Clinical paperPatterns of multiorgan dysfunction after pediatric drowning☆
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.