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Dumbuya JS, Chen X, Du J, Li S, Liang L, Xie H, Zeng Q. Hydrogen-rich saline regulates NLRP3 inflammasome activation in sepsis-associated encephalopathy rat model. Int Immunopharmacol 2023; 123:110758. [PMID: 37556997 DOI: 10.1016/j.intimp.2023.110758] [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: 06/10/2023] [Revised: 07/30/2023] [Accepted: 08/01/2023] [Indexed: 08/11/2023]
Abstract
Sepsis-associated encephalopathy (SAE) is characterised by long-term cognitive impairment and psychiatric illness in sepsis survivors, associated with increased morbidity and mortality. There is a lack of effective therapeutics for SAE. Molecular hydrogen (H2) plays multiple roles in septic diseases by regulating neuroinflammation, reducing oxidative stress parameters, regulating signalling pathways, improving mitochondrial dysfunction, and regulating astrocyte and microglia activation. Here we report the protective effect of hydrogen-rich saline in the juvenile SAE rat model and its possible underlying mechanisms. Rats were injected intraperitoneally with lipopolysaccharide at a dose of 5 mg/kg to induce sepsis; Hydrogen-rich saline (HRS) was administered 1 h after LPS induction at a dose of 5 ml/kg and nigericin at 1 mg/kg 1 h before LPS injection. H&E staining for neuronal damage, TUNEL assay for detection of apoptotic cells, immunofluorescence, ELISA protocol for inflammatory cytokines and 8-OHdG determination and western blot analysis to determine the effect of HRS in LPS-induced septic rats. Rats treated with HRS showed decreased TNF-α and IL-1β expression levels. HRS treatment enhanced the activities of antioxidant enzymes (SOD, CAT and GPX) and decreased MDA and MPO activities. The number of MMP-9 and NLRP3 positive immunoreactivity cells decreased in the HRS-treated group. Subsequently, GFAP, IBA-1 and CD86 immunoreactivity were reduced, and CD206 increased after HRS treatment. 8-OHdG expression was decreased in the HRS-treated rats. Western blot analysis showed decreased NLRP3, ASC, caspase-1, MMP-2/9, TLR4 and Bax protein levels after HRS treatment, while Bcl-2 expression increased after HRS treatment. These data demonstrated that HRS attenuated neuroinflammation, NLRP3 inflammasome activation, neuronal injury, and mitochondrial damage via NLRP3/Caspase-1/TLR4 signalling in the juvenile rat model, making it a potential therapeutic agent in the treatment of paediatric SAE.
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Affiliation(s)
- John Sieh Dumbuya
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282 PR China
| | - Xinxin Chen
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282 PR China
| | - Jiang Du
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282 PR China
| | - Siqi Li
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282 PR China
| | - Lili Liang
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282 PR China
| | - Hairui Xie
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282 PR China.
| | - Qiyi Zeng
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282 PR China.
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Cheung C, Kernan KF, Berg RA, Zuppa AF, Notterman DA, Pollack MM, Wessel D, Meert KL, Hall MW, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Banks RK, Reeder RW, Holubkov R, Carcillo JA, Fink EL. Acute Disorders of Consciousness in Pediatric Severe Sepsis and Organ Failure: Secondary Analysis of the Multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study. Pediatr Crit Care Med 2023; 24:840-848. [PMID: 37314247 PMCID: PMC10719421 DOI: 10.1097/pcc.0000000000003300] [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: 06/15/2023]
Abstract
OBJECTIVES Acute disorders of consciousness (DoC) in pediatric severe sepsis are associated with increased risk of morbidity and mortality. We sought to examine the frequency of and factors associated with DoC in children with sepsis-induced organ failure. DESIGN Secondary analysis of the multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study (PHENOMS). SETTING Nine tertiary care PICUs in the United States. PATIENTS Children less than 18 years old admitted to a PICU with severe sepsis and at least one organ failure during a PICU stay. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was frequency of DoC, defined as Glasgow Coma Scale (GCS) less than 12 in the absence of sedatives during an ICU stay, among children with severe sepsis and the following: single organ failure, nonphenotypeable multiple organ failure (MOF), MOF with one of the PHENOMS phenotypes (immunoparalysis-associated MOF [IPMOF], sequential liver failure-associated MOF, thrombocytopenia-associated MOF), or MOF with multiple phenotypes. A multivariable logistic regression analysis was performed to evaluate the association between clinical variables and organ failure groups with DoC. Of 401 children studied, 71 (18%) presented with DoC. Children presenting with DoC were older (median 8 vs 5 yr; p = 0.023), had increased hospital mortality (21% vs 10%; p = 0.011), and more frequently presented with both any MOF (93% vs 71%; p < 0.001) and macrophage activation syndrome (14% vs 4%; p = 0.004). Among children with any MOF, those presenting with DoC most frequently had nonphenotypeable MOF and IPMOF (52% and 34%, respectively). In the multivariable analysis, older age (odds ratio, 1.07; 95% CI, 1.01-1.12) and any MOF (3.22 [1.19-8.70]) were associated with DoC. CONCLUSIONS One of every five children with severe sepsis and organ failure experienced acute DoC during their PICU stay. Preliminary findings suggest the need for prospective evaluation of DoC in children with sepsis and MOF.
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Affiliation(s)
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Athena F. Zuppa
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital, Washington, DC, USA
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital, Washington, DC, USA
| | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, USA
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - John C. Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI, USA
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI, USA
| | - Rick E. Harrison
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | | | | | | | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
| | - Ericka L. Fink
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
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Dumbuya JS, Li S, Liang L, Zeng Q. Paediatric sepsis-associated encephalopathy (SAE): a comprehensive review. Mol Med 2023; 29:27. [PMID: 36823611 PMCID: PMC9951490 DOI: 10.1186/s10020-023-00621-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/10/2023] [Indexed: 02/25/2023] Open
Abstract
Sepsis-associated encephalopathy (SAE) is one of the most common types of organ dysfunction without overt central nervous system (CNS) infection. It is associated with higher mortality, low quality of life, and long-term neurological sequelae, its mortality in patients diagnosed with sepsis, progressing to SAE, is 9% to 76%. The pathophysiology of SAE is still unknown, but its mechanisms are well elaborated, including oxidative stress, increased cytokines and proinflammatory factors levels, disturbances in the cerebral circulation, changes in blood-brain barrier permeability, injury to the brain's vascular endothelium, altered levels of neurotransmitters, changes in amino acid levels, dysfunction of cerebral microvascular cells, mitochondria dysfunction, activation of microglia and astrocytes, and neuronal death. The diagnosis of SAE involves excluding direct CNS infection or other types of encephalopathies, which might hinder its early detection and appropriate implementation of management protocols, especially in paediatric patients where only a few cases have been reported in the literature. The most commonly applied diagnostic tools include electroencephalography, neurological imaging, and biomarker detection. SAE treatment mainly focuses on managing underlying conditions and using antibiotics and supportive therapy. In contrast, sedative medication is used judiciously to treat those showing features such as agitation. The most widely used medication is dexmedetomidine which is neuroprotective by inhibiting neuronal apoptosis and reducing a sepsis-associated inflammatory response, resulting in improved short-term mortality and shorter time on a ventilator. Other agents, such as dexamethasone, melatonin, and magnesium, are also being explored in vivo and ex vivo with encouraging results. Managing modifiable factors associated with SAE is crucial in improving generalised neurological outcomes. From those mentioned above, there are still only a few experimentation models of paediatric SAE and its treatment strategies. Extrapolation of adult SAE models is challenging because of the evolving brain and technical complexity of the model being investigated. Here, we reviewed the current understanding of paediatric SAE, its pathophysiological mechanisms, diagnostic methods, therapeutic interventions, and potential emerging neuroprotective agents.
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Affiliation(s)
- John Sieh Dumbuya
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Siqi Li
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Lili Liang
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Qiyi Zeng
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282, People's Republic of China.
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Alcamo AM, Barren GJ, Becker AE, Hayes K, Fitzgerald JC, Balamuth F, Pennington JW, Curley MA, Tasker RC, Topjian AA, Weiss SL. Validation of a Computational Phenotype to Identify Acute Brain Dysfunction in Pediatric Sepsis. Pediatr Crit Care Med 2022; 23:1027-1036. [PMID: 36214585 PMCID: PMC9722537 DOI: 10.1097/pcc.0000000000003086] [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: 01/09/2023]
Abstract
OBJECTIVES To validate a computational phenotype that identifies acute brain dysfunction (ABD) based on clinician concern for neurologic or behavioral changes in pediatric sepsis. DESIGN Retrospective observational study. SETTING Single academic children's hospital. PATIENTS Four thousand two hundred eighty-nine index sepsis episodes. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS An existing computational phenotype of ABD was optimized to include routinely collected variables indicative of clinician concern for acute neurologic or behavioral change (completion of CT or MRI, electroencephalogram, or new antipsychotic administration). First, the computational phenotype was compared with an ABD reference standard established from chart review of 527 random sepsis episodes to determine criterion validity. Next, the computational phenotype was compared with a separate validation cohort of 3,762 index sepsis episodes to determine content and construct validity. Criterion validity for the final phenotype had sensitivity 83% (95% CI, 76-89%), specificity 93% (90-95%), positive predictive value 84% (77-89%), and negative predictive value 93% (90-96%). In the validation cohort, the computational phenotype identified ABD in 35% (95% CI 33-36%). Content validity was demonstrated as those with the ABD computational phenotype were more likely to have characteristics of neurologic dysfunction and severe illness than those without the ABD phenotype, including nonreactive pupils (15% vs 1%; p < 0.001), Glasgow Coma Scale less than 5 (44% vs 12%; p < 0.001), greater than or equal to two nonneurologic organ dysfunctions (50% vs 25%; p < 0.001), and need for intensive care (81% vs 65%; p < 0.001). Construct validity was demonstrated by higher odds for mortality (odds ratio [OR], 6.9; 95% CI, 5.3-9.1) and discharge to rehabilitation (OR, 11.4; 95% CI 7.4-17.5) in patients with, versus without, the ABD computational phenotype. CONCLUSIONS A computational phenotype of ABD indicative of clinician concern for new neurologic or behavioral change offers a valid retrospective measure to identify episodes of sepsis that involved ABD. This computational phenotype provides a feasible and efficient way to study risk factors for and outcomes from ABD using routinely collected clinical data.
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Affiliation(s)
- Alicia M. Alcamo
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Pediatric Sepsis Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gregory J. Barren
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Andrew E. Becker
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Katie Hayes
- Pediatric Sepsis Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julie C. Fitzgerald
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Pediatric Sepsis Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Fran Balamuth
- Pediatric Sepsis Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey W. Pennington
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Martha A.Q. Curley
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Family and Community Health, The University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Robert C. Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
- Selwyn College, Cambridge University, Cambridge, United Kingdom
| | - Alexis A. Topjian
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott L. Weiss
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Pediatric Sepsis Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Dumbuya JS, Li S, Liang L, Chen Y, Du J, Zeng Q. Effects of hydrogen-rich saline in neuroinflammation and mitochondrial dysfunction in rat model of sepsis-associated encephalopathy. J Transl Med 2022; 20:546. [DOI: 10.1186/s12967-022-03746-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/31/2022] [Indexed: 11/28/2022] Open
Abstract
Abstract
Background
Sepsis-associated encephalopathy (SAE) is one of the most common types of sepsis-related organ dysfunction without overt central nervous system (CNS) infection. It is associated with higher mortality, low quality of life, and long-term neurological sequelae in suspected patients. At present there is no specific treatment for SAE rather than supportive therapy and judicious use of antibiotics, which are sometimes associated with adverse effects. Molecular hydrogen (H2) has been reported to play crucial role in regulating inflammatory responses, neuronal injury, apoptosis and mitochondrial dysfunction in adult models of SAE. Here we report the protective effect of hydrogen-rich saline in juvenile SAE rat model and its possible underling mechanism(s).
Materials and methods
Rats were challenged with lipopolysaccharide (LPS) at a dose of 8 mg/kg injected intraperitoneally to induce sepsis and hydrogen-rich saline (HRS) administered 1 h following LPS induction at a dose of 5 ml/kg. Rats were divided into: sham, sham + HRS, LPS and LPS + HRS. At 48 h, rats were sacrificed and Nissl staining for neuronal injury, TUNEL assay for apoptotic cells detection, immunohistochemistry, and ELISA protocol for inflammatory cytokines determination, mitochondrial dysfunction parameters, electron microscopy and western blot analysis were studied to examine the effect of HRS in LPS-induced septic rats.
Results
Rats treated with HRS improved neuronal injury, improvement in rats’ survival rate. ELISA analysis showed decreased TNF-α and IL-1β and increased IL-10 expression levels in the HRS-treated group. Apoptotic cells were decreased after HRS administration in septic rats. The numbers of GFAP and IBA-1positive cells were attenuated in the HRS-treated group when compared to the LPS group. Subsequently, GFAP and IBA-1 immunoreactivity were decreased after HRS treatment. Mitochondrial membrane potential detected by JC-1 dye and ATP content were decreased in septic rats, which were improved after HRS treatment, while release of ROS was increased in the LPS group reverted by HRS treatment, ameliorating mitochondrial dysfunction. Further analysis by transmission electron microscopy showed decreased number of mitochondria and synapses, and disrupted mitochondrial membrane ultrastructure in the LPS group, while HRS administration increased mitochondria and synapses number.
Conclusion
These data demonstrated that HRS can improve survival rate, attenuate neuroinflammation, astrocyte and microglial activation, neuronal injury and mitochondrial dysfunction in juvenile SAE rat model, making it a potential therapeutic candidate in treating paediatric SAE.
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Carlton EF, Gebremariam A, Maddux AB, McNamara N, Barbaro RP, Cornell TT, Iwashyna TJ, Prosser LA, Zimmerman J, Weiss S, Prescott HC. New and Progressive Medical Conditions After Pediatric Sepsis Hospitalization Requiring Critical Care. JAMA Pediatr 2022; 176:e223554. [PMID: 36215045 PMCID: PMC9552050 DOI: 10.1001/jamapediatrics.2022.3554] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/20/2022] [Indexed: 12/15/2022]
Abstract
Importance Children commonly experience physical, cognitive, or emotional sequelae after sepsis. However, little is known about the development or progression of medical conditions after pediatric sepsis. Objective To quantify the development and progression of 4 common conditions in the 6 months after sepsis and to assess whether they differed after hospitalization for sepsis vs nonsepsis among critically ill children. Design, Setting, and Participants This cohort study of 101 511 children (<19 years) with sepsis or nonsepsis hospitalization used a national administrative claims database (January 1, 2010, to June 30, 2018). Data management and analysis were conducted from April 1, 2020, to July 7, 2022. Exposures Intensive care unit hospitalization for sepsis vs all-cause intensive care unit hospitalizations, excluding sepsis. Main Outcomes and Measures Primary outcomes were the development of 4 target conditions (chronic respiratory failure, seizure disorder, supplemental nutritional dependence, and chronic kidney disease) within 6 months of hospital discharge. Secondary outcomes were the progression of the 4 target conditions among children with the condition before hospitalization. Outcomes were identified via diagnostic and procedural codes, durable medical equipment codes, and prescription medications. Differences in the development and the progression of conditions between pediatric patients with sepsis and pediatric patients with nonsepsis who survived intensive care unit hospitalization were assessed using logistic regression with matching weights. Results A total of 5150 survivors of pediatric sepsis and 96 361 survivors of nonsepsis intensive care unit hospitalizations were identified; 2593 (50.3%) were female. The median age was 9.5 years (IQR, 3-15 years) in the sepsis cohort and 7 years (IQR, 2-13 years) in the nonsepsis cohort. Of the 5150 sepsis survivors, 670 (13.0%) developed a new target condition, and 385 of 1834 (21.0%) with a preexisting target condition had disease progression. A total of 998 of the 5150 survivors (19.4%) had development and/or progression of at least 1 condition. New conditions were more common among sepsis vs nonsepsis hospitalizations (new chronic respiratory failure: 4.6% vs 1.9%; odds ratio [OR], 2.54 [95% CI, 2.19-2.94]; new supplemental nutritional dependence: 7.9% vs 2.7%; OR, 3.17 [95% CI, 2.80-3.59]; and new chronic kidney disease: 1.1% vs 0.6%; OR, 1.65 [95% CI, 1.25-2.19]). New seizure disorder was less common (4.6% vs 6.0%; OR, 0.77 [95% CI, 0.66-0.89]). Progressive supplemental nutritional dependence was more common (1.5% vs 0.5%; OR, 2.95 [95% CI, 1.60-5.42]), progressive epilepsy was less common (33.7% vs 40.6%; OR, 0.74 [95% CI, 0.65-0.86]), and progressive respiratory failure (4.4% vs 3.3%; OR, 1.35 [95% CI, 0.89-2.04]) and progressive chronic kidney disease (7.9% vs 9.2%; OR, 0.84 [95% CI, 0.18-3.91]) were similar among survivors of sepsis vs nonsepsis admitted to an intensive care unit. Conclusions and Relevance In this national cohort of critically ill children who survived sepsis, 1 in 5 developed or had progression of a condition of interest after sepsis hospitalization, suggesting survivors of pediatric sepsis may benefit from structured follow-up to identify and treat new or worsening medical comorbid conditions.
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Affiliation(s)
- Erin F. Carlton
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Acham Gebremariam
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Aline B. Maddux
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora
| | - Nancy McNamara
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Ryan P. Barbaro
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Timothy T. Cornell
- Lucille Packard Children’s Hospital, Stanford University, Palo Alto, California
| | - Theodore J. Iwashyna
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Lisa A. Prosser
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Jerry Zimmerman
- Seattle Children’s Hospital, Harborview Medical Center, University of Washington School of Medicine, Seattle
| | - Scott Weiss
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Children’s Hospital of Philadelphia, Pediatric Sepsis Program, Philadelphia, Pennsylvania
| | - Hallie C. Prescott
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Michigan, Ann Arbor
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Becker AE, Teixeira SR, Lunig NA, Mondal A, Fitzgerald JC, Topjian AA, Weiss SL, Griffis H, Schramm SE, Traynor DM, Vossough A, Kirschen MP. Sepsis-Related Brain MRI Abnormalities Are Associated With Mortality and Poor Neurological Outcome in Pediatric Sepsis. Pediatr Neurol 2022; 128:1-8. [PMID: 34992035 PMCID: PMC9685598 DOI: 10.1016/j.pediatrneurol.2021.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 11/28/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND It is not known whether brain magnetic resonance imaging (MRI) abnormalities in pediatric sepsis are associated with clinical outcomes. Study objectives were to (1) determine the prevalence and type of sepsis-related neuroimaging abnormalities evident on clinically indicated brain MRI in children with sepsis and (2) test the association of these abnormalities with mortality, new disability, length of stay (LOS), and MRI indication. METHODS Retrospective cohort study of 140 pediatric patients with sepsis and a clinically indicated brain MRI obtained within 60 days of sepsis onset at a single, large academic pediatric intensive care unit (PICU). Two radiologists systematically reviewed the first post-sepsis brain MRI and determined which abnormalities were sepsis-related. Outcomes compared in patients with versus without sepsis-related MRI abnormalities. RESULTS PICU mortality was 7%. Thirty patients had one or more sepsis-related MRI abnormality, yielding a prevalence of 21% (95% confidence interval 15%, 28%). Among those, 53% (16 of 30) had sepsis-related white matter signal abnormalities; 53% (16 of 30) sepsis-related ischemia, infarction, or thrombosis; and 27% (eight of 30) sepsis-related posterior reversible encephalopathy. Patients with one or more sepsis-related MRI abnormality had increased mortality (17% vs 5%; P = 0.04), new neurological disability at PICU discharge (32% vs 11%; P = 0.03), and longer PICU LOS (median 18 vs 11 days; P = 0.04) compared with patients without. CONCLUSIONS In children with sepsis and a clinically indicated brain MRI, 21% had a sepsis-related MRI abnormality. Sepsis-related MRI abnormalities were associated with increased mortality, new neurological disability, and longer PICU LOS.
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Affiliation(s)
- Andrew E. Becker
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sara R. Teixeira
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Nicholas A. Lunig
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Antara Mondal
- Department of Biomedical & Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Julie C. Fitzgerald
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,CHOP Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Alexis A. Topjian
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Scott L. Weiss
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,CHOP Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Heather Griffis
- Department of Biomedical & Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Stephanie E. Schramm
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Danielle M. Traynor
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Arastoo Vossough
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthew P. Kirschen
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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8
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The authors reply. Pediatr Crit Care Med 2020; 21:925-926. [PMID: 33009315 DOI: 10.1097/pcc.0000000000002498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Madden K, Callif CG, Tasker RC. Exposure to Anticholinergic Medications in Pediatric Severe Sepsis and Feasibility of Delirium Screening. J Pediatr Intensive Care 2020; 9:271-276. [PMID: 33133743 DOI: 10.1055/s-0040-1712144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/17/2020] [Indexed: 10/24/2022] Open
Abstract
In sepsis, anticholinergic dysregulation may result in encephalopathy or delirium during severe illness, either as a result of central inflammation or because of exposure to medications with anticholinergic activity. In this retrospective study, we determined the magnitude of anticholinergic drug exposure in 75 children with severe sepsis. We found that exposure over the first 5 days was high-median (interquartile range) daily anticholinergic drug scale score 4 (2-5)-and associated with higher vasoactive scores and death. We conclude that anticholinergic drug exposure is significant in severe sepsis, which means it may be a modifiable factor that should be studied further.
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Affiliation(s)
- Kate Madden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Charles G Callif
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States.,Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, United States
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Huang L, Peng S, Li R, Xie D, Huang D. Fulminant encephalopathy in a child with hyperferritinemic sepsis: a case report. BMC Neurol 2020; 20:73. [PMID: 32122316 PMCID: PMC7053145 DOI: 10.1186/s12883-020-01661-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 02/26/2020] [Indexed: 02/06/2023] Open
Abstract
Background Sepsis-associated encephalopathy (SAE) is epidemic in intensive care units and recognized as a fatal complication of sepsis. SAE is characterized by diffuse brain dysfunction and the correct diagnosis of SAE requires ruling out direct central nervous system (CNS) infection or other types of encephalopathy, such as hepatic encephalopathy, pulmonary encephalopathy, and other encephalopathy. Case presentation We reported a rare case of a 5-year-old girl who presented with abdominal pain, vomiting, recurrent seizures, and coma. Brain magnetic resonance imaging (MRI) showed diffuse white matter abnormalities in the brain on day 1. Cerebrospinal fluid (CSF) tests revealed that protein levels and glucose levels were normal without pleocytosis. CSF PCRs for pathogens were all negative. The electroencephalography examination demonstrated diffuse, generalized and slow background activity. The patient showed the symptom of hyperferritinemic sepsis with multiple organ dysfunction syndrome (MODS). SAE was also diagnosed by ruling out other encephalitis or encephalopathy. The patient made marked improvements of clinical symptoms and the lesions on brain imaging disappeared completely within two months after appropriate treatment including antibiotic treatments, methylprednisolone, intravenous immunoglobulin, membrane-based therapeutic plasma exchange (TPE), and continuous renal replacement therapy (CRRT). Conclusions SAE can be a fatal complication of sepsis which asks for immediate diagnosis and treatment. Few reports have focus on MRI imaging findings on the early onset of hyperferritinemic sepsis with MODS since these children were too ill to undergo an MRI scan. However, SAE might appear before other systemic features of sepsis are obvious, and MRI could show abnormal lesion in the brain during the early course. Therefore, MRI should be performed early to diagnose this fatal complication which would play important roles in improving the clinical outcomes by early initiation with appropriate treatments.
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Affiliation(s)
- Lilin Huang
- Department of Pediatrics, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China.
| | - Shumei Peng
- Department of Pediatrics, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - Ronghan Li
- Department of Pediatrics, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - Danyu Xie
- Department of Pediatrics, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - Dongping Huang
- Department of Pediatrics, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
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Algebaly H, ElSherbini S, Galal A, Hamdi R, Baz A, Elbeleidy A. Transcranial Doppler Can Predict Development and Outcome of Sepsis-Associated Encephalopathy in Pediatrics With Severe Sepsis or Septic Shock. Front Pediatr 2020; 8:450. [PMID: 32974238 PMCID: PMC7468380 DOI: 10.3389/fped.2020.00450] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 06/29/2020] [Indexed: 12/04/2022] Open
Abstract
Background and Aim: Sepsis is a common cause of pediatric intensive care unit (ICU) admission. Sepsis-associated encephalopathy (SAE) may occur owing to brain dysfunction in those patients and may be related to impaired cerebral microcirculation. Transcranial Doppler (TCD) can be used to detect this impairment. In this study, we aimed to assess the role of TCD in prediction of SAE and mortality in patients with severe sepsis or septic shock admitted to PICU. Patients and Methods: This prospective study included 75 children admitted to PICU owing to severe sepsis or septic shock. Upon admission, all patients were subjected to careful history taking, thorough clinical examination, and standard laboratory workup. Severity of clinical illness was assessed using the Pediatric Risk of Mortality (PRISM) III score. TCD was performed on the first day of admission after the normalization of systolic blood pressure with or without vasopressors. The primary study outcome was differences in the measurement of TCD in SAE, and the secondary outcome was discharge from ICU or mortality. Results: The study comprised 45 children with SAE and 30 age- and sex-matched children without SAE. In this study, SAE patients had significantly higher pulsatility index [PI; median interquartile range (IQR): 1.15 (0.98-1.48) vs. 1.0 (0.95-1.06), p = 0.002] and resistive index [RI; median (IQR): 0.68 (0.61-0.77) vs. 0.62 (0.59-0.64), p = 0.001] than had non-SAE patients. PI and RI showed good performance as predictors of subsequent SAE development [area under the curve (AUC): 0.72 and 0.73, respectively]. Non-survivors in SAE patients had significantly higher PRISM III. Receiver operating characteristic (ROC) curve analysis showed good performance of PI and RI as predictors of mortality at the end of follow-up. Conclusions: In children with SAE, cerebrovascular resistance is high and is associated with increased mortality.
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Affiliation(s)
- HebatAllah Algebaly
- Pediatric Critical Care Unit, Department of Pediatrics, Cairo University, Cairo, Egypt
| | - Seham ElSherbini
- Pediatric Critical Care Unit, Department of Pediatrics, Cairo University, Cairo, Egypt
| | - Ahmed Galal
- Pediatric Critical Care Unit, Children's Cancer Hospital, Cairo University, Cairo, Egypt
| | - Rania Hamdi
- Pediatric Imaging Unit, Department of Radiology, Cairo University, Cairo, Egypt
| | - Ahmed Baz
- Pediatric Imaging Unit, Department of Radiology, Cairo University, Cairo, Egypt
| | - Ahmed Elbeleidy
- Pediatric Critical Care Unit, Department of Pediatrics, Cairo University, Cairo, Egypt
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Sanz D, D'Arco F, Robles CA, Brierley J. Incidence and pattern of brain lesions in paediatric septic shock patients. Br J Radiol 2018; 91:20170861. [PMID: 29293365 DOI: 10.1259/bjr.20170861] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Brain injury is frequently observed during septic shock and may be primarily related to the direct effects of the septic insult on the brain or to secondary/indirect injuries (e.g. hypotension, hypoxaemia and hyperglycaemia). We sought to assess incidence and pattern of brain lesions diagnosed by neuroimaging in paediatric septic shock patients. METHODS Retrospective descriptive hospital-based study included paediatric patients with a single episode of septic shock admitted to our tertiary paediatric intensive care unit from January 2010 to December 2013. RESULTS 49 of 193 septic shock patients had a neuroimaging examination [CT only 22 (45%), MRI only 14 (29%) and both 13 (27%)]. Neuroimaging was normal in 16 patients (33%) and showed acute lesions in 20 patients (40%). The most frequent findings were: cerebral infarcts/hypoxic ischaemic injury in 8 (16%) and cerebritis in 7 (14%). The incidence of acute brain lesion in our septic shock cohort was 10% (20 of 193). CONCLUSION The diagnosis of brain dysfunction in septic shock patients relies essentially on neurological examination and neurological tests, such as electroencephalography and neuroimaging. Neuroimaging can reveal acute intracerebral structural lesions and their reversibility, helping with management and prognosis. Advances in knowledge: Ischaemic lesions and cerebritis are the most common brain anomalies complicating paediatric septic shock.
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Affiliation(s)
- Debora Sanz
- 1 Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Trust , London , UK
| | - Felice D'Arco
- 2 Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Trust , London , UK
| | - Carlos Andres Robles
- 2 Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Trust , London , UK
| | - Joe Brierley
- 1 Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Trust , London , UK
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13
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Neuroimaging in Sepsis: Panacea or Pandora's Box? Pediatr Crit Care Med 2017; 18:716-717. [PMID: 28691959 DOI: 10.1097/pcc.0000000000001174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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