Acute Neurologic Dysfunction in Critically Ill Children: The PODIUM Consensus Conference

CONTEXT Acute neurologic dysfunction is common in critically ill children and contributes to outcomes and end of life decision-making. OBJECTIVE To develop consensus criteria for neurologic dysfunction in critically ill children by evaluating the evidence supporting such criteria and their association with outcomes. DATA SOURCES Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020, by using a combination of medical subject heading terms and text words to define concepts of neurologic dysfunction, pediatric critical illness, and outcomes of interest. STUDY SELECTION Studies were included if the researchers evaluated critically ill children with neurologic injury, evaluated the performance characteristics of assessment and scoring tools to screen for neurologic dysfunction, and assessed outcomes related to mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. Studies with an adult population or premature infants (≤36 weeks' gestational age), animal studies, reviews or commentaries, case series with sample size ≤10, and studies not published in English with an inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were abstracted from each study meeting inclusion criteria into a standard data extraction form by task force members. DATA SYNTHESIS The systematic review supported the following criteria for neurologic dysfunction as any 1 of the following: (1) Glasgow Coma Scale score ≤8; (2) Glasgow Coma Scale motor score ≤4; (3) Cornell Assessment of Pediatric Delirium score ≥9; or (4) electroencephalography revealing attenuation, suppression, or electrographic seizures. CONCLUSIONS We present consensus criteria for neurologic dysfunction in critically ill children.

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Gastrointestinal Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

PEDIATRICS ◽

10.1542/peds.2021-052888h ◽

2022 ◽

Vol 149 (Supplement_1) ◽

pp. S53-S58

Author(s):

Katri V. Typpo ◽

Sharon Y. Irving ◽

Jose M. Prince ◽

Nazima Pathan ◽

Ann-Marie Brown

Keyword(s):

Critical Illness ◽

Critically Ill ◽

Task Force ◽

Data Extraction ◽

Case Series ◽

Current Evidence ◽

Abdominal Radiograph ◽

Critically Ill Children ◽

Gastrointestinal Dysfunction ◽

Plain Abdominal Radiograph

CONTEXT Prior criteria to define pediatric multiple organ dysfunction syndrome (MODS) did not include gastrointestinal dysfunction. OBJECTIVES Our objective was to evaluate current evidence and to develop consensus criteria for gastrointestinal dysfunction in critically ill children. DATA SOURCES Electronic searches of PubMed and EMBASE were conducted from January 1992 to January 2020, using medical subject heading terms and text words to define gastrointestinal dysfunction, pediatric critical illness, and outcomes. STUDY SELECTION Studies were included if they evaluated critically ill children with gastrointestinal dysfunction, performance characteristics of assessment/scoring tools to screen for gastrointestinal dysfunction, and assessed outcomes related to mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. Studies of adults or premature infants, animal studies, reviews/commentaries, case series with sample size ≤10, and non-English language studies with inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were abstracted from each eligible study into a standard data extraction form along with risk of bias assessment by a task force member. RESULTS The systematic review supports the following criteria for severe gastrointestinal dysfunction: 1a) bowel perforation, 1b) pneumatosis intestinalis, or 1c) bowel ischemia, present on plain abdominal radiograph, computed tomography (CT) scan, magnetic resonance imaging (MRI), or gross surgical inspection, or 2) rectal sloughing of gut mucosa. LIMITATIONS The validity of the consensus criteria for gastrointestinal dysfunction are limited by the quantity and quality of current evidence. CONCLUSIONS Understanding the role of gastrointestinal dysfunction in the pathophysiology and outcomes of MODS is important in pediatric critical illness.

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Respiratory Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

PEDIATRICS ◽

10.1542/peds.2021-052888g ◽

2022 ◽

Vol 149 (Supplement_1) ◽

pp. S48-S52

Author(s):

Nadir Yehya ◽

Robinder G. Khemani ◽

Simon Erickson ◽

Lincoln S. Smith ◽

Courtney M. Rowan ◽

...

Keyword(s):

Critically Ill ◽

Data Extraction ◽

Case Series ◽

Consensus Conference ◽

Small Sample ◽

Critically Ill Children ◽

Evidence Based ◽

Sample Sizes ◽

Eligibility Criteria ◽

Respiratory Dysfunction

CONTEXT Respiratory dysfunction is a component of every organ failure scoring system developed, reflecting the significance of the lung in multiple organ dysfunction syndrome. However, existing systems do not reflect current practice and are not consistently evidence based. OBJECTIVE We aimed to review the literature to identify the components of respiratory failure associated with outcomes in children, with the purpose of developing an operational and evidence-based definition of respiratory dysfunction. DATA SOURCES Electronic searches of PubMed and Embase were conducted from 1992 to January 2020 by using a combination of medical subject heading terms and text words to define respiratory dysfunction, critical illness, and outcomes. STUDY SELECTION We included studies of critically ill children with respiratory dysfunction that evaluated the performance of metrics of respiratory dysfunction and their association with patient-centered outcomes. Studies in adults, studies in premature infants (≤36 weeks’ gestational age), animal studies, reviews and commentaries, case series with sample sizes ≤10, and studies not published in English in which we were unable to determine eligibility criteria were excluded. DATA EXTRACTION Data were abstracted into a standard data extraction form. RESULTS We provided binary (no or yes) and graded (no, nonsevere, or severe) definitions of respiratory dysfunction, prioritizing oxygenation and respiratory support. The proposed criteria were approved by 82% of members in the first round, with a score of 8 of 9 (interquartile range 7–8). LIMITATIONS Exclusion of non-English publications, heterogeneity across the pediatric age range, small sample sizes, and incomplete handling of confounders are limitations. CONCLUSIONS We propose definitions for respiratory dysfunction in critically ill children after an exhaustive literature review.

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Hematologic Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

PEDIATRICS ◽

10.1542/peds.2021-052888k ◽

2022 ◽

Vol 149 (Supplement_1) ◽

pp. S74-S78

Author(s):

Jennifer A. Muszynski ◽

Jill M. Cholette ◽

Marie E. Steiner ◽

Marisa Tucci ◽

Allan Doctor ◽

...

Keyword(s):

Platelet Count ◽

Critically Ill ◽

Organ Dysfunction ◽

English Language ◽

Data Extraction ◽

Case Series ◽

Hemoglobin Concentration ◽

Consensus Conference ◽

Data Sources ◽

Critically Ill Children

CONTEXT Studies of organ dysfunction in children are limited by a lack of consensus around organ dysfunction criteria. OBJECTIVES To derive evidence-informed, consensus-based criteria for hematologic dysfunction in critically ill children. DATA SOURCES Data sources included PubMed and Embase from January 1992 to January 2020. STUDY SELECTION Studies were included if they evaluated assessment/scoring tools to screen for hematologic dysfunction and assessed outcomes of mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. Studies of adults or premature infants, animal studies, reviews/commentaries, small case series, and non-English language studies with inability to determine eligibility were excluded. DATA EXTRACTION Data were abstracted from each eligible study into a standard data extraction form along with risk of bias assessment. RESULTS Twenty-nine studies were included. The systematic review supports the following criteria for hematologic dysfunction: thrombocytopenia (platelet count <100000 cells/µL in patients without hematologic or oncologic diagnosis, platelet count <30000 cells/µL in patients with hematologic or oncologic diagnoses, or platelet count decreased ≥50% from baseline; or leukocyte count <3000 cells/µL; or hemoglobin concentration between 5 and 7 g/dL (nonsevere) or <5 g/dL (severe). LIMITATIONS Most studies evaluated pre-specified thresholds of cytopenias. No studies addressed associations between the etiology or progression of cytopenias overtime with outcomes, and no studies evaluated cellular function. CONCLUSIONS Hematologic dysfunction, as defined by cytopenia, is a risk factor for poor outcome in critically ill children, although specific threshold values associated with increased mortality are poorly defined by the current literature.

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Immune System Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

PEDIATRICS ◽

10.1542/peds.2021-052888n ◽

2022 ◽

Vol 149 (Supplement_1) ◽

pp. S91-S98

Author(s):

Mark W. Hall ◽

Joseph A. Carcillo ◽

Timothy Cornell

Keyword(s):

Immune System ◽

Critically Ill ◽

Lymphocyte Count ◽

Task Force ◽

Ex Vivo ◽

Data Extraction ◽

Case Series ◽

Adverse Outcomes ◽

Critically Ill Children ◽

Immune System Dysfunction

CONTEXT Immune system dysfunction is poorly represented in pediatric organ dysfunction definitions. OBJECTIVE To evaluate evidence for criteria that define immune system dysfunction in critically ill children and associations with adverse outcomes and develop consensus criteria for the diagnosis of immune system dysfunction in critically ill children. DATA SOURCES We conducted electronic searches of PubMed and Embase from January 1992 to January 2020, using medical subject heading terms and text words to define immune system dysfunction and outcomes of interest. STUDY SELECTION Studies of critically ill children with an abnormality in leukocyte numbers or function that is currently measurable in the clinical laboratory in which researchers assessed patient-centered outcomes were included. Studies of adults or premature infants, animal studies, reviews and commentaries, case series (≤10 subjects), and studies not published in English with inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were abstracted from eligible studies into a standard data extraction form along with risk of bias assessment by a task force member. RESULTS We identified the following criteria for immune system dysfunction: (1) peripheral absolute neutrophil count <500 cells/μL, (2) peripheral absolute lymphocyte count <1000 cells/μL, (3) reduction in CD4+ lymphocyte count or percentage of total lymphocytes below age-specific thresholds, (4) monocyte HLA-DR expression <30%, or (5) reduction in ex vivo whole blood lipopolysaccharide-induced TNFα production capacity below manufacturer-provided thresholds. LIMITATIONS Many measures of immune system function are currently limited to the research environment. CONCLUSIONS We present consensus criteria for the diagnosis of immune system dysfunction in critically ill children.

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Scoring Systems for Organ Dysfunction and Multiple Organ Dysfunction: The PODIUM Consensus Conference

PEDIATRICS ◽

10.1542/peds.2021-052888d ◽

2022 ◽

Vol 149 (Supplement_1) ◽

pp. S23-S31

Author(s):

Luregn J. Schlapbach ◽

Scott L. Weiss ◽

Melania M. Bembea ◽

Joseph A. Carcillo ◽

Francis Leclerc ◽

...

Keyword(s):

Critically Ill ◽

Organ Dysfunction ◽

Data Extraction ◽

Severity Of Illness ◽

Scoring Systems ◽

Multiple Organ ◽

Consensus Conference ◽

Critically Ill Children ◽

Multiple Organ Dysfunction ◽

Scoring Tools

CONTEXT Multiple scores exist to characterize organ dysfunction in children. OBJECTIVE To review the literature on multiple organ dysfunction (MOD) scoring systems to estimate severity of illness and to characterize the performance characteristics of currently used scoring tools and clinical assessments for organ dysfunction in critically ill children. DATA SOURCES Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020. STUDY SELECTION Studies were included if they evaluated critically ill children with MOD, evaluated the performance characteristics of scoring tools for MOD, and assessed outcomes related to mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. DATA EXTRACTION Data were abstracted into a standard data extraction form by a task force member. RESULTS Of 1152 unique abstracts screened, 156 full text studies were assessed including a total of 54 eligible studies. The most commonly reported scores were the Pediatric Logistic Organ Dysfunction Score (PELOD), pediatric Sequential Organ Failure Assessment score (pSOFA), Pediatric Index of Mortality (PIM), PRISM, and counts of organ dysfunction using the International Pediatric Sepsis Definition Consensus Conference. Cut-offs for specific organ dysfunction criteria, diagnostic elements included, and use of counts versus weighting varied substantially. LIMITATIONS While scores demonstrated an increase in mortality associated with the severity and number of organ dysfunctions, the performance ranged widely. CONCLUSIONS The multitude of scores on organ dysfunction to assess severity of illness indicates a need for unified and data-driven organ dysfunction criteria, derived and validated in large, heterogenous international databases of critically ill children.

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Renal Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

PEDIATRICS ◽

10.1542/peds.2021-052888j ◽

2022 ◽

Vol 149 (Supplement_1) ◽

pp. S66-S73

Author(s):

Julie C. Fitzgerald ◽

Rajit K. Basu ◽

Dana Y. Fuhrman ◽

Stephen M. Gorga ◽

Amanda B. Hassinger ◽

...

Keyword(s):

Serum Creatinine ◽

Renal Dysfunction ◽

Critically Ill ◽

Urine Output ◽

Data Extraction ◽

Case Series ◽

Adverse Outcomes ◽

Assessment Tools ◽

Current Evidence ◽

Critically Ill Children

CONTEXT Renal dysfunction is associated with poor outcomes in critically ill children. OBJECTIVE To evaluate the current evidence for criteria defining renal dysfunction in critically ill children and association with adverse outcomes. To develop contemporary consensus criteria for renal dysfunction in critically ill children. DATA SOURCES PubMed and Embase were searched from January 1992 to January 2020. STUDY SELECTION Included studies evaluated critically ill children with renal dysfunction, performance characteristics of assessment tools for renal dysfunction, and outcomes related to mortality, functional status, or organ-specific or other patient-centered outcomes. Studies with adults or premature infants (≤36 weeks' gestational age), animal studies, reviews, case series, and studies not published in English with inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were extracted from included studies into a standard data extraction form by task force members. RESULTS The systematic review supported the following criteria for renal dysfunction: (1) urine output <0.5 mL/kg per hour for ≥6 hours and serum creatinine increase of 1.5 to 1.9 times baseline or ≥0.3 mg/dL, or (2) urine output <0.5 mL/kg per hour for ≥12 hours, or (3) serum creatinine increase ≥2 times baseline, or (4) estimated glomerular filtration rate <35 mL/minute/1.73 m2, or (5) initiation of renal replacement therapy, or (6) fluid overload ≥20%. Data also support criteria for persistent renal dysfunction and for high risk of renal dysfunction. LIMITATIONS All included studies were observational and many were retrospective. CONCLUSIONS We present consensus criteria for renal dysfunction in critically ill children.

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Coagulation Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

PEDIATRICS ◽

10.1542/peds.2021-052888l ◽

2022 ◽

Vol 149 (Supplement_1) ◽

pp. S79-S83

Author(s):

E. Vincent S. Faustino ◽

Oliver Karam ◽

Robert I. Parker ◽

Sheila J. Hanson ◽

Leonardo R. Brandão ◽

...

Keyword(s):

Critical Illness ◽

Critically Ill ◽

Limit Of Detection ◽

Task Force ◽

Data Extraction ◽

Adverse Outcomes ◽

Current Evidence ◽

Critically Ill Children ◽

Upper Limit ◽

Coagulation Dysfunction

CONTEXT Previous criteria for coagulation dysfunction in critically ill children were based mainly on expert opinion. OBJECTIVE To evaluate current evidence regarding coagulation tests associated with adverse outcomes in children to inform criteria for coagulation dysfunction during critical illness. DATA SOURCES Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020 by using a combination of medical subject heading terms and text words to define concepts of coagulation dysfunction, pediatric critical illness, and outcomes of interest. STUDY SELECTION Studies were included if critically ill children with coagulation dysfunction were evaluated, if performance characteristics of assessment and/or scoring tools to screen for coagulation dysfunction were evaluated, and if outcomes related to mortality or functional status, organ-specific outcomes, or other patient-centered outcomes were assessed. DATA EXTRACTION Data were abstracted from each eligible study into a standard data extraction form, along with risk of bias assessment, by a task force member. RESULTS The systematic review supports the presence of at least 2 of the following criteria reflecting coagulation dysfunction in the absence of liver dysfunction: platelet count <100 000 cells per μL, international normalized ratio >1.5, fibrinogen level <150 mg/dL, and D-dimer value above 10 times the upper limit of normal, or above the assay’s upper limit of detection if this limit is below 10 times the upper limit of normal. LIMITATIONS The proposed criteria for coagulation dysfunction are limited by the available evidence and will require future validation. CONCLUSIONS Validation of the proposed criteria and identified scientific priorities will enhance our understanding of coagulation dysfunction in critically ill children.

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