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.     

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.     

Pediatric risk of mortality (PRISM) score in meningococcal disease

To assess the pediatric risk of mortality (PRISM) score as a prognostic scoring system in severe meningococcal disease, the files of 53 consecutive patients admitted to a tertiary pediatric intensive care with a clinical diagnosis of meningococcal disease and positive cultures from blood and/or cerebrospinal fluid were analysed. PRISM-score-based expected mortality was compared with observed mortality. Expected mortality in the whole study population was 29% while observed mortality was 19% (P < 0.05). The highest expected and observed mortality was found in septicaemic patients without (documented) meningitis, while meningitis patients without septicaemia had the lowest mortality. All patients with a mortality risk below 18.3% (n = 29) survived whereas all those with a mortality risk of 65% or higher (n = 7) died. Of the 17 patients with a mortality risk between 18.3% and 63.9%, 14 survived and 3 died. The area under the receiver-operating characteristic (ROC) curve was 0.94, which is at least comparable with the best-performing meningococcal-disease-specific scoring systems. Conclusion The PRISM score is a useful generic measure of severity of illness in meningococcal disease and can be used to determine the effectiveness of different treatment strategies. Received: 5 May 1999 / Accepted: 11 January 2000     

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.     

Comparison of two different severity scores (Paediatric Risk of Mortality [PRISM] and the Glasgow Meningococcal Sepsis Prognostic Score [GMSPS]) in meningococcal disease: preliminary analysis

Two different illness severity scores, Pediatric Risk of Mortality (PRISM) and the Glasgow Meningococcal Sepsis Prognostic Score (GMSPS), were evaluated and compared in meningococcal disease in two paediatric intensive care units. Forty-nine children with a median age of 36 months who had meningococcal sepsis confirmed by laboratory data were evaluated. Overall mortality was 18%. The median GMSPS was 3 in survivors and 8 in non-survivors. A GMSPS > or = 8 was significantly associated with death (p = 0.0001) with a mortality predictivity and specificity of 70% and 92.5%, respectively. The median PRISM score in survivors was 5.5 and 23 in non-survivors. A PRISM score of > or = 11 was significantly related to death (p < 0.0001). The Kendal correlation co-efficient between GMSPS and PRISM showed tau = 0.6859 (p = 0.0000). It is concluded that GMSPS and PRISM are useful methods for identifying and classifying children into low and high risk categories. GMSPS > or = 8 or a PRISM score > or = 11 are significantly predictive of mortality.     

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.     

Study of Predictive Value of Pediatric Risk of Mortality (PRISM) Score in Children with End Stage Liver Disease and Fulminant Hepatic Failure

Objective  

To evaluate the use of the PRISM score as a predictor of outcome in patients with end stage liver disease (ESLD) and fulminant hepatic failure (FHF).     

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.     

Simplified PRISM III score and outcome in the pediatric intensive care unit

BACKGROUND: To evaluate the association of the PRISM III (pediatric risk of mortality) score with the infant outcome in the pediatric intensive care unit (PICU), and to determine if this score could be simplified. METHODS: A prospective cohort study was carried out with 170 infants who were consecutively admitted to the PICU. The PRISM III score with 17 physiologic variables was performed during the first 8 h of admission to the unit. Statistical analysis was done with logistic regression, odds ratios (OR) with 95% confidence intervals (95% CI), and receiver operating curve. The Alfa value was set at 0.05. RESULTS: There were 42 deaths (24.7%). The two main causes of death were septic shock (28.6%) and head trauma (16.7%). The PRISM III score had a sensitivity of 0.71, and a specificity of 0.64 as a mortality predictor. Out of the 17 physiologic variables only four of them were significant: abnormal pupillary reflexes OR 9.9 (95% CI, 3.5-28.4), acidosis OR 3.1 (95% CI, 2.0-4.9), blood urea nitrogen concentration OR 1.03 (95% CI, 1.01-1.04), and white blood cell count OR 1.02 (95% CI, 1.01-1.03). The whole logistic regression model had a coefficient of determination R(2) = 0.219, P < 0.001. CONCLUSIONS: In this setting, the PRISM III score had good sensitivity and specificity to predict mortality. This score could be simplified using only the four variables that were significant in this study. This modified PRISM III score could reduce the cost of patient care especially in developing countries PICU.     

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.     

Benign (non-paroxysmal) familial chorea. Paediatric perspectives.

We describe a non-progressive choreo-athetoid disorder of early onset, present in three families. There were no appreciable abnormalities in pregnancy, during the perinatal period, or in infancy. In each case the family history suggested transmission as an autosomal dominant trait, the gene showing diminished penetrance. Other families have been reported with the disorder and such titles as benign familial chorea, familial essential (benign chorea, or hereditary non-progressive chorea of early onset have been given to it. Our experience suggests that this is not a rare disorder, and that it is one likely to present in the paediatric age group; correct diagnosis is important so that unnecessary investigations are not undertaken, genetic counselling can be given, and proper management advice offered to families and schools.     

Evaluation of the Paediatric Index of Mortality in children managed on adult intensive care units.

OBJECTIVE: To evaluate the performance of the Paediatric Index of Mortality (PIM) in children cared for in adult intensive care units (ICUs) in district general hospitals in the South West Region of England. DESIGN AND SETTING: An observational survey of all children admitted to adult ICUs in 15 district general hospitals between November 2000 and August 2002. For comparison, data were also collected from the regional paediatric ICUs between November 2000 and March 2002. RESULTS: Data were collected from 374 children admitted to adult ICUs and 850 children admitted to the regional paediatric ICU. There were significant differences in the patient characteristics between the two groups. In the adult ICU paediatric population, PIM discriminated well between death and survival (Az ROC = 0.96 (95% confidence interval, 0.93 to 0.99)) and calibrated well across deciles of risk (goodness of fit chi2 = 4.55 (8 df), p = 0.8). CONCLUSIONS: PIM performs well as a risk adjustment method in children whose entire care remains in the adult ICU of a district general hospital. This is important should the Paediatric Intensive Care Audit Network (PICAnet) decide to extend its data collection beyond paediatric intensive care units to other units caring for critically ill children.     

Joint Meeting of the Scottish Paediatric Society (Summer Meeting) and the Paediatric Section of the Royal Society of Medicine

Scottish Paediatric Society     

Paediatric acute respiratory distress syndrome (PARDS)

Acute respiratory distress syndrome (ARDS) is a syndrome with acute, diffuse, inflammatory lung injury associated with non-haemodynamic lung oedema. It is responsible for almost a quarter of the ventilated patients in intensive care. The causes of ARDS are variable. They include primary pulmonary diseases such as pneumonia, drowning and aspiration and extra-pulmonary conditions including sepsis, trauma or burns. Although ARDS is well recognized in children, it is, in our experience, underdiagnosed in the paediatric intensive care units. This short article describes the diagnostic criteria, the causes and the management of ARDS in children.