Development and Validation of the Neonatal Risk Estimate Score for Children Using Extracorporeal Respiratory Support.

OBJECTIVE: To develop and validate the Neonatal Risk Estimate Score for Children Using Extracorporeal Respiratory Support, which estimates the risk of in-hospital death for neonates prior to receiving respiratory extracorporeal membrane oxygenation (ECMO) support. STUDY DESIGN: We used an international ECMO registry (2008-2013); neonates receiving ECMO for respiratory support were included. We divided the registry into a derivation sample and internal validation sample, by calendar date. We chose candidate variables a priori based on published evidence of association with mortality; variables independently associated with mortality in logistic regression were included in this parsimonious model of risk adjustment. We evaluated model discrimination with the area under the receiver operating characteristic curve (AUC), and we evaluated calibration with the Hosmer-Lemeshow goodness-of-fit test. RESULTS: During 2008-2013, 4592 neonates received ECMO respiratory support with mortality of 31%. The development dataset contained 3139 patients treated in 2008-2011. The Neo-RESCUERS measure had an AUC of 0.78 (95% CI 0.76-0.79). The validation cohort had an AUC = 0.77 (0.75-0.80). Patients in the lowest risk decile had an observed mortality of 7.0% and a predicted mortality of 4.4%, and those in the highest risk decile had an observed mortality of 65.6% and a predicted mortality of 67.5%. CONCLUSIONS: Neonatal Risk Estimate Score for Children Using Extracorporeal Respiratory Support offers severity-of-illness adjustment for neonatal patients with respiratory failure receiving ECMO. This score may be used to adjust patient survival to assess hospital-level performance in ECMO-based care.

A normal capillary refill time of ≤ 2 seconds is associated with superior vena cava oxygen saturations of ≥ 70%.

OBJECTIVE: To test the hypothesis that a normal capillary refill time (CRT) ≤ 2 seconds is associated with superior vena cava oxygen saturation (ScvO2) ≥ 70% in critically ill children. STUDY DESIGN: Two-year, prospective study in a tertiary-level pediatric intensive care unit. Whenever ScvO2 measurements were obtained, central (forehead/sternum) and peripheral (finger/toe) CRTs were concomitantly assessed. RESULTS: Central and peripheral CRTs ≤ 2 seconds were both associated with ScvO2 ≥ 70% (P < .01). Sensitivity/specificity analyses revealed that central CRT ≤ 2 seconds demonstrated a sensitivity of 84.4%, specificity of 71.4%, positive predictive value of 93.1%, and negative predictive value of 50.0% in predicting ScvO2 ≥ 70%. Peripheral CRT ≤ 2 seconds had a sensitivity of 71.9%, specificity of 85.7%, positive predictive value of 95.8%, and negative predictive value of 40.0% in predicting ScvO2 ≥ 70%. CONCLUSIONS: A normal CRT ≤ 2 seconds can be predictive of ScvO2 ≥ 70%. Our study corroborates the recommendations of the Pediatric Advanced Life Support curricula targeting a normal CRT ≤ 2 seconds as a therapeutic endpoint for goal-directed shock resuscitation. This clinical target remains particularly relevant in community hospitals when the ability to obtain central venous catheter access may be limited and ScvO2 data unavailable.