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Multiple Organ Dysfunction Interactions in Critically Ill Children
Colleen M Badke1,2,3, Anoop Mayampurath4, L Nelson Sanchez-Pinto1,2,3
1Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.
Insights
Certain combinations of organ dysfunctions in critically ill children significantly increase mortality risk. Understanding these interactions is key to improving outcomes for pediatric patients with multiple organ dysfunction.
Area of Science:
- Pediatric Critical Care Medicine
- Pathophysiology of Organ Dysfunction
- Epidemiology of Critical Illness
Background:
- Multiple organ dysfunction (MOD) is a major cause of death in critically ill children.
- Current criteria for pediatric organ dysfunction do not fully account for complex interactions between failing organs.
- Understanding these interactions is crucial for improving patient outcomes.
Purpose of the Study:
- To determine if specific combinations of organ system dysfunctions are associated with increased morbidity or mortality in critically ill children.
- To identify which organ dysfunction interactions pose the highest risk.
Main Methods:
- Retrospective observational cohort study of critically ill children (2010-2018).
- Included patients with at least two organ dysfunctions by day 3, using Pediatric Organ Dysfunction Information Update Mandate (PODIUM) criteria.
- Analyzed combinations of two organ dysfunctions using logistic regression and classification and regression trees (CART).
Main Results:
- Of 7,897 patients, 5.6% died. Cardiovascular + endocrinologic, cardiovascular + neurologic, and cardiovascular + respiratory dysfunctions were associated with the highest absolute number of deaths.
- Liver + cardiovascular, respiratory + hematologic, and respiratory + renal interactions showed the highest mortality rates.
- Neurologic + respiratory, hematologic + immunologic, and endocrinologic + respiratory were common interactions in persistent MOD. Absence of respiratory and liver dysfunction correlated with lowest mortality risk.
Conclusions:
- Specific combinations of organ dysfunctions significantly increase the risk of death or persistent MOD in critically ill children.
- The three most frequent organ dysfunction interactions accounted for 75% of mortality in the study cohort.
- Further research into these specific combinations is warranted to guide clinical management and improve outcomes.
Introduction:
Multiple organ dysfunction (MOD) is a common pathway to morbidity and death in critically ill children. Defining organ dysfunction is challenging, as we lack a complete understanding of the complex pathobiology. Current pediatric organ dysfunction criteria assign the same diagnostic value-the same "weight"- to each organ system. While each organ dysfunction in isolation contributes to the outcome, there are likely complex interactions between multiple failing organs that are not simply additive.
Objective:
Determine whether certain combinations of organ system dysfunctions have a significant interaction associated with higher risk of morbidity or mortality in critically ill children.
Methods:
We conducted a retrospective observational cohort study of critically ill children at two large academic medical centers from 2010 and 2018. Patients were included in the study if they had at least two organ dysfunctions by day 3 of PICU admission based on the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) criteria. Mortality was described as absolute number of deaths and mortality rate. Combinations of two pediatric organ dysfunctions were analyzed with interaction terms as independent variables and mortality or persistent MOD as the dependent variable in logistic regression models.
Results:
Overall, 7,897 patients met inclusion criteria and 446 patients (5.6%) died. The organ dysfunction interactions that were significantly associated with the highest absolute number of deaths were cardiovascular + endocrinologic, cardiovascular + neurologic, and cardiovascular + respiratory. Additionally, the interactions associated with the highest mortality rates were liver + cardiovascular, respiratory + hematologic, and respiratory + renal. Among patients with persistent MOD, the most common organ dysfunctions with significant interaction terms were neurologic + respiratory, hematologic + immunologic, and endocrinologic + respiratory. Further analysis using classification and regression trees (CART) demonstrated that the absence of respiratory and liver dysfunction was associated with the lowest likelihood of mortality.
Implications And Future Directions:
Certain combinations of organ dysfunctions are associated with a higher risk of persistent MOD or death. Notably, the three most common organ dysfunction interactions were associated with 75% of the mortality in our cohort. Critically ill children with MOD presenting with these combinations of organ dysfunctions warrant further study.
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