Clinical scientists at Ann & Robert H. Lurie Children’s Hospital of Chicago were part of a diverse, international group of experts charged by the Society of Critical Care Medicine (SCCM) with the development and validation of new data-driven criteria for sepsis In children. Sepsis is a major public health burden, claiming the lives of more than 3.3 million children worldwide each year.
The new pediatric sepsis criteria, called the Phoenix criteria , follow the paradigm shift in recent adult criteria that define sepsis as a severe response to an infection involving organ dysfunction , as opposed to a previous focus on systemic inflammation. The new pediatric sepsis criteria and their development are presented in two articles published in JAMA in January 2024 and announced simultaneously at the SCCM Critical Care Congress in Phoenix, Arizona.
International consensus criteria for pediatric sepsis and septic shock Key points Ask How should children with suspected infection at increased risk of mortality, indicative of sepsis, be identified? Findings Using an international survey, systematic review and analysis of more than 3 million pediatric healthcare visits, and a consensus process, new criteria for sepsis and septic shock in children were developed. Pediatric sepsis in children (<18 years) with suspected infection was identified by at least 2 points on the new Phoenix Sepsis Score, including dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems; and septic shock as sepsis with at least 1 cardiovascular point on the Phoenix Sepsis Score. Meaning The new criteria for pediatric sepsis and septic shock are applicable globally. |
Importance
Sepsis is a leading cause of death among children worldwide. The current pediatric criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection, but excluded children.
Aim
Update and evaluate criteria for sepsis and septic shock in children.
Evidence Review
The Society of Critical Care Medicine (SCCM) convened a working group of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents.
Using evidence from an international survey, a systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million visits to electronic medical records from 10 sites on 4 continents, a modified Delphi consensus process was employed. to develop criteria.
Findings
According to the survey data, the majority of pediatric physicians used sepsis to refer to an infection with life-threatening organ dysfunction , which differed from previous pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant criteria for the term, severe sepsis.
The SCCM Task Force recommends that sepsis in children be identified by a Phoenix Sepsis score of at least 2 points in children with suspected infection, indicating life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. .
Children with a Phoenix Sepsis score of at least 2 points had an in-hospital mortality of 7.1% in higher resource settings and 28.5% in lower resource settings, more than 8 times that of children with suspected infection that did not meet these criteria.
Mortality was higher in children who had organ dysfunction in at least 1 of 4 organ systems (respiratory, cardiovascular, coagulation, and/or neurological) that was not the primary site of infection.
Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point on the Phoenix Sepsis Score , including severe hypotension for age, blood lactate greater than 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively.
Conclusions and relevance
The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the SCCM International Pediatric Sepsis Definition Working Group using a large international database and survey, systematic review and meta-analysis. and a modified Delphi consensus approach. A Phoenix Sepsis score of at least 2 identified life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiologic evaluation, and research in pediatric sepsis and septic shock worldwide. world.
Key concepts for pediatric sepsis
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Criteria to identify children with septic shock
Pediatric septic shock was identified in children with sepsis by at least 1 point on the cardiovascular component of the Phoenix Sepsis Score (ie, severe hypotension for age, blood lactate >5 mmol/L, or receipt of vasoactive medication).
Because vasoactive medications may not be available in some clinical settings, this approach allowed the identification of septic shock in the absence of such resources. The prevalence of septic shock among children with sepsis was 53.7% (5,502 of 10,243) in higher-resource settings and 81.3% (1,260 of 1,549) in lower-resource settings and was associated with in-hospital mortality of 10.8% (593 of 5502) and 33.5% (422 of 1260), respectively.
Dysfunction of organs distant from the primary site of infection
Children who met Phoenix sepsis criteria included those with organ dysfunction limited to the infected primary organ (e.g., isolated respiratory dysfunction in a child with pneumonia) and those with Phoenix Sepsis scores indicating dysfunction of organs distant from the primary site of infection (eg, respiratory disease, dysfunction in a child with meningitis).
However, children with sepsis and dysfunction of organs remote from the primary site of infection , including patients with septic shock and those with multiple organ dysfunction, represent an important and distinct subset of children with sepsis. Children with sepsis and remote organ dysfunction had higher mortality (8.0% [700 of 8,728] and 32.3% [427 of 1,320] in higher- and lower-resource settings, respectively) and accounted for 85.2%. (8,728 of 10,243) and 85.2%. (1320 of 1549) of children with sepsis in higher and lower resource settings, respectively.
In contrast, children with a Phoenix Sepsis score of at least 2 who had organ dysfunction limited to the primary site of infection had a mortality of 1.7% and 6.1% in higher- and lower-resource settings, respectively.
Discussion
The Phoenix criteria for pediatric sepsis and septic shock, developed with an international survey, a systematic review, analysis of more than 3 million pediatric visits, and a modified Delphi consensus process, were designed to reliably identify children with sepsis. for clinical care purposes. , benchmarking, quality improvement, epidemiology and research in pediatric sepsis.
The method used to develop the criteria leveraged knowledge gained through the Sepsis-3 process while incorporating novel elements, utilizing a globally diverse working group, and drawing on data from diverse healthcare systems.
The SIRS should no longer be used to diagnose sepsis in children , and since any life-threatening condition is serious, the term severe sepsis is redundant. The Phoenix criteria were intended to be globally applicable and were named in reference to the symbolic meaning of the mythological phoenix and the location where the criteria were presented during the 2024 SCCM Congress (Phoenix, Arizona).
Comments
“The latest pediatric sepsis criteria were developed almost 20 years ago and were based on expert opinion, while the new criteria we derived are based on electronic medical record data and analysis of more than 3 million pediatric healthcare visits. in 10 hospitals around the world even in low-resource settings,” said lead author of one of the papers, L. Nelson Sanchez-Pinto, MD, MBI, a critical care physician at Lurie Children’s, who co-led the data set. of the SCCM working group with Tellen D. Bennett. , MD, MS, at the University of Colorado.
“We used a machine learning approach to narrow down the elements that were most effective in identifying children at high risk of dying from organ dysfunction in the context of infection. The criteria we developed are based on four systems: cardiovascular, respiratory, neurological and coagulation. “These criteria are better than older ones at identifying children with infections at higher risk of poor outcomes and are applicable globally, even in low-resource settings.”
Dr. Sánchez-Pinto is an associate professor of pediatrics and preventive medicine at Northwestern University Feinberg School of Medicine, as well as a Warren and Eloise Batts Research Fellow at Lurie Children’s. Her data-based work to derive the new sepsis criteria was funded by the National Institutes of Health (NIH).
Researchers
The SCCM leadership team that brought together the Pediatric Sepsis Task Force included Lauren Sorce, PhD, RN, CPNP-AC/PC, FCCM, FAAN, Founders Board Nurse Scientist and Lurie Associate Director of Nursing Research Children’s, as well as an assistant professor. of Pediatrics at Northwestern University Feinberg School of Medicine. Dr. Sorce has since been named president of SCCM.
The Pediatric Sepsis Task Force also included Elizabeth Alpern, MD, MSCE, division chief of emergency medicine at Lurie Children’s and professor of pediatrics at Northwestern University Feinberg School of Medicine.
Research at Ann & Robert H. Lurie Children’s Hospital of Chicago is conducted through the Stanley Manne Children’s Research Institute, which focuses on improving children’s health, transforming pediatric medicine, and ensuring healthier futures through the pursuit incessant knowledge. Lurie Children’s is a nonprofit organization committed to providing access to exceptional care for every child. It is ranked as one of the best children’s hospitals in the country by US News & World Report. Lurie Children’s is the pediatric training camp of Northwestern University Feinberg School of Medicine.
