Each month Pediatric Critical Care Medicine publishes a number of print and online articles. All pages are worth reading. Yet, many readers only have time to look at select content; usually research work focusing on a field of personal interest, or general reviews and special articles. Therefore, I am pleased to highlight for all readers my Editor’s Choice of three articles in the January 2021 issue, which are on the theme of late outcomes in pediatric intensive care unit (PICU) patients (1–3). The first two articles examine the trajectory of functional outcome after PICU discharge (1,2). The third article is about patients with sepsis and links this trajectory in post-intensive care outcome to illness-related changes in serum biomarker levels (3). All three articles will be freely available for one month.
What is the “functional outcome” 6 months after PICU discharge with a new morbidity?
Pollack MM, Banks R, Holubkov R, et al: Long-Term Outcomes of PICU Patients Discharged With New, Functional Status Morbidity (1).
The Functional Status Score (4) and a clinical prediction model of mortality or survival (with or without new morbidity) at PICU discharge (5) were developed in studies of over 10,000 patients. These investigators now report 6-month follow-up in a subgroup of 127 patients with new morbidity at hospital discharge (1). In general, assessing prognosis at PICU discharge is not informative: close to 1-in-3 patients will die or develop new morbidity, but there is improvement in many other survivors.
When severe sepsis causes “new disability”, is there improvement 1 year later?
Sankar J, Moodu S, Kumar K, et al: Functional Outcomes at 1 Year After PICU Discharge in Critically Ill Children With Severe Sepsis (2).
This article examines the same idea as the first article (1)–longitudinal outcome in those with “new disability” at PICU discharge (2). Here, however, the focus is what happens 3- and 12-months after severe sepsis in a cohort of 70 patients with new disability during illness. Serial assessments after sepsis show a trajectory of recovery similar to that observed in the general PICU cohort (1).
Is “persistent, serious deterioration of health-related quality-of-life” 3 months after septic shock associated with serum biomarker levels during illness?
Wong HR, Reeder RW, Banks R, et al: Biomarkers for Estimating Risk of Hospital Mortality and Long-Term Quality of Life Morbidity After Surviving Pediatric Septic Shock: A Secondary Analysis of the Life After Pediatric Sepsis Evaluation Investigation (3).
Two lines of investigations–the Life after Pediatric Sepsis Evaluation (LAPSE) (6) and the Pediatric Sepsis Biomarker Risk Model (7)–come together in the third article (3). We already know much about the LAPSE cohort of 389 patients with community-acquired septic shock. For example, recent secondary analyses showed: 1) in 204 children, the trajectory in physical and psychosocial health-related quality-of-life (HRQL) over the first year (8); and 2) in 179 children, the associations between acute physiologic derangement, renal dysfunction and HRQL at 3 months (9). Like the other two Editor’s Choice articles on trajectory of recovery (1,2), many of the LAPSE cohort recovered (8). Now, we read about another secondary analysis in a subset of 117 LAPSE study patients in whom HRQL evaluation at 3 months was assessed along with blood biomarker levels during illness (3). (These biomarkers reflect potential states of inflammation, innate immune response, cell stress and death, and tissue breakdown.) The composite biomarker analyses showed association with 3-month HRQL. The implication of these results is further discussed in an accompanying editorial (10).
These three articles are my Editor’s Choice because the new information about time course of recovery after critical illness in those with morbidities should make a difference to how we view future work on clinical performance and quality metrics, patient-related outcomes, and clinical trials (1,2). The studies add to a body of knowledge that shows we cannot continue to use “new morbidity” at PICU discharge as a meaningful or reliable guide to later outcome. Finally, studying the combination of biomarker analyses and acute physiologic abnormality during septic shock (3,10), along with later outcomes assessments, may provide insights into treatment targets and a better understanding of the elusive sepsis-associated encephalopathy.
1. Pollack MM, Banks R, Holubkov R, et al. Long-Term Outcomes of PICU Patients Discharged With New, Functional Status Morbidity. Pediatr Crit Care Med. 2021; 22:27–39
2. Sankar J, Moodu S, Kumar K, et al. Functional Outcomes at 1 Year After PICU Discharge in Critically Ill Children With Severe Sepsis. Pediatr Crit Care Med. 2021; 22:40–49
3. Wong HR, Reeder RW, Banks R, et al. Biomarkers for Estimating Risk of Hospital Mortality and Long-Term Quality of Life Morbidity After Surviving Pediatric Septic Shock: A Secondary Analysis of the Life After Pediatric Sepsis Evaluation Investigation. Pediatr Crit Care Med. 2021; 22:8–15
4. Pollack MM, Holubkov R, Glass P, et al. Functional Status Scale: New pediatric outcome measure. Pediatrics. 2009; 124:e18–e28
5. Pollack MM, Holubkov R, Funai T, et al. Simultaneous prediction of new morbidity, mortality, and survival without morbidity from pediatric intensive care: a new paradigm for outcomes assessment. Crit Care Med. 2015; 43:1699–1709
6. Zimmerman JJ, Banks R, Berg RA, et al. Trajectory of mortality and health related quality of life morbidity following community-acquired pediatric septic shock. Crit Care Med. 2020; 48:329–337
7. Wong HR, Cvijanovich NZ, Anas N, et al. Pediatric sepsis biomarker model-II: Redefining the pediatric sepsis biomarker risk model with septic shock phenotype. Crit Care Med. 2016; 44:2010–2017
8. Meert KL, Reeder R, Maddux AB, et al. Trajectories and risk factors for altered physical and psychosocial health-related quality of life after pediatric community-acquired septic shock. Pediatr Crit Care Med. 2020; 21:869–878
9. Starr MC, Banks R, Reeder RW, et al. Severe acute kidney injury is associated with increased risk of death and new morbidity after pediatric septic shock. Pediatr Crit Care Med. 2020; 21:e686–e695
10. Leteurtre S, Recher M. Pediatric Sepsis Biomarker Risk Model With Outcome After PICU Discharge: A Strong Research Tool, but Let Us Not Forget Composite Prognostic Factors! Pediatr Crit Care Med. 2021; 22:125–126