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Platelet Indices as Predictive Markers of Prognosis in Pediatric Septic Shock Patients

June 2017
Iranian Journal of Pediatrics In Press(In Press)

DOI:10.5812/ijp.7212

Authors:

Won Kyoung Jhang

Asan Medical Center

Seong Jong Park

Asan Medical Center

Background: Platelet indices are used as predictive marker of mortality in adult critically ill patients. Objectives: To compare platelet counts, mean platelet volumes (MPV), and platelet distribution widths (PDW) in surviving and non-surviving pediatric septic shock patients and to assess whether platelet count and indices can be utilized as predictive markers of mortality in these patients. Methods: A retrospective study was performed based on collected data on pediatric patients admitted for septic shock to pediatric intensive care unit. Complete blood cell count, platelet counts, MPV, and PDW on admission were compared in survivors and non-survivors, as well as in patients with and without underlying hemato-oncologic disease. Results: Of 83 children, 21 (25.3%) died within 28 days of hospital admission. Mean platelet count was significantly higher in the 62 survivors than in 21 non-survivors (146.6 ± 133.7 × 10³/mm³ vs 46.1 ± 44.1 × 10³/mm³, P = 0.000). MPV and PDW were also higher in survivors, though not statistically significant (P = 0.059, P = 0.077). The platelet counts were significantly higher in survivors than in non-survivors with (P = 0.044) and without (P = 0.015) hemato-oncologic disease. Based on area under receiver operating characteristic curves, platelet count was the strongest predictor of mortality in pediatric patients without underlying hemato-oncologic disease (area under the curve = 0.857). The survival probability in this group was 96.77% when platelet count exceeded 106.5 × 10³/mm³. Conclusions: Thrombocytopenia is a useful predictive marker of mortality in pediatric septic shock patients, both with and without underlying hemato-oncologic disease.

Receiver Operating Characteristic (ROC) Curve Analysis of the Associations Between Platelet Counts and Mortality

…

. Patient Characteristics a

…

. Clinical Characteristics of Survivors and Non-Survivors a

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. Mean Platelet Counts in Survivors and Non-Survivors

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. Cutoff Values for Platelet Count in Patients With and Without Hemato- Oncologic Diseases a

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Iran J Pediatr. In Press(In Press):e7212.

Published online 2017 June 12.

doi: 10.5812/ijp.7212.

Research Article

Platelet Indices as Predictive Markers of Prognosis in Pediatric Septic

Shock Patients

Seung Jun Choi,1Eun-Ju Ha,1Won Kyoung Jhang,1and Seong Jong Park1,*

1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Republic of

Korea

*Corresponding author: Dr. Seong Jong Park, Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children’s Hospital, University of

Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul 138-736, Republic of Korea. Tel: +82-230103390, Fax: +82-230103725, E-mail: goodjobman79@naver.com

Received 2016 May 22; Revised 2017 February 09; Accepted 2017 March 19.

Abstract

Background: Platelet indices are used as predictive marker of mortality in adult critically ill patients.

Objectives: Tocompare platelet counts, mean platelet volumes (MPV), and platelet distribution widths (PDW) in surviving and non-

surviving pediatric septic shock patients and to assess whether platelet count and indices can be utilized as predictive markers of

mortality in these patients.

Methods: A retrospective study was performed based on collected data on pediatric patients admitted for septic shock to pediatric

intensive care unit. Complete blood cell count, platelet counts, MPV, and PDW on admission were compared in survivors and non-

survivors, as well as in patients with and without underlying hemato-oncologic disease.

Results: Of 83 children, 21 (25.3%) died within 28 days of hospital admission. Mean platelet count was signiﬁcantly higher in the 62

survivors than in 21 non-survivors (146.6 ±133.7 ×103/mm3vs 46.1 ±44.1 ×103/mm3, P = 0.000). MPV and PDW were also higher in

survivors, though not statistically signiﬁcant (P = 0.059, P = 0.077). The platelet counts were signiﬁcantly higher in survivors than

in non-survivors with (P = 0.044) and without (P = 0.015) hemato-oncologic disease. Based on area under receiver operating charac-

teristic curves, platelet count was the strongest predictor of mortality in pediatric patients without underlying hemato-oncologic

disease (area under the curve = 0.857). The survival probability in this group was 96.77% when platelet count exceeded 106.5 ×

103/mm3.

Conclusions: Thrombocytopenia is a useful predictive marker of mortality in pediatric septic shock patients, both with and without

underlying hemato-oncologic disease.

Keywords: Septic Shock, Pediatrics, Platelet Indices, Pediatric Intensive Care Unit, Mortality

1. Introduction

Thrombocytopenia is frequently encountered in pa-

tients admitted to intensive care units (ICUs), and has been

shown to be predictive of mortality in adult patients (1-

4), as well as in pediatric patients admitted to pediatric

ICUs (PICUs) (5). Thrombocytopenia in sepsis patients is

caused by combinations of several mechanisms, including

decreased platelet synthesis, increased platelet destruc-

tion, and thrombus formation (6), with approximately 40%

of patients with severe sepsis having platelet counts below

80,000/mm3(7). During episodes of septic shock, platelets

aggregate around the site of inﬂammation, with subse-

quent multiorgan failure aggravating thrombocytopenia

(8).

Several studies have shown that platelet counts and

function are reduced in patients with severe sepsis and sep-

tic shock (9-11). Moreover, platelet indices, such as mean

platelet volume (MPV) and platelet distribution width

(PDW), have been associated with these conditions (12,13).

Increased MPV was observed in adults with septic shock

(14) and in neonatal sepsis patients (15). Less is known, how-

ever, about platelet counts and platelet indices in pediatric

sepsis patients.

This study was designed to evaluate the association of

platelet counts and platelet indices with mortality in pe-

diatric septic shock patients, as well as to assess whether

platelet parameters are predictive markers of survival

in these patients. Because the presence of underlying

hemato-oncologic disease may greatly inﬂuence baseline

platelet counts, the associations between platelet parame-

ters and mortality were separately analyzed in groups of

patients with and without underlying hemato-oncologic

disease.

2. Methods

The medical records of pediatric patients admitted to

the PICU of Asan medical center children’s hospital, Seoul,

Korea, from February 2012 through May 2015, with a diag-

nosis of septic shock, were retrospectively reviewed. Septic

International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the

original work is properly cited.

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Choi SJ et al.

shock was deﬁned according to the 2005 international pe-

diatric sepsis consensus conference (IPSCC) criteria (16).

The demographic characteristics, underlying diseases,

sources of infection, and laboratory results of all included

patients were obtained from their medical records. The

severity of illness and organ dysfunction were assessed by

measuring Pediatric Risk of Mortality III (PRISM III) scores,

sequential organ failure assessment (SOFA) scores, and Va-

soactive Inotropic Scores (VIS) within 24 hrs of PICU admis-

sion.

Complete blood cell (CBC) count and blood chemistry

were measured within 1 hour of admission to the PICU.

Platelet count, MPV, and PDW were obtained from routine

CBC results. All statistical analyses were performed using

Windows SPSS software, version 18. Continuous variables

in survivors and non-survivors were compared using in-

dependent t-tests. Receiver operating characteristic (ROC)

curve analyses were performed to evaluate the usefulness

of platelet parameters as prognostic markers. For each

variable, 95% conﬁdential intervals (CIs) and optimal cut-

oﬀ points were determined. A P value less than 0.05 was

considered statistically signiﬁcant.

The study protocol was approved by the institutional

review board of the Asan Medical Center.

3. Results

A total of 90 pediatric patients were admitted to the

PICU for septic shock from February 2012 to May 2015.

Seven patients were excluded owing to a lack of relevant

data at admission, including MPV and PDW; thus, 83 pa-

tients were enrolled. The 28 day in-hospital mortality rate

was 25.3% (21/83). Of the 83 patients, 78 (94.0%) had un-

derlying diseases, with 38 having hemato-oncologic dis-

eases. Pathogenic microorganisms were documented in

47 patients. The most common Gram-positive and Gram-

negative bacteria were Staphylococcus aureus and Kleb-

siella pneumoniae, respectively, and all cases of fungal sep-

sis were attributed to Candida albicans (Table 1).

Age, sex, and length of PICU stay did not diﬀer signif-

icantly in survivors and non-survivors. PRISM III, SOFA,

and VIS scores, all of which reﬂect disease severity, were

signiﬁcantly greater in the non-survivors than in sur-

vivors. Documentation of pathogen was not associated

with survival, but underlying disease was. Of the 21 non-

survivors, 14 (66.7%) had underlying hemato-oncologic dis-

ease. C-reactive protein (CRP) and lactate concentrations

were signiﬁcantly higher in non-survivors than in sur-

vivors. Platelet count was 3-fold higher in survivors than

in non-survivors (146.6 ±133.7 ×103/mm3vs 46.1 ±44.1 ×

103/mm3, P = 0.000). Mean MPV (P = 0.059) and PDW (P =

Table1. Patient Characteristicsa

Variables No. of Patients

N83

Age, months 128.0 ±159.6

Gender,male/female 52/31

Mortality 21 (25.3)

Underlying disease 78 (94.0)

Hemato-oncologic disease 38 (48.7)

Neurologic disease 13 (16.7)

Cardiac disease 8 (10.3)

Pulmonary disease 6 (7.7)

Chronic renal disease 5 (6.4)

Gastrointestinal disease 3 (3.8)

Endocrinologic disease 3 (3.8)

Other 2 (2.6)

Proven microorganism 47 (56.6)

Gram-positive bacteria 19 (40.4)

Staphylococcus aureus 5

Streptococcus mitis 3

Streptococcus agalactiae 2

Staphylococcus hominis 2

Enterococcus faecalis 2

Other 5

Gram-negative bacteria 22 (46.8)

Klebsiella pneumonia 9

Escherichia coli 5

Pseudomonas aeruginosa 4

Enterobacter cloacae 2

Other 2

Fungus 6 (12.8)

Candida albicans 6

aValues are expressed as mean ±SD or No. (%).

0.077) were higher in survivors, but the diﬀerences were

not statistically signiﬁcant (Table 2).

The associations between platelet count and mortal-

ity according to underlying disease were analyzed sepa-

rately in the 38 patients with and the 45 without hemato-

oncologic disease. Mean platelet counts in both sub-

groups were signiﬁcantly higher in survivors than in non-

survivors (Table 3). ROC analysis showed that the areas un-

der the curve (AUCs) were 0.796 for all patients, 0.722 for

patients with hemato-oncologic diseases, and 0.857 for pa-

2Iran J Pediatr. In Press(In Press):e7212.

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Choi SJ et al.

Table2. Clinical Characteristics of Survivors and Non-Survivorsa

Variables All Patients (n = 83) Survivors (n = 62) Non-Survivors (n = 21) P Value

Age, mo 128.0 ±159.6 114.4 ±85.0 168.3 ±282.9 0.182

Male 52 (62.7) 38 (61.3) 14 (66.7) 0.796

Length of PICU stay 14.84 ±15.30 14.77±15.82 15.05 ±14.00 0.944

PRISM III score 15.67 ±8.17 13.55 ±5.67 21.95 ±10.95 0.003

SOFA score 9.71 ±3.17 8.87 ±2.72 12.19 ±3.16 0.000

VIS 35.00 ±38.46 27.66 ±25.19 56.68 ±58.88 0.039

Hemato-oncologic disease 38 (45.8) 24 (38.7) 14 (66.7) 0.042

Proven microorganism 47(56.6) 35 (56.5) 12 (57.1) 0.956

Laboratory ﬁndings

WBC, mm36,567 ±7,468 7,223 ±7,487 4,633 ±7,243 0.171

Platelet, ×103/mm3121.1 ±125.3 146.6 ±133.7 46.1 ±44.1 0.000

Mean platelet volume, ﬂ 10.50 ±1.12 10.63 ±1.18 10.10 ±0.80 0.059

Platelet distribution width, ﬂ 12.17 ±2.81 12.48 ±2.98 11.23 ±2.05 0.077

CRP,mg/dL 15.03 ±9.41 13.85±8.85 18.52 ±10.33 0.049

Lactate, mmol/L 3.88 ±4.06 2.45±2.21 8.10 ±5.25 0.000

Abbreviations: CRP, C-reactive protein; PICU,pediatric intensive care unit; PRISM III, pediatric risk of mortality III; SOFA, sequential organ failure assessment; VIS, vasoac-

tive inotropic scores; WBC, white blood cell.

aValues are expressed as mean ±SD or No. (%).

tients without hemato-oncologic diseases (Figure 1). Us-

ing Youden’s J-statistics, we calculated that the platelet

count cutoﬀs for predicting mortality were 52.0 ×103/mm3

for all patients, 30.5 ×103/mm3for patients with hemato-

oncologic diseases, and 106.5 ×103/mm3for patients with-

out hemato-oncologic diseases, with sensitivities of 71.4%,

78.6%, and 85.7%, respectively, and speciﬁcities of 71.0%,

66.7%, and 78.9%, respectively. The accuracies, positive pre-

dictive values, and negative predictive values for these cut-

oﬀs are shown in Table 4. The risk ratios for mortality in

these three groups of patients with platelet counts under

the cutoﬀ values were 6.111, 7.333, and 22.5, respectively (Ta-

ble 4). With the signiﬁcant variable from the univariate

analysis, a multivariate logistic regression analysis was ex-

ecuted, and the platelet count was statistically signiﬁcant

(OR = 0.988, P = 0.04, Table 5).

4. Discussion

Thrombocytopenia is frequently encountered in se-

vere sepsis patients (9) and has been associated with prog-

nosis (17,18). However the association between platelet

indices and mortality in septic shock patients is unclear.

For example, increased MPV has been associated with

mortality in adult septic shock patients (19,20), but has

shown contradictory results in neonatal patients with sep-

Table3. Mean Platelet Counts in Survivors and Non-Survivors

Platelet, ×

103/mm3

Survivors (n = 62) Non-Survivors (n

= 21)

P Value

All patients 146.6 ±133.7 46.1 ±44.1 0.000

With hemato-

oncologic

diseases

43.1 ±22.4 28.6 ±16.9 0.044

Without hemato-

oncologic

diseases

211.9 ±133.6 81.0 ±61.0 0.015

sis (21). Our study, involving pediatric septic shock pa-

tients, showed that platelet count on PICU admission was

signiﬁcantly associated with mortality, but that platelet in-

dices such as MPV and PDW were not associated with mor-

tality in these patients.

This study had two major ﬁndings. First, platelet count

was predictive of mortality in pediatric septic shock pa-

tients, regardless of the underlying disease. Whether or

not these patients had an underlying hemato-oncologic

disease did not aﬀect the association between platelet

count and mortality. Low platelet counts are not un-

common in patients with hemato-oncologic diseases, even

during disease-free periods, due both to the underly-

ing disease itself and to treatment methods such as

Iran J Pediatr. In Press(In Press):e7212. 3

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Choi SJ et al.

000.0 697.0

With hemato-oncologic diseases 0.722 0.024 0.546–0.898

Without hemato-oncologic diseases 0.857 0.003 0.700–1.000

Abbreviations: H-O, hema to-oncologic diseases

All patient

Platelet AUC P - value 95% CI

Sensitivity

Total

H-O

Non-H-H

1 - Speciﬁcity

0.0 0.2 0.4 0.6 0.8 1.0

1.0

0.8

0.6

0.4

0.2

0.0

0.692–0.900

Figure 1. Receiver Operating Characteristic (ROC) Curve Analysis of the Associations Between Platelet Counts and Mortality

chemotherapy and irradiation. We found, however, that

the mean platelet count in surviving patients with hemato-

oncologic diseases was 43.1 ×103/mm3, which, although

lower than the normal reference range, and even lower

than minimum criteria(50.0 ×103/mm3) of the pediatric

risk of mortality (PRISM) III score, was signiﬁcantly higher

than that of non-survivors with hemato-oncologic dis-

eases. Even among patients without hemato-oncologic dis-

eases, who had baseline platelet counts in the normal refer-

ence range, platelet count was predictive of mortality, with

an AUC of 0.857, a sensitivity of 85.7%, and a speciﬁcity of

78.9%.

The second major ﬁnding of this study was the deter-

mination of cutoﬀ values for platelet count predictive of

mortality, suggesting speciﬁc reference ranges that can

be utilized in clinical settings. Platelet counts showed ex-

cellent negative predictive values in all patients (88.0%)

and in patients with (84.2%) and without (96.8%) hemato-

oncologic diseases. Patients with platelet count higher

than the cutoﬀ values would therefore be at decreased risk

of 28 day mortality. For example, the predicted surviv-

ability rate in pediatric septic shock patients without un-

derlying hemato-oncologic diseases and an initial platelet

count of 106.5 ×103/mm3is 96.8%.

Additional studies are needed to determine whether

platelet transfusions that maintain adequate platelet

count can reduce mortality rates in pediatric septic shock

patients. Platelet transfusion guidelines recommend dif-

ferent criteria based on the underlying disease or clinical

status of the patients (22-24). We observed that a cutoﬀ

value of 30.5 ×103/mm3had optimal sensitivity and speci-

ﬁcity in patients with hemato-oncologic diseases. Thus,

future studies may address whether platelet transfusions

that maintain platelet counts above this cutoﬀ in pediatric

septic shock patients with underlying hemato-oncologic

diseases can potentially enhance survival rate.

This study had several limitations. It was a retrospec-

tive observational study with a small sample size con-

ducted in a single medical center. Further, we did assess the

eﬀects of microorganisms on platelet counts. Microorgan-

isms have been shown to alter platelet responses in both

very low birth weight infants (25,26) and adults (14). How-

4Iran J Pediatr. In Press(In Press):e7212.

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Choi SJ et al.

Table 4. Cutoﬀ Values for Platelet Count in Patients With and Without Hemato-

Oncologic Diseasesa

Validation

Values

All Patients With hemato-

Oncologic

Diseases

Without

Hemato-

Oncologic

Diseases

Platelet, ×

103/mm3

52.0 30.5 106.5

Sensitivity 71.4 78.6 85.7

Speciﬁcity 71.0 66.7 78.9

Accuracy 71.1 71.0 80.0

Positive

predictive value

45.5 57.9 42.9

Negative

predictive value

88.0 84.2 96.8

Risk ratio 6.111 7.333 22.500

95% CI 2.046 - 18.251 1.583 - 33.967 2.357 - 214.778

P Value 0.001 0.017 0.002

Abbreviation: CI, conﬁdence interval.

aValues are expressed as %.

Table5. Multivariate Logistic Regression Analysis for Mortality

Variables Coeﬃcient P Value Odds Ratio (95%

Conﬁdence Interval)

PRISM III 0.092 0.145 1.096 (0.969 - 1.240)

SOFA 0.230 0.062 1.258 (0.988 - 1.601)

VIS -0.002 0.813 0.998 (0.981 - 1.015)

Platelet counts -0.012 0.040 0.988 (0.977 - 0.999)

MPV -0.694 0.230 0.500 (0.161 - 1.551)

PDW -0.008 0.974 0.992 (0.630 - 1.563)

Abbreviation: MPV, mean platelet volume; PDW, platelet distribution width;

PRISM III, pediatric risk of mortality III; SOFA, sequential organ failure assess-

ment; VIS, Vasoactive Inotropic Scores.

ever, microorganism growth was documented in few of

these patients. Large-scale, prospective, multicenter stud-

ies that include data on microorganisms are needed to val-

idate our ﬁndings.

In conclusion, platelet count is a useful predictor of

mortality in pediatric septic shock patients, regardless of

the presence of underlying hemato-oncologic disease. In

contrast, MPV and PDW were not signiﬁcant predictors of

patient mortality.

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Article

Jan 2022

CONTEXT Studies of organ dysfunction in children are limited by a lack of consensus around organ dysfunction criteria. OBJECTIVES To derive evidence-informed, consensus-based criteria for hematologic dysfunction in critically ill children. DATA SOURCES Data sources included PubMed and Embase from January 1992 to January 2020. STUDY SELECTION Studies were included if they evaluated assessment/scoring tools to screen for hematologic dysfunction and assessed outcomes of mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. Studies of adults or premature infants, animal studies, reviews/commentaries, small case series, and non-English language studies with inability to determine eligibility were excluded. DATA EXTRACTION Data were abstracted from each eligible study into a standard data extraction form along with risk of bias assessment. RESULTS Twenty-nine studies were included. The systematic review supports the following criteria for hematologic dysfunction: thrombocytopenia (platelet count <100000 cells/µL in patients without hematologic or oncologic diagnosis, platelet count <30000 cells/µL in patients with hematologic or oncologic diagnoses, or platelet count decreased ≥50% from baseline; or leukocyte count <3000 cells/µL; or hemoglobin concentration between 5 and 7 g/dL (nonsevere) or <5 g/dL (severe). LIMITATIONS Most studies evaluated pre-specified thresholds of cytopenias. No studies addressed associations between the etiology or progression of cytopenias overtime with outcomes, and no studies evaluated cellular function. CONCLUSIONS Hematologic dysfunction, as defined by cytopenia, is a risk factor for poor outcome in critically ill children, although specific threshold values associated with increased mortality are poorly defined by the current literature.

Performance of Platelet Mass Index as a Marker of Severity for Sepsis and Septic Shock in Children

Article

Jun 2021

Platelet mass index (PMI) as a prognostic indicator in pediatric sepsis is not reported. In this retrospective observational study, we evaluated PMI's performance as a prognostic indicator in children aged younger than 18 years with sepsis and septic shock in relationship with survival. Over 5 years, we collected data of 122 children admitted to our pediatric intensive care unit (PICU). PMI accuracy was assessed with sensitivity and specificity and its discrimination was assessed using the area under the receiver operating characteristic curve (AUC). The median PMI values on days 1 and 3 of PICU admission were lower among nonsurvivors. On day 1 of PICU admission, a cutoff PMI value of 1,450 fL/nL resulted in a sensitivity of 72% and a specificity of 69%, and the AUC was 0.70 (95% confidence interval [CI]: 0.55–0.86). Similarly, on day 3, a cutoff of 900 fL/nL resulted in a sensitivity of 71% and a specificity of 70%, and the AUC was 0.76 (95% CI: 0.59–0.92). Our exploratory study suggests that low PMI in children with septic shock is associated with increased mortality. Considering the PMI's fair performance, further studies have to assess its clinical value.

The Use of Platelet Count and Indices as Prognostic Factors for Mortality in Children with Sepsis

Article

Full-text available

Aug 2024

Background Sepsis is still one of the leading causes of mortality and morbidity in children worldwide. Consumptive coagulopathy and suppression of thrombopoiesis in the bone marrow resulting from immune dysregulation are pathological mechanisms that cause thrombocytopenia in sepsis. Platelet count (PLT) and indices, such as mean platelet volume (MPV), platelet distribution width (PDW), and plateletcrit (PCT) are markers of platelet activation and are strongly influenced by platelet morphology and proliferation kinetics. We aimed to study the use of platelet count and indices as predictors of mortality in children with sepsis. Methods This is a cross-sectional study of 45 children diagnosed with sepsis on admission at Haji Adam Malik Hospital, Medan, North Sumatra, Indonesia, between October and November 2022. Blood samples were drawn upon admission, and platelet count and indices were then determined for all children. Subjects were followed up till discharge from hospital or death. Receiver Operating Characteristic (ROC) curve analysis of platelet parameters was done to determine the area under the curve (AUC), optimal cut-off value, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in predicting mortality in children with sepsis. Using the cut-off values from ROC curve analysis, the odds ratio with 95% confidence interval was calculated using multiple logistic regression analyses. A P value less than 0.05 was considered statistically significant. Results MPV, PDW, and PDW/PLT were significantly higher in non-survivors than survivors (P=0.04, P=0.02, and P=0.04, respectively). ROC curve analysis showed that PDW had the largest AUC (0.708 [95% CI=0.549–0.866]) with a cut-off value of 14.1%, sensitivity of 63.6%, and specificity of 82.6%. PDW was also the only parameter that significantly affected the outcome of children with sepsis. PDW≥14.1% at admission increases the risk of mortality by 5.7 times. Conclusion Admission PDW is a fast and specific tool to predict the outcome of children with sepsis.

Vasoactive-inotropic Score for Early Detection and Mortality Prediction of Sepsis in Children

Article

Full-text available

Mar 2021

BACKGROUND: Early detection and treatment of sepsis can prevent septic shock and reduce mortality rate. Troponin can become a prognostic factor in sepsis. However, not all health facilities are equipped to assess troponin levels. Vasoactive-inotropic score (VIS) is a simpler and more accessible method to describe hemodynamic status. The aim of this study was to assess the suitability of VIS score as early prognosis and mortality predictor of sepsis METHODS: A retrospective study was conducted to determine the correlation between VIS and troponin levels for sepsis cases in Pediatric Intensive Care Unity (PICU) Haji Adam Malik Hospital, Medan from January 2018 to December 2019. VIS score at 48 hours, maximum VIS score, pediatric logistic organ dysfunction-2 (PELOD-2) score, cardiac troponin levels at 48 hours were taken from medical records. RESULTS: There were 54 samples analyzed. VIS scores were positively correlated (p

Coagulation Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

Article

Jan 2022

CONTEXT Previous criteria for coagulation dysfunction in critically ill children were based mainly on expert opinion. OBJECTIVE To evaluate current evidence regarding coagulation tests associated with adverse outcomes in children to inform criteria for coagulation dysfunction during critical illness. DATA SOURCES Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020 by using a combination of medical subject heading terms and text words to define concepts of coagulation dysfunction, pediatric critical illness, and outcomes of interest. STUDY SELECTION Studies were included if critically ill children with coagulation dysfunction were evaluated, if performance characteristics of assessment and/or scoring tools to screen for coagulation dysfunction were evaluated, and if outcomes related to mortality or functional status, organ-specific outcomes, or other patient-centered outcomes were assessed. DATA EXTRACTION Data were abstracted from each eligible study into a standard data extraction form, along with risk of bias assessment, by a task force member. RESULTS The systematic review supports the presence of at least 2 of the following criteria reflecting coagulation dysfunction in the absence of liver dysfunction: platelet count <100 000 cells per μL, international normalized ratio >1.5, fibrinogen level <150 mg/dL, and D-dimer value above 10 times the upper limit of normal, or above the assay’s upper limit of detection if this limit is below 10 times the upper limit of normal. LIMITATIONS The proposed criteria for coagulation dysfunction are limited by the available evidence and will require future validation. CONCLUSIONS Validation of the proposed criteria and identified scientific priorities will enhance our understanding of coagulation dysfunction in critically ill children.

Evaluation of Platelet Indices and Sepsis Markers in Neonates with Different Types of Sepsis: Platelet Indices and Sepsis Markers in Neonatal Sepsis

Article

Full-text available

Nov 2024

Sepsis in neonates was the main reason for morbidity and mortality globally, primarily in developing countries. The World Health Organization (WHO) approximates that sepsis affects approximately 3 million neonates annually, causing about 750,000 deaths. Platelet indices such as Platelet Crit distribution width (PCT), Platelet Width Volume (PWV), and Mean Platelet Distribution (MPD) were considered major biomarkers for diagnosis. Objective: To evaluate the alterations in platelet indices and septic markers (CRP) in neonates with sepsis as compared to established reference values. Methods: This cross-sectional study was conducted at the Department of Hematology and Transfusion Medicine in the Children's Hospital and University of Child Health Sciences, Lahore, from November 2023 to February 2024. 57 neonates of the Neonatal Intensive Care Unit (ICU) were sampled. Platelet indices, including PCT, PDW, MPV, and C-reactive protein (CRP), were measured using automated hematology analyzers. Data were analyzed by using SPSS V-23.0. One sample T-test was used to compare the means with the reference value. Results: The mean platelet count was significantly lower. MPV and PDW were significantly elevated in neonates with sepsis compared to the reference value, while PCT was considerably lower. CRP levels were significantly elevated in neonates with sepsis. Conclusions: This study concluded that platelet indices and CRP levels were valued biomarkers for diagnosing and treating neonatal sepsis. These well-established inflammatory markers suggest a strong systemic inflammatory response typically associated with sepsis.

Renal Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

Article

Jan 2022

CONTEXT Renal dysfunction is associated with poor outcomes in critically ill children. OBJECTIVE To evaluate the current evidence for criteria defining renal dysfunction in critically ill children and association with adverse outcomes. To develop contemporary consensus criteria for renal dysfunction in critically ill children. DATA SOURCES PubMed and Embase were searched from January 1992 to January 2020. STUDY SELECTION Included studies evaluated critically ill children with renal dysfunction, performance characteristics of assessment tools for renal dysfunction, and outcomes related to mortality, functional status, or organ-specific or other patient-centered outcomes. Studies with adults or premature infants (≤36 weeks' gestational age), animal studies, reviews, case series, and studies not published in English with inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were extracted from included studies into a standard data extraction form by task force members. RESULTS The systematic review supported the following criteria for renal dysfunction: (1) urine output <0.5 mL/kg per hour for ≥6 hours and serum creatinine increase of 1.5 to 1.9 times baseline or ≥0.3 mg/dL, or (2) urine output <0.5 mL/kg per hour for ≥12 hours, or (3) serum creatinine increase ≥2 times baseline, or (4) estimated glomerular filtration rate <35 mL/minute/1.73 m2, or (5) initiation of renal replacement therapy, or (6) fluid overload ≥20%. Data also support criteria for persistent renal dysfunction and for high risk of renal dysfunction. LIMITATIONS All included studies were observational and many were retrospective. CONCLUSIONS We present consensus criteria for renal dysfunction in critically ill children.

Criteria for Pediatric Sepsis—A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce

Article

Full-text available

Oct 2021
CRIT CARE MED

Objective: 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. Data sources: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020. Study selection: 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. Data extraction: 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. Data synthesis: 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). Conclusions: 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.

Trombocitopenia na sepse: um importante marcador prognóstico

Article

Full-text available

Mar 2012

OBJECTIVE: To demonstrate an association between thrombocytopenia and platelet behavior in predicting mortality in septic patients.METHODS: Patients with criteria for sepsis at admission or at any time during hospitalization were selected; patients hospitalized for less than 24 hours were excluded. Thrombocytopenia was defined as a platelet count lower than 150.000/mm3, and recovery was defined as returning to levels above 150.000/mm3 after showing thrombocytopenia. We assessed the admission prognosis variables (APACHE II), platelet counts during the hospitalization and outcomes.RESULTS: Of the 56 patients included, 34 developed thrombocytopenia during sepsis (Group 1) and had a 76.4% mortality rate. The mortality rate among patients not showing thrombocytopenia (Group 2) was 40.9% (RR 1.87; 95% CI 1.12 - 3.12; p = 0.0163). In 44.1% of Group 1 patients, the platelet counts drops by >50% compared with the admission counts; 93.3% of these patients eventually died (RR 1.48; 95% CI 0.93 - 2.36; p = 0.0528). Among the Group 1 patients showing recovered platelet counts, 53.3% survived; 100% of the patients with unrecovered thrombocytopenia died (RR 2.14; 95% CI 1.35 - 3.39; p = 0.0003). Among the patients with APACHE II scores > 22, the thrombocytopenic patients had an 81.8% mortality rate (p = 0.25), while no deaths occurred among the non-thrombocytopenic patients. For the patients with APACHE II scores ≤ 22, the mortality rate of the thrombocytopenic patients was 74% (p = 0.0741), versus 42.8% for the non-thrombocytopenic patients.CONCLUSION: For this sample of septic patients, thrombocytopenia and its progression, defined as a >50% drop or failure to recover platelet count, were shown to be markers of poor prognosis.

An Increase in Mean Platelet Volume from Baseline Is Associated with Mortality in Patients with Severe Sepsis or Septic Shock

Article

Full-text available

Mar 2015
PLOS ONE

Mean platelet volume (MPV) is suggested as an index of inflammation, disease activity, and anti-inflammatory treatment efficacy in chronic inflammatory disorders; however, the effect of MPV on sepsis mortality remains unclear. Therefore, we investigated whether the change in MPV between hospital admission and 72 hours (ΔMPV72h-adm) predicts 28-day mortality in severe sepsis and/or septic shock. We prospectively enrolled 345 patients admitted to the emergency department (ED) who received standardized resuscitation (early goal-directed therapy) for severe sepsis and/or septic shock between November 2007 and December 2011. Changes in platelet indices, including ΔMPV72h-adm, were compared between survivors and non-survivors by linear mixed model analysis. The prognostic value of ΔMPV72h-adm for 28-day mortality was ascertained by Cox proportional hazards model analysis. Thirty-five (10.1%) patients died within 28 days after ED admission. MPV increased significantly during the first 72 hours in non-survivors (P = 0.001) and survivors (P < 0.001); however, the rate of MPV increase was significantly higher in non-survivors (P = 0.003). Nonetheless, the difference in the platelet decline rate over the first 72 hours did not differ significantly between groups (P = 0.360). In multivariate analysis, ΔMPV72h-adm was an independent predictor of 28-day mortality, after adjusting for plausible confounders (hazard ratio, 1.44; 95% confidence interval, 1.01-2.06; P = 0.044). An increase in MPV during the first 72 hours of hospitalization is an independent risk factor for adverse clinical outcomes. Therefore, continuous monitoring of MPV may be useful to stratify mortality risk in patients with severe sepsis and/or septic shock.

The Impact of Various Platelet Indices as Prognostic Markers of Septic Shock

Article

Full-text available

Aug 2014
PLOS ONE

Introduction Platelet indices, including mean platelet volume (MPV), are readily available blood tests, although their prognostic value in patients with septic shock has not been fully explored. Current evidence has found contradictory results. This study aims to explore the behavior of platelet indices in septic shock and their clinical prognostic value. Methods Charts of septic shock patients from January to December 2012 in a tertiary medical center in Northern China were reviewed retrospectively. Platelet indices were recorded during the first five consecutive days after admission, as well as the penultimate and the last day of hospital stay. The data were compared between surviving and non-surviving patients. Results A total of 124 septic shock patients were enrolled. Thirty-six of the patients survived and 88 of them expired. MPV in the non-survivor group was higher than that of the survivor group, especially on the last day. PDW and PLCR showed increased trends, while PCT and PLT decreased in the non-survivor group. Among the PLT indices, MPV had the highest area under the receiver operating characteristic curve (0.81) with a precision rate of 75.6% at a cut-off of 10.5.Compared with other more usual septic shock prognostic markers, MPV is second only to lactate for the highest area under the curve. Conclusion A statistically significant difference was seen between survivors and non-survivors for platelet indices which make them easily available and useful prognostic markers for patients in septic shock.

Thrombocytopenia in the Intensive Care Unit Setting

Article

Full-text available

Sep 1990
J Intensive Care Med

Thrombocytopenia is a commonly encountered labora tory abnormality in the intensive care unit setting. Al though moderate degrees of thrombocytopenia may be dismissed as clinically trivial, severe thrombocytopenia can have catastrophic consequences. This review di vides the potential pathogenesis of thrombocytopenia into three pathophysiological categories: (1) produc tive, (2) consumptive, and (3) distributional. The im portant etiologies and appropriate therapies for throm bocytopenia in each of these categories are discussed. We have attempted to emphasize the underlying patho genic mechanisms as well as highlight the diagnostic dilemmas likely to be faced by intensive care unit physi cians. Although this review stresses those thrombocyto penic disorders most likely to be encountered in the intensive care unit, chronic etiologies of thrombocy topenia are also discussed because preexistent throm bocytopenia will further complicate the care of any acutely ill intensive care unit patient.

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

Article

Full-text available

Feb 2013

OBJECTIVE:: To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. DESIGN:: A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS:: The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations. RESULTS:: Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). CONCLUSIONS:: Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.

The efficacy and safety of recombinant human activated protein C for the treatment of patients with severe sepsis

Article

Dec 2000
CRIT CARE MED

Surviving Sepsis Campaign

Article

Feb 2013
CRIT CARE MED

Objective: To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. Design: A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. Methods: The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations. Results: Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). Conclusions: Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.

Platelet Counts, MPV and PDW in Culture Proven and Probable Neonatal Sepsis and Association of Platelet Counts with Mortality Rate

Article

May 2014

Objective: To determine frequency of thrombocytopenia and thrombocytosis, the MPV (mean platelet volume) and PDW (platelet distribution width) in patients with probable and culture proven neonatal sepsis and determine any association between platelet counts and mortality rate. Study design: Descriptive analytical study. Place and duration of study: NICU, Fazle Omar Hospital, from January 2011 to December 2012. Methodology: Cases of culture proven and probable neonatal sepsis, admitted in Fazle Omar Hospital, Rabwah, were included in the study. Platelet counts, MPV and PDW of the cases were recorded. Mortality was documented. Frequencies of thrombocytopenia (< 150000/mm3) and thrombocytosis (> 450000/mm3) were ascertained. Mortality rates in different groups according to platelet counts were calculated and compared by chi-square test to check association. Results: Four hundred and sixty nine patients were included; 68 (14.5%) of them died. One hundred and thirty six (29%) had culture proven sepsis, and 333 (71%) were categorized as probable sepsis. Thrombocytopenia was present in 116 (24.7%), and thrombocytosis was present in 36 (7.7%) cases. Median platelet count was 213.0/mm3. Twenty eight (27.7%) patients with thrombocytopenia, and 40 (12.1%) cases with normal or raised platelet counts died (p < 0.001). Median MPV was 9.30, and median PDW was 12.30. MPV and PDW of the patients who died and who were discharged were not significantly different from each other. Conclusion: Thrombocytopenia is a common complication of neonatal sepsis. Those with thrombocytopenia have higher mortality rate. No significant difference was present between PDW and MPV of the cases who survived and died.

Thrombocitopenia in sepsis: an important prognosis factor

Article

Mar 2012

To demonstrate an association between thrombocytopenia and platelet behavior in predicting mortality in septic patients. Patients with criteria for sepsis at admission or at any time during hospitalization were selected; patients hospitalized for less than 24 hours were excluded. Thrombocytopenia was defined as a platelet count lower than 150.000/mm³, and recovery was defined as returning to levels above 150.000/mm³ after showing thrombocytopenia. We assessed the admission prognosis variables (APACHE II), platelet counts during the hospitalization and outcomes. Of the 56 patients included, 34 developed thrombocytopenia during sepsis (Group 1) and had a 76.4% mortality rate. The mortality rate among patients not showing thrombocytopenia (Group 2) was 40.9% (RR 1.87; 95% CI 1.12 - 3.12; p = 0.0163). In 44.1% of Group 1 patients, the platelet counts drops by >50% compared with the admission counts; 93.3% of these patients eventually died (RR 1.48; 95% CI 0.93 - 2.36; p = 0.0528). Among the Group 1 patients showing recovered platelet counts, 53.3% survived; 100% of the patients with unrecovered thrombocytopenia died (RR 2.14; 95% CI 1.35 - 3.39; p = 0.0003). Among the patients with APACHE II scores > 22, the thrombocytopenic patients had an 81.8% mortality rate (p = 0.25), while no deaths occurred among the non-thrombocytopenic patients. For the patients with APACHE II scores ≤ 22, the mortality rate of the thrombocytopenic patients was 74% (p = 0.0741), versus 42.8% for the non-thrombocytopenic patients. For this sample of septic patients, thrombocytopenia and its progression, defined as a >50% drop or failure to recover platelet count, were shown to be markers of poor prognosis.

Guidelines for the use of platelet transfusions

Article

Jan 1992

Platelet Indices as Predictive Markers of Prognosis in Pediatric Septic Shock Patients

Abstract and Figures

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