Impact of puberty as threshold to differentiate outcome of out-of-hospital cardiac arrest care groups: a nationwide observational study in France.

BACKGROUND: Since 2005, the international guidelines for out-of-hospital cardiac arrest (OHCA) use puberty to differentiate paediatric and adult care. This threshold is mainly relied on the more frequent respiratory aetiologies in children. Hitherto, to the best of our knowledge, no study has compared the characteristics and outcomes of non-pubescent children, adolescents and adult patients with OHCA. In this study, we intended to describe the characteristics, outcome and factors associated with survival of patients who experienced OHCA in the three groups: children, adolescents (pubescent<18 years) and adults (<65 years), to assess the pertinence of the guidelines. METHODS: Data from the French national cardiac arrest registry (2012-2017) were used in this nationwide observational study. Victims of OHCA who were <65 years old were included. The characteristics and outcomes of children and adolescents, and adolescents and adults were compared. Logistic regression was performed in each group to identify factors associated with survival at day 30. RESULTS: We included 934 children, 433 adolescents and 26 952 adults. Respiratory aetiology was more frequent and shockable rhythm less frequent in children compared with adolescents (25.5% vs 17.2%, p=0.025 and 2.4% vs 6.8%, p<0.001, respectively). However, these differences were not observed between adolescents and adults (17.2% vs 14.1%, p=0.266 and 6.8% vs 10%, p=0.055, respectively). Between children and adolescents, and adolescents and adults, there was no significant difference in survival at day 30 (8.6%vs 9.8% and 9.8% vs 8.5%, respectively). For all groups, shockable initial rhythm was a factor of survival. CONCLUSION: Frequency of respiratory aetiologies and shockable rhythm were common in adolescents and adults and different between children and adolescents. These results indicate that puberty as a threshold in international guidelines seems to be relevant.

Can the Pediatric Logistic Organ Dysfunction-2 Score on Day 1 Be Used in Clinical Criteria for Sepsis in Children?

OBJECTIVE: A recent task force has proposed the use of Sequential Organ Failure Assessment in clinical criteria for sepsis in adults. We sought to evaluate the predictive validity for PICU mortality of the Pediatric Logistic Organ Dysfunction-2 and of the "quick" Pediatric Logistic Organ Dysfunction-2 scores on day 1 in children with suspected infection. DESIGN: Secondary analysis of the database used for the development and validation of the Pediatric Logistic Organ Dysfunction-2. SETTINGS: Nine university-affiliated PICUs in Europe. PATIENTS: Only children with hypotension-low systolic blood pressure or low mean blood pressure using age-adapted cutoffs-and lactatemia greater than 2 mmol/L were considered in shock. MEASUREMENTS AND MAIN RESULTS: We developed the quick Pediatric Logistic Organ Dysfunction-2 score on day 1 including tachycardia, hypotension, and altered mentation (Glasgow < 11): one point for each variable (range, 0-3). Outcome was mortality at PICU discharge. Discrimination (Area under receiver operating characteristic curve-95% CI) and calibration (goodness of fit test) of the scores were studied. This study included 862 children with suspected infection (median age: 12.3 mo; mortality: n = 60 [7.0%]). Area under the curve of the Pediatric Logistic Organ Dysfunction-2 score on day 1 was 0.91 (0.86-0.96) in children with suspected infection, 0.88 (0.79-0.96) in those with low systolic blood pressure and hyperlactatemia, and 0.91 (0.85-0.97) in those with low mean blood pressure and hyperlactatemia; calibration p value was 0.03, 0.36, and 0.49, respectively. A Pediatric Logistic Organ Dysfunction-2 score on day 1 greater than or equal to 8 reflected an overall risk of mortality greater than or equal to 9.3% in children with suspected infection. Area under the curve of the quick Pediatric Logistic Organ Dysfunction-2 score on day 1 was 0.82 (0.76-0.87) with systolic blood pressure or mean blood pressure; calibration p value was 0.89 and 0.72, respectively. A score greater than or equal to 2 reflected a mortality risk greater than or equal to 19.8% with systolic blood pressure and greater than or equal to 15.9% with mean blood pressure. CONCLUSION: Among children admitted to PICU with suspected infection, Pediatric Logistic Organ Dysfunction-2 score on day 1 was highly predictive of PICU mortality suggesting its use to standardize definitions and diagnostic criteria of pediatric sepsis. Further studies are needed to determine the usefulness of the quick Pediatric Logistic Organ Dysfunction-2 score on day 1 outside of the PICU.

Daily estimation of the severity of organ dysfunctions in critically ill children by using the PELOD-2 score.

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Invasive pneumococcal disease in children can reveal a primary immunodeficiency.

BACKGROUND: About 10% of pediatric patients with invasive pneumococcal disease (IPD) die from the disease. Some primary immunodeficiencies (PIDs) are known to confer predisposition to IPD. However, a systematic search for these PIDs has never been carried out in children presenting with IPD. METHODS: We prospectively identified pediatric cases of IPD requiring hospitalization between 2005 and 2011 in 28 pediatric wards throughout France. IPD was defined as a positive pneumococcal culture, polymerase chain reaction result, and/or soluble antigen detection at a normally sterile site. The immunological assessment included abdominal ultrasound, whole-blood counts and smears, determinations of plasma immunoglobulin and complement levels, and the evaluation of proinflammatory cytokines. RESULTS: We included 163 children with IPD (male-to-female ratio, 1.3; median age, 13 months). Seventeen children had recurrent IPD. Meningitis was the most frequent type of infection (87%); other infections included pleuropneumonitis, isolated bloodstream infection, osteomyelitis, endocarditis, and mastoiditis. One patient with recurrent meningitis had a congenital cerebrospinal fluid fistula. The results of immunological explorations were abnormal in 26 children (16%), and a PID was identified in 17 patients (10%), including 1 case of MyD88 deficiency, 3 of complement fraction C2 or C3 deficiencies, 1 of isolated congenital asplenia, and 2 of Bruton disease (X-linked agammaglobulinemia). The proportion of PIDs was much higher in children aged >2 years than in younger children (26% vs 3%; P < .001). CONCLUSIONS: Children with IPD should undergo immunological investigations, particularly those aged >2 years, as PIDs may be discovered in up to 26% of cases.

Nonrespiratory pediatric logistic organ dysfunction-2 score is a good predictor of mortality in children with acute respiratory failure.

OBJECTIVE: Multiple organ dysfunction, not respiratory failure, is the major cause of death in children with acute lung injury or acute respiratory distress syndrome. This study was undertaken to estimate the predictive value of death of the nonrespiratory Pediatric Logistic Organ Dysfunction-2 in children with acute respiratory failure. DESIGN: Analysis of the database of the recently published Pediatric Logistic Organ Dysfunction-2. SETTING: Nine multidisciplinary, tertiary-care PICU of university-affiliated hospitals in France and Belgium. PATIENTS: All consecutive children (excluding neonates) admitted to these PICUs (June 2006 to October 2007) and having acute respiratory failure. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We prospectively 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 in the Pediatric Logistic Organ Dysfunction-2 score, the most abnormal value observed during time points was collected. Outcome was vital status at PICU discharge. We used areas under receiver operating characteristic curve to estimate the discrimination and Hosmer-Lemeshow goodness-of-fit tests to estimate calibration of the Pediatric Logistic Organ Dysfunction-2 and the nonrespiratory Pediatric Logistic Organ Dysfunction-2 scores, with correction for the optimism bias using a bootstrap resampling method. We included 1,572 consecutive patients (median age, 20.6 months; interquartile range, 5.5-80.2; mortality rate, 9.5%). Discrimination of the Pediatric Logistic Organ Dysfunction-2 and the nonrespiratory Pediatric Logistic Organ Dysfunction-2 were excellent (areas under receiver operating characteristic curve = 0.93 and 0.92, respectively) and calibration (chi-square test for goodness-of-fit = 5.8, p = 0.45 and 7.6, p = 0.27, respectively) was good. The four nonrespiratory organ dysfunctions were closely related to the risk of mortality (p< 0.001). CONCLUSION: Our study demonstrates that the nonrespiratory Pediatric Logistic Organ Dysfunction-2 score of the entire PICU stay is highly predictive of death in children with acute respiratory failure of whom 94.3% were invasively ventilated. The nonrespiratory Pediatric Logistic Organ Dysfunction-2 score could represent the nonrespiratory organ failure definition tool whose development was recommended in the international expert recommendations on pediatric acute respiratory distress syndrome.

PELOD-2: an update of the PEdiatric logistic organ dysfunction score.

OBJECTIVE: 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. DESIGN: Prospective multicenter cohort study. SETTING: Nine multidisciplinary, tertiary-care PICUs of university-affiliated hospitals in France and Belgium. PATIENTS: All consecutive children admitted to these PICUs (June 2006-October 2007). INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: 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. CONCLUSION: 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.

Prognostic value of shock index in children with septic shock.

OBJECTIVES: Septic shock is frequent in children and is associated with high mortality and morbidity rates. Early recognition of severe sepsis improve outcome. Shock index (SI), ratio of heart rate (HR) and systolic blood pressure (SBP), may be a good noninvasive measure of hemodynamic instability that has been poorly studied in children. The aim of the study was to explore the usefulness of SI as an early index of prognosis for septic shock in children. METHODS: The study was retrospective and performed in 1 pediatric intensive care unit at a university hospital. The following specific data were collected at 0, 1, 2, 4, and 6 hours after admission: HR and SBP for SI calculation and lactate concentration. Patients were divided into 2 groups according to their outcome (death/survival). RESULTS: A total of 146 children admitted with septic shock between January 2000 and April 2010 were included. Shock index was significantly different between survivors and nonsurvivors at 0, 4, and 6 hours after admission (P = 0.02, P = 0.03, and P = 0.008, respectively). Age-adjusted SIs were different between survivors and nonsurvivors at 0 and 6 hours, with a relative risk of death at these time points of 1.85 (1.04-3.26) (P = 0.03) and 2.17 (1.18-3.96) (P = 0.01), respectively. Moreover, an abnormal SI both at admission and at 6 hours was predictive of death with relative risk of 1.36 (1.05-1.76). CONCLUSIONS: In our population of children with septic shock, SI was a clinically relevant and easily calculated predictor of mortality. It could be a better measure of hemodynamic status than HR and SBP alone, allowing for the early recognition of severe sepsis.

Patient Characteristics and Severity Trajectories in a Pediatric Intermediate Care Unit.

OBJECTIVES: To describe the characteristics of patients admitted to Pediatric Intermediate Care Units (PImCU) and to assess their illness severity trajectories. METHODS: This prospective, observational, multicentre cohort study was conducted in seven French PImCUs between September 2012 and January 2014. All consecutive patients aged under 18 were included. The severity of illness was evaluated through the Paediatric Advanced Warning Score (PAWS), measured every 8 h for each patient. A latent class mixed model was used to identify severity trajectory classes. RESULTS: A total of 2868 patients were included. The median [interquartile range] age was 29 [5-103] mo and the median length of stay was 1 [1-3] d. The primary indication for admission was respiratory (44%). Almost 3% of the patients were subsequently transferred to a pediatric intensive care unit. Three severity trajectory classes were identified. In one class, comprising the largest proportion of patients, the PAWS was low on admission and did not change markedly over time. In this class, patients were older and had a shorter length of stay. The other two classes were characterized by a higher PAWS on admission and rapid or slow improvement. These patients were more severely ill, mostly due to respiratory failure. CONCLUSIONS: A large proportion of patients had a stable profile and no signs of severity which suggests that the stay in PImCU was not indicated but a part of these patients have remained stable perhaps because of the advanced monitoring and intensive nursing in these units. CLINICAL TRIAL REGISTRATION: The study was registered with ClinicalTrials.gov Protocol, Identifier: NCT02304341, ClinicalTrials.gov .

Refining the Pediatric Multiple Organ Dysfunction Syndrome.

Since its introduction into the medical literature in the 1970s, the term multiple organ dysfunction syndrome (or some variant) has been applied broadly to any patient with >1 concurrent organ dysfunction. However, the epidemiology, mechanisms, time course, and outcomes among children with multiple organ dysfunction vary substantially. We posit that the term pediatric multiple organ dysfunction syndrome (or MODS) should be reserved for patients with a systemic pathologic state resulting from a common mechanism (or mechanisms) that affects numerous organ systems simultaneously. In contrast, children in whom organ injuries are attributable to distinct mechanisms should be considered to have additive organ system dysfunctions but not the syndrome of MODS. Although such differentiation may not always be possible with current scientific knowledge, we make the case for how attempts to differentiate multiple organ dysfunction from other states of additive organ dysfunctions can help to evolve clinical and research priorities in diagnosis, monitoring, and therapy from largely organ-specific to more holistic strategies.

Scoring Systems for Organ Dysfunction and Multiple Organ Dysfunction: The PODIUM Consensus Conference.

CONTEXT: Multiple scores exist to characterize organ dysfunction in children. OBJECTIVE: To review the literature on multiple organ dysfunction (MOD) scoring systems to estimate severity of illness and to characterize the performance characteristics of currently used scoring tools and clinical assessments for organ dysfunction in critically ill children. DATA SOURCES: Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020. STUDY SELECTION: Studies were included if they evaluated critically ill children with MOD, evaluated the performance characteristics of scoring tools for MOD, and assessed outcomes related to mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. DATA EXTRACTION: Data were abstracted into a standard data extraction form by a task force member. RESULTS: Of 1152 unique abstracts screened, 156 full text studies were assessed including a total of 54 eligible studies. The most commonly reported scores were the Pediatric Logistic Organ Dysfunction Score (PELOD), pediatric Sequential Organ Failure Assessment score (pSOFA), Pediatric Index of Mortality (PIM), PRISM, and counts of organ dysfunction using the International Pediatric Sepsis Definition Consensus Conference. Cut-offs for specific organ dysfunction criteria, diagnostic elements included, and use of counts versus weighting varied substantially. LIMITATIONS: While scores demonstrated an increase in mortality associated with the severity and number of organ dysfunctions, the performance ranged widely. CONCLUSIONS: The multitude of scores on organ dysfunction to assess severity of illness indicates a need for unified and data-driven organ dysfunction criteria, derived and validated in large, heterogenous international databases of critically ill children.

Whole pulmonary assessment 1 year after paediatric acute respiratory distress syndrome: prospective multicentre study.

BACKGROUND: Long-term pulmonary sequelae, including 1-year thoracic computed tomography (CT) sequelae of paediatric acute respiratory distress syndrome (ARDS) remain unknown. The purpose of the study was to determine pulmonary abnormalities in child survivors of pulmonary (p-ARDS) and extra-pulmonary ARDS (ep-ARDS) 1 year after paediatric intensive care unit discharge (PICUD). METHODS: Prospective multicentre study in four paediatric academic centres between 2005 and 2014. Patients with ARDS were assessed 1 year after PICUD with respiratory symptom questionnaire, thoracic CT and pulmonary function tests (PFT). RESULTS: 39 patients (31 p-ARDS) aged 1.1-16.2 years were assessed. Respiratory symptoms at rest or exercise and/or respiratory maintenance treatment were reported in 23 (74%) of children with p-ARDS but in 1 (13%) of those with ep-ARDS. Thoracic CT abnormalities were observed in 18 (60%) of children with p-ARDS and 4 (50%) of those with ep-ARDS. Diffuse and more important CT abnormalities, such as ground glass opacities or mosaic perfusion patterns, were observed in 5 (13%) of children, all with p-ARDS. PFT abnormalities were observed in 30 (86%) of patients: lung hyperinflation and/or obstructive pattern in 12 (34%) children, restrictive abnormalities in 6 (50%), mild decrease in diffusing capacity in 2 (38%) and 6-min walking distance decrease in 11 (73%). Important PFT abnormalities were observed in 7 (20%) children, all with p-ARDS. Increasing driving pressure (max plateau pressure-max positive end-expiratory pressure) was correlated with increasing CT-scan abnormalities and increasing functional residual capacity (more hyperinflation) (p < 0.005). CONCLUSIONS: Children surviving ARDS requiring mechanical ventilation present frequent respiratory symptoms, significant CT-scan and PFT abnormalities 1 year after PICUD. This highlights the need for a systematic pulmonary assessment of these children. Trial registration The study was registered on Clinical Trials.gov PRS (ID NCT01435889).

Pediatric Organ Dysfunction Information Update Mandate (PODIUM) Contemporary Organ Dysfunction Criteria: Executive Summary.

Prior criteria for organ dysfunction in critically ill children were based mainly on expert opinion. We convened the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) expert panel to summarize data characterizing single and multiple organ dysfunction and to derive contemporary criteria for pediatric organ dysfunction. The panel was composed of 88 members representing 47 institutions and 7 countries. We conducted systematic reviews of the literature to derive evidence-based criteria for single organ dysfunction for neurologic, cardiovascular, respiratory, gastrointestinal, acute liver, renal, hematologic, coagulation, endocrine, endothelial, and immune system dysfunction. We searched PubMed and Embase from January 1992 to January 2020. Study identification was accomplished using a combination of medical subject headings terms and keywords related to concepts of pediatric organ dysfunction. Electronic searches were performed by medical librarians. Studies were eligible for inclusion if the authors reported original data collected in critically ill children; evaluated performance characteristics of scoring tools or clinical assessments for organ dysfunction; and assessed a patient-centered, clinically meaningful outcome. Data were abstracted from each included study into an electronic data extraction form. Risk of bias was assessed using the Quality in Prognosis Studies tool. Consensus was achieved for a final set of 43 criteria for pediatric organ dysfunction through iterative voting and discussion. Although the PODIUM criteria for organ dysfunction were limited by available evidence and will require validation, they provide a contemporary foundation for researchers to identify and study single and multiple organ dysfunction in critically ill children.

Assessment of the Pediatric Index of Mortality 2 with the Pao2/Fio2 ratio derived from the Spo2/Fio2 ratio: a prospective pilot study in a French pediatric intensive care unit.

OBJECTIVE: The Pediatric Index of Mortality 2 is a mortality prediction tool used in pediatric intensive care units. Arterial blood gas sampling that is required to calculate the Pao2/Fio2 ratio is often unavailable. Several authors have proposed mathematical relations between the Pao2/Fio2 and Spo2/Fio2 ratios. The main objective of this study was to assess the validity of the Pediatric Index of Mortality 2 score and three modified Pediatric Index of Mortality 2 scores with the Pao2/Fio2 ratio calculated from the Spo2/Fio2 ratio. DESIGN: Prospective observational study of consecutive patients admitted during a 23-month period. SETTING: A multidisciplinary French pediatric intensive care unit. PATIENTS: One thousand forty-three patients, 80 of whom died (7.7%). INTERVENTIONS: None. MEASUREMENTS AND MAINS RESULTS: Only 15 of 1043 patients had a Pao2 measurement. Spo2/Fio2 ratio was determined for 338 patients (33%) for whom Fio2 was known and Spo2 was ≤ 97%. However, for mathematical reasons, Pao2/FIo2 ratio could be calculated from the three Spo2/Fio2 equations for 328 (31%), 295 (28%), and 100 (10%) patients, respectively. Discrimination assessed by the area under the receiver operating characteristic curve was 0.86 for Pediatric Index of Mortality 2 and the modified scores. Calibration assessed by the Hosmer-Lemeshow goodness-of-fit test was poor for Pediatric Index of Mortality 2 (p = .04) and one modified score (p = .03) and good for two other modified scores (p = .06, p = .09). CONCLUSION: This study suggests that the Spo2/Fio2 ratio could be used in place of Pao2/Fio2 for calculating Pediatric Index of Mortality 2. This must nonetheless be confirmed by a larger prospective multicenter study.

Daily estimation of the severity of multiple organ dysfunction syndrome in critically ill children.

BACKGROUND: Daily evaluation of multiple organ dysfunction syndrome has been performed in critically ill adults. We evaluated the clinical course of multiple organ dysfunction over time in critically ill children using the Pediatric Logistic Organ Dysfunction (PELOD) score and determined the optimal days for measuring scores. METHODS: We prospectively measured daily PELOD scores and calculated the change in scores over time for 1806 consecutive patients admitted to seven pediatric intensive care units (PICUs) between September 1998 and February 2000. To study the relationship between daily scores and mortality in the PICU, we evaluated changes in daily scores during the first four days; the mean rate of change in scores during the entire PICU stay between survivors and nonsurvivors; and Cox survival analyses using a change in PELOD score as a time-dependent covariate to determine the optimal days for measuring daily scores. RESULTS: The overall mortality among the 1806 patients was 6.4%. A high PELOD score (>or=20 points) on day 1 was associated with an odds ratio (OR) for death of 40.7 (95% confidence interval [CI] 20.3-81.4); a medium score (10-19 points) on day 1 was associated with an OR for death of 4.2 (95% CI 2.0-8.7). Mortality was 50% when a high score on day 1 increased on day 2. The course of daily PELOD scores differed between survivors and nonsurvivors. A set of seven days (days 1, 2, 5, 8, 12, 16 and 18) was identified as the optimal period for measurement of daily PELOD scores. INTERPRETATION: PELOD scores indicating a worsening condition or no improvement over time were indicators of a poor prognosis in the PICU. A set of seven days for measurement of the PELOD score during the PICU stay provided optimal information on the progression of multiple-organ dysfunction syndrome in critically ill children.

Differences in organ dysfunctions between neonates and older children: a prospective, observational, multicenter study.

INTRODUCTION: The multiple organ dysfunction syndrome (MODS) is a major cause of death for patients admitted to pediatric intensive care units (PICU). The Pediatric Logistic Organ Dysfunction (PELOD) score has been validated in order to describe and quantify the severity of organ dysfunction (OD). There are several physiological differences between neonates and older children. The objective of the study was to determine whether there are differences in incidence of ODs and mortality rate between full-term neonates (age <28 days) and older children. METHODS: In a prospective, observational study, 1806 patients, admitted to seven PICUs between September 1998 and February 2000 were included. The PELOD score, which includes six organ dysfunctions and 12 variables, was recorded daily. For each variable, the most abnormal value was used to define the daily OD. For each OD, the most abnormal value each day and that during the entire stay were used in calculating the daily PELOD and PELOD scores, respectively. The relationships between OD, daily OD, PELOD, daily PELOD and mortality were compared between the two strata (neonates, older children) based on the discrimination power, logistic and multiple regression analyses. RESULTS: Of the 1806 enrolled patients 171 (9.5%) were neonates. Incidence of MODS and mortality rate were higher among neonates than in older children (14.6% vs. 5.5%, P < 10(-7); 75.4%, vs. 50.9%, P < 10(-4); respectively). Daily PELOD scores were significantly higher in neonates from day 1 to day 4. Daily cardiovascular, respiratory and renal dysfunction scores from day 1 to day 4 as well as the PELOD score for the entire pediatric intensive care unit stay were also significantly higher in neonates. Neurological, cardiovascular, and hepatic dysfunctions were independent predictors of death among neonates while all ODs significantly contributed to the risk of mortality in older children. CONCLUSIONS: Our data demonstrate that incidence of MODS and mortality rate are higher among neonates compared to older children. Neurological, cardiovascular, and hepatic dysfunctions were the only significant contributors to neonatal mortality. Stratification for neonates versus older children might be useful in clinical trials where MODS is considered as an outcome measure.

Acute lung injury in children: therapeutic practice and feasibility of international clinical trials.

OBJECTIVES: To describe mechanical ventilation strategies in acute lung injury and to estimate the number of eligible patients for clinical trials on mechanical ventilation management. In contrast to adult medicine, there are few clinical trials to guide mechanical ventilation management in children with acute lung injury. DESIGN: A cross-sectional study for six 24-hr periods from June to November 2007. SETTING: Fifty-nine pediatric intensive care units in 12 countries in North America and Europe. PATIENTS: We identified children meeting acute lung injury criteria and collected detailed information on illness severity, mechanical ventilatory support, and use of adjunctive therapies. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 3823 patients screened, 414 (10.8%) were diagnosed with acute lung injury by their treating physician, but only 165 (4.3%) patients met prestablished inclusion/exclusion criteria to this trial and, therefore, would have been eligible for a clinical trial. Of these, 124 (75.2%) received conventional mechanical ventilation, 27 (16.4%) received high-frequency oscillatory ventilation, and 14 (8.5%) received noninvasive mechanical ventilation. In the conventional mechanical ventilation group, 43.5% were ventilated in a pressure control mode with a mean tidal volume of 8.3 ± 3.3 mL/kg; and there was no clear relationship between positive end-expiratory pressure and Fio2 delivery in the conventional mechanical ventilation group. Use of adjunctive treatments, including nitric oxide, prone positioning, surfactant, hemofiltration, recruitment maneuvers, steroids, bronchodilators, and fluid restriction, was highly variable. CONCLUSIONS: Our study reveals inconsistent mechanical ventilation practice and use of adjunctive therapies in children with acute lung injury. Pediatric clinical trials assessing mechanical ventilation management are needed to generate evidence to optimize outcomes. We estimate that a large number of centers (∼60) are needed to conduct such trials; it is imperative, therefore, to bring about international collaboration.

Use of paediatric early warning scores in intermediate care units.

OBJECTIVE: Paediatric early warning scores (EWS) were developed to detect deterioration in paediatric wards or emergency departments. The aim of this study was to assess the relationship between three paediatric EWS and clinical deterioration detected by the nurse in paediatric intermediate care units (PImCU). METHODS: This was a prospective, observational, multicentre study at seven French regional hospitals that included all children <18 years of age. Clinical parameters included in three EWS (Paediatric Advanced Warning Score, Paediatric Early Warning Score and Bedside Paediatric Early Warning System) were prospectively recorded every 8 hours or in case of deterioration. The outcome was a call to physician by the nurse when a clinical deterioration was observed. The cohort was divided into derivation and validation cohorts. An updated methodology for repeated measures was used and discrimination was estimated by the area under the receiver-operating curve. RESULTS: A total of 2636 children were included for 14 708 observations to compute a posteriori the EWS. The discrimination of the three EWS for predicting calls to physicians by nurses was good (range: 0.87-0.91) for the derivation cohort and moderate (range: 0.71-0.76) for the validation cohort. Equations for probability thresholds of calls to physicians, taking into account the time t, the score at time t and the score at admission, are available. CONCLUSION: These three EWS developed for children in paediatric wards or emergency departments can be used in PImCU to detect a clinical deterioration and predict the need for medical intervention.

Children with chronic conditions in pediatric intensive care units located in predominantly French-speaking regions: Prevalence and implications on rehabilitation care need and utilization.

OBJECTIVE: To estimate the prevalence of chronic conditions and/or disability in intensive care units admitting children (Pediatric Intensive Care Unit [PICU]) or both neonates and children (Neonatal and Pediatric Intensive Care Unit [NPICU]) and to describe available rehabilitation resources. DESIGN: A cross-sectional study on two separate days, using a web questionnaire. SETTING: NPICU/PICUs affiliated to the Groupe Francophone de Réanimation et Urgences Pédiatriques and the Réseau Mère-Enfant de la Francophonie. PATIENTS: Children >1 month of gestationally corrected age. MEASUREMENTS AND MAIN RESULTS: Disability was defined as a Pediatric Overall Performance Category >or=3 before admission and chronic conditions as hospitalization since birth or the presence before admission of any condition requiring ongoing pediatric subspecialty care that was expected to last >or=12 months. Intensivists indicated what rehabilitation services they would have ideally prescribed ("perceived needs") and those provided. Of 45 affiliated units, 8 PICUs and 15 NPICUs participated. Staff included or had access to a psychologist (11 and 5, respectively), a social worker (10 and 3), a physiotherapist (11 and 12), a "psychomotrician" (2 and 8), a child educator (1 and 6), and a speech-language pathologist (0 and 6). Among 289 recorded intensive care unit-days, 236 were analyzed (excluding those for children admitted after surgery): 57 concerned children hospitalized since birth and 179 children admitted from home. Among these 179 recorded intensive care unit-days, 107 concerned children with chronic conditions (including 50 concerning disabled children) and 72 previously healthy children. Thus, prevalence of chronic conditions, including children hospitalized since birth, was 67%. Rehabilitation services included respiratory physical therapy (552 visits), musculoskeletal physical therapy (71), neurologic physical therapy (37), rehabilitation for swallowing (11), and for speech-language disorders (1), representing 79% of perceived needs. CONCLUSIONS: Prevalence of chronic conditions in NPICU/PICU was 67%. More attention must be paid to the rehabilitation care needs of patients during their NPICU/PICU stay and after discharge.

The pediatric multiple organ dysfunction syndrome.

OBJECTIVES: To review the epidemiology of pediatric multiple organ dysfunction syndrome (MODS) and summarize current concepts regarding the pathophysiology of shock, organ dysfunction, and nosocomial infections in this population. DATA SOURCE: A MEDLINE-based literature search using the keywords MODS and child, without any restriction to the idiom. MAIN RESULTS: Critically ill children may frequently develop multisystemic manifestations during the course of severe infections, multiple trauma, surgery for congenital heart defects, or transplantations. Descriptive scores to estimate the severity of pediatric MODS have been validated. Young age and chronic health conditions have also been recognized as important contributors to the development of MODS. Unbalanced inflammatory processes and activation of coagulation may lead to the development of capillary leak and acute respiratory distress syndrome. Neuroendocrine and metabolic responses may result in insufficient adaptive immune response and the development of nosocomial infections, which may further threaten host homeostasis. CONCLUSIONS: Over the last 20 yrs, there has been an increasing knowledge on the epidemiology of pediatric MODS and on the physiologic mechanisms involved in the genesis of organ dysfunction. Nevertheless, further studies are needed to more clearly evaluate what is the long-term outcome of pediatric MODS.

Effects of inertance on respiratory mechanics measurements in mechanically ventilated children.

OBJECTIVE: The use of the first-order linear single compartment model when studying respiratory mechanics classically neglects inertance (Irs). We hypothesized that Irs would affect compliance (Crs) and resistance (Rrs) estimates in mechanically ventilated young children. DESIGN: Prospective study; single-center evaluation. SETTING: University-affiliated tertiary pediatric intensive care unit. PATIENTS: Forty-four patients with and without respiratory disease. INTERVENTIONS: Patients were studied during volume-controlled constant inspiratory flow ventilation. MEASUREMENTS AND MAIN RESULTS: Pressure (PaO) and flow (V') were analyzed according to two different models: a one-compartment first-order linear model according to PaO = (1/Crs) x V + Rrs x V' and a one-compartment second-order linear model according to PaO = (1/Crs) x V + Rrs x V' + Irs x V''. Irs was higher in children with vs. those without respiratory disease (median 0.00224 cm H2O/L/sec2, Q1-Q3 0.00180-0.00321 vs. median 0.00133 cm H2O/L/sec2, Q1-Q3 0.00072-0.00210; p < .001)). A positive correlation between Irs and the difference of Crs estimates between the first- and the second-order model was found in both groups (r = .84, p < .05 and r = .67, p < .05). Rrs estimates were similar in both groups. CONCLUSIONS: This study showed that the linear single-compartment model may not adequately estimate the respiratory mechanical properties in mechanically ventilated children, particularly in the presence of respiratory disease. Including an Irs term significantly diminished Crs estimates. A one-compartment second-order linear model might be a useful clinical tool in more adequately measuring respiratory mechanics and optimizing ventilatory settings in children with respiratory disease.