Immunocompromised-Associated Pediatric Acute Respiratory Distress Syndrome: Experience From the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Prospective Cohort Study

Comparing the clinical characteristics and risk factors of prognosis in pediatric ARDS with and without malignancies: a retrospective cohort study

BACKGROUND

The number of malignancy patients with respiratory failure is rising in pediatric intensive care units (PICU). Our study aims to compare the clinical characteristics and prognostic risk factors of acute respiratory distress syndrome (ARDS) with or without malignancies.

METHODS

This retrospective study reviewed medical records of 188 ARDS patients admitted to the PICU between January 2018 and December 2022, including 60 with malignancies and 128 without. Clinical data were collected within 48 h post-ARDS diagnosis. Multivariate logistic regression analysis and receiver operating characteristic curve (ROC) analysis were used to investigate the risk factors for PICU mortality in the malignancy and non-malignancy groups.

RESULTS

Compared with pediatric patients without malignancy, the ARDS patients with malignancy presented higher mortality (55.0% vs. 31.3%, P = 0.002), a higher incidence of community-acquired fungal infection (36.1% vs. 6.3%, P < 0.001) and multidrug resistance (MDR) bacteria (65.4% vs. 30.5%, P = 0.003). There were substantial differences in levels of lactate [1.5 (0.8-3.7) vs. 1.0 (0.7-2.0) mmol/L, P = 0.008], C-reactive protein (CRP) [150.0 (83.0-168.0) vs. 31.0 (10.0-108.0) mg/L, P = 0.02], procalcitonin (PCT) [10.4 (2.0-27.5) vs. 1.2 (0.3-6.2) mg/L, P < 0.001], counts of platelet [17.0 (8.0-73.0) vs. 232.0 (152.0-330.0) × 109/µL, P < 0.001], the distribution of CD8 + T [36.9 (26.0-53.6) vs. 21.9 (17.3-29.1) %, P < 0.001], CD19 + T cells [9.9 (0.9-30.2) vs. 33.6 (22-46.6) %, P < 0.001], and higher peak vasoactive-inotropic score (VIS) in ARDS with malignancy [73.0 (20-208) vs. 15.0 (5.0-82.0), P < 0.01]. In multivariable analysis, only VIS independently predicted mortality in ARDS patients with malignancy (OR, 1.011; 95% confidence interval [CI]: 1.003-1.018; P = 0.005). Neither pSOFA scores (OR, 1.249, 95% CI: 0.958-1.628, P = 0.101) nor lactate levels (OR, 1.192, 95% CI: 0.928-1.531, P = 0.170) showed significant associations.

CONCLUSION

ARDS patients with malignancies exhibited poorer outcomes. VIS is only an independent predictor of mortality in pediatric ARDS patients with malignancies.

The burden of pediatric critical illness among pediatric oncology patients in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Pediatric oncology patients have increased risk for critical illness; outcomes are well described in high-income countries (HICs); however, data is limited for low- and middle-income countries (LMICs).

METHODS

We systematically searched PubMed, EMBASE, Web of Science, CINAHL and Global Health databases for articles in 6 languages describing mortality in children with cancer admitted to intensive care units (ICUs) in LMICs. Two investigators independently assessed eligibility, data quality, and extracted data. We pooled ICU mortality estimates using random effect models.

RESULTS

Of 3641 studies identified, 22 studies were included, covering 4803 ICU admissions. Overall pooled mortality was 30.3 % [95 % Confidence-interval (CI) 21.7-40.6 %]. Mechanical ventilation [odds ratio (OR) 12.2, 95 %CI:6.2-24.0, p-value<0.001] and vasoactive infusions [OR 6.3 95 %CI:3.3-11.9, p-value<0.001] were associated with ICU mortality.

CONCLUSIONS

ICU mortality among pediatric oncology patients in LMICs is similar to that in HICs, however, this review likely underestimates true mortality due to underrepresentation of studies from low-income countries.

Biomarker-Based Risk Stratification Tool in Pediatric Acute Respiratory Distress Syndrome: Single-Center, Longitudinal Validation in a 2014-2019 Cohort

OBJECTIVES

The Pediatric Acute Respiratory Distress Syndrome Biomarker Risk Model (PARDSEVERE) used age and three plasma biomarkers measured within 24 hours of pediatric acute respiratory distress syndrome (ARDS) onset to predict mortality in a pilot cohort of 152 patients. However, longitudinal performance of PARDSEVERE has not been evaluated, and it is unclear whether the risk model can be used to prognosticate after day 0. We, therefore, sought to determine the test characteristics of PARDSEVERE model and population over the first 7 days after ARDS onset.

DESIGN

Secondary unplanned post hoc analysis of data from a prospective observational cohort study carried out 2014-2019.

SETTING

University-affiliated PICU.

PATIENTS

Mechanically ventilated children with ARDS.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Between July 2014 and December 2019, 279 patients with ARDS had plasma collected at day 0, 266 at day 3 (11 nonsurvivors, two discharged between days 0 and 3), and 207 at day 7 (27 nonsurvivors, 45 discharged between days 3 and 7). The actual prevalence of mortality on days 0, 3, and 7, was 23% (64/279), 14% (38/266), and 13% (27/207), respectively. The PARDSEVERE risk model for mortality on days 0, 3, and 7 had area under the receiver operating characteristic curve (AUROC [95% CI]) of 0.76 (0.69-0.82), 0.68 (0.60-0.76), and 0.74 (0.65-0.83), respectively. The AUROC data translate into prevalence thresholds for the PARDSEVERE model for mortality (i.e., using the sensitivity and specificity values) of 37%, 27%, and 24% on days 0, 3, and 7, respectively. Negative predictive value (NPV) was high throughout (0.87-0.90 for all three-time points).

CONCLUSIONS

In this exploratory analysis of the PARDSEVERE model of mortality risk prediction in a population longitudinal series of data from days 0, 3, and 7 after ARDS diagnosis, the diagnostic performance is in the "acceptable" category. NPV was good. A major limitation is that actual mortality is far below the prevalence threshold for such testing. The model may, therefore, be more useful in cohorts with higher mortality rates (e.g., immunocompromised, other countries), and future enhancements to the model should be explored.

Timing of intubation of pediatric hematopoietic cell transplant patients: an international survey

Introduction

Retrospective data suggest that pediatric hematopoietic cell transplant (HCT) patients placed on non-invasive ventilation (NIV) prior to intubation have increased risk of mortality compared to patients who are intubated earlier in their course. The HCT-CI subgroup of the PALISI Network set out to gain a better understanding of factors that influence clinician's decisions surrounding timing of intubation of pediatric HCT patients.

Methods

We validated and distributed a brief survey exploring potential factors that may influence clinician's decisions around timing of intubation of pediatric HCT patients with acute lung injury (ALI).

Results

One hundred and four of the 869 PALISI Network's members responded to the survey; 97 of these respondents acknowledged caring for HCT patients and were offered the remainder of the survey. The majority of respondents were PICU physicians (96%), with a small number of Advanced Practice Providers and HCT physicians. As expected, poor prognosis categories were perceived as a factors that delay timing to intubation whereas need for invasive procedures was perceived as a factor shortening timing to intubation. Concerns for oxygen toxicity or NIV-associated lung injury were not believed to influence timing of intubation.

Discussion

Our survey indicates increased risk of ALI from prolonged NIV and oxygen toxicity in HCT patients are not a concern for most clinicians. Further education of pediatric ICU clinicians around these risk factors could lead to improvement in outcomes and demands further study. Additionally, clinicians identified concerns for the patient's poor prognosis as a common reason for delayed intubation.

Risk factors predicting need for the pediatric intensive care unit (PICU) post-hematopoietic cell transplant, PICU utilization, and outcomes following HCT: a single center retrospective analysis

Hematopoietic cell transplant (HCT) is a curative treatment for multiple malignant and non-malignant disorders. While morbidity and mortality have decreased significantly over the years, some patients still require management in the pediatric intensive care unit (PICU) during their HCT course for additional respiratory, cardiovascular, and/or renal support. We retrospectively reviewed pediatric patients (0-18 years) who underwent HCT from January 2015-December 2020 at our institution to determine risk factors for PICU care and evaluate PICU utilization and outcomes. We also assessed pulmonary function testing (PFT) data to determine if differences were noted between PICU and non-PICU patients as well as potential evolution of pulmonary dysfunction over time. Risk factors of needing PICU care were lower age, lower weight, having an underlying inborn error of metabolism, and receiving busulfan-based conditioning. Nearly half of PICU encounters involved use of each of respiratory support types including high-flow nasal cannula, non-invasive positive pressure ventilation, and mechanical ventilation. Approximately one-fifth of PICU encounters involved renal replacement therapy. Pulmonary function test results largely did not differ between PICU and non-PICU patients at any timepoint aside from individuals who required PICU care having lower DLCO scores at one-year post-HCT. Future directions include consideration of combining our data with other centers for a multi-center retrospective analysis with the goal of gathering and reporting additional multi-center data to work toward continuing to decrease morbidity and mortality for patients undergoing HCT.