Mortality Rate in Pediatric Intensive Care Unit (PICU): A Local Center Experience

Authors

Mazandaran University of Medical sciences, Sari, Iran

Abstract

Introduction: Pediatric intensive care unit (PICU) has a specific location for management of children with serious and severe diseases.
Methods: This is s crass-sectional – analytical Study was performed on all children admitted in Boali hospitals PICU from March 2010 to March 2012 (2 years). 937 patients were analyzed.
Results: Out of 490 patient admitted in PICU (march2010 to march 2011), 35 was died (7.14%) but this was 6/04% (27/447 patients) in march2011 to march 2012 (table-1). Overall, 62 cases were died (6/6%) in two years [male =30 (3.2%), female =32 (3.4%)].
In conclusion, mortality rate is similar with other developed countries or higher level of medical care.

Keywords


Introduction:

Pediatric intensive care unit (PICU) has a specific location for management of children with serious and severe diseases. Often these patients need intensive care and respiration with ventilator devices. There fore, care of these patients associated more expensive costs for family and social (1-2). Duration of admission is variable depends to underlying Disorder.  stay duration more than 13 days considered long stay admission (1-2) but it is consider very long stay when more than  30 days (3).

Mortally and  morbidity  probably  more common  in patients with more duration  admission and more severe patients than they had short stay admission and less severe disorders(4). Limitation and discontinue of medial treatment in PICU cause 14 to 75% mortality (5, 6).  Medical treatment discontinue in developed countries is a main cause of mortality in PICU patients , despite, these ways cause many problems of legal and ethical for health care person(7). Children with different ages and weight and different diagnosis take different drugs propose at high risk. Knowledge of about different disorders, mortality rate and etiology of them could be more effective in primary, secondary and tertiary prevention.

The aim of this study increase knowledge of different health workers and health political makers about etiology and mortality of different disorders in PICU patients in Boalisina hospital from March 2010 until March 2012.

Methods:

This is s crass-sectional – analytical Study was performed on all children admitted in Boali hospitals PICU from March 2010 to March 2012 (2 years). 937 patients were analyzed.

We evaluated demographic characteristic such as gender, age, way of transport, diagnosis, GCS score, date of death, duration of admission and etiology of death. Data recorded in SPSS-13 and analyzed with T-test and Anova test. PV

Results:

Out of 490 patient admitted in PICU (march2010 to march 2011), 35 was died (7.14%) but this was 6/04% (27/447 patients) in march2011 to march 2012 (table-1). Overall, 62 cases were died (6/6%) in two years [male =30 (3.2%), female =32 (3.4%)].

Table 1 – Demographic characteristics (Gender, age) in died patients in PICU at Boali hospital from March 2010 to March 2012.

gender

march2010-september2010

october2010-march2011

Total

N (%)

march2011-september2011

october2011-march2012

Total

N (%)

Male

8

10

18(51)

7

5

12(44)

Female

8

9

17(49)

8

7

15(56)

Total

16

19

35(100)

15

12

27(100)

Age

male

Female

Total

male

female

Total

1-6 m

5

10

15

5

7

12

7-12 m

4

3

7

4

4

8

˃ 13 m

9

4

13

3

4

7

Total

18

17

35

12

15

27

 

Under 6 month (n=17) more died (27 .41%) for two years but after 1 year age, male gender more died (n=12, 19.35%).

The ranges of age were 1mto3/5 years old in 2010-2011 and 1m to 5 years old in 2011-2012. Our patients died more in nights than days. (Table 2).

Table2: distribution of diurnal death in our patients in PICU at Boali hospital form march2010 to march2012.

 

Year

Time of diurnal death

8Am-14

N(%)

14-20

N(%)

20-7Am

N(%)

Total

N(%)

2010-2011

11 (18)

8 (13)

16 (26)

35 (56)

2011-2012

6 (9)

8 (13)

13 (21)

27 (44)

Total

17 (27)

16 (26)

29 (47)

62 (100)

 

Location of life in our died patients were 13 cases (57%) from sari and other (n=6) 43% from ghaemshar were more common in 2010-2011 but were 20 cases from sari (74%) and 7 cases (26%) from other cities in 2010-2012.

The way of transport in our patients in 2010-2011; 17 cases by their family (direct) (49%) and other (18) 51% by heath care centers (hospital`s ambulance) by   registries. In 2011-2012, 14 cases (52%) were transport by their family (direct) and others (n=13) 48% by ambulance from other hospital due to registration. Transport by intubation was 12 cases (34%) in 2010-2012 and 15 cases (55%) in 2011-2012.

Etiology of disorders in our patients was neurologic disorders were common (31%) than metabolic disorders (14%) and leukemia (11%).  Hematologic disorders with malignancies (26%) then  with less common anomaly disorders (20%) and GT tract disorders (14%) was in 2010-2011. In all of patients, etiology of basal disorder includes: neurologic (n=15), Metabolic (n=8), Hematologic and oncology (n=13), heart (n=7), Pulmonary (n=5), Poisoning (n=3), GT tract (n=5), immunodeficiency (n=2), renal (n=1) and Skin (n=1).

Duration of admission was variable form 1 to 90 days (table 3).

Table-3: duration of admission in died cases in PICU at Boali hospital in 2010 -2012.

Duration of admission

(days)

2010-2011

2011-2012

Total

N (%)

1-2

10

9

19 (30)

3-7

8

8

16 (26)

8-14

3

2

5 (8)

15-30

3

2

7 (11)

˃ 30

9

6

15 (24)

Total

35

27

62 (100)

 Table 4- distribution of gender, age, transport, etiology, time of death and complication in PICU at Boali hospital in 2010-2011.

number

gender

Age

(month)

transport

diagnose

Time of death

complication

1

M

19

D

Cerebral Palsy

4 Am

Respiratory distress

2

F

2

D

CIC

15.45

Sepsis

3

M

1

A

hydrocephaly RDS

22

Respiratory failure

4

F

7

D

CHS

17

Sepsis

5

F

1

A

RDS

5.45 Am

Peritonitis

6

F

2

A

Coarctation of Aorta

11

Heart failure

7

M

16

D

CHD

3.30 Am

Heart failure

8

M

5

D

Duncan syndrome

14

Sepsis

9

F

5

A

Hirsh prong

12 Am

sepsis

10

F

31

D

CHD

10 Am

Heart failure

11

M

55

D

Adrenal insufficiency

11.30

shock

12

M

29

A

Acute Meylogenic Leukemia

13.15

sepsis

13

F

8

D

Drug poisoning

14

shock

14

M

42

D

FELS

13.30

Sepsis

15

M

5

D

ALL

19.45

Sepsis

16

F

3

A

ALL

20.30

Sepsis

17

F

46

A

Verding Hoffman

1 Am

Pneumonia

18

M

3

A

ALL

5 Am

Sepsis,DIC

19

F

7.5

D

Pure red cell aplasia

16

Sepsis

20

M

11

A

CHD,metabolic

7.30

Pneumonia

21

M

56

D

ALL

2.30

DIC

22

M

3

A

Nephrotic syndrome

5

Sepsis

23

M

21

A

Viral encephalitis

11.40

Brain death

24

F

4

D

Hepatic failure

4

Respiratory failure

25

M

15

A

Metabolic

17

DIC

26

M

12

D

Esophageal Atresia

10

Pneumonia

27

F

53

D

Gushe  disease

3.45

DIC

28

M

11

A

Opioid poisoning

9.35

DIC

29

F

5

A

metabolic

5

Sepsis

30

M

6

D

ToF

17

Heart failure

31

M

2

A

CHD

15.30

DIC

32

F

23

D

Biliary atresia

14.35

Sepsis

33

F

7

D

Cardiomyopathy

21.30

DIC

34

F

54

D

Brain tumor

7.15

Brain abscesses

35

F

9

A

ALL

24

sepsis

 F=Female M=Male A=ambulance D= Direct ALL=acute lymphocytic leukemia DIC=disseminated intravascular coagulopathy CHD=congenital heart disease ToF=tetralogy of falot  RDS=respiratory disseminated syndrome   FELS=fetal erythrohemophagocytic syndrome

 Table 5- distribution of gender, age, transport, etiology, time of death and complication in PICU at Boali hospital in 2011-2012.

 

number

gender

age

transport

diagnose

Time of death

Complication

1

M

8

D

Multiple anomaly

17.20

Renal failure

2

F

60

D

Dandy walker

17.30

sepsis

3

M

30

D

Leukodystrophy

23

pneumonia

4

M

3

A

Metabolic

22.35

Sepsis

5

M

3

A

Metabolic

19.30

pneumonia

6

F

4

D

Hydrocephaly

14.30

Respiratory failure

7

M

9

D

HUS

14.20

Shock

8

F

18

D

Phagocytic syndrome

14.40

Sepsis

9

F

60

D

Neuroblastoma

5.15

DIC

10

F

7

D

Werding haffman

13.30

pneumonia

11

M

60

A

Opioid poisoning

7

Respiratory  failure

12

F

11

D

Brain anomaly

15.30

Respiratory failure

13

M

6

D

Metabolic

7.30

Sepsis

14

M

39

D

HUS

4.20

Sepsis

15

M

2

A

Metabolic

21

Shock

16

F

3

A

Multiple anomaly

Hirsh prong

10

Heart failure

17

F

4

D

Epidermolysis bullosa

11

Septic shock

18

F

14

D

Metabolic

5.30

Encephalitis

19

F

9

D

CHD,hydrocephaly

23

Heart failure

20

F

8

D

Meningitis

1

Shock

21

F

5

D

Down syndrome

10.30

pneumonia

22

F

3

A

Cystic Fibrosis

13.40

pneumonia

23

F

1

D

Chronic lung disease

3

pneumonia

24

F

6

A

Werding Hoffman

4

pneumonia

25

F

2

A

Metabolic disorder

11.30

sepsis

26

M

25

D

Brain anomaly

22.30

DIC

27

M

2

A

Brain anomaly

22.45

Respiratory failure

CHD=congenital heart disease HUS=hemolytic uremic syndrome DIC= disseminated intravascular coagulopathy  A=Ambulance  D=Direct   M=Male  F=Female

Discussion:

Our study showed PICU mortality in our setting was higher than many other countries in the world (6/6%). Of course, this center is in the capital of mazandaran province in the north of Iran and it is a referral center for other cities and registries of more serious disease. We think, low mortally rate related to professional nursing, different children subspecialists physician, and adequate devices such as ventilators. In our study 22 cases (2.34%) were died with duration of admission more than 14 days and 35 cases (3.73%) died in first 7 days admission, but Naghib at al showed 4.6% mortality rate in their PICU patients (8) that in 22% of patients had more than 28 days (long stay admission). The mortality rate was lower in patientswith 7-14 days admission than before or after it in our study. There is not significant difference mortality rate between two genders (3/2% in male verse 3/4% in female). Therefore, both gender propose equally have mortality rate in a PICU center(7). Sands et al showed 5.1% mortality rate in their PICU center (9). Overall, the mortality rate in PICU was4-6 % in American (10), 7.3% in Canada and 5.8% in Europe.  Etiology of death is important for family and heath care politic managers. Out of 62 cases died in our center, 31 patients had congenital anomaly (50%), is the most common causes of mortality. These anomalies including: hematologic (n=15) 14%; metabolic (n=8) 13%; heart (n=7) 11% and skin (n=1) 1.6%. Among the hematologic and oncologic disorders (the most common etiology of death) in our center leukemia and pancytopenia was more common (n=13) 21% but in Naghib`s study, congenital anomalies with 28%, and heart disease with 28% were more common (8).sands et al showed infections and trauma each with 19.6% were more common etiology of death in PICU center and congenital anomaly (17.2%) and malignancy 16.2% were in future statues (9). However, often of these studies showed that anomalies and malignancy were more etiology of mortality in PICU. We think, one of the reasons of high incidence of congenital anomaly in our region is familial marriage. Therefore, for make lower anomalies, the government heath care managers should be take to suitable decision .Increased knowledge of general population, physicians (General practitioner, specialist and subspecialist) and heath care personals. Also, prenatal diagnosis will be improved and make a good law for abortion for congenital anomaly that they have poor prognosis.

Mean of ages of died patents in our study were 15.5 month but in sands study was 3 years old. However, in more study this was variable between 8months to 2.6 years old (10,11). Often of died patients in our study had age under 1 year (n=42) 68% higher than sands study (27.9%). However, it is expected that mortality rate is more common in infant than older children. (3,10) Duration of stay is important because serious and sever disease cases rapid and more mortality. According to our study, more mortality rate was in first 7 days is similar with other studies(12,13).

Therefore, this is a clear reason that showed often of PICU patients had very severe condition when received to PICU. Drug discontinue cause 13 to 55% mortality rate in PICU patients (9,12,14). In our culture, we did not it even in one patient but this was reported 5% in Malaysia (15). The main etiology of mortality in our patients were pneumonia and sepsis (n=18) 29% and DIC (n=17) 27% that is similar with other study such as Bilan that showed multiorgan dysfunctions (50%), sepsis 20% and DIC 10% (16).

Bilan reported respiration disorder (30%). Neurology (28%) and cardiovascular 16% involved more common etiology of PICU admission .  in this study morality rate was 60% in male and 40% in female with mean age 33.83month .50% mortally was in under1 year and 50% was higher than1 year age with mean duration of admission 5 days(16).

Elnawany showed 38% PICU mortality (17).but in India this was 35% ( 18) and in Argentina was lower (2.6%) (19). In Marcin study, 2.1 to 8.1% of PICU patient had been long stay admission. Outcome was not very well. Their age was lower and need more care(2).

Pollack et al showed children with more stay in PICU (more than 13 days), had lower ages and severe diseases. Also, chronic diseases were more common. They had more mortality rate in PICU (17.4% verse 7.3%). also, hospital mortality rate is more common (23.9% verse 8.7%) than they have short stay admission.  50% of PICU care related to these patients(20).

Gemke in a multi center study showed mean7.1% mortality rate (range1-10%) in PICU patients. one of the reasons of variant rate of mortality related the different severity of disorders(21).  

Vander Heide et al showed more common complication in the patients with stay more than 30 days admission than short study admission (2.9% verse1.2).Infection complication were more common (5%) but mortality rate was not significant between two groups (31.8 verse 26.7, P=0/54). However, more stay accompanied with more complications (22).

Campos Mino et al in Latin American countries showed 13.29% mean mortality rate in PICU but it is 5% in Europa. Cuba with 5.2% and Honduras with 25% was lowest and highest rates. In Spain and Portugal was 4% and 6% respectively (10).

In conclusion, our result is similar with other developed countries or higher level of medical care. Different subspecialists, pediatrics resident associated with professional nursing could be a significant decrease in PICU mortality rate.

Acknowledgment:

We thanks from all of PICU nurses of Buali hospital and Mr Tajvar for their cooperation.

Conflict of interest: No declared

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