We assessed the growth, distribution, and characteristics of pediatric intensive care in 2016.
Hospitals with PICUs were identified from prior surveys, databases, online searching, and clinician ...networking. A structured web-based survey was distributed in 2016 and compared with responses in a 2001 survey.
PICUs were defined as a separate unit, specifically for the treatment of children with life-threatening conditions. PICU hospitals contained greater than or equal to 1 PICU.
Physician medical directors and nurse managers.
None.
PICU beds per pediatric population (< 18 yr), PICU bed distribution by state and region, and PICU characteristics and their relationship with PICU beds were measured. Between 2001 and 2016, the U.S. pediatric population grew 1.9% to greater than 73.6 million children, and PICU hospitals decreased 0.9% from 347 to 344 (58 closed, 55 opened). In contrast, PICU bed numbers increased 43% (4,135 to 5,908 beds); the median PICU beds per PICU hospital rose from 9 to 12 (interquartile range 8, 20 beds). PICU hospitals with greater than or equal to 15 beds in 2001 had significant bed growth by 2016, whereas PICU hospitals with less than 15 beds experienced little average growth. In 2016, there were eight PICU beds per 100,000 U.S. children (5.7 in 2001), with U.S. census region differences in bed availability (6.8 to 8.8 beds/100,000 children). Sixty-three PICU hospitals (18%) accounted for 47% of PICU beds. Specialized PICUs were available in 59 hospitals (17.2%), 48 were cardiac (129% growth). Academic affiliation, extracorporeal membrane oxygenation availability, and 24-hour in-hospital intensivist staffing increased with PICU beds per hospital.
U.S. PICU bed growth exceeded pediatric population growth over 15 years with a relatively small percentage of PICU hospitals containing almost half of all PICU beds. PICU bed availability is variable across U.S. states and regions, potentially influencing access to care and emergency preparedness.
To estimate the prevalence of chronic conditions among children admitted to U.S. pediatric intensive care units and to assess whether patients with complex chronic conditions experience pediatric ...intensive care unit mortality and prolonged length of stay risk beyond that predicted by commonly used severity-of-illness risk-adjustment models.
Retrospective cohort analysis of 52,791 pediatric admissions to 54 U.S. pediatric intensive care units that participated in the Virtual Pediatric Intensive Care Unit Systems database in 2008.
Hierarchical logistic regression models, clustered by pediatric intensive care unit site, for pediatric intensive care unit mortality and length of stay >15 days. Standardized mortality ratios adjusted for severity-of-illness score alone and with complex chronic conditions.
Fifty-three percent of pediatric intensive care unit admissions had complex chronic conditions, and 18.5% had noncomplex chronic conditions. The prevalence of these conditions and their organ system subcategories varied considerably across sites. The majority of complex chronic condition subcategories were associated with significantly greater odds of pediatric intensive care unit mortality (odds ratios 1.25-2.9, all p values < .02) compared to having a noncomplex chronic condition or no chronic condition, after controlling for age, gender, trauma, and severity-of-illness. Only respiratory, gastrointestinal, and rheumatologic/orthopedic/psychiatric complex chronic conditions were not associated with increased odds of pediatric intensive care unit mortality. All subcategories were significantly associated with prolonged length of stay. All noncomplex chronic condition subcategories were either not associated or were negatively associated with pediatric intensive care unit mortality, and most were not associated with prolonged length of stay, compared to having no chronic conditions. Among this group of pediatric intensive care units, adding complex chronic conditions to risk-adjustment models led to greater model accuracy but did not substantially change unit-level standardized mortality ratios.
Children with complex chronic conditions were at greater risk for pediatric intensive care unit mortality and prolonged length of stay than those with no chronic conditions, but the magnitude of risk varied across subcategories. Inclusion of complex chronic conditions into models of pediatric intensive care unit mortality improved model accuracy but had little impact on standardized mortality ratios.
To determine the relationship between PICU volume and severity-adjusted mortality in a large, national dataset.
Retrospective cohort study.
The VPS database (VPS, LLC, Los Angeles, CA), a national ...multicenter clinical PICU database.
All patients with discharge dates between September 2009 and March 2012 and valid Pediatric Index of Mortality 2 and Pediatric Risk of Mortality III scores, who were not transferred to another ICU and were seen in an ICU that collected at least three quarters of data.
None.
Anonymized data received included ICU mortality, hospital and patient demographics, and Pediatric Index of Mortality 2 and Pediatric Risk of Mortality III scores. PICU volume/quarter was determined (VPS sites submit data quarterly) per PICU and was divided by 100 to assess the impact per 100 discharges per quarter (volume). A mixed-effects logistic regression model accounting for repeated measures of patients within ICUs was performed to assess the association of volume on severity-adjusted mortality, adjusting for patient and unit characteristics. Multiplicative interactions between volume and severity of illness were also modeled. We analyzed 186,643 patients from 92 PICUs, with an overall ICU mortality rate of 2.6%. Volume ranged from 0.24 to 8.89 per ICU per quarter; the mean volume was 2.61. The mixed-effects logistic regression model found a small but nonlinear relationship between volume and mortality that varied based on the severity of illness. When severity of illness is low, there is no clear relationship between volume and mortality up to a Pediatric Index of Mortality 2 risk of mortality of 10%; for patients with a higher severity of illness, severity of illness-adjusted mortality is directly proportional to a unit's volume.
For patients with low severity of illness, ICU volume is not associated with mortality. As patient severity of illness rises, higher volume units have higher severity of illness-adjusted mortality. This may be related to differences in quality of care, issues with unmeasured confounding, or calibration of existing severity of illness scores.
Background: When designing multicenter clinical trials, it is important to understand the characteristics of children who have received
ventilation in PICUs.
Methods: This study involved the ...secondary analysis of an existing data set of all children intubated and mechanically ventilated
from 16 US PICUs who were initially screened for a multicenter clinical trial on pediatric acute lung injury (ALI).
Results: A total of 12,213 children between 2 weeks and 18 years of age who were intubated and mechanically ventilated were included,
representing 30% of PICU admissions (center range, 20 to 64%). Of the children who received ventilation, 22% had cyanotic
congenital heart disease; 26% had respiratory failure but not bilateral pulmonary infiltrates on chest radiograph; 8% had
chronic respiratory disease; 7% had upper airway obstruction; and 5% had reactive airway disease. At least 1,457 patients
(15%) with respiratory failure lacked an arterial line. Of these patients, 97% had a positive end-expiratory pressure ⤠8
cm H 2 O, and 80% were supported on an F io 2 of ⤠0.40. Moreover, 104 of 904 patients (12%) with pulse oximetric saturation (Sp o 2 ) and F io 2 measurements available would have met the oxygenation criteria for ALI according to Sp o 2 /F io 2 ratio criteria.
Conclusions: At least 30% of children in a cross-section of US PICUs are endotracheally intubated, and 25% of those with respiratory failure
do not fulfill the radiographic criteria for ALI. Although few patients without an indwelling arterial line require more than
modest ventilator support, many may still meet the oxygenation criteria for ALI. These findings will facilitate sample size
calculations and help to determine feasibility for future trials on pediatric mechanical ventilation.
Post-extubation stridor may prolong length of stay in the intensive care unit, particularly if airway obstruction is severe and re-intubation proves necessary. Some clinicians use corticosteroids to ...prevent or treat post-extubation stridor, but corticosteroids may be associated with adverse effects ranging from hypertension to hyperglycaemia, so a systematic assessment of the efficacy of this therapy is indicated.
To determine whether corticosteroids are effective in preventing or treating post-extubation stridor in critically ill infants, children, or adults.
We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL and reference lists of articles. The most recent searches were conducted in January 2009.
Randomized controlled trials comparing administration of corticosteroids by any route with placebo in infants, children, or adults receiving mechanical ventilation via an endotracheal tube in an intensive care unit.
Three review authors independently assessed trial quality and extracted data.
Eleven trials involving 2301 people were included: six in adults, two in neonates, three in children. All but one examined use of steroids for the prevention of post-extubation stridor; the remaining one concerned treatment of existing post-extubation stridor in children. Patients were drawn from heterogeneous medical/surgical populations. Dexamethasone given intravenously at least once prior to extubation was the most common steroid regimen utilized (uniformly in neonates and children). In neonates the two studies found heterogeneous results, with no overall statistically significant reduction in post extubation stridor (RR 0.42; 95% CI 0.07 to 2.32). One of these studies was on high-risk patients treated with multiple doses of steroids around the time of extubation, and this study showed a significant reduction in stridor. In children, the two studies were clinically heterogeneous. One study included children with underlying airway abnormalities and the other excluded this group. Prophylactic corticosteroids tended to reduce reintubation and significantly reduced post-extubation stridor in the study that included children with underlying airway abnormalities (N = 62) but not in the study that excluded these children (N = 153). In six adult studies (total N = 1953), the use of prophylactic corticosteroid administration did not significantly reduce the risk of re-intubation (RR 0.48; 95% CI 0.19 to 1.22). While there was a significant reduction in the incidence of post extubation stridor (RR 0.47; 95% CI 0.22 to 0.99), there was significant heterogeneity (I(2)=81%, X(2)=26.36, df=5, p<0.0001). Subgroup analysis revealed that post extubation stridor could be reduced in adults with a high likelihood of post extubation stridor when corticosteroids were administered as multiple doses begun 12-24 hours prior to extubation compared to single doses closer to extubation; the test for interaction for multiple versus single doses indicated RRR 0.22 (95% CI 0.10 to 0.47) for stridor with multiple doses. Side effects were uncommon and could not be aggregated.
Using corticosteroids to prevent (or treat) stridor after extubation has not proven effective for neonates or children. However, given the consistent trends towards benefit, this intervention does merit further study, particularly for high risk children or neonates. In adults, multiple doses of corticosteroids begun 12-24 hours prior to extubation do appear beneficial for patients with a high likelihood of post extubation stridor.
Multicenter data regarding the around-the-clock (24/7) presence of an in-house critical care attending physician with outcomes in children undergoing cardiac operations are limited.
Patients younger ...than 18 years of age who underwent operations (with or without cardiopulmonary bypass CPB) for congenital heart disease at 1 of the participating intensive care units (ICUs) in the Virtual PICU Systems (VPS, LLC) database were included (2009-2014). The study population was divided into 2 groups: the 24/7 group (14,737 patients; 32 hospitals), and the No 24/7 group (10,422 patients; 22 hospitals). Propensity-score matching was performed to match patients 1:1 in the 24/7 group and in the No 24/7 group.
Overall, 25,159 patients from 54 hospitals qualified for inclusion. By propensity matching, 9,072 patients (4,536 patient pairs) from 51 hospitals were matched 1:1 in the 2 groups. After matching, mortality at ICU discharge was lower among the patients treated in hospitals with 24/7 coverage (24/7 versus No 24/7, 2.8% versus 4.0%; p = 0.002). The use of extracorporeal membrane oxygenation (ECMO), the incidence of cardiac arrest, extubation within 48 hours after operation, the rate of reintubation, and the duration of arterial line and central venous line use after operation were significantly improved in the 24/7 group. When stratified by surgical complexity, survival benefits of 24/7 coverage persisted among patients undergoing both high-complexity and low-complexity operations.
The presence of 24-hour in-ICU attending physician coverage in children undergoing cardiac operations is associated with improved outcomes, including ICU mortality. It is possible that 24-hour in-ICU attending physician coverage may be a surrogate for other factors that may bias the results. Further study is warranted.
To investigate the association between PICU shock index (the ratio of heart rate to systolic blood pressure) and PICU mortality in children with sepsis/septic shock. To explore cutoff values for ...shock index for ICU mortality, how change in shock index over the first 6 hours of ICU admission is associated with outcome, and how the use of vasoactive therapy may affect shock index and its association with outcome.
Retrospective cohort.
Single-center tertiary PICU.
Five hundred forty-four children with the diagnosis of sepsis/septic shock.
None.
From January 2003 to December 2009, 544 children met International Pediatric Sepsis Consensus Conference of 2005 criteria for sepsis/septic shock. Overall mortality was 23.7%. Among all patients, hourly shock index was associated with mortality: odds ratio of ICU mortality at 0 hour, 1.08, 95% CI (1.04-1.12); odds ratio at 1 hour, 1.09 (1.04-1.13); odds ratio at 2 hours, 1.09 (1.05-1.13); and odds ratio at 6 hours, 1.11 (1.06-1.15). When stratified by age, early shock index was associated with mortality only in children 1-3 and more than or equal to 12 years old. Area under the receiver operating characteristic curve in age 1-3 and more than or equal to 12 years old for shock index at admission was 0.69 (95% CI, 0.58-0.80) and 0.62 (95% CI, 0.52-0.72) respectively, indicating a fair predictive marker. Although higher shock index was associated with increased risk of mortality, there was no particular cutoff value with adequate positive or negative likelihood ratios to identify mortality in any age group of children. The improvement of shock index in the first 6 hours of ICU admission was not associated with outcome when analyzed in all patients. However, among patients whose shock index were above the 50th percentile at ICU admission for each age group, improvement of shock index was associated with lower ICU mortality in children between 1-3 and more than or equal to 12 years old (p = 0.02 and p = 0.03, respectively). When controlling for the use of vasoactive therapy within the first 6 hours with logistic regression analysis, shock index at hour 6 remained significantly associated with mortality (odds ratio, 1.09; 95% CI, 1.05-1.14).
Shock index may have promise as a marker of mortality in children with sepsis/septic shock. Although there is no clear cutoff shock index to identify risk of mortality, given the higher risk of mortality as shock index increases, children with elevated shock index may benefit from more aggressive resuscitation and higher level of care.
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