IMPORTANCE: The death of a pediatric patient with sepsis motivated New York to mandate statewide sepsis treatment in 2013. The mandate included a 1-hour bundle of blood cultures, broad-spectrum ...antibiotics, and a 20-mL/kg intravenous fluid bolus. Whether completing the bundle elements within 1 hour improves outcomes is unclear. OBJECTIVE: To determine the risk-adjusted association between completing the 1-hour pediatric sepsis bundle and individual bundle elements with in-hospital mortality. DESIGN, SETTINGS, AND PARTICIPANTS: Statewide cohort study conducted from April 1, 2014, to December 31, 2016, in emergency departments, inpatient units, and intensive care units across New York State. A total of 1179 patients aged 18 years and younger with sepsis and septic shock reported to the New York State Department of Health who had a sepsis protocol initiated were included. EXPOSURES: Completion of a 1-hour sepsis bundle within 1 hour compared with not completing the 1-hour sepsis bundle within 1 hour. MAIN OUTCOMES AND MEASURES: Risk-adjusted in-hospital mortality. RESULTS: Of 1179 patients with sepsis reported at 54 hospitals (mean SD age, 7.2 6.2 years; male, 54.2%; previously healthy, 44.5%; diagnosed as having shock, 68.8%), 139 (11.8%) died. The entire sepsis bundle was completed in 1 hour in 294 patients (24.9%). Antibiotics were administered to 798 patients (67.7%), blood cultures were obtained in 740 patients (62.8%), and the fluid bolus was completed in 548 patients (46.5%) within 1 hour. Completion of the entire bundle within 1 hour was associated with lower risk-adjusted odds of in-hospital mortality (odds ratio OR, 0.59 95% CI, 0.38 to 0.93, P = .02; predicted risk difference RD, 4.0% 95% CI, 0.9% to 7.0%). However, completion of each individual bundle element within 1 hour was not significantly associated with lower risk-adjusted mortality (blood culture: OR, 0.73 95% CI, 0.51 to 1.06, P = .10; RD, 2.6% 95% CI, −0.5% to 5.7%; antibiotics: OR, 0.78 95% CI, 0.55 to 1.12, P = .18; RD, 2.1% 95% CI, −1.1% to 5.2%, and fluid bolus: OR, 0.88 95% CI, 0.56 to 1.37, P = .56; RD, 1.1% 95% CI, −2.6% to 4.8%). CONCLUSIONS AND RELEVANCE: In New York State following a mandate for sepsis care, completion of a sepsis bundle within 1 hour compared with not completing the 1-hour sepsis bundle within 1 hour was associated with lower risk-adjusted in-hospital mortality among patients with pediatric sepsis and septic shock.
To determine the associations of demographic, clinical, laboratory, organ dysfunction, and illness severity variable values with: 1) sepsis, severe sepsis, or septic shock in children with infection ...and 2) multiple organ dysfunction or death in children with sepsis, severe sepsis, or septic shock.
MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020.
Case-control studies, cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years with suspected or confirmed infection, which included the terms "sepsis," "septicemia," or "septic shock" in the title or abstract.
Study characteristics, patient demographics, clinical signs or interventions, laboratory values, organ dysfunction measures, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed.
One hundred and six studies met eligibility criteria of which 81 were included in the meta-analysis. Sixteen studies (9,629 patients) provided data for the sepsis, severe sepsis, or septic shock outcome and 71 studies (154,674 patients) for the mortality outcome. In children with infection, decreased level of consciousness and higher Pediatric Risk of Mortality scores were associated with sepsis/severe sepsis. In children with sepsis/severe sepsis/septic shock, chronic conditions, oncologic diagnosis, use of vasoactive/inotropic agents, mechanical ventilation, serum lactate, platelet count, fibrinogen, procalcitonin, multi-organ dysfunction syndrome, Pediatric Logistic Organ Dysfunction score, Pediatric Index of Mortality-3, and Pediatric Risk of Mortality score each demonstrated significant and consistent associations with mortality. Pooled mortality rates varied among high-, upper middle-, and lower middle-income countries for patients with sepsis, severe sepsis, and septic shock (p < 0.0001).
Strong associations of several markers of organ dysfunction with the outcomes of interest among infected and septic children support their inclusion in the data validation phase of the Pediatric Sepsis Definition Taskforce.
In 2012, Rory Staunton, a healthy 12-year-old boy, presented to the emergency department (ED) of a community hospital in New York with symptoms that, in retrospect, were determined to be caused by ...sepsis. He was seen, discharged, and subsequently died of septic shock. Consequently, the governor introduced Rory’s Regulations, which mandated that hospitals in New York implement protocols to recognize and treat sepsis according to evidence-based guidelines. These efforts may result in large public health benefits for patients.
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However, crucial to Rory’s case was that his diagnosis was missed. Efforts to avoid missed or delayed diagnosis are greatly enhanced by knowledge of the frequency and course of similar cases, yet such data are unknown. We therefore examined the electronic health records of healthy adolescents who presented to 12 community hospital EDs in southwestern Pennsylvania during the same period (January 1, 2010, through December 31, 2012) with signs and symptoms similar to those of Rory Staunton.
Following initial stabilization, critically ill children often require transfer to a specialized pediatric hospital. While the use of specialized pediatric transport teams has been associated with ...improved outcomes for these patients, the additional influence of transfer mode (helicopter or ground ambulance) on clinical outcomes remains unknown.
We investigated the association between transport mode and outcomes among critically ill children transferred to a single pediatric hospital via a specialized pediatric transport team. We designed a retrospective cohort study to reduce indication bias by limiting analysis to patients for whom a helicopter transport was initially requested. We compared outcomes for those who ultimately traveled via helicopter, and for those who ultimately traveled via ground ambulance due to non-clinical factors.
We compared transport times, in-hospital mortality, and hospital length of stay by transport mode. Transport time in minutes was shorter for helicopter transports (median = 143, interquartile range IQR: 118–184) compared to ground ambulance transports (median = 289, IQR: 213–258; difference in medians = 146, 95% CI: 12 to 168, p < 0.001). In unadjusted analysis, helicopter transport was not associated with a difference in in-hospital mortality (helicopter = 6.0%, ground ambulance = 7.0%; 95% CI for difference: −6.6% to 3.3%; p = 0.64) but was associated with a statistically significant reduction in median hospital days (helicopter = 4, ground ambulance = 5; 95% CI -3 to 0; p = 0.04). In adjusted analyses, there were no statistically significant associations. These results were consistent across sensitivity analyses.
Among critically ill pediatric patients without traumatic injuries transported by a specialty team, those patients who would have been transferred by helicopter if available but were instead transferred by ground ambulance reached their site of definitive care approximately 2.5 h later. Helicopter transport for these patients was not associated with in-hospital mortality, but was potentially associated with reduced hospital length of stay.
•For critically ill children, helicopter transport to definitive care is faster.•While faster, helicopter transport is not associated with reduced mortality.•Helicopter transport may be associated with reduced hospital length of stay.
Objective
Social health is an important component of recovery following critical illness as modeled in the pediatric Post-Intensive Care Syndrome framework. We conducted a scoping review of studies ...measuring social outcomes (measurable components of social health) following pediatric critical illness and propose a conceptual framework of the social outcomes measured in these studies.
Data sources
PubMed, EMBASE, PsycINFO, CINAHL, and the Cochrane Registry
Study selection
We identified studies evaluating social outcomes in pediatric intensive care unit (PICU) survivors or their families from 1970–2017 as part of a broader scoping review of outcomes after pediatric critical illness.
Data extraction
We identified articles by dual review and dual-extracted study characteristics, instruments, and instrument validation and administration information. For instruments used in studies evaluating a social outcome, we collected instrument content and described it using qualitative methods adapted to a scoping review.
Data synthesis
Of 407 articles identified in the scoping review, 223 (55%) evaluated a social outcome. The majority were conducted in North America and the United Kingdom, with wide variation in methodology and population. Among these studies, 38 unique instruments were used to evaluate a social outcome. Specific social outcomes measured included individual (independence, attachment, empathy, social behaviors, social cognition, and social interest), environmental (community perceptions and environment), and network (activities and relationships) characteristics, together with school and family outcomes. While many instruments assessed more than one social outcome, no instrument evaluated all areas of social outcome.
Conclusions
The full range of social outcomes reported following pediatric critical illness were not captured by any single instrument. The lack of a comprehensive instrument focused on social outcomes may contribute to under-appreciation of the importance of social outcomes and their under-representation in PICU outcomes research. A more comprehensive evaluation of social outcomes will improve understanding of overall recovery following pediatric critical illness.
Although sleep problems are thought to be prevalent among patients who undergo dialysis, there is only limited information on the determinants of sleep quality and the change in sleep quality during ...the first year of dialysis treatment. This report uses data from a national cohort study of incident hemodialysis and peritoneal dialysis patients to identify the correlates of sleep quality and to determine the extent to which sleep quality is related to patients' health-related quality of life and survival. This report includes 909 incident dialysis patients who responded to questions about sleep quality. Three quarters of incident dialysis patients reported impaired sleep, and 14% had a decline in sleep quality in the first year of treatment. Poor sleep quality was significantly related to black race, higher serum phosphate, current smoking, benzodiazepine prescription, and complaints of severe restless legs. Poor baseline sleep quality was associated with lower SF-36 physical and mental component summary scores, vitality scores, and bodily pain scores (all P < 0.001). Younger age, current smoking, and benzodiazepine prescription were associated with decreases in sleep quality at 1 yr. There was no association between baseline sleep quality and survival; however, a decline in sleep quality during the first year on dialysis was associated with shorter survival (hazard ratio 1.44; 95% confidence interval 1.13 to 1.83; P = 0.003). Future work should examine the link between sleep quality and daytime functioning in the kidney failure population and the extent to which improving sleep quality will improve dialysis patient outcomes.
Background:
Skipping hemodialysis treatments and failing to adhere to prescribed diets are thought to injure hemodialysis patients.
Methods:
We examined predictors of hemodialysis skipping and ...laboratory measures of nonadherence and then examined the association of dialysis skipping and serum potassium and phosphate levels with survival.
Results:
Of 739 patients, 67 were classified as skippers because they were absent for greater than 3% of scheduled treatments. Black race (odds ratio OR, 2.26; 95% confidence interval CI, 1.30 to 3.92), current smoking (OR, 1.79; 95% CI, 1.02 to 3.13), and use of illicit drugs (OR, 3.96; 95% CI, 2.16 to 7.24) were associated with skipping. White race, increased serum phosphate level, greater creatinine level, and lower body mass index increased the likelihood of a serum potassium level greater than 5.0 mEq/L (mmol/L); younger age, greater serum potassium level, and greater serum creatinine level were associated with a serum phosphate level greater than 5.5 mg/dL (>1.78 mmol/L). Skipping was associated with an increased risk for death (hazard ratio HR, 1.69; 95% CI, 1.24 to 2.31), as were phosphate level greater than 5.5 mg/dL (HR, 1.59; 95% CI, 1.16 to 2.17) and potassium level greater than 5.0 mEq/L (HR, 1.50; 95% CI, 1.10 to 2.06). Skipping was associated with a lower likelihood of kidney transplantation in those younger than 65 years (OR, 0.41; 95% CI, 0.18 to 0.93).
Conclusion:
These findings show that hemodialysis patients of black race and those with current tobacco or illicit drug use are at risk for skipping dialysis treatments. Skipping treatments and markers of poor dietary adherence are strongly associated with greater risk for death. Targeting high-risk patients to understand reasons for nonadherence and to intervene could prevent premature death.
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