Trends in the Epidemiology of Pediatric Severe Sepsis*

Hartman, Mary E.; Linde-Zwirble, Walter T.; Angus, Derek C.; Watson, R. Scott

doi:10.1097/pcc.0b013e3182917fad

Cited by 458 publications

(423 citation statements)

References 13 publications

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“…These results suggest that a typical 16-bed PICU is likely to be treating at least one critically ill child for severe sepsis at any given time. Moreover, hospital mortality, often considered to be too low to practically study in pediatric severe sepsis, was 25% and exceeded prior epidemiological estimates that relied on retrospective administrative data (1,4,43). As in other studies, comorbid conditions were common (1,5,6,18,(44)(45)(46), and children with immunosuppressive conditions and preexisting renal disease exhibited the highest mortality.…”

Section: Discussionmentioning

confidence: 70%

“…Moreover, hospital mortality, often considered to be too low to practically study in pediatric severe sepsis, was 25% and exceeded prior epidemiological estimates that relied on retrospective administrative data (1,4,43). As in other studies, comorbid conditions were common (1,5,6,18,(44)(45)(46), and children with immunosuppressive conditions and preexisting renal disease exhibited the highest mortality. However, we could not determine whether death was attributable to sepsis or to an underlying comorbid Definition of abbreviations: ECMO = extracorporeal membrane oxygenation; G/GM-CSF = granulocyte/granulocyte-monocyte colony-stimulating factor; IVIG = intravenous immunoglobulin; RRT = renal replacement therapy.…”

Section: Discussionmentioning

confidence: 70%

“…Severe sepsis is a life-threatening condition commonly treated in pediatric intensive care units (PICUs) worldwide (1)(2)(3)(4)(5). It is estimated that over one-third of children who die in tertiary care PICUs within the United States have severe sepsis (6).…”

mentioning

confidence: 99%

“…It is estimated that over one-third of children who die in tertiary care PICUs within the United States have severe sepsis (6). Recent reports of a rising prevalence of pediatric sepsis (1,6,7) may reflect an expanding vulnerable population with chronic comorbidities (8,9), increasing rates of multidrug-resistant organisms and opportunistic infections (10,11), and a surge in sepsis surveillance (12,13). However, shifting patterns of diagnostic coding may confound current epidemiological estimates that are based largely on retrospectively identified cases in administrative databases (5,14), and prior studies using prospective case identification have been limited to few sites within single countries, thus precluding broad generalizations (2,5,15).…”

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confidence: 99%

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Global Epidemiology of Pediatric Severe Sepsis: The Sepsis Prevalence, Outcomes, and Therapies Study

Weiss

Fitzgerald

Pappachan

et al. 2015

Am J Respir Crit Care Med

823

625

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Rationale: Limited data exist about the international burden of severe sepsis in critically ill children.Objectives: To characterize the global prevalence, therapies, and outcomes of severe sepsis in pediatric intensive care units to better inform interventional trials.Methods: A point prevalence study was conducted on 5 days throughout 2013-2014 at 128 sites in 26 countries. Patients younger than 18 years of age with severe sepsis as defined by consensus criteria were included. Outcomes were severe sepsis point prevalence, therapies used, new or progressive multiorgan dysfunction, ventilator-and vasoactive-free days at Day 28, functional status, and mortality.Measurements and Main Results: Of 6,925 patients screened, 569 had severe sepsis (prevalence, 8.2%; 95% confidence interval, 7.6-8.9%). The patients' median age was 3.0 (interquartile range [IQR], 0.7-11.0) years. The most frequent sites of infection were respiratory (40%) and bloodstream (19%). Common therapies included mechanical ventilation (74% of patients), vasoactive infusions (55%), and corticosteroids (45%). Hospital mortality was 25% and did not differ by age or between developed and resourcelimited countries. Median ventilator-free days were 16 (IQR, 0-25), and vasoactive-free days were 23 (IQR,(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28). Sixty-seven percent of patients had multiorgan dysfunction at sepsis recognition, with 30% subsequently developing new or progressive multiorgan dysfunction. Among survivors, 17% developed at least moderate disability. Sample sizes needed to detect a 5-10% absolute risk reduction in outcomes within interventional trials are estimated between 165 and 1,437 patients per group.Conclusions: Pediatric severe sepsis remains a burdensome public health problem, with prevalence, morbidity, and mortality rates similar to those reported in critically ill adult populations. International clinical trials targeting children with severe sepsis are warranted.

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Section: Discussionmentioning

confidence: 70%

Section: Discussionmentioning

confidence: 70%

mentioning

confidence: 99%

mentioning

confidence: 99%

See 2 more Smart Citations

Global Epidemiology of Pediatric Severe Sepsis: The Sepsis Prevalence, Outcomes, and Therapies Study

Weiss

Fitzgerald

Pappachan

et al. 2015

Am J Respir Crit Care Med

823

625

View full text Add to dashboard Cite

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“…1,2 Challenges in diagnosing compensated septic shock in children are an important barrier to timely, guideline-compliant care. 3 Although international guidelines for management of pediatric septic shock have been established, triage protocols for the early detection of septic shock in the emergency department (ED) are not included.…”

mentioning

confidence: 99%

The Prevalence and Diagnostic Utility of Systemic Inflammatory Response Syndrome Vital Signs in a Pediatric Emergency Department

Scott

Deakyne

Woods

et al. 2015

Academic Emergency Medicine

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ObjectivesThis study sought to determine the prevalence, test characteristics, and severity of illness of pediatric patients with systemic inflammatory response syndrome (SIRS) vital signs among pediatric emergency department (ED) visits.MethodsThis was a retrospective descriptive cohort study of all visits to the ED of a tertiary academic free‐standing pediatric hospital over 1 year. Visits were included if the patient was <18 years of age and did not leave before full evaluation or against medical advice. Exclusion criteria were trauma diagnoses or missing documentation of vital signs. Data were electronically extracted from the medical record. The primary predictor was presence of vital signs meeting pediatric SIRS definitions. Specific vital sign pairs comprising SIRS were evaluated as predictors (temperature–heart rate, temperature–respiratory rate, and temperature‐corrected heart rate, in which a formula was used to correct heart rate for degree of temperature elevation). The primary outcome measure was requirement for critical care (receipt of a vasoactive agent or intubation) within 24 hours of ED arrival.ResultsThere were 56,210 visits during the study period; 40,356 met inclusion criteria. Of these, 6,596 (16.3%) visits had fever >38.5°C, and 6,122 (15.2% of included visits) met SIRS vital sign criteria. Among included visits, those with SIRS vital signs accounted for 92.8% of all visits with fever >38.5°C. Among patients with SIRS vital signs, 4993 (81.6%) were discharged from the ED without intravenous (IV) therapy and without 72‐hour readmission. Critical care within the first 24 hours was present in 99 (0.25%) patients: 23 patients with and 76 without SIRS vital signs. Intensive care unit (ICU) admission was present in 126 (2.06%) with SIRS vital signs and 487 (1.42%) without SIRS vital signs. SIRS vital signs were associated with increased risk of critical care within 24 hours (relative risk [RR] = 1.69, 95% confidence interval [CI] = 1.06 to 2.70), ICU admission (RR = 1.45, 95% CI = 1.19 to 1.76), ED laboratory tests (RR = 1.41, 95% CI = 1.37 to 1.45), ED IV medication/fluid administration (RR = 2.54, 95% CI = 2.29 to 2.82), hospital admission (RR = 1.52, 95% CI = 1.42 to 1.63), and 72‐hour readmission (RR = 1.31, 95% CI = 1.01 to 1.69). SIRS vital signs were not associated with 30‐day in‐hospital mortality (RR = 0.37, 95% CI = 0.05 to 2.82). SIRS vital signs had a low sensitivity for critical care requirement (23.2%, 95% CI = 15.3% to 32.8%). The pair of SIRS vital signs with the strongest association with critical care requirement was temperature and corrected heart rate (positive likelihood ratio = 2.74, 95% CI = 1.87 to 4.01).ConclusionsSystemic inflammatory response syndrome vital signs are common among medical pediatric patients presenting to an ED, and critical illness is rare. The majority of patients with SIRS vital signs were discharged without IV therapy and without readmission. Patients with SIRS vital signs had a statistically significant increased risk of critical care requirement, ED IV treatment, ED laboratory tests, admission, and readmission. However, SIRS vital sign criteria did not identify the majority of patients with mortality or need for critical care. SIRS vital signs had low sensitivity for critical illness, making it poorly suited for use in isolation in this setting as a test to detect children requiring sepsis resuscitation.

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Association Between Early Lactate Levels and 30-Day Mortality in Clinically Suspected Sepsis in Children

et al. 2017

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Improving emergency care of pediatric sepsis is a public health priority, but optimal early diagnostic approaches are unclear. Measurement of lactate levels is associated with improved outcomes in adult septic shock, but pediatric guidelines do not endorse its use, in part because the association between early lactate levels and mortality is unknown in pediatric sepsis. OBJECTIVE To determine whether the initial serum lactate level is associated with 30-day mortality in children with suspected sepsis. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study of a clinical registry of pediatric patients with suspected sepsis in the emergency department of a tertiary children's hospital from April 1, 2012, to December 31, 2015, tested the hypothesis that a serum lactate level of greater than 36 mg/dL is associated with increased mortality compared with a serum lactate level of 36 mg/dL or less. Consecutive patients with sepsis were identified and included in the registry following consensus guidelines for clinical recognition (infection and decreased mental status or perfusion). Among 2520 registry visits, 1221 were excluded for transfer from another medical center, no measurement of lactate levels, and patients younger than 61 days or 18 years or older, leaving 1299 visits available for analysis. Lactate testing is prepopulated in the institutional sepsis order set but may be canceled at clinical discretion. EXPOSURES Venous lactate level of greater than 36 mg/dL on the first measurement within the first 8 hours after arrival. MAIN OUTCOMES AND MEASURES Thirty-day in-hospital mortality was the primary outcome. Odds ratios were calculated using logistic regression to account for potential confounders. RESULTS Of the 1299 patients included in the analysis (753 boys [58.0%] and 546 girls [42.0%]; mean [SD] age, 7.3 [5.3] years), 899 (69.2%) had chronic medical conditions and 367 (28.3%) had acute organ dysfunction. Thirty-day mortality occurred in 5 of 103 patients (4.8%) with lactate levels greater than 36 mg/dL and 20 of 1196 patients (1.7%) with lactate levels of 36 mg/dL or less. Initial lactate levels of greater than 36 mg/dL were significantly associated with 30-day mortality in unadjusted (odds ratio, 3.00; 95% CI, 1.10-8.17) and adjusted (odds ratio, 3.26; 95% CI, 1.16-9.16) analyses. The sensitivity of lactate levels greater than 36 mg/dL for 30-day mortality was 20.0% (95% CI, 8.9%-39.1%), and specificity was 92.3% (90.7%-93.7%). CONCLUSIONS AND RELEVANCE In children treated for sepsis in the emergency department, lactate levels greater than 36 mg/dL were associated with mortality but had a low sensitivity. Measurement of lactate levels may have utility in early risk stratification of pediatric sepsis.

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Trends in the Epidemiology of Pediatric Severe Sepsis*

Abstract: Between 1995 and 2005, the prevalence of severe sepsis in U.S. children steadily rose, due to a significant increase in the prevalence of severe sepsis in newborns.

Cited by 458 publications

References 13 publications

Global Epidemiology of Pediatric Severe Sepsis: The Sepsis Prevalence, Outcomes, and Therapies Study

Global Epidemiology of Pediatric Severe Sepsis: The Sepsis Prevalence, Outcomes, and Therapies Study

The Prevalence and Diagnostic Utility of Systemic Inflammatory Response Syndrome Vital Signs in a Pediatric Emergency Department

Association Between Early Lactate Levels and 30-Day Mortality in Clinically Suspected Sepsis in Children

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