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A multidisciplinary investigation of a cluster of deaths on a paediatric intensive care unit
H Maguire1, J Watson, R George
1PHLS Communicable Disease Surveillance Centre (CDSC), Colindale, London.
Insights
A cluster of unexplained deaths in critically ill infants with congenital heart disease was investigated. Despite a thorough multidisciplinary investigation, no cause was identified, raising concerns about potential unknown factors.
Area of Science:
- Pediatric critical care medicine
- Infectious disease epidemiology
- Cardiothoracic surgery outcomes
Background:
- A cluster of six deaths occurred in young children with congenital heart disease post-cardiac surgery.
- Deaths were preceded by increased ventilatory pressure and pulmonary shadowing suggestive of pneumonitis.
Purpose of the Study:
- To investigate an unusual cluster of deaths in a pediatric intensive care unit (PICU).
- To identify the cause of sudden, unexplained deaths in critically ill pediatric cardiac patients.
Main Methods:
- A multidisciplinary investigation committee was formed.
- The PICU was temporarily closed during the investigation.
- Extensive testing for pathogens, toxins, and other potential causes was conducted.
Main Results:
- No specific bacterium, virus, fungus, toxic agent, or other pathogen was identified as the cause.
- The pattern of deaths suggested an outbreak, but a definitive cause remained elusive.
Conclusions:
- Despite a comprehensive investigation, the cause of the cluster of deaths could not be determined.
- The possibility of an unidentifiable cause or a highly unusual chance occurrence was considered unlikely.
Abstract:
During late December 1989 and early January 1990, a cluster of six unexplained deaths occurred on a paediatric intensive care unit (PICU) among children with congenital heart disease who had undergone cardiac surgical procedures. The children were all aged three years or less. In each case death was preceded by an unexpected increase in ventilatory pressure requirement followed by the development of a similar pulmonary shadowing on chest radiography. The radiological abnormality was felt to be consistent with a pneumonitis associated with some small airway disease. The clustering of these deaths, occurring in a similar unusual manner, was felt to constitute an outbreak warranting investigation. An Incident Committee was established to plan and manage a large multidisciplinary investigation during which the unit was temporarily closed. Following extensive investigation no bacterium, virus, fungus or other pathogen, toxic agent, or any other explanation for the cluster of deaths could be found. The possibility that the cluster occurred by chance remains although this was felt to be unlikely.