference in admission lactate level was found between survivors and nonsurvivors. The 24-h, peak, and average lactate levels were higher among nonsurvivors (P=0.005, 0.035, and 0.019, respectively). The 24-h lactate level and pSOFA score were independent predictors of mortality (adjusted odds ratio and 95% confidence interval=1.12 [1.02–1.23] and 1.80 [1.23–2.64], respectively]. The 24-h lactate level showed positive correlations with pSOFA, PRISM, and PIM2 (Spearman correlation coefficient=0.31, 0.23, 0.43; P=0.006, P=0.047, P<0.001, respectively). The 24-h lactate level had an area under the receiver operating characteristic curve (AUC) of 0.77 (P=0.013) for mortality prediction, while admission, peak, and average lactate level had an AUC of 0.69, 0.69, 0.71 (P=0.086, P=0.035, P=0.019), respectively. PIM2, PRISM, and pSOFA score had an AUC of 0.80, 0.78, 0.82 (P=0.001, P=0.001, and P<0.001), respectively. Combining 24-h lactate level with pSOFA demonstrated superior performance (AUC=0.88). ConclusionBoth 24-h lactate level and pSOAF are useful for prediction of mortality. Incorporating the 24-h lactate level into the pSOFA Score achieved superior prognostic utility.

Potassium disorders in pediatric emergency department: Clinical spectrum and management

IntroductionPotassium abnormalities are frequent in intensive care but their incidence in the emergency department is unknown. AimWe describe the spectrum of potassium abnormalities in our tertiary-level pediatric emergency department. MethodsRetrospective case-control study of all the patients admitted to a single-center tertiary emergency department over a 2.5-year period. We compared patients with hypokalemia (<3.0mEq/L) and patients with hyperkalemia (>6.0mEq/L) against a normal randomized population recruited on a 3:1 ratio with potassium levels between 3.5 and 5mEq/L. ResultsBetween January 1, 2013 and August 31, 2016 we admitted 108,209 patients to our emergency department. A total of 9342 blood samples were tested and the following potassium measurements were found: 60 cases of hypokalemia (2.8±0.2mEq/L) and 55 cases of hyperkalemia (6.4±0.6mEq/L). In total, 200 patients with normokalemia were recruited (4.1±0.3mEq/L). The main causes of the disorders were non-specific: lower respiratory tract infection (23%) and fracture (15%) for hypokalemia, lower respiratory tract (21.8%) and ear–nose–throat infections (20.0%) for hyperkalemia. Patients with hyperkalemia had an elevated creatinine level (0.72±1.6 vs. 0.40±0.16mg/dL, P<0.0001) with lower bicarbonate (19.4±3.8 vs. 21.8±2.8mmol/L, P=0.0001) and higher phosphorus levels (1.95±0.6 vs. 1.42±0.27mg/dL, P=0.0001). Patients with hypokalemia had an elevated creatinine level (0.66±0.71 vs. 0.40±0.16mg/dL, P<0.0001) and a lower phosphorus level (1.12±0.31 vs. 1.42±0.27mg/dL, P=0.0001). We did not observe significant differences in pH, PCO2, base excess and lactate, or in the mean duration of hospitalization in general wards and pediatric intensive care units according to the PIM and PRISM scores. DiscussionDyskalemia is rare in emergency department patients: 0.64% for hypokalemia and 0.58% for hyperkalemia. This condition could be explained by a degree of renal failure due to transient volume disturbance. The main mechanism is dehydration due to digestive losses, polypnea in young patients, and poor intake. In the case of hypokalemia, poor intake and digestive losses could be the main explanation. These disorders resolve easily with feeding or perfusion and do not impair development. ConclusionDyskalemia is rare in emergency department patients and is easily resolved with feeding or perfusion. A plausible etiological mechanism is a transient volume disturbance. Dyskalemia is not predictive of poor development in the emergency pediatric population.

Heart failure mortality prediction using PRISM score and development of a classification and regression tree model to refer patients for palliative care consultation

IntroductionWe sought to assess one-year mortality in heart failure (HF) patients by using (Placement Resource Indicator for Systems Management) PRISM, a disease nonspecific risk stratification score, and use it along with modified Seattle Heart Failure Model (SHFM) to guide patient selection for palliative care consultation. MethodsA retrospective study design was used to examine 1-year mortality in 689 HF patients admitted from 2012 to 2014. One-year mortality was calculated using Pmort30/PRISM and modified SHFM scores, and the predicted scores were validated using the area under the ROC curve. CART was used to develop an algorithm to classify patients based on their mortality risk. ResultsThe discriminatory ability of PRISM categorical score (AUC = 0.701) was not significantly different than the discriminatory ability of modified SHFM (AUC = 0.686) (DeLong's test p = 0.56) but improved significantly with the combination of PRISM (categorical) score + modified SHFM (AUC = 0.740) (p = 0.002). The predictive capability of the CART tree model after cross-validation was 72.2% (AUC 0.631). ConclusionOur study suggests PRISM score performed as well as modified SHFM for one-year mortality prediction. Moreover, the addition of modified SHFM to PRISM score increases discriminatory ability in predicting 1-year mortality in heart failure patients compared to either of the two models alone. Together, when combined in a CART model, they can be used to identify the population subset with the highest mortality risk and hence guide goals of care discussion.

Predictors for Mortality in Children with Scorpion Envenomation Admitted to Pediatric Intensive Care Unit, Qena Governorate, Egypt.

This study aimed to identify the clinical and laboratory manifestations that affect outcome of scorpion envenomation in children. It included 154 children admitted with scorpion sting envenomation over a period of 2 years. The epidemiological, clinical, and laboratory findings of patients were recorded, and grading of severity was performed based on local and systemic involvement. Organ failure was determined according to diagnostic criterion of multiple organ dysfunction syndrome, and severity of illness was assessed by the Pediatric Risk of Mortality (PRISM III) score. Of studied children, 58.4% were males and 41.6% were females. Children aged > 5 years suffered more scorpion stings (79.9%) than others did. The place of residence was rural more than urban, outdoor stings more than indoors, nocturnal more than diurnal, and most stings were on the exposed areas of the limbs. Based on clinical evaluation, 37.7% of patients were classified as class I severity followed by class II (48.7%) and class III (13.6%). Among studied cases, 21 deaths (13.6%) were registered; all of them belonged to class III severity. Mortality was significantly higher in children with agitation, coma, convulsions, arrhythmia, heart failure, pulmonary edema, and priapism. There were significantly higher values of leukocytes, platelets, creatinine, liver enzymes, glucose, and creatine phosphokinase in non-survivors than in survivors. The presence of organ failure was associated with mortality. In addition, the need for mechanical ventilation and inotropic support were at increased risk of mortality. Moreover, a significant association was found between PRISM score and the number of failed organs with fatal outcome.

Vitamin A deficiency in critically ill children with sepsis

BackgroundData that indicate vitamin A status in critically ill children with sepsis are sparse. The association between serum vitamin A levels and the clinical outcomes of sepsis has not been well assessed. The aim of this study was to assess the prevalence of vitamin A deficiency in critically ill children with sepsis and its association with clinical outcomes.MethodsCritically ill children with sepsis admitted to the pediatric intensive care unit were engaged in this prospective study. Sex- and age-matched approximate-health children from the Department of Pediatric Surgery were enrolled as the control group. Blood samples were collected from all patients in the first 24 h of admission for the measurement of serum vitamin A status. We compared vitamin A status between the sepsis group and the control group. In addition, we compared the clinical characteristics of the two subgroups of septic patients with vitamin A deficiency and those without vitamin A deficiency. Univariate and multivariable methods were used to evaluate the association between vitamin A deficiency and septic shock.ResultsOne hundred sixty septic children and 49 approximate-health children were enrolled in this study. Vitamin A deficiency was found in 94 (58.8%) subjects in the study group and 6 (12.2%) subjects in the control group (P < 0.001). In septic patients, 28-day mortality and hospital mortality in patients with vitamin A deficiency were not significantly higher than that in patients without vitamin A deficiency (P > 0.05). However, vitamin A levels were inversely associated with higher PRISM scores in septic children with VAD (r = − 0.260, P = 0.012). Vitamin A deficiency was associated with septic shock with an unadjusted odds ratio (OR) of 3.297 (95% confidence interval (CI), 1.169 to 9.300; P = 0.024). In a logistic model, vitamin A deficiency (OR, 4.630; 95% CI, 1.027–20.866; P = 0.046), procalcitonin (OR, 1.029; 95% CI, 1.009–1.048; P = 0.003), and the Pediatric Risk of Mortality scores (OR, 1.132; 95% CI, 1.009–1.228; P = 0.003) were independently associated with septic shock.ConclusionThe prevalence of vitamin A deficiency was high in children with sepsis. Vitamin A deficiency may be a marker of mortality in critically ill children with sepsis.Trial registrationClinicaltrials.gov, NCT03598127

Impact of the development of acute kidney injury on patients admitted to the pediatric intensive care unit

ObjectiveTo identify the risk factors for the development of acute kidney injury and for short and long-term mortality of patients with acute kidney injury after admission to the Pediatric Intensive Care Unit. Materials and methodsRetrospective analysis of patients admitted to the Pediatric Intensive Care Unit from January 2004 to December 2008. Acute kidney injury was defined by the KDIGO criterion. Risk factors for acute kidney injury, in-hospital, and long-term mortality were obtained through multivariate logistic regression analysis. Long-term mortality (up to 2011) was obtained by searching the institution’s database and by telephone contact with patients’ family members. ResultsA total of 434 patients were evaluated and the incidence of acute kidney injury was 64%. Most acute kidney injury episodes (78%) occurred within the first 24hours after admission to the Pediatric Intensive Care Unit. The risk factors for the development of acute kidney injury were: low volume of diuresis, younger age, mechanical ventilation, vasoactive drugs, diuretics, and amphotericin. Lower weight, positive fluid balance, acute kidney injury, dopamine use and mechanical ventilation were independent risk factors for in-hospital mortality. Long-term mortality was 17.8%. Systolic blood pressure, PRISM score, low volume of diuresis, and mechanical ventilation were independent risk factors associated with long-term mortality after admission to the Pediatric Intensive Care Unit. ConclusionAcute kidney injury was a frequent, early event, and was associated with in-hospital mortality and long-term mortality after admission to the Pediatric Intensive Care Unit.

Clinical observation of venous-arterial extracorporeal membrane oxygenation in the treatment of refractory septic shock in children

Objective To investigate the efficacy of venous-arterial extracorporeal membrane oxygenation (VA-ECMO) in the treatment of refractory septic shock in children. Methods From January 2016 to December 2018, the clinical data of children with refractory septic shock (RSS) treated by VA-ECMO in Department of Critical Medicine Affiliated Children's Hospital of Shanghai Jiao Tong University were retrospectively analyzed. The patients with refractory septic shock (RSS) treated by VA-ECMO were compared with those with non-refractory septic shock (NRSS). Results There were 8 cases in the RSS-ECMO group and 6 cases in the NRSS-ECMO group. The sex, age, PRISM score, complication showed no significant difference in the two groups. The median time of ECMO in the RSS-ECMO group was 182 (141, 216) h , and 5 patients were survived and were discharged from the hospital. The blood lactic acid and vasoactive drug index in the RSS-ECMO group was significantly higher than that in the NRSS-ECMO group (P 0.05). After ECMO establishment, the mean invasive arterial pressure increased significantly at 6 h, and lactic acid decreased significantly at 12 h after ECMO support. SCVO2 returned to normal at 24-h ECMO therapy. Conclusions The success rate of VA-ECMO treatment in children with refractory septic shock complicated with MODS is similar to that of children with non-refractory septic shock. The relationship between ECMO and hemodynamic indexes in sepsis should be further explored. Key words: Venoarterial extracorporeal membrane oxygenation (VA-ECMO); Continuous renal replacement therapy (CRRT); Sepsis; Refractory septic shock; Mortality; Child

Predictive value of C-reactive protein and the Pediatric Risk of Mortality III Score for occurrence of postoperative ventilator-associated pneumonia in pediatric patients with congenital heart disease.

ImportanceVentilator‐associated pneumonia (VAP) is one of the most common complications after cardiac surgery in children with congenital heart disease (CHD). Early prediction of the incidence of VAP is important for clinical prevention and treatment.ObjectiveTo determine the value of serum C‐reactive protein (CRP) levels and the Pediatric Risk of Mortality III (PRISM III) score in predicting the risk of postoperative VAP in pediatric patients with CHD.MethodsWe performed a retrospective review of clinical data of 481 pediatric patients with CHD who were admitted to our pediatric intensive care unit. These patients received mechanical ventilation for 48 hours or longer after corrective surgery. On the basis of their clinical manifestations and laboratory results, patients were separated into two groups of those with VAP and those without VAP. CRP levels were measured and PRISM III scores were collected within 12 hours of admission to the pediatric intensive care unit. The Pearson correlation coefficient was used to evaluate the association of CRP levels and the PRISM score with the occurrence of postoperative VAP. A linear regression model was constructed to obtain a joint function and receiver operating curves were used to assess the predictive value.Results CRP levels and the PRISM III score in the VAP group were significantly higher than those in the non‐VAP group (P < 0.05). Receiver operating curves suggested that using CRP + the PRISM III score to predict the incidence of VAP after congenial heart surgery was more accurate than using either of them alone (CRP + the PRISM III score: sensitivity: 53.2%, specificity: 85.7%). When CRP + the PRISM III score was greater than 45.460, patients were more likely to have VAP.InterpretationAlthough using CRP levels plus the PRISM III score to predict the incidence of VAP after congenial heart surgery is more accurate than using either of them alone, its predictive value is still limited.

Hypomagnesemia as a predictor of mortality in critically ill pediatric patients in picu using prism score

Background: Magnesium is the fourth most abundant cation in the human body and the second most abundant intracellular cation after potassium. A potential relationship between low magnesium levels and increased mortality has been suggested in the literature. The objectives were to detect prevalence of hypomagnesemia in critically ill children, its association with sepsis and to correlate this with mortality.Methods: This study was an observational study done on 100 children who met the inclusion criteria, admitted to the PICU of Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India. Patients under the study were managed and treated according to their clinical status and supportive traditional treatment.Results: Prevalence of hypomagnesemia in critically ill pediatric patients was 53%. In this study, majority of the cases admitted to PICU were dengue (19%) and bronchopneumonia (15%) which were significantly associated with hypomagnesemia as p value was less than 0.05. As regard prognosis, Mg had an AUC of 0.576 for prediction of mortality whereas the AUC for PRISM score was 0.811. Logistic regression analysis showed that hypomagnesemia is a significant predictor for mortality among critically ill children (p value=0.028) and OR=3.180 (0.854-7.965).Conclusions: Present study has found high prevalence of hypomagnesemia in critically ill patients. Hypomagnesemia was associated with a higher mortality rate in critically ill patients and commonly associated with infections and respiratory diseases. Hypomagnesemia indicated poor outcome and higher mortality rates in critically ill patients.

Brain Death and Organ Donation in Paediatric Intensive Care Unit.

The purpose of the present study was to retrospectively analyse the brain death (BD) cases that were specified within the last 8 years in the paediatric intensive care unit of our hospital. Archive files and computer records of 23 paediatric cases were analysed. Data on age, gender, conditions that caused BD, paediatric risk of mortality (PRISM III) scores, time between suspicion of BD and issuing of BD report, confirmatory tests used, complications that occurred following the diagnosis of BD and time to cardiac arrest development after diagnosis of BD were recorded. The average age of the patients was 6.8±5.5 years. The most frequent cause of BD was intracranial haemorrhage (30.4%). The mean time to diagnosis after BD suspicion was 5.9±6.2 days. Electroencephalography was performed in 61% of the patients in addition to the apnoea test. Radiological imaging methods were used in 39% of the patients (n=9). Of the cases, 34.7% developed hypothermia, and 4.3% developed diabetes insipidus (DI). Among them, 43.4% had both DI and hypothermia. The mean PRISM score was calculated as 22±9.2. The donation rate of the families was 17%. The mean time to cardiac arrest development after diagnosis of BD was 6.9±7.4 days in non-donor cases where medical support had been reduced. Any patient with a neurologically poor prognosis in the intensive care unit should be considered to develop BD and diagnosed with BD without delay. The donation rate will increase if family interviews are done by an experienced and educated coordinator.

Study of PRISM III score as a predictor of mortality in PICU

Objectives: To determine the discriminative ability of PRISM III scoring system in predicting mortality in children admitted to PICU. Methods: Prospective observational study in all children 1 month to 12 years of age admitted to PICU during July2017 to June2018. Result: Out of 250 patients admitted in the PICU, 133 were male & 117 were female. In the age group of 1 month to 12 months, 30(22.22%) expired while in 12 months to 12 years,18(11.65%) expired. Due to respiratory system involvement, mortality was 24(16.43%), due to central nervous system 8(17.39%) and septicemia 12(46.15%) . At 12 hours of admission, 214 patients had PRISM score 0 to 4, out of which 14 expired. 17 patients had score of 5 to 9, out of which 15 expired.19 patients had score >10 having 100% mortality. PRISM 24 score was taken 12 hours after the 1st score. 216 patients had PRISM score between 0 to 4, out of which 14 expired. 8 patients had score of 5 to 9 & 26 patients had score >10, out of which all expired. Conclusion: Since mortality rises with increase in PRISM 3 score at the time of admission, PRISM III score can be taken as an indicator of the initial severity of illness. PRISM III can help in selecting sick children for PICU admission and optimum utilization of limited PICU resources.

Spectrum and Immediate Outcome of Acute Kidney Injury in a Pediatric Intensive Care Unit: A Snapshot Study from Indian Subcontinent.

ABSTRACTBackground and aimsAcute kidney injury (AKI) became an important cause of mortality and morbidity in critically ill children, despite advancement in its management. In developing countries etiology of AKI are different from that of developed countries.Materials and methodsThis observational study was carried out in pediatric intensive care unit (PICU) in 2 months to18 years of critically ill children. Kidney injury was defined and categorized by the pRIFLE criteria.ResultsOut of 361children, 86 children (23.8%) developed AKI at some point during admission, 275 children (age and sex matched) who did not develop kidney injury during hospitalization served as non-AKI children. Maximum cases of AKI were seen in 1–5 years of age. Maximum children of AKI were of viral encephalitis (n = 43, 50.0%) followed by scrub typhus (n = 14, 16.3%). Risk factors for the development of AKI were shock, PRISM score and longer hospital stay. In our study the mortality in AKI children (n = 30, 34.8%) was significantly higher (p = 0.005) as compared to non-AKI children (n = 56, 20.3%)). Duration on mechanical ventilation, PICU stay and hospital stay were also significantly (p = 0.001) higher in AKI children.ConclusionAKI is common in critically ill children and associated with high mortality and morbidity.How to cite this articleBharat A, Mehta A, Tiwari HC, Sharma B, Singh A, Singh V. Spectrum and Immediate Outcome of Acute Kidney Injury in a Pediatric Intensive Care Unit: A Snapshot Study from Indian Subcontinent. Indian J Crit Care Med 2019;23(8):352-355.

Non-invasive positive pressure ventilation immediately after extubation in children - a randomized study

Objective: To compare the effects of noninvasive positive pressure ventilation(NIPPV) and oxygen (OX) therapy in post-extubated patients on re-intubation rate, length of PICU and hospital stay and mortality. Methods: It was randomized interventional study.All patients on mechanical ventilation (MV) for more than 48 hours were assessed and were enrolled only after fulfilling inclusion criteria. Patients were randomized prior to extubation to receive NIPPV or OX therapy with mask after planned weaning and extubation following institutional protocols. Reintubation required within 48 hours of extubation was considered extubation failure. Results: 97 out of 137 patients were randomized and analyzed. There was no significant difference between two groups in the distribution of underlying disease, PRISM score 12 and 24, arterial blood gases, hemodynamic parameters and duration of invasive MV prior to extubation.The PaO2 at 2 and 6 hours after extubation were significantly higher in patients receiving NIPPV (P value 0.04, 0.01 respectively). Nineteen (19.5%) patients were reintubated within 48 hours of extubation. Thirteen (25%) patients belonged to OX group and 6 (13%) were in NIPPV group (P value 0.12, odds ratio 2.28, 95% CI 0.78-6.61). Commonest reason for reintubation was increased work of breathing. Four patients with failed extubation from OX group were provided rescue NIPPV with success. The total duration of stay in the PICU and hospital were not significantly different in study groups (P value 0.4, 0.4 respectively). Conclusion: Although reintubation were less, our study did not support early elective use of NIPPV immediately after extubation in children.