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

Defining Pediatric Chronic Critical Illness: A Scoping Review

OBJECTIVES

Children with chronic critical illness (CCI) are hypothesized to be a high-risk patient population with persistent multiple organ dysfunction and functional morbidities resulting in recurrent or prolonged critical care; however, it is unclear how CCI should be defined. The aim of this scoping review was to evaluate the existing literature for case definitions of pediatric CCI and case definitions of prolonged PICU admission and to explore the methodologies used to derive these definitions.

DATA SOURCES

Four electronic databases (Ovid Medline, Embase, CINAHL, and Web of Science) from inception to March 3, 2021.

STUDY SELECTION

We included studies that provided a specific case definition for CCI or prolonged PICU admission. Crowdsourcing was used to screen citations independently and in duplicate. A machine-learning algorithm was developed and validated using 6,284 citations assessed in duplicate by trained crowd reviewers. A hybrid of crowdsourcing and machine-learning methods was used to complete the remaining citation screening.

DATA EXTRACTION

We extracted details of case definitions, study demographics, participant characteristics, and outcomes assessed.

DATA SYNTHESIS

Sixty-seven studies were included. Twelve studies (18%) provided a definition for CCI that included concepts of PICU length of stay (n = 12), medical complexity or chronic conditions (n = 9), recurrent admissions (n = 9), technology dependence (n = 5), and uncertain prognosis (n = 1). Definitions were commonly referenced from another source (n = 6) or opinion-based (n = 5). The remaining 55 studies (82%) provided a definition for prolonged PICU admission, most frequently greater than or equal to 14 (n = 11) or greater than or equal to 28 days (n = 10). Most of these definitions were derived by investigator opinion (n = 24) or statistical method (n = 18).

CONCLUSIONS

Pediatric CCI has been variably defined with regard to the concepts of patient complexity and chronicity of critical illness. A consensus definition is needed to advance this emerging and important area of pediatric critical care research.

Nasolabial and distal limbs dry gangrene in newborn due to hypernatremic dehydration with disseminated intravascular coagulation: a case report

Introduction

Gangrene is the death of an organ or tissue due to lack of blood supply or bacterial infection. In neonates, gangrene is usually caused by sepsis, dehydration, maternal diabetes, asphyxia, or congenital anticoagulant deficiency. It commonly occurs in the extremities. Gangrene may lead to death or amputation of the limb. Early diagnosis and prompt management of the underlying cause halts the progression of the disease.

Case presentation

A 12-day-old neonate presented with a complaint of black discoloration of the nose and feet for 2 days. He was breastfeeding poorly and had signs of dehydration. Upon physical examination, he was tachycardic (pulse rate = 182 beats per minute), tachypneic (respiratory rate = 62 breaths per minute), and hypothermic (temperature = 35.0 oC). He lost 33.3% of his birth weight. He had demarcated cold, dry, and dark discoloration of the entire nose, nasal septum; upper lip; palate; bilateral distal lower limbs; and the left fifth finger. Dorsalis pedis arteries were not palpable on either side. On investigation, the baby had pancytopenia, hypernatremia, elevated creatinine, elevated coagulation profiles, and absent arterial flow in bilateral dorsal pedis arteries. He was treated for hypernatremic dehydration and possible sepsis. He was transfused with whole blood, platelets, and fresh frozen plasma, but finally, the patient passed away on the 7th day of admission.

Conclusion

The entire nose, upper lip, soft and hard palate, symmetric lower limb, and fifth finger gangrene due to severe hypernatremic dehydration complicated by disseminated intravascular coagulation may occur in the same patient. To avoid such serious neonatal problems, mothers should be properly educated about optimal breastfeeding techniques and schedule well-child visits 3–5 days after birth.

Outcomes following admission to paediatric intensive care: A systematic review

AIM

To describe the long-term health outcomes of children admitted to a paediatric intensive care unit.

METHODS

A systematic review of the literature was performed. Studies of children under 18 years of age admitted to a paediatric intensive care unit were included. Studies focussed on neonatal admissions and investigating specific paediatric intensive care unit interventions or admission diagnoses were excluded. A table was created summarising the study characteristics and main findings. Risk of bias was assessed using the Newcastle Ottawa Quality Assessment Scale for observational studies. Primary outcome was short-, medium- and long-term mortality. Secondary outcomes included measures of neurodevelopment, cognition, physical, behavioural and psychosocial function as well as quality of life.

RESULTS

One hundred and eleven studies were included, most were conducted in high-income countries and focussed on short-term outcomes. Mortality during admission ranged from 1.3 to 50%. Mortality in high-income countries reduced over time but this trend was not evident for lower income countries. Higher income countries had lower standardised mortality rates than lower income countries. Children had an ongoing increased risk of death for up to 10 years following intensive care admission as well as increased physical and psychosocial morbidity compared to healthy controls, with associated poorer quality of life.

CONCLUSIONS

There is limited high-level evidence for the long-term health outcomes of children after intensive care admission, with the burden of related morbidity remaining greater in poorly resourced regions. Further research is recommended to identify risk factors and modifiable factors for poor outcomes, which could be targeted in practice improvement initiatives.

A systematic literature review on the prevalence and etiology of meningitis among critically ill and hospitalized patients in India

BACKGROUND

In India, owing to multiple factors, such as insufficient laboratory capacity, poor reporting systems due to limited access to healthcare facilities and limited disease surveillance programmes, the actual disease burden of meningitis is unknown and may be largely under-reported.

OBJECTIVE

A systematic literature review was performed to describe: (a) the prevalence of meningitis; and (b) its etiological pathogen across different regions, age groups and patients with comorbidities.

METHOD

A systematic literature search was conducted between 1990 and 2020 using PubMed and Google Scholar databases to identify Indian studies reporting the prevalence rates and etiology of meningitis. A total of 51 studies were included in the final analysis.

RESULTS

A total of 38 studies reported prevalence of meningitis and 21 studies reported data on the etiology of meningitis in India. These studies included mixed patient populations: (a) pyogenic meningitis; (b) meningitis in sick or hospitalized patients with tuberculosis, acute febrile encephalopathy syndrome, septicaemia, invasive pneumococcal disease or respiratory compromise; and (c) meningitis patients with comorbidities. The prevalence of confirmed bacterial meningitis in the pediatric population (0-14 years) ranged between 0.5% and 61.8%. A total of seven studies reported the prevalence of meningitis in patients of all age groups (0-75 years), with prevalence ranging between 8.68% and 78.85%. Cryptococcal meningitis was predominant in patients with positive HIV/AIDS, with a prevalence ranging between 2.09% and 53.1%. Streptococcus pneumoniae was found to be the predominant pathogen causing meningitis across different regions of India, with a frequency ranging from 4% to 61.8% in patients of all age groups.

CONCLUSION

This systematic literature review displayed the possible range of frequency of bacterial meningitis pathogens across a wide variety of age groups in different regions of India. Further studies are warranted to monitor meningitis cases, which may facilitate the development of prevention and treatment strategies in India.

Time of Pediatric Intensive Care Unit Admission and Mortality: A Systematic Review and Meta-Analysis

The aim of this study was to determine the association between the time of admission (day, night, and/or weekends) and mortality among critically ill children admitted to a pediatric intensive care unit (PICU). Electronic databases that were searched include PubMed, Embase, Web of Science, CINAHL (Cumulative Index of Nursing and Allied Health Literature), Ovid, and Cochrane Library since inception till June 15, 2018. The article included observational studies reporting inhospital mortality and the time of admission to PICU limited to patients aged younger than 18 years. Meta-analysis was performed by a frequentist approach with both fixed and random effect models. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach was used to evaluate the quality of evidence. Ten studies met our inclusion criteria. Five studies comparing weekday with weekend admissions showed better odds of survival on weekdays (odds ratio [OR]: 0.77; 95% confidence interval [CI]: 0.60-0.99). Pooled data of four studies showed that odds of mortality were similar between day and night admissions (OR: 0.93; 95% CI: 0.77-1.13). Similarly, three studies comparing admission during off-hours versus regular hours did not show better odds of survival during regular hours (OR: 0.77; 95% CI: 0.57-1.05). Heterogeneity was significant due to variable sample sizes and time period. Inconsistency in adjusting for confounders across the included studies precluded us from analyzing the adjusted risk of mortality. Weekday admissions to PICU were associated with lesser odds of mortality. No significant differences in the odds of mortality were found between admissions during day versus night or between admission during regular hours and that during off-hours. However, the evidence is of low quality and requires larger prospective studies.

Burden of respiratory illnesses in pediatric intensive care unit and predictors of mortality: Experience from a low resource country

INTRODUCTION AND OBJECTIVES

Acute respiratory infections (ARI), a major cause of childhood mortality and morbidity, place substantial burden on health services worldwide. Due to scarce data regarding respiratory illnesses requiring Pediatric intensive care unit (PICU) admissions (especially in low income/developing countries), we studied the burden of respiratory illnesses in the PICU and the risk factors contributing to mortality.

METHODS

This prospective observational study was conducted over 18 months. Children (aged 1 month to 12 years) admitted to the PICU for acute respiratory/cardiorespiratory illnesses were enrolled. Demographic and clinical details of the study population were recorded and tabulated. Risk factors contributing to mortality (severity of illness [PRISM III score], diagnosis/etiology, need for mechanical ventilation, immunocompromised status, malnutrition, and length of stay [LOS]) were analyzed (using the χ² test or Fischer Exact test).

RESULTS

Two hundred and ninety-three children were enrolled (median age: 5 months; range, 1-132 months; male/female: 181/112). Mean LOS in PICU was 5.25 ± 5.48 days and mean length of hospital stay of 14.82 ± 13.35 days. Mechanical ventilation was required in 62.8% cases. Pneumonia contributed to 66.89% of respiratory admissions and 91% of mortality. Ninety patients (30.7%) died; mortality being higher in cardiorespiratory cases (52.7%). PRISM III score and shock (respiratory cases) and age below 1 year (cardiorespiratory group) were significantly associated with higher mortality ( P < 0.05).

CONCLUSIONS

Respiratory illnesses are a significant contributor to PICU admissions and are associated with significant mortality risk in presence of high PRISM III score and shock (respiratory group); and age below 1 year (cardiorespiratory group).

Comparison of Severity Scoring Systems in a Pediatric Intensive Care Unit in India: A Single-Center Prospective, Observational Cohort Study

Objective The aim of this study is to validate Pediatric Risk of Mortality (PRISM) and Pediatric Index of Mortality (PIM) scoring systems in a pediatric intensive care unit (PICU) in India. Design This is a single-center prospective cohort study. Setting This study was conducted at an eight-bed PICU. Methods PRISM- and PIM-based predicted mortality rates were calculated and compared in 120 pediatric patients. Results Estimated mortality using PRISM (5.68%) and PIM (8.84%) was lower than observed (21.7%) mortality. PIM had slightly better power of calibration than PRISM. The discriminatory performance of both models was comparable. Conclusion Both models can be validated with suitable changes according to PICU settings of India.

The epidemiological profile of pediatric patients admitted to the general intensive care unit in an Ethiopian university hospital

BACKGROUND

In least developing countries, there are few data on children's critical care. This makes the provision of aid and improvement of outcome difficult.

OBJECTIVES

To describe admission and outcome patterns of children managed in a general intensive care unit at Jimma University Specialized Hospital (JUSH), Ethiopia, over a 5-year period.

METHODS

A retrospective cross-sectional study design was used. All children from birth to 14 years of age who were admitted to the general ICU of the hospital from 2009-2013 were included. Patient charts and ICU documentation log were reviewed.

RESULTS

A total of 170 children were admitted to the ICU of JUSH over the study period. The greater share was taken by males (54.7%), with a male-to-female ratio of 1.2:1. The overall mortality rate was 40%. The majority of the children were in the age range of 10-14 years (38.8%). Of the total number of patients admitted, 34.7% were trauma cases, 45.8% of whom died. The highest percentage, 69.5%, of trauma patients were admitted for head injuries. Among the trauma cases, burn and polytrauma were the second and third leading causes (15.3%) of admission. Postoperative patients and medical patients accounted for the rest of the admitted cases (28.2% and 27.6% of the cases respectively).

CONCLUSION

The leading cause of admission and death was trauma. Postoperative and medical causes of admission were also significant. The mortality rate in the ICU was very high, and this could be due to various factors. Further research benchmarking and interventions are highly recommended.

Development of a PICU in Nepal: the experience of the first year

OBJECTIVE

Analysis of hospitalization data can help elucidate the pattern of morbidity and mortality in any given area. Little data exist on critically ill children admitted to hospitals in the resource-limited nation of Nepal. We sought to characterize the profile, management, and mortality of children admitted to one PICU.

DESIGN

Retrospective analysis.

SETTING

A newly established PICU in Nepal.

PATIENTS

All patients between the ages of 0 to 16 years admitted to the PICU from July 2009 to July 2010.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

In 12 months, 126 children were admitted to the PICU including 43% female patients. Sixty-three percent were under 5 years. Twenty-nine percent came from tertiary care hospitals and 38% from rural areas outside Kathmandu. Only 18% were transported by ambulance. Median distance travelled to be admitted was 30 km (interquartile range, 10-193). Highest number of admissions were in spring (40%) followed by summer (25%). Almost half were admitted for shock (45%), particularly septic shock (30%). The second commonest reason for admission was neurologic etiologies (15%). Neonatal admissions were also significant (19%). Mortality was 26% and was significantly associated with septic shock (p < 0.01), mechanical ventilation (p < 0.01), and multiple organ dysfunction (< 0.05). Almost one third of patients required mechanical ventilation; median duration was 4 days (interquartile range, 2-8). Mean length of stay in the hospital was 6.2 days (± 5.3) and median 4 (interquartile range, 2.5-9.0). Median Pediatric Risk of Mortality II score for nonsurvivors was 12 (interquartile range, 7-21), and median Pediatric Index of Mortality II for nonsurvivors was 10 (interquartile range, 3-32).

CONCLUSIONS

Within a short time of opening, the PICU has been seeing significant numbers of critically ill children. Despite adverse conditions and limited resources, survival of 75% is similar to many units in developing nations. Sepsis was the most common reason for PICU admission and mortality.

Chromosomal abnormalities in patients with congenital heart disease

Background

Chromosomal abnormalities (CAs) are an important cause of congenital heart disease (CHD).

Objective

Determine the frequency, types and clinical characteristics of CAs identified in a sample of prospective and consecutive patients with CHD.

Method

Our sample consisted of patients with CHD evaluated during their first hospitalization in a cardiac intensive care unit of a pediatric referral hospital in Southern Brazil. All patients underwent clinical and cytogenetic assessment through high-resolution karyotype. CHDs were classified according to Botto et al. Chi-square, Fisher exact test and odds ratio were used in the statistical analysis (p < 0.05).

Results

Our sample consisted of 298 patients, 53.4% males, with age ranging from 1 day to 14 years. CAs were observed in 50 patients (16.8%), and 49 of them were syndromic. As for the CAs, 44 (88%) were numeric (40 patients with +21, 2 with +18, 1 with triple X and one with 45,X) and 6 (12%) structural [2 patients with der(14,21), +21, 1 with i(21q), 1 with dup(17p), 1 with del(6p) and 1 with add(18p)]. The group of CHDs more often associated with CAs was atrioventricular septal defect.

Conclusions

CAs detected through karyotyping are frequent in patients with CHD. Thus, professionals, especially those working in Pediatric Cardiology Services, must be aware of the implications that performing the karyotype can bring to the diagnosis, treatment and prognosis and for genetic counseling of patients and families.

Síndrome de deleção 22q11.2 e cardiopatias congênitas

OBJETIVO: Revisar as características clínicas, etiológicas e diagnósticas da síndrome de deleção 22q11 e sua associação com as cardiopatias congênitas. FONTES DOS DADOS: Foram pesquisados artigos científicos presentes nos portais Medline, Lilacs e SciELO, utilizando-se descritores específicos como "22q11", "DiGeorge syndrome", "velocardiofacial syndrome", "congenital heart defects" e "cardio-vascular malformations". O período adotado para a revisão foi de 1980 a 2009. SÍNTESE DOS DADOS: As malformações cardíacas são os defeitos congênitos observados mais frequentemente ao nascimento e representam um problema importante de Saúde Pública. Dentre suas principais causas conhecidas destaca-se a síndrome de deleção 22q11, também chamada de síndrome de DiGeorge, síndrome velocardiofacial e CATCH22. Trata-se de uma doença autossômica domi-nante caracterizada por um fenótipo altamente variável, o que dificulta em muito seu reconhecimento clínico. Além disso, a maior parte dos pacientes apresenta uma microdeleção identificada principalmente por técnicas de citogenética molecular, como a hibridização in situ fluorescente, pouco disponíveis em nosso meio. De forma similar a outras síndromes, a síndrome de deleção 22q11 associa-se a certos defeitos cardíacos específicos, no caso os do tipo conotruncal. Apesar disso, não há ainda na literatura um consenso sobre quais os pacientes com car-diopatia congênita que deveriam ser investigados para a síndrome de deleção 22q11. CONCLUSÕES: Cardiologistas e cirurgiões cardíacos, espe-cialmente pediátricos, devem estar cientes das peculiaridades e dos cuidados dispensados à síndrome de deleção 22q11. Os indivíduos com a síndrome apresentam comumente alterações envolvendo vários sistemas, o que pode levar a dificuldades e a complicações durante seu manejo clínico e cirúrgico.

Management of acute renal failure in the pediatric intensive care unit

Pediatric acute renal failure (ARF) is a dynamic entity that has many causes. ARF is frequently seen in the pediatric population and is associated with increased mortality and long-term morbidity rates. Of importance is its early detection so as to allow interventions to either prevent or treat the disease timely during its course. Recent developments in the definitions and classification schemes and the identification of new biomarkers shall allow better predictive interventions for childhood ARF. ARF management in children requires special considerations. Optimal care for the pediatric patient requiring renal replacement therapy requires an understanding of the causes and patterns of pediatric ARF and recognition of the local expertise with respect to the personnel and equipment resources. The aim of this article is to review pediatric ARF management with an emphasis on emerging practice patterns and the modalities for renal replacement therapy.

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.

METHODS

All consecutive patients over a six month period were included in the study except patients with a PICU stay of less than 2 hours, those transferred to other PICUs, pediatric surgical cases, trauma patients and those dying within 24 hours of admission. The PRISM and PIM scores of all patients included in the study were computed and the outcome was noted in terms of survival or non-survival. Mortality discrimination was quantified by calculating the area under the receiver operating characteristic (ROC) curve. Hosmer and Lemeshow goodness-of-fit test was used to calibrate the scores.

RESULTS

Two hundred and thirty patients were enrolled with mean age of 40.6 months and male to female ratio of 1.2:1. There were 56 deaths (mortality rate 24.3%). The mortality in infants was higher (37.8 %) as compared to non-infants (16.2 %) (p = 0.011). The predicted deaths with PRISM score was 24.3%. The area under the ROC curve was 0.851 (95% CI 0.790-0.912). The Hosmer and Lemeshow goodness-of-fit test showed good calibration (p = 0.627, chi square = 1.75, degree of freedom = 3). The predicted deaths with the PIM score was 7.38%. The area under the ROC curve for PIM score was 0.838 (95 % CI 0.776-0.899). The Hosmer and Lemeshow goodness-of-fit showed a poor calibration for PIM score (p = 0.0281, chi-square = 10.866, degree of freedom = 4).

CONCLUSION

Both PRISM and PIM scores have a good discriminatory performance. The calibration with PRISM score is good but the PIM score displays poor calibration.

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.

Management of acute renal failure

Acute renal failure (ARF) is defined as an abrupt decline in the renal regulation of water, electrolytes, and acid-base balance. It continues to be an important factor contributing to the morbidity and mortality of critically ill infants and children. The frequency of specific diseases that result in ARF differs among different age-groups and geographical areas. The common causes in Indian children include hemolytic uremic syndrome, acute tubular necrosis, glomerulonephritis and urinary tract obstruction. Though the hallmark of renal failure is oliguria, there is increasing recognition of non-oliguric ARF often associated with the use of nephrotoxic drugs. The basic principles of management are avoidance of life-threatening complications, maintenance of fluid and electrolyte balance and nutritional support. Specific management of the underlying disorder is possible only in a minority of cases. All the major dialysis modalities--peritoneal dialysis (PD), hemodialysis (HD) and continuous hemofiltration--can be used to provide equivalent solute clearance and ultrafiltration. Peritoneal dialysis requires minimal equipment and infrastructure, and is easy to perform; this makes it the favoured modality in developing countries where resources for HD or continuous therapies may not be accessible. However, continuous hemofiltration is an excellent alternative to PD in patients with ARF and severe fluid overload. The prognosis of children with renal failure depends on the underlying condition and associated medical complications.