The occurrence of adverse events is associated with increased morbidity and mortality in children admitted to a single pediatric intensive care unit.

Healthcare can cause harm. The goal of this study is to evaluate the association between the occurrence of adverse events (AEs) and morbidity-mortality in critically ill children. A prospective cohort study was designed. All children admitted to the Pediatric Intensive Care Unit (PICU) between August 2016 and July 2017 were followed. An AE was considered any harm associated with a healthcare-related incident. AEs were identified in two steps: first, adverse clinical incidents (ACI) were recognized through direct observation and active surveillance by PICU physicians, and then the patient safety committee evaluated every ACI to define which would be considered an AE. The outcome was hospital morbidity-mortality. There were 467 ACI registered, 249 (53.31%) were considered AEs and the rate was 4.27/100 patient days. From the 842 children included, 142 (16.86%) suffered AEs, 39 (4.63%) experienced morbidity-mortality: 33 (3.92%) died, and 6 (0.71%) had morbidity. Multivariate analysis revealed that the occurrence of AEs was significantly associated with morbidity-mortality, OR 5.70 (CI95% 2.58-12.58, p = 0.001). This association was independent of age and severity of illness score.Conclusion: Experiencing AEs significantly increased the risk of morbidity-mortality in this cohort of PICU children.What is Known:• Many children suffer healthcare-associated harm during pediatric intensive care hospitalization.What is New:• This prospective cohort study shows that experiencing adverse events during pediatric intensive care hospitalization significantly increases the risk of morbidity and mortality independent of age and severity of illness at admission.

Incidence of morbidity and associated factors in a Pediatric Intensive Care Unit. / Incidencia de morbilidad y factores asociados en una Unidad de Cuidados Intensivos Pediátrica.

Introduction: The Functional Status Scale (FSS) was developed to measure acquired morbidity in pediatric patients. Objective: To estimate the incidence of acquired morbidity in the pediatric intensive care unit (PICU) and the presence of associated factors, and describe functional status after hospital discharge. Population and methods: Prospective cohort. All PICU admissions between August 2016 and July 2017. The FSS was used to measure acquired morbidity during hospitalization and up to 1 year after discharge. A univariate analysis was performed to investigate morbidity-associated factors. Results: A total of 842 patients were included. The incidence of morbidity at the PICU was 3.56 % (30/842) and persisted at 0.7 % for the entire cohort at hospital discharge (6/842). Within 1 year after discharge, the functional status of 3/6 patients improved. The univariate analysis showed an association between acquired morbidity at the PICU and the PIM2 score (odds ratio [OR]: 1.04; 95 % confidence interval [CI]: 1.01-1.07; p = 0.007), age younger than 1 year (OR: 2.93; 95 % CI: 1.36-6.15; p = 0.004), the use of assisted mechanical ventilation (AMV) (OR: 7.83; 95 % CI: 3.31-18.49; p = 0.0001) and central venous catheter (CVC) (OR: 38.08; 95 % CI: 5.16-280.95; p = 0.0001), and prolonged hospital stays (OR: 9.65; 95 % CI: 4.33-21.49; p = 0.0001). Conclusions: The incidence of morbidity was 3.56 % and was associated with an age younger than 1 year, patient severity at the time of admission, the use of AMV and CVC, and prolonged hospital stays.

Introducción. La escala de estado funcional (FSS, por su sigla en inglés) fue desarrollada para medir la morbilidad adquirida en los pacientes pediátricos. Objetivo. Estimar la incidencia de morbilidad adquirida en la unidad de cuidados intensivos pediátrica (UCIP), la presencia de factores asociados y describir el estado funcional tras el alta hospitalaria. Población y métodos. Cohorte prospectiva. Todas las admisiones en UCIP entre agosto de 2016 y julio de 2017. Se utilizó FSS para medir la morbilidad adquirida durante la hospitalización y hasta 1 año después del alta. Se realizó un análisis univariado para investigar los factores asociados con morbilidad. Resultados. Se incluyeron 842 pacientes. La incidencia de morbilidad en UCIP fue del 3,56 % (30/842) y persistió en el 0,7 % de toda la cohorte al alta hospitalaria (6/842). Antes del año, 3 de los 6 pacientes mejoraron la condición funcional. El análisis univariado mostró asociación entre la morbilidad adquirida en UCIP y el puntaje PIM2 (odds ratio [OR, por su sigla en inglés]: 1,04; intervalo de confianza del 95 % [IC95 %]: 1,01- 1,07; p = 0,007), la edad menor a 1 año (OR: 2,93; IC95 %: 1,36-6,15; p = 0,004), el uso de asistencia respiratoria mecánica (ARM) (OR: 7,83; IC95 %: 3,31-18,49; p = 0,0001) y de catéteres venosos centrales (CVC) (OR: 38,08; IC95 %: 5,16-280,95; p = 0,0001), y hospitalizaciones prolongadas (OR: 9,65; IC95 %: 4,33-21,49; p = 0,0001). Conclusiones. La incidencia de morbilidad fue del 3,56 % y se asoció con la edad menor a 1 año, la gravedad de los pacientes al momento de la admisión, el uso de ARM y CVC, y las hospitalizaciones prolongadas.

Hospital-acquired hyponatremia in postoperative pediatric patients: prospective observational study.

OBJECTIVE: To establish the incidence and factors associated with hospital-acquired hyponatremia in pediatric surgical patients who received hypotonic saline (sodium 40 mmol/L plus potassium 20 mmol/L) at the rate suggested by the Holliday and Segar's formula for calculations of maintenance fluids. DESIGN: Prospective, observational, cohort study. SETTING: Pediatric intensive care unit. PATIENTS: : Eighty-one postoperative patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Incidence and factors associated with hyponatremia (sodium < or = 135 mmol/L). Univariate analysis was conducted post surgery at 12 hrs and at 24 hrs. Mean values were compared with independent t test samples. Receiver operating characteristics curve analysis was performed in variables with a p <.05, and relative risks were calculated. Eighty-one patients were included in the study. The incidence of hyponatremia at 12 hrs was 17 (21%) of 81 (95% confidence interval, 3.7-38.3); at 24 hrs, it was was 15 (31%) of 48 (95% confidence interval, 11.4-50.6). Univariate analysis at 12 hrs showed that hyponatremic patients had a higher sodium loss (0.62 mmol/kg/hr vs. 0.34 mmol/kg/hr, p = .0001), a more negative sodium balance (0.39 mmol/kg/hr vs. 0.13 mmol/kg/hr, p < .0001), and a higher diuresis (3.08 mL/kg/hr vs. 2.2 mL/kg/hr, p = .0026); relative risks were 11.55 (95% confidence interval, 2.99-44.63; p = .0004) for a sodium loss >0.5 mmol/kg/hr; 10 (95% confidence interval, 2.55-39.15; p = .0009) for a negative sodium balance >0.3 mmol/kg/hr; and 4.25 (95% confidence interval, 1.99-9.08; p = .0002) for a diuresis >3.4 mL/kg/hr. At 24 hrs, hyponatremic patients were in more positive fluid balance (0.65 mL/kg/hr vs. 0.10 mL/kg/hr, p = .0396); relative risk was 3.25 (95% confidence interval, 1.2-8.77; p = .0201), for a positive fluid balance >0.2 mL/kg/hr. CONCLUSIONS: The incidence of hyponatremia in this population was high and progressive over time. Negative sodium balance in the first 12 postoperative hours and then a positive fluid balance could be associated with the development of postoperative hyponatremia.

Adequate agreement between venous oxygen saturation in right atrium and pulmonary artery in critically ill children.

OBJECTIVE: To determine the agreement between venous oxygen saturation in right atrium (Srao2) and pulmonary artery (Svo2) in critically ill pediatric patients. DESIGN: Retrospective, observational study. SETTING: Multidisciplinary pediatric intensive care unit from a general university hospital. PATIENTS: Thirty critically ill children in whom a pulmonary artery catheter (PAC) was inserted for catecholamine refractory shock (septic and cardiogenic, n = 18) and postoperative management (liver and cardiac transplant, n = 12). MEASUREMENTS AND MAIN RESULTS: Ninety measurements of Srao2 and Svo2 were obtained after placement of PAC and every 6 hrs for the first 12 hrs of pediatric intensive care unit admission. The agreement between Srao2 and Svo2 was determined through Bland and Altman methodology, concordance correlation coefficient, and the frequency of differences between Srao2 and Svo2. The frequency of differences between both saturations was evaluated in three categories: +/-1%-5%, +/-6%-9%, and higher than +/-10%. The first category was the threshold to consider both variables interchangeable. Changes of Srao2 related to clinically significant (>5%) increases and drops of Svo2 were analyzed. Srao2 and Svo2 were not significantly different: median (interquartile range) 83% (75%-86%) and 81% (75%-85%), respectively (p = 0.23). The frequency of differences between Srao2 and Svo2 was +/-1%-5%, 71 (79%); +/-6%-9%, 14 (15.5%); and higher than +/-10%, 5 (5.5%). Bland and Altman analysis showed a 2% bias with a 95% limits of agreement of -6.9% to 10.9%. The concordance correlation coefficient was 0.90. Svo2 increased in 11/90 measurements and Srao2 followed it 82% of the times. Svo2 decreased in 7/90 measurements and Srao2 followed it 100% of the times. CONCLUSION: The concordance analysis performed allows to conclude that there is an appropriate agreement between Svo2 and Srao2. This finding may become clinically relevant considering the difficulties associated to the use of PAC in children.

Validation of pediatric index of mortality 2 (PIM2) in a single pediatric intensive care unit of Argentina.

OBJECTIVE: Pediatric Index of Mortality 2 (PIM2) is an up-to-date mortality prediction model in the public domain that has not yet been widely validated. We aimed to evaluate this score in the population of patients admitted to our pediatric intensive care unit. DESIGN: Prospective cohort study. SETTING: Multidisciplinary pediatric intensive care unit in a general university hospital in Buenos Aires, Argentina. PATIENTS: All consecutive patients admitted between January 1, 2004, and December 31, 2005. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 1,574 patients included in the study. We observed 41 (2.6%) deaths, and PIM2 estimated 48.1 (3.06) deaths. Discrimination assessed by the area under the receiver operating characteristic curve was 0.9 (95% confidence interval, 0.89-0.92). Calibration across five conventional mortality risk intervals assessed by the Hosmer-Lemeshow goodness-of-fit test showed chi5 = 12.2 (p = .0348). The standardized mortality ratio for the whole population was 0.85 (95% confidence interval, 0.6-1.1). CONCLUSIONS: PIM2 showed an adequate discrimination between death and survival and a poor calibration assessed by the Hosmer-Lemeshow goodness-of-fit test. The standardized mortality ratio and clinical analysis of the Hosmer-Lemeshow table make us consider that PIM2 reasonably predicted the outcome of our patients.

Internal mammary artery injury after central venous catheterization.

OBJECTIVE: We describe an infrequent but potentially lethal complication: an iatrogenic injury of the internal mammary artery after central venous catheterization. DESIGN: Report of cases. SETTING: Pediatric intensive care unit. PATIENTS: The first patient we report on is a 3-yr-old girl who was severely neurologically damaged and was admitted to the pediatric intensive care unit for aspiration pneumonia and septic shock. Immediately after vein cannulation on the left internal jugular vein, the patient suffered hypotension and cardiac arrest, secondary to an adequately drained massive hemothorax. Restoration of spontaneous circulation was initially achieved, and the patient was transferred to the angiographic suite. Selective angiography during cardiopulmonary resuscitation for a second cardiac arrest revealed a laceration of the internal mammary artery. Resuscitation was not successful, and the patient died. The second case reported is a 7-yr-old girl admitted for bone marrow transplantation. She was electively taken to the angiographic suite for central venous insertion. An infraclavicular approach of the right subclavian vein was attempted, but radioscopy showed the guidewire inside the pleural space. Soon thereafter, the patient became hypotensive and was in shock. Radioscopy showed a large pleural effusion and a massive hemothorax was drained. Selective angiography demonstrated an injured internal mammary artery was embolized. Hemodynamics improved, and the patient was transferred to the pediatric intensive care unit, where she was extubated 12 hrs later. INTERVENTIONS: None. CONCLUSIONS: Central venous catheter placement in the intrathoracic vein may cause potentially lethal complications in the form of an injury to the internal mammary artery. Hypotension during or immediately after the procedure should be a warning of a serious adverse event, such as massive hemothorax, that may compromise life. Adequate drainage of the pleural cavity may not completely relieve vascular compression if some of the bleeding from an injured internal mammary artery is extrapleural. Early diagnosis and treatment by selective embolization of the injured vessel in interventional radiology is the first therapeutic choice and may be life saving.

Incidencia de morbilidad y factores asociados en una Unidad de Cuidados Intensivos Pediátrica / Incidence of morbidity and associated factors in a Pediatric Intensive Care Unit

Introducción. La escala de estado funcional (FSS, por su sigla en inglés) fue desarrollada para medir la morbilidad adquirida en los pacientes pediátricos. Objetivo. Estimar la incidencia de morbilidad adquirida en la unidad de cuidados intensivos pediátrica (UCIP), la presencia de factores asociados y describir el estado funcional tras el alta hospitalaria. Población y métodos. Cohorte prospectiva. Todas las admisiones en UCIP entre agosto de 2016 y julio de 2017. Se utilizó FSS para medir la morbilidad adquirida durante la hospitalización y hasta 1 año después del alta. Se realizó un análisis univariado para investigar los factores asociados con morbilidad. Resultados. Se incluyeron 842 pacientes. La incidencia de morbilidad en UCIP fue del 3,56 % (30/842) y persistió en el 0,7 % de toda la cohorte al alta hospitalaria (6/842). Antes del año, 3 de los 6 pacientes mejoraron la condición funcional. El análisis univariado mostró asociación entre la morbilidad adquirida en UCIP y el puntaje PIM2 (odds ratio [OR, por su sigla en inglés]: 1,04; intervalo de confianza del 95 % [IC95 %]: 1,01-1,07; p = 0,007), la edad menor a 1 año (OR: 2,93; IC95 %: 1,36-6,15; p = 0,004), el uso de asistencia respiratoria mecánica (ARM) (OR: 7,83; IC95 %: 3,31-18,49; p = 0,0001) y de catéteres venosos centrales (CVC) (OR: 38,08; IC95 %: ,16-280,95; p = 0,0001), y hospitalizaciones prolongadas (OR: 9,65; IC95 %: 4,33-21,49; p = 0,0001). Conclusiones. La incidencia de morbilidad fue del 3,56 % y se asoció con la edad menor a 1 año, la gravedad de los pacientes al momento de la admisión, el uso de ARM y CVC, y las hospitalizaciones prolongadas

Introduction. The Functional Status Scale (FSS) was developed to measure acquired morbidity in pediatric patients. Objective. To estimate the incidence of acquired morbidity in the pediatric intensive care unit (PICU) and the presence of associated factors, and describe functional status after hospital discharge. Population and methods. Prospective cohort. All PICU admissions between August 2016 and July 2017. The FSS was used to measure acquired morbidity during hospitalization and up to 1 year after discharge. A univariate analysis was performed to investigate morbidity-associated factors. Results. A total of 842 patients were included. The incidence of morbidity at the PICU was 3.56 % (30/842) and persisted at 0.7 % for the entire cohort at hospital discharge (6/842). Within 1 year after discharge, the functional status of 3/6 patients improved. The univariate analysis showed an association between acquired morbidity at the PICU and the PIM2 score (odds ratio [OR]: 1.04; 95 % confidence interval [CI]: 1.01-1.07; p = 0.007), age younger than 1 year (OR: 2.93; 95 % CI: 1.36-6.15; p = 0.004), the use of assisted mechanical ventilation (AMV) (OR: 7.83; 95 % CI: 3.31-18.49; p = 0.0001) and central venous catheter (CVC) (OR: 38.08; 95 % CI: 5.16-280.95; p = 0.0001), and prolonged hospital stays (OR: 9.65; 95 % CI: 4.33-21.49; p = 0.0001). Conclusions. The incidence of morbidity was 3.56 % and was associated with an age younger than 1 year, patient severity at the time of admission, the use of AMV and CVC, and prolonged hospital stays

[Parents' satisfaction in a single pediatric intensive care unit]. / Satisfacción de los padres de los pacientes en una unidad de cuidados intensivos pediátricos.

Aim of study. To validate and apply an instrument to measure parents' degree of satisfaction from patients admitted to Pediatric Intensive Care Unit of Hospital Italiano de Buenos Aires. Population and methods. Picker's Pediatric Acute Care questionnaire was applied after translation to Spanish, determination of face and content validity and also reliability. Overall and domain satisfaction scores were calculated. Population was divided in High and Low Levels of satisfaction according to the answer to the question "How would you rate the care received?" Variables associated with High and Low Levels of satisfaction were identified. Results. Face validity, content validity and reliability were adequate (α Cronbach= 0.87). The average overall satisfaction score was 85.7 (95%CI 83.5-87.8). Domain satisfaction scores were: general impression, 84.8 (95%CI 82.3-87.3); accessibility and availability, 88.8 (95%CI 86.4-91.2); consideration and respect, 85.7 (95%CI 83.1-88.3); coordination and integration of care, 84.6 (95%CI 80.9-88.3); information and communication, 85.5 (95%CI 82-89); relationship between parents and health care team, 89.5 (95%CI 86.7-92.3); physical comfort, 91.8 (95%CI 89-94.6) and continuity of care 70.9 (95%CI 64.9-76.9). This last score, significantly lower than previous ones, permitted recognize an area to improve; 89% (89/100) of parents were in High satisfaction group. All of them said that their children received the care needed when needed and 98.2% that their children were treated with dignity and respect and that both, doctors and nurses, were interested in easing pain. Conclusions. The validation of the instrument was adequate. Care received when needed, and treating patients in a dignified and respectful manner are associated with high levels of satisfaction

Introducción. El objetivo fue validar y aplicar un instrumento para medir satisfacción de padres de pacientes internados en Cuidados Intensivos Pediátricos del Hospital Italiano de Buenos Aires. Población y métodos. Aplicamos el cuestionario Picker's Pediatric Acute Care luego de traducirlo y determinar su validez de construcción, contenido y consistencia interna. Calculamos puntaje de satisfacción general y dominios. La población fue dividida en Alto y Bajo Grados de Satisfacción según la respuesta a la pregunta "¿Cómo calificaría los cuidados recibidos?" Las variables asociadas con estos grupos fueron identificadas. Resultados. Validez de construcción, contenido y consistencia interna fueron adecuados (α de Cronbach= 0,87). El puntaje de satisfacción general fue 85,7 (IC95% 83,5-87,8). Los puntajes por dominios fueron, impresión general, 84,8 (IC95% 82,3-87,3); accesibilidad y disponibilidad, 88,8 (IC95% 86,4-91,2); consideración y respeto, 85,7 (IC95% 83,1-88,3); coordinación e integración de cuidados, 84,6 (IC95% 80,9-88,3); información y comunicación, 85,5 (IC95% 82-89); relación entre padres y equipo de salud, 89,5 (IC95% 86,7-92,3); confort físico, 91,8 (IC95% 89-94,6) y continuidad de cuidados 70,9 (IC95% 64,9-76,9). Este último puntaje, significativamente menor a los anteriores, permitió identificar un aspecto por mejorar. El 89% (89/100) de los padres se incluyó en el Grupo Alto Grado de Satisfacción. El 100% manifestó que sus hijos habían recibido cuidados que necesitaban cuando los necesitaban y 98,2% que sus hijos habían sido tratados con dignidad y respeto, y que tanto a médicos como a enfermeras les interesaba calmar el dolor. Conclusiones. La validación del instrumento fue adecuada. Los cuidados oportunos y el trato digno y respetuoso se asocian con altos niveles de satisfacción.

Satisfacción de los padres de los pacientes en una unidad de cuidados intensivos pediátricos / Parents’ satisfaction in a single pediatric intensive care unit

El objetivo fue validar y aplicar un instrumento para medir satisfacción de padres de pacientes internados en Cuidados Intensivos Pediátricos del Hospital Italiano de Buenos Aires. Población y métodos. Aplicamos el cuestionario Picker’s Pediatric Acute Care luego de traducirlo y determinar su validez de construcción, contenido y consistencia interna. Calculamos puntaje de satisfacción general y dominios. La población fue dividida en Alto y Bajo Grados de Satisfacción según la respuesta a la pregunta “ ¿Cómocalificaría los cuidados recibidos?” Las variables asociadas con estos grupos fueron identificadas. Resultados. Validez de construcción, contenido y consistencia interna fueron adecuados (α de Cronbach= 0,87). El puntaje de satisfacción generalfue 85,7 (IC95 por ciento 83,5-87,8). Los puntajes por dominios fueron, impresión general, 84,8 (IC95 por ciento82,3-87,3); accesibilidad y disponibilidad, 88,8 (IC95 por ciento 86,4-91,2); consideración y respeto, 85,7(IC95 por ciento 83,1-88,3); coordinación e integración decuidados, 84,6 (IC95 por ciento 80,9-88,3); información y comunicación, 85,5 (IC95 por ciento 82-89); relación entre padres y equipo de salud, 89,5 (IC95 por ciento 86,7-92,3); confort físico, 91,8 (IC95 por ciento 89-94,6) y continuidad de cuidados 70,9 (IC95 por ciento 64,9-76,9). Este últimopuntaje, significativamente menor a los anteriores, permitió identificar un aspecto por mejorar. El 89 por ciento (89/100) de los padres se incluyó en el Grupo Alto Grado de Satisfacción. El 100 por ciento manifestó que sus hijos habían recibido cuidados que necesitaban cuando los necesitaban y 98,2 por ciento que sus hijos habían sido tratados con dignidad y respeto, y que tanto a médicos como a enfermeras les interesaba calmar el dolor. Conclusiones. La validación del instrumento fue adecuada. Los cuidados oportunos y el trato digno y respetuoso se asocian con altos niveles de satisfacción.