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Morbidity and Mortality in Critically Ill Children. II. A Qualitative Patient-Level Analysis of Pathophysiologies and
Kathleen L Meert1, Russell Banks2, Richard Holubkov2
1Department of Pediatrics, Children's Hospital of Michigan, Wayne State.
Insights
Critically ill children in pediatric intensive care units (PICUs) often experience morbidity and mortality due to impaired substrate delivery and inflammation. Future research should focus on these conditions and novel therapies like cell regeneration to improve outcomes.
Area of Science:
- Pediatric Critical Care Medicine
- Pathophysiology
- Clinical Research
Background:
- Pediatric intensive care units (PICUs) manage critically ill children facing significant morbidity and mortality.
- Understanding the underlying pathophysiologic processes is crucial for developing effective treatments.
Purpose of the Study:
- To identify key pathophysiologic processes contributing to morbidity and mortality in PICUs.
- To explore potential therapeutic advances for preventing or reducing adverse outcomes in critically ill children.
Main Methods:
- A qualitative content analysis was performed on intensivists' conclusions.
- Conclusions were derived from a structured review of medical records for critically ill children.
- The study included a cohort of children from eight children's hospitals.
Main Results:
- Impaired substrate delivery (e.g., hypoxia, ischemia) was the most common pathophysiology (54.1%), often linked to low cardiac output or arrest.
- Inflammation (35.6%) related to sepsis and respiratory failure, and direct tissue injury (21.9%) like CNS trauma were also frequent.
- Chronic conditions contributed to adverse outcomes in over half the patients (53.4%).
Conclusions:
- Low cardiac output, inflammation-related organ failures, and central nervous system trauma are primary drivers of morbidity and mortality in PICUs.
- A research agenda targeting these pathophysiologies and novel therapies, such as cell regeneration and immune modulation, is recommended to improve patient outcomes.
Objectives:
To describe at the individual patient level the pathophysiologic processes contributing to morbidity and mortality in PICUs and therapeutic additions and advances that could potentially prevent or reduce morbidity and mortality.
Design:
Qualitative content analysis of intensivists' conclusions on pathophysiologic processes and needed therapeutic advances formulated by structured medical record review.
Setting:
Eight children's hospitals affiliated with the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network.
Patients:
A randomly selected cohort of critically ill children with a new functional morbidity or mortality at hospital discharge. New morbidity was assessed using the Functional Status Scale and defined as worsening by two or more points in a single domain from preillness baseline.
Interventions:
None.
Measurements And Main Results:
Of 292 children, 175 (59.9%) had a new morbidity and 117 (40.1%) died. The most common pathophysiology was impaired substrate delivery (n = 158, 54.1%) manifesting as global or regional hypoxia or ischemia due to low cardiac output or cardiac arrest. Other frequent pathophysiologies were inflammation (n = 104, 35.6%) related to sepsis, respiratory failure, acute respiratory distress syndrome, or multiple organ dysfunction; and direct tissue injury (n = 64, 21.9%) including brain and spinal cord trauma. Chronic conditions were often noted (n = 156, 53.4%) as contributing to adverse outcomes. Drug therapies (n = 149, 51.0%) including chemotherapy, inotropes, vasoactive agents, and sedatives were the most frequently proposed needed therapeutic advances. Other frequently proposed therapies included cell regeneration (n = 115, 39.4%) mainly for treatment of neuronal injury, and improved immune and inflammatory modulation (n = 79, 27.1%).
Conclusions:
Low cardiac output and cardiac arrest, inflammation-related organ failures, and CNS trauma were the most common pathophysiologies leading to morbidity and mortality in PICUs. A research agenda focused on better understanding and treatment of these conditions may have high potential to directly impact patient outcomes.
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