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Comparison of Pediatric Severe Sepsis Managed in U.S. and European ICUs
John S Giuliano1, Barry P Markovitz, Joe Brierley
11Division of Critical Care Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT. 2Division of Pediatric Critical Care, Departments of Pediatrics and Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA. 3Department of Critical Care and Bioethics, Great Ormond Street Hospital NHS Trust, London, United Kingdom. 4Department of Pediatrics, Royal Hospital for Children, Glasgow, Scotland. 5Intensive Care Department, Sydney Children's Hospital, Randwick, NSW, Australia. 6Department of Pediatrics, University of Malaya Medical Center, Kuala Lumpur, Malaysia. 7Paediatric Intensive Care Unit, Division of Paediatric Critical Care, Department of Pediatrics, Lady Cilento Children's Hospital, Brisbane, QLD, Australia. 8Department of Pediatric Intensive Care, Hospital El Carmen de Maipu, Universidad Andres Bello, Santiago, Chile. 9Division of Critical Care Medicine, Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 10Department of Political Science, Penn State University, University Park, PA. 11Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children's Hospital, Penn State University College of Medicine, Hershey, PA.
Insights
Pediatric severe sepsis management varies between European and U.S. pediatric intensive care units (PICUs). Despite differences in patient severity and therapies, adjusted outcomes for severe sepsis in children were similar across regions.
Area of Science:
- Pediatric critical care medicine
- Infectious diseases
- Epidemiology
Background:
- Pediatric severe sepsis is a major global health concern with limited therapeutic advancements.
- Existing multicenter clinical trials have not yielded new therapies for pediatric severe sepsis.
- Geographic variations in management may influence outcomes and trial design.
Purpose of the Study:
- To compare the management of pediatric severe sepsis in European and U.S. pediatric intensive care units (PICUs).
- To identify geographic variations in patient characteristics, therapies, and outcomes.
- To inform the design of future international clinical studies on pediatric severe sepsis.
Main Methods:
- Secondary analysis of the Sepsis PRevalence, OUtcomes, and Therapies (SPROUT) study.
- Comparison of PICU characteristics, patient demographics, therapies, and outcomes between European and U.S. PICUs.
- Multivariable regression models to adjust for patient characteristics and determine differences in morbidity and mortality.
Main Results:
- European PICUs were smaller and managed younger patients with higher illness severity, often admitted from wards.
- European patients received more frequent invasive mechanical ventilation, central venous access, and vasoactive infusions.
- After adjustment for patient characteristics, no significant differences in mortality or morbidity were found between European and U.S. PICUs.
Conclusions:
- Children with severe sepsis in European PICUs exhibit higher illness severity and receive more intensive therapies compared to U.S. PICUs.
- Despite treatment intensity differences, adjusted morbidity and mortality rates for pediatric severe sepsis are comparable between European and U.S. PICUs.
- Future international trials for pediatric severe sepsis should consider regional care approaches and potential factors like PICU bed availability.
Objectives:
Pediatric severe sepsis remains a significant global health problem without new therapies despite many multicenter clinical trials. We compared children managed with severe sepsis in European and U.S. PICUs to identify geographic variation, which may improve the design of future international studies.
Design:
We conducted a secondary analysis of the Sepsis PRevalence, OUtcomes, and Therapies study. Data about PICU characteristics, patient demographics, therapies, and outcomes were compared. Multivariable regression models were used to determine adjusted differences in morbidity and mortality.
Setting:
European and U.S. PICUs.
Patients:
Children with severe sepsis managed in European and U.S. PICUs enrolled in the Sepsis PRevalence, OUtcomes, and Therapies study.
Interventions:
None.
Measurements And Main Results:
European PICUs had fewer beds (median, 11 vs 24; p < 0.001). European patients were younger (median, 1 vs 6 yr; p < 0.001), had higher severity of illness (median Pediatric Index of Mortality-3, 5.0 vs 3.8; p = 0.02), and were more often admitted from the ward (37% vs 24%). Invasive mechanical ventilation, central venous access, and vasoactive infusions were used more frequently in European patients (85% vs 68%, p = 0.002; 91% vs 82%, p = 0.05; and 71% vs 50%; p < 0.001, respectively). Raw morbidity and mortality outcomes were worse for European compared with U.S. patients, but after adjusting for patient characteristics, there were no significant differences in mortality, multiple organ dysfunction, disability at discharge, length of stay, or ventilator/vasoactive-free days.
Conclusions:
Children with severe sepsis admitted to European PICUs have higher severity of illness, are more likely to be admitted from hospital wards, and receive more intensive care therapies than in the United States. The lack of significant differences in morbidity and mortality after adjusting for patient characteristics suggests that the approach to care between regions, perhaps related to PICU bed availability, needs to be considered in the design of future international clinical trials in pediatric severe sepsis.
