Refractory septic shock in children: a European Society of Paediatric and Neonatal Intensive Care definition.

Abstract

PURPOSE:

Although overall paediatric septic shock mortality is decreasing, refractory septic shock (RSS) is still associated with high mortality. A definition for RSS is urgently needed to facilitate earlier identification and treatment. We aim to establish a European society of paediatric and neonatal intensive care (ESPNIC) experts' definition of paediatric RSS.

METHODS:

We conducted a two-round Delphi study followed by an observational multicentre retrospective study. One hundred and fourteen paediatric intensivists answered a clinical case-based, two-round Delphi survey, identifying clinical items consistent with RSS. Multivariate analysis of these items in a development single-centre cohort (70 patients, 30 % mortality) facilitated development of RSS definitions based on either a bedside or computed severity score. Both scores were subsequently tested in a validation cohort (six centres, 424 patients, 11.6 % mortality).

RESULTS:

From the Delphi process, the draft definition included evidence of myocardial dysfunction and high blood lactate levels despite high vasopressor treatment. When assessed in the development population, each item was independently associated with the need for extracorporeal life support (ECLS) or death. Resultant bedside and computed septic shock scores had high discriminative power against the need for ECLS or death, with areas under the receiver operating characteristics curve of 0.920 (95 % CI 0.89-0.94), and 0.956 (95 % CI 0.93-0.97), respectively. RSS defined by a bedside score equal to or higher than 2 and a computed score equal to or higher than 3.5 was associated with a significant increase in mortality.

CONCLUSIONS:

This ESPNIC definition of RSS accurately identifies children with the most severe form of septic shock.

• Authors: Luc Morin, Samiran Ray, Clare Wilson, Solenn Remy, Mohamed Rida Benissa, Nicolaas J G Jansen, Etienne Javouhey, Mark J Peters, Martin Kneyber, Daniele De Luca, Simon Nadel, Luregn Jan Schlapbach, Graeme Maclaren, Pierre Tissieres, ESPNIC Refractory Septic Shock Definition Taskforce the Infection Systemic Inflammation Sepsis section of ESPNIC
• Journal: Intensive care medicine (Intensive Care Med) Vol. 42 Issue 12 Pg. 1948-1957 (Dec 2016) ISSN: 1432-1238 [Electronic] United States
• PMID: 27709263 (Publication Type: Journal Article, Multicenter Study, Observational Study, Validation Study)

Chemical References

• Vasoconstrictor Agents
• Lactic Acid

Topics

• Child
• Child, Preschool
• Consensus
• Delphi Technique
• Europe
• Female
• Humans
• Infant
• Intensive Care Units, Pediatric
• Lactic Acid (blood)
• Male
• ROC Curve
• Retrospective Studies
• Severity of Illness Index
• Shock, Septic (diagnosis, mortality, therapy)
• Statistics, Nonparametric
• Surveys and Questionnaires
• Terminology as Topic
• Vasoconstrictor Agents (therapeutic use)