Clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock from Rohtak, Haryana: A prospective observational study

Vasoactive Ventilation Renal Score as a Predictor of Outcomes in Children Admitted to PICU: An Observational Study

OBJECTIVES

To determine the area under curve (AUC) for vasoactive ventilation renal score (VVRS) > 10 at 24-h of admission for predicting mortality in children aged 1-12 years admitted to pediatric intensive care unit (PICU). To also determine the AUC for VVRS > 10 at 48-h of admission for predicting mortality and to determine the AUC of VVRS > 10 at 24-h and 48-h of admission for predicting PICU stay > 3 days, hospital stay > 10 days and mechanical ventilation > 3 days.

METHODS

This observational study included 310 children aged 1-12 years admitted in PICU. All required parameters were noted, and VVRS, ventilation index and change in creatinine at 24-h and 48-h of admission were recoded. Receiver operating characteristic curves were computed to determine the predictive role of VVRS > 10 at 24-h and 48-h for mortality, duration of PICU stay, hospital stay and mechanical ventilation.

RESULTS

Seventy nine (25%) patients succumbed during the study. VVRS > 10 at 24-h and 48-h had a good predictive role for mortality with AUC of 0.873 (sensitivity 89.87%, specificity 69.70%) and 0.996 (sensitivity 96.20%, specificity 96.10%), respectively. Best cutoffs derived for VVRS (24-h), and VVRS (48-h) were > 2.5 and > 13.5. A higher AUC, sensitivity and specificity of VVRS at 48-h were observed for predicting prolonged PICU stay, duration of mechanical ventilation and hospital stay.

CONCLUSIONS

VVRS at 24-h and 48-h has a good predictive role for mortality in children admitted to PICU.

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.

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.

A novel digital health approach to improving global pediatric sepsis care in Bangladesh using wearable technology and machine learning

Sepsis is the leading cause of child death globally with low- and middle-income countries (LMICs) bearing a disproportionate burden of pediatric sepsis deaths. Limited diagnostic and critical care capacity and health worker shortages contribute to delayed recognition of advanced sepsis (severe sepsis, septic shock, and/or multiple organ dysfunction) in LMICs. The aims of this study were to 1) assess the feasibility of a wearable device for physiologic monitoring of septic children in a LMIC setting and 2) develop machine learning models that utilize readily available wearable and clinical data to predict advanced sepsis in children. This was a prospective observational study of children with sepsis admitted to an intensive care unit in Dhaka, Bangladesh. A wireless, wearable device linked to a smartphone was used to collect continuous recordings of physiologic data for the duration of each patient's admission. The correlation between wearable device-collected vital signs (heart rate [HR], respiratory rate [RR], temperature [T]) and manually collected vital signs was assessed using Pearson's correlation coefficients and agreement was assessed using Bland-Altman plots. Clinical and laboratory data were used to calculate twice daily pediatric Sequential Organ Failure Assessment (pSOFA) scores. Ridge regression was used to develop three candidate models for advanced sepsis (pSOFA > 8) using combinations of clinical and wearable device data. In addition, the lead time between the models' detection of advanced sepsis and physicians' documentation was compared. 100 children were enrolled of whom 41% were female with a mean age of 15.4 (SD 29.6) months. In-hospital mortality rate was 24%. Patients were monitored for an average of 2.2 days, with > 99% data capture from the wearable device during this period. Pearson's r was 0.93 and 0.94 for HR and RR, respectively) with r = 0.72 for core T). Mean difference (limits of agreement) was 0.04 (-14.26, 14.34) for HR, 0.29 (-5.91, 6.48) for RR, and -0.0004 (-1.48, 1.47) for core T. Model B, which included two manually measured variables (mean arterial pressure and SpO2:FiO2) and wearable device data had excellent discrimination, with an area under the Receiver-Operating Curve (AUC) of 0.86. Model C, which consisted of only wearable device features, also performed well, with an AUC of 0.78. Model B was able to predict the development of advanced sepsis more than 2.5 hours earlier compared to clinical documentation. A wireless, wearable device was feasible for continuous, remote physiologic monitoring among children with sepsis in a LMIC setting. Additionally, machine-learning models using wearable device data could discriminate cases of advanced sepsis without any laboratory tests and minimal or no clinician inputs. Future research will develop this technology into a smartphone-based system which can serve as both a low-cost telemetry monitor and an early warning clinical alert system, providing the potential for high-quality critical care capacity for pediatric sepsis in resource-limited settings.

Profiling Molecular Changes of Host Response to Predict Outcome in Children with Septic Shock

Background

Septic shock is associated with high mortality and there is significant heterogeneity in the host response. The aim of this study was to understand the genome-wide expression transcriptomic signatures in children with septic shock and correlate them with outcomes.

Methods

This was a prospective study conducted on children (aged 1 month to 18 years) admitted to the PICU (June-December 2021) with septic shock. Demographic details, clinical details, and administered treatment were collected. Differential gene expression analysis was performed to understand the genes and pathways affecting in different subjects.

Results

Fifteen patients were recruited (Septic shock survivors (n = 5), nonsurvivors (n = 5), and non-sepsis controls (n = 5). The median age of the patients in survivors and nonsurvivors was 15 (13, 24) months and 180 (180, 184) months, respectively. The sepsis-survivors vs nonsepsis possessed 983 upregulated and 624 downregulated genes while comparing sepsis nonsurvivors (SNS) with nonsepsis yielded 1,854 upregulated and 1,761 downregulated genes. Further, the lowest number of deregulated genes (383 upregulated and 486 downregulated) were present in SNS compared to sepsis survivors. The major Reactome pathways, found upregulated in SNSs relative to survivors included CD22 mediated B cell receptor (BCR) regulation, scavenging of heme from plasma, and creation of C4 and C2 activators while T cell receptor (TCR) signaling, the common pathway of fibrin clot formation and generation of second messenger molecules were found to be downregulated.

Conclusion

Mortality-related gene signatures are promising diagnostic biomarkers for pediatric sepsis.

How to cite this article

Lalitha AV, Vasudevan A, Moorthy M, Ramaswamy G. Profiling Molecular Changes of Host Response to Predict Outcome in Children with Septic Shock. Indian J Crit Care Med 2024;28(9):879-886.

The Use of Platelet Count and Indices as Prognostic Factors for Mortality in Children with Sepsis

Background

Sepsis is still one of the leading causes of mortality and morbidity in children worldwide. Consumptive coagulopathy and suppression of thrombopoiesis in the bone marrow resulting from immune dysregulation are pathological mechanisms that cause thrombocytopenia in sepsis. Platelet count (PLT) and indices, such as mean platelet volume (MPV), platelet distribution width (PDW), and plateletcrit (PCT) are markers of platelet activation and are strongly influenced by platelet morphology and proliferation kinetics. We aimed to study the use of platelet count and indices as predictors of mortality in children with sepsis.

Methods

This is a cross-sectional study of 45 children diagnosed with sepsis on admission at Haji Adam Malik Hospital, Medan, North Sumatra, Indonesia, between October and November 2022. Blood samples were drawn upon admission, and platelet count and indices were then determined for all children. Subjects were followed up till discharge from hospital or death. Receiver Operating Characteristic (ROC) curve analysis of platelet parameters was done to determine the area under the curve (AUC), optimal cut-off value, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in predicting mortality in children with sepsis. Using the cut-off values from ROC curve analysis, the odds ratio with 95% confidence interval was calculated using multiple logistic regression analyses. A P value less than 0.05 was considered statistically significant.

Results

MPV, PDW, and PDW/PLT were significantly higher in non-survivors than survivors (P=0.04, P=0.02, and P=0.04, respectively). ROC curve analysis showed that PDW had the largest AUC (0.708 [95% CI=0.549-0.866]) with a cut-off value of 14.1%, sensitivity of 63.6%, and specificity of 82.6%. PDW was also the only parameter that significantly affected the outcome of children with sepsis. PDW≥14.1% at admission increases the risk of mortality by 5.7 times.

Conclusion

Admission PDW is a fast and specific tool to predict the outcome of children with sepsis.

Modelling climate impacts on paediatric sepsis incidence and severity in Bangladesh

Background

Sepsis is a leading cause of paediatric mortality worldwide, disproportionately affecting children in low- and middle-income countries. The impacts of climate change on the burden and outcomes of sepsis in low- and middle-income countries, particularly in paediatric populations, remain poorly understood. We aimed to assess the associations between climate variables (temperature and precipitation) and paediatric sepsis incidence and mortality in Bangladesh, one of the countries most affected by climate change.

Methods

We conducted retrospective analyses of patient-level data from the International Centre for Diarrhoeal Disease Research, Bangladesh, and environmental data from the National Oceanic and Atmospheric Administration. Using random forests, we assessed associations between sepsis incidence and sepsis mortality with temperature and precipitation between 2009-22.

Results

A nonlinear relationship between temperature and sepsis incidence and mortality was identified. The lowest incidence occurred at an optimum temperature of 26.6°C with a gradual increase below and a sharp rise above this temperature. Higher precipitation levels showed a general trend of increased sepsis incidence. A similar distribution for sepsis mortality was identified with an optimum temperature of 28°C.

Conclusions

Findings suggest that environmental temperature and precipitation play a role in paediatric sepsis incidence and sepsis mortality in Bangladesh. As children are particularly vulnerable to climate impacts, it is important to consider climate change in health care planning and resource allocation, especially in resource-limited settings, to allow for surge capacity planning during warmer and wetter seasons. Further prospective research from more globally representative data sets will provide more robust evidence on the nature of the relationships between climate variables and paediatric sepsis worldwide.

The Microbiome and Metabolome of the Gut of Children with Sepsis and Septic Shock

BACKGROUND

There is limited understanding of alteration of gut microbiota and metabolome in children with sepsis/septic shock.

METHODS

In this prospective observational study carried out in a pediatric intensive care unit of a tertiary care center from 2020 to 2022, patients aged <17 years with sepsis/septic shock and healthy children (HC) were enrolled. We characterized the gut bacterial compositions by metagenome sequencing and metabolomes by untargeted gas chromatography-mass spectrometry. The primary outcome was to compare the gut microbiota and metabolome of children with sepsis/septic shock with that of HC. The Firmicutes/Bacteroidetes (F/B) ratio was compared between children with sepsis/septic shock and HC. Key secondary outcomes were to evaluate association of factors associated with a low F/B ratio in children with sepsis/septic shock.

RESULTS

A total of 40 children (63% boys) (15 children with sepsis and septic shock and 10 healthy children) with a median (IQR) age of 5.5 (1.5, 10) years were enrolled. In the fecal microbiota, the α-diversity index including Shannon and Simpson indices of the sepsis/septic shock groups was significantly lower than that of the HC. The samples lacked beneficial Bifidobacterium spp. and were dominated by Bacteroides, Enterobacteriaceae, and Enterococcaceae. There was reduction in short-chain fatty acids (SCFAs) in patients with sepsis/septic shock as compared to healthy children. A lower F/B ratio (≤1.57) of the gut microbiota discriminated well between children with sepsis/septic shock and HC. Factors associated with lower F/B ratio were male gender, clinical GI dysfunction, elevated inflammatory markers, and higher organ failure scores.

CONCLUSION

There were significant alterations in the gut microbiota and metabolome in children with sepsis/septic shock as compared to healthy children. Larger study is needed to confirm these exploratory findings and develop potential therapeutic targets that will improve outcomes in children with sepsis/septic shock.

Hematological Indices for Identifying Adverse Outcomes in Children Admitted to Pediatric ICUs

BACKGROUND

The pediatric ICU (PICU) is a specialized area where critically sick children are managed. The mortality rates in PICUs are higher in developing countries as compared to developed nations. Many of these deaths could be prevented if very sick children were identified soon after they arrived at the health facility. Hematological indices like platelet lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) have been frequently used in adults as indicators of mortality. However, their use in the pediatric population is limited due to a lack of validated reference intervals.

OBJECTIVE

The objective of the study is to assess the role of hematological indices in identifying adverse outcomes in terms of mortality in children admitted to the PICU.

MATERIALS AND METHODS

It is a prospective, observational study done at a tertiary care hospital. All children aged one year to 12 years admitted to the PICU were enrolled in the study. A sample for complete blood count was taken within one hour of admission to the PICU. Children who had received blood products in the last two months, those on chronic medications (>two weeks) that can affect bone marrow cellularity, and known cases of hematological disorders such as megaloblastic anemia, hematological malignancies, immune thrombocytopenia, and aplastic anemia were excluded from the study. PLR, NLR, and platelets to mean platelet volume ratio (PLT/MPV) were determined and compared among the survivors and non-survivors.

RESULTS

 Out of 275 enrolled patients, 119 (43.3%) patients expired during the study period. While PLR had high sensitivity and NLR had high specificity (85.71% and 92.31%, respectively) for predicting mortality, none of these parameters had a good area under the curve (AUC) in our study. PLT/MPV of ≥32 had a sensitivity of 39.5% and a specificity of 56.41% for predicting mortality.

CONCLUSIONS

Hematological parameters have been used across the world to predict ICU mortality. PLR and NLR are simple hematological biomarkers, easy to calculate, and cost-effective, and ratios are better than individual parameters. More studies and stratified samples are required to evaluate the role of hematological markers in identifying the risk of mortality in children admitted to PICUs.

Pediatric sepsis profile in a tertiary-care hospital in Indonesia: a 4-year retrospective study

AIM

This study aimed to explore the factors contributing to mortality and its management among pediatric sepsis patients at a single center in Indonesia.

METHOD

We conducted a retrospective study of children admitted due to sepsis from January 2015 to December 2019 in an Indonesian tertiary hospital.

RESULTS

The mortality rate of pediatric sepsis in our study was 76.1% among 176 records with outcome identified. Mortality was significantly associated with septic shock at triage, number of organ failure, intensive care unit admission, inotropic use, septic shock and severe sepsis during hospitalization. Timing of antibiotic use did not affect mortality. Death within the first 24 h occurred in 41.8% of subjects, mostly due to septic shock.

CONCLUSION

This study illuminates the current state of pediatric sepsis management in our Indonesian hospital, revealing it as inadequate. Findings highlight the need for improved pre-hospital systems and sepsis recognition tools, and wider use of mechanical ventilators and advanced monitoring due to limited pediatric intensive care unit beds. Future research should focus on hospital-specific sepsis protocols to reduce pediatric sepsis mortality rates.

Reporting of Social Determinants of Health in Pediatric Sepsis Studies

OBJECTIVE

Standardized, consistent reporting of social determinants of health (SDOH) in studies on children with sepsis would allow for: 1) understanding the association of SDOH with illness severity and outcomes, 2) comparing populations and extrapolating study results, and 3) identification of potentially modifiable socioeconomic factors for policy makers. We, therefore, sought to determine how frequently data on SDOH were reported, which factors were collected and how these factors were defined in studies of sepsis in children.

DATA SOURCES AND SELECTION

We reviewed 106 articles (published between 2005 and 2020) utilized in a recent systematic review on physiologic criteria for pediatric sepsis.

DATA EXTRACTION

Data were extracted by two reviewers on variables that fell within the World Health Organization's SDOH categories.

DATA SYNTHESIS

SDOH were not the primary outcome in any of the included studies. Seventeen percent of articles (18/106) did not report on any SDOH, and a further 36.8% (39/106) only reported on gender/sex. Of the remaining 46.2% of articles, the most reported SDOH categories were preadmission nutritional status (35.8%, 38/106) and race/ethnicity (18.9%, 20/106). However, no two studies used the same definition of the variables reported within each of these categories. Six studies reported on socioeconomic status (3.8%, 6/106), including two from upper-middle-income and four from lower middle-income countries. Only three studies reported on parental education levels (2.8%, 3/106). No study reported on parental job security or structural conflict.

CONCLUSIONS

We found overall low reporting of SDOH and marked variability in categorizations and definitions of SDOH variables. Consistent and standardized reporting of SDOH in pediatric sepsis studies is needed to understand the role these factors play in the development and severity of sepsis, to compare and extrapolate study results between settings and to implement policies aimed at improving socioeconomic conditions related to sepsis.

Prognostic factors and models to predict pediatric sepsis mortality: A scoping review

Introduction

Several scoring systems are available to assess the severity of sepsis in pediatric patients in diverse settings worldwide. This study investigates the quality and applicability of predictive models for determining pediatric sepsis mortality, especially in acute care and limited-resource settings.

Data sources

Mortality prediction factors and models were searched in four databases using the following criteria: developed for pediatric health care, especially in acute settings, and with mortality as an outcome.

Study selection

Two or more reviewers performed the study selection to ensure no bias occurred. Any disagreements were solved by consensus or by the decision of a third reviewer.

Data extraction

The authors extracted the results and mapped the selected studies qualitatively to describe the prognostic properties of the risk factors and models proposed in the study.

Data synthesis

The final analysis included 28 mortality prediction models. Their characteristics, analysis, and performance measures were summarized. Performance was described in terms of calibration and discrimination, including assessing for risk of bias and applicability. A modified version of the PRISM-III score based on physiologic criteria (PRISM-III-APS) increased its predictive value to 0.85-0.95. The vasoactive-inotropic score at 12 h had a strong independent association with death. Albumin had an excellent predictive value when combined with other variables. Lactate, a biomarker widely measured in patients with sepsis, was highly associated with mortality. The bioimpedance phase angle was not considered applicable in our setting. Measurement using more straightforward methods, such as mid-upper arm circumference, was feasible in numerous health care facilities.

Conclusion

Leveraging prognostic models to predict mortality among pediatric patients with sepsis remains an important and well-recognized area of study. While much validation and development work remains to be done, available prognostic models could aid clinicians at the bedside of children with sepsis. Furthermore, mortality prediction models are essential and valuable tools for assessing the quality of care provided to critically ill pediatric patients.

Serum Ferritin for Predicting Outcome in Children With Severe Sepsis in the Pediatric Intensive Care Unit

OBJECTIVES

To evaluate the prognostic ability of serum ferritin when estimated within 5 days of onset of illness in children with severe sepsis admitted to a pediatric intensive care unit.

METHODS

This observational study enrolled children aged 1 month to 12 years with severe sepsis. Hemoglobin, serum ferritin and C-reactive protein levels were measured within five days of illness. Final outcomes were recorded in all enrolled children.

RESULTS

70 children with median (IQR) age of 27 (8,108) months were enrolled during the study period (July, 2019 to August, 2021). 28 (40%) of these had poor outcome (non-survival). The median (IQR) level of serum ferritin was 1369 (558-5607) ng/mL in non-survivors and 282 (129-680) ng/mL in survivors (P<0.05). A significant correlation was seen between serum ferritin and Pediatric Risk of Mortality III (PRISM III) score (r=0.364 P=0.002) and pediatric Sequential Organ Failure Assessment (pSOFA) score (r=0.246 P=0.04) at 48 hours of admission. 54 (77.1%) children were anemic. Serum ferritin levels in children with anemia also had a good predictive ability for poor outcome [AUC: 0.764, 95% CI: 0.634, 0.894].

CONCLUSIONS

Serum ferritin levels, within five days of onset of illness, predicted poor outcome in critically ill children with severe sepsis and in children with microcytic anemia.

Threshold of Inotropic Score and Vasoactive-Inotropic Score for Predicting Mortality in Pediatric Septic Shock

OBJECTIVE

To determine the threshold of the inotropic score (IS) and vasoactive-inotropic score (VIS) for predicting mortality in pediatric septic shock.

METHOD

This retrospective cohort study included children aged 1 mo to 13 y with septic shock, requiring vasoactive medication. The area under curve receiver operating characteristic (AUROC) was calculated using mean IS and mean VIS to predict PICU mortality, and Youden index cut points were generated. Sensitivity, specificity, and binary regression analysis were performed.

RESULTS

A total of 176 patients were enrolled (survivor, n = 72, 41% and nonsurvivor, n = 104, 59%). For predicting the PICU mortality, AUROC (95% CI) of IS was 0.80 (0.74-0.86) [sensitivity of 88.5 (80.7-94) and specificity of 58.3 (46.1-69.8)] and AUROC of VIS was 0.88 (0.82-0.92) [sensitivity of 83.7 (75.1-90.2) and specificity of 80.6 (69.5-89)]. The respective cutoff scores of IS and VIS were 28 and 42.5. On regression analysis (adjusted odds ratio, 95% CI), illness severity (PRISM-III) (1.12, 1.05-1.12), worst lactate value (1.31, 1.08-1.58), IS (> 28) (3.98, 1.24-12.80), and VIS (> 42.5) (4.66, 1.57-13.87) independently predicted the PICU mortality (r² = 0.625).

CONCLUSION

Threshold of inotropic score (> 28) and vasoactive-inotropic score (> 42.5) were independently associated with PICU mortality. In addition to IS and VIS, severity and worst lactate value independently predicted septic shock mortality in PICU.

Serum Ferritin for Predicting Outcome in Children With Severe Sepsis in the Pediatric Intensive Care Unit

OBJECTIVES

To evaluate the prognostic ability of serum ferritin when estimated within 5 days of onset of illness in children with severe sepsis admitted to a pediatric intensive care unit.

METHODS

This observational study enrolled children aged 1 month to 12 years with severe sepsis. Hemoglobin, serum ferritin and C-reactive protein levels were measured within five days of illness. Final outcomes were recorded in all enrolled children.

RESULTS

70 children with median (IQR) age of 27 (8,108) months were enrolled during the study period (July, 2019 to August, 2021). 28 (40%) of these had poor outcome (non-survival). The median (IQR) level of serum ferritin was 1369 (558-5607) ng/mL in non-survivors and 282 (129-680) ng/mL in survivors (P<0.05). A significant correlation was seen between serum ferritin and Pediatric Risk of Mortality III (PRISM III) score (r=0.364 P=0.002) and pediatric Sequential Organ Failure Assessment (pSOFA) score (r=0.246 P=0.04) at 48 hours of admission. 54 (77.1%) children were anemic. Serum ferritin levels in children with anemia also had a good predictive ability for poor outcome [AUC: 0.764, 95% CI: 0.634, 0.894].

CONCLUSIONS

Serum ferritin levels, within five days of onset of illness, predicted poor outcome in critically ill children with severe sepsis and in children with microcytic anemia.

Criteria for Pediatric Sepsis-A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce

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.

Prediction of the Development of Severe Sepsis Among Children With Intestinal Failure and Fever Presenting to the Emergency Department

OBJECTIVES

Children with intestinal failure (IF) and fever are frequently bacteremic, but risk factors for development of sepsis in this population are not well delineated. Our objective was to determine what clinical factors available on arrival to the emergency department (ED), including commonly used vital sign thresholds, predicted the subsequent development of severe sepsis in children with IF and fever.

STUDY DESIGN

This was a retrospective cohort study of children younger than 21 years with IF presenting to a tertiary care ED between 2010 and 2016 with fever who did not have hypotensive septic shock on arrival. The primary outcome was development of severe sepsis within 24 hours of ED arrival, as defined by consensus criteria. We identified predictors of severe sepsis using both univariate and multivariate models and calculated the test characteristics of 3 different sets of vital sign criteria in determining risk of severe sepsis.

RESULTS

In 26 (9.4%) of 278 encounters, the patient developed severe sepsis within 24 hours of arrival to the ED; 3 were excluded due to hypotensive shock on arrival. Predictors of severe sepsis included history of intestinal pseudo-obstruction (odds ratio, 8.2; 95% confidence interval, 2.3-30.2) and higher initial temperature (odds ratio, 1.7; 95% confidence interval, 1.2-2.3). The 3 sets of vital sign criteria had widely varying sensitivity and specificity in identifying development of severe sepsis.

CONCLUSIONS

History of intestinal pseudo-obstruction and higher fever predicted increased risk of severe sepsis among children with IF and fever presenting to an ED. No single set of vital sign criteria had both high sensitivity and specificity for this diagnosis.

Factors associated with mortality of pediatric sepsis patients at the pediatric intensive care unit in a low-resource setting

Background

Sepsis is the leading cause of death worldwide in pediatric populations. Studies in low-resource settings showed that the majority of pediatric patients with sepsis still have a high mortality rate.

Methods

We retrospectively collected records from 2014 to 2019 of patients who had been diagnosed with sepsis and admitted to PICU in our tertiary hospital. Cox proportional hazard regression modeling was used to evaluate associations between patient characteristics and mortality.

Results

Overall, 665 patients were enrolled in this study, with 364 (54.7%) boys and 301 (46.3%) girls. As many as 385 patients (57.9%) died during the study period. The median age of patients admitted to PICU were 1.8 years old with interquartile range (IQR) ±8.36 years and the median length of stay was 144 h (1–1896 h). More than half 391 patients (58.8%) had a good nutritional status. Higher risk of mortality in PICU was associated fluid overload percentage of > 10% (HR 9.6, 95% CI: 7.4–12.6), the need of mechanical ventilation support (HR 2.7, 95% CI: 1.6–4.6), vasoactive drugs (HR 1.5, 95% CI: 1.2–2.0) and the presence of congenital anomaly (HR 1.4, 95% CI: 1.0–1.9). On the contrary, cerebral palsy (HR 0.3, 95% CI: 0.1–0.5) and post-operative patients (HR 0.4, 95% CI: 0.3–0.6) had lower mortality.

Conclusion

PICU mortality in pediatric patients with sepsis is associated with fluid overload percentage of > 10%, the need for mechanical ventilation support, the need of vasoactive drugs, and the presence of congenital anomaly. In septic patients in PICU, those with cerebral palsy and admitted for post-operative care had better survival.

Prognostic value of baseline carotid blood flow in critically ill children with septic shock

BACKGROUND AND AIM

Hemodynamic monitoring and cardiac output (CO) assessment in the ICU have been trending toward less invasive methods. Carotid blood flow (CBF) was suggested as a candidate for CO assessment. The present study aimed to test the value of carotid artery ultrasound analysis in prediction of mortality in pediatric patients with septic shock.

METHODOLOGY/PRINCIPAL FINDING

Forty children with septic shock were included in the study. Upon admission, patients were subjected to careful history taking and thorough clinical examination. The consciousness level was assessed by the Glasgow Coma Scale (GCS). Laboratory assessment included complete blood count, C-reactive protein, arterial blood gases, serum electrolytes, and liver and kidney function tests. Electrical cardiometry was used to evaluate hemodynamic parameters. Patients were also subjected to transthoracic 2-D echocardiography. CBF was evaluated using GE Vivid S5 ultrasound device through dedicated software. At the end of study, 14 patients (35.0%) died. It was found that survivors had significantly higher CBF when compared non-survivors [median (IQR): 166.0 (150.0-187.3) versus 141.0 (112.8-174.3), p = 0.033]. In addition, it was noted that survivors had longer ICU stay when compared with non-survivors [16.5 (9.8-31.5) versus 6.5 (3.0-19.5) days, p = 0.005]. ROC curve analysis showed that CBF could significantly distinguish survivors from non-survivors [AUC (95% CI): 0.3 (0.11-0.48), p = 0.035] (Fig 2). Univariate logistic regression analysis identified type of shock [OR (95% CI): 28.1 (4.9-162.4), p<0.001], CI [OR (95% CI): 0.6 (0.43-0.84), p = 0.003] and CBF [OR (95% CI): 0.98 (0.96-0.99), p = 0.031]. However, in multivariate analysis, only type of shock significantly predicted mortality.

CONCLUSIONS

CBF assessment may be a useful prognostic marker in children with septic shock.

Echocardiographic Parameters and Mortality in Pediatric Sepsis: A Systematic Review and Meta-Analysis

OBJECTIVE

We conducted a systematic review and meta-analysis to investigate the prognostic value of echocardiographic parameters in pediatric septic patients.

DATA SOURCES

MEDLINE, PubMed, and EMBASE (last update April 5, 2020).

STUDY SELECTION

Observational studies of pediatric sepsis providing echocardiographic parameters in relation to mortality.

DATA EXTRACTION

Echocardiography data were categorized as those describing left ventricular systolic or diastolic function, right ventricular function, and strain echocardiography parameters. Data from neonates and children were considered separately. Analysis is reported as standardized mean difference and 95% CI.

DATA SYNTHESIS

We included data from 14 articles (n = 5 neonates, n = 9 children). The fractional shortening was the most commonly reported variable (11 studies, n = 555 patients) and we did not identify an association with mortality (standardized mean difference 0.22, 95% CI [-0.02 to 0.47]; p = 0.07, I2 = 28%). In addition, we did not find any association with mortality also for left ventricular ejection fraction (nine studies, n = 417; standardized mean difference 0.06, 95% CI [-0.27 to 0.40]; p = 0.72, I2 = 51%), peak velocity of systolic mitral annular motion determined by tissue Doppler imaging wave (four studies, n = 178; standardized mean difference -0.01, 95% CI [-0.34 to 0.33]; p = 0.97, I2 = 0%), and myocardial performance index (five studies, n = 219; standardized mean difference -0.51, 95% CI [-1.10 to 0.08]; p = 0.09, I2 = 63%). However, in regard to left ventricular diastolic function, there was an association with mortality for higher early wave of transmitral flow/peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging ratio (four studies, n = 189, standardized mean difference -0.45, 95% CI [-0.80 to -0.10]; p = 0.01, I2 = 0%) or lower peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging wave (three studies, n = 159; standardized mean difference 0.49, 95% CI [0.13-0.85]; p = 0.008, I2 = 0%). We did not find any association with mortality for early wave of transmitral flow/late (atrial) wave of trans-mitral flow ratio (six studies, n = 273; standardized mean difference 0.28, 95% CI [-0.42 to 0.99]; p = 0.43, I2 = 81%) and peak velocity of systolic mitral annular motion determined by tissue Doppler imaging wave measured at the tricuspid annulus (three studies, n = 148; standardized mean difference -0.18, 95% CI [-0.53 to 0.17]; p = 0.32, I2 = 0%). Only a few studies were conducted with strain echocardiography.

CONCLUSIONS

This meta-analysis of echocardiography parameters in pediatric sepsis failed to find any association between the measures of left ventricular systolic or right ventricular function and mortality. However, mortality was associated with higher early wave of transmitral flow/peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging or lower peak velocity of early diastolic mitral annular motion determined by tissue Doppler imaging, indicating possible importance of left ventricular diastolic dysfunction. These are preliminary findings because of high clinical heterogeneity in the studies to date.

Safety and Feasibility of Antibiotic De-escalation in Critically Ill Children With Sepsis - A Prospective Analytical Study From a Pediatric ICU

Introduction: De-escalation is the key to balance judicious antibiotic usage for life-threatening infections and reducing the emergence of antibiotic resistance caused by antibiotic overuse. Robust evidence is lacking regarding the safety of antibiotic de-escalation in culture negative sepsis. Materials and Methods: Children admitted to the PICU during the first 6 months of 2019 with suspected infection were included. Based on the clinical condition, cultures and septic markers, antibiotics were de-escalated or continued at 48-72 h. Outcome data like worsening of primary infection, acquisition of hospital acquired infection, level of ICU support and mortality were captured. Results: Among the 360 admissions, 247 (68.6%) children received antibiotics. After excluding 92 children, 155 children with 162 episodes of sepsis were included in the study. Thirty four episodes were not eligible for de-escalation. Among the eligible group of 128 episodes, antibiotics were de-escalated in 95 (74.2%) and continued in 33 (25.8%). The primary infection worsened in 5 (5.2%) children in the de-escalation group and in 1 (3%) in non de-escalation group [Hazard ratio: 2.12 (95%CI: 0.39-11.46)]. There were no significant differences in rates of hospital acquired infection, mortality or length of ICU stay amongst the groups. Blood cultures and assessment of clinical recovery played a major role in de-escalation of antibiotics and the clinician's hesitation to de-escalate in critically ill culture negative children was the main reason for not de-escalating among eligible children. Conclusion: Antibiotic de-escalation appears to be a safe strategy to apply in criticallly ill children, even in those with negative cultures.

Comparison of Ventilator-free Days at 14 and 28 days as a Clinical Trial Outcome in Low- and Middle-income Countries

Aims and objectives

Reporting ventilator-free days (VFDs) with time frame of 28 days is a popular composite outcome measure (COM) in trials. However, early deaths and shorter pediatric intensive care unit (PICU) stay predominate in low- and middle-income countries (LMICs). A shorter time frame may reduce sample size required. We planned to compute sample size requirements for different effect sizes from datasets of previously conducted prospective studies for 28-day and 14-day time frames (VFD₂₈ vs VFD₁₄) to examine the hypothesis.

Materials and methods

The VFD₂₈ and VFD₁₄ were defined. Datasets of five prospective studies from PICU of our hospital were analyzed to estimate sample sizes for target reductions of 1–9 days in VFDs and other COMs for the two time frames. Reconfirmation of results was done with datasets of two other studies from PICUs of two geographical extremes of the country.

Results

Time-to-event occurred within 14 days in majority of patients. Sample size required for VFD₁₄ is about one-fifth to one-sixth of what is required for VFD₂₈ for target reductions of 1–9 days for all the enrolled studies. The same was true for other COMs as well. The hypothesis was supported by datasets of two other studies used for reconfirmation.

Conclusion

Choice of time frame for assessing VFDs and other COMs in clinical trials should be guided by the clinical context. A shorter time frame may be rewarding in terms of smaller sample size in the prevalent clinical setting of LMICs. Further confirmation with more datasets and prospective studies is desirable.

How to cite this article

Baranwal AK, Kumar MP, Gupta PK. Comparison of Ventilator-free Days at 14 and 28 days as a Clinical Trial Outcome in Low- and Middle-income Countries. Indian J Crit Care Med 2020;24(10):960–966.

The predictors of outcome and progression of pediatric sepsis and septic shock: A prospective observational study from western India

Introduction:

There is a paucity of studies on the progression and outcome of Systemic Inflammatory Response Syndrome (SIRS) with its determinants.

Aims and Objectives:

To determine the predictors of the outcome and progression of pediatric sepsis and septic shock.

Materials and Methods:

Prospective observational study of children fulfilling criteria of SIRS and their progression to sepsis, severe sepsis, and septic shock (clinically and biochemically) was conducted at a tertiary care center.

Results:

Totally, 200 children were recruited over a period of 21 months (from February 2016 to October 2017). Most cases (80, 40%) were infants. Of the total, 188 (94%) cases were of an infective etiology (mostly respiratory system). Temperature and heart rate were the two commonest SIRS parameters which were deranged. Blood cultures were positive in only 25 (12.5%) cases. Out of the total 200 children, 108 progressed to sepsis, of which 26 progressed to severe sepsis, of which 22 progressed to septic shock. Abnormal leukocyte count, culture positivity and severe acute malnutrition were significantly associated with progression of SIRS patients to septic shock (P = 0.001, 0.00001 and 0.002, respectively). Factors associated with mortality were positive blood culture, multiorgan dysfunction, late hospital admissions, severe acute malnutrition, and requirement of supportive care (P values-<0.0001, <0.0001, 0.03, <0.0001 and <0.0001, respectively).

Conclusions:

SIRS can progress to septic shock if not identified early. The predictors of mortality were positive blood cultures, multiorgan dysfunction, late hospital admissions, severe acute malnutrition, and requirement of supportive care. The predictors of progression to septic shock were abnormal leukocyte count, culture positivity, and severe acute malnutrition.

Association Between Vitamin D Deficiency and Duration of Hospital Stay, Pediatric Intensive Care Unit Stay, and Ventilation; Pediatric Risk of Mortality Score; and Rate of Readmission: A Prospective Observational Study

Introduction The study aims to evaluate the association between a deficiency of Vitamin D level with the duration of hospital stay, pediatric intensive care unit (PICU) stay, and ventilation; the pediatric risk of mortality (PRISM) score, and the rate of readmission. Materials and methods This prospective observational study was conducted from November 2014 to October 2015, and the study population consisted of children admitted to the pediatric intensive care unit (PICU) in a tertiary care hospital of Puducherry. After measuring vitamin D levels, children were allotted into three categories depending on their serum 25(OH)D levels as the sufficient group (25[OH]D level ≥ 30 ng/mL), insufficient group (25[OH]D level = 20 - 29.9 ng/mL), and deficient group (25[OH]D level < 20 ng/mL). Among these three groups, the duration of hospital stay, PICU stay, and ventilation; the PRISM score, and the rate of readmission were compared. Results A total of 522 patients were included in the study. Based on their 25(OH)D level, 222 patients (42.5%) were in the sufficient category, 153 patients (29.3%) were in the deficient category, and 147 patients (28.2%) were in the insufficient category. Vitamin D deficiency state is not statistically significantly associated with the duration of hospital stay (P = .84), duration of PICU stay (P = .69), duration of ventilation (P = .48), PRISM score (P = .63), and rate of readmission (P = .91). Conclusions Longer hospital stay, prolonged PICU stay, longer duration of ventilation, and higher PRISM III score were independent risk factors for higher mortality in the PICU. However, lower vitamin D levels are not statistically significant to predict mortality among the study population.

Admission platelet count and indices as predictors of outcome in children with severe Sepsis: a prospective hospital-based study

BACKGROUND

Sepsis is still one of the main causes of infants and children mortality especially in developing, economically challenged countries with limited resources. Our objective in this study was to determine, the prognostic value of platelet count, mean platelet volume (MPV), platelet distribution width (PDW) and plateletcrit (PCT) in critically ill infants and children with severe sepsis, as they are readily available biomarkers, that can guide clinicians during managing of severe sepsis.

METHODS

Sixty children were included; they were diagnosed with severe sepsis according to the international pediatric sepsis consensus conference criteria. At admission to Pediatric intensive care unit, complete blood count with platelet count and parameters (MPV, PDW and PCT) and C-reactive protein (CRP) level were determined for all children. Also, assessment of the Pediatric Risk of Mortality (PRISM III) score was done to all. These children were followed up till discharge from hospital or death. Accordingly, they were grouped into: (1) Survivor group: included 41 children. (2) Non-survivor group: included 19 children.

RESULTS

Platelet count and PCT were significantly lower (p < 0.001) and MPV was significantly higher in non-survivor than survivors (p = 0.004). MPV/PLT, MPV/PCT, PDW/PLT, PDW/PCT ratios were found to be significantly higher in the non-survivors than survivor (p < 0.001 in all). PCT with sensitivity = 94.74%, was the most sensitive platelet parameter for prediction of death, while MPV/PCT was the most sensitive ratio (sensitivity = 94.7%).

CONCLUSION

Thrombocytopenia, platelet indices and their ratios, especially plateletcrit and MPV/PCT, are readily available, sensitive, prognostic markers, that can identify the severe sepsis patients with poorest outcome.

Cytokine Levels in Critically Ill Children With Severe Sepsis and Their Relation With the Severity of Illness and Mortality

OBJECTIVE

To study the baseline cytokine levels and their relation with the severity of illness and mortality in critically ill children with severe sepsis.

DESIGN

Subgroup analysis of a randomized, double-blind, placebo-controlled trial.

SETTING

Pediatric intensive care unit of a tertiary level teaching hospital in India.

PATIENTS

Fifty children with severe sepsis aged 3 months to 12 years.

MATERIAL AND METHODS

Blood was collected at admission for estimation of pro-inflammatory (interleukin 6 [IL-6], IL-12p70, IL-17, and tumor necrotic factor α [TNF-α]) and anti-inflammatory (IL-10 and transforming growth factor β1 [TGF-β1]) cytokines.

PRIMARY OUTCOME

To find out correlation between cytokine levels and severity of illness scores (Pediatric Risk of Mortality [PRISM] III score, Sequential Organ Failure Assessment [SOFA], and Vasoactive-Inotropic Score [VIS]).

SECONDARY OUTCOMES

To compare cytokine levels among survivors and nonsurvivors.

RESULTS

Baseline pro-inflammatory cytokine levels (median [interquartile range]) were IL-6: 189 (35-285) pg/mL, IL-12p: 48 (28-98) pg/mL, IL-17: 240 (133-345) pg/mL, and TNF-α: 296 (198-430) pg/mL; anti-inflammatory cytokine levels were IL-10: 185 (62-395) pg/mL and TGF-β1: 204 (92-290) ng/mL. Pro-inflammatory cytokines showed positive correlation with PRISM III score: IL-6 (Spearman correlation coefficient, ρ = 0.273, P = .06), IL-12 (ρ = 0.367, P = .01), IL-17 (ρ = 0.197, P = .17), and TNF-α (ρ = 0.284, P = .05), and anti-inflammatory cytokines showed negative correlation: IL-10 (ρ = -0.257, P = .09) and TGF-β (ρ = -0.238, P = .11). Both SOFA and VIS also showed weak positive correlation with IL-12 (ρ = 0.32, P = .03 and ρ = 0.31, P = .03, respectively). Among nonsurvivors (n = 5), the levels of all the measured pro-inflammatory cytokines were significantly higher as compared to survivors, IL-6: 359 (251-499) pg/mL versus 157 (97-223) pg/mL, P < .0001, IL-12p70: 167 (133-196) pg/mL versus 66 (30-100) pg/mL, P < .0001, IL-17: 400 (333-563) pg/mL versus 237 (122-318) pg/mL, P = .009, and TNF-α: 409 (355-503) pg/mL versus 330 (198-415) pg/mL, P = .002, respectively.

CONCLUSION

In critically ill children with severe sepsis, pro-inflammatory cytokines (especially IL-12p70) showed a weak positive correlation with severity of illness and were significantly higher among nonsurvivors.

Characterization and Outcome of Two Pediatric Intensive Care Units with Different Resources

Background

The pediatric intensive care units (PICUs) in developing countries have a higher mortality outcome due to a wide variety of causes. Identifying differences in the structure, patient characteristics, and outcome between PICUs with different resources may add evidence to the need for incorporating more PICUs with limited resources in the contemporary critical care research to improve the care provided for severely ill children.

Methods

A retrospective study was conducted at Egyptian and Japanese PICUs as examples of resource-limited and resource-rich units, respectively. We collected and compared data of nonsurgical patients admitted between March 2018 and February 2019, including the patients' demographics, diagnosis, PICU length of stay, outcome, predicted risk of mortality using pediatric index of mortality-2 (PIM-2), and functional neurological status using the Pediatric Cerebral Performance Category (PCPC) scale.

Results

The Egyptian unit had a lower number of beds with a higher number of annual admission/bed than the Japanese unit. There was a shortage in the number of the skilled staff at the Egyptian unit. Nurse : patient ratios in both units were only similar at the nighttime (1 : 2). Most of the basic equipment and supplies were available at the Egyptian unit. Both actual and PIM-2 predicted mortalities were markedly higher for patients admitted to the Egyptian unit, and the mortality was significantly associated with age, severe sepsis, and PIM-2. The length of stay was shorter at the Egyptian unit.

Conclusion

The inadequate structure and the burden of more severely ill children at the Egyptian unit appear to be the most important causes behind the higher mortality at this unit. Increasing the number of qualified staff and providing cost-effective equipment may help in improving the mortality outcome and the quality of care.

Lactate Measurements and Their Association With Mortality in Pediatric Severe Sepsis in India: Evidence That 6-Hour Level Performs Best

PURPOSE

To investigate association of static and dynamic lactate indices with early mortality (within 48 hours of admission), as well as need for vasopressors and mechanical ventilation in pediatric severe sepsis/shock. To explore optimal cutoffs of lactate indices. We hypothesized that dynamic indices are superior to static indices in predicting early mortality.

METHODS

This prospective cohort study involved children (aged <14 years) admitted in emergency department, tertiary care teaching hospital in North India with severe sepsis/shock (2015-2016). Arterial lactate was measured at admission (X0) and after 6 hours (X6). Primary outcome of the measurement was early mortality. Association between lactate indices- lactate at 0 hours (Lac0), lactate after 6 hours (Lac6), time-weighted average (LacTW), delta (ΔLac), clearance (LacCl%) and early mortality, need for vasopressors, and mechanical ventilation-was assessed using Student t test/Mann-Whitney test. Area under the receiver operating characteristic curve (AUROC) for early mortality deduced for all lactate indices and compared with reference (Lac0). Optimal cutoffs (maximizing both sensitivity and specificity) and their positive predictive value (PPV) and negative predictive value (NPV) were determined.

RESULTS

During the study period, 116 children were assessed. Septic shock was present at admission in 56.9% children; 50% of children died during the next 48 hours. Lac0, Lac6, and LacTW were significantly higher, and LacCl% was lower in nonsurvivors versus survivors (all P < .001). Lac6 (0.837 [0.76-0.91]) had significantly higher AUROC (95% confidence interval) than Lac0 (0.77; P = .03). Abnormal lactate metrics (higher Lac0, Lac6, LacTW, and lower LacCl%) were associated with vasopressors need and mechanical ventilation. On logistic regression, Lac6 emerged as an independent predictor of early mortality as well as vasopressor and mechanical ventilation need. The optimal cutoff of Lac6 for identifying early mortality with good sensitivity, specificity, PPV, and NPV was ≥2.65 (76, 85, 83, 78).

CONCLUSIONS

Lactate6 is the best marker associated with early mortality and higher level of care in severe sepsis/septic shock in resource-poor regions.

Prevalence and Management of Septic Shock among Children Admitted at the Kenyatta National Hospital, Longitudinal Survey

BACKGROUND

Paediatric septic shock is a subset of sepsis associated with high mortality. Implementing the existing international Surviving Sepsis Campaign Guidelines 2012 (SSCG) have contributed to reduction of mortality in many places but these have not been adopted in our setting. The current study aimed at documenting the practice at a national referral hospital.

METHODS

A hospital based longitudinal survey carried out among 325 children from September to October 2016. Children aged 0 days (≥37 weeks gestation) to12 years were included. The aim was to determine the prevalence, audit the management and determine the outcome at 72 hours of septic shock among children admitted at the Kenyatta National Hospital (KNH). A standard questionnaire was used for data collection and Surviving Sepsis Guideline 2012 was used as a reference for auditing the management of septic shock. Data was stored in MS-EXCEL and analysed in STATA 12.

RESULTS

The prevalence of septic shock was 50 (15.4%), with a median age of 4 months. Septic shock was recognized by the attending clinician in 28 (56%). The level of care to children with septic shock was not to the level recommended by the SSCG 2012. Odds of being diagnosed with septic shock reduced with age (odds ratio 4.38 (1.7-11.0), p = 0.002) and no child aged above 60 months age was diagnosed with septic shock. The mortality was 35 (70%) at 72 hours of admission, with a median of 14 hours. Infants had the highest case fatality of 82.6%. It was found that lack of mechanical ventilation, and presence of hypotension at admission were associated with greater mortality (p values of 0.03 and 0.01 respectively).

CONCLUSION

The prevalence rate of septic shock is 15.4% among children admitted at the KNH and is associated with high mortality. The advanced degree of shock contributed to mortality. The level of care at KNH was not to the level of SSCG 2012, and hence the need to include septic shock management guidelines/protocols in our local Kenyan paediatric guideline.

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

OBJECTIVES:

To evaluate the association of severe vitamin D deficiency with clinically important outcomes in children with septic shock.

METHODS:

We enrolled children ≤17 years with septic shock prospectively over a period of 6 months. We estimated 25-hydroxyvitamin D [25 (OH) D] levels at admission and 72 hours. Severe deficiency was defined as serum 25 (OH) <10 ng/mL. We performed univariate and multivariate analysis to evaluate association with clinically important outcomes.

RESULTS:

Forty-three children were enrolled in the study. The prevalence of severe vitamin D deficiency was 72% and 69% at admission and 72 hours, respectively. On univariate analysis, severe vitamin D deficiency at admission was associated with lower rates of shock reversal, 74% (23) versus 25% (3); relative risk (95% confidence interval [CI]): 2.9 (1.09-8.08), at 24 hours and greater need for fluid boluses (75 vs 59 mL/kg). On multivariate analysis, nonresolution of shock at 24 hours was significantly associated with severe vitamin D deficiency after adjusting for other key baseline and clinical variables, adjusted odds ratio (95% CI): 12 (2.01-87.01); 0.01.

CONCLUSION:

The prevalence of severe vitamin D deficiency is high in children with septic shock admitted to pediatric intensive care unit. Severe vitamin D deficiency at admission seems to be associated with lower rates of shock reversal at 24 hours of ICU stay. Our study provides preliminary data for planning interventional studies in children with septic shock and severe vitamin D deficiency.

Global Case-Fatality Rates in Pediatric Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis

IMPORTANCE

The global patterns and distribution of case-fatality rates (CFRs) in pediatric severe sepsis and septic shock remain poorly described.

OBJECTIVE

We performed a systematic review and meta-analysis of studies of children with severe sepsis and septic shock to elucidate the patterns of CFRs in developing and developed countries over time. We also described factors associated with CFRs.

DATA SOURCES

We searched PubMed, Web of Science, Excerpta Medica database, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central systematically for randomized clinical trials and prospective observational studies from earliest publication until January 2017, using the keywords "pediatric," "sepsis," "septic shock," and "mortality."

STUDY SELECTION

Studies involving children with severe sepsis and septic shock that reported CFRs were included. Retrospective studies and studies including only neonates were excluded.

DATA EXTRACTION AND SYNTHESIS

We conducted our systematic review and meta-analysis in close accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled case-fatality estimates were obtained using random-effects meta-analysis. The associations of study period, study design, sepsis severity, age, and continents in which studies occurred were assessed with meta-regression.

MAIN OUTCOMES AND MEASURES

Meta-analyses to provide pooled estimates of CFR of pediatric severe sepsis and septic shock over time.

RESULTS

Ninety-four studies that included 7561 patients were included. Pooled CFRs were higher in developing countries (31.7% [95% CI, 27.3%-36.4%]) than in developed countries (19.3% [95% CI, 16.4%-22.7%]; P < .001). Meta-analysis of CFRs also showed significant heterogeneity across studies. Continents that include mainly developing countries reported higher CFRs (adjusted odds ratios: Africa, 7.89 [95% CI, 6.02-10.32]; P < .001; Asia, 3.81 [95% CI, 3.60-4.03]; P < .001; South America, 2.91 [95% CI, 2.71-3.12]; P < .001) than North America. Septic shock was associated with higher CFRs than severe sepsis (adjusted odds ratios, 1.47 [95% CI, 1.41-1.54]). Younger age was also a risk factor (adjusted odds ratio, 0.95 [95% CI, 0.94-0.96] per year of increase in age). Earlier study eras were associated with higher CFRs (adjusted odds ratios for 1991-2000, 1.24 [95% CI, 1.13-1.37]; P < .001) compared with 2011 to 2016. Time-trend analysis showed higher CFRs over time in developing countries than developed countries.

CONCLUSIONS AND RELEVANCE

Despite the declining trend of pediatric severe sepsis and septic shock CFRs, the disparity between developing and developed countries persists. Further characterizations of vulnerable populations and collaborations between developed and developing countries are warranted to reduce the burden of pediatric sepsis globally.

Shock Index-A Useful Noninvasive Marker Associated With Age-Specific Early Mortality in Children With Severe Sepsis and Septic Shock: Age-Specific Shock Index Cut-Offs

BACKGROUND

Aim of the study was to analyze the association of shock index (SI) from 0 to 6 hours with early mortality in severe sepsis/septic shock and to explore its age-specific cut-off values. To investigate association of change in SI over first 6 hours with early mortality.

METHODS

A prospective cohort study of children (<14 years) admitted in emergency department, tertiary care hospital with severe sepsis or septic shock, divided into 3 groups: group 1: 1 month to <1 year; group 2: 1 to <6 years; group 3: 6 to 12 years. Shock index (SI = heart rate/systolic blood pressure) measured at admission (X0) and hourly till 6 hours (X1-6). Primary outcome was death within 48 hours of admission. Area under receiver operating characteristic curves were constructed for SI (0-6). Optimal cut-offs of SI 0 and SI 6, maximizing both sensitivity and specificity were determined and positive and negative predictive values (PPV, NPV) were calculated.

RESULTS

From 2015 to 2016, 120 children were recruited. Septic shock was present at admission in 56.7% children. Early mortality was 50%. All hourly shock indices (SI 0-6) were higher among nonsurvivors in group 2 (P ≤ .03) and group 3 (P < .001). In group 1, SI after 2 hours was higher in nonsurvivors (P 2-6: ≤ .02). Area under receiver operating characteristic curves (95% CI) for SI at 0 hour was 0.72 (0.5-0.9), 0.66 (0.5-0.8), and 0.77 (0.6-0.9) and at 6 hours was 0.8 (0.6-1), 0.75 (0.6-0.9), and 0.8 (0.7-1) in 3 groups. The cut-off values of SI 0 (sensitivity; specificity; PPV; NPV) in 3 groups: 1.98 (77; 75; 67; 83), 1.50 (65; 65; 68; 63), and 1.25 (90; 67; 77; 83) and SI6: 1.66 (85; 80; 73; 89), 1.36 (73; 70; 73; 70), and 1.30 (74; 73; 78; 69). Improvement of SI over 6 hours was associated with better outcome. Children with higher SI at both time points had higher mortality than those with SI score below the cut-offs (P = .001).

CONCLUSIONS

Age-specific SI cut-off values may identify children at high risk of early mortality in severe sepsis/septic shock and allow for better targeted management.

Off-Hours Admissions and Mortality in PICU Without 24-Hour Onsite Intensivist Coverage

OBJECTIVE

To evaluate whether the off-hours admission has any effect on risk-adjusted mortality and length of stay for nonelective patients admitted to a pediatric intensive care unit (PICU) without 24-hour in-house intensivist coverage.

DESIGN

Prospective cohort study.

SETTING

A 34-bed tertiary PICU.

PATIENTS

All consecutive nonelective patients aged 0 to 14 years admitted from January 2012 to June 2015.

MEASUREMENTS AND MAIN RESULTS

A total of 1254 patients were nonelectively admitted to the PICU. They were categorized according to time of PICU admission as either office hours (07:30 to 16:30 from Sunday to Thursday and whenever an intensivist is present in the ICU) or off-hours (16:30 to 07:30, Friday and Saturday and public holidays). Standardized mortality rates (SMRs) of patients admitted during off-hours were compared to SMRs of patients admitted during office hours using Pediatric Risk of Mortality (PRISM2) score. Multivariate logistic regression was used to assess the effect of time of admission on outcome after adjustment for severity of illness using the PRISM2. The mortality observed in the office-hours group was 9.4% and in the off-hours group was 8.1%. The PRISM2-based SMR was 0.83 (95% confidence interval [CI]: 0.43-1.47) for the office-hours group and 0.68 (95% CI: 0.34-1.36) for the off-hours group. No significant differences in length of ICU stay or duration of mechanical ventilation were observed between patients admitted during off-hours and those admitted during office hours. In the logistic regression model, off-hours admission was not significantly associated with a higher mortality (odds ratio: 0.85, 95% CI: 0.57-1.27; P = .44).

CONCLUSIONS

The absence of an in-house intensivist during off-hours is not associated with an increase in mortality, length of ICU stay, or duration of mechanical ventilation for patients admitted to our pediatric ICU.

Adherence to surviving sepsis guidelines among pediatric intensivists. A national survey

OBJECTIVES

To assess the compliance with the 2006 American College of Critical Care-Pediatric Advanced Life Support (ACCM-PALS) guidelines for sepsis management, and the 2012 surviving sepsis campaign (SSC), for the management of pediatric patients with sepsis and to identify the main barriers to adherence to these guidelines. Methods: In November 2015, a prospective cohort study in which a web based electronic survey using a case scenario to explore the usual management of a child with severe sepsis was designed and sent to all consultant pediatric intensivists practicing in Kingdom of Saudi Arabia (KSA). Adherences to 2012 SSC guidelines and to 4 algorithmic time-specific goals outlined in the ACCM-PALS guidelines were measured. Results: Sixty-one (76%) of 80 consultant pediatric intensivists working in KSA responded to the survey. Of the 61 respondents, 94% reported administering antibiotics within one hour of the child presentation, 98% reported starting resuscitation by giving fluid boluses, 93% reported starting vasopressor if the patient remained hypotensive despite fluid resuscitation, and 86% reported they would start hydrocortisone in case of catecholamine refractory shock. In total, 80% of the intensivists reported full adherence to all of the 4 components in the ACCM-PALS bundle; 50% reported that the absence of a locally written protocol was the main barrier to adherence to the SSC guidelines. Conclusion: Pediatric intensivists reported good adherence to the 2006 ACCM-PALS guidelines and 2012 SSC guidelines with some variability in interpretation of the recommendations. The absence of a written protocol was the main reported barrier to adherence to these guidelines.

Beneficial Effects of Omega-3 Supplement to the Enteral Feeding in Children With Mild to Moderate Sepsis

OBJECTIVE

The objective was to investigate the benefits of supplementing enteral feeding with omega-3 fatty acids in children with mild to moderate sepsis and its effects on acute-phase reactants and interleukin 6 (IL-6) level.

METHODS

The study was a prospective randomized, double-blind, placebo-controlled study from January 2012 to June 2014, which included 2 groups of children with mild to moderate sepsis tolerating enteral feeding. Group A included 60 children supplemented with omega-3 fatty acids, whereas group B included 60 children who received enteral feeding without omega-3 supplementation. Both groups had complete blood pictures, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), serum albumin, and IL-6 before and after 7 days from supplementation.

RESULTS

There was a significant improvement in hemoglobin percentage ( P < .0001), total white blood cell (WBC) count ( P < .0001), and platelet count ( P < .0001) and significant decrease in CRP ( P < .0001), ESR ( P < .0001), IL-6 ( P < .0001), and albumin level ( P < .001) in the supplemented group than the nonsupplemented group. The supplemented group also had a significantly shorter duration of stay in pediatric intensive care unit (PICU; P < .01) and decreased death rate than the nonsupplemented group.

CONCLUSION

Children with mild to moderate sepsis showed significant improvement in inflammatory markers and had shorter PICU admission when enteral feeding was supplemented with omega-3 essential fatty acids.