Scientific Letter
Mortality and adequacy of therapeutic effort in a tertiary pediatric intensive care department: An 11-year review
Mortalidad y adecuación del esfuerzo terapéutico en un servicio terciario de cuidados intensivos pediátricos: revisión de 11 años
I. Leoz Gordillo, A. García-Salido
, C. Niño Taravilla, G. de Lama Caro-Patón, M.I. Iglesias Bouzas, A. Serrano González
Corresponding author
Servicio de Cuidados Intensivos Pediátricos, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Se describen con líneas continuas y de arriba hacia abajo: la mortalidad total, los pacientes en los que no se indica adecuación y los pacientes con adecuación del esfuerzo terapéutico. En línea discontinua se observan los pacientes en los que no consta la actitud al final de vida. En las diferentes barras de frecuencias se observa de izquierda a derecha en cada año: pacientes sanos, oncohematológicos, neurológicos, respiratorios e incluidos en el grupo “otros”.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I. Leoz Gordillo, A. García-Salido, C. Niño Taravilla, G. de Lama Caro-Patón, M.I. Iglesias Bouzas, A. Serrano González" "autores" => array:6 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Leoz Gordillo" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "García-Salido" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Niño Taravilla" ] 3 => array:2 [ "nombre" => "G." "apellidos" => "de Lama Caro-Patón" ] 4 => array:2 [ "nombre" => "M.I." 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Leoz Gordillo, A. García-Salido, C. Niño Taravilla, G. de Lama Caro-Patón, M.I. Iglesias Bouzas, A. Serrano González" "autores" => array:6 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Leoz Gordillo" ] 1 => array:4 [ "nombre" => "A." "apellidos" => "García-Salido" "email" => array:1 [ 0 => "citopensis@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Niño Taravilla" ] 3 => array:2 [ "nombre" => "G." "apellidos" => "de Lama Caro-Patón" ] 4 => array:2 [ "nombre" => "M.I." "apellidos" => "Iglesias Bouzas" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Serrano González" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cuidados Intensivos Pediátricos, Hospital Infantil Universitario Niño Jesús, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Mortalidad y adecuación del esfuerzo terapéutico en un servicio terciario de cuidados intensivos pediátricos: revisión de 11 años" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1917 "Ancho" => 3167 "Tamanyo" => 419249 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mortality per groups and end-of-life approach in the study period. The straight lines from up to bottom represent overall mortality, patients where the ATE remained unreported, and patients were the ATE was actually reported. The dotted lines represent patients were the end-of-life approach remained unreported. The different frequency bars show, from left to right, and per year: health patients, hemato-oncological patients, neurological patients, respiratory patients, and patients included in the group “other”.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the context of the critically ill child, the decisions that have to do with the adequacy of therapeutic effort (ATE) are, at the same time, cause for debate and reason for clinical interest. This is particularly the case in situations where the expected improvement has not occurred and technology is key for life support purposes.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1–3</span></a> At present, the medical literature that describes end-of-life care in pediatric intensive care units (PICU)<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> is scarce.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We hereby present a study that describes the characteristics of patients who have died in our PICU during the last decade. It is an observational retrospective study conducted after obtaining the approval from the clinical research ethics committee. The clinical reports of whose patients who died in the PICU from January 1 2006 through December 31 2016 were reviewed. The variables collected were: epidemiological, presence of underlying disease prior to PICU admission, cause for admission, care received (hemodynamic, respiratory, renal, antimicrobial, hematological and nutritional), main cause of death, days of stay at the PICU, day of admission, and adaptation of life support (cause, referral activity, and participation of the family in end-of-life care). A descriptive analysis of the answers was conducted using the SPSS<span class="elsevierStyleSup">®</span> 19.0 software for Windows. Qualitative data were expressed as absolute frequencies and percentages, and quantitative data as means and interquartile ranges or as means and standard deviations based on the characteristics of the variable under analysis. In cases where one comparative analysis was conducted, qualitative data were compared using the chi-square test. <span class="elsevierStyleItalic">p</span> values <0.05 were considered statistically significant.</p><p id="par0015" class="elsevierStylePara elsevierViewall">9049 children were reviewed of which 151 (1.7%) died; 147 patients (77 boys/70 girls) with an average age of 6.3 years old (IQR 0.05–21 years old) were included in the study. There were, on average, 13.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.4 deaths per year. Seventy-eight (78) out of the 147 patients had hemato-oncological conditions. Of the total number of patients with hemato-oncological conditions who died, 56/78 received one hematopoietic progenitor-cell transplantation (HPCT) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Thirty-six (36) patients did not have a clinically significant disease (24.5%).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The most common cause for admission was respiratory failure (55/147) followed by sepsis/serious infection (35/147). Patients without a personal clinical history were admitted to the PICU following severe trauma (11/36) and septic shock (7/36).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Hemodynamic support was used in 117/147 patients. In 45/147 patients non-invasive mechanical ventilation was required, while 138/147 patients required invasive mechanical ventilation; 70/147 patients suffered renal failure being extra-renal depuration required in 34/70 patients; 115/147 patients required transfusion of hemoderivatives and 60/136 patients parenteral nutrition.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The most common cause of death was refractory hypoxemia (51/146; in one patient the main cause for death was not reported) followed by sepsis (31/146) and brain death (31/146). In patients without a significant clinical history, brain death was the main cause of death (18/36); among the patients with hemato-oncological disease (43/78) the main cause of death was refractory hypoxemia.</p><p id="par0035" class="elsevierStylePara elsevierViewall">When it comes to the ATE, in 88 out of the 147 patients, this remained unexplained. The most common cause of death in the group without ATE was brain death (31/88) followed by sepsis/septic shock (26/88). In 41/59 of the remaining patients a report was given on the ATE as well as on why and what measures implemented. Twenty-seven (27) patients had hemato-oncological conditions being refractory hypoxemia the disease these measures were more commonly implemented against (22/41; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001). Only in 2 out of the 75 patients who died due to acute or sudden disease life support adequacy measures were implemented. Only in one patient without an underlying prior disease ATE measures were implemented. The ATE measures were more commonly implemented following hemodynamic instability (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.04), need for mechanical ventilation (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002), renal failure (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.01), parenteral nutrition (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) and transfusions of hemoderivatives (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.04).</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patients whose ATE was reported had longer hospital stays (22<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17 days versus 5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.7 days, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05). The reason why the ATE was implemented had to do with both the irreversibility of the disease that prompted the PICU admission (in 18 out of 41 patients) and the poor prognosis of the underlying disease (in 12 out of 41 patients). Both the hemodynamic and the ventilatory support were withdrawn in 8/41 patients. Measures focused on well-being, sedation and analgesia were a priority in 7/41 patients. It was decided not to implement any new extraordinary measures in 6/41 patients and in 4/41 patients any pharmacological therapy not aimed at improving the patient's well-being was withdrawn. In 16 patients, the therapeutic remains unknown. The family was informed at all time and involved in the decision-making process in 29/41 patients.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the series provided more than half of the patients who died suffered from hemato-oncological disease. In these, the HPCT was a prior common event.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> In turn, the ATE is often reported in patients with a prior condition and it would determine their prognosis prior to their referral to the PICU.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3,6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This decision was barely reported in healthy children or in severe and acute processes with a quick resolution.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The ATE was associated with longer hospital stays. Although we do not mean to say that in order to consider the ATE it was required that a “certain amount of time” would need to pass, it does seem that this aspect was key in the decision-making process. Refractory hypoxemia was the main cause of death in the group of patients where the ATE was reported.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Parents and caregivers were included in more than half the cases of ATE. It is well known that its perspective influences the therapeutic goal and defines well-being as a priority.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">This study has some limitations though. Except for epidemiological data, the remaining data were not collected thoroughly. They do not even include information on severity assessment scales at admission and in 4 patients no variable could be collected for the study. It would certainly be interesting to collect prospective and multicenter data with the exact time and moment when each change is implemented in the decision-making process.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In sum, given the specific conditions of our center, patients with onco-hematological conditions and, in particular, those with a prior history of HPCT are the main group of patients where the ATE was reported. Mainly, it was associated with long hospital stays, being the inotropic drug and ventilatory support withdrawal the most common measures implemented. We hope that this study will revitalize the debate and increase our actual knowledge on the ATE in the PICUs of our country. The creation of a national registry on this regard not only seems interesting but necessary.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Leoz Gordillo I, García-Salido A, Niño Taravilla C, de Lama Caro-Patón G, Iglesias Bouzas MI, Serrano González A. Mortalidad y adecuación del esfuerzo terapéutico en un servicio terciario de cuidados intensivos pediátricos: revisión de 11 años. Med Intensiva. 2018;42:561–563.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1917 "Ancho" => 3167 "Tamanyo" => 419249 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mortality per groups and end-of-life approach in the study period. The straight lines from up to bottom represent overall mortality, patients where the ATE remained unreported, and patients were the ATE was actually reported. The dotted lines represent patients were the end-of-life approach remained unreported. The different frequency bars show, from left to right, and per year: health patients, hemato-oncological patients, neurological patients, respiratory patients, and patients included in the group “other”.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[in Spanish]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Withdrawal of assisted ventilation in the home: making decisions in paediatric palliative care" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Garcia-Salido" 1 => "M. Monleon-Luque" 2 => "M. Barcelo-Escario" 3 => "C. del Rincon-Fernandez" 4 => "E. Cata-del Palacio" 5 => "R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 6 | 8 |
| 2024 October | 44 | 40 | 84 |
| 2024 September | 34 | 24 | 58 |
| 2024 August | 53 | 39 | 92 |
| 2024 July | 34 | 26 | 60 |
| 2024 June | 42 | 48 | 90 |
| 2024 May | 35 | 24 | 59 |
| 2024 April | 50 | 32 | 82 |
| 2024 March | 51 | 23 | 74 |
| 2024 February | 38 | 41 | 79 |
| 2024 January | 23 | 29 | 52 |
| 2023 December | 29 | 37 | 66 |
| 2023 November | 37 | 42 | 79 |
| 2023 October | 29 | 27 | 56 |
| 2023 September | 22 | 37 | 59 |
| 2023 August | 20 | 28 | 48 |
| 2023 July | 30 | 29 | 59 |
| 2023 June | 27 | 19 | 46 |
| 2023 May | 32 | 40 | 72 |
| 2023 April | 37 | 19 | 56 |
| 2023 March | 37 | 30 | 67 |
| 2023 February | 30 | 31 | 61 |
| 2023 January | 19 | 19 | 38 |
| 2022 December | 46 | 30 | 76 |
| 2022 November | 27 | 37 | 64 |
| 2022 October | 50 | 40 | 90 |
| 2022 September | 34 | 35 | 69 |
| 2022 August | 43 | 44 | 87 |
| 2022 July | 34 | 54 | 88 |
| 2022 June | 73 | 25 | 98 |
| 2022 May | 41 | 34 | 75 |
| 2022 April | 24 | 31 | 55 |
| 2022 March | 25 | 42 | 67 |
| 2022 February | 20 | 22 | 42 |
| 2022 January | 22 | 32 | 54 |
| 2021 December | 30 | 47 | 77 |
| 2021 November | 25 | 34 | 59 |
| 2021 October | 40 | 75 | 115 |
| 2021 September | 24 | 34 | 58 |
| 2021 August | 15 | 37 | 52 |
| 2021 July | 15 | 40 | 55 |
| 2021 June | 27 | 24 | 51 |
| 2021 May | 36 | 41 | 77 |
| 2021 April | 68 | 65 | 133 |
| 2021 March | 55 | 28 | 83 |
| 2021 February | 41 | 23 | 64 |
| 2021 January | 29 | 28 | 57 |
| 2020 December | 31 | 16 | 47 |
| 2020 November | 16 | 12 | 28 |
| 2020 October | 32 | 25 | 57 |
| 2020 September | 22 | 12 | 34 |
| 2020 August | 16 | 15 | 31 |
| 2020 July | 12 | 18 | 30 |
| 2020 June | 19 | 14 | 33 |
| 2020 May | 15 | 12 | 27 |
| 2020 April | 20 | 15 | 35 |
| 2020 March | 7 | 4 | 11 |
| 2020 February | 35 | 37 | 72 |
| 2020 January | 24 | 23 | 47 |
| 2019 December | 22 | 20 | 42 |
| 2019 November | 18 | 21 | 39 |
| 2019 October | 23 | 16 | 39 |
| 2019 September | 27 | 18 | 45 |
| 2019 August | 30 | 24 | 54 |
| 2019 July | 22 | 19 | 41 |
| 2019 June | 21 | 10 | 31 |
| 2019 May | 30 | 23 | 53 |
| 2019 April | 13 | 19 | 32 |
| 2019 March | 3 | 4 | 7 |
| 2019 February | 0 | 5 | 5 |
| 2019 January | 1 | 15 | 16 |
| 2018 December | 1 | 0 | 1 |
Show all
