Pediatric mortality probability estimated from pre-ICU severity of illness.

OBJECTIVE: The Pediatric Risk of Mortality (PRISM) score is a measure of illness severity based on abnormalities observed in the bedside examination and laboratory assessment. PRISM scores obtained after pediatric intensive care unit (PICU) admission predict mortality probability, but no previous efforts to evaluate mortality risk before PICU admission have been reported. Our study was performed on patients admitted to PICUs at four pediatric tertiary care centers to derive a quantitative estimate of hospital mortality probability as a function of PRISM scores obtained at referring hospitals before PICU transfer. Performance of the model was tested by evaluating accuracy of mortality predictions obtained from pre-ICU PRISM scores in a separate validation set of patients. METHODS: Patients were randomized to the derivation or validation sets. Data were recorded prospectively from observations made at hospitals referring to the study PICUs. Patients included 780 infants and children with medical and surgical emergencies and trauma. Electively admitted patients were excluded from analysis. RESULTS: The relationship between mortality probability (P) and the pre-ICU PRISM score is expressed by the equation: P = er/(1 + er). In this equation, r is an empirical function of the pre-ICU PRISM score: r = .197 x PRISM - 4.705. The mortality probability rises from near 0 at low scores, approaching 1 (certainty) above a PRISM score of 40. Mortality probability exceeds 10% at a score of 13 and exceeds 50% at a score of 24. Performance of predictions in the validation set of patients was evaluated for five categories of mortality probability. The observed number of deaths corresponded to predicted mortality across the range of illness severity. When compared for each tertiary institution, observed mortality rates were similar to predictions for three of four institutions. For data obtained at institution D, the observed mortality of 17% significantly exceeded the 7% predicted rate. In infants younger than 1 year, as well as children 1 year and older, observed mortality rates were similar to predicted. CONCLUSIONS: The pre-ICU PRISM score as a measure of illness severity provides an estimate of hospital mortality probability. Further investigation is required to determine the use of pre-ICU mortality estimates in making clinical decisions.

Reduction of morbidity in interhospital transport by specialized pediatric staff.

OBJECTIVE: We prospectively compared the occurrence of morbidity during high-risk interhospital transport in two types of transport systems: specialized tertiary center-based vs. nonspecialized, referring hospital-based. DESIGN: Concurrent, prospective comparison of morbidity at two pediatric centers that use different types of transport team. SETTING: Two tertiary care pediatric intensive care units (ICU). The specialized team consisted of a pediatric resident, pediatric intensive care nurse, and a pediatric respiratory therapist. Comparison was made with referring institution transports by nonspecialized personnel to a second center. The two centers were similar in size and patient mix, with referral areas of similar population and rural/urban ratio. PATIENTS: One hundred forty-one patients transported to two tertiary pediatric ICUs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two types of events were assessed: vital signs and other observable clinical events were described as "physiologic deteriorations." Events such as loss of intravenous access, endotracheal tube mishaps, and exhaustion of oxygen supply were described as "intensive care-related adverse events." Pretransport severity of illness and therapy were described by Pediatric Risk of Mortality (PRISM) and Therapeutic Intervention Scoring System (TISS) scores. Only high-risk patients with PRISM scores of > or = 10 were analyzed. Intensive care-related adverse events occurred in one (2%) of 49 transports by the specialized team and 18 (20%) of 92 transports by nonspecialized personnel. The difference is statistically significant (p < .05). Physiologic deterioration was similar in the two groups occurring in five (11%) of 47 specialized team transports and 11 (12%) of 92 transports by the nonspecialized team. CONCLUSION: We conclude that specialized pediatric teams can reduce transport morbidity. This is the first published study to compare two models of pediatric transport using identical definitions of severity and morbidity.

Late-onset intestinal obstruction in cystic fibrosis--meconium ileus equivalent.

Four patients who suffered from cystic fibrosis and late-onset bowel obstruction (meconium ileus equivalent), and who were treated by surgery, are discussed. The importance of early correct diagnosis is stressed, since surgery may be prevented if bowel washouts and oral medications are given before the condition becomes complicated.