Association of Organ Dysfunction Scores
and Functional Outcomes Following Pediatric
Critical Illness*
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Travis J. Matics, DO1,2; Neethi P. Pinto, MD, MS1; L. Nelson Sanchez-Pinto, MD, MBI3,4
Objectives: Short-term and long-term morbidity and mortality are
common following pediatric critical illness. Severe organ dysfunc-
tion is associated with significant in-hospital mortality in critically ill
children; however, the performance of pediatric organ dysfunction
scores as predictors of functional outcomes after critical illness
has not been previously assessed.
Design: Secondary analysis of a prospective observational cohort.
Setting: A multidisciplinary, tertiary, academic PICU.
Patients: Patients less than or equal to 18 years old admitted be-
tween June 2012 and August 2012.
Interventions: None.
Measurements and Main Results: The maximum pediatric Se-
quential Organ Failure Assessment and Pediatric Logistic
Organ Dysfunction-2 scores during admission were calculated.
The Functional Status Scale score was obtained at baseline, 6
months and 3 years following discharge. New morbidity was de-
fined as a change in Functional Status Scale greater than or equal
to 3 points from baseline. The performance of organ dysfunction
scores at discriminating new morbidity or mortality at 6 months
and 3 years was measured using the area under the curve. Sev-
enty-three patients met inclusion criteria. Fourteen percent had
new morbidity or mortality at 6 months and 23% at 3 years. The
performance of the maximum pediatric Sequential Organ Failure
Assessment and Pediatric Logistic Organ Dysfunction-2 scores
*See also p. 778.
1
Department of Pediatrics, The University of Chicago, Chicago, IL.
2
Division of Pediatric Critical Care, Department of Pediatrics, Advocate
Children’s Hospital, Oak Lawn, IL.
3
Division of Critical Care Medicine, Ann & Robert H. Lurie Children’s Hos-
pital, Chicago, IL.
4
Department of Pediatrics, Northwestern University Feinberg School of
Medicine, Chicago, IL.
All authors conceptualized, designed, analyzed, drafted the article for im-
portant intellectual content, and collected the data.
The authors have disclosed that they do not have any potential conflicts
of interest.
For information regarding this article, E-mail: travis.matics@advocate-
health.com
Copyright © 2019 by the Society of Critical Care Medicine and the World
Federation of Pediatric Intensive and Critical Care Societies
DOI: 10.1097/PCC.0000000000001999
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Copyright © 2019 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Unauthorized reproduction of this article is prohibited
at discriminating new morbidity or mortality was excellent at 6
months (areas under the curves 0.9 and 0.88, respectively) and
good at 3 years (0.82 and 0.79, respectively).
Conclusions: Severity of organ dysfunction is associated with
longitudinal change in functional status and short-term and long-
term development of new morbidity and mortality. Maximum pedi-
atric Sequential Organ Failure Assessment and Pediatric Logistic
Organ Dysfunction-2 scores during critical illness have good to
excellent performance at predicting new morbidity or mortality up
to 3 years after critical illness. Use of these pediatric organ dys-
function scores may be helpful for prognostication of longitudinal
functional outcomes in critically ill children. (Pediatr Crit Care
Med 2019; 20:722–727)
Key Words: critical care outcomes; functional status score;
morbidity; organ dysfunction scores; pediatric; pediatric intensive
care units
A
s a result of significant reductions in mortality in the
PICU, the number of children surviving critical illness
is growing (1–3). With this lower mortality rate, the re-
duction of long-term morbidity has emerged as a new frontier
for clinically meaningful outcomes following critical illness,
and the assessment of new morbidity is becoming increasingly
important in pediatric critical care (1, 2).
The prevalence of new morbidity immediately following
pediatric critical illness is approximately 5%—about twice the
mortality rate—and is found in diverse populations of chil-
dren involving various areas of dysfunction (2). Reported new
morbidity includes physical, psychosocial, and neurocognitive
deficits that interfere with daily life and normal development (1).
These new morbidities often occur on a continuum with mor-
tality, as both outcomes are strongly associated with many of the
same risk factors, such as age, reason for admission, comorbidi-
ties, and severity of illness (3). Further characterizing both short-
term and long-term functional outcomes after critical illness and
identifying the risk factors associated with these outcomes may
have important implications for improving the care of affected
children (4). This characterization may help in the identification
of modifiable risk factors in susceptible patients who may benefit
 Feature Articles

from targeted interventions during and after critical illness with

the goal of reducing the burden of new morbidity and optimizing
long-term outcomes (2, 3). In conjunction with identifying these
risk factors, accurately prognosticating long-term functional out-
comes could be used to inform clinical decision-making and to
help patients, families, and healthcare providers understand the
impact of critical illness on long-term outcomes (5).
Organ dysfunction (OD) scores are predictive of in-hospital
mortality in both adults and children and can be used to risk-
stratify patients for clinical and research purposes (6–9). In
adults, increased OD and severity of illness scores have been asso-
ciated with increased long-term morbidity in survivors of critical
illness (10), but in children, the performance of pediatric OD as
a predictor of new, long-term morbidity after critical illness has
not been previously described. The goal of our study was to assess
the association between two pediatric OD scores during critical
illness with longitudinal functional outcomes after critical illness.

METHODS
Patient Population
Patients were enrolled between June 2012 and August 2012 in the
PICU of The University of Chicago Medicine Comer Children’s
Hospital, an urban, academic, tertiary care center that admits
medical and surgical pediatric patients (4). Patients were eligible
for inclusion if they were under 18 years old and experienced
their first PICU admission within the study period. Patients were
excluded if they were in the legal custody of the state or if their
parent or guardian was not fluent in English. The original pro-
spective study, as reported by Pinto et al (4) enrolled 129 patients
and had follow-up information for 77 patients at 6 months and
70 patients at 3 years. For the secondary analysis presented in this
article, we included only patients who had follow-up information
for at least 6 months and complete data available to calculate their Figure 1. Study flow diagram.
pediatric OD scores during their PICU course. Four patients with
incomplete data were excluded, resulting in a final sample of 73
longitudinal new morbidity or mortality: the pediatric Se-
patients at 6 months and 66 patients at 3 years (Fig. 1).
quential Organ Failure Assessment (pSOFA) score (with a pos-
Study Measurements sible range of 0–24 points) and the Pediatric Logistic Organ
Functional Status Scale. The Functional Status Scale (FSS) was Dysfunction (PELOD)–2 score (with a possible range of 0–33
used to measure longitudinal functional status. The FSS is an points) (7, 9). We calculated the daily score of the two pedi-
easily administrable, granular, objective assessment tool devel- atric OD scoring systems for each 24-hour period from PICU
oped and validated by the Collaborative Pediatric Critical Care admission until day 28 of hospital stay, discharge, or death,
Research Network to measure functional status (2, 11). The FSS whichever came first. In addition, we calculated the Pediatric
is composed of six domains of function: mental status, sensory, Risk of Mortality (PRISM) III score using clinical variables
communication, motor function, feeding, and respiratory status. from the first 24 hours of PICU stay (12).
Individual domain scores range from 1 (normal) to 5 (very se-
vere dysfunction), with total scores ranging from 6 to 30. Outcomes
Data to calculate the FSS prior to admission (baseline) and The primary outcome was new morbidity or mortality, which
at hospital discharge were extracted from an electronic health was evaluated at 6 months (“short-term outcomes”) and 3
record database (Epic Systems Corporation, Verona, WI), as years (“long-term outcomes”) after critical illness. New mor-
described by Pinto et al (4). Telephone follow-up was used to cal- bidity was defined as a worsening of FSS by 3 or more points
culate the FSS at 6 months and 3 years using a standardized tele- from preillness baseline to follow-up based on the original def-
phone script by three trained members of the study team (3, 4). inition proposed by Pollack et al (2), which was based on both
Pediatric OD and Severity of Illness Scores. We assessed consensus perception of the significance of this difference and
the performance of two pediatric OD scores at discriminating a comparison of change in mean FSS scores versus Pediatric

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 Matics et al

TABLE 1. Demographic and Clinical Characteristics of Survivors With or Without New

Morbidity or Mortality at 6 Months and 3 Years After Critical Illness
6-mo Follow-Up, n = 73 3-yr Follow-Up, n = 66
New Morbidity or Mortality New Morbidity or Mortality

Variablea No, n = 63 Yes, n = 10 p No, n = 51 Yes, n = 15 p

Age, median (IQR), yr 8.8 (2.4–12) 8.3 (1.3–11.5) 0.79 9.9 (3.8–12.3) 2.2 (0.8–11.5) 0.11
Male, n (%) 35 (56) 4 (40) 0.36 28 (55) 11 (73) 0.31
Race/ethnicity, n (%)
  African American/Black 40 (63) 2 (20) 0.01 33 (65) 5 (33) 0.009
 Asian 2 (3) 0 (0) 2 (4) 0 (0)
 Hispanic 5 (8) 1 (10) 5 (10) 0 (0)
 White 14 (22) 4 (40) 10 (20) 7 (47)
 Other 2 (3) 3 (30) 1 (2) 3 (20)
Admission type, n (%)b
  Respiratory failure 16 (25) 2 (20) 0.7 15 (30) 2 (13) 0.21
  Neurologic compromise 11 (17) 2 (20) 0.85 8 (16) 3 (20) 0.69
  Cardiovascular compromise 3 (5) 1 (10) 0.5 1 (2) 1 (7) 0.35
 Trauma 4 (6) 1 (10) 0.67 3 (6) 1 (7) 0.91
 Metabolic/poisoning 6 (10) 0 (0) 0.31 6 (12) 0 (0) 0.16
  Hematologic derangement 5 (8) 1 (10) 0.83 4 (8) 1 (7) 0.88
  Postoperative recovery 17 (27) 1 (10) 0.25 13 (25) 5 (33) 0.55
  Cardiac postoperative 1 (2) 1 (10) 0.13 1 (2) 1 (7) 0.35
 Other 0 (0) 1 (10) 0.01 0 (0) 1 (7) 0.06
Required mechanical ventilation, n (%) 11 (17) 9 (90) < 0.001 7 (14) 11 (73) < 0.001
Required vasoactive infusions, n (%) 3(5) 4 (40) < 0.001 2 (4) 5 (33) 0.001
PICU LOS, median (IQR), d 2 (1–3) 7 (3–45) 0.002 2 (1–3) 8 (2–41) 0.002
Hospital LOS, median (IQR), d 4 (2–9) 32 (13–78) < 0.001 4 (2–8) 28 (12–69) < 0.001
Maximum organ dysfunction score, median (IQR)
  Pediatric Sequential Organ Failure 3 (1–5) 10 (8–14) < 0.001 3 (1–5) 8 (6–14) < 0.001
Assessment
  Pediatric Logistic Organ Dysfunction-2 2 (2–6) 10 (9–14) < 0.001 2 (2–4) 9 (5–13) < 0.001
Pediatric Risk of Mortality III score at 2 (0–6) 12 (5–16) 0.003 2 (0–6) 11 (3–16) 0.002
admission, median (IQR)
Baseline Functional Status Scale, 6 (7–7) 6 (6–8) 0.33 6 (6–6) 7 (6–8) 0.06
median (IQR)
IQR = interquartile range, LOS = length of stay.
a
Continuous variables are presented as median (IQR) values.
b
Admission type was determined using the primary diagnosis code at admission of the International Classification of Diseases, 9th Revision, Clinical
Modification.

Overall Performance Category scores. Mortality was defined as Statistical Analysis

dying within each time interval. Data were analyzed using Stata Version 14 (StataCorp, College
The secondary outcome was the change in FSS from base- Station, TX). Categorical values were compared using the chi-
line to follow-up, which was evaluated at 6 months and 3 years square test and continuous variables using the Mann-Whitney
in survivors at each interval. U test. A p value of less than 0.05 was considered statistically

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 Feature Articles

Figure 2. Performance of the organ dysfunction scores at discriminating new morbidity or mortality at 6 mo (A) and 3 yr (B) after critical illness. AUC =
area under the curve, Max = maximum, PELOD-2 = Pediatric Logistic Organ Dysfunction-2, PRISM III = Pediatric Risk of Mortality III, pSOFA = pediatric
Sequential Organ Failure Assessment.

significant. The performance of the scores at discriminating
new morbidity or mortality at 6 months and 3 years after crit-
ical illness was evaluated using the area under the curve (AUC).
The diagnostic performance of the pediatric OD scores at a
single cut-point was determined using the Youden index, which
is the optimal cut-point at which both the sensitivity and spec-
ificity are maximized. In survivors, the univariate association
between the maximum and mean scores for each pediatric OD
score and the change in FSS from baseline to 6 months and
from baseline to 3 years after critical illness was determined
using linear regression.
Informed consent was obtained from the child’s parent or
guardian. The institutional review board at The University of
Chicago approved this study.
RESULTS
A total of 73 patients met inclusion criteria, 53% were male
and had a median age of 8.7 years (interquartile range, 2.2–
11.9 yr). Patients enrolled in the study had similar demo-
graphic and clinical characteristics to other patients admitted
to the PICU during the same time period. Enrolled patients
had similar median age (8.7 [2.2–11.9] vs 5.9 [1.5–13.5])
and proportion of males (53% vs 56%), African-Americans
(59% vs 58%), Whites (26% vs 21%), and surgical admissions
(27% vs 24%). They also had similar PICU mortality (4.1%
vs 3.5%) and median hospital length of stay (4.5 [2.1–12.9]
vs 3.8 [2–7.7]).
Patients in the study had 14% new morbidity or mortality
at 6 months and 23% at 3 years. Mortality was 7% at 6 months
and 11% at 3 years. Race and ethnicity were significantly
associated with development of new morbidity or mortality at
both 6 months (p = 0.01) and 3 years (p = 0.009) after critical
illness. Neither age nor gender was significantly associated with
outcome at either follow-up interval. New morbidity or mor-
tality at both 6 months and 3 years was associated with need for
mechanical ventilation, need for vasoactive infusions, increased
PICU length of stay, increased hospital length of stay, as well as
maximum pSOFA and PELOD-2 scores, and PRISM III score
at admission. Notably, baseline FSS was not significantly asso-
ciated with new morbidity or mortality at 6 months or 3 years
(Table 1).
Primary Outcome
Performance of the pSOFA and PELOD-2 scores at discrimi-
nating new morbidity or mortality at discharge was excellent at
6 months (AUCs 0.9 and 0.88, respectively) (Fig. 2A) and good
at 3 years (AUCs 0.82 and 0.79, respectively) (Fig. 2B). PRISM
III calculated in the initial 24 hours of ICU admission had fair
to good discrimination for poor functional outcomes at both
short-term and long-term follow-up intervals (AUC 0.79 and
0.75, respectively) (Fig. 2).
The optimal single cut-point for discrimination of new
morbidity or mortality was determined using the Youden
index. The diagnostic performances of the maximum pediatric
OD scores at a single cut-point at each follow-up interval are
presented in Table 2.
Secondary Outcome
In survivors, there was a positive linear association between max-
imum pSOFA and PELOD-2 scores and worsening FSS score at 6

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 Matics et al

TABLE 2. Diagnostic Performance of the Organ Dysfunction Scores for New Morbidity or
Mortality at 6 Months and 3 Years After Critical Illness Using the Youden Index Cut-Point
Maximum Pediatric Sequential Maximum Pediatric Logistic
Organ Failure Assessment Score Organ Dysfunction-2 Score

6 mo (95% CI) 3 yr (95% CI) 6 mo (95% CI) 3 yr (95% CI)

Diagnostic Measures (Score ≥ 7) (Score ≥ 6) (Score ≥ 9) (Score ≥ 5)

Sensitivity (%) 90 (56–100) 80 (52–96) 80 (44–98) 80 (52–96)

Specificity (%) 78 (66–87) 80 (67–90) 87 (77–94) 77 (63–87)
Positive predictive value (%) 39 (28–52) 55 (40–69) 50 (33–67) 50 (37–64)
Negative predictive value (%) 98 (88–100) 93 (83–97) 97 (89–99) 93 (82–97)
Positive likelihood ratio 4.1 (2.4–6.7) 4.1 (2.2–7.5) 6.3 (3.1–12.9) 3.4 (2–5.9)
Negative likelihood ratio 0.1 (0.02–0.8) 0.3 (0.1–0.7) 0.2 (0.1–0.8) 0.3 (0.1–0.7)

TABLE 3. Univariate Association of Organ Dysfunction Score and Change in Functional

Status Scale in Survivors at 6 Months and 3 Years After Critical Illness Using Linear
Regression
Change From Baseline Functional Status Scale

Scoring System 6 mo (n = 68) 3 yr (n = 58)

Maximum OD scorea Coefficient (95% CI) p Coefficient (95% CI) p

 pSOFA 0.17 (0.07–0.27) 0.001 0.11 (0.0–0.22) 0.05
 PELOD-2 0.18 (0.06–0.3) 0.004 0.13 (0.0–0.26) 0.04
Mean OD score a

 pSOFA 0.37 (0.15–0.58) 0.001 0.37 (0.15–0.58) 0.01

 PELOD-2 0.47 (0.21–0.74) 0.001 0.39 (0.1–0.68) 0.01
OD = organ dysfunction, PELOD-2 = Pediatric Logistic Organ Dysfunction-2, pSOFA = pediatric Sequential Organ Failure Assessment.
Overall maximum and mean scores for each scoring system were calculated using data from PICU admission until day 28 of hospital stay, discharge, or death,
a

whichever came first.

months (p = 0.001 and p = 0.004, respectively) and 3 years (p = 0.04
and p = 0.05, respectively). This association was also present when
using mean pSOFA and PELOD-2 scores (Table 3).
DISCUSSION
In this study, we demonstrate that, regardless of the baseline
functional status, severity of OD during critical illness predicts
the degree of loss of function in survivors of critical illness at
6 months and 3 years after discharge. Furthermore, the max-
imum pSOFA and PELOD-2 scores during critical illness have
good to excellent performance at discriminating new mor-
bidity or mortality up to 3 years after critical illness.
This is the first study to analyze the performance of pe-
diatric OD scores with regard to prediction of longitudinal
functional outcomes after critical illness. In a recent landmark
multicenter study of critically ill children, Pollack et al (3)
found that severity of illness at admission, measured using the
PRISM III score, was significantly associated with new mor-
bidity and mortality at hospital discharge. Here, we extend
the follow-up time-window to 6 months and 3 years and use
OD scores as surrogates of severity of illness during the ICU
course, in addition to severity of illness at admission.
Pinto et al (4) previously demonstrated that cumulative
morbidity and mortality more than doubled in children after 3
years of critical illness, highlighting the importance of focusing
not just on the risk of in-hospital morbidity and mortality
in critically ill children, but also on the long-term outcomes
of survivors. Although not all morbidity or mortality can
be attributed to a single episode of critical illness, it is plau-
sible that an episode of severe critical illness characterized by
a significant degree of OD will increase the risk for repeated
episodes of critical illness, progressive loss of function, and
increased risk of mortality.
Other researchers have studied functional outcomes in spe-
cific subgroups of patients, especially survivors of sepsis. A
retrospective analysis of 384 children with severe sepsis found
that 34% of survivors had a decline in their functional status at
28 days (13). Risk analysis demonstrated that baseline PRISM
III score, in addition to source of infection, recent trauma,
and cardiopulmonary resuscitation were each associated with
poor functional outcomes. In the adult population, sepsis has

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been associated with significant functional impairments in
survivors, with the development of one to two new functional
morbidities on average, a three-fold increase in moderate-to-
severe cognitive impairment, and a high prevalence of mental
health issues (14). Although the risk factors and baseline char-
acteristics are likely very different in children, it is reasonable
to expect that pediatric survivors of sepsis are also at risk of
developing significant long-term morbidity. Further studies to
characterize the risk factors and incidence of new morbidity
in survivors of pediatric sepsis and other pediatric critical ill-
nesses, such as acute respiratory distress syndrome and mul-
tiple organ dysfunction syndrome, are needed.
The results of this study have important implications. If val-
idated, they imply that information regarding the degree of OD
during critical illness may be valuable to parents and health-
care providers for prognostication of long-term outcomes and
decision-making purposes. In addition, OD scores can help
predict which children might benefit from additional support
and rehabilitation after critical illness, allowing targeted sup-
port to high-risk survivors. Whether additional support and
rehabilitation can lead to decreased longitudinal morbidity in
pediatric survivors of critical illness will have to be prospec-
tively evaluated.
This study has several limitations. First, a relatively small
cohort of patients from a single site was used given the com-
plexity of assessing short-term and long-term functional out-
comes in these patients. Second, patients were recruited during
a single season, which limits the generalizability of the per-
formance of the OD scores to other times of the year. Third,
the small sample size precluded us from performing subgroup
analyses, including stratification by specific comorbidities,
race, or age groups. Finally, because of language proficiency
limitations on the part of the research team performing phone
interviews, only English-speaking families were approached
for consent and enrolled in the study, limiting the generaliz-
ability to non–English-speaking patients. However, we believe
the implications of our results are important and, therefore, a
larger multicenter validation study is warranted.
CONCLUSIONS
Short-term and long-term morbidity and mortality are com-
mon following pediatric critical illness. Severity of OD is as-
sociated with short-term and long-term change in functional
status. Furthermore, the maximum pSOFA and PELOD-2
scores during critical illness have good to excellent perfor-
mance at predicting new morbidity or mortality up to 3 years
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Feature Articles
after critical illness. This is the first study to assess the associa-
tion of OD and longitudinal functional outcomes in children,
but a larger, multicenter validation study is warranted.
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