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Darnell R, Brown A, Laing E, Edwards J, Harrison DA, Manning JC, Peters MJ, Ramnarayan P, Ray S, Sadique Z, Scholefield BR, Shortt D, Lampro L, Au C, Rowan KM, Mouncey P, Inwald DP. Protocol for a Randomized Controlled Trial to Evaluate a Permissive Blood Pressure Target Versus Usual Care in Critically Ill Children with Hypotension (PRESSURE). Pediatr Crit Care Med 2024; 25:629-637. [PMID: 38629915 PMCID: PMC11216373 DOI: 10.1097/pcc.0000000000003516] [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] [Indexed: 07/03/2024]
Abstract
OBJECTIVES Management of hypotension is a fundamental part of pediatric critical care, with cardiovascular support in the form of fluids or vasoactive drugs offered to every hypotensive child. However, optimal blood pressure (BP) targets are unknown. The PRotocolised Evaluation of PermiSSive BP Targets Versus Usual CaRE (PRESSURE) trial aims to evaluate the clinical and cost-effectiveness of a permissive mean arterial pressure (MAP) target of greater than a fifth centile for age compared with usual care. DESIGN Pragmatic, open, multicenter, parallel-group randomized control trial (RCT) with integrated economic evaluation. SETTING Eighteen PICUs across the United Kingdom. PATIENTS Infants and children older than 37 weeks corrected gestational age to 16 years accepted to a participating PICU, on mechanical ventilation and receiving vasoactive drugs for hypotension. INTERVENTIONS Adjustment of hemodynamic support to achieve a permissive MAP target greater than fifth centile for age during invasive mechanical ventilation. MEASUREMENTS AND MAIN RESULTS Randomization is 1:1 to a permissive MAP target or usual care, stratified by site and age group. Due to the emergency nature of the treatment, approaching patients for written informed consent will be deferred until after randomization. The primary clinical outcome is a composite of death and days of ventilatory support at 30 days. Baseline demographics and clinical status will be recorded as well as daily measures of BP and organ support, and discharge outcomes. This RCT received Health Research Authority approval (reference 289545), and a favorable ethical opinion from the East of England-Cambridge South Research Ethics Committee on May 10, 2021 (reference number 21/EE/0084). The trial is registered and has an International Standard RCT Number (reference 20609635). CONCLUSIONS Trial findings will be disseminated in U.K. national and international conferences and in peer-reviewed journals.
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Affiliation(s)
- Robert Darnell
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Alanna Brown
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Emma Laing
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Julia Edwards
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Joseph C Manning
- School of Healthcare, College of Life Sciences, University of Leicester, Leicester, United Kingdom
| | - Mark J Peters
- Infection, Immunity and Inflammation, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Padmanabhan Ramnarayan
- Department of Surgery and Cancer, Imperial College London, St Mary's Campus, London, United Kingdom
| | - Samiran Ray
- Infection, Immunity and Inflammation, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Zia Sadique
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Barnaby R Scholefield
- Department of Paediatric Critical Care Medicine, Hospital for Sick Children, University Avenue, Toronto, ON, Canada
| | - Dermot Shortt
- Patient representative, c/o Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Lamprini Lampro
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Carly Au
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Kathy M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - David P Inwald
- Paediatric Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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2
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Jariyasakoolroj T, Chattipakorn SC, Chattipakorn N. Potential biomarkers used for risk estimation of pediatric sepsis-associated organ dysfunction and immune dysregulation. Pediatr Res 2024:10.1038/s41390-024-03289-y. [PMID: 38834784 DOI: 10.1038/s41390-024-03289-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 04/03/2024] [Accepted: 05/11/2024] [Indexed: 06/06/2024]
Abstract
Pediatric sepsis is a serious issue globally and is a significant cause of illness and death among infants and children. Refractory septic shock and multiple organ dysfunction syndrome are the primary causes of mortality in children with sepsis. However, there is incomplete understanding of mechanistic insight of sepsis associated organ dysfunction. Biomarkers present during the body's response to infection-related inflammation can be used for screening, diagnosis, risk stratification/prognostication, and/or guidance in treatment decision-making. Research on biomarkers in children with sepsis can provide information about the risk of poor outcomes and sepsis-related organ dysfunction. This review focuses on clinically used biomarkers associated with immune dysregulation and organ dysfunction in pediatric sepsis, which could be useful for developing precision medicine strategies in pediatric sepsis management in the future. IMPACT: Sepsis is a complex syndrome with diverse clinical presentations, where organ dysfunction is a key factor in morbidity and mortality. Early detection of organ complications is vital in sepsis management, and potential biomarkers offer promise for precision medicine in pediatric cases. Well-designed studies are needed to identify phase-specific biomarkers and improve outcomes through more precise management.
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Affiliation(s)
- Theerapon Jariyasakoolroj
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Siriporn C Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
- Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand.
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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3
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Liu R, Yu Z, Xiao C, Xu F, Xiao S, He J, Shi Y, Hua Y, Zhou J, Zhang G, Wang T, Jiang J, Xiong D, Chen Y, Xu H, Yun H, Sun H, Pan T, Wang R, Zhu S, Huang D, Liu Y, Hu Y, Ren X, Shi M, Song S, Luo J, He G, Zhang J. Epidemiology and Clinical Characteristics of Pediatric Sepsis in PICUs in Southwest China: A Prospective Multicenter Study. Pediatr Crit Care Med 2024; 25:425-433. [PMID: 38353591 DOI: 10.1097/pcc.0000000000003450] [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: 02/16/2024]
Abstract
OBJECTIVES To describe the epidemiological characteristics of pediatric sepsis in Southwest China PICUs. DESIGN A prospective, multicenter, and observational study. SETTING Twelve PICUs in Southwest China. PATIENTS The patients admitted to the PICU from April 1, 2022, to March 31, 2023. The age ranged from 28 days to 18 years. All patients met the criteria of severe sepsis or septic shock. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 31 PICUs invited to participate, 12 PICUs (capacity of 292 beds) enrolled patients in the study. During the study period, 11,238 children were admitted to the participating PICUs, 367 (3.3%) of whom met the diagnosis of severe sepsis or septic shock. The most prevalent sites of infection were the respiratory system (55%) and the digestive system (15%). The primary treatments administered to these patients included antibiotics (100%), albumin (61.3%), invasive mechanical ventilation (58.7%), glucocorticoids (55.6%), blood products (51%), gammaglobulin (51%), and vasoactive medications (46.6%). Sepsis-related mortality in the PICU was 11.2% (41/367). Nearly half of the sepsis deaths occurred within the first 3 days of PICU admission (22/41, 53.7%). The mortality rate of septic shock (32/167, 19.2%) was significantly higher than that of severe sepsis (9/200, 4.5%; p < 0.001). The outcomes of a multivariate logistic regression analysis suggested that a higher pediatric Sequential Organ Failure Assessment score, and the use of invasive mechanical ventilation and vasoactive medications were independently associated with PICU mortality in children with sepsis. CONCLUSIONS This report updates the epidemiological data of pediatric sepsis in PICUs in Southwest China. Sepsis is still a life-threatening disease in children.
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Affiliation(s)
- Rong Liu
- Department of Pediatric Critical Care, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Zhicai Yu
- Department of Pediatric Critical Care, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Changxue Xiao
- Department of Pediatric Critical Care, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Feng Xu
- Department of Pediatric Critical Care, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Shufang Xiao
- Department of Pediatric Critical Care, Kunming Children's Hospital, Kunming, China
| | - Juan He
- Department of Pediatric Critical Care, Kunming Children's Hospital, Kunming, China
| | - Yan Shi
- Department of Pediatric Critical Care, The First People's Hospital of Liangshan Yi Autonomous Prefecture, Liangshan Yi autonomous Prefecture, Sichuan, China
| | - Yuanyuan Hua
- Department of Pediatric Critical Care, The First People's Hospital of Liangshan Yi Autonomous Prefecture, Liangshan Yi autonomous Prefecture, Sichuan, China
| | - Jimin Zhou
- Department of Pediatric Critical Care, The First People's Hospital of Liangshan Yi Autonomous Prefecture, Liangshan Yi autonomous Prefecture, Sichuan, China
| | - Guoying Zhang
- Department of Pediatric Critical Care, Chengdu Women's and Children's Central Hospital, Chengdu, Sichuan, China
| | - Tao Wang
- Department of Pediatric Critical Care, Chengdu Women's and Children's Central Hospital, Chengdu, Sichuan, China
| | - Jianyu Jiang
- Department of Pediatric Critical Care, Chongqing University Three Gorges Hospital, Wanzhou, Chongqing, China
| | - Daoxue Xiong
- Department of Pediatric Critical Care, Chongqing University Three Gorges Hospital, Wanzhou, Chongqing, China
| | - Yan Chen
- Department of Pediatric Critical Care, Guizhou Provincial Children's Hospital, Zunyi, Guizhou, China
| | - Hongbo Xu
- Department of Pediatric Critical Care, Guizhou Provincial Children's Hospital, Zunyi, Guizhou, China
| | - Hong Yun
- Department of Pediatric Critical Care, Guizhou Provincial Children's Hospital, Zunyi, Guizhou, China
| | - Hui Sun
- Department of Pediatric Critical Care, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Tingting Pan
- Department of Pediatric Critical Care, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Rui Wang
- Department of Pediatric Critical Care, Yuxi Children's Hospital, Yuxi, Yunnan, China
| | - Shuangmei Zhu
- Department of Pediatric Critical Care, Yuxi Children's Hospital, Yuxi, Yunnan, China
| | - Dong Huang
- Department of Pediatric Critical Care, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Yujiang Liu
- Department of Pediatric Critical Care, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Yuhang Hu
- Department of Pediatric Critical Care, Sichuan Provincial Maternity and Child Health Hospital, Chengdu, Sichuan, China
| | - Xinrui Ren
- Department of Pediatric Critical Care, Sichuan Provincial Maternity and Child Health Hospital, Chengdu, Sichuan, China
| | - Mingfang Shi
- Department of Pediatric Critical Care, The First People's Hospital of Yibin, Yibin, Sichuan, China
| | - Sizun Song
- Department of Pediatric Critical Care, The First People's Hospital of Yibin, Yibin, Sichuan, China
| | - Jumei Luo
- Department of Pediatric Critical Care, The First People's Hospital of Yibin, Yibin, Sichuan, China
| | - Gang He
- Department of Pediatric Critical Care, Nanchong Central Hospital, Nanchong, China
| | - Juan Zhang
- Department of Pediatric Critical Care, Nanchong Central Hospital, Nanchong, China
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4
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Podd BS, Banks RK, Reeder R, Telford R, Holubkov R, Carcillo J, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Sward K, Dean JM, Randolph AG. Early, Persistent Lymphopenia Is Associated With Prolonged Multiple Organ Failure and Mortality in Septic Children. Crit Care Med 2023; 51:1766-1776. [PMID: 37462434 DOI: 10.1097/ccm.0000000000005993] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
OBJECTIVES Sepsis-associated immune suppression correlates with poor outcomes. Adult trials are evaluating immune support therapies. Limited data exist to support consideration of immunomodulation in pediatric sepsis. We tested the hypothesis that early, persistent lymphopenia predicts worse outcomes in pediatric severe sepsis. DESIGN Observational cohort comparing children with severe sepsis and early, persistent lymphopenia (absolute lymphocyte count < 1,000 cells/µL on 2 d between study days 0-5) to children without. The composite outcome was prolonged multiple organ dysfunction syndrome (MODS, organ dysfunction beyond day 7) or PICU mortality. SETTING Nine PICUs in the National Institutes of Health Collaborative Pediatric Critical Care Research Network between 2015 and 2017. PATIENTS Children with severe sepsis and indwelling arterial and/or central venous catheters. INTERVENTIONS Blood sampling and clinical data analysis. MEASUREMENTS AND MAIN RESULTS Among 401 pediatric patients with severe sepsis, 152 (38%) had persistent lymphopenia. These patients were older, had higher illness severity, and were more likely to have underlying comorbidities including solid organ transplant or malignancy. Persistent lymphopenia was associated with the composite outcome prolonged MODS or PICU mortality (66/152, 43% vs 45/249, 18%; p < 0.01) and its components prolonged MODS (59/152 [39%] vs 43/249 [17%]), and PICU mortality (32/152, 21% vs 12/249, 5%; p < 0.01) versus children without. After adjusting for baseline factors at enrollment, the presence of persistent lymphopenia was associated with an odds ratio of 2.98 (95% CI [1.85-4.02]; p < 0.01) for the composite outcome. Lymphocyte count trajectories showed that patients with persistent lymphopenia generally did not recover lymphocyte counts during the study, had lower nadir whole blood tumor necrosis factor-α response to lipopolysaccharide stimulation, and higher maximal inflammatory markers (C-reactive protein and ferritin) during days 0-3 ( p < 0.01). CONCLUSIONS Children with severe sepsis and persistent lymphopenia are at risk of prolonged MODS or PICU mortality. This evidence supports testing therapies for pediatric severe sepsis patients risk-stratified by early, persistent lymphopenia.
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Affiliation(s)
- Bradley S Podd
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Russell K Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Ron Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Russell Telford
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Joseph Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Robert A Berg
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
- Department of Pediatrics, Central Michigan University, Mt. Pleasant, MI
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI
| | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA
| | - Athena F Zuppa
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Katherine Sward
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
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5
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Rubnitz Z, Sun Y, Agulnik A, Merritt P, Allison K, Ferrolino J, Dallas R, Tang L, Wolf J. Prediction of attributable mortality in pediatric patients with cancer admitted to the intensive care unit for suspected infection: A comprehensive evaluation of risk scores. Cancer Med 2023; 12:21287-21292. [PMID: 38011018 PMCID: PMC10726759 DOI: 10.1002/cam4.6709] [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: 08/10/2023] [Revised: 10/18/2023] [Accepted: 11/01/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE To evaluate the performance of existing sepsis scores for prediction of adverse outcomes in children with cancer admitted to the ICU with suspected sepsis. DESIGN Retrospective chart review using data available at 1, 6, 12, and 24 h after ICU admission to calculate the Pediatric Risk of Mortality 3 (PRISM-3), Pediatric Sequential Organ Failure Assessment (pSOFA), Paediatric Logistic Organ Dysfunction 2 (PELOD-2), and Quick Pediatric Sequential Organ Failure Assessment (qSOFA) scores. Area under the receiver operator characteristic curve (AUROC) was used to evaluate performance for prediction of attributable mortality. Sensitivity analyses included recalculation of scores using worst preceding values for each variable, excluding hematologic parameters, and prediction of alternative outcomes. SETTING St. Jude Children's Research Hospital, a pediatric comprehensive cancer center in the USA. PATIENTS Pediatric patients (<25 years of age) receiving conventional therapy for cancer admitted to the ICU with suspected sepsis between 2013 and 2019. RESULTS Of 207 included episodes of suspected sepsis, attributable mortality was 16 (7.7%) and all evaluated sepsis scores performed poorly (maximal AUROC of 0.73 for qSOFA at 1 and 24 h). Sensitivity analyses did not identify an alternative approach that significantly improved prediction. CONCLUSIONS Currently available sepsis scores perform poorly for prediction of attributable mortality in children with cancer who present to ICU with suspected sepsis. More research is needed to identify reliable predictors of adverse outcomes in this population.
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Affiliation(s)
- Zachary Rubnitz
- Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Yilun Sun
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Asya Agulnik
- Department of Global Pediatric MedicineSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Pamela Merritt
- Department of Infectious DiseasesSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Kim Allison
- Department of Infectious DiseasesSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Jose Ferrolino
- Department of Infectious DiseasesSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Ronald Dallas
- Department of Infectious DiseasesSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Li Tang
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Joshua Wolf
- Department of Infectious DiseasesSt. Jude Children's Research HospitalMemphisTennesseeUSA
- Department of PediatricsUniversity of Tennessee Health Science CenterMemphisTennesseeUSA
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6
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Weiss SL. PICS-ing Up on Something Real in Pediatric Sepsis? Chest 2023; 164:1071-1072. [PMID: 37945185 DOI: 10.1016/j.chest.2023.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 05/31/2023] [Indexed: 11/12/2023] Open
Affiliation(s)
- Scott L Weiss
- Division of Critical Care, Department of Pediatrics, Nemours Children's Health, Wilmington, DE; Departments of Pediatrics & Pathology, Anatomy, and Cell Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA.
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7
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Bottari G, Caruso M, Paionni E, De Luca M, Romani L, Pisani M, Grandin A, Gargiullo L, Zampini G, Gagliardi C, Fegatelli DA, Vestri A, Lancella L, Porzio O, Muda AO, Villani A, Atti MCD, Raponi M, Cecchetti C. Accuracy of Pancreatic Stone Protein for diagnosis of sepsis in children admitted to pediatric intensive care or high-dependency care: a pilot study. Ital J Pediatr 2023; 49:134. [PMID: 37805604 PMCID: PMC10559422 DOI: 10.1186/s13052-023-01540-6] [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: 06/28/2023] [Accepted: 09/25/2023] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND Pancreatic Stone Protein (PSP) is one of the most promising diagnostic and prognostic markers. The aim of the study was to assess the accuracy of PSP, compared to C-Reactive Protein (CRP), and Procalcitonin (PCT) for sepsis diagnosis in pediatric patients. Furthermore, we explored the correlation of PSP levels with sepsis severity and organ failure measured with PELOD-2 score. METHODS Forty pediatric patients were enrolled following admission to pediatric intensive care, high dependency care or pediatric ward. PSP blood levels were measured in Emergency Department (nanofluidic point-of-care immunoassay; abioSCOPE, Abionic SA, Switzerland) on day 1, 2, 3, 5 and 7 from the onset of the clinical signs and symptoms of sepsis or SIRS. Inclusion criteria were: 1) patient age (1 month to 18 years old), 2) signs and symptoms of SIRS, irrespective of association with organ dysfunction. Exclusion criteria were: 1) hemato-oncological diseases and/or immunodeficiencies, 2) pancreatic diseases. RESULTS Septic patients showed higher PSP levels than those with non-infectious systemic inflammation. The optimal cut-off in diagnosis of sepsis for PSP at day 1 was 167 ng/ml resulted in a sensitivity of 59% (95% IC 36%-79%) and a specificity of 83% (95% IC 58%-96%) with an AUC of 0.636 for PSP in comparison to AUC of 0.722 for PCT and 0.503 for C-RP. ROC analysis for outcome (survival versus no survival) has showed AUC 0.814 for PSP; AUC 0.814 for PCT; AUC of 0.657 for C-RP. CONCLUSIONS PSP could distinguish sepsis from non-infectious systemic inflammation; however, our results need to be confirmed in larger pediatric population.
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Affiliation(s)
- Gabriella Bottari
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCSS, Piazza Sant'Onofrio 4, 00165, Rome, Italy.
| | - Mariangela Caruso
- Department of Anesthesia and Intensive Care, Catholic University of Rome, Residency School of Anesthesia and Intensive Care, Catholic University, Rome, Italy
| | - Emanuel Paionni
- Clinical Laboratory Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maia De Luca
- Infectious Disease Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Lorenza Romani
- Infectious Disease Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Mara Pisani
- Pediatric Emergency Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Annalisa Grandin
- General Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| | - Livia Gargiullo
- General Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| | - Giorgio Zampini
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCSS, Piazza Sant'Onofrio 4, 00165, Rome, Italy
| | - Chiara Gagliardi
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCSS, Piazza Sant'Onofrio 4, 00165, Rome, Italy
| | - Danilo Alunni Fegatelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185, Rome, Italy
| | - Annarita Vestri
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185, Rome, Italy
| | - Laura Lancella
- Infectious Disease Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Ottavia Porzio
- Clinical Laboratory Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Onetti Muda
- Clinical Laboratory Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
- Scientific Direction, Bambino Gesù Children's Hospital, Rome, Italy
| | - Alberto Villani
- General Pediatric and Infectious Disease Unit, Pediatric Emergency Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marta Ciofi Degli Atti
- Clinical Pathways and Epidemiology Unit-Medical Direction, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Corrado Cecchetti
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCSS, Piazza Sant'Onofrio 4, 00165, Rome, Italy
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8
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Nygaard U, Dungu KHS, von Linstow ML, Lundstrøm K, Zhang H, Vissing NH. Lactate as a Screening Tool for Critical Illness in a Pediatric Emergency Department. Pediatr Emerg Care 2023; 39:735-738. [PMID: 36190394 DOI: 10.1097/pec.0000000000002860] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Lactate has in some pediatric emergency departments (PEDs) gained acceptance as a screening tool for critical illness, with cut-off values of 2.0 to 2.5 mmol/L. We aimed to investigate if lactate could predict the need of acute resuscitation in patients in a PED. PATIENTS AND METHODS This retrospective observational cohort study included patients aged 0 to 17 years admitted to the PED at Copenhagen University Hospital in Denmark from January 1, 2019 to January 1, 2021. Patients were included if they had lactate measured as part of their routine blood sampling because of acute PED evaluation. Area under the receiver operating characteristic (ROC) curve (AUC) was calculated to assess the ability of lactate to predict the need of acute resuscitation. In patients without need of acute resuscitation, we calculated the lactate upper limit as the 95th percentile, and significant predictors were included in a multiple linear regression model. RESULTS A total of 1355 children were included. Fourteen (1%) children with a need of acute resuscitation had a median lactate of 1.7 mmol/L (interquartile range, 1.4-2.3) versus 1.6 mmol/L (interquartile range, 1.3-2.1) in children without need of resuscitation ( P > 0.05). The AUC for lactate to predict acute resuscitation was 0.56 (95% confidence interval, 0.54-0.59). In children without need of acute resuscitation, the 95th percentile of lactate was 3.2 mmol/L, and 392 (29.8%) had lactate greater than 2.0 mmol/L. Increasing age and venous sampling were associated with lower lactate. Lactate was not associated with sex, pediatric early warning score, or duration of hospital admission. The 95th percentile of lactate after inhaled beta-2-agonists was 5.0 mmol/L. CONCLUSIONS In children evaluated in a PED, lactate achieved a low AUC, suggesting a poor ability of predicting acute resuscitation. In children without need of acute resuscitation, the 95th percentile for lactate was 3.2 mmol/L, higher than the generally accepted cut-off values. This is important to recognize to avoid concern in otherwise clinically stable children. Our data did not support the use of lactate as a screening tool for early recognition of critical illness in a PED.
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Affiliation(s)
| | - Kia Hee Schultz Dungu
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marie-Louise von Linstow
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kaare Lundstrøm
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - He Zhang
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nadja Hawwa Vissing
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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9
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Bottari G, Guzzo I, Cappoli A, Labbadia R, Perdichizzi S, Serpe C, Creteur J, Cecchetti C, Taccone FS. Impact of CytoSorb and CKRT on hemodynamics in pediatric patients with septic shock: the PedCyto study. Front Pediatr 2023; 11:1259384. [PMID: 37780052 PMCID: PMC10540853 DOI: 10.3389/fped.2023.1259384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 08/21/2023] [Indexed: 10/03/2023] Open
Abstract
Background There is a lack of data to support the use of hemoadsorption in pediatric septic shock. The aim of our study was to assess the effectiveness and safety of CytoSorb therapy in this setting. Methods Phase II interventional single arm pilot study in which 17 consecutive children admitted with septic shock who required continuous kidney replacement therapy (CKRT) and weighed ≥10 kg were included. A CytoSorb (CytoSorbents Inc, New Jersey, USA) hemoadsorption cartridge was added to the CKRT every 24 h for a maximum of 96 h. A control group of 13 children with septic shock treated with CKRT but not hemoadsorption at Children's Hospital Bambino Gesù and enrolled in the EuroAKId register was selected as an historical cohort. The primary outcome of the study was a reduction in vasopressor or inotrope dose of >50% from baseline by the end of CytoSorb therapy. Secondary outcomes included hemodynamic and biological changes, changes in severity scores, and 28-day mortality. Results There were significant decreases in the Vasoactive Inotropic Score (VIS) and the Pediatric Logistic Organ Dysfunction 2 (PELOD-2) score at 72 and 96 h from the start of the CytoSorb therapy compared to baseline; the reductions were larger in the hemoadsorption group than in the control group (historical cohort). 28-day mortality was lower, although not significantly, in the hemoadsorption group when compared to the control group (5/17 [29%] vs. 8/13 [61%] OR 0.26 [95% CI: 0.05-1.2]; p = 0.08). Conclusions CytoSorb therapy may have some benefits in pediatric patients with septic shock. Future larger randomized trials are needed in this setting. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT05658588, identifier (Clinicaltrials.gov NCT05658588).
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Affiliation(s)
- Gabriella Bottari
- Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Isabella Guzzo
- Department of Pediatrics, Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Cappoli
- Department of Pediatrics, Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Raffaella Labbadia
- Department of Pediatrics, Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Salvatore Perdichizzi
- Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Carmela Serpe
- Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Jacques Creteur
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Corrado Cecchetti
- Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
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10
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Marchetto L, Comoretto R, Gregori D, Da Dalt L, Amigoni A, Daverio M. Sepsis Prognostic Scores Accuracy in Predicting Adverse Outcomes in Children With Sepsis Admitted to the Pediatric Intensive Care Unit From the Emergency Department: A 10-Year Single-Center Experience. Pediatr Emerg Care 2023; 39:378-384. [PMID: 37256281 DOI: 10.1097/pec.0000000000002938] [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: 06/01/2023]
Abstract
OBJECTIVE To compare the performance of several prognostic scores calculated in the first 24 hours of admission (day 1) in predicting mortality and morbidity among critically ill children with sepsis presenting to the pediatric emergency department (PED) and then admitted to the pediatric intensive care unit (PICU). METHODS Single-center, retrospective cohort study in children with a diagnosis of sepsis visiting the PED and then admitted to the PICU from January 1, 2010 to December 31, 2019. Sepsis organ dysfunction scores-pediatric Sequential Organ Failure Assessment (pSOFA) (Schlapbach, Matics, Shime), quickSOFA, quickSOFA-L, Pediatric Logistic Organ Dysfunction (PELOD)-2, quickPELOD-2, and Pediatric Multiple Organ Dysfunction score-were calculated during the first 24 hours of admission (day 1) and their performance compared with systemic inflammatory response syndrome (SIRS) and severe sepsis-International Consensus Conference on Pediatric Sepsis(ICCPS)-derived criteria-using the area under the receiver operating characteristic curve. Primary outcome was PICU mortality. Secondary outcomes were: a composite of death and new disability (ie, change from baseline Pediatric Overall Performance Category score ≥1); prolonged PICU length of stay (>5 d); prolonged invasive mechanical ventilation (MV) (>3 d). RESULTS Among 60 patients with sepsis, 4 (6.7%) died, 7 (11.7%) developed new disability, 26 (43.3%) experienced prolonged length of stay, and 21 (35%) prolonged invasive MV. The prognostic ability in mortality discrimination was significantly higher for organ dysfunction scores, with PELOD-2 showing the best performance (area under the receiver operating characteristic curve, 0.924; 95% confidence interval, 0.837-1.000), significantly better than SIRS 3 criteria (0.924 vs 0.509, P = 0.009), SIRS 4 criteria (0.924 vs 0.509, P < 0.001), and severe sepsis (0.924 vs 0.527, P < 0.001). Among secondary outcomes, PELOD-2 performed significantly better than SIRS criteria and severe sepsis to predict prolonged duration of invasive MV, whereas better than severe sepsis to predict "poor outcome" (mortality or new disability). CONCLUSIONS Day 1 organ dysfunction scores performed better in predicting mortality and morbidity outcomes than ICCPS-derived criteria. The PELOD-2 was the organ dysfunction score with the best performance for all outcomes.
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Affiliation(s)
| | | | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua, Italy
| | - Liviana Da Dalt
- Pediatric Emergency Department, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Angela Amigoni
- From the Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Marco Daverio
- From the Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
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11
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Sujjavorakul K, Katip W, Kerr SJ, Wacharachaisurapol N, Puthanakit T. Predicting the Area under the Plasma Concentration-Time Curve (AUC) for First Dose Vancomycin Using First-Order Pharmacokinetic Equations. Antibiotics (Basel) 2023; 12:antibiotics12040630. [PMID: 37106993 PMCID: PMC10135334 DOI: 10.3390/antibiotics12040630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
To treat critically ill patients, early achievement of the target area under the plasma concentration-time curve/minimum inhibitory concentration (AUC/MIC) in the first 24 h is recommended. However, accurately calculating the AUC before steady state is an obstacle to this goal. A first-order pharmacokinetic equation to calculate vancomycin AUC after a first dose of vancomycin has never been studied. We sought to estimate AUC using two first-order pharmacokinetic equations, with different paired concentration time points, and to compare these to the actual first dose vancomycin AUC calculated by the linear-log trapezoid rule as a reference. The equations were validated using two independent intensive first dose vancomycin concentration time data sets, one from 10 adults and another from 14 children with severe infection. The equation with compensation for the alpha distribution phase using a first vancomycin serum concentration from 60 to 90 min and the second concentration from 240 to 300 min after the completed infusion showed good agreement and low bias of calculated AUC, with mean differences <5% and Lin's correlation coefficient >0.96. Moreover, it gave an excellent correlation with Pearson's r > 0.96. Estimating the first dose vancomycin AUC calculated using this first-order pharmacokinetic equation is both reliable and reproducible in clinical practice settings.
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Affiliation(s)
- Kritsaporn Sujjavorakul
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Critical Care Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Wasan Katip
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand
- Epidemiology Research Group of Infectious Disease (ERGID), Chiang Mai University, Chiang Mai 50200, Thailand
| | - Stephen J Kerr
- Biostatistics Centre, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- The Kirby Institute, The University of New South Wales, Kensington, NSW 2052, Australia
- HIV-NAT, The Thai Red Cross AIDS Research Centre, Bangkok 10330, Thailand
| | - Noppadol Wacharachaisurapol
- Center of Excellence in Clinical Pharmacokinetics and Pharmacogenomics, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Thanyawee Puthanakit
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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12
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Miura S, Michihata N, Hashimoto Y, Matsui H, Fushimi K, Yasunaga H. Descriptive statistics and risk factor analysis of children with community-acquired septic shock. J Intensive Care 2023; 11:6. [PMID: 36782278 PMCID: PMC9923917 DOI: 10.1186/s40560-023-00652-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/24/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Children with community-acquired septic shock can rapidly deteriorate and die in acute-care hospitals. This study aimed to describe the mortality, timing, and risk factors in children with community-acquired septic shock. METHODS This is a retrospective cohort study using a national inpatient database in Japan. The study population included children (age < 20 years) who were admitted to acute-care hospitals with a diagnosis of sepsis from July 2010 to March 2020, who were treated with antibiotics, and who were supported with vasoactive drugs within three days of hospitalization. We used a Cox proportional-hazards regression model to identify risk factors for earlier death. RESULTS Among 761 eligible children, the median age was 3 (interquartile range, 0-11) years and 57.2% had underlying conditions. Among these, 67.1% were admitted to accredited intensive care units within three days of hospitalization and 38.6% were transported from other hospitals. The median hospital volume, defined as the number of eligible children in each hospital over the study period, was 4 (interquartile range, 2-11). Overall, 244 children died (in-hospital mortality rate, 32.1%). Among them, 77 (31.6%) died on the first day, and 156 (63.9%) died within three days of hospitalization. A Cox proportional-hazards regression model showed that earlier death was associated with lower hospital volume and age 1-5 years, whereas it was inversely associated with admission to an accredited intensive care unit and transport from other hospitals. Among 517 survivors, 178 (34.4%) were discharged with comorbidities. CONCLUSIONS Children with community-acquired septic shock had high mortality, and early death was common. Our findings may warrant future efforts to enhance the quality of initial resuscitation for sepsis in low-volume hospitals and to ensure a healthcare system in which children with sepsis can be treated in accredited intensive care units.
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Affiliation(s)
- Shinya Miura
- Department of Pediatrics, St. Marianna University School of Medicine, 2 Chome-16-1 Sugao, Miyamae Ward, Kawasaki, Kanagawa, Japan. .,Teikyo University Graduate School of Public Health, Tokyo, Japan.
| | - Nobuaki Michihata
- grid.26999.3d0000 0001 2151 536XDepartment of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yohei Hashimoto
- grid.26999.3d0000 0001 2151 536XDepartment of Ophthalmology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan ,grid.26999.3d0000 0001 2151 536XDepartment of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- grid.26999.3d0000 0001 2151 536XDepartment of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- grid.265073.50000 0001 1014 9130Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hideo Yasunaga
- grid.26999.3d0000 0001 2151 536XDepartment of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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13
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McCahill C, Laycock HC, Guris RJD, Chigaru L. State-of-the-art management of the acutely unwell child. Anaesthesia 2022; 77:1288-1298. [PMID: 36089884 PMCID: PMC9826095 DOI: 10.1111/anae.15816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 01/11/2023]
Abstract
Children make up around one-fifth of all emergency department visits in the USA and UK, with an increasing trend of emergency admissions requiring intensive care. Anaesthetists play a vital role in the management of paediatric emergencies contributing to stabilisation, emergency anaesthesia, transfers and non-technical skills that optimise team performance. From neonates to adolescents, paediatric patients have diverse physiology and present with a range of congenital and acquired pathologies that often differ from the adult population. With increasing centralisation of paediatric services, staff outside these centres have less exposure to caring for children, yet are often the first responders in managing these high stakes situations. Staying abreast of the latest evidence for managing complex low frequency emergencies is a challenge. This review focuses on recent evidence and pertinent clinical updates within the field. The challenges of maintaining skills and training are explored as well as novel advancements in care.
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Affiliation(s)
- C. McCahill
- Department of AnaesthesiaGreat Ormond Street HospitalLondonUK
| | - H. C. Laycock
- Department of AnaesthesiaGreat Ormond Street HospitalLondonUK,Department of Surgery and CancerImperial CollegeLondonUK
| | - R. J. Daly Guris
- Department of Anesthesiology and Critical Care MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA,Department of Anesthesiology and Critical CareUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - L. Chigaru
- Department of AnaesthesiaGreat Ormond Street HospitalLondonUK,Children's Acute Transport ServiceLondonUK
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14
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Al-Eyadhy A, Hasan G, Temsah MH, Alseneidi S, Alalwan M, Alali F, Alhaboob A, Alabdulhafid M, Alsohime F, Almaziad M, Somily AM. Initial Fluid Balance Associated Outcomes in Children With Severe Sepsis and Septic Shock. Pediatr Emerg Care 2022; 38:e1112-e1117. [PMID: 34469401 DOI: 10.1097/pec.0000000000002520] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Net fluid balance and its role in sepsis-related mortality is not clear; studies suggest that aggressive fluid resuscitation can help in treatment, whereas others consider it is associated with poor outcomes. This study aimed to clarify the possible association of initial 24 hours' fluid balance with poor outcomes in pediatric patients with sepsis. METHODS Retrospective data analysis included pediatric patients admitted with suspected or proven sepsis or septic shock to pediatric intensive care unit (PICU) of a tertiary care teaching hospital in Saudi Arabia. RESULTS The study included 47 patients; 13 (28%) died, and mortality rate was significant in children with neurologic failure (P < 0.02), mechanical ventilation within 24 hours of admission (P < 0.03), leukopenia (P < 0.02), abnormal international normalized ratio (P < 0.02), initial blood lactate levels higher than 5 mmol/L (P < 0.02), or positive fluid balance at 24 hours of admission to the PICU (P < 0.001). CONCLUSION Among children with sepsis and/or septic shock, there is significant association between mortality and initial high blood lactate levels and positive fluid balance at 24 hours from admission to the PICU.
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Affiliation(s)
- Ayman Al-Eyadhy
- From the Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | | | - Mohamad-Hani Temsah
- From the Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | | | | | | | - Ali Alhaboob
- From the Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Majed Alabdulhafid
- From the Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Fahad Alsohime
- From the Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Mohamed Almaziad
- From the Pediatric Intensive Care Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Ali Mohammed Somily
- Department of Pathology and Laboratory Medicine, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
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15
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Massaud-Ribeiro L, Silami PHNC, Lima-Setta F, Prata-Barbosa A. Pediatric Sepsis Research: Where Are We and Where Are We Going? Front Pediatr 2022; 10:829119. [PMID: 35223703 PMCID: PMC8873512 DOI: 10.3389/fped.2022.829119] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/20/2022] [Indexed: 01/15/2023] Open
Abstract
Sepsis continues to be one of the leading causes of admission to the Pediatric Intensive Care Unit, representing a great challenge for researchers and healthcare staff. This mini review aims to assess research on pediatric sepsis over the years. Of the 2,698 articles retrieved from the Scopus database, the 100 most cited were selected (50 published since 2000 and 50 published since 2016). The most cited studies, published in the 21st century, are highlighted, with their main findings and perspectives.
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Affiliation(s)
- Letícia Massaud-Ribeiro
- Pediatric Intensive Care Unit, Department of Pediatrics, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Pediatric Intensive Care Unit, Department of Pediatrics, Instituto Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Pedro Henrique Nunes Costa Silami
- Pediatric Intensive Care Unit, Department of Pediatrics, Instituto Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.,Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Estadual da Criança, Rio de Janeiro, Brazil
| | - Fernanda Lima-Setta
- Pediatric Intensive Care Unit, Department of Pediatrics, Instituto Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.,Department of Pediatrics, Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, Brazil
| | - Arnaldo Prata-Barbosa
- Department of Pediatrics, Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, Brazil
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16
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Queensland Pediatric Sepsis Breakthrough Collaborative: Multicenter Observational Study to Evaluate the Implementation of a Pediatric Sepsis Pathway Within the Emergency Department. Crit Care Explor 2021; 3:e0573. [PMID: 34765981 PMCID: PMC8577679 DOI: 10.1097/cce.0000000000000573] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. To evaluate the implementation of a pediatric sepsis pathway in the emergency department as part of a statewide quality improvement initiative in Queensland, Australia.
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17
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Schlapbach LJ, de Oliveira CF, Raman S, de Souza D. Metabolic resuscitation in pediatric sepsis: a narrative review. Transl Pediatr 2021; 10:2678-2688. [PMID: 34765493 PMCID: PMC8578751 DOI: 10.21037/tp-21-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 05/27/2021] [Indexed: 12/21/2022] Open
Abstract
Sepsis, defined as infection with associated organ dysfunction, accounts for most childhood deaths due to infection globally. Evidence for the optimal support of children with septic shock refractory to the initial sepsis management bundle remains minimal. There is an urgent need for more effective interventions. Administration of hydrocortisone in children with septic shock might fasten shock resolution, and has been shown to dampen the systemic host immune response, augment adrenergic effects, and support the stress response. Ascorbic acid (vitamin C) is one of the most powerful naturally occurring antioxidants and has beneficial effects on multiple pathways which are severely deranged during septic shock. A regimen combining hydrocortisone, ascorbic acid, and thiamine termed "metabolic resuscitation" or "HAT therapy" has been tested in large trials in critically ill adults with sepsis with conflicting results. Available information on intravenous ascorbic acid indicates an excellent safety profile even at very high doses both in adults and children. Given the pharmacological properties and beneficial effects shown both in vitro and in animal studies, and its safety profile, ascorbic acid either as a single therapy or as part of HAT treatment represents a promising candidate for future pediatric sepsis treatments. While pediatric age groups may be more susceptible to ascorbic acid deficiency during sepsis, there is a lack of high-quality trial data on HAT therapy in this age group. A single centre retrospective study identified potential for mortality benefit in children with septic shock, and the results from a randomized controlled pilot trial are being awaited. It is imperative for pediatric research on ascorbic acid and HAT in children with sepsis to critically investigate key questions related to pharmacology, dosing, timing, feasibility, safety, effects on short- and long-term outcomes, and generalisability in view of the global burden of sepsis.
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Affiliation(s)
- Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | | | - Sainath Raman
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia
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18
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Weiss SL, Fitzgerald JC, Balamuth F. Let Us Not Forget Early Mortality in Pediatric Sepsis. Pediatr Crit Care Med 2021; 22:434-436. [PMID: 33790212 PMCID: PMC8023721 DOI: 10.1097/pcc.0000000000002689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Scott L. Weiss
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie C. Fitzgerald
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fran Balamuth
- Pediatric Sepsis Program at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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19
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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: 8] [Impact Index Per Article: 2.7] [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.
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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
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20
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Dave M, Barry S, Coulthard P, Daniels R, Greenwood M, Seoudi N, Walton G, Patel N. An evaluation of sepsis in dentistry. Br Dent J 2021; 230:351-357. [PMID: 33772188 DOI: 10.1038/s41415-021-2724-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/26/2020] [Indexed: 12/31/2022]
Abstract
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It is a major health concern and causes substantial morbidity and mortality. It is imperative that the signs of sepsis are identified early in both adult and paediatric patients and appropriately escalated to initiate early treatment and improve prognosis. This paper aims to discuss the change in classification from the previous systemic inflammatory response syndrome (SIRS) criteria to the current definition in adults and also the unchanged definition in children. The hallmark signs of sepsis (both red and amber flags) are discussed in relation to their underlying cellular mechanisms to provide a comprehensive overview for clinicians in primary care, hospital and community settings. The rise of antimicrobial resistance is also an increasing global health concern with resistant bacteria from common infections likely to result in greater patient morbidity and worse outcomes.A literature search identified reported sepsis cases in dentistry through searches in Ovid Medline and Embase from January 1990 to December 2019. Only primary studies were included with no restrictions on languages. Four articles were identified which reported sepsis associated with tooth extractions, dental abscess and submental/submandibular cellulitis. It is well known that locoregional infections of dental origin have the potential to cause sepsis. Therefore, dental healthcare professionals need to be vigilant and understand the specific signs and escalation protocols to ensure patient safety.
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Affiliation(s)
- Manas Dave
- Academic Clinical Fellow in Oral and Maxillofacial Pathology, University of Manchester, UK.
| | - Siobhan Barry
- Professor and Honorary Consultant in Paediatric Dentistry, University of Manchester, UK
| | - Paul Coulthard
- Dean for Dentistry and Institute Director, Professor of Oral and Maxillofacial Surgery, Queen Mary University London, UK
| | - Ron Daniels
- , Consultant in Critical Care, Executive Director UK Sepsis Trust and Chief Executive of the Global Sepsis Alliance; University Hospitals Birmingham NHS Foundation Trust, UK
| | - Mark Greenwood
- Consultant in Oral and Maxillofacial Surgery and Honorary Professor of Medical Education in Dentistry, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, UK
| | - Noha Seoudi
- Senior Clinical Lecturer in Oral Microbiology, Queen Mary University London, UK
| | - Graham Walton
- Consultant in Special Care Dentistry, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Neil Patel
- Senior Lecturer in Oral Surgery, University of Manchester, UK
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21
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Ruth A, Vogel AM, Adachi I, Shekerdemian LS, Bastero P, Thomas JA. Central venoarterial extracorporeal life support in pediatric refractory septic shock: a single center experience. Perfusion 2021; 37:385-393. [PMID: 33719730 DOI: 10.1177/02676591211001782] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Venoarterial extracorporeal membrane oxygenation (VA ECMO) is recognized as a potential support therapy for pediatric patients with refractory septic shock (RSS). This review aims to report our experience with central VA cannulation in pediatric patients with RSS, and to compare this with peripheral VA ECMO cannulations for this condition at our institution. DESIGN Retrospective case series. SETTING Pediatric and cardiac intensive care units in an academic pediatric hospital. PATIENTS All patients 0-18 years old meeting criteria of RSS placed on VA ECMO between January 2011 and December 2018. INTERVENTIONS None. MEASUREMENTS Demographics, relevant clinical variables, ECMO run details, and outcomes were collected. RESULTS Between 2011 and 2018, 14 children were placed on VA ECMO for RSS. Nine were cannulated centrally, with the rest placed on peripheral VA ECMO. Overall survival to hospital discharge was 57.1% (8/14), with 66.7% of the central cannulation cohort surviving versus 40% in the peripheral cannulation (p = 0.34). Median ECMO duration was 147.1 hours (IQR: 91.9-178.6 hours), with survivors having a median length of 147.1 (IQR: 138.5-185.7) versus non survivors 114.7 hours (IQR: 63.7-163.5), p = 0.48. Overall median ICU length of stay (LOS) was 19 days (IQR: 10.5-42.2). The median % maximum flow achieved on VA ECMO was higher in the central cannulation group at 179.6% (IQR: 154.4-188.1) versus the peripheral with 133.5% (98.1-149.1), p = 0.01. Functional status scale (FSS) was used to capture morbidity. All survivors had a mean increase in their FSS from baseline. In the centrally cannulated group, 50% (4/8) received mediastinal exploration, but none developed mediastinitis. In terms of blood product utilization, the central cannulation received more platelets compared to the peripherally cannulated group (median 15.6 vs 3.3 mL/kg/day, p = 0.03). CONCLUSION A central approach to VA ECMO cannulation is feasible and has potential for good patient outcomes in selected patients.
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Affiliation(s)
- Amanda Ruth
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Iki Adachi
- Division of Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Lara S Shekerdemian
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Patricia Bastero
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - James A Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
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22
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Hegamyer E, Smith N, Thompson AD, Depiero AD. Treatment of suspected sepsis and septic shock in children with chronic disease seen in the pediatric emergency department. Am J Emerg Med 2021; 44:56-61. [PMID: 33581601 DOI: 10.1016/j.ajem.2021.01.026] [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: 11/02/2020] [Revised: 01/10/2021] [Accepted: 01/11/2021] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Research demonstrates that timely recognition and treatment of sepsis can significantly improve pediatric patient outcomes, especially regarding time to intravenous fluid (IVF) and antibiotic administration. Further research suggests that underlying chronic disease in a septic pediatric patient puts them at higher risk for poor outcomes. OBJECTIVE To compare treatment time for suspected sepsis and septic shock in pediatric patients with chronic disease versus those without chronic disease seen in the Pediatric Emergency Department (PED). METHODS We reviewed patient data from a pediatric sepsis outcomes dataset collected at two tertiary care pediatric hospital sites from January 2017-December 2018. Patients were stratified into two groups: those with and without chronic disease, defined as any patient with at least one of eight chronic health conditions. INCLUSION CRITERIA patients seen in the PED ultimately diagnosed with sepsis or septic shock, patient age 0 to 20 years and time zero for identification of sepsis in the PED. EXCLUSION CRITERIA time zero unavailable, inability to determine time of first IVF or antibiotic administration or patient death within the PED. Primary analysis included comparison of time zero to first IVF and antibiotic administration between each group. RESULTS 312 patients met inclusion criteria. 169 individuals had chronic disease and 143 did not. Median time to antibiotics in those with chronic disease was 41.9 min versus 43.0 min in patients without chronic disease (p = 0.181). Time to first IVF in those with chronic disease was 22.0 min versus 12.0 min in those without (p = 0.010). Those with an indwelling line/catheter (n = 40) received IVF slower than those without (n = 272), with no significant difference in time to antibiotic administration by indwelling catheter status (p = 0.063). There were no significant differences in the mode of identification of suspected sepsis or septic shock between those with versus without chronic disease (p = 0.27). CONCLUSIONS Study findings suggest pediatric patients with chronic disease with suspected sepsis or septic shock in the PED have a slower time to IVF administration but equivocal use of sepsis recognition tools compared to patients without chronic disease.
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Affiliation(s)
- Emily Hegamyer
- Division of Emergency Medicine, Department of Pediatrics, Nemours, Alfred I. Dupont Hospital for Children. 1600 Rockland Road, Wilmington, DE 19803, United States of America.
| | - Nadine Smith
- Division of Emergency Medicine, Department of Pediatrics, Nemours, Alfred I. Dupont Hospital for Children. 1600 Rockland Road, Wilmington, DE 19803, United States of America.
| | - Amy D Thompson
- Division of Emergency Medicine, Department of Pediatrics, Nemours, Alfred I. Dupont Hospital for Children. 1600 Rockland Road, Wilmington, DE 19803, United States of America.
| | - Andrew D Depiero
- Division of Emergency Medicine, Department of Pediatrics, Nemours, Alfred I. Dupont Hospital for Children. 1600 Rockland Road, Wilmington, DE 19803, United States of America.
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23
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Cruz AT, Lane RD, Balamuth F, Aronson PL, Ashby DW, Neuman MI, Souganidis ES, Alpern ER, Schlapbach LJ. Updates on pediatric sepsis. J Am Coll Emerg Physicians Open 2020; 1:981-993. [PMID: 33145549 PMCID: PMC7593454 DOI: 10.1002/emp2.12173] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 12/11/2022] Open
Abstract
Sepsis, defined as an infection with dysregulated host response leading to life-threatening organ dysfunction, continues to carry a high potential for morbidity and mortality in children. The recognition of sepsis in children in the emergency department (ED) can be challenging, related to the high prevalence of common febrile infections, poor specificity of discriminating features, and the capacity of children to compensate until advanced stages of shock. Sepsis outcomes are strongly dependent on the timeliness of recognition and treatment, which has led to the successful implementation of quality improvement programs, increasing the reliability of sepsis treatment in many US institutions. We review clinical, laboratory, and technical modalities that can be incorporated into ED practice to facilitate the recognition, treatment, and reassessment of children with suspected sepsis. The 2020 updated pediatric sepsis guidelines are reviewed and framed in the context of ED interventions, including guidelines for antibiotic administration, fluid resuscitation, and the use of vasoactive agents. Despite a large body of literature on pediatric sepsis epidemiology in recent years, the evidence base for treatment and management components remains limited, implying an urgent need for large trials in this field. In conclusion, although the burden and impact of pediatric sepsis remains substantial, progress in our understanding of the disease and its management have led to revised guidelines and the available data emphasizes the importance of local quality improvement programs.
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Affiliation(s)
- Andrea T. Cruz
- Sections of Emergency Medicine and Infectious DiseaseDepartment of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Roni D. Lane
- Division of Pediatric Emergency Medicinethe University of Utah Primary Children's HospitalSalt Lake CityUtahUSA
| | - Fran Balamuth
- Division of Emergency MedicineDepartment of PediatricsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Paul L. Aronson
- Section of Pediatric Emergency MedicineDepartments of Pediatrics and Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - David W. Ashby
- Sections of Emergency Medicine and Infectious DiseaseDepartment of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Mark I. Neuman
- Division of Emergency MedicineDepartment of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Ellie S. Souganidis
- Sections of Emergency Medicine and Infectious DiseaseDepartment of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Elizabeth R. Alpern
- Division of Emergency MedicineDepartment of PediatricsAnn & Robert H. Lurie Children's HospitalFeinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | - Luregn J. Schlapbach
- Department of Intensive Care Medicine and Neonatologyand Children's Research CenterUniversity Children's Hospital of ZurichUniversity of ZurichZurichSwitzerland
- Paediatric Critical Care Research GroupThe University of Queensland and Queensland Children's HospitalBrisbaneQueenslandAustralia
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24
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Longitudinal Trajectories of Caregiver Distress and Family Functioning After Community-Acquired Pediatric Septic Shock. Pediatr Crit Care Med 2020; 21:787-796. [PMID: 32541376 PMCID: PMC9125433 DOI: 10.1097/pcc.0000000000002404] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To identify trajectories and correlates of caregiver distress and family functioning in families of children who survived community-acquired septic shock. We hypothesized that: 1) a substantial subset of families would demonstrate trajectories of persistent elevated caregiver distress and impaired family functioning 12 months after hospitalization and 2) sociodemographic and clinical risk factors would be associated with trajectories of persistent distress and family dysfunction. DESIGN Prospective cohort. SETTING Fourteen PICUs in the United States. PATIENTS Caregivers of 260 children who survived community-acquired septic shock. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Caregivers completed ratings of distress on the Brief Symptom Inventory and of family functioning on the Family Assessment Device at baseline, 1, 3, 6, and 12 months after hospitalization. Results from group-based trajectory modeling indicated that 67% of the current sample was characterized by persistent low caregiver distress, 26% by persistent moderate to high distress that remained stable across 12 months (high-risk caregiver distress group), and 8% by initial high distress followed by gradual recovery. Forty percent of the sample was characterized by stable high family functioning, 15% by persistent high dysfunction across 12 months (high-risk family functioning group), 12% by gradually improving functioning, and 32% by deteriorating function over time. Independently of age, child race was associated with membership in the high-risk caregiver distress group (non-white/Hispanic; effect size, -0.12; p = 0.010). There were no significant sociodemographic or clinical correlates of the high-risk family functioning group in multivariable analyses. CONCLUSIONS Although the majority of families whose children survived community-acquired septic shock were characterized by resilience, a subgroup demonstrated trajectories of persistently elevated distress and family dysfunction during the 12 months after hospitalization. Results suggest a need for family-based psychosocial screening after pediatric septic shock to identify and support at-risk families.
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25
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MacLaren G. In sepsis-induced heart failure, extracorporeal membrane oxygenation can provide support. Lancet 2020; 396:515-517. [PMID: 32828179 DOI: 10.1016/s0140-6736(20)30762-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 03/24/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore 119074, Singapore.
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26
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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.
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27
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 2020; 46:10-67. [PMID: 32030529 PMCID: PMC7095013 DOI: 10.1007/s00134-019-05878-6] [Citation(s) in RCA: 274] [Impact Index Per Article: 68.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 52 research priorities were identified. CONCLUSIONS A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, UK
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, UK
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | | | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, Singapore
- Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark E Nunnally
- New York University Langone Medical Center, New York, NY, USA
| | | | - Raina M Paul
- Advocate Children's Hospital, Park Ridge, IL, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France
- Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-Sur-Yvette, France
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28
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med 2020; 21:e52-e106. [PMID: 32032273 DOI: 10.1097/pcc.0000000000002198] [Citation(s) in RCA: 473] [Impact Index Per Article: 118.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified. CONCLUSIONS A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, United Kingdom
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | - Akash Deep
- King's College Hospital, London, United Kingdom
| | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, and Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | | | | | - Adrienne G Randolph
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Lyvonne N Tume
- University of the West of England, Bristol, United Kingdom
| | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,College of Nursing, University of Iowa, Iowa City, IA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | - Niranjan Kissoon
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-sur-Yvette, France
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Schlapbach LJ, Chiletti R, Straney L, Festa M, Alexander D, Butt W, MacLaren G. Defining benefit threshold for extracorporeal membrane oxygenation in children with sepsis-a binational multicenter cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:429. [PMID: 31888705 PMCID: PMC6937937 DOI: 10.1186/s13054-019-2685-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 11/26/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND The surviving sepsis campaign recommends consideration for extracorporeal membrane oxygenation (ECMO) in refractory septic shock. We aimed to define the benefit threshold of ECMO in pediatric septic shock. METHODS Retrospective binational multicenter cohort study of all ICUs contributing to the Australian and New Zealand Paediatric Intensive Care Registry. We included patients < 16 years admitted to ICU with sepsis and septic shock between 2002 and 2016. Sepsis-specific risk-adjusted models to establish ECMO benefit thresholds with mortality as the primary outcome were performed. Models were based on clinical variables available early after admission to ICU. Multivariate analyses were performed to identify predictors of survival in children treated with ECMO. RESULTS Five thousand sixty-two children with sepsis and septic shock met eligibility criteria, of which 80 (1.6%) were treated with veno-arterial ECMO. A model based on 12 clinical variables predicted mortality with an AUROC of 0.879 (95% CI 0.864-0.895). The benefit threshold was calculated as 47.1% predicted risk of mortality. The observed mortality for children treated with ECMO below the threshold was 41.8% (23 deaths), compared to a predicted mortality of 30.0% as per the baseline model (16.5 deaths; standardized mortality rate 1.40, 95% CI 0.89-2.09). Among patients above the benefit threshold, the observed mortality was 52.0% (13 deaths) compared to 68.2% as per the baseline model (16.5 deaths; standardized mortality rate 0.61, 95% CI 0.39-0.92). Multivariable analyses identified lower lactate, the absence of cardiac arrest prior to ECMO, and the central cannulation (OR 0.31, 95% CI 0.10-0.98, p = 0.046) as significant predictors of survival for those treated with VA-ECMO. CONCLUSIONS This binational study demonstrates that a rapidly available sepsis mortality prediction model can define thresholds for survival benefit in children with septic shock considered for ECMO. Survival on ECMO was associated with central cannulation. Our findings suggest that a fully powered RCT on ECMO in sepsis is unlikely to be feasible.
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Affiliation(s)
- Luregn J Schlapbach
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Australia. .,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, 4101, Australia. .,Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Roberto Chiletti
- University of Melbourne, Melbourne, Australia.,Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Lahn Straney
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Marino Festa
- Paediatric Intensive Care Unit, Children's Hospital Westmead, Sydney, Australia.,Kids Critical Care Research Group, Kids Research, Sydney Children's Hospitals Network, Sydney, Australia
| | - Daniel Alexander
- Paediatric Intensive Care Unit, Perth Children's Hospital, Perth, Australia
| | - Warwick Butt
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Graeme MacLaren
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia.,Cardiothoracic Intensive Care Unit, National University Health System, Singapore, Singapore
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Vekaria-Hirani V, Kumar R, Musoke RN, Wafula EM, Chipkophe IN. Prevalence and Management of Septic Shock among Children Admitted at the Kenyatta National Hospital, Longitudinal Survey. Int J Pediatr 2019; 2019:1502963. [PMID: 31929805 PMCID: PMC6942836 DOI: 10.1155/2019/1502963] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 08/13/2019] [Accepted: 09/03/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Paediatric septic shock is a subset of sepsis associated with high mortality. Implementing the existing international Surviving Sepsis Campaign Guidelines 2012 (SSCG) have contributed to reduction of mortality in many places but these have not been adopted in our setting. The current study aimed at documenting the practice at a national referral hospital. METHODS A hospital based longitudinal survey carried out among 325 children from September to October 2016. Children aged 0 days (≥37 weeks gestation) to12 years were included. The aim was to determine the prevalence, audit the management and determine the outcome at 72 hours of septic shock among children admitted at the Kenyatta National Hospital (KNH). A standard questionnaire was used for data collection and Surviving Sepsis Guideline 2012 was used as a reference for auditing the management of septic shock. Data was stored in MS-EXCEL and analysed in STATA 12. RESULTS The prevalence of septic shock was 50 (15.4%), with a median age of 4 months. Septic shock was recognized by the attending clinician in 28 (56%). The level of care to children with septic shock was not to the level recommended by the SSCG 2012. Odds of being diagnosed with septic shock reduced with age (odds ratio 4.38 (1.7-11.0), p = 0.002) and no child aged above 60 months age was diagnosed with septic shock. The mortality was 35 (70%) at 72 hours of admission, with a median of 14 hours. Infants had the highest case fatality of 82.6%. It was found that lack of mechanical ventilation, and presence of hypotension at admission were associated with greater mortality (p values of 0.03 and 0.01 respectively). CONCLUSION The prevalence rate of septic shock is 15.4% among children admitted at the KNH and is associated with high mortality. The advanced degree of shock contributed to mortality. The level of care at KNH was not to the level of SSCG 2012, and hence the need to include septic shock management guidelines/protocols in our local Kenyan paediatric guideline.
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Affiliation(s)
- Varsha Vekaria-Hirani
- Department of Paediatrics and Child Health, University of Nairobi, P.O. Box 19676-00202, Nairobi, Kenya
| | - Rashmi Kumar
- Department of Paediatrics and Child Health, University of Nairobi, P.O. Box 19676-00202, Nairobi, Kenya
| | - Rachel N. Musoke
- Department of Paediatrics and Child Health, University of Nairobi, P.O. Box 19676-00202, Nairobi, Kenya
| | - Ezekiel M. Wafula
- Department of Paediatrics and Child Health, University of Nairobi, P.O. Box 19676-00202, Nairobi, Kenya
| | - Idris N. Chipkophe
- Department of Paediatrics and Anesthesia, Kenyatta National Hospital, P.O. Box 20723-00202, Nairobi, Kenya
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31
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Wulff A, Montag S, Steiner B, Marschollek M, Beerbaum P, Karch A, Jack T. CADDIE2-evaluation of a clinical decision-support system for early detection of systemic inflammatory response syndrome in paediatric intensive care: study protocol for a diagnostic study. BMJ Open 2019; 9:e028953. [PMID: 31221891 PMCID: PMC6588987 DOI: 10.1136/bmjopen-2019-028953] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Systemic inflammatory response syndrome (SIRS) is one of the most critical indicators determining the clinical outcome of paediatric intensive care patients. Clinical decision support systems (CDSS) can be designed to support clinicians in detection and treatment. However, the use of such systems is highly discussed as they are often associated with accuracy problems and 'alert fatigue'. We designed a CDSS for detection of paediatric SIRS and hypothesise that a high diagnostic accuracy together with an adequate alerting will accelerate the use. Our study will (1) determine the diagnostic accuracy of the CDSS compared with gold standard decisions created by two blinded, experienced paediatricians, and (2) compare the system's diagnostic accuracy with that of routine clinical care decisions compared with the same gold standard. METHODS AND ANALYSIS CADDIE2 is a prospective diagnostic accuracy study taking place at the Department of Pediatric Cardiology and Intensive Care Medicine at the Hannover Medical School; it represents the second step towards our vision of cross-institutional and data-driven decision-support for intensive care environments (CADDIE). The study comprises (1) recruitment of up to 300 patients (start date 1 August 2018), (2) creation of gold standard decisions (start date 1 May 2019), (3) routine SIRS assessments by physicians (starts with recruitment), (4) SIRS assessments by a CDSS (start date 1 May 2019), and (5) statistical analysis with a modified approach for determining sensitivity and specificity and comparing the accuracy results of the different diagnostic approaches (planned start date 1 July 2019). ETHICS AND DISSEMINATION Ethics approval was obtained at the study centre (Ethics Committee of Hannover Medical School). Results of the main study will be communicated via publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT03661450; Pre-results.
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Affiliation(s)
- Antje Wulff
- Peter L. Reichertz Institute for Medical Informatics, TU Braunschweig and Hannover Medical School, Hannover, Germany
| | - Sara Montag
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Bianca Steiner
- Peter L. Reichertz Institute for Medical Informatics, TU Braunschweig and Hannover Medical School, Braunschweig, Germany
| | - Michael Marschollek
- Peter L. Reichertz Institute for Medical Informatics, TU Braunschweig and Hannover Medical School, Hannover, Germany
| | - Philipp Beerbaum
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - André Karch
- Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany
| | - Thomas Jack
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
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32
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Inwald DP, Canter R, Woolfall K, Mouncey P, Zenasni Z, O’Hara C, Carter A, Jones N, Lyttle MD, Nadel S, Peters MJ, Harrison DA, Rowan KM. Restricted fluid bolus volume in early septic shock: results of the Fluids in Shock pilot trial. Arch Dis Child 2019; 104:426-431. [PMID: 30087153 PMCID: PMC6557227 DOI: 10.1136/archdischild-2018-314924] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 07/10/2018] [Accepted: 07/15/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine the feasibility of Fluids in Shock, a randomised controlled trial (RCT) of restricted fluid bolus volume (10 mL/kg) versus recommended practice (20 mL/kg). DESIGN Nine-month pilot RCT with embedded mixed-method perspectives study. SETTING 13 hospitals in England. PATIENTS Children presenting to emergency departments with suspected infection and shock after 20 mL/kg fluid. INTERVENTIONS Patients were randomly allocated (1:1) to further 10 or 20 mL/kg fluid boluses every 15 min for up to 4 hours if still in shock. MAIN OUTCOME MEASURES These were based on progression criteria, including recruitment and retention, protocol adherence, separation, potential trial outcome measures, and parent and staff perspectives. RESULTS Seventy-five participants were randomised; two were withdrawn. 23 (59%) of 39 in the 10 mL/kg arm and 25 (74%) of 34 in the 20 mL/kg arm required a single trial bolus before the shock resolved. 79% of boluses were delivered per protocol in the 10 mL/kg arm and 55% in the 20 mL/kg arm. The volume of study bolus fluid after 4 hours was 44% lower in the 10 mL/kg group (mean 14.5 vs 27.5 mL/kg). The Paediatric Index of Mortality-2 score was 2.1 (IQR 1.6-2.7) in the 10 mL/kg group and 2.0 (IQR 1.6-2.5) in the 20 mL/kg group. There were no deaths. Length of hospital stay, paediatric intensive care unit (PICU) admissions and PICU-free days at 30 days did not differ significantly between the groups. In the perspectives study, the trial was generally supported, although some problems with protocol adherence were described. CONCLUSIONS Participants were not as unwell as expected. A larger trial is not feasible in its current design in the UK. TRIAL REGISTRATION NUMBER ISRCTN15244462.
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Affiliation(s)
- David Philip Inwald
- Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College Healthcare London NHS Trust, London, UK
| | - Ruth Canter
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Kerry Woolfall
- Department of Psychological Sciences, North West Hub for Trials Methodology, University of Liverpool, Liverpool, UK
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Zohra Zenasni
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Caitlin O’Hara
- Department of Psychological Sciences, North West Hub for Trials Methodology, University of Liverpool, Liverpool, UK
| | | | | | - Mark D Lyttle
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK,Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
| | - Simon Nadel
- Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College Healthcare London NHS Trust, London, UK
| | - Mark J Peters
- Respiratory, Critical Care and Anaesthesia Section, Institute of Child Health, University College London Great Ormond Street, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
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Chawla A, Ray S, Matettore A, Peters MJ. Arterial carboxyhaemoglobin levels in children admitted to PICU: A retrospective observational study. PLoS One 2019; 14:e0209452. [PMID: 30845230 PMCID: PMC6405068 DOI: 10.1371/journal.pone.0209452] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/21/2019] [Indexed: 01/07/2023] Open
Abstract
While carbon monoxide (CO) is considered toxic, low levels of endogenously produced CO are protective against cellular injury induced by oxidative stress. Carboxyhaemoglobin (COHb) levels have been associated with outcomes in critically ill adults. We aimed to describe the distribution of carboxyhaemoglobin in critically ill children and the relationship of these levels with clinical outcomes. This retrospective observational study was conducted at a large tertiary paediatric intensive care unit (PICU). We included all children admitted to the PICU over a two-year period who underwent arterial blood gas analysis. We measured the following: (i) Population and age-related differences in COHb distribution; (ii) Change in COHb over the first week of admission using a multi-level linear regression analysis; (iii) Uni- and multivariable relationships between COHb and length of ventilation and PICU survival. Arterial COHb levels were available for 559/2029 admissions. The median COHb level was 1.20% (IQR 1.00-1.60%). Younger children had significantly higher COHb levels (p-value <2 x 10-16). Maximum Carboxyhaemoglobin was associated with survival 1.67 (95% CI: 1.01-2.57; p-value = 0.02) and length of ventilation (OR 5.20, 95% CI: 3.07-7.30; p-value = 1.8 x 10-6) following multi-variable analysis. First measured and minimum COHb values were weakly associated with length of ventilation, but not survival. In conclusion, children have increased COHb levels in critical illness, which are greater in younger children. Higher COHb levels are associated with longer length of ventilation and death in PICU. This may reflect increased oxidative stress in these children.
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Affiliation(s)
- Ankur Chawla
- Respiratory, Critical Care and Anaesthesia Section, UCL GOSH Institute of Child Health, London, United Kingdom
| | - Samiran Ray
- Respiratory, Critical Care and Anaesthesia Section, UCL GOSH Institute of Child Health, London, United Kingdom
- Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, United Kingdom
- * E-mail:
| | - Adela Matettore
- Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Mark J Peters
- Respiratory, Critical Care and Anaesthesia Section, UCL GOSH Institute of Child Health, London, United Kingdom
- Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, United Kingdom
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34
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Souza DCD, Brandão MB, Piva JP. From the International Pediatric Sepsis Conference 2005 to the Sepsis-3 Consensus. Rev Bras Ter Intensiva 2019; 30:1-5. [PMID: 29742230 PMCID: PMC5885223 DOI: 10.5935/0103-507x.20180005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 08/14/2017] [Indexed: 01/11/2023] Open
Affiliation(s)
- Daniela Carla de Souza
- Unidade de Terapia Intensiva Pediátrica, Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Barciela Brandão
- Unidade de Terapia Intensiva Pediátrica, Hospital das Clínicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Jefferson Pedro Piva
- Departamento de Pediatria, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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35
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Harley A, Latour JM, Schlapbach LJ. The Role of Parental Concerns in the Recognition of Sepsis in Children: A Literature Review. Front Pediatr 2019; 7:161. [PMID: 31131264 PMCID: PMC6509218 DOI: 10.3389/fped.2019.00161] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 04/08/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Sepsis is a time critical disease and outcomes strongly depend on time to initiation of appropriate treatment in hospital. A range of studies have assessed sepsis recognition in hospital settings, whereas little is known about sepsis recognition in the community. The decision-making of parents in seeking medical care may substantially impact survival of children with sepsis. An improved understanding of the parental perspective in recognizing sepsis is urgently needed to inform the design of education campaigns and consideration of using parental concerns as a trigger in sepsis screening tools. Aim: To review the literature on parental concerns in the diagnosis of sepsis in children. Methods: A literature review on parental concerns in pediatric sepsis was performed accessing publications in PubMed, CINAHL and Medline published between 1990 and 2018. In addition, we compared guidelines and online institutional sepsis recognition tools and assessed whether parental concerns were used for screening. Results: Out of 188 articles reviewed, 11 met the criteria. One article was found prospectively assessing the diagnostic performance of parental concern in children evaluated for infection, indicating high positive (16.4) and negative likelihood ratio (0.23) for sepsis/meningitis in presence of parental concerns. The role of parental concern was listed as a sign assisting recognition of sepsis in four studies reporting original data, and six reviews commented on parental concern listed as a factor upon diagnosis of sepsis. When comparing selected examples of institutional sepsis pathways available online, parental concern was variably listed as a criterion to prompt evaluation for sepsis. Conclusions: Despite some guidelines emphasizing the role of parental concern in recognizing sepsis, there is a paucity of data in the field. An improved understanding of whether parental concerns adds diagnostic value to sepsis recognition at acceptable sensitivity and specificity is urgently needed. Future prospective studies should assess whether including parental concerns in sepsis screening tools benefits the assessment resulting in early diagnosis and treatment of children with sepsis.
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Affiliation(s)
- Amanda Harley
- Paediatric Critical Care Research Group, Child Health Research Centre and Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia.,School of Nursing, The University of Queensland, Brisbane, QLD, Australia
| | - Jos M Latour
- Faculty of Health and Human Sciences, School of Nursing and Midwifery, University of Plymouth, Plymouth, United Kingdom
| | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, Child Health Research Centre and Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia.,Department of Paediatrics, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
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36
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de Souza DC, Machado FR. Epidemiology of Pediatric Septic Shock. J Pediatr Intensive Care 2018; 8:3-10. [PMID: 31073502 DOI: 10.1055/s-0038-1676634] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 11/11/2018] [Indexed: 12/18/2022] Open
Abstract
Sepsis, or dysregulated host response to infection, is considered a worldwide public health problem. It is a major childhood disease both in terms of frequency and severity, and severe sepsis is still considered the main cause of death from infection in childhood. This review provides an overview of the epidemiology of pediatric septic shock. The prevalence of severe sepsis and septic shock among hospitalized children ranges from 1 to 26%. Mortality is high, ranging from 5% in developed countries to up to 35% in developing countries. However, 10 years after the publication of pediatric sepsis definitions, a global perspective on the burden of this disease in childhood is still missing. Major obstacles to a better knowledge of sepsis epidemiology in children are the absence of an adequate disease definition and not having sepsis as a cause of death in the World Health Organization Global Burden of Disease Report, which is one of the most important sources of information for health policies decision-making in the world. Several studies performed in both developed and developing countries have shown that mortality from septic shock is high and is associated with delayed diagnosis, late treatment, and nonadherence to the treatment guidelines. Reducing mortality from sepsis in childhood is a worldwide challenge, especially in developing countries, where the highest number of cases and deaths are recorded and where financial resources are scarce. Many specialists consider that prevention, education, and organization are key to achieve a reduction in the burden of sepsis.
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Affiliation(s)
- Daniela Carla de Souza
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Sírio-Libanês, São Paulo, São Paulo, Brazil.,Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitário da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Flávia Ribeiro Machado
- Department of Anesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
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37
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Lin GL, McGinley JP, Drysdale SB, Pollard AJ. Epidemiology and Immune Pathogenesis of Viral Sepsis. Front Immunol 2018; 9:2147. [PMID: 30319615 PMCID: PMC6170629 DOI: 10.3389/fimmu.2018.02147] [Citation(s) in RCA: 173] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 08/30/2018] [Indexed: 12/11/2022] Open
Abstract
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis can be caused by a broad range of pathogens; however, bacterial infections represent the majority of sepsis cases. Up to 42% of sepsis presentations are culture negative, suggesting a non-bacterial cause. Despite this, diagnosis of viral sepsis remains very rare. Almost any virus can cause sepsis in vulnerable patients (e.g., neonates, infants, and other immunosuppressed groups). The prevalence of viral sepsis is not known, nor is there enough information to make an accurate estimate. The initial standard of care for all cases of sepsis, even those that are subsequently proven to be culture negative, is the immediate use of broad-spectrum antibiotics. In the absence of definite diagnostic criteria for viral sepsis, or at least to exclude bacterial sepsis, this inevitably leads to unnecessary antimicrobial use, with associated consequences for antimicrobial resistance, effects on the host microbiome and excess healthcare costs. It is important to understand non-bacterial causes of sepsis so that inappropriate treatment can be minimised, and appropriate treatments can be developed to improve outcomes. In this review, we summarise what is known about viral sepsis, its most common causes, and how the immune responses to severe viral infections can contribute to sepsis. We also discuss strategies to improve our understanding of viral sepsis, and ways we can integrate this new information into effective treatment.
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Affiliation(s)
- Gu-Lung Lin
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Joseph P McGinley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Simon B Drysdale
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom.,Department of Paediatrics, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
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38
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Solé A, Jordan I, Bobillo S, Moreno J, Balaguer M, Hernández-Platero L, Segura S, Cambra FJ, Esteban E, Rodríguez-Fanjul J. Venoarterial extracorporeal membrane oxygenation support for neonatal and pediatric refractory septic shock: more than 15 years of learning. Eur J Pediatr 2018; 177:1191-1200. [PMID: 29799085 DOI: 10.1007/s00431-018-3174-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/05/2018] [Accepted: 05/10/2018] [Indexed: 12/29/2022]
Abstract
UNLABELLED The objective of the study was to report our institutional experience in the management of children and newborns with refractory septic shock who required venoarterial extracorporeal membrane oxygenation (VA ECMO) treatment, and to identify patient-and infection-related factors associated with mortality. This is a retrospective case series in an intensive care unit of a tertiary pediatric center. Inclusion criteria were patients ≤ 18 years old who underwent a VA ECMO due to a refractory septic shock due to circulatory collapse. Patient conditions and support immediately before ECMO, analytical and hemodynamic parameter evolution during ECMO, and post-canulation outcome data were collected. Twenty-one patients were included, 13 of them (65%) male. Nine were pediatric and 12 were newborns. Median septic shock duration prior to ECMO was 29.5 h (IQR, 20-46). Eleven patients (52.4%) suffered cardiac arrest (CA). Neonatal patients had worse Sepsis Organ Failure Assessment (SOFA) score, Oxygenation Index and PaO2/FiO2 ratio, blood gas analysis, lactate levels, and left ventricular ejection fraction compared to pediatric patients. Survival was 33.3% among pediatric patients (60% if we exclude pneumococcal cases) and 50% among newborns. Hours of sepsis evolution and mean airway pressure (MAP) prior to ECMO were significantly higher in the non-survivor group. CA was not a predictor of mortality. Streptococcus pneumoniae infection was a mortality risk factor. There was an improvement in survival during the second period, from 14.3 to 57.2%, related to shorter sepsis evolution before ECMO placement, better candidate selection, and greater ECMO support once the patient was placed. CONCLUSION Patients with refractory septic shock should be transferred precociously to a referral ECMO center. However, therapy should be used with caution in patients with vasoplegic pattern shock or S. pneumoniae sepsis. What is Known: • Children with refractory septic shock have significant mortality rates, and although ECMO is recommended, overall survival is low. • There are no studies regarding characteristics of infections as predictors of pediatric survival in ECMO. What is New: • Septic children should be transferred precociously to referral ECMO centers during the first hours if patients do not respond to conventional therapy. • Treatment should be used with caution in patients with vasoplegic pattern shock or S. pneumoniae sepsis.
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Affiliation(s)
- Anna Solé
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Iolanda Jordan
- Pediatric Intensive Care Unit, Sant Joan de Déu Hospital, Paediatric Infectious Diseases Research Group, Institut Recerca Hospital Sant Joan de Déu, CIBERESP, Barcelona, Spain
| | - Sara Bobillo
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Julio Moreno
- Neonatal Intensive Care Unit Service, Hospital de Sant Joan de Déu Maternal, Fetal and Neonatology Center Barcelona (BCNatal), University of Barcelona, Barcelona, Spain
| | - Monica Balaguer
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Lluisa Hernández-Platero
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Susana Segura
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Francisco José Cambra
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Elisabeth Esteban
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Javier Rodríguez-Fanjul
- Neonatal Intensive Care Unit Service, Hospital de Sant Joan de Déu Maternal, Fetal and Neonatology Center Barcelona (BCNatal), University of Barcelona, Barcelona, Spain. .,Pediatric Emergency Transport, Servei Emergències Mèdiques (SEM), Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain.
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Abstract
Sepsis is the body's systemic response to infection and is a serious health care concern that affects neonatal, pediatric, and adult populations worldwide. Severe sepsis (sepsis that has progressed to cellular dysfunction and organ damage or evidence of hypoperfusion) and septic shock (sepsis with persistent hypotension despite adequate fluid resuscitation) are still associated with high mortality rates despite improvements in the management of infectious processes. The cellular processes that occur as a result of the inflammatory response in sepsis, including impaired perfusion and microcirculatory coagulation, can lead to organ system dysfunction. Early recognition of sepsis can help prompt treatment to improve patient care. Current pediatric guidelines emphasize early recognition, aggressive fluid resuscitation, and administration of antibiotics within the first hour for a better outcome. The practitioner needs to always be mindful of the possibility of sepsis when examining a patient with potential symptoms. [Pediatr Ann. 2018;47(7):e292-e299.].
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Schlapbach LJ, Straney L, Bellomo R, MacLaren G, Pilcher D. Prognostic accuracy of age-adapted SOFA, SIRS, PELOD-2, and qSOFA for in-hospital mortality among children with suspected infection admitted to the intensive care unit. Intensive Care Med 2018; 44:179-188. [PMID: 29256116 PMCID: PMC5816088 DOI: 10.1007/s00134-017-5021-8] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/06/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE The Sepsis-3 consensus task force defined sepsis as life-threatening organ dysfunction caused by dysregulated host response to infection. However, the clinical criteria for this definition were neither designed for nor validated in children. We validated the performance of SIRS, age-adapted SOFA, quick SOFA and PELOD-2 scores as predictors of outcome in children. METHODS We performed a multicentre binational cohort study of patients < 18 years admitted with infection to ICUs in Australia and New Zealand. The primary outcome was ICU mortality. SIRS, age-adapted SOFA, quick SOFA and PELOD-2 scores were compared using crude and adjusted area under the receiver operating characteristic curve (AUROC) analysis. RESULTS Of 2594 paediatric ICU admissions due to infection, 151 (5.8%) children died, and 949/2594 (36.6%) patients died or experienced an ICU length of stay ≥ 3 days. A ≥ 2-point increase in the individual score was associated with a crude mortality increase from 3.1 to 6.8% for SIRS, from 1.9 to 7.6% for age-adapted SOFA, from 1.7 to 7.3% for PELOD-2, and from 3.9 to 8.1% for qSOFA (p < 0.001). The discrimination of outcomes was significantly higher for SOFA (adjusted AUROC 0.829; 0.791-0.868) and PELOD-2 (0.816; 0.777-0.854) than for qSOFA (0.739; 0.695-0.784) and SIRS (0.710; 0.664-0.756). CONCLUSIONS SIRS criteria lack specificity to identify children with infection at substantially higher risk of mortality. We demonstrate that adapting Sepsis-3 to age-specific criteria performs better than Sepsis-2-based criteria. Our findings support the translation of Sepsis-3 into paediatric-specific sepsis definitions and highlight the importance of robust paediatric organ dysfunction characterization.
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Affiliation(s)
- Luregn J Schlapbach
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.
- Paediatric Critical Care Research Group, Mater Research Institute, The University of Queensland, Brisbane, Australia.
- Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Children's Health Queensland, Brisbane, Australia.
- Department of Pediatrics, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland.
| | - Lahn Straney
- Department of Pediatrics, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Rinaldo Bellomo
- University of Melbourne, Melbourne, Australia
- Intensive Care, Austin Health, Melbourne, Australia
| | - Graeme MacLaren
- University of Melbourne, Melbourne, Australia
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore, Singapore
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - David Pilcher
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation (CORE), ANZICS House, Levers Terrace, Carlton South, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran, VIC, Australia
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42
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van Nassau SC, van Beek RH, Driessen GJ, Hazelzet JA, van Wering HM, Boeddha NP. Translating Sepsis-3 Criteria in Children: Prognostic Accuracy of Age-Adjusted Quick SOFA Score in Children Visiting the Emergency Department With Suspected Bacterial Infection. Front Pediatr 2018; 6:266. [PMID: 30327759 PMCID: PMC6174358 DOI: 10.3389/fped.2018.00266] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/06/2018] [Indexed: 12/21/2022] Open
Abstract
Background: Recent attempts to translate Sepsis-3 criteria to children have been restricted to PICU patients and did not target children in emergency departments (ED). We assessed the prognostic accuracy of the age-adjusted quick Sequential Organ Failure Assessment score (qSOFA) and compared the performance to SIRS and the quick Pediatric Logistic Organ Dysfunction-2 score (qPELOD-2). We studied whether the addition of lactate (qSOFA-L) would increase prognostic accuracy. Methods: Non-academic, single-center, retrospective study in children visiting the ED and admitted with suspected bacterial infection between March 2013 and January 2018. We defined suspected bacterial infection as initiation of antibiotic therapy within 24 h after ED entry. Age-adjusted qSOFA, SIRS, qPELOD-2, and qSOFA-L scores were compared by area under the receiver operating characteristics curve (AUROC) analysis. Primary outcome measure was PICU transfer and/or mortality and secondary outcome was prolonged hospital length of stay. Results: We included 864 ED visits [474 (55%) male; median age 2.5 years; IQR 9 months-6 years], of which 18 were transferred to a PICU and 6 ended in death [composite outcome PICU transfer and/or mortality; 23 admissions (2.7%)]. 179 (22.2%) admissions resulted in prolonged hospital length of stay. PICU transfer and/or death was present in 22.5% of visits with qSOFA≥2 (n = 40) compared to 2.0% of visits with qSOFA<2 (n = 444) (p < 0.01). qSOFA tends to be the best predictor of PICU transfer and/or mortality (AUROC 0.72 (95% CI, 0.57-0.86) compared to SIRS [0.64 (95% CI, 0.53-0.74), p = 0.23] and qPELOD-2 [0.60 (95% CI, 0.45-0.76), p = 0.03)]. Prolonged hospital length of stay was poorly predicted by qSOFA (AUROC 0.53, 95% CI 0.46-0.59), SIRS (0.49, 95% CI 0.44-0.54), and qPELOD-2 (0.51, 95%CI 0.45-0.57). qSOFA-L resulted in an AUROC of 0.67 (95% CI, 0.50-0.84) for PICU transfer and/or mortality and an AUROC of 0.56 (95% CI, 0.46-0.67) for prolonged hospital length of stay. Conclusion: The currently proposed bedside risk-stratification tool of Sepsis-3 criteria, qSOFA, shows moderate prognostic accuracy for PICU transfer and/or mortality in children visiting the ED with suspected bacterial infection. The addition of lactate did not improve prognostic accuracy. Future prospective studies in larger ED populations are needed to further determine the utility of the qSOFA score.
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Affiliation(s)
| | - Ron H van Beek
- Department of Pediatrics, Amphia Hospital, Breda, Netherlands
| | - Gertjan J Driessen
- Department of Pediatrics, Juliana Children's Hospital, Haga Teaching Hospital, The Hague, Netherlands
| | - Jan A Hazelzet
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Navin P Boeddha
- Department of Pediatrics, Amphia Hospital, Breda, Netherlands.,Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands.,Division of Pediatric Infectious Diseases and Immunology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
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43
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Weiss SL, Peters MJ. Focus on paediatrics: 2017. Intensive Care Med 2017; 44:235-237. [PMID: 29285583 DOI: 10.1007/s00134-017-5025-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 12/09/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Scott L Weiss
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Blvd, Wood Building Suite 6026A, Philadelphia, PA, 19104, USA.
| | - Mark J Peters
- Peadiatric Intensive Care Unit, Great Ormond St Hospital for Children NHS Foundation Trust, London, UK
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The Epidemiology of Hospital Death Following Pediatric Severe Sepsis: When, Why, and How Children With Sepsis Die. Pediatr Crit Care Med 2017; 18:823-830. [PMID: 28549024 PMCID: PMC5581233 DOI: 10.1097/pcc.0000000000001222] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The epidemiology of in-hospital death after pediatric sepsis has not been well characterized. We investigated the timing, cause, mode, and attribution of death in children with severe sepsis, hypothesizing that refractory shock leading to early death is rare in the current era. DESIGN Retrospective observational study. SETTING Emergency departments and ICUs at two academic children's hospitals. PATIENTS Seventy-nine patients less than 18 years old treated for severe sepsis/septic shock in 2012-2013 who died prior to hospital discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Time to death from sepsis recognition, cause and mode of death, and attribution of death to sepsis were determined from medical records. Organ dysfunction was assessed via daily Pediatric Logistic Organ Dysfunction-2 scores for 7 days preceding death with an increase greater than or equal to 5 defined as worsening organ dysfunction. The median time to death was 8 days (interquartile range, 1-12 d) with 25%, 35%, and 49% of cumulative deaths within 1, 3, and 7 days of sepsis recognition, respectively. The most common cause of death was refractory shock (34%), then multiple organ dysfunction syndrome after shock recovery (27%), neurologic injury (19%), single-organ respiratory failure (9%), and nonseptic comorbidity (6%). Early deaths (≤ 3 d) were mostly due to refractory shock in young, previously healthy patients while multiple organ dysfunction syndrome predominated after 3 days. Mode of death was withdrawal in 72%, unsuccessful cardiopulmonary resuscitation in 22%, and irreversible loss of neurologic function in 6%. Ninety percent of deaths were attributable to acute or chronic manifestations of sepsis. Only 23% had a rise in Pediatric Logistic Organ Dysfunction-2 that indicated worsening organ dysfunction. CONCLUSIONS Refractory shock remains a common cause of death in pediatric sepsis, especially for early deaths. Later deaths were mostly attributable to multiple organ dysfunction syndrome, neurologic, and respiratory failure after life-sustaining therapies were limited. A pattern of persistent, rather than worsening, organ dysfunction preceded most deaths.
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Early Death From Pediatric Severe Sepsis: Still a Problem and a Mandate for Future Clinical Research. Pediatr Crit Care Med 2017; 18:891-892. [PMID: 28863088 DOI: 10.1097/pcc.0000000000001239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Epidemiology of blood culture-proven bacterial sepsis in children in Switzerland: a population-based cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2017; 1:124-133. [PMID: 30169202 DOI: 10.1016/s2352-4642(17)30010-x] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 06/03/2017] [Accepted: 06/06/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Sepsis is a leading cause of childhood mortality worldwide. We assessed population-based incidence and outcomes of blood culture-proven bacterial sepsis in children in Switzerland. METHODS We did a multicentre, prospective, cohort study at ten paediatric hospitals in Switzerland. We included neonates and children younger than 17 years with blood culture-proven bacterial sepsis. Children were eligible if they met criteria for systemic inflammatory response syndrome-according to 2005 paediatric consensus definition- at the time of blood culture sampling. Incidence was calculated by dividing the number of annual sepsis episodes in the study for the years 2012-15 by the end-of-year resident paediatric population in Switzerland. The primary outcome was in-hospital mortality in the first 30 days after sepsis onset. FINDINGS Between Sept 1, 2011, and Dec 31, 2015, we enrolled 1096 children to our study. Of 1181 episodes of blood culture-proven bacterial sepsis, 382 (32%) occurred in 379 previously healthy children, 402 (34%) in 391 neonates, and 397 (34%) in 341 children with comorbidities. Incidence was 25·1 cases per 100 000 (95% CI 23·8-26·4) in children and 146·0 cases per 100 000 (133·2-159·6) in neonates. Central line-associated bloodstream infections and primary bloodstream infections accounted for 569 (48%) of 1181 episodes, and organ dysfunction was present in 455 (39%) of 1181 episodes. Escherichia coli (242 of 1181 [20%]), Staphylococcus aureus (177 of 1181 [15%]), coagulase-negative staphylococci (135 of 1181 [11%]), and Streptococcus pneumoniae (118 of 1181 [10%]) were the most prevalent pathogens in our study, accounting for 57% of episodes. The overall case-fatality ratio was 7% (82 of 1181 episodes; 95% CI 5·6-8·6), and it was higher in neonates (11%, 45 of 402 episodes; 8·4-14·8; adjusted odds ratio [OR] 4·41, 95% CI 1·75-11·1) and children with comorbidities (7%, 27 of 397 episodes; 4·6-9·9; OR 4·97, 1·84-13·4) compared with previously healthy children (3%, ten of 382 episodes; 1·3-4·9). The case-fatality ratio was 1% (five of 726 episodes [95% CI 0·3-1·7]) for children without organ dysfunction, which increased to 17% (77 of 455 episodes [13·7-20·8]) when organ dysfunction was present (adjusted OR 4·84, 95% CI 1·40-16·7). INTERPRETATION The burden of blood culture-proven bacterial sepsis on child health remains considerable. We recorded key differences in predominant organisms, severity, and outcome between neonates, previously healthy children, and children with comorbidities. Although for most episodes of blood culture-proven bacterial sepsis, no organ dysfunction was seen, presence of organ dysfunction was strongly associated with mortality. FUNDING Swiss National Science Foundation, Swiss Society of Intensive Care, Bangerter Foundation, Vinetum and Borer Foundation, and Foundation for the Health of Children and Adolescents.
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Bobelytė O, Gailiūtė I, Zubka V, Žilinskaitė V. Sepsis epidemiology and outcome in the paediatric intensive care unit of Vilnius University Children's Hospital. Acta Med Litu 2017; 24:113-120. [PMID: 28845129 PMCID: PMC5566950 DOI: 10.6001/actamedica.v24i2.3492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Research was carried out at the paediatric intensive care unit (paediatric ICU) of the Children’s Hospital, affiliate of Vilnius University Hospital Santariškių klinikos.
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Affiliation(s)
| | - Ieva Gailiūtė
- Medical Faculty, Vilnius University, Vilnius, Lithuania
| | - Vytautas Zubka
- Children's Hospital, Affiliate of Vilnius University Hospital Santariškių klinikos, Vilnius, Lithuania
| | - Virginija Žilinskaitė
- Medical Faculty, Vilnius University, Vilnius, Lithuania.,Children's Hospital, Affiliate of Vilnius University Hospital Santariškių klinikos, Vilnius, Lithuania
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The intensive care medicine clinical research agenda in paediatrics. Intensive Care Med 2017; 43:1210-1224. [PMID: 28315043 DOI: 10.1007/s00134-017-4729-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 02/16/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Intensive Care Medicine set us the task of outlining a global clinical research agenda for paediatric intensive care (PIC). In line with the clinical focus of this journal, we have limited this to research that may directly influence patient care. METHODS Clinician researchers from PIC research networks of varying degrees of formality from around the world were invited to answer two main questions: (1) What have been the major recent advances in paediatric critical care research? (2) What are the top 10 studies for the next 10 years? RESULTS (1) Inclusive databases are well established in many countries. These registries allow detailed observational studies and feasibility testing of clinical trial protocols. Recent trials are larger and more valuable, and (2) most common interventions in PIC are not evidenced-based. Clinical studies for the next 10 years should address this deficit, including: ventilation techniques and interfaces; fluid, transfusion and feeding strategies; optimal targets for vital signs; multiple organ failure definitions, mechanisms and treatments; trauma, prevention and treatment; improving safety; comfort of the patient and their family; appropriate care in the face of medical complexity; defining post-PICU outcomes; and improving knowledge generation and adoption, with novel trial design and implementation strategies. The group specifically highlighted the need for research in resource-limited environments wherein mortality remains often tenfold higher than in well-resourced settings. CONCLUSION Paediatric intensive care research has never been healthier, but many gaps in knowledge remain. We need to close these urgently. The impact of new knowledge will be greatest in resource-limited environments.
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Schlapbach LJ, MacLaren G, Festa M, Alexander J, Erickson S, Beca J, Slater A, Schibler A, Pilcher D, Millar J, Straney L. Prediction of pediatric sepsis mortality within 1 h of intensive care admission. Intensive Care Med 2017; 43:1085-1096. [PMID: 28220227 DOI: 10.1007/s00134-017-4701-8] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 01/27/2017] [Indexed: 01/03/2023]
Abstract
PURPOSE The definitions of sepsis and septic shock have recently been revised in adults, but contemporary data are needed to inform similar approaches in children. METHODS Multicenter cohort study including children <16 years admitted with sepsis or septic shock to ICUs in Australia and New Zealand in the period 2012-2015. We assessed septic shock criteria at ICU admission to define sepsis severity, using 30-day mortality as outcome. Through multivariable logistic regression, a pediatric sepsis score was derived using variables available within 60 min of ICU admission. RESULTS Of 42,523 pediatric admissions, 4403 children were admitted with invasive infection, including 1697 diagnosed as having sepsis/septic shock on admission. Mortality was 8.5% (144/1697) and 50.7% of deaths occurred within 48 h of admission. The presence of septic shock as defined by the 2005 consensus was sensitive but not specific in predicting mortality (AUC = 0.69; 95% CI 0.65-0.72). Combinations of hypotension, vasopressor therapy, and lactate >2 mmol/l discriminated poorly (AUC <0.60). Multivariate models showed that oxygenation markers, ventilatory support, hypotension, cardiac arrest, serum lactate, pupil responsiveness, and immunosuppression were the best-performing predictors (0.843; 0.811-0.875). We derived a pediatric sepsis score (0.817; 0.779-0.855), and every one-point increase was associated with a 28.5% (23.8-33.2%) increase in the odds of death. Children with a score ≥6 had 19.8% mortality and accounted for 74.3% of deaths. The sepsis score performed comparably when applied to all children admitted with invasive infection (0.810; 0.781-0.840). CONCLUSIONS We observed mortality patterns specific to pediatric sepsis that support the need for specialized definitions of sepsis severity in children. We demonstrated the importance of lactate, cardiovascular, and respiratory derangements at ICU admission for the identification of children with substantially higher risk of sepsis mortality.
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Affiliation(s)
- Luregn J Schlapbach
- Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland, Brisbane, Australia. .,Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Brisbane, Australia. .,Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore, Singapore.,Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Marino Festa
- Paediatric Intensive Care Unit, Children's Hospital Westmead, Sydney, Australia
| | - Janet Alexander
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation (CORE), ANZICS House, Ievers Terrace, Carlton South, Melbourne, Australia.,School of Medicine, University of Queensland, Brisbane, Australia
| | - Simon Erickson
- Paediatric Intensive Care Unit, Princess Margaret Hospital for Children, Perth, Australia
| | - John Beca
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
| | - Anthony Slater
- Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Brisbane, Australia
| | - Andreas Schibler
- Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland, Brisbane, Australia.,Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Brisbane, Australia
| | - David Pilcher
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation (CORE), ANZICS House, Ievers Terrace, Carlton South, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran, VIC, Australia
| | - Johnny Millar
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Lahn Straney
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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