Functional Outcomes at 1 Year After PICU Discharge in Critically Ill Children With Severe Sepsis

Abstract

Objectives: To evaluate the functional outcomes in critically ill children with severe sepsis using the Pediatric Overall Performance Category scale and Pediatric Cerebral Performance Category scale and to evaluate the risk factors for “worse outcomes.” Design: Prospective observational cohort study. Setting: Tertiary care PICU from September 2017 to October 2019. Patients: One hundred twenty-one children with severe sepsis, 2 months to 17 years old, admitted to PICU. Interventions: None. Measurements and Main Results: Pediatric Overall Performance Category and Pediatric Cerebral Performance Category scores were recorded at admission, PICU discharge, at 3 months and 1 year after discharge. “New disability” was defined as Pediatric Overall Performance Category and Pediatric Cerebral Performance Category score change “from baseline score” by greater than or equal to 1 category. Risk factors for “worse outcomes” (defined as “death” or “new disability”) were evaluated by univariate and multivariate analysis. At admission, 33% (n = 39) had mild to moderate “overall disability” (Pediatric Overall Performance Category) and 26% (n = 32) had mild to moderate “cognitive disability” (Pediatric Cerebral Performance Category). At PICU discharge (n = 89 children), 50.5% (n = 45) had “new disability” in overall function (Pediatric Overall Performance Category scores) and 28% (n = 25) had “new disability” in cognitive function (Pediatric Cerebral Performance Category scores). At 3 months follow-up (n = 85 children), “new disability” at PICU discharge improved in 65% (n = 28/43) and 50% (n = 12/24) of those with “overall disability” (Pediatric Overall Performance Category) and “cognitive disability” (Pediatric Cerebral Performance Category), respectively. At 1-year follow-up (n = 84 children), only 5% (n = 2/43) had residual “new disability” in overall function (Pediatric Overall Performance Category) and 14% (n = 3/21) had residual “new disability” in cognitive function. PICU mortality was 26% (n = 32). The proportion with “worse outcomes” was 64% (n = 77). Risk factors for worse outcomes on univariate analysis included higher Pediatric Index of Mortality-3 scores, day 1 pediatric Sequential Organ Failure Assessment score, receiving cardiopulmonary resuscitation during the ICU stay, and treatments received such as ventilation and Vasoactive-Inotrope Score. On multivariate analysis, only day 1 pediatric Sequential Organ Failure Assessment score and receiving cardiopulmonary resuscitation during the ICU stay were found to be statistically significant. Conclusions: Children with severe sepsis had significant “new onset” mild to moderate functional disability at PICU discharge, and most of these children recovered within 1 year after PICU discharge. Day 1 pediatric Sequential Organ Failure Assessment score and patient receiving cardiopulmonary resuscitation during the ICU stay were found to be the significant risk factors of “worse outcomes.”

Dynamic Transitions of Pediatric Sepsis: A Markov Chain Analysis

“…In conclusion, we used a discrete-time Markov chain to characterize the illness trajectory following sepsis. Pediatric sepsis is a heterogeneous disease that can result in mortality or significant morbidity and prolonged physical disability (3,4). Using the entropy based on Markov chain transition matrices, we found a different structure of dynamic transitions based on ventilator use but not age group.…”

“…Illness state 1 has risk scores in the range [1,2], representing those with an increased risk. Risk scores in the range [2,3] compose illness state 2, and represent a higher illness state than the preceding states of 0 and 1. The highest risk illness state, 3, contains all scores 3 or higher.…”

“…In the United States, more than one-third of children who die in tertiary care Pediatric Intensive Care Units (PICUs) have severe sepsis (2). In addition, survivors of sepsis have increased lengths of hospitalizations and are at risk of long-term complications (3,4). Despite growing research in this area, sepsis remains a significant cause of pediatric morbidity and mortality.…”

Functional Outcomes in Survivors of Pediatric Sepsis: A Scoping Review and Discussion of Implications for Low- and Middle-Income Countries

“…The studies from LMIC on functional outcome in pediatric sepsis are scarce. In the study by Sankar et al ( 26 ), the common infection sources were respiratory (35%), gastrointestinal (31%), and neurologic (21%) with 37% having comorbidities at admission. The difference in the proportion of children with new disability from the baseline using POPC and PCPC scores was significant ( p < 0.0001).…”

Functional Outcomes and Morbidity in Pediatric Sepsis Survivors: A Tanzanian Experience

“…Due to lack of a standardized definition and measurement tool, pediatric morbidity outcome data are highly varied secondary to the use of different assessment tools, various outcomes measures, heterogenous patient populations, and differing durations of follow-up ( 17 , 22 ). Estimates for development of new morbidity following septic episodes vary widely, ranging from 12 to 50%, primarily assessed in resource-rich settings ( 1 , 9 , 10 , 14 , 16 , 18 , 19 , 23 ). Multiple factors have been associated with higher risk for morbidity, including source of infection, recent trauma, acute kidney injury, receipt of cardiopulmonary resuscitation (CPR), more severe illness, and longer ICU and hospital stay ( 10 , 14 , 16 , 19 ).…”