1
|
Wang G, Jiang X, Fu Y, Gao Y, Jiang Q, Guo E, Huang H, Liu X. Development and validation of a nomogram to predict the risk of sepsis-associated encephalopathy for septic patients in PICU: a multicenter retrospective cohort study. J Intensive Care 2024; 12:8. [PMID: 38378667 PMCID: PMC10877756 DOI: 10.1186/s40560-024-00721-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/08/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Patients with sepsis-associated encephalopathy (SAE) have higher mortality rates and longer ICU stays. Predictors of SAE are yet to be identified. We aimed to establish an effective and simple-to-use nomogram for the individual prediction of SAE in patients with sepsis admitted to pediatric intensive care unit (PICU) in order to prevent early onset of SAE. METHODS In this retrospective multicenter study, we screened 790 patients with sepsis admitted to the PICU of three hospitals in Shandong, China. Least absolute shrinkage and selection operator regression was used for variable selection and regularization in the training cohort. The selected variables were used to construct a nomogram to predict the risk of SAE in patients with sepsis in the PICU. The nomogram performance was assessed using discrimination and calibration. RESULTS From January 2017 to May 2022, 613 patients with sepsis from three centers were eligible for inclusion in the final study. The training cohort consisted of 251 patients, and the two independent validation cohorts consisted of 193 and 169 patients. Overall, 237 (38.7%) patients developed SAE. The morbidity of SAE in patients with sepsis is associated with the respiratory rate, blood urea nitrogen, activated partial thromboplastin time, arterial partial pressure of carbon dioxide, and pediatric critical illness score. We generated a nomogram for the early identification of SAE in the training cohort (area under curve [AUC] 0.82, 95% confidence interval [CI] 0.76-0.88, sensitivity 65.6%, specificity 88.8%) and validation cohort (validation cohort 1: AUC 0.80, 95% CI 0.74-0.86, sensitivity 75.0%, specificity 74.3%; validation cohort 2: AUC 0.81, 95% CI 0.73-0.88, sensitivity 69.1%, specificity 83.3%). Calibration plots for the nomogram showed excellent agreement between SAE probabilities of the observed and predicted values. Decision curve analysis indicated that the nomogram conferred a high net clinical benefit. CONCLUSIONS The novel nomogram and online calculator showed performance in predicting the morbidity of SAE in patients with sepsis admitted to the PICU, thereby potentially assisting clinicians in the early detection and intervention of SAE.
Collapse
Affiliation(s)
- Guan Wang
- Department of Pediatrics, Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Xinzhu Jiang
- Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Yanan Fu
- Department of Medical Engineering, Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Yan Gao
- Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Qin Jiang
- Department of Pediatrics, Jinan Children's Hospital of Shandong University, No. 23976 Jingshi Road, Jinan, 250000, Shandong, China
| | - Enyu Guo
- Department of Pediatrics, Jining First People's Hospital, No. 6 JianKang Road, Jining, 272000, Shandong, China
| | - Haoyang Huang
- School of Public Health of Shandong University, No. 44 West Wenhua Road, Jinan, 250000, Shandong, China
| | - Xinjie Liu
- Department of Pediatrics, Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China.
| |
Collapse
|
2
|
Papadogeorgou P, Boutsikou T, Boutsikou M, Pergantou E, Mantzou A, Papassotiriou I, Iliodromiti Z, Sokou R, Bouza E, Politou M, Iacovidou N, Valsami S. A Global Assessment of Coagulation Profile and a Novel Insight into Adamts-13 Implication in Neonatal Sepsis. BIOLOGY 2023; 12:1281. [PMID: 37886991 PMCID: PMC10604288 DOI: 10.3390/biology12101281] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/28/2023]
Abstract
Neonatal sepsis is a life-threatening condition associated with significant morbidity and mortality. Sepsis-induced coagulopathy is a well-recognized entity, signifying the strong cross-talk between inflammation and coagulation. The aim of the present study was to compare the coagulation profile between the acute phase of sepsis and recovery in term and preterm neonates. Additional comparisons to healthy neonates were undertaken. Levels of clotting, anti-clotting factors and ADAMTS-13 (A disintegrin and metalloprotease with thrombospondin type-1 motives), the cleaving protein of von Willebrand factor (VWF), were measured in 16 term and preterm neonates in the acute phase of infection and following recovery, as well as in 18 healthy neonates. Clotting times were prolonged, while levels of particular clotting factors were lower in the acute phase of infection compared to controls and recovery. On the other hand, levels of fibrinogen, factor VIII (FVIII) and VWF were significantly higher in the acute phase in comparison to controls and recovery, while they remained persistently higher in the infection group compared to controls. In regard to the anticlotting mechanism, a clear suppression was observed in septic neonates. ADAMTS-13 levels were significantly lower in the acute phase of infection in comparison to controls and recovery (p = 0.015 and 0.004, respectively), while a trend toward superimposed normalization was demonstrated post infection, as higher ADAMTS-13 levels were measured in recovered neonates compared to controls (p = 0.002). The coagulation profile is considerably deranged in neonatal sepsis. ADAMTS-13 deficiency in septic neonates is a novel finding with promising future implications, as ADAMTS-13 substitution may serve as a useful therapeutic option in neonatal sepsis, prompting further investigation in future studies.
Collapse
Affiliation(s)
- Paraskevi Papadogeorgou
- Neonatal Department, Medical School, National and Kapodistrian University of Athens, Aretaieio Hospital, 115 28 Athens, Greece
| | - Theodora Boutsikou
- Neonatal Department, Medical School, National and Kapodistrian University of Athens, Aretaieio Hospital, 115 28 Athens, Greece
| | - Maria Boutsikou
- Neonatal Department, Medical School, National and Kapodistrian University of Athens, Aretaieio Hospital, 115 28 Athens, Greece
| | - Eleni Pergantou
- Haemostasis Unit/Haemophilia Centre, “Aghia Sophia” Children’s Hospital, 115 27 Athens, Greece
| | - Aimilia Mantzou
- First Department of Paediatrics, Medical School, National and Kapodistrian University of Athens, “Aghia Sophia” Children’s Hospital, 115 27 Athens, Greece
| | - Ioannis Papassotiriou
- First Department of Paediatrics, Medical School, National and Kapodistrian University of Athens, “Aghia Sophia” Children’s Hospital, 115 27 Athens, Greece
| | - Zoi Iliodromiti
- Neonatal Department, Medical School, National and Kapodistrian University of Athens, Aretaieio Hospital, 115 28 Athens, Greece
| | - Rozeta Sokou
- Neonatal Department, Medical School, National and Kapodistrian University of Athens, Aretaieio Hospital, 115 28 Athens, Greece
| | - Elena Bouza
- 2nd Neonatal Intensive Care Unit, “Aghia Sophia” Children’s Hospital, 115 27 Athens, Greece
| | - Marianna Politou
- Blood Transfusion Department, Aretaieio Hospital, Medical School, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Nikoletta Iacovidou
- Neonatal Department, Medical School, National and Kapodistrian University of Athens, Aretaieio Hospital, 115 28 Athens, Greece
| | - Serena Valsami
- Blood Transfusion Department, Aretaieio Hospital, Medical School, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| |
Collapse
|
3
|
He W, Xi Q, Cui H, Zhang P, Huang R, Wang T, Wang D. Liang-Ge Decoction Ameliorates Coagulation Dysfunction in Cecal Ligation and Puncture-Induced Sepsis Model Rats through Inhibiting PAD4-Dependent Neutrophil Extracellular Trap Formation. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2023; 2023:5042953. [PMID: 37159591 PMCID: PMC10163969 DOI: 10.1155/2023/5042953] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 01/30/2023] [Accepted: 02/14/2023] [Indexed: 05/11/2023]
Abstract
Liang-Ge (LG) decoction could ameliorate coagulation dysfunction in septic model rats. However, the mechanism of LG in treating sepsis still needs to be clarified. Our current study established a septic rat model to evaluate the effect of LG on coagulation dysfunction in septic rats first. Second, we investigated the effect of LG on NET formation in septic rats. Finally, NETs and PAD4 inhibitors were further used to clarify if LG could improve the mechanism of sepsis coagulation dysfunction by inhibiting NET formation. Our findings indicated that treatment with LG improved the survival rate, reduced inflammatory factor levels, enhanced hepatic and renal function, and reduced pathological changes in rats with sepsis. LG could also alleviate coagulation dysfunction in septic model rats. Besides, LG treatment reduced NETs formation and decreased PAD4 expression in neutrophiles. In addition, LG treatment showed a similar result in comparison to the treatment with either NET inhibitors or PAD4 inhibitors alone. In conclusion, this study confirmed that LG has therapeutic effects on septic rats. Furthermore, the improvement of coagulation dysfunction in septic rats by LG was achieved through inhibiting PAD4-mediated NET formation.
Collapse
Affiliation(s)
- Wenju He
- Department of Integration of Traditional Chinese and Western Medicine, First Central Hospital Affiliated to Nankai University, Tianjin First Central Hospital, Tianjin, China
| | - Qiang Xi
- Department of Practice and Education, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Huantian Cui
- Shandong Provincial Key Laboratory of Animal Cell and Developmental Biology, School of Life Sciences, Shandong University, Qingdao, China
| | - Pingping Zhang
- Department of Integration of Traditional Chinese and Western Medicine, First Central Hospital Affiliated to Nankai University, Tianjin First Central Hospital, Tianjin, China
| | - Rui Huang
- Department of Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Taihuan Wang
- Department of Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Dongqiang Wang
- Department of Integration of Traditional Chinese and Western Medicine, First Central Hospital Affiliated to Nankai University, Tianjin First Central Hospital, Tianjin, China
| |
Collapse
|
4
|
Kim KS, Oh AR, Park J, Ryu JA. Association between Fibrinogen-to-Albumin Ratio and Prognosis in Patients Admitted to an Intensive Care Unit. J Clin Med 2023; 12:jcm12041407. [PMID: 36835941 PMCID: PMC9962887 DOI: 10.3390/jcm12041407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/05/2023] [Accepted: 02/09/2023] [Indexed: 02/12/2023] Open
Abstract
The objective of this study was to investigate the usefulness of fibrinogen-to-albumin ratio (FAR) as a prognostic marker in patients admitted to an intensive care unit (ICU) compared with Sequential Organ Failure Assessment (SOFA) score, a widely used prognostic scoring system. An inverse probability weighting (IPW) was used to control for selection bias and confounding factors. After IPW adjustment, the high FAR group showed significantly higher risk of 1-year compared with low FAR group (36.4% vs. 12.4%, adjust hazard ratio = 1.72; 95% confidence interval (CI): 1.59-1.86; p < 0.001). In the receiver-operating characteristic curve analysis associated with the prediction of 1-year mortality, there was no significant difference between the area under the curve of FAR on ICU admission (C-statistic: 0.684, 95% CI: 0.673-0.694) and that of SOFA score on ICU admission (C-statistic: 0.679, 95% CI: 0.669-0.688) (p = 0.532). In this study, FAR and SOFA score at ICU admission were associated with 1-year mortality in patients admitted to an ICU. Especially, FAR was easier to obtain in critically ill patients than SOFA score. Therefore, FAR is feasible and might help predict long-term mortality in these patients.
Collapse
Affiliation(s)
- Keun-Soo Kim
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Ah-Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
- Correspondence: (J.P.); (J.-A.R.); Tel.: +82-2-3410-6399 (J.-A.R.); Fax: 82-2-2148-7088 (J.-A.R.)
| | - Jeong-Am Ryu
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
- Correspondence: (J.P.); (J.-A.R.); Tel.: +82-2-3410-6399 (J.-A.R.); Fax: 82-2-2148-7088 (J.-A.R.)
| |
Collapse
|
5
|
Yao C, Zhang G, Zhang N, Li R, Sun S, Zhang L, Xia Y, Chen S, Sun J, Chen M. Fibrinogen Is Associated with Prognosis of Critically Ill Patients with Sepsis: A Study Based on Cox Regression and Propensity Score Matching. Mediators Inflamm 2023; 2023:7312822. [PMID: 36994229 PMCID: PMC10042635 DOI: 10.1155/2023/7312822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 03/31/2023] Open
Abstract
Introduction Sepsis is a common syndrome in critically ill patients. Fibrinogen was reported to be associated with the prognosis of sepsis patients. Materials and Methods Data was acquired from Multiparameter Intelligent Monitoring in Intensive Care Database IV (MIMIC-IV) version 1.0. Cox proportional hazards regression was utilized to estimate the relationship between fibrinogen and inhospital mortality. The cumulative incidence of mortality by fibrinogen level was estimated through the Kaplan-Meier curve. Restricted cubic spline (RCS) was used to assess nonlinear relationship. Subgroup analysis was also conducted to evaluate the robustness of the association between fibrinogen and inhospital mortality. Propensity score matching (PSM) was applied to adjust for confounding factors. Results A total of 3365 patients, including 2031 survivors and 1334 nonsurvivors, were enrolled in our study. The survivors had a significantly elevated levels of fibrinogen compared with the deceased. The elevated level of fibrinogen was significantly associated with a decrease in mortality in multivariate Cox regression before and after PSM (HR 0.66, P < 0.001 and HR 0.73, P < 0.001, respectively). RCS showed a nearly linear relationship. Subgroup analysis demonstrated the robustness of the association in most subpopulations. However, the association between decreased levels of fibrinogen and increased inhospital mortality was denied after PSM. Conclusion The elevated level of fibrinogen hints at better overall survival in critically ill patients with sepsis. Decreased levels of fibrinogen may be of little value in identifying patients with a high risk of death.
Collapse
Affiliation(s)
- Chi Yao
- 1Department of Urology, Zhongda Hospital, Southeast University, Nanjing 210009, China
- 2School of Medicine, Southeast University, Nanjing 210009, China
| | - Guangyuan Zhang
- 1Department of Urology, Zhongda Hospital, Southeast University, Nanjing 210009, China
- 2School of Medicine, Southeast University, Nanjing 210009, China
| | - Nieke Zhang
- 1Department of Urology, Zhongda Hospital, Southeast University, Nanjing 210009, China
- 2School of Medicine, Southeast University, Nanjing 210009, China
| | - Renjie Li
- 2School of Medicine, Southeast University, Nanjing 210009, China
| | - Si Sun
- 1Department of Urology, Zhongda Hospital, Southeast University, Nanjing 210009, China
- 2School of Medicine, Southeast University, Nanjing 210009, China
| | - Lei Zhang
- 1Department of Urology, Zhongda Hospital, Southeast University, Nanjing 210009, China
- 2School of Medicine, Southeast University, Nanjing 210009, China
| | - Yi Xia
- 2School of Medicine, Southeast University, Nanjing 210009, China
| | - Shuqiu Chen
- 1Department of Urology, Zhongda Hospital, Southeast University, Nanjing 210009, China
- 2School of Medicine, Southeast University, Nanjing 210009, China
| | - Jin Sun
- 2School of Medicine, Southeast University, Nanjing 210009, China
- 3Department of Urology, Xuyi People's Hospital, Huaian 211799, China
| | - Ming Chen
- 1Department of Urology, Zhongda Hospital, Southeast University, Nanjing 210009, China
- 2School of Medicine, Southeast University, Nanjing 210009, China
| |
Collapse
|
6
|
Outcomes of Overt and Non-overt Disseminated Intravascular Coagulation Using the ISTH DIC Scoring System in Children: A Single-Center Study. Mediterr J Hematol Infect Dis 2023; 15:e2023004. [PMID: 36660355 PMCID: PMC9833309 DOI: 10.4084/mjhid.2023.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/15/2022] [Indexed: 01/03/2023] Open
Abstract
Background Several disseminated intravascular coagulation (DIC) scoring systems are used for prognosticating the clinical outcomes of patients with DIC. However, research on children is scarce. Therefore, this study compared the clinical outcomes of overt and non-overt DIC using the International Society on Thrombosis and Hemostasis (ISTH) DIC scoring system. Methods This retrospective study reviewed data on children aged one month to 15 years diagnosed with DIC between 2003 and 2014. Results Of 244 patients, 179 (73.4%) had overt DIC, and 65 (26.6%) had non-overt DIC. The most common causes were infection (84.8%), tissue injury (7%), and malignancies (2.9%). The 28-day case fatality rate was significantly higher for overt than non-overt DIC (76% vs. 15.6%; P < 0.001). DIC scores were significantly associated with mortality (R2 = 0.89). Each clinical parameter (platelet count, prothrombin time, and fibrin degradation products) was associated with mortality (P = 0.01). On multivariable analysis, the factors associated with death were platelet counts ≤ 50 000 cells/mm3 (OR, 2.42; 95% CI, 1.08-5.42; P = 0.031); overt DIC score (OR, 7.62; 95% CI, 2.94-19.75; P < 0.001); renal dysfunction (OR, 2.92; 95% CI, 1.34-6.37; P = 0.007); shock (OR, 39.62; 95% CI, 4.99-314.84; P = 0.001); and acute respiratory distress syndrome (OR, 25.90; 95% CI, 3.12-214.80; P = 0.003). Conclusions The 28-day case-fatality rate was significantly higher for patients with overt than non-overt DIC and concordant with ISTH scores. ISTH DIC scores can be used as a clinical predictor for DIC in children.
Collapse
|
7
|
Abstract
During sepsis, an initial prothrombotic shift takes place, in which coagulatory acute-phase proteins are increased, while anticoagulatory factors and platelet count decrease. Further on, the fibrinolytic system becomes impaired, which contributes to disease severity. At a later stage in sepsis, coagulation factors may become depleted, and sepsis patients may shift into a hypo-coagulable state with an increased bleeding risk. During the pro-coagulatory shift, critically ill patients have an increased thrombosis risk that ranges from developing micro-thromboses that impair organ function to life-threatening thromboembolic events. Here, thrombin plays a key role in coagulation as well as in inflammation. For thromboprophylaxis, low molecular weight heparins (LMWH) and unfractionated heparins (UFHs) are recommended. Nevertheless, there are conditions such as heparin resistance or heparin-induced thrombocytopenia (HIT), wherein heparin becomes ineffective or even puts the patient at an increased prothrombotic risk. In these cases, argatroban, a direct thrombin inhibitor (DTI), might be a potential alternative anticoagulatory strategy. Yet, caution is advised with regard to dosing of argatroban especially in sepsis. Therefore, the starting dose of argatroban is recommended to be low and should be titrated to the targeted anticoagulation level and be closely monitored in the further course of treatment. The authors of this review recommend using DTIs such as argatroban as an alternative anticoagulant in critically ill patients suffering from sepsis or COVID-19 with suspected or confirmed HIT, HIT-like conditions, impaired fibrinolysis, in patients on extracorporeal circuits and patients with heparin resistance, when closely monitored.
Collapse
|
8
|
Faustino EVS, Karam O, Parker RI, Hanson SJ, Brandão LR, Monagle P. Coagulation Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference. Pediatrics 2022; 149:S79-S83. [PMID: 34970670 DOI: 10.1542/peds.2021-052888l] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Previous criteria for coagulation dysfunction in critically ill children were based mainly on expert opinion. OBJECTIVE To evaluate current evidence regarding coagulation tests associated with adverse outcomes in children to inform criteria for coagulation dysfunction during critical illness. DATA SOURCES Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020 by using a combination of medical subject heading terms and text words to define concepts of coagulation dysfunction, pediatric critical illness, and outcomes of interest. STUDY SELECTION Studies were included if critically ill children with coagulation dysfunction were evaluated, if performance characteristics of assessment and/or scoring tools to screen for coagulation dysfunction were evaluated, and if outcomes related to mortality or functional status, organ-specific outcomes, or other patient-centered outcomes were assessed. DATA EXTRACTION Data were abstracted from each eligible study into a standard data extraction form, along with risk of bias assessment, by a task force member. RESULTS The systematic review supports the presence of at least 2 of the following criteria reflecting coagulation dysfunction in the absence of liver dysfunction: platelet count <100 000 cells per μL, international normalized ratio >1.5, fibrinogen level <150 mg/dL, and D-dimer value above 10 times the upper limit of normal, or above the assay's upper limit of detection if this limit is below 10 times the upper limit of normal. LIMITATIONS The proposed criteria for coagulation dysfunction are limited by the available evidence and will require future validation. CONCLUSIONS Validation of the proposed criteria and identified scientific priorities will enhance our understanding of coagulation dysfunction in critically ill children.
Collapse
Affiliation(s)
- E Vincent S Faustino
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Robert I Parker
- Hematology/Oncology, Department of Pediatrics (Emeritus), Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Sheila J Hanson
- Critical Care Section, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, Wisconsin
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Paul Monagle
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Department of Clinical Haematology, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | | |
Collapse
|
9
|
Muszynski JA, Cholette JM, Steiner ME, Tucci M, Doctor A, Parker RI. Hematologic Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference. Pediatrics 2022; 149:S74-S78. [PMID: 34970675 DOI: 10.1542/peds.2021-052888k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Studies of organ dysfunction in children are limited by a lack of consensus around organ dysfunction criteria. OBJECTIVES To derive evidence-informed, consensus-based criteria for hematologic dysfunction in critically ill children. DATA SOURCES Data sources included PubMed and Embase from January 1992 to January 2020. STUDY SELECTION Studies were included if they evaluated assessment/scoring tools to screen for hematologic dysfunction and assessed outcomes of mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. Studies of adults or premature infants, animal studies, reviews/commentaries, small case series, and non-English language studies with inability to determine eligibility were excluded. DATA EXTRACTION Data were abstracted from each eligible study into a standard data extraction form along with risk of bias assessment. RESULTS Twenty-nine studies were included. The systematic review supports the following criteria for hematologic dysfunction: thrombocytopenia (platelet count <100000 cells/µL in patients without hematologic or oncologic diagnosis, platelet count <30000 cells/µL in patients with hematologic or oncologic diagnoses, or platelet count decreased ≥50% from baseline; or leukocyte count <3000 cells/µL; or hemoglobin concentration between 5 and 7 g/dL (nonsevere) or <5 g/dL (severe). LIMITATIONS Most studies evaluated pre-specified thresholds of cytopenias. No studies addressed associations between the etiology or progression of cytopenias overtime with outcomes, and no studies evaluated cellular function. CONCLUSIONS Hematologic dysfunction, as defined by cytopenia, is a risk factor for poor outcome in critically ill children, although specific threshold values associated with increased mortality are poorly defined by the current literature.
Collapse
Affiliation(s)
- Jennifer A Muszynski
- Department of Pediatrics, Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Jill M Cholette
- Department of Pediatrics, Critical Care Medicine, University of Rochester, Rochester, New York
| | - Marie E Steiner
- Department of Pediatrics, Critical Care Medicine & Hematology, University of Minnesota, Minneapolis, Minnesota
| | - Marisa Tucci
- Department of Pediatrics, Critical Care Medicine, CHU Sainte Justine, University of Montreal, Montreal, QC, Canada
| | - Allan Doctor
- Department of Pediatrics, Critical Care Medicine & Center for Blood Oxygen Transport and Hemostasis, University of Maryland, Baltimore, Maryland
| | - Robert I Parker
- Department of Pediatrics, Hematology/Oncology, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | | |
Collapse
|
10
|
Menon K, Schlapbach LJ, Akech S, Argent A, Biban P, Carrol ED, Chiotos K, Jobayer Chisti M, Evans IVR, Inwald DP, Ishimine P, Kissoon N, Lodha R, Nadel S, Oliveira CF, Peters M, Sadeghirad B, Scott HF, de Souza DC, Tissieres P, Watson RS, Wiens MO, Wynn JL, Zimmerman JJ, Sorce LR. Criteria for Pediatric Sepsis-A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce. Crit Care Med 2022; 50:21-36. [PMID: 34612847 PMCID: PMC8670345 DOI: 10.1097/ccm.0000000000005294] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine the associations of demographic, clinical, laboratory, organ dysfunction, and illness severity variable values with: 1) sepsis, severe sepsis, or septic shock in children with infection and 2) multiple organ dysfunction or death in children with sepsis, severe sepsis, or septic shock. DATA SOURCES MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020. STUDY SELECTION Case-control studies, cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years with suspected or confirmed infection, which included the terms "sepsis," "septicemia," or "septic shock" in the title or abstract. DATA EXTRACTION Study characteristics, patient demographics, clinical signs or interventions, laboratory values, organ dysfunction measures, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed. DATA SYNTHESIS One hundred and six studies met eligibility criteria of which 81 were included in the meta-analysis. Sixteen studies (9,629 patients) provided data for the sepsis, severe sepsis, or septic shock outcome and 71 studies (154,674 patients) for the mortality outcome. In children with infection, decreased level of consciousness and higher Pediatric Risk of Mortality scores were associated with sepsis/severe sepsis. In children with sepsis/severe sepsis/septic shock, chronic conditions, oncologic diagnosis, use of vasoactive/inotropic agents, mechanical ventilation, serum lactate, platelet count, fibrinogen, procalcitonin, multi-organ dysfunction syndrome, Pediatric Logistic Organ Dysfunction score, Pediatric Index of Mortality-3, and Pediatric Risk of Mortality score each demonstrated significant and consistent associations with mortality. Pooled mortality rates varied among high-, upper middle-, and lower middle-income countries for patients with sepsis, severe sepsis, and septic shock (p < 0.0001). CONCLUSIONS Strong associations of several markers of organ dysfunction with the outcomes of interest among infected and septic children support their inclusion in the data validation phase of the Pediatric Sepsis Definition Taskforce.
Collapse
Affiliation(s)
- Kusum Menon
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Luregn J. Schlapbach
- Pediatric and Neonatal ICU, University Children`s Hospital Zurich, Zurich, Switzerland, and Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Samuel Akech
- KEMRI Wellcome Trust Research Program, Nairobi, Kenya
| | - Andrew Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, Cape Town, South Africa
| | - Paolo Biban
- Department of Paediatrics, Verona University Hospital, Verona, Italy
| | - Enitan D. Carrol
- Department of Clinical Infection Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Liverpool, United Kingdom
| | | | | | - Idris V. R. Evans
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, and The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA
| | - David P. Inwald
- Paediatric Intensive Care Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Paul Ishimine
- Departments of Emergency Medicine and Pediatrics, University of California San Diego School of Medicine, La Jolla, CA
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia and British Columbia Children’s Hospital, Vancouver, BC, Canada
| | - Rakesh Lodha
- All India Institute of Medical Sciences, Delhi, India
| | - Simon Nadel
- St. Mary’s Hospital, Imperial College Healthcare NHS Trust, and Imperial College London, London, United Kingdom
| | | | - Mark Peters
- University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Benham Sadeghirad
- Departments of Anesthesia and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Halden F. Scott
- Departments of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Daniela C. de Souza
- Departments of Pediatrics, Hospital Sírio-Libanês and Hospital Universitário da Universidade de São Paulo, São Paolo, Brazil
| | - Pierre Tissieres
- Pediatric Intensive Care, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Matthew O. Wiens
- University of British Columbia, Vancouver, BC, Canada
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - James L. Wynn
- Department of Pediatrics, University of Florida, Gainesville, FL
| | - Jerry J. Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Lauren R. Sorce
- Ann & Robert H. Lurie Children’s Hospital and Department of Pediatrics, Northwestern University Feinberg School of Medicine, Lurie Children’s Pediatric Research & Evidence Synthesis Center (PRECIISE): A JBI Affiliated Group, Chicago, IL
| |
Collapse
|
11
|
Bekhit OE, Yousef RM, Abdelrasol HA, Mohammed MA. Serum Albumin Level as a Predictor of Outcome in Patients Admitted to Pediatric Intensive Care Units. Pediatr Emerg Care 2021; 37:e855-e860. [PMID: 34908378 DOI: 10.1097/pec.0000000000002567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The aim of this study was to assess serum albumin level on admission to the pediatric intensive care unit (PICU) as a prognostic indicator. METHODS A prospective study was conducted in Fayoum University Children's Hospital. The study subjects' demographics and clinical and laboratory data were recorded. Pediatric Risk of Mortality III (PRISM-III) score was calculated. Serum albumin level was assessed within 24 hours from admission. Outcomes included mortality, PICU and hospital stay, need and duration of mechanical ventilation, and inotrope use. RESULTS The incidence of admission hypoalbuminemia was 26%. The study subjects had a significantly higher mortality rate than subjects with normal albumin levels (42.3% vs 17.6%, respectively, P = 0.011). Each unit of increase in serum albumin decreased the risk of mortality by 28.9% (odds ratio, 0.289; confidence interval, 0.136-0.615, P = 0.001). Serum albumin showed a fair discriminatory power (area under the curve, 0.738). At a cutoff point of ≤3.7 g/dL, albumin had a 79.2% sensitivity, 67.1% specificity, 43.2% positive predictive value, and 91.1% negative predictive value. Incorporation of serum albumin with PRISM-III score was more predictive of mortality than either predictors alone (area under the curve, 0.802). No significant difference was found between the 2 groups regarding either PICU and hospital stay as well as the need and duration of ventilation. CONCLUSIONS In PICUs, admission hypoalbuminemia is a good predictor of mortality. Further studies to confirm the value of adding serum albumin to PRISM-III score are recommended.
Collapse
|
12
|
Crighton GL, Huisman EJ. Pediatric Fibrinogen PART II-Overview of Indications for Fibrinogen Use in Critically Ill Children. Front Pediatr 2021; 9:647680. [PMID: 33968851 PMCID: PMC8097134 DOI: 10.3389/fped.2021.647680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/09/2021] [Indexed: 01/16/2023] Open
Abstract
Bleeding is frequently seen in critically ill children and is associated with increased morbidity and mortality. Fibrinogen is an essential coagulation factor for hemostasis and hypofibrinogenemia is an important risk factor for bleeding in pediatric and adult settings. Cryoprecipitate and fibrinogen concentrate are often given to critically ill children to prevent bleeding and improve fibrinogen levels, especially in the setting of surgery, trauma, leukemia, disseminated intravascular coagulopathy, and liver failure. The theoretical benefit of fibrinogen supplementation to treat hypofibrinogenemia appears obvious, yet the evidence to support fibrinogen supplementation in children is sparce and clinical indications are poorly defined. In addition, it is unknown what the optimal fibrinogen replacement product is in children and neonates or what the targets of treatment should be. As a result, there is considerable variability in practice. In this article we will review the current pediatric and applicable adult literature with regard to the use of fibrinogen replacement in different pediatric critical care contexts. We will discuss the clinical indications for fibrinogen supplementation in critically ill children and the evidence to support their use. We summarize by highlighting current knowledge gaps and areas for future research.
Collapse
Affiliation(s)
| | - Elise J. Huisman
- Department of Hematology, Erasmus MC–Sophia Children's Hospital, Rotterdam, Netherlands
- Department of Clinical Chemistry and Blood Transfusion, Erasmus MC, Rotterdam, Netherlands
- Department of Transfusion Medicine, Sanquin Blood Supply, Amsterdam, Netherlands
| |
Collapse
|
13
|
Huisman EJ, Crighton GL. Pediatric Fibrinogen PART I-Pitfalls in Fibrinogen Evaluation and Use of Fibrinogen Replacement Products in Children. Front Pediatr 2021; 9:617500. [PMID: 33968842 PMCID: PMC8097151 DOI: 10.3389/fped.2021.617500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/26/2021] [Indexed: 11/13/2022] Open
Abstract
Fibrinogen is a key coagulation protein, playing a critical role in hemostasis. It is the first factor to decrease to critical levels during bleeding. Hypofibrinogenemia is an important risk factor for bleeding in clinical settings, including pediatric surgery. Yet, the optimal measurement of fibrinogen levels is subject to debate, as is the critical threshold for intervention. Fibrinogen replacement may be provided by cryoprecipitate and fibrinogen concentrate. Whilst both products contain fibrinogen, they are not equivalent, each has its own advantages and disadvantages, especially for pediatric use. Unfortunately, medical literature to support fibrinogen replacement in children is limited. In this article we review the current diagnostic tools to measure fibrinogen, with respect to their use in the pediatric critical care setting. Secondly, we evaluate the different fibrinogen replacement therapies, focusing on cryoprecipitate and fibrinogen concentrate and examine their individual product characteristics, associated risks and benefits, different dosing strategies and specific pitfalls for use in children. We summarize by highlighting current knowledge gaps and areas for future research.
Collapse
Affiliation(s)
- Elise J Huisman
- Department of Hematology, Erasmus Medical Center (MC)-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Clinical Chemistry and Blood Transfusion, Erasmus Medical Center (MC), Rotterdam, Netherlands.,Department of Transfusion Medicine, Sanquin Blood Supply, Amsterdam, Netherlands
| | | |
Collapse
|
14
|
Nairz M, Weiss G. Iron in infection and immunity. Mol Aspects Med 2020; 75:100864. [PMID: 32461004 DOI: 10.1016/j.mam.2020.100864] [Citation(s) in RCA: 163] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/25/2020] [Accepted: 05/05/2020] [Indexed: 12/12/2022]
Abstract
Iron is an essential micronutrient for virtually all living cells. In infectious diseases, both invading pathogens and mammalian cells including those of the immune system require iron to sustain their function, metabolism and proliferation. On the one hand, microbial iron uptake is linked to the virulence of most human pathogens. On the other hand, the sequestration of iron from bacteria and other microorganisms is an efficient strategy of host defense in line with the principles of 'nutritional immunity'. In an acute infection, host-driven iron withdrawal inhibits the growth of pathogens. Chronic immune activation due to persistent infection, autoimmune disease or malignancy however, sequesters iron not only from infectious agents, autoreactive lymphocytes and neoplastic cells but also from erythroid progenitors. This is one of the key mechanisms which collectively result in the anemia of chronic inflammation. In this review, we highlight the most important interconnections between iron metabolism and immunity, focusing on host defense against relevant infections and on the clinical consequences of anemia of inflammation.
Collapse
Affiliation(s)
- Manfred Nairz
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Austria
| | - Günter Weiss
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Austria; Christian Doppler Laboratory for Iron Metabolism and Anemia Research, Medical University of Innsbruck, Austria.
| |
Collapse
|
15
|
Dagnino APA, Campos MM, Silva RBM. Kinins and Their Receptors in Infectious Diseases. Pharmaceuticals (Basel) 2020; 13:ph13090215. [PMID: 32867272 PMCID: PMC7558425 DOI: 10.3390/ph13090215] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/23/2020] [Accepted: 08/25/2020] [Indexed: 01/08/2023] Open
Abstract
Kinins and their receptors have been implicated in a series of pathological alterations, representing attractive pharmacological targets for several diseases. The present review article aims to discuss the role of the kinin system in infectious diseases. Literature data provides compelling evidence about the participation of kinins in infections caused by diverse agents, including viral, bacterial, fungal, protozoan, and helminth-related ills. It is tempting to propose that modulation of kinin actions and production might be an adjuvant strategy for management of infection-related complications.
Collapse
|
16
|
Fibrinogen as a Prognostic Predictor in Pediatric Patients with Sepsis: A Database Study. Mediators Inflamm 2020; 2020:9153620. [PMID: 32410872 PMCID: PMC7204196 DOI: 10.1155/2020/9153620] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/21/2020] [Accepted: 04/06/2020] [Indexed: 01/27/2023] Open
Abstract
Background Systemic inflammatory response and vascular endothelial cell injury during sepsis lead to coagulopathy. Fibrinogen has been reported as a biomarker of coagulopathy; however, the prognostic value of fibrinogen remains undefined in pediatric patients with sepsis. The aim of this study was to assess fibrinogen level on pediatric intensive care unit (PICU) admission and to elucidate the relationship between fibrinogen levels and in-hospital mortality in children with sepsis. Methods We conducted a database study. The sepsis database was divided into a training set (between July 2014 and June 2018) and a validation set (from July 2018 to June 2019). The clinical and laboratory parameters on PICU admission and in-hospital mortality in sepsis database were collected and analyzed. Results A total of 819 pediatric patients were included from database as a training set. The overall hospital mortality was 12.1% (99/819). The fibrinogen levels were significantly lower in nonsurvivors than survivors. Multivariate logistic regression analysis showed significant associations between fibrinogen, lactate level, and hospital mortality (fibrinogen: odds ratio (OR), 0.767 (95% CI: 0.628-0.937), P = 0.009; lactate: OR, 1.346 (95% CI: 1.217-1.489), P < 0.001, respectively), which was confirmed in a validation set (0.616 [95% CI: 0.457-0.829], P = 0.001; 1.397 [95% CI: 1.245-1.569], P < 0.001, respectively). The hospital mortality of patients with fibrinogen < 1 g/L, 1-2 g/L, 2-3 g/L, or over 3 g/L displayed an obvious difference (62.5% vs. 27.66% vs. 18.1% vs. 4.2%, respectively). Furthermore, the area under the receiver operating characteristic curve (ROC) for fibrinogen in predicting hospital mortality was 0.780 (95% CI: 0.711-0.850) in pediatric patients with sepsis. Conclusions Fibrinogen is a valuable prognostic biomarker for pediatric sepsis. The level of fibrinogen lower than 2 g/L on PICU admission is closely related to the greater risk of hospital death in pediatric sepsis.
Collapse
|