Joseph A Carcillo

Society of Critical Care Medicine, Pittsburgh, Pennsylvania, United States

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Publications (267)908.49 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Assessments of care including quality assessments adjusted for physiological status should include the development of new morbidities as well as mortalities. We hypothesized that morbidity, like mortality, is associated with physiological dysfunction and could be predicted simultaneously with mortality. Prospective cohort study from December 4, 2011, to April 7, 2013. General and cardiac/cardiovascular PICUs at seven sites. Randomly selected PICU patients from their first PICU admission. None. Among 10,078 admissions, the unadjusted morbidity rates (measured with the Functional Status Scale and defined as an increase of ≥ 3 from preillness to hospital discharge) were 4.6% (site range, 2.6-7.7%) and unadjusted mortality rates were 2.7% (site range, 1.3-5.0%). Morbidity and mortality were significantly (p < 0.001) associated with physiological instability (measured with the Pediatric Risk of Mortality III score) in dichotomous (survival and death) and trichotomous (survival without new morbidity, survival with new morbidity, and death) models without covariate adjustments. Morbidity risk increased with increasing Pediatric Risk of Mortality III scores and then decreased at the highest Pediatric Risk of Mortality III values as potential morbidities became mortalities. The trichotomous model with covariate adjustments included age, admission source, diagnostic factors, baseline Functional Status Scale, and the Pediatric Risk of Mortality III score. The three-level goodness-of-fit test indicated satisfactory performance for the derivation and validation sets (p > 0.20). Predictive ability assessed with the volume under the surface was 0.50 ± 0.019 (derivation) and 0.50 ± 0.034 (validation) (vs chance performance = 0.17). Site-level standardized morbidity ratios were more variable than standardized mortality ratios. New morbidities were associated with physiological status and can be modeled simultaneously with mortality. Trichotomous outcome models including both morbidity and mortality based on physiological status are suitable for research studies and quality and other outcome assessments. This approach may be applicable to other assessments presently based only on mortality.
    Critical care medicine 05/2015; DOI:10.1097/CCM.0000000000001081 · 6.15 Impact Factor
  • Trung C Nguyen, Joseph A Carcillo
    Pediatric Critical Care Medicine 05/2015; 16(4):383-5. DOI:10.1097/PCC.0000000000000372 · 2.33 Impact Factor
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    ABSTRACT: The magnitude and role of the cellular immune response following pediatric traumatic brain injury remains unknown. We tested the hypothesis that macrophage/microglia and T-cell activation occurs following pediatric traumatic brain injury by measuring cerebrospinal fluid levels of soluble cluster of differentiation 163 and ferritin and soluble interleukin-2 receptor α, respectively, and determined whether these biomarkers were associated with relevant clinical variables and outcome. Retrospective analysis of samples from an established, single-center cerebrospinal fluid bank. PICU in a tertiary children's hospital. Sixty-six pediatric patients after severe traumatic brain injury (Glasgow Coma Scale score < 8) who were 1 month to 16 years old and 17 control patients who were 1 month to 14 years old. None. Cerebrospinal fluid levels of soluble cluster of differentiation 163, ferritin, and soluble interleukin-2 receptor α were determined by enzyme-linked immunosorbent assay at two time points (t1 = 17 ± 10 hr; t2 = 72 ± 15 hr) for each traumatic brain injury patient. Cerebrospinal fluid levels of soluble cluster of differentiation 163, ferritin, and soluble interleukin-2 receptor α after traumatic brain injury were compared with controls and analyzed for associations with age, patient sex, initial Glasgow Coma Scale score, diagnosis of abusive head trauma, the presence of hemorrhage on CT scan, and Glasgow Outcome Scale score. Cerebrospinal fluid level of soluble cluster of differentiation 163 was increased in traumatic brain injury patients at t2 versus t1 and controls (median, 95.4 ng/mL [interquartile range, 21.8-134.0 ng/mL] vs 31.0 ng/mL [5.7-77.7 ng/mL] and 27.8 ng/mL [19.1-43.1 ng/mL], respectively; p < 0.05). Cerebrospinal fluid level of ferritin was increased in traumatic brain injury patients at t2 and t1 versus controls (8.3 ng/mL [<7.5-19.8 ng/mL] and 8.9 ng/mL [<7.5-26.7 ng/mL] vs <7.5 ng/mL below lower limit of detection, respectively; p < 0.05). Cerebrospinal fluid levels of soluble interleukin-2 receptor α in traumatic brain injury patients at t2 and t1 were not different versus controls. Multivariate regression revealed associations between high ferritin and age 4 years or younger, lower Glasgow Coma Scale score, abusive head trauma, and unfavorable Glasgow Outcome Scale score. Children with traumatic brain injury demonstrate evidence for macrophage activation after traumatic brain injury, and in terms of cerebrospinal fluid ferritin, this appears more prominent with young age, initial injury severity, abusive head trauma, and unfavorable outcome. Further study is needed to determine whether biomarkers of macrophage activation may be used to discriminate between aberrant and adaptive immune responses and whether inflammation represents a therapeutic target after traumatic brain injury.
    Pediatric Critical Care Medicine 04/2015; DOI:10.1097/PCC.0000000000000400 · 2.33 Impact Factor
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    ABSTRACT: To examine the feasibility of deploying a virtual web service for sharing data within a research network, and to evaluate the impact on data consistency and quality. Virtual machines (VMs) encapsulated an open-source, semantically and syntactically interoperable secure web service infrastructure along with a shadow database. The VMs were deployed to 8 Collaborative Pediatric Critical Care Research Network Clinical Centers. Virtual web services could be deployed in hours. The interoperability of the web services reduced format misalignment from 56% to 1% and demonstrated that 99% of the data consistently transferred using the data dictionary and 1% needed human curation. Use of virtualized open-source secure web service technology could enable direct electronic abstraction of data from hospital databases for research purposes. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.
    Journal of the American Medical Informatics Association 03/2015; DOI:10.1093/jamia/ocv009 · 3.93 Impact Factor
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    ABSTRACT: To evaluate patterns of multiorgan dysfunction and neurologic outcome in children with respiratory and cardiac arrest after drowning. Single center retrospective chart review of children aged 0 to 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 24hours 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. 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 24hours of admission were respiratory, followed by neurologic, cardiovascular, gastrointestinal, hematological, and least commonly, renal. 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. Copyright © 2015. Published by Elsevier Ireland Ltd.
    Resuscitation 02/2015; 90. DOI:10.1016/j.resuscitation.2015.02.005 · 3.96 Impact Factor
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    ABSTRACT: Changes in technology and increased reports of successful extracorporeal life support use in patient populations, such as influenza, cardiac arrest, and adults, are leading to expansion of extracorporeal life support. Major limitations to extracorporeal life support expansion remain bleeding and thrombosis. These complications are the most frequent causes of death and morbidity. As a pilot project to provide baseline data for a detailed evaluation of bleeding and thrombosis in the current era, extracorporeal life support patients were analyzed from eight centers in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Retrospective analysis of patients (< 19 yr) reported to the Extracorporeal Life Support Organization registry from eight Collaborative Pediatric Critical Care Research Network centers between 2005 and 2011. Tertiary children's hospitals within the Collaborative Pediatric Critical Care Research Network. The study cohort consisted of 2,036 patients (13% with congenital diaphragmatic hernia). None. In the cohort of patients without congenital diaphragmatic hernia (n = 1,773), bleeding occurred in 38% of patients, whereas thrombosis was noted in 31%. Bleeding and thrombosis were associated with a decreased survival by 40% (relative risk, 0.59; 95% CI, 0.53-0.66) and 33% (odds ratio, 0.67; 95% CI, 0.60-0.74). Longer duration of extracorporeal life support and use of venoarterial cannulation were also associated with increased risk of bleeding and/or thrombotic complications and lower survival. The most common bleeding events included surgical site bleeding (17%; n = 306), cannulation site bleeding (14%; n = 256), and intracranial hemorrhage (11%; n = 192). Common thrombotic events were clots in the circuit (15%; n = 274) and the oxygenator (12%; n = 212) and hemolysis (plasma-free hemoglobin > 50 mg/dL) (10%; n = 177). Among patients with congenital diaphragmatic hernia, bleeding and thrombosis occurred in, respectively, 45% (n = 118) and 60% (n = 159), Bleeding events were associated with reduced survival (relative risk, 0.62; 95% CI, 0.46-0.86) although thrombotic events were not (relative risk, 0.92; 95% CI, 0.67-1.26). Bleeding and thrombosis remain common complications in patients undergoing extracorporeal life support. Further research to reduce or eliminate bleeding and thrombosis is indicated to help improve patient outcome.
    Pediatric Critical Care Medicine 02/2015; 16(2):167-74. DOI:10.1097/PCC.0000000000000317 · 2.33 Impact Factor
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    ABSTRACT: To investigate significant new morbidities associated with pediatric critical care.
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    ABSTRACT: Thrombocytopenia-associated multiple organ failure can lead to high mortality in critically ill children, possibly related to consequences of thrombotic microangiopathy. Plasma exchange therapy may improve thrombotic microangiopathy. The purpose of this observational cohort study is to describe whether there is an association between use of plasma exchange therapy and outcome in the Turkish thrombocytopenia-associated multiple organ failure network.
    Pediatric Critical Care Medicine 07/2014; 15(8). DOI:10.1097/PCC.0000000000000227 · 2.33 Impact Factor
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    ABSTRACT: The cortisol response during critical illness varies widely among patients. Our objective was to examine single nucleotide polymorphisms in candidate genes regulating cortisol synthesis, metabolism, and activity to determine if genetic differences were associated with variability in the cortisol response among critically ill children.
    Pediatric Critical Care Medicine 07/2014; 15(8). DOI:10.1097/PCC.0000000000000193 · 2.33 Impact Factor
  • Joseph A Carcillo
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    ABSTRACT: To review the past year's literature, and selected prior literature relevant to these most recent findings, regarding intravenous fluid choices in the management of critically ill children.
    Current Opinion in Critical Care 06/2014; DOI:10.1097/MCC.0000000000000119 · 3.18 Impact Factor
  • Pediatric Critical Care Medicine 06/2014; 15(5):486-488. DOI:10.1097/PCC.0000000000000098 · 2.33 Impact Factor
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    ABSTRACT: IMPORTANCE Functional status assessment methods are important as outcome measures for pediatric critical care studies. OBJECTIVE To investigate the relationships between the 2 functional status assessment methods appropriate for large-sample studies, the Functional Status Scale (FSS) and the Pediatric Overall Performance Category and Pediatric Cerebral Performance Category (POPC/PCPC) scales. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study with random patient selection at 7 sites and 8 children's hospitals with general/medical and cardiac/cardiovascular pediatric intensive care units (PICUs) in the Collaborative Pediatric Critical Care Research Network. Participants included all PICU patients younger than 18 years. MAIN OUTCOMES AND MEASURES Functional Status Scale and POPC/PCPC scores determined at PICU admission (baseline) and PICU discharge. We investigated the association between the baseline and PICU discharge POPC/PCPC scores and the baseline and PICU discharge FSS scores, the dispersion of FSS scores within each of the POPC/PCPC ratings, and the relationship between the FSS neurologic components (FSS-CNS) and the PCPC. RESULTS We included 5017 patients. We found a significant (P < .001) difference between FSS scores in each POPC or PCPC interval, with an FSS score increase with each worsening POPC/PCPC rating. The FSS scores for the good and mild disability POPC/PCPC ratings were similar and increased by 2 to 3 points for the POPC/PCPC change from mild to moderate disability, 5 to 6 points for moderate to severe disability, and 8 to 9 points for severe disability to vegetative state or coma. The dispersion of FSS scores within each POPC and PCPC rating was substantial and increased with worsening POPC and PCPC scores. We also found a significant (P < .001) difference between the FSS-CNS scores between each of the PCPC ratings with increases in the FSS-CNS score for each higher PCPC rating. CONCLUSIONS AND RELEVANCE The FSS and POPC/PCPC system are closely associated. Increases in FSS scores occur with each higher POPC and PCPC rating and with greater magnitudes of change as the dysfunction severity increases. However, the dispersion of the FSS scores indicated a lack of precision in the POPC/PCPC system when compared with the more objective and granular FSS. The relationship between the PCPC and the FSS-CNS paralleled the relationship between the FSS and POPC/PCPC system.
    05/2014; 168(7). DOI:10.1001/jamapediatrics.2013.5316
  • Pediatric Critical Care Medicine 05/2014; 15(4):380-2. DOI:10.1097/PCC.0000000000000096 · 2.33 Impact Factor
  • Joseph A Carcillo
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    ABSTRACT: This is a synopsis of the term newborn and infant portion of the 2007 document (Brierley et al., Crit Care Med 2009;37(2):666-88) which examined and graded new studies performed to test the utility and efficacy of the 2002 recommendations. This 2007 document examined and graded relevant new treatment and outcome studies to determine to what degree, if any, the 2002 guidelines should be modified. More than 30 clinical investigators and clinicians affiliated with the Society of Critical Care Medicine who had special interest in hemodynamic support of pediatric patients with sepsis volunteered to be members of the "update" task force. Subcommittees were formed to review and grade the literature using the evidence-based scoring system of the American College of Critical Care Medicine. The literature was accrued in part by searching PUBMED/MEDLINE using the following keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, and ECMO. The search was narrowed to identify studies specifically relevant to term newborns, infants, and children. "Best Practice Outcomes" were identified and described clinical practice in these centers was used as a model. The new taskforce is presently working on updating new guidelines evaluating the literature of the past 6 years.
    Early human development 03/2014; 90S1:S45-S47. DOI:10.1016/S0378-3782(14)70015-5 · 1.93 Impact Factor
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    ABSTRACT: E-PAS2014:1150.5
    Pediatric Academic Societies'; 01/2014
  • 43rd Annual Critical Care Congress; 12/2013
  • Joseph A Carcillo
    Critical care medicine 12/2013; 41(12):e489. DOI:10.1097/CCM.0000000000000058 · 6.15 Impact Factor
  • Critical care medicine 10/2013; 41(10):e295. DOI:10.1097/CCM.0b013e3182a51cf0 · 6.15 Impact Factor
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    ABSTRACT: Objectives: The aim of this study was to evaluate the relative frequency of pediatric in-hospital cardiopulmonary resuscitation events occurring in ICUs compared to general wards. We hypothesized that the proportion of pediatric cardiopulmonary resuscitation provided in ICUs versus general wards has increased over the past decade, and this shift is associated with improved resuscitation outcomes. Design: Prospective and observational study. Setting: Total of 315 hospitals in the American Heart Association’s Get With The Guidelines-Resuscitation database. Patients: Total of 5,870 pediatric cardiopulmonary resuscitation events between January 1, 2000 and September 14, 2010. Cardiopulmonary resuscitation events were defined as external chest compressions longer than 1 minute. Interventions: None. Measurements and Main Results: The primary outcome was proportion of total ICU versus general ward cardiopulmonary resuscitation events over time evaluated by chi-square test for trend. Secondary outcome included return of spontaneous circulation following the cardiopulmonary resuscitation event. Among 5,870 pediatric cardiopulmonary resuscitation events, 5,477 (93.3%) occurred in ICUs compared to 393 (6.7%) in inpatient wards. Over time, significantly more of these cardiopulmonary resuscitation events occurred in the ICU compared to the wards (test for trend: p < 0.01), with a prominent shift noted between 2003 and 2004 (2000–2003: 87–91% vs 2004–2010: 94–96%). In a multivariable model controlling for within center variability and other potential confounders, return of spontaneous circulation increased in 2004–2010 compared with 2000–2003 (relative risk, 1.08; 95% CI, 1.03–1.13). Conclusions: In-hospital pediatric cardiopulmonary resuscitation is much more commonly provided in ICUs than in wards, and the proportion has increased significantly over the past decade, with concomitant increases in return of spontaneous circulation.
    Critical Care Medicine 10/2013; 41(10):2292-2297. DOI:10.1097/CCM.0b013e31828cf0c0 · 6.15 Impact Factor
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    ABSTRACT: Background:Sepsis continues to be a leading cause of death in infants and children. Natural killer (NK) cells serve as a bridge between innate and adaptive immunity, yet their role in pediatric sepsis has not been well characterized.Methods:We tested the hypothesis that decreased NK cell cytotoxicity is a common feature of pediatric systemic inflammatory response syndrome (SIRS)/sepsis patients by measuring, using flow cytometry, NK cell cytotoxicity and cell surface phenotype in the peripheral blood of 38 pediatric intensive care patients who demonstrated signs and symptoms of either SIRS and/or sepsis.Results:NK cell cytotoxicity was significantly reduced in PBMC of pediatric SIRS/sepsis patients as compared to healthy controls, and the percentage of CD56(dim) CD16(+) cytotoxic NK cells in peripheral blood mononuclear cells (PBMC) was lower in patients with SIRS/sepsis than in normal donors. However, on a per cell basis, CD56(dim) CD16(+) NK cells in patients mediated cytotoxicity as well as those in normal donors.Conclusion:The NK cell dysfunction in pediatric SIRS/sepsis patients reflects a quantitative rather than a qualitative difference from normal.Pediatric Research (2013); doi:10.1038/pr.2013.121.
    Pediatric Research 07/2013; 74(4). DOI:10.1038/pr.2013.121 · 2.84 Impact Factor

Publication Stats

12k Citations
908.49 Total Impact Points

Institutions

  • 2015
    • Society of Critical Care Medicine
      Pittsburgh, Pennsylvania, United States
  • 1997–2015
    • Childrens Hospital of Pittsburgh
      • • Department of Pediatric Critical Care Medicine
      • • Department of Pediatrics
      Pittsburgh, Pennsylvania, United States
  • 1995–2014
    • University of Pittsburgh
      • • Department of Pediatrics
      • • Department of Critical Care Medicine
      • • Department of Medicine
      • • Division of Pediatric Pathology at Children's Hospital of Pittsburgh of UPMC
      Pittsburgh, Pennsylvania, United States
  • 2013
    • Cooper University Hospital
      Camden, New Jersey, United States
    • Boston Children's Hospital
      Boston, Massachusetts, United States
  • 2011–2013
    • UPMC
      Pittsburgh, Pennsylvania, United States
    • Hospital of the University of Pennsylvania
      Philadelphia, Pennsylvania, United States
  • 2006–2011
    • University of Utah
      • Department of Pediatrics
      Salt Lake City, UT, United States
    • Cincinnati Children's Hospital Medical Center
      Cincinnati, Ohio, United States
  • 2010
    • University of British Columbia - Vancouver
      Vancouver, British Columbia, Canada
  • 2005–2008
    • University of São Paulo
      • Faculty of Medicine (FM)
      San Paulo, São Paulo, Brazil
    • Baylor College of Medicine
      • Department of Pediatrics
      Houston, TX, United States
  • 2004
    • Stony Brook University
      • Department of Pediatrics
      Stony Brook, NY, United States
  • 2003
    • University of Rochester
      • School of Nursing
      Rochester, New York, United States
    • National Institute of Child Health and Human Development
      Maryland, United States
  • 2001
    • University of Malaya
      • Department of Paediatrics
      Kuala Lumpor, Kuala Lumpur, Malaysia
  • 1999
    • Humboldt-Universität zu Berlin
      Berlín, Berlin, Germany
  • 1996
    • Berkeley Earth
      Washington, Washington, D.C., United States