Evaluation of a Pediatric Early Warning Score Across Different Subspecialty Patients. (Duke)

Dean NP, et al. Evaluation of a Pediatric Early Warning Score Across Different Subspecialty Patients. Pediatr Crit Care Med. 2017 Jul;18(7):655-660.

OBJECTIVE: To evaluate the ability of a Pediatric Early Warning Score to predict deterioration in different subspecialty patient populations.

DESIGN: Single center, retrospective cohort study. Patients were classified into five groups: 1) cardiac; 2) hematology/oncology/bone marrow transplant; 3) surgical; 4) neurologic; and 5) general medical. The relationship between the Pediatric Early Warning Score and unplanned ICU transfer requiring initiation of specific ICU therapies (intubation, high-flow nasal cannula, noninvasive ventilation, inotropes, or aggressive fluid hydration within 12 hr of transfer) was evaluated.

SETTING: Tertiary care, free-standing, academic children’s hospital.

PATIENTS: All hospitalized acute care patients admitted over a 6-month time period (September 2012 to March 2013).

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: During the study time period, 33,800 patient-days and 136 deteriorations were evaluated. Area under the curve ranged from 0.88 (surgical) to 0.94 (cardiac). Sensitivities for a Pediatric Early Warning Score greater than or equal to 3 ranged from 75% (surgical) to 94% (cardiology) and number needed to evaluate to find one deterioration was 11.5 (neurologic) to 43 patients (surgical). Sensitivities for a Pediatric Early Warning Score greater than or equal to 4 ranged from 54% (general medical) to 79% (hematology/oncology/bone marrow transplant) and number needed to evaluate of 5.5 (neurologic) to 12 patients (general medical). Sensitivities for a Pediatric Early Warning Score of greater than or equal to 5 ranged from 25% (surgical) to 58% (hematology/oncology/bone marrow transplant) and number needed to evaluate of 3.5 (cardiac, hematology/oncology/bone marrow transplant, neurologic) to eight patients (surgical).

CONCLUSIONS: An elevated Pediatric Early Warning Score is associated with ICU transfer and receipt of ICU-specific interventions in patients across different pediatric subspecialty patient populations.

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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.

Serum Albumin Is an Independent Predictor of Clinical Outcomes in Critically Ill Children. (Ward)

Leite HP, et al. Serum Albumin Is an Independent Predictor of Clinical Outcomes in Critically Ill Children. Pediatr Crit Care Med. 2016 Feb;17(2):e50-7.

OBJECTIVES: Serum albumin is a strong biomarker of disease severity and prognosis in adult patients. In contrast, its value as predictor of outcome in critically ill children has not been established. We aimed to determine whether admission hypoalbuminemia is associated with outcome in a general pediatric population of critically ill patients, taking into account the inflammatory response, disease severity, and nutritional status of the patient.

DESIGN: Analysis of prospectively collected database.

SETTING: PICU of a teaching hospital.

PATIENTS: Two hundred seventy-one patients consecutively admitted. Neonates, patients with chronic liver or kidney disease, inborn errors of metabolism, those who received prior administration of albumin solution, and readmissions were excluded.

MEASUREMENTS AND MAIN RESULTS: Outcome variables were 60-day mortality, probability of ICU discharge at 60 days, and ventilator-free days. Potential exposure variables for the outcome were sex, age, nutritional status, albumin, C-reactive protein and serum lactate at admission, and Pediatric Index of Mortality 2 score. Admission hypoalbuminemia was present in 64.2% of patients. After adjustment for confounding factors, only serum lactate, Pediatric Index of Mortality 2 score, and serum albumin were associated with higher mortality: the increase of 1.0 g/dL in serum albumin at admission resulted in a 73% reduction in the hazard of death (hazard ratio, 0.27; 95% CI, 0.14-0.51; p < 0.001). The increase of 1 g/dL in serum albumin was also independently associated with a 33% rise in the probability of ICU discharge (subhazard ratio, 1.33; 95% CI, 1.07-1.64; p = 0.008) and increased ventilator-free-days (odds ratio, 1.86; 95% CI, 0.56-3.16; p = 0.005).

CONCLUSIONS: Hypoalbuminemia at admission to a PICU is associated with higher 60-day mortality, longer duration of mechanical ventilation, and lower probability of ICU discharge. These associations are independent of the magnitude of inflammatory response, clinical severity, and nutritional status.

Use of time from fever onset improves the diagnostic accuracy of C-reactive protein in identifying bacterial infections. (Kamat)

Segal I, Ehrlichman M, Urbach J, Bar-Meir M. Use of time from fever onset
improves the diagnostic accuracy of C-reactive protein in identifying bacterial
infections. Arch Dis Child. 2014 May 15.

OBJECTIVE: To determine whether the input of time from fever onset will change the accuracy of C-reactive protein (CRP) in diagnosing bacterial infections in febrile children.

STUDY DESIGN: We performed a prospective observational study on febrile children presenting to the emergency department. The diagnostic performance of CRP at different time points from fever onset was compared using a receiver operating characteristic (ROC) curve.

RESULTS: Among 373 patients included, 103 (28%) had bacterial infection. The optimal cut-off for CRP suggesting bacterial infection changed with time from fever onset: 6 mg/dL for >12-24 h of fever; 10.7 and 12.6 mg/dL at >24-48 and >48 h of fever, respectively. The input of time from fever onset improved the area under the ROC curve from 0.83 (95% CI 0.78 to 0.88) for CRP overall to 0.87 (95% CI 0.77 to 0.96) and 0.90 (95% CI 0.84 to 0.97) at >24-48 and >48 h of fever, respectively. Duration of fever mostly affected the ability of CRP to correctly rule out bacterial infections. CRP level of 2 mg/dL obtained at ≤24 h of fever corresponds with a post-test probability for bacterial infection of 10%, whereas the same value obtained >24 h of fever reduces the risk to 2%.

CONCLUSIONS: Clinicians should apply different CRP cut-off values depending on whether they are trying to rule in or rule out bacterial infection, but also depending on fever duration at the time of CRP testing.

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