Certainty and mortality prediction in critically ill children

Objectives: The objective of this study is to investigate the relationship between a physician's subjective mortality prediction and the level of confidence with which that mortality prediction is made. Design and participants: The study is a prospective cohort of patients less than 18 years of age admitted to a tertiary Paediatric Intensive Care Unit (ICU) at a University Children's Hospital with a minimum length of ICU stay of 10 h. Paediatric ICU attending physicians and fellows provided mortality risk predictions and the level of confidence associated with these predictions on consecutive patients at the time of multidisciplinary rounds within 24 hours of admission to the paediatric ICU. Median confidence levels were compared across different ranges of mortality risk predictions. Results: Data were collected on 642 of 713 eligible patients (36 deaths, 5.6%). Mortality predictions greater than 5% and less than 95% were made with significantly less confidence than those predictions <5% and >95%. Experience was associated with greater confidence in prognostication. Conclusions: We conclude that a physician's subjective mortality prediction may be dependent on the level of confidence in the prognosis; that is, a physician less confident in his or her prognosis is more likely to state an intermediate survival prediction. Measuring the level of confidence associated with mortality risk predictions (or any prognostic assessment) may therefore be important because different levels of confidence may translate into differences in a physician's therapeutic plans and their assessment of the patient's future

Dynamic assessment of severity of illness in pediatric intensive care.

Severity of illness in 293 pediatric ICU patients was assessed by a daily estimate of ICU survival. The probability of nonsurvival was obtained by logistic regression analysis, using physiologic stability index (PSI) values from previous days as time-dependent covariates. Only PSI values from the previous 2 days gave statistically significant predictions of short-term (less than 24 h) outcome. When the prediction model derived from these data was tested prospectively on a separate set of 345 pediatric patients, there was excellent agreement between observed and predicted short-term mortality. Receiver operating characteristic curves for the 345 patients were statistically equivalent to those originally derived for the 293 patients, and this prediction model had significantly (p less than .025) more accuracy than prediction based on admission PSI. These results indicate that this model for daily risk assessment is statistically reliable and objective, as verified against eventual outcome. In the 345 patients, ICU mortality was predicted with 89% sensitivity and 91% specificity. This prediction model may be used to stratify patient groups for clinical studies, or identify very low-risk patients for potential early ICU discharge

Postanesthetic apnea and periodic breathing in infants

We designed this prospective study to determine the incidence of perioperative apnea and/or periodic breathing in infants undergoing general anesthesia for inguinal herniorrhaphy in the first year of life. We also attempted to define the age at which a prematurely born infant \u27outgrows\u27 possible apneic episodes. Eighty-six patients were studied. Thirty-eight infants were premature and 48 infants were full term. Seven of the full-term infants were ≤44 weeks conceptual age, and 41 were \u3e44 weeks conceptual age at the time of surgery. Periodic breathing was noted only in 14 ex-prematures with a conceptual age less than or equal to 44 weeks compared with those with a conceptual age greater than 44 weeks. These 14 (63.6%) had postoperative PB greater than 0.5% without bradycardia on pneumogram. Two of these patients showed PB as late as 5 h postoperatively. None of the patients in either group required endotracheal intubation or controlled ventilation postoperatively