Standardized mortality rate in groups of patients treated in a pediatric intensive care unit

Sastav populacija bolesnika može među jedinicama intenzivnog liječenja djece biti bitno različit. Razlike u sastavu između izvorne populacije na kojoj je sustav izveden i populacija bolesnika na kojima se sustav predviđanja smrtnosti primjenjuje, kao i pojedinih skupina unutar populacije, čine točnost predviđanja smrtnosti nepouzdanom. Prikupili smo pokazatelje za izračun Paediatric Index of Mortality (PIM 2) sustava za 591 uzastopce primljena bolesnika u jedinicu intenzivnog liječenja djece (JILD). Izračunali smo odvojeno zamijećenu smrtnost (ZS), predviđenu smrtnost (PS) i standardizirani omjer smrtnosti (SOS) za različite skupine bolesnika. PS je bila viša od ZS za kirurške bolesnike, kao i za bolesnike primljene u hitnim stanjima. Unutar dijagnostičkih skupina, SOS je bio < 1 za neurološke bolesnike, a u bolesnika s bolestima dišnog sustava bio je > 1. Unutar dobnih skupina, SOS je bio > 1 u predškolske djece, a u adolescenata je SOS bio 1 u bolesnika koji su dugo liječeni. Predikcijska sposobnost sustava PIM2 nije, dakle, jednaka za sve skupine unutar populacije bolesnika. To znači da razlika u sastavima populacija bolesnika može biti uzrokom manje preciznosti izračuna PS u odnosu na ZS. Ova poteškoća može biti izrazita u jedinicama s malim i jednolikim populacijama bolesnika.The composition of patient population in pediatric intensive care units may vary significantly. The differences in composition between original population based on which the system was derived and patient population on whom the mortality rate forecast system is applied, as on certain groups within the population, make the accuracy of mortality predictions unreliable. We collected factors for calculation of Paediatric Index of Mortality (PIM 2) system for 591 patients consecutively admitted to pediatric intensive care unit (PICU). We separately calculated observed mortality (OM), predicted mortality (PM) and standardized mortality rate (SMR) for different groups of patients. PM was higher than OM for surgical patients, as well as for emergency patients. Within diagnostic groups, SMR was 1. Within age groups, SMR was > 1 in preschool children, and 1 in longterm hospitalized patients. Predictive ability of PIM2 system is, therefore not equal for all groups within patient population. Meaning, the difference in patient population composition can be the cause of less precise calculation of PM compared to OM. This problem can be more expressed in units with smaller and uniform patient populations

Prvi hrvatski pedijatrijski bolesnik s Geotrichum capitatum respiratornom infekcijom

Geotrichum capitatum can cause infections in humans and its importance has recently been recognized in patients with immunosuppressive conditions. In this report we present the first Croatian pediatric patient with pneumonia in whom G. capitatum was isolated in three sequential bronchoalveolar lavage and tracheal aspiration specimens.Geotrichum capitatum može uzrokovati infekcije u ljudi i njegov značaj je nedavno prepoznat u imunosuprimiranih bolesnika. U ovom radu prikazujemo prvog hrvatskog pedijatrijskog bolesnika s pneumonijom u kojeg je G. capitatum izoliran u tri uzastopna bronhoalveolarna lavata i aspirata traheje

FUNCTIONAL OUTCOME OF CHILDREN TREATED IN AN INTENSIVE CARE UNIT (ICU)

Uvod: Ishod bolesnika nakon liječenja ne određuje samo težina osnovne bolesti nego i njegovo stanje prije hopsitalizacije. Cilj: Utvrditi ishod bolesnika liječenih u JIL-u, osobito djece s kroničnim bolestima. Ispitanici i metode: Podatci su prikupljani prospektivno. Ishod je procijenjen uporabom ljestvice Pediatric Overall Performance Category (POPC) za 449-ero djece liječene u JIL-u, KBC Split. Procijenjeno je funkcionalno stanje prije hospitalizacije i na otpustu iz bolnice - u bolesnika s neurorazvojnim bolestima, s drugim kroničnim bolestima i bez kronične bolesti. POPC je ljestvica od šest stupnjeva, od zbroja 1 (normalan) do 6 (mrtav), u rasponu koji upućuje na sve veće stupnjeve funkcionalnog oštećenja. Svaki stupanj ljestvice je popraćen definicijama stanja koje su prikladne za dob. Procijenili smo bazalno funkcionalno stanje bolesnika (bPOPC) prije pojave osnovne bolesti, koja je neposredno uzrokovala hospitalizaciju, temeljem razgovora s roditeljima. Ocjena funkcije prije otpusta (dPOPC od engl. discharge functional score) odnosila se na bolesnikovo stanje prije otpusta iz JIL-a. Rezultati: Funkcionalno stanje na otpustu bilo je značajno ovisno o funkcionalnom stanju prije hospitalizacije i o predviđenoj smrtnosti. Djeca s neurorazvojnim bolestima imala su značajno lošiju bazalnu ocjenu i značajno manje pogoršanje funkcionalnog morbiditeta pri otpustu u usporedbi s djecom bez kronične bolesti i onom s drugim kroničnim bolestima. Zaključci: Ljestvica POPC je dokazala svoju primjenjivost u maloj jedinici intenzivnog liječenja i na heterogenoj populaciji bolesnika. Zato je treba uzeti u obzir za redovitu procjenu kakvoće rada u zdravstvu, jer je to jednostavno i pouzdano sredstvo. U suprotnosti s ostalim bolesnicima, funkcionalno stanje djece s neurorazvojnim bolestima značajno je obilježeno utjecajem komorbiditeta. Njihovo stanje prije hospitalizacije bilo je već lošije od stanja ostale djece i stoga se nije moglo značajno promijeniti pri otpustu.Introduction: Patients’ outcome is determined not only by the severity of the index illness, but also the impact of the patients’ pre-admission comorbid status. Aim: We intended to evaluate the outcome of patients treated in a pediatric ICU, with special emphasis on the group of children with chronic diseases. Methods and subjects: The data was obtained prospectively and outcome was assessed according to the Pediatric Overall Performance Category (POPC) scale for 449 sick children in the pediatric ICU of Split University Hospital. Functional performance was assessed as the pre-admission score and the discharge score in patients with neurodevelopmental disabilities, patients with other chronic diesases, and those without a chronic disease. POPC is a six-point scale ranging from the score of 1 (normal) to 6 (dead), with interim points representing progressively greater functional impairment. Each scale category is accompanied by age-appropriate operational definitions. Functional performance of patients was assessed as the baseline, pre-admission score (bPOPC), prior to the index disease, based on an interview with each child\u27s parent. The discharge functional score (dPOPC) was evaluated before transfer of patients from the PICU. Results: The discharge functional status was significantly dependent on the pre-admission functional status and the predicted mortality. Children with neurodevelopmental disabilities had a significantly worse baseline score and significantly smaller deterioration of functional morbidity at discharge compared to children with no chronic disease and children with other chronic diseases. Conclusions: The POPC scale proved its applicability in a small ICU, with a heterogenous population of patients. It should therefore be considered for regular evaluation of the quality of health care, as a simple and accurate tool. As opposed to other patients, the functional status of children with neurodevelopmental disabilities was markedly influenced by their comorbidity. Their pre-admission status was worse than the status of other children, and hence could not deteriorate significantly at discharge

Patau sindrom

Genetic syndromes caused by chromosomal aberrations involve a recognizable pattern of multiple congenital anomalies with increased neonatal and infant mortality, making care challenging for the family, primary care practitioners, and specialists. About 28% of children born with trisomy 13 die during the fi rst week of life. The median life expectancy is about 2.5 days. We present a 12-year-old girl, the longest living patient with Patau syndrome in Croatia, followed-up from the birth until the age of 12 years. The conventional nonintervention approach has been revised and we suggest changing the traditional view of the condition.Genetski sindromi uzrokovani kromosomnim aberacijama uključuju prepoznatljivi obrazac višestrukih prirođenih anomalija s povećanom smrtnošću novorođenčadi i dojenčadi, što skrb za njih čini teškom za obitelj, liječnike primarne zdravstvene skrbi i specijaliste. Oko 28% djece rođene s trisomijom 13 umire tijekom prvog tjedna života. Srednje očekivano trajanje života je oko 2,5 dana. Prikazujemo 12-godišnju djevojčicu, najduže živuću bolesnicu s Patauovim sindromom u Hrvatskoj, koju pratimo od rođenja do njezine sadašnje dobi od 12 godina. Konvencionalni pristup zasnovan na izostanku intervencije doživio je reviziju, a mi predlažemo promjenu tradicionalnog pogleda na ovo stanje

Pokušaj samoubojstva ingestijom oleandrova lišća i liječenje digoksin-specifičnim Fab imunoglobulinskim fragmentima – prikaz slučaja

Natural cardiac glycosides have positive inotropic heart effects but at high, toxic doses they can cause life-threatening cardiac arrhythmias. Here we present the first Croatian case of a 16-year-old girl who attempted suicide by eating dried oleander leaves, which contain natural cardiac glycosides, and her treatment with a specific antidote. The girl presented with an oedema of the uvula indicating local toxicity, severe bradycardia, first-degree atrioventricular block, drowsiness, and vomiting. Having taken her medical history, we started treatment with atropine, intravenous infusion of dextrose-saline solution and gastroprotection, but it was not successful. Then we introduced digoxin-specific Fab antibody fragments and within two hours, the patient’s sinus rhythm returned to normal. Cases of self-poisoning with this oleander are common in South-East Asia, because it is often used as a medicinal herb, and digoxin-specific Fab fragments have already been reported as effective antidote against oleander poisoning there. Our case has taught us that it is important to have this drug in the hospital pharmacy both for digitalis and oleander poisoning.Prirodni srčani glikozidi imaju pozitivan inotropni učinak na srce. U visokim, toksičnim dozama mogu prouzročiti za život opasne srčane aritmije. Predstavljamo prvi hrvatski slučaj pokušaja samoubojstva 16-godišnje djevojke konzumiranjem oleandrovih suhih listova, koji sadrže prirodne srčane glikozide, i liječenje specifičnim protuotrovom. Djevojka je također imala edem uvule kao znak lokalne toksičnosti. Svi podatci dobiveni su analizom dokumentacije iz medicinskoga kartona. U djevojke se javila značajna bradikardija, atrioventrikularni blok prvog stupnja, pospanost i povraćanje. Početno liječenje atropinom, intravenskom infuzijom fiziološke otopine i 5 % glukoze uz gastroprotekciju nisu bili učinkoviti. Pacijentica je zatim liječena digoksin-specifičnim Fab imunoglobulinskim fragmentima. Unutar dva sata od primjene lijeka srčani se ritam promijenio u normalni sinusni ritam. Ovo je rijedak slučaj pokušaja suicida samootrovanjem na našim prostorima. Slučajevi samootrovanja ovom biljkom česti su u jugoistočnoj Aziji jer se ondje često koristi kao biljni proizvod za samoliječenje. Digoksin specifični Fab fragmenti su protuotrov za predoziranje digoksinom, kao i za akutnu intoksikaciju ovom biljkom. Važno je imati ovaj lijek u bolničkoj ljekarni kako za intoksikaciju digitalisom tako i za otrovanje ovom biljkom

Emotional and behavioral outcomes and quality of life in school-age children born as late preterm: retrospective cohort study

Aim To determine the effect of late preterm birth and treatment at the intensive care unit (ICU) on school-age children’s emotional and behavioral problems and quality of life (QoL). Methods Emotional and behavioral problems and QoL were investigated in 6-12-year-olds who were born late preterm at the University Hospital Center Split in the period from January 2002 to March 2008. The study included 126 late preterm children treated in ICU (LP-ICU group), 127 late preterm children not treated in ICU (LP-non-ICU group), and 131 full-term children treated in ICU (FT-ICU group). Emotional and behavioral difficulties were assessed using the Child Behavior Checklist. QoL was evaluated with the Royal Alexandra Hospital for Children Measure of Function questionnaire. The data was collected via telephone interview with mothers during 2014. Results Late preterm children had a nearly 5-fold risk for internalizing problems in comparison with FT-ICU children (OR 4.76, 95% confidence interval [CI] 2.37-9.56 and OR 4.82, 95% CI 2.25-10.37 in LP-ICU and LP-non-ICU children, respectively). They also had a greater risk for externalizing problems (OR 3.08, 95% CI 1.44-6.61 and OR 2.68, 95% CI 1.14-6.28, respectively) and total problems (OR 6.29, 95% CI 2.86-13.83 and OR 7.38, 95% CI 3.08-17.69, respectively) and a considerably increased risk for lower QoL (OR 12.79, 95% CI 5.56-29.41 and OR 5.05, 95% CI 2.04-12.48, respectively). Conclusion Children born late preterm had a greater risk for emotional and behavioral problems and lower QoL during childhood than their full-term born peers and they experienced serious health problems upon birth

Clinical Scoring Systems in Predicting Health-Related Quality of Life of Children with Injuries

The aim of the study was to explore the association between Glasgow Coma Scale (GCS), Paediatric Index ofMortality (PIM2) and Injury Severity Score (ISS), and the long-term outcome of children with injuries. The health related quality of life (HRQL) was assessed by using the Royal Alexandra Hospital for children Measure of Function (RAHC MOF), 12 months post discharge. Out of 118 children with injuries (9% of all patients), 75 had injury of the head as the leading injury. There were no significant differences at admission in the severity of clinical condition, as expressed by PIM2 and ISS, between patients with head injuries and patients with other injured leading body regions. Children with head injuries had significantly worse HRQOL than children with other leading injured body region (p<0.045), and children from road traffic accidents had significantly worse HRQL (p=0.004), compared to other mechanisms of injury. HRQL correlated significantly with GCS (p=0.027), but not with ISS and PIM2. As the conclusion, among all scoring systems applied, only GCS, which demonstrates severity of head injury, showed significant impact on long-term outcome of injured children

Long-term quality of life of patients treated in the pediatric intensive care unit

Preživljavanje nakon teške bolesti ili ozljede je važno, ali funkcionalno zdravlje i kakvoća života ovisna o zdravlju najvažnija su mjerila ishoda i bolesnikove dobrobiti. Ispitali smo promjenu dugoročne kakvoće života djece šest i 12 mjeseci nakon otpusta iz JILD-a. U prospektivno istraživanje u razdoblju od jedne i pol godine uključeno je 200 djece, u dobi 10 do 18 godina, liječene u JILD-u, 159 djece bez kroničnih bolesti i 41 dijete s kroničnim bolestima. Kontrolnu skupinu djece istovrsnih demografskih obilježja prikupili smo u ambulantama. Djeca su razvrstana prema dijagnostičkom kazalu ANZPIC Registry koji se koristi u JILD-u. Za procjenu dugoročne kakvoće života djece upotrijebili smo RAHC MOF bodovni sustav. Ispitali smo koja od sljedećih mjerila ishoda utječu na promjenu dugoročne kakvoće života: prisutnost kronične bolesti, dani strojne ventilacije, dani boravka u JILD-u i težina bolesti. Težina bolesti procijenjena je predviđenim rizikom smrtnosti (PIM 2), a težina ozljede bodovnim sustavima GCS i ISS. Ispitali smo promjenu kakvoće života kronično bolesne djece nakon šest i 12 mjeseci od otpusta iz JILD-a u odnosu na djecu u ambulantama. Dokazali smo da se kakvoća života nakon otpusta iz JILD-a početno pogoršava. Međutim, dugoročno se broj djece s pogoršanjem kakvoće života smanjuje pa je u 70% djece kakvoća života dobra. Na pogoršanje dugoročne kakvoće života šest mjeseci od otpusta iz JILD-a utječu: prisutnost kronične bolesti, ozljede, više dana strojne ventilacije, dulji boravak u JILD-u i više vrijednosti PIM-a. Nakon 12 mjeseci na pogoršanje dugoročne kakvoće života utječe prisutnost kronične bolesti i dulji boravak u JILD-u. Kod djece s kroničnim bolestima 12 mjeseci nakon otpusta iz JILD-a došlo je do pogoršanja kakvoće života, u odnosu na ambulantnu djecu s kroničnim bolestima. Zaključili smo da je dugoročno praćenje djece liječene u JILD-u potrebno kako bismo procijenili: tjelesne posljedice i njihov utjecaj na rast i razvoj, psihološke posljedice, te njihov utjecaj na kakvoću života bolesnika kao i potrebu za liječenjem i potporom nakon otpusta. Važno je znati koji čimbenici utječu na promjenu kakvoće života te nastojati poboljšati medicinsku skrb. Promicanje razvoja optimalnog zdravlja za svu djecu zahtijeva veliku pozornost društva, a mjerenje kakvoće života ovisne o zdravlju ključno je u tom procesu.Survival after a critical illness and injury is important, but functional health and Health Related Quality of Life (HRQoL) are the most important outcome measures and measures of patient's well being. In our study, we investigated the change in quality of life in children six and 12 months after treatment in PICU. 200 children, aged 10 to 18, treated in PICU during the period of 18 months, 159 of them without chronic diseases and 41 with chronic diseases, were included in this prospective study. The control group of children with the same demographic characteristics was collected in outpatient clinics. The children were classified according ANZPIC Registry diagnostic codes used in PICU. RAHC MOF score system was used for evaluating long-term quality of life in children. We investigated which of the following outcome measures influence the change in long-term quality of life: chronic disease, number of ventilation days, length of stay in PICU and severity of illness. The severity of illness was evaluated by PIM 2. GCS and ISS score systems were used to evaluate the severity of injury. Furthermore, we investigated the change in quality of life in chronically ill children six and 12 months after discharge from PICU in relation to the children from outpatient clinics. We confirmed that quality of life worsens after treatment in PICU. However, on the long term, the number of children with a decreased quality of life is reduced and in 70% of children the long-term quality of life is good. Chronic disease, injury, days of mechanical ventilation, length of stay and higher values of PIM 2 negatively affect the quality of life six months after discharge from PICU. Chronic disease and longer stay in PICU negatively affect the quality of life 12 months after the discharge. In children with chronic disease quality of life worsened 12 months after discharge from PICU in relation to the children from outpatient clinics. Our study revealed that a long-term follow-up research of paediatric intensive care survivors is needed to evaluate: physical sequelae and their impact during growth and development, psychological sequelae and their impact on the QoL of patients and the need for treatment and support after discharge. It is important to determine the factors which influence the change in quality of life and to try to improve medical care. Promoting the development of optimum health for all children requires greater public attention, and measuring HRQoL is a key element in that process