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Curley MAQ, Watson RS, Killien EY, Kalvas LB, Perry-Eaddy MA, Cassidy AM, Miller EB, Talukder M, Manning JC, Pinto NP, Rennick JE, Colville G, Asaro LA, Wypij D. Design and rationale of the Post-Intensive Care Syndrome - paediatrics (PICS-p) Longitudinal Cohort Study. BMJ Open 2024; 14:e084445. [PMID: 38401903 PMCID: PMC10895227 DOI: 10.1136/bmjopen-2024-084445] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 01/31/2024] [Indexed: 02/26/2024] Open
Abstract
INTRODUCTION As paediatric intensive care unit (PICU) mortality declines, there is growing recognition of the morbidity experienced by children surviving critical illness and their families. A comprehensive understanding of the adverse physical, cognitive, emotional and social sequelae common to PICU survivors is limited, however, and the trajectory of recovery and risk factors for morbidity remain unknown. METHODS AND ANALYSIS The Post-Intensive Care Syndrome - paediatrics Longitudinal Cohort Study will evaluate child and family outcomes over 2 years following PICU discharge and identify child and clinical factors associated with impaired outcomes. We will enrol 750 children from 30 US PICUs during their first PICU hospitalisation, including 500 case participants experiencing ≥3 days of intensive care that include critical care therapies (eg, mechanical ventilation, vasoactive infusions) and 250 age-matched, sex-matched and medical complexity-matched control participants experiencing a single night in the PICU with no intensive care therapies. Children, parents and siblings will complete surveys about health-related quality of life, physical function, cognitive status, emotional health and peer and family relationships at multiple time points from baseline recall through 2 years post-PICU discharge. We will compare outcomes and recovery trajectories of case participants to control participants, identify risk factors associated with poor outcomes and determine the emotional and social health consequences of paediatric critical illness on parents and siblings. ETHICS AND DISSEMINATION This study has received ethical approval from the University of Pennsylvania Institutional Review Board (protocol #843844). Our overall objective is to characterise the ongoing impact of paediatric critical illness to guide development of interventions that optimise outcomes among children surviving critical illness and their families. Findings will be presented at key disciplinary meetings and in peer-reviewed publications at fixed data points. Published manuscripts will be added to our public study website to ensure findings are available to families, clinicians and researchers. TRIALS REGISTRATION NUMBER NCT04967365.
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Affiliation(s)
- Martha A Q Curley
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - R Scott Watson
- University of Washington School of Medicine, Seattle, Washington, USA
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Elizabeth Y Killien
- University of Washington School of Medicine, Seattle, Washington, USA
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Laura Beth Kalvas
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mallory A Perry-Eaddy
- School of Nursing, University of Connecticut, Storrs, Connecticut, USA
- School of Medicine, University of Connecticut, Farmington, Connecticut, USA
| | - Amy M Cassidy
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erica B Miller
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Mritika Talukder
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joseph C Manning
- School of Healthcare, University of Leicester, Leicester, UK
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Neethi P Pinto
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Janet E Rennick
- McGill University Health Centre, Montreal Children's Hospital, Montreal, Québec, Canada
- Ingram School of Nursing, McGill University, Montreal, Québec, Canada
| | | | - Lisa A Asaro
- Boston Children's Hospital, Boston, Massachusetts, USA
| | - David Wypij
- Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
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Affiliation(s)
- Elizabeth Y. Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Center for Child Health, Behavior, & Development, Seattle Children’s Research Institute, Seattle, WA, USA
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Smith MB, Dervan LA, Watson RS, Ohman RT, Albert JEM, Rhee EJ, Vavilala MS, Rivara FP, Killien EY. Family Presence at the PICU Bedside: A Single-Center Retrospective Cohort Study. Pediatr Crit Care Med 2023; 24:1053-1062. [PMID: 38055001 DOI: 10.1097/pcc.0000000000003334] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
OBJECTIVES To determine factors associated with bedside family presence in the PICU and to understand how individual factors interact as barriers to family presence. DESIGN Mixed methods study. SETTING Tertiary children's hospital PICU. SUBJECTS Five hundred twenty-three children of less than 18 years enrolled in the Seattle Children's Hospital Outcomes Assessment Program from 2011 to 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Quantitative: Family was documented every 2 hours. Exposures included patient and illness characteristics and family demographic and socioeconomic characteristics. We used multivariable logistic regression to identify factors associated with presence of less than 80% and stratified results by self-reported race. Longer PICU length of stay (LOS), public insurance, and complex chronic conditions (C-CD) were associated with family presence of less than 80%. Self-reported race modified these associations; no factors were associated with lower bedside presence for White families, in contrast with multiple associations for non-White families including public insurance, C-CD, and longer LOS. Qualitative: Thematic analysis of social work notes for the 48 patients with family presence of less than 80% matched on age, LOS, and diagnosis to 48 patients with greater than or equal to 95% family presence. Three themes emerged: the primary caregiver's prior experiences with the hospital, relationships outside of the hospital, and additional stressors during the hospitalization affected bedside presence. CONCLUSIONS We identified sociodemographic and illness factors associated with family bedside presence in the PICU. Self-reported race modified these associations, representing racism within healthcare. Family presence at the bedside may help identify families facing greater disparities in healthcare access.
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Affiliation(s)
- Mallory B Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Leslie A Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA
| | - Robert T Ohman
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA
| | - J Elaine-Marie Albert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
| | - Eileen J Rhee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington, Seattle, WA
| | - Monica S Vavilala
- Department of Anesthesiology, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Frederick P Rivara
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
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Killien EY. Early career investigator biocommentary. Pediatr Res 2023; 94:1866. [PMID: 37660178 DOI: 10.1038/s41390-023-02806-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 09/04/2023]
Affiliation(s)
- Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA.
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Killien EY, Watson RS, Banks RK, Reeder RW, Meert KL, Zimmerman JJ. Predicting functional and quality-of-life outcomes following pediatric sepsis: performance of PRISM-III and PELOD-2. Pediatr Res 2023; 94:1951-1957. [PMID: 37185949 PMCID: PMC10860342 DOI: 10.1038/s41390-023-02619-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/28/2023] [Accepted: 04/03/2023] [Indexed: 05/17/2023]
Abstract
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.
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Affiliation(s)
- Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA.
- Harborview Injury Prevention & Research Center, Seattle, WA, USA.
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Center for Child Health, Behavior, & Development, Seattle Children's Research Institute, Seattle, WA, USA
| | | | | | - Kathleen L Meert
- Division of Pediatric Critical Care Medicine, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt. Pleasant, MI, USA
| | - Jerry J Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Center for Clinical & Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
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Killien EY. A Revolving Door to the Intensive Care Unit for Children Surviving Acute Respiratory Distress Syndrome. JAMA Netw Open 2023; 6:e2331781. [PMID: 37682575 PMCID: PMC10882940 DOI: 10.1001/jamanetworkopen.2023.31781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Affiliation(s)
- Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle
- Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington
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Emeriaud G, Pons-Òdena M, Bhalla AK, Shein SL, Killien EY, Alapont VMI, Rowan C, Baudin F, Lin JC, Grégoire G, Napolitano N, Mayordomo-Colunga J, Diaz F, Cruces P, Medina A, Smith L, Khemani RG. Noninvasive Ventilation for Pediatric Acute Respiratory Distress Syndrome: Experience From the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Prospective Cohort Study. Pediatr Crit Care Med 2023; 24:715-726. [PMID: 37255352 PMCID: PMC10524424 DOI: 10.1097/pcc.0000000000003281] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES The worldwide practice and impact of noninvasive ventilation (NIV) in pediatric acute respiratory distress syndrome (PARDS) is unknown. We sought to describe NIV use and associated clinical outcomes in PARDS. DESIGN Planned ancillary study to the 2016/2017 prospective Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study. SETTING One hundred five international PICUs. PATIENTS Patients with newly diagnosed PARDS admitted during 10 study weeks. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Children were categorized by their respiratory support at PARDS diagnosis into NIV or invasive mechanical ventilation (IMV) groups. Of 708 subjects with PARDS, 160 patients (23%) received NIV at PARDS diagnosis (NIV group). NIV failure rate (defined as tracheal intubation or death) was 84 of 160 patients (53%). Higher nonrespiratory pediatric logistic organ dysfunction (PELOD-2) score, Pa o2 /F io2 was less than 100 at PARDS diagnosis, immunosuppression, and male sex were independently associated with NIV failure. NIV failure was 100% among patients with nonrespiratory PELOD-2 score greater than 2, Pa o2 /F io2 less than 100, and immunosuppression all present. Among patients with Pa o2 /F io2 greater than 100, children in the NIV group had shorter total duration of NIV and IMV, than the IMV at initial diagnosis group. We failed to identify associations between NIV use and PICU survival in a multivariable Cox regression analysis (hazard ratio 1.04 [95% CI, 0.61-1.80]) or mortality in a propensity score matched analysis ( p = 0.369). CONCLUSIONS Use of NIV at PARDS diagnosis was associated with shorter exposure to IMV in children with mild to moderate hypoxemia. Even though risk of NIV failure was high in some children, we failed to identify greater hazard of mortality in these patients.
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Affiliation(s)
- Guillaume Emeriaud
- Department of Pediatrics, Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Marti Pons-Òdena
- Inmune and Respiratory dysfunction in the child research group. Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950 Esplugues de Llobregat, Spain
- Pediatric Intensive Care and Intermediate care Department, Sant Joan de Déu University Hospital, Universitat de Barcelona, Esplugues de Llobregat, Spain
| | - Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, USA
| | - Steven L Shein
- Rainbow Babies and Children’s Hospital, Division of Pediatric Critical Care Medicine, Cleveland Ohio USA
| | - Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, USA
| | | | - Courtney Rowan
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Florent Baudin
- Réanimation Pédiatrique, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon, France
| | - John C Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, USA
| | - Gabrielle Grégoire
- Applied Clinical Research Unit, CHU Sainte-Justine, Montreal, QC, Canada
| | - Natalie Napolitano
- Respiratory Therapy Department, Children’s Hospital of Philadelphia, USA
| | - Juan Mayordomo-Colunga
- Pediatric Intensive Care Unit. Hospital Universitario Central de Asturias, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - Franco Diaz
- Instituto de Ciencias e innovación en medicina (ICIM), Universidad del Desarrollo, Santiago de Chile
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago de Chile
| | - Pablo Cruces
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago de Chile
- Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Alberto Medina
- Pediatric Intensive Care Unit. Hospital Universitario Central de Asturias, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Spain
| | - Lincoln Smith
- Department of Pediatrics, University of Washington, Seattle Children’s Hospital, USA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, USA
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Ohman RT, Killien EY. Prevention of Pediatric Acute Respiratory Distress Syndrome: The Holy Grail Remains Elusive. Pediatr Crit Care Med 2023; 24:622-624. [PMID: 37409900 PMCID: PMC10328550 DOI: 10.1097/pcc.0000000000003231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Affiliation(s)
- Robert T. Ohman
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Elizabeth Y. Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention & Research Center, Seattle, WA, USA
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Abstract
Importance Estimates of the number of US children receiving intensive care unit (ICU) care and ICU admission patterns over time are lacking. Objective To determine how ICU admission patterns, use of critical care services, and the characteristics and outcomes of critically ill children have changed from 2001 to 2019. Design, Setting, and Participants This population-based retrospective cohort study used data from the Healthcare Cost and Utilization Project's state inpatient databases from a total of 21 US states in 2001, 2004, 2010, 2016, and 2019. Hospitalized children aged 0 to 17 years, excluding newborns (during birth hospitalization), were included. Patients admitted to rehabilitation institutions or psychiatric hospitals were also excluded. Data were analyzed from July 2021 to December 2022. Exposures Care in a nonneonatal ICU. Main Outcomes and Measures From extracted patient data, International Classification of Diseases, Ninth Revision, Clinical Modification, and Tenth Revision, Clinical Modification, codes were used to identify diagnoses, comorbid conditions, organ failures, and mechanical ventilation. Generalized linear Poisson regression and the Cuzick test were used to evaluate trends. US Census data were used to generate age- and sex-adjusted national estimates of ICU admissions and costs. Results Of 2 157 991 pediatric admissions, 275 656 (12.8%) included ICU care. The mean (SD) age was 6.43 (6.10) years; 121 894 individuals were female (44.2%), and 153 731 were male (55.8%). From 2001 to 2019, the prevalence of ICU care among hospitalized children increased from 10.6% to 15.5%. The percentage of ICU admissions in children's hospitals rose from 51.2% to 85.1% (relative risk [RR], 1.66; 95% CI, 1.64-1.68). The percentage of children admitted to an ICU with an underlying comorbidity increased from 46.2% to 57.0% (RR, 1.23; 95% CI, 1.22-1.25), and the percentage with preadmission technology dependence increased from 16.4% to 23.5% (RR, 1.44; 95% CI, 1.40-1.48). The prevalence of multiple organ dysfunction syndrome increased from 6.8% to 21.0% (RR, 3.12; 95% CI, 2.98-3.26), while mortality decreased from 2.5% to 1.8% (RR, 0.72; 95% CI, 0.66-0.79). Hospital length of stay increased by 0.96 days (95% CI, 0.73-1.18) for ICU admissions from 2001 to 2019. After inflation adjustment, total costs for a pediatric admission involving ICU care nearly doubled between 2001 and 2019. Nationally, an estimated 239 000 children were admitted to a US ICU in 2019, corresponding to $11.6 billion in hospital costs. Conclusions and Relevance In this study, the prevalence of children receiving ICU care in the US increased, as did length of stay, technology use, and associated costs. The US health care system must be equipped to care for these children in the future.
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Affiliation(s)
- Elizabeth Y. Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle
- Harborview Injury Prevention & Research Center, Seattle, Washington
- Pediatric Critical Care Medicine, Seattle Children’s Hospital, Seattle, Washington
| | - Matthew R. Keller
- Institute for Informatics, Washington University in St Louis, St Louis, Missouri
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle
- Pediatric Critical Care Medicine, Seattle Children’s Hospital, Seattle, Washington
- Center for Child Health, Behavior & Development, Seattle Children’s Research Institute, Seattle, Washington
| | - Mary E. Hartman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
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Killien EY. Impaired Neurocognition, Quality of Life, and Behavior Following Multisystem Inflammatory Syndrome in Children: A Result of the Illness or the Pandemic? Pediatr Crit Care Med 2023; 24:341-344. [PMID: 37026724 PMCID: PMC10083875 DOI: 10.1097/pcc.0000000000003200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Affiliation(s)
- Elizabeth Y. Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention & Research Center, Seattle, WA, USA
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Killien EY, Grassia KL, Butler EK, Mooney SJ, Watson RS, Vavilala MS, Rivara FP. Variation in tracheostomy placement and outcomes following pediatric trauma among adult, pediatric, and combined trauma centers. J Trauma Acute Care Surg 2023; 94:615-623. [PMID: 36730091 PMCID: PMC10038845 DOI: 10.1097/ta.0000000000003848] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tracheostomy placement is much more common in adults than children following severe trauma. We evaluated whether tracheostomy rates and outcomes differ for pediatric patients treated at trauma centers that primarily care for children versus adults. METHODS We conducted a retrospective cohort study of patients younger than 18 years in the National Trauma Data Bank from 2007 to 2016 treated at a Level I/II pediatric, adult, or combined adult/pediatric trauma center, ventilated >24 hours, and who survived to discharge. We used multivariable logistic regression adjusted for age, insurance, injury mechanism and body region, and Injury Severity Score to estimate the association between the three trauma center types and tracheostomy. We used augmented inverse probability weighting to model the likelihood of tracheostomy based on the propensity for treatment at a pediatric, adult, or combined trauma center, and estimated associations between trauma center type with length of stay and postdischarge care. RESULTS Among 33,602 children, tracheostomies were performed in 4.2% of children in pediatric centers, 7.8% in combined centers (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.20-1.81), and 11.2% in adult centers (aOR, 1.81; 95% CI, 1.48-2.22). After propensity matching, the estimated average tracheostomy rate would be 62.9% higher (95% CI, 37.7-88.1%) at combined centers and 85.3% higher (56.6-113.9%) at adult centers relative to pediatric centers. Tracheostomy patients had longer hospital stay in pediatric centers than combined (-4.4 days, -7.4 to -1.3 days) or adult (-4.0 days, -7.2 to -0.9 days) centers, but fewer children required postdischarge inpatient care (70.1% pediatric vs. 81.3% combined [aOR, 2.11; 95% CI, 1.03-4.31] and 82.4% adult centers [aOR, 2.51; 95% CI, 1.31-4.83]). CONCLUSION Children treated at pediatric trauma centers have lower likelihood of tracheostomy than children treated at combined adult/pediatric or adult centers independent of patient or injury characteristics. Better understanding of optimal indications for tracheostomy is necessary to improve processes of care for children treated throughout the pediatric trauma system. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Elizabeth Y. Killien
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Kalee L. Grassia
- Department of Pediatric Critical Care Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Elissa K. Butler
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Department of Surgery, University of Montreal, Montreal, Quebec, Canada
| | - Stephen J. Mooney
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
| | - Monica S. Vavilala
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Frederick P. Rivara
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA
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Killien EY, Maddux AB, Tse SM, Watson RS. Outcomes of Children Surviving Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S28-S44. [PMID: 36661434 PMCID: PMC9869462 DOI: 10.1097/pcc.0000000000003157] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To summarize the evidence for the Second Pediatric Acute Lung Injury Consensus Conference-2 (PALICC-2) recommendations for assessment of outcomes among patients surviving pediatric acute respiratory distress syndrome (PARDS). DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION We conducted a scoping review to identify studies evaluating outcomes following PARDS. We included studies of survivors of PARDS, acute respiratory failure with a high proportion of PARDS patients, or other critical illnesses if PARDS-specific outcomes could be extracted. DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. Of 8,037 abstracts screened, we identified 20 articles for inclusion. Morbidity following PARDS was common and affected multiple domains of pulmonary and nonpulmonary function. There was insufficient evidence to generate any evidence-based recommendations. We generated eight good practice statements and five research statements. A panel of 52 experts discussed each proposed good practice statement and research statement, and the agreement rate was measured with an online voting process. Good practice statements describe the approach to clinical outcome assessment, assessment of pulmonary outcomes of children surviving PARDS, and assessment of nonpulmonary outcomes of children surviving PARDS including health-related quality of life and physical, neurocognitive, emotional, family, and social functioning. The five research statements relate to assessment of patient preillness status, use of postdischarge endpoints for clinical trials, the association between short-term and longer term outcomes, the trajectory of recovery following PARDS, and practices to optimize follow-up. CONCLUSIONS There is increasing evidence that children are at risk for impairments across a range of pulmonary and nonpulmonary health domains following hospitalization for PARDS. The results of this extensive scoping review and consensus conference involving experts in PARDS research, clinical care, and outcomes assessment provide guidance to clinicians and researchers on postdischarge follow-up to optimize the long-term health of patients surviving PARDS.
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Affiliation(s)
- Elizabeth Y. Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA
| | - Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Sze Man Tse
- Department of Pediatrics, University of Montréal, Montréal, Canada
- Division of Respiratory Medicine, Department of Pediatrics, Sainte-Justine University Hospital Center, Montréal, Québec, Canada
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Child Health, Behavior, & Development, Seattle Children’s Research Institute, Seattle, WA
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13
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Emeriaud G, López-Fernández YM, Iyer NP, Bembea MM, Agulnik A, Barbaro RP, Baudin F, Bhalla A, Brunow de Carvalho W, Carroll CL, Cheifetz IM, Chisti MJ, Cruces P, Curley MAQ, Dahmer MK, Dalton HJ, Erickson SJ, Essouri S, Fernández A, Flori HR, Grunwell JR, Jouvet P, Killien EY, Kneyber MCJ, Kudchadkar SR, Korang SK, Lee JH, Macrae DJ, Maddux A, Modesto I Alapont V, Morrow BM, Nadkarni VM, Napolitano N, Newth CJL, Pons-Odena M, Quasney MW, Rajapreyar P, Rambaud J, Randolph AG, Rimensberger P, Rowan CM, Sanchez-Pinto LN, Sapru A, Sauthier M, Shein SL, Smith LS, Steffen K, Takeuchi M, Thomas NJ, Tse SM, Valentine S, Ward S, Watson RS, Yehya N, Zimmerman JJ, Khemani RG. Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2). Pediatr Crit Care Med 2023; 24:143-168. [PMID: 36661420 PMCID: PMC9848214 DOI: 10.1097/pcc.0000000000003147] [Citation(s) in RCA: 47] [Impact Index Per Article: 47.0] [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] [Indexed: 01/21/2023]
Abstract
OBJECTIVES We sought to update our 2015 work in the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS), considering new evidence and topic areas that were not previously addressed. DESIGN International consensus conference series involving 52 multidisciplinary international content experts in PARDS and four methodology experts from 15 countries, using consensus conference methodology, and implementation science. SETTING Not applicable. PATIENTS Patients with or at risk for PARDS. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eleven subgroups conducted systematic or scoping reviews addressing 11 topic areas: 1) definition, incidence, and epidemiology; 2) pathobiology, severity, and risk stratification; 3) ventilatory support; 4) pulmonary-specific ancillary treatment; 5) nonpulmonary treatment; 6) monitoring; 7) noninvasive respiratory support; 8) extracorporeal support; 9) morbidity and long-term outcomes; 10) clinical informatics and data science; and 11) resource-limited settings. The search included MEDLINE, EMBASE, and CINAHL Complete (EBSCOhost) and was updated in March 2022. Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to summarize evidence and develop the recommendations, which were discussed and voted on by all PALICC-2 experts. There were 146 recommendations and statements, including: 34 recommendations for clinical practice; 112 consensus-based statements with 18 on PARDS definition, 55 on good practice, seven on policy, and 32 on research. All recommendations and statements had agreement greater than 80%. CONCLUSIONS PALICC-2 recommendations and consensus-based statements should facilitate the implementation and adherence to the best clinical practice in patients with PARDS. These results will also inform the development of future programs of research that are crucially needed to provide stronger evidence to guide the pediatric critical care teams managing these patients.
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Affiliation(s)
- Guillaume Emeriaud
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montréal, QC, Canada
| | - Yolanda M López-Fernández
- Pediatric Intensive Care Unit, Department of Pediatrics, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
| | - Narayan Prabhu Iyer
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Melania M Bembea
- Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Ryan P Barbaro
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Florent Baudin
- Pediatric Intensive Care Unit, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Réanimation Pédiatrique, Lyon, France
| | - Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles. Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | | | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Mohammod J Chisti
- Dhaka Hospital, International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Departamento de Pediatría, Unidad de Paciente Crítico Pediátrico, Facultad de Ciencias de la Vida, Hospital El Carmen de Maipú, Santiago, Chile
| | - Martha A Q Curley
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mary K Dahmer
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Heidi J Dalton
- Department of Pediatrics and Heart and Vascular Institute, INOVA Fairfax Medical Center, Falls Church, VA
| | - Simon J Erickson
- Department of Paediatric Critical Care, Perth Children's Hospital Western Australia, Perth, WA, Australia
| | - Sandrine Essouri
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montréal, QC, Canada
| | - Analía Fernández
- Pediatric Intensive Care Unit, Emergency Department, Hospital General de Agudos "C. Durand" Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Jocelyn R Grunwell
- Division of Critical Care, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Philippe Jouvet
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montréal, QC, Canada
| | - Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sapna R Kudchadkar
- Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Departments of Pediatrics, Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Steven Kwasi Korang
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles. Keck School of Medicine, University of Southern California, Los Angeles, CA
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jan Hau Lee
- KK Women's and Children's Hospital, Singapore and Duke-NUS Medical School, Singapore
| | | | - Aline Maddux
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | | | - Brenda M Morrow
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Vinay M Nadkarni
- Department of Anesthesiology, Critical Care and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles. Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Martí Pons-Odena
- Immunological and Respiratory Disorders, Paediatric Critical Care Unit Research Group, Institut de Recerca Sant Joan de Déu, Pediatric Intensive Care and Intermediate Care Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Michael W Quasney
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | | | - Jerome Rambaud
- Departement of Pediatric and Neonatal Intensive Care, Armand-Trousseau Hospital, Sorbonne University, Paris, France
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, and Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, MA
| | - Peter Rimensberger
- Division of Neonatology and Paediatric Intensive Care, University of Geneva, Geneva, Switzerland
| | - Courtney M Rowan
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - L Nelson Sanchez-Pinto
- Departments of Pediatrics (Critical Care) and Preventive Medicine (Health & Biomedical Informatics), Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Anil Sapru
- Division of Pediatric Critical Care, Department of Pediatrics, University of California Los Angeles, Los Angeles, CA
| | - Michael Sauthier
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montréal, QC, Canada
| | - Steve L Shein
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lincoln S Smith
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA
| | - Katerine Steffen
- Department of Pediatrics, Division of Pediatric Critical Care, Stanford University, Palo Alto, CA
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Sciences, Penn State University College of Medicine, Hershey, PA
| | - Sze Man Tse
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montréal, QC, Canada
| | - Stacey Valentine
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Shan Ward
- Department of Pediatrics, University of California San Francisco, Benioff Children's Hospitals, San Francisco and Oakland, CA
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute Seattle, WA
| | - Nadir Yehya
- Department of Anesthesiology, Critical Care and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jerry J Zimmerman
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA
- Harborview Medical Center, University of Washington School of Medicine, Seattle, WA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles. Keck School of Medicine, University of Southern California, Los Angeles, CA
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14
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Killien EY, Zahlan JM, Lad H, Watson RS, Vavilala MS, Huijsmans RLN, Rivara FP. Epidemiology and outcomes of multiple organ dysfunction syndrome following pediatric trauma. J Trauma Acute Care Surg 2022; 93:829-837. [PMID: 35358103 PMCID: PMC9525450 DOI: 10.1097/ta.0000000000003616] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Existing studies have found a low prevalence of multiple organ dysfunction syndrome (MODS) in pediatric trauma patients, typically applying adult criteria to single-center pediatric cohorts. We used pediatric criteria to determine the prevalence, risk factors, and outcomes of MODS among critically injured children in a national pediatric intensive care unit (PICU) database. METHODS We conducted a retrospective cohort study of PICU patients 1 month to 17 years with traumatic injury in the Virtual Pediatric Systems, LLC database from 2009 to 2017. We used International Pediatric Sepsis Consensus Conference criteria to identify MODS on Day 1 of PICU admission and estimated the risk of mortality and poor functional outcome (Pediatric Overall/Cerebral Performance Category ≥3 with ≥1 point worsening from baseline) for MODS and for each type of organ dysfunction using generalized linear Poisson regression adjusted for age, comorbidities, injury type and mechanism, and postoperative status. RESULTS Multiple organ dysfunction syndrome was present on PICU Day 1 in 23.1% of 37,177 trauma patients (n = 8,592), with highest risk among patients with injuries associated with drowning, asphyxiation, and abuse. Pediatric intensive care unit mortality was 20.1% among patients with MODS versus 0.5% among patients without MODS (adjusted relative risk, 32.3; 95% confidence interval, 24.1-43.4). Mortality ranged from 1.5% for one dysfunctional organ system to 69.1% for four or more organ systems and was highest among patients with hematologic dysfunction (43.3%) or renal dysfunction (29.6%). Death or poor functional outcome occurred in 46.7% of MODS patients versus 8.3% of patients without MODS (adjusted relative risk, 4.3; 95% confidence interval 3.4-5.3). CONCLUSION Multiple organ dysfunction syndrome occurs more frequently following pediatric trauma than previously reported and is associated with high risk of morbidity and mortality. Based on existing literature using identical methodology, both the prevalence and mortality associated with MODS are higher among trauma patients than the general PICU population. Consideration of early organ dysfunction in addition to injury severity may aid prognostication following pediatric trauma. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Elizabeth Y. Killien
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
| | - Jana M. Zahlan
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Hetal Lad
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
| | - Monica S. Vavilala
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Roel L. N. Huijsmans
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
- University Medical Center Utrecht, Utrecht, Netherlands
| | - Frederick P. Rivara
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA
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15
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Pinto NP, Maddux AB, Dervan LA, Woodruff AG, Jarvis JM, Nett S, Killien EY, Graham RJ, Choong K, Luckett PM, Heneghan JA, Biagas K, Carlton EF, Hartman ME, Yagiela L, Michelson KN, Manning JC, Long DA, Lee JH, Slomine BS, Beers SR, Hall T, Morrow BM, Meert K, del Pilar Arias Lopez M, Knoester H, Houtrow A, Olson L, Steele L, Schlapbach LJ, Burd RS, Grosskreuz R, Butt W, Fink EL, Watson RS. A Core Outcome Measurement Set for Pediatric Critical Care. Pediatr Crit Care Med 2022; 23:893-907. [PMID: 36040097 PMCID: PMC9633391 DOI: 10.1097/pcc.0000000000003055] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To identify a PICU Core Outcome Measurement Set (PICU COMS), a set of measures that can be used to evaluate the PICU Core Outcome Set (PICU COS) domains in PICU patients and their families. DESIGN A modified Delphi consensus process. SETTING Four webinars attended by PICU physicians and nurses, pediatric surgeons, rehabilitation physicians, and scientists with expertise in PICU clinical care or research ( n = 35). Attendees were from eight countries and convened from the Pediatric Acute Lung Injury and Sepsis Investigators Pediatric Outcomes STudies after PICU Investigators and the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network PICU COS Investigators. SUBJECTS Measures to assess outcome domains of the PICU COS are as follows: cognitive, emotional, overall (including health-related quality of life), physical, and family health. Measures evaluating social health were also considered. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Measures were classified as general or additional based on generalizability across PICU populations, feasibility, and relevance to specific COS domains. Measures with high consensus, defined as 80% agreement for inclusion, were selected for the PICU COMS. Among 140 candidate measures, 24 were delineated as general (broadly applicable) and, of these, 10 achieved consensus for inclusion in the COMS (7 patient-oriented and 3 family-oriented). Six of the seven patient measures were applicable to the broadest range of patients, diagnoses, and developmental abilities. All were validated in pediatric populations and have normative pediatric data. Twenty additional measures focusing on specific populations or in-depth evaluation of a COS subdomain also met consensus for inclusion as COMS additional measures. CONCLUSIONS The PICU COMS delineates measures to evaluate domains in the PICU COS and facilitates comparability across future research studies to characterize PICU survivorship and enable interventional studies to target long-term outcomes after critical illness.
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Affiliation(s)
- Neethi P. Pinto
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine and Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Leslie A. Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington and Seattle Children’s, Seattle, WA, USA
| | - Alan G. Woodruff
- Department of Anesthesiology, Section of Pediatric Critical Care Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Jessica M. Jarvis
- Department of Physical Medicine and Rehabilitation, Division of Pediatric Rehabilitation Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sholeen Nett
- Department of Pediatrics, Section of Critical Care Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Elizabeth Y. Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington and Seattle Children’s, Seattle, WA, USA
| | - Robert J. Graham
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Karen Choong
- Departments of Pediatrics, Critical Care, Health Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Peter M. Luckett
- Department of Pediatrics, UT Southwestern Medical Center and Division of Pediatric Critical Care Medicine, Children’s Health, Dallas, TX, USA
| | - Julia A. Heneghan
- Division of Critical Care, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, USA
| | - Katherine Biagas
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, The Renaissance School of Medicine at Stony Brook University and the Stony Brook Children’s Hospital, Stony Brook, NY, USA
| | - Erin F. Carlton
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan; Susan B. Meister Child Health Evaluation and Research Center; Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Mary E. Hartman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Lauren Yagiela
- Division of Critical Care, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI; Department of Pediatrics, Central Michigan University, Mount Pleasant, MI, USA
| | - Kelly N. Michelson
- Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joseph C. Manning
- Centre for Children and Young People Health Research, School of Health Sciences, University of Nottingham, Nottingham, UK; Nottingham Children’s Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Debbie A. Long
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia
| | - Jan Hau Lee
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
| | - Beth S. Slomine
- Department of Neuropsychology, Kennedy Krieger Institute; Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sue R. Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Trevor Hall
- Department of Pediatrics, Division of Pediatric Psychology, Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health & Science University, Portland, OR, USA
| | - Brenda M. Morrow
- Department of Paediatrics and Child Health; University of Cape Town; Cape Town; South Africa
| | - Kathleen Meert
- Division of Critical Care, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI; Department of Pediatrics, Central Michigan University, Mount Pleasant, MI, USA
| | - Maria del Pilar Arias Lopez
- Department of Pediatric Critical Care, Hospital de Niños Ricardo Gutierrez. SATI-Q Program. Argentine Society of Intensive Care, Buenos Aires. Argentina
| | - Hennie Knoester
- Pediatric Intensive Care Unit, Emma Children’s Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Amy Houtrow
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lenora Olson
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Lisa Steele
- Nationwide Children’s Hospital, Columbus, OH, USA
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology, Children`s Research Center, University Children`s Hospital Zurich, Zurich, Switzerland; and Child Health Research Centre, University of Queensland, Brisbane, Australia
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Center for Surgical Care, Children’s National Hospital, Washington, DC, USA
| | | | - Warwick Butt
- Intensive Care Unit, Royal Children’s Hospital Melbourne, Australia
| | - Ericka L. Fink
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington and Seattle Children’s, Seattle, WA, USA
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16
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Lyons VH, Robinson JR, Mills B, Killien EY, Mooney SJ. A Clinician's Guide to Conducting Research on Causal Effects. J Surg Res 2022; 278:155-160. [PMID: 35598499 PMCID: PMC9444568 DOI: 10.1016/j.jss.2022.04.059] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/03/2022] [Accepted: 04/08/2022] [Indexed: 11/16/2022]
Abstract
Surgeons are uniquely poised to conduct research to improve patient care, yet a gap often exists between the clinician's desire to guide patient care with causal evidence and having adequate training necessary to produce causal evidence. This guide aims to address this gap by providing clinically relevant examples to illustrate necessary assumptions required for clinical research to produce causal estimates.
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Affiliation(s)
- Vivian H Lyons
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, Michigan; Harborview Injury Prevention & Research Center, University of Washington, Seattle, Washington
| | - Jamaica Rm Robinson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Brianna Mills
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, Washington; Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
| | - Elizabeth Y Killien
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, Washington; Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington.
| | - Stephen J Mooney
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, Washington; Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
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17
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Affiliation(s)
- Elizabeth Y. Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention & Research Center, Seattle, WA, USA
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18
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Smith MB, Killien EY, Dervan LA, Rivara FP, Weiss NS, Watson RS. The association of severe pain experienced in the pediatric intensive care unit and postdischarge health-related quality of life: A retrospective cohort study. Paediatr Anaesth 2022; 32:899-906. [PMID: 35426458 PMCID: PMC9990726 DOI: 10.1111/pan.14460] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/15/2022] [Accepted: 04/10/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pain may be a modifiable risk factor for lower health-related quality of life after pediatric critical illness. AIM To evaluate the association between severe pain experienced in the (pediatrc intensive care unit) and postdischarge health-related quality of life. METHODS This was a retrospective cohort study. Children aged 1 month to 18 years admitted to the pediatric intensive care unit and enrolled in the Seattle Children's Hospital Outcomes Assessment Program were included. Pain was assessed every 2 h by bedside nursing staff using a behavioral pain scale or numeric pain scale. A day of severe pain was defined as a pediatric intensive care unit day with ≥25% of pain scores ≥7/10. Baseline (preadmission) and postdischarge (median 6 weeks) health-related quality of life was assessed by the Pediatric Quality of Life Inventory (PedsQL™) or the Stein Jessop Functional Status II-R (FS II-R, for children with developmental disability). The cohort was stratified by diagnosis category (surgical vs. medical), and associations were measured using linear regression models. RESULTS Among 546 patients, 11.9% experienced ≥1 day of severe pain. In multivariable linear regression, each day of severe pain was independently associated with a lower postdischarge health-related quality of life score by 3.6 points (95% CI -6.3 to -0.9) adjusted for baseline health-related quality of life score, age, baseline cognitive function, days with multi-organ dysfunction, pediatric intensive care unit length of stay, and decline in overall function. This association was stronger among surgical patients than medical patients with each day of severe pain resulting in a lower postdischarge health-related quality of life score by 5.3 points (95% CI -9.6 to -0.9) versus 2.6 points (95% CI -5.8 to 0.6). Surgical patients had lower postdischarge emotional functioning than physical functioning subdomain scores. CONCLUSIONS Children who experience severe pain in the pediatric intensive care unit have lower postdischarge health-related quality of life adjusting for baseline health-related quality of life, particularly among children who have undergone surgery. Attention to pain management may be important to improve postdischarge health-related quality of life.
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Affiliation(s)
- Mallory B Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA.,Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
| | - Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA.,Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
| | - Leslie A Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA.,Center for Clinical & Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Frederick P Rivara
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA.,Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA, USA.,Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - Noel S Weiss
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - Robert Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA.,Center for Child Health, Behavior, & Development, Seattle Children's Research Institute, Seattle, WA, USA
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19
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Affiliation(s)
- Elizabeth Y Killien
- Seattle Children's Hospital, Harborview Medical Center, Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Jerry J Zimmerman
- Seattle Children's Hospital, Harborview Medical Center, Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle
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20
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Abstract
OBJECTIVES To evaluate whether delirium during pediatric critical illness is associated with post-discharge health-related quality of life. DESIGN Retrospective cohort study. SETTING Academic tertiary care center. PATIENTS Children 1 month to 18 years old admitted to the PICU or cardiac ICU and enrolled in the Seattle Children's Hospital Outcomes Assessment Program. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Delirium was assessed twice daily using the Cornell Assessment of Pediatric Delirium; a score greater than or equal to 9 (with fluctuating level of arousal for children with developmental disability) indicated delirium. Baseline (pre-admission) and post-discharge health-related quality of life were assessed by the Pediatric Quality of Life Inventory (Mapi Research Trust, Lyon, France) or the Functional Status II-R (for children with developmental disability). Among 534 patients, delirium was common (44%), as was clinically important decline in health-related quality of life (≥ 4.5 points) from baseline to follow-up (22%), measured at median 6.6 weeks post-hospital discharge (interquartile range, 5.1-8.5). On univariate analysis, children with delirium had similar likelihood of health-related quality of life decline compared with those without (25.5% vs 19.7%; p = 0.1). Using multivariable logistic regression adjusting for age, medical complexity, predicted risk of mortality, admission diagnosis, receipt of noninvasive ventilation, hospital length of stay, time to follow-up, and parent age, delirium was independently associated with health-related quality of life decline among children assessed by the Pediatric Quality of Life Inventory (adjusted odds ratio, 2.0; 95% CI, 1.1-3.5). Among children evaluated with the Functional Status II-R, delirium was not independently associated with health-related quality of life decline (odds ratio, 1.4; 95% CI, 0.6-3.2). In both groups, longer time to follow-up was also independently associated with improvements in health-related quality of life. CONCLUSIONS Delirium during the ICU stay is associated with decline in health-related quality of life from baseline to post-discharge follow-up among children assessed by the Pediatric Quality of Life Inventory, who were generally characterized by normal baseline cognitive function and less medical comorbidity. This association was not present among children assessed by the Functional Status II-R, potentially due to their higher overall risk of health-related quality of life decline, or other clinical differences that modify the effects of delirium in this group.
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Affiliation(s)
- Leslie A. Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Clinical & Translational Research, Seattle Children’s Research Institute, Seattle, WA
| | - Elizabeth Y. Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA
| | - Mallory B. Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Child Health, Behavior, & Development, Seattle Children’s Research Institute, Seattle, WA
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21
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Brown SR, Roberts JS, Killien EY, Brogan TV, Farris R, Di Gennaro JL, Barreto J, McMullan DM, Weiss NS. Factors Associated with Pediatric In-Hospital Recurrent Cardiac Arrest. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0041-1741404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractThe objective of this article was to identify demographic and clinical factors associated with early recurrent arrest (RA) (<48 hours) and late RA (≥48 hours) among pediatric inpatients following an initial in-hospital cardiac arrest. A retrospective cohort study of inpatients was performed in a free-standing academic quaternary care children's hospital. All inpatients were <18 years old with a cardiac arrest event requiring ≥1 minute of cardiopulmonary resuscitation with the return of spontaneous circulation sustained for ≥20 minutes at Seattle Children's Hospital from February 1, 2012 to September 18, 2019. Of the 237 included patients, 20 (8%) patients had an early RA and 30 (13%) had a late RA. Older age and severe pre-arrest acidosis were associated with a higher risk of early RA, odds ratios (OR) 1.2 (95% confidence interval [CI] 1.1–1.3) per additional year and 4.6 (95% CI 1.2–18.1), respectively. Pre-arrest organ dysfunction was also associated with a higher risk of early RA with an OR of 3.3 (95% CI 1.1–9.4) for respiratory dysfunction, OR 1.4 (95% CI 1.1–1.9) for each additional dysfunctional organ system, and OR 1.1 (95% CI 1–1.2) for every one-point increase in PELOD2 score. The neonatal illness category was associated with a lower risk of late RA, OR 0.3 (95% CI 0.1–0.97), and severe post-arrest acidosis was associated with a higher risk of late RA, OR 4.2 (95% CI 1.1–15). Several demographic and clinical factors offer some ability to identify children who sustain a recurrent cardiac arrest, offering a potential opportunity for intervention to prevent early recurrent arrest.
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Affiliation(s)
- Stephanie R. Brown
- Division of Pediatric Critical Care Medicine, Oklahoma Children's Hospital, Oklahoma City, Oklahoma, United States
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Joan S. Roberts
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington, United States
- Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Elizabeth Y. Killien
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington, United States
- Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Thomas V. Brogan
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington, United States
- Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Reid Farris
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington, United States
- Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Jane L. Di Gennaro
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington, United States
- Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Jessica Barreto
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington, United States
- Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - D. Michael McMullan
- Division of Congenital Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington, United States
- Department of Surgery, University of Washington, Seattle, Washington, United States
| | - Noel S. Weiss
- Department of Epidemiology, University of Washington, Seattle, Washington, United States
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22
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Killien EY, Loftis LL, Clark JD, Muszynski JA, Rissmiller BJ, Singleton MN, White BR, Zimmerman JJ, Maddux AB, Pinto NP, Fink EL, Watson RS, Smith M, Ringwood M, Graham RJ. Health-related quality of life outcome measures for children surviving critical care: a scoping review. Qual Life Res 2021; 30:3383-3394. [PMID: 34185224 PMCID: PMC9116894 DOI: 10.1007/s11136-021-02928-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Health-related quality of life (HRQL) has been identified as one of the core outcomes most important to assess following pediatric critical care, yet there are no data on the use of HRQL in pediatric critical care research. We aimed to determine the HRQL instruments most commonly used to assess children surviving critical care and describe study methodology, patient populations, and instrument characteristics to identify areas of deficiency and guide investigators conducting HRQL research. METHODS We queried PubMed, EMBASE, PsycINFO, Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Registry for studies evaluating pediatric critical care survivors published 1970-2017. We used dual review for article selection and data extraction. RESULTS Of 60,349 citations, 66 articles met inclusion criteria. The majority of studies were observational (89.4%) and assessed HRQL at one post-discharge time-point (86.4%), and only 10.6% of studies included a baseline assessment. Time to the first follow-up assessment ranged from 1 month to 10 years post-hospitalization (median 3 years, IQR 0.5-6). For 26 prospective studies, the median follow-up time was 0.5 years [IQR 0.25-1]. Parent/guardian proxy-reporting was used in 83.3% of studies. Fifteen HRQL instruments were employed, with four used in >5% of articles: the Health Utility Index (n = 22 articles), the Pediatric Quality of Life Inventory (n = 17), the Child Health Questionnaire (n = 16), and the 36-Item Short Form Survey (n = 9). CONCLUSION HRQL assessment in pediatric critical care research has been centered around four instruments, though existing literature is limited by minimal longitudinal follow-up and infrequent assessment of baseline HRQL.
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Affiliation(s)
- Elizabeth Y Killien
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, FA 2.112, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
| | - Laura L Loftis
- Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jonna D Clark
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, FA 2.112, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Jennifer A Muszynski
- Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Brian J Rissmiller
- Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Marcy N Singleton
- Pediatric Critical Care, Children's Hospital At Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Benjamin R White
- Pediatric Critical Care Medicine, Penn State University College of Medicine, Hershey, PA, USA
| | - Jerry J Zimmerman
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, FA 2.112, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Aline B Maddux
- Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Neethi P Pinto
- Critical Care Medicine, Department of Anesthesiology and Critical Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - R Scott Watson
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, FA 2.112, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - McKenna Smith
- Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Melissa Ringwood
- Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Robert J Graham
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
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23
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Abstract
BACKGROUND Results of recent studies suggest that the incidence and mortality of ARDS may be higher than previously thought in pediatric trauma patients. We conducted a systematic review of the literature on incidence, risk factors, prognostic factors, and outcomes of ARDS after pediatric trauma in the ICU. METHODS Medical literature databases were searched up to April 2020. Guidelines for reporting systematic reviews and meta-analyses were followed. Articles that reported quantitative data with regard to the incidence, risk factors, prognostic factors, mortality, or other outcomes for ARDS in subjects with pediatric trauma admitted to the ICU were included. Two authors independently screened and assessed eligibility of all identified studies, collected data, and assessed the methodological quality of selected studies. Data extraction was performed by using a standardized data extraction sheet. Quality assessment was performed by using the Newcastle-Ottawa scale for cohort studies. A meta-analysis was not performed because the studies used overlapping cohorts or different ARDS criteria. RESULTS Nine studies were included. The incidence was reported in 4 studies, risk factors in 1, mortality in 7, and other outcomes in 2. The largest cohort included 148,749 subjects from a national trauma database. The ARDS incidence was 1.8%-7.6% when using adult ARDS criteria, with 1.8% in the largest cohort, and 4.2% when using pediatric ARDS criteria. Mortality was 7.6%-22.9% when using adult ARDS criteria and 11.1%-34.0% when using the pediatric ARDS criteria. Identified risk factors included mechanism of injury, higher injury severity scores, abnormal breathing frequencies, and lower Glasgow coma scale scores at hospital presentation. ARDS was associated with a longer duration of mechanical ventilation, longer ICU and hospital length of stay, and a higher likelihood of requiring post-discharge care. CONCLUSIONS The ARDS incidence of 4.2% in the subjects with pediatric trauma in the ICU was comparable with 3.2% in the general pediatric ICU population; however, mortality associated with trauma-associated ARDS was higher and more commonly due to multi-system organ failure rather than hypoxemia.
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Affiliation(s)
- Roel Ln Huijsmans
- University Medical Center Utrecht, Utrecht, The Netherlands. .,Intensive Care Unit, Wilhemina Children's Hospital, Utrecht, The Netherlands.,Utrecht University, Utrecht, The Netherlands
| | - Elizabeth Y Killien
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Luke Ph Leenen
- University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Josephus Pj Van Gestel
- University Medical Center Utrecht, Utrecht, The Netherlands.,Intensive Care Unit, Wilhemina Children's Hospital, Utrecht, The Netherlands
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24
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Abstract
OBJECTIVES To evaluate the optimal timing of tracheostomy for injured adolescents. DESIGN Retrospective cohort study. SETTING Trauma facilities in the United States. PATIENTS Adolescents (age 12-17 yr) in the National Trauma Data Bank (2007-2016) who were ventilated for greater than 24 hours and survived to discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After stratifying by traumatic brain injury diagnosis, we compared ICU and hospital length of stay, pneumonia, and discharge disposition of patients with tracheostomy prior to three cut points (3, 7, and 14 d after admission) to 1) patients intubated at least as long as each cut point and 2) patients with tracheostomy on or after each cut point. Of 11,045 patients, 1,391 (12.6%) underwent tracheostomy. Median time to tracheostomy was 9 days (interquartile range, 6-13 d) for traumatic brain injury and 7 days (interquartile range, 3-12 d) for nontraumatic brain injury patients. Nontraumatic brain injury patients with tracheostomy prior to 7 days had 5.6 fewer ICU days (-7.8 to -3.5 d) and 5.7 fewer hospital days (-8.8 to -2.7 d) than patients intubated greater than or equal to 7 days and had 14.8 fewer ICU days (-19.6 to -10.0 d) and 15.3 fewer hospital days (-21.7 to -8.9 d) than patients with tracheostomy greater than or equal to 7 days. Similar differences were observed at 14 days but not at 3 days for both traumatic brain injury and nontraumatic brain injury patients. At the 3- and 7-day cut points, both traumatic brain injury and nontraumatic brain injury patients with tracheostomy prior to the cut point had lower risk of pneumonia and risk of discharge to a facility than those with tracheostomy after the cut point. CONCLUSIONS For injured adolescents, tracheostomy less than 7 days after admission was associated with improved in-hospital outcomes compared with those who remained intubated greater than or equal to 7 days and with those with tracheostomy greater than or equal to 7 days. Tracheostomy between 3 and 7 days may be the optimal time point when prolonged need for mechanical ventilation is anticipated; however, unmeasured consequences of tracheostomy such as long-term complications and care needs must also be considered.
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Affiliation(s)
- Elissa K. Butler
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Department of Surgery, University of Washington, 1959 NE Pacific Street, WA 98195 USA
- Department of Surgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210 USA
| | - Elizabeth Y. Killien
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington and Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105 USA
| | - Jonathan I. Groner
- Center for Pediatric Trauma Research and Department of Pediatric Surgery, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
| | - Saman Arbabi
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Department of Surgery, University of Washington, 1959 NE Pacific Street, WA 98195 USA
| | - Monica S. Vavilala
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Department of Anesthesiology & Pain Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195 USA
| | - Frederick P. Rivara
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Division of General Pediatrics, Department of Pediatrics, University of Washington and Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105 USA
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25
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Killien EY, Huijsmans RLN, Vavilala MS, Schleyer AM, Robinson EF, Maine RG, Rivara FP. Association of Psychosocial Factors and Hospital Complications with Risk for Readmission After Trauma. J Surg Res 2021; 264:334-345. [PMID: 33848832 DOI: 10.1016/j.jss.2021.02.031] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/26/2021] [Accepted: 02/27/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Unplanned hospital readmissions are associated with morbidity and high cost. Existing literature on readmission after trauma has focused on how injury characteristics are associated with readmission. We aimed to evaluate how psychosocial determinants of health and complications of hospitalization combined with injury characteristics affect risk of readmission after trauma. MATERIALS AND METHODS We conducted a retrospective cohort study of adult trauma admissions from July 2015 to September 2017 to Harborview Medical Center in Seattle, Washington. We assessed patient, injury, and hospitalization characteristics and estimated associations between risk factors and unplanned 30-d readmission using multivariable generalized linear Poisson regression models. RESULTS Of 8916 discharged trauma patients, 330 (3.7%) had an unplanned 30-d readmission. Patients were most commonly readmitted with infection (41.5%). Independent risk factors for readmission among postoperative patients included public insurance (adjusted Relative Risk (aRR) 1.34, 95% CI 1.02-1.76), mental illness (aRR 1.39, 1.04-1.85), and chronic renal failure (aRR 2.17, 1.39-3.39); undergoing abdominal, thoracic, or neurosurgical procedures; experiencing an index hospitalization surgical site infection (aRR 4.74, 3.00-7.50), pulmonary embolism (aRR 3.38, 2.04-5.60), or unplanned ICU readmission (aRR 1.74, 1.16-2.62); shorter hospital stay (aRR 0.98/d, 0.97-0.99), and discharge to jail (aRR 4.68, 2.63-8.35) or a shelter (aRR 4.32, 2.58-7.21). Risk factors varied by reason for readmission. Injury severity, trauma mechanism, and body region were not independently associated with readmission risk. CONCLUSIONS Psychosocial factors and hospital complications were more strongly associated with readmission after trauma than injury characteristics. Improved social support and follow-up after discharge for high-risk patients may facilitate earlier identification of postdischarge complications.
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Affiliation(s)
- Elizabeth Y Killien
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington.
| | - Roel L N Huijsmans
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; University Medical Center Utrecht, Utrecht, Netherlands
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Anneliese M Schleyer
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington; Hospital Quality and Patient Safety, Harborview Medical Center, Seattle, Washington
| | - Ellen F Robinson
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Rebecca G Maine
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; Division of Trauma, Burn, and Critical Care Surgery, Department of Surgery, University of Washington, , Washington
| | - Frederick P Rivara
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, Washington
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26
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Heneghan JA, Sobotka SA, Hallman M, Pinto N, Killien EY, Palumbo K, Murphy Salem S, Mann K, Smith B, Steuart R, Akande M, Graham RJ. Outcome Measures Following Critical Illness in Children With Disabilities: A Scoping Review. Front Pediatr 2021; 9:689485. [PMID: 34277522 PMCID: PMC8283563 DOI: 10.3389/fped.2021.689485] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 04/01/2021] [Accepted: 06/08/2021] [Indexed: 11/13/2022] Open
Abstract
Children with disabilities compose a substantial portion of admissions and bed-days in the pediatric intensive care unit (PICU) and often experience readmissions over time. Impacts of a PICU admission on post-discharge health status may be difficult to distinguish from pre-existing disability in this population. Efforts to standardize outcome measures used for children with disabilities may help identify morbidities associated with PICU hospitalizations. Although a scoping review of outcome measures to assess children after episodes of critical illness has recently been published, it is not known to what extent these measures are appropriate for use in children with disabilities. This limits our ability to effectively measure long-term outcomes following critical illness in this important patient population. Through mixed methodology of scoping review and multi-stakeholder consensus, we aimed to identify and describe instruments previously utilized for this purpose and to explore additional tools for consideration. This yielded 51 measures across a variety of domains that have been utilized in the PICU setting and may be appropriate for use in children with disabilities. We describe characteristics of these instruments, including the type of developmental domains assessed, availability of population data, validation and considerations regarding administration in children with disabilities, and ease of availability of the instrument to researchers. Additionally, we suggest needed alterations or accommodations for these instruments to augment their utility in these populations, and highlight areas for future instrument development.
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Affiliation(s)
- Julia A Heneghan
- Division of Pediatric Critical Care Medicine, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States
| | - Sarah A Sobotka
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, The University of Chicago, Chicago, IL, United States
| | - Madhura Hallman
- Division of Pediatric Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Neethi Pinto
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States
| | - Kathryn Palumbo
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, United States
| | - Sinead Murphy Salem
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Kilby Mann
- Department of Physical Medicine and Rehabilitation, Children's Hospital Colorado, University of Colorado, Aurora, CO, United States
| | - Barbara Smith
- Departments of Physical Therapy and Pediatrics, University of Florida, Gainesville, FL, United States
| | - Rebecca Steuart
- Division of Hospital Medicine, Cincinnati Children's Medical Center, Cincinnati, OH, United States
| | - Manzilat Akande
- Department of Pediatrics, Oklahoma University Health Sciences Center, Oklahoma, OK, United States
| | - Robert J Graham
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
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27
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Erickson SL, Killien EY, Wainwright M, Mills B, Vavilala MS. Mean Arterial Pressure and Discharge Outcomes in Severe Pediatric Traumatic Brain Injury. Neurocrit Care 2020; 34:1017-1025. [PMID: 33108627 DOI: 10.1007/s12028-020-01121-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVE Optimizing blood pressure is an important target for intervention following pediatric traumatic brain injury (TBI). The existing literature has examined the association between systolic blood pressure (SBP) and outcomes. Mean arterial pressure (MAP) is a better measure of organ perfusion than SBP and is used to determine cerebral perfusion pressure but has not been previously examined in relation to outcomes after pediatric TBI. We aimed to evaluate the strength of association between MAP-based hypotension early after hospital admission and discharge outcome and to contrast the relative strength of association of hypotension with outcome between MAP-based and SBP-based blood pressure percentiles. METHODS We examined the association between lowest age-specific MAP percentile within 12 h after pediatric intensive care unit admission and poor discharge outcome (in-hospital death or transfer to a skilled nursing facility) in children with severe (Glasgow Coma Scale score < 9) TBI who survived at least 12 h. Poisson regression results were adjusted for maximum head Abbreviated Injury Scale (AIS) severity score, maximum nonhead AIS, and vasoactive medication use. We also examined the ability of lowest MAP percentile during the first 12 h to predict discharge outcomes using receiver operating curve characteristic analysis without adjustment for covariates. We contrasted the predictive ability and the relative strength of association of blood pressure with outcome between MAP and SBP percentiles. RESULTS Data from 166 children aged < 18 years were examined, of whom 20.4% had a poor discharge outcome. Poor discharge outcome was most common among patients with lowest MAP < 5th percentile (42.9%; aRR 5.3 vs. 50-94th percentile, 95% CI 1.2, 23.0) and MAP 5-9th percentile (40%; aRR 8.5, 95% CI 1.9, 38.7). Without adjustment for injury severity or vasoactive medication use, lowest MAP percentile was moderately predictive of poor discharge outcome (AUC: 0.75, 95% CI 0.66, 0.85). In contrast, lowest SBP was associated with poor discharge outcome only for the < 5th percentile (50%; aRR 5.4, 95% CI 1.3, 22.2). Lowest SBP percentile was moderately predictive of poor discharge outcome (AUC: 0.82, 95% CI 0.74, 0.91). CONCLUSIONS In children with severe TBI, a single MAP < 10th percentile during the first 12 h after Pediatric Intensive Care Unit admission was associated with poor discharge outcome. Lowest MAP percentile during the first 12 h was moderately predictive of poor discharge outcome. Lowest MAP percentile was more strongly associated with outcome than lowest SBP percentile but had slightly lower predictive ability than SBP.
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Affiliation(s)
- Scott L Erickson
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA.,Department of Epidemiology, University of Washington, Seattle, USA
| | - Elizabeth Y Killien
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA. .,Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Mark Wainwright
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, USA
| | - Brianna Mills
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA.,Department of Epidemiology, University of Washington, Seattle, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA
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28
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Abstract
OBJECTIVES Pediatric protocols to guide allocation of limited resources during a disaster lack data to validate their use. The 2011 Pediatric Emergency Mass Critical Care Task Force recommended that expected duration of critical care be incorporated into resource allocation algorithms. We aimed to determine whether currently available pediatric illness severity scores can predict duration of critical care resource use. DESIGN Retrospective cohort study. SETTING Seattle Children's Hospital. PATIENTS PICU patients admitted 2016-2018 for greater than or equal to 12 hours (n = 3,206). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We developed logistic and linear regression models in two-thirds of the cohort to predict need for and duration of PICU resources based on Pediatric Risk of Mortality-III, Pediatric Index of Mortality-3, and serial Pediatric Logistic Organ Dysfunction-2 scores. We tested the predictive accuracy of the models with the highest area under the receiver operating characteristic curve (need for each resource) and R (duration of use) in a validation cohort of the remaining one of three of the sample and among patients admitted during one-third of the sample and among patients admitted during surges of respiratory illness. Pediatric Logistic Organ Dysfunction score calculated 12 hours postadmission had higher predictive accuracy than either Pediatric Risk of Mortality or Pediatric Index of Mortality scores. Models incorporating 12-hour Pediatric Logistic Organ Dysfunction score, age, Pediatric Overall Performance Category, Pediatric Cerebral Performance Category, chronic mechanical ventilation, and postoperative status had an area under the receiver operating characteristic curve = 0.8831 for need for any PICU resource (positive predictive value 80.2%, negative predictive value 85.9%) and area under the receiver operating characteristic curve = 0.9157 for mechanical ventilation (positive predictive value 85.7%, negative predictive value 89.2%) within 7 days of admission. Models accurately predicted greater than or equal to 24 hours of any resource use for 78.9% of patients and greater than or equal to 24 hours of ventilation for 83.1%. Model fit and accuracy improved for prediction of resource use within 3 days of admission, and was lower for noninvasive positive pressure ventilation, vasoactive infusions, continuous renal replacement therapy, extracorporeal membrane oxygenation, and length of stay. CONCLUSIONS A model incorporating 12-hour Pediatric Logistic Organ Dysfunction score performed well in estimating how long patients may require PICU resources, especially mechanical ventilation. A pediatric disaster triage algorithm that includes both likelihood for survival and for requiring critical care resources could minimize subjectivity in resource allocation decision-making.
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Affiliation(s)
- Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Brianna Mills
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Nicole A Errett
- Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, WA
| | - Vicki Sakata
- Northwest Healthcare Response Network, Tukwila, WA
- Pediatric Emergency Medicine, Mary Bridge Children's Hospital, Tacoma, WA
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Frederick P Rivara
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA
| | - Niranjan Kissoon
- Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
| | - Mary A King
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
- Northwest Healthcare Response Network, Tukwila, WA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
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Sodders MD, Killien EY, Stansbury LG, Vavilala MS, Moore M. Race/Ethnicity and Informal Caregiver Burden After Traumatic Brain Injury: A Scoping Study. Health Equity 2020; 4:304-315. [PMID: 32760875 PMCID: PMC7398439 DOI: 10.1089/heq.2020.0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2020] [Indexed: 01/07/2023] Open
Abstract
Background: Informal caregivers for persons with traumatic brain injury (TBI) face a range of unique issues, and racial/ethnic group differences in caregiver challenges are poorly understood. We undertook a scoping study of peer-reviewed literature to assess the quantity and quality of available research describing differences by race/ethnicity in informal caregiving roles and burden. Methods: Using Arksey and O'Malley's framework and guided by the Preferred Reporting Items of Systematic Reviews and Meta-analyses Extension for Scoping Reviews, we conducted electronic searches of PubMed, CINAHL, PsycARTICLES, PsycINFO, Social Work Abstracts, Embase, and Scopus to identify peer-reviewed studies that examined TBI informal caregiver burden and reported on the influences of race or ethnicity. Results: Among 4523 unique publications identified and screened, 11 studies included sufficient race/ethnicity data and were included in the analysis. Of these, six studies described civilian populations and five described military Veterans Affairs (VA). Included studies revealed that nonwhite caregivers and white caregivers use different approaches and coping strategies in their caregiving role. Some studies found differences in caregiver burden by race or ethnicity, others did not. Most were limited by a small sample size and overdependence on assessment tools not validated for the purposes or populations for which they were used. This was particularly true for race/ethnicity as a factor in TBI caregiver burden in VA groups, where essential characteristics moderate the association of race/ethnicity with socioeconomic factors. Conclusions: This scoping study highlights the paucity of information on race/ethnicity as a factor in TBI caregiver burden and roles, and suggests that innovative and alternative approaches to research are needed to explore needed changes in practice.
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Affiliation(s)
- Mark D Sodders
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA.,Department of Child, Family, and Population Health Nursing, School of Nursing, University of Washington, Seattle, Washington, USA.,Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Elizabeth Y Killien
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Lynn G Stansbury
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA.,Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA.,Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Megan Moore
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA.,School of Social Work, University of Washington, Seattle, Washington, USA
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Killien EY, Mills B, Vavilala MS, Watson RS, OʼKeefe GE, Rivara FP. Association between age and acute respiratory distress syndrome development and mortality following trauma. J Trauma Acute Care Surg 2020; 86:844-852. [PMID: 30633097 DOI: 10.1097/ta.0000000000002202] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Improved understanding of the relationship between patient age and acute respiratory distress syndrome (ARDS) development and mortality following traumatic injury may help facilitate generation of new hypotheses about ARDS pathophysiology and the role of novel treatments to improve outcomes across the age spectrum. METHODS We conducted a retrospective cohort study of trauma patients included in the National Trauma Data Bank who were admitted to an intensive care unit from 2007 to 2016. We determined ARDS incidence and mortality across eight age groups for the entire 10-year study period and by year. We used generalized linear Poisson regression models adjusted for underlying mortality risk (injury mechanism, Injury Severity Score, admission Glasgow Coma Scale score, admission heart rate, and admission hypotension). RESULTS Acute respiratory distress syndrome occurred in 3.1% of 1,297,190 trauma encounters. Acute respiratory distress syndrome incidence was lowest among pediatric patients and highest among adults aged 35 to 64 years. Acute respiratory distress syndrome mortality was highest among patients 80 years or older (43.9%), followed by 65 to 79 years (30.6%) and 4 years or younger (25.3%). The relative risk of mortality associated with ARDS was highest among the pediatric age groups, with an adjusted relative risk (aRR) of 2.06 (95% confidence interval [CI], 1.72-2.70) among patients 4 years or younger compared with an aRR of 1.51 (95% CI, 1.42-1.62) for the entire cohort. Acute respiratory distress syndrome mortality increased over the 10-year study period (aRR, 1.03 per year; 95% CI, 1.02-1.05 per year), whereas all-cause mortality decreased (aRR, 0.98 per year; 95% CI, 0.98-0.99 per year). CONCLUSIONS While ARDS development following traumatic injury was most common in middle-aged adults, patients 4 years or younger and 65 years or older with ARDS experienced the highest burden of mortality. Children 4 years or younger were disproportionately affected by ARDS relative to their low underlying mortality following trauma that was not complicated by ARDS. Acute respiratory distress syndrome-associated mortality following trauma has worsened over the past decade, emphasizing the need for new prevention and treatment strategies. LEVEL OF EVIDENCE Prognostic/epidemiological study, level III.
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Affiliation(s)
- Elizabeth Y Killien
- From the Harborview Injury Prevention and Research Center (E.Y.K., B.M., M.S.V., G.E.O., F.P.R.), University of Washington, Seattle, Washington; Division of Pediatric Critical Care Medicine, Department of Pediatrics (E.Y.K., R.S.W.), University of Washington, Seattle, Washington; Department of Anesthesiology and Pain Medicine (M.S.V.), University of Washington, Seattle, Washington; Center for Child Health, Behavior, and Development (R.S.W., F.P.R.), Seattle Children's Research Institute, Seattle, Washington; Department of Surgery (G.E.O.), University of Washington, Seattle, Washington; Division of General Pediatrics, Department of Pediatrics (F.P.R.), University of Washington, Seattle, Washington
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Watson RS, Asaro LA, Hutchins L, Bysani GK, Killien EY, Angus DC, Wypij D, Curley MAQ. Risk Factors for Functional Decline and Impaired Quality of Life after Pediatric Respiratory Failure. Am J Respir Crit Care Med 2019; 200:900-909. [PMID: 31034245 PMCID: PMC6812438 DOI: 10.1164/rccm.201810-1881oc] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 04/24/2019] [Indexed: 11/16/2022] Open
Abstract
Rationale: Poor outcomes of adults surviving critical illness are well documented, but data in children are limited.Objectives: To identify factors associated with worse postdischarge function and health-related quality of life (HRQL) after pediatric acute respiratory failure.Methods: We assessed functional status at baseline, discharge, and 6 months after pediatric ICU discharge and HRQL 6 months after discharge in 2-week- to 17-year-olds mechanically ventilated for acute respiratory failure in the RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) trial. We assessed HRQL via Infant and Toddler Quality of Life Questionnaire-97 (<2 yr old) or Pediatric Quality of Life Inventory (≥2 yr old). We categorized patients with normal baseline function as having impaired HRQL if scores were greater than 1 SD below mean norms for Infant and Toddler Quality of Life Questionnaire-97 growth and development or Pediatric Quality of Life Inventory total score.Measurements and Main Results: One-fifth (n = 192) of 949 patients declined in function from baseline to postdischarge; 20% (55/271) had impaired growth and development; 19% (64/343) had impaired HRQL. In multivariable analyses, decline in function was associated with baseline impaired function, prematurity, cancer, respiratory failure etiology, ventilation duration, and clonidine (odds ratio [OR] = 2.14; 95% confidence interval [CI] = 1.22-3.76). Independent predictors of impaired growth and development included methadone (OR = 2.27; 95% CI = 1.18-4.36) and inadequate pain management (OR = 2.94; 95% CI = 1.39-6.19). Impaired HRQL was associated with older age, non-white or Hispanic race, cancer, and inadequate sedation management (OR = 3.15; 95% CI = 1.74-5.72).Conclusions: Postdischarge morbidity after respiratory failure is common and associated with admission factors, exposure to critical care therapies, and pain and sedation management.
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Affiliation(s)
- R Scott Watson
- Department of Pediatrics, University of Washington, Seattle, Washington
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Lisa A Asaro
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Larissa Hutchins
- Department of Patient Care Services, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - G Kris Bysani
- Medical City Children's Hospital, Dallas, Texas
- Pediatric Acute Care Associates of North Texas, Dallas, Texas
| | - Elizabeth Y Killien
- Department of Pediatrics, University of Washington, Seattle, Washington
- Harborview Injury Prevention and Research Center, Seattle, Washington
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Martha A Q Curley
- School of Nursing and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
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Yang JT, Erickson SL, Killien EY, Mills B, Lele AV, Vavilala MS. Agreement Between Arterial Carbon Dioxide Levels With End-Tidal Carbon Dioxide Levels and Associated Factors in Children Hospitalized With Traumatic Brain Injury. JAMA Netw Open 2019; 2:e199448. [PMID: 31418806 PMCID: PMC6704750 DOI: 10.1001/jamanetworkopen.2019.9448] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
IMPORTANCE Alterations in the partial pressure of carbon dioxide, arterial (Paco2) can affect cerebral perfusion after traumatic brain injury. End-tidal carbon dioxide (EtCO2) monitoring is a noninvasive tool used to estimate Paco2 values. OBJECTIVE To examine the agreement between Paco2 and EtCO2 and associated factors in children with traumatic brain injury. DESIGN, SETTING, AND PARTICIPANTS A secondary analysis was conducted using data from a prospective cohort study of 137 patients younger than 18 years with traumatic brain injury who were admitted to the pediatric intensive care unit of a level I trauma center between May 1, 2011, and July 31, 2017. Analysis was performed from December 17, 2018, to January 10, 2019. MAIN OUTCOMES AND MEASURES The closest EtCO2 value obtained within 30 minutes of a Paco2 value and the closest systolic blood pressure value obtained within 60 minutes prior to a Paco2 value during the first 24 hours after admission were recorded. The main outcome of Paco2-EtCO2 agreement was defined as Paco2 between 0 and 5 mm Hg greater than the paired EtCO2 value, and it was determined using Bland-Altman analysis, Passing and Bablok regression, and the Pearson correlation coefficient. Multivariable regression models determined which factors were associated with agreement. RESULTS The analysis included 137 patients (34 girls and 103 boys; mean [SD] age, 10.0 [6.3] years) and 445 paired Paco2-EtCO2 data points. On average, Paco2 was 2.7 mm Hg (95% limits of agreement, -11.3 to 16.7) higher than EtCO2. Overall, 187 of all Paco2-EtCO2 pairs (42.0%) agreed. There was larger variation in the Paco2-EtCO2 difference during the first 8 hours compared with 9 to 24 hours after admission to the pediatric intensive care unit. Development of pediatric acute respiratory distress syndrome within 24 hours of admission was associated with a lower likelihood of Paco2-EtCO2 agreement (adjusted odds ratio, 0.20; 95% CI, 0.08-0.51) compared with no development of pediatric acute respiratory distress syndrome. A diagnosis of pediatric acute respiratory distress syndrome 1 to 7 days after admission was associated with a larger first-day Paco2-EtCO2 difference compared with those who never developed pediatric acute respiratory distress syndrome (mean [SD] difference, 4.48 [3.70] vs 0.46 [5.50] mm Hg). CONCLUSIONS AND RELEVANCE In this study of pediatric traumatic brain injury, Paco2-EtCO2 agreement was low, especially among patients with pediatric acute respiratory distress syndrome. Low Paco2-EtCO2 agreement early in hospitalization may be associated with future development of pediatric acute respiratory distress syndrome. Data on EtCO2 should not be substituted for data on Paco2 during the first 24 hours.
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Affiliation(s)
- Jen-Ting Yang
- Harborview Injury Prevention and Research Center, University of Washington, Seattle
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle
| | - Scott L. Erickson
- Harborview Injury Prevention and Research Center, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
| | - Elizabeth Y. Killien
- Harborview Injury Prevention and Research Center, University of Washington, Seattle
- Department of Pediatrics, University of Washington, Seattle
| | - Brianna Mills
- Harborview Injury Prevention and Research Center, University of Washington, Seattle
| | - Abhijit V. Lele
- Harborview Injury Prevention and Research Center, University of Washington, Seattle
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle
| | - Monica S. Vavilala
- Harborview Injury Prevention and Research Center, University of Washington, Seattle
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle
- Department of Pediatrics, University of Washington, Seattle
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Engen RM, Killien EY, Davis JL, Symons JM, Hartmann SM. C septicum Complicating Hemolytic Uremic Syndrome: Survival Without Surgical Intervention. Pediatrics 2017; 139:peds.2016-1362. [PMID: 28183731 PMCID: PMC5330394 DOI: 10.1542/peds.2016-1362] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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] [Accepted: 10/24/2016] [Indexed: 12/13/2022] Open
Abstract
Clostridium septicum is an anaerobic bacterium that causes rapidly progressive myonecrosis, bacteremia, and central nervous system infection. It has been reported as a complication of Escherichia coli hemolytic uremic syndrome (HUS) in 8 children worldwide; 5 children died, and the 3 reported survivors had surgically treated disease. We present 3 cases of C septicum complicating HUS in children, including the first 2 reported cases of survival without surgical intervention. All patients presented with classic cases of HUS with initial clinical improvement followed by deterioration. Patient 1 had rising fever, tachycardia, and severe abdominal pain 24 hours after admission. She developed large multifocal intraparenchymal cerebral hemorrhages and died 12 hours later. Autopsy revealed C septicum intestinal necrosis, myonecrosis, and encephalitis. Patient 2 had new fever, increasing leukocytosis, and severe abdominal pain on hospital day 4. She was diagnosed with C septicum bacteremia and treated with metronidazole, meropenem, and clindamycin. Patient 3 had new fever and increasing leukocytosis on hospital day 3; blood cultures grew C septicum, and she was treated with penicillin. Patients 2 and 3 improved rapidly and did not require surgery. C septicum is a potential co-infection with E coli It thrives in the anaerobic environment of E coli-damaged intestinal mucosa and translocates to cause systemic infection. Fever, tachycardia, a rising white blood cell count, and abdominal pain out of proportion to examination are key findings for which physicians should be vigilant. Timely evaluation by anaerobic blood culture and early initiation of antibiotics are necessary to prevent fatalities.
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Affiliation(s)
| | | | - Jessica L. Davis
- Pathology, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, Washington; and,Departments of Pathology and Laboratory Medicine, University of California San Francisco, San Francisco, California
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Zimmerberg B, Martinez AR, Skudder CM, Killien EY, Robinson SA, Brunelli SA. Effects of gestational allopregnanolone administration in rats bred for high affective behavior. Physiol Behav 2010; 99:212-7. [DOI: 10.1016/j.physbeh.2009.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Revised: 03/23/2009] [Accepted: 05/20/2009] [Indexed: 10/20/2022]
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