Department of Pediatrics, The Chinese University of Hong Kong, 6/F, Clinical Science Building, Prince of Wales Hospital, Shatin, Hong Kong, SAR, China.
BMC Anesthesiol. 2013 Nov 17;13(1):43. doi: 10.1186/1471-2253-13-43.
Etiologies of pediatric intensive care unit (PICU) mortality are diverse. This study aimed to investigate the pattern of PICU mortality in a regional trauma center, and explore factors associated with prolonged non-survival.
Demographic data of all PICU deaths in a regional trauma center were analyzed. Factors associated with prolonged nonsurvival (length of stay) were investigated with univariate log rank and multivariate Cox-Regression forward stepwise tests.
There were 88 deaths (males 61%; infants 23%) over 10 years (median PICU stay = 3.5 days, interquartile range: 1 and 11 days). The mean annual mortality rate of PICU admissions was 5.8%. Septicemia with gram positive, gram negative and fungal pathogens were present in 13 (16%), 13 (16%) and 4 (5%) of these patients, respectively. Viruses were isolated in 25 patients (28%). Ninety percent of these 88 patients were ventilated, 75% required inotropes, 92% received broad spectrum antibiotic coverage, 32% received systemic corticosteroids, 56% required blood transfusion and 39% received anticonvulsants. Thirty nine patients (44%) had a DNAR (Do-Not-Attempt-Resuscitation) order with their deaths at the PICU. Comparing with non-trauma category, trauma patients had higher mortality score, no premorbid disease, suffered asystole preceding PICU admission and subsequent brain death. Oncologic conditions were the most prevalent diagnosis in the non-trauma category. There was no gunshot or asthma death in this series. Prolonged non-survival was significantly associated with DNAR, fungal infections, and mechanical ventilation but negatively associated with bacteremia.
Death in the PICU is a heterogeneous event that involves infants and children. Resuscitation was not attempted at the time of their deaths in nearly half of the patients in honor of parents' wishes. Parents often make DNAR decision when medical futility becomes evident. They could be reassured that DNAR did not mean "abandoning" care. Instead, DNAR patients had prolonged PICU stay and received the same level of PICU supports as patients who did not respond to cardiopulmonary resuscitation.
儿科重症监护病房（PICU）死亡的病因多种多样。本研究旨在调查区域性创伤中心 PICU 死亡率的模式，并探讨与延长非生存时间相关的因素。
分析区域性创伤中心所有 PICU 死亡患者的人口统计学数据。使用单因素对数秩检验和多因素 Cox 回归向前逐步检验，探讨与延长非生存（住院时间）相关的因素。
在 10 年间共发生 88 例死亡（男性占 61%；婴儿占 23%）（中位 PICU 住院时间为 3.5 天，四分位间距为 1 天至 11 天）。PICU 入院患者的年平均死亡率为 5.8%。13 例（16%）、13 例（16%）和 4 例（5%）患者分别存在革兰阳性菌、革兰阴性菌和真菌病原体败血症。25 例患者分离出病毒。这些患者中 90%接受机械通气，75%需要使用正性肌力药物，92%接受广谱抗生素覆盖，32%接受全身皮质类固醇治疗，56%需要输血，39%接受抗惊厥药物治疗。88 例患者中有 39 例（44%）下达了 DNAR（不尝试复苏）医嘱，他们在 PICU 死亡。与非创伤组相比，创伤患者的死亡率评分更高，无前期疾病，在进入 PICU 前发生心搏骤停并随后发生脑死亡。肿瘤是非创伤组最常见的诊断。本系列中无枪击伤或哮喘死亡病例。延长非生存时间与 DNAR、真菌感染和机械通气显著相关，但与菌血症呈负相关。
PICU 死亡是一个异质性事件，涉及婴儿和儿童。在近一半的患者中，由于尊重父母的意愿，他们在死亡时没有进行复苏。当医疗无效变得明显时，父母通常会做出 DNAR 决定。他们可以放心，DNAR 并不意味着“放弃”治疗。相反，DNAR 患者的 PICU 住院时间延长，并接受与未对心肺复苏有反应的患者相同水平的 PICU 支持。
