Paediatric community-acquired septic shock: results from the REPEM network study

Abstract

Introduction and purpose of the studyWith this study we aimed to describe a “true world” picture of severe paediatric ‘community-acquired’ septic shock and establish the feasibility of a future prospective trial on early goal-directed therapy in children. During a 6-month to 1-year retrospective screening period in 16 emergency departments (ED) in 12 different countries, all children with severe sepsis and signs of decreased perfusion were included.ResultsA 270,461 paediatric ED consultations were screened, and 176 cases were identified. Significant comorbidity was present in 35.8 % of these cases. Intensive care admission was deemed necessary in 65.7 %, mechanical ventilation in 25.9 % and vasoactive medications in 42.9 %. The median amount of fluid given in the first 6 h was 30 ml/kg. The overall mortality in this sample was 4.5 %. Only 1.2 % of the survivors showed a substantial decrease in Paediatric Overall Performance Category (POPC). ‘Severe’ outcome (death or a decrease ≥2 in POPC) was significantly related (p < 0.01) to: any desaturation below 90 %, the amount of fluid given in the first 6 h, the need for and length of mechanical ventilation or vasoactive support, the use of dobutamine and a higher lactate or lower base excess but not to any variables of predisposition, infection or host response (as in the PIRO (Predisposition, Infection, Response, Organ dysfunction) concept).ConclusionThe outcome in our sample was very good. Many children received treatment early in their disease course, so avoiding subsequent intensive care. While certain variables predispose children to become septic and shocked, in our sample, only measures of organ dysfunction and concomitant treatment proved to be significantly related with outcome. We argue why future studies should rather be large multinational prospective observational trials and not necessarily randomised controlled trials.

Fluid Bolus Therapy-Based Resuscitation for Severe Sepsis in Hospitalized Children

“…Nonrandomized Studies. We identified eight observational studies (16)(17)(18)(19)(20)(21)(22)(23); their characteristics are summarized in Table 5. Six of the eight studies were retrospective (Table 5).…”

Sepsis in Children

“…About half of those who survive these 28 days are rehospitalized at least once. Comorbidity is important in the development and late mortality of and rehospitalization in pediatric sepsis [74,75].…”

Surviving sepsis campaign in children

“…La comparaison de deux groupes de sepsis grave dont 81 % développaient un choc septique (126 avant intervention de 2009 à 2011, et 116 après intervention de 2011 à 2013) montrait une amélio-ration significative de l'ensemble des éléments de la prise en charge (Tableau 7) [60]. L'étude de Van de Voorde et al incluant 176 cas de sepsis grave admis dans 16 SAU rapportait, sans plus de précision, que beaucoup d'enfants étaient traités de façon précoce (mortalité : 4,5 %) ; tous les enfants sauf 6 recevaient leurs antibiotiques avant la 3 e heure, mais 43 % des enfants seulement avaient eu un remplissage ≥ 40 ml/kg dans les six 1 res heures [18]. À l'inverse, une étude utilisant un scénario de sepsis grave envoyé aux responsables médicaux de 12 établissements membres du Réseau Mè re-Enfant de la Francophonie a rapporté une forte adhésion aux recommandations de la campagne SAS (compliance > 90 %) sauf pour le maintien d'une pression veineuse centrale adéquate et le contrôle glycémique [61].…”

“…Le méningocoque n'est rapporté que dans l'étude de Hartman et al où il représente 0,4 à 1,2 % des agents responsables de sepsis grave. Deux études ont récemment rapportées les agents pathogènes bactériens identifiés chez les enfants admis dans des SAU avec un sepsis grave ou un choc septique[17,18]. Celle de Gaines et al rétrospective, réalisée aux États-Unis ne rapportait pas Tableau 1 Sites d'infection et agents pathogènes chez les enfants ayant un sepsis grave, d'après Ruth et al[6].…”