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.     

小儿严重脓毒症并发多器官功能障碍综合征的研究

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

Candida colonization and candidemia in a pediatric intensive care unit.

OBJECTIVE: To evaluate role of Candida colonization in development of candidemia and to identify risk factors associated with Candida colonization and candidemia in children treated for severe sepsis or septic shock in a pediatric intensive care unit (PICU) for >5 days. DESIGN: Prospective observational. SETTING: PICU of a tertiary care teaching hospital. SUBJECTS: Of 186 children, aged 1 month to 14 yrs, consecutively admitted to PICU for severe sepsis or septic shock, 65 patients having a stay of >5 days. INTERVENTIONS: Clinical and demographic data at admission and variables likely to influence Candida colonization were recorded. Oropharyngeal, rectal, and skin (groin) swabs were taken on days 0, 2, 5, and 7 of admission. Blood for fungal culture (two samples 48 hrs apart) was obtained if a patient developed signs of sepsis. The yeast growth was identified by conventional methods. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated, and multivariate logistic regression analysis was conducted. MEASUREMENTS AND MAIN RESULTS: Colonization by Candida species occurred in 45 (69%) patients. Oropharyngeal (52%) and rectal (43%) colonization was more common than skin (34%) colonization. The colonizing species were C. tropicalis (34.2%), C. parapsilosis (28.8%), C. albicans (14.4%), and others. Use of central venous catheters was the only independent predictor of colonization on multivariate logistic regression (OR 4.1; 95% CI 1.01-17.1). Twenty (30.2%) patients developed candidemia; 18 (90%) of them were colonized, 15 (75%) with the same Candida species. Independent predictors of candidemia on multivariate stepwise logistic regression analysis were presence of colonization (OR 5.1; 95% CI 1.01-25.6, p = .048) and Pediatric Risk of Mortality score (OR 1.3; 95% CI 1.02-1.6, p = .034). CONCLUSIONS: Monitoring for colonization with Candida species in children undergoing treatment for severe sepsis or sepsis shock in PICU for >5 days may offer opportunity for early intervention for prevention of candidemia.     

Study of nosocomial primary bloodstream infections in a pediatric intensive care unit

Bloodstream infections (BSI) are the commonest cause of nosocomial infections (NI) in PICU. Knowledge about their magnitude, risk factors and outcome are important in devising appropriate prevention and control measures. Our objective was to study the incidence, etiology, risk factors and outcome of primary BSI in PICU. A prospective cohort of 285 patients consecutively admitted to PICU from July 2003-04, having a stay of >48 h, were enrolled and monitored for BSI till discharge from ICU or death. Primary BSI was defined as per CDC criteria 1988. Data of patients with BSI was compared with those without BSI with respect to demographic details, PRISM III, primary diagnosis, nutritional status, device utilization and invasive procedures to identify risk factors for BSI. Variables significant on univariate analysis were subjected to multiple logistic regression analysis. Outcome was measured as length of PICU stay (LOS) and survival or death. There were 116 episodes of primary BSI in 86 (30%) patients; the incidence being 31.2 episodes/1000 patient days. The mean age of the patients with BSI was 3.7 +/- 3.5 years. Predominant isolates were Gram-negative (53.5%); Klebsiella pneumoniae (n = 21) being the commonest. Staphylococcus aureus (n = 18) was the most common Gram-positive organism. Seven of the 9 (77.8%) yeast isolates were Candida tropicalis. Younger age, higher PRISM III, lower hemoglobin, pre-existing infection, higher frequency and duration of device utilization (CVC, urinary catheter, endotracheal tube, mechanical ventilation) were significant risk factors on univariate analysis. On multiple logistic regressions, hemoglobin (OR 1.24, 95% CI 1.1-1.4, p = 0.002) duration of urinary catheter (OR 0.91, 95% CI 0.84-0.98, p = 0.015) and pre-existing infection (OR 0.46, 95% CI 0.23-0.93, p = 0.03) were independent risk factors for primary BSI. The median LOS was significantly longer in patients with BSI compared to those without (16 vs. 7 days, p = 0.0001) 47% of patients with BSI died as compared to 26% deaths in the whole cohort (p = 0.002). Just over half the cases of BSI in our PICU were caused by Gram-negative bacteria. Lower hemoglobin, pre-existing infection and prolonged duration of urinary catheter were independent risk factors identified on multivariate analysis. BSI was associated with significantly higher mortality and longer stay in our PICU.     

小儿死亡危险评分的临床应用

目的观察小儿死亡危险评分(PRISM评分)与PICU急性危重症患儿预后的关系。方法对2003年2-10月PICU收治急性危重症45例,回顾性评定PRISM评分,并依据评分分组,记录患儿临床资料和住院时间、预后。结果PRISM 评分<15分24例,>15分21例。两组年龄、体质量和院内感染率均无显著差异(P均>0.05)。两组死亡率分别为8.1%(2/ 24例)和38.1%(8/21例),PRISM评分<15分组死亡率明显低于>15分组(x2=4.14 P<0.05)。PRISM>15分组存活病例住院天数(13.2±6.1)d显著长于PRISM<15分组(9.7±8.5)d(t=1.74.P<0.05)。结论PRISM评分越高,死亡率随之增加。PRISM评分增高,患儿住院时间越长。PRISM评分能够准确评估急性危重症病人的严重程度和预后。     

Short‐term and long‐term mortality following pediatric intensive care

Background: The aim of the present study was to examine short‐term and long‐term mortality following discharge from the pediatric intensive care unit (PICU). Methods: This was a prospective observational study. Data collected consisted of demographics, severity scores, procedures, treatment, need for and duration of mechanical ventilation (MV), length of PICU and hospital stay, and mortality at PICU and hospital discharge, at 3 and 6 months and at 1 and 2 years. Results: A total of 300 patients (196 boys and 104 girls), aged 54.26 ± 49.93 months, were included in the study. Median (interquartile range) Pediatric Risk of Mortality (PRISM III‐24) score was 7 (3–11) and predicted mortality rate was 11.16%. MV rate was 67.3% (58.3% at admission) for 6.54 ± 14.15 days, and length of PICU and hospital stay was 8.85 ± 23.28 days and 20.69 ± 28.64 days, respectively. Mortality rate at discharge was 9.7% and cumulative mortality rate thereafter was 12.7%, 15.0%, 16.7%, 19.0%, and 19.0% at hospital discharge, 3 months, 6 months, 1 year and 2 years, respectively. Significant risk factors of PICU mortality were inotrope use, PRISM III‐24 score >8, MV, arterial and central venous catheterization, nosocomial infection, complications, and cancer. Independent predictors of mortality at discharge were inotrope use and PRISM III‐24 score, whereas predictors of mortality at 2 years were comorbidity and cancer. Conclusions: A 2 year follow‐up period seems sufficient for a comprehensive mortality analysis of PICU patients. Severity of critical illness is the key factor of short‐term mortality, whereas comorbidity is the major determinant of long‐term mortality.     

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.     

Prediction of mortality by application of PRISM score in intensive care unit.

OBJECTIVE: Prediction of mortality by application of Pediatric Risk of Mortality (PRISM) score in Pediatric Intensive Care Unit (PICU) patients under Indian circumstances. DESIGN: Prospective study. SETTING: PICU of a tertiary care multi-specialty hospital. METHODS: 100 sick pediatric patients admitted consecutively in PICU were taken for this study. PRISM score was calculated. Hospital outcome was recorded as (died/survived). The predicted death was calculated by the formula: RESULTS: Of 100 patients, 18 died and 82 survived. By PRISM score 49 children had the score of 1-9. The expected death in this group was 10.3% (n = 5.03) and the observed death was 8.2% (n = 4). Among 45 children with the score of 10-19, the expected mortality was 21.2% (n = 9.6) and observed was 24.4% (n = 11). There were 3 patients with the score of 20-29, the expected mortality in this group was 39.3% (n = 1.18) and observed mortality 33.3% (n = 1). There were 3 patients with score > or = 30, observed death 66.3% (n = 2) and expected mortality was 74.7% (n = 2.24). There was no significant difference between expected and observed mortality in any group. (p > 0.5). ROC analysis showed area under the curve of 72%. CONCLUSION: PRISM score has good predictive value in assessing the probability of mortality in relation to children admitted to a PICU under Indian circumstances.     

Going back for more: an evaluation of clinical outcomes and characteristics of readmissions to a pediatric intensive care unit.

OBJECTIVE: To determine mortality, length of stay, and factors associated with readmissions to the pediatric intensive care unit (PICU). DESIGN: A retrospective analysis of prospectively collected data. SETTING: A 16-bed medical-surgical tertiary PICU and a coexisting 15-bed pediatric cardiac intensive care unit. PATIENTS: All admissions from July 1, 1998, through June 30, 2004. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Of 8,885 total eligible admissions, 711 (8%) were readmissions to the PICU. The median age of the overall cohort was 35.2 months (interquartile range, 5.5-128.2). Readmitted patients were younger (10.4 vs. 37.7 months, p < .01), had greater severity of illness (p < .01), and were more likely to be admitted emergently (p < .01), in comparison with single admissions. In multivariate analyses, readmitted patients had a trend toward higher odds of mortality (odds ratio, 1.39; 95% confidence interval, 0.98-1.98) and stayed 2.96 days longer in the PICU (95% confidence interval, 1.98-3.94) compared with single admissions to the PICU. Factors independently associated with PICU readmission were infant age (odds ratio, 1.98; 95% confidence interval, 1.57-2.49), emergent admission (odds ratio, 2.21; 95% confidence interval, 1.78-2.77), illness severity (odds ratio, 1.03; 95% confidence interval, 1.01-1.04), and time of the year between July and September (odds ratio, 1.52; 95% confidence interval, 1.20-1.93). A diagnosis of trauma was associated with low likelihood of PICU readmission (odds ratio, 0.30; 95% confidence interval, 0.18-0.50). CONCLUSIONS: Patients readmitted to the PICU during the same hospitalization have significantly adverse outcomes. The study highlights important factors associated with PICU readmissions that can be incorporated into efforts to reduce mortality and resource utilization associated with readmission of critically ill children.     

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

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

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

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

The pediatric risk of mortality score in infants and children with fulminant liver failure

The pediatric risk of mortality (PRISM) score as a severity scoring system has never been assessed in infants and children with fulminant liver failure (FLF). A retrospective case study of 109 infants and children admitted in a 22-bed pediatric and neonatal intensive care unit of a tertiary university hospital, National Referral Center for Pediatric Liver Transplantation, from March 1986 to August 1997 was carried out. PRISM score was not significantly different within etiologic FLF categories, or between infants and children. However, PRISM score (mean +/- SD) showed significant difference (p = 0.001) between the 27 patients who spontaneously recovered with supportive care (8.8 +/- 5.0) and 82 patients who underwent emergency liver transplantation (ELT) or those who died before (14.9 +/- 7.7). PRISM score-based probability of mortality was underestimated when compared with observed mortality. A death probability higher than 20% had a 24% sensitivity and 95% specificity for severe outcome. Reciever operating characteristic curve for PRISM score showed elevated discriminative power (Az = 0.91) for discerning children with severe outcome from those who spontaneously recovered with supportive care. A PRISM score more than 10 showed an odds ratio of 2.69 for predicting severe outcome (95% CI: 1.11-6.55; p = 0.038). In conclusion, the PRISM score is an accurate means of severity assessment in pediatric FLF. However, PRISM score-based mortality was of low predictive value.     

儿童重症监护室主动出院患儿的多中心前瞻性队列研究

背景：在中国PICU,患儿主动出院是医生常面对的无奈和棘手的问题。 目的：探讨PICU主动出院患儿死亡与存活的临床特征,并分析影响主动出院后死亡的因素。 设计：多中心前瞻性队列研究。 方法：以2016年8月1日至2017年7月31日华东地区8家儿童专科医院PICU主动出院的连续病例为队列人群,以主动出院后28 d内电话随访的存活和死亡为队列结局终点,采集主动出院患儿人群特征、原因、病种、用于小儿危重病例评分（PCIS）和小儿死亡危险评分（PRISMⅢ）评价的所有参数。采用Logistic风险模型分析主动出院死亡的影响因素。 主要结局指标：主动出院后28 d内病死率。 结果：8家医院PICU共4 952例进入本文分析,住院病死率56%（279/4 059）。主动出院893例（18.1%）中,男518例（58.0%）,女375例。年龄中位数1.4岁;主动出院后28 d内失访3例,死亡550例（61.6%）,存活340例。主动出院病例农村占比高于城市(62.2% vs 37.8%),主动出院后28 d内死亡病例农村占比高于存活病例（65.0% vs 57.8%）,差异均有统计学意义;主动出院病例死亡病因感染占49.2%,病因不明、肿瘤、先天畸形和遗传代谢分别约占10%。主动出院病例死亡［8(3,15)］与存活［3(0,7)］PRISMⅢ评分差异有统计学意义。对主动出院死亡与在院死亡病例的临床特征行单因素分析,差异有统计学意义的变量进入Logistic回归分析,主动出院的农村病例较城市病例死亡风险增加55%（OR=1.554,95%CI：1.112~2.173,P=0.01）、无医疗保险病例较有医疗保险病例死亡风险增加169%（OR=2.686,95%CI：1.910~3.778,P=0.000）;院前有心肺复苏史的患儿出院死亡风险降低53%（OR=0.467,95%CI：0.271~0.802,P=0.006）,PRISMⅢ每降低1分,出院死亡风险降低4%（OR=0.962,95%CI：0.946~0.978,P=0.000）。 结论：中国华东8家医院PICU狭义病死率56%,广义的病死率16.8%（829/4 959）;居住地为农村、无医疗保险增加了主动出院死亡风险。院前有心肺复苏史能降低主动出院的死亡风险。     

The impact of pediatric intensive care unit volume on mortality: a hierarchical instrumental variable analysis.

OBJECTIVE: To evaluate the relation between annual pediatric intensive care unit (PICU) admission volume and mortality. DESIGN: Nonconcurrent cohort design. SETTING: Pediatric patients included in the most currently available research database from the Pediatric Intensive Care Unit Evaluations (PICUEs). PATIENTS: A total of 34,880 consecutive pediatric admissions to a contemporary volunteer sample of 15 U.S. PICUs. MEASUREMENTS AND MAIN RESULTS: We conducted an instrumental variable analysis and adjusted for similarities between patients admitted to different PICUs using mixed-effects, hierarchical techniques. Case mix and severity of illness was adjusted for using patient-level data and the Pediatric Risk of Mortality, version III (PRISM III). On average, admission to higher-volume PICUs was associated with lower severity-adjusted mortality (odds ratio = 0.68 per 100 patient increase in volume; 95% confidence interval: 0.52-0.89) when volume was analyzed as a linear term; however, when PICU volume was analyzed as a quadratic term, we found the lowest severity-adjusted mortality rates among PICUs with annual admission volumes between 992 and 1,491. Furthermore, lower severity-adjusted mortality rates were primarily found among patients with less than a 10% PRISM III predicted risk of mortality. CONCLUSIONS: Although there is an association between lower severity-adjusted mortality among higher volume PICUs, our data suggest that best outcomes are among mid- to large-sized PICUs. These data support minimum annual admission criteria for PICUs but raise the concern that PICUs with very high annual admission volumes may operate beyond an ideal capacity.     

Incidence and Risk Factors for Venous Thromboembolism in Critically Ill Children With Cardiac Disease

Cardiac disease is a risk factor for venous thromboembolism (VTE) in children. In this study, we investigated the incidence and risk factors of VTE in critically ill children with cardiac disease, who were prospectively followed-up for VTE after admission to a tertiary care pediatric intensive care unit (PICU). Risk factors were compared between VTE cases and (1) patients in the cohort who did not develop VTE and (2) the next three cardiac patients sequentially admitted to the PICU (case control). Forty-one cases of VTE were identified from 1070 admissions (3.8%). Thirty-seven percent of VTE cases were central venous catheter (CVC)–associated, and 56% of cases were intracardiac. Sixty-six percent of patients were receiving anticoagulation at the time of VTE diagnosis. Increased VTE incidence was associated with unscheduled PICU admission, age <6 months, extracorporeal membrane oxygenation, increased number of CVCs, increased number of CVC days, higher risk of mortality score, and longer PICU stay. Using logistic regression, VTE was associated with single-ventricle physiology (odds ratio [OR] 11.2, 95% CI 3.0–41.9), widened arterial-to-somatic oxygen saturation gradient (SpO₂–rSO₂ >30) (OR 4.3, 95% CI 1.1–16), and more CVC days (OR 1.1, 95% CI 1.04–1.13). Risk factors for VTE in critically ill children with cardiac disease include younger age, single-ventricle cardiac lesions, increased illness severity, unscheduled PICU admission, and complicated hospital course.     

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     

小儿危重评分和死亡危险评分在监护室中的应用

目的 通过对PICU危重患儿小儿危重评分(PCIS)和小儿死亡危险评分(PRISM)的比较判断两种评分的临床应用价值.方法 对580例PICU住院患儿按照小儿危重评分标准、死亡及器官衰竭情况进行分组,根据各组PRISM评分分析比较各组问的差异性.结果 危重组、极危重组与非危重组各组间的PRISM评分差异有显著性(P<0.01);死亡组与存活组的PRISM评分值的差异也有显著性(P<0.01);PRISM评分随器官衰竭数增加而增高(P<0.05).结论 小儿危重评分和死亡危险评分对临床危重患儿的病情危重程度、死亡危险程度的判断有指导价值.     

Risk factors for intraventricular hemorrhage in very low birth weight infants in Tehran, Iran

Intraventricular hemorrhage (IVH) is an important cause of morbidity and mortality in very low birth weight (VLBW) infants; 80-90% of cases occur between birth and the third day of life. In a retrospective case control clinical study, files of all premature infants with birth weights <1500 grams admitted between April 2004 and October 2005 to the Neonatal Intensive Care Unit (NICU) of Akbar Abadi Hospital were reviewed. We determined risk factors that predispose to the development of high-grade IVH (grades 3 and 4) in VLBW infants. Thirty-nine infants with IVH grade 3 and 4 were identified. A control group of 82 VLBW infants were also selected. Prenatal data, delivery characteristics, neonatal course data and reports of cranial ultrasonography were carefully collected for both groups. Those variables that achieved significance (p<0.05) in univariate analysis were entered into multivariate logistic regression analysis. A total of 325 VLBW infants were evaluated. Mortality rate was 21.5%. Multivariate logistic analysis showed that the following factors are associated with greater risk of high-grade IVH occurrence: lower gestational age (OR: 3.72; 95% CI: 1.65-8.38), birth weight (OR: 3.42; 95% CI: 1.65-8.38), mechanical ventilation (OR: 4.14; 95% CI: 1.35-12.2), tocolytic therapy with magnesium sulfate (OR: 4.40; 95% CI: 1.10-24.5), hyaline membrane disease (HMD, OR: 3.16; 95% CI: 1.42-7.45), symptomatic hypotension (OR: 2.32; 95% CI: 1.06-5.42), hypercapnia (OR: 1.9; 95% CI: 1.1-3.4) and Apgar score at 5 minutes (OR: 1.58; 95% CI: 1.59-6.32).     

Evaluation of Pediatric Risk of Mortality (PRISM) scoring in African children with falciparum malaria.

OBJECTIVE: Little is known about the use of generic severity scores in severe childhood infectious diseases. The purpose of this prospective study was to evaluate the performance of the Pediatric Risk of Mortality (PRISM) scoring system in predicting the outcome of falciparum malaria in African children. DESIGN, SETTING, PATIENTS: All children admitted to a 120-bed pediatric ward in a tertiary care hospital in Dakar, Senegal, with a primary diagnosis of acute malaria were assigned a PRISM score after 24 hrs or at time of death. INTERVENTIONS: None. RESULTS: PRISM discrimination, evaluated by areas under receiver operating characteristic curves (AUC), was good both for all acute malaria cases (n = 311; lethality, 9%; AUC, 0.89; 95% confidence interval [CI], 0.85-0.92) and for severe malaria cases (n = 233; lethality, 12%; AUC, 0.86; 95% CI, 0.81-0.90). However, the number of children who died was greater than the number of deaths predicted by PRISM (standardized mortality ratio, 2.16; 95% CI, 1.46-2.87). CONCLUSION: This discrepancy observed in five classes of expected mortality (Hosmer-Lemeshow chi-square test, p < .001) may have been due to chance (sample size too small for a valid test), to a lower standard of care in Dakar than in the American hospitals where PRISM was designed, or to a failure of PRISM to classify risk in severe malaria.