From the International Pediatric Sepsis Conference 2005 to the Sepsis-3 Consensus

Features of Metabolites and Biomarkers in Inflammatory and Infectious Complications of Childhood Cancers

Background: In the treatment of oncological diseases in children, the search for opportunities for the earlier detection of complications to improve treatment results is very important. Metabolomic studies are actively conducted to stratify different groups of patients in order to identify the most promising markers. Methods: Three groups of patients participated in this study: healthy children as a control group (n = 18), children with various malignant oncological diseases (leukemia, lymphoma, nephroblastoma, ependymoma, etc.) as patients (n = 40) without complications, and patients (n = 31) with complications (inflammatory and infectious). The mitochondrial metabolites (succinic and fumaric acids); biomarkers related to inflammation such as C-reactive protein (CRP), procalcitonin (PCT), and presepsin (PSP); and sepsis-associated aromatic metabolites, such as phenyllactic (PhLA), hydroxyphenyllactic (p-HPhLA), and hydroxyphenylacetic acids (p-HPhAA), were identified. Results: It was found that children with malignant oncological diseases had profound metabolic dysfunction compared to healthy children, regardless of the presence of systemic inflammatory response syndrome (SIRS) or sepsis. The prognostic ability of procalcitonin and presepsin for detecting sepsis was high: AUROC = 0.875, cut-off value (Youden index) = 0.913 ng/mL, and AUROC = 0.774, with cut-off value (Youden index) of 526 pg/mL, respectively. Conclusions: A significant increase in aromatic microbial metabolites and biomarkers in non-survivor patients that is registered already in the first days of the development of complications indicates the appropriateness of assessing metabolic dysfunction for its timely targeted correction.

Evaluation Value and Clinical Significance of Cardiac Troponin Level and Pediatric Sequential Organ Failure Score in the Definition of Sepsis 3.0 in Critically Ill Children

Objective

A case-control study was conducted to explore the value and clinical significance of troponin level and pediatric sequential organ failure score in the evaluation of sepsis 3.0 definition in critically ill children.

Methods

180 children with sepsis who were admitted to the ICU from March 2019 to June 2021 were enrolled in our hospital as the research objects. In addition, 100 children with general infection did not meet the diagnostic criteria of systemic inflammatory response syndrome (SIRS) as controls. The creatine kinase MB (CK-MB) and cardiac troponin I (cTnI) data at the 1st and 24-72 h after admission to pediatric intensive care unit (PICU) were enrolled as the observation indexes of myocardial enzymology. In the meantime, the relevant literature was reviewed to obtain the indicators related to sepsis death. The data of the first examination in the medical history data were enrolled for analysis. According to the definition of sepsis 3.0 in critically ill children, they were assigned into sepsis and nonsepsis group. According to the survival outcome of discharge and 30 days after discharge, the patients were assigned into the death subgroup and survival subgroup and were assigned into the sequential organ failure assessment (SOFA) score ≥ 2 subgroup and< 2 subgroup according to SOFA score. COX proportional hazard regression was used to analyze the relationship between CK-MB, cTnI, and SOFA scores and prognosis. ROC curve was adopted to analyze the value of CK-MB, cTnI, and SOFA scores in the evaluation of critical sepsis in children.

Results

Univariate analysis indicated that the prognosis of children with sepsis was correlated with abnormal levels of CK-MB and cTnI, SOFA score, oxygenation index < 200, mean arterial pressure, and Glasgow coma scale (GCS), and the difference was statistically significant (P < 0.05). The results of COX regression analysis indicated that the variables that were remarkably associated with death from sepsis in children were CK-MB, elevated cTnI levels, and SOFA score ≥ 2, and serum cTnI and/or CK-MB levels and SOFA score were remarkably higher correlation (r = 0.453, P < 0.05). In terms of the myocardial enzyme levels in the sepsis group and the nonsepsis group, the levels of CK-MB and (or) cTnI augmented in 121/180 cases (67.22%) in the sepsis group and in 19/100 cases (19.00%) in the nonsepsis group. The levels of CK-MB and (or) cTnI were augmented, and the difference was statistically significant (P < 0.05). The levels of CK-MB and cTnI in the sepsis group at admission to ICU and 24 to 72 hours after admission were remarkably higher compared to the nonsepsis group. The levels of CK-MB and cTnI at 24-72 h were higher compared to ICU. The myocardial enzyme levels of different SOFA scores and survival outcome subgroups in the sepsis group were compared. The subgroup with SFOA score ≥ 2 points had remarkably higher levels of CK-MB and (or) cTnI than the subgroup with <2 points. The survival subgroup of CK-MB and cTnI level was remarkably higher compared to the death subgroup, the CK-MB and cTnI levels in each subgroup at 224-72 hours were remarkably higher compared to the ICU, and the difference was statistically significant (P < 0.05). Kaplan-Meier method and log-rank test indicated that the survival rates of groups 1 to 4 at 30 days were 33.23%, 78.71%, 40.03%, and 100.00%, respectively. The average survival time and their 95% CI were 12.82 d (10.52~ 16.26 d), 22.34 d (18.76~ 25.81 d), 14.65 d (11.62~ 16.38 d), and 30 d (30.00~ 30.00 d), respectively. Pairwise comparison indicated that the survival time of children in group 1 was the shortest, and that in group 4 was the longest. The results of ROC curve research showed that the CK-MB, cTnI, and SOFA scores and AUC for the combination test were 0.778 (95% CI 0.642–0.914), 0.736 (95% CI 0.602–0.890), 0.848 (95% CI 0.733–0.963), and 0.934 (95% CI 0.854–0.999), respectively. The AUC of combined diagnosis was remarkably higher compared to single factor prediction, and the difference was statistically significant (P < 0.05). Predictive value showed the joint test > SOFA score > CK − MB > cTnI.

Conclusion

Troponin level and pediatric SOFA score can be adopted as effective indicators to assess the severity and prognosis of patients with sepsis and can guide the formulation of a reasonable treatment plan.

Melatonin as a master regulator of cell death and inflammation: molecular mechanisms and clinical implications for newborn care

Melatonin, more commonly known as the sleep hormone, is mainly secreted by the pineal gland in dark conditions and regulates the circadian rhythm of the organism. Its intrinsic properties, including high cell permeability, the ability to easily cross both the blood–brain and placenta barriers, and its role as an endogenous reservoir of free radical scavengers (with indirect extra activities), confer it beneficial uses as an adjuvant in the biomedical field. Melatonin can exert its effects by acting through specific cellular receptors on the plasma membrane, similar to other hormones, or through receptor-independent mechanisms that involve complex molecular cross talk with other players. There is increasing evidence regarding the extraordinary beneficial effects of melatonin, also via exogenous administration. Here, we summarize molecular pathways in which melatonin is considered a master regulator, with attention to cell death and inflammation mechanisms from basic, translational and clinical points of view in the context of newborn care.

Changes of rScO2 and ScvO2 in children with sepsis-related encephalopathy with different prognoses and clinical features

Clinical features of sepsis-associated encephalopathy in children with different prognoses were analyzed and the changes of regional cerebral oxygen saturation (rScO₂) and central venous oxygen saturation (ScvO₂) were measured. Eighty children with sepsis-related encephalopathy, admitted to the Pediatric Intensive Care Unit (PICU) of the Children's Hospital Affiliated to Zhengzhou University, were enrolled in this study and post-intensive care syndrome (PICS) scoring was performed within 24 h after admission. Patients were separated into groups according to the score results and treatment outcomes. Clinical features, functional tests, imaging examinations, PICS scores, and modified Glasgow Coma Scale (GCS) scores were compared among children with varying severities and prognoses. The changes of rScO₂ and ScvO₂ at different time-points among children with different prognoses were measured and compared. According to PICS scores, there were 8 non-critically ill children, 42 critically ill children, and 30 extremely critically ill children. Fifty-two children survived, and the survival rate was 65%. Comparison of the clinical characteristics of children with different conditions showed that deep coma, generalized seizure, severe electroencephalogram (EEG) abnormalities, and the survival of children were significantly associated with the severity of disease (P<0.05). At the same time, compared to the survivors group, the rates of generalized seizures and severe EEG abnormalities were significantly increased in the deceased children group, while the PICS and GCS scores were significantly decreased (P<0.05). rScO₂ values in the deceased group were lower than those in the survival group at different time-points, but the differences were not significant (P>0.05). On the contrary, ScvO₂ values were significantly higher in the deceased group than those in the survivors group (P<0.05). The lower the PICS and GCS scores in children with sepsis-related encephalopathy, the more serious the condition, and the more likely to develop disturbance of consciousness, epileptic seizures, and abnormal EEG changes. Whereas, changes of ScvO₂ are closely related to prognosis.

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.