Extracorporeal therapies in pediatric severe sepsis: findings from the pediatric health-care information system

Abstract

IntroductionPediatric severe sepsis (PSS) continues to be a major health problem. Extracorporeal therapies (ETs), defined as extracorporeal membrane oxygenation (ECMO) and RRenal replacement therapyenal replacement therapy (RRT), are becoming more available for utilization in a variety of health conditions. We aim to describe (1) rates of utilization of ET in PSS, (2) outcomes for PSS patients receiving ET, and (3) epidemiologic characteristics of patients receiving ET.MethodsWe conducted a retrospective review of a prospectively collected database. Data from the Pediatric Health Information System (PHIS) database collected by the Children’s Hospital Association (CHA) from 2004–2012 from 43 US children’s hospitals’ pediatric intensive care units (PICUs) were used. Patients with PSS were defined by (1) International Classification of Diseases, 9th Revision (ICD-9) codes reflecting severe sepsis and septic shock and (2) ICD-9 codes of infection and organ dysfunction as defined by updated Angus criteria. Among the patients with PSS, those with a PHIS flag of ECMO or RRT were identified further as our main cohort.ResultsFrom 2004 to 2012, 636,842 patients were identified from 43 hospitals, and PSS prevalence was 7.7 % (49,153 patients). Nine point eight percent (4795 patients) received at least one form of ET, and the associated mortality rate was 39 %. Mortality rates were 47.8 % for those who received ECMO, 32.3 % in RRT, and 58.0 % in RRT + ECMO. Underlying co-morbidities were found in 3745 patients (78.1 %) who received ET (81 % for ECMO, 77.9 % in RRT, and 71.2 % in those who received both). There was a statistically significant increase in ECMO utilization in patients with at least three organ dysfunctions from 2004 to 2012 (6.9 % versus 10.3 %, P < 0.001) while RRT use declined (24.5 % versus 13.2 %, P < 0.001). After 2009, there was a significant increase in ECMO utilization (3.6 % in 2004–2008 versus 4.0 % in 2009–2012, P = 0.004). ECMO and RRT were used simultaneously in only 500 patients with PSS (1 %).ConclusionsETs were used in a significant portion of PSS patients with multiple organ dysfunction syndrome (MODS) during this time period. Mortality was significant and increased with increasing organ failure. ECMO use in PSS patients with MODS increased from 2004 to 2012. Further evaluation of ET use in PSS is warranted.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-1105-4) contains supplementary material, which is available to authorized users.

Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children

“…As such, children with life-threatening sepsis-induced ARDS are often considered as candidates for ECMO rescue [477], and PALICC endorsed ECMO for the treatment of refractory hypoxia [24]. The use of ECMO in pediatric sepsis has increased over the past decade [478,479]; whether this has improved survival remains to be determined [480]. To date, no RCT examining the effect of ECMO on outcome in pediatric sepsis has been published.…”

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“…Despite limited data specific for the neonatal septic population, utilization of adjunctive extracorporeal techniques during ECMO has become standard practice. In a retrospective analysis of pediatric admissions for sepsis between 2004 and 2012 collected via Pediatric Health Information System (PHIS), 169 children under 1 year of age received both ECMO and renal replacement therapy (RRT) (58). Hypoxia, arterial hypotension, low cardiac output state, diastolic steal via PDA, and high vasoactive support can lead to acute kidney injury (AKI) in neonates with sepsis (59).…”

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“…A previous study reviewed the characteristics of patients with pediatric burn sepsis, including patient categorization, diagnosis and treatment and it was identified that the mortality rate of pediatric patients with burn sepsis is significantly higher mortality than that of adult patients (4). Although an increasing number of strategies have been explored for the treatment of pediatric burn sepsis, the mortality rate remains high (5,6). Additionally, the physiological characteristics, drug treatment and inflammatory responses to burn injury in pediatric patients differ significantly compared with those in adult patients (7)(8)(9).…”