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Gladen KM, Tellez D, Napolitano N, Edwards LR, Sanders RC, Kojima T, Malone MP, Shults J, Krawiec C, Ambati S, McCarthy R, Branca A, Polikoff LA, Jung P, Parsons SJ, Mallory PP, Komeswaran K, Page-Goertz C, Toal MC, Bysani GK, Meyer K, Chiusolo F, Glater-Welt LB, Al-Subu A, Biagas K, Hau Lee J, Miksa M, Giuliano JS, Kierys KL, Talukdar AM, DeRusso M, Cucharme-Crevier L, Adu-Arko M, Shenoi AN, Kimura D, Flottman M, Gangu S, Freeman AD, Piehl MD, Nuthall GA, Tarquinio KM, Harwayne-Gidansky I, Hasegawa T, Rescoe ES, Breuer RK, Kasagi M, Nadkarni VM, Nishisaki A. Adverse Tracheal Intubation Events in Critically Ill Underweight and Obese Children: Retrospective Study of the National Emergency Airway for Children Registry (2013-2020). Pediatr Crit Care Med 2024; 25:147-158. [PMID: 37909825 PMCID: PMC10841296 DOI: 10.1097/pcc.0000000000003387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Extremes of patient body mass index are associated with difficult intubation and increased morbidity in adults. We aimed to determine the association between being underweight or obese with adverse airway outcomes, including adverse tracheal intubation (TI)-associated events (TIAEs) and/or severe peri-intubation hypoxemia (pulse oximetry oxygen saturation < 80%) in critically ill children. DESIGN/SETTING Retrospective cohort using the National Emergency Airway for Children registry dataset of 2013-2020. PATIENTS Critically ill children, 0 to 17 years old, undergoing TI in PICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Registry data from 24,342 patients who underwent TI between 2013 and 2020 were analyzed. Patients were categorized using the Centers for Disease Control and Prevention weight-for-age chart: normal weight (5th-84th percentile) 57.1%, underweight (< 5th percentile) 27.5%, overweight (85th to < 95th percentile) 7.2%, and obese (≥ 95th percentile) 8.2%. Underweight was most common in infants (34%); obesity was most common in children older than 8 years old (15.1%). Underweight patients more often had oxygenation and ventilation failure (34.0%, 36.2%, respectively) as the indication for TI and a history of difficult airway (16.7%). Apneic oxygenation was used more often in overweight and obese patients (19.1%, 19.6%) than in underweight or normal weight patients (14.1%, 17.1%; p < 0.001). TIAEs and/or hypoxemia occurred more often in underweight (27.1%) and obese (24.3%) patients ( p < 0.001). TI in underweight children was associated with greater odds of adverse airway outcome compared with normal weight children after adjusting for potential confounders (underweight: adjusted odds ratio [aOR], 1.09; 95% CI, 1.01-1.18; p = 0.016). Both underweight and obesity were associated with hypoxemia after adjusting for covariates and site clustering (underweight: aOR, 1.11; 95% CI, 1.02-1.21; p = 0.01 and obesity: aOR, 1.22; 95% CI, 1.07-1.39; p = 0.002). CONCLUSIONS In underweight and obese children compared with normal weight children, procedures around the timing of TI are associated with greater odds of adverse airway events.
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Affiliation(s)
- Kelsey M Gladen
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - David Tellez
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lauren R Edwards
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital and Medical Center, University of Nebraska Medical Center, Omaha, NE
| | - Ronald C Sanders
- Section of Critical Care Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR
| | - Taiki Kojima
- Department of Anesthesiology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Matthew P Malone
- Section of Critical Care Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR
| | - Justine Shults
- Department of Biostatistics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Conrad Krawiec
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, PA
| | - Shashikanth Ambati
- Pediatric Critical Care Medicine, Department of Pediatrics, Albany Medical Center, Albany, NY
| | - Riley McCarthy
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Aline Branca
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Lee A Polikoff
- Division of Critical Care Medicine, Department of Pediatrics, The Warren Alpert Medical School at Brown University, Providence, RI
| | - Philipp Jung
- Department of Pediatrics, University Children's Hospital, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Simon J Parsons
- Department of Pediatrics, Section of Critical Care Medicine, Alberta Children's Hospital, Calgary, AB, Canada
| | | | | | - Christopher Page-Goertz
- Pediatric Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH
| | - Megan C Toal
- Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - G Kris Bysani
- Pediatric Critical Care Medicine, Department of Pediatrics, Medical City Children's Hospital, Dallas, TX
| | - Keith Meyer
- Division of Critical Care Medicine, Nicklaus Children's Hospital, Herber Wertheim College of Medicine Florida International University, Miami, FL
| | - Fabrizio Chiusolo
- Anesthesia and Critical Care Medicine, ARCO, Bambino Gesú Children's Hospital, Rome, Italy
| | - Lily B Glater-Welt
- Division of Pediatric Critical Care, Cohen Children's Medical Center of New York, Queens, NY
| | - Awni Al-Subu
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Katherine Biagas
- Pediatric Critical Care Medicine, Department of Pediatrics, The Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| | - Michael Miksa
- Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY
| | - John S Giuliano
- Department of Pediatrics, Section of Critical Care Medicine, Yale University School of Medicine, New Haven, CT
| | - Krista L Kierys
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA
| | - Andrea M Talukdar
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital and Medical Center, University of Nebraska Medical Center, Omaha, NE
| | | | - Laurence Cucharme-Crevier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Michelle Adu-Arko
- Division of Pediatric Critical Care, Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Asha N Shenoi
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Kentucky, Lexington, KY
| | - Dai Kimura
- Critical Care Medicine, Department of Pediatrics, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL
| | - Molly Flottman
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Louisville, Norton Children's Hospital, Louisville, KY
| | - Shantaveer Gangu
- Critical Care Medicine, Department of Pediatrics, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL
| | - Ashley D Freeman
- Pediatric Critical Care Medicine, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA
| | - Mark D Piehl
- Pediatric Critical Care Medicine, Department of Pediatrics, WakeMed Children's Hospital, Raleigh, NC
| | - G A Nuthall
- Pediatric Critical Care, Department of Pediatrics, Starship Children's Hospital, Auckland, New Zealand
| | - Keiko M Tarquinio
- Pediatric Critical Care Medicine, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Ilana Harwayne-Gidansky
- Pediatric Critical Care Medicine, Department of Pediatrics, Bernard and Millie Duker Children's Hospital, Albany, NY
| | - Tatsuya Hasegawa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Erin S Rescoe
- Division of Pediatric Critical Care, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY
| | - Ryan K Breuer
- Division of Critical Care Medicine, John R. Oishei Children's Hospital, Buffalo, NY
| | - Mioko Kasagi
- Pediatric Critical Care and Emergency Medicine, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Carlson JP, Peña K, Burjonrappa S. The Obesity Paradox in the Pediatric Trauma Patient. J Pediatr Surg 2024; 59:275-280. [PMID: 37993398 DOI: 10.1016/j.jpedsurg.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Obesity is a chronic disease that adversely impacts patient outcomes and increasingly affecting the pediatric population. According to the CDC, in 2020 the prevalence of obesity among children and adolescents was estimated to be as high as 19.7%. The obesity paradox is the increased survival for overweight and obese adult trauma patients when compared to patients with healthy weights. The aim of this study was to analyze the impact of BMI and outcomes in the pediatric trauma population. METHODS Trauma patients in the 2-18 years age group and reported to the 2017-2019 National Trauma Data Bank were identified. CDC growth charts and z-scores were calculated to categorize patients into four subgroups: underweight (<5th percentile), healthy weight (5th-85th percentile), overweight (85th-95th percentile), and obesity (>95th percentile). Primary outcome studied was the mortality rate. Secondary outcomes included injury severity score (ISS), hospital length of stay (LOS), ICU LOS, and number of days on a ventilator. Continuous and categorical data were analyzed using ANOVA and Chi-squared test, respectively, using the healthy BMI category as reference group. P < 0.05 was considered significant. RESULTS A total of 161,458 patients [Underweight: 9148 (6%), Healthy weight: 88,009 (55%), Overweight: 26,740 (17%), and Obese: 37,561 (23%)] were included. The mean age was 11 years (SD:5.1). Total mortality for the patient set was 1825 (1.13%). The lowest mortality rate was in the obese group. The ISS was lowest in the obese group, while ICU LOS and days on ventilator were no different than control patients. Hospital LOS and transfer to rehabilitation rates were higher in the obese population. CONCLUSION Obesity appears to have a protective effect on mortality and significantly better secondary outcomes in the pediatric trauma population. Further study is necessary to evaluate the interplay between body weight and outcomes in pediatric trauma and disease states. LEVEL OF EVIDENCE III.
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Tantivit N, Mulekar M, Kaulfers AM, Lim WY. Impact of Weight on Severity of Hospital Course in Children Admitted With COVID-19. Glob Pediatr Health 2023; 10:2333794X231220873. [PMID: 38143516 PMCID: PMC10748557 DOI: 10.1177/2333794x231220873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/21/2023] [Accepted: 11/29/2023] [Indexed: 12/26/2023] Open
Abstract
Objective. To describe the impact of weight on length of stay (LOS) and oxygen requirement among hospitalized children with COVID-19. Methods. This is a retrospective review of 153 children admitted for COVID-19 from March 2020 to October 2021. Body mass index (BMI) percentile and weight-for-age (WFA) percentile were used to determine weight status for children ≥2 years and <2 years respectively. Results. We found 2 distinct patterns for patients <2 years and ≥2 years; The likelihood of needing oxygen and LOS ≥ 5 days was higher for children ≥2 years with BMI ≥ 85th percentile (P = .0415 and P = .0197). Among those <2 years, mean WFA percentile decreased with increasing oxygen need (P = .0325). There was a negative correlation between LOS and WFA percentile (r = -.31, P = .0123). Conclusion. It is important to stratify patients' risk according to their age, BMI and WFA percentile during hospitalization for COVID 19.
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Beni CE, Rice-Townsend SE, Esangbedo ID, Jancelewicz T, Vogel AM, Newton C, Boomer L, Rothstein DH. Outcome of Extracorporeal Cardiopulmonary Resuscitation in Pediatric Patients Without Congenital Cardiac Disease: Extracorporeal Life Support Organization Registry Study. Pediatr Crit Care Med 2023; 24:927-936. [PMID: 37477526 DOI: 10.1097/pcc.0000000000003322] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVES To describe the use of extracorporeal cardiopulmonary resuscitation (ECPR) in pediatric patients without congenital heart disease (CHD) and identify associations with in-hospital mortality, with a specific focus on initial arrest rhythm. DESIGN Retrospective cohort study using data from pediatric patients enrolled in Extracorporeal Life Support Organization (ELSO) registry between January 1, 2017, and December 31, 2019. SETTING International, multicenter. PATIENTS We included ECPR patients under 18 years old, and excluded those with CHD. Subgroup analysis of patients with initial arrest rhythm. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 567 patients: neonates (12%), infants (27%), children between 1 and 5 years old (25%), and children over 5 years old (36%). The patient cohort included 51% males, 43% of White race, and 89% not obese. Most suffered respiratory disease (26%), followed by acquired cardiac disease (25%) and sepsis (12%). In-hospital mortality was 59%. We found that obesity (adjusted odds ratio [aOR], 2.28; 95% CI, 1.21-4.31) and traumatic injury (aOR, 6.94; 95% CI, 1.55-30.88) were associated with greater odds of in-hospital mortality. We also identified lower odds of death associated with White race (aOR, 0.64; 95% CI, 0.45-0.91), ventricular tachycardia (VT) as an initial arrest rhythm (aOR, 0.36; 95% CI, 0.16-0.78), return of spontaneous circulation before cannulation (aOR, 0.56; 95% CI, 0.35-0.9), and acquired cardiac disease (aOR, 0.43; 95% CI, 0.29-0.64). Respiratory disease was associated with greater odds of severe neurologic complications (aOR, 1.64; 95% CI, 1.06-2.54). CONCLUSIONS In children without CHD undergoing ECPR, we found greater odds of in-hospital mortality were associated with either obesity or trauma. The ELSO dataset also showed that other variables were associated with lesser odds of mortality, including VT as an initial arrest rhythm. Prospective studies are needed to elucidate the reasons for these survival differences.
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Affiliation(s)
| | | | - Ivie D Esangbedo
- Department of Pediatrics, Section of Cardiac Critical Care, University of Washington, Seattle, WA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Department of Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Christopher Newton
- Department of Surgery, University of California San Francisco Benioff Children's Hospital Oakland, Oakland, CA
| | - Laura Boomer
- Department of Surgery, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, VA
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Hill NE, Friedman DL, Godown J, Zarnegar-Lumley S. Cough, Shortness of Breath, and Malaise in a 19-year-old Adolescent. Pediatr Rev 2023; 44:S72-S76. [PMID: 37777228 DOI: 10.1542/pir.2022-005906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Affiliation(s)
- Nina E Hill
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Debra L Friedman
- Division of Hematology and Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Justin Godown
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Sara Zarnegar-Lumley
- Division of Hematology and Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
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Ondee T, Pongpirul K, Udompornpitak K, Sukkummee W, Lertmongkolaksorn T, Senaprom S, Leelahavanichkul A. High Fructose Causes More Prominent Liver Steatohepatitis with Leaky Gut Similar to High Glucose Administration in Mice and Attenuation by Lactiplantibacillus plantarum dfa1. Nutrients 2023; 15:1462. [PMID: 36986190 PMCID: PMC10056651 DOI: 10.3390/nu15061462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 03/30/2023] Open
Abstract
High-sugar diet-induced prediabetes and obesity are a global current problem that can be the result of glucose or fructose. However, a head-to-head comparison between both sugars on health impact is still lacking, and Lactiplantibacillus plantarum dfa1 has never been tested, and has recently been isolated from healthy volunteers. The mice were administered with the high glucose or fructose preparation in standard mouse chaw with or without L. plantarum dfa1 gavage, on alternate days, and in vitro experiments were performed using enterocyte cell lines (Caco2) and hepatocytes (HepG2). After 12 weeks of experiments, both glucose and fructose induced a similar severity of obesity (weight gain, lipid profiles, and fat deposition at several sites) and prediabetes condition (fasting glucose, insulin, oral glucose tolerance test, and Homeostatic Model Assessment for Insulin Resistance (HOMA score)). However, fructose administration induced more severe liver damage (serum alanine transaminase, liver weight, histology score, fat components, and oxidative stress) than the glucose group, while glucose caused more prominent intestinal permeability damage (FITC-dextran assay) and serum cytokines (TNF-α, IL-6, and IL-10) compared to the fructose group. Interestingly, all of these parameters were attenuated by L. plantarum dfa1 administration. Because there was a subtle change in the analysis of the fecal microbiome of mice with glucose or fructose administration compared to control mice, the probiotics altered only some microbiome parameters (Chao1 and Lactobacilli abundance). For in vitro experiments, glucose induced more damage to high-dose lipopolysaccharide (LPS) (1 µg/mL) to enterocytes (Caco2 cell) than fructose, as indicated by transepithelial electrical resistance (TEER), supernatant cytokines (TNF-α and IL-8), and glycolysis capacity (by extracellular flux analysis). Meanwhile, both glucose and fructose similarly facilitated LPS injury in hepatocytes (HepG2 cell) as evaluated by supernatant cytokines (TNF-α, IL-6, and IL-10) and extracellular flux analysis. In conclusion, glucose possibly induced a more severe intestinal injury (perhaps due to LPS-glucose synergy) and fructose caused a more prominent liver injury (possibly due to liver fructose metabolism), despite a similar effect on obesity and prediabetes. Prevention of obesity and prediabetes with probiotics was encouraged.
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Affiliation(s)
- Thunnicha Ondee
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Krit Pongpirul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- School of Global Health, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
- Clinical Research Center, Bumrungrad International Hospital, Bangkok 10110, Thailand
- Department of Infection Biology & Microbiomes, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 3GB, UK
| | - Kanyarat Udompornpitak
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Warumphon Sukkummee
- Center of Excellence in Clinical Pharmacokinetics and Pharmacogenomics, Department of Pharmacology, Faculty of Medicine Chulalongkorn University, Bangkok 10330, Thailand
| | - Thanapat Lertmongkolaksorn
- Research Management and Development Division, Office of the President, Mahidol University, Nakhon Pathom 73170, Thailand
| | - Sayamon Senaprom
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Asada Leelahavanichkul
- Center of Excellence in Translational Research in Inflammation and Immunology Research Unit (CETRII), Department of Microbiology, Chulalongkorn University, Bangkok 10330, Thailand
- Nephrology Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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Nosaka N, Anzai T, Uchimido R, Mishima Y, Takahashi K, Wakabayashi K. An anthropometric evidence against the use of age-based estimation of bodyweight in pediatric patients admitted to intensive care units. Sci Rep 2023; 13:3574. [PMID: 36864218 PMCID: PMC9981604 DOI: 10.1038/s41598-023-30566-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 02/25/2023] [Indexed: 03/04/2023] Open
Abstract
Age-based bodyweight estimation is commonly used in pediatric settings, but pediatric ICU patients often have preexisting comorbidity and resulting failure to thrive, hence their anthropometric measures may be small-for-age. Accordingly, age-based methods could overestimate bodyweight in such settings, resulting in iatrogenic complications. We performed a retrospective cohort study using pediatric data (aged < 16 years) registered in the Japanese Intensive Care Patient Database from April 2015 to March 2020. All the anthropometric data were overlaid on the growth charts. The estimation accuracy of 4 age-based and 2 height-based bodyweight estimations was evaluated by the Bland-Altman plot analysis and the proportion of estimates within 10% of the measured weight (ρ10%). We analyzed 6616 records. The distributions of both bodyweight and height were drifted to the lower values throughout the childhood while the distribution of BMI was similar to the general healthy children. The accuracy in bodyweight estimation with age-based formulae was inferior to that with height-based methods. These data demonstrated that the pediatric patients in the Japanese ICU were proportionally small-for-age, suggesting a special risk of using the conventional age-based estimation but supporting the use of height-based estimation of the bodyweight in the pediatric ICU.
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Affiliation(s)
- Nobuyuki Nosaka
- Department of Intensive Care Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan.
| | - Tatsuhiko Anzai
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryo Uchimido
- Department of Intensive Care Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan
| | - Yuka Mishima
- Department of Intensive Care Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan
| | - Kunihiko Takahashi
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kenji Wakabayashi
- Department of Intensive Care Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan
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Rupp Hanzen Andrades G, Abud Drumond Costa C, Crestani F, Tedesco Tonial C, Fiori H, Santos IS, Celiny Ramos Garcia P. Association of nutritional status with clinical outcomes of critically ill pediatric patients with complex chronic conditions. Clin Nutr 2022; 41:2786-2791. [PMID: 36379176 DOI: 10.1016/j.clnu.2022.10.019] [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: 04/07/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS There is a high prevalence of children with complex chronic conditions (CCCs) in pediatric intensive care units (PICUs). However, information on the nutritional status (NS) of this specific population is limited. This study aimed to evaluate the NS of critically ill pediatric patients with CCCs and to relate it to clinical outcomes. METHODS A retrospective cohort study of children admitted to a PICU over a 4-year period. We classified NS according to body mass index-for-age (BMI/A) and height-for-age (H/A) z-scores, using the World Health Organization (WHO) growth curves as a reference. We recorded the presence of CCC according to the definition proposed by Feudtner et al. Severity on admission was measured using the Pediatric Index of Mortality 2 (PIM2). We assessed the following outcomes: mortality, multiple organ dysfunction syndrome during PICU stay, and PICU length of stay (LOS). RESULTS We included 1753 children in the study. Presence of CCC accounted for 49.8% (873) of the sample. Among children with CCCs, 61.7% (539) had appropriate weight, 19.8% (173) were underweight, and 18.4% (161) were overweight. H/A was considered inadequate in 32.2% (281) of patients with CCCs, a higher rate than in those without CCCs (25.3%; 132) (p < 0.001). Regarding outcomes, underweight children had more organ dysfunctions and prolonged LOS. The association only remained for prolonged LOS when adjusting for confounders. Although underweight children had a higher PIM2-predicted risk of mortality, there was no significant difference in actual mortality between the three NS groups (p = 0.200). CONCLUSIONS The rates of nutritional inadequacies in patients with CCCs were high. Underweight was independently associated with prolonged LOS in children with CCC.
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Affiliation(s)
- Gabriela Rupp Hanzen Andrades
- Post Graduate Program in Pediatrics and Child Health of PUCRS - Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga, 6681 - Partenon, Porto Alegre, 90619-900 - RS, Brazil.
| | - Caroline Abud Drumond Costa
- Post Graduate Program in Pediatrics and Child Health of PUCRS - Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga, 6681 - Partenon, Porto Alegre, 90619-900 - RS, Brazil.
| | - Francielly Crestani
- Post Graduate Program in Pediatrics and Child Health of PUCRS - Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga, 6681 - Partenon, Porto Alegre, 90619-900 - RS, Brazil.
| | - Cristian Tedesco Tonial
- Post Graduate Program in Pediatrics and Child Health of PUCRS - Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga, 6681 - Partenon, Porto Alegre, 90619-900 - RS, Brazil.
| | - Humberto Fiori
- Post Graduate Program in Pediatrics and Child Health of PUCRS - Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga, 6681 - Partenon, Porto Alegre, 90619-900 - RS, Brazil.
| | - Ina S Santos
- Post-graduate Program in Epidemiology, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3(o) Andar, Pelotas, 96020-220 - RS, Brazil.
| | - Pedro Celiny Ramos Garcia
- Post Graduate Program in Pediatrics and Child Health of PUCRS - Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga, 6681 - Partenon, Porto Alegre, 90619-900 - RS, Brazil; Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga, 6681 - Partenon, Porto Alegre, 90619-900 - RS, Brazil.
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The unmet need for critical care at a quaternary paediatric intensive care unit in South Africa. S Afr Med J 2022; 112:871-878. [DOI: 10.7196/samj.2022.v112i11.16452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Indexed: 11/12/2022] Open
Abstract
Background. Paediatric intensive care, a valuable resource that improves the outcomes of critically ill children, is often scarce.
Objective. To evaluate the need for paediatric intensive care beds and compare the outcomes of admitted and non-admitted deserving cases.
Methods. A prospective evaluation of all bed requests, in terms of need for intensive care and outcomes of those admitted and not admitted to a paediatric intensive care unit (PICU), was performed between July 2017 and June 2018. Factors for refusal and for poor outcomes were evaluated.
Results. Of the 811 bed requests, 32.6% (n=264, p<0.001) were denied access. Of the 231 deserving cases who were denied access, 85.7% (n=198) were due to unavailability of a PICU bed. Patients not admitted to PICU had a twofold increased risk of dying compared with those admitted (34.4% v. 15.5% respectively, p<0.001), even though the patient characteristics of both groups were similar (age, gender and nutritional status). In those admitted, risk factors for mortality were requiring transfusion of blood and platelets (56.0%, p<0.001), requiring two or more inotropes (52.5%, p<0.001), instability on admission (41.3%, p<0.001), prior cardiac arrest (32.0%, p=0.021), severe acute malnutrition (26.9%, p=0.043), fungal infection (22.2%, p=0.004) and emergency admission (18.0%, p<0.001). In those not admitted, prior cardiac arrest (100%, p<0.001) and emergency referral (42.3%, p<0.001) were associated with adverse outcomes.
Conclusion. The need for PICU beds exceeds availability, with a consequent twofold increase in mortality among cases not admitted to PICU. Paediatric critical care services have increased at appropriate sites of need following completion of this study.
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10
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Nutrition in Pediatric Intensive Care: A Narrative Review. CHILDREN 2022; 9:children9071031. [PMID: 35884015 PMCID: PMC9318205 DOI: 10.3390/children9071031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/04/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022]
Abstract
Nutrition support in pediatric intensive care is an integral part of a complex approach to treating critically ill children. Smaller energy reserves with higher metabolic demands (a higher basal metabolism rate) compared to adults makes children more vulnerable to starvation. The nutrition supportive therapy should be initiated immediately after intensive care admission and initial vital sign stabilization. In absence of contraindications (unresolving/decompensated shock, gut ischemia, critical gut stenosis, etc.), the preferred type of enteral nutrition is oral or via a gastric tube. In the acute phase of critical illness, due to gluconeogenesis and muscle breakdown with proteolysis, the need for high protein delivery should be emphasized. After patient condition stabilization, the acute phase with predominant catabolism converts to the anabolic phase and intensive rehabilitation, where high energy demands are the keystone of a positive outcome.
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11
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Halvorson EE, Thurtle DP, Easter A, Lovato J, Stockwell DC. Body Mass Index Category and Adverse Events in Hospitalized Children. Acad Pediatr 2022; 22:747-753. [PMID: 34543672 DOI: 10.1016/j.acap.2021.09.004] [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: 01/30/2021] [Revised: 08/24/2021] [Accepted: 09/09/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To identify associations between patient body mass index (BMI) category and adverse event (AE) rate, severity, and preventability in a cohort of children discharged from an academic children's hospital. METHODS We identified patients 2 to 17 years old consecutively discharged between June and October 2018. Patient age, sex, height, and weight were used to categorize patients as having underweight, normal weight, overweight, or obesity. We used the Global Assessment of Pediatrics Patient Safety trigger tool to identify AEs, which were scored for harm and preventability. The primary outcome was the rate of AEs; these were compared with Poisson regression. We used multivariable logistic regression to model event preventability. RESULTS We reviewed 834 encounters in 680 subjects; 51 (7.5%) had underweight, 367 (54.0%) had normal weight, 112 (16.5%) had overweight, and 150 (22.1%) had obesity. Our cohort experienced 270 AEs, with an overall rate of 69.7 (61.8-78.5) AEs per 1000 patient-days: 67.7 (46.4-98.7) in underweight, 70.0 (59.4-82.4) in normal weight, 58.6 (42.5-79.7) in overweight, and 80.4 (62.5-103.6) in obesity, P = .46. No associations were seen between BMI category and AE severity. Children with obesity had an increased rate of preventable AEs (P < .01), but this association did not persist in the multivariable model. CONCLUSIONS In this single-center study, we did not find associations between BMI category and rate, severity, or preventability of AEs.
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Affiliation(s)
- Elizabeth Eby Halvorson
- Department of Pediatrics, Wake Forest School of Medicine (EE Halvorson and A Easter), Winston-Salem, NC.
| | | | - Ashley Easter
- Department of Pediatrics, Wake Forest School of Medicine (EE Halvorson and A Easter), Winston-Salem, NC
| | - James Lovato
- Department of Biostatistics, Wake Forest School of Medicine (J Lovato), Winston-Salem, NC
| | - David C Stockwell
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine (DC Stockwell), Baltimore, Md
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12
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Ondee T, Pongpirul K, Janchot K, Kanacharoen S, Lertmongkolaksorn T, Wongsaroj L, Somboonna N, Ngamwongsatit N, Leelahavanichkul A. Lactiplantibacillus plantarum dfa1 Outperforms Enterococcus faecium dfa1 on Anti-Obesity in High Fat-Induced Obesity Mice Possibly through the Differences in Gut Dysbiosis Attenuation, despite the Similar Anti-Inflammatory Properties. Nutrients 2021; 14:nu14010080. [PMID: 35010955 PMCID: PMC8746774 DOI: 10.3390/nu14010080] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 12/22/2022] Open
Abstract
Fat reduction and anti-inflammation are commonly claimed properties of probiotics. Lactiplantibacillus plantarum and Enterococcus faecium were tested in high fat-induced obesity mice and in vitro experiments. After 16 weeks of probiotics, L. plantarum dfa1 outperforms E. faecium dfa1 on the anti-obesity property as indicated by body weight, regional fat accumulation, serum cholesterol, inflammatory cytokines (in blood and colon tissue), and gut barrier defect (FITC-dextran assay). With fecal microbiome analysis, L. plantarum dfa1 but not E. faecium dfa1 reduced fecal abundance of pathogenic Proteobacteria without an alteration in total Gram-negative bacteria when compared with non-probiotics obese mice. With palmitic acid induction, the condition media from both probiotics similarly attenuated supernatant IL-8, improved enterocyte integrity and down-regulated cholesterol absorption-associated genes in Caco-2 cell (an enterocyte cell line) and reduced supernatant cytokines (TNF-α and IL-6) with normalization of cell energy status (extracellular flux analysis) in bone-marrow-derived macrophages. Due to the anti-inflammatory effect of the condition media of both probiotics on palmitic acid-activated enterocytes was neutralized by amylase, the active anti-inflammatory molecules might, partly, be exopolysaccharides. As L. plantarum dfa1 out-performed E. faecium dfa1 in anti-obesity property, possibly through the reduced fecal Proteobacteria, with a similar anti-inflammatory exopolysaccharide; L. plantarum is a potentially better option for anti-obesity than E. faecium.
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Affiliation(s)
- Thunnicha Ondee
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (T.O.); (K.J.)
| | - Krit Pongpirul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (T.O.); (K.J.)
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
- Bumrungrad International Hospital, Bangkok 10110, Thailand
- Correspondence: (K.P.); (A.L.)
| | - Kantima Janchot
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (T.O.); (K.J.)
| | - Suthicha Kanacharoen
- Department of Biology, Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD 21218, USA;
| | - Thanapat Lertmongkolaksorn
- Research Management and Development Division, Office of the President, Mahidol University, Nakhon Pathom 73170, Thailand;
| | - Lampet Wongsaroj
- Department of Microbiology, Faculty of Science, Chulalongkorn University, Bangkok 10330, Thailand; (L.W.); (N.S.)
| | - Naraporn Somboonna
- Department of Microbiology, Faculty of Science, Chulalongkorn University, Bangkok 10330, Thailand; (L.W.); (N.S.)
- Microbiome Research Unit for Probiotics in Food and Cosmetics, Chulalongkorn University, Bangkok 10330, Thailand
| | - Natharin Ngamwongsatit
- Department of Clinical Sciences and Public Health, Faculty of Veterinary Science, Mahidol University, Nakhon Pathom 73170, Thailand;
| | - Asada Leelahavanichkul
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Translational Research in Inflammation and Immunology Research Unit (TRIRU), Department of Microbiology, Chulalongkorn University, Bangkok 10330, Thailand
- Nephrology Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Correspondence: (K.P.); (A.L.)
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13
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Abstract
ABSTRACT In the last few decades, obesity became one of the world's greatest health challenges reaching a size of global epidemic in virtually all socioeconomic statuses and all age groups. Obesity is a risk factor for many health problems and as its prevalence gradually increases is becoming a significant economic and health burden. In this manuscript we describe how normal respiratory and cardiovascular physiology is altered by obesity. We review past and current literature to describe how obesity affects outcomes of patients facing critical illnesses and discuss some controversies related to this topic.
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Affiliation(s)
- Itay Ayalon
- Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Department of Pediatric Critical Care, Tel-Aviv, Israel
| | - Lauren Bodilly
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer Kaplan
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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14
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Díaz F, González-Dambrauskas S, Cristiani F, Casanova DR, Cruces P. Driving Pressure and Normalized Energy Transmission Calculations in Mechanically Ventilated Children Without Lung Disease and Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2021; 22:870-878. [PMID: 34054120 DOI: 10.1097/pcc.0000000000002780] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare the new tools to evaluate the energy dissipated to the lung parenchyma in mechanically ventilated children with and without lung injury. We compared their discrimination capability between both groups when indexed by ideal body weight and driving pressure. DESIGN Post hoc analysis of individual patient data from two previously published studies describing pulmonary mechanics. SETTING Two academic hospitals in Latin-America. PATIENTS Mechanically ventilated patients younger than 15 years old were included. We analyzed two groups, 30 children under general anesthesia (ANESTH group) and 38 children with pediatric acute respiratory distress syndrome. INTERVENTIONS Respiratory mechanics were measured after intubation in all patients. MEASUREMENTS AND MAIN RESULTS Mechanical power and derived variables of the equation of motion (dynamic power, driving power, and mechanical energy) were computed and then indexed by ideal body weight. Driving pressure was higher in pediatric acute respiratory distress syndrome group compared with ANESTH group. Receiver operator curve analysis showed that driving pressure had the best discrimination capability compared with all derived variables of the equation of motion indexed by ideal body weight. The same results were observed when the subgroup of patients weighs less than 15 kg. There was no difference in unindexed mechanical power between groups. CONCLUSIONS Driving pressure is the variable that better discriminates pediatric acute respiratory distress syndrome from nonpediatric acute respiratory distress syndrome in children than the calculations derived from the equation of motion, even when indexed by ideal body weight. Unindexed mechanical power was useless to differentiate against both groups. Future studies should determine the threshold for variables of the energy dissipated by the lungs and their association with clinical outcomes.
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Affiliation(s)
- Franco Díaz
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
- Instituto de Ciencias e Innovación en Medicina (ICIM), Universidad del Desarrollo, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network)
- Unidad de Cuidados Intensivos Pediátricos Especializados, Casa de Galicia, Montevideo, Uruguay
- Unidad de Cuidados Intensivos de Niños, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
- Centro Hospitalario Pereira Rossell, Cátedra de Anestesiología, Facultad de Medicina. Universidad de la República, Montevideo, Uruguay
- Departamento de Post-Grado Pediatría, Escuela de Medicina, Facultad de Ciencias Médicas, Universidad de Santiago de Chile, Santiago, Chile
- Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Sebastián González-Dambrauskas
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network)
- Unidad de Cuidados Intensivos Pediátricos Especializados, Casa de Galicia, Montevideo, Uruguay
- Unidad de Cuidados Intensivos de Niños, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - Federico Cristiani
- Centro Hospitalario Pereira Rossell, Cátedra de Anestesiología, Facultad de Medicina. Universidad de la República, Montevideo, Uruguay
| | - Daniel R Casanova
- Departamento de Post-Grado Pediatría, Escuela de Medicina, Facultad de Ciencias Médicas, Universidad de Santiago de Chile, Santiago, Chile
| | - Pablo Cruces
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network)
- Centro Hospitalario Pereira Rossell, Cátedra de Anestesiología, Facultad de Medicina. Universidad de la República, Montevideo, Uruguay
- Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
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15
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Thavamani A, Umapathi KK, Sankararaman S, Roy A. Effect of obesity on mortality among hospitalized paediatric patients with severe sepsis. Pediatr Obes 2021; 16:e12777. [PMID: 33719208 DOI: 10.1111/ijpo.12777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 01/25/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Severe sepsis is one of the leading causes of mortality among children. Studies in adults have suggested a protective effect of obesity on mortality among patients hospitalized with sepsis. Paediatric studies evaluating similar relationship is lacking. METHODS We analysed non-overlapping years of the Kids Inpatient Database (KID) and National Inpatient Sample (NIS) database between 2003 and 2014 of all paediatric patients with severe sepsis (PSS) up to 20 years of age. PSS was defined using specific International Classification of Diseases (ICD) codes and modified Angus criteria. Using ICD-9 diagnosis codes, patients were divided into three mutually exclusive groups (obesity, morbid obesity and control groups), and these groups were compared for outcomes measures including in-hospital mortality and healthcare resource utilization using the length of stay and inflation-adjusted hospitalization charges. RESULTS We analysed 109 026 hospitalizations due to PSS. The prevalence rate of obesity was 1.5% (n = 1643), and morbid obesity was 1.05% (n = 1147). Multivariate regression models showed obesity was associated with 63% (OR 0.37, CI: 0.29-0.47, p < 0.001) and 54% reduction in mortality among PSS patients and patients with septic shock respectively. Contrastingly, morbid obesity was not associated with mortality among PSS patients and but was associated with 1.37 times (CI: 1.06-1.78, p = 0.01) increased risk of mortality among paediatric patients with septic shock. CONCLUSIONS Paediatric obesity is associated with reduced mortality among patients with PSS, with the exception of morbid obesity. Further prospective studies are needed to better understand the relationship between obesity and outcomes in PSS.
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Affiliation(s)
- Aravind Thavamani
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, UH Rainbow Babies and Children's hospital/Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Krishna Kishore Umapathi
- Division of Paediatric Cardiology, Department of Paediatrics, Rush University Medical Centre, Chicago, Illinois, USA
| | - Senthilkumar Sankararaman
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, UH Rainbow Babies and Children's hospital/Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Aparna Roy
- Division of Paediatric Critical Care, Department of Paediatrics, Metroheath Medical Centre/Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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16
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Tripathi S, Christison AL, Levy E, McGravery J, Tekin A, Bolliger D, Kumar VK, Bansal V, Chiotos K, Gist KM, Dapul HR, Bhalala US, Gharpure VP, Heneghan JA, Gupta N, Bjornstad EC, Montgomery VL, Walkey A, Kashyap R, Arteaga GM. The Impact of Obesity on Disease Severity and Outcomes Among Hospitalized Children with COVID-19. Hosp Pediatr 2021; 11:e297-e316. [PMID: 34168067 DOI: 10.1542/hpeds.2021-006087] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Sandeep Tripathi
- Children's Hospital of Illinois, OSF Saint Francis Medical Centre, Peoria, Illinois;
| | | | | | | | | | | | | | | | | | | | | | - Utpal S Bhalala
- The Children's Hospital of San Antonio, Baylor College of Medicine
| | | | | | - Neha Gupta
- University of Oklahoma College of Medicine, OK
| | | | | | - Allan Walkey
- Boston University School of Public Health, Boston, Massachusetts
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17
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Pace A, Zobel A, Gearman L, Seitzer D, Larson-Nath C, Somani A. Improving the rate of anthropometric measurements in the pediatric intensive care unit. Nutr Clin Pract 2021; 36:1276-1283. [PMID: 33930222 DOI: 10.1002/ncp.10659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malnutrition occurs in approximately 25% of pediatric intensive care patients and correlates with increased length of stay, prolonged ventilation, and mortality. Anthropometric measurements should be obtained at admission and throughout hospitalization to evaluate nutrition status. We aimed to increase documentation, reporting, and discussion of anthropometric measurements, including height/length, weight, and occipital frontal circumference (OFC) within 24 hours of admission and weekly. METHODS A multifaceted process improvement model was implemented over 1 month. Interventions included education, recruiting nurse champions, process mapping, new equipment, and formal discussion of nutrition status during rounds. A proportions hypothesis test compared frequency of anthropometric measures obtained during each study phase: preintervention, postintervention, and sustainment. RESULTS In terms of admission metrics over respective study phases, the PICU had fluctuation in weights (91%, 98%, and 97%) and height (49%, 73%, and 71%) and increased rates in OFC (36%, 61%, and 65%). The cardiovascular intensive care unit (CVICU) had stable weights (100%, 100%, and 100%) and increased rates in height (87%, 94%, and 95%) and OFC (28%, 64%, and 86%), respectively. In terms of weekly metrics over study phases, the PICU had fluctuation in weights (91%, 89%, and 93%) and increased rates in heights (38%, 69%, and 76%) and OFC (45%, 76%, and 100%). The CVICU had increased rates in weights (98%, 100%, and 100%) and fluctuations in heights (50%, 83%, and 75%), and OFC (48%, 84%, and 75%). CONCLUSIONS Interventions increased rates of measurements. During the sustainment phase, there was regression in rates, although these remained above baseline. Additional interventions may increase compliance and foster change in unit culture.
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Affiliation(s)
- Autumn Pace
- University of Minnesota Medical School-Twin Cities, Minneapolis, Minnesota, USA
| | - Amanda Zobel
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Laura Gearman
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Dale Seitzer
- Fairview Health Services, Minneapolis, Minnesota, USA
| | | | - Arif Somani
- University of Minnesota Medical School-Twin Cities, Minneapolis, Minnesota, USA
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18
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Toh S, Ong C, Sultana R, Kirk AHP, Koh JC, Lee JH. Association between admission body mass index and outcomes in critically ill children: A systematic review and meta-analysis. Clin Nutr 2021; 40:2772-2783. [PMID: 33933743 DOI: 10.1016/j.clnu.2021.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/23/2021] [Accepted: 04/03/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND & AIMS The association between nutritional status at pediatric intensive care unit (PICU) admission with clinical outcomes remains unclear. We conducted this systematic review to summarize the overall impact of PICU admission body mass index (BMI) on clinical outcomes. METHODS We searched the following medical databases from inception through May 2020: PubMed, Excerpta Medica database (Embase), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, and Web of Science. We included studies on patients ≤18 years old admitted to a PICU that investigated the effect of BMI on mortality, PICU or hospital length of stay (LOS), or duration of mechanical ventilation (MV). Classification of underweight, overweight, and obese were based on each study's criteria. RESULTS There was a total of 21,558 patients from 20 included studies. 12,936 (60.0%), 2965 (13.8%), 2182 (10.1%), 3348 (15.5%) were normal weight, underweight, overweight, and obese patients, respectively. Relative to normal weight patients, underweight (OR 1.32, 95% CI 0.89-1.98; p = 0.171) and overweight/obese patients (OR 1.10, 95% CI 0.86-1.42; p = 0.446) did not have an increase risk in mortality. There was also no difference in duration of MV, PICU and hospital LOS between all three weight categories. Included studies were heterogeneous and lacked standardized nutritional categorization. Sensitivity analysis including only studies that used BMI z-scores as nutritional classification (n = 5) revealed that underweight patients had higher odds of mortality compared to patients with normal weight (OR 1.61, 95% CI 1.35-1.92; p < 0.001); studies that used percentiles as classification did not reveal any differences in mortality. Sensitivity analysis including only studies containing mixed PICU cohorts (i.e., excluding specialized cohorts e.g., congenital heart surgeries, burns) revealed higher mortality odds in underweight patients (OR 1.53, 95% CI 1.25-1.87; p < 0.001) and overweight/obese patients (OR 1.51, 95% CI 1.14-2.01; p = 0.004) relative to normal weight patients. CONCLUSIONS Our systematic review did not reveal any association between PICU admission BMI status and outcomes in critically ill children. Further investigation with standardized nutrition status classification on admission, stratified by patient subgroups, is needed to clarify the association between nutritional status and clinical outcomes of PICU patients.
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Affiliation(s)
- Samantha Toh
- Duke-NUS Medical School, 8 College Rd, 169857, Singapore
| | - Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, 100 Bukit Timah Rd, 229899, Singapore
| | - Rehena Sultana
- Duke-NUS Medical School, 8 College Rd, 169857, Singapore
| | - Angela Hui Ping Kirk
- Children's Intensive Care Unit, Division of Nursing, KK Women's and Children's Hospital, 100 Bukit Timah Rd, 229899, Singapore
| | - Janine Cynthia Koh
- Department of Paediatric Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Rd, 229899, Singapore
| | - Jan Hau Lee
- Duke-NUS Medical School, 8 College Rd, 169857, Singapore; Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Rd, 229899, Singapore.
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Lactobacillus acidophilus LA5 improves saturated fat-induced obesity mouse model through the enhanced intestinal Akkermansia muciniphila. Sci Rep 2021; 11:6367. [PMID: 33737543 PMCID: PMC7973717 DOI: 10.1038/s41598-021-85449-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/23/2021] [Indexed: 12/18/2022] Open
Abstract
Obesity, a major healthcare problem worldwide, induces metabolic endotoxemia through the gut translocation of lipopolysaccharides (LPS), a major cell wall component of Gram-negative bacteria, causing a chronic inflammatory state. A combination of several probiotics including Lactobacillus acidophilus 5 (LA5), a potent lactic acid-producing bacterium, has previously been shown to attenuate obesity. However, data on the correlation between a single administration of LA5 versus microbiota alteration might be helpful for the probiotic adjustment. LA5 was administered daily together with a high-fat diet (HFD) for 8 weeks in mice. Furthermore, the condition media of LA5 was also tested in a hepatocyte cell-line (HepG2 cells). Accordingly, LA5 attenuated obesity in mice as demonstrated by weight reduction, regional fat accumulation, lipidemia, liver injury (liver weight, lipid compositions, and liver enzyme), gut permeability defect, endotoxemia, and serum cytokines. Unsurprisingly, LA5 improved these parameters and acidified fecal pH leads to the attenuation of fecal dysbiosis. The fecal microbiome analysis in obese mice with or without LA5 indicated; (i) decreased Bacteroidetes (Gram-negative anaerobes that predominate in non-healthy conditions), (ii) reduced total fecal Gram-negative bacterial burdens (the sources of gut LPS), (iii) enhanced Firmicutes (Gram-positive bacteria with potential benefits) and (iv) increased Verrucomycobia, especially Akkermansia muciniphila, a bacterium with the anti-obesity property. With LA5 administration, A. muciniphila in the colon were more than 2,000 folds higher than the regular diet mice as determined by 16S rRNA. Besides, LA5 produced anti-inflammatory molecules with a similar molecular weight to LPS that reduced cytokine production in LPS-activated HepG2 cells. In conclusion, LA5 attenuated obesity through (i) gut dysbiosis attenuation, partly through the promotion of A. muciniphila (probiotics with the difficulty in preparation processes), (ii) reduced endotoxemia, and (iii) possibly decreased liver injury by producing the anti-inflammatory molecules.
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20
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Yu XR, Xie WP, Liu JF, Wang LW, Cao H, Chen Q. Effect of the Addition of Human Milk Fortifier to Breast Milk on the Early Recovery of Infants After Congenital Cardiac Surgery. Front Pediatr 2021; 9:661927. [PMID: 33987154 PMCID: PMC8110819 DOI: 10.3389/fped.2021.661927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/01/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: This article studied the effect of breast milk supplemented with human milk fortifier (HMF) on the early recovery of infants after congenital cardiac surgery. Methods: Infants undergoing congenital cardiac surgery were randomly divided into an intervention group (n = 27) and a control group (n = 27). Infants in the intervention group received HMF, and those in the control group were exclusively breastfed. The nutritional indicators at discharge, the postoperative recovery status, and nutritional-related complications were recorded. Results: Compared with the control group at the time of discharge, the weight and albumin and prealbumin levels of the intervention group were significantly increased (P < 0.05). The length of hospital stay of the intervention group was significantly reduced compared with that of the control group (P < 0.05). Although the length of ICU stay for the intervention group was shorter than that of the control group, the difference was not significant (P > 0.05). No significant difference in the incidence of postoperative nutrition-related complications was noted between the two groups (P > 0.05). Conclusion: Compared with breastfeeding alone, with HMF can improve postoperative weight gains, reduce the length of stay, and promote infants' early recovery after congenital cardiac surgery.
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Affiliation(s)
- Xian-Rong Yu
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Wen-Peng Xie
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Jian-Feng Liu
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Li-Wen Wang
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
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21
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Foster BA, Lane JE, Massey E, Noelck M, Green S, Austin JP. The Impact of Malnutrition on Hospitalized Children With Cerebral Palsy. Hosp Pediatr 2020; 10:1087-1095. [PMID: 33154081 PMCID: PMC7684553 DOI: 10.1542/hpeds.2020-0177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Children with cerebral palsy (CP) and other medical complexity comprise an outsized proportion of health care use. In this review, we describe the current science of assessment of nutritional status for children with CP, outline a systematic approach to assessing their nutritional status, delineate ramifications of malnutrition on hospitalization-associated outcomes, and identify knowledge gaps and means of addressing those gaps using quality improvement and clinical research tools. Methods to accurately assess body composition and adiposity in this population by using skinfolds, age, sex, and activity level are available but are not widely used. There are limitations in our current method of estimating energy needs in children with CP, who are at higher risk of both obesity and micronutrient deficiencies. There is some evidence of an association between malnutrition, defined as either underweight or obesity, and hospitalization-associated outcomes in children generally, although we lack specific data for CP. The gaps in our current understanding of optimal nutritional status and between current science and practice need to be addressed to improve health outcomes for this vulnerable patient population.
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Affiliation(s)
| | - Jennifer E Lane
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Elizabeth Massey
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Michelle Noelck
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Sarah Green
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Jared P Austin
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
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22
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Abstract
PURPOSE OF REVIEW Childhood obesity, with persistent chronic inflammation, is a worldwide epidemic. Obesity causes dysregulation throughout the immune system, affecting the balance and levels of cytokines, adipokines, and innate and adaptive immune cells. The present review focuses on the impact of obesity on immune function in children: altering the baseline activation state of immune cells and affecting the ability of the host to combat pathogens and malignancy and respond appropriately to vaccination. RECENT FINDINGS Obesity causes dysregulation of the immune system. Single-cell RNA-sequencing of adipose tissue and resident immune cells is quantifying the impact of obesity on the frequency of immune cell subsets and their states. The system-wide alterations in immune function in obesity are most evident upon perturbation, including the response to infection (e.g. increased risk of severe COVID-19 in the ongoing pandemic), vaccination, and malignancy. However, mechanistic research in pediatric obesity is limited and this impacts our ability to care for these children. SUMMARY We must better understand baseline and perturbed immune health in obese children to determine how to account for altered frequency and function of humoral and cellular immune components in acute infection, during vaccine design and when considering therapeutic options for this complex, medically vulnerable group.
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Affiliation(s)
- Xingyuan Fang
- Children’s Hospital of Philadelphia, Department of Pediatrics, Division of Allergy Immunology, Philadelphia, PA
| | - Jorge Henao-Mejia
- Children’s Hospital of Philadelphia, Department of Pathology, Division of Allergy Immunology, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sarah E. Henrickson
- Children’s Hospital of Philadelphia, Department of Pediatrics, Division of Allergy Immunology, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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23
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Ross PA, Newth CJL. Underweight is the highest PICU mortality risk factor among all other weight categories. J Pediatr 2020; 226:309-313. [PMID: 34756196 DOI: 10.1016/j.jpeds.2020.08.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Patrick A Ross
- University of Southern California Los Angeles, California
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24
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Verma S, Lumba R, Dapul HM, Gold-von Simson G, Phoon CK, Lighter JL, Farkas JS, Vinci A, Noor A, Raabe VN, Rhee D, Rigaud M, Mally PV, Randis TM, Dreyer B, Ratner AJ, Manno CS, Chopra A. Characteristics of Hospitalized Children With SARS-CoV-2 in the New York City Metropolitan Area. Hosp Pediatr 2020; 11:71-78. [PMID: 33033078 DOI: 10.1542/hpeds.2020-001917] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To describe the characteristics of hospitalized children with severe acute respiratory syndrome coronavirus 2 in New York City metropolitan area. PATIENTS AND METHODS This was a multicenter, retrospective cohort study at 4 hospitals comprising 82 hospitalized children (0-21 years) who tested positive for severe acute respiratory syndrome coronavirus 2 after symptoms and risk screening between March 1 and May 10, 2020. We subdivided patients on the basis of their admission to acute or critical care units and by age groups. Further subanalyses were performed between patients requiring respiratory support or no respiratory support. RESULTS Twenty-three (28%) patients required critical care. Twenty-nine (35%) patients requiring respiratory support, with 9% needing mechanical ventilation, and 1 required extracorporeal support. All patients survived to discharge. Children with any comorbidity were more likely to require critical care (70% vs 37%, P = .008), with obesity as the most common risk factor for critical care (63% vs 28%, P = .02). Children with asthma were more likely to receive respiratory support (28% vs 8%, P = .02), with no difference in need for critical care (P = .26). Children admitted to critical care had higher rates of renal dysfunction at presentation (43% vs 10%, P = .002). CONCLUSIONS Children with comorbidities (obesity and asthma in particular) were at increased risk for critical care admission and/or need for respiratory support. Children with renal dysfunction at presentation were more likely to require critical care.
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Affiliation(s)
- Sourabh Verma
- Departments of Pediatrics and .,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | | | - Heda M Dapul
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | | | - Colin K Phoon
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | - Jennifer L Lighter
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | - Jonathan S Farkas
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | - Alexandra Vinci
- Department of Pediatrics, Long Island School of Medicine, New York University, New York, New York
| | - Asif Noor
- Department of Pediatrics, Long Island School of Medicine, New York University, New York, New York
| | - Vanessa N Raabe
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York.,Department of Medicine, Vaccine Center, NYU Langone Health, New York, New York; and
| | | | | | - Pradeep V Mally
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | - Tara M Randis
- Departments of Pediatrics and Molecular Medicine, University of South Florida, Tampa, Florida
| | - Benard Dreyer
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | - Adam J Ratner
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York.,Microbiology, Grossman School of Medicine, New York University, New York, New York
| | | | - Arun Chopra
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
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25
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Panpetch W, Sawaswong V, Chanchaem P, Ondee T, Dang CP, Payungporn S, Leelahavanichkul A. Candida Administration Worsens Cecal Ligation and Puncture-Induced Sepsis in Obese Mice Through Gut Dysbiosis Enhanced Systemic Inflammation, Impact of Pathogen-Associated Molecules From Gut Translocation and Saturated Fatty Acid. Front Immunol 2020; 11:561652. [PMID: 33101279 PMCID: PMC7545113 DOI: 10.3389/fimmu.2020.561652] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/19/2020] [Indexed: 12/11/2022] Open
Abstract
Obesity induces gut leakage and elevates serum lipopolysaccharide (LPS), a major cell wall component of Gram-negative bacteria, through gut translocation. Because Candida albicans is prominent in human gut but not in mouse, C. albicans, a source of (1→3)-β-D-glucan (BG) in gut contents, was administered in high-fat diet (HFD)–induced obese mice at 1 week before sepsis induction by cecal ligation and puncture (CLP). As such, sepsis in Candida-administered obese mice was more severe than obese mice without Candida as determined by mortality, organ injury (liver and kidney), serum cytokines, gut leakage, endotoxemia, serum BG, and fecal Gram-negative bacteria (microbiome analysis). Mice subjected to CLP and fed a HFD, but not treated with Candida demonstrated a similar mortality to non-obese mice with more severe gut leakage and higher serum cytokines. In vitro experiments demonstrated that LPS plus BG (LPS + BG) induced higher supernatant cytokines from hepatocytes (HepG2) and macrophages (RAW264.7), compared with the activation by each molecule alone, and were amplified by palmitic acid, a representative saturated fatty acid. The energy production capacity of HepG2 cells was also decreased by LPS + BG compared with LPS alone as evaluated by extracellular flux analysis. However, Lactobacillus rhamnosus L34 (L34) improved sepsis, regardless of Candida administration, through the attenuation of gut leakage and gut dysbiosis. In conclusion, an impact of gut Candida was demonstrated by Candida pretreatment in obese mice that worsened sepsis through (1) gut dysbiosis–induced gut leakage and (2) amplified systemic inflammation due to LPS, BG, and saturated fatty acid.
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Affiliation(s)
- Wimonrat Panpetch
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Vorthon Sawaswong
- Program in Bioinformatics and Computational Biology, Graduate School, Chulalongkorn University, Bangkok, Thailand.,Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Prangwalai Chanchaem
- Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence in Systems Biology, Chulalongkorn University, Bangkok, Thailand
| | - Thunnicha Ondee
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Cong Phi Dang
- Medical Microbiology, Interdisciplinary Program, Graduate School, Chulalongkorn University, Bangkok, Thailand
| | - Sunchai Payungporn
- Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence in Systems Biology, Chulalongkorn University, Bangkok, Thailand
| | - Asada Leelahavanichkul
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Translational Research in Inflammation and Immunology Research Unit, Department of Microbiology, Chulalongkorn University, Bangkok, Thailand
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26
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Ayalon I, Woo JG, Basu RK, Kaddourah A, Goldstein SL, Kaplan JM. Weight as a Risk Factor for Mortality in Critically Ill Patients. Pediatrics 2020; 146:e20192829. [PMID: 32620676 PMCID: PMC7397732 DOI: 10.1542/peds.2019-2829] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To explore the hypothesis that obesity is associated with increased mortality and worse outcomes in children who are critically ill. METHODS Secondary analysis of the Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology study, a prospective, multinational observational study. Patients between 3 months and 25 years across Asia, Australia, Europe, and North America were recruited for 3 consecutive months. Patients were divided into 4 groups (underweight, normal weight, overweight, and obese) on the basis of their BMI percentile for age and sex. RESULTS A total of 3719 patients were evaluated, of whom 542 (14%) had a primary diagnosis of sepsis. One thousand fifty-nine patients (29%) were underweight, 1649 (44%) were normal weight, 423 (11%) were overweight, and 588 (16%) were obese. The 28-day mortality rate was 3.6% for the overall cohort and 9.1% for the sepsis subcohort and differed significantly by weight status (5.8%, 3.1%, 2.2%, and 1.8% for subjects with underweight, normal weight, overweight, and obesity, respectively, in the overall cohort [P < .001] and 15.4%, 6.6%, 3.6%, and 4.7% in the sepsis subcohort, respectively [P = .003]). In a fully adjusted model, 28-day mortality risk was 1.8-fold higher in the underweight group versus the normal weight group in the overall cohort and 2.9-fold higher in the sepsis subcohort. Patients who were overweight and obese did not demonstrate increased risk in their respective cohorts. Patients who were underweight had a longer ICU length of stay, increased need for mechanical ventilation support, and a higher frequency of fluid overload. CONCLUSIONS Patients who are underweight make up a significant proportion of all patients in the PICU, have a higher short-term mortality rate, and have a more complicated ICU course.
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Affiliation(s)
- Itay Ayalon
- Pediatric Intensive Care Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Jessica G Woo
- Divisions of Biostatistics and Epidemiology and
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Rajit K Basu
- Division of Critical Care Medicine, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia
| | | | - Stuart L Goldstein
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
- Center for Acute Care Nephrology, and
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer M Kaplan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
- Critical Care Medicine
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27
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Costa CAD, Mattiello R, Forte GC, Andrades GRH, Crestani F, Dalenogare IP, Einloft PR, Bruno F, Tonial CT, Garcia PCR. Clinical Outcomes in Critically Ill Children With Excess Weight: A Retrospective Cohort Study. Nutr Clin Pract 2020; 36:449-455. [PMID: 32618388 DOI: 10.1002/ncp.10541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Because of its high prevalence and negative impact on quality of life and longevity, overweight in childhood and adolescence is a major public health concern. The objective of the present study was to determine whether excess weight is associated with clinical outcomes in critically ill children and adolescents admitted to the pediatric intensive care unit (PICU). METHOD This retrospective cohort study was performed with children and adolescents admitted to a PICU over 3 years. Nutrition status was classified based on the body mass index z-score for age, following World Health Organization (WHO) criteria. The following outcomes were assessed: mortality, need for mechanical ventilation, length of admission, and multiple organ dysfunction syndrome. RESULTS Of 1468 patients admitted during the study period, 1407 were included in the study: 956 (68.0%) had adequate weight, 228 (16.2%) were overweight, and 223 (15.8%) were underweight. Associations were detected between most variables and all nutrition categories (underweight, adequate weight, and overweight). In the descriptive analysis, mortality was more prevalent in nutrition status extremes (extremely underweight or overweight). An independent association between nutrition status and mortality was not detected in any category. CONCLUSION Nutrition status was not independently associated with poor outcomes. However, overweight should be considered a potential risk factor for adverse clinical outcomes in PICU admissions.
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Affiliation(s)
- Caroline Abud Drumond Costa
- Post-graduate Program in Pediatrics and Child Health, School of Medicine, School of Health and Life Sciences, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil
| | - Rita Mattiello
- Department of Pediatrics, Post-graduate Program in Pediatrics and Child Health, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil
| | - Gabriele Carra Forte
- Post-graduate Program in Pediatrics and Child Health, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil
| | - Gabriela Rupp Hanzen Andrades
- Post-graduate Program in Pediatrics and Child Health, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil
| | - Francielly Crestani
- Post-graduate Program in Pediatrics and Child Health, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil
| | | | - Paulo Roberto Einloft
- Pediatric Intensive Care of Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil
| | - Francisco Bruno
- Department of Pediatrics, School of Medicine and Pediatric Intensive Care of Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil
| | - Cristian Tedesco Tonial
- Department of Pediatrics, School of Medicine and Pediatric Intensive Care of Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil
| | - Pedro Celiny Ramos Garcia
- Department of Pediatrics, Post-graduate Program in Pediatrics and Child Health, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil.,Pediatric Intensive Care of Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil.,Brazilian Council for Scientific and Technological Development (CNPq), Porto Alegre, RS, Brazil
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28
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Does obesity affect the short-term outcomes after cardiothoracic surgery in adolescents with congenital heart disease? Cardiol Young 2020; 30:372-376. [PMID: 31915104 DOI: 10.1017/s1047951119003329] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Obesity is a modifiable, independent risk factor for mortality and morbidity after cardiovascular surgery in adults. Our objective was to evaluate the impact of obesity on short-term outcomes in adolescents undergoing surgery for congenital heart disease (CHD). METHODS This retrospective chart review included patients 10-18 years of age who underwent CHD surgery. Our exclusion criteria were patients with a known genetic syndrome, heart transplantation, and patients with incomplete medical records. The clinical data collected included baseline demographics and multiple perioperative variables. Charting the body mass index in the Centers for Disease Control and Prevention growth curves, the entire cohort was divided into three categories: obese (>95th percentile), overweight (85th-95th percentile), and normal weight (<85th percentile). The composite outcome included survival, arrhythmias, surgical wound infection, acute neurologic injury, and acute kidney injury. RESULTS The study cohort (n = 149) had a mean standard deviation (SD), body mass index (BMI) of 22.6 ± 6.5 g/m2, and 65% were male. There were 27 obese (18.1%), 24 overweight (16.1%), and 98 normal weight (65.8%) patients. Twenty-seven (18%) patients had composite adverse outcomes. Overweight and obese patients had significantly higher adverse outcomes compared with normal weight patients (odds ratio (OR): 2.9; confidence interval (CI): 1-8.5, p = 0.04 and OR: 3; CI: 1-8.5, p = 0.03, respectively). In multivariate analysis, obesity was an independent predictor of adverse outcome in our cohort (p = 0.04). CONCLUSIONS Obesity is associated with short-term adverse outcome and increased health resource utilisation in adolescents following surgery for CHD. Further studies should evaluate if intervention in the preoperative period can improve outcomes in this population.
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29
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Tume LN, Valla FV, Joosten K, Jotterand Chaparro C, Latten L, Marino LV, Macleod I, Moullet C, Pathan N, Rooze S, van Rosmalen J, Verbruggen SCAT. Nutritional support for children during critical illness: European Society of Pediatric and Neonatal Intensive Care (ESPNIC) metabolism, endocrine and nutrition section position statement and clinical recommendations. Intensive Care Med 2020; 46:411-425. [PMID: 32077997 PMCID: PMC7067708 DOI: 10.1007/s00134-019-05922-5] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 12/28/2019] [Indexed: 01/09/2023]
Abstract
Background Nutritional support is considered essential for the outcome of paediatric critical illness. There is a lack of methodologically sound trials to provide evidence-based guidelines leading to diverse practices in PICUs worldwide. Acknowledging these limitations, we aimed to summarize the available literature and provide practical guidance for the paediatric critical care clinicians around important clinical questions many of which are not covered by previous guidelines. Objective To provide an ESPNIC position statement and make clinical recommendations for the assessment and nutritional support in critically ill infants and children. Design The metabolism, endocrine and nutrition (MEN) section of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) generated 15 clinical questions regarding different aspects of nutrition in critically ill children. After a systematic literature search, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was applied to assess the quality of the evidence, conducting meta-analyses where possible, to generate statements and clinical recommendations, which were then voted on electronically. Strong consensus (> 95% agreement) and consensus (> 75% agreement) on these statements and recommendations was measured through modified Delphi voting rounds. Results The final 15 clinical questions generated a total of 7261 abstracts, of which 142 publications were identified relevant to develop 32 recommendations. A strong consensus was reached in 21 (66%) and consensus was reached in 11 (34%) of the recommendations. Only 11 meta-analyses could be performed on 5 questions. Conclusions We present a position statement and clinical practice recommendations. The general level of evidence of the available literature was low. We have summarised this and provided a practical guidance for the paediatric critical care clinicians around important clinical questions. Electronic supplementary material The online version of this article (10.1007/s00134-019-05922-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lyvonne N Tume
- Faculty of Health and Society, University of Salford, Manchester, M6 6PU, UK. .,Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, East Prescot Road, Liverpool, L12 2AP, UK.
| | - Frederic V Valla
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, CarMEN INSERM UMR, 1060 Hospices Civils de Lyon, Lyon-Bron, France
| | - Koen Joosten
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Corinne Jotterand Chaparro
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Delémont, Switzerland.,Pediatric Intensive Care Unit, University Hospital of Lausanne, Lausanne, Switzerland
| | - Lynne Latten
- Nutrition and Dietetics, Alder Hey Children's Hospital Liverpool, Liverpool, UK
| | - Luise V Marino
- Department of Dietetics/Speech and Language Therapy, NIHR Biomedical Research Centre Southampton, University Hospital Southampton, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Isobel Macleod
- Pediatric Intensive Care Unit, Royal Hospital for Children, Glasgow, UK
| | - Clémence Moullet
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Delémont, Switzerland.,Pediatric Intensive Care Unit, University Hospital of Lausanne, Lausanne, Switzerland
| | - Nazima Pathan
- Department of Pediatrics, University of Cambridge, Hills Road, Cambridge, UK
| | - Shancy Rooze
- Pediatric Intensive Care Unit, Queen Fabiola Children's University Hospital, Brussels, Belgium
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Sascha C A T Verbruggen
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
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30
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Stephens K, Barker P, Bergeron E, Miller JL, Hagemann TM, Lewis TV, Neely S, Johnson PN. Comparison of Clinical Outcomes and Medication Use of Obese Versus Nonobese Children Admitted to the Pediatric Intensive Care Unit. Hosp Pharm 2019; 56:287-295. [PMID: 34381263 DOI: 10.1177/0018578719893373] [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: Few studies have compared clinical outcomes and medication use between obese and nonobese children in the pediatric intensive care unit (PICU). Objectives: The primary objective was to compare clinical outcomes including mortality, PICU length of stay (LOS), and mechanical ventilation (MV) requirement between obese and nonobese children. Secondary objectives included analysis of factors associated with these outcomes and medication use between groups. Methods: This retrospective study included children 2 to 17 years old admitted to the PICU over a 1-year time frame. Patients were categorized as obese, body mass index (BMI) ≥ 95th percentile, and nonobese (BMI < 95th percentile). Three binary regression models assessed the impact of obesity on clinical outcomes. Results: There were 834 admissions, with 22.1% involving obese children. There was no difference in mortality, MV requirement, or PICU LOS between groups. There were no associations with obesity and clinical outcomes found, but an association was noted for medication classes and receipt of continuous infusions on clinical outcomes. There was no difference noted in the median number (interquartile range [IQR]) of medications between obese and nonobese children, 8 (6-13) versus 9 (6-15), P = .38, but there was a difference in patients receiving a continuous infusion between obese and nonobese children, 24.4% versus 8.8%, P < .01. The 15 most used medications in both groups included analgesics, antimicrobials, corticosteroids, bronchodilators, and gastrointestinal agents. Conclusions: One-fifth of all admissions included obese children. Obesity was not associated with mortality, PICU LOS, and MV requirement, but the number of medication classes and continuous infusions were associated with these outcomes.
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Affiliation(s)
- Katy Stephens
- The University of Oklahoma College of Pharmacy, Oklahoma City, USA
| | - Philip Barker
- The University of Oklahoma College of Pharmacy, Oklahoma City, USA
| | - Erica Bergeron
- The University of Oklahoma College of Pharmacy, Oklahoma City, USA
| | - Jamie L Miller
- The University of Oklahoma College of Pharmacy, Oklahoma City, USA
| | - Tracy M Hagemann
- The University of Tennessee Health Science Center, Nashville, USA
| | - Teresa V Lewis
- The University of Oklahoma College of Pharmacy, Oklahoma City, USA
| | - Stephen Neely
- The University of Oklahoma College of Pharmacy, Oklahoma City, USA
| | - Peter N Johnson
- The University of Oklahoma College of Pharmacy, Oklahoma City, USA
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31
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Abstract
Severe sepsis and septic shock are the biggest cause of mortality in critically ill patients. Obesity today is one of the world's greatest health challenges. Little is known about the extent of involvement of the white adipose tissue (WAT) in sepsis and how it is being modified by obesity. We sought to explore the involvement of the WAT in sepsis. We hypothesize that sepsis induces browning of the WAT and that obesity alters the response of WAT to sepsis. Six-week-old C57BL/6 mice were randomized to a high-fat diet to induce obesity (obese group) or control diet (nonobese group). After 6 to 11 weeks of feeding, polymicrobial sepsis was induced by cecal ligation and puncture (CLP). Mice were sacrificed at 0, 18, and 72 h after CLP and epididymal WAT (eWAT), inguinal WAT, and brown adipose tissue (BAT) harvested. Both types of WAT were processed for light microscopy and transmission electron microscopy to assess for morphological changes in both obese and nonobese mice. Tissues were processed for immunohistochemistry, image analyses, and molecular analyses. BATs were used as a positive control. Nonobese mice have an extensive breakdown of the unilocular lipid droplet and smaller adipocytes in WAT compared with obese mice after sepsis. Neutrophil infiltration increases in eWAT in nonobese mice after sepsis but not in obese mice. Nonobese septic mice have an increase in mitochondrial density compared with obese septic mice. Furthermore, nonobese septic mice have an increase in uncoupling protein-1 expression. Although the WAT of nonobese mice have multiple changes characteristic of browning during sepsis, these changes are markedly blunted in obesity.
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Genomic Circuitry Underlying Immunological Response to Pediatric Acute Respiratory Infection. Cell Rep 2019; 22:411-426. [PMID: 29320737 DOI: 10.1016/j.celrep.2017.12.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 11/03/2017] [Accepted: 12/12/2017] [Indexed: 11/23/2022] Open
Abstract
Acute respiratory tract viral infections (ARTIs) cause significant morbidity and mortality. CD8 T cells are fundamental to host responses, but transcriptional alterations underlying anti-viral mechanisms and links to clinical characteristics remain unclear. CD8 T cell transcriptional circuitry in acutely ill pediatric patients with influenza-like illness was distinct for different viral pathogens. Although changes included expected upregulation of interferon-stimulated genes (ISGs), transcriptional downregulation was prominent upon exposure to innate immune signals in early IFV infection. Network analysis linked changes to severity of infection, asthma, sex, and age. An influenza pediatric signature (IPS) distinguished acute influenza from other ARTIs and outperformed other influenza prediction gene lists. The IPS allowed a deeper investigation of the connection between transcriptional alterations and clinical characteristics of acute illness, including age-based differences in circuits connecting the STAT1/2 pathway to ISGs. A CD8 T cell-focused systems immunology approach in pediatrics identified age-based alterations in ARTI host response pathways.
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Ross PA, Klein MJ, Nguyen T, Leung D, Khemani RG, Newth CJL, Bhalla AK. Body Habitus and Risk of Mortality in Pediatric Sepsis and Septic Shock: A Retrospective Cohort Study. J Pediatr 2019; 210:178-183.e2. [PMID: 31036411 DOI: 10.1016/j.jpeds.2019.03.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the association between body habitus and mortality in critically ill children with sepsis or septic shock. STUDY DESIGN This was a retrospective cohort study of prospectively collected data of children admitted to US pediatric intensive care units (PICUs) with a primary or secondary diagnosis of sepsis or septic shock. We separated body habitus into underweight, normal weight, overweight, and obese. Outcomes were mortality (primary), treatment with invasive mechanical ventilation (secondary), and time to PICU discharge for survivors (secondary). Multivariable analyses using mixed-effects logistic regression and shared frailty models clustered by unit and adjusted for confounding variables were used to assess the association between body habitus and outcomes. RESULTS There were 7038 children with sepsis or septic shock. Mortality was 10.1% (n = 714) and 52.9% (n = 3720) required invasive mechanical ventilation. Body habitus was not associated with mortality after controlling for hospital level effects and confounding variables. Children who were overweight and obese had greater odds of invasive mechanical ventilation (overweight OR 1.23 [95% CI 1.05-1.45], P = .011 and obese OR 1.57 [95% CI 1.37-1.80], P < .001) compared with children of normal weight. In survivors treated with invasive mechanical ventilation, children who were obese had a longer time to PICU discharge than children of normal weight (obese hazard ratio for discharge 0.84 [95% CI, 0.77-0.92], P < .0001). CONCLUSIONS There was no association between body habitus and mortality in critically ill children with sepsis. Children who were overweight and obese were more likely to receive invasive mechanical ventilation and mechanically ventilated survivors who were obsese had a longer time to PICU discharge.
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Affiliation(s)
- Patrick A Ross
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Margaret J Klein
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Tuan Nguyen
- Department of Pediatrics, Miller Children's and Women's Hospital of Long Beach, Long Beach, CA
| | - Dennis Leung
- Department of Pediatrics, University of North Carolina Healthcare Children's Hospital, Chapel Hill, NC
| | - Robinder G Khemani
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Christopher J L Newth
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Anoopindar K Bhalla
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
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[Overweight and clinical course in children younger than two years old hospitalized for lower respiratory tract infection]. NUTR HOSP 2019; 36:538-544. [PMID: 30958689 DOI: 10.20960/nh.2303] [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: 11/02/2022] Open
Abstract
Introduction Introduction: obesity is related to a higher morbidity and mortality in adults with respiratory infections but in children the evidence is limited. Objective: to study the association between overweight and clinical course in children younger than two years of age, hospitalized for lower respiratory tract infections (LRTI). Methods: retrospective study reviewing clinical records of children hospitalized by LRTI from 2009 to 2015. Demographic data, anthropometry, nutritional status (World Health Organization [OMS] 2006 reference) and clinical course. Results: we included 678 patients with a median age of 9.9 (range: 6.4 to 14.7) months, 55% were boys and 67% had viral pneumonia (67%). Treatment: 54.7% received basic care, 98.7% oxygen therapy, 35.4% noninvasive ventilation (NIV), 26.1% antibiotics and 47.5% corticosteroids. Regarding nutritional status, 10% had undernutrition (W/Az ≤ -1 in infants or W/Hz in the older ones), 55.2% were eutrophic and 34.8% were overweight (ME, W/Hz ≥ +1). Boys with overweight had higher frequency of viral pneumonia (75.4% vs 60.2%, p = 0.014), need for more complex care (27.7% vs 19.9%, p = 0.018) and length of NIV (4,5 [3-5.5] vs. [2-5.5] days, p = 0.007) than eutrophic. Infants had longer time of NIV than the older ones. In girls, no associations were found between nutritional status and clinical course. Conclusions: in this sample of young children hospitalized with LRTI,obesity and overweight, masculine sex and younger age were associated to worse clinical outcomes.
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Wang X, Buechler NL, Long DL, Furdui CM, Yoza BK, McCall CE, Vachharajani V. Cysteine thiol oxidation on SIRT2 regulates inflammation in obese mice with sepsis. Inflammation 2019; 42:156-169. [PMID: 30203196 DOI: 10.1007/s10753-018-0881-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Obesity increases morbidity and mortality in acute illnesses such as sepsis and septic shock. We showed previously that the early/hyper-inflammatory phase of sepsis is exaggerated in obese mice with sepsis; sirtuin 2 (SIRT2) modulates sepsis inflammation in obesity. Evidence suggests that obesity with sepsis is associated with increased oxidative stress. It is unknown whether exaggerated hyper-inflammation of obesity with sepsis modulates the SIRT2 function in return. We showed recently that SIRT6 oxidation during hyper-inflammation of sepsis modulates its glycolytic function. This study tested the hypothesis that increased oxidative stress and direct SIRT2 oxidation exaggerate hyper-inflammation in obesity with sepsis. Using spleen and liver tissue from mice with diet-induced obesity (DIO) we studied oxidized vs. total SIRT2 expression during hyper- and hypo-inflammation of sepsis. To elucidate the mechanism of SIRT2 oxidation (specific modifications of redox-sensitive cysteines) and its effect on inflammation, we performed site-directed mutations of redox-sensitive cysteines Cys221 and Cys224 on SIRT2 to serine (C221S and C224S), transfected HEK293 cells with mutants or WT SIRT2, and studied SIRT2 enzymatic activity and NFĸBp65 deacetylation. Finally, we studied the effect of SIRT2 mutation on LPS-induced inflammation using RAW 264.7 macrophages. In an inverse relationship, total SIRT2 decreased while oxidized SIRT2 expression increased during hyper-inflammation and SIRT2 was unable to deacetylate NFĸBp65 with increased oxidative stress of obesity with sepsis. Mechanistically, both the mutants (C221S and C224S) show decreased (1) SIRT2 enzymatic activity, (2) deacetylation of NFĸBp65, and (3) anti-inflammatory activity in response to LPS vs. WT SIRT2. Direct oxidation modulates SIRT2 function during hyper-inflammatory phase of obesity with sepsis via redox sensitive cysteines.
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Affiliation(s)
- Xianfeng Wang
- Department of Anesthesiology, Section on Critical Care, Department of Medicine, Section on Molecular Medicine, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Nancy L Buechler
- Department of Anesthesiology, Section on Critical Care, Department of Medicine, Section on Molecular Medicine, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.,Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - David L Long
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Cristina M Furdui
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Barbara K Yoza
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Charles E McCall
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Vidula Vachharajani
- Department of Anesthesiology, Section on Critical Care, Department of Medicine, Section on Molecular Medicine, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA. .,Department of Medicine, Section on Molecular Medicine, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.
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Body Composition and Acquired Functional Impairment in Survivors of Pediatric Critical Illness. Crit Care Med 2019; 47:e445-e453. [DOI: 10.1097/ccm.0000000000003720] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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The authors reply. Crit Care Med 2019; 45:e537-e538. [PMID: 28410326 DOI: 10.1097/ccm.0000000000002356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Association Between Tidal Volumes Adjusted for Ideal Body Weight and Outcomes in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2019; 20:e145-e153. [PMID: 30640889 PMCID: PMC6399049 DOI: 10.1097/pcc.0000000000001846] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The impact of tidal volume on outcomes in mechanically ventilated children with pediatric acute respiratory distress syndrome remains unclear. To date, observational investigations have failed to calculate tidal volume based on standardized corrections of weight. We investigated the impact of tidal volume on mortality and probability of extubation in pediatric acute respiratory distress syndrome using ideal body weight-adjusted tidal volume. DESIGN Retrospective analysis of an ongoing prospective cohort of pediatric acute respiratory distress syndrome patients. Tidal volume was calculated based on actual body weight and two different formulations of ideal body weight. SETTING PICU at a large, tertiary care children's hospital. PATIENTS Pediatric acute respiratory distress syndrome patients on conventional ventilation with a documented height or length. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 483 patients with a measured height or length at pediatric acute respiratory distress syndrome onset included in the final analysis, with 73 nonsurvivors (15%). At 24 hours, there remained 400 patients on conventional ventilation. When calculating tidal volume based on ideal body weight by either method, volumes were larger both at onset and at 24 hours compared with tidal volume based on actual body weight (all p < 0.001), and the proportion of patients being ventilated with tidal volumes greater than 10 mL/kg based on ideal body weight was larger both at onset (12.4% and 15.5%) and 24 hours (10.3% and 11.5%) compared with actual body weight at onset (3.5%) and 24 hours (4.0%) (all p < 0.001). Tidal volume, based on both actual body weight and ideal body weight, was not associated with either increased mortality or decreased probability of extubation after adjusting for oxygenation index in the whole cohort, whereas associations between higher tidal volume and poor outcomes were seen in subgroup analyses in overweight children and in severe pediatric acute respiratory distress syndrome. CONCLUSIONS Our retrospective analysis of a cohort of pediatric acute respiratory distress syndrome patients did not find a consistent association between tidal volume adjusted for ideal body weight and outcomes, although an association may exist in certain subgroups. Although it remains to be shown in a prospective trial whether high volumes or pressures are injurious in pediatric acute respiratory distress syndrome, tidal volume is likely an imprecise parameter for titrating lung-protective ventilation.
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Alipoor E, Hosseinzadeh-Attar MJ, Yaseri M, Maghsoudi-Nasab S, Jazayeri S. Association of obesity with morbidity and mortality in critically ill children: a systematic review and meta-analysis of observational studies. Int J Obes (Lond) 2019; 43:641-651. [PMID: 30705388 DOI: 10.1038/s41366-019-0319-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 12/11/2018] [Accepted: 12/14/2018] [Indexed: 12/21/2022]
Abstract
Recent studies have suggested that obesity might be protective in specific conditions such as critical illness; however, there are controversial data in critically ill children with obesity. The aim of this study was to investigate the association of obesity with mortality and other outcomes in these patients. We conducted a systematic review of observational studies investigating obesity in critically ill children, published by August 2017 in PubMed and Scopus. After screening documents, 15 articles with 142119 patients were included in the systematic review and meta-analysis. The results were reported with odds ratio (OR) or standard mean difference (SMD). The primary outcome was mortality and the secondary outcomes were length of ICU stay (ICU LOS), length of hospital stay (hospital LOS), and duration of mechanical ventilation (MV). The analysis showed that critically ill children without obesity had lower risk of mortality compared to patients with obesity (OR 0.79, 95% CI 0.64 to 0.97, P = 0.025, I2 = 35.2%). Hospital LOS was also significantly lower in children without obesity (pooled SMD -0.12, 95% CI -0.21 to -0.04, P = 0.004, I2 = 8.1%). There were no differences in ICU LOS (95% CI -0.19 to 0.01, P = 0.083) and duration of MV (95% CI -0.22 to 0.03, P = 0.136) between critically ill children with and without obesity. In conclusion, the current systematic review and meta-analysis revealed that critically ill children with obesity have higher risk of mortality and length of hospital stay compared to the group without obesity. Further prospective studies are essential to elucidate the role of obesity and underlying mechanisms in predicting outcomes of critically ill children.
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Affiliation(s)
- Elham Alipoor
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | | | - Mehdi Yaseri
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Saba Maghsoudi-Nasab
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Shima Jazayeri
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran. .,Pediatric Growth and Development Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran.
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Sharma K, Raszynski A, Totapally BR. The impact of body mass index on resource utilization and outcomes of children admitted to a pediatric intensive care unit. SAGE Open Med 2019; 7:2050312119825509. [PMID: 30719294 PMCID: PMC6348573 DOI: 10.1177/2050312119825509] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 12/31/2018] [Indexed: 12/31/2022] Open
Abstract
Introduction: Obesity is associated with poor health outcomes but may be protective in intensive care unit patients. The objective of this study is to describe the characteristics of underweight, normal weight, and obese children, and to compare their length of stay, resource utilization, and mortality. Methods: The charts of 1447 patients who were admitted to a tertiary-level pediatric intensive care unit during 1 calendar year were reviewed. Patients were divided into three groups: underweight (<5th percentile), normal (5th–95th percentiles), and obese (>95th percentile). Body mass index for age percentile was used for children older than age 2 years, and weight-for-height percentile was used for children younger than age 2 years. Demographic data, Pediatric Index of Mortality 2 score, Pediatric Index of Mortality 2 risk of mortality, hospital mortality, hospital length of stay, the use and duration of ventilator support, hemodynamic support, and dialysis were determined. Results: Fifteen percent of children were underweight, while 61.5% were normal weight and 23.5% were obese; 54.9% of the patients were male. The overall mortality was 1.87%, with no significant difference between the three weight groups. The racial distribution, prevalence, and duration of invasive and noninvasive ventilation, and the use of vasopressors, central venous lines, and dialysis were similar between three groups. Tube feeding and parenteral nutrition were used more often in the underweight group. Pediatric intensive care unit and hospital lengths of stays were higher in underweight children. Underweight children were younger when compared to normal or obese children. Pediatric Index of Mortality 2 scores and Pediatric Index of Mortality 2 risk of mortality scores were higher in underweight children. Conclusion: There were no significant differences between the three weight groups in mortality. Underweight children were younger and sicker, and received tube feeding and parenteral nutrition more frequently.
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Affiliation(s)
- Kamal Sharma
- Department of Pediatric Critical Care Medicine and Children's and Women's Hospital, University of South Alabama, Mobile, AL, USA
| | - Andre Raszynski
- Division of Critical Care Medicine, Nicklaus Children's Hospital, Miami, FL, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Balagangadhar R Totapally
- Division of Critical Care Medicine, Nicklaus Children's Hospital, Miami, FL, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
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Irving SY, Daly B, Verger J, Typpo KV, Brown AM, Hanlon A, Weiss SL, Fitzgerald JC, Nadkarni VM, Thomas NJ, Srinivasan V. The Association of Nutrition Status Expressed as Body Mass Index z Score With Outcomes in Children With Severe Sepsis: A Secondary Analysis From the Sepsis Prevalence, Outcomes, and Therapies (SPROUT) Study. Crit Care Med 2018; 46:e1029-e1039. [PMID: 30095495 PMCID: PMC6185775 DOI: 10.1097/ccm.0000000000003351] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The impact of nutrition status on outcomes in pediatric severe sepsis is unclear. We studied the association of nutrition status (expressed as body mass index z score) with outcomes in pediatric severe sepsis. DESIGN Secondary analysis of the Sepsis Prevalence, Outcomes, and Therapies study. Patient characteristics, ICU interventions, and outcomes were compared across nutrition status categories (expressed as age- and sex-adjusted body mass index z scores using World Health Organization standards). Multivariable regression models were developed to determine adjusted differences in all-cause ICU mortality and ICU length of stay by nutrition status. SETTING One-hundred twenty-eight PICUs across 26 countries. PATIENTS Children less than 18 years with severe sepsis enrolled in the Sepsis Prevalence, Outcomes, and Therapies study (n = 567). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Nutrition status data were available for 417 patients. Severe undernutrition was seen in Europe (25%), Asia (20%), South Africa (17%), and South America (10%), with severe overnutrition seen in Australia/New Zealand (17%) and North America (14%). Severe undernutrition was independently associated with all-cause ICU mortality (adjusted odds ratio, 3.0; 95% CI, 1.2-7.7; p = 0.02), whereas severe overnutrition in survivors was independently associated with longer ICU length of stay (1.6 d; p = 0.01). CONCLUSIONS There is considerable variation in nutrition status for children with severe sepsis treated across this selected network of PICUs from different geographic regions. Severe undernutrition was independently associated with higher all-cause ICU mortality in children with severe sepsis. Severe overnutrition was independently associated with greater ICU length of stay in childhood survivors of severe sepsis.
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Affiliation(s)
- Sharon Y. Irving
- University of Pennsylvania School of Nursing
- Department of Nursing, Children’s Hospital of Philadelphia
| | | | - Judy Verger
- Department of Nursing, Children’s Hospital of Philadelphia
| | - Katri V. Typpo
- Division of Critical Care Medicine, Department of Pediatrics, University of Arizona
| | - Ann-Marie Brown
- Division of Critical Care and Research Institute, Akron Children’s Hospital
| | | | - Scott L. Weiss
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania
| | - Julie C. Fitzgerald
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania
| | - Vinay M. Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania
| | - Neal J. Thomas
- Division of Pediatric Critical Care Medicine, Penn State Hershey Children’s Hospital, Penn State University College of Medicine
| | - Vijay Srinivasan
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania
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Chinese guidelines for the assessment and provision of nutrition support therapy in critically ill children. World J Pediatr 2018; 14:419-428. [PMID: 30155618 DOI: 10.1007/s12519-018-0175-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND This document represents the first evidence-based guidelines to describe best practices in nutrition therapy in critically ill children (> 1 month and < 18 years), who are expected to require a length of stay more than 2 or 3 days in a Pediatric Intensive Care Unit admitting medical patients domain. METHODS A total of 25,673 articles were scanned for relevance. After careful review, 88 studies appeared to answer the pre-identified questions for the guidelines. We used the grading of recommendations, assessment, development and evaluation criteria to adjust the evidence grade based on the quality of design and execution of each study. RESULTS The guidelines emphasise the importance of nutritional assessment, particularly the detection of malnourished patients. Indirect calorimetry (IC) is recommended to estimate energy expenditure and there is a creative value in energy expenditure, 50 kcal/kg/day for children aged 1-8 years during acute phase if IC is unfeasible. Enteral nutrition (EN) and early enteral nutrition remain the preferred routes for nutrient delivery. A minimum protein intake of 1.5 g/kg/day is suggested for this patient population. The role of supplemental parenteral nutrition (PN) has been highlighted in patients with low nutritional risk, and a delayed approach appears to be beneficial in this group of patients. Immune-enhancing cannot be currently recommended neither in EN nor PN. CONCLUSION Overall, the pediatric critically ill population is heterogeneous, and an individualized nutrition support with the aim of improving clinical outcomes is necessary and important.
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Justice L, Buckley JR, Floh A, Horsley M, Alten J, Anand V, Schwartz SM. Nutrition Considerations in the Pediatric Cardiac Intensive Care Unit Patient. World J Pediatr Congenit Heart Surg 2018; 9:333-343. [PMID: 29692230 DOI: 10.1177/2150135118765881] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Adequate caloric intake plays a vital role in the course of illness and the recovery of critically ill patients. Nutritional status and nutrient delivery during critical illness have been linked to clinical outcomes such as mortality, incidence of infection, and length of stay. However, feeding practices with critically ill pediatric patients after cardiac surgery are variable. The Pediatric Cardiac Intensive Care Society sought to provide an expert review on provision of nutrition to pediatric cardiac intensive care patients, including caloric requirements, practical considerations for providing nutrition, safety of enteral nutrition in controversial populations, feeding considerations with chylothorax, and the benefits of feeding beyond nutrition. This article addresses these areas of concern and controversy.
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Affiliation(s)
- Lindsey Justice
- 1 The Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | | | - Alejandro Floh
- 3 The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Megan Horsley
- 1 The Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Jeffrey Alten
- 1 The Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Vijay Anand
- 4 Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,5 Pediatric Cardiac Intensive Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Steven M Schwartz
- 3 The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
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Kim GJ, Newth CJL, Khemani RG, Wong SL, Coates AL, Ross PA. Does Size Matter When Calculating the "Correct" Tidal Volume for Pediatric Mechanical Ventilation?: A Hypothesis Based on FVC. Chest 2018; 154:77-83. [PMID: 29684318 DOI: 10.1016/j.chest.2018.04.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/06/2018] [Accepted: 04/02/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Tidal volumes standardized to predicted body weight are recommended for adult mechanical ventilation, but children are frequently ventilated by using measured body weight. The goal of this study was to examine the difference in FVC (in milliliters per kilogram [mL/kg]) by using measured body weight compared with predicted body weight in children. METHODS This retrospective analysis included outpatient pulmonary function tests (PFTs) from two datasets. Dataset one included 6- to 19-year-old patients undergoing PFTs from the nationally representative Canadian Health Measures Survey. Dataset two included 6- to 20-year-old patients undergoing PFTs at a freestanding children's hospital. FVC mL/kg values were analyzed against BMI z scores to show changes in FVC vs BMI between measured and predicted weight. RESULTS Dataset one included 5,394 PFTs from the Canadian survey. FVC from measured weight decreased as the BMI z score group increased. The median FVC from measured weight was 81.4 mL/kg in the lowest BMI z score group and 51.7 mL/kg in the highest BMI z score group. FVC from predicted weight increased slightly with increasing BMI z score group. Dataset two included 8,472 patient PFTs from clinical measurement. A decline in median FVC from measured weight (from 69.4 to 37.6 mL/kg) as BMI z score group increased was also seen. CONCLUSIONS FVC differs significantly when standardizing to measured weight vs predicted weight. Obese children have lung volumes reflecting their predicted body weight from height. Children with low or normal BMI have lung volumes reflecting measured body weight. These findings suggest that targeting tidal volume by using the lower of measured and predicted body weights would be the most lung-protective strategy.
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Affiliation(s)
- Gina J Kim
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Christopher J L Newth
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Robinder G Khemani
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Suzy L Wong
- Health Analysis Division, Statistics Canada, Ottawa, ON, Canada
| | - Allan L Coates
- Division of Respiratory Medicine and Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Patrick A Ross
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA.
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Ye S, Zhang Y, Zhang C, Xu D. Are platelet volume indices related to mortality in hospitalized children on mechanical ventilation? J Int Med Res 2018; 46:1197-1208. [PMID: 29322854 PMCID: PMC5972253 DOI: 10.1177/0300060517737211] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objectives To investigate platelet volume indices and in-hospital mortality in children on mechanical ventilation. Methods This retrospective study included children aged <16 years on mechanical ventilation, and compared parameters, measured on admission, between survivors and non-survivors. Dynamic platelet volume indices over the first 7 days were visualized. Independent risk factors of mortality were identified using multivariate logistic regression analysis. Results Out of 2 319 children aged 28 days–3 years, serum albumin (odds ratio [OR] 0.9, 95% confidence interval [CI] 0.85, 0.96), bilirubin (OR 1.01, 95% CI 1.0, 1.77), and lactic acid (OR 1.22, 95% CI 1.05, 1.38) levels were associated with mortality. Out of 2 415 children aged > 3 years, procalcitonin (OR 1.01, 95% CI 1.0, 1.01) and lactic acid (OR 1.22, 95% CI 1.09, 1.35) were associated with mortality. Platelet volume indices on admission were not independently associated with mortality in either group. Mean platelet volume (MPV) and platelet distribution width (PDW) showed different trends in non-survivors versus survivors over 1 week in both age groups. Conclusions Platelet volume indices may be associated with mortality in critically ill children receiving mechanical ventilation.
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Affiliation(s)
- Sheng Ye
- 1 Pediatric Intensive Care Unit, 37066 The Children's Hospital, Zhejiang University School of Medicine , Hangzhou, China
| | - Yanyi Zhang
- 2 Psychological Department, 37066 The Children's Hospital, Zhejiang University School of Medicine , Hangzhou, China
| | - Chenmei Zhang
- 1 Pediatric Intensive Care Unit, 37066 The Children's Hospital, Zhejiang University School of Medicine , Hangzhou, China
| | - Dan Xu
- 1 Pediatric Intensive Care Unit, 37066 The Children's Hospital, Zhejiang University School of Medicine , Hangzhou, China
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Anton-Martin P, Papacostas M, Lee E, Nakonezny PA, Green ML. Underweight Status Is an Independent Predictor of In-Hospital Mortality in Pediatric Patients on Extracorporeal Membrane Oxygenation. JPEN J Parenter Enteral Nutr 2018; 42:104-111. [PMID: 29505139 DOI: 10.1177/0148607116673185] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 09/06/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Malnutrition is associated with an increased risk of mortality in patients admitted to the intensive care unit. Children requiring extracorporeal membrane oxygenation (ECMO) support represent an extremely ill subset of this population. There is a lack of data on the impact of nutrition state on survival in this cohort. We examined the association between being underweight and in-hospital mortality among children supported with ECMO. MATERIALS AND METHODS This article reports on an observational retrospective cohort study performed among neonatal and pediatric patients supported with ECMO in a tertiary children's hospital from May 1996 through June 2013. Nutrition status on intensive care unit admission was defined with z scores on weight for length and body mass index. RESULTS Patients (N = 491) had a median age of 31 days (interquartile range, 2-771): 24.4% were underweight, and 8.9% were obese. During ECMO support, 88.3% received total parenteral nutrition, and 30.3% received enteral nutrition. Median maximum energy intake while receiving ECMO was 82 kcal/kg/d (interquartile range, 54.7-105). Multiple logistic regression showed that underweight status was associated with increased predicted odds of in-hospital mortality when compared with normal weight (odds ratio: 1.99, 95% confidence interval: 1.21-3.25, P = .006). Other factors associated with increased odds of mortality included extracorporeal cardiopulmonary resuscitation and the need for continuous renal replacement therapy. CONCLUSION Underweight status was an independent predictor for in-hospital mortality in our cohort of pediatric ECMO patients. Prospective studies evaluating the impact of metabolic state of children on ECMO should further define this relationship.
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Affiliation(s)
- Pilar Anton-Martin
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Papacostas
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elisabeth Lee
- Department of Clinical Nutrition, Children's Medical Center Dallas, Dallas, Texas
| | - Paul A Nakonezny
- Division of Biostatistics, Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael L Green
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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Rasouli MA, Newth CJL, Khemani RG, Ross PA. Predicting Body Height in a Pediatric Intensive Care Unit Using Ulnar Length. Front Pediatr 2018; 6:187. [PMID: 30035103 PMCID: PMC6023995 DOI: 10.3389/fped.2018.00187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/06/2018] [Indexed: 11/13/2022] Open
Abstract
Objective: To determine if ulnar length obtained by the bedside nurse can be used to estimate patient length. To compare our findings to previous predictive equations of height and ulnar length. To evaluate the performance of predictive equations for height and ulnar length on patients with syndromes that affect height. Design: Retrospective observational study of prospectively collected data. Settings: Multidisciplinary Pediatric Intensive Care Unit in a university teaching hospital. Patients: 1,177 patients, ages 1 month to 23 years. Mean age was 79.7 months (1,3 IQR 19.5, 164.5 months) and 55.4% male. Measurements: Ulnar length was obtained using digital calipers by bedside nurses in PICU as well as height and weight. The electronic health care record was used to extract patient information. Main Results: The predictive equation for height for the entire group is: height (cm) = 0.59*ulnar length (mm) + 13.1 (r2 = 0.93). Bland Altman analysis of the derivation formula applied to the testing group did not show any systematic bias. Conclusions: Our study shows that ulnar length measurements can be used to predict height with a simple linear formula in a PICU setting. Not having specific individuals or specific training for ulnar measurement did not seem to alter the accuracy (r2 = 0.93). The robust nature of the measurement and ease of use may make this an unconventional but reasonable alternative to obtaining height when that cannot be measured directly.
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Affiliation(s)
- Melody A Rasouli
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Christopher J L Newth
- Children's Hospital Los Angeles, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Robinder G Khemani
- Children's Hospital Los Angeles, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Patrick A Ross
- Children's Hospital Los Angeles, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
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Abstract
OBJECTIVES Pediatric obesity is highly prevalent and has been associated with poor outcomes for hospitalized children. Vascular access is essential in critically ill patients. The aim of this study was to evaluate whether critically ill children with obesity are more likely to undergo vascular device insertion (excluding peripheral IV catheters) and develop related complications. DESIGN Multi-institutional retrospective observational cohort study. SETTING Ninety-four U.S. PICUs included in the Virtual Pediatric Systems, LLC database. PATIENTS 120,272 unique patients 2 to less than 18 years old admitted between January 2009 and December 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were categorized into normal weight, overweight, and obese (class 1, 2, or 3); underweight patients were excluded. We used mixed-effects multivariable logistic regression to test body mass index category as an independent predictor of vascular device placement and associated complications, adjusted for age, sex, severity of illness, primary diagnosis, presence of a complex chronic condition, and admission related to trauma or surgery. A total of 73,964 devices were placed in 45,409 patients (37.8% of the total cohort received a vascular device). Most device types placed differed significantly by weight status. Subjects with class 3 obesity were less likely (odds ratio, 0.74; 95% CI, 0.67-0.81) to undergo placement of any device compared with normal weight patients. Patients with all classes of obesity were more likely to undergo placement of a peripherally inserted central catheter, with the strongest association in those with class 2 obesity (odds ratio, 1.26; 95% CI, 1.14-1.40). Class 1 and class 3 obesity were independent risk factors for developing a complication, with odds ratio of 1.31 (95% CI, 1.11-1.53) and 1.45 (95% CI, 1.07-1.99), respectively. CONCLUSIONS Severe obesity is associated with decreased overall likelihood of placement of a vascular access device but increased likelihood of peripherally inserted central catheter placement and of device-related complications.
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