Multiple organ dysfunction syndrome is the main cause of death in adult ICUs and in PICUs. The PEdiatric Logistic Organ Dysfunction score developed in 1999 was primarily designed to describe the ...severity of organ dysfunction. This study was undertaken to update and improve the PEdiatric Logistic Organ Dysfunction score, using a larger and more recent dataset.
Prospective multicenter cohort study.
Nine multidisciplinary, tertiary-care PICUs of university-affiliated hospitals in France and Belgium.
All consecutive children admitted to these PICUs (June 2006-October 2007).
None.
We collected data on variables considered for the PEdiatric Logistic Organ Dysfunction-2 score during PICU stay up to eight time points: days 1, 2, 5, 8, 12, 16, and 18, plus PICU discharge. For each variable considered for the PEdiatric Logistic Organ Dysfunction-2 score, the most abnormal value observed during time points was collected. The outcome was vital status at PICU discharge. Identification of the best variable cutoffs was performed using bivariate analyses. The PEdiatric Logistic Organ Dysfunction-2 score was developed by multivariable logistic regressions and bootstrap process. We used areas under the receiver-operating characteristic curve to evaluate discrimination and Hosmer-Lemeshow goodness-of-fit tests to evaluate calibration. We enrolled 3,671 consecutive patients (median age, 15.5 mo; interquartile range, 2.2-70.7). Mortality rate was 6.0% (222 deaths). The PEdiatric Logistic Organ Dysfunction-2 score includes ten variables corresponding to five organ dysfunctions. Discrimination (areas under the receiver-operating characteristic curve = 0.934) and calibration (chi-square test for goodness-of-fit = 9.31, p = 0.317) of the PEdiatric Logistic Organ Dysfunction-2 score were good.
We developed and validated the PEdiatric Logistic Organ Dysfunction-2 score, which allows assessment of the severity of cases of multiple organ dysfunction syndrome in the PICU with a continuous scale. The PEdiatric Logistic Organ Dysfunction-2 score now includes mean arterial pressure and lactatemia in the cardiovascular dysfunction and does not include hepatic dysfunction. The score will be in the public domain, which means that it can be freely used in clinical trials.
Daily or serial evaluation of multiple organ dysfunction syndrome (MODS) scores may provide useful information. We aimed to validate the daily (d) PELOD-2 score using the set of seven days proposed ...with the previous version of the score.
In all consecutive patients admitted to nine pediatric intensive care units (PICUs) we prospectively measured the dPELOD-2 score at day 1, 2, 5, 8, 12, 16, and 18. PICU mortality was used as the outcome dependent variable. The discriminant power of the dPELOD-2 scores was estimated using the area under the ROC curve and the calibration using the Hosmer-Lemeshow chi-square test. We used a logistic regression to investigate the relationship between the dPELOD-2 scores and outcome, and between the change in PELOD-2 score from day 1 and outcome.
We included 3669 patients (median age 15.5 months, mortality rate 6.1%, median length of PICU stay 3 days). Median dPELOD-2 scores were significantly higher in nonsurvivors than in survivors (p < 0.0001). The dPELOD-2 score was available at least at day 2 in 2057 patients: among the 796 patients without MODS on day 1, 186 (23.3%) acquired the syndrome during their PICU stay (mortality 4.9% vs. 0.3% among the 610 who did not; p < 0.0001). Among the 1261 patients with MODS on day 1, the syndrome worsened in 157 (12.4%) and remained unchanged or improved in 1104 (87.6%) (mortality 22.9% vs. 6.6%; p < 0.0001). The AUC of the dPELOD-2 scores ranged from 0.75 (95% CI: 0.67-0.83) to 0.89 (95% CI: 0.86-0.91). The calibration was good with a chi-square test between 13.5 (p = 0.06) and 0.9 (p = 0.99). The PELOD-2 score on day 1 was a significant prognostic factor; the serial evaluation of the change in the dPELOD-2 score from day1, adjusted for baseline value, demonstrated a significant odds ratio of death for each of the 7 days.
This study suggests that the progression of the severity of organ dysfunctions can be evaluated by measuring the dPELOD-2 score during a set of 7 days in PICU, providing useful information on outcome in critically ill children. Its external validation would be useful.
To the Editor: Anaphylaxis-related mortality (AMR) has been estimated at less than 1 per million population from the United States and the United Kingdom.1-3 In these countries, the AMR remained ...stable during the last decade.1-3 In contrast, the incidence of anaphylaxis fatalities increased in Australia from 1997 to 2013.4 The most common triggers of fatal anaphylaxis cases are drugs, insect venoms, and foods, with drugs accounting for most of the fatalities.1-4 In France, comprehensive data from anaphylaxis-related deaths are collected by the National Mortality Center. Advancing age is known to be another risk factor for fatal anaphylaxis.1-3 This is likely explained by underlying comorbidities, such as cardiovascular or cerebrovascular diseases, and also by an increased medication use.1 Fatal anaphylaxis is mostly due to medications, mainly antibiotics, as described in Australia and the United States.2-4 Our data showed a decrease in antibiotic-related fatal cases, especially during the last decade, in line with the decrease of 10.7% in antibiotic consumption reported in France (ANSM report 20136). ...our work is the longest time period study reporting AMR. Appendix Table E1Characteristics of anaphylaxis fatalities by specific cause Characteristic Anaphylaxis Iatrogenicn = 1011 (63%) Insect stingsn = 220 (13.7%) Foodn = 8 (0.5%) Unspecifiedn = 364 (22.7%) Alln = 1603 (100%) Sex, n (%) Men 439 (56.0) 159 (20.3) 6 (0.8) 180 (23.0) 784 (100) Women 572 (69.8) 61 (7.4) 2 (0.2) 184 (22.5) 819 (100) Population Adult 993 (63.5) 217 (13.9) 6 (0.4) 348 (22.3) 1564 (100) Pediatric 18 (46.2) 3 (7.8) 2 (5.1)...
Multisystem inflammatory syndrome in children (MIS-C or PIMS-TS) is a severe disease. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is used for positive and differential diagnosis, diagnosis ...of complications and severity, and cardiogenic shock prediction. However, contrasting cut-offs have been suggested. The aims of the present study were to compare NT-proBNP values depending on the time of measurement and to describe the NT-proBNP course during the MIS-C episode. The data from a single-centre cohort observational study on the impact of time to diagnosis, defined as the time from first symptom to diagnosis of MIS-C, were used for the purpose of this study, with an extended period of inclusion from May 2020 to April 2023. The timing and level of all NT-proBNP samples available for each patient were retrospectively collected. Thirty-seven children (18 (49%) females, median age 8.8 years, 14 (38%) with shock) were included. Until diagnosis, NT-proBNP increased with time and was significantly higher at 6 days from first symptoms than at 3 days (median (interquartile range) 32,933 (7773–61,592) versus 1994 (1291–4190) pg/mL, respectively,
p
= 0.031). From diagnosis, NT-proBNP decreased by at least 50% after 3.0 (2.1–5.3) days (
n
= 12) when NT-proBNP at diagnosis was low ≤ 11,000 pg/mL versus 1.8 (0.7–3.4) days (
n
= 16) when NT-proBNP at diagnosis was high (
p
= 0.040), and after 3.6 (2.4–5.9) days (
n
= 7) when fever persisted after 48 h versus 1.8 (0.8–3.0) days (
n
= 21) when fever resolved before 48 h (
p
= 0.004).
Conclusions
: During the MIS-C episode, NT-proBNP increased over time until diagnosis and treatment. It dropped faster thereafter in children with high NT-proBNP at diagnosis > 11,000 pg/mL and slower in case of persistent fever.
What is Known:
• NT-proBNP is useful in MIS-C for positive and differential diagnosis, diagnosis of complications and severity, and cardiogenic shock prediction.
• Contrasting cut-offs for differential diagnosis and severity assessment have been suggested.
What is New:
• Before diagnosis, NT-proBNP increases with time and is significantly higher at 6 days from first symptoms than at 3 days suggesting different cut-offs depending on the timing of measurement.
• From diagnosis and treatment initiation, the 50% NT-proBNP drop occurs earlier in children with high NT-proBNP at diagnosis > 11,000 pg/mL and later in children with persistent fever.
Background
Use of continuous renal replacement therapy in children receiving anti-infective drugs may lead to inappropriate concentrations with risks related to treatment failure, toxicity and ...emergence of multidrug-resistant bacteria. We aimed to describe anti-infective prescribing practices in critically ill children undergoing continuous renal replacement therapy.
Methods
An online survey to assess continuous renal replacement therapy, anti-infective prescribing and therapeutic drug monitoring practices was sent by e-mail to physicians working in pediatric intensive care units through the French-speaking Group of Pediatric Intensive Care and Emergency medicine (GFRUP).
Results
From April 1st, 2021 to May 1st, 2021, 26/40 pediatric intensive care units participated in the survey, corresponding to a response rate of 65%. Twenty-one were located in France and five abroad. All pediatric intensive care units administered continuous renal replacement therapy, primarily with Prismaflex™ System. Anti-infective prescriptions were adjusted to the presence of continuous renal replacement therapy in 23 (88%) pediatric intensive care units mainly according to molecular weight in 6 (23%), molecule protein binding in 6 (23%) and elimination routes in 15 (58%) including residual diuresis in 9 (35%), to the continuous renal replacement therapy flow in 6 (23%) and to the modality of continuous renal replacement therapy used in 15 (58%), pediatric intensive care units. There was broad variability among pediatric intensive care units and among physicians within the same unit. Barriers to therapeutic drug monitoring were mainly an excessive delay in obtaining results in 11 (42%) and the lack of an on-site laboratory in 8 (31%) pediatric intensive care units.
Conclusions
Our survey reported wide variability in anti-infective prescribing practices in children undergoing continuous renal replacement therapy, thus highlighting a gap in knowledge and the need for education and recommendations.
Graphical abstract
The Pediatric Logistic Organ Dysfunction-2 is a validated score that quantifies organ dysfunction severity and requires complex data collection that is time-consuming and subject to errors. We ...hypothesized that a computer algorithm that automatically collects and calculates the Pediatric Logistic Organ Dysfunction-2 (aPELOD-2) score would be valid, fast and at least as accurate as a manual approach (mPELOD-2).
Retrospective cohort study.
Single center tertiary medical and surgical pediatric critical care unit (Sainte-Justine Hospital, Montreal, Canada).
Critically ill children participating in four clinical studies between January 2013 and August 2018, a period during which mPELOD-2 data were manually collected.
None.
The aPELOD-2 was calculated for all consecutive admissions between 2013 and 2018 (n = 5,279) and had a good survival discrimination with an area under the receiver operating characteristic curve of 0.84 (95% CI, 0.81-0.88). We also collected data from four single-center studies in which mPELOD-2 was calculated (n = 796, 57% medical, 43% surgical) and compared these measurements to those of the aPELOD-2. For those patients, median age was 15 months (interquartile range, 3-73 mo), median ICU stay was 5 days (interquartile range, 3-9 d), mortality was 3.9% (n = 28). The intraclass correlation coefficient between mPELOD-2 and aPELOD-2 was 0.75 (95% CI, 0.73-0.77). The Bland-Altman showed a bias of 1.9 (95% CI, 1.7-2) and limits of agreement of -3.1 (95% CI, -3.4 to -2.8) to 6.8 (95% CI, 6.5-7.2). The highest agreement (Cohen's Kappa) of the Pediatric Logistic Organ Dysfunction-2 components was noted for lactate level (0.88), invasive ventilation (0.86), and creatinine level (0.82) and the lowest for the Glasgow Coma Scale (0.52). The proportion of patients with multiple organ dysfunction syndrome was higher for aPELOD-2 (78%) than mPELOD-2 (72%; p = 0.002). The aPELOD-2 had a better survival discrimination (area under the receiver operating characteristic curve, 0.81; 95% CI, 0.72-0.90) over mPELOD-2 (area under the receiver operating characteristic curve, 0.70; 95% CI, 0.59-0.82; p = 0.01).
We successfully created a freely available automatic algorithm to calculate the Pediatric Logistic Organ Dysfunction-2 score that is less labor intensive and has better survival discrimination than the manual calculation. Use of an automated system could greatly facilitate integration of the Pediatric Logistic Organ Dysfunction-2 score at the bedside and within clinical decision support systems.
Purpose
The Newborn Infant Parasympathetic Evaluation (NIPE) is a heart rate variability-based technology for assessing pain and comfort in neonates and infants under 2-years-old. This review aims to ...investigate the clinical utility of the NIPE.
Methods
Two investigators screened Pubmed/Medline and Google Scholar for relevant studies, independently. One investigator extracted data, which were reviewed by a second investigator.
Results
The NIPE was used during/after painful stimuli (6 studies), in the context of general anaesthesia (2 studies), and for comfort assessment (6 studies). A) Evaluation of procedural pain/distress: 2 studies reported that the mean-NIPE could be used for reliable monitoring of prolonged pain, and one study reported the association between instant-NIPE and pain after a stimulus but the instant-NIPE represents the NIPE average over 3 min. Two studies found no correlation between the NIPE and comfort behavior/pain scales, but they mainly differed in patients’ gestational age and evaluation methodology. B) There are only 2 studies for the evaluation of nociception during surgery under general anaesthesia with contradictory results. C) Studies assessing neonates’ comfort reported increased NIPE scores during skin-to-skin contact and during facilitated tucking associated with a human voice. No effect on NIPE scores of facilitated tucking during echocardiography was reported in preterm infants. One study reported significantly different NIPE scores with 2 surfactant therapy protocols. Overall, study populations were small and heterogeneous.
Conclusion
The results regarding NIPE’s performances differ between studies. Given the limited number of studies and the heterogeneous outcomes, more studies are required to confirm the NIPE usefulness in the different clinical settings.
PDF
