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Maccarana T, Pillon M, Bertozzi V, Carraro E, Cavallaro E, Bonardi CM, Marchetto L, Reggiani G, Tondo A, Rosa C, Comoretto RI, Amigoni A, Biffi A. Oncological pediatric early warning score: a dedicated tool to predict patient's clinical deterioration and need for pediatric intensive care treatment. Pediatr Hematol Oncol 2024:1-10. [PMID: 38973711 DOI: 10.1080/08880018.2024.2355543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/10/2024] [Indexed: 07/09/2024]
Abstract
Pediatric oncohematological patients frequently require PICU admission during their clinical history. The O-PEWS is a specific score developed to predict the need for PICU admission of oncohematological children. This study aimed at i) describing the trend of the O-PEWS in a cohort of patients hospitalized in the Pediatric Oncohematology ward and transferred to the PICU of Padua University Hospital, measured at different time-points in the 24 hours before PICU admission and to evaluate its association with mortality and presence of organ failure; ii) investigating the association between the recorded O-PEWS, and PIM3, number of organ failure and the need for ventilation, dialysis and inotropes. This retrospective single-center study enrolled oncohematological children admitted to the PICU between 2017 and 2021. The O-PEWS, ranging between 0 and 15, was calculated on the available medical records and the TIPNet-Network database at 24 (T-24), 12 (T-12), 6 (T-6) and 0 (T0) hours before PICU admission. RESULTS: 101 PICU admissions, related to 80 children, were registered. During the 24 hours prior to PICU admission, the O-PEWS progressively increased in all the patients. At T-24 the median O-PEWS was 3 (IQR 1-5), increasing to a median value of 6 (IQR 4-8) at T0. The O-PEWS was positively associated with mortality, organ failure and the need for ventilation at all the analyzed time-points and with the need for dialysis at T-6. The O-PEWS appears as a useful tool for predicting early clinical deterioration in oncohematological patients and for anticipating the initiation of life-support treatments.
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Affiliation(s)
| | - Marta Pillon
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy
| | | | - Elisa Carraro
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy
| | - Elena Cavallaro
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy
| | - Claudia Maria Bonardi
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy
| | - Luca Marchetto
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy
| | - Giulia Reggiani
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy
| | | | - Camilla Rosa
- Meyer Children's Hospital IRCCS', Firenze, Italy
| | | | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy
| | - Alessandra Biffi
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Department of Woman's and Child's Health, University-Hospital of Padova, Padova, Italy
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Martinato M, Comoretto RI, Biban P, Zanonato E, Simonini A, Montaguti A, Gitto E, Caramelli F, Ferrario S, Sagredini R, Alaimo N, Zito Marinosci G, Rossetti E, Cecchetti C, L'erario M, Vasile B, Ivani G, Bonanomi E, Astuto M, Gregori D, Mondardini MC, Amigoni A. Italian pediatric intensive care units admitting critically ill cancer children: results from a national survey. Minerva Anestesiol 2023; 89:850-858. [PMID: 37378625 DOI: 10.23736/s0375-9393.23.17329-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
BACKGROUND Pediatric patients affected by oncologic disease have a significant risk of clinical deterioration that requires admission to the intensive care unit. This study reported the results of a national survey describing the characteristics of Italian onco-hematological units (OHUs) and pediatric intensive care units (PICUs) that admit pediatric patients, focusing on the high-complexity treatments available before PICU admission, and evaluating the approach to the end-of-life (EOL) when cared in a PICU setting. METHODS A web-based electronic survey has been performed in April 2021, involving all Italian PICUs admitting pediatric patients with cancer participating in the study. RESULTS Eighteen PICUs participated, with a median number of admissions per year of 350 (IQR 248-495). Availability of Extracorporeal Membrane Oxygenation therapy and the presence of intermediate care unit are the only statistically different characteristics between large or small PICUs. Different high-level treatments and protocols are performed in OHUs, non depending on the volume of PICU. Palliative sedation is mainly performed in the OHUs (78%), however, in 72% it is also performed in the PICU. In most centers protocols that address EOL comfort care and treatment algorithms are missing, non depending on PICU or OHU volume. CONCLUSIONS A non-homogeneous availability of high-level treatments and in OHUs is described. Moreover, protocols addressing EOL comfort care and treatment algorithms in palliative care are lacking in many centers.
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Affiliation(s)
- Matteo Martinato
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Giuseppe Parenti Department of Statistics, Computer Science, Applications, University of Florence, Florence, Italy
| | - Rosanna I Comoretto
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Department of Sciences of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Paolo Biban
- University Hospital of Verona, Verona, Italy
| | | | | | | | | | - Fabio Caramelli
- S. Orsola-Malpighi IRCCS University Hospital, Bologna, Italy
| | | | | | | | | | | | | | | | | | - Giorgio Ivani
- AOU Città della Salute e della Scienza, Turin, Italy
| | | | | | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Flerlage T, Fan K, Qin Y, Agulnik A, Arias AV, Cheng C, Elbahlawan L, Ghafoor S, Hurley C, McArthur J, Morrison RR, Zhou Y, Park HJ, Carcillo JA, Hines MR. Mortality Risk Factors in Pediatric Onco-Critical Care Patients and Machine Learning Derived Early Onco-Critical Care Phenotypes in a Retrospective Cohort. Crit Care Explor 2023; 5:e0976. [PMID: 37780176 PMCID: PMC10538916 DOI: 10.1097/cce.0000000000000976] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVES To use supervised and unsupervised statistical methodology to determine risk factors associated with mortality in critically ill pediatric oncology patients to identify patient phenotypes of interest for future prospective study. DESIGN This retrospective cohort study included nonsurgical pediatric critical care admissions from January 2017 to December 2018. We determined the prevalence of multiple organ failure (MOF), ICU mortality, and associated factors. Consensus k-means clustering analysis was performed using 35 bedside admission variables for early, onco-critical care phenotype development. SETTING Single critical care unit in a subspeciality pediatric hospital. INTERVENTION None. PATIENTS There were 364 critical care admissions in 324 patients with underlying malignancy, hematopoietic cell transplant, or immunodeficiency reviewed. MEASUREMENTS Prevalence of multiple organ failure, ICU mortality, determination of early onco-critical care phenotypes. MAIN RESULTS ICU mortality was 5.2% and was increased in those with MOF (18.4% MOF, 1.7% single organ failure [SOF], 0.6% no organ failure; p ≤ 0.0001). Prevalence of MOF was 23.9%. Significantly increased ICU mortality risk was associated with day 1 MOF (hazards ratio [HR] 2.27; 95% CI, 1.10-6.82; p = 0.03), MOF during ICU admission (HR 4.16; 95% CI, 1.09-15.86; p = 0.037), and with invasive mechanical ventilation requirement (IMV; HR 5.12; 95% CI, 1.31-19.94; p = 0.018). Four phenotypes were derived (PedOnc1-4). PedOnc1 and 2 represented patient groups with low mortality and SOF. PedOnc3 was enriched in patients with sepsis and MOF with mortality associated with liver and renal dysfunction. PedOnc4 had the highest frequency of ICU mortality and MOF characterized by acute respiratory failure requiring invasive mechanical ventilation at admission with neurologic dysfunction and/or severe sepsis. Notably, most of the mortality in PedOnc4 was early (i.e., within 72 hr of ICU admission). CONCLUSIONS Mortality was lower than previously reported in critically ill pediatric oncology patients and was associated with MOF and IMV. These findings were further validated and expanded by the four derived nonsynonymous computable phenotypes. Of particular interest for future prospective validation and correlative biological study was the PedOnc4 phenotype, which was composed of patients with hypoxic respiratory failure requiring IMV with sepsis and/or neurologic dysfunction at ICU admission.
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Affiliation(s)
- Tim Flerlage
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN
| | - Kimberly Fan
- Division of Critical Care, Department of Pediatrics, MD Anderson Cancer Center, Houston, TX
| | - Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Asya Agulnik
- Department of Global Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Anita V Arias
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Cheng Cheng
- Division of Critical Care, Department Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Lama Elbahlawan
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Saad Ghafoor
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Caitlin Hurley
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Jennifer McArthur
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - R Ray Morrison
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Yinmei Zhou
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - H J Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Melissa R Hines
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
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Cardenas-Aguirre A, Hernandez-Garcia M, Lira-De-Leon B, Munoz-Brugal YL, Wang H, Villanueva-Diaz I, Ruiz-Perez E, Mijares-Tobias JM, Giles-Gonzalez AO, McArthur J, Escamilla-Aisan G, Arias A, Devidas M, Agulnik A. Outcomes for critical illness in children with cancer: Analysis of risk factors for adverse outcome and resource utilization from a specialized center in Mexico. Front Oncol 2022; 12:1038879. [DOI: 10.3389/fonc.2022.1038879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/03/2022] [Indexed: 12/02/2022] Open
Abstract
IntroductionChildren with cancer have a higher risk of adverse outcomes during critical illness than general pediatric populations. In Low- and middle-income countries, lack of resources can further negatively impact outcomes in critically ill children with cancer.MethodsIn this study, we describe the outcomes of a large cohort of children with cancer including mortality and resource utilization. We performed a retrospective review of all patients admitted to our PICU between December 12th, 2013 and December 31st, 2019. Outcomes were defined as recovery or death and resource utilization was described via use of critical care interventions, Length of stay as well as PICU- and Mechanical Ventilation- free days.ResultsOverall mortality was 6.9% while mortality in the unplanned admissions was 9.1%. This remained lower than expected mortality based on PIM2 scoring. Type of PICU admission, Neurological Deterioration as a cause of PICU admission, and PIM2 were significant as risk factors in univariate analysis, but only PIM2 remained significant in the multivariate analysis.DiscussionOur Study shows that high survival rates are achievable for children with cancer with critical illness in resource-limited settings with provision of high-quality critical care. Organizational and clinical practice facilitating quality improvement and early identification and management of critical illness may attenuate the impact of known risk factors for mortality in this population.
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Leung KKY, Ray S, Chan GCF, Hon KL. Functional outcomes at PICU discharge in hemato-oncology children at a tertiary oncology center in Hong Kong. Int J Clin Oncol 2022; 27:1904-1915. [PMID: 36149516 DOI: 10.1007/s10147-022-02244-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/03/2022] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Karen K Y Leung
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China.
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China.
| | - Samiran Ray
- Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Godfrey C F Chan
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China
| | - Kam Lun Hon
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China
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6
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Outcomes of Pediatric Oncology Patients Admitted to An Intensive Care Unit in a Resource-limited Setting. J Pediatr Hematol Oncol 2022; 44:89-97. [PMID: 34654757 DOI: 10.1097/mph.0000000000002345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 09/09/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Improved survival and intensified treatment protocols in pediatric oncology have resulted in an increased need for intensive care. However, in resource-constrained settings, the higher morbidity and mortality of these patients raises sensitive issues around the optimal use of limited critical care resources. METHODS Single-center, 10-year retrospective review of pediatric oncology patients admitted to the pediatric intensive care unit (PICU). RESULTS Of the 117 admissions, 70.1% had solid tumors, 61.5% were admitted electively, and 76.1% were admitted for noninfective indications. PICU mortality of oncology patients was 18.8% relative to the PICU mortality of all patients in the same period of 10.5%. In a multivariable analysis, factors shown to be independently associated with PICU mortality were infective indications for admission (relative risk=3.83, confidence interval: 1.16; 12.6, P=0.028) and vasoactive support (relative risk=7.50, confidence interval: 1.72; 32.8, P=0.0074). CONCLUSION The increased mortality associated with sepsis, organ dysfunction and need for organ support underscores the need for earlier recognition of and intervention in pediatric oncology patients requiring intensive care. Further prospective studies are needed to identify the most critical areas for improvement in the referral of these children to PICU, to optimize care and improve outcomes.
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7
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Hutt D, Arjona ET, Mekelenkamp H, Galimard JE, Kozijn A, Schröder T, Gjergji M, Dalissier A, Liptrott SJ, Murray J, Kenyon M, van Gestel JPJ, Corbacioglu S, Bader P. Safe transfer of pediatric patients from hematopoietic stem cell transplant unit into the pediatric intensive care unit: views of nurses and physicians. Bone Marrow Transplant 2022; 57:734-741. [PMID: 35190674 DOI: 10.1038/s41409-021-01559-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 11/26/2021] [Accepted: 12/22/2021] [Indexed: 11/09/2022]
Abstract
Sufficient communication between hematopoietic stem cell transplantation (HSCT) and pediatric intensive care unit (PICU) teams is pivotal for a successful advanced support in the PICU for HSCT-related complications. We evaluated perceived communication and barriers between both teams with the aim of providing recommendations for improvement. In this cross-sectional survey, a self-designed online questionnaire was distributed among ESPNIC and EBMT members. Data were analyzed using descriptive statistics. Over half of HSCT respondents employed a transfer indication protocol and patient assessment tool, but less structured checklist prior to patient transfer. Nearly all PICU respondents perceived this checklist as improvement for communication. Most HSCT and PICU physicians have daily rounds upon patient transfer while this is mostly missing between nursing teams. Half of both HSCT and PICU nurses indicated that HSCT training for PICU nurses could improve communication and patient transfer. Most respondents indicated that structured meetings between HSCT and PICU nurses could improve communication. Overall there is good communication between HSCT and PICU units, although barriers were noted between members of both teams. Based on our findings, we recommend use of a structured and specific checklist by HSCT teams, HSCT training for PICU personnel, and structured meetings between HSCT and PICU nurses.
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Affiliation(s)
- Daphna Hutt
- Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, 52621, Israel.
| | - Eugenia Trigoso Arjona
- Paediatric Transplant Unit, Hospital University and Polytechnic Hospital LA FE, Valencia, Spain
| | - Hilda Mekelenkamp
- Willem-Alexander Children's Hospital, Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Anne Kozijn
- EBMT Leiden Data Unit, Leiden, The Netherlands
| | | | | | | | | | - John Murray
- Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
| | - Michelle Kenyon
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - J P J van Gestel
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Regensburg, Regensburg, Germany
| | - Peter Bader
- Center for Child Health, Dept. of Oncology, Immunology and Stem Cell Transplantation, Goethe University, Frankfurt, Germany
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8
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Pravin RR, Huang BX, Sultana R, Tan CW, Goh KJ, Chan MY, Ng HJ, Phua GC, Lee JH, Wong JJM. Mortality Trends of Oncology and Hematopoietic Stem Cell Transplant Patients Supported on Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis. J Intensive Care Med 2021; 37:555-564. [PMID: 34396806 DOI: 10.1177/08850666211021561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is an increasing frequency of oncology and hematopoietic stem cell transplant (HSCT) patients seen in the intensive care unit and requiring extracorporeal membrane oxygenation (ECMO), however, prognosis of this population over time is unclear. METHODS MEDLINE, EMBASE, Cochrane and Web of Science were searched from earliest publication until April 10, 2020 for studies to determine the mortality trend over time in oncology and HSCT patients requiring ECMO. Primary outcome was hospital mortality. Random-effects meta-analysis model was used to obtain pooled estimates of mortality and 95% confidence intervals. A priori subgroup metanalysis compared adult versus pediatric, oncology versus HSCT, hematological malignancy versus solid tumor, allogeneic versus autologous HSCT, and veno-arterial versus veno-venous ECMO populations. Multivariable meta-regression was also performed for hospital mortality to account for year of study and HSCT population. RESULTS 17 eligible observational studies (n = 1109 patients) were included. Overall pooled hospital mortality was 72% (95% CI: 65, 78). In the subgroup analysis, only HSCT was associated with a higher hospital mortality compared to oncology subgroup [84% (95% CI: 70, 93) vs. 66% (95% CI: 56, 74); P = 0.021]. Meta-regression showed that HSCT was associated with increased mortality [adjusted odds ratio (aOR) 3.84 (95% CI 1.77, 8.31)], however, mortality improved with time [aOR 0.92 (95% CI: 0.85, 0.99) with each advancing year]. CONCLUSION This study reports a high overall hospital mortality in oncology and HSCT patients on ECMO which improved over time. The presence of HSCT portends almost a 4-fold increased risk of mortality and this finding may need to be taken into consideration during patient selection for ECMO.
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Affiliation(s)
- R R Pravin
- Department of Pediatrics, KK Women's & Children's Hospital, Singapore.,Yong-Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Rehena Sultana
- Center for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Chuen Wen Tan
- Duke-NUS Medical School, Singapore.,Department of Hematology, Singapore General Hospital, Singapore
| | - Ken Junyang Goh
- Duke-NUS Medical School, Singapore.,Department of Respiratory & Critical Care Medicine, Singapore General Hospital, Singapore
| | - Mei-Yoke Chan
- Duke-NUS Medical School, Singapore.,Pediatric Hematology/Oncology Service, Department of Pediatric Subspecialties, KK Women's & Children's Hospital, Singapore
| | - Heng Joo Ng
- Duke-NUS Medical School, Singapore.,Department of Hematology, Singapore General Hospital, Singapore
| | - Ghee Chee Phua
- Duke-NUS Medical School, Singapore.,Department of Respiratory & Critical Care Medicine, Singapore General Hospital, Singapore
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore.,Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's & Children's Hospital, Singapore
| | - Judith Ju-Ming Wong
- Duke-NUS Medical School, Singapore.,Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's & Children's Hospital, Singapore
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Graetz D, Kaye EC, Garza M, Ferrara G, Rodriguez M, Soberanis Vásquez DJ, Méndez Aceituno A, Antillon-Klussmann F, Gattuso JS, Mandrell BN, Baker JN, Rodriguez-Galindo C, Mack JW, Agulnik A. Qualitative Study of Pediatric Early Warning Systems' Impact on Interdisciplinary Communication in Two Pediatric Oncology Hospitals With Varying Resources. JCO Glob Oncol 2021; 6:1079-1086. [PMID: 32673079 PMCID: PMC7392735 DOI: 10.1200/go.20.00163] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Hospitalized pediatric oncology patients are at high risk of deterioration and require frequent interdisciplinary communication to deliver high-quality care. Pediatric early warning systems (PEWS) are used by hospitals to reduce deterioration, but it is unknown how these systems affect communication about patient care in high- and limited-resource pediatric oncology settings. METHODS This qualitative study included semistructured interviews describing PEWS and subsequent team communication at 2 pediatric cancer centers, 1 in the United States and 1 in Guatemala. Participants included nurses, and frontline and intensive care providers who experienced recent deterioration events. Transcripts were coded and analyzed inductively using MAXQDA software. RESULTS The study included 41 providers in Guatemala and 42 providers in the United States (33 nurses, 30 ward providers, and 20 pediatric intensive care providers). Major themes identified include “hierarchy,” “empowerment,” “quality and method of communication,” and “trigger.” All providers described underlying medical hierarchies affecting the quality of communication regarding patient deterioration events and identified PEWS as empowering. Participants from the United States described the algorithmic approach to care and technology associated with PEWS contributing to impaired clinical judgement and a lack of communication. In both settings, PEWS sparked interdisciplinary communication and inspired action. CONCLUSION PEWS enhance interdisciplinary communication in high- and limited-resource study settings by empowering bedside providers. Traditional hierarchies contributed to negative communication and, in well-resourced settings, technology and automation resulted in lack of communication. Understanding contextual elements is integral to optimizing PEWS and improving pediatric oncology outcomes in hospitals of all resource levels.
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Affiliation(s)
- Dylan Graetz
- St. Jude Children's Research Hospital, Memphis, TN
| | - Erica C Kaye
- St. Jude Children's Research Hospital, Memphis, TN
| | | | - Gia Ferrara
- St. Jude Children's Research Hospital, Memphis, TN
| | - Mario Rodriguez
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | | | - Federico Antillon-Klussmann
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | | | | | | | | | - Jennifer W Mack
- Dana Farber Cancer Institute, Boston Children's Hospital, Boston, MA
| | - Asya Agulnik
- St. Jude Children's Research Hospital, Memphis, TN
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10
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Sallee CJ, Smith LS, Rowan CM, Heckbert SR, Angelo JR, Daniel MC, Gertz SJ, Hsing DD, Mahadeo KM, McArthur JA, Fitzgerald JC. Early Cumulative Fluid Balance and Outcomes in Pediatric Allogeneic Hematopoietic Cell Transplant Recipients With Acute Respiratory Failure: A Multicenter Study. Front Oncol 2021; 11:705602. [PMID: 34354951 PMCID: PMC8329703 DOI: 10.3389/fonc.2021.705602] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/21/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To evaluate the associations between early cumulative fluid balance (CFB) and outcomes among critically ill pediatric allogeneic hematopoietic cell transplant (HCT) recipients with acute respiratory failure, and determine if these associations vary by treatment with renal replacement therapy (RRT). METHODS We performed a secondary analysis of a multicenter retrospective cohort of patients (1mo - 21yrs) post-allogeneic HCT with acute respiratory failure treated with invasive mechanical ventilation (IMV) from 2009 to 2014. Fluid intake and output were measured daily for the first week of IMV (day 0 = day of intubation). The exposure, day 3 CFB (CFB from day 0 through day 3 of IMV), was calculated using the equation [Fluid in - Fluid out] (liters)/[PICU admission weight](kg)*100. We measured the association between day 3 CFB and PICU mortality with logistic regression, and the rate of extubation at 28 and 60 days with competing risk regression (PICU mortality = competing risk). RESULTS 198 patients were included in the study. Mean % CFB for the cohort was positive on day 0 of IMV, and increased further on days 1-7 of IMV. For each 1% increase in day 3 CFB, the odds of PICU mortality were 3% higher (adjusted odds ratio (aOR) 1.03, 95% CI 1.00-1.07), and the rate of extubation was 3% lower at 28 days (adjusted subdistribution hazard ratio (aSHR) 0.97, 95% CI 0.95-0.98) and 3% lower at 60 days (aSHR 0.97, 95% CI 0.95-0.98). When day 3 CFB was dichotomized, 161 (81%) had positive and 37 (19%) had negative day 3 CFB. Positive day 3 CFB was associated with higher PICU mortality (aOR 3.42, 95% CI 1.48-7.87) and a lower rate of extubation at 28 days (aSHR 0.30, 95% CI 0.18-0.48) and 60 days (aSHR 0.30, 95% 0.19-0.48). On stratified analysis, the association between positive day 3 CFB and PICU mortality was significantly stronger in those not treated with RRT (no RRT: aOR 9.11, 95% CI 2.29-36.22; RRT: aOR 1.40, 95% CI 0.42-4.74). CONCLUSIONS Among critically ill pediatric allogeneic HCT recipients with acute respiratory failure, positive and increasing early CFB were independently associated with adverse outcomes.
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Affiliation(s)
- Colin J. Sallee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, United States
| | - Lincoln S. Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, United States
| | - Courtney M. Rowan
- Division of Critical Care, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Susan R. Heckbert
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, United States
| | - Joseph R. Angelo
- Renal Section, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Megan C. Daniel
- Division of Critical Care, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, United States
| | - Shira J. Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Saint Barnabas Medical Center, Livingston, NJ, United States
| | - Deyin D. Hsing
- Division of Critical Care, Department of Pediatrics, Weil Cornell Medical College, New York Presbyterian Hospital, New York City, NY, United States
| | - Kris M. Mahadeo
- Stem Cell Transplantation and Cellular Therapy, Children’s Cancer Hospital, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Jennifer A. McArthur
- Division of Critical Care, Department of Pediatrics, St Jude Children’s Research Hospital, Memphis, TN, United States
| | - Julie C. Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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11
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Garza M, Graetz DE, Kaye EC, Ferrara G, Rodriguez M, Soberanis Vásquez DJ, Méndez Aceituno A, Antillon-Klussmann F, Gattuso JS, Mandrell BN, Baker JN, Rodriguez-Galindo C, Agulnik A. Impact of PEWS on Perceived Quality of Care During Deterioration in Children With Cancer Hospitalized in Different Resource-Settings. Front Oncol 2021; 11:660051. [PMID: 34249696 PMCID: PMC8260684 DOI: 10.3389/fonc.2021.660051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/31/2021] [Indexed: 12/16/2022] Open
Abstract
Background Children with cancer are at high risk for clinical deterioration and subsequent mortality. Pediatric Early Warning Systems (PEWS) have proven to reduce the frequency of clinical deterioration in hospitalized patients. This qualitative study evaluates provider perspectives on the impact of PEWS on quality of care during deterioration events in a high-resource and a resource-limited setting. Methods We conducted semi-structured interviews with 83 healthcare staff (nurses, pediatricians, oncology fellows, and intensivists) involved in recent deterioration events at two pediatric oncology hospitals of different resource levels: St. Jude Children’s Research Hospital (SJCRH; n = 42) and Unidad Nacional de Oncología Pediátrica (UNOP; n = 41). Interviews were conducted in the participant’s native language (English or Spanish), translated into English, and transcribed. Transcripts were coded and analyzed inductively. Results Providers discussed both positive and negative perspectives of clinical deterioration events. Content analysis revealed “teamwork,” “experience with deterioration,” “early awareness,” and “effective communication” as themes associated with positive perception of events, which contributed to patient safety. Negative themes included “lack of communication,” “inexperience with deterioration,” “challenges with technology”, “limited material resources,” “false positive score,” and “objective tool.” Participants representing all disciplines across both institutions shared similar positive opinions. Negative opinions, however, differed between the two institutions, with providers at UNOP highlighting limited resources while those at SJCRH expressing concerns about technology misuse. Conclusion Providers that care for children with cancer find PEWS valuable to improve the quality of hospital care, regardless of hospital resource-level. Identified challenges, including inadequate critical care resources and challenges with technology, differ by hospital resource-level. These findings build on growing data demonstrating the positive impact of PEWS on quality of care and encourage wide dissemination of PEWS in clinical practice.
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Affiliation(s)
- Marcela Garza
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Dylan E Graetz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Erica C Kaye
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Mario Rodriguez
- Department of Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | | | - Federico Antillon-Klussmann
- Department of Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | - Jami S Gattuso
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Belinda N Mandrell
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States.,Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
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12
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Use of recombinant activated factor VII for uncontrolled bleeding in a haematology/oncology paediatric ICU cohort. Blood Coagul Fibrinolysis 2021; 31:440-444. [PMID: 32833802 DOI: 10.1097/mbc.0000000000000942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
: Bleeding among critically ill paediatric haematology/oncology (CIPHO) patients leads to significant morbidity and mortality. Recombinant activated factor VII (rFVIIa) has shown some benefits in previous reported off-label use when conventional therapies have failed. However, data in CIPHO are lacking. We retrospectively studied (2006-2014) the efficacy and outcomes in CIPHO patients younger than 21 years who received at least one rFVIIa dose for bleeding in the ICU. Of 39 patients, the majority had leukaemia (59%), bone marrow transplantation (77%) and a life-threatening bleed (80%) with most common site being pulmonary haemorrhage (44%). Most needed invasive mechanical ventilation (87%) or vasopressor support (59%). After rFVIIa administration, 56% had cessation or decreased bleeding. Packed red blood cell transfusion requirements decreased significantly 48-72 h after rFVIIa administration. Lower baseline prothrombin time and more rFVIIa doses were related to bleeding control. A favourable response was associated with higher survival (55% in responders versus 18% in nonresponders, P = 0.019). Overall, bleeding-related mortality was 37.5%, highest in pulmonary haemorrhage. Two patients had thromboembolic events. Use of rFVIIa for CIPHO patients appears to be well tolerated with low adverse events. Despite half of the patients having a favourable response of cessation or decrease in bleeding after rFVIIa administration, mortality was high. These findings highlight the need for prospective studies to evaluate interventions to improve outcomes in this population.
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13
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Graetz DE, Giannars E, Kaye EC, Garza M, Ferrara G, Rodriguez M, Soberanis Vasquez DJ, Mendez Aceituno A, Antillon-Klussmann F, Gattuso JS, Andes KL, Mandrell BN, Baker JN, Rodriguez-Galindo C, Agulnik A. Clinician Emotions Surrounding Pediatric Oncology Patient Deterioration. Front Oncol 2021; 11:626457. [PMID: 33718195 PMCID: PMC7947818 DOI: 10.3389/fonc.2021.626457] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/18/2021] [Indexed: 12/16/2022] Open
Abstract
Background Pediatric oncology patients have a high rate of clinical deterioration frequently requiring critical care. Patient deterioration events are distressing for clinicians, but little is known about how Pediatric Early Warning Systems (PEWS) impact clinicians' emotional responses to deterioration events. Methods Semi-structured interviews were conducted with 83 nurses, pediatricians, oncologists, and intensive care clinicians who had recently participated in a patient deterioration event at two pediatric oncology hospitals of different resource-levels: St. Jude Children's Research Hospital (N = 42 participants) in Memphis, Tennessee or Unidad Nacional de Oncología Pediátrica (N = 41 participants) in Guatemala City, Guatemala. Interviews were conducted in the participants' native language (English or Spanish), transcribed, and translated into English. Each transcript was coded by two researchers and analyzed for thematic content. Results Emotions around patient deterioration including concern, fear, and frustration were reported across all disciplines at both hospitals. Concern was often triggered by an elevated PEWS score and usually resulted in increased attention, which reassured bedside clinicians that patients were receiving necessary interventions. However, persistently elevated PEWS scores, particularly at St. Jude Children's Research Hospital, occasionally resulted in a false sense of relief, diminishing clinician attention and negatively impacting patient care. Nurses at both institutions described how PEWS amplified their voices, engendering confidence and empowerment, two of the only positive emotions described in the study. Conclusion Clinicians experienced a range of emotions while caring for high-risk patients in the setting of clinical deterioration. These emotions have the potential to contribute to compassion fatigue and burnout, or to resilience. Acknowledgment and further investigation of the complex interplay between PEWS and clinician emotions are necessary to maximize the impact of PEWS on patient safety while simultaneously supporting staff wellbeing.
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Affiliation(s)
- Dylan E Graetz
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Emily Giannars
- Department of Public Health, Emory University School of Public Health, Atlanta, GA, United States
| | - Erica C Kaye
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Marcela Garza
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Mario Rodriguez
- Department of Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | | | - Federico Antillon-Klussmann
- Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | - Jami S Gattuso
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Karen L Andes
- Department of Public Health, Emory University School of Public Health, Atlanta, GA, United States
| | - Belinda N Mandrell
- Department of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
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14
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Agulnik A, Cárdenas A, Carrillo AK, Bulsara P, Garza M, Alfonso Carreras Y, Alvarado M, Calderón P, Díaz R, de León C, Del Real C, Huitz T, Martínez A, Miralda S, Montalvo E, Negrín O, Osuna A, Perez Fermin CK, Pineda E, Soberanis D, Juárez Tobias MS, Lu Z, Rodriguez-Galindo C. Clinical and organizational risk factors for mortality during deterioration events among pediatric oncology patients in Latin America: A multicenter prospective cohort. Cancer 2021; 127:1668-1678. [PMID: 33524166 PMCID: PMC8248122 DOI: 10.1002/cncr.33411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hospitalized pediatric hematology-oncology (PHO) patients have frequent clinical deterioration events (CDE) requiring intensive care unit (ICU) admission, particularly in resource-limited settings. The objective of this study was to describe CDEs in hospitalized PHO patients in Latin America and to identify event-level and center-level risk factors for mortality. METHODS In 2017, the authors implemented a prospective registry of CDEs, defined as unplanned transfers to a higher level of care, use of ICU-level interventions on the floor, or nonpalliative floor deaths, in 16 PHO centers in 10 countries. PHO hospital admissions and hospital inpatient days were also reported. This study analyzes the first year of registry data (June 2017 to May 2018). RESULTS Among 16 centers, 553 CDEs were reported in PHO patients during 11,536 admissions and 119,414 inpatient days (4.63 per 1000 inpatient days). Event mortality was 29% (1.33 per 1000 inpatient days) but ranged widely across centers (11%-79% or 0.36-5.80 per 1000 inpatient days). Significant risk factors for event mortality included requiring any ICU-level intervention on the floor and not being transferred to a higher level of care. Events with organ dysfunction, a higher severity of illness, and a requirement for ICU intervention had higher mortality. In center-level analysis, hospitals with a higher volume of PHO patients, less floor use of ICU intervention, lower severity of illness on transfer, and lower rates of floor cardiopulmonary arrest had lower event mortality. CONCLUSIONS Hospitalized PHO patients who experience CDEs in resource-limited settings frequently require floor-based ICU interventions and have high mortality. Modifiable hospital practices around the escalation of care for these high-risk patients may contribute to poor outcomes. Earlier recognition of critical illness and timely ICU transfer may improve survival in hospitalized children with cancer.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee.,Division of Critical Care, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Adolfo Cárdenas
- Critical Care Medicine, Hospital Infantil Teletón de Oncología, Queretaro, Mexico
| | - Angela K Carrillo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Purva Bulsara
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Marcela Garza
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Manuel Alvarado
- Critical Care, Hospital del Niño Dr. José Renán Esquivel, Panama City, Panama
| | - Patricia Calderón
- Oncology, Hospital Infantil Manuel de Jesús Rivera, Managua, Nicaragua
| | - Rosdali Díaz
- Pediatric Oncology, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Claudia de León
- Pediatric Critical Care, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | - Claudia Del Real
- Pediatric Oncology, Benemérito Hospital General con Especialidades ¨Juan María de Salvatierra", La Paz, Mexico
| | - Tania Huitz
- Pediatric Oncology, Centro Estatal de Oncología de Campeche, Campeche, Mexico
| | | | - Scheybi Miralda
- Pediatric Critical Care, Hospital Escuela Universitario, Tegucigalpa, Honduras
| | - Erika Montalvo
- Pediatric Critical Care, Sociedad de Lucha contra el Cáncer Núcleo de Quito, Quito, Ecuador
| | - Octavia Negrín
- Hematology, Hospital Infantil Dr. Robert Reid Cabral, Santo Domingo, Dominican Republic
| | - Alejandra Osuna
- Hematology/Oncology, Hospital Pediátrico de Sinaloa, Sinaloa, Mexico
| | - Clara Krystal Perez Fermin
- Hematology/Oncology, Hospital Infantil Regional Universitario Dr. Arturo Guillón, Santiago, Dominican Republic.,Biomedical and Clinical Research Center, Santiago, Dominican Republic
| | - Estuardo Pineda
- Oncology, Hospital Nacional de Niños Benjamín Bloom, San Salvador, El Salvador
| | - Dora Soberanis
- Hematology/Oncology, Unidad Nacional de Oncología Pediátrica, Guatemala City, Guatemala
| | | | - Zhaohua Lu
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
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15
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Magri Teles ND, Silva DCBD, Araujo ORD, Maia Lemos PDS, Oliveira FLCD. Undernutrition as an Aggravating Risk for Hospital Death in Critically Ill Children with Cancer. Nutr Cancer 2020; 73:2627-2632. [PMID: 33153333 DOI: 10.1080/01635581.2020.1844244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Undernourished children with cancer are at major risk for adverse outcomes. We intended to model nutritional status as risk factor for hospital death. METHODS Retrospective analysis of two cohorts of children admitted in an oncology/hematology intensive care unit. Logistic regression was used for model building. RESULTS The derivation cohort had 155 patients, with a median age of 104.9 mo., and 36 deaths (23.2%). Twenty-eight children (18.1%) had the z score of the body mass index < -2. A multivariate model with the variables "relapse of oncological disease" (Odds Ratio 3.14, P = 0.025), "surgical case" (OR 0.22, P = 0.002), "intubation/mechanical ventilation" (OR 8.38, P = 0.000) and "body mass index z score < -2" (OR 3.21, P = 0.024) generated a logit with good predictive capacity for "hospital death". In the validation cohort, with 450 patients (median age of 92.7 mo.), the model was able to predict 55.5 of the 58 observed deaths (Standardized Mortality Rate = 1.04, 95% CI 0.80-1.34, P = 0.72), with P = 0.68 in the Hosmer test. The AUC was 0.90 (95% CI 0.86-0.93). CONCLUSION Undernutrition increases the risk of death, and is a variable that should be included in predictive mortality algorithms.
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Affiliation(s)
- Nayara Dorascenzi Magri Teles
- Support Group for Adolescents and Children with Cancer (GRAACC)/Institute of Pediatric Oncology (IOP)/Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Dafne Cardoso Bourguignon da Silva
- Support Group for Adolescents and Children with Cancer (GRAACC)/Institute of Pediatric Oncology (IOP)/Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Orlei Ribeiro de Araujo
- Support Group for Adolescents and Children with Cancer (GRAACC)/Institute of Pediatric Oncology (IOP)/Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Priscila Dos Santos Maia Lemos
- Support Group for Adolescents and Children with Cancer (GRAACC)/Institute of Pediatric Oncology (IOP)/Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
| | - Fernanda Luisa Ceragioli de Oliveira
- Support Group for Adolescents and Children with Cancer (GRAACC)/Institute of Pediatric Oncology (IOP)/Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil
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16
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Abstract
We evaluated the performance of PRISM IV for pediatric cancer patients, and adapted and calibrated the algorithm to calculate mortality probabilities for these patients. An ambidirectional cohort was used, and data were collected from March 2017 prospectively to April 2019, and retrospectively to November 2014. The derivation set for model building contained 500 patients, and a validation set of 503 patients. Risk variables for hospital death were tested in logistic regression models encompassing PRISM IV components. There were 128 deaths (12.7%), being 65 deaths in the validation set. In the validation set, the PRISM IV algorithm had an area under the receiver operating characteristic curve of 0.89, with P=0.13 by Hosmer-Lemeshow test, and predicted 33 of the 65 deaths for a standardized mortality rate of 1.8 (95% confidence interval, 1.4-2.9; P<0.001 by Mid-P test). Our modified algorithm had an area under the receiver operating characteristic curve of 0.93, with P=0.3 by Hosmer-Lemeshow test and an standardized mortality rate of 1.02 (95% confidence interval, 0.79-1.19). The modified algorithm predicted 63.7 of 65 deaths. The PRISM IV algorithm was a poor predictor of mortality in children with cancer. The modified algorithm improved the predictive performance.
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17
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Arias AV, Garza M, Murthy S, Cardenas A, Diaz F, Montalvo E, Nielsen KR, Kortz T, Sharara-Chami R, Friedrich P, McArthur J, Agulnik A. Quality and capacity indicators for hospitalized pediatric oncology patients with critical illness: A modified delphi consensus. Cancer Med 2020; 9:6984-6995. [PMID: 32777172 PMCID: PMC7541142 DOI: 10.1002/cam4.3351] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/21/2020] [Accepted: 07/14/2020] [Indexed: 01/09/2023] Open
Abstract
Background Hospitalized pediatric hematology‐oncology (PHO) patients are at high risk for critical illness, especially in resource‐limited settings. Unfortunately, there are no established quality indicators to guide institutional improvement for these patients. The objective of this study was to identify quality indicators to include in PROACTIVE (PediatRic Oncology cApaCity assessment Tool for IntensiVe carE), an assessment tool to evaluate the capacity and quality of pediatric critical care services offered to PHO patients. Methods A comprehensive literature review identified relevant indicators in the areas of structure, performance, and outcomes. An international focus group sorted potential indicators using the framework of domains and subdomains. A modified, three‐round Delphi was conducted among 36 international experts with diverse experience in PHO and critical care in high‐resource and resource‐limited settings. Quality indicators were ranked on relevance and actionability via electronically distributed surveys. Results PROACTIVE contains 119 indicators among eight domains and 22 subdomains, with high‐median importance (≥7) in both relevance and actionability, and ≥80% evaluator agreement. The top five indicators were: (a) A designated PICU area; (b) Availability of a pediatric intensivist; (c) A PHO physician as part of the primary team caring for critically ill PHO patients; (d) Trained nursing staff in pediatric critical care; and (e) Timely PICU transfer of hospitalized PHO patients requiring escalation of care. Conclusions PROACTIVE is a consensus‐derived tool to assess the capacity and quality of pediatric onco‐critical care in resource‐limited settings. Future endeavors include validation of PROACTIVE by correlating the proposed indicators to clinical outcomes and its implementation to identify service delivery gaps amenable to improvement.
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Affiliation(s)
- Anita V Arias
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Marcela Garza
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Adolfo Cardenas
- Hospital Infantil Teletón de Oncología (HITO), Querétaro, México
| | - Franco Diaz
- Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Erika Montalvo
- Pediatric Critical Care Unit, SOLCA Quito, Quito, Ecuador
| | - Katie R Nielsen
- Division of Pediatric Critical Care, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Teresa Kortz
- Division of Pediatric Critical Care, University of California San Francisco, San Francisco, CA, USA
| | - Rana Sharara-Chami
- Department of Pediatric and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Paola Friedrich
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jennifer McArthur
- Division of Pediatric Critical Care, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA.,Division of Pediatric Critical Care, St. Jude Children's Research Hospital, Memphis, TN, USA
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18
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Jhang WK, Park SJ. Evaluation of Disseminated Intravascular Coagulation in Critically Ill Pediatric Hemato-oncology Patients with Septic Shock. Thromb Haemost 2020; 120:1505-1511. [PMID: 32772349 DOI: 10.1055/s-0040-1714737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) is a serious complication in septic shock. This study aimed to evaluate DIC and associated clinical outcomes using the International Society on Thrombosis and Hemostasis (ISTH) and modified ISTH overt DIC scores in critically ill pediatric hemato-oncology patients with septic shock. METHODS Pediatric hemato-oncology patients with septic shock admitted to the pediatric intensive care unit (PICU) of a tertiary children's hospital between January 2013 and February 2020 were included. We modified the ISTH overt DIC score by eliminating the platelet domain and compared the performances of the ISTH and the modified ISTH overt DIC scores in DIC diagnosis and PICU mortality prediction of these patients. RESULTS DIC was diagnosed in 56.4 and 38.5% of patients by ISTH and modified ISTH overt DIC scores, respectively. Patients with DIC showed a higher pediatric risk of mortality (PRISM) III, pediatric sequential organ failure assessment (pSOFA) scores, and PICU mortality than those without DIC (p < 0.05). The modified ISTH overt DIC score was an independent prognostic factor for PICU mortality and showed a larger area under the receiver operating characteristic curve than the ISTH overt DIC score (0.687 vs. 0.695). Addition of the DIC diagnosis improved the performance of PRISM III in predicting PICU mortality. CONCLUSION Critically ill pediatric hemato-oncology patients with septic shock frequently experience DIC, which was adequately evaluated by both ISTH and modified ISTH overt DIC scores. Considering the characteristics of these patients, the modified ISTH overt DIC score may be a promising prognostic factor for clinical outcomes in these critically ill pediatric patients.
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Affiliation(s)
- Won Kyoung Jhang
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong Jong Park
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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19
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Rr P, Tan EEK, Sultana R, Thoon KC, Chan MY, Lee JH, Wong JJM. Critical illness epidemiology and mortality risk in pediatric oncology. Pediatr Blood Cancer 2020; 67:e28242. [PMID: 32187445 DOI: 10.1002/pbc.28242] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/16/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Pediatric oncology patients admitted to the pediatric intensive care unit (PICU) are at high risk of mortality. This study aims to describe the epidemiology of and the risk factors for mortality in these patients. STUDY DESIGN This is a retrospective cohort study including all consecutive PICU oncology admissions from 2011 to 2017. Demographic and clinical risk factors between survivors and nonsurvivors were compared. Both univariate and multivariate Cox proportional hazard regression models were used to quantify the association between 60-day mortality and admission categories, accounting for other covariates (Pediatric Risk Of Mortality [PRISM] III score and previous bacteremia). MAIN OUTCOME MEASURES The primary outcome was 60-day mortality. RESULTS The median (interquartile range) age and PRISM III scores of pediatric oncology patients admitted to the PICU were 7 (3, 12) years and 3 (0, 5), respectively. The most common underlying oncological diagnoses were brain tumors (73/200 [36.5%]) and acute lymphoblastic leukemia (36/200 [18.0%]). Emergency admissions accounted for approximately half of all admissions (108/200 [54.0%]), including cardiovascular (24/108 [22.2%]), neurology (24/108 [22.2%]), respiratory (22/108 [20.4%]), and "other" indications (38/108 [35.2%]). The overall 60-day mortality was 35 of 200 (17.5%). Independent risk factors for mortality were emergency respiratory and neurology categories of admission (adjusted hazard ratio[aHR]: 5.62, 95% confidence interval [95% CI]: 1.57, 20.19; P = .008 and aHR: 6.96, 95% CI: 2.04, 23.75; P = .002, respectively) and previous bacteremia (aHR: 3.37, 95% CI: 1.57, 7.20; P = .002). CONCLUSION Emergency respiratory and neurology admissions and previous bacteremia were independent risk factors for 60-day mortality for pediatric oncological patients admitted to the PICU.
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Affiliation(s)
- Pravin Rr
- Department of Pediatrics, KK Women's & Children's Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Enrica Ee Kar Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Pediatric Subspecialties, Pediatric Hematology/Oncology Service, KK Women's & Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Rehena Sultana
- Center for Quantitative Medicine, Duke-NUS Medical School, The Academia, Singapore
| | - Koh Cheng Thoon
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore.,Infectious Disease Service, Department of Pediatrics, KK Women's & Children's Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Mei-Yoke Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Pediatric Subspecialties, Pediatric Hematology/Oncology Service, KK Women's & Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Jan Hau Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore.,Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's & Children's Hospital, Singapore
| | - Judith Ju-Ming Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore.,Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's & Children's Hospital, Singapore
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Extracorporeal membrane oxygenation in the pediatric population - who should go on, and who should not. Curr Opin Pediatr 2020; 32:416-423. [PMID: 32332330 DOI: 10.1097/mop.0000000000000904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The role of extracorporeal membrane oxygenation (ECMO), a method of providing cardiorespiratory support in instances of cardiac or respiratory failure, in neonates and children continues to expand and evolve. This review details the current landscape of ECMO as it applies to neonates and children. RECENT FINDINGS Specifically, this review provides the most recent evidence for which patients should be considered for the various forms of ECMO including venovenous ECMO, venoarterial-ECMO, and extracorporeal cardiopulmonary resuscitation. Specific topics to be discussed include indications and contraindications for the different types of ECMO in neonates and children, anticoagulation strategies and ways to monitor end-organ function, outcomes specific to the different types and populations with a focus on meaningful survival to discharge and neurologic outcomes, and consideration of special populations such as low birth weight infants, traumatically injured patients, and children who received recent bone marrow transplants. This review also discusses still unanswered questions surrounding the most appropriate use of ECMO as its role and applications continue to evolve. SUMMARY With rapidly increasing utilization of ECMO, neonatologists and pediatricians should be aware of the most recent evidence guiding its indications, applications, and limitations.
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21
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Agulnik A, Gossett J, Carrillo AK, Kang G, Morrison RR. Abnormal Vital Signs Predict Critical Deterioration in Hospitalized Pediatric Hematology-Oncology and Post-hematopoietic Cell Transplant Patients. Front Oncol 2020; 10:354. [PMID: 32266139 PMCID: PMC7105633 DOI: 10.3389/fonc.2020.00354] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 02/28/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction: Hospitalized pediatric hematology-oncology and post-hematopoietic cell transplant (HCT) patients have frequent deterioration requiring Pediatric Intensive Care Unit (PICU) care. Critical deterioration (CD), defined as unplanned PICU transfer requiring life-sustaining interventions within 12 h, is a pragmatic metric to evaluate emergency response systems (ERS) in pediatrics, however, it has not been investigated in these patients. The goal of this study was to evaluate if CD is an appropriate metric to assess effectiveness of ERS in pediatric hematology-oncology and post-HCT patients and if it is preceded by an actionable period of vital sign changes. Methods: A retrospective review of all unplanned PICU transfers and floor cardiopulmonary arrests in a dedicated pediatric hematology-oncology hospital between August 2014 and July 2016. Vital signs and physical exam findings 48 h prior to events were converted to Pediatric Early Warning System-Like Scores (PEWS-LS) using cardiovascular, respiratory, and neurologic criteria. Results: There were 220 deterioration events, with 107 (48.6%) meeting criteria for CD, representing a rate of 2.98 per 1,000-inpatient-days. Using the first event per hospitalization (n = 184), patients with CD had higher mortality (17.4 vs. 7.6%, p = 0.045), fewer median ICU-free-days (21 vs. 24, p = 0.011), ventilator-free-days (25 vs. 28, p < 0.001), and vasoactive-free-days (27 vs. 28, p < 0.001). Using vital sign data 48 h prior to deterioration events, those with CD had higher PEWS-LS on PICU admission (p < 0.001), spent more time with elevated PEWS-LS prior to PICU transfer (p = 0.008 to 0.023) and had a longer time from first abnormal PEWS-LS (p = 0.007 to 0.043). Significant difference between the two groups was observed as early as 4 h prior to the event (p = 0.047). Conclusion: Hospitalized pediatric hematology-oncology and post-HCT patients have frequent deterioration resulting in a high mortality. In these patients, CD is over 13 times more common than floor cardiopulmonary arrests and associated with higher mortality and fewer event-free days, making it a useful metric in these patients. CD is preceded by a long duration of abnormal vital signs, making it potentially preventable through earlier recognition.
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Affiliation(s)
- Asya Agulnik
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States.,Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jeffrey Gossett
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Angela K Carrillo
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Guolian Kang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - R Ray Morrison
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
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22
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Agulnik A, Antillon-Klussmann F, Soberanis Vasquez DJ, Arango R, Moran E, Lopez V, Rodriguez-Galindo C, Bhakta N. Cost-benefit analysis of implementing a pediatric early warning system at a pediatric oncology hospital in a low-middle income country. Cancer 2019; 125:4052-4058. [PMID: 31436324 DOI: 10.1002/cncr.32436] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/06/2019] [Accepted: 07/10/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hospitalized pediatric oncology patients are at high risk of clinical decline and mortality, particularly in low-income and middle-income countries (LMICs). Pediatric early warning systems (PEWS) assist with the early identification of deterioration. To the authors' knowledge, no studies to date have evaluated the cost-benefit of PEWS in LMICs. METHODS A PEWS was implemented at the National Pediatric Oncology Unit (Unidad Nacional de Oncologia Pediatrica [UNOP]), a pediatric oncology hospital in Guatemala, resulting in a reduction in unplanned pediatric intensive care unit (PICU) transfers. Variable costs of maintaining the PICU and hospital floor were calculated for the year prior to and after the implementation of PEWS using administrative data. PEWS implementation costs were tabulated. The number of PICU inpatient days averted due to reduced unplanned PICU transfers after implementation was calculated, adjusting for changes in hospital inpatient days. Savings per inpatient day from unplanned PICU transfers were calculated. All costs were adjusted for inflation. RESULTS There were 457 fewer PICU inpatient days due to unplanned transfers noted the year after implementation of PEWS, adjusting for changes in hospital volume. The variable costs of an unplanned PICU transfer versus a bed on the hospital floor was $806 per day. The total cost of implementing PEWS at UNOP was $13,644 ($7 per admission). Through reductions in variable PICU costs, UNOP saved a net $173 per admission ($354,514 annual net savings) after implementation of PEWS. The cost savings were sustained in a series of more conservative 1-way sensitivity analyses. CONCLUSIONS Implementation of PEWS at UNOP resulted in an incremental savings due to a reduction in the number of unplanned PICU transfers. The results of the current study demonstrate that hospital investment in PEWS can improve the quality of pediatric cancer care, optimize PICU use, and reduce costs.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Federico Antillon-Klussmann
- Unidad Nacional de Oncologıa Pediatrica, Guatemala City, Guatemala.,Francisco Marroquin University School of Medicine, Guatemala City, Guatemala
| | | | - Rosa Arango
- Unidad Nacional de Oncologıa Pediatrica, Guatemala City, Guatemala
| | - Elmer Moran
- Unidad Nacional de Oncologıa Pediatrica, Guatemala City, Guatemala
| | - Victor Lopez
- Unidad Nacional de Oncologıa Pediatrica, Guatemala City, Guatemala
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
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23
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Aljabari S, Balch A, Larsen GY, Fluchel M, Workman JK. Severe Sepsis-Associated Morbidity and Mortality among Critically Ill Children with Cancer. J Pediatr Intensive Care 2018; 8:122-129. [PMID: 31404226 DOI: 10.1055/s-0038-1676658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 11/05/2018] [Indexed: 01/20/2023] Open
Abstract
Severe sepsis (SS) in pediatric oncology patients is a leading cause of morbidity and mortality. We investigated the incidence of and risk factors for morbidity and mortality among children diagnosed with cancer from 2008 to 2012, and admitted with SS during the 3 years following cancer diagnosis. A total of 1,002 children with cancer were included, 8% of whom required pediatric intensive care unit (PICU) admission with SS. Death and/or multiple organ dysfunction syndrome occurred in 34 out of 99 PICU encounters (34%). Lactate level and history of stem-cell transplantation were significantly associated with the development of death and/or organ dysfunction ( p < 0.05).
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Affiliation(s)
- Salim Aljabari
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Alfred Balch
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Gitte Y Larsen
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Mark Fluchel
- Division of Pediatric Hematology and Oncology, Department of pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Jennifer K Workman
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
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24
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Zhu Y, Zhu X, Deng M, Wei H, Zhang M. Causes of death in hospitalized children younger than 12 years of age in a Chinese hospital: a 10 year study. BMC Pediatr 2018; 18:8. [PMID: 29347924 PMCID: PMC5773040 DOI: 10.1186/s12887-017-0981-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 12/29/2017] [Indexed: 11/15/2022] Open
Abstract
Background In China, the majority (77%) of urban children die in hospitals. Hospital-based review could provide insight leading to improvements in clinical practice and increase the survival of critically ill children. The aim of the present study is to identify the trends of immediate causes and chronic underlying diseases associated with deaths of children at one of the largest teaching hospitals in China over a period of 10 years (2006–2015). Methods A retrospective analysis of data of all children aged 1 month to 11 years who died at Xinhua Hospital between 2006 and 2015. Demographic details, main causes of deaths, and chronic underlying diseases were reviewed. Results Case fatality rate was 0.55% (510/93,443) and it represented 0.41–0.80% deaths per year. Overall, the most common immediate causes of deaths in hospitalized children were pneumonia (36.7%), sepsis (13.5%), tumour (11.4%), followed by nontraumatic intracranial or gastrointestinal hemorrhage (10.6%) and cardiac shock (9.6%). Over 70% of the deaths in children were complicated with chronic underlying diseases. Congenital abnormality was the most frequent chronic underlying disease observed in infants (60.3%) and tumour was the main chronic underlying disease in toddlers (31.1%) and older children (44%). Conclusions Infectious diseases, especially pneumonia, were the major immediate causes of deaths, and the mortality in the study population decreased with age. Tumour and other noninfectious disease accounted for more deaths in older children. Chronic underlying diseases were found in most deaths of children. Electronic supplementary material The online version of this article (10.1186/s12887-017-0981-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yueniu Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Xiaodong Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China.
| | - Mengyan Deng
- Department of Pediatric Critical Care Medicine, Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Hongxia Wei
- Department of Pediatric Critical Care Medicine, Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Mingjun Zhang
- Department of Pediatric Critical Care Medicine, Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
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Zinter MS, Holubkov R, Steurer MA, Dvorak CC, Duncan CN, Sapru A, Tamburro RF, McQuillen PS, Pollack MM. Pediatric Hematopoietic Cell Transplant Patients Who Survive Critical Illness Frequently Have Significant but Recoverable Decline in Functional Status. Biol Blood Marrow Transplant 2017; 24:330-336. [PMID: 29128553 DOI: 10.1016/j.bbmt.2017.10.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 10/31/2017] [Indexed: 12/28/2022]
Abstract
The number of pediatric hematopoietic cell transplant (HCT) patients who survive pediatric intensive care unit (PICU) admission is increasing, yet little is known about their functional morbidity after PICU discharge. We hypothesized that relative to control subjects, pediatric HCT patients who survive PICU admission would have greater rates of new functional morbidity at the time of PICU discharge and only some of these patients would return to their functional baseline by the end of the hospitalization. We performed a retrospective cohort study with secondary data analysis of the Trichotomous Outcomes in Pediatric Critical Care dataset. The pediatric HCT cohort was identified by querying International Classification of Diseases, 9th edition, diagnostic codes. A control group consisted of previously healthy patients matched 4:1 on age, sex, and illness severity, as estimated by the Pediatric Risk of Mortality (PRISM) score. We benchmarked our findings by comparing with a previously healthy group of children with lower respiratory tract infections. Functional impairment was measured by the Functional Status Scale, wherein new morbidity was defined as an increase of ≥3 points relative to the prehospital baseline. Relative to matched control subjects, HCT patients had similar admission PRISM scores (P = .516) but greater PICU mortality (12.9% [11/85] versus 6.2% [21/340], P = .035). However, among those who survived to PICU discharge, HCT patients had similar rates of new morbidity at PICU discharge (14.9% [11/74] versus 17.2% [55/319], P = .622) and similar rates of resolution of new morbidity by hospital discharge (54.5% [6/11] versus 60.0% [33/55], P = .737). Relative to the comparison group with lower respiratory tract infections, HCT patients had both greater admission PRISM scores (P < .001) and greater PICU mortality (12.9% [11/85] versus 1.6% [5/308], P < .001). However, among those who survived to PICU discharge, HCT patients again displayed similar rates of new morbidity at PICU discharge (14.9% [11/74] versus 22.1% [67/303], P = .168) as well as resolution of new morbidity by hospital discharge (54.5% [6/11] versus 71.6% [48/67], P = .299). For pediatric HCT patients PICU survival with new functional morbidity is as prevalent an outcome as PICU mortality. Although pediatric HCT patients have greater PICU mortality than age-, sex-, and PRISM-matched control subjects, they have similar rates of new functional morbidity at PICU discharge and similar resolution of new functional morbidity at hospital discharge. Future interventions focused on improving functional status in pediatric HCT survivors of critical illness are warranted.
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Affiliation(s)
- Matt S Zinter
- Department of Pediatrics, Division of Critical Care, Benioff Children's Hospital, University of California-San Francisco School of Medicine, San Francisco, California.
| | - Richard Holubkov
- Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah
| | - Martina A Steurer
- Department of Pediatrics, Division of Critical Care, Benioff Children's Hospital, University of California-San Francisco School of Medicine, San Francisco, California
| | - Christopher C Dvorak
- Department of Pediatrics, Division of Allergy, Immunology, and Blood & Marrow Transplantation, Benioff Children's Hospital, University of California-San Francisco School of Medicine, San Francisco, California
| | - Christine N Duncan
- Department of Pediatrics, Division of Stem Cell Transplantation, Boston Children's Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Anil Sapru
- Department of Pediatrics, Division of Critical Care, Mattel Children's Hospital, University of California-Los Angeles School of Medicine, San Francisco, California
| | | | - Patrick S McQuillen
- Department of Pediatrics, Division of Critical Care, Benioff Children's Hospital, University of California-San Francisco School of Medicine, San Francisco, California
| | - Murray M Pollack
- Department of Pediatrics, Division of Critical Care, Children's National Medical Center, George Washington University School of Medicine, Washington, DC
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Zinter MS, DuBois SG, Spicer A, Matthay K, Sapru A. Pediatric cancer type predicts infection rate, need for critical care intervention, and mortality in the pediatric intensive care unit. Intensive Care Med 2014; 40:1536-44. [PMID: 25023526 PMCID: PMC4177269 DOI: 10.1007/s00134-014-3389-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/27/2014] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Matt S Zinter
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco-School of Medicine, 505 Parnassus Ave, M680, San Francisco, 94143-0106, CA, USA,
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Outcome of invasive mechanical ventilation after pediatric allogeneic hematopoietic SCT: results from a prospective, multicenter registry. Bone Marrow Transplant 2014; 49:1287-92. [PMID: 25068426 DOI: 10.1038/bmt.2014.147] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 06/02/2014] [Accepted: 06/04/2014] [Indexed: 11/09/2022]
Abstract
Exact data on prognosis of children receiving invasive mechanical ventilation (IMV) after allogeneic hematopoietic SCT (HSCT) is lacking. We therefore started a prospective registry in four European university HSCT centers (Leiden, Paris, Prague and Utrecht) and their pediatric intensive care units (PICUs). The registry started in January 2009. In January 2013, the four centers together had treated a total of 83 admissions with IMV. The case fatality rate in these patients was 52%. Mortality 6 months after PICU discharge was 45%. There were significant differences between centers in the proportion of children who received IMV after HSCT (6-23%, P<0.01), in severity of disease on admission to PICU (predicted mortality 14-37%, P<0.01), in applying noninvasive ventilation before IMV (3-75% of admissions, P<0.01) and in the use of renal replacement therapy (RRT) (8-58% of admissions, P<0.01). Severe impairment in oxygenation, use of RRT and CMV viremia were independent predictors of mortality. Our study shows that mortality in children receiving IMV after HSCT remains high, but has clearly improved compared with older studies. Patient selection and treatment in PICU differed significantly between centers, which underscores the need to standardize and optimize the PICU admission criteria, ventilatory strategies and therapies applied in PICU.
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28
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Di Nardo M, Locatelli F, Palmer K, Amodeo A, Lorusso R, Belliato M, Cecchetti C, Perrotta D, Picardo S, Bertaina A, Rutella S, Rycus P, Di Ciommo V, Holzgraefe B. Extracorporeal membrane oxygenation in pediatric recipients of hematopoietic stem cell transplantation: an updated analysis of the Extracorporeal Life Support Organization experience. Intensive Care Med 2014; 40:754-6. [PMID: 24556913 DOI: 10.1007/s00134-014-3240-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Matteo Di Nardo
- Pediatric Intensive Care Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Bambino Gesù Children's Hospital, Piazza Sant'Onofrio 4, 00165, Rome, Italy,
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29
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The critically ill pediatric hematopoietic stem cell transplant patient: what have we learned? Pediatr Crit Care Med 2013; 14:326-8. [PMID: 23462355 DOI: 10.1097/pcc.0b013e31827d0e46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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