Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
Eur J Pediatr. 2019 Oct;178(10):1589-1596. doi: 10.1007/s00431-019-03446-0. Epub 2019 Sep 4.
Early recognition of critically ill patients is of paramount importance to reduce pediatric mortality and morbidity. We created a risk stratification system combining vital parameters and predefined risk factors aimed at reducing the risk of unrecognized clinical deterioration compared with conventional Pediatric Early Warning Systems (PEWS). This single-center retrospective case cohort study included infants (gestational age ≥ 37 weeks) to adolescents (aged <18 years) with unplanned pediatric intensive care unit (PICU) admission between April 01, 2014, and February 28, 2018. The sensitivity in the 24 h prior to endpoint of the Pediatric Risk Evaluation and Stratification System (PRESS) was compared with that of the conventional PEWS and calculated as the proportion of study patients who received a high-risk score. Seventy-four PICU admissions were included. PRESS and PEWS sensitivities at 2 h prior to endpoint were 0.70 (95%CI 0.59 to 0.80) and 0.30 (95%CI 0.20 to 0.42) respectively (p < 0.001). Excluding patients with seizures, PRESS sensitivity increased to 0.75 (95%CI 0.64 to 0.85). Forty-nine patients (66%) scored positive on at least one high-risk factor, and "worried sign" was scored in 31 patients (42%).Conclusion: Risk stratification seems advantageous for a faster detection of clinical deterioration, providing opportunity for earlier intervention. What is Known: • Prompt detection of clinical deterioration is of essential importance to reduce morbidity and mortality. • Conventional Pediatric Early Warning Systems (PEWS) have limited sensitivity and a short window of detection of 1 to 2 h. What is New: • Risk stratification based on context factors allows earlier identification of patients at risk, well before deviation of vital signs. • Risk stratification combined with continuous monitoring of deteriorating trends in vital signs could lead to the development of next-generation warning systems achieving true patient safety.
早期识别危重症患儿对于降低儿科病死率和发病率至关重要。我们创建了一个风险分层系统，将生命体征和预设的危险因素相结合，旨在降低与传统儿科早期预警系统（PEWS）相比临床恶化未被识别的风险。这项单中心回顾性病例队列研究纳入了 2014 年 4 月 1 日至 2018 年 2 月 28 日期间因计划外入住儿科重症监护病房（PICU）的婴儿（胎龄≥37 周）至青少年（年龄<18 岁）。在儿科风险评估和分层系统（PRESS）终点前 24 小时的敏感性与传统 PEWS 进行了比较，并计算为接受高风险评分的研究患者比例。共纳入 74 例 PICU 入院患者。PRESS 和 PEWS 在终点前 2 小时的敏感性分别为 0.70（95%CI 0.59 至 0.80）和 0.30（95%CI 0.20 至 0.42）（p<0.001）。排除癫痫发作患者后，PRESS 敏感性增加至 0.75（95%CI 0.64 至 0.85）。至少有 1 个高危因素评分阳性的患者 49 例（66%），“担心体征”评分 31 例（42%）。结论：风险分层似乎有利于更快地发现临床恶化，为更早的干预提供机会。已知：· 及时发现临床恶化对于降低发病率和死亡率至关重要。· 传统的儿科早期预警系统（PEWS）的敏感性有限，检测窗口为 1 至 2 小时。新发现：· 基于背景因素的风险分层可更早识别有风险的患者，远早于生命体征的偏差。· 将风险分层与生命体征恶化趋势的连续监测相结合，可能会开发出新一代预警系统，实现真正的患者安全。
