Septic Shock in Children in an Urban Area in Western Germany – Outcome, Risk Factors for Mortality and Infection Epidemiology

Abstract

Background: Only sparse data exist about children with septic shock in Europe. The present study aimed to evaluate demographics, treatment, outcome and risk factors for mortality in Western Germany.

Patients: Children with septic shock aged 2 months to 17 years.

Methods: In a multi-center retrospective study of 20 children´s hospitals data were obtained and analyzed by chart review. Risk factors for mortality were identified and assessed by multivariate regression analysis.

Results: Overall mortality in 83 cases with septic shock was 25% (21 patients). Significant risk factors were high PRISM III score, low pH, low arterial systolic blood pressure, presence of disseminated intravascular coagulation and extent of multi-organ failure, but not lactate (p=0.05) and base excess (p=0.065). Mortality in hospitals which treated 10 or more patients (category 1) was 17% and increased to 22% in hospitals which treated 3–6 patients (category 2). In hospitals with only 1 or 2 patients (category 3) mortality rate was 61% (p<0.01 when compared to category 1 or 2). A stepwise increase was also seen in the severely sick patients according to PRISM III (>19): category 1: 23%, category 2: 40%, category 3: 62.5% (p<0.05 for comparison of category 1 and 3). Multivariate analysis of significant risk factors revealed low number of treated patients as the only individual risk factor for mortality.

Conclusion: Mortality from pediatric septic shock in an urban area in Western Germany is high. Disease severity and treatment in a department with few cases were associated with increased mortality.

Zusammenfassung

Hintergrund: In Europa gibt es wenige Daten über den septischen Schock bei Kindern. Die vorliegende Studie untersuchte demografische Daten, Behandlungsmodalitäten, Outcome und Risikofaktoren für Mortalität in Westdeutschland.

Patienten: Säuglinge, Kinder und Jugendliche mit septischem Schock im Alter von 2 Monaten bis 17 Jahren.

Methoden: Durch retrospektive Akteneinsicht wurde in 20 Kinderkliniken Daten gesammelt und ausgewertet. Mögliche Risikofaktoren für Mortalität wurden identifiziert und mittels multipler Regression ausgewertet.

Ergebnisse: Die Mortalität bei 83 Fällen mit septischem Schock betrug 25% (21 Patienten). Als signifikante Risikofaktoren konnten hoher PRISM III score, niedriger pH, niedriger systolischer Blutdruck, Vorhandensein einer disseminierten intravasalen Gerinnung und eine hohe Anzahl an Organdysfunktionen ermittelt werden, jedoch nicht Laktat (p=0,05) und Basenexzess (p=0,065). Die Mortalität in Kinderkliniken, die mehr als 10 Patienten behandelten (Kategorie 1), betrug 17% und stieg auf 22% in Kinderkliniken, die 3–6 Patienten behandelten (Kategorie 2). In Krankenhäusern mit 1-2 Patienten (Kategorie 3) betrug die Mortalität 61% (p<0.01 im Vergleich zu Kategorie 1 und 2). Ein schrittweiser Anstieg der Mortalität konnte auch für die schwer Erkrankten (PRISM III >19) gesehen werden: Kategorie 1: 23%, Kategorie 2: 40% und Kategorie 3: 62,5% (p<0,05 für den Vergleich Kategorie 1 und 3). Die multivariate Analyse von signifikanten Risikofaktoren ergab die Behandlung von 1-2 Patienten als einzigen individuellen Risikofaktor für Mortalität.

Schlussfolgerung: Die Mortalität des septischen Schocks im Kindesalter in Westdeutschland ist hoch. Die Schwere der Erkrankung und die Behandlung in einer Abteilung mit wenigen Fällen waren mit erhöhter Mortalität assoziiert.

Key Words

children - septic shock - risk factors - Germany

Schlüsselwörter

Kinder - septischer Schock - Risikofaktoren - Deutschland

• References

• 1 Brierley J, Carcillo JA, Choong K et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37: 666-688
• 2 Dellinger RP, Levy MM, Rhodes A et al. Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup: Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013; 39: 165-228
• 3 Goldstein B, Giroir B, Randolph A.. International pediatric consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6: 2-8
• 4 Inwald DP, Tasker RC, Peters MJ et al. on behalf of the Paediatric Intensive Care Study Group . (PICS-SG). Emergency management of children with severe sepsis in the United Kingdom: the results of the Paediatric Intensive Care Society sepsis audit. Arch Dis Child 2009; 94: 348-353
• 5 Larsen GY, Mechan N, Greenberg R. An emergency department septic shock protocol and care guideline for children initiated at triage. Pediatrics 2012; 127: e1585-e1592
• 6 Launay E, Gras-Le Guen C, Martinot A et al. Suboptimal care in the initial management of children who died from severe bacterial infection: A population-based confidential inquiry. Pediatr Crit Care Med 2010; 11: 469-474
• 7 Kim YA, Ha EJ, Won KJ et al. Early blood lactate area as a prognostic marker in pediatric septic shock. Intensive Care Med 2013; 39: 1818-1823
• 8 Kissoon N, Carcillo JA, Espinosa V et al. Global Sepsis Initiative Vanguard Center Contributors: World Federation of Pediatric Intensive Care and Critical Care Societies: Global Sepsis Initiative. Pediatr Crit Care Med 2011; 12: 494-503
• 9 Kutko MC, Calarco MP, Flaherty MB. Mortality rates in pediatric septic shock with and without multiple organ system failure. Pediatr Crit Care 2003; 4: 333-337
• 10 Oliveira CF, Nogueira de Sá FR, Oliveira DSF et al. Time- and fluid-sensitive resuscitation for hemodynamic support of children in septic shock. Ped Emerg Care 2008; 12: 810-815
• 11 Paul R, Neuman MI, Monuteaux MC et al. Adherence to PALS sepsis guidelines and hospital length of stay. Pediatrics 2012; 130: e273-e280
• 12 Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated pediatric risk of mortality score. Crit Care Med 1996; 24: 743-752
• 13 Shime N, Kawasaki T, Saito O et al. Incidence and risk factors for mortality in paediatric severe sepsis: results from the national paediatric intensive care registry in Japan. Intensive Care Med 2012; 38: 1191-1197
• 14 Van de Voorde P, Emerson B, Gomez B et al. Paediatric community-acquired septic shock: results from the REPEM network study. Eur J Pediatr 2013; 172: 667-674
• 15 Wolfler A, Silvani P, Musicco M et al. Italian Pediatric Sepsis Study (SISPe) group. Incidence of and mortality due to sepsis, severe sepsis and septic shock in Italian pediatric intensive care units; a prospective national survey. Intensive Care Med 2008; 34: 1690-1697