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- Kalzen, Håkan
(author)
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Paediatric intensive care in Sweden : an epidemiological survey focusing on diagnostic panorama, outcome and factors influencing long-term mortality
- 2018
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Doctoral thesis (other academic/artistic)abstract
- Background: In the 1990´s, studies of paediatric intensive care around the world had shown better outcome for children treated in PICUs compared to adult ICUs (AICU). In Sweden no nationwide data on children needing ICU care was present. Aim/Methods: To quantify the Swedish need for and outcome of intensive care for children, a retrospective multicenter cohort study was set up to include all children admitted to intensive care in from March 1998 to March 2001. The cohort was monitored for five years and survival data analyzed. (Study I). When analyzing the data, it was obvious that PIM2 score and a more extended data set to study factors involved in long-term mortality post PICU care was needed. A new three-year cohort was formed, this time with only PICU admissions from January 1, 2008 to December 31, 2010 (Study II). During the time of the study PIM2 score was not reported from AICUs. Arterial blood gas (ABG) is one among several variables included into the PIM2 score. We felt that to minimize unnecessary trauma, the routine use of ABG was unwarranted unless clinically indicated or for certain groups of children. We therefore studied a subset of the cohort to determine how PIM2 score predictability was influenced with or without ABG (Study III). It was noted that some of the children who died in the years after discharge, did so outside the PICU (Study II). We therefore performed an additional study of the 268 children whom died in the latter cohort to determine if limitation of medical treatment (LOMT) was the factor opposing PICU readmission for these children when turning fatally ill (Study IV). Results/Conclusions: We found that the outcome of intensive care for Swedish children was on par with international published data and 56% of the paediatric intensive care admissions were to AICUs. A 20-fold increased risk of death five years post PICU discharge was also found for the cohort (Study I). In the following cohort we found that having multiple admission (MADM) compared to single admissions (SADM) and/or a complex chronic conditions (CCC) significantly impaired the long-term outcome for five out of the seven different admission diagnosis groups (Study II). We also found that since Study I there was an increase in transfer from AICU to PICU from 65 to at least 278 children. In Study III we could show that the PIM2 score only becomes more accurate (although not significantly) if ABG is taken for the admission diagnostic group respiratory. In Study IV we in detail studied the 268 children that died in the cohort and could show that 123 (46%) died outside PICU. At the time of death 75% of them had a LOMT in place limiting readmission to PICU. Of the children not readmitted to PICU, 75% also had a CCC and 60% were males.
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| 2. |
- Kalzén, Håkan, et al.
(author)
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Survival after PICU admission : The impact of multiple admissions and complex chronic conditions
- 2018
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In: PLoS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 13:4
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Journal article (peer-reviewed)abstract
- Objective Factors predicting survival over time after pediatric intensive care unit (PICU) admissions are not fully understood. The primary aim of the current study was to investigate whether multiple admissions (MADM) compared to single PICU admissions (SADM) were associated with poor survival over time after being admitted to PICU facilities. Our secondary aim was to investigate if the presence of a complex chronic condition (CCC) would further impair prognosis. Design A closed cohort of all children up to 16 years of age admitted to the three PICUs in Sweden between 2008 and 2010 was prospectively collected and followed until 2012, providing survival data for at least one but up to four years of follow-up. Setting Three Swedish tertiary referral centers for pediatric intensive care and extracorporeal membrane oxygenation (ECMO) care were used. Patients In total, 3, 688 Swedish children with 5, 019 PICU admissions were included. Interventions No interventions were conducted. Measurements An extensive data set was recorded, including up to four-year survival information following first PICU admission. The patients were assigned to seven admission diagnostic groups, which were then divided into SADM or MADM groups. The difference in survival over time and mortality rates (MR) and mortality rate ratios (MRR) were calculated. SADM and MADM groups with and without an existing CCC were formed. The difference in survival over time between groups was calculated. Main results A highly significant difference in survival over time was noted between SADM and MADM patients (p<0.0001), which was intensified by the presence of a CCC. MADM patients with a CCC had the worst outcome, while SADM patients without a CCC had the best outcome. MADM patients with no CCC demonstrated decreased survival over time compared to SADM patients with a CCC. Survival over time was statistically worsened for patients with MADM compared to SADM for the following admission diagnostic groups: Cardiovascular, Gastrointestinal/Renal, Respiratory, Neurological, and Miscellaneous. The mortality rate (deaths/patient year of follow-up) during the time of follow-up was 0.023 for SADM and 0.062 for MADM patients. The mortality rate ratio (MRR) between these groups was 2.69. Conclusion Compared to single admissions, multiple admissions to PICU were associated with a significant decrease in survival over time in some but not all diagnostic groups. Regarding our secondary aim, we found that when the presence of a CCC is factored into the survival analysis, survival over time is further impaired.
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