title: Extracorporeal therapies in pediatric severe sepsis: findings from the pediatric health-care information system.
abstract: BACKGROUND
  Pediatric severe sepsis (PSS) continues to be a major health problem. Extracorporeal therapies (ETs), defined as extracorporeal membrane oxygenation (ECMO) and RRenal replacement therapyenal replacement therapy (RRT), are becoming more available for utilization in a variety of health conditions. We aim to describe (1) rates of utilization of ET in PSS, (2) outcomes for PSS patients receiving ET, and (3) epidemiologic characteristics of patients receiving ET.
  
  
  METHODS
  We conducted a retrospective review of a prospectively collected database. Data from the Pediatric Health Information System (PHIS) database collected by the Children's Hospital Association (CHA) from 2004-2012 from 43 US children's hospitals' pediatric intensive care units (PICUs) were used. Patients with PSS were defined by (1) International Classification of Diseases, 9th Revision (ICD-9) codes reflecting severe sepsis and septic shock and (2) ICD-9 codes of infection and organ dysfunction as defined by updated Angus criteria. Among the patients with PSS, those with a PHIS flag of ECMO or RRT were identified further as our main cohort.
  
  
  RESULTS
  From 2004 to 2012, 636,842 patients were identified from 43 hospitals, and PSS prevalence was 7.7 % (49,153 patients). Nine point eight percent (4795 patients) received at least one form of ET, and the associated mortality rate was 39 %. Mortality rates were 47.8 % for those who received ECMO, 32.3 % in RRT, and 58.0 % in RRT + ECMO. Underlying co-morbidities were found in 3745 patients (78.1 %) who received ET (81 % for ECMO, 77.9 % in RRT, and 71.2 % in those who received both). There was a statistically significant increase in ECMO utilization in patients with at least three organ dysfunctions from 2004 to 2012 (6.9 % versus 10.3 %, P < 0.001) while RRT use declined (24.5 % versus 13.2 %, P < 0.001). After 2009, there was a significant increase in ECMO utilization (3.6 % in 2004-2008 versus 4.0 % in 2009-2012, P = 0.004). ECMO and RRT were used simultaneously in only 500 patients with PSS (1 %).
  
  
  CONCLUSIONS
  ETs were used in a significant portion of PSS patients with multiple organ dysfunction syndrome (MODS) during this time period. Mortality was significant and increased with increasing organ failure. ECMO use in PSS patients with MODS increased from 2004 to 2012. Further evaluation of ET use in PSS is warranted.
authors.affiliation: Division of Pediatric Critical Care Medicine, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA, 30322, USA. amanda.ruth@choa.org.|Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive, Atlanta, GA, 30322, USA. amanda.ruth@choa.org.
authors.forename: Amanda
authors.initials: A
authors.lastname: Ruth
authors.affiliation: Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive, Atlanta, GA, 30322, USA. courtney.mccracken@emory.edu.
authors.forename: Courtney E
authors.initials: CE
authors.lastname: McCracken
authors.affiliation: Division of Pediatric Critical Care Medicine, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA, 30322, USA. james.fortenberry@choa.org.|Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive, Atlanta, GA, 30322, USA. james.fortenberry@choa.org.|Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA. james.fortenberry@choa.org.
authors.forename: James D
authors.initials: JD
authors.lastname: Fortenberry
authors.affiliation: Division of Pediatric Critical Care Medicine, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA, 30322, USA. kiran.hebbar@choa.org.|Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive, Atlanta, GA, 30322, USA. kiran.hebbar@choa.org.|Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA. kiran.hebbar@choa.org.
authors.forename: Kiran B
authors.initials: KB
authors.lastname: Hebbar
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015897:Comorbidity; D016208:Databases, Factual; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods / Q000401:mortality / Q000706:statistics & numerical data; D005260:Female; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009102:Multiple Organ Failure / Q000453:epidemiology; D017582:Renal Replacement Therapy / Q000379:methods* / Q000401:mortality / Q000706:statistics & numerical data; D012189:Retrospective Studies; D018805:Sepsis / Q000453:epidemiology / Q000401:mortality / Q000628:therapy*; D014481:United States / Q000453:epidemiology; D055815:Young Adult