Performance of Pediatric Index of Mortality in a Tertiary Care PICU in India

Pediatric index of mortality-3 (PIM-3) is the latest update of one of the commonly used scoring systems in pediatric intensive care. It has free accessibility and is easy to use. However, there are some skepticisms regarding its practical usefulness in resource-limited settings. Hence, there is a need to generate region-specific data to evaluate its performance in different case mixes and resource constraints. The aim of the study is to evaluate the performance of the PIM-3 score in predicting mortality in a tertiary care PICU of a developing country. This was a retrospective cohort study. All children aged 1 month to 18 years admitted to the PICU during the study period from July 2016 to December 2018 were included. We reviewed the patient admission details and the case records of the enrolled. patients. Patient demographics, disease profile, co-morbidities, and PIM-3 scores were recorded along with the outcome. Area under receiver operating characteristics (AUROC) curves was used to determine discrimination. Standardized mortality ratio (SMR) and Hosmer Lemeshow goodness of fit were used to assess the calibration. Out of 282 children enrolled, 62 (21.9%) died. 58.5% of the patients were males, and 60% were less than 5 years of age. The principal diagnoses included respiratory and neurological conditions. The AUROC for PIM-3 was 0.961 (95% CI [0.93, 0.98]) and overall SMR was 1.28 (95% CI [0.96, 1.59]). Hosmer-Lemeshow goodness-of-fit was suggestive of poor calibration (χ 2 = 11.7, p < 0.05). We concluded that PIM-3 had good discrimination but poor calibration in our PICU setting.

Evaluation of Severity of Illness Scores in the Pediatric ECMO Population

Though commonly used for adjustment of risk, severity of illness and mortality risk prediction scores, based on the first 24 h of intensive care unit (ICU) admission, have not been validated in the pediatric extracorporeal membrane oxygenation (ECMO) population. We aimed to determine the association of Pediatric Index of Mortality 2 (PIM2), Pediatric Risk of Mortality Score III (PRISM III) and Pediatric Logistic Organ Dysfunction (PELOD) scores with mortality in pediatric patients on ECMO. This was a retrospective cohort study of children ≤18 years of age included in the Pediatric ECMO Outcomes Registry (PEDECOR) from 2014 to 2018. Logistic regression and Receiver Operating Characteristics (ROC) curves were used to calculate the area under the curve (AUC) to evaluate association of mortality with the scores. Of the 655 cases, 289 (44.1%) did not survive until hospital discharge. AUCs for PIM2, PRISM III, and PELOD predicting mortality were 0.52, 0.52, and 0.51 respectively. PIM2, PRISM III, and PELOD scores are not associated with odds of mortality for pediatric patients receiving ECMO. These scores for a general pediatric ICU population should not be used for prognostication or risk stratification of a select population such as ECMO patients.

Comparison of urine albumin creatinine ratio with the pediatric index of mortality 2 score for prediction of pediatric intensive care unit outcomes

Background Predicting morbidity and mortality in a pediatric intensive care unit (PICU) is of extreme importance to make precise decisions for better outcomes. Aim We compared the urine albumin creatinine ratio (ACR) with the established PICU score, pediatric index of mortality 2 (PIM 2) for predicting PICU outcomes. Methods This cross-sectional study enrolled 67 patients admitted to PICU with systemic inflammatory response syndrome. Urine ACR was estimated on admission, and PIM 2 score was calculated. ACR was compared with PIM 2 for PICU outcome measures: the need for inotropes, development of multiple organ dysfunction syndrome (MODS), duration of PICU stay, and survival. Results Microalbuminuria was found in 77.6% of patients with a median ACR of 80 mg/g. ACR showed a significant association with the need for inotropes (p < 0.001), MODS (p = 0.001), and significant correlation to PICU stay (p 0.001, rho = 0.361). The area under the receiver operating characteristic curve for ACR (0.798) was comparable to that of PIM 2 (0.896). The cutoff value of ACR derived to predict mortality was 110 mg/g. The study subjects were divided into 2 groups: below cutoff and above the cutoff. Outcome variables, inotrope use, MODS, mortality, and PICU stay compared between these subgroups, were statistically significant. Conclusion ACR is a good predictor of PICU outcomes and is comparable to PIM 2 for mortality prediction.

Assessment of suitability of pediatric index of mortality 2 score for monitoring the outcome of pediatric intensive care unit patients and associated risk factors of mortality in a tertiary care center in South India

Background: Pediatric index of mortality 2 (PIM 2) score is an illness severity and scoring systems used for predicting outcome of children admitted to PICU. The objective was to evaluate the usefulness of PIM 2 score in predicting mortality in our PICU, assess whether the model is calibrated to our case mix and to compare the observed and expected death rates by calculating standardised mortality ratio. Methods: It was a prospective observational study done in a tertiary care center from January 2019 to June 2020. Consecutive 120 patients admitted to PICU aged from 1 month to 18 years were enrolled in study. PIM 2 scoring was calculated for the data obtained within 1 hour of admission to PICU. The outcome was recorded as death or discharge. PIM 2 logit score is calculated using software.Results: PIM2 can discriminate between death and survival with area under curve (AUC) of 0.867 with 95% CI (0.729,0.980). PIM 2 predicted death rate was significant (p<0.001). The model is well calibrated with Hosmer- Lemeshow Goodness-of-fit test p=0.961 (p>0.05). The observed death rates are equal to predicted death rates and standardized mortality ratio (SMR) is equal to 1. Conclusions: PIM 2 score predicted mortality correlated well with observed mortality in PICU patients. The model is well calibrated for use in our set up and discriminate well between survivors and non-survivors.

Validation of Pediatric Index of Mortality 3 in a Single Referral Pediatric Intensive Care Unit in Iran

Objectives: The research aimed to evaluate the Pediatric Index of Mortality 3 (PIM-3) for determining the risk of mortality among pediatric intensive care unit patients. Methods: A retrospective analysis was conducted on case records, as well as patient data from all admissions to the PICU of Mofid Children’s Hospital, Tehran, from October 2017 to February 2018. Employing an android calculator application, the PIM-3 score was estimated early within the first PICU admission. Then, the PIM-3 score and mortality rate were analyzed using the Mann-Whitney U test. In addition, calibration and discrimination were assessed by the Hosmer-Lemeshow goodness-of-fit test and a receiver operating characteristic curve method, respectively. Finally, the Standardized Mortality Ratio (SMR) was calculated. Results: In this study, 365 young infants, ranging from 10 to 29-months-old, were included. The overall mortality rate was 10.4%. Further, the patients’ PIM-3 scores ranged from 0.06% to 2.37% (95% confidence interval), with a mean of 1.45% (4.16% in non-survivors and 1.14% in survivors). The SMR was estimated at 7.18, demonstrating the underprediction of the death rate. The AUC of 0.714 (95% CI: 0.626 to 0.801) demonstrated a fair to good discrimination power of PIM-3 as an international standard risk-adjusted mortality indicator. Moreover, this score underpredicted the risk of mortality in young infants admitted to our ICU in 2017. Generally, the prediction was weak among low-risk patients. Therefore, the Pediatric Index of Mortality-3 score has the potential to be implemented in our PICU by modifying the expected probability of death by multiplying the original PIM-3 score by 7.12.

Validity of Pediatric Index of Mortality 2 score as an Outcome Predictor in Pediatric ICU of a Public Sector Tertiary Care Hospital in Pakistan

Pediatric Index of Mortality 2 (PIM-2) is one of the leading mortality scores used in intensive care units all around the world. We assessed its validity as an outcome predictor in a pediatric intensive care unit (PICU) of Mayo Hospital/King Edward Medical University Lahore, Pakistan. We enrolled 154 consecutive admissions, aged 1 month to 13 years, requiring intensive care from January to June of 2019. Patient demographics along with PIM-2 data were collected; PIM-2 score and mortality risk was calculated; and the outcome recorded as death or survival. The median age at admission was 0.50 years (interquartile range [IQR]: 0.24–1.78) and the median weight was 5.0 kg (IQR: 3.08–10.0) with females constituting 54%; malnutrition was also common (66%). Observed mortality was 29.9% (46 out of 154) and expected mortality (cut-off ≥ 99.8%) was 27.9% with a standardized mortality ratio of 1.07 (95% confidence interval [CI]: 0.79–1.41). Sepsis was the most common diagnosis at admission (27.9%) with the highest mortality (52.2%). Chi-square analysis revealed a sensitivity of 54.3% and a specificity of 83.3% (p-value 0.00). PIM-2 score showed acceptable discrimination between survivors and nonsurvivors with an area under the receiver operating characteristic curve of 0.75 (95% CI: 0.67–0.84) (p-value = 0.00); however, poor calibration according to Hosmer–Lemeshow goodness of fit test (Chi-square = 15.80, df = 7, and p-value of 0.027 [< 0.1]), thus requiring recalibration according to local population characteristics.