Refractory septic shock in children: a ESPNIC definition

Despite the overall decreasing mortality in paediatric patients with sepsis in recent years, refractory septic shock (RSS) that is unresponsive to standard resuscitation is still associated with very poor outcomes. The recent Sepsis-3 consensus redefined adult sepsis and septic shock according to their associated mortality risk, aiming at early recognition and management. Unfortunately, paediatric organ dysfunction scores to date have failed at these aims, warranting revision of current paediatric sepsis and septic shock definitions.

This article, recently published in Intensive Care Medicine, describes the development of the first paediatric septic shock scores aimed at diagnosing RSS in PICU patients. A taskforce designated by the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) conducted a clinical case-based, two-round Delphi survey amongst 114 paediatric intensivists to identify clinical features of RSS and draft a definition. This was then applied to a single-centre cohort, leading to development of a RSS definition based on either a computed or a bedside septic shock score (cSSS and bSSS). Both scores were subsequently validated in a multicentre retrospective cohort.

The draft definition of RSS included an association of myocardial dysfunction, hyperlactataemia and high vaso-inotrope support. These three variables were independently associated with death or the need for extracorporeal life support (ECLS) in the single-centre cohort. A cSSS ≥3.5 and bSSS ≥2 were highly discriminative of both outcomes in the validation cohort, with AUC of 0.956 and 0.920 respectively. Myocardial dysfunction posed the highest weight to both scores.

This manuscript provides the first paediatric RSS definition, based on two scores strongly discriminative of death or need of ECLS. The cSSS may be a very useful tool to compare populations in future multicentre clinical trials. Additionally, the bSSS could facilitate selection of the sickest patients that may benefit from a rescue therapy. Unfortunately, we are still lacking a score able to detect children at highest risk of death at presentation to guide early management.

Take home messages:

  • Myocardial dysfunction, high lactate and high vaso-inotrope support are strong independent predictors of death or need for ECLS.
  • Both RSS scores can be useful epidemiological tools for future clinical interventional trials. 
  • A Sepsis 3-like score is still lacking to facilitate early recognition and management of sepsis and septic shock in children.

Article review submitted by Cecilia Korb and Angela Aramburoon behalf of the ESICM Journal Review Club (EJRC).


References

Morin L et al. Refractory septic shock in children: a European Society of Paediatric and Neonatal Intensive Care definition.
Intensive Care Med. 2016 Dec;42(12):1948-1957. Epub 2016 Oct 5. DOI/10.1007/s00134-016-4574-2 (OPEN ACCESS)

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