Pediatric Critical Care Illness Severity Toolkit: Stata Commands for Calculation of Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction Scores.

Introduction: Illness severity scoring tools, such as PRISM III/IV, PIM-3, and PELOD-2, are widely used in pediatric critical care research. However, their application is hindered by complex calculation processes, privacy concerns with third-party online calculators, and challenges in accurate implementation within statistical packages. Methods: We have developed a comprehensive, open-source toolkit for implementing the PIM-3, Simplified PIM-3, and PELOD-2 scores. The toolkit includes the pim3 and pelod2 commands and is compatible with Stata versions 12 and above. It features robust data validation, error messaging, a graphical interface, and support for SI and Imperial units. The toolkit's accuracy was validated through unit testing and synthetic data, comparing results with existing implementations. Results: In performance tests, the toolkit exhibited a median processing time of 21.82 seconds for PELOD-2, 14.06 seconds for PIM-3, and 9.74 seconds for Simplified PIM-3, when applied to datasets of 10,000,000 records. It consistently achieved 100% accuracy in both synthetic data tests and manual spot checks. Conclusion: The toolkit decreases processing time and improves accuracy in calculating pediatric critical care severity scores such as PELOD-2, PIM-3, and Simplified PIM-3. Its application in large datasets and validation highlights its utility as a tool for streamlining pediatric critical care research.

Serum Ferritin and PELOD-2 Scores in Critically Ill Septic Children - a Cross-sectional Single-center Study.

Objective: This study aims to assess the correlation of ferritin serum level and PELOD-2 score, and determine the effectiveness of ferritin serum level as early indicator of organ dysfunction. Methods: This was a cross-sectional study carried out to pediatric patients with sepsis in the Pediatric Intensive Care Unit Haji Adam Malik and Universitas Sumatera Utara hospital from June 2021 - January 2022. Complete blood work was done, and ferritin serum level and PELOD-2 score were measured on the first and third day of hospital stay of all the sixty participants aged 1-18 years old with sepsis. The correlation was measured using Spearman test, with p<0.05 indicating a significant correlation. Results: The median level of serum ferritin level was 480 (24.7 - 22652) ng/mL. There were 20% patients with ferritin level <200 ng/mL, 26.7% with ferritin level 200-500 ng/mL, and 53.3% patients with ferritin >500 ng/mL. The median score of PELOD-2 was 4. There was a significant correlation of serum ferritin and PELOD-2 score on day 1 of hospital stay. Conclusion: The ferritin serum level is effective as an early indicator of organ dysfunction until PELOD-2 score is established. There is a positive correlation between serum ferritin and PELOD-2 score. There is a link between elevated ferritin and worse disease prognosis.

The Various Scoring Systems in Pediatric Intensive Care Units: A Prospective Observational Study.

BACKGROUND: The discrimination power of the pediatric risk of mortality (PRISM), pediatric index of mortality (PIM), sequential organ failure assessment (SOFA), and pediatric logistic organ dysfunction (PELOD) may not always be true for countries such as India due to differences in factors from those nations where these scoring systems were validated. Therefore, this study was undertaken to determine and compare severity, course of illness, and outcomes in critically ill children admitted to the pediatric intensive care unit (PICU) using different scoring systems such as PRISM 4, PIM 3, PELOD 2, and the pediatric sequential organ failure assessment (pSOFA ) score, and to analyze the clinical spectrum and demographic profile of children admitted to the PICU. MATERIALS AND METHOD: This was a prospective, single-center, observational study conducted in the PICU of the Indira Gandhi Institute of Medical Science, Patna, India, over two years. Two hundred children in the age group of one month to 14 years admitted to the PICU were recruited into the study. Prognostic scoring systems, including PRISM4 and PIM3, were used to compare the outcome, mortality, and length of PICU stay, whereas PELODS and pSOFA were descriptive scores that assessed the multiorgan dysfunction. A correlation between the different scoring systems and the outcome was determined. RESULTS: The majority of children (26.5%, n=53) were one to three years of age. The maximum number of patients was male (66.5%, n=133). Renal complications were the predominant admission diagnosis in 19% (n=38) of children. The mortality rate was found to be 18.5%. The mortality was most common in infants <1 year of age (n=11, 29.73%) and those of the male sex (n=22, 59.46%). A significant correlation was found between length of stay and mortality (p<0.00001). A significant positive correlation was observed between mortality and PRISM 4, PIM 3, PELOD 2, and pSOFA scores on the first day of admission (p<0.00001). The pSOFA and PELOD2 showed better discrimination power (area under the curve (AUC): 0.77 and 0.74, respectively). CONCLUSION: The study concluded that the pSOFA and PELOD2 scores are reliable predictors of mortality in critically ill children.

The Role of Blood Purification by HA330 as Adjunctive Treatment in Children with Septic Shock.

INTRODUCTION: Despite advances in supportive care for critically ill patients, sepsis remains an important cause of death worldwide in the PICU. One of the hallmarks of sepsis is hyperinflammation due to the excessive release of inflammatory mediators. Recently, new therapeutic approaches, such as immune modulation and blood purification, have been tried to improve outcomes in patients with septic shock. METHODS: This study is a prospective observational study composed of children with septic shock and the PELOD-2 score ≥10 or the PRISM-3 score ≥15. All received 2-4 h of HA330 treatment on 2 consecutive days, used as adjunctive therapy. The effectiveness of HA330 hemoperfusion was evaluated by improving the PELOD-2 and PRISM-3 scores, the vasoactive inotropic score (VIS), and inflammatory markers from baseline to 72 h after the use of HA330 hemoperfusion. RESULTS: Twelve patients hospitalized in the PICU and diagnosed with septic shock between July 2021 and May 2022 were included in this study and received hemoperfusion with HA330. The average PELOD-2 and PRISM-3 scores decreased significantly from 9.5 (IQR: 6.5-13.0) at baseline to 2.0 (IQR: 0-6.5) at 72 h (p = 0.002) and from 16.5 (IQR: 15.0-20.5) at baseline to 5.5 (IQR: 2.0-9.5) at 72 h (p = 0.002), respectively. The VIS decreased significantly from baseline to 72 h (p = 0.003). IL-6, procalcitonin, and lactate levels also decreased significantly from baseline to 72 h (p = 0.005, 0.03, and 0.03, respectively). Two of 12 patients expired due to their underlying condition (2/12, 16.7%). Device-related adverse events did not occur in this study. CONCLUSIONS: Our observational case series suggests a possible role for HA330 hemoperfusion as an adjunctive treatment of refractory septic shock in children with high severity scores in the context of rapid improvement in organ dysfunction, without serious adverse effects.

Comparative Analysis of Intensive Care Prognosis Scoring Systems and Acute Kidney Injury Scores (AKIN and pRIFLE) in Critically Ill Children.

The development of AKI (acute kidney injury) in critically ill patients in pediatric intensive care units (PICUs) is one of the most important factors affecting mortality. There are scoring modalities used to predict mortality in PICUs. We compared the AKIN (Acute Kidney Injury Network) and pRIFLE (pediatric risk, injury, failure, loss, and end stage) AKI classifications and PICU scoring modalities in this study. METHODS: A total of 716 children, whose serum creatinine levels were within the normal limits at the time of admission to the PICU between January 2018 and December 2020, were included. Along with the demographic and clinical variables, AKIN and pRIFLE classifications were recorded at the most advanced stage of AKI. Along with the PIM-2, PRISM III, and PELOD-2 scores, the highest value of the pSOFA score was recorded. RESULTS: According to the pRIFLE and AKIN classifications, 62 (8.7%) patients developed kidney injury, which had a statistically significant effect on mortality. The occurrence of renal injury was found to be statistically strongly and significantly correlated with high PRISM III, PELOD-2, and pSOFA scores. When the stages of kidney injury according to the AKIN criteria were compared with the PRISM III, PELOD 2, and pSOFA scores, a significant difference was found between the patients who did not develop AKI and those who developed stage 1, stage 2, and stage 3 kidney injury. For the PRISM III, PELOD 2, and pSOFA scores, there were no significant differences between the stages according to the AKIN criteria. A substantial difference was discovered between the patients who did not develop AKI and those who were in the risk, injury, and failure plus loss stages according to the pRIFLE criteria. According to the PIM-2 ratio and pRIFLE criteria, there was a statistically significant difference between patients in the injury and failure plus loss stages and those who did not develop AKI. CONCLUSIONS: Our study is the first pediatric study to show a substantial correlation between the variables associated with the PICU scoring modalities in critically ill children with AKI. Identifying the risk factors for the development of AKI and planning antimicrobial regimens for patients with favorable prognoses at the time of PICU admission could lower mortality rates.

Red Cell Distribution Width on First Day Intensive Care Unit Admission in Paediatrics.

Red distribution width (RDW) has recently been acclaimed as prognostic marker for mortality in critically-ill patients. However, this claim is still unclear and reports are still inadequate for the association between RDW and mortality in critically-ill paediatric patients. This research assessed the correlation between RDW within 24 hours of PICU (paediatric intensive care unit) admission and PELOD-2 score. A cross-sectional study was carried out involving 59 pediatric patients admitted to the PICU Haji Adam Malik Hospital, Medan, Indonesia, from May to July 2019. The association between RDW and PELOD-2 score was assessed by using Spearman correlation test. The RDW level of paediatric patients in the PICU on the first 24 hours was elevated (median 14.7%, range 11.4-31.2%). The median of PELOD-2 score assessment was 8 (range 2-21). There was no significant correlation between RDW and PELOD-2 in this research (r=0.187, p=0.156).

Acute gastrointestinal injury in critically ill children: Impact on clinical outcome.

AIM: To estimate acute gastrointestinal injury (AGI) in critically ill children and association of its severity with mortality. METHODS: In a prospective cohort study, critically ill children (1 month-18 years) were enrolled. Gastrointestinal symptoms over the first week of admission were classified into AGI grades 1 through 4, using a paediatric adaptation of European Society of Intensive Care Medicine AGI definitions. Performance of AGI grades in predicting 28-day mortality was evaluated. RESULTS: Of 151 children enrolled, 71 (47%, 95% confidence interval (CI): 38.9-55.3%) developed AGI, with AGI grades 1, 2, 3 and 4 in 22.5%, 15.9%, 6.6% and 2%, respectively. The 28-day mortality progressively increased with AGI grade 0 (15%), 1 (35%), 2 (50%), 3 (70%), through 4 (100%), P < 0.001. Association of AGI grades with 28-day mortality was significant even after adjustment for disease severity, age and nutritional status (odds ratio (OR) = 2.152, 95% CI: 1.455, 3.184). Among AGI grades, and paediatric logistic organ dysfunction-2 score components, cardiovascular (OR = 1.525, 95% CI: 1.142, 2.037) and haematological (OR = 1.719, 95% CI: 1.067, 2.772) components of paediatric logistic organ dysfunction-2 score and AGI grades (OR = 1.565, 95% CI: 1.001, 2.449) showed significant association with 28-day mortality. CONCLUSIONS: Nearly half of the critically ill children developed AGI. AGI grades were independently associated with increased mortality, and mortality progressively increased with AGI grade.

Prognostic factors and models to predict pediatric sepsis mortality: A scoping review.

Introduction: Several scoring systems are available to assess the severity of sepsis in pediatric patients in diverse settings worldwide. This study investigates the quality and applicability of predictive models for determining pediatric sepsis mortality, especially in acute care and limited-resource settings. Data sources: Mortality prediction factors and models were searched in four databases using the following criteria: developed for pediatric health care, especially in acute settings, and with mortality as an outcome. Study selection: Two or more reviewers performed the study selection to ensure no bias occurred. Any disagreements were solved by consensus or by the decision of a third reviewer. Data extraction: The authors extracted the results and mapped the selected studies qualitatively to describe the prognostic properties of the risk factors and models proposed in the study. Data synthesis: The final analysis included 28 mortality prediction models. Their characteristics, analysis, and performance measures were summarized. Performance was described in terms of calibration and discrimination, including assessing for risk of bias and applicability. A modified version of the PRISM-III score based on physiologic criteria (PRISM-III-APS) increased its predictive value to 0.85-0.95. The vasoactive-inotropic score at 12 h had a strong independent association with death. Albumin had an excellent predictive value when combined with other variables. Lactate, a biomarker widely measured in patients with sepsis, was highly associated with mortality. The bioimpedance phase angle was not considered applicable in our setting. Measurement using more straightforward methods, such as mid-upper arm circumference, was feasible in numerous health care facilities. Conclusion: Leveraging prognostic models to predict mortality among pediatric patients with sepsis remains an important and well-recognized area of study. While much validation and development work remains to be done, available prognostic models could aid clinicians at the bedside of children with sepsis. Furthermore, mortality prediction models are essential and valuable tools for assessing the quality of care provided to critically ill pediatric patients.

Evaluation of Severity of Illness Scores in the Pediatric ECMO Population.

Though commonly used for adjustment of risk, severity of illness and mortality risk prediction scores, based on the first 24 h of intensive care unit (ICU) admission, have not been validated in the pediatric extracorporeal membrane oxygenation (ECMO) population. We aimed to determine the association of Pediatric Index of Mortality 2 (PIM2), Pediatric Risk of Mortality Score III (PRISM III) and Pediatric Logistic Organ Dysfunction (PELOD) scores with mortality in pediatric patients on ECMO. This was a retrospective cohort study of children ≤18 years of age included in the Pediatric ECMO Outcomes Registry (PEDECOR) from 2014 to 2018. Logistic regression and Receiver Operating Characteristics (ROC) curves were used to calculate the area under the curve (AUC) to evaluate association of mortality with the scores. Of the 655 cases, 289 (44.1%) did not survive until hospital discharge. AUCs for PIM2, PRISM III, and PELOD predicting mortality were 0.52, 0.52, and 0.51 respectively. PIM2, PRISM III, and PELOD scores are not associated with odds of mortality for pediatric patients receiving ECMO. These scores for a general pediatric ICU population should not be used for prognostication or risk stratification of a select population such as ECMO patients.

Hypocoagulable Tendency on Thromboelastometry Associated With Severity and Anticoagulation Timing in Pediatric Septic Shock: A Prospective Observational Study.

Objective: To identify whether coagulation profiles using thromboelastometry are associated with outcomes in pediatric septic shock. The primary outcomes were the development of disseminated intravascular coagulation (DIC) and the severity of the pediatric intensive care unit (PICU) existing scoring systems, while the secondary outcome was hospital mortality. This study aimed to contribute to current findings of the limitations of conventional tests in determining the optimal timing of anticoagulation in sepsis. Design: A prospective, observational study conducted between August 2019 and August 2020. Setting: PICU at a pediatric tertiary hospital in Hanoi, Vietnam. Patients: Fifty-five pediatric patients who met the septic shock criteria were enrolled. Measurements and Main Results: Fifty-five patients with septic shock were recruited. At the time of diagnosis, thromboelastometry revealed normocoagulability, hypercoagulability, and hypocoagulability in 29, 29, and 42% of the patients, respectively (p > 0.05); however, most patients in the overt DIC and non-survival groups progressed to hypocoagulability (82 and 64%, respectively). The overt DIC, PELOD-2 > 8, PRISM-III > 11, and non-survival group had a significant hypocoagulable tendency according to thromboelastometry parameters [prolonged clotting time (CT) and clot formation time (CFT); and reduced α-angle (α), maximum clot firmness (MCF), thrombodynamic potential index (TPI)] compared to the non-overt DIC, PELOD-2 ≤ 8, PRISM-III score ≤ 11 and survival group (p < 0.05). Conventional parameters between the normocoagulable and hypercoagulable groups were not different (p > 0.05). Hypocoagulability was characterized by lower platelet count and fibrinogen level, higher prolonged prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (APTT), and higher D-dimer level than in hypercoagulability (p < 0.05). Hypocoagulable tendency on thromboelastometry had a higher hazard at a PT > 16.1 s [area under the curve (AUC) = 0.747, odds ratio (OR) = 10.5, p = 0.002], INR > 1.4 (AUC = 0.754, OR = 6.9, p = 0.001), fibrinogen <3.3 g/L (AUC = 0.728, OR = 9.9, p = 0.004), and D-dimer > 3,863 ng/mL (AUC = 0.728, OR = 6.7, p = 0.004). Conclusions: Hypocoagulable tendency using thromboelastometry is associated with the severity of septic shock. Conventional coagulation tests may fail to detect hypercoagulability, which is crucial in determining anticoagulation timing.

Sequential Organ Failure Assessment Score As a Predictor of Outcome in Sepsis in Pediatric Intensive Care Unit.

Sequential organ failure assessment (SOFA) score is used as a predictor of outcome of sepsis in the pediatric intensive care unit. The aim of the study is to determine the application of SOFA scores as a predictor of outcome in children admitted to the pediatric intensive care unit with a diagnosis of sepsis. The design involved is prospective observational study. The study took place at the multidisciplinary pediatric intensive care unit (PICU), tertiary care hospital, South India. The patients included are children, aged 1 month to 18 years admitted with a diagnosis of sepsis (suspected/proven) to a single center PICU in India from November 2017 to November 2019. Data collected included the demographic, clinical, laboratory, and outcome-related variables. Severity of illness scores was calculated to include SOFA score day 1 (SF1) and day 3 (SF3) using a pediatric version (pediatric SOFA score or pSOFA) with age-adjusted cutoff variables for organ dysfunction, pediatric risk of mortality III (PRISM III; within 24 hours of admission), and pediatric logistic organ dysfunction-2 or PELOD-2 (days 1, 3, and 5). A total of 240 patients were admitted to the PICU with septic shock during the study period. The overall mortality rate was 42 of 240 patients (17.5%). The majority (59%) required mechanical ventilation, while only 19% required renal replacement therapy. The PRISM III, PELOD-2, and pSOFA scores correlated well with mortality. All three severity of illness scores were higher among nonsurvivors as compared with survivors ( p < 0.001). pSOFA scores on both day 1 (area under the curve or AUC 0.84) and day 3 (AUC 0.87) demonstrated significantly higher discriminative power for in-hospital mortality as compared with PRISM III (AUC, 0.7), and PELOD-2 (day 1, [AUC, 0.73]), and PELOD-2 (day 3, [AUC, 0.81]). Utilizing a cutoff SOFA score of >8, the relative risk of prolonged duration of mechanical ventilation, requirement for vasoactive infusions (vasoactive infusion score), and PICU length of stay were all significantly increased ( p < 0.05), on both days 1 and 3. On multiple logistic regression, adjusted odds ratio of mortality was elevated at 8.65 (95% CI: 3.48-21.52) on day 1 and 16.77 (95% confidence interval or CI: 4.7-59.89) on day 3 ( p < 0.001) utilizing the same SOFA score cutoff of 8. A positive association was found between the delta SOFA ([Δ] SOFA) from day 1 to day 3 (SF1-SF3) and in-hospital mortality (chi-square for linear trend, p < 0.001). Subjects with a ΔSOFA of ≥2 points had an exponential mortality rate to 50%. Similar association was-observed between ΔSOFA of ≥2 and-longer duration of inotropic support ( p = 0.0006) with correlation co-efficient 0.2 (95% CI: 0.15-0.35; p = 0.01). Among children admitted to the PICU with septic shock, SOFA scores on both days 1 and 3, have a greater discriminative power for predicting in-hospital mortality than either PRISM III score (within 24 hours of admission) or PELOD-2 score (days 1 and 3). An increase in ΔSOFA of >2 adds additional prognostic accuracy in determining not only mortality risk but also duration of inotropic support as well.

Day-1 PELOD-2 and day-1 quick PELOD-2 scores in children with sepsis in the PICU / Desempenhos dos escores PELOD-2 no dia 1 e quick PELOD-2 no dia 1 em crianças com sepse na UTIP

Abstract Objectives: This study aimed to evaluate the predictive validity of the day-1 PELOD-2 and day-1 "quick" PELOD-2 (qPELOD-2) scores for in-hospital mortality in children with sepsis in a pediatric intensive care unit (PICU) of a developing country. Methods: The data of 516 children diagnosed as sepsis were retrospectively analyzed. The children were divided into survival group and non-survival group, according to the clinical outcome 28 days after admission. Day-1 PELOD-2, day-1 qPELOD-2, pediatric SOFA (pSOFA), and P-MODS were collected and scored. Receiver operating characteristic (ROC) curves were plotted, and the efficiency of the day-1 PELOD-2, day-1 qPELOD-2 score, pSOFA, and P-MODS for predicting death were evaluated by the area under the ROC curve (AUC). Results: The day-1 PELOD-2 score, day-1 qPELOD-2 score, pSOFA, and P-MODS in the non-survivor group were significantly higher than those in the survivor group. ROC curve analysis showed that the AUCs of the day-1 PELOD-2 score, day-1 qPELOD-2 score, pSOFA, and P-MODS for predicting the prognosis of children with sepsis in the PICU were 0.916, 0.802, 0.937, and 0.761, respectively (all p < 0.05). Conclusions: Both the day-1 PELOD-2 score and day-1 qPELOD-2 score were effective and able to assess the prognosis of children with sepsis in a PICU of a developing country. Additionally, the day-1 PELOD-2 score was superior to the day-1 qPELOD-2 score. Further studies are needed to verify the usefulness of the day-1 qPELOD-2 score, particularly outside of the PICU.

Resumo Objetivos: A finalidade de nosso estudo foi avaliar a validade preditiva dos escores PELOD-2 no dia 1 e "quick" PELOD-2 no dia 1 com relação à mortalidade hospitalar em crianças com sepse em uma UTIP de um país em desenvolvimento. Métodos: Foram analisados retrospectivamente os dados de 516 crianças diagnosticadas com sepse. As crianças foram divididas em grupo sobrevida e grupo não sobrevida de acordo com o desfecho clínico de 28 dias após internação. Foram coletadas e pontuadas as variáveis PELOD-2 no dia 1, qPELOD-2 no dia 1, pediatric Sequential Organ Failure Assessment (pSOFA) e Pediatric Multiple Organ Dysfunction Score (P-MODS). A curva da característica de operação do receptor (ROC) foi plotada e a eficiência preditiva do PELOD-2 no dia 1, o escore qPELOD-2 no dia 1, pSOFA, P-MODS com relação a óbito foram avaliados pela área abaixo da curva (AUC) da curva ROC. Resultados: O escore PELOD-2 no dia 1, escore qPELOD-2 no dia 1, pSOFA e P-MODS no grupo não sobrevida foram significativamente maiores do que os no grupo sobrevida. A análise preditiva da curva ROC mostrou que as AUCs do escore PELOD-2 no dia 1, escore qPELOD-2 no dia 1, pSOFA e P-MODS com relação ao prognóstico de crianças com sepse na UTIP foi 0,916, 0,802, 0,937 e 0,761, respectivamente (todas p < 0,05). Conclusões: Tanto o escore PELOD-2 no dia 1 e o escore qPELOD-2 no dia 1 foram válidos e conseguiram avaliar o prognóstico de crianças com sepse em uma UTIP de um país em desenvolvimento. Além disso, o escore PELOD-2 no dia 1 foi superior ao escore qPELOD-2 no dia 1. São necessários estudos adicionais para verificar a utilidade do escore qPELOD-2 no dia 1, principalmente fora da UTIP.

Assessment of PELOD-2 and PIM-3 scores of children coming from the war in Syria.

OBJECTIVES: Since the civil war in Syria began, millions of Syrians have left the country and been forced to migrate to other countries. Turkey is the country with the most refugees hosting 3.6 million refugees. This study aimed to compare the PIM-3 score, PELOD-2 score, PELOD-2 predicted death rate (PDR), mortality rates, demographic data, and outcomes of patients admitted to pediatric intensive care units between refugee children living in Turkey, pediatric patients brought directly from the border by the emergency services, and the general Turkish population. METHODS: This was a retrospective study performed between February 2018 and February 2019 at Hatay State Hospital, very close to the Syrian border. The study included 158 patients. Patients were divided into three groups: Turkish citizens, those living in Turkey as refugees, and those brought from the border. RESULTS: Of the patients, 57 were Turkish citizens, 33 were refugees, and 68 were brought from the border. For patients, the mean PIM-3 score was 25.62±27.70, the PELOD-2 score was 8.03±4.72, and PELOD2-PDR was 16.07±23.45. The median scores for PIM-3, PELOD-2, and PELOD2-PDR of patients brought from the Syrian border were higher compared with Turkish citizens and refugees. There was no significant difference between refugees and Turkish citizens. Of the patients, 27 died, with the distribution being 15% Turkish citizens, 26% refugees, and 59% brought from the border. The mortality of patients transported from the border was statistically significant (P=0.03). CONCLUSION: We consider that the source of the difference between patients brought from the border and those living in Turkey may be associated with the continuing war beyond our borders and children experiencing insufficient care conditions. In conclusion, it is not just weapons that cause death in war, and children unfortunately suffer because of this situation.

A Good Workman Never Blames His Tools: Appropriate Use of Severity of Illness Scoring Systems Determines Their Utility!

Scoring systems in intensive care units allow assessment of the severity of disease and predicting mortality. They also help in allocation of resources and benchmarking performance when compared to other units and hence to development of skills within a unit. Their use needs to go beyond just mortality prediction and unit statistics. The data collected are useful for resource allocation, unit audits, comparison with local units as well as for quality improvement programs and education. HOW TO CITE THIS ARTICLE: Udani S. A Good Workman Never Blames His Tools: Appropriate Use of Severity of Illness Scoring Systems Determines Their Utility! Indian J Crit Care Med 2020;24(8):628-629.

Day-1 PELOD-2 and day-1 "quick" PELOD-2 scores in children with sepsis in the PICU.

OBJECTIVES: This study aimed to evaluate the predictive validity of the day-1 PELOD-2 and day-1 "quick" PELOD-2 (qPELOD-2) scores for in-hospital mortality in children with sepsis in a pediatric intensive care unit (PICU) of a developing country. METHODS: The data of 516 children diagnosed as sepsis were retrospectively analyzed. The children were divided into survival group and non-survival group, according to the clinical outcome 28 days after admission. Day-1 PELOD-2, day-1 qPELOD-2, pediatric SOFA (pSOFA), and P-MODS were collected and scored. Receiver operating characteristic (ROC) curves were plotted, and the efficiency of the day-1 PELOD-2, day-1 qPELOD-2 score, pSOFA, and P-MODS for predicting death were evaluated by the area under the ROC curve (AUC). RESULTS: The day-1 PELOD-2 score, day-1 qPELOD-2 score, pSOFA, and P-MODS in the non-survivor group were significantly higher than those in the survivor group. ROC curve analysis showed that the AUCs of the day-1 PELOD-2 score, day-1 qPELOD-2 score, pSOFA, and P-MODS for predicting the prognosis of children with sepsis in the PICU were 0.916, 0.802, 0.937, and 0.761, respectively (all p < 0.05). CONCLUSIONS: Both the day-1 PELOD-2 score and day-1 qPELOD-2 score were effective and able to assess the prognosis of children with sepsis in a PICU of a developing country. Additionally, the day-1 PELOD-2 score was superior to the day-1 qPELOD-2 score. Further studies are needed to verify the usefulness of the day-1 qPELOD-2 score, particularly outside of the PICU.

Are We Aware that Hyperphosphatemia Affects Mortality and Morbidity as much as Hypophosphatemia in Pediatric Intensive Care Patients?

OBJECTIVE: Hypophosphatemia was previously shown to affect the duration of admission, mechanical ventilator requirements, mortality and morbidity during pediatric intensive care. Different from previous studies, our study was planned with the aim of showing whether hyperphosphatemia affects morbidity and mortality in pediatric intensive care patients as much as hypophosphatemia. METHOD: Patients' ages, genders, reason for admission, underlying diseases, phosphorus levels examined on admission and on the 1-4th and 5-10th-days, duration on mechanical ventilation, duration of admission, final status and PRISM and PELOD scores calculated in the first 24 hours of admission were recorded. RESULTS: Mortality was distinctly higher for those who were hypophosphatemic and hyperphosphatemic compared to those who were normophosphatemic. The highest mortality was identified in those who were hyperphosphatemic on the 5-10th-days. PELOD scores were only significantly different according to admission phosphorus levels (p:0.04). CONCLUSION: In our study, we identified that hyperphosphatemia is a serious problem as hypophosphatemia for patients who admitted to the PICU. Patients identified to be hyperphosphatemic on admission had a significantly higher PELOD score. The significant difference of hyperphosphatemia in terms of PELOD score is one of the important points shown in our study. It should not be forgotten that like hypophosphatemia, hyperphosphatemia may cause serious problems in pediatric intensive care patients.

Pediatric Logistic Organ Dysfunction-2 (Pelod-2) score as a model for predicting mortality in pediatric burn injury.

Multiple organ dysfunction syndrome (MODS) is an important cause of mortality in burn injury. Pediatric Organ Logistic Dysfunction (PELOD)-2 score as a descriptive scoring system for organ dysfunction has been highly predictive of mortality in children with suspected infection, but its usefulness for burn patients is unknown. All pediatric burn patients hospitalized in Cipto Mangunkusumo Hospital (CMH) in Jakarta, Indonesia, from January 2012 to January 2017 were studied. Gender, age, nutritional status, burn characteristics, total body surface area burned (%TBSA), depth of burn, inhalation injury, time interval to resuscitation and surgery, day one ABSI and PELOD-2 score, and mortality as outcome were recorded. Bivariate and multivariate analysis logistic regressions were done to generate a mortality prediction model. Mortality rate among subjects was 20.3%. Bivariate analysis showed that extensive %TBSA, depth of burn, presence of inhalation injury, PELOD-2 score and ABSI score in pediatric burn patients were significantly associated with mortality (p<0.001). In multivariate analysis, only PELOD-2 score was independently associated with mortality. PELOD-2 score mortality prediction rate was far lower than actual mortality. Mortality rate by the new model was close to the actual mortality rate. Our new combined model could be used to calculate probability of death based on day 1 PELOD-2 score in pediatric burn patients.

La mort après brûlure est fréquemment due à une défaillance multiviscérale. Le score PELOD 2 s'est révélé efficace dans la prédiction de mortalité de l'enfant septique mais n'a pas été évalué chez l'enfant brûlé. Tous les enfants brûlés hospitalisés dans l'hôpital Cipto Mangunkusumo de Djakarta (Indonésie) entre janvier 2012 et janvier 2017 ont été évalués. L'âge, le sexe, l'état nutritionnel, la surface brûlée, sa profondeur, l'existence d'une inhalation de fumées, les délais jusqu'à la réanimation et la chirurgie, ABSI et PELOD 2 à J1 et mortalité (20,3%) ont été colligés. Des analyse bivariée puis multivariée ont été réalisées afin de construire un modèle prédictif de mortalité. PELOD 2 comme ABSI étaient de bons prédicteurs de mortalité, les prédictions de PELOD 2 s'avérant très optimistes. Toutefois, seul PELOD 2 apparaissait comme un prédicteur indépendant de mortalité. Un modèle combinant les mortalités prédites par ABSI et PELOD 2 s'est avéré mieux corrélé à la mortalité observée. Il pourrait être utilisé chez les enfants brûlés.

Correlation of Troponin Level (Troponin T, Troponin I) With PELOD-2 Score in Sepsis as a Predictive Factor of Mortality.

BACKGROUND: Sepsis in children with cardiovascular involvement can increase mortality. Recently, many studies have been conducted to investigate troponin as an early marker of myocardial dysfunction, associated with pediatric sepsis score. Pediatric Logistic Organ Dysfunction 2 (PELOD-2) score is recent scoring to assess organ dysfunction in sepsis children. AIM: To determine the correlation between troponin T, troponin I with PELOD-2 score in sepsis as a predictive factor of mortality. METHODS: A prospective cohort study was conducted on sepsis children in PICU Haji Adam Malik General Hospital, Medan. Assessment of PELOD-2 score, serum troponin T, and troponin I levels performed on the first day and 48 hours after sepsis was diagnosed. Patients were observed until moved to the ward or died. RESULTS: A group of 41 subjects were recruited in this study. Troponin T level at 24 hours did not correlate with PELOD-2 scores. Troponin T level at 48 hours was positively correlated with PELOD-2 score (r = 0.771, p < 0.001) and had a significant association with the mortality rate (p < 0.001). Troponin T at 48 hours could be used as a predictive factor of mortality (AUC 86.4%, p < 0.001) with a cut-off point of 40.3 ng/mL (76% sensitivity, 75% specificity, RR 2.48). Troponin I levels at 24 and 48 hours also had strong correlation with PELOD-2 score (r = 0.326, p = 0.037; r = 0.691, p < 0.001) and could be used as a predictor of mortality in pediatric patients with sepsis (AUC 74.8%, p 0.008; AUC 92.6%, p < 0.001). The cut-off point of troponin I at 24 hours was 0.075 ng/mL (68% sensitivity, 68.8% specificity, RR 1.84) and at 48 hours was 0.125 ng/mL (80% sensitivity, 81.3% specificity, RR 3.13). CONCLUSION: Serum troponin T and troponin I levels at 48 hours have positive correlation with PELOD-2 score as a predictive factor of mortality in pediatric patients with sepsis.

Evaluation of BCL2 and TNFα as mRNA biomarkers for monitoring the immune response in critically ill children.

BACKGROUND: Hospital acquired infection (HAI) and multiple organ dysfunctions (MODS) remain a leading cause of death in pediatric intensive care unit (PICU) despite the great efforts to control it. OBJECTIVE: Our objective was to assess the mRNA of TNFα and BCL2 for prediction of HAI and/or MODS in our community. PATIENTS AND METHODS: Fifty children, admitted to PICU, were included in the study after exclusion of cases of end-stage renal failure, end-stage liver failure and congenital immune deficiency. Serial Blood samples were collected for complete blood count (CBC) and other routine investigations. Gene expression of (TNFα and BCL2) was quantified using quantitative real time PCR (qRT-PCR). Centers of disease control (CDC) criteria were used to detect HAI, and organ failure index (OFI). Pediatric logistic organ dysfunction (PELOD) and pediatric risk of mortality (PRISM) scores were used for follow up. The results were compared between the group who acquired HAI and who didn't. Gene expression was tested with a ROC curve to detect its ability to predict HAI. MAIN RESULTS: The overall complication (HAI and/or MODS) rate was 52%, Complicated cases had a significantly longer duration of stay in PICU (0.002) and in overall hospital stay (p = 0.013) and a higher death rate (p = 0.000). On day1; TNFα, BCL2 and lymphocytic count were lower in patients who developed complications (p = 0.02, p = 0.000 and p = 0.04, respectively), all had the ability to predict the complications with AUC (0.7, 0.8 and 0.67 respectively). On day 4: TNFα and BCL2 returned to normal levels while the lymphocytic count still lower in complicated cases, p = 0.001 and AUC = 0.73. CONCLUSIONS: TNFα and BCL2 on admission can predict HAI and MODS (AUC = 0.7 and AUC = 0.8), but were of no use in the follow-up, however, the lymphocytic count is a rapid, easy and cheap test to assess the immune state with a good predictive and follow up values.

Translating Sepsis-3 Criteria in Children: Prognostic Accuracy of Age-Adjusted Quick SOFA Score in Children Visiting the Emergency Department With Suspected Bacterial Infection.

Background: Recent attempts to translate Sepsis-3 criteria to children have been restricted to PICU patients and did not target children in emergency departments (ED). We assessed the prognostic accuracy of the age-adjusted quick Sequential Organ Failure Assessment score (qSOFA) and compared the performance to SIRS and the quick Pediatric Logistic Organ Dysfunction-2 score (qPELOD-2). We studied whether the addition of lactate (qSOFA-L) would increase prognostic accuracy. Methods: Non-academic, single-center, retrospective study in children visiting the ED and admitted with suspected bacterial infection between March 2013 and January 2018. We defined suspected bacterial infection as initiation of antibiotic therapy within 24 h after ED entry. Age-adjusted qSOFA, SIRS, qPELOD-2, and qSOFA-L scores were compared by area under the receiver operating characteristics curve (AUROC) analysis. Primary outcome measure was PICU transfer and/or mortality and secondary outcome was prolonged hospital length of stay. Results: We included 864 ED visits [474 (55%) male; median age 2.5 years; IQR 9 months-6 years], of which 18 were transferred to a PICU and 6 ended in death [composite outcome PICU transfer and/or mortality; 23 admissions (2.7%)]. 179 (22.2%) admissions resulted in prolonged hospital length of stay. PICU transfer and/or death was present in 22.5% of visits with qSOFA≥2 (n = 40) compared to 2.0% of visits with qSOFA<2 (n = 444) (p < 0.01). qSOFA tends to be the best predictor of PICU transfer and/or mortality (AUROC 0.72 (95% CI, 0.57-0.86) compared to SIRS [0.64 (95% CI, 0.53-0.74), p = 0.23] and qPELOD-2 [0.60 (95% CI, 0.45-0.76), p = 0.03)]. Prolonged hospital length of stay was poorly predicted by qSOFA (AUROC 0.53, 95% CI 0.46-0.59), SIRS (0.49, 95% CI 0.44-0.54), and qPELOD-2 (0.51, 95%CI 0.45-0.57). qSOFA-L resulted in an AUROC of 0.67 (95% CI, 0.50-0.84) for PICU transfer and/or mortality and an AUROC of 0.56 (95% CI, 0.46-0.67) for prolonged hospital length of stay. Conclusion: The currently proposed bedside risk-stratification tool of Sepsis-3 criteria, qSOFA, shows moderate prognostic accuracy for PICU transfer and/or mortality in children visiting the ED with suspected bacterial infection. The addition of lactate did not improve prognostic accuracy. Future prospective studies in larger ED populations are needed to further determine the utility of the qSOFA score.