Pediatric Septic Shock Patients Research Articles

Biomarker Assessment of a High-Risk, Data-Driven Pediatric Sepsis Phenotype Characterized by Persistent Hypoxemia, Encephalopathy, and Shock.

Identification of children with sepsis-associated multiple organ dysfunction syndrome (MODS) at risk for poor outcomes remains a challenge. We sought to the determine reproducibility of the data-driven "persistent hypoxemia, encephalopathy, and shock" (PHES) phenotype and determine its association with inflammatory and endothelial biomarkers, as well as biomarker-based pediatric risk strata. We retrained and validated a random forest classifier using organ dysfunction subscores in the 2012-2018 electronic health record (EHR) dataset used to derive the PHES phenotype. We used this classifier to assign phenotype membership in a test set consisting of prospectively (2003-2023) enrolled pediatric septic shock patients. We compared profiles of the PERSEVERE family of biomarkers among those with and without the PHES phenotype and determined the association with established biomarker-based mortality and MODS risk strata. Twenty-five PICUs across the United States. EHR data from 15,246 critically ill patients with sepsis-associated MODS split into derivation and validation sets and 1,270 pediatric septic shock patients in the test set of whom 615 had complete biomarker data. None. The area under the receiver operator characteristic curve of the modified classifier to predict PHES phenotype membership was 0.91 (95% CI, 0.90-0.92) in the EHR validation set. In the test set, PHES phenotype membership was associated with both increased adjusted odds of complicated course (adjusted odds ratio [aOR] 4.1; 95% CI, 3.2-5.4) and 28-day mortality (aOR of 4.8; 95% CI, 3.11-7.25) after controlling for age, severity of illness, and immunocompromised status. Patients belonging to the PHES phenotype were characterized by greater degree of systemic inflammation and endothelial activation, and were more likely to be stratified as high risk based on PERSEVERE biomarkers predictive of death and persistent MODS. The PHES trajectory-based phenotype is reproducible, independently associated with poor clinical outcomes, and overlapped with higher risk strata based on prospectively validated biomarker approaches.

Whole blood transcriptomics identifies subclasses of pediatric septic shock

BackgroundSepsis is a highly heterogeneous syndrome, which has hindered the development of effective therapies. This has prompted investigators to develop a precision medicine approach aimed at identifying biologically homogenous subgroups of patients with septic shock and critical illnesses. Transcriptomic analysis can identify subclasses derived from differences in underlying pathophysiological processes that may provide the basis for new targeted therapies. The goal of this study was to elucidate pathophysiological pathways and identify pediatric septic shock subclasses based on whole blood RNA expression profiles.MethodsThe subjects were critically ill children with cardiopulmonary failure who were a part of a prospective randomized insulin titration trial to treat hyperglycemia. Genome-wide expression profiling was conducted using RNA sequencing from whole blood samples obtained from 46 children with septic shock and 52 mechanically ventilated noninfected controls without shock. Patients with septic shock were allocated to subclasses based on hierarchical clustering of gene expression profiles, and we then compared clinical characteristics, plasma inflammatory markers, cell compositions using GEDIT, and immune repertoires using Imrep between the two subclasses.ResultsPatients with septic shock depicted alterations in innate and adaptive immune pathways. Among patients with septic shock, we identified two subtypes based on gene expression patterns. Compared with Subclass 2, Subclass 1 was characterized by upregulation of innate immunity pathways and downregulation of adaptive immunity pathways. Subclass 1 had significantly worse clinical outcomes despite the two classes having similar illness severity on initial clinical presentation. Subclass 1 had elevated levels of plasma inflammatory cytokines and endothelial injury biomarkers and demonstrated decreased percentages of CD4 T cells and B cells and less diverse T cell receptor repertoires.ConclusionsTwo subclasses of pediatric septic shock patients were discovered through genome-wide expression profiling based on whole blood RNA sequencing with major biological and clinical differences.Trial Registration This is a secondary analysis of data generated as part of the observational CAF-PINT ancillary of the HALF-PINT study (NCT01565941). Registered March 29, 2012.

Relationship between serum ferritin level and outcome of septic shock in children

Background Sepsis is a life-threatening organ dysfunction caused by dysregulation of the immune system against infection. Sepsis that leads to septic shock is one of the causes of morbidity and mortality in children who are treated in intensive care and inpatient rooms. Ferritin is a protein whose synthesis is increased in inflammatory and infectious conditions and can be a marker of active infection. The cut off ferritin in septic shock was not established and not absolutely clear in our patients. Objective To determine the cut-off value of ferritin levels in patient with septic shock and the relationship between high serum ferritin levels with poor outcome (mortality) in pediatric patients with septic shock. Methods This study used an observational-analytic design with prospective cohort study design. The research was conducted in pediatric ward, Prof. Dr. I.G.N.G. Ngoerah hospital from October 2021 to August 2022. Data analysis was done in 2 steps, first by using receiver operator characteristic curves to find the optimal cut-off point value and the second step was bivariate and multivariate analysis to determine the relationship between ferritin levels and the outcome of septic shock in children. The significance level (α) of this study was set with probability value less than 0.05. Results This study involved 76 subjects, 49 subjects died and 27 subjects survive. The Area Under Curve of ferritin levels from ROC curve obtained was ​​83.7% (p=0.001, 95% CI 74.2%-93.1%). The cut off for ferritin level 660.78 ng/ml gave sensitivity 85.7% and specificity 77.8% for mortality in patients with septic shock. The value of ferritin levels ³ 660.78 generate mortality risk 39.50 times (95% CI 8.057 – 183.422) in pediatric patients with septic shock. Conclusion Higher ferritin levels can increase the risk of mortality in pediatric septic shock patients.

Red Blood Cell Distribution Width (RDW) as a predictor of septic shock in children

Link of Video Abstract: https://youtu.be/Exh1T2szfoE Background: Septic shock is a prevalent PICU condition requiring prompt intervention. Using the PELOD II score, which has multiple characteristics to examine, it is challenging to predict prognosis in healthcare-limited settings. A link has recently been shown between red blood cell distribution width (RDW) and mortality risk in critically ill patients, albeit the exact mechanism is unknown. Methods: This retrospective observational study examined RDW values in pediatric septic or non-septic shock patients. This study examined patient clinical features, RDW hematological markers (RDW-CV, RDW-SD, and RDW/albumin ratio), and the area under the curve to determine the cut-off for the hematological marker, sensitivity, and specificity. Results: Sixty-one pediatric patients met the inclusion criteria (33 with septic shock and 28 with non-septic shock). The red cell distribution width coefficient variation (RDW-CV) (p=0,058), red cell distribution width standard deviation (RDW-SD) (p=0,05), and RDW Albumin Ratio (RAR) (p=0,014) were shown to be significantly different between the septic shock and non-septic shock groups. The cut-off value for RDW-CV was 15.3% (53.6% sensitivity and 97% specificity), 47.4 fl for RDW-SD (64.3% sensitivity and 84.8% specificity), and 5.65 for RDW/albumin ratio (71.4% sensitivity and 84.8% specificity). RDW-CV odd ratio was 36.9 (95% confidence interval (CI) 4.41-308.96, p 0.001), RDW-SD odd ratio was 10.08 (95% confidence interval (CI) 2.95-34.34, p 0,001), and RDW/albumin ratio was 14.00 (95% confidence interval (CI) 3.98-49.16, p 0,001). Conclusion: Increased RDW can be one marker in pediatric patients with septic shock. Increased levels of RDW/albumin ratio are significantly associated with the incidence of septic shock. Through the (ROC) area under the curve, the RDW/albumin ratio has better capabilities compared to other predictor markers.

THE ASSOCIATION BETWEEN CORTICOSTEROID USE AND PROGNOSIS AND MORTALITY IN CHILDREN WITH SEPTIC SHOCK: A SYSTEMATIC REVIEW

Background/ objectives: The leading factor in pediatric death is septic shock. The use of corticosteroids, however, is still debatable. The management of septic shock has included the adjunct use of several corticosteroids and treatment plans. At the cellular and tissular levels, the various medications and their modes of administration differ qualitatively and quantitatively. This comprehensive analysis looked at the likelihood of mortality and prognosis for children with septic shock who were supplemented with corticosteroids. Methods: PubMed, Web of Science, Science Direct, and Google Scholarwere systematically searched to include the relevant literature. Rayyan QRCI was used throughout this systematic approach. Results/ Interpretation: The use of corticosteroids in pediatric septic shock patients is debatable. However, this study supports that corticosteroids are not recommended for children with septic shock. In order to increase generalizability and determine the ideal timing to begin treatment, the ideal dose of hydrocortisone (or an equivalent), and the duration and mode of withdrawal from treatment, additional studies are required to examine the role of prolonged low-dose corticosteroid treatment for septic shock in developing nations.

Use of hemodynamic and laboratory monitoring tools to reduce the risk of mortality from pediatric septic shock

Background Early recognition of septic shock in terms of clinical, macrocirculatory hemodynamic, and microcirculatory laboratory parameters is a fundamental challenge in the emergency room and intensive care unit for early identification, adequate management, prevention of disease progression, and reduction of mortality risk.
 Objective To evaluate for possible correlations between survival outcomes of post-resuscitation pediatric septic shock patients and parameters of clinical signs, macrocirculatory hemodynamics, as well as microcirculatory laboratory findings.
 Methods This prospective, study was conducted in the PICU at Saiful Anwar Hospital, Malang, East Java. Inclusion criteria were children diagnosed with septic shock according to the 2005 Surviving Sepsis Campaign (SSC) criteria, aged >30 days-18 years, who were followed up for 72h after resuscitation. The measured variables such as cardiac index (CI), systemic vascular resistance index (SVRI), stroke volume index (SVI) were obtained from ultrasonic cardiac output monitor (USCOM). Blood gas and lactate were obtained from laboratory findings. Heart rate, pulse strength, extremity temperature, mean arterial pressure (MAP), systolic blood pressure (SBP), capillary refill time (CRT), Glasgow coma scale (GCS), and diuretic used were obtained from hemodynamic monitoring tools. Survival outcomes of post-resuscitation pediatric septic shock patients were noted.
 Results There was a significant correlation between the outcomes of the pediatric septic shock patients 72h after fluid resuscitation and clinical, macrocirculatory hemodynamic, and microcirculatory laboratory parameters. After the 6th hour of observation, strong pulse was predictive of survival, with 88.2% area under the curve (AUC). At the 12th hour of observation, MAP >50th percentile for age was predictive of survival, with 94% AUC.
 Conclusion For pediatric patients with septic shock, the treatment target in the first 6 hours is to improve strength of pulse, and that in the first 12 hours is to improve MAP >50th percentile for age to limit mortality.

Sepsis associated acute kidney injury in pediatric intensive care unit.

We aimed to compare the acute kidney injury (AKI) incidence in pediatric septic shock patients according to the three different classifications. We analyzed retrospectively 52 patients with severe sepsis between January 2019 and December 2019. While 21 patients have been diagnosed with SA-AKI according to the pRIFLE criteria, 20 children have been diagnosed according to the AKIN criteria, and 21 children have been diagnosed according to the KDIGO criteria. Older age, lower platelet count were determined as independently risk factor for SA-AKI. Older age and higher PRISM score were associated with mortality. According to Canonical correlation coefficients, pRIFLE is the most successful classification to distinguish AKI state. The canonical correlation coefficients for pRIFLE, KDIGO, and AKIN were 0.817, 0.648, and 0.615, respectively. Although AKI incidence was similar between the three classifications, pRIFLE was the most successful classification to distinguish AKI state.

The Correlations of Human Atrial Natriuretic Peptide on Cardiac Function and Hemodynamics in Pediatric Septic Shock.

PurposeWe aimed to determine the correlations of human Atrial Natriuretic Peptide (ANP) on cardiac function and hemodynamics in pediatric septic shock.Patients and MethodsWe conducted an observational and prospective study on 30 children with septic shock. Measurement of the level of human atrial natriuretic peptide was determined in the serum of patients. Cardiac power (CP) is a cardiac function parameter measured with cardiac output (cardiovascular flow) and mean arterial (intravascular) pressure. Cardiac output and mean arterial pressure were monitored using pressure recording analytical methods (PRAM). Hemodynamic status was represented by a vasoactive inotropic score.ResultsThirty pediatric septic shock patients fulfilled the eligibility criteria. The human ANP level was not significantly different in pediatric septic shock on three days of examination. Cardiac power was significantly different in pediatric septic shock on three days of examination. There was a correlation between human ANP and cardiac power on day 3 and human ANP and VIS on day 2.ConclusionThere was a significant correlation between human ANP level and cardiac power on day 3 and ANP level and VIS on day 2. The cardiac power on day 3 and VIS on 48 hours can be alternatives to evaluate the hemodynamic status and cardiac function concerning human ANP in pediatric septic shock.

O006 / #776: ASSOCIATION BETWEEN VASOACTIVE INOTROPIC SCORE (VIS) AND ADVERSE OUTCOME IN PEDIATRIC SEPTIC SHOCK PATIENTS ADMITTED AT PEDIATRIC INTENSIVE CARE UNIT

Aims & Objectives: To determine the association of VIS to adverse outcomes in pediatric septic shock patients who are admitted in the Philippine Children’s Medical Center. Methods: This is a prospective cohort study of all septic shock PICU patients aged 1 month to 18 years old. Vasoactive Inotropic Score (VIS) was calculated at 0, 6, 12, 24, and 48 hours post PICU admission as described by Gaies, et. al. Demographic and clinical data were collected. Primary outcomes were ventilator days and ICU length of stay. Secondary outcomes were death during hospitalization, cardiac arrest, and need for intubation. STATA 13.1 was used for data analysis and a P value <0.05 was considered significant.Results: Eighty-four patients met the inclusion criteria and were enrolled in the study with the median age of 36 months. Sixty-two patients were intubated, 34 went to cardiac arrest and 33 died during the hospitalization. Fourteen patients were ventilated for >=6 days and 20 stayed in the PICU for >=12 days. This study showed a strong association between VIS at 0, 6, 12, 24, 48 hours and maximum VIS with the secondary outcomes specifically risk of intubation, cardiac arrest, and death during hospitalization. Results showed that initial upto maximal VIS within 48 hours may capture a component of illness in pediatric sepsis that highlights cardiovascular instability. Conclusions: VIS is easily measured and if validated in pediatric sepsis, has the potential to standardize the quantification of hemodynamic support, identify, and stratify high-risk patient populations, and be used as a surrogate outcome measure.

Association between Vasoactive Inotropic Score and adverse outcome in pediatric septic shock patients admitted at the Pediatric Intensive Care Unit

Association between Vasoactive Inotropic Score and adverse outcome in pediatric septic shock patients admitted at the Pediatric Intensive Care Unit

Differential gene expression analysis reveals novel genes and pathways in pediatric septic shock patients

Septic shock is a devastating health condition caused by uncontrolled sepsis. Advancements in high-throughput sequencing techniques have increased the number of potential genetic biomarkers under review. Multiple genetic markers and functional pathways play a part in development and progression of pediatric septic shock. We identified 53 differentially expressed pediatric septic shock biomarkers using gene expression data sampled from 181 patients admitted to the pediatric intensive care unit within the first 24 hours of their admission. The gene expression signatures showed discriminatory power between pediatric septic shock survivors and nonsurvivor types. Using functional enrichment analysis of differentially expressed genes, we validated the known genes and pathways in septic shock and identified the unexplored septic shock-related genes and functional groups. Differential gene expression analysis revealed the genes involved in the immune response, chemokine-mediated signaling, neutrophil chemotaxis, and chemokine activity and distinguished the septic shock survivor from non-survivor. The identification of the septic shock gene biomarkers may facilitate in septic shock diagnosis, treatment, and prognosis.

Translational gap in pediatric septic shock management: an ESPNIC perspective

BackgroundThe Surviving Sepsis Campaign and the American College of Critical Care Medicine guidelines have provided recommendations for the management of pediatric septic shock patients. We conducted a survey among the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) members to assess variations to these recommendations.MethodsA total of 114 pediatric intensive care physicians completed an electronic survey. The survey consisted of four standardized clinical cases exploring seven clinical scenarios.ResultsAmong the seven different clinical scenarios, the types of fluids were preferentially non-synthetic colloids (albumin) and crystalloids (isotonic saline) and volume expansion was not limited to 60 ml/kg. Early intubation for mechanical ventilation was used by 70% of the participants. Norepinephrine was stated to be used in 94% of the PICU physicians surveyed, although dopamine or epinephrine is recommended as first-line vasopressors in pediatric septic shock. When norepinephrine was used, the addition of another inotrope was frequent. Specific drugs such as vasopressin or enoximone were used in < 20%. Extracorporeal life support was used or considered by 91% of the physicians audited in certain specific situations, whereas the use of high-flow hemofiltration was considered for 44%.ConclusionsThis pediatric septic shock management survey outlined variability in the current clinician-reported practice of pediatric septic shock management. As most recommendations are not supported by evidence, these findings outline some limitation of existing pediatric guidelines in regard to context and patient’s specificity.

Corticosteroids for pediatric septic shock patients

Background Septic shock remains a major cause of mortality and admission to the pediatric intensive care unit (PICU) in children. Management includes adequate fluid resuscitation, followed by catecholamine infusion, if needed. Corticosteroid therapy is advised for catecholamine-refractory shock, although this practice is controversial, as it was not beneficial in other studies.&#x0D; Objective To assess corticosteroid use in pediatric septic shock patients in Cipto Mangunkusumo Hospital.&#x0D; Methods This cross-sectional study included all patients aged 1 month-18 years with a diagnosis of septic shock during the study period of January 2014 to July 2018 admitted in PICU Dr. Cipto Mangunkuskumo Hospital, Jakarta. Data obtained from medical records were, age, sex, immunology status, port d’entrée of sepsis, inotropic and vasopressor usage, mechanical ventilation, corticosteroid type, hospital length of stay (LOS), and mortality outcome.&#x0D; Results Of 217 children with septic shock, 12 patients (5.5%) received corticosteroid therapy. The most common corticosteroid given was hydrocortisone (80%), with a 2 mg/kg BW loading dose, followed by a continuous infusion dose of 2-50 mg/kg BW/day. Almost all patients (11/12) received corticosteroid therapy until they died. Median duration of corticosteroid use was 2 (range 1-7) days, median number of inotropes and vasopressors used was 3 (range 2-4) agents, median LOS was 3 (range 1-9) days, and mortality rate was 100%.&#x0D; Conclusion A small proportion of pediatric septic shock patients received corticosteroid therapy. Their mortality rate was 100%. Further clinical study is needed to evaluate the benefit of corticosteroid therapy in pediatric septic shock patients.

Elevated central venous pressure is associated with increased mortality in pediatric septic shock patients

BackgroundCentral venous pressure (CVP) is an important factor affecting capillary blood flow, and it is associated with poor outcomes in adult septic shock patients. However, whether a similar association exists in pediatric patients remains unclear.MethodsWe retrospectively analyzed data from patients admitted to our pediatric intensive care unit (PICU) between February 2009 and July 2015. Patients were divided into two groups—survivors and nonsurvivors—according to 28-day mortality. The associations between (a) mortality and CVP at 6, 24, 48, and 72 h after initiating treatment for established septic shock was analyzed and (b) initial serum lactic acid levels and 6-h CVP.ResultsTwo hundred twenty-six patients were included in this study, and the mortality rate was 29.6% (67 deaths, nonsurvivor group). Initial serum lactic acid levels, Pediatric Risk of Mortality (PRISM) III score, and Vasoactive–Inotropic Score (VIS) within 24 h after PICU admission were significantly higher in the nonsurvivors than in survivors (1.3 [0.9, 2.4] vs. 3.9 [1.6, 8.0] mmol/l, 11.0 [7.0, 15.0] vs. 17.0 [10.0, 21.5], 12.0 [7.0, 25.0] vs. 22.5 [8.0, 55.0], respectively with p-values < 0.001, < 0.001, and 0.009, respectively). In addition, compared to survivors, a greater percentage of nonsurvivors required mechanical ventilation (92.5% vs. 51.6%, p < 0.001) and showed a greater extent of fluid overload at 48 h after admission (3.9% vs. 1.9%, p = 0.006), along with higher 6-h CVP (10.0 [7.0, 16.0] vs. 8.0 [5.0, 11.0] mmHg, p < 0.001). Patient survival according to levels of CVP (CVP < 8 mmHg, CVP 8–12 mmHg, or CVP > 12 mmHg) showed that the CVP > 12-mmHg group had significantly greater mortality rates (50.0%, p = 0.002) than the other groups (21.3% and 27.5%). Furthermore, multivariate analysis identified significant associations of CVP > 12 mmHg, serum lactic acid levels, and the need for mechanical ventilation with mortality (OR: 2.74, 1.30, and 12.51, respectively; 95% CI: 1.11–6.72, 1.12–1.50, and 4.12–37.96, respectively).ConclusionsElevated CVP is an independent risk factor for mortality in pediatric septic shock patients.

Comparative study on the outcome of Early Goal Directed Therapy (EGDT) versus standard care in pediatric septic shock patients: A prospective open labeled randomized controlled trial

Background : Sepsis in children is a noteworthy cause of morbidity and mortality all over the world. Given the crucial need to reduce the mortality from sepsis, conflicting results from adult studies and lack of high quality pediatric controlled study warrant a trial to examine the effectiveness of early goal directed therapy (EGDT) versus standard care in Indian patients. Methods : The trial was a prospective open labeled randomized controlled trial conducted from 1st July 2015 to 30th June 2017. All children from one month of age to 12 years with septic shock fulfilling the inclusion criteria were enrolled in the study. Eligible patients were randomized and allocated one of the two study groups (EGDT Group and standard care group). If the patient was assigned to EGDT, the EGDT protocol adapted from Rivers et al. was commenced by the treating team within one hour of enrollment. If the patient was assigned to standard care, no changes were made to the plan of the treating team. Results : The 110 patients were recruited from July 2015 to June 2017. Out of 110 patients, 54 patients were randomized to the EGDT group and 56 randomized to the standard care group. The trial had to be stopped after an interim analysis by the independent data monitoring committee indicated the futility of the study. The overall all-cause mortality at 28 days of the study population was 53.6%. Children in the EGDT group had 46.3% mortality while children in the standard care group had 60.7% mortality (p=0.13). There was 14.4% absolute risk reduction of mortality in the EGDT group. There was no difference in any secondary outcome regarding the proportion of patients achieving therapeutic end points at 6 hours, use and duration of organ support, SOFA and PeLOD score and length of PICU and hospital stay. Conclusion : Our study suggests that the implementation of the early goal directed therapy (EGDT) by the addition of intermittent ScvO2 monitoring and protocolized management did not improve mortality in the EGDT group compared to standard care group. The implementation of EGDT needed the greater intensity of treatment in the form of inotrope and packed RBCs transfusion requirement.

The use of bedside echocardiography for measuring cardiac index and systemic vascular resistance in pediatric patients with septic shock.

ObjectiveFollow-up of cardiac index and systemic vascular resistance index by bedside echocardiography until resuscitation.MethodsA set of hemodynamic parameters was obtained, including cardiac output, stroke volume, cardiac index, systemic vascular resistance index, velocity time integral, myocardial performance index, capillary refill time, and heart rate at 0 hours after fluid boluses before the start of inotropes, and followed up after 6 hours and 24 hours.ResultsIncluded were 45 patients with community-acquired septic shock. Septic foci were gastroenteritis (24%), intestinal perforation requiring emergency surgery (24%), pneumonia (20%), central nervous system infection (22%) and soft tissue infection (8%). Klebsiella and Enterobacter were the most frequent isolates. We estimated the factors affecting the cardiac index: high central venous pressure at zero time (r = 0.33, p = 0.024) and persistently high heart rate at hour 6 (r = 0.33, p = 0.03). The systemic vascular resistance index was high in most patients at 0 and 24 hours and at the time of resuscitation and inversely affected the cardiac index as well as affecting the velocity time integral (r = -0.416, -0.61, 0.55 and -0.295). Prolonged capillary refill time was a clinical predictor of the low velocity time integral at 24 hours (r = -0.4). The mortality was 27%. Lower systemic vascular resistance index and higher cardiac output were observed in nonsurviving patients.ConclusionThere was a persistently high systemic vascular resistance index in cold shock patients that influenced the stroke volume index, cardiac index, and velocity time integral. The use of echocardiograms for hemodynamic measurements is important in pediatric septic shock patients to adjust dilators, and vasopressor doses and achieve resuscitation targets in a timely manner.

Intraosseous Versus Intravenous Access in Pediatric Septic Shock Patients Admitted to Alexandria University Pediatric Intensive Care Unit.

The cornerstone of emergency management of sepsis is early, goal-directed therapy. The purpose of this study was to evaluate the effect of intraosseous (IO) vs. intravenous (IV) access for resuscitation of patients with septic shock admitted to pediatric intensive care unit. This prospective interventional randomized clinical trial study was conducted on 60 patients with septic shock who need rapid administration of fluids and drugs; 30 cases were randomly chosen for IO vascular access, while the other 30 were selected for IV access. The IO route was successfully secured in all cases with a significant shorter time of vascular access insertion, shorter length of stay and reduction in mortality in IO group vs. IV group (p = 0.001, 0.045, 0.002, respectively). In pediatric emergencies, as in case of shock, the use of IO route is recommended to get rapid vascular access as soon as possible, as it revealed better outcome.

Pathogens and outcomes in pediatric septic shock patients supported by extracorporeal membrane oxygenation.

Refractory septic shock is the leading cause of mortality in children. There is limited evidence to support extracorporeal membrane oxygenation (ECMO) use in pediatric septic shock. We described the etiology and outcomes of septic patients in our institution and attempted to find predictive factors. We retrospectively reviewed 55 pediatric patients with septic shock who required ECMO support in a tertiary medical center from 2008 to 2015. Septic shock was defined as culture proved or clinical suspected sepsis with hypotension or end-organ hypoperfusion. ECMO would be applied when pediatric advanced life support steps were performed thoroughly without clinical response. Patient's demographics, laboratory parameters before and after ECMO, and outcomes were analyzed. Among 55 children with ECMO support, 31% of them survived on discharge. For 25 immunocompromised patients, causal pathogens were found in 17 patients: 7 due to bacteremia, 9 with preexisting virus infections and one with invasive fungal infection. Among 30 previously healthy patients, causal pathogens were found in 18 patients: 10 due to bacteremia (the most common was pneumococcus), 7 with preexisting virus infections including influenza (n=4), adenovirus (n=2), RSV, and 1 patient had mixed virus and bacterial infections. Predictive factors associated with death were arterial blood gas pH, CO2 and Glasgow Coma Scale (p<0.05). SOFA score was a valuable predictive scoring system for outcome prediction (p<0.05). Pediatric patients with refractory septic shock had high mortality rate and ECMO could be used as a rescue modality, and SOFA score could be applied to predict outcomes.

Platelet Indices as Predictive Markers of Prognosis in Pediatric Septic Shock Patients

Background: Platelet indices are used as predictive marker of mortality in adult critically ill patients. Objectives: To compare platelet counts, mean platelet volumes (MPV), and platelet distribution widths (PDW) in surviving and non-surviving pediatric septic shock patients and to assess whether platelet count and indices can be utilized as predictive markers of mortality in these patients. Methods: A retrospective study was performed based on collected data on pediatric patients admitted for septic shock to pediatric intensive care unit. Complete blood cell count, platelet counts, MPV, and PDW on admission were compared in survivors and non-survivors, as well as in patients with and without underlying hemato-oncologic disease. Results: Of 83 children, 21 (25.3%) died within 28 days of hospital admission. Mean platelet count was significantly higher in the 62 survivors than in 21 non-survivors (146.6 ± 133.7 × 103/mm3 vs 46.1 ± 44.1 × 103/mm3, P = 0.000). MPV and PDW were also higher in survivors, though not statistically significant (P = 0.059, P = 0.077). The platelet counts were significantly higher in survivors than in non-survivors with (P = 0.044) and without (P = 0.015) hemato-oncologic disease. Based on area under receiver operating characteristic curves, platelet count was the strongest predictor of mortality in pediatric patients without underlying hemato-oncologic disease (area under the curve = 0.857). The survival probability in this group was 96.77% when platelet count exceeded 106.5 × 103/mm3. Conclusions: Thrombocytopenia is a useful predictive marker of mortality in pediatric septic shock patients, both with and without underlying hemato-oncologic disease.

Evaluation of Early Corticosteroid Therapy in Management of Pediatric Septic Shock in Pediatric Intensive Care Patients: A Randomized Clinical Study.

Septic shock is a major healthcare problem. Adrenal insufficiency (AI) in children with septic shock is a recognized complication, yet is controversial regarding its management and effect on mortality. According to the current guidelines, children with risk factors for AI should receive a stress dose of steroids in step 3 of treatment. This study aimed to evaluate and compare early corticosteroid therapy with the traditional use of steroids among pediatric septic shock patients. This prospective randomized interventional clinical study included 3 groups of patients (32 each) and was conducted in Alexandria University pediatric intensive care unit. By protocol, the first group received steroids in step 3 of the treatment according to the current international guidelines (group A), and the second group was managed as group A and was tested for AI by adrenal stimulation test using intramuscular adrenocorticotropic hormone (cosyntropin) (group B). The third group received steroids at the start of fluid therapy (group C). A fourth group (group D) was created by adding patients from groups A and B who needed corticosteroids in the third stage of therapy according to the international protocol in 1 group. All patients were evaluated for basal serum cortisol and plasma adrenocorticotropic hormone concentrations. The data showed a statistically significant shorter shock reversal time among patients receiving corticosteroids at the start of treatment compared with those who received it at the third step of treatment (P = 0.046); however, mortality was not statistically different among the groups. In addition, there was no superinfection in cases receiving early steroid therapy. Early use of corticosteroid in patients with septic shock might shorten the shock reversal time without increase in mortality or superinfection.