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Published on: April 7, 2021
Multiple Organ Dysfunction in Children Mechanically Ventilated for Acute Respiratory Failure
Scott L Weiss1, Lisa A Asaro, Heidi R Flori
11Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 2Department of Cardiology, Boston Children's Hospital, Boston, MA. 3Division of Pediatric Critical Care, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI. 4Division of Critical Care, Department of Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, MO. 5Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA. 6Department of Pediatrics, Harvard Medical School, Boston, MA. 7School of Nursing, University of Pennsylvania, Philadelphia, PA. 8Critical Care and Cardiovascular Program, Boston Children's Hospital, Boston, MA.
Insights
Extrapulmonary organ dysfunction is common in pediatric acute respiratory failure, often occurring with sepsis and significantly increasing mortality risk. Early identification and management are crucial for better outcomes.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Medicine
- Pediatric Critical Illness
Background:
- Extrapulmonary organ dysfunction (EPOD) impact in pediatric acute respiratory failure (PARF) is not well understood.
- Sepsis and lung injury severity may influence EPOD and outcomes.
Purpose of the Study:
- Determine EPOD frequency, timing, and risk factors in PARF.
- Assess the independent association of multiple organ dysfunction syndrome (MODS) with PARF outcomes.
Main Methods:
- Secondary analysis of the Randomized Evaluation of Sedation Titration for Respiratory Failure trial (2009-2013).
- Included 2,449 children mechanically ventilated for PARF across 31 US academic PICUs.
- Used logistic and proportional hazards regression, accounting for PICU clustering.
Main Results:
- 73% of patients had EPOD; 63% had concurrent MODS (day 0/1), 10% had new MODS (day 2+).
- Sepsis-related lung injury strongly correlated with concurrent MODS (93%).
- Concurrent MODS (aOR 6.54) and new MODS (aOR 3.21) independently predicted 90-day mortality.
Conclusions:
- EPOD is frequent in pediatric acute respiratory failure, often concurrent with respiratory dysfunction, particularly in sepsis.
- Both concurrent and new-onset MODS are significant independent risk factors for mortality in this population.
Objectives:
The impact of extrapulmonary organ dysfunction, independent from sepsis and lung injury severity, on outcomes in pediatric acute respiratory failure is unclear. We sought to determine the frequency, timing, and risk factors for extrapulmonary organ dysfunction and the independent association of multiple organ dysfunction syndrome with outcomes in pediatric acute respiratory failure.
Design:
Secondary observational analysis of the Randomized Evaluation of Sedation Titration for Respiratory Failure cluster-randomized prospective clinical trial conducted between 2009 and 2013.
Setting:
Thirty-one academic PICUs in the United States.
Patients:
Two thousand four hundred forty-nine children mechanically ventilated for acute respiratory failure enrolled in Randomized Evaluation of Sedation Titration for Respiratory Failure.
Measurements And Main Results:
Organ dysfunction was defined using criteria published for pediatric sepsis. Multiple organ dysfunction syndrome was defined as respiratory dysfunction one or more extrapulmonary organ dysfunctions. We used multivariable logistic regression to identify risk factors for multiple organ dysfunction syndrome, and logistic or proportional hazards regression to compare clinical outcomes. All analyses accounted for PICU as a cluster variable. Overall, 73% exhibited extrapulmonary organ dysfunction, including 1,547 (63%) with concurrent multiple organ dysfunction syndrome defined by onset on day 0/1 and 244 (10%) with new multiple organ dysfunction syndrome with onset on day 2 or later. Most patients (93%) with indirect lung injury from sepsis presented with concurrent multiple organ dysfunction syndrome, whereas patients with direct lung injury had both concurrent (56%) and new (12%) multiple organ dysfunction syndrome. Risk factors for concurrent multiple organ dysfunction syndrome included older age, illness severity, sepsis, cancer, and moderate/severe lung injury. Risk factors for new multiple organ dysfunction syndrome were moderate/severe lung injury and neuromuscular blockade. Both concurrent and new multiple organ dysfunction syndrome were associated with 90-day in-hospital mortality (concurrent: adjusted odds ratio, 6.54; 95% CI, 3.00-14.25 and new: adjusted odds ratio, 3.21; 95% CI, 1.48-6.93) after adjusting for sepsis, moderate/severe lung injury, and other baseline characteristics.
Conclusions:
Extrapulmonary organ dysfunction was common, generally occurred concurrent with respiratory dysfunction (especially in sepsis), and was a major risk factor for mortality in pediatric acute respiratory failure.
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