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Hakim H, Richardson T, Riggs R, Auletta JJ, DiGerolamo K, Hron JD, Kohorst M, Laurie K, Maixner M, Mulcahy Levy JM, Ohlsen TJD, Orsey AD, Prudowsky ZD, Raghu VK, Redfern W, Rozenfeld RA, Workman JK, Wilkes JJ. Sepsis Mortality in Hospitalized Children With Cancer Is Associated With Lack of a Screening Tool. Hosp Pediatr 2025; 15:237-246. [PMID: 39933563 DOI: 10.1542/hpeds.2024-007956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 11/05/2024] [Indexed: 02/13/2025]
Abstract
OBJECTIVE Sepsis is associated with significant morbidity and mortality in pediatric hematology, oncology, and transplant (PHOT) patients. This study characterized PHOT patients who developed hospital-onset sepsis more than 12 hours after admission and identified risk factors for 30-day sepsis-attributable (SA) mortality. PATIENTS AND METHODS We analyzed an existing multicenter database of sepsis collected prospectively over 5 years (2017-2021) as part of the Improving Pediatric Sepsis Outcomes Collaborative. Sepsis was defined using operational elements documented in the health records based on International Classification of Diseases, Tenth Revision codes, treatment, diagnostic tests, and sepsis screen, huddle, or order set use. RESULTS A total of 9604 sepsis episodes in PHOT patients from 49 hospitals were analyzed: 70.5% were identified in the emergency department (ED), 10.9% in inpatient settings less than or equal to 12 hours from admission, and 18.6% were hospital onset. Only 52.5% of patients with hospital-onset sepsis were identified using a sepsis recognition method compared with 87.2% in the ED (P < .001). The overall 30-day SA mortality was 2.2%, with a higher rate (6.9%) among those with hospital-onset sepsis compared with those who developed sepsis at presentation or less than or equal to 12 hours (1.1%, P < .001). CONCLUSIONS Although the difference in SA mortality between hospitalized and nonhospitalized patients may be impacted by nonmeasurable confounders inherent to the type of patients presenting in the different care settings, we reported system-based improvements that may reduce mortality. The 30-day SA mortality was lower in hospitalized PHOT patients when sepsis was detected by early recognition methods, supporting the need for efforts to implement sepsis recognition tools in the inpatient setting.
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Affiliation(s)
- Hana Hakim
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Ruth Riggs
- Children's Hospital Association, Lenexa, Kansas
| | | | - Kimberly DiGerolamo
- School of Nursing, Villanova University, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jonathan D Hron
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Mira Kohorst
- Division of Pediatric Hematology Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Jean M Mulcahy Levy
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colorado
| | - Timothy J D Ohlsen
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Andrea D Orsey
- Department of Pediatrics, University of Connecticut School of Medicine, Center for Cancer and Blood Disorders, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Zachary D Prudowsky
- Department of Pediatrics, Section of Pediatric Hematology-Oncology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Vikram K Raghu
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Wendi Redfern
- Department of Advanced Practice Nursing, Children's Wisconsin, Milwaukee, Wisconsin
| | - Ranna A Rozenfeld
- Department of Pediatrics, Alpert Medical School, Brown University, Hasbro Children's Hospital, Providence, Rhode Island
| | - Jennifer K Workman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah
| | - Jennifer J Wilkes
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Xiao YP, Cheng YC, Chen C, Xue HM, Yang M, Lin C. Identification of the Shared Gene Signatures of HCK, NOG, RNF125 and Biological Mechanism in Pediatric Acute Lymphoblastic Leukaemia and Pediatric Sepsis. Mol Biotechnol 2025; 67:80-90. [PMID: 38123749 PMCID: PMC11698841 DOI: 10.1007/s12033-023-00979-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 11/02/2023] [Indexed: 12/23/2023]
Abstract
The shared mechanisms between pediatric acute lymphoblastic leukaemia (ALL) and pediatric sepsis are currently unclear. This study was aimed to explore the shared key genes of pediatric ALL and pediatric sepsis. The datasets involved were downloaded from the Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) between disease and control samples in GSE13904 and GSE79533 were intersected. The least absolute shrinkage and selection operator (LASSO) and the boruta analyses were performed in GSE13904 and GSE79533 separately based on shared DEGs, and shared key genes were obtained by taking the intersection of sepsis-related key genes and ALL-related key genes. Three shared key genes (HCK, NOG, RNF125) were obtained, that have a good diagnostic value for both sepsis and ALL. The correlation between shared key genes and differentially expressed immune cells was higher in GSE13904 and conversely, the correlation of which was lower in GSE79533. Suggesting that the sharing key genes had a different impact on the immune environment in pediatric ALL and pediatric sepsis. We make the case that this study provides a new perspective to study the relationship between pediatric ALL and pediatric sepsis.
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Affiliation(s)
- Ying-Ping Xiao
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Yu-Cai Cheng
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Chun Chen
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Hong-Man Xue
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Mo Yang
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China.
- Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China.
| | - Chao Lin
- Pediatric Hematology Laboratory, Division of Hematology/Oncology, Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China.
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3
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Huang H, Zhang R, Chen J, Dang H, Liu C, Lu S, Fu YQ. Comparing the clinical characteristics and outcomes of septic shock children with and without malignancies: a retrospective cohort study. J Pediatr (Rio J) 2024; 100:633-639. [PMID: 38968957 PMCID: PMC11662747 DOI: 10.1016/j.jped.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 06/03/2024] [Accepted: 06/03/2024] [Indexed: 07/07/2024] Open
Abstract
OBJECTIVE There is an amelioration in mortality rates of septic shock patients with malignancies over time, but it remains uncertain in children. Therefore, the authors endeavored to compare the clinical characteristics, treatment needs, and outcomes of septic shock children with or without malignancies. METHODS The authors retrospectively analyzed the data of children admitted to the PICU due to septic shock from January 2015 to December 2022 in a tertiary pediatric hospital. The main outcome was in-hospital mortality. RESULTS A total of 508 patients were enrolled. The proportion of Gram-negative bacteria and fungal infections in children with malignancies was significantly higher than those without malignancies. Septic shock children with malignancies had a longer length of stay (LOS) in the hospital (21 vs. 11 days, p<0.001). However, there were no statistically significant differences in the LOS of PICU (5 vs. 5 days, p = 0.591), in-hospital mortality (43.0 % vs. 49.4 %, p = 0.276), and 28-day mortality (49.2 % vs. 44.7 %, p = 0.452). The 28-day survival analysis (p = 0.314) also showed no significant differences. CONCLUSION Although there are significant differences in the bacterial spectrum of infections, the septic shock children with or without malignancies showed a similar mortality rate. The septic shock children with malignancies had longer LOS of the hospital.
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Affiliation(s)
- Haixin Huang
- Children's Hospital of Chongqing Medical University, Department of Critical Care Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics Metabolism and Inflammatory Diseases, Chongqing, China
| | - Ruichen Zhang
- Children's Hospital of Chongqing Medical University, Department of Critical Care Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics Metabolism and Inflammatory Diseases, Chongqing, China
| | - Jian Chen
- Children's Hospital of Chongqing Medical University, Department of Critical Care Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics Metabolism and Inflammatory Diseases, Chongqing, China
| | - Hongxing Dang
- Children's Hospital of Chongqing Medical University, Department of Critical Care Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics Metabolism and Inflammatory Diseases, Chongqing, China
| | - Chengjun Liu
- Children's Hospital of Chongqing Medical University, Department of Critical Care Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics Metabolism and Inflammatory Diseases, Chongqing, China
| | - Siwei Lu
- Children's Hospital of Chongqing Medical University, Department of Critical Care Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics Metabolism and Inflammatory Diseases, Chongqing, China
| | - Yue-qiang Fu
- Children's Hospital of Chongqing Medical University, Department of Critical Care Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics Metabolism and Inflammatory Diseases, Chongqing, China
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Wittmann Dayagi T, Nirel R, Avrahami G, Amar S, Elitzur S, Fisher S, Gilead G, Gilad O, Goldberg T, Izraeli S, Kadmon G, Kaplan E, Krauss A, Michaeli O, Stein J, Steinberg-Shemer O, Tamary H, Tausky O, Toledano H, Weissbach A, Yacobovich J, Yanir AD, Zon J, Nahum E, Barzilai-Birenboim S. A Need for a Novel Survival Risk Scoring System for Intensive Care Admissions Due to Sepsis in Pediatric Hematology/Oncology Patients. J Intensive Care Med 2024; 39:484-492. [PMID: 37981801 DOI: 10.1177/08850666231216362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Background: Children with hemato-oncological diseases or following stem cell transplantation (SCT) are at high risk for life-threatening infections; sepsis in this population constitutes a substantial proportion of pediatric intensive care unit (PICU) admissions. The current pediatric prognostic scoring tools to evaluate illness severity and mortality risk are designed for the general pediatric population and may not be adequate for this vulnerable subpopulation. Methods: Retrospective analysis was performed on all PICU admissions for sepsis in children with hemato-oncological diseases or post-SCT, in a single tertiary pediatric hospital between 2008 and 2021 (n = 233). We collected and analyzed demographic, clinical, and laboratory data and outcomes for all patients, and evaluated the accuracy of two major prognostic scoring tools, the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) and the Pediatric Risk of Mortality III (PRISM III). Furthermore, we created a new risk-assessment model that contains additional parameters uniquely relevant to this population. Results: The survival rate for the cohort was 83%. The predictive accuracies of PELOD-2 and PRISM III, as determined by the area under the curve (AUC), were 83% and 78%, respectively. Nine new parameters were identified as clinically significant: age, SCT, viral infection, fungal infection, central venous line removal, vasoactive inotropic score, bilirubin level, C-reactive protein level, and prolonged neutropenia. Unique scoring systems were established by the integration of these new parameters into the algorithm; the new systems significantly improved their predictive accuracy to 91% (p = 0.01) and 89% (p < 0.001), respectively. Conclusions: The predictive accuracies (AUC) of the PELOD-2 and PRISM III scores are limited in children with hemato-oncological diseases admitted to PICU with sepsis. These results highlight the need to develop a risk-assessment tool adjusted to this special population. Such new scoring should represent their unique characteristics including their degree of immunosuppression and be validated in a large multi-center prospective study.
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Affiliation(s)
- Talya Wittmann Dayagi
- Division of Haematology and Oncology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Nirel
- Department of Statistics and Data Science, Hebrew University, Jerusalem, Israel
| | - Galia Avrahami
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shira Amar
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sarah Elitzur
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Salvador Fisher
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gil Gilead
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Gilad
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tracie Goldberg
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shai Izraeli
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kadmon
- Department of pediatric intensive care unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eytan Kaplan
- Department of pediatric intensive care unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviva Krauss
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orli Michaeli
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jerry Stein
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orna Steinberg-Shemer
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hannah Tamary
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Osnat Tausky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatrics, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Helen Toledano
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avichai Weissbach
- Department of pediatric intensive care unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joanne Yacobovich
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaf D Yanir
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jessica Zon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elhanan Nahum
- Department of pediatric intensive care unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomit Barzilai-Birenboim
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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5
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Rubnitz Z, Sun Y, Agulnik A, Merritt P, Allison K, Ferrolino J, Dallas R, Tang L, Wolf J. Prediction of attributable mortality in pediatric patients with cancer admitted to the intensive care unit for suspected infection: A comprehensive evaluation of risk scores. Cancer Med 2023; 12:21287-21292. [PMID: 38011018 PMCID: PMC10726759 DOI: 10.1002/cam4.6709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/18/2023] [Accepted: 11/01/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE To evaluate the performance of existing sepsis scores for prediction of adverse outcomes in children with cancer admitted to the ICU with suspected sepsis. DESIGN Retrospective chart review using data available at 1, 6, 12, and 24 h after ICU admission to calculate the Pediatric Risk of Mortality 3 (PRISM-3), Pediatric Sequential Organ Failure Assessment (pSOFA), Paediatric Logistic Organ Dysfunction 2 (PELOD-2), and Quick Pediatric Sequential Organ Failure Assessment (qSOFA) scores. Area under the receiver operator characteristic curve (AUROC) was used to evaluate performance for prediction of attributable mortality. Sensitivity analyses included recalculation of scores using worst preceding values for each variable, excluding hematologic parameters, and prediction of alternative outcomes. SETTING St. Jude Children's Research Hospital, a pediatric comprehensive cancer center in the USA. PATIENTS Pediatric patients (<25 years of age) receiving conventional therapy for cancer admitted to the ICU with suspected sepsis between 2013 and 2019. RESULTS Of 207 included episodes of suspected sepsis, attributable mortality was 16 (7.7%) and all evaluated sepsis scores performed poorly (maximal AUROC of 0.73 for qSOFA at 1 and 24 h). Sensitivity analyses did not identify an alternative approach that significantly improved prediction. CONCLUSIONS Currently available sepsis scores perform poorly for prediction of attributable mortality in children with cancer who present to ICU with suspected sepsis. More research is needed to identify reliable predictors of adverse outcomes in this population.
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Affiliation(s)
- Zachary Rubnitz
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Yilun Sun
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Asya Agulnik
- Department of Global Pediatric MedicineSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Pamela Merritt
- Department of Infectious DiseasesSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Kim Allison
- Department of Infectious DiseasesSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Jose Ferrolino
- Department of Infectious DiseasesSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Ronald Dallas
- Department of Infectious DiseasesSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Li Tang
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Joshua Wolf
- Department of Infectious DiseasesSt. Jude Children's Research HospitalMemphisTennesseeUSA
- Department of PediatricsUniversity of Tennessee Health Science CenterMemphisTennesseeUSA
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Gaugler M, Swinger N, Rahrig AL, Skiles J, Rowan CM. Multiple Organ Dysfunction and Critically Ill Children With Acute Myeloid Leukemia: Single-Center Retrospective Cohort Study. Pediatr Crit Care Med 2023; 24:e170-e178. [PMID: 36728709 PMCID: PMC10081947 DOI: 10.1097/pcc.0000000000003153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To describe the prevalence of multiple organ dysfunction syndrome (MODS) and critical care utilization in children and young adults with acute myeloid leukemia (AML) who have not undergone hematopoietic cell transplantation (HCT). DESIGN Retrospective cohort study of MODS (defined as dysfunction of two or more organ systems) occurring any day within the first 72 hours of PICU admission. SETTING Large, quaternary-care children's hospital. PATIENTS Patients 1 month through 26 years old who were treated for AML from 2011-2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eighty patients with AML were included. These 80 patients had a total of 409 total non-HCT-related hospital and 71 PICU admissions. The majority 53 of 71 of PICU admissions (75%) were associated with MODS within the first 72 hours. MODS was present in 49 of 71 of PICU admissions (69%) on day 1, 29 of 52 (56%) on day 2, and 25 of 32 (78%) on day 3. The organ systems most often involved were hematologic, respiratory, and cardiovascular. There was an increasing proportion of renal failure (8/71 [11%] on day 1 to 8/32 [25%] on day 3; p = 0.02) and respiratory failure (33/71 [47%] to 24/32 [75%]; p = 0.001) as PICU stay progressed. The presence of MODS on day 1 was associated with a longer PICU length of stay (LOS) (β = 5.4 [95% CI, 0.7-10.2]; p = 0.024) and over a six-fold increased risk of an LOS over 2 days (odds ratio, 6.08 [95% CI, 1.59-23.23]; p = 0.008). Respiratory failure on admission was associated with higher risk of increased LOS. CONCLUSIONS AML patients frequently require intensive care. In this cohort, MODS occurred in over half of PICU admissions and was associated with longer PICU LOS. Respiratory failure was associated with the development of MODS and progressive MODS, as well as prolonged LOS.
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Affiliation(s)
- Mary Gaugler
- Department of Pediatrics, Division of General Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Nathan Swinger
- Department of Pediatrics, Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - April L Rahrig
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Jodi Skiles
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Courtney M Rowan
- Department of Pediatrics, Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
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7
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Sazonov V, Abylkassov R, Tobylbayeva Z, Saparov A, Mironova O, Poddighe D. Case Series: Efficacy and Safety of Hemoadsorption With HA-330 Adsorber in Septic Pediatric Patients With Cancer. Front Pediatr 2021; 9:672260. [PMID: 34178889 PMCID: PMC8225958 DOI: 10.3389/fped.2021.672260] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/19/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Sepsis is a frequent cause of death in hospitalized patients and, in detail, in neonatal, pediatric, and adult intensive care units (ICUs). Severe sepsis has a very poor prognosis. Indeed, the mortality rate varies between 30 and 70% during the first 7-14 days. Despite a timely and appropriate therapy, the prognosis of severe sepsis is too often negative. Therefore, new therapeutic resources are under investigation in order to further improve prognosis. Case series: Here, we reported three septic children in whom we used extracorporeal blood purification therapy with hemoadsorption device HA330 (Jafron Biomedical Co., Ltd., China), aiming to scavenge and eliminate bacterial toxins and inflammatory mediators from the blood. Discussion and Conclusion: This small case series first showed that hemoperfusion with HA330 cartridge may be an effective and relatively safe adjunctive treatment to counterbalance the cytokine storm in septic children with hematological disorders. Further studies are needed to confirm and further support its safety and efficacy in a large number of pediatric patients.
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Affiliation(s)
- Vitaliy Sazonov
- Department of Biomedical Sciences, Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
- Pediatric Anesthesiology and Intensive Care Unit, National Research Center for Maternal and Child Health, “University Medical Center”, Nur-Sultan, Kazakhstan
| | - Ramazan Abylkassov
- Pediatric Anesthesiology and Intensive Care Unit, National Research Center for Maternal and Child Health, “University Medical Center”, Nur-Sultan, Kazakhstan
- Department of Medicine, Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
| | - Zaure Tobylbayeva
- Pediatric Anesthesiology and Intensive Care Unit, National Research Center for Maternal and Child Health, “University Medical Center”, Nur-Sultan, Kazakhstan
| | - Askhat Saparov
- Pediatric Anesthesiology and Intensive Care Unit, National Research Center for Maternal and Child Health, “University Medical Center”, Nur-Sultan, Kazakhstan
| | - Olga Mironova
- Pediatric Anesthesiology and Intensive Care Unit, National Research Center for Maternal and Child Health, “University Medical Center”, Nur-Sultan, Kazakhstan
| | - Dimitri Poddighe
- Department of Medicine, Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
- Department of Pediatrics, National Research Center for Maternal and Child Health, “University Medical Center”, Nur-Sultan, Kazakhstan
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8
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McCormick M, Friehling E, Kalpatthi R, Siripong N, Smith K. Cost-effectiveness of levofloxacin prophylaxis against bacterial infection in pediatric patients with acute myeloid leukemia. Pediatr Blood Cancer 2020; 67:e28469. [PMID: 32710709 PMCID: PMC7722035 DOI: 10.1002/pbc.28469] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/08/2020] [Accepted: 05/18/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Infections are the leading cause of therapy-related mortality in pediatric patients with acute myeloid leukemia (AML). Although effectiveness of levofloxacin antibacterial prophylaxis in oncology patients is recognized, its cost-effectiveness is unknown. This study evaluated epidemiologic data regarding levofloxacin use and the cost-effectiveness of this strategy as the cost per bacteremia episode, intensive care unit (ICU) admission, and death avoided in children with AML. PROCEDURE A retrospective cohort study using the Pediatric Health Information System (PHIS) database compared demographic and clinical characteristics and receipt of levofloxacin prophylaxis in children with AML admitted for chemotherapy from January 1, 2014, through December 31, 2018. We then developed a decision analysis model in this population that compared costs associated with bacteremia, ICU admission, or death secondary to bacteremia to levofloxacin prophylaxis cost from a healthcare perspective. Time horizon is one chemotherapy cycle. Probabilistic and one-way sensitivity analyses evaluated model uncertainty. RESULTS Prophylaxis cost $8491 per bacteremia episode prevented compared with an average added hospital cost of $119 478. Prophylaxis cost $81 609 per ICU admission avoided, compared with an average added hospital cost of $94 181. Prophylaxis cost $220 457 per death avoided. In sensitivity analysis, at a willingness-to-pay threshold of $100 000 per bacteremia episode avoided, prophylaxis remained cost-effective in 94.6% of simulations. Prophylaxis use was more common in recent years in patients with relapsed disease and with chemotherapy regimens considered more intensive. CONCLUSION Prophylaxis is cost-effective in preventing bacterial infections in patients with AML. Findings support increased use in patients considered at high risk of bacterial infection secondary to myelosuppression.
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Affiliation(s)
- Meghan McCormick
- Division of Pediatric Hematology-Oncology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Erika Friehling
- Division of Pediatric Hematology-Oncology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ramasubramanian Kalpatthi
- Division of Pediatric Hematology-Oncology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nalyn Siripong
- The Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kenneth Smith
- Department of Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Prevalence of Children With Complex Chronic Conditions in PICUs of Argentina: A Prospective Multicenter Study. Pediatr Crit Care Med 2020; 21:e143-e151. [PMID: 31851126 DOI: 10.1097/pcc.0000000000002223] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the prevalence of children with complex chronic conditions in PICUs in Argentina. To describe the demographic profile, clinical course and outcomes in PICU of children with complex chronic condition in comparison to previously healthy children. DESIGN Prospective, observational multicenter study. SETTING Nineteen PICUs located in Argentina belonging to public and private institutions. PATIENTS All children admitted to the participating PICUs between March 1, 2015, and February 28, 2016. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS We analyzed 3,483 PICU admissions. The prevalence of complex chronic condition was 48.06% (95% CI, 46.39-49.72). Cardiovascular complex chronic condition was predominant (22.24% [421/1,893]), followed by neuromuscular complex chronic condition (18.75% [355/1,893]) and malignant disease 17.7% (335/1,893). Technologic dependence was present in 22.22% of the patients (372 of 1,674). Predominant admission diagnosis was postoperative (36.6%) and respiratory disease (28.32%). Children with complex chronic condition had higher mortality than previously healthy patients (odds ratio, 2.74; 95% CI, 2.01-3.73). The risk of prolonged stay (≥ 26 d) was also higher (odds ratio, 1.44; 95% CI, 1.10-1.89). Rate utilization of the following devices was higher in patients with complex chronic condition: mechanical ventilation (odds ratio, 1.35; 95% CI, 1.12-1.63), central venous catheter (odds ratio, 1.24; 95% CI, 1.04-1.48), and arterial monitoring (odds ratio, 1.33; 95% CI, 1.09-1.63). CONCLUSIONS We observed a high prevalence of patients with complex chronic condition in this sample of argentine PICUs. These patients presented higher mortality and resource use than previously healthy children. This information is valuable to understand the impact that patients with complex chronic condition have on PICU performance and enables proper planning of care.
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Aljabari S, Balch A, Larsen GY, Fluchel M, Workman JK. Severe Sepsis-Associated Morbidity and Mortality among Critically Ill Children with Cancer. J Pediatr Intensive Care 2018; 8:122-129. [PMID: 31404226 DOI: 10.1055/s-0038-1676658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 11/05/2018] [Indexed: 01/20/2023] Open
Abstract
Severe sepsis (SS) in pediatric oncology patients is a leading cause of morbidity and mortality. We investigated the incidence of and risk factors for morbidity and mortality among children diagnosed with cancer from 2008 to 2012, and admitted with SS during the 3 years following cancer diagnosis. A total of 1,002 children with cancer were included, 8% of whom required pediatric intensive care unit (PICU) admission with SS. Death and/or multiple organ dysfunction syndrome occurred in 34 out of 99 PICU encounters (34%). Lactate level and history of stem-cell transplantation were significantly associated with the development of death and/or organ dysfunction ( p < 0.05).
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Affiliation(s)
- Salim Aljabari
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Alfred Balch
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Gitte Y Larsen
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Mark Fluchel
- Division of Pediatric Hematology and Oncology, Department of pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Jennifer K Workman
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
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Ippolito D, Masetto A, Talei Franzesi C, Bonaffini PA, Casiraghi A, Sironi S. Relative volume measured with magnetic resonance imaging is an articular collapse predictor in hematological pediatric patients with femoral head osteonecrosis. World J Radiol 2016; 8:750-756. [PMID: 27648169 PMCID: PMC5002506 DOI: 10.4329/wjr.v8.i8.750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/10/2016] [Accepted: 06/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the potential value of femoral head (FH) volume measurements to predict joint collapse, as compared to articular surface involvement, in post-treatment osteonecrosis (ON) in pediatric patients affected by lymphoproliferative diseases.
METHODS Considering 114 young patients with lymphoproliferative diseases undergone a lower-limbs magnetic resonance imaging (MRI) examination between November 2006 and August 2012 for a suspected post-treatment ON, we finally considered a total of 13 cases (7 males, mean age 15.2 ± 4.8 years), which developed a FH ON lesions (n = 23). The MRI protocol included coronal short tau inversion recovery and T1-weighted sequences, from the hips to the ankles. During the follow-up (elapsed time: 9.2 ± 2 mo), 13/23 FH articular surface (FHS) developed articular deformity. The first MRI studies with diagnosis of ON were retrospectively analyzed, measuring FH volume (FHV), FHS, ON volume (ONV) and the articular surface involved by ON (ONS). The relative involvement of FHS, in terms of volume [relative volume (RV): ONV/FHV] and articular surface [relative surface (RS): ONS/FHS], was then calculated.
RESULTS By using receiver operating characteristic curve analysis (threshold of 23% of volume involvement), RV predicted articular deformity in 13/13 FHS [sensitivity 100%, specificity 90%, accuracy 95%, positive predictive value (PPV) 93%, negative predictive value (NPV) 100%]. Considering a threshold of 50% of articular involvement, RS predicted articular deformity in 10/13 femoral heads (sensitivity 77%, specificity 100%, accuracy 87%, PPV 100%, NPV 77%).
CONCLUSION RV might be a more reliable parameter than RS in predicting FH deformity and could represent a potential complementary diagnostic tool in the follow-up of femoral heads ON lesions.
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Supporting information retrieval from electronic health records: A report of University of Michigan's nine-year experience in developing and using the Electronic Medical Record Search Engine (EMERSE). J Biomed Inform 2015; 55:290-300. [PMID: 25979153 DOI: 10.1016/j.jbi.2015.05.003] [Citation(s) in RCA: 315] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/31/2015] [Accepted: 05/05/2015] [Indexed: 12/18/2022]
Abstract
OBJECTIVE This paper describes the University of Michigan's nine-year experience in developing and using a full-text search engine designed to facilitate information retrieval (IR) from narrative documents stored in electronic health records (EHRs). The system, called the Electronic Medical Record Search Engine (EMERSE), functions similar to Google but is equipped with special functionalities for handling challenges unique to retrieving information from medical text. MATERIALS AND METHODS Key features that distinguish EMERSE from general-purpose search engines are discussed, with an emphasis on functions crucial to (1) improving medical IR performance and (2) assuring search quality and results consistency regardless of users' medical background, stage of training, or level of technical expertise. RESULTS Since its initial deployment, EMERSE has been enthusiastically embraced by clinicians, administrators, and clinical and translational researchers. To date, the system has been used in supporting more than 750 research projects yielding 80 peer-reviewed publications. In several evaluation studies, EMERSE demonstrated very high levels of sensitivity and specificity in addition to greatly improved chart review efficiency. DISCUSSION Increased availability of electronic data in healthcare does not automatically warrant increased availability of information. The success of EMERSE at our institution illustrates that free-text EHR search engines can be a valuable tool to help practitioners and researchers retrieve information from EHRs more effectively and efficiently, enabling critical tasks such as patient case synthesis and research data abstraction. CONCLUSION EMERSE, available free of charge for academic use, represents a state-of-the-art medical IR tool with proven effectiveness and user acceptance.
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Xu XJ, Tang YM, Song H, Yang SL, Xu WQ, Shi SW. Corticosteroid administration is associated with improved outcome of patients presenting high inflammatory cytokine levels during septic shock. Pediatr Blood Cancer 2014; 61:2243-8. [PMID: 25174717 DOI: 10.1002/pbc.25132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 05/12/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND This study aimed to investigate the corticosteroid effects on pediatric hematology/oncology patients with septic shock. PROCEDURE We performed a retrospective study by examining data from a prospective observational study in pediatric hematology/oncology patients with septic shock. We compared the clinical features and the outcomes of the patients treated with and without corticosteroid. RESULTS One hundred episodes of septic shock were recorded in this study. The 28-day mortality of this cohort was 14.0%. Sixty-eight episodes of shock were treated with corticosteroids while 32 were not. The demographic features and disease severity were comparable between patients with and without corticosteroid treatment. Corticosteroid therapy was associated with improved shock reversal rate (92.6% vs. 78.1%, P = 0.049) and decreased 28-day mortality rate (8.8 ± 3.4% vs. 25.0 ± 7.7%, P = 0.032) in univariate analysis. For patients who received vasopressor support, corticosteroid therapy was associated with shortened duration of vasopressor infusion in univariate analysis as well (median: 44 hour vs. 92 hour, P = 0.035). In multivariate analysis, corticosteroid therapy did not show significant impact on the outcome for the whole cohort (HR = 0.36, P = 0.079), but it decreased the 28-day mortality of patients presenting high inflammatory cytokine levels (HR = 0.29, 95% CI, 0.09-0.95, P = 0.040). Corticosteroid administration did not increase the superinfection rate (24.2% vs. 8.3%, P = 0.134) and did not result in superinfection-related death in this cohort. CONCLUSIONS Corticosteroid administration is associated with improved outcome in pediatric hematology/oncology patients presenting high inflammatory cytokine levels during septic shock. Pediatr Blood Cancer 2014;61:2243-2248. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Xiao-Jun Xu
- Division of Hematology/Oncology, Children's Hospital of Zhejiang University School of Medicine, Hangzhou, PR China; Key Laboratory of Reproductive Genetics (Zhejiang University), Ministry of Education, Hangzhou, PR China
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Zinter MS, DuBois SG, Spicer A, Matthay K, Sapru A. Pediatric cancer type predicts infection rate, need for critical care intervention, and mortality in the pediatric intensive care unit. Intensive Care Med 2014; 40:1536-44. [PMID: 25023526 PMCID: PMC4177269 DOI: 10.1007/s00134-014-3389-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/27/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE Up to 38 % of children with cancer require pediatric intensive care unit (PICU) admission within 3 years of diagnosis, with reported PICU mortality of 13-27 % far exceeding that of the general PICU population. PICU outcomes data for individual cancer types are lacking and may help identify patients at risk for poor clinical outcomes. METHODS We performed a retrospective multicenter analysis of 10,365 PICU admissions of cancer patients no greater than 21 years old among 112 PICUs between 1 January 2009 and 30 June 2012. We evaluated the effect of cancer type, age, gender, genetic syndrome, stem cell transplantation, PRISM3 score, infections, and critical care interventions on PICU mortality. RESULTS After excluding scheduled perioperative admissions, cancer patients represented 4.2 % of all PICU admissions (10,365/246,346), had overall mortality of 6.8 % (708/10,365) vs. 2.4 % (5,485/230,548) in the general PICU population (RR = 2.9, 95 % CI 2.7-3.1, p < 0.001), and accounted for 11.4 % of all PICU deaths (708/6,215). Hematologic cancer patients had greater median PRISM3 score (8 vs 2, p < 0.001), rates of sepsis (27 vs 9 %, RR = 2.9, 95 % CI 2.6-3.1, p < 0.001), and mortality (9.6 vs 4.5 %, RR = 2.1, 95 % CI 1.8-2.5, p < 0.001) compared to solid cancer patients. Among hematologic cancer patients, stem cell transplantation, diagnosis of acute myeloid leukemia, PRISM3 score, and infection were all independently associated with PICU mortality. CONCLUSIONS Children with cancer account for 4.2 % of PICU admissions and 11.4 % of PICU deaths. Hematologic cancer patients have significantly higher admission illness severity, rates of infections, and PICU mortality than solid cancer patients. These data may be useful in risk stratification for closer monitoring and patient counseling.
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Affiliation(s)
- Matt S Zinter
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco-School of Medicine, 505 Parnassus Ave, M680, San Francisco, 94143-0106, CA, USA,
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Laddie J, Craig F, Brierley J, Kelly P, Bluebond-Langner M. Withdrawal of ventilatory support outside the intensive care unit: guidance for practice. Arch Dis Child 2014; 99:812-6. [PMID: 24951460 PMCID: PMC4145452 DOI: 10.1136/archdischild-2013-305492] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To review the work of one tertiary paediatric palliative care service in facilitating planned withdrawal of ventilatory support outside the intensive care setting, with the purpose of developing local guidance for practice. METHODS Retrospective 10-year (2003-2012) case note review of intensive care patients whose parents elected to withdraw ventilation in another setting. Demographic and clinical data revealed common themes and specific incidents relevant to local guideline development. RESULTS 18 children (aged 2 weeks to 16 years) were considered. Three died prior to transfer. Transfer locations included home (5), hospice (8) and other (2). Primary pathologies included malignant, neurological, renal and respiratory diseases. Collaborative working was evidenced in the review including multidisciplinary team meetings with the palliative care team prior to discharge. Planning included development of symptom management plans and emergency care plans in the event of longer than anticipated survival. Transfer of children and management of extubations demonstrated the benefits of planning and recognition that unexpected events occur despite detailed planning. We identified the need for local written guidance supporting healthcare professionals planning and undertaking extubation outside the intensive care setting, addressing the following phases: (i) introduction of withdrawal, (ii) preparation pretransfer, (iii) extubation, (iv) care postextubation and (v) care postdeath. CONCLUSIONS Planned withdrawal of ventilatory support outside the intensive care setting is challenging and resource intensive. The development of local collaborations and guidance can enable parents of children dependent on intensive care to consider a preferred place of death for their child, which may be outside the intensive care unit.
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Affiliation(s)
- Joanna Laddie
- Evelina London Children's Hospital, Guys and St Thomas's NHS Foundation Trust, London, UK
| | - Finella Craig
- The Louis Dundas Centre for Children's Palliative Care, Great Ormond Street Children's Hospital NHS Foundation Trust, London, UK
| | - Joe Brierley
- Great Ormond Street Children's Hospital NHS Foundation Trust, London, UK
| | - Paula Kelly
- The Louis Dundas Centre for Children's Palliative Care, University College London, Institute of Child Health and Lecturer in Child and Adolescent Nursing, Kings College London, London, UK.
| | - Myra Bluebond-Langner
- The Louis Dundas Centre for Children's Palliative Care, University College London, Institute of Child Health, London, UK,Rutgers University, Camden, New Jersey, USA
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