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

Luregn J Schlapbach, Graeme MacLaren, Marino Festa, Janet Alexander, Simon Erickson, John Beca, Anthony Slater, Andreas Schibler, David Pilcher, Johnny Millar, Lahn Straney, 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

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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.

Original languageEnglish
Pages (from-to)1085-1096
Number of pages12
JournalIntensive Care Medicine
Volume43
Issue number8
DOIs
Publication statusPublished - 1 Aug 2017

Keywords

  • Childhood
  • Infection
  • Mortality
  • Sepsis
  • Septic shock

Cite this

Schlapbach, L. J., MacLaren, G., Festa, M., Alexander, J., Erickson, S., Beca, J., ... 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 (2017). Prediction of pediatric sepsis mortality within 1 h of intensive care admission. Intensive Care Medicine, 43(8), 1085-1096. https://doi.org/10.1007/s00134-017-4701-8
Schlapbach, Luregn J ; MacLaren, Graeme ; Festa, Marino ; Alexander, Janet ; Erickson, Simon ; Beca, John ; Slater, Anthony ; Schibler, Andreas ; Pilcher, David ; Millar, Johnny ; Straney, Lahn ; 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. / Prediction of pediatric sepsis mortality within 1 h of intensive care admission. In: Intensive Care Medicine. 2017 ; Vol. 43, No. 8. pp. 1085-1096.
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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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Schlapbach, LJ, MacLaren, G, Festa, M, Alexander, J, Erickson, S, Beca, J, Slater, A, Schibler, A, Pilcher, D, Millar, J, Straney, L & 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 2017, 'Prediction of pediatric sepsis mortality within 1 h of intensive care admission', Intensive Care Medicine, vol. 43, no. 8, pp. 1085-1096. https://doi.org/10.1007/s00134-017-4701-8

Prediction of pediatric sepsis mortality within 1 h of intensive care admission. / Schlapbach, Luregn J; MacLaren, Graeme; Festa, Marino; Alexander, Janet; Erickson, Simon; Beca, John; Slater, Anthony; Schibler, Andreas; Pilcher, David; Millar, Johnny; Straney, Lahn; 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.

In: Intensive Care Medicine, Vol. 43, No. 8, 01.08.2017, p. 1085-1096.

Research output: Contribution to journalArticleResearchpeer-review

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AU - Schlapbach, Luregn J

AU - MacLaren, Graeme

AU - Festa, Marino

AU - Alexander, Janet

AU - Erickson, Simon

AU - Beca, John

AU - Slater, Anthony

AU - Schibler, Andreas

AU - Pilcher, David

AU - Millar, Johnny

AU - Straney, Lahn

AU - 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

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AB - 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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Schlapbach LJ, MacLaren G, Festa M, Alexander J, Erickson S, Beca J et al. Prediction of pediatric sepsis mortality within 1 h of intensive care admission. Intensive Care Medicine. 2017 Aug 1;43(8):1085-1096. https://doi.org/10.1007/s00134-017-4701-8