Systemic corticosteroids remain controversial in the treatment of pediatric patients with severe sepsis. Recent studies in septic adults have shown decreased mortality with the use of hydrocortisone ...in patients with relative adrenal insufficiency. We conducted this large retrospective cohort study to further characterize severe sepsis in infants and children and correlates of outcome, including the use of steroids.
Retrospective cohort study.
The Pediatric Health Information System (PHIS), an administrative database of the Child Health Corporation of America (CHCA), was queried for inpatients 0-17 yrs of age with severe sepsis (defined here as an International Classification of Disease 9th edition code for infection with use of simultaneous mechanical ventilation and vasoactive infusions) from 2001 to 2002. In addition to demographic information, use of systemic corticosteroids (hydrocortisone, methylprednisolone, or dexamethasone) concurrent with the ventilatory and vasoactive support was collected.
Data from PHIS.
None.
Patients (n = 6693) were identified at 27 PHIS-participating CHCA member hospitals. Overall mortality was 24%; univariate predictors of death included use of steroids (odds ratio OR, 1.9; 95% confidence interval (CI), 1.7, 2.2), older age (e.g., 13-17 yrs vs. neonates; OR, 1.6; 95% CI, 1.3, 2.0), a hematologic-oncologic diagnosis (OR, 5.87; 95% CI, 4.19, 8.23), and moderate vs. high case volume (OR, 1.25; 95% CI, 1.09, 1.44). Age, hematologic-oncologic diagnosis, case volume, and use of steroids remained independent predictors of mortality in multivariable analysis.
From this administrative database analysis, there is no evidence that steroids are associated with improved outcome in critically ill infants and children with sepsis. Although steroids may be given preferentially to more severely ill children, their use was associated with increased mortality. Clinicians should maintain equipoise on this topic pending prospective randomized clinical trials.
Disparities in health care have been documented between different racial groups in the United States. We hypothesize that there will be racial variance in the timing of the Glenn and Fontan ...procedures for children with single-ventricle physiology.
We performed a retrospective review of a national pediatric intensive care unit database (Virtual PICU Performance System, LLC).
Children with hypoplastic left heart syndrome, tricuspid atresia, and common ventricle, admitted from January 2006 to July 2008, were included. Data included race, weight, age, medical length of stay, Paediatric Index of Mortality 2 score, and survival.
None.
There were 423 patients from 29 hospitals. The study population was 7.6% black, 13.0% Hispanic, 59.8% white, 9.2% "other," and 11.6% had missing racial/ethnic information. Diagnoses included 255 patients with hypoplastic left heart syndrome, 91 with tricuspid atresia, and 77 with common ventricle. The median age for the Glenn procedure (n = 205) was 5.5 months (interquartile range, 4.6-7.0 months) and 39.7 months (interquartile range, 32.4-50.6 months) for the Fontan procedure (n = 218). There was no difference between the median age at the time of the Glenn or Fontan procedures between the different racial/ethnic groups (p = .65 and p = .16, respectively). The medical length of intensive care unit stay for patients receiving the Glenn and Fontan procedures was 3.7 days (interquartile range, 1.9-6.1 days) and 3.7 days (interquartile range, 1.9-6.8 days), respectively. There were no differences in medical length of intensive care unit stay for the Glenn procedure between the different racial/ethnic groups (p = .21). Hispanic patients had a longer medical length of intensive care unit stay (6.3 days; interquartile range, 3.1-9.9 days) than white patients (2.9 days; interquartile range, 1.8-5.3 days) for the Fontan procedure (p = .008).
The timing of single-ventricle palliative procedures was not affected by race/ethnicity.
The Family Satisfaction in the Intensive Care Unit 24 (FS-ICU 24) survey consists of two domains (overall care and medical decision-making) and was validated only for family members of adult patients ...in the ICU. The purpose of this study was to evaluate the internal consistency and construct validity of the FS-ICU 24 survey modified for parents/caregivers of pediatric patients (Pediatric Family Satisfaction in the Intensive Care Unit 24 pFS-ICU 24) by comparing it to McPherson's PICU satisfaction survey, in a similar racial/ethnic population as the original Family Satisfaction in the Intensive Care Unit validation studies (English-speaking Caucasian adults). We hypothesized that the pFS-ICU 24 would be psychometrically sound to assess satisfaction of parents/caregivers with critically ill children.
A prospective survey examination of the pFS-ICU 24 was performed (1/2011-12/2011). Participants completed the pFS-ICU 24 and McPherson's survey with the order of administration alternated with each consecutive participant to control for order effects (nonrandomized). Cronbach's alphas (α) were calculated to examine internal consistency reliability, and Pearson correlations were calculated to examine construct validity.
University-affiliated, children's hospital, cardiothoracic ICU.
English-speaking Caucasian parents/caregivers of children less than 18 years old admitted to the ICU (on hospital day 3 or 4) were approached to participate if they were at the bedside for greater than or equal to 2 days.
Fifty parents/caregivers completed the surveys (mean age ± SD = 36.2±9.6 yr; 56% mothers). The α for the pFS-ICU 24 was 0.95 and 0.92 for McPherson's survey. Overall, responses for the pFS-ICU 24 and McPherson's survey were significantly correlated (r = 0.73; p < 0.01). The average overall pFS-ICU 24 satisfaction score was 92.6 ± 8.3. The average pFS-ICU 24 satisfaction with care domain and medical decision-making domain scores were 93.3 ± 8.8 and 91.2 ± 8.9, respectively.
The pFS-ICU 24 is a psychometrically sound measure of satisfaction with care and medical decision-making of parents/caregivers with children in the ICU.
Abstract Purpose The purposes of the study are to determine the interobserver variability in the clinical assessment of pediatric upper airway obstruction (UAO) and to explore how variability in ...assessment of UAO may contribute to risk factors and incidence of postextubation UAO. Materials This is a prospective trial in 2 tertiary care pediatric intensive care units. Bedside practitioners performed simultaneous, blinded UAO assessments on 112 children after endotracheal extubation. Results Agreement among respiratory therapists, pediatric intensive care nurses, and pediatric intensive care physicians was poor for cyanosis ( κ = 0.01) and hypoxemia at rest ( κ = 0.14) and fair for consciousness ( κ = 0.27), air entry ( κ = 0.32), hypoxemia with agitation ( κ = 0.27), and pulsus paradoxus ( κ = 0.23). When looking at “stridor” and “retractions,” defined using more than 2 grades of severity from the Westley Croup Score, the interrelater reliability was moderate ( κ = 0.43 and κ = 0.47, respectively). This could be improved marginally by dichotomizing the presence or absence of stridor ( κ = 0.54) or retractions ( κ = 0.53). The overall incidence of UAO after extubation (stridor plus retractions) could range from 7% to 22%, depending on how many providers were required to agree. Conclusions Physical findings routinely used for UAO have poor interobserver reliability among bedside providers. This variability may contribute to inconsistent findings regarding incidence, risk factors, and therapies for postextubation UAO.
Asthma is a common chronic disease with profound impacts upon individuals and the US health care system. Inadequate health care coverage has been associated with more frequent and severe ...exacerbations of the disease. We examined the relationship between adequacy of health care coverage and use of emergent care of adults with asthma.
The 2001 Behavioral Risk Factor Surveillance System was the source of data on adults with current asthma. Bivariate and multiple logistic regression analysis modeled identifiable factors in predicting urgent or emergent care.
Key variables included demographics and information on self-reported gaps in health care coverage. The primary outcome was emergency room or urgent care visits for worsening of asthma symptoms. Of 16,234 subjects nationally with current asthma, 2,195 from eight states had valid responses to a supplemental module asking about emergency room use or urgent care visits because of asthma. Thirty four percent of these individuals required such care in the previous year. Having an interruption in health care coverage in the past year was associated with an increased risk of needed urgent or emergent care (crude Odds Ratio OR 1.48, 95% confidence intervals CI1.03, 2.1). The association was not statistically significant in the adjusted multivariate model including race/ethnicity, employment status, gender, age, education and the ability to identify a primary physician (adjusted OR 1.2, 95% CI 0.8, 1.8).
This study provides population-level, generalizable evidence of increased risk of exacerbations of asthma in adults and (1) their demographic characteristics, and (2) continuous adequate health care coverage.
To assess the impact of calfactant (a modified natural bovine lung surfactant) in immunocompromised children with acute lung injury and to determine the number of patients required for a definitive ...clinical trial of calfactant in this population.
Post hoc analysis of data from a previous randomized, control trial.
Tertiary care pediatric intensive care units.
All children, defined as immunocompromised, enrolled in a multicenter, masked, randomized, control trial of calfactant for acute lung injury conducted between July 2000 and July 2003.
Patients received either an intratracheal instillation of calfactant or an equal volume of air placebo in a protocolized manner.
Eleven of 22 (50%) calfactant-treated patients died when compared with 18 of 30 (60%) placebo patients (absolute risk reduction 10.0%, 95% confidence interval CI -17.3, 37.3). Among the 23 patients with an initial oxygen index (OI) >/=13 and </=37, 44% (4 of 9) of calfactant-treated patients died in comparison with 71% (10 of 14) of placebo (absolute risk reduction 27.0%, 95% CI -13.2, 67.2). Only 33% (3 of 9) of calfactant patients died before intensive care discharge in comparison with 71% (10 of 14) of placebo (absolute risk reduction 38.1%, 95% CI -0.7, 76.9). Calfactant therapy was associated with improved oxygenation in these 23 patients. Using an OI entry criterion of (13 </= OI </= 37), stratifying on the presence of hematopoietic stem cell transplantation, and accepting the 27% difference in mortality observed in this analysis, 63 patients would be required in each arm of a randomized, control trial to demonstrate a significant effect of calfactant on mortality in this patient population assuming a two-sided alpha of 0.05 and a power of 0.85.
These preliminary data suggest a potential benefit of calfactant in this high-risk population. A clinical trial powered to appropriately assess these findings seems warranted and feasible.
•Pediatric acute respiratory distress syndrome (PARDS) has a high mortality.•Data do not support calfactant for children with leukemia/lymphoma, hematopoietic cell transplantation, and ...PARDS.•Allogeneic hematopoietic cell transplantation patients with PARDS have higher mortality than other groups.•Conducting research among these children is challenging but necessary.
To assess if calfactant reduces mortality among children with leukemia/lymphoma or after hematopoietic cell transplantation (HCT) with pediatric acute respiratory distress syndrome (PARDS), we conducted a multicenter, randomized, placebo-controlled, double-blinded trial in 17 pediatric intensive care units (PICUs) of tertiary care children's hospitals. Patients ages 18 months to 25 years with leukemia/lymphoma or having undergone HCT who required invasive mechanical ventilation for bilateral lung disease with an oxygenation index (OI) > 10 and <37 were studied. Interventions used were intratracheal instillation of either calfactant or air placebo (1 or 2 doses). Forty-three subjects were enrolled between November 2010 and June 2015: 26 assigned to calfactant and 17 to placebo. There were no significant differences in the primary outcome, which was survival to PICU discharge (adjusted hazard ratio of mortality for calfactant versus placebo, 1.78; 95% confidence interval, .53 to 6.05; P = .35), OI, functional outcomes, or ventilator-free days, adjusting for risk strata and Pediatric Risk of Mortality (PRISM) score. Despite the risk-stratified randomization, more allogeneic HCT patients received calfactant (76% and 39%, respectively) due to low recruitment at various sites. This imbalance is important because independent of treatment arm and while adjusting for PRISM score, those with allogeneic HCT had a nonsignificant higher likelihood of death at PICU discharge (adjusted odds ratio, 3.02; 95% confidence interval, .76 to 12.06; P = .12). Overall, 86% of the patients who survived to PICU discharge also were successfully discharged from the hospital. These data do not support the use of calfactant among this high mortality group of pediatric leukemia/lymphoma and/or HCT patients with PARDS to increase survival. In spite of poor enrollment, allogeneic HCT patients with PARDS appeared to be characterized by higher mortality than even other high-risk immunosuppressed groups. Conducting research among these children is challenging but necessary, because survival to PICU discharge usually results in successful discharge to home.
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