Early changes in SOFA score as a prognostic factor in pediatric oncology patients requiring mechanical ventilatory support

Pulmonary hypertension in the intensive care unit after pediatric allogeneic hematopoietic stem cell transplant: incidence, risk factors, and outcomes

Objective

To determine the incidence, risk factors, and outcomes of pulmonary hypertension (PH) in the pediatric intensive care unit (PICU) after pediatric hematopoietic stem cell transplant (HCT).

Methods

This was a retrospective study of pediatric patients who underwent allogeneic HCT between January 2008-December 2014 at a center contributing to the Center for International Blood and Marrow Transplant Research data registry. Incidence of PH was assessed from PICU diagnostic codes from records merged from the Virtual Pediatric Systems database. Regression and survival analyses identified factors associated with post-HCT PH. Additional post-HCT morbidities and survival after PH were also assessed.

Results

Among 6,995 HCT recipients, there were 29 cases of PH, a cumulative incidence of 0.42% (95% CI 0.27%-0.57%) at 60 months post-HCT. In the sub-cohort of 1,067 patients requiring intensive care after HCT, this accounted for a PH prevalence of 2.72% (95% CI 1.74-3.69%). There was an increased risk of developing PH associated with Black/African American race, metabolic disorders, partially HLA-matched or cord blood allografts, graft-versus-host prophylaxis regimen, and lower pre-HCT functional status. Patients who developed PH had significant PICU comorbidities including heart failure, pulmonary hemorrhage, respiratory failure, renal failure, and infections. Survival at 6 months after diagnosis of post-HCT PH was 51.7% (95% CI 32.5%-67.9%).

Conclusions

PH is a rare but serious complication in the pediatric post-HCT population. A significant burden of additional comorbidities, procedural interventions, and risk of mortality is associated with its development. Close monitoring and prompt intervention for this severe complication are necessary in this vulnerable population.

Prognostic factors and predictive scores for 6-months mortality of hematopoietic stem cell transplantation recipients admitted to the pediatric intensive care unit

Objective

Despite advances in hematopoietic stem cell transplantation (HSCT), a considerable number of pediatric HSCT patients develops post-transplant complications requiring admission to the pediatric intensive care unit (PICU). The objective of this study was to evaluate clinical findings, PICU supportive therapy and outcome as well as predictive factors for 6-months survival after discharge of HSCT patients from PICU.

Study design

This retrospective single-center analysis investigated patient characteristics, microbiological findings, reasons for admission and death of 54 cases accounting for 94 admissions to the PICU of the University Children's Hospital Tuebingen from 2002 to 2017. We compared clinical characteristics between children with and without 6-months survival after discharge from PICU following HSCT. Finally, we assessed the potential prognostic value of the oncological Pediatric Risk of Mortality Score (O-PRISM), the Pediatric Sequential Organ Failure Assessment Score (pSOFA) and the pRIFLE Criteria for Acute Kidney Injury for 6-months survival using Generalized Estimating Equations (GEE) and Receiver Operating Characteristic curves.

Results

Respiratory insufficiency, gastroenterological problems and sepsis were the most common reasons for PICU admission. Out of 54 patients, 38 (70%) died during or after their last PICU admission, 30% survived for at least six months. When considering only first PICU admissions, we could not determine prognostic factors for 6-months mortality. In contrast, under consideration of all PICU admissions in the GEE model, ventilation (p=0.03) and dialysis (p=0.007) were prognostic factors for 6-months mortality. Furthermore, pSOFA (p=0.04) and O-PRISM (p=0.02) were independent risk factors for 6-months mortality considering all PICU admissions.

Conclusion

Admission of HSCT patients to PICU is still associated with poor outcome and 69% of patients died within 6 months. Need for respiratory support and dialysis are associated with poor outcome. Prediction of 6-months survival is difficult, especially during a first PICU admission. However, on subsequent PICU admissions pSOFA and O-PRISM scores might be useful to predict mortality. These scores should be prospectively evaluated in further studies to verify whether they can identify pediatric HSCT recipients profiting most from transferal to the PICU.

Functional outcomes at PICU discharge in hemato-oncology children at a tertiary oncology center in Hong Kong

BACKGROUND

Advancements in cancer treatment have resulted in longer survival but often at the expense of new therapy-associated morbidities. The aim of this study is to evaluate functional outcomes of hemato-oncology patients at PICU discharge, and to identify associated risk factors.

METHODS

A single-center retrospective observational study. All children (< 19 years) with a hemato-oncology diagnosis admitted to the Hong Kong Children's Hospital PICU over a 2-year period were included. Functional status upon admission and discharge were compared. Univariable and multi-variable analyses were employed to identify risk factors associated with new morbidities.

RESULTS

Out of 288 PICU admissions, there were 277 live discharges (mortality 4%), of which 52 (18.8%) developed new morbidities. Emergency admission, severity of illness at admission, organ dysfunction and support were associated with new morbidities (OR 1.08-11.96; p < 0.05). Adjusting for confounding factors, higher Pediatric Logistic Organ Dysfunction 2 score at admission was significantly associated with development of new morbidities (OR 1.34; 95% CI 1.18-1.54; p < 0.001).

CONCLUSION

Critically ill children with hemato-oncological diseases had a higher rate of developing new morbidities (18.8%) compared with the general PICU population (4-8%). This was associated with severity of illness at admission. Further work is warranted to understand the lasting effects of these new morbidities and mitigating interventions.

Accuracy of SIRS, age-adapted pSOFA, and quick SOFA scoring systems for predicting outcomes in paediatric patients with sepsis: a meta-analysis

BACKGROUND

Sepsis is the leading cause of mortality in children. Several scoring systems are used to predict outcome and mortality for pediatric patients with sepsis, but how they compare to each other in terms of sensitivity and specificity is unclear.

METHODS

The systematic literature review was performed following PRISMA guidelines. Publically accessible search engines and study databases such as PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), and Google Scholar were scanned for articles published from January 1990 to March 2021 using relevant key words. All relevant studies were analyzed separately by two reviewers. A random-effects model was used to calculate the pooled sensitivity and pooled specificity with a 95% confidence interval (CI). Heterogeneity was evaluated using I², which estimates the percentage of variation between study results due to heterogeneity rather than sampling error.

RESULTS

Eleven studies met inclusion criteria and evaluated the SOFA scoring system. The pooled sensitivity, specificity, and SROC for prediction of mortality were 83% (95% CI: 76%-88%), 72% (95% CI: 60%-81%), and 85% (95% CI: 82%-88%), respectively. Six studies examined the SIRS system. Pooled sensitivity, specificity, and SROC were 80% (95% CI: 64%-90%), 36% (95% CI: 23%-51%), and 59% (95% CI: 55%-63%), respectively.

CONCLUSION

This meta-analysis shows that SOFA was superior to SIRS for predicting mortality in PICU patients with sepsis. Additional prospective multi-centric studies are needed to better evaluate and validate this finding.

Therapeutics for paediatric oncological emergencies

Background

With advancements in the field of oncology, cancer survival rates have improved dramatically but modern cancer treatments also come with an increasing number of disease and treatment-associated complications. This article provides an updated narrative review on the pathophysiology, clinical presentations and latest management strategies for common paediatric oncological emergencies.

Methods

An extensive PubMed^® search of all human studies in the English literature was performed in Clinical Queries for different oncology syndromes and conditions using the following Medical Subject Headings: “tumour lysis syndrome”, “hyperleukocytosis”, “disseminated intravascular coagulation”, “superior mediastinal syndrome”, “superior vena cava syndrome”, “sepsis”, “severe inflammatory response syndrome”, “acute respiratory distress syndrome”, “posterior reversible encephalopathy syndrome” and “reversible posterior leukoencephalopathy syndrome”. Categories were limited to clinical trials and reviews for ages from birth to 18 years.

Results

The general description, presentation and management of these oncologic emergencies are systematically described. Early recognition along with prompt and proactive treatment can reduce the chances of potential complications and improve the clinical outcomes, thereby improving not only survival rates in oncology patients but also their clinical outcomes and quality of life.

Conclusions

Oncologic emergencies are associated with significant mortality and morbidity. Healthcare professionals involved with the care of oncology patients must be vigilant of these emergencies.

A nomogram to predict in-hospital mortality of neonates admitted to the intensive care unit

Background

To explore the influencing factors for in-hospital mortality in the neonatal intensive care unit (NICU) and to establish a predictive nomogram.

Methods

Neonatal data were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Both univariate and multivariate logit binomial general linear models were used to analyse the factors influencing neonatal death. The area under the receiver operating characteristics (ROC) curve was used to assess the predictive model, which was visualized by a nomogram.

Results

A total of 1258 neonates from the NICU in the MIMIC-III database were eligible for the study, including 1194 surviving patients and 64 deaths. Multivariate analysis showed that red cell distribution width (RDW) (odds ratio [OR] 0.813, p=0.003) and total bilirubin (TBIL; OR 0.644, p<0.001) had protective effects on neonatal in-hospital death, while lymphocytes (OR 1.205, p=0.025), arterial partial pressure of carbon dioxide (PaCO₂; OR 1.294, p=0.016) and sequential organ failure assessment (SOFA) score (OR 1.483, p<0.001) were its independent risk factors. Based on this, the area under the curve of this predictive model was up to 0.865 (95% confidence interval 0.813 to 0.917), which was also confirmed by a nomogram.

Conclusions

The nomogram constructed suggests that RDW, TBIL, lymphocytes, PaCO₂ and SOFA score are all significant predictors for in-hospital mortality in the NICU.

Evaluation of the Neonatal Sequential Organ Failure Assessment and Mortality Risk in Preterm Infants With Late-Onset Infection

IMPORTANCE

Infection in neonates remains a substantial problem. Advances for this population are hindered by the absence of a consensus definition for sepsis. In adults, the Sequential Organ Failure Assessment (SOFA) operationalizes mortality risk with infection and defines sepsis. The generalizability of the neonatal SOFA (nSOFA) for neonatal late-onset infection-related mortality remains unknown.

OBJECTIVE

To determine the generalizability of the nSOFA for neonatal late-onset infection-related mortality across multiple sites.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter retrospective cohort study was conducted at 7 academic neonatal intensive care units between January 1, 2010, and December 31, 2019. Participants included 653 preterm (<33 weeks) very low-birth-weight infants.

EXPOSURES

Late-onset (>72 hours of life) infection including bacteremia, fungemia, or surgical peritonitis.

MAIN OUTCOMES AND MEASURES

The primary outcome was late-onset infection episode mortality. The nSOFA scores from survivors and nonsurvivors with confirmed late-onset infection were compared at 9 time points (T) preceding and following event onset.

RESULTS

In the 653 infants who met inclusion criteria, median gestational age was 25.5 weeks (interquartile range, 24-27 weeks) and median birth weight was 780 g (interquartile range, 638-960 g). A total of 366 infants (56%) were male. Late-onset infection episode mortality occurred in 97 infants (15%). Area under the receiver operating characteristic curves for mortality in the total cohort ranged across study centers from 0.71 to 0.95 (T0 hours), 0.77 to 0.96 (T6 hours), and 0.78 to 0.96 (T12 hours), with utility noted at all centers and in aggregate. Using the maximum nSOFA score at T0 or T6, the area under the receiver operating characteristic curve for mortality was 0.88 (95% CI, 0.84-0.91). Analyses stratified by sex or Gram-stain identification of pathogen class or restricted to infants born at less than 25 weeks' completed gestation did not reduce the association of the nSOFA score with infection-related mortality.

CONCLUSIONS AND RELEVANCE

The nSOFA score was associated with late-onset infection mortality in preterm infants at the time of evaluation both in aggregate and in each center. These findings suggest that the nSOFA may serve as the foundation for a consensus definition of sepsis in this population.

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

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

Prognostic Factors of ICU Mortality in Pediatric Oncology Patients With Pulmonary Complications

OBJECTIVE

This study aimed to determine prognostic factors associated with mortality in pediatric oncology patients admitted to the intensive care unit (ICU) with pulmonary complications.

MATERIALS AND METHODS

This retrospective cohort study included patients 21 years of age with underlying oncologic diseases admitted to the ICU of a Korean Tertiary Referral Hospital with pulmonary complications from April 2009 to March 2017. Patients admitted for perioperative management or nonpulmonary complications were excluded. Demographic, laboratory, and clinical parameters (eg, Glasgow Coma Scale [GCS], pediatric Sequential Organ Failure Assessment [pSOFA], and Pediatric Logistic Organ Dysfunction [PELOD] scores) were reviewed.

RESULTS

Overall, 110 patients (62 male, 56.3%) with a median age of 13 years (interquartile range: 8 to 16 y) were studied. The median ICU stay was 8 days (interquartile range: 4.25 to 16 d). Forty-five (40.9%) patients required mechanical ventilation. The overall mortality rate was 59.1% (65/110 patients). A multivariate logistic regression identified a low GCS score, peripheral oxygen saturation/fraction of inspired oxygen ratio, and hematocrit and increased total bilirubin as significantly associated with increased mortality. The pSOFA and PELOD scores on days 1 and 3 postadmission predicted in-ICU mortality, with corresponding areas under the curve of 0.80/0.76 and 0.87/0.83, respectively.

CONCLUSION

Several clinical scores and factors may predict mortality in pediatric oncology patients with pulmonary complications.

Comprehensive Prognostication in Critically Ill Pediatric Hematopoietic Cell Transplant Patients: Results from Merging the Center for International Blood and Marrow Transplant Research (CIBMTR) and Virtual Pediatric Systems (VPS) Registries

Critically ill pediatric allogeneic hematopoietic cell transplant (HCT) patients may benefit from early and aggressive interventions aimed at reversing the progression of multiorgan dysfunction. Therefore, we evaluated 25 early risk factors for pediatric intensive care unit (PICU) mortality to improve mortality prognostication. We merged the Virtual Pediatric Systems and Center for International Blood and Marrow Transplant Research databases and analyzed 936 critically ill patients ≤21 years of age who had undergone allogeneic HCT and subsequently required PICU admission between January 1, 2009, and December 31, 2014. Of 1532 PICU admissions, the overall PICU mortality rate was 17.4% (95% confidence interval [CI], 15.6% to 19.4%) but was significantly higher for patients requiring mechanical ventilation (44.0%), renal replacement therapy (56.1%), or extracorporeal life support (77.8%). Mortality estimates increased significantly the longer that patients remained in the PICU. Of 25 HCT- and PICU-specific characteristics available at or near the time of PICU admission, moderate/severe pre-HCT renal injury, pre-HCT recipient cytomegalovirus seropositivity, <100-day interval between HCT and PICU admission, HCT for underlying acute myeloid leukemia, and greater admission organ dysfunction as approximated by the Pediatric Risk of Mortality 3 score were each independently associated with PICU mortality. A multivariable model using these components identified that patients in the top quartile of risk had 3 times greater mortality than other patients (35.1% versus 11.5%, P < .001, classification accuracy 75.2%; 95% CI, 73.0% to 77.4%). These data improve our working knowledge of the factors influencing the progression of critical illness in pediatric allogeneic HCT patients. Future investigation aimed at mitigating the effect of these risk factors is warranted.

PICU mortality of children with cancer admitted to pediatric intensive care unit a systematic review and meta-analysis

BACKGROUND

Outcomes for children diagnosed with cancer have improved dramatically over the past 20 years. However, although 40% of pediatric cancer patients require at least one intensive care admission throughout their disease course, PICU outcomes and resource utilization by this population have not been rigorously studied in this specific group.

METHODS

Using a systematic strategy, we searched Medline, Embase, and CINAHL databases for articles describing PICU mortality of pediatric cancer patients admitted to PICU. Two investigators independently applied eligibility criteria, assessed data quality, and extracted data. We pooled PICU mortality estimates using random-effects models and examined mortality trends over time using meta-regression models.

RESULTS

Out of 1218 identified manuscripts, 31 studies were included covering 16,853 PICU admissions with the majority being retrospective in nature. Overall pooled weighted mortality was 27.8% (95% confidence interval (CI), 23.7-31.9%). Mortality decreased slightly over time when post-operative patients were excluded. The use of mechanical ventilation (odds ratio (OR): 18.49 [95% CI 13.79-24.78], p < 0.001), inotropic support (OR: 14.05 [95% CI 9.16-21.57], p < 0.001), or continuous renal replacement therapy (OR: 3.24 [95% CI 1.31-8.04], p = 0.01) was significantly associated with PICU mortality.

CONCLUSIONS

PICU mortality rates of pediatric cancer patients are far higher when compared to current mortality rates of the general PICU population. PICU mortality has remained relatively unchanged over the past decades, a slight decrease was only seen when post-operative patients were excluded. This compared infavorably with the improved mortality seen in adults with cancer admitted to ICU, where research-led improvements have led to the paradigm of unlimited, aggressive ICU management without any limitations on resuscitations status, for a time-limited trial.

Prediction of ICU mortality in critically ill children : Comparison of SOFA, GCS, and FOUR score

INTRODUCTION

The SOFA (Sequential Organ Failure Assessment), GCS (Glasgow Coma Scale), and FOUR (Full Outline of UnResponsiveness) scores are the most commonly used scoring systems to predict the risk of mortality and morbidity in intensive care units (ICUs). The aim of the current study was to compare the predictive ability of these three models for predicting medical/surgical ICU mortality in critically ill children.

METHODS

In the current observational and prospective study, a total of 90 consecutive patients, age ≤18 years, admitted to medical and surgical ICUs, were enrolled. The SOFA, GCS, FOUR score and demographic characteristics of all children were recorded on the first day of admission. For statistical analyses, a receiver operator characteristic (ROC) curve, the Hosmer-Lemeshow goodness of fit test, and logistic regression were used (95% confidence interval).

RESULTS

The SOFA, GCS, and FOUR scores between survivors and nonsurvivors were statistically different (p = 0.002, p < 0.001, p = 0.004, respectively). The discrimination power for SOFA, GCS, and FOUR score was moderate (area under ROC [AUC] curve: 75.1%; standard error [SE]: 6.0%, 72.9% [SE: 7.2%], 78.7% [SE: 6.6%], respectively). The only well-calibrated model was GCS (x² = 2.76, p = 0.59).

CONCLUSIONS

The performance of the three predictive models SOFA, GCS, and FOUR score for predicting outcomes in children admitted to medical and surgical ICUs was good. The discrimination was moderate for all three models, and calibration was good just for GCS. GCS was superior in predicting outcome in critically ill children; however, further studies are needed to validate these scores in the pediatric population.

Evaluation of disseminated intravascular coagulation scores in critically ill pediatric patients with septic shock

PURPOSE

To evaluated the outcome predictability of DIC scores in critically ill children with septic shock.

MATERIALS AND METHODS

Pediatric patients with septic shock who were admitted to the pediatric intensive care unit of a tertiary care children's hospital between January 2013 and December 2017 were enrolled. We analyzed the association between DIC and clinical outcomes. DIC was diagnosed based on the International Society on Thrombosis and Hemostasis (ISTH), Japanese Association for Acute Medicine (JAAM), and modified JAAM DIC criteria.

RESULTS

Among the 89 patients, DIC was diagnosed in 66.3%, 61.8%, and 41.6% of patients using the JAAM, modified JAAM, and ISTH DIC criteria, respectively. Overall 28-day mortality was 14.6%. DIC patients had worse outcomes, including a higher 28-day mortality and multiorgan dysfunction syndrome (MODS) than those without DIC. The DIC scores were well correlated with the MODS scores. The JAAM and modified JAAM DIC scores showed good outcome predictability (p < 0.05) with areas under the receiver operating characteristic curve of 0.765 and 0.741, respectively.

CONCLUSIONS

Critically ill children with septic shock frequently experience DIC. Patients with DIC had worse outcomes than those without DIC. JAAM and modified JAAM DIC scores could be promising outcome predictors in these patients.

Hospital Variation in Intensive Care Resource Utilization and Mortality in Newly Diagnosed Pediatric Leukemia

OBJECTIVES

To evaluate hospital-level variability in resource utilization and mortality in children with new leukemia who require ICU support, and identify factors associated with variation.

DESIGN

Retrospective cohort study.

SETTING

Children's hospitals contributing to the Pediatric Health Information Systems administrative database from 1999 to 2011.

PATIENTS

Inpatients less than 25 years old with newly diagnosed acute lymphocytic leukemia or acute myeloid leukemia requiring ICU support (n = 1,754).

INTERVENTIONS, MEASUREMENTS, AND MAIN RESULTS

Evaluated exposures included leukemia type, year of diagnosis, and hospital-wide proportion of patients with public insurance. The main outcome was hospital mortality. Wide variability existed in the ICU resources used across hospitals. Combined acute lymphocytic leukemia and acute myeloid leukemia mortality varied by hospital from 0% (95% CI, 0-14.8%) to 42.9% (95% CI, 17.7-71.1%). A mixed-effects model with a hospital-level random effect suggests significant variation across hospitals in mortality (p = 0.007). When including patient and hospital factors as fixed effects into the model, younger age, acute myeloid leukemia versus acute lymphocytic leukemia diagnosis, leukemia diagnosis prior to 2005, hospital-wide proportion of public insurance patients, and hospital-level proportion of leukemia patients receiving ICU care are significantly associated with mortality. The variation across hospitals remains significant with all patient factors included (p = 0.021) but is no longer significant after adjusting for the hospital-level factors proportion of public insurance and proportion receiving ICU care (p = 0.48).

CONCLUSIONS

Wide hospital-level variability in ICU resource utilization and mortality exists in the care of children with leukemia requiring ICU support. Hospital payer mix is associated with some mortality variability. Additional study into how ICU support could be standardized through clinical practice guidelines, impact of payer mix on hospital resources allocation to the ICU, and subsequent impact on patient outcomes is warranted.

Serial evaluation of the SOFA score is reliable for predicting mortality in acute severe pancreatitis

Acute severe pancreatitis caused high mortality, and several scoring systems for predicting mortality are available. We evaluated the effectiveness of serial measurement of several scoring systems in patients with acute severe pancreatitis.We retrospectively obtained serial measurements of Ranson, Acute Physiology and Chronic Health Assessment (APACHE) II, and Sequential Organ Failure Assessment (SOFA) scores of 159 patients with acute severe pancreatitis.The overall mortality rate was 20%, and early mortality (in the first 2 weeks) occurred in 10 (7.4%) patients, while late mortality occurred in 17 (12.6%).All scoring systems were reliable for predicting overall and intensive care unit mortality, while the SOFA score on day 7 presented the largest area under the receiver operator characteristic (ROC) curve (0.858, SE 0.055). Changes in scores over time were evaluated for predicting the progression of organ failure, and the change in SOFA score on hospital day 7 or no interval change in SOFA score was associated with higher mortality rates.APACHE II and SOFA scores are both sensitive for predicting mortality in acute pancreatitis. The serial SOFA scores showed reliable for predicting mortality. Hospital day 7 is a reasonable time for SOFA score reassessment to predict late mortality in acute severe pancreatitis.

Sequential Organ Failure Assessment predicts outcomes of pulse indicator contour continuous cardiac output-directed goal therapy: A prospective study

According to the new sepsis definitions, septic shock is defined as a subset of sepsis in which the underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality. We evaluated the predictive efficacy of the Sequential Organ Failure Assessment (SOFA) score in critically ill patients with septic shock undergoing pulse indicator contour continuous cardiac output (PiCCO)-directed goal therapy (PDGT).We conducted a single-center, prospective, observational study of 52 patients with septic shock undergoing PDGT. The putative prognostic factors, including the severity scores (SOFA and Acute Physiology and Chronic Health Evaluation II [APACHE II] scores), were analyzed within 24 hours after diagnosis of septic shock. We assessed and compared the predictive efficacy of risk factors for 28-day mortality of patients with septic shock undergoing PDGT.Among the patients with septic shock undergoing PDGT, the SOFA scores of nonsurvivors were significantly higher than those of survivors (P < .001); the area under the receiver operating characteristics curve was higher for SOFA than for APACHE II (P = .005). The outcomes of the logistic regression analysis for 28-day mortality showed that the odds ratio, 95% confidence interval, and P-value of SOFA were 1.6, 1.2 to 2.1, and <.001, respectively.The predictive model of the SOFA score is able to accurately predict the outcomes of critically ill patients with septic shock undergoing PDGT.

Pathogens and outcomes in pediatric septic shock patients supported by extracorporeal membrane oxygenation

BACKGROUND

Refractory septic shock is the leading cause of mortality in children. There is limited evidence to support extracorporeal membrane oxygenation (ECMO) use in pediatric septic shock. We described the etiology and outcomes of septic patients in our institution and attempted to find predictive factors.

METHODS

We retrospectively reviewed 55 pediatric patients with septic shock who required ECMO support in a tertiary medical center from 2008 to 2015. Septic shock was defined as culture proved or clinical suspected sepsis with hypotension or end-organ hypoperfusion. ECMO would be applied when pediatric advanced life support steps were performed thoroughly without clinical response. Patient's demographics, laboratory parameters before and after ECMO, and outcomes were analyzed.

RESULTS

Among 55 children with ECMO support, 31% of them survived on discharge. For 25 immunocompromised patients, causal pathogens were found in 17 patients: 7 due to bacteremia, 9 with preexisting virus infections and one with invasive fungal infection. Among 30 previously healthy patients, causal pathogens were found in 18 patients: 10 due to bacteremia (the most common was pneumococcus), 7 with preexisting virus infections including influenza (n = 4), adenovirus (n = 2), RSV, and 1 patient had mixed virus and bacterial infections. Predictive factors associated with death were arterial blood gas pH, CO₂ and Glasgow Coma Scale (p < 0.05). SOFA score was a valuable predictive scoring system for outcome prediction (p < 0.05).

CONCLUSIONS

Pediatric patients with refractory septic shock had high mortality rate and ECMO could be used as a rescue modality, and SOFA score could be applied to predict outcomes.

Evaluation of Disseminated Intravascular Coagulation Scores in Critically Ill Pediatric Patients

OBJECTIVES

Disseminated intravascular coagulation is a complex systemic thrombohemorrahgic disorder, which may contribute to organ failure. We aimed to compare the detection rate of the disseminated intravascular coagulation, early in the course of ICU admission, of the two disseminated intravascular coagulation scoring systems defined by International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine criteria and the prognostic value of disseminated intravascular coagulation scores in critically ill pediatric patients.

DESIGN

Single-center retrospective observational study.

SETTING

PICU in a tertiary care children's hospital.

PATIENTS

Pediatric patients admitted in the PICU between January 2013 and December 2014.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 191 patients were included. Among them, 15.7% and 29.8% of the patients were diagnosed with disseminated intravascular coagulation by International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine criteria, respectively. The diagnostic concordance rate between the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems was 52.6%. As the Pediatric Risk of Mortality III, the modified Sequential Organ Failure Assessment, and the Pediatric Multiple Organ Dysfunction Syndrome scores increased, the percentage of patients with disseminated intravascular coagulation increased stepwise. The disseminated intravascular coagulation scores correlated well with these severity scores. Overall, the 28-day mortality was 9.9%. There were significant differences in most variables consisting of the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems between survivor and nonsurvivors. Patients detected to have disseminated intravascular coagulation by the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems showed higher mortality than patients without disseminated intravascular coagulation. The areas under the receiver operating characteristic curve of the Japanese Association for Acute Medicine score and International Society on Thrombosis and Hemostasis score were 0.788 (95% CI, 0.675-0.900) and 0.716 (95% CI, 0.598-0.834), respectively.

CONCLUSIONS

Both the International Society on Thrombosis and Hemostasis and the Japanese Association for Acute Medicine scoring systems are useful for detection of the disseminated intravascular coagulation in critically ill pediatric patients. These scores correlate well with other severity scores, including Pediatric Risk of Mortality III, modified Sequential Organ Failure Assessment, and Pediatric Multiple Organ Dysfunction Syndrome. Disseminated intravascular coagulation scores are also significantly associated with 28-day mortality, suggesting that these could be promising prognostic factors.

Relationship Between Beta Cell Dysfunction and Severity of Disease Among Critically Ill Children: A STROBE-Compliant Prospective Observational Study

Although beta cell dysfunction has been proved to predict prognosis among humans and animals, its prediction on severity of disease remains unclear among children. The present study was aimed to examine the relationship between beta cell dysfunction and severity of disease among critically ill children.This prospective study included 1146 critically ill children, who were admitted to Pediatric Intensive Care Unit (PICU) of Hunan Children's Hospital from November 2011 to August 2013. Information on characteristics, laboratory tests, and prognostic outcomes was collected. Homeostasis model assessment (HOMA)-β, evaluating beta cell function, was used to divide all participants into 4 groups: HOMA-β = 100% (group I, n = 339), 80% ≤ HOMA-β < 100% (group II, n = 71), 40% ≤ HOMA-β < 80% (group III, n = 293), and HOMA-β < 40% (group IV, n = 443). Severity of disease was assessed using the worst Sequential Organ Failure Assessment (SOFA) score, Pediatric Risk of Mortality (PRISM) III score, incidence of organ damage, septic shock, multiple organ dysfunction syndrome (MODS), mechanical ventilation (MV) and mortality. Logistic regression analysis was used to evaluate the risk of developing poor outcomes among patients in different HOMA-β groups, with group I as the reference group.Among 1146 children, incidence of HOMA-β < 100% was 70.41%. C-peptide and insulin declined with the decrement of HOMA-β (P < 0.01). C-reactive protein and procalcitonin levels, rather than white blood cell, were significantly different among 4 groups (P < 0.01). In addition, the worst SOFA score and the worst PRISMIII score increased with declined HOMA-β. For example, the worst SOFA score in group I, II, III, and IV was 1.55 ± 1.85, 1.71 ± 1.93, 1.92 ± 1.63, and 2.18 ± 1.77, respectively. Furthermore, patients with declined HOMA-β had higher risk of developing septic shock, MODS, MV, and mortality, even after adjusting age, gender, myocardial injury, and lung injury. For instance, compared with group I, the multivariate-adjusted odds ratio (95% confidence interval) for developing septic shock was 2.17 (0.59, 8.02), 2.94 (2.18, 6.46), and 2.76 (1.18, 6.46) among patients in group II, III, and IV, respectively.Beta cell dysfunction reflected the severity of disease among critically ill children. Therefore, assessment of beta cell function is critically important to reduce incidence of adverse events in PICU.

Respiratory Failure in Children With Hemato-oncological Diseases Admitted to the PICU: A Single-center Experience

Respiratory failure (RF) is a main cause of pediatric intensive care unit (PICU) admission in children with hemato-oncological diseases. We present a retrospective chart review of children admitted to our PICU because of RF (January 2006 to December 2010). The aims of this study are the following: (1) to describe the demographical and clinical characteristics and respiratory management of these children; and (2) to identify the factors associated with mechanical ventilation (MV) and mortality. A total of 69 patients, encompassing 88 episodes, were included (55/88 cases were hypoxemic RF). The first respiratory support at PICU admission was, in decreasing order of frequency, high-flow oxygen nasal cannula (HFNC; 50/88), noninvasive ventilation (NIV; 13/88), and oxygen nasal cannula (16/88). MV was necessary in 47/88 episodes, 38/47 after another respiratory support. In 18/28 children with initial NIV, MV was required later. MV was associated with O-PRISM score, NIV requirement, suspected respiratory infection, and days of PICU treatment. Patients without MV showed an increased survival rate (P=0.001). In summary, the hypoxemic RF was the main cause of PICU admission, and HFNC or NIV was almost always the first respiratory support. The use of MV was associated with a higher mortality rate. The utility of precocious HFNC or NIV should be investigated in larger clinical studies.

Pediatric cancer type predicts infection rate, need for critical care intervention, and mortality in the pediatric intensive care unit

PURPOSE

Up to 38 % of children with cancer require pediatric intensive care unit (PICU) admission within 3 years of diagnosis, with reported PICU mortality of 13-27 % far exceeding that of the general PICU population. PICU outcomes data for individual cancer types are lacking and may help identify patients at risk for poor clinical outcomes.

METHODS

We performed a retrospective multicenter analysis of 10,365 PICU admissions of cancer patients no greater than 21 years old among 112 PICUs between 1 January 2009 and 30 June 2012. We evaluated the effect of cancer type, age, gender, genetic syndrome, stem cell transplantation, PRISM3 score, infections, and critical care interventions on PICU mortality.

RESULTS

After excluding scheduled perioperative admissions, cancer patients represented 4.2 % of all PICU admissions (10,365/246,346), had overall mortality of 6.8 % (708/10,365) vs. 2.4 % (5,485/230,548) in the general PICU population (RR = 2.9, 95 % CI 2.7-3.1, p < 0.001), and accounted for 11.4 % of all PICU deaths (708/6,215). Hematologic cancer patients had greater median PRISM3 score (8 vs 2, p < 0.001), rates of sepsis (27 vs 9 %, RR = 2.9, 95 % CI 2.6-3.1, p < 0.001), and mortality (9.6 vs 4.5 %, RR = 2.1, 95 % CI 1.8-2.5, p < 0.001) compared to solid cancer patients. Among hematologic cancer patients, stem cell transplantation, diagnosis of acute myeloid leukemia, PRISM3 score, and infection were all independently associated with PICU mortality.

CONCLUSIONS

Children with cancer account for 4.2 % of PICU admissions and 11.4 % of PICU deaths. Hematologic cancer patients have significantly higher admission illness severity, rates of infections, and PICU mortality than solid cancer patients. These data may be useful in risk stratification for closer monitoring and patient counseling.

Outcome of pediatric acute myeloid leukemia patients receiving intensive care in the United States

OBJECTIVE

Children with acute myeloid leukemia are at risk for sepsis and organ failure. Outcomes associated with intensive care support have not been studied in a large pediatric acute myeloid leukemia population. Our objective was to determine hospital mortality of pediatric acute myeloid leukemia patients requiring intensive care.

DESIGN

Retrospective cohort study of children hospitalized between 1999 and 2010. Use of intensive care was defined by utilization of specific procedures and resources. The primary endpoint was hospital mortality.

SETTING

Forty-three children's hospitals contributing data to the Pediatric Health Information System database.

PATIENTS

Patients who are newly diagnosed with acute myeloid leukemia and who are 28 days through 18 years old (n = 1,673) hospitalized any time from initial diagnosis through 9 months following diagnosis or until stem cell transplant. A reference cohort of all nononcology pediatric admissions using the same intensive care resources in the same time period (n = 242,192 admissions) was also studied.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One-third of pediatric patients with acute myeloid leukemia (553 of 1,673) required intensive care during a hospitalization within 9 months of diagnosis. Among intensive care admissions, mortality was higher in the acute myeloid leukemia cohort compared with the nononcology cohort (18.6% vs 6.5%; odds ratio, 3.23; 95% CI, 2.64-3.94). However, when sepsis was present, mortality was not significantly different between cohorts (21.9% vs 19.5%; odds ratio, 1.17; 95% CI, 0.89-1.53). Mortality was consistently higher for each type of organ failure in the acute myeloid leukemia cohort versus the nononcology cohort; however, mortality did not exceed 40% unless there were four or more organ failures in the admission. Mortality for admissions requiring intensive care decreased over time for both cohorts (23.7% in 1999-2003 vs 16.4% in 2004-2010 in the acute myeloid leukemia cohort, p = 0.0367; and 7.5% in 1999-2003 vs 6.5% in 2004-2010 in the nononcology cohort, p < 0.0001).

CONCLUSIONS

Pediatric patients with acute myeloid leukemia frequently required intensive care resources, with mortality rates substantially lower than previously reported. Mortality also decreased over the time studied. Pediatric acute myeloid leukemia patients with sepsis who required intensive care had a mortality comparable to children without oncologic diagnoses; however, overall mortality and mortality for each category of organ failure studied was higher for the acute myeloid leukemia cohort compared with the nononcology cohort.