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Survival after PICU admission: The impact of multiple admissions and complex chronic conditions
Håkan Kalzén1, Björn Larsson1, Staffan Eksborg2
1Department of Paediatric Anaesthesia, Intensive Care and ECMO services, Astrid Lindgren Children's Hospital, Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden.
Insights
Multiple pediatric intensive care unit (PICU) admissions significantly decrease survival over time compared to single admissions, especially for children with complex chronic conditions (CCC). This highlights the critical impact of admission history on pediatric patient outcomes.
Area of Science:
- Pediatric critical care medicine
- Survival analysis
- Epidemiology
Background:
- Understanding factors influencing long-term survival after pediatric intensive care unit (PICU) admission is crucial.
- The impact of multiple pediatric intensive care unit admissions (MADM) versus single admissions (SADM) on survival is not fully elucidated.
- The role of complex chronic conditions (CCC) in modifying prognosis after PICU admission requires further investigation.
Purpose of the Study:
- To determine if multiple pediatric intensive care unit admissions (MADM) are associated with poorer survival compared to single admissions (SADM).
- To investigate whether the presence of a complex chronic condition (CCC) further impairs prognosis in pediatric intensive care unit patients.
- To analyze survival differences across various diagnostic groups based on admission status (SADM vs. MADM) and CCC presence.
Main Methods:
- A prospective cohort study of 3,688 children admitted to three Swedish PICUs between 2008 and 2010.
- Follow-up data collected until 2012, providing up to four years of survival information.
- Patients categorized into single admission (SADM) and multiple admission (MADM) groups, with and without complex chronic conditions (CCC), for comparative survival analysis.
Main Results:
- Multiple pediatric intensive care unit admissions (MADM) were significantly associated with decreased survival over time compared to single admissions (SADM) (p<0.0001).
- The presence of a complex chronic condition (CCC) intensified the negative impact of MADM on survival, with MADM patients with CCC having the worst outcomes.
- Survival was statistically worsened for MADM patients compared to SADM across several diagnostic groups, including Cardiovascular, Gastrointestinal/Renal, Respiratory, Neurological, and Miscellaneous.
Conclusions:
- Multiple pediatric intensive care unit admissions are a significant risk factor for reduced long-term survival in children.
- The presence of complex chronic conditions exacerbates the negative prognostic impact of multiple admissions.
- Findings underscore the importance of considering admission history and underlying health conditions in predicting outcomes for pediatric intensive care unit survivors.
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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