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Recurrent Intensive Care Episodes and Mortality Among Children With Severe Neurologic Impairment
Katherine E Nelson1,2,3,4,5, Jingqin Zhu3,4, Joanna Thomson6,7
1Pediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
Recurrent pediatric intensive care unit critical illness episodes (PICU-CIEs) in children with severe neurologic impairment (SNI) showed a modest link to short-term mortality. These findings challenge the assumption that multiple PICU admissions predict high mortality risk in this population.
Area of Science:
- Pediatric critical care medicine
- Neurology
- Epidemiology
Background:
- Children requiring pediatric intensive care unit (PICU) admission face elevated mortality risks.
- Children with severe neurologic impairment (SNI) often require PICU care due to complex medical needs.
- The impact of recurrent PICU critical illness episodes (PICU-CIEs) on mortality in SNI patients is not well understood.
Purpose of the Study:
- To determine the association between the number of recent PICU-CIEs and survival in children with SNI.
- To investigate the prognostic significance of PICU-CIE frequency in a vulnerable pediatric population.
Main Methods:
- A population-based retrospective cohort study utilizing health administrative data from Ontario, Canada (2002-2020).
- Included 4774 children with SNI and at least one PICU-CIE.
- Analyzed 1-year survival conditioned on the number and severity of preceding PICU-CIEs.
Main Results:
- Ten-year survival was 81% for children <1 year and 84% for those ≥1 year.
- Non-neurologic complex chronic conditions and medical technology assistance were associated with increased mortality.
- Conditional 1-year mortality remained below 20% irrespective of PICU-CIE frequency or severity.
- Among high-risk PICU-CIEs, 1-year survival decreased from 90% after the first to 81% after the fourth episode.
Conclusions:
- A modest, dose-dependent association exists between PICU-CIEs and short-term mortality in children with SNI.
- The study data do not support the notion that recurrent PICU admissions inherently lead to high subsequent mortality.
- Findings suggest a nuanced understanding of PICU-CIEs' prognostic value in SNI patients is needed.
Importance:
Children requiring care in a pediatric intensive care unit (PICU) are known to have increased risk of subsequent mortality. Children with severe neurologic impairment (SNI)-who carry neurologic or genetic diagnoses with functional impairments and medical complexity-are frequently admitted to PICUs. Although recurrent PICU critical illness episodes (PICU-CIEs) are assumed to indicate a poor prognosis, the association between recurrent PICU-CIEs and mortality in this patient population is poorly understood.
Objective:
To assess the association between number of recent PICU-CIEs and survival among children with severe neurologic impairment.
Design, Setting, And Participants:
This population-based retrospective cohort study used health administrative data from April 1, 2002, to March 31, 2020, on 4774 children born between 2002 and 2019 with an SNI diagnosis code in an Ontario, Canada, hospital record before 16 years of age and a first PICU-CIE from 2002 to 2019. Data were analyzed from November 2021 to June 2023.
Exposure:
Pediatric intensive care unit critical illness episodes (excluding brief postoperative PICU admissions).
Main Outcome And Measures:
One-year survival conditioned on the number and severity (length of stay >15 days or use of invasive mechanical ventilation) of PICU-CIEs in the preceding year.
Results:
In Ontario, 4774 children with SNI (mean [SD] age, 2.1 [3.6] months; 2636 [55.2%] <1 year of age; 2613 boys [54.7%]) were discharged alive between 2002 and 2019 after their first PICU-CIE. Ten-year survival after the initial episode was 81% (95% CI, 79%-82%) for children younger than 1 year of age and 84% (95% CI, 82%-86%) for children 1 year of age or older; the age-stratified curves converged by 15 years after the initial episode at 79% survival (95% CI, 78%-81% for children <1 year and 95% CI, 75%-84% for children ≥1 year). Adjusted for age category and demographic factors, the presence of nonneurologic complex chronic conditions (adjusted hazard ratio [AHR], 1.70 [95% CI, 1.43-2.02]) and medical technology assistance (AHR, 2.32 [95% CI, 1.92-2.81]) were associated with increased mortality. Conditional 1-year mortality was less than 20% regardless of number or severity of recent PICU-CIEs. Among children with high-risk PICU-CIEs, 1-year conditional survival decreased from 90% (95% CI, 89%-91%) after the first PICU-CIE to 81% (95% CI, 77%-86%) after the fourth PICU-CIE.
Conclusions And Relevance:
This cohort study of children with SNI demonstrated a modest dose-dependent association between PICU-CIEs and short-term mortality. These data did not support the conventional wisdom that recurrent PICU admissions are associated with subsequent high mortality risk.
