Validation of the pediatric refractory septic shock definition: Posthoc analysis of a controlled trial

Abstract BackgroundThe European Society of Pediatric and Neonatal Intensive Care (ESPNIC) developed and validated a definition of pediatric refractory septic shock (RSS), based on two septic shock scores (SSS). Both bSSS and cSSS were found to be strongly associated with mortality. We aimed at assessing the accuracy of the RSS definition on a prospective cohort from India. Methods Post-hoc analysis of a cohort issued from a double-blind randomized trial that compared first-line vasoactive drugs in children with septic shock. Sequential bSSS and cSSS from 60 children (single center study, 53% mortality) were analyzed. The prognostic value of the ESPNIC RSS definition was tested for 28-day all-cause mortality. ResultsIn this septic shock cohort, RSS was diagnosed in 35 patients (58.3%) during the first 24 hours. Death occurred in 30 RSS patients (85.7% mortality) and in 2 non-RSS patients (8% mortality), OR=60.9 [95% CI: 10.5-676.2], p<0.001 with a median delay from sepsis onset of 3 days [1.0-6.7]. Among patients diagnosed with RSS, the mortality was not significantly different according to vasopressors randomization. Diagnosis of RSS with bSSS and cSSS had a high discrimination for death with an area under the receiver operating curve of 0.916 [95% CI: 0.843-0.990] and 0.925 [95% CI: 0.845-1.000], respectively. During the first day of septic shock, the best interval for prognostication was after the 12th hour following septic shock as compared to 0-6 hours or 6-12 hours (AUC 0.973 [95% CI: 0.925-1.000] versus 0.876 [95% CI: 0.780-0.972] and 0.955 [95% CI: 0.899-1.000] respectively), p=0.011. ConclusionsThe ESPNIC SSS accurately identifies children in refractory septic shock with a best interval between 12 and 24 hour of septic shock. Both bSSS and cSSS had high discrimination for 28-day mortality.