A Systematic Review of Risk Factors Associated With Cognitive Impairment After Pediatric Critical Illness. (Land)

Kachmar AG, et al. A Systematic Review of Risk Factors Associated With Cognitive Impairment After Pediatric Critical Illness. Pediatr Crit Care Med. 2018 Mar;19(3):e164-e171.

OBJECTIVES: To identify risk factors associated with cognitive impairment as assessed by neuropsychologic tests in neurotypical children after critical illness.

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Repeated Critical Illness and Unplanned Readmissions Within 1 Year to PICUs. (Chaudhary)

Edwards JD, Lucas AR, Boscardin WJ, Dudley RA. Repeated Critical Illness and Unplanned Readmissions Within 1 Year to PICUs. Crit Care Med. 2017 Aug;45(8):1276-1284.

OBJECTIVES: To determine the occurrence rate of unplanned readmissions to PICUs within 1 year and examine risk factors associated with repeated readmission.

DESIGN: Retrospective cohort analysis.

SETTING: Seventy-six North American PICUs that participated in the Virtual Pediatric Systems, LLC (VPS, LLC, Los Angeles, CA).

PATIENTS: Ninety-three thousand three hundred seventy-nine PICU patients discharged between 2009 and 2010.


MEASUREMENTS AND MAIN RESULTS: Index admissions and unplanned readmissions were characterized and their outcomes compared. Time-to-event analyses were performed to examine factors associated with readmission within 1 year. Eleven percent (10,233) of patients had 15,625 unplanned readmissions within 1 year to the same PICU; 3.4% had two or more readmissions. Readmissions had significantly higher PICU mortality and longer PICU length of stay, compared with index admissions (4.0% vs 2.5% and 2.5 vs 1.6 d; all p < 0.001). Median time to readmission was 30 days for all readmissions, 3.5 days for readmissions during the same hospitalization, and 66 days for different hospitalizations. Having more complex chronic conditions was associated with earlier readmission (adjusted hazard ratio, 2.9 for one complex chronic condition; hazard ratio, 4.8 for two complex chronic conditions; hazard ratio, 9.6 for three or more complex chronic conditions; all p < 0.001 compared no complex chronic condition). Most specific complex chronic condition conferred a greater risk of readmission, and some had considerably higher risk than others.

CONCLUSIONS: Unplanned readmissions occurred in a sizable minority of PICU patients. Patients with complex chronic conditions and particular conditions were at much higher risk for readmission.

A Simple and Robust Bedside Model for Mortality Risk in Pediatric Patients With Acute Respiratory Distress Syndrome. (Sirignano)

Spicer AC, et al. A Simple and Robust Bedside Model for Mortality Risk in Pediatric Patients With Acute Respiratory Distress Syndrome. Pediatr Crit Care Med. 2016 Aug 3. [Epub ahead of print]

OBJECTIVES: Despite declining mortality, acute respiratory distress syndrome is still involved in up to one third of pediatric intensive care deaths. The recently convened Pediatric Acute Lung Injury Consensus Conference has outlined research priorities for the field, which include the need for accurate bedside risk stratification of patients. We aimed to develop a simple yet robust model of mortality risk among pediatric patients with acute respiratory distress syndrome to facilitate the targeted application of high-risk investigational therapies and stratification for enrollment in clinical trials.

DESIGN: Prospective, multicenter cohort.

SETTING: Five academic PICUs.

PATIENTS: Three hundred eight children greater than 1 month and less than or equal to 18 years old, admitted to the ICU, with bilateral infiltrates on chest radiograph and PaO2/FIO2 ratio less than 300 in the clinical absence of left atrial hypertension.


MEASUREMENTS AND MAIN RESULTS: Twenty clinical variables were recorded in the following six categories: demographics, medical history, oxygenation, ventilation, radiographic imaging, and multiple organ dysfunction. Data were measured 0-24 and 48-72 hours after acute respiratory distress syndrome onset (day 1 and 3) and examined for associations with hospital mortality. Among 308 enrolled patients, mortality was 17%. Children with a history of cancer and/or hematopoietic stem cell transplant had higher mortality (47% vs 11%; p < 0.001). Oxygenation index, the PaO2/FIO2 ratio, extrapulmonary organ dysfunction, Pediatric Risk of Mortality-3, and positive cumulative fluid balance were each associated with mortality. Using two statistical approaches, we found that a parsimonious model of mortality risk using only oxygenation index and cancer/hematopoietic stem cell transplant history performed as well as other more complex models that required additional variables.

CONCLUSIONS: In the PICU, oxygenation index and cancer/hematopoietic stem cell transplant history can be used on acute respiratory distress syndrome day 1 or day 3 to predict hospital mortality without the need for more complex models. These findings may simplify risk assessment for clinical trials, counseling families, and high-risk interventions such as extracorporeal life support.

Analysis of Unplanned Intensive Care Unit Admissions in Postoperative Pediatric Patients. (Sirignano)

Landry EK, et al. Analysis of Unplanned Intensive Care Unit Admissions in Postoperative Pediatric Patients. J Intensive Care Med. 2016 Aug 15. [Epub ahead of print]

BACKGROUND: Currently, there are only a few retrospective, single-institution studies that have addressed the prevalence and risk factors associated with unplanned admissions to the pediatric intensive care unit (ICU) after surgery. Based on the limited amount of studies, it appears that airway and respiratory complications put a child at increased risk for unplanned ICU admission. A more extensive and diverse analysis of unplanned postoperative admissions to the ICU is needed to address risk factors that have yet to be revealed by the current literature.

AIM: To establish a rate of unplanned postoperative ICU admissions in pediatric patients using a large, multi-institution data set and to further characterize the associated risk factors.

METHODS: Data from the National Anesthesia Clinical Outcomes Registry were analyzed. We recorded the overall risk of unplanned postoperative ICU admission in patients younger than 18 years and performed univariate and multivariate logistic regression analysis to identify the associated patient, surgical, and anesthetic-related characteristics.

RESULTS: Of the 324 818 cases analyzed, 211 reported an unexpected ICU admission. There was an increased likelihood of unplanned postoperative ICU in infants (age <1 year) and children who were classified as American Society of Anesthesiologists physical status classification of III or IV. Likewise, longer case duration and cases requiring general anesthesia were also associated with unplanned ICU admissions.

CONCLUSION: This study establishes a rate of unplanned ICU admission following surgery in the heterogeneous pediatric population. This is the first study to utilize such a large data set encompassing a wide range of practice environments to identify risk factors leading to unplanned postoperative ICU admissions. Our study revealed that patient, surgical, and anesthetic complexity each contributed to an increased number of unplanned ICU admissions in the pediatric population.