Primary Outcome Measures in Pediatric Septic Shock Trials: A Systematic Review

Adaptive platform trials rather than randomised controlled trials for paediatric sepsis

Adaptive platform trials (APTs) offer a promising alternative to traditional randomised controlled trials for evaluating treatments for paediatric sepsis. Randomised controlled trials, despite being the gold standard for establishing causality between interventions and outcomes, make many assumptions about disease prevalence, severity and intervention effects, which are often incorrect. As a result, the evidence for most treatments for paediatric sepsis are based on low-quality evidence. APTs use accrued data rather than assumptions to power trial adaptations. They can assess multiple treatments simultaneously with shared research infrastructure. As such, APTs offer a more efficient, flexible and more effective way to identify optimal treatments. The proposed Paediatric Adaptive Sepsis Platform Trial, leveraging the Paediatric Research in Emergency Departments International Collaborative network's infrastructure, will evaluate resuscitation fluids, vasoactive medications, corticosteroids and antimicrobials. This trial has the potential to substantially impact clinical practice and reduce global sepsis mortality in children.

Pro-opiomelanocortin and ACTH-cortisol dissociation during pediatric cardiac surgery

In critically ill adults, high plasma cortisol in face of low ACTH coincides with high pro-opiomelanocortin (POMC) levels. Glucocorticoids further lower ACTH without affecting POMC. We hypothesized that in pediatric cardiac surgery-induced critical illness, plasma POMC is elevated, plasma ACTH transiently rises intraoperatively but becomes suppressed post-operatively, and glucocorticoid administration amplifies this phenotype. From 53 patients (0-36 months), plasma was obtained pre-operatively, intraoperatively and on post-operative day 1 and 2. Plasma was also collected from 24 healthy children. In patients, POMC was supra-normal pre-operatively (p<0.0001) but no longer thereafter (p<0.05). ACTH was never high in patients. While in glucocorticoid-naive patients ACTH became suppressed by post-operative day 1 (p<0.0001), glucocorticoid-treated patients had suppressed ACTH already intraoperatively (p≤0.0001). Pre-operatively high POMC, not accompanied by increased plasma ACTH, suggests a centrally-activated HPA-axis with reduced pituitary processing of POMC into ACTH. Increasing systemic glucocorticoid availability with glucocorticoid treatment accelerated the suppression of plasma ACTH.

Sepsis epidemiology in Australan and New Zealand children (SENTINEL): protocol for a multicountry prospective observational study

INTRODUCTION

Sepsis affects 25.2 million children per year globally and causes 3.4 million deaths, with an annual cost of hospitalisation in the USA of US$7.3 billion. Despite being common, severe and expensive, therapies and outcomes from sepsis have not substantially changed in decades. Variable case definitions, lack of a reference standard for diagnosis and broad spectrum of disease hamper efforts to evaluate therapies that may improve sepsis outcomes. This landscape analysis of community-acquired childhood sepsis in Australia and New Zealand will characterise the burden of disease, including incidence, severity, outcomes and cost. Sepsis diagnostic criteria and risk stratification tools will be prospectively evaluated. Sepsis therapies, quality of care, parental awareness and understanding of sepsis and parent-reported outcome measures will be described. Understanding these aspects of sepsis care is fundamental for the design and conduct of interventional trials to improve childhood sepsis outcomes.

METHODS AND ANALYSIS

This prospective observational study will include children up to 18 years of age presenting to 12 emergency departments with suspected sepsis within the Paediatric Research in Emergency Departments International Collaborative network in Australia and New Zealand. Presenting characteristics, management and outcomes will be collected. These will include vital signs, serum biomarkers, clinician assessment of severity of disease, intravenous fluid administration for the first 24 hours of hospitalisation, organ support therapies delivered, antimicrobial use, microbiological diagnoses, hospital and intensive care unit length-of-stay, mortality censored at hospital discharge or 30 days from enrolment (whichever comes first) and parent-reported outcomes 90 days from enrolment. We will use these data to determine sepsis epidemiology based on existing and novel diagnostic criteria. We will also validate existing and novel sepsis risk stratification criteria, characterise antimicrobial stewardship, guideline adherence, cost and report parental awareness and understanding of sepsis and parent-reported outcome measures.

ETHICS AND DISSEMINATION

Ethics approval was received from the Royal Children's Hospital of Melbourne, Australia Human Research Ethics Committee (HREC/69948/RCHM-2021). This included incorporated informed consent for follow-up. The findings will be disseminated in a peer-reviewed journal and at academic conferences.

TRIAL REGISTRATION NUMBER

ACTRN12621000920897; Pre-results.

Functional Outcomes in Survivors of Pediatric Sepsis: A Scoping Review and Discussion of Implications for Low- and Middle-Income Countries

BACKGROUND

Pediatric sepsis is an important cause of mortality and morbidity in low- and middle-income countries (LMIC), where there is a huge burden of infectious diseases. Despite shortage of resources, adapting protocol-based care has reduced sepsis-related deaths but survivors of pediatric sepsis are at risk of poor functional outcomes.

OBJECTIVES

To perform a scoping review of the literature on functional outcomes of pediatric sepsis survivors after discharge from the intensive care unit (ICU) and discuss the implications for patients in LMICs. The outcomes include prevalence of survival with reduced functional outcomes or quality of life (QoL) and changes over time during follow-up or recovery, and these outcomes were compared with other groups of children.

METHODS

We searched major medical electronic databases for relevant literature from January 2005 until November 2021, including Medline (via PubMed), Embase, CINAHL, and Google Scholar databases. We included observational studies and follow-up data from clinical trials involving children/adolescents (≤18 years) who were admitted to pediatric intensive care unit (PICU) and got discharged finally. Major focus was on survivors of sepsis in LMIC. We followed PRISMA guidelines for scoping reviews (PRISM-ScR).

RESULTS

We included eight papers reporting data of functional outcomes in 2,915 children (males = 53%, and comorbidity present in 56.6%). All included studies were either a prospective or retrospective cohort study. Studies were classified as Level II evidence. Disabilities affecting physical, cognitive, psychological, and social function were reported in children following discharge. Overall disability reported ranged between 23 and 50% at hospital discharge or 28 days. Residual disability was reported at 1, 3, 6, and 12 months of follow-up with an overall improving trend. Failure to recover from a baseline HRQL on follow-up was seen in one-third of survivors. Organ dysfunction scores such as pSOFA, PeLOD, vasoactive inotrope score, neurological events, immunocompromised status, need for CPR, and ECMO were associated with poor functional outcome.

CONCLUSIONS

The research on functional outcomes in pediatric sepsis survivors is scarce in LMIC. Measuring baseline and follow-up functional status, low-cost interventions to improve management of sepsis, and multidisciplinary teams to identify and treat disabilities may improve functional outcomes.

Identifying the critically ill paediatric oncology patient: a study protocol for a prospective observational cohort study for validation of a modified Bedside Paediatric Early Warning System score in hospitalised paediatric oncology patients

INTRODUCTION

Hospitalised paediatric oncology patients are at risk to develop acute complications. Early identification of clinical deterioration enabling adequate escalation of care remains challenging. Various Paediatric Early Warning Systems (PEWSs) have been evaluated, also in paediatric oncology patients but mostly in retrospective or case-control study designs. This study protocol encompasses the first prospective cohort with the aim of evaluating the predictive performance of a modified Bedside PEWS score for non-elective paediatric intensive care unit (PICU) admission or cardiopulmonary resuscitation in hospitalised paediatric oncology patients.

METHODS AND ANALYSIS

A prospective cohort study will be conducted at the 80-bed Dutch paediatric oncology hospital, where all national paediatric oncology care has been centralised, directly connected to a shared 22-bed PICU. All patients between 1 February 2019 and 1 February 2021 admitted to the inpatient nursing wards, aged 0-18 years, with an International Classification of Diseases for Oncology (ICD-O) diagnosis of paediatric malignancy will be eligible. A Cox proportional hazard regression model will be used to estimate the association between the modified Bedside PEWS and time to non-elective PICU transfer or cardiopulmonary arrest. Predictive performance (discrimination and calibration) will be assessed internally using resampling validation. To account for multiple occurrences of the event of interest within each patient, the unit of study is a single uninterrupted ward admission (a clinical episode).

ETHICS AND DISSEMINATION

The study protocol has been approved by the institutional ethical review board of our hospital (MEC protocol number 16-572/C). We adapted our enrolment procedure to General Data Protection Regulation compliance. Results will be disseminated at scientific conferences, regional educational sessions and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Netherlands Trial Registry (NL8957).

Integrating Focused Cardiac Ultrasound Into Pediatric Septic Shock Assessment

OBJECTIVES

To assess focused cardiac ultrasound impact on clinician hemodynamic characterization of patients with suspected septic shock as well as expert-generated focused cardiac ultrasound algorithm performance.

DESIGN

Retrospective, observational study.

SETTING

Single-center, noncardiac PICU.

PATIENTS

Less than 18 years old receiving focused cardiac ultrasound study within 72 hours of sepsis pathway initiation from January 2014 to December 2016.

INTERVENTIONS

Hemodynamics of patients with suspected septic shock were characterized as fluid responsive, myocardial dysfunction, obstructive physiology, and/or reduced systemic vascular resistance by a bedside clinician before and immediately following focused cardiac ultrasound performance. The clinician's post-focused cardiac ultrasound hemodynamic assessments were compared with an expert-derived focused cardiac ultrasound algorithmic hemodynamic interpretation. Subsequent clinical management was assessed for alignment with focused cardiac ultrasound characterization and association with patient outcomes.

MEASUREMENTS AND MAIN RESULTS

Seventy-one patients with suspected septic shock (median, 4.7 yr; interquartile range, 1.6-8.1) received clinician performed focused cardiac ultrasound study within 72 hours of sepsis pathway initiation (median, 2.1 hr; interquartile range, -1.5 to 11.8 hr). Two patients did not have pre-focused cardiac ultrasound and 23 patients did not have post-focused cardiac ultrasound hemodynamic characterization by clinicians resulting in exclusion from related analyses. Post-focused cardiac ultrasound clinician hemodynamic characterization differed from pre-focused cardiac ultrasound characterization in 67% of patients (31/46). There was substantial concordance between clinician's post-focused cardiac ultrasound and algorithm hemodynamic characterization (33/48; κ = 0.66; CI, 0.51-0.80). Fluid responsive (κ = 0.62; CI, 0.40-0.84), obstructive physiology (к = 0.87; CI, 0.64-1.00), and myocardial dysfunction (1.00; CI, 1.00-1.00) demonstrated substantial to perfect concordance. Management within 4 hours of focused cardiac ultrasound aligned with algorithm characterization in 53 of 71 patients (75%). Patients with aligned management were less likely to have a complicated course (14/52, 27%) compared with misaligned management (8/19, 42%; p = 0.25).

CONCLUSIONS

Incorporation of focused cardiac ultrasound in the evaluation of patients with suspected septic shock frequently changed a clinician's characterization of hemodynamics. An expert-developed algorithm had substantial concordance with a clinician's post-focused cardiac ultrasound hemodynamic characterization. Management aligned with algorithm characterization may improve outcomes in children with suspected septic shock.

Measuring More than Mortality: A scoping review of air ambulance outcome measures in a combined Institutes of Medicine and Donabedian quality framework

INTRODUCTION

Measuring the performance of air ambulance services are complex and dynamic due to the variability and interconnectedness of emergency systems. The aim of this study is to review the range and nature of air ambulance outcome measures published in peer review articles and construct a quality framework based on the results. A scoping review of the literature was conducted to identify outcome measures that evaluate the quality of air ambulance services. Combined frameworks from the Institutes of Medicine (IOM) and Dr. Avedia Donabedian were used to create a dashboard structure for a framework of air ambulance outcome measures.

METHODS

A literature search strategy was undertaken, following PRISMA-ScR guidelines and included eight databases over the period 2001-2019. Qualitative content analysis was conducted in 4-phases: 1) table summary of selected article outcome measures, 2) content analysis themes, codes of outcome measures and independent variables 3) narrative description of main themes 4) visual dashboard diagram of service priorities and quality strategies, based on the findings.

RESULTS

Thirty-four articles were screened by full text and eighteen met the selection criteria. Twenty codes emerged and were grouped to form eight consistent outcome themes; asset/ team type, access to definitive interventions, prehospital factors, mortality, morbidity, responsiveness of service, accessibility of service and patient disposition.

CONCLUSIONS

A quality framework consisting of eight outcome measures was created, it also identified seven gaps which ordinarily require performance evaluation; patient comfort and satisfaction reporting, cultural awareness training, safety alarms in place to identify volume stress, optimal coordination of resources, cost of service analysis, comprehensive patient journey time and an adaptive referral system analysis. The measures in the framework provide a broad perspective of air ambulance performance we believe will help decision-making and planning to improve patients experience and outcomes.

Core outcome set in paediatric sepsis in low- and middle-income countries: a study protocol

INTRODUCTION

Sepsis is the leading cause of death in children worldwide and has recently been declared a major global health issue. New interventions and a concerted effort to enhance our understanding of sepsis are required to address the huge burden of disease, especially in low- and middle-income countries (LMIC) where it is highest. An opportunity therefore exists to ensure that ongoing research in this area is relevant to all stakeholders and is of consistently high quality. One method to address these issues is through the development of a core outcome set (COS).

METHODS AND ANALYSIS

This study protocol outlines the phases in the development of a core outcome set for paediatric sepsis in LMIC. The first step involves performing a systematic review of all outcomes reported in the research of paediatric sepsis in low middle-income countries. A three-stage international Delphi process will then invite a broad range of participants to score each generated outcome for inclusion into the COS. This will include an initial two-step online survey and finally, a face-to-face consensus meeting where each outcome will be reviewed, voted on and ratified for inclusion into the COS.

ETHICS AND DISSEMINATION

No core outcome sets exist for clinical trials in paediatric sepsis. This COS will serve to not only highlight the heavy burden of paediatric sepsis in this setting and aid collaboration and participation between all stakeholders, but to promote ongoing essential high quality and relevant research into the topic. A COS in paediatric sepsis in LMIC will advocate for a common language and facilitate interpretation of findings from a variety of settings. A waiver for ethics approval has been granted by University of British Columbia Children's and Women's Research Ethics Board.

Dynamics and prognostic value of the hypothalamus-pituitary-adrenal axis responses to pediatric critical illness and association with corticosteroid treatment: a prospective observational study

PURPOSE

Increased systemic cortisol availability during adult critical illness is determined by reduced binding-proteins and suppressed breakdown rather than elevated ACTH. Dynamics, drivers and prognostic value of hypercortisolism during pediatric critical illness remain scarcely investigated.

METHODS

This preplanned secondary analysis of the PEPaNIC-RCT (N = 1440), after excluding 420 children treated with corticosteroids before PICU-admission, documented (a) plasma ACTH, (free)cortisol and cortisol-metabolism at PICU-admission, day-3 and last PICU-day, their prognostic value, and impact of withholding early parenteral nutrition (PN), (b) the association between corticosteroid-treatment and these hormones, and (c) the association between corticosteroid-treatment and outcome.

RESULTS

ACTH was normal upon PICU-admission and low thereafter (p ≤ 0.0004). Total and free cortisol were only elevated upon PICU-admission (p ≤ 0.0003) and thereafter became normal despite low binding-proteins (p < 0.0001) and persistently suppressed cortisol-metabolism (p ≤ 0.03). Withholding early-PN did not affect this phenotype. On PICU-day-3, high free cortisol and low ACTH independently predicted worse outcome (p ≤ 0.003). Also, corticosteroid-treatment initiated in PICU, which further suppressed ACTH (p < 0.0001), was independently associated with poor outcomes (earlier live PICU-discharge: p < 0.0001, 90-day mortality: p = 0.02).

CONCLUSION

In critically ill children, systemic cortisol availability is elevated only transiently, much lower than in adults, and not driven by elevated ACTH. Further ACTH lowering by corticosteroid-treatment indicates active feedback inhibition at pituitary level. Beyond PICU-admission-day, low ACTH and high cortisol, and corticosteroid-treatment, predicted poor outcome. This suggests that exogenously increasing cortisol availability during acute critical illness in children may be inappropriate. Future studies on corticosteroid-treatment in critically ill children should plan safety analyses, as harm may be possible.

Health-Related Quality of Life Among Survivors of Pediatric Sepsis

OBJECTIVES

Mortality from pediatric sepsis has steadily declined over the past several decades; however, little is known about morbidity among survivors. We aimed to determine the prevalence of and risk factors for failure to recover to baseline health-related quality of life following community-acquired pediatric sepsis.

DESIGN

Retrospective cohort study.

SETTING

Seattle Children's Hospital.

PATIENTS

Children aged 1 month to 21 years admitted to the inpatient wards or ICUs from 2012 to 2015 who met 2005 consensus sepsis criteria within 4 hours of hospitalization and were enrolled in the hospital's Outcomes Assessment Program with baseline, admission, and post-discharge health-related quality of life data available.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We assessed health-related quality of life with the Pediatric Quality of Life Inventory for pre-admission baseline, admission, and post-discharge (median, 31 d) status. We determined associations between patient and illness characteristics with failure to recover within 4.5 points of baseline at follow-up (the minimum clinically significant difference between two scores). Of 790 patients, 23.8% failed to recover to baseline health-related quality of life at follow-up. Factors associated with failure to recover were septic shock, older age, private insurance, complex chronic disease, immune compromise, CNS infection or bacteremia, ICU admission, and longer length of stay. On multivariable analysis controlling for time to follow-up, failure to recover was independently associated with septic shock (relative risk, 1.79; 95% CI, 1.24-2.58), older age (relative risk, 1.02/yr; 95% CI, 1.01-1.05), immune compromise (relative risk, 1.83; 95% CI, 1.40-2.40), and length of stay (relative risk, 1.03/d; 95% CI, 1.01-1.04).

CONCLUSIONS

Nearly one-quarter of children surviving hospitalization for community-acquired sepsis experienced a clinically significant deterioration in health-related quality of life. We identify risk factors for poor outcomes following sepsis and highlight the need for ongoing evaluation and treatment by primary and specialty care providers for pediatric sepsis survivors after hospital discharge.

Major Adverse Kidney Events in Pediatric Sepsis

BACKGROUND AND OBJECTIVES

Major adverse kidney events, a composite of death, new kidney replacement therapy, or persistent kidney dysfunction, is a potential patient-centered outcome for clinical trials in sepsis-associated kidney injury. We sought to determine the incidence of major adverse kidney events within 30 days and validate this end point in pediatric sepsis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a retrospective observational study using the Pediatric Health Information Systems Plus database of patients >6 months to <18 years old with a diagnosis of severe sepsis/septic shock; orders for bacterial blood culture, antibiotics, and at least one fluid bolus on hospital day 0/1; and known hospital disposition between January 2007 and December 2011. The primary outcome was incidence of major adverse kidney events within 30 days. Major adverse kidney events within 30 days were validated against all-cause mortality at hospital discharge, hospital length of stay, total hospital costs, hospital readmission within 30 days and 1 year, and lowest eGFR between 3 months and 1 year after discharge. We reported incidence of major adverse kidney events within 30 days with 95% confidence intervals using robust SEM and used multivariable logistic regression to test the association of major adverse kidney events within 30 days with hospital costs and mortality.

RESULTS

Of 1685 admissions, incidence of major adverse kidney events within 30 days was 9.6% (95% confidence interval, 8.1% to 11.0%), including 4.5% (95% confidence interval, 3.5% to 5.4%) death, 1.7% (95% confidence interval, 1.1% to 2.3%) kidney replacement therapy, and 5.8% (95% confidence interval, 4.7% to 6.9%) persistent kidney dysfunction. Patients with versus without major adverse kidney events within 30 days had higher all-cause mortality at hospital discharge (28% versus 1%; P<0.001), higher total hospital costs ($61,188; interquartile range, $21,272-140,356 versus $28,107; interquartile range, $13,056-72,697; P<0.001), and higher proportion with eGFR<60 ml/min per 1.73 m² between 3 months and 1 year after discharge (19% versus 4%; P=0.001). Major adverse kidney events within 30 days was not associated with length of stay or readmissions.

CONCLUSIONS

In children with sepsis, major adverse kidney events within 30 days are common, feasible to measure, and a promising end point for future clinical trials.

Contributions of a survey and retrospective cohort study to the planning of a randomised controlled trial of corticosteroids in the treatment of paediatric septic shock

Background

Randomised controlled trials (RCTs) are challenging to conduct in a paediatric critical-care environment. Background work, including surveys and observational studies, is often used to determine disease estimates, sample sizes and design protocols when planning such RCTs. Our objective was to determine the necessity of performing a survey or a retrospective chart review or both when planning an RCT on corticosteroids in the treatment of paediatric septic shock.

Methods

We compared information on corticosteroid use for moderate to severe paediatric septic shock obtained from a survey of physician beliefs and stated practices with that obtained from a retrospective cohort study. The survey was conducted between February and March 2012 and the retrospective study included children from birth to 17 years of age admitted from January 2010 to June 2011. The survey and the retrospective study were conducted at four academic tertiary care centres in Canada.

Results

Survey responses from 23 physicians and retrospective data from 81 septic shock patients were included. The survey identified time to discontinuation of vasoactive infusions as the most feasible and clinically important outcome for an RCT on corticosteroids for paediatric septic shock. The retrospective chart review provided means and standard deviations for the suggested primary outcome, from which we could estimate sample sizes and justify the minimal clinically important difference. The survey found that physicians believe that patients with severe septic shock were most likely to benefit from corticosteroid administration but the majority stated they would be unwilling to randomise such patients, suggesting a lack of individual physician equipoise. The combined information from the survey and retrospective study suggested that enrolment of patients with moderate septic shock would be more feasible but that strategies would still have to be implemented to prevent open-label corticosteroid use.

Conclusions

The survey provided valuable information on the choice of primary outcome, target population and physician equipoise. The retrospective study provided estimates of patient numbers, the minimal clinically important difference, evidence for community equipoise and physician practice patterns. Strong consideration should be given to performing both types of studies prior to conducting RCTs in paediatric critical-care environments.

Beyond Survival: Pediatric Critical Care Interventional Trial Outcome Measure Preferences of Families and Healthcare Professionals

OBJECTIVES

To identify, in addition to survival, preferred outcome measures of PICU family care providers and PICU healthcare professionals for interventional trials enrolling critically ill children, and to describe general attitudes of family care providers and healthcare professionals regarding research in the PICU.

DESIGN

Cross-sectional survey examining subject experience with clinical research and personal preferences for outcome measures for a hypothetical interventional clinical trial.

SETTING

PICUs within four academic children's hospitals in the United States and Canada.

SUBJECTS

Two cohorts including family members of critically ill children in PICUs (family care providers) and multidisciplinary staff working in the PICUs (healthcare professionals).

INTERVENTIONS

Administration of a short, deidentified survey.

MEASUREMENTS

Demographic data were collated for the two subject groups. Participants were queried regarding their attitudes related to research conducted in the PICU. In addition to survival, each group was asked to identify their three most important outcomes for an investigation examining whether or not an intervention helps seriously ill children recover.

MAIN RESULTS

Demographics for family care providers (n = 40) and healthcare professionals (n = 53) were similarly distributed. Female respondents (79.8%) predominated. Participants (98.9%) ascertained the importance of conducting research in the PICU, but significant challenges associated with this goal in the high stress PICU environment. Both quality of life and functioning after leaving the hospital were chosen as the most preferred outcome measure, with 77.5% of family care providers and 84.9% of healthcare professionals indicating this choice. Duration of organ dysfunction was identified by 70.0% of family care providers and 40.7% of healthcare professionals as the second most preferred outcome measure.

CONCLUSIONS

In addition to survival, long-term quality of life/functional status and duration of organ dysfunction represent important interventional trial outcome measures for both families of critically ill children, as well as the multidisciplinary team who provides critical care.