J Pediatr Intensive Care
DOI: 10.1055/s-0042-1753536
Original Article

Beyond Vital Signs: Pediatric Sepsis Screening that Includes Organ Failure Assessment Detects Patients with Worse Outcomes

Jesseca A. Paulsen
1   Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
,
Karen M. Wang
2   Department of Pediatrics, Pediatric Residency Program, University of Alabama at Birmingham, Birmingham, Alabama, United States
,
Isabella M. Masler
2   Department of Pediatrics, Pediatric Residency Program, University of Alabama at Birmingham, Birmingham, Alabama, United States
,
Jessica F. Hicks
3   Performance Improvement and Accreditation Department, Children's of Alabama, Birmingham, Alabama, United States
,
Sherry N. Green
3   Performance Improvement and Accreditation Department, Children's of Alabama, Birmingham, Alabama, United States
,
4   Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
› Author Affiliations
Funding None.

Abstract

Pediatric sepsis screening is recommended. The 2005 Goldstein criteria, the basis of our institutional sepsis screening tool (ISST), correlate poorly with clinically diagnosed sepsis. The study objective was to retrospectively evaluate the ISST sensitivity compared with the Pediatric Sequential Organ Failure Assessment (pSOFA). This was a single-center retrospective cohort study. The primary outcome was pSOFA score and ISST sensitivity for severe sepsis. Secondary outcomes included clinical outcome measures. In this severe sepsis cohort (N = 491), pSOFA and ISST sensitivity were 57.6 and 61.1%, respectively. In regression analysis for a positive pSOFA, positive blood culture (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.1–4.3, p = 0.025), older age (OR 1.006, 95% CI 1.003–1.009, p < 0.001), and pulmonary infectious source (OR 3.3, 95% CI 1.6–6.5, p = 0.001) demonstrated independent association. In regression analysis for a positive ISST, older age (OR 1.003, 95% CI 1–1.006, p = 0.031) and intra-abdominal infectious source (OR 0.3, 95% CI 0.1–0.8, p = 0.014) demonstrated independent association. A negative ISST was associated with higher intensive care unit (ICU) admission prevalence (p = 0.01) and fewer ICU-free days (p = 0.018). A positive pSOFA score was associated with higher ICU admission prevalence, vasopressor requirement, and vasopressor days as well as fewer ICU, hospital, and mechanical ventilation-free days (all p < 0.001). Exploratory analysis combining the ISST and pSOFA into a hybrid screen demonstrated superior sensitivity (84.3%) and outcome discrimination. The pSOFA demonstrated noninferior sensitivity to a Goldstein-based institutional sepsis screening model. Further, pSOFA was a better discriminator of poor clinical outcomes. An exploratory hybrid screening model shows superior performance but will require prospective study.

Supplementary Material



Publication History

Article published online:
28 July 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 
  • References

  • 1 Weiss SL, Fitzgerald JC, Pappachan J. et al; Sepsis Prevalence, Outcomes, and Therapies (SPROUT) Study Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Global epidemiology of pediatric severe sepsis: the sepsis prevalence, outcomes, and therapies study. Am J Respir Crit Care Med 2015; 191 (10) 1147-1157 Erratum in: Am J Respir Crit Care Med 2016;193(2):223–4. PMID: 25734408; PMCID: PMC4451622
  • 2 Evans IVR, Phillips GS, Alpern ER. et al. Association between the New York sepsis care mandate and in-hospital mortality for pediatric sepsis. JAMA 2018; 320 (04) 358-367
  • 3 Weiss SL, Fitzgerald JC, Balamuth F. et al. Delayed antimicrobial therapy increases mortality and organ dysfunction duration in pediatric sepsis. Crit Care Med 2014; 42 (11) 2409-2417
  • 4 Lane RD, Funai T, Reeder R, Larsen GY. High reliability pediatric septic shock quality improvement initiative and decreasing mortality. Pediatrics 2016; 138 (04) e20154153
  • 5 van Paridon BM, Sheppard C, , G GG, Joffe AR. Alberta Sepsis Network. Timing of antibiotics, volume, and vasoactive infusions in children with sepsis admitted to intensive care. Crit Care 2015; 19: 293
  • 6 Weiss SL, Peters MJ, Alhazzani W. et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Pediatr Crit Care Med 2020; 21 (02) e52-e106
  • 7 Leigh S, Grant A, Murray N. et al. The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department. BMC Med 2019; 17 (01) 48
  • 8 Schlapbach LJ, Weiss SL, Wolf J. Reducing collateral damage from mandates for time to antibiotics in pediatric sepsis-primum non nocere. JAMA Pediatr 2019; 173 (05) 409-410
  • 9 Goldstein B, Giroir B, Randolph A. International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6 (01) 2-8
  • 10 Scott HF, Deakyne SJ, Woods JM, Bajaj L. The prevalence and diagnostic utility of systemic inflammatory response syndrome vital signs in a pediatric emergency department. Acad Emerg Med 2015; 22 (04) 381-389
  • 11 Weiss SL, Fitzgerald JC, Maffei FA. et al; SPROUT Study Investigators and Pediatric Acute Lung Injury and Sepsis Investigators Network. Discordant identification of pediatric severe sepsis by research and clinical definitions in the SPROUT international point prevalence study. Crit Care 2015; 19 (01) 325
  • 12 Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R. Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med 2015; 372 (17) 1629-1638
  • 13 Wee BYH, Lee JH, Mok YH, Chong SL. A narrative review of heart rate and variability in sepsis. Ann Transl Med 2020; 8 (12) 768
  • 14 Singer M, Deutschman CS, Seymour CW. et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315 (08) 801-810
  • 15 Matics TJ, Sanchez-Pinto LN. Adaptation and validation of a pediatric sequential organ failure assessment score and evaluation of the sepsis-3 definitions in critically ill children. JAMA Pediatr 2017; 171 (10) e172352
  • 16 Larsen GY, Brilli R, Macias CG. et al; IMPROVING PEDIATRIC SEPSIS OUTCOMES COLLABORATIVE INVESTIGATORS. Development of a quality improvement learning collaborative to improve pediatric sepsis outcomes. Pediatrics 2021; 147 (01) e20201434
  • 17 Mohamed El-Mashad G, Said El-Mekkawy M, Helmy Zayan M. Paediatric sequential organ failure assessment (pSOFA) score: A new mortality prediction score in the paediatric intensive care unit. An Pediatr (Engl Ed) 2020; 92 (05) 277-285
  • 18 Kim K, Kim S, Lee JW, Yoon JS, Chung NG, Cho B. Prognostic factors of ICU mortality in pediatric oncology patients with pulmonary complications. J Pediatr Hematol Oncol 2020; 42 (04) 266-270
  • 19 Lalitha AV, Satish JK, Reddy M, Ghosh S, George J, Pujari C. Sequential organ failure assessment score as a predictor of outcome in sepsis in pediatric intensive care unit. J Pediatr Intensive Care 2021; 10 (02) 110-117
  • 20 Wu Z, Liang Y, Li Z. et al. Accuracy comparison between age-adapted SOFA and SIRS in predicting in-hospital mortality of infected children at China's PICU. Shock 2019; 52 (03) 347-352
  • 21 Scott HF, Brilli RJ, Paul R. et al; Improving Pediatric Sepsis Outcomes (IPSO) Collaborative Investigators.. Evaluating pediatric sepsis definitions designed for electronic health record extraction and multicenter quality improvement. Crit Care Med 2020; 48 (10) e916-e926
  • 22 Menon K, Schlapbach LJ, Akech S. et al; Pediatric Sepsis Definition Taskforce of the Society of Critical Care Medicine. Criteria for pediatric sepsis—a systematic review and meta-analysis by the pediatric sepsis definition taskforce. Crit Care Med 2022; 50 (01) 21-36