학술논문
Recurrent Intensive Care Episodes and Mortality Among Children With Severe Neurologic Impairment.
Document Type
Academic Journal
Author
Nelson KE; Pediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada.; Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.; ICES, Toronto, Ontario, Canada.; Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.; Zhu J; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.; ICES, Toronto, Ontario, Canada.; Thomson J; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.; Mahant S; Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.; ICES, Toronto, Ontario, Canada.; Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.; CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada.; Widger K; Pediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada.; ICES, Toronto, Ontario, Canada.; Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.; Feudtner C; The Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.; Cohen E; Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.; ICES, Toronto, Ontario, Canada.; Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.; CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada.; Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada.; Pullenayegum E; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.; Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.; Feinstein JA; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado and Children's Hospital Colorado.
Source
Publisher: American Medical Association Country of Publication: United States NLM ID: 101729235 Publication Model: Electronic Cited Medium: Internet ISSN: 2574-3805 (Electronic) Linking ISSN: 25743805 NLM ISO Abbreviation: JAMA Netw Open Subsets: MEDLINE
Subject
Language
English
Abstract
Importance: Children requiring care in a pediatric intensive care unit (PICU) are known to have increased risk of subsequent mortality. Children with severe neurologic impairment (SNI)-who carry neurologic or genetic diagnoses with functional impairments and medical complexity-are frequently admitted to PICUs. Although recurrent PICU critical illness episodes (PICU-CIEs) are assumed to indicate a poor prognosis, the association between recurrent PICU-CIEs and mortality in this patient population is poorly understood.
Objective: To assess the association between number of recent PICU-CIEs and survival among children with severe neurologic impairment.
Design, Setting, and Participants: This population-based retrospective cohort study used health administrative data from April 1, 2002, to March 31, 2020, on 4774 children born between 2002 and 2019 with an SNI diagnosis code in an Ontario, Canada, hospital record before 16 years of age and a first PICU-CIE from 2002 to 2019. Data were analyzed from November 2021 to June 2023.
Exposure: Pediatric intensive care unit critical illness episodes (excluding brief postoperative PICU admissions).
Main Outcome and Measures: One-year survival conditioned on the number and severity (length of stay >15 days or use of invasive mechanical ventilation) of PICU-CIEs in the preceding year.
Results: In Ontario, 4774 children with SNI (mean [SD] age, 2.1 [3.6] months; 2636 [55.2%] <1 year of age; 2613 boys [54.7%]) were discharged alive between 2002 and 2019 after their first PICU-CIE. Ten-year survival after the initial episode was 81% (95% CI, 79%-82%) for children younger than 1 year of age and 84% (95% CI, 82%-86%) for children 1 year of age or older; the age-stratified curves converged by 15 years after the initial episode at 79% survival (95% CI, 78%-81% for children <1 year and 95% CI, 75%-84% for children ≥1 year). Adjusted for age category and demographic factors, the presence of nonneurologic complex chronic conditions (adjusted hazard ratio [AHR], 1.70 [95% CI, 1.43-2.02]) and medical technology assistance (AHR, 2.32 [95% CI, 1.92-2.81]) were associated with increased mortality. Conditional 1-year mortality was less than 20% regardless of number or severity of recent PICU-CIEs. Among children with high-risk PICU-CIEs, 1-year conditional survival decreased from 90% (95% CI, 89%-91%) after the first PICU-CIE to 81% (95% CI, 77%-86%) after the fourth PICU-CIE.
Conclusions and Relevance: This cohort study of children with SNI demonstrated a modest dose-dependent association between PICU-CIEs and short-term mortality. These data did not support the conventional wisdom that recurrent PICU admissions are associated with subsequent high mortality risk.
Objective: To assess the association between number of recent PICU-CIEs and survival among children with severe neurologic impairment.
Design, Setting, and Participants: This population-based retrospective cohort study used health administrative data from April 1, 2002, to March 31, 2020, on 4774 children born between 2002 and 2019 with an SNI diagnosis code in an Ontario, Canada, hospital record before 16 years of age and a first PICU-CIE from 2002 to 2019. Data were analyzed from November 2021 to June 2023.
Exposure: Pediatric intensive care unit critical illness episodes (excluding brief postoperative PICU admissions).
Main Outcome and Measures: One-year survival conditioned on the number and severity (length of stay >15 days or use of invasive mechanical ventilation) of PICU-CIEs in the preceding year.
Results: In Ontario, 4774 children with SNI (mean [SD] age, 2.1 [3.6] months; 2636 [55.2%] <1 year of age; 2613 boys [54.7%]) were discharged alive between 2002 and 2019 after their first PICU-CIE. Ten-year survival after the initial episode was 81% (95% CI, 79%-82%) for children younger than 1 year of age and 84% (95% CI, 82%-86%) for children 1 year of age or older; the age-stratified curves converged by 15 years after the initial episode at 79% survival (95% CI, 78%-81% for children <1 year and 95% CI, 75%-84% for children ≥1 year). Adjusted for age category and demographic factors, the presence of nonneurologic complex chronic conditions (adjusted hazard ratio [AHR], 1.70 [95% CI, 1.43-2.02]) and medical technology assistance (AHR, 2.32 [95% CI, 1.92-2.81]) were associated with increased mortality. Conditional 1-year mortality was less than 20% regardless of number or severity of recent PICU-CIEs. Among children with high-risk PICU-CIEs, 1-year conditional survival decreased from 90% (95% CI, 89%-91%) after the first PICU-CIE to 81% (95% CI, 77%-86%) after the fourth PICU-CIE.
Conclusions and Relevance: This cohort study of children with SNI demonstrated a modest dose-dependent association between PICU-CIEs and short-term mortality. These data did not support the conventional wisdom that recurrent PICU admissions are associated with subsequent high mortality risk.