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OBJECTIVE: To improve understanding of the causes of morbidity and mortality among critically ill children in the countries studied. DESIGN: Survey of hospital records between 1992 and 1994. SETTING: Six pediatric intensive care units (ICUs) (four ICUs in Mexico City and two ICUs in Ecuador). PATIENTS: Consecutive patients (n = 1,061) admitted to the units studied. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The mortality rate for low-risk patients (pediatric Risk of Mortality [PRISM] score of < or = 10, n = 701) was more than four times the rate predicted by the PRISM score (8.1% vs. 1.8%, p < .001), with an additional 11.3% of this group incurring major morbidity. The mortality rate for moderate-risk patients (PRISM scores of 11 to 20, n = 232) was more than twice predicted (28% vs. 12%, p < .001). For low-risk patients, death was significantly associated with tracheal intubation, central venous cannulation, pneumonia, age of < 2 months, use of more than two antibiotics, and nonsurgical diagnosis (after controlling for PRISM score). Central venous cannulation and tracheal intubation in the lower-risk groups were performed more commonly in units in Mexico than in one comparison unit in the United States (p < .001). CONCLUSIONS: For six pediatric ICUs in Mexico and Ecuador, mortality was significantly higher than predicted among lower-risk patients. Tracheal intubation, central catheters, pneumonia, sepsis, and nonsurgical status were associated with poor outcome for low-risk groups. We speculate that reducing the use of invasive central catheters and endotracheal intubation for lower-risk patients, coupled with improved infection control, could lower mortality rates in the population studied.

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This study was undertaken in order to evaluate for the first time the usefulness of PRISM score to predict outcome in pediatric patients in the Intensive Care Area of the Emergency Department at the Instituto Nacional de Pediatría in Mexico City. A prolective evaluation of PRISM score was done using 100 consecutive pediatric patients admitted to INP-ED between July and November 1992 and considered critically ill by the attending pediatricians to calculate by a lineal logistic model the expected mortality and compare with the observed one. Using a cut-off of r = 0, we evaluated at the same time the sensitivity, specificity and efficiency of this score. Fifty-eight patients were male and 42 were female. The mean age was 51 months with a range of 3 days -192 months. PRISM score for survivors was in general 8.7 +/- 7.2 and 25.8 +/- 14 for nonsurvivors (p < 0.001). Based on the logistic regression coefficients defined by Pollack et al., our sample of 100 patients was estimated to expect 12.91 deaths whereas in fact 11 were observed. Inspection of the survival rates across the different categories of expected mortality showed agreement and consistency in relation to original reports (9). The sensitivity, specificity and efficiency in general were 1.0, 0.98 and 0.98, respectively. The PRISM is an objective and efficient method which helps physicians to predict patients' outcome and risk of mortality, providing the medical staff with an epidemiological criteria. Additionally, it may be helpful in decision-making for ICU admissions and correct identification of patients who can benefit from that level of care.

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The authors present their experience with correct placement of an endotracheal tube. Thirty children were intubated for different indications following the same method. The correct position of the tube was confirmed by chest films. The method included: 1. Tracheal tube introduction by direct laryngoscopy. 2. Deliberate tube displacement to the main right bronchus. 3. Auscultatory carina detection while giving positive pressure ventilation with ambu, when the respiratory murmur appears in the left hemithorax. 4. Tube withdrawal a distance equal to the patient's little finger length, leaving off the tracheal tube tip at an appropriate distance from the carina. The placement was found correct in 29 cases.

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The study included ten patients with severe metabolic acidosis (pH under 7.0) and clinical signs of shock. In four of them assisted ventilation was indicated as an urgency. In the other six patients assisted ventilation was used since the beginning, simultaneously with reposition of blood volume and administration of sodium bicarbonate. There were much better results with the latter management, with faster correction of the acidosis, without any complications and good survivorship.

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The electrocardiograms of 150 newborns who were born in Mexico City (2,240 m. above sea level) were obtained in the first 24 hours of life and six weeks later. The electrocardiographic changes were similar to those observed at sea level; AQRS shifted to the left, the T waves became negative in the right precordial leads and the R/S relation increased in the left precordial leads. Mid-altitude does not affect the pulmonary vascular maturation of the normal newborn.

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