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Prediction of pediatric sepsis mortality within 1 h of intensive care admission

Intensive Care Medicine volume 43, pages 1085–1096 (2017)Cite this article

Abstract

Purpose

The definitions of sepsis and septic shock have recently been revised in adults, but contemporary data are needed to inform similar approaches in children.

Methods

Multicenter cohort study including children <16 years admitted with sepsis or septic shock to ICUs in Australia and New Zealand in the period 2012–2015. We assessed septic shock criteria at ICU admission to define sepsis severity, using 30-day mortality as outcome. Through multivariable logistic regression, a pediatric sepsis score was derived using variables available within 60 min of ICU admission.

Results

Of 42,523 pediatric admissions, 4403 children were admitted with invasive infection, including 1697 diagnosed as having sepsis/septic shock on admission. Mortality was 8.5% (144/1697) and 50.7% of deaths occurred within 48 h of admission. The presence of septic shock as defined by the 2005 consensus was sensitive but not specific in predicting mortality (AUC = 0.69; 95% CI 0.65–0.72). Combinations of hypotension, vasopressor therapy, and lactate >2 mmol/l discriminated poorly (AUC <0.60). Multivariate models showed that oxygenation markers, ventilatory support, hypotension, cardiac arrest, serum lactate, pupil responsiveness, and immunosuppression were the best-performing predictors (0.843; 0.811–0.875). We derived a pediatric sepsis score (0.817; 0.779–0.855), and every one-point increase was associated with a 28.5% (23.8–33.2%) increase in the odds of death. Children with a score ≥6 had 19.8% mortality and accounted for 74.3% of deaths. The sepsis score performed comparably when applied to all children admitted with invasive infection (0.810; 0.781–0.840).

Conclusions

We observed mortality patterns specific to pediatric sepsis that support the need for specialized definitions of sepsis severity in children. We demonstrated the importance of lactate, cardiovascular, and respiratory derangements at ICU admission for the identification of children with substantially higher risk of sepsis mortality.

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Abbreviations

BMT:

Bone marrow transplant

ECMO:

Extracorporeal membrane oxygenation

OR:

Odds ratio

PICU:

Pediatric intensive care unit

PIM:

Pediatric index of mortality

SSC:

Surviving Sepsis Campaign

SOFA:

Sequential (Sepsis-related) Organ Failure Assessment

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Acknowledgements

We thank the Paediatric Study Group of the Australian and New Zealand Intensive Care Society for supporting this study (Simon Erickson, Princess Margaret Hospital for Children, Perth, Australia; Andreas Schibler, Debbie Long, Jan Alexander, Lady Cilento Children’s Hospital, Brisbane, Australia; John Beca, Claire Sherring, Starship Children’s Hospital, Auckland, New Zealand; Gary Williams, Janelle Young, Mary Lou Morritt, Sydney Children’s Hospital, Randwick, Australia; Johnny Millar, Carmel Delzoppo, Warwick Butt, Royal Children’s Hospital, Melbourne, Australia; Subodh Ganu, Georgia Letton, Women’s and Children’s Hospital, Adelaide, Australia; Marino Festa, Westmead Children’s Hospital, Sydney, Australia). We also thank the intensivists, data managers, and other staff in the participating ICUs for their data contributions. The ANZPIC Registry is one of four registries managed by the Australian and New Zealand Intensive Care Society’s Centre for Outcome and Resource Evaluation (ANZICS CORE). ANZICS CORE is supported by the Ministry of Health (New Zealand) and State and Territory Health Departments (Australia).

Author information

Affiliations

  1. Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland, Brisbane, Australia

    Luregn J. Schlapbach & Andreas Schibler

  2. Paediatric Intensive Care Unit, Lady Cilento Children’s Hospital, Brisbane, Australia

    Luregn J. Schlapbach, Anthony Slater & Andreas Schibler

  3. Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    Luregn J. Schlapbach

  4. Cardiothoracic Intensive Care Unit, National University Health System, Singapore, Singapore

    Graeme MacLaren

  5. Paediatric Intensive Care Unit, The Royal Children’s Hospital, Melbourne, Australia

    Graeme MacLaren & Johnny Millar

  6. Paediatric Intensive Care Unit, Children’s Hospital Westmead, Sydney, Australia

    Marino Festa

  7. The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation (CORE), ANZICS House, Ievers Terrace, Carlton South, Melbourne, Australia

    Janet Alexander & David Pilcher

  8. School of Medicine, University of Queensland, Brisbane, Australia

    Janet Alexander

  9. Paediatric Intensive Care Unit, Princess Margaret Hospital for Children, Perth, Australia

    Simon Erickson

  10. Paediatric Intensive Care Unit, Starship Children’s Hospital, Auckland, New Zealand

    John Beca

  11. Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia

    David Pilcher

  12. Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran, VIC, Australia

    David Pilcher

  13. Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia

    Lahn Straney

Authors
  1. Luregn J. Schlapbach
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  2. Graeme MacLaren
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  3. Marino Festa
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  4. Janet Alexander
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  5. Simon Erickson
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  6. John Beca
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  7. Anthony Slater
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  8. Andreas Schibler
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  9. David Pilcher
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  10. Johnny Millar
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  11. Lahn Straney
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Consortia

On behalf of the Australian & New Zealand Intensive Care Society (ANZICS) Centre for Outcomes & Resource Evaluation (CORE) and Australian & New Zealand Intensive Care Society (ANZICS) Paediatric Study Group

Corresponding author

Correspondence to Luregn J. Schlapbach.

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Conflicts of interest

This work was supported by a Clinical Research Seeding Grant from Mater Research Institute—The University of Queensland. Dr Straney receives salary support from the National Medical Health and Research Council (NHMRC) Australian Resuscitation Outcomes Consortium (Aus-ROC) Centre of Research Excellence #1029983 (https://www.ausroc.org.au).

Ethical approval

The study was based on existing dataset and performed according to the Helsinki declaration.

Role of funding source

The Mater Research Institute, The University of Queensland, and the National Medical Health and Research Council (NHMRC) Australian Resuscitation Outcomes Consortium (Aus-ROC) Centre of Research Excellence who funded the project and Dr Straney had no involvement in the design, analysis, and writing of the present manuscript.

Additional information

Take-home message: We observed mortality patterns specific to pediatric sepsis which indicate the need for pediatric-specific sepsis definitions. Applying the 2005 criteria for septic shock was sensitive but not specific in predicting sepsis mortality. We demonstrate the relevance of lactate, cardiovascular, and respiratory derangements at ICU admission to identify children with substantially higher sepsis mortality; a simple derived pediatric sepsis score, based on variables known within 60 min of ICU admission, was able to identify children with sepsis at substantially higher risk of mortality.

The investigators of the ANZICS CORE and PSG groups are fully listed in the ESM 2.

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Schlapbach, L.J., MacLaren, G., Festa, M. et al. Prediction of pediatric sepsis mortality within 1 h of intensive care admission. Intensive Care Med 43, 1085–1096 (2017). https://doi.org/10.1007/s00134-017-4701-8

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  • DOI: https://doi.org/10.1007/s00134-017-4701-8

Keywords

  • Childhood
  • Mortality
  • Infection
  • Sepsis
  • Septic shock