Critical Illness Factors Associated With Long-Term Mortality and Health-Related Quality of Life Morbidity Following Community-Acquired Pediatric Septic Shock*

Abstract

Objectives: A companion article reports the trajectory of long-term mortality and significant health-related quality of life disability among children encountering septic shock. In this article, the investigators examine critical illness factors associated with these adverse outcomes. Design: Prospective, cohort-outcome study, conducted 2013–2017. Setting: Twelve United States academic PICUs. Patients: Critically ill children, 1 month to 18 years, with community-acquired septic shock requiring vasoactive-inotropic support. Interventions: Illness severity, organ dysfunction, and resource utilization data were collected during PICU admission. Change from baseline health-related quality of life at the month 3 follow-up was assessed by parent proxy-report employing the Pediatric Quality of Life Inventory or the Stein-Jessop Functional Status Scale. Measurements and Main Results: In univariable modeling, critical illness variables associated with death and/or persistent, serious health-related quality of life deterioration were candidates for multivariable modeling using Bayesian information criterion. The most clinically relevant multivariable models were selected among models with near-optimal statistical fit. Three months following septic shock, 346 of 389 subjects (88.9%) were alive and 43 of 389 had died (11.1%); 203 of 389 (52.2%) had completed paired health-related quality of life surveys. Pediatric Risk of Mortality, cumulative Pediatric Logistic Organ Dysfunction scores, PICU and hospital durations of stay, maximum and cumulative vasoactive-inotropic scores, duration of mechanical ventilation, need for renal replacement therapy, extracorporeal life support or cardiopulmonary resuscitation, and appearance of pathologic neurologic signs were associated with adverse outcomes in univariable models. In multivariable regression analysis (odds ratio [95% CI]), summation of daily Pediatric Logistic Organ Dysfunction scores, 1.01/per point (1.01–1.02), p < 0.001; highest vasoactive-inotropic score, 1.02/per point (1.00–1.04), p = 0.003; and any acute pathologic neurologic sign/event, 5.04 (2.15–12.01), p < 0.001 were independently associated with death or persistent, serious deterioration of health-related quality of life at month 3. Conclusions and Relevance: Biologically plausible factors related to sepsis-associated critical illness organ dysfunction and its treatment were associated with poor outcomes at month 3 follow-up among children encountering septic shock.

Updates on pediatric sepsis

“…95 Lower quality-of-life scores were associated with multiorgan dysfunction, renal replacement therapy, ECMO or cardiopulmonary resuscitation, and duration of mechanical ventilation and inotropes. 96 Similar findings were observed internationally. 11 Given that most children with sepsis are younger than 10 years of age, the long-term impact of sepsis sequelae on children, their families, and society cannot be emphasized enough.…”

“…Of concern, more than one‐third of pediatric survivors had not regained their baseline health‐related quality of life one year after an episode of community‐acquired sepsis 95 . Lower quality‐of‐life scores were associated with multiorgan dysfunction, renal replacement therapy, ECMO or cardiopulmonary resuscitation, and duration of mechanical ventilation and inotropes 96 . Similar findings were observed internationally 11 .…”

Implementation of a Follow-Up System for Pediatric Sepsis Survivors in a Large Academic Pediatric Intensive Care Unit

“…We found that performing the needs assessment, in particular demonstrating the high estimated rate of new morbidity in sepsis survivors in historical patients cared for at our hospital, was helpful in justifying the costs of the program. In the Life After Pediatric Sepsis Evaluation study, it was shown that changes in FSS or Pediatric Overall Performance Category score between days 1 and 7 were highly predictive of death or severe deterioration in HRQL 3 months after sepsis (12). Incorporating these scores as screening tools to identify those most likely to benefit from a sepsis follow-up program might further refine the appropriate target population and limit costs associated with a program like this.…”

“…The largest decrease was seen in the first month after discharge with 50% of survivors below baseline HRQL, with some recovery that plateaued between 3 months and 1 year after discharge. Children with more organ dysfunction and those requiring higher levels of vasoactive infusion support were at highest risk of serious deterioration in HRQL (12). Furthermore, children without chronic comorbidities were disproportionately impacted by deterioration in HRQL (13).…”

Clinical Factors Influencing End-of-Life Care in a Chinese Pediatric Intensive Care Unit: A Retrospective, post-hoc Study

“…Most post-neonatal pediatric intensive care unit (PICU) admissions account for majority of pediatric deaths in developed countries, especially in the United States ( 1 , 2 ). However, recent technological advances in pediatric research have significantly reduced the mortality rates among PICU admissions by prolonging the life of critically ill patients ( 3 – 5 ). Three recent multicenter studies have reported a decline in PICU mortality rates of ~<3% in western countries ( 6 – 8 ).…”