1241: Identification of Acute Brain Dysfunction in Pediatric Sepsis Using Four Definitions

Decrypting Sepsis-Associated Brain Dysfunction: A Computational Phenotype That Can Hack It*

“…However, varied names and definitions for sepsis-associated brain dysfunction complicate efforts to identify optimal treatment approaches. As Alcamo et al (6) note in this issue of Pediatric Critical Care Medicine, brain involvement in sepsis and septic shock "…goes by a variety of terms including sepsis-associated encephalopathy, sepsis-induced brain dysfunction, or sepsis-associated delirium…" Accordingly, a validated, well-performing definition applicable to electronic health records (EHRs) is needed to aid surveillance efforts and epidemiological assessments, with the ultimate intent of improving outcomes. This is not a new undertaking for Alcamo et al (6), who have spent years developing and validating a structured, composite, "computational phenotype of acute brain dysfunction (CP ABD ). "…”

“…As Alcamo et al (6) note in this issue of Pediatric Critical Care Medicine, brain involvement in sepsis and septic shock "…goes by a variety of terms including sepsis-associated encephalopathy, sepsis-induced brain dysfunction, or sepsis-associated delirium…" Accordingly, a validated, well-performing definition applicable to electronic health records (EHRs) is needed to aid surveillance efforts and epidemiological assessments, with the ultimate intent of improving outcomes. This is not a new undertaking for Alcamo et al (6), who have spent years developing and validating a structured, composite, "computational phenotype of acute brain dysfunction (CP ABD ). " Akin to other epidemiological breakthroughs, like the simple questionnaires used to link smoking with lung cancer in the 1950s, CP ABD is constructed with a straightforward methodology that belies its broad utility (7).…”

“…To further establish the soundness of CP ABD , Alcamo et al (6) compare it to other definitions of sepsis-related neurologic dysfunction, including those created by Proulx et al (11), the International Pediatric Sepsis Consensus Conference (IPSCC) (12), and the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) (13). Proulx et al (11) put forward the most severe definition of sepsis-related brain dysfunction, requiring pupils to be fixed and dilated or a total Glasgow Coma Scale score (GCS) less than 5.…”

“…This is not a new undertaking for Alcamo et al (6), who have spent years developing and validating a structured, composite, “computational phenotype of acute brain dysfunction (CP ABD ).” Akin to other epidemiological breakthroughs, like the simple questionnaires used to link smoking with lung cancer in the 1950s, CP ABD is constructed with a straightforward methodology that belies its broad utility (7). Using structured data ubiquitous in modern EHR databases, CP ABD assesses whether a patient had MRI or CT brain imaging, an electroencephalogram (EEG), or was treated with an antipsychotic medication during an inpatient encounter.…”

“…This is especially relevant given the recent, milestone release of the international Phoenix consensus criteria for sepsis in children, which defines sepsis-related neurologic dysfunction as a GCS less than or equal to 10 (1 point) or fixed pupils bilaterally (2 points) and is not accounted for by Alcamo et al (6) and Schlapbach et al (15) Instead, the reference standard in the present work encompasses much milder phenotypes of brain dysfunction, including “headache not relieved by fluid resuscitation” and “agitation” to name only 2 of the approximately 11 clinical scenarios described by the authors. How this decision will influence the use of CP ABD as the world decides how to use the new Phoenix criteria remains to be determined, though the reference standard devised by Alcamo et al (6) might be interpreted as at least one collective voice claiming that brain dysfunction compatible with sepsis occurs well before a patient becomes stuporous, comatose, or develops two nonreactive pupils.…”