A Retrospective Cohort Study Comparing Outcomes of Pediatric Intensive Care Patients after Changing from Higher to Permissive Blood Pressure Targets

Abstract

New neurological morbidity post pediatric intensive care (PIC) poses substantial problems, with a need to understand the relationship of outcome to blood pressure (BP) targets. The aim of the study is to see whether a change from a higher BP targeted strategy to a permissive one improved outcomes for development of new neurological morbidity, length of stay (LOS), and PIC-acquired infection. A retrospective cohort analysis was undertaken, comparing outcomes before and after the change. The higher BP cohort targets were set using standardized age-based centiles. In the permissive cohort, lower BPs were allowed, dependent on physiological variables. Targeted treatment continued throughout the critical illness. New neurological morbidity was defined as any deterioration from baseline, attributable to the admission, measured by post discharge clinical and records review over a minimum period of 4 years. Results were analyzed with IBM SPSS Statistics v26. Of 123 admissions in the permissive and 214 admissions in the higher BP target cohorts, 88 (72%) and 188 (88%) survived without new neurological morbidity (permissive vs. higher cohort OR 0.348 [95% CI 0.197–0.613] p <0.001). Median LOS was 2 (interquartile [IQ] range 2–5) and 3 (IQ range 2–6) days for the permissive and higher cohorts, respectively (p = 0.127). Three (2.4%) and 7 (3.3%) admissions in the permissive and higher BP cohorts respectively suffered PIC-acquired infection (p = 0.666). A higher BP targeted strategy was associated with protection from new neurological morbidity as compared with a permissive strategy, supporting the need for prospective studies into BP targets.

Keywords

post-intensive care syndrome - new neurological morbidity - sepsis - outcome - pediatric intensive care

Ethics Approval

Formal approval was obtained from the hospital clinical governance department, reference number, NA.2015.012. The supervising university for submission for thesis contribution for Master of Science waived requirement for further ethical approval. PICanet has permission to collect data under section 251 of the NHS Act 2006 (originally enacted under Section 60 of the Health and Social Care Act 2001).[22]

Publikationsverlauf

Eingereicht: 11. Juli 2022

Angenommen: 09. September 2022

Artikel online veröffentlicht:
01. November 2022

• References

• 1 Ong C, Lee JH, Leow MK, Puthucheary ZA. Functional outcomes and physical impairments in pediatric critical care survivors: a scoping review. Pediatr Crit Care Med 2016; 17 (05) e247-e259
• 2 Heneghan JA, Pollack MM. Morbidity: changing the outcome paradigm for pediatric critical care. Pediatr Clin North Am 2017; 64 (05) 1147-1165
• 3 Herrup EA, Wieczorek B, Kudchadkar SR. Characteristics of postintensive care syndrome in survivors of pediatric critical illness: a systematic review. World J Crit Care Med 2017; 6 (02) 124-134
• 4 Matettore A, Ray S, Harrison DA. et al. Correction to: paediatric intensive care admission blood pressure and risk of death in 30,334 children. Intensive Care Med 2019; 45 (10) 1500-1501
• 5 Carcillo JA, Kuch BA, Han YY. et al. Mortality and functional morbidity after use of PALS/APLS by community physicians. Pediatrics 2009; 124 (02) 500-508
• 6 Suttipongkaset P, Chaikittisilpa N, Vavilala MS. et al. Blood pressure thresholds and mortality in pediatric traumatic brain injury. Pediatrics 2018; 142 (02) e20180594
• 7 Kumar R, Singhi S, Singhi P, Jayashree M, Bansal A, Bhatti A. Randomized controlled trial comparing cerebral perfusion pressure-targeted therapy versus intracranial pressure-targeted therapy for raised intracranial pressure due to acute CNS infections in children. Crit Care Med 2014; 42 (08) 1775-1787
• 8 Zimmerman JJ, Banks R, Berg RA. et al; Life After Pediatric Sepsis Evaluation (LAPSE) Investigators. Critical illness factors associated with long-term mortality and health-related quality of life morbidity following community-acquired pediatric septic shock. Crit Care Med 2020; 48 (03) 319-328
• 9 Carcillo JA, Fields AI. American College of Critical Care Medicine Task Force Committee Members. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002; 30 (06) 1365-1378
• 10 Maitland K, Kiguli S, Opoka RO. et al; FEAST Trial Group. Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011; 364 (26) 2483-2495
• 11 Raman S, Peters MJ. Fluid management in the critically ill child. Pediatr Nephrol 2014; 29 (01) 23-34
• 12 Lopes CLS, Piva JP. Fluid overload in children undergoing mechanical ventilation. Rev Bras Ter Intensiva 2017; 29 (03) 346-353
• 13 Márquez-González H, Casanova-Bracamontes L, Muñoz-Ramírez CM, Peregrino-Bejarano L, Bolaños-Téllez B, Yáñez-Gutiérrez L. Relation between fluid overload and mortality in children with septic shock. Arch Argent Pediatr 2019; 117 (02) 105-113
• 14 Legrand M, Payen D. Understanding urine output in critically ill patients. Ann Intensive Care 2011; 1 (01) 13
• 15 VanValkinburgh D, Kerndt CC, Hashmi MF. Inotropes And Vasopressors. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2021. January. Accessed September 25, 2021, at: https://www.ncbi.nlm.nih.gov/books/NBK482411/
• 16 Harron K, Mok Q, Parslow R, Muller-Pebody B, Gilbert R, Ramnarayan P. Risk of bloodstream infection in children admitted to paediatric intensive care units in England and Wales following emergency inter-hospital transfer. Intensive Care Med 2014; 40 (12) 1916-1923
• 17 Weiss SL, Peters MJ, Alhazzani W. et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Pediatr Crit Care Med 2020; 21 (02) e52-e106
• 18 Recognition of respiratory failure and shock. In: Chameides L, Hazinski MF. eds. Pediatric Advanced Life Support.1994 to 1997 ed. Dallas: American Heart Association; 1997: 2-5
• 19 Department of Health, Health Service Directorate. Paediatric intensive care “A Framework for the Future”. Report from the National Coordinating Group on Paediatric Critical Care to the Chief Executive of the NHS Executive 1997; 8: 16
• 20 Recognition and Management of the Seriously Ill Child. In: European Resuscitation Council and Rescuscitation Council (UK). European Paediatric Life Support. 2 nd ed.. London: Resuscitation Council UK; 2006: 9
• 21 Bone RC, Balk RA, Cerra FB. et al; The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992; 101 (06) 1644-1655
• 22 Paediatric Intensive Care Audit Network. . Accessed January 06, 2021, at: https://www.PICanet.org.uk/
• 23 Slater A, Shann F, Pearson G. Paediatric Index of Mortality (PIM) Study Group. PIM 2: a revised version of the paediatric index of mortality. Intensive Care Med 2003; 29 (02) 278-285
• 24 Gupta P, Rettiganti M, Gossett JM, Daufeldt J, Rice TB, Wetzel RC. Development and validation of an empiric tool to predict favorable neurologic outcomes among PICU patients. Crit Care Med 2018; 46 (01) 108-115
• 25 Feudtner C, Feinstein JA, Zhong W, Hall M, Dai D. Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation. BMC Pediatr 2014; 14: 199
• 26 Farris RW, Weiss NS, Zimmerman JJ. Functional outcomes in pediatric severe sepsis: further analysis of the researching severe sepsis and organ dysfunction in children: a global perspective trial. Pediatr Crit Care Med 2013; 14 (09) 835-842
• 27 Topjian AA, Gutierrez-Colina AM, Sanchez SM. et al. Electrographic status epilepticus is associated with mortality and worse short-term outcome in critically ill children. Crit Care Med 2013; 41 (01) 215-223
• 28 Fiser DH. Assessing the outcome of pediatric intensive care. J Pediatr 1992; 121 (01) 68-74
• 29 Crouchman M, Rossiter L, Colaco T, Forsyth R. A practical outcome scale for paediatric head injury. Arch Dis Child 2001; 84 (02) 120-124
• 30 Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988; 16 (03) 128-140
• 31 Vavilala MS, Lee LA, Lam AM. The lower limit of cerebral autoregulation in children during sevoflurane anesthesia. J Neurosurg Anesthesiol 2003; 15 (04) 307-312
• 32 Malbrain MLNG, Van Regenmortel N, Saugel B. et al. Principles of fluid management and stewardship in septic shock: it is time to consider the four D's and the four phases of fluid therapy. Ann Intensive Care 2018; 8 (01) 66
• 33 Cheifetz IM. Cardiorespiratory interactions: the relationship between mechanical ventilation and hemodynamics. Respir Care 2014; 59 (12) 1937-1945
• 34 Asfar P, Meziani F, Hamel JF. et al; SEPSISPAM Investigators. High versus low blood-pressure target in patients with septic shock. N Engl J Med 2014; 370 (17) 1583-1593
• 35 Nath Kundu R, Biswas S, Das M. Mean arterial pressure classification: a better tool for statistical interpretation of blood pressure related risk covariates 2017. Cardiology and Angiology: An International Journal 6 (01) 1-7
• 36 NICE. Sepsis. . Accessed December 15, 2021, at: https://www.nice.org.uk/guidance/qs161/chapter/Quality-statement-3-Intravenous-fluids
• 37 Stockwell JA. Nosocomial infections in the pediatric intensive care unit: affecting the impact on safety and outcome. Pediatr Crit Care Med 2007; 8 (Suppl. 02) S21-S37
• 38 PICANet. A decade of data. 2014 . Accessed June 25, 2021, at: https://www.picanet.org.uk/wp-content/uploads/sites/25/2018/05/PICANet_A_Decade_of_Data_2014_Annual_Report_Summary.pdf
• 39 Gilpin D, Hancock S. Referral and transfer of the critically ill child. BJA Educ 2016; 16: 253-257
• 40 Hagedoorn NN, Zachariasse JM, Moll HA. A comparison of clinical paediatric guidelines for hypotension with population-based lower centiles: a systematic review. Crit Care 2019; 23 (01) 380