EVALUATION OF THE HYPOTHALAMIC-PITUITARY-ADRENAL AXIS IN A PAEDIATRIC INTENSIVE CARE UNIT.

BACKGROUND: Relative adrenal insufficiency (RAI) is the inadequate production of cortisol due to dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis during a severe illness. We evaluated the HPA axis and RAI in a tertiary pediatric intensive care unit (PICU). METHODS: A total of 100 PICU patients were included in this prospective cohort study. Basal serum levels of adrenocorticotropic hormone (ACTH), cortisol values were compared with those in the control group. A low-dose ACTH stimulation test was performed in patients with basal cortisol levels below 18 µg/dL. RESULTS: The basal cortisol levels of the PICU patients were significantly higher than those of the control group (P < 0.05). All tested patients (n= 24) had delta cortisol levels > 9 µg/dL and a peak cortisol response > 18 µg/dL. Basal cortisol levels were positively correlated with Pediatric Risk of Mortality (PRISM) III scores (P < 0.05; r = 0.363). The basal or stimulated cortisol levels of the patients who received glucocorticoid treatment were higher than the cut-off levels. CONCLUSIONS: High basal or stimulated cortisol levels are indicative of disease severity in the acute phase of stress. Patients with very high cortisol levels should be particularly carefully monitored because of the high mortality risk.

Performance of Pediatric Risk of Mortality III and Pediatric Index of Mortality III Scores in Tertiary Pediatric Intensive Unit in Saudi Arabia.

Objective: To assess the performance of the Pediatric Risk of Mortality III (PRISM III) and Pediatric Index of Mortality III (PIM III) indices in a tertiary pediatric intensive care unit (PICU) in Saudi Arabia and to identify the factors affecting the observed performance. Design: Retrospective, single-center study using data collected from the Virtual Pediatric Systems web-based database. Setting: King Fahad Medical City PICU, Saudi Arabia. Patients: All pediatric patients <14 years of age admitted between 1 January 2015, and 31 December 2019. Interventions: Comparison of PRISM III and PIM III performances in predicting mortality across different age groups, disease categories, and resuscitation decision statuses. Measurements: Normality of distribution was assessed using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Patient characteristics were compared between survivors and non-survivors. The medians and ranges were calculated for continuous data, whereas frequencies and percentages were used for nominal data. The Mann-Whitney U test, Kruskal-Wallis test, and Chi-square test were used to compare the characteristics of survivors and non-survivors. Main Results: There was a significant difference between the predicted mortality and observed mortality in both the PRISM III and PIM III. Better discrimination was found after excluding do-not-resuscitate (DNR) patients. The worst calibration and discrimination were recorded for infants <12 months of age. The PRISM III performed significantly better in patients with metabolic/genetic and central nervous system illnesses. Non-DNR patients had a lower standardized mortality rate using the PRISM III and PIM III. The PRISM III and PIM III indices performed better in patients who died within the first week of admission. Conclusion: These models had sufficient discrimination ability and poor calibration. Since they were designed for particular patient characteristics and PICUs, further testing in different environments is necessary before utilization for planning and assessing performance. Alternatively, new models could be developed which are suitable for local PICUs.

Use of a Mortality Prediction Model in Children on Mechanical Ventilation: A 5-Year Experience in a Tertiary University Hospital.

PURPOSE: Currently, several scoring systems for predicting mortality in severely ill children who require treatment in a pediatric intensive care unit (PICU) have been established. However, despite providing high-quality care, children might develop complications that can cause rapid deterioration in health status and can lead to death. Hence, this study aimed to establish a simple early predictive mortality (SEPM) model with high specificity in identifying severely ill children who would possibly benefit from extensive mechanical ventilation during PICU admission. PATIENTS AND METHODS: This is a retrospective longitudinal study that included pediatric patients aged older than two weeks who were on mechanical ventilation and were admitted to the PICU of King Fahd Hospital of the University from January 2015 to December 2019. RESULTS: In total, 400 pediatric patients were included in this study. The mortality rate of children on mechanical ventilation was 28.90%, and most deaths were associated with respiratory (n = 124 [31%]), cardiovascular (n = 76 [19%]), and neurological (n = 68 [17%]) causes. The SEPM model was reported to be effective in predicting mortality, with an accuracy, specificity, and sensitivity of 92.5%, 97.31%, and 66.15%, respectively. Moreover, the accuracy, specificity, and sensitivity of the Pediatric Risk of Mortality (PRISM) III score in predicting mortality was 95.25%, 98.51%, and 78.46%, respectively. CONCLUSION: The SEPM model had a high specificity for mortality prediction. In this model, only six clinical predictors were used, which might be easily obtained in the early period of PICU admission. The ability of the SEPM model and the PRISM III score in predicting mortality in severely ill children was comparable. However, the accuracy of the newly established model in other settings should be validated, and a prospective longitudinal study that considers the effect of the treatment on the model's predictive ability must be conducted.

Lactate clearance prognosticates outcome in pediatric septic shock during first 24 h of intensive care unit admission.

This study was undertaken to examine the clinical utility of lactate clearance as an indicator of mortality in pediatric septic shock, and to compare the performance of lactate clearance at 6, 12, and 24 h for predicting in-hospital and 60-day mortality. Pediatric patients with septic shock were prospectively studied. Vital signs, laboratory values, Pediatric Risk of Mortality Score, and pediatric logistic organ dysfunction score were obtained at presentation (hour 0), hour 6, hour 24 and over the first 72 h of hospitalization. Lactate clearance was obtained at 6, 12, and 24 h of hospital admission. Therapy received, outcome parameters of mortality, and duration of hospitalization were recorded. The primary outcome variable of 60-day mortality rate was 31.25%. Only lactate clearance at 6 and 24 h was significantly associated with mortality, with odds of 0.97 (95% CI, 0.951-981; p < 0.001) and 0.975 (95% CI, 0.964-0.986; p < 0.001), respectively. Approximately there was a 24% decrease in likelihood of mortality for each 10% increase in lactate clearance at 24 h. At a threshold value of 10% 6-h lactate clearance had a sensitivity of 0.948 and specificity of 0.571, while at a threshold of 20% 24-h lactate clearance had a sensitivity of 0.922 and specificity of 0.629. The comparison of clearance at 6 and 24 h using receiver operating characteristic showed that former was "fair" (area under the curve = 0.753) and later was "good" (area under the curve = 0.81) in predicting mortality in pediatric septic shock. CONCLUSION: We concluded that optimal lactate clearance in pediatric septic shock both during the early presentation and after the initial "golden hours" is associated with lower in-hospital and 60-day mortality. Further, 24-h lactate clearance appears superior to 6 h lactate clearance in predicting mortality in such patients.

Continuous renal replacement therapy in children after cardiac surgery.

OBJECTIVE: The objective was to study the clinical course of children requiring continuous renal replacement therapy (CRRT) after cardiac surgery and to analyze the factors associated with mortality. METHODS: A prospective observational study was performed that included all children requiring CRRT after cardiac surgery, comparing these patients with other critically ill children requiring CRRT. Univariate and multivariate analyses were performed to determine the influence of each factor on mortality. RESULTS: Eighty-one (4.9%) of 1650 children undergoing cardiac surgery required CRRT; 65 of them (80.2%) presented multiorgan failure. Children starting CRRT after cardiac surgery had lower mean arterial pressure and lower urea and creatinine levels, and were more likely to require mechanical ventilation than other children on CRRT. The incidence of complications was similar. Cardiac surgery increased the probability of requiring CRRT for more than 14 days. Mortality was 43% in children receiving CRRT after cardiac surgery and 29% in other children (P = .05). Factors associated with mortality in the univariate analysis were age less than 12 months, weight less than 10 kg, higher Pediatric Risk of Mortality Score, hypotension, lower urea and creatinine on starting CRRT, and use of hemofiltration. In the multivariate analysis, the only factor associated with mortality was hypotension on starting CRRT (hazard ratio, 4.01; 95% confidence interval, 1.2-13.4; P = .024). CONCLUSIONS: Although only a small percentage of children undergoing cardiac surgery required CRRT, mortality in these patients was high. Hypotension at the time of starting the technique was the only factor associated with a higher mortality.

Nutritional-metabolic factors affecting nitrogen balance and substrate utilization in the critically ill.

To determine clinical, anthropometric, metabolic, and nutritional factors affecting nitrogen balance somatic protein status and substrate utilization in critically ill children measured energy expenditure (MEE) was measured by indirect calorimetry within 24 hr of an acute illness, solid organ transplantation, or cardiovascular surgery. Predicted basal metabolic rate was calculated using the Schofield equation. Somatic protein was estimated by the creatinine-height index. Nitrogen balance (NB) was calculated by subtracting the total nitrogen input from output. The net substrate (fat, carbohydrate, and protein) oxidation rates were calculated using the Weir formula modified by Frayn. Sixty-eight NB studies, indirect calorimetric and anthropometric measurements performed in 37 patients. Nitrogen balance was worse when the MEE/Predicted basal metabolic rate ratio was < 0.9 or > 1.1. The incidence of negative NB was 91% when the caloric intake was less than MEE and 9% when it was equal to or greater than MEE (P < 0.05). On day 1, 27% had mild to moderate somatic protein depletion and 5.4% had severe somatic protein depletion. Only the persistence of stress and co-morbidity were associated with the creatinine-height index (P < 0.001). Without Multiple Organ System Failure (MOSF), there was a trend toward positive nitrogen balance by day 7 while with MOSF, negative nitrogen balance persisted even by day 7 (P < 0.05). When caloric intake was less than MEE, mean substrate utilization was 48.6% from lipid, 37.1% from carbohydrate, and 14.3% from proteins. But, when caloric intake was greater than MEE, mean substrate utilization was 83.3% from carbohydrate and 16.7% from protein. Significant negative nitrogen balance and somatic protein depletion develops in critically ill pediatric patients, especially when they are inadequately fed, develop MOSF, or have previous chronic illness. Caloric intake and MOSF independently affect substrate utilization.

The performance of pediatric risk of mortality score in pediatric patients with severe hand,foot and mouth disease / 中国小儿急救医学

Objective To comment the severity of severe hand,foot and mouth disease(HFMD)by pediatric risk of mortality score(PRISM),and assess the performance of PRISM in predicting mortality or complication probability in HFMD.Methods Four hundred and twenty-four severe HFMD pediatric patients were recruited in the study from 1th Jan 2010 to 31th June 2013.Information on the outcome and the varia-bles required to calculate PRISM score were collected.The logistic regression model developed in the learning sample was evaluated in the test sample by calculating the area under the receiver operating characteristic (ROC)curve to assess discrimination pneumorrhagia and death.Calibration across deciles of risk was evalua-ted using the Hosmer-Lemeshow goodness-of-fit χ2 test.Results The area under the ROC curve were 0.87 (95%CI 0.80~0.94 )for PRISM in predicting pneumorrhagia probability.The area under the ROC curve were 0.87(95%CI 0.80~0.95)for PRISM in predicting mortality probability.The PRISM in observed and expected pneumorrhagia did not demonstrate good calibration at ten mortality risk intervals (χ2 =36.66, P<0.001 ).The PRISM in observed and expected mortality did not demonstrate good calibration at ten mortali-ty risk intervals(χ2 =41.11,P<0.001).Conclusion The PRISM score is demonstrated good discrimination of pneumorrhagia and death in HFMD pediatric patients,but the performance of calibration is not good.

Roles of Pediatric Critical Illness Score and Pediatric Risk of Mortality Score in Children with Acute Respiratory Distress Syndrome and the Correlation between Them / 实用儿科临床杂志

Objective To explore the prognostic value of pediatric critical illness score(PCIS)and pediatric risk of mortality score(PRISMⅢ)and the accuracy for evaluating the state of children with acute respiratory distress syndrome(ARDS).Methods Seventy-one cases hospitalized children from 29 days to 14 years old of Hebei ARDS cooperation group were selected during the 13 months between 2005 and 2006.All cases were confirmed according to ARDS diagnostic standard.For prospective studies,the patients were scored simultaneously with PCIS and PRISMⅢ at different times:when the patients entered PICU,when the patients were in the worst situation in PICU,when the patients were diagnosed as ARDS and when ARDS was serious.The data were performed by using Logistic regression etc.Results Values of Logistic regression were P

Clinical Application of Pediatric Risk of Mortality Score in Pediatric Intensive Care Unit / 实用儿科临床杂志

15, the mortality was38.1%(n = 8).There was significantly difference both in mortality (x2 = 4.14 P