Aziz Khyzer B, Boss Renee D, Yarborough Christina C, Raisanen Jessica C, Neubauer Kathryn, Donohue Pamela K
Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland, USA.
J Pain Symptom Manage. 2021 Apr;61(4):763-769. doi: 10.1016/j.jpainsymman.2020.09.016. Epub 2020 Sep 15.
Most pediatric deaths occur in an intensive care unit, and treatment specific predictors of mortality could help clinicians and families make informed decisions.
To investigate whether the intensity of vasopressor therapy for pediatric patients, regardless of diagnosis, predicts in-hospital mortality.
Single-center, retrospective medical chart review of children aged 0-17 who were admitted between 2005 and 2015 at a pediatric tertiary care center in the U.S. and received any vasopressor medication-dopamine, dobutamine, epinephrine, vasopressin, norepinephrine, or hydrocortisone.
During the 10-year period, 1654 patients received at least one vasopressor medication during a hospitalization. Median age at the time of hospitalization was three months, and the median duration of hospitalization was 23 days; 8% of patients had two to five hospitalizations in which they received vasopressors. There were 176 total patients who died while receiving vasopressors; most (93%) died during their first hospitalization. The most common diagnosis was sepsis (34%), followed by congenital heart disease (17%). Dopamine was the most commonly prescribed first-line vasopressor (70%), and hydrocortisone was the most commonly prescribed second-line vasopressor (49%) for all pediatric patients. The incidence of mortality rose sequentially with escalating vasopressor support, increasing from under 10% with the first vasopressor to 48% at the maximum number of agents. The odds of death almost doubled with the addition of each new vasopressor.
The intensity of vasopressor therapy for pediatric patients, regardless of diagnosis, is associated with in-hospital mortality; vasopressor escalation should trigger intensive palliative care supports.
大多数儿科死亡发生在重症监护病房，特定治疗的死亡率预测指标有助于临床医生和家属做出明智决策。
探讨无论诊断如何，儿科患者血管活性药物治疗强度是否可预测住院死亡率。
对2005年至2015年间在美国一家儿科三级护理中心住院的0至17岁儿童进行单中心回顾性病历审查，这些儿童接受了任何血管活性药物——多巴胺、多巴酚丁胺、肾上腺素、血管加压素、去甲肾上腺素或氢化可的松。
在这10年期间，1654例患者在住院期间至少接受了一种血管活性药物治疗。住院时的中位年龄为3个月，中位住院时间为23天；8%的患者有2至5次住院并接受了血管活性药物治疗。共有176例患者在接受血管活性药物治疗期间死亡；大多数（93%）在首次住院期间死亡。最常见的诊断是脓毒症（34%），其次是先天性心脏病（17%）。对于所有儿科患者，多巴胺是最常用的一线血管活性药物（70%），氢化可的松是最常用的二线血管活性药物（49%）。死亡率随着血管活性药物支持强度的增加而依次上升，从第一种血管活性药物使用时的不到10%增加到最大用药数量时的48%。每增加一种新的血管活性药物，死亡几率几乎翻倍。
无论诊断如何，儿科患者血管活性药物治疗强度与住院死亡率相关；血管活性药物升级应引发强化姑息治疗支持。
