The predictors of outcome and progression of pediatric sepsis and septic shock

Abstract

Introduction: There is a paucity of studies on the progression and outcome of Systemic Inflammatory Response Syndrome (SIRS) with its determinants. Aims and Objectives: To determine the predictors of the outcome and progression of pediatric sepsis and septic shock. Materials and Methods: Prospective observational study of children fulfilling criteria of SIRS and their progression to sepsis, severe sepsis, and septic shock (clinically and biochemically) was conducted at a tertiary care center. Results: Totally, 200 children were recruited over a period of 21 months (from February 2016 to October 2017). Most cases (80, 40%) were infants. Of the total, 188 (94%) cases were of an infective etiology (mostly respiratory system). Temperature and heart rate were the two commonest SIRS parameters which were deranged. Blood cultures were positive in only 25 (12.5%) cases. Out of the total 200 children, 108 progressed to sepsis, of which 26 progressed to severe sepsis, of which 22 progressed to septic shock. Abnormal leukocyte count, culture positivity and severe acute malnutrition were significantly associated with progression of SIRS patients to septic shock (P = 0.001, 0.00001 and 0.002, respectively). Factors associated with mortality were positive blood culture, multiorgan dysfunction, late hospital admissions, severe acute malnutrition, and requirement of supportive care (P values-<0.0001, <0.0001, 0.03, <0.0001 and <0.0001, respectively). Conclusions: SIRS can progress to septic shock if not identified early. The predictors of mortality were positive blood cultures, multiorgan dysfunction, late hospital admissions, severe acute malnutrition, and requirement of supportive care. The predictors of progression to septic shock were abnormal leukocyte count, culture positivity, and severe acute malnutrition.

Criteria for Pediatric Sepsis—A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce*

“…Pooled estimates supported an increased odds of mortality in patients with severe acute malnutrition ( 31 , 40 , 41 ), chronic conditions ( 31 , 33 , 42 – 50 ), and oncologic conditions ( 23 , 31 , 47 , 51 – 54 ) (Supplementary Fig. 1, http://links.lww.com/CCM/G820 ).…”

“…Among children with sepsis, severe sepsis, and septic shock, pooled estimates provide strong support for increased mortality with hypotension ( 46 , 47 , 58 , 59 ), use of vasoactive agents/inotropes ( 26 , 31 – 33 , 40 , 41 , 44 , 49 , 50 , 58 , 60 – 69 ), increased vasoactive-inotropic score (VIS) ( 51 , 53 , 68 , 70 – 72 ), increased shock index ( 58 , 73 , 74 ), decreased level of consciousness ( 58 , 59 , 67 ), decreased Glasgow Coma Scale (GCS) ( 53 , 70 , 75 ), and mechanical ventilation ( 26 , 28 , 31 , 32 , 40 – 44 , 46 , 49 – 51 , 53 , 58 – 62 , 65 – 69 , 71 , 72 , 75 – 80 ) (Supplementary Fig. 2, http://links.lww.com/CCM/G821 ).…”

“…Pooled estimates provide strong support for a difference in the following laboratory measures between nonsurvivors and survivors: lower serum pH ( 53 , 58 , 72 , 75 ), higher lactate ( 43 , 50 , 51 , 53 , 60 – 62 , 65 , 68 , 71 , 72 , 74 – 76 , 81 – 83 ), higher serum base deficit ( 62 , 71 , 75 , 76 , 84 , 85 ), higher urea ( 58 , 76 , 81 , 86 ), higher creatinine ( 53 , 58 , 71 , 76 , 81 , 83 , 85 , 86 ), lower platelet count ( 41 , 43 , 50 , 53 , 58 , 62 , 71 , 77 , 81 , 83 – 85 , 87 , 88 ), lower fibrinogen ( 62 , 81 , 84 , 85 , 87 ), higher potassium ( 62 , 71 , 76 ), lower albumin ( 53 , 76 , 83 ), higher procalcitonin ( 26 , 35 , 43 , 76 , 83 , 85 , 89 – ...…”

Delayed Presentation and Mortality in Children With Sepsis in a Public Tertiary Care Hospital in Tanzania

“…For the first logistic regression model, wasting was used to represent malnutrition as it was determined to be the most clinically significant form of malnutrition for this cohort. Potential confounding factors in the relationship between delayed presentation and mortality were identified a priori based on clinical knowledge and a literature review, which were severity of disease (measured by the Lambaréné Organ Dysfunction Score, LODS, Figure 3), age, patient comorbidities, and malnutrition (1,13,14,(24)(25)(26)(27)(28)(29)(30)(31)(32). Patient age was considered because there are age-associated differences in clinical presentations of sepsis that could potentially influence time to presentation to care (1,28), and age is a well-known predictive factor in pediatric sepsis mortality (24,29).…”

“…Comorbidities among patients in the cohort were also considered in the analysis because they have been found to influence pediatric sepsis mortality (13,14). Malnutrition was considered a standalone comorbidity in analysis, as it is significantly associated with pediatric sepsis mortality (30)(31)(32) and could affect time to presentation to care.…”