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

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

PEDIATRICS ◽

10.1542/peds.2021-052888e ◽

2022 ◽

Vol 149 (Supplement_1) ◽

pp. S32-S38

Author(s):

Mark S. Wainwright ◽

Kristin Guilliams ◽

Sujatha Kannan ◽

Dennis W. Simon ◽

Robert C. Tasker ◽

...

Keyword(s):

Glasgow Coma Scale ◽

Critically Ill ◽

Task Force ◽

Data Extraction ◽

Adult Population ◽

Case Series ◽

Consensus Conference ◽

Critically Ill Children ◽

Coma Scale ◽

Neurologic Dysfunction

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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Cystatin C- an early marker indicative of renal dysfunction in critically ill children: a prospective cohort study

International Journal of Contemporary Pediatrics ◽

10.18203/2349-3291.ijcp20193709 ◽

2019 ◽

Vol 6 (5) ◽

pp. 1981

Author(s):

Hawwa M.S. Siddiqua ◽

Mathew John ◽

V. C. Manoj ◽

Rati Santhakumar

Keyword(s):

Acute Kidney Injury ◽

Cohort Study ◽

Serum Creatinine ◽

Renal Dysfunction ◽

Critically Ill ◽

Cystatin C ◽

Prospective Cohort ◽

Kidney Injury ◽

Critically Ill Children ◽

Serum And Urine

Background: Acute kidney injury (AKI) is a sudden onset of kidney failure or kidney damage that happens within a few hours or a few days and can also affect other organs such as brain, heart and the lungs. Hence early diagnosis and intervention is needed to improve the outcome of the children. In these studies this objective was to determine if cystatin C is an early marker indicative of renal dysfunction in critically ill children and to determine if Cystatin C can detect Acute kidney injury earlier than serum creatinine.Methods: This prospective cohort study was undertaken in PICU at Jubilee Mission Medical College from December 2016- May 2018. Blood samples were collected from 34 critically ill children for serum creatinine estimation at 0,24 and 48 hours of admission and serum and urine were collected for cystatin C estimation at admission. Children were categorized into AKI and NON-AKI based on pRIFLE criteria. Comparison of cystatin C values with serum creatinine was performed and Statistical analysis was done using IBM SPSS version 20.Results: A total of 34 critically ill children were enrolled in this study, out of which 12 children progressed to AKI during the course of illness according to modified Pediatric Risk, Injury, Failure, Loss, End Stage Renal Disease (pRIFLE) criteria. We found a strong positive correlation between cystatin C at 0 hours and serum creatinine at 48 hours among AKI groups.Conclusions: Serum and Urine cystatin C are early markers to diagnose AKI in critically ill children. Serum cystatin C is more sensitive than urine cystatin C for the diagnosis of AKI.

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Iatrogenic Opioid Withdrawal in Critically Ill Patients: A Review of Assessment Tools and Management

Annals of Pharmacotherapy ◽

10.1177/1060028017724538 ◽

2017 ◽

Vol 51 (12) ◽

pp. 1099-1111 ◽

Cited By ~ 10

Author(s):

Ada W. Chiu ◽

Sofia Contreras ◽

Sangeeta Mehta ◽

Jennifer Korman ◽

Marc M. Perreault ◽

...

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Assessment Tool ◽

Data Extraction ◽

Management Strategies ◽

Pediatric Intensive Care ◽

Opioid Withdrawal ◽

Assessment Tools ◽

Critically Ill Children ◽

Reference List

Objective: To (1) provide an overview of the epidemiology, clinical presentation, and risk factors of iatrogenic opioid withdrawal in critically ill patients and (2) conduct a literature review of assessment and management of iatrogenic opioid withdrawal in critically ill patients. Data Sources: We searched MEDLINE (1946–June 2017), EMBASE (1974–June 2017), and CINAHL (1982–June 2017) with the terms opioid withdrawal, opioid, opiate, critical care, critically ill, assessment tool, scale, taper, weaning, and management. Reference list of identified literature was searched for additional references as well as www.clinicaltrials.gov . Study Selection and Data Extraction: We restricted articles to those in English and dealing with humans. Data Synthesis: We identified 2 validated pediatric critically ill opioid withdrawal assessment tools: (1) Withdrawal Assessment Tool–Version 1 (WAT-1) and (2) Sophia Observation Withdrawal Symptoms Scale (SOS). Neither tool differentiated between opioid and benzodiazepine withdrawal. WAT-1 was evaluated in critically ill adults but not found to be valid. No other adult tool was identified. For management, we identified 5 randomized controlled trials, 2 prospective studies, and 2 systematic reviews. Most studies were small and only 2 studies utilized a validated assessment tool. Enteral methadone, α-2 agonists, and protocolized weaning were studied. Conclusion: We identified 2 validated assessment tools for pediatric intensive care unit patients; no valid tool for adults. Management strategies tested in small trials included methadone, α-2 agonists, and protocolized sedation/weaning. We challenge researchers to create validated tools assessing specifically for opioid withdrawal in critically ill children and adults to direct management.

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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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Association Between Furosemide Exposure and Clinical Outcomes in a Retrospective Cohort of Critically Ill Children

Frontiers in Pediatrics ◽

10.3389/fped.2020.589124 ◽

2021 ◽

Vol 8 ◽

Author(s):

Xiaomei Dai ◽

Jiao Chen ◽

Wenjing Li ◽

Zhenjiang Bai ◽

Xiaozhong Li ◽

...

Keyword(s):

Clinical Outcomes ◽

Critically Ill ◽

Urine Output ◽

Conclusive Evidence ◽

Adverse Outcomes ◽

Critically Ill Children ◽

Multivariate Logistic Regression Model ◽

Fluid Accumulation ◽

Increased Risk ◽

The Impact

Furosemide is commonly prescribed in critically ill patients to increase the urine output and prevent fluid overload (FO) and acute kidney injury (AKI), but not supported by conclusive evidence. There remain conflicting findings on whether furosemide associates with AKI and adverse outcomes. Information on the impact of furosemide on adverse outcomes in a general population of pediatric intensive care unit (PICU) is limited. The aim of the cohort study was to investigate the associations of furosemide with AKI and clinical outcomes in critically ill children.Study Design: We retrospectively reviewed a cohort of 456 critically ill children consecutively admitted to PICU from January to December 2016. The exposure of interest was the use of furosemide in the first week after admission. FO was defined as ≥5% of daily fluid accumulation, and mean FO was considered significant when mean daily fluid accumulation during the first week was ≥5%. The primary outcomes were AKI in the first week after admission and mortality during PICU stay. AKI diagnosis was based on Kidney Disease: Improving Global Outcomes criteria with both serum creatinine and urine output.Results: Furosemide exposure occurred in 43.4% of all patients (n = 456) and 49.3% of those who developed FO (n = 150) in the first week after admission. Patients who were exposed to furosemide had significantly less degree of mean daily fluid accumulation than those who were not (1.10 [−0.33 to 2.61%] vs. 2.00 [0.54–3.70%], P < 0.001). There was no difference in the occurrence of AKI between patients who did and did not receive furosemide (22 of 198 [11.1%] vs. 36 of 258 [14.0%], P = 0.397). The mortality rate was 15.4% (70 of 456), and death occurred more frequently among patients who received furosemide than among those who did not (21.7 vs. 10.5%, P = 0.002). Furosemide exposure was associated with increased odds for mortality in a multivariate logistic regression model adjusted for body weight, gender, illness severity assessed by PRISM III score, the presence of mean FO, and AKI stage [adjusted odds ratio (AOR) 1.95; 95%CI, 1.08–3.52; P = 0.026].Conclusion: Exposure to furosemide might be associated with increased risk for mortality, but not AKI, in critically ill children.

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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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Acute Liver Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

PEDIATRICS ◽

10.1542/peds.2021-052888i ◽

2022 ◽

Vol 149 (Supplement_1) ◽

pp. S59-S65

Author(s):

James E. Squires ◽

Patrick J. McKiernan ◽

Robert H. Squires

Keyword(s):

Hepatic Encephalopathy ◽

Liver Transplant ◽

Critically Ill ◽

Organ Dysfunction ◽

Liver Dysfunction ◽

Data Extraction ◽

Chronic Liver ◽

Screening Tools ◽

Current Evidence ◽

Critically Ill Children

CONTEXT Develop evidence-based criteria for individual organ dysfunction. OBJECTIVES Evaluate current evidence and develop contemporary consensus criteria for acute liver dysfunction with associated outcomes in critically ill children. DATA SOURCES Electronic searches of PubMed and Embase conducted from January 1992 to January 2020, used medical subject heading terms and text words to characterize acute liver dysfunction and outcomes. STUDY SELECTION Studies evaluating critically ill children with acute liver dysfunction, assessed screening tools, and outcomes were included. Studies evaluating adults, infants ≤36 weeks gestational age, or animals or were reviews/commentaries, case series with sample size ≤10, or non-English language studies were excluded. DATA EXTRACTION Data were abstracted from each eligible study into a data extraction form along with risk of bias assessment by a task force member. RESULTS The systematic review supports criteria for acute liver dysfunction, in the absence of known chronic liver disease, as having onset of symptoms <8 weeks, combined with biochemical evidence of acute liver injury, and liver-based coagulopathy, with hepatic encephalopathy required for an international normalized ratio between 1.5 and 2.0. LIMITATIONS Unable to assess acute-on-chronic liver dysfunction, subjective nature of hepatic encephalopathy, relevant articles missed by reviewers. CONCLUSIONS Proposed criteria identify an infant, child, or adolescent who has reached a clinical threshold where any of the 3 outcomes (alive with native liver, death, or liver transplant) are possible and should prompt an urgent liaison with a recognized pediatric liver transplant center if liver failure is the principal driver of multiple organ dysfunction.

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