The Epidemiology of Hospital Death Following Pediatric Severe Sepsis: When, Why, and How Children With Sepsis Die*

Abstract

Objective The epidemiology of in-hospital death after pediatric sepsis has not been well characterized. We investigated the timing, cause, mode, and attribution of death in children with severe sepsis, hypothesizing that refractory shock leading to early death is rare in the current era. Design Retrospective observational study. Setting Emergency departments and intensive care units at two academic children’s hospitals. Patients Seventy-nine patients <18 years-old treated for severe sepsis/septic shock in 2012–2013 who died prior to hospital discharge. Measurements and Main Results Time to death from sepsis recognition, cause and mode of death, and attribution of death to sepsis were determined from medical records. Organ dysfunction was assessed via daily PELOD-2 scores for seven days preceding death with an increase ≥5 defined as worsening organ dysfunction. The median time to death was 8 (IQR 1–12) days with 25%, 35%, and 49% of cumulative deaths within 1, 3, and 7 days of sepsis recognition, respectively. The most common cause of death was refractory shock (34%), then MODS after shock recovery (27%), neurologic injury (19%), single-organ respiratory failure (9%), and non-septic comorbidity (6%). Early deaths (≤3 days) were mostly due to refractory shock in young, previously healthy patients while MODS predominated after three days. Mode of death was withdrawal in 72%, unsuccessful CPR in 22%, and irreversible loss of neurologic function in 6%. Ninety percent of deaths were attributable to acute or chronic manifestations of sepsis. Only 23% had a rise in PELOD-2 that indicated worsening organ dysfunction. Conclusions Refractory shock remains a common cause of death in pediatric sepsis, especially for early deaths. Later deaths were mostly attributable to MODS, neurologic, and respiratory failure after life-sustaining therapies were limited. A pattern of persistent, rather than worsening, organ dysfunction preceded most deaths.

Relation between fluid overload and mortality in children with septic shock

“…The second model analyzed the presence of refractory shock and found that the only associated outcome measures were the %FO accumulated at 96 h > 10 % and the PIM2 score. Authors like Weiss et al, 26 have established that when septic shock is refractory to inotropes/ vasopressors, mortality increases to 34 %. In this cohort, the frequency of refractory shock was 12.4 %, and was higher in the dead patient group (22.5 % versus 7.1 %).…”

Relación entre sobrecarga hídrica y mortalidad en niños con shock séptico

“…En el segundo modelo, se analizó la presencia de shock refractario y se encontraron como únicas variables asociadas el %SH acumulado a 96 h > 10 y la escala PIM-2. Autores como Weiss y cols., 26 han asociado que, cuando el shock séptico tiene un comportamiento refractario a inotrópico/ vasopresor, la mortalidad se incrementa al 34 %. En esta cohorte, la frecuencia de shock refractario fue del 12,4 % con una mayor proporción en el grupo de muertos (el 22,5 % vs. el 7,1 %).…”

Epidemiology of Pediatric Septic Shock

“…Several studies in both developed and developing countries have shown that mortality from septic shock is associated with suboptimal care: delayed diagnosis and treatment and nonadherence to the treatment guidelines. 4,44,45 In a retrospective observational study at emergency departments and ICUs at two academic children's hospital, Weiss et al 46 observed that early pediatric sepsis mortality was high (49% in the first 7 days from sepsis recognition). In this study, children who died on the first 3 days from sepsis recognition were younger, more likely to be developed community-acquired sepsis and more likely to be previously healthier than children who died later.…”