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Open Access Research article

Prolonged non-survival in PICU: does a do-not-attempt-resuscitation order matter

Kam Lun E Hon1*, Terence Chuen Wai Poon1, William Wong1, Kin Kit Law2, Hiu Wing Mok2, Ka Wing Tam2, Wai Kin Wong2, Hiu Fung Wu2, Ka Fai To3, Kam Lau Cheung1, Hon Ming Cheung1, Ting Fan Leung1, Chi Kong Li1 and Alexander K C Leung4

Author Affiliations

1 Department of Pediatrics, The Chinese University of Hong Kong, 6/F, Clinical Science Building, Prince of Wales Hospital, Shatin, Hong Kong, SAR, China

2 Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong

3 Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong

4 Department of Pediatrics, The University of Calgary, 2500 University Dr NW, Calgary AB T2N 1N4, Canada

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BMC Anesthesiology 2013, 13:43  doi:10.1186/1471-2253-13-43

Published: 17 November 2013

Abstract

Background

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.

Methods

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.

Results

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.

Conclusions

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.

Keywords:
Bacteria; Fungus; PICU; Pediatric intensive care; Malignancy; Mortality; Oncology; PIM2; Sepsis; Trauma; Virus; Do-not-attempt-resuscitation (DNAR); Not-responding-to-cardiopulmonary-resuscitation (NRCPR); Brain death; Organ donation