Racial and Ethnic Variation in Pediatric Cardiac Extracorporeal Life Support Survival. (Carroll)

Chan T, et al. Racial and Ethnic Variation in Pediatric Cardiac Extracorporeal Life Support Survival. Crit Care Med. 2017 Apr; 45(4):670-678.

OBJECTIVES: Previous studies have suggested an association between nonwhite race and poor outcomes in small subsets of cardiac surgery patients who require extracorporeal life support. This study aims to examine the association of race/ethnicity with mortality in pediatric patients who receive extracorporeal life support for cardiac support.

DESIGN: Retrospective analysis of registry data.

SETTING: Prospectively collected multi-institutional registry data.

SUBJECTS: Data from all North American pediatric patients in the Extracorporeal Life Support International Registry who received extracorporeal life support for cardiac support between 1998 and 2012 were analyzed. Multivariate regression models were constructed to examine the association between race/ethnicity and hospital mortality, adjusting for demographics, diagnosis, pre-extracorporeal life support care, extracorporeal life support variables, and extracorporeal life support-related complications.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Of 7,106 patients undergoing cardiac extracorporeal life support, the majority of patients were of white race (56.9%) with black race (16.7%), Hispanic ethnicity (15.8%), and Asian race (2.8%) comprising the other major race/ethnic groups. The mortality rate was 53.9% (n = 3,831). After adjusting for covariates, multivariate analysis identified black race (relative risk = 1.10; 95% CI, 1.04-1.16) and Hispanic ethnicity (relative risk = 1.08; 95% CI, 1.02-1.14) as independent risk factors for mortality.

CONCLUSIONS: Black race and Hispanic ethnicity are independently associated with mortality in children who require cardiac extracorporeal life support.

Greater Protein and Energy Intake May Be Associated With Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. (Betters)

Compher C, Chittams J, Sammarco T, et al. Greater Protein and Energy Intake May Be Associated With Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017 Feb; 45(2):156-163.

OBJECTIVES: Controversy exists about the value of greater nutritional intake in critically ill patients, possibly due to varied patient nutritional risk. The objective of this study was to investigate whether clinical outcomes vary by protein or energy intake in patients with risk evaluated by the NUTrition Risk in the Critically Ill score.

DESIGN: Prospective observational cohort.

SETTING: A total of 202 ICUs.

PATIENTS: A total of 2,853 mechanically ventilated patients in ICU greater than or equal to 4 days and a subset of 1,605 patients in ICU greater than or equal to 12 days.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: In low-risk (NUTrition Risk in the Critically Ill, < 5) and high-risk (NUTrition Risk in the Critically Ill, ≥ 5) patients, mortality and time to discharge alive up to day 60 were assessed relative to nutritional intake over the first 12 days using logistic regression and Cox proportional hazard regression, respectively. In high-risk but not low-risk patients, mortality was lower with greater protein (4-d sample: odds ratio, 0.93; 95% CI, 0.89-0.98; p = 0.003 and 12-d sample: odds ratio, 0.90; 95% CI, 0.84-0.96; p = 0.003) and energy (4-d sample: odds ratio, 0.93; 95% CI, 0.89-0.97; p < 0.001 and 12-d sample: odds ratio, 0.88; 95% CI, 0.83-0.94; p < 0.001) intake. In the 12-day sample, there was significant interaction among NUTrition Risk in the Critically Ill category, mortality, and protein and energy intake, whereas in the 4-day sample, the test for interaction was not significant. In high-risk but not low-risk patients, time to discharge alive was shorter with greater protein (4-d sample: hazard ratio, 1.05; 95% CI, 1.01-1.09; p = 0.01 and 12-d sample: hazard ratio, 1.09; 95% CI, 1.03-1.16; p = 0.002) and energy intake (4-d sample: hazard ratio, 1.05; 95% CI, 1.01-1.09; p = 0.02 and 12-d sample: hazard ratio, 1.09; 95% CI, 1.03-1.16; p = 0.002). In the 12-day sample, there was significant interaction among NUTrition Risk in the Critically Ill category, time to discharge alive, and protein and energy intake, whereas in the 4-day sample, the test for interaction was not significant.

CONCLUSIONS: Greater nutritional intake is associated with lower mortality and faster time to discharge alive in high-risk, longer stay patients but not significantly so in nutritionally low-risk patients.

Impact of Source Control in Patients With Severe Sepsis and Septic Shock. (Betters)

Martínez ML, et al. Impact of Source Control in Patients With Severe Sepsis and Septic Shock. Crit Care Med. 2017 Jan;45(1):11-19.

OBJECTIVES: Time to clearance of pathogens is probably critical to outcome in septic shock. Current guidelines recommend intervention for source control within 12 hours after diagnosis. We aimed to determine the epidemiology of source control in the management of sepsis and to analyze the impact of timing to source control on mortality.

DESIGN: Prospective observational analysis of the Antibiotic Intervention in Severe Sepsis study, a Spanish national multicenter educational intervention to improve antibiotherapy in sepsis.

SETTING: Ninety-nine medical-surgical ICUs in Spain.

PATIENTS: We enrolled 3,663 patients with severe sepsis or septic shock during three 4-month periods between 2011 and 2013.

INTERVENTIONS: Source control and hospital mortality.

MEASUREMENTS AND MAIN RESULTS: A total of 1,173 patients (32%) underwent source control, predominantly for abdominal, urinary, and soft-tissue infections. Compared with patients who did not require source control, patients who underwent source control were older, with a greater prevalence of shock, major organ dysfunction, bacteremia, inflammatory markers, and lactic acidemia. In addition, compliance with the resuscitation bundle was worse in those undergoing source control. In patients who underwent source control, crude ICU mortality was lower (21.2% vs 25.1%; p = 0.010); after adjustment for confounding factors, hospital mortality was also lower (odds ratio, 0.809 [95% CI, 0.658-0.994]; p = 0.044). In this observational database analysis, source control after 12 hours was not associated with higher mortality (27.6% vs 26.8%; p = 0.789).

CONCLUSIONS: Despite greater severity and worse compliance with resuscitation bundles, mortality was lower in septic patients who underwent source control than in those who did not. The time to source control could not be linked to survival in this observational database.

Development and Validation of a Score to Predict Mortality in Children Undergoing Extracorporeal Membrane Oxygenation for Respiratory Failure: Pediatric Pulmonary Rescue With Extracorporeal Membrane Oxygenation Prediction Score. (Betters)

Bailly DK, et al. Development and Validation of a Score to Predict Mortality in Children Undergoing Extracorporeal Membrane Oxygenation for Respiratory Failure: Pediatric Pulmonary Rescue With Extracorporeal Membrane Oxygenation Prediction Score. Crit Care Med. 2017 Jan;45(1):e58-e66.

OBJECTIVE: Our objective was to develop and validate a prognostic score for predicting mortality at the time of extracorporeal membrane oxygenation initiation for children with respiratory failure. Preextracorporeal membrane oxygenation mortality prediction is important for determining center-specific risk-adjusted outcomes and counseling families.

DESIGN: Multivariable logistic regression of a large international cohort of pediatric extracorporeal membrane oxygenation patients.

SETTING: Multi-institutional data.

PATIENTS: Prognostic score development: A total of 4,352 children more than 7 days to less than 18 years old, with an initial extracorporeal membrane oxygenation run for respiratory failure reported to the Extracorporeal Life Support Organization’s data registry during 2001-2013 were used for derivation (70%) and validation (30%). Bidirectional stepwise logistic regression was used to identify factors associated with mortality. Retained variables were assigned a score based on the odds of mortality with higher scores indicating greater mortality. External validation was accomplished using 2,007 patients from the Pediatric Health Information System dataset.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: The Pediatric Pulmonary Rescue with Extracorporeal Membrane Oxygenation Prediction score included mode of extracorporeal membrane oxygenation; preextracorporeal membrane oxygenation mechanical ventilation more than 14 days; preextracorporeal membrane oxygenation severity of hypoxia; primary pulmonary diagnostic categories including, asthma, aspiration, respiratory syncytial virus, sepsis-induced respiratory failure, pertussis, and “other”; and preextracorporeal membrane oxygenation comorbid conditions of cardiac arrest, cancer, renal and liver dysfunction. The area under the receiver operating characteristic curve for internal and external validation datasets were 0.69 (95% CI, 0.67-0.71) and 0.66 (95% CI, 0.63-0.69).

CONCLUSIONS: Pediatric Pulmonary Rescue with Extracorporeal Membrane Oxygenation Prediction is a validated tool for predicting in-hospital mortality among children with respiratory failure receiving extracorporeal membrane oxygenation support.

Lactated Ringer Is Associated With Reduced Mortality and Less Acute Kidney Injury in Critically Ill Patients: A Retrospective Cohort Analysis. (Colman)

Zampieri FG, et al. Lactated Ringer Is Associated With Reduced Mortality and Less Acute Kidney Injury in Critically Ill Patients: A Retrospective Cohort Analysis. Crit Care Med. 2016 Aug 5. [Epub ahead of print]

OBJECTIVES: To assess the impact of the percentage of fluid infused as Lactated Ringer (%LR) during the first 2 days of ICU admission in hospital mortality and occurrence of acute kidney injury.

DESIGN: Retrospective cohort.

SETTING: Analysis of a large public database (Multiparameter Intelligent Monitoring in Intensive Care-II).

PATIENTS: Adult patients with at least 2 days of ICU stay, admission creatinine lower than 5 mg/dL, and that received at least 500 mL of fluid in the first 48 hours.

INTERVENTIONS: None.

MEASUREMENT AND MAIN RESULTS: 10,249 patients were included in mortality analysis and 8,085 were included in the acute kidney injury analysis. For acute kidney injury analysis, we excluded patients achieving acute kidney injury criteria in the first 2 days of ICU stay. Acute kidney injury was defined as stage 2/3 Kidney Disease: Improving Global Outcomes creatinine criteria and was assessed from days 3-7. The effects of %LR in both outcomes were assessed through logistic regression controlling for confounders. Principal component analysis was applied to assess the effect of volume of each fluid type on mortality. Higher %LR was associated with lower mortality and less acute kidney injury. %LR effect increased with total volume of fluid infused. For patients in the fourth quartile of fluid volume (> 7 L), the odds ratio for mortality for %LR equal to 75% versus %LR equal to 25% was 0.50 (95% CI, 0.32-0.79; p < 0.001). Principal component analysis suggested that volume of Lactated Ringer and 0.9% saline infused had opposite effects in outcome, favoring Lactated Ringer.

CONCLUSIONS: Higher %LR was associated with reduced hospital mortality and with less acute kidney injury from days 3-7 after ICU admission. The association between %LR and mortality was influenced by the total volume of fluids infused.

Association of Hospital Structure and Complications With Mortality After Pediatric Extracorporeal Membrane Oxygenation. (Williams)

Nasr VG, Faraoni D, DiNardo JA, Thiagarajan RR. Association of Hospital Structure and Complications With Mortality After Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med. 2016 Jul;17(7):684-91.

OBJECTIVES: Extracorporeal membrane oxygenation is increasingly utilized to provide cardiopulmonary support to critically ill children. Although life-saving in many instances, extracorporeal membrane oxygenation support is associated with considerable morbidity and mortality. This study evaluates the effect of extracorporeal membrane oxygenation complications and extracorporeal membrane oxygenation hospital characteristics on mortality in neonates and children supported with extracorporeal membrane oxygenation.

DESIGN: Retrospective analysis of administrative data.

SETTING: Data from 31 U.S. states included in 2012 Healthcare Cost and Utilization Project Kids’ Inpatient Database.

PATIENTS: Children treated with extracorporeal membrane oxygenation.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Study subject were identified using International Classification of Diseases, 9th Edition Clinical Modification code 39.65 and classified into six diagnostic categories: 1) cardiac surgery, 2) non-surgical heart disease, 3) congenital diaphragmatic hernia, 4) neonatal respiratory failure, 5) pediatric respiratory failure, and 6) sepsis. Demographics, hospital characteristics, and outcome information were used in a multivariate logistic regression analysis to determine factors associated with mortality. We identified 1,465 children treated with extracorporeal membrane oxygenation. Overall mortality was 40% (591/1,465). Mortality was independently associated with diagnosis (heart disease: odds ratio, 1.7; p = 0.01; congenital diaphragmatic hernia: odds ratio, 5.1; p < 0.001; and sepsis odds ratio: 2.4; p = 0.003 compared with neonatal respiratory failure) time from hospital admission to extracorporeal membrane oxygenation of more than 10 days (odds ratio, 4.5; p < 0.001) and extracorporeal membrane oxygenation complications (renal [odds ratio: 5; p < 0.001] and neurologic [odds ratio, 1.4; p = 0.03] injury). In addition, hospitals with bed size less than 400 had higher mortality (odds ratio, 1.4; p = 0.02). In patients with any extracorporeal membrane oxygenation complication, probability of mortality was lower for extracorporeal membrane oxygenation patients in larger hospitals, 38% (95% CI, 37-39) versus 44% (95% CI, 43-46) with p value of less than 0.001.

CONCLUSIONS: Extracorporeal membrane oxygenation mortality was significantly associated with patient diagnosis, time to extracorporeal membrane oxygenation initiation, extracorporeal membrane oxygenation complications, and extracorporeal membrane oxygenation hospital bed size. Improved survival in larger hospitals supports centralization of extracorporeal membrane oxygenation services to larger centers.