International Consensus Criteria for Pediatric Sepsis and Septic Shock

Vitamin D Deficiency and Clinical Outcomes in Critically Ill Pediatric Patients: A Systematic Review and Meta-Analysis

Context

Vitamin D deficiency (VDD) is common in paediatric populations, and its relationship with critical care outcomes warrants further investigation.

Objective

The aim is to examine the association between VDD and clinical outcomes in children admitted to the Pediatric Intensive Care Unit (PICU).

Methods

This systematic review and meta-analysis investigated the impact of VDD on clinical outcomes in PICU patients. A comprehensive search of Embase, Web of Science, PubMed, and Cochrane databases was conducted. Our primary outcomes were mortality and sepsis incidence, while secondary outcomes included length of stay (LOS), need for inotropic support, and need for and duration of mechanical ventilation. Eligible studies included infants and children aged 1 month to 18 years admitted to the PICU, with baseline 25-hydroxyvitamin D levels measured on admission. Two independent reviewers screened studies, extracted data, and assessed quality. Pooled estimates were obtained using a random-effects model.

Results

Out of 2298 screened studies, 27 met the inclusion criteria, comprising 4682 patients. VDD was defined as 25-hydroxyvitamin D levels <20 ng/mL and <30 ng/mL in 22 and 5 studies, respectively. VDD was associated with increased mortality (odds ratio [OR] 2.05, 95% CI 1.21-3.48) and a greater need for inotropic support (OR 2.02, 95% CI 1.43-2.85) than children with vitamin D sufficiency (VDS). No differences were observed between VDD and VDS groups in terms of sepsis incidence postadmission, LOS, or the need for and duration of mechanical ventilation.

Conclusion

VDD in critically ill pediatric patients was associated with increased mortality and higher need for inotropic support. Further research is warranted to evaluate the potential benefits of vitamin D supplementation in this high-risk population.

Low levels of CD39+ Tregs may predict poor outcome in children with sepsis

OBJECTIVES

Sepsis is a life-threatening condition caused by a dysregulated immune response. This study aimed to explore immune dysregulation in pediatric sepsis and identify prognostic biomarkers for mortality prediction.

METHODS

Ninety-nine children with sepsis were followed for 28 days. Flow cytometry was used to analyze T cells, T-helper cells, B cells, natural killer (NK) cells, dendritic cells (DCs), and their subpopulations. Correlations between CD39+ regulatory T cells (Tregs), plasmacytoid DCs (pDCs), and transitional B cells with Phoenix Sepsis Score (PSS) were assessed. Receiver operating characteristic and Kaplan-Meier analyses were used to evaluate the prognostic value of CD39+ Tregs and pDCs. Cytokine levels were measured using a cytometric bead array.

RESULTS

CD39+ Tregs and transitional B cells were significantly lower in the nonsurvival and remote groups, while pDCs showed the opposite trend. CD39+ Tregs were negatively correlated with PSS, and pDCs were positively correlated. CD39+ Tregs below 12.45 % and pDCs above 0.96 % were both strong predictors of increased mortality risk. CD39+ Tregs maintained stable predictive performance within 72 h.

CONCLUSIONS

CD39+ Tregs and pDCs may serve as potential prognostic biomarkers in pediatric sepsis, with specific thresholds predicting increased mortality risk.

Cellulitis in Pediatric Patients: Recognition and Management in the Era of Evolving Resistance

Cellulitis, a bacterial skin infection most frequently caused by group A streptococci (Streptococcus pyogenes) and less so by Staphylococcus aureus, commonly occurs in pediatric patients. The non-specific clinical presentation of poorly demarcated, expanding erythema, and warmth is common to a multitude of similarly presenting conditions, contributing to challenges in accurate diagnosis. There is also no gold standard diagnostic test for cellulitis, as laboratory assessments, tissue and blood cultures, and imaging studies have not been helpful. These adjunctive studies may be useful, however, for ruling out mimickers or more serious or complicating conditions, such as osteomyelitis, necrotizing fasciitis, or abscess. Diagnosis remains largely clinical and evaluation by a dermatologist and/or infectious disease specialist continues to be the clinical gold standard. As a result, access to specialty care and further research into helpful adjunctive measures, such as thermal imaging, are imperative for accurate diagnosis and management to prevent inappropriate antibiosis. Multidrug resistance has continued to evolve since the initial emergence of community-associated methicillin-resistant Staphylococcus aureus, with more recent studies showing an overall decline of methicillin-resistant S. aureus in the community and highest rates remaining in the Southern region of the USA. Despite changing resistance patterns, inappropriate prescribing patterns have persisted and contribute to rising rates of resistance to antibiotics such as trimethoprim-sulfamethoxazole and clindamycin. Therefore, accurate diagnosis and subsequent management with the narrowest possible antimicrobial therapy is ideal both for individual patient outcomes and for public health.

The lack of a biorepository during vaccine trials: A lost opportunity to understand staphylococcal immunity

Development of a vaccine against Staphylococcus aureus has proven to be difficult, in no small measure due to our lack of understanding of the human immune response to this pathogen. Because the human immune response is distinct from other species often used for pre-clinical animal models, including non-human primates, it will be necessary to perform studies in humans to guide vaccine development. One can view the staphylococcal vaccine clinical trials as an opportunity to study human immune response to S. aureus infections, which of course provide outcome data. In order to gain maximal information from these clinical trials, biological materials should be taken during the trial. In this commentary article, we explore a mechanism for such collection.

The utility of neonatal sequential organ failure assessment in mortality risk in all neonates with suspected late-onset infection

OBJECTIVE

Assess the utility of the neonatal sequential organ failure assessment score (nSOFA) for evaluation-specific mortality discrimination in all late-onset infection (LOI) evaluations.

METHODS

Retrospective Cohort of all neonates who had an LOI evaluation from 2012 to 2023 in a single level IV Academic NICU in Florida, USA. The primary outcome was LOI-evaluation-specific mortality.

RESULTS

1481 neonates had 2916 LOI evaluations with a 3.8% mortality rate. The AUROC for the nSOFA score at evaluation was 0.76 (95% CI 0.71-0.81) and improved to 0.82 (95% CI 0.78-0.87) six hours after. nSOFA ≥2 within 6 h of the start of the LOI was 87% sensitive and 66% specific, with a 99% NPV for mortality, p < 0.0001.

CONCLUSIONS

The nSOFA score had good to excellent mortality discrimination at the LOI evaluation level. These results solidify the utility of the nSOFA score as the foundation for a consensus definition of neonatal sepsis.

MAPK14 drives Ferroptosis and immune dysfunction in pediatric Sepsis-induced acute lung injury

OBJECTIVE

Sepsis-induced acute lung injury (ALI) is driven by inflammation, oxidative stress, and immune suppression. MAPK14 (p38α) plays a role in ferroptosis and immune regulation, but its specific function in pediatric sepsis remains unclear. Therefore, our study aimed to explore the role and underlying mechanism of MAPK14 in pediatric sepsis.

METHODS

Bioinformatics analysis of GSE26440 and FerrDb identified ferroptosis-related genes in pediatric sepsis. STRING database was used to predict the proteins associated with MAPK14. MAPK14 expression in whole blood samples, LPS-treated MLE-12 cells, and a CLP mouse model was detected by qRT-PCR and western blot. Ferroptosis was assessed by measuring MDA, GSH, and Fe2+ levels, while ROS accumulation was analyzed using DCFH-DA staining and DHE staining. A cycloheximide (CHX) assay was performed to assess TTP53 protein stability. MPO immunohistochemistry and PD-L1 immunofluorescence assessed neutrophil infiltration, and flow cytometry evaluated neutrophil apoptosis.

RESULTS

Bioinformatics analysis of GSE26440 and FerrDb identified MAPK14 as a ferroptosis-related gene in pediatric sepsis. MAPK14 expression was upregulated in sepsis patient samples, LPS-treated MLE-12 cells and CLP mouse lung tissues. Overexpression of MAPK14 led to increased MDA and Fe2+ levels, reduced GSH, and elevated ROS fluorescence intensity, confirming its role in promoting ferroptosis. Mechanistically, MAPK14 upregulated TTP53, which in turn suppressed SLC7A11 and GPX4, further driving ferroptosis. MAPK14 overexpression stabilized TTP53 and enhanced its activity. Additionally, MAPK14 enhanced MPO and PD-L1 expression to promote neutrophil infiltration and immune suppression. Additionally, MAPK14 overexpression inhibited neutrophil apoptosis, promoted neutrophil infiltration and enhanced immune suppression.

CONCLUSION

MAPK14 drives ferroptosis via the TTP53/SLC7A11/GPX4 pathway and exacerbates immune suppression by promoting neutrophil infiltration.

Outcome reporting in neonatal septic shock studies: A systematic review

OBJECTIVES

Neonatal septic shock is a critical condition requiring immediate and individualised intervention. Despite extensive research, there is a significant heterogeneity in outcome reporting across studies which may lead to incomparability of study results and limit evidence synthesis. The aim of this systematic review was to identify and analyse outcomes reported in studies focussing on interventions for neonatal septic shock to inform the development of a core outcome set to standardise outcome reporting for future research and practice.

METHODS

We conducted this systematic review following the Core Outcome Measures in Effectiveness Trials initiative framework and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We systematically searched PubMed, Embase (Ovid), and the Cochrane Library, covering all records until September 2024. Four independent reviewers performed literature screening and data extraction, with disagreements resolved by consensus among two additional reviewers. Extracted outcomes and their definitions were standardised and categorised into core areas and domains using a 38-item standardised taxonomy.

RESULTS

From 7139 records, 25 studies involving 4957 neonates were included, yielding 136 outcomes. After consolidation, 66 unique outcomes were identified and classified into four core areas based on the established taxonomy. The most frequently reported area was physiological/clinical outcomes (72%, 18 of 25 studies), encompassing 32 outcomes. This was followed by death (68%, 17/25), resource use (48%, 12/25), and adverse events (36%, 9/25). In addition, outcomes related to life impact were not measured in the included studies.

CONCLUSIONS

This review demonstrates considerable heterogeneity in outcome reporting across neonatal septic shock studies and highlights the absence of life impact measures. These findings support the need for developing a standardised core outcome set to enhance outcome reporting consistency and clinical relevance.

Dynamic risk stratification and treatment optimization in sepsis: the role of NLPR

Background

Sepsis, characterized by immune dysregulation, inflammatory cascades, and coagulation dysfunction, remains a global health challenge with high mortality, particularly in patients with multiple organ dysfunction syndrome (MODS). Existing prognostic tools, such as SOFA and APACHE II scores, are limited by complexity and lack of real-time monitoring, necessitating simple and reliable biomarkers for risk stratification and individualized management.

Objective

This study aimed to evaluate the prognostic value of the neutrophil-to-lymphocyte-to-platelet ratio (NLPR) for mortality in sepsis patients and explore its potential utility in dynamic risk stratification and treatment optimization.

Methods

We conducted a retrospective cohort study using the MIMIC-IV database (v3.1), including adult sepsis patients meeting Sepsis-3.0 criteria. NLPR was calculated based on neutrophil, lymphocyte, and platelet counts within 24 h of admission. Patients were stratified into quartiles (Q1-Q4) based on NLPR values. Kaplan-Meier survival analysis, Cox regression models, and restricted cubic spline (RCS) analysis were performed to assess NLPR's association with 28-day, 90-day, and 365-day mortality. Subgroup analyses examined NLPR's performance in diverse clinical populations.

Results

NLPR was a strong and independent predictor of mortality at all time points. Patients in the highest NLPR quartile (Q4) had significantly higher 28-day (28.22% vs. 12.64%), 90-day (36.82% vs. 18.06%), and 365-day (44.94% vs. 25.58%) mortality compared to the lowest quartile (Q1, all P < 0.001). Cox regression confirmed the independent association of high NLPR with mortality after adjusting for confounders such as age, gender, BMI, and SOFA scores. RCS analysis identified nonlinear relationships between NLPR and mortality, with critical thresholds (e.g.,NLPR = 6.5 for 365-day mortality) providing actionable targets for early risk identification. Subgroup analysis revealed consistent predictive performance across clinical populations, with amplified risks in younger patients, malnourished individuals, and those with acute kidney injury.

Conclusion

NLPR is a simple, accessible, and robust biomarker for sepsis risk stratification, integrating inflammation and coagulation data. It complements traditional scoring systems, provides actionable thresholds for early intervention, and facilitates dynamic monitoring. These findings underscore NLPR's potential to improve clinical decision-making and outcomes in sepsis management, warranting validation in prospective multicenter studies.

Sex Differences in Pediatric Sepsis Mortality: A Systematic Review and Meta-Analysis

OBJECTIVES

Pediatric sepsis remains a leading cause of childhood mortality worldwide. Sex differences have been shown to modify risk factors, treatment, and outcome of various diseases, and adult studies revealed sex differences in pathophysiological responses to septic shock. We aimed to perform a systematic review and meta-analysis on the association of sex with outcomes in hospitalized children with sepsis.

DATA SOURCES

Medline and Embase databases were searched for studies of children < 18 years with sepsis published between January 01, 2005, and March 31, 2022.

STUDY SELECTION

We included cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years which included sepsis, severe sepsis or septic shock, and mortality as an outcome.

DATA EXTRACTION

Study characteristics, patient demographics, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed.

DATA SYNTHESIS

We screened 14,791 studies, with 912 full-text reviews and inclusion of 124 studies. The total population involved 426,163 patients, of which 47% (201,438) were girls. Meta-regression showed moderate evidence for a higher mortality in boys compared with girls. The estimated risk difference of mortality between boys and girls with all types of sepsis was -0.005 (95% CI, -0.0099 to -0.00001; p = 0.049), indicating slightly higher mortality for boys. When including the World Bank income level as a moderator, the effect was -0.008 (95% CI, -0.013 to -0.002; p = 0.005).

CONCLUSIONS

This large systematic review and meta-analysis on sex differences in pediatric sepsis mortality showed moderate evidence for a higher sepsis mortality in boys compared with girls. The effect persisted when adjusting for country's income level.

Subtherapeutic Meropenem Antibiotic Exposure in Children With Septic Shock Assessed by Noncompartmental Pharmacokinetic Analysis in a Prospective Dataset

OBJECTIVES

To define meropenem plasma concentrations and pharmacodynamic exposure metrics in children with septic shock during the first 3 days of PICU hospitalization.

DESIGN

Pharmacokinetic sampling was undertaken in 19 subjects receiving standard meropenem dosing (20 mg/kg/dose, 8 hr) recruited from March 2019 to March 2022. Sampling occurred once each day following meropenem given 24 hours apart, during the first 3 PICU days. Data analysis was completed in 2023 and noncompartmental analysis was performed to assess pharmacodynamic exposure targets for sepsis. Clearance and volume of distribution at 20 mg/kg/dose were used to simulate mean exposures at 40 and 60 mg/kg/dose.

SETTING

PICU in a tertiary care center.

SUBJECTS

Patients 4 weeks old or older with hypotension requiring fluid resuscitation and vasopressor therapy, receiving meropenem as empiric therapy for sepsis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Augmented renal clearance (ARC) was documented in eight of 19 subjects, previously associated with subtherapeutic plasma concentrations, while three of 19 had acute kidney injury and decreased renal clearance. When assessed by pharmacodynamic exposure targets for sepsis (plasma meropenem concentrations above the minimum inhibitory concentration [MIC] of Pseudomonas aeruginosa for 70% or 100% of the dosing interval), ten of 19 and nine of 19 children, respectively, had subtherapeutic plasma meropenem exposures during PICU day 1, even for pathogens with an MIC considered "susceptible" by U.S. Food and Drug Administration criteria. Therapeutic meropenem pharmacodynamic exposures were associated with a positive 24-hour fluid balance on PICU day 1 and a negative 24-hour fluid balance by day 3, although profound variability was noted in fluid administered and renal output.

CONCLUSIONS

Given the variability in meropenem systemic exposure in pediatric septic shock, therapeutic drug monitoring, or monitoring for ARC, is suggested during the first days of hospitalization to allow daily assessments of dosing needs to achieve pharmacodynamic exposure targets for sepsis.

Association Between Tidal Volume in Invasive Mechanical Ventilation and Mortality in Children With Extracorporeal Membrane Oxygenation

Mechanical ventilation (MV) strategies in children on extracorporeal membrane oxygenation (ECMO) have not been studied much and the ventilatory parameters to avoid greater lung damage are still unclear. Our objective was to determine the relationship between conventional tidal volume (4-8 ml/kg, CTV) versus low tidal volume (<4 ml/kg, LTV) and mortality in children with MV at the beginning of ECMO. This was a retrospective cohort study that included 101 (10.9 months interquartile range [IQR]: 6.0-24.0) children. Children with LTV had greater odds of hospital mortality (adjusted odds ratio [aOR]: 2.45; 95% confidence interval [CI]: 1.05-5.71; p = 0.03) regardless of age, reason for ECMO, and disease severity, as well as a longer duration of MV after ECMO. We found no differences between the groups in other MV settings. The CTV group required fewer fibrobronchoscopies than patients with LTV (aOR: 0.38; 95% CI: 0.15-0.99; p = 0.04). We found that a tidal volume (V T ) lower than 4 ml/kg at the onset of ECMO support in children with MV was associated with higher odds of mortality, longer post-decannulation ventilation, and a greater need for fibrobronchoscopies. Lung-protective bundles in patients with ECMO and MV should consider the V T to maintain plateau and driving pressure that avoid major lung injury caused by MV.

Impact of an evidence-based sepsis pathway on paediatric hospital clinical practice: A quality improvement study

OBJECTIVES

To assess the impact of implementing a sepsis pathway and education program on key sepsis outcomes and performance targets in a tertiary paediatric hospital.

METHODS

A quality improvement study using a multi-modal screening process and pragmatic clinical definitions. Treatment of all children with septic shock and sepsis without shock 4 months prior to pathway/education package launch was compared with those meeting definitions 8 months post-launch.

RESULTS

Over the study period, 1483 episodes were screened; 517 episodes met study definitions (171 pre-launch; 346 post-launch). Eighty-two episodes met septic shock definitions (15.9%) and 435 met sepsis without shock definitions (84.1%). A total of 143 episodes pre-launch and 271 episodes post-launch were managed exclusively at Perth Children's Hospital (PCH). Post intervention, the pathway form was utilised in 146 of 271 episodes (53.9%). Pathway/education package introduction was associated with a reduction in the median time from recognition to antibiotic administration (60 [IQR: 26; 115] to 45 min [IQR: 16; 75] for those with septic shock and/or sepsis without shock treated exclusively at PCH; P < 0.001). The proportion receiving antibiotic therapy within recommended timeframes significantly increased (septic shock within 60 min: 70.0% to 92.5%, P < 0.03; sepsis without shock within 180 min; 86.2% to 94.8%, P = 0.005). No statistically significant change in length of stay, intensive care admission, mortality or antibiotic consumption was observed following pathway launch.

CONCLUSIONS

Paediatric sepsis pathway and education package implementation can reduce time to antibiotics in sepsis and aid local data collection and surveillance of patients treated for sepsis.

Integrating bioinformatics and machine learning for comprehensive analysis and validation of diagnostic biomarkers and immune cell infiltration characteristics in pediatric septic shock

This study aims to predict and diagnose pediatric septic shock through the screening of immune infiltration-related biomarkers. Three gene expression datasets were accessible from the Gene Expression Omnibus repository. The differentially expressed genes were identified using the R 4.3.2 ( https://www.r-project.org/ ), followed by gene set enrichment analysis. Thereafter, the genes were identified utilizing machine-learning algorithms. The receiver operating characteristic curve was employed to assess the discrimination and effectiveness of the hub genes. The inflammatory and immune status of pediatric septic shock was evaluated through cell-type identification by estimating relative subsets of RNA transcripts (CIBERSORT). The correlation between diagnostic markers and infiltrating immune cells was further examined. Overall, we detected 12 differentially expressed genes. CD177, MCEMP1, MMP8, and OLAH were examined as diagnostic indicators for pediatric septic shock, revealing statistically significant differences (P < 0.01) and diagnostic efficacy in the validation cohort. The immune cell infiltration analysis suggests that various immune cells may contribute to the onset of pediatric septic shock. Furthermore, all diagnostic characteristics may exhibit varying degrees of correlation with immune cells. This study identifies four potential biomarkers-CD177, MCEMP1, MMP8, and OLAH-that provide diagnostic value and novel insights into immune dysregulation in pediatric septic shock. Through the integration of bioinformatics and machine learning methodologies, we offer a novel perspective on the immune mechanisms involved in pediatric septic shock, potentially facilitating more targeted and personalized therapies for individual patients.

Changes in Epidemiology in Pediatric Invasive Group A Streptococcal Infections in Ireland During the 2022-2023 Outbreak

BACKGROUND

From October 2022 to June 2023, there was a 4-fold increase in pediatric invasive group A streptococcus cases (iGAS) in the Republic of Ireland. This project aimed to better understand the clinical characteristics and disease course of iGAS in children in Ireland to inform Public Health interventions and messaging for carers, clinicians and the public.

METHODS

All cases of iGAS notified to Public Health under 16 years from October 2022 to June 2023 inclusive were collated. A clinical case review of every death and hospitalization was performed under the auspices of the National Incident Management team using an online questionnaire. Analysis was performed using a 2-sided Fischer's exact test and 1-way analysis of variance.

RESULTS

Of 180 cases of iGAS in children, 167 had clinical data collected; 33 of 49 with skin and soft tissue infection had active varicella, and 69 of 167 had at least 1 respiratory viral coinfection. Seventy-four of 167 required therapeutic procedural intervention, and 34 of 167 required pediatric intensive care unit admission. Ten of 12 patients who died had necrotizing pneumonia, and 8 had an out-of-hospital cardiac arrest. Compared with historical data, significant changes in iGAS epidemiology in children were seen, with an increase in respiratory diagnoses, a decrease in musculoskeletal disease and an increased need for procedural intervention.

CONCLUSIONS

The rapidity and severity of secondary deterioration and death in children with iGAS highlight the importance of sepsis awareness in primary and secondary care. The high prevalence of viral coinfection emphasizes the importance of current vaccine uptake and expansion of the national schedule to include varicella zoster virus.

Glycyrrhizin alleviates brain injury in necrotizing enterocolitis model mice by suppressing HMGB1/TLR4 pathway

BACKGROUND

Systemic inflammation from necrotizing enterocolitis (NEC) can adversely affect the developing central nervous system. Evidence indicates that gut-derived high mobility group box 1 (HMGB1) can migrate to the brain and activate microglia.

OBJECTIVE

To determine if glycyrrhizin, an HMGB1 inhibitor, can reduce microglial pyroptosis and neuroinflammatory injury in NEC by modulating the HMGB1/ Toll-like receptor 4 (TLR4) pathway.

METHODS

HMGB1 levels were analyzed in clinical NEC samples. NEC models were induced through hypoxia, cold exposure, and overfeeding. BV2 microglial cells were stimulated with lipopolysaccharide (LPS) to mimic NEC-induced inflammation. Histological assessments were performed on the intestines and brain. Cell proliferation was evaluated employing the cell counting kit-8 (CCK-8) assay. Real-time quantitative polymerase chain reaction (RT-qPCR) quantified mRNA levels of HMGB1, TLR4, nuclear factor kappa B p65 (NF-κB p65), tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1β, IL-6, and IL-18. Protein expression was analyzed using western blotting, ELISA, immunohistochemistry, and immunofluorescence for key markers. Small interfering RNAs (siRNAs) targeted HMGB1 and TLR4.

RESULTS

Elevated levels of HMGB1 were observed in both clinical NEC samples and the NEC mouse model, with higher concentrations detected in feces, cerebrospinal fluid, and brain tissue. In the NEC patients, Spearman analysis revealed a significant correlation between elevated HMGB1 levels in CSF and fecal supernatant. Treatment with glycyrrhizin appeared to mitigate brain damage in the NEC mice and seemed to reduce LPS-induced inflammation in BV2 microglial cells. Additionally, glycyrrhizin enhanced the expression of tight junction protein occludin and myelin basic protein (MBP), which may be associated with improvements in behavioral performance observed in the NEC mice. Furthermore, glycyrrhizin treatment resulted in a reduction of key inflammatory mediators, including NF-κB p65, NOD-like receptor protein 3 (NLRP3), Caspase-1 p20, gasdermin D (GSDMD), IL-1β, and IL-18 in brain tissue and BV2 microglial cells. These results suggest that glycyrrhizin may exert its effects, at least in part, through modulation of the HMGB1/TLR4 signaling pathway.

CONCLUSION

Glycyrrhizin effectively mitigates neuroinflammatory injury in NEC by inhibiting the HMGB1/TLR4 pathway, preserving MBP, protecting the blood-brain barrier, and reducing pyroptosis in BV2 microglial cells. These findings suggest that glycyrrhizin may provide a novel therapeutic approach for improving neurological outcomes in NEC.

Prevalence and Associated Explanatory Factors for Augmented Renal Clearance in Early Sepsis: Single-Center, Retrospective PICU Cohort in China, 2022-2023

OBJECTIVES

We aimed to 1) evaluate the prevalence of augmented renal clearance (ARC) in pediatric sepsis patients; 2) analyze potential explanatory factors associated with ARC out of hemodynamic, oxygenation, and inflammatory parameters; and 3) assess ARC outcomes.

DESIGN

Retrospective, single-center, cohort from January 2022 to June 2023.

SETTING

PICU at a tertiary care hospital in China.

PATIENTS

Children 28 days to 16 years of age admitted with sepsis defined using Phoenix Sepsis Criteria.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among 69 patients, 34 (49.3%) were categorized as having ARC. Designation as having ARC, vs. not, was associated with being younger (median 2.4 vs. 7.2 years, p < 0.001), hemodynamic and intrarenal flow changes, and higher C-reactive protein levels (31.0 vs. 12.0 mg/L, p < 0.05). None of the 34 patients with ARC developed acute kidney injury, but 22 of 35 non-ARC patients did. ARC was associated with shorter PICU stays (median 7 vs. 11 days, p < 0.05). Univariate regression analyses identified fluid balance, cardiac function parameters, renal resistive index, and inflammatory markers as explanatory factors associated with ARC.

CONCLUSIONS

In this retrospective cohort of pediatric sepsis patients admitted to the PICU, the prevalence of early-onset ARC is around 50%, and younger patients may be at risk. The presence of ARC is associated with hemodynamic and inflammatory responses. Taken together, more prospective work is needed, with an emphasis on drug-level targeting and a better understanding of interactions with intrarenal pathophysiology.

Peptidomics characteristics of pediatric sepsis

Sepsis, a life-threatening organ dysfunction caused by a dysregulated host response to infection, has an approximately 25% in-hospital mortality rate. Identifying early biomarkers of pediatric sepsis is crucial for improving outcomes. This study explored the differential expression of peptides in patients with sepsis compared to healthy controls and those with common infections using plasma peptidomic analysis. Blood samples were collected from 10 pediatric patients with sepsis admitted to Hunan Children's Hospital in 2021, along with 20 age- and sex-matched healthy controls and five children with common infections. Differential peptide precursor proteins underwent gene ontology and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses and protein-protein interaction analysis using the STRING database. Intotal, 3149 endogenous peptides corresponding to 480 precursor proteins were identified. Compared to the healthy group, the sepsis group exhibited 1113 differentially expressed peptides, with 880 upregulated and 233 downregulated. Compared with the common infection group, the sepsis group showed 181 upregulated and 86 downregulated peptides. These differences were primarily in the humoral immune response and complement and coagulation cascades. This study identified specific alterations in peptide expression in the plasma of patients with sepsis, most notably in peptides related to SAA1, complement C3, hemoglobin, and haptoglobin. These peptides are involved in the acute inflammatory response, complement system, and free hemoglobin pathways, indicating their crucial roles in sepsis pathology. These findings provide new insights into the mechanisms of sepsis and suggest potential applications for these peptides in sepsis diagnosis and treatment, to enhance early diagnosis and therapeutic outcomes.

Uncovering knowledge of pediatric sepsis and recognition of septic shock: a survey among Brazilian pediatricians

OBJECTIVE

To evaluate the ability of Brazilian pediatricians to recognize sepsis and septic shock in children.

METHODS

A cross-sectional multicenter survey was conducted among Brazilian pediatricians between May and June 2023, before the release of the new Phoenix sepsis criteria in 2024. An online electronic system was used for surveys to characterize the knowledge and skills of physicians in the diagnosis and treatment of sepsis in children. The questions related to the diagnosis and treatment of sepsis and septic shock in children were based on the International Pediatric Sepsis Consensus Conference, the American College of Critical Care Medicine Guidelines, and the Surviving Sepsis Campaign in Pediatrics. Descriptive statistical analyses were performed using R software.

RESULTS

Pediatricians were surveyed about the recognition, knowledge, and management of pediatric patients with sepsis and septic shock. The responses of 355 physicians from all regions of Brazil were analyzed, with the majority from the southeastern region of the country (53.3%). In clinical practice, the most utilized criteria for diagnosing sepsis included inappropriate tachycardia (92%), temperature alteration (88.2%), and the presence of a suspected or confirmed infectious focus (87.9%). For septic shock, capillary refill time alteration (87.1%), arterial hypotension (84.8%), and changes in the level of consciousness (82.2%) were the predominant indicators. A total of 55.6% pediatricians reported having the potential to obtain venous or intraosseous access within 5 minutes, and 59.3% could administer antibiotics within the first hour. Approximately one-quarter (27.5%) of the participants responded that it was possible to infuse 40 - 60mL/kg in 1 hour. The most commonly used solution for fluid resuscitation was isotonic saline (70.9%), followed by Ringer's lactate (45.0%). The infusion of a vasopressor was considered in patients who did not improve after receiving an infusion of 40 - 60mL/kg (75.8%).

CONCLUSION

This is the first study to assess the knowledge of sepsis and septic shock among the Brazilian pediatric population. The results reveal a significant deficiency in the recognition of sepsis. This study demonstrated a gap between evidence and clinical practice. Adherence to international guidelines needs to be improved.

Validation of the Phoenix Criteria for Sepsis and Septic Shock in a Pediatric Intensive Care Unit

The applicability of the Phoenix criteria and Phoenix Sepsis Score in higher-resource pediatric intensive care units (PICUs) outside the United States requires further validation. A retrospective cohort study analyzed electronic health records of 1,304 PICU admissions under 18 years old with suspected infection between February 2017 and December 2023. The score was calculated using two methods: 24-hour assessment, based on worst sub-scores within 24 hours of admission, and prompt assessment, using values closest to admission within 6 hours before or after. Based on the 24-hour assessment, in-hospital mortality was 8.3% for sepsis and 10.3% for septic shock. The score demonstrated an area under the precision-recall curve of 0.42 (95% confidence interval, 0.31-0.55) for in-hospital mortality. Results were consistent across both assessment methods. The Phoenix criteria and the Phoenix Sepsis Score are reliable predictors of mortality outcomes. Further investigation in diverse clinical settings is warranted.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2024

The 2024 revised edition of the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock (J-SSCG 2024) is published by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine. This is the fourth revision since the first edition was published in 2012. The purpose of the guidelines is to assist healthcare providers in making appropriate decisions in the treatment of sepsis and septic shock, leading to improved patient outcomes. We aimed to create guidelines that are easy to understand and use for physicians who recognize sepsis and provide initial management, specialized physicians who take over the treatment, and multidisciplinary healthcare providers, including nurses, physical therapists, clinical engineers, and pharmacists. The J-SSCG 2024 covers the following nine areas: diagnosis of sepsis and source control, antimicrobial therapy, initial resuscitation, blood purification, disseminated intravascular coagulation, adjunctive therapy, post-intensive care syndrome, patient and family care, and pediatrics. In these areas, we extracted 78 important clinical issues. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 42 GRADE-based recommendations, 7 good practice statements, and 22 information-to-background questions were created as responses to clinical questions. We also described 12 future research questions.

External Validation of the Phoenix Sepsis Score in Children With Suspected Community-Acquired Sepsis

Importance

The novel Phoenix Sepsis Score and sepsis criteria were derived and validated using a multicountry dataset and proposed as a new definition for sepsis in children.

Objective

To externally validate the Phoenix Sepsis Score and sepsis criteria in a cohort of children hospitalized with suspected community-acquired sepsis.

Design, Setting, and Participants

This diagnostic study used data from the multicenter, multicountry Sepsis Epidemiology in Australian and New Zealand Emergency Departments (SENTINEL) study, collected from 2021 to 2023 and including 90-day follow-up. Children admitted to the hospital through 11 emergency departments in Australia and New Zealand and treated with parenteral antibiotics with either (1) a provisional diagnosis of sepsis or (2) treatment for sepsis (intravenous fluid bolus to treat poor perfusion) were included.

Exposure

Development of organ dysfunction over the first 24 hours of hospitalization.

Main Outcomes and Measures

The main outcomes were (1) in-hospital mortality and (2) death or requirement for extracorporeal life support (ECLS) within 72 hours of hospitalization.

Results

A total of 6232 children were included in the analysis, with a median (IQR) age of 2.1 (0.3-7.1) years, 3386 (54.1%) male, in-hospital mortality of 60 (1.0%), and death or ECLS within 72 hours in 36 (0.6%). In this population, the worst Phoenix Sepsis Score calculated over the first 24 hours of hospitalization had an area under the precision recall curve of 0.17 (95% CI, 0.07-0.28) for predicting in-hospital mortality and 0.23 (95% CI, 0.11-0.36) for predicting death or ECLS within 72 hours. Overall, 306 children (4.9%) met the Phoenix sepsis criteria, of whom 33 (10.8%) died in the hospital (nearly half of the total number who died) and 28 (9.2%) died or required ECLS within 72 hours. The Phoenix sepsis criteria had a sensitivity of 55.0% (95% CI, 41.6%-67.9%) and positive predictive value (PPV) of 10.8% (95% CI, 7.6%-14.9%) for in-hospital mortality and sensitivity of 77.8% (95% CI, 60.8%-89.9%) and PPV of 9.2% (95% CI, 6.2%-13.0%) for death or ECLS within 72 hours. Coagulation data for the calculation of the Phoenix Sepsis Score were missing in more than 85% of children.

Conclusions and Relevance

In this multicenter diagnostic study of children hospitalized with suspected sepsis, the Phoenix Sepsis Score and sepsis criteria had similar performance to the original derivation and validation cohorts. The small proportion of children meeting Phoenix sepsis criteria, missingness of data, timing of application, and lack of sensitivity for in-hospital mortality limit the clinical utility of the criteria.

Methods for identifying health status from routinely collected health data: An overview

Routinely collected health data (RCD) are currently accelerating publications that evaluate the effectiveness and safety of medicines and medical devices. One of the fundamental steps in using these data is developing algorithms to identify health status that can be used for observational studies. However, the process and methodologies for identifying health status from RCD remain insufficiently understood. While most current methods rely on International Classification of Diseases (ICD) codes, they may not be universally applicable. Although machine learning methods hold promise for more accurately identifying the health status, they remain underutilized in RCD studies. To address these significant methodological gaps, we outline key steps and methodological considerations for identifying health statuses in observational studies using RCD. This review has the potential to boost the credibility of findings from observational studies that use RCD.

Obesity as a Risk Factor in Pediatric Sepsis: A Retrospective Comparative Study Under the Phoenix Definition

Background: The relationship between sepsis outcomes and obesity has attracted significant interest in the medical community. However, this association has not been tested under Phoenix criteria, which represent the new pediatric sepsis definition, defining sepsis as life-threatening organ dysfunction in the setting of infection. Methods: A single-center, observational, retrospective study of pediatric sepsis patients from January 2014 to December 2019. The PICU was located within a tertiary pediatric center in the United States. Children more than one month old, but less than 18 years old, with a diagnosis of sepsis were included. Results: Six hundred and twenty-seven patients with a diagnosis of sepsis based on the Sepsis-2 definition were identified. Within the cohort, 554 patients met the definition of sepsis under the Phoenix criteria. Patients were classified based on the body habitus as underweight, normal, overweight, and obese. Obese patients had significantly higher mortality compared to the normal weight group (p = 0.033). More renal dysfunction was also seen in the obesity group (p = 0.0007). No difference in the frequency of identified Gram-positive, Gram-negative bacterial, viral, or fungal sepsis was observed between normal-weight and obese patients. Conclusions: In our cohort of pediatric sepsis, obesity was significantly associated with a higher degree of organ dysfunction and mortality. However, no difference in the incidence of identified bacterial, fungal, or viral sepsis was observed.

Proteomic profiling of plasma extracellular vesicles identifies signatures of innate immunity, coagulation, and endothelial activation in septic patients

Plasma extracellular vesicles (EVs) are cell-derived lipid particles and reportedly play a role in sepsis pathogenesis. This study aimed to identify EV cargo proteins in septic patients and explore their association with key sepsis pathophysiology. Plasma EVs were subjected to Tandem Mass Tag (TMT)-based quantitative proteomic analysis. We identified 522 differentially expressed (DE) EV proteins in septic patients (n=15) compared to the healthy controls (n=10). The KEGG analysis of the DE proteins revealed multiple functional pathways linked to sepsis, e.g., complement/coagulation, platelet activation, phagosome, inflammation, and neutrophil extracellular trap formation. Weighted Gene Coexpression Network Analysis of 1,642 EV proteins identified nine unique protein modules, some of which were highly correlated with the sepsis diagnosis and diverse plasma markers, including organ injury, inflammation, coagulopathy, and endothelial activation. Cell type-specific enrichment analysis revealed the cellular origins of EVs, including immune and epithelial cells, neurons, and glial cells. Thus, the current study discovered complex proteomic signatures in plasma EVs that are closely associated with key pathophysiological responses in sepsis. These findings support the importance of EV cargo proteins in the patients' immune responses, coagulation, and endothelial activation and lay the foundation for future mechanistic study of plasma EVs in sepsis pathogenesis.

Assessment of Phoenix Sepsis Score, pSOFA, PELOD-2, and PRISM III in Pediatric Intensive Care

Background/Objectives: Early identification of pediatric sepsis complications in intensive care is challenging and requires improved diagnostic tools. This study aimed to compare the Phoenix Sepsis Score (PSS), pSOFA, PELOD-2, and PRISM III in assessing clinical complexity in children with septic and critical conditions in the PICU and to identify the most suitable scale for this patient cohort. Methods: Data were collected prospectively from 53 children between June 2022 and January 2024. Patients were categorized into septic (n = 42) and non-infectious SIRS (n = 11) and further classified by outcome-with/without complications (n = 23/30). The predictive accuracy of the scoring systems was evaluated by discrimination and calibration and by recalibration for the PSS for improved performance. Results: Respiratory (18.8%) and neurological complications (9.4%) were the most common adverse events. Clinical deterioration was observed in 43.4% of cases, including one fatality. Patients with complications stayed longer in the PICU (14 ± 10 days). In the patients with complications, all scoring systems had higher median values. Only PSS showed a significant difference (p = 0.0023). PSS demonstrated the highest overall predictive accuracy (76.2%) outperforming PRISM III (62.3%) and PELOD-2 (58.5%). The pSOFA scale showed high accuracy (88.0%) in identifying patients without complications. The strongest association was between chronic disease (hazard ratio Exp(B) = 1.718) and deteriorations, while mechanical ventilation suggested a reduced risk of complications (Exp(B) = 0.509). Conclusions: PSS showed superior predictive accuracy (76.2%) for deteriorations in pediatric patients with suspected infection and proved adaptable for further validation in larger populations.

Sepsis in Critically Ill Children in Bolivia: Multicenter Retrospective Evaluation of the Phoenix Criteria for Sepsis in a 2023 Cohort

OBJECTIVES

We evaluated the Phoenix criteria and the Phoenix Sepsis Score in a multicenter retrospective cohort of critically ill children with a clinical diagnosis of sepsis or septic shock in Bolivia. In addition, we aimed to assess whether management in a PICU at high altitude in the Bolivian Andes was associated with the performance of the respiratory dysfunction component in the Phoenix Sepsis Score.

DESIGN

Multicenter retrospective cohort study.

SETTING

Fourteen PICUs in Bolivia.

PATIENTS

Children admitted to the PICU with a clinical diagnosis of sepsis or septic shock from January 2023 to December 2023.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 273 patients with a diagnosis of sepsis in 2023, of which 257 (94.1%) met the 2024 Phoenix criteria for sepsis, and 166 (60.8%) met the systemic inflammatory response syndrome (SIRS)-based criteria for sepsis. Among the 257 patients meeting Phoenix sepsis criteria, 86 died (33.5%). Of the patients with Phoenix-based sepsis, there were 100 of 257 (38.9%) who were SIRS-negative, and 27 of 100 died (27.0%). After correcting the oxygenation indices for altitude, 149 of 273 patients (54.6%) had a lower Phoenix respiratory score and an associated mortality more consistent with the expected mortality of the newly derived subscore. Patients at higher altitudes had higher hemoglobin levels and higher estimated oxygen carrying capacity, and these data were independently associated with lower odds of mortality after controlling for altitude-corrected Phoenix score.

CONCLUSIONS

In this 2023, retrospective cohort of PICU patients with sepsis in Bolivia, we have found that the majority met the 2024 Phoenix sepsis criteria, but less than two-thirds met the SIRS-based criteria for diagnosis. However, the respiratory score in the Phoenix criteria overestimated the severity of respiratory dysfunction in more than half of the cohort, likely because the score does not take account of the Andean adaptation to high altitude, with higher oxygen carrying capacity.

Bacterial and Fungal Infections in Pediatric Acute Liver Failure and Their Impact on Clinical Outcomes

OBJECTIVES

The current study aimed to explore the prevalence, predictors and outcomes of infections in pediatric acute liver failure (PALF).

METHODS

Data were retrieved from a prospectively maintained database of patients admitted with PALF between January 2012 and June 2024. "Sepsis" was defined as the presence of systemic inflammatory response syndrome with suspected or proven infection. Patients with positive bacterial and/or fungal cultures were labeled as "culture-positive sepsis." Outcome variables included native liver survival (NLS) and overall survival (OS) at day 28.

RESULTS

A total of 422 patients of PALF were included in the study of whom 195 (46.21%) fulfilled the criteria of sepsis and 71 (16.8%) had culture-positive sepsis. Bronchoalveolar fluid (37/81, 45.7%) was the commonest site of culture positivity followed by blood (29, 35.8%). More than 80% of cultures grew Gram-negative organisms with a high prevalence of carbapenem (77.1%) and multidrug (60%) resistance. These organisms were sensitive to colistin and newer beta-lactam combinations. Intensive care unit (ICU) stay, mechanical ventilation, grade 3-4 hepatic encephalopathy and use of extracorporeal liver support systems were associated with culture-positive sepsis. Patients with culture-negative sepsis had lower NLS and OS, whereas patients with culture-positive sepsis had outcomes comparable with patients without sepsis. However, culture-positive severe sepsis patients had significantly lowered NLS (33.3%) and OS (42.9%) at day 28.

CONCLUSION

There is a high prevalence of carbapenem and multidrug-resistant sepsis in PALF. ICU stay and use of extracorporeal support are factors independently associated with sepsis. While culture-positive sepsis did not significantly affect survival, patients with severe sepsis had lower NLS and OS.

Serial Lactate in Clinical Medicine - A Narrative Review

BackgroundBlood lactate is commonly used in clinical medicine as a diagnostic, therapeutic and prognostic guide. Lactate's growing importance in many disciplines of clinical medicine and academic enquiry is underscored by the tenfold increase in publications over the past 10 years. Lactate monitoring is presently shifting from single to serial measurements, offering a means of assessing response to therapy and to guide treatment decisions. With the promise of wearable lactate sensors and their potential integration in electronic patient records and early warning scores, the utility of serial lactate measurement deserves closer scrutiny.MethodsArticles included in this review were identified by searching MEDLINE, PubMed and EMBASE using the term "lactate" alone and in combination with "serial", "point of care", "clearance", "prognosis" and "clinical". Authors were assigned vetting of publications according to their specialty (anesthesiology, intensive care, trauma, emergency medicine, obstetrics, pediatrics and general hospital medicine). The manuscript was assembled in multidisciplinary groups guided by underlying pathology rather than hospital area.FindingsLactate's clinical utility as a dynamic parameter is increasingly recognized. Several publications in the last year highlight the value of serial measurements in guiding therapy. Outside acute clinical areas like the emergency room, operating room or intensive care, obtaining lactate levels is often fraught with difficulty and delays.InterpretationMeasuring serial lactate and lactate clearance offers regular feedback on response to therapy and patient status. Particularly on the ward, wearable devices integrated in early warning scores via the hospital IT system are likely to identify deteriorating patients earlier than having to rely on observations by an often-overstretched nursing workforce.

The Phoenix Sepsis Score in Pediatric Oncology Patients With Sepsis at PICU Admission: Test of Performance in a European Multicenter Cohort, 2018-2020

OBJECTIVES

The Pediatric Sepsis Definition Task Force developed and validated a new organ dysfunction score, the Phoenix Sepsis Score (PSS), as a predictor of mortality in children with suspected or confirmed infection. The PSS showed improved performance compared with prior scores. However, the criteria were derived in a general pediatric population, in which only 10% had cancer. Given that pediatric cancer patients with sepsis have higher mortality compared with noncancer patients with sepsis, we aimed to assess the PSS in PICU patients with cancer and sepsis.

DESIGN

Retrospective multicenter cohort study.

SETTING

Twelve PICUs across Europe.

PATIENTS

Each PICU identified patients 18 years young or younger, with underlying malignancy and suspected or proven sepsis, and admission between January 1, 2018, and January 1, 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The PSS and three other scores, including Phoenix-8, Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score, and pediatric Sequential Organ Failure Assessment (pSOFA) score, were calculated for comparison. The primary outcome was 90-day all-cause mortality. We compared score performance using area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC) analyses. Among 383 patients with proven or suspected sepsis, 90-day mortality was 19.3% (74/383). We failed to identify an association between a particular score and performance for 90-day mortality. The mean (95% CI) values for the AUROC of each score was: PSS 0.66 (0.59-0.72), Phoenix-8 0.65 (0.58-0.72), PELOD-2 0.64 (0.57-0.71), and pSOFA 0.67 (0.60-0.74) and for the AUPRC of each score: PSS 0.32 (0.23-0.42), Phoenix-8 0.32 (0.23-0.42), PELOD-2 0.32 (0.22-0.43), and pSOFA 0.36 (0.26-0.46). Similar results were obtained for PICU mortality or sepsis-related PICU mortality.

CONCLUSIONS

Contrary to the general PICU population, our retrospective test of the PSS in a PICU oncology dataset with suspected or proved sepsis from European PICUs, 2018-2020, failed to identify improved performance in association with mortality. This unique patient population deserves development of organ dysfunction scores that reflect organ dysfunction and mortality data specifically from these patients and will require prospective validation in future studies.

Antithrombin and Activated Protein C in Pediatric Sepsis: Prospective Observational Study of Outcome

OBJECTIVES

To assess antithrombin and activated protein C (aPC) levels in relation to disseminated intravascular coagulation (DIC) and severe outcomes in pediatric sepsis.

DESIGN

Prospective, observational study conducted between April 2023 and October 2024. Coagulation profiles including conventional coagulation, antithrombin activity, and aPC were obtained at PICU admission.

SETTING

PICU in the Vietnam National Children's Hospital, Hanoi, Vietnam.

SUBJECTS

PICU admissions, 1 month to 18 years old, with sepsis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred thirty children (78 males; median age 7.5 mo) with mortality 23/130 (17.7%). The prevalence of overt DIC was 37 of 130 (28.5%). Nonsurvival at 28 days, compared with survival, was associated with hemorrhage and/or thrombosis at presentation, and higher number of dysfunctional organs, and overt DIC. Those with overt DIC, compared with not, had longer activated partial thromboplastin time, higher international normalized ratio and d -dimer, and lower antithrombin, and aPC. Activity of antithrombin and aPC correlated inversely with the Vasoactive-Inotropic Score in survivors ( p = 0.002 and 0.009, respectively). Patients with a cutoff value for antithrombin less than 63.5% had a mortality risk with area under the receiver operating characteristic (AUROC) curve 0.64, with sensitivity 0.51 and specificity 0.74, and positive predictive value 0.30. Regarding overt DIC, a cutoff value for antithrombin less than 55.5% had an AUROC 0.78, sensitivity 0.72 and specificity of 0.73, and positive predictive value 0.52.

CONCLUSIONS

In this observational study of pediatric sepsis patients, first 24-hour coagulation data in those who did not-survive to 28 days, vs. survivors showed an associated prior lower level of antithrombin in nonsurvivors. Furthermore, using the outcome of overt DIC and nonovert DIC in the first 72 hours, we found that lower levels of antithrombin or aPC are each associated with overt DIC and nonovert DIC in pediatric sepsis. Further validation work is needed in larger case series of pediatric sepsis.

Building global collaborative research networks in paediatric critical care: a roadmap

Paediatric critical care units are designed for children at a vulnerable stage of development, yet the evidence base for practice and policy in paediatric critical care remains scarce. In this Health Policy, we present a roadmap providing strategic guidance for international paediatric critical care trials. We convened a multidisciplinary group of 32 paediatric critical care experts from six continents representing paediatric critical care research networks and groups. The group identified key challenges to paediatric critical care research, including lower patient numbers than for adult critical care, heterogeneity related to cognitive development, comorbidities and illness or injury, consent challenges, disproportionately little research funding for paediatric critical care, and poor infrastructure in resource-limited settings. A seven-point roadmap was proposed: (1) formation of an international paediatric critical care research network; (2) development of a web-based toolkit library to support paediatric critical care trials; (3) establishment of a global paediatric critical care trial repository, including systematic prioritisation of topics and populations for interventional trials; (4) development of a harmonised trial minimum set of trial data elements and data dictionary; (5) building of infrastructure and capability to support platform trials; (6) funder advocacy; and (7) development of a collaborative implementation programme. Implementation of this roadmap will contribute to the successful design and conduct of trials that match the needs of globally diverse paediatric populations.

Predictive value of initial lactate levels for mortality and morbidity in critically ill pediatric trauma patients: a retrospective study from a Turkish pediatric intensive care unit

BACKGROUND

This study investigated the relationship between initial lactate levels and both mortality and morbidity in critically ill pediatric trauma patients requiring intensive care.

METHODS

This retrospective study at tertiary center's pediatric intensive care unit from January 2020 to June 2024 aimed to characterize trauma patients and assess admission lactate levels' prognostic value.

RESULTS

A total of 190 critically ill pediatric trauma patients were included in the study. The mortality rate was 7.9%, with most deaths occurring within the first 48 hours of admission. Initial lactate levels ≥6.9 mmol/L demonstrated moderate predictive power (area under the curve [AUC], 0.878) for mortality. Pediatric Risk of Mortality III (PRISM III) score showed good predictive ability (AUC, 0.922), while Pediatric Trauma Scores exhibited variable predictive performance (AUC, 0.863). Higher initial lactate levels were significantly associated with severe brain injury, the need for intubation, and an increased incidence of thoracic or abdominal injuries.

CONCLUSIONS

Initial lactate levels and PRISM III score are effective predictors of mortality in critically ill pediatric trauma patients. Lactate levels ≥5 mmol/L upon admission should prompt close monitoring and consideration of aggressive management strategies.

Evaluation of Phoenix Sepsis Score Criteria: Exploratory Analysis of Characteristics and Outcomes in an Emergency Transport PICU Cohort From the United Kingdom, 2014-2016

OBJECTIVES

To assess characteristics and outcomes of children with suspected or confirmed infection requiring emergency transport and PICU admission and to explore the association between the 2024 Phoenix Sepsis Score (PSS) criteria and mortality.

DESIGN

Retrospective analysis of curated data from a 2014-2016 multicenter cohort study.

SETTING

PICU admission following emergency transport in South East England, United Kingdom, from April 2014 to December 2016.

PATIENTS

Children 0-16 years old ( n = 663) of whom 444 (67%) had suspected or confirmed infection.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The PSS was calculated as a sum of four individual organ subscores (respiratory, cardiovascular, neurological, and coagulation) using the worst values during transport (i.e., from referral until the time of PICU admission). A score cutoff of greater than or equal to 2 points was used to define sepsis; and septic shock was defined as sepsis plus 1 or more cardiovascular subscore points. Sepsis occurred in 260 of 444 children (58.6%) with suspected or confirmed infection, with septic shock occurring in 177 of 260 (68.1%) of those with sepsis. A PSS score greater than or equal to 2 points occurred in 37 of 67 bronchiolitis cases, 19 of 35 meningoencephalitis cases, 30 of 47 pneumonia/empyema cases, 38 of 46 septic/toxic shock cases, nine of 15 severe sepsis cases, and 58 of 118 definite viral infections. Overall, 14 of 444 children died (3.2%). There were 12 deaths in the 260 children with PSS greater than or equal to 2, and two deaths in the 184 children with PSS less than 2 (4.6% vs. 1.1%; absolute difference, 3.5%; 95% CI, 0.1-6.9%; p = 0.04).

CONCLUSIONS

In 2014-2016, over half of the critically ill children undergoing emergency transport to PICU with presumed or confirmed infection, and meeting retrospectively applied PSS criteria for sepsis, had a range of clinical diagnoses including bronchiolitis, meningoencephalitis, and pneumonia/empyema. Furthermore, the PSS criteria for categorization of sepsis and septic shock were associated with outcome and may be of value in future risk-stratification in clinical trials.

Phoenix Sepsis Criteria in Critically Ill Children: Retrospective Validation Using a United States Nine-Center Dataset, 2012-2018

OBJECTIVES

To perform: 1) external validation of the Phoenix Sepsis Score and Phoenix sepsis criteria in a multicenter cohort of critically ill children with infection and a comparison with the 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria; 2) a study of Phoenix sepsis criteria performance in patient subgroups based on age and comorbidities; 3) an assessment of microbiological profile of children with Phoenix sepsis; and 4) a study of the performance of the Phoenix-8 score.

DESIGN

Secondary, retrospective analysis of a multicenter cohort study from 2012 to 2018.

SETTING

Nine PICUs in the United States.

PATIENTS

PICU admissions with suspected infection.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among 25,680 encounters of children with suspected or confirmed infection on PICU admission (4.6% in-hospital mortality), 11,168 (43%) met Phoenix criteria for sepsis or septic shock (9% in-hospital mortality). The Phoenix criteria generally outperformed the IPSCC criteria at discriminating mortality in all critically ill children with infections and across all subgroup analyses, including age group, malignancy, or technology dependence. Of 11,168 patients who met Phoenix criteria, 28% were negative for IPSCC criteria for sepsis and these had higher in-hospital mortality than those who met IPSCC sepsis criteria but not Phoenix criteria (4.7% vs.1.7%; p < 0.001), which was similar to the mortality of patients without sepsis (1.3%). Sepsis was associated with respiratory or bloodstream infection, most commonly Pseudomonas aeruginosa or Staphylococcus aureus. The Phoenix-8 score had good discrimination of mortality in children with infections, comparable to or better than validated and widely used severity of illness and organ dysfunction scores.

CONCLUSIONS

In 2012-2018, among U.S. patients with suspected or confirmed infection admitted to nine PICUs, those with the highest risk of mortality can be identified using the Phoenix sepsis criteria, including in children of different age groups and those with major comorbidities.

Comparison of the Pediatric Sequential Organ Failure Assessment (p SOFA) Score and Lactate Clearance as Predictors of Morbidity and Mortality in Pediatric Sepsis: A Prospective Observational Study

BACKGROUND

Sepsis continues to be a leading cause of illness and mortality in children around the world. Various scoring systems have been devised to predict the outcome of pediatric sepsis. Pediatric sequential organ failure assessment (p SOFA) and lactate clearance are the two commonly used methods.

OBJECTIVE

The aim of this study was to compare the p SOFA score with lactate clearance as predictors of morbidity and mortality in pediatric sepsis, to compare the initial plasma lactate level and lactate clearance, and to know which is better to predict outcomes in sepsis and septic shock.

METHODS

This prospective observational study was conducted in a pediatric intensive care unit of a tertiary care teaching hospital from July 2022 to June 2024. The blood lactate level and p SOFA score were assessed at admission and at 24 and 48 hours, and lactate clearance was calculated at 24 and 48 hours of admission. The receiver operating characteristic (ROC) curve was plotted to predict deaths using p SOFA, lactate level, and lactate clearance.

RESULTS

A total of 71 children were enrolled in the study. All children were divided into two groups, 58 (82%) survivors and 13 (18%) non-survivors. The most common diagnosis was pneumonia, observed in 31 (43.6%) children. Compared to survivors, non-survivors had a higher prevalence of multiple organ dysfunction syndrome (MODS). The most common organ system involved was the cardiovascular, in 50 (70%) cases. For predicting mortality, p SOFA scores were statistically significant at admission and at 24 and 48 hours with a high area under the curve (AUC) at 48 hours (0.985). Lactate clearance at 24 hours was a better predictor of mortality than at 48 hours with a higher AUC (0.958).

CONCLUSION

Both p SOFA score at 48 hours and lactate clearance at 24 hours were significant predictors of mortality. Among both parameters, lactate clearance at 24 hours was superior in predicting mortality early.

Clinical Characteristics and Influencing Factors of Feeding Intolerance After Surgery for Neonatal Necrotizing Enterocolitis

BACKGROUND

Feeding intolerance (FI) following surgery for neonatal necrotizing enterocolitis (NEC) can impact recovery and prognosis, making the early identification of FI risk essential for optimizing management and improving outcomes.

METHODS

We retrospectively collected data from patients who underwent surgery for NEC between January 2013 and December 2023. Multivariate binary logistic regression was performed to identify independent factors influencing postoperative feeding intolerance.

RESULTS

Of the 519 infants enrolled in this retrospective study, 155 (29.9%) were diagnosed with feeding intolerance, while 364 (70.1%) were identified as having feeding tolerance. Compared to infants with feeding tolerance, those with feeding intolerance had lower birth weight, smaller gestational age, and lower Apgar scores (all p < 0.01). A 5 min Apgar < 7 (OR 4.794; 95%CI 1.339-17.156), the interval between diagnosis and surgery (OR 0.973; 95%CI 0.947-1.000), and primary anastomosis resection (OR 0.278, 95%CI 0.139-0.555) were identified as significant factors influencing postoperative feeding intolerance. The results remained consistent after performing propensity score matching analysis. Feeding intolerance may result in prolonged hospital stays, and more complications such as retinopathy of prematurity, intestinal failure-associated liver disease, and intraventricular hemorrhage.

CONCLUSIONS

A lower 5 min Apgar score, shorter interval from diagnosis to surgery and intestine resection with ostomy are associated with a higher incidence of FI after surgery. FI after NEC surgery can prolong recovery and increase family burden.