Performance of PRISM III and PELOD-2 scores in a pediatric intensive care unit

The death risk of pediatric patients with cancer-related sepsis requiring continuous renal replacement therapy: a retrospective cohort study

OBJECTIVE

To assess the outcome of patients with cancer-related sepsis requiring continuous renal replacement therapy (CRRT) in a single-center pediatric intensive care unit (PICU).

METHOD

Children with sepsis who necessitate CRRT from January 2017 to December 2021 were enrolled. The patients with leukemia/lymphoma or solid tumors were defined as underlying cancer. Multivariate logistic regression analysis was performed to identify the death risk factors in patients with cancer-related sepsis.

RESULTS

A total of 146 patients were qualified for inclusion. Forty-six (31.5%) patients with cancer-related sepsis and 100 (68.5%) non-cancer-related sepsis. The overall PICU mortality was 28.1% (41/146), and mortality was significantly higher in cancer-related sepsis patients compared with non-cancer patients (41.3% vs. 22.0%, p = 0.016). Need mechanical ventilation, p-SOFA, acute liver failure, higher fluid overload at CRRT initiation, hypoalbuminemia, and high inotropic support were associated with PICU mortality in cancer-related sepsis patients. Moreover, levels of IL-6, total bilirubin, creatinine, blood urea nitrogen, and international normalized ratio were significantly higher in non-survivors than survivors. In multivariate logistic regression analysis, pediatric sequential organ failure assessment (p-SOFA) score (OR:1.805 [95%CI: 1.047-3.113]) and serum albumin level (OR: 0.758 [95%CI: 0.581 -0.988]) were death risk factors in cancer-related sepsis receiving CRRT, and the AUC of combined index of p-SOFA and albumin was 0.852 (95% CI: 0.730-0.974).

CONCLUSION

The overall PICU mortality is high in cancer-related sepsis necessitating CRRT. Higher p-SOFA and lower albumin were independent risk factors for PICU mortality.

Hematological Indices for Identifying Adverse Outcomes in Children Admitted to Pediatric ICUs

BACKGROUND

The pediatric ICU (PICU) is a specialized area where critically sick children are managed. The mortality rates in PICUs are higher in developing countries as compared to developed nations. Many of these deaths could be prevented if very sick children were identified soon after they arrived at the health facility. Hematological indices like platelet lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) have been frequently used in adults as indicators of mortality. However, their use in the pediatric population is limited due to a lack of validated reference intervals.

OBJECTIVE

The objective of the study is to assess the role of hematological indices in identifying adverse outcomes in terms of mortality in children admitted to the PICU.

MATERIALS AND METHODS

It is a prospective, observational study done at a tertiary care hospital. All children aged one year to 12 years admitted to the PICU were enrolled in the study. A sample for complete blood count was taken within one hour of admission to the PICU. Children who had received blood products in the last two months, those on chronic medications (>two weeks) that can affect bone marrow cellularity, and known cases of hematological disorders such as megaloblastic anemia, hematological malignancies, immune thrombocytopenia, and aplastic anemia were excluded from the study. PLR, NLR, and platelets to mean platelet volume ratio (PLT/MPV) were determined and compared among the survivors and non-survivors.

RESULTS

 Out of 275 enrolled patients, 119 (43.3%) patients expired during the study period. While PLR had high sensitivity and NLR had high specificity (85.71% and 92.31%, respectively) for predicting mortality, none of these parameters had a good area under the curve (AUC) in our study. PLT/MPV of ≥32 had a sensitivity of 39.5% and a specificity of 56.41% for predicting mortality.

CONCLUSIONS

Hematological parameters have been used across the world to predict ICU mortality. PLR and NLR are simple hematological biomarkers, easy to calculate, and cost-effective, and ratios are better than individual parameters. More studies and stratified samples are required to evaluate the role of hematological markers in identifying the risk of mortality in children admitted to PICUs.

Pharmacist Metrics in the Pediatric Intensive Care Unit: an Exploration of the Medication Regimen Complexity-Intensive Care Unit (MRC-ICU) Score

INTRODUCTION

The medication regimen complexity-intensive care unit (MRC-ICU) score has been developed and validated as an objective predictive metric for patient outcomes and pharmacist workload in the adult critically ill population. The purpose of this study was to explore the MRC-ICU and other workload metrics in the pediatric ICU (PICU).

METHODS

This study was a retrospective cohort of pediatric ICU patients admitted to a single institution -between February 2, 2022 - August 2, 2022. Two scores were calculated, including the MRC-ICU and the pediatric Daily Monitoring System (pDMS). Data were extracted from the electronic health record. The primary outcome was the correlation of the MRC-ICU to mortality, as measured by Pearson -correlation -coefficient. Additionally, the correlation of MRC-ICU to number of orders was evaluated. Secondary -analyses explored the correlation of the MRC-ICU with pDMS and with hospital and ICU length of stay.

RESULTS

A total of 2,232 patients were included comprising 2,405 encounters. The average age was 6.9 years (standard deviation [SD] 6.3 years). The average MRC-ICU score was 3.0 (SD 3.8). For the primary outcome, MRC-ICU was significantly positively correlated to mortality (0.22 95% confidence interval [CI 0.18 - 0.26]), p<0.05. Additionally, MRC-ICU was significantly positively correlated to ICU length of stay (0.38 [CI 0.34 - 0.41]), p<0.05. The correlation between the MRC-ICU and pDMS was (0.72 [CI 0.70 - 0.73]), p<0.05.

CONCLUSION

In this pilot study, MRC-ICU demonstrated an association with existing prioritization metrics and with mortality and length of ICU stay in PICU population. Further, larger scale studies are required.

Component-resolved diagnosis in childhood and prediction of asthma in early adolescence: A birth cohort study

INTRODUCTION

Component-resolved diagnosis (CRD) has been decisive in exploring the mechanisms of IgE sensitization, but the predictive ability to detect asthma has not been addressed. We aim to develop and evaluate the performance of a personalized predictive algorithm for asthma that integrates information on allergic sensitization using CRD.

METHODS

One thousand one hundred one twenty-five children from the Generation XXI birth cohort were randomly selected to perform a screening test for allergic sensitization and a subsample was characterized using CRD against 112 allergen components. Allergen components were analyzed using volcano plots and partial least squares (PLS) analysis. Logistic regression was performed to assess the associations between the obtained latent components (LC) and allergic outcomes (asthma, rhinitis, eczema) including other potential predictors used in previous asthma risk scores. The accuracy of the model in predicting asthma was assessed using Receiver Operating Characteristic (ROC) curve statistics.

RESULTS

In the PLS, the first LC was positively associated with asthma, rhinitis, and eczema. This LC was mainly driven by positive weights for Der p 1/2/23, Der f 1/2, and Fel d 1. The main components in the second LC were pollen and food allergens. History of early wheezing and parental allergy were included in the predictive model and the area under the curve improved to 0.82.

CONCLUSIONS

This is the first approach to improve the clinical applicability of CRD by combining CRD and clinical data to predict asthma at 13 years. Sensitization to distinct allergen molecules seems relevant to improve the accuracy of asthma prediction models.

Predicting functional and quality-of-life outcomes following pediatric sepsis: performance of PRISM-III and PELOD-2

BACKGROUND

Illness severity scores predict mortality following pediatric critical illness. Given declining PICU mortality, we assessed the ability of the Pediatric Risk of Mortality-III (PRISM) and Pediatric Logistic Organ Dysfunction-2 (PELOD) scores to predict morbidity outcomes.

METHODS

Among 359 survivors <18 years in the Life After Pediatric Sepsis Evaluation multicenter prospective cohort study, we assessed functional morbidity at hospital discharge (Functional Status Scale increase ≥3 points from baseline) and health-related quality of life (HRQL; Pediatric Quality of Life Inventory or Functional Status II-R) deterioration >25% from baseline at 1, 3, 6, and 12 months post-admission. We determined discrimination of admission PRISM and admission, maximum, and cumulative 28-day PELOD with functional and HRQL morbidity at each timepoint.

RESULTS

Cumulative PELOD provided the best discrimination of discharge functional morbidity (area under the receive operating characteristics curve [AUROC] 0.81, 95% CI 0.76-0.87) and 3-month HRQL deterioration (AUROC 0.71, 95% CI 0.61-0.81). Prediction was inferior for admission PRISM and PELOD and for 6- and 12-month HRQL assessments.

CONCLUSIONS

Illness severity scores have a good prediction of early functional morbidity but a more limited ability to predict longer-term HRQL. Identification of factors beyond illness severity that contribute to HRQL outcomes may offer opportunities for intervention to improve outcomes.

IMPACT

Illness severity scores are commonly used for mortality prediction and risk stratification in pediatric critical care research, quality improvement, and resource allocation algorithms. Prediction of morbidity rather than mortality may be beneficial given declining pediatric intensive care unit mortality. The PRISM and PELOD scores have moderate to good ability to predict new functional morbidity at hospital discharge following pediatric septic shock but limited ability to predict health-related quality of life outcomes in the year following PICU admission. Further research is needed to identify additional factors beyond illness severity that may impact post-discharge health-related quality of life.

Comparison of Three Different Multiple Organ Dysfunction Scores for Predicting Mortality after Neonatal Cardiac Surgery

Infants who undergo cardiac surgery frequently have complications that may advance to multiple organ failure and result in mortality. This study aims to compare three different multiple organ dysfunction scoring systems: the Neonatal Multiple Organ Dysfunction (NEOMOD) score, the modified NEOMOD score, and the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score in predicting postoperative 30-day mortality in neonates undergoing cardiac surgery. This retrospective cohort study was conducted between January 2019 and February 2021 in a single unit on neonates operated on due to congenital heart disease in the first 28 days of life. Patients who underwent off-pump surgeries were excluded from the study. The NEOMOD, modified NEOMOD, and PELOD-2 scores were calculated for each of the first 3 days following surgery. A total of 138 patients were included. All scores had satisfactory goodness-of-fit and at least good discriminative ability on each day. The modified NEOMOD score consistently demonstrated the best prediction among these three scores after the first day, reaching its peak performance on day 2 (area under curve: 0.824, CI: 0.75-0.89). Our findings suggest that NEOMOD and modified NEOMOD scores in the first 72 h could potentially serve as a predictor of mortality in this population.

Pediatric Reference Change Value Optimized for Acute Kidney Injury: Multicenter Retrospective Study in China

OBJECTIVES

The standard definition of pediatric acute kidney injury (AKI) is evolving, especially for critically ill in the PICU. We sought to validate the application of the Pediatric Reference Change Value Optimized for Acute Kidney Injury in Children (pROCK) criteria in critically ill children.

DESIGN

Multicenter retrospective study.

SETTING

Six PICUs in mainland China.

PATIENTS

One thousand six hundred seventy-eight hospitalized children admitted to the PICU with at least two creatinine values within 7 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

AKI was diagnosed and staged according to the Pediatric Risk, Injury, Failure, Loss, End-Stage Renal Disease (pRIFLE), the Kidney Disease Improving Global Outcomes (KDIGO), and the pROCK criteria. Multiple clinical parameters were assessed and analyzed along with 90-day follow-up outcomes. According to the definitions of pRIFLE, KDIGO, and pROCK, the prevalence of AKI in our cohort of 1,678 cases was 52.8% (886), 39.0% (655), and 19.0% (318), respectively. The presence of AKI, as defined by pROCK, was associated with increased number of injured organs, occurrence of sepsis, use of mechanical ventilation, use of continuous renal replace therapy ( p < 0.05), higher Pediatric Risk of Mortality III score, and higher Pediatric Logistic Organ Dysfunction-2 score ( p < 0.001). The survival curve of 90-day outcomes showed that pROCK was associated with shorter survival time (LogRank p < 0.001), and pROCK definition was associated with better separation of the different stages of AKI from non-AKI ( p < 0.001).

CONCLUSIONS

In this retrospective analysis of AKI criteria in PICU admissions in China, pROCK is better correlated with severity and outcome of AKI. Hence, the pROCK criteria for AKI may have better utility in critically ill children.

The Role of Childhood Obesity in Acute Presentations and Outcomes of Hospitalized COVID-19 Patients

Background and objective

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has affected all regions, demographics, and age groups worldwide. However, few studies have investigated the prevalence of childhood obesity and severe COVID-19 presentation in a predominately Hispanic population. In light of this, we investigated the role of underlying obesity in COVID-19 presentations and outcomes at a tertiary care children’s hospital by using subcategories based on patients' body mass index (BMI).

Methods

We conducted a single-center retrospective study involving 77 pediatric patients aged 18 years and younger, who were hospitalized with suspected or verified COVID-19 between February 2020 and January 2021. We collected data on height, weight, and BMI and categorized patients based on the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) definition(s) of obesity. We also collected data on demographics, mode of presentation, need for pediatric intensive care unit (PICU) admission, the severity of illness at the time of PICU admission, and data related to outcomes. We analyzed the data using logistical regression with Firth’s biased reduction method wherever applicable.

Results

In our cohort, over 85% of the patients identified as belonging to Hispanic ethnicity (n=66); the median age of the cohort was 8.69 years, and 50.65% were classified as obese (n=39). We found a statistically significant relationship between underlying obesity and one or more comorbidities (p<0.001). BMI classification was significantly dependent on the incidence of multisystem inflammatory syndrome in children (MIS-C) (p=0.0353). Furthermore, the bivariate analysis confirmed that acute kidney injury (AKI) (p=0.048) and MIS-C predictors (p<0.001) were significantly associated with PICU admission status. The combined model confirmed a significant relationship between MIS-C and both PICU admission status (p<0.001) and obese BMI classification (p=0.002). PICU admission status led to increased hospital length of stay (LOS) (p<0.001). Patient age (p=0.003), underweight BMI (p=0.034), and obese BMI (P=0.008) were significant predictors of PICU LOS. Of note, the survival rate among admitted COVID-19 patients was 93.5%.

Conclusion

Based on our findings on the prevalence of underlying obesity in admitted COVID-19 patients at the Children’s Hospital of San Antonio, over 50% of pediatric patients were obese and predominately Hispanic. Obesity was significantly associated with patient age, comorbidities, MIS-C status, and PICU LOS. Hospital mortality in pediatric COVID-19 patients was low (6.49%) and consistent with other studies in the literature showing lower rates of mortality in children versus mortality in adult patients with COVID-19.

Clinical implications of discrepancies in predicting pediatric mortality between Pediatric Index of Mortality 3 and Pediatric Logistic Organ Dysfunction-2

Background

Pediatric Index of Mortality 3 (PIM 3) and Pediatric Logistic Organ Dysfunction-2 (PELOD-2) are validated tools for predicting mortality in children. Research suggests that these tools may have different predictive performance depending on patient group characteristics. Therefore, we designed this study to identify the factors that make the mortality rates predicted by the tools different.

Methods

This retrospective study included patients (<18 years) who were admitted to a pediatric intensive care unit from July 2017 to May 2019. After defining the predicted mortality of PIM 3 minus the predicted mortality rate of PELOD-2 as “difference in mortality prediction,” the clinical characteristics significantly related to this were analyzed using multivariable regression analysis. Predictive performance was analyzed through the Hosmer-Lemeshow test and area under the receiver operating characteristic curve (AUROC).

Results

In total, 945 patients (median [interquartile range] age, 3.0 [0.0–8.0] years; girls, 44.7%) were analyzed. The Hosmer-Lemeshow test revealed AUROCs of 0.889 (χ²=10.187, P=0.313) and 0.731 (χ²=6.220, P=0.183) of PIM 3 and PELOD-2, respectively. Multivariable linear regression analysis revealed that oxygen saturation, partial pressure of CO₂, base excess, platelet counts, and blood urea nitrogen levels were significant factors. Patient condition-related factors such as cardiac bypass surgery, seizures, cardiomyopathy or myocarditis, necrotizing enterocolitis, cardiac arrest, leukemia or lymphoma after the first induction, bone marrow transplantation, and liver failure were significantly related (P<0.001).

Conclusions

Both tools predicted observed mortality well; however, caution is needed in interpretation as they may show different prediction results in relation to specific clinical characteristics.

Impact of Intracranial Hypertension on Outcome of Severe Traumatic Brain Injury Pediatric Patients: A 15-Year Single Center Experience

Background: Intracranial hypertension (IC-HTN) is significantly associated with higher risk for an unfavorable outcome in pediatric trauma. Intracranial pressure (ICP) monitoring is widely becoming a standard of neurocritical care for children. Methods: The present study was designed to evaluate influences of IC-HTN on clinical outcomes of pediatric TBI patients. Demographic, injury severity, radiologic characteristics were used as possible predictors of IC-HTN or of functional outcome. Results: A total of 118 pediatric intensive care unit (PICU) patients with severe TBI (sTBI) were included. Among sTBI cases, patients with GCS < 5 had significantly higher risk for IC-HTN and for mortality. Moreover, there was a statistically significant positive correlation between IC-HTN and severity scoring systems. Kaplan−Meier analysis determined a significant difference for good recovery among patients who had no ICP elevations, compared to those who had at least one episode of IC-HTN (log-rank chi-square = 11.16, p = 0.001). A multivariable predictive logistic regression analysis distinguished the ICP-monitored patients at risk for developing IC-HTN. The model finally revealed that higher ISS and Helsinki CT score increased the odds for developing IC-HTN (p < 0.05). Conclusion: The present study highlights the importance of ICP-guided clinical practices, which may lead to increasing percentages of good recovery for children.

Predictive Value of Ionized Calcium for Prognosis of Sepsis in Very Low Birth Weight Infants

Purpose

Previous studies have shown that ionized calcium (iCa) is strongly correlated with critical illnesses, including sepsis. However, there are few studies on the association of iCa levels and sepsis in very low birth weight infants (VLBWI). Therefore, the aim of this study was to investigate the role of iCa in assessing the severity of sepsis and in predicting the prognosis of sepsis in VLBWI.

Patients and Methods

249 eligible VLBWI with sepsis were included in the present study and were divided into good and poor prognosis groups according to prognosis. We collected complete laboratory and clinical data. The lowest iCa measured during the first 24h from sepsis onset was recorded, and the Pediatric Risk of Mortality (PRISM III) score was calculated for each newborn.

Results

Neonatal mortality was higher in the hypocalcemia group (32.80% vs 12.80%, P < 0.001), and iCa levels were negatively correlated with PRISM III scores (r= −0.819, P < 0.001). The result of multiple logistic regression analysis showed that iCa was an independent predictor of poor prognosis (odds ratio [OR]= 0.558, 95% confidence interval [CI], 0.406–0.768, P < 0.001). Furthermore, our data demonstrated that iCa was also an independent predictor for the occurrence of death in VLBWI with sepsis who have a poor prognosis (OR= 0.659, 95% CI, 0.445–0.977, P =0.038). ROC curve analysis showed that iCa had good discriminatory power in predicting the poor prognosis (AUC=0.739, 95% CI, 0.664–0.813, P <0.001) in VLBWI with sepsis.

Conclusion

iCa levels correlate with the severity of sepsis and can be an independent predictor of poor prognosis in VLBWI with sepsis.

Internal validation and evaluation of the predictive performance of models based on the PRISM-3 (Pediatric Risk of Mortality) and PIM-3 (Pediatric Index of Mortality) scoring systems for predicting mortality in Pediatric Intensive Care Units (PICUs)

PURPOSE

The study was aimed to assess the prognostic power The Pediatric Risk of Mortality-3 (PRISM-3) and the Pediatric Index of Mortality-3 (PIM-3) to predict in-hospital mortality in a sample of patients admitted to the PICUs.

DESIGN AND METHODS

The study was performed to include all children younger than 18 years of age admitted to receive critical care in two hospitals, Mashhad, northeast of Iran from December 2017 to November 2018. The predictive performance was quantified in terms of the overall performance by measuring the Brier Score (BS) and standardized mortality ratio (SMR), discrimination by assessing the AUC, and calibration by applying the Hosmer-Lemeshow test.

RESULTS

A total of 2446 patients with the median age of 4.2 months (56% male) were included in the study. The PICU and in-hospital mortality were 12.4 and 16.14%, respectively. The BS of the PRISM-3 and PIM-3 was 0.088 and 0.093 for PICU mortality and 0.108 and 0.113 for in-hospital mortality. For the entire sample, the SMR of the PRISM-3 and PIM-3 were 1.34 and 1.37 for PICU mortality and 1.73 and 1.78 for in-hospital mortality, respectively. The PRISM-3 demonstrated significantly higher discrimination power in comparison with the PIM-3 (AUC = 0.829 vs 0.745) for in-hospital mortality. (AUC = 0.779 vs 0.739) for in-hospital mortality. The HL test revealed poor calibration for both models in both outcomes.

CONCLUSIONS

The performance measures of PRISM-3 were better than PIM-3 in both PICU and in-hospital mortality. However, further recalibration and modification studies are required to improve the predictive power to a clinically acceptable level before daily clinical use.

PRACTICE IMPLICATIONS

The calibration of the PRISM-3 model is more satisfactory than PIM-3, however both models have fair discrimination power.

Comparison of Pediatric Sequential Organ Failure Assessment and Pediatric Risk of Mortality III Score as Mortality Prediction in Pediatric Intensive Care Unit

Objective: To assess and compare the diagnostic accuracy of the Pediatric Risk of Mortality (PRISM) III score and Pediatric Sequential Organ Failure Assessment (p-SOFA) for the prediction of mortality in critically ill children.

Methodology: This was a cross-validation study conducted at the Pediatric Intensive Care Unit (PICU) of the National Institute of Child Health Karachi from February 2021 to July 2021. Two hundred eighty-six critically ill children of age one month to 15 years of either gender staying in PICU for more than 24 hours were included. Within 24 hours of admission, the p-SOFA and PRISM III 24 scores were calculated for all eligible children. The outcome of the study was mortality within 30 days of PICU admitted children. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 23.

Results: The median age was 24 months (range: 1-144 months). The 30-day mortality was estimated as 57%. The p-SOFA and PRISM scores were significantly greater in children who did not survive than survivors. The maximum p-SOFA score (area under the curve (AUC)=0.81, 95% CI=0.76-0.86, p=0.001) and PRISM III 24 score (AUC=0.75, 95% CI=0.69-0.81, p=0.001) had good discrimination for 30-day mortality. For the prediction of 30-day mortality at the cut-off value of p-SOFA>2, the sensitivity was 93.87%, specificity was 38.21%, and accuracy was 69.93%. Whereas at the cut-off value of PRISM III 24 score>8, the sensitivity was 55.83%, specificity was 77.24%, and accuracy was 65.03%.

Conclusion: The p-SOFA score is a good predictor for 30-day mortality in critically ill children and had better accuracy than the PRISM III 24 score.

Multisystem inflammatory syndrome in children during severe acute respiratory syndrome coronavirus-2 pandemic in Turkey: A single-centre experience

AIM

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection may result in a life-threatening hyperinflammatory condition named multisystem inflammatory syndrome in children (MIS-C). We aimed to assess demographics, clinical presentations, laboratory characteristics and treatment outcomes of patients with MIS-C.

METHODS

We performed a retrospective study of patients with MIS-C managed between August 2020 and March 2021 at Dr. Sami Ulus Maternity Child Health and Diseases Training and Research Hospital in Turkey.

RESULTS

A total of 45 patients (23 male, 51%) with a median age of 8.7 years (interquartile range: 5.6-11.7 years) were enrolled to study. The SARS-CoV-2 serology was positive in 43 (95%) patients. Organ-system involvement included the dermatologic in 41 (91%), cardiovascular in 39 (87%), hematologic in 36 (80%) and gastrointestinal in 36 (80%) patients. Acute anterior uveitis was diagnosed in nine (20%) patients. Two patients presented with clinical findings of deep neck infection such as fever, neck pain, trismus, swelling and induration on the cervical lymph node. One patient presented with Henoch-Schonlein purpura-like eruption. Coronary artery dilatation was detected in five (11%) patients. For treatment of MIS-C, intravenous immunoglobulin was used in 44 (98%) patients, methylprednisolone in 27 (60%) and anakinra in 9 (20%) patients. The median duration of hospitalisation was nine days. All patients recovered.

CONCLUSIONS

Children with MIS-C might have variable clinical presentations. Acute anterior uveitis might be a prominent presentation of MIS-C and require ophthalmological examination. It is essential to make patient-based decisions and apply a stepwise approach for the treatment of this life-threatening disease.

Prognostic factors and models to predict pediatric sepsis mortality: A scoping review

Introduction

Several scoring systems are available to assess the severity of sepsis in pediatric patients in diverse settings worldwide. This study investigates the quality and applicability of predictive models for determining pediatric sepsis mortality, especially in acute care and limited-resource settings.

Data sources

Mortality prediction factors and models were searched in four databases using the following criteria: developed for pediatric health care, especially in acute settings, and with mortality as an outcome.

Study selection

Two or more reviewers performed the study selection to ensure no bias occurred. Any disagreements were solved by consensus or by the decision of a third reviewer.

Data extraction

The authors extracted the results and mapped the selected studies qualitatively to describe the prognostic properties of the risk factors and models proposed in the study.

Data synthesis

The final analysis included 28 mortality prediction models. Their characteristics, analysis, and performance measures were summarized. Performance was described in terms of calibration and discrimination, including assessing for risk of bias and applicability. A modified version of the PRISM-III score based on physiologic criteria (PRISM-III-APS) increased its predictive value to 0.85-0.95. The vasoactive-inotropic score at 12 h had a strong independent association with death. Albumin had an excellent predictive value when combined with other variables. Lactate, a biomarker widely measured in patients with sepsis, was highly associated with mortality. The bioimpedance phase angle was not considered applicable in our setting. Measurement using more straightforward methods, such as mid-upper arm circumference, was feasible in numerous health care facilities.

Conclusion

Leveraging prognostic models to predict mortality among pediatric patients with sepsis remains an important and well-recognized area of study. While much validation and development work remains to be done, available prognostic models could aid clinicians at the bedside of children with sepsis. Furthermore, mortality prediction models are essential and valuable tools for assessing the quality of care provided to critically ill pediatric patients.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Association between early fluid overload and mortality in critically-ill mechanically ventilated children: a single-center retrospective cohort study

Background

Positive fluid overload (FO) may cause adverse effect. This study retrospectively analyzed the relationship between early FO and in-hospital mortality in children with mechanical ventilation (MV) in pediatric intensive care unit (PICU).

Methods

This study retrospectively enrolled 309 children (ages 28 days to 16 years) receiving invasive MV admitted to the PICU of Xinhua Hospital from March 2014 to March 2019. Children receiving MV for less than 48 h were excluded. The FO in the first 3 days of MV was considered to the early FO. Patients were divided into groups according to early FO and survival to evaluate the associations of early FO, percentage FO(%FO) > 10%, and %FO > 20% with in-hospital mortality.

Results

A total of 309 patients were included. The mean early FO was 8.83 ± 8.81%, and the mortality in hospital was 26.2% (81/309). There were no significant differences in mortality among different FO groups (P = 0.053) or in early FO between survivors and non-survivors (P = 0.992). Regression analysis demonstrated that use of more vasoactive drugs, the presence of multiple organ dysfunction syndrome, longer duration of MV, and a non-operative reason for PICU admission were related to increased mortality (P < 0.05). Although early FO and %FO > 10% were not associated with in-hospital mortality (β = 0.030, P = 0.090, 95% CI = 0.995–1.067; β = 0.479, P = 0.153, 95% CI = 0.837–3.117), %FO > 20% was positively correlated with mortality (β = 1.057, OR = 2.878, P = 0.029, 95% CI = 1.116–7.418).

Conclusions

The correlation between early FO and mortality was affected by interventions and the severity of the disease, but %FO > 20% was an independent risk factor for in-hospital mortality in critically ill MV-treated children.

Characterization and Outcomes of Hospitalized Children With Coronavirus Disease 2019: A Report From a Multicenter, Viral Infection and Respiratory Illness Universal Study (Coronavirus Disease 2019) Registry

OBJECTIVES

Multicenter data on the characteristics and outcomes of children hospitalized with coronavirus disease 2019 are limited. Our objective was to describe the characteristics, ICU admissions, and outcomes among children hospitalized with coronavirus disease 2019 using Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study: Coronavirus Disease 2019 registry.

DESIGN

Retrospective study.

SETTING

Society of Critical Care Medicine Viral Infection and Respiratory Illness Universal Study (Coronavirus Disease 2019) registry.

PATIENTS

Children (< 18 yr) hospitalized with coronavirus disease 2019 at participating hospitals from February 2020 to January 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was ICU admission. Secondary outcomes included hospital and ICU duration of stay and ICU, hospital, and 28-day mortality. A total of 874 children with coronavirus disease 2019 were reported to Viral Infection and Respiratory Illness Universal Study registry from 51 participating centers, majority in the United States. Median age was 8 years (interquartile range, 1.25-14 yr) with a male:female ratio of 1:2. A majority were non-Hispanic (492/874; 62.9%). Median body mass index (n = 817) was 19.4 kg/m2 (16-25.8 kg/m2), with 110 (13.4%) overweight and 300 (36.6%) obese. A majority (67%) presented with fever, and 43.2% had comorbidities. A total of 238 of 838 (28.2%) met the Centers for Disease Control and Prevention criteria for multisystem inflammatory syndrome in children, and 404 of 874 (46.2%) were admitted to the ICU. In multivariate logistic regression, age, fever, multisystem inflammatory syndrome in children, and pre-existing seizure disorder were independently associated with a greater odds of ICU admission. Hospital mortality was 16 of 874 (1.8%). Median (interquartile range) duration of ICU (n = 379) and hospital (n = 857) stay were 3.9 days (2-7.7 d) and 4 days (1.9-7.5 d), respectively. For patients with 28-day data, survival was 679 of 787, 86.3% with 13.4% lost to follow-up, and 0.3% deceased.

CONCLUSIONS

In this observational, multicenter registry of children with coronavirus disease 2019, ICU admission was common. Older age, fever, multisystem inflammatory syndrome in children, and seizure disorder were independently associated with ICU admission, and mortality was lower among children than mortality reported in adults.

Early Neurologic Recovery, Practice Pattern Variation, and the Risk of Endotracheal Intubation Following Established Status Epilepticus

OBJECTIVE

To quantify the association between early neurologic recovery, practice pattern variation, and endotracheal intubation during established status epilepticus, we performed a secondary analysis within the cohort of patients enrolled in the Established Status Epilepticus Treatment Trial (ESETT).

METHODS

We evaluated factors associated with the endpoint of endotracheal intubation occurring within 120 minutes of ESETT study drug initiation. We defined a blocked, stepwise multivariate regression, examining 4 phases during status epilepticus management: (1) baseline characteristics, (2) acute treatment, (3) 20-minute neurologic recovery, and (4) 60-minute recovery, including seizure cessation and improving responsiveness.

RESULTS

Of 478 patients, 117 (24.5%) were intubated within 120 minutes. Among high-enrolling sites, intubation rates ranged from 4% to 32% at pediatric sites and 19% to 39% at adult sites. Baseline characteristics, including seizure precipitant, benzodiazepine dosing, and admission vital signs, provided limited discrimination for predicting intubation (area under the curve [AUC] 0.63). However, treatment at sites with an intubation rate in the highest (vs lowest) quartile strongly predicted endotracheal intubation independently of other treatment variables (adjusted odds ratio [aOR] 8.12, 95% confidence interval [CI] 3.08-21.4, model AUC 0.70). Site-specific variation was the factor most strongly associated with endotracheal intubation after adjustment for 20-minute (aOR 23.4, 95% CI 6.99-78.3, model AUC 0.88) and 60-minute (aOR 14.7, 95% CI 3.20-67.5, model AUC 0.98) neurologic recovery.

CONCLUSIONS

Endotracheal intubation after established status epilepticus is strongly associated with site-specific practice pattern variation, independently of baseline characteristics, and early neurologic recovery and should not alone serve as a clinical trial endpoint in established status epilepticus.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov Identifier: NCT01960075.

Performance of PRISM III, PELOD-2, and P-MODS Scores in Two Pediatric Intensive Care Units in China

Objective: The performances of the pediatric risk of mortality score III (PRISM III), pediatric logistic organ dysfunction score-2 (PELOD-2), and pediatric multiple organ dysfunction score (P-MODS) in Chinese patients are unclear. This study aimed to assess the performances of these scores in predicting mortality in critically ill pediatric patients. Methods: This retrospective observational study was conducted at two tertiary-care PICUs of teaching hospitals in China. A total of 1,253 critically ill pediatric patients admitted to the two Pediatric Intensive Care Units (PICUs) of the First Affiliated Hospital, Sun Yat-Sen University from August 2014 to December 2019 and Shen-Zhen Children's Hospital from January 2019 to December 2019 were analyzed. The indexes of discrimination and calibration were applied to evaluate score performance for the three models (PRISM III, PELOD-2, and P-MODS scores). The receiver operating characteristic (ROC) curve was plotted, and the efficiency of PRISM III, PELOD-2, and P-MODS in predicting death were evaluated by the area under ROC curve (AUC). Hosmer-Lemeshow goodness-of-fit test was used to evaluate the degree of fitting between the mortality predictions of each scoring system and the actual mortality. Results: A total of 1,253 pediatric patients were eventually enrolled in this study (median age, 38 months; overall mortality rate, 8.9%; median length of PICU stay, 8 days). Compared to the survival group, the non-survival group showed significantly higher PRISM III, PELOD-2, and P-MODS scores [PRISM III: 18 (12, 23) vs. 11 (0, 16); PELOD-2, 8 (4, 10) vs. 4 (0, 6); and P-MODS: 5 (4, 9) vs. 3 (0, 4), all P < 0.001]. ROC curve analysis showed that the AUCs of PRISM III, PELOD-2, and P-MODS for predicting the death of critically ill children were 0.858, 0.721, and 0.596, respectively. Furthermore, in the Hosmer-Lemeshow goodness-of-fit test, PRISM III and PELOD-2 showed the better calibration between predicted mortality and observed mortality (PRISM III: χ² = 5.667, P = 0.368; PELOD-2: χ² = 9.582, P = 0.276; P-MODS: χ² = 12.449, P = 0.015). Conclusions: PRISM III and PELOD-2 can discriminate well between survivors and non-survivors. PRISM III and PELOD-2 showed the better calibration between predicted and observed mortality, while P-MODS showed poor calibration.

Prediction of Acquired Morbidity Using Illness Severity Indices in Pediatric Intensive Care Patients

OBJECTIVES

To assess the ability of two illness severity scores, Pediatric Logistic Organ Dysfunction Score 2 and Pediatric Index of Mortality 3, in predicting PICU-acquired morbidity.

DESIGN

Retrospective chart review conducted from April 2015 to March 2016.

SETTING

Single-center study in a multidisciplinary PICU in a tertiary pediatric hospital in Singapore.

PATIENTS

The study included all index admissions of patients 0-18 years old to the PICU during the study period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Three outcomes were assessed at hospital discharge: mortality, survival with new morbidity defined as an increase in the Functional Status Scale score of greater than or equal to 3 points from baseline, and survival without morbidity. Of 577 consecutive admissions, 95 were excluded: 82 readmissions, 10 patients greater than or equal to 18 years old, two patients with missing baseline data, and one transferred to another PICU. Of 482 patients, there were 37 hospital deaths (7.7%) and 39 (8.1%) with acquired new morbidity. Median admission Pediatric Logistic Organ Dysfunction Score 2 and Pediatric Index of Mortality 3 scores differed among the three outcome groups. In addition, differences were found in emergency admission and neurologic diagnosis rates, PICU mechanical ventilation usage rates, and PICU length of stay. The highest proportion of neurologic diagnoses was observed in the new morbidity group. The final model simultaneously predicted risks of mortality, survival with new morbidity and survival without morbidity using admission Pediatric Logistic Organ Dysfunction Score 2 score, admission type, neurologic diagnosis, and preexisting chronic disease. Pediatric Logistic Organ Dysfunction Score 2 was superior to Pediatric Index of Mortality 3 in predicting risks of mortality and new morbidity, as indicated by volume under surface values of 0.483 and 0.362, respectively.

CONCLUSIONS

Risk of mortality, survival with new morbidity, and survival without morbidity can be predicted simultaneously using admission Pediatric Logistic Organ Dysfunction Score 2, admission type, admission diagnosis, and preexisting chronic disease. Future independent studies will be required to validate the proposed model before clinical implementation.

Comparison of pediatric scoring systems for mortality in septic patients and the impact of missing information on their predictive power: a retrospective analysis

Background

Scores can assess the severity and course of disease and predict outcome in an objective manner. This information is needed for proper risk assessment and stratification. Furthermore, scoring systems support optimal patient care, resource management and are gaining in importance in terms of artificial intelligence.

Objective

This study evaluated and compared the prognostic ability of various common pediatric scoring systems (PRISM, PRISM III, PRISM IV, PIM, PIM2, PIM3, PELOD, PELOD 2) in order to determine which is the most applicable score for pediatric sepsis patients in terms of timing of disease survey and insensitivity to missing data.

Methods

We retrospectively examined data from 398 patients under 18 years of age, who were diagnosed with sepsis. Scores were assessed at ICU admission and re-evaluated on the day of peak C-reactive protein. The scores were compared for their ability to predict mortality in this specific patient population and for their impairment due to missing data.

Results

PIM (AUC 0.76 (0.68-0.76)), PIM2 (AUC 0.78 (0.72-0.78)) and PIM3 (AUC 0.76 (0.68-0.76)) scores together with PRSIM III (AUC 0.75 (0.68-0.75)) and PELOD 2 (AUC 0.75 (0.66-0.75)) are the most suitable scores for determining patient prognosis at ICU admission. Once sepsis is pronounced, PELOD 2 (AUC 0.84 (0.77-0.91)) and PRISM IV (AUC 0.8 (0.72-0.88)) become significantly better in their performance and count among the best prognostic scores for use at this time together with PRISM III (AUC 0.81 (0.73-0.89)). PELOD 2 is good for monitoring and, like the PIM scores, is also largely insensitive to missing values.

Conclusion

Overall, PIM scores show comparatively good performance, are stable as far as timing of the disease survey is concerned, and they are also relatively stable in terms of missing parameters. PELOD 2 is best suitable for monitoring clinical course.

An Assessment of Clinical and System Drivers of Family Satisfaction in the PICU

OBJECTIVE

Investigate clinical and system drivers of family satisfaction in the PICU.

DESIGN

Mixed methods qualitative and quantitative (observational) study. Qualitative interviews with families were performed as a pilot to inform modality of survey distribution based on family preferences. A validated pediatric satisfaction survey deployed to family members for 7 months with a corresponding chart review and administrative data collection.

SETTING

PICU in a tertiary children's hospital.

PATIENTS

Two hundred six families of patients admitted to the PICU more than 48 hours.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Families preferred surveys distributed electronically on a tablet in the PICU setting. The Pediatric Family Satisfaction-ICU survey was used to assess comfort with medical decision-making and communication with the care team. Capture rate of all eligible patients was 69.5% and response rate was 90.8%. Overall, 64.7% of respondents were highly satisfied, whereas over one third were not highly satisfied; families of Hispanic ethnicity (odds ratio of lower satisfaction of families with Hispanic ethnicity: 2.09; 95% CI, 1.01-4.33; p = 0.047) and high social stressors (odds ratio of higher satisfaction among high stressed subgroup: 0.49; 95% CI, 0.24-0.99; p = 0.047) reported statistically significant lower satisfaction. Additional free-text responses were identified in 21% of respondents, with the majority of comments indicating wishes for improvements clustered around communication with the medical team or sleeping environment of families and patients.

CONCLUSIONS

High capture rates of family satisfaction in the PICU can be obtained with a PICU-specific survey, limiting barriers to completion by including family preferences, and distributing in the PICU setting. Less than two-third of PICU families are highly satisfied; patients of Hispanic ethnicity and those with high social stressors predict low satisfaction, whereas illness severity, age, and PICU length of stay did not have statistical significance. Local improvement teams can use this approach to drive enhanced satisfaction.

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

OBJECTIVES

This 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.

METHODS

The 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).

RESULTS

The 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).

CONCLUSIONS

Both 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.

Prediction of Pediatric Critical Care Resource Utilization for Disaster Triage

OBJECTIVES

Pediatric protocols to guide allocation of limited resources during a disaster lack data to validate their use. The 2011 Pediatric Emergency Mass Critical Care Task Force recommended that expected duration of critical care be incorporated into resource allocation algorithms. We aimed to determine whether currently available pediatric illness severity scores can predict duration of critical care resource use.

DESIGN

Retrospective cohort study.

SETTING

Seattle Children's Hospital.

PATIENTS

PICU patients admitted 2016-2018 for greater than or equal to 12 hours (n = 3,206).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We developed logistic and linear regression models in two-thirds of the cohort to predict need for and duration of PICU resources based on Pediatric Risk of Mortality-III, Pediatric Index of Mortality-3, and serial Pediatric Logistic Organ Dysfunction-2 scores. We tested the predictive accuracy of the models with the highest area under the receiver operating characteristic curve (need for each resource) and R (duration of use) in a validation cohort of the remaining one of three of the sample and among patients admitted during one-third of the sample and among patients admitted during surges of respiratory illness. Pediatric Logistic Organ Dysfunction score calculated 12 hours postadmission had higher predictive accuracy than either Pediatric Risk of Mortality or Pediatric Index of Mortality scores. Models incorporating 12-hour Pediatric Logistic Organ Dysfunction score, age, Pediatric Overall Performance Category, Pediatric Cerebral Performance Category, chronic mechanical ventilation, and postoperative status had an area under the receiver operating characteristic curve = 0.8831 for need for any PICU resource (positive predictive value 80.2%, negative predictive value 85.9%) and area under the receiver operating characteristic curve = 0.9157 for mechanical ventilation (positive predictive value 85.7%, negative predictive value 89.2%) within 7 days of admission. Models accurately predicted greater than or equal to 24 hours of any resource use for 78.9% of patients and greater than or equal to 24 hours of ventilation for 83.1%. Model fit and accuracy improved for prediction of resource use within 3 days of admission, and was lower for noninvasive positive pressure ventilation, vasoactive infusions, continuous renal replacement therapy, extracorporeal membrane oxygenation, and length of stay.

CONCLUSIONS

A model incorporating 12-hour Pediatric Logistic Organ Dysfunction score performed well in estimating how long patients may require PICU resources, especially mechanical ventilation. A pediatric disaster triage algorithm that includes both likelihood for survival and for requiring critical care resources could minimize subjectivity in resource allocation decision-making.

The Ethics of Creating a Resource Allocation Strategy During the COVID-19 Pandemic

The coronavirus disease 2019 pandemic has affected nearly every aspect of medicine and raises numerous moral dilemmas for clinicians. Foremost of these quandaries is how to delineate and implement crisis standards of care and, specifically, how to consider how health care resources should be distributed in times of shortage. We review basic principles of disaster planning and resource stewardship with ethical relevance for this and future public health crises, explore the role of illness severity scoring systems and their limitations and potential contribution to health disparities, and consider the role for exceptionally resource-intensive interventions. We also review the philosophical and practical underpinnings of crisis standards of care and describe historical approaches to scarce resource allocation to offer analysis and guidance for pediatric clinicians. Particular attention is given to the impact on children of this endeavor. Although few children have required hospitalization for symptomatic infection, children nonetheless have the potential to be profoundly affected by the strain on the health care system imposed by the pandemic and should be considered prospectively in resource allocation frameworks.

Pediatric Risk of Mortality III Score - Predictor of Mortality and Hospital Stay in Pediatric Intensive Care Unit

Background

Pediatric Risk of Mortality (PRISM) III score is one of the widely used scoring systems to quantify critical illness in the pediatric age group. This study was carried out to find the association of PRISM III score with the outcome (discharge/mortality) and also hospital stay in survivors and nonsurvivors.

Setting

The study was conducted in a tertiary care hospital from January 2014 to June 2015.

Materials and Methods

A total of 524 patients were admitted, and after excluding the patients who met the exclusion criteria, 486 patients were analyzed.

Statistical Analysis

Logistic regression was used to find the association of variables under the PRISM III score with mortality. Linear regression was used to find the association of PRISM III score with length of stay.

Results

Mortality was 31%; male: female ratio was 1.5:1. Maximum patients presented with respiratory system involvement (26.3%), and maximum mortality (20.3%) was observed in the patients with respiratory involvement. Discrimination by the model between mortality and survival was excellent (receiver operating characteristic curve [0.903]). Maximum risk of mortality was noticed in mechanically ventilated patients (odds ratio [OR]: 10.87) followed by lower systolic blood pressure (OR: 2.72), deranged prothrombin time, partial thromboplastin time (OR: 1.50), deranged mental status (OR: 1.41), and tachycardia (OR: 1.37). Length of stay (LOS) in patients increased till PRISM III score of 25. Average LOS in survivors was 4.327 days which was not accounted by difference in PRISM III score between different patients. With each unit increase in PRISM III score, LOS increased by 5 h.

Conclusions

PRISM III score has excellent capacity to discriminate between survival and mortality. PRISM III score can be used to predict LOS among survivors.

Comparison of the Automated Pediatric Logistic Organ Dysfunction-2 Versus Manual Pediatric Logistic Organ Dysfunction-2 Score for Critically Ill Children

OBJECTIVES

The Pediatric Logistic Organ Dysfunction-2 is a validated score that quantifies organ dysfunction severity and requires complex data collection that is time-consuming and subject to errors. We hypothesized that a computer algorithm that automatically collects and calculates the Pediatric Logistic Organ Dysfunction-2 (aPELOD-2) score would be valid, fast and at least as accurate as a manual approach (mPELOD-2).

DESIGN

Retrospective cohort study.

SETTING

Single center tertiary medical and surgical pediatric critical care unit (Sainte-Justine Hospital, Montreal, Canada).

PATIENTS

Critically ill children participating in four clinical studies between January 2013 and August 2018, a period during which mPELOD-2 data were manually collected.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The aPELOD-2 was calculated for all consecutive admissions between 2013 and 2018 (n = 5,279) and had a good survival discrimination with an area under the receiver operating characteristic curve of 0.84 (95% CI, 0.81-0.88). We also collected data from four single-center studies in which mPELOD-2 was calculated (n = 796, 57% medical, 43% surgical) and compared these measurements to those of the aPELOD-2. For those patients, median age was 15 months (interquartile range, 3-73 mo), median ICU stay was 5 days (interquartile range, 3-9 d), mortality was 3.9% (n = 28). The intraclass correlation coefficient between mPELOD-2 and aPELOD-2 was 0.75 (95% CI, 0.73-0.77). The Bland-Altman showed a bias of 1.9 (95% CI, 1.7-2) and limits of agreement of -3.1 (95% CI, -3.4 to -2.8) to 6.8 (95% CI, 6.5-7.2). The highest agreement (Cohen's Kappa) of the Pediatric Logistic Organ Dysfunction-2 components was noted for lactate level (0.88), invasive ventilation (0.86), and creatinine level (0.82) and the lowest for the Glasgow Coma Scale (0.52). The proportion of patients with multiple organ dysfunction syndrome was higher for aPELOD-2 (78%) than mPELOD-2 (72%; p = 0.002). The aPELOD-2 had a better survival discrimination (area under the receiver operating characteristic curve, 0.81; 95% CI, 0.72-0.90) over mPELOD-2 (area under the receiver operating characteristic curve, 0.70; 95% CI, 0.59-0.82; p = 0.01).

CONCLUSIONS

We successfully created a freely available automatic algorithm to calculate the Pediatric Logistic Organ Dysfunction-2 score that is less labor intensive and has better survival discrimination than the manual calculation. Use of an automated system could greatly facilitate integration of the Pediatric Logistic Organ Dysfunction-2 score at the bedside and within clinical decision support systems.

Clinical Effects and Outcomes After Polymyxin B-Immobilized Fiber Column Direct Hemoperfusion Treatment for Septic Shock in Preterm Neonates

OBJECTIVES

To compare the effectiveness and mortality of early-onset sepsis or late-onset sepsis treatments with polymyxin B-immobilized fiber column direct hemoperfusion in terms of effectiveness and mortality in preterm infants with septic shock.

DESIGN

Retrospective cohort study.

SETTING

Neonatal ICU within a tertiary care hospital.

PATIENTS

Of 1,115 patients, 49 had blood culture-proven sepsis between January 2013 and December 2018; six and five patients with septic shock had undergone polymyxin B-immobilized fiber column direct hemoperfusion treatment for early-onset sepsis (early-onset sepsis group) and late-onset sepsis (late-onset sepsis group), respectively.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Baseline demographic characteristics of both groups were similar. The time from decision to treatment induction was significantly shorter in the early-onset sepsis group than that in the late-onset sepsis group (p = 0.008). The mortality rate after 28 days of treatment and the hospital mortality were significantly lower in the early-onset sepsis group than in the late-onset sepsis group (p = 0.026 and 0.015, respectively). The PaO2/FIO2 ratio was significantly higher in the early-onset sepsis group than in the late-onset sepsis group at the end of the treatment (p = 0.035). In addition, median arterial-to-alveolar oxygen tension ratio significantly improved from 0.19 to 0.55, and median blood pressure also significantly improved from 32.5 to 40.0 mm Hg after the treatment in the early-onset sepsis group. Interleukin-6 levels significantly decreased after treatment in the early-onset sepsis group (p = 0.037). The Pediatric Risk of Mortality III score was similar between the early-onset sepsis and late-onset sepsis groups before and after the treatment. Intraventricular hemorrhage events occurred in both groups, but with no significant differences (p = 0.175).

CONCLUSIONS

Polymyxin B-immobilized fiber column direct hemoperfusion treatment for preterm infants with septic shock due to early-onset sepsis is associated with earlier hemodynamic and respiratory status improvements and with lower mortality than that due to late-onset sepsis. Early neonatal septic shock detection and polymyxin B-immobilized fiber column direct hemoperfusion induction may improve the prognosis of affected infants.

Performance of Three Mortality Prediction Scores and Evaluation of Important Determinants in Eight Pediatric Intensive Care Units in China

Background: The mortality prediction scores were widely used in pediatric intensive care units. However, their performances were unclear in Chinese patients and there were also no reports based on large sample sizes in China. This study aims to evaluate the performances of three existing severity assessment scores in predicting PICU mortality and to identify important determinants. Methods: This prospective observational cohort study was carried out in eight multidisciplinary, tertiary-care PICUs of teaching hospitals in China. All eligible patients admitted to the PICUs between Aug 1, 2016, and Jul 31, 2017, were consecutively enrolled, among whom 3,957 were included for analysis. We calculated PCIS, PRISM IV, and PELOD-2 scores based on patient data collected in the first 24 h after PICU admission. The in-hospital mortality was defined as all-cause death within 3 months after admission. The discrimination of mortality was assessed using the area under the receiver-operating characteristics curve (AUC) and calibrated using the Hosmer-Lemeshow goodness-of-fit test. Results: A total of 4,770 eligible patients were recruited (median age 18.2 months, overall mortality rate 4.7%, median length of PICU stay 6 days), and 3,957 participants were included in the analysis. The AUC (95% confidence intervals, CI) were 0.74 (0.71-0.78), 0.76 (0.73-0.80), and 0.80 (0.77-0.83) for PCIS, PRISM IV, and PELOD-2, respectively. The Hosmer-Lemeshow test gave a chi-square of 3.16 for PCIS, 2.16 for PRISM IV and 4.81 for PELOD-2 (p ≥ 0.19). Cox regression identified five predictors from the items of scores better associated with higher death risk, with a C-index of 0.83 (95%CI 0.79-0.86), including higher platelet (HR = 1.85, 95% CI 1.59-2.16), invasive ventilation (HR = 1.40, 1.26-1.55), pupillary light reflex (HR = 1.31, 95% CI 1.22-1.42) scores, lower pH (HR 0.89, 0.84-0.94), and extreme PaO₂ (HR 2.60, 95% CI 1.61-4.19 for the 1st quantile vs. 4th quantile) scores. Conclusions: Performances of the three scores in predicting PICU mortality are comparable, and five predictors were identified with better prediction to PICU mortality in Chinese patients.

Outcome of children with systemic rheumatic diseases admitted to pediatric intensive care unit: An experience of a tertiary hospital

Objective

To report the outcome of children with rheumatic diseases admitted to pediatric intensive care unit (PICU) in a tertiary hospital.

Methods

Database from PICU and pediatric rheumatology section used to retrieve all candidate patients admitted to PICU from June 2000 to December 2017. Medical records of all enrolled patients reviewed for diagnosis, organ involvement, reason of PICU admission, the length of stay, and outcome.

Results

Twenty-five patients (17 female, 8 male) with total of 41 admissions identified. The median PICU stay was 13.5 days (range, 3–24). The most frequent diagnoses were systemic lupus erythematosus (SLE) (48%), followed by systemic vasculitis (16%). Most admissions were from the medical ward (68.3%), while 24.4% from the emergency room. The main reason of PICU admission was a disease flare or related complications (48.8%), followed by infection (34.2%). Fifty one percent of the admissions were due to respiratory dysfunction, 46% required non-invasive respiratory support while 38% was in need for mechanical ventilation. During PICU stay, anti-microbial agents used 90.3%, immunosuppressive treatment adjustment 75.6%, anti-hypertensive 24.4% and vasopressors 12.2%. Twelve patients (48%) fully recovered and 40% partially recovered while three patients died during their PICU stay. The causes of death were macrophage activation syndrome complicated by sepsis in two patients and advanced pulmonary hypertension in one patient.

Conclusion

Our data showed that children with rheumatic diseases, particularly SLE, are mostly admitted to PICU with serious disease exacerbation or severe infection. To improve the outcome, early diagnosis of critical condition and proper intervention are fundamental in reducing mortality.

Outcomes Analysis of Children Diagnosed With Hemophagocytic Lymphohistiocytosis in the PICU

OBJECTIVES

Describe a single center experience of hemophagocytic lymphohistiocytosis in a PICU over a 10-year period, to identify clinical features that may be associated with worse outcomes, including mortality, hospital and ICU length of stay, and functional and cognitive impairments on discharge.

DESIGN

Retrospective electronic medical record review, 2007-2017.

SETTING

PICU located in a large urban academic quaternary care children's hospital.

PATIENTS

All children admitted with hemophagocytic lymphohistiocytosis to our PICU from 2007 to 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All patients were identified utilizing International Classification of Diseases, 9th Revision and International Classification of Diseases, 10th Revision codes. Each chart was reviewed for demographic information, hemophagocytic lymphohistiocytosis diagnostic criteria, laboratory data, Pediatric Risk of Mortality Score III, clinical features and events of ICU stay, and PICU and hospital (length of stay). Mortality at 1 year and change in Functional Status Scale from admission to discharge were recorded. There were 42 admissions with 33 unique patients. Median Pediatric Risk of Mortality score at admission was 9 (interquartile range, 7-16). Median PICU length of stay was 7 days (interquartile range, 2-21 d) and hospital length of stay was 24 days (interquartile range, 14-37 d). During their ICU stay, 56% of patients received mechanical ventilation, 43% required vasoactives, 18% required continuous renal replacement therapy, and 5% received extracorporeal life support. Clinical factors related to increased PICU length of stay included Pediatric Risk of Mortality III score (p = 0.019), maximum lactate dehydrogenase (p = 0.017), maximum total bilirubin (p = 0.042), need for mechanical ventilation (p = 0.002), vasoactive use (p = 0.02), and secondary infection (p = 0.007). The most common therapies for hemophagocytic lymphohistiocytosis included steroids (93%), etoposide (55%), and anakinra (48%). Of the 26 patients who survived to hospital discharge, 19% had newly acquired morbidities. Overall 1-year mortality was 42%.

CONCLUSIONS

Hemophagocytic lymphohistiocytosis diagnosed in the PICU is a disease with high mortality. Patients who survive to discharge had relatively little morbidity, however, the mortality risk in the year following discharge continued to remain high.

Prognostic roles of time to positivity of blood culture in children with Streptococcus pneumoniae bacteremia

We aimed to investigate the relationship between time to positivity (TTP) of blood cultures and clinical outcomes in children with S. pneumoniae bacteremia. Children with S. pneumoniae bacteremia hospitalized in Children's Hospital of Chongqing Medical University from May 2011 to December 2017 were enrolled retrospectively. Overall, 136 children with S. pneumoniae bacteremia were enrolled. The standard cutoff TTP was 12 h. We stated that in-hospital mortality is significantly higher in the early TTP (≤ 12 h) group than that in the late TTP (> 12 h) group (41.70% vs 8.00%, P < 0.001). Septic shock occurred in 58.30% of patients with early TTP and in 21.00% of patients with late TTP (P < 0.001). Independent risk factors of in-hospital mortality and septic shock in children with S. pneumoniae bacteremia included early TTP, need for invasive mechanical ventilation, and PRISM III score ≥ 10. Overall, TTP ≤ 12 h appeared to associate with the worse outcomes for children with S. pneumoniae bacteremia.

EVALUATION OF THE HYPOTHALAMIC-PITUITARY-ADRENAL AXIS IN A PAEDIATRIC INTENSIVE CARE UNIT

Background

Relative adrenal insufficiency (RAI) is the inadequate production of cortisol due to dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis during a severe illness. We evaluated the HPA axis and RAI in a tertiary pediatric intensive care unit (PICU).

Methods

A total of 100 PICU patients were included in this prospective cohort study. Basal serum levels of adrenocorticotropic hormone (ACTH), cortisol values were compared with those in the control group. A low-dose ACTH stimulation test was performed in patients with basal cortisol levels below 18 µg/dL.

Results

The basal cortisol levels of the PICU patients were significantly higher than those of the control group (P < 0.05). All tested patients (n= 24) had delta cortisol levels > 9 µg/dL and a peak cortisol response > 18 µg/dL. Basal cortisol levels were positively correlated with Pediatric Risk of Mortality (PRISM) III scores (P < 0.05; r = 0.363). The basal or stimulated cortisol levels of the patients who received glucocorticoid treatment were higher than the cut-off levels.

Conclusions

High basal or stimulated cortisol levels are indicative of disease severity in the acute phase of stress. Patients with very high cortisol levels should be particularly carefully monitored because of the high mortality risk.

Predictors of Late Palliative Care Referral in Children With Cancer

CONTEXT

Early integration of palliative care (PC) in the management of children with high-risk cancer is widely endorsed by patients, families, clinicians, and national organizations. However, optimal timing for PC consultation is not standardized, and variables that influence timing of PC integration for children with cancer remain unknown.

OBJECTIVES

To investigate associations between demographic, disease, treatment, and end-of-life attributes and timing of PC consultation for children with high-risk cancer enrolled on a PC service.

METHODS

A comprehensive standardized tool was used to abstract data from the medical records of 321 patients treated at a large academic pediatric cancer center, who died between 2011 and 2015.

RESULTS

Gender, race, ethnicity, enrollment on a Phase I protocol, number of high-acuity hospitalizations, and receipt of cardiopulmonary resuscitation were not associated with timing of PC involvement. Patients with hematologic malignancy, those who received cancer-directed therapy during the last month of life, and those with advance directives documented one week or less before death had higher odds of late PC referral (malignancy: odds ratio [OR] 3.24, P = 0.001; therapy: OR 4.65, P < 0.001; directive: OR 4.81, P < 0.0001). Patients who received hospice services had lower odds of late PC referral <30 days before death (OR 0.31, P < 0.001).

CONCLUSION

Hematologic malignancy, cancer-directed therapy at the end of life, and delayed documentation of advance directives are associated with late PC involvement in children who died of cancer. Identification of these variables affords opportunities to study targeted interventions to enhance access to earlier PC resources and services for children with high-risk cancer and their families.

Predictors of Location of Death for Children with Cancer Enrolled on a Palliative Care Service

BACKGROUND

In the U.S., more children die from cancer than from any other disease, and more than one third die in the hospital setting. These data have been replicated even in subpopulations of children with cancer enrolled on a palliative care service. Children with cancer who die in high-acuity inpatient settings often experience suffering at the end of life, with increased psychosocial morbidities seen in their bereaved parents. Strategies to preemptively identify children with cancer who are more likely to die in high-acuity inpatient settings have not been explored.

MATERIALS AND METHODS

A standardized tool was used to gather demographic, disease, treatment, and end-of-life variables for 321 pediatric palliative oncology (PPO) patients treated at an academic pediatric cancer center who died between 2011 and 2015. Multinomial logistic regression was used to predict patient subgroups at increased risk for pediatric intensive care unit (PICU) death.

RESULTS

Higher odds of dying in the PICU were found in patients with Hispanic ethnicity (odds ratio [OR], 4.02; p = .002), hematologic malignancy (OR, 7.42; p < .0001), history of hematopoietic stem cell transplant (OR, 4.52; p < .0001), total number of PICU hospitalizations (OR, 1.98; p < .0001), receipt of cancer-directed therapy during the last month of life (OR, 2.96; p = .002), and palliative care involvement occurring less than 30 days before death (OR, 4.7; p < .0001). Conversely, lower odds of dying in the PICU were found in patients with hospice involvement (OR, 0.02; p < .0001) and documentation of advance directives at the time of death (OR, 0.37; p = .033).

CONCLUSION

Certain variables may predict PICU death for PPO patients, including delayed palliative care involvement. Preemptive identification of patients at risk for PICU death affords opportunities to study the effects of earlier palliative care integration and increased discussions around preferred location of death on end-of-life outcomes for children with cancer and their families.

IMPLICATIONS FOR PRACTICE

Children with cancer who die in high-acuity inpatient settings often experience a high burden of intensive therapy at the end of life. Strategies to identify patients at higher risk of dying in the pediatric intensive care unit (PICU) have not been explored previously. This study finds that certain variables may predict PICU death for pediatric palliative oncology patients, including delayed palliative care involvement. Preemptive identification of patients at risk for PICU death affords opportunities to study the effects of earlier palliative care integration and increased discussions around preferred location of death on end-of-life outcomes for children with cancer and their families.

Illness and end-of-life experiences of children with cancer who receive palliative care

BACKGROUND

The field of pediatric palliative oncology is newly emerging. Little is known about the characteristics and illness experiences of children with cancer who receive palliative care (PC).

METHODS

A retrospective cohort study of 321 pediatric oncology patients enrolled in PC who died between 2011 and 2015 was conducted at a large academic pediatric cancer center using a comprehensive standardized data extraction tool.

RESULTS

The majority of pediatric palliative oncology patients received experimental therapy (79.4%), with 40.5% enrolled on a phase I trial. Approximately one-third received cancer-directed therapy during the last month of life (35.5%). More than half had at least one intensive care unit hospitalization (51.4%), with this subset demonstrating considerable exposure to mechanical ventilation (44.8%), invasive procedures (20%), and cardiopulmonary resuscitation (12.1%). Of the 122 patients who died in the hospital, 44.3% died in the intensive care unit. Patients with late PC involvement occurring less than 30 days before death had higher odds of dying in the intensive care unit over the home/hospice setting compared to those with earlier PC involvement (OR: 4.7, 95% CI: 2.47-8.97, P < 0.0001).

CONCLUSIONS

Children with cancer who receive PC experience a high burden of intensive treatments and often die in inpatient intensive care settings. Delayed PC involvement is associated with increased odds of dying in the intensive care unit. Prospective investigation of early PC involvement in children with high-risk cancer is needed to better understand potential impacts on cost-effectiveness, quality of life, and delivery of goal concordant care.

Can the Pediatric Logistic Organ Dysfunction-2 Score on Day 1 Be Used in Clinical Criteria for Sepsis in Children?

OBJECTIVE

A recent task force has proposed the use of Sequential Organ Failure Assessment in clinical criteria for sepsis in adults. We sought to evaluate the predictive validity for PICU mortality of the Pediatric Logistic Organ Dysfunction-2 and of the "quick" Pediatric Logistic Organ Dysfunction-2 scores on day 1 in children with suspected infection.

DESIGN

Secondary analysis of the database used for the development and validation of the Pediatric Logistic Organ Dysfunction-2.

SETTINGS

Nine university-affiliated PICUs in Europe.

PATIENTS

Only children with hypotension-low systolic blood pressure or low mean blood pressure using age-adapted cutoffs-and lactatemia greater than 2 mmol/L were considered in shock.

MEASUREMENTS AND MAIN RESULTS

We developed the quick Pediatric Logistic Organ Dysfunction-2 score on day 1 including tachycardia, hypotension, and altered mentation (Glasgow < 11): one point for each variable (range, 0-3). Outcome was mortality at PICU discharge. Discrimination (Area under receiver operating characteristic curve-95% CI) and calibration (goodness of fit test) of the scores were studied. This study included 862 children with suspected infection (median age: 12.3 mo; mortality: n = 60 [7.0%]). Area under the curve of the Pediatric Logistic Organ Dysfunction-2 score on day 1 was 0.91 (0.86-0.96) in children with suspected infection, 0.88 (0.79-0.96) in those with low systolic blood pressure and hyperlactatemia, and 0.91 (0.85-0.97) in those with low mean blood pressure and hyperlactatemia; calibration p value was 0.03, 0.36, and 0.49, respectively. A Pediatric Logistic Organ Dysfunction-2 score on day 1 greater than or equal to 8 reflected an overall risk of mortality greater than or equal to 9.3% in children with suspected infection. Area under the curve of the quick Pediatric Logistic Organ Dysfunction-2 score on day 1 was 0.82 (0.76-0.87) with systolic blood pressure or mean blood pressure; calibration p value was 0.89 and 0.72, respectively. A score greater than or equal to 2 reflected a mortality risk greater than or equal to 19.8% with systolic blood pressure and greater than or equal to 15.9% with mean blood pressure.

CONCLUSION

Among children admitted to PICU with suspected infection, Pediatric Logistic Organ Dysfunction-2 score on day 1 was highly predictive of PICU mortality suggesting its use to standardize definitions and diagnostic criteria of pediatric sepsis. Further studies are needed to determine the usefulness of the quick Pediatric Logistic Organ Dysfunction-2 score on day 1 outside of the PICU.

Development and validation of a mortality risk model for pediatric sepsis

Pediatric sepsis is a burdensome public health problem. Assessing the mortality risk of pediatric sepsis patients, offering effective treatment guidance, and improving prognosis to reduce mortality rates, are crucial.We extracted data derived from electronic medical records of pediatric sepsis patients that were collected during the first 24 hours after admission to the pediatric intensive care unit (PICU) of the Hunan Children's hospital from January 2012 to June 2014. A total of 788 children were randomly divided into a training (592, 75%) and validation group (196, 25%). The risk factors for mortality among these patients were identified by conducting multivariate logistic regression in the training group. Based on the established logistic regression equation, the logit probabilities for all patients (in both groups) were calculated to verify the model's internal and external validities.According to the training group, 6 variables (brain natriuretic peptide, albumin, total bilirubin, D-dimer, lactate levels, and mechanical ventilation in 24 hours) were included in the final logistic regression model. The areas under the curves of the model were 0.854 (0.826, 0.881) and 0.844 (0.816, 0.873) in the training and validation groups, respectively.The Mortality Risk Model for Pediatric Sepsis we established in this study showed acceptable accuracy to predict the mortality risk in pediatric sepsis patients.

RBC Distribution Width: Biomarker for Red Cell Dysfunction and Critical Illness Outcome?

OBJECTIVES

RBC distribution width is reported to be an independent predictor of outcome in adults with a variety of conditions. We sought to determine if RBC distribution width is associated with morbidity or mortality in critically ill children.

DESIGN

Retrospective observational study.

SETTING

Tertiary PICU.

PATIENTS

All admissions to St. Louis Children's Hospital PICU between January 1, 2005, and December 31, 2012.

INTERVENTIONS

We collected demographics, laboratory values, hospitalization characteristics, and outcomes. We calculated the relative change in RBC distribution width from admission RBC distribution width to the highest RBC distribution width during the first 7 days of hospitalization. Our primary outcome was ICU mortality or use of extracorporeal membrane oxygenation as a composite. Secondary outcomes were ICU- and ventilator-free days.

MEASUREMENTS AND MAIN RESULTS

We identified 3,913 eligible subjects with an estimated mortality (by Pediatric Index of Mortality 2) of 2.94% ± 9.25% and an actual ICU mortality of 2.91%. For the study cohort, admission RBC distribution width was 14.12% ± 1.89% and relative change in RBC distribution width was 2.63% ± 6.23%. On univariate analysis, both admission RBC distribution width and relative change in RBC distribution width correlated with mortality or the use of extracorporeal membrane oxygenation (odds ratio, 1.19 [95% CI, 1.12-1.27] and odds ratio, 1.06 [95% CI, 1.04-1.08], respectively; p < 0.001). After adjusting for confounding variables, including severity of illness, both admission RBC distribution width (odds ratio, 1.13; 95% CI, 1.03-1.24) and relative change in RBC distribution width (odds ratio, 1.04; 95% CI, 1.01-1.07) remained independently associated with ICU mortality or the use of extracorporeal membrane oxygenation. Admission RBC distribution width and relative change in RBC distribution width both weakly correlated with fewer ICU- (r = 0.038) and ventilator-free days (r = 0.05) (p < 0.001).

CONCLUSIONS

Independent of illness severity in critically ill children, admission RBC distribution width is associated with ICU mortality and morbidity. These data suggest that RBC distribution width may be a biomarker for RBC injury that is of sufficient magnitude to influence critical illness outcome, possibly via oxygen delivery impairment.

Daily estimation of the severity of organ dysfunctions in critically ill children by using the PELOD-2 score

INTRODUCTION

Daily or serial evaluation of multiple organ dysfunction syndrome (MODS) scores may provide useful information. We aimed to validate the daily (d) PELOD-2 score using the set of seven days proposed with the previous version of the score.

METHODS

In all consecutive patients admitted to nine pediatric intensive care units (PICUs) we prospectively measured the dPELOD-2 score at day 1, 2, 5, 8, 12, 16, and 18. PICU mortality was used as the outcome dependent variable. The discriminant power of the dPELOD-2 scores was estimated using the area under the ROC curve and the calibration using the Hosmer-Lemeshow chi-square test. We used a logistic regression to investigate the relationship between the dPELOD-2 scores and outcome, and between the change in PELOD-2 score from day 1 and outcome.

RESULTS

We included 3669 patients (median age 15.5 months, mortality rate 6.1%, median length of PICU stay 3 days). Median dPELOD-2 scores were significantly higher in nonsurvivors than in survivors (p < 0.0001). The dPELOD-2 score was available at least at day 2 in 2057 patients: among the 796 patients without MODS on day 1, 186 (23.3%) acquired the syndrome during their PICU stay (mortality 4.9% vs. 0.3% among the 610 who did not; p < 0.0001). Among the 1261 patients with MODS on day 1, the syndrome worsened in 157 (12.4%) and remained unchanged or improved in 1104 (87.6%) (mortality 22.9% vs. 6.6%; p < 0.0001). The AUC of the dPELOD-2 scores ranged from 0.75 (95% CI: 0.67-0.83) to 0.89 (95% CI: 0.86-0.91). The calibration was good with a chi-square test between 13.5 (p = 0.06) and 0.9 (p = 0.99). The PELOD-2 score on day 1 was a significant prognostic factor; the serial evaluation of the change in the dPELOD-2 score from day1, adjusted for baseline value, demonstrated a significant odds ratio of death for each of the 7 days.

CONCLUSION

This study suggests that the progression of the severity of organ dysfunctions can be evaluated by measuring the dPELOD-2 score during a set of 7 days in PICU, providing useful information on outcome in critically ill children. Its external validation would be useful.