1
|
Baker AH, Leland SB, Freiman E, Herigon JC, Eisenberg MA. Characteristics and Outcomes of Culture-Positive and Culture-Negative Pediatric Sepsis. J Pediatr 2023; 263:113718. [PMID: 37659590 DOI: 10.1016/j.jpeds.2023.113718] [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] [Received: 05/31/2023] [Revised: 08/21/2023] [Accepted: 08/29/2023] [Indexed: 09/04/2023]
Abstract
OBJECTIVES To compare the outcomes of pediatric severe sepsis and septic shock among patients with culture-positive and culture-negative sepsis and to determine if there are differentiating markers of disease severity between these 2 populations during their initial presentation and emergency department (ED) stay. STUDY DESIGN Retrospective cohort study of patients ≤21 years of age who presented to the ED of a single children's hospital with severe sepsis or septic shock from June 1, 2017 to June 5, 2019. RESULTS There were 235 patients who met criteria for severe sepsis or septic shock. Of these, 139 (59.1%) had culture-negative sepsis and 96 (40.9%) had culture-positive sepsis. In the adjusted multivariable model, children with culture-negative sepsis had more intensive care unit (ICU)-free days than those with culture-positive sepsis (27.3 vs 24.1; adjusted median differences [aMD] -2.6 [-4.4, -0.8]). There were no differences in mortality or hospital-free days. On initial presentation, there were no differences in fever, hypothermia, tachycardia, tachypnea, or hypotension between the 2 groups. There were no differences in proportion of patients receiving the following interventions: intravenous (IV) antibiotics, IV fluids, vasoactive medications, CPR, intubation, or time from arrival to provision of these interventions. CONCLUSIONS Culture-negative sepsis constitutes a substantial proportion of pediatric severe sepsis and septic shock. In this study, patients with culture-negative and culture-positive sepsis presented similarly on arrival to the ED and received similar treatments while there. Patients with culture-negative sepsis had more ICU-free days than those with culture-positive sepsis, although differences in hospital length of stay (LOS) and mortality were not observed.
Collapse
Affiliation(s)
- Alexandra H Baker
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA.
| | - Shannon B Leland
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Eli Freiman
- Department of Emergency Medicine, Newton Wellesley Hospital, Newton, MA
| | - Joshua C Herigon
- Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO; Department of Pediatrics, University of Missouri - Kansas City School of Medicine, University of Missouri, Kansas City, MO
| | - Matthew A Eisenberg
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA
| |
Collapse
|
2
|
Campbell JI, Shanahan KH, Bartick M, Ali M, Goldmann D, Shaikh N, Allende-Richter S. Racial and Ethnic Differences in Length of Stay for US Children Hospitalized for Acute Osteomyelitis. J Pediatr 2023; 259:113424. [PMID: 37084849 PMCID: PMC10527861 DOI: 10.1016/j.jpeds.2023.113424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/02/2022] [Accepted: 03/31/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVE To examine the associations between race and ethnicity and length of stay (LOS) for US children with acute osteomyelitis. STUDY DESIGN Using the Kids' Inpatient Database, we conducted a cross-sectional study of children <21 years old hospitalized in 2016 or 2019 with acute osteomyelitis. Using survey-weighted negative binomial regression, we modeled LOS by race and ethnicity, adjusting for clinical and hospital characteristics and socioeconomic status. Secondary outcomes included prolonged LOS, defined as LOS of >7 days (equivalent to LOS in the highest quartile). RESULTS We identified 2388 children discharged with acute osteomyelitis. The median LOS was 5 days (IQR, 3-7). Compared with White children, children of Black race (adjusted incidence rate ratio [aIRR] 1.15; 95% CI, 1.05-1.27), Hispanic ethnicity (aIRR 1.11; 95% CI, 1.02-1.21), and other race and ethnicity (aIRR 1.12; 95% CI, 1.01-1.23) had a significantly longer LOS. The odds of Black children experiencing prolonged LOS was 46% higher compared with White children (aOR, 1.46; 95% CI, 1.01-2.11). CONCLUSIONS Children of Black race, Hispanic ethnicity, and other race and ethnicity with acute osteomyelitis experienced longer LOS than White children. Elucidating the mechanisms underlying these race- and ethnicity-based differences, including social drivers such as access to care, structural racism, and bias in provision of inpatient care, may improve management and outcomes for children with acute osteomyelitis.
Collapse
Affiliation(s)
- Jeffrey I Campbell
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA.
| | | | - Melissa Bartick
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA
| | - Mohsin Ali
- Division of Infectious Diseases, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Don Goldmann
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA
| | - Nadia Shaikh
- Department of Pediatrics, University of Illinois College of Medicine at Peoria, Peoria, IL
| | | |
Collapse
|
3
|
Endrich O, Triep K, Schlapbach LJ, Posfay-Barbe KM, Heininger U, Giannoni E, Stocker M, Niederer-Loher A, Kahlert CR, Natalucci G, Relly C, Riedel T, Aebi C, Berger C, Agyeman PKA. Sensitivity of ICD coding for sepsis in children-a population-based study. INTENSIVE CARE MEDICINE. PAEDIATRIC AND NEONATAL 2023; 1:5. [PMID: 37342815 PMCID: PMC10261837 DOI: 10.1007/s44253-023-00006-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/16/2023] [Indexed: 06/23/2023]
Abstract
Background International Classification of Diseases 10th edition (ICD-10) is widely used to describe the burden of disease. Aim To describe how well ICD-10 coding captures sepsis in children admitted to the hospital with blood culture-proven bacterial or fungal infection and systemic inflammatory response syndrome. Methods Secondary analysis of a population-based, multicenter, prospective cohort study on children with blood culture-proven sepsis of nine tertiary pediatric hospitals in Switzerland. We compared the agreement of validated study data on sepsis criteria with ICD-10 coding abstraction obtained at the participating hospitals. Results We analyzed 998 hospital admissions of children with blood culture-proven sepsis. The sensitivity of ICD-10 coding abstraction was 60% (95%-CI 57-63) for sepsis; 35% (95%-CI 31-39) for sepsis with organ dysfunction, using an explicit abstraction strategy; and 65% (95%-CI 61-69) using an implicit abstraction strategy. For septic shock, the sensitivity of ICD-10 coding abstraction was 43% (95%-CI 37-50). Agreement of ICD-10 coding abstraction with validated study data varied by the underlying infection type and disease severity (p < 0.05). The estimated national incidence of sepsis, inferred from ICD-10 coding abstraction, was 12.5 per 100,000 children (95%-CI 11.7-13.5) and 21.0 per 100,000 children (95%-CI 19.8-22.2) using validated study data. Conclusions In this population-based study, we found a poor representation of sepsis and sepsis with organ dysfunction by ICD-10 coding abstraction in children with blood culture-proven sepsis when compared against a prospective validated research dataset. Sepsis estimates in children based on ICD-10 coding may thus severely underestimate the true prevalence of the disease. Supplementary Information The online version contains supplementary material available at 10.1007/s44253-023-00006-1.
Collapse
Affiliation(s)
- Olga Endrich
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Medical Directorate, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Karen Triep
- Medical Directorate, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology, and Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
- Child Health Research Center, University of Queensland, Brisbane, Australia
| | - Klara M. Posfay-Barbe
- Pediatric Infectious Diseases Unit, Children’s Hospital of Geneva, University Hospitals of Geneva, Geneva, Switzerland
| | - Ulrich Heininger
- Infectious Diseases and Vaccinology, University of Basel Children’s Hospital, Basel, Switzerland
| | - Eric Giannoni
- Clinic of Neonatology, Department Mother-Woman-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | | | | | - Giancarlo Natalucci
- Family Larsson-Rosenquist Foundation Centre for Neurodevelopment, Growth and Nutrition of the Newborn, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Christa Relly
- Division of Infectious Diseases and Hospital Epidemiology, Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Thomas Riedel
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Pediatrics, Cantonal Hospital Graubuenden, Chur, Switzerland
| | - Christoph Aebi
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Berger
- Division of Infectious Diseases and Hospital Epidemiology, Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Philipp K. A. Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | |
Collapse
|
4
|
Becker AE, Teixeira SR, Lunig NA, Mondal A, Fitzgerald JC, Topjian AA, Weiss SL, Griffis H, Schramm SE, Traynor DM, Vossough A, Kirschen MP. Sepsis-Related Brain MRI Abnormalities Are Associated With Mortality and Poor Neurological Outcome in Pediatric Sepsis. Pediatr Neurol 2022; 128:1-8. [PMID: 34992035 PMCID: PMC9685598 DOI: 10.1016/j.pediatrneurol.2021.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 11/28/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND It is not known whether brain magnetic resonance imaging (MRI) abnormalities in pediatric sepsis are associated with clinical outcomes. Study objectives were to (1) determine the prevalence and type of sepsis-related neuroimaging abnormalities evident on clinically indicated brain MRI in children with sepsis and (2) test the association of these abnormalities with mortality, new disability, length of stay (LOS), and MRI indication. METHODS Retrospective cohort study of 140 pediatric patients with sepsis and a clinically indicated brain MRI obtained within 60 days of sepsis onset at a single, large academic pediatric intensive care unit (PICU). Two radiologists systematically reviewed the first post-sepsis brain MRI and determined which abnormalities were sepsis-related. Outcomes compared in patients with versus without sepsis-related MRI abnormalities. RESULTS PICU mortality was 7%. Thirty patients had one or more sepsis-related MRI abnormality, yielding a prevalence of 21% (95% confidence interval 15%, 28%). Among those, 53% (16 of 30) had sepsis-related white matter signal abnormalities; 53% (16 of 30) sepsis-related ischemia, infarction, or thrombosis; and 27% (eight of 30) sepsis-related posterior reversible encephalopathy. Patients with one or more sepsis-related MRI abnormality had increased mortality (17% vs 5%; P = 0.04), new neurological disability at PICU discharge (32% vs 11%; P = 0.03), and longer PICU LOS (median 18 vs 11 days; P = 0.04) compared with patients without. CONCLUSIONS In children with sepsis and a clinically indicated brain MRI, 21% had a sepsis-related MRI abnormality. Sepsis-related MRI abnormalities were associated with increased mortality, new neurological disability, and longer PICU LOS.
Collapse
Affiliation(s)
- Andrew E. Becker
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sara R. Teixeira
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Nicholas A. Lunig
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Antara Mondal
- Department of Biomedical & Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Julie C. Fitzgerald
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,CHOP Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Alexis A. Topjian
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Scott L. Weiss
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,CHOP Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Heather Griffis
- Department of Biomedical & Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Stephanie E. Schramm
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Danielle M. Traynor
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Arastoo Vossough
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthew P. Kirschen
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
5
|
Kohn-Loncarica G, Hualde G, Fustiñana A, Monticelli MF, Reinoso G, Cortéz M, Segovia L, Mareco-Naccarato G, Rino P. Use of Inotropics by Peripheral Vascular Line in the First Hour of Treatment of Pediatric Septic Shock: Experience at an Emergency Department. Pediatr Emerg Care 2022; 38:e371-e377. [PMID: 33214518 DOI: 10.1097/pec.0000000000002295] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Mortality in pediatric septic shock remains unacceptably high. Delays in vasopressor administration have been associated with an increased risk of mortality. Current treatment guidelines suggest the use of a peripheral vascular line (PVL) for inotropic administration in fluid-refractory septic shock when a central vascular line is not already in place. The aim of this study was to report local adverse effects associated with inotropic drug administration through a PVL at a pediatric emergency department setting in the first hour of treatment of septic shock. METHODS A prospective, descriptive, observational cohort study of patients with septic shock requiring PVL inotropic administration was conducted at the pediatric emergency department of a tertiary care pediatric hospital. For the infusion and postplacement care of the PVL for vasoactive drugs, an institutional nursing protocol was used. RESULTS We included 49 patients; 51% had an underlying disease. Eighty-four percent of the children included had a clinical "cold shock." The most frequently used vasoactive drug was epinephrine (72%). One patient presented with local complications. CONCLUSIONS At our center, infusion of vasoactive drugs through a PVL was shown to be safe and allowed for adherence to the current guidelines for pediatric septic shock.
Collapse
|
6
|
Pediatric sepsis survival in pediatric and general emergency departments. Am J Emerg Med 2021; 51:53-57. [PMID: 34673476 DOI: 10.1016/j.ajem.2021.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Understanding differences in mortality rate secondary to sepsis between pediatric and general emergency departments (EDs) would help identify strategies to improve pediatric sepsis care. We aimed to determine if pediatric sepsis mortality differs between pediatric and general EDs. METHODS We performed a nationally representative, retrospective cohort study using the 2008-2017 Nationwide Emergency Department Sample (NEDS) to examine visits by patients less than 19 years old with a diagnostic code of severe sepsis or septic shock. We generated national estimates of study outcomes using NEDS survey weights. We compared pediatric to general EDs on the outcomes of ED mortality and hospital mortality. We determined adjusted mortality risk using logistic regression, controlling for age, gender, complex care code, and geographic region. RESULTS There were 54,129 weighted pediatric ED visits during the study period with a diagnosis code of severe sepsis or septic shock. Of these visits, 285 died in the ED (0.58%) and 5065 died during their hospital stay (9.8%). Mortality risk prior to ED disposition in pediatric and general EDs was 0.31% and 0.72%, respectively (adjusted odds ratio (aOR), 95% confidence interval (CI): 0.36 (0.14-0.93)). Mortality risk prior to hospital discharge in pediatric and general EDs was 7.5% and 10.9%, respectively (aOR, 95% CI: 0.55 (0.41-0.72)). CONCLUSIONS In a nationally representative sample, pediatric mortality from severe sepsis or septic shock was lower in pediatric EDs than in general EDs. Identifying features of pediatric ED care associated with improved sepsis mortality could translate into improved survival for children wherever they present with sepsis.
Collapse
|
7
|
Application of the Improving Pediatric Sepsis Outcomes Definition for Pediatric Sepsis to Nationally Representative Emergency Department Data. Pediatr Qual Saf 2021; 6:e468. [PMID: 35018312 PMCID: PMC8741269 DOI: 10.1097/pq9.0000000000000468] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 04/21/2021] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. To compare encounter estimates and demographics of pediatric patients (<18 years) meeting modified Improving Pediatric Sepsis Outcomes (IPSO) criteria for sepsis to cohorts obtained using other criteria for pediatric sepsis from administrative datasets.
Collapse
|
8
|
Use of Negative Pressure Ventilation in Pediatric Critical Care: Experience in 56 PICUs in the Virtual Pediatric Systems Database (2009-2019). Pediatr Crit Care Med 2021; 22:e363-e368. [PMID: 33729731 DOI: 10.1097/pcc.0000000000002690] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Negative pressure ventilation may be more physiologic than positive pressure ventilation, but data describing negative pressure ventilation use in the PICU are limited. We aimed to describe the epidemiology and outcomes of PICU patients receiving negative pressure ventilation. DESIGN Descriptive analysis of a large, quality-controlled multicenter database. SETTING Fifty-six PICUs in the Virtual Pediatric Systems database who reported use of negative pressure ventilation. PATIENTS Children admitted to a participating PICU between 2009 and 2019 who received negative pressure ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 788 subjects, 71% were less than 2 years old, and 45% had underlying health conditions. Two concurrent aspiration events were the only adverse events reported. After excluding one over-represented center, the 3 years with the most negative pressure ventilation usage were 2017-2019 (all > 25 cases/yr and ≥ 13 centers reporting usage). Among those 187 children, the most common primary diagnoses were bronchiolitis and cardiac disease (both 15.5%), 24.1% required endotracheal intubation after negative pressure ventilation, and 9.1% died. CONCLUSIONS Negative pressure ventilation is being used in many PICUs, most commonly for pulmonary infections or cardiac disease, in children with high rates of subsequent intubation and mortality and with few documented adverse events. Use at individual centers is rare but increasing, suggesting need for prospective collaboration to better evaluate the role of negative pressure ventilation in the PICU.
Collapse
|
9
|
Abstract
OBJECTIVES To assess the prevalence of immunocompromised diagnoses among children with severe sepsis and septic shock, and to determine the association between immunocompromised diagnoses and clinical outcomes after adjustment for demographics and illness severity. DESIGN Retrospective multicenter cohort study. SETTING Eighty-three centers in the Virtual Pediatric Systems database. PATIENTS Children with severe sepsis or septic shock admitted to a participating PICU between January 1, 2012, and December 31, 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Across 83 centers, we identified 10,768 PICU admissions with an International Classification of Diseases, 9th Revision, Clinical Modification code for severe sepsis or septic shock; 3,021 of these patients (28%) had an immunocompromised diagnosis. To evaluate variation across centers and determine factors associated with PICU mortality, we used mixed-effect logistic regression models. Among patients without hematopoietic cell transplant, congenital immunodeficiency (adjusted odds ratio, 1.90; 95% CI, 1.24-2.92), multiple prior malignancies (adjusted odds ratio, 1.86; 95% CI, 1.15-2.99), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 3.09; 95% CI, 1.91-4.98) were associated with an increased odds of PICU mortality. Among patients with prior hematopoietic cell transplant, liquid malignancy (adjusted odds ratio, 3.15; 95% CI, 2.09-4.74), congenital immunodeficiency (adjusted odds ratio, 6.94; 95% CI, 3.84-12.53), multiple prior malignancies (adjusted odds ratio, 3.54; 95% CI, 1.80-6.95), and hemophagocytic lymphohistiocytosis (adjusted odds ratio, 2.79; 95% CI, 1.36-5.71) were associated with an increased odds of PICU mortality. PICU mortality varied significantly by center, and a higher mean number of sepsis patients per month in a center was associated with lower PICU mortality (adjusted odds ratio, 0.94; 95% CI, 0.90-0.98). PICU resource utilization varied by immunocompromised diagnosis and history of hematopoietic cell transplant, and among survivors immunocompromised patients have shorter median PICU length of stay compared with patients without immunocompromised diagnoses (p < 0.001). CONCLUSIONS Immunocompromised diagnoses are present in 28% of children with severe sepsis or septic shock. Multiple prior malignancies, hemophagocytic lymphohistiocytosis, congenital immunodeficiency, and hematopoietic cell transplant are independently associated with an increased odds of PICU mortality in children with severe sepsis or septic shock. Significant variation exists in PICU mortality among centers despite adjustment for immunocompromised diagnoses, known risk factors for sepsis-related mortality, and center-level sepsis volume.
Collapse
|
10
|
Johnson KT, Görges M, Murthy S. Characteristics and Timing of Mortality in Children Dying With Infections in North American PICUs. Pediatr Crit Care Med 2021; 22:365-379. [PMID: 33591070 DOI: 10.1097/pcc.0000000000002667] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate the characteristics and timing of death of children with severe infections who die during PICU admission. DESIGN We analyzed demographics, timing of death, diagnoses, and common procedures in a large cohort obtained from the Virtual Pediatrics Systems database, focusing on early deaths (< 1 d). SETTING Clinical records were prospectively collected in 130 PICUs across North America. PATIENTS Children admitted between January 2009 and December 2014 with at least one infection-related diagnosis at time of death. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Analysis included data from 106,464 children admitted to PICUs. The 4,240 children (4%) who died were older than PICU survivors. The median (interquartile range) duration in PICU prior to death was 7.1 days (2.1-21.3 d), with 635 children (15%) dying early (< 1 d of PICU admission). Children who died early were older, more likely to have septic shock, and more likely to have received cardiopulmonary resuscitation than those who died later. Withdrawal of care was less likely in early deaths compared with later deaths. After adjusting for age, sex, sepsis severity, procedures (including cardiopulmonary resuscitation and heart, lung, and renal support), and number of admissions contributed per PICU, it was found that children admitted from the emergency department, inpatient floors, or referring hospitals had significantly greater risk of early death compared with children admitted from the operating room. CONCLUSIONS A substantial proportion of children admitted to PICU with severe infections die early and differ from those dying later in diagnoses, procedures, and admitting location. The emergency department is a key source of critically ill patients. Understanding characteristics of early deaths may yield recruitment considerations for clinical trials enrolling children at high risk of early death.
Collapse
Affiliation(s)
- K Taneille Johnson
- Department of Pediatrics, Division of Critical Care, University of British Columbia, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Matthias Görges
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia (UBC), Vancouver, BC, Canada
- Research Institute, BC Children's Hospital (BCCH), Vancouver, BC, Canada
| | - Srinivas Murthy
- Department of Pediatrics, Division of Critical Care, University of British Columbia, Vancouver, BC, Canada
- Research Institute, BC Children's Hospital (BCCH), Vancouver, BC, Canada
| |
Collapse
|
11
|
Li Z, Huang B, Yi W, Wang F, Wei S, Yan H, Qin P, Zou D, Wei R, Chen N. Identification of Potential Early Diagnostic Biomarkers of Sepsis. J Inflamm Res 2021; 14:621-631. [PMID: 33688234 PMCID: PMC7937397 DOI: 10.2147/jir.s298604] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/22/2021] [Indexed: 12/12/2022] Open
Abstract
Objective The goal of this article was to identify potential biomarkers for early diagnosis of sepsis in order to improve their survival. Methods We analyzed differential gene expression between adult sepsis patients and controls in the GSE54514 dataset. Coexpression analysis was used to cluster coexpression modules, and enrichment analysis was performed on module genes. We also analyzed differential gene expression between neonatal sepsis patients and controls in the GSE25504 dataset, and we identified the subset of differentially expressed genes (DEGs) common to neonates and adults. All samples in the GSE54514 dataset were randomly divided into training and validation sets, and diagnostic signatures were constructed using least absolute shrink and selection operator (LASSO) regression. The key gene signature was screened for diagnostic value based on area under the receiver operating characteristic curve (AUC). STEM software identified dysregulated genes associated with sepsis-associated mortality. The ssGSEA method was used to quantify differences in immune cell infiltration between sepsis and control samples. Results A total of 6316 DEGs in GSE54514 were obtained spanning 10 modules. Module genes were mainly enriched in immune and metabolic responses. Screening 51 genes from among common genes based on AUC > 0.7 led to a LASSO model for the training set. We obtained a 25-gene signature, which we validated in the validation set and in the GSE25504 dataset. Among the signature genes, SLC2A6, C1ORF55, DUSP5 and RHOB were recognized as key genes (AUC > 0.75) in both the GSE54514 and GSE25504 datasets. SLC2A6 was identified by STEM as associated with sepsis-associated mortality and showed the strongest positive correlation with infiltration levels of Th1 cells. Conclusion In summary, our four key genes may have important implications for the early diagnosis of sepsis patients. In particular, SLC2A6 may be a critical biomarker for predicting survival in sepsis.
Collapse
Affiliation(s)
- Zhenhua Li
- Department of Emergency Medicine, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, 530022, People's Republic of China.,Intensive Care Unit, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, 530022, People's Republic of China
| | - Bin Huang
- Intensive Care Unit, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, 530022, People's Republic of China
| | - Wenfeng Yi
- Intensive Care Unit, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, 530022, People's Republic of China
| | - Fei Wang
- Department of Emergency Medicine, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, 530022, People's Republic of China
| | - Shizhuang Wei
- Department of Emergency Medicine, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, 530022, People's Republic of China
| | - Huaixing Yan
- Department of Emergency Medicine, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, 530022, People's Republic of China
| | - Pan Qin
- Department of Emergency Medicine, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, 530022, People's Republic of China
| | - Donghua Zou
- Department of Emergency Medicine, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, 530022, People's Republic of China
| | - Rongguo Wei
- Department of Clinical Laboratory, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, 530022, People's Republic of China
| | - Nian Chen
- Department of Infectious Diseases, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, 530022, People's Republic of China
| |
Collapse
|
12
|
Ginsburg S, Conlon T, Himebauch A, Glau C, Weiss S, Weber MD, O'Connor MJ, Nishisaki A. Left Ventricular Diastolic Dysfunction in Pediatric Sepsis: Outcomes in a Single-Center Retrospective Cohort Study. Pediatr Crit Care Med 2021; 22:275-285. [PMID: 33534389 DOI: 10.1097/pcc.0000000000002668] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Left ventricular diastolic dysfunction is associated with difficulty in ventilator weaning and increased mortality in septic adults. We evaluated the association of left ventricular diastolic dysfunction with outcomes in a cohort of children with severe sepsis and septic shock. DESIGN Retrospective cohort study. SETTING Single-center noncardiac PICU. PATIENTS Age greater than 1 month to less than 18 years old with severe sepsis or septic shock from January 2011 to June 2017 with echocardiogram within 48 hours of sepsis onset. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Echocardiograms were retrospectively assessed for mitral inflow E (early) and A (atrial) velocity and e' (early mitral annular motion) septal and lateral velocity. Left ventricular diastolic dysfunction was defined as E/e' greater than 10, E/A less than 0.8, or E/A greater than 1.5. Left ventricular diastolic dysfunction was present in 109 of 204 patients (53%). The data did not demonstrate an association between the presence of left ventricular diastolic dysfunction and the proportion of children requiring invasive mechanical ventilation at the time of echocardiogram (difference in proportion, +5% [72% vs 67%; 95% CI, -8% to 17%]; p = 0.52). The duration of mechanical ventilation was median 192.9 hours (interquartile range, 65.0-378.4 hr) in the left ventricular diastolic dysfunction group versus 151.0 hours (interquartile range, 45.7-244.3 hr) in the group without left ventricular diastolic dysfunction. The presence of left ventricular diastolic dysfunction was not significantly associated with ICU length of stay or mortality. Exploratory analyses revealed that an alternative definition of left ventricular diastolic dysfunction, solely defined by E/e' greater than 10, was found to have an association with mechanical ventilation requirement at the time of echocardiogram (difference in proportion, +15%; 95% CI, 3-28%; p = 0.02) and duration of mechanical ventilation (median, 207.3 vs 146.9 hr). CONCLUSIONS The data failed to show an association between the presence of left ventricular diastolic dysfunction defined by both E/e' and E/A and the primary and secondary outcomes. When an alternative definition of left ventricular diastolic dysfunction with E/e' alone was used, there was a significant association with respiratory outcomes.
Collapse
Affiliation(s)
- Sarah Ginsburg
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Thomas Conlon
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Adam Himebauch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Christie Glau
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Scott Weiss
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.,Children's Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia, PA
| | - Mark D Weber
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Matthew J O'Connor
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Fitzgerald JC, Kelly NA, Hickey C, Balamuth F, Thomas NH, Hogan A, Stack NJ, Trimarchi T, Weiss SL. Implementation of a Follow-Up System for Pediatric Sepsis Survivors in a Large Academic Pediatric Intensive Care Unit. Front Pediatr 2021; 9:691692. [PMID: 34150690 PMCID: PMC8212949 DOI: 10.3389/fped.2021.691692] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/04/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Survivors of pediatric sepsis often develop new morbidities and deterioration in quality of life after sepsis, leading to a need for improved follow-up for children who survive sepsis. Objective: To implement a follow-up system for pediatric sepsis survivors in a pediatric health system. Methods: We performed a retrospective case series of patients treated for sepsis from October 2018 through October 2019 in a pediatric intensive care unit in a quaternary children's hospital, and describe implementation of a follow-up system for sepsis survivors. Program planning started in 2017 with multidisciplinary meetings including physical, occupational, and speech therapists, teachers, neuropsychologists, and coordinators from other survivorship programs (neonatology, stroke, and oncology). In 2018, a workshop was held to consult with local and national experts. The Pediatric Sepsis Survivorship Program launched in October 2018 led by a nurse coordinator who met with families to educate about sepsis and offer post-discharge follow-up. Patients with high pre-existing medical complexity or established subspecialty care were referred for follow-up through existing care coordination or subspecialty services plus guidance to monitor for post-sepsis morbidity. For patients with low-moderate medical complexity, the nurse coordinator administered a telephone-based health-assessment 2-3 months after discharge to screen for new physical or psychosocial morbidity. Patients flagged with concerns were referred to their primary physician and/or to expedited neuropsychological evaluation to utilize existing medical services. Results: Of 80 sepsis patients, 10 died, 20 were referred to care coordination by the program, and 13 had subspecialty follow-up. Five patients were followed in different health systems, four were adults not appropriate for existing follow-up programs, four remained hospitalized, and four were missed due to short stay or unavailable caregivers. The remaining 20 patients were scheduled for follow-up with the Pediatric Sepsis Program. Nine patients completed the telephone assessment. Four patients were receiving new physical or occupational therapy, and one patient was referred for neuropsychology evaluation due to new difficulties with attention, behavior, and completion of school tasks. Conclusions: Implementation of an efficient, low-cost pediatric sepsis survivorship program was successful by utilizing existing systems of care, when available, and filling a follow-up gap in screening for select patients.
Collapse
Affiliation(s)
- Julie C Fitzgerald
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Anesthesiology, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, United States.,Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Nancy-Ann Kelly
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Christopher Hickey
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Fran Balamuth
- Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Pediatrics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, United States
| | - Nina H Thomas
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Psychiatry, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, United States
| | - Annique Hogan
- Department of Pediatrics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, United States.,Department of Pediatrics, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Noelle J Stack
- Care Management Department, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Tara Trimarchi
- Care Management Department, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Scott L Weiss
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Anesthesiology, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, United States.,Pediatric Sepsis Program, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| |
Collapse
|
15
|
Joining Datasets Without Identifiers: Probabilistic Linkage of Virtual Pediatric Systems and PEDSnet. Pediatr Crit Care Med 2020; 21:e628-e634. [PMID: 32511201 DOI: 10.1097/pcc.0000000000002380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To 1) probabilistically link two important pediatric data sources, Virtual Pediatric Systems and PEDSnet, 2) evaluate linkage accuracy overall and in patients with severe sepsis or septic shock, and 3) identify variables important to linkage accuracy. DESIGN Retrospective linkage of prospectively collected datasets from Virtual Pediatrics Systems, Inc (Los Angeles, CA) and the PEDSnet consortium. SETTING Single-center academic PICU. PATIENTS All PICU encounters between January 1, 2012, and December 31, 2017, that were deterministically matched between the two datasets. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We abstracted records from Virtual Pediatric Systems and PEDSnet corresponding to PICU encounters and probabilistically linked using 44 features shared by the two datasets. We generated a gold standard deterministic linkage using protected health information elements, which were then removed from datasets. We then calculated candidate pair log-likelihood ratios for all pairs of subjects and selected optimal pairs in a two-stage algorithm. A total of 22,051 gold standard PICU encounter pairs were identified over the study period. The optimal linkage model demonstrated excellent discrimination (area under the receiver operating characteristic curve > 0.99); 19,801 cases (89.9%) were matched with 13 false positives. The addition of two protected health information dates (admission month, birth day-of-year) increased to 20,189 (91.6%) the cases matched, with three false positives. Restricting to patients with Virtual Pediatric Systems diagnosis of severe sepsis or septic shock (n = 1,340 [6.1%]) matched 1,250 cases (93.2%) with zero false positives. Increased number of laboratory values present in the first 12 hours of admission significantly increased log-likelihood ratios, suggesting stronger candidate pair matching. CONCLUSIONS We demonstrated the use of probabilistic linkage to accurately join two complementary pediatric critical care datasets at a single academic PICU in the absence of protected health information. Combining datasets with curated diagnoses and granular measurements can validate patient acuity metrics and facilitate multicenter machine learning algorithms. We anticipate these methods will generalize to other common PICU diagnoses.
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW Sepsis remains among the leading causes of childhood mortality worldwide. This review serves to highlight key areas of knowledge gain and ongoing controversies pertinent to sepsis in children. RECENT FINDINGS Several recent publications describe the epidemiology of paediatric sepsis, demonstrating the impact on child health in terms of mortality and morbidity, and the shortcomings of current paediatric sepsis definitions. Although emerging data support the importance of organ dysfunction as a hallmark of paediatric sepsis, the understanding of host susceptibility to sepsis and to sepsis severity remains very limited. Next-generation sequencing and host transcriptomics have the potential to provide new insights into the pathogenesis of sepsis and may enable personalized medicine approaches. Despite good observational data indicating benefit of sepsis recognition and treatment bundles, the evidence for the individual bundle components remains scarce, implying an urgent need for large trials. SUMMARY Recent studies have demonstrated distinct epidemiological patterns pertinent to age groups, healthcare settings, and comorbidities in the era post meningococcal epidemics. Although sepsis quality improvement initiatives have led to substantial outcome improvements, there is urgency for innovative trials to reduce uncertainty around the optimal approach for the recognition and treatment of sepsis in children.
Collapse
|
17
|
|