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qualitative data were compared using the chi-square test&#46; <span class="elsevierStyleItalic">p</span> values &#60;0&#46;05 were considered statistically significant&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">9049 children were reviewed of which 151 &#40;1&#46;7&#37;&#41; died&#59; 147 patients &#40;77 boys&#47;70 girls&#41; with an average age of 6&#46;3 years old &#40;IQR 0&#46;05&#8211;21 years old&#41; were included in the study&#46; There were&#44; on average&#44; 13&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;4 deaths per year&#46; Seventy-eight &#40;78&#41; out of the 147 patients had hemato-oncological conditions&#46; Of the total number of patients with hemato-oncological conditions who died&#44; 56&#47;78 received one hematopoietic progenitor-cell transplantation &#40;HPCT&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Thirty-six &#40;36&#41; patients did not have a clinically significant disease &#40;24&#46;5&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The most common cause for admission was respiratory failure &#40;55&#47;147&#41; followed by sepsis&#47;serious infection &#40;35&#47;147&#41;&#46; Patients without a personal clinical history were admitted to the PICU following severe trauma &#40;11&#47;36&#41; and septic shock &#40;7&#47;36&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Hemodynamic support was used in 117&#47;147 patients&#46; In 45&#47;147 patients non-invasive mechanical ventilation was required&#44; while 138&#47;147 patients required invasive mechanical ventilation&#59; 70&#47;147 patients suffered renal failure being extra-renal depuration required in 34&#47;70 patients&#59; 115&#47;147 patients required transfusion of hemoderivatives and 60&#47;136 patients parenteral nutrition&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The most common cause of death was refractory hypoxemia &#40;51&#47;146&#59; in one patient the main cause for death was not reported&#41; followed by sepsis &#40;31&#47;146&#41; and brain death &#40;31&#47;146&#41;&#46; In patients without a significant clinical history&#44; 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Only in one patient without an underlying prior disease ATE measures were implemented&#46; The ATE measures were more commonly implemented following hemodynamic instability &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#44; need for mechanical ventilation &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#44; renal failure &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#44; parenteral nutrition &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; and transfusions of hemoderivatives &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patients whose ATE was reported had longer hospital stays &#40;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17 days versus 5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;7 days&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The reason why the ATE was implemented had to do with both the irreversibility of the disease that prompted the PICU admission &#40;in 18 out of 41 patients&#41; and the poor prognosis of the underlying disease &#40;in 12 out of 41 patients&#41;&#46; Both the hemodynamic and the ventilatory support were withdrawn in 8&#47;41 patients&#46; Measures focused on well-being&#44; sedation and analgesia were a priority in 7&#47;41 patients&#46; It was decided not to implement any new extraordinary measures in 6&#47;41 patients and in 4&#47;41 patients any pharmacological therapy not aimed at improving the patient&#39;s well-being was withdrawn&#46; In 16 patients&#44; the therapeutic remains unknown&#46; The family was informed at all time and involved in the decision-making process in 29&#47;41 patients&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the series provided more than half of the patients who died suffered from hemato-oncological disease&#46; In these&#44; the HPCT was a prior common event&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> In turn&#44; the ATE is often reported in patients with a prior condition and it would determine their prognosis prior to their referral to the PICU&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3&#44;6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This decision was barely reported in healthy children or in severe and acute processes with a quick resolution&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The ATE was associated with longer hospital stays&#46; Although we do not mean to say that in order to consider the ATE it was required that a &#8220;certain amount of time&#8221; would need to pass&#44; it does seem that this aspect was key in the decision-making process&#46; Refractory hypoxemia was the main cause of death in the group of patients where the ATE was reported&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Parents and caregivers were included in more than half the cases of ATE&#46; It is well known that its perspective influences the therapeutic goal and defines well-being as a priority&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4&#44;7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">This study has some limitations though&#46; Except for epidemiological data&#44; the remaining data were not collected thoroughly&#46; They do not even include information on severity assessment scales at admission and in 4 patients no variable could be collected for the study&#46; It would certainly be interesting to collect prospective and multicenter data with the exact time and moment when each change is implemented in the decision-making process&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In sum&#44; given the specific conditions of our center&#44; patients with onco-hematological conditions and&#44; in particular&#44; those with a prior history of HPCT are the main group of patients where the ATE was reported&#46; Mainly&#44; it was associated with long hospital stays&#44; being the inotropic drug and ventilatory support withdrawal the most common measures implemented&#46; We hope that this study will revitalize the debate and increase our actual knowledge on the ATE in the PICUs of our country&#46; The creation of a national registry on this regard not only seems interesting but necessary&#46;</p></span>"
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Scientific Letter
Mortality and adequacy of therapeutic effort in a tertiary pediatric intensive care department: An 11-year review
Mortalidad y adecuación del esfuerzo terapéutico en un servicio terciario de cuidados intensivos pediátricos: revisión de 11 años
I. Leoz Gordillo, A. García-Salido
Corresponding author
citopensis@yahoo.es

Corresponding author.
, C. Niño Taravilla, G. de Lama Caro-Patón, M.I. Iglesias Bouzas, A. Serrano González
Servicio de Cuidados Intensivos Pediátricos, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mortality per groups and end-of-life approach in the study period&#46; The straight lines from up to bottom represent overall mortality&#44; patients where the ATE remained unreported&#44; and patients were the ATE was actually reported&#46; The dotted lines represent patients were the end-of-life approach remained unreported&#46; The different frequency bars show&#44; from left to right&#44; and per year&#58; health patients&#44; hemato-oncological patients&#44; neurological patients&#44; respiratory patients&#44; and patients included in the group &#8220;other&#8221;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the context of the critically ill child&#44; the decisions that have to do with the adequacy of therapeutic effort &#40;ATE&#41; are&#44; at the same time&#44; cause for debate and reason for clinical interest&#46; This is particularly the case in situations where the expected improvement has not occurred and technology is key for life support purposes&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#8211;3</span></a> At present&#44; the medical literature that describes end-of-life care in pediatric intensive care units &#40;PICU&#41;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> is scarce&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We hereby present a study that describes the characteristics of patients who have died in our PICU during the last decade&#46; It is an observational retrospective study conducted after obtaining the approval from the clinical research ethics committee&#46; The clinical reports of whose patients who died in the PICU from January 1 2006 through December 31 2016 were reviewed&#46; The variables collected were&#58; epidemiological&#44; presence of underlying disease prior to PICU admission&#44; cause for admission&#44; care received &#40;hemodynamic&#44; respiratory&#44; renal&#44; antimicrobial&#44; hematological and nutritional&#41;&#44; main cause of death&#44; days of stay at the PICU&#44; day of admission&#44; and adaptation of life support &#40;cause&#44; referral activity&#44; and participation of the family in end-of-life care&#41;&#46; A descriptive analysis of the answers was conducted using the SPSS<span class="elsevierStyleSup">&#174;</span> 19&#46;0 software for Windows&#46; Qualitative data were expressed as absolute frequencies and percentages&#44; and quantitative data as means and interquartile ranges or as means and standard deviations based on the characteristics of the variable under analysis&#46; In cases where one comparative analysis was conducted&#44; qualitative data were compared using the chi-square test&#46; <span class="elsevierStyleItalic">p</span> values &#60;0&#46;05 were considered statistically significant&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">9049 children were reviewed of which 151 &#40;1&#46;7&#37;&#41; died&#59; 147 patients &#40;77 boys&#47;70 girls&#41; with an average age of 6&#46;3 years old &#40;IQR 0&#46;05&#8211;21 years old&#41; were included in the study&#46; There were&#44; on average&#44; 13&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;4 deaths per year&#46; Seventy-eight &#40;78&#41; out of the 147 patients had hemato-oncological conditions&#46; Of the total number of patients with hemato-oncological conditions who died&#44; 56&#47;78 received one hematopoietic progenitor-cell transplantation &#40;HPCT&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Thirty-six &#40;36&#41; patients did not have a clinically significant disease &#40;24&#46;5&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The most common cause for admission was respiratory failure &#40;55&#47;147&#41; followed by sepsis&#47;serious infection &#40;35&#47;147&#41;&#46; Patients without a personal clinical history were admitted to the PICU following severe trauma &#40;11&#47;36&#41; and septic shock &#40;7&#47;36&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Hemodynamic support was used in 117&#47;147 patients&#46; In 45&#47;147 patients non-invasive mechanical ventilation was required&#44; while 138&#47;147 patients required invasive mechanical ventilation&#59; 70&#47;147 patients suffered renal failure being extra-renal depuration required in 34&#47;70 patients&#59; 115&#47;147 patients required transfusion of hemoderivatives and 60&#47;136 patients parenteral nutrition&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The most common cause of death was refractory hypoxemia &#40;51&#47;146&#59; in one patient the main cause for death was not reported&#41; followed by sepsis &#40;31&#47;146&#41; and brain death &#40;31&#47;146&#41;&#46; In patients without a significant clinical history&#44; brain death was the main cause of death &#40;18&#47;36&#41;&#59; among the patients with hemato-oncological disease &#40;43&#47;78&#41; the main cause of death was refractory hypoxemia&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">When it comes to the ATE&#44; in 88 out of the 147 patients&#44; this remained unexplained&#46; The most common cause of death in the group without ATE was brain death &#40;31&#47;88&#41; followed by sepsis&#47;septic shock &#40;26&#47;88&#41;&#46; In 41&#47;59 of the remaining patients a report was given on the ATE as well as on why and what measures implemented&#46; Twenty-seven &#40;27&#41; patients had hemato-oncological conditions being refractory hypoxemia the disease these measures were more commonly implemented against &#40;22&#47;41&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Only in 2 out of the 75 patients who died due to acute or sudden disease life support adequacy measures were implemented&#46; Only in one patient without an underlying prior disease ATE measures were implemented&#46; The ATE measures were more commonly implemented following hemodynamic instability &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#44; need for mechanical ventilation &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#44; renal failure &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#44; parenteral nutrition &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; and transfusions of hemoderivatives &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patients whose ATE was reported had longer hospital stays &#40;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17 days versus 5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;7 days&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The reason why the ATE was implemented had to do with both the irreversibility of the disease that prompted the PICU admission &#40;in 18 out of 41 patients&#41; and the poor prognosis of the underlying disease &#40;in 12 out of 41 patients&#41;&#46; Both the hemodynamic and the ventilatory support were withdrawn in 8&#47;41 patients&#46; Measures focused on well-being&#44; sedation and analgesia were a priority in 7&#47;41 patients&#46; It was decided not to implement any new extraordinary measures in 6&#47;41 patients and in 4&#47;41 patients any pharmacological therapy not aimed at improving the patient&#39;s well-being was withdrawn&#46; In 16 patients&#44; the therapeutic remains unknown&#46; The family was informed at all time and involved in the decision-making process in 29&#47;41 patients&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the series provided more than half of the patients who died suffered from hemato-oncological disease&#46; In these&#44; the HPCT was a prior common event&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> In turn&#44; the ATE is often reported in patients with a prior condition and it would determine their prognosis prior to their referral to the PICU&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3&#44;6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This decision was barely reported in healthy children or in severe and acute processes with a quick resolution&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The ATE was associated with longer hospital stays&#46; Although we do not mean to say that in order to consider the ATE it was required that a &#8220;certain amount of time&#8221; would need to pass&#44; it does seem that this aspect was key in the decision-making process&#46; Refractory hypoxemia was the main cause of death in the group of patients where the ATE was reported&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Parents and caregivers were included in more than half the cases of ATE&#46; It is well known that its perspective influences the therapeutic goal and defines well-being as a priority&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4&#44;7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">This study has some limitations though&#46; Except for epidemiological data&#44; the remaining data were not collected thoroughly&#46; They do not even include information on severity assessment scales at admission and in 4 patients no variable could be collected for the study&#46; It would certainly be interesting to collect prospective and multicenter data with the exact time and moment when each change is implemented in the decision-making process&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In sum&#44; given the specific conditions of our center&#44; patients with onco-hematological conditions and&#44; in particular&#44; those with a prior history of HPCT are the main group of patients where the ATE was reported&#46; Mainly&#44; it was associated with long hospital stays&#44; being the inotropic drug and ventilatory support withdrawal the most common measures implemented&#46; We hope that this study will revitalize the debate and increase our actual knowledge on the ATE in the PICUs of our country&#46; The creation of a national registry on this regard not only seems interesting but necessary&#46;</p></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mortality per groups and end-of-life approach in the study period&#46; The straight lines from up to bottom represent overall mortality&#44; patients where the ATE remained unreported&#44; and patients were the ATE was actually reported&#46; The dotted lines represent patients were the end-of-life approach remained unreported&#46; The different frequency bars show&#44; from left to right&#44; and per year&#58; health patients&#44; hemato-oncological patients&#44; neurological patients&#44; respiratory patients&#44; and patients included in the group &#8220;other&#8221;&#46;</p>"
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Article information
ISSN: 21735727
Original language: English
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