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Alcamo AM, Becker AE, Barren GJ, Hayes K, Pennington JW, Curley MAQ, Tasker RC, Balamuth F, Weiss SL, Fitzgerald JC, Topjian AA. Diagnostic Identification of Acute Brain Dysfunction in Pediatric Sepsis and Septic Shock in the Electronic Health Record: A Comparison of Four Definitions in a Reference Dataset. Pediatr Crit Care Med 2024:00130478-990000000-00343. [PMID: 38738953 DOI: 10.1097/pcc.0000000000003529] [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] [Indexed: 05/14/2024]
Abstract
OBJECTIVES Acute brain dysfunction (ABD) in pediatric sepsis has a prevalence of 20%, but can be difficult to identify. Our previously validated ABD computational phenotype (CPABD) used variables obtained from the electronic health record indicative of clinician concern for acute neurologic or behavioral change. We tested whether the CPABD has better diagnostic performance to identify confirmed ABD than other definitions using the Glasgow Coma Scale or delirium scores. DESIGN Diagnostic testing in a curated cohort of pediatric sepsis/septic shock patients. SETTING Quaternary freestanding children's hospital. SUBJECTS The test dataset comprised 527 children with sepsis/septic shock managed between 2011 and 2021 with a prevalence (pretest probability) of confirmed ABD of 30% (159/527). MEASUREMENTS AND MAIN RESULTS CPABD was based on use of neuroimaging, electroencephalogram, and/or administration of new antipsychotic medication. We compared the performance of the CPABD with three GCS/delirium-based definitions of ABD-Proulx et al, International Pediatric Sepsis Consensus Conference, and Pediatric Organ Dysfunction Information Update Mandate. The posttest probability of identifying ABD was highest in CPABD (0.84) compared with other definitions. CPABD also had the highest sensitivity (83%; 95% CI, 76-89%) and specificity (93%; 95% CI, 90-96%). The false discovery rate was lowest in CPABD (1-in-6) as was the false omission rate (1-in-14). Finally, the prevalence threshold for the definitions varied, with the CPABD being the definition closest to 20%. CONCLUSIONS In our curated dataset of pediatric sepsis/septic shock, CPABD had favorable characteristics to identify confirmed ABD compared with GCS/delirium-based definitions. The CPABD can be used to further study the impact of ABD in studies using large electronic health datasets.
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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, PA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Pediatric Sepsis Program, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Andrew E Becker
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Gregory J Barren
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Katie Hayes
- Pediatric Sepsis Program, The Children's Hospital of Philadelphia, Philadelphia, PA
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jeffrey W Pennington
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Martha A Q Curley
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Family and Community Health, The University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Selwyn College, Cambridge University, Cambridge, United Kingdom
| | - Fran Balamuth
- Pediatric Sepsis Program, The Children's Hospital of Philadelphia, Philadelphia, PA
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Scott L Weiss
- Division of Critical Care Medicine, Nemours Children's Hospital, Wilmington, DE
| | - Julie C Fitzgerald
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Pediatric Sepsis Program, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alexis A Topjian
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Clemens N, Wilson PM, Lipshaw MJ, Depinet H, Zhang Y, Eckerle M. Association between positive blood culture and clinical outcomes among children treated for sepsis in the emergency department. Am J Emerg Med 2024; 76:13-17. [PMID: 37972503 DOI: 10.1016/j.ajem.2023.10.045] [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: 06/01/2023] [Revised: 10/02/2023] [Accepted: 10/25/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE Among children treated for sepsis in a pediatric emergency department (ED), compare clinical features and outcomes between those with blood cultures positive versus negative for a bacterial pathogen. DESIGN Single-center retrospective cohort study. SETTING Pediatric emergency department (ED) at a quaternary pediatric care center. PATIENTS Children aged 0-18 years treated for sepsis defined by the Children's Hospital Association's Improving Pediatric Sepsis Outcomes (IPSO) definition. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed 1307 patients treated for sepsis during the study period, of which 117 (9.0%) had blood cultures positive for a bacterial pathogen. Of children with blood culture positive sepsis, 62 (53.0%) had organ dysfunction compared to 514 (43.2%) with culture negative sepsis (adjusted odds ratio 1.56, 95% confidence interval (CI) 1.04-2.34, adjusting for age, high risk medical conditions, and time to antibiotics). Children with blood culture positive sepsis had a larger base deficit, -4 vs -1 (p < 0.01), and higher procalcitonin, 3.84 vs 0.56 ng/mL (p < 0.01). CONCLUSIONS Children meeting the IPSO Sepsis definition with blood culture positive for a bacterial pathogen have higher rates of organ dysfunction than those who are culture negative, although our 9% rate of blood culture positivity is lower than previously cited literature from the pediatric intensive care unit.
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Affiliation(s)
- Nancy Clemens
- Division of Emergency Medicine, Division of Pediatrics, Geisinger Medical Center, Geisinger Commonwealth School of Medicine, 100 North Academy Ave, Danville, PA 17822, USA.
| | - Paria M Wilson
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, 3333 Burnett Ave, Cincinnati, OH 45229, USA
| | - Matthew J Lipshaw
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, 3333 Burnett Ave, Cincinnati, OH 45229, USA
| | - Holly Depinet
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, 3333 Burnett Ave, Cincinnati, OH 45229, USA
| | - Yin Zhang
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, 3333 Burnett Ave, Cincinnati, OH 45229, USA
| | - Michelle Eckerle
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, 3333 Burnett Ave, Cincinnati, OH 45229, USA
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Baker AH, Leland SB, Freiman E, Herigon JC, Eisenberg MA. Characteristics and Outcomes of Culture-Positive and Culture-Negative Pediatric Sepsis. J Pediatr 2023; 263:113718. [PMID: 37659590 DOI: 10.1016/j.jpeds.2023.113718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/21/2023] [Accepted: 08/29/2023] [Indexed: 09/04/2023]
Abstract
OBJECTIVES To compare the outcomes of pediatric severe sepsis and septic shock among patients with culture-positive and culture-negative sepsis and to determine if there are differentiating markers of disease severity between these 2 populations during their initial presentation and emergency department (ED) stay. STUDY DESIGN Retrospective cohort study of patients ≤21 years of age who presented to the ED of a single children's hospital with severe sepsis or septic shock from June 1, 2017 to June 5, 2019. RESULTS There were 235 patients who met criteria for severe sepsis or septic shock. Of these, 139 (59.1%) had culture-negative sepsis and 96 (40.9%) had culture-positive sepsis. In the adjusted multivariable model, children with culture-negative sepsis had more intensive care unit (ICU)-free days than those with culture-positive sepsis (27.3 vs 24.1; adjusted median differences [aMD] -2.6 [-4.4, -0.8]). There were no differences in mortality or hospital-free days. On initial presentation, there were no differences in fever, hypothermia, tachycardia, tachypnea, or hypotension between the 2 groups. There were no differences in proportion of patients receiving the following interventions: intravenous (IV) antibiotics, IV fluids, vasoactive medications, CPR, intubation, or time from arrival to provision of these interventions. CONCLUSIONS Culture-negative sepsis constitutes a substantial proportion of pediatric severe sepsis and septic shock. In this study, patients with culture-negative and culture-positive sepsis presented similarly on arrival to the ED and received similar treatments while there. Patients with culture-negative sepsis had more ICU-free days than those with culture-positive sepsis, although differences in hospital length of stay (LOS) and mortality were not observed.
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Affiliation(s)
- Alexandra H Baker
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA.
| | - Shannon B Leland
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Eli Freiman
- Department of Emergency Medicine, Newton Wellesley Hospital, Newton, MA
| | - Joshua C Herigon
- Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO; Department of Pediatrics, University of Missouri - Kansas City School of Medicine, University of Missouri, Kansas City, MO
| | - Matthew A Eisenberg
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA
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Kim DH, Park SJ, Jhang WK. Comparison of the clinical characteristics and clinical outcomes of culture-positive septic shock and culture-negative septic shock among pediatric patients. PLoS One 2023; 18:e0288615. [PMID: 37450547 PMCID: PMC10348532 DOI: 10.1371/journal.pone.0288615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVES Among pediatric patients with septic shock, culture-negative septic shock (CNSS) is common but there have been limited data on its clinical characteristics and prognosis. We compared the clinical characteristics and clinical outcomes between culture-positive septic shock (CPSS) and CNSS in pediatric patients. DESIGN Retrospective single-center study. SETTING Pediatric intensive care unit (PICU) of a tertiary referral hospital. PATIENTS All pediatric patients who were admitted to the PICU due to septic shock between January 2010 and November 2021, except for those with fungal or viral infections and those who expired on the day of admittance to the PICU. The primary outcome was 30-day mortality and in-hospital mortality. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 294 patients (CPSS group, n = 185 [62.9%]; CNSS group, n = 109 [37.1%]) were included. The rates of 30-day mortality and in-hospital mortality (30-day mortality 22.7% vs 22%, in-hospital mortality 29.7% vs 25.7%) were not significantly different between the CPSS group and the CNSS group. The two groups showed comparable results in clinical outcomes such as the requirement for mechanical ventilator and renal replacement therapy, PICU stay duration, and the duration of MV and vasopressor/inotrope support. Among the CPSS group, 98 (53%) patients who were infected with multi-drug resistance (MDR) bacteria had significantly higher rates of 30-day mortality and in-hospital mortality than those infected with non-MDR bacteria. CONCLUSIONS Among pediatric patients, the CPSS group and CNSS group did not show significant differences in clinical features and mortality. Among the CPSS group, those with MDR bacteria had poorer prognosis.
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Affiliation(s)
- Da Hyun Kim
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong Jong Park
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Kyoung Jhang
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
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Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113.,Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA.,Selwyn College, Cambridge University, Cambridge, United Kingdom
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