Identifying futility in a paediatric critical care setting: a prospective observational study.

AIMS: To determine the extent of futile care provided to critically ill children admitted to a paediatric intensive care setting. METHODS: Prospective evaluation of consecutive admissions to a 20 bedded multidisciplinary paediatric intensive care unit of a North London teaching hospital over a nine month period. Three previously defined criteria for futility were used: (1) imminent demise futility (those with a mortality risk greater than 90% using the Paediatric Risk of Mortality (PRISM II) score); (2) lethal condition futility (those with conditions incompatible with long term survival); and (3) qualitative futility (those with unacceptable quality of life and high morbidity). RESULTS: A total of 662 children accounting for 3409 patient bed days were studied. Thirty four patients fulfilled at least one of the criteria for futility, and used a total of 104 bed days (3%). Only 33 (0.9%) bed days were used by patients with mortality risk greater than 90%, 60 (1.8%) by patients with poor long term prognosis, and 16 (0.5%) by those with poor quality of life. Nineteen of 34 patients died; withdrawal of treatment was the mode of death in 15 (79%). CONCLUSIONS: Cost containment initiatives focusing on futility in the paediatric intensive care unit setting are unlikely to be successful as only relatively small amounts of resources were used in providing futile care. Paediatricians are recognising futility early and may have taken ethically appropriate measures to limit care that is futile.     

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.     

Adrenal insufficiency in septic shock

BACKGROUND—Functional adrenal insufficiency has been documented in critically ill adults.OBJECTIVE—To document the incidence of adrenal insufficiency in children with septic shock, and to evaluate its effect on catecholamine requirements, duration of intensive care, and mortality.SETTING—Sixteen-bed paediatric intensive care unit in a university hospital.METHODS—Thirty three children with septic shock were enrolled. Adrenal function was assessed by the maximum cortisol response after synthetic adrenocorticotropin stimulation (short Synacthen test). Insufficiency was defined as a post-Synacthen cortisol increment < 200 nmol/l.RESULTS—Overall mortality was 33%. The incidence of adrenal insufficiency was 52% and children with adrenal insufficiency were significantly older and tended to have higher paediatric risk of mortality scores. They also required higher dose vasopressors for haemodynamic stability. In the survivor group, those with adrenal insufficiency needed a longer period of inotropic support than those with normal function (median, 3 v 2 days), but there was no significant difference in duration of ventilation (median, 4 days for each group) or length of stay (median, 5 v 4 days). Mortality was not significantly greater in children with adrenal insufficiency than in those with adequate adrenal function (6 of 17 v 5 of 16,respectively).CONCLUSION—Adrenal insufficiency is common in children with septic shock. It is associated with an increased vasopressor requirement and duration of shock.     

Paediatric use of intensive care

OBJECTIVES--To determine the number of children from a defined population who use intensive care facilities, to analyse bed occupancy data for those children, and to estimate the number of intensive care beds required to satisfy this demand throughout the year. DESIGN--Examination of admission data books from intensive care units within the four Birmingham health authorities and the neighbouring health authorities. RESULTS--Two hundred and ninety seven children resident within the four Birmingham health authorities used intensive care facilities in a calendar year. One hundred and forty one (47%) of these were admitted for specialist paediatric services. Of the remaining 156, 106 (68%) were cared for in adult intensive care units, 46 (29%) in a paediatric intensive care unit and four (3%) in a special care baby unit. Use of intensive care varied from none to 11 patients each day, and was lowest in the summer and highest during the winter months. During periods of peak demand, one in 19,000 (5.3/100,000) children were using intensive care facilities. CONCLUSIONS--These data provide a population based minimum need for paediatric intensive care beds. They are higher than previous estimates and do not include provision for children from outside Birmingham, or for those denied intensive care due to bed shortages. These factors and the marked seasonal variation in demand need to be considered when planning intensive care services for children if bed shortages are to be avoided.     

Paediatric use of intensive care.

OBJECTIVES--To determine the number of children from a defined population who use intensive care facilities, to analyse bed occupancy data for those children, and to estimate the number of intensive care beds required to satisfy this demand throughout the year. DESIGN--Examination of admission data books from intensive care units within the four Birmingham health authorities and the neighbouring health authorities. RESULTS--Two hundred and ninety seven children resident within the four Birmingham health authorities used intensive care facilities in a calendar year. One hundred and forty one (47%) of these were admitted for specialist paediatric services. Of the remaining 156, 106 (68%) were cared for in adult intensive care units, 46 (29%) in a paediatric intensive care unit and four (3%) in a special care baby unit. Use of intensive care varied from none to 11 patients each day, and was lowest in the summer and highest during the winter months. During periods of peak demand, one in 19,000 (5.3/100,000) children were using intensive care facilities. CONCLUSIONS--These data provide a population based minimum need for paediatric intensive care beds. They are higher than previous estimates and do not include provision for children from outside Birmingham, or for those denied intensive care due to bed shortages. These factors and the marked seasonal variation in demand need to be considered when planning intensive care services for children if bed shortages are to be avoided.     

The prediction and cost of futility in the NICU

Aim: To quantify the cost and prediction of futile care in the Neonatal Intensive Care Unit (NICU). Methods: We observed 1813 infants on 100 000 NICU bed days between 1999 and 2008 at the University of Chicago. We determined costs and assessed predictions of futility for each day the infant required mechanical ventilation. Results: Only 6% of NICU expenses were spent on nonsurvivors, and in this sense, they were futile. If only money spent after predictions of death is considered, futile expenses fell to 4.5%. NICU care was preferentially directed to survivors for even the smallest infants, at the highest risk to die. Over 75% of ventilated NICU infants were correctly predicted to survive on every day of ventilation by every caretaker. However, predictions of ‘die before discharge’ were wrong more than one time in three. Attendings and neonatology fellows tended to be optimistic, while nurses and neonatal nurse practitioners tended to be pessimistic. Conclusions: Criticisms of the expense of NICU care find little support in these data. Rather, NICU care is remarkably well targeted to patients who will survive, particularly when contrasted with care in adult ICUs. We continue to search for better prognostic tools for individual infants.     

Mortality in severe meningococcal disease

AIM—To evaluate mortality of critically ill children admitted with meningococcal disease.METHODS—Prospective study of all children admitted to a regional paediatric intensive care unit (PICU) between January 1995 and March 1998 with meningococcal disease. Outcome measures were actual overall mortality, predicted mortality (by PRISM), and standardised mortality ratio.RESULTS—A total of 123 children were admitted with meningococcal disease. There was an overall PICU mortality of 11 children (8.9%). The total mortality predicted by PRISM was 24.9. The standardised mortality ratio (SMR) was 0.44. Results were compared with those from four previously published meningococcal PICU studies (USA, Australia, UK, Netherlands) in which PRISM scores were calculated. The overall PICU mortality and SMR were lower than those in the previously published studies.CONCLUSION—Compared with older studies and calibrating for disease severity, this study found a decrease in the mortality of critically ill children with meningococcal disease.     

Serum lactate as a predictor of mortality after paediatric cardiac surgery

OBJECTIVE—To assess the value of sequential lactate measurement in predicting postoperative mortality after surgery for complex congenital heart disease in children.DESIGN—Prospective observational study.SETTING—Sixteen bedded paediatric intensive care unit (PICU).SUBJECTS—Ninety nine children ( 90 survivors, nine non-survivors).MEASUREMENTS—Serum lactate and base deficit were measured on admission and every six hours thereafter. Data were analysed by Mann-Whitney and Fisher''s exact tests.RESULTS—There was considerable overlap in initial lactate values between the survivor and non-survivor groups. Initial lactate was significantly raised in non-survivors (median 8.7, range 1.9-17.6 mmol/l) compared with survivors (median 2.4, range 0.6-13.6 mmol/l) (p = 0.0002). Twenty one patients (21.1%) with initial lactate concentrations greater than 4.5 mmol/l survived to PICU discharge. Using receiver operating characteristic analysis an initial lactate of 6 mmol/l had the optimum predictive value for mortality. Initial postoperative serum lactate >6 mmol/l predicted mortality with sensitivity 78%, specificity 83%, and positive predictive value of only 32%.CONCLUSION—Initial lactate concentrations have poor positive predictive value for mortality. The routine measurement of lactate for this purpose cannot be justified in clinical practice.     

Recent trends in hospital use by children in England

BACKGROUND—Routine hospital statistics for England appear to overestimate use of children''s wards and include numbers of well newborn babies staying with their mothers after delivery ("well babies").AIM—To review trends in use of children''s wards excluding data on newborn babies.METHODS—We reviewed routine, published, and age stratified data requested from the Department of Health to identify separately "well babies" and babies receiving neonatal specialist care from admissions (surgical and paediatric) to children''s wards.RESULTS—Routine reports for paediatric activity contain large numbers of "well babies", (almost half the total) as well as babies receiving specialist neonatal care. After excluding these, paediatric admissions represent 9.9% of the child population aged under 5years each year (an additional 2.5% are admitted for surgical care). Between 1989 and 1997 paediatric admissions rose by 19% and surgical admissions fell by 25% with a plateau reached in overall child admissions. There are now fewer beds in which children stay for a shorter time and there is more day case surgery. Neonatal specialist care work has risen despite a fall in births.CONCLUSION—Categories should be established for reporting paediatric episodes on children''s wards separately from those on neonatal units, with better identification of "well babies". When monitoring use of children''s inpatient facilities or planning new units, care must be taken to separate paediatric data on neonatal units from work on children''s wards. Children''s surgical episodes should also be taken into account.     

Use of complementary treatment by those hospitalised with acute illness

AIM—To determine the frequency of use of complementary treatment and measure its impact on clinical outcomes in a hospitalised general paediatric population.METHODS—A population based random sample of children admitted to the general paediatric service at a metropolitan children''s hospital in Auckland, New Zealand from February to July 1998. Children with asthma, pneumonia, bronchiolitis, gastroenteritis, or fever were eligible. Data collected by personal interview with parents and by review of the medical records of these children.RESULTS—251 of 511 eligible children admitted during the study period were enrolled. Forty four children (18%) had received complementary treatment during the hospitalising illness. Most children (77%) had been seen in primary care before hospitalisation. The proportion that were seen in primary care and the number of primary care visits before hospitalisation did not vary with receipt of complementary treatment. The proportion of children who were prescribed medications before hospitalisation was significantly greater for those who had received complementary treatment compared with those who had not (59% v 39%). There was no significant difference between users and non-users of complementary treatment in the severity of the illness at presentation, investigations performed, treatment administered, or length of inpatient stay.CONCLUSION—A substantial proportion of children hospitalised with acute medical illnesses have received complementary treatment. Alternative health care is used as an adjunct rather than an alternative to conventional health care. Receipt of complementary treatment has no significant effect on clinical outcomes for children hospitalised with common acute medical illnesses.     

Evaluation of guidelines for emergency triage assessment and treatment in developing countries

AIM—To evaluate performance of a simplified algorithm and treatment instructions for emergency triage assessment and treatment (ETAT) of children presenting to hospital in developing countries.METHODS—All infants aged 7 days to 5 years presenting to an accident and emergency department were simultaneously triaged and assessed by a nurse and a senior paediatrician. Nurse ETAT assessment was compared to standard emergency advanced paediatric life support (APLS) assessment by the paediatrician. Sensitivity, specificity, and predictive values were calculated and appropriateness of nurse treatments was evaluated.RESULTS—The ETAT algorithm as used by nurses identified 731/3837 patients (19.05%); 98 patients (2.6%) were classified as needing emergency treatment and 633 (16.5%) as needing priority assessment. Sensitivity was 96.7% with respect to APLS assessment, 91.7% with respect to all patients given priority by the paediatrician, and 85.7% with respect to patients ultimately admitted. Specificity was 90.6%, 91.0%, and 85.2%, respectively. Nurse administered treatment was appropriate in 94/102 (92.2%) emergency conditions.CONCLUSIONS—The ETAT algorithm and treatment instructions, when carried out by nurses after a short specific training period, performed well as a screening tool to identify priority cases and as a treatment guide for emergency conditions.     

Recollection of children following intensive care

BACKGROUND AND AIMS—The recollections of critically ill children following discharge from the paediatric intensive care unit (PICU) have not previously been described. We have interviewed such children to establish the nature of their recollections.METHODS—Children aged 4 years and above were interviewed following discharge from the PICU at the Queens Medical Centre, Nottingham, either in hospital or at home, using a semistructured interview. Their recollections were recorded and interpreted by content analysis.RESULTS—A total of 38 interviews were carried out; 44 specific recollections were reported, the majority being neutral (60%) or positive (25%). Only 15% of recollections were negative. Negative recollections related to aspects of medical care and environmental factors. No child treated with neuromuscular blocking agents remembered any period of therapeutic paralysis.CONCLUSIONS—Children''s recollections of PICU are mainly neutral or positive. Mechanically ventilated children sedated with midazolam and morphine remember little of endotracheal intubation.     

Guias de ingreso,alta y triage para las unidades de cuidados intensivos pediátricos en España

A paediatric intensive care unit (PICU) is a separate physical facility or unit specifically designed for the treatment of paediatric patients who, because of the severity of illness or other life-threatening conditions, require comprehensive and continuous inten-sive care by a medical team with special skills in paediatric intensive care medicine. Timely and personal intervention in intensive care reduces mortality, reduces length of stay, and decreases cost of care. With the aim of defending the right of the child to receive the highest attainable standard of health and the facilities for the treatment of illness and rehabilitation, as well as ensuring the quality of care and the safety of critically ill paediatric patients, the Spanish Association of Paediatrics (AEP), Spanish Society of Paediatric Intensive Care (SECIP) and Spanish Society of Critical Care (SEMICYUC) have approved the guidelines for the admission, discharge and triage for Spanish PICUs. By using these guidelines, the performance of Spanish paediatric intensive care units can be optimised and paediatric patients can receive the appropriate level of care for their clinical condition.     

Which children account for repeated admissions within 1 year in a Brazilian pediatric intensive care unit?

ObjectiveWhile studies have focused on early readmissions or readmissions during the same hospitalization in a pediatric intensive care unit, little is known about the children with recurrent admissions. We sought to assess the characteristics of patients readmitted within 1 year in a Brazilian pediatric intensive care unit.MethodsThis was a retrospective study carried out in a tertiary pediatric intensive care unit. The outcome was the maximum number of readmissions experienced by each child within any 365-day interval during a 5-year follow-up period.ResultsOf the 758 total eligible admissions, 75 patients (9.8%) were readmissions. Those patients accounted for 33% of all pediatric intensive care unit bed care days. Median time to readmission was 73 days for all readmissions. Logistic regression showed that complex chronic conditions (odds ratio 1.07), severe to moderate cognitive disability (odds ratio 1.08), and use of technology assistance (odds ratio 1.17) were associated with readmissions. Multiple admissions had a significantly prolonged duration of mechanical ventilation (8 vs. 6 days), longer length of pediatric intensive care unit (7 vs 4 days) and hospital stays (20 vs 9 days), and higher mortality rate (21.3% vs 5.1%) compared with index admissions.ConclusionThe rate of pediatric intensive care unit readmissions within 1 year was low; however, it was associated with a relevant number of bed care days and worse outcomes. A 30-day index of readmission may be inadequate to mirror the burden of pediatric intensive care unit readmissions. Patients with complex chronic conditions, poor functional status or technology assistance are at higher risk for readmissions. Future studies should address the impact of qualitative interventions on healthcare and recurrent admissions.     

Quantifying high dependency care: a prospective cohort study in Yorkshire (UK)

High dependency care (HDC) is a level of care situated between intensive care and usual ward care with its delivery being independent of location. Inadequate definition makes it problematic to determine the number of children receiving HDC, to identify their care setting and therefore to undertake service planning. We aimed to estimate the volume of hospital inpatient HDC in a geographically defined population using a customised measurement tool in four types of paediatric hospital services (1) tertiary specialist wards, (2) tertiary paediatric intensive care units, (3) district general hospitals (DGHs) general wards and (4) wards at a major acute general hospital. A region-wide prospective cohort study during 2005 collected data to develop a 36-item HDC measurement tool, which then identified children receiving HDC by day and night. The cohort identified 1,763 children as receiving HDC during an admission to 1 of 36 hospital wards in 14 hospitals. HDC was delivered during 9,077 shift periods of 12 h or 4,538 bed days. The volume of care and patient profiles varied by hospital type, within hospital by ward type and by age and season. Tertiary specialist wards and ICUs provided 72% of HDC, with the remainder delivered at the DGHs and the major acute general hospital. The volume of admissions to tertiary specialist wards showed little seasonality and children tended to be older (26% were aged 10–15 years). By comparison, admissions to DGHs were younger with an excess during the winter months. This is the first UK study to quantify HDC from empirical data encompassing all hospital and ward types within a large clinical network. A lack of HDC-designated beds across the region resulted in HDC delivery on all types of hospital wards. The study size and representativeness makes the estimated number of HDC bed days per head of population likely to reflect the wider UK population.     

Paediatric prehospital care: postal survey of paramedic training managers

BACKGROUND—The process of prehospital care continues to develop in the UK.AIMS—To evaluate the availability of important paediatric resuscitation equipment in emergency ambulances and the extent of paramedic training in paediatric emergency medicine.METHODS—Postal survey of paramedic training managers.RESULTS—Completed questionnaires were returned by 41 (93%) training managers. No trust provided all of the equipment listed. Facemasks and self inflating bags (of appropriate sizes for all children) are provided by 32% and 42% of trusts respectively. Less than one third carry paediatric oximeter probes. Of the respondents, 16 (39%) trusts provide less than eight hours training in paediatric emergency medicine and five (12%) offer no training at all. Ongoing education varies from none to regular yearly updates.CONCLUSIONS—Paramedics seem ill prepared to deal with paediatric emergencies. Important deficiencies in the provision of equipment and training are noted. The results of this survey provide information against which improvements can be measured.     

Ventilator-associated pneumonia in a paediatric intensive care unit in a developing country with high HIV prevalence

Aim:   To obtain preliminary prevalence, aetiological and outcome data on South African paediatric patients with ventilator-associated pneumonia (VAP).
Methods:   Non-bronchoscopic bronchoalveolar lavage (BAL) specimens taken between January 2004 and September 2005 were prospectively recorded and related clinical data were retrospectively reviewed. VAP was defined as a new isolate on BAL and a modified Clinical Pulmonary Infection Score ≥5.
Results:   A total of 230 patients aged 3.9 (2.2–9.1) months (median interquartile range (IQR) ) underwent 309 BALs during 244 paediatric intensive care unit (PICU) admissions. Most patients (84%) were admitted with acute infectious diseases, with a 70% incidence of comorbidity. Thirty-three patients (14.3%) were HIV-exposed but uninfected and 58 (25.2%) were HIV-infected.
Of 172 BALs taken ≥48 h after intubation, 63 specimens from 55 patients fulfilled VAP criteria. Acinetobacter baumannii was the most common VAP pathogen, followed by Klebsiella pneumoniae , viruses, yeasts and Staphylococcus aureus.
Patients who developed VAP had a higher proportion of comorbid conditions (76% vs. 55%, P = 0.01) and reintubations (39% vs. 12%, P < 0.0001) when compared with non-VAP patients. Median (IQR) length of PICU stay was 12.5 (5–21) days versus 8 (5–14) days ( P = 0.03); and the risk adjusted PICU mortality was 1.38 versus 0.79 ( P = 0.002) in VAP versus non-VAP patients, respectively.
Conclusions:   VAP is associated with significant morbidity and mortality and may relate to the high incidence of comorbid conditions in this population. Primary VAP pathogens differ from developed countries.