Hypophosphatemia in Critically Ill Children: Risk Factors,Outcome and Mechanism

Objectives

To determine the prevalence of hypophosphatemia in critically ill children and its association with clinical outcomes; to determine risk factors and mechanism of hypophosphatemia.

Methods

Levels of serum phosphate, phosphate intake, renal phosphate handling indices and blood gases were measured on days 1, 3, 7 and 10 of pediatric intensive care unit (PICU) stay. Hypophosphatemia was defined as any serum phosphorus <3.8 mg/dl for children younger than 2 y and <3.5 mg/dl for children 2 y or older. Renal phosphate loss was assessed using the ratio of tubular maximum reabsorption of phosphate (TmP) to glomerular filtration rate (GFR) [TmP/GFR].

Results

Prevalence of hypophosphatemia was 71.6 % (95 % CI: 64.6–78.6). On adjusted analysis, hypophosphatemia was associated with prolonged PICU length of stay (PICU LOS > 6 d) (adjusted OR: 3.0 [95 % CI: 1.4–6.7; p = 0.005]) but not associated with increased mortality. Renal phosphate threshold was significantly lower on all the days in hypophosphatemic group compared to that of non-hypophosphatemic group. No statistically significant difference in the amount of phosphate intake was seen in both the groups.

Conclusions

Hypophosphatemia is highly prevalent in critically ill children and is associated with prolonged PICU LOS. Increased phosphate loss in urine is one of the mechanism responsible for hypophosphatemia in critically ill children.

     

Predictors of mortality in pediatric trauma: experiences of a level 1 trauma center and an assessment of the International Classification Injury Severity Score (ICISS)

Objectives

Injury severity scoring tools allow systematic comparison of outcomes in trauma research and quality improvement by indexing an expected mortality risk for certain injuries. This study investigated the predictive value of the empirically derived ICD9-derived Injury Severity Score (ICISS) compared to expert consensus-derived scoring systems for trauma mortality in a pediatric population.

Methods

1935 consecutive trauma patients aged <18 years from 1/2000 to 12/2012 were reviewed. Mechanism of injury (MOI), Injury Severity Score (ISS), Revised Trauma Score (RTS), Trauma Score ISS (TRISS), and ICISS were compared using univariate and multivariate logistic regression analysis and receiver operator characteristic analysis.

Results

The population was a median age of 11 ± 6 year, 70 % male, and 76 % blunt injury. Median ISS 13 ± 12 and overall mortality 3.5 %. Independent predictors of mortality were initial hematocrit [odds ratio (OR) 0.83 (0.73–0.95)], HCO3 [OR 0.82 (0.67–0.98)], Glasgow Coma Scale score [OR 0.75 (0.62–0.90)], and ISS [OR 1.10 (1.04–1.15)]. TRISS was superior to ICISS in predicting survival [area under receiver operator curve: 0.992 (0.982–1.000) vs 0.888 (0.838–0.938)].

Conclusions

ICISS was inferior to existing injury scoring tools at predicting mortality in pediatric trauma patients.

     

Prehospital blood transfusions in pediatric trauma and nontrauma patients: a single-center review of safety and outcomes

Purpose

Prehospital transfusions are a novel yet increasingly accepted intervention in the adult population as part of remote damage control resuscitation, but prehospital transfusions remain controversial in children. Our purpose was to review our pediatric prehospital transfusion experience over 12 years to describe the safety of prehospital transfusion in appropriately triaged trauma and nontrauma patients.

Methods

Children (<18 years) transfused with packed red blood cells (pRBC) or plasma during transport to a single regional academic medical center between 2002 and 2014 were identified. Admission details, in-hospital clinical course, and outcomes were analyzed.

Results

28 children were transfused during transport; median age was 8.9 ± 7 years and 15 patients were male (54%). Most patients required at least one additional unit of blood products during their hospitalization (79%), and/or required operative intervention (53%), endoscopy (7%), or died during their hospitalization (14%). Comparison of trauma patients (n = 16) and nontrauma patients (n = 12) revealed that nontrauma patients were younger, more anemic, more coagulopathy on admission, and required more ongoing transfusion in the hospital. Trauma patients were more likely to need operative intervention. No patient had a transfusion reaction.

Conclusion

Remote damage control prehospital transfusions of blood products were safe in this small group of appropriately triaged pediatric patients. Further studies are needed to determine if outcomes are improved and to devise a rigorous protocol for this prehospital intervention for critically ill pediatric patients.

     

Impact of simulation-based training on perceived provider confidence in acute multidisciplinary pediatric trauma resuscitation

Purpose

Simulation-based training has the potential to improve team-based care. We hypothesized that implementation of an in situ multidisciplinary simulation-based training program would improve provider confidence in team-based management of severely injured pediatric trauma patients.

Methods

An in situ multidisciplinary pediatric trauma simulation-based training program with structured debriefing was implemented at a free-standing children’s hospital. Trauma providers were anonymously surveyed 1 month before (pre-), 1 month after (post-), and 2 years after implementation.

Results

Survey response rate was 49% (n?=?93/190) pre-simulation, 22% (n?=?42/190) post-simulation, and 79% (n?=?150/190) at 2-year follow-up. These providers reported more anxiety (p?=?0.01) and less confidence (p?=?0.02) 1-month post-simulation. At 2-year follow-up, trained providers reported less anxiety (p?=?0.02) and greater confidence (p?=?0.01), compared to untrained providers.

Conclusions

Implementation of an in situ multidisciplinary pediatric trauma simulation-based training program may initially lead to increased anxiety, but long-term exposure may lead to greater confidence.

Level of evidence

II, Prospective cohort.

     

Urinary neutrophil gelatinase-associated lipocalin (NGAL) and serum cystatin C measurements for early diagnosis of acute kidney injury in children admitted to PICU

Background

Acute kidney injury (AKI) is common in critically ill children with significant mortality and morbidity. Serum creatinine is an insensitive and late biomarker compared to newly proposed AKI biomarkers.

Methods

Prospective study in pediatric intensive care unit (PICU) over three months to compare between serum cystatin-C (s-Cys-C) and urinary neutrophil gelatinase-associated lipocalin (uNGAL) as AKI biomarkers at multiple time points with pediatric risk, injury, failure, loss, end-stage renal disease (pRIFLE) classification in diagnosing AKI.

Results

Forty children were recruited. Of these 40 children, 22 developed AKI according to pRIFLE criteria. There was no significant difference between AKI and non-AKI in age (P = 0.29). Post cardiac surgery, renal insult was the main cause of AKI (27.3%). There was a twofold increased risk of incident AKI in those patients with high baseline uNGAL at PICU admission and almost a fourfold increased risk in patients with high baseline s-Cys-C at PICU admission. uNGAL levels were highly predictive of AKI during the follow-up period [area under the curve (AUC) = 0.76, 95% confidence interval (CI) 0.61–0.92]. The cutoff point with the highest correctly classified proportion was 223 ng/mL (≥ 12 centiles) which correctly predict 80.0% patients with AKI, with a corresponding sensitivity of 72.7% and a specificity of 89.9%. AUC for s-Cys-C was 0.86 (95% CI 0.75–0.97), and the highest correctly classified proportion was 1009 µg/L (≥ 13 centiles); 75% of patients with AKI, with a corresponding sensitivity of 63.6% and a specificity of 88.9%.

Conclusion

uNGAL and s-Cys-C predicts AKI early in critically ill children.

     

Erfassung eines Delirs bei pädiatrischen Intensivpatienten

Background

Delirium in pediatric intensive care patients is usually diagnosed based on nonstandardized clinical evaluation. Recently, the Cornell Assessment of Pediatric Delirium (CAPD), a validated, practical screening tool for the pediatric intensive care unit (PICU), has become available. The aims of this study were to establish a German version of the CAPD and to compare the results of the score with the bedside nurse’s assessment.

Methods

An authorized German version of the CAPD was evaluated in a prospective study on 93 patients (3.5 ± 4.7 [0–17] years) who needed treatment on the PICU following elective surgery. When the patients were awake, the same two trained investigators conducted the CAPD and asked for the bedside nurse’s assessment twice daily in the morning and evening for 5 consecutive days.

Results

A total of 61 patients (65.5?%) were diagnosed with delirium. Half of these patients (n = 31, 33.3?%) had severe delirium and the other half (n = 30, 32.2?%) had milder symptoms for a maximum of 24 h, which could be distinguished from sedative hangover by analysis of the individual test items. Clinical assessment by the bedside nurses deviated significantly from the CAPD results in symptomatic patients, patients with mild delirium, patients on normal wards, and neurologically impaired children.

Conclusions

After appropriate training, the CAPD can be performed easily and rapidly. Nearly two thirds of all postoperative pediatric intensive care patients develop a mild or severe delirium during their clinical course. Diagnosis of pediatric delirium by clinical evaluation alone is particularly difficult on normal care wards and in patients with mild delirium or neurological impairment.

     

Hypertension and prehypertension among adolescents in secondary schools in Enugu,South East Nigeria

Background

Hypertension is a prevalent cardiovascular disease risk factor among blacks and adolescent hypertension can progress into adulthood.

Objective

To determine the prevalence of hypertension and prehypertension among secondary school adolescents in Enugu South East Nigeria.

Methodology

A study of 2694 adolescents aged 10-18 years in Enugu metropolis was carried out. Socio-demographic profile anthropometric and blood pressure readings were obtained. Derived measurements such as Prehypertension, hypertension and BMI were obtained.

Results

The results showed that the mean systolic blood pressure and diastolic blood pressure for males were 106.66+ 11.80 mmHg and 70.25 + 7.34 mmHg respectively. The mean SBP and DBP for females were 109.83+ 11.66 mmHg and 72.23 + 8.26 mmHg respectively (p < 0.01). Blood pressure was found to increase with age. Prevalence of hypertension and prehypertension was 5.4% and 17.3% respectively with a higher rate in females (6.9%) than males (3.8%). Prevalence of prehypertension among males and females were 14.3% and 20.1% respectively. The prevalence of obesity was 1.9%.

Conclusion

Modifiable risk factors exist among adolescents. Early lifestyle modification and a strengthened school health are recommended.

     

Long-term outcome and need of re-operation in gastro-esophageal reflux surgery in children

Background

Fundoplication is considered a mainstay in the treatment of gastro-esophageal reflux. However, the literature reports significant recurrences and limited data on long-term outcome.

Aims

To evaluate our long-term outcomes of antireflux surgery in children and to assess the results of redo surgery.

Methods

We retrospectively analyzed all patients who underwent Nissen fundoplication in 8 consecutive years. Reiterative surgery was indicated only in case of symptoms and anatomical alterations. A follow-up study was carried out to analyzed outcome and patients’ Visick score assessed parents’ perspective.

Results

Overall 162 children were included for 179 procedures in total. Median age at first intervention was 43 months. Comorbidities were 119 (73 %), particularly neurological impairments (73 %). Redo surgery is equal to 14 % (25/179). Comorbidities were risk factors to Nissen failure (p = 0.04), especially children suffering neurological impairment with seizures (p = 0.034). Follow-up datasets were obtained for 111/162 = 69 % (median time: 51 months). Parents’ perspectives were excellent or good in 85 %.

Conclusions

A significant positive impact of redo Nissen intervention on the patient’s outcome was highlighted; antireflux surgery is useful and advantageous in children and their caregivers. Children with neurological impairment affected by seizures represent significant risk factors.

     

Use of venovenous ECMO for neonatal and pediatric ECMO: a decade of experience at a tertiary children’s hospital

Background

Advances in extracorporeal membrane oxygenation (ECMO) have led to increased use of venovenous (VV) ECMO in the pediatric population. We present the evolution and experience of pediatric VV ECMO at a tertiary care institution.

Methods

A retrospective cohort study from 01/2005 to 07/2016 was performed, comparing by cannulation mode. Survival to discharge, complications, and decannulation analyses were performed.

Results

In total, 160 patients (105 NICU, 55 PICU) required 13?±?11 days of ECMO. VV cannulation was used primarily in 83 patients with 64% survival, while venoarterial (VA) ECMO was used in 77 patients with 54% survival. Overall, 74% of patients (n?=?118) were successfully decannulated; 57% survived to discharge. VA ECMO had a higher rate of intra-cranial hemorrhage than VV (22 vs 9%, p?=?0.003). Sixteen VA patients (21%) had radiographic evidence of a cerebral ischemic insult. No cardiac complications occurred with the use of dual-lumen VV cannulas. There were no differences in complications (p?=?0.40) or re-operations (p?=?0.85) between the VV and VA groups.

Conclusion

Dual-lumen VV ECMO can be safely performed with appropriate image guidance, is associated with a lower rate of intra-cranial hemorrhage, and may be the preferred first-line mode of ECMO support in appropriately selected NICU and PICU patients.

Level of evidence

II.

     

Quantifying the pediatric surgical need in Uganda: results of a nationwide cross-sectional,household survey

Purpose

Little is known about the prevalence of pediatric surgical conditions in low- and middle-income countries. Many children never seek medical care, thus the true prevalence of surgical conditions in children in Uganda is unknown. The objective of this study was to determine the prevalence of surgical conditions in children in Uganda.

Methods

Using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey, we enumerated 4248 individuals in 2315 households in 105 randomly selected clusters throughout Uganda. Children aged 0–18 were included if randomly selected from the household; for those who could not answer for themselves, parents served as surrogates.

Results

Of 2176 children surveyed, 160 (7.4 %) reported a currently untreated surgical condition. Lifetime prevalence of surgical conditions was 14.0 % (305/2176). The predominant cause of surgical conditions was trauma (48.4 %), followed by wounds (19.7 %), acquired deformities (16.2 %), and burns (12.5 %). Of 90 pediatric household deaths, 31.1 % were associated with a surgically treatable proximate cause of death (28/90 deaths).

Conclusion

Although some trauma-related surgical burden among children can be adequately addressed at district hospitals, the need for diagnostics, human resources, and curative services for more severe trauma cases, congenital deformities, and masses outweighs the current capacity of hospitals and trained pediatric surgeons in Uganda.

     

Impact of system factors and modifiable ICU interventions on the outcome of cardio-pulmonary resuscitation in PICU

Objectives

To assess the impact of system factors and modifiable interventions on outcome of cardiac arrest in a pediatric intensive care unit.

Design

Retrospective medical record review.

Setting

Pediatric intensive care unit of a hospital in China.

Participants

Children (age<14 yrs) who had cardiac arrest within our PICU over a period of two years.

Results

Sixty-one of the 94 cardiac arrest events were successfully resuscitated. There was no significant association between personal and unit factors with immediate outcomes in our unit. The rate of unsuccessful resuscitation in sedated patients and those without sedation was 26% and 50%, respectively. Unsuccessful resuscitation occurred in 19% of patients who were on positive pressure ventilation as compared with 74% for those without positive pressure ventilation. Arrests which had resuscitation attempts that lasted more than 30 min had 135-fold higher odds of unsuccessful outcome. 78% of patients who received base supplement at the time of arrest had unsuccessful resuscitation compared with 21% for those without base supplement.

Conclusions

Our data shows no impact of system factors on the outcome of cardio-pulmonary resuscitation in our PICU. Prearrest sedation in pediatric critical ill patients might be beneficial to the outcome of cardiac arrests.

     

Association of Fluid Overload with Mortality in Critically-ill Mechanically Ventilated Children

Objectives

To study the association of fluid overload with mortality and morbidity in critically-ill mechanically ventilated children.

Design

Prospective observational study.

Setting

Pediatric Intensive Care Unit (PICU) of a tertiary care hospital, New Delhi, India.

Participants

118 children (age 1 mo - 15 y) requiring mechanical ventilation.

Outcome measures

Primary: Association of fluid overload with mortality. Secondary: Association of fluid overload with oxygenation, organ dysfunction, duration of mechanical ventilation and PICU stay.

Results

Cumulative fluid overload of ≥15% was observed in 74 (62.7%) children. About 50% of these children reached cumulative fluid overload of ≥15% within the first 5 days of PICU stay. The mortality was 40.5% in those with ≥15% cumulative fluid compared to 34% in the rest [OR (95% CI): 1.02 (0.97, 1.07)]. On multivariate analysis, after adjusting for confounders, cumulative fluid overload ≥15% was associated with higher maximum PELOD (pediatric logistic organ dysfunction) score (Median: 21 vs. 12; P = 0.03), longer median duration of mechanical ventilation (10 vs. 4 d; P <0.0001) and PICU stay (13.5 vs. 6 d; P <0.0001). There was no significant association of fluid overload with oxygenation index (P=0.32).

Conclusion

There is no association of fluid overload with mortality. However, it is associated with poor organ function, longer duration of mechanical ventilation and PICU stay in critically-ill, mechanically ventilated children.

     

Predictors and Outcome of Acute Kidney Injury in Children with Diabetic Ketoacidosis

Objective

To identify predictors and outcome of acute kidney injury (AKI) in children with diabetic ketoacidosis (DKA) admitted to a Pediatric Intensive Care Unit (PICU).

Methods

Retrospective case review of 79 children with DKA admitted between 2011-2014.

Results

28 children developed AKI during the hospital stay; 20 (71.4%) recovered with hydration alone. Serum chloride at 24 hours was independently associated with AKI. Children with AKI had prolonged acidosis, longer PICU stay, and higher mortality.

Conclusions

Majority of children with AKI and DKA recover with hydration. Hyperchloremia at 24 hours had independent association with AKI, although cause-effect relation could not be ascertained.

     

Survival after emergency department thoracotomy in the pediatric trauma population: a review of published data

Background/purpose

The utility of EDT in the adult trauma population, using well-defined guidelines, is well established, especially for penetrating injuries. Since the introduction of these guidelines, reports on the use of EDT for pediatric trauma have been published, and these series reveal a dismal, almost universally fatal, outcome for EDT following blunt trauma in the child. This report reviews the clinical outcomes of EDT in the pediatric population.

Materials/methods

We performed a review of EDT in the pediatric population using the published data from 1980 to 2017. Variables extracted included mechanism of injury and mortality. To minimize bias, single case reports were not included in the review.

Results

Upon review of four decades of published literature on the use of emergency department thoracotomy (EDT) in the pediatric population, mortality rates are comparable between adults and pediatric patients for penetrating thoracic trauma. In contrast, in pediatric patients sustaining blunt trauma, no patient under the age of 15 has survived.

Conclusion

In patients between 0 and 14 years of age presenting with no signs of life following blunt trauma, withholding EDT should be considered. Patients between the ages of 15 and 18 should be treated in accordance with adult ATLS principles for the management of thoracic trauma.

Level of evidence

Level IV

     

Outcome Prediction Value of Red Cell Distribution Width in Critically-ill Children

Objective

To study the association between red cell distribution width (RDW) and mortality in critically-ill children admitted in a Pediatric intensive care unit (PICU).

Methods

101 participants were recruited consecutively over 3 months. Data collected included demographics, vital parameters, laboratory values, severity and organ failure scores, RDW for the first 5 days of admission, duration of PICU stay and survival outcome.

Results

11 patients died during study period. High RDW at admission (RDW D1) correlated significantly with mortality (P=0.007). The odds of death increased by 15 to 23 times with rise in RDW D1 from 18% to >21%. The optimal RDW D1 cut-off value for mortality was 18.6%, which yielded sensitivity 90.9%, specificity 70.8%, positive predictive value 27.8%, negative predictive value 98.4%, and area under curve (AUC) 0.83 (95%CI 0.737, 0.925). 29 out of 60 (48.3%) patients with RDW D4 >18% had PICU stay of ≥7 days.

Conclusion

High (≥18.6%) RDW at admission and its persistent high levels are associated with high mortality and prolonged stay in PICU, respectively.

     

Re-evaluation of liver transaminase cutoff for CT after pediatric blunt abdominal trauma

Purpose

Current guidelines for computed tomography (CT) after blunt trauma were developed to capture all intra-abdominal injuries (IAI). We hypothesize that current AST/ALT guidelines are too low leading to unnecessary CT scans for children after blunt abdominal trauma (BAT).

Methods

Patients who received CT of the abdomen after blunt trauma at our Level I Pediatric Trauma Center were stratified into a high risk (HR) (liver/spleen/kidney grade ≥III, hollow viscous, or pancreatic injuries) and low risk (LR) (liver/kidney/spleen injuries grade ≤II, or no IAI) groups.

Results

247 patients were included. Of the 18 patients in the HR group, two required surgery (splenectomy and sigmoidectomy). Transfusion was required in 30% of grade III and 50% of grade IV injuries. Eleven (5%) patients in LR group were transfused for indications other than IAI, and none were explored surgically. Both AST (r = 0.44, p < 0.001) and ALT (r = 0.43, p < 0.001) correlated with grade of liver injury. Using an increased threshold of AST/ALT, 400/200 had a negative predictive value of 96% in predicting the presence of HR liver injuries.

Conclusion

The current cutoff of liver enzymes leads to over-identification of LR injuries. Consideration should be given to an approach that aims to utilize CT in pediatric BAT that identifies clinically HR injury.

     

IVC filter placements in children: nationwide comparison of practice patterns at adult and children’s hospitals using the Kids’ Inpatient Database

Background

Inferior vena cava (IVC) filter placement in children has been described in literature, but there is variability with regard to their indications. No nationally representative study has been done to compare practice patterns of filter placements at adult and children’s hospitals.

Objective

To perform a nationally representative comparison of IVC filter placement practices in children at adult and children’s hospitals.

Materials and methods

The 2012 Kids’ Inpatient Database was searched for IVC filter placements in children <18 years of age. Using the International Classification of Diseases, 9th Revision (ICD-9) code for filter insertion (38.7), IVC filter placements were identified. A small number of children with congenital cardiovascular anomalies codes were excluded to improve specificity of the code used to identify filter placement. Filter placements were further classified by patient demographics, hospital type (children’s and adult), United States geographic region, urban/rural location, and teaching status. Statistical significance of differences between children’s or adult hospitals was determined using the Wilcoxon rank sum test.

Results

A total of 618 IVC filter placements were identified in children <18 years (367 males, 251 females, age range: 5–18 years) during 2012. The majority of placements occurred in adult hospitals (573/618, 92.7%). Significantly more filters were placed in the setting of venous thromboembolism in children’s hospitals (40/44, 90%) compared to adult hospitals (246/573, 43%) (P<0.001). Prophylactic filters comprised 327/573 (57%) at adult hospitals, with trauma being the most common indication (301/327, 92%). The mean length of stay for patients receiving filters was 24.5 days in children’s hospitals and 18.4 days in adult hospitals.

Conclusion

The majority of IVC filters in children are placed in adult hospital settings. Children’s hospitals are more likely to place therapeutic filters for venous thromboembolism, compared to adult hospitals where the prophylactic setting of trauma predominates.

     

Testicular atrophy following inguinal hernia repair in children

Purpose

We sought to determine the incidence and timing of testicular atrophy following inguinal hernia repair in children.

Methods

We used the TRICARE database, which tracks care delivered to active and retired members of the US Armed Forces and their dependents, including?>?3 million children. We abstracted data on male children?<?12 years who underwent inguinal hernia repair (2005–2014). We excluded patients with history of testicular atrophy, malignancy or prior related operation. Our primary outcome was the incidence of the diagnosis of testicular atrophy. Among children with atrophy, we calculated median time to diagnosis, stratified by age/undescended testis.

Results

8897 children met inclusion criteria. Median age at hernia repair was 2 years (IQR 1–5). Median follow-up was 3.57 years (IQR 1.69–6.19). Overall incidence of testicular atrophy was 5.1/10,000 person-years, with the highest incidence in those with an undescended testis (13.9/10,000 person-years). All cases occurred in children \(\le\)?5 years, with 72% in children <?2 years. Median time to atrophy was 2.4 years (IQR 0.64–3), with 30% occurring within 1 year and 75% within 3 years.

Conclusion

Testicular atrophy is a rare complication following inguinal hernia repair, with children?<?2 years and those with an undescended testis at highest risk. While 30% of cases were diagnosed within a year after repair, atrophy may be diagnosed substantially later.

Level of evidence

Prognosis Study, Level II.