Siva P. Namachivayam

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.

Changing oral vaccine to inactivated polio vaccine might increase mortality

We, the undersigned, write as physicians and scientists committed to optimising the benefi cial eff ects of vaccines to reduce infant mortality worldwide. In settings with high childhood mortality, live vaccines such as oral polio vaccine (OPV), BCG vaccine, and measles vaccine might have heterologous (non-specific) effects that reduce mortality from diseases other than poliomyelitis, tuberculosis, and measles, respectively, whereas inactivated vaccines might increase all-cause mortality. The importance of these eff ects is controversial. In 2014, the WHO Special Advisory Group of Experts (SAGE) reviewed the evidence regarding the non-specific effects of vaccines and concluded that further research is warranted. On average, about 75 cases of vaccine-associated paralytic poliomyelitis are reported each year worldwide, and WHO has suggested that OPV be gradually replaced by inactivated polio vaccine (IPV) to reduce the number of such cases. Results from a randomised trial in 2015 suggest that OPV might have benefi cial non-specific effects that reduce allcause mortality by 17%, possibly to a greater extent in boys than in girls, whereas previous evidence suggests that IPV increases all-cause mortality by 10%. Consequently, the proposed change from OPV to IPV might lead to increased all-cause mortality through loss of the beneficial non-specific eff ects of the live vaccine, and adverse non-specifi c eff ects of the inactivated vaccine. Replacement of OPV with IPV could translate to approximately 4000 deaths for each case of vaccineassociated paralytic poliomyelitis prevented, and might cause more than 300 000 additional deaths each year. In view of the possible effects on all-cause mortality, more data need week 6 of MBCT—so tapering and MBCT treatment obviously overlapped to some extent. Since evidence is accumulating that withdrawal symptoms after discontinuation of selective serotonin reuptake inhibitors (SSRIs) are more detrimental and prolonged than assumed (up to 1 year), we suggest that the discontinuation process might have interfered with the therapeutic effects of MBCT. In a systematic review, gradual tapering did not eliminate withdrawal reactions. We do not know what the predominant class of medication was in the study by Kuyken and colleagues, but it seems likely that SSRIs were involved to a large extent. Thus, we argue that, by consecutively undertaking medication tapering followed by a longer washout period before starting MBCT, even stronger eff ects of MBCT might be observed. In other studies, responders to cognitive behavioral therapy showed relapse rates of 39% in the 68 weeks after psychotherapy and 68% after discontinuation of medication; therefore, the discontinuation syndrome might explain the relatively high relapse rate of 44% in Kuyken and colleagues’ study of MBCT.

Trends in the incidence and outcome of paediatric out-of-hospital cardiac arrest: A 17-year observational study

BACKGROUND System-based improvements to the chain of survival have yielded increases in survival from out-of-hospital cardiac arrest (OHCA) in adults. Comparatively little is known about the long-term trends in incidence and survival following paediatric OHCA. METHODS Between 2000 and 2016, we included children aged ≤16 years who suffered a non-traumatic OHCA in the state of Victoria, Australia. Trends in incidence and unadjusted outcomes were assessed using linear regression and a non-parametric test for trend. Multivariable logistic regression with multiple imputation was used to identify arrest factors associated with event survival and survival to hospital discharge. RESULTS Of the 1301 paediatric OHCA events attended by emergency medical services (EMS), 948 (72.9%) received an attempted resuscitation. The overall incidence of EMS-attended and EMS-treated events was 6.7 and 4.9 cases per 100,000 person-years, with no significant changes in trend. Although the proportion of cases with OHCA identified in the call and receiving bystander CPR increased over time, EMS response times also increased. Unadjusted event survival rose from 23.3% in 2000 to 33.3% in 2016 (p trend = .007), and survival to hospital discharge rose from 9.4% to 17.7% over the same period (p trend = .04). Increases in survival to hospital discharge were largely driven by initial shockable arrests, which rose from 33.3% in 2000 to 60.0% in 2016 (p trend = .005). Survival after initial shockable arrests was higher if the first shock was delivered by either first responder or public AED compared with paramedics (83.3% vs. 40.0%, p = .04). After adjustment, the odds of event survival and survival to hospital discharge increased independent of baseline characteristics, by 7% (OR 1.07, 95% CI: 1.03, 1.11; p = .001) and 8% (OR 1.08, 95% CI: 1.01, 1.15; p = .02) per study year, respectively. CONCLUSIONS Survival following paediatric OHCA increased in our region over a 17 year period. This was driven, in part, by improving outcomes for initial shockable arrests.

Rhabdomyolysis in a Tertiary PICU: A 10-Year Study.

Objectives: Rhabdomyolysis is a disorder of muscle breakdown. The aim of this study was to describe the epidemiology of rhabdomyolysis in children admitted to a PICU and to assess the relationship between peak creatinine kinase and mortality. Design: Retrospective cohort study in children admitted to the PICU with rhabdomyolysis between January 1, 2005, and December 31, 2014. Demographic, clinical, and outcome data were recorded. Outcomes were analyzed by level of peak creatinine kinase value (0–10,000, 10,001–50,000, > 50,000IU/L). Long-term renal outcomes were reported for PICU survivors. Setting: A single-centre academic tertiary PICU. Patients: Children admitted to the PICU with serum creatinine kinase level greater than 1,000 IU/L. Interventions: None. Measurements and Main Results: There were 182 children with rhabdomyolysis. The median peak creatinine kinase value was 3,583 IU/L (1,554–9,608). The primary diagnostic categories included sepsis, trauma, and cardiac arrest. Mortality for peak creatinine kinase values 0–10,000, 10,001–50,000, and > 50,000 IU/L were 24/138 (17%), 6/28 (21%), and 3/16 (19%), respectively (p = 0.87). Children with a peak creatinine kinase greater than 10,000 IU/L had a longer duration of mechanical ventilation and ICU length of stay than children with peak creatinine kinase less than 10,000. Renal replacement therapy was administered in 29/182 (16%). There was longer duration of mechanical ventilation (273 [141–548] vs. 73 [17–206] hr [p < 0.001]) and ICU length of stay (334 [147–618] vs. 100 [37–232] hr (p < 0.001)] in children receiving renal replacement therapy. Continuous veno-venous hemofiltration was the most common modality 23/29 (79%). Only one child required renal replacement therapy postintensive care stay, and adverse long-term renal outcomes were uncommon. Conclusions: In children with rhabdomyolysis requiring intensive care, peak creatinine kinase was not associated with mortality but is associated with greater use of intensive care resources. Chronic kidney disease is an uncommon sequelae of rhabdomyolysis in children requiring intensive care.

Abstract O-08: OVER-SHUNTING IS ASSOCIATED WITH WORSE OUTCOMES THAN A BLOCKED SHUNT AFTER SYSTEMIC TO PULMONARY SHUNT PROCEDURE

OVER-SHUNTING IS ASSOCIATED WITH WORSE OUTCOMES THAN A BLOCKED SHUNT AFTER SYSTEMIC TO PULMONARY SHUNT PROCEDURE K.W. Soo1, J. Brink2, Y. d’Udekem2, W. Butt3, S.P. Namachivayam3 1National Heart Institute IJN, Paediatric and Congenital Heart Centre, Kuala Lumpur, Malaysia 2Royal Children’s Hospital, Department of Cardiac Surgery, Melbourne, Australia 3Royal Children’s Hospital, Department of Intensive Care, Melbourne, Australia

48 Trends in the incidence and outcome of paediatric out-of-hospital cardiac arrest in victoria, australia

Aim System-based improvements to the chain of survival have yielded significant increases in survival from out-of-hospital cardiac arrest (OHCA) in adults. Comparatively little is known about the long-term trends in incidence and survival following paediatric OHCA. Method Between 2000 and 2016, we included paediatrics aged ≤16 years who suffered a non-traumatic OHCA in the state of Victoria, Australia. Trends in incidence and unadjusted outcomes were assessed using linear regression. Adjusted trends in event survival and survival to hospital discharge were assessed using multivariable logistic regression. Results Of the 1301 paediatric OHCA attended by emergency medical services (EMS), 948 (72.9%) received an attempted resuscitation. The overall incidence of EMS-attended OHCA was 6.7 cases per 1 00 000 person-years, with no significant change over time. Although median EMS response times increased over time, the proportion of cases with OHCA identified in the call and receiving bystander cardiopulmonary resuscitation (CPR) also increased. Unadjusted event survival rose from 23.3% in 2000 to 33.3% in 2016 (p trend=0.007). Over the same period, survival to hospital discharge rose from 9.4% to 17.7% (p trend=0.04). After multivariable adjustment, the odds of event survival and survival to hospital discharge increased independently of arrest factors, by 7% (OR 1.07, 95% CI: 1.03, 1.12; p=0.001) and 8% (OR 1.08, 95% CI: 1.01, 1.15; p=0.02) respectively. Bystander CPR and OHCA identification in the call were not associated with survival. Conclusion In our region, survival following paediatric OHCA increased significantly over a 17 year period. However, the factors contributing to this improvement require further investigation. Conflict of interest None Funding ZN is funded by a National Health and Medical Research Council (NHMRC) Early Career Fellowship (#1146809).

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

*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.

Outcomes After Pediatric Critical Illness: Important to Be Accurate.

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