A randomized controlled trial of high parenteral protein feeding in septic children: the role of tumor necrosis factor-alpha-308 polymorphism

BACKGROUND Septic children cause high protein degradation and inadequate nutritional intake would worsen the outcomes. In addition, there are conflicting results of association between tumor necrosis factor-α (TNFA)-308 polymorphism and poorer outcomes. This study was aimed to investigate the impact of high protein feeding in septic children and to examine the role of the TNFA-308 polymorphism in outcome of sepsis. METHODS In this randomized controlled trial, septic children were randomly assigned to receive either high protein feeding (amino acid of 4 g/kg of body weight [kgBW]/day) or standard nutrient (amino acid of 2 g/kgBW/day) for three days in the pediatric intensive care unit of four hospitals in Indonesia. The patient’s enrollment was done between April 2016 and May 2017. The primary outcome was the pediatric logistic organ dysfunction (PELOD) score. TNFA-308 polymorphism was investigated using restriction fragment length polymorphism method in both groups. PELOD score was analyzed as mean differences and gene polymorphism was analyzed with mortality in a subgroup. RESULTS There were 40 children in each group. PELOD score on day-1 (22.4 versus 20.5, p = 0.429), day-2 (20.5 versus 19.8, p = 0.815), and day-3 (18.8 versus 19.8, p = 0.772) were not lower in high protein feeding compared to standard feeding. TNFA-308 polymorphism had no role in mortality of both groups (high protein, p = 0.426; standard, p = 0.456). CONCLUSIONS From this study, researchers concluded that a high protein intervention did not significantly decrease the PELOD score, length of stay, and duration of ventilator use in both groups.

Prospective Observational Cohort Study on Dexmedetomidine and Midazolam in Mechanically Ventilated Children

Introduction: Though target sedation was achieved with Midazolam and Dexmedetomidine, Dexmedetomidine has demonstrated the lesser complications and shorter duration of stay in Intensive Care Unit (ICU). Most of the studies are reported from high income countries. The studies on Midazolam and Dexmedetomidine use in mechanically ventilated children are scanty in low-middle income regions. Aim: To compare the efficacy of Midazolam and Dexmedetomidine for sedation in mechanically ventilated children. Materials and Methods: This prospective observational cohort study was conducted in academic hospital Paediatric Intensive Care Unit (PICU) from March 2015 to June 2016. Children aged less than 13 years mechanically ventilated for more than 24-hour and received sedative with either infusion of Midazolam or Dexmedetomidine without loading dose were involved. Patients with unstable haemodynamic throughout PICU stay and expired within 24-hour and incomplete medical data were excluded. Intermittent Fentanyl/Morphine was used as when needed as per treating team decisions. Sedation assessment was performed with Ramsey sedation scale (RSS, target=3-4 out of 6), Tracheal suctioning score and PICU sedation score. The primary outcome was “percentage of time with target sedation” till extubation. The secondary outcome was the cumulative dose of sedation used, the need for rescue sedation and the rate of complications, organ dysfunction {by Sequential Organ Failure Assessment (SOFA) score and Paediatric Logistic Organ Dysfunction (PELOD) score} and the length of stay in ventilation, PICU and mortality. Results: A total of 115 patients (Midazolam-group, n=63 and Dexmedetomidine-group, n=52) were enrolled. The median age was 12 months (IQR 8-30). Mean (±SD) PRISM-III score was 11.3±7.2. About 54.8% were ventilated for respiratory pathology, followed by CNS pathology (25.2%) and sepsis (10.4%). Mean (±SD) percentage of the duration of proper sedation was not significantly different in Midazolam-group (83.4±15.6) and Dexmedetomidine-group (81.4±17) (p=0.510). The cumulative dose (microgram per kg) requirement was higher in Midazolam-group {median (IQR) 12.2 (9.8-17.1) vs. 9.6 (5-15.3); p=0.019)}.No difference was note in need for “rescue dose of sedation” per patient {median (IQR) 1 (0-2) vs. 1 (0-2)}, rate of complications (bradycardia 9.5% vs. 1.9%; hypotension 9.5% vs. 5.8%). No difference was noted in organ dysfunction score {mean difference, 95% CI; SOFA score: -0.2 (-1.6 to 1.33); p=0.808 and PeLOD score: 1.3 (-1.5 to 4.1); p=0.364}, duration of ventilation (median, IQR 2.7 (2-3.3) vs. 2.0 (1.5-3.1) days and mortality (20.6% vs. 21.2%). PICU stay was significantly lower in Midazolam-group (median, IQR 3 days, 1-5 vs. 5 days, 4-6; p=<0.001). Conclusion:Midazolam and Dexmedetomidine were associated with similar target sedation with a comparable rate of complications in mechanically ventilated children. However, Midazolam required a higher cumulative dose to achieve target sedation.

Evaluation of modified paediatric logistic organ dysfunction scoring system in predicting the outcome in critically ill children

Background: The Pediatric Logistic Organ Dysfunction (PELOD) score has been earlier validated for scoring of children in the Pediatric Intensive Care Unit (PICU). We have modified the PELOD score to adapt to resource limited settings by replacing Partial pressure of Oxygen (PaO2) / Fraction of inspired oxygen (FiO2)ratio, Partial pressure of carbon dioxide (PaCO2), and mechanical ventilation by three new variables i.e. Respiratory rate, Chest retraction and Peripheral Capillary Oxygen Saturation (SpO2). Aim of this study was to assess the 'Modified PELOD' scoring system and correlate it with the prognosis of children in the PICU.Methods: A prospective, observational, hospital-based study on 75 critically ill patients admitted in the PICU from age one month to 15 years was done, during a period of one year, from June 2015 to May 2016. The modified PELOD scoring system was calculated for the patients during the first 24 hours of admission. Patients were followed up until they got discharged from the PICU or died.Results: Modified PELOD scores ranged from 1- 42 in this study, of which patients with higher values had worst prognosis. Modified PELOD score ≥23 had increased risk of mortality.Conclusions: The Modified PELOD score can be used to predict outcome even in resource limited settings. The mortality rate increases with increase in number of organs having dysfunction. Length of stay less than 48 hours is critical in terms of monitoring and management, as the chances of mortality are high during this period.

Triiodothyronine levels and mortality in children with sepsis and septic shock

Background Sepsis is the most common cause of death in infants and children. It can cause hormonal imbalances, such as euthyroid sick syndrome (ESS), which may increase the risk of death.Objective To evaluate a possible correlation between the level of triiodothyronine (T3) and mortality in children with sepsis and septic shock.Methods An observational cohort study was conducted on 80 children with sepsis and septic shock from October 2015 until January 2016 in Haji Adam Malik General Hospital, Medan. Subjects underwent PELOD score and T3 examination on the first day admitted in Haji Adam Malik General Hospital. Chi-square test was used to analyze for a correlation between the T3 values and mortality. Results Of the 80 consecutive subjects, 39 (48.75%) had low T3 level on the first day. Of these 39 children, 36 (92.3%) died. Subjects with low T3 level had a 6.31 times higher risk of mortality(PR 6.31; 95%CI 2.99 to 13.28; P<0.001). Of the 31 subjects with high PELOD score, 23 (74.2%) had decreased T3 (PR=2.27; 95%CI 1.45 to 3.57; P<0.001).Conclusion Low T3 level has significant relationship with mortality in children with sepsis and septic shock.

Triiodothyronine levels and mortality in children with sepsis and septic shock

Background Sepsis is the most common cause of death in infants and children. It can cause hormonal imbalances, such as euthyroid sick syndrome (ESS), which may increase the risk of death.Objective To evaluate a possible correlation between the level of triiodothyronine (T3) and mortality in children with sepsis and septic shock.Methods An observational cohort study was conducted on 80 children with sepsis and septic shock from October 2015 until January 2016 in Haji Adam Malik General Hospital, Medan. Subjects underwent PELOD score and T3 examination on the first day admitted in Haji Adam Malik General Hospital. Chi-square test was used to analyze for a correlation between the T3 values and mortality. Results Of the 80 consecutive subjects, 39 (48.75%) had low T3 level on the first day. Of these 39 children, 36 (92.3%) died. Subjects with low T3 level had a 6.31 times higher risk of mortality(PR 6.31; 95%CI 2.99 to 13.28; P<0.001). Of the 31 subjects with high PELOD score, 23 (74.2%) had decreased T3 (PR=2.27; 95%CI 1.45 to 3.57; P<0.001).Conclusion Low T3 level has significant relationship with mortality in children with sepsis and septic shock.

Lactate profiles of pediatric shock patients in Cipto Mangunkusumo General Hospital 2015: a pilot study

Background The 2015 Surviving Sepsis Campaign (SSC) guidelines for management of shock recommend blood lactate to assess the success of resuscitation in shock. However, a study in adults found that 1/3 of septic shock patients had normal lactate levels (alactatemia) and lower mortality rates.Objective To evaluate lactate profiles, possible factors affecting lactate levels, and mortality outcomes in pediatric shock patients in the emergency room (ER) and pediatric intensive care unit (PICU).Methods This was a retrospective study on pediatric shock patients aged 1 month to 18 years in the ER or PICU from June 2014 to December 2015. Data were taken from subjects’ medical records including lactate levels, examination data required to calculate a PELOD score, and mortality outcomes.Results Of 223 shock patients evaluated, only 92 cases (41.2%) underwent lactate examinations. Of these, 59 (64.1%) had alactatemia and 33 (35.9%) had hyperlactatemia. A total of 23.7% of the alactatemia group and 36.4% of the hyperlactatemia group died, thus, the initial lactate level was not significantly associated with patient outcomes (P=0.197). The mortality rates of patients with <10% and ³10% lactate clearance were 31.3% and 17.6%, respectively (P=0.362).Conclusion In alactatemia patients, lactate level can not be used as a goal for resuscitation. Further study is needed to find a biomarker for assessing the success of pediatric shock resuscitation. Moreover, the clinical relevance of alactatemia is uncertain in pediatric shock patients.

The Use of PELOD Score in Predicting Acute Kidney Injury in Critically Ill Children

Introduction: Acute kidney injury (AKI) significantly increases morbidity and mortality in critically ill children. Prognostic indicators such as Pediatric Logistic Organ Dysfunction (PELOD) score is associated with factors related to renal dysfunction. The aim of this study was to study the AKI incidence and correlate the PELOD score with AKI in critically ill children admitted to PICU at Dr. Soetomo Hospital Surabaya Indonesia.Material and Methods: A prospective study was conducted to all children admitted to PICU during 15 January-14 April 2014. Demographic data (age, sex, PICU indications, PELOD scores, AKI staging by pRIFLE at admission) and outcome after 7 days at PICU were recorded. All data were analyzed descriptively (p<0.05).Results: A total of 56 (47.1%) out of 119 children were studied. The rest was excluded for being <3 months old, had end-stage kidney disease or complex cardiac problem, and cardiac catheterization. Mean age of subjects was 49.7 (SD 46.2) months, male-to-female ratio of 1.2:1. PICU indication was dominated by shock (35.7%), followed by CNS dysfunction in 13 (23.2%) and respiratory failure in 12 (21.4%) children. AKI was noted in 15 (26.8%) children, mostly (10.7%) in Injury stage with 5 (8.9%) in Risk and 4 (7.1%) in Failure stages. PELOD scores at admission ranged from 0 to 20 (mean 4.34, SD 5.87), higher scores in AKI group (7.8±6.64 vs 3.1±5.09, P=0.013). Twelve (21.4%) children died, 7 (58.3%) had AKI with 3 (25.0%) each in Risk and Failure while 1(8.3%) in Injury (p<0.05).Conclusion: PELOD score can be used as a predictor for AKI in critically ill children.J Nepal Paediatr Soc 2016;36(2):165-169.

PELOD score, serum procalcitonin, and lactate levels in pediatric sepsis

Background Sepsis remains a major cause of morbidity andmortality among critically ill children in the pediatric intensivecare unit (PICU). Procalcitonin and lactate have been used asbiomarkers of sepsis, as they have been correlated with diseaseseverity, organ failure and death. The Pediatric Logistic OrganDysfunction (PELOD) score is a tool to assess the severity oforgan dysfunction in critically ill children.Objective To investigate the correlation between PELOD scoreand procalcitonin and lactate levels in pediatric sepsis.Methods A cross-sectional study was conducted in childrenwith sepsis who were admitted to the PICU from April to July2012. Sepsis was defined as systemic inflammatory responsesyndrome (SIRS), as a result of suspected or proven infection.Proven infection was defined as positive culture findings (blood,􀁘􀁕􀁌􀁑􀁈􀀃 􀁒􀁕􀀃 􀁒􀁗􀁋􀁈􀁕􀀃 􀁖􀁓􀁈􀁆􀁌􀁐􀁈􀁑􀁖􀀌􀀃 􀁄􀁑􀁇􀀒􀁒􀁕􀀃 􀁖􀁈􀁕􀁘􀁐􀀃 􀁓􀁕􀁒􀁆􀁄􀁏􀁆􀁌􀁗􀁒􀁑􀁌􀁑􀀃 􀂕􀀕􀀃 􀁑􀁊􀀒mL. Spearman’s test was used to assess for correlations betweenPELOD scores and procalcitonin as well as lactate levels.Results Thirty-two patients were analyzed, consisting of 18 malesand 14 females with an age range of 1-432 months (median 21months). There was no statistically significant correlation betweenprocalcitonin level and PELOD score (r=- 0.186, 95%CI -0.502to 0.174, P=0.308) nor between lactate level(r=-0.069, 95%CI-0.408 to 0.287, P=0.709) and PELOD score.Conclusion Serum procalcitonin and lactate levels are notcorrelated with PELOD scores in children with sepsis.

Use of pediatric logistic organ dysfunction in determining prognostic among pediatric intensive care unIt patIents

Background Pediatric intensive care unit is the place for caring the children \\lith higher risk of mortality, usually with multiple organ dysfunction syndrome (MODS) that can increase difficulty in detennining prognostic. Th erefore, an objective severity of illness and organ dysfunction score is needed. Pediatric logistic organ dysfunction (PELOD) score can be considered as a representative for probability of death and predicting the prognostic.Objective To determine the prognostic of patients in PICU Mohammad Hoesin hospital (RSMH), Palembang, using PELOD score.Methods An observational study was conducted from April-September 2009 among PICU patients. PELOD score was assessed in the first 24 hour. S tatistical analysis was performed using Z-Mann Whitney test, Hosmer-Lemeshow goodness-of-fit, ROC curve and survival analysis Kaplan Meier (KM).Results There were 45 (55%) boys and 36 (44%) girls with mean age 51 (SD 6 ,4 7) months. Children with MODS were 75%. Death was 37 (45%) and survival was 44 (54%) with mean length of stay was 181,92 (SE 30,23) hours. PELOD score was from 0 to 51. The best PELOD score related to death in coordinate point was 20,5 with ROC 0,862. Length of stay in grup \\lith PELOD score < 20.5 was 371.22 (SE 82.13) hours and > 20.5 was 93 (SE 17.48) hours (log rank P=0.000). S urvival function KM showed that the higher PELOD score, the shorter length of stay in PICU.Henceforth, the higher probability prediction of mortality.Conclusion PELOD score can be used as a prognostic predictor of mortality among PICU patients in Mohammad Hoesin Hospital (RSMH), Palemhang.