Admission PaO2 and Mortality in Critically Ill Children: A Cohort Study and Systematic Review.

OBJECTIVE: To describe the relationship between PaO2 at intensive care admission and mortality in critically ill children and to review systematically the literature describing this relationship. DESIGN: Cohort study: A review of consecutive tertiary pediatric intensive care admissions (January 2004 to December 2014) in a single center. The relationship between admission Pao2 and crude and standardized mortality was explored using nonlinear regression. Systematic review: A search of MEDLINE (1950 to January 2015), EMBASE (1980 to January 2015), Cochrane and Database of Abstracts of Reviews of Effects databases was undertaken using the following terms: "hyperoxia," "hypoxia," "critically ill children," "pediatric intensive care," "mortality," and/or "survival." SETTING: Tertiary PICU. PATIENTS: Patients younger than 18 years of age. INTERVENTIONS: The association of hyperoxia (PaO2, > 300 torr [40 kPa]) and hypoxia (PaO2, < 60 torr [8 kPa] or peripheral oxygen saturations, < 90%) to mortality in critically ill children was explored. MEASUREMENTS AND MAIN RESULTS: Cohort study: Of 14,321 admissions, 7,410 children had recorded PaO2 and FIO2 at admission. Crude mortality was 7.4% (555/7,410). This varied with admission PaO2 from 15.4% (204/1,324) in the hypoxia group (< 8 kPa) to 5.3% (287/5,385) with normoxia and 9.1% (64/701) in the hyperoxic group (> 40 kPa). Nonlinear regression displayed a "U-shaped" relationship between PaO2 and crude and case-mix adjusted mortality. Systematic review: Fourteen studies and one conference abstract were eligible for inclusion. Eleven studies (n = 5,280) relate to hypoxia with combined odds ratio for death, of 3.13 (95% CI, 1.79-5.48; p < 0.001) compared to normoxia. Six studies (n = 2,012) relate to hyperoxia and suggest no effect on mortality compared to normoxia (odds ratio, 1.15; 95% CI, 0.42-3.17; p = 0.77). CONCLUSIONS: Hypoxia at admission is associated with increased mortality in critically ill children, whereas the association with hyperoxia is less clear. The cohort study demonstrated a U-shaped association between admission PaO2 and mortality. Further examination is needed to explore the effect of hyperoxia upon mortality prediction accuracy.

Weight-for-age distribution and case-mix adjusted outcomes of 14,307 paediatric intensive care admissions.

AIMS: To determine whether the paediatric intensive care (PIC) population weight distribution differs from the UK reference population and whether weight-for-age at admission is an independent risk factor for mortality. METHODS: Admission weight-for-age standard deviation scores (SDS) were calculated for all PIC admissions (March 2003-December 2011) to Great Ormond Street Hospital: this is the number of standard deviations (SD) between a child's weight and the UK mean weight-for-age. Categorised into nine SDS groups, standardised mortality ratios (SMR) and logistic regression were used to assess the relationship between weight-for-age at admission and risk-adjusted mortality. RESULTS: Out of 12,458 admissions, mean weight-for-age was 1.04 SD below the UK reference population mean (p < 0.0001). Based on 942 deaths, risk-adjusted mortality was lowest in those with mild-to-moderately raised weight-for-age (SDS 0.5-2.5) and highest in children with extreme under- or overweight (SDS < -3.5 and SDS > +3.5). Logistic regression indicated that age, gender, ethnicity and weight-for-age are independent risk factors for mortality. South Asian and 'other' ethnicities had significantly increased risk of death compared to children of white and black ethnic origin. CONCLUSION: The PIC population mean weight-for-age is significantly lower than the UK reference mean. The extremes of weight-for-age are over-represented, especially underweight. Weight-for-age at admission is an independent risk factor for mortality. A U-shaped association between weight and risk-adjusted mortality exists, with the lowest risk of death in children who are mild-to-moderately overweight. Future studies should determine the impact of malnutrition on risk-adjusted mortality and investigate the aetiology of risk disparities with ethnicity.

Paediatric unplanned reattendance rate: A&E clinical quality indicators.

The new accident and emergency (A&E) unplanned reattendance rate clinical quality indicator is intended to drive reduction of avoidable reattendances. Validation data for reattendance rates in children are awaited. The aim of this three site observational study is to establish the rate and reasons for unplanned reattendance to UK paediatric A&Es. Each centre undertook retrospective case note review of children attending at least twice within 7 days. Unplanned reattendance rates at the three centres were 5.1%, 5.2% and 4.4%. Reducing unnecessary unplanned reattendances is beneficial for patients, service capacity and efficacy. This study has identified two groups for targeting reattendance reduction: parents of children returning with the same diagnosis, severity unchanged and parents who bypass primary care resources. Clear communication and early involvement of experienced clinicians are paramount. This study has indicated that a 1%-5% unplanned reattendance rate is realistic, achievable and can drive improvement in children's services.