Abstract
ObjectivesThe heterogeneity of sepsis makes it difficult to predict outcomes using existing severity of illness tools. The vasoactive-inotrope score (VIS) is a quantitative measure of the amount of vasoactive support required by patients. We sought to determine if a higher aggregate VIS over the first 96 h of vasoactive medication initiation is associated with increased resource utilization and worsened clinical outcomes in pediatric patients with severe sepsis.DesignRetrospective cohort study.SettingSingle-center at Children's Wisconsin in Milwaukee, WI.PatientsOne hundred ninety-nine pediatric patients, age less than 18 years old, diagnosed with severe sepsis, receiving vasoactive medications between January 2017 and July 2019.InterventionsRetrospective data obtained from the electronic medical record, calculating VIS at 2 h intervals from 0–12 h and at 4 h intervals from 12–96 h from Time 0.MeasurementsAggregate VIS derived from the hourly VIS area under the curve (AUC) calculation based on the trapezoidal rule. Data were analyzed using Pearson's correlations, Mann-Whitney test, Wilcoxon signed rank test, and classification, and regression tree (CART) analyses.Main ResultsHigher aggregate VIS is associated with longer hospital LOS (p < 0.0001), PICU LOS (p < 0.0001), MV days (p = 0.018), increased in-hospital mortality (p < 0.0001), in-hospital cardiac arrest (p = 0.006), need for ECMO (p < 0.0001), and need for CRRT (p < 0.0001). CART analyses found that aggregate VIS >20 is an independent predictor for in-hospital mortality (p < 0.0001) and aggregate VIS >16 for ECMO use (p < 0.0001).ConclusionsThere is a statistically significant association between aggregate VIS and many clinical outcomes, allowing clinicians to utilize aggregate VIS as a physiologic indicator to more accurately predict disease severity/trajectory in pediatric sepsis.
Highlights
Sepsis is a leading cause of pediatric morbidity and mortality, accounting for 80,000 pediatric hospitalizations yearly in the U.S alone with ∼5,000 deaths and 25–40% of patients suffering long term complications [1–4]
Fifty-six percent of subjects were admitted from the Children’s Wisconsin (CW) Emergency Department and 19% from the acute care floors
One eligible patient was excluded from the mechanical ventilation cohort as an outlier as he/she was only mechanically ventilated for 0.1 days
Summary
Sepsis is a leading cause of pediatric morbidity and mortality, accounting for 80,000 pediatric hospitalizations yearly in the U.S alone with ∼5,000 deaths and 25–40% of patients suffering long term complications [1–4]. The highest risk of in-hospital mortality secondary to refractory septic shock occurs within the first 48–72 h of sepsis recognition or ICU admission [5, 6]. A clinical predictive tool utilizing a physiologic biomarker to assess pediatric severe sepsis in real time may be beneficial in clinical decision making. Appreciating that the highest risk of mortality is within the first 48–72 h of sepsis identification or ICU admission, it would be beneficial to study a cohort over a longer duration of time, such as 96 h [5, 6]. It would be beneficial to study the correlation of the total inotropic demand over this time period as there is currently no literature on a 96-h aggregate VIS and its relationship to clinical outcomes in pediatric patients diagnosed with critical sepsis, severe sepsis, or septic shock
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