Validation of the pediatric refractory septic shock definition: post hoc analysis of a controlled trial

Abstract

Background The European Society of Pediatric and Neonatal Intensive Care (ESPNIC) developed and validated a definition of pediatric refractory septic shock (RSS), based on two septic shock scores (SSS). Both bedside SSS (bSSS) and computed SSS (cSSS) were found to be strongly associated with mortality. We aimed at assessing the accuracy of the RSS definition on a prospective cohort from India. Methods Post hoc analysis of a cohort issued from a double-blind randomized trial that compared first-line vasoactive drugs in children with septic shock. Sequential bSSS and cSSS from 60 children (single-center study, 53% mortality) were analyzed. The prognostic value of the ESPNIC RSS definition was tested for 28-day all-cause mortality. Results In this septic shock cohort, RSS was diagnosed in 35 patients (58.3%) during the first 24 h. Death occurred in 30 RSS patients (85.7% mortality) and in 2 non-RSS patients (8% mortality), OR = 60.9 [95% CI: 10.5–676.2], p < 0.001 with a median delay from sepsis onset of 3 days [1.0–6.7]. Among patients diagnosed with RSS, the mortality was not significantly different according to vasopressors randomization. Diagnosis of RSS with bSSS and cSSS had a high discrimination for death with an area under the receiver operating curve of 0.916 [95% CI: 0.843–0.990] and 0.925 [95% CI: 0.845–1.000], respectively. High prognostic accuracy of the bSSS was found in the first hours following intensive care admission. The best interval of prognostication occurs after the 12th hour following treatment initiation (AUC 0.973 [95% CI: 0.925–1.000]). Conclusions The ESPNIC refractory septic shock definition accurately identifies, within the first 6 h of septic shock management, children with lethal outcome.

Association between maximum norepinephrine dosage and mortality risk in neonates with septic shock

“…The bedside SSS (bSSS) refers to a scale ranging from 0 to 5 points, with 1 point attributed for a LAC > 8 mmol/L, 1 point for VIS > 200, and 3 points for the presence of severe cardiomyopathy, as defined by a cardiac index < 2.2L/min/m 2 or a left ventricle ejection fraction < 25%. The computed SSS (cSSS) was calculated as follows: cSSS = 1.1 LAC + 1.001 VIS + 18 (in the presence of severe cardiomyopathy) 12 .…”

Ultrasound in Refractory Septic Shock: Have We Pitched and Pictured It Correctly Yet?

“…A score based on blood lactate, vasoactive inotrope score, and echocardiographic assessment of cardiac function could discriminate nonsurvivors early; however, there is not enough evidence to construct a management algorithm that works and improves the outcome of such patients with highest risk of death. 11 The present report by Natraj et al is a welcome concept; however, larger studies, preferably in a randomized design, are required in this specific population of persistent or refractory shock patients to understand the role of advanced hemodynamic assessment tools and quantify the effect of tiered assessment-based management strategies on clinical outcome.…”