Outcomes of Children With Firearm Injuries Admitted to the PICU in the United States.

OBJECTIVES: Firearm-related injury is the second leading cause of injury and death for children 1-18 years old in United States. The objective of our study was to analyze the outcomes of children admitted to the PICU with firearm injuries. DESIGN: Retrospective study. SETTING: PICUs in United States contributing data to Virtual Pediatric Systems, LLC, from January 2009 to December 2017. PATIENTS: Children age 1 month to 18 years old admitted to the PICU with firearm injury, identified by external cause of injury E-codes and International Classification of Diseases, 9th Edition, and International Classification of Diseases, 10th Edition, codes were identified. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 1,447 cases identified of which 175 (12%) died in the PICU. Unintentional firearm injury (67.7%) and assault with a firearm injury (20%) comprised 90% of the cases. Males comprised 78% of the cohort (1,122) and race distribution included 45% Black (646), 27% White (390), and 12% Hispanic (178). Among the children who died in the PICU, 55% were 13-18 years old. Children attempting suicide with a firearm were more likely to die in the PICU as compared to the other causes of firearm injury. Based on their Pediatric Overall Performance Category and Pediatric Cerebral Performance Category scores at discharge, there is high morbidity in children with firearm injuries. CONCLUSIONS: Mortality rate of children with firearm injury admitted to the PICU is high. Children admitted to the PICU with suicide attempt with a firearm carried the highest mortality. Further studies may help further define the epidemiology of firearm injuries in children and plan interventions to minimize these unnecessary deaths.

Change in Frequency of Invasive and Noninvasive Respiratory Support in Critically Ill Pediatric Subjects.

BACKGROUND: Noninvasive respiratory support has become more popular in the pediatric population and may prevent or replace invasive procedures, such as endotracheal intubation, in certain circumstances. The objective was to examine the frequency of invasive and noninvasive respiratory support from 2009 to 2017 in critically ill pediatric patients and to determine patient-related factors associated with invasive support using the Virtual Pediatric Systems, LLC database. METHODS: This was an analysis of prospectively collected data on admissions with respiratory support from 17 pediatric ICUs from 2009 to 2017 reported within the Virtual Pediatric Systems database. We determined the frequency of invasive and noninvasive respiratory support over the study period by measuring the number of admissions with either invasive or noninvasive support within a given year divided by the total number of pediatric ICU admissions with respiratory support during the same year. Factors associated with invasive support were examined in univariate and multivariate regressions. RESULTS: A total of 69,262 cases of respiratory support were included. There was a decrease in the rate of invasive support over the study period from 66.9% to 48.5% (P value for test of trend < .001) and an increase in the rate of noninvasive support from 28.7% to 57.7% (P value for test of trend < .001). Trauma cases and subjects < 1 month old were more likely to receive invasive support. Cases occurring in later years and subjects with Black or Hispanic race were less likely to receive invasive support. CONCLUSIONS: From 2009 to 2017, the frequency of admissions with invasive respiratory support decreased, and those with noninvasive respiratory support increased. By 2017, the frequency of noninvasive respiratory support was greater than that of invasive respiratory support.

The Impact of Coronavirus Disease 2019 Pandemic on U.S. and Canadian PICUs.

OBJECTIVES: There are limited reports of the impact of the coronavirus disease 2019 pandemic focused on U.S. and Canadian PICUs. This hypothesis-generating report aims to identify the United States and Canadian trends of coronavirus disease 2019 in PICUs. DESIGN AND SETTING: To better understand how the coronavirus disease 2019 pandemic was affecting U.S. and Canadian PICUs, an open voluntary daily data collection process of Canadian and U.S. PICUs was initiated by Virtual Pediatric Systems, LLC (Los Angeles, CA; http://www.myvps.org) in mid-March 2020. Information was made available online to all PICUs wishing to participate. A secondary data collection was performed to follow-up on patients discharged from those PICUs reporting coronavirus disease 2019 positive patients. MEASUREMENTS AND MAIN RESULTS: To date, over 180 PICUs have responded detailing 530 PICU admissions requiring over 3,467 days of PICU care with 30 deaths. The preponderance of cases was in the eastern regions. Twenty-four percent of the patients admitted to the PICUs were over 18 years old. Fourteen percent of admissions were under 2 years old. Nearly 60% of children had comorbidities at admission with the average length of stay increasing by age and by severity of comorbidity. Advanced respiratory support was necessary during 67% of the current days of care, with 69% being conventional mechanical ventilation. CONCLUSIONS: PICUs have been significantly impacted by the pandemic. They have provided care not only for children but also adults. Patients with coronavirus disease 2019 have a high frequency of comorbidities, require longer stays, more ventilatory support than usual PICU admissions. These data suggest several avenues for further exploration.

Reclassifying by highest complexity operation rather than first operation influences mortality after pediatric heart surgery.

OBJECTIVE: To evaluate the effect on mortality of reclassifying patients undergoing pediatric heart reoperations of varying complexity by operation of highest complexity instead of by first operation. METHODS: Data from the Virtual Pediatric Systems Database on children aged < 18 years who underwent heart surgery (with or without cardiopulmonary bypass) were included (2009-2015). Only patients who underwent reoperations during the same hospitalization were included. Patients were classified based on the first cardiovascular operation (the index operation), and on the complexity of the operation (the operation with the highest Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery [STAT] mortality category of each hospital admission) performed. RESULTS: Of 51,047 patients (73 centers), 22,393 met inclusion criteria. Using index operation as the classifying operation, the number of patients classified in the STAT 1 category increased by approximately 2.5 times compared with the highest-complexity operation (index, 7,077 and highest complexity, 2,654). In contrast, when the highest-complexity classification was used, we noted an increase in the number of patients in other STAT categories. We also noted higher mortality in all STAT categories when patients were classified by index operation instead of by highest complexity (index vs highest STAT category 1, 0.6% vs 0.2%; category 2, 2.4% vs 0.8%; category 3, 3.1% vs 2.1%; category 4, 5.8% vs 5.6%; and category 5, 16.7% vs 16.5%). CONCLUSIONS: This study demonstrates differences in the reported number of patients and reported mortality in each STAT category among children undergoing various heart reoperations during the same hospitalization by classifying patients based on index operation compared with the operation of highest complexity.

Performance of Pediatric Risk of Mortality Score Among Critically Ill Children With Heart Disease.

OBJECTIVE: To evaluate the performance of the Pediatric Risk of Mortality 3 (PRISM-3) score in critically ill children with heart disease. METHODS: Patients <18 years of age admitted with cardiac diagnoses (cardiac medical and cardiac surgical) to one of the participating pediatric intensive care units in the Virtual Pediatric Systems, LLC, database were included. Performance of PRISM-3 was evaluated with discrimination and calibration measures among both cardiac surgical and cardiac medical patients. RESULTS: The study population consisted of 87,993 patients, of which 49% were cardiac medical patients (n = 43,545) and 51% were cardiac surgical patients (n = 44,448). The ability of PRISM-3 to distinguish survivors from nonsurvivors was acceptable for the entire cohort (c-statistic 0.86). However, PRISM-3 did not perform as well when stratified by varied severity of illness categories. Pediatric Risk of Mortality 3 underpredicted mortality among patients with lower severity of illness categories (quintiles 1-4) whereas it overpredicted mortality among patients with greatest severity of illness category (fifth quintile). When stratified by Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery (STS-EACTS) categories, PRISM-3 overpredicted mortality among the STS-EACTS mortality categories 1, 2, and 3 and underpredicted mortality among the STS-EACTS mortality categories 4 and 5. Pediatric Risk of Mortality 3 overpredicted mortality among centers with high cardiac surgery volume whereas it underpredicted mortality among centers with low cardiac surgery volume. CONCLUSION: Data from this large multicenter study do not support the use of PRISM-3 in cardiac surgical or cardiac medical patients. In this study, the ability of PRISM-3 to distinguish survivors from nonsurvivors was fair at best, and the accuracy with which it predicted death was poor.

Association of 24/7 In-House Intensive Care Unit Attending Physician Coverage With Outcomes in Children Undergoing Heart Operations.

BACKGROUND: Multicenter data regarding the around-the-clock (24/7) presence of an in-house critical care attending physician with outcomes in children undergoing cardiac operations are limited. METHODS: Patients younger than 18 years of age who underwent operations (with or without cardiopulmonary bypass [CPB]) for congenital heart disease at 1 of the participating intensive care units (ICUs) in the Virtual PICU Systems (VPS, LLC) database were included (2009-2014). The study population was divided into 2 groups: the 24/7 group (14,737 patients; 32 hospitals), and the No 24/7 group (10,422 patients; 22 hospitals). Propensity-score matching was performed to match patients 1:1 in the 24/7 group and in the No 24/7 group. RESULTS: Overall, 25,159 patients from 54 hospitals qualified for inclusion. By propensity matching, 9,072 patients (4,536 patient pairs) from 51 hospitals were matched 1:1 in the 2 groups. After matching, mortality at ICU discharge was lower among the patients treated in hospitals with 24/7 coverage (24/7 versus No 24/7, 2.8% versus 4.0%; p = 0.002). The use of extracorporeal membrane oxygenation (ECMO), the incidence of cardiac arrest, extubation within 48 hours after operation, the rate of reintubation, and the duration of arterial line and central venous line use after operation were significantly improved in the 24/7 group. When stratified by surgical complexity, survival benefits of 24/7 coverage persisted among patients undergoing both high-complexity and low-complexity operations. CONCLUSIONS: The presence of 24-hour in-ICU attending physician coverage in children undergoing cardiac operations is associated with improved outcomes, including ICU mortality. It is possible that 24-hour in-ICU attending physician coverage may be a surrogate for other factors that may bias the results. Further study is warranted.