EJRC Article Review

Paediatric sepsis definitions are based upon expert consensus from the International Paediatric Sepsis Consensus Conference [1]. The adult Sepsis-3 update on definitions has changed how patients with sepsis are identified, thus impacting on the research and quality indicators associated with its management [2].

Schlapbach et al. compared the performance of SIRS, age-adapted SOFA, quick SOFA (qSOFA) and PELOD-2 as outcome predictors in children [3]. Using data from the ANZICS registry, a multicentre cohort of patients who were under 18 years and admitted with infection in Australia and New Zealand from 2000 to 2016 were evaluated. Primary outcome was defined as in-hospital mortality, with secondary outcome a composite of in-hospital mortality or ICU length of stay 3 days or longer. The investigators developed an age-adapted SOFA score using PELOD-2 criteria (assessing organ dysfunction), and qSOFA (altered mentation, arterial hypotension and tachypnoea) was adapted using the 2005 consensus statement definitions.

There were 2271 PICU admission encounters for confirmed or suspected infection with complete SIRS data on the registry, with median age of 13 years. Overall mortality was 5.8%, with 36.6% reaching the composite secondary outcome. 81.8% of children met at least 2 SIRS criteria at the time of admission. 58.3% were classified as severe sepsis, with mortality of 7.4%.

• AUROC analysis for in-hospital mortality favoured both the SOFA score and PELOD-2 scores over the SIRS/severe sepsis/qSOFA definitions (p<0.001).
• PELOD-2 offers highest discrimination for the composite secondary outcome.
• Binary performance was best for a PELOD-2 score of >

The strength of this large study relates to applying stringent data-driven validation procedures to allow comparison of currently used assessment for prognostic scores. ANZICS and ANZPIC registry data are prospective and provide a broad spectrum of hospital settings where patients <18 years are admitted.

Its main weakness is that the analysed dataset dates from before the introduction of the 2005 consensus statement, where some important measurements such as lactate were lacking. The infant group is under-represented in this cohort. Given the biggest physiological differences are likely to be seen in this group, the PELOD-2’s discriminatory capabilities may have been underestimated. 

Take Home Messages

• PELOD-2 score has the best validity in predicting mortality in children with infection.
• Age-specific SOFA translation of sepsis-3 definitions appears to offer more clinical value (to characterise organ dysfunction) than qSOFA as a screening tool.
• SIRS performs poorly to discriminate children with infection at substantially higher mortality risk.

This article review was prepared by Dr Charlotte BRIAR and Dr Amy CHAN-DOMINY (EJRC member), Paediatric Intensive Care Unit, Royal Brompton & Harefield NHS Foundation Trust, London, on behalf of the ESICM Journal Review Club.

References

[1] Goldstein B, Giroir B, Randolph A (2005) International paediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in paediatrics. Paediatr Crit Care Med 6:2–8

[2] Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM, Hotchkiss RS, Levy MM, Marshall JC, Martin GS, Opal SM, Rubenfeld GD, van der Poll T, Vincent JL, Angus DC (2016) The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 315:801–810 – OPEN ACCESS

[3] Schlapbach LJ, Straney L, Bellomo R, MacLaren G, Pilcher D. Prognostic accuracy of age‑adapted SOFA, SIRS, PELOD‑2, and qSOFA for in‑hospital mortality among children with suspected infection admitted to the intensive care unit. Int Care Med 2018; 44(2): 179-88 – OPEN ACCESS