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Becker A, Filipp M, Lantz C, Glinton K, Thorp EB. HIF-1α is required to differentiate the neonatal Macrophage protein secretome from adults. Cell Immunol 2024; 403-404:104861. [PMID: 39098245 DOI: 10.1016/j.cellimm.2024.104861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/13/2024] [Accepted: 07/28/2024] [Indexed: 08/06/2024]
Abstract
The immune response to stress diverges with age, with neonatal macrophages implicated in tissue regeneration versus tissue scarring and maladaptive inflammation in adults. Integral to the macrophage stress response is the recognition of hypoxia and pathogen-associated molecular patterns (PAMPs), which are often coupled. The age-specific, cell-intrinsic nature of this stress response remains vague. To uncover age-defined divergences in macrophage crosstalk potential after exposure to hypoxia and PAMPs, we interrogated the secreted proteomes of neonatal versus adult macrophages via non-biased mass spectrometry. Through this approach, we newly identified age-specific signatures in the secretomes of neonatal versus adult macrophages in response to hypoxia and the prototypical PAMP, lipopolysaccharide (LPS). Neonatal macrophages secreted proteins most consistent with an anti-inflammatory, regenerative phenotype protective against apoptosis and oxidative stress, dependent on hypoxia inducible transcription factor-1α (HIF-1α). In contrast, adult macrophages secreted proteins consistent with a pro-inflammatory, glycolytic phenotypic signature consistent with pathogen killing. Taken together, these data uncover fundamental age and HIF-1α dependent macrophage responses that may be targeted to calibrate the innate immune response during stress and inflammation.
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Affiliation(s)
- Amanda Becker
- Department of Pediatrics, Division of Critical Care Medicine, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611 USA.
| | - Mallory Filipp
- Department of Pathology, Northwestern Feinberg School of Medicine, Chicago, IL 60611 USA
| | - Connor Lantz
- Department of Pathology, Northwestern Feinberg School of Medicine, Chicago, IL 60611 USA
| | - Kristofor Glinton
- Department of Pathology, Northwestern Feinberg School of Medicine, Chicago, IL 60611 USA
| | - Edward B Thorp
- Department of Pathology, Northwestern Feinberg School of Medicine, Chicago, IL 60611 USA.
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Gaetani M, Maratta C, Akinkugbe O, Ginter D, Baleilevuka-Hart M, Helmers A, Guerguerian AM, Mtaweh H. Invasive Group A Streptococcal Infections in Pediatric Critical Care: A Retrospective Cohort Study. Hosp Pediatr 2024; 14:573-583. [PMID: 38864108 DOI: 10.1542/hpeds.2024-007733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/29/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND AND OBJECTIVE The reported rising global rates of invasive group A Streptococcus (iGAS) infection raise concern for disease related increase in critical illness and fatalities. An enhanced understanding of various presentations to health care and clinical course could improve early recognition and therapy in children with iGAS. The objective of this study was to describe the epidemiology of iGAS infections among children admitted to critical care. METHODS A retrospective cohort study of children admitted to the PICU at The Hospital for Sick Children, in Toronto, Canada, between March 2022 and June 2023. Eligible patients were 0 to 18 years, with a diagnosis of iGAS infection. We describe the proportion of children admitted to the PICU with iGAS over the study period, their clinical characteristics, the frequency and timing of therapies, discharge versus baseline function, and PICU mortality. RESULTS Among the 1820 children admitted to the PICU, 29 (1.6%) patients had iGAS infection. Of these 29 patients, 80% (n = 23) survived to hospital discharge. Patients who survived generally had favorable functional outcomes. Despite the high severity of illness and mortality described in this cohort, 61% returned to their baseline functional status by hospital discharge. CONCLUSIONS This is the first report of critically ill children with iGAS in Canada during the increased incidence reported worldwide. We describe the clinical course of iGAS infection in children admitted to PICU with access to advanced extracorporeal interventions. Though there is a high mortality rate in this cohort, those who survive have favorable outcomes.
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Affiliation(s)
- Melany Gaetani
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Institute of Health Policy, Management and Evaluation
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Christina Maratta
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Institute of Health Policy, Management and Evaluation
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Olugbenga Akinkugbe
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Institute of Health Policy, Management and Evaluation
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Dylan Ginter
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Marica Baleilevuka-Hart
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Andrew Helmers
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Anne-Marie Guerguerian
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Haifa Mtaweh
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
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3
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Lv H, Huang L, Yang X, Zhang C, Yu H, Shang X. The clinical effectiveness of sivelestat in treating sepsis patients with both acute respiratory distress syndrome and septic cardiomyopathy. J Cardiothorac Surg 2024; 19:399. [PMID: 38937755 PMCID: PMC11210008 DOI: 10.1186/s13019-024-02835-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 06/14/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND We aimed to assess the efficacy of the neutrophil elastase inhibitor, sivelestat, in the treatment of sepsis-induced acute respiratory distress syndrome (ARDS) and septic cardiomyopathy (SCM). METHODS Between January 2019 and December 2021, we conducted a randomized trial on patients who had been diagnosed with sepsis-induced acute respiratory distress syndrome (ARDS) and septic cardiomyopathy (SCM) at Wuhan Union Hospital. The patients were divided into two groups by random envelop method, the Sivelestat group and the Control group. We measured the serum concentrations of Interleukin (IL)-6, IL-8, Tumor necrosis factor-α (TNF-α), and High-mobility group box 1 (HMGB1) at five time points, which were the baseline, 12 h, 24 h, 48 h, and 72 h after admission to the ICU. We evaluated the cardiac function by sonography and the heart rate variability (HRV) with 24-hour Holter recording between the time of admission to the intensive care unit (ICU) and 72 h after Sivelestat treatment. RESULTS From January 2019 to December 2021, a total of 70 patients were included in this study. The levels of IL-6, IL-8, and TNF-α were significantly lower in the Sivelestat group at different time points (12 h, 24 h, 48 h, and 72 h). HMGB1 levels were significantly lower at 72 h after Sivelestat treatment (19.46 ± 2.63pg/mL vs. 21.20 ± 2.03pg/mL, P = 0.003). The stroke volume (SV), tricuspid annular plane systolic excursion (TAPSE), early to late diastolic transmitral flow velocity (E/A), early (e') and late (a') diastoles were significantly low in the Control group compared with the Sivelestat group. Tei index was high in the Control group compared with the Sivelestat group (0.60 ± 0.08 vs. 0.56 ± 0.07, P = 0.029). The result of HRV showed significant differences in standard deviation of normal-to-normal intervals (SDNN), low frequency (LF), and LF/HF (high frequency) between the two groups. CONCLUSIONS Sivelestat can significantly reduce the levels of serum inflammatory factors, improve cardiac function, and reduce heart rate variability in patients with Sepsis-induced ARDS and SCM.
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Affiliation(s)
- Hui Lv
- Department of ICU, Wuhan No.1 Hospital, No.215 Zhongshan Avenue, Wuhan, China
| | - Langjing Huang
- Department of Cardiovascular Medicine, Changsha Economic Development Zone Hospital, Changsha, China
| | - Xiuhong Yang
- Department of ICU, Wuhan No.1 Hospital, No.215 Zhongshan Avenue, Wuhan, China
| | - Changdong Zhang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277 Jiefang Avenue, Jianghan District, Wuhan, 430022, Hubei Province, China
| | - Hao Yu
- Department of Cardiology, Wuhan No.1 Hospital, No.215 Zhongshan Avenue, Wuhan, China
| | - Xiaoke Shang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277 Jiefang Avenue, Jianghan District, Wuhan, 430022, Hubei Province, China.
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Niamsanit S, Saengthongpitag T, Uppala R, Sitthikarnkha P, Techasatian L, Saengnipanthkul S. Survey of Thai Physicians' Practice in Pediatric Septic Shock. CHILDREN (BASEL, SWITZERLAND) 2024; 11:597. [PMID: 38790592 PMCID: PMC11120040 DOI: 10.3390/children11050597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 04/26/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
(1) Background: Sepsis management in children is crucial, especially in emergency services. This study aims to evaluate Thai physicians' knowledge gaps in the emergency management of sepsis in children and to evaluate their adherence to the current sepsis clinical practice guidelines. (2) Methods: This is a cross-sectional survey of Thai physicians' management of septic shock in children. The survey was conducted through online questionnaires from March 2019-April 2019. (3) Results: Of the 366 responders, 362 (98.9%) were completed. Most of the responders were general practitioners (89.2%) and pediatricians (10.8%). The time from positive sepsis screening to being evaluated by physicians within 15 min was reported by 83.9%. The most common choice of fluid resuscitation was normal saline solution (77.3%). The practice of a fluid loading dose (20 mL/kg) consistent with the guidelines was 56.3%. The selection of the first vasoactive agent in warm shock (norepinephrine) and cold shock (epinephrine) according to recommendations in the guidelines was 74.3% and 36.2%, respectively. There was a significant difference between general practitioners and pediatricians in terms of knowledge about initial fluid resuscitation and the optimal vasoactive agent in cold shock (p-value < 0.001). In the multivariate model, factors associated with the guideline-based decision-making of vasoactive agent choice for cold shock were specialist training (pediatrician) and the completion of sepsis management training certification, with adjusted odds ratios (AORs) of 7.81 and 2.96, but working experience greater than ten years was inconsistent with the guideline-based decision-making (AOR 0.14). (4) Conclusions: Thai clinicians were unfamiliar with pediatric sepsis therapy standards, specifically the quantity of early fluid resuscitation and the appropriate vasoactive medications for cold shock. To encourage adherence to the guidelines, we propose a regularly required training course on pediatric sepsis management.
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Affiliation(s)
- Sirapoom Niamsanit
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, 123 Mittraphap Road, Muang, Khon Kaen 40002, Thailand; (S.N.); (P.S.); (L.T.); (S.S.)
| | - Teerapat Saengthongpitag
- Department of Pediatrics, Faculty of Medicine, Suranaree University of Technology, Nakhon Ratchasima 30000, Thailand;
| | - Rattapon Uppala
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, 123 Mittraphap Road, Muang, Khon Kaen 40002, Thailand; (S.N.); (P.S.); (L.T.); (S.S.)
| | - Phanthila Sitthikarnkha
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, 123 Mittraphap Road, Muang, Khon Kaen 40002, Thailand; (S.N.); (P.S.); (L.T.); (S.S.)
| | - Leelawadee Techasatian
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, 123 Mittraphap Road, Muang, Khon Kaen 40002, Thailand; (S.N.); (P.S.); (L.T.); (S.S.)
| | - Suchaorn Saengnipanthkul
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, 123 Mittraphap Road, Muang, Khon Kaen 40002, Thailand; (S.N.); (P.S.); (L.T.); (S.S.)
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Mu CT, Lin YJ, Chen CH, Hsia SH, Lin JJ, Chan OW, Yen CW, Chiu CC, Chang HP, Su YT, Lee EP. Diastolic/systolic blood pressure ratio for predicting febrile children with sepsis and progress to septic shock in the emergency department. BMC Emerg Med 2024; 24:78. [PMID: 38693496 PMCID: PMC11064385 DOI: 10.1186/s12873-024-00995-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 04/24/2024] [Indexed: 05/03/2024] Open
Abstract
OBJECTIVE Given the scarcity of studies analyzing the clinical predictors of pediatric septic cases that would progress to septic shock, this study aimed to determine strong predictors for pediatric emergency department (PED) patients with sepsis at risk for septic shock and mortality. METHODS We conducted chart reviews of patients with ≥ 2 age-adjusted quick Sequential Organ Failure Assessment score (qSOFA) criteria to recognize patients with an infectious disease in two tertiary PEDs between January 1, 2021, and April 30, 2022. The age range of included patients was 1 month to 18 years. The primary outcome was development of septic shock within 48 h of PED attendance. The secondary outcome was sepsis-related 28-day mortality. Initial important variables in the PED and hemodynamics with the highest and lowest values during the first 24 h of admission were also analyzed. RESULTS Overall, 417 patients were admitted because of sepsis and met the eligibility criteria for the study. Forty-nine cases progressed to septic shock within 48 h after admission and 368 were discharged without progression. General demographics, laboratory data, and hemodynamics were analyzed by multivariate analysis. Only the minimum diastolic blood pressure/systolic blood pressure ratio (D/S ratio) during the first 24 h after admission remained as an independent predictor of progression to septic shock and 28-day mortality. The best cutoff values of the D/S ratio for predicting septic shock and 28-day mortality were 0.52 and 0.47, respectively. CONCLUSIONS The D/S ratio is a practical bedside scoring system in the PED and had good discriminative ability in predicting the progression of septic shock and in-hospital mortality in PED patients. Further validation is essential in other settings.
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Affiliation(s)
- Chun-Ting Mu
- Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ying-Jui Lin
- Department of Pediatrics, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Ho Chen
- Department of Pediatrics, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, No. 5, Fu-Hsin Street, Kweishan, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, No. 5, Fu-Hsin Street, Kweishan, Taoyuan, Taiwan
- Division of Pediatric Neurology, Chang Gung Children's Hospital, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Oi-Wa Chan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, No. 5, Fu-Hsin Street, Kweishan, Taoyuan, Taiwan
| | - Chen-Wei Yen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Che Chiu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Pediatrics, Tucheng Composite Municipal Hospital, New Taipei City, Taiwan
| | - Han-Pi Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, No. 5, Fu-Hsin Street, Kweishan, Taoyuan, Taiwan
| | - Ya-Ting Su
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Pediatric Endocrinology and Genetics, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - En-Pei Lee
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, No. 5, Fu-Hsin Street, Kweishan, Taoyuan, Taiwan.
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Becker A, Filipp M, Lantz C, Glinton K, Thorp EB. HIF-1α is Required to Differentiate the Neonatal Macrophage Secretome from Adults. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.04.24.591000. [PMID: 38712137 PMCID: PMC11071477 DOI: 10.1101/2024.04.24.591000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
The immune response to stress diverges with age, with neonatal macrophages implicated in tissue regeneration versus tissue scarring and maladaptive inflammation in adults. Integral to the macrophage stress response is the recognition of hypoxia and pathogen-associated molecular patterns (PAMPs), which are often coupled. The age-specific, cell-intrinsic nature of this stress response remains vague. To uncover age-defined divergences in macrophage crosstalk potential after exposure to hypoxia and PAMPs, we interrogated the secreted proteomes of neonatal versus adult macrophages via non-biased mass spectrometry. Through this approach, we newly identified age-specific signatures in the secretomes of neonatal versus adult macrophages in response to hypoxia and the prototypical PAMP, lipopolysaccharide (LPS). Neonatal macrophages polarized to an anti-inflammatory, regenerative phenotype protective against apoptosis and oxidative stress, dependent on hypoxia inducible transcription factor-1α ( HIF-1α). In contrast, adult macrophages adopted a pro-inflammatory, glycolytic phenotypic signature consistent with pathogen killing. Taken together, these data uncover fundamental age and HIF-1α dependent macrophage programs that may be targeted to calibrate the innate immune response during stress and inflammation.
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7
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Webb LV, Evans J, Smith V, Pettibone E, Tofil J, Hicks JF, Green S, Nassel A, Loberger JM. Sociodemographic Factors are Associated with Care Delivery and Outcomes in Pediatric Severe Sepsis. Crit Care Explor 2024; 6:e1056. [PMID: 38415020 PMCID: PMC10896474 DOI: 10.1097/cce.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
IMPORTANCE Sepsis is a leading cause of morbidity and mortality in the United States and disparate outcomes exist between racial/ethnic groups despite improvements in sepsis management. These observed differences are often related to social determinants of health (SDoH). Little is known about the role of SDoH on outcomes in pediatric sepsis. OBJECTIVE This study examined the differences in care delivery and outcomes in children with severe sepsis based on race/ethnicity and neighborhood context (as measured by the social vulnerability index). DESIGN SETTING AND PARTICIPANTS This retrospective, cross-sectional study was completed in a quaternary care children's hospital. Patients 18 years old or younger who were admitted between May 1, 2018, and February 28, 2022, met the improving pediatric sepsis outcomes (IPSO) collaborative definition for severe sepsis. Composite measures of social vulnerability, care delivery, and clinical outcomes were stratified by race/ethnicity. MAIN OUTCOMES AND MEASURES The primary outcome of interest was admission to the PICU. Secondary outcomes were sepsis recognition and early goal-directed therapy (EGDT). RESULTS A total of 967 children met the criteria for IPSO-defined severe sepsis, of whom 53.4% were White/non-Hispanic. Nearly half of the cohort (48.7%) required PICU admission. There was no difference in illness severity at PICU admission by race (1.01 vs. 1.1, p = 0.18). Non-White race/Hispanic ethnicity was independently associated with PICU admission (odds ratio [OR] 1.35 [1.01-1.8], p = 0.04). Although social vulnerability was not independently associated with PICU admission (OR 0.95 [0.59-1.53], p = 0.83), non-White children were significantly more likely to reside in vulnerable neighborhoods (0.66 vs. 0.38, p < 0.001). Non-White race was associated with lower sepsis recognition (87.8% vs. 93.6%, p = 0.002) and less EGDT compliance (35.7% vs. 42.8%, p = 0.024). CONCLUSIONS AND RELEVANCE Non-White race/ethnicity was independently associated with PICU admission. Differences in care delivery were also identified. Prospective studies are needed to further investigate these findings.
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Affiliation(s)
- Lece V Webb
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Jakob Evans
- Department of Pediatrics, Pediatrics Residency Program, University of Alabama at Birmingham, Birmingham, AL
| | - Veronica Smith
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Elisabeth Pettibone
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | | | - Jessica Floyd Hicks
- Performance Improvement and Accreditation Department, Children's of Alabama, Birmingham, AL
| | - Sherry Green
- Performance Improvement and Accreditation Department, Children's of Alabama, Birmingham, AL
| | - Ariann Nassel
- Lister Hill Center for Health Policy, School of Public Health, University of Alabama at Birmingham, AL
| | - Jeremy M Loberger
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
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Abstract
Shock occurs when there is energy failure due to inadequate oxygen/glucose delivery to meet metabolic demands. Shock is a leading cause of death and disability in children worldwide. Types of shock include hypovolemic, cardiogenic, distributive, and obstructive. This review provides an overview of the epidemiology, pathophysiology, and clinical signs and symptoms of each of these types of shock, followed by a discussion of advancements in diagnostic tests and tools and management/treatment principles for different categories of shock.
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Affiliation(s)
- Ashley Bjorklund
- Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN
- Division of Pediatric Critical Care, University of Minnesota, Minneapolis, MN
| | - Joseph Resch
- Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN
- Division of Pediatric Critical Care, University of Minnesota, Minneapolis, MN
| | - Tina Slusher
- Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN
- Division of Pediatric Critical Care, University of Minnesota, Minneapolis, MN
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9
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Chen J, Tu X, Huang M, Xie Y, Lin Y, Hu J. Prognostic value of platelet combined with serum procalcitonin in patients with sepsis. Medicine (Baltimore) 2023; 102:e34953. [PMID: 37653816 PMCID: PMC10470786 DOI: 10.1097/md.0000000000034953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/22/2023] [Accepted: 08/04/2023] [Indexed: 09/02/2023] Open
Abstract
Sepsis, a common and life-threatening condition in critically ill patients, is a leading cause of death in intensive care units. Over the past few decades, there has been significant improvement in the understanding and management of sepsis. However, the mortality rate remains unacceptably high, posing a prominent challenge in modern medicine and a significant global disease burden. A total of 295 patients with sepsis admitted to the hospital from January 2021 to December 2022 were collected and divided into survival group and death group according to their 28-day survival status. The differences in general clinical data and laboratory indicators between the 2 groups were compared. Receiver operating characteristic curve analysis was used to evaluate the predictive value of platelet (PLT) and procalcitonin (PCT) for the prognosis of sepsis patients within 28 days. A total of 295 patients were diagnosed with sepsis, and 79 died, with a mortality rate of 26.78%. The PLT level in the death group was lower than that in the survival group; the PCT level in the death group was higher than that in the survival group. The receiver operating characteristic curve showed that the area under the curve of PCT and PLT for evaluating the prognosis of sepsis patients were 0.808 and 0.804, respectively. Kaplan-Meier survival analysis showed that the 28-day survival rate of the low PLT level group was 19.0% and that of the high PLT level group was 93.1% at the node of 214.97 × 109/L, and the difference between the 2 groups was statistically significant (χ2 = 216.538, P < .001). The 28-day survival rate of the low PCT level group was 93.4% and that of the high PCT level group was 51.7% at the node of 2.85 ng/mL, and the difference between the 2 groups was statistically significant (χ2 = 63.437, P < .001). There was a negative correlation between PCT level and PLT level (r = -0.412, P < .001). Platelet combined with serum procalcitonin detection has high predictive value for judging the 28-day prognosis of sepsis, and it can be used as an index for evaluating the patient's condition and prognosis, and is worthy of clinical promotion and application.
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Affiliation(s)
- Jianhui Chen
- Department of Critical Care Medicine, Affiliated Hospital of Putian University, Putian City, Fujian Province, China
| | - Xiaoyan Tu
- Department of Critical Care Medicine, Union Hospital Affiliated to Fujian Medical University, Fuzhou City, Fujian Province, China
| | - Minghuan Huang
- Department of Nephrology, Affiliated Hospital of Putian University, Putian City, Fujian Province, China
| | - Ying Xie
- School of Mechanical, Electrical and Information Engineering, Putian University, Putian City, China
| | - Yanya Lin
- Department of Critical Care Medicine, Affiliated Hospital of Putian University, Putian City, Fujian Province, China
| | - Jianxiong Hu
- The School of Clinical Medicine, Fujian Medical University, Fujian, China
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Qin Y, Caldino Bohn RI, Sriram A, Kernan KF, Carcillo JA, Kim S, Park HJ. Refining empiric subgroups of pediatric sepsis using machine-learning techniques on observational data. Front Pediatr 2023; 11:1035576. [PMID: 36793336 PMCID: PMC9923004 DOI: 10.3389/fped.2023.1035576] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/05/2023] [Indexed: 01/31/2023] Open
Abstract
Sepsis contributes to 1 of every 5 deaths globally with 3 million per year occurring in children. To improve clinical outcomes in pediatric sepsis, it is critical to avoid "one-size-fits-all" approaches and to employ a precision medicine approach. To advance a precision medicine approach to pediatric sepsis treatments, this review provides a summary of two phenotyping strategies, empiric and machine-learning-based phenotyping based on multifaceted data underlying the complex pediatric sepsis pathobiology. Although empiric and machine-learning-based phenotypes help clinicians accelerate the diagnosis and treatments, neither empiric nor machine-learning-based phenotypes fully encapsulate all aspects of pediatric sepsis heterogeneity. To facilitate accurate delineations of pediatric sepsis phenotypes for precision medicine approach, methodological steps and challenges are further highlighted.
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Affiliation(s)
- Yidi Qin
- Department of Human Genetics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Rebecca I. Caldino Bohn
- Department of Human Genetics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Aditya Sriram
- Department of Human Genetics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Soyeon Kim
- Division of Pediatric Pulmonary Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Hyun Jung Park
- Department of Human Genetics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
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11
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Gill M, Raghu V, Ferguson E, Marcinick A, Rosen J, Butler G, Horvat C, Crowley K. Reduction in Antibiotic Delivery Time Following Improving Pediatric Sepsis Outcomes Quality Improvement Initiative at a Major Children's Hospital. J Pediatr Pharmacol Ther 2023; 28:55-62. [PMID: 36777976 PMCID: PMC9901321 DOI: 10.5863/1551-6776-28.1.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 02/23/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Sepsis causes morbidity and mortality in pediatric patients, but timely antibiotic administration can improve sepsis outcomes. The pharmacy department can affect the time from order to delivery of antibiotics. By evaluating the pharmacy process, this study aimed to decrease the time from antibiotic order to delivery to within 45 minutes. METHODS All antibiotic orders placed following a positive sepsis screen for acute care patients at a freestanding children's hospital from April 1, 2019, to December 31, 2019, were reviewed. Lean Six Sigma methodology including process mapping was used to identify and implement improvements, including educational interventions for providers. Outcome measures included time from antibiotic order placement to delivery and to administration. Additional assessment of process measures included evaluation of order priority, PowerPlan (an internally created order set) use, and delivery method. RESULTS Ninety-eight antibiotic orders for 85 patients were evaluated. In an individual chart of antibiotic delivery time, a trend towards faster delivery time was observed after interventions. Stat orders (40.5 minutes [IQR, 19.5-48]) were delivered more quickly than routine orders (51 minutes [IQR, 45-65]; p < 0.001). Orders using the PowerPlan (20.5 minutes [IQR, 18.5-38]) were delivered more quickly than those that did not (47 minutes [IQR, 34-64]; p < 0.01). Shorter time to administration was observed with pneumatic tube delivery (41 minutes [IQR, 20-50]) than with direct delivery to a health care provider (51 minutes [IQR, 31-83]; p < 0.05) or to the automated dispensing cabinet's refrigerator (47 minutes [IQR, 41-62]; p < 0.0001). CONCLUSIONS Multifactorial coordinated interventions within the pharmacy department improve medication delivery time for pediatric sepsis antibiotic orders.
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Affiliation(s)
- Meghan Gill
- Department of Pharmacy (EF, KC, MG), UPMC Children's Hospital of Pittsburgh
| | - Vikram Raghu
- Department of Pediatrics (VR, JR), UPMC Children's Hospital of Pittsburgh, PA
| | - Elizabeth Ferguson
- Department of Pharmacy (EF, KC, MG), UPMC Children's Hospital of Pittsburgh
| | - Adrienne Marcinick
- Health Informatics (AM, GB, CH), UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Johanna Rosen
- Department of Pediatrics (VR, JR), UPMC Children's Hospital of Pittsburgh, PA
| | - Gabriella Butler
- Health Informatics (AM, GB, CH), UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Christopher Horvat
- Pediatric Critical Care Medicine (CH), UPMC Children's Hospital of Pittsburgh, PA,Health Informatics (AM, GB, CH), UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Kelli Crowley
- Department of Pharmacy (EF, KC, MG), UPMC Children's Hospital of Pittsburgh
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12
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Association of Red Cell Distribution Width-to-Platelet Ratio and Mortality in Patients with Sepsis. Mediators Inflamm 2022; 2022:4915887. [PMID: 36204660 PMCID: PMC9532144 DOI: 10.1155/2022/4915887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/30/2022] [Indexed: 11/23/2022] Open
Abstract
Background As a novel inflammatory index, the ratio of red cell distribution width (RDW) to platelet count (RPR) may have prognostic value in some critical illnesses. However, studies on the prognostic influence of RPR in patients with sepsis are few. This study is aimed at investigating the association between RPR levels and 28-day mortality in patients with sepsis. Methods Data of patients with sepsis were obtained from the Medical Information Mart for Intensive Care III database. The best cut-off value was calculated by establishing the receiver operating characteristic curve (ROC), and the predictive ability of different indicators was compared through the area under the curve (AUC). The association between RPR levels and 28-day mortality was assessed using the Cox proportional hazards model. Restrictive cubic spline analysis was applied to the multivariable Cox model to investigate the nonlinear relationship between RPR and 28-day mortality. Results A total of 3367 patients with sepsis were included in the study. A nonlinear relationship was observed between RPR and 28-day mortality, showing a trend of a first rapid increase and a gradual increase. For the prediction of mortality, the best cut-off value for RPR was 0.109, with an AUC of 0.728 (95% confidence interval [CI]: 0.709–0.747). The predictive capability of RPR was superior to those of RDW, platelet, SOFA score, and SAPS II score. After adjusting for various confounding factors, high RPR was significantly associated with increased mortality with adjusted hazard ratios of 1.210 (95% CI: 1.045–1.400) for categorical variables and 2.826 (95% CI: 2.025–3.944) for continuous variables. Conclusion Elevated RPR level is significantly correlated with a high risk of 28-day mortality in patients with sepsis and can be a new predictor of patient prognosis.
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13
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The Presence of PDL-1 on CD8+ Lymphocytes Is Linked to Survival in Neonatal Sepsis. CHILDREN 2022; 9:children9081171. [PMID: 36010061 PMCID: PMC9406495 DOI: 10.3390/children9081171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022]
Abstract
Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Neonatal sepsis is the main cause of death in newborns, especially preterm infants. The pathogenesis of sepsis is based on a hyper-inflammatory syndrome combined with an immunosuppressive mechanism in sepsis. This study aimed to find critical parameters that are associated with the outcome of newborns with suspected sepsis. Understanding the association might have clinical relevance for immuno-monitoring, outcome prediction, and targeted therapy. Methods: A total of 210 newborn infants no older than 4 days with suspected sepsis at admission in Karaganda (Kazakhstan) were prospectively enrolled. Blood cultures were incubated, and pathogens in positive cultures were determined by MALDI-TOF. An immunological assay for blood cell components was conducted by flow cytometry with antibody cocktails. The diagnostic criteria for neonatal sepsis were identified by qualified neonatologists and included both clinical sepsis and/or positive blood culture. The analyzed infants were grouped into non-septic infants, surviving septic infants, and deceased septic infants. The results showed that deceased septic newborns had a lower level of CD8+ lymphocytes and higher PDL-1 expression in comparison with surviving septic newborns. PDL-1 expression on CD8+ T cells might play an immunosuppressive role during neonatal sepsis and might be used as a laboratory biomarker in the future.
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14
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Souganidis ES, Patel B, Sampayo EM. Physician-Specific Utilization of an Electronic Best Practice Alert for Pediatric Sepsis in the Emergency Department. Pediatr Emerg Care 2022; 38:e1417-e1422. [PMID: 35696307 DOI: 10.1097/pec.0000000000002778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early recognition of sepsis remains a critical goal in the pediatric emergency department (ED). Although this has led to the development of best practice alerts (BPAs) to facilitate screening and bundled care, research on how individual physicians interact with sepsis alerts and protocols is limited. This study aims to identify common reasons for acceptance and rejection of a sepsis BPA by pediatric emergency medicine (PEM) physicians and understand how the BPA affects physician management of patients with suspected sepsis. METHODS This is a qualitative study of PEM physicians in a quaternary-care children's hospital. Data were collected through semistructured interviews and analyzed through an iterative coding process until thematic saturation was achieved. Member checking was completed to ensure trustworthiness. Thematic analysis of PEM physicians' rejection reasons in the electronic health record was used to categorize their responses and calculate each theme's frequency. RESULTS Twenty-two physicians participated in this study. Seven physicians (32%) relied solely on patient characteristics when deciding to accept the BPA, whereas the remaining physicians considered nonpatient factors specific to the ED environment, individualized practice patterns, and BPA design. Eleven principal reasons for BPA rejection were derived from 1406 electronic health record responses, with clinical appearance not consistent with shock being the most common. Physicians identified the BPA's configuration and incomplete understanding of the BPA as the biggest barriers to utilization and provided strategies to improve the BPA screening process and streamline sepsis care. Physicians emphasized the need for further BPA education for physicians and triage staff and improved transparency of the alert. CONCLUSIONS Physicians consider patient and nonpatient factors when responding to the BPA. Improved BPA functionality combined with measures to enhance screening, optimize sepsis management, and educate ED providers on the BPA may increase satisfaction with the alert and promote more effective utilization when it fires.
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Affiliation(s)
- Ellie S Souganidis
- From the Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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15
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Evren G, Karaarslan U, Yildizdas D, Şik G, Azapağası E, Konca C, Kendirli T, Udurgucu M, Koroglu TF. Epidemiology of pediatric severe sepsis and septic shock in Turkey: Prevalence, Results and Treatments Study. Acta Paediatr 2022; 111:1995-2003. [PMID: 35818128 DOI: 10.1111/apa.16484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/08/2022] [Indexed: 11/28/2022]
Abstract
AIM This study was aimed at characterizing the prevalence, management, and outcomes of pediatric severe sepsis and septic shock in tertiary pediatric intensive care units (PICUs) in Turkey. METHODS A point prevalence study was conducted on five days over the course of one year in 29 PICUs in Turkey. Outcomes included severe sepsis and septic shock point prevalence, therapies used, duration of PICU stay, and mortality at day 28. RESULTS Of the 1757 children who were admitted to the PICU during the study period, 141 (8.0%) children met the consensus criteria for severe sepsis and 23 (1.3%) children met the criteria for septic shock. Pediatric severe sepsis and septic shock accounted for 8% and 1.3% of all PICU admissions, respectively. The median age of the patients was 2.6 years (interquartile range (IQR), 0.7-8.6 years). Enteral nutrition (79.3%) was preferred compared to parenteral nutrition (31.1%) for the first 3 days after PICU admission. A total of 39 patients died while in the PICU, for a 23.8% mortality rate, which did not vary by age. CONCLUSION The mortality rate was similar to that in other studies. Hematologic-immunologic comorbidity, parenteral nutrition and the use of vasoactive drugs were independently associated with mortality.
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Affiliation(s)
- Gultac Evren
- Dokuz Eylul University Hospital, Pediatric ICU, Pediatrics, Izmir, Turkey
| | - Utku Karaarslan
- Behcet Uz Hospital, Pediatric ICU, Pediatrics, Izmir, Turkey
| | | | - Guntulu Şik
- Istanbul University, Pediatric ICU, Pediatrics, Istanbul, Turkey
| | - Ebru Azapağası
- Sami Ulus Hospital, Pediatric ICU, Pediatrics, Ankara, Turkey
| | - Capan Konca
- Adiyaman University, Pediatric ICU, Pediatrics, Adiyaman, Turkey
| | - Tanil Kendirli
- Ankara University, Pediatric ICU, Pediatrics, Ankara, Turkey
| | | | - Tolga F Koroglu
- Dokuz Eylul University Hospital, Pediatric ICU, Pediatrics, Izmir, Turkey
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16
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Fan B, Klatt J, Moor MM, Daniels LA, Sanchez-Pinto LN, Agyeman PKA, Schlapbach LJ, Borgwardt KM. Prediction of recovery from multiple organ dysfunction syndrome in pediatric sepsis patients. Bioinformatics 2022; 38:i101-i108. [PMID: 35758775 PMCID: PMC9236580 DOI: 10.1093/bioinformatics/btac229] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Motivation Sepsis is a leading cause of death and disability in children globally, accounting for ∼3 million childhood deaths per year. In pediatric sepsis patients, the multiple organ dysfunction syndrome (MODS) is considered a significant risk factor for adverse clinical outcomes characterized by high mortality and morbidity in the pediatric intensive care unit. The recent rapidly growing availability of electronic health records (EHRs) has allowed researchers to vastly develop data-driven approaches like machine learning in healthcare and achieved great successes. However, effective machine learning models which could make the accurate early prediction of the recovery in pediatric sepsis patients from MODS to a mild state and thus assist the clinicians in the decision-making process is still lacking. Results This study develops a machine learning-based approach to predict the recovery from MODS to zero or single organ dysfunction by 1 week in advance in the Swiss Pediatric Sepsis Study cohort of children with blood-culture confirmed bacteremia. Our model achieves internal validation performance on the SPSS cohort with an area under the receiver operating characteristic (AUROC) of 79.1% and area under the precision-recall curve (AUPRC) of 73.6%, and it was also externally validated on another pediatric sepsis patients cohort collected in the USA, yielding an AUROC of 76.4% and AUPRC of 72.4%. These results indicate that our model has the potential to be included into the EHRs system and contribute to patient assessment and triage in pediatric sepsis patient care. Availability and implementation Code available at https://github.com/BorgwardtLab/MODS-recovery. The data underlying this article is not publicly available for the privacy of individuals that participated in the study. Supplementary information Supplementary data are available at Bioinformatics online.
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Affiliation(s)
- Bowen Fan
- Department of Biosystems Science and Engineering, ETH Zurich, Basel 4058, Switzerland.,SIB Swiss Institute of Bioinformatics, Lausanne 1015, Switzerland
| | - Juliane Klatt
- Department of Biosystems Science and Engineering, ETH Zurich, Basel 4058, Switzerland.,SIB Swiss Institute of Bioinformatics, Lausanne 1015, Switzerland
| | - Michael M Moor
- Department of Biosystems Science and Engineering, ETH Zurich, Basel 4058, Switzerland.,SIB Swiss Institute of Bioinformatics, Lausanne 1015, Switzerland
| | - Latasha A Daniels
- Division of Critical Care, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Lazaro N Sanchez-Pinto
- Division of Critical Care, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Philipp K A Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital University of Bern, Bern 3010, Switzerland
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, Zurich 8032, Switzerland.,Paediatric Intensive Care Unit, Child Health Research Center, Queensland Children's Hospital, The University of Queensland, Brisbane, Australia
| | - Karsten M Borgwardt
- Department of Biosystems Science and Engineering, ETH Zurich, Basel 4058, Switzerland.,SIB Swiss Institute of Bioinformatics, Lausanne 1015, Switzerland
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17
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Domínguez-Rojas JA, Caqui P, Sanchez A, Coronado Munoz AJ. Methylene blue for the treatment of refractory septic shock secondary to listeriosis in a paediatric patient. BMJ Case Rep 2022; 15:e243772. [PMID: 35228212 PMCID: PMC8886372 DOI: 10.1136/bcr-2021-243772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Current therapies frequently used for refractory septic shock include hydrocortisone, vasopressin, extracorporeal membrane oxygenation (ECMO) support, inodilators, levosimendan and methylene blue. The evidence for these treatments is very limited. We present a case of a 5-year-old patient with refractory septic shock, secondary to Listeria monocytogenes meningitis. She presented with status epilepticus and developed septic shock. Shock persisted despite multiple high-dose vasoactive medications. ECMO support was not available. The medical team decided to use methylene blue to revert the vasoplegia, with excellent results. Shortly after the administration, vasopressors were weaned off and the high lactate cleared. She developed severe neurological sequelae due to brain haemorrhage secondary to the Listeria meningitis. The evidence supporting methylene blue for refractory septic shock in paediatric patients is limited. This case represents the effectiveness of this therapy without secondary effects.
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Affiliation(s)
- Jesús Angel Domínguez-Rojas
- Deparment of Pediatrics, National Hospital Edgardo Rebagliati Martins, Lima, Peru
- Deparment of Critical Care, Instituto Nacional De Salud Del Niño Breña, Lima, Peru
| | - Patrick Caqui
- Department of Pediatrics, Hospital Nacional Hipolito Unanue, Lima, Peru
| | - Abel Sanchez
- Department of Pediatrics, Hospital Nacional Hipolito Unanue, Lima, Peru
| | - Alvaro J Coronado Munoz
- Deparment of Pediatrics, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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18
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Medeiros DNM, Mafra ACCN, Souza DCD, Troster EJ. Epidemiology and treatment of sepsis at a public pediatric emergency department. EINSTEIN-SAO PAULO 2022; 20:eAO6131. [PMID: 35303049 PMCID: PMC8868818 DOI: 10.31744/einstein_journal/2022ao6131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 02/05/2021] [Indexed: 11/05/2022] Open
Abstract
Objective To describe the clinical characteristics and treatment of children with sepsis, severe sepsis, and septic shock at a pediatric emergency department of a public hospital. Methods A retrospective, observational study. The medical records of patients included in the hospital Pediatric Sepsis Protocol and patients with discharge ICD-10 A41.9 (sepsis, unspecified), R57 (shock) and A39 (meningococcal meningitis) were evaluated. Results A total of 399 patients were included. The prevalence of sepsis, severe sepsis, and septic shock at the emergency room were 0.41%, 0.14% and 0.014%, respectively. The median age was 21.5 months for sepsis, 12 months for severe sepsis, and 20.5 months for septic shock. Sepsis, severe sepsis, and septic shock were more often associated with respiratory diseases. The Respiratory Syncytial Virus was the most common agent. The median time to antibiotic and fluid administration was 3 hours in patients with sepsis and severe sepsis. In patients with septic shock, the median times to administer antibiotics, fluid and vasoactive drugs were 2 hours, 2.5 hours and 6 hours, respectively. The median length of hospital stay for patients with sepsis, severe sepsis and septic shock were 3 days, 4 days and 1 day, respectively. The overall mortality was 2%. Conclusion Sepsis had a low prevalence. Early diagnosis and recognition are a challenge for the emergency care pediatrician, the first place of admission.
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19
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Yuniar I, Hafifah CN, Adilla SF, Shadrina AN, Darmawan AC, Nasution K, Ranakusuma RW, Safitri ED. Prognostic factors and models to predict pediatric sepsis mortality: A scoping review. Front Pediatr 2022; 10:1022110. [PMID: 36908280 PMCID: PMC9998070 DOI: 10.3389/fped.2022.1022110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/28/2022] [Indexed: 02/25/2023] Open
Abstract
Introduction Several scoring systems are available to assess the severity of sepsis in pediatric patients in diverse settings worldwide. This study investigates the quality and applicability of predictive models for determining pediatric sepsis mortality, especially in acute care and limited-resource settings. Data sources Mortality prediction factors and models were searched in four databases using the following criteria: developed for pediatric health care, especially in acute settings, and with mortality as an outcome. Study selection Two or more reviewers performed the study selection to ensure no bias occurred. Any disagreements were solved by consensus or by the decision of a third reviewer. Data extraction The authors extracted the results and mapped the selected studies qualitatively to describe the prognostic properties of the risk factors and models proposed in the study. Data synthesis The final analysis included 28 mortality prediction models. Their characteristics, analysis, and performance measures were summarized. Performance was described in terms of calibration and discrimination, including assessing for risk of bias and applicability. A modified version of the PRISM-III score based on physiologic criteria (PRISM-III-APS) increased its predictive value to 0.85-0.95. The vasoactive-inotropic score at 12 h had a strong independent association with death. Albumin had an excellent predictive value when combined with other variables. Lactate, a biomarker widely measured in patients with sepsis, was highly associated with mortality. The bioimpedance phase angle was not considered applicable in our setting. Measurement using more straightforward methods, such as mid-upper arm circumference, was feasible in numerous health care facilities. Conclusion Leveraging prognostic models to predict mortality among pediatric patients with sepsis remains an important and well-recognized area of study. While much validation and development work remains to be done, available prognostic models could aid clinicians at the bedside of children with sepsis. Furthermore, mortality prediction models are essential and valuable tools for assessing the quality of care provided to critically ill pediatric patients.
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Affiliation(s)
- Irene Yuniar
- Department of Child Health, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Cut Nurul Hafifah
- Department of Child Health, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Sharfina Fulki Adilla
- Department of Child Health, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Arifah Nur Shadrina
- Department of Child Health, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Anthony Christian Darmawan
- Department of Child Health, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Kholisah Nasution
- Department of Child Health, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Respati W Ranakusuma
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Eka Dian Safitri
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
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20
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Ferdosian F, Jarahzadeh MH, Bahrami R, Nafei Z, Jafari M, Raee-Ezzabadi A, Mirjalili SR, Neamatzadeh H. Association of IL-6 -174G > C Polymorphism with Susceptibility to Childhood Sepsis: A Systematic Review and Meta-Analysis. Fetal Pediatr Pathol 2021; 40:638-652. [PMID: 32057284 DOI: 10.1080/15513815.2020.1723149] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BackgroundThis meta-analysis evaluates the correlation between the IL-6 -174 G > C polymorphism and susceptibility of childhood sepsis. Methods: We searched PubMed, ISI Web of Knowledge, Scopus, CNKI, SID, SciELO databases until December 30, 2019 to identify all eligible studies. Results: A total of 17 studies with 1,287 cases and 2,482 controls were identified. Pooled data revealed that there was no significant association between the IL-6 -174 G > C polymorphism and risk childhood sepsis in the overall population. When stratified analysis was carried out by age group of cases, no associations were found in neonates and pediatrics. However, in ethnicity-based subgroups, a significant association was found in Caucasians and Africans. Conclusions: There was no significant association of the IL-6 -174G > C polymorphism with susceptibility to sepsis in childhood overall, but there was an association with the Caucasian and African ethnic subgroups.
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Affiliation(s)
- Farzad Ferdosian
- Department of Pediatrics, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.,Children Growth Disorder Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | | | - Reza Bahrami
- Neonatal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Nafei
- Department of Pediatrics, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.,Children Growth Disorder Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammadali Jafari
- Department of Emergency Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Ali Raee-Ezzabadi
- Department of Emergency Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Seyed Reza Mirjalili
- Department of Pediatrics, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.,Mother and Newborn Health Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Hossein Neamatzadeh
- Mother and Newborn Health Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.,Department of Medical Genetics, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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21
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Elalfy MS, Ragab IA, AbdelAal NM, Mahfouz S, Rezk AR. Study of the diagnostic criteria for hemophagocytic lymphohistiocytosis in neonatal and pediatric patients with severe sepsis or septic shock. Pediatr Hematol Oncol 2021; 38:486-496. [PMID: 33622175 DOI: 10.1080/08880018.2021.1887983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Septic shock is a major public health concern. However, the clinical and laboratory criteria for sepsis overlap with those for hemophagocytic lymphohistiocytosis (HLH), and their differentiation can be challenging. The aim of this study was to compare HLH criteria among patients diagnosed with neonatal sepsis and childhood sepsis and to study the outcomes in patients fulfilling the diagnostic criteria for HLH. A cross-sectional study included 50 neonates and children with severe sepsis and/or septic shock. Clinical and laboratory data and HLH diagnostic criteria were studied in relation to patients outcome. Of all patients, 18% fulfilled three of the eight HLH diagnostic criteria, 2% fulfilled four criteria, and 4% fulfilled five criteria. All patients who fulfilled three or more of the criteria died. Mortality was higher in the presence of more positive HLH criteria and in pediatric age groups. However, the distributions of the HLH criteria were comparable for pediatric and neonatal patients with severe sepsis/septic shock, and their mortality rates were not significantly different when based on the criteria.
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Affiliation(s)
- Mohsen S Elalfy
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
| | - Iman A Ragab
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
| | - NourEldin M AbdelAal
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
| | - Sara Mahfouz
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
| | - Ahmed R Rezk
- Department of Pediatrics, Department of Hematology-Oncology, Neonatal Intensive Care Unit and Pediatric Intensive Care Unit, Ain Shams University, Cairo, Egypt
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22
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Hu S, Pi Q, Luo M, Cheng Z, Liang X, Luo S, Xia Y. Contribution of the NLRP3/IL-1β axis to impaired vasodilation in sepsis through facilitation of eNOS proteolysis and the protective role of melatonin. Int Immunopharmacol 2021; 93:107388. [PMID: 33529913 DOI: 10.1016/j.intimp.2021.107388] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/27/2020] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
Endothelial dysfunction is a typical characteristic of sepsis. Endothelial nitric oxide synthase (eNOS) is important for maintaining endothelial function. Our previous study reported that the NLRP3 inflammasome promoted endothelial dysfunction by enhancing inflammation. However, the effects of NLRP3 on eNOS require further investigation. Therefore, the present study aimed to investigate the role of NLRP3 on eNOS expression levels in cecal ligation and puncture-induced impaired endothelium-dependent vascular relaxation and to determine the protective effects of melatonin. eNOS expression levels were discovered to be downregulated in the mesenteric arteries of sepsis model mice. Inhibiting NLRP3 with 10 mg/ kg MCC950 or inhibiting IL-1β with 100 mg diacerein rescued the eNOS expression and improved endothelium-dependent vascular relaxation. In vitro, IL-1β stimulation downregulated eNOS expression levels in human aortic endothelial cells (HAECs) in a concentration- and time-dependent manner, while pretreatment with 1 µM of the proteasome inhibitor MG132 reversed this effect. In addition, treatment with 10 mg/kg MG132 also prevented the proteolysis of eNOS and improved endothelium-dependent vascular relaxation in vivo. Notably, treatment with 30 mg/kg melatonin downregulated NLRP3 expression levels and decreased IL-1β secretion, subsequently increasing the expression of eNOS and improving endothelium-dependent vascular relaxation. In conclusion, the findings of the present study indicated that the NLRP3/IL-1β axis may impair vasodilation by promoting the proteolysis of eNOS and melatonin may protect against sepsis-induced endothelial relaxation dysfunction by inhibiting the NLRP3/IL-1β axis, suggesting its pharmacological potential in sepsis.
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Affiliation(s)
- Shupeng Hu
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing 400016, China
| | - Qiangzhong Pi
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing 400016, China
| | - Minghao Luo
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing 400016, China
| | - Zhe Cheng
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing 400016, China
| | - Xiaoxue Liang
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing 400016, China
| | - Suxin Luo
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Yong Xia
- Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing 400016, China; Davis Heart and Lung Research Institute, Division of Cardiovascular Medicine, 473 West 12th Avenue, Columbus, OH 43210, USA.
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Mitchell HK, Reddy A, Montoya-Williams D, Harhay M, Fowler JC, Yehya N. Hospital outcomes for children with severe sepsis in the USA by race or ethnicity and insurance status: a population-based, retrospective cohort study. THE LANCET. CHILD & ADOLESCENT HEALTH 2021; 5:103-112. [PMID: 33333071 PMCID: PMC9020885 DOI: 10.1016/s2352-4642(20)30341-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/02/2020] [Accepted: 10/08/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Disparities in outcomes of adult sepsis are well described by insurance status and race and ethnicity. There is a paucity of data looking at disparities in sepsis outcomes in children. We aimed to determine whether hospital outcomes in childhood severe sepsis were influenced by race or ethnicity and insurance status, a proxy for socioeconomic position. METHODS This population-based, retrospective cohort study used data from the 2016 database release from the Healthcare Cost and Utilization Project Kids' Inpatient Database (KID). The 2016 KID included 3 117 413 discharges, accounting for 80% of national paediatric discharges from 4200 US hospitals across 47 states. Using multilevel logistic regression, clustered by hospital, we tested the association between race or ethnicity and insurance status and hospital mortality, adjusting for individual-level and hospital-level characteristics, in children with severe sepsis. The secondary outcome of length of hospital stay was examined through multilevel time to event (hospital discharge) regression, with death as a competing risk. FINDINGS 12 297 children (aged 0-21 years) with severe sepsis with or without shock were admitted to 1253 hospitals in the 2016 KID dataset. 1265 (10·3%) of 12 297 patients did not have race or ethnicity data recorded, 15 (0·1%) were missing data on insurance, and 1324 (10·8%) were transferred out of hospital, resulting in a final cohort of 9816 children. Black children had higher odds of death than did White children (adjusted odds ratio [OR] 1·19, 95 % CI 1·02-1·38; p=0·028), driven by higher Black mortality in the south (1·30, 1·04-1·62; p=0·019) and west (1·58, 1·05-2·38; p=0·027) of the USA. We found evidence of longer hospital stays for Hispanic children (adjusted hazard ratio 0·94, 95% CI 0·88-1·00; p=0·049) and Black children (0·88, 0·82-0·94; p=0·0002), particularly Black neonates (0·53, 95% CI 0·36-0·77; p=0·0011). We observed no difference in survival between publicly and privately insured children; however, other insurance status (self-pay, no charge, and other) was associated with increased mortality (adjusted OR 1·30, 95% CI 1·04-1·61; p=0·021). INTERPRETATION In this large, representative analysis of paediatric severe sepsis in the USA, we found evidence of outcome disparities by race or ethnicity and insurance status. Our findings suggest that there might be differential sepsis recognition, approaches to treatment, access to health-care services, and provider bias that contribute to poorer sepsis outcomes for racial and ethnic minority patients and those of lower socioeconomic position. Studies are warranted to investigate the mechanisms of poorer sepsis outcomes in Black and Hispanic children. FUNDING None.
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Affiliation(s)
- Hannah K Mitchell
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Anireddy Reddy
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Michael Harhay
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA; Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Jessica C Fowler
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Medeiros DNM, Shibata AO, Pizarro CF, Rosa MDLA, Cardoso MP, Troster EJ. Barriers and Proposed Solutions to a Successful Implementation of Pediatric Sepsis Protocols. Front Pediatr 2021; 9:755484. [PMID: 34858905 PMCID: PMC8631453 DOI: 10.3389/fped.2021.755484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/04/2021] [Indexed: 11/23/2022] Open
Abstract
The implementation of managed protocols contributes to a systematized approach to the patient and continuous evaluation of results, focusing on improving clinical practice, early diagnosis, treatment, and outcomes. Advantages to the adoption of a pediatric sepsis recognition and treatment protocol include: a reduction in time to start fluid and antibiotic administration, decreased kidney dysfunction and organ dysfunction, reduction in length of stay, and even a decrease on mortality. Barriers are: absence of a written protocol, parental knowledge, early diagnosis by healthcare professionals, venous access, availability of antimicrobials and vasoactive drugs, conditions of work, engagement of healthcare professionals. There are challenges in low-middle-income countries (LMIC). The causes of sepsis and resources differ from high-income countries. Viral agent such as dengue, malaria are common in LMIC and initial approach differ from bacterial infections. Some authors found increased or no impact in mortality or increased length of stay associated with the implementation of the SCC sepsis bundle which reinforces the importance of adapting it to most frequent diseases, disposable resources, and characteristics of healthcare professionals. Conclusions: (1) be simple; (2) be precise; (3) education; (5) improve communication; (5) work as a team; (6) share and celebrate results.
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Affiliation(s)
| | - Audrey Ogawa Shibata
- Pediatric Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Marta Pessoa Cardoso
- Pediatric Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo Juan Troster
- Faculdade Israelita de Ciências em Saúde, Hospital Albert Einstein, São Paulo, Brazil
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25
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Sayed SZ, Mahmoud MM, Moness HM, Mousa SO. Admission platelet count and indices as predictors of outcome in children with severe Sepsis: a prospective hospital-based study. BMC Pediatr 2020; 20:387. [PMID: 32814554 PMCID: PMC7437045 DOI: 10.1186/s12887-020-02278-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 08/06/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Sepsis is still one of the main causes of infants and children mortality especially in developing, economically challenged countries with limited resources. Our objective in this study was to determine, the prognostic value of platelet count, mean platelet volume (MPV), platelet distribution width (PDW) and plateletcrit (PCT) in critically ill infants and children with severe sepsis, as they are readily available biomarkers, that can guide clinicians during managing of severe sepsis. METHODS Sixty children were included; they were diagnosed with severe sepsis according to the international pediatric sepsis consensus conference criteria. At admission to Pediatric intensive care unit, complete blood count with platelet count and parameters (MPV, PDW and PCT) and C-reactive protein (CRP) level were determined for all children. Also, assessment of the Pediatric Risk of Mortality (PRISM III) score was done to all. These children were followed up till discharge from hospital or death. Accordingly, they were grouped into: (1) Survivor group: included 41 children. (2) Non-survivor group: included 19 children. RESULTS Platelet count and PCT were significantly lower (p < 0.001) and MPV was significantly higher in non-survivor than survivors (p = 0.004). MPV/PLT, MPV/PCT, PDW/PLT, PDW/PCT ratios were found to be significantly higher in the non-survivors than survivor (p < 0.001 in all). PCT with sensitivity = 94.74%, was the most sensitive platelet parameter for prediction of death, while MPV/PCT was the most sensitive ratio (sensitivity = 94.7%). CONCLUSION Thrombocytopenia, platelet indices and their ratios, especially plateletcrit and MPV/PCT, are readily available, sensitive, prognostic markers, that can identify the severe sepsis patients with poorest outcome.
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Affiliation(s)
- Samira Z. Sayed
- Pediatric Department, Children’s University hospital, Faculty of Medicine, Minia University, El-Minya, Egypt
| | - Mohamed M. Mahmoud
- Pediatric Department, Children’s University hospital, Faculty of Medicine, Minia University, El-Minya, Egypt
| | - Hend M. Moness
- Clinical Pathology Department, Children’s University hospital, Faculty of Medicine, Minia University, El-Minya, Egypt
| | - Suzan O. Mousa
- Pediatric Department, Children’s University hospital, Faculty of Medicine, Minia University, El-Minya, Egypt
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26
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Bulatova YY, Maltabarova NA, Zhumabayev MB, Li TA, Ivanova MP. Modern Diagnostics of Sepsis and Septic Shock in Children. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2020. [DOI: 10.29333/ejgm/7879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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