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RESUMO Objetivo: Determinar a concordância da classificação do risco de mortalidade por meio do uso dos escores Pediatric Index of Mortality (PIM) 2 e 3. Métodos: Avaliação de uma coorte retrospectiva pela análise dos pacientes admitidos à unidade de terapia intensiva pediátrica entre abril de 2016 e dezembro de 2018. Calculamos o risco de mortalidade por meio do PIM 2 e do 3. Realizaram-se análises para determinar a concordância entre a classificação de risco obtida com ambas as escalas pela utilização do cálculo do Kappa não ponderado e linearmente ponderado. Resultados: Incluímos 722 pacientes, sendo que 66,6% destes tinham uma condição crônica. A mortalidade global foi de 3,7%. O coeficiente Kappa de concordância para classificação dos pacientes, segundo o risco com o PIM 2 e o 3, foi moderado: 0,48 (IC95% 0,43 - 0,53). Após ponderação linear, a concordância foi substancial: 0,64 (IC95% 0,59 - 0,69). Para pacientes de cirurgia cardíaca, a concordância para a classificação de risco foi regular: 0,30 (IC95% 0,21 - 0,39); após ponderação linear, a concordância foi apenas moderada: 0,49 (IC95% 0,39 - 0,59). O PIM 3 acusou um risco mais baixo do que o PIM 2 em 44,8% dos pacientes desse subgrupo. Conclusão: Nosso estudo comprova que o PIM 2 e o 3 não são clinicamente equivalentes e não devem ser usadas de forma intercambiável para avaliação da qualidade em diferentes unidades de terapia intensiva. Devem ser conduzidos estudos de validação antes que se utilizem os PIM 2 e 3 em situações específicas.
ABSTRACT Objective: To determine the concordance of mortality risk classification through the use of the Pediatric Index of Mortality (PIM) 2 and 3. Methods: Through a retrospective cohort, we evaluated patients admitted to the pediatric intensive care unit between April 2016 and December 2018. We calculated the mortality risk with the PIM 2 and 3. Analyses were carried out to determine the concordance between the risk classification obtained with both scales using unweighted and linearly weighted kappa. Results: A total of 722 subjects were included, and 66.6% had a chronic condition. The overall mortality was 3.7%. The global kappa concordance coefficient for classifying patients according to risk with the PIM 2 and 3 was moderate at 0.48 (95%CI 0.43 - 0.53). After linear weighting, concordance was substantial at 0.64 (95%CI 0.59 - 0.69). For cardiac surgery patients, concordance for risk classification was fair at 0.30 (95%CI 0.21 - 0.39), and after linear weighting, concordance was only moderate at 0.49 (95%CI 0.39 - 0.59). The PIM 3 assigned a lower risk than the PIM 2 in 44.8% of patients in this subgroup. Conclusion: Our study proves that the PIM 2 and 3 are not clinically equivalent and should not be used interchangeably for quality evaluation across pediatric intensive care units. Validation studies must be performed before using the PIM 2 or PIM 3 in specific settings.
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Humanos , Criança , Unidades de Terapia Intensiva Pediátrica , Mortalidade Hospitalar , Pediatria , Estudos RetrospectivosRESUMO
BACKGROUND: Mortality in pediatric intensive care units (PICUs) is elevated, with limited information generated from Mexico. OBJECTIVE: To identify the standardized mortality (SM) at the Hospital del Niño Morelense's (HNM) (Child from Morelos' Hospital) PICU. MATERIAL AND METHODS: Electronic records of seriously ill patients admitted at the HNM's PICU during 2014 (n = 130) were used. SM was calculated using the observed mortality and the probability of death by PIM2. The area under the ROC curve (AUC) was used to identify the discriminatory capacity of PIM2, and the Hosmer Lemeshow (HL) test to calibrate it. By using odds ratios (OR) and 95% confidence intervals (95% CI), risk factors of mortality were identified. RESULTS: There were no differences between observed mortality and expected mortality with PIM2 (17.7%; HL p = 0.17), resulting in a SM of 1. The AUC of PIM2 was 0.76 (95% CI, 0.68 0.83). Risk factors associated to mortality were: admission due to medical diagnosis (OR 3.22; 95% CI, 1.08 10.76), absence of pupillary light reflex (OR 7.36; 95% CI, 1.81 29.68), high risk diagnosis according to PIM2 (OR 3.85; 95% CI, 1.16 12.03), and coming from the Emergency Room showed a borderline result (OR 2.80; 95% CI, 0.98 8.69; chi-squared, p = 0.04). CONCLUSIONS: Mortality observed in the HNM's PICU during 2014 was elevated, but similar to predicted mortality by PIM2 score, with a SM of 1. PIM2 is a validated score used all over the world, which is useful to predict the expected mortality in PICUs.
INTRODUCCIÓN: la mortalidad en las unidades de cuidados intensivos pediátricos (UCIP) es elevada, con escasa información generada en México. OBJETIVO: identificar la mortalidad estandarizada (ME) en la UCIP del Hospital del Niño Morelense (HNM). MATERIAL Y MÉTODOS: se usaron los expedientes electrónicos de enfermos críticos admitidos en la UCIP del HNM durante 2014 (n = 130). Se calculó la ME empleando la mortalidad observada y la probabilidad de muerte mediante PIM2. Se empleó el área bajo la curva ROC (ABC ROC) para identificar la capacidad discriminatoria de PIM2, y la prueba de Hosmer Lemeshow (HL) para calibrarla. Mediante razón de momios (RM) e intervalo de confianza al 95% (IC 95%) se identificaron los factores de riesgo de mortalidad. RESULTADOS: no hubo diferencias entre la mortalidad observada y la esperada con PIM2 (17.7%; HL p = 0.17), lo cual generó una ME de 1. El ABC ROC de PIM2 fue 0.76 (IC 95% 0.68 0.83). Los factores de riesgo asociados a mortalidad fueron: ingreso por diagnóstico médico (RM 3.22; IC 95% 1.08 10.76), ausencia de reflejo pupilar (RM 7.36; IC 95% 1.81 29.68), diagnóstico de alto riesgo según PIM2 (RM 3.85; IC 95% 1.16 12.03) y proceder de Urgencias fue limítrofe (RM 2.80; IC 95% 0.98 8.69; chi cuadrada p = 0.03). CONCLUSIONES: la mortalidad observada en la UCIP del HNM durante 2014 fue elevada, pero igual que la predicha por la escala PIM2, con ME de 1. La escala PIM2 es una escala internacional validada que es útil para predecir la posibilidad de muerte en las UCIP.
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Mortalidade Hospitalar , Unidades de Terapia Intensiva Pediátrica , Criança , Hospitalização , Humanos , México/epidemiologiaRESUMO
Pediatric index of mortality (PIM)-2 and PIM3 are the most recent versions of severity of illness scoring generated from a pediatric intensive care unit (PICU) population in Australia and the United Kingdom. The authors present a single-center evaluation of a performance of these scores in a PICU in Colombia. PIM3 seemed to demonstrate a marginally better performance at predicting mortality, although the discrimination was similar for both scores. Incorporation of this approach to the rest of the units throughout the country would help with benchmarking PICU performance. HOW TO CITE THIS ARTICLE: Rahiman S. Does Pediatric Index of Mortality "Score" in Colombia? Indian J Crit Care Med 2020;24(11):1018-1019.
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OBJECTIVE: To investigate differences in sepsis mortality between prepubertal and postpubertal males and females. STUDY DESIGN: This was a retrospective review of the Virtual PICU Systems (VPS) database (including 74 pediatric intensive care units [PICUs]) for 2006-2008. We included prepubertal (aged 2-7 years) and postpubertal (aged 16-21 years) children with a primary diagnosis of sepsis admitted to a participating PICU. RESULTS: Prepubertal females (n = 272; 9.9% mortality) and prepubertal males (n = 303; 10.9% mortality) had similar mortality and severity of illness (Pediatric Index of Mortality 2 risk of mortality [PIM 2 ROM]). Postpubertal females (n = 233; mortality, 5.6%) had lower mortality than postpubertal males (n = 212; mortality, 11.8%; P = .03). PIM 2 ROM was higher for postpubertal males than postpubertal females (P = .02). After controlling for hospital specific effects with multivariate modeling, in postpubertal children, female gender was independently associated with a lower initial severity of illness (PIM 2 ROM: OR, 0.77; 95% CI, 0.62-0.96; P = .02). CONCLUSION: Sepsis mortality is similar in prepubertal males and females. However, postpubertal males have a higher sepsis mortality than postpubertal females, likely related to their greater severity of illness on PICU admission. These outcome differences in postpubertal children may reflect a hormonal influence on the response to infection or differences in underlying comorbidities, source of infection, or behavior.
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Mortalidade Hospitalar , Puberdade , Sepse/mortalidade , Índice de Gravidade de Doença , Adolescente , Fatores Etários , Criança , Pré-Escolar , Estudos de Coortes , Bases de Dados Factuais , Feminino , Humanos , Unidades de Terapia Intensiva Pediátrica , Modelos Lineares , Modelos Logísticos , Masculino , Análise Multivariada , Estudos Retrospectivos , Fatores Sexuais , Estados Unidos/epidemiologia , Adulto JovemRESUMO
Las escalas PIM (Índice de Mortalidad Pediátrica) y PELOD (Índice Pediátrico de Disfunción Orgánica) son sistemas de evaluación que permiten la estimación de la severidad de la enfermedad y el ajuste del riesgo de mortalidad en grupos heterogéneos de pacientes. El objetivo del presente trabajo fue el de validar las escalas PIM y PELOD en una Unidad de Cuidados Intensivos pediátrica (UCIP). Metodología. Fueron incluidos 97 niños con edad menor o igual a 12 años; las variables estudiadas fueron la mortalidad o sobrevida durante la estancia en UCI. PIM incluye 7 variables medidas durante la primera hora de admisión a UCI; PELOD incluye disfunción de seis sistemas orgánicos en 12 variables. Para estimar discriminación, se utilizó el área bajo la curva de rendimiento diagnóstico, y para evaluar calibración, la bondad de ajuste de Hosmer-Lemeshow. Resultados. Edad media 4,0 años (rango intercuartil 1,0-8,1); estancia 6,0 días; (rango 3,0 a 17,0); las principales causas de ingreso a UCIP fueron accidentes 30, sepsis 19, neurológicas 14. Desarrollaron disfunción orgánica múltiple 58 (59,8%) de 97. La mortalidad observada fue de 17,5%. La predicción de riesgo de mortalidad por PIM fue significativamente más alta en no sobrevivientes (0,48±0,35) que sobrevivientes (0,18±0,23; t test 3,40 p<0,003); calibración (p=0,025) y discriminación (área bajo la curva = 0,79 ± 0,057; p<0,001) de PIM fue buena. Conclusión: PIM es una medida válida de predicción de riesgo de mortalidad en UCIP en nuestro medio
The Pediatric Index of Mortality (PIM) and Pediatric Logistic Organ Dysfunction (PLOD) scale are scoring systems that allow assessment of the severity of illness and mortality risk adjustment in heterogeneous groups of patients. The aim of this study was to validate the accuracy and reliability of PIM and PELOD scoring in a pediatric Intensive Care Unit (ICU) Methods: 97 children under 12 years of age were included. Survival and mortality during the stay in the ICU were studied. PIM scale includes 7 parameters measured during the first hour of admission to the ICU; PELOD includes dysfunction of 6 organs and systems in 12 variables. The area under the curve was used to assess discrimination and calibration was assessed with the Hosmer-Lemeshow goodness of fit test. Results: The median patient age was 4,0 years (inter-quartile range 1,0-8,1), median length of stay was 6 days (range 3-17). Main causes for admission to the ICU were accidents 30, sepsis 19, neurological 14. Fifty eight patients (59,8%) developed multiple organic dysfunction. Observed mortality was 17,5%. Prediction of risk of mortality with PIM was significantly higher in non survivors (0,48 ± 0,35) than in survivors (0,18 ± 0,23); t test 3,40 p<0,003; calibration (p=0,025) and discrimination (area under the curve = 0,79±0,057; p<0,001) for PIM was good. Conclusions: PIM is a valid prediction index for mortality risk in pediatric ICU in our hospitals