Short-term and long-term mortality following pediatric intensive care

Mortality and associated factors among children admitted to an intensive care unit in muhimbili national hospital, from the time of admission to three months after discharge: a prospective cohort study

BACKGROUND

Mortality of children admitted to Intensive Care Units (ICU) is higher in low-to-middle-income countries (LMICs) as compared to high-income countries (HICs). There is paucity of information on outcomes following discharge from ICU, especially from sub-Saharan Africa region. This study was conducted to determine mortality and its associated factors among children admitted to Pediatric ICU (PICU) at Muhimbili National Hospital, from admission to three months after discharge.

METHODOLOGY

This was a hospital-based prospective cohort study conducted between July 2021 and May 2022, among children admitted to PICU who were followed up for 3-month after discharge. Structured questionnaires were used to collect data from their medical charts. Telephone interviews were made after discharge. Medical records and verbal autopsy were used to determine the cause of death after discharge. Cox regression analysis was performed to assess the association between variables. A p-value of < 0.05 was considered statistically significant. Survival after PICU discharge was estimated by Kaplan - Meier curve.

RESULTS

Of 323 children recruited, 177(54.8%) were male, with a median age of 17 months (1-168). The leading cause of PICU admission was severe sepsis 90/323(27.9%). A total of 161/323 children died, yielding an overall mortality of 49.8%. Of 173 children discharged from PICU, 33(19.1%) died. The leading cause of death among children who died in the general ward or as readmission into PICU was sepsis 4/17(23.5%). Respiratory diseases 4/16(25.0%) were the commonest cause of death among those who died after hospital discharge. Independent predictors of overall mortality included single organ dysfunction with hazard ratio(HR):5.97, 95% confidence interval (CI)(3.05-12.26)] and multiple organ dysfunction [HR:2.77,95%CI(1.03-2.21)]. Chronic illness[HR:8.13,95%CI(2.45-27.02)], thrombocytosis [HR:3.39,95%CI(1.32-8.73)], single[HR:3.57,95%CI(1.42-9.03)] and multiple organ dysfunction[HR:3.11,95%CI(1.01-9.61)] independently predicted post-PICU discharge mortality.

CONCLUSION

Overall mortality and post- PICU discharge mortality were high and more likely to affect children with organ dysfunction, chronic illness, and thrombocytosis. The leading causes of mortality post- PICU discharge were sepsis and respiratory diseases. There is a need for a focused follow up plan of children post- PICU discharge, further research on the long term survival and strategies to improve it.

Risks for death after admission to pediatric intensive care (PICU)-A comparison with the general population

OBJECTIVE/AIM

The aim of the study was to quantify excess mortality in children after admission to a Pediatric Intensive Care Unit (PICU), compared to the age and sex matched general Swedish population.

DESIGN

Single-center, retrospective cohort study.

SETTING

Registry study of hospital registers, a national population register and Statistics Sweden.

PATIENTS

Children admitted to a tertiary PICU in Sweden in 2008-2016.

INTERVENTIONS

None.

MAIN RESULTS

In total, 6,487 admissions (4,682 patients) were included in the study. During the study period 444 patients died. Median follow-up time for the entire PICU cohort was 7.2 years (IQR 5.0-9.9 years). Patients were divided into four different age groups (0-28 d, > 28 d -1 yr, > 1-4 yr, and > 4 yr) and four different risk stratification groups [Predicted Death Rate (PDR) intervals: 0-10%, > 10-25%, > 25-50%, and > 50%] at admission. Readmission was seen in 929 (19.8%) patients. The Standardized Mortality Ratios (SMRs) were calculated using the matched Swedish population as a reference group. The SMR for the entire study group was 49.8 (95% CI: 44.8-55.4). For patients with repeated PICU admissions SMR was 108.0 (95% CI: 91.9-126.9), and after four years 33.9 (95% CI: 23.9-48.0). Patients with a single admission had a SMR of 35.2 (95% CI: 30.5-40.6), and after four years 11.0 (95% CI: 7.0-17.6). The highest SMRs were seen in readmitted children with oncology/hematology (SMR = 358) and neurologic (SMR = 192) diagnosis. Children aged >1-4 years showed the highest SMR (325). In PDR group 0-10% children with repeated PICU admissions (n = 798), had a SMR of 100.

CONCLUSION

Compared to the matched Swedish population, SMRs were greatly elevated up to four years after PICU admission, declining from over 100 to 33 for patients with repeated PICU admissions, and from 35 to 11 for patients with a single PICU admission.

Criteria for Pediatric Sepsis-A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce

OBJECTIVE

To determine the associations of demographic, clinical, laboratory, organ dysfunction, and illness severity variable values with: 1) sepsis, severe sepsis, or septic shock in children with infection and 2) multiple organ dysfunction or death in children with sepsis, severe sepsis, or septic shock.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020.

STUDY SELECTION

Case-control studies, cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years with suspected or confirmed infection, which included the terms "sepsis," "septicemia," or "septic shock" in the title or abstract.

DATA EXTRACTION

Study characteristics, patient demographics, clinical signs or interventions, laboratory values, organ dysfunction measures, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed.

DATA SYNTHESIS

One hundred and six studies met eligibility criteria of which 81 were included in the meta-analysis. Sixteen studies (9,629 patients) provided data for the sepsis, severe sepsis, or septic shock outcome and 71 studies (154,674 patients) for the mortality outcome. In children with infection, decreased level of consciousness and higher Pediatric Risk of Mortality scores were associated with sepsis/severe sepsis. In children with sepsis/severe sepsis/septic shock, chronic conditions, oncologic diagnosis, use of vasoactive/inotropic agents, mechanical ventilation, serum lactate, platelet count, fibrinogen, procalcitonin, multi-organ dysfunction syndrome, Pediatric Logistic Organ Dysfunction score, Pediatric Index of Mortality-3, and Pediatric Risk of Mortality score each demonstrated significant and consistent associations with mortality. Pooled mortality rates varied among high-, upper middle-, and lower middle-income countries for patients with sepsis, severe sepsis, and septic shock (p < 0.0001).

CONCLUSIONS

Strong associations of several markers of organ dysfunction with the outcomes of interest among infected and septic children support their inclusion in the data validation phase of the Pediatric Sepsis Definition Taskforce.

Outcomes following admission to paediatric intensive care: A systematic review

AIM

To describe the long-term health outcomes of children admitted to a paediatric intensive care unit.

METHODS

A systematic review of the literature was performed. Studies of children under 18 years of age admitted to a paediatric intensive care unit were included. Studies focussed on neonatal admissions and investigating specific paediatric intensive care unit interventions or admission diagnoses were excluded. A table was created summarising the study characteristics and main findings. Risk of bias was assessed using the Newcastle Ottawa Quality Assessment Scale for observational studies. Primary outcome was short-, medium- and long-term mortality. Secondary outcomes included measures of neurodevelopment, cognition, physical, behavioural and psychosocial function as well as quality of life.

RESULTS

One hundred and eleven studies were included, most were conducted in high-income countries and focussed on short-term outcomes. Mortality during admission ranged from 1.3 to 50%. Mortality in high-income countries reduced over time but this trend was not evident for lower income countries. Higher income countries had lower standardised mortality rates than lower income countries. Children had an ongoing increased risk of death for up to 10 years following intensive care admission as well as increased physical and psychosocial morbidity compared to healthy controls, with associated poorer quality of life.

CONCLUSIONS

There is limited high-level evidence for the long-term health outcomes of children after intensive care admission, with the burden of related morbidity remaining greater in poorly resourced regions. Further research is recommended to identify risk factors and modifiable factors for poor outcomes, which could be targeted in practice improvement initiatives.

Pediatric Sepsis Definition-A Systematic Review Protocol by the Pediatric Sepsis Definition Taskforce

Supplemental Digital Content is available in the text.

Sepsis is responsible for a substantial proportion of global childhood morbidity and mortality. However, evidence demonstrates major inaccuracies in the use of the term “sepsis” in clinical practice, coding, and research. Current and previous definitions of sepsis have been developed using expert consensus but the specific criteria used to identify children with sepsis have not been rigorously evaluated. Therefore, as part of the Society of Critical Care Medicine’s Pediatric Sepsis Definition Taskforce, we will conduct a systematic review to synthesize evidence on individual factors, clinical criteria, or illness severity scores that may be used to identify children with infection who have or are at high risk of developing sepsis-associated organ dysfunction and separately those factors, criteria, and scores that may be used to identify children with sepsis who are at high risk of progressing to multiple organ dysfunction or death.

Five-Year Survival and Causes of Death in Children After Intensive Care-A National Registry Study

OBJECTIVES

The aim of the study was to compare long-term mortality and causes of death in children post admission to an ICU with a control population of same age.

DESIGN

Longitudinal follow-up study.

SETTING

Registry study of a national ICU register and hospital registries.

PATIENTS

Children admitted to an ICU in the years 2009 and 2010.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The mortality and causes of death following ICU discharge were analyzed retrospectively. The median follow-up period was 4.9 years (25-75th percentiles, 4.4-5.5 yr). The causes of death in survivors 30 days after ICU discharge were compared with a cohort of 1 million children of the general population of same age. In total, 2,792 children were admitted to an ICU during the study period. Of those, 53 (1.9%) died in the ICU and 2,739 were discharged. Thirteen children died within 30 days of discharge, and 68 died between 30 days and the end of follow-up (December 31, 2014). In the control population (n = 1,020,407 children), there were 1,037 deaths (0.10%) from 2009 to 2014. The standardized mortality rate for the children admitted to the ICU during the study period was 53.4 (95% CI, 44.7-63.2). The standardized mortality rate for those children alive 1 year after discharge was 16.7 (12.1-22.6). One-year cumulative mortality was 3.3%. The most common causes of death in subjects alive 30 days post ICU were cancer (35.3%), neurologic (17.6%), and metabolic diseases (11.7%), whereas trauma was the most common cause in the control group (45.3%).

CONCLUSIONS

There was an increased risk of death in a cohort of ICU-admitted children even 3 years after discharge. In those who survived 30 days after discharge, medical causes of death were dominant, whereas deaths due to trauma were most common in the control group.

Designing optimal mortality risk prediction scores that preserve clinical knowledge

Many in-hospital mortality risk prediction scores dichotomize predictive variables to simplify the score calculation. However, hard thresholding in these additive stepwise scores of the form "add x points if variable v is above/below threshold t" may lead to critical failures. In this paper, we seek to develop risk prediction scores that preserve clinical knowledge embedded in features and structure of the existing additive stepwise scores while addressing limitations caused by variable dichotomization. To this end, we propose a novel score structure that relies on a transformation of predictive variables by means of nonlinear logistic functions facilitating smooth differentiation between critical and normal values of the variables. We develop an optimization framework for inferring parameters of the logistic functions for a given patient population via cyclic block coordinate descent. The parameters may readily be updated as the patient population and standards of care evolve. We tested the proposed methodology on two populations: (1) brain trauma patients admitted to the intensive care unit of the Dell Children's Medical Center of Central Texas between 2007 and 2012, and (2) adult ICU patient data from the MIMIC II database. The results are compared with those obtained by the widely used PRISM III and SOFA scores. The prediction power of a score is evaluated using area under ROC curve, Youden's index, and precision-recall balance in a cross-validation study. The results demonstrate that the new framework enables significant performance improvements over PRISM III and SOFA in terms of all three criteria.

Hypertension and health outcomes in the PICU

OBJECTIVES

Reports of the burden of hypertension in hospitalized children are emerging, but the prevalence and significance of this condition within the PICU are not well understood. The aims of this study were to validate a definition of hypertension in the PICU and assess the associations between hypertension and acute kidney injury, PICU length of stay, and mortality.

DESIGN AND SETTING

Single-center retrospective study using a database of PICU discharges between July 2011 and February 2013.

PATIENTS

All children discharged from the PICU with length of stay more than 6 hours, aged 1 month through 17 years. Exclusions were traumatic brain injury, incident renal transplant, or hypotension.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Potential definitions of hypertension utilizing combinations of standardized cutoff percentiles, durations, initiation or dose escalation of antihypertensives, and/or billing diagnosis codes for hypertension were compared using receiver operator characteristic curves against a manual medical record review. Multivariable logistic and linear regression analyses were conducted using the selected definition of hypertension to assess its independent association with acute kidney injury and PICU length of stay, respectively. A definition requiring three systolic and/or diastolic readings above standardized 99th percentiles plus 5 mm Hg over 1 day was selected (area under the curve, 0.91; sensitivity, 94%; specificity, 87%). Among the 1,215 patients in this analysis, the prevalence of hypertension was 25%. Hypertension was independently associated with acute kidney injury (odds ratio, 2.89; 95% CI, 1.64-5.09; p < 0.01) and increased PICU length of stay (1.50 d; 95% CI, 0.94-2.05; p < 0.01) in multivariable analyses. Deaths were rare-0 in the normotension group and 3 (1%) in the hypertension group-but were statistically different (p = 0.02).

CONCLUSIONS

Hypertension is common in the PICU and is associated with worse clinical outcomes. Future studies are needed to confirm these results.

Patients with primary immunodeficiencies in pediatric intensive care unit: outcomes and mortality-related risk factors

PURPOSES

The aims of this study were to review the frequency, characteristics, and the clinical course of primary immunodeficiency (PID) patients admitted to pediatric intensive care unit (PICU) and attempt to identify factors related with mortality that might predict a poor outcome.

METHODS

We performed a retrospective review of children with PID aged 1 month to 18 years and admitted to PICU from January 2002 to January 2012 in our tertiary teaching children's hospital.

RESULTS

There were a total of 51 patients accounting for 71 admissions to the PICU. The most common diagnosis was severe combined immunodeficiency. Respiratory problems were the leading cause for admission. A total of 20 patients received hematopoietic stem cell transplantation. Immune reconstitution was achieved in 9 (45 %) patients and eight of them did survive. In all 56 % of all admission episodes resulted in survival. Risk factors for mortality included requirement of mechanical ventilation (P < .001), number of organ system failure (P = .013), need for renal replacement therapy (P < .001), use of inotropes (P < .001), higher Pediatric Logistic Organ Dysfunction (PELOD) score (P = .005), and length of PICU stay (P < .001).

CONCLUSIONS

This is the first study regarding the outcome and mortality-related risk factors for PID patients requiring PICU admission. We suggest that PICU management is as important as early diagnosis and treatment for these patients. Prediction of those at risk for poorer outcome might be beneficial for accurate intensive care management and survival.

[Pediatric intermediate care unit in general hospital: recent survey in French Polynesia]

In 2006, decrees relating to pediatric critical care defined the main rules of pediatric intermediate care units (PIMU). These units ensure continuous monitoring of children at risk of critical deterioration without requiring invasive support. In French Polynesia, a PIMU has been integrated into the general pediatric ward since the new hospital opened in November 2010. We conducted a prospective observational study of patients admitted to the PIMU depending on whether they were surgical patients or were secondarily transferred to the ICU or were transferred via long-distance medical air transport for specialized care. For the very first operational year, 199 children (median age, 3 years old) were admitted to the PIMU: for the most part respiratory (31.7%) and neurologic (23.6%) failures were involved. Surgical patients more often required a prosthesis or treatments associated with serious adverse effects than nonsurgical patients (respectively, 46% vs. 16%, P<0.01; 29% vs. 7%, P<0.01) and the length of the hospital stay was longer (5 days vs. 2, P<0.01). Patients who were secondarily transferred to the ICU had a higher admission Pediatric RISk of Mortality (PRISM) score (6 vs. 4, P<0.01) and required more treatments associated with serious adverse effects (50% vs. 20%, P<0.01) than nontransferred patients. The length of the hospital stay was longer (6days) for patients who underwent long-distance medical transport. In addition to PIMU defining criteria, the use of treatments associated with serious adverse effects should be considered risk factors of impaired prognosis in local practical procedures. Assessment of PIMU activity should take into account that intensive surgical care and geographical isolation are closely related to increased length of hospital stay.

Invasive candidiasis in pediatric intensive care in Greece: a nationwide study

PURPOSE

To record the practices for prevention and management of invasive candidiasis in the PICU and investigate the epidemiology of candidiasis and its outcome nationwide.

METHODS

A multicenter national study among PICUs throughout Greece. A questionnaire referring to local practices of prevention and management of candidemia was filled in, and a retrospective study of episodes that occurred during 5 years was conducted in all seven Greek PICUs.

RESULTS

Clinical practices regarding surveillance cultures, catheter replacement protocols and antibiotic use were similar, although the case mix differed. In all PICUs prophylactic antifungal treatment was administered in transplant and neutropenic oncology patients. Discrepancy existed between PICUs concerning the first-line antifungal agents and treatment duration of candidemia. Twenty-two candidemias were nationally recorded between 2005 and 2009 with a median incidence of 6.4 cases/1,000 admissions. Median age was 8.2 (0.3-16.6) years. Candida albicans was isolated in 45.4 % of episodes followed by Candida parapsilosis (22.7 %). Common findings were presence of central venous and urinary catheters as well as mechanical ventilation and administration of antibiotics with anti-anaerobic activity in almost all patients with candidemia. Total parenteral nutrition was administered to five (22.7 %) patients. Most of the patients had a chronic underlying disease; five were oncology patients, and two-thirds of those with candidemia were colonized with Candida spp. Lipid amphotericin B formulations were the predominant therapeutic choice (54.5 %). Thirty-day mortality was 18.2 %.

CONCLUSION

This first national study adds information to the epidemiology of candidemia in critically ill children. In these special patients, candidemia has a relatively low incidence and tends toward non-albicans Candida preponderance.

Prognostic value of blood zinc, iron, and copper levels in critically ill children with pediatric risk of mortality score III

We aimed to explore the association of blood Zn, Fe, and Cu concentrations and changes in the pediatric risk of mortality (PRISM) score in critically ill children, to predict prognosis. We included 31 children (22 boys and 9 girls, 1 month to 5 years old), who had been admitted to the intensive care unit of our hospital and who were critically ill according to PRISM score of III. Another 20 children (12 boys, 8 girls, 3 months to 5 years old) who were brought to the hospital for a health checkup were included as controls. We recorded clinical data, time in the intensive care unit, prognosis, and PRISM III score for critically ill children. Blood Cu, Zn, and Fe values were measured by inductively coupled plasma atomic emission spectrophotometry. Zn and Fe levels were significantly lower in patients than in controls (all p < 0.05). Cu levels differed between patients and controls, but not significantly (p > 0.05). In ill children, blood Zn and Fe concentrations were inversely correlated with PRISM III score (Zn: r = -0.36; Fe: r = -0.50, both p < 0.05), with no significant correlation of blood Cu level and PRISM III score (r = -0.13, p > 0.05). Serious illness in children may lead to decreased Zn and Fe blood concentrations. Zn and Fe supplements may be beneficial for critically ill children.