A Vital Sign-Based Model to Predict Clinical Deterioration in Hospitalized Children

Pediatric Critical Care Medicine: September 2020 – Volume 21 – Issue 9 – p 811-819
doi: 10.1097/PCC.0000000000002411

Abstract

Objectives: 

Up to 37% of children admitted to the PICU develop acute kidney injury as defined by Kidney Disease: Improving Global Outcomes criteria. We describe the prevalence of acute kidney injury in a mixed pediatric intensive care cohort using this criteria. As tools to stratify patients at risk of acute kidney injury on PICU admission are lacking, we explored the variables at admission and day 1 that might predict the development of acute kidney injury.

Design: 

Single-center retrospective observational study.

Setting: 

Thirty-six–bed surgical/medical tertiary PICU.

Patients: 

Children from birth to less than or equal to 16 years old admitted between 2015 and 2018.

Interventions: 

None.

Measurements and Main Results: 

Clinical data were extracted from the PICU clinical information system. Patients with baseline creatinine at admission greater than 20 micromol/L above the calculated normal creatinine level were classified as “high risk of acute kidney injury.” Models were created to predict acute kidney injury at admission and on day 1. Out of the 7,505 children admitted during the study period, 738 patients (9.8%) were classified as high risk of acute kidney injury at admission and 690 (9.2%) developed acute kidney injury during PICU admission. Compared to Kidney Disease: Improving Global Outcomes criteria as the reference standard, high risk of acute kidney injury had a lower sensitivity and higher specificity compared with renal angina index greater than or equal to 8 on day 1. For the admission model, the adjusted odds ratio of developing acute kidney injury for high risk of acute kidney injury was 4.2 (95% CI, 3.3–5.2). The adjusted odds ratio in the noncardiac cohort for high risk of acute kidney injury was 7.3 (95% CI, 5.5–9.7). For the day 1 model, odds ratios for high risk of acute kidney injury and renal angina index greater than or equal to 8 were 3.3 (95% CI, 2.6–4.2) and 3.1 (95% CI, 2.4–3.8), respectively.

Conclusions: 

The relationship between high risk of acute kidney injury and acute kidney injury needs further evaluation. High risk of acute kidney injury performed better in the noncardiac cohort.

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Prediction of Acute Kidney Injury on Admission to Pediatric Intensive Care

Pediatric Critical Care Medicine: September 2020 – Volume 21 – Issue 9 – p 811-819
doi: 10.1097/PCC.0000000000002411

Abstract

Objectives: 

Up to 37% of children admitted to the PICU develop acute kidney injury as defined by Kidney Disease: Improving Global Outcomes criteria. We describe the prevalence of acute kidney injury in a mixed pediatric intensive care cohort using this criteria. As tools to stratify patients at risk of acute kidney injury on PICU admission are lacking, we explored the variables at admission and day 1 that might predict the development of acute kidney injury.

Design: 

Single-center retrospective observational study.

Setting: 

Thirty-six–bed surgical/medical tertiary PICU.

Patients: 

Children from birth to less than or equal to 16 years old admitted between 2015 and 2018.

Interventions: 

None.

Measurements and Main Results: 

Clinical data were extracted from the PICU clinical information system. Patients with baseline creatinine at admission greater than 20 micromol/L above the calculated normal creatinine level were classified as “high risk of acute kidney injury.” Models were created to predict acute kidney injury at admission and on day 1. Out of the 7,505 children admitted during the study period, 738 patients (9.8%) were classified as high risk of acute kidney injury at admission and 690 (9.2%) developed acute kidney injury during PICU admission. Compared to Kidney Disease: Improving Global Outcomes criteria as the reference standard, high risk of acute kidney injury had a lower sensitivity and higher specificity compared with renal angina index greater than or equal to 8 on day 1. For the admission model, the adjusted odds ratio of developing acute kidney injury for high risk of acute kidney injury was 4.2 (95% CI, 3.3–5.2). The adjusted odds ratio in the noncardiac cohort for high risk of acute kidney injury was 7.3 (95% CI, 5.5–9.7). For the day 1 model, odds ratios for high risk of acute kidney injury and renal angina index greater than or equal to 8 were 3.3 (95% CI, 2.6–4.2) and 3.1 (95% CI, 2.4–3.8), respectively.

Conclusions: 

The relationship between high risk of acute kidney injury and acute kidney injury needs further evaluation. High risk of acute kidney injury performed better in the noncardiac cohort.

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Criticality – A New Concept of Severity of Illness for Hospitalized Children

Pediatric Critical Care Medicine: September 15, 2020 – Volume Online First – Issue – doi: 10.1097/PCC.0000000000002560

Abstract

Objectives: 

To validate the conceptual framework of “criticality,” a new pediatric inpatient severity measure based on physiology, therapy, and therapeutic intensity calibrated to care intensity, operationalized as ICU care.

Design: 

Deep neural network analysis of a pediatric cohort from the Health Facts (Cerner Corporation, Kansas City, MO) national database.

Setting: 

Hospitals with pediatric routine inpatient and ICU care.

Patients: 

Children cared for in the ICU (n = 20,014) and in routine care units without an ICU admission (n = 20,130) from 2009 to 2016. All patients had laboratory, vital sign, and medication data.

Interventions: 

None.

Measurements and Main Results: 

A calibrated, deep neural network used physiology (laboratory tests and vital signs), therapy (medications), and therapeutic intensity (number of physiology tests and medications) to model care intensity, operationalized as ICU (versus routine) care every 6 hours of a patient’s hospital course. The probability of ICU care is termed the Criticality Index. First, the model demonstrated excellent separation of criticality distributions from a severity hierarchy of five patient groups: routine care, routine care for those who also received ICU care, transition from routine to ICU care, ICU care, and high-intensity ICU care. Second, model performance assessed with statistical metrics was excellent with an area under the curve for the receiver operating characteristic of 0.95 for 327,189 6-hour time periods, excellent calibration, sensitivity of 0.817, specificity of 0.892, accuracy of 0.866, and precision of 0.799. Third, the performance in individual patients with greater than one care designation indicated as 88.03% (95% CI, 87.72–88.34) of the Criticality Indices in the more intensive locations was higher than the less intense locations.

Conclusions: 

The Criticality Index is a quantification of severity of illness for hospitalized children using physiology, therapy, and care intensity. This new conceptual model is applicable to clinical investigations and predicting future care needs.

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Approach to the pre-school child with sudden loss of consciousness

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Paediatrics and Child Health
Volume 30, Issue 9, September 2020, Pages 333-337

Abstract

There are several causes for sudden loss of consciousness in pre-school children. These include Transient Loss of Consciousness (T-LOC), which encompasses a group of disorders with the following characteristics: abnormal motor control, loss of responsiveness, amnesia for the period of unconsciousness, and a short duration. There are three main categories of T-LOC in pre-school children: syncope, resulting from a sudden and reversible lack of oxygenated blood supplied to the brain, often caused by transient impairment of cardiac output or systemic arterial hypotension. Secondly, epileptic seizures due to excessive and hypersynchronous cortico-neuronal electrical activity in the brain, and thirdly, “unexplained T-LOC,” which includes cases not yet diagnosed fully, and those for which a pathophysiological mechanism has not yet been identified, despite thorough investigations. Reflex Anoxic Seizures (RAS) are important in the differential diagnosis of non-epileptic paroxysmal events in infants and pre-school children. Parents and carers who witness these episodes are understandably anxious, and the mainstay of management is ensuring that the correct diagnosis is made, reassurance is given, and both the patient and parents are educated about the condition. Diagnosis can be made based off a detailed history, including an eyewitness account of the episode, as well as clinical examinations. This review aims to describe an approach to the diagnosis and management of T-LOC in pre-school children.

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Fluid and electrolyte balance in children

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Paediatrics and Child Health
Volume 30, Issue 9, September 2020, Pages 328-332

Abstract

Safe intravenous fluid prescription in children requires an understanding of certain basic principles to avoid adverse events. Careful consideration needs to be given to both the appropriate rate and composition of the fluids to be administered with frequent re-assessment. This review will examine the indications for parenteral fluid management; maintenance requirements, correction of any deficit and replacement of ongoing losses. The role of non-osmotic secretion of anti-diuretic hormone (ADH) is discussed and children at particular risk are identified. We review complications associated with intravenous fluid therapy, in particular hyponatraemic encephalopathy and discuss the management of this medical emergency. Other electrolyte abnormalities that may arise are highlighted. Fluid management in children with diabetic ketoacidosis is also reviewed.

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Chronic peritoneal dialysis in children

Paediatrics and Child Health
Volume 30, Issue 9, September 2020, Pages 319-327

Abstract

Chronic kidney failure is rare in children and adolescents. The availability and types of kidney replacement therapy (KRT) vary widely, with a global prevalence of 18–100 per million age-related population (pmarp). Approximately 1000 children are on KRT in the UK (prevalence 64.8 pmarp). Almost 25% are on dialysis. Chronic peritoneal dialysis (PD) is the dialysis modality of choice in younger children given its almost universal applicability, cost-effectiveness and the possibility of a home-based treatment. This is most compatible with a child’s schooling and social life. Advances in technology have improved outcomes even for the youngest children, but mortality remains high and the morbidity and burden of care should not be underestimated. Optimal management of children on dialysis requires a multidisciplinary team and consideration of the child and family’s expectations. With few high-quality randomized trials, clinicians are reliant on prospective cohort studies and international registries to inform and improve management strategies. Children on dialysis have a lifetime of KRT ahead of them. The selection of dialysis modality and management must consider the principles of dialysis access preservation. This review summarizes current epidemiology, principles of dialysis, PD access, modalities, prescriptions and complications of PD, as well as a brief discussion on PD in infants with their unique ethical and technical considerations.

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When do children need kidney replacement therapy?

Paediatrics and Child Health
Volume 30, Issue 9, September 2020, Pages 313-318

Abstract

Kidney replacement therapy (KRT) can provide lifesaving support for children with severely impaired kidney function. The decision about who needs KRT and when is often complex. Many acute kidney problems will resolve with conservative maanagemenent but some children with chronic or acute kidney impairment will find themselves in a position where KRT is required either as a bridge to recovery or kidney transplantation. Less commonly, children with metabolic disorders may find that the ability of their own kidneys is overwhelmed by excessive production of certain metabolites. These children may also benefit from short term KRT. This article aims to help paediatricians in training understand which children need kidney replacement therapy, the various types of treatment available, and when they are used.

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Cystic fibrosis newborn screening: the importance of bloodspot sample quality

Archives of Disease in Childhood Published Online First: 28 August 2020. doi: 10.1136/archdischild-2020-318999

Abstract

Objective Wales has an immunoreactive trypsin (IRT)-DNA cystic fibrosis (CF) newborn screening (NBS) programme. Most CF NBS false negative cases are due to an IRT concentration below the screening threshold. The accuracy of IRT results is dependent on the quality of the dried bloodspot (DBS) sample. The aim of this study was to determine the cause of false negative cases in CF NBS and their relationship to DBS quality.

Design Longitudinal birth cohort.

Setting Wales 1996–2016.

Patients Children with CF.

Interventions Identification of all CF patients with triangulation of multiple data sources to detect false negative cases.

Main outcome measures False negative cases.

Results Over 20 years, 673 952 infants were screened and 239 were diagnosed with CF (incidence 1:2819). The sensitivity of the programme was 0.958, and positive predictive value was 0.476. Eighteen potential false negatives were identified, of whom eight were excluded: four screened outside Wales, two had complex comorbidities, no identified cystic fibrosis transmembrane conductance regulator (CFTR) variants on extended analysis and thus not considered to have CF and two were diagnosed after their 16th birthday. Of the 10 false negatives, 9 had a low DBS IRT and at least one common CFTR variant and thus should have received a sweat test under the programme. DBS cards were available for inspection for five of the nine false negative cases—all were classified as small/insufficient or poor quality.

Conclusions The majority of false negatives had a low bloodspot IRT, and this was associated with poor quality DBS. The optimal means to improve the sensitivity of our CF NBS programme would be to improve DBS sample quality.

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Long-term oxygen therapy in children with sickle cell disease and hypoxaemia

Archives of Disease in Childhood Published Online First: 02 September 2020. doi: 10.1136/archdischild-2020-319347

Abstract

Objective To evaluate the acceptability and safety profile of nocturnal long-term oxygen therapy (LTOT) in children with sickle cell disease (SCD) and chronic hypoxaemia.

Design Retrospective cohort study.

Patients, setting and intervention Children with SCD who started LTOT from 2014 to early 2019 in two tertiary hospitals in London, UK were retrospectively enrolled. Patients who started disease-modifying therapies <12 months before LTOT or while on LTOT were excluded.

Main outcome measures Minor and major adverse events during LTOT were reported. Laboratory and clinical data, transcranial Doppler (TCD) scans and overnight oximetry studies performed at steady state within 12 months before and after starting LTOT were compared.

Results Nineteen children (10 males; median age 12 years, range 6–15) were included. Nearly half of them (9/19; 47%) were on hydroxyurea at baseline. No child discontinued LTOT because of intolerance or poor adherence. No major adverse events were reported. Laboratory data did not show significant changes in haemoglobin and reticulocyte count after 1 year of follow-up. No statistically significant change in the incidence of vaso-occlusive pain events was noted (median annual rate from 0.5 to 0 episode per patient/year; p=0.062). Overnight oximetry tests performed while on LTOT showed improvements in all oxygen saturation parameters (mean overnight and nadir SpO₂, % of time spent with SpO₂ <90%) compared with the baseline.

Conclusion LTOT is a safe and feasible treatment option for children with SCD and chronic hypoxaemia.

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Neurodevelopmental status and follow-up in preschool children with heart disease in London, UK

Archives of Disease in Childhood Published Online First: 09 September 2020. doi: 10.1136/archdischild-2019-317824

Abstract

Objective To describe neurodevelopment and follow-up services in preschool children with heart disease (HD).

Design Secondary analysis of a prospectively collected multicentre dataset.

Setting Three London tertiary cardiac centres.

Patients Preschool children<5 years of age: both inpatients and outpatients.

Methods We analysed results of Mullen Scales of Early Learning (MSEL) and parental report of follow-up services in a representative convenience sample evaluated between January 2014 and July 2015 within a previous study.

Results Of 971 preschool children: 577 (59.4%) had ≥1 heart operation, 236 (24.3%) had a known diagnosis linked to developmental delay (DD) (‘known group’) and 130 (13.4%) had history of clinical event linked to DD. On MSEL assessment, 643 (66.2%) had normal development, 181 (18.6%) had borderline scores and 147 (15.1%) had scores indicative of DD. Of 971 children, 609 (62.7%) were not receiving follow-up linked to child development and were more likely to be under these services with a known group diagnosis, history of clinical event linked to DD and DD (defined by MSEL). Of 236 in known group, parents of 77 (32.6%) and of 48 children not in a known group but with DD 29 (60.4%), reported no child development related follow-up. DD defined by MSEL assessment was more likely with a known group and older age at assessment.

Conclusions Our findings indicate that a ‘structured neurodevelopmental follow-up pathway’ in preschool children with HD should be considered for development and evaluation as children get older, with particular focus on those at higher risk.

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