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Refractory septic shock in children: a European Society of Paediatric and Neonatal Intensive Care definition
Luc Morin1, Samiran Ray2, Clare Wilson3
1Paediatric Intensive Care Unit, Paris South University Hospitals, AP-HP, 78 Rue du General Leclerc, 94275, Le Kremlin-Bicêtre, France.
Insights
Refractory septic shock (RSS) in children has high mortality. A new European Society of Paediatric and Neonatal Intensive Care (ESPNIC) definition, based on myocardial dysfunction and high lactate despite vasopressors, accurately identifies severe cases.
Area of Science:
- Pediatric critical care medicine
- Neonatal intensive care
- Septic shock research
Background:
- Refractory septic shock (RSS) in children carries a high mortality rate, necessitating improved diagnostic criteria.
- Existing definitions for RSS are insufficient for timely identification and treatment initiation.
Purpose of the Study:
- To establish a consensus definition for pediatric refractory septic shock (RSS) by European experts.
- To develop and validate clinical criteria for identifying severe pediatric septic shock.
Main Methods:
- A two-round Delphi study involving 114 pediatric intensivists to identify key RSS indicators.
- Multivariate analysis and retrospective multicenter studies (development and validation cohorts) to create and test RSS severity scores.
Main Results:
- The Delphi process identified myocardial dysfunction and high lactate levels despite vasopressor use as key RSS indicators.
- Developed bedside and computed scores demonstrated high discriminative power for predicting extracorporeal life support (ECLS) or death (AUCs 0.920 and 0.956).
- The ESPNIC definition, using specific score thresholds, significantly correlated with increased mortality.
Conclusions:
- The newly established ESPNIC definition effectively identifies pediatric patients with the most severe form of septic shock.
- This definition aids in earlier recognition and management of pediatric refractory septic shock.
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.