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Original Article
Pediatrics Post–intensive-care morbidity among pediatric patients in Thailand: prevalence, risk factors, and the importance of the post–intensive-care clinic
Acute and Critical Care 2024;39(4):600-610.
DOI: https://doi.org/10.4266/acc.2024.01011
Published online: November 18, 2024

Division of Pediatric Critical Care, Department of Pediatrics, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand

Corresponding author: Chanapai Chaiyakulsil Division of Pediatric Critical Care, Department of Pediatrics, Thammasat University Hospital, Faculty of Medicine, Thammasat University, 95 Phahol Yothin Rd, Klong-Neung, Klong-Luang, Pathumthani 12120, Thailand Tel: +66-2926-9514, Email: chanapai.chai@hotmail.com
• Received: August 8, 2023   • Revised: May 20, 2024   • Accepted: August 29, 2024

© 2024 The Korean Society of Critical Care Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Background
    Long-term survival data for critically ill children discharged to post-intensive care clinics are scarce, especially in Asia. The main objective of this study was to assess the prevalence of post–intensive-care morbidity among pediatric intensive care unit (PICU) survivors at 1 month and 1 year after hospital discharge and to identify the associated risk factors.
  • Methods
    We conducted a retrospective chart review of all children aged 1 month to 15 years who were admitted to the PICU for >48 hours from July 2019 to July 2022 and visited a post–intensive-care clinic 1 month and 1 year after hospital discharge. Post-intensive care morbidity was defined using the Pediatric Cerebral Performance Category (PCPC). Descriptive statistics, univariate, and multivariate analyses were conducted.
  • Results
    A total of 111 children visited the clinic at 1 month, and 100 of these children visited the clinic at 1 year. Only 39 of 111 children (35.2%) had normal PCPC assessments at 1 month, while 54 of 100 (54.0%) were normal at 1 year. Baseline developmental delays were significantly associated with any degree of disability and at least moderate disability at both time points. Mechanical ventilation for >7 days was associated with at least moderate disability at both time points, while PICU stay >7 days was significantly associated with moderate disability at 1 month and any degree of disability at 1 year.
  • Conclusions
    A substantial percentage of PICU survivors had persistent disabilities even 1 year after critical illness. A structured multidisciplinary post–intensive-care follow-up plan is warranted to provide optimal care for such children.
  • Key Words: children; intensive care; morbidity
With the recent progress in technology and medicine, pediatric intensive care mortality has been significantly reduced. Thus, mortality alone is not a reliable indicator of the quality of intensive care. Frameworks to evaluate post-intensive care morbidity have been evolving. The concept of post-intensive care syndrome (PICS; mainly in the adult population) was first introduced at the Society of Critical Care Medicine conference in 2010 [1-3]. This syndrome is defined as a group of impairments comprising physical, cognitive, mental, and social health that arise or worsen after critical illness and can persist beyond acute care hospitalization, with varying trajectories of recovery [1,2]. A framework for pediatric PICS (PICS-P) was established by Manning et al. [1] and encompasses the baseline status of a child and family as well as the intensive care experiences as factors for the development of PICS-P. Previous studies showed that substantial numbers of children surviving critical illness suffered from post-intensive care morbidities [1,4-11].
The intensive care unit (ICU) liberation bundles or ABCDEF bundles have been implemented in several institutions around the globe in an attempt to mitigate PICS-P [12]. Nevertheless, as noted above, the trajectories of recovery among post-intensive care survivors vary, with many requiring long-term care. Thus, a new type of post–intensive-care clinics for children has been developed. A pilot study by Snell et al. [13] in 2018 included children diagnosed with severe sepsis, acute respiratory failure requiring >1 day of mechanical ventilation, or delirium for >4 days for a follow-up visit. The study revealed a significantly lower 60-day readmission rate among the pediatric patients who were followed compared to those who were not (5% vs. 48.7%). Another study by de Sonnaville et al. [14] enrolled 65 children 6–12 years of age who were previously admitted to a pediatric intensive care unit (PICU) for acute bronchiolitis at <1 year of age. The study demonstrated poor speech and attention performance and poor verbal memory, especially among children with lower birthweight and younger age at follow-up. Most such studies, including a study in Thailand [8], focused on short-term morbidity. Long-term follow-up studies in children surviving critical illness with admission to a pediatric post–intensive-care clinic (PPICC) are scarce in the literature, especially in Asia. Currently, few hospitals in Asia offer follow-up visits for children surviving critical illness. Thus, the data on post-intensive care morbidity in children in the area are very limited. Thus, the main objective of this study was to assess the prevalence of post-intensive care morbidity in PICU survivors at 1 month and 1 year after hospital discharge and to evaluate the importance of post-intensive care follow-up and the use of a post–intensive-care clinic. By assessing morbidity at 1 month and 1 year post-discharge, the recovery trajectory also was assessed and risk factors for morbidities identified.
This study was approved by the Ethics Committee of Thammasat University Hospital, Thammasat University, Thailand (No. MTU-PE-TU-0-134/66). No informed consent was required due to the study’s retrospective nature.
Study Design and Participants
We conducted a retrospective chart review of all children aged 1 month to 15 years of age who were admitted to the PICU of Thammasat University Hospital for >48 hours from July 2019 to July 2022 and who had visited a PPICC at 1 month and 1 year after hospital discharge. The PICU at the study center was a mixed medical-surgical tertiary ICU within a university hospital and received approximately 25–30 patients monthly.
Pediatric Post-intensive Care Clinic
The PPICC at the participating institution opened in June 2019 as one of the first such clinics in the country. The clinic's mission and objectives are similar to those of continuity clinics for sick children. The clinic is held once a week and staffed by a consultant pediatric intensivist who is responsible for the evaluation, screening, and initial management of PICS and associated morbidity. Appointments for the PPICC are offered to all patients admitted to the PICU for >48 hours, and the first of these is scheduled for 2–4 weeks after hospital discharge. The clinical consultation during each visit includes assessment of overall health and well-being using the Pediatric Cerebral Performance Category (PCPC) scale and developmental progression according to age-specific milestones and school performance, reconciling medications, recording vaccination status, and responding to parental concerns and questions. The appropriate specialists, such as developmental-behavioral pediatricians, pediatric physiotherapists, occupational therapists, dentists, nutritionists, and speech therapists, are consulted as required. Patients are followed regularly based on medical needs. The general discharge criteria from the clinic are at least two visits with normal development for age without school or parental concerns for at least 1 year after hospital discharge.
Operational Definitions
For this study, post–intensive-care morbidity was defined using the PCPC scale, which was developed by Fiser [15] to effectively measure and quantify childhood morbidity after critical illness. The scale mainly focuses on daily life and cognitive morbidity and can easily be applied in a busy clinical setting. The PCPC scale ranges from a score of 1 to 6: 1 (normal for age; school-age child able to attend regular class), 2 (mild disability; able to engage at the age-appropriate level, able to attend regular class, but grade might not be appropriate for age), 3 (moderate disability; age-appropriate independent activities but requiring special education or presence of learning disabilities), 4 (severe disability; dependent on others for daily activity), 5 (coma or vegetative state), and 6 (brain death) [15,16].
All demographic data as well as baseline developmental status, admission diagnosis, underlying comorbidities, PICU duration, and ventilator days, as well as PCPC score at 1 month and 1 year after hospital discharge, were recorded. The records of all participants who were admitted to the PICU more than once were reviewed only once based on the first PICU admission.
Statistical Analyses
All PCPC scores of 2–6 were considered to represent morbidity. All demographic data, PICU length of stay, ventilator days, and other continuous data were analyzed using descriptive statistics (mean, standard deviation, median, and range, where appropriate). The prevalence of abnormal PCPC was reported as a percentage. Where appropriate, risk factors were analyzed using the chi-square or Fisher’s exact test. Univariate and multivariate analyses were conducted. Multivariate analyses were completed for factors that had a P<0.05 on univariate analyses. The children’s PCPC scores at 1 month and 1 year were compared using repeated-measures within-subjects analyses. Children who visited the PPICCS at 1 month but were lost to follow-up at 1 year were only included in the analysis of 1-month morbidity and descriptive cohort analysis. All statistical analyses were performed using SPSS version 24 (IBM Corp.).
Demographic Data
Four hundred sixty-eight children were admitted to the PICU during the study period, 168 of whom fulfilled the inclusion criteria and were offered a follow-up visit. One hundred eleven patients visited the PPICC at 1 month after discharge, of whom 11 were lost to follow-up at 1 year (Figure 1). Table 1 outlines the demographic data of the children in the cohort. The median age of the overall cohort was 1.7 years (interquartile range [IQR], 0.3–4.7 years). Seventy children (63.1%) were male. Underlying cardiovascular comorbidity was the most common underlying condition among the children in the cohort (43.3%, mainly ventricular septal defect and tetralogy of Fallot). The most common PICU admission diagnoses were cardiovascular conditions (50.5%; mostly congestive heart failure and postoperative care for cardiac surgery such as ventricular septal defect closure and tetralogy of Fallot correction), pulmonary conditions (21.6%, mostly pneumonia), and neurologic conditions (9.0%, mostly status epilepticus and encephalitis). Seventeen 17 children (15.3%) were diagnosed with baseline developmental delays at PICU admission. Genetic comorbidities such as Down’s syndrome, Treacher Collins syndrome, and Pierre Robin Sequence were found in 7 of 17 children (41.1%) with baseline development delays. Others conditions identified at baseline included autistic spectrum disorder and congenital heart diseases with developmental delays.
A total of 70 children (63.1%) required inotropic support and 96 children (86.5%) were mechanically ventilated. The median Pediatric Risk for Mortality III [17] score was 4.0 (IQR, 2.0–7.0) and the median vasoactive inotropic score [18] was 14.0 (IQR, 8.0–29.0). Continuous infusion of sedative and neuromuscular blocking agents was administered to 88 (79.3%) and 27 children (24.3%), respectively. The median duration of mechanical ventilation and PICU stay was 7.0 days (IQR, 2.0–11.8 days) and 10.0 days (IQR, 6.0–15.0 days), respectively. Extracorporeal membrane oxygenation (ECMO) was utilized in 11 children (9.9%).
Overall Pediatric Cerebral Performance Category
The data analyses revealed that 39 of 111 (35.2%) and 54 of 100 (54.0%) of the children had normal PCPC scores at 1 month and 1 year, respectively (Table 1). A total of 100 was included in the final analyses of risk factors associated with the development of any disability (identified by PCPC scores) at any time point. The PCPC scores revealed that 69 of 100 children (69.0%) developed a disability at some point of analysis. A significantly greater proportion of children with delayed development at baseline later developed disability than children with normal PCPC scores at baseline (23.2% vs. 0%, P=0.002).
As assessed using the PCPC, 39 of 100 children (39%) suffered from at least moderate disability at some point of analyses (Table 2). There was a significantly smaller percentage of boys in the group with at least moderate disability than in the normal-to-mild disability group (51.3% vs. 73.8%, P=0.031). Children with at least moderate disability had undergone significantly longer median duration of mechanical ventilator than children who had normal-to-mild disability (9.0 days [IQR, 4.0–20.5] vs. 4.0 days [IQR, 2.0–10.0], P=0.010). The proportion of children requiring mechanical ventilation and PICU admission for greater than 7 days was also significantly larger in the group with at least moderate disability (ventilator >7 days: 53.8% vs. 29.5%, P=0.008; PICU >7 days: 79.5% vs. 59.0%, P=0.049). The group with at least moderate disability comprised a significantly smaller percentage of children diagnosed with non-pulmonary conditions (66.7% vs. 88.5%, P=0.011) and admitted for surgical procedures (23.1% vs. 49.2%, P=0.012). Furthermore, there was a significantly larger percentage of children with at least moderate disability in the delayed development group at both 1 month and 1 year (15/17 [88.2%] vs. 27/94 [28.7%] at 1 month and 13/16 [81.3%] vs. 16/84 [19.0%] at 1 year, P<0.001) (Table 3).
After multivariate analyses, delayed development and >7 days of mechanical ventilation remained the significant risk factors for development of at least moderate disability, with adjusted odds ratios (aORs) of 31.22 (95% CI, 4.68–208.34; P<0.001) and 4.45 (95% CI, 1.15–17.19; P=0.030), respectively. Male sex and surgical admission were significant protective factors, with aORs of 0.27 (95% CI, 0.08–0.94; P=0.040) and 0.17 (95% CI, 0.05–0.62; P=0.008), respectively (Supplementary Table 1). All children with disabilities were referred to specialists according to their needs and problems. Of these, 31 of 69 (44.9%) children with disabilities were referred to physiotherapists, 14 of 69 (20.3%) to speech therapists, and 35 of 69 (50.7%) to developmental and behavioral pediatricians.
PCPC Data at 1 Month after Hospital Discharge
At 1 month, 72 of 111 children (64.8%) had some degree of disability, and 42 of 111 children (37.8%) had at least moderate disability (Tables 4 and 5). Table 4 illustrates the risk factors for development of some degree of disability at 1 month. Similar to the overall PCPC data, the disability group comprised a significantly larger percentage of children with baseline developmental delays than without (23.6% vs. 0%, P=0.001). There were significantly more children in the disability group who required prolonged sedation and prolonged mechanical ventilation (>7 days sedation: 43.1% vs. 20.5%, P=0.039; >7 days mechanical ventilation: 51.4% vs. 25.6%, P=0.025). The median duration of mechanical ventilation was also significantly longer in the disability group (9.0 days [IQR, 3.0–14.3] vs. 4.0 days [IQR, 2.0–9.8], P=0.025). The crude ORs for development of any disability at 1 month, for children with delayed development at baseline, and for those who required >7 days ventilation or sedation were 24.91 (95% CI, 1.45–426.62; P=0.001), 2.11 (95% CI, 1.12–3.97; P=0.018), and 2.09 (95% CI, 1.04–4.20; P=0.039), respectively. Due to inadequate numbers of children with delayed development at baseline in the normal PCPC group, multivariate analyses were conducted with only two factors and revealed a nonsignificant association with an aOR of 0.825 (95% CI, 0.07–9.60; P=0.825) for children requiring >7 days sedation and an aOR of 4.16 (95% CI, 0.36–47.68; P=0.252) for children who required prolonged mechanical ventilation.
Table 5 demonstrates a significantly larger percentage of children with at least moderate disability at 1 month compared to that with baseline developmental delay (35.7% vs. 2.9%, P<0.001) and prolonged (>7 days) PICU admission (81.0% vs. 60.9%, P=0.035). The percentage of children who required surgical admission was again significantly lower in the group with at least moderate disability (21.4% vs. 46.4%, P=0.009). Univariate and multivariate analyses to identify risk factors associated with at least moderate disability at 1 month are outlined in Supplementary Table 2. The aORs for baseline developmental delays, surgical admission, and >7 days in the PICU were 20.77 (95% CI, 4.14–104.15; P<0.001), 0.30 (95% CI, 0.11–0.85; P=0.023), and 2.54 (95% CI, 0.87–7.37; P=0.087), respectively.
PCPC Data at 1 Year after Hospital Discharge
A total of 46 of 100 children (46%) had some disability and 29 of 100 children (29%) had at least moderate disability at 1 year after discharge (Tables 6 and 7). Children in any disability group were significantly younger than their normal PCPC counterparts (1.3 years [IQR, 0.2–5.0] vs. 3.2 years [IQR, 0.4–6.0], P=0.009) and had longer median duration of mechanical ventilation (9.0 days [IQR, 4.0–19.0] vs. 4.0 days [IQR, 1.0–10.0), P=0.008). The percentages of children younger than 3 years old, with delayed development, and who required >7 days of mechanical ventilation were significantly higher among the disability group (age <3 years old: 67.4% vs. 46.3%, P=0.044; delayed development: 32.6% vs. 1.9%, P<0.001; ventilator >7 days: 50.0% vs. 29.6%, P=0.030). A significantly lower percentage of children in the disability group required surgical admission and non-pulmonary admission (surgical admission: 23.9% vs. 51.9%, P=0.007; non-pulmonary admission: 69.6% vs. 88.9%, P=0.023). Upon multivariate analyses, age <3 years, baseline developmental delay, surgical admission, and prolonged (>7 days) mechanical ventilation were significantly associated with the development of some level of disability at 1 year after hospital discharge, with aORs of 5.60 (95% CI, 1.62–19.30; P=0.006), 109.06 (95% CI, 8.58–1,386.43; P<0.001), 0.17 (95% CI, 0.05–0.59; P=0.005), and 3.52 (95% CI, 1.11–11.19; P=0.033), respectively (Supplementary Table 3).
There was a significantly larger proportion of children with delayed development among the group with at least moderate disability at 1-year (44.8% vs. 4.2%, P<0.001) (Table 7). The median duration of mechanical ventilation was longer in the group with at least moderate disability (9.5 days [IQR, 3.8–20.3] vs. 4.5 days [IQR, 2.0–10.8], P=0.047). A significantly lower percentage of children with at least moderate disability required surgical admission (20.7% vs. 46.5%, P=0.023), ECMO support (15.5% vs. 0%, P=0.031), or continuous infusion of sedatives (65.5% vs. 85.9%, P=0.028). Due to the inadequate number of children with at least moderate disability, ECMO support was not included in the final multivariate analyses. After multivariate analyses, delayed development was associated with increased risk of at least moderate disability at 1 year, with an aOR of 25.42 (95% CI, 5.32– 121.57; P<0.001), while surgical admission served as a protective factor, with an aOR of 0.21 (95% CI, 0.05–0.78; P=0.021) (Supplementary Table 4).
A significantly lower percentage of children had abnormal PCPC scores at 1 year than at 1 month. The within-subjects repeated-measures analyses revealed a significant reduction of disability in children with developmental delays at baseline (P<0.001). Approximately 26.1% (29/111) had unplanned hospital readmission within 1 year of hospital discharge, with a median readmission time of 2 months (IQR, 1.0–6.5). Children with baseline developmental impairment were more likely to be readmitted within 1 year compared with those without impairment (47.1% vs. 22.3%, P=0.037). No risk factors were associated with readmission. No mortality was observed within 1 year of discharge.
The study revealed that a considerable number of PICU survivors continued to suffer from persistent disabilities even 1 year after critical illness. Only 54 of 100 children (54.0%) had normal PCPC scores at 1 year, while 29 of 100 (29%) suffered from at least a moderate degree of disability. These findings were slightly different from those reported in a prospective study by Volaki et al. [16] in which 66.0% of children had normal PCPC scores and 13.4% had at least moderate disability at 2 years after PICU discharge. Even after the exclusion of children with baseline developmental delays, approximately 19.0% of the PICU survivors in the current study suffered from at least a moderate level of disability as identified by the PCPC score 1 year after discharge. These differences might be explained by the different time points at which PCPC scores were obtained in the two studies. Volaki et al. [16] demonstrated an improvement toward the baseline PCPC at 2 years after discharge. Another 2015 study by Als et al. [5] reported that disability persisted at 1 year of follow-up but had shown improvement. This is similar to the finding of significant reduction in disability in this study (even in children with baseline developmental impairment) in the within-subjects repeated-measures analyses to compare the PCPC of children at 1 month and 1 year of follow-up. Despite this reduction in disability, the persistence of some degree of disability was further supported by another recent long-term study by de Sonnaville et al. [14] which demonstrated persistent poor speech and verbal performance years after PICU admission. These findings highlight the importance of long-term follow-up of PICU patients using structured, multidisciplinary care. Several recent reports have raised awareness of these issues and outline the measurement modalities and quantification of PICS-P across settings [19-21]. As outlined in the study by Heneghan et al. [20], approximately 51 measurement tools have been developed to quantify PICS-P at variable time points, complicating their proper use in busy clinic settings. The PCPC scale is a simple and less time-consuming tool that focuses on the activities of daily living and cognitive morbidity and can reflect the status of the child after intensive care discharge.
A report from the United Kingdom stated that 10% of admissions comprised children who had neurodevelopmental comorbidity and occupied 50% of bed days. Children with developmental impairment were among the most vulnerable PICU patients as they had a greater risk of developing critical illness, prolonged PICU stay, and death [19]. In the present study, multivariate analyses demonstrated that baseline developmental delays were significantly associated with some degree of disability at any time point and with at least moderate disability at both time points. Furthermore, prolonged (>7 days) mechanical ventilation was associated with at least a moderate disability at some time point, whilst PICU stay >7 days was significantly associated with moderate disability at 1 month and some degree of disability at 1 year. Thus, these groups of children were at a significantly higher risk of long-term disability. A significant relationship between prolonged PICU admission and moderate to severe disability as assessed by the PCPC score was also reported by Fiser et al. [22]. Similar to an earlier study [16], Fiser et al. [22] associated surgical admission with a lower risk of at least moderate disability at both time points after adjusting for other statistically significant risk factors. In contrast to the study [16], which reported that respiratory admissions were associated with better outcomes while cardiovascular patients were associated with worse outcomes, the present study showed no significant association of any particular admission diagnosis group with development of some disability at any time point in the multivariate analyses.
An earlier pilot study by Gelsinger reported that post–intensive-care follow-up included readmission of only 5% of patients within 60 days; this readmission rate was substantially lower than in the current study (26.1%). This difference might be due to the use of different inclusion criteria for the study subjects and the small population size in the previous study. Nevertheless, it is alarming that approximately one-quarter of critically ill children treated in clinical practice were readmitted within 1 year of discharge, with a median time to readmission of 2.0 months (IQR, 1.0–6.5 months). It is even more alarming that almost half of the children with developmental impairment at baseline (47.1%) were readmitted within 1 year. These outcomes can lead to higher medical costs and further disability.
The major strength of this study was the demonstration of longitudinal progression of the functional outcomes of PICU survivors and the findings indicating the importance of post-intensive care follow-up. These data substantiated the few published studies addressing this topic. Several limitations should be outlined. Caution should be exercised when interpreting the results. This study was conducted in a single center, a university hospital with a wide range of pediatric subspecialists, so the generalizability of the results might be limited. Furthermore, the study was not adequately powered to demonstrate whether unplanned readmission was associated with further disability among children with developmental impairment. While the study was undertaken at an institution with an established PPICC, the analyses indicated that a substantial percentage of children continued to have disabilities despite a significant reduction in the degree of disability even after regular, multidisciplinary follow-up and referrals. These findings indicate the need for further quality improvement studies and protocols to improve the quality of life of such children in both the PICU setting and post-intensive care setting, especially children who experience prolonged PICU stay, prolonged mechanical ventilation, and baseline developmental delays.
A substantial number of PICU survivors had persistent disabilities even 1 year after critical illness. A structured multidisciplinary post-intensive care follow-up plan is warranted to provide optimal care for children after PICU discharge, especially for those with baseline developmental delays and/or who undergo prolonged (>7 days) PICU stays and mechanical ventilation.
▪ A substantial number of pediatric intensive care unit (PICU) survivors had persistent disabilities even 1 year after critical illness.
▪ A structured post–intensive-care follow-up assessment completed by a multidisciplinary team including a pediatric intensivist, a developmental and behavioral pediatrician, a physiotherapist, and a speech and occupational therapist is warranted to provide optimal care for children after PICU discharge.
▪ Ideally, the first follow-up visit for such patients should occur within the first month after hospital discharge.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

This study was supported by the Research Group in Pediatric Care of the Faculty of Medicine of the Thammasat University Hospital, Thammasat University.

ACKNOWLEDGMENTS

The author would like to thank all the residents, faculty, and nursing staff of the involved hospital as well as the Research Group for Pediatric Care for their strong support and extensive cooperation in making this project successful. The author would also to extend special appreciation to all the developmental-behavioral pediatricians, physiotherapists, and occupational therapists who improve the lives of their pediatric patients.

AUTHOR CONTRIBUTIONS

All the work was done by CC.

Supplementary materials can be found via https://doi.org/10.4266/acc.2024.01011.
Supplementary Table 1.
Univariate and multivariate analyses for at least moderate disability
acc-2024-01011-Supplementary-Table-1.pdf
Supplementary Table 2.
Univariate and multivariate analyses for at least moderate disability at 1 month
acc-2024-01011-Supplementary-Table-2.pdf
Supplementary Table 3.
Univariate and multivariate analyses for abnormal PCPC at 1 year
acc-2024-01011-Supplementary-Table-3.pdf
Supplementary Table 4.
Univariate and multivariate analyses for the risk factors of development of at least moderate disability at 1 year
acc-2024-01011-Supplementary-Table-4.pdf
Figure 1.
Population flowchart. PICU: pediatric intensive care unit.
acc-2024-01011f1.jpg
Table 1.
Demographic data among groups
Factor All patients (n=111) Normal function (n=31)a) Any disability (n=69)a) P-value
Age (yr) 2 (0–5) 4 (0–8) 2 (0–4) 0.257
Age <3 yr 66 (60) 13 (42) 43 (62) 0.081
Male 70 (63.1) 21 (67.7) 44 (63.8) 0.822
Underlying disease 0.108
 None 41 (36.9) 14 (45.2) 19 (27.6)
 Cardiovascular 48 (43.3) 16 (51.6) 30 (43.5)
 Genetic 7 (6.3) - 7 (10.2)
 Neurologic 5 (4.5) - 5 (7.2)
 Pulmonology 3 (2.7) - 2 (2.9)
 Allergy 2 (1.8) 1 (3.2) 1 (1.4)
 Gastrointestinal 2 (1.8) - 2 (2.9)
 Developmental disorder 2 (1.8) - 2 (2.9)
 Hematology and Oncology 1 (0.9) - 1 (1.4)
Admission diagnosis 0.391
 Cardiovascular 56 (50.5) 19 (61.3) 34 (49.4)
 Pulmonology 24 (21.6) 3 (9.7) 17 (24.6)
 Neurologic 10 (9.0) 3 (9.7) 6 (8.7)
 Gastrointestinal 5 (4.5) 3 (9.7) 2 (2.9)
 Renal 3 (2.7) 1 (3.2) 2 (2.9)
 Septic shock 3 (2.7) - 2 (2.9)
 Oncology 4 (3.6) 1 (3.2) 3 (4.3)
 Trauma 4 (3.6) - 2 (2.9)
 Genetic 1 (0.9) - 1 (1.4)
 Dermatology 1 (0.9) 1 (3.2) -
Delayed development 17 (15.3) - 16 (23.2) 0.002
Surgical admission 41 (36.9) 15 (48.4) 24 (34.8) 0.268
PRISM III 4.0 (2.0–7.0) 3.0 (2.0–7.0) 4.0 (1.5–7.0) 1.000
Inotropes 70 (63.1) 19 (61.3) 45 (65.2) 0.822
VIS 14.0 (8.0–29.0) 14.0 (10.0–23.0) 17.0 (9.0 -33.0) 0.700
ECMO support 11 (9.9) 3 (9.7) 8 (11.6) 1.000
Mechanically ventilated 96 (86.5) 25 (80.6) 61 (88.4) 0.354
Ventilator days 7.0 (2.0–11.8) 4.0 (1.0–9.0) 8.0 (3.0–15.0) 0.104
Ventilator >7 days 47 (42.3) 7 (22.6) 32 (46.4) 0.056
PICU stay (day) 10.0 (6.0–15.0) 8.0 (5.0–13.0) 11.0 (6.0–19.0) 0.110
PICU >7 days 76 (68.5) 19 (61.3) 48 (69.6) 0.492
Sedation 88 (79.3) 24 (77.4) 56 (81.2) 0.788
Sedation >7 days 39 (35.1) 6 (19.4) 26 (37.7) 0.086
NMB use 27 (24.3) 7 (22.6) 16 (23.2) 1.000
NMB >7 days 11 (9.9) 2 (6.5) 9 (13.0) 0.371
PCPC at 1 month - - -
 Normal 39 (35.2)
 Mild disability 30 (27.0)
 Moderate disability 21 (18.9)
 Severe disability 21 (18.9)
PCPC at 1 year (n=100) - - -
 Normal 54 (54.0)
 Mild disability 17 (17.0)
 Moderate disability 15 (15.0)
 Severe disability 14 (14.0)

Values are presented as median (interquartile range) or number (%).

PRISM III: Pediatric Risk for Mortality III score [17]; VIS: vasoactive inotropic score [18]; ECMO: extracorporeal membrane oxygenation; PICU: pediatric intensive care unit; NMB: neuromuscular blocker; PCPC: Pediatric Cerebral Performance Category.

a)The patients who were lost to follow at any time point in the study were not included in the analysis for the risk of dysfunction. Thus, only 100 patients were analyzed.

Table 2.
Risk factors for the development of at least moderate dysfunction at any time point of analyses
Factor Normal to mild disability (n=61) At least moderate disability (n=39) P-value
Age (yr) 3 (0–5) 2 (0–5) 0.617
Age <3 yr 32 (52.5) 24 (61.5) 0.414
Male 45 (73.8) 20 (51.3) 0.031
Underlying disease 0.277
 None 23 (37.8) 10 (25.6)
 Cardiovascular 32 (52.6) 14 (35.7)
 Genetic 1 (1.6) 6 (15.4)
 Neurologic - 5 (12.9)
 Allergy 1 (1.6) 1 (2.6)
 Pulmonology 1 (1.6) 1 (2.6)
 Gastrointestinal 1 (1.6) 1 (2.6)
 Developmental disorder 1 (1.6) 1 (2.6)
 Hematology and oncology 1 (1.6) -
Admission diagnosis 0.018
 Cardiovascular 40 (65.5) 13 (33.3)
 Pulmonology 7 (11.5) 13 (33.3)
 Neurologic 4 (6.6) 5 (12.9)
 Gastrointestinal 4 (6.6) 1 (2.6)
 Renal 2 (3.3) 1 (2.6)
 Septic shock - 2 (5.1)
 Oncology 2 (3.3) 2 (5.1)
 Trauma - 2 (5.1)
 Genetic 1 (1.6) -
 Dermatology 1 (1.6) -
Delayed development 2 (3.3) 14 (35.9) <0.001
Surgical admission 30 (49.2) 9 (23.1) 0.012
Median PRISM III 3.0 (1.5–6.5) 5.0 (2.0–7.0) 0.682
Inotropes 40 (65.6) 24 (61.5) 0.831
VIS 14.0 (10.0–31.8) 17.5 (4.5–29.0) 0.949
ECMO support 7 (11.5) 4 (10.3) 1.000
Mechanically ventilated 53 (86.9) 33 (84.6) 0.774
Median ventilator days 4.0 (2.0–10.0) 9.0 (4.0–20.5) 0.010
Ventilator >7 days 18 (29.5) 21 (53.8) 0.008
Median PICU stay (day) 9.0 (4.0–13.0) 15.0 (8.0–22.0) 0.072
PICU >7 days 36 (59.0) 31 (79.5) 0.049
Sedation 51 (83.6) 29 (74.4) 0.309
Sedation >7 days 16 (26.2) 16 (41.0) 0.057
NMB use 13 (21.3) 10 (25.6) 0.634
NMB >7 days 5 (8.2) 6 (15.4) 0.414

Values are presented as median (interquartile range) or number (%).

PRISM III: Pediatric Risk for Mortality III score [17]; VIS: vasoactive inotropic score [18]; ECMO: extracorporeal membrane oxygenation; PICU: pediatric intensive care unit; NMB: neuromuscular blocker.

Table 3.
Comparison of Pediatric Cerebral Performance Scale based on baseline development
Factor Normal development Delayed development P-value
PCPC at 1 month (n=94) (n=17) <0.001
 Normal 39 (41.5) -
 Mild disability 28 (29.8) 2 (11.8)
 Moderate disability 16 (17.0) 5 (29.4)
 Severe disability 11 (11.7) 10 (58.8)
PCPC at 1 year (n=84) (n=16) <0.001
 Normal 53 (63.1) 1 (6.2)
 Mild disability 15 (17.9) 2 (12.5)
 Moderate disability 10 (11.9) 5 (31.3)
 Severe disability 6 (7.1) 8 (50.0)

Values are presented as number (%).

PCPC: Pediatric Cerebral Performance Category.

Table 4.
Risk factors for the development of disability at 1 month
Factor Normal function (n=39) Any disability (n=72) P-value
Age (yr) 3 (0–8) 2 (0–4) 0.640
Age <3 yr 19 (48.7) 47 (65.3) 0.107
Male 27 (69.2) 43 (59.7) 0.411
Underlying disease 0.067
 None 19 (48.6) 22 (30.6)
 Cardiovascular 17 (43.6) 31 (43.1)
 Genetic - 7 (9.6)
 Neurologic - 5 (6.9)
 Allergy 1 (2.6) 1 (1.4)
 Pulmonology 1 (2.6) 2 (2.8)
 Gastrointestinal - 2 (2.8)
 Developmental disorder 1 (2.6) 1 (1.4)
 Hematology and oncology - 1 (1.4)
Admission diagnosis 0.261
 Cardiovascular 21 (53.8) 35 (48.5)
 Pulmonology 6 (15.4) 18 (25.0)
 Neurologic 5 (12.8) 5 (6.9)
 Gastrointestinal 3 (7.7) 2 (2.8)
 Renal 2 (5.1) 1 (1.4)
 Septic shock - 3 (4.2)
 Oncology 1 (2.6) 3 (4.2)
 Trauma - 4 (5.6)
 Genetic - 1 (1.4)
 Dermatology 1 (2.6) -
Delayed development - 17 (23.6) 0.001
Surgical admission 16 (41.0) 25 (34.7) 0.542
Median PRISM III 3.0 (2.0–6.0) 5.0 (2.0–7.0) 0.173
Inotropes 22 (56.4) 48 (66.7) 0.309
VIS 14.0 (8.8–23.5) 13.5 (6.5-29.0) 0.773
ECMO support 3 (7.7) 8 (11.1) 0.744
Mechanically ventilated 32 (82.1) 64 (88.9) 0.386
Ventilator days 4.0 (2.0–9.8) 9.0 (3.0–14.3) 0.025
Ventilator >7 days 10 (25.6) 37 (51.4) 0.018
PICU stay 8.0 (4.0–12.0) 11.0 (6.0–18.8) 0.078
PICU >7 days 23 (59.0) 53 (73.6) 0.136
Sedation 29 (74.4) 59 (81.9) 0.462
Sedation >7 days 8 (20.5) 31 (43.1) 0.039
NMB use 7 (17.9) 20 (27.8) 0.354
NMB >7 days 2 (5.1) 9 (12.5) 0.662

Values are presented as median (interquartile range) or number (%).

PRISM III: Pediatric Risk for Mortality III score [17]; VIS: vasoactive inotropic score [18]; ECMO: extracorporeal membrane oxygenation; PICU: pediatric intensive care unit; NMB: neuromuscular blocker.

Table 5.
Risk factors for the development of at least moderate disability at 1 month
Factor Normal to mild disability (n=69) At least moderate disability (n=42) P-value
Age (yr) 2 (0–5) 2 (0–5) 0.608
Age <3 yr 40 (58.0) 26 (61.9) 0.696
Male 47 (68.1) 23 (54.8) 0.224
Underlying disease 0.073
 None 30 (43.6) 11 (26.2)
 Cardiovascular 33 (47.9) 15 (35.6)
 Genetic - 7 (16.7)
 Neurologic - 5 (11.9)
 Allergy 1 (1.4) 1 (2.4)
 Pulmonology 2 (2.9) 1 (2.4)
 Gastrointestinal 1 (1.4) 1 (2.4)
 Developmental disorder 1 (1.4) 1 (2.4)
 Hematology and oncology 1 (1.4) -
Admission diagnosis 0.126
 Cardiovascular 42 (61.0) 14 (33.2)
 Pulmonology 11 (15.9) 13 (31.0)
 Neurologic 5 (7.3) 5 (11.9)
 Gastrointestinal 4 (5.8) 1 (2.4)
 Renal 2 (2.9) 1 (2.4)
 Septic shock 1 (1.4) 2 (4.8)
 Oncology 2 (2.9) 2 (4.8)
 Trauma 1 (1.4) 3 (7.1)
 Genetic - 1 (2.4)
 Dermatology 1 (1.4) -
Delayed development 2 (2.9) 15 (35.7) <0.001
Surgical admission 32 (46.4) 9 (21.4) 0.009
Median PRISM III 3.0 (2.0–7.0) 5.0 (2.0–7.0) 0.208
Inotropes 45 (65.2) 25 (59.5) 0.551
VIS 14.0 (10.0–24.0) 13.0 (4.5–29.0) 0.971
ECMO support 7 (10.1) 4 (9.5) 1.000
Mechanically ventilated 60 (87.0) 36 (85.7) 1.000
Median ventilator days 5.5 (2.0–10.8) 9.0 (4.0–19.8) 0.102
Ventilator >7 days 25 (36.2) 22 (52.4) 0.091
Median PICU stay (days) 9.0 (4.5–13.0) 12.5 (8.0–22.0) 0.387
PICU >7 days 42 (60.9) 34 (81.0) 0.035
Sedation 57 (82.6) 31 (73.8) 0.335
Sedation >7 days 22 (31.9) 17 (40.5) 0.180
NMB use 16 (23.2) 11 (26.2) 0.820
NMB >7 days 5 (7.2) 6 (14.3) 0.264

Values are presented as median (interquartile range) or number (%).

PRISM III: Pediatric Risk for Mortality III score [17]; VIS: vasoactive inotropic score [18]; ECMO: extracorporeal membrane oxygenation; PICU: pediatric intensive care unit; NMB: neuromuscular blocker.

Table 6.
Risk factors for the development of any disability at 1 year
Factor Normal function (n=54) Any disability (n=46) P-value
Age (yr) 3 (0–6) 1 (0–5) 0.009
Age <3 yr 25 (46.3) 31 (67.4) 0.044
Male 38 (70.4) 27 (58.7) 0.293
Underlying disease 0.205
 None 21 (38.8) 12 (26.2)
 Cardiovascular 29 (53.7) 17 (37.0)
 Genetic 1 (1.9) 6 (13.0)
 Neurologic - 5 (10.9)
 Allergy 2 (3.7) -
 Pulmonology - 2 (4.3)
 Gastrointestinal - 2 (4.3)
 Developmental disorder - 2 (4.3)
 Hematology and oncology 1 (1.9) -
Admission diagnosis 0.035
 Cardiovascular 36 (66.7) 17 (37.0)
 Pulmonology 6 (11.1) 14 (30.4)
 Neurologic 3 (5.5) 6 (13.0)
 Gastrointestinal 3 (5.5) 2 (4.3)
 Renal 1 (1.9) 2 (4.3)
 Septic shock - 2 (4.3)
 Oncology 3 (5.5) 1 (2.1)
 Trauma - 2 (4.3)
 Genetic 1 (1.9) -
 Dermatology 1 (1.9) -
Delayed development 1 (1.9) 15 (32.6) <0.001
Surgical admission 28 (51.9) 11 (23.9) 0.007
Median PRISM III 4.0 (1.8–7.0) 3.0 (1.5–7.0) 0.801
Inotropes 37 (68.5) 27 (58.7) 0.403
VIS 14.0 (10.0–28.5) 13.0 (6.0 -29.0) 0.327
ECMO support 6 (11.1) 5 (10.9) 1.000
Mechanically ventilated 47 (87.0) 39 (84.8) 0.779
Median ventilator days 4.0 (1.0–10.0) 9.0 (4.0–19.0) 0.008
Ventilator >7 days 16 (29.6) 23 (50.0) 0.030
PICU stay (days) 8.0 (4.8–13.3) 11.0 (6.0–21.3) 0.186
PICU >7 days 33 (61.1) 34 (73.9) 0.205
Sedation 45 (83.3) 35 (76.1) 0.454
Sedation >7 days 14 (25.9) 18 (39.1) 0.107
NMB use 11 (20.4) 12 (26.1) 0.634
NMB >7 days 4 (7.4) 7 (15.2) 0.414

Values are presented as median (interquartile range) or number (%).

PRISM III: Pediatric Risk for Mortality III score [17]; VIS: vasoactive inotropic score [18]; ECMO: extracorporeal membrane oxygenation; PICU: pediatric intensive care unit; NMB: neuromuscular blocker.

Table 7.
Risk factors for the development of at least moderate disability at 1 year
Factor Normal to mild disability (n=71) At least moderate disability (n=29) P-value
Age (yr) 3 (0–5) 1 (0–5) 0.531
Age <3 yr 37 (52.1) 19 (65.5) 0.270
Male 47 (66.2) 18 (62.1) 0.818
Underlying disease 0.107
 None 27 (38.1) 6 (20.8)
 Cardiovascular 37 (52.1) 9 (31.0)
 Genetic 1 (1.4) 6 (20.7)
 Neurologic - 5 (17.2)
 Allergy 2 (2.8) -
 Pulmonology 1 (1.4) 1 (3.4)
 Gastrointestinal 2 (2.8) -
 Developmental disorder - 2 (6.9)
 Hematology and oncology 1 (1.4) -
Admission diagnosis 0.001
 Cardiovascular 46 (64.8) 7 (24.2)
 Pulmonology 10 (14.1) 10 (34.5)
 Neurologic 4 (5.6) 5 (17.2)
 Gastrointestinal 5 (7.1) -
 Renal 1 (1.4) 2 (6.9)
 Septic shock - 2 (6.9)
 Oncology 3 (4.2) 1 (3.4)
 Trauma - 2 (6.9)
 Genetic 1 (1.4) -
 Dermatology 1 (1.4) -
Delayed development 3 (4.2) 13 (44.8) <0.001
Surgical admission 33 (46.5) 6 (20.7) 0.023
Median PRISM III 4.0 (1.0–7.0) 3.0 (2.0–7.0) 0.659
Inotropes 48 (67.6) 16 (55.2) 0.259
VIS 15.5 (10.0– 36.3) 12.5 (7.0 -25.0) 0.885
ECMO support 11 (15.5) - 0.031
Mechanically ventilated 64 (90.1) 22 (75.9) 0.108
Ventilator days 4.5 (2.0–10.8) 9.5 (3.8–20.3) 0.047
Ventilator >7 days 25 (35.2) 14 (48.3) 0.052
PICU stay (day) 9.0 (5.0–15.0) 15.0 (7.0–22.0) 0.313
PICU >7 days 45 (63.4) 22 (75.9) 0.252
Sedation 61 (85.9) 19 (65.5) 0.028
Sedation >7 days 21 (29.6) 11 (37.9) 0.106
NMB use 17 (23.9) 6 (20.7) 0.799
NMB >7 days 7 (9.9) 4 (13.8) 0.371

Values are presented as median (interquartile range) or number (%).

PRISM III: Pediatric Risk for Mortality III score [17]; VIS: vasoactive inotropic score [18]; ECMO: extracorporeal membrane oxygenation; PICU: pediatric intensive care unit; NMB: neuromuscular blocker.

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      Post–intensive-care morbidity among pediatric patients in Thailand: prevalence, risk factors, and the importance of the post–intensive-care clinic
      Acute Crit Care. 2024;39(4):600-610.   Published online November 18, 2024
      DOI: https://doi.org/10.4266/acc.2024.01011
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    Post–intensive-care morbidity among pediatric patients in Thailand: prevalence, risk factors, and the importance of the post–intensive-care clinic
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    Figure 1. Population flowchart. PICU: pediatric intensive care unit.

    Figure 1.

    Post–intensive-care morbidity among pediatric patients in Thailand: prevalence, risk factors, and the importance of the post–intensive-care clinic
    Factor All patients (n=111) Normal function (n=31)a) Any disability (n=69)a) P-value
    Age (yr) 2 (0–5) 4 (0–8) 2 (0–4) 0.257
    Age <3 yr 66 (60) 13 (42) 43 (62) 0.081
    Male 70 (63.1) 21 (67.7) 44 (63.8) 0.822
    Underlying disease 0.108
     None 41 (36.9) 14 (45.2) 19 (27.6)
     Cardiovascular 48 (43.3) 16 (51.6) 30 (43.5)
     Genetic 7 (6.3) - 7 (10.2)
     Neurologic 5 (4.5) - 5 (7.2)
     Pulmonology 3 (2.7) - 2 (2.9)
     Allergy 2 (1.8) 1 (3.2) 1 (1.4)
     Gastrointestinal 2 (1.8) - 2 (2.9)
     Developmental disorder 2 (1.8) - 2 (2.9)
     Hematology and Oncology 1 (0.9) - 1 (1.4)
    Admission diagnosis 0.391
     Cardiovascular 56 (50.5) 19 (61.3) 34 (49.4)
     Pulmonology 24 (21.6) 3 (9.7) 17 (24.6)
     Neurologic 10 (9.0) 3 (9.7) 6 (8.7)
     Gastrointestinal 5 (4.5) 3 (9.7) 2 (2.9)
     Renal 3 (2.7) 1 (3.2) 2 (2.9)
     Septic shock 3 (2.7) - 2 (2.9)
     Oncology 4 (3.6) 1 (3.2) 3 (4.3)
     Trauma 4 (3.6) - 2 (2.9)
     Genetic 1 (0.9) - 1 (1.4)
     Dermatology 1 (0.9) 1 (3.2) -
    Delayed development 17 (15.3) - 16 (23.2) 0.002
    Surgical admission 41 (36.9) 15 (48.4) 24 (34.8) 0.268
    PRISM III 4.0 (2.0–7.0) 3.0 (2.0–7.0) 4.0 (1.5–7.0) 1.000
    Inotropes 70 (63.1) 19 (61.3) 45 (65.2) 0.822
    VIS 14.0 (8.0–29.0) 14.0 (10.0–23.0) 17.0 (9.0 -33.0) 0.700
    ECMO support 11 (9.9) 3 (9.7) 8 (11.6) 1.000
    Mechanically ventilated 96 (86.5) 25 (80.6) 61 (88.4) 0.354
    Ventilator days 7.0 (2.0–11.8) 4.0 (1.0–9.0) 8.0 (3.0–15.0) 0.104
    Ventilator >7 days 47 (42.3) 7 (22.6) 32 (46.4) 0.056
    PICU stay (day) 10.0 (6.0–15.0) 8.0 (5.0–13.0) 11.0 (6.0–19.0) 0.110
    PICU >7 days 76 (68.5) 19 (61.3) 48 (69.6) 0.492
    Sedation 88 (79.3) 24 (77.4) 56 (81.2) 0.788
    Sedation >7 days 39 (35.1) 6 (19.4) 26 (37.7) 0.086
    NMB use 27 (24.3) 7 (22.6) 16 (23.2) 1.000
    NMB >7 days 11 (9.9) 2 (6.5) 9 (13.0) 0.371
    PCPC at 1 month - - -
     Normal 39 (35.2)
     Mild disability 30 (27.0)
     Moderate disability 21 (18.9)
     Severe disability 21 (18.9)
    PCPC at 1 year (n=100) - - -
     Normal 54 (54.0)
     Mild disability 17 (17.0)
     Moderate disability 15 (15.0)
     Severe disability 14 (14.0)
    Factor Normal to mild disability (n=61) At least moderate disability (n=39) P-value
    Age (yr) 3 (0–5) 2 (0–5) 0.617
    Age <3 yr 32 (52.5) 24 (61.5) 0.414
    Male 45 (73.8) 20 (51.3) 0.031
    Underlying disease 0.277
     None 23 (37.8) 10 (25.6)
     Cardiovascular 32 (52.6) 14 (35.7)
     Genetic 1 (1.6) 6 (15.4)
     Neurologic - 5 (12.9)
     Allergy 1 (1.6) 1 (2.6)
     Pulmonology 1 (1.6) 1 (2.6)
     Gastrointestinal 1 (1.6) 1 (2.6)
     Developmental disorder 1 (1.6) 1 (2.6)
     Hematology and oncology 1 (1.6) -
    Admission diagnosis 0.018
     Cardiovascular 40 (65.5) 13 (33.3)
     Pulmonology 7 (11.5) 13 (33.3)
     Neurologic 4 (6.6) 5 (12.9)
     Gastrointestinal 4 (6.6) 1 (2.6)
     Renal 2 (3.3) 1 (2.6)
     Septic shock - 2 (5.1)
     Oncology 2 (3.3) 2 (5.1)
     Trauma - 2 (5.1)
     Genetic 1 (1.6) -
     Dermatology 1 (1.6) -
    Delayed development 2 (3.3) 14 (35.9) <0.001
    Surgical admission 30 (49.2) 9 (23.1) 0.012
    Median PRISM III 3.0 (1.5–6.5) 5.0 (2.0–7.0) 0.682
    Inotropes 40 (65.6) 24 (61.5) 0.831
    VIS 14.0 (10.0–31.8) 17.5 (4.5–29.0) 0.949
    ECMO support 7 (11.5) 4 (10.3) 1.000
    Mechanically ventilated 53 (86.9) 33 (84.6) 0.774
    Median ventilator days 4.0 (2.0–10.0) 9.0 (4.0–20.5) 0.010
    Ventilator >7 days 18 (29.5) 21 (53.8) 0.008
    Median PICU stay (day) 9.0 (4.0–13.0) 15.0 (8.0–22.0) 0.072
    PICU >7 days 36 (59.0) 31 (79.5) 0.049
    Sedation 51 (83.6) 29 (74.4) 0.309
    Sedation >7 days 16 (26.2) 16 (41.0) 0.057
    NMB use 13 (21.3) 10 (25.6) 0.634
    NMB >7 days 5 (8.2) 6 (15.4) 0.414
    Factor Normal development Delayed development P-value
    PCPC at 1 month (n=94) (n=17) <0.001
     Normal 39 (41.5) -
     Mild disability 28 (29.8) 2 (11.8)
     Moderate disability 16 (17.0) 5 (29.4)
     Severe disability 11 (11.7) 10 (58.8)
    PCPC at 1 year (n=84) (n=16) <0.001
     Normal 53 (63.1) 1 (6.2)
     Mild disability 15 (17.9) 2 (12.5)
     Moderate disability 10 (11.9) 5 (31.3)
     Severe disability 6 (7.1) 8 (50.0)
    Factor Normal function (n=39) Any disability (n=72) P-value
    Age (yr) 3 (0–8) 2 (0–4) 0.640
    Age <3 yr 19 (48.7) 47 (65.3) 0.107
    Male 27 (69.2) 43 (59.7) 0.411
    Underlying disease 0.067
     None 19 (48.6) 22 (30.6)
     Cardiovascular 17 (43.6) 31 (43.1)
     Genetic - 7 (9.6)
     Neurologic - 5 (6.9)
     Allergy 1 (2.6) 1 (1.4)
     Pulmonology 1 (2.6) 2 (2.8)
     Gastrointestinal - 2 (2.8)
     Developmental disorder 1 (2.6) 1 (1.4)
     Hematology and oncology - 1 (1.4)
    Admission diagnosis 0.261
     Cardiovascular 21 (53.8) 35 (48.5)
     Pulmonology 6 (15.4) 18 (25.0)
     Neurologic 5 (12.8) 5 (6.9)
     Gastrointestinal 3 (7.7) 2 (2.8)
     Renal 2 (5.1) 1 (1.4)
     Septic shock - 3 (4.2)
     Oncology 1 (2.6) 3 (4.2)
     Trauma - 4 (5.6)
     Genetic - 1 (1.4)
     Dermatology 1 (2.6) -
    Delayed development - 17 (23.6) 0.001
    Surgical admission 16 (41.0) 25 (34.7) 0.542
    Median PRISM III 3.0 (2.0–6.0) 5.0 (2.0–7.0) 0.173
    Inotropes 22 (56.4) 48 (66.7) 0.309
    VIS 14.0 (8.8–23.5) 13.5 (6.5-29.0) 0.773
    ECMO support 3 (7.7) 8 (11.1) 0.744
    Mechanically ventilated 32 (82.1) 64 (88.9) 0.386
    Ventilator days 4.0 (2.0–9.8) 9.0 (3.0–14.3) 0.025
    Ventilator >7 days 10 (25.6) 37 (51.4) 0.018
    PICU stay 8.0 (4.0–12.0) 11.0 (6.0–18.8) 0.078
    PICU >7 days 23 (59.0) 53 (73.6) 0.136
    Sedation 29 (74.4) 59 (81.9) 0.462
    Sedation >7 days 8 (20.5) 31 (43.1) 0.039
    NMB use 7 (17.9) 20 (27.8) 0.354
    NMB >7 days 2 (5.1) 9 (12.5) 0.662
    Factor Normal to mild disability (n=69) At least moderate disability (n=42) P-value
    Age (yr) 2 (0–5) 2 (0–5) 0.608
    Age <3 yr 40 (58.0) 26 (61.9) 0.696
    Male 47 (68.1) 23 (54.8) 0.224
    Underlying disease 0.073
     None 30 (43.6) 11 (26.2)
     Cardiovascular 33 (47.9) 15 (35.6)
     Genetic - 7 (16.7)
     Neurologic - 5 (11.9)
     Allergy 1 (1.4) 1 (2.4)
     Pulmonology 2 (2.9) 1 (2.4)
     Gastrointestinal 1 (1.4) 1 (2.4)
     Developmental disorder 1 (1.4) 1 (2.4)
     Hematology and oncology 1 (1.4) -
    Admission diagnosis 0.126
     Cardiovascular 42 (61.0) 14 (33.2)
     Pulmonology 11 (15.9) 13 (31.0)
     Neurologic 5 (7.3) 5 (11.9)
     Gastrointestinal 4 (5.8) 1 (2.4)
     Renal 2 (2.9) 1 (2.4)
     Septic shock 1 (1.4) 2 (4.8)
     Oncology 2 (2.9) 2 (4.8)
     Trauma 1 (1.4) 3 (7.1)
     Genetic - 1 (2.4)
     Dermatology 1 (1.4) -
    Delayed development 2 (2.9) 15 (35.7) <0.001
    Surgical admission 32 (46.4) 9 (21.4) 0.009
    Median PRISM III 3.0 (2.0–7.0) 5.0 (2.0–7.0) 0.208
    Inotropes 45 (65.2) 25 (59.5) 0.551
    VIS 14.0 (10.0–24.0) 13.0 (4.5–29.0) 0.971
    ECMO support 7 (10.1) 4 (9.5) 1.000
    Mechanically ventilated 60 (87.0) 36 (85.7) 1.000
    Median ventilator days 5.5 (2.0–10.8) 9.0 (4.0–19.8) 0.102
    Ventilator >7 days 25 (36.2) 22 (52.4) 0.091
    Median PICU stay (days) 9.0 (4.5–13.0) 12.5 (8.0–22.0) 0.387
    PICU >7 days 42 (60.9) 34 (81.0) 0.035
    Sedation 57 (82.6) 31 (73.8) 0.335
    Sedation >7 days 22 (31.9) 17 (40.5) 0.180
    NMB use 16 (23.2) 11 (26.2) 0.820
    NMB >7 days 5 (7.2) 6 (14.3) 0.264
    Factor Normal function (n=54) Any disability (n=46) P-value
    Age (yr) 3 (0–6) 1 (0–5) 0.009
    Age <3 yr 25 (46.3) 31 (67.4) 0.044
    Male 38 (70.4) 27 (58.7) 0.293
    Underlying disease 0.205
     None 21 (38.8) 12 (26.2)
     Cardiovascular 29 (53.7) 17 (37.0)
     Genetic 1 (1.9) 6 (13.0)
     Neurologic - 5 (10.9)
     Allergy 2 (3.7) -
     Pulmonology - 2 (4.3)
     Gastrointestinal - 2 (4.3)
     Developmental disorder - 2 (4.3)
     Hematology and oncology 1 (1.9) -
    Admission diagnosis 0.035
     Cardiovascular 36 (66.7) 17 (37.0)
     Pulmonology 6 (11.1) 14 (30.4)
     Neurologic 3 (5.5) 6 (13.0)
     Gastrointestinal 3 (5.5) 2 (4.3)
     Renal 1 (1.9) 2 (4.3)
     Septic shock - 2 (4.3)
     Oncology 3 (5.5) 1 (2.1)
     Trauma - 2 (4.3)
     Genetic 1 (1.9) -
     Dermatology 1 (1.9) -
    Delayed development 1 (1.9) 15 (32.6) <0.001
    Surgical admission 28 (51.9) 11 (23.9) 0.007
    Median PRISM III 4.0 (1.8–7.0) 3.0 (1.5–7.0) 0.801
    Inotropes 37 (68.5) 27 (58.7) 0.403
    VIS 14.0 (10.0–28.5) 13.0 (6.0 -29.0) 0.327
    ECMO support 6 (11.1) 5 (10.9) 1.000
    Mechanically ventilated 47 (87.0) 39 (84.8) 0.779
    Median ventilator days 4.0 (1.0–10.0) 9.0 (4.0–19.0) 0.008
    Ventilator >7 days 16 (29.6) 23 (50.0) 0.030
    PICU stay (days) 8.0 (4.8–13.3) 11.0 (6.0–21.3) 0.186
    PICU >7 days 33 (61.1) 34 (73.9) 0.205
    Sedation 45 (83.3) 35 (76.1) 0.454
    Sedation >7 days 14 (25.9) 18 (39.1) 0.107
    NMB use 11 (20.4) 12 (26.1) 0.634
    NMB >7 days 4 (7.4) 7 (15.2) 0.414
    Factor Normal to mild disability (n=71) At least moderate disability (n=29) P-value
    Age (yr) 3 (0–5) 1 (0–5) 0.531
    Age <3 yr 37 (52.1) 19 (65.5) 0.270
    Male 47 (66.2) 18 (62.1) 0.818
    Underlying disease 0.107
     None 27 (38.1) 6 (20.8)
     Cardiovascular 37 (52.1) 9 (31.0)
     Genetic 1 (1.4) 6 (20.7)
     Neurologic - 5 (17.2)
     Allergy 2 (2.8) -
     Pulmonology 1 (1.4) 1 (3.4)
     Gastrointestinal 2 (2.8) -
     Developmental disorder - 2 (6.9)
     Hematology and oncology 1 (1.4) -
    Admission diagnosis 0.001
     Cardiovascular 46 (64.8) 7 (24.2)
     Pulmonology 10 (14.1) 10 (34.5)
     Neurologic 4 (5.6) 5 (17.2)
     Gastrointestinal 5 (7.1) -
     Renal 1 (1.4) 2 (6.9)
     Septic shock - 2 (6.9)
     Oncology 3 (4.2) 1 (3.4)
     Trauma - 2 (6.9)
     Genetic 1 (1.4) -
     Dermatology 1 (1.4) -
    Delayed development 3 (4.2) 13 (44.8) <0.001
    Surgical admission 33 (46.5) 6 (20.7) 0.023
    Median PRISM III 4.0 (1.0–7.0) 3.0 (2.0–7.0) 0.659
    Inotropes 48 (67.6) 16 (55.2) 0.259
    VIS 15.5 (10.0– 36.3) 12.5 (7.0 -25.0) 0.885
    ECMO support 11 (15.5) - 0.031
    Mechanically ventilated 64 (90.1) 22 (75.9) 0.108
    Ventilator days 4.5 (2.0–10.8) 9.5 (3.8–20.3) 0.047
    Ventilator >7 days 25 (35.2) 14 (48.3) 0.052
    PICU stay (day) 9.0 (5.0–15.0) 15.0 (7.0–22.0) 0.313
    PICU >7 days 45 (63.4) 22 (75.9) 0.252
    Sedation 61 (85.9) 19 (65.5) 0.028
    Sedation >7 days 21 (29.6) 11 (37.9) 0.106
    NMB use 17 (23.9) 6 (20.7) 0.799
    NMB >7 days 7 (9.9) 4 (13.8) 0.371
    Table 1. Demographic data among groups

    Values are presented as median (interquartile range) or number (%).

    PRISM III: Pediatric Risk for Mortality III score [17]; VIS: vasoactive inotropic score [18]; ECMO: extracorporeal membrane oxygenation; PICU: pediatric intensive care unit; NMB: neuromuscular blocker; PCPC: Pediatric Cerebral Performance Category.

    The patients who were lost to follow at any time point in the study were not included in the analysis for the risk of dysfunction. Thus, only 100 patients were analyzed.

    Table 2. Risk factors for the development of at least moderate dysfunction at any time point of analyses

    Values are presented as median (interquartile range) or number (%).

    PRISM III: Pediatric Risk for Mortality III score [17]; VIS: vasoactive inotropic score [18]; ECMO: extracorporeal membrane oxygenation; PICU: pediatric intensive care unit; NMB: neuromuscular blocker.

    Table 3. Comparison of Pediatric Cerebral Performance Scale based on baseline development

    Values are presented as number (%).

    PCPC: Pediatric Cerebral Performance Category.

    Table 4. Risk factors for the development of disability at 1 month

    Values are presented as median (interquartile range) or number (%).

    PRISM III: Pediatric Risk for Mortality III score [17]; VIS: vasoactive inotropic score [18]; ECMO: extracorporeal membrane oxygenation; PICU: pediatric intensive care unit; NMB: neuromuscular blocker.

    Table 5. Risk factors for the development of at least moderate disability at 1 month

    Values are presented as median (interquartile range) or number (%).

    PRISM III: Pediatric Risk for Mortality III score [17]; VIS: vasoactive inotropic score [18]; ECMO: extracorporeal membrane oxygenation; PICU: pediatric intensive care unit; NMB: neuromuscular blocker.

    Table 6. Risk factors for the development of any disability at 1 year

    Values are presented as median (interquartile range) or number (%).

    PRISM III: Pediatric Risk for Mortality III score [17]; VIS: vasoactive inotropic score [18]; ECMO: extracorporeal membrane oxygenation; PICU: pediatric intensive care unit; NMB: neuromuscular blocker.

    Table 7. Risk factors for the development of at least moderate disability at 1 year

    Values are presented as median (interquartile range) or number (%).

    PRISM III: Pediatric Risk for Mortality III score [17]; VIS: vasoactive inotropic score [18]; ECMO: extracorporeal membrane oxygenation; PICU: pediatric intensive care unit; NMB: neuromuscular blocker.

    Table 1.

    Table 2.

    Table 3.

    Table 4.

    Table 5.

    Table 6.

    Table 7.

    ACC : Acute and Critical Care
    © The Korean Society of Critical Care Medicine.
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