Effect of Severe Vitamin D Deficiency at Admission on Shock Reversal in Children With Septic Shock: A Prospective Observational Study

Care Bundles plus Detailed Nursing on Mortality and Nursing Satisfaction of Patients with Septic Shock in ICU

Objective

To evaluate the effect of care bundles combined with detailed nursing on the mortality and nursing satisfaction of patients with septic shock in the intensive care unit (ICU).

Methods

Ninety patients with septic shock in the ICU admitted to our hospital from April 2019 to April 2020 were recruited and assigned to an experimental group and a control group via the random table method, with 45 cases in each group. The control group adopted conventional nursing, and the experimental group received care bundles combined with detailed nursing. The nursing effect, satisfaction, and mortality of the two groups were compared. The “Glasgow Coma Scale” (GCS) was used to evaluate the coma of the patients, the “Coma Recovery Scale” (CRS-R) was used to assess the state of consciousness of the patients, and the “Hospital Anxiety and Depression” (HAD) scale was used to evaluate the patient's emotional status before and after the intervention.

Results

The experimental group showed a significantly higher nursing efficiency and better nursing satisfaction than the control group (P < 0.05). Lower mortality was found in the experimental group in contrast to the control group (P < 0.05). The experimental group had higher GCS scores and CRS-R scores and lower HAD scores than the control group (P < 0.05).

Conclusion

Care bundles plus detailed nursing for patients with septic shock in the ICU improve the nursing effect and nursing satisfaction, reduce the mortality rate, and mitigate the clinical symptoms of patients, which shows great potential in clinical application and promotion.

Vitamin D and morbidity in children with multisystem inflammatory syndrome related to Covid-19

Background

Multisystem inflammatory syndrome (MIS-C) is a clinical presentation reported in children related to Coronavirus-19 infection who present with a toxic shock like syndrome. Vitamin D deficiency has been postulated to play a role with severity of coronavirus infection in adult patients and other viral respiratory infections.

Objective

This study aims to investigate if severe vitamin D deficiency was associated with increased disease severity and cardiac involvement in MIS-C.

Methods

This is a retrospective and single center study. We included hospitalized patients less than 18 years of age with diagnosis of MIS-C between March and July 2020. Severe vitamin D deficiency was defined as 25-OH vitamin D level < 10 ng/ml within 48 h of admission. The composite outcome severe disease included patients requiring inotropes, mechanical ventilation, and extracorporeal membrane oxygenation.

Results

Of the 31 patients with MIS-C, 45% were male and 58% were African American. The median age was 8 (1–13) years. Ten patients had severe vitamin D deficiency with a mean level of 7.2 ng/ml. Ninety percent of patients with severe vitamin D deficiency had severe disease (P < 0.001). Patients with severe vitamin D deficiency had an increased risk of cardiac involvement (P < 0.001).

Conclusions

We describe a potential association between severe vitamin D deficiency and severe disease in children presenting with MIS-C. Severe vitamin D deficiency predisposes patients for cardiovascular involvement and may play a critical role in the host immune response to COVID-19 infection. Future prospective studies at the basic science and clinical level should be pursued to better delineate this association.

Hypovitaminosis D and Parathyroid Hormone Response in Critically Ill Children with Sepsis: A Case-control Study

Background: Critically ill Indian children have a higher prevalence of vitamin D deficiency. However, there is not much data available on the subgroup with sepsis. It has been reported that there is an impaired response of parathyroid hormone (PTH) to vitamin D deficiency in critically ill children and adults. Hence, we also sought to analyze the PTH response to vitamin D among the subgroup of critically ill children with sepsis.

Patients and methods: Vitamin D and PTH levels of 84 critically ill children with sepsis (cases) and 84 controls were compared between November 2018 and February 2020. Hypovitaminosis D was defined as levels <30 ng/mL.

Results: The median (IQR) of vitamin D for cases was 26 (21.30–29.95) ng/mL and that for controls 39.3 (33.65–50.2) ng/mL; p <0.001. Cases had a higher prevalence of hypovitaminosis D as compared to controls (79.7 vs 9.5%; p <0.001). Among the cases, mortality was 24.6% in the 65 children with hypovitaminosis D and 10.5% in those with sufficient vitamin D; the differences were not statistically significant (p = 0.339). There were no significant differences in the duration of pediatric intensive care unit (PICU) stay, serum calcium, PTH, and disease severity among the aforementioned groups. Out of the 65 children with hypovitaminosis D, only 9 (13.8%) were PTH responders. There were no statistically significant differences in mortality, the PICU stay, or disease severity at admission between PTH responders and nonresponders.

Conclusions: Hypovitaminosis D was more prevalent among critically ill children with sepsis compared to controls. Parathyroid gland response to hypovitaminosis D was impaired in children with sepsis.

How to cite this article: Kubsad P, Ravikiran SR, Bhat KG, Kamath N, Kulkarni V, Manjrekar PA, et al. Hypovitaminosis D and Parathyroid Hormone Response in Critically Ill Children with Sepsis: A Case-control Study. Indian J Crit Care Med 2021;25(8):923–927.

Thiamine Status in Children with Septic Shock from a Developing Country: A Prospective Case-Control Study

OBJECTIVE

Mitochondrial dysfunction is central to sepsis-induced multi-organ dysfunction. Thiamine deficiency may contribute to mitochondrial dysfunction and thus high mortality. Study was planned to assess thiamine status in children with septic shock in comparison to healthy controls from a developing country and to study the effect of thiamine levels on its outcome.

METHODS

A prospective case-control study (April 2017 to May 2018) enrolling consecutive children with septic shock as 'cases' (n = 76), their healthy siblings (n = 51) and apparently healthy children from immunization clinic (n = 35) as 'controls'. Whole blood total thiamine (WBTT) level was measured on days 1, 10 and 1-month post-discharge. Outcome parameters were acute care area free days on days 14 and 28, and mortality.

RESULTS

WBTT [nMol/l; median (interquartile range, IQR)] was significantly lower on day 1 in cases compared with sibling controls [23.1 (21.8-26.3) vs. 36.9 (33.6-40.5); p < 0.001]. It fell further on day 10 [20.8 (18.1-21.1); p < 0.02]. Levels rose significantly 1-month post-discharge [35.5 (31.2-36.6)] and became comparable to sibling controls (p = 0.4). Immunization clinic controls also had lower WBTT [42.3 (40.1-45.9)], but was significantly higher than sibling controls and cases at 1-month post-discharge (p < 0.001). Survivors and non-survivors of septic shock were similar. WBTT levels did not correlate with any of the severity indicators of septic shock or its outcomes.

CONCLUSIONS

WBTT was significantly low in all children, and fell further during septic shock. Observed severe deficiency might have precluded any further association of thiamine levels with severity of septic shock and its outcome. Data obtained may inform trials on metabolic resuscitation in paediatric septic shock in developing countries. Lay summaryThiamine deficiency may contribute to high mortality in paediatric septic shock as thiamine is an essential factor for functioning of mitochondria, the powerhouse of the cells. This prospective case-control study was conducted to assess thiamine status in children with septic shock in comparison with healthy controls in a developing country. Consecutive children with fluid-refractory septic shock were enrolled as 'cases'. Their apparently healthy siblings, and apparently healthy children from immunization clinic, were enrolled as 'controls'. The whole blood total thiamine (WBTT) level was measured on days 1, 10 and 1 month after hospital discharge. Seventy-six children were enrolled as cases, 51 children as sibling controls and 35 children as immunization clinic controls. WBTT was significantly lower on day 1 in cases as compared with their sibling controls. It fell further on day 10. The level rose significantly after a month of discharge and became comparable to sibling controls. Immunization clinic controls also had lower WBTT but was significantly higher compared with sibling controls and cases at 1-month post-discharge. Survivors and non-survivors of septic shock had similar WBTT levels. Observed severe deficiency might have precluded any further association of thiamine levels with septic shock outcome.

Vitamin D in Acute and Critically Sick Children with a Subgroup of Sepsis and Mortality: A Meta-Analysis

A meta-analysis study was performed to evaluate the relationship between vitamin D deficiency children and sepsis and acute and critically mortality. Through a systematic literature search up to December 2019, 23 studies with 4451 children, 2500 children with vitamin D deficiency were identified reporting relationships between vitamin D deficiency and sepsis and/or acute and critical care unit mortality (six sepsis only, four acute and critically mortality only and 13 both sepsis and acute and critically mortality). Odd ratio (OR) with 95% confidence intervals (CIs) was calculated comparing vitamin D deficiency children to normal vitamin D children on the bases of sepsis and mortality in acute and critical care units using the dichotomous method with a random effect model. No significant difference was found between males and females in pooled studies all together (OR, 0.72; 95% CI, 0.43-1.22). Vitamin D deficiency children (OR, 2.24; 95% CI, 1.42-3.53) had higher sepsis compared to normal vitamin D children. Also, vitamin D deficiency children (OR, 1.77; 95% CI, 1.26-2.49) had higher acute and critically mortality compared to normal vitamin D children but not as much as that in sepsis. The extent of increased sepsis was higher than that in acute and critically mortality. The impact of vitamin D deficiency in children was observed in all populations. Based on this meta-analysis, vitamin D deficiency in children may have an independent-relationship with up to 2.24 fold risk of sepsis and acute and critical care unit mortality. This relationship forces us to recommend checking vitamin D concentration in all critically ill children.

Longitudinal Study of CPK-MB and Echocardiographic Measures of Myocardial Dysfunction in Pediatric Sepsis: Are Patients with Shock Different from Those without?

Background

Sepsis-induced myocardial dysfunction has implications on outcome. For lack of echocardiography in resource-limited settings, myocardial biomarkers may be an alternative monitoring tool.

Objective

This study was planned to explore the longitudinal behavior of creatine phosphokinase-MB (CPK-MB) in children with sepsis with and without shock, and its correlation with clinical and echocardiographic parameters over the first 10 days.

Design

Prospective observational study.

Setting

Tertiary care hospital in a lower-middle-income economy of South Asia.

Patients

Children (3 months to 12 years) with nonshock sepsis (NSS) (n = 40) and septic shock survivors (SSSs) (n = 40) after optimal resuscitation. Patients with catecholamine refractory shock, preexisting heart disease, and cardiorespiratory event within the past 1 month were excluded from the study.

Measurements and main results

Pediatric logistic organ dysfunction (PeLOD) score, vasoactive inotrope score (VIS), CPK-MB, and echocardiographic measures of myocardial function were recorded on days 1, 3, 7, and 10. Echocardiography was repeated at 1 month. Both groups were similar at baseline. The SSSs had higher CPK-MB (180 vs 53 IU/L; p < 0.001) and PeLOD score (2 ± 0.4 vs 11.7 ± 5.1, p < 0.001) on day 1 compared to the NSS children. More than half of the SSS and none of the NSS patients had myocardial dysfunction. Reduction in CPK-MB over 10 days correlated well with improvement in PeLOD (p < 0.01), VIS (p = 0.04), and echocardiographic measures of myocardial dysfunction (p < 0.05) among SSSs. At 1 month follow-up, all had normal echocardiography.

Conclusion

The SSSs had markedly elevated CPK-MB, and its fall paralleled the improvement in clinical status and myocardial dysfunctions. The CPK-MB could be a potential monitoring tool for septic cardiomyopathy in resource-limited settings.

How to cite this article

Baranwal AK, Deepthi G, Rohit MK, Jayashree M, Angurana SK, Kumar-M P. Longitudinal Study of CPK-MB and Echocardiographic Measures of Myocardial Dysfunction in Pediatric Sepsis: Are Patients with Shock Different from Those without? Indian J Crit Care Med 2020;24(2):109–115.

Association of vitamin D deficiency with clinical outcomes in critically ill Korean children

BACKGROUND/OBJECTIVES

Vitamin D is a pleiotropic hormone that affects various body organ systems. We evaluated the prevalence of a vitamin D deficiency (VDD) and its potential role in the clinical condition of critically ill Korean children.

SUBJECTS/METHODS

Patients under 18 years old with a 25(OH) vitamin D measurement on the first day of PICU admission were included from among the children admitted to the pediatric intensive care unit (PICU) of our tertiary children's hospital between October 2017 and January 2019.

RESULTS

A total of 172 pediatric patients were enrolled. The mean 25(OH) vitamin D level was 17.5 ± 12.8 ng/mL. There was a 65.1% prevalence of VDD (25(OH) vitamin D level < 20 ng/mL). VDD was associated with age at PICU admission, gastrointestinal/hepatobiliary disorders, International Society of Thrombosis and Hemostasis disseminated intravascular coagulation (ISTH DIC) score, pediatric multiple organ dysfunction syndrome (pMODS) score and with several laboratory test findings including hemoglobin, platelet, C-reactive protein, serum albumin, total bilirubin, prothrombin time, and anti-thrombin III levels. Most of these parameters also showed significant linear correlations with the 25(OH) vitamin D level (P < 0.05). However, no statistically meaningful association was found between VDD and other clinical conditions such as the need for a mechanical ventilator, requirement for vasoactive drugs, duration of the PICU and hospital stays, or PICU mortality.

CONCLUSION

There is a high prevalence of VDD in critically ill Korean children. There were significant associations between the 25(OH) vitamin D level and gastrointestinal/hepatobiliary disorders, the pMODS score and with coagulation related factors. Further large-scale studies with more specific subgroup analyses are required to more precisely assess the clinical implications of VDD in critically ill pediatric patients.

Importance of vitamin D in acute and critically ill children with subgroup analyses of sepsis and respiratory tract infections: a systematic review and meta-analysis

OBJECTIVES

To estimate the prevalence of 25-hydroxyvitamin D (25(OH)D) deficiency and investigate its association with mortality in children with acute or critical conditions.

DESIGN

Systematic review and meta-analysis of observational studies.

DATA SOURCES

PubMed, OVID, Google Scholar and the Cochrane Library searched until 21 December 2018.

ELIGIBILITY CRITERIA

Studies of children hospitalised with acute or critical conditions who had blood 25(OH)D levels measured.

DATA EXTRACTION AND SYNTHESIS

We obtained pooled prevalence estimates of 25(OH)D deficiency and ORs for mortality. We calculated 95% CI and prediction intervals and investigated heterogeneity and evidence of small-study effects.

RESULTS

Fifty-two studies were included. Of 7434 children, 3473 (47.0%) were 25(OH)D deficient (<50 nmol/L). The pooled prevalence estimate of 25(OH)D deficiency was 54.6% (95% CI 48.5% to 60.6%, I²=95.3%, p<0.0001). Prevalence was similar after excluding smaller studies (51.5%). In children with sepsis (18 studies, 889 total individuals) prevalence was 64.0% (95% CI 52.0% to 74.4%, I²=89.3%, p<0.0001) and 48.7% (95% CI 38.2% to 59.3%; I²=94.3%, p<0.0001) in those with respiratory tract infections (RTI) (25 studies, 2699 total individuals). Overall, meta-analysis of mortality (18 cohort studies, 2463 total individuals) showed increased risk of death in 25(OH)D deficient children (OR 1.81, 95% CI 1.24 to 2.64, p=0.002, I²=25.7%, p=0.153). Four (22.0%) of the 18 studies statistically adjusted for confounders. There were insufficient studies to meta-analyse sepsis and RTI-related mortality.

CONCLUSIONS

Our results suggest that 25(OH)D deficiency in acute and critically ill children is high and associated with increased mortality. Small-study effects, reverse causation and other biases may have confounded results. Larger, carefully designed studies in homogeneous populations with confounder adjustment are needed to clarify the association between 25(OH)D levels with mortality and other outcomes.

PROSPERO REGISTRATION NUMBER

CRD42016050638.

Vitamin D deficiency and clinical outcomes related to septic shock in children with critical illness: a systematic review

PURPOSE

Low vitamin D blood levels are related to many clinical outcomes in children with critically illness. However, the relationship of it and septic shock has not been systematically analyzed. The objective of this review was to evaluate the effect of vitamin D on septic shock and predict if vitamin D administration can improve prognosis of it.

MATERIALS AND METHODS

Online databases were searched up to June 1st, 2017 for studies on the relation of vitamin D deficiency (VDD) and clinical outcomes on septic shock in children with critical illness. The primary end point was the effect of VDD on occurrence of septic shock. The secondary endpoints were the association of VDD and clinical outcomes related to septic shock. We summarized the strength of association between VDD and each factor on septic shock. Individual factors were defined as strong, moderate, weak, or inconclusive according to the numbers of the article supporting the relation between them.

RESULTS

Eight studies published between 2012 and 2017, for a total of 1367 patients, were included in the final analysis. We extracted eight patient-level factors and among them one showed strong association of VDD and septic shock. Four factors demonstrated moderate or weak strength of evidence for it: nonresolution of shock, catecholamine refractory shock, fluid boluses, vasopressor use. But evidence for the association between VDD and severity of illness, stay of pediatric intensive care unit (PICU), are weak. Most of the articles showed no significant association between VDD and mortality.

CONCLUSIONS

Among critically ill children, VDD might be associated with the occurrence and resolution of septic shock. A larger multicenter trial could conclusively confirm these findings. Further research is also needed to identify vitamin D administration for better outcomes in pediatric patients.