CUTE RESPIRATORY DISTRESS syndrome (ARDS) was originally termed the adult respiratory distress syndrome because it resembled the clinical picture of infant respiratory distress syndrome (IRDS), and both exhibited hyaline membranes at autopsy. 1,2 Avery and Mead 3 first reported that lung surfactant quantity and activity were abnormal in infants with IRDS and surfactant replacement has subsequently become standard therapy for premature infants at risk for or having IRDS. Petty and Ashbaugh 2 described qualitative and quantitative surfactant deficiencies in their initial description of ARDS and the subsequent scientific literature (recently reviewed by Notter 4) has supported the role of surfactant dysfunction in both ARDS and less severe acute lung injury (ALI). 5 Surfactant replacement in ARDS and ALI has been Author Affiliations and Participating Hospitals and Collaborating Investigators are listed at the end of this article. Financial Disclosures: Dr Willson has received research grants from ONY Inc (Amherst, NY). Dr Egan is president and equity owner of ONY Inc.
Critically ill children are at significant risk for developing anemia and receiving blood transfusions. Transfusion in the PICU was associated with worse outcomes. It is imperative to minimize blood loss from blood draws and to set clear transfusion thresholds.
OBJECTIVE To estimate the prevalence of chronic conditions among children admitted to U.S. pediatric intensive care units (PICU) and to assess whether patients with complex chronic conditions (CCC) experience PICU mortality and prolonged LOS risk beyond that predicted by commonly-used severity-of-illness risk-adjustment models. DESIGN, SETTING, & PATIENTS Retrospective cohort analysis of 52,791 pediatric admissions to 54 U.S. PICUs that participated in the Virtual Pediatric Intensive Care Unit Performance System (VPS) database in 2008. MEASUREMENTS Hierarchical logistic regression models, clustered by PICU site, for PICU mortality and length of stay (LOS) > 15 days. Standardized mortality ratios (SMR) adjusted for severity-of-illness score alone and with CCC. MAIN RESULTS Fifty-three percent of PICU admissions had a CCC, 18.5% had a non-complex chronic conditions (NCCC). The prevalence of these conditions and their organ system subcategories varied considerably across sites. The majority of CCC subcategories were associated with significantly greater odds of PICU mortality (odds ratios [OR] 1.25–2.9, all P values <0.02) compared to having a non-complex chronic condition (NCCC) or no chronic condition, after controlling for age, gender, trauma, and severity-of-illness. Only respiratory, gastrointestinal, and rheumatologic/orthopedic/psychiatric CCC were not associated with increased odds of PICU mortality. All subcategories were significantly associated with prolonged LOS. All NCCC subcategories were either not associated or negatively associated with PICU mortality, and most were not associated with prolonged LOS, compared to having no chronic conditions. Among this group of PICUs, adding CCCs to risk-adjustment models led to greater model accuracy but did not substantially change unit-level SMRs. CONCLUSIONS Children with CCC were at greater risk for PICU mortality and prolonged LOS than those with no chronic conditions, but the magnitude of risk varied across subcategories. Inclusion of CCCs into models of PICU mortality improved model accuracy but had little impact on SMRs.
Objective The epidemiology and outcomes of Multiple Organ Dysfunction Syndrome (MODS) are incompletely characterized in the pediatric population due to small sample size and conflicting diagnoses of organ failure. We sought to describe the epidemiology and outcomes of early MODS in a large clinical database of PICU patients based on consensus definitions of organ failure. Design Retrospective analysis of a contemporaneously collected clinical PICU database. Setting VPICU Performance System (VPS) database patient admissions from 1/2004-12/2005 for 35 US children’s hospitals. Patients We evaluated 63,285 consecutive PICU admissions from 1/2004-12/2005 in the VPS database. We excluded patients <1 month or >18 years of age, and hospitals with >10% missing values for MODS variables. We identified day 1 MODS by International Pediatric Sepsis Consensus Conference (IPSCC) criteria with day 1 laboratory and vital sign values. We evaluated functional status using Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) scores from PICU admission and discharge. Interventions Analysis: Student’s t-test, Χ2, Mann-Whitney rank sum, Kruskal-Wallis, linear and logistic regression. Measurements and Main Results We analyzed 44,693 admissions from 28 hospitals meeting inclusion criteria. Overall PICU mortality was 2.8%. We identified day 1 MODS in 18.6% of admissions. Patients with day 1 MODS had higher mortality (10.0% v. 1.2%, p<0.001), longer PICU length of stay (3.6 v. 1.3 days, p<0.001) and larger change from baseline POPC and PCPC scores at time of PICU discharge (p<0.001). Infants had the highest incidence of day 1 MODS (25.2% vs. 16.5%, p<0.001) compared to other age groups. Conclusions Using the largest clinical dataset to date and consensus definitions for organ failure, we found that children with MODS present on day one of ICU admission have worse functional outcomes, higher mortality, and longer PICU length of stay than children who do not have MODS on day one. Infants are disproportionally affected by MODS.
Deming 1961 Deming MV, Oech SR. Steroid and antihistaminic therapy for post-intubation subglottic edema in infants and children.
Survival after the Norwood procedure is associated with institutional Norwood procedure volume but not with individual surgeon case volume, suggesting the need for improvements in institutional-based approaches to the care of children with hypoplastic left heart syndrome and the need for establishing regional referral centers for such high-risk procedures to improve patient survival.
BackgroundYoung maternal age has long been associated with higher infant mortality rates, but the role of socioeconomic factors in this association has been controversial. We sought to investigate the relationships between infant mortality (distinguishing neonatal from post-neonatal deaths), socioeconomic status and maternal age in a large, retrospective cohort study.MethodsWe conducted a population-based cohort study using linked birth-death certificate data for Missouri residents during 1997–1999. Infant mortality rates for all singleton births to adolescent women (12–17 years, n = 10,131; 18–19 years, n = 18,954) were compared to those for older women (20–35 years, n = 28,899). Logistic regression was used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI) for all potential associations.ResultsThe risk of infant (OR 1.95, CI 1.54–2.48), neonatal (1.69, 1.24–2.31) and post-neonatal mortality (2.47, 1.70–3.59) were significantly higher for younger adolescent (12–17 years) than older (20–34 years) mothers. After adjusting for race, marital status, age-appropriate education level, parity, smoking status, prenatal care utilization, and poverty status (indicated by participation in WIC, food stamps or Medicaid), the risk of post-neonatal mortality (1.73, 1.14–2.64) but not neonatal mortality (1.43, 0.98–2.08) remained significant for younger adolescent mothers. There were no differences in neonatal or post-neonatal mortality risks for older adolescent (18–19 years) mothers.ConclusionSocioeconomic factors may largely explain the increased neonatal mortality risk among younger adolescent mothers but not the increase in post-neonatal mortality risk.
At least 30% of children in a cross-section of US PICUs are endotracheally intubated, and 25% of those with respiratory failure do not fulfill the radiographic criteria for ALI. Although few patients without an indwelling arterial line require more than modest ventilator support, many may still meet the oxygenation criteria for ALI. These findings will facilitate sample size calculations and help to determine feasibility for future trials on pediatric mechanical ventilation.
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