Association of early hypotension in pediatric sepsis with development of new or persistent acute kidney injury

[Time to Antibiotics (TTA) - Reassessment from the German Working Group for Fever and Neutropenia in Children and Adolescents (DGPI/GPOH)]

BACKGROUND

The current German guidance from 2016 recommends a Time to Antibiotics (TTA) of<60 min in children and adolescents with febrile neutropenia (FN).

METHODS

Critical analysis of available studies and recent meta-analyses, and discussion of the practical consequences in the FN working group of the German Societies for Paediatric Oncology and Haematology and Paediatric Infectious Diseases.

RESULTS

The available evidence does not support a clinically significant outcome benefit of a TTA<60 min in all paediatric patients with FN. Studies suggesting such a benefit are biased (mainly triage bias), use different TTA definitions and display further methodical limitations. In any case, a TTA<60 min remains an essential component of the 1st hour-bundle in paediatric cancer patients with septic shock or sepsis with organ dysfunction.

CONCLUSION

Provided that all paediatric FN patients receive a structured medical history and physical examination (including vital signs) by experienced and trained medical personnel in a timely fashion, and provided that a sepsis triage and management bundle is established and implemented, a TTA lower than 3 hours is sufficient and reasonable in stable paediatric cancer patients with FN.

Preeclamptic programming unevenly perturbs inflammatory and renal vasodilatory outcomes of endotoxemia in rat offspring: modulation by losartan and pioglitazone

Introduction: Preeclampsia (PE) enhances the vulnerability of adult offspring to serious illnesses. The current study investigated whether preeclamptic fetal programming impacts hemodynamic and renal vasodilatory disturbances in endotoxic adult offspring and whether these interactions are influenced by antenatal therapy with pioglitazone and/or losartan. Methods: PE was induced by oral administration of L-NAME (50 mg/kg/day) for the last 7 days of pregnancy. Adult offspring was treated with lipopolysaccharides (LPS, 5 mg/kg) followed 4-h later by hemodynamic and renovascular studies. Results: Tail-cuff measurements showed that LPS decreased systolic blood pressure (SBP) in male, but not female, offspring of PE dams. Moreover, PE or LPS reduced vasodilations elicited by acetylcholine (ACh, 0.01-7.29 nmol) or N-ethylcarboxamidoadenosine (NECA, 1.6-100 nmol) in perfused kidneys of male rats only. The latter effects disappeared in LPS/PE preparations, suggesting a postconditioning action for LPS against renal manifestation of PE. Likewise, elevations caused by LPS in serum creatinine and inflammatory cytokines (TNFα and IL-1β) as well as in renal protein expression of monocyte chemoattractant protein-1 (MCP-1) and AT1 receptors were attenuated by the dual PE/LPS challenge. Gestational pioglitazone or losartan reversed the attenuated ACh/NECA vasodilations in male rats but failed to modify LPS hypotension or inflammation. The combined gestational pioglitazone/losartan therapy improved ACh/NECA vasodilations and eliminated the rises in serum IL-1β and renal MCP-1 and AT1 receptor expressions. Conclusion: Preeclamptic fetal programming of endotoxic hemodynamic and renal manifestations in adult offspring depends on animal sex and specific biological activity and are reprogrammed by antenatal pioglitazone/losartan therapy.

Sepsis associated acute kidney injury in pediatric intensive care unit

BACKGROUND

We aimed to compare the acute kidney injury (AKI) incidence in pediatric septic shock patients according to the three different classifications.

METHODS

We analyzed retrospectively 52 patients with severe sepsis between January 2019 and December 2019.

RESULTS

While 21 patients have been diagnosed with SA-AKI according to the pRIFLE criteria, 20 children have been diagnosed according to the AKIN criteria, and 21 children have been diagnosed according to the KDIGO criteria. Older age, lower platelet count were determined as independently risk factor for SA-AKI. Older age and higher PRISM score were associated with mortality. According to Canonical correlation coefficients, pRIFLE is the most successful classification to distinguish AKI state. The canonical correlation coefficients for pRIFLE, KDIGO, and AKIN were 0.817, 0.648, and 0.615, respectively.

CONCLUSION

Although AKI incidence was similar between the three classifications, pRIFLE was the most successful classification to distinguish AKI state.

Risk Factors for Sepsis-Associated Acute Kidney Injury in the PICU: A Retrospective Cohort Study

OBJECTIVES

Acute kidney injury (AKI), particularly of greater severity and longer duration, is associated with increased morbidity and mortality in the pediatric population. AKI frequently occurs during sepsis, yet the knowledge of risk factors for sepsis-associated AKI in the PICU is limited. We aimed to identify risk factors for AKI that develops or persists after 72 hours from sepsis recognition in pediatric patients with severe sepsis.

DESIGN

Retrospective cohort study.

SETTING

PICU at an academic, tertiary-care center.

PATIENTS

Children greater than 1 month and less than or equal to 18 years with severe sepsis in the combined cardiac and medical/surgical PICU between December 1, 2013, and December 31, 2020, at the University of Virginia Children's Hospital.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The cohort included 124 patients with severe sepsis with 33 patients (27%) who were postcardiac surgery with cardiopulmonary bypass. AKI was defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The primary outcome was severe AKI, defined as KDIGO stage 2 or 3 AKI present at any point between days 3 and 7 after sepsis recognition. Severe AKI was present in 25 patients (20%). Factors independently associated with severe AKI were maximum vasoactive-inotropic score (VIS) within 48 hours after sepsis recognition and fluid overload. The presence of severe AKI was associated with increased inhospital mortality.

CONCLUSIONS

In children with severe sepsis, the degree of hemodynamic support as measured by the VIS and the presence of fluid overload may identify patients at increased risk of developing severe AKI.