Outcomes Associated With Timing of Neurologic Dysfunction Onset Relative to Pediatric Sepsis Recognition*

Abstract

To compare outcomes associated with timing-early versus lateof any neurologic dysfunction during pediatric sepsis.DESIGN: Secondary analysis of a cross-sectional point prevalence study. SETTING:A total of 128 PICUs in 26 countries. PATIENTS:Less than 18 years with severe sepsis on 5 separate days (2013)(2014). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:Patients were categorized as having either no neurologic dysfunction or neurologic dysfunction (i.e., present at or after sepsis recognition), which was defined as Glasgow Coma Scale score less than 5 and/or fixed dilated pupils. Our primary outcome was death or new moderate disability (i.e., Pediatric Overall [or Cerebral] Performance Category score ≥3 and change ≥1 from baseline) at hospital discharge, and 87 of 567 severe sepsis patients (15%) had neurologic dysfunction within 7 days of sepsis recognition (61 at sepsis recognition and 26 after sepsis recognition). Primary site of infection varied based on presence of neurologic dysfunction. Death or new moderate disability occurred in 161 of 480 (34%) without neurologic dysfunction, 45 of 61 (74%) with neurologic dysfunction at sepsis recognition, and 21 of 26 (81%) with neurologic dysfunction after sepsis recognition (p < 0.001 across all groups). On multivariable analysis, in comparison with those without neurologic dysfunction, neurologic dysfunction whether at sepsis recognition or after was associated with increased odds of death or new moderate disability (adjusted odds ratio, 4.9 [95% CI, 2.

Editor’s Choice Articles for December

“…reflects the full spectrum of acute brain dysfunction during sepsis. The work builds on previous research reported in PCCM (9,10) and helps our field to make progress in studying the problem of neurologic or behavioral changes in sepsis. There is no related editorial but do re-read the two previous commentaries on "sepsis encephalopathy, " which remain relevant today (11,12).…”

Late-Onset Neurologic Dysfunction in Pediatric Sepsis—What Brains Might Learn From Kidneys and Persistent Acute Kidney Injury*

“…This group reported greatest odds of mortality in the multiple organ dysfunction syndrome phenotype with severe, persistent neurologic dysfunction. All these investigations, including the current report in PCCM (1), used different specific definitions for CNS dysfunction in sepsis, and all described meaningfully increased association with mortality (6). At this point, it is reasonable to infer that the development of any CNS dysfunction in a septic patient, at any point in their illness, should be considered an extremely concerning.…”

“…This issue of Pediatric Critical Care Medicine (PCCM ) includes an important article describing the relationship between the timing of development of encephalopathy relative to the identification of pediatric sepsis (1). The authors used the existing data set collected for a large, multicenter point prevalence study of pediatric sepsis, the Sepsis Prevalence, Outcomes and Therapies Study (2).…”

“…The identification of “late-onset CNS dysfunction” is very interesting and warrants further consideration (1). Presumably, resuscitation has previously been initiated, and hemodynamics improved.…”

“…Accepting that the concept of septic encephalopathy almost certainly represents a diverse group of pathologies and in the absence of a formal consensus definition, it is probably time to accept that any CNS dysfunction identified in the septic child (i.e., by physical examination and/or investigation such as brain scan and electroencephalography) represents septic encephalopathy. The article by Alcamo et al (1) performs the important task of identifying distinct temporal phenotypes of CNS injury in the setting of sepsis. The association of these findings with morbidity and mortality endorses the importance of better understanding the pathophysiology of these states and working to identify therapeutics that might prevent the development of late-onset septic encephalopathy.…”