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Verlaat CW, Zegers M, Klein R, van Waardenburg D, Kuiper JW, Riedijk M, Kneyber M, Timmers B, van Heerde M, Hazelzet JA, van der Hoeven J, Lemson J. Adverse Events in Pediatric Critical Care Nonsurvivors With a Low Predicted Mortality Risk: A Multicenter Case Control Study. Pediatr Crit Care Med 2023; 24:4-16. [PMID: 36521013 PMCID: PMC9799043 DOI: 10.1097/pcc.0000000000003103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Some patients with a low predicted mortality risk in the PICU die. The contribution of adverse events to mortality in this group is unknown. The aim of this study was to estimate the occurrence of adverse events in low-risk nonsurvivors (LN), compared with low-risk survivors (LS) and high-risk PICU survivors and nonsurvivors, and the contribution of adverse events to mortality. DESIGN Case control study. Admissions were selected from the national Dutch PICU registry, containing 53,789 PICU admissions between 2006 and 2017, in seven PICUs. PICU admissions were stratified into four groups, based on mortality risk (low/high) and outcome (death/survival). Random samples were selected from the four groups. Cases were "LN." Control groups were as follows: "LS," "high-risk nonsurvivors" (HN), and "high-risk survivors" (HS). Adverse events were identified using the validated trigger tool method. SETTING Patient chart review study. PATIENTS Children admitted to the PICU with either a low predicted mortality risk (< 1%) or high predicted mortality risk (≥ 30%). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 419 patients were included (102 LN, 107 LS, 104 HN, and 106 HS). LN had more complex chronic conditions (93.1%) than LS (72.9%; p < 0.01), HN (49.0%; p < 0.001), and HS (48.1%; p < 0.001). The occurrence of adverse events in LN (76.5%) was higher than in LS (13.1%) and HN (47.1%) ( p < 0.001). The most frequent adverse events in LN were hospital-acquired infections and drug/fluid-related adverse events. LN suffered from more severe adverse events compared with LS and HS ( p < 0.001). In 30.4% of LN, an adverse event contributed to death. In 8.8%, this adverse event was considered preventable. CONCLUSIONS Significant and preventable adverse events were found in low-risk PICU nonsurvivors. 76.5% of LN had one or more adverse events. In 30.4% of LN, an adverse event contributed to mortality.
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Affiliation(s)
- Carin W Verlaat
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke Zegers
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Richard Klein
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick van Waardenburg
- Department of Pediatric Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jan Willem Kuiper
- Department of Pediatric Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Maaike Riedijk
- Department of Pediatric Intensive Care, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Martin Kneyber
- Department of Pediatric Intensive Care, University Medical Center Groningen, Groningen, The Netherlands
| | - Brigitte Timmers
- Department of Pediatric Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc van Heerde
- Department of Pediatric Intensive Care, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jan A Hazelzet
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Joris Lemson
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Verlaat CW, Wubben N, Visser IH, Hazelzet JA, van der Hoeven J, Lemson J, van den Boogaard M. Retrospective cohort study on factors associated with mortality in high-risk pediatric critical care patients in the Netherlands. BMC Pediatr 2019; 19:274. [PMID: 31387556 PMCID: PMC6683538 DOI: 10.1186/s12887-019-1646-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 07/29/2019] [Indexed: 11/25/2022] Open
Abstract
Background High-risk patients in the pediatric intensive care unit (PICU) contribute substantially to PICU-mortality. Complex chronic conditions (CCCs) are associated with death. However, it is unknown whether CCCs also increase mortality in the high-risk PICU-patient. The objective of this study is to determine if CCCs or other factors are associated with mortality in this group. Methods Retrospective cohort study from a national PICU-database (2006–2012, n = 30,778). High-risk PICU-patients, defined as patients < 18 years with a predicted mortality risk > 30% according to either the recalibrated Pediatric Risk of Mortality-II (PRISM) or the Paediatric Index of Mortality 2 (PIM2), were included. Patients with a cardiac arrest before PICU-admission were excluded. Results In total, 492 high-risk PICU patients with mean predicted risk of 24.8% (SD 22.8%) according to recalibrated PIM2 and 40.0% (SD 23.8%) according to recalibrated PRISM were included of which 39.6% died. No association was found between CCCs and non-survival (odds ratio 0.99; 95% CI 0.62–1.59). Higher Glasgow coma scale at PICU admission was associated with lower mortality (odds ratio 0.91; 95% CI 0.87–0.96). Conclusions Complex chronic conditions are not associated with mortality in high-risk PICU patients. Electronic supplementary material The online version of this article (10.1186/s12887-019-1646-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carin W Verlaat
- Radboud Institute for Health Sciences, Department of Intensive Care Medicine Radboud, university medical center, Internal post 709, P.O. box 9101, 6500HB, Nijmegen, The Netherlands.
| | - Nina Wubben
- Department of intensive care, Radboud university medical center, Nijmegen, the Netherlands
| | - Idse H Visser
- researcher Dutch Pediatric Intensive Care Evaluation, Department of Pediatric Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Jan A Hazelzet
- department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | - Joris Lemson
- Department of intensive care, Radboud university medical center, Nijmegen, the Netherlands
| | - Mark van den Boogaard
- Department of intensive care, Radboud university medical center, Nijmegen, the Netherlands
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Teheux L, Verlaat CW, Lemson J, Draaisma JMT, Fuijkschot J. Risk stratification to improve Pediatric Early Warning Systems: it is all about the context. Eur J Pediatr 2019; 178:1589-1596. [PMID: 31485752 PMCID: PMC6733815 DOI: 10.1007/s00431-019-03446-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 07/31/2019] [Accepted: 08/06/2019] [Indexed: 11/30/2022]
Abstract
Early recognition of critically ill patients is of paramount importance to reduce pediatric mortality and morbidity. We created a risk stratification system combining vital parameters and predefined risk factors aimed at reducing the risk of unrecognized clinical deterioration compared with conventional Pediatric Early Warning Systems (PEWS). This single-center retrospective case cohort study included infants (gestational age ≥ 37 weeks) to adolescents (aged <18 years) with unplanned pediatric intensive care unit (PICU) admission between April 01, 2014, and February 28, 2018. The sensitivity in the 24 h prior to endpoint of the Pediatric Risk Evaluation and Stratification System (PRESS) was compared with that of the conventional PEWS and calculated as the proportion of study patients who received a high-risk score. Seventy-four PICU admissions were included. PRESS and PEWS sensitivities at 2 h prior to endpoint were 0.70 (95%CI 0.59 to 0.80) and 0.30 (95%CI 0.20 to 0.42) respectively (p < 0.001). Excluding patients with seizures, PRESS sensitivity increased to 0.75 (95%CI 0.64 to 0.85). Forty-nine patients (66%) scored positive on at least one high-risk factor, and "worried sign" was scored in 31 patients (42%).Conclusion: Risk stratification seems advantageous for a faster detection of clinical deterioration, providing opportunity for earlier intervention. What is Known: • Prompt detection of clinical deterioration is of essential importance to reduce morbidity and mortality. • Conventional Pediatric Early Warning Systems (PEWS) have limited sensitivity and a short window of detection of 1 to 2 h. What is New: • Risk stratification based on context factors allows earlier identification of patients at risk, well before deviation of vital signs. • Risk stratification combined with continuous monitoring of deteriorating trends in vital signs could lead to the development of next-generation warning systems achieving true patient safety.
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Affiliation(s)
- Lara Teheux
- Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Carin W. Verlaat
- Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joris Lemson
- Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jos M. T. Draaisma
- Radboud Institute for Health Sciences, Amalia Children’s Hospital, Department of Pediatrics, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Joris Fuijkschot
- Radboud Institute for Health Sciences, Amalia Children’s Hospital, Department of Pediatrics, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Verlaat CW, van der Starre C, Hazelzet JA, Tibboel D, van der Hoeven J, Lemson J, Zegers M. The occurrence of adverse events in low-risk non-survivors in pediatric intensive care patients: an exploratory study. Eur J Pediatr 2018; 177:1351-1358. [PMID: 29946855 PMCID: PMC6096770 DOI: 10.1007/s00431-018-3194-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/07/2018] [Accepted: 06/12/2018] [Indexed: 11/29/2022]
Abstract
We studied the occurrence of adverse events (AEs) in low-risk non-survivors (LNs), compared to low-risk survivors (LSs), high-risk non-survivors (HNs), and high-risk survivors (HSs) in two pediatric intensive care units (PICUs). The study was performed as a retrospective patient record review study, using a PICU-trigger tool. A random sample of 48 PICU patients (0-18 years) was chosen, stratified into four subgroups of 12 patients: LNs, LSs, HNs, and HSs. Primary outcome was the occurrence of AEs. The severity, preventability, and nature of the indentified AEs were determined. In total, 45 AEs were found in 20 patients. The occurrence of AEs in the LN group was significantly higher compared to that in the LS group and HN group (AE occurrence: LN 10/12 patients, LS 1/12 patients; HN 2/12 patients; HS 7/12 patients; LN-LS difference, p < 0.001; LN-HN difference, p < 0.01). The AE rate in the LN group was significantly higher compared to that in the LS and HN groups (median [IQR]: LN 0.12 [0.07-0.29], LS 0 [0-0], HN 0 [0-0], and HS 0.03 [0.0-0.17] AE/PICU day; LN-LS difference, p < 0.001; LN-HN difference, p < 0.01). The distribution of the AEs among the four groups was as follows: 25 AEs (LN), 2 AEs (LS), 8 AEs (HN), and 10 AEs (HS). Fifteen of forty-five AEs were preventable. In 2/12 LN patients, death occurred after a preventable AE. CONCLUSION The occurrence of AEs in LNs was higher compared to that in LSs and HNs. Some AEs were severe and preventable and contributed to mortality. What is Known: • 59-76% of all PICU patients encounter at least one adverse event during their PICU stay. • It is unknown if adverse events play a role in death of low-risk PICU patients. What is New: • In low-risk PICU non-survivors, occurrence of adverse events is higher compared to low-risk PICU survivors and to high-risk PICU non-survivors. • Severe and preventable adverse events occur in low-risk PICU non-survivors, some contributing to mortality.
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Affiliation(s)
- Carin W. Verlaat
- Department of Intensive Care, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, Internal Post 709, 6500 HB Nijmegen, The Netherlands
| | - Cynthia van der Starre
- Department of Neonatal and Pediatric Intensive Care, Erasmus University Medical Center–Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Jan A. Hazelzet
- Department of Public Health, Erasmus University Medical Center–Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Pediatric Intensive Care, Erasmus Medical Center–Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Johannes van der Hoeven
- Department of Intensive Care, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, Internal Post 709, 6500 HB Nijmegen, The Netherlands
| | - Joris Lemson
- Department of Intensive Care, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, Internal Post 709, 6500 HB Nijmegen, The Netherlands
| | - Marieke Zegers
- Department of Intensive Care and IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Verlaat CW, Visser IH, Wubben N, Hazelzet JA, Lemson J, van Waardenburg D, van der Heide D, van Dam NA, Jansen NJ, van Heerde M, van der Starre C, van Asperen R, Kneyber M, van Woensel JB, van den Boogaard M, van der Hoeven J. Factors Associated With Mortality in Low-Risk Pediatric Critical Care Patients in The Netherlands. Pediatr Crit Care Med 2017; 18:e155-e161. [PMID: 28178075 DOI: 10.1097/pcc.0000000000001086] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine differences between survivors and nonsurvivors and factors associated with mortality in pediatric intensive care patients with low risk of mortality. DESIGN Retrospective cohort study. SETTING Patients were selected from a national database including all admissions to the PICUs in The Netherlands between 2006 and 2012. PATIENTS Patients less than 18 years old admitted to the PICU with a predicted mortality risk lower than 1% according to either the recalibrated Pediatric Risk of Mortality or the Pediatric Index of Mortality 2 were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 16,874 low-risk admissions were included of which 86 patients (0.5%) died. Nonsurvivors had more unplanned admissions (74.4% vs 38.5%; p < 0.001), had more complex chronic conditions (76.7% vs 58.8%; p = 0.001), were more often mechanically ventilated (88.1% vs 34.9%; p < 0.001), and had a longer length of stay (median, 11 [interquartile range, 5-32] d vs median, 3 [interquartile range, 2-5] d; p < 0.001) when compared with survivors. Factors significantly associated with mortality were complex chronic conditions (odds ratio, 3.29; 95% CI, 1.97-5.50), unplanned admissions (odds ratio, 5.78; 95% CI, 3.40-9.81), and admissions in spring/summer (odds ratio, 1.67; 95% CI, 1.08-2.58). CONCLUSIONS Nonsurvivors in the PICU with a low predicted mortality risk have recognizable risk factors including complex chronic condition and unplanned admissions.
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Affiliation(s)
- Carin W Verlaat
- 1Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands. 2Dutch Pediatric Intensive Care Evaluation, Department of Pediatric Intensive Care, Erasmus Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands. 3Radboud University, Nijmegen, The Netherlands. 4Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands. 5Department of Pediatric Intensive Care, Academic Hospital Maastricht, The Netherlands. 6Faculty Board Member, PICE Registry, the Netherlands. 7Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, The Netherlands. 8Department of Pediatric Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands. 9Department of Pediatric Intensive Care, VU University Medical Center, Amsterdam, The Netherlands. 10Department of Neonatal and Pediatric Intensive Care, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands. 11Department of Pediatric Intensive Care, University Medical Center Groningen, Groningen, The Netherlands. 12Department of Pediatric Intensive Care, Academic Medical Center, Amsterdam, The Netherlands. This work was performed at the Department of Pediatric Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Abstract
Congenital pulmonary lymphangiectasis can be a cause of respiratory distress of the newborn infant. We present a case of congenital pulmonary lymphangiectasis presenting as a unilateral hyperlucent lung. Such a presentation has only once been previously described.
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Affiliation(s)
- C W Verlaat
- Department of Paediatrics, University of Nijmegen, The Netherlands
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