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.     

Continuous allocation: The problem with EPTS and pediatric kidney candidates

Background

The 2014 Kidney Allocation System (KAS) introduced longevity matching for adult candidates using the Estimated Post-Transplant Survival (EPTS) score, which includes candidate age, time on dialysis, diabetes status, and number of previous solid organ transplants. The proposed continuous distribution framework may expand the use of this attribute to pediatric candidates, but there is no data on its performance among pediatric kidney transplant recipients.

Methods

We performed a retrospective cohort study of 6800 pediatric kidney transplant recipients from 2001 to 2011 using Organ Procurement and Transplantation Network (OPTN) data. EPTS score was calculated for each patient and compared to reported patient survival to estimate the validity of the score in children.

Results

The median age of patients was 14.01 years (IQR 9.29–16.37 years), and dialysis vintage was 0.67 years (IQR 0–1.82 years). 18.2% of the cohort had a prior transplant and 1% had diabetes. Median EPTS score was 2 (IQR 1–2). Seven percent of patients died during the study period and 54.7% of the cohort was censored prior to 10 years. The c-statistic was 0.505 (95% CI: 0.49–0.53).

Conclusion

Overall, EPTS is not a valid predictor of patient survival among pediatric kidney transplant recipients.     

Long-term mortality in pediatric solid organ recipients—A nationwide study

Background

The present study aimed at investigating long-term mortality of patients who underwent solid organ transplantation during childhood and at identifying their causes of death.

Methods

A cohort of 233 pediatric solid organ transplant recipients who had a kidney, liver, or heart transplantation between 1982 and 2015 in Finland were studied. Year of birth-, sex-, and hometown-matched controls (n = 1157) were identified using the Population Register Center registry. The Causes of Death Registry was utilized to identify the causes of death.

Results

Among the transplant recipients, there were 60 (25.8%) deaths (median follow-up 18.0 years, interquartile range of 11.0–23.0 years). Transplant recipients' risk of death was nearly 130-fold higher than that of the controls (95% CI 51.9–1784.6). The 20-year survival rates for kidney, liver, and heart recipients were 86.1% (95% CI 79.9%–92.3%), 58.5% (95% CI 46.2%–74.1%), and 61.4% (95% CI 48.1%–78.4%), respectively. The most common causes of death were cardiovascular diseases (23%), infections (22%), and malignancies (17%). There were no significant differences in survival based on sex or transplantation era.

Conclusion

The late mortality is still significantly higher among pediatric solid organ recipients in comparison with controls. Cardiovascular complications, infections, and cancers are the main causes of late mortality for all studied transplant groups. These findings emphasize the cruciality of careful monitoring of pediatric transplant recipients in order to reduce long-term mortality.     

Using pediatric liver grafts (≤6 yr) for adult recipients: A considerable option?

In LT, the common policy is to allocate pediatric liver grafts to pediatric recipients. Pediatric organs are also offered to adults if there is no pediatric recipient. However, they are rarely accepted for adult recipients. So far, there is no information available reporting outcome of LT in adult recipients using pediatric livers from donors ≤6 yr. In this study, we included nine adult recipients (seven females and two males) who received grafts from children ≤6 yr from January 2008 to December 2013. We evaluated the graft quality, the GBWR and analyzed the recipients’ perioperative course. Laboratory samples and graft perfusion were analyzed. Nine adults with a median age of 49 yr (range: 25–65) and a median weight of 60 kg (range: 48–64) underwent LT with a pediatric donor graft. Median donor age was five yr (range: 3–6). Median GBWR was 1.02 (range: 0.86–1.45). After a median follow‐up of 3.9 yr (range: 11 months–6.6 yr), patient survival was 100%; graft survival was 89%. One patient needed re‐transplantation on the second postoperative day due to PNF. Eight recipients were discharged from the ICU after 2–9 days with a regular graft function. Doppler scans revealed regular flow patterns at any time. Only if denied for pediatric recipients, the use of pediatric livers from donors ≤6 yr for adult recipients is a considerable option.     

Invasive candidiasis in liver transplant patients: Incidence and risk factors in a pediatric cohort

Prolonged OR, re‐transplantation, and high‐volume intraoperative transfusion have been associated with increased risk for IC in adult LT recipients. Antifungal prophylaxis is recommended for adult patients with these risk factors. There are limited data on the incidence of and risk factors for IC in pediatric LT recipients. A retrospective cohort study of all pediatric LT patients at the CHOP between 2000 and 2012 and the CHP between 2004 and 2012 was performed to define the incidence of IC within 30 days of LT. A 3:1 matched case–control study with incidence density sampling was performed. Conditional logistic regression analyses were used to explore risk factors associated with IC. Among 397 recipients, the incidence of IC was 2.5%. Bivariate analyses showed that ICU admission prior to transplant, OR > 10 h, intraoperative volume infusion of >300 mL/kg, and broad‐spectrum antibiotics were significantly associated with IC. In a multivariate model, only ICU admission remained significantly associated with IC. Antifungal prophylaxis was not significantly protective against IC. The low incidence of IC and lack of an identified protective effect from antifungal prophylaxis suggest that prophylaxis in pediatric LT recipients should not be routinely recommended to prevent IC events in the first 30 days post‐transplant.     

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.

     

Comparison of in-hospital morbidity and mortality in HIV-infected and uninfected children after surgery

Purpose

Increasingly HIV-infected children can be expected to require surgery. The aim of this study was to compare the outcome of HIV-infected and HIV-unexposed children undergoing surgery.

Patients and methods

A prospective study of children less than or equal to 60?months admitted to a tertiary pediatric surgical service from July 2004 to July 2008. Children underwent age-definitive HIV testing and were followed up postoperatively for complications, length of stay and mortality.

Results

Three hundred and twenty-seven children were enrolled: 82 (23?%) HIV-infected and 245 (67?%) were HIV-unexposed. Eighty-four (26?%) children were malnourished, which was higher in the HIV-infected group [41 (50.0?%) vs. 43 (17.5?%), relative risk (RR) 2.9; 95?% confidence interval (CI) 2.0–4.1; p?<?0.0001]. Three hundred and twenty-eight surgical procedures were performed. A similar number of major [28 (34.2?%) vs. 64 (26.1?%); p?=?0.2] and emergency procedures [37 (45.1?%) vs. 95 (38.8?%); p?=?0.34] were performed in each group. HIV-infected children had a higher rate of contamination at surgery [40 (48.7?%) vs. 49 (20?%); RR 2.43 (CI 1.7–3.4); p?<?0.0001]. There were more complications in the HIV-infected group [34 (41.5?%) vs. 14 (5.7?%); RR 7.3 (CI 4.1–12.8); p?<?0.0001]. The most common complications were surgical site complications 30 (55?%), followed by postoperative infections, 19 (34?%). Infections with drug-resistant organisms occurred more commonly in HIV-infected children [11/19 (58?%) vs. 2/13 (15?%); RR 3.8 (CI 1.3–14.2); p?=?0.02]. The median length of hospital stay was longer in the HIV-infected group [4 (IQR 2–14) vs. 2 (IQR 1–4) days; p?=?0.0001]. There was a higher mortality amongst the HIV-infected group [6 (7.3?%) vs. 0 (0?%); p?<?0.0001].

Conclusion

HIV-infected children have a higher rate of postoperative complications and mortality compared with HIV-unexposed children.     

The impact of surgical strategies on outcomes for pediatric chronic pancreatitis

Purpose

To review our institutional experience in the surgical treatment of pediatric chronic pancreatitis (CP) and evaluate predictors of long-term pain relief.

Methods

Outcomes of patients ≤21 years surgically treated for CP in a single institution from 1995 to 2014 were evaluated.

Results

Twenty patients underwent surgery for CP at a median of 16.6 years (IQR 10.7–20.6 years). The most common etiology was pancreas divisum (n = 7; 35%). Therapeutic endoscopy was the first-line treatment in 17 cases (85%). Surgical procedures included: longitudinal pancreaticojejunostomy (n = 4, 20%), pancreatectomy (n = 9, 45%), total pancreatectomy with islet autotransplantation (n = 2; 10%), sphincteroplasty (n = 2, 10%) and pseudocyst drainage (n = 3, 15%). At a median follow-up of 5.3 years (IQR 4.2–5.3), twelve patients (63.2%) were pain free and five (26.3%) were insulin dependent. In univariate analysis, previous surgical procedure or >5 endoscopic treatments were associated with a lower likelihood of pain relief (OR 0.06; 95% CI 0.006–0.57; OR 0.07; 95%, CI 0.01–0.89). However, these associations were not present in multivariate analysis.

Conclusion

In children with CP, the step-up practice including a limited trial of endoscopic interventions followed by surgery tailored to anatomical abnormalities and gene mutation status is effective in ensuring long-term pain relief and preserving pancreatic function.

     

Overweight,central obesity,and cardiometabolic risk factors in pediatric liver transplantation

PTMS describes the presence of ≥3 cardiometabolic risk factors that include obesity, hypertension, dyslipidemia, and IR. The prevalence of the clustering of ≥3 cardiometabolic risk factors or central obesity has not been studied in pediatric LT recipients. Single‐center, cross‐sectional study. Inclusion criteria: LT recipients 2–18 yr‐old, at least one yr post‐LT. Exclusion criteria: recipients of liver retransplants or multivisceral transplants. Eighty‐seven patients were identified. Median age was 9.8 yr (range 2–18), median time since LT was 6.9 yr (range 1–17). The most common indication for LT was biliary atresia (56%), and the most frequently used immunosuppressant was tacrolimus (80%). The prevalence of overweight and obesity was 21% and 5%, respectively. Central obesity affected 14%, hypertension 44%, IR 27%, low HDL 20%, and hypertriglyceridemia 39% of patients. The prevalence of ≥3 cardiometabolic risk factors was 19%. Fifty percent of the overweight/obese patients had ≥3 risk factors. Time since transplant, immunosuppression and renal function were not different between those with <3 or ≥3 risk factors. Clustering of cardiometabolic risk factors is prevalent in pediatric LT recipients, suggesting an increased risk of future CV events.     

Measles,mumps, rubella (vaccine) and varicella vaccines in pediatric liver transplant: An initial analysis of post‐transplant immunity

Varicella and measles infection represents a significant source of morbidity and mortality for pediatric LT recipients. We evaluated the prevalence and correlates of post‐transplant immunity in pediatric LT recipients previously immunized against measles (n = 72) and varicella (n = 67). Sixteen of seventy‐two (22%) patients were measles non‐immune, and 42/67 (63%) were varicella non‐immune after LT. Median time from LT to titers for measles and varicella was 4.0 and 3.3 years, respectively. In the measles cohort, non‐immune patients received fewer pretransplant vaccine doses (P = 0.026) and were younger at both time of vaccination (P = 0.006) and LT (P = 0.004) compared with immune patients. Upon multivariable analysis, weight > 10 kg at LT (OR 5.91, 95% CI 1.27‐27.41) and technical variant graft (OR 0.07, 95% CI 0.01‐0.37) were independently, significantly associated with measles immunity. In the varicella cohort, non‐immune patients received fewer pretransplant vaccine doses (P = 0.028), were younger at transplant (P = 0.022), and had less time lapse between their last vaccine and transplant (P = 0.012) compared with immune patients. Upon multivariate analysis, time > 1 year from last vaccine to LT was independently, significantly associated with varicella immunity (OR 3.78, CI 1.30‐11.01). This study demonstrates that non‐immunity to measles and varicella is a prevalent problem after liver transplantation in children and identifies 3 unique risk factors for non‐immunity in this high‐risk population.     

Shear wave elastography and shear wave dispersion correlated to biopsy at the scheduled follow-up of pediatric liver grafts

Background

It is unknown how shear wave dispersion (SWD) is displayed in pediatric liver transplant recipients and not fully elucidated how ultrasound shear wave elastography (2D-SWE) display within this cohort, which is important to determine to improve noninvasive surveillance of these patients. The study aimed to compare SWE and SWD values with histopathology in pediatric liver recipients.

Methods

Forty-eight pediatric liver recipients were examined with SWE in conjunction with an elective liver biopsy (clinically without complication). Additionally, SWD values were measured in 21 children. SWE and SWD values were compared to histologically determined fibrosis graded as none-to-mild (F0–1) and moderate-to-severe (F2–4), and inflammation graded as low (grade 0–1) and high (grade 2–4).

Results

Two children were excluded due to SWE IQR/median > 30% kPa. The mean age across 46 included patients was 10.9 years (range 1.4–18). The number of patients and median (range) SWE value (kPa) for each stage of fibrosis were: F0–1 [n = 23; 5.8 (3.2–16.1)], F2 [n = 22; 6.0 (4.5–25.9)], F3 [n = 1; 33.3], and F4 [n = 0]. Significantly higher SWE values and greater variability were registered in F2–4 vs. F0–1 (p = .05). Grade of fibrosis correlated weakly to SWE values (r = .3; p = .05), but not to SWD values (r = .2; p = .27). In patients with low-grade inflammation, median SWD was 13.7 m/s KHz (10.7–17.6). Only one patient had high-grade inflammation.

Conclusions

Uncomplicated transplanted liver grafts in a small pediatric cohort revealed slightly increased SWE and SWD values compared to previously reported values in healthy children. This likely reflect both the fibrotic and inflammatory elements in the grafts; however, other confounders impacting the liver's viscoelastic properties are also probable factors.     

Risk factors associated with pediatric intensive care unit admission and mortality after pediatric stem cell transplant: possible role of renal involvement

Background

Hematopoietic stem-cell transplant (HSCT) is associated with many risk factors for life-threatening complications. Post-transplant critical illness often requires admission to the pediatric intensive care unit (PICU).

Methods

A retrospective analysis was made on the risk factors associated with PICU admission and mortality of all HSCT patients at Helen DeVos Children’s Hospital from October 1998 to November 2008.

Results

One hundred and twenty-four patients underwent HSCT, with 19 (15.3%) requiring 29 PICU admissions. Fifty patients received autologous, 38 matched sibling, and 36 matched un-related donor HSCT, with 10%, 13% and 25% of these patients requiring PICU admission, respectively (P=0.01). Among the HSCT patients, those who were admitted to the PICU were more likely to have renal involvement by either malignancy requiring nephrectomy or a post transplant complication increasing the likelihood of decreased renal function (21.1% vs. 4.8%, P=0.03). PICU admissions were also more likely to receive pre-transplant total body irradiation (52.6% vs. 27.6%, P=0.03). Among 29 patients with PICU admission, 3 died on day 1 after admission, and 5 within 30 days (a mortality rate of 17%). Thirty days after PICU admission, non-survivors had a higher incidence of respiratory failure and septic shock on admission compared with survivors (80% vs. 16.7%, P=0.01 and 80% vs. 4.2%, respectively, P=0.001). Two survivors with chronic renal failure underwent renal transplantation successfully.

Conclusions

Total body irradiation and renal involvement are associated with higher risk for PICU admissions after HSCT in pediatric patients, while septic shock upon admission and post-admission respiratory failure are associated with mortality.     

Pediatric renal transplantation—A UNOS database analysis of donor–recipient size mismatch

Background

We used the BSAi (Donor BSA/Recipient BSA) to assess whether transplanting a small or large kidney into a pediatric recipient relative to his/her size influences renal transplant outcomes.

Methods

We included 14 322 single-kidney transplants in pediatric recipients (0–17 years old) (01/2000–02/2020) from the United Network for Organ Sharing database. We divided cases into four BSAi groups (BSAi ≤ 1, 1 < BSAi ≤ 2, 2 < BSAi ≤ 3, BSAi > 3).

Results

There were no differences concerning delayed graft function (DGF) or primary non-function (PNF) rates, whether the grafts were from living or brain-dead donors. In both transplants coming from living donors and brain-dead donors, cases with BSAi > 3 and cases with 2 < BSAi ≤ 3 had similar graft survival (p = .13 for transplants from living donors, p = .413 for transplants from brain-dead donors), and both groups had longer graft survival than cases with 1 < BSAi ≤ 2 and cases with BSAi ≤ 1 (p < .001). The difference in 10-year graft survival rates between cases with BSAi > 3 and cases with BSAi ≤ 1 reached around 25% in both donor types. The better graft survival in transplants with BSAi > 2 was confirmed in multivariable analysis.

Conclusions

There is no significant impact of donor-recipient size mismatch on DGF and PNF rates in pediatric renal transplants. However, graft survival is significantly improved when the donor's size is more than twice the pediatric recipient's size.     

The use of hepatitis B immunoglobulin with or without hepatitis B vaccine to prevent de novo hepatitis B in pediatric recipients of anti‐HBc–positive livers

Prophylactic measures are used to reduce DNHB after HBsAg‐negative patients receive anti‐HBc–positive liver grafts. This study investigated the incidence of DNHB and clinical outcomes in pediatric LT recipients under HBIG prophylaxis, with or without hepatitis B vaccination. Between 1995 and 2013, 51 HBsAg‐negative pediatric recipients underwent living‐donor LT from anti‐HBc–positive donors. The median (range) age was 4 (0.1‐17) years, 23 (45%) were male, and 71% were negative for both anti‐HBc and anti‐HBc. During a median follow‐up of 12.1 (0.06‐19.9) years, 13 (25.4%) developed DNHB; 7 of the 13 achieved HBsAg seroconversion after administration of LAM or ETV. Among studied patients, 20 (39%) received hepatitis B vaccination, and 2 of them (10%) developed DNHB. At last follow‐up, 41% (21/51) discontinued HBIG either after successful HBV vaccination (n = 17) or retransplantation with anti‐HBc–negative grafts (n = 4). In conclusion, pediatric LT recipients of anti‐HBc–positive grafts, most of them were naïve to HBV infection, were at high risk of DNHB, and consistent monitoring for the early detection of DNHB was necessary. A combination use of post‐LT vaccination is promising prophylactic strategy against DNHB.     

Prompt administration of antibiotics is associated with improved outcomes in febrile neutropenia in children with cancer

Background

Time‐to‐antibiotic (TTA) administration is a widely used quality‐of‐care measure for children with cancer and febrile neutropenia (FN). We sought to determine whether TTA is associated with outcomes of FN.

Procedure

A single‐center, retrospective cohort study was conducted of 1,628 FN admissions from 653 patients from 2001 to 2009. Outcome variables included (1) an adverse event (AE) composite of in‐hospital mortality, pediatric intensive care unit (PICU) admission within 24 hours of presentation, and/or fluid resuscitation ≥40 ml/kg within 24 hours of presentation and (2) length of stay (LOS). TTA was measured as a continuous variable and in 60‐minute intervals. Mixed regression models were constructed to evaluate associations of TTA with the outcome variables after adjusting for relevant covariates including cancer diagnosis, degree of myelosuppression, and presence of bacteremia.

Results

The composite AE outcome occurred in 11.1% of admissions including 0.7% in‐hospital mortality, 4.7% PICU admission, and 10.1% fluid resuscitation. In univariate analysis, TTA was associated with the composite AE outcome (Odds Ratio [OR] 1.29, 95% CI 1.02–1.64) but not LOS. In multivariate analysis, after adjustment for relevant covariates, 60‐minute TTA intervals were associated with the composite AE outcome (61–120 minutes vs. ≤60 minutes, OR 1.81, 95% CI 1.01–3.26). Unexpectedly, admission from the emergency department (ED) was also independently associated with the composite AE outcome (ED vs. clinic, OR 3.15, 95% CI 1.95–5.09).

Conclusions

TTA and presentation to the ED are independently associated with poor outcomes of FN. Pediatr Blood Cancer 2013;60:1299–1306. © 2013 Wiley Periodicals, Inc.     

Factors predicting health‐related quality of life in pediatric liver transplant recipients in the functional outcomes group

Data from 997 pediatric LT recipients were used to model demographic and medical variables as predictors of lower levels of HRQOL. Data were collected through SPLIT FOG project. Patients were between 2 and 18 yr of age and survived LT by at least 12 months. Parents and children (age ≥ 8 yr) completed PedsQL? 4.0 Generic Core and CF Scales at one time point. Demographic and medical variables were obtained from SPLIT. HRQOL scores were categorized as “poor” based on lower 25% of scores for each measure. Logistic regression models were generated. Single‐parent households (OR 1.94, CI 1.13–3.33, p = 0.017), anti‐seizure medications (OR 3.99, CI 1.26–12.70, p = 0.019), and number of days hospitalized (OR 1.03, CI 1.01–1.06, p = 0.0067) were associated with lower self‐reported HRQOL. Parent data identified increasing age at transplant, age 5–12 yr at survey, hospitalization >21 days at LT, re‐operations, diabetes, and growth failure at LT as additional predictors of generic HRQOL. Male gender, single‐parent households, higher bilirubin levels at LT, and use of anti‐seizure medication predicted lower cognitive function scores. HRQOL following pediatric LT is related to medical and demographic variables.     

Lactate clearance as a marker of mortality in Pediatric Intensive Care Unit

Objectives

To correlate lactate clearance with Pediatric Intensive Care Unit (PICU) mortality.

Methods

45 (mean age 40.15 mo, 60% males) consecutive admissions in the PICU were enrolled between May 2012 to June 2013. Lactate clearance (Lactate level at admission — level 6 hr later × 100 / lactate level at admission) in first 6 hours of hospitalization was correlated to in-hospital mortality and PRISM score.

Results

Twelve out of 45 patients died. 90% died among those with delayed/poor clearance (clearance <30%) compared to 8.5% in those with good clearance (clearance >30%) (P<0.001). Lactate clearance <30% predicted mortality with sensitivity of 75%, specificity of 97%, positive predictive value of 90%, and negative predictive value of 91.42%. Predictability was comparable to PRISM score >30.

Conclusion

Lactate clearance at six hours correlates with mortality in the PICU.     

Early Postoperative Albumin Administration Contributes to Morbidity After the Fontan Operation

The Fontan operation has low mortality, but is associated with significant postoperative morbidity, including prolonged chest tube output (PCTO), which is associated with prolonged hospital length of stay (PLOS). We sought to identify variables present early in the clinical course that could predict patients at high risk for PCTO and PLOS. Retrospective data were collected on 84 Fontan (extracardiac conduit) operations from 1/2008 to 12/2013 at a single institution. PCTO was defined as ≥8 days (>75th percentile); PLOS was defined as ≥12 days postoperatively (>75th percentile). Multivariate regression was used to determine covariates associated with PCTO and PLOS. Median age was 3.5 years (IQR 3–5); weight was 14.5 kg (IQR 13–17). There was no mortality. LOS was 9 days (IQR 3–11), and duration of chest tube drainage 6 days (IQR 5–8) at 15 ml/kg/day (IQR 9–20). In univariate analysis, only systemic right ventricle, 24-h 5 % albumin administration, 24-h fluid balance, and 12-h inotrope score were associated with PCTO. In multivariate analysis, only 5 % albumin administration in first 24 h (p < 0.001) and PCTO were independently associated with PLOS. ROC curve analysis showed patients receiving >25 ml/kg of 5 % albumin in first 24-h predicted PLOS (94 % specificity, 93 % sensitivity, AUC = 0.95, p < 0.001). Increased colloid in the first 24-h post-CPB strongly predicts PCTO and PLOS after Fontan operation, potentially providing an early identification of a cohort with unfavorable Fontan physiology. A better understanding of the role of colloid resuscitation after Fontan is necessary, and efforts to reduce perioperative colloid administration could decrease hospital morbidity     

Risk factors for hospitalization at the pediatric intensive care unit among infants and children younger than 5 years of age diagnosed with infectious diseases

BackgroundChildren hospitalized with infectious diseases may develop severe, life-threatening conditions, often requiring admission to pediatric intensive care unit (PICU). The objectives of this study were to identify independent risk factors for PICU hospitalization with an infectious disease in children <5 years of age.MethodsIn southern Israel, two populations live side by side: the middle–high income Jewish population and the low-income Bedouin population, both receiving equal and free medical care at the only tertiary medical center in the area. The study population included all children born in southern Israel and hospitalized at PICU with an infectious disease during 1991–2012. Risk factors for PICU hospitalizations were retrospectively studied by Kaplan–Meier and Cox proportional hazard survival analyses.Results9951 Jewish children and 18,002 Bedouin children were enrolled; overall, 1135 episodes of PICU hospitalizations with an infectious disease were recorded (879, 77.4% Bedouin and 256, 22.6% Jewish patients). Bedouin children had a higher risk for PICU hospitalization with an infectious disease compared with Jewish children (adjusted Hazard Ratio [adj. HR] 1.7, 95% CI 1.5–2.0); maternal multiparity and low-birth weight (<2500 g) were additional risk factors for PICU hospitalization with an infectious disease compared to firstborns (adj. HR = 1.2, 95% CI 1.0–1.5) or to children with a birth weight ≥2500 g (adj. HR = 1.5, 95% 1.2–1.9). Older age was a protective factor for PICU hospitalization (adj. HR = 0.98, 95% CI 0.97–0.99). Children hospitalized with a central nervous system infection had the highest risk of PICU hospitalization (adj. HR 6.8, 95% CI 5.5–8.4), followed by those with urinary tract infections (UTI, adj. HR 3.1, 95% CI 2.5–3.8) and those with lower respiratory tract infections (LRTI, adj. HR 2.9, 95% CI 2.4–3.4).ConclusionBedouin ethnicity, low birth weight, maternal multiparity and younger age were significant risk factors for PICU hospitalizations with an infectious disease. Among the infectious diseases analyzed, CNS infection had the highest risk for PICU hospitalization, followed by UTI and LRTI.     

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.