Oncology patients in a pediatric intensive care unit--a 7-year experience

BACKGROUND: As a result of improved therapeutic and diagnostic modalities the survival rate of children with neoplastic disease has increased dramatically. The consequences of these scientific advances have led to increased malignancy-related critical complications requiring the expertise of intensive care practitioners. PATIENTS: From all children admitted to the pediatric intensive care unit (PICU) of the Martin-Luther University Halle those with hematologic-oncologic condition were evaluated. RESULTS: From 4068 PICU admissions 196 (4.8%) oncologic patients were identified. Most of them were admitted for postoperative care, monitoring or intervention. 24 patients were admitted because of severe disease or treatment related complications. 14 out of 24 (58%) patients died on PICU. Mortality was significant higher in a subgroup requiring mechanical ventilation or suffering from sepsis. All patients but two with multi-organ system failure (> or = 2 organs) died. CONCLUSIONS: Children with neoplastic disease can benefit from pediatric intensive care unit (PICU) support. Successful treatment of life-threatening complications requires a close cooperation of pediatric oncology and PICU. Further studies are necessary to improve therapeutic strategies in oncology patients requiring PICU admission.     

Factores pronósticos de evolución complicada en la bronquiolitis que requiere ingreso en cuidados intensivos pediátricos

ObjectiveTo analyse the prognostic factors for complications in children with bronchiolitis admitted to a pediatric intensive care unit (PICU).Patients and methodA retrospective study was performed on children with bronchiolitis admitted into a PICU between 2000 and 2006. Univariate and multivariate analysis were performed to study the prognostic factors of complications, mechanical ventilation requirements, mortality and PICU stays of more than 15 days.ResultsA total of 110 patients were studied, of whom 72 (65.5%) had high risk factors: prematurity (39.1%), cardiac disease (38.2%) and bronchopulmonary dysplasia (16.3%). A total of 82.7% of patients had complications; 26% need invasive mechanical ventilation and the mortality was 3.6%, and 16.4% stayed in PICU for more than 15 days. Factors associated with mechanical ventilation were the clinical Wood-Downes score and heart disease. A weight less than 5 kg was associated with complications; heart disease and invasive mechanical ventilation were associated with a longer PICU stay; prematurity and mechanical ventilation were associated with mortality.ConclusionsChildren with bronchiolitis admitted into the PICU had a high frequency of complications, often needed mechanical ventilation and had long stays in the PICU, but the mortality is low. The best prognostic factors on admission into the PICU were the acute respiratory insufficiency score, the presence of heart disease and were premature at birth.     

Demographic profile and outcome analysis of a tertiary level pediatric intensive care unit

Objective : To study the profile and outcome of children admitted to a tertiary level pediatric intensive care unit (PICU) in India.Methods : Prospective study of patient demographics, PRISM III scores, diagnoses, treatment, morbidity and mortality of all PICU admissions.Results : 948 children were admitted to the PICU. Mean age was 41.48 months. Male to female ratio was 2.95:1. Mean PRISM III score on admission was 18.50. Diagnoses included respiratory (19.7%), cardiac (9.7%), neurological (17.9%), infectious (12.5%), trauma (11.7%), other surgical (8.8%).196 children (20.68%) required mechanical ventilation. Average duration of ventilation was 6.39 days. 27 children (30.7 children /1000 admissions) had acute respiratory distress syndrome. Gross mortality was 6.7% (59 patients). PRISMIII adjusted mortality was directly proportional to PRISMIII scores. 49.5% of nonsurvivors had multiorgan failure. Average length of PICU stay was 4.52 +/−2.6 days. Complications commonly encountered Were atelectasis (6.37%), accidental extubation (2%), and pneumothorax (0.9%). Incidence of nosocomial infections was 16.86%.Conclusion : Our data appears to be similar with regards to PRISMIII scores and adjusted mortality, length of the PICU stay, and duration of ventilation, to previously published western data. Multiorgan failure remains a major cause of death. As expected, Dengue and malaria were common. Incidence of nosocomial infections was somewhat high. Interestingly, more boys got admitted to the PICU as compared to girls. Clearly more studies are required to assess the overall outcomes of critically ill children in India     

Driscoll Children's Hospital respiratory syncytial virus database: risk factors, treatment and hospital course in 3308 infants and young children, 1991 to 2002

BACKGROUND: Treatment of respiratory syncytial virus (RSV) lower respiratory tract infection has historically been one of the most frequent reasons for admission to Driscoll Children's Hospital. OBJECTIVE: The objective of this study was to examine the relationship of risk factors for a severe and complicated disease course to the treatment and hospital length of stay. METHODS: Subjects were identified through a retrospective review of the medical records of all patients discharged with a diagnosis of RSV lower respiratory tract infection during 9 of the 11 RSV seasons between July 1, 1991 and June 30, 2002. The RSV seasons from 1991-1992 to 1994-1995 were compared with the RSV seasons from 1995-1996 to 2001-2002 with regard to treatment and hospital course. RESULTS: There were a total of 3308 admissions. Compared with patients with no risk factors, higher percentages of patients with age <6 weeks, history of prematurity, congenital heart disease and neurologic disease were admitted to the pediatric intensive care unit (PICU) and required mechanical ventilation (P < 0.001). Also the hospital length of stay was longer for patients with each of these individual risk factors (P < 0.001). The hospital length of stay and the percentages of patients admitted to the PICU and requiring on mechanical ventilation increased as the number of risk factors increased from zero to 3 or more (P < 0.001). Of patients with 3 or more risk factors, the average hospital length of stay was 13.5 days; 67% were admitted to the PICU, and 47% required mechanical ventilation. Ribavirin use decreased in patients with each of the individual risk factors (P < 0.001) as well as in patients with one or more risk factors (P < 0.001). At the same time the PICU admission rate increased from 6.1% to 11.2% (P < 0.001). CONCLUSIONS: Patients with three or more risk factors were at very high risk for having a severe or complicated disease course associated with admission to the PICU, placement on mechanical ventilation and a longer hospital length of stay.     

Outcome of children with neuromuscular disease admitted to paediatric intensive care

Aims: To determine the outcome of children with neuromuscular disease (NMD) following admission to a tertiary referral paediatric intensive care (PICU). Methods: All children with chronic NMD whose first PICU admission was between July 1986 and June 2001 were followed up from their first PICU admission to time of study. The outcomes recorded were death in or outside of PICU, duration of PICU admission, artificial ventilation during admission and following discharge from PICU, and readmission to PICU. Results: Over 15 years, 28 children were admitted on 69 occasions. Sixteen (57%) children had more than one admission. The median duration of PICU admission was 4 days (range 0.5–42). Twenty three per cent of unplanned admissions resulted in the commencement of respiratory support that was continued after discharge from the PICU. Severity of functional impairment was not associated with longer duration of stay or higher PRISM scores. Ten children (36%) died, with four (14%) deaths in the PICU. A higher proportion of children with severe limitation of function were among children that died compared to survivors. Conclusion: Most children with NMD admitted to the PICU recover and are discharged without the need for prolonged invasive ventilation. However, in this group of children, the use of non-invasive home based ventilation is common and they are likely to require further PICU admission.     

Outcome of children with neuromuscular disease admitted to paediatric intensive care.

AIMS: To determine the outcome of children with neuromuscular disease (NMD) following admission to a tertiary referral paediatric intensive care (PICU). METHODS: All children with chronic NMD whose first PICU admission was between July 1986 and June 2001 were followed up from their first PICU admission to time of study. The outcomes recorded were death in or outside of PICU, duration of PICU admission, artificial ventilation during admission and following discharge from PICU, and readmission to PICU. RESULTS: Over 15 years, 28 children were admitted on 69 occasions. Sixteen (57%) children had more than one admission. The median duration of PICU admission was 4 days (range 0.5-42). Twenty three per cent of unplanned admissions resulted in the commencement of respiratory support that was continued after discharge from the PICU. Severity of functional impairment was not associated with longer duration of stay or higher PRISM scores. Ten children (36%) died, with four (14%) deaths in the PICU. A higher proportion of children with severe limitation of function were among children that died compared to survivors. CONCLUSION: Most children with NMD admitted to the PICU recover and are discharged without the need for prolonged invasive ventilation. However, in this group of children, the use of non-invasive home based ventilation is common and they are likely to require further PICU admission.     

Incidence and Risk Factors for Venous Thromboembolism in Critically Ill Children With Cardiac Disease

Cardiac disease is a risk factor for venous thromboembolism (VTE) in children. In this study, we investigated the incidence and risk factors of VTE in critically ill children with cardiac disease, who were prospectively followed-up for VTE after admission to a tertiary care pediatric intensive care unit (PICU). Risk factors were compared between VTE cases and (1) patients in the cohort who did not develop VTE and (2) the next three cardiac patients sequentially admitted to the PICU (case control). Forty-one cases of VTE were identified from 1070 admissions (3.8%). Thirty-seven percent of VTE cases were central venous catheter (CVC)–associated, and 56% of cases were intracardiac. Sixty-six percent of patients were receiving anticoagulation at the time of VTE diagnosis. Increased VTE incidence was associated with unscheduled PICU admission, age <6 months, extracorporeal membrane oxygenation, increased number of CVCs, increased number of CVC days, higher risk of mortality score, and longer PICU stay. Using logistic regression, VTE was associated with single-ventricle physiology (odds ratio [OR] 11.2, 95% CI 3.0–41.9), widened arterial-to-somatic oxygen saturation gradient (SpO₂–rSO₂ >30) (OR 4.3, 95% CI 1.1–16), and more CVC days (OR 1.1, 95% CI 1.04–1.13). Risk factors for VTE in critically ill children with cardiac disease include younger age, single-ventricle cardiac lesions, increased illness severity, unscheduled PICU admission, and complicated hospital course.     

Intensive care experience with sclerotherapy for cervicofacial lymphatic malformations.

OBJECTIVE: To describe a cohort of patients needing intensive care support after sclerotherapy for cervicofacial lymphatic malformations. DESIGN: Retrospective review of case records of patients undergoing sclerotherapy between January 2004 and November 2006. SETTING: A tertiary, university-affiliated, pediatric teaching hospital. PATIENTS: Five patients needing admission to a pediatric intensive care unit (PICU) following sclerotherapy with OK432. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Five patients needed a total of 13 PICU admissions. Ages ranged from 4 months to 19 months. All patients had extensive lesions that involved the airways, mediastinum, or floor of the mouth, documented by magnetic resonance imaging. Nine admissions involved elective intubation and ventilation following sclerotherapy due to the extent of lesions. There were four urgent admissions to the PICU with respiratory distress ranging from 3 to 18 days after sclerotherapy. The mean duration of admission was 7 days (total 93 days, range 2-22 days). Total ventilated hours were 1656 hrs with a range of 16.5-370 hrs per admission. Multiple procedures, such as drainage of cysts and further sclerotherapy procedures, were performed before extubation on the PICU. CONCLUSIONS: Children with extensive disease and airway involvement need multiple PICU admissions. The potential for life-threatening respiratory embarrassment is unpredictable following sclerotherapy. Consideration should be given to performing further sclerotherapy while the patients are intubated in the PICU. The PICU provides a safe and secure environment for such procedures.     

MultiCenter outcome of pediatric oncology patients requiring intensive care

A retrospective cohort study was conducted to evaluate the intensive care outcome of pediatric cancer patients between 1996 and 1998. The study comprised 20 pediatric intensive care units (PICUs) and 802 patients with cancer requiring PICU care. Patients with a history of cancer were identified from PICUs participating in the Pediatric Intensive Care Unit Evaluations program. Their demographics, resource requirements, and outcomes were compared with those of noncancer patients. Cancer patients comprised 3.3% (802/24,431) of PICU admissions. Overall PICU survival was not different between cancer and noncancer patients (95% vs. 96%, p =.2). Cancer patients were older (99 +/- 3 vs. 72 +/- 1 months, p <.001), had similar gender distributions, and had similar lengths of stay (3.3 +/- 0.2 vs. 3.9 +/- 0.1 days, p =.98). The majority (72%) were admitted to the PICU for postoperative care; PICU survival in these patients was 100, 100, and 71% for those not receiving mechanical ventilation or vasoactive agent infusion, those receiving either mechanical ventilation or vasoactive agent infusion, and those receiving both, respectively. PICU survival in nonoperative patients was 87% overall; survival for those requiring ventilation, vasoactive infusions, or both was 93, 89 and 46%. Overall hospital survival was 99% in operative cancer patients and 81% in nonoperative patients (p =.004, operative vs. nonoperative patients). Pediatric cancer patients receiving intensive care do well overall. Outcomes have substantially improved and, in general, the diagnosis of cancer should not limit the provision of intensive care. Additionally, resource use in terms of lengths of stay in the PICU is not different between cancer and noncancer patients.     

Intravenous immunoglobulins in severe Guillian-Barre syndrome in childhood

Objective : This is a retrospective analysis of 25 children with severe Guillaln-Barre syndrome admitted to our PICU.Method : All children were treated with intravenous immunoglobulins (IVIG) in a dose of 2 g/kg body weight over 2–5 days in addition to supportive and respiratory care. Seventeen children were elective admissions to the PICU whereas 8 children were transferred from other hospitals in a critical condition. Five of 8 of the late referrals died as compared to none of the elective admissions.Result : All 8 of the late referrals required mechanical ventilation as against 3 of the 17 elective admissions. Mean duration of PICU stay in the late referrals was 27 days as compared to 15 days in the elective admissions.Conclusion : The authors concur with previously published reports, that early use of IVIG could reduce the mortality and the need for intubation and mechanical ventilation.     

中国25家儿科重症监护病房主要配置及住院状况调查分析

目的 调查中国儿科重症监护病房（PICU）的基本配置及住院患儿状况。方法 应用问卷调查中国25家PICU的基本配置，应用儿童危重病例评分和美国PICU出入院指南，对2004年1月1日至2005年6月30日各PICU 29 d至14周岁住院患儿均进行为期12个月的危重病例筛选。结果 中国25家PICU平均床位数（11.4±8.0）张，呼吸机数（6.1±3.7）台，44.0%（11/25）的PICU能进行中心静脉压监测。收治病例12 018例，危重病例60.5％（7 269/12 018）。危重病例中内科疾病占769%（5 590/7 269），外科疾病占16.8%（1 233/7 269），其他科室疾病占6.3%（456/ 7 269）；平均住院日6.3 d；肺炎41.4%（3 013/7 269），脓毒症95%（688/7 269），外伤5.5%（397/7 269），呼吸衰竭27.6%（2 009/7 269）； 行机械通气26.9 %（1 957/7 269），行机械通气>24 h 17.9%（1 300/7 269），ARDS 1.44%（105/7 269）。研究期间，危重病例中病死率为6.7%（485/7 269，95% CI:6.1%～7.3%），PICU中病死率为40%（485/12 018，95% CI:3.7%～4.4%）。主要疾病病死率为1.3%～61.0%，不同PICU间收治患儿及病死率均存在差异。结论 中国PICU配置仍处于初级水平，收治患儿标准及危重患儿病死率可能存在差异。     

MultiCenter Outcome of Pediatric Oncology Patients Requiring Intensive Care

A retrospective cohort study was conducted to evaluate the intensive care outcome of pediatric cancer patients between 1996 and 1998. The study comprised 20 pediatric intensive care units (PICUs) and 802 patients with cancer requiring PICU care. Patients with a history of cancer were identified from PICUs participating in the Pediatric Intensive Care Unit Evaluations program. Their demographics, resource requirements, and outcomes were compared with those of noncancer patients. Cancer patients comprised 3.3% (802/24,431) of PICU admissions. Overall PICU survival was not different between cancer and noncancer patients (95% vs. 96%, p = .2). Cancer patients were older (99 &#45 3 vs. 72 &#45 1 months, p < .001), had similar gender distributions, and had similar lengths of stay (3.3 &#45 0.2 vs. 3.9 &#45 0.1 days, p = .98). The majority (72%) were admitted to the PICU for postoperative care; PICU survival in these patients was 100, 100, and 71% for those not receiving mechanical ventilation or vasoactive agent infusion, those receiving either mechanical ventilation or vasoactive agent infusion, and those receiving both, respectively. PICU survival in nonoperative patients was 87% overall; survival for those requiring ventilation, vasoactive infusions, or both was 93, 89 and 46%. Overall hospital survival was 99% in operative cancer patients and 81% in nonoperative patients ( p = .004, operative vs. nonoperative patients). Pediatric cancer patients receiving intensive care do well overall. Outcomes have substantially improved and, in general, the diagnosis of cancer should not limit the provision of intensive care. Additionally, resource use in terms of lengths of stay in the PICU is not different between cancer and noncancer patients.     

Going back for more: an evaluation of clinical outcomes and characteristics of readmissions to a pediatric intensive care unit.

OBJECTIVE: To determine mortality, length of stay, and factors associated with readmissions to the pediatric intensive care unit (PICU). DESIGN: A retrospective analysis of prospectively collected data. SETTING: A 16-bed medical-surgical tertiary PICU and a coexisting 15-bed pediatric cardiac intensive care unit. PATIENTS: All admissions from July 1, 1998, through June 30, 2004. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Of 8,885 total eligible admissions, 711 (8%) were readmissions to the PICU. The median age of the overall cohort was 35.2 months (interquartile range, 5.5-128.2). Readmitted patients were younger (10.4 vs. 37.7 months, p < .01), had greater severity of illness (p < .01), and were more likely to be admitted emergently (p < .01), in comparison with single admissions. In multivariate analyses, readmitted patients had a trend toward higher odds of mortality (odds ratio, 1.39; 95% confidence interval, 0.98-1.98) and stayed 2.96 days longer in the PICU (95% confidence interval, 1.98-3.94) compared with single admissions to the PICU. Factors independently associated with PICU readmission were infant age (odds ratio, 1.98; 95% confidence interval, 1.57-2.49), emergent admission (odds ratio, 2.21; 95% confidence interval, 1.78-2.77), illness severity (odds ratio, 1.03; 95% confidence interval, 1.01-1.04), and time of the year between July and September (odds ratio, 1.52; 95% confidence interval, 1.20-1.93). A diagnosis of trauma was associated with low likelihood of PICU readmission (odds ratio, 0.30; 95% confidence interval, 0.18-0.50). CONCLUSIONS: Patients readmitted to the PICU during the same hospitalization have significantly adverse outcomes. The study highlights important factors associated with PICU readmissions that can be incorporated into efforts to reduce mortality and resource utilization associated with readmission of critically ill children.     

The Value of Serum Uric Acid as a Mortality Prediction in Critically Ill Children

Objective

The role of initial serum uric acid on admission in critically ill patients is controversial; we presumed that uric acid level can predict the mortality of the admitted patients to intensive care unit as a simple test.

Methods

Totally, 220 consecutively admitted children (96 girls, 124 boys) with mean age 3.5 years, who were at least 24 hours in pediatric intensive care unit (PICU), were enrolled in a prospective cohort study during January 2006 to December 2007. The subsequent PICU admission in the same hospitalization, those who were discharged from the hospital and then re-admitted to the PICU during the observation period, and the patients with chronic renal failure were excluded. Serum uric acid level was measured during the first day of PICU admission. Death or transfer from PICU was considered as final outcome. The statistical analysis was done by using linear regression analysis, ROC curve, Student t-test, and Chi- square. P value less than 0.05 was considered significant.

Findings

From 44 patients who had serum uric acid level more than 8 mg/dl, 17 cases died showing with a higher relative risk of 1.88, higher mortality (P<0.05). The relative risk of death in patients who had serum uric acid >8 mg/dl and needed vasopressor was 1.04, and in those under mechanical ventilation 1.33. In patients who scored pediatric risk of mortality of >38 it was 1.4, and in septic cases 4 (P<0.05). Stepwise linear regression analysis showed that mainly the need for mechanical ventilation (P=0.001) and vasopressor had statistically significant correlation with the poor outcome (P=0.001).

Conclusion

Uric acid level during the first day of intensive critical care admission is not an independent risk of mortality in PICU. Need for mechanical ventilation or inotropic agents was associated with poor outcome and only higher uric acid level in sepsis played an additive risk factor role.     

Risk factors associated with pediatric intensive care unit admission and mortality after pediatric stem cell transplant: possible role of renal involvement

Background

Hematopoietic stem-cell transplant (HSCT) is associated with many risk factors for life-threatening complications. Post-transplant critical illness often requires admission to the pediatric intensive care unit (PICU).

Methods

A retrospective analysis was made on the risk factors associated with PICU admission and mortality of all HSCT patients at Helen DeVos Children’s Hospital from October 1998 to November 2008.

Results

One hundred and twenty-four patients underwent HSCT, with 19 (15.3%) requiring 29 PICU admissions. Fifty patients received autologous, 38 matched sibling, and 36 matched un-related donor HSCT, with 10%, 13% and 25% of these patients requiring PICU admission, respectively (P=0.01). Among the HSCT patients, those who were admitted to the PICU were more likely to have renal involvement by either malignancy requiring nephrectomy or a post transplant complication increasing the likelihood of decreased renal function (21.1% vs. 4.8%, P=0.03). PICU admissions were also more likely to receive pre-transplant total body irradiation (52.6% vs. 27.6%, P=0.03). Among 29 patients with PICU admission, 3 died on day 1 after admission, and 5 within 30 days (a mortality rate of 17%). Thirty days after PICU admission, non-survivors had a higher incidence of respiratory failure and septic shock on admission compared with survivors (80% vs. 16.7%, P=0.01 and 80% vs. 4.2%, respectively, P=0.001). Two survivors with chronic renal failure underwent renal transplantation successfully.

Conclusions

Total body irradiation and renal involvement are associated with higher risk for PICU admissions after HSCT in pediatric patients, while septic shock upon admission and post-admission respiratory failure are associated with mortality.     

Inborn errors of metabolism in a neonatology unit: Impact and long‐term results

Background: Inborn errors of metabolism (IEM) have greater repercussions in neonatology units. The goal of our study was to evaluate the impact of IEM in a neonatology unit and the outcome of these neonates. Methods: All patients with IEM admitted in our unit were evaluated during an 8‐year period for specific diagnosis, clinical features, therapy and long‐term neurodevelopment. Results: The study group was comprised of 31 infants, 18 of which required admission to the neonatal intensive care unit (NICU) (1.63% of income) due to severe symptoms. Twenty‐two of the 31 had an earlier diagnosis and treatment due to expanded newborn screening, made from the third day of life. The most frequent diagnosis in the NICU, representing 66.66% (12/18), was diseases that cause an endogenous intoxication. Despite the diagnosis by tandem mass spectrometry, many of these patients had severe clinical symptoms prior to the screening results. Aggressive support was often necessary (extracorporeal removal therapy, mechanical ventilation). Death occurred generally in the first year of life (5/6). The death rate in the NICU was 10.3%. The survivors presented higher scores on the Psychomotor Development Index if the diagnosis of the disease was either made or helped by screening. This also depends on the type of disease. Conclusion: Earlier diagnosis by expanded newborn screening and earlier treatment is essential in order to be able to prevent neurological sequelae.     

Do weekends or evenings matter in a pediatric intensive care unit?

OBJECTIVE: To assess what independent influence, if any, weekend or evening admission to a pediatric intensive care unit (PICU) staffed 24 hrs/day, 7 days/wk by in-house, board-certified pediatric intensivists might have on mortality. DESIGN AND PATIENTS: A retrospective study of 5,968 consecutive admissions to the PICU from August 1996 to December 2003 for patients aged 0 days to 21 yrs. SETTING: A single, 14-bed, multidisciplinary PICU at an academic medical center. MEASUREMENTS: Standardized mortality ratios of observed-to-predicted mortality were derived with their corresponding p values. Multivariate logistic regression was used to test the independent effect of weekend admission, weekend discharge/death, and evening PICU admission on mortality for the entire sample and, separately, for only emergency admissions, controlling for other significant predictor variables or interaction terms. RESULTS: Overall, crude mortality was significantly higher on the weekend (weekday, 2.2%; weekend, 5.0% [p = .0000]) and in the evening (day, 2.1%; evening, 3.8% [p = .0004]). Assessing the entire sample using multivariate logistic regression, neither weekend admission (p = .146), weekend discharge/death (p = .348), nor evening PICU admission (p = .711) showed a significant relationship with mortality controlling for other significant factors. Limiting the scope to the emergency admissions subset, neither weekend admission (p = .135), weekend discharge/death (p = .278), nor evening PICU admission (p = .867) were significant predictors of mortality. Weekend and evening admissions differed in important ways from weekday and daytime admissions, making simple comparisons of crude mortality rates inappropriate. Weekend and evening admissions were more likely to be emergency, nonoperative patients; have a lower Pediatric Risk of Mortality III score but have a higher overall predicted mortality risk; and differ in the distributions of patients by primary diagnosis. CONCLUSIONS: Using multivariate logistic regression to control for important clinical differences, neither weekend admission, weekend discharge/death, nor evening admission had a significant independent effect on mortality risk in the entire sample or for the emergency patient subset. Our findings are consistent with previous work demonstrating the benefit of intensive care units staffed 24 hrs/day, 7-days/wk by in-house, board-certified intensivists.     

Children with human immunodeficiency virus infection admitted to a paediatric intensive care unit in South Africa

BACKGROUND: Early data regarding the outcome of human immunodeficiency virus (HIV)-infected children in paediatric intensive care units (PICU) suggested mortality as high as 100%. Recent studies report mortality of 38%. Survival depends on the indication for admission. OBJECTIVES: To describe the prevalence, duration of stay, and outcome of HIV-infected patients in a single PICU over a 1-year period. Additional objectives included describing the indications for admission as well as the clinical and laboratory characteristics of HIV-infected infants and children requiring PICU admission. METHOD: Retrospective chart review of all children with serological proof of HIV admitted to PICU at Tygerberg Children's Hospital from 1 January to 31 December 2003. RESULTS: Of the 465 patients admitted, 47 (10%) were HIV-infected. For HIV-infected children the median age on admission was 4 months. The median duration of stay was 6 days, significantly longer than for the non-HIV group (p = 0.0001). Fifty-seven percent had advanced clinical and immunological disease. Seventeen died in PICU and four shortly afterwards, poor PICU outcome was significantly associated with HIV status (p = 0.001). Lower total lymphocyte count (p = 0.004) and higher gamma globulin level (p = 0.04) were paradoxically the only findings significantly associated with survival. Acute respiratory failure (ARF) accounted for 76% of admissions, including Pneumocystis jiroveci in 38%. Fifty-one percent had evidence of cytomegalovirus infection. CONCLUSIONS: HIV-infected children requiring PICU can survive despite the lack of availability of antiretroviral therapy.     

中国儿童重症监护病房体外膜肺氧合技术应用现状调查

目的：了解中国PICU体外膜肺氧合( ECMO)技术开展及ECMO疗效情况。方法采用问卷调查方式,2015年3月至2015年8月对全国三级甲等医院PICU进行调查。结果共调查了38家儿童医院或综合医院的PICU,其中儿童医院28家,综合医院10家。10家医院的PICU拥有12台ECMO设备;能开展ECMO技术的单位6家,准备开展ECMO技术的单位14家;接受过ECMO培训的医院8家。共有63例患儿在 PICU 内接受非开胸 ECMO 治疗,成功撤离 ECMO 者49例,有效率77.8％;36例存活,存活率57.1％。儿童患者(大于28 d)51例,其中呼吸系统疾病21例,心脏疾病28例,心肺衰竭2例;存活出院31例,存活率60.8％。新生儿患者12例,呼吸系统疾病10例,心脏疾病2例,存活出院5例,存活率41.7％。结论国内儿科领域ECMO技术尚处于起步阶段,且发展不均衡,整体上存活率低于国际水平,今后需要进一步增加ECMO技术在儿科领域应用的临床实践,提高国内危重患儿的救治水平。     

Bronchiolitis treated with mechanical ventilation: prognosis factors and outcome in a series of 135 children]

Viral bronchiolitis is usually associated with favorable outcome as regard to mortality. Only few studies reported severe bronchiolitis requiring mechanical ventilation, and respiratory outcome is not well described. METHODS: Therefore, we conducted a retrospective study in a series of 135 children admitted in a single Pediatric Intensive Care Unit (PICU) over a four year period (1994-1998). All of them were admitted for viral bronchiolitis requiring mechanical ventilation. RESULTS: At admission, 83% of them were less than three months old. Prematurity at birth was present in 33,3%. Mortality was observed in four cases (2,9%), all premature babies with mechanical ventilation at birth. Univariate analysis showed as main factors associated to mortality: prematurity (P =0,056) and acute respiratory distress syndrome (P =0,017). Childhood asthma was observed in 40,4% of children without any associated factor wether at birth or in PICU related to such outcome. CONCLUSION: Bronchiolitis associated with mechanical ventilation is particularly observed in very young babies and prematurity is the main factor associated to mortality. Mechanical ventilation seems not to be associated with unfavorable respiratory outcome. Considering physiology and population, non invasive ventilation could be an effective alternative of mechanical ventilation.