COMPARISON OF THE PEDIATRIC RISK OF MORTALITY,

PEDIATRIC INDEX OF MORTALITY, AND PEDIATRIC

INDEXOF MORTALITY 2 MODELS IN A PEDIATRIC
INTENSIVE CARE UNIT IN CHINA
Journal Reading
Rahmawan Sakup M.

Pembimbing
DR. dr. Edi Hartoyo Sp.A (K)
INTRODUCTION
The aim of pediatric intensive care units
(PICUs) is to provide quality care for
critically ill children.

Pediatric risk of mortality (PRISM and PRISM III

and the pediatric index of mortality and pediatric
index of mortality 2 (PIM and PIM2) are used to
measure the severity illness and mortality risk.

Performance of the PRISM and PIM scoring

systems has been compared only in certain
specific disease categories or within heterogenic
groups of patients from PICUs
In previous study in 2015, only 412 discontinuous
critically ill pediatric patients transferred to Hunan
Children’s Hospital were included.

The present study was designed to compare the

performances of PRISM, PIM, and PIM2 for 852
continuous critically ill pediatric patients in a
PICU in China.
P I C O P
All patients consecutively admitted to
the PICU in Hunan Children’s
Hospital between January 1 and
December 31, 2014.

I No intervention.
Pediatric risk of mortality (PRISM),

C pediatric index of mortality (PIM),

and revised pediatric index of
mortality 2 (PIM2)

O Discriminatory performance of
PRISM, PIM, and PIM2.
 METHODS
Exclusion

Inclusion

Population
Died within 2
hours of
Design admission or if
Patients who they were
survived until discharged
All patients
consecutively the end of the within 24 hours
admitted to the PICU stay of admission.
PICU in Hunan
Analytic
Children’s Hospital
comparative
from Jan 1 - Dec 31,
study
2014.
METHODS
852 patients
enrolled

107 patients
died

745 patients
survived
RESULTS
Results

• Expected mortality was 94.14 patients (11.05%) by PRISM, 56.50

(6.63%) by PIM, and 50.20 (5.89%) by PIM2.
• The estimated probabilities of death revealed a positive and
significant correlation between PRISM and the 2 PIM models with
a Pearson correlation coefficient of r=0.490 (P<0.001) and 0.477
(P<0.001), respectively. The correlation coefficient between PIM
and PIM2 was 0.938 (P<0.001).
Results

• The Bland–Altman plot was used to reveal the differences

between the 2 scores. The Bland–Altman plot with linear
regression analyses with 95% confidence limits is presented in
Figs. 2–4. A significant difference among the PRISM, PIM, and
PIM2 was not observed.
DISCUSSION
 DISCUSSION
• All 3 scoring systems demonstrated acceptable discrimination
between death and survival with AUCs>0.70.
• The fit between observed and expected outcomes was close for all
3 models.
• In the present study, under-prediction in certain predicted
probability levels could be related to the PICU in question.
 DISCUSSION
• First, the majority of patients enrolled in this study had respiratory
disorders. And patients with mechanical ventilation have normal
blood gases at admission to PICU, which lead to the lower value of
FiO2/PaO2 and base excess. Thus, these patients would have low
scores for all 3 models.
• Second, under-prediction could be attributed to the low number of
deaths at each risk interval.
• Third, due to the availability of specialized emergency medical
services and transfer centers, patients are often stabilized before
admission to the PICU.
 DISCUSSION
• This study has demonstrated that the performance of the 3 models
is similar in terms of their capacity to discriminate between
surviving and moribund patients. Nevertheless, PIM exhibited a
poor calibration capacity.
Strength and Limitation
01 STRENGTH

• Appropriate follow up
• Appropriate variables involved

02 LIMITATION

• Small sample size

• All data used in this study were
obtained from a single PICU
 VALIDITY
Are the results of the study valid?
1. Was the defined representative sample of
patients assembled at a common (usually early)
point in the course of their disease?
2. Was patient follow-up sufficiently long and
complete
3. Were outcome criteria either objective or applied
in a blind fashion?
Yes.
This study comprised all consecutive patients
admitted to PICU. This study used the sample size
calculating formula for a validation study.
Yes.
This study was conducted at Hunan Children’s
Hospital between January 1 and December 31,
2014. The follow up started from the admission to
patient outcomes (death or survival) and length of
stay in the PICU were also recorded.
Yes.
Data were collected by a team of experienced
research nurses, and the treating team was blinded
to these scores and predictions.
 IMPORTANCE

How likely are the outcomes over time? How precise are the prognostic estimates?
All 3 scoring systems demonstrated acceptable The small sample size is likely to interfere with the
discrimination between death and survival. accurate application of the Hosmer–Lemeshow test for
goodness of fit.

The fit between observed and expected outcomes was Further confirmation of the results obtained in this
close for all 3 models. study is warranted before the generalized use of these
scores in a hospital setting.
 APPLICABILITY
Can I apply this valid, important evidence about prognosis to my patient?
Is my patient so different to those in the study that My patients have similar characteristic with those in
the results cannot apply the study. The result can be applied to my patients
Will this evidence make a clinically important impact Yes, this evidence will make a clinically important
on my conclusions about what to offer to tell my impact
patients?
• PRISM, PIM, and PIM2 scores
discriminate between surviving and
moribund patients. Both the PRISM
and PIM2 models displayed good
calibrations, while this was not the
case for PIM.
• A positive correlation was observed
across the PRISM, PIM, and PIM2
scores.
• Application of PRISM had a good
score in PICU in China.

Conclusion
Thank You