Advances in the Management of Pediatric Septic Shock: Old Questions, New Answers

Role of diagnostic tests for sepsis in children: a review

Paediatric sepsis has a significant global impact and highly heterogeneous clinical presentation. The clinical pathway encompasses recognition, escalation and de-escalation. In each aspect, diagnostics have a fundamental influence over outcomes in children. Biomarkers can aid in creating a larger low-risk group of children from those in the clinical grey area who would otherwise receive antibiotics 'just in case'. Current biomarkers include C reactive protein and procalcitonin, which are limited in their clinical use to guide appropriate and rapid treatment. Biomarker discovery has focused on single biomarkers, which, so far, have not outperformed current biomarkers, as they fail to recognise the complexity of sepsis. The identification of multiple host biomarkers that may form a panel in a clinical test has the potential to recognise the complexity of sepsis and provide improved diagnostic performance. In this review, we discuss novel biomarkers and novel ways of using existing biomarkers in the assessment and management of sepsis along with the significant challenges in biomarker discovery at present. Validation of biomarkers is made less meaningful due to methodological heterogeneity, including variations in sepsis diagnosis, biomarker cut-off values and patient populations. Therefore, the utilisation of platform studies is necessary to improve the efficiency of biomarkers in clinical practice.

Management of septic shock by pediatric residents: An area for quality improvement

BACKGROUND

Compliance with sepsis guidelines has been shown to be linked to better outcomes in patients with septic shock; however, adherence to these guidelines is not consistent among pediatric healthcare providers. In Tunisia, the management of children with septic shock is initiated by the pediatric resident on call.

METHODS

This study assessed the compliance of Tunisian pediatric residents with the 2020 "Surviving Sepsis Campaign" guidelines and identified factors that could improve compliance. We conducted a cross-sectional national study based on an online survey (SurveyMonkey) presenting a clinical pediatric case of septic shock. The survey was sent to the 200 residents registered in the Tunisian pediatric residency program.

RESULTS

The response rate was 72%, with 144 residents replying to the survey. Up to 72.9% of the residents had good compliance with the 1-h bundle: obtaining blood cultures prior to antibiotics, early administration of intravenous (IV) antibiotics, IV fluid expansion, and vasopressor for fluid-refractory septic shock. Factors independently associated with good compliance were a pediatric intensive care unit rotation (odds ratio [OR]: 5.17, 95% confidence interval [CI]: 1.44-18.58; p = 0.012), availability of a written protocol (OR: 9.09, 95% CI: 2.67-30.97; p<0.001), an on-call senior supervisor on site (OR: 6.76, 95% CI: 2.24-20.40; p = 0.001), and European Pediatric Advanced Life Support (EPALS) certification (OR: 13.47, 95% CI: 3.05-59.31; p = 0.001).

CONCLUSION

These factors could be considered in the process of a quality improvement strategy that ultimately better promotes performance in pediatric sepsis management and may improve patient outcomes.

MiR-702-3p inhibits the inflammatory injury in septic H9c2 cells by regulating NOD1

BACKGROUND

Cardiac insufficiency is a common complication of sepsis and septic shock and is the most common cause of death in critically ill patients. Recent studies have found that microRNAs (miRNAs) play a potential role in sepsis as markers, but little is known about their functional effects on sepsis-induced cardiomyopathy (SIC).

OBJECTIVE

This study is designed to explore the possible role and underlying mechanisms of miR-702-3p in septic cardiomyopathy.

METHODS

As expected, H9c2 cells were induced with lipopolysaccharide (LPS) to construct the model of septic cardiomyopathy. The expression of miR-702-3p was detected by qRT-PCR assay and those of IL-1β, IL-6 and TNF-α by ELISA assay. The viability, proliferation and apoptosis of LPS-treated H9c2 cells were determined by CCK-8, EdU, flow cytometry and western blot assays. Moreover, Nucleotide-binding oligomerization domain-containing protein 1 (NOD1) was predicted and confirmed as a direct target of miR-702-3p by TargetScan, miRwalk and miRDB prediction and dual-luciferase reporter gene assays.

RESULTS

While LPS can weaken the viability of H9c2 cells, miR-702-3p enhances that of LPS-treated H9c2 cells by inhibit the expressions of TNF-α, IL-6, IL-1β. We found NOD1 is a target gene of miR-702-3p, and over-expression of NOD1 restores the inhibitory effects of miR-702-3p on the LPS-treated H9c2 cells.

CONCLUSION

MiR-702-3p played an important role in the pathogenesis of sepsis cardiomyopathy via targeting NOD1, suggesting that miR-702-3p may be a potential new target for the treatment of SIC.

Controversies in the application of corticosteroids for pediatric septic shock treatment: a preferred reporting items for systematic reviews and meta-analysis-compliant updated meta-analysis

OBJECTIVES

Septic shock is the major cause of childhood mortality. However, the application of corticosteroids remains controversial. This work aimed to analyze the source of controversy based on existing data and recent randomized controlled trials by meta-analysis and to assess whether it can avoid these factors to guide clinical treatment.

METHODS

We searched the public databases up to 8 June 2019 and included only randomized controlled trials. The primary outcome was mortality. Sensitivity analysis, subgroup analysis, and dose-response meta-analysis were performed in this work.

RESULTS

We included twelve studies consisting of 701 children in the meta-analysis. For primary outcome, the fixed-effect model showed steroids could significantly reduce the mortality compared to the control (Odds Ratio: 0.67; 95% confidence interval: 0.46-0.98; P = .041). However, the random-effect model showed a negative result (Odds Ratio: 0.69; 95% confidence interval: 0.32-1.51; P = .252). None of the subgroup results rejected the null hypothesis that the overall effect equaled zero. Dose-response effect analysis showed that increased dosage at a low dosage might reduce the mortality, while at a high dosage, increasing the dose might increase the mortality. Moreover, the grading of recommendations assessment, development, and evaluation level of evidence is low for mortality.

CONCLUSIONS

Corticosteroid application is not recommended for septic shock children under current medical conditions.