World Federation of Pediatric Intensive Care and Critical Care Societies: Global Sepsis Initiative

Modelling climate impacts on paediatric sepsis incidence and severity in Bangladesh

Background

Sepsis is a leading cause of paediatric mortality worldwide, disproportionately affecting children in low- and middle-income countries. The impacts of climate change on the burden and outcomes of sepsis in low- and middle-income countries, particularly in paediatric populations, remain poorly understood. We aimed to assess the associations between climate variables (temperature and precipitation) and paediatric sepsis incidence and mortality in Bangladesh, one of the countries most affected by climate change.

Methods

We conducted retrospective analyses of patient-level data from the International Centre for Diarrhoeal Disease Research, Bangladesh, and environmental data from the National Oceanic and Atmospheric Administration. Using random forests, we assessed associations between sepsis incidence and sepsis mortality with temperature and precipitation between 2009-22.

Results

A nonlinear relationship between temperature and sepsis incidence and mortality was identified. The lowest incidence occurred at an optimum temperature of 26.6°C with a gradual increase below and a sharp rise above this temperature. Higher precipitation levels showed a general trend of increased sepsis incidence. A similar distribution for sepsis mortality was identified with an optimum temperature of 28°C.

Conclusions

Findings suggest that environmental temperature and precipitation play a role in paediatric sepsis incidence and sepsis mortality in Bangladesh. As children are particularly vulnerable to climate impacts, it is important to consider climate change in health care planning and resource allocation, especially in resource-limited settings, to allow for surge capacity planning during warmer and wetter seasons. Further prospective research from more globally representative data sets will provide more robust evidence on the nature of the relationships between climate variables and paediatric sepsis worldwide.

Peripheral Veno-Arterial-Extracorporeal Membrane Oxygenation for Refractory Septic Shock in Children: A Multicenter Review

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is utilized as a rescue therapy in the management of pediatric patients with refractory septic shock. Multiple studies support the use of a central cannulation strategy in these patients. This study aimed to assess the survival of and identify mortality risk factors in pediatric patients supported with peripheral veno-arterial (VA) ECMO in the setting of septic shock.

METHODS

We retrospectively reviewed and compared clinical characteristics of 40 pediatric patients supported with peripheral VA ECMO for refractory septic shock, at two tertiary care children's hospitals from 2006 to 2020. Our hypothesis was that peripheral VA ECMO is effective in supporting cardiac function and improving tissue oxygenation in most pediatric patients with refractory septic shock.

RESULTS

The overall rate of survival to discharge was 52.5%, comparable to previously reported survival for pediatric sepsis on ECMO. With the exclusion of patients with an oncologic process, the survival rate rose to 62.5%. There was a statistically significant difference in mean pump flow rates within 2 hours of initiation of ECMO between survivors and non-survivors (98 mL/kg/min vs 76 mL/kg/min, P  =  .050). There was no significant difference between pre-ECMO vasoactive inotropic score (VIS) in survivors and non-survivors. A faster decrease in VIS in the first 24 hours was associated with lower mortality.

CONCLUSIONS

From this large case series, we conclude that peripheral VA ECMO is a safe and effective modality to support pediatric patients with refractory septic shock, provided there is establishment of high ECMO pump flows in the first few hours after cannulation and improvement in the VIS.

The evolving value of older biomarkers in the clinical diagnosis of pediatric sepsis

Sepsis remains the leading cause of childhood mortality worldwide. The evolving definition of pediatric sepsis is extrapolated from adult studies. Although lacking formal validation in the pediatric population, this working definition has historically proven its clinical utility. Prompt identification of pediatric sepsis is challenging as clinical picture is often variable. Timely intervention is crucial for optimal outcome, thus biomarkers are utilized to aid in immediate, yet judicious, diagnosis of sepsis. Over time, their use in sepsis has expanded with discovery of newer biomarkers that include genomic bio-signatures. Despite recent scientific advances, there is no biomarker that can accurately diagnose sepsis. Furthermore, older biomarkers are readily available in most institutions while newer biomarkers are not. Hence, the latter's clinical value in pediatric sepsis remains theoretical. Albeit promising, scarce data on newer biomarkers have been extracted from research settings making their clinical value unclear. As interest in newer biomarkers continue to proliferate despite their ambiguous clinical use, the literature on older biomarkers in clinical settings continue to diminish. Thus, revisiting the evolving value of these earliest biomarkers in optimizing pediatric sepsis diagnosis is warranted. This review focuses on the four most readily available biomarkers to bedside clinicians in diagnosing pediatric sepsis. IMPACT: The definition of pediatric sepsis remains an extrapolation from adult studies. Older biomarkers that include C-reactive protein, procalcitonin, ferritin, and lactate are the most readily available biomarkers in most pediatric institutions to aid in the diagnosis of pediatric sepsis. Older biomarkers, although in varying levels of reliability, remain to be useful clinical adjuncts in the diagnosis of pediatric sepsis if used in the appropriate clinical context. C-reactive protein and procalcitonin are more sensitive and specific among these older biomarkers in diagnosing pediatric sepsis although evidence varies in different age groups and clinical scenarios.

A Study to Compare Ultrasound-guided and Clinically Guided Fluid Management in Children with Septic Shock

Background

To evaluate the role of ultrasound during initial fluid resuscitation along with clinical guidance in reducing the incidence of fluid overload on day 3 in children with septic shock.

Materials and methods

It was a prospective, parallel limb open-labeled randomized controlled superiority trial done in the PICU of a government-aided tertiary care hospital in Eastern India. Patient enrolment took place between June 2021 and March 2022. Fifty-six children aged between 1 month and 12 years, with proven or suspected septic shock, were randomized to receive either ultrasound-guided or clinically guided fluid boluses (1:1 ratio) and subsequently followed up for various outcomes. The primary outcome was frequency of fluid overload on day 3 of admission. The treatment group received ultrasound-guided fluid boluses along with the clinical guidance and the control group received the same but without ultrasound guidance upto 60 mL/kg of fluid boluses.

Results

The frequency of fluid overload on day 3 of admission was significantly lower in the ultrasound group (25% vs 62%, p = 0.012) as was the median (IQR) cumulative fluid balance percentage on day 3 [6.5 (3.3-10.3) vs 11.3 (5.4-17.5), p = 0.02]. The amount of fluid bolus administered was also significantly lower by ultrasound [median 40 (30-50) vs 50 (40-80) mL/kg, p = 0.003]. Resuscitation time was shorter in the ultrasound group (13.4 ± 5.6 vs 20.5 ± 8 h, p = 0.002).

Conclusion

Ultrasound-guided fluid boluses were found to be significantly better than clinically guided therapy, in preventing fluid overload and its associated complications in children with septic shock. These factors make ultrasound a potentially useful tool for resuscitation of children with septic shock in the PICU.

How to cite this article

Kaiser RS, Sarkar M, Raut SK, Mahapatra MK, Uz Zaman MA, Roy O, et al. A Study to Compare Ultrasound-guided and Clinically Guided Fluid Management in Children with Septic Shock. Indian J Crit Care Med 2023;27(2):139-146.

Sepsis in Children in Latin America: Gaps, Inequities, and Improvement Strategies

ABSTRACT

Pediatric sepsis is a worldwide public health issue because of its high mortality rate, which increases even more in low-income countries. In this article, we review the Latin American background, the burdens of pediatric sepsis in Latin America, and the Caribbean, as well as some strategies that could help improve the outcomes of sepsis in these regions from a public health view.

Outcomes of Single-Dose Empirical Antibiotic Treatment in Children With Suspected Sepsis Implemented in the Emergency Department

OBJECTIVES

Implementing a single-dose empirical antibiotic (SDEA) strategy at the emergency department (ED) in children with suspected sepsis may improve outcomes. We aim to evaluate the outcomes of the SDEA strategy for children with suspected sepsis at the ED in a tertiary care center in Bangkok.

METHODS

Children who met the predefined checklist screening criteria for suspected sepsis were administered single-dose intravenous cefotaxime 100 mg/kg, or meropenem 40 mg/kg if they were immunocompromised or recently hospitalized. The medical records of children diagnosed with sepsis and septic shock caused by bacterial or organ-associated bacterial infections before and after implementation of the SDEA strategy were reviewed.

RESULTS

A total of 126 children with sepsis before and 127 after implementation of the SDEA strategy were included in the analysis. The time from hospital arrival to antibiotic initiation was significantly reduced after implementation of the SDEA strategy: median, 241 (110-363) minutes before versus 89 (62-132) minutes after ( P < 0.001), with an increased number of patients starting antibiotics within 3 hours of hospital arrival: 42.1% vs 85.0% ( P < 0.001). Comparing before and after SDEA implementation, children receiving SDEA had a shorter median duration of antibiotic therapy: 7 (5-13.3) versus 5 (3-7) days ( P = 0.001), shorter length of hospital stay: 10 (6-16.3) versus 7 (4-11) days ( P = 0.001), and fewer intensive care unit admissions: 30 (23.8%) versus 17 (13.4%; P = 0.036); however, mortality was not different: 3 (2.4%) in both groups. In multivariate analysis, SDEA strategy was the independent factor associated with reduced intensive care unit admission or death. Adherence to SDEA was 91.4%. Single-dose empirical antibiotic was retrospectively considered not necessary for 22 children (11.9%), mostly diagnosed with viral infections afterward.

CONCLUSIONS

Single-dose empirical antibiotic at the ED is an effective strategy to reduce the time from hospital arrival to antibiotic initiation and can help improve outcomes of sepsis in children.

Prevalence of Cardiac Dysfunction in Malawian Children With Severe Febrile Illness

OBJECTIVES

To investigate the prevalence of left ventricular systolic dysfunction (LVSD) in Malawian children with severe febrile illness and to explore associations between LVSD and mortality and lactate levels.

DESIGN

Prospective observational study.

SETTING

Pediatric ward of a tertiary government referral hospital in Malawi.

PATIENTS

Children between 60 days and 10 years old with severe febrile illness (fever with at least one sign of impaired perfusion plus altered mentation or respiratory distress) were enrolled at admission from October 2017 to February 2018.

INTERVENTIONS

Focused cardiac ultrasound (FoCUS) was performed, and serum lactate was measured for each child at enrollment, with repeat FoCUS the following day. LV systolic function was later categorized as normal, reduced, severely reduced, or hyperdynamic by two pediatric cardiologists blinded to clinical course and outcomes.

MEASUREMENTS AND MAIN RESULTS

Fifty-four children were enrolled. LVSD was present in 14 children (25.9%; 95% CI, 15.4-40.3%), of whom three had severely reduced function. Thirty patients (60%) had a lactate greater than 2.5 mmol/L, of which 20 (40%) were markedly elevated (>5 mmol/L). Ten children died during admission (18.5%). Of children who survived, 22.7% had decreased LV systolic function versus 40% of those who died. Dysfunction was not associated with mortality or elevated lactate.

CONCLUSIONS

Cardiac dysfunction may be present in one in four Malawian children with severe febrile illness, and mortality in these patients is especially high. Larger studies are needed to further clarify the role cardiac dysfunction plays in mortality and integrate practical bedside assessments for decision support around individualized resuscitation strategies.

Is this as good as it gets? Implications of an asymptotic mortality decline and approaching the nadir in pediatric intensive care

Despite advances in medicine, some children will always die; a decline in pediatric intensive care unit (PICU) mortality to zero will never be achieved. The mortality decline is correspondingly asymptotic, yet we remain preoccupied with mortality outcomes. Are we at the nadir, and are we, thus, as good as we can get? And what should we focus to benchmark our units, if not mortality? In the face of changing case-mix and rising complexity, dramatic reductions in PICU mortality have been observed globally. At the same time, survivors have increasing disability, and deaths are often characterized by intensive life-sustaining therapies preceded by prolonged admissions, emphasizing the need to consider alternate outcome measures to evaluate our successes and failures. What are the costs and implications of reaching this nadir in mortality outcomes? We highlight the failings of our fixation with survival and an imperative to consider alternative outcomes in our PICUs, including the costs for both patients that survive and die, their families, healthcare providers, and society including perspectives in low resource settings. We describe the implications for benchmarking, research, and training the next generation of providers.Conlusion: Although survival remains a highly relevant metric, as PICUs continue to strive for clinical excellence, pushing boundaries in research and innovation, with endeavors in safety, quality, and high-reliability systems, we must prioritize outcomes beyond mortality, evaluate "costs" beyond economics, and find novel ways to improve the care we provide to all of our pediatric patients and their families. What is Known: • The fall in PICU mortality is asymptotic, and a decline to zero is not achievable. Approaching the nadir, we challenge readers to consider implications of focusing on medical and technological advances with survival as the sole outcome of interest. What is New: • Our fixation with survival has costs for patients, families, staff, and society. In the changing PICU landscape, we advocate to pivot towards alternate outcome metrics. • By considering the implications for benchmarking, research, and training, we may better care for patients and families, educate trainees, and expand what it means to succeed in the PICU.

Comparing the precision of the pSOFA and SIRS scores in predicting sepsis-related deaths among hospitalized children: a multi-center retrospective cohort study

BACKGROUND

The latest sepsis definition includes both infection and organ failure, as evidenced by the sequential organ failure assessment (SOFA) score. However, the applicability of the pediatric SOFA score (pSOFA) is not yet determined. This study evaluated the effectiveness of both pSOFA and system inflammatory reaction syndrome (SIRS) scores in predicting sepsis-related pediatric deaths.

METHODS

This is a retrospective multi-center cohort study including hospitalized patients <18 years old with diagnosed or not-yet-diagnosed infections. Multivariate analyses were carried out to evaluate risk factors for in-hospital mortality. According to Youden index (YI), three sub-categories of pSOFA were screened out and a new simplified pSOFA score (spSOFA) was formed. The effectiveness and accuracy of prediction of pSOFA, SIRS and spSOFA was retrieved from the area under the receiver operating characteristic curve (AUROC) and Delong's test.

RESULTS

A total of 1,092 participants were eligible for this study, and carried a 23.4% in-hospital mortality rate. The 24-h elevated pSOFA score (24 h-pSOFA), bloodstream infection, and mechanical ventilation (MV) requirement were major risk factors associated with sepsis-related deaths. The AUROC analysis confirmed that the spSOFA provided good predictive capability in sepsis-related pediatric deaths, relative to the 24 h-pSOFA and SIRS.

CONCLUSIONS

The pSOFA score performed better than SIRS in diagnosing infected children with high mortality risk. However, it is both costly and cumbersome. We, therefore, proposed spSOFA to accurately predict patient outcome, without the disadvantages. Nevertheless, additional investigations, involving a large sample population, are warranted to confirm the conclusion of this study.

How Are Clinicians Treating Children With Sepsis in Emergency Departments in Latin America?: An International Multicenter Survey

OBJECTIVE

Guidelines adherence in emergency departments (EDs) relies partly on the availability of resources to improve sepsis care and outcomes. Our objective was to assess the management of pediatric septic shock (PSS) in Latin America's EDs and to determine the impact of treatment coordinated by a pediatric emergency specialist (PEMS) versus nonpediatric emergency specialists (NPEMS) on guidelines adherence.

METHODS

Prospective, descriptive, and multicenter study using an electronic survey administered to PEMS and NPEMS who treat PSS in EDs in 14 Latin American countries.

RESULTS

We distributed 2164 surveys with a response rate of 41.5%, of which 22.5% were PEMS. Overall American College of Critical Care Medicine reported guidelines adherence was as follows: vascular access obtained in 5 minutes, 76%; fluid infusion technique, 60%; administering 40 to 60 mL/kg within 30 minutes, 32%; inotropic infusion by peripheral route, 61%; dopamine or epinephrine in cold shock, 80%; norepinephrine in warm shock, 57%; and antibiotics within 60 minutes, 82%. Between PEMS and NPEMS, the following differences were found: vascular access in 5 minutes, 87.1% versus 72.7% (P < 0.01); fluid infusion technique, 72.3% versus 55.9% (P < 0.01); administering 40 to 60 mL/kg within 30 minutes, 42% versus 29% (P < 0.01); inotropic infusion by peripheral route, 75.7% versus 56.3% (P < 0.01); dopamine or epinephrine in cold shock, 87.1% versus 77.3% (P < 0.05); norepinephrine in warm shock, 67.8% versus 54% (P < 0.01); and antibiotic administration within first 60 minutes, 90.1% versus 79.3% (P < 0.01), respectively. Good adherence criteria were followed by 24%. The main referred barrier for sepsis care was a failure in its recognition, including the lack of triage tools.

CONCLUSIONS

In some Latin American countries, there is variability in self-reported adherence to the evidence-based recommendations for the treatment of PSS during the first hour. The coordination by PEMS support greater adherence to these recommendations.

Microbial contamination of the hands of healthcare providers in the operating theatre of a central hospital

Background

Effort is invested in maintaining the sterility of the operating field, but less attention is paid to potential healthcare associated infection (HAI) sources through patient contact with non-scrubbed healthcare providers (HCPs). A single microbiological assessment of hands can provide a good assessment of the potential dynamic transmission of microorganisms. The aim of this study was to identify and quantify the microbial growth on the hands of HCPs in the operating theatres of Chris Hani Baragwanath Academic Hospital.

Methods

A prospective, contextual and descriptive study design was followed. Seventy-five samples were collected using convenience sampling from an equal number of surgeons, anaesthetists and nurses. Specimens were taken using agar plates and underwent semi-quantitative analysis.

Results

All the hands of the HCPs displayed growth; 95% grew commensals and 64% grew pathogens. Eighteen commensal microorganisms and 21 pathological microorganisms were noted. Comparisons of commensal, pathological and combined levels of contamination among the three groups were not statistically significant (p = 0.061, p = 0.481, p = 0.236). No significant difference between the growth of combined microorganisms (p = 0.634) and pathological microorganisms (p = 0.499) among the groups. Surgeons had significantly more commensal growth (p = 0.041). There was no statistically significant difference between sexes (p = 0.290).

Conclusion

It was concerning that 100% of the hands of HCPs who were about to commence with the surgical list had microbial growth. These HCPs could have already been in contact with patients and equipment in the theatre environment.

Can acute-phase response biomarkers differentiate infection from inflammation postpediatric cardiac surgery?

Background:

Infection is a common serious complication postpediatric cardiac surgery. Diagnosis of infection after cardiopulmonary bypass (CPB) is difficult in the presence of surgical stress, hemodynamic instability, and inflammatory reaction.

Aim:

The purpose of this study is to investigate the value of available inflammatory biomarkers and its validity to differentiate infection from inflammation postpediatric cardiac surgery and to find the trend and the change in the level of these biomarkers shortly after cardiac surgery.

Methods:

We conducted a prospective study that included all children who underwent cardiac surgery in Prince Sultan Cardiac Centre-Qassim from November 2013 to October 2015. C-reactive protein, erythrocyte sedimentation rate, white blood cell count, and neutrophil count were measured for all patients presurgery, 4 consecutive days postsurgery, and predischarge. Patients were divided into two groups (the infected and the noninfected group). We compared the level of biomarkers between both groups. Then, we further analyzed the effects of CPB and preoperative steroid on postoperative inflammatory biomarker levels. Collected data were then reviewed and analyzed.

Results:

There were 134 pediatric cardiac patients included during the study period. Group 1 (bacterial negative culture group) had 125 cases and Group 2 (bacterial positive culture group) had nine cases. We found no statistically significant difference in inflammatory biomarker elevation between both groups. Only Group 2 had higher (RACHS) Risk adjustment for congenital heart surgery score, more ventilator days, and more drop in platelet count on the 2^nd and 3^rd postoperative days in comparison with the noninfected group 1. Both groups of patients who were in on and off CPB had the same level of inflammatory biomarkers with no significant differences. Giving corticosteroid preoperatively did not affect the trend of biomarker elevation and made no difference when it was compared to the group of patients who did not receive corticosteroid before surgery.

Conclusion:

Common inflammatory biomarkers cannot differentiate between infection and inflammation within the first 5 days postpediatric cardiac surgery as these reflect the inflammatory process rather than infection. Trend is more important than single reading.

Delayed Presentation and Mortality in Children With Sepsis in a Public Tertiary Care Hospital in Tanzania

Background: Over 40% of the global burden of sepsis occurs in children under 5 years of age, making pediatric sepsis the top cause of death for this age group. Prior studies have shown that outcomes in children with sepsis improve by minimizing the time between symptom onset and treatment. This is a challenge in resource-limited settings where access to definitive care is limited. Methods: A secondary analysis was performed on data from 1,803 patients (28 days-14 years old) who presented to the emergency department (ED) at Muhimbili National Hospital (MNH) from July 1, 2016 to June 30, 2017 with a suspected infection and ≥2 clinical systemic inflammatory response syndrome criteria. The objective of this study was to determine the relationship between delayed presentation to definitive care (>48 h between fever onset and presentation to the ED) and mortality, as well as the association between socioeconomic status (SES) and delayed presentation. Multivariable logistic regression models tested the two relationships of interest. We report both unadjusted and adjusted odds ratios and 95% confidence intervals. Results: During the study period, 11.3% (n = 203) of children who presented to MNH with sepsis died inhospital. Delayed presentation was more common in non-survivors (n = 90/151, 60%) compared to survivors (n = 614/1,353, 45%) (p ≤ 0.01). Children who had delayed presentation to definitive care, compared to those who did not, had an adjusted odds ratio for mortality of 1.85 (95% CI: 1.17-3.00). Conclusions: Delayed presentation was an independent risk factor for mortality in this cohort, emphasizing the importance of timely presentation to care for pediatric sepsis patients. Potential interventions include more efficient referral networks and emergency transportation systems to MNH. Additional clinics or hospitals with pediatric critical care may reduce pediatric sepsis mortality in Tanzania, as well as parental education programs for recognizing pediatric sepsis.

l. Arifeen S, Wall SN. Managing possible serious bacterial infection of young infants where referral is not possible: Lessons from the early implementation experience in Kushtia District learning laboratory, Bangladesh

BACKGROUND

Serious infections account for 25% of global newborn deaths annually, most in low-resource settings where hospital-based treatment is not accessible or feasible. In Bangladesh, one-third of neonatal deaths are attributable to serious infection; in 2014, the government adopted new policy for outpatient management of danger signs indicating possible serious bacterial infections (PSBI) when referral was not possible. We conducted implementation research to understand what it takes for a district health team to implement quality outpatient PSBI management per national guidelines.

METHODS

PSBI management was introduced as part of the Comprehensive Newborn Care Package in 2015. The study piloted this package through government health systems with limited partner support to inform scale-up efforts. Data collection included facility register reviews for cases seen at primary level facilities; facility readiness and provider knowledge and skills assessments; household surveys capturing caregiver knowledge of newborn danger signs and care-seeking for newborn illness; and follow-up case tracking, capturing treatment adherence and outcomes. Analysis consisted of descriptive statistics.

RESULTS

Over the 15-month implementation period, 1432 young infants received care, of which 649 (45%) were classified as PSBI. Estimated coverage of care-seeking increased from 22% to 42% during the implementation period. Although facility readiness and providers' skills increased, providers' adherence to guidelines was not optimal. Among locally managed PSBI cases, 75% completed the oral antibiotic course and 15% received the fourth day follow-up. Care-seeking remained high among private providers (95%), predominantly village health doctors (over 80%).

CONCLUSIONS

Facility readiness, including health care provider knowledge and skills were strengthened; future efforts should focus on improving provider adherence to guidelines. Social and behavior change strategies targeting families and communities should explore shifting care-seeking from private, possibly less-qualified providers. Strategies to improve private sector management of PSBI cases and improved linkages between private and public sector providers could be explored.

Septic shock in pediatrics: the state-of-the-art

OBJECTIVE

Review the main aspects of the definition, diagnosis, and management of pediatric patients with sepsis and septic shock.

SOURCE OF DATA

A search was carried out in the MEDLINE and Embase databases. The articles were chosen according to the authors' interest, prioritizing those published in the last five years.

SYNTHESIS OF DATA

Sepsis remains a major cause of mortality in pediatric patients. The variability of clinical presentations makes it difficult to attain a precise definition in pediatrics. Airway stabilization with adequate oxygenation and ventilation if necessary, initial volume resuscitation, antibiotic administration, and cardiovascular support are the basis of sepsis treatment. In resource-poor settings, attention should be paid to the risks of fluid overload when administrating fluids. Administration of vasoactive drugs such as epinephrine or norepinephrine is necessary in the absence of volume response within the first hour. Follow-up of shock treatment should adhere to targets such as restoring vital and clinical signs of shock and controlling the focus of infection. A multimodal evaluation with bedside ultrasound for management after the first hours is recommended. In refractory shock, attention should be given to situations such as cardiac tamponade, hypothyroidism, adrenal insufficiency, abdominal catastrophe, and focus of uncontrolled infection.

CONCLUSIONS

The implementation of protocols and advanced technologies have reduced sepsis mortality. In resource-poor settings, good practices such as early sepsis identification, antibiotic administration, and careful fluid infusion are the cornerstones of sepsis management.

Epidemiology of Pediatric Severe Sepsis in Main PICU Centers in Southwest China

OBJECTIVES

To estimate the prevalence, management, and outcomes of pediatric severe sepsis in the main PICUs in Southwest China.

DESIGN

A prospective, observational, and multicenter study.

SETTING

Eight PICUs in Southwest China with 19 (13-24) beds and 1,322 (1,066-1,452) annual admissions each.

PATIENTS

A total of 10,598 patients (29 d to 18 yr old) were consecutively admitted between September 1, 2016, and August 31, 2017. All patients were screened and evaluated for severe sepsis or septic shock. Of them, 10,353 patients were excluded due to incomplete data or not meeting the consensus criteria for severe sepsis or septic shock; 245 patients were included with complete data.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Finally, 245 patients who were diagnosed with severe sepsis or septic shock were included in the study, with an incidence rate of 2.3%. Of them, 64.0% of the enrolled patients were male with 80.8% being less than 5 years old and 60.8% being from rural areas. The respiratory system was the most common organ system in which dysfunction was observed (76.7%) as well as the most frequently infected site (37.6%). The primary therapies were antibiotics (99.0%), immunoglobulin (88.3%), mechanical ventilation (78.4%), vasoactive infusions (59.6%), and corticosteroids (46.1%). Among the 188 patients who had respiratory dysfunction, 173(92%) required mechanical ventilation and 39 (20.7%) met the criteria for pediatric acute respiratory distress syndrome. Seven of the patients with pediatric acute respiratory distress syndrome died (7/39, 17.9%). The median durations for mechanical ventilation and vasoactive medications were 123.5 hours (35.25-226.00 hr) and 2 days (1-5 d), respectively. Eighty-six percent of patients had multiple organ dysfunction syndrome at the point at which severe sepsis was recognized, and 31% had underlying conditions. The hospital mortality rate was 18.8%.

CONCLUSIONS

This report is the first to present the prevalence, treatment, and outcomes of pediatric severe sepsis in the main PICU centers in Southwest China. The mortality rate remains high; therefore, improved clinical management and implementation of large-scale clinical trials are necessary to improve early diagnoses and treatment.

Diagnostic and prognostic significance of serum miRNA-146-a expression in Egyptian children with sepsis in a pediatric intensive care unit

BACKGROUND

Previous studies have suggested a strong genetic effect on sepsis pathogenesis. The present study aimed to investigate the role of miRNA-146-a expression in pediatric sepsis.

METHODS

The study included 55 pediatric sepsis patients and 60 control children of the same age and sex. Serum miRNA-146-a expression was measured using a quantitative real-time polymerase chain reaction. C-reactive protein, interleukin-6, tumor necrosis factor-α and procalcitonin levels were measured by an enzyme-linked immunosorbent assay. The outcome of the pediatric sepsis group was determined at 28 days of follow up.

RESULTS

The results obtained revealed that serum miRNA-146-a levels were significantly decreased in sepsis group compared to the control group. Serum level of miRNA-146a correlated with sepsis severity, with the pediatric septic shock group having the lowest level, followed by the severe sepsis and sepsis groups. The miRNA-146-a level could indicate sepsis (area under curve = 0.803). Serum miRNA-146-a expression was negatively associated with C-reactive protein, pro-calcitonin, interleukin-6 and tumor necrosis factor-α. Patients with miRNA-146-a at a level lower than 0.4 had an increased mortality rate.

CONCLUSIONS

miRNA-146-a is of significant diagnostic and prognostic value in pediatric sepsis and could be used for planning therapeutic strategies.

The Protective Effects of Protease Inhibitor MG-132 on Sepsis-Induced Acute Lung Rats and Its Possible Mechanisms

Background

The aim of the present study was to investigate the protective effects of protease inhibitor MG-132 on sepsis-induced acute lung injury rats.

Material/Methods

Sprague Dawley rats were employed to induce sepsis by cecal ligation and puncture (CLP) method. Rats were divided into 4 groups: control, sham, model (CLP), and MG-132. Histopathology observation was detected by hematoxylin and eosin staining. The ratio of wet lung to dry lung (W/D) was calculated. In addition, the levels of inflammatory factors in bronchoalveolar lavage fluid (BALF) were measured by enzyme-linked immunosorbent assay (ELISA). Also, superoxide dismutase (SOD) and malondialdehyde (MDA) levels were evaluated. Western blotting was performed to measure the expression of hypoxia-inducible factor-1 α (HIF-1α). In order to assess the role of HIF-1α, YC-1, the inhibitor of HIF-1α, was used to treat the rats. The expression of phosphor-mTOR (p-mTOR), p-4EBP1, and p-EIF4E were evaluated by western blotting.

Results

Obvious pathological injury and increasing ratio of W/D in the model group were observed. Both pathological injury and W/D were improved in the MG-132 group, and the greatest improvement could be seen in the YC-1+MG-132 group. Furthermore, the MDA levels in the MG-132 group was decreased, accompanied by an increase in SOD levels. The level of HIF-1α was increased in the model group while a decreased was detected in the MG-132 group. The levels of inflammatory factors were high in the model group, whereas the opposite result was found in the MG-132 group, and the lowest in were in the YC-1+MG-132 group. Furthermore, the expression levels of p-mTOR, p-4EBP1, and p-EIF4E proteins were downregulated in the MG-132 group compared to the model group, and the lowest was in the YC-1+MG-132 group.

Conclusions

Our study suggested that MG-132 was able to protect against acute lung injury via inhibition of HIF-1α mediated mTOR/4EBP1/EIF4E pathway.

Adaptable Xerogel-Layered Amperometric Biosensor Platforms on Wire Electrodes for Clinically Relevant Measurements

Biosensing strategies that employ readily adaptable materials for different analytes, can be miniaturized into needle electrode form, and function in bodily fluids represent a significant step toward the development of clinically relevant in vitro and in vivo sensors. In this work, a general scheme for 1st generation amperometric biosensors involving layer-by-layer electrode modification with enzyme-doped xerogels, electrochemically-deposited polymer, and polyurethane semi-permeable membranes is shown to achieve these goals. With minor modifications to these materials, sensors representing potential point-of-care medical tools are demonstrated to be sensitive and selective for a number of conditions. The potential for bedside measurements or continuous monitoring of analytes may offer faster and more accurate clinical diagnoses for diseases such as diabetes (glucose), preeclampsia (uric acid), galactosemia (galactose), xanthinuria (xanthine), and sepsis (lactate). For the specific diagnostic application, the sensing schemes have been miniaturized to wire electrodes and/or demonstrated as functional in synthetic urine or blood serum. Signal enhancement through the incorporation of platinum nanoparticle film in the scheme offers additional design control within the sensing scheme. The presented sensing strategy has the potential to be applied to any disease that has a related biomolecule and corresponding oxidase enzyme and represents rare, adaptable, sensing capabilities.

Development of a computerized paediatric intensive care unit septic shock pathway: improving user experience

The purpose of this study was to understand the user experience with a computerized septic shock protocol relative to the workflow of Paediatric Intensive Care Unit clinicians. The need for data-driven, condition-specific, computerized protocols in the intensive care unit helps improve decision-making at the bedside. PICU clinicians were interviewed and given pre-and post-implementation surveys asking their opinions on the current PICU septic shock protocol, as well as the current electronic health record being used at [Paediatric Academic Medical Center]. User preferences guided adjustments toward improved usability of the septic shock protocol. Computerized Physician Order Entry, a critical component of the septic shock protocol, allows for more streamlined processes, more complete records, and more time to care for patients. This study revealed that although clinicians had an unfavorable view of the EHR in general, the computerized septic shock protocol was very well-received with an overall usability score of 82.

Assessing the causes of under-five mortality and proportion associated with pneumococcal diseases in Cameroon. A case-finding retrospective observational study: 2006-2012

BACKGROUND

Vital registration data outlining causes of deaths (CoD) are important for a sustainable health system, targeted interventions and other relevant policies. There is data paucity on vital registration systems in developing countries. We assessed the leading causes and proportions of under-five deaths, and particularly those related to pneumococcal infections in Yaoundé, Cameroon, using hospital registration data.

METHODS

A retrospective case-finding observational study design was used to access and identify data on 817 death cases in children under-five years of age recorded in health facilities in Yaoundé, within the period January 1, 2006 and December 31, 2012. Patients' files were randomly selected and needed information including demographic data, date of admission, clinical and laboratory diagnosis, principal and/or underlying causes of death were abstracted into structured case report forms. The International Classification of Diseases and Clinical Modifications 10th revision (ICD-10-CM) codes (ICD10Data.com 2017 edition) were used to classify the different CoD, retrospectively. Ascertainment of CoD was based on medical report and estimates were done using the Kaplan-Meier procedure and descriptive statistics.

RESULTS

Of the 817 death records assessed, malaria was the leading CoD and was responsible for 17.5% of cases. Meningitis was the second largest CoD with 11.0%; followed by sepsis (10.0%), Streptococcus pneumoniae infections (8.3%), malnutrition (8.3%), gastro-enteritis / diarrhoea (6.2%), anaemia (6.1%) and HIV (3.5%), respectively.

CONCLUSION

The main CoD in this population are either treatable or vaccine-preventable; a trend consistent with previous reports across developing countries. Besides, the health effects from non-communicable infections should not be neglected. Therefore, scaling-up measures to reduce causes of under-five deaths will demand sustainable efforts to enhance both treatment and disease prevention strategies, to avoid a decline in the progress towards reducing under-five deaths by 2/3 from the 1990 baseline.

Pediatric bloodstream infections in metropolitan Australia

BACKGROUND

Bloodstream infections (BSIs) cause significant morbidity and mortality of children worldwide. The aim of this study was to investigate BSI in children and determine the identity of causative organism and their susceptibility patterns in a metropolitan public hospital in Australia.

METHODS

We retrospectively reviewed children aged 0-16 years admitted to a public hospital from January 1, 2010 to August 31, 2014 inclusive, and whose blood cultures revealed bacteraemia. Data were collected regarding patient demographics, species of bacteria isolated, antimicrobial susceptibility of these isolates, and clinical outcomes.

RESULTS

Out of 96 patients with BSI, 55 (57.3%) were males. The median age was 3.35 years (IQR 0.44-7.46), and there were 2 mortalities. Common sites of infection were the respiratory tract (16.6%, n = 16), bone and joints (15.6%, n = 15) and the urinary tract (11.5%, n = 11). The most frequent isolates were Staphylococcus aureus (27.0%), Escherichia coli (14.0%) and Streptococcus pneumoniae (12.0%). Whilst most bacterial isolates displayed susceptibility (> 90%) to common antimicrobial agents, only 57.1% (8/14) of Escherichia coli isolates were susceptible to ampicillin and 58.3% (7/12) were susceptible to co-trimoxazole.

CONCLUSIONS

Gram-positive bacteria accounted for the majority of pediatric BSIs, of which invasive pneumococcal disease remains a noteworthy cause. The majority of isolates, except Escherichia coli, were susceptible to commonly used antimicrobials. This study confirms the knowledge of high rates of resistance of Escherichia coli to ampicillin. Therefore, empirical treatment should still include gentamicin. Monitoring of resistance patterns is warranted to ensure that antibiotic therapy remains appropriate.

Evaluation of systemic inflammatory response syndrome-negative sepsis from a Chinese regional pediatric network

Background

The identification of sepsis in children varies depending on the definition used. Our purpose was to compare clinical data and outcome of atypical sepsis, manifested as having sepsis but not fulfilling the criteria of systemic inflammatory response syndrome (SIRS-negative sepsis, SNS), in children based on the modified Angus criteria with those of sepsis (S) and severe sepsis (SS) based on the international consensus criteria.

Methods

Pediatric departments in 11 regional city and county referral hospitals with emergency and intensive care settings in Huai’an serving for 843,000 children participated in a parallel multicenter prospective survey. Clinical data registry was used to recruit those who fulfilled the diagnostic criteria for pediatric sepsis from all admissions (n = 27,836) from 28 days to 15 years old, from September 1, 2010 to August 31, 2011.

Results

A total of 1606 children met the criteria for pediatric sepsis and were divided into three groups: S, (n = 1377), SS (n = 153, including 32 septic shock), based on the consensus definition criteria, and SNS (n = 76) based on the modified Angus criteria. Most deaths (38/54, 70.3%) occurred within three days of admission. The SNS mainly occurred in infants and was associated with cardiopulmonary and neurologic dysfunction without satisfying the SIRS criteria.

Conclusions

SNS differed from SS in that it predominantly affected infants and manifested with cardiopulmonary and neurologic dysfunction. There were no laboratory variables which were useful in identification of SNS, or predicting response to therapy or outcome.

Epidemiology of Pediatric Septic Shock

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.

The global burden of sepsis: barriers and potential solutions

Sepsis is a major contributor to the global burden of disease. The majority of sepsis cases and deaths are estimated to occur in low and middle-income countries. Barriers to reducing the global burden of sepsis include difficulty quantifying attributable morbidity and mortality, low awareness, poverty and health inequity, and under-resourced and low-resilience public health and acute health care delivery systems. Important differences in the populations at risk, infecting pathogens, and clinical capacity to manage sepsis in high and low-resource settings necessitate context-specific approaches to this significant problem. We review these challenges and propose strategies to overcome them. These strategies include strengthening health systems, accurately identifying and quantifying sepsis cases, conducting inclusive research, establishing data-driven and context-specific management guidelines, promoting creative clinical interventions, and advocacy.

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.

The Top Ten Websites in Critical Care Medicine Education Today

INTRODUCTION:

The number of websites for the critical care provider is rapidly growing, including websites that are part of the Free Open Access Med(ical ed)ucation (FOAM) movement. With this rapidly expanding number of websites, critical appraisal is needed to identify quality websites. The last major review of critical care websites was published in 2011, and thus a new review of the websites relevant to the critical care clinician is necessary.

METHODS:

A new assessment tool for evaluating critical care medicine education websites, the Critical Care Medical Education Website Quality Evaluation Tool (CCMEWQET), was modified from existing tools. A PubMed and Startpage search from 2007 to 2017 was conducted to identify websites relevant to critical care medicine education. These websites were scored based on the CCMEWQET.

RESULTS:

Ninety-seven websites relevant for critical care medicine education were identified and scored, and the top ten websites were described in detail. Common types of resources available on these websites included blog posts, podcasts, videos, online journal clubs, and interactive components such as quizzes. Almost one quarter of websites (n = 22) classified themselves as FOAM websites. The top ten websites most often included an editorial process, high-quality and appropriately attributed graphics and multimedia, scored much higher for comprehensiveness and ease of access, and included opportunities for interactive learning.

CONCLUSION:

Many excellent online resources for critical care medicine education currently exist, and the number is likely to continue to increase. Opportunities for improvement in many websites include more active engagement of learners, upgrading navigation abilities, incorporating an editorial process, and providing appropriate attribution for graphics and media.

Tie2 protects the vasculature against thrombus formation in systemic inflammation

Disordered coagulation contributes to death in sepsis and lacks effective treatments. Existing markers of disseminated intravascular coagulation (DIC) reflect its sequelae rather than its causes, delaying diagnosis and treatment. Here we show that disruption of the endothelial Tie2 axis is a sentinel event in septic DIC. Proteomics in septic DIC patients revealed a network involving inflammation and coagulation with the Tie2 antagonist, angiopoietin-2 (Angpt-2), occupying a central node. Angpt-2 was strongly associated with traditional DIC markers including platelet counts, yet more accurately predicted mortality in 2 large independent cohorts (combined N = 1,077). In endotoxemic mice, reduced Tie2 signaling preceded signs of overt DIC. During this early phase, intravital imaging of microvascular injury revealed excessive fibrin accumulation, a pattern remarkably mimicked by Tie2 deficiency even without inflammation. Conversely, Tie2 activation normalized prothrombotic responses by inhibiting endothelial tissue factor and phosphatidylserine exposure. Critically, Tie2 activation had no adverse effects on bleeding. These results mechanistically implicate Tie2 signaling as a central regulator of microvascular thrombus formation in septic DIC and indicate that circulating markers of the Tie2 axis could facilitate earlier diagnosis. Finally, interventions targeting Tie2 may normalize coagulation in inflammatory states while averting the bleeding risks of current DIC therapies.

Overview of the incidence, early identification and management of sepsis

Sepsis is a potentially life-threatening condition that is triggered by an infection. Sepsis is an urgent public health issue globally, and is one of the leading causes of death in emergency departments and hospitals. However, consensus definitions of sepsis are imprecise and the incidence and costs of the condition are thought to be underestimated. This article discusses the incidence of sepsis globally and nationally, and the effects of the condition. It emphasises the early identification and effective management of sepsis, which remain crucial to improving patient outcomes such as morbidity and mortality. It also outlines the nurse's role in providing sepsis care.

Inotropic Therapy for Sepsis

Sepsis, severe sepsis, and septic shock represent a dynamic clinical syndrome involving a systemic inflammatory response, circulatory changes, and end-organ dysfunction from an infection. Early aggressive management to restore perfusion and/or improve hypotension is critical to improving outcomes. Although the basic management principles of early goal-directed therapy for sepsis have not undergone significant changes, there has been a recent shift in recommendations related to the timing and type of inotropic support. The purpose of this article is to review fluid management along with previous and current inotrope recommendations in pediatric sepsis and septic shock.

The Utilization of the Surviving Sepsis Campaign Care Bundles in the Treatment of Pediatric Patients with Severe Sepsis or Septic Shock in a Resource-Limited Environment: A Prospective Multicenter Trial

Background:

Sepsis is a common condition affecting the lives of infants and children worldwide. Although implementation of the surviving sepsis campaign (SSC) care bundles was once believed to be effective in reducing sepsis mortality rates, the approach has recently been questioned.

Methods:

The study was a prospective, interventional, multicenter trial. Infants and children aged 1 month to 15 years in seven different large academic centers in Thailand who had been diagnosed with severe sepsis or septic shock. They were given treatment based on the SSC care bundles.

Results:

A total of 519 children with severe sepsis or septic shock were enrolled in the study. Among these, 188 were assigned to the intervention group and 331 were recruited to the historical case–control group. There were no significant differences in the baseline clinical characteristics. The intervention group was administered a significantly higher fluid bolus than was the control group (28.3 ± 17.2 cc/kg vs. 17.7 ± 10.6 cc/kg; P = 0.02) with early vasopressor used (1.5 ± 0.7 h) compared to control group (7.4 ± 2.4 h, P < 0.05). More importantly, our sepsis mortality reduced significantly from 37% ± 20.7% during the preintervention period to 19.4% ± 14.3% during the postintervention period (P < 0.001).

Conclusion:

Our study demonstrated a significant reduction in sepsis mortality after the implementation of the SSC care bundles. Early diagnosis of the disease, optimum hemodynamic resuscitation, and timely antibiotic administration are the key elements of sepsis management.

Paediatric sepsis, the under-recognised killer: quality improvement initiative of outreach teaching in paediatric sepsis

Sepsis is the leading cause of child's death, yet it is well known that the rapid initiation of simple, timely interventions reduces morbidity and mortality. This paper shares our findings on the barriers doctors in training have identified to delivering such care. We also share the results of a pilot paediatric intensive care unit outreach teaching programme designed to directly address these highlighted concerns.

Personalized identification of differentially expressed pathways in pediatric sepsis

Sepsis is a leading killer of children worldwide with numerous differentially expressed genes reported to be associated with sepsis. Identifying core pathways in an individual is important for understanding septic mechanisms and for the future application of custom therapeutic decisions. Samples used in the study were from a control group (n=18) and pediatric sepsis group (n=52). Based on Kauffman's attractor theory, differentially expressed pathways associated with pediatric sepsis were detected as attractors. When the distribution results of attractors are consistent with the distribution of total data assessed using support vector machine, the individualized pathway aberrance score (iPAS) was calculated to distinguish differences. Through attractor and Kyoto Encyclopedia of Genes and Genomes functional analysis, 277 enriched pathways were identified as attractors. There were 81 pathways with P<0.05 and 59 pathways with P<0.01. Distribution outcomes of screened attractors were mostly consistent with the total data demonstrated by the six classifying parameters, which suggested the efficiency of attractors. Cluster analysis of pediatric sepsis using the iPAS method identified seven pathway clusters and four sample clusters. Thus, in the majority pediatric sepsis samples, core pathways can be detected as different from accumulated normal samples. In conclusion, a novel procedure that identified the dysregulated attractors in individuals with pediatric sepsis was constructed. Attractors can be markers to identify pathways involved in pediatric sepsis. iPAS may provide a correlation score for each of the signaling pathways present in an individual patient. This process may improve the personalized interpretation of disease mechanisms and may be useful in the forthcoming era of personalized medicine.

Clinical outcomes and mortality before and after implementation of a pediatric sepsis protocol in a limited resource setting: A retrospective cohort study in Bangladesh

BACKGROUND

Pediatric sepsis has a high mortality rate in limited resource settings. Sepsis protocols have been shown to be a cost-effective strategy to improve morbidity and mortality in a variety of populations and settings. At Dhaka Hospital in Bangladesh, mortality from pediatric sepsis in high-risk children previously approached 60%, which prompted the implementation of an evidenced-based protocol in 2010. The clinical effectiveness of this protocol had not been measured. We hypothesized that implementation of a pediatric sepsis protocol improved clinical outcomes, including reducing mortality and length of hospital stay.

MATERIALS AND METHODS

This was a retrospective cohort study of children 1-59 months old with a diagnosis of sepsis, severe sepsis or septic shock admitted to Dhaka Hospital from 10/25/2009-10/25/2011. The primary outcome was inpatient mortality pre- and post-protocol implementation. Secondary outcomes included fluid overload, heart failure, respiratory insufficiency, length of hospital stay, and protocol compliance, as measured by antibiotic and fluid bolus administration within 60 minutes of hospital presentation.

RESULTS

404 patients were identified by a key-word search of the electronic medical record; 328 patients with a primary diagnosis of sepsis, severe sepsis, or septic shock were included (143 pre- and185 post-protocol) in the analysis. Pre- and post-protocol mortality were similar and not statistically significant (32.17% vs. 34.59%, p = 0.72). The adjusted odds ratio (AOR) for post-protocol mortality was 1.55 (95% CI, 0.88-2.71). The odds for developing fluid overload were significantly higher post-protocol (AOR 3.45, 95% CI, 2.04-5.85), as were the odds of developing heart failure (AOR 4.52, 95% CI, 1.43-14.29) and having a longer median length of stay (AOR 1.81, 95% CI 1.10-2.96). There was no statistically significant difference in respiratory insufficiency (pre- 65.7% vs. post- 70.3%, p = 0.4) or antibiotic administration between the cohorts (pre- 16.08% vs. post- 12.43%, p = 0.42).

CONCLUSIONS

Implementation of a pediatric sepsis protocol did not improve all-cause mortality or length of stay and may have been associated with increased fluid overload and heart failure during the study period in a large, non-governmental hospital in Bangladesh. Similar rates of early antibiotic administration may indicate poor protocol compliance. Though evidenced-based protocols are a potential cost-effective strategy to improve outcomes, future studies should focus on optimal implementation of context-relevant sepsis protocols in limited resource settings.

Sepsis epidemiology and outcome in the paediatric intensive care unit of Vilnius University Children's Hospital

Research was carried out at the paediatric intensive care unit (paediatric ICU) of the Children’s Hospital, affiliate of Vilnius University Hospital Santariškių klinikos.

Use of biomarkers in pediatric sepsis: literature review

Despite advances in recent years, sepsis is still a leading cause of hospitalization and mortality in infants and children. The presence of biomarkers during the response to an infectious insult makes it possible to use such biomarkers in screening, diagnosis, prognosis (risk stratification), monitoring of therapeutic response, and rational use of antibiotics (for example, the determination of adequate treatment length). Studies of biomarkers in sepsis in children are still relatively scarce. This review addresses the use of biomarkers in sepsis in pediatric patients with emphasis on C-reactive protein, procalcitonin, interleukins 6, 8, and 18, human neutrophil gelatinase, and proadrenomedullin. Assessment of these biomarkers may be useful in the management of pediatric sepsis.

A Randomized Controlled Trial of Corticosteroids in Pediatric Septic Shock: A Pilot Feasibility Study

OBJECTIVE

To determine the feasibility of conducting a randomized controlled trial of corticosteroids in pediatric septic shock.

DESIGN

Randomized, double-blind, placebo controlled trial.

SETTING

Seven tertiary level PICUs in Canada.

PATIENTS

Children newborn to 17 years old inclusive with suspected septic shock.

INTERVENTION

Administration of IV hydrocortisone versus placebo until hemodynamic stability is achieved or for a maximum of 7 days.

MEASUREMENTS AND MAIN RESULTS

One hundred seventy-four patients were potentially eligible of whom 101 patients met eligibility criteria. Fifty-seven patients were randomized, and 49 patients (23 and 26 patients in the hydrocortisone and placebo groups, respectively) were included in the final analysis. The mean time from screening to randomization was 2.4 ± 2.1 hours and from screening to first dose of study drug was 3.8 ± 2.6 hours. Forty-two percent of potentially eligible patients (73/174) received corticosteroids prior to randomization: 38.5% (67/174) were already on corticosteroids for shock at the time of screening, and in 3.4% (6/174), the treating physician wished to administer corticosteroids. Six of 49 randomized patients (12.2%) received open-label steroids, three in each of the hydrocortisone and placebo groups. Time on vasopressors, days on mechanical ventilation, PICU and hospital length of stay, and the rate of adverse events were not statistically different between the two groups.

CONCLUSIONS

This study suggests that a large randomized controlled trial on early use of corticosteroids in pediatric septic shock is potentially feasible. However, the frequent use of empiric corticosteroids in otherwise eligible patients remains a significant challenge. Knowledge translation activities, targeted recruitment, and alternative study designs are possible strategies to mitigate this challenge.

The Angiopoietin-Tie2 Signaling Axis in Systemic Inflammation

Systemic inflammation is a hallmark of commonly encountered diseases ranging from bacterial sepsis to sterile syndromes such as major trauma. Derangements in the host vasculature contribute to the cardinal manifestations of sepsis in profound ways. Recent studies of control pathways regulating the vascular endothelium have illuminated how this single cell layer toggles between quiescence and activation to affect the development of shock and multiorgan dysfunction. This article focuses on one such control pathway, the Tie2 receptor and its ligands the angiopoietins, to describe a growing body of genetic, biochemical, mechanistic, and human studies that implicate Tie2 as a critical switch. In health, activated Tie2 maintains the endothelium in a quiescent state characterized by dynamic barrier function and antiadhesion against circulating leukocytes. In sepsis and related diseases, expression of the angiopoietins becomes markedly imbalanced and Tie2 signaling is greatly attenuated. These rapid molecular changes potentiate pathophysiologic responses throughout the body, resulting in injurious vascular leakage and organ inflammation. The Tie2 axis, therefore, may be a promising avenue for future translational studies.

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

OBJECTIVE

To evaluate all published pediatric randomized controlled trials of patients with septic shock from any cause to examine the outcome measures used, the strengths and limitations of these measurements and whether the trial outcomes met feasibility criteria.

DATA SOURCES

We used a previously published database of pediatric critical care randomized controlled trials (PICUtrials.net) derived from searches of MEDLINE, EMBASE, LILACS, and CENTRAL.

STUDY SELECTION

We included randomized controlled trials of interventions to children admitted to a PICU with septic or dengue hemorrhagic shock which were published in English.

DATA EXTRACTION

Study characteristics and outcomes were retrieved by two independent reviewers with disagreement being resolved by a third reviewer. We defined feasibility as 1) recruitment of at least 90% of the targeted sample size and agreement of the observed outcome rate in the control group with the rate used for the sample size calculation to within 10% or 2) finding of a statistically significant difference in an interim or final analysis.

DATA SYNTHESIS

Nineteen of 321 identified articles were selected for review. Fourteen of 19 studies (74%) provided an a priori definition of their primary outcome measure in their "Methods section." Mortality rate was the most commonly reported primary outcome (8/14; 57%), followed by duration of shock (4/14; 29%) followed by organ failure (1/14; 7%). Only three of 19 included trials met feasibility criteria.

CONCLUSIONS

Our review found that use of mortality alone as a primary outcome in pediatric septic shock trials was associated with significant limitations and that long-term patient-centered outcomes were not used in this setting. Composite outcomes incorporating mortality and long-term outcomes should be explored for use in future pediatric septic shock trials.

Interrupting pathways to sepsis: Effectiveness of an intervention to reduce delays in timely care for sick children in rural Bangladesh

RATIONALE

The time it takes for a child with suspected sepsis to receive care is critical.

OBJECTIVE

We evaluated care-seeking practices for sick children under 5 years in rural Bangladesh, following interpersonal communication to inform households of newly introduced supports for quality care. Based on the Delays Framework, we assessed length and source of care-seeking delays, use of formal providers, and autonomous decision-making among mothers.

METHOD

Using two cross-sectional rounds before and after the 3-year intervention (August 2012 and August 2015), we surveyed 400 mothers of recently sick children in 26 randomly sampled villages from 2 intervention and 2 control subdistricts, using structured questions about delays. Six to ten times during the 18-month intervention period, local workers communicated four key messages to most intervention households in 292 villages: serious symptoms of suspected sepsis in children, a call-in center number for referral advice, a reliable transport hub, and upgrades to the local hospital.

RESULTS

Compared to baseline, endline results demonstrated a significant difference in the total delay between the onset of child's illness and seeking external care, with intervention families having shorter delays. Over 90% of mothers informed someone in the family, mainly the husband, about the sick child before acting to seek care. Delays due to transportation and receiving provider care were short and not different. Using a benchmark of seeking external care within 24 h of onset, only 14.14% of intervention households and 13.40% of control households were "timely" in seeking care. Approximately 78% of parents, similar for the two groups, sought care from a non-formal practitioner (the village doctor).

CONCLUSION

The results demonstrate that the delay in deciding to seek external care is most serious, and that communication strategies at the community level are necessary to increase the uptake of improved health services.

Managing Neonatal and Early Childhood Syndromic Sepsis in Sub-District Hospitals in Resource Poor Settings: Improvement in Quality of Care through Introduction of a Package of Interventions in Rural Bangladesh

Introduction

Sepsis is dysregulated systemic inflammatory response which can lead to tissue damage, organ failure, and death. With an estimated 30 million cases per year, it is a global public health concern. Severe infections leading to sepsis account for more than half of all under five deaths and around one quarter of all neonatal deaths annually. Most of these deaths occur in low and middle income countries and could be averted by rapid assessment and appropriate treatment. Evidence suggests that service provision and quality of care pertaining to sepsis management in resource poor settings can be improved significantly with minimum resource allocation and investments. Cognizant of the stark realities, a project titled ‘Interrupting Pathways to Sepsis Initiative’ (IPSI) introduced a package of interventions for improving quality of care pertaining to sepsis management at 2 sub-district level public hospitals in rural Bangladesh. We present here the quality improvement process and achievements regarding some fundamental steps of sepsis management which include rapid identification and admission, followed by assessment for hypoxemia, hypoglycaemia and hypothermia, immediate resuscitation when required and early administration of parenteral broad spectrum antibiotics.

Materials and Method

Key components of the intervention package include identification of structural and functional gaps through a baseline environmental scan, capacity development on protocolized management through training and supportive supervision by onsite ‘Program Coaches’, facilitating triage and rapid transfer of patients through ‘Welcoming Persons’ and enabling rapid treatment through ‘Task Shifting’ from on-call physicians to on-duty paramedics in the emergency department and on-call physicians to on-duty nurses in the inpatient department.

Results

From August, 2013 to March, 2015, 1,262 under-5 children were identified as syndromic sepsis in the emergency departments; of which 82% were admitted. More neonates (30%) were referred to higher level facilities than post-neonates (6%) (p<0.05). Immediately after admission, around 99% were assessed for hypoxemia, hypoglycaemia and hypothermia. Around 21% were hypoxemic (neonate-37%, post-neonate-18%, p<0.05), among which 94% received immediate oxygenation. Vascular access was established in 78% cases and 85% received recommended broad spectrum antibiotics parenterally within 1 hour of admission. There was significant improvement in the rate of establishing vascular access and choice of recommended first line parenteral antibiotic over time. After arrival in the emergency department, the median time taken for identification of syndromic sepsis and completion of admission procedure was 6 minutes. The median time taken for completion of assessment for complications was 15 minutes and administration of first dose of broad spectrum antibiotics was 35 minutes. There were only 3 inpatient deaths during the reporting period.

Discussion and Conclusion

Needs based health systems strengthening, supportive-supervision and task shifting can improve the quality and timeliness of in-patient management of syndromic sepsis in resource limited settings.