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Predicting Delayed Shock in Multisystem Inflammatory Disease in Children: A Multicenter Analysis From the New York
Deborah A Levine1, Vincent Uy1, William Krief2
1From the Departments of Emergency Medicine and Pediatrics, NewYork-Presbyterian/Weill Cornell Medicine, New York.
Insights
Predicting delayed shock in children with multisystem inflammatory disease (MIS-C) is crucial. Elevated C-reactive protein, low lymphocyte percentage, and low platelet count are key indicators of shock risk in MIS-C patients.
Area of Science:
- Pediatric critical care medicine
- Pediatric infectious diseases
- Pediatric rheumatology
Background:
- Multisystem inflammatory disease in children (MIS-C) can lead to shock, a critical complication.
- Early identification of patients at risk for delayed shock is essential for timely intervention.
- Predicting shock development in MIS-C is challenging due to its complex presentation.
Purpose of the Study:
- To identify independent predictors of delayed shock (≥3 hours from ED arrival) in MIS-C patients.
- To develop a predictive model for identifying MIS-C patients at low risk of delayed shock.
- To improve risk stratification and guide clinical management of MIS-C.
Main Methods:
- Retrospective cross-sectional study across 22 pediatric emergency departments.
- Inclusion of patients meeting WHO criteria for MIS-C from April to June 2020.
- Analysis of clinical and laboratory factors associated with delayed shock development.
Main Results:
- Of 248 MIS-C patients, 35% experienced shock, with 66% of those developing delayed shock.
- Independent predictors for delayed shock included CRP > 20 mg/dL, lymphocyte percent < 11%, and platelet count < 220,000/uL.
- A low-risk prediction model (CRP < 6 mg/dL, lymphocyte percent > 20%, platelet count > 260,000/uL) showed 93% sensitivity for identifying patients not progressing to delayed shock.
Conclusions:
- Serum CRP, lymphocyte percentage, and platelet count effectively differentiate risk for delayed shock in MIS-C.
- These laboratory markers can stratify MIS-C patients by shock progression risk.
- The findings aid in situational awareness and guiding the level of care for MIS-C patients.
Objectives:
Patients with multisystem inflammatory disease in children (MIS-C) are at risk of developing shock. Our objectives were to determine independent predictors associated with development of delayed shock (≥3 hours from emergency department [ED] arrival) in patients with MIS-C and to derive a model predicting those at low risk for delayed shock.
Methods:
We conducted a retrospective cross-sectional study of 22 pediatric EDs in the New York City tri-state area. We included patients meeting World Health Organization criteria for MIS-C and presented April 1 to June 30, 2020. Our main outcomes were to determine the association between clinical and laboratory factors to the development of delayed shock and to derive a laboratory-based prediction model based on identified independent predictors.
Results:
Of 248 children with MIS-C, 87 (35%) had shock and 58 (66%) had delayed shock. A C-reactive protein (CRP) level greater than 20 mg/dL (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.4-12.1), lymphocyte percent less than 11% (aOR, 3.8; 95% CI, 1.7-8.6), and platelet count less than 220,000/uL (aOR, 4.2; 95% CI, 1.8-9.8) were independently associated with delayed shock. A prediction model including a CRP level less than 6 mg/dL, lymphocyte percent more than 20%, and platelet count more than 260,000/uL, categorized patients with MIS-C at low risk of developing delayed shock (sensitivity 93% [95% CI, 66-100], specificity 38% [95% CI, 22-55]).
Conclusions:
Serum CRP, lymphocyte percent, and platelet count differentiated children at higher and lower risk for developing delayed shock. Use of these data can stratify the risk of progression to shock in patients with MIS-C, providing situational awareness and helping guide their level of care.
