Janet Alexander

Paediatric index of mortality 3: An updated model for predicting mortality in pediatric intensive care

Objectives: To provide an updated version of the Paediatric Index of Mortality 2 for assessing the risk of mortality among children admitted to an ICU. Design: International, multicenter, prospective cohort study. Setting: Sixty ICUs that accept pediatric admissions in Australia, New Zealand, Ireland, and the United Kingdom. Patients: All children admitted in 2010 and 2011 younger than 18 years old at the time of admission and either died in ICU or were discharged. Patients who were transferred to another ICU were not included. Fifty-three thousand one hundred twelve patient admissions were included in the analysis. Interventions: None. Measurement and Main Results: A revised prediction model was built using logistic regression. Variable selection was based on significance at the 95% level and overall improvement of the model’s discriminatory performance and goodness of fit. The final model discriminated well (area under the curve, 0.88, 0.88–0.89); however, the model performed better in Australia and New Zealand than in the United Kingdom and Ireland (area under the curve was 0.91, 0.90–0.93 and 0.85, 0.84–0.86, respectively). Conclusions: Paediatric Index of Mortality 3 provides an international standard based on a large contemporary dataset for the comparison of risk-adjusted mortality among children admitted to intensive care.

Mortality related to invasive infections, sepsis, and septic shock in critically ill children in Australia and New Zealand, 2002–13: a multicentre retrospective cohort study

BACKGROUND Severe infections kill more than 4·5 million children every year. Population-based data for severe infections in children requiring admission to intensive care units (ICUs) are scarce. We assessed changes in incidence and mortality of severe infections in critically ill children in Australia and New Zealand. METHODS We did a retrospective multicentre cohort study of children requiring intensive care in Australia and New Zealand between 2002 and 2013, with data from the Australian and New Zealand Paediatric Intensive Care Registry. We included children younger than 16 years with invasive infection, sepsis, or septic shock. We assessed incidence and mortality in the ICU for 2002-07 versus 2008-13. FINDINGS During the study period, 97 127 children were admitted to ICUs, 11 574 (11·9%) had severe infections, including 6688 (6·9%) with invasive infections, 2847 (2·9%) with sepsis, and 2039 (2·1%) with septic shock. Age-standardised incidence increased each year by an average of 0·56 cases per 100 000 children (95% CI 0·41-0·71) for invasive infections, 0·09 cases per 100 000 children (0·00-0·17) for sepsis, and 0·08 cases per 100 000 children (0·04-0·12) for septic shock. 260 (3·9%) of 6688 patients with invasive infection died, 159 (5·6%) of 2847 with sepsis died, and 346 (17·0%) of 2039 with septic shock died, compared with 2893 (3·0%) of all paediatric ICU admissions. Children admitted with invasive infections, sepsis, and septic shock accounted for 765 (26·4%) of 2893 paediatric deaths in ICUs. Comparing 2008-13 with 2002-07, risk-adjusted mortality decreased significantly for invasive infections (odds ratio 0·72, 95% CI 0·56-0·94; p=0·016), and for sepsis (0·66, 0·47-0·93; p=0·016), but not significantly for septic shock (0·79, 0·61-1·01; p=0·065). INTERPRETATION Severe infections remain a major cause of mortality in paediatric ICUs, representing a major public health problem. Future studies should focus on patients with the highest risk of poor outcome, and assess the effectiveness of present sepsis interventions in children. FUNDING National Medical Health and Research Council, Australian Resuscitation Outcomes Consortium, Centre of Research Excellence (1029983).

Pandemic H1N1 in children requiring intensive care in Australia and New Zealand during winter 2009

OBJECTIVE: To describe in detail the pediatric intensive care experience of influenza A, particularly pandemic H1N1-09, in Australia and New Zealand during the 2009 Southern Hemisphere winter and to compare the pediatric experience with that of adults. METHOD: This was an inception-cohort study of all children who were admitted to intensive care with confirmed influenza A during winter 2009 at all general ICUs and PICUs in Australia and New Zealand. RESULTS: From June 1 through August 31, 2009, 107 children (20.0 per million [95% confidence interval: 16.1–23.8]) with influenza A, including 83 (15.5 per million [95% confidence interval: 12.1–18.9]) with H1N1-09 were admitted to ICUs. Fifty-two percent (39 of 75) of children with H1N1-09 had 1 or more comorbidity, most commonly neurologic (20%). Most (48 of 83 [58%]) presented with pneumonia. Thirteen of 83 (16%) had neurologic presentations. Eighty percent of the children with H1N1-09 required ventilation. Mortality was lower than in adults: 6 of 83 (7%) vs 114 of 668 (17%) (P = .02). The median length of stay for children with H1N1-09 was 5 days. Children with H1N1-09 occupied 773 bed-days (147 per million children) and 5.8% of specialist PICU beds. Presentation with septic shock or after cardiac arrest and the presence of 1 or more comorbidities were risk factors for severe disease. CONCLUSIONS: H1N1-09 caused a substantial burden on pediatric intensive care services in Australia and New Zealand. Compared with adults, children more commonly had nonrespiratory presentations and required ventilation more often but had a lower mortality rate.

Five-Year Survival of Children With Chronic Critical Illness in Australia and New Zealand.

Objective:Outcomes for children with chronic critical illness are not defined. We examined the long-term survival of these children in Australia and New Zealand. Design:All cases of PICU chronic critical illness with length of stay more than 28 days and age 16 years old or younger in Australia and New Zealand from 2000 to 2011 were studied. Five-year survival was analyzed using Kaplan-Meir estimates, and risk factors for mortality evaluated using Cox regression. Setting:All PICUs in Australia and New Zealand. Patients:Nine hundred twenty-four children with chronic critical illness. Intervention:None. Measurements and Main Results:Nine hundred twenty-four children were admitted to PICU for longer than 28 days on 1,056 occasions, accounting for 1.3% of total admissions and 23.5% of bed days. Survival was known for 883 of 924 patients (95.5%), with a median follow-up of 3.4 years. The proportion with primary cardiac diagnosis increased from 27% in 2000–2001 to 41% in 2010–2011. Survival was 81.4% (95% CI, 78.6–83.9) to PICU discharge, 70% (95% CI, 66.7–72.8) at 1 year, and 65.5% (95% CI, 62.1–68.6) at 5 years. Five-year survival was 64% (95% CI, 58.7–68.6) for children admitted in 2000–2005 and 66% (95% CI, 61.7–70) if admitted in 2006–2011 (log-rank test, p = 0.37). After adjusting for admission severity of illness using the Paediatric Index of Mortality 2 score, predictors for 5-year mortality included bone marrow transplant (hazard ratio, 3.66; 95% CI, 2.26–5.92) and single-ventricle physiology (hazard ratio, 1.98; 95% CI, 1.37–2.87). Five-year survival for single-ventricle physiology was 47.2% (95% CI, 34.3–59.1) and for bone marrow transplantation 22.8% (95% CI, 8.7–40.8). Conclusions:Two thirds of children with chronic critical illness survive for at-least 5 years, but there was no improvement between 2000 and 2011. Cardiac disease constitutes an increasing proportion of pediatric chronic critical illness. Bone marrow transplant recipients and single-ventricle physiology have the poorest outcomes.

Burden of disease and change in practice in critically ill infants with bronchiolitis.

Bronchiolitis represents the most common cause of non-elective admission to paediatric intensive care units (ICUs). We assessed changes in admission rate, respiratory support, and outcomes of infants <24 months with bronchiolitis admitted to ICU between 2002 and 2014 in Australia and New Zealand. During the study period, bronchiolitis was responsible for 9628 (27.6%) of 34 829 non-elective ICU admissions. The estimated population-based ICU admission rate due to bronchiolitis increased by 11.76 per 100 000 each year (95% CI 8.11–15.41). The proportion of bronchiolitis patients requiring intubation decreased from 36.8% in 2002, to 10.8% in 2014 (adjusted OR 0.35, 95% CI 0.27–0.46), whilst a dramatic increase in high-flow nasal cannula therapy use to 72.6% was observed (p<0.001). We observed considerable variability in practice between units, with six-fold differences in risk-adjusted intubation rates that were not explained by ICU type, size, or major patient factors. Annual direct hospitalisation costs due to severe bronchiolitis increased to over USD30 million in 2014. We observed an increasing healthcare burden due to severe bronchiolitis, with a major change in practice in the management from invasive to non-invasive support that suggests thresholds to admittance of bronchiolitis patients to ICU have changed. Future studies should assess strategies for management of bronchiolitis outside ICUs. Changing thresholds to admit bronchiolitis patients to PICU have had a major impact on cost and resource utilisation http://ow.ly/AVA630a08rx

Burden and outcomes of severe pertussis infection in critically ill infants

Objectives: Despite World Health Organization endorsed immunization schedules, Bordetella pertussis continues to cause severe infections, predominantly in infants. There is a lack of data on the frequency and outcome of severe pertussis infections in infants requiring ICU admission. We aimed to describe admission rates, severity, mortality, and costs of pertussis infections in critically ill infants. Design: Binational observational multicenter study. Setting: Ten PICUs and 19 general ICUs in Australia and New Zealand contributing to the Australian and New Zealand Paediatric Intensive Care Registry. Patients: Infants below 1 year of age, requiring intensive care due to pertussis infection in Australia and New Zealand between 2002 and 2014. Measurements and Main Results: During the study period, 416 of 42,958 (1.0%) infants admitted to the ICU were diagnosed with pertussis. The estimated population-based ICU admission rate due to pertussis ranged from 2.1/100,000 infants to 18.6/100,000 infants. Admission rates were the highest among infants less than 60 days old (p < 0.0001). Two hundred six infants (49.5%) required mechanical ventilation, including 20 (4.8%) treated with high-frequency oscillatory ventilation, 16 (3.8%) with inhaled nitric oxide, and 7 (1.7%) with extracorporeal membrane oxygenation. Twenty of the 416 children (4.8%) died. The need for mechanical ventilation, high-frequency oscillatory ventilation, nitric oxide, and extracorporeal membrane oxygenation were significantly associated with mortality (p < 0.01). Direct severe pertussis–related hospitalization costs were in excess of USD

Trends in PICU admission and survival rates in children in Australia and New Zealand following cardiac arrest

1,000,000 per year. Conclusions: Pertussis continues to cause significant morbidity and mortality in infants, in particular during the first months of life. Improved strategies are required to reduce the significant healthcare costs and disease burden of this vaccine-preventable disease.

The burden of invasive infections in critically ill indigenous children in Australia

Objectives: To describe the temporal trends in rates of PICU admissions and mortality for out-of-hospital cardiac arrests and in-hospital cardiac arrests admitted to PICU over the last decade. Design: Multicenter, retrospective analysis of prospectively collected binational data of the Australian and New Zealand Paediatric Intensive Care Registry. All nine specialist PICUs in Australia and New Zealand were included. Patients: All children admitted between 2003 and 2012 to PICU who were less than 16 years old at the time of admission. Interventions: None. Measurements and Main Results: There were a total of 71,425 PICU admissions between 2003 and 2012. Overall, cardiac arrest accounted for 1.86% of all admissions (1,329 cases), including 677 cases of in-hospital cardiac arrest (51.0%) and 652 cases of out-of-hospital cardiac arrest (49.0%). Over the last decade, there has been a 29.6% increase in the odds of PICU survival for all pediatric admissions (odds ratio, 1.30; 95% CI, 1.09–1.54). By contrast, there was no significant improvement in the risk-adjusted odds of survival for out-of-hospital cardiac arrest admissions (odds ratio, 1.03; 95% CI, 0.50–2.10; p = 0.94) or in-hospital cardiac arrest admissions (odds ratio, 1.03; 95% CI, 0.54–1.98; p = 0.92). Conclusions: Despite improvements in overall outcomes in children admitted to Australian and New Zealand PICUs, survival of children admitted with out-of-hospital cardiac arrest or in-hospital cardiac arrest did not change significantly over the past decade.

Five-Year Survival of Children With Chronic Critical Illness in Australia and New Zealand

Objectives: To describe the incidence and mortality of invasive infections in Indigenous children admitted to paediatric and general intensive care units (ICUs) in Australia.

Prediction of pediatric sepsis mortality within 1 h of intensive care admission

*Department of Paediatric Intensive Care, Royal Childrens Hospital; †Murdoch Childrens Research Institute, Melbourne; ‡Australia and New Zealand Paediatric Intensive Care Registry; §Paediatric Intensive Care Unit, Lady Cilento Childrens Hospital, Childrens Health Queensland, Brisbane; ||Paediatric Intensive Care Unit, Princess Margaret Hospital, Perth; ¶Department of Paediatrics, University of Melbourne, Parkville; #Paediatric Intensive Care Unit, Childrens Hospital at Westmead, Sydney; **Paediatric Intensive Care Unit,Womens and Childrens Hospital, Adelaide, Australia; ††Paediatric Intensive Care Unit, Starship Childrens Hospital, Auckland, New Zealand; ‡‡Department of Pediatrics, Inselspital, University of Bern, Bern, Switzerland; §§Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland, Brisbane; and ||||Paediatric Intensive Care Unit, Sydney Childrens Hospital, Sydney, Australia.