Does PELOD measure organ dysfunction…and is organ function a valid surrogate for death?

Performance of the pediatric logistic organ dysfunction (PELOD) and (PELOD-2) scores in a pediatric intensive care unit of a developing country

The study aimed to compare two scores: the pediatric logistic organ dysfunction (PELOD) with its updated version (PELOD-2) in describing the severity of organ dysfunction in pediatric intensive care unit (PICU) and assess the performance of PELOD-2 in the Egyptian population. A prospective cohort study of 200 patients consecutively admitted to PICU between July 2015 and A 2016 was included. The median age was 6 months, and the male to female ratio was 1.04. The median length of PICU stay was 4 days. The overall predicted number of deaths using PELOD was 76 patients whereas, by PELOD-2, it was 50 patients. The observed mortality was 50 patients. The area under the receiving operating characteristic curve was excellent for both PELOD and PELOD-2 (0.93 and 0.91, respectively). The Hosmer and Lemeshow goodness-of-fit test showed good calibration of PELOD-2 (χ ² = 9.9, p = 0.27), while PELOD showed poor calibration (χ ² = 42, p = 0.000) in the same studied group.

CONCLUSION

Both scores had excellent discrimination. PELOD-2 is reproducible and easier to perform and had better calibration compared to PELOD score. What is Known: • Pediatric logistic organ dysfunction (PELOD) score was developed 1999 and validated in 2003 to describe the organ dysfunction severity in pediatric intensive care units. • A new and easier version of (PELOD-2) was developed 2013 in France and Belgium to replace the old score. It is important to assess the performance of the new score in other population else than the original. What is New: In an Egyptian pediatric intensive care, the performance of the score revealed: • PELOD-2 was an excellent discriminatory score comparable to the original score. • PELOD-2 calibrated well in the Egyptian population while the old score had poor calibration.

Relationship between risk-adjustment tools and the pediatric logistic organ dysfunction score

BACKGROUND

The Risk-Adjusted Classification for Congenital Heart Surgery (RACHS-1) method and Aristotle Basic Complexity (ABC) scores correlate with mortality. However, low mortality rates in congenital heart disease (CHD) make use of mortality as the primary outcome measure insufficient. Demonstrating correlation between risk-adjustment tools and the Pediatric Logistic Organ Dysfunction (PELOD) score might allow for risk-adjusted comparison of an outcome measure other than mortality.

METHODS

Data were obtained from the Virtual PICU Systems database. Patients with postoperative CHD between 2009 and 2010 were included. Correlation between RACHS-1 category and PELOD score and between ABC level and PELOD score was examined using Spearman rank correlation. Consistency of PELOD scores across institutions for given levels of case complexity was examined using Kruskal-Wallis nonparametric analysis of variance.

RESULTS

A total of 1,981 patient visits among 12 institutions met inclusion criteria. Positive correlations between PELOD score and RACHS-1 category (r s = .353, P < .0001) as well as between PELOD score and ABC level (r s = .328, P < .0001) were demonstrated. Variability in PELOD scores across individual centers for given levels of case complexity was observed (P < .04).

CONCLUSIONS

Risk-Adjusted Classification for Congenital Heart Surgery categories and ABC levels correlate with postoperative organ dysfunction as measured by PELOD. However, the correlation was weak, potentially due to limitations of the PELOD score itself. Identification of a more accurate metric of morbidity for the congenital heart disease population is needed.

Adjunctive corticosteroid therapy in pediatric severe sepsis: observations from the RESOLVE study

OBJECTIVE

To assess whether corticosteroids, used as adjunctive therapy for pediatric severe sepsis, is associated with improved outcomes.

DESIGN

Retrospective cohort study examining the clinical database derived from the RESOLVE (REsearching severe Sepsis and Organ dysfunction in children: a gLobal perspective, F1K-MC-EVBP) trial of activated protein C for pediatric severe sepsis.

SETTING

A total of 104 pediatric centers in 18 countries from which data were originally gathered.

SUBJECTS

Children with severe sepsis (n = 477), requiring both vasoactive-inotropic infusions and mechanical ventilation. Within this cohort, 193 children received corticosteroids during their septic episode and 284 did not.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Baseline summary characteristics demonstrated that children receiving or not receiving corticosteroids had similar demographics and disease severity as indicated by age, gender, mean Pediatric Risk of Mortality scores, and mean number of organ dysfunctions. Use of adjunctive corticosteroids increased during the F1K-MC-EVBP trial. Indications for corticosteroid prescription were therapeutic (89%, mostly shock) and prophylactic (13%). All cause 28-day mortality among children receiving and not receiving corticosteroids was 15.1% and 18.8%, respectively, p = .30. There was no difference in mean vasoactive-inotropic infusion days between the corticosteroid and no corticosteroid groups, 4.5 days vs. 4.3 days, respectively, p = .59. Similarly there was no difference in mean ventilator days between the corticosteroid and no corticosteroid groups, 8.3 days vs. 7.7 days, respectively, p = .38.

CONCLUSIONS

Children with severe sepsis who received adjunctive corticosteroid therapy exhibited similar illness severity compared with those who did not. No definitive improvement in outcomes can be attributable to adjunctive corticosteroid therapy in the largest pediatric sepsis trial conducted to date.

Differences in organ dysfunctions between neonates and older children: a prospective, observational, multicenter study

Introduction

The multiple organ dysfunction syndrome (MODS) is a major cause of death for patients admitted to pediatric intensive care units (PICU). The Pediatric Logistic Organ Dysfunction (PELOD) score has been validated in order to describe and quantify the severity of organ dysfunction (OD). There are several physiological differences between neonates and older children. The objective of the study was to determine whether there are differences in incidence of ODs and mortality rate between full-term neonates (age <28 days) and older children.

Methods

In a prospective, observational study, 1806 patients, admitted to seven PICUs between September 1998 and February 2000 were included. The PELOD score, which includes six organ dysfunctions and 12 variables, was recorded daily. For each variable, the most abnormal value was used to define the daily OD. For each OD, the most abnormal value each day and that during the entire stay were used in calculating the daily PELOD and PELOD scores, respectively. The relationships between OD, daily OD, PELOD, daily PELOD and mortality were compared between the two strata (neonates, older children) based on the discrimination power, logistic and multiple regression analyses.

Results

Of the 1806 enrolled patients 171 (9.5%) were neonates. Incidence of MODS and mortality rate were higher among neonates than in older children (14.6% vs. 5.5%, P < 10^-7; 75.4%, vs. 50.9%, P < 10^-4; respectively). Daily PELOD scores were significantly higher in neonates from day 1 to day 4. Daily cardiovascular, respiratory and renal dysfunction scores from day 1 to day 4 as well as the PELOD score for the entire pediatric intensive care unit stay were also significantly higher in neonates. Neurological, cardiovascular, and hepatic dysfunctions were independent predictors of death among neonates while all ODs significantly contributed to the risk of mortality in older children.

Conclusions

Our data demonstrate that incidence of MODS and mortality rate are higher among neonates compared to older children. Neurological, cardiovascular, and hepatic dysfunctions were the only significant contributors to neonatal mortality. Stratification for neonates versus older children might be useful in clinical trials where MODS is considered as an outcome measure.