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Pediatric Early Warning System (PEWS) Association with ICU Mortality in Children with Acute Lymphoblastic Leukemia: A
Yedil Kurakbayev1,2, Abay Kussainov3, Kuanysh Umbetov4
1Department of Anesthesiology, Resuscitation and Intensive Care, JSC "Scientific Center of Pediatrics and Pediatric Surgery", 146 Al-Farabi Avenue, Almaty 050040, Kazakhstan.
Insights
Pediatric Early Warning System (PEWS) monitoring did not improve survival for critically ill children with acute lymphoblastic leukemia (ALL) in Kazakhstan. Inflammatory and cardiorespiratory issues were more strongly linked to mortality than PEWS alerts.
Area of Science:
- Pediatric critical care medicine
- Hematology-oncology
- Public health in middle-income countries
Background:
- Childhood acute lymphoblastic leukemia (ALL) presents significant morbidity and mortality, especially in middle-income nations.
- The Pediatric Early Warning System (PEWS) aims to improve care escalation for critically ill children.
- The independent impact of PEWS on survival in pediatric ALL patients in Kazakhstan and Central Asia remains underexplored.
Purpose of the Study:
- To evaluate the independent effect of implementing 24-hour PEWS monitoring on intensive care unit (ICU) mortality among children with ALL.
- To identify key factors associated with ICU mortality in this high-acuity pediatric population.
Main Methods:
- Retrospective review of ICU admissions for pediatric ALL patients (0-18 years) across pre- and post-PEWS implementation periods.
- Data collection included demographic, clinical, transfusion, vital signs, symptoms, laboratory, and instrumental data.
- Univariable and multivariable logistic regression analyses were performed to determine associations with ICU mortality.
Main Results:
- Overall ICU mortality was 21.7% across 255 admissions.
- PEWS implementation showed no statistically significant association with reduced ICU mortality (AOR 0.89), despite lower unadjusted mortality post-implementation.
- Bilateral pneumonia (AOR 7.45), frequent hyperthermia (AOR 5.42), and systemic inflammatory response syndrome (AOR 4.61) were strongly associated with mortality.
Conclusions:
- In critically ill pediatric ALL patients, inflammatory and cardiorespiratory derangements appear to be more critical determinants of survival than ward-based PEWS surveillance alone.
- Improving outcomes necessitates integrating early warning systems with prompt deterioration management, targeted cardiopulmonary support, and context-specific resource allocation.
- Sole reliance on surveillance scores may not be sufficient; a comprehensive approach to managing critically ill children with ALL is required.
Abstract:
Background and Objectives: Childhood acute lymphoblastic leukemia (ALL) carries substantial morbidity, mortality, and economic burden, particularly in middle-income countries. The Pediatric Early Warning System (PEWS) is designed to trigger timely escalation of care, yet its independent impact on survival among critically ill leukemic children has not been well defined in Kazakhstan and Central Asia. Materials and Methods: We conducted a retrospective review all ICU admissions for patients aged 0-18 years with ALL at the National Center of Pediatrics, Almaty, across two periods: pre-implementation (January 2020-December 2022) and post-implementation of 24 h PEWS monitoring (September 2023-December 2024). The primary outcome was ICU mortality. Seven domains of covariates-demographic, clinical history, transfusion, vital signs, symptoms, laboratory, and instrumental data-were extracted. Univariable and multivariable logistic regression models were used to assess associations with mortality. Results: Among 255 admissions (105 during PEWS implementation; 150 prior to PEWS implementation), overall ICU mortality was 21.7%. After adjustment, PEWS implementation was not associated with reduced ICU mortality (AOR 0.89), despite a lower unadjusted mortality (15.9% vs. 26.6%). The most clinically relevant secondary findings included strong associations between mortality and bilateral pneumonia (AOR 7.45), ≥4 episodes of hyperthermia within 24 h of ICU admission (AOR 5.42), and systemic inflammatory response syndrome (AOR 4.61). Conclusions: These findings suggest that, within this high-acuity cohort, inflammatory and cardiorespiratory derangements outweigh any potential survival benefit from ward-based PEWS surveillance. Optimizing outcomes will require integrating early warning systems with timely deterioration management, focused cardiopulmonary support, and resource allocation tailored to the clinical context-rather than relying solely on surveillance scores.
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