Refractory septic shock in children: a European Society of Paediatric and Neonatal Intensive Care definition

Abstract

PurposeAlthough overall paediatric septic shock mortality is decreasing, refractory septic shock (RSS) is still associated with high mortality. A definition for RSS is urgently needed to facilitate earlier identification and treatment. We aim to establish a European society of paediatric and neonatal intensive care (ESPNIC) experts’ definition of paediatric RSS.MethodsWe conducted a two-round Delphi study followed by an observational multicentre retrospective study. One hundred and fourteen paediatric intensivists answered a clinical case-based, two-round Delphi survey, identifying clinical items consistent with RSS. Multivariate analysis of these items in a development single-centre cohort (70 patients, 30 % mortality) facilitated development of RSS definitions based on either a bedside or computed severity score. Both scores were subsequently tested in a validation cohort (six centres, 424 patients, 11.6 % mortality).ResultsFrom the Delphi process, the draft definition included evidence of myocardial dysfunction and high blood lactate levels despite high vasopressor treatment. When assessed in the development population, each item was independently associated with the need for extracorporeal life support (ECLS) or death. Resultant bedside and computed septic shock scores had high discriminative power against the need for ECLS or death, with areas under the receiver operating characteristics curve of 0.920 (95 % CI 0.89–0.94), and 0.956 (95 % CI 0.93–0.97), respectively. RSS defined by a bedside score equal to or higher than 2 and a computed score equal to or higher than 3.5 was associated with a significant increase in mortality.ConclusionsThis ESPNIC definition of RSS accurately identifies children with the most severe form of septic shock.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-016-4574-2) contains supplementary material, which is available to authorized users.

Can the Pediatric Logistic Organ Dysfunction-2 Score on Day 1 Be Used in Clinical Criteria for Sepsis in Children?*

“…In children having a low SBP with hyperlactatemia (n=69) the d1PELOD-2 was 7.5 (5)(6)(7)(8)(9)(10)(11) in those who survived (66.7%) and 17 (13)(14)(15)(16)(17)(18)(19)(20) in those who died (33.3%) (p<0.0001). In those having a low MBP with hyperlactatemia (n=88) the d1PELOD-2 was 7 (5-10) in children who survived (69.43%) and 16 (13)(14)(15)(16)(17)(18)(19)(20) in those who died (30.7%) (p=0.0001). The odds ratio of death per unit of the d1PELOD-2 was 1.50 (95%CI :1.39 -1.63) in our population as a whole (table 3).…”

“…Our study has some limitations. First, our database is almost 10 years old, and mortality should have improved due to changes in treatments; however, studies conducted on more recent database reported that the PELOD-2 score remains reflective of outcome (19,20). Second, as mentioned above, we did not screen our data base with sepsis defined on the basis of 2005 International Sepsis Consensus Conference (4); however, the sensitivity of SIRS criteria has been criticized because they miss patients with infection and organ failure (6,8,21).…”

Bacterial infections in children after liver transplantation: A single‐center surveillance study of 345 consecutive transplantations

“…In our study cohort, 27% of patients with septic shock and 17% of patients in the combined group of severe sepsis or septic shock died. This is a substantially higher rate compared with recent data from a large database in Australia, New Zealand, and Europe, 11,12 reporting a mortality rate between 11.6% and 17% for septic shock. One has to keep in mind that these studies also included immunocompetent patients, which might account for the difference in mortality.…”

A clinical prediction model to identify patients at high risk of hemodynamic instability in the pediatric intensive care unit

“…Mainly, the heart rate increases by activation of the sympathetic nervous system, and urine output decreases by activation of the renin–angiotensin–aldosterone system. Other clinical features such as cold extremities, mottled skin, and prolonged capillary refill time were not considered in the model as they are signs of decompensated shock and thus represent the physiological state clinicians are trying to avoid [12]. …”