Mortality patterns among critically ill children in a Pediatric Intensive Care Unit of a developing country

Addressing 10 Myths About Pediatric Palliative Care

With advances in biomedical sciences, a growing number of conditions affecting children have evolved from being considered life-limiting to almost chronic diseases. However, improvements in survival rates often come at a cost of increased medical complexity and lengthy hospitalizations, which can be associated with a poorer quality of life. This is where pediatric palliative care (PPC) can play a significant role. PPC is a specialty of healthcare that focuses on the prevention and relief of suffering in children with serious conditions. Unfortunately, despite the well-identified need for PPC services across pediatric specialties, multiple misconceptions persist. Common myths about palliative care are identified and deconstructed in light of the most recent evidenced-based references in the field to provide guidance to healthcare providers to address these. PPC is often associated with end-of-life care, loss of hope, and cancer. Some healthcare providers and parents also believe that information like diagnosis should be withheld from children for their emotional protection. These examples of misconceptions hinder the integration of pediatric palliative care and its additional layer of support and clinical expertise. PPC providers have advanced communication skills, are able to instill hope in the face of uncertainty, are trained to initiate and implement individualized pain and symptom management plans, and understand how to improve the quality of life in children with serious illnesses. Improved awareness about the scope of PPC is needed to ensure that children benefit from the maximum expertise and support throughout their complex health trajectories.

Incidence and Mortality Trends in Critically Ill Children: A Korean Population-Based Study

BACKGROUND

Monitoring mortality trends can help design ways to improve survival, but observation of national mortality trends in critically ill children is lacking for the Korean population.

METHODS

We analyzed the incidence and mortality trends of children younger than 18 years admitted to an intensive care unit (ICU) from 2012 to 2018 using the Korean National Health Insurance database. Neonates and neonatal ICU admissions were excluded. Multivariable logistic regression analyses were performed to estimate the odds ratio of in-hospital mortality according to admission year. Trends in incidence and in-hospital mortality of subgroups according to admission department, age, presence of intensivists, admissions to pediatric ICU, mechanical ventilation, and use of vasopressors were evaluated.

RESULTS

The overall mortality of critically ill children was 4.4%. There was a significant decrease in mortality from 5.5% in 2012 to 4.1% in 2018 (P for trend < 0.001). The incidence of ICU admission in children remained around 8.5/10,000 population years (P for trend = 0.069). In-hospital mortality decreased by 9.2% yearly in adjusted analysis (P < 0.001). The presence of dedicated intensivists (P for trend < 0.001, mortality decrease from 5.7% to 4.0%) and admission to pediatric ICU (P for trend < 0.001, mortality decrease from 5.0% to 3.2%) were associated with significant decreasing trends in mortality.

CONCLUSION

Mortality among critically ill children improved during the study period, and the improving trend was prominent in children with high treatment requirements. Varying mortality trends, according to ICU organizations, highlight that advances in medical knowledge should be supported structurally.

Descriptive and Clinical Characteristics of Nonsurvivors in a Tertiary Pediatric Intensive Care Unit in Turkey: 6 Years of Experience

The objective of this study was to identify the characteristics of nonsurvivors in a pediatric intensive care unit (PICU) in Turkey. This is a retrospective analysis of patients who died in a tertiary PICU over a 6-year period from 2016 to 2021. Data were drawn from electronic medical records and resuscitation notes. Mode of death was categorized as failed cardiopulmonary resuscitation (F-CPR) or brain death. Among the 161 deaths, 136 nonsurvivors were included and 30.1% were younger than 1 year. Severe pneumonia, respiratory failure, and acute respiratory distress syndrome (ARDS) (31.6%) were the most common primary diagnoses. The most common mode of death was F-CPR (86.8%). More than half of the subjects had been admitted from pediatric emergency departments (58.1%), and more than half (53.7%) had died within 7 days in the PICU. Patients admitted from pediatric emergency departments had the lowest frequency of comorbidities (p < 0.001). Severe pneumonia, respiratory failure, and ARDS diagnoses were significantly more frequent in those who died after 7 days (p < 0.001), whereas septicemia, shock, and multiple organ dysfunction were more common among those who died within the first day of PICU admission (p < 0.001). It may be important to note that patients referred from wards are highly likely to have comorbidities, while those referred from pediatric emergency departments may be relatively younger. Additionally, patients with septicemia, shock, or multiple organ dysfunction were more likely to die earlier (within 7 days), especially compared with those with severe pneumonia, respiratory failure, or ARDS.

Acute kidney injury following multisystem inflammatory syndrome associated with SARS-CoV-2 infection in children: a systematic review and meta-analysis

INTRODUCTION

Multisystem inflammatory syndrome (MIS-C) is a rare paediatric hyper-inflammatory disorder that occurs following SARS-CoV-2 infection. Acute kidney injury (AKI) occurs in approximately one-quarter to one-third of the patients with MIS-C and is associated with poor prognosis in critically ill children. This systematic review is aimed to evaluate the incidence of AKI, mortality, and the need for kidney replacement therapy (KRT) in patients with MIS-C.

METHODS

We searched databases from Medline, EMBASE, Cochrane Register, and Google Scholar from December 2019 to December 2021 with our search strategy. Studies meeting the following criteria were included in this systematic review: (1) articles on AKI in MIS-C; (2) studies providing AKI in MIS-C and COVID-19 infection separately; (3) studies reporting outcomes such as mortality, KRT, serum creatinine; length of hospital/ICU stay.

QUALITY ASSESSMENT

The quality of the included studies was independently assessed by using the National Heart Lung and Blood Institute (NHLBI) quality assessment tool for cohort studies and case series.

STATISTICAL ANALYSIS

Outcomes and their 95% confidence intervals (CI) were reported if a meta-analysis of these outcomes was conducted. Heterogeneity was reported using I² statistics, and heterogeneity ≥ 50% was considered high. We used Baujat's plot for the contribution of each study toward overall heterogeneity. In sensitivity analysis, the summary estimates were assessed by repeating meta-analysis after omitting one study at a time. Forest plots were used for reporting outcomes in each study and with their 95% CI. All statistical tests were performed using R software version 4.0.3.

RESULTS

A total of 24 studies were included in this systematic review and of these, 11 were included in the meta-analysis. The pooled proportion of patients with MIS-C developing AKI was 20% (95% CI: 14-28%, I² = 80%). Pooled proportion of death in children with MIS-C was 4% (95% CI: 1-14%; I² = 93%). The odds of death in patients with AKI were 4.68 times higher than in patients without AKI (95% CI: 1.06-20.7%; I² = 17%). The overall pooled proportion of MIS-C-induced AKI patients requiring KRT was 15% (95% CI: 4-42%; I² = 91%).

CONCLUSION

Approximately one-fifth of children with MIS-C develop AKI which is associated with higher odds of death. PROSPERO registration: CRD42022306170 A higher resolution version of the Graphical abstract is available as Supplementary information.

Admission Pattern and Treatment Outcome in Pediatric Intensive Care Unit, Tertiary Hospital, Addis Ababa, Ethiopia

BACKGROUND

Knowledge of the clinical profile and outcomes of critically ill children admitted to Pediatric Intensive Care Unit (PICU) in developing countries aids with the identification of priorities and the resources needed to improve the outcome of critically ill patients. This study aimed to assess the admission pattern, outcomes, and associated factors of patients admitted to the PICU of St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.

METHODS

Institutional-based cross-sectional study was done. Data was collected through chart abstraction from patients admitted to the PICU between January 2017 and December 2018. SPSS 20.0 was used to analyze the data. Descriptive statistics, cross-tabulations, and logistic regressions were used.

RESULTS

A total of 260 pediatric patients were analyzed. The mean age at admission was 48.13 ± 53.65 months, with M: F ratio of 1.4:1. The mean and median duration of PICU stay was 7.26 ±6.87 days, and 6.0 days respectively. The most commonly affected organ systems were the central nervous system (79, 33.2%) and respiratory system (55, 23.1%). Mechanical ventilation and admission after cardiopulmonary resuscitation (p < 0.001) were independent predictors of mortality. Infectious causes of illnesses were the leading causes of admission and death in the PICU.

CONCLUSION

The mortality rate of our PICU was 21.1 %. In this study, post-cardiopulmonary resuscitation admission and use of mechanical ventilation were statistically significant predictors of mortality indicating the need for well equipping and staffing the PICU to improve the outcome of such critically sick patients.

Is this as good as it gets? Implications of an asymptotic mortality decline and approaching the nadir in pediatric intensive care

Despite advances in medicine, some children will always die; a decline in pediatric intensive care unit (PICU) mortality to zero will never be achieved. The mortality decline is correspondingly asymptotic, yet we remain preoccupied with mortality outcomes. Are we at the nadir, and are we, thus, as good as we can get? And what should we focus to benchmark our units, if not mortality? In the face of changing case-mix and rising complexity, dramatic reductions in PICU mortality have been observed globally. At the same time, survivors have increasing disability, and deaths are often characterized by intensive life-sustaining therapies preceded by prolonged admissions, emphasizing the need to consider alternate outcome measures to evaluate our successes and failures. What are the costs and implications of reaching this nadir in mortality outcomes? We highlight the failings of our fixation with survival and an imperative to consider alternative outcomes in our PICUs, including the costs for both patients that survive and die, their families, healthcare providers, and society including perspectives in low resource settings. We describe the implications for benchmarking, research, and training the next generation of providers.Conlusion: Although survival remains a highly relevant metric, as PICUs continue to strive for clinical excellence, pushing boundaries in research and innovation, with endeavors in safety, quality, and high-reliability systems, we must prioritize outcomes beyond mortality, evaluate "costs" beyond economics, and find novel ways to improve the care we provide to all of our pediatric patients and their families. What is Known: • The fall in PICU mortality is asymptotic, and a decline to zero is not achievable. Approaching the nadir, we challenge readers to consider implications of focusing on medical and technological advances with survival as the sole outcome of interest. What is New: • Our fixation with survival has costs for patients, families, staff, and society. In the changing PICU landscape, we advocate to pivot towards alternate outcome metrics. • By considering the implications for benchmarking, research, and training, we may better care for patients and families, educate trainees, and expand what it means to succeed in the PICU.

All-cause mortality in a pediatric intensive care unit at a teaching hospital in Amman, Jordan

BACKGROUND

The aim of this study was to describe the main causes of admission to a general pediatric intensive care unit (PICU), and examine the main causes of mortality in this patient population. In addition, we describe the percentage of patients who died following a failed cardiopulmonary resuscitation (CPR) versus do not resuscitate (DNR) orders.

METHODS

This was a retrospective, cohort study with a chart review of admissions and mortality cases that occurred in the PICU. Mortality rates in pediatric admissions are reported with a description of demographics, diagnosis, length of stay, use of mechanical ventilation, use of vasoactive agents, preexisting comorbidities, the presence of a DNR order, and final cause of mortality. Modes of mortality were described as failed CPR or a DNR order.

RESULTS

During the study period there were 1,523 admissions to the PICU. Of those, 102 patients died with an overall mortality rate of 6.7%. Patients who died tended to be younger, and the majority (85%) had a preexisting comorbidity, with neuromuscular disease being the most common. The majority of the patients who died (69%) required invasive ventilation. The most common immediate cause of mortality was respiratory disease and the highest case fatality was among those with cardiac disease. Of those patients who died, 90% had failed CPR and 10% had a DNR order. Care was not withdrawn from any patient.

CONCLUSION

This study describes the diagnostic categories of children admitted to the PICU, with respiratory disease being the most common cause of admission and mortality. The majority of children who died had an existing comorbidity and did not have a DNR order at the time of their death.

The Utility of Bedside Assessment Tools and Associated Factors to Avoid Antibiotic Overuse in an Urban PICU of a Diarrheal Disease Hospital in Bangladesh

BACKGROUND

Antibiotic exposure in the pediatric intensive care unit (PICU) is very high, although 50% of all antibiotics may be unnecessary. We aimed to determine the utility of simple bedside screening tools and predicting factors to avoid antibiotic overuse in the ICU among children with diarrhea and critical illness.

METHODS

We conducted a retrospective, single-center, case-control study that included children aged 2-59 months who were admitted to PICU with diarrhea and critical illness between 2017 and 2020.

RESULTS

We compared young children who did not receive antibiotics (cases, n = 164) during ICU stay to those treated with antibiotics (controls, n = 346). For predicting the 'no antibiotic approach', the sensitivity of a negative quick Sequential Organ Failure Assessment (qSOFA) was similar to quick Pediatric Logistic Organ Dysfunction-2 (qPELOD-2) and higher than Systemic Inflammatory Response Syndrome (SIRS). A negative qSOFA or qPELOD-2 score calculated during PICU admission is superior to SIRS to avoid antibiotic overuse in under-five children. The logistic regression analysis revealed that cases were more often older and independently associated with hypernatremia. Cases less often had severe underweight, altered mentation, age-specific fast breathing, lower chest wall in-drawing, adventitious sound on lung auscultation, abdominal distension, developmental delay, hyponatremia, hypocalcemia, and microscopic evidence of invasive diarrhea (for all, p < 0.05).

CONCLUSION

Antibiotic overuse could be evaded in PICU using simple bedside screening tools and clinical characteristics, particularly in poor resource settings among children with diarrhea.

[Mortality pattern in children aged 3-59 months hospitalized in the Intensive Care Unit at a Paediatric Center in Yaounde-Cameroon]

Introduction

le risque de décès serait élevé dans les unités des soins intensifs (USI) des pays en développement. Nous décrivons les décès survenus à l’Unité des Soins Intensifs du Centre Mère et Enfant de Yaoundé au Cameroun.

Méthodes

étude rétrospective portant sur les caractéristiques cliniques, sociodémographiques, l’itinéraire thérapeutique ainsi que certains facteurs associés aux décès survenus entre 2010 et 2014 chez 200 patients âgés de 3-59 mois.

Résultats

sur 2675 patients admis, 1807 étaient âgés de 3 à 59 mois et 303 sont décédés. Les taux de mortalité global et spécifique à cette tranche d’âge étaient de 11,3% et de 16,7% respectivement. La plupart (152/200 soit 76,0%) décédait à moins de 24 mois et le délai médian de leur admission était de 7 jours. Plus de la moitié (57,0%) avait recouru à un centre de santé et seuls 66 (33,0%) avaient bénéficié d’une référence. Le paludisme grave (41,5%), la pneumonie (22,7%) et la gastroentérite (27,8%) étaient les pathologies les plus incriminées. La malnutrition et le VIH/Sida constituaient les causes sous-jacentes de décès chez 23,0% et 20,5% de sujets respectivement. La présence de la gastroentérite multipliait le risque de décès d’environ 6 fois (OR = 5,76; P = 0,000) lorsque la malnutrition et l’infection à VIH étaient présentes. Les décès survenaient majoritairement (90,0%) dans les 72 heures d’admission.

Conclusion

certaines pathologies auraient pu être traitées avec des moyens simples afin d’éviter les complications nécessitant une réanimation dans un contexte à ressources limitées. Il est crucial d’intensifier la lutte contre le paludisme, l’infection à VIH et la malnutrition.

Drug-Induced Liver Injury in Critically Ill Children Taking Antiepileptic Drugs: A Retrospective Study

•

Critically ill children on anti-epileptic drugs often receive multiple concomitant drugs with potential to result in liver injury.

•

Antimicrobial drugs followed by drugs for stress ulcer prophylaxis form the major drug classes with the risk of DILI that are concomitantly administered with anti-epileptic drugs in critically ill children.

Background

Antiepileptic drugs are among the leading causes of drug-induced liver injury (DILI). Due to critical illness, children admitted to intensive care units are more prone to DILI.

Objective

We attempted to elucidate the association between antiepileptic drug use and the associated factors resulting in DILI in a pediatric intensive care unit of a tertiary care hospital.

Methods

We carried out an observational retrospective study on children receiving antiepileptic drugs. Details on their demographic characteristics, drugs, serum levels of antiepileptic drugs and liver function tests, and hospital stay were recorded. Council for International Organizations of Medical Sciences definitions were adhered to when defining DILI. LiverTox (https://livertox.nih.gov) and DILIrank were used to assess the risks of hepatotoxicity of the concomitant drugs. Regression models were developed for predicting DILI.

Results

Five out of 9 patients taking phenobarbitone (55.6%), 9 out of 12 taking phenytoin monotherapy (75%), 7 out of 10 taking phenytoin/phenobarbitone (70%), all 3 receiving phenytoin/phenobarbitone/valproate sodium, and 1 with phenytoin/carbamazepine developed DILI either in the form of hepatocellular injury or liver biochemical test abnormalities. None of the patients had cholestatic or mixed type of liver injury. All the critically ill children received at least 2 concomitant drugs with hepatotoxic potential. Concomitant category B hepatotoxic drugs and toxic drug levels were significantly associated with increased risk of DILI. Similarly, a trend was observed for less-DILI-concern concomitant drug class and toxic drug levels when the drugs were analyzed by DILIrank classification.

Conclusions

A significant proportion of critically ill children taking antiepileptic drugs experience DILI. Guidelines recommending use of drugs with reduced risk of potential hepatotoxicity for various concomitant disease states in such children admitted to intensive care units receiving antiepileptic drugs are urgently needed.

Pediatricians' Perceptions Toward Do Not Resuscitate: A Survey in Saudi Arabia and Literature Review

OBJECTIVE

To explore the pediatricians' attitudes and perceptions toward do-not-resuscitate (DNR) orders in a specific region of the world not fully explored before.

METHODS

A cross-sectional study was conducted between March 4 and May 30, 2018. Pediatricians from three public hospitals in the city of Riyadh were asked to respond to a questionnaire consisting of 22 questions designed to meet the objectives of our study.

RESULTS

A total of 203 pediatricians (51.2% female) completed the questionnaire, both junior pediatricians (JPs) and senior pediatricians (SPs). A majority (58.9% of JPs and 61.4% of SPs) thought patients have the right to demand intensive care, despite their terminal illness. Half the participants in both groups thought that DNR is a physician's decision. Only 9.3% of JPs and 12.5% of SPs felt comfortable discussing DNR with patients/families. Medical school was also a source of knowledge on DNR issues, mainly for JPs (40.2% of JPs vs 20.8% of SPs, P=0.005). Half the participants felt that DNR is consistent with Islamic beliefs, while 57.9% of JPs vs 41.7% of SPs felt they are legally protected. Hospital policy was clear to 48.6% of JPs vs 66.7% of SPs, while procedure was clear to 35.5% of JPs vs 49% of SPs.

CONCLUSION

Several factors are present that may hinder DNR implementation, such as doubts concerning being legally protected, doubts concerning consistency with Islamic sharia, unclear policies and procedures, and lack of training and orientation on DNR issues. Policies may need to include patients as decision-makers.

Life-Sustaining Treatment Status at the Time of Death in a Japanese Pediatric Intensive Care Unit

BACKGROUND

Substantial variability exists among countries regarding the modes of death in pediatric intensive care units (PICUs). However, there is limited information on end-of-life care in Japanese PICUs. Thus, this study aimed to elucidate the characteristics of end-of-life care practice for children in a Japanese PICU.

METHODS

We examined life-sustaining treatment (LST) status at the time of death based on medical chart reviews from 2010 to 2014. All deaths were classified into 3 groups: limitation of LST (limitation group, death after withholding or withdrawal of LST or a do not attempt resuscitation order), no limitation of LST (no-limitation group, death following failed resuscitation attempts), or brain death (brain death group).

RESULTS

Of the 62 patients who died, 44 (71%) had limitation of LST, 18 (29%) had no limitation of LST, and none had brain death. In the limitation group, the length of PICU stay was longer than that in the no-limitation group (13.5 vs 2.5 days; P = .01). The median time to death after the decision to limit LST was 2 days (interquartile range: 1-5.5 days), and 94% of the patients were on mechanical ventilation at the time of death in the limitation group.

CONCLUSIONS

Although limiting LST was a common practice in end-of-life care in a Japanese PICU, a severe limitation of LST such as withdrawal from the ventilator was hardly practiced, and a considerable LST was still provided at the time of death.

Predictors of mortality in a paediatric intensive care unit in Kigali, Rwanda

BACKGROUND

The enormous burden of critical illness in resource-limited settings has led to a growing interest in paediatric critical care in these regions. However, published data on the practice of critical care and patient outcomes in these settings are scant.

OBJECTIVE

This study sought to identify risk factors associated with mortality in the newly established Paediatric Intensive Care Unit (PICU) at Kigali University Teaching Hospital (KUTH) in Rwanda and test the predictive ability of a newly devised mortality risk score, the modified PRISM (MP) score.

METHODS

All admissions to the PICU at KUTH from October 2012 to October 2014 were included. Demographic and physiological data on each patient were gathered and each was assigned a MP score. This prospective cross-sectional study examined the association between the characteristics and physiological status of these patients and mortality. Using logistic regression, factors associated with mortality in the PICU were analysed.

RESULTS

A total of 213 children were admitted to the PICU during the study period. Three patients were excluded because of missing data. Of this total, 59% were male, 25% were neonates and nearly 60% were moderately to severely malnourished. The overall mortality rate was 50%. On bivariate analysis, factors associated with increased mortality were male sex, use of vasoactive medications, a MP score ≥ 5, a discharge diagnosis of septic shock, and malnutrition on admission. On multivariate analysis, only the use of vasoactive drugs [odds ratio (OR) 12.24, 95% confidence interval (CI) 4.4-35.4, p < 0.001] and MP score ≥ 5 (OR 16.1, CI 6.3-40.8, p < 0.001) were associated with mortality.

CONCLUSION

The observed mortality rate was in the range reported in other resource-limited settings. The initial attempt to create and implement a risk of mortality tool for this setting determined a score that could identify those patients at higher risk of mortality. In PICUs in resource-limited settings, the gathering of data and use of severity of illness tools could improve care in a number of ways.