Prolonged non-survival in PICU: does a do-not-attempt-resuscitation order matter

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• 作者：Kam Lun E Hon (1)
  Terence Chuen Wai Poon (1)
  William Wong (1)
  Kin Kit Law (2)
  Hiu Wing Mok (2)
  Ka Wing Tam (2)
  Wai Kin Wong (2)
  Hiu Fung Wu (2)
  Ka Fai To (3)
  Kam Lau Cheung (1)
  Hon Ming Cheung (1)
  Ting Fan Leung (1)
  Chi Kong Li (1)
  Alexander K C Leung (4)
  
• 关键词：Bacteria ; Fungus ; PICU ; Pediatric intensive care ; Malignancy ; Mortality ; Oncology ; PIM2 ; Sepsis ; Trauma ; Virus ; Do ; not ; attempt ; resuscitation (DNAR) ; Not ; responding ; to ; cardiopulmonary ; resuscitation (NRCPR) ; Brain death ; Organ donation
• 刊名：BMC Anesthesiology
• 出版年：2013
• 出版时间：December 2013
• 年：2013
• 卷：13
• 期：1
• 全文大小：173 KB
• 参考文献：1. Balk RA: Pathogenesis and management of multiple organ dysfunction or failure in severe sepsis and septic shock. / Crit Care Clin 2000,16(2):337-52. vii CrossRef
  2. Sands R, Manning JC, Vyas H, Rashid A: Characteristics of deaths in paediatric intensive care: a 10-year study. / Nurs Crit Care 2009,14(5):235-40. CrossRef
  3. Gruenberg DA, Shelton W, Rose SL, Rutter AE, Socaris S, McGee G: Factors influencing length of stay in the intensive care unit. / Am J Crit Care 2006,15(5):502-09.
  4. Strand K, Walther SM, Reinikainen M, Ala-Kokko T, Nolin T, Martner J, / et al.: Variations in the length of stay of intensive care unit nonsurvivors in three scandinavian countries. / Crit Care 2010,14(5):R175. CrossRef
  5. Hon KL, Hung E, Tang J, Chow CM, Leung TF, Cheung KL, / et al.: Premorbid factors and outcome associated with respiratory virus infections in a pediatric intensive care unit. / Pediatr Pulmonol 2008,43(3):275-80. CrossRef
  6. Hon KL, Leung TF, Chan SY, Cheung KL, Ng PC: Indoor versus outdoor childhood submersion injury in a densely populated city. / Acta Paediatr 2008,97(9):1261-264. CrossRef
  7. Hon KL, Leung TF, Cheung KL, Nip SY, Ng J, Fok TF, / et al.: Severe childhood injuries and poisoning in a densely populated city: where do they occur and what type? / J Crit Care 2010,25(1):175-2. CrossRef
  8. Rimsza ME, Schackner RA, Bowen KA, Marshall W: Can child deaths be prevented? the arizona child fatality review program experience. / Pediatrics 2002,110(1 Pt 1):e11. CrossRef
  9. Meyer S, Gottschling S, Gortner L: The prognosis of children with cancer in the PICU. / J Pediatr Hematol Oncol 2009,31(12):990-91. CrossRef
  10. Dursun O, Hazar V, Karasu GT, Uygun V, Tosun O, Yesilipek A: Prognostic factors in pediatric cancer patients admitted to the pediatric intensive care unit. / J Pediatr Hematol Oncol 2009,31(7):481-84. CrossRef
  11. Hon KL, Leung AK: Childhood accidents: injuries and poisoning. / Adv Pediatr 2010,57(1):33-2. CrossRef
  12. Hon KL, Chan J, Cheung KL: Head injuries after short falls: different outcomes despite similar causes. / Hong Kong Med J 2010,16(6):497-98.
  13. Slater A, Shann F, Pearson G: Paediatric index of mortality P. PIM2: a revised version of the paediatric index of mortality. / Intens Care Med 2003,29(2):278-85.
  14. Devictor DJ, Nguyen DT: Forgoing life-sustaining treatments in children: a comparison between Northern and Southern European pediatric intensive care units. / Pediatr Crit Care Med 2004,5(3):211-15. CrossRef
  15. El Halal MG, Barbieri E, Filho RM, Trotta EA, Carvalho PR: Admission source and mortality in a pediatric intensive care unit. / Indian J Crit Care Med 2012,16(2):81-6. CrossRef
  16. Devictor DJ, Latour JM: Forgoing life support: how the decision is made in European pediatric intensive care units. / Intensive Care Med 2011,37(11):1881-887. CrossRef
  17. Vernon DD, Dean JM, Timmons OD, Banner W Jr, Allen-Webb EM: Modes of death in the pediatric intensive care unit: withdrawal and limitation of supportive care. / Crit Care Med 1993,21(11):1798-802. CrossRef
  18. Hon KL, Nelson EA: Gender disparity in paediatric hospital admissions. / Ann Acad Med Singapore 2006,35(12):882-88.
  19. Gray J, Gossain S, Morris K: Three-year survey of bacteremia and fungemia in a pediatric intensive care unit. / Pediatr Infect Dis J 2001,20(4):416-21. CrossRef
  20. Cugno C, Cesaro S: Epidemiology, risk factors and therapy of candidemia in pediatric hematological patients. / Pediatr Rep 2012,4(1):e9. CrossRef
  21. Brissaud O, Guichoux J, Harambat J, Tandonnet O, Zaoutis T: Invasive fungal disease in PICU: epidemiology and risk factors. / Ann Intensive Care 2012,22(2(1)):6. CrossRef
  22. Haase R, Lieser U, Kramm C, Stiefel M, Vilser C, Bernig T, / et al.: Management of oncology patients admitted to the paediatric intensive care unit of a general children’s hospital - a single center analysis. / Klin Padiatr 2011,223(3):142-46. CrossRef
  23. Akhtar N, Fadoo Z, Panju S, Haque A: Outcome and prognostic factors seen in pediatric oncology patients admitted in PICU of a developing country. / Indian J Pediatr 2011,78(8):969-72. CrossRef
  24. Davidoff AM: Pediatric oncology. / Semin Pediatr Surg 2010,19(3):225-33. CrossRef
  25. Hon KL: Dying with parents: an extreme form of child abuse. / World J Pediatr 2011,7(3):266-68. CrossRef
  26. Hon KL: No guns at children: not even a toy one! / Indian J Pediatr 2011,78(12):1556-557. CrossRef
  27. Vital E, Oliveira R, Do Ceu MM, De Matos MG: Injuries and risk-taking behaviours in Portuguese adolescents: highlights from the health behaviour in school-aged children survey. / J Safety Res 2011,42(5):327-31. CrossRef
  28. Carvalho PR, Rocha TS, Santo AE, Lago P: Modes of death in the PICU of a tertiary care hospital. / Rev Assoc Med Bras 2001,47(4):325-31. CrossRef
  29. Molzahn AE, Starzomski R, McDonald M, O’Loughlin C: Chinese Canadian beliefs toward organ donation. / Qual Health Res 2005,15(1):82-8. CrossRef
  30. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2253/13/43/prepub
  
• 作者单位：Kam Lun E Hon (1)
  Terence Chuen Wai Poon (1)
  William Wong (1)
  Kin Kit Law (2)
  Hiu Wing Mok (2)
  Ka Wing Tam (2)
  Wai Kin Wong (2)
  Hiu Fung Wu (2)
  Ka Fai To (3)
  Kam Lau Cheung (1)
  Hon Ming Cheung (1)
  Ting Fan Leung (1)
  Chi Kong Li (1)
  Alexander K C Leung (4)
  
  1. Department of Pediatrics, The Chinese University of Hong Kong, Prince of Wales Hospital, 6/F, Clinical Science Building, Shatin, Hong Kong, SAR, China
  2. Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
  3. Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
  4. Department of Pediatrics, The University of Calgary, 2500 University Dr NW, Calgary, AB, T2N 1N4, Canada
  
• ISSN：1471-2253

文摘

Background Etiologies of pediatric intensive care unit (PICU) mortality are diverse. This study aimed to investigate the pattern of PICU mortality in a regional trauma center, and explore factors associated with prolonged non-survival. Methods Demographic data of all PICU deaths in a regional trauma center were analyzed. Factors associated with prolonged nonsurvival (length of stay) were investigated with univariate log rank and multivariate Cox-Regression forward stepwise tests. Results There were 88 deaths (males 61%; infants 23%) over 10?years (median PICU stay--.5?days, interquartile range: 1 and 11?days). The mean annual mortality rate of PICU admissions was 5.8%. Septicemia with gram positive, gram negative and fungal pathogens were present in 13 (16%), 13 (16%) and 4 (5%) of these patients, respectively. Viruses were isolated in 25 patients (28%). Ninety percent of these 88 patients were ventilated, 75% required inotropes, 92% received broad spectrum antibiotic coverage, 32% received systemic corticosteroids, 56% required blood transfusion and 39% received anticonvulsants. Thirty nine patients (44%) had a DNAR (Do-Not-Attempt-Resuscitation) order with their deaths at the PICU. Comparing with non-trauma category, trauma patients had higher mortality score, no premorbid disease, suffered asystole preceding PICU admission and subsequent brain death. Oncologic conditions were the most prevalent diagnosis in the non-trauma category. There was no gunshot or asthma death in this series. Prolonged non-survival was significantly associated with DNAR, fungal infections, and mechanical ventilation but negatively associated with bacteremia. Conclusions Death in the PICU is a heterogeneous event that involves infants and children. Resuscitation was not attempted at the time of their deaths in nearly half of the patients in honor of parents-wishes. Parents often make DNAR decision when medical futility becomes evident. They could be reassured that DNAR did not mean “abandoning-care. Instead, DNAR patients had prolonged PICU stay and received the same level of PICU supports as patients who did not respond to cardiopulmonary resuscitation.