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The Epidemiology of Hospital Death Following Pediatric Severe Sepsis: When, Why, and How Children With Sepsis Die*

Weiss, Scott L. MD, MSCE1; Balamuth, Fran MD, PhD, MSCE2; Hensley, Josey RN3; Fitzgerald, Julie C. MD, PhD1; Bush, Jenny RNC1; Nadkarni, Vinay M. MD, MS1; Thomas, Neal J. MD, MSc4; Hall, Mark MD3; Muszynski, Jennifer MD3

Pediatric Critical Care Medicine: September 2017 - Volume 18 - Issue 9 - p 823-830
doi: 10.1097/PCC.0000000000001222
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Objective: The epidemiology of in-hospital death after pediatric sepsis has not been well characterized. We investigated the timing, cause, mode, and attribution of death in children with severe sepsis, hypothesizing that refractory shock leading to early death is rare in the current era.

Design: Retrospective observational study.

Setting: Emergency departments and ICUs at two academic children’s hospitals.

Patients: Seventy-nine patients less than 18 years old treated for severe sepsis/septic shock in 2012–2013 who died prior to hospital discharge.

Interventions: None.

Measurements and Main Results: Time to death from sepsis recognition, cause and mode of death, and attribution of death to sepsis were determined from medical records. Organ dysfunction was assessed via daily Pediatric Logistic Organ Dysfunction-2 scores for 7 days preceding death with an increase greater than or equal to 5 defined as worsening organ dysfunction. The median time to death was 8 days (interquartile range, 1–12 d) with 25%, 35%, and 49% of cumulative deaths within 1, 3, and 7 days of sepsis recognition, respectively. The most common cause of death was refractory shock (34%), then multiple organ dysfunction syndrome after shock recovery (27%), neurologic injury (19%), single-organ respiratory failure (9%), and nonseptic comorbidity (6%). Early deaths (≤ 3 d) were mostly due to refractory shock in young, previously healthy patients while multiple organ dysfunction syndrome predominated after 3 days. Mode of death was withdrawal in 72%, unsuccessful cardiopulmonary resuscitation in 22%, and irreversible loss of neurologic function in 6%. Ninety percent of deaths were attributable to acute or chronic manifestations of sepsis. Only 23% had a rise in Pediatric Logistic Organ Dysfunction-2 that indicated worsening organ dysfunction.

Conclusions: Refractory shock remains a common cause of death in pediatric sepsis, especially for early deaths. Later deaths were mostly attributable to multiple organ dysfunction syndrome, neurologic, and respiratory failure after life-sustaining therapies were limited. A pattern of persistent, rather than worsening, organ dysfunction preceded most deaths.

1Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

2Division of Emergency Medicine, Department of Pediatrics, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

3Division of Critical Care Medicine, Nationwide Children’s Hospital, The Ohio State University School of Medicine, Columbus, OH.

4Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children’s Hospital, Penn State University College of Medicine, Hershey, PA.

*See also p. 891.

This study was performed at the Children’s Hospital of Philadelphia and Nationwide Children’s Hospital.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

Supported, in part, by the Department of Anesthesiology and Critical Care at the Children’s Hospital of Philadelphia. Dr. Weiss is also supported by National Institute of General Medical Science K23-GM110496. Dr. Balamuth is also supported by National Institute of Child Health and Human Development K23-HD082368. Dr. Muszynski is also supported by National Heart, Lung, and Blood Institute K08-HL123925.

Dr. Weiss’ institution received funding from National Institute of General Medical Science K23-GM110496; he received support for article research from the National Institutes of Health (NIH); and he received funding from ThermoFisher Scientific (honorarium for lecture). Dr. Balamuth’s institution received funding from the NIH, and she received support for article research from the NIH. Dr. Thomas’ institution received funding from the Food and Drug Administration, and he received funding from Therabron and CareFusion. Dr. Muszynski’s institution received funding from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Scott L. Weiss, MD, MSCE, Assistant Professor of Critical Care and Pediatrics, Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. E-mail: WeissS@email.chop.edu

Copyright © 2017 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies