Elsevier

Resuscitation

Volume 90, May 2015, Pages 91-96
Resuscitation

Clinical paper
Patterns of multiorgan dysfunction after pediatric drowning☆

https://doi.org/10.1016/j.resuscitation.2015.02.005Get rights and content

Abstract

Aims

To evaluate patterns of multiorgan dysfunction and neurologic outcome in children with respiratory and cardiac arrest after drowning.

Methods

Single center retrospective chart review of children aged 0–21 years admitted between January 2001 and January 2012 to the pediatric intensive care unit at Children's Hospital of Pittsburgh with a diagnosis of drowning/submersion/immersion. Organ dysfunction scores were calculated for first 24 h of admission as defined by the Pediatric Logistic Organ Dysfunction Score-1 (PELOD-1) and Pediatric Multiple Organ Dysfunction Score (P-MODS). Neurologic outcome at hospital discharge was assigned Pediatric Cerebral and Overall Performance Category Scale scores.

Results

We identified 60 cases of pediatric drowning in which 21 children experienced cardiorespiratory arrest (CA) and 39 had respiratory arrest (RA). All children with CA had multiorgan failure and 81% had a poor neurologic outcome at hospital discharge while 49% of children with RA had multiorgan failure and none had an unfavorable neurological outcome (p < 0.001). The most common organ failures in both CA and RA groups within the first 24 h of admission were respiratory, followed by neurologic, cardiovascular, gastrointestinal, hematological, and least commonly, renal.

Conclusion

Patterns of organ failure differ in children with CA and RA due to drowning. The contribution of multiorgan failure to poor outcome and evaluation of the impact of augmenting cerebral resuscitation with MOF-targeting therapies after drowning deserves to be explored.

Introduction

Drowning is the leading cause of unintentional injury-related death and disability worldwide between the ages of 1 and 4 years and the third leading cause in the United States between the ages of 1 and 21 years.1 Drowning occurs from primary respiratory impairment due to submersion in a liquid medium,2, 3, 4 and is followed by breath-holding and involuntary laryngospasm that leads to hypercapnia, hypoxemia, and if prolonged, respiratory (RA) and or cardiorespiratory arrest (CA).2, 5, 6 Systemic hypoxemia and/or ischemia during RA or CA, respectively, increase the risk of hepatic, renal, and neurologic organ injury and reversible or irreversible impairment of function.2, 5, 7

Duration of submersion under water and need for cardiopulmonary resuscitation (CPR) after extraction are associated with outcome in pediatric drowning. Children who progress to CA and have generalized edema present on early brain computed tomography uniformly have poor outcomes.8 Children with RA are still at increased risk of disability and death.9 Reports on neurologic outcome and mortality after drowning-related RA are lacking but mortality in all-cause acute respiratory failure is 22–40% in children.10, 11

Typpo and colleagues12 have reported on multiple organ dysfunction syndrome (MODS) on Day 1 of pediatric intensive care unit (PICU) admission and found an incidence of 18%, with 30–35% of those having an unfavorable neurologic outcome. Post-resuscitation MODS is not well described after pediatric drowning specifically. Our primary objective was to explore the severity and patterns of MODS in the first 24 h in children with CA and RA after drowning.

Section snippets

Methods

This is a single center retrospective chart review of children aged 0–21 years admitted between January 2001 and January 2012 to the PICU at Children's Hospital of Pittsburgh with a diagnosis of drowning, submersion, or immersion per International Classification of Diseases, volume 9 (ICD-9) codes (994.1, E830, E830.1–830.9, E832, E910, E910.1–910.4, E910.8, E910.9, E954, E965, E984, E979.8). The Institutional Review Board of University of Pittsburgh approved the study and informed consent was

Patients and drowning characteristics

We identified 60 children who met study criteria over the study period with a median age of 2.4 years and 60% were males (Table 1). Fifty-seven events occurred in the summer months (May–October). Forty-one (68%) of the events were unwitnessed and the median reported submersion time was 2 min (range 0–30 min). Median CPR duration in children with CA was 2 min and ranged from 1 to 90 min. Thirty-nine (65%) children were in RA and 21 (35%) were in CA at the drowning location. Most 41 (68%) children

Discussion

To our knowledge, this is the first study to describe and compare early (first 24 h of PICU admission) patterns of organ dysfunction in children with CA or RA due to drowning. Multiorgan dysfunction and unfavorable neurologic outcome were more common and more severe after CA in comparison to children with RA. The most common organ system failures in both groups were the respiratory, neurologic and cardiovascular systems. Although having RA did not preclude development of early MODS, favorable

Conclusions

Drowning with CA conferred the greatest risk for early MODS and resulted in a worse neurologic outcome than children with RA, but MODS in children with RA did not result in unfavorable outcome. Prospective research is needed to discern whether or not specific therapies targeting extra-cerebral facets of MODS, particularly, respiratory, and cardiovascular targets in the resuscitation and post-resuscitation periods may confer added benefit to current brain-oriented therapy to improve outcomes

Conflict of interest statement

None declared.

Acknowledgements

The authors are supported by a variety of federal grants (PMK: NS070003; JAC: GM108618; MJB: NS081041; ELF: K23NS065132).

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    ☆

    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.02.005.

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