Incidence of acute respiratory distress syndrome: a comparison of two definitions

OBJECTIVES—To determine the incidence and outcome of acute respiratory distress syndrome (ARDS) in children by comparing two commonly used definitions: the lung injury score and the American-European Consensus Conference definition. The causes and risk for developing ARDS were also studied.METHODS—Part prospective and retrospective analysis of 8100 consecutive hospital admissions from 1 June 1995 to 1 April 1997.RESULTS—Twenty one patients fulfilled the criteria for ARDS. Both definitions identified the same group of patients. The incidence was 2.8/1000 hospital admissions or 4.2% of paediatric intensive care unit admissions. The main causes were sepsis and pneumonia. Mortality was 13 of 21. Factors predicting death were a high admission paediatric risk of mortality (PRISM) score (30.38 v 18.75) and the presence of multiple organ dysfunction syndrome (92% v 25%).CONCLUSION—Both definitions identified similar groups of patients. The incidence in this population was higher than that reported elsewhere, but mortality and cause were similar to those in developed countries. Poor outcome was associated with sepsis, a high admission PRISM score, and simultaneous occurrence of other organ dysfunction.     

Sepsis, severe sepsis and septic shock in paediatric multiple organ dysfunction syndrome

OBJECTIVES: To determine the association between severity of sepsis with outcome and severity of illness in children with multiple organ dysfunction syndrome (MODS). MATERIALS: Four hundred and ninety-five consecutive paediatric intensive care unit (PICU) admissions were analysed. multiple organ dysfunction syndrome was defined as simultaneous dysfunction of >/= 2 organ system and sepsis by the American College of Chest Physicians and Society of Critical Care Medicine Consensus Conference definition. RESULTS: Eighty-four patients developed MODS. The incidence of sepsis, severe sepsis and septic shock in these patients was 10.7%, 23.8% and 17.9%, respectively. Worsening categories of sepsis were associated with: (1) a higher mean admission Paediatric Risk of Mortality (PRISM II): 36.6 +/- 25.9, 56.8 +/- 32.1 and 73.6 +/- 28.5%, respectively (P = 0. 005), (2) a larger number of organ dysfunctions: mean MODS index of 37%, 46% and 58%, respectively (P = 0.007), and (3) a higher mortality: 22.2%, 65% and 80%, respectively (P = 0.03). CONCLUSION: Presence of sepsis, severe sepsis and septic shock was associated with an increasing severity of illness, increased number of organ dysfunctions and a distinct risk of mortality among critically ill children.     

Evaluation of the outcome of patients admitted to the pediatric intensive care unit in Alexandria using the pediatric risk of mortality (PRISM) score

The aim of this prospective study was to evaluate the use of pediatric risk of mortality (PRISM) score to predict the patient outcome in Alexandria Pediatric Intensive Care Unit (PICU). The study included all admissions to a tertiary care teaching hospital for 13 months. All patients were subjected to thorough history taking and clinical examination. The PRISM score was obtained within 8 h from admission (including 14 parameters with 34 variables). The primary affected system, referral site, number of organ failure on admission, length of hospital stay (LOS) and outcome of patients were recorded. The bed occupancy rate, turnover rate, average LOS, total and adjusted death rates were also recorded. Results showed that the total and adjusted mortality rates were 50 and 38 per cent respectively (n = 205/406 and 125/326, respectively). The mean PRISM score on admission was 26. Non-survivors showed a significantly higher mean score compared with survivors (36 vs. 17). Non-survivors compared with survivors, were significantly younger (12 vs. 23 months), had shorter LOS (3.8 vs. 5.3 days), three or four organ system failure on admission (77 vs. 25 per cent, and 9 vs. 0 per cent of patients) and had significantly higher percentage of sepsis syndrome and neurological diseases, as the primary affected system (20 vs. 10 per cent and 26 vs. 16 per cent). The PRISM score showed a significant positive correlation only with the number of organ failure on admission (r = 0.8104; p < 0.001). The cut-off point of survival was a PRISM score 26 with expected/observed ratio of 1.05 for non-survivors with 91.6 per cent accuracy. Multiple logistic regression analysis revealed that PRISM score, LOS, and the primary affected system were relevant predictors of patient outcome in PICU. In conclusion, the PRISM score is proved to be a good predictor of outcome for children admitted to a PICU with a cut-off point of 26. The mortality in the PICU is affected by LOS, primary system affected, and number of organ failure on admission.     

La escala pediátrica de evaluación del fallo multiorgánico secuencial (pSOFA): una nueva escala de predicción de la mortalidad en la unidad de cuidados intensivos pediátricos

ObjectivesTo assess performance of the age-adapted SOFA score in children admitted into Paediatric Intensive Care Units (PICUs) and whether the SOFA score can compete with the systemic inflammatory response syndrome (SIRS) in diagnosing sepsis, as recommended in the Sepsis-3 consensus definitions.MethodsTwo-centre prospective observational study in 281 children admitted to the PICU. We calculated the SOFA, Pediatric Risk of Mortality (PRISM), and Pediatric Index of Mortality-2 (PIM2) scores and assessed for the presence of SIRS at admission. The primary outcome was 30-day mortality.ResultsThe SOFA score was higher in nonsurvivors (P<.001) and mortality increased progressively across patient subgroups from lower to higher SOFA scores. The receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) of the SOFA score for predicting 30-day mortality was 0.89, compared to AUCs of 0.84 and 0.79 for the PRISM and PIM2 scores, respectively. The AUC of the SOFA score for predicting a prolonged stay in the PICU was 0.67. The SOFA score was correlated to the PRISM score (r_s=0.59) and the PIM2 score (r_s=0.51). In children with infection, the AUC of the SOFA score for predicting mortality was 0.87 compared to an AUC of 0.60 using SIRS. The diagnosis of sepsis applying a SOFA cutoff of 3 points predicted mortality better than both the SIRS and the SOFA cutoff of 2 points recommended by the Sepsis-3 consensus.ConclusionsThe SOFA score at admission is useful for predicting outcomes in the general PICU population and is more accurate than SIRS for definition of paediatric sepsis.     

Paediatric intensive care in Kuala Lumpur, Malaysia: a developing subspecialty

Paediatric intensive care in Malaysia is a developing subspecialty with an increasing number of specialists with a paediatric background being involved in the care of critically ill children. A part prospective and part retrospective review of 118 consecutive non-neonatal ventilated patients in University Hospital, Kuala Lumpur was carried out from 1 June 1995 to 31 December 1996 to study the clinical epidemiology and outcome in our paediatric intensive case unit (PICU). The mean age of the patients was 33.9 +/- 6.0 months (median 16 months). The main mode of admission was emergency (96.6 per cent) with an overall mortality rate of 42 per cent (50/118). The mean paediatric risk of mortality (PRISM) score was 20 +/- 0.98 SEM, with 53 per cent of patients having a score of over 30 per cent. Multiorgan dysfunction (MODS) was identified in 71 per cent of patients. Admission efficiency (mortality risk > 1 per cent) was 97 per cent. Standardized mortality rate using PRISM was an acceptable 1.06. The main diagnostic categories were respiratory (32 per cent), neurology (22 per cent), haematology-oncology (18 per cent); the aetiology of dysfunction was mainly infective. Non-survivors were older (29.5 vs. 13.8 months, p < 0.0001), had more severe illness (mean PRISM score 30 vs. 14, p < 0.0001), were more likely to develop MODS (96 vs. 53 per cent, p < 0.0001) and required more intervention and monitoring. Paediatric intensive care in Malaysia differs widely from that in developed countries in patient characteristics, severity of illness, and care modalities provided.     

Incidence,management and mortality of acute hypoxemic respiratory failure and acute respiratory distress syndrome from a prospective study of Chinese paediatric intensive care network

Aim: To investigate the incidence, clinical management, mortality and its risk factors, major outcome and costs of acute hypoxemic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS) in a Chinese network of 26 paediatric intensive care unit (PICU). Methods: In a consecutive 12‐month period, AHRF and ARDS were identified and followed up for 90 days or until death or discharge. Results: From a total of 11 521 critically ill patients, 461 AHRF were identified in which 306 developed ARDS (66.4%), resulting in incidences of 4% and 2.7%, respectively, with pneumonia (75.1%) and sepsis (14.7%) as main underlying diseases and 83% were 5 years and 1 month‐old. In‐hospital mortality of AHRF was 41.6% (44.8% for ARDS), accounted for 15.5% of all PICU deaths. For those of pneumonia or sepsis with AHRF and ARDS, mortality and its relative risk were significantly higher than those without. Relatively lower tidal volume and total fluid balance, adequate upper limit of PaCO₂ in the early PICU days, and family affordability, tended to result in better outcome. Conclusion: In this prospective study, AHRF had high possibilities to develop ARDS and death risk, as impacted by ventilation settings and fluid intake in the early treatment, as well as socioeconomic factors, which should be considered for implementation of standard of care in respiratory therapy.     

Risk adjusted mortality of critical illness in a defined geographical region.

AIMS: To evaluate the performance of the Paediatric Risk of Mortality (PRISM) score in a population of UK children and to use this score to examine severity of illness adjusted mortality of critically ill children <16 years old in a defined geographical region. METHODS: Observational study of a defined population of critically ill children (<16 years old) admitted to hospitals in the South West Region between 1 December 1996 and 30 November 1998. RESULTS: Data were collected from 1148 eligible admissions. PRISM was found to perform acceptably in this population. There was no significant difference between the overall number of observed deaths and those predicted by PRISM. Admissions with mortality risk 30% or greater had significantly greater odds ratio for death in general intensive care units compared with the tertiary paediatric intensive care unit. CONCLUSIONS: Children with a high initial risk of mortality based on PRISM score were significantly more likely to survive in a tertiary paediatric intensive care unit than in general intensive care units in this region. However, there was no evidence from this study that admissions with lower mortality risk than 30% had significantly worse mortality in non-tertiary general units than in tertiary paediatric intensive care units.     

小儿严重脓毒症并发多器官功能障碍综合征的研究

目的 小儿脓毒症是PICU的常见疾病,具有较高的病死率.本研究旨在了解小儿脓毒症的临床特点及转归,探寻儿童严重脓毒症的死亡危险因素.方法 分析2008年1月至12月收入我院PICU的脓毒症病例,对严重脓毒症患儿作单因素分析,并建立Logistic回归模型,探寻儿童严重脓毒症的死亡危险因素.结果 纳入脓毒症患儿103例,病死率16.5%.严重脓毒症45例,其死亡危险因素是PRISM Ⅲ评分(OR 1.502;95%CI 1.131～1.995)和病程中外周血血小板计数最高值(OR 0.991;95%CI0.982～1.000).小儿严重脓毒症伴随1、2、3、4个及4个以上脏器功能障碍的病死率分别为10.0%、11.1%、44.4%、68.8%,差异具有非常显著性(P＜0.001).最常受累的是心血管系统(75.6%)和呼吸系统(66.7%),严重脓毒症伴发MODS死亡危险因素是呼吸系统(OR 23.179;95%CI2.095～256.522)和肾脏(OR 9.637;95%CI 1.698～54.703)功能受累.结论 小儿严重脓毒症的死亡危险因素是PRISM Ⅲ评分和病程中外周血血小板计数最高值.小儿脓毒症合并MODS提示预后不良,其病死率与发生功能障碍的脏器数目呈正相关,呼吸系统和肾脏功能受累是儿童脓毒症死亡的危险因素.     

Risk adjusted mortality of critical illness in a defined geographical region

Aims: To evaluate the performance of the Paediatric Risk of Mortality (PRISM) score in a population of UK children and to use this score to examine severity of illness adjusted mortality of critically ill children <16 years old in a defined geographical region. Methods: Observational study of a defined population of critically ill children (<16 years old) admitted to hospitals in the South West Region between 1 December 1996 and 30 November 1998. Results: Data were collected from 1148 eligible admissions. PRISM was found to perform acceptably in this population. There was no significant difference between the overall number of observed deaths and those predicted by PRISM. Admissions with mortality risk 30% or greater had significantly greater odds ratio for death in general intensive care units compared with the tertiary paediatric intensive care unit. Conclusions: Children with a high initial risk of mortality based on PRISM score were significantly more likely to survive in a tertiary paediatric intensive care unit than in general intensive care units in this region. However, there was no evidence from this study that admissions with lower mortality risk than 30% had significantly worse mortality in non-tertiary general units than in tertiary paediatric intensive care units.     

Prospective evaluation of the Paediatric Risk of Mortality (PRISM) score.

The performance of the admission day Paediatric Risk of Mortality (PRISM) score for outcome prediction was assessed prospectively in 270 consecutive admissions, aged 3 days to 18.6 years, to a paediatric intensive care unit. Using a cut off of r = 0.00 (expected mortality = 50%), the overall sensitivity (correct prediction of death) was 48% while specificity (correct prediction of survival) was 99%, comparable with the original validation data of the score in the USA. Outcome prediction was most accurate when the stay in the paediatric intensive care unit was between one and four days. Sensitivity was appreciably lower for operative patients (17%) compared with non-operative patients (71%) because of a failure to predict deaths after cardiac surgery. The sensitivity (41%) and specificity (99%) using five variables (systolic blood pressure, Glasgow coma scale, carbon dioxide tension, and serum bicarbonate and serum calcium concentrations) was similar to that using all 14 variables. Six variable ranges related differently with non-survival compared with the score. It is concluded that the performance of the PRISM score is institution independent and good for short stay patients. It underpredicts deaths after cardiac surgery. Only five variables may be needed for satisfactory outcome prediction. Some of the variables need reweighting for paediatric intensive care units in the UK.     

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??Objective??To explore the relationship between hypoalbuminemia and disease severity and the prognosis in children with severe sepsis. Methods??From June 1??2015 to June 1??2017??119 cases diagnosed as sepsis complicated by hypoalbuminemia by retrospective were accepted PICU admission in Hunan Provincial Children’s Hospital. According to albumin levels in 24 h PICU admission into severe hypoalbuminemia group??≤ 25 g/L????moderate hypoalbuminemia group????30 g/L????mild hypoalbuminemia group????35 g/L?? and albumin normal group????35 g/L??. To analyze the changes of the severity and prognosis of severe sepsis in children with different albumin levels. Results??The incidence of hypoalbuminemia in children with severe sepsis was 71.43%. ??For children with severe sepsis??the lower the albumin levels??the higher the number of organ failure??and the higher the mortality??It’s negatively correlated??r??-0.457??P??0.000??. ??Single factor analysis found that with the serum albumin levels decreasing??the PRISM?? score was increased??the PICS score was decreased??the mechanical ventilation time??the hospital stay and PICU stay were increased. ??Multiple factor analysis showed that albumin level ≤ 25 g/L and MODS≥ 3 was independent risk factors for the prognosis of children with severe sepsis. Conclusion??The incidence of hypoalbuminemia in patients with severe sepsis is higher. The serum albumin level was inversely associated with the number of organ failure and disease severity??the lower albumin levels??the higher the illness??the worse prognosis.     

Validation of the PELOD score for multiple organ dysfunction in children

We conducted a prospective study to identify the children having multiple organ dysfunction at admission using the PELOD score, and its impact on the mortality in a pediatric intensive care unit of a tertiary care hospital in north India over a 13 month period. Data were collected in a predesigned collection sheet and the PELOD score was calculated. 209 patients were admitted. In 37.2% primary indication of admission was severe sepsis/ septic shock. Ninety-one percentage of children admitted had multiple organ dysfunction. The area under the curve for predicting death using PELOD score equation was 0.80.     

重症监护室免疫抑制和免疫健全脓毒症患儿28天内死亡因素的病例对照研究

目的评估伴免疫抑制相关基础疾病的儿童重症监护室脓毒症患儿入PICU 28 d内死亡及其危险因素。方法病例对照研究。回顾性收集复旦大学附属儿科医院（我院）因脓毒症/脓毒性休克收入PICU的患儿临床资料,分为免疫抑制组和免疫健全组,考察免疫抑制患儿入PICU 28 d内死亡的危险因素。结果2015年12月1日至2018年12月31日我院PICU出院诊断脓毒症连续病例385例,排除入科后24 h内死亡和PICU获得性脓毒症病例,251例PICU脓毒症/脓毒性休克患儿进入本文分析,免疫抑制组110例 (43.8%),免疫健全组141例。与免疫健全组比较,免疫抑制组以住院转入患儿（70%）为主,PICU维持治疗需求（血管活性药物、有创/无创机械通气）高、24 h PRISM评分高,不明确感染部位比例高,免疫抑制组接受ECMO治疗者全部死亡,持续肾脏代替治疗（CRRT）存活率为17.4%,入PICU第28 d病死率69.1%。免疫健全组和免疫抑制组28 d内存活和死亡患儿比较,除脓毒性休克、有创机械通气、CRRT、PRISM Ⅲ评分、乳酸>2 mmol·L-1比例、PICU住院时间、总住院时间、脱离PICU时间、24 h内放弃治疗、总放弃治疗差异有统计学意义外,应用血管活性药物在免疫抑制组入PICU 28 d内存活和死亡因素比较中差异有统计学意义。多因素COX比例风险模型分析显示,PRISM Ⅲ评分、有创机械通气、乳酸>2 mmol·L-1是免疫抑制组和免疫健全组入PICU 28 d内病死率的共同危险因素,休克是免疫抑制组入PICU 28 d内病死率的危险因素。结论重症监护室脓毒症患儿病死率较高;伴免疫抑制相关基础疾病的脓毒症患儿病死率更高;PRISMⅢ评分、48 h内有创机械通气和入院乳酸值(>2 mmol·L-1)是其预后的重要危险因素。应建立早期预警指标,对免疫抑制患儿进行早期识别,早期干预,可能改善预后。     

重症监护室免疫抑制和免疫健全脓毒症患儿28天内死亡因素的病例对照研究

目的评估伴免疫抑制相关基础疾病的儿童重症监护室脓毒症患儿入PICU 28 d内死亡及其危险因素。方法病例对照研究。回顾性收集复旦大学附属儿科医院（我院）因脓毒症/脓毒性休克收入PICU的患儿临床资料，分为免疫抑制组和免疫健全组，考察免疫抑制患儿入PICU 28 d内死亡的危险因素。结果2015年12月1日至2018年12月31日我院PICU出院诊断脓毒症连续病例385例，排除入科后24 h内死亡和PICU获得性脓毒症病例，251例PICU脓毒症/脓毒性休克患儿进入本文分析，免疫抑制组110例 (43.8%)，免疫健全组141例。与免疫健全组比较，免疫抑制组以住院转入患儿（70%）为主，PICU维持治疗需求（血管活性药物、有创/无创机械通气）高、24 h PRISM评分高，不明确感染部位比例高，免疫抑制组接受ECMO治疗者全部死亡，持续肾脏代替治疗（CRRT）存活率为17.4%，入PICU第28 d病死率69.1%。免疫健全组和免疫抑制组28 d内存活和死亡患儿比较，除脓毒性休克、有创机械通气、CRRT、PRISM Ⅲ评分、乳酸>2 mmol·L-1比例、PICU住院时间、总住院时间、脱离PICU时间、24 h内放弃治疗、总放弃治疗差异有统计学意义外，应用血管活性药物在免疫抑制组入PICU 28 d内存活和死亡因素比较中差异有统计学意义。多因素COX比例风险模型分析显示，PRISM Ⅲ评分、有创机械通气、乳酸>2 mmol·L-1是免疫抑制组和免疫健全组入PICU 28 d内病死率的共同危险因素，休克是免疫抑制组入PICU 28 d内病死率的危险因素。结论重症监护室脓毒症患儿病死率较高；伴免疫抑制相关基础疾病的脓毒症患儿病死率更高；PRISMⅢ评分、48 h内有创机械通气和入院乳酸值(>2 mmol·L-1)是其预后的重要危险因素。应建立早期预警指标，对免疫抑制患儿进行早期识别，早期干预，可能改善预后。     

危重病患儿急性颅内高压及脑水肿的病因和病死危险因素分析

目的　调查儿科重症监护病区 (PICU)危重病患儿发生急性颅内高压及脑水肿的原因、流行病学特点和病死危险因素。方法　总结 1999年 1月 - 2 0 0 3年 12月 ,我院PICU危重病患者中 ,急性颅内高压及脑水肿患儿的病因、预后与多器官功能不全综合征 (MODS)的关系。利用队列研究对患者病死危险因素进行分析。结果　 14 4 6例危重病患儿中 ,2 16例发生急性颅内高压及脑水肿 ,病死率2 9 2 %。 5年间病死率无明显变化 (χ2 =0 371,P =0 985 )。神经系统与非神经系统原发疾病病死率差异无统计学意义 (χ2 =0 5 4 6 ,P =0 4 6 0 )。神经系统感染、意外伤害和败血症是常见病因 ,分别占2 7 8%、2 2 4 %和 10 2 %。对 12个死亡因素进行统计学分析 ,显示合并器官衰竭数目、年龄小、入科当日危重评分值、有基础疾病、呼吸衰竭和瞳孔大小改变与病死率显著相关 (P <0 0 5或P <0 0 0 1)。结论　 1999年以来 ,颅内高压及脑水肿患儿的病死率依然很高。神经系统感染、意外伤害和败血症是主要发病危险因素 ;患病年龄小于 1岁、低危重评分及合并MODS是病死主要危险因素。     

Epidemiology and Outcome of Sepsis in a Tertiary Care PICU of Pakistan

Objective

To determine the epidemiology and outcome of sepsis in children admitted in pediatric intensive care unit (PICU) of a tertiary care hospital.

Methods

Retrospective review of children 1?mo to 14?y old, admitted to the PICU with severe sepsis or septic shock from January 2007 through December 2008 was done. Demographic, clinical and laboratory features of subjects were reviewed. The primary outcome was mortality at the time of discharge from PICU. The independent predictors of mortality were modeled using multiple logistic regression.

Results

In 2?years, 17.3% (133/767) children admitted to the PICU had sepsis. Median age was 18?mo (IQR 6–93?mo), with male: female ratio of 1.6:1. Mean PRISM III score was 9 (±7.8). One third had culture proven infection, majority (20%) having bloodstream infection. The frequency of multi-organ dysfunction syndrome (MODS) was 81% (108/133). The case specific mortality rate of sepsis was 24% (32/133). Multi-organ dysfunction (Adjusted OR 18.0, 95% CI 2.2–144), prism score of >10 (Adjusted OR 1.5, 95% CI 0.6–4.0) and the need for?>?2 inotropes (Adjusted OR 3.5, 95% CI 1.3–9.2) were independently associated with mortality due to sepsis.

Conclusions

The presence of septic shock and MODS is associated with high mortality in the PICU of developing countries.     

Assessing the risk of mortality in paediatric cancer patients admitted to the paediatric intensive care unit: a novel risk score?

Intensive front-line protocols have improved survival in children with malignancies; however, intensive multimodal therapy of paediatric malignancies can be associated with a significant risk of serious adverse events. Common risk scores (PRISM, PRISM III, APACHE-II) fail to predict mortality in these patients. A retrospective chart analysis of 32 paediatric cancer patients admitted to the Paediatric Intensive Care Unit (PICU) at the University Hospital of Saarland between January 2001 and December 2003 for life-threatening complications was performed. The aim of this study was to assess risk factors for short-term outcome (survival vs. non-survival when leaving the PICU) and to develop a risk score to estimate outcome in these patients. Overall survival was good (25 of 32 patients). Mortality rate was significantly related to leukaemia/lymphoma ( P =0.029), to the number of organ failures ( P <0.0001), neutropenia ( P =0.001), septic shock ( P =0.025), mechanical ventilation ( P =0.01) and inotropic support ( P =0.01). Employing multiple logistic regression, the strongest predictor for poor outcome was the number of organ failures ( P <0.05). A risk score (cut-off value: >3 points for non-survival) which included the following risk factors (non-solid tumour, number of organ failures ( n >2), neutropenia, septic shock, mechanical ventilation, and inotropic medication) yielded a sensitivity of 7/7 (95% CI: 4.56–7.00), a specificity of 23/25 (95% CI: 18.49–24.75), a positive predictive value of 23/23 (95% CI: 19.80–23.00), and a negative predictive value of 7/9 (95% CI: 3.60–8.74) for the time of admission to the PICU. Conclusion:Although our risk of mortality score is of prognostic value in assessing short-term outcome in these patients, prospective validation in a larger study cohort is mandatory. Furthermore, it must be emphasised that this risk score must not be used for decision-making in an individual patient.     

No resuscitation orders and withdrawal of therapy in French paediatric intensive care units

Objective: To determine the incidence of different modes of death in French paediatric intensive care units and to compare patients' characteristics, including a severity of illness score (Paediatric Risk of Mortality: PRISM score) and prior health status (Paediatric Overall Performance Category scale), according to the mode of death. Design: A 4-month prospective cohort study. Setting: Nine French multidisciplinary paediatric intensive care units. Patients: All patients who died in PICUs, except premature babies. Main results: Among 712 admissions, 13% patients died. Brain death was declared in 20%, failure of cardiopulmonary resuscitation occurred in 26%, do-not-resuscitate status was identified in 27%, and withdrawal of supportive therapy was noted in 27%. The PRISM score and the baseline Paediatric Overall Performance Category were not different between the four groups. Brain-dead patients were older than those in whom a do-not-resuscitate order and withdrawal of therapy were made (median age 81 vs 7 and 4 months). Conclusions: Decisions to limit or to withdraw supportive care were made for a majority of patients dying in French paediatric intensive care units. Chronic health evaluation and severity of illness index are not sufficient to describe dead-patient populations.     

儿童脓毒症发生毛细血管渗漏综合征的临床危险因素分析

目的：探讨脓毒症患儿出现毛细血管渗漏综合征(CLS)时的临床特点及相关危险因素。方法：回顾分析384例脓毒症患儿的临床资料。其中一般脓毒症304例,严重脓毒症54例,脓毒性休克26例。根据是否发生CLS将病例分为非CLS组（356例）和CLS组（28例）,将两组患儿的性别、年龄、营养不良、贫血、凝血功能障碍、白细胞计数、CRP、PCT、TNF、IL-1、IL-6、血糖、乳酸、PRISM Ⅲ评分、PICS评分、严重脓毒症及休克和器官功能衰竭≥3个等因素进行单因素分析,再将有统计学意义的指标作为自变量,进行多因素logistic 回归分析。结果：脓毒性休克、严重脓毒症和一般脓毒症组患儿CLS发生率分别为42.3%、20.1%及1.3%,差异有统计学意义（P＜0.01）。贫血、凝血功能障碍、CRP、PCT＞2 ng/mL、TNF、IL-1、IL-6、血糖、乳酸、PRISMⅢ评分、PICS评分、严重脓毒症及休克和MODS≥3个在非CLS组和CLS组间比较差异均有统计学意义（P<0.05）;严重脓毒症及休克和PRISMⅢ评分为脓毒症患儿发生CLS的独立危险因素。结论：脓毒症患儿病情越严重,PRISMⅢ评分越高,发生CLS的比例越高。故对于严重脓毒症和PRISMⅢ评分越高的患儿,早期监测感染标志物及血糖等相关结果,可能有助于早期识别CLS及积极干预,降低儿童脓毒症合并CLS的病死率。     

Severe upper airway obstruction in the tropics requiring intensive care

BACKGROUND: The clinical profile of severe upper airway obstruction, a challenging acute pediatric emergency, has not been extensively documented in the developing nations of the tropics. METHODS: The diagnostic categories, severity of illness and outcome from 63 episodes of severe upper airway obstruction in 56 children admitted to the Pediatric Intensive Care Unit between January 1994 and December 1999 were reviewed. Outcome variables studied included requirement for ventilation, mortality and complications. Severity of illness was determined with the Pediatric Risk of Mortality (PRISM) II score. RESULTS: Viral croup (29%) was the most common diagnosis, followed by mediastinal malignancy (13%), bacterial tracheitis (11%) and Pierre Robin syndrome (11%). There were no admissions for acute epiglottitis. Thirty episodes (48%) required ventilation for a median duration of 4.0 days. Bacterial tracheitis (100%) and subglottic stenosis (100%) were the most likely diagnoses requiring ventilation. Difficulty in intubation was encountered in 13 episodes (43%) involving, in particular, patients with bacterial tracheitis (83%; P = 0.006). Only two patients required a tracheostomy. The overall mortality was 11%. The PRISM score for all categories was generally low (mean 10.3 +/- 1.0; median 9.0). Non-survivors had a significantly higher PRISM II score than survivors (27.4 +/- 9.7 vs 8.1 +/- 4.9, respectively; P = 0.002) and were more likely to include children with bacterial tracheitis and mediastinal malignancy. CONCLUSIONS: There is marked heterogeneity in the causes of upper airway obstruction in the tropics with viral croup remaining the most common. A significant proportion required ventilation, but outcome is generally favorable, except in those with bacterial tracheitis and mediastinal malignancy.