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Pediatric rheumatic disease in the intensive care unit: Lessons learned from 15 years of experience in a tertiary care pediatric hospital

Radhakrishna, Suhas M. MD; Reiff, Andreas O. MD; Marzan, Katherine A. MD; Azen, Colleen MS; Khemani, Robinder G. MD, MsCI; Rubin, Sarah MD; Menteer, Jondavid MD; Brown, Diane E. MD; Shaham, Bracha MD

Pediatric Critical Care Medicine: May 2012 - Volume 13 - Issue 3 - p e181–e186
doi: 10.1097/PCC.0b013e318238955c
Online Clinical Investigations

Objective: This study describes the 15-yr experience of a large urban tertiary care children’s hospital in treating critically ill patients with pediatric rheumatic diseases.

Design: Retrospective case series.

Setting: Children’s Hospital Los Angeles, a large urban tertiary care children’s hospital.

Patients: All patients with pediatric rheumatic diseases admitted to the Children’s Hospital Los Angeles pediatric intensive care unit from January 1995 to July 2009.

Interventions: None.

Measurements and Main Results: An internal database and medical records were reviewed for demographics, diagnoses, treatments, organ dysfunction, interventions, infections, and outcomes. Standardized mortality ratio was calculated based on Pediatric Risk of Mortality III estimated mortality. Factors associated with mortality were identified by univariate analyses.

Ninety patients with 122 total admissions were identified. The majority of patients were Hispanic (63%), female (73%), and had systemic lupus erythematosus (62%). Pediatric rheumatic disease-related complications (50%) were the most common reason for admission; 32% of admissions involved multiorgan dysfunction. Eighteen admissions (15%) resulted in mortality. Deaths were most commonly attributed to combined infection and active rheumatic disease (50%), infection only (22%), rheumatic disease only (11%), or other causes (17%). In 30 (25%) admissions, a new rheumatologic diagnosis was established. Standardized mortality ratio was 0.72 (95% confidence interval 0.38-1.25) for pediatric rheumatic disease patients compared to 0.87 (95% confidence interval 0.79-0.96) for all pediatric intensive care unit patients. Factors associated with mortality included use of mechanical ventilation, vasopressors, and renal replacement (continuous venovenous hemodialysis) (all p < .05).

Conclusions: Pediatric rheumatic disease-related complications were the principal cause of pediatric intensive care unit admission. Deaths occurred most often from severe infections in patients with active rheumatic disease. Pediatric rheumatology patients admitted to the pediatric intensive care unit had outcomes similar to the global pediatric intensive care unit population when adjusted for severity of illness.

From the Divisions of Rheumatology (SMR, AOR, KAM, DEB, BS) and Cardiology (JM), General Clinical Research Center (CA), Department of Anesthesiology and Critical Care Medicine (RGK, SR), Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA.

The authors have not disclosed any potential conflicts of interest.

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©2012The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies