Severe Sepsis in Severely Malnourished Young Bangladeshi Children with Pneumonia: A Retrospective Case Control Study

Abstract

BackgroundIn developing countries, there is no published report on predicting factors of severe sepsis in severely acute malnourished (SAM) children having pneumonia and impact of fluid resuscitation in such children. Thus, we aimed to identify predicting factors for severe sepsis and assess the outcome of fluid resuscitation of such children.MethodsIn this retrospective case-control study SAM children aged 0–59 months, admitted to the Intensive Care Unit (ICU) of the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh from April 2011 through July 2012 with history of cough or difficult breathing and radiologic pneumonia, who were assessed for severe sepsis at admission constituted the study population. We compared the pneumonic SAM children with severe sepsis (cases = 50) with those without severe sepsis (controls = 354). Severe sepsis was defined with objective clinical criteria and managed with fluid resuscitation, in addition to antibiotic and other supportive therapy, following the standard hospital guideline, which is very similar to the WHO guideline.ResultsThe case-fatality-rate was significantly higher among the cases than the controls (40% vs. 4%; p<0.001). In logistic regression analysis after adjusting for potential confounders, lack of BCG vaccination, drowsiness, abdominal distension, acute kidney injury, and metabolic acidosis at admission remained as independent predicting factors for severe sepsis in pneumonic SAM children (p<0.05 for all comparisons).Conclusion and SignificanceWe noted a much higher case fatality among under-five SAM children with pneumonia and severe sepsis who required fluid resuscitation in addition to standard antibiotic and other supportive therapy compared to those without severe sepsis. Independent risk factors and outcome of the management of severe sepsis in our study children highlight the importance for defining optimal fluid resuscitation therapy aiming at reducing the case fatality in such children.

Hypoxaemia and septic shock were independent risk factors for mechanical ventilation in Bangladeshi children hospitalised for diarrhoea

“…The observation of a higher case fatality rate in children with diarrhoea requiring mechanical ventilation was not surprising. Our observation was consistent with a number of previous studies that involved children with diarrhoea who experienced septic shock , hypoxaemia , hypokalaemia and hyperkalaemia and often fatal outcomes.…”

“…The phenomenon ultimately leads to uncontrolled vasodilatation and hypotension , resulting in severe respiratory distress and potential respiratory failure. Septic shock in children with diarrhoea at admission and during hospitalisation might also follow the same phenomenon and could potentially require the support of mechanical ventilation.…”

“…Reductions in alveolar epithelial sodium and chloride transport were rampant, and this has been shown to impede clearance of fluid from the lung alveolus in severely malnourished children . Giving these children infusions of intravenous fluid was found to be associated with an increased risk of fatal consequences such as alveolar interstitial oedema followed by respiratory distress in a number of studies and the potentially need for mechanical ventilation. Moreover, observations of a significant association of intake of intravenous fluid with hypoglycaemia and hypokalaemia might have an impact for higher observation of mechanical ventilation among intravenous fluid users.…”

Determinants and Outcome of Metabolic Acidosis in Diarrheal Children Under 5 Years of Age in an Urban Critical Care Ward in Bangladesh

“… 6 However, a number of diarrheal children with metabolic acidosis may not present with dehydration, only present with features of severe sepsis and/or pneumonia, and they often require aggressive treatment with antibiotics and fluid resuscitation. 7 The clinical and biochemical parameters provide very rich and crucial information required for the management of such children. 5 However, we have little knowledge about the various presentations of diarrheal children having metabolic acidosis.…”

Clinical spectrum of severe acute malnutrition among children admitted to nutritional rehabilitation centre of a tertiary care hospital with special reference to incidence of bilateral pitting pedal oedema in children with severe acute malnutrition

“…The incidence of septicaemia (7%, p = 0.007) in the present study was similar to study done by Jobayerchisti et al (7%) and lesser when compared to study done by Page AL et al (23%). 18,19 Severe sepsis is associated with oxidative stress that leads to endogenous production of nitric oxide, this nitric oxide is responsible for uncontrolled vasodilation leading to death. 20,21 On the other hand both high intracellular and high extracellular sodium content and simultaneous reduction of alveolar epithelial sodium and chloride transport in severely malnourished children impedes clearance of fluid from alveolus.…”