Objective: To evaluate the prognostic performance of the Pediatric Index of Mortality 2 (PIM2), ferritin, lactate, C-reactive protein (CRP), and leukocytes, alone and in combination, in pediatric patients with sepsis admitted to the pediatric intensive care unit (PICU). Methods: A retrospective study was conducted in a PICU in Brazil. All patients aged 6 months to 18 years admitted with a diagnosis of sepsis were eligible for inclusion. Those with ferritin and C-reactive protein measured within 48 h and lactate and leukocytes within 24 h of admission were included in the prognostic performance analysis. Results: Of 350 eligible patients with sepsis, 294 had undergone all measurements required for analysis and were included in the study. PIM2, ferritin, lactate, and CRP had good discriminatory power for mortality, with PIM2 and ferritin being superior to CRP. The cutoff values for PIM2 (> 14%), ferritin (> 135 ng/mL), lactate (> 1.7 mmol/L), and CRP (> 6.7 mg/mL) were associated with mortality. The combination of ferritin, lactate, and CRP had a positive predictive value of 43% for mortality, similar to that of PIM2 alone (38.6%). The combined use of the three biomarkers plus PIM2 increased the positive predictive value to 76% and accuracy to 0.945. Conclusions: PIM2, ferritin, lactate, and CRP alone showed good prognostic performance for mortality in pediatric patients older than 6 months with sepsis. When combined, they were able to predict death in three-fourths of the patients with sepsis. Total leukocyte count was not useful as a prognostic marker.

The aim of this study was to verify the association of echocardiogram, ferritin, C-reactive protein, and leukocyte count with unfavorable outcomes in pediatric sepsis. A prospective cohort study was carried out from March to December 2014, with pediatric critical care patients aged between 28 days and 18 years. Inclusion criteria were diagnosis of sepsis, need for mechanical ventilation for more than 48h, and vasoactive drugs. Serum levels of C-reactive protein, ferritin, and leukocyte count were collected on the first day (D0), 24h (D1), and 72h (D3) after recruitment. Patients underwent transthoracic echocardiography to determine the ejection fraction of the left ventricle on D1 and D3. The outcomes measured were length of hospital stay and in the pediatric intensive care unit, mechanical ventilation duration, free hours of VM, duration of use of inotropic agents, maximum inotropic score, and mortality. Twenty patients completed the study. Patients with elevated ferritin levels on D0 had also fewer ventilator-free hours (p=0.046) and higher maximum inotropic score (p=0.009). Patients with cardiac dysfunction by echocardiogram on D1 had longer hospital stay (p=0.047), pediatric intensive care unit stay (p=0.020), duration of mechanical ventilation (p=0.011), maximum inotropic score (p=0.001), and fewer ventilator-free hours (p=0.020). Cardiac dysfunction by echocardiography and serum ferritin value was significantly associated with unfavorable outcomes in pediatric patients with sepsis.

To systematically review the evidence about the impact of nutritional status in critically-ill pediatric patients on the following outcomes during hospitalization in pediatric intensive care units: length of hospital stay, need for mechanical ventilation, and mortality. The search was carried out in the following databases: Lilacs (Latin American and Caribbean Health Sciences), MEDLINE (National Library of Medicine United States) and Embase (Elsevier Database). No filters were selected. A total of seven relevant articles about the subject were included. The publication period was between 1982 and 2012. All articles assessed the nutritional status of patients on admission at pediatric intensive care units and correlated it to at least one assessed outcome. A methodological quality questionnaire created by the authors was applied, which was based on some references and the researchers' experience. All included studies met the quality criteria, but only four met all the items. The studies included in this review suggest that nutritional depletion is associated with worse outcomes in pediatric intensive care units. However, studies are scarce and those existing show no methodological homogeneity, especially regarding nutritional status assessment and classification methods. Contemporary and well-designed studies are needed in order to properly assess the association between children's nutritional status and its impact on outcomes of these patients.

To determine the prevalence of life support limitation (LSL) in patients who died after at least 24h of a pediatric intensive care unit (PICU) stay, parent participation and to describe how this type of care is delivered. Retrospective cohort study in a tertiary PICU at a university hospital in Brazil. All patients aged 1 month to 18 years who died were eligible for inclusion. The exclusion criteria were those brain death and death within 24h of admission. 53 patients were included in the study. The prevalence of a LSL report was 45.3%. Out of 24 patients with a report of LSL on their medical records only 1 did not have a do-not-resuscitate order. Half of the patients with a report of LSL had life support withdrawn. The length of their PICU stay, age, presence of parents at the time of death, and severity on admission, calculated by the Pediatric Index of Mortality 2, were higher in patients with a report of LSL. Compared with other historical cohorts, there was a clear increase in the prevalence of LSL and, most importantly, a change in how limitations are carried out, with a high prevalence of parental participation and an increase in withdrawal of life support. LSLs were associated with older and more severely ill patients, with a high prevalence of family participation in this process. The historical comparison showed an increase in LSL and in the withdrawal of life support.

There is a high prevalence of children with complex chronic conditions (CCCs) in pediatric intensive care units (PICUs). However, information on the nutritional status (NS) of this specific population is limited. This study aimed to evaluate the NS of critically ill pediatric patients with CCCs and to relate it to clinical outcomes. A retrospective cohort study of children admitted to a PICU over a 4-year period. We classified NS according to body mass index-for-age (BMI/A) and height-for-age (H/A) z-scores, using the World Health Organization (WHO) growth curves as a reference. We recorded the presence of CCC according to the definition proposed by Feudtner et al. Severity on admission was measured using the Pediatric Index of Mortality 2 (PIM2). We assessed the following outcomes: mortality, multiple organ dysfunction syndrome during PICU stay, and PICU length of stay (LOS). We included 1753 children in the study. Presence of CCC accounted for 49.8% (873) of the sample. Among children with CCCs, 61.7% (539) had appropriate weight, 19.8% (173) were underweight, and 18.4% (161) were overweight. H/A was considered inadequate in 32.2% (281) of patients with CCCs, a higher rate than in those without CCCs (25.3%; 132) (p < 0.001). Regarding outcomes, underweight children had more organ dysfunctions and prolonged LOS. The association only remained for prolonged LOS when adjusting for confounders. Although underweight children had a higher PIM2-predicted risk of mortality, there was no significant difference in actual mortality between the three NS groups (p = 0.200). The rates of nutritional inadequacies in patients with CCCs were high. Underweight was independently associated with prolonged LOS in children with CCC.

Objective: To compare the nursing workload using the Nursing Activities Score (NAS), Therapeutic Intervention Scoring System-28 (TISS-28) and Nine Equivalents of Nursing Manpower Use Score (NEMS) instruments in children admitted to a Pediatric Intensive Care Unit in a university hospital. Method: A prospective cohort study performed in a Pediatric Intensive Care Unit, with a sample formed of all children hospitalized during the study period. Nursing workload was evaluated using the TISS-28, NEMS and NAS instruments, and further divided into two groups: Group 1 forming a category of basic activities items and Group 2 forming a category of other support and intervention activities. Results: The sample consisted of 490 Pediatric Intensive Care Unit admissions, totaling 4617 observations. NAS presented the best estimate of total working hours. TISS-28 and NEMS showed better agreement and the results showed strong correlations between NAS and TISS-28 and between NEMS and TISS-28. In Group 1 (basic activities), NAS(1) and TISS-28(1) showed moderate correlation, in Group 2 (specialized activities) the three instruments showed strong correlations. Conclusion: NAS stood out in the evaluation of nursing workload and showed good correlation and agreement with the TISS-28.