The profile and outcome of patients admitted to a pediatric intensive care unit

The records of all admissions to a 6-bed pediatric intensive care unit (PICU) over a period of 6 years were reviewed. The age, diagnosis, clinical service provided, duration of stay and outcome were recorded. Of the 3025 children admitted, 2092 (69.2%) were males. Neonates constituted 13.1% (400) and infants 57.1% (1727) of total admissions. The duration of stay ranged from 6 hours to 46 days, and 61 patients stayed for longer than 13 days (long-stay patients). The most common cause for admission was septicemia, seen in 459 patients (14.8%); 418 (13.8%) children had congenital heart disease, 407 (13.5%) lower respiratory tract infections (LRTI) and 261 (8.6%) meningitis. The most common conditions necessitating long-stay in the PICU were meningitis (20%), Landry-Guillain-Barre syndrome (16.6%), acute renal failure (20%), and septicemia (16.6%). There were 721 deaths giving a mortality of 23.5%. Of these 134 (18.6%) were due to septicemia, 103 (14.2%) due to congential heart disease, 77 (10.6%) due to meningitis and 55 (7.6%) due to LRTI. The highest case fatality rate was seen with encephalitis (52.6%), followed by hepatic coma (51.3%), malignancies (43.2%), septicemia (29.1%) and meningitis (29.5%). The mortality was lower (9.8%) in long-stay patients than in short-stay patients (24.6%). There was gradual increase in proportion of cases requiring interventions including artificial ventilation (1% to 35%), peritoneal dialysis (1.5% to 11%), insertion of central venous pressure lines (0 to 10%), over the last 6 years. The comparison of case fatality rates before and after the PICU was made a functionally independent unit eleven months ago, reveals a declining trend for certain diseases including LGB syndrome (22.5% to 0%) (p<0.02), dengue hemorrhagic fever (44% to 9%) (p<0.02), meningitis (34% to 20%). renal failure (17% to 10%), encephalitis (55% to 26%). The ventilator survival increased from 22% to 42% (p<0.001).     

End-of-life practices in patients admitted to pediatric intensive care units in Brazil: A retrospective study

ObjectiveTo determine the prevalence of life support limitation (LSL) in patients who died after at least 24 h of a pediatric intensive care unit (PICU) stay, parent participation and to describe how this type of care is delivered.MethodsRetrospective cohort study in a tertiary PICU at a university hospital in Brazil. All patients aged 1 month to 18 years who died were eligible for inclusion. The exclusion criteria were those brain death and death within 24 h of admission.Results53 patients were included in the study. The prevalence of a LSL report was 45.3%. Out of 24 patients with a report of LSL on their medical records only 1 did not have a do-not-resuscitate order. Half of the patients with a report of LSL had life support withdrawn. The length of their PICU stay, age, presence of parents at the time of death, and severity on admission, calculated by the Pediatric Index of Mortality 2, were higher in patients with a report of LSL. Compared with other historical cohorts, there was a clear increase in the prevalence of LSL and, most importantly, a change in how limitations are carried out, with a high prevalence of parental participation and an increase in withdrawal of life support.ConclusionsLSLs were associated with older and more severely ill patients, with a high prevalence of family participation in this process. The historical comparison showed an increase in LSL and in the withdrawal of life support.     

Application of the Pediatric Index of Mortality 2 in pediatric patients with complex chronic conditions

ObjectiveTo evaluate the performance of the Pediatric Index of Mortality 2 (PIM2) in a pediatric intensive care unit (PICU) with a high prevalence of patients with complex chronic conditions (CCCs), and compare the performance between patients with and without CCCs.MethodsA prospective cohort study was conducted in a PICU in Brazil, with patients admitted between 2009 and 2011. The performance was evaluated through discrimination and calibration. Discrimination was assessed by calculating the area under the ROC curve, and calibration was determined using the Hosmer-Lemeshow goodness-of-fit test.ResultsA total of 677 patients were included in the study, of which 83.9% had a CCC. Overall mortality was 9.7%, with a trend of higher mortality among patients with CCCs when compared to patients without CCCs (10.3% vs. 6.4%, p = 0.27), but with no difference in the mean probability of death estimated by PIM2 (5.9% vs. 5.6%, p = 0.5). Discrimination was considered adequate in the general population (0.840) and in patients with and without CCCs (0.826 and 0.944). Calibration was considered inadequate in the general population and in patients with CCCs (p < 0.0001 and p < 0.0001), but it was considered adequate in patients without CCCs (p = 0.527).ConclusionsPIM2 showed poor performance in patients with CCCs and in the general population. This result may be secondary to differences in the characteristics between the study samples (high prevalence of patients with CCCs); the performance of the PIM2 should not be ruled out.     

Performance of Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality (PIM), and PIM2 in a pediatric intensive care unit in a developing country.

OBJECTIVE: To determine the discriminative ability and calibration of existing scoring systems in predicting the outcome (mortality) in children admitted to an Indian pediatric intensive care unit (PICU). DESIGN: Prospective cohort study. SETTING: Pediatric Intensive Care Unit, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, from July 1, 2002, to July 31, 2003. PATIENTS: A total of 246 patients were admitted. After exclusion of 29 neonates and two patients who stayed in the PICU for 0.8. However, all the models underpredicted mortality. The likely reasons for this could be differences in the patient profile and greater load of severity of illness being managed with lesser resources--both physical and human--and differences in the quality of care.     

应用危重病例评分法预测PICU患儿的预后

目的　应用国内儿科危重病例评分法（ＰＣＩＳ）评价儿科ＩＣＵ（ＰＩＣＵ） 患儿的病情危重度,预计病死风险率,探讨死亡相关因素。方法　对１９９６ 年１ 月～１９９７ 年１２ 月ＰＩＣＵ 的６５０ 例住院患儿进行ＰＣＩＳ评分和资料分析。用ＳＡＳ统计软件,进行单因素分析和逐步Ｌｏｇｉｓｔｉｃ 回归筛选变量分析,根据评分值建立病死风险率预计公式１ ,并观察预计模型的准确性和对个体预后的判断能力。结果　死亡９７ 例,病死率１４．９ ％ 。评分值、基础疾病、心跳呼吸骤停、脏器衰竭数目、院内感染、住院日数和是否来源于其他病房与死亡密切相关（ Ｐ均＜ ０．０５） 。死亡独立危险因素为心跳呼吸骤停和脏器衰竭数目。根据入ＰＩＣＵ最初２４ 小时的最低评分值建立病死风险率预计公式：Ｌｏｇｉｔ（ｐ） ＝ ８．３９４ － ０．１２３ ×评分值,敏感度、特异性和阳性预计值分别为４３．３％ 、９４．９％ 和７７．２％ 。结论　（１）ＰＣＩＳ适用于ＰＩＣＵ 评估患儿病情危重度和个体病死风险率。（２）所得预计模型适合ＰＩＣＵ 近期应用。（３） 防止和减少心跳呼吸骤停的发生是降低病死风险率的关键。     

Validation of Pediatric Index of Mortality-2 Scoring System in a Single Pediatric Intensive Care Unit in Iran

Objective

A study to validate and calibrate Pediatric Index of Mortality-2 (PIM2) in children admitted to our pediatric intensive care unit (PICU).

Methods

This is a prospective cohort study performed in Bahrami Children''s Hospital affiliated to Tehran University of Medical Sciences. We studied the patients admitted to PICU from May 2007 to November 2008. Clinical measures were identified upon arrival in PICU. We used PIM2 score and logistic regression analysis to compare expected mortality risk with observed mortality rate. Receiver operating characteristics (ROC) curve analysis was done and standardized mortality ratio was calculated. PIM2 Index assessment was performed by use of Hosmer and Lemeshow goodness-of-fit test.

Findings

240 patients were included in this study. The model fit was achieved adequately (P value=0.741). The area under the ROC curve was 0.795 (0.715-0.875 for 95% confidence interval) and standardized mortality ratio was 1.8 (1.28-2.465 for 95% confidence interval) High-risk group diagnosis with adjusted odds ratio (AOR)=14.75, pupil reaction to light (AOR=0.13) and duration of stay in PICU (AOR=1.03) had significant statistical association to pediatric mortality.

Conclusion

PIM2 is a good index for prediction of mortality in our pediatric intensive care unit. This study revealed that there is significant statistical association between the children mortality and the length of hspita;ization, pupillary light reflex and the risk level category on admission.     

我院儿科ICU休克116例临床分析

目的 调查近年来休克的流行病学,临床特点和休克死亡相关因素,探讨小儿休克临床分型。方法：对１９９６年１月￣１９９７年１２月入院ＰＩＣＵ时或住院期间发生休克的病例进行回顾性临床分析。结果 ５９４例中１１６例发生休克,休克患病率１９．５％,死亡４９例,病死率４２．２％。外因,内因和医源混合因素引起的休克占７５．９％。休克死亡多因素变量分析显示：休克〉８小时,脏器低灌注〉１２小时,小儿危重病例评分（ＰＣ     

Performance of PRISM (Pediatric Risk of Mortality) score and PIM (Pediatric Index of Mortality) score in a tertiary care pediatric ICU

Objective  

To validate Pediatric Risk of Mortality (PRISM) and Pediatric Index of Mortality (PIM) score.     

Mortality Risk Prediction by Application of Pediatric Risk of Mortality Scoring System in Pediatric Intensive Care Unit

Objective

The Pediatric Risk of Mortality (PRISM) score is one of the scores used by many pediatricians for prediction of the mortality risk in the pediatric intensive care unit (PICU). Herein, we intend to evaluate the efficacy of PRISM score in prediction of mortality rate in PICU.

Methods

In this cohort study, 221 children admitted during an 18-month period to PICU, were enrolled. PRISM score and mortality risk were calculated. Follow up was noted as death or discharge. Results were analyzed by Kaplan-Meier curve, ROC curve, Log Rank (Mantel-Cox), Logistic regression model using SPSS 15.

Findings

Totally, 57% of the patients were males. Forty seven patients died during the study period. The PRISM score was 0-10 in 71%, 11-20 in 20.4% and 21-30 in 8.6%. PRISM score showed an increase of mortality from 10.2% in 0-10 score patients to 73.8% in 21-30 score ones. The survival time significantly decreased as PRISM score increased (P≤0.001). A 7.2 fold mortality risk was present in patients with score 21-30 compared with score 0-10. ROC curve analysis for mortality according to PRISM score showed an under curve area of 80.3%.

Conclusion

PRISM score is a good predictor for evaluation of mortality risk in PICU.     

The suitability of the Pediatric Index of Mortality (PIM), PIM2, the Pediatric Risk of Mortality (PRISM), and PRISM III for monitoring the quality of pediatric intensive care in Australia and New Zealand.

OBJECTIVE: To compare the performance of the Pediatric Index of Mortality (PIM), PIM2, the Pediatric Risk of Mortality (PRISM), and PRISM III in Australia and New Zealand. DESIGN: A two-phase prospective observational study. Phase 1 assessed the performance of PIM, PRISM, and PRISM III between 1997 and 1999. Phase 2 assessed PIM2 in 2000 and 2001. SETTING: Ten intensive care units in Australia and New Zealand. PATIENTS: Included in the study were 26,966 patients aged <16 yrs; 1,147 patients died in the intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Discrimination between death and survival was assessed by calculating the area under the receiver operating characteristic plot for each model. The areas (95% confidence interval) for PIM, PIM2, PRISM, and PRISM III were 0.89 (0.88-0.90), 0.90 (0.88-0.91), 0.90 (0.89-0.91), and 0.93 (0.92-0.94). The calibration of the models was assessed by comparing the number of observed to predicted deaths in different diagnostic and risk groups. Prediction was best using PIM2 with no difference between observed and expected mortality (standardized mortality ratio [95% confidence interval] 0.97 [0.86-1.05]). PIM, PRISM III, and PRISM all overpredicted death, predicting 116%, 130%, and 189% of observed deaths, respectively. The performance of individual units was compared during phase 1, using PIM, PRISM, and PRISM III. There was agreement between the models in the identification of outlying units; two units performed better than expected and one unit worse than expected for each model. CONCLUSIONS: Of the models tested, PIM2 was the most accurate and had the best fit in different diagnostic and risk groups; therefore, it is the most suitable mortality prediction model to use for monitoring the quality of pediatric intensive care in Australia and New Zealand. More information about the performance of the models in other regions is required before these results can be generalized.     

Demographic profile and outcome analysis of a tertiary level pediatric intensive care unit

Objective : To study the profile and outcome of children admitted to a tertiary level pediatric intensive care unit (PICU) in India.Methods : Prospective study of patient demographics, PRISM III scores, diagnoses, treatment, morbidity and mortality of all PICU admissions.Results : 948 children were admitted to the PICU. Mean age was 41.48 months. Male to female ratio was 2.95:1. Mean PRISM III score on admission was 18.50. Diagnoses included respiratory (19.7%), cardiac (9.7%), neurological (17.9%), infectious (12.5%), trauma (11.7%), other surgical (8.8%).196 children (20.68%) required mechanical ventilation. Average duration of ventilation was 6.39 days. 27 children (30.7 children /1000 admissions) had acute respiratory distress syndrome. Gross mortality was 6.7% (59 patients). PRISMIII adjusted mortality was directly proportional to PRISMIII scores. 49.5% of nonsurvivors had multiorgan failure. Average length of PICU stay was 4.52 +/−2.6 days. Complications commonly encountered Were atelectasis (6.37%), accidental extubation (2%), and pneumothorax (0.9%). Incidence of nosocomial infections was 16.86%.Conclusion : Our data appears to be similar with regards to PRISMIII scores and adjusted mortality, length of the PICU stay, and duration of ventilation, to previously published western data. Multiorgan failure remains a major cause of death. As expected, Dengue and malaria were common. Incidence of nosocomial infections was somewhat high. Interestingly, more boys got admitted to the PICU as compared to girls. Clearly more studies are required to assess the overall outcomes of critically ill children in India     

镇静在儿科重症监护病房的应用

镇静在危重患儿的治疗过程中已越来越受到重视,也普遍应用于临床.各种镇静药物及其使用方法、镇静水平的评估、镇静风险的防治等都有不同的文献报道.目前苯二氮(革)类是镇静的主要药物,咪达唑仑静脉维持是常用的镇静方法,Rasmay评分、舒适量表评分和脑电双频指数常用于评价镇静水平,良好的镇静评估和心电呼吸监护是防治镇静风险的关键.     

数字视频脑电图在儿科重症监护室的应用

儿科重症监护室(NICU、PICU)的患儿常存在各种原因导致脑损伤,数字视频脑电图检查可为病因诊断、病情变化监测、评估、预后等提供帮助,现将数字视频脑电图在 NICU 和 PICU 中常见疾病中的应用进行综述。     

儿科重症医学与遗传代谢病

遗传代谢病患儿经常以严重酸中毒、高氨血症、脑水肿、昏迷、嗜睡、抽搐、呕吐、肌无力、黄疸、呼吸困难等症状在PICU住院,小儿重症医学科医生应重视对遗传代谢病诊断和治疗的认识,提高对遗传代谢病的诊治水平.本文介绍了小儿重症医学科医生应基本掌握的遗传代谢病的概念、临床表现、诊断方法和基本治疗方法,并提出了对遗传代谢病重症危象患儿血液净化治疗的重要性.     

Application of different scoring systems and their value in pediatric intensive care unit

BackgroundLittle is known on the impact of risk factors that may complicate the course of critical illness. Scoring systems in ICUs allow assessment of the severity of diseases and predicting mortality.ObjectivesApply commonly used scores for assessment of illness severity and identify the combination of factors predicting patient’s outcome.MethodsWe included 231 patients admitted to PICU of Cairo University, Pediatric Hospital. PRISM III, PIM2, PEMOD, PELOD, TISS and SOFA scores were applied on the day of admission. Follow up was done using SOFA score and TISS.ResultsThere were positive correlations between PRISM III, PIM2, PELOD, PEMOD, SOFA and TISS on the day of admission, and the mortality rate (p < 0.0001). TISS and SOFA score had the highest discrimination ability (AUC: 0.81, 0.765, respectively). Significant positive correlations were found between SOFA score and TISS scores on days 1, 3 and 7 and PICU mortality rate (p < 0.0001). TISS had more ability of discrimination than SOFA score on day 1 (AUC: 0.843, 0.787, respectively).ConclusionScoring systems applied in PICU had good discrimination ability. TISS was a good tool for follow up. LOS, mechanical ventilation and inotropes were risk factors of mortality.     

儿童ICU规范化建设的思考

我国儿科重症医学近年来进入快速发展时期,在危重患儿的救治中发挥巨大作用,但由于起步较晚、地区发展不平衡,全国儿童ICU构建缺乏统一的指导性文件,在《重症医学科建设与管理指南(试行)》的推动下,应加快制定和完善我国儿童ICU的规范化建设.本文阐述了国际与国内儿童ICU发展现状、PICU运行模式、合理的人员和设备配置、ICU监护和救治技术、流程规范、质量指标,并提出相关建设建议.