CUTE RESPIRATORY DISTRESS syndrome (ARDS) was originally termed the adult respiratory distress syndrome because it resembled the clinical picture of infant respiratory distress syndrome (IRDS), and both exhibited hyaline membranes at autopsy. 1,2 Avery and Mead 3 first reported that lung surfactant quantity and activity were abnormal in infants with IRDS and surfactant replacement has subsequently become standard therapy for premature infants at risk for or having IRDS. Petty and Ashbaugh 2 described qualitative and quantitative surfactant deficiencies in their initial description of ARDS and the subsequent scientific literature (recently reviewed by Notter 4) has supported the role of surfactant dysfunction in both ARDS and less severe acute lung injury (ALI). 5 Surfactant replacement in ARDS and ALI has been Author Affiliations and Participating Hospitals and Collaborating Investigators are listed at the end of this article. Financial Disclosures: Dr Willson has received research grants from ONY Inc (Amherst, NY). Dr Egan is president and equity owner of ONY Inc.

Critically ill children are at significant risk for developing anemia and receiving blood transfusions. Transfusion in the PICU was associated with worse outcomes. It is imperative to minimize blood loss from blood draws and to set clear transfusion thresholds.

OBJECTIVE To estimate the prevalence of chronic conditions among children admitted to U.S. pediatric intensive care units (PICU) and to assess whether patients with complex chronic conditions (CCC) experience PICU mortality and prolonged LOS risk beyond that predicted by commonly-used severity-of-illness risk-adjustment models. DESIGN, SETTING, & PATIENTS Retrospective cohort analysis of 52,791 pediatric admissions to 54 U.S. PICUs that participated in the Virtual Pediatric Intensive Care Unit Performance System (VPS) database in 2008. MEASUREMENTS Hierarchical logistic regression models, clustered by PICU site, for PICU mortality and length of stay (LOS) > 15 days. Standardized mortality ratios (SMR) adjusted for severity-of-illness score alone and with CCC. MAIN RESULTS Fifty-three percent of PICU admissions had a CCC, 18.5% had a non-complex chronic conditions (NCCC). The prevalence of these conditions and their organ system subcategories varied considerably across sites. The majority of CCC subcategories were associated with significantly greater odds of PICU mortality (odds ratios [OR] 1.25–2.9, all P values <0.02) compared to having a non-complex chronic condition (NCCC) or no chronic condition, after controlling for age, gender, trauma, and severity-of-illness. Only respiratory, gastrointestinal, and rheumatologic/orthopedic/psychiatric CCC were not associated with increased odds of PICU mortality. All subcategories were significantly associated with prolonged LOS. All NCCC subcategories were either not associated or negatively associated with PICU mortality, and most were not associated with prolonged LOS, compared to having no chronic conditions. Among this group of PICUs, adding CCCs to risk-adjustment models led to greater model accuracy but did not substantially change unit-level SMRs. CONCLUSIONS Children with CCC were at greater risk for PICU mortality and prolonged LOS than those with no chronic conditions, but the magnitude of risk varied across subcategories. Inclusion of CCCs into models of PICU mortality improved model accuracy but had little impact on SMRs.