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

Comparison of radiologic findings between SARS-CoV-2 and other respiratory tract viruses in critically ill children during the COVID-19 pandemic

Background/aim

This study was planned because the radiological distinction of COVID-19 and respiratory viral panel (RVP)-positive cases is necessary to prioritize intensive care needs and ensure non-COVID-19 cases are not overlooked. With that purpose, the objective of this study was to compare radiologic findings between SARS-CoV-2 and other respiratory airway viruses in critically ill children with suspected COVID-19 disease.

Materials and methods

This study was conducted as a multicenter, retrospective, observational, and cohort study in 24 pediatric intensive care units between March 1 and May 31, 2020. SARS-CoV-2- or RVP polymerase chain reaction (PCR)-positive patients' chest X-ray and thoracic computed tomography (CT) findings were evaluated blindly by pediatric radiologists.

Results

We enrolled 225 patients in the study, 81 of whom tested positive for Coronovirus disease-19 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The median age of all patients was 24 (7-96) months, while it was 96 (17-156) months for COVID-19-positive patients and 17 (6-48) months for positive for other RVP factor (p < 0.001). Chest X-rays were more frequently evaluated as normal in patients with SARS-CoV-2 positive results (p = 0.020). Unilateral segmental or lobar consolidation was observed more frequently on chest X-rays in rhinovirus cases than in other groups (p = 0.038). CT imaging findings of bilateral peribronchial thickening and/or peribronchial opacity were more frequently observed in RVP-positive patients (p = 0.046).

Conclusion

Chest X-ray and CT findings in COVID-19 patients are not specific and can be seen in other respiratory virus infections.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPACT

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

A nomogram to predict 28-day mortality in neonates with sepsis: a retrospective study based on the MIMIC-III database

Background

Sepsis is the second-leading cause of death in neonates. We established a predictive nomogram to identify critically ill neonates early and reduce the time to treatment.

Methods

It is a retrospective case-control study based on the MIMIC-III database. The study population comprised 924 neonates diagnosed with sepsis.

Results

Neonates with sepsis included in the MIMIC-III database were enrolled, including 880 surviving neonates and 44 neonates who died. In the derivation dataset, stepwise regression and the Lasso algorithm were employed to select predictive variables, and the neonatal sequential organ failure assessment score (nSOFA) was calculated simultaneously. Bootstrap resampling was utilized to perform internal validation. The results indicated that the Lasso algorithm displayed superior discrimination, sensitivity, and specificity relative to stepwise regression and nSOFA scores. After 500 bootstrap resampling tests, the area under the receiver operating characteristic curve (AUC) of the Lasso algorithm was 0.912 (95% CI: 0.870-0.977). The nomogram based on the Lasso algorithm outperformed stepwise regression and nSOFA scores in terms of calibration and the clinical net benefit. This nomogram can assist in prognosticating neonatal severe sepsis and aid in guiding clinical practice while concurrently improving patient outcomes.

Conclusions

The established nomogram revealed that jaundice, corticosteroid use, weight, serum calcium, inotropes and base excess are all important predictors of 28-day mortality in neonates with sepsis. This nomogram can facilitate the early identification of neonates with severe sepsis. However, it still requires further modification and external validation to make it widely available.

Prediction of urinary dickkopf-3 for AKI, sepsis-associated AKI, and PICU mortality in children

BACKGROUND

Preoperative urinary dickkopf-3 (DKK3) is proposed as an early biomarker for the prediction of acute kidney injury (AKI) in patients undergoing cardiac surgery. We explored the clinical utility of urinary DKK3 for the early predictive value for AKI, sepsis-associated AKI (SA-AKI), and pediatric intensive care unit (PICU) mortality in critically ill children.

METHODS

Urine samples were collected during the first 24 h after admission for measurement of DKK3. AKI diagnosis was based on serum creatinine and urine output using the KDIGO criteria. SA-AKI was defined as AKI that occurred in children who met the sepsis criteria in accordance with the surviving sepsis campaign international guidelines for children.

RESULTS

Of the 420 children, 73 developed AKI, including 24 with SA-AKI, and 30 died during the PICU stay. The urinary DKK3 level was significantly associated with AKI, SA-AKI, and PICU mortality, even after adjustment for confounders. The area under the receiver operating characteristic curve of urinary DKK3 for the discrimination of AKI, SA-AKI, and PICU mortality was 0.70, 0.80, and 0.78, respectively.

CONCLUSION

Urinary DKK3 was independently associated with an increased risk for AKI, SA-AKI, and PICU mortality and may be predictive of the aforementioned issues in critically ill children.

IMPACT

Urinary dickkopf-3 (DKK3) has been identified as a preoperative biomarker for the prediction of acute kidney injury (AKI) following cardiac surgery or coronary angiography in adult patients. However, little is known about the clinical utility of urinary DKK3 in pediatric cohorts. This study demonstrated that urinary DKK3 is capable of early predicting AKI and pediatric intensive care unit (PICU) mortality and discriminating sepsis-associated AKI (SA-AKI) from other types of AKI. Urinary DKK3 may be an early biomarker for predicting AKI, SA-AKI, and PICU mortality in critically ill children.

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

The Use of Bioelectrical Impedance Analysis Measures for Predicting Clinical Outcomes in Critically Ill Children

Background

The study aimed to investigate the association of bioelectrical impedance analysis (BIA) for predicting clinical outcomes in critically ill children.

Methods

This single-center prospective observational study included patients admitted to a mixed Pediatric Intensive Care Unit (PICU). All patients underwent anthropometric measurement and BIA measurements in the first 24 h of admission. The patients were classified into different groups based on body mass index (BMI) for age. Electronic hospital medical records were reviewed to collect clinical data for each patient. All the obtained data were analyzed by the statistical methods.

Results

There were 231 patients enrolled in our study, of which 31.6% were diagnosed with malnutrition. The phase angle (PhA) of 90-day survivors was significantly higher than that of the non-survivors (4.3° ± 1.1°vs. 3.1° ± 0.9°, P = 0.02). The age-adjusted Spearman partial correlation analysis showed a weak negative correlation between PhA and duration of medical ventilation (r_s = -0.42, P < 0.05). Furthermore, length of stay in PICU has a very weak correlation with ECW/TBW (r_s = 0.29, P < 0.05), and a negative correlation with protein (r_s = -0.27, P < 0.05). Multivariate analysis found that PhA was a significant predictor associated with the 90-day mortality when it was adjusted for PRISM III score (adjusted OR = 1.51, CI: 1.10–2.07, p = 0.01). The area under the ROC (AUROC) of PhA for predicting 90-day mortality was 0.69 (95% CI: 0.53–0.85, p < 0.05), and the cutoff value of PhA was 3.0°, with a sensitivity and specificity of 83 and 53%, respectively.

Conclusion

BIA-derived PhA was found to be an independent predictor of 90-day mortality among critically ill children. A low PhA was associated with a prolonged duration of medical ventilation.